coronavirus : armageddon or bullshit ?

Coronavirus: Armageddon or Bullshit?

article written in French on Monday, March 2, 2020. 

Translated by N. Siam Tsieu. 

 
The figures you will find here come exclusively from reliable public sources: SPF Public Health (Ministry), WHO (World Health Organization) and CDC (US National Organization of Infectious Diseases).

Is coronavirus highly contagious?

To assess the contagion, we speak of the "R Zero" of the virus. That means how many people will get the virus if you put a sick individual in a room with 100 people.

The R zero for:

-          Flu is 1.3

-          Coronavirus is 2.2

-          Rubella is 6

The average incubation time for coronavirus is 6 days, so this means that if you place a sick individual in a room of 100 people, you will have:

-          On D6: 2.2 sick people + the first sick = 3.2

-          On D12: the 2.2 will each contaminate 2.2 people => 3.2 + 2.2 + 2.2 = 7.6 sick

-          On D18: 24 sick = 24% of the population

You can easily understand that a small outbreak can quickly lead to a major illness.

Compared to seasonal flu, coronavirus is 1.7 times more contagious than seasonal flu.

In Belgium, the average flu affects 500,000 people per year. Without more drastic precautionary measures than with flu, there is a risk of having 1.7 x 500,000 = 850,000 people infected with coronavirus in Belgium.

Why is that a problem?

The Chinese and Italian figures are very similar. This is bad news because for several reasons, it was hoped that the figures in Europe would be lower than in China (Better hospital coverage, fewer respiratory diseases related to pollution, lower population density, ...). These figures report that:

-          13.8% of patients with pneumonia requiring oxygen and hospitalization

-          6.1% of patients with pneumonia with several failing organs requiring hospitalization in intensive care.

Out of 850,000 people, this makes:

-          117,000 people hospitalized

-          52,000 people in need of intensive care.

There are 30,000 adult acute beds in Belgian hospitals. These include approximately 1,400 intensive care beds that have machines (breathers, dialysis, etc.) to manage the most severe cases of coronavirus.

30,000 beds for 117,000 people to be hospitalized.

1,400 beds for 52,000 people to be admitted to intensive care.

You don't have to be a great mathematician to understand that without doing anything, you're going to have a problem.

Because once these beds are filled, the patient will no longer be able to be treated by high technological means. He will go home and be treated with the means of the edge. This explains an outbreak of mortality in areas where the health care system has exceeded saturation. For example, the mortality of the virus in Italy is 2.6%. It rises to 3.9% in areas where hospitals have been saturated.

As an intensivist doctor, I experience this saturation of beds about once every 3 years when a seasonal flu is a little stronger than in previous years. So I know that this is a reality that is happening quickly in Belgium. Indeed, a month ago, the peak of the flu epidemic was reached. This flu, less lethal but more widespread, induces the admission of a significant number of patients to resuscitation for pneumonia. So much so that intensive bed occupancy rates are currently above 90%.  By taking 10% of the intensive beds, there are still 140 intensive beds available for the 52,000 potential coronaviruses.

There is a big risk of rising to 3.9% of 850,000 people and 33,150 deaths out of 11 million inhabitants (0.3% of the Belgian population who die). It's "little" (we're not all going to die as we sometimes hear) but still 100 times more than the number of people killed on the roads each year.

How should the authorities react?

In fact, things are already going on and are coming in several phases:

The first thing to do is to prevent the virus from spreading like a flu. The aim here is to avoid reaching 850,000 people infected.

In Phase 1, work is being made to prevent coronavirus from entering the country (quarantine). This has been done and we have failed: the virus is here and we are in phase 2 since March 1^st. In fact, Phase 1 always fails and only serves to give yourself time to find treatments or organize solutions. Ministers should not be blamed.

In Phase 2, we work to minimize the spread.

We start by raising awareness of compliance with basic hygiene measures:

•  Say hello from afar: don't shake hands and don't kiss
• Hand washing (soap - water or hydroalcoholic solution on dry hands) after each contact with bodily fluids (coughing, blowing, ...)
• Use disposable handkerchiefs/tissues
• Sneeze and cough in your elbow
• Stay home with as little visit as possible if you are sick
•  I'll talk about wearing the mask later: it's not magic...

This looks ineffective, but several epidemics have already been annihilated (for example Ebola) with simple measures of this type: it works better than closing boarders.

I am surprised that the ministers do not communicate more on this: on this occasion, I think we are not doing as good our neighboring countries.

The next step in Phase 2 is to reduce the risk of massive virus exchanges. Mass gatherings are prohibited. I am curious  to see if we will be as effective as our French neighbors when our government is in business today...

The next controversial step is Phase 3: reducing moderate gatherings: schools, trains, buses are closed, people from highly contaminated areas are banned from coming to work, etc. This step has not clearly shown any benefit and must be set up in any case AFTER the others.

Phase 2 or 3 may be successful in stemming the spread of the virus. Only a few hundred individuals will have been infected and hospitals will not be overcrowded. That is what we are hoping for.

Only after that, if it is still necessary, comes the hospital phase: we have not been able to contain the disease enough and the hospitals are saturated.

If we get to this point, we will have two problems: the hospitals will be full, with a limited staff. Indeed, it is known that patients are concentrated in care areas, caregivers are more at risk of being infected. In China, for example, 12% of the infected are caregivers! That would mean 100,000 infected caregivers here! Now you know that we already have a problem of lack of white coats in Belgium.

Hospitals will be full: We will then activate the "pandemic" plan coordinated by the minister and detailed in each hospital. What's going to happen:

-          First, all scheduled hospitalizations will be cancelled (knee surgery, ...) for an indefinite period and unless VITALE emergency.

-          We're going to cut hospitals into an "infected" area and a healthy area

-          Then we will shorten the length of stay in the hospital as much as possible: people will go out earlier than usual and people will be less likely to be admitted to the hospital when they come to the emergency room. You will understand that there will also be deaths here related to this policy. But they will be less numerous than those of coronavirus.

-          Then we will "push" the beds: we will use the respirators of the operating and recovery rooms to make "extensions" of the intensive care units, we will convert individual rooms into a common room, ...

-          And if we are still drowned despite all those measures, we will apply the ethical principle of distributive justice: between a 40-year-old with a heart attack and a 90-year-old senior with coronavirus, we will reserve the bed for the young person and send the senior home. There will be no choice.

Caregivers will also be sick: here, we have no magic solution. The solution is to minimize their number.

This can be done by:

-          Separating staff who work with infected people from the rest of the staff

-          By wearing gloves and gowns

-          By having them wear a special "FFP2" mask. Effectively, the standard surgical mask lets viruses pass through...

The difficulty we have at the moment is that GPs do not have an FFP2 mask, that they are out of stock in pharmacies and that the minister does not respond when asked if she will distribute it to general practitioners (which is done in France, for example). This gives doctors the feeling that there is a failure in the minister's management of this epidemic. Especially since the info is limited to 3-4 emails sent for doctors on the front line...

We have known since the Spanish flu of 1918 that when we are in this hospital phase, we have an increase in the number of deaths related to other diseases (heart disease, ...) in the uninfected population due to:

-          Lack of unoccupied structures

-          Lack of uninfected staff

As a result, there is a risk of going from 33,000 direct deaths to 50,000 direct and indirect deaths. It's the worst-case scenario.

Who will be those 50, 000 dead?

Elderly people and/or those with a chronic disease (diabetes, etc.): statistics show that an octogenarian has ten times more (bad) chance of dying than a 60-year-old. No child, even chronically ill (diabetes, ...), has died to date.

In conclusion:

-          The top priority is to avoid reaching these 850,000 infected people. It's still doable. It depends on the proper behavior of all. That's why the authorities are making such a media fuss: it's a bit like the fire patrols in the forests of Provence: when the fire is not gone, they are said to exaggerate. If the fire catches, they will be overwhelmed... You have your responsibility in this priority: please follow the hygiene measures.

-          The risk of having a major concern in hospitals is real. No one takes it lightly in the hospital directions.

-          We are not all going to die. In the worst-case scenario, 0.4% of Belgians will die, the majority in over 80s. Stop the psychosis.

In short, educate people around you in basic hygiene, share this text but remain reassured: unless you are octogenarian, the risk of dying remains around 0.1%.

With everyone's help, the virus will be contained, and the dead will be limited in the hundreds, as with a flu. And the grumpy people who have not understood anything will say that the population has been alarmed for nothing. So goes life...

Dr Philippe DEVOS

Intensivist at CHC Liège

President of Belgium's largest Doctor’s Union ABSYM

Note written on March 8, 2020:

This article has been read 500,000 times in one week: it is as viral as its subject. However, following a misinterpretation of my figures by some journalists, I think it is necessary to clarify certain points:

-          the figure of 850,000 people is a figure that would have been reached if everyone had considered it to be just a flu like every year. By the time I wrote the article, much of the world's arsenal was already in operation. It was already clear at that time that this figure would not be reached. The aim of presenting this figure was to make the population understand, while Belgium still had no cases, that doctors and authorities should be listened to. I believe that the patient must be an actor in his health and that he can only be an actor if he understands the stakes. This same error in announcing figures considered exaggerated was made by the professor of epidemiology of the most prestigious American medical school: Professor Lipsitch of Harvard has indeed calculated a contamination in the year of 40 to 70% of the world population if nothing was done:https://www.cbsnews.com/news/coronavirus-infection-outbreak-worldwide-virus-expert-warning-today-2020-03-02/

-          you will understand that I am convinced that numbers will be lower thanks to our joint action. But even with lower figures, the risk of hospital saturation persists: in Lombardy, the last stage of my description (distributive justice) has been reached today with only 620 contaminated per million inhabitants. I do not think any health system can stand out from that. Governments that declare it ignore the precautionary principle. As far as I am concerned, I prefer to act upstream and convince the population to try not to reach the 500 contaminated per million inhabitants. For this reason, individual behavior will be more decisive than mass measures. Staying cloistered at home when you have a small fever will be difficult for many people to accept. Washing your hands more than 5 times a day will also be difficult for many. Even no longer shaking hands seems inconceivable to some. Yet, it works. And if we don't, we will force the government to take drastic measures such as the one we see in Lombardy. I ask everyone to think about the responsibility they want to bear: danger is not at the level of the individual, it is collective. On the other hand, the bulk of the solution is not collective, it is individual.