(Updates have been moved to a new blog entitled COVID-19: The Brief for easy reference. Thank you.)

At the heart of every epidemic, is a story that is told wrong.

Technology and social media, the very tools in disseminating proper, legitimate, and timely information is the same ticking bomb that sows disinformation, fake news, and fear.

An international outbreak of respiratory illness due to a novel coronavirus has thrusted China in the limelight in recent weeks. And the global community has sounded the alarm bells.

What we know

1. The outbreak apparently began in Wuhan, China at a market that sold live poultry, seafood and wild animals. The virus has turned up in 28 countries to date. Travel to Wuhan and contact with people who were positive for the viral infection put people at risk for developing the disease.
2. The Philippines has reported the first death in a 44 year old patient who turned out positive for NCoV. His partner is the 38 year old female who was the first positive NCoV case in the country. Both had traveled from Wuhan to the Philippines, via HongKong, then through Cebu. According to the Department of Health, the tourists had gone to Dumaguete before traveling to Manila. The death of the patient in the Philippines is the FIRST REPORTED DEATH OF A PATIENT WITH NCoV outside of China.
3. Coronavirus can infect both animals and people. Clinical illness can range anywhere from a common cold to severe acute respiratory disorders (remember the 2003 SARS outbreak that killed almost 800 people?). The incubation period is quite disturbing. At the start of this infection, we thought that it would range from 8-14 days. There are unverified clinical data coming out from China that point to 2-24 days! Nevertheless, with all data gathered to date, the median incubation period is possibly 5.2 days.
4. Health authorities are alarmed because we don’t know how bad this novel coronavirus will manifest in the long term as it is just evolving. It is possible that because it is an emerging infection, most (if not all of us) have not developed any antibodies to this infectious disease yet and that makes us all vulnerable to coming down with an infection – whether it is mild or severe. What we do, however, know is that the current case fatality rate for the novel coronavirus ranges between 2-3%. SARS had a case fatality rate of 11%. Measles has a case fatality rate of 15%. And MERS has a case fatality rate of 35%.
5. The Wuhan coronavirus is most likely transmitted through respiratory secretions. Evidence also points to human-to-human transmission. As to HOW easily it is transmitted is another story in itself. While the medical journal The Lancet, suggested “that the virus was passed from one ill relative to six others; only two had contact with the initial patient.” This is not a complete history because all the patients actually came from Wuhan and may have had some other zoonotic exposure to some degree, not necessarily from ONE market alone. As to whether some of these patients become “super-spreaders” later on (they infect a large number of people) remains a mystery. What we do know is that the the estimated infectivity of the Wuhan/novel coronavirus is 2.5 (for every index case, there is the potential to spread it to 2-3 people). Note, how pale this compares to measles that has an infectivity of 15 (for every index case with measles, there is the potential to spread it to 15 people!).
6. The main treatment is supportive care. There are currently no drugs approved for any coronavirus diseases. And megadoses of vitamin C (I read somewhere people advocating this) isn’t really going to help. There is also no evidence that the virus does not survive tropical climate weather. The mere fact that countries like Singapore, Thailand, Vietnam, Malaysia, and Cambodia (and the Philippines) have cases is proof that this virus will survive anywhere.
7. The Chinese authorities have “locked-down” Wuhan and other affected cities – limiting travel to and from areas of the infection. The Chinese government has built two new hospitals for these patients alone. Shanghai and HongKong Disneyland were closed (and remain to be closed) in anticipation of millions of guests for the Chinese Lunar New Year. Many governments worldwide have begun intensive screening of passengers from Wuhan at entry ports. (That would mean that if you have no important or urgent matters to attend to in China, I would suggest that you defer your travel in the meantime until such time that we know the real scenario. Common sense dictates that if the local authorities are concerned, why do you even want to travel going there?) Several airlines (British Airlines was the first) have canceled or downscaled their flights TO and FROM China. Incidentally, all of the provinces of China now have reported coronavirus cases.
8. On February 8, the total number of deaths of 813 had surpassed the final total deaths due to SARS (774) in 2003. With 910 deaths (as of February 10, 2020), the number of deaths has surpassed the deaths with MERS (853) in 2012.
9. The disease is evolving and for accurate information on statistics, I suggest that the reader refer to http://www.worldometer.info/coronavirus for up-to-date details.
10. The WHO has provided a formal name to the disease caused by the novel Coronavirus and will henceforth be referred to as COVID19. SARS-CoV-2 is the suggested viral taxonomy for the novel coronavirus.

What we don’t know

1. Are the Chinese authorities being fully transparent with the number of infections and deaths? (It becomes suspicious that the numbers suddenly double in number each day like replicates from a factorial equation. The sudden knee-jerk reaction of locking down a whole city is an overkill.) If you look back at history, the SARS outbreak of 2003 began November 2002. The Chinese authorities did not report this to the WHO until 3 months later.
2. While the authorities claim that ONE market in Wuhan is the epicenter of the disease, and that medical scientists feel that the most likely primary source of the outbreak are animals, there are hundreds of markets all over Wuhan. This undermines the theory that the epicenter is in ONE specific market. It is most likely that IF animals are the likely source, identifying which animal it is may be important. And whether only ONE market in Wuhan was the source of the outbreak.
3. Is there going to be a vaccine soon? It’s everyone’s guess. While vaccine development sounds fairly easier today than a few decades ago, there’s still a lot to learn about this novel virus before we get to the drawing board. And I refer everyone to the blog post on “COVID-2019: Numbers that matter” for a discussion on this.
4. On a side note, the novel coronavirus is an emerging infection and emerging infections may be difficult to handle because we have very little information (YET) of the enemy at hand. The information out there is based on data that is the tip of the iceberg.
5. While there are increasing number of cases already, there has been NO report of a pediatric casualty. In fact, the demographic data being provided are simply number of cases. A breakdown according to age, sex, co-morbidities, etc. are direly lacking. The youngest confirmed case is a 30 hours old baby from Wuhan (Tribune.net.ph in an article from Agency-France published February 5, 2020) delivered to a NCoV positive mother. This is a clear case demonstrating the likelihood of vertical transmission of the virus. With these scant information, it is possible that children may have milder forms of the disease (if they get the infection) and that the lack of more severe presenting respiratory symptoms in this group may make us miss having them routinely tested unless they have exposure to a source case.
6. The youngest person to die from this virus is the 34 years old ophthalmologist who first reported the SARS-like illness outbreak in early December 2019. The report on how and when Dr. Li got the infection is sketchy. The information available on social media is that in early January 2020, Li had treated a woman with glaucoma without realizing she had NCoV. On January 10, Li had cough, then fever and two days later was in the hospital. He became seriously ill after a few weeks and passed away on February 7, 2020 (almost ONE MONTH after his clinical illness). (The Guardian, Feb 6, 2020). The course of illness of Li is perplexing and troublesome and requires more transparent data on the length of illness on the untimely demise of the doctor.
7. If patients recover from the disease (become negative after being positive in a test), how long will immunity last? Does bringing them back to a community with ongoing infection provide protection from getting reinfected and how severe (or mild) will it be the second time around?
8. How accurate are the test kits that are being used for the diagnosis of the infection? At what day of the illness do patients test positive and what are the limitations of the testing kits? Is there a correlation between illness and positive test results?

What can we do to protect ourselves

1. An ounce of prevention is worth a pound of cure. Wash your hands. Don’t put your dirty hands on any oral orifice. Don’t rub your eyes. In short, watch your personal hygiene. When you need to wear masks, make sure you have the right one and wear it correctly.
2. When you have a bad cough – practice cough etiquette and cover your nose and mouth by wearing a mask. This is especially true when you’re getting into an enclosed space (like an elevator). If you’re sick, please, do the world a favor and stay at home.
3. Avoid crowded places. Don’t bring your smaller kids with you when you need to run an errand or visit the sick. You will need to take care of yourself first. Very young children are a handful and they are difficult to care for especially in crowded places.
4. Reconsider your travel plans. It may take a few months before this tides over as we don’t know a lot about the virus and how the disease will evolve. YET.
5. For pediatric patients that need to have their routine immunizations, please make sure your kids get them ON TIME. You don’t want them getting sick with a different, more severe, preventable infection just because of the ongoing fear of the novel coronavirus. The vaccine-preventable diseases carry a far heavier mortality rate and disease burden.
6. Stay vigilant and update yourselves with correct information from the health authorities and verifiable news. Use social media to create a positive health environment and not as a platform for becoming “viral”. PUIs (or person under investigation) ARE NOT confirmed cases of novel coronavirus infections.

If you are residing in the Philippines, the Department of Health has provided a link on its website for local data, information, and guidances on the current NCoV issue.

Take home message

Be part of the population that use their brains during times of crisis. Don’t be part of the wild, noisy, no-brained, confusing disorder that creates pandemonium. No one benefits from dysfunction.

Update 14 February 2020 (as of 0800H)

1. There are now 1,489 deaths and 65,246 confirmed cases. The cumulative case fatality rate is at 2.28%. China has the bulk of cases and deaths (1,486 [99.85%] of the deaths are in China).

2. Japan has reported its first death in an 80 year old woman. Two additional cases in Japan include a taxi driver who had driven a Chinese passenger and a surgeon at a hospital in Yuasa-cho.

3. Outside of China, Japan has the most number of cases (251 from 247), followed now by Singapore with 58 cases (+11). In third is Hong Kong with 53 cases (+4) cases. Thailand is third with 33 cases. The sudden surge in the number of cases in Japan is due to an additional 44 confirmed cases on the Diamond Princess. The Japanese government is set to allow some of the passengers on the ship to recover on shore. Taiwan has had no additional case for over a week and remains at 18 positive cases for COVID-19.

Additional cases in other parts of the world (after 3pm today) are: Vietnam (1), Hong Kong (2), Singapore (8), the UK (1), the US (1), Malaysia (1), and India (2) as of this writing. The case in the UK is the first case in London.

3. In Hong Kong, a building’s piping system is being investigated as a potential source for airborne transmission through feces after after the 42nd case who lives 10 floors below the 12th confirmed case. It is hypothesized that an airborne route through vents not properly blocked may be the source of the transmission. Could this explain also the increase in cases on board the Diamond Princess? Through unblocked vents and thereby affirming the airborne route? (This will need further investigation and is hypothetical for now.)

3. The Philippines remains to report 3 confirmed cases with one death. The remaining 2 cases have recovered and are now NCoV negative. There are 441 cases considered PUI (persons under investigation). The good news? NO NEW CONFIRMED CASES HAVE BEEN REPORTED as of this post. More good news? More than half of those tested are negative (253 have tested negative and 186 have pending results). This website of the government is highly informative: https://ncovtracker.doh.gov.ph

4. ALL of China’s provinces and territories are affected by this outbreak.

5. The first death outside of China was in the Philippines. The cluster of fatalities remain in China and among the elderly and those with co-morbidities. Hong Kong reported its first death from the outbreak. A 39-year old man with history of travel to Wuhan on January 21, 2020 and returned to Hong Kong 2 days later presented with symptoms on January 31, 2020. The third death outside of China is an 80 year old Japanese woman.

6. The countries and territories with confirmed cases for the novel coronavirus: Thailand, Japan, Hong Kong, Singapore, Taiwan, Australia, Malaysia, Macau, Russia, France, the United States of America, South Korea, Germany, the United Arab Emirates, Canada, Britain, Vietnam, Italy, India, the Philippines, Nepal, Cambodia, Sri Lanka, Finland, Sweden, Spain and Belgium.

7. The World Health Organization has declared the coronavirus infection a global health emergency.

8. Several countries have issued a “DO NOT TRAVEL” to and from China advisory. Airlines have cancelled flights to and from China, with a couple of countries repatriating their citizens.

9. Is it likely to become a pandemic? A pandemic is declared when an ongoing epidemic is observed in two or more continents. What we do know is that it’s highly transmissible and spreading like influenza. Whether it is catastrophic is unknown at the moment. But the effects of a pandemic would definitely burden countries with less resources and fragile health care systems than wealthier nations.

*Disclosure: The author of this article is the Chief, Section of Pediatric Infectious Diseases, University of Santo Tomas Hospital, Manila, Philippines

**This part of the blog will be updated daily based on relevant and verifiable information. The author is disclosing that all information on this blog site is referenced appropriately and that all gathered information have been verified. Some of the comments provided are personal opinions posted as part of scientific discussion on the coronavirus.

In his book “The Emperor of All Maladies: A Biography of Cancer“, published in November 2010, Dr. Siddhartha Mukherjee weaves an ironically beautiful story of the life and times of one of health’s greatest adversary – cancer.

It is no wonder that this book won the Pulitzer Prize for General Non-Fiction, is on magazine TIME as one of the most influential 100 books in the last century and the New York Times magazine as among the 100 best works of non-fiction.

The sad truth is, we all have one immortal illness. From the day we are conceived, there is an interplay of existence between normal and abnormal cells in our body. “Cancer is not one disease but many diseases. We call them all ‘cancer’ because they share a fundamental feature: the abnormal growth of cells.” Both normal and abnormal cells reside in each and everyone of us. Like good and evil, they both co-exist. The dichotomy in the opposites of life. Yin and Yang. Black and White. Justice and injustice. Heaven and earth. Cancer cells are part of us. When abnormal cells proliferate, they take over the cellular regeneration of other cells in our body. The normal cells are eventually replaced by abnormal ones. Because life is one real battlefield. And survival, is that of the fittest.

Cancer, we now know, is a disease caused by the uncontrolled growth of a single cell. This growth is unleashed by mutations – changes in DNA that specifically affect genes that incite unlimited cell growth. In a normal cell, powerful genetic circuits regulate cell division and cell death. In a cancer cell, these circuits have been broken, unleashing a cell that cannot stop growing.

Cancer is built into our genomes: the genes that unmoor normal cell division are not foreign to our bodies, but rather mutated, distorted versions of the very genes that perform vital cellular functions. And cancer is imprinted in our society as we extend our life span as a species, we inevitably unleash malignant growth (mutations in cancer genes accumulate with aging; cancer is thus intrinsically related to age). If we seek immortality, then so, too, in a rather perverse sense, does the cancer cell.

“The Emperor of all Maladies: A Biography of Cancer” by Siddhartha Mukherjee

As early as almost five thousand years ago, the Egyptian physician Imhotep had reference to the disease, in his writings that describe and affliction characterized by “bulging of the breast”, and resistant to any known therapies. From Bennett to Virchow to Farber…this history of cancer is by far a deep and perplexing. Several thousand years down the road and we have barely notched the iceberg of neoplastic diseases. As various therapeutical modalities are developed to address what we do now know of certain cancers, the cancer cells seem to adapt for their own survival as well. No matter how we look at any form of disease wrought by cancer, all were deeply connected at the cellular level. They had one characteristic – an uncontrollable pathological urge to cell divide.

In a National Geographic article, it notes that the likely reason “cancer is a relative newcomer in the historical record is that it commonly afflicts those 65 years and older, and for a long time, few people lived long enough for cancer to be a concern.” While this may not be exactly good news for those growing older, it is inevitably the disconsolate painful truth. As Susan Sontag puts it bluntly, “Now it is cancer’s turn to be the disease that doesn’t knock before it enters.”

As Mukherjee puts is succinctly, “Civilization did not cause cancer, but by extending human life spans, civilization unveiled it.” The longer we live, the more likely that we will all have some form of cancer. Which will be our most likely exit from this world.

In the biography of cancer, Mukherjee takes us to a labyrinth of medical history, so graphically written and accurately detailed it makes one feel like part of the explorative journey to the root of the emperor. And like a Netflix series, his story telling ability will keep you mesmerized. A page-turner in every sense of the word, his graphic and dramatic description of cancer as an omnipotent lord of maladies will make even a layperson understand the history, physiology, pathology, treatment and outcome of cancer.

Cancer is not simply a clonal disease; it is a clonal evolving disease. If growth occurred without evolution, cancer cells would not be imbued with their potent capacity to invade, survive, and metastasize. Every generation of cancer cells creates a small number of cells that is genetically different from its parents. When a chemotherapeutic drug or the immune system attacks cancer, mutant clones that can resist the attack grow out. The fittest cancer cell survives. This mirth, relentless cycle of mutation, selection, and overgrowth generates cells that are more and more adapted to survival and growth. In some cases, the mutations speed up the acquisition of other mutations. The genetic instability, like a perfect madness, only provides more impetus to generate mutant clones. Cancer thus exploits the fundamental logic of evolution unlike any other illness. If we, as a species, are the ultimate product of Darwinian selection, then so, too, is this incredible disease that lurks inside us.

“The Emperor of all Maladies: A Biography of Cancer” by Siddhartha Mukherjee

The fundamental science of oncology has nothing to do with the evolution of cancer. These abnormal cells are with us in some strange way. From the air we breath, the food we eat, the living conditions or even some viral infection (Hepatitis B, Human Papilloma Virus, Ebstein Barr Virus, to name a few) that has triggered the transformation of normal cells to atypical ones and eventually to a cancerous disease has remained perplexing, mysterious, and a formidable foe to medical science.

The turn of the 20th century saw vaccines as the biggest contributor to preventing infectious diseases from eliminating the human population. The discovery of vaccines has dramatically averted morbidity and mortality from microorganisms that once upon a time had practically eradicated a nation. Drug discovery programs addressed treatment for chronic non-communicable illnesses, thereby improving the outcome and prognosis for diseases that used to have debilitating consequences.

The 21st century together with the rapid advances of science and technology changed the landscape of medicine. While the environment we live in has become more livable and human survival is at an all time high (70 is the new 60), living up to a century old has now become the goal. The search for immortality is at a frenzy. We all want to live forever. But forever will always have a price tag to pay.

The laws of medicine are really laws of uncertainty, imprecision, and incompleteness. They apply equally to all disciplines of knowledge where these forces come into play. They were laws of imperfection.

Law One:

A strong intuition is much more powerful than a weak test.

Law Two:

“Normals” teach us rules; “outliers” teach us laws.

Law Three:

For every perfect medical experiment, there is a perfect human bias.

“The Laws of Medicine” by Siddhartha Mukherjee

In spite of the rapid developments in the diagnosis and treatment of various diseases affecting human health, the scourge and challenge of cancer has remained a tough “cookie” to crack.

The formidably beautiful writing style engrosses the reader to a beautiful story on medical history; discovery of preventive medicine and epidemiology; of pharmacology, physiology, anatomy and biochemistry; of science being ensconced in myths and finally the realization of an entangled labyrinth of why a disease as terrible as cancer is the face of an enemy that has remained an enigma since time immemorial.

Mukherjee has masterfully immortalized the story of why cancer deserves to be the Emperor of All Maladies.