Covid-19 (the SARS-CoV-2) and you

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Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal http://www.alan-whiteside.com

4th March 2020

Introduction

I am expected to know something about epidemics and pandemics,1 and their causes and consequences. Many friends and colleagues have been asking me about Covid-19.

Here is a quick ‘fact sheet’ as of 4 March – what we know, what we don’t know, and what we need to know. I include hot links. Please feel free to send it on.

Red text indicates the figures or information will change, and probably rapidly.

Bold text indicates a key point.

Obvious public sources of information are:

There is no shortage of information, but it needs sorting and sifting. There is a great deal of uncertainty about the trajectory of the epidemic, and how and when it will resolve.

Predicting the course and consequences of epidemic disease is not new. It has been addressed in the science and intelligence communities and in literature. The emergence of AIDS in the 1980s gave rise to a concern about the security implications of disease. One result was the US National Intelligence Council’s National Intelligence Estimate on the Global Infectious Disease Threat, January 2000. It noted the surge in HIV/AIDS, TB, malaria, hepatitis, with HIV/AIDS and TB expected to be the major cause of death in developing countries by 2020. It stated: “Acute lower respiratory infections—including pneumonia and influenza—as well as diarrheal diseases and measles, appear to have peaked at high incidence levels”2. In the UK the Foresight project3 looked specifically at infectious disease and produced a multi-volume report in 20064. These and subsequent government work are prescient. The works of fiction detailing such events range from Albert Camus’ 1947 book The Plague to South African thriller writer Deon Meyer’s 2016 Fever.

The origins

Covid-19 is a new disease affecting humans. Like HIV, SARS and MERS the virus spread into the human population from an animal host. This means it is a zoonotic disease5. It is believed the original source were pangolins6 (bats may be implicated). Transmission first occurred in a Wuhan seafood wholesale market in Hubei Province of China that sold live and butchered animals. The theories about the origins of the disease are based on science (genetics) and epidemiology, the first cases being among those who worked or shopped there7. It soon became apparent that there was human-to-human transmission of the virus, giving cause for concern.

For lay people the etymology is complicated. The virus is officially called ‘severe acute respiratory syndrome coronavirus 2, abbreviated to SARS-CoV-2’.8 Viruses are named by the International Committee on Taxonomy of Viruses (ICTV)9. Covid-19 is the name of the disease. The WHO states: “From a risk communications perspective, using the name SARS can have unintended consequences in terms of creating unnecessary fear for some populations . . . For that reason and others, WHO has begun referring to the virus as ‘the virus responsible for COVID-19’ or ‘the COVID-19 virus’ when communicating with the public.”10

What do we know?

There had been about 93 000 cases reported at midday on Wednesday 4 March.11 Most, at this point, were in China. The situation is fluid with cases being reported from across the world. There are puzzling blank spots on the map, notably most of Africa and Latin America and China outside Hubei.12 Transmission is through touch (like SARS), typically when an individual touches a surface which has virus on it, then touches their mouth, eyes or nose;13 and through droplets, a sneeze or cough by an infected person.14

Most people who get Covid-19 experience nothing worse than mild flu symptoms: a fever, cough and shortness of breath. Generally, people recover quickly, indeed may not know they are/were infected. There is no mention, yet, of possible sexual transmission of Covid-19 for example through kissing and unprotected intercourse. It is not certain how quickly people become infectious; how long can they be asymptomatic but pass on the virus; if there any immunity for those who recover; and if people can be re-infected? This information will be available soon.

It is important to put the virus into perspective. It is more deadly than seasonal flu, the case fatality rate (CFR) in China was initially reported to be 2.3%.15 The CFR for seasonal flu in the US is typically less than 0.1% (1 death per every 1 000 cases).16 The rate for SARS was 9.6% and MERS 34%.17 Obviously some are at greater risk: people with underlying health conditions especially respiratory illness; the elderly; and health workers who have greater exposure to the virus. Note the chances of infection are thought to similar for all, (although incidence in children is very low). The disease is more likely to be serious, and lead to death for some cohorts, especially the elderly.

According to the Lancet of 27 February the number of cases have been doubling approximately every 7.4 days; the basic reproduction rate (the number of people infected by each case) is 2.2, it is roughly 1.3 for seasonal flu; person to person infections are taking place; the median age of infected people was 61 years; and asymptomatic infections can be a source of infection.18 Over half of those infected, up to 2 March 2020, had recovered.19 Currently, based on estimates of the incubation period, it is believed a 14-day quarantine is enough to prevent transmission.

Globally teams of epidemiologists are working to track the virus, predict where it might emerge, and assess interventions. The Centre for the Mathematical Modelling of Infectious Disease at the London School of Hygiene and Tropical Medicine20 produced the material I have sourced. Particularly important is the 28 February paper Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts by Hellewell, Abbott, et al.21 Scientists are seeking greater understanding of the virus, how it works, potential treatments and, the holy grail, a vaccine. Despite the advances in science, thanks to previous epidemics and pandemics (HIV lead to huge advances in virology),22 it will take time for treatment and a vaccine to be developed and distributed.23 Lagging in publishing, or sharing analyses, are social scientists.

One crucial question for planners is how linked is the epidemic to weather? In other words, is this like seasonal flu and incidence will decrease as the temperature rises. This might happen for two reasons: first the virus may not survive for as long outside the human body, and second people are more likely to be outside in fresh air. If it is linked, then northern hemisphere incidence should decline as southern hemisphere infection rates increase.

The extent of the epidemic on 4 March

As of 4 March, the largest number of cases of Covid-19 were in China with close to 80 000 cases and about 3 000 deaths across the country. There had been 66 337 infections and 2 727 deaths in Hubei and this gives rise to the question – Why have there been so few cases in the rest of China?24

There was an outbreak on a cruise ship docked in Japan. Interestingly, the WHO has not allocated these to a country. They appear in statistics as: “Cases identified on a cruise ship currently in Japanese territorial waters.” The data are for an ‘International conveyance (Diamond Princess)’ with 705 cases and 6 deaths.25 This may be a puzzle for researchers in future years.

There is a view that Chinese reporting has been good and the response effective. On 25 February Bruce Aylward of the WHO briefed journalists about his mission to China saying specialists did not see evidence of mild cases of Covid-19 evading detection. “So I know everybody’s been out there saying, ‘Whoa, this thing is spreading everywhere and we just can’t see it, tip of the iceberg.’ But the data that we do have don’t support that,” Aylward said during a briefing for journalists at WHO’s Geneva headquarters.26 The key message is: this is a rapidly developing epidemic and it is hard to predict what will happen next. See websites.27

One question is how many people have been infected and recovered. Obviously a 2.3% CFR means 97.7% of infected people are either still ill or have recovered. This is not HIV, where infection is (currently) for life. If there is some degree of immunity for people who have been infected that would be encouraging. A pandemic is defined as the worldwide spread of a disease above endemic levels, but the exact threshold for declaring one is vague. The WHO has declared a ‘public health emergency of international concern.’ In practice, the actions would not change were a pandemic to be declared. Containment measures are not simply about eliminating the disease. Delaying the onset of an outbreak and decreasing the peak is crucial to allow health systems to cope with sudden influxes of patients, especially those requiring intensive and barrier nursing.28

As of 4 March, there were reported cases in 68 countries.29 The vast majority, (80 270) in China, followed by South Korea (3 528), Iran (2 992), Italy (2 502) and Japan (282). In Europe, France (212) and Germany (240) had the highest number of cases. In North America the USA had 105 and Canada 30 cases. There had been 6 cases in Ecuador, 5 in Mexico, 2 in Brazil, and one each in Argentina, Chile and the Dominican republic. In Africa, Algeria reported 5 cases, Egypt 2 and Tunisia, Morocco, Senegal and Nigeria 1 case. Most counties have fewer than 50 cases but the situation is changing hourly.

Consequences

In addressing the consequences of the epidemic, I will not talk about epidemic spread; morbidity (illness) or mortality (death). These aspects are critical, but beyond the scope and mandate of this briefing. In addition, it is possible and hoped that the disease will be brought under control,30 but the consequences will ripple across the world for many months.

Health Systems

There will be a significant increased demand on health systems. Data from China shows older people, men, and people with pre-existing health conditions including cardiovascular disease, diabetes, chronic respiratory disease, hypertension and cancer are at greater risk of dying. This is further illustrated by an early infection cluster in the US. In Washington State: “More than 50 residents and staff from the Life Care Center in Kirkland are experiencing symptoms, and will be tested for coronavirus, said Dr Jeffrey Duchin, health officer for Seattle and King County”.31

It is estimated that 17% of infected people will need medical interventions. The health authorities should be planning for this and the plans should include the full gamut of activities from how many cases they expect, to when and what their needs will be. A key determinant of impact will be not just how many, but also whether they occur in a wave that could overwhelm services and affect workplaces. If containment (or viral, host or environmental characteristics) result in a slower rate of spread, this means that the same number of cases may occur over time but will be less disruptive and overwhelming. The health response ranges from simple reassurance over a telephone hotline to needing a respirator, and for some, body storage and funeral planning. The real concern is in countries with weak health systems. As yet Covid-19 has not emerged here in significant numbers. Many are in the south so the weather may play a role: as winter advances numbers could rise.

Social

The current global public response can best be described as mild hysteria. This will be maintained as the numbers continue to rise and people do not understand risk, or more accurately do not apply it to themselves. There has been discrimination and racist behaviour toward people of Asian appearance, reported in many news stories and not therefore footnoted here.

What we are seeing in terms of social impact is a retreat from intimacy and some forms of interaction. This is common sense from a public health point of view and is to be encouraged. There is a danger though that this will become the ‘new normal’. Given the nature of, particularly western economies, with the importance of the service sector, the knock on economic implications are serious.

Economic

  • A cruise ship in quarantine against a quay in Japan means, apart from those unfortunate souls aboard, many people are missing holidays. Will the crew be paid and for how long?
  • The Louvre in Paris is closed to visitors.
  • British Airways has cancelled flights to and from Beijing and Shanghai until 17 April.32 BBC Business News reports: ‘British Airways and budget rival Ryanair have cancelled hundreds of flights as demand for travel drops amid fears about the spread of coronavirus.’33
  • Holidays and flights are being cancelled globally. There will be fewer pilgrims on the 2020 Haj.
  • The Johannesburg stock exchange fell from 10 874 on Thursday 27 February to 9642 on Friday 28 February but had recovered to 10 212 by the afternoon of Tuesday 3 March.
  • On the London Stock Exchange, the FTSE 500 index fell from 4191.17 on 12 February to 3673.61 on the Friday 28 February and at midday on 3 March was at 3777.79. The initial response was that trillions of dollars were wiped off global stock markets up to the 28 February. There has been some recovery, but the markets can best be described as jittery.

The WHO director general told his 500 000 Twitter followers: “If you are 60+, or have an underlying condition like cardiovascular disease, a respiratory condition or diabetes, you have a higher risk of developing severe #COVID19. Try to avoid crowded areas, or places where you might interact with people who are sick”. Effectively the message is don’t go to the theatre or take public transport, but you are probably OK in a restaurant.

It is time for economists to engage with this disease. Risk scenarios that could be modelled are the economic costs of containment strategy including economic impact, particularly of reduced business and tourist travel under different epidemiological scenarios versus the economic costs of inaction and more infection. The reality is that global supply chains are being disrupted and many people, especially those in low paid and insecure employment, will see their incomes fall or stop. There are lessons to be drawn from previous global shocks such as 9/11 and SARS. The economic impact is the area to develop in future posts.

Conclusion

This is a concerning event and, to a large extent, we will have to watch as it plays out. At the outset I am writing for friends and colleagues and the man on the Clapham Omnibus,34 so let me turn to some practical responses. Be aware of the news. Protect yourself and others with simple common-sense precautions.

  • cover your mouth and nose when you cough or sneeze and bin used tissues;
  • wash hands frequently with soap and water or use an alcohol-based sanitiser;
  • avoid close contact with people who are unwell;
  • follow national guidelines on self-isolation if you have been exposed or feel unwell;35
  • do not touch your eyes, nose or mouth if your hands are not clean and
  • try to understand the science, support the scientists, and do not spread rumours.

Wearing a face mask is not complete protection, viruses can transmit through the eyes and some viral particles can penetrate masks. However, masks can capture most droplets, the main transmission route. The masks are critical for people who are infected as it prevents them transmitting the virus. Good quality masks are crucial to protect health professionals.

The restrictions on gatherings make sense. France has a temporary ban on public gatherings of more than 5 000 people in confined spaces. A half-marathon of 40 000 runners scheduled for 1 March in Paris was cancelled. Switzerland has banned events of more than 1 000 people.36 The logic is that these events are not currently high risk, but contact tracing would be nigh on impossible. Closing schools, especially for younger children may make sense, they are petri dishes for infections.

I am not going to write anymore on this. It has taken me six pages to get to this point. I know something about the implications of disease and shocks on economies. This may well be the most important aspect of the Covid-19 outbreak, and I have not done it justice. It is my intention to revisit this document once a week and write something. I will post on my blog and notify Facebook friends.

A big thank you to everyone who commented on the first draft. Please forward, post and disseminate. Comments to awhiteside@balsillieschool.ca

  1. Definitions. An epidemic when the rate of a disease reaches unexpectedly high levels affecting many people in a short time. A pandemic when epidemics are global. Endemic, low levels of continuous infection.
  2. In the US the National Intelligence Estimate on the re-emergence of the threat from infectious diseases worldwide and implications for the US https://www.dni.gov/files/documents/infectiousdiseases_2000.pdf accessed 2 March 2020.
  3. “Foresight creates challenging visions of the future to ensure effective strategies now” page iii, Foresight. Infectious Diseases: preparing for the Future. Executive Summary. Foresight was run by the Office of Science and Innovation under the direction of the Chief Scientific Adviser to the British Government.
  4. Foresight. Infectious Diseases: preparing for the Future. Executive Summary. Office of Science and Innovation, London 2006.
  5. A zoonotic disease is an infectious disease caused by bacteria, viruses, or parasites that spread from non-human animals (usually vertebrates) to humans https://en.wikipedia.org/wiki/Zoonosis accessed 2 March.
  6. https://en.wikipedia.org/wiki/Pangolin accessed 2 March 2020.
  7. D. Cyranoski, ‘Mystery deepens over animal source of coronavirus. Pangolins are a prime suspect, but a slew of genetic analyses has yet to find conclusive proof’ https://www.nature.com/articles/d41586-020-00548-w accessed March 2020.
  8. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it accessed 2 March 2020.
  9. https://talk.ictvonline.org/information/ accessed 2 March 2020.
  10. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it accessed 2 March 2020.
  11. https://infographics.channelnewsasia.com/covid-19/map.html accessed 4 March 2020
  12. The Johns Hopkins tracking map https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 accessed 2 March 2020.
  13. G. Hinsliff, M. Townsend, E. Helmore and J. Aglionby, ‘The day the world caught a cold’ https://www.theguardian.com/world/2003/apr/27/sars.johnaglionby accessed March 2020.
  14. ‘Looming threat of COVID-19 infection in Africa: act collectively, and fast’, Published Online 27 February 2020; https://doi.org/10.1016/S0140-6736(20)30464-5. See Online Articles https://doi.org/10.1016/S0140-6736(20)30411-6 accessed 2 March 2020.
  15. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200219-sitrep-30-covid-19.pdf accessed 2 March 2020. The case fatality rate is the number of deaths in reported cases, so, if people have mild symptoms and are not recorded as having the virus, this will be exaggerated.
  16. https://www.worldometers.info/coronavirus/coronavirus-death-rate/ accessed 2 March 2020.
  17. https://www.worldometers.info/coronavirus/coronavirus-death-rate/ accessed 2 March 2020.
  18. S. H. Ebrahim and Z.A. Memish, ‘COVID-19: preparing for superspreader potential among Umrah pilgrims to Saudi Arabia’ https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30466-9/fulltext accessed 2 March 2020.
  19. Data for cases, distribution and status of case: active mild or severe recovered or died are updated daily at https://www.worldometers.info/coronavirus/#repro accessed 2 March 2020.
  20. https://www.lshtm.ac.uk/research/centres/centre-mathematical-modelling-infectious-diseases accessed 2 March 2020.
  21. J. Hellewell, S. Abbott, A. Gimma, N. Bosse, et al., ‘Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts’, The Lancet: Global Health, Lancet Published Online https://doi.org/10.1016/S2214-109X(20)30074-7 accessed 2 March 2020.
  22. The 2008 Nobel Prize for Medicine was awarded to the discoverers of the HI Virus, Françoise Barré-Sinoussi and Luc Montagnier.
  23. The Guardian notes that despite the early release by Chinese researchers of the genetic sequence, “having a commercially available vaccine within a year would be quick” http://www.theguardian.com/world/2020/ feb/28/coronavirus-truth-myths-flu-covid-19-face-masks accessed 2 March 2020.
  24. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200229-sitrep-40-covid-19.pdf accessed 4 March 2020.
  25. Ibid
  26. https://www.statnews.com/2020/02/25/new-data-from-china-buttress-fears-about-high-coronavirus-fatality-rate-who-expert-says/ accessed 2 March 2020.
  27. WHO http://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen; national governments, e.g. public health, England http://www.gov.uk/government/topical-events/coronavirus-covid-19-uk-government-response; academic, e.g. Johns Hopkins University https://hub.jhu.edu/novel-coronavirus-information/ all accessed 2 March 2020.
  28. ‘Yes, it is worse than the flu: busting the coronavirus myths’, http://www.theguardian.com/world/2020/feb/28/coronavirus-truth-myths-flu-covid-19-face-masks accessed 2 March 2020.
  29. https://infographics.channelnewsasia.com See reference 11
  30. The UK government warns that this will go on for months. Personal view from news reports.
  31. https://www.theguardian.com/world/2020/mar/01/coronavirus-washington-state-nursing-home-lockdown accessed 2 March 2020.
  32. https://www.britishairways.com/travel/flightops/public/en_gb accessed 3 March 2020.
  33. https://www.bbc.co.uk/news/business-51713192 accessed 3 March 2020.
  34. Thank you for reading and looking at footnotes. In this serious subject this is my bit of fun. From Wikipedia: “The man on the Clapham omnibus is a hypothetical ordinary and reasonable person, used by the courts in English law where it is necessary to decide whether a party has acted as a reasonable person would – for example, in a civil action for negligence. The man on the Clapham omnibus is a reasonably educated, intelligent but nondescript person, against whom the defendant’s conduct can be measured. The term was introduced into English law during the Victorian era, and is still an important concept in British law.” https://en.wikipedia.org/wiki/The_man_on_the_Clapham_omnibus accessed 3 March 2020.
  35. In the UK https://111.nhs.uk/covid-19.
  36. https://www.eureporter.co/frontpage/2020/03/02/gatherings-banned-travel-restricted-as-coronavirus-cases- grow-worldwide/​ accessed 2 March 2020.