The COVID-19 GloHSA Risk Assessment report that has been just released. It intends to point key facts and questions to help policy decision makers in their daily duties regarding the COVID-19 outbreak strategic steering.

1. Global Health Security Alliance (GloHSA) I www.glohsa.com
Global Health Security Alliance
GloHSA
3|2020
COVID-19 RISK ASSESSMENT
REPORT
Thomas’ theorem
« If men define situations as real, they are real in their consequences »
09/03/2020

2. Dr Jan-Cedric Hansen on behalf of GloHSA Page 2 of 12
By 09/03/2020
What is certain
Since 31 December 2019 and as of 9 March 2020, 109,695 cases of COVID-19 (in accordance
with the applied case definitions in the affected countries) have been reported, including
3,811 deaths.
Confirmed cases
Africa Egypt (49), Algeria (20), Senegal (4), South Africa (3), Cameroon (2), Morocco
(2), Nigeria (1), Togo (1) and Tunisia (1)
Asia China (80 859), South Korea (7 382), Iran (6 566), Japan (488), Singapore (150),
Malaysia (99), Bahrain (79), Kuwait (64), Iraq (62), Thailand (50), Taiwan (45),
United Arab Emirates (45), Israel (39), India (34), Lebanon (32), Vietnam (30),
Palestine* (19), Oman (16), Qatar (15), Saudi Arabia (11), Philippines (10),
Indonesia (6), Pakistan (6), Afghanistan (4), Maldives (4), Bangladesh (3),
Cambodia (2), Bhutan (1), Jordan (1), Nepal (1) and Sri Lanka (1)
America United States (554), Canada (62), Brazil (25), Ecuador (14), Argentina (12), Chile
(10), Mexico (7), Peru (7), Costa Rica (5), Dominican Republic (2), Colombia (1)
and Paraguay (1)
Europe Italy (7 375), France (1 126), Germany (902), Spain (589), Switzerland (332),
United Kingdom (273), Netherlands (265), Sweden (203), Belgium (200),
Norway (169), Austria (102), Greece (73), Iceland (55), Denmark (38), San
Marino (37), Czech Republic (32), Finland (30), Portugal (30), Ireland (21),
Slovenia (16), Romania (15), Georgia (13), Croatia (12), Poland (11), Estonia
(10), Russia (10), Azerbaijan (9), Hungary (8), Belarus (6), Luxembourg (5),
Slovakia (5), Bulgaria (4), Latvia (3), Malta (3), North Macedonia (3), Albania
(2), Bosnia and Herzegovina (2), Andorra (1), Armenia (1), Holy See (1),
Liechtenstein (1), Lithuania (1), Moldova (1), Monaco (1), Serbia (1) and
Ukraine (1)
Oceania Australia (80) and New Zealand (5)
Other International conveyance in Japan (705)
Confirmed deaths
The deaths have been reported from China (3 122), Italy (366), Iran (194), South Korea (51),
United States (21), France (19), Japan (7), an international conveyance in Japan (6), Spain (5),
Iraq (4), Australia (3), Netherlands (3), United Kingdom (3), Switzerland (2), Germany (2),
Argentina (1), Egypt (1), San Marino (1), Taiwan (1) and Thailand (1).

3. Dr Jan-Cedric Hansen on behalf of GloHSA Page 3 of 12
Published key points for clinicians
● It belongs to the genus β‐Coronavirus an enveloped RNA + single-stranded virus
member of the Sarbecoviruses group 1
● Detection of viral particles in blood and bronchoalveolar lavage by RT-PCR 2
● Key viral proteins have more than 80% homology with those of SARS3
● The reproduction rate initially measured was from 2.0 to 3.04
(it seems to tend towards
1.0)
● The incubation period seems to be between 5 and 13 days 5
● The onset of symptoms settles over 3 to 6 days
● The clinical picture consists of fever, localized upper and lower respiratory symptoms,
diarrhea or a combination of those
● The median time between the onset of symptoms and dyspnea is 8 days; the most
frequent complications are acute respiratory distress (29%), cardiac decompensation
(12%) and secondary infection (10%)6
● Hospitalization occurs within 6 to 10 days after the onset of the first symptoms 7
● Biological abnormalities are marked by lymphopenia 8
● Radiological and CT-scan images are marked by ground-glass lung opacities
appearance, often peripheral or disseminated9
● Histopathological observations show a characteristic alveolar septal involvement in
addition to a classic inflammatory reaction 10
1
Fung, Liu. Human coronavirus: host-pathogen interaction. Annu. Rev. Microbiol., 73 (2019), pp. 529-557
2
Chu, Daniel KW, et al. "Molecular diagnosis of a novel coronavirus (2019-nCoV) causing an outbreak of
pneumonia." Clinical Chemistry (2020).
3
Zhu, Na, et al. "A novel coronavirus from patients with pneumonia in China, 2019." New England Journal of
Medicine (2020).
4
Zhou, Tao, et al. "Preliminary prediction of the basic reproduction number of the Wuhan novel coronavirus
2019-nCoV." arXiv preprint arXiv:2001.10530 (2020).
5
Li, Qun, et al. "Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia." New
England Journal of Medicine (2020).
6
Huang, Chaolin, et al. "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China." The
Lancet (2020).
7
Wang, Chen, et al. "A novel coronavirus outbreak of global health concern." The Lancet (2020).
8
Huang, Chaolin, et al. "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China." The
Lancet (2020).
9
Chung, Michael, et al. "CT imaging features of 2019 novel coronavirus (2019-nCoV)." Radiology (2020): 200230.
10
Li, Geng, et al. "Coronavirus infections and immune responses." Journal of Medical Virology (2020).

4. Dr Jan-Cedric Hansen on behalf of GloHSA Page 4 of 12
What we see
Regarding the global kinetic
The epidemic continues to progress regardless of containment measures in China and
elsewhere in a context where the weight of China still represents 88% of all cases documented
to date.
We note that the number of cases confirmed by direct detection of the virus follows an initially
exponential, then seems to switch to an asymptotic curve behavior and finally switches again
to an exponential aspect in a context where the relative percentage of fatal cases continues
to decrease.
The green arrow corresponds to a change in detection of possible cases in China. Chinese
decided to modify the “possible case” definition with « positive lung X-ray » to identify those
that will benefit from a PCR detection. It doesn’t seem that they are running short on tests
but that they adapt the screening to a more sensible but less specific pre-screening technique
(this makes perfect sense from the Disaster Medicine point of view).
It proves to be relevant for they identified more low symptomatic cases from the clinical point
of view but with Lung X-ray signs (which means they test for COVID-19 any influenza like illness
with positive lung X-Ray). This strategy is paying off since it allows the number of biologically
confirmed cases to be corrected.

5. Dr Jan-Cedric Hansen on behalf of GloHSA Page 5 of 12
The blue arrow points an inflexion in the curve that corresponds to the sudden increase of
cases outside China (possibly the point from which the epidemic became autonomous).
We note that since February 12, 2020 the WHO no longer communicates on the number of
severe cases.
It should also be borne in mind that, for the time being, this epidemic has nothing in common
with a seasonal flu in terms of its kinetics or its magnitude neither does it behave like the
"Disease X" we all dread. According to WHO, “Disease X” represents the knowledge that a
serious international epidemic could be caused by a pathogen currently unknown to cause
human disease. COVID-19 seems to express the unknown and global spread part of the
definition but does not express a high mortality level to be designated as such to date.
Regarding the instant kinetic
The green arrow corresponds to the change in detection procedure of possible cases in China
which brutally increased the number of cases detected accordingly.
The blue arrow designates the inflection point from which the epidemic possibly became
autonomous outside China.

6. Dr Jan-Cedric Hansen on behalf of GloHSA Page 6 of 12
Regarding estimated active cases
The graph below is an estimation of the actual number of active patients. It is based on the
cumulative number of documented confirmed cases minus the number of deaths minus the
number of patients 20 days ago (based on the assumption that patients are cured or dead 20
days after onset). This model is over simplistic, but it is the only one valuable available.
Blue and orange arrows point to the accident linked to the change of identification of
possible cases by China. The blue one to the sudden increase of identified cases. The orange
one to its mirror causes a sudden decrease of cases.
Special focus on Europe
As of 9 March 2020, 11 577 cases have been reported in the EU/EEA and the UK: Italy (7 375),
France (1 126), Germany (902), Spain (589), United Kingdom (273), Netherlands (265), Sweden
(203), Belgium (200), Norway (169), Austria (102), Greece (73), Iceland (55), Denmark (38),
Czech Republic (32), Finland (30), Portugal (30), Ireland (21), Slovenia (16), Romania (15),
Croatia (12), Poland (11), Estonia (10), Hungary (8), Luxembourg (5), Slovakia (5), Bulgaria (4),
Latvia (3), Malta (3), Liechtenstein (1) and Lithuania (1).
Although most cases reported in the EU/EEA and the UK outside some regions in Italy have
identified epidemiological links, there is an increasing number of cases without a defined chain
of transmission.

7. Dr Jan-Cedric Hansen on behalf of GloHSA Page 7 of 12
To date COVID-19 infection causes mild disease (i.e. non-pneumonia or mild pneumonia) in
about 80% of cases and most cases recover.
Nevertheless 14 % of infected patients express a more severe disease and 6% experience
critical illness that requires admission to an intensive care unit (ICU).
The great majority of the most severe illnesses, and deaths, have occurred among the elderly
and those with other chronic underlying conditions.
In addition, the COVID-19 global outbreak is currently causing huge economic and societal
disruptions.
The epidemic behaviour is currently obviously exponential.
Meanwhile, 396 deaths have been reported in the EU/EEA and the UK: Italy (366), France (19),
Spain (5), Netherlands (3) and the United Kingdom (3). The current death rate is 0.38/100,000
in italy as opposed to 0.21/100,000 in China (but 5.00/100,000 in Hubei Province)
Table hereafter shows the percentage of death regarding the number of documented cases.
It is not the computation of the death rate but rather an indirect indicator of the burden of
the healthcare system.

8. Dr Jan-Cedric Hansen on behalf of GloHSA Page 8 of 12
EU/EEA and the UK Cases Deaths %
Italy 7375 366 4,96%
France 1126 19 1,69%
Germany 902 0 0,00%
Spain 589 5 0,85%
United Kingdom 273 3 1,10%
Netherlands 265 3 1,13%
Sweden 203 0 0,00%
Belgium 200 0 0,00%
Norway 169 0 0,00%
Austria 102 0 0,00%
Greece 73 0 0,00%
Iceland 55 0 0,00%
Denmark 38 0 0,00%
Czech Republic 32 0 0,00%
Portugal 30 0 0,00%
Finland 30 0 0,00%
Ireland 21 0 0,00%
Slovenia 16 0 0,00%

9. Dr Jan-Cedric Hansen on behalf of GloHSA Page 9 of 12
Romania 15 0 0,00%
Croatia 12 0 0,00%
Poland 11 0 0,00%
Estonia 10 0 0,00%
Hungary 8 0 0,00%
Slovakia 5 0 0,00%
Luxembourg 5 0 0,00%
Bulgaria 4 0 0,00%
Malta 3 0 0,00%
Latvia 3 0 0,00%
Total 7264 213 2,93%
Regarding clinical data
The reproduction rate is still estimated at the moment at 2.2 (10 subjects carrying the virus
contaminate on average 22 other people). But, the well-documented case of the man from
Hove (near Brighton, UK) who attended a conference in Singapore, returned home and then
went skiing, and infected several of his contacts - considerably more than the estimated R
number of 2.2 - shows that in some cases considerably more people can be infected. Whether
the variance is quite considerable but random; purely associated with the sorts of activities
undertaken; or whether some individuals are biologically different “superspreaders” eg
shedding more virus than usual; or whether specific conditions such as overcrowded damp
places such as a “Mountain Chalet” or a subtropical housing or a cruise ship … is not clear yet.
The current incidence still seems to be 0.83 / 100,000 inhabitants (for the record, the monthly
incidence of influenza is regularly above 1000 / 100,000 inhabitants during an epidemic).
The average length of the incubation period is still estimated around 10 days.
According to the information available, the duration of hospitalizations for cases in France
seems to be around 20 days.

10. Dr Jan-Cedric Hansen on behalf of GloHSA Page 10 of 12
Average fatality rate in mainland China is 3% since Jan 10th. The higher fatality may be driven
by changes in case reporting protocols. Fatality rate outside of mainland China is 1.4%. (figures
are extracted from M2 Medical Intelligence, Inc daily posts on LinkedIn, with permission).
As a reminder, during an influenza epidemic, the proportion of hospitalizations with
resuscitation (10%, lethality in the order of 6%) and the average length of stay is around 8.6
days. Thus, the COVID-19 outbreak is not associated with global impact on the scale of an
antigenic shift influenza pandemic.
Healthcare providers specificities
In China, the rate of carers hospitalized due to occupational contamination reaches 6%.
By observing the images of the reports broadcast on the media, we see that the caregivers
have fairly sophisticated protective equipment but that often the mask is only a simple surgical
mask (FFP1) and for duck masks (FFP2), we do not know the frequency of renewal or the
average duration of wearing before renewal.
There is also a great proximity of patients with caregivers, which suggests a fairly intense re-
exposure rate and the possibility of a significant cumulative viral load on personal protective
equipment (PPE). Errors in doffing PPE (Taking off) can also reflect the death toll of the
caregivers (insufficient training or exhaustion). One should keep in mind that anxiety is driving
unnecessary PPE hoarding and may compromise PPE supplies.
The notion of "burden" or iterative exposure may also account for the fact that the virus shows
an infection capacity for young, healthy caregivers compared to its common target of frailty
elderly people.
Socio-economic specificities
Tensions over the supply of FFP1 masks appear due to demand not regulated by certain
national health authorities concerned and the lack of concerted or shared posture at
international level.
Tensions on the supply of several types of drugs - already pre-existing - linked to the relocation
to China of production sites are to be anticipated / monitored now.
What remains pending
● We still do not know if the reproduction rate, the percentage of symptomatic
cases, severe cases and fatal cases is homogeneous or not according to the regions
of the world or according to the mode of contamination (primary, secondary or
tertiary).
● The length of convalescence remains undocumented to date.
● The start of the contaminating viral excretion phase in the asymptomatic phase
and beyond the clinical phase, during convalescence has not yet been established.
● The predictive threshold viral load for severe symptomatology has not been
identified if it exists.

11. Dr Jan-Cedric Hansen on behalf of GloHSA Page 11 of 12
● The viral load in excreta which may be responsible for contamination in
asymptomatic patients has not been determined to date.
● The possibility of Antibody Dependent Enhancement (ADE) is not assessed
although ADE is used by Dengue, Chikungunya, HIV and feline coronaviruses
and SARS-CoV, while there is a report of a Chinese patient having
"recovered" only to require rehospitalization and ICU a short time later.
● Wild and farm animals do not appear to be monitored although they should for
they may become reservoirs or vectors.
● We do not know how to explain the reasons for the high rate of caregivers
contaminated by their patients (problems of effectiveness of personal protective
equipment, compliance with prevention and protection instructions, exotic
contamination method, specific effect of the repetition of the exposure vs viral
load,…).
● There is no projection of the impact of the caregiver absenteeism rate on the
capacity of establishments to cope with an Exceptional Health Situation if it were
to develop on any national territory.
● There is no projection on the impact of public health measures on the one hand,
on absenteeism linked to the epidemic on the other hand on the needs for
protective equipment, consumables, medical devices and pharmaceuticals.
● We have no projection on the impact of public health measures on the one hand,
on absenteeism linked to the epidemic on the other hand on the logistical
constraints linked to supply in a context where suppliers are mostly Chinese.
● It is unlikely that the widespread use of the mask as it appears in populations has
a real impact on the spread of the virus.
What key policy decision makers could consider
Key policy decision makers could consider having answers to the above questions that are
critical for them to make wise and sound decisions.
In addition they could consider a cindynic approach which consists in the identification of the
vulnerabilities of the systems/organisations/territories they rule/manage.
Among those common vulnerabilities are:
● Infallibility culture
○ Strong belief that Emergency/Humanitarian skills are enough to cope with
disasters
● Simplism culture
○ Reduction of problems to a false simplicity by ignoring complicating factors
such as logistic and congestion ones
● Navel-gazing culture
○ Coexistence of different metric/statistical systems or cases screening
methodology without reciprocal acknowledgement nor conversion of values
● Dilution of responsibilities
○ Multiplicity of actors and the differences in technical competencies between
the different actors without a clear hierarchy matrix

12. Dr Jan-Cedric Hansen on behalf of GloHSA Page 12 of 12
Bearing in mind that the dynamic of the epidemic, the environment, socio-economic flows, …
influence the vulnerability of any system/organisation/territory as well as actors/decision
makers’ play role at “Global”, “Individual”, “Interpersonal” & “Organisational” levels are
critical.
To know more
https://www.santepubliquefrance.fr/maladies-et-traumatismes/maladies-et-infections-
respiratoires/infection-a-coronavirus/articles/cas-de-pneumonies-associees-a-un-nouveau-
coronavirus-2019-ncov-a-wuhan-en-chine
https://www.ecdc.europa.eu/en/novel-coronavirus-china
https://ec.europa.eu/health/coronavirus_en
https://ec.europa.eu/health/sites/health/files/preparedness_response/docs/ev_20200131_
sr_en.pdf
https://glohsa.com
https://www.cdc.gov/coronavirus/2019-nCoV/summary.html
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/