LONDON – The COVID-19 outbreak appears to be sliding toward pandemic status, with the virus spreading to four more countries and confirmed cases and deaths mounting in infection hotspots in Italy, Iran and South Korea.

Parts of northern Italy are in lockdown, with 200-plus cases and seven deaths. Austria and Switzerland are reported to be considering closing their borders with Italy, and the EU has responded with a €232 million (US$252 million) package of aid, including €90 million for development of a vaccine and €10 million for therapeutics and diagnostics.

After confirming its first case as recently as Feb. 19, by Feb 24 Iran had reported 61 cases and 12 deaths. That number seems likely to increase as diagnostic testing gets into full swing. Neighboring countries have closed their borders, after the infection was spread by pilgrims returning home from holy sites in Qom, Iran.

Meanwhile, the number of cases in South Korea rose by 256 to 602 over the weekend, with five deaths recorded in total.

Tedros Adhanom Ghebreyesus, World Health Organization (WHO) director general, agreed the sudden increase in cases in Italy, Iran and South Korea is “deeply concerning” and acknowledged he understands why there is so much speculation about whether that means COVID-19 is now a pandemic disease. But he said, at present, there is no international uncontained spread.

“Does it have pandemic potential? Absolutely it does. Are we there yet? No,” Ghebreyesus said in his daily update on the state of play. The focus for now should remain on containment, whilst also preparing for if COVID-19 does become a pandemic disease, he said.

The latest figures from China are 77,362 cases and 2,618 deaths. In the 24 hours to 6 am CET on Feb. 24, there were 460 new cases and 150 deaths. Ghebreyesus said he is encouraged by the continued decline in cases in China.

Earlier on Feb. 24, the WHO joint expert mission to China presented its findings after two weeks traveling the country, talking to clinicians, tracking the epidemiology and assessing containment measures.

Bruce Aylward, leader of the mission, said the evidence is the epidemic peaked and plateaued in the country between Jan. 23 and Feb. 2, and has been steadily declining since then. The strict control measures that were put in place have saved hundreds of thousands of people from contracting the pathogen in China. There is no question that the “bold response” has changed the course of a rapidly escalating and deadly epidemic, said Aylward.

Two weeks ago when Aylward arrived in China, there were 2,500 new cases every day. Two weeks later, the number of new reported cases is 460. “That’s an 80% decline, and the decline we’re seeing is real,” he said.

The country rolled out the “most agile and aggressive disease containment exercise in history,” initially deploying old-fashioned measures such as handwashing and temperature monitoring. “But then very quickly, as the epidemic evolved, the response started to change. It moved from a one-size-fits-all, to a science and risk-based approach,” Aylward said, presenting the mission’s findings at a briefing in Beijing.

Some relief in sight

Amongst their conclusions, the WHO team found there has been no significant change in the DNA of the virus since the first genome sequence was released on Jan. 11.

Between 2% and 4% of people who contracted COVID-19 in Wuhan, the city at the epicenter of epidemic, died. Patients with mild disease recovered in around two weeks, while those with severe infections took three to six weeks to get better.

Aylward was in Wuhan on Feb. 22, where he said, “for the first time in weeks” hospitals have free beds. As another indicator the epidemic is waning, the principal investigator in one of the clinical trials running in the city told Aylward there are difficulties in recruiting new patients.

China is now looking at easing restrictions on travel and association, which the WHO mission agrees is appropriate. However, Aylward said, that does not mean a return to the status quo ante, but a “new normal” that recognizes the virus is likely to be around for months.

“The country should be getting back onto a regular footing, even though it is still dealing with a significant number of cases,” said Aylward. “The key to doing this will be in phasing the lifting of control measures.”

China’s success in “blunting” the outbreak holds lessons for other countries, as they respond to COVID-19. But, said Aylward, the global community “is not ready in mindset or materials” to contain the virus in the same way as China has done.

In its 45-page report, the WHO expert mission acknowledges there remain gaps in understanding of COVID-19.

Michael Ryan, WHO’s executive director of health emergencies, said there are different dynamics in every country. In Singapore, a cluster of cases occurred in people attending the same conference; in Iran, it was a religious gathering; taken overall, most clusters have been in families. “Transmission is driven by the context,” said Ryan.

The relatively high number of deaths among confirmed cases in Iran is probably due to the fact that only the most severe infections are being diagnosed at this point. “We need to understand the exact dynamics of what is happening in Iran,” Ryan said.

It is important to put in place and maintain control measures, even if the result is only to delay the peak of an epidemic. That would help, even in advanced health care systems, which are likely to be running at full capacity currently in the northern hemisphere flu season. “Even slowing down by one month would be a benefit,” Ryan said.

However, he questioned the rationale for closing borders within Europe, saying what is needed is good communication between states to stage a comprehensive and coherent public health response.

“We cannot shut down the world,” said Ryan. “We need to focus on risk management and understand the virus may cause an outbreak or epidemics in any number of countries, but they can be managed.”

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