COVID-19 Update
A study from Oxford university published this week has suggested that COVID-19 may already be more widespread than previously thought. As we have previously explained the more infectious and widespread this disease is, the less severe it will be on a case by case basis. This new study reaches different conclusions to the much quoted study from Imperial College London, which led to projections of high population mortality and was partly responsible for the accelerated public health measures in Europe and the US. It is important to understand that both these studies are epidemiological studies. They both use mathematical modelling to forecast how many people are likely to become infected and how many will die as a result. We explained the dangers of predicting mortality early in epidemics in a previous article. It is too early to be certain which model is closer to the truth.
We have updated our previous article on containment versus mitigation and management to help explain the public health strategies playing out internationally. These strategies are used at different stages of evolving epidemics. There are still many uncertainties about this new disease. In order to get an idea of how long it will be before things normalize and what the new normal is likely to be, there are really two questions which will be most important. They can be considered in terms of the two distinct concepts.
1. The Disease Process: Update Here
In the context of the disease, the crucial missing data is the incidence of milder and asymptomatic infections, in addition to the evidence of people who have previously been infected and have immunity. This will give us information about the true number of infections and a more accurate measure of the true severity rate on a case by case basis.
We are getting increasing evidence that COVID-19 may affect people with minimal or no symptoms. A study by the CDC of the Diamond Princess cruise ship suggested that 46.5% of cases that tested positive had no symptoms at that time and 17.9% never developed symptoms. Other studies of viral shedding point to similar conclusions. We will have more information over the next few weeks. As we have previously explained a disease which is more widespread with mild and asymptomatic cases, especially in younger people (and we really do not yet understand the role of children) will pose greater challenges in terms of public health controls but equally will make the disease less severe on a case by case basis. Widespread mild disease would be more suggestive of an epidemic which may be closer to the Oxford model above. In this situation, the epidemic is more likely to burn through more quickly and come under control with herd immunity. A disease which has less mild cases and a higher individual case fatality rate is more likely to behave like the Imperial model with peaks and troughs of disease activity over a longer time.
2. The Epidemic Process: Update Here
The most important question regarding the epidemic is the impact of the international public health measures in comparison to the proven effective containment strategies in Hong Kong, China, Korea and Singapore. We explained in our last email the importance of the epidemic curves in Italy as an early sign of the potential effectiveness of mitigation strategies in Europe. Remember that deaths are a lagging indicator and cumulative numbers give no value taken out of context. Focus on the rate of change of new cases both as a sign of the epidemic getting worse but also evidence of where the fires may be coming under control. A report in the Lancet this week suggests that there may have been some benefit on the Italian epidemic within 3-4 days of the first public health measures. It is early days but there are some signs that the Italian epidemic curve may be flattening. We will update the epidemic curves here.
Any disease which kills people is serious. Risk assessment requires context. The mortality of COVID-19 is likely to be 1% or less with the greatest impact on older people with coexisting illness. The mortality may be higher. If the Oxford study is correct it may be much lower. It seems to have little impact on children and young people in most circumstances. However, as the Director General of the WHO has emphasized this week, young people are not immune. A disease with a low case fatality rate may be devastating in population terms if it spreads widely. Young people are also likely to facilitate the spread via milder and symptomless infections. We would appeal to everybody in our population, especially the youngsters to think about the older and more vulnerable members of our community and be sensible in following the public health guidelines on social distancing. Remember, the public health measures are about flattening the peak of the epidemic to give us the best chance to develop treatments, understand the best methods of control and prevent the health systems from being overwhelmed.
All OT&P clinics have been fully operational throughout this process. We are supporting the Hong Kong public health strategy and have been working closely with the Department of Health. We can arrange telemedicine consultations and home testing, including in individuals who are self-isolating or in home quarantine. We have performed more than 500 tests for COVID-19 with more than 97% being negative. Most patients who have been positive have mild illness which supports the recent literature suggesting an increasing recognition of mild and asymptomatic cases. For most people COVID-19 will be a mild illness. We have regularly been asked the question “What should I do if I think I have COVID-19?” We have written a summary here. The first and most important answer is don’t panic.
All disrupting events have the potential to accelerate change. Over the last three years we have developed and built a bespoke clinic management system. Part of our goal was to integrate telemedicine functionality into our existing system. We have explained our current procedures for appointments here. Over the last few weeks up to 50% of all our consultations have been telemedicine consultations. It remains our view that personal consultations and physical examination will remain the mainstay of clinical practice. However, telemedicine will have a role and we envisage a situation in which we can enhance out of hours care in addition to providing support to business travellers. If you would like to be kept up to date with developments in this area please contact us at teleconsult@otandp.com
Hong Kong has world-class systems and expertise in the management of infectious disease. We are fortunate to have one of the best ‘medical fire departments’ in the world. The vast majority of recent cases of COVID-19 have been in one of three groups. People who had recently returned from overseas, direct contacts of a COVID-19 case or people already in quarantine. We would like to pay tribute to the medical and contact tracing teams of the department of health who really are the unsung heroes of this process.
Finally, we have discussed the anxiety epidemic. Information and education are key factors in the management of both infectious disease and anxiety. Evidence from the academic field of positive psychology teaches that our actions and behaviours influence our sense of well-being. Now is the time for exercise, mindfulness, meditation and gratitude. Enjoy the clear skies and listen to the sounds of the birds. Appreciate the early Spring, it is not long before the flame trees will be in full bloom.
All our articles are available in Chinese HERE.
