COVID-19 Poses Challenges in a Global World
Editor's Note: Information on COVID-19 continues to evolve on a daily, and sometimes hourly, basis. Much of the information contained in this article is of a general nature, but specific numbers referenced below were accurate as of press time in late February but have almost certainly changed since then.
As the March issue of Birmingham Medical News went to press, there were more than 83,000 confirmed cases of the latest coronavirus across more than 50 countries with nearly 3,000 reported deaths. The virus is now on every continent except Antarctica. World Health Organization Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, has outlined both signs of hope and causes for growing concern. With more cases reported outside of China, rather than inside, Tedros said the coronavirus outbreak has reached a "decisive point" and has "pandemic potential."
In an earlier address, Tedros said the WHO-China Joint Mission team had returned after traveling to Wuhan, China, the epicenter of COVID-19, where they found the epidemic peaked and plateaued between the 23rd of January and the 2nd of February and has been declining steadily since then. Additionally, the team found no significant change in the DNA of the virus, which is good news.
As for the arc of the virus in those who contract it, Tedros said people with mild disease recover in about two weeks, while those with severe or critical disease take three to six weeks to recover. The team, he continued, "found that the fatality rate is between 2 percent and 4 percent in Wuhan and 0.7 percent outside Wuhan."
Epidemic or Pandemic
Tedros noted many countries have done a good job in containing the virus so far. However, he said the sudden increases seen in Italy, Iran, and South Korea in late February were "deeply troubling." He urged governments to act swiftly to contain the virus.
"We are in a very delicate situation in which the outbreak can go in any direction based on how we handle it," he said. "This is not a time for fear. This is a time for taking action to prevent infection and save lives now.
Tedros said there should be at least three priorities for everyone. "First, all countries must prioritize protecting health workers. Second, we must engage communities to protect people who are most at risk of severe disease ... particularly the elderly and people with underlying health conditions. And third, we must protect countries that are the most vulnerable by doing our utmost to contain epidemics in countries with the capacity to do it."
Coronavirus & COVID-19
Infectious disease specialist William Schaffner, MD, professor of Medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine, noted coronaviruses are respiratory in nature. Severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) are two examples of outbreaks in the recent past.
"Human coronavirus is not typically serious. It just causes common colds," said Schaffner, who also serves as medical director for the National Foundation for Infectious Diseases. "However, some circulate in other animals and occasionally, they - quote/unquote - jump species."
He said the SARS virus probably came from small bats and civets, while the 2013 MERS virus was more directly linked to camels. "The current coronavirus has some bat genome, but it likely came to us through another animal that is yet to be identified," he said.
He added the death rate of COVID-19 at this point appears to be less than SARS or MERS but more than influenza. "Even if the rate of death is small, since it affects so many people, the absolute number of deaths becomes large," Schaffner said.
Containment
"In China, they are in the midst of conducting the largest human public health experiment of all time," Schaffner said of the massive quarantine that included the entire Hubei province. "Wuhan is a teeming metropolis of 11 million people. Now it's a ghost town," said Schaffner. "The population obeyed (the quarantine), and that's the whole point."
Interestingly, he added, "Much of the world did something else - they quarantined China." International airlines cancelled flights and most interaction with China hit pause. As the virus began spreading to other countries, similar containment efforts were undertaken - from keeping passengers on cruise ships to quarantining evacuated nationals back in their home countries. Following a sharp spike in cases in late February, Italy quarantined a wide swath of the northern region and enforced a ban on public events in 12 municipalities. A large number of corporations have cancelled conferences.
"If people can't congregate, the virus can't spread," Schaffner said, adding it would be very concerning if COVID-19 does continue spreading despite quarantines. "Now is about the time we would expect to see cases drop if this is working," he continued.
The effectiveness of quarantines also has to be factored into any review of the containment process. "The cruise ships clearly provided a challenge to public health," said Schaffner. "That turned out to be much less successful than anybody anticipated."
Fluid Figures
Another issue hampering analysis of the outbreak has been fluid definitions of confirmed cases coming out of China. "The case counts and what they mean have been very difficult to interpret," said Schaffner. "How you identify cases was defined and redefined and redefined again."
Public Health & Patient Safety
While it's impossible to be perfectly prepared or to predict exactly how much damage COVID-19 will cause going forward, Schaffner said the United States, led by the CDC, has marshalled resources.
Cases in America have been properly diagnosed and immediately isolated. Patients with confirmed cases have been admitted to hospitals and are receiving safe care, and providers are being protected through the rigorous infection control standards in place in this country.
"In close cooperation, our public health officials - local, state and federal - have worked hand-in-glove with clinicians to identify all the contacts of those infected and notify them," Schaffner said.
Going forward, providers who encounter patients with a fever and respiratory complaints should ascertain whether they have recently traveled to an affected area or been in contact with someone who has.
Editor's Note: At press time the CDC had confirmed the first case of coronavirus of 'unknown origin' in the United States in a patient who had neither traveled to an affected region nor been in contact with another known patient. The new case raises the specter of "community spread."
System Stresses
Global epidemics put major stress on broader medical and financial systems. In an increasingly global marketplace, that toll has been evident. Entire regions are being told to stay home, bringing commerce to a halt. Plants are closed in China so parts can't ship, which in turn halts production of goods across the globe.
The medical system is also strained in a pandemic. Pointing to the 2009 influenza strain, Schaffner said, "It stressed the medical care system in the United States." He noted no country can be "perfectly prepared" for such events. Hospitals don't sit empty waiting for an outbreak. No one stocks enough ventilators or masks to care for the majority of the population.
Those natural stresses are exacerbated by shrinking dollars. "We have a robust public health setup in the U.S., but public health departments at a state, local and federal level have had their budgets trimmed and whittled over the last 20 years," Schaffner said.
Schaffner pointed out being prepared to battle novel coronaviruses or other emerging threats requires sufficient, sustainable funding to lay the groundwork long before the flames are licking at the door. "If you're going to fight fires, you better have highly trained firefighters in place," he said.
WEB:
Vanderbilt Dept. of Health Policy
Vanderbilt Division of Infectious Diseases: https://medicine.vumc.org/infectious-diseases
National Foundation for Infectious Diseases
Alabama Department of Public Health
