COVID-19 CURVEBALLS

“When life throws you a curve ball, hit it out of the park.”

- Anonymous

“Every strike brings me closer to the next home run.”

- Babe Ruth

With the 2020 World Series now upon us, I thought using baseball analogies in this Germ Gem post would not only be timely but also appropriate since from the very beginning of this pandemic in December 2019, SARS-CoV-2 has been throwing the medical and scientific communities curveballs. This Germ Gem post highlights some of the nastiest curveballs that this coronavirus has thrown at its major league opponent...Team Homo sapiens.

What inning are we in? No one saw SARS-CoV-2 coming and no one knows when it will be defeated. The following is, however, what we do know.

The first inning. The virus clearly emerged in China, but the exact source and date are still under investigation. Most of the evidence still points to a live animal market in Wuhan where a spillover from a bat to a human occurred in late 2019.

No sooner had the coronavirus emerged than a major curve ball was thrown that plagues us to this day—politicization of the pandemic. In my four plus decade career as an internist and infectious diseases specialist, I’ve never seen anything remotely like it. In America, politicization first appeared when President Trump referred to SARS-CoV-2 as “the China virus” and called for defunding the World Health Organization (WHO).

By the time the WHO declared a pandemic in March 2020, SARS-CoV-2 had spread to at least 114 countries. Admittedly, the WHO was slow at the switch with its declaration. Nonetheless, this is not a time when the US should be considering defunding WHO; it is a time we should be increasing its funding to help address this global problem.

At the time when the WHO declared a pandemic, the US reported only 1,267 cases. But it didn’t take long for our country to take the lead in numbers of cases and deaths globally. As of this writing, we are still first in the world with India not far behind.

Innings 2 and 3. Since its discovery, SARS-CoV-2 has presented difficult and unexpected problems not just for epidemiologists but for clinicians and researchers as well. As has been discussed in prior Germ Gem posts, the clinical presentation of COVID-19 can be unique. Silent hypoxia, anosmia (loss of smell), blood clots, strokes in young people,and COVID brain are just a few of the clinical curveballs this virus has thrown at clinicians. Many of these unexpected clinical features are rooted in the unusual nature of COVID-19 as a multisystem disease related to the predilection of SARS-CoV-2 to attack endothelial cells that line blood vessels throughout the body.

How the virus interacts with the immune system is another curve ball. Our immune system provides us with a primary defense against all microbes. But when defending us against SARS-CoV-2, the immune system can overreact thereby igniting a “cytokine storm” that can cause vital organs to shut down. Teams of immunologists around the world remain busy trying to unravel the mechanisms of immune defense and immune-mediated injury. In addition, recent reports of reinfections raise the question of the durability of immunity with implications for the long-term efficacy of a vaccine when it arrives.

Over the past eight months, our understanding of how SARS-CoV-2 is transmitted has unfolded. Epidemiologists fielded one curveball after another. Initially, it wasn’t clear how the virus spread and whether there is value for everyone to wear a mask and to “social distance.”

We now know, however, that the virus is clearly spread mainly by an airborne route—both by large droplets and by smaller aerosols that stay aloft longer and travel farther. We also know that about 40% of infected persons are asymptomatic, yet they can transmit the virus through coughing, sneezing, loud speaking, and singing. While we might feel somewhat reassured by the fact that only about 20% of infected people actually spread the virus, we don’t yet know how to identify them versus the 80% that are non-transmitters. Also, we need to figure out what’s up with “superspreaders”—individuals who are more likely to infect others and who play a big role in fueling the pandemic. Nonetheless, it is now clear that we should all wear a mask when in public spaces and should keep a healthy distance (6 ft or more) from others.

Top of the 4th? According to Michael Osterholm, Ph.D., Director of the University of Minnesota’s Center for Infectious Diseases Policy and Research: “We’ve moved from inning two to inning three and I would say we’re probably in inning four, and in some places in the world we may be in inning five, even. But we still have a long way to go.”

Who would have believed in the early weeks of the pandemic that by mid-October, COVID-19 would have been reported in 217 countries, that the number of cases would surpass 39 million, and that more than 1 million lives would be taken by SARS-CoV-2?

Moreover, both the US and Europe are now witnessing an upsurge in cases. To get a current assessment of where the US stands in the 4th inning, four articles in the October 12, 2020 issue of the Journal of American Medical Association tell the sobering story of COVID-19’s costs to human lives and to our economy—by then the number of deaths (218,000) approached those from World War II, and the economic cost was estimated at $16 trillion.

The politicization curveball by the current administration has interfered with the work of the Center of Disease Prevention and Control (CDC) and the Federal Drug Administration (FDA). But the good news is that we have science and a number of trustworthy scientific leaders at the National Institutes of Health (NIH) on our team. We must ensure that they continue their good work free from all political pressure.

Innings 5 and beyond. By now everyone should be aware that the first four innings witnessed an unprecedented recruitment to Team Homo sapiens in the form of collaborations between academic institutions, non-profit organizations, such as the NIH, CDC, FDA, and WHO, and the pharmaceutical industry. These collaborations have led to increased knowledge of the tactics of SARS-CoV-2 and have delivered several treatments of COVID-19. And, it is highly likely that “Operation Warp Speed,” which is built upon these collaborations, will yield at least one safe and effective vaccine within the next several months—something we should all celebrate.

We do not know when or how the COVID-19 pandemic will end. And, we can expect some tough innings ahead. But we can be certain that our team is going to win. In his October 10th article “Reasons for Hope,” The Lancet editor Richard Horton points out that in the past, societies that faced much more devastating pandemics always bounced back stronger, smarter, and kinder. He suggests: “Something is stirring in the heart of our society. Old assumptions are being questioned. New directions are being proposed. Amid the carnage of COVID-19, a renaissance of hope is emerging. It’s time to join the conversation about the world to come.”