Post Publication Independent Review of

"COVID-19: what is next for public health?"

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Post Publication Independent Review of "COVID-19: what is next for public health?"

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Post Publication Independent Review of

COVID-19: what is next for public health?

David L Heymann

Nahoko Shindo

on behalf of the WHO Scientific and Technical Advisory Group for Infectious Hazards†

Published: February 13, 2020 DOI:

Review Comments:

1. Quote "The WHO Scientific and Technical Advisory Group for Infectious Hazards (STAG-IH), working with the WHO secretariat, reviewed available information about the outbreaks of 2019 novel coronavirus disease (COVID-19) on Feb 7, 2020, in Geneva, Switzerland, and concluded that the continuing strategy of containment for elimination should continue, and that the coming 2–3 weeks through to the end of February, 2020, will be crucial to monitor the situation of community transmission to update WHO public health recommendations if required." End of Quote. The authors have been quite reasonable to take time to update public health recommendations, so that more observation data will be at hand and better insight can be obtained through analysis of the same.

2. Quote "Genetic analysis early in the outbreak of COVID-19 in China revealed that the virus was similar to, but distinct from, severe acute respiratory syndrome coronavirus (SARS-CoV), but the closest genetic similarity was found in a coronavirus that had been isolated from bats.1" End of Quote. The authors have made an important statement here, that the virus was similar to, but distinct from SARS-CoV.

This paper was published on February 13, 2020 and maybe this article was not given the much needed attention, as another article "Viral dynamics in mild and severe cases of COVID-19" Yang Liu, Li-Meng Yan, Lagen Wan, Tian-Xin Xiang, Aiping Le, Jia-Ming Liu et al. Published:March 19, 2020 DOI: (whose post publication review is available at ) is comparing with SARS data as follows:

Quote "Overall, our data indicate that, similar to SARS in 2002–03,6 patients with severe COVID-19 tend to have a high viral load and a long virus-shedding period. " End of Quote. Ofcourse, there was another difficulty with this statement of those authors, which is available as Review Comment 10 in Part I. A faint beam of light at the end of the tunnel.... at

Reverting back to the discussion herewith, the authors of this article have made an important statement that the virus was similar to, but distinct from SARS, but the research community does not seem to have understood the significance of this statement and published their research articles based on erroneous understanding, without giving due significance to the point mentioned in this research article.

3. Quote "As there was in early January, 2020, scarce information available about the outbreak, knowledge from outbreaks caused by the SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV) formed the basis for WHO public health recommendations in mid-January.2 " End of Quote. Acceptable.

4. Quote "However, the availability of more evidence in the past month has shown major differences between the outbreaks and characteristics of COVID-19 compared with those of SARS-CoV." End of Quote. This statement is quite significant as the protocols, procedures and handling is going to be unique. This indicates that the outbreak of COVID-19 cannot be handled as other outbreaks were handled earlier. This makes essential the cooperation at Levels of Governments & Nations to formulate unique contingency plans to contain and treat the outbreak.

5. Quote "Recognising the Wuhan-focused and nationwide outbreak responses in China, WHO has encouraged countries with heavy air travel exchange with Wuhan to take precautionary public health measures2 and, if there is imported infection, to undertake activities that could lead to the elimination of the virus in human populations as occurred during the 2003 SARS outbreak.3 " End of Quote. This indicates that the primary channels of communication of the disease into each Nation are going to be those populations that come into proximity with travellers from Wuhan in specific and China in general. Identification & Quarantine of people with travel history relating to Wuhan & China will have to be done, so that the outbreak can be contained better.

6. Quote "COVID-19 is thought to have been introduced to human populations from the animal kingdom in November or December, 2019, as suggested by the phylogeny of genomic sequences obtained from early cases.7 The genetic epidemiology suggests that from the beginning of December, 2019, when the first cases were retrospectively traced in Wuhan, the spread of infection has been almost entirely driven by human-to-human transmission, not the result of continued spillover. There was massive transmission in a matter of weeks in Wuhan, and people in the resulting chains of transmission spread infection by national and international travel during the Chinese New Year holidays." End of Quote. This statement is quite significant with relevance to the expected outcome that through the international travellers, the whole world would get infected; and the effect will be felt on a very large footprint of the people, as a diverse cross section of the society comes into contact with an international traveller at multiple points.

7. Quote "COVID-19 seems to have different epidemiological characteristics from SARS-CoV. COVID-19 replicates efficiently in the upper respiratory tract and appears to cause less abrupt onset of symptoms, similar to conventional human coronaviruses that are a major cause of common colds in the winter season.8 Infected individuals produce a large quantity of virus in the upper respiratory tract during a prodrome period, are mobile, and carry on usual activities, contributing to the spread of infection. " End of Quote. This statement indicates that a client carrying the virus, would have maximally spread the virus, during the time that the client is active in the prodrome period. After the client is diagnosed positive, it will be a very difficult task to perform contact tracing to search and identify other prospective human beings who have come in contact and took a portion of the virus with them; the difficulty being that it is not going to be a linear path but branching out as a new path at every intersection or meeting point with another human being; in short it will be a web that spreads out radially and rapidly; within no time, engulfing the entire population and the population also will not be aware that they have contacted the virus as they will also be active during their prodrome period. This statement by the authors should have been given or should be given due respect to prevent the spread of the outbreak.

8. Quote "By contrast, transmission of SARS-CoV did not readily occur during the prodromal period when those infected were mildly ill, and most transmission is thought to have occurred when infected individuals presented with severe illness, thus possibly making it easier to contain the outbreaks SARS-CoV caused, unlike the current outbreaks with COVID-19.6" End of Quote. This statement needs to be read together with Review Comment 7.

9. Quote "COVID-19 also has affinity for cells in the lower respiratory tract and can replicate there, causing radiological evidence of lower respiratory tract lesions in patients who do not present with clinical pneumonia.8 There seem to be three major patterns of the clinical course of infection: mild illness with upper respiratory tract presenting symptoms; non-life-threatening pneumonia; and severe pneumonia with acute respiratory distress syndrome (ARDS) that begins with mild symptoms for 7–8 days and then progresses to rapid deterioration and ARDS requiring advanced life support" End Quote. This statement indicates that there is going to be a surprise after a short period. Treatment protocols are usually based on symptoms. When the symptoms are non-life threatening, the treatment protocol will not call for emergency procedures. But, immediately after a few days, symptoms turn from mild to critical, calling for emergency treatment protocols. This is where the difficulty actually lies. All patients with mild symptoms cannot be put on emergency protocols even when they dont display life-threatening symptoms; expecting that all will test positive for COVID-19 in a few days. Rapid deterioration of an otherwise healthy population into one with life-threatening symptoms will place an unbearable load on the treatment facilities and clinical personnel; coz make-shift Intensive Care Units cannot be commissioned at will, with ventilator facility for each bed (as the manifestation of the disease is going to be more prevalently felt in the respiratory function).

10. Quote "The case fatality ratio with COVID-19 has been difficult to estimate. The initial case definition in China included pneumonia but was recently adjusted to include people with milder clinical presentation and the current estimate is thought to be about 1–2%, which is lower than that for SARS (10%).9 The actual case fatality ratio of infection with COVID-19 will eventually be based on all clinical illness and at the time of writing information on subclinical infection is not available and awaits the development of serological tests and serosurveys." End of Quote. If what the authors have written is true, then the fatality rate of COVID-19 is going to be very much higher than actuals; coz the actual fatality rate can be decided only after including subclinical infection; that means that many deaths recorded under various reasons might have actually been caused by COVID-19.

11. Quote "Presently COVID-19 seems to spread from person to person by the same mechanism as other common cold or influenza viruses—ie, face to face contact with a sneeze or cough, or from contact with secretions of people who are infected. The role of faecal–oral transmission is yet to be determined in COVID-19 but was found to occur during the SARS outbreak.10" End of Quote. Reference 10 cited here gives indepth insight into the spread of SARS If COVID-19 can spread as SARS spread, then the entire sewage connectivity itself will blow the disease into most people. Though the role of faecal-oral transmission is yet to be determined in COVID-19, it doesnt rule out that COVID may not spread like or spread more worse than SARS via faecal-oral transmission through sewage pathways.

12. Quote "A plausible scenario based on the available evidence now is that the newly identified COVID-19 is causing, like seasonal influenza, mild and self-limiting disease in most people who are infected, with severe disease more likely among older people or those with comorbidities, such as diabetes, pulmonary disease, and other chronic conditions." End of Quote. This statement indicates that people with existing comorbidities are at more risk of infection from COVID-19 compared to healthy individuals.

13. Quote " Health workers and carers are at high risk of infection, and health-care-associated amplification of transmission is of concern as is always the case for emerging infections. People in long-term care facilities are also at risk of severe health consequences if they become infected." End of Quote. This statement needs to be given attention, because it indicates the potential for collateral damage.

14. Quote "Non-pharmaceutical interventions remain central for management of COVID-19 because there are no licensed vaccines or coronavirus antivirals. If the situation changes towards much wider community transmission with multiple international foci, the WHO strategy of containment for elimination could need to be adjusted to include mitigation strategies combined with the following activities currently recommended by STAG-IH on the WHO website." End of Quote. The need for strategic containment of the spread of the outbreak is spelt out here. Either a risky restricted community interaction can be maintained or a less risky total lockdown may be explored. If people can be made to co-operate, the less risky total lockdown may be a better solution.

15. Quote "First, close monitoring is needed of changes in epidemiology and of the effectiveness of public health strategies and their social acceptance." End of Quote. Since all existing functionaries of the Govt. will have their own roles to play in such nationwide outbreaks, a special team can be conveyed to implement this suggestion.

16. Quote "Second, continued evolution is needed of enhanced communication strategies that provide general populations and vulnerable populations most at risk with actionable information for self-protection, including identification of symptoms, and clear guidance for treatment seeking." End of Quote. Again, a new dedicated team needs to conveyed to fulfil this suggestion.

17. Quote "Third, continued intensive source control is needed in the epicentre in China—ie, isolation of patients and persons testing positive for COVID-19, contact tracing and health monitoring, strict health facility infection prevention and control, and use of other active public health control interventions with continued active surveillance and containment activities at all other sites where outbreaks are occurring in China.

Fourth, continued containment activities are needed around sites outside China where there are infected people and transmission among contacts, with intensive study to provide information on transmissibility, means of transmission, and natural history of infection, with regular reporting to WHO and sharing of data.

Fifth, intensified active surveillance is needed for possible infections in all countries using the WHO-recommended surveillance case definition.11" End of Quote. Hereagain, it could be any Nation instead of China, and dedicated new teams may be convened for each of these suggestions.

18. Quote "Sixth, preparation for resilience of health systems in all countries is needed, as is done at the time of seasonal influenza, anticipating severe infections and course of disease in older people and other populations identified to be at risk of severe disease." End of Quote. May be handled at the level of the Ministry of Health.

19. Quote "Seventh, if widespread community transmission is established, there should then be consideration of a transition to include mitigation activities, especially if contact tracing becomes ineffective or overwhelming and an inefficient use of resources. Examples of mitigation activities include cancelling public gatherings, school closure, remote working, home isolation, observation of the health of symptomatic individuals supported by telephone or online health consultation, and provision of essential life support such as oxygen supplies, mechanical ventilators and extracorporeal membrane oxygenation (ECMO) equipment." End of Quote. India seems to be doing this (at the time of writing down this review).

20. Quote "Eighth, serological tests need to be developed that can estimate current and previous infections in general populations." End of Quote. May be handled at the level of the Ministry of Health, nationwide.

21. Quote "Finally, continued research is important to understand the source of the outbreak by study of animals and animal handlers in markets to provide evidence necessary for prevention of future coronavirus outbreaks." End of Quote. This suggestion can be extended as all-inclusive and a dedicated vertical structure can be built in National Interests.

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