We are being far too complacent about COVID-19 and potential future pandemics

Part I

I don’t live my life in fear, but I also don’t subscribe to living my life in blissful ignorance and just accept whatever may come my way, or worse, just throwing caution to the wind. My personal approach is to be aware of the risks to the extent possible and reasonable, and then to make decisions as to the degree of mitigation efforts I am willing to undertake to reduce those risks according to how likely I think the risk is and how bad it would be if the risk materialized.

I write about this approach in detail in Chapter 15 of a book that I co-wrote with Dr. Ted Epperly entitled: “Preparing for the Next Global Outbreak: A Guide to Planning from the Schoolhouse to the White House,” released in April of 2023. https://www.press.jhu.edu/books/browse-all?keyword=Pate.

I want to give credit to Steve Skaggs, an executive who I was privileged to work with while I was President and CEO of St. Luke’s Health System. Steve taught me a lot about enterprise risk management, which has greatly informed and evolved my thinking on this subject.

You likely make these same kinds of decisions all the time and don’t realize the connection. Some of you likely just got your spouse or a child an iPhone or iPad or laptop for Christmas. You were faced with a barrage of decisions as to whether you wanted to purchase an extended warranty, a screen protector, a protection plan in the event something happens that is not covered by the warranty or you need a human being to help you with the technology, a protective case for the device, or an insurance plan that will cover loss of the device or damage so severe that the device cannot be repaired. All of these decisions likely caused you to reflect about the person you were getting the gift for; their prior track record of caring for, dropping or losing things; and how long you thought it likely they would use the device until the next must-have model comes out to then weigh against the cost of whatever protection option you were considering.

The thing is that risk mitigation measures involve trade-offs. If I choose not to get the screen protector, then I need to be extra careful not to drop my device because replacing the glass will be more expensive and more of a hassle. I have never lost or needed to repair my iPhone. If I purchase the insurance for my iPhone, I am out the cost if I never need it, but I have the piece of mind that if something does happen to it, I have made a good bargain by having the insurance. Everyone will weigh these factors, but likely give these factors different weight. I am unlikely to lose my iPhone, so it is more of a difficult decision to purchase the insurance; but for certain other members of my extended family, well, let’s just say it is not a difficult decision at all.

So, my general approach to a known risk is to consider how likely the risk is to materialize and how bad it might be if the risk did materialize. Let’s take influenza. I got influenza back when I was a resident physician assigned to work in a busy, county emergency room. I was young, healthy and probably in the best physical condition (other than for sleep deprivation) of my life at that point in time. However, I was miserable for a good 3 – 4 days, and sick enough that I missed about 5 days of work. If I was going to miss 5 days of work, I would have much preferred to have spent those days on a vacation with my wife, rather than at home in bed with fever, terrible body aching and a bad headache risking exposure of my wife and kids. Thus, my future risk calculations as to whether to get a flu shot and have a sore arm for a day or two, but be able to work, versus avoiding the risk of a sore arm every year, but assuming the risk that an average unvaccinated person will get influenza every 4 or so years was a no-brainer. I have received the influenza vaccine every year since then, and to my knowledge, I have not had another case of influenza.

Sometimes making risk mitigation decisions are fairly straightforward. The risk for influenza presents itself every year, generally over the same time period, and is highest among those with exposure to school-aged children. The risk for severe outcomes is highest among those who are over age 65 or under age 5, those who are pregnant, those who have chronic medical conditions (e.g., asthma, diabetes, heart disease). On the other hand, the flu shot is relatively inexpensive or in many cases free of charge, generally easy to get, and side effects mild.

But, sometimes, making risk mitigation decisions are not so straightforward, and we have seen this play-out with the current pandemic. Risk mitigation measures can be far more difficult when a new risk presents itself as the SARS-CoV-2 virus did, and because the risk is new, we actually don’t know how significant the risks are or how likely they are to occur. Unfortunately, we are, in general, very bad at judging these kinds of risks. The first mistake we often make, is we make an assessment of the risk by simply looking around us to see what seems to be happening. We all recall elected officials who were concluding that this couldn’t be a pandemic because people were not “dying in the streets,” perhaps an ignorant or cynical reference to outbreaks of the plague in pre-modern history. Obviously, if that is going to be the standard by which we judge whether to adopt mitigation measures, we are going to under-respond to infectious diseases and experience more illness and death than is necessary, or I would suggest, is prudent.

Looking around us may include more than just looking for dead bodies in the streets. Many will conclude that the risk can’t be that great because I don’t know anyone who is sick or anyone who has died from the disease. However, when a new pandemic is emerging, especially one that has begun overseas, it may take months before you would have people sick in your social circle. SARS-CoV-2 was first recognized to be causing illness in China in December of 2019, but we didn’t recognize the first case in the U.S. until the third week of January in 2020, and we didn’t identify our first case in Idaho until the second week of March. Obviously, the absence of illness affecting members of our family, friends or co-workers did not mean that the threat was not significant, and waiting to prepare and respond until it does will diminish any chance for containment of the spreading disease. As we write in Chapter 1 of our book, by the time the travel ban was implemented in the U.S., a U.S. citizen had already returned from China infected.

Unfortunately, there are many viruses that can cause serious disease and can be circulating around you, but you would not know it based on what I will call anecdotal observations, such as making an assessment solely on whether are any family members, co-workers or friends are sick. That is because, like SARS-CoV-2, oftentimes many of the people a virus infects may have no symptoms (asymptomatic) or may have mild and few, non-specific symptoms (pauci-symptomatic) that does not raise suspicion of the potentially serious virus causing the infection, but rather might be ascribed to having overdone things, being sleep deprived, or perhaps having “allergies.” A notorious example of this is poliovirus. When poliovirus circulates in a population, most parents of children will not know it. Their children may seem fine or may have symptoms that they would ascribe to just having a “stomach flu.” That is because, depending on the strain of poliovirus, only 1 child in 200 or more infected will develop the fully manifest and dreaded poliomyelitis. Going back to our risk framework, one might reasonably assess the risk of contracting poliomyelitis as being low (but increasing given vaccine hesitancy and global travel), but would reasonably have to assess the risk if their child was to get poliomyelitis as quite high since the health outcomes can be quite severe and life-long, including premature death. Then, these risks would be weighed against the cost, hassle and effectiveness of the mitigation measures – a series of 4 shots that every child can receive for free, are widely available in doctor’s offices and public health clinics and are extremely effective providing life-long protection against poliomyelitis.

The other problem with our risk assessments with new infectious diseases like COVID-19 is a focus on what we doctors would refer to as acute disease outcomes – what happens to the patient during the initial illness – the severity and length of the initial illness, whether the illness is likely to require a trip to the doctor or the emergency room, whether hospitalization is frequently necessary, and whether there is a significant risk of dying from the infection. This is where the media, press and public focused their attention during COVID-19. And, of course, as we saw in this pandemic, there will be those who will actually promote people getting infected as being good for their own health and leading to a state of so-called “herd immunity” (Dr. Epperly and I devote nearly all of chapter 12 of our book to explaining this flawed theory), if they consider the case fatality rate to be acceptably low.

However, as physicians we know (or should know) that there are plenty of viruses that don’t kill their hosts at the time of initial infection, but can cause serious health problems and even death months to years later (e.g., hepatitis C virus, Epstein Barr virus, measles virus, mumps virus, and human papilloma virus just to name a few). That doesn’t mean that all new pandemic viruses will cause long-term health consequences, but when we have high, sustained transmission rates to the extent that the majority of the population is becoming infected, and in many cases reinfected, prudence would call for adopting the “precautionary principle.”

The precautionary principle is often employed when the future risks are unknown, but there is some basis for anticipating that those risks may be significant and potentially serious in the future and the only known way to avoid those potential long term health consequences is to prevent infection until more time can pass to study whether health consequences occur and what they are. In this case, we knew from the original SARS coronavirus outbreak in 2002 – 2003 that even though most common coronaviruses did not cause significant disease burden, this coronavirus caused significant mortality and, in some individuals, long-term health consequences similar to what we began to see with SARS-CoV-2 in late 2020 and early 2021.

In fact, I commonly have heard some commenters recently say that infection is not the same thing as disease. I certainly believed that was likely to be the case in 2020, but I am far less persuaded of our ability to distinguish between the two since 2020, as we have seen increasing evidence of long-term health consequences, even in people who had asymptomatic or pauci-symptomatic infections. Now let me be clear, I am certainly not suggesting that everyone who is infected will develop long-term health consequences. What I am suggesting is that I don’t know who will develop long-term sequelae from infection (let alone multiple reinfections, which as I have pointed out in earlier blog posts do increase the risk of long-term health sequelae), and neither do those who are making that statement. It is not so much that the statement is technically wrong, as it is that I believe that statements like that suggest that we can distinguish at the time of infection those who will develop disease versus those who will not, which clearly is not true and I believe contributes to the public not making accurate risk assessments as they consider what is right for their selves and their families.

I mentioned above two important concepts. First, is that anecdotal observations are inherently biased and prone to misjudging risks. Second, is the precautionary principle when dealing with a novel virus for which there is wide-spread and sustained spread and no long-term follow-up. So, how do we make an accurate assessment of risk? We obtain data and until that point, we exercise the precautionary principle.

Let’s look at just a few examples of data and how they are showing that the conventional wisdom and anecdotal observations during this pandemic were wrong. [Let me just insert here that I have certainly not been right in every instance as I tried to anticipate and predict what would happen with this virus. However, through a combination of the precautionary principle, risk assessment and a healthy dose of good luck, neither my wife nor I, nor another family I regularly advise, have ever (to the best of our knowledge) been infected with SARS-CoV-2 or developed COVID-19. My interest in writing this blog post is not to suggest that I have always been right or that others were wrong. This is not a competition. This is about what can we learn from what we did right and what we did wrong, so hopefully, we can prepare for and manage through the next (and there will be a next) pandemic with better success, less illness and fewer deaths.]

The first example has been the common refrain that COVID just hospitalizes and kills those elderly folks who were going to die anyway. I have been persistent in trying to dissuade people of this notion on the weekly radio show (The Doctors Roundtable segment of Idaho Matters) I appear on (Boise State Public Radio on Wednesdays at 12 noon MT with host Gemma Gaudette). There has been data over the past couple of years that refutes that statement, but let’s look at a recent analysis and study published by the University of Oxford Assessment of COVID-19 as the Underlying Cause of Death Among Children and Young People Aged 0 to 19 Years in the US | Public Health | JAMA Network Open | JAMA Network.

The University’s Department of Computer Science found that during the time period August 1, 2021 through July 31, 2022, COVID-19 was the eighth leading cause of death in children and young people in the U.S. Keep in mind that the prevailing public view and that promoted by a number of physicians who engaged in disinformation campaigns was that children don’t get seriously ill from COVID, COVID is nothing more than a cold in children, and children don’t die from COVID. Further, young, healthy adults at their prime, were also led to believe that COVID, and even repeated COVID infections need not be a concern to them. By the end of this study period, large gatherings had become common-place again, masking seemed to be ever increasingly rare, there was far less interest in testing or receiving antiviral treatment when people became ill, few people were quarantining any longer following exposure to a known case of COVID, and many employers were no longer even requiring infected individuals to isolate. Schools seemed to have little interest in enhancing their air handling and filtration and eventually, to my shock, hospitals began to abandon masking even in cancer treatment areas and in neonatal and pediatric units.

What specifically did this analysis find:

• Among children and young people aged 0 – 19 years in the U.S., COVID-19 ranked eighth among all causes of death; fifth among all disease-related causes of death (i.e., excluding things like accidents); and first in deaths caused by infectious or respiratory diseases.
• By age group, COVID-19 ranked seventh (infants), seventh (1–4-year-olds), sixth (5–9-year-olds), sixth (10–14-year-olds), and fifth (15–19-year-olds).
• COVID-19 was the underlying cause for 2% of deaths in children and young people (800 out of 43,000), with an overall death rate of 1.0 per 100,000 of the population aged 0–19. The leading cause of death (perinatal conditions) had an overall death rate of 12.7 per 100,000; COVID-19 ranked ahead of influenza and pneumonia, which together had a death rate of 0.6 per 100,000.
• Like many diseases, COVID-19 death rates followed a U-shaped pattern across this age-range. COVID-19 death rates were highest in infants aged less than one year (4.3 per 100,000), second highest in those aged 15–19 years (1.8 per 100,000), and lowest in children aged 5 –9 years (0.4 per 100,000).
• Overall, deaths in children and young people were higher during the Delta and Omicron waves compared to previous waves (pre-July 2021), likely reflecting the higher numbers infected during these periods. Nevertheless, in the pre-Delta period of the pandemic, COVID-19 still ranked as the ninth leading cause of death overall.
• The month with the highest number of COVID-19 related deaths in 0 – 19-year-olds was January 2022 at 160.

Keep in mind that these statistics are only for those deaths that were reported as having been caused directly by COVID-19. Deaths where COVID-19 might have been a contributing cause to the death, but not the primary cause, were not included. Had the researchers included this group, the numbers would have been considerably higher.

Some have argued once confronted with data like this that the children who were hospitalized and died were those with serious underlying health conditions. However, another study showed that more than half of the children who developed severe disease were otherwise healthy and could not have been predicted to have developed severe disease.

Despite this data, the general public still is under the belief that COVID in children is no worse than a cold, and this, together with the vaccine hesitancy resulting from wide-spread, coordinated anti-vax and vaccine disinformation campaigns, likely accounts for the very low percentage of children, especially the youngest children being vaccinated with the COVID-19 vaccines.

Obviously, the absolute numbers of deaths in children from COVID-19 are low in comparison to older adults, but relative to other things that kill children, COVID-19 was significant.

The low absolute numbers caused some physicians to argue against COVID-19 boosters for children. Of course, some of these physicians were the same ones who spread vaccine disinformation and argued against anyone getting the COVID vaccines. Nevertheless, I was appalled to hear even a few reputable doctors argued against the COVID-19 boosters for children due to the low risk of serious illness or death. That has never been the sole or even major criteria for developing and administering children’s vaccines. It was yet another message to the public that we need not be concerned about long-term health impacts to children from repeated SARS-CoV-2 infections. Frankly, the truth is that we are only now beginning to comprehend the long-term health consequences of the initial infection, let alone from repeated infection, and none of these physicians can guarantee that children will not suffer long-term consequences. If the vaccine was not proven safe and effective in the general pediatric population, then withholding boosters might be a valid consideration. But, if some arbitrary hospitalization or mortality rate threshold is now going to be the criteria for childhood vaccines, there are going to be a lot of vaccines falling off the recommended childhood vaccination list. That would be a tragic mistake.

Why would I even think that long-term health consequences could be possible in children? Well, first of all, we see many signals for long-term health consequences in adults, and I have previously written a number of blog posts on that subject.

Nevertheless, I learned in medical school that children are not little adults. That means that we cannot necessarily assume that children will be affected by infection in the same manner as adults. Further, even disease in very young children can be different than in older children.

Because of the widespread misinformation that COVID-19 was not dangerous for kids and for young adults, we saw that pregnant women were often not aware of the increased risk to their unborn children from COVID-19, sometimes with disasterous outcomes. I also was appalled that some hospitals were not requiring masking in their pediatric and neonatal intensive care units. In addition, I worried for the young infants that I saw parents carrying into large gatherings, stores and restaurants.

Here are two recent studies that should cause all of us pause:

First is a prospective, multicenter trial that was conducted during the first two years of the pandemic. It was published in The Journal of Pediatrics on December 20, 2023. https://doi.org/10.1016/j.jpeds.2023.113876.  Three groups were compared: (1) 152 infants hospitalized for treatment of COVID-19; (2) 79 infants who were hospitalized for acute infections other than COVID-19; and 71 healthy controls who were not hospitalized or ill.

The study was designed to merely measure the levels of high sensitivity troponin, a blood marker for heart cell (myocyte) injury. If you have presented to the emergency room with chest pain, there is a good chance that you had a blood test for this marker, which in adults we use as one of the potential indicators of heart attack. High sensitivity troponin can be elevated with any cause of myocardial (heart muscle) injury, including myocarditis.

Those children hospitalized with COVID-19 were significantly more likely to have elevated high sensitivity troponin levels than either the healthy infants or the infants with other non-COVID infections, and those infants less than 3 months of age were especially more likely to have an elevation of troponin levels with infection.

The good news is that the troponin levels gradually returned to normal and the children showed no clinical evidence of heart disease at one year of follow-up. On the other hand, it remains unclear whether there are any long-term consequences until these children can be followed further out. [You might be asking yourself why the need to follow these children out further if everything looked okay 1 year later. That is because the immune systems of infants less than 6 months of age is immature and not fully developed. We are still learning about the immune response in adults to SARS-CoV-2 and we know almost nothing about the immune response in infants this young. We do see evidence of viral persistence in some adults and so a reasonable question would be whether these children clear the virus from their system.]

The other study was published in March of 2023. https://jamanetwork.com/journals/jamanetworkopen/ fullarticle/2802745. The researchers looked at the neurodevelopmental outcomes of infants born to mothers who had COVID-19 during their pregnancy compared to infants born to mothers with no known COVID-19 during their pregnancies. This was a cohort study of 18,355 infants delivered after February of 2020. After controlling for other risk factors such as premature delivery, the researchers found that male, but not female, infants born to mothers who had COVID-19 during their pregnancy were more likely to receive a neurodevelopmental diagnosis in the first year of life.

I have not provided an exhaustive review of studies looking at outcomes of infection in infants, but rather, I am just trying to make a point. I don’t know whether any of the infants with elevated troponin levels or any of the infants with neurodevelopmental delays will have long-term consequences from their exposure to the SARS-CoV-2 virus, but, neither does anyone else. I think if you asked any pediatrician, would you want your child or grandchild to be born with elevated troponin levels or to be diagnosed with a neurodevelopmental delay, they would respond that they would prefer they not be. The problem is that we won’t know whether there are long-term health consequences for years. I pray that there will not be. To me, it just seems prudent to exercise the precautionary principle until we know.

I have used infants as an example to make a point. We know the least about them, and they have no way to protect themselves. However, there are far more studies and reason for concern about the long-term health consequences in adults. I am surprised that employers are not exploring options to help protect their employees because if I am correct, even if they were to only act in their self-interests, not protecting their employees will impact their health plan costs, disability insurance costs, employee productivity, profitability, and recruitment costs.

In part 2 of this blog series, I will explain how we are being too complacent in our planning (or lack thereof) for the next pandemic.