Health May 4, 2020
Lessons from around the world – successes and failures in the Covid-19 pandemic 

By News - World Healthcare Journal

Coronaviruses are very common in animals, and they often cause mild diseases - such as a type of common cold. For a long time, they’ve been known to be transmissible among species, but they can be quite dangerous to humans.

The SARS epidemic, which was identified in November 2002, ended in July 2003 with 774 deaths and more than 8000 cases. There were 2,500 cases of MERS, which is the most lethal of them all and not finished yet, mainly in Saudi Arabia, the Arabian Peninsula, and also in South Korea with a high mortality rate.

However, the big difference between SARS, MERS, and the new Covid-19 virus, is the fact that even though the new Covid-19 virus seems to be less lethal at present, shedding of the virus can take place before symptoms appear - which is obviously an enormous challenge.

Normally, we contain epidemics and infectious diseases by quarantining people the moment they develop symptoms. But, if people are shedding the virus and potentially being infected before they even realise - how can you figure out who is going to get Covid-19, identify them, and quarantine them?

Learning from history 

The great pandemic of 1918, commonly known as the Spanish flu, affected a third of the global population - and caused 50m deaths. It was the second wave of the Spanish flu which was the most lethal, the largest contributing factor was because it was in wartime. The people who were well enough stayed in the trenches, putting themselves at further risk of exposure, and the people who are too sick were transported on crowded trains, and went straight into overburdened field hospitals – the inevitable result was enormous transmission.

The second wave of Spanish flu also caused mayhem. Enormous numbers of people were killed, often from a large immunological response - the cytokine storm  - associated with these coronaviruses. What's also interesting is that there was a third wave in 1919, and then it mutated. In many respects that could well be a concern with Covid-19.

If the world is to contain this pandemic, the solutions must be based upon epidemiological interventions, but also on political interventions and cultural issues. There are also human liberty issues, privacy issues, the list goes on. There are a whole series of factors which need to be considered and will take time to get right.

Potential solutions 

We have potential solutions – and the number one is obviously elimination but to achieve it would require a near-impossible level of cooperation.

But, eliminating and containing it is not impossible - in other words, the famous "flattening the curve"  - to ensure our healthcare systems don't get overwhelmed, using isolation, quarantine, social distancing and community containment, amongst others such as shielding and travel restrictions.

In my opinion, herd immunity is the only answer. But If that doesn't work, why bother to vaccinate? Vaccination is essentially trying to ensure you get a level of immunity within the population. There is huge potential for vaccination to work and we see many institutions developing them currently. Of course, there is also a potential for a cure – but these are all things that we do not have right now.

In the longer term, the end state for Covid would likely be through a mutation of the virus. That's certainly a distinct possibility. And secondly, that's what's happened in, we think, in the 1918 pandemic.

The Asian response 

Taiwan has 12m people and an ageing population. This is important, of course, because we know that Covid tends to affect older people more than anybody else. To date, they’ve had 429 confirmed cases and just six deaths - remarkably small numbers.

On hearing that there was an atypical pneumonia on 31 December, Taiwan actually emailed WHO, saying this could potentially be another MERS or SARS. They immediately initiated quarantine for people coming from Wuhan on the same day. Within a week, they had set up national committees to monitor the disease, and by the end of the month, they practically eliminated Covid within the country.

They introduced enormous amounts of technology around this strict quarantine, including apps for traffic control, dedicated taxes, food specially sent to vulnerable people, tracking and tracing people using GPS, employers reporting weekly on their employees. More importantly, the hospitals immediately segregated people coming into hospitals - so they were never a centre for spreading disease.

In South Korea, we saw extensive use of technology in the same way. It has a much bigger ageing population of 50m but, at the last count, only 10,750 confirmed cases with 244 deaths.

South Korea is the only country with experience of both SARS and MERS. So, they immediately turned the taps on the moment they got their first case in January. They had the issue with the church at Daegu – but they introduced all sorts of innovative systems, such as drive-through centres with positive pressure on one side, apps with built-in self-diagnosis, and a lot of contact tracing using GPS.

What's interesting about South Korea, even disregarding the Covid-19 crisis, is the fact that they use an enormous amount of cellular broadcasting services on their mobile phones. They really showed the world how you can use technology to its fullest extent.

Singapore has 14,000 confirmed cases and 14 deaths, their population is 5.6m, ageing again. Their first case was on 23rd January,  a Chinese man from Wuhan. They ended up in a situation where they had a quite serious epidemic, but very quickly put things under control.

Sing Health, the hospital complex that manages the east of Singapore, already had an automated visitor management system to register and review visitors coming into hospitals. This is the message from the Far East and from Asia: it’s all about systems which have already been set up.

The Middle-East method 

Saudi Arabia is the place where MERS was a significant problem with a population of 33.7m, not as ageing to the same degree as the Far East countries or European countries. They had 18,800 confirmed cases and 144 deaths, with the first case on 2 March, a Saudi national returning from Iran via Bahrain.

But, it is their use of technology which has been really interesting, particularly the “Mawid” app, which assists people in making self-diagnosis of their condition. This ties into the “SEHA” app,  the system which their Ministry of Health uses for managing consultations.

It's a wholly integrated system, and it is pretty impressive seeing that working. But we need to remember that they're in a situation where they used to having a large influx of people coming into their country, particularly during the  Hajj, which takes place over five or six days every year, and last year attracted 2.4m people.

Again, a lot of systems were already in place. The ministries immediately shared data, working very closely, and it shows in the way they managed the process.

All these countries have systems which assist an individual digitally and the government has a grip on what is going on around their country. In other words, they were ready.

The European response 

Italy is clearly one of the most interesting places, because with a population of 60.3 million, it really is the ageing centre of Europe. They have had just over 200,000 cases confirmed and at the last count, over 27,000 deaths.

I want to identify the differences in approach in north Italy, the epicentre of the pandemic in Europe.

Lombardy has a population of 10m, while Veneto has 5m. In Lombardy, there were 13,500 deaths approximately, and in Veneto, there were 1,300 deaths - that's an extraordinary difference, even if we take into account the concentration of the population.

 In Lombardy, they insisted on hospital admission immediately for everybody so they ended up in a situation where a lot of the workforce got infected. And then, of course, the workforce infected a lot of the people within the hospitals – it's a vicious cycle.

However, Veneto did the opposite. They only managed and assisted people in getting into hospitals when they had to, and tried to drive community management. In Lombardy, they were quicker to ventilate patients, and perhaps that had an effect, especially,  with older, multimorbid, patients. The likelihood is they can get secondary infections, and we need to remember that north of Italy is also an epicentre for anti-microbial resistance. Furthermore, the surveillance system in Italy was very regionalized, so it was very difficult to get a handle around what was going on in the rest of the country.

Germany has an ageing population of 83m people but has had only 6000 deaths. They started testing and tracing early, and the PCR test, which was developed at the Charite Hospital in Germany, is the one which was taken up by the World Health Organisation as the standard for identifying people with Covid. They are great lovers of infrastructure in terms of ventilated beds and workforce that goes with them, again important.

So not only did they manage the curve, but they also didn't displace anybody from ongoing treatments. They managed to share data in a way which I've never seen before - the Germans have done something here which is really quite extraordinary.

Denmark, when they had their first 500 cases confirmed on 11th March, immediately locked down as a country with no half measures. They continued to track and trace all the way through them and have continued since.

Finally,  Sweden is the big enigma in many respects. They had 19,900 confirmed cases, 2200 deaths, with a population of 10m- so the rate is four and half times that of Denmark. However, they didn’t use any community lockdown measures at all - and of course, potentially economically they could well be in a better position once this is over because they haven't had a shock to the system for the length of time that other countries have had.

An outbreak amongst their older people in care homes, despite the fact they tried to shield them, is responsible for half the deaths in Sweden and they're not quite sure why this has happened to date. And today, we don't know where this is going to end in Sweden. They could well be in a better place once the whole second wave comes through, and they could be the shining example, because at the end of the day, they will have greater herd immunity at the moment than we have.

In conclusion, what do we need to do at the moment to be in the best place for the second wave? The answer is simple - we need to invoke the power of the private, voluntary, and pharmaceutical sectors to get ready for Covid and non-Covid patients. This is about all of us. In some respects, in some countries, the differences in approach are very similar to what happened in 1918.

But most importantly, we must explore the potential for the new normal. It has taken years to get to where we are now, and there's a very real opportunity around the Covid pandemic to better our health systems as we come out of the pandemic.

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