This article was originally written for a scientific journal, due to repeated rejections it finds its place here.

Abstract:

COVID-19 has rampaged through the world distrusting lives and livelihoods. Despite the fact that we have numerous warnings of such an event happening from previous disease outbreaks such as influenza pandemic of 2009. Scientists have warned of such likely events in their publications and have warned the governments, even the WHO listed “Disease X” as a possible contagion of unknown origin that may be a threat to the world. However, governments have failed to address the seriousness of these possibilities that has now caused the world to suffer a terrible impact of the COVID-19 outbreak.

Keywords: COVID-19, SARS CoV-2, SARS, pandemic, disease-x

In the year of 2007, the scientific journal “Clinical Microbiology Reviews” published a review article titled, “Severe Acute Respiratory Syndrome Coronavirus as an Agent of Emerging and Re-emerging Infection” following the SARS outbreak of 2003¹. The authors, who were scientists from the University of Hong Kong claimed that there were many more viruses like SARS present in the environment and a simple untoward mutation or an event of transmission would be sufficient for another SARS like epidemic. The report went on to warn the world, especially the scientific community quote, “The presence of a large reservoir of SARS-CoV-like viruses in horseshoe bats, together with the culture of eating exotic mammals in southern China, is a time bomb. The possibility of the re-emergence of SARS and other novel viruses from animals or laboratories and therefore the need for preparedness should not be ignored.”

The database of scientific articles, Pubmed, is filled with similar articles of infectious diseases caused by nearly every communicable virus known to man, from the west Nile Virus to Ebola which warns of potential events of a pandemic scale. Unfortunately, they all fell on deaf ears only to be brough to light, temporarily, after an event occurs as in the case of the influenza pandemic of 2009 and the SARS CoV-2 pandemic of 2019.

In 2018, following numerous epidemics and one pandemic, the WHO recognised the threat that known, and unknown viruses could have on humanity. They thus asked the world to brace for it and introduced a list of priority diseases that posed the greatest threat in terms of pandemics and epidemics². This included one “Disease X”.

Disease X is a term that was and is meant to be given for any disease that may be the cause of the next massive pandemic. It can be caused by any organism known or unknown to man, mostly likely a virus, due to their ability to rapidly mutate and the zoonotic potential that they harness, that is, the ability to jump across species, such as from wild animals to humans.  It is also commonly referred to as a “spill over event” in scientific terms. Disease X is best described in the words of then US Secretary of State Donald Rumsfeld, as the “knowable unknown”. The scientific community recommended that the best way to prevent an outbreak of disease X is the mass surveillance of every pathogen present and identification of every virus and its possible mutants as well as identification of mutation events. This is an almost impossible and mammoth task that is handled by researchers and NGOs such as Coalition for Epidemic Preparedness Innovations or CEPI.

This approach, however, has its limitations due to which the best alternative approach would be to prepare for the inevitable. Massive yearly vaccination drives against known possible disease X candidates such as the flu hoped to achieve that goal aside from stocking of necessary medical equipment. However, the inefficiency of the latter was exposed during the pandemic of 2019 which is ongoing.

 In late 2019, a virus was identified to be going around in the Wuhan district of China. This virus was eventually named SARS CoV-2 and identified as the cause of COVID-19³. Despite measures and warnings by WHO, a lack of speedy measures and underestimation of the infectivity of the virus by governments all over the world lead all nations to be affected by the virus causing an overwhelming number of fatalities. Thus, causing a speedy transition from a China based epidemic to a pandemic. All this caused by a virus that appears to be mysteriously driven by Darwin’s theory of “survival of the fittest”, causing majorly the old and those with comorbidities of diabetes, hypertension, and heart diseases to have a much serious manifestation of the disease or complications like pneumonia once the immune system is stressed, and ultimately die (with a few outliers).

COVID-19 currently does not have any clinically proven, peer reviewed and published data to suggest a concrete treatment regimen. All data available is only in-vitro, with more studies being published rapidly. This includes the data on the antimalarial drug chloroquine, hydroxychloroquine, and antiviral drugs such as lopinavir, ritonavir, favipiravir, ribavirin, remdesivir, and galidesivir⁴. Often, agents which display activity in-vitro and in animal studies fail to display any beneficial effects in clinical trials. It was unfortunate that many nations including the US chose to jump the gun instead of waiting for the results of ongoing clinical trials to provide us with the necessary evidence of benefit. Such a move at a time like this where the public is confused and irrational, proved to be dangerous as many hoarded and unnecessarily consumed these drugs only to harm themselves. This was an especially sensitive issue as quinine-based drugs are known to have adverse effects on the heart, inner ear, and kidneys. Currently, there are more than 280 registered interventional clinical trials globally, either in progress or about to be initiated for various forms of treatment against COVID-19. Many of these are focused on these agents that have shown to be effective in-vitro in the lab.

One solution that is likely held promise was the use of plasma transfusion. This was a method that was tried in Taiwan during the SARS outbreak. The science behind this treatment process is that when a patient recovers from a disease their blood contains the antibodies against the pathogen. These antibodies are the tool by which the immune system quadrans off a pathogen and eliminates it. These antibodies remain in the blood for some time after the infection is eliminated and can be collected and transfused into another person who has still not recovered from the disease. The major disadvantage is that it cannot be done on a large scale since every person can only donate a limited amount of plasma at a time aside from some ethical issues.

Another great measure is the development of a vaccine. An effective vaccine would allow us to prevent further spread of the virus among the population and end the pandemic. Around the world numerous companies and institutes are currently working on a vaccine. This is not an easy task, as it involves many technical difficulties since the causative pathogen at hand is a virus and not bacteria. Viruses have their own set of difficulties since they cannot grow independently unlike bacteria. Viruses need a host to grow and multiply. Their ability to selectively infect (in most cases) only one type of host makes it difficult to grow them in a lab. Thus, the process of cultivating a virus in a lab then finding the appropriate method to render it harmless and induce an appropriate response from the human immune system is not only a daunting task, but also extremely time consuming. It would be nothing more than wishful thinking to expect a vaccine to be ready in less than a year as some may incorrectly imply.

It is fortunate that the virus exhibits a mortality rate as of now of 2-3% despite its highly infectious nature, with Italy having a fatality rate of around 7% a country where over 25% of the population was over the age of 65. Even for developed nations such as UK, USA and Israel the high infection rate has proven to be too much to handle. This is because despite having a robust infrastructure the sheer high volume of patients, the low manpower and low number of equipment have proven to be an Achille’s heel for them. US president Donald Trump was forced to use the defence production act, that allowed him pressurize industries to produce medical equipment for the nation.  Furthermore, unlike India, these nations failed to foresee the impact the virus would have on their healthcare infrastructure and did not implement a full-scale lockdown in time due to fear of the impact it would have on the economy. Some would argue such an impact is likely to be seen on the economy regardless of a lockdown.

We must consider ourselves lucky, in an alternative scenario where the virus would have been just as infective but had it had a higher fatality rate like that of that Ebola Virus, between 25%  to 90% the result would have been a global massacre. A situation worse than that of the black death would have arisen which killed almost a third of the population of Europe. This comparison helps us to gauge the importance preparedness. It brings to light the necessity for nations to focus more on medical research and development, improvement of manpower, equipment, and infrastructure in the healthcare sector. Especially, in nations such as India and China where the population resides in extremely close quarters, something that is worrisome when it comes to contagious diseases. Dense cities like Mumbai are a ticking time bomb, and the government needs to have a plan of action to manage the next possible outbreak in these locations more than others. Ideas like the conversion of the railway system into mobile healthcare unit is an innovative move in such a situation and more such ideas need to be developed and a protocol put into place. It is of great importance that the lesson learnt from this outbreak be incorporated into a new legislation perhaps into the existing disaster response system itself. Creating a national stockpile of personal protective equipment, respirators, oxygen supply, cleaning solutions, etc is something that can be worked upon in a manner similar to how a national arms stockpile is made, both being essential for our national security. Ideas and methods used during this response must be preserved and improved upon for rapid deployment and streamlined. One aspect of importance is the continuity of essential goods and services. Basic needs of the people must be addressed to ensure there is no panic and protest, which can hamper the measures to dampen the effects of a pandemic. Something that even countries like USA failed to achieve but India has largely managed to maintain ins most parts despite early hiccups and communication gaps.

The world has had increasingly worse epidemics and pandemics in the 21^st century. Despite this the global response to this in terms of preparedness for the management/containment of the next disease X has been very unsatisfactory. While nations boast to be superpowers by harnessing the strength of the atom as a deterrent against a nuclear war, nature under their very noses harnessed its own strength from the simple and oldest known weapon, the virus, the ultimate pathogen X. It has done so across centuries and will do so many more times in the future. An organism that is so tiny and not even classified in the realm of living things that brings about such panic and chaos, will it make us humans any wiser? Will SARS CoV-2 be the virus that finally opens our eyes? Or will it too be just another note of a scientist in the conclusion section of yet another article in a scientific journal just like the last pandemic? Isn’t it about time we realize that a piece of RNA, some proteins and glycoproteins can pretty much bring an entire civilization to its knees? Which virus will bring about the next Disease X? This is something we may all soon find out.

References:

1.        Cheng VCC, Lau SKP, Woo PCY, Kwok YY. Severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection [Internet]. Vol. 20, Clinical Microbiology Reviews. American Society for Microbiology Journals; 2007 [cited 2020 Nov 9]. p. 660–94. Available from: http://cmr.asm.org/

2.        Prioritizing diseases for research and development in emergency contexts [Internet]. [cited 2020 Nov 9]. Available from: https://www.who.int/activities/prioritizing-diseases-for-research-and-development-in-emergency-contexts

3.        Keni R, Alexander A, Nayak PG, Mudgal J, Nandakumar K. COVID-19: Emergence, Spread, Possible Treatments, and Global Burden. Front Public Heal [Internet]. 2020 May 28 [cited 2020 Nov 9];8:216. Available from: https://www.frontiersin.org/article/10.3389/fpubh.2020.00216/full

4.        What’s new | COVID-19 Treatment Guidelines [Internet]. [cited 2020 Nov 9]. Available from: https://www.covid19treatmentguidelines.nih.gov/whats-new/