While most cases of disease caused by COVID-19 will be mild, for certain people, it could be deadly.

By Rose Hoban

Seven friends in Seattle met for lunch on Feb. 25. One of the women, unbeknownst to herself or the others, was infected with the novel coronavirus, known as COVID-19.

By the end of the hour-long meal, three other women had been infected with the virus, which has been sweeping the Seattle area for weeks.

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“We were just sitting at a table,” said one of the three newly infected women, a 42-year-old named Cindy (we are only using her first name to preserve confidentiality). “We weren’t hugging. She wasn’t coughing or showing symptoms. I can’t even remember where she was sitting from me, it wasn’t next to me.”

On Feb. 28, Cindy woke up with a scratchy throat and a headache. By noon, she had to stop working and go to bed where she stayed for two days.

“I had a fever, I was feeling really tired, achy and I couldn’t work anymore,” she said in a phone interview with NC Health News. “It felt like the flu, where you were really too sick to get out of bed.

“By the third day, I was fine, but still containing myself.”

Cindy also had an intermittent cough throughout her interview on March 10, which she described as dry and persistent.

She is one of many in the Seattle area who was able to be tested for COVID-19 through the Seattle Flu Study, which pivoted quickly from tracking flu cases to tracking cases of COVID-19 using a home test kit. Their decision to test before getting federal approval initially got the program into hot water with the Food and Drug Administration.

Cindy heard about the flu study’s work and she called their headquarters.

“Two hours later, they Fedex’ed [a test] to me. I did a swab and it took about five days to get the results,” she said. Researchers from the Seattle Flu Study passed along the positive result to the King County Health Department, which called Cindy to give her the confirmation.

The day before she started feeling symptoms and confined herself, Cindy had lunch with three colleagues, two of them subsequently became sick and were confirmed as having COVID-19.

Once she fell ill, Cindy’s family took precautions. Her husband, who works in health care, immediately started sleeping on the sofa, while Cindy confined herself to her bedroom, keeping her two kids, 8 and 11, away.

“The kids have not shown any symptoms at all,” she said. Her husband got back a negative test on March 9. In a Facebook post to friends, Cindy said her daughter has a new chore: using a bleach-infused wipe to clean the doorknobs and surfaces in their house.

Cindy’s story is emblematic of how easily and quickly the new virus, which first was identified in Wuhan, China and now has been identified on six continents, can spread.

And while Cindy’s illness is a mild one, the data indicate that about 20 percent of cases will require medical intervention, and of those cases, many will require hospitalization.

It’s unclear yet, what percentage of people will die from COVID-19, but the data also point to the grim reality that older people, and people who have pre-existing illnesses are most at risk once they contract the disease.

Not yet overwhelmed

As of this writing, North Carolina has 8 identified coronavirus patients, but state health and human services secretary Mandy Cohen said she expects many more.

On Tuesday, Cohen and Gov. Roy Cooper advised older people and people with health conditions to avoid large gatherings such as this weekend’s ACC basketball tournament in Greensboro.

“We’re still very much learning how this impacts different populations,” Cohen told lawmakers at a legislative hearing on Tuesday. “For low-risk populations, it is seeming like it could be as mild as 24 hours of fever and a little bit of a cough.

For generally well folks the illness can look like a normal virus, with a little fever, a little body ache, cough.

“One of our cases … that was their symptom course,” Cohen said. “For others, we’re seeing weeks of fever, weeks of respiratory illness and then obviously, we’re seeing in other parts of the country, and in the world, folks in severe respiratory distress through a range of ages, although it seems to concentrate in older ages of 60, 70, 80.”

Cohen’s assertion has been backed up with studies taking place now around the world showing that about 20 percent of cases will need medical intervention of varying intensity.

In a paper published in late February in the Journal of the American Medical Association, Chinese researchers found that 14 percent of the cases they identified were “severe” and 5 percent were “critical.”

“COVID-19 rapidly spread from a single city to the entire country in just 30 days,” the Chinese researchers wrote. “The sheer speed of both the geographical expansion and the sudden increase in numbers of cases surprised and quickly overwhelmed health and public health services in China, particularly in Wuhan City and Hubei Province.”

It’s those severe and critical cases and the overwhelming of the health system in China that has Cohen worried. She said as much to lawmakers Tuesday, when talking about a similar situation in Italy, which implemented a nationwide travel ban and lockdown earlier this week.

“Looking at how quickly Italy went from 600 cases to being on full countrywide lockdown, 11 days,” she told lawmakers. “They went from 600 cases to full countrywide lockdown in 11 days. That’s concerning.”

On the same day that Cohen spoke to lawmakers, Italian authorities reported 977 new cases, pushing that country’s total over 10,000, with a total of 631 fatalities.

“What lockdown means to me is that their medical system got overwhelmed,” Cohen said.

That’s what she’s hoping to avoid.

What does ‘severe’ look like?

In China and other places, many of the most severe cases ended up in the hospital, on breathing machines or ventilators.

“One of the things we learned during H1N1 in 2009 is that ventilators were not helpful,” said former North Carolina state health director Jeff Engel in February. “What people needed was a much more aggressive therapy because their lungs were so heavily damaged.”

Chinese doctors noted the same thing with SARS in 2003 and with COVID-19, that also seems to be the case.

In one paper published by Chinese doctors at the Jinyintan Hospital in Wuhan, 13 out of an initial cohort of 41 patients required admission to the intensive care unit, where some needed mechanical ventilation. Twelve of the 41 progressed to a more serious diagnosis, known as acute respiratory distress syndrome, where the lungs become overwhelmed. For two of those patients, mechanical ventilation was insufficient and they required the use of a heart-lung machine (known as ECMO), which removes blood from the body, oxygenates it and then returns it back to the patient.

Six of those 41 patients eventually died.

The researchers found similar percentages in a later cohort of 99 patients, where 17 patients developed ARDS, with three requiring the heart-lung treatment. In that group, a total of 11 died.

Other data from China show that it’s seniors and those with serious health problems, such as high blood pressure, heart and lung diseases, diabetes and cancer, who end up hospitalized with coronavirus. And those patients treated in the ICU were more likely to be older, have underlying diseases, and were more likely to have displayed shortness of breath and a loss of appetite.

These are the scenarios that have state and hospital officials awake at night.

For example, David Weber at UNC Health has been making worst-case scenario plans with his team.

“We’ve thought about increasing our number of health care personnel by potentially using retired people who have been trained as doctors or our colleagues say working in the nursing school or School of Pharmacy, School of Public Health,” Weber told NC Health News.

“We can expand [our capacity], using 12-hour shifts on and off, providing places for people to eat and sleep so they could work longer shifts,” he said. “One could turn off elective surgery and use those ORs or recovery rooms to house severely ill patients.”

He also talked about converting entire units of the hospital into intensive care wards.

Weber and his team have even thought through how medical staff would provide child care if schools were to close.

“I think it’s a day care buddy system, where health care provider one takes children one night, and then the next day then buddy number two takes them and your alternative person goes to work,” he said.

But Cohen said she’s hoping North Carolina doesn’t have to go that far and is urging moves to “blunt” the spread of the disease. Thus her call for older people and people with underlying diseases to stay away from events such as basketball games.

The state is not yet “going to the step of canceling those kinds of things,” she told lawmakers Tuesday, noting it would “have huge impacts, communities, economics, so we have to balance those things”

“We don’t want to do it so early that we’re overreacting, we don’t want to do it so late that we missed the window to actually blunt the spread of the epidemic. It’s trying to get it just right, so those are hard calls to make.”