SARS-CoV-2: a time for clear and immediate action
Authors: Gregory A Poland
Journal: The Lancet Infectious Diseases (2020)

I have spent a 33-year career studying respiratory RNA viruses, devising vaccine approaches against them, and unravelling the human immune response to these viruses and vaccines, as well as promoting policies to minimise their effects. Over the past 10 weeks, I and many others have been in the thick of explaining what we know about coronaviruses and other respiratory viruses, and extrapolating this knowledge to understand severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to many health-care providers, organisations, media, and lay people. I have watched the rapid transmission of this virus across continents and around the globe. Based on the alarming rate of disease—along with my experience with RNA respiratory viruses—and what we are now observing in the USA and around the world, I have concluded that we must do what we do not want to do. We must take clear and compelling actions—now—that none of us want to take, and that many will reject. To be clear, none of us, me included, have a crystal ball; however, we do have the benefit of history, genetics, virology, and current epidemiology to guide us. We have seen rapid transmission of this virus, with concomitant high rates of severe disease and associated mortality, across many countries in real time. We understand more about viral reproductive number, generation time, incubation period, transmission modes, and the effect on health-care systems across multiple countries. The numbers of cases appear to be doubling roughly every 3–4 days in multiple countries. We do not have antivirals, vaccines, antibody-based therapeutics, or specific treatments. We can only offer supportive care—after the fact. Therefore, our only reasonable option is to maximally decrease viral transmission by maximally decreasing the opportunity for face-to-face interaction. In this regard, I believe that we as a global community should enter into a period of contextually appropriate suspension. The idea is to suspend all activities that are not absolutely essential and that involve face-to-face interactions and group gatherings. It is apparent from the kinetics of SARS-CoV-2 transmission, the rapidly growing number of cases, the increasing involvement of more and more countries and regions within those countries, and the surge of demand on an already maximum capacity and frequently overstressed medical system, that this lockdown is the safest course of action. Based on our current understanding of the virus, this will probably be necessary for a minimum of several months in order to best weather this storm. I believe this action is necessary for various reasons. First, we have an increasingly older age demographic across virtually all countries, as well as unprecedented rates of obesity, smoking, diabetes, and heart and lung disease, and an ever-growing population of people who are immunocompromised—all comorbidities that lead to significantly higher risks of severe disease and death from coronavirus disease 2019 (COVID-19). In turn, these huge numbers of people who are more severely affected by this virus require ongoing and more complex care, overwhelming many times over the capacity of medical systems to care for them. In turn, this high demand sharply drives up mortality rates while vital supplies, specialists, intensive care unit (ICU) beds, ventilators, and medicines are depleted. We have seen the worse effect of this virus in societies with older age demographics such as Italy compared with South Korea, which has a higher proportion of young people. Second, tremendous numbers of people, from all over the world, travel throughout the globe. The UN World Tourism Organization estimates that well over 1·5 billion people travel internationally each year—more than 4 million people per day. This movement and the mixing of people act as powerful accelerant fuel for this pandemic. Third, these large numbers of people also allow for mixing of people of all ages and all medical conditions; in particular, the mixing of children and younger adults (who can be infected and might have few or no symptoms) and older adults, which further accelerates the opportunity for older adults, who suffer disproportionately, to become infected. How and why would such actions work? The most important manoeuvre is to immediately decrease the risk of further human-to-human viral transmission. The idea is to drive down the opportunity for an infected person to transmit the virus to another uninfected person, in essence forcibly reducing the reproductive number of the virus. To achieve this reduction requires the suspension of all non-essential gatherings that provide opportunity for spread of the virus, including suspending travel, enacting school closures, cancelling social, church, or sports-related gatherings, and working from home wherever possible. In short, staying home. Putting these measures into place provides the opportunity to dramatically curb the speed at which the virus infects others. By flattening the epidemic curve, fewer people become ill at once, which dramatically decreases the surge in demand for medical care. For example, consider a community with a hospital that has 250 beds. Such a hospital has a small number of doctors, nurses, and other medical care personnel, as well as the necessary supplies to care for those who are ill. Such a hospital may have five to ten ICU beds and a very small number of ventilators. If five people get severely ill each week, they can probably be managed, with low rates of mortality. If 20 or 50 or 100 people become severely ill each week, the hospital and medical care system will be overwhelmed and the corresponding mortality rate will dramatically rise. Decreasing viral transmission, and therefore infection rates, is likely to decrease viral mutational rates, and increases time for the possible development of antiviral, monoclonal, and polyclonal therapies as well as vaccine countermeasures. Decreasing and spreading out high rates of illness, which results in a significantly lower mortality rate among those who do become ill, allows for resupply of crucially needed items to care for the ill, including personal protective equipment for health-care providers. I recognise that many will reject such a call to action, often because of not wanting to be inconvenienced, other financial and political agendas, the resulting disruption, and not wanting to do what is inherently counter to our nature. It seems in the current situation that people either panic or they dismiss the risk. But neither complacency nor panic is wise. It is inevitable at this point that this pandemic will get much worse before it gets better. For this reason, the willingness to take whatever actions are necessary to weather this pandemic while protecting the health and welfare of the maximum number of people possible—all while slowing down the explosive transmission and consequences of this virus—is what we must do. Now. I declare no competing interests.