Friday, March 06, 2020

COVID-19 Recommendations and Analysis

Updated 14 March 2020. New recommendations, now ten in total.

Updated 8 March 2020 with new recommendations.

This article is an attempt to compile facts concerning SARS-CoV-2 and its related disease COVID-19. Though I am not a medical expert, I will compile recommendations from reputed sources (available in the references). It is important that you know what precautions must be taken in the initial (containment) stage.

Then I will discuss matters arising, both statistical and political. That section is motivated by the anti-Chinese discourse and outright racism I have witnessed in the last weeks.

Please read this carefully. I am open to corrections in the comments.

Five Recommendations... and More

The World Health Organisation (WHO) should be your number one source of information. Let's examine their recommendations as a starting point [WHO 2020b]:

1. Regularly and thoroughly clean your hands with an alcohol-based hand rub or soap and water.

2. Maintain at least 1 metre distance between yourself and anyone who is coughing or sneezing.

3. Avoid touching eyes, nose and mouth.

4. Cover your mouth and nose with your bent elbow or tissue when you cough or sneeze. Dispose of the used tissue immediately.

5. If you have fever, cough and difficulty breathing, seek medical care early.

Given the severity and deadly attributes of the current strain, it is perhaps understandable that people wish to be more proactive than this list makes possible. However, this makes some people susceptible to false promises and internet scams. I refer you to the Myth Busters page for all the things that don't work [WHO 2020c]. Basically, you should ignore much of the "friendly" advice you find on social media.

I now wish to augment the recommendations with advice based on pertinent medical facts.

SARS-CoV-2 can be in the body up to ten days before symptoms are shown [Kampf et al. 2020]. Other reports say 14 days. Either way, people without any visible symptoms may indeed be carriers. That is how a flu manages to spread so rapidly. People who feel perfectly healthy continue to travel and mix with others.

The virus does not spread through the air itself, but instead through water droplets in the air [Kampf et al. 2020]. When these droplets are very fine (constituting an aerosol) they can travel further, though this distance is still low.

These facts make recommendation 2 above quite problematic. We don't know when someone might sneeze. What appears to be a benign cough might turn out to be otherwise. Furthermore, this advice does not correspond to the actual symptoms of COVID-19, which are: fever (88%), dry cough (68%), fatigue (38%), sputum production (33%), shortness of breath (18%), myalgia or arthralgi (muscle and joint ache) (14%), sore throat (14%), headache (14%), chills (11%), and less common symptoms [WHO 2020a, 12].

In other words, 32% of those infected might never cough. And in any case one can be asymptomatic and still transmitting the disease for up to two weeks.

Therefore the logical advice is to maintain a safe distance from everyone. This makes public transit and car pooling along with many work activities quite problematic. The WHO is understandably loath to make a recommendation this extreme, since they must maintain a proportional response. But now we see the reason for the Wuhan quarantine and what appeared to be severe travel restrictions in China. They were logical and required.

The coronavirus can also stay active on surfaces for up to nine days. Thankfully, common chemicals can kill the virus quickly. These include a 0.1% solution of bleach (sodium hypochlorite), 0.5% hydrogen peroxide, or 62–71% ethanol [Kampf et al.].

I will summarise the modified recommendations for ease of copying.


COVID-19 Recommendations

1. Regularly and thoroughly clean your hands with an alcohol-based hand rub or soap and water. The problem with the latter is you will be using a towel, which may itself not be clean.

2. Surface contact is the second way the virus spreads. Clean surfaces with bleach (0.1% solution of sodium hypochlorite), 0.5% hydrogen peroxide, or 62–71% ethanol [Kampf et al.]. (Bleach denatures in a few months. Keep cool and out of sunlight.)

3. Avoid touching eyes, nose, and mouth.

4. Maintain 1 to 2 metres between yourself and others in public. If you can reach out and touch someone, you are too close.

5. Avoid all large public gatherings, or any where you will need to violate the previous provision. This includes wedding, funerals, classrooms. Stop all international travel. Find other ways to work; telecommute if possible. Isolation is paramount in the early stages of mitigation.

6. Cover your mouth and nose with your bent elbow or tissue when you cough or sneeze. Dispose of used tissues immediately.

7. If you have fever, cough, or breathing problems, seek medical care. Do not volunteer yourself at a waiting room with symptoms of infection. Instead, call the medical practice and make special arrangements.

8. Do not hoard goods. Having a small supply of dry goods (tinned fish and veg, crackers, etc.) plus paper products is reasonable, but think of others.

9. Do not buy face masks. Common surgical masks are largely useless for the healthy, unless you also wear goggles. (Details in comments.)

10. Clean your phone. As an addendum to surface cleaning, be sure your computer mouse and keyboard are cleaned regularly. Most important, clean your mobile phone, since this is likely the object you touch most in a a typical day.


The Question of the Fatality Rate

The crude fatality ratio (CFR) is a subject of much speculation. This is quoted as high as 3.8% but could be less once the total number of infected are better quantified [WHO 2020a, 12]. Regardless, this virus is about ten times more deadly than the usual seasonal flu. (Please refer to the follow-up article for more details on this.)

What the average figure hides is a complex profile based on gender, age, and other factors.

First, men have a much higher CFR than women (4.7% vs. 2.8%) [WHO 2020a, 12]. This is not surprising, given that men are more susceptible to other coronavirus strains. "Man flu" is a real thing.

Underlying conditions have a large negative impact as follows. If you have a cardiovascular disease you are 13.2% more likely to die, diabetes 9.2%, hypertension 8.4%, chronic respiratory disease (including asthma) 8.0%, cancer 7.6% [WHO 2020a, 12].

Age is a huge factor. Thankfully, no children have yet died of the disease. If you are under 50 years old, the CFR is less than 1% (all else being equal) [NCPERRET 2020]. However, this rate triples to 1.3% for those in their fifties. If over 80, the rate is 14.8%.

The important take-away fact is that any one figure for CFR, no matter what this is, says nothing about an individual's chances. These are statistical averages.

The other important fact is that these figures only pertain when there is a concerted health response to the crisis, with ample health care resources. Death rates in China fell once the full weight of their medical system was brought to bear.


Response to the Crisis

Important factors in disease prevention include preparedness, reaction protocols and timeliness, plus the underlying health infrastructure. It is often noted that a society is only as safe as its poorest citizen.

I have read and heard many criticisms of China, some subtle, some outright racism. It is worth quoting the WHO report at length:

China's uncompromising and rigorous use of non-pharmaceutical measures to contain transmission of the COVID-19 virus in multiple settings provides vital lessons for the global response. This rather unique and unprecedented public health response in China reversed the escalating cases in both Hubei, where there has been widespread community transmission, and in the importation provinces, where family clusters appear to have driven the outbreak [WHO 2020a, 19].

This response is in contrast with what can be expected elsewhere:

Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China. These are the only measures that are currently proven to interrupt or minimize transmission chains in humans. Fundamental to these measures is extremely proactive surveillance to immediately detect cases, very rapid diagnosis and immediate case isolation, rigorous tracking and quarantine of close contacts, and an exceptionally high degree of population understanding and acceptance of these measures [19].

This positive evaluation of the Chinese government should be tempered with the well-publicised news concerning repression of information about the disease. However this seems to have been largely misunderstood, not surprising given press bias. It is likely less a matter of denial of the disease itself and more about the totalitarian desire to control information flow. The fact that a government official has publicaly praised the "whistleblower" doctor is hard to reconcile with the negative reporting in the West [Xinhua 2020].

Regardless of the China blame game, it is worth considering: will your government adopt the same rapid and effective response to the pandemic? In Wuhan "more than 1800 teams of epidemiologists, with a minimum of 5 people/team, are tracing tens of thousands of contacts a day" [WHO 2020a, 8] Can you see your government doing that?

As people become sick, hospital beds are required to care for their needs. The better the care, the higher the chance of recovery. In the case of COVID-19, recovery for severe patients can take 3 to 6 weeks. During this time artificial respiration and concentrated oxygen are required. Isolation via negative-pressure containment is also indicated.

In response to the crisis, Wuhan readied over 10,000 hospital beds across 30 hospitals for a population of 11 million [Statista Research Department 2020]. This included the 1,000 bed Huoshenshan Hospital, constructed from 23 January to 2 February 2020, and the 1,600 bed Leishenshan Hospital, proposed on 25 January 2020, funded two days later, and opened for patients on 8 February [CGTN America 2020; Xinhua 2020].

The population of Ireland is half that of Wuhan, so here's a thought experiment: Imagine the Irish government building a first-class isolation ward with 1,300 beds over two weeks. Right.

It's not just emergency situations that get this type of response in Asia. Here is a comparison of the number of hospital beds per 1000 people across various countries [OECD 2020]:

Japan: 13.05
South Korea: 12.27
China: 4.34
Ireland: 2.96
USA: 2.77
UK: 2.54
Canada: 2.5

It is apparent that many Asian states care more for their population's health than our own (Western) societies.

To prevent people from needing a hospital bed in the first place, it is important to self-isolate (when directed). This mitigates transmission to a degree that no other measure can. In China, citizens had little choice. This enforced isolation worked to control the crisis, the worst of which is already over [WHO 2020a].

In Western countries there has been a very different response. The USA has adopted their typical ostrich strategy [Walters et al. 2020]. What will happen when Usonian citizens are asked to avoid work for two weeks... or two months? They will work anyway, spreading the virus, since 80% of them would be out on the street without their next pay cheque [Reich 2018]. They really have no choice. By contrast, Chinese workers retain their pay when off sick [China Briefing 2020].

When citizens are not cared for on a day-to-day basis, it is impossible to fight a pandemic. So the worst may not be over. Containment has failed, despite the fact that China bought the world one month to prepare. What we get are pathetic responses like that here in Ireland [Government of Ireland 2020].

As an individual in a high-risk category, I hope for the best for all of us.


Dedication

To Dr. Li Wenliang, 1986–2020, and all who work on the front lines.


References

CGTN America. 2020. "First 30 viral pneumonia patients admitted in Leishenshan Hospital." CGTN America [website]. Available: https://america.cgtn.com/2020/02/09/first-30-viral-pneumonia-patients-admitted-in-leishenshan-hospital

China Briefing. 2020. "HR Compliance in China during the Coronavirus Outbreak: FAQs." China Briefing [website]. Available: https://www.china-briefing.com/news/coronavirus-china-hr-compliance-faqs/

Government of Ireland. 2020. "Ireland's response to COVID-19 (Coronavirus)" gov.ie [website], 6 March 2020. Available: https://www.gov.ie/en/publication/a02c5a-what-is-happening/

Kampf, G.; D. Todt; S. Pfaender; E. Steinmann. 2020. "Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents." The Journal of Hospital Infection 104.3, 246–251. Available: https://www.journalofhospitalinfection.com/article/S0195-6701(20)30046-3/fulltext

Organisation for Economic Co-operation and Development (OECD). 2020. "Health Care Resources." OECD [website], 6 March 2020. Available: https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_REAC#

Reich, Robert. 2018. "Almost 80% of US workers live from paycheck to paycheck." The Guardian [website], 29 July 2018. Available: https://www.theguardian.com/commentisfree/2018/jul/29/us-economy-workers-paycheck-robert-reich

Statista Research Department. 2020. "Number of new hospital beds to be added in the designated hospitals after the coronavirus COVID-19 outbreak in Wuhan, China as of February 2, 2020." Statistica [website]. Available: https://www.statista.com/statistics/1095434/china-changes-in-the-number-of-hospital-beds-in-designated-hospitals-after-coronavirus-outbreak-in-wuhan/

The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team (NCPERRET). 2020. "The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) — China, 2020" [preprint]. China CDC Weekly 2020.2.8, 113-122. Available: http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51

Walters, Joanna; Lauren Aratani; Peter Beaumont. 2020. "Trump calls WHO's global death rate from coronavirus 'a false number'." The Guardian [website], 5 March 2020. Available: https://www.theguardian.com/world/2020/mar/05/trump-coronavirus-who-global-death-rate-false-number.

World Health Organisation (WHO). 2020a. Report of the WHO - China Joint Mission on Coronavirus Disease 2019. Available: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf

World Health Organisation (WHO). 2020b. "Coronavirus disease (COVID-19) outbreak." WHO [website]. Available: https://www.who.int/emergencies/diseases/novel-coronavirus-2019.

World Health Organisation (WHO). 2020c. "Coronavirus disease (COVID-19) advice for the public: Myth Busters." WHO [website]. Available: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

Xinhua. 2020. "1,600 beds for Leishenshan Hospital to be delivered in Wuhan on Feb. 8." Xinhuanet [website], 7 February 2020. Available: http://www.xinhuanet.com/english/2020-02/07/c_138764454.htm.

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8 comments:

MichaelCoffey said...

I am living in China for 5 years now; currently one week into a visit to see relatives in Spain with my Irish-Chinese family, so half way through a 2-week self-quarantine. We have elected to do this through a sense of social responsibility. The European societies I know have no regard for personal safety over economic and social well-being, at the personal or leadership level. Yesterday's figures: our city in China has 2 cases of COVID-19 for 2 million people; Valencia, Spain has 32 cases for 1 million people and the city's las Fallas event is going full steam ahead, while Chinese restaurants remain empty. More logical thinking, less prejudice and fear would be good to see. You have a fine mind.

MichaelCoffey said...

You forgot to mention to wear masks: 56%of those identified with COVID-19 in one Wuhan study of thousands found that they showed no outward symptoms.

robin said...

Malia Jones, PhD,MPH has an article that basically confirms everything above.

https://docs.google.com/document/d/1cI_D3ULz6-qoBRMND8dIVz-naW92MqATphBg5bQEIjg/preview

robin said...

Michael, thanks for your comments. I have made the point of going to Chinese markets and restaurants here in Ireland, to show solidarity. And to get great food!

I agree that Europe could learn a lot from China, instead of constantly stigmatising the culture.

I have added a recommendation that people NOT buy masks. They are fairly useless if you are healthy. And many masks do nothing to prevent aerosol distribution even if you are sick.

Masks should be reserved for health care professionals working with the ill. In which case they will also have more complete isolation treatment.

This is the best advice I have learned. I know that people like wearing masks because it shows they are aware of the problem and being socially responsible. I do understand that. But it's a fairly knee-jerk response.

robin said...

Another informative article:

https://elemental.medium.com/why-we-should-care-commonly-asked-questions-and-answers-about-covid-19-6b166f1876e9

MichaelCoffey said...

My family have not been able to buy face masks in Europe so EU governments are constrained in what they can tell their public. I will continue visiting your site for audio data and experiences, not for medical opinions

robin said...

Most medical experts advise against using commonly-available face masks (the surgical kind) for the general public because, while they *are* partially effective, they are much less so than following the other protocols.

The reasons? They don't form a full seal, don't block fine aerosols, and don't protect the eyes. Further they lead to irritation, sweating, etc. which means more contact with the face, something that is contra-indicated. They need to be constantly replaced, which results in people hoarding large quantities of masks.

Besides which, is it really your plan to wear masks forever? Because the virus is not going away. The 1918 flu pandemic is still with us a century later (though now less virulent).

If you need to enter a high risk zone, such as a hospital dealing with coronavirus, then the advice would be different. But for day-to-day use, this is the consensus from numerous sources, The New Scientist, for example:

https://www.newscientist.com/article/2231535-can-an-n95-face-mask-protect-you-from-catching-the-new-coronavirus

A proper respirator type mask *is* effective, but if you are wearing one, that's one less for the health care professionals who really need them. And there is a worldwide shortage. My opinion (and this is the only part of this information that is opinion) is that this is selfish.

robin said...

How to self-isolate:

https://www.theguardian.com/world/2020/mar/14/coronavirus-how-to-self-isolate-covid-19-symptoms

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