By Mary Brophy Marcus
Just six weeks ago, almost no one was talking about coronavirus. But by the third week of January, stories about a worrisome illness spreading in China had taken over news cycles across the world. At first, all anyone knew was that it was contagious, causing serious respiratory illness in some and potentially deadly.
When the World Health Organization (WHO) issued their first coronavirus situation report on Jan. 20, they confirmed 282 cases of a novel coronavirus, 2019-nCoV, in four countries including China (278 cases), Thailand (2 cases), Japan (1 case) and the Republic of Korea (1 case). And there had been six deaths linked to it. Now, less than four weeks later, WHO’s day 23 situation report says 45,171 cases have been confirmed and there have been 1,115 deaths, all but one in China.
Seven Duke experts—whose specialties range from global and public health to infectious disease, global health policy and mental health—spoke with DGHI about where we are now with 2019-nCoV, addressing important questions on many of our minds.
What are we dealing with? How would you sum up the current state of the coronavirus outbreak?
Linfa Wang, professor and director of the Programme in Emerging Infectious Disease, Duke-NUS Medical School:
It has spread much faster and wider than originally thought. But the case fatality rate is still lower than severe acute respiratory syndrome (SARS) CRF rates. Although, the total number of deaths will almost certainly exceed that of SARS. The only promising aspect is the slight drop of “daily new cases” more recently, but it is too early to tell whether this will be sustained.
Shenglan Tang, deputy director, Duke Global Health Institute and Mary D.B.T. and James Semans professor in the Department of Population Health Science, Duke University School of Medicine:
Since Jan. 20, the Chinese government has taken this outbreak very seriously. Both the Chinese health sector and the whole society have now prioritized disease control at the highest level. To be honest, I personally think that some of the measures being implemented are too extreme, and an over-reaction, such as community health workers visiting households to measure peoples’ temperatures.
Are there solid public health response systems in place right now in China?
It is difficult to say, as China is a very large country and the socioeconomic development levels in different parts of the country vary greatly. The public health systems’ capacities for handling such an epidemic are different in different locations. Overall, most developed regions or urban cities are going to be more able to handle it compared to less developed regions or the rural areas.
Wenhui Mao, senior research and policy associate with the Center for Policy Impact in Global Health, Duke Global Health Institute:
After the SARS outbreak 17 years ago, the Chinese government started to work on building a more modern public health system. But over time, as far as I know, the funding for the public health system has reduced year after year and a lot of talented people did not want to stay in the system—they found better ways to earn a living. I think capacity in the public health system is also a big problem, and why they haven’t controlled this disease from the beginning. The health sector is imbalanced. The top hospitals have a huge amount of money and the best doctors, but at the primary levels, they don’t have that. So when the government cut transportation to Wuhan, without the proper support systems from the primary healthcare sector, it’s been very difficult to follow up with a systematic approach. Wuhan is a big city and so many people need food, and doctors need to go to the hospitals to treat patients. They need to track cases and help sick patients separate themselves from well family. There are not the supporting methods to support this policy. It’s created a kind of vacuum.
Are strong national health systems all we need for pandemic preparedness?
Gavin Yamey, professor of the practice of global health and public policy and director, Center for Policy Impact in Global Health:
Strong health systems are certainly a crucial foundation for preparedness. All countries, whether rich or poor, need to have a set of core national preparedness capabilities. For example, they need strong surveillance systems in place that can detect infectious diseases with pandemic potential, robust case detection, and effective contact tracing in order to identify and reach people who may have been in contact with an infected person. But that’s only part of the story.
Jonathan Quick, adjunct professor of global health, Duke Global Health Institute, and author of The End of Epidemics:
Over the last 20 years many countries, including China, made considerable progress in outbreak prevention and preparedness. Progress has generally come in bursts immediately following the 2003 SARS coronavirus epidemic, the bird and swine flu outbreaks through the late 2000s, and the 2014 Ebola epidemic. Nonetheless, according to the NTI-Johns Hopkins-Economist Intelligence Unit’s 2019 Global Health Security Index, fewer than 1-in-3 countries worldwide are fully prepared to prevent, detect, and respond to deadly new infectious disease outbreaks. The most vulnerable part of the world remains Africa, which has the largest concentration of countries least prepared for a serious outbreak of the new virus (map below).
Will the new coronavirus soon hit the US as hard as it’s hitting Wuhan, China, the epicenter of the outbreak?
Gregory Gray, professor of medicine, global health, and environmental health. Gray splits his time between Duke University in Durham, NC; Duke-NUS Medical School, in Singapor; and Duke Kunshan University, in China:
We are likely to see our own epidemic of US cases and perhaps a persistence of the virus in human populations for many years to come. If the 2019-nCoV becomes common (endemic) in the US, it will be very hard to control. The viral infections will be similar to the influenza A and B infections we see each winter, except everyone will initially be susceptible and most everyone will become ill. Fortunately, most people (>98%) will weather the infection without the need for supportive medical care (hospitalization).
Should US citizens panic?
Panic will not help us. Not to diminish the outbreak, but one way to look at 2019-nCoV is the way we view preparing income taxes. Each winter we collect our documents and set aside time to prepare our tax return. In a similar fashion we need to prepare for this viral infection. We need to think about what food and medical supplies we will need at home and how we will maintain our lives as best we can through several days of bed rest.
There is no reason to panic. Thus far, the US outbreak is small and well-controlled. Despite the public concern about the new coronavirus, based on current information, it is extremely unlikely that in the U.S., it would develop into anything close to the 2018 flu. The CDC estimates in the U.S. that the 2017-2018 seasonal influenza caused 48.8 million influenza illnesses, 959,000 hospitalizations, and 79,400 influenza-associated deaths. And the annual cost of seasonal influenza in the U.S. is over 90 billion. The seasonal flu vaccine does not fully protect against all flu strains, it nonetheless substantially reduces both the risk of infection and the risk of succumbing to the flu if infected. This is especially true for young children, older people, pregnant women, and those with chronic medical conditions.
Robin Gurwitch, professor in psychiatry and behavioral sciences, Department of Psychiatry and Behavioral Sciences and at the Center for Child and Family Health, Duke University School of Medicine:
When you’re talking about this virus, the story is continuing to evolve. Everyday we’re finding out new information and new ideas about what we should and shouldn’t do. It comes down to two things: stay informed to reduce anxiety and be sure to only turn to sources of trusted information. The Centers for Disease Control and Prevention and the Center for the Study of Traumatic Stress have both put out good guidance around coronavirus. That said, we shouldn’t spend every waking moment checking where it’s spreading. It’s important to take a news break.
How do health officials in countries not yet impacted by the novel virus stall/stop the spread?
The best we can do is hope to slow virus transmission with the hope that medical interventions will be identified in time to keep those most likely to experience severe diseases from dying. We also need to get the message out that when many infections are occurring only those with severe signs and symptoms—people with shortness of breath and severe chest pain, for example—should seek emergency care. It is common for healthcare systems to be overrun by the mildly ill and the “worried well” but those cases can become a barrier for others who need hospital supportive care.
By definition, pandemics cross national boundaries—they are global in nature and they require a global response, not just a national one. A whole set of “transnational” activities, called global public goods, are another critical plank in pandemic preparedness. These require collective funding by all countries. Such goods include developing medical countermeasures like pandemic vaccines, diagnostics and treatments, and stockpiling of medical supplies (including personal protective equipment), and ensuring that there is global “surge capacity” to rapidly scale up production and distribution of vaccines.
As with other airborne viruses, countries rely on established public health control measures. These include vigilant entry screening at air, land and sea ports; testing of all suspected cases; isolation and appropriate treatment for those infected; and tracing of anyone who the patient has come in contact with after being exposed.
How is this new coronavirus the same and different from seasonal flu?
These are very different viruses but have the same strategy and effect—they hijack a healthy person’s respiratory cells, cause respiratory illness, and spread to others.
Just like with flu, good hygiene habits, proper handwashing and sneezing and coughing etiquette, are important to help reduce the spread of illness. It’s the perfect opportunity to talk with your family about good health, to teach children about using soap and water and alcohol-based hand sanitizers, and to make sure you get plenty of rest and eat well. Teach young children how to sneeze into their arm and not to shake hands with someone who just sneezed into their hand.
Is there progress on a vaccine? Can one be made in time to help?
There is a huge race ongoing to make a vaccine for this. The most optimistic estimate is to have a vaccine for trial in three months. It is hard to predict whether it will be in time to help, as it depends how long the outbreak will last.
Who is making the vaccines and are Duke researchers involved?
Safety trials of inactivated vaccines will start soon. I was just drafted to help oversee the safety of one such trial. I suspect most will be funded by the National Institutes of Health in the U.S. I would not expect a safe vaccine to be approved by the U.S. Food and Drug Administration before at least six months.
What type of affect might the new coronavirus have on areas of peoples’ lives that are not health-related?
We are already seeing some of the secondary effects of a pandemic in China. Much misinformation and conspiracy theories have arisen. We are seeing xenophobia. We need to watch out for charlatans promoting miracle cures for personal gain when the alleged cures are worthless, fake vaccines and pharmaceuticals, off-label use of one medicine to fight a 2019-CoV infection when the medicine does not work and will cause more harm to the patient. We will likely see a resurgence of home remedies and what we often call “alternative therapies” which will have little value. We will see a run on health supplies like masks and goggles. We may also see a run on food supplies.
How was SARS ultimately contained? How is this case different?
Quarantine. It’s the most effective and traditional method of containing disease spread. The difference is that for SARS, most cases were severe and easy to detect and trace.
Are there any other tools (like better diagnostics) that could help track and control the outbreak?
Better and wider use of rapid diagnostic tests will certainly help, but it takes time to develop and deploy them.
Are people right to be worried about interactions with people who have recently been in places where coronavirus has been spreading? What’s the appropriate level of caution?
Yes. They should avoid contact with people coming from high risk areas. More importantly, for people returning from high risk areas, they need to home quarantine for 14 days even if there are no clinical symptoms.
What steps would be taken if a case emerges in the US, and more specifically on Duke’s campus?
Immediate quarantine and also quarantine of all close contacts. It is a small sacrifice for the individual, but the greatest help one can offer to society at this time.