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News : Coronavirus

UPDATED MEDICAL INFORMATION AND AMENDED RECOMMENDATIONS REGARDING CORONAVIRUS EPIDEMIC

Published July 16th, 2020

The current bulletin will be updated regularly until the situation stabilizes. Find more articles about COVID19 in our blog.

Where is information sourced from:  the most reputable international sources (WHO, Chinese CDC, CDC, international media, medical journals etc …) and government websites.

 

Overview / Historic reminder

In December 2019 a cluster of an apparently new kind of viral infection was first recognized in a Wuhan market, initially transmitted from animals (most probably a bat according to the WHO’s April 23rd report) to man but man to man transmission quickly developed with a rapid deterioration into a local epidemic in Hubei province. While there have been allegations that the virus could originate from a research laboratory, there is no objective evidence in this regard. The unfortunate coincidence with the Chinese New Year and a large number of Chinese people travelling both in country and abroad contributed to the rapid spread of this novel virus. The outbreak deteriorated in China in mid-January and forced the Chinese authorities to take stringent measures to confine the people and reduce transport, first in Wuhan and Hubei province and then in the whole country. Exported cases started to be reported at the end of the month in countries such as South Korea and Japan, and individual cases, initially often of Chinese origin or having travelled to China, were notified in several countries. The situation evolved rapidly, and restrictions in air travel began to be imposed. On January 30th the WHO declared a Public Health Emergency of International concern. On February 11th 2020 to be coherent with international virus and disease naming rules the International Committee on the Taxonomy of Viruses renamed the virus SARS-CoV-2 and the WHO named the disease COVID-19. In late February and early March new major outbreaks occurred in Iran and Italy, seeing a huge growth in the epidemic, which was now affecting over one hundred countries and territories. The WHO declared a PANDEMIC on March 11th. At that time, and as the situation in China was starting to improve, many countries in Europe introduced lockdown measures starting by Italy, extending rapidly in Western Europe and on most continents including countries like India or more recently in the USA, South America and Africa. In recent weeks the USA have remained a major area of growth of the numbers of affected people and deaths, with Russia and  South America, mainly Brazil and now Peru, recently becoming a very serious concern, while eastern Asia first and now Western Europe are starting gradual deconfinement and resuming activities, while maintaining precautions in place.  Local small outbreaks after deconfinement are useful warnings that all protection measures are still very important to follow. So far there have not been any reports of significant recurrences after deconfinement was initiated but authorities are carefully monitoring numbers, and lots of local outbreaks have been documented. The general director of WHO’s Eastern Mediterranean region, which includes Western Asia made a stern warning on June 10th about the worsening situation in his region. The  number of cases has grown very steeply in the last three weeks to 670000 along with 15000 deaths in the region then. Pakistan, Iran and Saudi Arabia alone accounted for more than 50% of the regional cases and the director insisted on the necessity to maintain social distancing and other preventive measures. Dr.Tedros, the head of the WHO, earlier this week warned again about not being overly optimistic, especially in countries in Asia and Europe who are beginning to further loosen restrictions. The pandemic is still accelerating. Half of the over 11 million total cases have occurred in the Americas, a quarter of the world cases are in the USA, which reported their highest number of new cases, over 53 thousand late last week, by far not only a reflection of the number of tests, but of the high level of transmission. WHO Director General Dr. Tedros has emphasized on July 2nd “the importance of focusing on a comprehensive approach to respond to the pandemic, not testing alone, not physical distancing alone, not contact tracing alone, or no masks alone, but doing all of those”. On July 9th he announced that an independent commission led by Ms. Clark, former prime minister of New Zealand and Ms. Sirleaf, former president of Liberia, would examine the performance of the WHO in responding to the COVID-19 crisis.

Clinical picture

The disease is highly contagious although it appears  that it may be less severe than other coronavirus diseases such as SARS or MERS at this stage.  Lockdown measures have been shown to reduce contagiousness: a French study showed that it reduced the reproductive number (the number of people infected by each case) from 3.3 to 0.5 (84% reduction). The proportion of severe cases has stabilized at around 15% of the total number of cases. Deaths, at around 4% to 5 % overall, and with wide variation between high (UK, France, Italy, Spain) and low (Germany, Austria, South Korea, Japan), occur mostly in older people above 70 years, and at a higher risk with underlying diseases such as diabetes, chronic pulmonary diseases and cardiovascular diseases. On May 10th, The WHO reported a possible increase of the risk of worsened outcome in patients ACE (angiotensin converting enzyme) inhibitors. The WHO also reported on May 27th that outcomes in smokers could be worse than in non-smokers, contrarily to what had been initially thought by some. The signs and symptoms to watch for are first of all contact with a proven or potential case or environment, then respiratory symptoms like cough and shortness of breath, and feeling sick, with often head and muscle aches. Fever is very often but not always present. The WHO is stating that cases are the most infectious in the first three days of the symptoms. A significant incidence of anosmia (loss of smelling sensation) is also reported. The incubation period usually lasts 3 to 7 days, rare cases are transmitted from symptom free patients, and the maximum is currently thought to be 14 days although there may be cases exceeding this length. In cases requiring admission to the intensive care unit for assisted ventilation, and often for ECMO (extra-corporeal membrane oxygenation), the duration of stay is usually long , between two and three weeks (sometimes even more), and is followed by a need for rehabilitation.  Some people retain chronic symptoms. During the unlocking phase protection measures must be in place. The WHO has published guidelines regarding unlocking , and in particular on re-opening of schools May 13TH and the need for a balance between protection against COVID and attention to potential social and educational losses.

Key protection measures

The key preventive measures are targeted towards avoidance of contact with potential sources of contamination, hygiene and strictly restricting diagnosis and treatment to facilities designated by the authorities.  The key measures are to decrease contacts, therefore travel has decreased over 90% and countries have introduced lockdowns that lasted or should last at least two months in most cases. Maintaining social distancing – especially during the unlocking phase – and isolation at home are key measures to reduce contagion. In addition, hand washing, disinfection and wearing masks for care and service providers, as well as for the public when in contact with others, are the key. Wearing masks in public places and good availability of testing have been associated to better resistance to the spread and impact of the epidemic. The same is true of the rapid identification and isolation and care of contacts.

Treatment

Access to regular treatment of usual diseases is limited and a lot of elective interventions have been cancelled during lockdowns. There is also a concern regarding the decrease in accessibility to regular vaccination programs, which enhances threats such as for instance measles. This may have been a source of increased morbidity and mortality. If someone feels symptoms possibly related to COVID-19 they should use the local public designated numbers. Access to testing is currently variable between countries, with some restricting the tests to public institutions, some to PR only and others more liberal and showing an opening to serology testing as well. Serological tests enabling the detection of antibodies are now being added and will help to determine immunity status. Access to tests and masks is increasing after initial shortages. Similarly several scientific studies are underway to investigate the objective value of several treatment modalities such as antiviral drugs, or hydroxychloroquine. So far there is no clear evidence that any treatment works well enough to be recommended as a standard. The only exception is cortisone in the very acute phase, which has been supported this week by the WHO on the basis of mainly British evidence. Similarly many groups are conducting research on vaccines, and a few early successes have been mentioned. This said no vaccine should be available before the very end of this year at the earliest. Obviously due to the huge decrease of flight availability not only tourists and expatriates have trouble returning home, but also providing a challenging environment for assistance. Exceptional evacuation of even COVID cases from isolated places or overwhelmed regions happens occasionally using air ambulances. Several companies offer specialized transport units, but clearly such evacuations are very complex to organize and expensive. Of course, sadly, the repatriation of mortal remains has also been a complicated task. The cases admitted to hospital can normally be offered especially oxygen supplementation and tight surveillance but many have to be admitted to intensive care. The duration of the stay as already mentioned is up to two or three  weeks with heavy physical and psychological rehabilitation needs.

Current global situation

At this stage the latest modified data available, most as of 15H00 July 15th Beijing time, from the Chinese CDC and from the WHO, July 14th 2020, 10H00 CEST, a total of 13464779 cases and 576739 deaths have been identified worldwide, a continued marked increase that shows that the problem remains a pandemic and is currently still quite acute in the United States, now mostly in southern states, which accounts for almost a third of all cases in the world but is active on all continents and especially worrying in South America and the Middle East today. As warned earlier the pandemic is still accelerating worldwide and our full attention is required. China is now mainly concerned about imported cases especially along its north-eastern border at this stage and has stopped allowing foreigners to enter the country. The beginning of a post crisis situation is also noticed in Korea and some European countries, notably Austria. A “high plateau” situation followed by a steady decrease of cases is currently observed in western Europe including Italy, France and Spain. Several countries in Asia and Western Europe have initiated gradual deconfinement measures. As mentioned earlier local clusters even in highly performing countries like South Korea or Germany serve as a reminder that a high level of caution is still required.  At the same time South America and the Middle East are hit hard. In Africa, which had been quiet so far, a 25% increase was documented in the last week. Some fear that the start of the fall in the southern hemisphere will be detrimental.

 

Europe

Italy, with 243344 cases and  34984 deaths, Spain (303699 and 28409), France (172377 and 30029), Germany (200766 and 9144), the UK (291373 and 44968) and now Russia (739947 and 11614) have high numbers which have challenged the capability of the overwhelmed health care delivery systems in many areas before the current improvement. Unfortunately, many senior homes have in particular become clusters for death cases in many countries.

Asia (without China)

Although it was hit early, right after China, which has reported 85677 cases and 4649 deaths, Asia has resisted quite well with the early exception of Iran, which accounts for 262173 cases and 13211 deaths and a bit of a worrying growth in Turkey (214983 cases and 5402 deaths). Israel has a high number of cases, 42360, given its small size but a remarkably low number of deaths, 371. South Korea has a comparatively low number of cases, 13512, very few of them recent except for a very recent small cluster, but few deaths (289) as has Japan (22583 and 984). This is probably due to the strong health infrastructure response and access to easy screening as in Japan and SE Asia. India has been hit much harder recently. It has 937844 cases and 24327 deaths.

 

The Americas

The Americas overall have more than half the worldwide cases and deaths. The USA is the country with the most cases, 3545077 as well as the most deaths 139143, and the government has acknowledged the extent of the challenge and began to restrict travel into the country, with week March 16 seeing the introduction of a travel ban to a number of European countries that has lasted since. California was the first state to introduce a lockdown, followed by others including New York, which was the hardest hit state in the country but is now under control. Florida is currently hit hard as are Texas and California. Some states are already loosening their lockdown despite high numbers and deaths every day. The numbers in South America are uneven but Brazil (1931204 cases and 74262 deaths), Peru (333867 cases and 12229 deaths), and Chile (319493 cases and 7069 deaths) have high numbers, and Mexico is growing as well, with 311486 cases and 36327 deaths. 

Africa

Africa still has a relatively low but growing number of cases and is doing its best together with international partners and NGO’s  to prepare as the impact could be severe given the relatively weak public health infrastructures. The 25 % increase in the overall number of cases for the continent in the last week is a source of concern. So far South Africa is reporting the highest figures (298292 cases and 2844 deaths). The continent as a whole has 49313 cases.

GENERAL RECOMMENDATIONS

1. First and foremost realize that this pandemic is a worldwide phenomenon and the more all of us take it seriously the lesser the health, sociological and economical impact. Worldwide the problem is still growing.

2. Avoid any contact with patients with COVID-19, and more generally with patients with cough and fever. When contact is required for help, protection by distance and if available masks and gloves is important.

3. Follow the usual hygiene precautions as a priority considering that regular handwashing, disinfection and adequate use of mask wearing, especially in public transport and crowded places, are part of these essential hygienic attitudes.

The use of masks in public places and especially public transport is more and more an approach countries favour with now scientific support.

4. Accept  the need for a worldwide push to reduce social interaction between people including long distance transportation to reduce contamination. From the corporate and company standpoint maximization of work at home is the key action when feasible.

5. Accept the drastic reduction in access to travel means when not required for functions such as international health programs.

6. Plan to maintain the current restrictions at least partially over time and take home the lessons learned regarding contagious disease prevention for the future

7. Support your local health care system and facilities helping fragile people such as the old people homes.

8. Maintain communications with colleagues, friends and families to reduce the risk of depressive reactions to the situation.

9. Carefully design deconfinement plans that should be gradual and supported by much increased preventive measures and carefully monitored. The use of both PCR and immunological tests to at least selected segments of the population may be an asset.