As the coronavirus outbreak evolves, we answer some key questions

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As a new coronavirus that has infected more than 1 million people around the world continues to spread, scientists and public health officials are racing to understand the virus and stop the growing public health crisis.

In this rapidly evolving situation, many unknowns remain. Here’s what we know so far about the new virus — called severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2 — and the disease that it causes. We will update these answers as more information becomes available.

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Some of the questions below include:

What is SARS-CoV-2?

The virus is a novel type of coronavirus, a family of viruses that typically cause colds. But three members of this viral family have caused deadly outbreaks. Severe acute respiratory syndrome coronavirus, or SARS-CoV, Middle East respiratory syndrome coronavirus, or MERS-CoV, and now SARS-CoV-2 all cause more severe disease, including pneumonia. SARS-CoV-2 got its name because it is similar to SARS-CoV.

The disease it causes is coronavirus disease, or COVID-19. Before virologists and public health officials named the virus and its disease, it was known as 2019 novel coronavirus, or 2019-nCoV.

Why are experts so worried about it?

There are still a lot of unknowns, including exactly how deadly the virus is. And SARS-CoV-2 is a new coronavirus and hadn’t infected people before the outbreak in China, so no one has prior immunity to it. That means everyone is susceptible to getting infected and transmitting the virus to others, so it can spread rapidly and widely.

A sudden, big spike in U.S. cases like we’ve seen in other countries would mean that COVID-19 patients could have to compete for hospital space with other sick people. Too big a spike could overwhelm hospitals.

Scientists and public health officials also worry about people in high-risk groups — including older adults or people with underlying health conditions — who appear more likely to develop severe disease.

But some experts also still see a chance to prevent the virus from taking root in the population, as other respiratory diseases have. Seasonal influenza, for example, causes yearly epidemics. Because flu infects millions of people, and kills about 0.1 percent of the people who get sick, that can mean tens of thousands of deaths in a single season. By tracing contacts and isolating sick patients, experts hope to prevent this from happening with COVID-19.

So how deadly is the new virus?

Most cases have been mild. Of known cases globally, an estimated 3.4 percent die, according to the World Health Organization. But that number varies from place to place — it’s 4.2 percent in Hubei Province, the epicenter of the outbreak, for instance, and 1.6 percent outside of China — and officials say the number will probably change as the outbreak continues.

That global number is higher than a previous estimate of 2.3 percent that came from a study of more than 44,000 cases in China through February 11. As of April 3, there have been more than 1 million confirmed cases and more than 55,000 confirmed deaths, according to data from Johns Hopkins University. Over 220,000 people are reported to have recovered from the virus.

For comparison, the 2003 SARS outbreak killed 774 people, or nearly 10 percent of the 8,000 people it sickened (SN: 3/26/03). The virus that causes MERS, a disease that still circulates in the Middle East, has claimed about 30 percent of the people it infects, or 866 people to date (SN: 7/8/16).

The overall deadliness of COVID-19 may not be known for some time, until researchers can determine how many people were infected, but didn’t have symptoms, or had very mild symptoms and didn’t get tested.

Who’s most at risk? What about young children?

Early data from China suggested that adults aged 60 or older and those with underlying health conditions are most vulnerable. More recent data from around the world support that, showing that older people, especially those with heart disease and other preexisting conditions such as asthma, chronic lung disease or severe obesity, are at higher risk for severe illness.

Preliminary data from the U.S. Centers for Disease Control and Prevention show that younger adults appear vulnerable to severe disease, too (SN: 3/19/20). Children and teenagers seem to rarely show symptoms or become seriously ill when they do catch the virus (SN: 2/14/20). Even though their symptoms are mild, infected children may still spread the virus.

Another study, published March 16 in Pediatrics, describes the disease in 2,143 children under 18 years old in China, about half of whom were from Hubei Province, the epicenter of the pandemic. Compared with adults, these children generally had milder cases. It’s unknown why most kids aren’t getting as sick as adults.

But children weren’t wholly protected. An estimated 5.9 percent of kids had severe or critical cases. Infants and preschoolers generally had more severe illnesses, including symptoms such as breathing trouble, than older kids, the team found. The researchers report one pediatric death, of a 14-year-old boy.

What are the symptoms?

People with COVID-19 often have a dry cough and sometimes shortness of breath. And the vast majority of patients with this illness have fever, according to reports characterizing patients from China.

One tricky thing is that these symptoms also apply to the flu and it’s still flu season in the United States, so most people with those symptoms now probably don’t have COVID-19.

Other respiratory illnesses, caused by the likes of rhinoviruses, enteroviruses and other viruses, don’t necessarily have fever, says Preeti Malani, an infectious disease specialist at the University of Michigan School of Medicine in Ann Arbor. Colds often include a runny nose, but that hasn’t been a symptom for COVID-19. Though many people infected with SARS-CoV-2 will probably experience mild symptoms, others can develop severe pneumonia.

How many undetected cases are out there?

No one knows for sure how many people have been infected with the coronavirus.  That’s partly because there aren’t enough test kits to test everyone, and partly because people may be infected with the virus but have no symptoms or very mild symptoms. Those people may, nevertheless, unwittingly infect others.

“There’s really no doubt that there are many undetected cases,” says Erik Volz, a mathematical epidemiologist at Imperial College London in England.

Why do we care about undetected cases?

Undetected cases matter because they may seed outbreaks when travelers carry them to other countries, says infectious disease dynamics researcher Katelyn Gostic of the University of Chicago. But even the best efforts to screen airline passengers for COVID-19 infections will miss about half of cases, she and colleagues report February 25 in eLife.

“Not only does screening at airports miss over 50 percent of travelers, but those failures are not due to correctable mistakes,” Gostic says. It’s not because sick travelers are trying to avoid detection or screeners aren’t good at their jobs. “It’s just a biological reality that a majority of infected travelers are fundamentally undetectable, because they don’t realize they’ve been exposed and they don’t yet show symptoms at the time when they pass through screening.”

That is true of almost every pathogen, but the coronavirus’s prevalence of mild and undetectable cases and airborne transmission are bigger challenges. People may catch the virus without ever knowing they were exposed and may develop mild cases that wouldn’t cause them to seek medical attention and get tested. Those people may unwittingly start epidemics in new places. “We just see this as inevitable,” Gostic says.

What’s the situation in the United States?

As of April 3, U.S. health officials have confirmed the coronavirus in at least 213,000 people across all 50 states, Washington D.C., and territories. Over 4,500 deaths have been confirmed, the CDC reports.

Officials announced the first COVID-19 case in the United States linked to travel on January 21 (SN: 1/21/20). On February 26 and 28, U.S. health officials announced that two women in California had been infected (SN: 2/28/20). Neither woman had traveled to affected areas and were not exposed to someone known to have the disease. Those cases were the first evidence of community spread of the disease in the United States.

In the wake of steadily rising case numbers, health officials have implemented social distancing measures, including advising people to avoid gatherings of more than 10 people. States have closed schools and shut down bars and restaurants and other nonessential businesses, in addition to issuing stay-at-home orders.

As of April 2, the New York Times reports that at least 297 million people in at least 38 states, 48 counties, 14 cities, Washington, D.C., and Puerto Rico are being encouraged to stay home.

What can I do to prepare?

Practicing good hygiene is the most important way to protect yourself. Tips from the WHO include washing hands with soap and water or alcohol-based sanitizers, disinfecting surfaces, and coughing or sneezing into your sleeve or using a tissue (SN: 2/28/20). If you think you are sick, stay home and avoid traveling.

The CDC also recommends having a plan in place for what will happen if you and your family have to stay home from work or school.

Does hand sanitizer actually work?

Though washing your hands with soap and water is best, hand sanitizers will also work.

Coronaviruses are enveloped viruses, meaning that when a single viral particle leaves an infected cell, it takes part of the cell’s membrane with it. This membrane forms a protective coating around the virus. But alcohol in hand sanitizer can disrupt this envelope and essentially kills the virus.

Are masks recommended for protection?

On April 3, the White House began encouraging people to wear cloth masks, even if they have no symptoms. Health officials in the United States and Europe had initially recommended that only people with COVID-19 symptoms and those caring for them wear masks, citing a fear of shortages for health care workers. Much of Asia recommends wearing the masks.

It’s important to remember that these masks are not meant to be a replacement for social distancing. And the masks are designed to protect others from the mask wearer, not the other way around. That’s because surgical masks are designed to keep germs in, not keep them out.

If a sick patient is wearing a surgical mask, the fabric will catch respiratory droplets and prevent viral particles from getting on surfaces other people might touch. But these types of masks are not designed to protect healthy people from viruses in the environment. Surgical masks don’t fit perfectly around the face, leaving gaps on the sides. Many people also don’t wear them properly — like leaving their nose exposed while covering their mouth, for instance.

What should I do if I think I have COVID-19?

If you have a fever and respiratory symptoms, call your medical provider ahead of time, infectious disease specialist Malani says, so they can let you know what the next step is. “This is not something that you can just walk into an urgent care and easily get tested,” she says.

Local health departments, with help from physicians, determine whether someone should be tested for the virus.

It’s important to remember that the risk of getting severely ill appears to be fairly low for many people. But “even though individual risk may be low, there’s still a need to take the situation seriously and do what you can to limit spread if it does start circulating in your community,” Gostic says.

How do doctors test for the virus?

WHO laboratory-testing guidelines suggest doctors take multiple samples, including nose and throat swabs, blood and sputum from the lower respiratory tract.

In the lab, researchers look for genetic evidence of the virus, using a method called reverse transcription polymerase chain reaction, or RT-PCR. If the virus is present, the technique produces copies of RNA — the virus’s genetic code — that is unique to SARS-like coronaviruses. For positive tests, researchers do further genetic analyses to pin down whether SARS-CoV-2 is the cause. The method relies on patients being sufficiently sick that they have high amounts of the virus for it to detect. Not everyone who is infected will have a positive test.

Although initial testing in the United States was limited to people with a travel history to Wuhan or contact with someone who had, the CDC expanded their testing criteria in the wake of the first cases of community spread. Now patients who have a doctor’s order can supposedly be tested. But many who are sick and whose doctors want them tested are still being turned away.

The first CDC diagnostic kits were also flawed, restricting the ability of local and state labs to screen patients. But officials have since allowed commercial and academic labs to develop their own tests, which has helped increase testing capacity. Those test results must then be confirmed at a state lab. Still, the number of tests and testing capabilities remain limited in the country.

Where did the virus come from?

Coronaviruses are zoonotic, meaning they originate in animals and sometimes leap to humans. Bats are often thought of as a source of coronaviruses, but in most cases they don’t pass the virus directly on to humans. SARS probably first jumped from bats into raccoon dogs or palm civets before making the leap to humans.

MERS, meanwhile, went from bats to camels before leaping to humans (SN: 2/25/14). A paper published January 22 in the Journal of Medical Virology suggests that the new coronavirus has components from bat coronaviruses, but that snakes may have passed the virus to humans. Many virologists, however, are skeptical that snakes are behind the epidemic (SN: 1/24/20). Other analyses have proposed pangolins as the source of the virus, but coronaviruses from pangolins are not as closely related to SARS-CoV-2 as bat viruses are, meaning the mystery is far from solved.

Current data suggest that the virus made the leap from animals to humans just once and has been passing from person to person ever since. Based on how closely related the patient viruses are, animals from the seafood market probably didn’t give people the virus multiple times as researchers originally thought, Bedford says. If the virus leaped from animals to humans more than once, the researchers would expect a greater number of mutations.

Why does knowing the virus’s origin matter at this point?

Pinpointing the source of the virus is a step toward protecting people from coming into contact with more infected animals, and possibly starting another outbreak.

Can pets get sick?

A cat in Belgium seems to have become infected with the coronavirus and may have had COVID-19. While the case — the first reported in cats — suggests that the animals can catch the virus, there is no evidence that felines play a role in spreading the coronavirus, and it’s still unclear how susceptible they are to the disease.

The cat probably picked up the virus from its owner, who fell ill with COVID-19 after traveling to northern Italy. About a week later, the cat started to show signs of illness: respiratory issues, nausea and diarrhea. In lab tests, feces and vomit samples showed high levels of SARS-CoV-2’s genetic material.

Earlier in March, the first dog tested positive for SARS-CoV-2 (SN: 3/5/20), followed by another pup on March 19. Neither dog had symptoms and both results were only weakly positive, but the first dog, a 17-year-old Pomeranian from Hong Kong, died of unknown causes shortly after its release from quarantine.

Several types of coronaviruses can infect animals and in some cases make them ill. So the CDC advises avoiding contact with pets and wearing a face mask if you are sick. Researchers reported in 2003 in Nature that cats could be infected with the SARS virus and transmit it to other cats in the same cage, but they didn’t show any symptoms. The same was true for ferrets, although the ferrets became sick.

In a study in the March 2020 issue of Journal of Virology, researchers note that SARS-CoV-2 can probably recognize ACE2 in cats, ferrets, orangutans, monkeys and some bat species. Another study,  published March 30 in Cell Host and Microbe, confirms SARS-CoV-2 can infect ferrets, too.

Still, pet owners shouldn’t panic. Cases in pets have been extremely rare so far. If COVID-19 were a serious problem for pets, we would know it by now. “Dogs and cats may be what we call dead-end hosts,” says Jane Sykes, a veterinarian at the University of California, Davis. “They get infected with the virus. They shed it, but they’re unlikely to shed it enough to spread it to people.”

The American Veterinary Medical Association recommends taking normal precautions when cleaning litter boxes and feeding animals. If owners test positive for COVID-19, they should consider having someone else in the household care for the pet while they’re sick or wear a mask around the pet and limit contact.

When will it end?

It’s a tough question for experts to answer, and right now, no one knows. On March 11, the WHO announced that it is now calling the coronavirus outbreak a pandemic, given its spread and rapidly growing impact (SN: 3/11/20).

Some experts say that social distancing will need to last one to three months at minimum, potentially longer (SN: 3/24/20). We could get a big break if the virus’ spread slows with warmer weather, though so far there’s no indication that will happen. “That would be a great stroke of luck,” says Maciej Boni, an epidemiologist at Penn State University, and may allow more people to return to work once the number of new cases begins to fall.

Keeping schools closed and encouraging people to generally stay home could suppress the pandemic after five months, according to a March 16 Imperial College London report. But once such restrictions are lifted the virus would, in all probability, come roaring back. Until a vaccine becomes available, potentially in 12 to 18 months, the report argues that major, society-wide social distancing measures are necessary.

It’s possible that the virus could begin circulating permanently in humans, like influenza or common colds. It’s unknown at this point if the virus might become seasonal like the flu.

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