Assessing Coronavirus (COVID-19) Risk

Coronavirus testing, data, and fatality rate with Dr. Kirk Parsley.

Key Takeaways

  • Current coronavirus data are biased toward the very sick, so the case fatality rate may be inaccurately high.
  • The risk from coronavirus death may not be much more than the risk from seasonal influenza.
  • A science-based approach to policy is preferable to a fear-based approach.

Is coronavirus risk as high as the media and government are making it out to be? I recently met with Dr. Kirk Parsley, to discuss coronavirus data, and what conclusions we can make. He thinks the data suggest we don’t need to be as concerned as we have been.

He also outlines a very thought provoking hypothesis, which is that there might be an upper limit in terms of how many people are susceptible to death from any kind of sickness in a population at any given time.

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In This Episode

Dr. Kirk Parsely’s Background … 00:05:29
How Do We Move Forward with COVID-19? … 00:07:25
Case Fatality Rate & Data Bias … 00:11:20
COVID Politics & Choosing A Direction … 00:15:57
Information & Fear … 00:18:59
Mask Effectiveness … 00:25:22
COVID Death Data & Test Data Challenges … 00:30:21
Relative Risk: COVID vs. Flu … 00:40:17
Herd Immunity … 00:49:12
Vaccine … 1:00:35
Coronavirus Testing … 1:04:08

How Do We Move Forward with COVID-19?

I’m sure we’re all in agreement that we needed to flatten the coronavirus curve so as not to overwhelm hospital capacity. But what does the long-term road from here look like? Are we going to try to mitigate until we have a viable treatment or coronavirus vaccine, or are we going to go fully in the other direction? What is the best path to take?

Dr. Parsley acknowledged that even though we really don’t know yet, “At the end of the day, regardless of what anybody’s calculations are, we’re going to have to expose most of the population to this. There’s really no way around that.”

“So I think the way ahead that makes the most sense is we need to protect the vulnerable and susceptible, which isn’t as severe as a lot of people think it is…at some point, we need to rise above that and we need to…put our toe in the deep end of the pool and…ease in there.”

Case Fatality Rate & Data Bias

One of the biggest challenges we face in making decisions about coronavirus is the lack of clear data. One of the least clear data points is the true case fatality rate (CFR). We don’t really know how many people are dying from COVID-19 compared to those who died with COVID-19, and we don’t know the true number of coronavirus infections. Dr. Parsley said, “If we’re only looking at people who are very, very sick going to the hospital and being tested, that’s a biased sample…So it throws off the math.”

And who is and isn’t getting tested is also influencing the data. “Anybody who is a positive case got tested for a reason. There’s a selection bias to that. And that selection bias could be that they were really sick. It could be that they were healthcare workers, it could be that maybe they were in a particularly vulnerable population, like in a retirement home…”

Dr. Parsley says that the challenge is, “If you test everybody in America, that data becomes useless because you’ve never tested everybody in America for anything else.”

What we really need to know is the case fatality rate, but until we have larger data sets and more widespread coronavirus testing, the data aren’t going to truly reflect the risk. So how else can we consider risk?

Relative Risk: COVID-19 vs. Flu      

Dr. Parsley suggested there are a lot of possible risks in life, so how do we assess whether COVID-19 is risky enough to warrant what we’re doing? “I think one of the things…is giving people relative risk data. How does this compare to XYZ?”

“The question is, is it dangerous enough to do what we’re doing? I think the answer to that is pretty clearly no.”

Dr. Parsley has been comparing seasonal flu data with coronavirus data, and thinks that the number of deaths will be within the statistical average for a bad flu year when all is said and done. ‘If we’re going to compare it to other influenza-like illnesses, in 2017-18, we had a really bad flu season and we had 61,000 deaths.”

He commented on his perception of the risk of cases and deaths if you’re fairly young and healthy: “I think that the data is very suggestive that this is not going to be some astronomically different death toll than what we’ve seen before.”

He also suggested that there might be an upper limit as to how many people die, because there are only so many susceptible people in the population who might die from a virus, like influenza virus or coronavirus, during any year.

He encouraged us to study the sources of data ourselves:

COVID-19 Politics & Choosing a Direction

Dr. Parsley: “I just think [the media] have done a bad job of presenting people with information that doesn’t lead to fear and excess risk. How you communicate risk is very important. I think we can all get behind a direction and go in that direction rather than what it feels like is happening: no one wants to be culpable for people dying or people losing their jobs. So they’re trying to kind of tow the middle line. And I’m not sure if that’s the best approach.”


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Mask Effectiveness

There’s a lot of debate about face masks and whether they are an effective method for coronavirus infection prevention.

Dr. Parsley shared a little metaphor about viral size: “If you enlarge the virus to the size of a marble, the smallest hole you could see on your mask would be 83 feet in diameter.” He cited a research study that was done in Korea, comparing viral transmission with no mask, a surgical mask, and an N-95 mask. Interestingly, there was no difference whether you had a mask on or not.

But Dr. Parsley admitted that a mask is “definitely better than nothing if you’re trying to reduce the absolute distance any person could spread [infection].” He added, “I just think that if we’re going to set policies, there needs to be scientifically based logic behind them.”

Coronavirus Vaccine

Dr. Parsley said that scientists seem optimistic about finding a coronavirus vaccine, but that we don’t really know if we’ll truly be able to develop one. But he also gave the caveat that “we really can’t just sit around and wait for that to happen. And even if it came out in two to three weeks, you still have to inoculate everybody.”

Coronavirus Testing

Dr. Parsley thinks the biggest benefit of coronavirus testing is to use it to do research to understand the patterns of getting infected with the virus, so we can learn more about how to effectively slow or stop the spread of the virus. “But the biggest benefit overall is that with more testing, we’ll have a better idea of how many people have it.”

The Bottom Line

According to Dr. Parsley, the threat of coronavirus may be overestimated, and we need to find ways to be clear about the relative risks of being infected. Accurate use of data will be one of our biggest assets.

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Discussion

I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!

2 thoughts on “Assessing Coronavirus (COVID-19) Risk

  1. Just some thoughts on this presentation.
    Herd immunity is sort of a “straw man.” Until we had a vaccine, there was no herd immunity to measles, for example, or small pox, or polio. Every year, the susceptible population had a great deal of morbidity and mortality. As a family physician, every year, I beat people over the head to get their influenza vaccine . . . . and to stay home when they are sick, and to wash their hands, etc. And I am personally aggrieved with the amount of morbidity and mortality with every flu season. It is not just that the “herd is culled” (hey, let’s just put all the oldsters on an ice flow so we don’t have to feed them), there is a lot of suffering that goes along with it.
    Of interest, a couple weeks ago, I saw my first case of gastroenteritis since January. I then realized that the last bronchitis/sinusitis I saw was the second week of shut down. So distancing and isolating and hand washing has been helpful. I don’t think we should shut everything down, necessarily, but at all times we should be aware of hygiene. After I have read the studies of people who don’t wash their hands in public bathrooms (men are far worse than women, and isn’t that just gross), I’m not excited about shaking anyone’s hand unless I personally see them wash it. I have my own observations that show that less contact and better hygiene slows down infectious disease I will mention later.
    I am 69 and in contact with the public — often the sick public — and I am not fearful. But I also have insulin resistance, irregular heart rhythm and this and that. I wear a two layer woven cotton mask with a filter of polypropylene (has an electrostatic charge that neutralizes virus and is in surgical masks) that gets changed every day. Depending on the day, I may change my mask up to three times, then they get washed. They are made so there is no gap under my chin or by my cheeks. and I’ve almost got the gap at the nose figured out. I suggest my patients wear masks in the office, but if they don’t, I don’t force them to — until I am going to get my nearly 70-year-old body up close and personal to examine them. Then I give them a mask and they put it on or they leave. I plan on practicing medicine for at least 15 more years and I want to enjoy some retirement. I am not as sanguine as the 70-year-old relative you quoted — I am not willing to sacrifice my viability and productivity because some other person is not willing to do the small courtesy of keeping their respiratory moisture to themselves.
    I recognize that a virus is very small. However, most viruses don’t live long or maintain their virulence very long outside a host cell. If they are in fine spray, droplets or mucous, it is a whole nother ball game. And masks do stop a lot of that spray. Folks need to be educated about how to fit a mask and to keep their dirty fingers off it, but that shouldn’t be too hard. The scrub nurses who terrify new doctors and nurses managed to teach us how to wear a mask.
    If masks are not helpful, then why did the case of two sick hair dressers exposing a total of a little over a hundred people at a New Jersey hair salon result in NO transmission (every one was wearing a mask as required), and the case of a group of young adults going out on the town in Florida result in all 14 of the people in the group testing positive, plus 7 bartenders? Sure they were young and they PROBABLY won’t come to harm (not a guarantee), but how much virus did they spread to people who COULD come to harm?
    And the pastor and his wife in either Oklahoma or Arkansas, I can’t remember which, who managed to infect over 30 in their congregation (3 of whom died), and there were 12 community cases from that exposure with another death.
    The nursing home in my town received an elderly patient from the hospital for rehab. He had horrible shortness of breath, but it was thought to be heart failure. No one bothered to test him before he went. Within three days, he was dead of the virus, and within 10 more days, ten other patients in the nursing home were dead, many were ill, and many staff were ill. One of those staff, a nurse’s aid, was among them. I saw her in my office for continued shortness of breath — once she was there, it was obvious I was seeing her for PTSD. During a “normal” flu season, our little nursing home doesn’t have 11 deaths on one floor in 14 days. In an average flu year here in the nursing home, almost NO ONE dies of flu — because all of them and all their caregivers have gotten their influenza and pneumoccocal vaccines!
    Did they have a good quality of life? No. After watching my father dwindle for two years in that nursing home, my children were given a new directive — if I can’t physically feed myself for more than just a brief illness, don’t feed me. But that wasn’t the contract we made with these people. We said by implication that we would take care of them, and we didn’t. I am sure you two didn’t mean to be unfeeling, However, the way you discussed “thinning the herd” sounded more like mercy killings. I am not against assisted suicide in strictly controlled situations. But allowing the vulnerable to die or accepting their deaths because “they would have died of something anyway” because we are too lazy or selfish to practice good hygiene and infectious disease medicine, amounts to willful participation in another human being’s death. Read “Animal Farm” again, in case you are getting cozy with that idea.
    Your discussion of this being like a bad flu season made me wonder if you have practiced any kind of community or hospital medicine over the last 20 years (I have). Only three or four times have we had to divert people because a hospital was too full. We have never had so many people on vents, that I know.
    The novel H1N1 year, there were a huge number of influenza cases, but the death rate wasn’t much more than a “usual” year, because the target population were much younger. I have already looked that one up when discussing this with someone else.
    Even comparing the death rate from the pandemic with our yearly traffic deaths is disingenuous. In 1965 (a year before I got my driver’s license), there were 47,089 traffic fatalities in the US. In 2018 (the last year in Wikipedia), there were 36,540. Doesn’t seem like much of a change. But the public health side of DOT in the United States didn’t accept those deaths and has worked really hard to make safer roads, safer cars, public education on impaired drivers, so the picture isn’t what it seems. In 1965, there were 24.24 deaths/100,000 people, we traveled around 887 billion miles and had about 5.3 deaths per 100 million miles. In 2018, we had 11.18 traffic deaths/100,000 people, traveled about 3,223 billion miles with 1.13 deaths per 100 million miles. With more miles traveled and more people traveling, if we had the per capita death rate we had in 1965, 79,992 people would have died last year on the road in the United States. Not only would that have been unacceptable, there are people who work in traffic safety who find our current highway death rate still unacceptable and continue to work hard on it. Or contemplate 40,000 people in the US dying every year from aviation related accidents. Would that be “thinning the herd” of people who were just too stupid to realize that planes are heavier than air and just can’t fly? After all, they would have died of something sometime.
    Finally, you don’t take into account the possible sequelae of this totally novel illness. The aftermath of the 1918 influenza saw people having relapses of severe fatigue. Measles can cause a fatal pancytopenia in a not insignificant number of people 5 to 7 years after recovering from the disease. My last post-polio patient died about 5 years ago. I’ve taken care of a handful of them . . . the pain and debility of post-polio syndrome makes me want to see the disease completely gone.
    We have here a virus that seems to enter the body through the endothelial cells, and not just lung endothelial cells. It increases the risk of not just pneumonia and ARDS, but also blood clotting in both veins and arteries (the famous COVID toes), can cause bowel ischemia and infarction and cause a cytokine storm the likes of which we haven’t seen since 1918. So what sort of sequelae is this going to cause? Are people going to end up with pulmonary fibrosis type scarring, given that even asymptomatic people positive for SARS-CoV-2 can have “ground glass opacities in their lungs on X-ray. Do we really want to experiment with allowing as many people to get sick as possible?
    Maybe we need to send some epidemiologists, doctors such as yourself, and politicians to South Korea and see what they are doing. Their population density is greater than ours, Seoul is larger than New York City, and at this point they are doing far less per capita testing than we are (not so at the beginning of the pandemic). They are still doing vigorous contact tracing and quarantining. But they never completely closed their economy. Of course, they have a decent government with no anti-scientific bias and a reasonably cooperative population who believe in working at least some of the time for the good of the society. Their death rate — 5 per million. Ours, 375 or so per million. Sweden’s, 517 per million. The worst influenza year we have had in modern history — 2018 with 80,000 deaths estimated, would have given us a death rate of 244/million — still way too high. Yes, everyone has to die and “pneumonia is an old man’s friend,” but you are discounting and overlooking the pain and suffering that goes a long with this. Since you emphasize a more healthy lifestyle and people taking responsibility for their own health, I would expect a different approach from you.
    Or maybe a delegation could go a study what is happening among the indigenous people in Brazil. Hmmmm, just thinning the herd.
    Especially since we have examples in South Korea, and Japan for example, where cases and deaths per capita have stayed low (and are probably accurate). Instead the United States and Brazil can go down in flames because we have corrupt and ignorant administrations. An uncontrolled epidemic of even good old influenza can bring the economy to its knees with no shut down. You can’t have half the employees of a meat packing firm be even moderately ill and keep the place open.
    What if this was Ebola? Not as virulent, say with an R0 of 1.5 or so. Maybe only has a true fatality rate of about 1%. But no one was immune to it, so everyone could get it. It involves, as you know, some really scary bowel symptoms and bleeding from every possible orifice, even if you have only a mild case and don’t die. How blase would the semi-auto packing good ole boys be about that? Would you and your guest be talking about achieving herd immunity? (By the way, a recent study in Sweden demonstrated that population samples in Stockholm showed only about a 6% immune antibody rate — and their death rate is at 517 per million and rising.)
    Sorry if this is so long and really contains no questions, but your discussion was deeply disturbing to me. There isn’t a need for fear, and I am not afraid. But I am going to do what I can to keep myself and my patients healthy. I’ll probably have to do it for a year. I am an adult. I can wear a mask in public for that long (Nancy Pelosi has a fashion designer making hers — what fun). I hope I never quit washing my hands as well as I am right now. And I won’t die if I don’t go to a movie or concert or medical meeting in person for a year or two. Especially if I might die if I do.

    1. I agree. I’m 65, diagnosed with microscopic colitis at 45. My aim is to stay healthy and continue to live. I may not have many good years left from all of my comorbid ailments but I would like to try to have the best years that I am able to have.

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