Part 47--COVID-19: The Current Status and Epidemiology-March-2020 [Part 1]

The 2019 coronavirus outbreak started in November, Wuhan city in Hubei Province in China. It is a previously unknown virus that belongs to the larger coronavirus family of viruses that usually infect wild animals (animals are a reservoir). Usually a zoonotic virus, the current novel coronavirus has mutated so that it has acquired characteristics needed to spread to humans from animals. This included its ability to attached to human cells and penetrate the cell wall through a natural receptor. Following the initial outbreak in Wuhan district in China, COVID-19 has spread worldwide infecting thousands of humans, worldwide, and had become a pandemic.

In addition to the standard precautions taken to prevent the spread of flu-like illness, it is necessary for implementing other measures, such as social distancing--minimizing exposure by limiting time in public places and public transportation, etc. This must be accompanied with other standard disease prevention procedures, including the good, personal hygiene: frequently washing hands, using face masks in the right set up, etc., to prevent the spread and acquiring this disease. 

Global outbreaks of COVID-19:

The current outbreak of coronavirus, COVID-19, has spread to most countries, mostly occurring through air travellers and (legal and illegal) border crossings. Despite major travel restrictions and locking down a few affected major cities, the virus rapidly spread across all provinces in China.  Once understood its aetiology, China took fundamental steps, such as banning, selling and eating exotic animals. However, for the initiation of restriction and social distancing took several weeks, during which the virus spread globally. During this latent period, apparently, few million residents from this province have coursed its border, carrying the virus.

In the current pandemic, air travel is responsible for more than 90% of transmission of the disease to a new country or a province.  Within a country/province, attending parties, ceremonies, congregations, and migration of people to other cities are the predominant ways of spreading the disease. Rather than taking extreme measures of locking down the entire country, controlling the access to and from the above-mentioned local sites is effective on social distancing and curtailing importing infections.

The spread of the COVID-19 is far worse than any country anticipated, especially the West. The rapidity and pattern of spread of COVID-19 have become a serious public health problem in all countries. While the death rate among healthy people below the age of 65 years is approximately 1%, administrations must take all necessary public health measures to prevent the current spread and a "secondary" spread, later this year. 

Negative ripple effects from shutting down all industries by the Indian government:

Some of the actions taken by governments are worse than inaction. One such example is the island-wide, a total ban of all industries by the Indian government on 25th of March. This forced over 250 million workers and migrants in cities to returned to their family homes in rural regions of the country. This created unprecedented chaos across all major cities in India.  Even if 0.001% of this group is exposed/infected or are in the incubation period, that amounts to 2,000 infected people taking the virus back to their rural communities across the country. 

In the absence of social distancing, it is estimated that each such person could inadvertently, infect up to 500 people; so, this group can infect approximately, one million Indians in the first round on COVID-19 infection in rural communities in India, within a month. It is noteworthy that, almost all these households have elderly parents (or uncles and aunts) and the sick. During the second round of infection, they can infect additional millions of rural Indians, causing significant morbidity and mortality among themselves. These people are economically not-well to do and unlikely to have access to modern healthcare facilities, including medications, hospitals, or ICU. What would they do, if they develop COVID-19? 

Already the Indian government is much short of cash. Shutting down all industries without an economic recovery plan and lack a provision of economic stimulus to people and small businesses, make it impossible for the government to collect its income: GST and taxes; this could bankrupt the Indian government in 5 months. If that happens, it will take a decade for India to recover from the mess from COVID-19, which made worse by one unwise governmental decision. 

Fake news and propagation of misleading information are major problems:

Hundreds, if not thousands, of professional-looking videos, are circulating that disseminate false and misleading information. Such false information includes, but is not limited to, the claim that an unknown scientist discovered a remedy for curing COVID-19, and a number of worthless home remedies, including taking high doses of vitamin C, frequent ingestion of garlic, or consumption of various herbs and/or animal products, consumption of extremely hot drinks or alcohol. Some of these worthless remedies, if used, can be harmful.

To prevent misguiding, it is important to obtain medical information from reputable sources, such as peer-reviewed academic journals, the Centre for Disease Control, and the NIH (https://www.nih.gov/health-information/coronavirus).  The management of some countries and states/provinces have little experience in dealing with such a rapidly spreading epidemic, thus, are not savvy or up-to-date with the real-time handling of the COVID-19 crises. 

The ability to adapt and generate adequate supply and facilities using new technologies and expertise to manage the supply the demand would make a significant difference to the clinical outcomes of these epidemics.  

The natural history of the disease:

The spray of droplets from coughs or sneezes of those with COVID-19 are larger than that with other respiratory viral diseases, and therefore, travel only up to two meters. Therefore, it is important to keep the distance between people (i.e., social distancing). COVID-19 is more contagious than SARS-CoV and MERS-CoV but less lethal. For example, the death rate from SARS was 9%, and from MERS, 35%; whereas, the death rate from COVID-19 is approximately 3.2%. 

Most people affected with the COVID-19 recover fully within a few days. Less than 8% of affected individuals require hospitalization. In half of them, the virus causes severe, life-threatening, lower respiratory tract infections that could lead to pulmonary hypertension, oedema, and severe pneumonia, which leads to respiratory distress syndrome (ARDS), requiring intensive care therapy to maintain the cardiac and pulmonary function until a natural recovery occurs through inherent immunity.  COVID-19 infection can also markedly exacerbate exiting chronic cardiac conditions, especially cardiac failure and unstable angina.

The failure of either the lungs or heart, or frequently both of these organs, is the cause of death in most people who died with COVID-19 infection. Many elderly have comorbidities, thus, they are the most vulnerable to develop severe complications and dying from it. Considering this, those with pre-existing lung (e.g., COPD, pulmonary fibrosis) or heart diseases (e.g., cardiac failure, hypertension) will experience a higher rate of mortality if infected with COVID-19.

Importance of implementing stronger public health measures:

During epidemics, standard public health measures must be enforced to prevent the occurrence of peaks of community outbreaks.  This will flatten the otherwise peaks of COVID-19 infection, which would markedly reduce the need for hospitalization. Especially, using the Social Distancing for adequate length of time is one of the most effective ways to minimizing the spread of COVID-19. This will be discussed in length in the next article on COVID-19.  In the absence of maintaining that, there is a great danger that the disease will come back, when movement restrictions, curfews, and lockdowns are removed. 

The current situation with the COVID-19 pandemic in the world is unprecedented.  It is heartening to see that few larger pharmaceutical companies, finally agreed to work together to develop armamentaria against the COVID-19, including vaccines, anti-viral agents, and testing procedures. 

In this regard, the U.S. Food and Drug Administration recently approved a new diagnostic test that could detect (or eliminate) the presence of coronavirus under 45 minutes, which potentially can be used in point of contact, including health checks at airports.  In addition, the global supply chain crisis, initiated in China has now extended to all industries and countries, while China is rapidly recovering.  Part 2 of this series will address the social distancing and the key issues related to essential public health measures and balancing with the needs of the public and human rights.

__________________________________________________________________________

Professor Sunil J. Wimalawansa, MD, Ph.D., MBA, DSc, is a physician-scientist, educator, social entrepreneur, and process consultant. He is a philanthropist with experience in long-term strategic planning and cost-effective investment and interventions globally for preventing non-communicable diseases [recent charitable work]. The author has no conflicts of interest and received no funding for this work.