As a retired epidemiologist I have been closely following
the Covid-19 Pandemic since mid-February.
I initially read all the WHO Situation Reports then started analysing
and compiling the public available data for some of the countries I had a
special interest. I have also been
compulsively reading news articles on the pandemic.
My analysis is rudimentary and limited to a few spreadsheets
but it is all helping me understand the Pandemic and satisfying my basic nerdy
tendencies. I suppose this is my way of
coping while under lockdown on a small sailboat in Marigot Bay, St Martin in
the Caribbean, trying not to worrying about when we can go somewhere out of the
hurricane zone all the while looking onshore at the still very visible damage
from the last hurricane in 2017.
What follows are two write ups that I have done in trying to
make sense of the world situation. Initially
I was not intending to put these words in a blog but now I will share them for
what they are worth. The first half of
the blog was written the end of March when the world had about 750,000 cases
and the US reported about 100,000 cases and less than 2000 deaths. The second half of this entry was written on
1 May when in less than 5 weeks the number of world cases increased to more
than 3.3 million and the US has recorded more deaths (>65,000) than it sustained
from 10+ years of fighting the Vietnam War.
29 March 2020
For the purposes of the first half of this discussion the
following definitions will be used.
Start of the epidemic in a country:
cumulative 100 cases, Epidemic ‘under control’ or incidence curve
flattened: consistently less than 200 cases per day. To date, 29 March 2020, only China and South
Korea have managed to get the outbreaks in their countries under control. It is still early days and there could be
another flare up in these countries but hopefully with continued good public
health infection control measures the worst is over for these countries.
China has taken about 45 days to get the worst of the
epidemic under control. At that point
China had about 80,000 cases and nearly 3000 deaths (about a 4% death rate at
this time but data is not complete). It
is now (29 March) day 70 of the epidemic and China’s daily new cases are around
100 and deaths are in single digits.
Korea, who has achieved the highest per capita testing rate
of any country, got the epidemic under control by day 20. At that point Korea had just under 8000 cases
and 66 deaths (less than 1% mortality rate – with caveats as data is not
complete). It is now in day 37 of their
epidemic and like China, Korea’s daily new cases are around 100 and daily deaths
are in single digits. The mortality rate
is 1.6% as of 29 March. Since Korea has
done such a high rate of testing (ie screened the greatest proportion of the
population) this mortality rate may prove to be the most accurate for the true
mortality rate for this virus.
Early Timeline
A bit more detail on the timeline of the epidemic in each of
these countries. China first reported
cases of a novel pneumonia to the WHO on 31 December 2019. At this time it had identified just over 30
cases. In less than 2 weeks China had
isolated, identified and sequenced the new coronavirus. It made the genetic sequence available to
other countries so they could start developing diagnostic testing kits.
By mid to late January other countries around the world were
reporting cases. Japan and Korea reported their first cases on the 15th
and 20th January, respectively.
At the time of Korea’s first case China had 278 confirmed cases. By the end of January there were just under
10,000 confirmed cases worldwide with just over 100 cases in 19 countries
outside China. (90% of the world cases were still in China.)
By the 15th of February, China still had 90% of
the world’s cases and reported over 50,000 cases. In all, cases of the coronavirus were
identified in 25 countries: Korea 28 cases, Australia 15 cases and the US 15
cases. All but 3 and 2 of these cases respectively
had a history of travel to China for Australia and the US. Thus evidence of community transmission was
clear by mid February for the US and Australia.
At this point when community transmission is noted, good outbreak
control would demand decisive public health measures: test, isolate, trace, and
more test, isolate, trace.
By the 1st of March, 19 of the 58 (33%) countries
outside of China who reported coronavirus infection were reporting local
transmission of the virus. On the 11th
of March the WHO declared Covid-19 a pandemic.
There were now over 100,000 cases worldwide. Thirty percent of those cases were now
outside China in 113 countries and territories; 63% of these countries were reporting
local transmission.
The data for the US cases is sketchy from the late January
to mid-March. From my reading of the
publically available data, the CDC only reported to the WHO 4-5 days per week
and the testing kits at this time were faulty.
No centralised reporting or response seemed to be occurring. Private labs were charging for tests and
public labs were given faulty kits.
By 16 March Johns Hopkins started publishing a dashboard of
world cases (https://www.medpagetoday.com/infectiousdisease/publichealth/84698
) compiling data from multiple sources.
This data is now more consistent and published in real time. The WHO situation reports continue to publish
case numbers and deaths by country.
These numbers are slightly different from the JH dashboard but in the
same ballpark. Generally there seems to
be a reporting delay with the WHO data and the data is a day or two behind the
JH dashboard reports.
Europe and the USA are now the epicentres of the pandemic. Italy, Spain, Germany and France are hardest
hit in Europe. Italy and Spain
instituted mandatory self-isolation and shut down of all non-essential business
on the 11th and 13th of March and France enacted
restrictions on the 17th. The
extent of the restrictions in Europe vary and were often incrementally
introduced, starting with suggestions of working from home and self-isolating
to closing schools and all businesses except groceries, pharmacies and a few
others deemed to be essential. I believe
now Italy and Spain are enlisting the military and police to enforce these
restrictions and streets are basically empty.
Although the USA restricted travel of foreign nationals from
China on 23 January, it did not follow through with further restrictions on travel. US citizens and permanent residents who had
travelled in China were not restricted or monitored. There also were only token restrictions and
follow-up for travellers from Europe. Nor
was there a co-ordinated approach to testing and monitoring until
mid-March. Indeed, from all reports the
outbreak control efforts are still fragmentary and vary substantially from
state to state. As of 29 March the USA
is in the 26th day of its outbreak and has over 125,000 cases. On day 26 of China’s outbreak 64,000 cases
were reported, half the number of cases even though China has four times the
population of the USA. In the last week
cases of coronavirus infection in the US have increased four-fold, from 33,000
to 130,000.
1 May 2020
How rapidly things have changed! In the 100 days since China reported about
100 cases, the virus is fully entrenched around the world in the worst pandemic
since Spanish Flu in 1918-19. The world
is in lockdown and a long economic recession/depression is upon us. There are now over 3.3 million confirmed
cases and over 230,000 deaths worldwide.
Europe and the US are currently the epicentres of the pandemic. The US has more than 1.1 million cases and
65,000 deaths while Spain, Italy, UK and France each have around one quarter of
a million confirmed cases and more than one tenth of them have died – death rates
that are 400-500 per million population.
Germany is fairing much better with a death rate of around
80/million. Australia and New Zealand
have done very well and basically the virus in those countries is under
control. Their infection trajectory
curves have flattened.
European countries, the US, New
Zealand and Australia are cautiously taking steps to open up and start the
economy again. This of course is quite a
reasonable action provided the testing, tracing and health care infrastructure
is in place to support any hot spots that may occur. I am not convinced the infrastructure is
adequate for all these places, especially in the US which has had by far, the
worst response to the Pandemic within the developed world. Many of the countries opening up still have
several thousand new cases every day and several hundred daily deaths. Time will tell how well this opening up goes.
For my own interest, I am monitoring
the data as best I can to see if we see a surge in cases. Obviously the epidemiologists and policy
makers around the world are also monitoring the situation using much more
sophisticated tools and more complete data than I have at my disposal sitting
on a small sailboat in the Caribbean. (I would love to be able to analyse some
of this data using SPSS or STATA but those analysis skills and software are
long gone for me.)
Learning Lessons
The Guardian published an article on the 10 lessons learned
so far from the Pandemic, (https://www.theguardian.com/world/2020/may/01/10-key-lessons-for-future-learned-fighting-covid-19-coronavirus-society)
which deserves further consideration. A
big question about this pandemic is why some countries seem to, so far, have come
through with relatively few deaths and minimal economic disruption. What are the factors and behaviours that have
contributed to this? The above article
explores these issues. I would like to add some comment to these issues to make
sense of it all for myself.
One of the major, if not the major, factor that seems to affect
the impact of the epidemic within a country is the speed in which that country
responded to the virus threat. The tools
and knowledge of how to respond to an epidemic threat are well established and
readily available and have been for decades, but the political will and ability
to take up and act on the knowledge varied greatly. To my mind, this current world crisis can be
seen as the great verdict on the coalescence of science and politics.
As mentioned at the beginning of this article, written over
a month ago, China reported to the WHO on 31 December the occurrence of a novel
pneumonia infection in the Wuhan province.
At this time it had identified about 30 cases. By the mid-January 2020, there were 282
laboratory confirmed cases in the world.
All but four of these cases were in China. At this time in the epidemic, only laboratory
confirmed cases were being counted. The
actual number of cases would have been much higher as accurate and wide spread
testing and identification of asymptomatic cases was not yet occurring. By the third week of January China locked
down Wuhan province, a province of more than 11 million people.
Much has been made by Trump and his ilk that China wilfully failed
to contain the virus and that the three week delay in locking down Wuhan lead
to the Pandemic. I do not make apologies
for China as it certainly made mistakes and this delay has had very dire consequences. Nevertheless this was a new disease with
unknown pathogenesis and infectivity. It
would be a rare country that would recognise the significance and world import of
a cluster of new pneumonia cases to the extent that it would think it necessary
to quarantine 11 million people within days of recognising cases. China did lock down in January and now 14 weeks
later the virus is contained in that country and there have been only a handful
of deaths and cases in the last fortnight.
Sadly 14 weeks ago Pandora’s Box was already well and truly opened.
However by the third week of January the world was made aware
that there was a new infectious disease that should be taken seriously. Every country that confirmed the arrival of
this new disease within their borders and failed to act quickly and decisively
contributed to the spread of the Covid-19 virus. To my mind they are even more ‘guilty’ (if
guilt can or even should be ascribed for a pandemic) as they were warned but
failed to act. With the proper actions
the virus could have and should have been contained within each country. South Korea, Thailand, Taiwan, Iceland,
Norway, Greece, New Zealand, and Australia are some of the countries that have
so far managed to do this and their infection trajectory has flattened with
minimal cases and death.
As we enter a new phase of the Pandemic in which countries
will begin to lift their quarantine, we will see how well science and politics coalesce.
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| Marigot Bay, St Martin |
