Managing the Invisible Virus Pandemic – learnings from the world

This article looks at the spread of COVID-19 and how some countries are struggling with and combatting the disease. It provides some general advice on how persons and countries can combat this disease.

Disease Data

The SARS-COV-2 virus can kill by (sudden) Acute Respiratory Syndrome or pneumonia. That is: the virus clogs up so many of the alveoli [1] of the lungs that blood becomes so hypoxic [2] that organs fail and life ceases. Fortunately, about 80% of people who get this disease will get a mild form of it and will recover without medical intervention. Probably about 5% to 10% will require hospitalisation and most of them will recover although the recovery for the severely affected elderly could take the rest of their life.

There is little evidence of the virus contaminating a patient’s blood stream, but a small number of deaths have been attributed to viral myocarditis. This means the virus has contaminated the pericardium and then the heart muscles. To contaminate the pericardium and myocardium suggests, to the author, that it may have got into the blood stream of those patients.

How it is Spread

Epidemiologists have confirmed the virus can be spread by some form of aerosolisation. This means that it is not just spread like flu by exhumed droplets on surfaces (and being picked up by hands and transferred to mucus membranes – eyes, nose, mouth) but by small clumps, possibly being bound up in very small droplets, being spread through the air after being shed from the lungs in normal breathing of an infected person. In a closed environment, such as a bus, researchers in China discovered an infected person could pass on the infection to a person 4.5 metres away if they were not wearing a mask. Furthermore, a study published in mid-March indicated it remained aerosolised for at least three hours [3] . Even after an infected person’s immune system has beaten the virus and the person is effectively cured, their lungs will still shed this virus for up to two more weeks. So, doctors tell patients to remain isolated for a further two weeks after they have become well. It can also be spread through faeces. So possibly even the flushing away of faeces of an infected person may cause some virus particles to become airborne and infect the next person using that toilet or adjacent toilets in that toilet block. It would therefore be spread very easily in “hole-in-the -ground” toilets that are used in China, other Asian and some Muslim countries. The faecal contamination arises through the virus contaminating the gastro-intestinal tract via the nose and throat and surviving the passage through the stomach.

The Spread of COVID-19

The experience of the passengers on the Diamond Princess was interesting and very distressing. The Diamond Princess was put effectively into quarantine in Yokohama because one passenger tested positive to the virus after getting off at Hong Kong. At that time the virus was not known to have become aerosolised. But that became obvious as more and more passengers got sick. As of 20 March (after four weeks of quarantine and more than three weeks since leaving the ship) 712 tested positive out of the 3,711 passengers and crew quarantined in their own cabins from 4 February for about a month. There have been seven deaths.  Most passengers have been transferred to their home countries and some first showed symptoms of the disease after arriving in their own country. So, at least 712 cases arose from just one infected person!

Another experience worth noting is the spread of the virus in South Korea (at 23 March, there have been 8,961 persons infected with 111 deaths and just over 1% of active cases being critical, that is in ICU). It is thought that one of the main sources of infection was a single infected person at a religious conference in Daegu and was then spread to other cities by the participants of that conference. In early March the virus was spreading faster in South Korea than any other country (although that may have been because the numbers there were more accurate than anywhere else due to vigorous testing).  Since 20 March its total cases have been growing daily by only about 1% so the infection rate has clearly peaked. This was because very strict community isolation measures were adopted very early in South Korea and they tested extra-ordinary numbers of their citizens. Community isolation measures were controlled by the Korean government monitoring at risk people through their mobile phones, a measure also adopted by Israel and Taiwan.

It is likely that North Korea will have many more times the number of infected people than South Korea (because of the porosity of its border with China). Vietnam and Thailand have the same problem.

There is major concern about the course of the infection throughout South East Asia.  At 23 March, the following are the reported cases, new cases that day and deaths to date.  In most of these countries these numbers (marked with an “X”) will be a fraction of the true numbers. 

There is a major outbreak in Iran (at 23 March, 23,049 cases with 1,812 deaths and a daily case growth rate of 22.7%). This appears to have originated in religious capital Qom. Iran does not appear to have enough reliable testing kits or medical care to cope with the outbreak. None of their cases are recorded as critical. It has already spread from Iran to many other middle eastern countries, as many travel to Qom. Many countries in the Middle East do not have the facilities to cope with this virus. Although the Saudis have closed Mecca, it was not until 15 March that Iran closed places of worship in Qom. Many Muslims who visit these places kiss the shrines and place their hands over surfaces as part of blessings. Such actions increase the spread of the virus

Because of China’s Belt and Road initiative there has been continual traffic between many African countries and China, so it is highly likely that the virus has taken hold in those countries.  But the extent of any real infection is relatively unknown and will remain that way for some time as these countries lack the type of health facilities needed to cope with the spread of this virus. Add to that some African countries have latent HIV, multi-drug resistant TB, occasional outbreaks of Ebola and Lassa haemorrhagic fever and large sections of African populations live in relatively unhygienic conditions. This virus will almost certainly kill many in African countries, which will then become repositories of this virus and eventually provide conditions for mutant strains of it to arise.

Italy has the largest outbreak outside China. According to WHO, at 23 March, Italy had the 2nd highest outbreak in the world with 63,927 cases – 50,418 active and 6,077 deaths. Although, the real numbers may be much higher than this as many cases in, for example, aged care facilities, coronavirus cases and deaths are not being reported and autopsies are not being performed. Of the active cases 6.4% are critical (in intensive care). The daily growth in cases is phenomenal at 23.1% (since case 100) but it is slowing down. In the last week the daily growth rate has been 3.6% but these are still big numbers when total cases are over 60,000. This outbreak resulted firstly in Northern Italian towns housing some 50,000 people being closed and conferences cancelled but as the numbers grew much higher all of Italy was closed down. Other countries in Europe and in the US are also currently experiencing exponential growth in cases and, unfortunately, in deaths.

It has been reported that Japan has only 1,128 cases, 42 deaths and apparently a low daily growth rate of less than 5%. However, it is believed that there is not enough testing necessary to pick up virus carriers.  Japan closed most schools but has not imposed strict social isolation rules. However, generally most Japanese people are impeccably clean, incredibly polite and thoughtful of each other. So, like many other Asian countries people wear masks if they consider they have any kind of upper respiratory infection. This may be the real reason for the low numbers.

Problems with the Invisible Virus

• According to WHO this virus has an incubation period of 2-14 days (WHO av. 5.2 days but other calculations put it as high as 12.5 days) but with outliers of 0-27 days. This wouldn’t be so bad if during the incubation stage the infected person was not infectious. However, with this virus the infected person will be infectious for almost the whole of the incubation period during the symptomatic period and for a week or two after symptoms have disappeared. This makes this virus incredibly insidious.
• Once an infected person becomes sick, it seems around 5% to 10%, will require hospital treatment but both the hospitalised and the non-hospitalised must be isolated otherwise they will continue to infect others. Once people are sick, their immune systems seem to take 2-4 weeks to counteract the virus during which time they remain infectious. Of those needing hospital treatment it seems that something like half will need oxygen and perhaps half of those people will eventually need intensive care. These proportions will be much higher for older people and people with co-morbidities – particularly diabetes and hypertension. Some doctors have recently suggested that older people who have survived a severe form of the disease may take up to 15 years to fully recover.
• Hospital doctors and nurses are not the only health care workers highly vulnerable to this virus. General Practitioners are highly vulnerable because sick infected people will go to them first. Dentists are also very susceptible to infection because of their close contact with their patient’s breath and saliva. Physiotherapists, massage therapists, chiropractors and osteopaths also work so close to people that they will become prone to becoming infected if a patient was infected.
• To slow the spread of this virus, Australian authorities are relying on border controls, people self-isolating and being calm and sensible. This is a tall order when Australian shops are already being stripped of essential supplies such as toilet paper, rice, pasta, paper towels and tissues as well as frozen meat and vegetables. Freezers are now unavailable as large numbers have been bought to store frozen food. Yet never has the government suggested that supermarkets will be closed, or people locked down to the extent that they can’t buy food and essentials.
• Because of their close contact with infected people and the stress that will be put on them, hospital staff are also more likely to be infected than other people. This will also put additional stress on the hospital system. Once a hospital system becomes completely stressed then difficult decisions will have to be made as to whom will get any treatment that may be currently available. Retirement villages, hostels and nursing homes will have similar issues. Although these institutions already have some isolation measures in place, they will eventually have to be totally isolated either to protect their residents/patients and to protect the visitors when cases are present.

How to Personally Prevent the Virus

• Wash your hands as often as possible and always if you are in a public place. Carry alcohol rub for use when soap and water are not available. When you wash your hands also wash your germ infected smart phone. While you are at it what about giving your computer keyboard and mouse a good clean. The virus can be just as easily transferred to your mucous membranes by your phone as by your hands and if your hands were infected, they can easily be reinfected if contact is resumed with what they were previously touching before you washed them.
• Wear a face mask – if only to stop you from touching your face.
• Remove all your facial hair (except eyebrows and eyelashes). The virus accumulates on facial hair.
• Avoid places where lots of people are in close contact: trains, buses, planes, ships, conferences, places of worship, gyms, discos, etc.
• Boost your immune system by eating plenty of fresh fruit and vegetables, having lots of exercise and making sure you have good vitamin D levels (or take 2000-4000 units of D3 a day as a supplement).
• Stay calm, don’t panic and don’t buy more supplies than you need for a week or so.

What may be able to control the Virus

• Schools – If kids are to be kept at school, like in Singapore, then they should be wearing masks (peer pressure is needed here). Teachers should always wear masks. All kids should have their temperature taken before they enter the school grounds. Kids with any symptoms must be either sent home or enter quarantine at school.
• Universities – The same as schools. All persons entering a university campus should be required to wear a mask in public and have their temperature checked.
• Social Isolation – We are seeing the government ramp up social distancing measures and closures of more service businesses. It may be wise to consider importing the measures using mobile phones from Israel, South Korea or Taiwan and impose fines on people required to self-isolate. The alternative is to lock the whole country down with significant consequences for the economy.
• Shops and Shopping Malls – No entry should be allowed without the person wearing a mask and having a normal temperature.

Conclusion

Singapore, China, Taiwan, South Korea and Hong Kong have shown the world how to control this virus. We are now encouraging social distancing and self isolation measures nationally. Australia has a choice. Let’s hope it makes the right one!

[1] Alveoli are an important part of the respiratory system whose function it is to exchange oxygen and carbon dioxide molecules to and from the bloodstream. These tiny, balloon-shaped air sacs sit at the very end of the respiratory tree and are arranged in clusters throughout the lungs.

[2] Hypoxic: inadequate levels of oxygen in the tissues and cells of the body

[3] Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1, Neeltje van Doremalen, Ph.D. et. Al, New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMc2004973