WeeklyWorker

12.03.2020

It is a pandemic

The number of cases outside China has increased 13-fold over the last two weeks alone, says James Linney.

At the time of writing the new coronavirus - now named SARS-CoV-2, which causes the COVID-19 clinical syndrome - has just been officially classified as a pandemic by the World Health Organisation. It was only a matter of time. The rate of infection has been soaring. Over the last two weeks alone the number of cases has grown 13-fold and it is likely that we are in the early stages of the outbreak.

Currently, according to the WHO,1 COVID-19 has been reported in 115 countries with a total of well over 100,000 individual cases. China still has by far the most of these, with 71%, followed by Italy (8%), South Korea (7%) and Iran (6%). A small glimmer of hope has been the dramatic fall in the number of new cases in China, where they have decreased from more than 2,000 per day to just 36 in the day before this article was written. Unfortunately, however, the virus is spreading as rapidly as ever elsewhere: Italy has seen 1,797 new cases in the past 24 hours.

It is still early days in terms of our understanding of the pathogenesis of the COVID-19 illness. The most common symptoms are fever, cough, shortness of breath, sore throat and fatigue. The majority of cases (about 80%) are mild, requiring no special treatment apart from rest, drinking fluids and paracetamol. The more severe ones can lead to increased shortness of breath, pneumonia and respiratory failure - so far there have been over 4,000 deaths. The case fatality rate (CFR) is an estimate, and is in constant flux. The WHO figures currently equate to a CFR of 3.5%, although this is likely to be an overestimation, due to an unknown number of cases not being reported due them being very mild; even so this is not a reassuring number.

The vast majority of deaths have been of people over 70 - mostly those who have other co-morbidities, such as cardiovascular or respiratory diseases. Interestingly (and something to be thankful for), the virus does not appear to affect young children as severely as adults. A study in China found that of the 45,000 cases examined 2.5% of children and teens who became infected developed severe disease and only 0.2% became critical.2 Another study found that children are just as vulnerable to contracting COVID-19,3 but for some reason the illness causes less morbidity and mortality; one theory being that more immature lungs do not have as many receptors affected by the virus. Another early study has reported that the median incubation period is five days and 97.5% of those who develop symptoms will do so within 11.5 days,4 giving credence to the 14-day quarantine period being applied.

There have already been over 5,000 studies published (mostly in China), contributing to a valuable, growing understanding of SARS-CoV-2; yet some of the most important questions remain unanswered: from what animal(s) did it originate? Will it fade out in the coming months, like we would expect from a seasonal influenza outbreak? Will it be possible to develop a vaccine? Will the virus be able to make small changes to its outer proteins to produce new strains (a process known as ‘antigenic drift’), meaning that any future vaccines will become ineffective? With so many unanswered questions, predictions about the global impact of COVID-19 are impossible at this stage.

In the United Kingdom, Chris Whitty, chief medical officer, has stated that a population-wide outbreak is likely and that up to 80% of people could be infected; this could potentially mean, in a worse-case scenario, up to a 100,000 deaths. Boris Johnson and Matt Hancock have been doing their best to try to appear in control, but they are both so obviously way out of their depth - with Johnson trying to stick to his general election tactic of repeating meaningless, pathetic mantras in press conferences. This time, instead of “get Brexit done”, we are told, “We can beat this” or “We know how to defeat this and we will”. Along with this hyperbole, we have the government’s published ‘Coronavirus action plan’: more useless verbosity; good only in giving Johnson something to say. We are currently in the ‘containment phase’, we are told, but very soon will be entering the ‘delay phase’ - which is essentially the same as the containment phase (plus some other stuff not thought of yet). At some point down the line we might get to the ‘mitigate phase,’ but meanwhile it is business as usual. Hopefully SARS-CoV-2 has been briefed as to what phase it should be in.

Two tactics

In reality, there are only two tactics when fighting an outbreak and they are not mutually exclusive. Firstly, containment: ie, trying to keep the virus in or out of a certain area - including quarantining, which is the isolating of a suspected infected person beyond the incubation period. We are already beyond the point where we can rely solely on containment: it is in the general population now, albeit in low levels.

It is crucial to continue to test people, try to identify where a case came from and trace contacts, whilst at the same time minimising the risk of people carrying the virus into and out of the country. Parallel to this - and something the UK government should have already started - must go the second tactic: mitigation. In other words, trying to stop the spread by reducing social contact and particularly large gatherings, where ‘super-spreading’ incidents are possible. Both China and Italy have attempted large-scale mitigation. China is implementing this (and no doubt strengthening its authoritarian military surveillance apparatus) on more than 60 million people in Hubei. Italy similarly is currently enforcing a country-wide lock-down. Draconian, military-style mitigation measures are counterproductive and lead to panic, misinformation and increase the chances of infected people fleeing. The best way to mitigate is through voluntary cooperation, the sharing of up-to-date information and transparency.

No matter what measures are taken now, COVID-19 is inevitably going to mean extreme pressure for the national health service in the coming months. This is an NHS already much depleted - with 100,000 vacancies5 and over 17,000 fewer beds, compared to 2010. Despite the vast majority of infected people not needing any medical input, the minority of very severe cases do require intensive supportive care, including dialysis for kidney failure and ventilation for respiratory failure. As Italy has discovered, hospital beds, trained staff, medical equipment (including ventilators) and plenty of capacity in intensive care units (ICUs) are the key to managing COVID-19. These are things that cannot be created quickly and no number of well-meaning volunteers or returning retired doctors are any sort of substitute for them. Italy has twice as many ICU beds per 100,000 population, compared to the UK, which ranks 24th out of 31 European countries in terms of ICU beds per head of population and 29th for hospital beds.6

This week’s budget included some token money for the NHS, but this is all too little, too late. If there is a large outbreak in the UK, it is not going to be the implementing of Johnson’s ‘delay phase’ that matters: rather the decade-long ‘NHS cuts phase’ that his party has ruthlessly enforced could result in thousands of unnecessary deaths.

  1. . www.who.int/docs/default-source/coronaviruse/situation-reports/20200310-sitrep-50-covid-19.pdf?sfvrsn=55e904fb_2.↩︎

  2. . http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51.↩︎

  3. . www.medrxiv.org/content/10.1101/2020.03.03.20028423v1.↩︎

  4. . https://annals.org/aim/fullarticle/2762808/incubation-period-coronavirus-disease-2019-covid-19-from-publicly-reported.↩︎

  5. . https://fullfact.org/health/nhs-vacancies.↩︎

  6. . https://link.springer.com/article/10.1007/s00134-012-2627-8/figures/1.↩︎