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Corona Question Corner

Eric Schneider

In Corona Question Corner (CQC), the Commonwealth Fund’s Eric Schneider, M.D., will answer our more personal questions about coronavirus using his own knowledge of medicine, health care research, and analogies ranging from baseball to bad television. Also, with levity and hope. Have a question for Dr. Schneider? You can submit to [email protected] and, if selected, he will publish and answer (to the best of his ability) your question without disclosing your name or affiliation. We’re all in this together. Please wash your hands before proceeding. 

FINE PRINT DISCLAIMER: The opinions expressed here are not official policy of the Commonwealth Fund. They are not a substitute for medical advice from a health professional, directives from government or public health authorities, or your own good judgment.

Why does the disease seem to be affecting different demographics in different countries? Italy has high fatality rates and Germany has low ones. What do you make of the CDC data reporting that in the U.S. there more severe cases in adults under 50 than were seen in China?

As of  April 7, 2020.

The comparative data we have are all over the map — literally. Case counts, hospitalizations, deaths. Every metric shows wild and weird variation between countries. We also see weirdness within the U.S. between states, but that is not so unusual. Studies from different places reveal different patterns of disease by age and even by different blood types. What explains all these differences?

CQC pointed out recently that this coronavirus doesn’t mutate very much. If the virus is the same everywhere, it can’t be blamed for the differences. Who gets sick and how sick they get must be because of something else. Many factors might cause differences. It could be about people: genetics, vaping habits, screen time, twitter habits, cyberbullying, or their preference for paper vs. plastic at the grocery store. It could be their insurance coverage, copayments, or deductibles, or those doctor visits they were skipping. Or, as the virus is slamming New York City, maybe it’s about social determinants. Like how your nearest subway station may be the best predictor of your health outcomes. Or if you are into climate change, maybe this is payback for degrading the environment. We used to do a lot of that before the BIG SHUTDOWN — you know, back when we had actual carbon footprints.

If we compare the U.S. to South Korea, the difference is very stark. They won several Oscars for Parasite AND vanquished COVID-19. We are wondering if we can keep the future body count to less than seven figures.

Bong Joon-Ho

Okay, okay. CQC can see you are motivated to use science — the method of generating hypotheses, testing them, and falsifying them (aka “shooting them down”) — as a bazooka in your quest for the truth. Karl Popper and CQC are with you. Science rocks!

So, you may be surprised that the experts’ answer is: “It may just be bad luck.” Eureka! That explains everything! Didn’t your mother say once that bad luck comes to everyone who doesn’t listen to her advice? Or was that your dad talking? Childhood was so long ago.

There are different kinds of bad luck. There is the bad luck in that we are fighting an invisible enemy. We should all be wearing x-ray microscope vision goggles. Next, nobody thought to collect the data researchers could use. Data are the lifeblood of science. Without those long overdue test kits, the lifeblood is nowhere to be found. Without lifeblood, those great ideas from research teams just aren’t happening.

Okay. No lifeblood. But there must be data somewhere. This is the digital age and data is the new oil! Americans may not know how to plan, but we sure know how to panic. And when it’s time to panic, we throw everything we have at a problem (including our smartphones, which happen to be within easy reach on the couch). If we don’t spend taxpayer money or have to get off the couch, maybe our smartphones will support the science. Smartphones collect data about our every move.

We also have tech billionaires. Maybe they could finance some really weird pet projects. Like the comprehensive study of the entire global pandemic based on testing everyone who lives in San Miguel county in Colorado. How does the virus affect the 8,000 rich Airbnb owners and ski bums hanging in Telluride? You’ll be dying to know!

The billionaire idea needs work. Still, the smartphone surveillance thing sounds cool and futuristic. But what about George Orwell’s 1984? If the smartphone surveillance is too obvious, wouldn’t people rise up like in Hong Kong last year or like Neo in the Matrix movies. One little red pill and people are wide awake, protesting, shooting stuff, burning stuff, and . . . kissing?

trinity's kiss

But give credit where credit is due. Those smart phones enabled the New York Times to track the virus from a Wuhan seafood market, to a train station, to gate 74 at Wuhan airport, to gate A20 at JFK, to a taxi to Times Square, to a hotel, dinner, and a performance of Cats (which turned out to be showing in Providence, Rhode Island). Then on to spring break in Fort Lauderdale but only after a brief side trip to Mardi Gras in New Orleans. Very cool visuals. All those dots marching like ants. The smartphone surveillance system has other neat applications. Have you seen the leaderboard on social distancing practices? States receive scores based on how smartphones are sloshing around within their borders. And you thought March Madness was cancelled this year!

Those variations in COVID-19 you see out there? Nothing really. Bad luck and early days with not enough data. A pandemic is like horse racing; you can’t tell which horse is in the lead when they first come out of the gate.

Is there any evidence that once you recover from coronavirus you are immune and can’t become infected again? Would a reinfection be less contagious and severe because the body has already created antibodies against the virus? Because viruses can mutate and there is no vaccine yet, I’ve been wondering if immunity (herd or individual) would even matter with coronavirus?

As of  April 2, 2020.

SARS-CoV-2 is a bummer in so many ways. Try to say SARS-CoV-2 really fast five times. It is a tongue twister, assuming you pronounced it once. And SARS-CoV-2 is also a bummer for pangolins.

Pangolin

Pangolins are a misunderstood and aggrieved lot. You thought they were dragons, but experts tell CQC they are anteaters. Apparently they are trafficked by criminals and unfairly smuggled into China. Now, they have been unfairly smuggled into the narrative of our global COVID-19 pandemic. Along with bats, pangolins were indicted as a transmission vector for SARS-CoV-2. (Turns out typing SARS-CoV-2 is a finger twister, too.) People are accusing pangolins of being viral jumper cables. It is true that these adorable little dragons (err, anteaters) carry viruses like coronaviruses, but scientists who know pangolins know they would never hurt a human being. Also — public service announcement — if your car battery dies while you are in isolation, pangolins are not actually very good jumper cables, either.

SARS-CoV-2 has its own special taste-and-lung-destroying powers. But it shares a lot of features with other viruses like Agent Smith.

Matrix Agent Smith

Humans and other vertebrates have been dealing with Agent Smith for millions of years. In humans, nearly all viruses generate an immune response. Our immune systems know a thing or two about surveillance and destruction. One of the cleverest viruses was HIV, the virus that causes AIDS. HIV had a special key that switched off T helper cells. Those T helper cells are sort of like the doorbell video camera that guards the front door to your house. Once T helper cells are knocked out, the rest of the immune system stays on coffee break. It’s as if the 911 operator and the police never got the call from your doorbell. They don’t even know your house is being robbed. HIV is very talented.

But SARS-CoV-2 is not so talented. For more on this, see the New York Times expert roundup. Like other coronaviruses, SARS-CoV-2 generates an immune response in most humans. Sometimes too much of an immune response, resulting in severe illness. But for most people, in the days you start to recover, the virus is already crippled and no longer infectious. You have immunity. And even if that immunity fades after a year or two, you are extremely unlikely to get reinfected right away.

The best news of the week was about the mutation (not to be confused with the arm wrestler The Mutant). When it comes to mutation, SARS-CoV-2 is kind of a dud. Scientists have studied the countless generations of SARS-CoV-2 ancestry seeking long-lost celebrity connections somewhere in the past three months. They report that the virus is pretty much the same worldwide even after traveling through half a million humans. In contrast, influenza virus mutates a lot. Flu needs a new vaccine every year because of those mutation powers. If SARS-CoV-2 doesn’t mutate, COVID-19 prevention might be as simple as one vaccine and done for life! Like an overhyped March Madness team, one and done! That’s good news for all of us. Except maybe for the vaccine manufacturer whose potential future global sales just tanked. But don’t worry, with an outrageous launch price, rebates, and pharmacy benefit manager shenanigans, the vaccine maker will be okay.


By now, you may have “herd” about “herd immunity.” But what is that really? How much herding is good? How much is too much? Aren’t herding and social distancing in conflict?

As of March 31, 2020.

Herds are great. We don’t appreciate how much we draw strength and protection from our herds. Herds are comforting. We gravitate toward herds and mostly follow wherever they go.

Here are some awesome things — and some less awesome things — about herds:

  1. You can get through most of life without too much thought or worry if you follow the herd. Herds can tell us what to wear, what to eat, what shows to watch, which of our social media posts are worthy, and where to spend our vacations. You can even go against the herd and the herd will let you know you did it. Admittedly the herd thing can go south, like when someone calls “fire” in a crowded theater. Stampedes are a bad feature of herds.
  2. Herds have invisible superpowers that lift other responsibilities from our shoulders. Herd immunity is one example. Herd immunity can make even crappy vaccines seem more effective.
herd immunity

Herd immunity was first described in 1923, but it has probably been around since the beginning of life. Before vaccines and antibiotics were invented, herd immunity was our only defense against infectious diseases.

But how does this work? Imagine you are a virus attacking a new population. You win by replicating and infecting as many people as you can. You lose when you can’t replicate any more. Being contagious helps a lot, but that’s not all it takes to win. You can’t make your humans too sick. If too many people get sick too quickly, you lose quickly. You need the humans to do your replication thing and infect more humans. But the humans have strategies too: one is individual immunity. Humans become immune when they recover. Next time you try to infect them, you hit a wall. The other human strategy is herd immunity. As increasing numbers of humans become immune, you have trouble finding nonimmune humans. The herd strikes back! Best of all, once most of the herd is immune, it's game over for you, virus.

We don’t know the exact number, but once 60 percent of the herd becomes immune, the virus can’t spread easily anymore. Think about this: what if all the healthy young people in the herd (roughly 60% of the population) could get the infection and get immunity before the older and chronically ill people were exposed? In theory, our hospitals and health care workers would be back to normal. However, we have also seen that younger people can contract the virus — and sometimes die.

This is a paradox. We would like to build herd immunity quickly, but the only safe path is to protect the vulnerable while we build it. Social distancing protects us from the virus, but it slows development of herd immunity because fewer people are getting infected. So as of now, we are unable to use our herd superpower. But at this point, it is way more important to protect the vulnerable and our health care workers. The herd superpower won’t go away. It will be there for us later in the pandemic.


A photographer at an event we attended two weeks ago was confirmed by testing to have COVID-19. Should we take extra precautions?

As of March 31, 2020.

Photographer at COVID event

Everyone will face this situation eventually. Someone tested positive and we were in the same room at the same time. As scary as it sounds, you only need to worry if you had close contact. Fine, but how close is close? And for how long?

The formal definition of close contact is “within 6 feet of the confirmed case for more than 15 minutes.” Unless you are a supermodel who specializes in close-ups, you probably won’t be that close to any photographer during your lifetime. If you were in the room but didn’t have close contact, you do not need to take extra precautions.

But what if the photographer sat next to you during dinner? In that situation, the usual precautions apply: self-isolate and monitor your symptoms and temperature. If you start to cough, have a fever, or feel malaise, you could call your doctor or nurse.

 

How long can the virus live on surfaces? Or more precisely, since March Madness was cancelled, if I make a shot with my basketball and it swishes, could it get coronavirus on it from someone else's basketball that also swished in before?

As of March 26, 2020.

CQC is at the white board, mapping this complex technical challenge. First, you seem to be skilled if you are not hitting the rim or throwing air balls. If you are an NBA player or your pick-up game involves NBA players, you can easily calculate your risk. Despite a shortage of tests, all NBA players have been tested. If their tests are negative, your net is safe. But if your game does not involve NBA players with negative test results? Call a timeout. What part of basketball does not involve close contact? All team sports have been banned. Even boxing. Especially boxing. Game over!

You say you are shooting alone. Ahh, the basketball version of Bowling Alone. That book documented a decline since the 1950’s in social capital.  Americans don’t gather together like they used to. How ironic that Americans have been preparing for this moment since the 1950s. But no one is an island. Who was on the court before you? Is the virus that causes COVID-19 hanging from the net for dear life while you dribble and set for your shot?

Experts debate whether viruses should be classified as living things or just toxic chemicals. While experts debate whether viruses are alive, let’s go to the journals. A recent study says that for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes the COVID-19 disease can “live” for up to three days on plastic and steel, but only for a matter of hours on cardboard and copper. Although the virus that causes COVID-19 can be detected on surfaces for that long, all coronaviruses are very fragile when stored outside the refrigerator in the open air. A study of another coronavirus, influenza, showed that virus on plastic or steel lost its punch after eight hours. On tissues, cloth, and cardboard, it may be infectious for less than 30 minutes. COVID-19 is not the flu. It is more dangerous if you catch it. But catching coronaviruses from surfaces is much more difficult than you might imagine.

On to basketballs and nets. Most basketballs are made of rubber — a plastic. Nets are still nylon. Nylon is a plastic. And if you hit the rim (you never do, right?), that’s made of steel or plastic. If someone’s ball drops the COVID-19 virus on the rim or net, that three-pointer at the buzzer could be a game-changer in more ways than one. CQC would opt for a one-day timeout between shooters on the court, especially in March when the virus may persist more easily because of cold weather.

By the way, this handy evidence applies to a lot of situations. Pumping gas? Wipe that nozzle between users. Groceries? Wipe down the plastic covered ones before you bring them into your house. Rims and nets? Wipe those only if you are slam-dunking like LeBron!

Lebron James takes dunk shot

Once a person has a positive COVID-19 test, how long are they a risk to infect others?

As of March 26, 2020.

It appears that people who are infected may be most contagious just before symptoms. They may be contagious even if they never had symptoms. A smattering of small case studies suggest that that people with confirmed COVID-19 are unlikely to transmit the virus 10 days after their first symptoms. Whatever virus they shed after their symptoms go away may be crippled by their immune systems. Crippled virus may not infect others. But what if they have no symptoms? The evidence is thin so we have to wait for better data.

Here is one way data can make a difference: South Korea has done more testing of its population than any other country. Findings were surprising. About half of all cases (people with positive test results) were among people under 50 years of age. Most of these younger people had mild symptoms or never had symptoms at all. Note the contrast with Italy, which found more cases among older people. What gives? The Italian picture is what you see when you only test sick people.

Evidence is accumulating that we need to go full South Korea as soon as possible.  If the US ends up with the South Korea trend, closing universities and having working-age adults work from home will have been a brilliant first step. The South Korea experience also implies that in our daily lives we must act as if anyone we come into contact with may be shedding COVID-19 virus. But no need to panic. Just keep washing hands, not touching your face, and staying six feet away from people. Not just from sick people, but from everyone. That is the true mantra of physical distancing (what some call social distancing).


Publication Details

Publication Date: April 7, 2020

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Eric C. Schneider, M.D.
Senior Vice President for Policy and Research, The Commonwealth Fund