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The Emerging Pandemic of Coronavirus and the Urgent Need for Public Health Leadership

      There is ample precedent for public health officials directing the control of emerging pandemics. Perhaps most notably, in the early 1960s, Alexander D. Langmuir, MD, Director of the Epidemic Intelligence Service and Epidemiology Program at the Centers for Disease Control and Prevention (CDC) began to work closely with Donald A. Henderson, MD, Chief of the Virus Disease Surveillance Program at the CDC. Langmuir first introduced the idea of surveilling communicable diseases of national importance,
      • Langmuir AD
      The surveillance of communicable diseases of national importance.
      and Henderson applied rigorous and evidenced-based public health principles and methodologies to the eradication of smallpox.
      • Langmuir AD
      • Henderson DA
      • Serfling RE
      The epidemiological basis for the control of influenza.
      ,
      • Henderson DA
      Smallpox, the Death of a Disease.
      ,
      • Henderson DA
      The development of surveillance systems.
      The surveillance of communicable diseases of national importance was first described by Langmuir as the critical watchfulness over the distribution and trends of incidence through the systematic collection, consolidation, and regular dissemination of data to all who need to know.
      • Langmuir AD
      The surveillance of communicable diseases of national importance.
      Since that time, as noted by Henderson, surveillance systems have increased in number and sophistication with advances in data collection, analysis, and communication.
      • Langmuir AD
      • Henderson DA
      • Serfling RE
      The epidemiological basis for the control of influenza.
      From influenza
      • Henderson DA
      Smallpox, the Death of a Disease.
      to smallpox,
      • Henderson DA
      The development of surveillance systems.
      the establishment of systematic reporting systems and prompt action based on results were critical factors. Over the course of just slightly more than a decade, during the tenures of Presidents Kennedy, Johnson, Nixon, and Ford, utilizing evidence-based leadership, these physicians led both US and worldwide efforts that resulted in smallpox becoming the first human disease ever eradicated from the face of the earth.
      Presently in the United States, healthcare providers are understandably confused about the current and future issues concerning coronavirus disease 2019 (COVID-19). This infectious disease is caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2) that is now responsible for an emerging pandemic. The first cases were reported in Wuhan, China on December 31, 2019.
      • Hennekens CH
      • Buring JE
      Epidemiology in Medicine.
      The first case in the United States was reported on January 22, 2020.

      World Health Organization. Coronavirus disease 2019 (COVID-19): situation report–53. Available athttps://www.who.int/docs/default-source/coronaviruse/situation-reports/20200313-sitrep-53-covid-19.pdf?sfvrsn=adb3f72_2. Accessed March 13, 2020.

      During that interval containment was potentially achievable in the United States, which would have included collaborative efforts, such as the widespread utilization of the rapid testing kits available from the World Health Organization. At present, however, strategies must be employed to flatten the curve to decrease avoidable morbidity and mortality, which include, but are not limited to, widespread testing with rapid turnaround and social distancing.
      • Langmuir AD
      The surveillance of communicable diseases of national importance.
      • Langmuir AD
      • Henderson DA
      • Serfling RE
      The epidemiological basis for the control of influenza.
      • Henderson DA
      Smallpox, the Death of a Disease.
      • Henderson DA
      The development of surveillance systems.
      • Hennekens CH
      • Buring JE
      Epidemiology in Medicine.
      In addition, some reports provide reassurance and others an ominous foreboding. The current incomplete totality of evidence provides cause for serious concerns and, more importantly, an urgent need for public health leadership, but neither reassurance nor alarm.
      On the one hand, it is reassuring that perhaps over 80% of symptomatic individuals will experience only mild flu-like symptoms. On the other hand, it is alarming that, as it appears, based on currently available data, perhaps 15% of affected patients will become seriously ill, and 5% will need critical care. As of Friday, March 13, at 1:00 PM ET, there were 125,048 confirmed cases and 4613 deaths (3.7%) worldwide.

      World Health Organization. Coronavirus disease 2019 (COVID-19): situation report–53. Available athttps://www.who.int/docs/default-source/coronaviruse/situation-reports/20200313-sitrep-53-covid-19.pdf?sfvrsn=adb3f72_2. Accessed March 13, 2020.

      As mentioned above, the first cases were reported in Wuhan, China, in late January 2020. Today, there are reported cases on every continent except Antarctica. In the United States, the numbers of confirmed cases and deaths have risen over the week from 307 cases and 17 deaths (5.5%) to 1629 cases and 41 deaths in 46 states and the District of Columbia, with an initial cluster in a nursing home in the state of Washington and currently another in New Rochelle, New York.

      Centers for Disease Control. Coronavirus disease 2019 (COVID-19).https://www.cdc.gov/coronavirus/2019-ncov/index.html. Accessed March 13, 2020.

      Healthcare providers should be aware that younger and healthy individuals will represent a larger proportion of the population who experience mild to moderate symptoms, and older individuals with preexisting conditions will be overrepresented among the deaths. They, along with their patients and the general public, should remain fully cognizant that the young and healthy are not free of risk of death, but there are large segments of the population at higher risk. These include adults aged ≥60 years; those with chronic diseases such as cardiovascular disease, diabetes mellitus, and lung disease; and those receiving chemotherapy or who are otherwise immunocompromised through illness or therapies. These guestimates about the numbers of cases will become more reliable with more widespread and accurate testing. It is somewhat sobering to note that South Korea, which has a population about one-sixth that of the United States, has tested over 240,000 or about 1 per 250 people. In contrast, the United States has tested 13,624, which includes 3903 from the CDC and 9721 from public health laboratories.

      Washington Post. South Korea is doing 10,000 coronavirus tests a day. The U.S. is struggling for even a small fraction of that. Available at: https://www.washingtonpost.com/world/asia_pacific/coronavirus-test-kits-south-korea-us/2020/03/13/007f14fc-64a1-11ea-8a8e-5c5336b32760_story.html. Accessed March 13, 2020.

      Healthcare providers should be reassured that in South Korea and the United States, among patients with symptoms, only about 3% tested positive for coronavirus.
      When the totality of evidence is incomplete, it is certainly appropriate for healthcare providers to remain uncertain in the choice of specific preventive and therapeutic measures for their individual patients. However, that is not the case for public health and regulatory authorities. These dedicated public servants have been trained to maximize benefits and minimize risks while attempting to prevent and treat apparently emerging pandemics. Thus, it seems altogether fitting and proper for public health officials to lead public health efforts and politicians to lead political efforts.
      Appropriate concerns—not fear—should play a major role in the emerging pandemic. Public health efforts should focus, primarily, although not exclusively, on public health issues. Economic considerations seem of greater importance than political considerations. In the United States and globally, there is already ample evidence of person-to-person transmission of what appears to be a highly infectious agent. In addition, collegial and collaborative multifactorial preventive and therapeutic measures in the United States and throughout the world are warranted to control the pandemic. Healthcare providers and the general public should be aware that any vaccine is likely to emerge only after 1 to 2 years. However, healthcare providers should also be aware that chloroquine phosphate has shown apparent efficacy and an acceptable safety profile against COVID-19.
      • Gao J
      • Tian Z
      • Yang X
      Breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies.
      During the 2018-2019 flu season, about 42.9 million Americans were clinical cases, of which 647,000 were hospitalized and about 61,200 died. Based on the current incomplete totality of evidence, it appears that coronavirus is comparable in communicability to influenza but with perhaps a 10-fold higher case fatality rate. If so, the guestimates suggest that if the epidemic continues to propagate in the United States, there may be 612,000 deaths and perhaps millions of hospitalizations. This staggering number of hospitalizations could paralyze the US healthcare delivery system. Further, the overcrowding of hospitals by patients with coronavirus may make it more difficult to provide lifesaving treatments to those with other life-threatening conditions. In addition, the estimated number of deaths is comparable to that of the most lethal epidemic of influenza in US history, which occurred in 1918. During that year, about 675,000 Americans died.

      Spreeuwenberg P, Kroneman M, Paget J. Reassessing the global mortality burden of the 1918 influenza pandemic. Am J Epidemiol. 187:2561-2567.

      We believe that Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, is the Babe Ruth of virology in general and influenza in particular. His proven capacity and capability for collaborative, expert leadership can guide the United States and the world through this pandemic and ensure our preparedness for the challenges ahead.

      References

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        The surveillance of communicable diseases of national importance.
        N Engl J Med. 1963; 268: 182-192
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        • Henderson DA
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        The epidemiological basis for the control of influenza.
        Am J Pub Health. 1954; 54: 563-571
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        Smallpox, the Death of a Disease.
        Prometheus Books, Amherst, NY2009
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        Am J Epidemiol. 2016; 183: 381-386
        • Hennekens CH
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        Epidemiology in Medicine.
        Little, Brown and Company, Boston, MA1987
      1. World Health Organization. Coronavirus disease 2019 (COVID-19): situation report–53. Available athttps://www.who.int/docs/default-source/coronaviruse/situation-reports/20200313-sitrep-53-covid-19.pdf?sfvrsn=adb3f72_2. Accessed March 13, 2020.

      2. Centers for Disease Control. Coronavirus disease 2019 (COVID-19).https://www.cdc.gov/coronavirus/2019-ncov/index.html. Accessed March 13, 2020.

      3. Washington Post. South Korea is doing 10,000 coronavirus tests a day. The U.S. is struggling for even a small fraction of that. Available at: https://www.washingtonpost.com/world/asia_pacific/coronavirus-test-kits-south-korea-us/2020/03/13/007f14fc-64a1-11ea-8a8e-5c5336b32760_story.html. Accessed March 13, 2020.

        • Gao J
        • Tian Z
        • Yang X
        Breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies.
        Biosci Trends. 2020; 14: 72-73
      4. Spreeuwenberg P, Kroneman M, Paget J. Reassessing the global mortality burden of the 1918 influenza pandemic. Am J Epidemiol. 187:2561-2567.

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