Intro by Vince Giuliano
It is a good guess that the earliest COVID-19 cases in many if not most countries were thought to reflect some other disease and never properly diagnosed. Because no testing was done and the medical establishments were completely unprepared for the pandemic, we shall never know for sure. I reported my having such a possible early case in the blog entry Longevity Views, — Did I have a COVID-19 infection? My case, assuming it indeed was COVID-19, was contracted in a crowded West to East airline flight on February 15. 2020. A member of my extended family Peter Mitchell put me in touch with Neil and Susan Johnson, UK medical science reporters who told a story remarkably similar to my own. In their case, almost like mine, COVID-19 was not thought to exist in the country until long afterwards. Their sickness harkens back to December 2019 and was contracted in airliners in Italy. Their story as they have written it follows.
Guest blog entry by Neil Johnson and Susan Johnson
According to a bulletin issued on 27 April by the WHO, the first recorded case of Covid-19 outside China was reported in Thailand on 13th January. On 29 January two Chinese nationals became the first recorded cases of the coronavirus infection in the UK. A week later, on 6 February, the first British national was diagnosed with the virus, though the infection was said to have been contracted in Singapore. It was not until 28 February that a British national was reported to have been infected within the UK.
This timeline, which is widely regarded as crucial to a proper understanding of exactly how and when the Covid-19 pandemic struck the UK, also underpins the epidemiological models determining UK government policy on minimizing the spread of the disease. If, however, evidence were to be produced that cases of Covid-19 had been present in the UK before the dates of the “officially” recognized cases, the reasoning behind both the epidemiological models and the disease-containment policies would need to be reviewed. It is in this context that we present the following account of our own illnesses which occurred in December 2019.
The nature and duration of the symptoms
Between mid- and late-December in 2019, we both became ill with all the symptoms which are now regarded as characteristic of Covid-19 and which are generally accepted as being retrospectively diagnostic of infection with SARS-CoV-2 when a person has died before a test could be carried out for the presence of the virus – as has frequently happened amongst residents of care homes.
On Wednesday 18 December, Susan was the first of us to fall ill, initially with vomiting and diarrhoea, followed rapidly by total exhaustion, very high temperatures leading to drenching sweating, and the development of respiratory symptoms: these latter began with irritation at the back of the throat which then progressed rapidly downwards into the lungs, leading to a severe and debilitating cough which lasted for more than two weeks and led to her taking to bed for the next three to four days. Though by Sunday 23 December Susan had recovered from the worst of her illness, and was just about well enough to collect some pre-ordered food for our Christmas dinner, her general exhaustion, high temperatures and cough persisted for several days, and the planned Christmas celebrations were all cancelled.
Neil’s illness began on Monday 23 December, five days after the commencement of Susan’s digestive problems. Whilst Neil did not experience either vomiting or diarrhoea, the exhaustion and drenching temperatures set in rapidly, followed by severe and sustained coughing and infection of the lungs, rapid breathing (over thirty breaths per minute), and low oxygen levels in the blood.
Both of us also suffered from various other symptoms, some of which which were not included in the early descriptions as being characteristic of SARS-CoV-2 infection, but which have more-recently been accepted as important components of the symptom spectrum:
- severe, itching conjunctivitis and blepharitis, with the accompanying redness and swelling of the tissues around the eyes, which we managed eventually to bring under control by the topical application of chloramphenicol ointment;
- loss of taste and smell, these being aspects of Susan’s illness in particular; the return of these senses to normality are still, at the time of writing, by no means complete in her case. Whilst Neil did not lose either sense entirely, he did experience a change in taste, being unable to countenance some foods which he had previously liked – as in Susan’s case this has reversed, but only slowly;
- loss of appetite, being the more obvious in Neil’s case, and resulting in his eating nothing for over a week, with consequent considerable loss of weight.
In the days after the symptoms of his illness first appeared, Neil’s condition deteriorated rapidly and he is sure that the close attention and care which Susan was able to give him were major elements in his eventual recovery, as she plied him with small amounts of water and food almost every five minutes, keeping up his level of hydration and energy reserves. Despite this, the worsening of Neil’s condition was so rapid and marked that on Friday 29 December we decided to telephone 111. We were referred to an out-of-hours general practitioner who, clearly alarmed by Neil’s red-eyed, grey-faced, gaunt and generally exhausted appearance, wavered on the edge of sending him to hospital; finally, however, and evidently reassured that he would continue to receive excellent care at home, the doctor prescribed a course of antibiotics (amoxicillin).
Neil’s condition remained more or less the same for the next week, at which point, on Friday 3 January, his GP prescribed a further week’s treatment with a different antibiotic (clarithromycin), and sent him for an X-ray that same day at the nearby hospital. The X-ray confirmed changes in the lungs characteristic of pneumonia. By Thursday 9 January, Neil gradually recovered his strength: whether or not the clarithromycin had proved effective, or whether his own immune system had eventually risen to the challenge, is not clear, but his improvement was such that a review by his GP led to the decision that no further antibiotic treatment was required. T he racking cough, though, persisted, eventually subsiding after three more weeks.
In view of Neil’s recovery following the prescription of a one-week course of clarithromycin, it is, perhaps, worthy of note that it has been known for at least a decade that some of the macrolide antibiotics (which include, in addition to clarithromycin, erythromycin, roxithromycin and azithromycin) possess antiviral potency, in part by way of inhibiting cytokine production, an effect specifically noticeable in bronchial epithelial cells. Such findings are particularly interesting in view of the recent suggestion by Professor Michael Lisanti and his co-workers at the University of Salford that azithromycin might well have a protective effect against SARS-CoV-2 virus infection if administered to doctors, nurses, paramedics and other health workers having direct contact with patients showing symptoms of Covid-19.
We find it curious that, with a few exceptions, the doctors to whom we have subsequently described our experience have seemed unwilling to acknowledge the possibility that we could have been infected with the SARS-CoV-2 virus. The usual response that we received was that this was just not possible because the virus was not present in the UK until late January. Our reply that, whilst that might be so, it was nevertheless possible that we had been infected by the virus outside the UK, was usually met with silence.
Travelling to and from Italy in mid-December
In fact, we had just returned from a short visit to Sardinia. Our outward journey on Wednesday 11 December had involved three separate flights – from Manchester to Amsterdam, Amsterdam to Rome, and Rome to Cagliari in Sardinia – with the reverse sequence of flights occurring on the return leg.
Although we had intended to spend a full day in Rome on the outward journey, a strike by Alitalia aircrew planned for two days later meant that we spent only one night there, catching the flight to Cagliari the next morning, Thursday 12 December. There were many others who, like us, had found it necessary to bring their journey forward one day because of the Alitalia strike and, as a result, the plane was so tightly packed that there was no room for all the passengers’ hand luggage, which had to be put into the hold instead. We both remarked on the number of passengers with very bad coughs, and we were concerned that we found ourselves seated right at the back of the plane from Rome to Cagliari (as, indeed, had been the case on both flights the previous day); we were therefore among the last to get off the plane when it landed at Cagliari, and we expressed to each other our concern that this involved our having to plod slowly through the same air that had been breathed in and out by the coughing passengers. Our seating at the back of the aircraft was, to our great discomfort, repeated on each of the three return flights – Cagliari to Rome, Rome to Amsterdam and Amsterdam to Manchester – five days later, on Tuesday 17 December.
The upshot of all this is that we had not only been through, and passed a night in, the country that was to be the first in Europe to be devastated by Covid-19, but we had spent the best part of two whole days breathing recycled air in aeroplanes containing many people who, to judge by the widespread coughing amongst them, could well have been infected with the SARS-CoV-2 virus. Moreover, we had spent several hours, on both outward and return journeys, waiting for our flight transfers in crowded airports where we were surrounded by people of many nationalities, including a high proportion of Chinese.
Implications for the currently accepted timeline for the appearance of Covid-19
If the symptoms of the illness to which we had both succumbed shortly after mid-December 2019 are – as they certainly appear to be — those which are now generally accepted as definitive of SARS-CoV-2 infection, then the conclusion that this virus was present, and possibly even widespread, in Europe by that time seems inescapable. If so, it would seem also to be inevitable that SARS-CoV-2 would have been brought into this country in December 2019, or perhaps even earlier, by those who, like ourselves, were asymptomatic at the time of entry into the UK, or who were displaying symptoms which, at that time, were attributed to the common cold or influenza. This would have been well before the report of the Wuhan Municipal Health Commission was issued on 31 December 2019, in which it was stated that a substantial number of cases of pneumonia had recently occurred in Wuhan, in the Chinese province of Hubei.
The conclusion that the SARS-CoV-2 virus was already circulating amongst sections of the population in Europe well before the Chinese report appeared, is in line with information recently provided by Dr Yves Cohen, Head of Resuscitation at the Avicenne and Jean Verdier Hospitals in Paris. Dr Cohen and his colleagues retested samples from 24 pneumonia patients who had received treatment in December 2019 and January 2020 with suspected influenza but whose tests had, at that time, proved negative for any influenza virus: one of these samples, from a man whose test had first been carried out on 27 December 2019, gave a positive result for SARS-CoV-2. Up to that point, it had been thought that the first three cases of Covid-19 in France had appeared on 24 January 2020. The patient, later identified as Amirouche Hammar, whose sample taken on 27 December 2019 had subsequently proved positive for SARSCoV-2 would not only have been ill for a while before the sample had been taken, but would have contracted the SARS-CoV-2 infection some time before his symptoms appeared. Assuming that the total period of infection prior to his being tested was of the order of two weeks, that would suggest that the SARS-CoV-2 virus had been present in France, and perhaps in other parts of Europe, too, at least as early as 13th December, and most probably before that date – before, in fact, we commenced our series of flights from the UK to Italy, and well before the first report of the infection was issued by China. This conclusion is supported by the fact that Monsieur Hammar had not travelled beyond the borders of France.
How and when the SARS-CoV-2 virus arrived in that country remain open questions, though suggestions are already being put forward. For example, on 25 March French pentathlete Elodie Clouvel, who had taken part in the World Military Games in Wuhan in October 2019, reported that whilst in Wuhan she had fallen ill with symptoms now accepted as indicative of Covid-19; she suggested that she, as well as several of her fellow athletes who had attended the games and had also reported similar symptoms, may have been responsible for bringing the SARS-CoV-2 virus into France on their return from China.
We have no doubt that, as time progresses, we shall all hear of many more cases of Covid-19-like illnesses having been reported in the weeks, and possibly months, before the Chinese report was made public. Such information will be crucial in understanding where and when (and, perhaps, how and why) the SARS-CoV-2 virus first entered the human population, as well as helping to elucidate the person-to-person transmission process (or processes) which allowed the illness to spread so rapidly throughout the world.
N. Johnson PhD, FBPsS, FRSB, S. Johnson PhD
About the authors
We are both retired and live just south of the English Lake District. Susan has a first degree in Zoology from Notingham Universityand took her PhD in Cancer Research in the Birmingham University Medical School before we moved to Lancaster where she became Managing Editor of Medical Science Research. I have two first degrees, the first in Chemistry & Zoology and the second in Psychology, and took my PhD, also in the Birmingham Medical School, in Experimental Neuropharmacology. I became a Lecturer in Psychology at Birmingham University before we moved to Lancaster where I became a Reader in Neuropharmacology in the Psychology, and eventually Head of Psychology, in the University of Lancaster. In late 2019 Susan started her own publishing house, which I later joined. We published and co-edited a clinical pharmacology journal, Reviews in Contemporary Pharmacotherapy, and published other medical and biomedical texts. We are both Fellows of the Royal Society of Medicine, and I am also a Fellow of the British Psychological Society, the Royal Society of Biology, and the International College of Neuro-psychopharmacology.