We also face a new threat. The next epidemic has a good chance of originating on a computer screen of a terrorist intent on using genetic engineering to create a synthetic version of the smallpox virus or a contagious and highly deadly strain of flu. So, the point is that we ignore the strong link between health security and international security at our peril. Whether it occurs by the hand of nature or at the hand of a terrorist, epidemiologists show through their models that a respiratory-spread pathogen would kill 30 million people in less than a year. And there is a reasonable probability of that taking place in the years ahead.
—Bill Gates talking at Munich Security Conference in 2017.
As the novel coronavirus—termed 2019-nCov, and later SARS-Co V-2—continued its spread beyond the borders of China, the World Health Organization (WHO) was forced to call it a public health emergency of international concern (PHEIC) on the Jan. 30.
Understandably, the outbreak has also spawned many conspiracy theories, which rely heavily on parts of Gates’ premise, curbed by up to 0.3%, while the first-quarter growth of the US economy itself could be reduced by up to 0.4%.
International Health Regulations (IHR) were agreed upon by the global community to improve the detect, assess, report and respond to public health events with potential spillover effects across borders. Under IHR, once a WHO member identifies a potential event, it must assess the public health risks and notify WHO. Since IHR came into being, WHO has declared four PHEICs namely, H1N1 influenza (2009), Polio (2014), Ebola (2014) and Zika virus (2016). Covid-19 is the fifth time a PHEIC is declared by the WHO.
There have been 43,000 global Covid-19 cases, around 42,700 are still within Chinese borders. All the deaths (1017), barring one, have been on Chinese soil.
The heavy-handed Chinese response has certainly limited the global spread of the disease. Tedros Adhanom Ghebreyesus, director-general of WHO repeated many times during the press conference that declared Covid-19 a PHEIC that WHO is declaring it a global health emergency not because of what is happening in China, but because the virus is spreading to countries with ill-prepared, “weak” health systems.
The disease spreading to countries like India which are quite unprepared to contain a potential spread has certainly contributed to the WHO’s decision to declare it a PHEIC.
The ministry of health and family welfare in India has termed the situation within the country hundreds of Indians who were stranded in Wuhan due to the outbreak.
Almost two weeks after the evacuation, the government reported that all Indian evacuees from Wuhan—645 of them—all three patients are medical students undergoing training in Wuhan.
Latest data indicate that about 82% of cases are mild, 18% cases are severe, of which 3% require intensive care; and that the fatalities are mostly old patients and those with pre-existing conditions. Many medical personnel are getting affected as well. Since the rapidly spreading Covid-19 is also a relatively mild infection with generic symptoms, many cases have not been counted and there is a high likelihood that the severity is overestimated, and it triggers panic. On the other end, in weak health systems like India, an ineffective surveillance system may not allow for aggressive case detection, thus underestimating the true burden.
Even for Nipah with a clamped down on foreign collaborations of Indian research institutions.
Given this context, Kerala’s response to Covid-19 has been remarkable. Kerala has been publishing under community surveillance in 34 states/union territories across India, around one-third are in Kerala alone. A day-wise graph of hospital-based and home-based surveillance is given below.
Of the suspected patients kept under isolation in hospitals, many are being discharged and shifted back to community surveillance as test results are negative and symptoms subside. At its peak, on Feb. 4, around 100 suspected patients were kept in various hospitals across the states; however, now the number is only 27. A total number of 380 samples were tested for Covid-19 until today, and 344 have already proven negative, as the next graph shows.
On Feb. 7, the Kerala government free of 2019-nCoV by early March, which seems overly optimistic, unless the global situation improves drastically.
Measures like contact tracing will have only limited impact once the spread beyond China becomes large enough. Judging from the sustained transmission within China and even in countries like Japan, Singapore, Korea and Germany, it is just a matter of time before the disease becomes truly “global”. Given China’s sphere of influence, it is likely that we will soon have cases reported in Africa, as the limiting factor currently seems to be community-level transmission.
The unfolding story of the cruise ship The Diamond Princess, off Japanese coast is instructive. In terms of positive cases of Covid-19, The Diamond Princess including Indians.
Countries like India will have to start thinking hard about a shift in strategy from containment to mitigation at some point. Given the fact that Covid-19 as of now is a relatively mild infection, many positive cases across India may be missed through misdiagnosis or missed diagnosis.
However, if there is sustained spread and panic sets in, irrespective of the relatively low case fatality rates, Covid-19 can kill many in India through two pathways. First, older and chronically ill can get potentially fatal Covid-19 infection at hospitals where they visit for routine treatment, and second, panic-stricken common flu patients can crowd hospitals and overwhelm the health care delivery capacity of private and public sector. The latter scenario can see many people in real need of advanced care getting left out. If there is community-level transmission in India, the resulting societal disruption will be immense, unless the government takes sufficient measures, and be ready for any eventuality in the coming months.
As the above graph shows, with strict travel restrictions and other measures in place, daily hospitalisations of suspected cases have shrunk considerably in Kerala, and the number of patients daily discharged after a negative report and subsided symptoms outnumber the former consistently. Timely dissemination of surveillance data was an effective way in which the government of Kerala managed to keep panic under check and gain the confidence of the community. The state looks ready for any possible spread even at the community level.
As the country braces for Covid-19’s impact, the government of India should ensure the regular release of state-wise data on quarantine and tests, which it compiles on a daily basis, so that media speculation is avoided. With Nipah, and now Covid-19, Kerala provides a template for the central government, of calm and alert public health problem-solving. Perhaps over and above what Kerala is doing on social media, the central government can effectively leverage WhatsApp, too, to allay fears, as Covid-19 spreads across the world.