Coronavirus Disease 2019 (COVID-19)

Bulletin: March 2020 Situation Report – Coronavirus Disease 2019 (COVID-19)

This SITREP is a Public Service Announcement sponsored by The Conceptium Group.

The outbreak of COVID-19 is a rapidly evolving public health crisis that may be termed a global pandemic. SPEAR will provide new information as it becomes available, in addition to updated guidance.

Facts you should know

Electron microscope image shows SARS-CoV-2 (yellow)—aka 2019-nCoV, the virus that causes COVID-19—isolated from a patient in the U.S., emerging from the surface of cells (blue/pink) cultured in the lab.

Background: Common human coronaviruses usually cause mild to moderate upper-respiratory tract illnesses, like the common cold. Most people get infected with one or more of these viruses at some point in their lives. This information applies to common human coronaviruses and should not be confused with COVID-19.

Health authorities worldwide are responding to an outbreak of respiratory disease caused by a novel coronavirus that was first detected in Wuhan Province, China, and which has now been detected in almost 70 locations internationally. The virus has been named “SARS-CoV-2”, and the disease it causes has been named “Coronavirus Disease 2019” (abbreviated “COVID-19”). On January 30th, 2020, the Emergency Committee of the World Health Organization (WHO) declared the outbreak a “Public Health Emergency of International Concern” (PHEIC), which is “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response”.

Epidemiology – Source and Initial Spread of the Virus

Coronaviruses cause zoonotic disease, transmitting from animals to humans. Coronaviruses are a large family of viruses that are common in people and many different species of animals, including camels, cattle, cats, and bats. Animal coronaviruses can infect people and then spread between people such as with MERS-CoV (Middle East Respiratory Syndrome – Coronavirus), SARS-CoV (Severe Acute Respiratory Syndrome – Coronavirus) – and now SARS-CoV-2. The SARS-CoV-2 virus is a betacoronavirus, like MERS-CoV and SARS-CoV. All three of these viruses have their origins in bats.

Pangolin (Valerius Tygart / CC BY-SA)

Contact-tracing of the earliest patients at the epicenter of the outbreak in Wuhan city, Hubei Province, China, suggested a link to a large seafood and live animal market, implying animal-to-person spread via an intermediary host. On the 7th of February, the South China Agricultural University in Guangzhou announced that two of its researchers, Shen Yongyi and Xiao Lihua, found a 99% match between the genome sequences of SARS-CoV-2 in pangolins and those in human patients. Definitive epidemiological conclusions cannot be made until further study of SARS-CoV-2 prevalence is conducted on representative samples of different species.

What is a Pangolin? The Pangolin is a nocturnal, scaly, ant-eating mammal that is imported in huge numbers to Chinese markets where its scales are considered to have healing qualities by traditional Chinese medicine practitioners and are valued at $3,000 per kilogram. Smugglers also ship pangolin innards, including fetuses, for traditional medicinal purposes.

Wuhan Market (SISTEMA 12 / CC BY-SA)

A pricelist at the Wuhan market shows a menagerie of animals or animal-based products including live foxes, crocodiles, wolf puppies, giant salamanders, snakes, rats, peacocks, porcupines, camel meat and other game. The illegal trade in wildlife has spawned unregulated markets where animals are kept with no sanitary inspections. These markets have previously been tolerated and sometimes actively promoted by local authorities in Southern China as an income-generating activity.

Action item: Ending the trade in wildlife will resolve the longer-term risks associated with animal reservoirs of zoonoses, particularly targeting the axis between local wildlife poachers in Sub-Saharan Africa and organized criminal smuggling networks.

As the outbreak grew, a growing number of patients reportedly did not have exposure to animal markets, indicating person-to-person spread outside Hubei and in countries outside China. Chinese authorities’ initial reaction to reports of the outbreak was to attempt to suppress the reports, most notoriously Dr. Li Wenliang’s, who was punished by police for warning people about the respiratory illness in online chat forums. Dr. Li Wenliang died of the virus on February 7th, 2020.

Chinese health authorities later imposed a draconian quarantine of the affected areas, earning praise from the WHO’s Director-General Tedros Adhanom. Although these latest measures have been somewhat successful in slowing the rate of incidence, the 12-day incubation period of the virus has allowed asymptomatic carriers to spread the disease to multiple international locations that now have community spread COVID-19.

Despite being far less deadly in terms of mortality rate than SARS-CoV, which had a fatality rate of approximately 10%, the mildness of its symptoms also means that COVID-19 establishes transmission chains that are wider and deeper. COVID-19 carriers may be asymptomatic, which makes it much harder to control the outbreak.

The interconnected nature of modern travel and trade networks quickly enable transmission vectors of highly transmissible disease to become a worldwide phenomenon. Early clusters of the disease such as cruise ships, airplanes and churches have eluded controls, creating pockets of transmission.

Understanding Contact-tracing – In public health, contact-tracing is the process of identification of persons who may have come into contact with an infected person and subsequent collection of further information about these contacts.

Understanding Community Spread – Community spread means some people have been infected, while it is not known how or where they became exposed. The solution to community spread: spread the community, ie: social-distancing – reduce high-density gatherings, reduce physical contact between individuals.

Understanding Prevalence vs Incidence – Incidence is a measure of the number of new cases of a characteristic that develop in a population in a specified time period; whereas prevalence is the proportion of a population who have a specific characteristic in a given time period, regardless of when they first developed the characteristic.

Cases Mapping of Coronavirus COVID-19 as of March 28th, 2020. Click here for updated map via CDC or view an interactive map via Johns Hopkins’ Coronavirus Resource Center.

Understanding the Trend: Just because a cluster has been identified and “contained” doesn’t mean that the identified cluster has not seeded another transmission chain that will go undetected until it establishes another cluster, and so forth. That is the definition of “going viral”. During the past 24 hours, as we wrote this situation report, 3 new countries (Bangladesh, Albania, and Paraguay) have all reported cases.

COVID-19 is armed with a long, asymptomatic incubation period that has allowed the virus to exploit weaknesses in human structures across the planet. From the initial reaction by Chinese authorities to suppress reports of the outbreak, thereby missing the opportunity for containment, to faulty testing kits, misapplied protocols, delays, and numerous missed opportunities, the virus has slipped through the gaps. Across the globe, similar patterns have repeated themselves. As the virus has established itself in new geographic clusters, health professionals limited testing to individuals with links to high-risk locations – China, Iran, South Korea, and Italy. These countries have adopted unprecedented policies of regional containment. Although such policies may reduce the rate of incidence in targeted areas, and help health systems avoid collapse, we believe that the policy of containment will ultimately fail. There will be a significant uptick in cases worldwide. Misguided decisions by health officials will continue to complicate an effective response, as we have seen in the US where:

• Federal health officials at the Centers for Disease Control (CDC) botched an initial diagnostic test and restricted screening to protocols requiring person-to-person links to a high-risk location outside of the US.
• Elected officials at the highest level, possibly seeking to minimize the outbreak during an election year, has sown confusion with misinformed comments often at odds with the facts.
• The supply of testing kits supplied by the CDC will not meet increased demand over the next few weeks.
• Medical staff dealing with infected patients have not been supplied with proper equipment, particularly key health workers such as home-carers and retirement home workers, who typically have not been given Personal Protective Equipment (PPE) and do not have paid sick leave.
• The US population of 2 million prisoners held in correctional facilities throughout the country may become deep reservoirs of infection, as testing kits are yet to be distributed to prison health workers.
• Transmission throughout the US will continue as the transmission chains grow in logarithmic scale, because of confusion over testing protocols and limited supply of testing kits.

These factors will not be addressed in time to break the chains of transmission. It is likely that the current trend of widespread transmission chains into community spread will continue until COVID-19 is widespread throughout the global community. It is no longer a question of “if”, but “when” this new reality affects the community in which you live. We all are faced with the pressing question of mitigation of risk, both on a community level and on an individual level. Panic is not preparation, and everyone has a part to play, from self-isolating if symptoms appear, to cooperating with one another as authorities announce inevitable school closures and cancellations of public gatherings, such as sporting events. Society will adapt during the next few months. As average temperatures rise, so will the incidence of this new virus decrease. The challenge to all will be to muster a collective effort to mitigate the damaging effects of this outbreak, both in terms of public health and in terms of societal impact.

What are the symptoms this coronavirus causes?

Reported illnesses have ranged from mild symptoms to severe illness and death for confirmed coronavirus disease 2019 (COVID-19) cases. The following symptoms may appear 2-14 days after exposure:

• Fever:
  • Temperature greater than 37.5 or 38.3 °C (99.5 or 100.9 °F)
  • Temperature in the anus (rectal) at or over 37.5-38.3 °C (99.5-100.9 °F). An ear (tympanic) or forehead (temporal) temperature may also be used.
  • Temperature in the mouth (oral) at or over 37.2 °C (99.0 °F) in the morning or over 37.7 °C (99.9 °F) in the afternoon
  • Temperature under the arm (axillary) at or over 37.2 °C (99.0 °F)
• Cough:
  • While a fever is the most common symptom of coronavirus, about two-thirds (67.7%) of patients get a cough — specifically a dry cough, in other words, a non-productive cough, because no phlegm is brought up.
• Shortness of breath:
  • A sensation of being out of breath
  • Tightness in your chest
  • Feeling “hungry” for air
  • Unable to breathe deeply
  • Feeling like you can’t breathe (suffocation)

Understanding the Risk: The majority of patients infected with COVID-19, approximately 80%, have experienced mild to moderate symptoms of illness consistent with influenza, and have fully recovered. However, COVID-19 virus has caused severe respiratory distress leading to pneumonia in other patients. Those who have fallen ill have been reported to suffer coughs, fever and breathing difficulties. In severe cases, organ failure can occur. As this is viral pneumonia, antibiotics are of no use. The antiviral drugs we have against the flu will not work. Recovery depends on the strength of the immune system. Many of those who have died had pre-existing medical conditions, such as asthma or diabetes.