With so much of the country shut down due to coronavirus, the News-Sun reached out to four experts in their fields to find out their thoughts on the pandemic.
From needing more data to the right approach to squashing the virus, the experts opinions vary but offer insight to what is happening and how it will play out.
The News-Sun spoke with:
• Dr. Craig Rhyne, Covenant health Regional Chief Medical Officer.
• John Ioannidis, Stanford University epidemiologist and co-director of its Meta-Research Innovation Center
• David R. Smith, DVM, PhD, Dipl. ACVPM, Dipl. Epidemiology, Department of Pathobiology and Population Medicine, Mississippi State University College of Veterinary Medicine
• Dr. Ariel Pablos-Mendez, M.D., MPH, professor of Medicine at Columbia University Medical Center, New York and former head of global health at the U.S. Agency for International Development
“I mean, everybody predicts who’s going to be the winner of the Super Bowl by mid-July every year, and we have no more accuracy with that than we do with predicting when the coronavirus will end,” — Dr. Craig Rhyne
“The problem is that we are still flying blind without data,” — Dr. Ariel Pablos-Mendez .
“We’re usually thinking about establishing herd immunity with a vaccine program,” — David R. Smith, DVM
“If the health system does become overwhelmed, the majority of the extra deaths may not be due to coronavirus — but to other common diseases and conditions such as heart attacks, strokes, trauma, bleeding, and the like that are not adequately treated,” — John Ioannidis, epidemiologist
When did the virus arrive?
Some people have speculated that the SARS-CoV-2 (COVID-19) virus did not “just happen” in March, but more likely has been in the U.S. for several months, possibly as early as December or November, because there was an unknown respiratory virus making the rounds with almost the same exact characteristics of the current pandemic.
“There was a round of respiratory disease, that unfortunately a lot of us caught (early in the year),” Covenant Health Regional Chief Medical Officer Dr. Craig Rhyne said. “We will never know if there is any relation whatsoever to the coronavirus with that round of what was presumably somewhat benign viral disease. We weren’t testing, we didn’t know to test, and we were not even aware at that point in time, of the coronavirus, even though it seems like the earlier cases in China were being recognized as early as November.”
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the viral strain which causes coronavirus disease 2019 (COVID-19), and is a respiratory illness. It is known generically as the coronavirus, and was previously referred to as novel coronavirus. SARS-CoV-2 is a positive-sense single-stranded RNA virus and is contagious in humans and other mammals. The World Health Organization (WHO) has designated the ongoing pandemic of SARS-CoV-2 (COVID-19) a public health emergency of international concern.
“If we had not known about a new virus out there, and had not checked individuals with PCR [virus] tests, the number of total deaths due to ‘influenza-like illness’ would not seem unusual this year,” Stanford University epidemiologist John Ioannidis, co-director of its Meta-Research Innovation Center said. “At most, we might have casually noted that flu this season seems to be a bit worse than average.”
“This epidemic is like an iceberg, meaning 80 to 90 percent of the patients you don’t realize because they are so mildly asymptomatic, or it was happening in January or February before we were thinking about it,” said Dr. Ariel Pablos-Mendez, M.D., MPH, professor of Medicine at Columbia University Medical Center, New York and former head of global health at the U.S. Agency for International Development (USAID), appointed by President Obama.
Is herd immunity the answer?
Herd immunity is something that will develop as more people contract the virus. It is something epidemiologists and medical professionals have known exists in any large groups of animals, and is what our vaccination protocols are based on.
“Herd immunity is the concept that is there’s enough individuals in a population that have immunity to some agent, like a coronavirus, that it can’t get established so it dies out,” said David R. Smith, DVM, PhD, Dipl. ACVPM, Dipl. Epidemiology, Department of Pathobiology and Population Medicine, Mississippi State University College of Veterinary Medicine. “That’s the simple concept, but it’s not as easy as that, because for this agent, we think maybe one infected individual might infect on average two or more, and those two infect four or more and it spreads through the population exponentially like that. And, we don’t yet have immunity to it, which is why we see it spread so rapidly around the globe. There eventually will be. Eventually, people will have gotten the infection and recovered from it, and hopefully have some immunity that lasts for some time.”
But herd immunity is usually developed with vaccines, which is why they are important for the entire population.
“We’re usually thinking about establishing herd immunity with a vaccine program,” said Smith, who earned his PhD in researching coronavirus in cattle, acting similar to the coronavirus the human population is currently experiencing as a pandemic. “We know a lot about coronavirus in animals. (In cattle,) it doesn’t cause illness in young, it causes illness in the older of the population of cattle.”
And, until there is a vaccination for it, developing antibodies and developing herd immunity may be the first line of defense in stopping the spread of the virus. Developing a good vaccine for SARS-CoV-2 might be a challenge, because, Smith said we have had difficulty in developing a good vaccine for related coronaviruses like SARS and Middle East Respiratory Syndrome (MERS).
“Herd immunity is not a policy goal, herd immunity is a fact of any viral infection. You don’t see it, you don’t plan it, it just happens,” Pablos-Mendez said. “We do have the experience of H1N1. H1N1 was like this virus in the sense that it ran like the wind across every country in the world for a year — it reached every continent of the world. When it reached over 50 percent of immunity in people, it ended. Not because we did X, Y, or Z, because most countries couldn’t do much, but it was because it infected enough people, it died and caused immunity.”
“We know that some of the people who have recovered from the coronavirus have developed IGM and IGG antibodies,” Rhyne said. We do not know, at this point in time how long those antibodies will persist, so herd immunity is a question that can’t be answered at this point in time because we just don’t have a track record with this virus.”
Both Pablos-Mendez and Smith used measles for comparison examples about herd immunity.
“A good example is measles,” Smith said. “We don’t want measles circulating in the population. We want to vaccinate people so that if measles ever gets introduced it has no where to go.”
“Immunity in individuals accumulates until you reach the level where it begins to block transmission, just like it does for preventable diseases like measles,” Pablos-Mendez said. “Depending on how competitive the virus is will set the levels of herd immunity to block transmission. Basically 60-80 percent need to be blocked before you can end transmission. In the case of measles, it’s close to 90 percent, which is why some people can get away with not vaccinating for measles. When the coverage starts going below that percentage, you start seeing outbreaks again.”
Smith again pointed out that even though medical professionals and veterinarians know a lot about different coronaviruses in animals, a vaccination is not easy to develop.
“It should (be) pointed out that for the many coronaviruses of domestic animals we only have a few vaccines. Even when there is a vaccine, we primarily rely (on) practices to keep the virus out of the population — herd or flock — or to prevent its spread to the most susceptible in the population. This is very much like the social distancing practices taken to decrease the rate of COVID-19 transmission in people.”
Is the data around COVID-19 sound?
Some experts say we can’t remotely guess if closing “non-essential” businesses and ordering, under penalty of law via fines and arrests, people to stay at home is the correct course of action — because most of the models are based on flawed data, or simply not enough data.
“We were completely unprepared for something so devastating. The problem is that we are still flying blind without data,” Pablos-Mendez said. “The testing of the acute cases has been reserved for the sickest patients. What I’ve been suggesting is we also need serology tests measuring blood antibodies two to three weeks after onset of the infection. That’s important because that tells us about whether that individual already had it and is now immune, which would be fantastic for healthcare workers today. We could know for sure if they are already immune, because my expectations is that most of them will be.”
“It’s interesting that you see forecasting models on when the virus will peak, on when the epidemic will peak. No one knows,” Rhyne said. “I mean, everybody predicts who’s going to be the winner of the Super Bowl by mid-July every year, and we have no more accuracy with that than we do with predicting when the coronavirus will end.”
Whether or not the U.S., and individual states like New Mexico are taking the right approach to the pandemic remains to be seen. Some question if it is better to social distance for too long, than not long enough.
“It’s a balance between the economic realities of social distancing and closure of non-essential businesses,” Rhyne said. “The country will have to go back to work at some point in time just to guarantee its survival. It’s a balance between running the risk of having a second wave of infections and getting people back to work so they can pay their rent and buy their groceries.”
But, managing the load on the health system through social distancing could possibly backfire, Ioannidis said.
“If the health system does become overwhelmed, the majority of the extra deaths may not be due to coronavirus — but to other common diseases and conditions such as heart attacks, strokes, trauma, bleeding, and the like that are not adequately treated,” he said. “If the level of the epidemic does overwhelm the health system and extreme measures have only modest effectiveness, then flattening the curve may make things worse. Instead of being overwhelmed during a short, acute phase, the health system will remain overwhelmed for a more protracted period. That’s another reason we need data about the exact level of the epidemic activity.
“(If we’re going to risk the) financial crisis, unrest, civil strife, war, and a meltdown of the social fabric (caused by extreme measures), we need unbiased prevalence and incidence data for the evolving infectious load to guide decision-making,” Ioannidis said.
“We don’t have the full data, but the data suggests that 80-90 percent of cases were not detected by the system, or are asymptomatic,” Pablos-Mendez said. “The lock downs have really been instituted without data.”
Does coronavirus mutate between species?
“For this virus in particular, this is an RNA virus and those are a group of viruses that do mutate relatively easily,” Smith said. “Historically, we think there have been jumps of coronaviruses to other species. For example, MERS, probably moved from bats to camels to people. Even the coronavirus I worked with probably moved from a mouse to cattle sometime in modern history. They do make species shifts. They tend, at the time to be species specific, but they do make shifts from one to another because of mutations.”
And, there are multiple coronaviruses across many species of animals. Pigs, turkeys, cattle, camels, bats, canidae (dogs), feline (cats), and rodents are a few of the species Smith named.
“What you’ll see is often there is a respiratory form of the disease or there’s an enteric form of the disease that causes diarrhea, and sometimes there’s a form that causes both,” Smith said. “This pandemic coronavirus we hear about some people having diarrhea illness along with it.”
Are we taking the right approach?
As to the approach most of the U.S. is taking, in basically shutting down the country, closing small businesses as “non-essential,” and putting people in what is effectively house-arrest, as opposed to actions being taken in other countries like Sweden, where the economy isn’t on shut-down, and only those in “high-risk” groups, like those over 65 or with underlying health concerns, are under stay-at-home- orders. The medical experts have different takes on the subject.
“What we’re doing by all of the social distancing, and washing hands, and all of those things is reducing that number from that on average two people get infected for every individual that gets infected to something less than two. If we could get that number below one the illness would eventually die out,” Smith said. “So, what we are doing is to help reduce the rate of transmission, which is very important, but it does prolong it. As long as there are still susceptibles out there, it will try to find them.”
“Sweden is implementing what I recommend,” Pablos-Mendez said. “95 percent of the deaths occur in people who are over 65 or have comorbidities. Healthy young people do not die from this virus. In China, one child died. In Japan, none. In Korea, none. In Italy, none. In the United States, with reports from the CDC last week, none. The one or two cases in children are being investigated. The one case in China happened because the child had leukemia or some other problem. Unlike the H1N1 virus a decade ago, that in America alone killed 358 children, this virus doesn’t kill children or young people who are healthy.
“Sweden is asking people over the age of 70 to stay home, or people who have underlying medical conditions to stay home, or people who happen to have a cold or pneumonia-like symptoms also to be isolated. But other than that Sweden is allowing young people to go out and keeping primary and kindergarten schools open. Only colleges have been moved to online. Otherwise people are encouraged to keep working, and are only limiting public gatherings of more than 50 people,” Pablos-Mendez added.
Rhyne said the approach most of the U.S. is taking, not counting the states who have not enacted any type of lock down, are more drastic than Sweden, and we won’t know for a while which is better.
“The approach we are taking is far more aggressive than the approach Sweden is taking,” Rhyne said. “Sweden thinks the rest of the world has lost their minds to do all the social distancing and separations that we are doing, closure of businesses, etc. Only time will tell. The accumulated wisdom of the rest of the world is that the social distancing will make a difference in terms of reducing, not the total number of cases, but the rapidity of which those cases spread. I think the Swedish approach of only isolating the elderly and those with comorbidity conditions is an interesting approach, but only epidemiology and a retrospective revue of that approach is ever going to give us the answers as to whether that was reasonable or not.”
“Unfortunately, we do not know if these measures work,” Ioannidis said. “School closures, for example, may reduce transmission rates. But they may also backfire if children socialize anyhow, if school closure leads children to spend more time with susceptible elderly family members, if children at home disrupt their parents ability to work, and more. School closures may also diminish the chances of developing herd immunity in an age group that is spared serious disease.”
“Fact is a public health and stable economies go hand in hand. But in the current COVID-19 response, we have pitted these against each other,” said Pablos-Mendez. “We either save lives by going on total lockdown or we go back to business as usual and sacrifice the lives of those most at risk. I stand for a middle of the road approach: maximize protection for seniors and vulnerable people, while letting the young and healthy with proven immunity to the virus go back to work. In order to do this, we need more data about immunity.”
“Lock downs of the economy, killing the economy, economic shocks, will kill more people than the virus,” Pablos-Mendez said. “This has been shown after the Soviet Union collapse, in many of the Soviet republics, life expectancy went down dramatically. We should not take this lightly, saying, let us lock down because we want to save lives — and I’m a doctor working on the front lines. It would really be shooting yourself in the foot to try to save some lives now, and then these situations that will kill more people are so predictable.”
“It’s difficult to know if we’re doing the right thing, because you don’t know what would have happened had we not taken these measures,” Smith said. “The things that we are doing are certainly slowing the rate of transmission.”
What about South Korea?
“We only were inspired by what South Korea did, and that’s OK, they did a nice job. They started earlier, maybe they caught the epidemic in a small number of people, maybe. Then they stopped it there, fantastic,” Pablos-Mendez said. “The problem with that is that 95 percent of Koreans have not seen the virus, and remain susceptible and the virus can come from anywhere. They don’t have many neighbors, luckily they’re like an island, there’s just North Korea, then they are surrounded by water. So maybe they can get away with having most of their people vulnerable, and just locking up the airports. But if it comes back into South Korea, it will spark the same thing. A lock down only sets the clocks back to December, because as long as there are any cases around the world that can take an airplane, that can go back, they must uphold their lock down. That’s not affordable in economics, or because of the life you loose because of it.”
What about Italy?
“In Italy, they were delayed, like we were, so the Italians believed that because we didn’t do home isolation quickly enough we got a spike of so many dead that you’ve seen,” Pablos-Mendez said. “Italy has 25 percent of its population over 65 versus only 15 percent in other countries. And, 95 percent of deaths are in people over 95 or have underlying medical conditions. So, if you have a lot of that in Italy, and you do, there are a lot more deaths. But because of the scary pictures in Italy, they went to a severe lock down. And, now they have peaked, and the numbers are coming down, which is wonderful, and people are saying, ‘see, the lock down worked.’ The fact is, we don’t know.
“We don’t know whether the lock down would have stopped it, like it did in South Korea, because they were late, but it might be because enough people got immunity in the background. We only can tell if you do serological testing,” Pablos-Mendez continued.
A published study done this week of blood donors in northern Italy, who did not know if they had COVID-19, and were not tested for it, revealed that among those donors 66 percent were sero-positive, meaning they had antibodies for COVID-19 in their blood.
“So in northern Italy, it is because of herd immunity, not because of the lock down,” Pablos-Mendez said. “Those two-thirds blocked transmission to the third that remained susceptible. If the virus cannot find a way to get to the remaining 30 percent of the population, then the virus dies. Which is also what happened with H1N1.”
Will a second wave occur if restrictions are lifted?
And, when the current restrictions that were hastily put in place are lifted, there will perhaps be another wave of infections of the virus, experts say.
“We know re-infections are rare, and questionable when reported, but they may happen. We know, like previous SARS epidemic of 2003 that immunity develops in two to three weeks and that it may last up to two to three years,” Pablos-Mendez said.
An analogy Smith gave was if there is a fire (those infected with the virus) burning very hot, and as people move, they are like embers from the fire hitting new fuel for the fire. Social distancing is like spreading out additional fuel sources for the fire, hoping that by doing so an ember can’t find the next fuel source, and dies out. Some embers will still find some of the spread out fuel sources, and there will be small flare-ups through time, but gets less as time goes on. But, if social distancing stops too soon, all of the fuel source piles back up, and an ember once again reignites the big blaze.
“It’s absolutely unclear at this point in time, if we will have a second wave when the social distancing and the business closures are relaxed,” Rhyne said. “The risk of doing that (lifting restrictions) is that we will experience a second peak of illnesses. But that’s what social distancing is all about. It’s about spreading it out. It’s not about eliminating the total number of cases we’re going to see. It’s about reducing the speed with which those overtake the healthcare system. If we do it right, it will be a manageable second wave.”
“But, unless we measure it, we won’t know where we are of if the lock downs are needed, or working, or when to stop (the lock downs),” Pablos-Mendez said. “The CDC last week approved a serology test, which is simpler than (the swab), and anyone can do it. If we could test all healthcare workers and know they are immune, that would be wonderful. If we could test whether New York has already reached 50 or 80 percent immunity, that would be fantastic so we know that people can go back to work.”
Blake Ovard is the managing editor at the News-Sun and can be reached at managingeditor@hobbsnews.com.
