When the Coronavirus speads

It’s now a matter of when, not if, for Australia. This is how we’re preparing for a jump in coronavirus cases


Katherine Gibney, The Peter Doherty Institute for Infection and Immunity; Brett Sutton, Monash University, and Jodie McVernon, University of Melbourne

While countries around the globe have been taking precautions to prevent the spread of COVID-19, the disease caused by the novel coronavirus, it has now been reported in 37 countries outside China.

As of February 26, close to 3,000 cases and 43 deaths had been recorded outside China. In Australia, we’ve so far seen 23 cases across five states.

The good news is currently there’s no evidence of “community transmission” of the virus in Australia. This means it’s not spreading locally. All cases have had travel connections to China or the Diamond Princess cruise ship, or very close contact with a confirmed case in Australia (being in the same family or tour group).

But as the list of countries with community transmission increases – it’s happening in South Korea, which has more than 1,200 cases, and Italy, which has 400 – so too does the risk of an escalation in Australia. It’s now a matter of “when” local transmission occurs, not “if”.

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In this climate, the Australian government has developed a national emergency response plan, which takes us through three phases. Prime Minister Scott Morrison yesterday announced we are activating this plan.

Phase 1

The current “Initial Action” stage of the COVID-19 plan focuses on preventing introduction and establishment of the disease in Australia through border measures and social distancing. These are measures designed to keep infected (or potentially infected) people away from healthy people.

In an effort to contain COVID-19 and delay it becoming established in Australia, the Australian government banned the entry of foreign nationals (excluding permanent residents) who had been in mainland China in the last 14 days. This ban has now been extended to March 7.

The return of Australian residents from China, and more recently year 11 and 12 students studying in Australia, has been strictly controlled.

People returning are required to go into home quarantine for 14 days after they leave China.

And at this stage, university students from China must spend 14 days in a third country before arriving in Australia.

Other countries have imposed their own border restrictions, as well as screening people for illness before they enter. These measures have undoubtedly slowed the spread of COVID-19 throughout the world and delayed its progression to a pandemic.

The first stage of Australia’s emergency plan aims to keep coronavirus out of the country as much as possible.

Phase 2

The true clinical severity of this disease remains highly uncertain, but overall it appears less severe than the 1918–19 influenza pandemic or SARS and more severe than the pandemic flu in 2009.

Importantly though, compared to other epidemic and pandemic diseases, COVID-19 is considered highly transmissible, so a large number of cases is likely.

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Given ongoing uncertainties, the plan doesn’t articulate the number of cases that would need to be diagnosed for the second phase, “Targeted Action”, to be enacted. The plan simply stipulates public health activities need to be balanced (or “proportionate”) to the magnitude and severity of the pandemic.

We would expect phase two to be put into place when we’re seeing community transmission occurring in Australia.

In this second phase, the current strict border measures and quarantine for arrivals will likely be relaxed as “keeping it out” becomes futile. The focus will shift to minimising spread within Australia and limiting the health, social and economic impact of the disease.

Australians might see a public health response like we’ve seen in Italy. This could include cancellation of large local gatherings (sporting matches and festivals), closure of schools, universities and some workplaces, and strict local travel restrictions.

Community members will be asked to take responsibility for their own “social distancing” if they have mild disease or have been in close contact with someone with the virus (by self-isolating or self-quarantining at home).

These measures, while disruptive to individuals and households, have been highly effective to date in preventing community transmission of COVID-19 in Australia and will remain very important throughout the response to this disease.

As case numbers rise, case management will need to be streamlined to make best use of finite resources within the health system, including personnel, primary care and hospital capacity and personal protective equipment. Options include greater use of fever assessment clinics, caring for COVID-19 patients together on wards, and keeping people out of hospitals and emergency departments if they don’t require that level of care.

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The government, public health experts and clinicians will actively review and be guided by new information to determine exactly which of these clinical and public health measures to put in place.

While many mild cases have been admitted to hospital during the containment phase, community-based care will be the reality for most people as we become more familiar with this disease and its usual course. This approach will allow us to provide higher levels of clinical care for those at greatest risk of poor outcomes, such as older people.

Phase 3

It’s likely, but not certain, that COVID-19 will remain in circulation beyond 2020 and become “endemic” in Australia – that is, here for good. But once the peak has passed (that’s when there’s a declining number of new infections and less demand on hospitals), the COVID-19 plan will move into the “Standdown” phase, which is essentially a return to “business as usual”.

We have a huge challenge ahead of us, but the measures we all take can make a big difference to how this plays out. Whether it’s isolation and quarantine or simply frequent handwashing and good cough etiquette, we can all help protect ourselves, our families, and the most vulnerable in society.

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The Conversation

Katherine Gibney, NHMRC early career fellow, The Peter Doherty Institute for Infection and Immunity; Brett Sutton, Adjunct Clinical Professor, Monash University, and Jodie McVernon, Professor and Director of Doherty Epidemiology, University of Melbourne

This article is republished from The Conversation under a Creative Commons license.

The pandemic

The virus is coming

Governments have an enormous amount of work to do

IN PUBLIC HEALTH, honesty is worth a lot more than hope. It has become clear in the past week that the new viral disease,covid-19, which struck China at the start of December will spread around the world. Many governments have been signalling that they will stop the disease. Instead, they need to start preparing people for the onslaught.

Officials will have to act when they do not have all the facts, because much about the virus is unknown. A broad guess is that 25-70% of the population of any infected country may catch the disease. China’s experience suggests that, of the cases that are detected, roughly 80% will be mild, 15% will need treatment in hospital and 5% will require intensive care. Experts say that the virus may be five to ten times as lethal as seasonal flu, which, with a fatality rate of 0.1%, kills 60,000 Americans in a bad year. Across the world, the death toll could be in the millions.

If the pandemic is like a very severe flu, models point to global economic growth being two percentage points lower over 12 months, at around 1%; if it is worse still, the world economy could shrink. As that prospect sank in during the week, the S&P 500 fell by 8% (see article).

Yet all those outcomes depend greatly on what governments choose to do, as China shows. Hubei province, the origin of the epidemic, has a population of 59m. It has seen more than 65,000 cases and a fatality rate of 2.9%. By contrast, the rest of China, which contains 1.3bn people, has suffered fewer than 13,000 cases with a fatality rate of just 0.4%. Chinese officials at first suppressed news of the disease, a grave error that allowed the virus to take hold. But even before it had spread much outside Hubei, they imposed the largest and most draconian quarantine in history. Factories shut, public transport stopped and people were ordered indoors. This raised awareness and changed behaviour. Without it, China would by now have registered many millions of cases and tens of thousands of deaths.

The World Health Organisation was this week full of praise for China’s approach. That does not, however, mean it is a model for the rest of the world. All quarantines carry a cost—not just in lost output, but also in the suffering of those locked away, some of whom forgo medical treatment for other conditions. It is still too soon to tell whether this price was worth the gains. As China seeks to revive its economy by relaxing the quarantine, it could well be hit by a second wave of infections. Given that uncertainty, few democracies would be willing to trample over individuals to the extent China has. And, as the chaotic epidemic in Iran shows, not all authoritarian governments are capable of it.

Yet even if many countries could not, or should not, exactly copy China, its experience holds three important lessons—to talk to the public, to slow the transmission of the disease and to prepare health systems for a spike in demand.

A good example of communication is America’s Centres for Disease Control, which issued a clear, unambiguous warning on February 25th. A bad one is Iran’s deputy health minister, who succumbed to the virus during a press conference designed to show that the government is on top of the epidemic.

Even well-meaning attempts to sugarcoat the truth are self-defeating, because they spread mistrust, rumours and, ultimately, fear. The signal that the disease must be stopped at any cost, or that it is too terrifying to talk about, frustrates efforts to prepare for the virus’s inevitable arrival. As governments dither, conspiracy theories coming out of Russia are already sowing doubt, perhaps to hinder and discredit the response of democracies.

The best time to inform people about the disease is before the epidemic. One message is that fatality is correlated with age. If you are over 80 or you have an underlying condition you are at high risk; if you are under 50 you are not. Now is the moment to persuade the future 80% of mild cases to stay at home and not rush to a hospital. People need to learn to wash their hands often and to avoid touching their face. Businesses need continuity plans, to let staff work from home and to ensure a stand-in can replace a vital employee who is ill or caring for a child or parent. The model is Singapore, which learned from SARS, another coronavirus, that clear, early communication limits panic.

China’s second lesson is that governments can slow the spread of the disease. Flattening the spike of the epidemic means that health systems are less overwhelmed, which saves lives. If, like flu, the virus turns out to be seasonal, some cases could be delayed until next winter, by which time doctors will understand better how to cope with it. By then, new vaccines and antiviral drugs may be available.

When countries have few cases, they can follow each one, tracing contacts and isolating them. But when the disease is spreading in the community, that becomes futile. Governments need to prepare for the moment when they will switch to social distancing, which may include cancelling public events, closing schools, staggering work hours and so on. Given the uncertainties, governments will have to choose how draconian they want to be. They should be guided by science. International travel bans look decisive, but they offer little protection because people find ways to move. They also signal that the problem is “them” infecting “us”, rather than limiting infections among “us”. Likewise, if the disease has spread widely, as in Italy and South Korea, “Wuhan-lite” quarantines of whole towns offer scant protection at a high cost.

Scrub up

The third lesson is to prepare health systems for what is to come. That entails painstaking logistical planning. Hospitals need supplies of gowns, masks, gloves, oxygen and drugs. They should already be conserving them. They will run short of equipment, including ventilators. They need a scheme for how to set aside wards and floors for covid-19 patients, for how to cope if staff fall ill, and for how to choose between patients if they are overwhelmed. By now, this work should have been done.

This virus has already exposed the strengths and weaknesses of China’s authoritarianism. It will test all the political systems with which it comes into contact, in both rich and developing countries. China has bought governments time to prepare for a pandemic. They should use it.

Original article published in The Economist

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