PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”

“Nearly six weeks after China announced the coronavirus outbreak, there’s still a surprising amount we don’t know about this newly discovered disease. But one thing is becoming clear: China’s silence in the earliest days of the crisis may have made it worse.

Chinese authorities delayed informing the world about the severity of a deadly disease spreading within the country’s borders — even trying to muzzle whistleblowers, like the late Dr. Li Wenliang. Now hailed as a national hero, Li was forced on January 3 by police to sign a letter saying he spread “untrue speech” for warning colleagues about the virus that eventually took his life.

With more than 40,500 people infected and 910 deaths, China’s missteps early on seem increasingly fateful. The fact that the international community has not acknowledged those missteps is also consequential…

But the reality is this: China’s mishandling and the ensuing silence from the international community is emblematic of how the global system governing the international response to pandemics fails to work, half a dozen global health experts told Vox.

Though we have global health laws — in particular, the International Health Regulations, or IHR — meant to guide countries dealing with outbreaks, they’re not actually enforceable. “You can’t penalize

[countries that]

don’t follow it,” said Devi Sridhar, the chair in global public health at the University of Edinburgh. Instead, the international community has to rely on “soft law and norms” — or “disease diplomacy.”..

The revised IHR asks countries to build out their disease surveillance capacities and report public health crises immediately. It also asks nations not yet affected by a new pathogen to avoid punishing those that are through travel and trade restrictions. “These revisions were all about trying to get countries to sacrifice their short-term interests for the long-term well-being of all countries,” said Sridhar…

 “The IHR operates on mutual trust largely, and it is a mutual trust,” said Eccleston-Turner. “That mutual trust has been eroded over a number of outbreaks where member states have ignored the recommendations from WHO.”” (A)

“Human intervention, or lack thereof, may also have been a factor. More than half a dozen doctors first discussed the threat of a potential coronavirus outbreak in early December only to be silenced by the local Communist Party, according to some critics of the government.

Yaxue Cao, founder and editor of the political pressure group ChinaChange.org, said a Wuhan doctor posted in a WeChat group to say there were seven cases of SARS connected to the seafood market. He was then scolded by the party disciplinary office, and forced to retract that, Cao said.

“From the same report, we learned that Wuhan health authorities were having overnight meetings about the new ‘SARS’ at end of December,” Cao posted on Jan. 27. “Earlier today. the Wuhan mayor said he was not ‘authorized’ to publicize the epidemic until Jan. 20.”…

The spread was likely helped by China’s Lunar New Year holiday last month. Wuhan mayor Zhou Xianwang said 5 million people had left the city before travel restrictions were imposed ahead of the Chinese New Year.

“People unfamiliar with China have trouble understanding the immense travel phenomenon that occurs during Lunar New Year, when, over a one-month period, some 3 billion people are on the move, many returning to their home towns and regions but others vacationing,” Tanner Brown, a Beijing-based journalist, wrote for MarketWatch last month. “Peak travel occurs this week.”..

People also may not know they’re carrying the virus. Symptoms of common human coronaviruses include a runny nose, headache, cough, sore throat, fever and a general feeling of being unwell, according to the CDC. Symptoms of the new coronavirus can include fever, cough and shortness of breath…

But it was weeks since the virus was first discovered before flights were curtailed, and the global travel industry is ideal for many viruses to travel long distances.

In an attempt to remain competitive, airlines have decreased their turnaround times in recent years. Many budget airlines have reduced turnaround times to 25 minutes by removing the seat pockets. Other airlines have managed to have long-haul turnaround times of 90 minutes. Not only do planes get a new plane load of passengers, they often get a completely different crew.

Deep cleans are not always possible during such turnarounds. Charles Gerba, a microbiologist at the University of Arizona, recommends using hand sanitizers or disinfectant wipes, particularly when traveling and/or at the office, where people may be reluctant to stay home if they’re sick.” (B)

“China’s new coronavirus may peter out. Or it might join the flu on the roster of the world’s winter illnesses — a bug that will be routinely vaccinated against. Or it might become a global pandemic, killing millions of people.

Experts don’t have enough information to predict which of these very different scenarios will come to pass. So for now, they are cautious.

“The issue is, we don’t know. And any sort of prediction would be ill-advised,” said the director of National Institute of Allergy And Infectious Disease, Anthony Fauci, at a Friday briefing by the presidential task force on coronavirus. “You really do prepare for the worst possible scenario.”

Scenario 1: The virus stays mostly in China

WHO officials this week still expressed hope that the Chinese government will largely contain the coronavirus through unprecedented travel restrictions and quarantine in Hubei province and elsewhere that most closely resemble martial law enacted over tens of millions of people. The quarantines began two weeks ago, and the coronavirus is thought to have an incubation period of up to 14 days, which is leading to questions about how well the measures have worked, especially after China locked down Guangzhou City, population 14 million, just this Friday…

Scenario 2: Another seasonal flu

If the coronavirus does manage to spread widely outside of China, it isn’t necessarily catastrophic. It could turn out to have seasonal behavior, flaring up in winter like the flu. That pattern has been seen in at least two of the common coronaviruses that affect people. If that’s the case for this new one, said Fauci, “when you start getting into the spring weather of April, May, and June, it almost certainly would start to turn around.”

On the downside, that means it would just come back next winter. That happened with the 1918 Spanish flu pandemic that hit the world in two seasonal waves.

Still, the extra time wouldn’t hurt, allowing for clinical trials to test the effectiveness of antiviral drugs used on an emergency basis in the outbreak. China has started two randomized clinical trials of a promising drug called remdesivir, overseen by respiratory disease expert Cao Bin at Beijing’s China–Japan Friendship Hospital. (One of the 12 US patients with the coronavirus tried the drug and recovered a day later.)..

Scenario 3: Deadly global pandemic

Then there’s the worst-case scenario: The relatively few cases popping up in dozens of countries flare up worldwide in the coming months with deadly consequences. It happened in 1957, when a flu pandemic killed 1.1 million people worldwide, and again in 1968, when another flu strain killed about 1 million people….

…That means the new coronavirus might have already skirted containment efforts and might be worse than reported in Hubei province, where some news reports have come of elderly people dying without ever being tested by hospitals. China’s nationwide travel ban, and reports of one province offering a $140 bounty to people who turn in recent arrivals from Wuhan, said Fisman, “are not things you do when you are winning against an outbreak.”…

The one caution about all predictions early in past outbreaks is that they don’t tend to match up with the outcome,” said Fisman, acknowledging his own expectations have worsened as the outbreak has continued. “We still don’t know a lot.”(C)

“As it continues to spread around the world, bringing panic with it, scientists are striving to develop ways of fighting this previously unknown threat. Sophisticated computer modelling is being used to track and predict its transmission, while virologists are attempting to engineer a vaccine. Others are seeking drug treatments that can help those who fall ill with the infection.

But this is not the first coronavirus scientists have encountered, and defeating them is harder than you might think. Even after decades of trying, coronaviruses are formidable foes…

In order to get a reliable model of how the disease spreads, Donnelly says, there are a few things we need to know about the virus. First, how long someone might be infected by it before developing symptoms. This is called the incubation period. Second, we need to know how long someone with the virus remains infectious for, and in cases where patients do not recover, how quickly the virus can cause death. “That helps us estimate the case fatality rate,” says Donnelly.

Super spreaders shed far larger numbers of the virus particles than other patients, increasing the chance they will infect someone else

Another important factor is the reproduction number, which is how many other people someone with the disease will infect. Donnelly and her colleagues have estimated the new coronavirus to have a reproduction number of about 2.6. “If that number is greater than one, then you expect there to be an outbreak,” she says….

Even if it can be diagnosed quickly, finding an effective treatment for a virus like this is famously difficult…

The speed at which coronaviruses mutate and so change their characteristics makes them hard to vaccinate against. Vaccines tend to train the immune system to target a particular feature, such as a protein structure on the shell of the virus. But by continually altering its appearance, our immune systems find it hard to recognise different infections. It is partly why the common cold has been so difficult to develop a vaccine against…

But it is still an open question as to whether a treatment or a vaccine will be found within a matter of months or if it will take years. Until then, says Donnelly, all that can be done is to continue to monitor the virus and try to stop it spreading.” (D)

“What do we most need to know next? For epidemiologists who track infectious diseases, the most pressing concerns are how to estimate the lethality of the disease and who is susceptible; getting detailed information on how it spreads; and evaluating the success of control measures so far.

No. 1 is the “clinical iceberg” question: How much of it is hidden below the surface? Because the outbreak is still evolving, we can’t yet see the totality of those infected. Out of view is some proportion of mildly infected people, with minor symptoms or no symptoms, who no one knows are infected…

In 2003, during the early days of the SARS outbreak, the medical community got the math wrong. At first, we believed that case fatality hovered between 2 percent and 3 percent. It took two pages of longhand algebra, written in Oxford, England, coded into a computer in London and then applied to data from Hong Kong, to get it right. The actual case fatality for Hong Kong was staggering: 17 percent…

Knowing the number of people likely to die, or who get seriously sick or have zero symptoms, will help health authorities determine the strength of the response required. They can better estimate how many isolation beds, heart-lung machines and medicines, among other things, are needed…

Along with getting a grasp on the level of severity is figuring out susceptibility, or who is most at risk for infection. The data so far indicates that this would include older adults, the obese and people with underlying medical conditions. There are few reports of children becoming infected. But are they not showing symptoms, or are they immune? And could they infect others as silent carriers?..

Returning to the big picture, we must also refine what we know about how the new coronavirus is passed between people. Even as the outbreak appears to keep escalating, we believe the rapid — sometimes necessarily draconian — response of governments and health authorities has made a dent in transmission. In another recent study, we estimated how many people could get infected if there were no drastic public health interventions. Our goal with this report was to sound the alarm over what could be, so that it wouldn’t be…

The goal is to stay at least a couple of steps ahead of the epidemic curve. Scientists must prepare health authorities to catch any subsequent waves of infections and prepare for the possibility that this particular virus could reappear seasonally — and maybe one day it could be only as bad as the common cold.

I’ve seen record-breaking outbreaks before and witnessed the world rally. If we all play our roles and remain on guard, then chances are we will defeat the new coronavirus, too…” (E)

“Even as U.S. authorities have taken the drastic steps of quarantining residents returning from China and temporarily banning foreign visitors who recently traveled to affected Chinese regions, they have urged the vast majority of U.S. residents to go about their regular activities.

But there are exceptions. People who returned from China on or after Feb. 3 have been formally quarantined or asked to stay home. And behind the scenes, local public health officials have launched painstaking efforts to reach “close contacts” of people with confirmed cases of the virus, dubbed 2019-nCoV, asking them to self-quarantine and submit to ongoing monitoring.

So what exactly is a ‘close contact’?..

For the new coronavirus, guidelines from the federal U.S. Centers for Disease Control and Prevention define “close contact” as anyone who has been within 6 feet of a person infected with the virus for a “prolonged period of time,” as well as those who have had direct contact with the infected person’s secretions. These guidelines are then interpreted by local public health departments…

In the US, health officials continue to stress low risk of coronavirus..

There is some case-by-case decision-making in assessing risk, Rudman said. Whether a health professional was wearing gloves, a mask or other protective equipment, and what kind of interaction they had with the patient, all factor in.

And because they work with people who are sick and may be at higher risk from infection, health care workers may be asked to take more extreme precautions. Santa Clara County’s public health department asked at least five people to go on two weeks of paid leave after a man who visited the hospital where they worked later tested positive for the virus.

Earlier cases were not so straightforward. One factor that has made the investigations particularly challenging is confusion over whether the virus can be spread by an infected person who is not showing symptoms. Health departments say that, given the uncertainty, they are taking a cautious approach and looking for any contacts going back three days before symptoms started. “Fortunately, we have so few cases, so we can do that,” Rudman said.

Rudman declined to say how many people are being monitored in Santa Clara but noted that having so few cases has meant she and her colleagues have had time to be methodical about who might be at risk. She hopes that will provide comfort to others in the community.” (F)

“A new report into the range of symptoms experienced by coronavirus patients suggests that around one in 10 suffer from diarrhea and nausea for a few days before developing breathing difficulties, leading to suggestions that the pathogen may be transmitted via feces. While this route of transmission has not been confirmed, the new data does raise the possibility that doctors may have missed some key early warning signs by focusing only on cases involving respiratory symptoms.

It has already been established that the virus is primarily passed on by droplets in an infected person’s cough, and the new study – which features in the Journal of the American Medical Association (JAMA) – found that the majority of coronavirus patients at a hospital in Wuhan, China, suffered from symptoms such as fever, muscle pain, and shortness of breath at the onset of the illness.

However, of the 138 patients observed by the study authors, 14 initially presented with diarrhea or nausea, developing more classic coronavirus symptoms a day or two later. According to Chinese media reports, doctors found traces of viral nucleic acids in the stool of patients who exhibited these atypical digestive symptoms.

The first US patient to be diagnosed with coronavirus is also said to have experienced diarrhea for a few days, and the virus was also found to be present in his feces.

While this doesn’t mean that fecal matter is responsible for the spread of the illness, it does provide evidence for another similarity between coronavirus and SARS, to which it is related. Back in 2003, hundreds of people in a Hong Kong housing estate became infected with SARS thanks to a plume of warm air emanating from a bathroom that had been used by an infected person…

Significantly, 41 percent of patients in the study became infected in hospital, with both healthcare workers and patients who had been hospitalized for other reasons catching coronavirus. Regardless of the transmission route, therefore, it seems that hospitals are a potential breeding ground for the virus, suggesting that improved hygiene may be necessary to prevent its spread.” (G)

“The coronavirus epidemic could grip about two-thirds of the world’s population if the deadly bug is not controlled, a top public health official said — as another expert predicted that cases in China could peak this month and fade away by April.

Professor Gabriel Leung, chair of public health medicine at Hong Kong University, told the Guardian he was examining the implications of the World Health Organization’s Monday warning that cases of coronavirus spreading outside China are the “tip of the iceberg.”

Most experts believe that each person infected can go on to transmit coronavirus to about 2.5 other people — creating an “attack rate” of 60 to 80 percent, Leung told the paper.

“Sixty percent of the world’s population is an awfully big number,” he said.

Even with a general fatality rate as low as 1 percent — a possibility once milder cases are taken into account — there could still be a massive global death toll, he added.

Meanwhile, experts are attempting to map out the likely course of the illness, Leung told the Guardian.

“Is 60 to 80 percent of the world’s population going to get infected?” he said. “Maybe not. Maybe this will come in waves. Maybe the virus is going to attenuate its lethality because it certainly doesn’t help it if it kills everybody in its path, because it will get killed as well.”

Health officials are also attempting to determine whether restrictions put in place in Wuhan — the epicenter of the outbreak — as well as other cities, have made a positive impact.

“Have these massive public health interventions, social distancing, and mobility restrictions worked in China?” Leung asked. “If so, how can we roll them out, or is it not possible?” “(H)

“The disease caused by the new coronavirus that’s sickened more than 42,000 people in China now has an official name: COVID-19. It stands for the coronavirus disease that was discovered in 2019.

The World Health Organization announced the name Tuesday, saying it was careful to find a name without stigma.

“We had to find a name that did not refer to a geographical location, an animal, or an individual or group of people,” WHO Director-General Tedros Adhanom Ghebreyesus said in a call with reporters.” (I)

“Time will tell if the new coronavirus ends up being less or more dangerous than the flu; we don’t fully know yet how bad it is. Usually, the diseases that stick around tend to become less lethal. Only live hosts can continue to make more viruses. Influenza is also pretty devious in how it mutates its surface molecules from year to year to evade immune system detection. If 2019-nCoV is not able to do that, people’s immunity to it could gradually improve.

But therein lies the paradox. The outcome that has public health officials really concerned is that 2019-nCoV will turn into something like a disease that we have a tough time making you worry about right now.

Every year physicians and public health officials try to get you to immunize yourselves against the flu, and far too many of you don’t. We beg you to practice proper precautions and hygiene — and, still, tens of thousands of people die, and too few worry enough.

Governments and employers could help by making it easier for sick people to stay home from work. Many Americans without paid sick leave go to work despite feeling ill, and many of those work at restaurants, schools and hospitals, where disease is easily spread.

The most significant defense the United States has to prevent pandemics is a solid public health infrastructure. The public has to trust it. The system also needs to be properly prepared and have the resources to handle a widespread infection. (The system is currently stretched thin and underfunded.) It’s critical to make sure there are enough medical supplies available, as well as necessities like food, to get a community through an outbreak.” (J)

“The Centers for Disease Control and Prevention is preparing for the coronavirus, named COVID-19, to “take a foothold in the U.S.,” Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, told reporters. “At some point, we are likely to see community spread in the U.S. or in other countries,” said Messonnier. “This will trigger a change in our response strategy.” (K)

“An apartment building in Hong Kong, its units linked by pipes. A department store in the eastern Chinese city of Tianjin, where more than 11,000 shoppers and employees mingled. A ski chalet in France, home base for a group of British citizens on vacation.

These sites, scattered around the world, have become linked by a grim commonality: They are places where pockets of new coronavirus cases have emerged in recent days, raising fears about the virus’s ability to spread quickly and far beyond its origins in central China.” (L)

“Right now scientists are trying to accomplish something that was inconceivable a decade ago: create a vaccine against a previously unknown virus rapidly enough to help end an outbreak of that virus. In this case, they’re trying to stop the spread of the new coronavirus that has already infected tens of thousands of people, mainly in China, and given rise to a respiratory condition now known as COVID-19.

Typically, making a new vaccine takes a decade or longer. But new genetic technologies and new strategies make researchers optimistic that they can shorten that timetable to months, and possibly weeks — and have a tool by the fall that can slow the spread of infection.” (M)

“As the new coronavirus continued to spread unabated within the city of Wuhan, China, government officials last week imposed draconian measures.

Workers in protective gear were instructed to go to every home in the city, removing infected residents to immense isolation wards built hastily in a sports stadium, an exhibition center and a building complex…

Many experts are skeptical that isolating thousands of patients in shelters can stanch the spread of the coronavirus. There are more than 40,000 cases in China now, in every province, although the wide majority are in Hubei Province.

“This is a bit like closing the barn door after the horses are already out,” said Dr. William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center in Nashville…

Wuhan’s makeshift shelters may yet become breeding grounds for infection, especially if patients are not properly screened, Dr. Markel and other experts said.

The patients already are in a weakened state, and facilities like these make it easy for viruses and bacteria to travel — not just the coronavirus, but also any of the dozens of pathogens that may thrive when people gather in tight quarters.

“Whenever we put people in facilities together, even during a hurricane, we are concerned about them getting infectious diseases,” said Nicole A. Errett, a researcher at the University of Washington who is a co-director of the Collaborative on Extreme Event Resilience.” (N)

“CMS sent a memo to state survey agency directors urging them to double down on compliance with basic infection control practices.

The memo includes information and links to resources to combat the illness caused by the novel coronavirus. It also states that healthcare staff and surveyors, including federal, state and local contractors are expected to adhere to standard infection control practices, such as CDC recommendations on standard hand hygiene practices.

In 2020 surveys, CMS and accrediting organization acute care surveyors will be especially alert to hand hygiene practices, including the use of alcohol-based hand rub/hand sanitizer, the preferred method of hand hygiene in clinical settings, the memo says.

“We know that adherence to basic infection control and prevention practices such as hand hygiene can help reduce the risk of infectious disease spread in all healthcare settings,” the memo reads.” (O)

“Successful outbreak control works like this: Patients report their symptoms to health-care workers. Those health-care workers then report unusual cases to local public-health officials who investigate the illness. Those officials may isolate ailing patients, identify others with whom they have come into contact, and monitor those individuals. The results of these investigations are reported to government officials, who communicate reliable information about the outbreak and its causes to the public and the press. That information enables those who are not sick to take measures, such as hand washing and avoiding crowds, to prevent themselves from getting infected and spreading the outbreak. The promise of reliable information and competent, supportive medical care convinces others who are suffering symptoms to come forward so that new cases are identified, tracked, and treated. This cycle continues until the virus stops infecting new people, the people already infected get well or perish, and the outbreak burns out.  

In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections like severe-acute respiratory syndrome and the Ebola virus. However, in many countries without responsive governments, open press, and rudimentary health-care systems, controlling an infection becomes much harder. Officials in repressive societies are more apt to rely on counterproductive censorship and quarantine measures that unduly interfere with citizens’ rights and spread distrust.” (P)

“Further increasing the danger of outbreaks and epidemics is another by-product of better health: complacency. In 2013, less than 0.5 percent of international health aid was devoted to preventing infectious-disease outbreaks, and the portion of the World Health Organization budget funded by dues from 194 member countries had dwindled to less than the budget of the New York City Department of Health. Starved of funds, the international system intended to control outbreaks like Ebola failed miserably in West Africa.

After that episode, the Obama administration established a White House–based directorate to respond to outbreaks and dedicated $1 billion to help poor countries build the basic capabilities to prevent, detect, and respond to pandemic threats. The Trump administration has assisted in the international response to Ebola in Congo and offered China help in the current coronavirus crisis, but it also dismantled the White House directorate on pandemic preparedness and urged that U.S. funding for global health security return to pre-2014 levels.” (Q)

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