COVID-19: Why Can’t it Just Go Away?
After all, didn’t SARS disappear?
I wake up most mornings wanting to believe that this pandemic is just a bad dream. We seem to be living in a poorly written disaster movie. Most of us are not directly impacted by the carnage, but are we all stunned by the social and economic impact. The strong will to open up our economy again is understandable.
Impatience fuels statements like these:
· “People die from car crashes, but we don’t stop people from driving.”
· “The flu kills tens of thousands each year, but we don’t shut down.”
· “We did not shut down for SARS, and it went away.”
Yet COVID-19 is still ravaging our country. It has rapidly become the leading cause of death in the United States. The social and economic shutdown has blunted its impact, but a sudden relaxation of restrictions throughout the country could lead to a huge resurgence that could overwhelm our health care system.
Why is this disease so different?
COVID-19 has a high rate of mortality. It is difficult to be precise, for many factors. The reported death rate globally hovers between 6 and 7 %, compared with .01% for the flu. COVID-19 is also more severe in older patients.
It is not just the death rate. SARS was much more lethal. Overall, about 15% of SARS patients overall died and more than 50% of senior patients succumbed.
World-wide, there were only 8,098 cases of SARS, resulting in 794 deaths. It was a wildfire that flamed out, precisely BECAUSE it was so deadly. The incubation period was brief. Infected people became ill quickly, before mixing in society and spreading the virus.
The virus causing COVID-19 is a stealthy and erratic killer. During its 7–10 day incubation period, people show no symptoms, but can spread the disease. At least 80% of infected people have only mild disease, and many — we don’t know the precise numbers — may not ever be sick.
While we do not know exact death rate, the top of the iceberg itself is huge. Many deaths due to COVID-19 may not be recognized as such.
“In the first five days of April, 1,125 people were pronounced dead in their homes or on the street in New York City, more than eight times the deaths recorded during the same period in 2019, according to the Fire Department.” (The News Atlantis.)
Reporting also underestimates the disease in other parts of the world. As of April 17, Pakistan reported 7,236 confirmed cases, with 731 deaths. But many people who die are not being tested for the virus, and therefore are not included in the official death counts, including hundreds of patients with respiratory illness who have been dead on arrival, or very soon after arrival, at Karachi hospitals.
Why did we have to resort to a shutdown to slow the pandemic?
We had no other option. The virus is spread by human contact. In the absence of a vaccine or a proven treatment, isolation is the only means of controlling the epidemic.
It is helpful to consider the eerie similarities between a biologic virus and a digital virus.
A virus is not a living germ. It is a tiny package containing genetic material. COVID-19 contains RNA. DNA is the double-stranded master plan housed in the chromosomes within each cell of the body. It is essentially the operating system of our bodies. DNA is the plan that is replicated when a cell divides in two, but RNA carries out the work of the cell. The COVID-19 RNA hijacks the processes inside cells to create many more copies of the itself.
In order to enter the cell, a virus must find a gateway. The viruses that cause COVID-19, like SARS, trick the cells by bonding to a protein on the cell wall, called ACE-2, an important receptor in the hormonal system which controls blood pressure and fluid balance. These receptors are plentiful in many parts of body, including the lung, the heart, the kidneys, and the part of the nose that perceives odors. COVID-19 is not just a viral pneumonia. Many patients with severe disease have kidney failure and need dialysis.
A digital virus also hijacks the operating system of our computer. It can be stealthy, without noticeably disrupting function, or it can cause the system to crash. Like a biologic virus, it uses the computer to generate more copies of itself and to export those copies to other computers. A computer virus, like a biologic virus, also enters through normal processes. It tricks us into opening infected attachments or clicking on dangerous url links. A digital virus can cause havoc, is difficult to detect and exterminate. As with an incurable biologic virus, infection is best avoided by using computer “hygiene” and vigilance.
A New Disease, not just a novel virus
COVID-19 is the new disease caused by the novel virus SARS-CoV-2. Its effect on the lung differs significantly from influenza and other corona viruses. COVID-19 patients can show up in the emergency room with dangerously low levels of oxygen, even though they are not gasping for air. Some patients are found dead in their home without any warning signs of severe disease. This is because the SARS-CoV-2 virus in a unique way.
In typical viral pneumonia, the lungs become inflamed and stiff and can fill up with fluid. But in COVID-19, the lungs often remain flexible, because this novel attacks the blood vessels instead of the lining of the air sacs. Small vessels clot off, blocking the flow of blood into the airspaces of the lungs, where oxygen gets absorbed into the blood stream. When the lungs remain pliable, patients are able to breathe normally, so they are not aware of the gradual decrease in blood oxygen until it reaches extremely low levels.
The virus can attack other blood vessels throughout the body, such as the heart, the kidneys, the brain, and the bowels. Heart attacks, strokes, kidney failure, and clotting of major arteries can occur suddenly, even after the lungs seem to be improving.
Another major difference in COVID-19, is that the severe stage of the disease involves harm from the overreaction of the patient’s immune system. Also, delayed reactions to the virus are believed to be the cause of a severe, thankfully rare, syndrome in children that damages the hearr and major blood vessels.
Why is the severity of disease so variable?
It is clear that old age and obesity are the biggest risk factors for severe illness. The precise mechanism for this difference is not known, and even within these categories, the severity is capricious. Research continues on many fronts to solve this mystery.
COVID-19 is not going away any time soon.
The disease will be with us until we have an effective vaccine. It is a stealth virus that can be spread by people who have no idea that they are infected. Fortunately, severe illness is rare in children. But because they can harbor a heavy viral load with no signs of illness, they could be efficient vectors for spreading the disease.
Light at the end of the tunnel
There are clear signs for hope. The shutdown has resulted in a plateau of new cases, decompressing the pressure on hospital staff and facilities. The care of patients has improved during this time, as it has become clear that COVID-19 is different from other viral pneumonias. Standard protocols for ventilator have been modified to adapt to the different lung pathologies. And clinical trials of treatments are beginning to show positive effects, including plasma donated from COVID-19 survivors and antiviral drugs.
Hope does not mean that we should suddenly let down our guard. Another wave of disease could cripple us again. Stepwise return to normalcy requires assuring medical facilities to handle not only continuing COVID, but also caring for all our other medical needs. We will need testing to identify patients and tracking to test and contain contacts. We will need to protect vulnerable populations and continue to observe hand-washing and social distancing. Less densely populated areas which have seen lesser rates infection should be able to emerge sooner. The risk of spreading infection contagion would logically be greatest in dense urban areas, where people live in large apartment buildings, sharing common corridors, stairwells, elevators, lobbies, and even laundry facilities. In the few weeks of reopening, spikes of disease have flared up, most notably in meat packing plants, where employees work in close quarters.
How can we ever get back to some semblance of normal?
You can slow down a speeding car by putting on the brakes. But if you keep your foot on the gas, the car will accelerate again as soon as you release the brakes. In the absence of a vaccine or even effective treatment, the COVID-19 engine is still powerful. Every relaxation of mitigation causes some increase in deaths. Experts believe the virus will surge again in the fall. Thus, reopening must be cautious
A diverse panel of experts, under the aegis of Harvard University, recently recommended that economic mobilization should occur in phases, “in sync with growth in our capacity to provide sustainable testing programs for mobilized sectors of the workforce.”
The pillars recovery are Testing, Tracing, and Targeted Isolation.
Testing alone will not control spread of the disease. A mechanism to use the results is required, tracing and testing the contacts of any subject who tests positive. People who are found positive should then be isolated from the general population until they are virus free.
CDC Guidelines for Reopening
After some delay, the CDC released detailed guidelines for how to minimize disease spread while opening businesses and schools.
As we gradually open our economy and society, we must not squander the progress that we have gained at great price.
We have learned some hard lessons, and if we apply that experience we will emerge stronger and healthier.
