By Dr. William Garrity of Suffield, Masters in Public Health
The United States now leads the world in confirmed coronavirus cases. But the U.S. also leads the world in promising research to slow the disease from spreading.
There is good news amidst the COVID-19 CoV pandemic. The take-home message is “Be not afraid.”
By studying and interpreting what we know of COVID-19 CoV there should be proportionately more hope than fear.
In the first part of this three-part series the epidemiology of COVID-19 is presented. The second part of this series reviews the pathophysiology of the disease. And in the third part treatment options are presented.
What is epidemiology? Epidemiology is the branch of medicine that is focused on the incidence, distribution and possible control of disease and other factors relating to health.
Another way of looking at epidemiology is to define it as the study of disease in populations.
One of the greatest fears people suffer infected with COvID-19 CoV is the fear of dying. But coronavirus risk calculation causal for disease or dying is a dependent variable — not fixed.
The literature in some cases offers some of the significant nonfatal consequences of the infection are merely associations of underlying existing disease such as allergies, asthma and COPD rather than the lethal pathophysiological severe respiratory disease course attributed to COVID-19 CoV.
In the U.S., there are variations in both the number of people suffering from the disease and dying among the states. There is a reason for this.
Even the morbidity-severity of the disease is different between individuals, age groups and even gender for age groups over 50.
The take-home message is that there are definitely variables that can positively impact the disease to improve or worsen outcomes and even define the condition as only COVID-19 CoV caused.
To effectively slow the infection from spreading rapidly or stop it, approximately 60% of people infected and recovered is needed or vaccinated.
What are some of the ways to slow or stop the coronavirus pandemic? If you simply rely on guerrilla warfare — a big shutdown measure — without finding every case, the spread of disease could come back in waves. What we have done by these big shutdowns is gained time.
Another take-home message is big shutdowns don’t actually stop the virus, they slow it. The virus is just going to sit you out. And the virus will circulate quietly among households until shutdowns are lifted. The key point is that shutdowns will buy time to get systems in place to manage the individual cases that are going to be fundamental to stopping this.
Bullet points to achieve immunity or slow the virus using retrospective data:
1. COVID-19 CoV is one of three coronavirus mutations causing severe acute respiratory syndrome. Retrospectively in China, where the infection is declining ,we can get a better view of the fatality rate. The cases reported outside Wuhan have mostly not been severe. It would be reasonable to infer that there might be a large number of undetected relatively mild infections in Wuhan and that the infection fatality risk is 1% or even less.
2. SARS Co-V occurred in 2002 and killed about 800 people while infecting 8,000. The SARS Co-V has a 10% fatality rate. MERS CoV occured in 2012 and killed 842 people and infected about 2,442 people. The Mers Co-V has a 35% fatality rate.
3. The initial data out of China suggested a death rate associated with COVID-19 CoV was 2.3%. Testing more people in China shows the number infected as compared with the number of deaths is significantly less — only 1% or less.
4. In the U.S every state has a different death rate. This is due to a number of variable factors. But to illustrate the disparity comparing the initial China death rate of 2.3% with Italy’s high rate of death from COVID-19 CoV, 7.2% will illuminate other key factors.
5. Italy’s high rate of death, similar to the variation of death rates in each state in this nation, may be explained the country’s relatively high proportion of older people. Italy’s relatively older population (23% are 65 years and older) and the lethality of the coronavirus in this age-group could partly explain its high death rate.
6. When stratified by age-group death rates of people 1 to 69 years, Italy and China look similar. But rates are higher in Italy among individual aged 70 years or older. And death rates are even higher among those aged 80 years or older. This difference was difficult to explain.
7. The explanation is illuminated by examining the data more closely. The question is how many patients had comorbid disease and how many comorbid diseases were there in each person infected?
8. In the subsample the mean age was 79.5 years of whom only 60 (30%) were women. Of all patients who died, 117 (30%) had ischemic heart disease, 126 (35.5%) had diabetes, 72 (20.3%) had cancer, 87 (24.5%) had atrial fibrillation, 24 (6.8%) had dementia and 34 (9.6%) had a stroke. Being male was a risk factor and not just the fact more men smoked. It is believed women may have a stronger immune system and are more likely to wash their hands. We don’t always understand why something is a risk factor. The gender gap was most significant for men in their 50s and tapered off only at 90.
9 The mean number of comorbidities of those who died in the subsample is 2.7. Only 3 patients had no underlying diseases (0.8%), 89 (25.1%) had one, 91 (25.6%) had two and 172 (48.5% had three or more.
10. When a change of strategy limited testing to patients who had severe symptoms there was a 19.3% positive rate and an apparent increase in death rate from 3.1% to 7.2%. The reason for the decrease in the death rate was because patients with milder illness were no longer tested. This was a statistical but important mathematical manipulation which skewed the data and caused misinterpretation of death rates.
1. Italian doctors called for countries to lock down. Questions asked around shutdowns include: Do they actually work? Another question is does strict social distancing work equally well over time or better? Does either one prevent further outbreaks? Are there unintended consequences?
2. In Italy it was found when strict social distancing measures were enforced on March 9 to March 11 the number of new coronavirus cases was surprisingly and significantly reduced to 24,747 by March 15, down from the 30,000 cases predicted in a March 13 analysis.
3. On March 9 the government issued a countrywide prohibition of public gatherings and suspended sporting and other events. Two days later, it tightened restrictions, closing shops selling nonessential products and services.
4. A lesson learned is the mortality rate was directly tied to both lockdown and social distancing factors. Lockdown decreased the incidence of new cases. The incidence of a disease conveys information regarding the risk of contracting the disease. The prevalence of the disease represents the number of cases at a given time. The prevalence determines how widespread the disease is. Both the incidence and prevalence of coronavirus disease outcomes were favorably affected by social distancing and lockdown.
5. The patients’ median age was 62 years (range of 37 to 75). Advanced age was associated with elevated viral load suggesting a possible explanation for the severity of coronavirus-related illness in the age group.
6. Higher virus loads in the older population early in the disease may imply spreading the disease is higher. This implies the elderly as a group may be most contagious and cause for spreading the disease during that time. This finding raised the possibility of a poorer or attenuated rapid development of antiviral resistance in the elderly
7. Patient-collected saliva from the back of the throat rather than specimens collected through the nose appeared more useful and safer. Self-collected saliva is much more acceptable to patients and is safer for health care workers.
8. Viral RNA was detected in one patent 25 days after symptoms began.
9. The viral genome did not show mutations which raises hope for an effective vaccine.
10. There are lessons learned from the Italy and China analysis and comparison. Not recognizing implications of data and therby lessons may negatively impact mortality rates, incidence and prevalence of the of Covid-19 CoV and severity of respiratory disease.
Resources from the CDC for children:
1. Clean hands often.
2. Avoid people who are sick.
3. Clean and disinfect high-touch surfaces daily.
4. Launder items including washable plush toys.
5. Limit social interactions.
6. Help children continue learning.
7. Create a schedule and routine for learning at home but be flexible.
8. Watch for signs of stress in your child. Seek counseling early. Be proactive not reactive.
9. Parents must learn to manage anxiety and stress.
10. Parents should be a good role model for their children.
I wish to thank the editor and owner of The North Central News, Gary Carra, for the opportunity to share this message of hope as a public service message. I write this article to share the less heard but overarching message of hope for individuals, parents and their children. And I write this because of one who inspires me everyday.
Dr. Garrity is a residency trained dual board certified primary care medical physician. Dr. Garrity graduated from Boston College, Magna Cum Laude, and The University of New England College of Osteopathic Medicine with honors. Dr. Garrity earned his masters of public health degree (MPH) with highest honors distinction from Nova Southeastern College of Osteopathic Medicine.
Dr. Garrity was selected to join and is a graduate of the Health Policy Fellow program from the combined program at NYIT and Ohio University. Dr. Garrity practices family medicine and neuromusculoskeletal medicine at 230 Mountain Road in Suffield. Dr. Garrity may be reached for office appointments or telemedicine appointments by calling (860) 668-4767 or e-mail: email@example.com