There’s the proverbial glass half-full or half-empty — and then there’s the cold shot of despair that comes with considering how much of the planet COVID-19 has yet to hit.
“As bad as it has been, the worst is yet to come,” says Daniel Lucey, MD, MPH, FIDSA, FACP, an infectious diseases physician at Georgetown University Medical Center in Washington, DC, who is closely following the novel coronavirus pandemic for the Infectious Diseases Society of America.
He went to Singapore and Hong Kong to assess the COVID-19 response in those cities recently.
“I think the virus will come back to China through travelers, as it already has in people returning,” he says. “While there were some cases in every one of their 31 provinces, it was mostly in Hubei province. That’s where the community immunity is for the most part in China. The rest of them — over 1 billion people — are still susceptible.”
Lucey has responded to or epidemiologically observed every major outbreak this century, including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), Ebola, and the 2009 H1N1 flu pandemic. Hospital Infection Control & Prevention asked for his take on COVID-19 in the following interview, which has been edited for length and clarity.
HIC: Historically speaking, how does this compare to previous pandemics?
Lucey: There are other coronaviruses, SARS, MERS, and those that cause the common cold. This is lower respiratory — this is pneumonia. This is the first coronavirus pneumonia that has caused a pandemic in humans. There are the influenza pandemics, and of course HIV/AIDS. The 2009 flu pandemic wasn’t as bad as everyone feared it would be. You have to go back pretty far to the really bad pandemic of flu from 1918 to 1920 that everyone still talks about. The influenza pandemics of 1957-58 and 1968-69 were not nearly as bad as the 1918 pandemic, but they were worse than 2009. HIV is in its own [category] because it is not spread through the air. For me, this coronavirus pneumonia is its own unique viral pandemic. We don’t have anything to compare it to — I don’t think it is comparable to SARS or MERS coronaviruses. I don’t think you can compare this coronavirus pandemic to seasonal influenza because it is much worse than that. As far as we know, no one in the human species had any preexisting immunity. In that sense, it is like pandemic flu, which there have only been four of in the last 100 years. What that means is this virus is likely to continue even in June, July, and August here in the Northern Hemisphere. Of course, it will be winter in the Southern Hemisphere, so I think it’s going to go year-round and spread — even though it will likely slow down during our summer. But it won’t go away like seasonal flu does in the summer. Pandemic flu in 2009 didn’t go away. Again, the key issue is that nobody has any [preexisting] immunity. There is no vaccine and so far, no proven treatments.
HIC: What do you think will be the impact of COVID-19 in the Southern Hemisphere during our summer in the United States?
Lucey: It’s going to get much worse in the coming weeks and months ahead. In winter in the Southern Hemisphere, it is going across South America, Southern Africa, parts of Indonesia, and Australia. We don’t know how bad it is going to be, but it is pretty clear the United States did not take appropriate precautions, so it is going to be much worse than it otherwise would have been. I don’t have confidence in how less-developed countries around the world, including the Southern Hemisphere, are going to take adequate precautions to avoid what has happened in Italy, Spain, and the United States. What are they going to do? They are not going to have [enough] healthcare PPE (personal protective equipment). It is going to be much worse than anything that we have seen, really, since 101-102 years ago.
HIC: While no one apparently had preexisting immunity, do you think that people who survive coronavirus infection will be immune?
Lucey: Yes, that is the assumption. For almost every infectious disease — with HIV, rabies, and some others being exceptions — if you survive, you have some immune response and usually there are measurable antibodies and T cells. Then you are generally protected against that exact same virus at least for some period of time — months, years, or sometimes for life, like smallpox. One implication or action of this assumption is taking the blood plasma that has antibodies from people who have survived and giving it to people who are still very sick in intensive care. China started doing that in early February. The FDA (Food and Drug Administration) has not [approved] compassionate use therapy to take the blood of people who have survived and infuse the antibody part, the plasma, into people who are very sick. [Although it is] not proof that survivors are immune, it is an action based on the assumption that the antibodies would kill or neutralize the virus in someone who is still very sick and has a lot of virus, for example, someone who is in intensive care or on a ventilator.
HIC: Is there any indication whether those who have had mild or asymptomatic cases would also have sufficient antibodies to confer immunity?
Lucey: I haven’t seen any data on that. I’m sure it is being studied. I would agree that in a mild case, the antibody titers would not be as high as in a more severe case where you have more virus and a much stronger [immune response]. If you survived, I would presume you would have higher levels of antibodies. The Chinese have been somewhat quietly talking about these asymptomatic cases. When I was in Shanghai and Hong Kong in February, they had asymptomatic cases, and now they are admitting they have many more. People who are asymptomatic are diagnosed by finding the virus via PCR (polymerase chain reaction). But to my knowledge no one has reported finding antibody titers in people who are asymptomatic or just mildly symptomatic — just from people who were very sick and survived. Hopefully, there will be some good news about therapies. In May 2020, there will be some results made public from randomized controlled trials in China. Hopefully, they will be well-designed studies that give us some answer about some treatment or prophylaxis that actually is shown to be effective in a randomized controlled trial.
HIC: What do you think about the new Centers for Disease Control and Prevention (CDC) recommendation allowing people to wear face masks in public?
Lucey: In every outbreak I’ve gone to with respiratory spread — from SARS in 2003 to COVID-19 in China and Hong Kong — everybody wears a mask. And if you don’t wear it properly, somebody will call you out on it and say, “Put your mask on properly.” To me, it’s not just the mask — it’s the culture, the mentality. There is a heightened sense of awareness that you must take many measures that might seem very small or insignificant. Disinfecting and wiping down elevator buttons is now being done in America. In Hong Kong, they did that in 2003 and are doing it now. There is an obvious contradiction in what the American people were told: “Surgical masks do not protect you against viral infection, so the public shouldn’t wear masks.” Then, [on] March 10, the CDC comes out and says it’s OK for healthcare workers to wear just a surgical mask [and face shield] when you are doing a nasopharyngeal swab for coronavirus. What is this really about? It is about this almost unconscionable U.S. national shortage of N95 respirators.