March 12, 2020
The common cold is the most prevalent infectious disease in humans. The typical adult gets two to three colds per year, and children average six to eight. In settings like schools and daycares, it can seem like children are keeping the wretched things in perpetuity. However, these viral upper respiratory infections have been part of the human condition since the dawn of time.
A head cold usually begins with fatigue and muscle aches, followed by chills, sneezing and headache. Runny nose and cough develop in short order. Adults usually do not run much fever, whereas children do. Onset of symptoms can be as soon as sixteen hours from initial exposure, and the misery peaks in two to four days. Significant symptoms will usually resolve in seven to ten days, though the cough can persist for as long as three weeks. However, after the requisite goopy misery most otherwise healthy humans recover normally and move on with their lives. COVID-19, on the other hand, is fundamentally different.
Virulent Viral Villains
There are about 200 different viruses that cause head colds. Rhinovirus is a sort of picornavirus, and is responsible for about 30 to 80% of colds, depending upon your geography. However, roughly 15% of head colds are caused by coronavirus. This is a common enveloped virus in the order Nidovirales with a positive-sense single-stranded RNA genome and a nucleocapsid of helical symmetry. But never mind any of that technical stuff. Here’s the real skinny.
Run-of-the-mill coronavirus is already everywhere. The coronavirus is a ubiquitous beastie affecting both mammals and birds around the globe. In chickens, coronavirus attacks the respiratory tree, but in cows and pigs it causes diarrhea. In humans, coronavirus typically precipitates unremarkable self-limited upper respiratory tract infections or head colds. Then there was Wuhan.
The COVID-19 Catastrophe
In December of 2019 in Wuhan, the capital of Hubei Province, China, there arose a novel strain of the traditional coronavirus. The science on this diabolical little monster is evolving rapidly. As a result, much could change from the moment I send this piece to my friend and editor Dave, and when this issue of Be Ready! hits newsstands. Try to bear with me.
As of now, nobody is completely sure where this particular strain originated. There are conspiracy theories propagated online that it was a bioengineered Chinese military weapon. Then again, there are also Internet theories that Mother Teresa had a baby with Bigfoot. Don’t believe everything you read on the Internet.
One working theory is that COVID-19 might have made the jump from bush meat in the form of snakes, bats, or even pangolins, a bizarre member of the armadillo family. Nobody in their right mind should be eating any of that. However, the current outbreak was suspected to have originated in a specific open-air market where bush meat and live animals were sold, called the Huanan Seafood Wholesale Market. Infections wherein a pathogen jumps from an animal to a human are called zoonotic.
Whether it is flu or coronavirus, specific animal species have generations of resistance built up to specific pathogens. However, when a virus endemic to one species makes the jump to another, the new host species will have little to no institutional immunity. This is what appears to have happened in Wuhan, and it is the chemical formula for epidemic chaos.
Powerful Petrifying Precedents
COVID-19 isn’t mankind’s first run-in with novel strains of the coronavirus. Between November 2002 and July 2003, another zoonotic strain of the coronavirus precipitated the SARS outbreak. SARS stands for Severe Acute Respiratory Syndrome, and it also arose in China.
SARS resulted in some 8,098 cases total and 774 deaths in seventeen different countries. This equates out to a 9.6% mortality rate. Most of the SARS cases manifested in China and Hong Kong. In 2017, Chinese scientists retrospectively traced the SARS strain through an intermediary vector, the civet, to cave-dwelling horseshoe bats in the Yunnan province. A civet is a jungle creature that looks like the arithmetic mean between a housecat and a weasel. Apparently, they eat those in China as well. There have been no documented cases of SARS since 2004.
MERS (Middle Eastern Respiratory Syndrome), or Camel Flu, is a similar but different coronavirus outbreak that originated in Saudi Arabia in 2012. MERS apparently arose in bats but was transmitted to humans via dromedary camels. To help control the spread of this disease, the government of Saudi Arabia warned its citizens to avoid contact with camels, eat only fully cooked camel meat, consume camel milk only after it was pasteurized, and to avoid drinking camel urine. I might have thought that last one would take care of itself, but apparently in that part of the world drinking camel urine is considered medicinal. Whatever…
While SARS moves via respiratory droplets and is quite contagious, we’re still not completely sure how MERS transfers within a population. The shocking bit about MERS is that it results in a roughly 36% mortality rate. It also favors men to women by a rate of 3.3 to 1. There have been new cases of MERS identified as recently as 2019.
The benchmark for global infectious pandemics in the modern era is the Spanish Flu of 1918. This novel flu infected 500 million people and affected every land mass on the planet, save a single island in the Amazon basin. The ultimate death toll was between 17 and 50 million people, or roughly 5% of the world’s population. The scary bit is how rapidly the Spanish Flu moved around the globe in the days before widespread air travel.
What Does It Look Like?
COVID-19 creates a lower respiratory infection with symptoms spanning from trivial, to deadly, and everything in between. The time period from exposure to onset of symptoms is between two and ten days, though there have been a few documented cases of transmission by carriers before they showed symptoms, which is extra special terrifying.
Unlike the typical head cold caused by more conventional strains of the coronavirus, COVID-19 does not typically cause much upper respiratory mischief. This means minimal sneezing, runny nose, and sore throat. COVID-19 more classically manifests as fever, deep cough, shortness of breath, and diarrhea.
Severe infection leads to pneumonia, kidney failure, and death. Of the first 41 cases admitted to hospitals in Wuhan, a third required intensive care and 15% died. Many of the dead had comorbidities like hypertension, diabetes, or heart disease. COVID-19 most commonly kills the very young or the very old.
However, at this stage of the epidemic there have also been several young, healthy folks die from this disease. One such victim was a 34-year-old Chinese ophthalmologist named Li Weliang. Li tried to spread the warning about the early effects of COVID-19 but was silenced by the Chinese police.
How Do You Catch It?
Coronavirus moves like any other head cold. This means the virus is concentrated in aerosolized droplets expelled when we cough or sneeze. The effective range for such a delivery system is roughly six feet. However, a viable virus can remain infectious on exposed surfaces like countertops, door handles, and light switches for up to nine days. There was some early suspicion that the virus might be passed via fecal-oral pathways like a stomach bug, but as of now this seems to have been discounted.
The most common way these viruses are transmitted is via contaminated hands. Somebody coughs into their hand and then opens a door. Somebody else comes by, opens the door, and scratches their face. That’s really all it takes.
The Basic Reproduction Number is the average number of people a single infected person will go on to infect. In the case of COVID-19 that number appears to be hovering between 2.13 and 3.11. That means each infected person will infect between two and three people before their symptoms resolve. Early studies in Wuhan showed the population of infected people doubling every 6.4 days.
Why Is It Such a Big deal?
As a sort of head cold, COVID-19 is not just contagious, it is profoundly contagious. If left to its own devices this virus would engulf the globe in days. Around 80% of those infected with COVID-19 recover without difficulty.
However, unlike a typical head cold, COVID-19 currently has an estimated mortality of around 2.3%. That’s about twenty times higher than seasonal flu, which kills up to 60,000 Americans per year. This preliminary number is undeniably spooky, but it is actually impossible to calculate a true absolute mortality rate until an outbreak is over.
What this means, practically speaking, is that if this thing gets loose it will create holy havoc on a planetary scale. In my busy urgent care clinic, if we were treating COVID-19 on the same scale we treat head colds and flu, then every day we would send a dozen patients to the ICU and two of our patients would die. Given the ease with which COVID-19 moves through a population, these numbers add up quickly.
The real problem with COVID-19 is airplanes. Unlike previous pandemics, nowadays people travel around the world in hours and take their pestilences with them. Direct international flights from Wuhan were connected to major cities throughout Europe and North America. One infected person who makes it to a crowded place like LAX or the major air terminals in Chicago or Atlanta could potentially infect dozens, if not hundreds, of other people who then move on to Lord knows where.
The Chinese, to their credit, have taken this outbreak very seriously once its severity became known. Travel restrictions, outdoor restrictions, and outright quarantines in China have affected an estimated 170 million people. The resulting stagnation of Chinese industry has sent ripples around the planet. Global oil prices have dropped significantly in recent weeks based upon decreased demand for petroleum in China. The price per gallon at our local pumps fell a full twenty cents as a result.
At time of writing, COVID-19 has been identified in 29 different countries. Travel restrictions and quarantine measures seem to be holding the virus at bay for now and the vast majority of COVID-19 cases have been contained inside China. However, China has a fairly well developed public health system. Should COVID-19 or something similar get loose someplace like North Korea or sub-Saharan Africa, the microbiological gloves truly come off.
What Can You Do?
COVID-19 hates bleach and alcohol. Either sanitizer, wiped across exposed inorganic surfaces, will kill the virus in fairly short order. It should be self-evident, but don’t put that stuff on your skin. Remember though, typical hand wipes may take up to three minutes to be effective. The use of face masks is controversial. N95 particulate masks are understood to be fairly effective at occluding the virus. However, occluding the virus is not really the primary mission of a face mask.
The primary benefit of a face mask is to keep you from touching your own face. Everybody scratches their face; it is an involuntary response. And now you’re thinking about doing it just because you read these words.
I was sick for the first two years of medical school. Once I finally broke the code on addressing the inevitable facial itches with my forearm instead of my hand, my respiratory maladies dropped precipitously. Nowadays, I swim in these germs every day, but really only get sick once every year or two. Basic hand management is the key.
It is also critically important that we get accustomed to compulsive hand washing, particularly in a healthcare environment. I wash my hands vigorously between every patient. This makes for dry cracking skin, particularly in cold weather, but that is the price you pay.
Portable hand sanitizers are almost all alcohol-based. To be effective they must contain at least 70% alcohol and should be left off for at least 30 seconds. Slather this stuff on your hands, and as it evaporates it will desiccate microscopic creepy crawlies. At least that’s the theory. Whenever possible, I prefer good old-fashioned soap and water.
Kids are a special category. Children are just nasty, and anyone who feels otherwise has clearly never met one. If you must care for sick children, just be exceptionally careful about hand management. Also, out of deference to his classmates, try not to be in too big a hurry to dump Junior back off at daycare if he is still showing symptoms.
How Might It Behave on Our Side of the Pond?
In wintertime during flu season, our hospitals and ICUs are typically stretched pretty thin, even without some kind of Chinese creeping crud thrown into the mix. The Chinese government has mobilized their military, built massive portable hospitals, and closed off entire regions of the country. Tens of millions of people have been quarantined. However, all it takes is one sick person in the wrong place, for even a day or two, to turn life upside down.
It wouldn’t take much to overwhelm the American healthcare system, and we have one the most well-developed public health infrastructures on the planet. A pestilence of this magnitude would push people indoors, shut down commerce, and crush our economy. In a centralized economy like China, the government controls most everything. In the land of the free, clamping down on travel and keeping folks indoors is massively more difficult.
COVID-19 seems terrifying, because it is terrifying. This is a head cold that kills one out of every fifty or so people who contract it. COVID-19 moves through a population like wildfire, slaying with wanton abandon. This deep into the Information Age, such a monster can circle the globe in an afternoon.
Viral respiratory infections like coronavirus and flu typically go someplace else when it gets warm. Nobody really knows where that someplace is. However, if we can hold on long enough, this particular pestilence should burn itself out when the sun comes back out and people start playing outside again. Still, we cannot really count on that.
There have been many historical examples of global pandemics that were much deadlier than COVID-19. In the era of ubiquitous air travel, however, the perfect storm of an easily-transmitted pathogen with a lofty kill rate has not yet had its way with the human population.
With COVID-19 now a pandemic, you might find yourself having to hunker down for a while at home with your family. Odds are you will not have to fight off the zombies, but you might not be able to run out to the local supermarket for resupply. For now, keep 30 days (90 days preferred) worth of shelf-stable food and water at the house, set aside some basic medicines and a few protective masks, and keep an eye on the news. Luck favors the prepared. Be ready!