The Coronavirus Pandemic
We have a world-wide epidemic (pandemic) caused by a coronavirus. It is clearly a serious disease, though not nearly as deadly as it’s predecessors SARS and MERS, or Ebola. It can fairly be compared to severe influenza. There is no vaccine, there may never be. There is no widely useful treatment, there may never be. Testing is available, but testing and tracing will continue to be problematic. The disease will continue to spread and likely always be with us, there will be more deaths, and there will be outbreaks. Science does not have a solution for this pandemic, doctors can only advise. The economic, public health, and social effects of the prevention and mitigation measures have been immense and are likely to be much worse than even now realized. We have to resume “normal”, but with reasonable mitigation practices, pretty much the ones we started with, pretty much with the same objective, to keep “the curve” flat.
The COVID-19 pandemic represents not only a “novel” coronavirus (SARS-CoV-2), but a novel world wide situation. The world is in chaos in many ways. The circumstances are truly unique, particularly in the response to the pandemic. The world has never had a coronavirus pandemic. There has never been a widespread shutdown of society and the economy. There are no experts for this unique situation, only experts on certain parts of the situation. Therefore, it is not surprising that there are confusion, fear, and changing assessments.
It should be acknowledged that pandemics are clearly understood only after the fact. Compiling data from all over the world, comparing all differing circumstances, and even trying to determine the validity of the data becomes a daunting task. Assessments (and recommendations) during a pandemic are sure to evolve and bound to err. We have only two examples of previous coronavirus outbreaks (epidemics), SARS (SARS-CoV) in 2003 and MERS (MERS-CoV) in 2012. These were limited outbreaks. Though the fatality rate was high, the diseases spread less effectively than COVID-19, therefore, they were controlled. Given a rapidly evolving epidemic from this new coronavirus, it was initially very concerning whether it would be as lethal as SARS and MERS. But, that quickly became doubtful.
We do have accumulated experience with influenza pandemics. COVID-19 would reasonably have been assumed to be influenza without laboratory identification of the new virus. Though there was early emphasis that this epidemic was not influenza (and it is not, technically), it has become clear that it is an ILI, “influenza-like illness”. The Centers for Disease Control has begun to put it under ILIs in some publications. Therefore, experience with past influenza pandemics is useful for understanding COVID-19. There have been influenza pandemics in 1918, 1957, 1968, and 2009. Furthermore, influenza viruses are endemic (ever present in the world) and produce outbreaks periodically. Seasonal influenza is different from pandemic influenza in several respects, but influenza always carries morbidity and mortality. We do have vaccines and treatments for influenza.
From accumulated science over the past several weeks, we now know about COVID-19:
-It is caused by a coronavirus, a class of viruses including SARS, MERS, and many common cold viruses.
-It spreads in the same manner as influenza (and similar to the common cold), from person to person primarily by respiratory droplets. Spread from surface contact appears minimal (the CDC has just clarified this, after millions of dollars have been spent on decontamination procedures).
-The incubation period may be from 3-14 days (commonly 4-5 days).
-Symptoms are highly variable, but generally like influenza or common cold: cough and shortness of breath, fever, headache, muscle aches, sore throat, loss of taste/smell.
-A large number of infected people have no symptoms but presumably are contagious.
-An infected person may be contagious even before their symptoms begin.
-The vast majority recover relatively easily. Elderly and infirm people are much more prone to serious disease and death.
-The overall mortality rate is likely below 1%.
-Non Pharmaceutical Interventions (NPIs), the same as recommended for influenza, are effective to slow and prevent spread.
-Treatment is supportive, including mechanical ventilation for serious cases.
-There is no accepted pharmaceutical treatment, may never be a truly efficacious one.
-There is no vaccine, may never be. (There is no vaccine for any other coronavirus.)
-Testing for the virus is now available, but the predictive value of these tests will not be known for awhile.
-Antibody testing is now available (indicating past disease, not current disease). This will be useful for disease control.
-There will be future outbreaks & the virus will likely always be with us. Therefore, there will be more deaths.
The assessments and management of this pandemic began with so many unknowns, it is no surprise that predictions and decisions were sometimes wrong. The question is clearly, where do we go from here? It is now questionable if lockdowns, in most locales, were ever a good choice, and certainly doubtful that they should continue. Decisions going forward will have to be made with no vaccine, no treatment, and suboptimal testing. The reason is that it is not possible to do what medical knowledge would prefer, that is, keep everyone from contact with everyone else. That would require lab rat cages. Yes, it might be the best control of the disease, but it is not sustainable. In fact, much early reaction to the outbreak was too much, too soon, and therefore not sustainable.
A reasonable case is made that we will have to proceed, forthwith, to reopen the economy, schools, and social functions. Various control measures can be employed as needed to protect the most vulnerable and to control outbreaks. The virus cannot be stopped; the herd immunity to be acquired is to our benefit. We have to learn to live with it as safely as possible while maintaining necessary and desirable function in society. I would say that will not be a “new normal”, we just have to return to normal as we can. Perhaps we will better manage future pandemics. There will be other pandemics.
Yes, the role of China in this, how the World Health Organization handled it and how the CDC handled it should be reviewed and critiqued, moreso some distance out from the pandemic. We could have perhaps been better prepared. The role of our government agencies should be reviewed. The CDC (Centers for Disease Control and Prevention) is the agency under HHS (Health and Human Services) that is primarily responsible for surveillance and preparedness for infectious diseases. It should be held responsible for that role, and should have been more visible and “in charge” during the outbreak. The National Institutes of Health (NIH), is the research agency under HHS, and should not be the primary agency managing a pandemic. And then we have the Office of the Surgeon General (threatening on April 5th that we were headed for the worst week of our lives, our Pearl Harbor moment), oh my. And the FDA, prominent in this battle, and still other government agencies performing similar, redundant functions. Also, we have state health departments – and governors – sometimes with different messages and edicts. Perhaps too many cooks in the kitchen? I would propose that the CDC should be the lead agency now and in the future, with a clear focused mission and adequate funding, and accountability.