Here's how coronavirus could become a pandemic—and why it matters

In the two months since the novel coronavirus was announced in China, it has expanded across the globe. Outbreaks have been reported in more than 50 countries with more than 85,000 confirmed cases and 2,900 deaths worldwide. Stock markets posted their biggest tumble since the 2008 recession this week as case counts of the virus, which causes the disease named COVID-19, rose sharply in places like Italy, Iran, and South Korea. Meanwhile, the U.S. Centers for Disease Control and Prevention announced that it’s just a matter of time before the virus thrives in America as well.

a group of people wearing costumes: A woman wearing a mask to prevent contracting the coronavirus reacts as employees from a disinfection service company sanitize a traditional market in Seoul, South Korea, February 26, 2020.

“It’s not so much a question of if this will happen anymore but rather more a question of exactly when this will happen and how many people in this country will have severe illness,” said Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, in a press briefing on Wednesday. On Saturday, Washington state announced the first U.S. death due to the novel coronavirus.

Given this globalized spread, the term “pandemic” is beginning to circulate among officials and the news media.

But public health authorities are stopping just short of officially labeling this emergency as a pandemic: In her remarks, Messonnier noted that the world is moving closer to meeting the criteria for a pandemic. Meanwhile, World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus also said this week that we’re on the precipice of a pandemic.

So what exactly is a pandemic—and what happens when a major public health agency, like the WHO, declares one? While calling this global health crisis a pandemic might not change the facts on the ground, it can stoke public fears and propel a shift in strategy toward mitigating harm.

What is a pandemic?

Global health crises tend to grow in phases. This chain of events starts with an “outbreak”—a sudden rise in confirmed cases of an disease that’s contained to a small geographic region like Wuhan. If the disease spreads just beyond that community—like how the novel coronavirus spread across China—then it becomes an epidemic.

Pandemics, according to their classical definition, are epidemics that cross international boundaries and affect a large number of people worldwide.

“It’s all about geography,” says Lauren Sauer, an assistant professor of emergency medicine and the director of operations with the Johns Hopkins Office of Critical Event Preparedness and Response. “It’s not about severity, it’s not about high versus low case counts. It’s…do we see spread across the globe?”

Not every widespread epidemic is considered a pandemic. Seasonal influenza, for example, checks those boxes—but its cyclic nature is what differentiates it from pandemic influenza, which can spread anywhere across both hemispheres regardless of the weather. (Will warming spring temperatures slow the coronavirus outbreak?)

A pandemic declaration also takes into account who is infected and where. If a person catches the coronavirus in China and travels back to their home country, they do not count toward the tally that ultimately decides a pandemic declaration—and neither does anyone they infect. Sauer says these constraints arose out of the lessons learned during the H1N1 pandemic in 2009, when the ease of global travel made it seem like the disease was spreading faster and more widely than it was. (Here’s how coronavirus spikes outside China show that travel bans aren’t working.)

Instead, public health authorities are looking for local transmission of COVID-19. That’s the stage where the virus begins spreading outside of China among people who have not recently traveled to the Asian nation. Early in an epidemic, most of those cases can be traced to travelers from the outbreak’s original site, in this case China. But as local transmission progresses, that contact tracing breaks down. At this turning point, the coronavirus can spread unnoticed, making it extremely difficult to control.

Some public health experts argue that the novel coronavirus has already achieved pandemic status when measured against these definitions: Cases have been confirmed on six continents, including 2,300 in South Korea and 650 in Italy. In many of the countries, outbreaks are being sustained locally, with the latest examples simmering in California, Oregon, and Washington.

On Saturday, Dr. Robert Redfield, director of the CDC, said the fatal case in Washington could not be traced to a known infected patient nor to a traveler from China. Meanwhile, the White House announced 14-day bans for any foreign nationals who have traveled through Iran, while the State Department issued its highest possible warning for travel to parts of Italy and South Korea. President Donald Trump said he is considering additional travel restrictions for the border with Mexico, even though the southern neighbor has only two confirmed cases versus the 62 reported in the U.S.

So what is stopping the WHO from calling this epidemic a pandemic? “In reality, it’s semantics,” Sauer says. “But semantics become important when you’re talking to the general public about these issues.”

Why pandemics do—and don’t—matter

Words matter. In a press briefing on Wednesday, director-general Ghebreyesus urged caution against rushing to cry “pandemic.”

“Using the word pandemic carelessly has no tangible benefit, but it does have significant risk in terms of amplifying unnecessary and unjustified fear and stigma, and paralyzing systems,” he said.

Lawrence Gostin, a Georgetown University professor who is also director of the World Health Organization Collaborating Center on National and Global Health Law, highlights that “panic” is literally in the word “pandemic.”

In 2009, people around the world panicked when the WHO described H1N1 influenza as a pandemic, Gostin says, and then the organization was later criticized for raising public alarm when the virus turned out to not be very lethal. H1N1 now returns seasonally and is part of our annual vaccine preparations.

“So the fact that this may become a pandemic is certainly a concern because this is much more deadly than the flu,” Gostin says, “but it’s something we’ll want to delay as long as possible until we get a vaccine, which should probably be within 12 to 18 months.” (Learn about how coronavirus compares to flu, Ebola, and other major outbreaks.)

From a legal standpoint, though, it doesn’t matter whether the WHO calls this a pandemic or not.

Gostin—who points out that the WHO doesn’t even actually “declare” pandemics—says the organization has already declared something far more significant: a Public Health Emergency of International Concern (PHEIC). That declaration legally allows the WHO to make recommendations on how member countries should handle an epidemic. It also mobilizes funding and political support.

So, what happens if COVID-19 is called a pandemic?

While “pandemic” might be merely a label without legal significance, it does have its value. A pandemic signifies that authorities no longer believe they can contain the spread of the virus and must move to mitigation strategies, like closing schools and canceling mass gatherings.

This is precisely why some public health experts argue that the WHO and other global agencies should go ahead and make the call, Sauer says. The sooner that public health authorities and first responders transition to mitigation measures—like the ones we see each year with the flu—the better.

In the U.S., the CDC has already shared its strategy for protecting communities in light of a coronavirus pandemic. It includes “social distancing measures” like closing schools and recommending telework to prevent infected people from spreading the disease to their classmates and colleagues. Events and mass gatherings could be postponed or even canceled. Even this summer’s Tokyo Olympics could be canceled if conditions seem too dangerous. And the CDC would advise delaying elective surgeries to ensure the availability of hospital beds.

Gostin says these social distancing measures are not something that a public health organization would recommend lightly as they impact families, communities, and economies.

“Kids still have to be educated, their parents still have to be able to go to work, and people want to get out and enjoy themselves as well,” Gostin says. “So it’s not something that we’d want to do. Only if it was necessary.”

Individuals can also take preventive measures of their own, including regularly washing their hands, covering their sneezes, and wiping down surfaces.

But Gostin says there’s one thing people really need to remember if the WHO starts calling this a pandemic: “It’s important not to panic.”

Editor’s Note: This story has been updated with the news of the first U.S. death, additional instances of local transmission in the U.S., and the travel restrictions implemented on Saturday, February 29. The story was originally published on February 28. 

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