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COVID-19 - The coronation of a new pandemic

Author : Greg Davies, director of market development, Assurity Consulting

31 March 2020

Microorganisms are amongst the simplest and oldest forms of life - although for viruses the debate as to whether they are living thing remains - with estimates of 1 trillion different species in existence.

They are, by nature, designed to mutate, adapt and evolve, so it is not surprising they are the one group of organisms to find a home in almost every environment on our planet, or that some of them can cause us real problems.

The epidemiology of epidemiology

Communicable diseases and populations are not happy bedfellows, usually resulting in the latter taking to their beds in a most unhappy state. We do though have clusters of disease occurring almost constantly worldwide.

For a disease to become an epidemic the “occurrence in a community or region of cases of illness” must be “clearly in excess of normal expectancy” (World Health Organisation (WHO) definition).

A pandemic is "an outbreak of a new pathogen (disease causing organism) that spreads easily from person to person across the globe" (again WHO definition). Epidemiology is the study and control of diseases.

Pandemics and epidemics are not new, through history as people increasingly gathered in greater groups, so communicable diseases have been able to spread more readily within populations.

Sourced by many as one of the earliest known examples of an epidemic is the reported outbreak of typhoid (Salmonella typhi) (or possibly a haemorrhagic fever) affecting Greece in the 420’s BC.

Since then there have been many others including:
• The Antonine Plague (Europe). Starting in 165 AD, possibly smallpox and estimated to have killed up to 10 million people;
• The Justinian Plague (Europe and Asia). Suspected of being the first “plague” (Yersinia pestis), started in 541 AD and accounted for possibly 20 to 50 million deaths;
• The Cocoliztli epidemics (Mexico). Between 1545 and 1580 two outbreaks believed to be of Salmonella enterica killed an estimated 7 to 17 million people;
• Between 1816 and 1890, multiple Cholera epidemics affecting Europe, North America, Asia and Russia killed millions.
• The Spanish flu, a worldwide influenza pandemic between 1918 and 1920 resulting in the deaths of 50 million people.
• HIV/Aids. Starting at some point in the 20th Century (there are a number of different opinions) the pandemic has killed 32 million people.

For many of these diseases, Plague, Cholera, Flu, Smallpox, Measles and Typhoid, they have, over time, caused repeated epidemics of various sizes across the globe.

These in turn have allowed us to study them and look at why and how they occur and so what can be done to help control them in the future, their epidemiology.

In conjunction with this, where we get an infection and survive, our bodies can build up a recognition and immunity to that disease. Across a population this is known as “herd immunity”.

For many diseases this will occur naturally and even be inherited, for others vaccinations are designed to serve that purpose. Along with vaccinations, antibiotics, sanitation, hygiene and education have gone a long way to controlling the risks of infectious diseases, but not necessarily eliminating them. As our disease epidemiology improves, we are also better able to manage epidemics and reduce the number and impact of and on those affected. If a disease is caused by a new agents however, the epidemiology and individual/herd immunity is not initially there, what then?

The crowning of the coronavirus

Coronaviruses (CoV) are a family of microorganisms, first identified in the 1960’s, that contain certain strains commonly found and causing disease in people.

Their name comes from the characteristic crown or halo look of the virus particle under electron microscopy, “corona” being the Latin for garland, crown or halo.

We are all highly likely to have been exposed to a coronavirus at some time in our lives.

They typically cause upper respiratory tract infections with cold and flu-like symptoms including a high temperature, runny nose, cough, headache and sore throat.

Over this century however we have seen several illnesses occur associated with coronaviruses not previously seen in humans, these are:
• Severe Acute Respiratory Syndrome (SARS) caused by SARS-CoV virus;
• Middle East Respiratory Syndrome (MERS) caused by MERS-CoV virus; and now
• Coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus.

These strains of the disease are termed new or “novel” coronaviruses (NCoV). They occur as a result of a virus “jumping” from one animal species to another and causing an infection that is then able to be passed on to other members of that new species.

Illness in us is usually a result close contact with an already infected person – coronaviruses are transmitted through respiring airborne droplets or direct contact with infected secretions/body fluids, and touching a surface contaminated with the virus (from those droplets or secretions) and then touching your eyes, nose or mouth.

SARS

SARS originated in China causing a self-limiting pandemic between 2002 and 2003. It is believed that, being a betacoronavirus, bats were the most likely primary host with the disease “jumping” to civet cats before infecting humans.

In total 26 countries were affected, with just over 8,098 cases reported and 774 deaths (9.5%) (National Health Service (NHS) website).

Symptoms included high temperature, malaise, myalgia (muscle pain), headache, rigors (shivering) and diarrhoea. Older people were particularly at risk, with over 50% of fatalities being older than 65.

According to WHO SARS has reappeared four times since the end of the 2003 pandemic “three times from laboratory accidents (Singapore and Chinese Taipei), and once in southern China where the source of infection remains undetermined although there is circumstantial evidence of animal-to-human transmission.”

MERS

MERS was first identified in 2012 in the Middle East (Jordan and Saudi Arabia). Again, a betacoronavirus, dromedary camels were suspected as a secondary host.

To date every case of the disease has continued to be linked residents in or travel around the Arabian Peninsula. Symptoms of MERS include fever, cough and shortness of breath.

In 2013 the WHO concluded "the risk of sustained person-to-person transmission appears to be very low” and by 2017 a total of 2,000 cases had been reported.

The disease itself can lead to severe respiratory illness, with “about 3 or 4 out of every 10 patients reported with MERS” (30% to 40%) dying, according to the American Centres for Disease Control and Prevention (CDC).

COVID-19

The WHO were initially alerted to a potentially new virus causing cases of pneumonia in the area around Wuhan City, Hubei Province of China on the 31st December 2019.

This new organism has been identified as another betacoronavirus and so is the same genera as both the SARS and MERS viruses.

It is again most likely to have originated from bats, although if a secondary host is involved it is not yet known what that may be.

With over 7,000 people infected, 170 deaths and the virus identified in at least 100 people in 20 other countries and territories outside China, on the 30th January 2020, the WHO’s International Health Regulations Emergency Committee declared the outbreak a “public health emergency of international concern” (PHEIC).

By the 12th March 2020, having spread to 34 provinces in China and a 117 other countries / territories worldwide, causing an aggregated 125,048 confirmed cases and 4613 deaths (3.6%) (WHO figures), the WHO have also now characterised COVID-19 as a pandemic.

Epidemiological studies identify the most common symptoms of COVID-19 are high temperature/fever, cough and shortness of breath.

The disease can be contracted by people of all ages, most are recovering. However, two groups of the population are at higher risk of developing a severe or fatal infection, these are older people and/or those with underlying medical conditions.

People regularly exposed to a high viral load of SARS-CoV-2 – such as the clinicians, nurses and others caring for those infected by the virus – are also at more risk.

Dethroning COVID-19

A strategy of isolation and screening people infected (or suspected to be infected) with SARS helped bring the pandemic under control in 2003.

And notwithstanding four subsequent cases, SARS has not been responsible for any reported disease since 2004.

The same isolation and screening procedures have been employed to initially manage COVID-19 and together with the ability to now test for the virus specifically, these have been used as strategies to varying degrees and in various ways across the world.

In the UK the Government and Devolved Administrations has established a four phase response to handling COVID-19, “contain, delay, research, mitigate”.

“Coronavirus: action plan. A guide to what you can expect across the UK” was published the 3rd March 2020.

The principles cover:
Contain - Its aim is to prevent/reduce the spread of the virus across the country by testing detecting and isolating early cases (travel related or community) and tracing people who have been in contact with those shown to be infected.
Delay – By slowing the rate at which COVID-19 spreads, it is hoped the percentage of the population infected at anyone, time can be managed in terms of its impact on our healthcare infrastructure and others services and businesses, etc. The summer months tend to see a decrease in colds and flu, so if the peak of the disease can be delayed, it should help in managing the knock on effects.
Research – This phase is run in parallel with contain and delay with centres around the world look at further developing diagnostic tests, care plans and through global alliances such as the Coalition for Epidemic Preparedness Innovations (CEPI) fund research into vaccines.
Mitigate – Depending on the extent of the spread of COVID-19 in the UK, this phase will involve plans to minimise the impact of the disease on society, our public services and economy, as well as supporting hospitals and other essential service to provide the best levels of care.

The “lockdown” is an example of this. This response was supported by a host of information and guidance from the Government, Public Health bodies, NHS and other organisations.

Due to the fact COVID-19 remains a new disease our knowledge of the virus continues to develop.

The lack of “herd immunity”, evolving risk management modelling and differing approaches to the disease means its spread and gathered epidemiological evidence varies between countries.

Using WHO information, as of the 30th March, globally there have been 693,224 confirmed cases reported, with sadly 33,106 people dying. The USA with over 122,653 confirmed cases is now the worst affected country.

Italy, Spain, Germany, France, Iran, Switzerland, Netherlands and the UK all have 10,000’s of confirmed cases reported, and a further 30 countries confirmed cases in the 1,000’s.

In China, where there are over 82, 000 confirmed cases, the rate of infection appears to be a slowing down across the country.

Demographics (population, age and density) and style of response (levels of testing, social distancing, isolation, healthcare capability and travel restrictions) also appear to be affecting factors.

With financial markets reacting adversely to the situation and disruptions to travel, business, schools, sporting and other events, how that will shape the curve of the delay phase remains to be seen.

The development of largescale antigen and antibody testing is gathering pace. Research into and production of a vaccine and/or applicable antiviral medications, are unlikely to be in time to offer any short-term additions to our armory against COVID-19, but we will get through and learn from this pandemic.

In the meantime, a risk-based approach to our activities, individually, as organisations, nationally and internationally, recognising the hazards and those at most harm, them implementing sensible and proportionate controls will be the key.


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