Without improving protection uncontrollable epidemic wave could sweep across Hungary

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Coronavirus spreads fundamentally predictably. If we have sound data, epidemiological processes can be projected with high accuracy, epidemiologist Beatrix Oroszi told Portfoio in an interview. The head of the Methodological Developments in the Health System project at the National Public Health Centre (NNK) also addressed the quality COVID-19 data Hungary currently has and publishes. Oroszi, a scientist at Semmelweis Univesity and member of the Epidemiological Modelling and Epidemiological Workgroup at the Ministry of Innovation and Technology, underlined that Hungary has reached its testing capacity that maxed out at around 70,000 tests a week. She stressed that this is the very reason why we should not be relaxed about the reproductive rate (R0) being stuck at around 1 because it is not. That is why they have stopped releasing this indicator for it would not reflect the actual epidemiological situation. In the interview, we have also talked about the (successful) management of the coronavirus pandemic by Germany, South Korea, Austria and Sweden, and also touched upon the subject of the most vulnerable groups. She highlighted that elderly people with underlying chronic diseases, as well as overweight/obese men should be the most concerned about contracting the novel coronavirus.
Oroszi Beatrix epidemiológus járvány koronavírus

Intervention to be kept to a minimum

Oroszi said epidemiological authorities work well if they can manage and keep under control infections, epidemics and pandemics with the least intrusion in people’s everyday lives and the functioning of the economy. The novel coronavirus brought about changes in this respect, she said, reminding that more than 50 million people were quarantined in China in January, something no one in the currently living generations had ever witnessed. Oroszi stressed that at time it was the right move and a necessary one to buy time to work out effective protective measures and to learn more about the virus.

COVID-19 not the deadliest disease but...

COVID-19 is by far not among the deadliest diseases, it’s an “enemy we should be able to beat”, said Oroszi.

The real problem is that it spreads easily and rapidly therefore it can make a lot of people sick within a very short period, as nearly everyone is susceptible to it.

Compared to other viruses in recent history (SARS in 2002 or MERS in 2012), the mortality rate of COVID-19 is much lower at around 0.6% and 1.5% among those with symptoms. (Approximately 35% of patients with Middle East respiratory syndrome coronavirus (MERS‐CoV) have died.)

If 3 million people are infected within a few months, even a 0.6% mortality rate corresponds to 18,000 deaths, and there are the cases where the recovered patients are left with long-term effects (the virus can damage the lungs, heart and brain, which increases the risk of long-term health problems). And even if you survive without lasting effects but need hospitalisation, the health care system will have to cope with the increased number of patients and it could cause problems if there’s a flood of patients within a short period, warned Oroszi.

Key risks

The degree of vulnerability grows with age

, stressed Oroszi, adding that age is only one factor and it does not mean that every elderly person will have severe symptoms or that no young person will fall seriously ill.

A 75-year-old grandparent runs a 220 times greater risk of severe COVID-19 symptoms than his/her 27-year-old grandchild.

Another risk factor regardless of age is chronic diseases

, e.g. cardiovascular diseases, poorly managed diabetes, high blood pressure (hypertension).

And the third key risk factor is being overweight/obese.

Oroszi stressed that Hungarians who are in these high-risk groups do not take sufficient care of themselves, they are not more disciplined when it comes to wearing a face mask or to reducing social contacts.

Long-lasting effects

Oroszi cited experience shared by health authorities in Lombardia, Italy. They found that 50% of recovered COVID-19 patients returning to check-ups continue to show symptoms even months after they had been discharged from the hospital. They complain of breathing difficulties, cardiovascular issues, predisposition to thrombosis, neurological disorders. Chronic fatigue syndrome (CFS) is relatively frequently developed by recovered COVID-19 patients. These all have a negative effect on the quality of life, and a lot of those affected were/are unable to return to their jobs. Lasting effects can appear also if the patients showed only mild symptoms, although less frequently.

The simultaneous presence of risk factors (e.g. an elderly person with underlying chronic disease who is also overweight) increase the risk of severe COVID-19 symptoms, said Oroszi. She noted that according to their experience, men usually fall more seriously ill to coronavirus than women, simply because more of them smoke and drink than women and they also tend to be worse off in the area of chronic diseases relative to women of similar age.

Lessons learned from 1st wave

When asked about the lessons learned from the first wave of the coronavirus pandemic, Oroszi said it was important to gauge the success on an overall social level rather than using a single metric, such as the number of infections or by the operability of the economy.

We are successful at managing an epidemic if we can keep it under control while both the society and the economy remain functional and are harmed as little as possible.

From this point of view the first lesson is that a high epidemiological preparedness helps a lot. Asian countries including China, South Korea and Taiwan had previous experiences with SARS in 2003 and learned their lesson. They had reinforced their epidemiological systems, trained experts and upgraded laboratories. It is a lot easier in some Asian countries to make people understand why wearing a mask is crucial, as they have been used to it for a decade. In Hungary and elsewhere in Europe a lot of people still feel wearing a mask is a problem.

I need to highlight Germany as a country with a well-developed and detailed pandemic plan which is vital in this battle because it is this preparedness that facilitates a fast response.

She also reminded that Germany has an extremely robust and prestigious pandemic system in place, led by the Robert Koch Institute. It is not an authority but a professional hub in charge of pandemic planning, operational management and co-ordination in case of a pandemic, prevention and scientific tasks. It is held in high professional regard and politicians listen when the institute has something to say.

Oroszi stressed the importance of early testing, citing South Korea and Germany as examples, as these countries also used the “calm” summer months to expand their testing capacities. She noted that they switched their testing capacities to turbo mode in the very stage of the pandemic, and from there onward testing and contact tracing told them where the pandemic was spreading and where it was receding. They knew where they had to intervene. Oroszi acknowledged that these countries also had to step up their testing capacities, adding that Germany has even set up contact tracing teams.

South Korea is another excellent example when it comes to combating coronavirus. The country is at a high level of technological development, and they immediately set up contactless sample collection facilities, including a drive-through points. By the end of March, South Korea performed 40 times as many tests as the USA and a smartphone app used for contact tracing is used widely by the population.

South Korea did not need a lockdown and its coronavirus-related mortality is among the lowest in the world.

Failed containment strategies

Asked about failed strategies to tame the spread of coronavirus Oroszi mentioned the United States and the United Kingdom. While experts thought they were the best prepared to fight the pandemic, it quickly turned out they could not have been more wrong.

“None of them were able to build appropriate testing capacities in the early stage and their epidemiological systems were unable to cope with a situation in which there was no vaccine, nor anti-viral medication and results were entirely conditional to traditional epidemiological measures.”

That was why coronavirus was able to spread almost uncontrollably which resulted in one of the highest mortality rates in the world in the first wave.

High predictability

Asked about the resurgence in the epidemic and whether this had been foreseeable, Oroszi replied that

The virus spreads basically predictably.

If we have sound data epidemiological processes can be projected with high accuracy, as the spread of the epidemic has biological and mathematical laws. The experience is that once lockdown measures are lifted people return to their regular, normal way of life. They’ll have more direct contacts while they ease their individual precautionary measures which, sooner or later, leads to a resurgence in the spread of the virus.

Oroszi stressed that if social distancing goes down the drain and people ignore protective measures (keeping distance, wearing a mask) while the number of contacts rises, it is only a matter of time before the virus comes back with a vengeance.

The rise in the number of cases may be slow at first, but once it picks up, the whole process will gather momentum quickly

, she warned.

At this virus we know that before an explosion in the number of cases latent transmission chains will dominate. The virus flares up here and there, letting us know that it’s still lurking here. If these hotspots (the one Hungary had in Pápa in early August) are not eradicated, the next stage is a boom in community spread all over the country, as it happened in the last weeks of August. People, particularly young ones, had more and more contacts at the end of the summer (freshman camps, weddings, other events).

Oroszi and Gergely Röst, research fellow in mathematics at the University of Szeged, warned already at the end of August that the basic reproduction number (R0) of the novel coronavirus was between 2.0 and 2.5, a value that is considered extremely dangerous. At that time, there were 50-100 new confirmed cases a day, versus more than 1,000 currently, yet experts warned about the risk of a boom in the number of cases.

They also warned that if the spread of coronavirus among young people cannot be contained then the elderly population will get the infection too. They were correct once again. Once senior citizens are infected, the number of patients requiring hospital care starts to rise and so does the number of coronavirus-related deaths.

The spread of epidemics can be projected scientifically but only if we work on the basis of data, facts and calculations.

Hungary's testing capacity reaches upper limit

When asked about Hungary being at the upper limit of its testing capacity, Oroszi said that

Indeed the maximum capacity of 70,000 tests a day has been reached and they were unable to raise it further over the last few weeks.

Some may argue that the spread of the epidemic has slowed down and we reached a plateau, but I don’t think so. If this halt came to pass because of a consolidation in the epidemiological situation, the share of positive tests should be constant or dropping. What we have seen over the past few weeks is that the share of positive tests has been rising and is currently over 10%. The World Health Organisation (WHO) recommended in May that a positive rate of less than 5% was to be maintained and a higher figure suggest a deficiency of testing capacities.

Hungary’s surveillance system has reached its upper limit, it can detect 800 to 1,200 cases per day. We cannot know if with an unlimited testing capacity we’d have 1,500 new confirmed cases per day or much more. But it is not true that we are not aware of the current epidemiological situation. Although the number of daily confirmed COVID-19 cases need to be taken with a pinch of salt, we have a lot more indicators by which we can assess the situation correctly.

Based on these we do not think the spread of coronavirus has decelerated markedly or that it reached a plateau. Instead it continues to show an ascending trend.

Alternative indicators

When asked about the alternative indicators, Oroszi stressed the importance of the positivity rate, adding that the number of new daily confirmed cases will be usable again once this rate is pushed below 5.0% again. Austria kept expanding its testing capacities and kept the percent positive rate under 5.0%, so it’s not an impossible mission.

Other key indicators are the rise in the frequency of serious cases requiring hospitalisation and changes in mortality.

The fastest and best information about the beginning of the process and the spread of the epidemic would be the number of daily confirmed cases, if that information were based on reliable data.

COVID-19 trends in Hungary are becoming increasingly unfavourable. We must not draw the wrong conclusion that we can relax about the consistent number of new daily cases as they imply the epidemic has plateaued and R0 is around 1, because it’s not true. Community spreading remains rapid therefore it needs to be tackled. Most health care workers contract the virus not in hospitals but in other communities, but it is possible that they will be the ones who will transmit the virus in the hospital while carrying it asymptomatically. We must not relax protective measures!

Responsibility of the individual

Oroszi once again stressed the responsibility of individuals, highlighting the importance of mask-wearing, social distancing and personal hygiene.

"[…] we should also not give up contact tracing and testing because other than these there is no good evidence-based method available right now."

If we do these two things right, contact tracing and individual protection, the trend can be reversed. If we don’t, I’m afraid that sooner or later there will be no choice but restrictive measures and locking the country down.

It is time to protect the elderly and chronic patients with increased vigilance. Those with underlying chronic diseases do not care enough, they often neglect safety measures such as mask-wearing and social distancing. Every single measure right now should be about not lowering the epidemiological protection level.

If safety measures are shrugged off and the speed at which coronavirus is spreading is not reduced, we’ll possibly face a surge in the autumn/winter that will be difficult to control.

The question is not when the epidemic curve will peak rather whether we can flatten the curve or not.

When asked about the current estimate on the reproduction number, Oroszi replied that they have decided against publishing this value for now. The reason is that the number of tests performed per week does not grow further, while the laboratory test percent positive goes up which suggests capacity shortage.

The R value calculated from surveillance data would not reflect the actual epidemiological situation therefore its publication would be misleading.

The key to successful strategies

When asked about the epidemiological strategies of other countries, such as Austria or Sweden, and whether these can be regarded as successful or not, Oroszi noted that Austria, for instance, has a similar number of new daily confirmed cases than in Hungary, but there’s a key difference.

She highlighted that Austria performs more than twice as many COVID-19 tests per 1,000 people a day than Hungary, and it has been constantly increasing its testing capacities since the outbreak in the spring.

Oroszi noted that while the positivity rate reached 5% in Austria in mid-September, testing capacities were expanded again to make sure it goes back to under 5% and it did. That is why Austria’s surveillance is more reliable than ours. We perform a lot fewer tests and Hungary’s positivity rate is more than double of Austria’s.

The apparent similarity between the two epidemic curves stems from the fact that Hungary is able to detect a lot fewer cases.

Oroszi once again highlighted the vital importance of contact tracing and the need to get the message through to people: you can transmit the infection even if you are asymptomatic or presymptomatic. That is why the close contacts of COVID-19 patients should be detected and quarantined as soon as possible, before they transmit the infection to others.

Setting a goal of lowering the positivity rate to 5% from north of 10% currently would be necessary 

but the spread [of coronavirus] can no longer be contained by boosting testing capacities, stepping up contact tracing and putting people in quarantine

, warned Oroszi.

It’s not up to testing whether you infect someone or not. There are three cardinal rules individuals should follow: wear a mask, keep a safety distance of at least 1.5 metres and cut your physical contacts.

When asked about the Swedish model, Oroszi noted that strict lockdown measures were avoided not only in Sweden, but also in Germany, Japan and South Korea and yet they have achieved good results at containing the spread of coronavirus.

Is there a Swedish model?

The Swedish model, Oroszi explained, is about how you can effectively contain the spread of the virus without implementing strict lockdown measures. But Sweden did close schools for those over 16 years of age and limited gatherings at 50 people and restricted travel. However, the main thought was that people will realise the importance of safety measures and will adhere to them without the state forcing them to do so. In the second wave, Sweden has embarked on a new testing strategy, stepping it up along with contact tracing. Oroszi also reminded that Sweden’s health care system is one of the best in Europe. They were wrong, however, at thinking that this strategy would not lead to a high mortality and that by the end of the first wave the immunity of the population to coronavirus will be greater.

The lesson we could learn from the Swedish model is that although the restrictive, safety measures were less stringent they kept them in place persistently even when the spread of the virus slowed down and fewer daily confirmed cases were reported. So far this approach appears to be successful in the second wave, added Oroszi.

Coronavirus deniers should keep it zipped

The epidemiologist said coronavirus deniers are a danger to all of us,

it lowers the efficiency of epidemiological protection measures and helps the spread of the virus.

If people do not understand what is happening around them and what role they play in protection they become more susceptible to all kinds of conspiracy theories. And this is where we cannot put all the blame on them, because it is our fault too.

Correct, honest and transparent communication and building trust is our job, in order to make them see the adopted measures serve their interest.

Cover photo by Zsófia Pályi

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