hello everyone it's Eric strong from
strong medicine today I am talking
coronavirus once again with important
updates on the diseases spread and
there's a lot to talk about community
transmission now occurring within the US
whether it's accurate to call it a
pandemic yet and of course whether it's
time to start panicking before any of
that let me first talk about the name
because not everyone has heard yet that
this virus and this disease have been
renamed two and a half weeks ago there
were joint announcements in one the
international committee on taxonomy of
viruses announced that novel coronavirus
2019 has been formally renamed SARS Co
v2 in order to highlight its genetic
similarity to the original SARS virus
this made sense to virologists but there
was some criticism that people might
mistakenly link Tsarskoe b2 to the more
deadly SARS disease of 2003 caused by
the virus now generally known as SARS
Kobe won meanwhile the whu-oh named the
disease caused by this virus Kovan 19
for corona virus disease 2019 I
personally think they took a confusing
name and made it even worse but I won't
talk anymore about disease naming
conventions today that was the topic of
my last video about the outbreak so
let's move on and talk numbers
the number of cases the number of
fatalities the case fatality rates and
how many countries were talking about
as of February 29th confirmed cases in
China are up to 880 thousand while the
rest of the world has 7,000 deaths in
China are at around 2,900 the rest of
the world has seen about 100 the disease
has now been found in over 60 countries
including particularly notable outbreaks
in South Korea Italy and Iran the case
fatality rate for koba 19 has remained 2
to 2.5 percent when considering all
cases but there are very important
predictors of mortality first it's very
age dependent
in the first six weeks or so of the
outbreak the measured case fatality rate
ranged from literally zero among
children under 9 to 15 percent among
those 80 and over with an inflection
points between the ages of 60 and 70 the
presence of chronic disease is
predictably a risk factor especially
cardiovascular disease respiratory
diseases like COPD and diabetes being
male has been identified as a risk
factor for death though it's not yet
known if that's an independent risk
factor or if it's due to confounding
factors like men in China being much
more likely to smoke than women and
there's also an important difference in
case fatality rate between countries for
example the measured 2 to 2.5 percent
overall rates is mostly driven by China
since that's where the vast majority of
cases still are but outside China the
rate appears to be closer to 1% or even
less possible explanations for the
difference include China failing to
identify mild cases which makes their
case fatality rate falsely elevated well
the excess deaths in China is because
their health care system is stretched
well beyond the capacity to deal with
this for example there just aren't
enough ICU beds and ventilators for the
most critically ill there so the rates
in the US and Europe when the full brunt
of the disease hits us will likely be
under 2 and may even be under 1 but it's
too early to say yet with any confidence
Iran on the other hand has reported 43
deaths among 600 cases a remarkable 7%
case fatality rates this is almost
certainly because they've been
struggling to identify milder cases
rather than because the disease or the
virus are somehow different there after
all Iran it's not really an obvious
place for a corona virus to have spread
early on and so the country was probably
particularly unprepared for it there
have been a few particularly notable
stories about the virus to spread these
include the nightmare quarantine of the
cruise ship diamond princess off Japan
after a handful of passengers tested
positive for the virus as many as 700
cases have been linked to the ship and
it will be an
investigation as to how many of those
cases and ultimate deaths were directly
caused by the in retrospect terrible
decision to quarantine the passengers on
board rather than evacuate them and due
to the reportedly lacks onboard
quarantine procedures another important
story about the outbreak concerns South
Korea where their local outbreak has
been strongly linked to a religious
group called the shin jungjie Church of
Jesus who happened to believe their
founder is the literal second coming of
Jesus Christ
this group was particularly prone to
facilitating the spread because of the
style in which they worship they're
packed together very closely and
frequently shouting during services
spreading respiratory droplets they also
reportedly encouraged worshippers to
come to services even when ill and both
the church is secretive and and the
church is secretive about membership due
to the fear of members being ostracized
in the community which makes tracking
down case contacts for public health
officials much more difficult these
situations with a diamond princess and
the shin dong-joo Church highlight the
diverse challenges that exist when
trying to contain an epidemic and then
there is the new story about community
transmission here in the u.s. there have
now been two confirmed cases of koban 19
here in California who have no relevant
travel or known contact history one in
Solano County on 226 and one announced
on 228 just one town away from where I
work at Stanford we have no idea how
they became infected though notably in
that first case in Solano County it's
very close to Travis Air Force Base
where some of the evacuees from the
diamond princess were isolated upon
returning to the US and from where there
were some horrifying stories about staff
being untrained and unequipped to be
interacting with possible coronavirus
cases that could be a coincidence
but maybe not it certainly seems a
little suspicious there also probable
coronavirus cases in Oregon and
Washington who saw their first corona
virus death today
and these cases have no obvious source
of transmission and there's a long-term
care facility in Washington in which
over 50 people have patients have staff
are reporting symptoms over all these
new cases are important for three
reasons first this is the first evidence
of community transmission in the US
where one person from the community who
has no contact to China or Asia is
transmitted to somebody else we are
likely at the inflection point where the
number of cases are going to start
climbing much more quickly this won't be
predominantly because of a sudden
overnight explosion of cases but rather
an artifact of the fact that testing is
becoming more widespread community
transmission has almost certainly been
going on here for several weeks
undetected people feeling mildly ill and
assuming that they just have a bad cold
or the flu there are probably dozens if
not hundreds of Americans walking around
with corona virus though not all are
equally contagious
the second reason is that there is early
evidence of potential spread in
healthcare facilities at least in the
Solano County case there was a
significant delay in the diagnosis in my
case because the CDC initially declined
UC Davis's request to test the patient
for corona virus this led to health care
workers potentially being exposed
combining this with the fact that it's
believed that asymptomatic individuals
can spread the disease it's easy to
imagine hospital based spread could have
occurred to other patients which may
have happened at the facility in
Washington given that we have no
vaccines and that the mortality rate is
particularly high in the elderly and the
chronically ill the idea of outbreaks
occurring in hospitals and nursing homes
is really scary and the third reason is
that the UC Davis case in particular
highlighted the potential problem with
the CDC serving as the sole gatekeeper
to coronavirus confirmation testing in
the United States and UC Davis had
access to the test directly many fewer
healthcare workers would have been
potentially exposed however the problem
with Kovan 19 testing it's actually a
lot more complicated than just we need
to be testing more people that's kind of
a huge rabbit hole that I'm not gonna
jump down right at this moment and at
least as a few days ago the CDC has
approved strategies to increase test
availability so hopefully this will soon
not be quite as big a problem this
brings me to one of the key questions
for today has corona virus or koban 19
if you prefer cross the threshold to
becoming a pandemic to answer that
question we need to first discuss what
is a pandemic it actually does not have
a universally agreed-upon definition but
one definition used by the wh0 is quote
an epidemic occurring worldwide or over
a very wide area crossing international
boundaries and usually affecting a large
number of people this is sufficiently
vague for that for better or worse the
w-h-o can apply slightly different
standards to different diseases
depending on how they want to message
preparedness to the public and how they
want to allocate
resources that's not the w-h-o of being
devious but rather gives them a little
flexibility in combating different
diseases because not all worldwide
outbreaks warrant the equivalent
response the w-h-o director-general has
recently further clarified that a
determination of whether a disease
should be classified as a pandemic is
based upon its geographical distribution
the severity of the Associated disease
and the impact it has on society in
general almost four weeks ago in a prior
video here on strong medicine I asserted
that coronavirus remained in epidemic
and not a pandemic at that time a few
viewers took exception to that but my
position was consistent with the
overwhelming majority of experts was
consistent with the fact that about 99
percent of cases were located in China
and that there was no significant
outbreak focused in any other country
fast forward a month though things now
look very different while the US has
been largely spared so far at least as
far as we know with just over 60 known
cases most of whom are diamond princess
evacuees there are now 3,500 cases in
South Korea 1,100 in Italy and 600 in
Iran and these numbers are climbing very
quickly as I said earlier at the time of
recording this there are now about 7,000
cases outside of China across more than
60 countries by tomorrow that number
could easily be at 8,000
there's even discussion that
consideration should be given to
canceling the 2020 Olympic Games in
Tokyo well I'm not an epidemiologist
this feels like to me coronavirus has
crossed the pandemic threshold for what
it's worth the w-h-o and CDC are still
saying not a pandemic yet it's being
classified as a quote global health
emergency
however pretty much everyone else is
saying that it will become I'm sorry
pretty much everyone is saying that it
will become a pandemic at some point if
not one already
unfortunately the common wisdom is that
this has obviously been a pandemic for a
while now and by common wisdom I mean
what everyone's uncle is saying on
Facebook so when the w-h-o and the CDC
are saying you know we're not
quite there yet it's leading to a major
credibility problem I don't think the
credibility problem is completely
justified but it's nevertheless leading
the public to become increasingly
skeptical of everything else those
institutions are saying and that's going
to get increasingly dangerous as a
number of cases Rises
so wine doesn't even matter I mean why
do we care what we call it it why do we
care if it's an epidemic or pandemic
what difference does it make well once
it's labeled a pandemic the broadest
public health goals start to shift a
little if the diseases spread worldwide
containment within one country or one
part of the world has obviously failed
so travel bands like the u.s.
restricting Chinese citizens from
visiting here lose their effectiveness
we aren't there yet
I think quarantine and returning
travelers from certain parts of Asia
that's still appropriate but that
probably won't be true for too much
longer
so once we've give up on containment
what should the focus be it becomes
mitigation trying to slow down the
spread in order to give time for vaccine
development to give time to study
antiviral medications and to prevent a
huge surge in the need for ICU beds a
surge which many hospitals are not
prepared to handle
in addition to frequent hand-washing
mitigation involves something called
social distancing social distancing
consists of five basic primary measures
isolation of sick individuals a home
quarantine of close contacts of those
sick individuals
changing work patterns to allow more
people to work from home or to spread
out shifts so that there are fewer
people at work at one time canceling
large group events like concerts and
sporting events like the Olympics and
even closing schools and daycare centers
in those communities that are hit
particularly hard
these five measures including school
closures have already been put into
place in China Japan Italy and South
Korea to some extent and they were
particularly strict about them in China
it's not clear that Americans would even
allow the degree of infringement on
freedom of movement that China enacted
so it's kind of hard to say what effect
those those actions might have here but
I think we should expect some work and
school closures here in the US and in
the rest of Europe as well now coming up
with formal plans for these types of
closures that takes time so if your
school or your company or your own
family doesn't have a plan yet they need
to start working on one it might not
become necessary hopefully it won't
become necessary but this is not the
kind of thing you want to throw together
at the last minute
whereas the previous containment
strategies were primarily the
responsibility of public health
departments and national governments
mitigation strategies like social
distancing and frequent hand-washing
these are primarily the responsibility
of individuals and local schools and
small businesses these involve a lot of
people who don't have the necessary
expertise to independently gauge risk or
to independently develop a science-based
response which is why it will become
increasingly important for lay persons
to pay attention to what experts are
saying about the pandemic
as mentioned before I note that the CDC
and w-h-o have a bit of a credibility
gap with the public right now however
they are still among the most
trustworthy sources of information in
addition to some public health experts
I'm active on Twitter who I'll be
listing in the video comments below so
as we've crossed into pandemic territory
and we have community transmission
occurring here in the US is it time to
panic the short answer is no it is not
time to panic but we collectively need
to be more concerned than we are or more
accurately our leaders need to be more
concerned than they are the United
States is woefully underprepared for the
corona virus pandemic for one thing last
May John Bolton as National Security
Advisor he eliminated the post of senior
director for global health security and
bio threats who sat on the National
Security Council now that might sound
like an esoteric job title but that
person they were the one in charge of
coordinating a National Response here in
the US - a serious pandemic our Vice
President Mike Pence has been tasked
with leading coronavirus response
efforts despite the fact that he has
absolutely no relevant experience Mick
Mulvaney the White House chief of staff
is calling the virus a hoax Larry Kudlow
the director of the National Economic
Council and a member of Pence's
coronavirus response team has falsely
claimed the virus is contained and
President Trump of course continues to
tweet out nonsense that's confusing the
public and downplaying the severity of
the situation now keep in mind I'm not
I'm not commenting here on the Trump
administration generally this is not
about whether Trump is a good or bad
president overall or whether one
supports traditional Republican or
democratic policies I am only talking
about coronavirus the biggest public
health threat to the United States since
at least the 2009 h1n1 flu pandemic and
the threat which still has to
potentially become much much more much
much worse than that
if we screw up our response which our
country is currently doing
I don't want the sound alarmist about
any of this if you have seen my prior
coronavirus videos you know that I was
not particularly concerned this might
grow into a global disaster but koban 19
has proven harder to contain than SARS
well no one is predicting that the kovat
19 pandemic represents an existential
risk to humanity it still might infect
millions of people and disrupt society
for months it's neither a hoax nor an
apocalypse but it is here it's serious
and we all need to deal with it every
person in the world shares some
responsibility at combating this disease
even if it's just washing our own hands
frequently not going to work when we're
sick and choosing to not spread virus
related conspiracy theories and false
information online
anyway that's it for today stay healthy
stay safe and if you want more periodic
coronavirus updates subscribe to this
channel I'll be posting another update
soon and as always we'll also be posting
videos on a variety of other medicine
topics that might be of interest thanks
for watching