Sunday Long Read: Viral Information

James Hamblin at the Atlantic gives us this week's Sunday Long Read on COVID-19, the Wuhan coronavirus, and what an epidemic scenario in the US would really mean.

The Harvard epidemiology professor Marc Lipsitch is exacting in his diction, even for an epidemiologist. Twice in our conversation he started to say something, then paused and said, “Actually, let me start again.” So it’s striking when one of the points he wanted to get exactly right was this: “I think the likely outcome is that it will ultimately not be containable.”

Containment is the first step in responding to any outbreak. In the case of COVID-19, the possibility (however implausible) of preventing a pandemic seemed to play out in a matter of days. Starting in January, China began cordoning off progressively larger areas, radiating outward from the city of Wuhan and eventually encapsulating some 100 million people. People were barred from leaving home, and lectured by drones if they were caught outside. Nonetheless, the virus has now been found in 24 countries.

Despite the apparent ineffectiveness of such measures—relative to their inordinate social and economic cost, at least—the crackdown continues to escalate. Under political pressure to “stop” the virus, last Thursday the Chinese government announced that officials in Hubei province would be going door-to-door, testing people for fevers and looking for signs of illness, then sending all potential cases to quarantine camps. But even with the ideal containment, the virus’s spread may have been inevitable. Testing people who are already extremely sick is an imperfect strategy if people can spread the virus without even feeling bad enough to stay home from work.

Lipsitch predicts that within the coming year, some 40 to 70 percent of people around the world will be infected with the virus that causes COVID-19. But, he clarifies emphatically, this does not mean that all will have severe illnesses. “It’s likely that many will have mild disease, or may be asymptomatic,” he said. As with influenza, which is often life-threatening to people with chronic health conditions and of older age, most cases pass without medical care. (Overall, about 14 percent of people with influenza have no symptoms.)

Lipsitch is far from alone in his belief that this virus will continue to spread widely. The emerging consensus among epidemiologists is that the most likely outcome of this outbreak is a new seasonal disease—a fifth “endemic” coronavirus. With the other four, people are not known to develop long-lasting immunity. If this one follows suit, and if the disease continues to be as severe as it is now, “cold and flu season” could become “cold and flu and COVID-19 season.”

At this point, it is not even known how many people are infected. As of Sunday, there have been 35 confirmed cases in the U.S., according to the World Health Organization. But Lipsitch’s “very, very rough” estimate when we spoke a week ago (banking on “multiple assumptions piled on top of each other,” he said) was that 100 or 200 people in the U.S. were infected. That’s all it would take to seed the disease widely. The rate of spread would depend on how contagious the disease is in milder cases. On Friday, Chinese scientists reported in the medical journal JAMA an apparent case of asymptomatic spread of the virus, from a patient with a normal chest CT scan. The researchers concluded with stolid understatement that if this finding is not a bizarre abnormality, “the prevention of COVID-19 infection would prove challenging.”

Even if Lipsitch’s estimates were off by orders of magnitude, they wouldn’t likely change the overall prognosis. “Two hundred cases of a flu-like illness during flu season—when you’re not testing for it—is very hard to detect,” Lipsitch said. “But it would be really good to know sooner rather than later whether that’s correct, or whether we’ve miscalculated something. The only way to do that is by testing.”

Originally, doctors in the U.S. were advised not to test people unless they had been to China or had contact with someone who had been diagnosed with the disease. Within the past two weeks, the CDC said it would start screening people in five U.S. cities, in an effort to give some idea of how many cases are actually out there. But tests are still not widely available. As of Friday, the Association of Public Health Laboratories said that only California, Nebraska, and Illinois had the capacity to test people for the virus.

With so little data, prognosis is difficult. But the concern that this virus is beyond containment—that it will be with us indefinitely—is nowhere more apparent than in the global race to find a vaccine, one of the clearest strategies for saving lives in the years to come.

The new normal is that COVID-19 hits the global population like a truck, and then becomes one of the many flu-like strains that are with us year after year, mutating, then reappearing. If Lipsitch's numbers are right, US fatalities could well be into the hundreds of thousands, and that's not counting the follow-on fatalities from complications from the illness, a hospital system overwhelmed by COVID-19 patients, and a just-in-time delivery system of supplies and basic staples when people suddenly find themselves unable to get things they need.

I'm not trying to panic people.  I want people to get good information, because lord knows there's a lot of bad information already out there.  But people need to take this seriously.