I’ve made my pleas for a humanitarian response to the outbreak in China but have not underscored the reasons for serious concern. Here I outline the realities we are facing, what we know, what we don’t yet know, and why we will know much more in two weeks.
- This virus cannot be modeled on past outbreaks of SARS. We know that compared to SARS this virus has vastly outstripped the increase in the number of cases by at least an order of magnitude if not more.
- The symptoms of infections of this virus are atypical of other SARS-like coronaviruses.
- There could be a 5-7 (or even up to 14, per CDC) day asymptomatic period, during which the thousands of individuals who traveled out of China would have had time to interact with and infect tens of other people, meaning tens of thousands of people would have been infected before the end of January.
- These people are now beginning to experience
- Dry Cough
- Fever
- Shortness of breath
- Nasal congestion
- After a few days they will experience
- Fatigue
- After a day or so more they may experience
- Nausea
- Vomiting
- Abdominal pain
- Loose stools
- You can hear Dr. John Campbell review some individual cases in detail in this useful video:
- In the critical phase, some patients begin to recover and feel better, only then to crash and become critically ill with low oxygen levels, eosinohilic and upper and lower lung pneumonia due to cellular death in the alveoli (grape-like clusters of air sacs in the lungs).
- Today on 2/6/2020, clearly those people would have had a chance to interact with tens of people each, potentially infected hundreds of thousand of people, who will in five more days’ time.
- Around the time that these individuals begin to present symptoms, some of the first cohort will be entering the critical phase of the disease. At this time, no one can predict who will progress and who will not. Originally reports from China were that the elderly and the immunocompromised were the only persons dying. Now, it’s clear that there is not any clear age-associated risk.
- Take, for example, the case of Dr. Wenlian Li.
Dr. Li’s report in December led the nation of China to take the SARS-like coronavirus theory seriously. He was harassed by local police and made to sign a retraction. But national government agencies took his warning serious and Li returned to work to help care for patients, and became infected. Dr. Li died today; he was 33.
Details from late January in this article reviewing clinical presentation:
https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)30183-5.pdf
“Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis* (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea* developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0–13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα.”
*(Dyspnoea means shortness of breath, haemoptysis means coughing up blood)
We Do Not Yet Know the Full Death Rate in China
The article above cites 15% mortality rate – but those cases are going to have been the worst cases presenting leading to suspicion of infection. The death rate outside China appears to be much lower than within China, which is at least 2% but according to some reports is in the double digits. The per-case death rate is hard to know because we do not know the accurate full number of people infected, and we also have to rely on death rate estimates from China via the WHO.
This website is going to be key to determining whether the death rate outside of China will catch up to the 2+% rate seen in China.
https://www.worldometers.info/coronavirus/
Right now the website reports 31,481 cases with 638 deaths, with 4,824 in critical condition, and 1,563 recovered. Unofficial reports of mass fatalities across Wuhei have many people convinced that the official death toll is unreliable.
Watch the Per-Case Fatality Rate Outside of China
Outside of China the apparent per-case fatality rate is still zero, with all deaths outside of China being two cases that originated in Wuhan and traveled outside of the country to Hong Kong and Phillipines. A reported death of a 22-year male in Malaysia reported to be infected with coronavirus has not been confirmed.
How will we know?
Watch the death rates in the people who have left China who are currently in quarantine.
The next two weeks will inform the world of the immediate threat of serious, deadly pandemic, or if, as I speculated, the Chinese or Asian population is somehow sensitized to 2019-nCoV or at higher risk of fatality.
Fatality rates in countries with large SARS and MERS outbreaks will tell us if the past outbreaks sensitized specific populations.
Thanks for the info and the link to the worldometers web site!
100% agree.
The most over looked fact and most underestimated challenge for proper assessment of the severity of this new virus is the following:
For fatal cases, the average time lag from symptom onset to death is *three weeks* (and even more so for younger age groups, see also the recent death of 34 year old Dr. Li Wenliang who died 5 weeks after symptom onset back on january 10).
This time lag is a well established fact in the literature about SARS/MERS-like corona virus infections.
This is unfortunately a very insidious property of this virus because it allows for it to spread in the community for many reproductive cycles virtually invisible to our detection.
When we finally detect the community outbreak due to large unexplained clusters pneumonia deaths it will already be much too late.
Because due to the 3-4 weeks time lag from infection to death the virus has already silently multiplied the number of infected people in the community by about a factor of 1000. (Assuming a case doubling rate of 3 and a proportion of 20% severe cases)
That is exactly what happened in Wuhan during the first weeks of January.
We see the result now.
We still have a head start of about 2-4 weeks compared to China and we should utilize it.
I think we could still win to ultimately contain this, but only if the following two measures are implemented around the world:
1. Anyone running any flu like symptoms with fever should self quarantaine for 3 weeks and wear a face mask even if there is NO china/travel related exposure)
2. Any case of influenza like illness (and any case of unexplained pneumonia) should be tested for 2019nCoV regardless of any travel related to china.
I’d say anyone symptomatic should assume they have it and self-quarantine.
Case numbers still grow but no longer exponentially.
But this is probably only due to the strict social distancing measures implemented in China.
We should look closely how the big Cities in China outside Wuhan/Hubei manage this because it is a model for how it could play out in other cities/countries of the world.
Looking closely means very strict police measures. Which is why voluntary social distancing and mass “common area” sanitation is needed around the world NOW. The WHO and CDC need to announce that the world should stop shaking hands and hugging, to use the Ebola “elbow bump” greeting and to wipe down common (shared) surfaces with bleach or viricidal wipes.
This section of your post is concerning:
“In the critical phase, some patients begin to recover and feel better, only then to crash and become critically ill with low oxygen levels, eosinohilic and upper and lower lung pneumonia due to cellular death in the alveoli (grape-like clusters of air sacs in the lungs).”
Questions:
1. Do you (anyone) have a % for “some patients”?
2. If you are one of the “crash” patients, what is the mortality rate?
3. What is the time period before “recover” and “crash”? Do you believe these people may have left their home/hospital believing they have recovered?
4. Do you believe the “falling dead” (video of people collapsing in China) is from this “crash phase”? They feel better, go walking and then collapse?
5. During the post seemingly recovery to crash phase contagious?
These are concerning situations – depending on your answers.
I agree that people should change travel plans and not go on cruises etc where they are going to be isolated for long periods of time with people who may have the virus and not know it as it happened in Japan. Using common sense is of prime importance I guess.
I do have a couple of questions that challenge some of the hypothesis of pandemic spread.
1) We have had at least 5 confirmed cases on 2019 nCoV who arrived from China to the USA in planes. While they have been confirmed as having the disease, not much has been heard about the rest of the 200-300 passengers on these aircraft who travelled with these people. Given that the person was contagious and given the fact that a plane is basically a tin can with a lot of people in close proximity, why have they not caught the virus?
2) What if anything is known about the people who have died and their SARS experimental vaccine status? Even the young doctor who died would have been of age to get a SARS vaccine. Is that vaccine causing more morbidity and mortality in people? Is that why we are seeing the majority of deaths in China and surrounding areas? Also we do not hear of many young children getting critically ill and dying of 2019 nCoV, why is that? Aside of the fact that they have not probably got the SARS vaccine in 2005 as they were not around.
3) Do you have any comparison of data for how fast the Ebola outbreak spread in West Africa a few years ago and the death rate which I know for a fact was much higher than this. Quarantine seemed to stop the spread of Ebola. Should we not expect the same for 2019 nCoV?
Thanks.
1. Many have very long asymptomatic periods prior to symptoms, so we do not know.
2. We do not know. China should tell us if there is a match-up b/t the dead and critically ill and past exposure to SARS Spike protein containing vaccines – or to reported SARS infection in the past.
3. Current estimate (2/7/2020) is R0 4-5 for 2019 nCoV – ti changes with isolation techniques and with behavior changes. Ebola was R0 2.5-3.5. So let’s keep our fluids to ourselves, don’t handshake, don’t hug/kiss to greet, use the Ebola elbow bump… disinfect common (shared) surfaces, like key pads, light swtiches, restroom fixtures, door handles… assign a “sanitary custodian” duty to one person on staff per hour… don’t touch your face, and as mom said, Wash Your Hands.
Hey James, Thanks for your articles and analysis. I following your article for a week now, very appreciate your contribution and effort on all.
I also highly appreciate your calling to help Chinese in humanitarian way. There isn’t many who have great value and human conscience as you, thank you again!
The situation here is really strange and bizarre…also scary…
I saw you need some more information about the virus..death rate..etc for your analysis. I am currently in China, I can’t get exact information, but on Chinese media there are more detailed information(compare with the information that got from the western media) about how many people in serious condition and some people who are just in observation/isolation. I hope these information would help you for the analysis… But don’t know how to contact you. I left my email and could email me. I hope I could contribute a bit for your research.
Thank you Yu Li, I’ll be in touch.
I had read an article (interview) with a Chinese Dr. who stated in the critical cases he is witnessing Cytokine Storm. https://www.straitstimes.com/asia/east-asia/reporters-notebook-life-and-death-in-a-wuhan-coronavirus-icu
Reading up on this – do you believe this is what is causing some of the people we witness collapsing on the street?
Can you bring clarity to the thought of coronavirus and the Cytokine Storm?
Could it be that the Chinese population reacts more stronger to the 2019-nCoV infection since they were given the SARS vaccine back when the SARS epidemics 2003/2004 was? I knew from personal contact with Chinese that a lot of the people suffered from the side-effects of the vaccination campaign then. Could it be that these vaccinations back then made them more sensitive to the novel 2019-nCoV infection?
Another aspect for the higher death rate in China might be the use of toxic antiviral drugs (HIV drugs) for the treatment of the infection [1]. These drugs, nucleoside reverse transcriptase inhibitors (NRTIs), have a high mitochondrial toxicity:
“Mitochondrial toxicity results from NRTI inhibition of a mitochondrial DNA polymerase. Mitochondrial toxicity manifests as myopathy, neuropathy, hepatic failure, and lactic acidosis. Routine lactate assessment in asymptomatic patients is not indicated. Lactate concentration should be obtained in patients taking NRTIs who have fatigue, nausea, vomiting, or vague abdominal pain. Mitochondrial toxicity can be fatal and is treated by supportive care and discontinuing NRTIs.” [2]
Also the increasingly use of toxic disinfecting agents currently in China [3] will weaken the immune system and will be cause short- and long-term health problems.
A person in China being infected with 2019-nCoV, having an compromised immune system due to the previous SARS vaccinations, being exposed to toxic disinfecting agents and then also taking toxic HIV drugs will have a high chance for a fatal outcome, I guess.
[1] https://www.businessinsider.com/wuhan-coronavirus-china-scrambles-for-hiv-drugs-for-treatment-2020-2?r=US&IR=T
[2] https://link.springer.com/article/10.1007/S13181-013-0325-8
[3] https://www.businessinsider.com/wuhan-coronavirus-china-dispatches-bleach-trucks-to-spray-down-cities-2020-2?r=US&IR=T
you have to explain better, so in China have they already tested the vaccine after SARS ?
there are reports that they have started a new vaccination campaign since December 1, 2019 … is true ?
Yes. Phase 1 trials of a SARS spike-protein based vaccines had at least 120 patients at final count – back in 2004.
A report from early on the Phase 1 trial.
https://www.businesswire.com/news/home/20041213005499/en/Sinovac-Biotech-Ltd.-Releases-Results-SARS-Vaccine
Yes Dec 1 a new law re: vaccination went into effectin China.
https://www.loc.gov/law/foreign-news/article/china-vaccine-law-passed/
thanks a lot !
but then the vaccination was done on a larger scale?
do we have direct sources from China?
a last hypothesis, even a previous contact with SARS virus could trigger the same protective effect “paradox” of vaccination?