We just finished one of the most turbulent years of our lives, which will be remembered as the Coronavirus epoch. We now know that nearly 84 million people in 191 countries were infected by Coronavirus in 2020. Those infections lead to approximately 1,8 million deaths.
On March 11, 2020, the World Health Organization (WHO) declared the coronavirus outbreak a pandemic. Soon after the WHO declared a pandemic, two prestigious institutions made predictions regarding the potential death toll different countries might experience; the Institute of Health and Evaluation ( IHME) predicted that there would be 84,000 deaths in the United States by August of 2020, while the Imperial College of London predicted 1,2 million individuals will die in the US. Both predictions were wrong as it is difficult for mathematical models to predict the severity of a pandemic and its resultant death rate. It is near impossible to foretell how inhabitants of different countries will adhere to preventative measures recommended by health authorities.
On December 31, 2020, the United States reported 20 million confirmed cases of Covid-19, which caused 347,000 deaths. In the same period, there were 14 million confirmed cases and 337,000 deaths in the 27 countries forming the European Union. An endless stream of publications both in the scientific journals and lay press have addressed the disease and how different governments responded to the challenge of one in a lifetime pandemic.
I have been following the pandemic since it was first announced by the officials in Wuhan city, in China's Hubei province. Therefore, I am writing this post to highlight certain aspects of the pandemic, as well as lessons learned in the past twelve months.
Upon reviewing the impact of the pandemic in different countries, I observed that the lay press primarily focused on the number of cases and the number of deaths reported by countries around the world. Although they are important metrics, it does not tell the whole story. Statistics such as the number of dead per million accurately assess the severity of the disease and how the health systems of different countries dealt with the epidemic. Although the United States leads the world in confirmed cases, several European countries record higher deaths per million than the United States (1,051). These countries include Belgium (1,693), Italy (1,244), Spain (1,086), and the United Kingdom (1108). Others such as France (967), Sweden ((873), Netherlands (664), Greece (465), and Germany (408) had lower death rates. It is now understood that the high death rates in Italy (1,244) and the State of New York (1,899) were not necessarily a result of inferior health systems, but more so from overwhelming caseloads exceeding intensive care units (ICU) capacity during the first wave of the pandemic.
Although some European countries such as Germany and Greece fared relatively well, several Asian countries have proven more successful in mitigating the impact of Covid-19. Japan had 28 deaths per million, South Korea reported 18 deaths per million, Singapore 5 deaths per million and China had 4 deaths per million. Taiwan's 802 confirmed cases and only 7 deaths since the beginning of the pandemic corresponds to 0,3 deaths per million - a most impressive accomplishment.
Another key metric regarding how countries' health systems are coping with the pandemic is the 7-day moving average of cases and deaths per million. In the last 7 days the deaths per million, for select countries were as follows; UK (91), Germany (80), Italy (80), US (56), Greece (50), France (40), Sweden (7), Japan (36), South Korea (4), Singapore (0), China (0), and Taiwan (0).
A brief discussion of different approaches taken by three countries in dealing with the pandemic will point to their successes and failures.
Taiwan is an island nation of 24 million that sits just 70 miles from mainland China. It has extensive business and social contacts with Wuhan, the epicenter of the SARS-CoV-2 viral outbreak. Therefore, it seemed inevitable that Taiwan would have been one of the severely impacted countries in the world. So, how did Taiwan manage to have only 802 cases and only 7 deaths due to the disease? On January 20, 2020, Taiwan activated its Central Epidemic Command Center(CECC), which rolled out several measures. First, it provided its citizens with three free masks. Six days later, Taiwan banned travel to and from Wuhan. A JAMA article by Wang et al explains how the CECC used big data analytics, new technology, and proactive testing to monitor and control the endemic. More importantly, the CECC served as the central source of information to the public, with daily conferences that provided reliable and easily understood information about the outbreak. Taiwan's impressive 0.3 deaths per million can be attributed to these measures, and the Taiwanese population's rapid adoption of simple preventive measures including masks, social distancing, and hand washing. Interestingly, Taiwan's Infection fatality rate (IFR) of the last 7 and/or 14 days remains 0 percent, as the last patient died on May 11, 2020.
Sweden, a northern European nation of 10 million people, instituted a controversial plan, reliant upon social distancing. Sweden allowed people to move freely - visiting restaurants, bars, and stores - without wearing masks if they kept distant from each other. Although not everyone in Sweden was happy with this approach, most Swedes were satisfied. Dr. Anders Tegnell, the epidemiologist, who advocated this approach believed that enough people will become immune by June of 2020, which would have given Sweden an advantage as most countries would have experienced a "second wave" later in the year - something that indeed happened. He also suggested that "lockdown" strategies have no scientific basis, especially when it comes to young adults and children as they do not transmit the disease. Sweden experienced a second wave, but its IFR of the last 7 days is 1.1% - among the lowest in Europe.
Greece, a southern European nation of 10 million, instituted two strict "lockdowns" as the method to control the spread of the pandemic. The first lockdown started on February 27 and the second on November 7, 2020. During the 2 1/2 months lockdown protocol, everyone in the country had to request permission to venture outside of their houses. Permission was granted for visiting a supermarket, a pharmacy, a doctor; or for taking a brief walk outdoors. Approval was granted by sending and receiving an SMS from a government agency. Those caught violating the lockdown were fined 300 euros. In addition, a total curfew was enacted between 9 pm and 6 am. It was due to the timely lockdowns, Greece experienced one of the lowest death rates (488) in Europe. Greece's IFR of the last 7 days of 8% suggests that its health system has been overwhelmed by the second wave of Covid-19 cases, similar to what happened in Italy and New York during the first wave of the pandemic.
A major development in the fight against Covid-19 was the development of two mRNA vaccines by Pfizer and Moderna. The vaccines which do not contain the live virus received emergency approval by the CDC in the United States and the European Medicines Agency (EMA) in the European Union. Since the vaccines were approved approximately 5 million people have been vaccinated in the United States. Although this represents 1.5% of the total population, States have prioritized the vaccination of health care workers, nursing and assisted living homes' residents, individuals over the age of 75, and individuals with underlying conditions that put them at high risk of complications and/or death from the disease. An encouraging development is the successful conclusion of the phase III trial of the Oxford vaccine and its subsequent approval by the UK Medicines and Health Products Regulatory Agency. AstraZeneca, the company that manufactures and distributes the vaccine, has initiated production and vaccinations have started in the United Kingdom. It is expected that the Oxford vaccine, which can be stored at temperatures found in regular refrigerators, therefore it is easier to distribute, will soon be approved by the CDC in the US and by the EMA in the European Union.
Two interesting but controversial approaches may be tried in the UK, in the near future. The UK is currently experiencing an increase in the number of new cases and an increase in its IFR. The first suggestion/plan is to give one dose of the vaccine(s) instead of two, as one dose is 70-80% effective. If such a policy is employed, then twice as many individuals can be vaccinated in the next few months. Therefore, the "herd immunity" threshold of 70% of the population could be reached earlier. The second approach under consideration by the UK is to give the second or booster dose of a vaccine from a different company if the vaccines of the first company have been exhausted. In the US, the Federal Government is in talks with Moderna regarding evidence from the phase II trial that two 50 microgram doses of its vaccine in individuals between the ages of 18 and 55, provides "identical immune response" to the recommended two 100 microgram doses. Finally, in France, they decided to vaccinate all individuals over the age of 75 instead of staggering by decades such as 85 and over, 75 to 85, etc as most countries do.
It should be noted that Russia was the first country that started vaccinating its citizens with the Sputnik V vaccine, which was developed by the Gamaleya National Center for Epidemiology and Microbiology. Two hundred thousand Russians have been vaccinated as of December 14, 2020. Israel has become the world leader in the fight against Covid-19 by procuring enough doses of Pfizer's vaccine and by vaccinating 10% of its population thus far, a true success story. At least 150 companies around the world are developing vaccines. Sinopharm and Sinovac in China have completed their phase III trials, and vaccination of China's 1.3 billion population has begun. China plans to vaccinate 50 million of its citizens by mid-February. The development of Covid-19 vaccines is a wonder of science, but the vaccines will not make Covid-19 disappear, thus people should continue preventive practices.
As of the end of 2020, the death of 346,000 individuals in the United States corresponds to a death rate of 0.1%, which is 5 to 10 times higher than the death rate from the seasonal flu. If the vaccines prove to be 80-90% effective, as it was found on the completion of clinical trials, then the future death rate(s) experienced by the US and other countries will be similar to that of seasonal flu - provided that their population gets vaccinated. I know this is a daring prediction, but I feel confident, that it will be the case.
In conclusion, while most people will like the complete eradication of the SARS-Cov-2 virus, it simply will not happen. Viruses and bacteria are integral members of Earth's ecosystem and it is a hybris to advocate for their destruction. A more reasonable approach for humans is to learn to co-exist with them and manage the deleterious effects with preventive measures. So far, the Taiwanese have done so most successfully, and the Swedes to a lesser degree. Wearing masks in enclosed spaces such as buses, keep social distance within reason, and employing hygienic practices such as regular hand washing, should be accepted and practiced by all. Limited lockdowns should be utilized as measures of last resort, as it is well known that they have an adverse economic impact. Finally, I expect the vaccine availability and usage to increase in 2021, and that medications such as dexamethasone, monoclonal antibodies, vitamin D3 will make the disease easier to control, allowing societies to return to normalcy, as we knew it.
