Covid-19; surrendering to the unknown – Alan Whiteside

It’s tempting to view the global Coronavirus pandemic as humanity going to war, hunkering down against a common enemy while researchers desperately try to find the silver-bullet vaccine and concoct novel therapeutics – but it’s more complex than that. Here global health policy expert Prof Alan Whiteside spreads the mitigation research net wider to blood types, genetics, the possible prophylactic effects of ART, and diet and health issues, such as BMI and hypertension. Giving us a global update, he highlights the uncertain data being generated, warning that while testing to gauge spread and locate hotspots is vital, the equipment is far too often inaccurate. Nor are the antibody tests, first touted by the UK government as being imminently available, yet accurate enough to be the promised game changer. Lockdown measures to flatten the infection curve are not just to reduce absolute numbers, but to spread them out over time so our health service can cope. South Africa’s stellar joint health command is going flat out to expand treatment capacity, educate the public (and healthcare staff), on basic hygiene protocols and the appropriate use of personal protective equipment. We don’t have the luxury of overwhelmed hospitals in Italy and Spain being able to transport patients across national borders to hospitals with capacity. Also; if you want to raise your thinking about Covid-19 to another level, read the stellar treatise called “The Coronation,” by Charles Eisenstein. – Chris Bateman 

Covid-19 watch: The complexity of data

By Professor Alan Whiteside* 

Introduction

Many of us have time on our hands at the moment. This is illustrated in unexpected ways: a clear-out resulting in a table of toys at the front of a house with a notice ‘FREE’; the distance we have walked on Sunday, an unbelievable – for me – 11 kilometres; and the recipe books being dusted off. I read a great deal normally and have just finished Erik Larson’s ‘The Splendid and the Vile: A Saga of Churchill, Family and Defiance During the Blitz’. It covers the period from Churchill’s appointment as Prime Minister on 10th May 1940, when Nazi forces over-ran Europe, to the end of 1941.[2] There are similarities between that period and where we are now: a sense of dread, a formidable and heartless enemy, and the need for good science and unity. This is not, as many journalists have implied: ‘the blitz spirit’, which has been parodied, most notably in Private Eye.[3] It is rather a sense of helplessness.

The Numbers

As of 8 am on 8th April 2020 the Johns Hopkins University of Medicine Coronavirus Resource Centre (JHUM) website recorded 1,431,357 infections globally.[4] I urge readers to look at the website. The country leading the count is the United States with an astonishing 399,886 cases. See below.

Table 1: Global and National Numbers of Covid-19 (alphabetical order)

DateGlobal casesChinaFranceItalySouth KoreaSouth AfricaSpainUnited KingdomUnited States
15th Feb69,00068,4001232802943
4th Mar93,00080,4802883,1005,600022286149
11th Mar120,00080,9002,30012,5007,800132,3004591,300
18th Mar201,50081,1009,10035,7008,40011613,9002,6007,800
25th Mar423,00081,70025,60074,4009,10070949,5009,60065,800
1st April861,00082,40057,000110,6009,9001,400104,10029,900213,400
8th April1,431,35782,783110,070135,58610,3841,749141,94255,949399,886

There are three main geographic centres. First, China and its neighbours; second, Western Europe and finally, so far, the United States. It must be remembered numbers are political. The JHUM interactive website gives three global numbers: total confirmed infections; total deaths; and total recovered. There is a graph with three tabs showing data from 22nd January 2020. The tab options are confirmed cases in absolute numbers; confirmed cases on a logarithmic scale; and daily increase. In addition to global data there are national, and some subnational level data. The USA is most detailed, data is given to county level.

The site and a Lancet article describes how the data are collected.[5] The website is a remarkable public domain resource. It allows us to measure the water level, with incredible precision, as the Titanic slips slowly below the surface. But is it accurate? I am going to digress briefly on statistics. In 1907 Mark Twain attributed the quote “There are three kinds of lies: lies, damned lies, and statistics” to British prime minister Benjamin Disraeli.[6] As a naïve economist[7] I believed data presented by officials and in national data sets. One day, in the 1980s, I was reviewing the Government of Lesotho ‘Annual Statistical Bulletin’ and learnt there were 12,350,186 chickens in Lesotho.[8] I have been wary since.

There are four possible statuses for infected people. All infections are believed to begin with a period when people show no symptoms (on average 5 days), but are contagious – able to pass the infection on. Therefore, lockdowns and social distancing are crucial in halting the epidemic. It is estimated about 30 percent of those infected with Covid-19 experience no symptoms but can pass the disease on for an estimated two weeks. They should experience some level of immunity for an, as yet, undetermined period. The bulk of those infected, 55 percent, will experience mild to moderate symptoms, followed by immunity. They are likely to be contagious for longer than asymptomatic people.

Severe symptoms are found in 10 percent of infections, who will require hospitalisation and oxygen. Critical symptoms are found in five percent of those infected. These individuals will require hospitalisation and ventilation in intensive care units. The case fatality rate varies from about 0.5 percent to about four percent. The infectiousness of a person will increase the more unwell they are.

We don’t know how many people have no or only mild symptoms, so are not recorded as having had Covid-19. That means epidemiologists do not know how big the at-risk population is. We know neither how big the numerator or the denominator is. It has been suggested that because humans have no experience of this virus, in the absence of interventions, 80 percent of people (presumably adults) could be infected over time. Further complications arise due to testing policies. Some, like the UK, have a policy of only testing once symptoms become severe. This means that the number of infections will be more grossly under-represented than in countries providing tests to people with mild symptoms, or where there is very aggressive contact tracing and testing of asymptomatic contacts.

The website www.ourworldindata.org gives useful definitions. ‘A confirmed case is “a person with laboratory confirmation of COVID-19 infection” as World Health Organization (WHO) explains. But specifics can differ and the European CDC, on which we rely, reports confirmed cases according to the applied case definition in the countries.’[9] What is important however is the number of confirmed cases is certainly not the same as the total number of cases. Confirmed cases are usually only those where a laboratory has confirmed the diagnosis.

The emphasis on flattening the curve is not to reduce the absolute number of infections (although that would be good), but spread them out so the health service can cope. This is why an antibody test to check for immunity would be a “game changer”, it would show how many people have been infected and recovered, especially in the ‘no symptoms’ and ‘mild to moderate’ categories. Last week I wrote ‘it seems that the launch of such an antibody test is imminent’. The Telegraph reported on 1st April: “The Government has announced that Britons will be able to conduct coronavirus antibody tests at home, with finger-prick kits that will be available from Amazon and Boots.” [10]  The British government has dialled back their promises, largely (and correctly) because the tests are not sufficiently accurate. The tests are on order but won’t be paid for or accepted until they are accurate.

The JHUM site gives the numbers of deaths and recoveries. In the footnote to the website it is stated: ‘Confirmed cases include presumptive positive cases. Recovered cases outside China are estimates based on local media reports and may be substantially lower than the true number. Active cases = total confirmed – total recovered – total deaths.’[11] The number recovered is calculated as those who have not died, but are no longer active cases. It is not clear how the number of deaths is established.

The data for the UK can be used to illustrate this. On 7th April 2020 there were 52,279 confirmed cases; 5,385 deaths and 287 people had recovered. Cases are those confirmed by an antigen test. Death figures need to be interpreted: “The figures on deaths relate, in almost all cases to patients who have died in hospital and who have tested positive for COVID-19 … The figures are compiled from validated data provided by NHS England …, Health Protection Scotland, Public Health Wales and the Public Health Agency (Northern Ireland). … These figures do not include deaths outside hospital, such as those in care homes, … The data includes confirmed cases reported as at 5pm the previous day. The amount of time between occurrence of death and reporting … could be a few days, so figures at 5pm may not include all deaths for that day.”[12]

The Evening Express in Scotland reported on 4th April: “A total of 13 people at the Burlington Court care home in the east end of Glasgow have died in the past seven days. None of the patients were tested for Covid-19 as they were not admitted to hospital but their families have been informed of a possible association with the virus. … the residents who died had underlying health conditions.”[13] These will not be ‘officially’ recorded as Covid-19 deaths. These data issues are repeated around the world, especially in under-resourced areas.

 Asia

China’s data indicates it has contained Covid-19. When my first communique was published on 4th March there were 80,270 cases, four weeks later there were barely 2,000 more. On 7th April, China reported 24-hours with no deaths. Do we believe this? According to BBC’s correspondent Stephen McDonell: “The first day with zero new reported coronavirus deaths since the National Health Commission started publishing daily figures is no doubt a cause for hope in China and even across the world. In a way it doesn’t matter if the figure is real. There has been much debate about the veracity of this country’s coronavirus statistics but, even if the overall number of infections and deaths is under-reported, the trend seems instructive. Why? Because the trend matches reality in so many ways.”[14] A critical independent analysis of the Chinese data would be valuable. Can they be replicated?

Initially, South Korea was the second worst affected country. It currently has just 9,887 cases, a small increase on last week’s 9,037 reported cases. It seems the epidemic is mostly under control in east Asia. Elsewhere numbers are increasing. India reported just 511 cases on 25th March, on 1st April 1,590 and 8th April 5,356. The government imposed a lockdown with just four hours’ notice. Millions of impoverished, now unemployed, urban dwellers exited cities trying to get to rural homes, some walking huge distances.[15]  India is facing not only a Covid-19 crisis but also a humanitarian one.

Europe

The situation in Europe remains dire. Spain, Italy, France and Germany each have over 100,000 cases. There is a difference in death rates: Spain had 14,045 deaths; Italy 17,127; France 10,343; Germany just 2,016. The UK had 55,949 cases and 6,171 deaths. Hospitals in Italy and Spain are overwhelmed, and patients are being transported across national borders to hospitals with capacity. Temporary hospitals are being erected in repurposed buildings such as exhibition centres and sports halls. In London, the ExCel centre was turned into Nightingale Hospital. It opened on 8rd April with 500 beds initially, but potential to expand to 4,000 patients.[16] [17] Similar initiatives are underway in other UK locations. Staffing needs are huge and retired staff are being urged to re-join the National Health Service. The care sector that looks after so many elderly vulnerable people is being neglected.

There are almost uniform, stringent lockdowns in place. The only shops open are pharmacies and food shops. All entertainment venues are shut. There was talk in the UK of ending the one hour per day, government permitted, walk and preventing people leaving their homes completely. Fortunately, this idea was quashed. I believe it would have led to social unrest. Thus far the British have been compliant and docile. In theory the three-week shutdown ends on 13th April.

The Guardian noted: ‘Gracie Bradley, policy and campaigns manager at the human rights organisation Liberty, said this week: “There have been amazing community responses to this pandemic, and people have shown they are willing to change the way they live – but that goodwill, and the broader aim of protecting public health, will be undermined by harsh and heavy-handed policing.”’[18] There must be a plan to end the restrictions, not just in the UK, but everywhere they have been imposed.

Africa

The low numbers continue to surprise. The epidemic has spread with only Lesotho not reporting cases. The most cases are in South Africa with 1,686, followed Algeria with 1,423. Nigeria reports 238. Possible reasons for low numbers are:

  • The continent and countries are lagging in the spread of the epidemic and case development. It is less connected to the outside world, and possibly has more spatial separation between privileged, travelling communities and poorer ones.
  • Failure to find, test and report cases, due to weak health systems, inadequate surveillance, laboratory capacity and public health infrastructure. There may be imported international epidemics, while the broader communal one is lagging and growing invisibly.
  • Climatic conditions may be less conducive to the spread of Covid-19.[19]
  • The possibility that the Bacillus Calmette–Guérin (BCG) tuberculosis vaccine provides protection. Interestingly a pre-Covid-19 peer reviewed paper suggested BCG had protective effects against non-related infections.[20] This may be significant for responding to Covid-19.[21]

South Africa is one of very few countries that seems to have flattened its curve, beginning after its President Ramaphosa enforced a tight national lockdown. Whether this will be maintained both during and after the lockdown and once it is relaxed has yet to be seen. A South African data source has been developed by a consortium including Wits, the NRF, iThemba Labs and Data Convergence.[22]

All reasons why some areas seem less impacted by Covid-19 than others must be explored. The AIDS epidemic taught the need to think laterally. Jack and Pat Caldwell, Australian demographers, were the first to report on the apparent protective nature of male circumcision against HIV acquisition. Initially this was greeted with scepticism. We now know it provides a 66 percent protection for men and is included in the armamentarium of HIV interventions.[23] Potential areas for Covid consideration include blood type, genetics, possible prophylactic effects of ART, diet and health issues, such as BMI and hypertension.

The Americas

South and Central America have reported low numbers. Brazil leads with 12,232 up from 5,812 cases on 1st April, followed Chile at 4,815 (2,738) and Ecuador at 3,747 (2,302).  Canada had 16,667 cases on 7th April (8,591 on 1st April) Mexico 2,439 (1,295). This is a doubling time of about a week. On 18th March the US Canadian border was closed to non-essential travel.

The US numbers are astonishing. It is first in global rankings with 399,886 cases (189,633 on 1st April and 46,805 on 25th March). The JHUM drills down to county level and the rash of red dots is frightening. New York is the hardest hit state. I am going to invite a colleague to write specifically on the epidemic in the US for next week. The response has been uneven and at the federal level it has left much to be desired. Some press conferences can generously be described as ‘a gong show’. “President Donald Trump’s contempt for science and disdain for experts who question his political narratives are driving his increasingly defensive and brittle management of the coronavirus pandemic.”[24] The President seems to still be pushing hydroxychloroquine as a potential drug for Covid-19.

Questions

Immunity

With normal seasonal flu, even a new strain, most people have some immunity, so most symptoms are relatively mild. No one has any level of immunity to Covid-19 so all are susceptible. This is a key argument for the stringent public health measures (and why ‘herd immunity’ can only be aspirational for the future). None-the-less some are less vulnerable than others, women, younger people and especially children have lower infection rates. There is no reason not to have the flu inoculation and indeed it is recommended for all those at risk of flu, to ensure people and health systems are more robust in the event of ongoing corona infections.

For people living with HIV the advice remains the same: begin taking or adhere to anti-retroviral medication. The links and interactions between Covid-19 and TB need further exploration.[25]

Seasonality

Many respiratory viruses are seasonal, more cases seen in winter than summer: lower temperatures and lower humidity facilitate transmission. Covid-19 entered China and the northern hemisphere in winter. At this point it is not clear if it will act like a seasonal virus. There are cases occurring in the southern hemisphere summer so there is much to learn as we track the disease. If it is seasonal there may be an uptick after October in the north and an increase in the South from June.

Face masks

There has been a major revision of advice in the past week. There was debate about use of face masks outside clinical settings. The South African Western Cape Department of Health policy guideline is that wider use of masks is indicated even for people who are not ill, especially in the public. The guidelines note ‘a mask is not a solve-all solution in the fight of Covid-19 and should never be used in isolation of basic good hygiene considerations’. Hand washing, distancing and quarantine remain critical. Given the shortage of medical masks cloth masks can be used. If appropriately used, and cleaned, they offer protection especially in crowded conditions and on public transport.[26]

Treatments and Vaccines

The control of the pandemic requires a cure and/or vaccine, there is no new information to report in this communique.

Economic Implications

The US has seen ‘off the charts job losses.’ According to Forbes on the 4th April, “The Bureau of Labor Statistics announced on Friday that the U.S. economy lost 701,000 jobs in March and that the January and February numbers were revised down by a total of 57,000. While 701,000 is a very large number, it will pale in comparison to next month’s report. … From the Bureau’s press release it stated, “It is important to keep in mind that the March survey reference period (March 8 to 14) predated many coronavirus-related business and school closures in the second half of the month.”

This means April’s employment report will contain the 3.3 million unemployment claims on March 26 (which was for the week ending March 21) and the 6.6 million claims from Thursday, April 2 (from the week ending March 28). And if 9.9 million isn’t chilling enough, the expectations are that millions more could be reported in the next few weeks.” [27]

This economic pain is not confined to the US, it is being felt everywhere. The Johannesburg stock exchange had recovered somewhat to 47,496 (7th April), but in the previous year the high was 59,544 and the low 37,177. In the UK on the same date the FTSE 500 was trading at 3,141, the peak was 4,257 on the 17th January and the low 2,727 on 23rd March. The loss of wealth across the world has been enormous. Many retirements will be postponed or more precarious than anticipated.

The people of the global south are facing unprecedented impoverishment. South Africa’s Minerals and Energy Minister Gwede Mantashe was “very concerned about industry and job losses” and “wanted to get the views of social partners about what must happen if lockdown gets extended. … suggests government is clearly thinking about a possible extension to the lockdown. But it is also seeking the views of various stakeholders, which also suggests it is weighing a number of options and opinions. … we must explore possibilities to ramp up slowly, but the industry needs to justify mining getting freedom to mobilise vs other economic sectors who will remain in lockdown.”[28]

Conclusion

As I finished this posting British Prime Minister Boris Johnson was entering his third day in the ICU at St Thomas’ hospital in London, giving rise to the first western Covid-19 political crisis. But there are countries where the epidemic is under control: China, South Korea and Japan. There are indications in the worst affected European countries that the ‘rate of increase may be slowing’. The situation in the US is ghastly. Hopefully will bring change to the way health and social care is delivered.

To end this blog, parts of East Africa are facing biblical locust swarms. These will, according to the U.N. Food and Agriculture Organization (FAO) wipe out crops in eastern Africa, leading to hunger and the possibility of starvation for more than 4 million. What does this have to do with Covid-19? Coronavirus-linked flight restrictions have delayed deliveries of pesticides and, at the current rate of spraying, stocks in Kenya will run out (within four days of the article).[29]

The lack of certainty as to when this will end, how the lockdown will be lifted and what the new normal will look like are all impossible to predict. I believe people will travel less, the risk of being stranded away from home, family and friends will be factored into decisions. I recognise I am a consumer and need to spend money in the economy. My goal will be to use more local and small businesses. I will think about supply chains and how goods are produced. This is a wakeup call for sustainability, understanding limits to growth, and for taking responsibility.

[1] Red text indicates figures or information will change. Bold text indicates a key point.

[2] Erik Larson’s ‘The Splendid and the Vile: A Saga of Churchill, Family and Defiance During the Blitz’, William Collins, London 2020, 585 pp, and thank you, reading mentor Jeff Sturchio, for this and other suggestions.

[3] Private Eye, ‘Fighting Talk’ page 12 No 1519

[4] https://coronavirus.jhu.edu/map.html

[5] https://systems.jhu.edu/research/public-health/ncov/  and Ensheng Dong, Hongru Du and Lauren Gardner ‘An interactive web-based dashboard to track COVID-19 in real time’ February 19, Lancet 2020DOI:https://doi.org/10.1016/S1473-3099(20)30120-1

[6] https://en.wikipedia.org/wiki/Lies,_damned_lies,_and_statistics

[7] Are there any other kinds?

[8] The country and chickens are true, but 64% of statistics are made up on the spot. Caveat emptor.

[9] https://ourworldindata.org/coronavirus#cases-of-covid-19

[10] https://www.telegraph.co.uk/news/2020/04/01/covid-19-coronavirus-home-test-kit-antibody-antigen/  accessed 1st April 2020. Boots is a pharmacy chain in the UK

[11]   https://coronavirus.jhu.edu/map.html

[12] https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public

[13] https://www.eveningexpress.co.uk/news/scotland/covid-19-linked-to-13-deaths-at-scottish-care-home/

[14] https://www.bbc.co.uk/news/world-asia-china-52195034

[15] https://www.bbc.co.uk/news/av/world-asia-india-52093574/coronavirus-huge-crowds-as-india-lockdown-sparks-mass-migration

[16] https://www.bbc.co.uk/news/av/uk-52039349/coronavirus-excel-centre-hospital-conversion-begins

[17] https://www.bbc.co.uk/news/health-52125059 accessed 7th April 2020

[18] https://www.theguardian.com/world/2020/apr/01/what-are-your-rights-in-lockdown-britain-coronavirus

[19] Miguel B. Araújo and Babak Naimi, ‘Spread of SARS-CoV-2 Coronavirus likely to be constrained by climate’, medRxiv preprint doi: https://doi.org/10.1101/2020.03.12.20034728.

[20] Rob J.W. Arts, Simone J.C.F.M. Moorlag, Boris Novakovic, Hendrik G. Stunnenberg, Reinout van Crevel

Mihai G. Netea et al, (2018), ‘BCG Vaccination Protects against Experimental Viral Infection in Humans through the Induction of Cytokines Associated with Trained Immunity’ Cell Host & Microbe 23, 89–100

2017 Elsevier Inc. https://doi.org/10.1016/j.chom.2017.12.010

[21] Aaron Miller, Mac Josh Reandelar, Kimberly Fasciglione, Violeta Roumenova, Yan Li, Gonzalo H Otazu, ‘Correlation between universal BCG vaccination policy and reduced morbidity and mortality for COVID-19: an epidemiological study’ medRxiv prepublication doi: https://doi.org/10.1101/2020.03.24.20042937

[22] https://datastudio.google.com/u/0/reporting/15817068-62f2-4101-8e0f-385e2ddd9326/page/wI9JB

[23] Caldwell, John C. and Pat Caldwell (1996). “The African AIDS epidemic”. Scientific American, Population Council. 274 (3): 40–46.

[24] https://edition.cnn.com/2020/04/06/politics/donald-trump-coronavirus-angry-defensive/index.html

[25] https://hub.jhu.edu/2020/03/30/andrew-pekosz-immunity-seasonality/

[26] https://www.westerncape.gov.za/department-of-health/news/covid-19-cloth-masks-public-use

[27] Trump’s Job Losses Will Exceed The Great Recession’s https://www.forbes.com/sites/chuckjones/2020/04/04/trumps-job-losses-will-exceed-the-great-recessions/

[28] https://www.dailymaverick.co.za/article/2020-04-07-599321

[29] https://www.dailymaverick.co.za/article/2020-04-03-east-africa-locust-swarms-gather-as-coronavirus-curbs-delay-pesticides

  • Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal www.alan-whiteside.com.
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