Quick and widespread testing and quarantine will help tackle the spread of COVID-19, not ultra-nationalism or hyper-capitalism.
By Prabir Purkayastha
The COVID-19 pandemic is now moving at a speed that the world had not anticipated a few weeks back. It reached its first 100,000 infected in 67 days, then doubled to 200,000 within the next 11 days, and now it has doubled again, reaching 400,000 by March 24. Europe, particularly the core European Union countries—Italy, Spain, France, and Germany—is the new epicenter of the COVID-19 epidemic. China, followed by South Korea, managed to contain their outbreaks; the European countries did not.
The USA is rapidly joining the ranks of the European countries. As its testing scope increases, a sharp increase in numbers is already visible. Only the Trump administration’s lack of testing—either intentional or due to incompetence—kept the real numbers lower.
Addressing a press conference on March 16, World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus said, “We have a simple message to all countries—test, test, test… All countries should be able to test all suspected cases. They cannot fight this pandemic blindfolded.” For countries that are in the community spread phase, extensive testing, followed by isolating those infected and rigorous contact tracing, is the only way to slow down further infections.
The problem is to identify the tipping point when a country moves from containment phase to community spread. So testing of those coming from high-risk countries, the contacts of those already infected, have to be supplemented by random testing in urban areas that already show a certain number of infections, testing cases of pneumonia in the hospitals, as well those who show COVID-19 like symptoms. It is only by casting a wide net that we can identify when a country, or a region, is moving from the containment stage to a community stage. In the community stage, the testing has to be far more extensive.
For countries such as India, the numbers are still small and could be thought of as in the containment stage. Though here again, the real numbers could be much higher, as testing has been confined to only a small section of the population. According to India’s premier medical body Indian Council of Medical Research (ICMR) guidelines, the only people who can be tested right now are those who are coming in from high-risk, COVID-19 affected countries, or those in direct contact with somebody who has already tested positive. Originally, ICMR had a pitiful number of test kits—only 100,000—though it is trying to ramp up testing capacity rapidly, importing test kits and licensing Indian manufacturers. Right now, given its existing capacity and its huge population, India’s tests per million rate is one of the lowest in the world.
In the containment phase, WHO recommends identifying and isolating the infected as early as possible. People should also impose social distancing: reduce the number of person-to-person contacts, maintain a certain distance from each other, and take other precautions such as hand washing. In this phase, we test for those coming from high-risk regions or in contact with those who have been confirmed as infected.
If containment fails, we enter the community phase, in which we do not know who is infecting whom. Then we need lockdowns and social isolation, coupled with extensive testing. This is the stage where a number of European countries, Iran and the U.S., are at now. If the number of infections cannot be controlled in this phase, they will overwhelm the health infrastructure. The consequence will be a large number of deaths, particularly among the old and those who have underlying risk factors such as asthma, heart disease and diabetes. They will need intensive care doctors, nurses, equipment for oxygen support, ventilators and machines that can oxygenate blood outside the body, and protective gear for medical personnel, which a hospital may no longer be able to provide. This is the reason for the lockdown—to slow down the spread or flatten the curve, reduce the peak, and distribute the load on the hospital systems over a longer period of time instead of overloading them all at once.
That is why a number of countries including India have entered into a period of lockdowns. Recognizing they do not have the ability to test extensively, they have decided to try to snap the transmission links. This will significantly drop the number of new infections, and give the governments and the health systems some breathing time. If they have spent the time wisely, building the capacity to test extensively, they can screen the population, identify contacts, and separate them from the general population. This is what China did in Wuhan along with lockdown, and South Korea did with extensive testing and with less-stringent lockdown to control their epidemics.
Unfortunately, once the numbers are high, simple lockdown does not work. New research co-authored by Xihong Lin, professor of biostatistics at Harvard T.H. Chan School of Public Health, along with Chinese colleagues in Wuhan has reported that it was lockdown along with centralized quarantine—separating into two groups those who were infected and those who were in contact with the infected—from the general population that brought down the infection rate. Those who tested positive were put in temporary hospitals, and those suspected were housed in dorms, hotels and other facilities, and tested regularly. This is what finally controlled the epidemic, bringing the numbers down dramatically.
If the hospitals are overwhelmed by the number of patients, as they were in Wuhan and now in Italy, the mortality rates will be much higher. In Wuhan, the case fatality ratio—the number of deaths to infected cases—was initially estimated (based largely on Wuhan figures) by WHO to be nearly 3.4 percent; it is now thought to be much lower. A recent study in Nature Medicine says that the number of people who did not show symptoms but were infected means that the case fatality ratio was closer to 1.4 percent there. The number of fatalities was significantly higher among the old, and those with other medical complications.
In Italy, Lombardy and nearby regions are seeing even worse figures. Italy’s death rates are higher perhaps because Italy has a significantly older population with more than 23 percent of its people above the age of 65. The median age of India’s population is about 27, against Italy’s 47. This may lead to a lower death rate from COVID-19 in India and other countries with younger populations. But given India’s poor health care system and a huge proportion of its working population on daily wages, loss of employment and earnings can also take a devastating toll.
Why did the U.S. and Western media decide on China-bashing about a disease that could create a global pandemic? It appears that they saw COVID-19 as simply another day in office, a continuation of the cold war against China. Rather than invoking a sense of global solidarity, a virulent campaign of racist propaganda was unleashed: COVID-19 has been called a “Chinese disease”; the Chinese are said to eat bats and snakes; and everyone else can keep COVID-19 away simply by isolating China, according to this line of misinformation.
China not only bought the world time, but also showed us how the disease can be fought. By imposing early lockdown and travel bans, they kept the community spread of the disease virtually localized in Hubei province, something that Italy and other EU countries failed to do. China also taught us early isolation of suspected cases in fever clinics for testing, rigorous contact testing, separating those mildly infected into makeshift care centers like gymnasiums, warehouses and stadiums, and putting those seriously sick into hospitals where much more support could be provided. They mobilized more than 40,000 doctors and nurses from other regions of China to come to Hubei and Wuhan to shore the crisis of medical personnel there.
U.S. action has been in sharp contrast. At the time China sent medical personnel to Iraq, the U.S. decided to bomb the country! And tried to grab a German company developing a COVID-19 vaccine, so that it can try to create an American monopoly over the vaccine. China is sending health teams, medical supplies and equipment to many countries including Italy and Iran. It has even sent masks to the U.S. Meanwhile, the U.S. is continuing its sanctions on Iran and Venezuela even though that is making it much more difficult for them to ship in medicines, medical equipment, and protective gear.
It is difficult to predict the likely course of the COVID-19 pandemic. It is a completely new virus. In the midst of the worst pandemic we have seen in the last hundred years, we are scrambling to make up our answers on the fly along with dealing with the pandemic itself. But certain questions need to be addressed, and at least provisional answers provided.
Are there medicines that can provide a cure for COVID-19?
At the moment, we have a set of drugs that seem to be working on some patients. A combination of lopinavir and ritonavir, used to treat AIDS, may work against COVID-19 in the early stage of the infection. Interferon alpha 2B, a product of Cuba’s strong biotech institutions, has also been used in China and now in Italy for a similar purpose. The drugs that have done well in China and now in France are the anti-malarial drugs chloroquine phosphate and hydroxychloroquine, which also have anti-viral properties. Both are cheap and widely available in generic form, but require further testing. Remdesivir, an experimental drug that failed against Ebola, has shown some promise against COVID-19, pushing up the share price of Gilead Sciences, its patent holder, in a steeply falling share market.
WHO has launched a major trial named Solidarity to test what it perceives as promising candidates to fight the epidemic. They are chloroquine and hydroxychloroquine; remdesivir; a combination of lopinavir and ritonavir; and the last, adding interferon beta to the lopinavir-ritonavir combination.
Is there a vaccine that will soon be available?
A number of institutions and companies are developing vaccines, using an array of approaches and technologies. Chinese, European and American firms are all in the fray. According to WHO, two vaccines are already under clinical trials, and another 42 are under pre-clinical evaluation.
The Ebola vaccine took five years to develop and receive approval for its use. This time, we may be able to shrink the time—from development to having 1 million doses ready for use—in 12-18 months. This would be the fastest development of a vaccine ever.
After a candidate vaccine is developed, it needs a series of tests. The first step is performing cell culture and animal tests to see if antibodies develop with the vaccine. Next, human trials are conducted on a small group of people to test the vaccine for safety. Given the emergency, the two sets of trials are currently being run in parallel. If the results are positive, the trials will then be repeated with a larger group size to test for safety, estimating the degree of immunity, immunization schedule and dose size of the vaccine. Only after this stage, are widespread trials carried out involving a large number of human subjects.
There is a limit to how much we can speed this process. The major speeding up that has occurred is developing genetically engineered vaccines that can be developed much faster than using conventional vaccine development processes.
What was UK PM Boris Johnson’s “herd immunity” hypothesis to deal with the COVID-19 epidemic?
This is the “theory” (which Johnson has since come to his senses and renounced) that if 60 percent of the people are infected, they will develop immunity that will stop or slow down the epidemic. This means that at least 60 percent of the UK’s roughly 60 million population—or 36 million—would have to fall sick before the UK becomes “COVID-19 hardened” against an epidemic. Calculations show that with hospitals being overwhelmed as they have been in Italy, death rates would be anything between 1 percent to 5 percent, or 360,000 to 1.8 million. As various people have pointed out, the world did not eradicate smallpox, polio, whooping cough, etc., through disease-based herd immunity, but only after the development of vaccines. This is why the UK now has changed tack after a modeling exercise showed these possible numbers, giving up its pseudo-scientific herd immunity strategy.
Will seasonality—meaning warm weather—slow down the virus?
The jury is out on that one. Most viruses show seasonality, as does the flu virus. It is possible that high temperature and/or high humidity can slow down the rate of transmission, but we have to ride out one season to find out. There have been two different studies, both of which have come to diametrically opposite conclusions. One is based on modeling infections and temperature. As this map shows, most of the countries currently in the throes of the epidemic are along a narrow east-west corridor, roughly along the latitude 30-50 degrees north, with average temperatures of 5-11 degrees Celsius, along with low humidity. However, another paper using Chinese data says that there is no evidence that temperature has any effect on COVID-19 transmission. It is quite possible that we will see the outbreak spread to other countries outside the band mentioned above, and the temperature-humidity hypothesis will not hold. But even if it does, we are postponing the outbreak to a future date.
How did the Chinese break the back of the COVID-19 spread?
A lot has been written about the “authoritarian” Chinese lockdowns and quarantines. Now that other countries are moving in the same direction, it is worthwhile to know what China actually did and not what the media said it did. WHO’s assistant director-general, Dr. Bruce Aylward, provides the answer in his interview to New Scientist:
Question (NS): Does that mean China has taken the model approach? Were those lockdowns that seemed so extreme at the beginning the right way to go?
Dr. Bruce Aylward: Everyone always starts at the wrong end of the China response. The first thing they did was to try to prevent the spread as much as they could, and make sure people knew about the disease and how to get tested.
To actually stop the virus, they had to do rapid testing of any suspect case, immediate isolation of anyone who was a confirmed or suspected case, and then quarantine the close contacts for 14 days so that they could figure out if any of them were infected. Those were the measures that stopped transmission in China, not the big travel restrictions and lockdowns.
When I spoke to Italy the other day, they said: “We’ve got these lockdowns in place.” I said: “Great, you’ve done the hard part, now you have to do the really hard part, and that is making sure the cases are effectively isolated.”
The key to stopping the epidemic in Wuhan was not simply the lockdowns; it was also the combination of quickly testing suspected patients, and then taking the necessary steps of isolation and treatment of those found positive. This is, as Dr. Aylward says, the really hard part that all of us have to implement when—and not if—COVID-19 takes an epidemic form in our countries.
Countries like India have a weak public health infrastructure, and an economy in which a huge number of people will have no earnings if lockdowns are imposed. How they craft a policy that works for most people while keeping the epidemic at bay is the challenge. Can divisive governments—currently focused on attacking their critics, alienating the minorities, and bailing out big capital—switch to building solidarity, extending public health and uniting all sections of the people? Or will Modi, Bolsonaro, Erdogan and others follow Big Brother Trump, believing ultra-nationalism, coupled with hyper-capitalism, will solve all their problems?
Prabir Purkayastha is the founding editor of Newsclick.in, a digital media platform. He is an activist for science and the Free Software movement.