COVID-19; is it time to hit the PANIC button?

Say hello to the madness; we are in a pandemic. In my last column I mentioned that the spread outside of China was still rare. Eeeuh, that didn’t age well… Today, three different continents are confronted with outbreaks of the virus, probably others will follow soon. Thousands are infected and a percentage of them have died. Since the virus hit the West it almost seems the world is in panic mode. There is such an overflow of good/vague/bad information surrounding this outbreak that is hard to keep track of it all and put things in perspective.

Luckily, I am here to change that: your very own, Thailand based, Infectious Disease Epidemiologist.

CO-NA-NA, what’s my name?

The issue with a new disease is that it is hard to immediately give it the right name. Some parents might now this feeling, waiting days after a birth to name their kid. The current disease almost changed names more often than Sean Combs, Puff Daddy, P. Diddy, Diddy, Puffy, Fluffy, Duffy, H. Duffy, Hilary Duffy, Hilary Duff did.

Today we call what used to be the “Wuhan-virus”, the “Corona Virus”, the “nCoV” by its WHO approved official name: COVID-19. It stands for “COronaVIrus Disease”-2019 (let’s don’t do a 2020 or 2021 version), the virus itself is called SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2).

FACT 1 : COVID-19 (still) not as bad as previous outbreaks

Let’s update the table from the last blog:

	COVID-19	MERS	SARS	H1N1
Year	2019	2012	2002	2009
Origin country	China	Saudi Arabia	China	Mexico
Source	Bats	Dromedary camels	Bats	Swines
Number of people infected to date	82.294	2.494	8.096	208.269
Case fatality	Susp. 2%	37%	9.6%%	4.20%
Countries with reported infections	57	27	27	175
Countries outside origin with reported deaths	7	16	8	124

https://www.who.int/docs/default-source/coronaviruse/situation-reports/; MERS-CoV: Middle East Respiratory syndrome; SARS-CoV: Severe Acute Respiratory Syndrome; H1N1: Swine flu

Although COVID-19 seems to be “better” than SARS, MERS and H1N1, it loses the battle in a who-is-a-good-disease competition to seasonal flu. In comparison with the seasonal flu COVID-19 has a higher case-fatality ratio. Seasonal flu has approximately 0.5% mortality rate, COVID-19 currently has a 2% rate (please read FACT 3).  COVID-19 also has a higher reproduction number; seasonal flu infects about 1 to 1.5 other person (tiny persons also count for 1, it is just statistics), COVID-19 appears to infect 1.5-2.5 other person. This means that COVID-19 could spread more widely. Lastly, for seasonal flu we have a vaccine!

FACT 2 : Younger than 50? No reason to panic

(Rest assured: this does not imply the following: Older than 50? Call your local undertaker at 555-…..)

Let me remind you that Coronaviruses have been among us humans for a long time already. Yes, this is a new variant and yes, it is more severe than the previously known ones, but if you look at the figures published by the Centers for Disease Control, China, you can see that if you’re younger than 50 years old, you will be fine.

And even if you do catch the virus, you would probably not even go to see a doctor. Symptoms are fever, dry cough and shortness of breath but range from mild (80% of the cases), severe (14% of the cases) and critically ill (5% of the cases).

Men are at higher risk of dying from COVID-19 than women (rate 3,25 to 1). And people with underlying illnesses like COPD (smoking history), diabetes or a bad working immune system due to medication or old age are also at higher risk [1]. These vulnerable groups are also the people that we usually give the vaccine for seasonal flu. You can see how they are at higher risk of dying from the COVID-19.

Also, <10 years old there have been (to date) no deaths and very few infections reported.

Characteristics	Confirmed cases,	Deaths,	Case fatality
	N (%)	N (%)	rate, %
Overall	44,672	1,023	2.3
Age, years
0–9	416 (0.9)	−	−
10–19	549 (1.2)	1 (0.1)	0.2
20–29	3,619 (8.1)	7 (0.7)	0.2
30–39	7,600 (17.0)	18 (1.8)	0.2
40–49	8,571 (19.2)	38 (3.7)	0.4
50–59	10,008 (22.4)	130 (12.7)	1.3
60–69	8,583 (19.2)	309 (30.2)	3.6
70–79	3,918 (8.8)	312 (30.5)	8.0
≥80	1,408 (3.2)	208 (20.3)	14.8

[2]

Just to clarify: these current mortality rates only apply on people of whom it is determined that they have COVID-19 (see again FACT 3). If you don’t have COVID-19: well, don’t text and drive!

FACT 3 You can have the virus and be fine

The symptoms of COVID-19, like I stated above, can be very mild with just some cough and runny nose. Recently, Yan Bai et al. published an interesting article of how even asymptomatic carriers can transmit the virus [3]. This means that you can be infected with COVID-19 and not have any symptoms.
That sheds an interesting light on the 2% mortality rate in FACT 1. If we would test the whole world, we would probably get a higher number of infected persons. Infected persons without even knowing it. This affects the mortality rate: which is deaths from the virus divided by persons infected by the virus. If currently more persons are unknowingly infected the mortality rate could be much lower (as the nominator increases). The absolute number of deaths of course doesn’t change, which is sad, but it might put the severity of the COVID-19 in a different perspective.

Conclusion: during an outbreak it is super difficult to make sense of any of the numbers and to have a complete picture of the outbreak.

FACT 4 Closing an office for 48 hours is pointless

Some companies close their office for two days when an employee is found to have COVID-19. The reason? Intensive cleaning of the office. This does not solve anything!

Yes, the virus can survive long on surfaces, so a good cleaning is very smart. But if after the big cleaning you will re-open the office again you might as well not have bothered. Persons have the disease in them for at least two weeks … spreading it to others … who probably come back to the office on day 3 … you understand where I am heading?

Recently I was in a hotel and at check in they took my temperature and every morning before breakfast they checked me before I could enter the breakfast room. That is a much smarter way to contain the outbreak. That gives us FACT 5.

FACT 5 Do’s and don’ts

Do	Don’t
Wash hands regular	Go to the current outbreak hotspots
Use desinfecting handgel	Go to a place where you are packed with other people with potential bad hygiene
Sneeze and cough in elbow	Panic
Read scientific facts	Trust Facebook
Think twice before traveling anywhere	Panic!!

Do the do’s and stay home when you have any symptoms and you are helping to stop this outbreak.

Well done, stay smart, until a next update!

 

References:

1. Sun P, Lu X, Xu C, Sun W, Pan B. Understanding of COVID-19 based on current evidence. J Med Virol 2020.
2. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020[J]. China CDC Weekly, 2020, 2(8): 113-122.
3. Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA.Published online February 21, 2020. doi:10.1001/jama.2020.2565

 

 

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The Who’s and What’s of the Wuhan/nCoV virus

The world is in shock, twitter is in meltdown and China looks like the zombie movie World War Z (without Brad Pitt unfortunately). “Facts” and panic are disturbingly intertwined. To provide some guidance, here for all non-medical people (and maybe even some medical) a brief summary of what is going on and how worried you should be.

An old friend presented in a novel way

Coronaviruses have been around us for a long time. The name Corona comes from Greek meaning Crown because of how it looks under the microscope. There are different forms of coronavirus and we’ve known a few already:

– CoV: common cold, super common and mild symptoms

– SARS-CoV: Severe Acute Respiratory Syndrome

– MERS-CoV: Middle East Respiratory syndrome

And now with the new outbreak:

– nCoV: the not so creatively named “novel Coronavirus”

In your life you have been infected with many coronaviruses only not with the dreaded novel, SARS or MERS variant, … just the common cold.

Don’t push the Panic button (… yet)

A little perspective, yes, the world is on high alert but at this moment there is no need to panic yet. I say “yet” because we’re still in the outbreak and who knows what will happen next.

At this moment the majority of the misery is in China. They have the highest number infected and deaths. There was only one country outside China with one death (Hong Kong not counting as separate country…), no other countries have yet reported. If you look at this table you can see how nCoV relates to the other Coronavirus pandemics as well as the H1N1 pandemic.

	nCoV	MERS	SARS	H1N1
Year	2019	2012	2002	2009
Origin country	China	Saudi Arabia	China	Mexico
Source	Bats	Dromedary camels	Bats	Swines
Number of people infected to date	28.276	2.494	8.096	208.269
Case fatality	susp 2%	37%	9.6%%	4.20%
Countries with reported infections	25	27	27	175
Countries outside origin with reported deaths	1	16	8	124

You can see that although the infection is spreading fast in China, the spread outside is still rare as well as the number of deaths outside of China. This is all very reassuring for the rest of the world although it doesn’t helpt China much.

This is de guidance of WHO pandemic criteria and you can see we’re currently in phase 4. The big questions is, will we get to phase 5 or 6? In other words: will there be an outbreak of the nCoV in a different country than China? Time will tell…

source: https://www.peakprosperity.com/coronavirus/

No hahahatjooo, Do hahahahandhygiene

You never know what happens next so just be cautious. The most important way of prevention of most infectious diseases is hand hygiene. Not just a quick splash of water on your hands but a real soapy two-minute wash and dry your hands after. Do this after visit to the toilet, before eating and after coughing/sneezing and you will be alright. Also please cover your mouth while coughing and sneezing to protect your surroundings. And if you’re sick don’t go to work or a different place where you can infect many others (see also “8 things you though you knew about the flu“).

Facemasks: if it won’t help Spiderman and Batman, it won’t help you

Wearing an ordinary medical facemask, although you look super cool with it, doesn’t help against viruses. Sorry. You would need a special very tight mask that prevents you from even smelling perfume if it was sprayed on your face.

If you do wear a facemask, please put the outside on the outside. It seems a complete “duh” remark but trust me I’ve seen public health professionals getting it wrong. And finally dispose the mask yourself and don’t put others at risk.

Stay safe and keep informed!

For more information: https://www.who.int/emergencies/diseases/novel-coronavirus-2019

How to tame your outbreak: 2, the fight against Malaria

In part 1 of How to tame your outbreak I have shared with you the three necessary steps to control an outbreak. These were: gather information, contain the spread and keep it safe. In theory it is as simple as opening a bag of crisps on a lonely and rainy Tuesday evening whilst sitting on the couch ready to watch Legally Blonde for the tenth time. Controlling an outbreak in practice is a whole different ballgame.

Now , I could share with you all the Outbreak control plans and actions about every Virus, Bacteria and what, but since I work closely with a Malaria Elimination Task Force (METF) at the Myanmar-Thailand border, let’s use Malaria as example.

So here we go: how to tame your Malaria Outbreak?

Step 1: gather information

Malaria is caused by a parasite and is transmitted via mosquito’s. They suck blood from a Malaria patient and inject that blood into a new patient, thus infecting them. We know what it is and also how it spreads. That was the easy part.

Step 2: contain the spread

To contain Malaria there are really three options we could take:

Option 1: eliminate the mosquito. In real life, super difficult, it is easier to erase the West African Black rhinoceros than these little biters.

Option 2: prevent it from biting you. DEET or bednets are helpful, but it’s not realistic for people living in remote areas to use DEET all the time.

Option 3: make sure everybody that gets infected is treated before a mosquito can bite them and spread it further. This means early detection and treatment with the anti malaria drugs that kill the parasite. With the upcoming resistance (here we go again) this option can also become very challenging.

So which option to choose? You could start with option 3: early treatment. Now this can be a tricky part. Especially in a rural area like right here on the border, there are many villages and people tend not to stay in just one place. They work in one place, live in a next and their family is somewhere else again. This means that in order to successfully contain the outbreak, you will have to map out all the villages that you need to target. In the case of METF this is over 1500 villages. Then you need:

• Healthposts where people can go to get tested and treated.
• Healthworkers, educated people to diagnose and treat patients
• Medication, power supply, charts, needles, tests, alcohol (not to party into the night but to disinfect), etc.
• Education of all people, including villagers. People need to understand what you’re doing and why they need to come as soon as they have fever.
• A way of communication between the health posts and the hospitals in order to be able to send the severe patients in time for care

METF currently has over 1200 health posts with more than 1600 health workers. Can you imagine the work goes in to an operation like that?! And how much money, perseverance, guts (especially in the remote and unsafe areas) and love for the people? In the meantime, you can try option 1 and 2 (kill the mosquito and prevent the bites).

Step 3: keep it safe

The WHO grants a certificate that a country is “Malaria Free” (like Paraguay recently) when:

“a country has proven, beyond reasonable doubt, that the chain of local transmission of all human malaria parasites has been interrupted nationwide for at least the past 3 consecutive years; and that a fully functional surveillance and response system that can prevent re-establishment of indigenous transmission is in place.”

This means that, although my wonderful colleagues at METF have done a tremendous job already, saving thousands of lives in at least two countries, we’re not getting the certificate yet.

Containing an Outbreak is newsworthy and is a certain money collector. Keeping it safe is the part of the “outbreak” that funders are least interested in. It’s not news anymore. No extra figures to show. It’s just being there and staying there and not going anywhere until you’re sure. And that could take years and years. However, don’t get your guard down. Venezuela was declared malaria free in 1960 but had a big outbreak in 2016 with 240,613 patients and 280 deaths. As soon as you stop being prepared, it will come back.

So thank you METF and keep fighting the good fight.

 

Picture: Suphak Nosten: In the middle of the border, the one crossing for care, the one to provide care, across the border

 

Ground Sero: when the world saw AIDS for the first time

Did I ever tell you that I like infectious diseases? No matter how horrible they are sometimes. The beauty of an infection is that one day it’s the deadliest in the world, like a bacterial pneumonia, the next moment you have penicillin, and everything is different again. Horrible diseases get chronic almost overnight.
The scary thing is: you don’t know from the start what the disease is and if it will ever be treatable. The most notorious diseases in this case is the ultimate queen of infections: HIV, AIDS, SIDA, Kimi. The story is like a movie. Better said: the story is used in many movies. And there’s a reason. It has a spectacular start, a thriller like chase and a (sort of) happy ending. Let’s look at the start and how the world seroconverted.

1981
Reagan has just started his powerplay with the cold Russians, in Tanzania president Nyerere is working his fourth term and the Netherlands are recovering from the inauguration of Queen Beatrix. Three places in the world, miles apart that don’t have anything in common. Or so it seems. This year, all three of them and many more, will be confronted with a disease that nobody knows. Oh, and 13 year old Lisa Lopez has no idea yet that she will be conquering the world a couple of years later with TLC and their hit song “Waterfalls”. Why is that related? Just continue reading.

California, US of A
Out of the blue, hundreds of young men start dying. Young, gay men. It’s a disease nobody had seen before and gets referred to as Gay cancer. The first reports suggest that the disease is spread through inhalation of a substance (like the inhalation of poppers), and really, definitely not an infectious disease. It leads to an immunodeficiency in men with a “particular lifestyle”. Vegans have a particular lifestyle, as do priests and the Eskimo, but in this case they were referring to male patients that, in the year prior to the symptoms, had sex with many different men. Beware, this was before Grindr and the Gay pride. A new term is made to describe the illness: GRID – Gay Related Immuno Deficiency.

Moshi, Tanzania
On a completely different continent, Dr William Howlett also gets introduced to this new disease. However, the case definition is definitely different than the USA one. Here, they look out for flying testosterony hunks, the primary affected group seems to be travelling men and stewards, who can easily transfer the disease from one country to the next. And whatever you may think about business men and stewards, in the definition of Tanzania’s dictionary the word “gay” is absent.

Haarlem, the Netherlands
Closer to my home, my currently retired supervisor (then a flaming thirty-year old) Reinier ten Kate saw a great denial. Most specialists that get in contact with the disease, don’t recognize the disease and can’t evaluate the risks properly. They see regular infections, but then all at the same time. So, they are categorized as many diseases, instead of being this special one. Specialists that never had to deal with acute situations all of a sudden found themselves in the Emergency Room and doctors whose medical fields seemed miles apart suddenly had to sit together and discuss. Could it be? The Gay thingy from the USA? In the small country of the Netherlands, surely we wouldn’t get this disease, right?! But unfortunately, denial is not always the answer.

Moshi, Tanzania
In the meantime, Dr Howlett identified 200 female prostitutes as potentially infected. The idea that a disease could have preference for a sexual orientation is classified as ridiculous. Still today the biggest infected group in this country is women.

California, United States of America
Back to our American friends. It appears to be difficult to get political attention and money to conduct decent research. Since the disease is primarily seen in Homosexuals in this country, the Christians call it the Wrath of the Jedi Khan, wait, no sorry, a wrath of God (I always confuse the two).
However, other patient groups start to get infected. Hemophilia patients, that receive blood transfusions very often, get infected. This proves that the disease is blood transmittable and is not per se related to having sex with men. Regardless, the rule is started that gay men are excluded from being a blood donor. A personal frustration of mine seeing that I have female friends that are at more risk of becoming HIV infected than my best friend that spend years spooning his long-term partner.

1983, World
Apparent is that the term GRID didn’t quite cover the problem and a new abbreviation is introduced to the world: CD (Compact Disc). Oh, and; AIDS: Acquired Immuno Deficiency Syndrome, caused by the Human Immunodeficiency Virus (HIV).

1994, TLC
The newly formed girl group TLC try to help the world with their “Waterfalls” by singing about dangerous lives and the consequences of this, including HIV. In an attempt to cast of the stigma around the disease, they sing about a girl infecting a boy.

Read for yourself:
Little precious has a natural obsession for temptation
But he just can’t see
She give him loving that his body can’t handle
But all he can say is, “Baby, it’s good to me”
One day he goes and takes a glimpse in the mirror
But he doesn’t recognize his own face
His health is fading and he doesn’t know why
Three letters took him to his final resting place 

Other songs about HIV/AIDS:
Madonna – In this life
Elton John – The last song
Bruce Springsteen – Streets of Philidelphia
U2 – One
Acda en de Munnink – Niemand sterft aan liefde
Janet Jackson – Together again
And many more.

That’s the history, this is how we as a species got in contact with this new virus that changed many lives forever. But stay tuned, the story continues next blog!

IMAGE: APAP PHOTO/RICK MAIMAN

 

Endemic, Epidemic, Pandemic: Semantic

Doctors have this habit of using a different vocabulary, making easy things sound very complicated. An example: ‘melena can be an indication of peptic ulceration’ actually means ‘blood out of your ass can be caused by stomach ulcers’. Why use difficult words: a. the doctor wants to sound very important and smart or b. they just don’t know the subject well enough to explain it in normal words. Or, as it said on one of the tiles on the wall at grandma’s house: ‘It takes an assbleeder to talk about assbleeders’.
Even in this blog we go over so many infections and sometimes I can get lost in the semantics. So, this time no specific infection, it’s just about how you can sound smart whilst taking about them.

Endemic

Endemic refers to a disease or condition that takes place in a specific region. For instance, Malaria is endemic in sub Saharan Africa but is not endemic in Europe. At least, not any more. Some diseases become endemic in new places all the time, the flu for example or the common cold. Other endemic conditions don’t move unfortunately: like the scraping throats and spitting on the floor at 5AM at our neighbor’s place in Thailand. Endemic as such is in short not something to be really scared about, especially when you take precautions (anti-malaria pills, flu-shot, earplugs)

Epidemic/Outbreak

Turning it up a notch. Epidemic means that in a period of time, more cases than expected in a community/area/season are suffering from the same condition or are infected with a specific disease. Scary stuff right. For instance, the epidemic of Ebola in 2014. Or obesity in America. By the way, a different word for epidemic is ‘Outbreak’. Remember that movie with Dustin Hoffman? That sweet little monkey – a real one, not mr. Hoffman – that turned out to be a real badass decease carrier? Outbreak = epidemic. Choose whatever sounds more spectacular.

Pandemic

Now the real trouble is when an Epidemic becomes a Pandemic, in which case the infection has spread worldwide. We’ve seen this, for instance, in the H1N1 time. More notorious examples are the Black Death pandemic (1346-1353: up to 200 Million deaths), the (Spanish) Flu pandemic (1918 – up to 50 Million deaths) and the HIV/AIDS Pandemic (peak 2005-2012 – 36 Million deaths)

Another movie example, watch ‘Contagion’ and you’ll understand what I’m talking about (really nice movie actually with Matt Damon and Jude Law… need I say more?). Storyline summary: ‘As the contagion spreads to millions of people worldwide, societal order begins to break down as people panic.’ Panic! If you do, you know you’re experiencing a Pandemic… Other movie must sees in this genre are Twelve monkeys (not about twelve monkeys) and World War Z.

Epidemiology

All these terms are very important for people that study diseases, epidemiologists. You might need some practice to master that word. I followed a masters in epidemiology and my husband still can’t pronounce it different than “epidedemology”, or something like that. Anyway, an epidemiologist studies how a disease behaves, spreads, etc. It is not that I am wearing a T-Shirt that says “I Love Pandemics”, … but that is only because I didn’t find it yet…

There you have it, some new words to drop in any conversation when you’re ordering beers at a bar and try to impress someone. Choose your words wisely though, nobody wants to know about the Endemics in your pants, the Epidemic fail you had at work or the Pandemic boxes you want to open…