The Diamond Princess, docked in Yokohama, Japan, now has a total of 454 cases, the largest case load outside of mainland China.

The rise in new cases of COVID-19 seemed to be slowing in mainland China, but concerns remain about local transmission in cities abroad such as Hong Kong, Singapore, and Japan, and on cruise ships.

China has confirmed 70644 cases and 1772 deaths as of 5 p.m. Central European Time, representing an increase of 2060 cases in the last 24 hours, according to the latest Chinese data. This comes even after the Chinese health authorities expanded diagnostic criteria to count “clinically confirmed” cases on top of lab-confirmed cases, the rate of new infections appears to have slowed.

However, “this trend must be interpreted very cautiously,” WHO Director General Dr Tedros Adhanom Ghebreyesus told reporters at a press briefing Monday. “It is too early to tell if this reported decline will continue.”

The slow, but steady growth in cases outside of China, however, particularly in Singapore and Japan, has also been a cause for concern among public health experts closely watching the epidemic unfold.  A total of 694 cases in 25 countries have been reported, along with three deaths.

Of particular note is yet another huge spike in the number of infections on the quarantined cruise ship, the Diamond Princess, to 454 confirmed cases as of Monday evening, which now represents the largest cluster of cases outside China. Some 189 passengers were classified as “asymptomatic carriers,” according to a statement from Japan’s Ministry of Health. The ship has been docked in Japan’s Yokohama port since 3 February.  Many of the original 3,600 passengers remain under a two-week quarantine while the Japanese government tests every one on the ship.  Some 1,723 have been tested so far. Those found to be infected with the virus, elderly people and those with other medical conditions have been allowed to disembark and complete their quarantine period in special facilities on shore.  Most of the 400 Americans on board the ship were evacuated earlier this morning, although they will they will have to undergo another two weeks of quarantine in the United States.

The strict measures being enacted for passengers on the Diamond Princess were not repeated for the Westerdam, a cruise ship that was finally allowed to dock in Cambodia last week after being stranded at sea for two weeks. Once clearing temperature and health checks, passengers were allowed to continue on their travel itineraries. However, one COVID-19 case was confirmed in a passenger after she had already disembarked and traveled to Malaysia.

Two more former Westerdam passengers, were, however, suspected of being ill are awaiting lab results for the virus after traveling to Singapore. Some 255 guests and 747 crew members are still waiting aboard the ship to complete further health checks.

Holland America, the owner of the Westerdam, said in a statement that no passengers had elevated temperatures upon disembarking. The 20 individuals who reported to the ship’s medical center also later tested negative for COVID-19.

The drastically different treatment of the passengers on the Westerdam and Diamond Princess highlight the very different national policies governing public health responses to contain the spread of the virus, as well as the different circumstances involving each ship. WHO’s Director General Dr Tedros Adhanom Ghebreyesus last week strenuously urged the government of Cambodia to allow the cruise ship to dock.  In the aftermath, he has not commented on the discovery of cases aboard the second ship, or on the very different procedures undertaken by Cambodia to screen and disembark passengers, as compared to Japan.  The Westerdam, which departed Hong Kong on 1 February had not identified any cases aboard while at sea, although the incubation period of the virus is believed to average 14 days.

“Measures should be taken proportional to the situation… Blanket measures may not help,” said Dr Tedros, in a press briefing today. “”There is no zero risk…[every action] has to be proportional to the situation.”

Number of COVID-19 cases worldwide, collected by Dingxiangyuan, which tracks national and sub-national press releases from health authorities.

Will COVID-19 Become a Pandemic?

Experts are worried that, despite the decline in new cases on mainland China, there may be potential for further spread, leading to some questioning whether it was time to label the outbreak a “pandemic” – or a global outbreak where every citizen could be infected.

The media frenzy around the outbreak has also been whipped up by published and pre-print studies estimating that the current number of infections is much higher than reported due to a high number of asymptomatic and mild cases, with some estimates in the range of 75,000 thousand infections in Wuhan alone. A WHO advisor, Ira Longini from the University of Florida, was quoted by Bloomberg News as projecting that up to two-thirds of the world’s population could be afflicted by COVID-19 if current measures to contain the virus’ spread are unsuccessful.

However, WHO scientists are cautious about using the “p” word, for fear of inducing widespread panic.

“For the general public, I think [pandemic] means the worst-case scenario. We need to be cautious… because it can create panic unnecessarily,” said WHO’s Sylvie Briand in Monday’s press briefing.

Added Mike Ryan, WHO’s head of Emergencies, “We have said that the risk for regional and global spread is high – that is not high of a pandemic, it’s high for further spread.

“We need to be careful not to drive fear in the world right now.”

On the WHO advisor’s prediction that the majority of the world could get infected by COVID-19, Ryan added that, “all predictions are important. But most predictions are wrong.”

Image Credits: Flickr/ Yoshikazu TAKADA, ncov.dxy.cn.

Nina Renshaw, Saman Zia-Zarifi, Luisa Cabal, Mariangela Simão, and Gian Luca Burci speak at Health and Law panel, moderated by Lawrence Gostin.

The International Health Regulations are in need of reform, experts say – to create a more nuanced system of alerting the public about international health emergencies that goes beyond the existing yes-no decision, and to improve compliance to IHR laws by member states during such outbreaks.

A high level panel of experts reviewed key concerns and possible solutions last week at the Geneva launch of the Legal Determinants of Health – The Lancet Commission, Global Health & the Law Report – hosted by UNAIDS on the margins of WHO’s Executive Board meeting.

The report, first published in 2019 at the height of the Democratic Republic of Congo’s Ebola outbreak, noted that implementation of the IHR, which is a binding legal convention between WHO member states, has been “plagued by incomplete state compliance”.

The issues surrounding the IHR’s use and compliance have received further attention within the public health community during the present coronavirus emergency (COVID-19)– where declaration of a Public Health Emergency of International Concern (PHEIC) was delayed because the dimensions of the crisis were initially unclear.

When an Emergency was finally declared on 30 January WHO Director General Dr Tedros Adhanom Ghebreyesus said at the time that “along with a red and a green light” the system needed a “yellow light” so that health systems could begin to prepare even before a full-blown international crisis had emerged.

The Lancet report on “harnessing law for global health and sustainable development” lays out a broader framework for why global health law is relevant to public health professionals.

The report shines light on certain systemic weaknesses of existing legal instruments, and argues that non-state actors could potentially drive change in reforming and ensuring stronger legal frameworks. The authors describe four legal “determinants of health” that they argue most fundamentally influence health and equity. And they recommend a slew of strategies that could make legal frameworks a more central imperative in the governance of global public health.

The “Legal Determinants of Health” & Recommendations for Action

The report lists four “legal determinants” of health that can “demonstrate the power of law to address the underlying social and economic causes of injury and disease.” These determinants also highlight areas of law where lawmakers can successfully intervene to improve health as follows:

  • SDG vision to action – Law can translate vision into action with respect to Sustainable Development Goals, in particular in laying the foundations for Universal Health Coverage. International institutions can set standards and support implementation and for national governments to create rights-based legal frameworks.
  • Strengthened governance – Law can strengthen the governance of national and global health institutions. These institutions, both at international and national levels, can used law to improve governance and safeguard public health and safety. (The report also notes that “domestic and international law are inter-related and bidirectional in their impact on health and justice)
  • Evidence-based health interventions – Law can be used to implement fair and evidence-based health interventions, drawing from examples of cases from communicable and non-communicable diseases and injuries. The report suggests WHO can increase legal capacity to spearhead the development of a global evidence-base for public health.
  • National legal capacity  – National governments must build legal capacities to enact and effectively implement public health laws. On a global level, the report recommends that WHO create  an independent standing commission on global health law.

On Reforming the IHR

The panel in Geneva largely agreed that the IHR, which has its origins in the International Sanitary Regulations first adopted in 1851 to standardize quarantine measures for cholera, plague and yellow fever, needs another revision, especially in the light of the COVID-19 outbreak.

On the other side of the WHO campus, meanwhile, senior officials had just informed the Executive Board that WHO would convene experts to work on an intermediate level of alert, to integrate more nuance into the current binary system that governs “yes or no” declarations of a Public Health Emergency of International Concern (PHEIC).

Speaking at the event, Gian Luca Burci, adjunct professor at the Graduate Institute, former WHO legal counsel, and one of the co-authors of the Lancet report, said that in exploring the gaps and weaknesses in the IHR, there is a need to look at the “design and politics” behind the law, not only how the existing law is being implemented.

The latest version of the IHR, adopted by WHO member states in 2005, served to codify much of what was already existing WHO practice for emergency response and management. However, a number of political compromises as well as assumptions were built into the design of the instrument, including the “assumptions that governments will act transparently, in good faith and in a spirit of solidarity. “Now these assumptions are getting tested. We do see instances of excesses and stigmatizing that result during outbreaks,” he said.

He recounted that the last version of the IHR, adopted in 2005, was also revised within a very short period of time between January 2004 to May 2005, in the aftermath of the outbreak of Severe Acute Respiratory Syndrome (SARS).

“This may explain some of the flaws we are witnessing, and perhaps there is a need to take a step back and rethink the design of the IHR with an open mind,” said Burci.

There are two approaches on reforming the IHR, Burci said. “One is to say that let’s not touch the text and try to improve its implementation. As a result we have seen the emergence of the global health security agenda and efforts at voluntary evaluations conducted outside the IHR framework.

“The second approach, which I consider more useful, is that we have a binding legal instrument, and if there is a flaw, may be there should a good faith attempt to sit back and find out how to change it. Sometimes, there is a need to amend the law, changing the assumptions, especially if proposals for new measures are inconsistent with the clear letter of the instrument as in the case of the binary approach to alert,” he explained.

However, Lawrence Gostin, faculty director of the O’Neill Institute for National and Global Health Law at Georgetown University and a lead author on the report, expressed concerns that in light of current global trends, reopening the IHR’s formal texts could risk weakening the text, giving greater leeway for decisions driven by populist governments and sentiments rather than evidence.

For instance, the IHR was meant to be seen as an instrument to balance human rights and public health objectives, he said. At the same time, in the current COVID-19 crisis, WHO has been “looking the other way,” even as China had restricted movement in affected areas.

On the politics of dealing with an outbreak, Burci said, “There are a number of variables that explain how states respond to a crisis of this magnitude. There are cultural, political, domestic and other factors that shape responses.

“Major crises are political events and governments do not simply respond by looking at epidemiological evidence”. Locking down an area, for example, may slow down the spread of the disease but may also create hardship for the affected population which encourages people to escape – the exact opposite of what is needed, he added.

A number of speakers underscored the importance of considering the principle of ‘proportionality’ based on rational evidence while evaluating states’ responses during an outbreak. The panel referred to the non-binding Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights (ICCPR) 1985 that asks states to strike a balance between protecting liberties and securing population health.

Lessons from Tobacco Control for Alcohol

Along with a consideration of the IHR’s legal frameworks, the Geneva panel discussion also discussed the potential role of law in responding to other public health challenges, including: tobacco control; the harmful use of alcohol; access to medicines; and the discrimination of marginalised people.

Despite uneven compliance with WHO’s Framework Convention on Tobacco Control (FCTC), the Lancet report credits the FCTC as having had a substantial impact in the uptake by many countries of legal measures that advance: smoking bans and marketing restrictions, such as pictorial warnings on packages, among others. Experts believe that lessons from tobacco control could be applied to other public health challenges.

Nina Renshaw, director of Policy and Advocacy at the NCD Alliance, said that political leaders were nonetheless reluctant to go beyond tobacco and craft laws that might curb the harmful use of alcohol and unhealthy foods that are the cause of many noncommunicable diseases, and were pushing instead for voluntary commitments. However, ultimately fighting NCDs requires legislation upstream of food and beverage industries, she asserted. “There need to be legal underpinnings to follow up on this,” she said.

“There is a desperate need for legally binding measures to address alcohol related death,”, she said, speaking even as countries attending the WHO Executive Board huddled not far away, to reach agreement on a new global action plan to address the harmful use of alcohol. Renshaw also advocated greater use of fiscal measures, e.g. excise duties or taxation, to both reduce harmful alcohol consumption and to increase public revenues to promote health.

Legal and regulatory interventions to prevent non-communicable diseases can promote “small changes across entire populations for a mass impact”, observes the Lancet report, noting that “law has the power to facilitate profound changes in behaviour.”

ACCESS TO MEDICINES

Speaking on the use of law for improving the access to medicines, Mariângela Simão, assistant director-general of Access to Medicines and Health Products at WHO, said, affordability is partly patent-related, but also emphasized on the importance of a legal framework to govern transparent procurement and pricing negotiations.

Simão said, “access to medicines is an excellent proxy for the right to health.” The situation in China also shows that in a globalised world no country is alone, she said referring to the current outbreak. The access to safe, quality drugs is important, including access to active pharmaceutical ingredients, she added.

To improve access to medicines and technologies, the Lancet report suggests “regulatory frameworks need to be reformed, or made more flexible to support development, deployment of effective therapeutic countermeasures. Legal obstacles to the effective deployment of counter-measures should be addressed and resolved in advance of future pandemics.”

Improving Legal Capacities

Overall, the Lancet report calls for building disciplinary bridges in order to build legal capacities by getting legal and medical professionals together. It also noted the contribution of effective health diplomacy in complex negotiations that resulted in the FCTC, the IHR or the PIP Framework.

But experts at the event, also noted that in reality, member states are not often keen on doing the hard legal work implicit in promulgating new laws, partly due to uneven their legal capacity. “We cannot cut and paste legal solutions from one country to another,” a senior WHO official present at the event cautioned.

The IHR, and its application, is to be the focus of another public lunchtime session this Wednesday, at the Geneva Graduate Institute – The global governance of outbreaks: from Ebola to the novel Coronavirus.

 

Priti Patnaik is an independent Geneva-based journalist and researcher.

[Press Information Bureau, Government of India]

In light of the threats to human health and biodiversity due to climate

and pollution, India marks the beginning of the “super year of Biodiversity” with the hosting of the 13th Conference of Parties (COP) of the Convention on the Conservation of Migratory Species of Wild Animals (CMS), an environmental treaty under the aegis of United Nations Environment Programme, from 17th to 22nd February 2020 at Gandhinagar in Gujarat.

Shri Prakash Javadekar (left) and Sveinung Rotevan (right)

Addressing a press conference, Union Environment Minister Shri Prakash Javadekar said that the year 2020 is a super year of Environment and will set the tone and tenor for the decade ahead. Highlighting the urgent nature of global environment issues including marine plastic litter, plastic pollution and microplastics, the Union minister said the issues cannot be solved by any one country alone.

On the side-lines of the COP, the Union Minister met a delegation led by Norwegian Minister of Climate and Environment, H.E. Mr. Sveinung Rotevan. India and Norway today agreed to jointly tackle concerns related to oceans, environment and climate matters.

The text of the Joint statement is as follows:

India – Norway Joint Statement on Climate and Environment

  1. Meeting at the beginning of the ‘2020 Super Year’ for the environment, the Ministers stressed that they will do their share to ensure that the 2020s will be a decade of rapid action on climate and environment.
  2. The two sides expressed interest to continue and strengthen the mutually beneficial cooperation on environment and climate between the two countries, including on ocean affairs.
  3. Actions that target climate change and air pollution at the same time pose a win-win situation. The two sides recognized that such actions should be stepped up, and agreed to work together to raise this agenda.
  4. The Ministers recognized that the Kigali Amendment to the Montreal Protocol for phasing down use of Hydrofluorocarbons (HFCs) could prevent up to 0.40C of warming by end of the century, Further, noting that universal ratification of Kigali Amendment to the Montreal Protocol shall allow realization of its full potential.
  5. The Ministers noted the results of the projects supported by Norway on issues / aspects related with phase down of HFCs. It was agreed to continue such projects for facilitating a smooth transition towards energy efficient solutions and technologies while phasing down HFCs.
  6. If managed properly, the ocean holds the key to meeting many of the Sustainable Development Goals. Integrated ocean management is central to achieving a sustainable blue economy. In 2019 Prime Minister Modi and Prime Minister Solberg welcomed the signing of the MoU on India-Norway Ocean Dialogue and the establishment of the Joint Task Force on Blue Economy for Sustainable Development. The two Ministers were pleased with the progress that has been made under this MoU, including the establishment of the Marine Pollution Initiative. They were particularly satisfied that Norway and India will sign a Letter of Intent on integrated ocean management including sustainable Blue Economy initiatives.
  7. The Ministers also noted the importance of delivering concrete, scalable solutions for ocean health and wealth at the UN Ocean Conference in Lisbon on June 2020.
  8. The Ministers further noted the importance of sustainable management of chemicals and waste and welcomed the cooperation between India and Norway on the implementation of the Stockholm Convention on Persistent Organic Pollutants and on the minimisation of discharge of marine litter.
  9. The Ministers emphasized a shared understanding of the global and urgent nature of marine plastic litter and microplastics and underlined that this issue cannot be solved by any one country alone. They are committed to supporting global action to address plastic pollution and exploring the feasibility of establishing a new global agreement on plastic pollution.
  10. The Ministers agreed to support and work together with other political leaders to prompt a global and effective response to curb the direct and indirect drivers of biodiversity loss. They agreed to work together to deliver an ambitious, strong, practical and effective global biodiversity framework at COP15 of CBD to be held in Kunming, China, in 2020.
  11. The Ministers further discussed the conservation of migratory species of wild animals. The Ministers recognized the importance of integrating ecological connectivity into the post-2020 global biodiversity framework.
  12. The Ministers stressed that international supply chains and finance must de-invest from deforestation and destruction of nature and invest in companies and projects that improve smallholder livelihoods while promoting sustainable production and consumption. They agreed to continue the discussion on forests and deforestation free supply chains.
  13. The Ministers stressed that the fifth United Nations Environment Assembly of the United Nations Environment Programme offers a good opportunity to call for greater international action on several environmental issues, in particular strengthening action for nature to achieve the Sustainable Development Goals.
  14. Minister Rotevan thanked Minister Javadekar for the great hospitality extended to him and his delegation during the visit. He invited Minister Javadekar to visit Norway and the Arctic, to further strengthen the collaboration between India and Norway on climate and environment.
  15. Norway and India will explore areas of cooperation in forestry and linking the same with climate change

The Opening Ceremony and Plenary session of the COP will take place on 17th February followed by Side Events and Working Group meetings till the Closing Ceremony on 22nd February. Prime Minister Narendra Modi will inaugurate the COP 13 via video conferencing. Numerous national and international organizations will showcase best practices in wildlife conservation during the course of the conference.

As the host, India shall be designated as the Presidency during the intersessional period following the meeting. The COP Presidency is tasked to provide political leadership and facilitate positive outcomes that further advance the objectives of the Convention, including steering efforts towards implementing the Resolutions and Decisions adopted by the Conference of Parties.

Migratory species of wild animals move from one habitat to another during different times of the year, due to various factors such as food, sunlight, temperature, climate, etc. The movement between habitats, can sometimes exceed thousands of kilometers/miles for some migratory birds and mammals. A migratory route will typically have nesting sites, breeding sites, availability of preferred food and requires the availability of suitable habitat before and after each migration.

India is home to several migratory species of wildlife including snow leopard, Amur falcons, bar headed Geese, black necked cranes, marine turtles, dugongs, humpbacked whales, etc.

Image Credits: Press Information Bureau Government of India.

Subway riders in Singapore, some do and some don’t wear masks.

SINGAPORE – Last Saturday, a day after Singapore raised its disease outbreak response alert for COVID-19 from yellow to orange as the first cases of local transmission of the virus were confirmed, supermarkets found themselves besieged by customers piling carts full of instant noodles, rice and toilet paper, among other essentials.

“As there are now a few local cases without any links to previous cases or travel history to China, we have stepped up our risk assessment from DORSCON Yellow to DORSCON Orange,” stated the Ministry of Health announcement, referring to its sophisticated disease outbreak alert system, which includes four public health preparedness levels – from green to the highest level of red.

“What if it gets worse?” said the more fearful, a succinct verbal summary of the Singaporean concept of “kiasi”— a self-deprecatory, half-joking, self-assigned, stereotypical response that literally translates to “scared to die”.

But, as suddenly as panic buying spiked, it vanished almost overnight.

“Was at the largest NTUC Fairprice [supermarket chain] in my estate – and happy to report that the ‘zombie-apocalypse’ crowd is gone,” observed one Singaporean cheerily on her Facebook page, on Sunday afternoon.

Local memes poking fun at the panic buyers and the more creatively-masked commuters and consumers made their rounds on social media, even as hand sanitiser and surgical masks flew off shelves and hours-long queues formed at retailers that still had items in stock.

In all available communication outlets, government ministers repeatedly assured the public that the country had more than sufficient “national stockpiles” of essential items, one of many responses in a steady stream of public announcements about both emerging details of the virus and appropriate behaviour.

The government has also had to reckon with rampant misinformation spreading by social media in one of the most connected, device-loving nations in the world, this week having to dispel rumours of emerging evidence that COVID-19 was “”airborne”.  In fact it is transmitted by droplets, which can be transmitted to others by coughing, sneezing or heavy breathing, or by touching a contaminated surface, but not merely as viruses hurtling through the air on their own.

Yellow is the same DORSCON level the the Ministry announced 17 years ago when the SARS outbreak gripped the small, densely-populated island state, but much has changed since then— among the new developments, almost everyone has an unverified theory gleaned off social media about the virus, its spread, its epidemiology, its origins, its development, and how to protect oneself.

But while social media can fuel darker knee-jerk reactions driven by peer pressure, it also means public scrutiny can be equally swift.

Just this week, unsettling echoes of the SARS outbreak sounded.  There were firsthand accounts of nurses working at Tan Tock Seng Hospital – the main hospital treating infectious diseases – being shunned emerged on social media. People reportedly gave a uniformed nurse a wide berth on public transport and refused to share an elevator with another, snapping at her to take the stairs. Another nurse posted a screenshot showing that her rideshare driver cancelled her trip because her destination was the hospital.

But in the same breath, these posts attracted tens of thousands of outraged messages directed at the bad behaviour, and expressing support for healthcare workers.

Some shoppers wear masks at a plaza near Paya Lebar MRT station in Singapore, on the outskirts of the city centre

The quality of the fear now is a faint shadow of what SARS evoked in 2003, an epidemic in which some 238 Singaporeans became ill and 33 Singaporeans died, many of them health care workers. Back then, among other things, taxis refused to pick up nurses outside that same hospital and buses wouldn’t stop for them to alight or board at bus stops in the area – which people avoided like the plague. The public scrambled to avoid nurses on trains,  buses, shopping plazas, food courts, and lifts.

This time, it’s just about business-as-usual, and one gets the sense of a well-oiled machine borne of the SARS experience: at peak hour for appointments at Tan Tock Seng Hospital, patients and visitors, wearing a motley of masks, are funneled via long but reasonably fast-moving queues at a number of selected entrances.

The entrances are teeming with masked, triaging staff, who direct the public to QR codes stuck on walls on the way in. These lead to a declaration page in a browser, with the usual questions (travel history, flulike symptoms) and a requirement to leave contact details. The queue fans out to a number of temperature-taking stations. If you pass, you get a sticker dot, a process repeated at the door of the specialist centres where normal medical appointments still continue.  Or, you can go online with a question regarding COVID-19, and a Ministry of Health bot will pop up to give you some answers.

Schools so far remained open this time around. They closed for a fortnight during SARS, and upon reopening, every schoolchild was given a thermometer and temperature-taking was scheduled each morning at school assembly.

To date, Singapore has 67 confirmed cases of the virus, with 764 having tested negative for COVID-19, and 91 cases still awaiting test results.

Contract tracing has uncovered links between previously announced and new cases— a process the Ministry of Health says was made possible with the assistance of the Singapore Police Force.

Five main clusters have emerged: two churches, a Chinese health product shop, a private business meeting held at a major hotel in the city centre, and a construction site.

But not all chains of transmission have been charted— contact tracing is still in progress for nine locally transmitted cases. And even a few such uncharted cases pose concerns to public health officials who aim to prevent the wider “community-based transmission” of the virus where containment of individual cases and the outbreak would become impossible.

Nonetheless, even as Singapore steps up measures to contain the virus, including increased cleaning in public places, Health Minister Gan Kim Yong stated at a press conference that there were no plans to further raise the current alert level.

“I want to say categorically that we have no plans to go to DORSCON red,” said Mr Gan, who co-chairs a multi-ministry task force with National Development Minister Lawrence Wong.

The government expects that the economy is likely to take a significant hit, but is trying to minimise retrenchments, if any, due to the virus.

The tourism industry, taxis and rideshare drivers are all feeling the pinch of government-imposed travel and visa restrictions which have severely limited incoming visitors from China, who make up a large proportion of the market. The local population remains cautious; crowds at some malls in the city last weekend were noticeably thin, after the orange alert. But the spectre of COVID-19, so far significantly less deadly than SARS (though more contagious), has not held Singaporeans in the same thrall.

And on Valentine’s Day evening in a busy mall hub on the city fringe, life went on—with long queues outside restaurants. The only clue that anything has changed was the fact that some of the faces of friends, families and couples standing in line were covered by masks.

Couples undeterred by COVID-19 form long queues outside restaurants on Valentine’s Day.

Jade Lee is a Singaporean journalist, living and working in the city. 

Image Credits: Jade Lee, Jade Lee , Singapore Ministry of Health, HP-Watch/Jade Lee.

A health worker in protective gear waiting near a residential area in Urumqi, Xinjiang, China.

Egypt confirmed its first COVID-19 case on Friday, the first on the African continent, Egyptian media said, a report also confirmed by the World Health Organization’s Egypt office in a tweet.  A  Health Ministry statement said that it had informed WHO of the infection in a foreign national, who had been tested and then placed in isolation at a hospital. The WHO message added that the case was asymptomatic. Although the English tweet by WHO was quickly removed, an Arabic version remained online Friday evening.

WHO Eastern Mediterranean Region Tweet, later removed in English; the Arabic remained.

Meanwhile, an official Chinese announcement said that some 1,716 healthcare workers had been infected with the virus, mostly in the epidemic’s epicentre of Wuhan and Hubei province. The announcement came as another 5,107 new cases of the novel virus were reported in China over the last 24 hours, bringing the cumulative total worldwide to 63,950 cases and 1382 deaths.

Abroad, the number of reported infections appeared more stable, with 507 cases on Friday, an increase of just seven people over the day before.

Even so, expert modeling assessments suggested that trends in Wuhan imply that the eventual number of COVID-19 infections could range anywhere between 5-40% the city’s population of over 10 million people, depending on how contagious the virus proves to be. Some projections have held that the virus could reach as much as two-thirds of the world’s population, should attempts underway now to contain it internationally fail.

Quarantine, Containment & Travel Restrictions 

Countries across Asia, Africa, Europe and the Americas were still working frantically to mitigate that threat not only by beefing up public health preparedness, which has been the main WHO focus, but also through a combination of tough travel restrictions and quarantines of suspected cases, both voluntary and forced.

In Hong Kong, which has 56 confirmed cases, officials were hurriedly leasing and building quarantine facilities  as part of a plan to repatriate some 2,200 residents currently trapped on the China mainland, ten of which are said to have the virus.

At Friday’s WHO press update on the epidemic developments, WHO’s Emergencies Head Mike Ryan cautioned that such policies also carry weighty ethical implications.

“Decisions on mass evacuation and mass quarantines need to be made with the highest public health standards and consideration of human rights,” Ryan said. “In general we need to be very careful in doing those kinds of processes, we have to balance the public health benefit against the issues of quarantine.. how we manage it, from an ethical and human rights perspective.”

He added that so far, Hong Kong has not requested advice from WHO on protocols for safely undertaking such an evacuation and quarantine.

WHO has, however, repeatedly advised countries to restrain from travel restrictions as an epidemic response, although some 72 countries have applied such restrictions anyway. Under the provisions of the International Health Regulations, a binding treaty on emergency response, countries are not required to follow those WHO recommendations, Ryan clarified.

“We issue general guidance which allows countries to act in good faith.. countries may exceed that,” Ryan said.

What is binding is that countries shall provide a “public health rationale” to WHO for restrictive measures that are taken, he said, adding, “In the end, sovereign countries are responsible for the health and welfare of their societies. They are entitled to make decisions….within their own national and legal frameworks.”

Mike Ryan, head of Emergencies at WHO

In other developments, WHO’s Director General Dr Tedros Adhanom Ghebreyesus, said that a team of a dozen international experts was set to arrive in Beijing this weekend to support the Chinese government response.  But he declined once more to say what countries or institutions were represented. “The experts are from very different countries, and really good in the area of their expertise, which is needed. …. we will give you more information about the experts whenever it is necessary,” he said.

As for earlier comments by US officials that they had not been included in the delegation, Ryan hinted that experts from the US were somehow be represented, saying, “with regards to the team, I believe we will have US experts. We will have to wait and see.” He noted that scientists often had fewer problems collaborating than politicians, and that in fact there has been “deep scientific collaboration between the United States and China, increasingly over the last 20 years. Not incidentally, the major scientific coordination organization in China is called China CDC,” he said. “Scientists collaborate regardless – we need to let them get on with it. ”

Health Worker Infections in China

As of midnight February 11, a total of 1,716 confirmed cases of infection of medical personnel were reported nationwide, “accounting for 3.8% of the confirmed cases nationwide. Six of them died unfortunately, accounting for 0.4% of national deaths,” according to a Chinese government press release [translated].

“Health workers are the glue that holds the health system together,” said Dr Tedros, speaking to the Geneva press briefing via a video link from Kinshasa, Democratic Republic of Congo (DRC), where he was on a visit to review next steps for strengthening the DRC health system as the Ebola emergency there winds down. “But we need to know more about this figure [of health worker infections], including the time and circumstances in which [Chinese] health workers became sick.”

Li Keqiang, Premier of the State Council of China, visited frontline health workers in Wuhan in late January.

The news about the health worker infections was released by Zeng Yixin, Deputy Director of the National Health Commission, at a press conference on Friday.  He said that Hubei Province, had reported 1502 confirmed cases of the novel coronavirus among medical staff, accounting for 87.5% of the confirmed cases of health workers staff across the country.

The city of Wuhan alone has reported 1,102 confirmed cases of medical staff, accounting for 73.4% of the confirmed cases of medical staff in Hubei Province.

“This is the first official release of data on infections and deaths of medical staff in this outbreak. Let us remember these ….medical workers who have been infected and sacrificed at the front line of the epidemic,” stated a press release issued after the conference.  “They are worth protecting, …and caring for!”

 

Image Credits: Wikimedia Commons: Gangston Tech, Twitter: @WHOEgypt, WHO, China Government Network.

A total of 59,907 cases of the new COVID-19 coronavirus have now been reported in China, according to the latest Chinese government data, posted as of midnight Thursday Beijing time. There was also a steep 48-hour increase in deaths from the disease inside China, now standing at 1,368. The second death outside of China, of a woman in her 80s, was reported Thursday in Japan. Elsewhere, the number of infected people hit 500, with cases scattered across 24 countries as of midnight Thursday Beijing time.

But to cope with the cases abroad, authorities continued to take drastic measures, with Viet Nam reported to be quarantining the Son Loi commune of some 10,000 people about 40 kilometers from Hanoi after six cases were discovered there. It was the first case of a mass quarantine outside of China since the virus began to spread, reported the Singaporean news channel CNA.

 

“This increase that you have seen in the past 24 hours is largely due to a change in how cases are being diagnosed and reported,” said WHO’s Emergencies Director, Mike Ryan, at a press briefing Thursday, explaining the huge leap in case reports in Hubei Province, the epidemic epicentre.  “We need to be very careful in interpreting any extremes.” He noted that some of the increase is also attributable to clinical cases reported days or even weeks ago, but only included now in the official data, after the reporting criteria was changed.

Government-reported data for COVID-19 cases in China, on a popular health workers website, as of 16:51 Central European Time.

Experts were also closely watching the situation in the two biggest COVID-19 hot spots outside of China.  On the Princess Diamond Cruise ship, where more than 3600 passengers and crew remained quarantined in Japan’s Yokohama harbor, a total of 218 passengers were reported on Thursday to be positive for the virus, a leap of 44 cases since Wednesday. Singapore, the next largest cluster, was reporting 58 cases Thursday evening, 11 more than Wednesday. Original contacts for some of the Singaporeans falling ill cannot be traced back to travel to or from China. This has sparked fears that wider community-based spread of the virus may be occurring, making Singapore the next test ground for virus containment.

Meanwhile, an international team of experts organized by WHO in collaboration with the Chinese government was set to head for Beijing to support the disease control and research effort.

Ryan declined to say if American experts from the US Centers for Disease Control or elsewhere, would take part: “There is a multinational team from all over the world, who will go to the field and that has been agreed,” he said, speaking at WHO’s Thursday press briefing. “They should begin flying over the weekend.  I won’t go into the details of their nationalities or their names…

“Once an offer is made, then the sending country has to finally accept to send, so I am not going to prempt any final decision by the sending countries. But I can assure you that the team is top-class scientists from all over the world and all of the countries that can contribute to an endeavour like this.”

For our full report, see here:

Image Credits: CNA News, Dingxiangyuan.

A healthcare worker vaccinates a man against Ebola.

The Director General of the World Health Organization today decided that the smoldering Ebola outbreak in the Democratic Republic of the Congo should remain a “public health emergency of international concern,” following recommendations from a committee of experts convened under the International Health Regulations.

The last embers of the 1.5 year long outbreak appeared to be dying out, with only 3 cases reported in the past week, and no cases in the past 3 days. The outbreak has been contained to only two health districts.

“As long as there is a single case of Ebola in an area as insecure and unstable as eastern DRC, the potential remains for a much larger epidemic,” said Dr Tedros Adhanom Ghebreyesus, director general of the WHO at a press briefing Wednesday.

With the WHO and worldwide media attention occupied by the coronavirus outbreak, “we must not forget Ebola,” added the Director General.

“Strengthening a health system may not be as sexy as responding to an outbreak, but it’s just as important,” he added. Dr Tedros will be flying to Kinshasa, DRC tomorrow to meet with president Félix Tshisekedi and discuss plans to further strengthen the country’s capacity to handle health emergencies.

There is a high “risk of resurgence” and a “risk of complacency” if the  PHEIC designation is abandoned, added the chair of the Emergency Committee, Robert Steffen.

Additionally, Steffen pointed to “two dark clouds on the horizon” – one being the continued security incidences that have “compromised the action of the health teams,” and the second being a lack of “solidarity” in the response. Security incidences have continued to be on the rise in the past few months, according to the Emergency Committee’s assessments.

For those reasons, WHO has determined that the risk of national and regional spread is still “high.”

Nonetheless, the Director general said, the “signs are extremely positive” in the Ebola outbreak. It seems likely that all districts affected by the outbreak will reach the 42-day Ebola-free threshold needed to declare the outbreak over by the next time the Emergency Committee reconvenes.

As of 10 February 2020, there were a total of 3431 cases and 2253 deaths. Between 3 and 9 February 2020, three new confirmed cases were reported in Beni Health Zone, North Kivu. More than 2000 contacts were being followed.

The Emergency Committee assessment noted that sustaining progress towards reducing the rate of new cases depended on the security situation and control of the well-known drivers of transmission, particularly in traditional health facilities, and on continued engagement with the community. A risk communication and community engagement programme has been developed, as has an EVD survivors programme.

Image Credits: Twitter: @WHOAFRO.

After two days of more hopeful signs that new cases of the novel coronavirus in China might be stabilizing, a sharp increase of 14,840 new COVID-19 infections was reported Thursday by the Province of Hubei, more than 10 times the previous day.

Meanwhile, Vietnamese authorities had reportedly imposed a mass quarantine on a number of villages in the Son Loi commune, about 40 kilometers from Hanoi, where six among the 16 cases confirmed so far in Viet Nam, have been reported. It was the first mass quarantine to be placed on an entire community outside of China where over 50 million people remain under partial or total lockdown in the city of Wuhan and around Hubei Province, where the novel coronavirus first first emerged in a wild animal market in December 2019.

CNA News report shows police patrol on perimeter of Viet Nam’s Son Loi commune. (CNA News)

The upsurge in China cases was in part due to an expansion of diagnostic criteria, said Hubei officials in a statement. Those who show clinical signs of COVID-19 were previously not included in the count, which only tallied lab-confirmed cases. However, officials amended the definition so that patients who show clear symptoms of the disease based on clinical exams and chest x-rays “can receive standardized treatment…as early as possible to further improve the success rate of treatment”[translated from Chinese].

A total of 59,907 cases had been reported in China on Thursday, according to the latest Chinese government data, posted just before midnight Beijing time. There was also a steep 48-hour increase in deaths, with total fatalities inside China now at 1,368. The second death outside of China was registered in Japan, in a woman in her 80s. Some 500 people in 24 other countries were also infected with the virus as of Thursday evening, central European time.

“This increase that you have seen in the past 24 hours is largely due to a change in how cases are being diagnosed and reported,” said WHO’s Emergencies Director, Mike Ryan at a press briefing Thursday, explaining the huge leap in case reports in Hubei Province, the epidemic epicentre.  “We need to be very careful in interpreting any extremes.” He noted that some of the increase is also attributable to clinical cases reported days or even weeks ago, but only included now after the reporting criteria was changed.

There were further spikes in the two biggest COVID-19 hot spots outside of China.  On the Princess Diamond Cruise ship, where more than 3600 passengers and crew remained quarantined in Japan’s Yokohama harbor, a total of 218 passengers tested positive for the virus, a leap of 44 cases since Wednesday. Singapore, the next largest cluster, was reporting 58 cases Thursday evening, 11 more than Wednesday.

Government-reported data for COVID-19 cases in China, on a popular health workers website, as of 16:51 Central European Time.

Experts are carefully watching trends in the Asian city-state, where original contacts for some of the Singaporeans falling ill cannot be traced. This has sparked fears that wider community-based spread of the virus may be occurring, making Singapore the next test ground for virus containment. Elsewhere, conferences and meetings were being delayed or cancelled, and school start dates suspended, as the fallout from the virus echoed across the Western Pacific region, Europe, and beyond.

The sharp uptick in reported cases on Thursday occured only hours after Dr Tedros Adhanom Ghebreyesus, World Health Organization director general warned that ¨the number of newly reported cases reported from China has stabilized over the past week, but that must be interpreted with extreme caution.”

“The outbreak could still go in any direction” he told reporters Wednesday after the conclusion of a two-day Global Research and Innovation Forum in Geneva, and just hours before Hubei province officials released the new daily numbers.

The forum sought to identify the best clinical care treatment for patients with the virus; explore why some people become seriously ill while others do not; as well as to forge ahead with a coordinated approach to research on potential treatments and vaccine candidates, said Dr Soumya Swaminathan, WHO chief scientist, describing outcomes of the meeting.

WHO Press Briefing on Coronavirus situation

First Large-Scale China Study Finds Case Fatality Rate Higher Than Previous Estimates

Meanwhile, the first large-scale study of some 4,021 Chinese patients with COVID-19 reported that the case fatality rate of confirmed people who fell ill in January was averaging about 3%, significantly higher than the 2% fatality rate that had been cited previously.

According to a pre-print version of the study by researchers from China Centers for Disease Control (China CDC), published on MedRXiv, patients 60 years or older had even higher fatality rates of 5.4%, as compared to 1.43% for that of younger patients.

Male patients also had a case fatality rate more than triple that of female patients – 4.45% as compared to 1.25%, the study found.

The study, which examined cases in 30 Chinese provinces including the virus epicentre of Wuhan, also provides the first detailed age distribution of confirmed cases of the virus, which had been known to researchers as 2019-nCoV, until WHO gave it a formal name on Tuesday.

Despite the higher fatality rates than previously assumed, the new COVID-19 virus is still less deadly than Severe Acute Respiratory Syndrome (SARS), which had a case fatality rate of 9.2%, during the 2002-03 epidemic, the study’s authors conclude. The COVID-19 virus transmissibility is similar to that of SARS – with a single infected person passing the virus to nearly 4 other people [3.77], on average.

Among those studied, people aged 30-65 years comprised the majority of reported cases, while 47.7% of patients were age 50 and over. The lowest incidence of reported cases was among people under 20 years of age.

Overall, more men than women were reported to be infected, the study found – although gender differences in incidence were only significant outside of Wuhan.

“The high incidence subpopulation outside Wuhan tended to be younger than in Wuhan,” the study’s authors also noted.

The study is the first published report covering a large group of Chinese patients.  But WHO scientists have noted that the true case-fatality rate remains difficult to assess in the early stages. The fatality rate could also prove to be lower if many people with asymptomatic or mild infections are missed by hospital-based surveillance systems.

Experts Closely Watching new COVID-19 hubs like Singapore

Outside of China, global health experts were closely watching trends in Singapore, which has the largest concentration of COVID-19 cases outside of China – with the exception of the Diamond Princess cruise ship.

Singaporeans clear out supermarket shelves on 8 February as coronavirus fears spike

The most worrisome aspect of Singapore’s outbreak is the emergence of cases in people whose original contact with the virus couldn’t be traced, experts have observed. If the outbreak expands from known chains of contacts into more “community-based” transmission, then it’s “game over” in terms of containment and preventing a worldwide pandemic, in the words of one BBC commentator.

In fact, some experts are already using the so-called “P” word. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told Health Policy Watch.  There is a “real possibility that it’s a pandemic – which means it could be a worldwide epidemic where most citizens are at risk of being infected,” he said in an interview.

But while WHO is closely watching the “behaviour of the virus outside of China,” Mike Ryan, WHO’s Emergencies head, has sought to mitigate fears about virus expansion abroad. He notes that the number of cases where contacts cannot be traced remains limited.

Ultimately, public health officials need to  pursue a two-track strategy of both containment and preparation for further expansion. “We must stop the virus while preparing countries for the arrival of the virus…. even if that sounds like a contradiction,” Ryan said, speaking in a press briefing on Wednesday.

Speaking on Thursday he said, “We can only find eight cases [abroad] that are not linked in some way to one of the identified transmission chains,” he observed. He said that researchers are rushing to develop a simple blood test for virus antibodies. But in the absence of such a test, it is difficult to determine how much broader “community” transmission might be occuring. “This may be only the tip of the iceberg, or the iceberg may not be as great,” he said.

Clinical Trials For Vaccine Candidates Could Begin In April

Following the conclusion of the WHO Research and Innovation Forum, WHO’s Chief Scientist Swaminathan told Health Policy Watch that clinical trials of the first COVID-19 vaccine candidate, could begin as early as April.

She said that tests of the first vaccine candidate, an mRNA vaccine, are being supported by the Oslo-based Coalition Epidemic Preparedness Initiative (CEPI) as part of a collaboration with the pharmaceutical company Moderna and the US National Institutes of Health. The vaccine candidate functions on principles similar to vaccines tested against other coronaviruses, such as SARS.

Swaminathan said that she was optimistic about China’s ability to quickly ramp up manufacturing capacity to produce any new vaccine shown to be effective. “There was a Chinese vaccine company present at the meeting, and they were very interested in collaborating on this, and they did raise the issue of exploring manufacturing capacity from an early stage,” she said.

In terms of therapies, trials have already started on the widely-used HIV drug combination, lopinavir-ritonavir as well as on an experimental drug called remdesivir, she noted, although it is “too early” to identify what might be the most promising treatments.

Ad for HIV/AIDS combination drug now being tested for effifacy against COVID-19

Tests of other antivirals, some Chinese traditional medicines, and the FDA approved treatment for seasonal flu, oseltamivir (Tamiflu) are also rapidly being scaled up, she said.

But there are a broad range of other potential treatments as well, she observed: “When we look at our clinical study registry there are about 87 – 89 trials [of antivirals] already under way, and about one-third of them are clinical trials.”

WHO Protests Cases of Stranded Maritime Passengers

Meanwhile, cases of COVID-19 continued to climb aboard the Princess Diamond, the cruise ship that has been under quarantine in while docked in Yokohama, Japan, since 7 February.

Of the 48 new cases of infection outside of China that were reported on Wednesday, 40 were on the ship, noted WHO’s Dr Tedros in his briefing to the press. That adds up to 174 passengers with confirmed cases of the coronavirus.

Dr Tedros protested the fact that in the wake of the Princess Diamond case, two other cruise ships have also been turned away from ports, despite having no suspect cases of the coronavirus.

He said that WHO would be issuing a communique with the International Maritime Organization, asking countries to respect the principle of “free pratique”, for ships’ movement, and proper care of passengers.

And he praised Cambodia’s government for finally agreeing to allow one of two other cruise ships, the Westerdam, to dock, after days of being stranded in international waters.

“Based on what we have been told, there are no suspected or confirmed cases of COVID-19 on board the Westerdam,” he said, noting that the ship is due to arrive in Cambodia Thursday morning.

“This is an example of the international solidarity we have consistently been calling for,” he said.

Inside China – Rising Concerns Over Health Worker Infections & Freedom Of Speech

Inside China, there were growing concerns about the rate of health worker infections, as the South China Morning Post reported that over 500 medical workers had been infected by COVID-19 in Wuhan by mid-January. Although the Chinese government has been releasing daily case counts, no separate tally of health worker cases has been made public.

That issue surfaced against the continuing current of protest over how the Chinese authorities’ repression of free speech might have delayed warnings about the virus and exacerbated its spread in the early days, highlighted by a new petition circulating on freedom of speech. The petition has been signed by hundreds of Chinese, including a number of notable Chinese academics, reported the South China Morning Press.

The petition followed the widely-mourned death on 6 February of Li Wenliang, one of eight doctors punished by Wuhan authorities in early January for “spreading rumors,” after he tried to warn fellow health workers about the new coronavirus on a social media chat.

WHO and its Director General Dr Tedros have also been criticized for white-washing the Chinese repression of initial reports of the novel coronavirus, which is believed to have first infected people working in, or visiting, a wild animal market in Wuhan in December 2019.

Asked about such criticism at Thursday’s press briefing, the WHO head was adamant that he was not pandering to Chinese political pressures in his repeated praise for the Chinese response.

“China doesn’t need, or want, to be praised. Let the truth speak for itself and the world can judge,” he told journalists, adding that thanks to China’s response measures,  “The rest of the world is still safer and in a better shape.

“If there is any failure, that should be challenged. We will assess and learn from it,” he said, adding, “We should not be stigmatizing or attacking a country, but stand in solidarity and fight against this common enemy, COVID-19, as humanity because we are one. This virus attacks every human being.”

Grace Ren contributed to this story.

 

This story was updated 13 February 2020, at 3:19AM & 19:00 CET .

 

Image Credits: CNA News, Dingxiangyuan, Yang et al.2020, Medrxiv, Cattan2011.

The novel coronavirus has been officially named by the World Health Organization as COVID-19, in the first day of a global consultation with about 400 researchers and public health experts charged with designing a coherent way forward to confront the expanding epidemic.

However, as the case count rose by Tuesday afternoon to 42,747 people with confirmed infections in China and 394 abroad, and the death count rose to 1018 people, according to the latest Beijing government data, there were still far more questions than answers about the new virus, which first emerged in December 2019 in a Wuhan, China food market selling wild animals.

“The main outcome we expect from this meeting is not immediate answers to every question that we have,” said World Health Organization Director General Dr Tedros Adhanom Ghebreyesus, at a Tuesday press briefing following the first day of the Global Research & Innovation Forum convened by WHO in Geneva.  “The main outcome is [to be] an agreed roadmap on what questions we need to ask, and how we will go about answering those questions.”

A scientist doing coronavirus research at the US National Institute of Allergies and Infectious Diseases (NAID) Vaccine Research Center (VRC).

While WHO and other partners have all placed a great deal of emphasis on the transparent sharing of scientific knowledge about the virus to rapidly advance solutions to the epidemic, the two-day forum ongoing Tuesday and Wednesday in Geneva has been closed to the public, and participants were reportedly asked to avoid speaking to the media.

“We were instructed not to speak externally really but what I’ll say is that the atmosphere was quite good and the report will be quite action focused,” one participant from a leading global health research institution told Health Policy Watch.

Key questions that remain unanswered by WHO, its global partners and advisors cover some of the most characteristics of the virus as well as the outbreak dynamics, such as:

How contagious is the virus and what preventive measures can the public take? And how easily can asymptomatic carriers pass it to others? WHO’s Dr Tedros stressed in Tuesday’s press briefing that the virus can be passed by the respiration of tiny airborne droplets from an infected person – and that makes it far more contagious than diseases such as Ebola, which raged for a year in the Democratic Republic of Congo, but now appears to be finally on the wane. At the same time, besides hand washing and maintaining distance from people who are visibly ill, WHO and other public health authorities have so far been unable to issue clear guidance as to what else the general public can do to protect themselves from the virus. For example, WHO experts have said that there is mixed evidence about the extent to which simple surgical masks may or may not provide an added measure of protection – despite their increasingly widespread use not only in China, but also in other potential outbreak hotspots, as well as on some airline carriers.

How long is the virus incubation period? Most scientists have estimated 14 days, but there have been some estimates of up to 24 days. However, 24-days so far appears to be an outlier figure, noted WHO’s Sylvie Briand, in a briefing on Monday,

What is the actual death-rate?  In terms of a simple calculation of the numbers of the confirmed infections as compared with those who died, the fatality rate has hovered around 2.4%, which is higher than the death rate for seasonal flu, running at about .05% in the US this flu season, and for which vaccines also exist.  Better tracking of the COVID-19 virus, and inclusion in records of more asymptomatic cases, which seem to be common, might yield a lower fatality rate, some WHO experts have suggested. At the same time, the death rate could also prove to be higher, cautioned Gabriel Leung, infectious disease specialist and dean of medicine at the University of Hong Kong, writing in the New York Times.  He noted that in the early days of the SARS epidemic, experts believed that the case fatality rate was hovering between 2-3 percent. It later proved to be much more deadly – with the fatality rate for SARS in Hong Kong a “staggering 17 percent.”

Why are there variations in the death rate of those infected in China and abroad? Among the latter 394 cases, only one person has died. The disparity has been attributed by some scientists to the fact that most of the cases abroad were among travelers who were presumably younger and more fit, whereas the cases in China have involved the whole population.

What is the age and gender breakdown of those seriously ill?  While WHO has reported that about 15% of cases are serious enough to require hospitalization, and these tend to be older, no more detailed breakdown of cases has released. However, a study published last week in JAMA of 138 people hospitalized in Wuhan in January noted that their median age was 55 years of age.  This suggests that a significant proportion of those becoming seriously ill could be younger than had been assumed. Slightly more than half of the hospitalizations were men. And while most people recovered, they also required long periods of hospital care, averaging ten days or more, the study noted – something that could overwhelm a health care system with weaker hospital capacity.

What about children?  There have not, however, been many reported cases in children, said Nancy Messonnier, director of the US Centers for Disease Control’s Center for Immunization and Respiratory Diseases, speaking at a panel on the coronavirus Tuesday at the Aspen Institute.  That should be good news, although if the cases are mild or asymptomatic, then children could also “seed” cases to other more vulnerable family members in the household.

What is the animal source of the novel infection?  WHO’s Sylvie Briand said in Tuesday’s briefing that the original source for the new coronavirus had likely been a bat, which are common carriers of many different types of coronaviruses. However, an assessment by Chinese researchers last week in Nature, and also cited by Leung, points to the endangered species of pangolins, or other small mammals, as likely the point of contact with humans. Pangolins are commonly hunted and sold in Asian live animal markets for their meat, while their scales are used as an ingredient in traditional medicines.

Aerial shots of a large quarantine site being built in Hong Kong as coronavirus cases climb above 40.
WHO Boosting Diagnostics Capacity – But Many Countries Lack Respiratory Care Facilities   

As soon as a public health emergency was declared on 30 January, WHO swung into action to equip low-income countries, particularly in Africa, with diagnostics to identify the virus in suspected cases. The results have been impressive, in just two weeks, 13 African countries as well as Iran have been equipped with the laboratory tests, and technicians from a dozen African countries were trained in their use last week. Another 150,000 tests were about to be shipped to more than 80 labs worldwide, WHO has said. Personal protective gear for health workers, critical to infection control, is also being shipped from WHO emergency stocks to countries lacking strong supplies.

However, if cases clusters appear in Africa, or expand more widely in hotspots of South-East Asia and elsewhere – other serious capacity issues will emerge for health systems, including quarantine and containment facilities, which are expensive to mount and maintain. There is also a lack of hospital respiratory equipment to support those with pneumonia-like symptoms – one of the most common features of serious illness, one WHO official noted on Tuesday.

“Severe cases tended to be taken in charge by an intensive care unit where you have to provide the respiratory equipment, and this capacity is very limited in many African cities,” said Michel Yao, head of emergencies in WHO’s African Regional Office, in an interview with National Public Radio. That lack of supportive care could lead to a much higher death rate in poor and underserved regions.

At least a dozen R&D biopharmaceutical companies are working on vaccines, antivirals or other treatments to confront the fast-spreading coronavirus, said Thomas Cueni, director general of the International Federation of Pharmaceutical Manufacturers, in an interview Monday with Health Policy Watch. The Chinese government has, meanwhile, authorized initial research or exploratory trials of some 30 existing anti-viral treatments developed to treat other serious viruses, including Ebola and HIV, as well as other coronaviruses such as SARS and MERS. Still, it may be some time before one or two of those being tested shows evidence of efficacy against this new virus.

And in the absence of effective medicines, providing good supportive care and preventing further infection spread, will be the main things that health care systems can do to combat the virus.

And that is why, for the moment, WHO’s Director General is placing his bets on “containment” strategies to slow the virus spread outside of China, what he is wont to call “a window of opportunity.”

“We are having a real problem in our hands, and we must take what is happening now seriously,” he said.  “I have a great concern that if this virus makes it to a weaker health system, it will create havoc. It will. For now, it doesn’t seem so, but this doesn’t mean that it will not happen. It depends on how we lead this response and how we respond to the outbreak,” he said.

Describing the virus as “Public Enemy Number 1,” the WHO Director General said: “The world talks about terrorism.  But to be honest, a virus is more powerful in creating economic, social and political upheaval than any terrorist attack.”

Grace Ren contributed to this story – Updated 12 February 2020

 

Image Credits: NIAID, Studio Incendo.

“We all have a vested interest to stop this epidemic,” says Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). As WHO on Tuesday convenes a Global Research & Innovation Forum to rapidly ramp up R&D, Cueni spoke with Health Policy Watch  about what he describes as  “the extraordinary willingness of everyone involved – regulators, pharma companies, public health institutes, and many others – to reach out and work collaboratively to respond to the 2019_nCoV.”

Thomas Cueni, director general of the IFPMA

Health Policy Watch: In terms of the R&D response to the coronavirus crisis, which has taken China and the world by storm, can you give a broad overview of what is going on the R&D front? 

Thomas Cueni: This is clearly a rapidly evolving situation, one where it is important to acknowledge how quickly things have moved in just a few weeks.  On 9 January 2020, the Chinese health authorities and the World Health Organization (WHO) announced the discovery of a novel coronavirus.  A virus that was confirmed as the agent responsible for the pneumonia cases and for which there are no known effective therapies.

Then in a matter of days, (11-12 January 2020), the Chinese authorities shared the full sequence of the so called 2019-nCoV genome, as detected in samples taken from the first patients.  Sharing the sequence of the virus is crucial for the development of specific diagnostic tests and the identification of potential treatment options.

Coronavirus spike protein structure: Enveloped viruses responsible for 30 percent of mild respiratory infections and atypical deadly pneumonia in humans worldwide. This illustration shows a viral membrane decorated with spike glycoproteins; highlighted in red is a potential neutralization site, a protein sequence that might be used as a target for vaccines. (Photo: NIH/David Veesler, University of Washington)

From that moment onward, the scientific community was able to start getting to grips with the new threat posed by the novel coronavirus.  As a first step, data- sharing channels are a must for researchers to mobilize.  Fortunately, the Global Initiative on Sharing All Influenza Data/GISAID Initiative, set up twelve years ago, was immediately pressed into action to share the information across their network.

From this point, it was possible for collaborative R&D platforms to begin to look at how they could respond.  CEPI (Coalition for Epidemic Preparedness Innovations), announced as early as 23 January 2020, that some companies were already lined up and ready to initiate vaccine development.  Since then, the European Innovative Medicines Initiative (IMI), a European Union public-private partnership with the pharma industry, has also begun looking into establishing collaborative initiative on 2019_nCoV therapeutics and diagnostics.

What characterizes the R&D approach for the novel coronavirus is that we are NOT starting from scratch.  The global collaborative research community has responded to health crises before.  SARS, MERS, and Ebola have, all in their own ways, forged pathways for collaboration to accelerate development of resources to tackle this new outbreak.  The 2016 WHO R&D Blueprint for Action to Prevent Epidemics, which put forward funding & coordination models for preparedness and response has clearly been important in helping pull together this week’s Forum to fast track R&D for the novel coronavirus.

HP-Watch: An important part of the R&D effort will be directed towards identifying/repurposing existing medical treatments –  Are there any promising existing treatments out there so far that have come on your radar – we were hearing about chloroquine and HIV drugs as one alternative last week?

Cueni: One of the main actions that the China government has already started to investigate is whether existing anti-viral drugs could be successfully repurposed to treat this novel type of coronavirus.

It has already authorized to test 30 compounds against 2019_nCoV. One of the key ones being Remdesivir, a new (experimental) antiviral drug by Gilead Sciences Inc. aimed at infectious diseases such Ebola and SARS. We understand that this treatment will be tested by a medical team from Beijing-based China-Japan Friendship Hospital for efficacy in treating the novel coronavirus.

This is just one of the experimental drugs that have not been approved for use to treat the novel coronavirus by drug regulators but that are in the frame to be repurposed.  Scientists in academia and companies are reviewing existing compounds and research. We have learnt about AbbVie’s Lopinavir – Repurposed HIV protease inhibitor (under the trade name Kaletra) as well.  Interferon and Oseltamivir which were used to treat some patients with MERS are also being tested.

Pharma industry associations such as the European Federation of Pharmaceutical Industries and Associations (EFPIA) have issued a call to their members to identify suitable assets in their libraries that could be utilized in the fight against coronaviruses.  Relevant assets include diagnostics and biomarkers, approved therapies, or compounds in development that could be repurposed for use in treating patients with the coronavirus.  EFPIA members have also been asked to identify any ACE inhibitors (used to dilate vessels and lower blood pressure), protease inhibitors (antivirals widely used to inhibit HIV)  or immunotherapies that could be relevant in the context of CoV.

Artificial Intelligence is finding its place in the process, and is being used to mine through medical information to find drugs that might be helpful for tackling the novel coronavirus. Overall, there has been an extraordinary willingness of everyone involved – regulators, pharma companies, public health institutes, and many others – to reach out and work collaboratively to respond to the 2019_nCoV.

HP-Watch: As for vaccines, the new Oslo-based Coalition for Epidemic Preparedness Innovations (CEPI) seems to be leading the search.  And it has signed a collaboration agreement with GSK as well as a number of other private sector partners.  However, Anthony Fauci, director of the US National Institutes of Health/National Institute of Allergy and Infectious Diseases, has pointed out that any vaccine would take at least a year to develop and approve, so the real solutions will have to be focused on “good public health measures” for now.  Any thoughts on this and the timeline?

Cueni: CEPI is clearly well positioned to demonstrate what the WHO rightly underscores as the importance of global collaboration among the public and private sector. The funding and research landscape for diseases of epidemic potential has evolved since the SARS and Ebola outbreaks.

Developing and approving repurposed or new diagnostics, vaccines and other treatments will all vary greatly. Clearly, the jury is out in terms of how long it will take; and lest we forget, an essential condition for better R&D preparedness and response is the availability of funding.

That notwithstanding, at least a dozen R&D biopharmaceutical companies are working on vaccines or antivirals and other treatments to help those infected with the fast-spreading contagion.

I’ve spoken to Thomas Breuer, chief medical officer of GlaxoSmithKline’s (GSK.L) vaccine unit, who said it was working with developers by providing a technology that could make their vaccines more potent.  He gives a timeframe of at least 12 to 18 months to develop an effective vaccine.

HP-Watch: With the efforts that are already going on, what more can this urgent  R&D meeting in Geneva called by WHO accomplish to advance critical public-private collaboration on R&D?   

Cueni: This week’s forum is timely, and the agenda will hopefully allow to scope out many of the R&D challenges and help identify the possible gaps.

The fact it was possible to quickly organize and assemble such a gathering of so many experts, including the R&D biopharmaceutical industry, is proof that there is today a clearly identified global health community that can be mobilised at short notice – I guess it is a positive legacy of past epidemics.

I think it would be wise to let the meeting take place before passing judgement on what further public-private collaboration is needed.  We have some good platforms in place such as CEPI and IMI who are as we understand going to contribute to the meeting this week.  Hopefully the resulting research roadmap and governance framework for the tackling of the novel coronavirus that will come out from the forum will recognize the ongoing contributions and role of the R&D biopharmaceutical industry.

HP-Watch: Regarding protective equipment, WHO raised an alarm last week about hoarding and price gouging for specialized masks and other PPE devices that health workers need desperately — and they stressed that this can happen at various points on the supply chain, from rubber plantation upward.  What measures can, or is, IFPMA taking to facilitate industry collaboration on this issue all along the supply chain?

Cueni: Panic, hording and speculation clearly have the potential to undermine the response to this public health epidemic. The R&D biopharmaceutical industry is going to great lengths to respond appropriately with the measured urgency that the situation demands. Many IFPMA member companies responded swiftly in the first week of the epidemic being announced to support the Chinese government with donations for diagnostics and protective equipment.

IFPMA and its members are monitoring the situation in China closely. R&D biopharmaceutical companies are working proactively to monitor their supply chains in order to prevent and mitigate potential shortages through close coordination with national regulatory authorities and other global stakeholders, including the World Health Organization.

Protective suits, surgical masks and respiratory masks
for health workers in China are loaded onto a truck at UNICEF’s global supply hub in Copenhagen on 28 January 2020.

HP Watch: In terms of the sharing of vital information about pathogens, to expedite research into therapies and vaccines, you recently noted that the Nagoya Protocol, which aims to ensure a country’s control over the genetic materials of indigenous plants and animals species, as part of biodiversity protection, needs to be urgently amended to exclude pathogens – otherwise this could greatly impede their sharing.  Can you please explain this complex issue.

Cueni: The Nagoya Protocol (NP) on Access and Benefit Sharing (ABS) is a legally-binding, supplementary international agreement to the Convention on Biological Diversity (CBD). Its objective is the fair and equitable sharing of benefits arising from using genetic resources for the conservation and sustainable use of biodiversity. To put it simply, the Nagoya Protocol has the laudable aim of giving each country sovereignty over its biological resources.

Today, more and more countries are moving towards enacting the Nagoya Protocol in national legislation, interpreting it in a way that requires sharing of the genetic resource and their information to be subject to negotiation between two parties.  The inclusion of pathogens (as a genetic resource) under the NP was not directly addressed in the final text, and the decision was made to leave it to each Party to “pay due regard” to potential public health risks when implementing legislation.

As I recently wrote in First Opinion in STAT, applying the Nagoya Protocol in the case of the novel coronavirus could have hindered or even prevented the global collaboration required to find new treatments or vaccines. Luckily, China has seemingly not followed Access and Benefit Sharing (ABS) requirements when it discovered the novel coronavirus 2019_nCoV.  In principle, a country with such a new virus could have embarked on discussions with each country, one by one, about how to share the sequence of this pathogen.

While we are today focusing on putting all our efforts on the novel coronavirus; there are other examples where difficulties can arise.  For example: in the case of seasonal influenza vaccines, the WHO acknowledged that there have been instances where sharing of seasonal influenza virus samples with WHO has been hindered, or halted altogether, on the grounds of conflicting or unclear local ABS legislation. This is concerning. If the WHO cannot fully see what strains of influenza viruses are circulating, the probability of them being able to make an incorrect recommendation with regards which strains to include in seasonal vaccines, increases quite substantially.

I firmly believe it is in the world’s best interests to promote trust and fairness for the sake of global public health by making the sharing of pathogens swift and predictable.  We must question the sense of retaining pathogens within the scope of the Nagoya Protocol and associated national legislation. It is in the interest of global public health and epidemic and pandemic preparedness for the international community to work towards an effective and internationally coherent approach to exempt pathogens from the protocol.

HP-Watch: As for the WHO’s Pandemic Influenza Preparedness (PIP) framework – which the WHO Executive Board (EB) also reviewed at its meeting last week – how does that framework fit into the current crisis?  Is it relevant, or not, in expediting needed R&D?

Cueni: The main objectives of the PIP Framework are to improve pandemic influenza preparedness and response, and strengthen the protection against the pandemic influenza by improving and strengthening the WHO global influenza surveillance and response system WHO GISRS, which includes a global network of national influenza centres, WHO collaborating centres and other research laboratories. The novel coronavirus brings the advantages of this network sharply into focus.

The PIP framework has as its objective to provide a fair, transparent, equitable, efficient, effective system for all.  In addition to ensuring that it operates on equal footing for all, it underscores the need for the sharing of H5N1 and other influenza viruses with human pandemic potential; as well as providing access to vaccines and sharing of other benefits.

The PIP Framework was adopted in 2011, but we have not yet seen its principles put into practice. It should also be noted that influenza is quite a unique situation, where potential manufacturers of a pandemic vaccine can leverage on developing and distributing seasonal vaccines annually, with global pandemic preparedness being underpinned by seasonal vaccine coverage; no other emerging virus can claim the same.

As the PIP Framework itself is not legally-binding for Member States, so far very few countries have made specific provisions for it in their national legislation. This means that, in the event of a pandemic, a country could refuse to immediately share their pandemic virus samples on the grounds of conflict with local ABS legislation.  This could lead to delays as bilateral contracts are negotiated,

This creates a situation of inequity where some countries include public health provisions in their local legislation, and are willing to share with the global community, but others do not on the basis that the Nagoya Protocol is an environmental piece of legislation.  The fear I have is that many legislators are not even aware in passing this legislation that public health could be impacted.

HP-Watch: Any other observations from the recent WHO EB debates on PIP, Ngoya and emergency preparedness ?

Cueni: I think that we cannot under-estimate the importance of having systems in place to make sure that the global health community can act fast to tackle threats to public health. The need for collaboration and alignment that are underpinned by effective networks and sharing platforms are key.

While the Executive Board had to deal with many tough questions, let us not lose sight of what is happening in Wuhan and beyond. My first thoughts are with all those affected by the outbreak of the novel coronavirus (nCov-2019).

The World Health Organization is clearly pulling out all the stops to handle this public health emergency.   The R&D biopharmaceutical industry is supporting the global community and the WHO; as an industry we are fully committed to joining global efforts to care of those affected, contain the outbreak and develop resources to tackle future outbreaks.

HP-Watch:  Other issues you would like to address at this critical moment – in terms of how to ensure what Tedros described as “solidarity, solidarity, solidarity” between public and private sectors.   

Cueni: Since the WHO declared the coronavirus a Public Health Emergency of International Concern on 30 January 2020, their continued leadership will be crucial in helping ensure an effective and appropriate response to this public health threat.

As a science-driven industry that aims to address some of the world’s biggest health care challenges, the R&D biopharmaceutical industry clearly has a role to play in developing new and improved medicines and vaccines to help respond to this epidemic.  The industry is fully supportive of efforts that will ensure the scientific community can respond quickly to the challenges this epidemic faces.

There are a number of factors today that give me hope that the situation can be managed.  Firstly, rapid access to the virus has speeded up the process of kick starting the search for solutions, secondly, there is global recognition, funding and structures in place to share the burden of R&D.  Last but not least, there are tried and tested sharing platforms in place for influenza that can be leveraged.

Epidemics are a time when we are all starkly reminded that putting up fences across the global health community does not work.  We all have a vested interest in trying to stop the epidemic from spreading, especially to countries with weaker health systems – this would be an absolute tragedy.  We all have a vested interest in finding treatments and preventative vaccines as soon as possible.

 

Image Credits: NIH/David Veesler, University of Washington, IFPMA , Prachatai.