COVID-19 Update

We have explained throughout this process the important distinction between the disease and the epidemic. These are two very distinct concepts. The battle against the illness is fought within the body. The fight against the sore throat, cough and in more severe cases pneumonia and multi-system immune insult. We have described the symptoms and what to do if you think you have COVID-19 here. For most people the infection will be mild and self-limiting. For a smaller number of people COVID-19 will need treatment in hospital. Vulnerable individuals, especially older men with other illnesses, seem more likely to develop the immune complications and some die. There is so much information that it can be hard to keep things in context. In Hong Kong everyone who is diagnosed with COVID-19 is admitted to hospital as a matter of public health policy. A small number of patients remain seriously ill and for some there may be a degree of residual lung damage, at present unknown, but for the majority of people, COVID-19 will be a relatively mild illness. Most of the recent patients have mild or no symptoms. In this context, the number of reported ‘recovered’ cases is misleading. Recovered cases in Hong Kong and China are based upon negative viral testing at an interval. This is not the same as getting over the flu because I “feel better”. There are many cases that have recovered in a traditional sense and some that never had symptoms. These people are sitting in hospital, feeling perfectly well but waiting for their tests to become negative for discharge. Recovered data in media charts is really of no value.

To explain that a disease is not generally serious on a case by case basis is not to say it is not important. COVID-19 is clearly an enormous public health challenge. A disease with a low case fatality will still kill a lot of people if it spreads widely. The nature of this disease means that is can overwhelm health systems, especially intensive care facilities. Numbers need context to give meaning and allow assessment of risk. COVID-19 has killed 45,000 people and the number is currently increasing. Measles kills 140,000 every year, mostly children, Influenza kills 650,000, 1.8 million die of gastroenteritis, again mostly children. Exactly where COVID-19 will sit on this list will be determined by the public health response to the epidemic and it will only be possible to be certain in retrospect.

Very early in this process we suggested that viral load may play a role in disease severity. There is now very good evidence that this is the case. It is a sad fact that any disease which kills health care workers at a higher rate than the rest of the population, is likely to reflect factors related to infectivity and viral load. In China, the excess mortality in healthcare workers was brought under control with meticulous infection control measures and personal protective equipment (PPE). The supply of medical equipment both for the provision of medical care and to protect health care workers, is one of the greatest challenges in this epidemic.

Whilst the battle against the disease is fought in the body and in hospitals, the battle against the epidemic is fought in the community. It is the blunt tools of education, information, testing, case identification, quarantine and social distancing that will win this battle.

There is still a fundamental misunderstanding about the principles involved in managing an epidemic. This virus is not floating around in the air like dragonflies. The majority of cases are occurring through family or other social clusters. The SARS-COV-2 virus is essentially a string of genetic material in a blob of fat. It has no will or self-determination. If it isn’t coughed into your face it falls to the floor or surfaces where it can only be transported by third parties. It can live for a while but is killed by soap and water, detergents, heat and UV light. If we wash hands regularly, maintain hygiene and observe the public health regulations especially social distancing at times of increasing community risk, we have some good models that suggest we can bring this epidemic under control.

In the management of infectious disease we must remember the lessons of the past whilst being mindful of the specifics of the present. As an example of not forgetting the past we review some recent evidence for Vitamin B3, which has recently been shown to have some value in the treatment of HIV and TB and may yet have a role in COVID-19.

Two weeks ago we described the importance of the epidemic curves in Italy as an important early sign of the modified containment and social distancing measures of Europe, in comparison to the structured testing, case identification and compulsory quarantine in Hong Kong, China and Singapore. There are continuing signs that the epidemic curves in Europe are coming under control. It is important to focus on the rate of change of new cases and not the cumulative number of deaths. Cumulative deaths will continue to rise until the epidemic ends and the rate of deaths will lag the resolving epidemic by 2-4 weeks in each location. Recent data suggests the UK is 2 weeks behind Italy so 4-6 weeks is a reasonable estimate for the European epidemic to settle accepting inevitable uncertainties. We will continue to keep the epidemic curves up to date HERE.

Recognizing the amount of information available on COVID-19 we will continue to keep our summaries on the disease and the epidemic up to date. We have also produced a summary of frequently asked questions. It remains our position that given adequate reliable and balanced information most people will feel less anxious about the situation. Remember that 99.99% of the Hong Kong population have not been diagnosed with COVID-19 but 100% of us have been impacted by the public health measures, the economic fallout and the anxiety. Anxiety is fundamentally about change, uncertainty and lack of control. Information and education are the key factors in the management of infectious disease and anxiety.

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