As the official U.S. death toll from COVID-19 passed 10,000, Surgeon General Jerome Adams warned that Americans should brace for “the hardest and saddest week” of their lives. During a press appearance over the weekend, he called the coming days “our Pearl Harbor moment, our 9/11 moment.” Inside New York–area hospitals, the prospects match his grim tone. In addition to struggling with widely-reported supply shortages, working seemingly endless shifts, and struggling to manage the influx of patients, infectious disease experts say that even as they’re racing to develop an effective vaccine, they are essentially learning on the job.
“The infection itself does have some perplexing features,” said Dr. Megan Coffee, a clinical assistant professor at the NYU Grossman School of Medicine specializing in infectious diseases and immunology, who coauthored a study about an experimental A.I. tool that predicts which patients with the virus will develop a serious respiratory illness. She listed just a few of the many unanswered questions: “We don’t yet know what we can do to prevent this immunologic response. We also don’t fully understand why some, who are healthy, go on to have severe disease and others, with more risk, do not.”
Specific characteristics of the virus likewise remain a mystery. “The pandemic of 1918…was associated with bacterial as well as viral pneumonia, which does not seem to be the case with the novel coronavirus,” said Dr. Joseph M. Vinetz, a professor at Yale School of Medicine who also specializes in infectious diseases. “But we still don’t know whether coronavirus can lead to secondary or superimposed bacterial pneumonia in addition to [causing] immune damage to the lungs, which is the primary cause of severe illness and death.” This coronavirus, he said, is puzzling due to its “unique combination of asymptomatic infectiousness, and the delayed onset of severe disease. Very perplexing.”
Dr. Sandra Gelbard, a Manhattan-based internist who specializes in preventative medicine and one of the first doctors in New York City to begin COVID-19 testing, described the current epidemic as “way, way more concerning than the first two coronaviruses”—SARS and MERS—“which is surprising because the first two were more lethal. But those viruses were contained. With this novel coronavirus, 25 to 50% walk around without symptoms. It is the right combination of lethality and transmissibility. This makes this virus a real global threat.”
Dr. Coffee concurred. “This is the disease we’ve always feared as infectious disease doctors—a respiratory-borne virus that spreads easily person-to-person, but with a high mortality,” she said. “Those of us who have worked on Ebola and other crises have feared for a while [that] this would be worse than anything we have ever seen.”
The results, said Dr. Gelbard, could be more devastating than current predictions suggest. “If we did intense social isolation like they did in China and South Korea, the number might have been around [100,000 deaths], but we missed the boat on that,” she said. “I don’t expect it to be 100,000 to 200,000 people dead. It could easily be 1 million.”
She added, “we really don’t know the mortality of this virus. We’re assuming at best it’s somewhere around the 1% mark. We can’t know at this point. No one knows.”
Meanwhile, as it spreads, the virus is changing. “The issue is that [it] is mutating,” said a New York City–based doctor treating COVID-19 patients. “We cannot predict what strain it will mutate to, and in some populations strains may be more virulent than others, so all we can do is prepare for the worst.” She added, “It’s scary because it is a disease that is ever-evolving. Just when we think we have figured out the pathophysiology of the disease process and how to manage it effectively, we realize there is a new loophole or nuance that the disease presents us with.”
Infectious disease doctors say while the virus is mutating, that process won’t necessarily make it more lethal. “It’s possible, but it’s also possible that it will not change phenotypically”—meaning it would behave the same way regardless of a change in its genetic code—“or that it could be less deadly over time,” said Dr. Megan Murray, a professor of global health and epidemiology at Harvard Medical School. “It is not the case that pathogens usually evolve to become more virulent.” Dr. Richard Martinello, an infectious disease expert at Yale School of Medicine, agreed, saying that though viruses evolve quickly, “most spontaneous mutations are deleterious and do not lead to more transmissible or more deadly pathogens.”
For now, though, those monitoring the novel coronavirus must simply watch and wait to see what it does next. “We do not yet have the full story on this virus,” said a New York–based doctor. “It’s too early to claim victory, full understanding, or even control over this killer…. It is definitely more deadly than we anticipated, and it has caught us off guard.”
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