In a timely wrap, public health researcher Alison Barrett reports on wide-ranging investigations into the nature of COVID-19 and its management.
How did it all begin?
A World Health Organization (WHO) investigation into the origins of the novel coronavirus in central China will release its report to the public soon.
In the meantime, preliminary findings were revealed last night (10 February) at a joint press conference between the WHO and Chinese officials.
The investigation sought to develop a better understanding of events in December 2019, and to determine if the virus started circulating earlier than that; and to understand how the virus emerged and was introduced to the human population.
Key conclusions from their investigation:
- While the research team found evidence the virus may have been in circulation a few weeks earlier than initially reported, they did not find evidence of widespread cases prior to December 2019.
- Evidence was found of circulation of a few sporadic cases beyond the Huanan Market, in Wuhan. The cases then spread more rapidly in January 2020.
- Evidence points towards a natural reservoir of the virus and similar viruses in bat population. The investigators did not have much success finding the primary source, after investigating the initial cases and Huanan Market.
Moving forward, they reported identifying four main hypotheses for the origins:
- Direct spillover from animal to human
- Spillover from an intermediary host species that might have allowed the virus to adapt more – they said this was the most likely cause and where future research would be primarily focused
- Introduction via food chain, such as frozen product in the Huanan Market
- Lab-related incident (considered “extremely unlikely”).
Challenging global health assumptions
Publication: Explaining COVID-19 performance: what factors might predict national responses? by Baum, F et al., on 29 January 2021 in the BMJ
In an analysis in the BMJ’s COVID-19: The Road to Equity and Solidarity collection Professor Fran Baum, from the Southgate Institute for Health, Society and Equity at Flinders University, and colleagues discussed factors that affected countries’ responses to COVID-19.
In October 2019, prior to the COVID-19 pandemic, the Global Health Security Index (GHSI) published a report summarising results of their analysis of global health security and preparedness for epidemics or pandemics.
One of their main findings was that the world was not prepared for a pandemic, and that while some countries were better prepared than others, no country was fully ready.
The index measured individual countries capabilities to respond to an epidemic or pandemic across six domains: prevention; detection and reporting; response; health system; compliance with norms; and risk of infectious disease outbreak. The higher the score out of 100, the better prepared a country was predicted to be for responding to, and experiencing lower measures of burden from, an epidemic or pandemic.
The United States and United Kingdom scored the highest on the GHSI for preparedness (ranked first and second, respectively) but as Baum and colleagues wrote, “both countries have done spectacularly badly in response to COVID-19, whether measured in deaths or economic damage”.
In this analysis, Baum and colleagues discussed ten potential reasons why the GHSI did not predict countries’ response more accurately.
- The GHSI measured individual nations’ preparedness, without considering the very nature of the current globalised world. Viruses spread rapidly with increased movement and travel.
- Bias to high income countries and emphasis on biosafety, when effective responses to pandemics also requires effective community participation and the involvement of a range of experts in decision making and planning.
- Failure to assess capacities of health systems. For example, countries with universal public health systems, such as Thailand, Vietnam, Australia and New Zealand, tended to have strong capabilities and have responded generally well to the pandemic. In contrast, the United States relies on for-profit healthcare, and England outsourced their testing and tracing programs to private companies that are not specifically trained in infectious disease management.
- Role of political leadership. While the GHSI measured trust in government, it did not consider the role that leadership plays in public health responses. New Zealand scored 54/100 on the GHSI and was ranked 35th place, but has shown one of the best responses to the pandemic, in part due to the leadership of Prime Minister Jacinder Ardern, who has been praised for being empathetic, a clear communicator and following evidence-based practices. Baum and colleagues wrote: “Given the vital importance of trust during a pandemic, political leaders who promote transparent government are more likely to mount a more effective response.”
- The importance of context was overlooked. When considering health interventions, it is important to consider the context of a countries’ political, social, cultural and financial systems. Many countries have similar political structures but have responded differently to the pandemic. For example, US, Belgium, Australia and South Africa are all federated states but responses and outcomes have been completely different.
- Limits of national wealth as predictive factor. The GHSI predicted that those with higher gross domestic product (GDP) per capita had a higher GHSI score. In contrast, those with lower GDP and income levels had a lower GHSI score and therefore predicted to perform poorly during a pandemic. This is not the case for all lower income countries. For example, Rwanda and Vietnam both have very low GDP per capita, and have had very low number of COVID-19 cases and deaths. The authors suggest this may be due to lower income countries allocating their limited resources more appropriately and tailored to their national context.
- No examination of inequalities within countries. Pre-existing inequalities have been exposed by the pandemic in many countries. In the UK and US, minority ethnic groups have experienced a higher burden of the disease.
- Importance of social security provisions. The GHSI didn’t consider the ability of countries to provide social security provisions (for example, rental assistance or income support) in their assessment.
- Civil society capacity not assessed. The capacity of a country to engage communities is especially important in countries where trust in the government is limited, and should be included in future versions of the GHSI.
- Gap between capacity and its application not assessed. While the GHSI assessed the “theoretical capacity” of a country’s ability to respond to an epidemic or pandemic, it did not assess a country’s willingness or actual capacity to respond. For example, although the US scored high on epidemiology training programs, political intervention prevented the Centres for Disease Control and Prevention from applying their skills to evidence-based responses.
Another example of this is, as highlighted in an independent review on the early responses to the pandemic, that when the World Health Organization warned of the public health emergency in January 2020, many countries ignored them.
Researchers from the Lowy Institute recently published an interactive COVID performance index with findings that support many of the statements in the analysis by Baum and colleagues, including that “levels of economic development or differences in political systems between countries had less of an impact on outcomes than often assumed or publicised”.
In tracking 98 countries’ performance over six measures (confirmed cases, deaths, cases per million people, deaths per million people, cases as a proportion of tests, tests per thousand people), they found that although similar measures were implemented across most parts of the globe to control the spread of the virus (for example, lockdowns, border closures, stay at home orders), it was how governments “convinced or compelled their citizens to adhere to these measures” that was different and “reflected the nature of their political systems”.
They found that the top ten countries based on the key measures were: New Zealand, Vietnam, Taiwan, Thailand, Cyprus, Rwanda, Iceland, Australia, Latvia and Sri Lanka.
While the GHSI correctly predicted the world was not prepared for a pandemic, the Index was not accurate in predicting which countries would mount a successful response to the COVID-19 pandemic and which would not.
In conclusion, the authors wrote: “The crucial lesson from the COVID-19 pandemic is that an effective response does not rely just on a strong public health system but also requires a society that is fair and offers all its citizens and residents social and economic security.”
Other articles with a focus on global issues arising during the pandemic can be read in the BMJ’s COVID-19: the road to equity and solidarity collection.
Dr Melissa Sweet from Croakey News has summarised many of the articles in the collection in this Twitter thread.
The ‘Second report on progress’ prepared by the Independent panel for pandemic preparedness and response for the WHO executive board in January 2021, can be viewed here.
Lowy Institute’s COVID-19 Performance Index is available to view here.
Publication: Trust in government increased during the COVID‐19 pandemic in Australia and New Zealand, by Goldfinch, S, Taplin, R and Gauld, R in the Australian Journal of Public Administration, on 6 January 2021
An online survey conducted in July 2020 found that levels of trust in both Australian and New Zealand governments has increased substantially since 2009, when a similar survey was conducted by the lead author, Shaun Goldfinch.
Of one thousand survey responses included in the final analysis, 80 percent of Australians and 83 percent of New Zealanders responded that they agreed their respective governments were “generally trustworthy.” This is in comparison to only 49 percent of Australians and 53 percent of New Zealanders in 2009.
The four-point scale questionnaire also asked questions about confidence in public health scientists, management of the pandemic and trust in each countries’ respective COVID-19 tracing apps.
The majority of respondents from both countries agreed that their government’s management of the pandemic had increased their trust in both the government and the health system.
While many agreed that their countries’ COVID-19 tracing apps were in the best interest of the public, only 44 percent of Australians and 24 percent of New Zealanders reported using the app.
Differences in survey responses were measured between Australian states and found to be minimal, with the authors writing that this was the case, “despite different political parties in state government and differing approaches to COVID-19 management”.
The authors suggest that the increased trust in the Australian and New Zealand governments may be due to less politicisation of the pandemic as seen in the United States.
As the survey was conducted during the pandemic, the results may not be reflective or predictive of long-term changes in trust.
The authors wrote in conclusion that “trust in government remains a central component of effective government” and, as discussed by Baum and colleagues, an important factor for a nations’ successful response to the pandemic.
Publication: People’s Experiences and Satisfaction with Telehealth During the COVID-19 Pandemic in Australia: Cross-Sectional Survey Study, by Isautier, JM et al., in Journal of Medical Internet Research, on 10 December 2020
In exploring Australians’ experiences with telehealth during the pandemic, researchers found that 61.9 percent of Australians reported their experience to be “just as good as” or “better than” their experiences with traditional healthcare services.
Prior to the pandemic, telehealth services were limited to rural and remote populations and accounted for 1.3 percent of all health services. With the introduction of a temporary Medicare subsidised telehealth program in March 2020 to enable access to health services that may have otherwise been delayed due to the pandemic, telehealth services accounted for 36 percent of all health services by April 2020.
Researchers conducted an online survey in June 2020 to compare Australian’s views of telehealth with traditional face-to-face healthcare and determine whether people thought telehealth would be useful after the pandemic.
Almost 44 percent of survey respondents reported they had used a telehealth service since the beginning of the pandemic.
People who were slightly older, female, had a higher level of education, greater prevalence of chronic health conditions and reported their own health to be poorer than the general population were more likely to use telehealth services than those who did not.
Several factors, including being male, having lower willingness to self-manage health and wellbeing, and having a history of anxiety and depression, were statistically associated with reporting a poor telehealth experience.
While more than half of respondents found their experience with telehealth to be good, some reasons were identified about why telehealth experiences were worse than traditional face-to-face health care experience:
- communication is not as effective as face-to-face
- limitations with technology
- issues with obtaining prescriptions and pathology results
- reduced confidence in the doctor
- additional burden for complex care, and
- the inability to be physically examined.
As an alternative option for patients who face challenges accessing or attending face-to-face healthcare, such as people from rural and remote communities, it is promising that so many people found it to be acceptable.
However, if the service is to remain beyond the pandemic, the authors recommend that some of the issues outlined above could be addressed by clearer communication about what types of healthcare can be provided via telehealth.
Investigating viral shedding
Publication: SARS-CoV-2, SARS-CoV, and MERS-CoV viral load dynamics, duration of viral shedding, and infectiousness: a systematic review and meta-analysis, by Cevik, M et al., in The Lancet: Microbe, on 1 January 2021
A systematic review recently published in The Lancet found that the average duration of viral shedding of the SARS-CoV-2 virus from the upper respiratory tract is 17 days.
Viral shedding is when the bodies’ cells release infected virus particles, primarily by exhaling, coughing, talking, or sneezing. The particles infected with SARS-CoV-2 may not be actively infectious, but could result in a positive COVID-19 test result. Further testing would determine if the case was infectious or not.
As highlighted in January when international tennis players arrived for the Australian Open Tennis and tested positive to COVID-19, viral shedding can also be detected in older cases. It is important to determine the infectiousness of older cases in order to ensure appropriate infection control measures are put in place.
The authors searched for articles that reported viral load dynamics (the number of virus particles in an individual) and duration of viral shedding in SARS-CoV-2, SARS-CoV and MERS-CoV between 1st January 2003 and 6th June 2020 in academic and grey literature databases. They included studies that had five or more participants, and were case studies, cohort studies or randomised control trials.
From 79 studies about SARS-CoV-2, they calculated the average duration of viral shedding from the upper and lower respiratory tracts and stool, finding that the average duration in lower respiratory tract was 16.6 days and 17.2 days in stools.
The longest duration of viral shedding was 83 days; and shedding duration was found to be longer in adults 60 years and older.
The authors found from that no study identified live virus after nine days of symptoms; so while viral shedding of SARS-CoV-2 can occur up to a few weeks, the virus is generally most infectious in the first week of illness, “emphasising the importance of immediate isolation with symptom onset early in the course of illness”.
The review’s limitations include that only six studies reported viral dynamics “exclusively in children,” indicating the limited information on viral dynamics in children; and that patients in the included studies received different treatments, which may change the viral dynamics. However, it does provide valuable information about the duration of viral shedding and load collated from many COVID-19 studies.
Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public health, rural health and health inequities. Follow on Twitter: @AlisonSBarrett. Croakey thanks her for providing this column as a probono service to our readers.
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