Where the 2019-nCoV outbreak is heading….

The situation in China is getting grimmer by the day. Yesterday, some 2900+ new cases of 2019-nCoV infections were reported. With the total number of infected exceeding 17000, this ugly new virus has blew away SARS in this aspect. A record number of people (57) died yesterday, pushing the total number of deaths due to the disease to 361. More lives have been lost in China to 2019-nCoV than SARS. These are breath-taking numbers

Hence, hearing then Health Minister speak in Parliament today was reassuring. The Ministry is certainly working their butts off to try and prevent local transmission of the 2019-nCoV. It is also working out scenarios on how to manage the situation should the virus be found to be transmitting locally.

This novel 2019-nCoV is one mean SOB, you have to admit. It’s as mean if not meaner that SARS in at least 3 ways.

For one, it has been now established that a patient is infectious even during the incubation period. This was published in as a correspondence to the NEJM by German doctors a few days ago.

Secondly, about 80% of patients exhibit easily detectable symptoms or signs such as fever or cough. That means even with temperature screening, 1 in 5 patients may escape detection. This was published in The Lancet a few days ago too.

Thirdly, Chinese health officials suggest that a person may get re-infected with the virus. In other words, one is not off the hook as immunity may be fleeting. If that is the case, it would also suggest it may very difficult to develop an effective vaccine that confers lasting immunity.

Singapore has been gearing up to meet the threat of 2019-nCoV. It certainly warmed the heart of this hobbit to see our NSF boys packing surgical masks for distribution to every household in Singapore.

Since we are on the issue of masks. This hobbit would like to say a few words about our mask policy. The official message is, unless you are dealing with potential high risk patients, such as potential suspect patients, one doesn’t have to wear a mask.

But on the ground and when policies are actually rolled out, there is wide variation in interpretation. This can be observed on the 1 Feb 2020 print copy of The Straits Times. On one page was an article describing how during the ruling party PAP’s Meet-The-People Sessions (MPS), temperature screening is now being carried out. The same article also said that MPs and party activists should not be wearing masks (in line with the prevailing instructions of government then).

Several pages later, under reporting coverage for the recently held Chingay Festival, there was a large photograph showing masked-up temperature screeners checking on Chingay Festival attendees. I think the Chingay Festival is an event sanctioned by the government.

Personally for me, I think the logical thing to do in a gathering of normal-risk people, is NOT to conduct temperature screening and NOT to wear a mask, if we truly believe there is no local transmission of the disease. We should conduct temperature screening when there is a gathering of higher-risk persons, such as patients seeking care (and accompanying persons) in hospitals or clinics. In which case, temperature screeners should wear a surgical mask because they need to be protected in case a suspect case of 2019-nCoV turns up. Therefore, to forbid a screener from wearing a mask suggests that there is practically no chance of the screener meeting a suspect case, in which case, then why screen at all? Does this make sense? In other words, do not screen for fever at all. But if you do decide to conduct temperature screening, please let the screener wear a mask.

Another interesting feature is the definition of a suspect case. The current MOH definition of a suspect case of the 2019-nCoV infection (unchanged since 25 January) is:

a) A person with clinical signs and symptoms suggestive of pneumonia or severe respiratory infection with breathlessness AND travel to mainland China within 14 days before onset of illness; OR

b) A person with an acute respiratory illness of any degree of severity who, within 14 days before onset of illness had:

  • Been to Wuhan city or Hubei Province, China; OR
  • Been to a hospital in mainland China; OR
  • Had close contact with a case of 2019 novel coronavirus infection.

On 1 Feb 2020, Singapore moved to bar all recent travellers to China from entering Singapore (other than Singapore residents). This would suggest that the authorities have deemed that the risk of contracting 2019-nCoV is so high for the whole of China that it makes no sense to distinguish a person who has been to Hubei province from another person who has been to another part of Mainland China in terms of risk posed to Singapore.

As such, this hobbit thinks that the case definition of a suspect case should likewise not make any distinction between Wuhan, Hubei or a hospital in mainland China. I hope someone updates the case definition soon.

A third interesting feature in the latest list of notifiable diseases under Section 6 of the infectious Diseases Act, 2019-nCoV is NOT on the list as of today if you google it. But if you login through SingPass into the CD LENS system, it is there. Can someone please fix this discrepancy? Very confusing to simpleton hobbits.

Finally, back to Epicentre China. This week and over the next few days, Wuhan will be commissioning an additional 2600 beds to treat 2019-nCoV patients in its two coronavirus hospitals: Huoshenshan (fire god mountain) and Leishenshan (thunder god mountain) hospitals. Beijing has also brought out of mothball a SARS hospital with 1000 beds (Xiaotangshan hospital). This probably reflects what the Chinese leadership is thinking now about where the 2019-nCoV epidemic is heading. This is what we call a “lead indicator”, as opposed to lag indicators that tell us about things that have already happened. Health authorities build hospitals and commission beds in anticipation that they will mostly be filled. With such a huge number of beds put into circulation at such blinding speed, it suggests that the worst is yet to come and the outbreak has not been brought under control yet. The daily surging number of new infections and deaths also underscore this point.

This hobbit will be looking out if more such coronavirus hospitals will be built in China soon. If more are built, then it suggests that the epidemic is still growing quickly. If no new hospitals are built, then it may be that growth of the epidemic is slowing down or that the epidemic is being slowly brought under control. Or maybe the authorities have concluded isolating and treating these patients in new hospitals may be futile in controlling the epidemic and other measures need to be taken.

In the Napoleonic era, Prussian diplomat von Metternich said “When French sneezes, the whole of Europe catches a cold”. This was modified in the later half of the last century to “When America sneezes, the whole world catches a cold”, to underline America’s preeminent place in world affairs. Given the current state of the 2019-nCoV epidemic, it may not be out of place to say that “When China catches pneumonia, the whole of Asia is breathless”

We are in this for the long haul, folks.








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