On 31 December, 2019, the government of China informed the World Health Organization (WHO) of a novel pneumonia in Wuhan, Hubei Province, possibly with an epicenter in an public market that sold live wild animals for human consumption (including bats and pangolin, an armadillo-like mammal that is endangered because of a fallacious belief that its keratinous scales have medicinal properties).
The infectious agent was identified as a previously unidentified coronavirus on 9 January, 2020, sequenced genetically on 12 January and patient to healthcare worker transmission was verified on 20 January. The virus is named SARS-CoV-2, and the resulting illness is called COVID-19. Although two unique coronaviruses had been previously identified in humans, the similarity of this virus with those that caused previous epidemics led to well-placed fears in the scientific and medical community . On January 30, the World Health Organization declared the outbreak to be a public health emergency of international concern.
Coronaviruses were first identified in the early 2000s as causal agents of two epidemics of pneumonia like diseases: SARS (Sudden Acute Respiratory Syndrome) and MERS (Middle Eastern Respiratory Syndrome). Although two different types of coronaviruses had been previously identified in humans, the very high mortality rate of SARS and MERS were relatively unique. The spread of SARS was limited, largely in China, and eventually only 8,076 cases were identified. Of these, however, 778 patients died. SARS achieved global notoriety because of this high mortality rate.
MERS is a related coronavirus first identified in humans in 2012. Like SARS, its global spread has been limited, only around 2,200 cases have been identified. Its symptoms are general, mostly flu-like but with lower gastrointestinal symptoms as well. The majority of the cases—over 1,800—are in Saudi Arabia, and younger to middle aged men seem to be most affected (perhaps because they are more likely to be in contact with camels). Like SARS, the principal animal reservoir is bats, but much animal-human transmission occurs after humans interact with infected dromedary camels. So this too appears to be a limited, although ongoing, disease outbreak. Why the concern? Because this virus is significantly more lethal than SARS, with over 35% of infected patients to date dying of the disease. Like SARS, elderly patients are more vulnerable, particularly those with pulmonary illnesses or diabetes.
Like SARS and MERS, the primary reservoir for SARS-CoV-2 appears to be bats, although other mammals that humans either interact with or eat also serve as reservoirs. Both interspecies and intraspecies transmission are present. The incubation period in humans is estimated at 2–10 days. Most resulting illnesses are mild, with fever, cough, and other flu- or cold-like upper respiratory symptoms. In more severely ill patients, pneumonia develops, often within a week of infection and at least in hospital experience in China as many as 10% of hospitalized patients go on to develop severe, potentially life-threatening, symptoms. Like SARS, COVID-19 is uncommon in children and in those with healthy immune systems, and like other influenzas it is most dangerous in the elderly or in those with medical compromise. Unlike SARS, there is a broader range of symptoms, with more cases on the mild side of the spectrum. As I write this column (5 March 2020), 95,280 cases are reported in 70 countries, with 3,280 deaths attributed to the virus. The majority of illnesses and deaths are in China, but deaths are now reported in the US.
Who, if anyone, should worry? First, right now unless you are an epidemiologist, public health official or healthcare planner, first responder, or hospital worker, you don’t need to worry very much. Acknowledging that this represents a fair chunk of people that should legitimately be worried, ordinary citizens don’t need to worry too much. As we have repeatedly been told, average precautions against viral transmissibility such as handwashing and staying home if you are ill is all most of us need to do.
But concern is there. Coronaviruses are known infectious agents in humans. Coronaviruses have interspecies and intraspecies transmissibility from animals to humans and between humans. Coronavirus infection is difficult to diagnose specifically, initial symptoms are nonspecific and may resemble the common cold or mild influenza and therefore may be ignored. It has an asymptomatic incubation period that facilitates spread. Coronaviruses are adaptable and mutate regularly, as do many flu viruses (which is why epidemiologists play an annual guessing game to determine what strain will be prevalent in the next flu season and design vaccines accordingly). Some mutations result in mild illness, some are much more dangerous, like MERS, with incredibly high lethality rates. Thus, the potential for SARS-CoV-2 to become a pandemic illness is present. Public health officials are right to be alarmed and are right to communicate this alarm.
Many complain that our response to a disease that at this point seems to more resemble the common cold or flu than a more dangerous illness is hysterical and that the mass media is doing the public a disservice by spreading panic. Actually, most of what I have read in the mass media appears to be an accurate summation of what is appearing in the medical literature (the Journal of the American Medical Association, British Medical Journal and New England Journal of Medicine are providing readers with much pertinent clinical information and making most of this available at no charge to nonsubscribers. These are excellent sources for you and many of your patients). Unquestionably charlatans and hucksters have also entered the fray, selling quack nostrums, ineffective masks, and peddling disinformation and politically charged hysteria. Most of us are equipped to discern what is careful reporting from fear-mongering. But the bottom line is that as both healthcare providers and citizens we need to be concerned, even though overall spread is limited and mortality rates are relatively low. History teaches us that we need to be anticipating worse. The great influenza pandemic a century ago provided health lessons that should not be forgotten.
One hundred years ago, in 1919 and 1920, the world experienced one of the most deadly pandemics in history—the H1N1 flu epidemic, colloquially known as the Spanish flu. Approximately 27% of the world population was infected (around 500 million people) and the number of deaths were estimated between 40 and 50 million. It is still debated whether the disease was so deadly because of unique characteristics of the virus or whether public health conditions prevalent after the first world war contributed, with malnutrition being rampant and large numbers of people housed in refugee or relocation camps. If the latter hypothesis is true, the elevated mortality rate was principally due to bacterial infections in those with weakened immune systems. The variability in overall mortality rates may buttress this assumption. In more developed countries, like the US, overall mortality was lower (<1%) of worldwide mortality estimates (2–3%). In less developed countries, or in countries where war or famine had weakened populations, mortality was much higher and often exceeded 10%. Twenty-eight percent of the Iranian population is estimated to have been killed by the virus.
Another interesting facet of the flu pandemic was that approximately halfway through the epidemic the prevalent virus mutated into a deadlier form. Although those who had been exposed to the earlier virus developed immunity, the second phase was characterized by higher death rates among young, previously healthy individuals, most tragically striking young servicemen who had escaped death in armed conflict. The mutated form was hemorrhagic and rapidly destroyed lung tissue, making it impossible for victims to breathe. Public health resources were rapidly overwhelmed.
What we are experiencing today is of course nothing like the pandemic of 100 years ago. At the present time, overall mortality rates from COVID-19 are low, and the virus is limited to a few concentrated areas, but is clearly spreading. The majority of cases are mild. Ordinary citizens need not be alarmed, but we must remain informed.
The CDC has the most useful resource available with information appropriate to both patients and providers. It provides epidemiological updates and clinical guidance regarding the virus. It is a very valuable resource to provide to anxious patients.
Another very good resource is the World Health Organization’s rolling update on coronavirus. This again has material appropriate for both providers and patients.
Finally, the American Association for the Advancement of Science (AAAS) has released several updates on coronavirus.
- Do not go to work or associate with others if you are ill. Until a reliable test for coronavirus is commonly available, it’s smartest to presume that you have a communicable illness of whatever type. Be just and don’t expose others.
- Unless you are in an infected community, common sense applies. We are still in cold and flu season, as the CDC reminds us. Take the same precautions as you would against the cold and flu, including regular handwashing, coughing or sneezing into your sleeve (not your hands), staying home from work or school if you feel ill and getting your flu shot if you haven’t already (really—just do it!).
- Don’t invest in dietary supplements, masks, or other so-called preventive measures unless you have spare cash you need to get rid of. A lottery ticket is probably a wiser investment at this point in time.
- Advise patients to cancel appointments if they are ill.
- If you are a practitioner, particularly in private practice, ensure that you can contact patients and colleagues should your offices suddenly close or if you become ill. Now is a good time to examine what mechanisms you have put it place for continuity of care in the case of provider illness. If you do not have practice management insurance covering provider illness, you may wish to consider this.
- If appropriate and if you’re equipped and trained to do so, you may wish to provide telepsychology services to such patients. Are electronic platforms you would use outside the office HIPAA compliant? Are your informed consent forms up to date and do they discuss alternate mechanisms of service provision if office-based practice becomes impossible?
- If you’re an employer, make sure your emergency preparedness plan is up to date, including telework provisions. Stay tuned to the CDC and WHO releases.
Chances are good that none of us will need to consider any of these options. But even in the absence of illness. it’s a wise idea to take this opportunity to ensure your policies, plans, and forms are up to date.
Copyright © 2020 National Register of Health Service Psychologists. All Rights Reserved.
3.18.20 Update: See my more recent column on this topic!