Containment is futile: Is the COVID-19 coronavirus the pathogen of the century ‘everyone is waiting for’?

By | March 8, 2020

The dog is doing well.

The Pomeranian tested positive for coronavirus this week after its Hong Kong owner was infected with COVID-19, making it the first believed case of human-to-animal transmission.

Pets aren’t believed to be drivers of transmission, however questions about the infected pooch opened and closed a World Health Organization briefing Thursday, illustrating just how jumpy people feel. WHO leaders refrained once again from using the “p” word, but experts say there is no question the globe is now in the early stages of a pandemic, and there is growing consensus the pathogen is no longer containable.

Canada has recorded its first suspected case of community-acquired COVID-19, an inevitable yet still momentous development in the outbreak. A Vancouver-area woman in her 50s with no travel history to an affected area and no known contact with anyone infected with the virus tested positive for COVID-19 after she saw her doctor for what she thought was the flu. Health officials are now searching for the source of infection.

A sign is seen in the window of a coronavirus pop-up store in Washington, DC, on March 6, 2020. Nicholas Kamm/AFP via Getty Images

In the U.S., where dozens of cases with no obvious source of infection are under investigation, mathematical modellers are coming up with projections and various scenarios. Early predictions were that the virus would infect between 40 and 70 per cent of adult humanity. Those projections were revised downward this week, to 20 to 60 per cent. Still, it’s a bit of a mug’s game, because not all the data is in, and even then, the figures don’t really matter. Community spread “is going be widespread, it’s going to be severe, people will get ill, and we have to prepare for all of this,” says McMaster University infectious diseases expert Dr. Marc Loeb. “You can’t pull your punches with some of the messages. This is going to be a challenging situation.”

As the virus spreads, the focus will move from containment, identifying imported, travel-related cases, isolating the infected and tracing their contacts to keep them from generating new clusters, to mitigation, slowing how quickly the virus unfurls and trying to flatten the curve by reducing the amount of contact we have with one another. Entire cities won’t be put under lockdown, as happened in China. Drones won’t be dispatched to scold those who dare leave home without a mask. Instead, the goal would be to minimize serious illness and overall deaths, while minimizing “societal disruption,” a not-so-simple task.

It will become an egalitarian virus; everyone will have it

“If transmission is very rapid, the interventions to try and slow down that spread are interventions that will have significant implications for communities and families” such as school closures, says Dr. Amy Greer, Canada Research Chair in population disease modelling at the University of Guelph who is involved in Canada’s pandemic preparations. “Who is going to look after your kids? How long will schools be closed? Do you have a plan for that?”

Healthy people will have mild cases. They’ll be ill, and miss a week or two from work. People 65 and older and those with heart disease, diabetes, asthma, cancer, hypertension or other chronic, underlying medical conditions will have the highest risk of severe pneumonia, acute respiratory distress syndrome, sepsis, septic shock and death.

While new cases in China are falling, the virus is surging in Italy as well as Iran, where medical workers told CNN the bodies of those confirmed to have coronavirus are being treated with calcium oxide, to prevent them from contaminating the soil around their burial plots. And although the outbreak in China appears to be subsiding, others are wondering whether there could be a second epidemic wave.

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“Has China just experienced a herald wave, to use terminology borrowed from those who study tsunamis,” Antoine Flahault, of the University of Geneva, writes in this week’s The Lancet, “and is the big wave still to come?”

In Canada, pandemic plans are being dusted off. Health and emergency response officials are praying any major outbreak holds off until after flu season to avoid hospitals being swamped with the bonafide sick as well as the worried well. A pandemic would strain hospital resources substantially and lead to a surge of patients who must be tested and treated, doctors from eight Toronto hospitals warn in an article published Friday in the Canadian Medical Association Journal. Given most people won’t be acutely ill, the country must urgently ramp up the ability to test outside homes and in special clinics, they warn, “as a surge of cases appears inevitable.” The goal is to minimize the number of people going to emergency and potentially infecting healthcare workers.

The World Health Organization ratcheted up the alarm this week when it pegged the case fatality rate at 3.4 per cent, many times more severe than a typical influenza season, ahead even of the 1918 flu pandemic, but lower than the hit rate (10 per cent) for SARS. However, the true denominator isn’t known — what’s the ratio of deaths to the actual number of people infected? The case fatality rate will likely come down once the real denominator is determined, and the only way we’ll know the true number of infected is via testing to look for antibodies in people, because not everyone shows symptoms. Who does and doesn’t have the virus is going to be one of the most significant challenges, Marc Lipsitch, head of Harvard T. H. Chan School of Public Health’s Center for Communicable Disease Dynamics, said at a forum this week.

Commuters, wearing protective face masks, ride the Vaporetto boat line in Venice, Italy, on March 5, 2020. The coronavirus outbreak has hit particularly hard in Italy. Francesca Volpi/Bloomberg

COVID-19 is holding other cards to its chest. Among the secrets it still hasn’t given up: Why are there so few reported cases in children? Is it because they are somehow immune to infection? If so, why do as Italy has done and close all schools? Or, are children only mildly infected, but super-efficient, asymptomatic spreaders? What sort of trajectory will we see once community transition starts? Could this be, as Bill Gates fears, the “once-in-a-century” pathogen everyone is waiting for? “I hope it’s not that bad, but we should assume it will be until we know otherwise,” Gates writes in the New England Journal of Medicine.

With a safe vaccine against COVID-19 at least a year away, Canadians are showing increasing signs of jitteriness. Slightly more of us are anxious we may contract the virus than were a month ago, according to a new DART & Maru/Blue Poll. When asked, “how concerned are you about actually contracting the coronavirus yourself,” 32 per cent of 1,513 randomly selected Canadians surveyed on March 1 — representing roughly 10 million Canadians — said they were very or somewhat concerned about getting infected, up from 29 per cent when the exact question was fielded one month earlier. There’s been no change in the number of people avoiding taking public transit (five per cent) but a slight uptick in the percentage of people buying hand sanitizer, washing their hands more often or avoiding sporting events, movies, theatres and restaurants.

“In a way, it’s good news, isn’t it, that people aren’t running around panicking too much? I’ve seen some evidence on social media of panicking — buying toilet paper and other bizarre items,” says medical historian Mark Honigsbaum, author of The Pandemic Century: One Hundred Years of Panic, Hysteria and Hubris.

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Still, he thinks that for many, the penny hasn’t really dropped. “My gut feeling is that this is what a 1918-style pandemic might look like today,” Honigsbaum says.

“People have talked for years now about the ‘big one.’ Well, the big one doesn’t necessarily have to have catastrophic mortality, off-the-scale figures like 1918.”

Two pandemics are never the same, he says. History doesn’t repeat, but it sometimes rhymes, the old maxim goes. “What we’re seeing now rhymes,” says Honigsbaum, a lecturer at City, University of London. “Strip away the media and social media, all of which didn’t really exist in 1918. Most people wouldn’t really be aware of a thing called Spanish flu until you actually had this mortal wave and lots of people were sent to hospital.”

Customers wait in line to buy water, toilet paper and other supplies, on fears that the COVID-19 coronavirus will force people to stay indoors, at a Costco in Burbank, California on March 6, 2020. Robyn Beck/AFP via Getty Images

“In the initial stages of the 1918 pandemic,the Spanish flu caused a mild illness and relatively few people died. It was only when the flu returned in the fall and large numbers of peope were hospitalized with severe pneumonias that everyone woke up to the threat.”

As of Friday, there were more than 98,000 confirmed cases of COVID-19, and at least 3,380 confirmed deaths. Since its debut in Wuhan eight weeks ago, the virus has infected our psyche, spawning an “epidemic of catastrophizing” that has hammered the stock market, stranded cruise ships, cut oil output, shut down schools and “increased social conflict and xenophobia,” anthropologist and cognitive scientist Samuel Paul Veissière writes in Psychology Today.

“We should pause to remark that COVID-19 is extraordinarily successful epidemiologically, precisely because it is not extremely lethal,” writes Veissière, an assistant professor of psychiatry at McGill University. Ebola, by contrast, “is a rather stupid virus: It kills its host — and itself — too quickly to spread far enough to reshape other species’ life-ways to cater to its needs.”

“The good news is that you will almost certainly not die from,” COVID-19 he adds, though a two to three week respiratory illness, others note, isn’t a merry-go-round of fun, either.

But to appreciate the “full — and very real — power of the coronavirus, we need to enter the rabbit hole of evolved human psychology,” Veissière says.

My gut feeling is that this is what a 1918-style pandemic might look like today

Much of it comes down to a deeply inbuilt negativity bias, the human tendency to focus more on the negative than the positive. There’s an evolutionary reasoning for it, Veissière writes. “Cues that signal the presence of pathogens tend to elicit automatic disgust responses, so as to help us avoid strangers.”

But to him, COVID-19 is as much a cognitive epidemic. Word of a strange, mysterious pathogen from another country is ticking all the boxes, “it’s hitting all the right spots in terms of our mental vulnerabilities,” he told the Post. It colonizes our attention, he says.

Even a name matters, and the WHO appears to have been cautious. “They didn’t call it Wuhan bat virus, which would have been a disastrous name,” says Dr. Steven Taylor, a professor and clinical psychologist at the University of British Columbia and author of The Psychology of Pandemics: Preparing for the Next Global Outbreak of Infectious Disease.

“If you name it after a place, and this is what had been done previously — Russia flu, Hong Kong flu, Asian flu — you’re going to promote discrimination and heighten this fear of strangers. That’s going to raise xenophobia and racism.” Naming emerging infections after animals — dog flu, or swine flu — also causes people to go around needlessly culling animals.

You don’t want to make people overly anxious but you don’t want to play it down

“On the other hand you need to give it a name that conveys to people that this is something that they should take seriously,” Taylor says. “You’re walking a fine line. You don’t want to make people overly anxious but you don’t want to play it down. COVID-19 has a nice sci-fi, neutral name, but it’s easy to see how it could be a dangerous virus with a name like that.”

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“Pandemic” is also an emotionally laden term. It evokes images of the Spanish flu, of hospitals with rows upon rows of the sick and dying, of corpses stacked up. “It’s like setting off a fire alarm,” Taylor says, and, once this pandemic is officially declared, it will only ramp up anxiety.

And efforts to slow community spread — travel restrictions, movement restrictions, quarantines — might exacerbate the psychological problems involved in getting people to behave in certain ways to reduce the risk to themselves and vulnerable others. “When conditions are right, epidemics can potentially create a medical version of the Hobbesian nightmare — the war of all against all,” Philip Strong wrote in a paper on “epidemic psychology” published in 1990.

It begins with fear — “fear that I might catch the disease and the suspicion that you may already have it and might pass it on to me.” Although he was writing about HIV and AIDS, in any novel outbreak “the whole environment, human, animal and inanimate may be rendered potentially infectious,” Strong writes. “If we do not know what is happening, who knows where the disease might spring from?”

As the virus spread, people will no longer associate it with the Wuhan virus. “It will become an egalitarian virus; everyone will have it,” Taylor says. People will remain wary and cautious of strangers, but that caution will broaden and diversify. Some will be wary of healthcare workers, as happened with SARS. “Healthcare workers and their families were avoided, shunned and discriminated against because people in their communities thought they were carrying the infections.”

Strategies to slow down the spread in the community will depend on controlling human behaviour, he says, and getting people to agree to things like self-isolation, when we’re already facing an epidemic of loneliness, or getting vaccinated (should a safe one become available) in an era where vaccine hesitancy is one of the top 10 global health threats.

Some degree of concern is reasonable, Taylor says. It would be reasonable to have a two-week supply of food and necessary medications on hand. It makes sense to wash our hands frequently and be mindful of not touching our eyes after touching surfaces. We should be listening to healthcare authorities. But we shouldn’t be losing sleep over COVID-19.

Influenza patients crowd into an emergency hospital near Fort Riley, Kansas in 1918. The Spanish flu pandemic killed at least 20 million people worldwide. U.S. National Museum of Health and Medicine

The Spanish flu killed 20 to 50 million. We’re unlikely to see anything like that. “Containment at a global level is probably not something that is going to be possible in the long term,” says Greer, of the University of Guelph. It’s possible COVID-19 could become a new, endemic virus that lingers to become just another influenza-like illness. Canadian health officials continue to stress the risk to Canadians is low, and while Honigsbaum says the “keep calm, carry on as usual” messaging may be prudent, “That was the message in Italy, and now they’ve closed all the schools for two weeks.”

“It’s not the zombie apocalypse. You don’t need to go up and fill up your car or stock up with toilet paper, but I think it would be wise to make sure you have ibuprofen and basic medical supplies,” he says. “Not because you might necessarily need them now, but you want to make sure you have them before people panic buy them.

“That’s the kind of bind we’re in.”

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