Volunteers in protective suits disinfect a railway station as China tries to contain an outbreak of coronavirus, Changsha, Hunan province, February 4, 2020, photo by Stringer/Reuters

q&a

Coronavirus Outbreak Intensifies: Q&A with RAND Experts

Volunteers in protective suits disinfect a railway station as China tries to contain an outbreak of coronavirus, Changsha, Hunan province, February 4, 2020

Photo by Stringer/Reuters

March 5, 2020

Cases of coronavirus, or COVID-19, have now spread to at least 75 countries, infecting nearly 100,000 people across the globe—most in China, the epicenter of the outbreak.

With concerns about the disease rising, we asked a group of RAND researchers to answer a wide range of questions about the crisis:

  • Jennifer Bouey, the Tang Chair in China Policy Studies at RAND, is an epidemiologist whose research focuses on global health strategies and the social determinants of health.
  • Courtney Gidengil is a senior physician policy researcher who is board-certified in both general pediatrics and pediatric infectious diseases.
  • Mahshid Abir is a senior physician policy researcher whose research focuses on hospital surge capacity and the effects of overcrowding at medical facilities.
  • Andrew Mulcahy is a senior policy researcher who studies prescription drug and health care payment policy.
  • Lori Uscher-Pines is a senior policy researcher whose work focuses on health care delivery via telemedicine, as well as emergency preparedness and response.
  • Elizabeth Petrun Sayers is a behavioral and social scientist who researches how traditional and new media shape risk perceptions and health behaviors.

What follows are edited highlights from their responses.

Put this outbreak into perspective. Has it peaked, or is it just getting started?

Jennifer Bouey: Well, COVID-19 is not just a China problem. In fact, after late February, we've seen that the number of coronavirus cases is growing faster outside China than inside China.

However, China still has 85 percent of the confirmed cases of coronavirus—that's more than 80,000 people—and 88 percent of the deaths from coronavirus have happened in Wuhan and Hubei province. After a very dramatic quarantine procedure, we're seeing case numbers in China start to go down.

But we're still seeing an East Asia cluster forming, with Korea and Japan joining China. Iran is reporting more cases every day. And in Europe, Italy is another epicenter. In the United States, we'll probably see more cases in the coming days.

When will the outbreak peak? That's hard to predict, but I think it will come in waves. Globally, I don't think it has peaked yet. I think we'll see coronavirus spread to more countries in the second quarter of 2020 and maybe even into the third quarter for countries that don't have the capacity to test for the disease.

Courtney Gidengil: Some people are wondering whether the virus will go away in the summer, like seasonal influenza does. A break in the infection rate would allow the health care system to prepare for a possible future wave. Unfortunately, some preliminary data looking at spread across provinces in China and other countries seems to indicate that, unlike the flu, the spread of this virus may not be as affected by warmth and humidity.

Looking to other viruses in the coronavirus family like SARS and MERS also supports this—MERS transmission does not seem to go down in the summer, and while SARS did dip, it was concurrent with a lot of other efforts that may have explained the decrease.

So, while it is still possible we may see a temporary break in cases this summer, we should also be prepared for steady transmission over the next few months.

Are there lessons to be learned from China's experience so far?

Bouey: China's response has been quite dramatic. I don't know that any other country in the world could carry out their quarantine methods. These may have bought some time and slowed down disease transmission. But I don't think that any travel ban or quarantine can completely protect an area. This disease is highly contagious, and there are lots of mild cases. In fact, China just reported on Wednesday that it had 75 cases of coronavirus that were imported from people traveling to China from other countries. So none of these “social distancing” policies can provide 100 percent protection.

What about the U.S. perspective—how are efforts to respond to the outbreak looking, and what should we expect moving forward?

Mahshid Abir: The CDC is predicting that the transmission rate is going to go up in the coming weeks. And that's happening against the backdrop of a flu season that's still pretty active. Because the symptoms of coronavirus and the flu are so similar, there will probably be a lot of concerned people with mild to severe symptoms showing up at emergency departments and hospitals. That means that the health systems need to evaluate their surge plans, identify gaps, and make sure that they're ready to respond.

There's also a toll on health care workers themselves. On an average day, a lot of health systems and hospitals operate near or at capacity, particularly those in urban centers. They're already strained. Now, some providers may be concerned about coming to work, because they're worried that they may get the disease. So we're adding the stress of the unknown to an already stressful situation.

Access to diagnostic tests for the coronavirus has received a lot of attention lately. Where does that stand?

Abir: The difficulty is figuring out who to test. The recommendations about that are changing. This gets back to the symptoms of coronavirus being very similar to those of the flu. There needs to be consistent messaging around when to test and who to test. I don't think we're quite there yet.

Andrew Mulcahy: Right, and even when you get past the issue of who to test, there are still issues around the availability of the test in the U.S. There seem to have been some missteps in the initial push to get a test into the field. There were concerns about an ineffective ingredient and contamination in the first set of test kits that were sent out to state labs.

We need to make sure we're doing both diagnosis and containment in parallel and not focusing on one at the expense of the other.

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Over the past couple of weeks, there's been a real push to get more test kits out. The U.S. Department of Health and Human Services recently announced that there were about 75,000 test kits out there. This is probably only a fraction of what we need moving forward. It really feels like we're playing catch-up. Other countries have rolled out testing at a much broader scale.

Abir: Yes, getting more tests out into the field is essential. We also can't forget about containment. Effective and quick identification of potential cases is crucial. We need to be very proactive in hospitals and make sure that we protect people and screen them at the point of entry.

We need to make sure we're doing both diagnosis and containment in parallel and not focusing on one at the expense of the other.

What about a vaccine—are we anywhere close to having one for this coronavirus?

Mulcahy: It's important not to gloss over what's involved in developing a new vaccine or treatment, then getting approval to use it. I don't think that a coronavirus vaccine is right around the corner. Even if all the relevant parties do everything they can to speed things along, it's still a long process. We should be careful not to expect that a vaccine or treatment will be available anytime soon. And even when they are, there are questions about how they get to patients, and at what price.

Gidengil: We likely aren't closer than 12 months away from having a vaccine, although some companies have indicated promising movement in terms of getting vaccines ready for the first stage of testing.

Perhaps the bigger question for the United States is how well accepted such a vaccine would be. The vaccine for seasonal flu is safe, and while it is variably effective at preventing illness (about 45 percent this season), it is very good at preventing severe outcomes like hospitalization and death.

But in spite of this, our vaccination rates are still much lower than we would like. We also know from our work during the H1N1 pandemic that people's willingness to get vaccinated declined well before a vaccine was available. As we develop a vaccine, we should also be thinking about how to ensure vaccination rates are as high as they can be among those who need it, and how to communicate about the vaccine and roll it out to the public.

We're seeing various mortality rates for “normal” flu versus the mortality rate for COVID-19. Can you explain the different figures?

Gidengil: There are a number of reasons for the uncertainty around both the COVID-19 and seasonal flu mortality rates.

First, the severity of the seasonal flu varies by season, so there are different figures out there. But a reasonable one is about 0.1 percent. However, it was even lower than that for the H1N1 strain of flu. The mortality rate for COVID-19 is extremely uncertain, because this is a rapidly evolving situation with not as much data as we would like right now.

Another consideration is that we don't yet know the true denominator of all those who are sick with the coronavirus due to lack of testing, including here in the United States. So the quoted mortality rate that the WHO just put out of 3.4 percent is probably higher than what the final estimate will be once the dust settles.

We also know that the clinical course of the coronavirus can be in the order of weeks when it's a severe case, so we may also be somewhat underestimating the mortality rate by not counting the outcomes of those who are currently sick. Both COVID-19 and influenza seem to have in common that their mortality rates vary a lot by age. At the end of the day, what may be most relevant to people is the mortality rate for particular age groups and by particular coexisting conditions.

Let's talk about schools. We're seeing them close in Italy, Japan, and even Washington State and New York State. What are the implications of school closures, and how are these decisions made?

Lori Uscher-Pines: A school closure is just one type of “social distancing,” which Jennifer mentioned earlier. It's most effective when combined with other mitigation strategies, such as encouraging people to work from home and canceling mass gatherings.

There are a couple of different types of school closure. You can close schools preemptively, to prevent a disease from coming to a community. You can also close schools reactively, in response to, say, 10 percent of your students and staff staying home sick. Schools in the U.S. are mostly considering preemptive school closure at the moment.

We should be careful not to expect that a coronavirus vaccine or treatment will be available anytime soon.

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I think it's important that districts revisit some of their preparedness plans for the flu and consider how school closures might work. There are a lot of challenges: how to make up for lost instruction time and how to deliver free or reduced-cost lunches to kids who depend on them, for example. And parents need to be thinking about how they will manage childcare.

It's also important to note that, in the U.S., this is a local decision. So you could see neighboring districts making different decisions about whether and when to close and when to reopen. That can present communications challenges that are frustrating to parents. There could also be situations where a district closes schools because of perceptions of risk among the public, because parents are afraid and will keep their kids at home no matter what. It's very challenging to manage.

Let's turn to travel. What are some of the myths and realities as it relates to the coronavirus and travel?

Elizabeth Petrun Sayers: The key thing to consider is the CDC's recommendations for postponing and canceling travel. You should consider where you're traveling and for what purpose.

In terms of fear about traveling, there are a lot of myths. For example, people are worried about the air filtration systems on planes. But generally speaking, most viruses and germs don't spread easily that way. It's more important to avoid folks that are sick. This can be hard on a plane, so you have to use your best judgment.

There are also a lot of rumors about surgical masks. You do not need to wear a surgical mask to protect yourself. You can wear one if you yourself are sick and are trying to prevent the spread of illness to others. Personal protective equipment or PPE—sort of like a hazmat suit—is also really not necessary for air travel.

Abir: Unfortunately, there is really high demand for surgical masks here in the U.S. It's really important to let people know that these are not effective. It's just a reflection of the anxiety around COVID-19.

Let's talk about that anxiety. How do you think the American public is responding to the outbreak so far?

Petrun Sayers: There's always a challenge between balancing facts and fear. We're in this spot where the immediate risk to your average American is very low, but there's still a need to take precautions right now. I think folks can hear the preparedness message and just assume that the worst is coming. This is consistent with how similar situations have played out in the past. Authorities need to pay attention to both the risk we actually face and the public's risk perception.

What about the role of misinformation and conspiracy theories during an outbreak like this?

Petrun Sayers: There are always conspiracy theories. The main one is that the origin of a virus somehow stems from human intention, rather than a natural occurrence. For example, people might think that coronavirus is a bioweapon. That's happening online right now.

These happen, time and time again, in part because these kinds of theories can actually help reduce anxiety. If folks are looking for explanations, conspiracy theories can sometimes help them feel better. That's why conspiracy theories can be appealing.

Whenever there's a disease epidemic, there are always two other epidemics alongside it: disinformation and stigma.

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In this particular case, I think that a lot skepticism about China's public health system is fueling uncertainty. The fact that it was difficult to tell what was going on in the outbreak's early days made it harder to contain rumors and conspiracy theories.

Bouey: I completely agree. Whenever there's a disease epidemic, there are always two other epidemics that happen alongside it: disinformation and stigma. With disinformation, there are a ton of conspiracy theories out there, some pointing to China, some to the U.S. When people aren't sure what's going on, they make up stories.

What are some of the potential economic effects of the outbreak?

Mulcahy: It's hard to overstate just how global the prescription drug industry is. Many drugs used by patients in the U.S. are manufactured outside the U.S., particularly in Asia, or they're manufactured here but rely on components from other countries. So as coronavirus affects manufacturing in other countries, that can affect the supply of prescription drugs in the U.S.

In terms of policy, we should start viewing the pharmaceutical industry as the global enterprise that it is. Supply-chain vulnerabilities come with the fact that drug inputs and products are shipping all over the globe. Disruptions halfway across the world affect patients here.

Bouey: Businesses in China are really feeling the effects of the outbreak. The quarantine and all these regulations have ground the economy to a halt. It's going to be a slow recovery, and Beijing is very anxious to reopen factories. Larger companies are more likely to reopen, because they have to meet requirements intended to prevent coronavirus from spreading again. That can be harder for small and medium-sized businesses.

At the individual level, when should we be going to the doctor's office? Or should we be avoiding hospitals?

Abir: Generally speaking, I don't think that people in the U.S. should change their health-seeking behaviors. If you're an older adult, and it's just a routine visit, maybe you could reschedule that for further down the line. But postponing routine visits can be consequential, too.

If you don't have a true emergency, though, you may want to avoid emergency departments, not just to reduce your own risk, but to avoid the strain on the health care system. You can always call your doctor for guidance.

This seems like an opportunity for telemedicine. Should we be more focused on that?

Abir: It really varies from health care system to health care system. Some have taken up virtual care a lot more than others. It differs from specialty to specialty, too. It's a mixed bag.

Uscher-Pines: I think telemedicine is going to have a significant role in the response to COVID-19. It really has the potential to improve triage and help with the management of scarce resources.

But as Mahshid mentioned, telemedicine has been slow to catch on. Our research shows that only about 4 percent of the U.S. population has ever had a video visit, despite the fact that telemedicine has been around for a while. Innovation takes a long time, but there have also been regulatory and reimbursement barriers that have prevented greater growth.

Telemedicine could have a significant role in the response. It has the potential to improve triage and can help with the management of scarce resources.

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Anyhow, telemedicine could be key in supporting a “social distancing,” mass-quarantine scenario. Someone sitting at home could use telemedicine to assess the need for in-person care and help them avoid showing up somewhere like an emergency department, where they could potentially be exposed to coronavirus.

In fact, telemedicine is already being used in some interesting ways in the ongoing response. Some telemedicine firms are screening for coronavirus. We're also seeing some health systems convert visits for chronic health issues to telehealth when they can, to prevent exposure. And a clinician down the hall could even use telemedicine to treat a patient in isolation in a hospital, helping limit the number of providers that could potentially be exposed.

Finally, what do U.S. households need to do to prepare?

Uscher-Pines: The CDC hasn't yet made official recommendations that Americans start stockpiling food and water for coronavirus. But FEMA has had guidance in place for years that households should have preparedness kits that include things like a three-day supply of food and water, medication, things you might need for your kids, and so on. I think those recommendations still apply here.

Some Americans are beginning to worry about a shelter-in-place emergency, and they're starting to think about keeping two to four weeks' worth of food, water, and other household essentials. Again, that's not something the CDC is advocating at this point but, if you have the money to buy extra supplies and the space to store them, that's an option.

Pete Wilmoth and Jeffrey Hiday