The Imperial College COVID-19 Response Team has published a report on epidemiolocal modelling of non-pharmaceutical interventions (NPIs) to reduce COVID-19 cases and deaths and the demand for healthcare.
While our understanding of infectious diseases and their prevention is now very different compared to in 1918, most of the countries across the world face the same challenge today with COVID-19, a virus with comparable lethality to H1N1 influenza in 1918, they report. Two fundamental strategies are possible:
(a) Suppression. Here the aim is to reduce the reproduction number (the average number of secondary cases each case generates), R, to below 1 and hence to reduce case numbers to low levels or (as for SARS or Ebola) eliminate human-to-human transmission. The main challenge of this approach is that NPIs (and drugs, if available) need to be maintained – at least intermittently - for as long as the virus is circulating in the human population, or until a vaccine becomes available. In the case of COVID-19, it will be at least a 12-18 months before a vaccine is available. Furthermore, there is no guarantee that initial vaccines will have high efficacy.
(b) Mitigation. Here the aim is to use NPIs (and vaccines or drugs, if available) not to interrupt transmission completely, but to reduce the health impact of an epidemic, akin to the strategy adopted by some U.S. cities in 1918, and by the world more generally in the 1957, 1968 and 2009 influenza pandemics. In the 2009 pandemic, for instance, early supplies of vaccine were targeted at individuals with pre-existing medical conditions which put them at risk of more severe disease. In this scenario, population immunity builds up through the epidemic, leading to an eventual rapid decline in case numbers and transmission dropping to low levels.
We modified an individual-based simulation model developed to support pandemic influenza planning to explore scenarios for COVID-19 in G.B. In brief, individuals reside in areas defined by high-resolution population density data. Contacts with other individuals in the population are made within the household, at school, in the workplace and in the wider community.
Transmission events occur through contacts made between susceptible and infectious individuals in either the household, workplace, school or randomly in the community, with the latter depending on spatial distance between contacts. Per-capita contacts within schools were assumed to be double those elsewhere in order to reproduce the attack rates in children observed in past influenza pandemics. With the parameterization above, approximately one third of transmission occurs in the household, one third in schools and workplaces and the remaining third in the community. These contact patterns reproduce those reported in social mixing surveys.
We assumed an incubation period of 5.1 days. Infectiousness is assumed to occur from 12 hours prior to the onset of symptoms for those that are symptomatic and from 4.6 days after infection in those that are asymptomatic with an infectiousness profile over time that results in a 6.5-day mean generation time. We assume that symptomatic individuals are 50% more infectious than asymptomatic individuals. On recovery from infection, individuals are assumed to be immune to re-infection in the short term. Evidence from the Flu Watch cohort study suggests that re-infection with the same strain of seasonal circulating coronavirus is highly unlikely in the same or following season.
Infection was assumed to be seeded in each country at an exponentially growing rate (with a doubling time of 5 days) from early January 2020, with the rate of seeding being calibrated to give local epidemics which reproduced the observed cumulative number of deaths in G.B. or the U.S. seen by March 14, 2020.
Analyses of data from China as well as data from those returning on repatriation flights suggest that 40-50% of infections were not identified as cases. This may include asymptomatic infections, mild disease and a level of under-ascertainment. We therefore assume that two-thirds of cases are sufficiently symptomatic to self-isolate (if required by policy) within 1 day of symptom onset, and a mean delay from onset of symptoms to hospitalization of 5 days. We assume that 30% of those that are hospitalized will require critical care (invasive mechanical ventilation or ECMO) based on early reports from COVID-19 cases in the U.K., China and Italy. Based on expert clinical opinion, we assume that 50% of those in critical care will die and an age-dependent proportion of those that do not require critical care die (calculated to match the overall IFR). We calculate bed demand numbers assuming a total duration of stay in hospital of 8 days if critical care is not required and 16 days (with 10 days in ICU) if critical care is required. With 30% of hospitalized cases requiring critical care, we obtain an overall mean duration of hospitalization of 10.4 days, slightly shorter than the duration from hospital admission to discharge observed for COVID-19 cases internationally (who will have remained in hospital longer to ensure negative tests at discharge) but in line with estimates for general pneumonia admissions.
In the (unlikely) absence of any control measures or spontaneous changes in individual behavior, we would expect a peak in mortality (daily deaths) to occur after approximately 3 months. In such scenarios, given an estimated R0 of 2.4, we predict 81% of the G.B. and U.S. populations would be infected over the course of the epidemic. Epidemic timings are approximate given the limitations of surveillance data in both countries: The epidemic is predicted to be broader in the U.S. than in G.B. and to peak slightly later. This is due to the larger geographic scale of the U.S., resulting in more distinct localized epidemics across states than seen across G.B. The higher peak in mortality in G.B. is due to the smaller size of the country and its older population compared with the U.S. In total, in an unmitigated epidemic, we would predict approximately 510,000 deaths in G.B. and 2.2 million in the U.S., not accounting for the potential negative effects of health systems being overwhelmed on mortality.