Coronavirus outbreak: Is there a cause for alarm?

The emergence of a novel coronavirus (preliminarily referred to as 2019-nCoV) has taken hold of public attention in the last month. MIMS Doctor speaks to Professor Dale Fisher, a senior consultant at the Division of Infectious Diseases, National University Hospital, Singapore, to get a better picture of the situation and steps being undertaken in Singapore to prevent spread of the virus.

“In my view, few places could be better prepared than Singapore. There has been tremendous investment in pandemic preparedness since severe acute respiratory syndrome (SARS),” said Fisher.

“I think it is likely that eventually we will see transmission in a lot more countries. Currently there is a lot of fear because of what we don’t know but we will know more about the transmission and the severity in a few weeks. I believe it will be quite transmissible but less severe than SARS, maybe something more like flu which of course is still dangerous to some. This is both my personal view and one that is shared by many other healthcare professionals,” he said.

“Although it has claimed lives, it is possible that the virus is not so severe, with a mortality rate closer to that of the common flu, for example, 1–2 in 1,000 people. We will learn more about this in the coming weeks,” he added.

Local precautions

According to Fisher, steps have been taken at multiple levels to reduce the likelihood of spread of the virus.

Strict protocols have been put in place in public hospitals to identify, test, and manage suspect cases. Additionally, there is a “whole-of-government approach” with decisive and swift governmental actions with inter-ministry cooperation.

“Regular updates are made to the community through established channels, which raises public awareness and education and helps people make rational informed decisions,” he said.

Regional precautions

Additionally, a statement issued by Datuk Dr Noor Hisham Abdullah, the Director-General of Health, Ministry of Health (MOH), Malaysia, recommended that individuals postpone any trips to China, while those who feel ill within 14 days of returning from China should seek urgent medical attention and notify their doctor of their recent travels. [MOH Malaysia, available at http://www.moh.gov.my/moh/press_releases/Kenyataan%20Akhbar%20KPK%2030%20Januari%202020_SITUASI%20TERKINI%20JANGKITAN%202019%20NOVEL%20CORONAVIRUS%20(2019-nCoV)%20DI%20MALAYSIA%20.pdf, accessed 2 February 2020]

In the Philippines, Health Secretary Francisco T. Duque III highlighted the measures being taken by the Philippine government to control the spread of the virus including issuing a temporary travel ban for travellers from China, Macao, and Hong Kong.

“[The Department of Health (DOH)] is monitoring every development on the 2019-nCoV very closely and is taking proactive measures to contain the spread of this virus in our country. This health event is fast-evolving and fluid. We are continuously recalibrating our plans and efforts as the situation develops,” he said.

“We are providing the public with constant updates and advisories as frequently as possible, so all I ask from the public now is to heed the advisories from official DOH channels and to refrain from sharing unverified and unvalidated information,” he added. [DOH, Republic of the Philippines, available at https://www.doh.gov.ph/press-release/DOH-reveals-more-negative-2019-nCoV-cases-confirms-first-nCoV-ARD-death-in-PH, accessed 2 February 2020]

Clearing up misconceptions

“There is absolutely no reason to panic. There is no spread in Singapore although admittedly it is likely to come.* We believe it will be mild for most people and possibly have a mortality rate about the same as flu,” said Fisher.

The usual flu prevention precautions such as distancing oneself from individuals with flu-like symptoms and covering the nose and mouth when coughing could help prevent the spread. Individuals who are ill should avoid going to work and should see a doctor; however, if they need to be at work, they should wear a mask and practice frequent hand hygiene, he said.

“Most people believe masks are everything. If you don’t wash your hands frequently or wear the mask properly without touching it, then it doesn’t help. In those cases, social distancing is better than wearing a mask,” he pointed out.

Lower mortality than SARS

The novel coronavirus or 2019-nCoV, was first linked to a seafood market in Wuhan, China. [BMJ 2020;368:m308; Centers for Disease Control and Prevention (CDC), available at https://www.cdc.gov/coronavirus/2019-ncov/summary.html, accessed 30/1/2020].

The most common symptoms of 2019-nCoV are respiratory symptoms, shortness of breath, cough, and fever. Severe cases of the viral infection can manifest as pneumonia and can result in death. While there is no treatment for the infection, the symptoms can be successfully managed. [World Health Organization (WHO), available at https://www.who.int/news-room/q-a-detail/q-a-coronaviruses, accessed 30/1/2020]

While the infection has led to more than 100 deaths, the situation may be less dire than thought. “The good news is that the data to date suggest that this virus may have a lower mortality than SARS [and] we have a diagnostic test,” said Professor Peter Piot from the London School of Hygiene and Tropical Medicine, London, UK. [BMJ 2020;368:m308]

Bats the primary reservoir?

Full-length genomic sequencing of the virus taken from five patients showed that they “share 79.5 percent sequence identify” to the SARS coronavirus and, on a whole genome level, is 96 percent identical to a bat coronavirus. [bioRxiv 2020;doi:10.1101/2020.01.22.914952]

“Given its close similarity to bat coronaviruses, it is likely that bats are the primary reservoir for the virus. Whether 2019-nCoV is transmitted directly from bats or by means of intermediate hosts is important to understand and will help define zoonotic transmission patterns,” noted Professor Stanley Perlman from the University of Iowa, Iowa City, US, in an editorial. [N Engl J Med 2020;doi:10.1056/NEJMe2001126]

While initially thought to be non-transmittable between humans, it is now established that human-to-human transmission is possible. “[However], the extent of interhuman transmission and the spectrum of clinical disease need to be determined,” Perlman added.

Public health emergency

Following the second meeting of the International Health Regulations (2005) Emergency Committee, the WHO declared the situation a public health emergency at a global level (Public Health Emergency of International Concern). [WHO, available at https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov), accessed 31/1/2020]

As of writing, a total of 20,630 cases have been confirmed globally. A majority of the cases are in China (n=20,471, resulting in 425 deaths), with the outbreak largely centred around Hubei Province (13,522 confirmed cases). [WHO, available at https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200204-sitrep-15-ncov.pdf?sfvrsn=88fe8ad6_2, accessed 5 February 2020] Singapore had 24 confirmed cases and Malaysia had 10. [MOH Singapore, available at https://www.moh.gov.sg/news-highlights/details/confirmed-cases-of-local-transmission-of-novel-coronavirus-infection-in-singapore; MOH Malaysia, available at http://www.moh.gov.my/index.php/pages/view/2274, accessed 5 February 2020] Two cases were confirmed in the Philippines, resulting in one death. Duque III pointed out that this was an imported case, with no evidence of local transmission. [DOH Philippines, available at https://www.doh.gov.ph/press-release/DOH-reveals-more-negative-2019-nCoV-cases-confirms-first-nCoV-ARD-death-in-PH, accessed 2 February 2020]

While border screening has been implemented in many countries, these measures may not identify all cases as some individuals may be asymptomatic. [BMJ 2020;368:m308]

“[However], to acquire the infection, you have to be exposed to someone with it. Despite rumours, there is no evidence so far to suggest that it can be acquired from someone with no symptoms … It is unlikely or at worst it is rare,” noted Fisher.