13 February 2020

COVID19 Outside China Shows Value Of Early Response

The statistics surrounding the coronavirus erupting out of Wuhan, China, officially labeld COVID19, and more colloquially known as "Wuhan Coronavirus" paint a grim picture. As of this morning (Thursday, February 13), there were nearly 60,000 cases in China alone, and over 1,000 deaths:
In China:
59,804 cases
1,367 dead
5,911 recovered.

Case Fatality Rate ~ 18.7% 
Outside China:
581 cases
3 deaths
75 recovered

Case Fatality Rate ~ 3.8%
While even the fatality rate outside of China is an alarmingly high rate (epidemiologists blanch at any fatality rate greater than 2%), the variance between the cases inside China and outside China are quite remarkable--enough so as to warrant closer inspection as to why.

One thing these numbers illustrate is the importance of early interventions and responses, both at the personal and public health levels.

China Declared War On Coronavirus

China has had, by far the most rhetorically aggressive and demonstrably intrusive response to COVID19.  From the top on down, they have used quite literally the language of war, and evoked patriotic imagery to elicit public support for their containment efforts. Much of that rhetoric is overshadowed by the brutality and even barbarism of some of their efforts--arrests, incarceration of asymptomatic individuals, and even violence and gunplay

China went to war against the coronavirus in a very literal sense of the word.

China also, unfortunately, went to war against the truth and against transparency.  They have consistently manipulated the data they have been reporting, even going so far as to revise the definition of a "confirmed" case to produce a temporary drop in the numbers--only to have to reverse direction and dramatically revise upward their disease counts in Hubei Province just a few days later.

The scale of China's response is staggering: 400 million people under quarantine by February 7, 80% of their economic output and 90% of their exporting businesses completely shut down since around January 23.

The World Watches, Waits, But No War (Yet)

By comparison, other than travel restrictions to and from China, the rest of the world has done comparatively little: only one small Vietnamese town, Son Loi, has instituted community-wide quarantine measures. The United States has quarantined American citizens repatriated from Wuhan, some of whom have since tested positive for the virus. Japan has quarantined a cruise ship, the Diamond Princess, whose passengers are steadly testing positive in increasing numbers.

There have been no mass quarantines of countries.

There have been no closures of businesses.

Yet there have been no mass outbreak of cases internationally.  As I have rhetorically asked multiple times, "where are the cases?"

For a disease that is highly contagious, there have been surprisingly few cases outside of China. There are no cases reported in Africa. There are no cases reported in Indonesia.

It is not for nothing that this disease has received on Twitter the moniker "China flu".

(Update: We now have an answer to the question "Where are the cases?" The answer--for now--is South Korea, Iran, and Italy. It is worth noting that the fatality rates thus far in South Korea and Italy appear to be demonstrably lower than in Iran, providing a tragic reiteration of the importance of early interventions in treating this disease. 

Both Italy and South Korea have initiated localized quarantines and closed down public places--responses significantly less draconian than China's belated response. Time will tell if these are successful in slowing the spread of the disease.

More disturbingly, we are getting warnings from South Korea of impending deaths, making this disease more lethal than the international numbers initially presented.)

Diamond Princess: A Case Study In The Rough

The Diamond Princess cruise ship provides an intriguing middle ground between China and the rest of the world. When the ship docked in Yokohama, Japan, a single patient presented with COVID19 symptoms. That single patient became ten, which quickly became 70. The most recent count has the number of infected passengers at 218.

There are more cases on that one ship than there are in any other country, although the numbers still pale in comparison to China.

As of this writing, no passengers on the Diamond Princess have died. Japan's first death from COVID19 was someone with no connection to the cruise ship. 

On board the vessel, the disease has been far more contagious than overall internationally, but nowhere near as contagious as in China.

While the passengers have been quarantined, they have also had access to medical care, arguably to a greater extent than in Wuhan, where the disease quickly overwhelmed the healthcare system. As early as the first quarantine, of Wuhan, the city was reporting a lack of protective gear for its healthcare workers. One of the earliest signs that something was amiss with China's reported case numbers was the claim that, with just 850 reported cases, Wuhan was running out of hospital beds. Such shortages have not been the experience of the cases on the Diamond Princess, nor have they been the experience of the US evacuees from Wuhan during their quarantine stay.

Early Intervention Clearly Makes A Difference

As shocking as a pleasure cruise liner being turned into a "plague ship" can be, the Diamond Princess yet provides a bit of bright light into the darkness of this disease.  It shows conclusively the advantages of early interventions. On the ship, as patients have either tested positive or turned symptomatic, they have been removed to an hospital and are presumably receiving fluids, oxygen, and other supportive therapies while their body fights off the disease.

In Wuhan, doctors have been turning patients away for lack of beds and resources. Essentially, some untold number of people have been effectively denied care for the disease, at least until it reaches a level of severity where hospitalization is mandated, if only to limit the spread of the disease further.

Even in Africa, with some of the weakest healthcare systems on the planet, preparations are being made to ensure patient care and comfort against the day when COVID19 finally reaches that continent. Early response is still the best response (hardly an original idea in any area of healthcare).

China Has Been Late Response And No Response

Far from having early and aggressive responses to the disease, China's response has been either tardy or nonexistent.

The disease was first noted on December 26, 2019 (officially). 

The World Health Organization was notified of the disease on December 31, 2019.

WHO identified the disease as a new coronavirus on January 9, 2020.

No quarantine or containment of Wuhan or anywhere else was initiated until January 23. By the time quarantines were intiated in Wuhan, an estimated 5 million people had left the city for the Lunar New Year holiday.  5 million potential carriers of the disease were moving around China and the world--as evidenced by the cases appearing at the time of the quarantines in other countries. With shortages of face masks and other supplies, a good deal of otherwise mundane preventative measures simply have not been done.

Further, China took the step of altering diagnostic criteria deviating from the WHO diagnostic criteria, with the result that fewer patients were actually "confirmed" to have the disease, and thus fewer patients were being treated for the disease, at least until the criteria were revised again to include all patients showing symptoms even without a positive test result. Quite literally, people in China have to get sufficiently sick to warrant treatment before any intervention is done.

The Ounce Of Prevention Still Outperforms The Pound Of Cure

It would be facetious to ascribe all the differences between the disease totals inside China and outside China to the simple steps of early diagnosis, early intervention, and early quarantine. Yet we should not discount these factors either. The Diamond Princess cases prove not only that COVID19 is an highly transmissible and contagious disease, but that it is also a manageable disease, and a containable one--there have been no reports of coronavirus in Japan emerging from the cruise ship. The disease is on the Diamond Princess, but it is staying on the Diamond Princess.

The best time to solve any problem is when it is small. The worst time to solve any problem is when it is big. The best way to solve big problems is to whittle it down to small problems. 

COVID19 is being resolved outside of China when it is small--a case here, a case there, a few cases on a cruise ship easily isolated. COVID19 was not resolved inside China when it was small, and now resolution appears all but out of reach. China must now wait for the disease to run its course, and abate naturally.

The Known And The Unknown

We do not yet know the true origin of COVID19. We do not yet know whether a vaccine will be easy or hard to synthesize. We do not know much about this disease.

What we know about COVID19 is that early interventions produce the best outcomes. We know that early quarantines prevent wider spread of the disease. We know that even developing countries, with less economic stature than China or the United States, and with less developed healthcare infrastructure, can confront and contain the disease (at least so far). The disease statistics we have prove these things in abundance.

We know that China chose not to act early, not to quarantine early, not even to treat patients early. We know that China chose a path of quiescence and inaction rather than aggression and intervention.

Sadly, this means we know something else about COVID19. We know China had the opportunity to prevent this epidemic, and we know that China chose to miss that opportunity.

22 February 2020: Updated to include discussion of epidemic outbreaks in South Korea, Iran, and Italy.

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