The bug is way ahead

Monday 18 May 2020

Quarantine is the secret to success

Quarantine is the secret to success


I received a message today from a good friend in Scandinavia. He has spent the last four weeks recovering from Covid-19. His message was very simple:

“I hope you are well and please stay away from Covid-19 – it is a tough one!”

The poor guy, who is normally extraordinarily fit, has been put through his paces with the virus. He is now through and out the other side but, by all accounts, it was a close one.

When good friends are affected, and even more so family, it brings home the importance of social distancing and the need for this thing called “quarantine”. The media these days is filled with talk about quarantine for new arrivals from overseas and how this may lead to the death of the travel industry. The word on the street is that by the end of this month, anyone arriving in the UK from any country, apart from the Republic of Ireland, will have to self-isolate in a private residence for 14 days.

The UK airlines have declared this would kill their industry, which seems a fair prediction. After the airlines were included, it was stated that port arrivals would need to do the same. Then France was exempted, but now it is included. I then learned that lorry drivers will be exempt. Additions and subtractions come and go daily and no one has yet said how this system might be policed. I pray that a bigwig somewhere will soon make a final decision and the country can start making plans. Meanwhile overseas family holidays must come into question, as even if you reach wherever you are going, there is no guarantee you will get back.

Quarantine fetaures in the Old Testament

Quarantine fetaures in the Old Testament

Quarantine, which has been suggested, has been around for a very long time and even appears in the Old Testament. In Leviticus, when the Bible is considering leprosy, the following description features:

“…the priest shall isolate the affected person for seven days. On the seventh day the priest shall examine him, and if the affection has remained unchanged in colour and the disease has not spread on the skin, the priest shall isolate him for another seven days.”

Even in the Bible, it was realised that man’s worst enemy was man.

The word “quarantine” derives from the Venetian quarantena, which means 40 days. It stems from the 14thcentury, the plague era, when incoming ships to Venice were initially detained by the port authorities for a month in a lagoon. The 40-day period was an advance on the so-called trentino (30 days) that had initially been used in 1347, in the Republic of Ragusa, Dalmatia. This has since become Dubrovnik, Croatia. In 1423, the first known maritime quarantine station was created on the island of Santa Maria di Nazareth in the Venetian lagoon. It was called Lazaretto, perhaps because of its association with the St Lazarus Hospital for Lepers in Jerusalem. The Lazaretto was a squalid place to be.

Lazaretto Vecchio, off Venice, designed as a quarantine location (Alinari Archives/CORBIS/Getty images)

Lazaretto Vecchio, off Venice, designed as a quarantine location (Alinari Archives/CORBIS/Getty images)

Why 40 days was chosen is difficult to say, but it was the period that Jesus spent in the Judean desert, east of Jerusalem, to be alone with God. In addition, Lent is 40 days long, not including Sundays. Moses spent 40 days on Mount Sinai and there were 40 days between Jesus’ resurrection and ascension, so in a deeply religious era, 40 days seems a natural choice. The Prophet Muhammad was also 40 years old when he first received the revelation from the archangel Gabriel. This period may also relate to the fact that, according to current estimates, the bubonic plague had a 37-day period from infection to death, so a 40-day quarantine covered this perfectly.

There have been plenty of occasions when quarantine has been effectively used. There was Eyam in 1665 (bubonic plague), East Samoa in 1918 (influenza), Yugoslavia in 1972 (smallpox) and many others. Even space crew are quarantined when they have returned to earth to prevent possible interplanetary contamination. Lunar samples are also held in biosecure laboratories, just in case.

As the current pandemic progresses, I have seen plenty of fellow Brits who believe they are the exception, and if they individually break the rules of lockdown there will be no problem. It is this same mentality that will lead to a 14-day quarantine being disregarded, if and when it is introduced. There are always those who believe they think better than the bug.

To understand the risks that someone ignoring quarantine, or for that matter breaking lockdown, can create, look no further than the SARS outbreak of 2002-2004. This, too, began in China, albeit in Foshan, Guangdong. I have no idea why China seems so often to be the start of these horrors. That will be for others to discover. But for this first SARS epidemic, which lasted approximately eight months, 8000 people were infected in 29 countries and at least 774 died.

The disease began on 16 November 2002 in a Foshan farmer, but it was not until 10 February 2003, nearly three months later, that China notified the WHO. For a while, information was not even allowed out of Guangdong province. Early in the epidemic the Chinese government discouraged the press from reporting on SARS and the visit by a WHO team to Guangdong province was delayed for several weeks. Somehow, I do not find this surprising in that part of the world. Covid-19 seems to be a replay.

On 31 January 2003, the first super-spreader, Zhou Zuofen, a fishmonger, was admitted to a Guangzhou hospital, the Sun Yat-sen Memorial Hospital, and managed to infect 30 nurses and doctors. The virus then soon spread to nearby hospitals. One member of staff at the Sun Yat-sen Memorial Hospital was Liu Jianlun. He was a professor of respiratory medicine.

Layout of ninth floor of Hotel Metropole in Hong King

Layout of ninth floor of Hotel Metropole in Hong King

On 21 February 2003, Liu travelled with his wife to Hong Kong, to attend a family wedding. There, they checked into room 911 on the 9th floor of the Metropole Hotel. The next morning, 22 February 2003, he fell sick and was admitted to a nearby hospital. He died on 4 March 2003. It is thought that Liu was a superspreader as 23 other guests at the Metropole Hotel subsequently developed SARS, including seven from the ninth floor. The virus was found in the corridor outside Liu’s room and by the lift. Liu’s brother-in-law fell sick on 1 March 2003 and died by 19 March 2003.

Across the corridor from Liu, on the ninth floor of the Metropole Hotel, was a Chinese-American. This was Johnny Chen from Hanoi, Vietnam. He must have come across Liu in Hong Kong before returning to Vietnam, as by 26 February 2003 he had been admitted to the French Hospital of Hanoi, where he infected at least 38 members of staff. He was evacuated back to Hong Kong but died on 13 March 2003.

Among the staff who examined Johnny Chen was a Carlo Urbani, a specialist in infectious diseases, who worked with the WHO. He saw that other hospital staff were falling ill, realised there was a new and dangerous disease at play, and told the world. Carlo Urbani himself became infected and died on 29 March 2003.

The tragedies continued. Another guest at the Metropole Hotel, Kwan Sui-Chu, returned to Canada with the disease, died within ten days of arrival, but by then had infected her son, Tse Chi Kwai. He was admitted to Toronto’s Scarborough Grace Hospital, now renamed Birchmount Hospital, where he lay in casualty for 12 hours. During this period up to 200 patients passed through the unit. Beside him on a trolley was 76-year-old Joe Pollack, who required treatment for an irregular heartbeat. Ten days later, Joe Pollack and his wife were dead. Tse Chi Kwai died on 13 March 2003, eight days after his mother.

A further guest at the Metropole returned to Singapore and spread the disease there while another guest ended up in a Hong Kong hospital. In Hong Kong, he infected at least 99 hospital workers, including 17 medical students.

This particular SARS outbreak also revealed something unexpected about disease transmission and air travel. On 15 March 2003, Air China Flight 112 took off from Hong Kong and headed to Beijing. On board was a 72-year-old man infected with SARS. He would later become the index passenger for the infection of another 20 passengers and two crew. This led to the dissemination of the disease to inner Mongolia and south to Thailand. This was an unusual incident as the infected passengers were sitting some distance from the index passenger and the flight was only three hours in length. Until that time, it was thought that flights would need to be for at least eight hours and a passenger would have to sit within two rows of an index passenger to become infected.

The situation this morning - 18 May 2020 (courtesy Center for Systems Science and Engineering at Johns Hopkins University)

The situation this morning – 18 May 2020 (courtesy Center for Systems Science and Engineering at Johns Hopkins University)

By 30 March 2003, the Hong Kong authorities had quarantined a housing estate in Amoy Gardens because of a massive outbreak of SARS in the building, affecting more than 200 residents. Most of the cases were found in north-westerly apartments of the block. It was likely the disease was brought there by an infected patient who had been discharged from the Prince of Wales Hospital and had visited his older brother who lived on the seventh floor of the estate. The virus was thought to have been transmitted through excretion and via the drainage system. Dried-up P-traps in the system harboured the virus, which a maritime breeze blew into the estate’s balconies and stairwell ventilation.

To me, these stories read as horror and show why governments take pandemics seriously. It is why nations have lockdown and why quarantine was developed. Disease can lurk around any corner and come at you from the most unlikely source. Other people can be well dressed, well-spoken and wealthy, but they can still carry disease, even without realising it.

Never believe you can out-think a bug and certainly not Covid-19. It is way ahead of you.