Two Op-Eds on SARS: Then and Now

This week two op-eds caught my attention. The first, “Preventing the Next SARS” was written in 2003 by Ezekiel Emanuel, the American oncologist and bioethicist. The second, “Living in Hell,” is a personal essay from a resident of Wuhan published today, March 3rd, 2020. While separated by 17 years and two continents, the juxtaposition of the two articles illustrates the dire urgency and need to learn all we can from one outbreak in order to prevent or minimize the human impact of future infectious epidemics, particularly as COVID-19 continues to wreak havoc across the globe.

Originating in the Guangdong province of China, the 2003 SARS outbreak began as a “mysterious illness” characterized by severe respiratory symptoms. The outbreak lasted for six months, from February-July. When Emanuel wrote his op-ed in May 2003, the SARS crisis had begun to stabilize. Yet, he cautiously warns that it would be a “huge mistake” after containment to “move on, to focus on the next issue.”

According to Emanuel, virologists explain that China is the source of viruses that cause respiratory infections due to the close proximity of people and animals in cohabitation. Without specifying zoonosis, he provides the example of birds shedding the influenza virus in their stools where pigs eating from the ground can absorb the bird virus. Moreover, “pigs can harbor both both human and bird viruses, creating an environment in which genes can be exchanged, leading to new strains of old viruses or new viruses that can infect and kill humans” (Emanuel). He also mentions the “staggering” financial resources required “to improve the millions of small farms, slaughterhouses and housing and sanitation in China.” Emanuel states, “Traditions surrounding cuisine and food preparation can be barriers to better hygiene, but concerns for health should prevail.”

In contrast to Emanual’s op-ed written after the original SARS outbreak reached its peak, the second article is a personal essay written during the current outbreak of COVID-19.The author, a resident of Wuhan, writes anonymously in fear of reprisals from the Chinese government. He describes what it is like during the lock-down, as well as the gap that exists between government propaganda and reality. Questions and inconsistencies haunt the writer, particularly the fact that the government announced the lockdown of Wuhan at 2AM on the second to last morning before the Lunar New Year. He explains that his childhood ambition was to become a journalist, but as he became an adult and realized that he lived in a regime in which truth could not be told, he needed to find another career.

The anonymous writer tells how others around him have had to reckon with reality…that infected patients were first treated at the beginning of December, but the government did not inform the public until much later, missing the window of prevention. He describes the mad rush to gather food and other necessities after the lockdown was announced. How residents were asked to provide rides to medical workers, despite a ban imposed on residents preventing them from riding. How medical workers were not given adequate medical supplies leading to their exposure to the virus. How the government locked down the internet, further preventing residents from obtaining supplies such as masks. How dormitories of medicine students have become appropriated for quarantined patients. And how younger residents (born after 1995) who grew up during a time of prosperity and have had a more positive view of the government, now face the reality that overcrowded hospitals turn away their  family members infected by the coronavirus.

~~ Janette Canare

Emanuel, Ezekiel J. “Opinion | Preventing the Next SARS.” The New York Times, May 12, 2003, sec. Opinion. https://www.nytimes.com/2003/05/12/opinion/preventing-the-next-sars.html.

NPR.org. “Personal Essay From Wuhan: ‘Living In Hell.’” Accessed March 3, 2020. https://www.npr.org/sections/goatsandsoda/2020/03/03/809965742/personal-essay-from-wuhan-living-in-hell.

Kyasanur Forest disease (KFD) in Karnataka, India

Kyasanur Forest disease (KFD) -- also known as monkey fever -- has claimed its 2nd victim in the Indian state of Karnataka, a 64 year old who died on 29 February.

The death comes almost a month after a woman in the Shivamogga district of Karnataka state, died due to the disease. She died while being moved to a hospital in Manipal from Shivamogga.

According to Dr. Ashok Kumar, "Two cases of KFD have been confirmed in Siddapura.  Samples from the carcass of the monkey also revealed the presence of the virus. We have enough vaccine and are creating awareness among the public about vaccination. KFD surfaces from March to May but has appeared as early as January this year."

In Shivamogga alone, 55 people have tested positive for the KFD virus. "Of 55 positive cases, 22 people were vaccinated with 2 and 3 rounds of vaccination," a medical officer said.

KFD is an acute febrile illness caused by Kyasanur Forest disease virus (KFDV), a member of the family Flaviviridae, characterized by severe muscle pain, gastrointestinal symptoms, and bleeding. The virus was 1st identified in 1957 after it was isolated from a sick monkey from the Kyasanur Forest in Karnataka State. The disease is transmitted to humans following a tick bite or contact with an infected animal, especially a sick or recently dead monkey. There is no evidence of person-to-person transmission.

KFD typically occurs during the dry season from November through May and is related to the increased activity of the nymphs of ticks. Exposure to adult ticks and nymphs in rural areas increases the risk of infection; herders, forest workers, farmers, and hunters are particularly at risk.

~~ Steve Blasberg

Epidemics as Tests of Rationality

One of the fascinating angles that a health epidemic such as the current Corona outbreak brings to the forth is the degree to which humans can (or cannot) be approximated as rational agents. We would like to think of ourselves as rational beings, but as the growing field of behavioral economics has shown, reality is far from it. A real human made of flesh and blood is far from the rational contemplating platonic agent we hope it to be. To put it differently, it looks like our brains have certain bugs (or features, depending on how one look at it) which become especially noticeable under certain new conditions.

As an example, it seems like our rationality is particularly vulnerable whenever we are faced with situations that involve probabilities. Most people have no problem handling judgments that require basic mathematical operations like addition or multiplication or even more complex operations such as solving equations. However, the same people often cannot make rational conclusions when faced even with the simplest situations that involve probabilities or statistics. There has been many excellent works that have shown these deficiencies in detail. For example, Daniel Kahneman's Thinking Fast and Slow is a classic and detailed study of the subject.1

One of these shortcomings that helps us understand the reactions to the current Corona outbreak better is what Kahneman calls the "availability" heuristics. This is the case where people make decisions or judgments about the probability of an event based on examples or instances of that event that they can access most easily. In the current context, this means judging the severity of the situation based on the most readily available examples or images. And because for most people the news outlets are their window to the reality, and because those outlets are saturated with news about the Corona outbreak, the natural conclusion is to associate a very high risk with the corona virus. In other words, the public perception of the risk associated with the virus is almost independent of the actual statistics and data. That there is a higher risk of dying from the flu than from Covid19 (at least as of now) does not seem to matter.

This non-rational response has profound effects as it tends to be amplified in situations involving closed positive feedback loops, leading to unstable behavior. As a result, we have witnessed the biggest drop in the financial markets in the past few days since the depression of 2008. In other words, we panic not because of some real world reality, but because others have panicked. And our panic causes more panics in others, which in turn causes more panic in us, etc. Clearly, this outbreak is far more than an infectious disease outbreak. It is also a laboratory for studying the nature of human behavior.

~~ Moe Azadeh

1. Daniel Kahneman, Thinking Fast and Slow, Farrar, Straus and Giroux, 2011.

Coronavirus Patient at UC-Davis Hospital Was Not Tested For Days

I have been telling my family and friends to not panic about coronavirus, but an article published two hours ago in The New York Times has me a bit rattled. NYT reporters Roni Caryn Rabin and Sheri Fink document that a patient in California – later revealed to be in Davis – had to wait days to be tested for coronavirus, even though doctors requested the test. This patient, who has now tested positive, may be the first person in the United States to be infected through community spread, the CDC reported yesterday.

While it is possible that the patient was exposed to a traveler returning from an outbreak zone, the source of the infection is unknown, and may very well be a case of local, community transmission. 

The delay in the patient’s testing – which delayed the diagnosis and thus presumably delayed appropriate containment measures - was due to federal restrictions limiting testing to patients who have recently traveled to China or know they have had contact with someone with coronavirus.

In the midst of criticism of the federal government’s slow response to the epidemic, President Trump named Vice President Mike Pence to coordinate the government’s response, deemphasizing the seriousness of the threat. “The risk to the American people remains very low,” said Mr. Trump. “We have the greatest experts, really in the world, right here.” 

Meanwhile, the actual experts, doctors at the Universtiy of California, Davis Medical Center, considered coronavirus as a possible diagnosis when the patient was first admitted last week, but were unable to obtain appropriate testing procedures because of the stringent restrictions of the federal agency that conducts such testing.

The patient was moved to the medical center from another hospital in Northern California (where??) with a suspected viral infection, and was already in bad shape and using a ventilator upon arrival, UC Davis wrote in a letter yesterday. “Upon admission, our team asked public health officials if this case could be Covid-19,” the letter said. The medical center requested testing from the C.D.C. “Since the patient did not fit the existing C.D.C. criteria for Covid-19, a test was not immediately administered. U.C. Davis Health does not control the testing process.”

Previous to this case, public health officials have traced the source of all the infections in the U.S. to a trip abroad or a known patient. If this patient has had no contact with anyone coming from an affected country, then that means there are already undiagnosed cases of coronavirus in the community, here in Northern California. 

To be honest, I would still recommend to family and friends that they not panic. As has been pointed out repeatedly in class, this virus will certainly make its way through the human population, and the best thing we can do is wash our hands, get enough sleep, and not suppress our immune systems by stressing about it. 

At the same time, my 13-year-old daughter just came downstairs and said “my throat hurt” and my husband teased, “is it coronavirus?” We laughed, but if my daughter did happen to contract a respiratory illness that put her on a ventilator and her doctors suspected coronavirus, I would be furious if she was unable to be tested. 

~~ Amy Allebest
https://www.nytimes.com/2020/02/27/health/coronavirus-testing-california.html

United States 2019-NCOVID Testing Ramps Up

AS 2019-NCOVID continues to spread throughout the United States so too does urgency for significantly increasing testing capacity for the virus. “The Trump administration said on Monday that nearly a million tests could be administered for the coronavirus in the United States by the end of this week, a significant escalation of screening as the American death toll reached six and U.S. infections topped 100.” Both public and private sector entities are being leveraged to increase the United States testing capacity in a short amount of time. It is widely expected that as testing capacity expands so too will the number of confirmed cases.

Getting enough testing supplies distributed throughout the country for such a new virus has proven difficult. Last Tuesday and Wednesday only 337 additional testing kits were made available with each kit being capable of testing approximately 350 people. As the virus moves closer to pandemic proportions, it is clear that capacity to address it will have to increase in similar proportion. In addition to increasing testing capacity, the White House is also looking to take steps that could potentially decrease the number of new cases entering the country through an expansion of the existing 2019-NCOVID related travel ban. While details of what countries may be included are still unknown, Italy, South Korea, and Iran seem to be likely candidates due to the scope of their outbreaks.

While work on a vaccine is still moving ahead as quickly as possible it looks as though getting something to market is at a minimum one year away. Additionally, some have been critical of the pace at which testing has occurred. A variety of factors including a focus on keeping the virus out of the country, poor leadership, and faulty test kits have been cited as the cause of delays.

Citation: Weiland, Noah and Emily Cochrane. “Close to a Million Could Be Tested for the Coronavirus This Week, Health Official Says.” The New York Times, 2 March 2020. https://www.nytimes.com/2020/03/02/us/politics/coronavirus-testing.html. Accessed 3 March 2020.

Post by Richard Hackmann

Cranberry vs Noro: A New Approach to Treating Produce for Norovirus

With all the craze around COVID-19, it’s hard to even imagine that any other virus poses any risk to human health. But you can rest assured, scientists are still looking for ways to combat our greatest microscopic foes such as the infamous norovirus. Norovirus - a member of the caliciviridae family - ravages dorms, cruise ships and any communities in close quarters, and they take refuge in foods to disperse gastroenteritis to unsuspecting victims worldwide. Noro is also hardy for a virus as they are resistant to cold pasteurization such as irradiation that is used to kill other microbes. In order to kill the virus, the produce would need to be treated with high dose X-rays that destroy the chemical properties of the plants. Recently, researchers found that organic acids and polyphenol in cranberry juice and citrus extract alters the viral protein structure in norovirus and makes them susceptible to normal pasteurization treatments. The technique is an exciting new approach to safely and naturally eliminate the dangerous Norovirus using ingredients that will not harm the consumer or strip nutrients that make fresh fruits and vegetables worth eating. 

~Avi Kaye

Article: Gobeil et al. Radiosensitivity increase in FCV‐F9 virus using combined treatments with natural antimicrobials and γ‐irradiation. Journal of Applied Microbiology, 2020. https://doi.org/10.1111/jam.14596

The glaring loophole in U.S. virus response: Human error

This broad, far reaching Politico piece summarizes the way in which even the best laid pandemic plans can go awry through the simple reason that people mess up. The article then contrasts the money being devoted towards fighting the coronavirus with mistakes made by agencies and local health workers. The CDC’s test had serious flaws, and their testing guidelines proved too narrow. A California man was in the hospital for a week undiagnosed because of these strict guidelines, exposing himself to staffers. In general, there exists a lack of protection for health care workers. Long term care facilities appear especially vulnerable, considering their elderly population has compromised immune systems. For a pandemic plan to work, everything must go exactly as planned; oftentimes small mistakes have lasting, outsized consequences. In this way the current COVID19 response mirrors the Ebola outbreak in 2014. In that situation, a Dallas hospital misdiagnosed an Ebola patient, leading to widespread panic. The most encouraging part of the article came when the author quotes Tom Frieden who explained that so long as officials prove adaptable to changing conditions and are transparent with the public, confidence ought to be maintained. In addition, so long as decisions continue to be made based on the science, the public has no cause for alarm.

Patrick Moynahan

https://www.politico.com/news/2020/03/02/loophole-coronavirus-response-human-error-118491