By Richard Moskowitz MD
Hunkered down at home like everyone else, I feel blessed and deeply grateful to be able to enjoy the simple pleasure of being alive and well among friends and loved ones, and to share these reflections on the present emergency, what led up to it, and where we may be headed with it. They fall into two general categories: first, it's the real thing, not a hoax; and second, there are plans to make long-term use of it in ways that are both seriously unhealthy and unacceptably repressive.
- It's the Real Thing.
In several respects, the illness we know as COVID-19 resembles and follows the pattern of the generic "flu syndrome" that the United States and much of the world experiences very year, notably in winter, consisting of various combinations of fever, fatigue, weakness, muscle aches, URI symptoms, and/or GI upset, and linked to an array of familiar viruses, including influenzas, coronaviruses, and others, as well as a definite risk of complicating bacterial and viral pneumonias, with tens of thousands of deaths in the US alone, according to the CDC.
These are considered par for the course, and not thought to require any quarantine, extreme social distancing, hand-washing, or any other emergency public health measures, other than the annual flu shot, which is said to be the only thing we need to protect ourselves, despite the facts that
1) the flu vaccine doesn't work well, because influenza viruses are notoriously mutable, even within the same season; and because
2) it doesn't even cover the other viruses responsible for "the flu;" and
3) the new coronavirus is actually more virulent in flu vaccine recipients.
In any case, the illness known as COVID-19 is more dangerous than the seasonal flu in several important respects. First, it is extremely contagious, more so even than the measles, which has an attack rate of nearly 100%, but can only spread by the sneezing and coughing of infected droplets through the air. This new strain of coronavirus remains infective for hours or even days on various surfaces after being deposited by hand contact, and is commonly spread that way as well, onto the hands of those who touch it and then carry it up to their nose and mouth.
Second, to an equally unprecedented extent, this virus very often, indeed most often, produces no symptoms and no illness at all, or one with mild symptoms that never needs medical attention. More so than for any other infectious disease, this means that measuring its true virulence and death rate, and accurately tracing the trajectory of the outbreak, depend on identifying and isolating these asymptomatic and minimally symptomatic cases, especially wherever significant clusters of the illness appear.
Containment has been accomplished quite effectively in countries with previous experience that were well-prepared with adequate testing materials, like South Korea, Taiwan, and Singapore, as well as in small communities, like one in northeastern Italy with a population of 3000, where in response to its first confirmed case an alert microbiologist tested and isolated the entire town, identified a large number of asymptomatic cases, and successfully brought the outbreak to a halt within a few weeks. Even a huge and populous country like China, notwithstanding a delay of several weeks when the government minimized it and tried to cover it up, eventually succeeded in containing the outbreak by enforcing strict quarantine of large segments of the population. In all of these cases, the outbreak lasted about 3 months, and has so far not reappeared since the restrictions were lifted.
The third distinctive feature of the outbreak, which is equally surprising in view of the large majority of cases with very mild symptoms or no symptoms at all, has been the relatively small number of cases requiring hospitalization among children and healthy adults, and with deaths observed predominantly in the elderly and those weakened and immunocompromised with pre-existing chronic diseases, especially in nursing homes and extended-care facilities with residents in close contact.
A related finding is the distinctive "ground-glass" appearance of the lungs in many fatal cases at autopsy, with bronchioles and alveoli completely occluded by thick, tenacious mucus, which may help explain their often remarkably sudden deaths, sometimes with no advanced warning, even when the clinical picture had actually been improving. A fibrosing pneumonitis has also been identified as a chronic complication in some of those who survived.