28 February 2020

Getting ready for a COVID-19 pandemic

Communicable Disease Global Health Respiratory

Prime Minister Scott Morrison has called COVID-19 a pandemic, triggering the implementation of Australia’s emergency response plan and strengthening Border Force capabilities to stop potentially infected people entering the country.

While the epidemic centred in Hubei appears to have peaked and to be in decline, SARS-CoV-2 is now present in more than 40 countries.

As Mr Morrison made the announcement yesterday afternoon, Australia had still had only 23 cases, 15 having come from China and recovered, the rest recently evacuated from the Diamond Princess. Thousands have tested negative and there has been no community transmission.

With 82,500 cases and 2800 deaths so far, the virus now has a presence in more than 40 countries, with community transmission and deaths in in South Korea, Italy, Iran and Japan.

The World Health Organisation is still resisting the “P-word”. Dr Tedros Adhanom Ghebreyesus said earlier yesterday that using the word carelessly “has no tangible benefit, but it does have significant risk in terms of amplifying unnecessary and unjustified fear and stigma, and paralysing systems”.

But Professor Raina MacIntyre, head of the biosecurity program at the University of NSW’s Kirby Institute, told TMR yesterday the government’s response was “a reasonable call”, as the virus was spreading in Europe, aided by its lack of borders under the Schengen agreement, and around Asia and the Middle East.

The government has also extended a travel ban on people coming from China, despite criticism from the WHO that such bans were not effective.

“They definitely are,” Professor MacIntyre said. “It’s travel that’s a vector for infections around the world. We’ve seen it with so many different infections – Ebola, SARS, MERS coronavirus – where an outbreak starts in one country and spreads through aeroplanes. So yes, if you stop flights coming in from affected areas you will stop cases coming in.”

A landmark was reached on Wednesday when for the first time more new cases of the illness were reported outside than inside China.

“Simultaneously China is bringing its epidemic under control but it’s popping up in other countries,” Professor MacIntyre said.

“All that effort that China put into the lockdowns and travel restrictions – which was effective and did have a massive impact on the transmission – has to be matched by every other country. Otherwise we’re going to see it taking off in another country with a massive population and less capability than China to jump on it.

“I don’t think we could enact the same kind of lockdowns in Australia. Certainly the US wouldn’t be able to because of the strong focus on individual rights, whereas in China that was possible. When it comes to the control of infectious diseases, the kinds of measures that work are quite draconian measures.”

The case fatality rate is still hard to estimate but appears to be around 3% in Hubei and lower elsewhere.

Even 2 or 3% would have heavy implications for the Australian health system, Professor MacIntyre said, since sustained transmission could result in “anywhere from 25-70% of the population getting infected”.

On top of the death rate in China, she said, 14% of cases were hospitalised and 5% needed intensive care beds. That translated to up to 400,000 Australians dying, almost two million people needing a hospital bed and 650,000 people needing an ICU bed.

But our countries’ different age profiles meant SARS-CoV-2 could cause more severe illness and death in Australia than China.

“We have an ageing population, much older than the Chinese population,” Professor MacIntyre said. “So proportionate to our population size we could see more of an impact.

“High-income countries have advanced medical care that keeps people alive longer. But there are biological factors with ageing that no amount of money can fix. Our immune system start to fail at the age of 50 and it fails exponentially from then on, no matter how rich or healthy you are, so older people are at greater risk for any infection.”

She said since so many supply chains out of China had been affected, and China produced many pharmaceutical components, it was possible that medicines shortages would ensue.

The Australian Health Sector Emergency Response Plan for COVID-19 says that “if a global pandemic develops, it would be almost impossible to prevent widespread community transmission in Australia … A significant local outbreak of COVID-19 would place very substantial pressure on the health system.”

Even a disease of moderate clinical severity might require “surge staffing” in hospitals and dedicated clinics, leading the medical community to wonder online where that extra capacity would be drawn from.

GPs should contact their PHNs for help obtaining personal protective equipment such as masks, it says.

RACGP president Dr Harry Nespolon has been calling for more protective equipment, more consistent messaging from the various levels of government and a role for GPs in planning for a pandemic. He is also calling for the temporary introduction of a Medicare telehealth item so GPs can be remunerated for assessing patients over the phone.

This week in the US, the first case of unknown transmission appeared in California, just as the CDC was warning Americans to prepare for community spread. In a move that has reassured absolutely no one, US President Donald Trump assigned his Vice President Mike Pence to lead the administration’s response.

Research into prevention and treatment are proceeding at record speed, but still not fast enough to affect patients in the current round of infections.

Biotech company Moderna announced its vaccine was ready for Phase I human trials, after a mere six weeks in development; the testing and approvals process will take at least a year.

A University of Queensland team has also created a vaccine candidate in just three weeks, but is still months out from clinical testing.

Gilead is expanding trials of its promising antiviral remdesivir to countries outside China. Results from a trial already under way in Wuhan are expected in April.

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