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Covid-19: weathering the storm

BMJ 2020; 368 doi: (Published 26 March 2020) Cite this as: BMJ 2020;368:m1199

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COVID-19 Pandemic: The difficult unresolved increasing challenges in weathering the storm

The ‘COVID-19 Pandemic’ as ‘Topical Conversation’ necessitates our ‘Weathering the Storm’ as a ‘Global Imperative’ [1]. That ‘COVID-19 Pandemic’ is an ‘Unimaginable Storm’ in the 21st Century tasking the ‘Global Health Community Preparedness’ is no longer news; A ‘Storm’ of Sudden and Huge Magnitude! More tasking in the 21st Century are the very ‘Difficult Unresolved Increasing Challenges’ that MUST be surmounted to successfully ‘Weather the Storm’; ‘Weathering’ implying surviving the ‘Storm’ but without the ‘Ravaging and Devastating Outcomes’!! The ‘Challenges’ will be explored, as ‘Tantalizing Teasers’, thus: ‘Coronavirus Issues’, ‘Intervention Issues’ and ‘Sustainable Benefits Issues’.

Coronavirus Issues: These are ‘Challenges’ related to the ‘Aetiological Agent’ of the ‘Global Pandemic’.

1. ‘Nomenclatural Difficulty’: Difficulty with ‘Nomenclatural Exactitude’ tainted the ‘Agent’ and ‘Disease’ from the ‘Outset’! The ‘Agent’? The ‘Wuhan Virus’, ‘Wuhan Coronavirus’, ‘China Coronavirus’, ‘China Virus’, ‘Chinese Virus’ etc! The WHO initially, in January 2020, named the ‘Agent’: ‘2019-nCoV’!! Some indicate ‘nCoV-2019’!! The International Committee on Virus Taxonomy adopted ‘SARS-CoV-2’ suggesting the ‘Agent’ is related to the ‘SARS Coronavirus’ and to avoid, together with World Health Organization, World Organization for Animal Health and Food and Agriculture Organization etc, ‘Attention’ to a Place, People and Animal [2-4]!!! ‘Attention’ to previous ‘Outbreaks’: Crimean-Congo Haemorrhagic Fever, Ebola Virus Disease, Lassa Fever, Marburg Virus Disease, Middle-East Respiratory Syndrome, Monkeypox, Rift Valley Fever, Zika Virus Disease! Still another name: ‘Human Coronavirus 2019 (HCoV-19)’ [5] and yet others uphold ‘SARS-CoV-2’ as appropriate [6]!! The WHO recommended for the ‘Disease’: ‘Coronavirus Disease 2019 (COVID-19)’ but the ‘Novel Pandemic Literature’ is replete with a ‘Rainbow of Inconsistencies’: COVID-19, Covid-19, covid-19, Coronavirus (Covid-19), Corona Virus, ‘Kung-Flu’!!! With so much ‘Nomenclatural Difficulty’, the ‘Virus’ and the ‘Disease’ can only continue to enjoy an unfettered latitude as a ‘Pandemic’!!!! For the ‘Agent’ and ‘Disease’, there should be NO POLITICS in the ‘Global Nomenclature’ consistent with previous ‘Outbreak Agents’/ ‘Diseases’ to undergird a ‘Consistent Concerted Global Intervention’!!!

2. ‘Natural Biological Agent’ or ‘Man-Made Biological Agent’ or ‘Bioterrorism or Economic Terrorism Agent’. The ‘Pandemic Literature’ (Scientific, Biomedical, Social Media etc) is replete with suggestions of this being a ‘Natural Outbreak’ or ‘Man-Made Disaster’ by ‘A Group’ targeted against ‘Others’! This can only pose further ‘Challenges’ to ‘Weathering the Storm’!!

3. ‘Novel Virus’; No ‘Human Immunity’: Being a ‘Novel Coronavirus’, there is currently ‘NO HUMAN IMMUNITY’ and, therefore, the ‘PANDEMIC’ was a matter of time!

4. No known ‘Effective Vaccine’ and ‘Effective Treatment’: Again, being a ‘Novel Coronavirus Disease’, there is currently no known ‘Vaccine’ and ‘Effective Treatment’ for the ‘Agent’/ ‘Disease’!

5. Possible ‘Genetic/ Genomic Diversity’ complicates ‘Virulence’, ‘Infectivity’ and ‘Transmissibility’ making the ‘COVID-19 Pandemic’ more overwhelmingly ravaging and devastating [7]! Also, ‘Coronavirus Genomic Diversity’ is a ‘Cog in the Wheel’ for ‘Vaccine Production’ at the moment!! This will be addressed further under ‘Intervention Issues’

6. Possible ‘Viral Recombination Capacity’ confounds ‘Disease Specifics’: This is suggested to facilitate ‘Cross-species Transmission’ (From Bat to Man!) and together with ‘Genomic Diversity’, contribute to ‘Some Unusual-Confusing Manifestations’ of the ‘COVID-19’: Neurological and Gastrointestinal Symptoms [8-10]! Possible ‘Faeco-Oral Transmission’ is being explored as ‘Live Viruses’ and ‘Viral Particles’ have been recovered from ‘Stool Specimens’ [11,12]!!

7. Possible ‘Aerosolization’ confounds ‘Transmission Modalities’ by adding plausible ‘Airborne Transmission’ to the ‘Disease Spreading Equation’ with the ‘Controversial Role’ for ‘Face Masks Use’: ‘Surgical Masks’, ‘Respirators (N95, FFP3)’, ‘Medical Masks’, etc [11,13]!

8. Suggested possible ‘≥ 25% Pre-Symptomatic and Asymptomatic Transmission’: This makes ‘Containment’ and ‘Mitigation Measures’ quite ‘Challenging’ as ‘One may be in contact with an infected person without knowing it’ and this, indeed, is a ‘Difficult Hurdle to Surmount’ [14,15]!

9. Possible ‘Reinfection’: There are suggestions that there may be ‘Reinfection’ after ‘Recovery’! Could this be part of the ‘Genomic Diversity’/ ‘Recombinant Virus’ possibilities? Duration of ‘Infectivity’; Any role for ‘Convalescent Serum’?

10. ‘COVID-19 Mortality’: The low ‘1-2% Case-Fatality’ is a ‘Mixed Bag’! Most Cases survive but the ‘Survivors’ (Asymptomatic and Mild to Moderate Cases) form the ‘Potential Large Pool’ for ‘Increased Transmissibility’!!

11. ‘Susceptibility’: All ‘Age Groups’ are affected by the ‘SARS-CoV-2’ with higher mortality in the older groups but survival has been reported in a 103-year old and mortality in an infant raising ‘Ethical Issues’ in ‘Critical Care Prioritization’!

12. The ‘Scientific Mathematical Projection Models’ and ‘Disease Predictions’ suggest the ‘COVID-19 Pandemic’ to dispose a ‘Peak/ Apex’ of the ‘Epidemic Curve’ far ahead of the ‘Preparedness Capacity’ of virtually every Country worldwide accounting for the ‘Ravaging and Devastating Scourge’!

13. The ‘Screening/ Testing Capacities’ are overwhelmed by the ‘Exponential Rates’ of the Disease; The ‘Dynamically Ravaging Soaring and Devastating Pandemic’ outstrips the ‘Screening/ Testing Capacities’ with the result that the ‘COVID-19’ is well ahead of Nations!

14. The ‘Ravaging and Devastating Scourge’ outstrips the ‘Critical Care Capacities’: The ‘Exponential Transmission Rates’ and ‘Critically Severe Adult Respiratory Distress Syndrome’ overwhelm the ‘Critical Care Capacities’ of most Hospitals worldwide with the unacceptable ‘Gory Mortality Numbers/ Data’!

15. The distinction between ‘International Spread’ and ‘Community Spread’: The capacity of ‘SARS-CoV-2’ for remarkable ‘Pre-Symptomatic and Asymptomatic Transmission’ readily facilitates both ‘International Spread’ and ‘Community Spread’ making the ‘COVID-19 Pandemic’ a ‘Public Health Nightmare’!

16. ‘COVID-19’/ ‘Ascribed Mortality’: Mortality is reported and ascribed to ‘SARS-CoV-2’ in patients with ‘COVID-19’ but several such Reports do not critically Investigate the ‘Possible Confounding Contributors’ to incontrovertibly ascribe the ‘Mortality’ to the ‘SARS-CoV-2’-‘COVID-19’ Dyad!

17. ‘Epidemic Curve Peak and Epicentre’: The ‘COVID-19 Epicentre’ with the peculiarities of the ‘Novel Coronavirus’ is rapidly shifting from Country to Country and from Region to Region within the same Country adding to the ‘Increasing Challenges’ of addressing the ‘Pandemic’!

This ‘Communication’ addresses the ‘Coronavirus Issues’ in the overall ‘Challenges Conversation’ on ‘Weathering the Storm’ of the ‘COVID-19 Pandemic’. This first discourse is on the ‘COVID-19 Pandemic Programmatic Challenges’ as they relate to grappling with, and understanding, the ‘Coronavirus Complexities and Intricacies’ that occupy the ‘Arrowhead’ of the current enlarging ‘Storm’ and the ‘Capacity’ to ‘Weather’ through it! The ‘Other Challenges’ will, hopefully, be explored in ‘Other Communications’ and they include: ‘COVID-19 Intervention Issues’ and the ‘Sustainable Benefits Issues’!! The ‘Triad of Issues-Challenges’ MUST be addressed in ‘Weathering the Storm’!!!

1. Godlee F. COVID-19: Weathering the storm. BMJ 2020; 368:M1199 of 26th March 2020
2. Zhu N, Zhang D, Wang W et al. A novel coronavirus from patients with pneumonia in China, 2019. N Eng J Med DOI:10.1056/NEJMMoa2001017 of 24th January 2020
3. Gorbalenya AE, Baker SC, Bric RS et al. Severe ARS-related Coronavirus: the species and its viruses- a statement of the Coronavirus Study Group. BioRxxiv 2020 DOI:2020.02.07.937862 of 11th February 2020
4. WHO. Disease Outbreaks. of 12th February 2020
5. Jang S, Shi Z, Shu Y et al. A distinct name is needed for the new coronavirus. Lancet 2020; 395:949
6. Wu Y, Ho W, Huang Y et la. SARS-CoV-2 is an appropriate name for the new coronavirus. Lancet 2020; 395:949-950
7. Shen Z, Xiao Y, Kang L et al. Genomic diversity of SARS-CoV-2 in Coronavirus Disease 2019 patients. Clin Inf Dis. of 9th March 2020
8. Ji W, Wang W, Zhao X, Zai J, Li X. Cross-species transmission of the newly identified coronavirus 2019-nCoV. J Med Virol 2020; 92:433-440
9. Talan J. COVID-19: Neurologists in Italy to Colleagues in US: Look for Poorly-Defined Neurological Conditions in Patients with the Coronavirus. of 27th March 2020
10. Jin X, Lian J-S, Hu J-H et al. Epidemiological, Clinical and Virological Characteristics of 74 Cases of Coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. Gut Epub ahead of print doi:10.1136/gutjnl-2020-320926 of 17th March 2020
11. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), 16-24 February 2020
12. Hindson J. COVID-19: Faecal-Oral Transmission? Nat Rev Gastroenterol & Hepatol 2020.
13. Ather B, Edemekong PF. Airborne Precations. In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing 2020 Jan.
14. COVID-1: Lessons and Recommendations. of 12th March 2020
15. Tian L, Li X, Qi F, Tang Q-Y. Presymptomatic Transmission in the Evolution of the COVID-19 Pandemic.

Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria.
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria.
UNICEF-Trained BFHI Master Trainer,
ICDC-Trained in Code Implementation,
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria,
*No Competing Interests.

Competing interests: No competing interests

31 March 2020
Professor of Child Health and Neonatology, University of Benin and Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria. Also, UNICEF-Trained BFHI Master Trainer and ICDC-Trained in Code Implementaion. Also a Technical Expert/ Consultant on FMOH-UNICEF-NAFDAC Project on Code Implementation in Nigeria
Institute of Child Health, College of Medical Sciences, University of Benin, Benin City, Nigeria