A mere century ago, an H1N1 influenza virus pandemic dubbed the “1918 Spanish flu” infected half a billion people worldwide, then representing 27% of the global population. Even amongst healthier young adults, the virus and a corresponding bacterial superinfection killed 50-100 million, eliminating 3-6% of the global population.
Learning from our societal shortcomings, the past 100 years has seen a revolution in medical research, public health services, hygiene and sanitation standards, and international health cooperation. However, the unsettling fact remains, scientists estimate only around 10% of potentially dangerous pathogens have been documented.
As news outlets frenzy over the mounting death toll, the World Health Organization declared a global health emergency over the outbreak of a novel (new) coronavirus originating from Wuhan, China, which in a few weeks has infected over 63,000 and killed over 1,300 people in China alone. The WHO has officially named the novel coronavirus virus COVID-19. Coronaviruses are carried by birds and mammals, and when contracted by humans, cause potentially life-threatening respiratory illnesses. The viruses range from the common cold to the more deadly SARS (also originating from China), which killed 774 people, or 10% of the people infected during an eight-month outbreak in 2003.
Coronaviruses are spread person-to-person mainly through coming into contact with infectious droplets spread through coughing and sneezing.
China and global health authorities have implemented quarantine measures deemed the most far-reaching ever enacted to protect against the still unpredictable virus. However, to keep perspective, the Center for Disease Control and Prevention reports over 200,000 Americans are hospitalized from seasonal influenza annually, with 35,000 dying. According to the DuPage County Health Department, over the past five months, 32 county citizens have been hospitalized with severe respiratory issues from the flu, with six patients dying.
Liz Murphy serves as the department’s communicable disease and epidemiology manager. She said for any outbreak, the public health protocols follow the same protective steps.
“First, we work to identify infected cases and establish if there is person-to-person transmission of the virus,” said Murphy. “If there is, we must quickly identify all potential exposures. We track the people infected patients have been around and start to monitor our contacts. We examine locations where they first felt symptomatic. We collect all the data, and epidemiologists analyze it and ask questions about the data to look for trends. If it’s food-borne, what have they consumed? Are only men contracting a virus? Is the disease affecting only children or the elderly? The data provides clues to how the outbreak is progressing and how to combat its spread.”
Past deadly outbreaks such as SARS, MERS and Ebola have proven to global health authorities that quarantining exposed people and monitoring contacts is the most effective protocol. However, with larger, transnational outbreaks such as Ebola, such protocols require an arduous undertaking by participating governments. China’s containment efforts include banning travel across 17 cities, covering 50 million people. The cities’ industry and economic retail have come to a virtual standstill.
The U.S. State Department has denied entry to all foreign visitors who have recently visited China and warned Americans not to travel to the country. American citizens were evacuated from Wuhan and quarantined in Alaska. Upon the CDC’s orders, 195 military members were also evacuated from Wuhan and quarantined in California.
The first person-to-person transmission in America happened in Illinois between a woman recently in Wuhan and her husband. Both patients are in a hospital isolation unit and tendered by specially trained staff donning protective gear. Transmission-based precautions, including the staff’s safety equipment and patient placement, are categorized by contagion type, whether close-contact, droplet or airborne contamination. Illinois public health officials are working to establish potential contacts and monitor their daily symptoms. Quarantine and isolation are recommended on a case-by-case basis.
Murphy said establishing potential contacts depends on the virus’s method and effectiveness of transmission.
“For transmission, coronaviruses need very close personal contact between people, especially compared to measles where an infected person may leave a room, and an hour later the disease is still contagious in lingering airborne droplets,” said Murphy. “Based on the evidence, we may recommend quarantine for specific people who are currently not experiencing symptoms. We ask them to remain away from public events and stay home. This is especially important if the outbreak has asymptomatic transmission, like measles. Because the obvious rash is one of measles’ later symptoms, measles can transmit between people before symptoms occur. You may have a fever, cough or respiratory symptoms and be spewing the virus before you know what you have yet.”
CDC officials are currently predicting the incubation period for the novel coronavirus may be up to two weeks before showing symptoms. While SARS killed 10% of infected people, and early projections are 2% for the novel coronavirus, its subtle symptoms may prove containment efforts more strenuous.
The CDC’s labs have been testing specimens to determine people with the novel coronavirus versus the seasonal flu. State public health labs may be soon receiving testing kits.
Murphy said public health officials always stress the importance of immunizations for preventable diseases, cooking food to proper temperatures to prevent food-borne pathogens, and frequently washing hands, coughing and sneezing into your arm, and staying home while sick to prevent contagion.
She said collaboration between local health departments and teamwork between states under the guidance of the CDC is extremely important given the circumstances of larger outbreaks. Global teamwork enabled the WHO to develop and administer a vaccine to help control the serious 2009 H1N1 pandemic (the “Swine flu”), which infected between 11-21% of the population, killing between 150,000-575,000 people. There is no specific treatment for the novel coronavirus, and a vaccine may take over a year to develop. SARS was contained before a vaccine was developed.
Such collaboration also helped the CDC issue travel advisories during the Ebola outbreak, monitor people based on travel history, and issue specific travel advisories for groups like pregnant women during the Zika outbreak.
“Outbreaks are opportunities for us to focus on improving our processes and boosting preparedness,” said Murphy. “For an annual disease like West Nile, we review our procedures and learn how to best prepare for next season. For a coronavirus outbreak, we have to maintain situational awareness. Our technological capacity for managing outbreaks has vastly improved. Today, we have encrypted and secure online platforms for people to log-in and monitor symptoms they may be experiencing. We can securely ask them questions about their symptoms and when they first began. The capacity to collect data faster and with greater ease has sped up our investigatory process.”
Murphy said the expedited data allows the department to be proactive, like setting up additional immunization clinics during a measles or mumps outbreak in public places like schools. If a pathogen is food-borne, an environmental health team can identify the food’s source and inspect why transmission is occurring.
Murphy said communication between public institutions, like schools, and local health departments are crucial for promoting healthy practices.
After an Arizona State University student tested positive for the novel coronavirus, members of the student body called for the suspension of classes until safety was ensured. With a significant portion of international students, colleges’ preparedness will be tested over this new outbreak.
College of DuPage officials have advised teachers, staff and students to be on the alert for people with symptoms. Following health department advice, the suspected person should be offered a surgical mask to prevent contagion, immediately isolated in a private room and contacted by trained local health experts.
Murphy said students with questions should view the department website’s fact sheets on the novel coronavirus and other conditions such as influenza, measles and acute gastroenteritis. The department’s monthly Communicable Disease Review also provides case numbers for countywide diseases and provides preventative healthcare recommendations. DuPage hasn’t seen a case of measles for several years, but cases of sexually-transmitted chlamydia outnumber all other communicable diseases combined.
As the dynamic between societies and changing environments evolve, virus transmission between animals and humans may become more prevalent. A new wave of epidemiology students will be necessary to better understand our global cohabitation with pathogens.
Emily Murskyj is an epidemiologist at the DuPage County Health Department who comes from a microbiology background.
“After working a couple years in an immunology research lab, I became more interested in the bigger picture of disease,” said Murskyj. “I took public health classes to analyze health from a population level. How can we gain a larger perspective on what’s going on in your city, your county, or your nation? Receiving a bachelor’s in microbiology and a master’s in public health prepared me for working at a local department where we are required to work on a wide variety of health problems the county is experiencing.”
Murphy double majored in biology and wildlife ecology as an undergrad.
“I was very interested in the host, agent and environment relationship where we see disease transmission, particularly between animals and humans such as with coronaviruses,” said Murphy. “Public health and epidemiology is not just infectious disease. I was focused on health disparity issues such as trends and patterns related to heroin and opioid use or maternal mortality. Maternal mortality is experienced higher among black women than other ethnicities. We can look at how obesity differs in various populations. Epidemiology comes into play whenever data analysis is required.
“Students need a natural curiosity about the interplay of environmental and societal factors,” continued Murphy. “You need attention to detail and an appreciation for acquiring a high data set. It is very motivating to be passionate about the field and critical to stay inspired and continuously believe in our mission of safeguarding public health.”