Corona and responsible actors- and what should be done now

To allow people to travel to affected areas and back is irresponsible, here's why
One argument reads that this virus is a rich man's disease. Yes, it is true that people who can afford themselves to travel and who did so during Sprink Break, have taken this infection with them from nothern Italy and other massively affected areas following the Wuhan outbreak of December 2019. One cannot hold someone accountable for traveling abroad when no one was noticed about the virus emerging in what would soon become high risk areas. But when a warning was emitted in our country, people still travelled to affected areas in order to return home, fallen ill to COVID-19.

People are always affected by other people's actions. To travel abroad to an epicentre is a choice that puts others at risk. A risk nobody has asked for and made many of us powerless. People with chronic diseases did not have a choice. They are, to a great extent, dependent on how others behave after contracting an infection. Furthermore, it has been very irresponsible to allow people to travel to affected areas. 

The thought alone of limiting physical freedom by imposing travel restrictions, seemed not negotiable to many of our governments. It was decided to not impose travel restrictions from an economical point of view. Short term economical benefits prevailed over taking measures to ward off this virus as much and as long as possible. Also, a fear of acting discriminative has withheld governments from enforcing restrictive measures, such as containment. 

Blame is only natural if institutions with authority and responsibility fail or refuse to take measures to prevent unnecessary damage. Delay leads to unnecessary damage. Unnecessary is damage evidently caused by leaning back and not acting upon a serious threat. An authority that trivializes problems and takes a wait-and-see-attitude, intervenes deeply in the lives of citizens. What's more: authorities have been acting contrary to containment. The prevention phase was a crucial phase, during which containment should have been the foremost strategy to keep the curve of patients falling ill to COVID-19 as flat as possible.

"Anything we say in advance of a pandemic is alarmist; anything we say afterwards is inadequate"- Michael Leavitt, 2006
Some say: scientists try to evoke panic and mass hysteria. How's that? People did not want their perception of freedom to be limited. How much is this perceived kind of freedom worth on a scale of life? People will actually experience what freedom really means to them, once they will have to live in a vacuum. The problem with people in general is that awareness before any kind of disaster is deemed "hysteria". Some of them say "we should not go overboard with measures" even before having taken any measures at all. Those people need to see it happen before their eyes to realise it might be mean. Ask yourself: is awareness really worse than neglect? 

I'll tell you this: it's been 20 years since scientists have been warning the world for this outbreak. A virus is not a matter of revolution, it's evolution. Researchers have observed developments, in case mutations to RaTG13, and estimated an outbreak would happen in the course of 2019. I pulled my ACP Medicine out and searched for biochemical information on coronaviruses. A study written in 2007 reads that "Future outbreaks of nCoV should be limited by isolation of patients with suspected SARS for at least 10 days. In case of documented SARS, patients should be isolated for at least 20 days to prevent a spread." Sadly, to this date none of these recommendations have been taken to heart by governments, except for a few, like China. To come awake too late is bad. Being fully aware and not taking the right measures is downward terrible. By ignoring recommendations backed by scientific practice that has been developed for over the past 20 years, you, as an authority, are responsible for every death that occurs due to your negligence.

Taking recommendations backed by scientific evidence is not born out of a sense of panic, but very realistic and useful. We, as citizens, are responsible for taking measures to prevent further transmission.

ACP Medicine, a 2007 SARS study: prevention is key. Patients with suspected SARS should be isolated for at least 10 days. In cases with confirmed SARS, patients should be isolated for 10 days after the abatement of fever.

Containment: what should be done now
Many West European people, especially the Dutch and German, praise themselves for having  phlegmatic temperament. While being sensible would be recommendable, it is in fact indifference that a good amount of Dutch people consider to be 'nuchter'. Indifference, as in "lean back, wait and we'll see, because it is just another storm that will pass by itself" is not going to help society out of this epidemic. It is not going to contribute to containment. 
The government has decided (well actually it did not make any 'decisions') to leave it up to people whether they want to restrict their daily activities. "Just use your common sense". 

What does "common sense" mean with regards to COVID-19? People have to decide whether to stay at home or to continue their activities while being infected. People have visited hospitals and general practitioners after being infected with 2019-nCoV. One man has mentioned to have been tested seropositive for COVID-19 on 1 March 2020. He used public transport to visit the city's hospital, in order to be tested positive for COVID on 9 March 2020. Hence, people are given a responsibility that they cannot handle or understand.

Everything should be done to enable hospitals to treat their patients, without getting stuck in an overflow of people falling ill to COVID-19. A shortage of ICU beds (Intensive Care Unit) and ventilators is a threat that has to be avoided right now. If our governments fail to enforce all restrictions needed, hospitals will be faced by abhorrent questions of triage. Similar to wartime, people with compromised immune systems and relatively older people will have to be sacrificed to treat relatively younger, non-compromised patients. This is why there is no time left to overthink possible scenarios.

Rules of containment
- The government should suspend all flights, except for cargo. As of today, an impossible threat is still imposed on all of us, by admitting flights and travelers from high-risk areas in this country. This is a threat for for everyone within our borders. Do not consider the suspension of flights and other forms of travel too much of a draconian measure. It is sheer necessity to prohibit flights and travel in order to flatten the curve;
- Close the borders;
- All schools should be closed right now;
- Quarantine people who have been exposed to 2019-nCoV right now. Do not leave it up to people whether they should continue their daily activities and social commitmens;
- A regulation that reads that "gathering with hundreds of people or more is discouraged, gathering with a maximum of 20 people is recommended" is insufficient and does not comply with containment, nor does it comply with mitigation. It was estimated that every infected individual, asymptomatic cases included, has the potential to infect approximately three persons. Thus, a regulation limiting the number of people participating in meetings should be replaced by a rule of conduct stipulating that meetings should be avoided.

Coronavirus SARS-CoV-2: awareness. On complications of 2019-nCoV and transmission routes

People finally realize that coronavirus 2019-nCoV/SARS-CoV-2 is not a flu, but a virus of a completely different nature ('analogies create blind spots', to quote Peckham in his commentary in The Lancet of 2 March 2020). This virus, like any virus, should be taken seriously. Realism has nothing to do with panic. Some people let themselves be soothed by trusting that everything will function properly and that it will end with a hiss. I am in favor of more people being critical. A critical attitude is different from unfounded panic. 

What is evident in the media storm that blows over our country is the need of the population for transparency about the risks of the virus, the measures being taken to limit further spread and the seriousness of the situation. Reports that people who transmit symptoms and despite submitting a request are not tested, reports that people coming from risk areas are not restricted from having intensive contact with third parties and the fact that 'privacy' is used as an excuse. People don't need numbers and statistics made up to provide them with a false sense of safety. People need transparency, even if the number of cases might be a shock. It's patronizing to hide truths and laugh actual threats off. Mystery must give the impression that everything is under control, but a lack of transparency causes suspicion.

I will illustrate this with two examples. In the initial phase, the responsible authorities issued the message that people from risk areas are only contagious when they show symptoms such as a high fever. It was already clear at the time of reporting that infected people were already contagious before the onset of the first symptoms. Also, people were not checked if they reported a sore throat, while they were indeed infected and a sore throat is listed as one of the first symptoms of infection with 2019-nCoV as well. The RIVM cites fever as the main factor to report a suspected infection, while fever can occur up to 8 days later in 11.5% of seriously ill patients.

In this report, I will discuss the importance of limitation and prevention of 2019-nCoV and its L and S strains, the complications caused by 2019-nCoV and the transmission routes of coronaviruses. Lastly, I will discuss to what extent governments have acted too late upon the global spread. I base my reporting solely on empirical and clinical studies that have been published in scientific journals such as The Lancet, Nature Magazine and AAAS.

Why is it so important to limit the spread of the virus?
First, there is currently no vaccine against coronaviruses. Secondly, the spread of viruses must be limited to prevent successful mutations as much as possible. Coronavirus 2019-nCoV is a loot to the strain of a precursor that, according to calculations, existed 65 years earlier. 2019-nCoV most likely has this precursor in common with bat coronavirus RaTG13 (Mining coronavirus genomes for clues to the outbreak's origins, AAAS, January 31, 2020). On March 3, 2020, it is known that an L and S variant of the corona virus are active (On the origin and continuing evolution of SARS-CoV-2, National Science Review, nwaa036, published on March 3, 2020). 

Pathogenecity and transmissibility are intertwined. Substantial and consistent interruption of transmission from one person to another (R < 1) is key to control and eradication of 2019-nCoV (Pathogenecity and transmissibility of 2019-nCoV- A quick overview and comparison with other emerging viruses, Microbes and Infection, published online on 4 Februari 2020).

Complications of SARS-CoV-2
The extent of the worldwide influence of the active virus mutations cannot be estimated right now. It is clear that SARS-CoV-2 can cause serious complications. In a patient population with severe symptoms, damage to the organ functions occurs: in a control group, 67% had ARDS (Acute Respiratory Distress Syndrome), 15% kidney failure, 23% heart failure and 29% liver failure. X-rays of the group examined show lesions in the tissue of both lungs (Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study, The Lancet, published on 24 February 2020). Edema occurs at an early stage of ARDS, characterized by the presence of nucleoli in the vesicles.

Coronaviruses have neuroinvasive capacities. Like respiratory viruses in general, they can cause permanent damage to the central nervous system. Coronaviruses can lead to encephalitis via the blood-brain barrier, as accumulation of interleukin-6 increases the permeability of the blood-brain barrier. The rapid replication of the pathogens of SARS-CoV-2 is a risk factor for initiating overreaction of the human immune system, where viral meningitis can occur (Human Coronaviruses and other respiratory viruses: Underestimated opportunistic pathogens of the Central Nervous System ?, Viruses 2020, 12 (1), 14, published December 20, 2019). In a young patient group with CoV, a slight accumulation of IL-6, IL-8 and MCP-1 in the brain fluid was observed. MCP-1 is involved in initiating inflammatory responses in the brain (Coronavirus infections in the Central Nervous System and respiratory tract show distinct features in hospitalized children, Intervirology 2016, vol. 59, no. 3, published in February 2017).

Based on pathological examination of one case of ARDS, it is recommended to treat severe cases with corticosteroids and artificial respiration (Pathological findings or COVID-19 associated with acute respiratory distress syndrome, The Lancet, published on February 18, 2020). The downside to medical treatment is that liver damage can occur, in addition to the risk of liver damage due to coronavirus infection (Liver injury in COVID-19: management and challenges, The Lancet, published March 4, 2020). Data on previous corticosteroid treatments of lung disease (including Dexamethasone) caused by SARS-CoV and MERS-CoV do not provide conclusive information on the effectiveness of corticosteroids. Because the potential benefits do not outweigh the damage caused by corticosteroids, researchers do not recommend treatment with corticosteroids (Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury, The Lancet, vol. 395, issue 10223, P473-475, 15 February 2020).

What are the transmission routes for SARS-CoV-2?
Contamination with 2019-nCoV can occur through the eyes (2019-nCoV transmission through the ocular surface must not be ignored, The Lancet, vol. 395, issue 10224, PE39, February 22, 2020). Because only 1 in 5 people wash their hands sufficiently, there is a high risk of people getting infected as a result of poo getting into the mouth (Enteric involvement or coronaviruses: is faecal-oral transmission or SARS-CoV-2 possible? The Lancet Gastroenterology & Hepatology, published on February 19, 2020). Breathing drops and poop particles end up on surfaces. Coronaviruses can remain active on surfaces for up to 9 days (Persistence of coronaviruses on inanimate surfaces and their inactivation within biocidal agents, Journal of Hospital Infection, vol. 104 issue 3, March 2020). But there's another, less visible transmission route: that of the aerosol transmission. Tiny particles may reach the tract of the host. The airborne or aerosol transmission route was also a major contributor to the SARS-CoV-1 epidemic in 2003, as a tower in the Amoy Gardens in Hong Kong was discovered to be a SARS-transmitting housing complex due to faulty ventilation.

Have international governments acted too late? Yes: delayed detection and reporting and a lack of restrictions in the first phase have seriously damaged global prevention
It is always easy talking in hindsight, but that is not the case this time: beforehand it was clear that unnecessary risks would be taken by not acting directly, but waiting, relying on sheer hope instead of taking measures. Lessons had already been learned from the SARS and MERS epidemics. 

Containment must be applied immediately to curb the spread of corona viruses. Early detection and reporting of 2019-nCoV cases was delayed, the public was not informed in time about the first phase of the outbreak (Early lessons from the frontline of the 2019-nCoV outbreak, The Lancet, vol. 395, issue 10225, P687, February 29, 2020). A lack of medical resources and hospital beds has contributed to the inability to curb the outbreak of the virus in the first phase.

During Chinese New Year, 5 million people from the Wuhan epicentre were able to travel to other countries and to other areas within China. Outside of China, traveling to high-risk areas, traveling people from high-risk provinces in China to other countries (including northern Italy), the Venetian Carnival, German and Dutch Carnival, and other massive occasions have contributed to the worldwide spread of the 2019 coronavirus. After it was announced that northern Italy and South Tyrol were risky areas, tourists were still allowed to travel to these areas and return to their home country. Governments should have acted at this crucial stage. Only rapid detection and isolation of infected persons, including those with mild symptoms, can limit the further spread of the virus. It is not appropriate for a government agency to advise people to remain silent, to refuse to test people who show symptoms of SARS-CoV-2 and to resort to ill advice such as 'do not shake hands'.