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Waves of an epidemic: HIV-Aids has clues on how Covid-19 will unfold – SA health expert

The prospect of Covid-19 continuing to hammer the world for much of the year is a scary prospect – not only for the physically vulnerable but for entrepreneurs, employers and employees. Recessions loom. Governments have effectively closed off the cash flow to economies as they instruct schools to send pupils and teachers home, borders to shut and citizens to stay indoors and self-isolate. For Professor Alan Whiteside, who co-authored a book with Clem Sunter on ‘AIDS the challenge for South Africa’ in 2000, the situation looks bleak and will get worse. But this too shall pass. – Jackie Cameron

Covid-19 watch: The crisis deepens

By Professor Alan Whiteside*

Thank you to everyone reading and reposting this. Everything I write is public domain so please share. I am keeping this, and future posts to about 4 pages of text. I provide sources as well as commentary. Figures will change, probably rapidly. Bold text indicates a key point. 

Introduction 

Covid-19 was officially declared a pandemic by the Director General of the WHO on 11th March. This is largely a formality and does not change the response.  The need for clear information and guidance remains paramount. A week ago, the British Government appeared to be going its own way, essentially arguing for building up herd immunity. On 6th March Prime Minister Johnson held a lengthy press conference changing advice, based on newly released science. This will be addressed below. 

Across the world there is recognition by governments and political leaders this is the most serious health crisis since the 1919 flu. Canadian Journal The Walrus published ‘An Anatomy of the Pandemic’ noting: “Novel pathogens inspire a particularly pointed sort of anxiety among doctors. Many familiar pathogens are lethal on a broad scale – influenza caused over 34,000 deaths in the US in 2018/19, for instance – but their behaviour is known and tends to be consistent. Seasonal influenz … is monitored carefully and understood well enough that vaccines may be prepared… the best-case scenario for influenza each year includes many deaths… The downside risk is not infinite… With novel pathogens, this is not true. The worst-case scenario is undefined.”

Movement of people has shut down, and countries and regions isolate. The potential psychological economic and social implications are emerging. Science can and will deliver a vaccine and treatments, probably sooner than expected. I need to draw from the arts including philosophy, poetry and literature to get to grips with what is going on. The phrase ‘This too shall pass’ originated in Persia. We should remind ourselves of this and Shelley’s Ozymandias with the shattered statue of a king:

And on the pedestal these words appear:

‘My name is Ozymandias, king of kings:

Look on my works, ye Mighty, and despair!’

Nothing beside remains. Round the decay

Of that colossal wreck, boundless and bare

The lone and level sands stretch far away.

Early in my work on AIDS we produced a graph with three lines, see Figure 1. This argued there were three waves. The first the silent spread of HIV infections (this was, in the absence of treatment), followed by AIDS cases some six to ten years later. The final curve was of impact. The context of AIDS without treatment meant workers dying, children being orphaned, and elderly people being left without carers. Our first projections were deeply pessimistic, and the reality was much less ghastly than we imagined. Maybe ‘crying wolf’ was a necessary part of the response. 

One of the issues with the epidemic is dealing with the reality that there will be deaths. Those who die leave families and loved ones. Triage is a harsh truth most societies have never had to face. It keeps ethicists awake, but of necessity our healthcare workers must make these decisions and, heart-breaking as it is, it will become increasingly common. There are not enough ventilators, so who gets them? When the epidemic ends nations will need psychotherapy but front-line staff must get it.   

Figure 1. Waves of an Epidemic

The graph represents the epidemic curves in March 2020. The interventions are to make points A1 and A2 lower and later. We can plan for social, economic and psychological impacts and our recovery.

The number of new reported infections continues to climb. On Wednesday 18th March at 12h00 there were 201,530 cases (up from 119,132 on 11th March). The number outside China now exceeds those in the country (81,102 many of whom have recovered), in Hubei there were 67,800 cases, 56,886 have recovered and 3,122 died, leaving 7,792 active cases. Second highest is Italy with 31,506 (10,149 a week ago). Iran is 3rd at 16,169 (8 082), Spain moved into 4th place with 13,716 cases, while Germany with 9,877 moved ahead of South Korea at 8,413. The rest of Europe sees numbers climbing.

Every Central and South American country except Guatemala and Nicaragua report cases, with Brazil leading the field with 346 cases followed by Chile at 201, Ecuador at 111 and all others below 100 but on an upward trajectory. Despite the fervent wishes of Donald Trump, the US is eighth with 4,496 cases, up from 1,037 cases on the 11th March. Canada has 596 cases.

Africa’s low numbers continue to surprise, Egypt has 196 cases, South Africa is second at 116 cases. In north Africa Mali, Niger, and Chad; in central Africa Uganda and Burundi have yet to report; in southern Africa there have been no cases from Angola, Lesotho, Botswana, Zimbabwe, Zambia, Malawi and Mozambique. Why? Possible answers are:

  • The continent and countries are lagging in the spread of the epidemic and case development.
  • There is a failure to find and report cases, especially given weak health systems, inadequate surveillance, little laboratory capacity and limited public health infrastructure.
  • Climatic conditions are less conducive to the spread of Covid-19.

The evidence is people who recover have some level of immunity and will not be reinfected. It is worth repeating that most people will suffer no more slight symptoms and may not be recorded as having had the virus, a problem for epidemiologists and policy makers. Testing is a complex process. There may be false positive and false negative results, this matters hugely at an individual level, but not for epidemic tracking. Testing will be covered next week. 

Last week I pointed out that discrepancies in national case numbers were puzzling. Are there real differences, or is it a question of time and effectiveness of response? There are important lessons from the countries where Covid-19 seems under control: China, South Korea, Singapore, Taiwan and perhaps Japan. What worked? Leadership, mass mobilisation of state and public health officials, contact tracing and Draconian quarantine? Can this authoritarian response be replicated? Unfortunately, most of the world is experiencing a rapidly worsening pandemic

There are links with weather and the flu ‘season’, will these also apply to Covid-19? As the summer begins in the north will the number of cases fall? 

Epidemic responses

These have dramatically changed in the UK and the US in the past few days. I begin with a positive story from Italy, in the Financial Times of 17th March: “An infection control experiment that was rolled out in a small Italian community at the start of Europe’s coronavirus crisis has stopped all new infections in the town that was at the centre of the country’s outbreak… Through testing and retesting of all 3,300 inhabitants of the town of Vò, near Venice, regardless of whether they were exhibiting symptoms, and rigorous quarantining of their contacts once infection was confirmed, health authorities have been able to completely stop the spread of the illness there.” Vò may be to Covid-19 what Eyam was to the plague of 1665, a Derbyshire village that self-isolated. 

In the United Kingdom the Government published ‘The Coronavirus Action Plan, a guide to what you can expect across the UK’ on 3rd March 2020. There were to be four stages of response: containment: stopping Covid-19 from taking hold through detecting early cases and contact tracing; delay the spread: ensure health facilities are not overwhelmed and the peak is later and lower; research: contiguous to all other stages and; mitigation. This was widely criticised nationally and internationally. 

On 11th March the Chancellor presented his budget saying: “The recent COVID-19 outbreak is creating short-term uncertainty. The Office for Budget Responsibility’s (OBR) economy and fiscal forecast does not reflect the now global spread of COVID-19 nor an outbreak in the UK. The OBR notes that the spread and impact of a COVID-19 outbreak clearly represents a downside risk to the forecast, but the scale is highly uncertain and the economic impact is likely to be temporary.” It was not enough. 

On the 16th March Boris Johnson flanked by Chris Whitty, the Chief Medical Officer and Sir Patrick Vallance, the Chief Scientific Advisor gave an extended press conference and presented a new action plan. The following day 17th March the Chancellor announced a new package of financial measures to support the economy. It included £330bn in loans, £20bn in other aid, a business rates holiday, and grants for retailers and pubs. Rishi Sunak said Britain faced “economic emergency. Never in peacetime have we faced an economic fight like this one.” 

In the US similar interventions have been announced. Most remarkable has been the complete volte-face by Trump. On the 24th February he tweeted: “The Coronavirus is very much under control in the USA … Stock market starting to look very good to me”. On the 17th March the tweet was “I’ve always known this is real – this is a pandemic. I felt it was a pandemic before it was called a pandemic.”  This has been reflected in Fox news coverage, their change of tack is extraordinary.

Impact

This is crucial for the future of not just countries but, perhaps, humanity. Again, in this update I am not going to be able to do it justice. An interesting anomaly in the UK is schools remain open although universities are closed. The government is urging social distancing and has advised people to avoid cinemas and theatres, but has not closed them.

Health Systems

There is significant increased demand on health systems, and they will not be able to cope. We simply do not have enough ventilators in the world. Illness increases with age and age increases comorbidity. People over 60, and especially those over 80, with other health conditions are at greatest risk. The Chinese CDC reported 2.3% of all the people with confirmed cases of Covid-19 in China died. The fatality rate rose to 14.8% in people over 80; the fatality rate was 1.3% in the 50- to 60-year-old  cohort; 0.4% in 40-year olds; 0.2% in the 10- to 39-year-olds; and negligible for children under 10.

There is preparation for the impending waves of people needing treatment. In the UK elective surgery is postponed, there are plans to re-employ and deploy retired National Health Service staff; people are instructed not to go to Accident and Emergency departments; and are asked to self-isolate. Children are not significantly affected. They may be infected but seem to have it very mildly. However, this is a threat for grandparents involved in childcare.

The issue of HIV and Covid-19 co-morbidity has received little attention to date. We have not yet seen significant cases in places with a high HIV burden. There has been one set of guidance, from the Southern African HIV Clinicians’ Society: “At the moment, very little is known about the interaction between HIV and COVID-19. Nonetheless, some reasonable assumptions based on experience with other infections, such as influenza, can be made with regard to immune-suppressed individuals.” (https://sahivsoc.org/) HIV-infected people who are on treatment probably should not worry. The greatest concern is for those who are HIV positive and not on treatment, especially those with TB.”

Social and psychological

The current global public response has remained at the ‘moderate to serious hysteria’ level, fuelled by the media. It will continue as numbers rise and people do not understand risk, or more accurately do not apply it to themselves. France has brought in rules that everyone must remain inside and need to have very good reason to venture out of their homes. This is being enforced by the police. Free movement is on hold around the world. What does all this mean? The British psyche is to turn to the ‘Blitz mentality’ and the ‘Dunkirk spirit’ (sorry German friends, I am not sure what you do). How long can this be maintained? More next week.

Economic 

The stock markets continued to fall up till the 17th March and again I need to return to this topic. This needs to cover the shrinking economies and mass unemployment. There will be a global recession and here the questions are how deep, how long and who will be hit worst?

Conclusion

The situation is bleak and will get worse, but there are hopeful signs, in the OECD countries at least. The response is uniform and driven by ever better science. There is consensus that letting the virus “pass through the community” is not a good public health strategy. ‘Herd immunity’ is complex, cavalier and probably not acceptable in a democracy. One commentator wrote the early response in the UK was based on the fantasy of precise control over a complex system. This was/is like the whole Brexit “take back control” ideology.

WHO head Tedros Adhanom Ghebreyesus argues there has not been an urgent enough escalation in testing, isolation and contact tracing, the “backbone” of the global response. It is not possible to “fight a fire blindfolded”, and social distancing measures and hand washing will not alone extinguish the epidemic.

Perhaps this is the moment to move towards real social justice, equity and fairness. What we have been doing up to now has not been working. As Einstein is reputed to have  said: “the definition of insanity is doing the same thing over and over and expecting different results”. We need to take this lesson from science and apply it to society, Covid-19 makes it imperative.

  • A big thank you to everyone who provided comments on these communiques. Please forward, post and disseminate. Feel free to contact me on [email protected]
  • Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal www.alan-whiteside.com.

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