In the waters off Yokohama, Japan, a deadly virus infected one in five people tested aboard a cruise ship, where they had spent two weeks waiting for medical clearance to leave. In Hubei, the Chinese province at the epicentre of the COVID-19 outbreak, the virus has killed people at a rate seven times higher than elsewhere in China.
In much of the world, COVID-19 has spread relatively slowly. But the speed and severity of the outbreak in some areas has prompted specialists in China and Japan to raise new questions about the role authorities responding to the epidemic may have themselves played in facilitating its spread.
Among the most damning accusations came from Japan, where Kento Iwata, a specialist in infectious diseases at Kobe University, described a day he spent aboard the Diamond Princess cruise ship Tuesday. He found “completely inadequate” infection-control measures, including a failure to properly separate a green zone free of the virus from a red infectious zone. “It was completely chaotic,” he said, describing a medical officer without protective gear who said she had already been infected and appeared to have given up on further measures to shield herself.
“I was so scared,” Prof. Iwata said in a video posted to YouTube, recounting a question he posed to a quarantine official: “Do you want to infect everybody in the ship?
“Everywhere could have virus, and everybody was not careful about it,” he added.
Of the confirmed cases outside China, fully 61 per cent were aboard the Diamond Princess. Hundreds of passengers disembarked Wednesday. Some are being evacuated to their home countries, including Canada.
Further questions arose with the publication Tuesday of an extensive study by Chinese researchers, who examined 72,314 patient records to glean insights into the behaviour of the virus. They found that in Hubei, 2.9 per cent of people diagnosed with the virus have died, fully seven times the rate in other Chinese provinces.
The first cases were discovered in Wuhan, the capital of Hubei, but the virus has since spread to every province and region of the country.
The far higher mortality rate inside Hubei has prompted researchers and the sick alike to ask why.
In Hubei, “it’s pretty clear that a lot of infections have occurred within hospitals,” said Keiji Fukuda, who has held senior advisory positions at the World Health Organization and is now the director of the division of community medicine and public health practice at the University of Hong Kong. That includes at least 1,716 confirmed cases among health-care workers, according to the report by China’s Novel Coronavirus Pneumonia Emergency Response Epidemiology Team.
“Has adequate training been provided to health-care workers? Do they have the right equipment to carry it out? Did they have enough people? Or is it simply that conditions were overcrowded and so things just broke down?” Dr. Fukuda asked.
Numerous factors can influence the local death rate from an epidemic. Because Hubei was first affected, it would tend to see an early surge of deaths. It could be that the “Hubei health-care system is focusing more on the most severe cases,” said Marc Lipsitch, a professor of epidemiology at the Harvard T.H. Chan School of Public Health. But it’s also possible that the “Hubei health-care system is overwhelmed and can’t provide good care.”
The virus has been particularly deadly for the elderly, killing almost 15 per cent of those 80 and older. Only 1 per cent of confirmed patients in China are babies, children and teens, and the country has seen just one death in people under the age of 19. But the demographics of Hubei are almost identical to those elsewhere in China.
“Why would the case fatality be higher in one case than the other? The most likely explanation is difference in the quality of care,” said Arthur Reingold, a Berkeley School of Public Health scholar who specializes in prevention and control of infectious diseases.
Chinese medical authorities have dismissed another possibility: that the virus in Hubei has mutated to a more deadly form. “Could the virus strain, after it moved from Hubei to other places, have some changes in its nature? That makes no sense. The world is faced with the same virus strain or mutation,” said Zhao Yiming, director of the clinical epidemiology research centre at Peking University Third Hospital.
Authorities in Wuhan initially sought to keep the spread of a new virus quiet, and local doctors have said they did not use proper protective equipment at first. As the outbreak quickly worsened, hospitals grew crowded, with long lines of people waiting for care in confined spaces.
Chinese authorities have also placed people with mild to moderate symptoms in large communal quarantine facilities, raising fears that some people are contracting it while in a form of quarantine.
Meanwhile, state media have continued to report shortfalls this week in hospital supplies of masks and protective clothing.
Still, the spread at care facilities is not unique to China – or to the COVID-19 outbreak. “With Ebola, a lot of the transmission took place in hospitals,” Dr. Fukuda said. Even with plenty of theoretical knowledge, infection prevention is “really hard to do well,” he said.
Hospitals with the best success rates have redesigned their architecture, reconsidered the pathways patients move through and insisted on epidemic control training for all staff – everyone from doctors to cleaners. Even the protocols for managing the behaviour of the ill must be fine-tuned.
“One of the patients who spread a lot of infections related to MERS [Middle East respiratory syndrome] was quite active in the emergency-room area, going around to different places and so on,” Dr. Fukuda said.
“It would be nice to say it’s as simple as overcrowding,” he said. “But it’s probably not that simple.”
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