Over the course of this past week, California has emerged as one of the two west coast epicenters for community transmission of COVID-19 (the "novel coronavirus") ─ community transmission means spread of the virus is not linked to travel or close contact with an infected person. The other U.S. epicenter is Washington state, where at least nine people have died as a result of the virus, for a U.S. total death count of 11 people by Wednesday evening.
The number of cases related to community transmission is increasing daily, and reports now indicate the novel coronavirus has spread to both the east and west coasts of the United States. However, public health officials are careful to caution against panic, arguing that there is no empirical evidence to support a conclusion that the virus will spread rapidly across the nation. For the most part, public health officials argue that spread of the virus has been largely contained, for now.
The World Health Organization (the "WHO") notes that since the novel coronavirus was first detected in Wuhan, China in December 2019 it has spread to more than 62 countries, sickened more than 100,000 people, and killed more than 3,000, including nearly 2,850 known deaths in China. However, the WHO also points out that in 55 of the 62 countries where the virus has been detected, the number of reported cases is fewer than 100. Only four of the countries report more than 1,000 cases of novel coronavirus; and 90% of all known cases are in China.
Public health officials also observe that the coronavirus suffers from a low fatality rate. The U.S. Center for Disease Control (the "CDC") states the virus has a fatality rate of approximately 2% ─ considered low compared to other coronaviruses like SARS and MERS, which have case fatality rates of approximately 11% and 35%, respectively, but higher than influenza (0.1%). The 1918 flu pandemic had an unusually high fatality rate of around 2%, killing more than 50 million people worldwide including more than 675,000 in the U.S. Thus far, the novel coronavirus appears to be more contagious than most strains of the flu, and roughly as contagious as strains that appear in pandemic flu seasons.
Each person with the coronavirus appears to infect 2.2 other people on average; however, that estimate is skewed by the lack of initial management of the outbreak. By comparison, the infection rate for the seasonal flu is approximately 1.3.
It remains unknown if the novel coronavirus fatality rate will increase or decrease, as more must be learned about the virus, the way it spreads, and the rate of infection. If the actual infection rate turns out to be quite high, for example, then it may mean that the fatality rate of the virus is much lower, and closer to the influenza rate of 0.1%.
One thing that is understood is that like with other illnesses, patients 65 and older and patients suffering from other illnesses are more likely to succumb to the novel coronavirus. One other important difference: while the flu can be dangerous to children, particularly very young ones, children infected with the novel coronavirus tend to have mild or no symptoms. Whether the novel coronavirus poses a serious threat to pregnant women remains unknown at this time. In any event, the vast majority of individuals who contract the virus will experience mild to moderate symptoms, and the course of treatment will be to remain at home and treat symptoms similar to how one would treat for a severe cold or influenza. Data from China suggest that of novel coronavirus patients receiving medical attention, 80% had mild infections, 15% had severe illnesses, and 5% were critical.
To date, the U.S. has been able to keep its number of confirmed COVID-19 cases low by detecting, tracking and isolating cases through travel restrictions and quarantines. According to the CDC, however, with a growing number of countries experiencing community spread of the illness, successful containment at the nation's borders is no longer feasible. For this reason, federal and state agencies are declaring states of emergency to accelerate containment procedures and to offer public assurances that the novel coronavirus is receiving attention of government leaders.
On an individual level, the best way to be prepared for any potential outbreak of the novel coronavirus is to be educated. In the interest of public health, and to avoid unnecessary concern, the City Manager's Weekly offers this Special Report, not as medical advice, but as basic information about the novel coronavirus so that you can separate fact from fiction and make decisions that are to the best interests of you and your family.
What, exactly, is the coronavirus?
Coronaviruses, named for their crown-like shape, are a large family of viruses common to many species of mammals and birds. On rare occasion, animal coronaviruses can evolve and spread among humans, causing respiratory tract infections that are typically mild, with cold-like symptoms, though rarer forms such as SARS, MERS and COVID-19 can be lethal or cause more complicated lower respiratory tract infections, such as pneumonia or bronchitis. The virus at the center of the latest outbreak, the COVID-19, is being referred to as a novel (new) coronavirus because it was first reported in late December 2019, following the tracing of a pneumonia outbreak in Wuhan, China, to the virus. The novel coronavirus has a 96% similarity to a bat coronavirus, so an origin in bats is widely suspected.
Because the virus is new and public health officials lack significant medical laboratory testing and Point-of-Care Diagnostics (PCD), medical professionals have little insight to offer at this time on patient treatment. PCD or Point-of-Care Testing, defined as medical diagnostic testing at or near the point of patient care, is generally considered essential to developing sound medical treatment. Until the nation's public health officials have more exposure to patients, the life cycle of the infection, patient responses, and approved courses of treatment, the CDC advises that individuals with respiratory illnesses should seek out medical professionals for proper diagnosis and treatment.
What are the symptoms associated with the virus?
Patients with COVID-19 have reported symptoms similar to other respiratory illnesses, including mild to severe symptoms of fever, cough and shortness of breath that typically begin two to 14 days after exposure, the CDC reports. Sore throat and diarrhea have also been reported in some patients. Many patients with severe complications from the virus have pneumonia in both lungs, although it can be present even among patients whose cases are not severe. For many, however, the symptoms may be so mild that medical attention is not sought. Antibody tests, which can determine if a person is infected, are under development.
The CDC is asking those with symptoms and a recent travel history to China or other countries with a high number of cases to call their health department for advice before seeking care. If you can’t reach the health department, call your health care provider before going in. The CDC also has tips for what to do if you become infected with COVID-19.
How is the virus medically treated?
There is no specific antiviral treatment for COVID-19 at this time, just relief from symptoms. However, the CDC is conducting a clinical trial to test the safety and efficacy of the drug remdesivir as a potential treatment in adults with COVID-19.
Is a coronavirus vaccine under development?
Scientists at the National Institutes of Health (NIH) and elsewhere have been working on developing a vaccine for COVID-19 since Chinese health authorities made the genetic sequence of the virus available. However, the CDC and public health officials caution that a vaccine is likely more than eighteen months away, at minimum, from being available to the public. Even under an accelerated testing program, the National Institute of Allergy and Infectious Diseases (NIAID) reports that months long clinical trials are required to determine a vaccine's safety and efficacy in people. If the vaccine proves safe and effective in the trials and is rushed through regulatory processes, it will still need to be mass-produced, which will likely add several more months to the timeline.
After viral infections, people generally develop antibodies in their blood that will help fight off future reoccurrences of the virus. However, immunity can wane, and it may be necessary to receive seasonal vaccines. There is currently no approved anti-viral vaccine for the novel coronavirus. An experimental vaccine is under development, but it may take 18 months or longer before it is available for use. In comparison, the flu vaccine, which is widely available, generally has a 40% to 60% efficacy rate.
Will a flu shot provide protection from the novel coronavirus?
There is no evidence that the flu shot or the pneumococcal vaccination will provide any protection from the coronavirus, according to the CDC; however, these vaccines should not be avoided. Adults should receive the flu shot annually to increase chances for staying healthy during the winter season ─ remaining healthy will improve a person's chance to combat the virus in the event of infection. Furthermore, the CDC estimates that the flu was responsible for 34,200 deaths in the 2018-19 flu season. Avoiding the flu also lessens the burden on the health care system, allowing it to focus on dealing with a potential COVID-19 outbreak.
How is the coronavirus spreading?
U.S. Health officials are still trying to understand how COVID-19 is spreading among the general population. What experts do know is largely based on what is known about similar coronaviruses. When person-to-person transmission occurred with Middle Eastern respiratory syndrome coronavirus (MERS-CoV) and severe acute respiratory syndrome coronavirus (SARS-CoV), respiratory droplets from coughs and sneezes from an infected person were the likely culprit, according to the CDC. Those droplets, the CDC says, can land in the mouths or noses of nearby people or be inhaled into the lungs.
It may be possible to get COVID-19 by touching a contaminated surface or object and then touching your mouth, nose or eyes, but this is not thought to be the main way the virus spreads, according to the CDC.
The CDC now considers that it may be possible for an infected person to spread the virus before exhibiting symptoms; however, people are thought to be most contagious when they are sick with the symptoms of the virus.
What is the best way to avoid contraction of the virus?
According to the CDC, the best way to prevent the spread of COVID-19 is to avoid exposure. This is why the CDC recommends against trips to China, South Korea, Italy, Japan, Iran and other countries where the virus is rapidly spreading. The CDC has also heightened travel warnings for areas with sustained community transmission.
Health officials also advise taking everyday steps that can prevent the spread of respiratory viruses.
- Wash your hands often with soap and water (scrub for at least 20 seconds), and use alcohol-based hand sanitizer when soap is not an option;
- Avoid touching your eyes, nose and mouth with unwashed hands, and;
- Steer clear of sick people;
- Stay home when you are sick, and clean and disinfect frequently touched objects and surfaces.
Who is most at risk to the virus?
Early data appears to indicate that older, unhealthy adults are being hit particularly hard by the coronavirus. The majority of people who have died from the disease are over age 50, according to information from China’s National Health Commission; and a study in the New England Journal of Medicine that analyzed the first 425 people with the virus found that the median age of patients was 59.
The CDC reports the following two reasons for susceptibility by older adults:
- They are more likely to suffer from underlying conditions that hinder the body's ability to cope with and recover from illness, such as chronic obstructive pulmonary disease; and
- As humans age the lungs become less resilient and less elastic, contributing to increased inflammation and loss of airway and respiratory function.
The CDC offers no additional or special health advisories for older Americans other than to use normal commonsense hand-hygiene etiquette.
Is the use of facemasks effective?
Snug fitting facemasks may offer a minimal level of protection, but only when properly worn. Facemasks with respiratory valves are more effective than regular paper surgical masks. The Food and Drug Administration (FDA) states that if a facemask is to be worn, a snug-fitting N95-type respirator blocks large-particle droplets and most small particles that are transmitted by coughs and sneezes. However, no facemask, including a properly fitted N95, should not be counted on to eliminate risk of illness. Furthermore, facemasks are not designed for children or for people with facial hair. If a facemask is to be worn, the FDA cautions that they must be worn with meticulous care, and users must avoid putting their hands underneath the mask or doing anything that would contaminate the face and eyes. The CDC advises that there is no need for the public to wear facemasks. Furthermore, depleting facemask supplies now will only make preventive efforts more complicated if the virus spreads in U.S. communities.
Will handwashing reduce the risk of exposure to the virus?
According to the CDC, the most effective way to reduce risk for a respiratory illness or infection is with proper hand hygiene. Hands should be washed before eating, after using the restroom, and after leaving a crowded place. The CCD recommends scrubbing hands often with soap for at least 20 seconds, and using a hand sanitizer that contains at least 60% alcohol when soap and water are not an option. Also, the CDC points to the importance of good sleep and a healthy diet to help stay in front of illness.
Should travel plans be revised?
Because the risk of COVID-19 spreading throughout the U.S. community is low at this time, the CDC advises that there is no reason to fear or halt domestic travel plans. This advice could change, however, if COVID-19 begins spreading at the community level in the U.S.
Individuals with international travel plans should visit the CDC's Travel Health Notices page for any precautions and travel alerts related to a particular destination. Because the situation is constantly changing, travel advice should only be obtained from credible sources, such as the CDC and the WHO. Stay informed, but do not panic.
The WHO and the U.S. government have declared the coronavirus outbreak a public health emergency, and federal officials are warning Americans not to travel to certain countries, including China and South Korea, due to their high number of COVID-19 cases. The CDC also is advising travelers headed to Iran, Italy and Japan to exercise increased caution. The agency issued a Level 2 travel alert for these countries on February 24, 2020, as they are experiencing sustained spread of COVID-19. Older adults and people with chronic medical conditions should consider postponing nonessential travel to these destinations, according to federal officials.
The CDC says that other areas with apparent community spread of the coronavirus (meaning cases are occurring without a known source of exposure) include Singapore, Thailand, Taiwan, Hong Kong and Vietnam.
If travel to a country that’s experiencing a spike in coronavirus cases is necessary, the CDC recommends washing hands often, avoid contact with sick people, and avoid touching your eyes, nose and mouth with unwashed hands.
The U.S. government is also encouraging citizens to reconsider travel by cruise ship to Asia. According to the State Department, those planning cruises to other international destinations should be prepared for strict screening procedures, even disruptions to travel itineraries. Passengers planning cruise vacations should contact their cruise line companies directly on the current rules and restrictions.
The decision to take or not take a vacation is evolving, as the virus spreads globally. In the end, it is up to the individual to decide what their personal risk preference is. In the end, the CDC advises that the following factors should be considered:
- Where are you going?The CDC advises against “nonessential travel” to China and South Korea (Level 3 warning). When it comes to other countries, the answer is less clear.The CDC has grouped Japan, Italy and Iran into its Level 2 category, and advises practicing enhanced precautions, which includes avoiding contact with sick people and frequent, thorough handwashing or sanitizing. It adds that older adults and those with chronic medical conditions should consider postponing all nonessential travel.All travelers should routinely check country-specific risk-status updates at the CDC, WHO and U.S. State Department websites.
- Is the trip covered with travel insurance?Travel experts recommend “cancel for any reason” (CFAR) coverage to avoid concern over the global spread of the virus. According to creditcards.com, regular travel insurance, including the kind that comes free with some premium credit cards, will not cover cancellations based on fear, worry, or concern.A CFAR policy will usually add about 50% to the price of a basic trip cancellation policy, and average 4% to 10% of a trip's cost. Most insurers require travelers to purchase policies within 21 days (sometimes within 7 or 14 days) of paying for their trips.If an uninsured trip is booked further out, the traveler can either hope for an improved situation or anticipate that the trip may be cancelled by the travel provider, in which case travel funds would be returned.
- Consider providers with no-fee cancellations.JetBlue is suspending change and cancellation fees for flights booked between February 27 and March 11, 2020 for trips completed by June 2020 — even though it serves areas only in the Americas, which are still not heavily affected by the coronavirus.In addition, some cruise lines are relaxing their cancellation policies.CruiseCritic.com has a full, updated list of cruise lines’ coronavirus-related policies.
Risk takers, on the other hand, may find exceptional deals and upgrades, particularly in Asia and Europe. France's Finance Minister, for example, reports that the country has had 30% to 40% fewer tourists since the coronavirus was identified among the French population in January 2020. If an epidemic does start to spread across the United States and other parts of the world that are now relatively unaffected, worries about international travel may then become a nonissue because if the virus is in communities all over the world, then risk from travel would no longer be of concern.
Are pet populations a source of the virus?
The CDC says there is no reason to think that any animal or pets in the U.S. might be a source of infection for the novel coronavirus. Nonetheless, the CDC cautions that it is always a good idea to hand wash with soap and water after coming into contact with pets to protect against various common bacteria such as E. coli and salmonella that can pass between pets and humans.
Is there reason to be concerned about packages and products from China?
Both the CDC and the WHO say there is currently no evidence to show the virus can spread through non-food packages and products shipped from China, South Korea or other countries.
What can the public do to prepare for an outbreak?
- Business and schools can prepare contingency plans and communicate those plans to students, parents and guardians.
- Employees can speak to employers about telework options.
- Adult children can consider options on how to care for elderly family members and friends.
- Patients can speak to their doctors about how to prepare in the event of infection.
- People who are sick should consider self-isolation to avoid contracting or spreading the novel coronavirus.
- People with chronic illnesses can prepare to have a three-month supply of medications on hand.To avoid shortages, stockpiling other supplies is not recommended.
- Practice good hygiene by washing hands regularly throughout each day using soap and warm water.
- Follow the expert advice and guidance of the CDC and local public health officials.
- Do not become panicked.
- Do not listen to rumors and conspiracies, and listen only to trustworthy news outlets.
- At the first sign of fever or respiratory illness, see your doctor.
What are health officials doing to prepare for an outbreak?
In the absence of a vaccine to prevent COVID-19 or medication to treat it, the CDC is preparing for an outbreak with non-pharmacological interventions. What these interventions look like at the community level will vary, depending on local conditions and the potential or real spread of the virus.
- “Social distancing” — avoiding crowds and staying home when you are sick — will likely be one of the top strategies recommended by public health officials. Depending on the severity of the situation, communities may see school closures, an increase in teleworking, and the cancellation of mass gatherings.
- In the health care setting, hospitals may need to triage patients differently, and providers may need to increase tele-health services and delay elective surgeries, according to the CDC.
- Employers may want to consider tele-working as an option, where practical.
- Parents and guardians can check in with school systems about plans for tele-schooling.
- The CDC has issued guidance for health care providers, and state and local health departments are working to make sure hospitals and clinics have what they need to limit the spread of the illness.Plans to distribute more testing kits at the local level are also under development. Testing kits from the CDC arrived last week in California.The testing kits will be used to help California medical experts to identify and treat COVID-19 cases, trace potential exposures, and better protect the public.The new testing kits replace previously flawed kits sent to the state.Guidance protocols will not allow for testing of patients without travel history to affected world regions.
- To accelerate testing capabilities, the U.S. Food and Drug Administration (FDA) announced this past Saturday a policy allowing certain laboratories to use tests they developed and validated before the FDA has reviewed them.The CDC is implementing testing guidelines that will expand the number of labs that can test for the virus.
- Because the COVID-19 virus is now found in over 50 countries, the CDC has revised its containment strategy, recognizing that quarantine and travel restrictions are no longer effective containment tools.Initially, the strategy was effective in delaying disease transmission in the U.S.; but with recent reports of community transmission, the CDC now believes the virus may be found in people with minimal or no symptoms and that asymptomatic people can be contagious.Because it is unknown if the trajectory of the virus will be mild, moderate or severe, the CDC cautions that Americans should plan for "disruption to everyday life, similar to what has occurred in China, Japan, Italy, Iran, Korea and a growing list of countries with significant numbers of infected persons.Mass gatherings may be postponed or changed, conferences and sporting events cancelled, schools and employment centers may see an increase in telecommuting, and public health organizations may begin treating the virus as a severe form of influenza.
Is Congress taking any steps to deal with the outbreak?
Yesterday, the House of Representatives passed an $8.3 billion emergency coronavirus package to tackle the potential of a spreading epidemic. The Senate will take up the bill for a vote today, and the President is expected to sign the bill into law by week's end.
The bill includes $7.7 billion in discretionary spending to bolster vaccine development, research, equipment stockpiles and state and local health programs assistance, and far exceeds the Trump Administration's earlier request for $1.25 billion. The bill includes the following funding measures:
- $400 million would be transferred to state and local governments within 30 days following enactment, with each state receiving no less than $4 million to help combat spread of the virus.
- $490 million in mandatory spending would be used to lift constraints on Medicare's payments for telehealth so beneficiaries can freely consult their doctors remotely, avoiding hospitals and physicians' offices where they might risk exposure to the virus.
- $3.1 billion would be provided to shore up medical supplies and supplement the Strategic National Stockpile.
- $100 million would be used for community health centers.
- $826 million would go to the National Institute of Allergy and Infectious Diseases for the development of coronavirus vaccines, treatments and tests.Americans would have access to the vaccine regardless of their ability to pay.
- CDC would receive $2.2 billion, including $950 million to support the response efforts of state and local health agencies.
- $61 million would go to the Food and Drug Administration (FDA) for vaccines and other efforts to counter the virus, keeping up with shortages in medical products, and boosting U.S. manufacturing for those items.
- $1.3 billion would be used to assist the U.S. Agency for International Development to aid in the global fight against the novel coronavirus, including raising the cap from $10 million to $100 million for emergency evacuations.
- $20 million would go to the Small Business Administration to increase the number of loans given to businesses affected by the outbreak.
- $136 million would be used to replace funds transferred by the Trump Administration from other accounts to be used in the early stages of the coronavirus response.
The federal government must still determine levels of coordination across all 50 states, territories to ensure enough test kits are available, and that proper diagnostic protocols are followed.
The CDC acknowledges that during the outbreak of a new virus, there is a lot of uncertainty. Guidance and advice will likely be interim, fluid, and subject to change as health officials learn more. For these reasons, employees and community members should regularly visit the CDC Coronavirus page for updates on the novel coronavirus.