COVID-19: What we know, what we're still learning… and what it all means for insurers

As the world wrestles to contain COVID-19 and control its complicated social and economic consequences, here is a fact-based perspective to help sift through the noise, understand what it means for insurance and know what to watch for.

NOTE: Even before the coronavirus outbreak had its official name, Swiss Re's Life Guide began offering underwriting guidance. This will soon include new dedicated guidelines for underwriting exposure to acute COVID-19 or a history of infection. Clients can learn more at Life Guide here.

As another highly pathogenic coronavirus known to jump from animals to humans and then from human to human, COVID-19's clinical picture is still incomplete, but we continue to learn more as comparative data and patterns begin to emerge. 

The facts on how COVID-19 compares with seasonal flu

Although COVID-19 and seasonal influenza both typically spread from droplets that come from mouth and nose and lead to respiratory issues, they differ in symptoms, spread and severity.

As a point of reference, deaths from seasonal influenza range between 290'000 to 650'000 each year according to the World Health Organisation. In the 2017-2018 flu season in the US an estimated 45 million people fell ill with influenza (13.6% of the US population). This included 21 million associated medical visits, 810'000 hospitalizations, and 61'000 deaths as reported by the Centers for Disease Control. The Case Fatality Rate (CFR) of those patients who went to see the doctor was 0.29%.

COVID-19 shows an observed CFR of 2.3% for the Hubei Province, compared to 0.4% for patients in other Provinces in China as reported by CDC China. In contrast the observed CFR in Italy has been very high (7.2%) and dominated by very old patients.1 One factor may be the age of Italy's population which is the oldest and most socially integrated population in Europe. Also, as testing expands, often more mild cases are found, lowering the overall CFR. This is the case in South Korea, which reported a rate of 1.3% in late March.

Factors that influence mortality

  • The observed proportion of deaths in Hubei Province and Italy increases with age band and is higher in the elderly.  (See table). 
  • For the 4.7% of patients in Hubei Province who developed a critical condition, reported deaths were 49%2.
  • In Italy 58% of cases were male while 42% were female1.
  • Patients in Hubei who reported no comorbid conditions had an observed CFR of 0.9%.
  • Patients in Hubei with pre-existing comorbid conditions had elevated CFR of: 10.5% cardiovascular disease; 7.3% diabetes; 6.3% chronic respiratory disease; 6.0% hypertension; 5.6% cancer2.

Death rate comparison between Hubei Province in China and Italy

Source: Onder et al. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. (China 21 February, Italy 23 March)

We've compared the first death toll insights released by Italy (through 24 March) with those of China's Hubei Province which show a marked difference in the two populations. Both countries have a higher death toll for the very old, but it's more pronounced in Italy. Also both countries report a high number of critical cases (4.7% for China and 4.5% for Italy). These cases require access to intensive care for survival and put the healthcare system under stress in the absence of any effective treatment or vaccine.

Will efforts to control and contain keep us ahead of the tipping point?

Swiss Re continues to model various scenarios, but it's still too early to forecast.  Here are some important data points to consider.

  • The US CDC estimates CFR from COVID-19 in China was as high as 12% in the epicenter of the epidemic and as low as 0.4% in the less severely affected areas in China3.
  • The high CFR values are likely associated with a breakdown of the healthcare system in the absence of pharmaceutical interventions (vaccination and antiviral drugs) and a skew of infected cases towards elderly lives and those with comorbidities, especially for those infected in a hospital setting.
  • Lower infection rates and CFR values may be associated with early public health interventions (including social distancing, quarantine, enhanced infection control in healthcare settings, and movement restrictions, especially among the elderly), as well as enhanced hygiene measures in the general population and better management of healthcare system capacity.
The quicker governments react with interventions the more likely infection rates can be brought under control and the higher the likelihood that the mortality rate will be reduced.

The latest on vaccine and therapy development

Pharmaceutical companies and research laboratories are in a race to develop vaccines that could protect people from COVID-19.

Nearly 400 global clinical trials related to COVID-19 are under way, evaluating the effectiveness of candidate vaccines and therapies. Still, experts warn progress will be slow and it could be 12 to 18 months due to the time it takes to develop, test, manufacture and distribute a vaccine.

COVID-19 diagnosis relies on measuring viral RNA by polymerase chain reaction (PCR). Immunological tests measuring anti-COVID-19 IgM and IgG have come out in China and will become available in Western Europe and the US. They are needed to analyze COVID-19 epidemiology and to guide public health interventions.

The selection of a suitable target antigen and the choice of vaccine platform are informed by experience with SARS-1 and MERS-CoV vaccine studies.4 The virus surface spike with its receptor binding domain might be a good vaccine antigen to induce neutralizing antibodies that prevent the virus to dock to the cell surface. DNA-based vaccines are the fastest platform available as a response to emerging pathogens, but results are uncertain 5. Other strategies include adenoviral vectors and recombinant proteins. 

Can we make use of approved drugs used for other diseases?

Several studies are exploring whether drugs discovered for other uses might be effective treatments for COVID-19.4 The antimalarial drug hydroxychloroquine seems to have benefits in patients diagnosed with COVID-19, based on preliminary clinical trial findings from China and France.

Remdesivir, an antiviral therapy that was developed to treat Ebola virus but was abandoned after proving less effective than rival drugs, is now tried in COVID-19 patients.6 The drug company has administered the experimental drug - though it hasn’t been proven to work - on a compassionate basis to several hundred patients with confirmed, severe COVID-19 infections in the US, Europe and Japan.

Approved HIV drugs are another group under study. Kaletra and Prezcobix were given in January, supplied free to Chinese authorities for testing in COVID-19 patients. Chinese media have reported that Kaletra has been effective in preliminary analysis, but later was shown it had no effects on viral load and survival.7

Evidence is accumulating that the subgroup of COVID-19 patients with severe pneumonia and acute respiratory syndrome have a cytokine storm syndrome 8. Theoretical therapeutic options include steroids, intravenous immunoglobulin, selective cytokine blockade (eg, anakinra or tocilizumab). Two Interleukin-6 antagonists have attracted the attention recently. Kevzara, a drug approved to treat rheumatoid arthritis is tested if it could antagonize the cytokine storm and treat acute respiratory syndrome (ARDS). A similar-acting Interleukin-6 antagonist which is approved to treat cytokine storms caused by CAR-T cancer treatments 9. Actemra, is also under investigation for treating or preventing ARDS in COVID-19 10.

What does it mean for insurers?

The spread and mortality rate of COVID-19 is introducing a range of new complexities for insurers in claims, underwriting, policy terms and more. We are working with our clients to help understand and address them.

A key element that remains uncertain is the assumption RO – which defines how many people an infected person will transmit the virus to in the susceptible population.The effective rate of reproduction will differ between countries and vary over time as governments implement a range of measures from social distancing to full lock downs of affected regions.

The mortality impact on life insurance portfolios will be similarly difficult to assess. Early estimates for the CFR vary widely by geography and age bands, with the additional difficulty of adjusting for deaths among those who are still infected at the time of observation, as well as the impact of under-reported symptomatic and asymptomatic cases.

What is Swiss Re's response?

We have been actively monitoring the situation from the start and already applying what we've learned from experience in Asia and now with other markets. We are working closely with clients who want to better understand what this means for underwriting and claims.

For underwriting guidance, we will soon offer a dedicated COVID-19 page in Life Guide, the industry's most widely used underwriting manual. This will include support for current and past infection as well as guidelines for possible exposures.

We are also working with our clients on other ways to help manage risk including dedicated questions around COVID-19 and some temporary changes to existing practices which might leave insurers exposed to anti-selection.

But most of all, should a policyholder be diagnosed with a condition which meets the policy terms and conditions we will pay the benefit. This is why insurance was invented. It's why our industry exists, and we stand ready to pay valid claims when our clients and policyholders need it most.

Just the facts: Summary of experience

  • Most common symptoms reported are: fever (88%), dry cough (68%) and fatigue (38%).
  • Incubation is around 5 days. Infectivity likely peaks when there are symptoms, but asymptomatic people have tested positive and were potentially infectious.
  • Case Fatality Rate (deaths as a proportion of infected cases) increases with age and is especially high at elderly ages. Fatality is also significantly higher in those with comorbidities including heart, lung disease, diabetes and hypertension.
  • Containment by isolation and contact tracing is still the best first line defense but once out of control, social distancing becomes an additional measure to slow the spread and flatten the curve – or slow the number of new infections. 
  • Even when movement and normalcy returns, a temporary surge in cases is likely as people return to work and public places.

References

  1. Livingston E, Bucher K. Coronavirus Disease 2019 (COVID-19) in Italy. JAMA. Published online March 17,
    2020.
  2. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019
    (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for
    Disease Control and Prevention. JAMA. Published online February 24, 2020.
  3. Estimating Risk for Death from 2019 Novel Coronavirus Disease, China, January–February 2020. Kenji
    Mizumoto and Gerardo Chowell; Emerging Infectious Diseases, Volume 26, Number 6, 2020.
  4. Baden, L. R., & Rubin, E. J. (2020). Covid-19 – The Search for Effective Therapy. N Engl J Med.
  5. https://www.wsj.com/articles/drugmaker-moderna-delivers-first-coronavirus-vaccine-for-humantesting-
    11582579099 Accessed on 20.03.2020
  6. Nakkazi, E. (2018). Randomised controlled trial begins for Ebola therapeutics. Lancet, 392(10162), 2338.
  7. Cao et al. (2020). A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19. N Engl J Med.
  8. Puja et al. COVID-19: consider cytokine storm syndromes and immunosuppression. The Lancet. Available
    online 16 March 2020.
  9. http://www.news.sanofi.us/2020-03-16-Sanofi-and-Regeneron-begin-global-Kevzara-R-sarilumabclinical-
    trial-program-in-patients-with-severe-COVID-19 Accessed 20.03.2020
  10. https://www.roche.com/media/releases/med-cor-2020-03-19.htm Accessed 20.03.2020

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COVID-19: What we know, what we're still learning… and what it all means for insurers

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