During December 2019, a pneumonia outbreak was reported in Wuhan, China. On 31 December that outbreak was traced to a previously unknown strain of coronavirus among a cluster of people presenting pneumonia that had no clear cause. It was given the interim name 2019-nCoV by the World Health Organisation (WHO), later renamed SARS-CoV-2 by the International Committee on Taxonomy of Viruses. It is now known as COVID-19.
As I complete writing this on 27 February 2020, there have been 82,186 confirmed cases and 2,804 confirmed deaths in the coronavirus pneumonia outbreak. There will be a margin of error for unreported cases, especially those well away from the established areas. The Wuhan strain has been identified as a new strain of Betacoronavirus from group 2B with a ~70% genetic similarity to the SARS-CoV. It also has a 96% similarity to a bat coronavirus, so an origin in bats is widely suspected. At first the Huanan Seafood Market was suspected as the source, however other researchers speculated that the market may not have been the original source of viral transmission to humans. At this point in time the exact source is still being sought.
How people catch COVID-19
COVID-19 is mainly transmitted through human-to-human transmission, the main vector being respiratory droplets emitted when people cough, sneeze or exhale. The virus has an incubation period of between two and fourteen days. Thereafter symptoms that develop include fever, coughing and respiratory difficulties. Further development includes pneumonia, acute respiratory distress syndrome and death. At present there are neither effective vaccines nor antiviral treatments available. Clinical treatment is mainly confined to the management of symptoms and supportive therapy. The procedure in China and increasingly other countries is that a person who suspects they are carrying the virus should monitor their health for around fourteen days, wear a surgical mask and call a healthcare worker to ask for medical advice rather than directly visiting a clinic. As of 0800 CET on 27 February 2020, the 82,186 cases have been confirmed, including 78,499 in all provinces of China and already in 47 other countries and territories plus the cruise ship, Diamond Princess. Of these, 46,477 cases are current infections, of which 8,469 or 18% are in a serious condition. In China, the daily increase in new cases peaked between 23 and 27 January. There are known to have been 2,804 deaths caused by coronavirus, which now includes 57 outside China, thus already exceeding that of the 2003 SARS outbreak.
In Europe it is already present in 15 countries. Transmission has mainly been attributed to travellers returning from the Wuhan province in China but now the cruise ship Diamond Princess is under the spotlight as a possible source. A case study, published in the Journal of the American Medical Association, offered possible evidence about how it is spreading, thus also suggesting that it might be very difficult to stop. A 20 year old woman from Wuhan travelled hundreds of kilometres to another city where she is believed to have infected five family members without showing symptoms of infection according to scientists in China, thus offering evidence that COVID-19 can be transmitted asymptomatically.
According to Dr Meiyun Wang of the People’s Hospital of Zhengzhou University and colleagues, the woman travelled 650km from Wuhan to Anyang in Henan province on 10 January. She visited several relatives who later became ill. Doctors isolated the woman and tested her for coronavirus, that initially tested negative, but a follow-up test proved to be positive. Five of her relatives developed COVID-19 pneumonia, however as of 11 February, the woman had still not developed any symptoms herself, the CT scan of her chest showed that it remained normal and there was no sign of fever, stomach or respiratory symptoms, such as a cough or sore throat. The risk of asymptomatic transmission makes containment all the harder, especially if symptoms of carrying the virus do not show early on. This is reason for concern. But don’t panic. As this cartoon shows, in France there are around 10,000 deaths from flu each year but even before the two deaths to date from coronavirus caused pneumonia there is an ‘end of the world’ type panic.
Coronavirus in Europe
Italy has had 470 cases, 12 of them fatal. The majority are in the north, relatively close to neighbouring countries, but it is spreading. Italy has become the country with the highest number of cases and deaths in Europe, with over 60% of all European cases; also it is the country with most cases among all western nations and is proportionately the fast rate of spread worldwide at present. Elsewhere in Europe Austria, Belgium, Croatia, Estonia, Finland, France, Germany, Greece, Norway, Russia, Spain, Sweden, Switzerland and UK have small numbers of cases and, thus far, the only deaths apart from Italy were in France. The director general of the WHO, Dr Tedros Adhanom Ghebreyesus, spoke of a narrowing of the window of opportunity to control the current epidemic, with the tipping point, after which our ability to prevent a global pandemic ends, seeming closer by about 22 February. Certainly, the identification of a large cluster of cases in Italy is a serious worry for Europe, especially whilst there are expected to be quite a few new cases identified with the rate of new cases being identified grows without precise clues to where transmission is occurring. A major pandemic may develop, infecting anything between 40% and 70% of all people worldwide, although many of them will be asymptomatic, therefore carriers rather that sufferers of the virus.
Pandemics in history
Whenever we think of pandemics, bubonic plague tends to spring to mind. Between 1346 and 1353 an outbreak of the ‘Black Death’ devastated much of Europe, Africa and Asia. The estimated death toll was somewhere between 75 and 200 million people. The plague was thought to have originated in East Asia, most likely to have crossed continents through the fleas carried by rats that were common aboard merchant ships. Ports were the major urban centres at that time, thus perfect breeding ground for rats and fleas, allowing the pestilence to ravage three continents. The variance in estimates was one far lower, but mass graves that carry evidence of bubonic plague are consistently pushing the estimation upward to show just how destructive it was. More recently there have been major pandemics. From 1918 to 1920 a terrifyingly deadly outbreak of influenza spread round the globe, infecting over a third of the world’s population and ending the lives of between 20 and 50 million people. Again, the actual number is unknown but the upper estimate is very likely to be right.
Asian flu was a pandemic outbreak of Influenza A of the H2N2 subtype, originating in China in 1956 with a two year life as a major epidemic. It travelled rapidly from the province of Guizhou to Singapore, Hong Kong and on to Europe and USA. Estimates for the death toll vary depending on the source, but the WHO places the final count at approximately two million deaths, alone nearly 70,000 in the USA. Then there was a category 2 flu pandemic, sometimes referred to as ‘Hong Kong Flu’, in 1968 that was caused by the H3N2 strain of the Influenza A virus, a genetic offshoot of the H2N2 subtype. It is an example to learn from right now; from the first reported case in July 1968 in Hong Kong, it took only 17 days before outbreaks were reported in Singapore and Vietnam, within three months had spread to The Philippines, India, Australia, Europe and USA. While that pandemic had a comparatively low mortality rate at 0.5%, it still caused the deaths of more than a million people, including approximately half a million people in Hong Kong, in the order of 15% of the population at that time. Most recently, HIV/AIDS has shown itself to be a global pandemic, causing the deaths of over 36 million people since 1981. At present there is a calculated 31 to 35 million people living with HIV, the vast majority in Sub-Saharan Africa, where 5% of the population, or roughly 21 million people, are infected. I worked on a small part of the social research with street children in West Africa in the early 1990s as part of the WHO Global Programme on AIDS. The number of children who were HIV positive was an eye opener for me. I went there assuming it would have been among the children who sold sex, but it was often sex with peers, children who had been abused and exploited, rape being commonplace on city streets where they lived and some who claimed never to have had sex did not know how they had become infected. Most of the work I was doing was to be present at open meetings they were invited to, recording case studies through interpreters in many cases, stories of frightened children who already knew that once HIV became full blown AIDS they would die. When epidemics become part of the mainstream of society I learned that there is a kind of fatalism that keeps people going, knowing that in the end the sickness will win.
Epidemics and pandemics have been with us for all of human history, usually at their most virulent when population numbers are high and density at its greatest. Thus, alongside influenza, there have been quite constantly waves of cholera, typhus, measles and smallpox. Alone measles is estimated to have ended the lives of around 200 million people worldwide over the last century and a half. In the year 2000 it killed approaching 800,000 people out of 40 million cases worldwide. It is an endemic disease, which means it is continually present in a community; therefore numerous people develop immunity or are asymptomatic. In populations that have never been exposed to measles, exposure to it can be devastating. In 1529; for instance an outbreak in Cuba killed two-thirds of the indigenous population who had earlier survived smallpox. It killed in the region of 400,000 Europeans per year toward the end of the 18 century, then during the 20 century estimates make smallpox responsible for 300 to 500 million deaths. Until the early 1950s, up to 50 million cases occurred annually. However, as a result of successful vaccination campaigns throughout the 19 and 20 centuries, the last known natural case was in Somalia in 1977; the WHO certified its eradication in December 1979. Other diseases including leprosy, malaria, tuberculosis and yellow fever have been major causes for concern in the past with ongoing programmes for their elimination ongoing, but quite slow. More recent phenomena such as Ebola virus in West Africa from 2013 to 2016 have been contained and no longer expected to spread. In 2015 and 2016 there was a widespread epidemic of Zika fever, caused by the Zika virus in Brazil, that spread to other parts of South and North America. It also reached some islands in the Pacific, and Southeast Asia. In January 2016, WHO said that the virus was expected to spread throughout most of the Americas by the end of the year; however in November of that year they announced the end of the Zika epidemic.
The present situation
Thus a strain of coronavirus is the current concern. Coronaviruses (CoV) have been known since the early 2000s. They are a large family of viruses that cause illnesses ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV), also known as camel flu, and Severe Acute Respiratory Syndrome (SARS-CoV). A novel coronavirus (nCoV) is a new strain identified that has not previously been identified in humans. They are zoonotic, which means they are transmitted between animals and people. Research found, for instance, that SARS-CoV was transmitted from civet cats to humans and MERS-CoV from dromedary camels to humans. Several other identified coronaviruses are present in a number of animals that have not (yet) infected humans. The most common symptoms of infection include respiratory problems; coughs, shortness of breath and respiration difficulties, sometimes accompanied by fever. In the most severe cases, infection may cause pneumonia, SARS, kidney failure and possible death. In 2003, an Italian doctor, Carlo Urbani, was the first physician to identify SARS as a newly developed and perilously contagious disease. He also became infected and died. Rapid action on the part of national and international health authorities, including the WHO, helped to slow down transmission, in due course broke the chain of transmission, thus ended localised epidemics before they could become pandemic. However, it has not yet been eradicated, therefore could re-emerge, which gives good reason for monitoring and reporting of suspicious cases of atypical pneumonia. Thus, although with some unfortunate delay, the SARS-CoV-2 was identified in Wuhan. By the time it was recognised transmission had already begun, including outside of China with the cruise ship Diamond Princess an almost perfect ‘incubator’ given the proximity of passengers and crew. It appears to have begun on the ship when a man from Hong Kong boarded the ship in Japan and stayed for five days, until disembarking in Hong Kong. When the ship docked in Yokohama, it had 3,711 crew and passengers on board. It then took Japanese officials over 72 hours to lock down the ship after being notified of the Hong Kong man’s case. By the next morning, 10 people on the ship had tested positive for the virus, at the time of writing it is 691 with four deaths. The Japanese Ministry of Health placed the entire ship under 14 days quarantine. However, it was already too late; other passengers who left the ship transmitted the disease and became ill themselves. As of early morning 27 February, 2,804 deaths have been attributed to COVID-19. Most of the fatalities, around 80%, are among people over the age of 60, of whom 75% had pre-existing health conditions including cardiovascular diseases and diabetes; the case fatality rate is estimated at approximately 2–3%.
I, for instance, with both a cardiac and a respiratory condition, both normally very easy to manage, would be considered highest risk. There again, having never suffered influenza ever, it is possible I carry resistance that would make me an asymptomatic carrier.
On 30 January 2020, after the confirmation of human-to-human transmission outside China and an increase in the number of cases in other countries, the WHO declared the outbreak a Public Health Emergency of International Concern (PHEIC). It is the sixth PHEIC since that measure was invoked during the 2009 swine flu pandemic. On 25 February, the WHO said that ‘the world should do more to prepare for a possible coronavirus pandemic,’ stating that while it was still too early to categorically call it a pandemic, all countries should nonetheless be ‘in a phase of preparedness.’ In Italy the disease is still apparently spreading, some parts of northern regions are on lock down and transport links across borders tightly controlled, airports particularly being monitored closely. Given the concentration in the Milan area, it is not unlikely Malpensa airport could be closed at some stage. Major hub airports, of which Malpensa is one, are being closely scrutinised at present with travellers needing to be prepared to abandon plans to fly on routes using them. Some countries are preparing for outbreaks at which point in time schools would be among the first places shut down. Concert halls, social centres and other places where large concentrations of people gather are almost certain to be closed very quickly. When the roughly 2% of all cases die, by age groups they are 80+ years old 14.8%; 70-79 years old 8.0%; 60-69 years old 3.6%; age groups between 20 and 59 begin at approximately 0.2% at the bottom to just under 1.5% at the upper end, the lower ages are 10-19 years old 0.2% 0-9 years old no fatalities. The death rate by comorbidity, which is to say a pre-existing condition: cardiovascular disease 10.5%; diabetes 7.3%; chronic respiratory disease 6.3%; hypertension 6.0%; cancer 5.6%; no pre-existing conditions 0.9%. The estimated incubation time is between two and fourteen days although an outlier of 27 days is the longest recorded incubation thus far. The transmission rate (Ro) is two or three persons infected by each carrier.
The standard recommendations for prevention of infection include regular hand washing, using alcohol if there is the least suspicion of contact, covering one’s mouth and nose when coughing or sneezing and avoiding close contact with anyone showing symptoms of any respiratory illness such as coughs and sneezes. Where I live in southwest France there are, thus far, no cases of COVID-19 but with an exceptionally early spring upon us, blossom on trees has brought on early symptoms of hay fever, thus signs that could be considered indicators of infection. In Europe where populations living in very close proximity are to avoid a major outbreak, the recommendations are for people to restrict movement, especially international travel, limiting it to the most essential trips only. Older and younger individuals should particularly be protected from infection. At present they are recommending that people take simple precautions to reduce exposure to and transmission of coronavirus, for which there is no specific cure or vaccine. Their specific advice is: Frequently wash hands with an alcohol-based hand rub or warm water and soap; cover mouth and nose with a flexed elbow or tissue when sneezing or coughing – if using an arm, make sure it is immediately and thoroughly sterilised; avoid close contact with anyone who has a fever or cough even if there is no indication coronavirus is present where they are; if people have a fever, are coughing or having difficulty breathing then seek early medical help and explain any recent travel history with healthcare providers; avoid direct, unprotected contact with live animals and surfaces in contact with animals when visiting markets in affected areas; avoid eating raw or undercooked animal products and exercise care when handling raw meat, milk or animal organs to avoid cross-contamination with uncooked foods.
China’s top law-making body is expected to permanently tighten rules on trading wildlife in the wake of the coronavirus outbreak, which may have originated in a wild animal market in Wuhan. Scientists speculate that this could include a ban on eating some wild meat. The government has already temporarily suspended buying and selling wild animal products that are commonly for food, fur and traditional medicines in China although the emergency measure will be lifted when the outbreak ends. The Standing Committee of the National People’s Congress, the highest decision-making body, will decide how the trade in wildlife products should be regulated in the long term. The outcome of the meeting later this year should set the tone for revision of the country’s main wildlife trade law which at present only bans the trade of some rare and endangered species. It will also potentially provide a lead for other countries to follow.
A senior International Olympic Committee member, Dick Pound, said that there is a two-to-three month window in which to make a decision on whether this year’s Olympic Games in Tokyo should be cancelled if the disease proves to be too dangerous. He pointed out that as the Games draw nearer things have to start happening. Security has to be ramped up, food needs to be available, the Olympic Village must be ready, likewise hotels and media will be in there making their preparations and installing facilities such as studios. If the IOC decides the games are too high a risk, then they will almost certainly need to be cancelled. The Six Nations rugby games between Ireland and Italy in Dublin have been postponed and may yet be definitively cancelled. The 7 March men’s game at the Aviva Stadium as well as the women’s match on 8 March and an Under-20s Six Nations fixture between the countries on 6 March may be held later depending on how the illness develops in the immediate future. The International Rugby Football Union is in talks over England’s matches in Rome over the weekend 13 to 15 March with the prospect of the tournament being unfinished for the first time in half a century. Other sporting events are likely to be similarly affected.
As yet there is no vaccine although several medical bodies, including the WHO, are attempting to develop at least an initial vaccine by the end of April. Then a major programme of vaccinations needs to be set up. That may by then be a Sisyphean task. The WHO mission director, Bruce Aylward, who has visited Wuhan as part of a taskforce to see the situation on the ground has spoken to the media about coronavirus with the warning that the world is ‘simply not ready’ for a pandemic. An in depth analysis, reviewing the findings from the report of the taskforce compiled during two weeks in China will be published this week. One of the questions that must be addressed now is which factors are determining the decline in China, especially the limited spread of the virus outside of Hubei where it first appeared? There are now more new cases occurring every day outside of China than in that country. Worldwide, it is notable that the number of freshly recovered patients has been greater than the number of newly infected people every day since 19 February. Despite increases in South Korea and Japan, the number of serious and critical cases, as well as of new deaths, is declining worldwide. Overnight there have been no new reported cases or deaths in Italy. However, as the day goes on this will inevitably be ‘old news’, but with a great deal of luck see the actual numbers go down.
So, why is this matter drawn to the attention of Europa United? We look at issues on our continent face on, do not turn our backs on the rest of the world and now this is among us. One ongoing theme that crosses many of the issues we cover is human frailty, irrespective of whether we identify it as such or otherwise, and this is a situation that might yet test our resolve. Whilst we mainly concentrate on political, social and economic events on our continent there are other, often global, events that remind us how reliable we are on each other when it comes to the bottom line of our survival. We make no illusions, preferring the truth and doing whatever we can to inform with that in mind. Coronavirus is with us now, it may become a vast, destructive pandemic or may soon be controlled and in decline. Either way, this is a warning we choose not to ignore.