Tom Jefferson: Covid 19—many questions, no clear answers

Because of my background as an epidemiologist and Cochrane researcher, and my involvement in the H1N1 outbreak, I often get stopped in the street, or in a bar, or the gym, and asked about covid-19. The questions are usually: how long does it take for the symptoms to manifest? How can I avoid it? Is it serious? These are just a few examples, and they are no different to what people would ask, say, in a park in Leeds or a subway in New York. Except that I live in Italy, the third most hit country in the world, my youngest children go to school locally, and my grandchildren are due to come over to Italy soon to see us. 

The tone of my answers is usually dismissive. I explain the nature of influenza-like illnesses, the fact that it is a syndrome, there is not a single cause, and the gallery of “culprits” increases as time goes on. But it is mysterious, it comes and goes. That is why it is called influenza, as our forefathers ascribed its waxing and waning to the influenza degli astri, or “influence of the planets.” Meaning they had not a clue as to where and how it started and where it went. We are still clueless.

There is, however, one question that my Italian friends often ask me to which I have no answer: how is this different from the seasonal influenza-like illnesses we are used to? Mario, a weight training paramedic, looked to me as the font of all knowledge, but I think his faith is misplaced.

To begin with I muttered something about bats, birds, wet markets, a novel virus and so on. I deftly got on with what I was doing, but I was left with a nagging feeling of ignorance.

Well, the virus serotype is new, sure, but is that enough to justify the frenetic media attention? Cases increased rapidly in China and then, of all places, here in Italy, and so have the number of deaths. At the time of writing there have been 2838 deaths recorded in China and 86 elsewhere in the world, according to the World Health Organization. Even though no one knows for certain how many people die of influenza every year, 2828 deaths in the space of three months compared to the nearly 900 000 deaths a month in China alone for all causes (mainly cancer and cardiovascular accidents) does not sound like much. And how do 86 deaths worldwide (excluding China) compare with deaths from influenza and influenza-like illness? Do not bother looking it up: we do not know.

Perhaps the death rate, the ratio of confirmed cases to deaths, could explain the furore? It seems to be anything between 0.18% to 4.9% (depending on where you look), on average below that of other coronavirus outbreaks. And deaths seem to be concentrated in older age groups and in people with pre-existing morbidities.

So I cannot answer my nagging doubts, there does not seem to be anything special about this particular epidemic of influenza-like illness.

There are, however, two consequences of this situation that bother me.

The first is the lack of institutional credibility as perceived by my friends. They range from firefighters, policemen, and even a GP—not the kind of people you would want to alienate in an emergency. A restaurant owner told me he would never report himself to the health authority as that would mean at least two weeks of closure and his business would go to the wall.  

Jokers and spoofers are doing overtime on the web. The authorities cried wolf in 2005 and 2009 with influenza and see what you get now.

The second is that once the limelight has moved on, will there be a serious and concentrated international effort to understand the causes and origins of influenza-like illnesses and the life cycle of its agents?

Past form tells me not, and we will go back to pushing influenza as a universal plague under the roof of the hot house of commercial interest. Note the difference: Influenza (caused by influenza A and B viruses, for which we have licensed vaccines and drugs), not influenza-like illnesses against which we should wash our hands all the year round, not just now.

Meanwhile, I still cannot answer Mario’s question: what’s different this time?

Tom Jefferson is an an epidemiologist and Cochrane researcher, based in Rome, Italy. 

Competing interests: Please see full statement here