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“We are at a turning point”: The coronavirus outbreak is looking more like a pandemic

Health experts say it’s time to prepare for worldwide spread on all continents.

Residents of Hong Kong wear masks as a precautionary measure against the spread of the Covid-19 novel coronavirus on February 23, 2020.
Vivek Prakash/AFP/Getty Images

During the past two months, as the new coronavirus outbreak spiraled into a global threat, countries around the world have scrambled to impose travel bans, quarantine millions, and isolate sick people in an attempt to stop the spread of the new virus.

Yet, as of Tuesday, there were more than 80,000 cases of Covid-19 in nearly 40 countries, including case tolls in Italy, Iran, and South Korea that have surged almost overnight, and an ongoing outbreak on a cruise ship off Japan.

The likelihood that we’re in a pandemic, a new disease that spreads around the world — or that we’re hurtling toward one — seems higher than just a week ago. That means more countries are likely to see spread of the virus within their borders very soon — and that includes the US, the Centers for Disease Control and Prevention (CDC) warned Tuesday.

“The data over the last week, and the spread in other countries, has raised our level of concern and our level of expectation we’re going to have community spread here,” said Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases at CDC. “It’s not a question of if this will happen, but when this will happen, and how many people in this country will have severe illnesses.”

Other public health experts agreed, telling Vox that containing the virus — fully halting its spread — may no longer be possible.

“I don’t think the answer is shutting down the world to stop this virus. It’s already out,” said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy.

“When several countries have widespread transmission, then spillover to other countries is inevitable,” said Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases.

If stopping the virus is increasingly out of reach, health officials will have to accept that it’s everywhere and move into a new phase in their response strategy. (To be clear, a disease outbreak can become a pandemic without being especially severe or fatal.)

“We are at a turning point in the Covid-19 epidemic,” said Lawrence Gostin, a global health law professor at Georgetown University. “We must prepare for the foreseeable possibility, even probability, that Covid-19 may soon become a pandemic affecting countries on virtually all continents.”

A look at new outbreaks outside China, and what they tell us about how this virus is moving, helps explain why.

Numerous countries (and one cruise ship) have seen rapid spread of the coronavirus

Source: Johns Hopkins University Center for Systems Science and Engineering

As of February 25, there were more than 2,600 cases of Covid-19 outside China. That’s an increase from around 500 cases just over a week ago.

Sizable outbreaks are popping up in places that had barely registered any cases mere days ago. Many of these new cases are occurring in people who never traveled to China, or from an unknown source. The virus has also entered a few relatively contained environments — cruise ships and prisons — and spread like a wildfire, revealing its contagiousness and how difficult it is to stop. Let’s dive into the latest developments.

South Korea now has the most cases outside of China: 977 as of Tuesday, up from only 30 a week before. Many of them are linked to a secretive religious group, known as the Shincheonji Church of Jesus, in the city of Daegu.

A medical professional is seen at a preliminary testing facility at the National Medical Center in Seoul, South Korea, where patients suspected of contracting coronavirus are assessed on February 21, 2020.
Chung Sung-Jun/Getty Images

The country’s president, Moon Jae-in, has put South Korea on its highest alert level over the outbreak, giving cities the power to impose their own containment measures. “This will be a momentous time when the central government, local governments, health officials and medical personnel and the entire people must wage an all-out, concerted response to the problem,” he said, according to the New York Times.

As of Tuesday, Iran reported 95 cases, including 19 deaths. Its outbreak was first identified days after authorities there said they had no Covid-19 within their borders. Cases with links to Iran have already turned up in other countries, including Canada and Lebanon.

Very quickly, the country’s narrative about the virus has changed. Schools and universities across the country are being shuttered as a “preventive measure,” along with some cinemas and restaurants, according to Al Jazeera.

A medical team checks on travelers at the Shalamjah border crossing, near Basra, upon their return from Iran on February 21, 2020.
Hussein Faleh/AFP via Getty Images

But this outbreak might be much larger than it looks now, according to disease modelers who have been tracking it. “The fact that you’re getting exported cases and deaths reflects that the underlying burden of illness is much larger than what is being reported,” said Isaac Bogoch, a professor and infectious diseases expert at the University of Toronto.

Italy is now home to the biggest Covid-19 outbreak outside of Asia: 322 people have confirmed infections, including at least 10 deaths. The worrisome rise in cases in the country’s north has prompted authorities to impose severe measures to try to stop the virus. Sporting, religious, and cultural events have been canceled, along with university classes. Authorities are also fining anyone who tries to enter or leave areas where the outbreak is occurring, including 11 towns in the Lombardy region.

Italian Prime Minister Giuseppe Conte announced a “national emergency” due to the coronavirus outbreak and imposed quarantines on the Lombardy and Veneto regions.
Marco Di Lauro/Getty Images

The Diamond Princess cruise ship in Japan, which quarantined 3,600 passengers and crew after an 80-year-old man tested positive for the virus, now has 691 cases associated with an ongoing outbreak there, including three deaths. That’s the second-largest local outbreak outside of China. Japanese authorities ordered the quarantine in early February in an attempt to contain the virus — but the effort backfired dramatically.

“They’ve basically trapped a bunch of people in a large container with [the] virus,” said University of Toronto epidemiology professor David Fisman over email. Public health experts and researchers now believe the quarantine probably generated more cases — both because the virus appears to be highly contagious and because proper quarantine protocols weren’t followed.

Passengers look out from balconies on the Diamond Princess cruise ship while it is docked in Yokohama, Japan, on February 6, 2020.
Carl Court/Getty Images

By February 18, Japanese officials began letting passengers off the ship who tested negative for the virus — and within days, a case turned up among them, mirroring the situation on another cruise ship in Asia, the Westerdam. After one woman disembarked, she tested positive for the virus in Malaysia, setting off a global search for other passengers who may have been exposed.

Why this looks like the beginning of a pandemic

These outbreaks outside of China, along with the latest science on Covid-19, suggest we may soon see a rapid rise in infections in more countries around the world. Here’s why.

1) The virus is very contagious, and some people seem to be able to infect others before they know they’re sick: Researchers currently believe one infected person generally infects two to three others, which would make the new coronavirus more contagious than other coronaviruses, like SARS and MERS.

“For a virus pretty closely related to SARS, it shows very effective person-to-person transmission, something nobody really expected,” Stephen Morse, a professor of epidemiology at Columbia University Mailman School of Public Health, told Vox. Look at the cruise ship in Japan, the thousands of health care workers in China who have been infected, and the situation in China’s prisons for more evidence of Covid-19’s potential for rapid spread.

Javier Zarracina and Christina Animashaun/Vox

At the same time, the latest science suggests some people may transmit the virus very early in their illness or even before they are showing symptoms — which is again different from SARS and MERS and suggests this virus looks about as contagious as seasonal influenza.

SARS was eventually contained because, when people began to show symptoms, they were only just becoming contagious. And if they were promptly isolated, and their contacts traced and isolated, too, it was possible to stop the virus from spreading, explained Minnesota’s Osterholm. But “trying to stop influenza-like transmission is like trying to stop the wind. It’s virtually impossible,” he told Vox.

For these reasons, Osterholm said the fact that extraordinary measures to contain this virus haven’t worked to stop its global spread doesn’t mean Covid-19 containment failed. “Containment never had a chance because of the influenza-virus-like transmission.”

2) Countries are still mostly looking for the disease in people who’ve traveled from China: The main method of screening in many countries is still testing passengers coming from China or from Hubei province only. But as we’ve seen, spread is happening beyond those people. And other cases may be undetected.

“We don’t really know if there is community transmission going on in other parts of the world because for the most part countries are not doing diagnostic testing on anyone but returning travelers or their close contacts,” Tom Inglesby, director of the Center for Health Security of the Johns Hopkins Bloomberg School of Public Health, told Vox.

Though the US CDC maintains that the risk of spread in the US is low, it’s beginning to change its screening strategy to look for people with the virus who aren’t returning travelers from China. It will use the national flu surveillance tracking infrastructure to test patients who have flu symptoms for Covid-19 in five cities across the US.

3) With flu season ongoing, it can take time to identify cases and outbreaks: “The challenge with this illness is that the clinical symptoms resemble other viral illnesses, like flu,” said Inglesby. So people with the flu, and doctors examining them, may not even be thinking of Covid-19 yet, especially in people who haven’t traveled to China.

4) China’s case toll is falling — but it may see another surge soon as travel restrictions are gradually lifted: The country has taken extraordinarily draconian measures to stop this virus, quarantining millions, and shutting down transit and travel. But the business community is growing increasingly frustrated with the restrictions and is pressuring government officials to ease some of them.

This is “the most intense human social distancing effort in modern public health,” Osterholm said. “What happens when all these people start to go back to work, and public transport is back, and crowding occurs? This is at best a temporary respite in the numbers in China.”

5) Many countries are only now getting testing up and running: Even the US, with one of the most highly resourced health systems in the world, doesn’t have adequate diagnostic capacity right now:

And the same is true for other countries around the world. For example, until last week, only two countries in Africa — Senegal and South Africa — had the lab capacity to screen for this virus. While other countries are now scaling up, this outbreak has been going on since late last year, and it’s possible cases have gone uncounted.

So far, only one case has been detected in Africa — in Egypt — yet Africa is thought to be at particular risk given its economic ties to China, with more than a million Chinese workers.

“If the disease spreads to fragile states it would be even harder to contain. Many states are undergoing political violence or are poorly governed, such as Syria, the Democratic Republic of the Congo, Yemen, and Afghanistan,” said Gostin. “Others have weak health systems, for example in sub-Saharan Africa.”

6) Some people may have abdominal pain before respiratory symptoms — and that’s not something health officials are screening for: This coronavirus is still very new, and we don’t know its entire spectrum of illness yet, but we’re learning the disease may sometimes surface in surprising ways. Though it’s a respiratory infection, a recent JAMA article found some have abdominal symptoms such as discomfort first. This means “we may not be detecting cases that do not present in the classic way with fever and respiratory symptoms,” said William Schaffner, an infectious disease expert at Vanderbilt University.

Putting all this together, it means there’s probably many more Covid-19 cases than are being detected right now — and many more to come. That’s something models have repeatedly shown. One of the latest, from Imperial College London, estimated that about “two-thirds of Covid-19 cases exported from mainland China have remained undetected worldwide, potentially resulting in multiple chains of as yet undetected human-to-human transmission outside mainland China.”

We need to prepare for a pandemic

Keep in mind: A disease can spread widely and become a pandemic without being particularly severe. And no one knows yet what the death rate of a Covid-19 pandemic would be — mostly because we don’t yet know precisely how lethal this disease is.

On February 16, China’s CDC published a report of the first 72,314 patients with confirmed or suspected Covid-19 in mainland China. It’s the largest such analysis to date. And it found an overall case fatality rate of 2.3, suggesting Covid-19 is less deadly than SARS, which killed around 10 percent of those infected. The death toll was also much higher among the elderly. And many cases — around 80 percent — were mild. As more and more mild or asymptomatic cases are found, the death rate is likely to drop.

Still, Osterholm warned, even a 1 or 2 percent case fatality rate could equate to a lot of deaths if Covid-19 continues to spread around the world. “A 2 percent case fatality rate is 20 times higher than a bad flu year,” he said. (Seasonal flu has about a 0.1 percent case fatality rate.) “So now, you can infect many more people than the flu and add a case fatality that is as much as 20 times higher.”

What’s more, a less severe pandemic still has the potential to overwhelm a country’s health system. The current data from China suggests as many as 5 to 10 percent of patients need care in an ICU, Osterholm said. Many countries may not have enough beds or equipment to care for the needy, not to mention such care could cost billions.

For now, countries need to move from trying to contain the virus to mitigating its harm — reducing the spread and caring for the very sick, said Jennifer Nuzzo, an infectious disease expert and senior scholar at the Johns Hopkins Center for Health Security. “It is beyond time,” she added.

This means hospitals need to be ready with Covid-19 protocols, health care workers need to be protected with access to protective equipment such as face masks, and countries need plans in place for maintaining supply chains and carrying on with travel and trade.

Recent outbreaks in Germany, France, and the UK suggest high-income countries with strong public health systems may be able to control the virus’s spread, at least for now.

But it’s also possible they, too, are harboring outbreaks that have yet to be detected. And as the virus moves around the world and infections mount, even high-income countries are likely to struggle, Osterholm said. “I think we have to expect there are going to be many locations around the world that will experience what China is experiencing.”


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