As this Coronavirus pandemic continues to spread, infect and kill more people we need to look the effects of this crisis. Peter Drobac reported that flattening the curve is the next goal to this new viral pandemic.
It’s always been a question of when, and not whether, humanity would face another challenge on the scale of the 1918 flu pandemic.
The novel coronavirus is shaping up to be that challenge, with events moving at an unnerving pace. Since emerging in Wuhan, China in late 2019, more than 125,000 cases and 4,600 deaths have been reported worldwide. Officially a pandemic, the virus is shining a harsh spotlight on the strengths and weaknesses of the world’s health systems.
At first glance, the US should be well positioned to respond to a disease outbreak. It spends more than any other country on its health system, boasts a high concentration of specialists and laboratories, and has some of the world’s most respected public health experts. Yet with coronavirus, the US is courting catastrophe.
Because of serious problems with testing, coronavirus has been silently spreading in the US for nearly two months. A Harvard epidemiologist has cautioned that up to 60% of the adult population could become infected. With a health system already operating near its capacity in the height of flu season, this would spell disaster.
Hospitals would be overwhelmed. Shortages of intensive care beds and ventilators would cause death rates to rise. And people with other medical conditions, from complicated pregnancies to heart attacks, would find it more difficult to access the care they need. During the West African Ebola outbreak, health system collapse meant there were nearly as many deaths due to other diseases as from Ebola itself.
Before we all panic, there are some bright spots. Countries in Asia have shown that it is possible to bring the coronavirus epidemic under control, and they’ve had success in different ways.
But first, it’s important to understand what has gone wrong in the US.
Caught flat-footed
When the first coronavirus case was reported in the US on January 20, 2020, alarm bells were already sounding around the world. Unprecedented control measures in China, including the effective quarantine of nearly 100 million people, slowed the spread of the virus and bought the rest of the world time. But while other countries began preparing for the epidemic, the US was caught flat-footed.
Rather than use WHO-approved test kits, the US Centers for Disease Control and Prevention (CDC) developed its own coronavirus test. Regulations prohibited private and university labs from developing tests themselves. Problems with the CDC’s test, along with overly narrow testing criteria, created a massive testing bottleneck.
Fewer than 10,000 tests have been conducted in the US. Compare that with over 200,000 in South Korea. Case detection is the most fundamental part of a public health response to an outbreak. When we can’t do that, we’re operating in the dark.
Meanwhile, years of attempted budget cuts and the elimination of the federal Global Health Security office left America’s vaunted public health agencies less prepared to coordinate a response across the country’s fragmented and unequal health system. Unsteady presidential leadership has sowed confusion and misinformation.
So while 1,215 cases have been reported in 42 states, actually as of Sunday there was only the state of West Virginia that didn’t have a case of the virus, the real number is probably much higher. And with an epidemic that doubles every five days when unchecked, the US may not be far behind Italy.
Flattening the curve
So, what can the US learn from the Asian countries that have managed to blunt the spread of novel coronavirus? While no country has been able to stop the spread of the virus completely, several have managed to “flatten the curve.” What does this mean?
Flattening the epidemic curve means slowing the spread of new infections. This can ensure that not too many people are infected at the same time, giving health systems a better chance to cope. It also buys time, as researchers race to develop and test treatments and vaccines.
New cases in China have gone dropped from a flood to a trickle, at least for now, where they are only reporting 8-10 cases per day since Friday. But it required putting vast swaths of the country on total lockdown, exacting enormous economic and social pain. Italy is now following suit.
Singapore responded early, employing tried-and-tested public health measures: testing, enforced quarantine, and tracing contacts with surgical precision. The US is probably too late for this approach.
Taiwan also responded briskly, establishing a central command center, implementing targeted travel bans and proactive testing, and social distancing measures such as school closures.
South Korea may offer the best example of what could be possible in the US. Like the US, they had to play catch-up, facing a surge of infections tied to a secretive church in Daegu. The pillar of their response has been widespread, free testing, including drive-through test sites. Technology has aided the tracing of contacts, using GPS tracking. Rather than creating a total lockdown, they opted for social distancing measures targeting transmission hot spots. The number of daily new cases has dropped from a peak of 851 to fewer than 250.
Such measures would be workable in the US, but there is no time to waste. The testing bottleneck appears to be loosening, but it may be weeks before testing capacity can catch up to demand. Where possible, localities are taking matters into their own hands.
In Seattle, one of the country’s transmission hot spots, the University of Washington launched a Korea-style drive-through test centre for its employees and students. In New Rochelle, New York, schools, churches and other gathering places in a “containment area” have been closed down. And mass gatherings are beginning to be cancelled across the country.
Efforts like this need to be scaled and spread dramatically—and quickly. Financial barriers to testing and medical care need to be eliminated, particularly for America’s large uninsured population. Hospitals and healthcare workers will need support to develop parallel care systems for coronavirus patients.
And as school closures, working from home, and transport restrictions are implemented more widely, efforts are needed to protect the most vulnerable.
The Trump administration needs to put the experts in charge and ask Congress for a blank cheque to give them the resources they need. It’s time for a war footing.
Most importantly, everyone needs to understand that life in the time of coronavirus is different.
A recession is unlikely but not impossible
Covid-19 infects the world economy?
As reported in Finance and Economics, if the final week of February saw financial markets jolted awake to the dangers of a COVID-19 pandemic, the first week of March has seen policymakers leaping into action. The realization that global GDP will probably shrink for part of this year, and the looming risk of a financial panic and credit-crunch, has led central banks to slash interest rates at a pace last seen in the financial crisis of 2007-09.
On March 3rd the Federal Reserve lowered its policy rate by 0.5 percentage points, two weeks before its scheduled monetary-policy meeting. Central banks in Australia, Canada and Indonesia have also cut rates. The European Central Bank and the Bank of England are expected to follow. If the money-markets are right, more Fed cuts are in store. A composite measure of the global monetary-policy rate, compiled by Morgan Stanley, a bank, is expected to fall to 0.73% by June, from 1% at the start of the year and 2% at the start of 2019.
Yet there is an uneasy feeling that a flurry of rate cuts may not be the solution to this downturn. In part that reflects the fact that they are already so low. A golden rule of crisis-fighting is that in order to be credible you should always have more ammunition available. In 2008-10 the global composite policy rate fell by three percentage points. Today, outside America, rich-world interest rates are close to, at, or below zero. Even the Fed has limited scope to cut much further—one reason, perhaps, why share prices failed to revive in the hours after its latest move.
The tension also stems from the peculiarity of the shock that the economy faces—one that involves demand, supply and confidence effects. The duration of the disruption mainly depends on the severity of the outbreak and the public-health measures undertaken to contain it. Given those uncertainties, policymakers know that while interest-rate cuts are an option, they also need fiscal and financial measures to help business and individuals withstand a temporary but excruciating cash crunch.
One way the virus hurts the economy is by disrupting the supply of labour, goods and services. People fall ill. Schools close, forcing parents to stay at home. Quarantines might force workplaces to shut entirely. This is accompanied by sizable demand effects. Some are unavoidable: sick people go out less and buy fewer goods. Public-health measures, too, restrict economic activity. Putting more money into consumers’ hands will do little to offset this drag, unlike your garden-variety downturn. Activity will resume only once the outbreak runs its course.
Then there are nasty spillovers. Both companies and households will face a cash crunch. Consider a sample of 2,000-odd listed American firms. Imagine that their revenues dried up for three months but that they had to continue to pay their fixed costs, because they expected a sharp recovery. A quarter would not have enough spare cash to tide them over, and would have to try to borrow or retrench. Some might go bust. Researchers at the Bank for International Settlements, a club of central banks, find that over 12% of firms in the rich world generate too little income to cover their interest payments.
Many workers do not have big safety buffers either. They risk losing their incomes and their jobs while still having to make mortgage repayments and buy essential goods. More than one in ten American adults would be unable to meet a $400 unexpected expense, equivalent to about two days’ work at average earnings, according to a survey by the Federal Reserve. Fearing a hit to their pockets, people could start to hoard cash rather than spend, further worsening firms’ positions.
Modeling the resulting hit to economic activity is no easy task. In China, which is a month ahead of the rest of the world in terms of the outbreak, a survey of purchasing managers shows that manufacturing output in February sank to its lowest levels since factory bosses were first surveyed in 2004. It seems likely that GDP will contract in the first quarter for the first time since the death of Mao Zedong in 1976.
Forecasters are penciling in sharp falls in output elsewhere (see chart 1). Goldman Sachs, a bank, reckons global GDP will shrink at an annualized rate of 2.5% in the first quarter. With luck the slump will end once the virus stops spreading. But even if that happens the speed and size of the economic bounce-back also depends on the extent to which those costly spillovers are avoided.
That is why central bankers and finance ministries are turning to more targeted interventions (see chart 2). These fall into three broad categories: policies to ensure that credit flows smoothly through banks and money markets; measures to help companies bear fixed costs, such as rent and tax bills; and measures to protect workers by subsidizing wage costs.
Start with credit flows. Central banks and financial regulators have tried to ensure that markets do not seize up, but instead continue to provide funds to those who need them. On March 2nd the Bank of Japan conducted ¥500bn ($4.6bn) of repo operations to ensure enough liquidity in the system. The People’s Bank of China has offered 800bn yuan ($115bn, or 0.8% of GDP) in credit to banks so long as they use it to make loans to companies badly hit by the virus. Banks have been asked to go easy on firms whose loans are coming due.
Governments are also helping firms with their costs, the second kind of intervention. Singapore plans corporate-tax breaks, and rental and tax rebates for commercial property. Korea will give cash to small firms struggling to pay wages. Italy will offer tax credits to firms that experience a 25% drop in turnover. In China the government has told state landlords to cut rents and given private-sector landlords subsidies to follow suit.
The final set of measures is meant to protect workers by preventing lay-offs and keeping incomes stable. China’s government has enacted a temporary cut to social-security contributions. Japan will subsidize wages of people who are forced to take time off to care for children or for sick relatives. Singapore has announced cash grants for employers of affected workers.
Today these policies are being sporadically announced, and their implementation is uncertain. As the virus spreads, expect more interest-rate cuts—but also the systematic deployment of a more complex cocktail of economic remedies. ■
As the Pandemic Spreads, Will There Be Enough Ventilators?
Patti Neighmond noted that as the coronavirus that causes COVID-19 spreads across the United States, there are continuing concerns among hospitals, public health experts and government leaders that hospital intensive care units would be hard-pressed to handle a surge in seriously ill patients.
A key limiting factor to being able to provide good care, they say, is the number of ventilation machines — ventilators — a hospital has on hand to help the most seriously ill patients breathe.
“The coronavirus, like many respiratory viruses, can cause inflammation in the lungs,” explains Dr. William Graham Carlos a pulmonary critical care specialist at Indiana University School of Medicine “And when the lungs become inflamed, the membranes that transfer oxygen from the air into the blood become blocked.”
When patients develop this type of viral pneumonia, they often require bedside ventilators which, Carlos says “can supply higher levels of oxygen and also help push air into the lungs to open them up, and afford more opportunity to get oxygen into the patient.”
Ventilators are generally a temporary bridge to recovery — many patients in critical care who need them do get better. These machines can be crucial to sustaining life in certain emergency situations. And if there is a surge in seriously ill patients, as COVID-19 spreads, ventilators could be in short supply, from hospital to hospital or nationally.
And if there’s an increase in very sick patients on a scale like what happened in China, Dr. Eric Toner says, the U.S. is not prepared. Toner studies hospital preparedness for pandemics at the Johns Hopkins Center for Health Security.
“We are not prepared, nor is any place prepared for a Wuhan-like outbreak,” Toner tells NPR, “and we would see the same sort of bad outcomes that they saw in Wuhan — with a very high case fatality rate, due largely to people not being able to access the needed intensive care.”
Toner says all hospitals have some lifesaving ventilators, but that number is proportional to the number of hospital beds in the institution. An average-sized hospital with 150 beds, for example, might have 20 ventilators. If more were needed, hospitals that need them could rent them, he says — at least for now. But if there’s a surge of need in a particular community — patients with serious pneumonia from COVID-19 or pneumonia related to flu, for example — all hospitals in the area would be competing to rent from the same place. “So that’s a very finite resource” he says.
The latest study available estimates there are about 62,000 ventilators in hospitals nationwide. That figure is seven years old — so the actual number could be higher.
There are also some machines in federally stockpiled emergency supplies, though the exact number isn’t public.
“There is a strategic national stockpile of ventilators, but the numbers are classified,” says Toner. It’s been “publicly stated,” he says, that there are about 10,000 ventilators in the national stockpile. “That number might be a bit outdated, but it’s probably about right,” he says. Other estimates range from 4,000 to somewhat less than 10,000.
You Have A Fever And A Dry Cough. Now What?
While any extra ventilators would be an important addition, Toner says it likely wouldn’t be enough to sustain the entire country through an experience like that seen in Wuhan, China.
If there’s not enough capacity at one hospital, it may be possible to transfer patients to another, he says.
“Not every community is going to be hit simultaneously; some cities will be badly affected while others are not so badly affected and then the wave of disease will move on.” So, in some cases, Toner says, it seems likely that patients could be transferred from an area where ventilators are scarce to an area where the supply is adequate.
But if hospitals continue to be overwhelmed, he says, at that point, “tough decisions would have to be made about who gets access to a ventilator and who does not.”
All health care providers and hospitals are now working overtime to try to prevent that sort of scenario.
Dr. Craig Coopersmith with Emory University School of Medicine, and a spokesperson for the Society of Critical Care Medicine, says he sees signs all across America that medical communities are working together to prepare.
Evergreen Hospital in Washington State, for example, which treated some of the first U.S. COVID-19 patients in late February, this week posted online its own “Lessons for Hospitals.” There has been a lot of ongoing communication, Coopersmith says, between hospitals, professional societies and individuals — in person, by phone and via shared Listservs and social media.
“In multiple ways, people are linking with each other to say ‘I’m not going to do this in isolation; tell me how you’re doing this, let me tell you how I’m doing this and let’s share lessons with each other,’ ” Coopersmith says.
The pandemic, he adds, is “remarkably challenging. But he sees the health care system’s response to it as remarkably heartening, “with everyone working together to ensure what’s best for patients, caregivers and the community.”
What does the coronavirus do to your body? Everything to know about the infection process
A visual guide of coronavirus infection, symptoms of COVID-19 and the effects of the virus inside the body, in graphics
Javier Zarracina and Adrianna Rodriquez reported that as the COVID-19 pandemic spreads across the U.S. – canceling major events, closing schools, upending the stock market and disrupting travel and normal life – Americans are taking precautions against the new coronavirus that causes the disease sickening and killing thousands worldwide.
The World Health Organization and U.S. Centers for Disease Control and Prevention advise the public be watchful for fever, dry cough and shortness of breath, symptoms that follow contraction of the new coronavirus known as SARS-CoV-2.
From infection, it takes approximately five to 12 days for symptoms to appear. Here’s a step-by-step look at what happens inside the body when it takes hold.
Coronavirus infection
According to the CDC, the virus can spread person-to-person within 6 feet through respiratory droplets produced when an infected person coughs or sneezes.
It’s also possible for the virus to remain on a surface or object, be transferred by touch and enter the body through the mouth, nose or eyes.
Dr. Martin S. Hirsch, senior physician in the Infectious Diseases Services at Massachusetts General Hospital, said there’s still a lot to learn but experts suspect the virus may act similarly to SARS-CoVfrom 13 years ago.
“It’s a respiratory virus and thus it enters through the respiratory tract, we think primarily through the nose,” he said. “But it might be able to get in through the eyes and mouth because that’s how other respiratory viruses behave.”
When the virus enters the body, it begins to attack.
Fever, cough and other COVID-19 symptoms
It can take two to 14 days for a person to develop symptoms after initial exposure to the virus, Hirsch said. The average is about five days.
Once inside the body, it begins infecting epithelial cells in the lining of the lung. A protein on the receptors of the virus can attach to a host cell’s receptors and penetrate the cell. Inside the host cell, the virus begins to replicate until it kills the cell.
This first takes place in the upper respiratory tract, which includes the nose, mouth, larynx and bronchi.
The patient begins to experience mild version of symptoms: dry cough, shortness of breath, fever and headache and muscle pain and tiredness, comparable to the flu.
Dr. Pragya Dhaubhadel and Dr. Amit Munshi Sharma, infectious disease specialists at Geisinger, say some patients have reported gastrointestinal symptoms such as nausea and diarrhea, however it’s relatively uncommon.
Symptoms become more severe once the infection starts making its way to the lower respiratory tract.
Pneumonia and autoimmune disease
The WHO reported last month about 80% of patients have a mild to moderate disease from infection. A case of “mild” COVID-19 includes a fever and cough more severe than the seasonal flu but does not require hospitalization.
Those milder cases are because the body’s immune response is able to contain the virus in the upper respiratory tract, Hirsch says. Younger patients have a more vigorous immune response compared to older patients.
Dr. Pragya Dhaubhadel and Dr. Amit Munshi Sharma, infectious disease specialists at Geisinger, say some patients have reported gastrointestinal symptoms such as nausea and diarrhea, however it’s relatively uncommon.
Symptoms become more severe once the infection starts making its way to the lower respiratory tract.
Pneumonia and autoimmune disease
The WHO reported last month about 80% of patients have a mild to moderate disease from infection. A case of “mild” COVID-19 includes a fever and cough more severe than the seasonal flu but does not require hospitalization.
Those milder cases are because the body’s immune response is able to contain the virus in the upper respiratory tract, Hirsch says. Younger patients have a more vigorous immune response compared to older patients.
The 13.8% of severe cases and 6.1% critical cases are due to the virus trekking down the windpipe and entering the lower respiratory tract, where it seems to prefer growing.
“The lungs are the major target,” Hirsch said.
As the virus continues to replicate and journeys further down the windpipe and into the lung, it can cause more respiratory problems like bronchitis and pneumonia, according to Dr. Raphael Viscidi, infectious disease specialist at Johns Hopkins Medicine.
Pneumonia is characterized by shortness of breath combined with a cough and affects tiny air sacs in the lungs, called alveoli, Viscidi said. The alveoli are where oxygen and carbon dioxide are exchanged.
When pneumonia occurs, the thin layer of alveolar cells is damaged by the virus. The body reacts by sending immune cells to the lung to fight it off.
“And that results in the linings becoming thicker than normal,” he said. “As they thicken more and more, they essentially choke off the little air pocket, which is what you need to get the oxygen to your blood.”
“So it’s basically a war between the host response and the virus,” Hirsch said. “Depending who wins this war we have either good outcomes where patients recover or bad outcomes where they don’t.”
Restricting oxygen to the bloodstream deprives other major organs of oxygen including the liver, kidney and brain.
In a small number of severe cases that can develop into acute respiratory distress syndrome (ARDS), which requires a patient be placed on a ventilator to supply oxygen.
However, if too much of the lung is damaged and not enough oxygen is supplied to the rest of the body, respiratory failure could lead to organ failure and death.
Viscidi stresses that outcome is uncommon for the majority of patients infected with coronavirus. Those most at risk to severe developments are older than 70 and have weak immune responses. Others at risk include people with pulmonary abnormalities, chronic disease or compromised immune systems, such as cancer patients who have gone through chemotherapy treatment.
Viscidi urges to public to think of the coronavirus like the flu because it goes through the same process within the body. Many people contract the flu and recover with no complications.
“People should remember that they’re as healthy as they feel,” he said. “And shouldn’t go around feeling as unhealthy as they fear.”
Coronavirus Disease 2019: Myth vs. Fact
There’s a lot of information circulating about Coronavirus Disease 2019 (COVID), so it’s important to know what’s true and what’s not. Lisa Maragakis, M.D., M.P.H., senior director of infection prevention at Johns Hopkins, helps clarify information to help keep you and your family healthy and safe.
TRUE or FALSE? A vaccine to cure COVID-19 is available.
FALSE.
True: There is no vaccine for the new coronavirus right now. Scientists have already begun working on one, but developing a vaccine that is safe and effective in human beings will take many months.
TRUE or FALSE? You can protect yourself from COVID-19 by swallowing or gargling with bleach, taking acetic acid or steroids, or using essential oils, salt water, ethanol or other substances.
FALSE.
True: None of these recommendations protects you from getting COVID-19, and some of these practices may be dangerous. The best ways to protect yourself from this coronavirus (and other viruses) include:
Washing your hands frequently and thoroughly, using soap and hot water.
Avoiding close contact with people who are sick, sneezing or coughing.
In addition, you can avoid spreading your own germs by coughing into the crook of your elbow and staying home when you are sick.
TRUE or FALSE? The new coronavirus was deliberately created or released by people.
FALSE.
True: Viruses can change over time. Occasionally, a disease outbreak happens when a virus that is common in an animal such as a pig, bat or bird undergoes changes and passes to humans. This is likely how the new coronavirus came to be.
TRUE or FALSE? Ordering or buying products shipped from China will make a person sick.
FALSE.
True: Researchers are studying the new coronavirus to learn more about how it infects people. As of this writing, scientists note that most viruses like this one do not stay alive for very long on surfaces, so it is not likely you would get COVID-19 from a package that was in transit for days or weeks. The illness is most likely transmitted by droplets from an infected person’s sneeze or cough, but more information is emerging daily.
TRUE or FALSE? A face mask will protect you from COVID-19.
FALSE.
True: Certain models of professional, tight-fitting respirators (such as the N95) can protect health care workers as they care for infected patients.
For the general public without respiratory illness, wearing lightweight disposable surgical masks is not recommended. Because they don’t fit tightly, they may allow tiny infected droplets to get into the nose, mouth or eyes. Also, people with the virus on their hands who touch their face under a mask might become infected.
People with a respiratory illness can wear these masks to lessen their chance of infecting others. Bear in mind that stocking up on masks makes fewer available for sick patients and health care workers who need them.
We all have to utilize the best actions to get through this pandemic with good hygiene, cleaning surfaces and social distancing. Remember, we have no vaccines, not antiviral agents proven to work. Therefore, we need to our immune systems and the health care system to flatten the outbreak curve. We need to take the police out of the equation and decision making and support our health care, our workers who will lose their jobs due to this pandemic and the economy. Now!!
I don’t know whether you all remember my last few sentences of last week’s post but I was so encouraged this week because it seems that maybe some of the politicians are reading my blog (yeah right!?!?) or they recognize the severity of the measles problem today. So, I want to continue the discussion starting with a number of States who get the message.
Musings of a Doc with an MBA 