SARS-CoV-2

From a virologist at Stanford studying / trying to solve coronavirus. Feel free to share.

As promised, this post is going to be much more in depth—and LONG. Feel free to skip the paragraphs and jump to the bullets, but I’d urge you to read completely if you have the time.

The main reason why I became a PhD virologist, having spent the last 13+ years studying RNA viruses like influenza, is precisely because of where we now find ourselves. The world has a short memory and we are woefully unprepared for a real pandemic. In my current job as a research scientist in the Glenn Laboratory at Stanford Medicine we are actively thinking about new virus targets, and designing and testing new antiviral drugs against SARS-CoV-2. I am thinking about this pandemic professionally and personally.

That said, I am not the last word on CoV-2. I beg that you all follow the reputable sources I’ll link to at the bottom of this post so you can stay up to date on the pandemic. Sadly, given this administration’s misinformation and censoring campaign, I can no longer recommend the CDC website for a complete accounting of the outbreak.

There are many qualified public health officers/scientists/ physicians and journalists out there compiling/publishing/ analyzing the data I will present below. Some of us disagree with each other. Most of us do not. Keep in mind that the growing pandemic is a moving target for analysis. There is a din of noise surrounding the CoV-2 outbreak, and I have held back for this long since I didn’t want to add to it. Given the disastrous response from our government and the lack of consistently accurate information being given to the public—I feel compelled to weigh in.

First, the good news: while devastating, this pandemic is more akin to a dress rehearsal awaiting the big show—that show being a virus that is both highly infectious and highly lethal, like a super-transmissible avian flu. Thankfully, SARS-CoV-2 is not that virus. But that doesn’t mean it won’t be destructive nor that it won’t have far-reaching consequences.

The U.S. had a chance (months, in fact, of chances) to get in front of this crisis but squandered it. What could have been managed—or at least mitigated—is now truly snowballing. From not making test kits early enough to a total paucity of testing, the inadequacy of med supply stock piles, the 2018 dismantling of pandemic preparedness funds/agency, and finally to the absolutely abhorrent misinformation machine and total ineptitude that is our own president and the administration that protects his interests over ours, we are now in a worsening crisis of at least part of our own doing. But we’re here now, so what’s actually happening out there and what does it mean?

I’ve now had multiple iterations of the same conversation with many people wanting to know what’s real vs not regarding the CoV-2 pandemic. Here’s my bullet points:

• SARS-CoV-2 is the official virus name. COVID-19 is the name of the disease it causes.(e.g. how HIV causes AIDS)
• CoV-2 is predicted to eventually infect most of the world’s population within the year, and therefore has a high probability to seasonally recur. Best guess in the pub health community is 60-80% of the population will be infected, meaning ~4B eventual infections.
• Case fatality likely to be ~ 0.7%, probably closer to 0.5% and no more than 1%. The current fatality numbers being reported are skewed high and premature. We don’t have an accurate picture of the denominator, ie how many people are actually infected. Right now, the bulk of people getting tested are those that have more severe disease. Countries that are testing widely, like S. Korea, are catching many more positive cases that show little-to-no symptoms. Currently S. Korea’s fatality rate is around 0.7%. This likely represents the upper end of what we can expect. Italy’s fatality rate is higher, despite broad testing, but they are also burdened with an older population that has high comorbidities. Same with numbers coming from cruise ships. Most scientists believe actual fatalities to be below 1%. Note: that is still 10x worse than seasonal flu.
• Taken together, the first two points mean that within the year if we do not take more drastic measures now, we can be looking at ~40M deaths. This is not an alarmist number, but a real one. Fatalities will decline rapidly once herd immunity takes place (ie, once most people develop immunity) and successful antiviral interventions come about, including a vaccine, but these won’t be available for the current wave nor the next wave.
• The soonest we’ll likely see a vaccine ready for distribution is 1.5 years from now.Importantly, this means we’ll have at least one additional CoV-2 wave before we have a vaccine/prevention strategy. Some say they can get vaccines out within the year, but given the labor-intensive manufacturing, safety and efficacy testing, production, distribution, etc, I think 18mo or even longer is a safer bet.
• CoV-2 is not like the flu. There are some similarities in terms of transmission method, overlapping of symptoms, and the potential to turn into a seasonal occurrence, but these two viruses are very different.
• 0.6%-1% fatality is still multiple orders of magnitude larger than flu’s (~0.1%). We have antiviral drugs and vaccines to help manage influenza; we currently have none for CoV-2.
• If CoV-2 becomes seasonal, we’ll have the additive effect of flu’s yearly morbidity and mortality plus CoV-2. Our healthcare system as it stands now, is not equipped to handle this.
• There’s quite a bit we don’t know about CoV-2, which makes it dangerous. We don’t know if you can build a lasting immune memory to the virus or if you can be reinfected (some scientists are now saying they believe this to be true, but it remains to be shown); if the virus will mutate to a more/less aggressive form; if it’s able to infect other species in addition to humans; why it spares children but is so lethal to elderly, and if this can change; how immuno-protective the vaccines will be, and whether they’ll need to be redesigned yearly like flu vaccines; etc.
• This is also NOT like the 1918 flu pandemic.There we didn't have many of the basic medical interventions, much less antibiotics etc, that we have today. And the 1918 pandemic was much deadlier (~3%).
• Those most at-risk for COVID-19 should take social distancing to the extreme now (persons 60 yrs above and persons with comorbidities). This means no travel, avoiding public spaces, avoiding physical interactions, no gym or exercise classes, extra diligence on hand washing, etc. This applies both to folks in the current outbreak hotspots like the Bay Area and Seattle, as well as to all the at-risk folks in the U.S. and elsewhere.
• Persons under 20 years old, particularly kids and infants, are uniquely resistant to the disease. There are lots of hypotheses why this is the case, but as it stands now, no healthy adolescent or child has died or even had severe disease due to CoV-2. They are, however, still getting infected. Because kids are messy, touch all sorts of things, and congregate with lots of other kids/parents/grandparents, they make for great virus vectors to transmit the disease. This is why closing down schools is so important.
• The “80% will experience mild disease” is a misnomer. Imagine the worst flu of your life, but you recover without med assistance: welcome to "mild disease." Medically, mild cases are any that you recover from at home. It’s true that some demographics, like healthy adults and esp young kids, are likely to experience few to no symptoms at all, but I also wouldn’t count on just getting the sniffles or a mild fever either.
• Everyone should employ at least some form of social distancing for the foreseeable future.Because we don’t have vaccines/therapeutics to help stop the disease, the best thing we can do is limit its spread by not giving it new hosts for transmission. We do this by limiting our exposure to other people. It’s a pain in the ass. Your life is going to change dramatically. Schools will and should close. Public events should be cancelled. Everyone where possible should work from home. Social distancing is an industry killer, but right now, it’s the only tangible and proven means of mitigating the public health impact. We do not want to be in Italy’s position of rationing access to ICU care because there are more patients in acute crisis than beds/resources available. Social distancing gives the healthcare system more time to “flatten the curve”
• Finally, for every # of people infected you hear reported in your area, you can safely multiply that number by 10x to 40x to get the real picture. In the bay area we have 200+ confirmed cases--best guess is we're actually closer to 5,000 or more.

And despite all of the above, if you suspect you're sick with CoV or someone you know is, I still don't know how to help instruct you on where you can get tested or even if you can get access to testing at this point. That's seriously fucked up. The U.S. is so far behind the world in this respect, it's reprehensible. So yeah, SOCIAL DISTANCING people.

The above is a lot to take in. I want to stress that it’s not time to panic. Most of us will get through this unscathed, but inconvenienced. CoV-2 will likely recur and we will see this virus again and again. Let’s get our shit together during this first pass, so we save ourselves and our resources for the next round.

My CoV information go-tos:

1. Johns Hopkins Center for Systems Science and Engineering, global map with current cases presented in a dashboard format: https://gisanddata.maps.arcgis.com/…/opsdashboa…/index.html…
2. Daily COVID-19 reports published by the WHO: https://www.who.int/…/novel-coronavirus-2…/situation-reports
3. The European Centers for Disease Control and Prevention: https://www.ecdc.europa.eu/en/novel-coronavirus-china
4. New England Journal of Medicine and The Lancet are great for more about the virus and disease itself.

Finally, The Washington Post, The New York Times, and The Atlantic are all doing solid work on the reporting front.

Stay safe and stay sane, friends,
Rachel
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Rachel Hagey Saluti, PhD
Research Scientist
J. Glenn Laboratory
Stanford University School of Medicine
(512) 797-2596 || rhagey@stanford.edu