Covid-19 Pandemic; observations thus far.

There have been more than 10 million cases and more than 500,000 deaths worldwide due to Covid-19 as of today. It is nearly impossible from the new cases and death numbers that are presented even by respectable sites for someone to reach a conclusion on how Covid-19 pandemic compares those in the past.  The cultural differences among people and the enormous variation of lockdowns, from very strict to light to mini make comparisons very difficult.  The examples below provide us with information on how four distinct populations fared due to their unique characteristics.

On the cruise vessel Diamond Princess 3,618 tests were performed on 3,711 people (2,666 passengers and 1,045 crew).  712 of the tests or 19% were positive. Half of those tested had symptoms while half were asymptomatic. There were 14 deaths.  The death rate of the entire cohort (crew + passengers) was 0.37% while the death rate among those who tested positive, who were likely elderly, it was 2%.  In a brief report has been published in the Journal of Emerging Infectious Diseases, the interested reader, can find epidemiological information regarding Covid-19 in a group of people who were isolated in close proximity within the confines of a vessel. The passengers and crew were quarantined in Yokohama, Japan and the lockdown was total. 

In the State of Ohio 787,929 tests were performed, of which 52,419 or 6.7% of which were positive. There were 2,890 deaths.  The death rate for the 10 million inhabitants is 0.03%.  The death rate is 6% among those who tested positive.  Ohio enacted what I consider a light lockdown.

In Greece a total of 308,392 tests were performed of which 3,409 or 1.11% were positive.  There were 192 deaths.  The death rate from Covid-19 among the 10 million inhabitants is 0.002%.  The death rate is 6% among those who tested positive.  Greece enacted a strict lockdown. 

In Sweden a total of 444,600 tests were performed and 68,451 or 15 % were positive.  There were 5,333 deaths.  The death rate from Covid-19 among the 10 million inhabitants is 0.05% while it is 8% among those who tested positive.  Sweden enacted a mini lockdown allowing its inhabitants to continue their lives as in the past forbidding only gatherings of more than 50 people.

The cultural differences among people and the enormous variation of lockdowns from very strict to light to minimal make comparisons near impossible.  Also, the way different societies care of their elders and those at risk varies not only between countries but also between big cities and small villages within the same country.  The three above mentioned countries have near identical populations (10 million) but fewer than 10,000 elderly are housed in nursing homes in Greece a country in which the elderly are cared at home.  Approximately 30,000 elderly are in nursing homes in Sweden to more than 100,000 in Ohio.  Also, the number of people incarcerated differs as well, from approximately 6,000 in Sweden to 10,000 in Greece to 50,000 in Ohio.  Finally, risk factors such as smoking is more prevalent in Greece while obesity is more prevalent in Ohio. 

In the past 6 months we have learned that certain practices such as social distancing, avoidance of crowded places and wearing masks, the practice of respiratory etiquette and other hygienic practices such as washing hands are effective.  Intense early testing and contact tracing in the early phase of the epidemic have been employed successfully by several Asian countries such as Singapore, S. Korea and Taiwan.   We also learned that strict infection control measures at hospitals, nursing homes, meat processing facilities, prisons and cruise ships are necessary. 

We now know that locking down entire countries adversely impacts economies.  McKinsey's researchers estimate that government deficits could reach $30 trillion by 2023.  Stanford University's epidemiologist John Ioannidis believes that the infection fatality rate (IFR) of Covid-19 can vary from less than that of Influenza to ten times more.  It all depends on case mix, how patients are treated and what age group is infected.  It is known that almost 80% of the deaths are individuals over the age of 80 or those with poor health due to risk factors.  Since several countries  such as Taiwan, Singapore, S. Korea and Japan have dealt successfully with the viral epidemic, hopefully the rest of the countries can decrease their fatality rate if a second or more waves take place. (In the picture the US daily fatality rate as depicted in a NYT article)   

Taiwan, Japan, Sweden and Greece; a tale of four countries.

Early in 2020, the world started taking notice that a novel coronavirus disease, was spreading in the Chinese city of Wuhan.  It was later named, SARS-CoV-2 and the disease Covid-19.  As of today, there are slightly more than 6 million confirmed cases around the world and the global death toll has surpassed 370,000.   

Taiwan is an island nation of 24 million that sits just 70 miles from China.  More than four-hundred thousands of its citizens work in China and more than 2 million Chinese visit Taiwan every year thus a massive outbreak of the disease named Covid-19 seemed all but inevitablefor Taiwan would be one of the hardest hit countries.  Yet despite the odds, Taiwan has recorded only 441 cases of the disease as of today, with only 7 patients dying.  

So how did Taiwan manage to have so few cases and so few deaths from the disease.  First and most important Taiwan enacted prevention measures early.  On Dec. 31, the day the Wuhan authorities announced that there were several patients with an unidentified type of pneumonia, Taiwan activated stricter control measures with testing of incoming travellers with fever and questioned suspected travellers about their contact history.

On Jan 20, Taiwan activated its Central Epidemic Command Center (CECC), which rolled out more than 124 measures such as banning all exports of surgical masks and providing all its citizens with two free masks.  On Jan 26 it banned travel to and from Wuhan.  According to a March 3 article published in JAMA, the CECC rolled out measures that included border control, case identification, quarantine for all travelers from regions hard hit by the disease, and postponing the reopening of schools following the winter break.  The center also served as the source of information for the public, with daily press conferences that provided the population with reliable and easy to understand information about the outbreak.  It was thanks to these measures that Taiwan experienced one of the smallest fatality rates in the world of only 0.3 deaths per million.

Japan went its own way, limiting tests to only the most severe cases.

Japan — the grayest country in the world and a popular tourist destination with large, crowded cities — has one of the lowest mortality rates from Covid-19. Τhe government never forced businesses to close and the medical system did not get overwhelmed. 

Japan focused on quickly containing small outbreaks through contact tracing. It has focused on lessening people’s anxiety and stressing the basic science of prevention: wash your hands, wear a mask, keep your distance from others.

A public education campaign urged people to avoid the “Three C’s” which are closed spaces with poor ventilation, crowded places and close contact.

Last week, Prime Minister Abe declared Japan’s battle against the outbreak a success, taking the country off its “lockdown lite” that lasted only a month and a half.  Japan experienced one of the smallest fatality rates in the world of only 7 deaths per million.

As the virus spread across Europe, many Greeks feared that Greece would be hit as bad asItaly and Spain.  On Feb. 27, a day after the country’s first Covid-19 case was diagnosed the government canceled the annual carnival and all sporting events and on March 11, it closed down schools and universities. Two days later all travelers from abroad had to go through a two-week mandatory quarantine.  It also closed down cafes, restaurants, libraries and museums.  Attendance of mass in churches was also forbidden even during Holy week and Easter. 

Everyone in the country during the 2 ½ months lockdown had to request permission by sending an SMS each time we were to leave our homes, to go to supermarkets, doctors’ offices, pharmacies to visit and help our elderly relatives, to go for a walk or risk a fine.

(Picture of an empty Monastiraki square in Athens with view of the Acropolis in the background.)  

The government established a council of experts who issued information and advice on a daily basis.  It was the willingness of most Greeks to comply with experts’ suggestions that brought about an outstanding result of only 2,915 confirmed cases and 175 deaths as of today.  Greece similarly to Japan tested for the virus less than 1 percent of the population. As of today, 15,903 tests per million were performed mostly on people admitted to hospitals with symptoms and those who have been in contact with confirmed cases. Spot tests on travelers coming into the country from abroad were performed as well.  For comparison purposes Germany and Austria countries that also had very good results performed 47,194 and 47,477 tests per million of inhabitants respectively.  

As of this week, the number of cases and more important the number of deaths per million comparing to other European countries point to a Greek success story.  So, what was Greece’s good result due to?  First, as Taiwan, Greece enacted its plan, a strict lockdown, earlier than most European countries.  Second, the population of 11 million Greeks lives in a mainland which is mountainous, the size of which is 50,000 square miles, and which is surrounded by two seas the Aegean (82,000 square miles) and the Ionian sea (65,000 square miles) with more than a thousand islands,  thus the country is sparsely populated as its physical characteristics make contact between villages and small towns difficult, which after all was forbidden during the lockdown.  Third, most of the Greeks accepted the enacted recommendations of social distancing and adhered to its principles.   Greece experienced one of the smallest fatality rates in Europe of only 18 deaths per million.

(Picture of a deserted beach in Porto Rafti, Greece)

Sweden's controversial plan to deal with the coronavirus allowed for people to go outside, visit restaurants, bars  and shops as long as they kept distant from each other.  Sweden closed high schools and universities and did not allow gatherings of more than 50 people.  Although not everyone in Sweden is happy with this approach, the majority of the people were satisfied.

Anders Tegnell, who advocated this approach, estimated that 40% of the people in Stockholm will be immune by the end of June which will give the country a big advantage, as most of the countries will experience a “big second wave” later this year.  As of May 20th, only 7.3% of Stockholm’s inhabitants have antibodies to Covid-19.  He also said the “lockdown strategy” has not scientific basis especially when it comes to the young and children as they do not transmit the disease.   Sweden has reported zero coronavirus deaths in the last 24 hours, for the first time since March 13.  Sweden experienced fatality rate was average in Europe with 440 deaths per million.

So, which approach should countries follow in the future when an infectious disease appears to be spreading and the danger of an epidemic is real?  Extensive testing such as performed in Singapore allows authorities to quickly determine who is infected and isolate them.  More than 90% of cases in Singapore  were mostly young, healthy men. Of those who died, 95% were more than 60 years old, while the vast majority of those infected were between the ages of 20 and 59. 

Taiwan’s and Greece’s success stories suggest that an early detection of a pandemic and enactment of measures for its control minimize the number of cases, flattens the curve and deaths.  

The “lockdown light’ approach of Japan also ensured a low death fatality rate.   

The open society approach with social distancing as it was practiced in Sweden has higher death toll but left the economy minimally affected.  

All four countries followed their experts’ advice and their policies did not become a source of political discord.  Unfortunately, fear and politicization of crises stigmatize governments or groups of people without helping to solve the challenge at hand therefore are ultimately unproductive.  Hopefully, in 2021 an effective vaccine will become available that will limit the prevalence of the disease.  Past pandemics such as the 1918-1919 Spanish flu, still have lessons we all can learn and benefit from as most viral pandemics have similarities therefore similar measures such social distancing, wearing masks when in crowded places, washing our hands often, use of hand sanitiser,  sneezing and coughing etiquette, often help in their control.  

Finally, going out for a walk and spending time in nearby park or nature reserve reduces stress and help us feel healthier and happier.  Looking at greenery and listening at nature’s sounds including total silence afforded to us in remote areas can boost our sense of well-being.   

Well, my friends this is the last post on pandemics and Covid-19.  In my opinion the pandemic will die down on its own as most epidemics do and all of us those infected or not will remember the Covid-19 epoch for the rest of our lives.

(Picture of the view and the undeveloped path  I took my daily walk that helped my mood during the lockdown) 

Corona virus

Some maybe wondering why I post about the Coronavirus in a blog devoted primarily to traveling.  Because viruses travel along with humans.  The reason they named the novel virus Corona virus is because under electron microscopy it looks like the crown royals wear.  Corona viruses and Rhinoviruses are the etiologic factors of common cold.  Most of the colds in the winter are due to Corona viruses while those in early fall, spring and summer are due to Rhinoviruses.   The novel Corona virus was recently renamed to Covid-19 belongs in the family of viruses that humans and other mammals harbor in our bodies. 

Covid-19 emerged in Hubei province in central China in late December 2019 and subsequently spread in 59 countries around the world.  As of March 6, 2020 at 12:15 UCT/GMT the World Health Organization (WHO) reported 100,242 infections and 3,408 deaths.  China the epicenter of the epidemic has reported 80,559 infections and 3,042 deaths.  South Korea has reported 6,593 cases and 42 deaths while Iran is next with 4,747 cases and 124 deaths and Italy follows with 3,858 cases and 148 deaths. The overall death rate is 3.4% but this is not an accurate estimate as it does not take into account the mild or asymptomatic cases that are not recorded.

Interestingly according to the Centers for Disease Control and Prevention (CDC) there have been 30-40 million million flu cases, and between 15-40,000 deaths in the 2019-2020 flu season in the USA alone, a disease that can be prevented but individuals decide not to get vaccinated to their and other people peril.  

The most common symptoms of Covid-19 infection are fever, headache and coughing as the virus tend to affect the lungs.  

Although it is impossible to avoid completely exposure in an epidemic there are several precautionary measures that people should take such as covering their nose and mouth when sneezing or coughing.

The simplest and most effective measure in the dissemination of the virus is washing hands with soap and water if we believe we’ve touched surfaces contaminated by nasal excretions. 

Wearing masks is a sensible way to prevent exposing others and maybe avoid viral exposure to ourselves.  Other reasonable precautions are avoiding contact with live animals that are known to harbor the virus such as bats, and finally avoiding eating uncooked meat. 

As in every epidemic people should exercise reasonable precautions while in the same time excessive measures should be avoided.  We should remember that similar epidemics have taken place in the past.  The MERS viral epidemic had a mortality rate of 10% while the SARS had a mortality rate of 5%.  The Corona virus mortality is estimated to be between 1-2%.  (Doctor Schnabel of Rome, is coper engraving by Paulus Fürst of a plague doctor in 1656)

Needless to say, that the mortality rate of the above-mentioned epidemics was negligible when is compared with the Plague or Black Death which is estimated to have killed 25 million individuals that represented one third of Europe’s population. The plague may have reduced the world population from an estimated 475 million to 350–375 million in the 14th century. (Image Saint Sebastian interceding to God for the Plague stricken. By Josse Lieferinxe exhibited at The Walter’s Art Gallery, Baltimore, Maryland, USA)