Coronavirus U-Turn: virus far worse than thought

Dr Lance O’Sullivan and I appeared together on a breakfast TV show yesterday for a a backflip bigger than Ben Hur. We had thought coronavirus was not that deadly and would pass the way of SARS.

For those of you unfamiliar with NZ politics, Lance is a widely known and respected health advocate, and former New Zealander of the Year, so backflipping is not something he does lightly.

So what has happened since I wrote this and Lance wrote that about a month ago? The answer is we now know a lot more about this threat than we did then. So how has the situation changed in a month?

The cruise ship, Diamond Princess helps contextualise the virus. Being an encapsulated environment where (almost) everyone was tested (24 got off the ship untested), we can have better than usual confidence in the epidemiological data it provides. 

As of today, 705 out of the 3,711 passengers and crew have been infected, with four deaths. The best data I can find about the critical count is a bit old but puts it at 29.

From those numbers we can do some maths:

• Infection rate 705/3711 = 19% or 1 in 5
• Critical rate 29/705 = 4.1%
• Death rate 4/705 = 0.57%
• Critical rate per person 29/3711 – 0.8% 1:125
• Death rate per person 4/3711 – 1:1000

This data from Wuhan for ICU grade critical patients puts the mortality at 61.5% so, sadly, it would not be surprising to see more of the Diamond Princess critical patients die. In some ways there are no great surprises in the data in that being older or having comorbid conditions predicts a bad prognosis and a higher likelihood of death.

However, if you combine the data from the Diamond Princess with other insights from Wuhan we see the average age of people who died was 64 as opposed to 59 for those who survived. We see 70% of the sickest patients are male and that 8 out of 10 medical staff who became critically ill died. The point here is not that I’m a doctor and that scares me (although it does) it’s more around the fact medical staff are typically relatively healthy and middle-aged rather than old.

It’s hard to know if the conditions on the Diamond Princess promoted the spread of the virus, or, alternatively, if the quarantine reduced the spread. 

It’s also hard to know, given it is summer in Australia and our community is widely dispersed if we will see the same ~20% infection rate.

While hopeful no more passengers die, they may, and that may push the death rate up from under 1% to the 2% currently being suggested.

Whilst we’re not all on a boat, but extrapolating from the Diamond Princess figures, in Australia with a population around 25 million we could see 5 million infections, 200,000 critically unwell, and 25,000 deaths.

Vaccine production and drug shortages

This is a light at the end of the tunnel. Virologist Dr Helen Petousis-Harris, suggests we could have a workable vaccine in 12 weeks time with over 80 clinical trials already in progress worldwide.

There is another problem nobody is talking about. The regions responsible for 80% of China’s exports are in lockdown and have been for weeks.

The last time a significant amount of China’s export capacity was impacted was when a limited number of chemical factories around Beijing were closed just before and during the Olympics to reduce the smog.

This four week closure was documented to cause worldwide shortages of a the APIs used to make many of our drugs, including penicillin.

This August 2019 article lays it out:

Last month, the U.S.-China Economic and Security Review Commission held a hearing on the United States’ growing reliance on China’s pharmaceutical products. The topic reminded me of a spirited discussion described in Bob Woodward’s book, Fear: Trump in the White House. In the discussion, Gary Cohn, then chief economic advisor to President Trump, argued against a trade war with China by invoking a Department of Commerce study that found that 97 percent of all antibiotics in the United States came from China. “If you’re the Chinese and you want to really just destroy us, just stop sending us antibiotics,” he said. [Italics added]

However, it won’t just be antibiotics that end up in short supply. Diet coke depends on an artificial sweetener and Coke has already warned it’s going to be in short supply.

While I’m pretty certain I can live without Diet Coke, the increasing number of medications in short supply being documented by the Therapeutic Goods Administration (TGA) represent a real worry.

Here is the TGA list of medication shortages.

For the critical shortages:

• 27 products were added in February 2020
• 16 products were added in January 2020
• 3 products were added in December 2019
• 1 product was added in November 2019
• 6 products were added in October  2019
• 1 product was added in September 2019
• 0 products were added in August 2019
• 1 product was added in July 2019

Part of this trend is inevitable – a product that is in short supply now will eventually get resupplied. However, even allowing for that there is a pretty clear trend noting that penicillin featured heavily. That’s not really a surprise given 3 of the 4 factories that produce penicillin are in China.

Though this doesn’t paint the full picture as ‘the TGA’s website currently lists 219 drug shortages – and this is only 15% of the pharmaceuticals that are actually in short supply, according to a survey of hospital pharmacists.’

Where too now?

China’s President Xi JinPing has called for a return to work in areas of low and moderate infection.

So what are some of the practical things for citizens like us to consider?

• Cough hygiene and hand hygiene can be done by anyone and are known to be helpful
• People with flu like symptoms should be encouraged to self isolate and not go to work, or indeed, sit in doctor’s waiting rooms
• If you’re taking regular medications don’t leave it until the last moment to get your next prescription – we may see some supply issues