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Thursday, March 19, 2020

AHEAD OF PRINT: Is COVID-19 Overblown?

'Don't You Think This Whole Thing is Overblown?'

BY MARK MOSLEY, MD, MPH

I work in an emergency department in Wichita, KS. That may not matter, but it's important to have context. We have one confirmed case of COVID-19 (from a cruise ship) as of today, March 19. But we are testing hardly anyone—yet. Patients and friends ask several times a day, "Don't you think this whole thing is overblown?"

A certain number of political assumptions are implicit in this question. I will not speculate on what these may be or why they are there, other than recognizing that they are there. The most common and rational reason people ask (or believe COVID-19 is overblown) is expressed in their follow-up question, "How is this any different from the flu we have every year?" And in that question is the unstated: We don't respond this way to the flu.

One thing emergency medicine has taught me is that when you step into an unknown and potentially volatile situation, you begin by finding an immediate point of agreement—even if you know that you will have to tackle a potential area of disagreement at the end of the conversation or visit. My initial answer is, "Great question. For young and otherwise healthy people, COVID-19 will not be much different from a bad year of influenza." This appears to be true if one looks at absolute risk for the otherwise healthy people (0.1% mortality for influenza and a projected 0.6-0.8% for COVID-19).

Then I ask them, "Do you know how many people in the United States have been hospitalized and died from the flu in just the past few months?" (Crickets.) So I continue, "The CDC gives conservative estimates of 36 million flu illnesses with 370,000 hospitalizations and 22,000 deaths—with more than 144 deaths in children."

It is possible, even probable, that many in our city will be exposed to COVID-19, just as they have been exposed to and acquired influenza over the past several months. And like influenza, many people will have no symptoms, mild ones, or even severe symptoms that will knock them out of work or school for a week. Just like with influenza, some who are elderly, immunocompromised, or have significant comorbidities will die as a result of COVID-19. And there will be the rare occasion where an otherwise healthy child or adult contracts the virus and dies. This will attract front-page coverage, but these stories, however emotionally powerful and tragic, will be extremely rare. Healthy people, pregnant women, and young children are not in significant danger.

So why the drastic response? Because there are some significant differences from what we normally do during flu season:

  • If COVID-19 were identical to influenza (it's not; it's worse), we will have at least 350,000 additional hospitalizations and at least 22,000 additional deaths.
  • We have no vaccine and no treatment for COVID-19, and it is highly unlikely we will have a truly effective one this year.
  • Because we have not been exposed to COVID-19 before and because it has some different viral characteristics than seasonal influenza, it is expected to spread more rapidly.
  • The rapid uptick in cases will overwhelm many of our emergency and hospital systems, including critical human resources, who will be quarantined due to the infection. This is the perfect storm: Half of your EMS personnel, ED staff, and ICU staff are taking care of half of your community coming through the hospital doors. COVID-19 will affect our ability to take care of heart attacks, strokes, trauma, and other emergencies.

The social responsibility message is as important as the personal risk message, and is not contradictory to the personal risk message but produces a very different kind of emotion. It can induce fear instead of reassurance. We need to contain and mitigate COVID-19 now to the very best of our abilities. We are at a poker table being asked how much we are willing to bet, but the cards have not yet been dealt. This does not mean that we are just guessing; other tables have already been dealt their hands. South Korea has been successful. Italy has not. This is a public health strategy executed by the government with a primary objective to flatten the curve, to spread the disease out over months instead of weeks.

This may seem overblown if you are healthy. It probably is—for you. This will be even more frustrating as individuals are hit even harder by the economic aftershocks. But as the saying goes, this is not about you, it is about us. We have to protect our elderly, our neighborhood children's grandparents, those with cancer, with transplants, those on dialysis, those with COPD and heart conditions, and all of those patients in our community who need a fully staffed ED and ICU.

This is not overblown.

Dr. Mosley is an emergency physician in Wichita, KS.

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