New England Journal of Medicine Cuts Through the H

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There is zero doubt that Vice President Mike Pence was correct this weekend when he said that the coronavirus (Covid-19) epidemic was being weaponized by the Democrats to try to prevent the re-election of President Trump. The weaponization comes on two fronts: depressing the financial markets and misrepresenting what the Trump administration is doing in response to the spread of the virus. Both of the attacks, though, rely on one key ingredient–unreasoning fear.

A couple days ago, New England Journal of Medicine ran an editorial titled Covid-19 — Navigating the Uncharted. An editorial in a scientific journal is usually a survey or summary of several articles in an issue that cover the same subject. The critical thing here is that the authors are three of the most respected experts on infectious diseases in the world: Anthony S. Fauci, M.D., who leads the National Institute of Allergy and Infectious Diseases (NIAID). Dr. Fauci has been at the epicenter of every infectious disease outbreak in the US since the AIDS epidemic came on the scene. H. Clifford Lane, M.D., runs the clinical research programs for NIAID. Robert R. Redfield, M.D. is the head of the Centers for Disease Control and Prevention.

The editorial points out that the disease seems to be most prevalent in the elderly and those already ill and that it has yet to be diagnosed in anyone under 15.

The median age of the patients was 59 years, with higher morbidity and mortality among the elderly and among those with coexisting conditions (similar to the situation with influenza); 56% of the patients were male. Of note, there were no cases in children younger than 15 years of age. Either children are less likely to become infected, which would have important epidemiologic implications, or their symptoms were so mild that their infection escaped detection, which has implications for the size of the denominator of total community infections.

The most important takeaway is that Covid-19 is not the bubonic plague and it is certainly not even the 1918 influenza equivalent:

This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively.

While the editorial says that a vaccine should begin Phase 1 Clinical Trials in the spring, the close in solution lies in old-school public health activities:

However, given the efficiency of transmission as indicated in the current report, we should be prepared for Covid-19 to gain a foothold throughout the world, including in the United States. Community spread in the United States could require a shift from containment to mitigation strategies such as social distancing in order to reduce transmission. Such strategies could include isolating ill persons (including voluntary isolation at home), school closures, and telecommuting where possible.

In short, this is the lay of the land. The disease is most lethal to the elderly who are already sick with something else or who are immune compromised. So when it strikes hospitals and nursing homes the results will be ugly. It does not seem to effect children, though children might very well be asymptomatic vectors of the disease. If you do come down with Covid-19 and are otherwise healthy, your prognosis is the same as if you had come down with seasonal flu. The only way we have of combating it at present is by quarantine and by avoiding crowds.

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