Covid-19: The Basics

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Coronaviruses (CoV) are a large family of viruses responsible for widely known respiratory diseases that have caused epidemic outbreaks in recent years such as the Severe Acute Respiratory Syndrome (SARS), the Middle East Respiratory Syndrome (MERS), and the ongoing Coronavirus Disease 2019 (COVID-19). These viruses are endemic to many different species of animals, including camels, cattle, cats, and bats. These viruses can be seemingly benign in animals, while in others they can cause respiratory tract infections and diarrhea.[1] Coronaviruses prove especially virulent when they are transmitted among humans who can suffer a range of respiratory illnesses ranging from flu-like symptoms to lung lesions and pneumonia.[2] Its symptoms include fever, a dry cough, a general feeling of fatigue, and breathing difficulties.

The name coronavirus comes from the Latin corona, meaning “crown” or “halo.” The viruses have club-shaped protein spikes covering their surface which, when viewed under an electron microscope, resembles a crown or solar corona. Coronaviruses are found to be present among many mammals, with several known coronaviruses circulating in them that have not yet infected humans. However, other types that infect humans were first identified in the 1960s when they were discovered from the nasal cavities of human patients with the common cold.[3]

Transmission

An infographic showing how the SARS-CoV-2 virus contained in droplets can be shed through a cough or sneeze or create a thin film of pathogens on surfaces and spread COVID-19. Vibal infographic based on MIT / Lung.org / US CDC / journalofhospitalinfection.com.

Some coronaviruses can be transmitted from animals to people. Other studies on SARS revealed its probable transmission from civet cats to humans, while MERS was traced from dromedary camels to humans. The transmission between humans is thought to occur among people in close contact via respiratory droplets generated by sneezing and coughing.[4] The viruses’ use their “spike” protein on their surfaces to infect other cells, a process that is activated by a certain cell enzyme. This enzyme is found in lots of human tissues, including the lungs, liver, and small intestines—which might explain why these pathogens are easily transmitted to humans.[5]

The pathogen SARS-CoV-2 and the disease it causes, COVID-19

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the seventh known coronavirus to infect people, after 229E, NL63, OC43, HKU1, MERS-CoV, and the first SARS-CoV.[6] It is a “novel” virus, meaning it is a new virus that had not been previously identified in humans. Its infection is called the Coronavirus Disease 2019 or COVID-19. Initially called 2019-nCoV Acute Respiratory Disease, COVID-19 is a contagious disease that causes flu-like symptoms such as dry cough, fever, fatigue, and shortness of breath. In some cases the ailment may progress to pneumonia and multiple organ failures. As seen in reports of several countries, the fatality rate may range from less than one and up to three and even four percent per diagnosed cases. Because infections are belatedly or haphazardly reported, the fatality rate can vary widely among countries. It can also vary widely when categorized by age groups and health conditions.[7]

Similar to other coronavirus diseases like MERS and SARS, COVID-19 is transmitted between humans through respiratory droplets, which are often shed during coughing and sneezing.[8] Its symptoms generally manifest between two and 14 days, with an average of five days after a person has been exposed. The infection can be initially diagnosed from a combination of symptoms and risk factors. A positive laboratory confirmation is obtained by taking a swab of the nose or throat areas, and then analyzing it for the existence of genetic markers of the virus. In addition, a chest CT scan can speedily confirm its spread, especially in the upper respiratory system.

Among the coronaviruses, COVID-19 has been the deadliest, leading to a pandemic with over 114 million confirmed cases worldwide and 2.53 million deaths as of March 2021. In the Philippines, 578,381 cases have been confirmed, with 12,322 deaths (as of March 2021).

The virus was first reported in Hubei province (with its capital Wuhan), China, from where it infected 89,912 Chinese and killed 4,636 (or a fatality rate of almost 4%) from as of March 2021. The cases in China have slowed down as opposed to the United States, whose cases have soared to 28 million, making it the most affected country in the world. Worldwide, the virus has sickened 114 million people and killed 2,530,723 in 181 countries as of March 2021.[9] After the disease spread rapidly in Iran and Europe and other parts in the world, the World Health Organization (WHO) initially declared the 2019–2020 coronavirus outbreak a “Public Health Emergency of International Concern” and soon after, WHO raised its alert level to a global pandemic.[10] After local and community transmissions were reported in many countries, travel bans were implemented to stem the spread of the disease.

The case study of China

Although the first public notification on the new virus was made on 31 December 2019, its first known case was traced back to 1 December 2019 in Wuhan, Hubei, China. A month later, the number of reported cases with infections of flu-like symptoms or pneumonia rapidly increased. The Chinese government then alerted the World Health Organization (WHO) that patients with a novel type of coronavirus were being treated by its health authorities in Wuhan. An early investigation was launched, suggesting that the source of the virus may have been linked to a seafood market in the city[11] that sold live animals, leading scientists and medical experts to suspect that it had been transmitted via animals and that it was closely related to other coronaviruses like coronaviruses in bats and pangolins as well as the first SARS-CoV.

181 countries are currently affected by the COVID-19 pandemic. Bookmark the John Hopkins University COVID-19 tracker, an interactive website where you can keep abreast of global and country statistics and monitor the actual trendline of the infection curve. Copyright 2020 Johns Hopkins University, all rights reserved.

On 11 January 2020, Chinese state media reported its first patient to die from the disease. During the early stages, the number of cases doubled approximately every seven and a half days.[12] January was a critical period when the virus spread to other Chinese provinces due to the travel leading up to China’s biggest holiday—the Chinese New Year or the Chunyun period—with Wuhan being a transport hub and major rail interchange.[13] Days later, the Chinese government reported nearly 140 new cases in a day, including two people in Beijing and one in Shenzhen, bringing the number of infected to 6,174 people by 20 January 2020. Three days later on New Year’s Eve, China implemented a strict quarantine to stop the virus from further spreading, imposing a total lockdown in Wuhan and other cities in Hubei province.[14]

On 30 January, the worsening situation prompted the WHO to declare the outbreak to be a Public Health Emergency of International Concern, a situation regarded as a public health risk to other nations that required immediate national and international action.[15]

To stem the further spread of infection, measures were taken to effect extreme social distancing and even complete lockdowns by authorities throughout China. Such draconian steps led to curbed economic activity, which was confirmed by China’s National Bureau of Statistics on 16 March 2020. It reported a set of daunting year-on-year setbacks in the first two months of the calendar year: a 13.5% drop in industrial production, a 20.5 % fall in consumption, and a decline of 13 percent in services production, all enormous sacrifices for the sake of public health.[16] However, these extreme measures led to a landmark announcement with the report of 18 March 2020 when China announced that it had recorded zero local infections, thus proving that the viral spread could be stopped. However, another worrying development was also reported. Thirty-four cases of infections are also registered, but this time from international arrivals, signaling that public health may be once again threatened by a second wave of infections.[17]

Outside of China, the countries that have been most affected are the US, Spain, Italy, Germany, France, Iran, United Kingdom, Turkey, Switzerland, and Belgium.

The spread in Asia

In South Korea, the first confirmed case was announced on 20 January 2020. A month later, confirmed cases jumped to 346, which was mostly attributed to a patient who participated in a local church activity. By 21 March, the country had about 8,652 cases and 100 deaths, with a fatality rate of around 1 percent. Travel bans were imposed and mass gatherings have been restricted since then.[18] The quick countermeasures taken by the South Korean government included efficient and rapid testing, rapid isolation, and eventually, social distancing directives. The South Korean Center for Disease Control and Prevention gives daily updates on the spread of the disease and even sends smartphone alerts informing the public of an infected person’s previous movements within the area, a move considered by some as an invasion of privacy, which however has been the key in identifying infection clusters early on. Korea also pioneered drive-through and walk-through testing centers, allowing people to be rapidly screened without burdening hospitals with the danger of contamination.[19] Such alert measures resulted in limiting new confirmed cases to less than 100 for three days in a row, demonstrating the efficacy of their countermeasures.

In Japan, the first confirmed case was that of a 30-year-old Chinese national who was tested positive on 16 January 2020.[20] He had previously traveled to Wuhan. Two weeks later, a dozen more contracted COVID-19. The government later on put the cruise ship Diamond Princess—which left Yokohama with 3,700 passengers for a round-trip cruise—in a quarantine, after some passengers exhibited symptoms of the disease. Seven hundred twelve passengers later on tested positive for the virus[21] as of 21 March.

Iran, on the other hand, reported its first confirmed cases of people with COVID-19 on 19 February 2020 in the famed pilgrimage city of Qom.[22] The numbers jumped rapidly to over 55,743 infections, with 3,453 deaths as of 5 April, making it the eighth country after the US and Italy with the highest numbers of fatalities.[23] Proving that the virus reached up to the highest echelon of its government, the virus also infected some senior government officials, including its deputy health minister Iraj Harirchi.[24]

Southeast Asia

Meanwhile, several Southeast Asian countries have strengthened their measures amid the COVID-19 threat. Indonesia imposed international travel restrictions on Italy, Spain, Germany, France, Britain, Switzerland, and Vatican City beginning 20 March. This moved by the Thai government for all visitors from abroad. Travelers who visited China, Italy, Iran, South Korea, and Macau for the past fourteen days will be quarantined. The government ordered the airlines to check if the passengers have been to the mentioned countries within the last fourteen days.

As of 1 March 2021, Indonesia has the highest number of cases and deaths, ahead of the Philippines in both aspects. No deaths have been reported in Cambodia, East Timor, and Laos. All of them, along with Brunei, are the four least affected countries in Asia (excluding the special administrative region of Macau).[25] In an effort to stem the spread of the disease, the Southeast Asian governments implemented different levels of quarantine.[26] Indonesia also banned foreign arrivals, with the Philippines stopping foreign arrivals on the island of Luzon.

North America

Cases have been confirmed in Antigua and Barbuda, the Bahamas, Canada, Costa Rica, Cuba, the Dominican Republic, Guatemala, Honduras, Jamaica, Mexico, Panama, Saint Lucia, Saint Vincent and the Grenadines, Trinidad and Tobago, the United States, Aruba, the Cayman Islands, Curacao, Guadeloupe, Martinique, Saint Barthelemy, and Saint Martin, with the United States having the most confirmed cases at around 312,237 by 5 April 2020.[27] Hollywood actor Tom Hanks, TV host Chris Cuomo, pop icon Pink, and NBA players like Rudy Gobert and Donovan Mitchell tested positive for COVID-19.

The Centers for Disease Control and Prevention (CDC), the leading national public health institute of the United States, as well as the federal and state governments, has taken measures for the containment of the disease, which include travel bans, community mitigation strategies, mass dissemination of information, and medical assistance.[28] Former US President Donald Trump issued travel restrictions from China as early as 31 January 2020.[29]Increasingly the US government issued travel bans and other travel restrictions.[30] Most of the states imposed stay-at-home regulations, while dozens of the largest countries such as Russia and India decreed lockdowns that have affected an unimaginable total of 4 billion people.

South America

As of 1 March 2021 all countries in South America, including the French overseas department of French Guiana, have been seeded with infections, with Brazil having the most number of cases at over 8 million, followed by Colombia with 2,233,589 and Argentina with 2,077,228.[31]

The pandemic in Europe

A surveillance report of the World Health Organization on the number of COVID-19 cases reported in the Western Pacific region as of 4 April 2020. Note that the Philippines ranks number 5 in total number of cases, while Vietnam with almost the same population has been more successful in containing the spread to just 239. Note also that some countries like Fiji and Papua New Guinea are not able to submit daily updates to WHO. Source: https://reliefweb. int/sites/reliefweb.int/files/ resources/20200404-sitrep75-covid-19.pdf.

The outbreak in Europe, however, was the final straw that led the WHO to declare COVID-19 as a pandemic. The almost 60,000 confirmed cases in the continent on 16 March 2020 was characterized as a 13-fold increase in the number of infected and by then represented almost a third of the total number of cases worldwide.[32] All countries in Europe have at least one case of COVID-19 except for Montenegro. While the increase in the number of infected people has slowed down in Asia, the opposite is happening in Europe, making the continent an active center of the disease as of 13 March 2020, according to WHO.

After the first cases—two Chinese tourists in Rome—were confirmed on 31 January 2020, the number of infected in Italy immediately rose to over a thousand after a month. It started with 16 confirmed cases in Lombardy, and then spread to nearby regions in the country.[33] By 16 March, there were already around 25,000 cases, making it the country in Europe with the most number of infected—and the second-highest number of positive cases as well as of deaths in the world, after mainland China. This prompted Italian Prime Minister Guiseppe Conte to place the entire country under quarantine.[34]

A bar graph showing the geographical distribution of daily COVID-19 infections in Europe and United Kingdom (color coded by country) as of 4 April 2020. Note the increasing numbers of cases being reported in Estonia, Iceland, and Romania, apart from the large numbers already reported in Italy, France, Spain, and Germany. Significant growing clusters of transmission have been reported in Portugal, Ireland, United Kingdom, and even as far as Iceland. European Centre for Disease Protection and Control, accessed 5 April 2020, https://www.ecdc.europa.eu/en/cases-2019- ncov-eueea.

In Spain, the first confirmed case of COVID-19 was a tourist from Germany who was then admitted to University Hospital of the Nuestra Señora de Candelaria in Tenerife of the Canary Islands on 31 January 2020. However, the spread of the virus was believed to have occurred through a medical doctor from Lombardy, Italy, who was vacationing in Tenerife and tested positive in the same university hospital. Soon enough, multiple cases were detected on the island involving people who had come in contact with the doctor.[35] Cases in mainland Spain, which also swiftly increased, involved people who had visited Italy at the time the outbreak in the country was just beginning. Spain had one of the fastest rates of COVID-19 contagion in the world, prompting its government to declare a state of emergency and follow the restrictive actions of France.[36]

In Germany, the first case was confirmed in Bavaria on 27 January 2020. Multiple cases were then introduced by travelers from Italy, China, and Iran in the state of Baden-Württemberg.[37] As of 5 April, there were already 96,092 cases of infection in the country.[38] From a more benign outlook, German authorities have taken increasingly restrictive measures, closing all schools and banning events of more than 50 people as the disease took its toll around the country. Also, places of public congregations such as museums, cinemas, gyms, and nightclubs have been temporarily closed. The German chancellor Angela Merkel even took to outlawing overnight stays in hotels, an uncharacteristic and sudden turnaround for its once staunchly pan-European leader who also took to gladly closing borders with Switzerland, Austria, Luxembourg, France, and Denmark.[39]

The most dramatic shift occurred in Britain, whose initial strategy to combat the pandemic was anchored on its belief in the concept of “herd immunity.”. The theory was based on letting most of its population acquire immunity to the novel virus if it could be proven to induce a longer-term immunity, and assuming that re-infections would not reoccur. However, after researchers at Imperial College of London had prepared a report modeling the ghastly prospect of 250,000 Britons dying by the end of June, Prime Minister Boris Johnson quickly turned around and abandoned the policy of “mitigation,” and has turned to increasingly stringent regulations for social distancing and community isolation.

Covid-19 in the Philippines

The Philippines has been one of the most affected countries in Southeast Asia since the first case was identified on 30 January 2020 involving a Chinese woman who was confined at San Lazaro Hospital in Manila.[40] After the country recorded its first local transmission on 7 March 2020, the virus quickly spread to nearby cities, eventually affecting 81 provinces and overwhelming hospitals and medical institutions. The country has had the second most number of cases which, at 684,311 as of 24 March 2021, is the 2nd highest, next to Indonesia.[41] The government immediately placed most of the country in different levels of community quarantines or "lockdowns" to prevent further spread of the virus and to "flatten the curve." The quarantines, however, has resulted in a sharp economic decline since the World War II (at 9.5% contraction), with many businesses shutting down and thousands of people losing jobs.

Starting September in 2020 until the end of the year, the number of daily cases dwindled. But beginning March 2021, the cases surged again to record high, forcing the government to implement another quarantines in many affected areas.

The debate over the perceived fatality rate

As of 1 March 2021, 114 million confirmed cases worldwide and 2.53 million deaths have been reported.[42] The current number of deaths has surpassed the combined fatalities of other coronavirus-related diseases such as SARS and MERS. The fatality rate varies from one to even 12.3 percent in the case of Italy.[43] Older people and those with current and prevailing conditions are most likely to succumb to the disease than the younger ones. However, the fatality rate is likely to decrease as more widespread testing is carried, positive carriers isolated, and medical personnel become more familiar with the diagnosis and treatment of the disease’s symptoms.

In statistical terms, the perceived fatality rate is made less credible because the numbers that have been pooled are taken only from the very tiny batch of those seriously ill as opposed to testing hundreds of thousands of people who exhibit little or even no symptoms as had been done by South Korea.

Thus, there is much debate about the assessment of COVID-19’s fatality rate and the assessment of its risk. Although the scale of mortality of millions is hard to grasp, several scientists have published estimates, such as that of Dr. James Lawler in his projection of infection and fatality rates in the US alone. Under varying assumptions, the study showed that an infection rate of 30% of the US population with a 0.5% fatality rate would result in 480,000 deaths in a year, making it the third leading cause of deaths behind cancer and heart disease. However, even at a conservative infection rate of 10% of the population, the number of deaths would drop to 154,000, which, however, would also be sizable.[44] Another study by the US Centers for Disease Control and Prevention prepared four scenarios, which ranged from a minimum of 200,000 and a catastrophic 1.7 million deaths, projecting an undue tragedy of epic proportions.

One of the more dire projections shook the US and UK governments, causing President Donald Trump and Prime Minister Boris Johnson to take action. Prepared by the Imperial College of London under the team of Dr. Neil Ferguson, it predicted that 510,000 Britons and 2.2 million Americans would die if their two governments did not introduce more stringent interventions.[45]

A strong contrarian view was expressed by John P.A. Ioannidis, who pointedly stated that “Reported case fatality rates, like the official 3.4% rate from the World Health Organization, cause horror—and are meaningless. Patients who have been tested for SARS-CoV-2 are disproportionately those with severe symptoms and bad outcomes. As most health systems have limited testing capacity, selection bias may even worsen in the near future. […] That huge range [of fatality rates] markedly affects how severe the pandemic is and what should be done. A population-wide case fatality rate of 0.05% is lower than seasonal influenza. If that is the true rate, locking down the world with potentially tremendous social and financial consequences may be totally irrational. It’s like an elephant being attacked by a house cat. Frustrated and trying to avoid the cat, the elephant accidentally jumps off a cliff and dies.”[46]

Medicinal treatment and pandering to false hope

A drug that offers promises or false hope? Sanofi’s Plaquenil, or generically known as hydroxychloroquine, is commonly used to treat malaria, lupus, and rheumatoid arthritis. Some studies in vitro or in animals have shown some efficacious effect. However, falsely touting it as an approved drug against COVID-19 offers misplaced hope and endangers its availability for those who presently use it as prescription medication for more common ailments.

Currently, there is no prescribed specific medicinal treatment to combat COVID-19. The essential strategy for treating a COVID-19 patient is supportive care as it would be done for any patient with severe viral pneumonia.[47] The Emcrit COVID-19 Internet Book of Critical Care has noted that a vast majority of patients will do fine without any therapy. However, in more severe cases, experimental antiviral therapy has been attempted. In particular chloroquine and hydroxychloroquine have been tried in China. A study limited to chloroquine used in vitro using cell lines demonstrated that “chloroquine can inhibit COVID-19 with a 50% inhibitory concentration of 1 uM, implying that therapeutic levels could be achieved in humans.[48] However, an earlier study conducted on mice during the original SARS outbreak demonstrated chloroquine had no effect.[49]

Former US Pres. Donald Trump falsely touted both drugs as having been pre-approved for therapeutic uses against COVID-19 on 19 March 2020, confusing people all over the world and inciting a global rush for the medicines, causing their shortages from Nigeria to the Philippines, where they were widely available for malaria, lupus, and rheumatic arthritis due to their anti-inflammatory effects, Minutes later, Trump’s FDA commissioner Dr. Stephen Hahn walked back the boastful claim, which offered false hope to thousands of sufferers. The studies on the efficacy of those drugs were not based on carefully monitored studies, which are the only guarantee for drug efficacy, as clarified by Dr. Anthony S. Fauci.[50]

The WHO has taken a more scientific and wider effort called SOLIDARITY to coordinate and collect robust data of experimental therapeutic medicines. It recommended four drug regimens, whose use should be reported by participating hospitals. Instead of recommending new drugs, it has looked to already developed drugs for other diseases with safe profiles. These included anti-HIV antiviral remdesivir, the anti-malaria drug chloroquine and its cousin hydroxychloroquine, a combo treatment using two HIV drugs lopinavir and ritonavir, and another combination treatment using the latter two with interfereron-beta, an immune system booster.[51]

Vaccines

As of March 2021, eleven vaccines that finished necessary clinical trials have been made available for public use: two RNA vaccines (the Pfizer–BioNTech vaccine and the Moderna vaccine), four conventional inactivated vaccines (BBIBP-CorV, Covaxin, CoronaVac, and CoviVac), four viral vector vaccines (Sputnik V, the Oxford–AstraZeneca vaccine, Convidicea, and the Johnson & Johnson vaccine), and one peptide vaccine (EpiVacCorona). Among the vaccines, the Pfizer-BioNTech vaccine was the first to be authorized by a stringent regulatory authority for emergency use, and the first cleared for regular use.[52] Many countries have begun distributing vaccines using phased allocation methodology, which prioritizes high-risk individuals, including the elderly and the medical frontliners. With billions of vaccine doses ordered, the world's richest countries have monopolized over half of current and projected production doses of vaccines, leaving low-and-medium-income countries struggling to secure vaccines. Ten countries in total have so far administered 75 percent of all Covid-19 vaccines—while over 100 countries have not yet received a single dose.[53]

In the Philippines, President Rodrigo Duterte ordered the Food and Drug Administration to grant emergency-use authorization (EUA) to COVID-19 vaccines and treatments to allow them to be approved within a month instead of the usual six-month review process, provided that manufacturers also obtain prior EUA from their country or other countries with mature regulator.[54] Pfizer-BioNTech was the first manufacturer to apply EUA. The Philippines has ordered 15 million doses from Pfizer-BioNTech, 17 million doses from Oxford-AstraZeneca, and 25 million doses from China-based Sinovac Biotech. Delivery of the vaccines is, however, hampered by the availability of supply. In 1 March, the Philippines received 600,000 doses of vaccines donated by Sinovac, whose vaccines were reported to have only 50% efficacy rate.[55]

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