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Author: Jean-Claude Muller, 穆卓Executive Editor at BtoBioInnovation  jcm9144@gmail.com

SPECIAL REPORT #20.5

COVID-19: Ongoing Activities (Part 2)

It is becoming increasingly difficult to report on Covid-19 (the official name given by the WHO to coronavirus 2019-nCov by the WHO on February 11, 2020) with accuracy and with validated data.

On February 12, the Hubei government reported 14, 840 new cases and 242 new deaths within one day. An almost tenfold increase over previous days. The surge in number of cases was due for most of the part to adoption of a new classification including the number of clinically diagnosed cases into the number of confirmed cases. Of the 14, 840 cases added, 13,332 were due to the new classification while 1,508 were new cases.  On February 14, the National Health Commission in China officially reported that it deduced 108 previously reported deaths and 1,043 previously reported cases from the total Hubei Province due to a previous mistake in “repeated statistics”.

The live update we have, as we are writing are: 64,456 Covid-19 cases, 1,384 deaths, 10,584 serious or critical cases, 7,101 recovered affecting all over 28 countries and territories in the world. Total deaths are 1,381 in China, 1 in Hong Kong, 1 in the Philippines and 1 in Japan (a woman in her 80s reported on January 13). Transmission rate (Ro) is estimated around 3 (3-4 newly infected from 1 case). Fatality rate estimated by WHO is around 2% and incubation period is estimated between 2-14 days. Without knowing more precisely how many people are infected it is far too early to validate this mortality figure.

Many experts are now questioning the reliability of the official figures published since January 20, 2020. Since this very date, China has already changed five times its calculation mode, nothing seems logical and nobody knows precisely how the information is collected and analysed.  “In terms of monitoring the progression of the outbreak of infections, it is quite a sensible idea to also report probable cases “said Ben Cowling a professor of infectious disease epidemiology at the University of Hong Kong.

Several figures are now becoming a major concern and raise legitimate questions : 

• The real number of new cases, their location, the validity of diagnosis and the relevance of the persistence of the Covid-19 in the environment? 
• Are they enough hospitals beds in Wuhan?

Previously, only patients that had received positive tests from a laboratory test were included in the reported case count. Confirmed cases will now be based on clinical diagnosis with the use of Computerised Tomography (CT) scans whereas they were only counted as probable before. Normal lungs appear black on CT scan, but coronavirus scans appear to have white patches that radiologist refer to as “ground glass opacity”. With such type of clinical information available, doctors will have more discretion to give patients immediate standardized treatment, instead of waiting for the results of laboratory test. “There have been reports of likely infected individuals being turned away from hospitals and sent home because the medical system in Hubei is being overwhelmed, with the focus on treating the more severely ill patients” said Charles Chiu, a professor of medicine at the University of California in San Francisco. and possibly because of an increasing lack of hospitals beds by now in spite of the 2,600 new beds made available late January. A few hours after the spike of the new cases, the Chinese central government announced that the Communist Party Secretary of Hubei, Jiang Chaoliang was removed from his post and is being replaced by the mayor of Shanghai, Ying Yong. Jiang is the highest-ranking party official removed from office so far over the outbreak.

According to local officials as many as five million people left Wuhan and the region before  the Chinese government implemented the lockdown of the city on January 23. A very high percentage of the five million are workers who returned to their homes and villages, where medical facilities do not allow massive testing. Many of those infected people are almost certainly not being recorded and are still not allowed to return to the Hubei region. The region, where the virus is believed to have originated, has more than 80% of all the reported current official cases. The Wuhan HouShenShan hospital authorities are now highly focused at reducing the risk of cross-infection.  On February 2^nd, a Chinese newborn was diagnosed with the coronavirus, just 30 hours after birth, the youngest case recorded so far. The baby’s mother tested positive before she gave birth, it is unclear how the disease was transmitted: in the womb or after birth. The situation of the Diamond Princess cruise ship in quarantine docked in Yokohama (Japan) is worth describing.  With a total number of 218 infected people, nearly 6% of the 3,711 passengers and crew members, the cruise ship has the highest infection rate of Covid-19 anywhere in the world. The city of Wuhan, with a population of more than 11 million has an infection rate of less than 0.3%. With up to 40 new cases almost every day, the situation in the Diamond Princess highlights the risk of the Covid-19 infection spreading in confined spaces. According to various health experts, close-contact environments greatly facilitate the transmission of the virus through droplets but also with contaminated surfaces (see below). Due to the long duration passengers spend on their boat, a cruise ship clearly represents the highest risk of any other type of transportation, like planes and trains. “On an airplane, or on a train, if there were exposure to the virus, you probably only have one generation of transmission because of the duration of the journey. On a cruise, the transmission could be sequential. One person may infect another, who may infect another” said Hui-lin Yen, an expert on influenza transmission at the University of Hong Kong. The outbreak on the Japanese ship perfectly mirrors the disease spread in Wuhan and the small confined ecosystem on the vessel is becoming a perfect real-world cluster of the Covid-19 to be monitored and accurately studied by healthcare experts outside of China.

Whereas health authorities thought that the incubation period was of 2-14 days, as with most viruses, during which the virus is contagious and could therefore be handled with a quarantine of about 14 days, there is now increasing evidence that this number could very well be underestimated and by far. A recent publication online of February 6 by Günther Kampf et al. in the Journal of Hospitalisation reports about the persistence of various coronaviruses on inanimate surfaces. The paper compiles analysis from 22 studies which reveal that human coronaviruses such as Severe Acute Respiratory Syndrome (SARS) coronavirus, Middle East Respiratory Syndrome (MERS) and endemic human coronaviruses (HCoV) can persist on inanimate surfaces like metal, glass  or plastic for up to nine days and be another major transmission vector. Low temperature and high air humidity are even increasing the lifespan of viruses on inanimate surfaces. Human-to human transmission have been described with incubation times between 2-10 days facilitating its spread via droplets, contaminated hands or surfaces. The latter one may have been overlooked in term of importance in particular since an airborne transmission via feces is being investigated in Hong Kong. Fortunately disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite efficiently inactivates the infected surfaces within 1 minute. No surprise therefore that Chinese authorities have launched massive disinfection campaigns in the most affected areas of the Hubei region. Healthcare experts now worry about the appropriate quarantine on the Japanese Diamonds Princess cruise ship. The quarantine began February 5 after the company learned that a passenger from Hong Kong who had previously been on board had tested positive. Less than ten days later the number has soared to 218. Not sure at all that the confinement which was set to end February 19 will be relieved quickly. Up till now only passengers with reported symptoms and those who live in the same cabins have been tested. But shortage of Covid-19 test kits have prevented the Japanese health authorities  from testing all passengers and crew members and obliged them to prioritizing elderly passengers and those living in windowless cabins. If tested negative, they will be the first allow to be disembark and be housed at designated lodgings on land and be confined there for another few days.  The Holland America’s MS Westerdam, another cruise ship, was denied entry to five ports including Thailand, Taiwan, Guam and has finally docked in Cambodia on February 13. Passengers on the World Dream cruise ship in Hong Kong were held docked there for four days after the company learned than three passengers who had sailed on the vessel earlier were confirmed to have the virus. Passengers and crew members were allowed to disembark on February 10, after they all tested negative for the virus.

Lunar New Year holidays have been extended in many places and companies have kept their offices closed until February 10 and even February 17. Chinese authorities have asked citizens to still stay at home and avoid a sudden massive travelling and commuting of hundreds of millions of people from their homes to their offices, with some exceptions of course. One of them is the healthcare givers community and the healthcare industry workers in order to make sure that there will be no shortage of needed supply in drugs, diagnostics, hospital materials and consumables. For instance, China WuXi Biologics resumed its production on February 10 at its three sites but indicated that it is taking most stringent precautions to protect its employees and products in the face of the Covid-19. None the mentioned sites are located in the Hubei region.

Several scientists who study infectious diseases have wondered if climate change has triggered that virus to jump from animals to human at this time. Although there is clearly no evidence in this particular outbreak, scientists are convinced that spreading of virus linked diseases will change as the planet warms for two main reasons:

• The emergence of new pathogens, that had been buried for millennia by glaciers and permafrost, are progressively released into the atmosphere and are pathogens which human kind may never have come across previously.
• The emergence of more temperature resistant pathogens. As pathogens are exposed to gradually higher temperature, they become better equipped to survive the increasing temperature inside the human body when fever occurs. Every time we have a very hot day, there is a selection event of pathogens and the ones that survive and reproduce are better adapted to higher temperatures in our bodies.

On February 12, after two days special session in Geneva, WHO has declared that “this epidemic can spread in any direction from now”.

All this is a bit scary. It is indeed scary every time a new deadly pathogen emerges and where, suddenly, we are facing a lot of “known unknows”. But as long as we are unaware they exist we are just facing a lot of “unknown unknows” and that keeps us calm and not terrified by the threat.

The outbreak of Covid-19 has triggered a massive worldwide move whereby all scientists involved in infectious diseases are now focusing unprecedented efforts in order to rapidly unravel the underlying hidden features and characteristics of this deadly virus. The remit of the biopharmaceutical industry is to build up immediate capacities for all kinds of coronavirus antivirals and the gist of its contribution is now to be working hard at findings new ones with higher and better efficiency against Covid-19. Immense efforts are also ongoing within the academic and private sector to deliver active diagnostics and identify best possible treatments including preventive vaccines. In comparison with the 2003 SARS outbreak, it is remarkable to see how fast the international scientific and medical community is getting involved in deciphering all aspects of the epidemic and finding most appropriate solutions to keep the spreading of the disease under control.

February 14, 2020

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