Ending the Covid-19 Epidemic

KOMPAS/AGUS SUSANTO

Clowns resemble coronavirus disease (Covid-19) tauke a walk around in the socialization of Operation Safety 2020 by the Jakarta Metropolitan Police in the Gelora Bung Karno area, Jakarta, Monday (6/4/2020).

A good understanding of the virus is needed to free ourselves from the grip of the Covid-19 pandemic.

If medicines and hospital facilities to treat severe cases of the disease can be provided, we can escape the grip of this pandemic. The large-scale social restrictions (PSBB) should be implemented in Java and Bali, as well as densely populated urban areas.

Wave of Pandemic

The Covid-19 pandemic is still in the logarithmic phase. However, the shocks have already been incredible. The death toll, relatively speaking, is not very high. As of 17 April 2020, worldwide deaths from the disease amounted to 6.73 percent of confirmed cases.

However, the pandemic has been more deadly in terms of its impacts on the socioeconomic life of the state and society. Workers are being laid off, many factories have closed due to the absence of raw materials or the closure of markets. Stock markets have plummeted. Export and import activities have ground to a halt. Tourism has become deserted.

Also read: World Needs 6 Million Additional Nurses to Fight Covid-19

The Covid-19 pandemic is now entering the second global wave, assuming that the first wave was the outbreak in China. Two global epicenters now exist, in Europe and the United States. Indonesia was affected during this second wave. If this pandemic shows one thing, it is that not a single country was ready for it.

The Spanish flu pandemic of 1918 saw three waves in its pattern of outbreaks. The second wave recorded was deemed to be the most formidable wave. This is what is happening now, all over the world.

Covid-19 is extremely transmissible compared to its two predecessors. Since it was first detected at the end of 2019, the virus has infected 750,890 people around the world as of 31 March 2020 and 2,165,500 people by 17 April. During the eight months of the SARS outbreak, only 8,000 confirmed cases were recorded. MERS was even slower, recording only around 2,000 cases in 2012-2017. The manner by which the three coronaviruses are transmitted is also different. Covid-19 spreads rapidly among a larger number of people in a community (community transmission), while SARS and MERS spread primarily in the hospital setting.

The CFR for Covid-19 has yet to be determined. Z. The study by Wu and J.M. McGoogan (2020) published in The Journal of the American Medical Association (JAMA) states that SARS and MERS have CFRs of around 9 percent and 35 percent, respectively.

With regard to its infectiousness, the writer expects that the infectivity of the Covid-19 virus could approach that of the SARS or the MERS viruses.

Why does the Covid-19 virus spread so rapidly, and how contagious is it? From this writer\'s observations, the Covid-19 virus has unique molecular features in that some features resemble the SARS virus while others resemble the MERS virus. With regard to its infectiousness, the writer expects that the infectivity of the Covid-19 virus could approach that of the SARS or the MERS viruses. However, we will only learn of the figure after the pandemic has ended.

Also read: Analyzing the Global Spread of Covid-19

The incredible speed at which Covid-19 has spread is certainly influenced by the genetic characteristics of the virus. Air travel, which increased 130 percent in 2019 compared to 2003-2004 (www.statista.com), should not cause the spread of Covid-19 to skyrocket compared to SARS. The global population may also have a small role in its spread. The World Bank’s 2018 data shows that the world population increased by 37 percent in 2003-2018 (https://data.worldbank.org/).

AFP/MARCO BERTORELLO

Nurses work to prepare the Intensive care unit in the new Covid-19 Hospital on March 29, 2020 in Verduno, near Alba, Northwestern Italy on the eve of its official opening, as part of the measures taken to fight against the spread of the novel coronavirus. - The hospital have seven beds of intensive care and fifty beds for patients infected by the COVID-19.

The Covid-19 ‘belt’

The data shows that we are facing a virus that transmits efficiently between human beings. However, Covid-19 seems vulnerable to high temperatures and humidity. Looking at Johns Hopkins University’s map of hot zones of infection, the Covid-19 virus spreads mainly in areas of moderate to cold temperatures.

The centers of local outbreaks form a kind of "Covid-19 belt". This belt starts from China and stretches westward across Iran and Turkey to shift slightly north in Europe, and then crosses the Atlantic to the United States. Low survivability at high temperatures and high humidity has also been indicated for the SARS and MERS viruses.

The outbreaks to the south of this "Covid-19 belt" are akin to a spillover effect. In areas that have hot and humid climates, or are currently in summer, the virus does not survive long. To the north of the belt are relatively few cases, because extremely cold temperatures keep residents indoors. The number of cases in northern regions of the globe could increase in line with rising seasonal temperatures without adequate intervention. Despite the spillover effect, countries to the south of the imaginary Covid-19 belt are not at low risk, either.

Several countries like Indonesia, the Philippines, and India have high population densities, so the virus has a great chance of spreading. Social restrictions implemented in tropical countries, including Indonesia, can be very effective as long as their citizens follow them in a disciplined manner.

AFP/LEO RAMIREZ

People bow in front of Tiananmen Gate in Beijing during a three minute national memorial to commemorate people who died in the COVID-19 coronavirus outbreak, on April 4, 2020. - China came to a standstill to mourn patients and medical staff killed by the coronavirus, with the world\'s most populous country observing a nationwide three-minute silence.

Focus on severe casesTo design a long-term plan to escape the grip of this pandemic, we must understand how this virus makes people sick and how it kills. Experts have divided Covid-19 into three stages of infection. Stage I is the period of asymptomatic incubation. Stage II is the period of mild symptoms. Stage III is the period of severe respiratory symptoms.

Strategies to trigger an immune response in stages I and II would be very helpful. This includes the administration of hyperimmune serum. The virus that causes Covid-19 also relies on the proteases in its host to multiply. Therefore, anti-protease medicines could help patients recover from the disease.

However, some patients may experience a kind of impaired immune response, which leads to Stage III of infection. The writer believes that this impaired response occurs due to a combination of genetic factors and the pathogenesis of Covid-19. In this group of patients, immune disorders trigger a “cytokine storm” at the start of acute respiratory distress. Being in a prime condition of health could be detrimental to patients in this group.

Anti-inflammatory drugs and other medicines that can be used in symptomatic treatment can be considered. In several cases, patients need intensive care treatment using a mechanical ventilator. Artificial respiration equipment can save their lives. Stage III patients develop jelly-like fluids or fibrin in their lungs due to Covid-19, similar to the lungs of people who are drowning. Several researchers have pointed to hyaluronan as a primary component, as it has a high absorbent capability.Medications that suppress hyaluronan and its production can save lives, including certain herbal medicines and vitamins. Data on the immunity response of Covid-19 patients has not been published to date. Whether antibodies play a role in recovery is as yet unknown. Publications on SARS data indicate that antibodies are present in only about 10 percent of patients who have recovered from the disease. Vaccine development will face obstacles here. Vaccines that generate antibodies could induce a cytokine storm as an immunoresponse to viral infection, as has been revealed previously.

AFP/MARIO TAMA/GETTY IMAGES

Nurses and supporters protest the lack of personal protective gear available at UCI Medical Center amid the coronavirus pandemic on April 3, 2020 in Orange, California. Hospitals nationwide are facing shortages of PPE due to the COVID-19 outbreak.

What can be done to “switch off” the Covid-19 pandemic, when it is caused by such a complex virus? In my opinion, medicines and health facilities to treat Stage III patients must be prioritized. The data shows that the majority of people who are exposed do not become ill. Those who present clinical symptoms only show mild symptoms. Information from the World Health Organization (WHO) shows 80 percent of patients recover without any special treatment. Data from the outbreak aboard Diamond Princess in Japan, published in the Eurosurveillance journal on infectious disease surveillance, could be used as a benchmark. Around 75 percent of the cruise ship’s passengers and crew were exposed to the virus, but not infected. While 8 percent of those who tested positive were asymptomatic and 17 percent developed symptoms.

If we use information from the WHO regarding the cruise ship case, only 3.4 percent of the population needs special treatment.

Therefore, the proportion of patients who required hospital treatment is relatively small. Stage II patients may recover with the intervention of hyperimmune serum and symptomatic relief medications. The proportion of patients who require intensive care treatment with a ventilator is even smaller. If we use information from the WHO regarding the cruise ship case, only 3.4 percent of the population needs special treatment. Of these, about 10 percent of patients need ventilators, or 0.34 percent of the population. The figure could be smaller in real conditions, or around 25 percent lower than the extreme condition aboard the cruise ship at about 0.1 percent of the population.

Also read: Coronavirus Turns over Immunity into Weapon that Backfires

Assuming that the average patient needs to be on a ventilator for 15 days, one ventilator can be used to treat 24 people per annum. That means that an intensive care unit (ICU) needs enough ventilators to treat 0.004 percent of the population. For Indonesia with its 280 million population, this means it needs 11,200 ventilators. Bali, which has a population of 4 million, needs 160 ventilators. A country or region that is able to meet 50 percent of its ventilator needs can give a sense of security to its people.

The PSBB has been implemented as a non-pharmaceutical strategy throughout Java and Bali, the two islands with the highest population densities in Indonesia. This means a high risk of human-to-human transmission. Outside these two islands, the PSBB can be imposed in densely populated cities. If the medicines and hospitals are ready, Indonesia can free itself from the grip of the Covid-19 pandemi.

Gusti Ngurah Mahardika, Professor of Virology, Udayana University, Bali