Outbreak, Epidemic, Pandemic - Wuhan and Beyond
Updated: Feb 19, 2020
The 2019 novel coronavirus (COVID-19) emergence in China has the international community reeling with fears of what comes next. To understand concerns, and mitigate the unknown, Gist Say'n examines the impact of outbreaks, epidemics, and pandemics.
On December 31st, 2019, China informed the World Health Organization (WHO) of several strange cases of pneumonia in Wuhan City. The virus causing them did not seem to match any other known virus. On January 7th, Chinese authorities confirmed that they had identified a new coronavirus.
Members of the vast family of coronaviruses range in severity to include everything from the common cold to Middle East respiratory syndrome (MERS) that appeared in 2012 and Severe Acute Respiratory Syndrome (SARS) that emerged in 2003. The temporary name of this new virus was the 2019 Novel Coronavirus (2019-nCoV).
Coronaviruses are common in many different species of animals, including camels, cattle, cats, and bats. Though it is rare, animal coronaviruses can jump from an animal reservoir to infect people and then begin to spread from person to person such as with MERS and SARS. Experts believe this is also the case with the Novel (or new) Coronavirus.
According to Chinese officials, in December, early patients in this outbreak of respiratory illness linked back to a large seafood and live animal market located in Wuhan, a Chinese city of 11 million people. This link suggests an initial animal-to-person spread. As the outbreak continued, a growing number of patients became infected without having exposure to animal markets, which indicates the virus became able to spread person-to-person, a fact confirmed by the rapid spread of the disease across Wuhan and beyond.
From the day it was informed, WHO began working with Chinese authorities and global experts, to study the virus to learn how it affects the people it infects, how they can be treated, and what countries can do to slow it down and protect their citizens.
WHO reports that as of February 9th, the 2019 Novel Coronavirus has infected more than 40,000 people, with thousands of new cases added each day. Ninety-nine percent of all these cases are currently in China, but 24 other countries have reported more than 200 additional cases. Official numbers state that more than 900 people have died from the virus, all but two has been in China.
The numbers continue to rise despite the fact that China has made unprecedented efforts to sequestered tens of millions of its citizens in multiple cities. In addition, numerous countries, including the United States, are severely limiting travel to and from the communist nation.
It seems that the location of the emergence of this outbreak gave the virus a head start. When a doctor, an ophthalmologist, in Wuhan first saw a disturbing number of what he thought was SARS cases pop up in December, he decided to share the information with former classmates on a closed chat advising them to be on the lookout. Within days police came to him to issue him a formal sanction. They ordered him to stop rumor mongering and threatened him.
Even if you can get past the fact that China's government was actively monitoring the doctor's private chat (it is, after all, a way of life in the socialist regime), you must also try to understand why the doctors were threatened rather than applauded for their vigilance. By trying to suppress the facts, Chinese authorities gave the virus a better chance to spread.
Now that the outbreak is an epidemic, on the brink of a pandemic, the communist government is looking for ways to mitigate economic and diplomatic losses. On February 3rd, Beijing accused the United States of spreading fear over the Novel Coronavirus outbreak by pulling its embassy personal and nationals out of China and restricting travel instead of offering significant aid. A claim, by the way, that the Center for Disease Control (CDC) says, is incorrect.
During a briefing on February 3rd, Dr. Nancy Messonnier, Director of CDC National Center for Respiratory Diseases, said they had extended an offer of expertise to China.
"What I can say is that we have folks ready to go to China as soon as that offer is finalized. I understand that there still are negotiations in process on that. And really, we are just waiting. As soon as we are allowed to go, we will be there. And, you know, we do have an expert already in the field as part of CDC's continuing work with China. So, he's already in the field and therefore could be there immediately. So, we are still waiting for that invitation."
Politically, China is being China. However, even though it could have perhaps acted quicker to share information about the virus with the international medical community, it has acted faster than in past situations to try and contain the outbreak, for which the medical community is giving it high praise.
Global Health Emergency
"Over the past few weeks, we have witnessed the emergence of a previously unknown pathogen, which has escalated into an unprecedented outbreak, and which has been met by an unprecedented response. As I have said repeatedly since my return from Beijing, the Chinese government is to be congratulated for the extraordinary measures it has taken to contain the outbreak, despite the severe social and economic impact those measures are having on the Chinese people. We would have seen many more cases outside China by now - and probably deaths - if it were not for the government's efforts and the progress they have made to protect their own people and the people of the world. The speed with which China detected the outbreak, isolated the virus, sequenced the genome, and shared it with WHO and the world are very impressive, and beyond words."
As an aside, given that China has bio-engineering labs in Wuhan, there have been unsubstantiated claims that the virus somehow emerged from one of them. This could explain the speed at which they identified and sequenced the virus, but again, there is no proof.
"So is China's commitment to transparency and to supporting other countries. In many ways, China is actually setting a new standard for outbreak response, and it's not an exaggeration. "
Unfortunately, the spread of the virus has continued to pick up speed, so... and this is the critical part...
"We must act now to help countries prepare for that possibility. For all of these reasons, I'm declaring a Public Health Emergency of International Concern over the global outbreak of novel coronavirus. The main reason for this declaration is not because of what is happening in China, but because of what is happening in other countries."
The declaration of a global public health emergency is not something the WHO takes lightly, but the formula used as to when to declare one can be hard to follow.
This is only the fifth time WHO has invoked a global public health emergency since the H1N1 (swine flu) outbreak in 2009.
In that year-long pandemic, more than 12-thousand people died just in the United States, and it's estimated that between 151,700 and 575,400 people perished worldwide.
In 2014, WHO released two Public Health Emergencies of International Concern, first, there was one that followed the re-emergence of a higher than average number of Polio cases (400 cases in 2013), which was spreading into new countries. Then later that year, one was issued for Ebola. The 2014 West African Ebola outbreak lasted until 2016, with 28,639 cases and 11,316 deaths, making it the deadliest Ebola outbreak in history.
In 2016, while Brazil prepared to host the Olympics, the alarm sounded again as a Zika virus outbreak engulfed South America, and continued to creep everywhere that the mosquitoes that transmit it can survive.
Then in August of 2018, Ebola again gained ground in Africa. This ongoing outbreak is the tenth one faced by the Democratic Republic of Congo. As the risk that the deadly virus might spread beyond Africa increased, the WHO declared the outbreak as an international public health emergency in July of 2019.
All these cases had different elements that lead to a global declaration of emergency. Determining when an outbreak becomes an epidemic, and then advances to be classified a pandemic is also not a pure numbers game.
According to the World Health Organization, an outbreak is the occurrence of disease cases that goes above normal expectations. The number of cases it takes to be called an outbreak varies according to the disease-causing agent, and the size and type of previous and existing exposure to the agent.
Disease is opportunistic, so outbreaks can result from a variety of reasons that include humanitarian crises, forced migration, environmental degradation, reduced access to health services, and trying to survive in zones of prolonged conflict. A disease does not have to be unknown or untreatable to have an outbreak. Diphtheria, a bacterial disease that is preventable through a simple, inexpensive vaccine, is one such example. Once affecting millions, in recent decades, it faced eradication. Yet now it is making a dramatic comeback, not only amongst Rohingya refugees forced to live in unsafe conditions but in other vulnerable communities around the world. Outbreaks can also have seasonal patterns, like with the Flu.
To better understand how things are classified, you need a working knowledge of the definitions. If a disease's occurrences are infrequent and irregular, the Centers for Disease Control and Prevention (CDC) calls them Sporadic. However, a disease or infection that maintains a constant and/or prevalent presence within a defined geographic area is considered Endemic. When a disease causes a sudden increase in the number of cases that is greater than expected in a given population, the outbreak becomes an Epidemic. An Epidemic that has spread over several countries or continents, affecting a large number of people in them, should be labeled a Pandemic.
When an epidemic is officially redefined as a pandemic, the most significant difference is that more governments are involved in attempting to prevent the progression of the disease and, potentially, treat the people who have it. According to the CDC, the FDA can also begin issuing "emergency use authorizations" (EUAs) during a pandemic, which allows doctors to use medications outside of the FDA-approved use. For example, during the swine flu pandemic, the FDA issued EUAs for two antiviral drugs trying to prevent the Flu in young children and to treat patients who had symptoms for more than two days, something for which Tamiflu was not previously prescribed.
It takes masterful medical detective work, rapid and coordinated international information sharing, and resources with deep pockets and influence to stem the spread of a rapidly emerging disease. These things are critical. History is full of cautionary tales of what can happen when diseases spread unchecked.
Plague is one of the oldest, and most feared, of all diseases.
Like the shark and crocodile, the plague was such an efficient killer that it had little reason to evolve; it just kept making the rounds.
Historically, the plague has been responsible for several widespread pandemics with high mortality. During the fourteenth century, it was known as the "Black Death," causing more than 50 million deaths across Europe.
It resurfaced in 1665 for the "Great Plague of London" to kill twenty percent of the city's population. They used mass graves to bury the dead, and fear caused the slaughter of thousands of cats and dogs. The outbreak eventually tapered off in 1666. Science has since taught us that the plague is primarily carried by rats that have developed an immunity to it and is most frequently transferred to humans by fleas that have tried to feed on the rats first. That knowledge alone helped mitigate the plague's ability to spread.
Nowadays, plague is pretty easy to prevent and is treatable with antibiotics if detected early enough, plus infection can be prevented through the use of standard precautions. Even so, it is still around. For example, it appears annually in Madagascar where thousands are routinely infected and 100's die.
Despite the relative ease of treatment, the CDC says the Plague's association with the "Black Death" still weighs heavy on the popular conscience, and its outbreaks are therefore regularly cited in media reports and tabloid headlines.
The CDC points to this as an example of the gravity of elevating outbreaks to epidemics and pandemics. It believes it is essential to strike a balance between encouraging countries to be ready to act in case of an outbreak while avoiding panic that could result in unnecessary or counterproductive measures such as trade restrictions or travel bans on affected countries.
While the Plague remains basically the same disease it has been for centuries. Other bacteria and viruses are not content to rest on past achievements. They are always evolving, trying to outwit and outmatch the human immune system.
Perhaps with designs to overthrow the plague as the world's most prolific illness and killer, the flu grew to pandemic levels five times in less than 100 years.
It started as the "Spanish Flu" (so-known because during WWI, Spain was the only country that allowed its press to cover the story freely) spread around the world in a pandemic beginning in 1918. According to the CDC, this especially virulent H1N1 influenza rapidly effected and caused severe lung damage. It came from an avian (bird) reservoir, but the virus's exact origin remains unclear. One of the possibilities is an army base in the United States that later deployed troops to Europe.
However it got there, once the pathogen reached the trenches of World War I, there was no stopping it. The CDC estimates that about 500 million people, a full third of the world's population, became infected with this virus. Before it was through, the Spanish Flu killed 675,000 people in the United States and caused at least 50 million deaths worldwide. A global figure that eclipsed all the lives claimed by the violence of the First World War, which was around 17 million.
The flu retook center stage on a pandemic scale in 1957 as the "Asian Flu." This H2N2 strain began in East Asia. By April, it made its way from Singapore to Hong Kong, and it appeared in coastal cities in the United States by summer. An estimated 1.1 million people died of the Asian Flu worldwide, with 116,000 of those deaths occurring in the United States.
About ten years later, the ever-changing flu virus again reinvented its self as the "Hong Kong Flu." This one originated in China in July of 1968. Caused by an influenza A virus (H3N2), this third pandemic flu outbreak to occur in the 20th century killed one million people worldwide and about 100,000 people in the U.S.
That brings us to the most recent flu pandemic. Initially known as "Swine Flu," it emerged in 2009 as a novel H1N1 influenza virus previously unidentified in either humans or animals. The virus, first detected in the U.S., spread quickly across the country and the world. The CDC says that between April 12th, 2009, and April 10th, 2010, there were 60.8 million cases, almost 275,000 hospitalizations, and 12,469 deaths (range: 8868-18,306) in just the U.S. The CDC estimates that up to 575,400 people died worldwide.
Unlike previous outbreaks, older adults often had immunity to this flu, likely from earlier exposure to a similar H1N1 virus. This time those primarily affected by the Flu Pandemic of 2009 ((H1N1)pdm09) were middle-aged adults and children. The pandemic officially ended on August 10th, 2010, but the (H1N1)pdm09 virus continues to circulate as a seasonal flu virus, causing illness, hospitalization, and deaths around the globe every year.
WHO officials say, every year, up to 650,000 people die while three to five million battle severe flu infections. A billion more suffer milder effects. It is an ever-changing deadly foe.
In this age of air travel that allows unknown contagions to skip undetected across continents in hours rather than weeks, months, or years, the CDC knew it could not stop this new coronavirus from reaching the United States. However, it does want to slow it down long enough to mitigate its impact.
While work on a vaccine is underway, the United States is taking aggressive precautions. The government has chartered flights to bring U.S. employees, citizens, and depends back from China, and is then quarantining them on military bases for at least 14 days. It stopped commercial airline flights to China. It is refusing entry to any foreigners that recently traveled to China that are not permanent residents or U.S. family members. Others who made their way to the U.S. before becoming ill are being closely monitored by local health authorities who remain in contact with the CDC.
Dr. Nancy Messonnier, Director of CDC National Center for Respiratory Diseases says the dozen or so cases currently being treated across the United States show a vast degree of severity:
"I can tell you we have seen a spectrum of illness among cases in the U.S. some of them seem pretty mild. At least a few have at least at some point in the course of their illness been more severely ill. And there have been some ups and downs in the course of these patients that are sicker. I would note that there are no deaths in the United States. Some of our patients have had oxygen requirements during the course of their illness. There is the first death outside China now reported. And the data coming out of China continues to say that the people who are at higher risk for severe disease and death are those who are older and with underlying health conditions. And so, obviously, we'll need to wait and hope that we don't see that level of that here in the United States. Our clinical folks are working on everything we can do to make sure those patients get the optimal care we can provide for them."
Here's the Gist
Since research began for this article and podcast, things have been in constant flux. Initial reports indicate this virus spreads easily through close contact and airborne contamination similar to a flu virus, and you don't have to feel sick to be contagious. Initial data also indicates that the 2019 Novel Coronavirus has a lower mortality rate than other coronaviruses. Meaning fewer people will die when they contract it than those who catch MERS or SARS. But scientists are concerned that if many people only get mild symptoms, it can quickly spread and then mutate into a more lethal strain.
New viruses are very unpredictable, and initial findings can change or can be inaccurate.
Dr. Li Wenliang, a Chinese Dr. initially treated as a criminal for sounding an early alarm, is now being called a whistleblower. Unfortunately, on February 7th, he reportedly succumb to the disease and died. His death is concerning for several reasons. He seemed to be a healthy 34-year-old who began getting medical care early, and even though he claimed to take precautions so as not to infect his pregnant wife, she is now in an ICU.
Rumors abound. Most prominent is the fear that the Chinese government is not being transparent with information related to the severity of the epidemic, which is has engulfed the nation and is causing citizens to question the communist government harshly. The most conspiratory rumor is that police killed the Dr. and are blaming his death on the virus. People in China are so upset, the Chinese government has announced an investigation into "issues" surrounding his death.
Bottom line, it's a mess over there. By any measure, China's outbreak is now an epidemic. Despite China's unprecedented efforts to contain it, the virus as reached from Wuhan to cross the international boundaries of at least 24 countries. Once the numbers in those countries rise, the World Health Organization will have no choice but to call it what it is fast becoming, a pandemic.
It's ok to agree or disagree, I'm Gist Say'n.