It is now more than three months since the World Health Organization designated the COVID-19 crisis a pandemic. Much progress has reportedly been made toward a vaccine, but the most optimistic prognoses are that this is still several months away. While parts of Europe have been reopening in recent days, the number of fresh cases of contagion worldwide has been reaching new daily heights.
In Israel, with a death toll just over 300, a gradual reopening of the economy has led to a rise in cases and concerns that some restrictions may have to be reimposed, but, as of this writing, not a drastic rise in seriously ill patients or deaths.
Throughout the crisis, The Times of Israel has been intermittently interviewing Prof. Yehuda Carmeli, the head of Israel’s National Institute for Antibiotic Resistance and Infection Control, who says he has “helped here and there” with the government’s response to the pandemic but is “not among the decision-makers.” Carmeli also heads the Department of Epidemiology at the Tel Aviv Sourasky Medical Center and is a professor at the Sackler School of Medicine at Tel Aviv University.
In our latest conversation, conducted over Zoom on Monday evening, Carmeli again helped us make sense of what we now know about a virus that is both relatively simple and devastating: He estimates that it will ultimately kill “many millions” worldwide. He lays to rest exaggerated concerns about its transmission via surfaces. He explains why wearing masks really makes a difference. And he notes that the desperately sought vaccine — if and when it comes — will not effectively protect those who are most vulnerable to COVID-19, especially the elderly.
Nonetheless, Carmeli pronounces himself more optimistic than he was three months ago, because data from serological tests increasingly shows that the mortality rate for those exposed to the virus is far, far lower than initial data had indicated. The “many millions” he now believes will ultimately die before most of the world’s population becomes immune would have been a far, far higher total otherwise.
The Q&A that follows was conducted in English and has been edited for clarity and brevity.
The Times of Israel: We’re so many weeks into this crisis, and I’m just staggered by how little we seem to know definitively. I know that you won’t know everything either, but you’ll know a lot more than most of us. So here goes with a barrage of questions.
1. I am looking at statistics on the Johns Hopkins and Worldometer sites and I see an ongoing rise in the number of new daily cases around the world, and a death toll rising toward half a million. Basically, it would seem, we’re not through this at all. Do you think we’re through the worst?
Yehuda Carmeli: No, no. We’re just at the beginning. By the end of this event, we assume that about 80 or more percent of the world population will get infected, unless there is a vaccine that will prevent many of the people from getting the disease. All models say that about at least 80 percent of the population will be infected.
2. And what does that mean in terms of deaths? I’m sorry to be so brutal.
The likelihood of someone who’s younger than 50 [dying from the virus] is extremely small.
What we know now is that in people below the age of 50, the risk of death is two among every 1,000 people diagnosed as having the disease. But what we’ve also learned is that for every person [in that age group] diagnosed as having the disease, somewhere between 10 and 50 people were exposed to the virus and developed immunity. So the 2 per 1,000 figure [is misleading. The real mortality figure for those aged 50 and under who are exposed to the virus] is two per 10,000-50,000.
If we look at the population of Israel, and two in about 20,000-30,000 people below the age of 50 are dying, we’ll have about 650 [fatalities] below the age of 50.
If we go to the population older than 70, the chance of dying is much higher. It’s eight percent for those over 70 [diagnosed as having the disease]. And 15 percent among those who are over 80. There are lots of variables, but that will be about 4,000 or 5,000 Israelis dying in the 70+ age group.
Your take is that eventually about 650 Israelis aged 50 and under will die from COVID-19, and another 4,000-5,000 over 70?
I would say the overall number of deaths expected [in Israel from COVID-19] is about 7,500-8,500
And what about in the 50-70 range?
Again, there are a lot of assumptions here. But I would say the overall number of deaths expected [in Israel from COVID-19] is about 7,500-8,500.
3. Unless we have a vaccine, or unless we find better treatments?
I have little hope for better vaccines or treatment. I’ll tell you why.
It’s likely that we will have a vaccine in a year. But vaccines are usually much less efficacious in the older population and in immunocompromised patients — and those are the people who actually most need the protection. And I don’t think we’ll be able to vaccinate enough of the population to get herd immunity just by the vaccine. So I think that the virus will continue to move around, and will reach the non-immune older population and the more vulnerable population.
We probably will not be able to make a huge impact on the number of people who will die.
I should stress: Everything I’ve said until now is true only as long as we have an operational health care system. If the health care system is overwhelmed, then more people will die. So the important thing here is making sure that we are not overwhelming the health care system.
I want to recap. What you’ve said is very bleak, relatively speaking. Israel has 300 dead, and would like to think the worst is over. But you’re telling me thousands of Israelis are going to die.
4. How long is this going to last? How long a period are you thinking of here?
Much depends on our response. If we do well in controlling the spread, it will probably take two or three years. If we are not, then it will happen in a short time, and then we will overwhelm the health care system, and we’ll have more deaths.
I want to be sure. I’m in the journalistic community. We’re supposedly the sensationalists and the people who inflate and make drama. But the numbers you’re setting out here indicate you are predicting an accelerating rate of death — not a slowing. Because we’ve been going on for three months; we’ve got 300 dead. And you’re talking about several thousand deaths in the next two, three years.
Yes. I don’t think anyone believes that we can eliminate the virus, so we are destined to have at least 80% of the population infected. The numbers I gave are actually optimistic. I would say very cautious.
Do you think that the 300 death toll is misleadingly low? That in fact more Israelis have died of COVID-19 than have been officially recorded?
There are probably a few [COVID-19] deaths that have been missed, but I don’t think that’s a big issue. As of about a month ago, based on serological tests, probably two or three percent of the population, up to about 300,000 people, had been exposed to the virus — so, thus far, we are just seeing the effect of the virus on a small part of the population, and we had 300 deaths.
5. And globally, what do these figures mean? It means millions globally, doesn’t it?
We have to remember that every year in Israel more than 1,000 people die from influenza. And we don’t think twice about it. It doesn’t disturb us in our everyday lives. We try to encourage people to get vaccinated. Most people don’t. But we don’t change our way of life because 1,000 people die each year from the flu.
So, if the numbers I just mentioned of maybe 8,000 dead would have happened over a period of five, eight years, we probably would have tolerated it reasonably well. The problem is that COVID-19 is a new virus, and people are not immune, and it spreads very rapidly, so it all can happen in a very short time. So first, that’s very difficult to accept. And second, it may overwhelm the health care system and lead to even more deaths.
Our truly major task — and this is against our natural wishes — is to extend this outbreak for as long as possible [to avoid overwhelming the heath care system
6. If we weren’t behaving as relatively sensibly as we are — we don’t travel on airplanes; we don’t crowd too much; we supposedly wear masks; we social-distance from each other — if we weren’t doing all that, your numbers would be worse? Your predictions would be worse?
So if we look at the endgame, it shouldn’t be worse.
If we overwhelm the health care system, then the numbers may go up. But otherwise, let’s assume that the health care system has no limits, and can treat everyone, no matter how condensed the cases are, then the endgame would be the same.
So our truly major task — and this is against our natural wishes — is to extend this outbreak for as long as possible [to avoid overwhelming the heath care system].
This is complicated, so forgive me. You said that by the end, 80 percent of us are going to have this, one way or another. So how does that differ from influenza?
With influenza, about 10 percent of the population are infected each year. And the others are relatively immune or they’re not getting infected. But with COVID-19, we have 100 percent of the population which is not immune. When you go to, say, Lombardy in Italy, apparently 40-50 percent of the population got infected in three months or four months. So you see a four-year influenza-sized death toll during a three-month period.
7. Why is it that in some places the contagion is so high and in others, it’s so much lower? How is it that Lombardy or London, say, or Belgium, relatively speaking, have such high infection rates, and places like Gaza, for goodness’ sake, the West Bank, Greece, do not?
There are several explanations and a lot of unknowns. One explanation is we judge how much infection there is by the severe cases and by mortality. And where you have a younger population, you don’t have a lot of sick people and you don’t have a lot of mortality. So if you go to Gaza where probably 60-70 percent of the population is less than 18 years old, and probably 80 percent of the population is less than 50, then even if there is a lot of infection going on, you would see very few severe cases and death, and much less diagnosis too. If you do serology testing, which looks at immunity, or exposure, you will find many more exposed than you would see elsewhere.
If you go to countries with older populations, or regions with older populations, then you would notice a lot more disease.
Second, we live in networks, so if the [virus] reaches a network of older people, if it goes into a nursing home, or in Italy where many of the old people live with their grandchildren and so on, you get old people disproportionately exposed to the outbreak.
And then, third, if your health care system is overwhelmed, people with relatively milder disease, medium severity disease, cannot get the supportive treatment that they need and may deteriorate and die, when otherwise they would have survived.
8. You don’t think climate is a factor?
The evidence does not support that climate is important. The evidence from COVID-19 shows both countries with hot weather, and different humidities, and cold weather, have been affected, sometimes severely.
On the other hand, other coronaviruses do have a seasonal effect. Other coronaviruses that cause just a runny nose are more active in the winter than in the summer. We’ll have to wait for next year to know more definitively.
9. I spoke to a Hebrew University scientist, Prof. Shy Arkin, who’s trying to find a treatment, early on in this crisis. Arkin said this is a simple virus, maybe 24 proteins. And he was pretty optimistic about treatments. He stressed that we hadn’t found vaccines for coronaviruses in humans in the past, but he was optimistic about treatment. Are there different strains of this virus? Does it mutate? Is it a simple virus?
It’s a simple virus. Any virus mutates. But it seems that this one, relatively, does not mutate a lot. So we can hope there will be protective immunity after disease.
Regarding treatment, I have not seen many extremely effective treatments against viruses, and definitely not against acute infection.
You can have prophylactic treatment… You’ll take it if you have seen someone who was sick, or take it through the winter — like President Trump is doing right now with chloroquine or whatever. I don’t think that’s very practical. I don’t know that we have anything now that is effective.
Second, you can try to treat people who are mildly ill so they will not deteriorate to have severe disease. And lastly, you can treat people with severe disease.
I think the most likely treatment will be for patients with relatively severe or severe disease. I think we’ll be able maybe to prevent –it’s a guess — maybe 20 percent of the deaths. That’s what we can expect from a good treatment, not more than that.
10. There’s been a lot of talk in the last few days of a more contagious, aggressive strain.
Most evidence so far shows that the strains are quite similar to each other, so the virus is really quite homogeneous. It depends what you call a “strain.” Mutation will occur. And even one mutation can make a difference.
Vaccines are not very effective in the older population
If there will be a very nonvirulent strain that is very contagious, and will infect many people, who will get immunity but will not be sick, that would be nice… But I don’t know that that’s going to happen. I think that’s too much to expect.
11. If this is a not particularly complicated virus, that doesn’t seem to mutate a great deal, why are you so pessimistic about vaccination?
I hope there will be an effective vaccine in a year, or at the end of next winter. That’s the timeline. Tony Fauci [the director of the US National Institute of Allergy and Infectious Diseases] said he hopes there will be something in December. But even if there is something approved in December, it will be a year from now before it will be produced in large quantities and delivered.
Second, vaccines are not very effective in the older population. And here, that’s where you [most] need a vaccine.
So a vaccine can limit the disease. It can limit the spread. If it’s given to children in school, maybe there will be less transmission and so on. But in the end, the virus will continue to be transmitted. You will not gain full immunity, of all people, like with smallpox, where the entire population is immune. It will be much more like influenza; you’ll get some protection.
12. What you’re saying is that a lot of old people are going to die from this virus…
And there’s nothing that we can do about that. But if we maintain social distancing and we’re fairly sensible, we won’t overwhelm the whole health service…
… in the course of dealing with this. They’ll die gradually, over the next few years.
That should be our goal — to make sure that the health care system is not overwhelmed.
Whereas if we all just lived it up and went to parties and all went back to work, the death rate would not be much higher, it would just be much quicker.
Except it could be higher because more people would die, including of other illnesses, because hospitals would be overwhelmed.
13. You mentioned President Trump there. Trump is taking something that I understood to not be effective…
There is a lot of evidence and indications to suggest that chloroquine is ineffective and will not work. If I were sick, I would refuse to receive it.
There is remdesivir, which is an antiviral agent that has been trialed and has been shown to be successful. Its success is limited success. It’s maybe reducing progression to more severe disease. That’s something I would take, even though it’s not having a huge effect. The problem is that it’s almost impossible to get, because there is limited supply.
The third treatment is serum treatment — serum taken from people who recovered from the disease, developed antibodies. You take their serum, and you inject the serum into people who are sick now. It’s a relatively primitive treatment. It has been trialed since the 1920s or so. But as in other diseases, it has a potential to improve treatment. There is limited but promising evidence that such treatment can be helpful with COVID-19 — again, in reducing the number of people who progress from medium-level disease to severe disease, or from severe disease to death, by maybe 30 percent or so.
To transmit via a surface, a droplet would have to fall onto a surface, remain wet, someone would have to touch the surface and immediately touch his nose or his mouth
And there are efforts to develop synthetic protective antibodies. That’s promising.
There are many other things that are trialed, but there is no evidence, and I’m not sure there is much rationale, that they would work.
14. Does this virus transmit via surfaces or not?
In a very limited way. It transmits primarily by droplets — droplets of saliva that travel a distance of up to two meters most of the time. It rarely transmits by air to a more distant area. And it rarely transmits via surfaces. To transmit via a surface, a droplet would have to fall onto a surface, remain wet, someone would have to touch the surface and immediately touch his nose or his mouth. Even that’s really a droplet that has been moved by hand.
The idea being advocated that you need to disinfect your credit card and so on, is craziness. Unless someone sneezes on your credit card, you don’t need to disinfect it.
15. That explains the focus on masks, when originally masks were not seen as crucial. Would you say that’s a crucial defense?
That’s a very hot topic for debate, almost to a religious level. And I would say I’m a believer. You don’t need sophisticated masks, but good masks.
It can be a simple medical mask. It can be a homemade mask, as long as it’s made from a dense material. We posted instructions on how to prepare those on the website of the Health Ministry. They give very good protection.
When we send health care workers to treat patients, they wear masks. It’s not 100%, but close to 100%, protection.
If I sneeze, it won’t go out. And if somebody sneezes in my direction, it won’t come in.
That’s exactly true.
16. What of the relative dangers of contagion indoors and outdoors?
When we speak about droplets, at a distance of up to two meters, it doesn’t matter if it’s indoors or outdoors. But once we start to speak about greater distances, then outdoors it’s less transmissible than indoors.
Simply because the droplets will disperse more rapidly?
17. Do we know more about the preexisting medical conditions that would make younger people more vulnerable?
People with chronic diseases, especially lung diseases or immune deficiencies, need to be more careful.
18. And smokers?
Smoking is not healthy, but I don’t think there is evidence that young smokers have a [greater] problem.
19. What about origins? What do we think we know about how this originated?
There is a lot of evidence that it is not man-made. But the discussion is very political and will continue for a long time
We know it’s closest to some bat viruses, so probably it evolved in bats and then somehow found its way into humans, probably after going through some change that allows easy transmission between people. Most people believe that there was an intermediate animal between bats and humans. And there is a lot of discussion over which animal it was.
But certainly not man-made?
There is a lot of evidence that it is not man-made. But the discussion is very political and will continue for a long time.
I don’t think it’s a plague. The best example or the best correlate would be the Spanish flu
20. Can you give some kind of one-step-back perspective? In terms of things that have battered human health, how should we look at this? This is really a plague? Where does it rank, historically, in terms of seriousness?
I don’t think it’s a plague. The best example or the best correlate would be the Spanish flu a hundred years ago, at the end of World War I, where a new influenza virus emerged and killed millions of people around the world, and it took about two or three years until most of the population became immune.
It didn’t fade away? People became immune.
And that’s what you think will probably happen here?
Yeah, I think so.
And you said before millions will die around the world, according to your statistical take.
Tens of millions? Hundreds of millions?
This is some new thing that’s going to kill the elderly and vulnerable, and we have to get through it as best we can?
That’s what I think. Unless we are extremely lucky with a splendid vaccine.
21. Is what you’re telling me now what you would have said three months ago, or are you more pessimistic?
I’m actually more optimistic, because what’s happened in the last month or two is that we have the results of serology testing from different places. Before that, most people spoke about one in every two patients being symptomatic. The numbers we had were among diagnosed people. No one knew if there were more people who were exposed, became immune, and we didn’t know about them.
Now, the serology testing has shown that probably somewhere between 10 to 50 people have been exposed, and developed antibodies, for every one person that has been diagnosed. So all the numbers for mortality [rate] go down 10- or 50-fold.
22. I’ve read the suggestion that the best advice health professionals could give the public is to maximize their health. In other words, eat well, exercise, because you’re going to be exposed to this virus and you will not be as vulnerable if you’re in good health.
Yes, and it’s also important to stay young.