Germs and Statistics and Vaccines and Fear and Pickup Trucks: Stuff to Know as We Prepare for COVID-19

Let’s go back to high school biology class: You may remember that the world is full of germs, living things that are too small to be seen without a microscope. There are many classes of these microorganisms including:

- Fungus including yeast which can cause diaper rash and which you also need to bake bread.
- Bacteria which can cause strep throat but also helps us to digest food and absorb water from our intestines.
- Viruses which can cause meningitis and AIDS but which can sometimes protect us against harmful bacteria.

What we often don’t appreciate is that our bodies are also full of microorganisms. In fact, according to the National Institutes of Health website, “The human body contains trillions of microorganisms — outnumbering human cells by 10 to 1. Because of their small size, however, microorganisms make up only about 1 to 3 percent of the body’s mass (in a 200-pound adult, that’s 2 to 6 pounds of bacteria), but play a vital role in human health.”

While that may seem kind of gross, without these bacteria and other “good” germs, what we call our “normal flora,” we simply could not live. This is why, if you have ever come to see me as a doctor for your kids, you know that I will never prescribe oral antibiotics unless they are absolutely necessary. The one overarching precept I recall most clearly from Dr. Sanders, my Pharmacology (Drug) Professor at the Creighton School of Medicine was, “For every good effect a drug has, it has at least ten bad side effects, so you better be DAMN sure that good effect is worth the ten bad things.”

The Big Bad of antibiotic use is that it screws up your normal bacterial flora. Even the most specifically-targeted antibiotics will kill off a lot of “friendly” bacteria in your gut, on your skin, and in your respiratory tract which can lead to fungal skin, mouth, and genital infections, diarrhea, and overgrowth of problematic bacteria. (It’s also why, my grown up friends, you should not take an antibiotic prescription for a strep throat unless your doc actually tests for it or press your doc into giving you a Z-pak prescription over the phone without being seen.)

So how does all this work? How does our body figure this out? Well, the instant a mom’s water breaks in the birth process, the newborn is encountering a whole new world of microorganisms. The baby’s immune system kicks in and starts assessing these germs as they land on the skin and in the nose and mouth and in the lungs and gut.

Essentially, the immune system is like the cop on the beat, looking out for suspicious characters and behavior. Mostly it’s white blood cells which, in my case for example, were cruising around looking at molecules and proteins and polysaccharides and deciding, “Yep, that’s Kenny, and THAT’S Kenny, but WHOA! That’s not Kenny!” These foreign substances get flagged, and the immune system decides whether this is Friend of Foe. If Friend, it is tolerated and allowed to stick around. If Foe, then the immune system will create proteins called antibodies which are tailored to lock onto the offending germ and inactivate or destroy it. The immune system can also create an entire clone of white blood cells specifically designed to search out and destroy these harmful germs.

So to recap, it’s important to realize that:

1) The vast majority of germs in our environment are either harmless or even helpful.
2) Some germs are very harmful, and we are wise to try to both avoid them and to give our immune system the ability to fight them the moment they show up.

Regarding the second point, this is why we create vaccines. Vaccines are made either of parts of a harmful germ, like some proteins and polysaccharides, that are enough to get the immune system up to speed on this Foe, or they include a weakened version of the virus that cannot cause disease but can stimulate the immune system to get to work. Even when you get a vaccine, it takes your body’s immune system a week and a half or longer to create an adequate, effective response. If you pick up the germ in its wild form in the world, it takes your immune system just as long to create that immune response, and the harmful germs can create a great deal of havoc in that time.

Which brings us to COVID-19. This is not a “new” virus in the sense of new on the planet. It seems likely that it is a strain that has existed in animals, likely bats, for an unknown length of time, and that it has recently jumped to humans through wild animal open air markets.

However COVID-19 got to humans, the sensible questions are:

1) How do I protect myself and my family?
2) How lethal is it?
3) When will there be a vaccine?
4) Am I at risk?

COVID-19 seems to be spreading pretty much like any other respiratory virus, chiefly by us touching surfaces that someone with the virus has coughed or sneezed on and then touching our nose, mouth, or eyes. When I come to protection, then, this is pretty straightforward:

• Wash or sanitize your hands frequently.
• Don’t touch your face.
• Sneeze or cough into your sleeve, not your hand.
• If you feel sick, stay home except to seek medical attention.
• If others feel sick, avoid them, and counsel them to stay home.
• Do things that are always good for your health. Exercise. Meditate. Eat right. Get a good night’s sleep.
• And DO NOT waste your money on masks. They are useless.

This is what doctors have been telling people to do during cough and flu season, well, forever. If there’s an upside to the COVID-19 warnings, perhaps we’ll keep a few million Americans from catching the flu and a few thousand from dying of it. (And of course, you CAN get a vaccine for flu which will cut your chances of catching flu in half, so get it!)

As for the lethality of COVID-19, that is still not quite known. Among the most lethal viral infections is Ebola which can have a death rate of up to 90% and of course, HIV/AIDS, which, in the years before effective treatment, was almost 100% lethal, even if that took many years to happen. COVID-19 does not seem to be as lethal as diseases caused by other strains of coronavirus like SARS (about 10%) or MERS (over 30%).

Part of the problem with coming up with this figure for COVID-19 is, what is the denominator? We still don’t know how many people have been infected or what percentage will test positive with no symptoms whatsoever. In the coming weeks, we are going to be hearing about rapidly rising numbers of people testing positive for coronavirus. Keep in mind that, while some of this is because of new cases, a lot is because people are just now being tested and may have been positive for some time yet have felt fine and may never get sick.

To look at another example, what are the chances of dying from West Nile virus infection? The odds of getting the most severe forms of West Nile disease are about one in 150. The overall death rate in severe disease is about 10%. However, that makes the overall odds of dying from a West Nile infection about one in 1,500, or 0.06%. So until we know how prevalent COVID-19 is in the community, the death rate is going to be a changing statistic.

As for a vaccine, it is likely going to be over a year and likely closer to two years before one is available to the general public. It just takes that long till a candidate vaccine is developed and tested for both safety and effectiveness. Much worse than not having a COVID-19 vaccine is having a vaccine that is doesn’t work or causes harm.

As of who’s at risk, COVID-19 seems to be most severe in older adults, especially if they have chronic health problems, particularly breathing and heart problems. If this describes you, you might want to be more vigilant.

What is more scary than anything about COVID-19, though, is that it is so completely new in our experience so that there’s so much stuff we simply don’t know. Human beings don’t like that. As a doctor, I feel that it will be something that we will need to respect and be on the lookout for. I feel that it will be worse than the president says, but it will not rise to the worst fears we feel right now.

Of course, even if COVID-19 ends up being about as bad as the seasonal flu, that’s still really bad. Over 20,000 Americans have died of flu this season, and we still have three months to go. So why aren’t we freaking out about the flu? Before I answer that question, I’m going to tell you a story:
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“AIDS and the Pickup Truck”

In the late 1980s a hemophiliac boy in Belleville, Illinois, was diagnosed with AIDS. He had presumably contracted HIV years earlier through the blood products that had been used to create clotting factors that were supposed to save his life before there was a reliable blood test for HIV. By the time he was diagnosed, though, the mode of transmission of HIV — blood-borne or sexually transmitted — was well-known, not just to the scientific community but to the general public. Nevertheless, there were calls from many parents in the Belleville school district to have the child segregated from his classmates and either taught at home or in a separate classroom.

At that time, I was working at a federally-qualified health center in East St. Louis and was also the chair of the St. Clair County Task Force on AIDS. During the furor, I was asked to be on a panel with the directors of the St. Clair County Health Department and the East Side Health District, which served East St. Louis, at a community meeting at Belleville High School. The three of us sat at a folding table in the gym at Belleville High School facing the bleachers which were filled with parents, many there with small children. After my two colleagues and I were introduced by a school district administrator, we went through the basics of HIV transmission and assured parents that they had nothing to fear from a child with AIDS being in the same classroom as their child. Then, the floor was opened to questions.

Many people spoke at once, and it is difficult to adequately portray the intensity of anger and fear that suffused every question and comment. “What if this kid bites my child?” “What if this kid drinks out of a water fountain and then my kid does?” “What if there’s a mosquito in the room that bites that kid and then bites my kid? What then?” Question after question in the same vein, us trying to present evidence and be reassuring until, after almost two hours, a father asked the question that inevitably gets asked at a time like this: “Doctor, can you absolutely promise that my child won’t get AIDS from that kid?”

I was tired and getting exasperated. Why weren’t these people listening to reason? I sighed. “Look. I wish I could, but it’s impossible to prove a negative. What we’re saying is that the evidence is overwhelming that people do not get AIDS from just being in the same room with someone who’s got AIDS, or from drinking out of the same water fountain as them, or from just hugging them. But can I absolutely, positively promise you that your son won’t get AIDS? No. But what I can tell you is that the probability of your child catching AIDS from another kid in the same classroom is about as vanishingly small as the probability of a meteorite crashing through the ceiling of this gym in the next five seconds and killing all of us.”

The father glared at me silently. He sat down slowly, but it was clear that the meeting was over, and no one had been convinced that their child was not in imminent danger form this kid with AIDS.

I said goodbye to my colleagues and walked out into the cool evening. I looked up to see Orion, my favorite constellation. I gazed at the Hunter for a while and took a deep breath, knowing that he would be wheeling over overhead for eons after we were all gone. As I stood silently, I saw parents and kids heading to their vehicles.

One of them was the father who wanted positive, absolute assurance that his child would be safe. He was with a woman who I assumed was his wife and a couple of kids who I assumed were their children. They walked together to a pickup truck. He got in the driver side. The woman got in the passenger side. The kids scrambled into the bed of the pickup, and one they were settled, they pulled out. As they drove off, I heard the children’s laughter and squeals fade into the distance as they rolled around unrestrained in the back of the pickup while their dad drove them off into the night.
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We human beings are spectacularly bad at risk assessment. We drive instead of flying because we heard about a plane crash once, even though driving is a gazillion times more likely to kill us than flying. We don’t get our flu shot because we’ve never gotten the flu shot, and we’ve never gotten the flu so we don’t need it. We put our kinds in the back of a pickup truck because we’ve driven this way a thousand times, and we just know that a deer is not going to run out in front of us while I’m driving.

We like control, even if it’s only an illusion. With COVID-19 that may take the form of wearing a face mask (again, useless) or not leaving the house or buying up all the toilet paper at Costco. (I have NO idea what THAT is all about!)

What’ we often fail to apprecite is that, even with the most serious and scary viral infections, it is generally a very small number of people who end up being severely affected. For example, before we had a vaccine, about four to five percent of people infected with polio had minor symptoms such as fever, muscle weakness, headache, nausea and vomiting. One to two percent of infected persons developed severe muscle pain and stiffness in the neck and back. Less than one percent of polio cases resulted in paralysis.

That’s not to dismiss the severity of any infection, and certainly if you are one of those with the most severe form, it is devastating, but rather to say that it is likely that a very high percentage of us will likely be exposed to this coronavirus, and the vast majority of those of us exposed to it will likely get over it pretty quickly. Again, since we do not know who will be the ones who will be most severely affected, we need to be cautious and do all we can to prevent spread, especially to those who seem most at risk, primarily older adults with underlying respiratory conditions. Still, there is reason to hope that we will get through this.

For myself, I’m still going to go to work, see my patients, go out to dinner, live my life. I will pay very close attention to the threat of COVID-19. And I will do all those things I need to do to avoid viral infections and to help my patients to do so. But I’m not going to let COVID-19 shut down my life.