Imagine finding your way out of a forested swamp at night not knowing if your next step leads you closer to the edge or deeper into the morass.
That’s what officials dealing with the corona virus disease 2019 (CoViD-19) must feel.
It reminds me of the months I led a UN team to fight the Ebola outbreak in Africa in 2014-2015. In the field of public health, trying to make the best decisions from a pile of often-confusing data, and an even larger stack of unknowns is a matter of course, but when faced with a global health emergency, it is a heavy burden.
With every passing week, we gather new data on CoViD-19, although faulty and conflicting information abound. What do we know so far, and how can we protect ourselves?
CoViD-19 is a virus first detected in December 2019 in Wuhan, China. For many people, the virus causes mild symptoms (cough, runny nose, sore throat and fever) but it can be severe for others (breathing difficulties, shortness of breath, pneumonia, acute respiratory distress syndrome), and fatal to some.
It appears that the elderly and those with pre-existing conditions such as diabetes and heart disease are more susceptible to severe illness.
Stopping the transmission
As far as we know, CoViD-19 is transmitted person-to-person mostly when tiny droplets are ejected by an infected person who coughs or sneezes, and those droplets land in someone’s nose, mouth or eyes, or are inhaled into the lungs.
If we assume CoViD-19 is typical of most respiratory viruses, then people are most contagious when they show symptoms.
This leads me to the first thing you can do to protect yourself: Maintain a social distance of at least one meter between yourself and others, avoid shaking hands, and move at least two meters away from people coughing and sneezing.
Most respiratory viruses can also be transmitted when persons touch surfaces contaminated with the virus and subsequently touch their mouths, noses, or eyes.
So the second thing we can do to protect ourself: Wash hands often with soap and water, or use an alcohol-based sanitizer (at least 60 percent alcohol). Be sure to use enough sanitizer to cover the hands, and rub for about 25 seconds or until dry. Remember that sanitizers do not work well if the hands are greasy or soiled.
Frequent hand hygiene is important especially in public places.
When I trained doctors and nurses in Africa during the Ebola crisis, I put a harmless fluorescent powder on a pen, and handed it out with the sign-in sheets. I then used blacklight–which causes the powder to glow to show how quickly and unconsciously people transferred the powder to their mouths and noses. By using the powder, I also showed government officials how shaking hands transferred the powder on other people’s hands, and how a cursory hand wash was ineffective.
To prevent the spread of germs, I recommend we wet our hands, apply soap, clean and rinse the faucet handle, then apply more soap. Lather well, not just the palms but also the backs of the hands, between and around the fingers, and finger tips for 20 seconds. (Here’s a tip: Sing the “Happy Birthday” song twice while latherin your hands with soap.) Then rinse well, and dry with a clean towel or air dry.
These two common-sense precautions–maintaining social distance and frequent hand hygiene–will go a long way to protect us not just from CoViD-19 but from respiratory infections in general.
What about masks? Diseases, such as the flu, SARS and CoViD-19 can be transmitted by droplets that settle quickly out of the air within one to two meters.
The World Health Organization recommends using precautions for droplet transmission: that means a regular medical mask.
However, for health professionals conducting procedure that could release aerosols, an N95 mask and a face shield or goggles are recommended.
Unless you are doing a tracheal intubation, use a regular facemask and leave the N95 masks for those who need them the most: our frontline health workers.
Also, when it comes to masks, use common sense. Some use masks loosely or lower the mask to cover only their mouths, leaving the noses unprotected.
I have also seen people who frequently pulled down or removed the uncomfortable masks without washing their hands, or reused cloth masks (less effective) without washing them well between use.
In these examples, the masks were problematic since any CoViD-19 on the outside of the masks would have transferred to their hands, and eventually, the respiratory tract.
Unless one works in crowded quarters or among people who might have respiratory infections, the face mask may provide only minimal added protection especially by keeping you from touching your nose and mouth. At worst, it could give a false sense of security if improperly used or removed without hand hygiene.
Disrupting the contagion
What can we do personally to halt the spread of COVID-19? If we have a cough and mild respiratory symptoms, stay home until we are better. Wear a mask if we go out so as to protect others. If we have fever or difficulty breathing, we may have a respiratory infection and should seek medical attention promptly. Let the health worker know if we traveled recently to an area where CoViD-19 has been reported, or if we were in close contact with someone who did and may be experiencing respiratory symptoms.
Another way to disrupt the spread of CoViD-19 is by practicing good cough and sneezing etiquette. The WHO recommends coughing and sneezing into a tissue covering the nose and mouth, immediately discarding the tissue into a closed trash bin, and washing hands.
If there’s no tissue, another recommendation is to bend your arm, place it in front of your mouth, and cough or sneeze into the crook of your elbow.
Although studies show that these procedure only partially block the dispersal of droplets, they are considered by many health officials as better than coughing or sneezing into bare hands, and inevitably touching doorknobs, light switches, handrails. Not covering up at all is the worst, and bad manners, too.
This begs the question: after sneezing or coughing, how long does CoViD-19 remain infectious in the environment?
The short answer is: we don’t know. Again, some basics. A virus is an infectious agent that needs the cell of a living host such as an animal to replicate. Outside the cell, a virus exists as a particle of genetic material protected by a coat of protein.
One often reads that some viruses can “survive” for days in the environment, but it may simply mean that the genetic material can still be identifiable even though it’s no longer infectious.
The ability for viruses to remain infectious in the environment depends a lot on the concentration of the virus, the type of surface it is on, temperature, relative humidity and time.
For example, the SARS coronavirus quickly loses its ability to infect at high temperatures (e.g., 38°C) and high relative humidity (80 percent or more).
The flu and other respiratory viruses could survive for many hours on hard surfaces like plastic or steel, compared to several minutes to an hour on porous surfaces like fabrics and tissue.
In general, thorough cleaning with soap and water will remove most microbes. For schools and public facilities, clean hard surfaces daily and wipe door handles, railings, faucets, computer keyboards with alcohol for added safety.
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Other questions
How long does it take to cause symptoms? The incubation time for CoViD-19 is still unknown although the US Center for Disease Control & Prevention estimates it could be between two to 14 days.
Just how deadly is CoViD-19? That is yet another unknown. Computing the case fatality rate is not simple when an epidemic is ongoing since the real number of cases is often underestimated as mild cases are under-reported.
One also has to account for delays in reporting, the time it takes between diagnosis and either recovery or death, as well as variations in how countries track cases, and differences in the quality of medical care.
A note on vaccines and treatment drugs: there are currently no vaccines or drugs proven effective against CoViD-19. Much has been written about efforts to have vaccines ready for testing in several weeks, and how antiviral drugs previously developed for SARS, MERS, Ebola and HIV are being re-purposed.
Lest you think a vaccine or drug is just around the corner, be aware that even after accelerated lab testing to identify candidates, they must yet undergo at least three phases of clinical trials to prove their effectiveness, and to determine appropriate doses and methods of administration, side effects and safety.
China has begun phase 1 clinical trials of some drugs and plans to test a total of 30 therapies. An ambitious timeline for Phase 1 trials is two to four months. After candidates pass Phase 2 and 3 trials, they still have to be manufactured in huge quantities and made widely available. Antiviral agents and vaccines are urgently needed but it may be a while.
Response of governments
One major challenge to government officials is how to present COVID-19 to the public. Communicating on a regular basis what is known, what is unknown, what is being done, and what people can do is an essential public health response.
People have a right to be informed. Officials should proactively dispel misinformation and myths while being frank about the lack of data or degree of uncertainty of information.
The public should be encouraged to take precautions and be provided with timely advice.
The goal is to address people’s concerns while preventing panic or complacency, and at the same time gaining the trust and cooperation of the public.
I am reminded of Taiwan’s Minister of Health & Welfare Chen Shih-chung. In addition to daily press briefings, he has repeatedly exhorted citizens to adopt protective measures, and even donned a protective suit to personally escort Taiwanese evacuees from China to quarantine centers. During a press conference on Feb. 4, he was visibly moved as he announced Taiwan’s 11th confirmed case. When local media revealed that he had gone without sleep for 48 hours due to his intense schedule, many people rallied behind him. That level of public support will undoubtedly serve the country well as it struggles to contain the burgeoning epidemic.
Risk communication is only part of a larger strategy. Governments must expand national and local capabilities for diagnostic testing, surveillance, including case reporting and contact tracing, risk assessment, rapid response, health emergency planning including medical incident command structures, contingency planning at points of entry, case management training, logistics and supply management, and infection prevention and control, among others.
Facing the future
CoViD-19 is a zoonotic virus, meaning that the disease spreads between animals and humans. Whether it originated in bats, pangolins, snakes, or other animals is not yet clear, but it apparently spread to humans in the seafood market in Wuhan where wildlife was illegally traded.
For this reason, the WHO recommends avoiding wet markets where illegal wildlife is sold, and following general food safety practices, such as cooking food thoroughly.
Examples of other zoonotic viruses are the SARS coronavirus, which may have originated in bats then jumped to civet cats to humans; MERS coronavirus which was transmitted by camels; Ebola filovirus found in bats, forest antelopes, and infected monkeys; and H5N1 flu virus in birds.
If there are reservoirs of CoViD-19, SARS, Ebola and H5N1 in the wild, does it mean they could again be re-transmitted to humans?
Sadly, just as Ebola is making its 10th comeback in 40 years in Congo, and a new outbreak of H5N1 has been reported in Shaiyang, China, epidemics of zoonotic diseases could become the new normal.
CoViD-19 may return periodically just like the four common coronaviruses already circulating in humans, or like the seasonal influenza virus that we have gotten used to, even though it sickens millions and kills around half a million people a year.
Intensification of agricultural practices and loss of habitats are pushing wildlife species together into smaller spaces, facilitating the transfer of new microorganisms to susceptible native species.
The illegal international trade in wildlife, a multibillion-dollar industry, is undergoing a resurgence.
Climate change is altering the geographic distribution of diseases transmitted by vectors such as mosquitoes or flies.
Many developing countries have poor health infrastructures unable to cope with disease outbreaks.
Add to this mix the ease of domestic and international travel through transport hubs swarming with people from many places, and you have the “perfect storm” for more epidemics in the future.
During my work on Ebola in west Africa, I warned officials that Ebola outbreaks will recur so they should invest in strengthening their health systems.
For the Philippines, whether it’s SARS, measles, polio, dengue, or CoViD-19, an epidemic is a reminder and an opportunity to further enhance our health emergency response capabilities at all levels. In this way, we can minimize suffering and loss of life, as we slog through future swamps of contagion.
Jorge Emmanuel, Ph.D.
SU adjunct professor
DOST Balik-Scientist
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Dr. Emmanuel was chief technical advisor for the UN Development Program. He led a team during the 2014 Ebola crisis in Liberia, Sierra Leone, and Guinea. He was trained in chemistry, engineering, environmental science, public health, and infection control.