The course of this disease is changing every day so this information is up to 1st March 2020
WHERE CAN I GET RELIABLE UP TO DATE INFORMATION ?
There is a lot of misinformation in the media, go to a reliable source .The GOV.UK Public Health has advice for travellers and people living in and outside the UK. They recommend people returning from certain towns in Lombardy and Po regions of Italy ,as well as parts of China, Iran and South Korea to self isolate at home for 14 days even if they feel well.
This differs from the information given by Sanitat of Generalitat Valenciana who recommend you carry on as normal, observing hygiene measures such as frequent hand washing, using a hanky if you cough or sneeze and watch out for symptoms.
Also the World Health Organisation have a very good site. https://www.who.int/
Also the European Centre For Disease Control https://www.ecdc.europa.eu/en
WHAT IS COVID-19 ? IS IT A NEW VIRUS OR IS IT LIKE OTHER ILLNESSES IN THE PAST ?
Covid-19 is an new infection caused by a corona-virus similar to that which caused the SARS epidemic from November 2003 to June 2004.It was transmitted from animals to people starting in the city of Wuhan in Hubei province. The World Health Authority WHO was notified about it on 31st Dec 2019.
These coronaviruses can cause infections from mild colds to the serious SARS and MERS respiratory infections. This is the sixth type of coronavirus discovered. The latest theory is that it mutated to be able to infect humans form a very similar virus found in Pangolins which are illegally caught and eaten in the area of China where the epidemic started.
WHAT ARE THE SYMPTOMS? HOW WOULD I KNOW IF I HAVE BEEN INFECTED?
Covid-19 starts as any cold or flu with fever, dry cough and generally feeling unwell. Some people may have very mild symptoms or no symptoms at all. 14% of people, especially the elderly or people with chronic disease may go on to get serious lung disease. The infection is spread by fine droplets infected people emit when they cough or sneeze.
The incubation period is from 2 to 10 days. Testing with a thermometer is not an accurate way of telling if someone is infected as the temperature may be normal when someone is infected.But if the temperature is raised it is an indication of infection though it is unlikely to be Covid-19 unless you have returned form a high risk area or have had close contact with someone from a high risk area.
It is thought that infected people can spread the virus from very early on in the illness when they have only very mild symptoms and may just think they have a normal cold or flu.
You need close contact with an infected person to catch the disease as the droplets do not travel great distances in the air. Close contact is defined as either direct face to face contact for any length of time or more than 15 minutes of contact at a distance of less than 1 metre. There is only 1 case of local contact so far occurring in Valencia and that was contact between friends not a casual contact. Touching contaminated surfaces is another way the virus spreads so hand washing is very important.
AM I AT RISK ?
Most cases as of 1st March 2020 in Spain have occurred in people returning from Italy, so at present if you have not travelled to the high risk areas listed below your risk of getting it is very low. HIGH RISK COUNTRIES AS OF 1st March 2020
NORTH ITALY ,CHINA ,SOUTH KOREA ,IRAN , JAPAN and SINGAPORE
If you have been to these high risk countries and have symptoms of Fever Couch or Shortness of breath or are worried you should call 900 300 555 or if they don’t speak English 112. You should not go to the doctor or hospital, a medical team will visit you at home.
HOW IS IT SPREAD ? HOW CAN I PREVENT MYSELF GETTING IT ?
The Covid-19 virus is produced on the membranes of the mouth and nose early on in the infection and is spread out by sneezing and coughing. This produces fine droplets load with the virus. In cold dry weather the droplets stay in the air longer, while in hot humid air the droplets tend to fall to the floor. That is one reason that colds and flu occur more often in winter and in cold climates. You should always cover your nose and mouth and use hankies if you cough or sneeze. And dispose of hankies in sealed bins.
The virus is also passed on by touching contaminated surfaces and then touching your nose and mouth so you should always wash your hands or use alcohol based gels after coming home, before eating and food preparation and after using the bathroom.
If going to the hospital you should used the hand cleaner provided. In Villa Hospital they have installed one at the main entrance so you should use it on entering and leaving the hospital. The virus does not live long outside the body so you are unlikely to get it from handling objects such as packages from China.
Shops in Valencia area running out of hand gels and face masks,but you can get 96% alcohol from chemists and supermarkets.Masks are not thought to be effective except as used by trained health professionals who will use FFP 2 or 3 masks.These have a valve on them for breathing. Cheap masks are useless. Also you have to take them off correctly by the straps behind the ears being careful not to touch the mask ,which may be contaminated.
IS THERE A BLOOD TEST FOR COVID 19 ?
A blood test was developed within weeks of isolating the virus. It took six months to develop one for SARS. It is a PCR test and is thought to be very accurate (sensitive) and can detect the virus at very low concentrations early in the disease,
IS THERE ANY TREATMENT SHOULD I GET IT ? IS THERE A VACCINE YET ?
A vaccine has been developed in the USA just 42 days after sequencing the Covid-19 genome and has been sent to China for trial. But 17 years after the SARS epidemic no vaccine has proved successful against SARS despite many attempts to develop one.
Antivirals medicines used for other infections such as HIV and Ebola are being trialled in China. There has been a case in the press of a 62 year old man from Seville who was very ill and was treated successfully with drugs used against HIV.
Otherwise treatment is similar to other cases of pneumonia but with stricter isolation.
A study of 1000 patients in China demonstrated that 14% were very ill, 5% were admitted to an intensive care unit, 2.5% needed a ventilator and about 1.5% died. Some people with very severe disease have been treated by heart lung machines ie extra-corporeal circulation. Some had multi organ failure which if not fatal can take weeks and months to recover from
Cases in England will be treated in four Airborne High Consequence Infectious Diseases Treatment Centres, or Airborne HCIDs. Two in London and two in the north of England. They probably just have a few beds each. I imagine that it is similar in Spain.
That is why the Chinese had to build two x 1 thousand bed hospitals in less than a fortnight in the city of Wuhan which is the epicentre of the disease. At the beginning of Feb 2020 they were treating almost 4,000 patients in temporary hospitals in gyms and exhibition centres. These would not have had the high security facilities needed to isolate patients and keep staff safe.
You have to admire the dedication of the nurses and doctors who have to look after Covid-19 patients, wearing very hot and uncomfortable protective clothing and putting themselves at risk of acquiring the infection. Some staff have died themselves from the disease.
HOW DEADLY IS IT ?
Mortality is thought to be 2% of confirmed cases in the new Covid-19. However the case fatality rate of Covid-19 from Chinese data, appears higher in people with chronic diseases,heart, lung,diabetes and cancer etc. where it averages about 8%. People over 60 have increased mortality from Covid-19,estimated to be about 14% in people over 80. However many people with mild disease who are never tested,are not included so the death rate could be lower.
COMPARISON WITH OTHER SIMILAR RESPIRATORY DISEASES
SARS had a mortality rate of 10%., Normal seasonal flu has a mortality of 0.1% or 1 in a thousand people die who get flu. Avian/bird flu generally have higher mortality 10-20% but usually they do not pass on from human to human.
IS IT WORSE THAN SEASONAL FLU THAT KILLS THOUSANDS EVERY YEAR ?
Some people think that influenza or flu is more deadly than Covid-19.
Between 5% and 20% of people each year in non-tropical countries get Influenza. Flu has a case fatality rate of just 0.05% to 0.1% , compared to Covid-19’s 2%. Flu has been estimated to by the Centre For Disease Control USA to kill about half a million people a year worldwide.
Reproductive Number or R is the number of people on average 1 person with the virus goes on to infect. The higher the number R the worse the epidemic will be.
The R for normal seasonal flu is 1.27, lower than the 1.95 R WHO attributes to Covid-19. So Covid-19 has twenty to forty times higher mortality than influenza and the higher in R in Covid-19 means the rate of increase in cases is much faster.
However influenza constantly circulates the earth following the seasons in non tropical countries. While Covid-19 is still largely confined to several provinces in China north of Hong Kong. The epicentre is the city of Wuhan. 93% of cases and deaths have occurred in China. The number of deaths per day in China peaked in late January and then started to fall to about 300 a day but has risen to over 500 on 1st March for reasons unknown.
However Covid-19 spread from just one centre in China and it is still possible to keep the infection controlled by testing people with symptoms, and isolating them if the have the virus. Tracing their contacts and making them self isolate for 14 days is an important tool in preventing spread of the virus. This is only possible in countries with a well organised public health system. Developed countries will have a plan in place for dealing with pandemics.
WHAT ABOUT THE SPANISH FLU. THAT WAS WORSE WASN’T IT ?
So called Spanish Flu from 1917 to 1920 was the worst pandemic in history. It was probably an H1N1 bird flu virus that mutated to infect humans. Again it originated in China not Spain and killed about 50 million people worldwide. It had 2 waves the second more deadly than the first and it killed mostly people young adults. The overall R was 1.8, its mortality was between 10% and 20%. So it was between 5 and 10 times more deadly than Covid-19 though it spread as easily with R of 1.8 .
HOW DOES COVID-19 COMPARE TO LAST GLOBAL PANEDMIC IN 2009
Developed countries have plans to deal with influenza pandemics.
The last one was the swine flu pandemic in 2009. It affected about 1 billion people worldwide about 14% of the world’s population, more than got the Spanish flu. But only about 300,0000 people died from it so it was a much less lethal virus with a mortality rate of 0.008%. The pandemic influenza plans can be adapted for Covid-19
IS IT WORSE THAN SARS ?
There were 8000 cases of SARS in 2003/4 with 765 deaths and no death after 2004. While to date there are about 86,000 confirmed cases of Covid-19 with 2906 recorded deaths and the epidemic has not yet peaked. SARS was more difficult to contract as the virus was emitted from the lungs at a later stage of the illness when the person had pneumonia.
That is probably why SARS did not spread as much as flu and Covid-19 and the epidemic ended fairly quickly. The R was 1.7 in Hong Kong, whereas in Toronto where it also spread R was 0.86 because of better healthcare and public health. With an R less than 1 the epidemic will die out.
WILL COVID-19 CAUSE A GLOBAL PANDEMIC ?
It appears that Covid-19 prefers cold weather so the arrival of spring should help to reduce numbers in the northern hemisphere. Australia has 24 confirmed cases and is entering autumn. Tropical countries have seen very little local transmission except for Singapore,Malaysia,Thailand, Iran and UAE. While the USA has had a few cases of local transmission as have the big four EU countries, Italy has 888 confirmed cases while it’s neighbours France and Germany have only 57 each. The epidemic got out of control in Italy because surveillance was started late.The UK has just 20 cases with 4 local transmission. There does seem to be a shift of the infection to northern Europe. South America, Canada,and Africa have seen no local transmission. The USA has had 62 cases mostly imported, but with local spread occurring in Washington State. While the Cruise Liner Diamond Princess has had 705 cases of infection.
WHAT CAN BE DONE TO PREVENT SPREAD ON A MASSIVE SCALE ?
There is a WHO plan called FFX (First Few Ten) to trace and isolate all initial cases and their contacts when the virus arrives in a new country. This was based on a UK plan carried out in the 2009 Swine Flu epidemic known as The First Few Hundred. The idea is that if you can stop the spread of the virus in the first few hundred cases and the infection will die out or at least slow down until the warmer weather reduces its contagiousness.
This requires isolating people returning from very high risk areas and anyone with symptoms. If they test positive then all their contacts have to be traced asked to self isolate for 14 days and submit to testing. If someone self isolates in their home they must avoid all contact with everyone including family members.
If this fails and Covid-19 spreads widely in the community then more drastic lockdown measures have to be introduced as in China and now in parts of Northern Italy. This requires limiting travel,closing schools and institutions and banning mass gatherings and events etc.
What is the R Reproductive number and why is it so important ? Maths for Geeks
When trying to assess how serious an epidemic is likely to be, you need to know how lethal the virus is or case fatality rate to use the correct jargon. But also you need to know how easily it is passed on from one person to another. As well as the incubation time, from contracting the infection to shedding the virus and becoming contagious to others.
The number of people one person infects on average is known as the Reproductive Number or R. If R is 1 ,then one person on average infects one other person. However it will not generate an epidemic as 1×1 x1 x1x1 =1. So if the incubation time is one week then one person a week will be infected every week, and five people in 5 weeks. It is called a linear function.
However if R is 2 there will be an epidemic. ie one person on average infects 2 people, these 2 people each infect another two people, 2x2x2x2x2=32. Adding up all the people from the five generations of transmission gives 62 people infected by one person. So small changes in R have a big impact. It is exponential growth in new cases. Each week the number of new cases is not the same but it doubles every week.
Giving a practical example related to Covid-19. If say 10 people come to a new country with the virus and they spread it on average to only 9 people then the R is 0.9. So after 5 generations of local spread, you have 9+8.1+ 7.29+6.6+5.9= 37 people infected after 5 weeks, but the numbers of new people infected each week will gradually reduce to zero and the infection will be contained.
If on the other hand these 10 people infected 11 people on average the R would be 1.1 and the generations of local spread would be 11 +12.1+13.31+14.64+16.1= about 67 people The numbers increase slowly at each generation of local transmission and there would be an epidemic. If the incubation period is 1 week, after 5 weeks those initial 10 people would have caused 67 infections in the new country.
Now what happens after 5 generations with an R of 2 . ( The WHO estimates R between 1.4 and 2.5). So 10 people infected with the virus coming to a country would generate the following infections:20+40+80+160+320=620 people infected after 5 weeks and 1,860 after 6 weeks. This is comparable with what has happened in Italy (1128 cases to date). They reported just 9 cases a week ago. But this was due to a lack of detection and reporting than a true picture of the epidemic in Northern Italy.
WHO produce daily situation reports on their website so you can roughly estimate R values yourself once the virus is transmitted mostly by local spread rather than being imported.
Local spread has not yet been recorded in the vast majority of the world area outside China, and is only significant in Northern Italy,Iran, Japan, South Corea and Singapoure.
There have been isolated cases of local spread in Spain, UK ,France,Germany, Netherlands,Norway and Croatia. But this could change rapidly.There are reports of local spread in Washington State in the USA.
This is why public health measures to reduce the spread by even a little can be so effective in controlling infection. People can play their part by using hankies when they cough and sneeze and frequently washing their hands. If R can be reduced to less than one the epidemic would eventually end.
Hopefully Covid-19 will be a winter epidemic that will start to die out by late spring as did the SARS epidemic from Nov. 2003 to June 2004.
This article was written by Kevin Jackson communications coordinator of Help International Benidorm and a retired GP having worked in the UK and Spain
It was based on personal reading of the literature any errors are down to me personally and not Help Benidorm International
The information in this post is based on reliable sources, among them;
World Health Organisation
Sanitat Generalitat Valenciana
Public Health England
Centre for Disease Control Atlanta USA.
British Medical Journal
JAMA journal of the American Medical Association
New England Journal of Medicine
and other medical journals.
This post was written by Kevin Jackson a retired GP.
He and not Help International Benidorm is responsible for any errors it may contain.