The Washington Post - 20.02.2020

thursday, february 20 , 2020. the washington post eZ su A

the coronavirus outbreak

BY CAROLYN Y. JOHNSON

The mounting toll of coronavi-
rus deaths, involving health-care
workers on the front lines of the
disease and older people in hospi-
tals, raises a basic question: How
does the new virus make people
sick, and why does it kill some of
them?
No one knows how or why the
novel coronavirus leads to death
in just a small percentage of pa-
tients — about 2 percent of those
infected, according to prelimi-
nary numbers. Based on what we
know about related illnesses, in-
cluding severe acute respiratory
syndrome (SARS), experts hy-
pothesize that the difference be-
tween a lethal infection and one
that feels like a bad cold probably
hinges on the interaction between
the virus and a person’s immune
system.
The virus attacks and kills cells

in all cases, but serious illness

depends on how the immune sys-

tem responds, and that can be

influenced by age, gender, genet-

ics and underlying medical condi-

tions. The initial damage caused

by the virus can trigger a powerful

and counterproductive overreac-

tion by the immune system.

“What you get is the initial

damage and rush of inflammatory

cells, but the damage is so exten-

sive that the body’s immune re-

sponse is completely over-

whelmed — which causes even

more immune response, more im-

mune cells and more damage,”

said Matthew Frieman, a virolo-

gist at the University of Maryland

School of Medicine.

The coronavirus is spread

when an infected person sneezes

or coughs, spraying droplets

through the air. The sick person

might sneeze directly in another

person’s face or expel droplets

widely, contaminating surfaces

that healthy people touch before

unknowingly spreading germs to

their mouths or noses. Health-

care workers are at e specially high

risk because they are exposed to

very high doses of the virus and

also perform procedures — such

as putting patients on ventilators

to help them breathe — that can

spread it.

With infection, the virus proba-

bly begins to multiply inside cells

lining the airway, which are

fringed with hairlike structures.

Coronaviruses that cause com-

mon colds are excellent at infect-

ing the upper airway, while SARS

tended to go deeper in the lungs.

As t he coronavirus gains s trength,

Frieman said, dead cells are

sloughed off and collect in the

airway, making breathing diffi-

cult.

“If the virus replicates very

quickly, before your body has a

chance to try and prevent it with

an immune response, or if the

immune response comes in too

late, then it can’t control the virus

and starts going berserk,” s aid An-

thony Fehr, a virologist at t he Uni-

versity of Kansas.

This is what scientists refer to

as a “cytokine storm,” which

causes the immune system to

start sending cells ready to do

battle into the lungs. At that point,

it’s not just the virus doing dam-

age to the body; the immune sys-

tem begins wreaking havoc on the

infected person — also known as

the “host” i n medical parlance.

“The experience with other re-

spiratory viruses would suggest it

is a combination of the virus doing

damage to the airways, secondary

infections and the interplay with

the host immune response,” said

Erica S. Shenoy, an infectious dis-

eases specialist at Massachusetts

General Hospital.

The general risk factors for this

mismatch between the immune

system and any respiratory illness

include advanced age and under-

lying chronic illnesses, including

diabetes and high blood pressure,

though public health experts are

eager to understand more about

who is most vulnerable in the

current o utbreak.

“Every individual is different,”

Fehr said, a nd there are differenc-

es in how young and old or male

and female immune systems re-

act. “There are lots of dynamics at

play when you talk about each

individual and how they might die

from this virus or why they might

survive.”

Problems can also stack up.

Vineet Menachery, a virologist at

the University of Te xas Medical

Branch, suspects that the corona-

virus may work much like SARS.

When the virus gets deep into the

lungs, it can damage alveoli, the

air sacs that take in oxygen. As

cellular damage accumulates,

lung tissue begins to stiffen. The

heart must work harder to get

limited oxygen to the rest of the

organs.

“What makes this new virus so

damaging is you’re losing lung

function, and that puts a strain on

every organ in your body,” Men-

achery said.

In t he patients who recover, t he

immune system’s response has

worked: It has cleared the virus,

with inflammation receding. Ye t

experts don’t know the long-term

outcome for these people. It’s p os-

sible they will gain immunity and

be protected from reinfection. Or

they might contract a less severe

case in the future — or not be

protected at all. They also might

gain only temporary immunity.

It’s y et a nother unanswered ques-

tion about the coronavirus.

[email protected]

Experts: Severity of illness is tied to individual immune system responses

BY SIMON DENYER

TOKYO — A Japanese infectious
disease specialist who visited the
quarantined Diamond Princess
decried “chaotic” and “scary” con-
ditions on the cruise liner that
gave the coronavirus more oppor-
tunity to spread.
Kentaro Iwata, a professor f rom
Kobe University, said he was left
troubled by the lack of virus-con-
trol protocols, such as designated
“red z ones” on the s hip, w hich h as
been on lockdown at a dock in
Yokohama for more than two
weeks.
“It was completely chaotic,”
Iwata said in a YouTube video
posted late Tuesday, after he s pent
several hours on the s hip a s part o f
an assessment t eam.
“I was so scared of g etting covid-
19 because t here w as no way to tell
where the virus is, no green zone,
no red zone — everywhere could
have the virus,” he said in English,
describing the normal practice of
cordoning off separate contami-
nated and v irus-free areas. Anoth-
er video, in Japanese, was viewed
more than 1.3 million times.
For Japan’s government, it was
another stinging critique of its
handling of the outbreak, includ-
ing what critics call sluggish re-
sponses in imposing border con-
trols earlier this m onth and ramp-
ing up virus testing.
In the past few days, the num-
ber of covid-19 cases — even out-
side the quarantined Diamond
Princess — has more than doubled
to 79, with many of the new cases
not t raceable to China.
That has forced health officials
to acknowledge that “local trans-
mission” has begun and it’s now
“impossible” t o prevent the virus
from spreading.
The virus has put politicians on
the defensive all over the world as
they struggle to react to a fast-
evolving threat — with Japanese
Prime Minister Shinzo Abe and
his government the latest to feel
the heat.
Here, the criticism echoes that
leveled at the country during the
2011 Fukushima nuclear disaster

— a reluctance to admit the scale

of the problem, a lack of firm

political leadership and a famous-

ly cautious bureaucracy.

‘So scared’

On the Diamond Princess,

meanwhile, at least 542 people

have been found to have the virus,

out of 2,404 people tested, with

results still awaited on the final

1,300 tests.

Four people working on or

around the ship during the quar-

antine period have also contracted

the virus: a quarantine officer, a

Health Ministry official, an ambu-

lance driver and a medical staffer.

A Japanese man and woman —

both in their 80 s, who were passen-

gers on the ship — died Thursday,

according to Japanese public

broadcaster NHK, marking the

first time one of the cruise ship

passengers has died.

The Japanese government in-

sists the quarantine was a success

and began letting its citizens who

have tested negative off the ship

Wednesday. They were allowed to

take public transport home.

But the fact that the U.S. govern-

ment evacuated its citizens before

the quarantine period ended —

and will subject them to an addi-

tional 14-day confinement in the

United States — was an acknowl-

edgment that it has a very different

view.

“My deep worry has been that

we are essentially condemning

[people on board] to infection be-

cause of the close quarters in

which they’re staying,” s aid Jenni-

fer Nuzzo, a senior scholar at the

Johns Hopkins Center for Health

Security in Baltimore. “And to

what end are we doing this? Is it

because we’re trying to keep the

virus out of the country? Japan

already has local transmission.”

Iwata, the health expert, called

the ship’s infection-control mea-

sures “completely inadequate.”

“Bureaucrats were in charge of

everything” without a single pro-

fessional infection control special-

ist on board, he said.

“I never had fear of getting infec-

tion myself, for Ebola, SARS, chol-

era, because I know how to protect

myself, how to protect others and

how infection control should be,”

he said, describing his past work in

Africa and with teams dealing with

severe acute respiratory syndrome

(SARS) in the early 2000 s.

“But inside the Diamond Prin-

cess,” he said, “I was so scared.”

He has since returned to his

home in Kobe but has isolated

himself in a room for fear of infect-

ing his family.

Responding to Iwata’s com-

plaints, Japanese chief govern-

ment spokesman Yoshihide Suga

said the government had been “im-

plementing measures to prevent

the spread of the infection thor-

oughly.”

Falling support

Two opinion polls published

Monday show support for Abe’s

government falling by five per-

centage p oints and significant lev-

els of dissatisfaction with the gov-

ernment’s handling of the out-

break.

The cost to Japan’s already

struggling e conomy could be cata-

strophic, while the possible impli-

cations for the Summer Olympics

in To kyo are almost unthinkable.

The new coronavirus has

moved fast, but the government’s

response has been slow and mis-

guided, many experts say.

On Jan. 23, Japan began using

monitors to check temperatures

of passengers flying in from Chi-

na, but it didn’t starting denying

entry to people from Hubei prov-

ince until F eb. 1 , a day after the U. S.

administration barred all foreign

travelers from China.

By then, thousands of tourists

from Hubei had entered the coun-

try, some bringing the virus with

them.

Critics said A be appeared keen-

er to avoid offending China ahead

of a visit by President Xi Jinping

planned for April than tackling

the p roblem head on.

“The government s eems to have

been inordinately complacent

when it should have been imple-

menting sensible countermea-

sures and preparing for an out-

break,” s aid Jeff K ingston, director

of Asian s tudies at Temple Univer-

sity Japan.

Masahiro Kami, executive di-

rector at Medical Governance Re-

search Institute in To kyo, said it

was apparent the virus was

spreading in Japan as early as Feb.

4, after a Thai couple returned

home with t he disease a fter a vaca-

tion in Japan.

Instead of relying on border

controls, Kami argues the health

ministry should have moved

much more aggressively to work

with private sector companies to

expand virus testing capacity in-

stead of relying on the ministry’s

own o verburdened National Insti-

tute of Infectious Diseases.

“It’s all about risk management

at the expense of the larger crisis

itself,” s aid Koichi Nakano, a polit-

ical science professor at Sophia

University in Tokyo.

The politics of China

In response, Foreign Minister

To shimitsu Motegi said Japan has

consistently taken action in line

with the changing situation in

China and intends “to continue to

tackle the situation with all our

might.”

A new “aggressive” s trategy an-

nounced by Japan’s Health Minis-

try this week recognized that a

change of a pproach was r equired.

Te st kits supplied by private-

sector companies are finally g oing

to be used to expand testing to

more than 3,000 assessments a

day, w hile beds in specialist hospi-

tals will be reserved for more se-

vere cases, rather than trying to

isolate people with mild symp-

toms.

A public education campaign

has begun and citizens are being

discouraged from attending non-

essential mass gatherings. Atten-

tion must also shift on how to

protect Japanese over 65 years

old, who make up a quarter of the

population, experts say.

Instead of restricting tests to

people who can show some link to

China or another infected person,

tests are now being made avail-

able to anyone with symptoms of

the disease — one of the reasons

for the recent j ump in cases.

“With many emerging infec-

tions, when they’re first recog-

nized, there are so many un-

knowns,” said Jeffrey Duchin, a

professor of medicine and infec-

tious diseases at the University of

Washington. “You’re almost al-

ways in a no-win situation. But

you have to really adjust your

tactics and your strategies as you

go.”

[email protected]

akiko Kashiwagi contributed to this

report.

Japanese government is under fire for response to illness

Jae c. hong/associated press

Commuters, many with masks, walk along a sidewalk Wednesday in Tokyo. Health officials now say

that “local transmission” has begun and that i t’s “ impossible” to prevent the virus from spreading.

Critics say officials have

moved slowly in dealing

with fast spread

charly triballeau/agence france-presse/ getty images

People walk by the coast in Yokohama, Japan. A cruise ship has

been on lockdown at a dock in the city for more than two weeks.

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