Discussing The Coronavirus Outbreak with Dr. Paul Offit


Featuring: Felipe Nogueira, Paul Offit · At: ·

Paul Offit is a pediatrician and an expert on vaccines, immunology, and virology. He is the co-inventor of the rotavirus vaccine recommended for universal use in children by the CDC. Offit is also the director of the Vaccine Education Center at The Children’s Hospital of Philadelphia.

He is the author of many scientific papers and it is also a prolific writer with many books about vaccines and other medicine issues written for a popular audience, such as Vaccinated: One Man’s Quest to Defeat the World’s Deadliest Diseases. His most recent book is Overkill: When Modern Medicine Goes Too Far and will be published by HarperCollins on April.

In this interview, I talked with Offit about the recent outbreak of coronavirus (COVID-19) and its repercussions.

Nogueira: Are you busy because of the coronavirus outbreak? 

Offit: It is dominating our lives. I think the fear of the virus is a bigger problem than the virus itself.

Nogueira: Can we say so far this virus is worse than the swine flu (H1N1) outbreak on 2009? 

Offit: No. Probably the best data comes from South Korea, where they tested more than 100,000 people. They found 6,000 cases and 42 deaths, which is a mortality rate of about 0.7%. Maybe it is a little worse than the 2009 H1N1 pandemic, but not much. Even the seasonal flu has a mortality of about 0.5%. The problem with coronavirus is that people think they are more likely to die if they get it. I think all evidence says that is not true.

Nogueira: Doesn’t this fear of the virus come from the high mortality rate 3%, or 6% considering closed cases, that’s been reported?  Even the World Health Organization (WHO) reported those numbers. I think the problem with those numbers is that we don’t how many people really have the virus, as we cannot as this moment know exactly how many people have, for instance, a mild disease. 

Offit: That is the reason that I think the South Korea’s data is important; they screened 100,000 citizens.They have a better idea of the amount of asymptomatic infections and mild symptomatic infections. Thus, they could understand better the tip and not only the base of the iceberg. The United States were very slow to get out a diagnostic test. South Korea had tested 25,000 people before U.S. tested 500 people. We need to have a better idea of what the mortality rate is, but in my understanding it is far lower than the WHO is reporting.

Nogueira: Regarding the actions done by governments around the world: In Italy, schools were closed and also the soccer competition was suspended in the last weekend. Do you think it is more motivated by fear than the real danger of the virus?

Offit: Yes. This year, in the United States, there were between 300,000 and 500,000 hospitalizations from influenza. We had between 20,000 and 45,000 deaths. Of those, 154 occurred in children.

In the last two months since COVID-19 has been in United States, 20 children have died from influenza; no children have died from COVID-19.

I wish that every week they put up the number of deaths from influenza and the number of deaths from COVID-19; we would realize that influenza is far worse. But we do not quarantine and we do not cancel meetings or shut down schools, churches, and synagogues from influenza. I do not understand what the difference is. If these two viruses are likely to cause infection and disease, why we are treating one different from the other? What worries me is that our administration has recommended people to go to their doctors and ask to get tested for COVID-19. I think people with mild symptoms are going to their doctors wondering if they have COVID-19. This is going to be a real impact on the American healthcare system.  It will make it harder to get resources and harder to help people who really need it. I think we are going to do more harm than good in all this.

Nogueira: Are those people with coronavirus who need help treated different than severe cases of influenza?

Offit: Some symptoms are different. It is more likely to have a higher fever and dry cough with coronavirus than with influenza, but a part from this they are very similar respiratory viruses. What worries me is that we created such fear that people are susceptible to get treatments that are not going to work; the health and wellness community will get into this. And there are people interested in making a vaccine. I hope we do not rush it through, because the fact is, like influenza, the people most likely to die from coronavirus are the elderly and people with heart disease. The nursing home outbreak in United States is responsible for a large number of deaths we had in the country.

Nogueira:  Aren’t people getting ahead of themselves when they mention a vaccine? Vaccines take time to develop and to be tested. What is the shortest amount of time required to have a vaccine for COVID-19 ready?  

Offit:  I can’t imagine that a vaccine would be ready for phase 3 efficacy trial within two years. It is not like we have been working in the coronavirus in the last 20 years. When Ebola outbreak occurred in West Africa, the National Institutes of Health have been working on Ebola vaccine for 20 years. They have done animal-model testing and phase 1 and 2 safety and immunogenicity testing. When an outbreak occurred, they had the vaccine in the vials and they were ready to test it. This is not true for coronavirus; we don’t have a history of making a coronavirus vaccine. How are we going to make it? Is it going to be an mRNA vaccine? Is it going to be a DNA vaccine? Is it going to be a purified-protein vaccine? Is it going to be a vector vaccine? Nobody knows. And certainly the FDA needs to regulate this product, because everybody in United States would take the vaccine even if it was not tested, remembering that most people are not going to die from this virus even if they get it.

Nogueira: What about some drug that already exists and can be used in the case of coronavirus? 

Offit: In general, antivirals are not wonder drugs. Oseltamivir, an neuraminidase inhibitor, might save a day of symptoms of influenza, assuming the person is otherwise healthy. For people who are immune compromised, who are more likely to shed virus for much longer, those antivirals may be of value.

The problem with viruses is they replicate in cells. Unlike bacteria, you have at some level to affect transcription or translation. But by the time you have symptoms, probably most of the viral replication has already happened. That is why antivirals do not make a big difference.

Nogueira: A 2014 Cochrane Review [1] has shown what you said: oseltamivir is not a wonder drug for influenza. So we shouldn’t expect that is going to be a wonder drug for coronavirus, right?

The notion of cure is not really the right one for viruses. It is possible to treat bacterial meningitis and bacterial pneumonia; you kill those bacteria and the patient gets dramatically better, but that is not the way antivirals work.

When a person is infected with the virus, the virus starts to reproduce itself. As the virus reproduces itself, the body responds and makes an immune response. That is when the person develops symptoms. You develop symptoms within the immune response. With the immune response, the viral shedding starts to decrease. Probably, you are shedding the most virus one day or two before the symptoms. As you develop symptoms, the amount of viral shedding goes down. Thus, the most of the damage that has been done by the virus has usually been done by the time you develop symptoms. I think that is the main reason why antivirals are not terribly effective.

Nogueira: Are the deaths from coronavirus mainly from the pneumonia?

Offit: In the data from China, people have died directly from viral pneumonia or from Acute Respiratory Stress Syndrome, which is the so-called cytokine storm: a reaction to the pneumonia.

While researchers are working to stem the contagion, the best advice for personal safety is to wash your hands frequently, avoid touching your face, and avoid large crowds—especially if you are elderly or immune compromised.

Reference: 

  1. Jefferson, T., M.A Jones MA, P. Doshi, et al. 2014. Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD008965. DOI: 10.1002/14651858.CD008965.pub4.

        

Felipe Nogueira received his PhD in Medical Science from Rio Janeiro State University (UERJ). He has Master degree in Computer Science. As a science writer, Felipe was a regular columnist for Skeptical Briefs-the newsletter of the Committee for Skeptical Inquiry. He has also made contributions to Skeptical Inquirer and Skeptic magazines. His articles can be found at https://www.csicop.org/author/Felipe_nogueira and http://skepticismandscience.blogspot.com/