Time has been carved into two epochs: before and after coronavirus. In our new reality, our loved ones choke to death in near total isolation. Outside of our hospitals, life has ground to a halt. We are trapped in our homes. We are losing our jobs. Businesses are going to the wall. The global economy is teetering on the edge of disaster. In Spain and Italy, intensive care units are collapsing under the number of dead and dying. Such is the scale of suffering, doctors are forced to choose between who should live and who should die with the military enlisted to handle the sheer volume of dead bodies. Soon, many more nations will have their own versions of these stories.
It took just twelve weeks for the virus to bring the world to a halt, to put our lives and our societies on lockdown. More than 40,000 people have already lost their lives. But this is only the grim first act of the coronavirus crisis. In the absence of a vaccine or any proven treatments, it’s likely that Covid-19 – the disease caused by the novel coronavirus – is here to stay for at least the next year. While the worst part of the outbreak is immediately ahead of us, it will be a long time before life returns to normal.
For the British government, this realisation came like a punch to the gut. From its bungled communications in early March, it seemed like officials were hoping that Covid-19 would be a short, sharp, shock – racing through the population until enough herd immunity was built up against the virus that its pace would be naturally halted. If any vestiges of this approach still remained, they were stamped out by March 16 when a report from Imperial College London set out the cost of inaction over coronavirus. Without a switch to much wider social distancing measures, the capacity of intensive care units would be exceeded eight-fold and 250,000 people would die – and that was in a best-case scenario.
The same day the Imperial report was published, the UK prime minister, Boris Johnson, advised everyone in the country to stay at home and avoid pubs, restaurants and theatres. A week later this became a total lockdown with police given the power to fine people who were outside for anything other than a small list of state-sanctioned activities: exercise, shopping for food, travelling for essential work or helping the vulnerable. Overnight, the social fabric in the UK had contracted immeasurably.
How long will it all last? These words – in their various forms – are thrown at politicians and civil servants at the government’s daily press briefings. The answers may inspire more or less confidence depending on to whom you listen. Johnson’s initial register was optimistic hubris, telling the public on March 19 that in twelve weeks we could “turn the tide” on coronavirus and eventually “send it packing” altogether. Ten days later, the deputy chief medical officer Jenny Harries struck a more sober tone, warning that social distancing measures might be in place for six months, and perhaps even longer.
Either of these scenarios – twelve weeks or six months – will likely only encompass the beginning of our fight against Covid-19. While there is a faint hope that transmission could fade away altogether during summer, it is more likely that the threat of this disease – its devastating impact on health and insidious undermining of our society – is here to stay until we have a vaccine. Things are unlikely to be normal again for a long, long time.
Covid-19 is a perfect storm of a disease. Infectious enough that it creeps from person to person until hospitals are overwhelmed, but slow enough that drastic lockdown measures, like those put in place by China, seem to have an effect on its spread. If it was any more infectious it would have swept through the world’s population before we had much of a chance to react. “This is just the awkward in-between,” says Julia Gog, a professor of mathematical biology at the University of Cambridge.
In 2018, Gog worked on a BBC documentary where she ran a simulation of a pandemic influenza outbreak taking hold in the UK. When she set the case fatality rate (CFR) – the proportion of people with confirmed infections who die of the disease – she opted for two per cent: about as bad as she could imagine making a TV show about. It is still too early for us to know the true CFR of Covid-19, but by some estimates it is already out-stripping this fictional figure. One study puts it at between 0.25 and 3.0 per cent. In Italy, it is currently above ten per cent, while in the UK the figure hovers at just above six per cent – although the true figures are likely to be much lower as we simply don’t know how many infections are currently going undetected.
“The death rate is horrible. It’s very clear it’s a function of age and a function of underlying conditions, but the death rate is just horrible,” says Gog. In Europe, around four per cent of all cases require intensive care treatment or respiratory support, while 30 per cent of cases require hospitalisation. It’s this sickening cocktail of disease severity and infectiousness that has overwhelmed intensive care units in Italy, where the death toll has passed 11,500.
But a sizeable chunk of people infected with Covid-19 experience only mild symptoms or none at all. An analysis of people repatriated from China at the end of January found that between 40 and 50 per cent of people returning to their home countries had undetected infections. Tests from the quarantined cruise ship Diamond Princess found that almost half of those who had the virus showed no symptoms at the time. This adds up to a large reservoir of healthy – or only mildly unwell – people going about their normal lives who may be unwittingly spreading the virus to more vulnerable people. By the time the first patients start turning up at hospitals with severe respiratory distress, it is already too late – the virus has spread further than we were able to trace and the goal had changed from containment to simply surviving the coming tidal surge.
And it’s a fight we’re going into blindfolded. Although the UK government has lagged behind others in terms of detecting Covid-19 – as of March 20, South Korea had performed 317,000 tests versus the UK’s 65,000 – testing only gives us a partial picture of the spread of the disease. While most countries are ramping up their testing capacity – the UK has set itself the goal of performing 25,000 Covid-19 tests every day – it is inevitable that the number of confirmed cases will rise. Increased testing will give us a glimpse at how widely the infection has spread while the true number of cases continues to elude us.
A more useful place to look is at the number of deaths. Since most people who end up dying from Covid-19 will report to hospital and test positive for the disease, we can be more confident that there aren’t vast numbers of deaths going unrecorded. In this way, deaths give us a more true picture of the outbreak.
But here we are hamstrung again. It takes roughly 18 daysfor someone to die from Covid-19, from the first onset of symptoms to their final breath. There is also a gap between a person first being exposed to the virus and them showing symptoms, the disease’s incubation period. For Covid-19 this may range from one to 14 days, with most estimates putting it at five days. By the time a person dies of Covid-19 it may have been more than three weeks since they were exposed to the disease.
Using deaths to measure our progress against Covid-19 is like peering into the past through a pinhole. In the UK, the number of new deaths from Covid-19 has generally been increasing from one day to the next. Every day brings with it a new record, but this is to be expected. The people who died today were likely to have been infected before the government even put in place its first social distancing recommendations. In Italy, where the whole country went into total lockdown on March 10, it is still not yet clear whether the number of daily deaths is in consistent decline.
“This is something I’m worried about,” says Gog. “I think people are going to expect [the lockdown] to reduce the number of deaths tomorrow and it won’t. It’ll keep climbing for a while and I think people are going to find that very tough to deal with.”
While the rest of us remain glued to rolling news coverage, the real fight will be taking place in NHS intensive care wards. There, at least, there is a glimmer of hope. According to the latest modelling from Imperial College London, it doesn’t look like intensive care unit capacity will be breached across the UK as a whole. “In this current strategy being adopted we think that in some areas of the country ICUs will get very close to capacity but it won’t be breached at a national level,” Neil Ferguson, an epidemiologist who is part of the team of scientists advising the government’s response, told the House of Commons Science and Technology Committee on March 25. “There will be some areas of the country that are extremely stressed but we are reasonably confident […] that at a national level we will be within capacity.”
According to Ferguson, intensive care units will hit their peak demand within the next two weeks. If the UK’s social distancing measures have been effective, we should see demand start to ease after this point as the number of new infections in the UK slows. On March 30, the UK’s chief scientific advisor Patrick Vallance hinted that he had seen evidence that the Covid-19’s reproduction number – a measure of how many new infections are sparked by each infected person – was already in decline. If that number gets below one, the amount of new cases will start to decline. This will be our first hint that the UK’s strategy is working. Then the real work to defeat Covid-19 can begin.
The world is now caught in a terrifying real-time experiment. In Japan, schools are set to open in April after a shutdown of more than a month. Although the country experienced one of the earliest significant outbreaks outside of China, its total number of cases has remained relatively low. In Hubei – once the epicentre of the global outbreak and a province with more than 3,100 Covid-19 deaths – the lockdown is slowly being lifted. At its peak, more than 56 million people in Wuhan and the surrounding areas lived under near-total lockdown with people confined to their homes and all travel suspended.
Neither of these countries has halted the spread of Covid-19. In Japan the number of new cases has been increasing and now stands at 1,866. At the peak of its outbreak in February China saw more than 5,000 new cases every day. As of March 30 it was still reporting more than 100 new cases daily – most of them apparently imported from abroad. But the risk is that when social distancing measures are peeled back, the number of infections will start to rise again: the so-called ‘second peak’ that governments are desperate to avoid.
A second outbreak can be even more devastating than the first. Although the Spanish Flu started in March 1918, it was the second wave in the summer and the third the following winter that accounted for the majority of its estimated death toll of 50 million. The problem for countries currently under lockdown is that it’s very hard to predict when a second peak will occur, how bad it will be, or if it will happen at all. In one Harvard study, epidemiologists modelling the shape of a future second outbreak found that any one-time social distancing efforts now would push the epidemic peak into the autumn, where intensive care units are potentially even more stretched than now.
Social distancing is a double-edged sword. While it achieves the vital task of slowing the spread of the disease and stopping it from reaching the most vulnerable in society, it also leaves the majority of a population with no chance of getting a disease and gaining potentially valuable immunity. In his House of Commons evidence session, Ferguson estimated that even after the peak of the disease has passed in London, the worst-hit area in the UK, only five to ten per cent of the population will have contracted the disease. As soon as social distancing measures are lifted, the virus might race through the rest of the population leaving intensive care units once again swamped.i
In the UK, the Imperial College report draws similar conclusions to the Harvard study. Its models suggest that even with a five-month period of social distancing, the UK will experience a second peak in mid-November. Both reports suggest that only intermittent and sustained social distancing will avoid a second peak, but the measures may have to be in place for well over a year for this to be successfully avoided. The Harvard study says the measures may be necessary until 2022, whereas the Imperial paper notes that any vaccine may be at least 18 months away and when it does come, we don’t know how effective it will be. Germany is reportedly planning to ease the transition from lockdown by issuing so-called “immunity certificates” that would allow people to leave lockdown early if they tested positive for antibodies to the virus. The UK has ordered 3.5 million of its own antibody tests, but it’s not yet clear how the government plans to use them.
“To totally eliminate the threat, I think a vaccine is probably what’s going to be needed. It’s just not feasible to think about herd immunity or achieving some level of infection in a population in a way that doesn’t collapse things,” says Natalie Dean, a biostatician at the University of Florida. There are currently 44 different vaccines being evaluated for use against Sars-CoV-2, the virus that causes Covid-19, with two of them at the clinical trial stage already.
But here the virus has delivered another stroke of bad luck. “If this had been a novel flu strain I think everyone was geared up to learn how to make a vaccine pretty quickly. This is going to be much harder,” says Gog. We don’t have a tried-and-tested coronavirus vaccine that we can tweak to defend us against this new coronavirus. Even for the most hopeful candidate vaccines – those that are in human trials already – it is likely to be at least twelve to eighteen months before they are declared safe to use, manufactured, shipped and ready.
What will happen in the meantime? Dean says that the suppression period is an opportunity to buy ourselves a little time and scale up testing and contact tracing systems that could help us keep a lid on outbreaks until a vaccine is ready. It is little surprise that countries that have had previous outbreaks of coronaviruses are among those who are managing to contain their outbreaks most successfully. South Korea, which was hit by an outbreak of Middle East Respiratory Syndrome (MERS) in 2015, has managed to flatten the curve of its own outbreak, going from a peak of more than 800 daily cases to its current rate of around 100 per day. Out of the country’s 9,786 confirmed cases just 162 people have died, a case fatality rate currently below that of the UK, Italy, France, Spain and China.
South Korea acted decisively in the early stages of its outbreak, testing widely and retracing the footsteps of anyone with a confirmed positive test. According to a report in the New York Times the country’s contact tracers were like detectives, poring over security camera footage, credit card records and GPS data to track down known contacts. Mild cases were diverted to specialist centres to keep hospitals clear for the most seriously ill patients and cut down possible transmission within hospitals. People ordered into self-quarantine were tracked by an app that alerted officials if they broke their isolation, with fines reaching as high as £2,000.
Widespread testing could be vital for stamping out the sparks of new outbreaks, Dean says.
“Information is very powerful. People respond to actionable information like a test […] that allows you to inform people who may have been exposed and then also to implement some sort of isolation so that person is no longer able to infect others.” According to the BBC, the NHS is considering asking people to use a contact tracing app that would warn people who have been in contact with someone who has tested positive for coronavirus.
But until a vaccine puts a definitive end to the outbreak, governments will have to stay open to the possibility of re-implementing lockdowns. “If things seem like they’re not working we’re going to have to be willing to clamp back down,” Dean says. Even with effective testing, isolation and contact tracing regimes, the situation can veer out of control devastatingly quickly. The next 18 months are likely to pass in a haze of transitory terror.
In October 2021, after we’ve all lined up patiently for our jabs and the threat of the virus has receded, we may finally start to count the damage the novel coronavirus has wrought on our lives. “We will be paying for this year for many decades to come in terms of the economic impact,” Ferguson told the select committee at his evidence session. The UK’s economic output is set to drop by 15 per cent in the second quarter of 2020 and unemployment may double. It is likely we’re now facing the deepest recession since the financial crisis.
But there are also the impacts that are harder to quantify: the parents who could never say goodbye to their dying children; the young people who worked for years towards exams they never got to take; the careers derailed and the mental health impact of clear spring days that were spent in fear and isolation. All of these tolls will leave their mark on an entire generation. And then, once our debts are counted and wounds are patched up, we must prepare ourselves for the next pandemic.
Matt Reynolds is WIRED’s science editor. He tweets from @mattsreynolds1
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