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Archive for the ‘Outbreaks’ Category

Estimating the True Case-Fatality Rate of COVID-19

For several months, we have been inundated by reports summarizing incidence and mortality data for COVID-19, on both the national and global level. In a previous ProMED post I cautioned that “reported cases” cannot be equated with “total cases” without inclusion of individuals with asymptomatic of sub-clinical infection that do not seek medical care. [1] If a large segment of the population is found to be seropositive, we might conclude that the true case-fatality ratio of COVID-19 is lower than official data might suggest. A seroprevalence study reported this week seems to provide solid evidence that this is the case. [2]

A national survey of individuals identified IgG antibody toward SARS-CoV-2 in 5.0% of the general population of Spain. At the stated specificity of 100% and sensitivity of 98%, the true seropositivity may be estimated at 5.15%. Although factors which determine seroprevalence rates in Spain need not apply to other countries, the following chart extrapolates the potential impact of a 5.15% population seroprevalence on case-fatality data from high-incidence countries in the European Region, United States and China. [3]

The impact of future SARS-CoV-2 seroprevalence surveys will largely depend in the quality of the test itself, the duration of immunity and protective role of the antibody, possible emergence of newer strains of coronavirus, and other factors. In any event, additional seroprevalence data will play a key role in planning our response to this pandemic going forward.

COVID-19 Reported vs. Estimated cases

Country Reported cases % of population Reported Deaths CFR (%)* Estimated cases** Estimated CFR (%)***
Belgium 55,280 0.48% 9,052 16.4 596,548 1.52
China 82,947 0.0058% 4,634 5.6 74,125,174 0.0063
France 179,569 0.28% 28,108 15.7 3,360,686 1.14
Germany 176,651 0.21% 8,049 4.6 4,313,197 0.19
Israel 16,617 0.19% 272 1.6 444,866 0.061
Italy 225,435 0.37% 31,908 14.1 3,114,329 1.02
Spain 277,719 0.59% 27,650 10 2,407,759 1.14
U.K. 243,695 0.35% 34,636 14.3 3,493,878 0.99
U.S.A 1,527,664 0.46% 90,978 6 17,034,349 0.53

* CFR = deaths / cases X 100
** True number of cases based on population seroprevalence of 5.15%
*** Adjusted CFR = deaths / estimated true cases X 100

References

  1. ProMED – What’s the denominator 20200228.7035438
  2. ProMED – Spain: seroprevalence study 20200516.7342334
  3. https://www.worldometers.info/coronavirus/ (status as of May 17)

Is it Safe to Go Back to the Gym? Dr. Berger talks to Shape.com

Illustration of two females exercising in a gym

Many states are relaxing their stay-at-home guidelines, which includes opening up fitness facilities to the public again.  Most must operate under a limited capacity, enhanced cleaning and sanitation practices, and use signs and floor markers to ensure social distancing. But the big question is whether it’s safe to go back? Experts warn social distancing may not be so easy at a gym.

“A gym is just another venue in which disease can be passed from person to person, and the risk of contracting COVID-19 might increase there, where group sports and games require close personal contact,” our co-founder and infectious disease specialist, Dr. Stephen Berger explained to Shape.com

“The fact that you might be young and healthy won’t affect your chance of becoming infected; it will really only increase your chances of surviving an infection without severe or fatal consequences.”

Similarly, if you’re in a region where local officials are mandating or strongly urging residents to wear face masks or other facial coverings in public, the gym is not exempt from those guidelines, notes Dr. Berger.

You can read the entire article here.

And don’t forget to follow us on Twitter, Facebook, and LinkedIn. We’ve got exciting updates about our new interface!

What’s The Difference Between a Face Mask and a Condom?

Cloth surgical masks were first used in the late 19th century and were replaced by modern masks during the 1960s. Surgeons do not wear masks to protect themselves from the patient, but to protect the patient from their own oral and nasal bacteria. 

In any case, masks do protect the users themselves. A variety of masks are currently marketed in a wide range of design, material, filtering specifications, and prices. Both cloth and paper masks will offer protection against COVID-19…. but not one-hundred-percent protection. For this reason, we must observe additional precautions such as social distancing, hand washing, etc. 

Can COVID-19 get through the face mask?

Masks are designed to filter out small particles from the air. In theory, the virus that causes COVID-19 could easily evade even the high-quality masks that we see in our streets lately. More than 200,000 individual viruses would fit into the period at the end of this sentence. The good news is that we become infected through somewhat larger particles, consisting of the virus itself, mucus, cellular debris from the lungs and throat, etc. 

A face mask is not a substitute for social distancing

Sadly, masks also tend to give the user a false sense of security.

When I see neighbors in masks sitting next to others I will ask, “If I were to tell you that the other guy is actually infected with coronavirus, will you continue to sit with him? Or will you back away? After all, you do have a mask? If he is also wearing a mask, will you be reassured? 

I am reminded of the early days of the AIDS pandemic which continues to this day. Young travelers en-route to exotic countries would assure me that they will use condoms. I would ask them, “If you found out that this specific person is HIV-positive will you continue to partner with them? After all, you are wearing a condom!” 

How to properly wear a face mask

Masks should be as closely fitted to the skin as possible. The nose must also be covered. Note that when people are tested for the virus, a swab is inserted into the nose – because that is where the virus is

We often see medical professionals – and even doctors in the operating room – with masks worn below the nose. This is not only poor practice, it is blatantly illogical! Several years ago, we conducted an experiment to test the influence of mask position on contamination rates in an operating room – see Effect of Surgical Mask Position on Bacterial Contamination of the Operative Field

Regarding the problem of eyeglass fogging, my surgical colleagues recommend that the mask must be pressed tightly onto the skin under the eyes, but worn loosely under the chin to redirect the flow of exhaled air.

So, here’s a thought! Walking among strangers without a mask is like having unprotected casual sex. But, unlike venereal diseases (and even HIV / AIDS) COVID-19 can kill, and you may well become a danger to the lives of your loved ones!

GIDEON’s Dr. Stephen Berger offers up important coronavirus safety tips in Parade.com article

Besides consistent hand washing, self-quarantining, and social distancing, people want to know the best ways to remain healthy and reduce their risk of getting COVID-19. 

Parade.com wrote about ‘14 Ways to Stay Safe During the Coronavirus Pandemic’, which included everything from maintaining good support systems to consistent exercise to covering your face and how that can and can’t protect you. GIDEON co-founder Dr. Stephen Berger discussed important information to remember when it comes to wearing face masks.

Here’s what was covered in the article:

Realize that covering up your face is not an excuse to not social distance.

In early April, the CDC made the recommendation that Americans should wear masks and cloth face coverings whenever going out in public. But experts want you to know that this is not a reason to now get together with friends or to forgo the social distancing recommendations of keeping 6-feet away. While face masks can help to reduce the amount of viral respiratory droplets released into an environment, they are not 100% effective at keeping you safe from the coronavirus.

“Extremely small particles, including the virus itself, might pass through the spaces that allow air to pass,” Dr. Berger, told Parade. He added that facial coverings do not cover the eyes, which is another channel in which the virus can be transmitted.
“And face masks do not protect our hands, clothing, objects that we may be carrying. All of these are exposed to contaminated secretions and might infect us at some later time.”

You can read the entire article here

…But There Are No Cases in Turkmenistan

written by Dr. Stephen A. Berger

If you search the Internet for countries which have reported COVID-19, an endless variety of sources will describe the status of this disease in 207 countries and their dependencies. Few if any of these sites mention countries where this disease does not exist!

As of April 19, GIDEON lists twenty-four countries (10.4% of the global total) that had not yet encountered a single case. Ironically, at this point, these countries enjoy a form of “medical isolation” – thanks to the disease itself! The chance that a traveler – let alone an infected traveler – can arrive in a new country is vanishingly-small because the idea of international travel has been erased by COVID-19.

In most cases, countries that are not reporting COVID-19 cases have instituted travel restrictions, surveillance and preventive measures (masks, social distancing, etc). Several Pacific Island Nations listed below are geographically isolated, lack sufficient medical resources, and enforce similar forms of restriction and enforcement.

The approach of two European countries – Tajikistan and Turkmenistan – is notably different. Although Tajikistan enforces restricted travel and quarantine for arriving travelers, large public gatherings and sporting events are not restricted. Face masks, though not required, are commonly seen in the streets. In contrast, a report by Reporters Without Borders stated that Turkmenistan had banned the use of the word “coronavirus” and that people wearing masks could be arrested. Nonetheless, Turkmenistan does ascribe an absence of COVID-19 cases to strict enforcement of travel restrictions and announced in early April that all citizens will be tested for the virus.

A seeming absence of COVID-19 in North Korea has led to considerable speculation and even conspiracy theories. The fact that this country shares a border with China would suggest that infected individuals are likely to have entered the country; however, North Korea did impose closure of the border at an early stage of the Chinese outbreak, and imposes strict control, surveillance, and quarantine over potential cases.

Countries Which Have Not Reported COVID-19 (as of April 19)

  – Travel bans enforced including restrictions on incoming aircraft

  – Has physically refused entry to approaching cruise ships

    – State of Emergency declared

    – No additional information available

American Samoa

Christmas Island

Cook Islands

Kiribati

Lesotho

Marshall Islands

Micronesia

Nauru

Niue

Norfolk Island

North Korea

Palau

Pitcairn Island

Saint Helena

Samoa

Solomon Islands

Tajikistan

Tokelau

Tonga

Turkmenistan

Tuvalu  

Vanuatu

Wallis and Futuna Islands

Wake Island

 

Update: Posted in ProMED

Neglected Diseases – Neglected Once Again

written by Dr. Stephen A. Berger

For several years, the World Health Organization has been following a group of twenty-or-so Neglected Tropical DiseasesIn the Developed World, these conditions are largely unknown to the general public, and even to physicians working in fields outside of Epidemiology and Infectious Diseases. In only three months, the list of neglected diseases has grown to include more than 360 infectious conditions – all because of a single new viral disease called COVID-19.

As of this morning, 287 cases of COVID-19 had been reported in the DRC (Democratic Republic of Congo) resulting in 23 deaths. How many are aware that this same country is in the midst of a massive outbreak of Ebola – which has claimed 3,457 cases and 2,266 deaths to date. Since January 1, nearby Nigeria has reported 188 deaths from Lassa fever, compared to only 13 deaths from COVID-19. 

Saudi Arabia is currently experiencing a massive outbreak of coronavirus infection, but not the one you’ve been reading about. For more than seven years, infection by MERS-CoV (a close “relative” of the COVID-19 virus) has infected 2,044 Saudis and claimed the lives of 821. Compare this to the current COVID-19 outbreak, which has killed “only” 83 Saudis as of today. Any patient who walks into a clinic in Rio, Paris or New York, and says that he has a cough and fever, will be rushed into an isolation room by a group of people draped in masks, gowns, goggles, and gloves. After all….what else could this be?! The answer to that question becomes apparent in the following list, generated by GIDEON.

Note in this screenshot that I’ve asked the computer to list all possible diseases that could explain the presence of fever, cough, and pneumonia in a group of American adults. The GIDEON program tells me that COVID-19 is “number one” on the list, with a statistical likelihood of 83%. But no less than 65 other diseases also appear on this list, including, as you might expect, Influenza and a variety of common viral conditions.

The message here is simple: in the era of COVID-19, not every disease IS COVID-19.

Don’t panic. Prepare

Dr.Tracey McNamara on West Nile Fever and COVID-19

 

As interviewed by Edward Borton, GIDEON

What was the experience of discovering a new virus outbreak on your doorstep?

When New York City announced that people were dying of unusual encephalitis, I was struck by the timing and proximity between this event and an outbreak of crow deaths. Upon ruling out all known viruses that cause inflammation of the brain in birds, in the United States: exotic Newcastle, avian influenza, and Eastern Equine encephalitis (EEE), I knew this was something new.

It wasn’t until I picked up the phone and called the U.S. Army and said “I think it’s something new to veterinary medicine. I think it’s the same thing killing people in New York City, but no one will test my samples.” That one phone call changed everything because the military had a different mindset. When you say ‘something unusual, new and killing people’, they immediately thought of bioterrorism, and the West Nile virus is indeed a biowarfare weapon.

 

Was there a significant media response at the time? How does the response compare with what we’re experiencing today?

It was pretty crazy. We faced the same situation: a disease that we had never seen in the Western Hemisphere, and knew nothing about. We didn’t know what it was going to do, who it was going to make sick, only that it had already killed people. The scientists had nothing but questions about this virus and the public was extremely anxious.

To minimize panic, everyone was told ‘it’s only affecting the very young and the very old’.  Public health officials were telling people to wear mosquito repellent and destroy mosquito habitats if found in or near your home. Sadly, a lot of people were saying, ‘I don’t have to worry about this’.

It seems to be an instinctive response to a novel threat, to just deny it,  but sticking your head in the sand doesn’t mean something isn’t going to walk up and bite you on the butt.

 

Do you feel that the technology available to the industry is sufficient right now or does it need to improve before we start moving things forward?

I think the technology is there. There are companies using artificial intelligence and algorithms to detect anomalous events. It just hasn’t been applied to the animal sector.

We need to improve the speed of diagnostics. When the Ebola virus outbreaks took place, that prompted scientists to look into portable deep sequencing in the field. There is a company that developed a tool that’s smaller than a lunchbox, which allows you to take a swab, stick it in the device and in two hours you can download the results to your laptop. In two hours, you could know what you’re dealing with, whether it’s Ebola, or another virus, bacteria, fungus, parasite or unicellular organisms.

Another really powerful thing is a species neutral diagnostic test. It doesn’t matter if it’s human, environmental or animal. We’re probably talking 10 years from now, but it has been deployed in the field for Ebola, so we will eventually replace all our other methods of diagnostic tests we’re currently using.

 

Do you think we’ll see a new wave of people inspired to get involved in healthcare as a result of the current outbreak? 

Yes, I think so. Young people, they’re so interconnected, they’re online constantly. They will make terrific advances.

There is a phrase used when teaching medical students – ‘when you hear hoofbeats in the distance, think horses, not zebras.’ None of us can afford to think that way anymore, we all have to be thinking about zebras.

We, as human beings, have to find a way to bring all of our expertise together and to respond quickly. That will prevent major mortalities, no matter what profession you’re in. We all have a different mindset but that is what we need – multi-disciplinary teams.

We truly are all in this together and everyone has a role to play. I hope everyone keeps that in mind. Don’t panic. Prepare. Don’t get scared. Prepare. Work with the officials that are working around the clock trying to get their arms around us.

 

Dr. Tracey McNamara was hugely influential in the discovery of the West Nile Virus outbreak in the United States in 1999 and has been in the field of veterinary pathology for over 32 years, including Professor of Pathology at Western University of Health Sciences for almost 13 years.

Tracey gave a TedX talk at UCLA on ‘How monitoring animal health can predict human disease outbreaks’, which is available here.

 

Is COVID-19 the new plague?

written by Dr. Stephen A. Berger

A frightening pandemic arises from animals in Asia and spreads westward, killing thousands in Italy, France, Spain, and many other countries. The more severe infections are characterized by cough and fever, leading to progressive pneumonia. There is no specific treatment available, and entire cultures live in fear and uncertainty.  

And so, during 541-542 C.E. Yersinia pestis the bacterium that causes bubonic plague, spread out from China into the Byzantine Empire. Few were spared, and an estimated 25 to 100 million Europeans went on to die during repeated waves of infection that struck the region over the next 200 years. As many as 5,000 plague deaths per day were recorded in the city of Constantinople. This “Justinian Plague” is named for the Emperor Justinian, who managed to survive an attack of the illness (less-fortunate victims included Pope Pelagius II and Wighard, Archbishop of Canterbury) 

In recent years, much is written regarding the risk of the spread of infectious diseases related to global warming. In fact, there is some evidence that the Justinian plague was the product of global cooling. Five years before the onset of the pandemic, emissions from a volcano may have significantly lowered atmospheric temperature, resulting in the migration of rodents deprived of food. Fleas, which spread plague from rodents to humans, are unable to efficiently digest their blood meals at low temperatures, causing them to vomit as they attempt to feed again – injecting contaminated material into their hosts. 

The Justinian plague largely spared the Arabian Peninsula, thus nourishing the rise of Islam and Arab armies which easily went on to conquer large areas of a devastated Europe. 

From 1347 to 1351, a second plague pandemic – The Black Death – killed 75 to 200 million humans – an estimated ten-to-sixty percent of the European population. Once again, the disease originated in Asia, entering through Sicily on Genoese galleys, and reaching Venice in 1348. The irony of a pestilence from China spreading through northern Italy is obvious in light of current events. Just as the Justinian Plague claimed the life of Bishop Wighard, the Black Death killed two Archbishops of Canterbury in a single year – Thomas Bradwardine and John de Ufford.   

Just as the Justinian Plague altered the future of Europe, the Black Death may well have paved a path into the Renaissance.  

As of March 2020, there is little similarity between COVID-19 and Bubonic plague; but the current massive disruption of society will surely have consequences for human civilization in years to come.

Read more on the global status of Major Coronaviruses

Read more on the global status of Plague

Ebola, forgotten but not gone

written by Dr. Stephen A. Berger, Dr. Yaakov Dickstein, and Edward Borton

The recent WHO decision to declare the novel coronavirus outbreak a Public Health Emergency of International Concern (PHEIC), while both appropriate and hardly surprising, offers the opportunity to reflect on the previous PHEIC which was declared, namely the Ebola epidemic in Kivu region, Democratic Republic of the Congo (DRC). And you should really say the ongoing Ebola epidemic, as during the time since the declaration in July 2019 through to the present day (March 2020), a total of 3,453 cases have been reported [1].

The nCoV-2019 outbreak is still ballooning; as of today, over 400,000 confirmed cases worldwide with no signs of slowing down [2]. To date, there have been 19,786 fatalities, a mortality rate which is notably higher than the rate observed in the 2018-9 influenza pandemic (>2.5%) and significantly higher than AH1N1 (~0.05%) [3,4]. As you might have hoped, the response has been incredibly rapid, faster than ever seen before with a new human pathogen. Within weeks of identifying an outbreak of respiratory illness, the virus has been identified, sequenced and cultured; rapid tests are available for diagnosis (albeit with continuing broadening and narrowing); at least two randomized controlled trials (RCTs) are being performed to analyze the effect of antiviral medications, one with a new drug; and the largest infection control effort in history is underway, including the quarantine of more than 50 million inhabitants in Hubei province, China [5]. Internationally, airlines have ceased operating to China; large-scale surveillance of suspected patients and their contacts is being performed around the clock, and naturally, the media response has been extensive. It would prove more difficult to find someone who didn’t know of the new coronavirus than someone unaware.

The history of Ebola is different, both in impact and response. Ebola is vicious; out of 3,453 cases confirmed since the beginning of the current outbreak, 2264 or 66% have died, similar to ratios from previous outbreaks and among the highest case fatality rates of any human pathogen [1]. First isolated in 1976 following separate outbreaks in Sudan and what was then Zaire, there have been numerous outbreaks of Ebola since, both small and large, however scientific and media attention was limited for the first 20 years. An average of just 9 yearly publications related to the virus was published between 1977-1994 and it was only in 1995, when a major outbreak occurred in DRC, that interest began to be generated [6]. Coincidentally, the movie ‘Outbreak’, released just two months before the first cases in the DRC, also served to increase public awareness of the disease. It was the 2014-6 epidemic, however, which displayed the epidemic potential of the disease, with nearly 30000 suspected cases and more than 11000 fatalities [7]. The declaration of a PHEIC and a global response followed, including the use of experimental antiviral treatment and vaccination. Nevertheless, it took two years before the epidemic terminated.

It may well be an inconvenient truth that the responsiveness to any outbreak will be based on the impact on Western society, chiefly the economy, rather than the severity of the illness and endangerment to human life and well-being. Notwithstanding the vast amount of funds the global economy generates for medical research and treatment production, a more consistent global approach to tackling both the outbreaks themselves and managing awareness and attention would give less developed countries a better platform to address the events in a timely manner, minimizing the risk of extreme outcomes.

Thankfully the current outbreak has been less explosive than that of 2014-6, which could explain, if not forgive, the correspondingly tepid response; while organizations such as Médecins Sans Frontières (MSF, Doctors Without Borders) have been on the front lines from the beginning, it took the WHO four reviews of its original negative decision before they announced a PHEIC. Unfortunately, the situation has been complicated considerably by an ongoing conflict, which has escalated to actively target healthcare workers, including 386 attacks with 77 injured and 7 dead in 2019 [8]. Nevertheless, work has continued and has borne fruit and new cases of Ebola have declined significantly during the current outbreak since the end of September 2019, with only one newly-confirmed case this past week and hopefully, an end is close [1].

Outside of any political or economic reason, it is perhaps human nature to be attracted and fascinated in that which is new and shrouded in mystery and misinformation, and it is seemingly appropriate that the word “novel” (from Latin Novus, “new” or “fresh”) has been incorporated into the name of the virus which now makes the headlines. All the same, the fact that a public health emergency is currently of less international import or concern does not make it any less important or pressing, especially to the locals and health care workers fighting the illness. Given the WHO saw fit to label it as such an emergency, it should also see fit to continue rendering assistance proportionate to that description until the emergency is completely over and the region free from further risk; otherwise why have such labels at all?

Read more on the global status of Ebola

  1. https://www.who.int/emergencies/diseases/ebola/drc-2019. Accessed 3rd March 2020
  2. https://coronavirus.jhu.edu/map.html. Accessed 11th March.2020
  3. Taubenberger JK, Morens DM. 1918 Influenza: the mother of all pandemics. Emerg Infect Dis 2006 Jan;12(1):15-22
  4. Nishiura H. The virulence of pandemic influenza A (H1N1) 2019: an epidemiological perspective on the case-fatality ratio. Expert Rev Respir Med. 2010 Jun;(4)3:329-38
  5. See ProMED string for Novel coronavirus at https://promedmail.org/
  6. Pubmed search for “Ebola”, performed 6.2.2020. https://www.ncbi.nlm.nih.gov/pubmed
  7. WHO Ebola virus disease fact sheet. https://www.who.int/en/news-room/fact-sheets/detail/ebola-virus-disease. Accessed 6.2.2020.
  8. https://www.scientificamerican.com/article/ebola-response-workers-killed-in-attacks-force-withdrawal-from-critical-drc-region/. Accessed 6.2.2020.

Japanese Encephalitis in India

Outbreaks in Japanese encephalitis (JE) / Acute encephalitis syndrome (AES) have been reported from Assam and Uttar Pradesh in recent weeks.  Since 2008, official reports from India do distinguish between these two entities.  The following chart [1] indicates that although India has experienced increasing rates for both JE and AES on a national level,  incidence has not increased in these two states. [2,3]

 

References:
1. Gideon e-Gideon multi-graph tool,   https://www.gideononline.com/cases/multi-graphs/
2. Berger S. Infectious Diseases of India, 2019. 620 pages , 109 graphs , 6,807 references. Gideon e-books, https://www.gideononline.com/ebooks/country/infectious-diseases-of-india/
3. Berger S. Japanese Encephalitis: Global Status, 2019. 100 pages , 66 graphs , 1,208 references.  Gideon e-books, https://www.gideononline.com/ebooks/disease/japanese-encephalitis-global-status/

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