World hurtles towards a pandemic following explosion of COVID-19 cases

COVID-19

Dr Adrian Hyzler
Chief Medical Officer

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Since the first notification on 31st December 2019 of 40+ cases of an unusual viral pneumonia of unknown origin in Wuhan, capital city of Hubei province in central China, the infection now known as ‘COVID-19’ has spread at an alarming rate to all of mainland China. The ‘Sars-CoV-19’ virus has now spread to 33 countries and territories around the world, and one international conveyance (the “Diamond Princess” cruise ship in the port of Yokohama, Japan).

A novel coronavirus is thought to have jumped from a ‘still unknown’ animal source to humans in Wuhan’s ‘Huanan South China Seafood Market’ in early December 2019. Coronaviruses are a large family of viruses with some causing mild illness, such as the common cold, and others more severe disease such as MERS (Middle East Respiratory Syndrome) and SARS (Severe Acute Respiratory Syndrome).

The virus infects the lungs causing a respiratory tract infection, with initial symptoms of fever with dry cough and sore throat. It can progress to shortness of breath and breathing difficulties leading to viral pneumonia. It is thought to cause severe illness in around one in five cases leading to respiratory, cardiac, liver and renal failure – current information points to a ‘fatality rate’ of around 2.5% of all confirmed cases, according to the WHO, but this is likely to fall as numbers swell when milder case numbers are added. The vast majority of the fatalities have been in Hubei province – 80% of the deaths have been in over 60yr olds and 75% have had pre-existing medical conditions.

On 30 January 2020 the International Health Regulations Emergency Committee agreed that the outbreak now meets the criteria for a Public Health Emergency of International Concern. There is currently no vaccine or specific treatment, though trials of anti-viral and anti-HIV medication have started to be used in controlled clinical trials.

The virus is transmitted from a sick person to a healthy person through respiratory droplets when the sick person coughs or talks close to another person. Current diagnostic tests have yielded positive results from a variety of specimens including throat swabs from asymptomatic people and faeces. These positive results are not a conclusive indication that people are contagious. People may have been exposed and infected but are NOT necessarily transmitting the disease. More investigations into potential other routes of transmission are ongoing. What has been reported so far it that the main driver of transmission is droplet transmission from people with symptoms

It is advised to avoid gatherings of people, avoid people who are obviously ill and/or coughing and to wash your hands regularly with soap and water or alcohol-based hand sanitiser. Within the APAC region in particular you should also avoid all contact with wild or farm animals and you should not eat uncooked or undercooked meat and eggs.

Round-up of key points

  • There are currently more than 77,000 confirmed cases of COVID-19, and the death toll is approaching 2,600 people – that is a case fatality rate of 2.4%. The official figures have now been reset by the Chinese authorities on a number of occasions, leading to confusion among international epidemiologists. To date, 25,000 people are confirmed to have recovered while over 11,000 people (15%) remain in serious or critical condition. Confirmed case numbers continue on a consistently downward trajectory with an increase of around 3-5% each day. Deaths continue to climb at a rate of around 6% each day. These figures are provided by the Chinese Centre for Disease Control.
  • China continues to exercise severe population movement controls. China’s leader, Xi Jinping, has said that the outbreak represents the most difficult public health emergency since the founding of the People’s Republic of China in 1949. The Party has called for “an orderly return to work in small and medium-sized businesses”. At the same time, the National People’s Congress, the country’s legislative body, announced that it was preparing to postpone its annual meetings, scheduled for the first week of March. Last week Beijing, a city of more than 20 million people, said anyone returning to the city must go into self-imposed quarantine for 14 days, or face stiff penalties; road blocks are in place on the major highways into Shanghai and are only allowing entry to vehicles containing Shanghai residents or registered workers; Xiaogan city, in central Hubei, has banned residents from leaving their homes in an attempt to curtail the virus. It has the second highest number of confirmed cases in China, after nearby Wuhan; Xinxian in Henan province, south of Beijing, announced it is extending quarantine to 21 days for citizens returning from Wuhan, following two unusual cases of COVID-19. Supporters of the Party leadership will stress the impressive mobilisation of resources, while detractors will focus on the lack of transparency and concern over the accuracy of Chinese information. Daily flights within mainland China are down from 15,000 to just 2,000 per day.
  • Wuhan and Hubei province continue to bear the brunt of the cases and the death toll from COVID-19. Of all the confirmed cases of COVID-19 around the world, 81% are in Hubei province, as well as 95% of all deaths. Wuhan city authorities are currently building another 19 temporary hospitals in addition to the existing 13 facilities. This will extend the bed capacity to 30,000 by 25th February.
  • Outside China, the second largest cluster of cases occurred on the Diamond Princess cruise ship, that remains quarantined off the Japanese port of Yokohama. Most of the passengers have now left the vessel, either back to their homes in Japan, or evacuated by the various governments around the world. Confirmed cases remain in hospital in Japan. There were 57 new cases (55 crew members and two passengers, of which 52 were asymptomatic) reported overnight in Japan as well as one new death (a man in his 80s). So far, a total of 691 infected people were found among 3,011 passengers and crew members tested (23% infection rate), out of 3,711 total people on the ship. 36 people remain seriously or critically ill and there have been three confirmed deaths.
  • During the evacuation of the US citizens from the Diamond Princess, all of whom were assumed to be free of infection, the Japanese authorities informed the US health team that 14 of the passengers had tested positive for COVID-19. The samples had been collected a few days previously but the results had only just come through while they were on the way to the airport. Following emergency high level discussions with the US government, it was decided that these confirmed cases would continue the repatriation, but would be isolated at the back of the plane. They went straight to dedicated hospitals on their return to the US. Since their return a further 18 have tested positive for COVID-19. Evacuated passengers have also confirmed positive on their return to the UK, Australia, Japan and Israel.
  • COVID-19 has spread to 36 countries and territories worldwide, with new cases in Bahrain, Afghanistan and Kuwait. There are no longer active cases in 10 of these countries, where all cases that have been confirmed have recovered (including the one death in the Philippines). The only confirmed case on the African continent, an elderly Chinese tourist visiting Egypt, has also recovered, to leave no active cases on the continent. There have still been no cases reported in South America.
  • There have now been 32 deaths outside of China, the latest being in Italy, Iran, Japan and the Republic of Korea.
  • The US Centres for Disease Control and Prevention (CDC) has stated that this virus represents a “tremendous Public Health threat and that it is likely that community spread may eventually happen in the United States”. The CDC has raised the threat alert to Level 2 (“practice enhanced precautions”) for two countries in South-East Asia: Japan and South Korea. Both of these countries are experiencing ‘sustained, community spread of COVID-19’. Older adults (over 60 years of age) and those with chronic medical conditions (read our latest advice for information on high risk groups) should consider postponing non-essential travel. Anyone returning home from these countries should be aware that if they feel sick with fever, cough or difficulty breathing within 14 days of their return, they should phone their doctor or emergency department and report their symptoms and travel history.
  • The UK Foreign Office has amended its travel advice for the Republic of Korea as cases of the new coronavirus, and the disease it causes, increased. It advised against all but essential travel to the cities of Daegu and Cheongdo in the country, which have been declared “special care zones” by South Korean authorities. The Singapore Ministry of Health has also advised its citizens to avoid non-essential travel to Daegu and Cheongdu. Air New Zealand has cancelled flights between Auckland and Seoul and Israel is not allowing South Korean citizens into the country.
  • Within the MENA region (referring to the Middle East, North Africa, Afghanistan and Pakistan) Lebanon and Israel have both reported cases over the weekend. Today there are new cases in Afghanistan, Bahrain and Kuwait. Afghanistan has announced a state of emergency.
  • Turkey, Iraq and Pakistan have closed land borders with Iran, and Afghanistan has suspended travel to the neighbouring country, amid concerns about the growing numbers of people being infected by Sars-CoV-2. Iran normally has strong travel connections to these countries, as well as Iraq which has reported one case – importations and outbreaks in these countries where health systems are particularly weak, would be concerning in terms of capacities to detect the virus and contain spread. Overriding these concerns is the fate of hundreds of thousands of displaced people and refugees in Iraq and Syria, many of whom have already impaired immunities, less access to state health care and live in highly concentrated population groups. Close proximity of infected people is thought to sharply increase mortality – most of these displaced people live in tents. Kuwait Airways announced Saturday that it would evacuate more than 700 Kuwaiti nationals from the Iranian city of Mashhad – already three of these have tested positive for COVID-19.

Cases surge in the Republic of Korea as it becomes the country with the most confirmed cases outside of China

The Republic of Korea has reported the largest number of confirmed infections outside of China, surpassing the outbreak on the Diamond Princess cruise ship docked in Yokohama, Japan, which has seen 691 cases. A seventh person has died and the number of confirmed cases has jumped to more than 800, an increase of 231 on the previous day.

President Moon Jae-in called the next few days ‘critical’, and raised the alert level to the highest, Level 4: Serious, thus empowering the government to lock down cities and restrict travel. The last few days have seen numbers of cases explode from 31 cases to 833 in under a week.

More than half of the country’s cases are among members of a secretive religious group, the Shincheonji Church of Jesus, and their relatives or contacts. Between Daegu, the country’s fourth largest city, and a nearby province where the sect’s members often do volunteer work, 465 people have tested positive. More than 1,250 members of the sect have reported potential symptoms, and officials are still trying to locate hundreds of members so they can be screened. Meanwhile, South Korean officials have designated the cities of Daegu and Cheogdo as ‘special care zones’, with public facilities closed and mass gathering events suspended.

In Busan, South Korea’s second largest city, public libraries, a horse racetrack and facilities for senior citizens closed when the city reported its first coronavirus case on Friday. Many churches are closed, instead offering prayer services online. Samsung Electronics said on Saturday that one COVID-19 case had been confirmed at its mobile device factory complex in the South-Eastern city of Gumi, causing a shutdown of the entire facility – the plant has reopened today. The K-League suspended the start of the football season and schools have been shut throughout the country. In Seoul, several large public venues have been closed and gatherings at rallies have been banned. Israel refused to allow some 200 non-Israelis to disembark from a plane which had arrived from South Korea, sending them back to Seoul; the 12 Israelis on board were quarantined. Several other countries are restricting entry to travellers from the Republic of Korea. Air New Zealand has suspended flights between Auckland and Seoul, and it is likely that other airlines will rapidly follow suit – Vietnamese Bamboo Airways and Mongolian Airlines have also suspended all flights to and from South Korea.

Iran reports a case fatality ratio of around 25%, sparking fears of under-reporting of case numbers

The Islamic Republic of Iran, which insisted as recently as last Tuesday that it had no coronavirus cases, confirmed 64 cases and twelve deaths on Monday, according to Iranian state media, making it the country with the highest death toll outside of China. The ruling party ordered the closure of schools, universities and cultural centres in 14 provinces.

The outbreak is centred on the holy city of Qom, with cases in Tehran and the northern city of Rasht, but officials warned that the virus may already have spread to “all cities in Iran”. Iran was the first country in the Middle East to declare deaths related to the virus.

Already, cases of travellers from Iran testing positive for the virus have turned up in Canada and Lebanon, and on Saturday, the United Arab Emirates confirmed that two Iranian travellers had the virus. Today the first case in Afghanistan has been confirmed near the Iranian border, and also three new cases in Kuwait all returning from the Iranian city of Mashhad, as well as the first case in Bahrain, also arriving from Iran.

It is clear that there must have been cases in Iran for some weeks and it is unlikely that Iran will have the resources and facilities to adequately identify cases and adequately manage them if case numbers are large. The ratio of deaths to confirmed cases is around 25% which is much, much higher than any other region in the world, including Wuhan. This suggests that the numbers have been significantly under-reported. The expected number of cases would be approaching 1,000 if figures are extrapolated from the rest of the world’s data.

Italy becomes the European centre of the COVID-19 outbreak

Italian authorities have implemented drastic measures with stringent controls to try to halt the coronavirus outbreak in the north of the country, threatening fines and three month prison sentences on anyone caught entering or leaving outbreak areas, as a third person was confirmed to have died on Sunday. The number of cases of the virus in the country has risen to 224, with at least 25 patients in critical condition. Italy has three quarters of all cases in Europe and seven out of the eight deaths have occurred here (the one other death occurred in France). Patient zero (the initial case) has still not been confirmed, though it is thought to be a researcher at Unilever who remains in intensive care. Where he acquired the virus remains unknown.

Police are patrolling 11 towns, with a combined population of 50,000 people that have been in lockdown since Friday evening – mostly in the Lombardy region in the north of Italy, where the first locally transmitted case emerged. There have been further cases in the Veneto region, where the last two days of the Venice Carnival have been cancelled, and isolated cases in Milan and Rome. Schools have been closed across the affected region and all sports and public events have been cancelled. Churches, cultural centres and movie theatres have been closed. The Armani fashion show was shown to an empty room while the opera house has suspended all performances. Italians have been advised to avoid crowded places including the metro, buses, trains and gyms.

Austria has blocked all train traffic from Italy after a Eurocity train from Venice destined for Munich with two suspected cases was stopped at the border while testing took place.

Questions are being asked about the initial lack of any quarantine measures for travellers from China in the first weeks of the outbreak.

COVID-19: What do we know?

Total cases: 79,698, up 409 since yesterday (0.5% increase)
Number of cases in China: 77,345 (99% of all cases)
Number of deaths in China: 2,593, up 151 since yesterday (6% increase)
Deaths outside China: 32 (most recent deaths in Iran, Republic of Korea, Italy)
Total recovered: 25,164
Currently infected: 51,909
40,341 are in mild condition (78%)
11,568 are in critical condition (22%)
Number of countries affected: 36 of which 10 have no active cases

Symptoms

Typical symptoms of Sars-CoV-2 (the temporary name given to the novel coronavirus causing the COVID-19 disease) include:

  • Fever
  • Dry cough
  • Sore throat

This may progress to a severe pneumonia causing shortness of breath and breathing difficulties.

Generally, this virus causes more severe symptoms in people with weakened immune systems, older people (over 60 years of age), and those with long-term conditions like diabetes, cardiovascular disease, hypertension, cancer and cerebrovascular disease.

Transmission

Spread has been confirmed to occur from human-to-human among close contacts – this is defined as 15 minutes exposure within six foot radius of a confirmed case or two hours exposure in an enclosed space such as an office. Person-to-person spread is thought to occur mainly via respiratory droplets produced when an infected person coughs or sneezes, similar to how influenza and other respiratory pathogens spread. These droplets can land in the mouths, noses or eyes of people who are nearby or possibly be inhaled into the lungs. It’s currently unclear if a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, however, precautions should be taken to avoid touching surfaces.

China CDC advise that criteria for applying quarantine of “close contacts” have been extended to include those who were close to the confirmed patients two days before the symptoms began.

Click here to see our latest advice to travellers and employers.

Treatment

There is currently no licensed treatment or vaccine for the disease. Clinical trials are ongoing within China with anti-viral and anti-HIV medications and dozens of scientists around the world are working to develop a vaccine, though this is not expected to be available until 2021.

When will COVID-19 be declared a pandemic?

Outbreaks of novel diseases are inevitable and are emerging at an increasing frequency around the world, not least because of the close relationship between humans and animals as has been the case in recent epidemics of SARS, MERS and swine flu. The recent ‘COVID-19’ epidemic that originated in Wuhan is thought to have been transmitted from bats to an, as yet unknown, intermediate reservoir, and on to humans. This coronavirus is particularly contagious and also has a mortality rate that is much higher than seasonal influenza. It is becoming increasingly obvious that it is simply not possible to prevent the spread of the ‘Sars-CoV-2’ coronavirus that causes COVID-19 to different parts of the world. We would certainly appear to be hurtling into the inevitable declaration of a ‘pandemic’.

However, it should be remembered that from an epidemiological viewpoint, the term pandemic refers to the geographical spread of a disease. A pandemic is commonly associated with a ‘deadly apocalyptic event’ but in reality the definition of a pandemic has already been met, even though it has not yet been acknowledged by the World Health Organisation. One of the key indicators for pandemic status is “sustained community transmission across countries and continents” and this has clearly been demonstrated in the case of COVID-19 in the Republic of Korea, Japan and, in the last few days, in the Islamic Republic of Iran.

It is important, again from an epidemiological point of view, to talk openly about whether we are diverting resources from preparedness at the community level, in trying to contain an epidemic. Pandemics have flourished in an era of fast travel networks and dense populations and both have been key elements in this COVID-19 epidemic.

The Ebola virus outbreak in the eastern Democratic Republic of the Congo (DRC) is one such pandemic threat. However, after more than 18 months and dedicated support from the WHO and neighbouring countries and aid organisations, just three cases are left. Yet the DRC and many other deeply vulnerable countries in Africa and elsewhere are already screening for Sars-CoV-19 that is expected to make its way to the continent.

Previous disease outbreaks, such as SARS, suggest what could be next for COVID-19. There are three main scenarios: the disease could spread into a global pandemic; it could remain largely contained within China and taper off on its own; or it could become another illness that never leaves us, flaring up seasonally as the flu does now.

It seems that containment is becoming less and less likely as there have now been confirmed cases in 36 countries, albeit ten of those no longer have active cases. There has been sustained community spread in at least two continents, with significant outbreaks in Japan, the Republic of Korea and Italy – the focus of cases and deaths of course continues to be in China. There was very significant transmission on board the Diamond Princess cruise ship that ended up quarantined off the Japanese port of Yokohama, with nearly 700 confirmed cases and three deaths – further cases in evacuated passengers have been identified in the UK, Australia, Israel and the US. Over 50 countries have implemented travel bans or restrictions.

Now Italy has embarked on a similar response to the outbreak that has spread rapidly in the northern Italian regions of Lombardy and Veneto, by closing off 11 towns and effectively containing 50,000 people. It is yet to be seen whether such measures can be reproduced anywhere near as effectively in a democratic European nation.

The WHO may be hesitant to declare a pandemic, as the label comes with significant political and economic consequences. When the WHO last declared a pandemic for the ‘H1N1 influenza’ (‘swine flu’) outbreak in 2009, the decision was later criticised by some countries, who felt the decision resulted in unnecessary fear and overly aggressive responses. The declaration, for example, prompted many countries to spend large sums on vaccines, even though the H1N1 strain of influenza proved to be relatively mild.

Nevertheless, the outbreak worsens by the day and it seems that WHO Director General, Dr Tedros Ghebreyesus was laying the foundations for an announcement when he said last Friday that, “the window of opportunity is still there, but the window of opportunity is narrowing. We need to act quickly before it closes completely.”

Typically, outbreaks are contained using public health measures of quarantine, isolation, surveillance, and vaccination. This disease-control approach targets a single pathogen at a time. At the moment we lack the resources of both treatment and vaccination.

Before moving further down this path of coercion and restriction of movement, it is worth understanding how this has become the norm and considering whether these kinds of measures are the wisest response. It is generally believed that decisions about epidemic control measures have an emphasis on exclusion and introduce a xenophobic response, cutting transport links, prohibiting entry to entire nations and enforcing mandatory quarantine to specific groups of people. When the aim is to protect the general public from coming into contact with infected people you can see the logic of the response. However, in the case of people in Wuhan being dragged out of their homes and put into enforced quarantine with no prior confirmation of infection, or thousands of healthy cruise ship passengers and crew being detained on a vessel that was in effect an incubator for disease, resulting in a transmission rate many times higher than in any other setting, there is a moral question to answer.

This coronavirus looks like it is here to stay. It is time to expand from fire-fighting the disease with containment strategies that inhibit the world economy and end up limiting the healthcare provision of many, many millions of people in developing countries, and moving towards fire-proofing that helps to prevent these pathogens from jumping from animals to humans in the first place. Even if containment limits the spread of this epidemic/pandemic, other outbreaks will keep happening, until the world decides to limit the animal-human crossover.

If pandemics are indeed the single biggest threat humanity faces, then we need to decide whether we want to face this head-on.

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