14 days to freedom

If you have been following my blog since the beginning (thanks!) you may have seen my post of the benefits of self-isolation and 14 days to freedom.

Well, guess what? My time is up!

As I post this we are passing day 25 in lock-down and I have had no symptoms, not even a mild cold.

As far as I’m concerned, that means FREEDOM!

Freedom from fear, freedom from anxiety but not, unfortunately, freedom from quarantine.

So when can we expect life to go back to ‘normal’? Read on.

This week, I’m revising my original predictions, comparing the latest data from China against EU countries in advanced stages of the epidemic (Italy, Spain & France), to understand when current quarantine conditions may be reduced.

Be warned, the next few sections are full of data, but by the end I hope it will all make sense 🙂

Success in China

First, the good news.

According to the latest data as of 23 March, 2020, more than 73,159 patients with SARS-CoV-2 pneumonia have recovered and been discharged (3).

Hubei and Wuhan reported no new confirmed or suspected cases for five consecutive days, and the number of confirmed cases continues to drop.

Deaths have been predominantly in single digits since March 13th.

People have returned to work, schools are re-opening and travel bans have been relaxed through the strict implementation of social distancing, the use of masks and widescale testing.

China is aggressively testing, isolating and quarantining every new case of Covid-19 and using social media and geolocation data to track and inform anyone who has had contact with an infected individual.

And every exposed individual is required to self-isolate for 14 days, enforcement of which is through advanced community surveillance.

The current EU situation

In Europe, Italy’s number of confirmed daily deaths has been in decline since March 28th.

Spain and France have also seen declining numbers since April 4th and 5th, respectively.

EDIT: The numbers in France showed a large increase on 08/04 due to the addition of rest home deaths and cases which are now being counted in the countrywide total.

More time needs to pass to confirm this trend, however, it matches the most recent trajectory of Covid-19 in China (more on this below).

The reported number of deaths is the most accurate measure for the epidemic, due to insufficient and inaccurate global testing.

These results indicate that current non-pharmaceutical prevention methods are working to significantly decrease the spread and rate of transmission of SARS-CoV-2, the virus that causes the disease, Covid-19.

Understanding the rate of transmission

The spread of an emerging infectious disease is measured via the rate of transmission, or Rt.

The measurement of Rt is only relevant when it’s a new disease with no known vaccination and no way to control the risk of spread.

• When Rt is maintained at less than 1, it means that an infected person will infect less than 1 other person and the spread of disease will decline.
• If the Rt is greater than 1, it means an infected person will spread the disease to the number of people indicated by Rt and infections will continue to increase until the epidemic peaks and declines due to herd immunity.

For example, at the start of the epidemic in China, the rate of transmission was Rt4.4. Meaning that one person spread the disease to 4 other people and so on and so forth (2). Hence exponential growth.

The Rt in China is now 0.94.

Rt in Europe

WHO currently estimates the global Rt for Covid-19 to be between 2-2.5.

In general, this means that without intervention, every single person infected with SARS-CoV-2 will infect between 2 and 2.5 people.

In France alone this would lead to 1.6M infected and 55,482 deaths.

Initially in Europe, the average Rt was estimated to be 3.87, reducing to 1.43 following non-pharmaceutical interventions i.e lock-down.

Proving that quarantine has a positive effect on controlling the rate of transmission of SARS-CoV-2.

So far, only a small proportion of the global population has been infected, on average 4.9% with variances between 1.9% – 11% depending on population demographics, living conditions, access to clean water, Government action and public response.

This is only an estimate as widescale testing for the presence of antibodies in people who had no or only mild symptoms has not yet commenced.

However, these estimates imply we are not even close to herd immunity (50-75% of entire population) and lifting the lockdown will require careful management to avoid a large recurrence of cases.

Ending lock-down

Using China’s trajectory, we can predict when countries in advanced stages of the epidemic (Italy, Spain, France and to a point UK) can expect a reduction in lock-down interventions (click to enlarge).

However, this virus is not simply going to go away following the quarantine period.

While non-pharmaceutical intervention methods are doing an excellent job at controlling the rate of transmission, once the quarantine is lifted, and without a vaccine, alternative methods of control must be established.

These alternative methods involve advanced information on epidemiology and a step-by-step approach including:

• Finding, testing and isolating every new case of Covid-19
• Tracking and quarantine of all contacts
• Strong community education, participation, and ownership around normal physical distancing
• Adherence to hygiene standards (handwashing, coughing into your elbow, wearing a mask and self-quarantine when sick)
• And giving communities the power to control infection by managing distances and capacities.

While China is exploiting and use of individuals’ personal data to track and trace carriers of Covid-19, this is unlikely to be accepted within a democratic country.

So the major method of control of this virus is up to you and me.

To stop the spread of the virus we must all work together to protect one another and the world around us.

Undoubtedly, our lives are going to be vastly different from anything we have ever known for at least the next 12 months and its how we handle this situation now, which will make the difference to our future.

Moving forwards

The end goal is to stop transmission completely and this requires a concerted effort by all of us.

Herd immunity through exposure or vaccination is currently not a viable option.

The countries covered in this study and many others will remain in lock-down for the next 3-4 weeks and strict adherence is essential.

Even if you have not been in contact with another person, outside of your home, in 14 days, A-symptomatic individuals can transmit the virus for up to 24 days (2).

In addition, if you have been sick, in some cases the virus is still present and transmittable, up to 14 days post-recovery.

Adhering to strict quarantine measures for 6 weeks is the minimum amount of time required to reduce rates of transmission close to Rt = 1 and give healthcare facilities time to catch up.

Once the 6 weeks are up, strict control of population movement is required to maintain the positive results of quarantine.

This means no big parties, no large events, and no immediate travel.

In the coming weeks, some businesses will be able to open but under strict guidelines of good hygiene and social distancing.

If you consider that just one person has the potential to infect another 2-4, you can understand the reason to exercise caution.

In regards to the Governments response and the re-opening of schools and public spaces, advanced information on the epidemiology of individual populations is required.

Schools and public spaces in locations with no confirmed cases are likely to be able to return to normal well in advance of areas with ANY cases.

Before any decisions can be made, country-wide antibody testing and the effect of Covid-19 on individual age groups is required.

Along with the identification and isolation of EVERY SINGLE CASE and every potential for onward transmission.

Post quarantine, if you get sick, you need to be tested (and isolated) ASAP and every single person you have had contact with, in the 14 days prior, notified, tested and isolated.

Controlling the spread of Covid-19 and protecting the vulnerable will take a coordinated effort from every single one of us.

And we must stop thinking about our individual needs and consider the impact our actions have not only on another person but on our global collective freedom.

Ending Covid-19

The end of Covid-19 is currently only possible by stopping transmission and this is up to you.

Herd immunity can only be achieved through vaccination or exposure of 75% of the population to the disease.

That’s the worldwide population – not just in country.

Currently, less than 5% of the global population is estimated to have been exposed to SARS-CoV-2 and until widespread antibodies testing is available, natural herd immunity is impossible to predict.

The course of natural herd immunity would lead to 116M deaths based on 75% of the population being infected and approximately 2% dying.

While scientists around the globe are in an arms race to create a vaccine, its unlikely to be ready during the course of this epidemic due to the complex approval stages required for extensive vaccine use.

And even then – we need to vaccinate 75% of those who have not had Covid-19.

The best we can hope for is a positive public response and advancement in the treatment and management of patients with Covid-19.

Treatments for Covid-19

There is currently no cure for Covid-19, however the following treatments are being tested to reduce limit exposure and aid in recovery:

• Chloroquine phosphate, an anti-malaria drug is being tested by healthcare workers to reduce the rate of transmission, pre-exposure.
• In a case study of 6 patients based in France, early trials combining Azithrimgin, an antibiotic that fights bacteria with hydroxychloroquine has had a 100% success rate in curing the viral disease.
• Convalescent plasma therapy using virus-free plasma containing SARS-CoV-2 specific antibodies, taken from recovered Covid-19 patients, has aided in the recovery of critically ill patients.
• The UK is close to finalising an ‘at home’ recovered antibodies test that will be available at pharmacies and online with Amazon.

So while there is positive action happening all over the world through the collaboration of scientists, healthcare workers, and Governments, those of us who are sitting at home need to think about what our next actions will be to prevent the spread of disease.

How can you implement good hygiene and social distancing into your daily life and business and how can you support your community to do the same?

WORLD HEALTH DAY

Today is World Health Day and along with the World Health Organisation, I want to say a massive THANK YOU to all the healthcare workers who are being pushed to their limit in this time of global need.

You are all amazing. Thank you!

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References

(1) Estimating the number of infection and the impact of non-pharmaceutical interventions on Covid-19 in 11 European Countries. Imperial College COVID-19 Response Team.

Leung, C. (n.d.). The difference in the incubation period of 2019 novel coronavirus (SARS-CoV-2) infection between travelers to Hubei and nontravelers: The need for a longer quarantine period. Infection Control & Hospital Epidemiology, 1-3. doi:10.1017/ice.2020.81

(3) Qiang Shu. Epidemiological analysis of COVID-19 and practical experience from China. Approved for publication. doi: 10.1002/jmv.25813