There are worrying signs the coronavirus outbreak is entering a new phase, with spread outside of China — until recently at low levels — beginning to rapidly pick up steam.
Experts point to the sharp rise of the number of cases in South Korea, which went from 30 on Monday to 204 by Friday, and in Italy, which had no cases at the start of Friday and 16 at the end of it. Five of the infected people in Italy are health workers.
Iran — which began the week with no confirmed cases and ended it with 18, four of whom have already died — is a particular source of concern, having exported two cases within 36 hours of announcing it had found two patients infected with the virus. A traveler from Canada and another from Lebanon tested positive for the virus after returning home from Iran.
The fact that Iran is already exporting cases suggests transmission there is far more widespread than the official numbers would indicate, said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy.
“I think people are missing the importance of a case like the Canadian traveler to Iran,” he said, referring to a case reported by health officials in British Columbia on Thursday. “This tells us that there has to be a much larger number of people infected in Iran and we’re literally just detecting the tip of the iceberg.”
Even Iranian health officials acknowledged that likelihood. “It’s possible that it exists in all cities in Iran,” health ministry official Minou Mohrez said, according to the official IRNA news agency.
Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, resisted the notion Friday that the outbreak was at a tipping point. But he did tell reporters that the “window of opportunity” to stop spread of the virus is shrinking.
“Our window of opportunity is narrowing,” said Tedros, as he is known. “We need to act quickly before it closes completely.”
The WHO has been seeking funding to help developing countries prepare to cope with the outbreak and has been urging countries to prepare their health systems to respond, if efforts to stop spread of the virus fail.
“This outbreak could go in any direction. It could even be messy,” he warned. “What I’m saying is: It’s in our hands now. If we do well within the narrowing window of opportunity, we can avert any serious crisis. If we squander the opportunity, then there will be a serious problem on our hands.”
As of Friday there were nearly 77,000 cases reported globally, with all but 1,200 reported by China. There were also roughly 2,350 deaths.
The growth in the daily case count in China has been tamped down of late by the country’s extraordinary quarantine effort. Cities that are home to tens of millions of people have been on virtual lockdown for several weeks. While the apparent impact of those measures has instilled hope in some that there is still time to stop circulation of the virus, skeptics warn that disease levels in China could rebound when the country eases its movement restrictions and allows people to return to their jobs.
Most of China’s cases have occurred in Hubei province, where the outbreak appears to have begun in the city of Wuhan. But Tedros noted that there has been a worrying uptick in cases in Shandong province; he said the WHO is asking China for more information about that situation.
Gary Kobinger, director of the Infectious Disease Research Center at Laval University in Quebec, also said Friday he believes stopping the virus is still a possibility. Kobinger is on an expert committee that advises the WHO’s Health Emergencies Program; the group wrote a recent letter to the journal The Lancet urging the world to continue to try to stop spread and eliminate the virus, as was done with the virus responsible for the 2002-2003 SARS outbreak.
“We’re not at the tipping point to say ‘OK, this is now unstoppable.’ I don’t think we are there yet, personally,” Kobinger told STAT. “We’re definitely in a grey zone where you could argue both ways and be wrong or right both ways.”
Osterholm and others suggested overly narrow testing protocols are obscuring the world’s ability to see how far the virus has spread. In the United States, for instance, the Centers for Disease Control only recommends testing people who have symptoms and have been to China or who have symptoms and have been in contact with a suspected or confirmed case.
“Basically if you get tested and you’re found and you’re positive, then we know. But how many people right now are not being tested who are just like this case in Canada?” he asked.
If the Canadian doctor who caught the country’s most recent case had been following that type of protocol, the woman who returned from Iran would not have been tested for Covid-19, the disease the new virus causes.
Bonnie Henry, British Columbia’s provincial health officer, said an astute emergency department doctor ordered the test because of the woman’s recent international travel. It turned out to be a good call.
“It is not something we are recommending … but we have had a low threshold for testing and the lab will test if there is a request from an emergency room with compatible symptoms,” Henry said.
Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, said Friday that the agency may broaden its recommendations for who should be tested if spread in countries outside of China continues to grow.
With the rapid upswing in cases in multiple countries, a number of experts are warning the world needs to plan for wider global spread of this virus.
“We need to start with assumption that we will be facing a pandemic,” said Caitlin Rivers, an assistant professor of epidemiology at the Johns Hopkins Center for Health Security. “If that doesn’t come to pass, then great. But I think we have an opportunity to learn from the lessons that we’re observing in Hubei province. And it’s in our best interest to lean in on that.”
Andrew Joseph contributed reporting.