WHO’s team of experts lands in Tehran to support the COVID-19 response in Iran.

As Iran faces one of the most serious surges in COVID-19 cases around the world, WHO’s Director General Dr Tedros Adhanom Ghebreyesus, welcomed US President Donald Trump’s olive branch toward its bitter enemy, who on Monday told the Conservative Political Action Congress  “if we can help the Iranians with this problem we are certainly willing to do so.”

“I would like to comment on the statement of the United States, in support of Iran,” said Ghebreyesus, speaking at a WHO press briefing, shortly after a WHO team had touched down in Tehran, laden with materials for 200,000 COVID-19 lab tests as well as health worker protective equipment, funded by the United Arab Emirates.

“I think we have a common enemy now, and using health, and especially fighting this virus as a bridge for peace, is very, very important,” Dr. Tedros said, adding that the United Arab Emirates support for the aid parcel was “another example of solidarity.”

“This is very encouraging,” he added.  “We would like to thank the two countries, but also stressing the importance of solidarity at this time. It’s a common enemy and we have to stand together in unison to fight it. These early signs are very encouraging and as humanity we should stand together.

Despite reports of some 8739 infections proliferating in over 60 countries abroad, WHO Officials remained optimistic that containment of the new COVID-19 virus might still be possible – even to the point of eventually interrupting transmission “if we are effective and lucky.”

But even if that endgame proves elusive, the same aggressive measures will slow down the virus’s onward march – as China’s example has now demonstrated, said WHO’s top emergency team leadership on Monday.

The effects of China’s containment strategy were visibly on display Monday, Dr Tedros underlined. China was reporting just 207 cases in the last 24 hours, the lowest numbers since 22 January, and only 8 of those cases had occurred outside of the virus epicentre of Hubei Province. In contrast, cases abroad were nine times higher than the previous day. Along with Iran, epidemics in in Italy, the Republic of Korea and Japan continued “are our greatest concern,”  the WHO Director General underlined.

Global Cases of COVID-19 as of 5:30PM CET 2 March 2020.

UN in Geneva, Louvre and Other European Institutions Follow Italy In Closing Doors To Public

In Europe, both governments and institutions were ramping up their responses, amidst spontaneous reactions of public concern.

The UN headquarters in Geneva, which welcomes about 100,000 visitors a year, “temporarily” suspended public tours on Monday. Switzerland banned public gatherings of over 1,000 people, a move that was soon followed by the cancellation or postponement of upcoming meetings and events in the Geneva hub of international institutions and NGOs, which are clustered in the city.

And the Louvre Museum in Paris which welcomes some 30,000 visitors a day, remained closed for a second day, while employee union representives reviewed personal protective measures with the museum management, which had offered them hand sanitizer, while they were requesting masks.

Currently, there is no WHO recommendation for workers in such settings to wear masks. Rather WHO has said that wearing masks by healthy people in the workplace is only necessary in health care settings, for emergency response teams and cleaning crews, or for interviews of suspected COVID-19 cases by border guards. The Louvre’s union representatives, however, had also asked why the museum wasn’t covered by the official French ban on gatherings of more than 5,000 people, which issued last week as a COVID-19 response.  “You will easily admit that the Louvre Museum is a confined space and that it receives more than 5,000 people a day,” union representative Christian Galani was quoted as saying to the Associated Press.

Such moves followed Italy’s temporary closure last week of several major Milanese tourist sites and the premature closure of the Venice Carnivale, while cases in northern Italy escalated throughout the week.  As of Monday evening, Italy was reporting some 1694 cases, and 34 deaths, nearly three times as many as it had reported on Friday.

However, Dr Tedros expressed hope that the sharp increases of infections in the European country most affected by the outbreak would soon begin to subside, saying that Italy had dramatically boosted its surveillance.  “Of course they were surprised, but they have strong institutions and we believe that they can bring it together,” he said.

In countries such as Korea, which was reporting some 4,335 cases, nearly double the number of last Friday, the virus epicentre continued to revolve around known infection clusters around the city of Daegu, where the outbreak first began amongst members of a cult-like church.  However that also offers hope that the outbreak can be brought under control, said the WHO Director General.

“Containment is possible in all countries that are affected. That is why we are saying the comprehensive approach is very, very important,” said Tedros.

“OK,  we are close to 90,000 cases, we have more than 3,000 deaths and some 65 countries are affected.  But among those countries, 38 have less than ten cases. And among other 20 countries, you have 120-140 cases,” he said.

“So a one side fits all approach doesn’t work, blanket recommendation doesn’t work,” he said.

Treatment of Seriously Ill – Big Confounder for Health Systems

One of the biggest confounding factors is not just the fatality rate of the new virus – which at 2% is still much higher than seasonal flu – but the threat it poses to health care systems ability to provide adequate intensive care at the sheer numbers that could be required if the virus spread accelerates.

While 80% of people only experience mild symptoms, some 20% of victims require hospitalization. And of those hospitalized, about 30-40% of people require care with medical oxygen, supplied  through a respirator, said WHO technical lead Maria Van Kherkove.

Hospital intensive care units and respiratory beds in middle- or high-income countries with excellent health systems can easily become overwhelmed by people who become seriously ill, said WHO officials, citing the experience in Hubei Province as such an example. In lower income settings, such equipment may be rare or non-existent in many hospital settings.

“Most countries, even sophisticated health systems, have very limited intensive care capacity, in terms of the clinical beds that they have,” said Mike Ryan, WHO Emergencies head. “Ventilators need trained technicians, extra-corporeal oxygen support requires very high level of technical support. This is not just an issue for weaker health systems.”

Ryan said that focusing on early diagnosis and provision of care will also help prevent some of the progression to more serious cases. “Most countries will struggle if they see large numbers of patients needing intensive care.”

The length of care required is another challenge, he added, saying. “We are seeing patients spending many, many days, up to 24 days, in a critical care environment. That is occupying a lot of beds for a very long time.  So all countries are going to have to think very carefully about how they manage the critical care component of this disease.”

That reinforces the message, that tough containment strategies, including vigilant identification of suspected cases, testing, quarantine and treatment of those found ill, along with aggressive tracing and following of contacts, all are essential to bring down the overall case load that countries might face, Ryan said.

“Here we have a disease where we don’t have a vaccine, we don’t have treatments, we don’t understand its transmission and its mortality,” he said. “All countries can be looking for cases right now and can aggressively find cases and follow them, so we can help each other.

“Here we have seen that with the right measures, it can be suppressed.”

WHO Updates Travel Advice – Acknowledges that “Temporary” Restrictions May Be Useful

Following a spike in cases around the world, which were traced back to travel from the new  COVID-19 hotspots of Italy and Iran, WHO issued new travel restriction recommendations, most notably acknowledging that “in certain circumstances, measures that restrict the movement of people may prove temporarily useful.”

That contrasts sharply with the strong advice against any travel restrictions whatsosever that the Agency had maintained until this point.

However, the updated advice still contains the caveat that such bans should be “short in duration,” and reassessed regularly to make sure they are “proportionate” to public health risks.

“Travel measures that significantly interfere with international traffic may only be justified at the beginning of an outbreak, as they may allow countries to gain time, even if only a few days, to rapidly implement effective preparedness measures,” the guidance states.

At a press conference of the European Commission, officials pledged to maintain the “mobility” of European citizens, and maintain open borders between countries of the so-called Schengen zone – although health checks in some instances could be reinforced. A new assessment by the European Centres for Disease Control (ECDC) Risk Assessment described the regional risks associated with the COVID-19 epidemic to be “moderate to high.”

The ECDC warned, however, that “In the event of established and widespread community transmission, current containment measures may no longer be an efficient use of resources. If this occurs, action should be taken to prepare for a mitigation strategy that includes co-ordinated efforts to protect the health of EU/EEA and UK citizens by decreasing the burden on healthcare systems and protecting populations at risk of severe disease.”

EU COVID-19 response site has been established to provide situation updates and relevant information on medical, transport and economic issues linked to the epidemic.

Elsewhere, the US confirmed it’s first two deaths by the coronavirus in Washington state over the weekend, where a cluster of 10 cases in King County is suspected to be the first identified local outbreak of COVID-19 in the country.

Nancy Messonier, director of the US CDC’s Center for the National Center for Immunization and Respiratory Diseases (NCIRD) said in a statement on Saturday, “We will continue to respond to COVID-19 in an aggressive way to contain and blunt the threat of this virus. While we still hope for the best, we continue to prepare for this virus to become widespread in the United States.”

Still, the new WHO recommendations do not explicitly sanction restrictions on the movement of people within so-called “affected-areas” – locales which are seeing sustained local transmission of the virus rather than just a cluster of imported cases.

Citing Hubei Province as an example of an “affected” area, WHO indicates that recommended containment measures should include: “control measures that focus on prevention… active surveillance for the early detection and isolation of cases, the rapid identification and close monitoring of persons in contacts with cases, and the rapid access to clinical care, particularly for severe cases.” 

The agency falls short of recommending measures some of the more drastic that were taken in Hubei, and have been tried  more recently in countries such as Italy, including restricting public transportation and locking down towns and villages with local transmission. 

However, the spirit of the new measures clearly is influenced by the recent report issued by the WHO-China Joint Mission, that returned last week from China and reported how effective measures there had been.

Image Credits: Twitter: @DrTedros, John's Hopkins CSSE.

Abdul Rasyid, a TB MDR patient, works as a motivator in the inpatient TB MDR ward at the Persahabatan Hospital in Jakarta, Indonesia

While health leaders battle a global outbreak of a dangerous new virus, a consortium of partners is entering the fight against one of humankind’s oldest infectious diseases, tuberculosis.

A group of philanthropic, non-profit, and private sector organizations on Thursday launched a collaboration to accelerate development for a “pan-TB” treatment regimen to treat drug-sensitive and drug-resistant forms of the deadliest infectious disease in the world.

The first-of-its kind Project to Accelerate New Treatments for Tuberculosis (PAN-TB collaboration) aims to develop safe treatment regimens that have little to no drug resistance and advance them through phase 2 clinical trials – universal regimens that can treat multiple different strains of TB.

“The development of a regimen that can treat both drug-sensitive and drug-resistant tuberculosis could be a game changer for how the world addresses TB and growing antimicrobial resistance,” said Penny Heaton, chief executive officer of the Bill & Melinda Gates Medical Research Institute, a founding member of the consortium, in a press release. 

The need for new treatment options is high. There exists no single treatment available to treat all forms of TB. Only three new drugs have been approved for the treatment of TB in the past 50 years – bedaquiline, delamanid, and pretomanid, which was just approved in August 2019 by the United States Food and Drug Administration.

In 2018, the World Health Organization estimated that there were 10 million new cases of TB and almost 1.5 million deaths. It’s estimated that there were 500,000 cases of drug-resistant TB, in which almost half of the patients died.

Currently, even the easiest to treat strain of TB – known as drug-sensitive or drug-susceptible TB – requires a regimen of four core drugs taken for at least 6 months.

Despite being known as the easiest to treat form of active TB, the current WHO-recommended regimen for drug-sensitive TB still consists of a grueling 6 month treatment – a combination of four different antibiotic pills taken daily for two months, followed by another four months of taking two antibiotics per day.

But even this regimen is not sufficient to treat forms of drug-resistant TB, or strains resistant to any of the four core drugs. These deadly strains require different treatment courses – which may contain more than 5 different drugs and take up to two years to complete. It’s estimated such drug-resistant TB strains killed 230,000 people in 2017.

However, to diagnose drug-resistant TB, patients must undergo additional testing.

The new PAN-TB initiative aims to develop regimens that can be used to cure both drug-sensitive and drug-resistant strains of TB, cutting down on the need to test for drug-resistance and potentially giving patients safer, shorter, and simpler treatment options.

A spokesperson for the consortium told Health Policy Watch that the exact drug candidates for the phase 2 trials are still being identified.

However, the spokesperson added that the Bill and Melinda Gates Foundation has committed grant funds for non-clinical studies to identify promising compounds for the treatment course. The Bill and Melinda Gates Medical Research Institute will fund and lead clinical studies in the partnership.

The pharmaceutical partners include Evotec, GlaxoSmithKline, Johnson & Johnson, and Otsuka Pharmaceuticals, and will contribute in-kind resources, including providing access to a library of candidate compounds, and dedicating scientific and technical expertise to the initiative.

The global PAN-TB collaboration aims to link up with another TB drug development initiative launched just a few weeks prior on 29 January, the European Accelerator of Tuberculoses Regime (ERA4TB) project, a 30-partner initiative funded by the European Commission. ERA4TB aims to accelerate preclinical identification of promising compounds, while PAN-TB aims to take such preclinical discoveries through to the end of costly phase 2 clinical trials.

Image Credits: Bill & Melinda Gates Foundation/Prashant Panjiar.

“All of Government” Approach; Inspectors in South Korea check a firefighting agency’s COVID-19 preparedness.

China has reported it’s lowest level of new COVID-19 infections in a month, with just 327 cases over the past 24 hours.  At the same time, cases abroad exploded overnight with 1,000 more people reported to be infected with the virus in some 49 countries. Most f new cases were heavily concentrated in the emerging global hotspots of: Korea, which saw 732 new cases since Thursday evening; Iran, 143 new cases and 8 deaths; and Italy, where new cases appeared to decline then spike against a cumulative total of 888 cases and 21 deaths, according to Italian national authorities.

Graph captured 4:45AM CET 29 February. Note, national agencies may report more up-to-date numbers.

Italy and Iran were also proving to powerful vectors of exported cases to other countries – reflecting how effectively the virus moves along with international travel.

“Since yesterday, Denmark, Estonia, Lithuania, Netherlands and Nigeria have all reported their first cases. All these cases have links to Italy,” said WHO’s Director General Dr Tedros Adhanom Ghebreyesus in a Friday press briefing.  “24 cases have been exported from Italy to 14 countries, and 97 cases have been exported from Iran to 11 countries.

“The continued increase in the number of cases, and the number of affected countries over the last few days, are clearly of concern… and we have now increased our assessment of the risk of spread and the risk of impact of COVID-19 to very high at a global level,” said Dr. Tedros.

Global tracking of COVID-19 as of 5:30PM CET 28 February. Note, national agencies may report more up-to-date numbers

Tough Message from Report of WHO-China Joint Mission

The assessment came as the report of a WHO-convened international team to China was released, containing tough messages to global health policymakers about what countries need to do to contain the epidemic, and the worldwide risks in the event of failure.

“The COVID-19 virus is unique among human coronaviruses in its combination of high transmissibility, substantial fatal outcomes in some high-risk groups, and ability to cause huge societal and economic disruption,” the report concludes. “The COVID-19 virus must be considered capable of causing enormous health, economic and societal impacts in any setting. It is not SARS and it is not influenza. Building scenarios and strategies only on the basis of well-known pathogens risks failing to exploit all possible measures to slow transmission of the COVID-19 virus, reduce disease and save lives.”

The report finds that the decline in cases in China, even in the absence of effective vaccines and drugs, is “real,” virtually unprecedented, and provides “vital lessons” for the global response.

“In the face of a previously unknown virus, China has rolled out perhaps the most ambitious, agile and aggressive disease containment effort in history. The strategy that underpinned this containment effort was initially a national approach that promoted universal temperature monitoring, masking, and hand washing. However, as the outbreak evolved, and knowledge was gained, a science and risk-based approach was taken to tailor implementation. Specific containment measures were adjusted to the provincial, county and even community context.”

 

(Joint WHO-China Report)

“China’s uncompromising and rigorous use of non-pharmaceutical measures to contain transmission of the COVID-19 virus in multiple settings provides vital lessons for the
global response. This rather unique and unprecedented public health response in China reversed the escalating cases in both Hubei, where there has been widespread community transmission, and in the importation provinces, where family clusters  appear to have driven the outbreak.”

(Joint WHO-China Report)

However the experts warn that: “Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China.”

And that is despite the fact that, “These are the only measures that are currently proven to interrupt or minimize transmission chains in humans. Fundamental to these measures is extremely
proactive surveillance to immediately detect cases, very rapid diagnosis and”immediate case isolation, rigorous tracking and quarantine of close contacts, and an exceptionally high degree of population understanding and acceptance of these measures.

The experts outline, however, a set of far-reaching recommendations for what countries need to prepare for, or carry out in the case of those already facing outbreaks, including:

  • Active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantine of close contacts;
  • Expanded surveillance and sceening of people with symptoms of atypical pneumonia;
  • Public education;
  • Involvement of all government sectors in the response effort.

In the even more dramatic means are needed, the mission report advises countries to conduct “simulations for the deployment of even more stringent measures to interrupt transmission chains as needed (e.g. the suspension of large-scale gatherings and the closure of schools and workplaces).

The Joint Mission consisted of 25 national and international experts from China, Germany, Japan, Korea, Nigeria, Russia, Singapore, the United States of America and the World Health
Organization (WHO). The Joint Mission was headed by Dr Bruce Aylward of WHO and Dr Wannian Liang of the People’s Republic of China.

WHO Recommends No Travel Restrictions: No WHO Comment On Masks For Vulnerable Groups or in COVID-19 Hotspots 

Despite the increasingly clear association between disease spread and international travel from hot spots,  WHO’s top emergency response officials, including WHO Emergencies Head Mike Ryan and the Director General himself, have continued to speak out against restrictions on international travel.  Rather than barring any incoming travelers from any particular countries or hotspots, the inherent risks need to be “managed” by preparing health facilities in countries to detect, quarantine and treat incoming cases of virus transmission, they have repeatedly said.

“WHO advises against the application of any restrictions of international traffic based on the information currently available on this event,” states the most recent WHO guidance on international travel, from 27 January. Although China sharply restricted its own outgoing travel from its country to get a handle on the epidemic, it is a contradiction WHO officials have never sought to explain.

WHO has  also generally recommended against the widespread use of face masks outside of health care settings, describing it as largely unecessary, even though this was another key element of China’s containment policy, as noted by the Joint Mission.

Even for at-risk groups such as older people living in epidemic hotspots; for border police and airport workers working face to face with travelers; or for older and at-risk commuters moving about in outbreak areas in crowded conditions, there is virtually no WHO recommendation to don a mask.

Rather, WHO recommendations state that masks should be reserved almost exclusively for people who are themselves ill, or for health care settings:

  • “If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.”
  • “Wear a mask if you are coughing or sneezing.”

Otherwise, however, the messages issued by top WHO leadership over the past week have largely echoed those of the Joint Mission report.

In the Friday briefing, both Dr Tedros and Ryan said that national disease strategies should continue to focus on “containment” of COVID-19 transmission, as compared to “mitigation”  – noting that without containment measures, health systems even rich countries could be quickly overwhelmed by a surge of seriously ill patients requiring respiratory treatment and critical care, which they would be ill-prepared to provide.

“What we see at the moment are linked epidemics of COVID-19 in several countries, but most cases can still be traced to known contacts or clusters of cases. We do not see evidence as yet that the virus is spreading freely in communities,” said Dr Tedros.

One exception to that has been the United States, where the Centers for Disease Control and Prevention (CDC) on Friday confirmed COVID-19 in California resident who has no at-risk travel history or exposure to another known patient.  The case has raised alarm bells that other COVID-19 infections may have passed under the radar in the US, where testing has been limited by the rigid CDC protocols and many state labs lacked training or capacity properly use the CDC test kits that they received.

However, infections with no prior source of COVID-19 contact remain the exception rather than the rule, said Dr Tedros, at the briefing.

“As long as that’s the case, we still have a chance of containing this virus if robust action is taken to detect cases early, isolate and care for patients and trace contacts,” he said. “As I said yesterday, there are different scenarios in different countries, and different scenarios within the same country.

“The key to containing this virus is to break the chains of transmission.”

This story was updated on 29 February 2020 to accurately reflect the cases of COVID-19 in Italy.

Image Credits: South Korea National Fire Agency, DXY, John's Hopkins CSSE.

Nicola Magrini (left), outgoing secretary of the WHO Essential Medicines List Committee, and Dr Tedros (right) at the launch of the electronic EML.

The World Health Organization launched the first-ever digital version of its latest Model list of Essential Medicines (EML) on Thursday. The move is the latest step in WHO’s effort to explore technology in a new focus on digital health.

“For more than 40 years, the list has become a reliable and credible source of the most important drugs,”  said Dr Tedros Adhanom Ghebreyesus, director-general of WHO at the launch of the new electronic tool, which will “revolutionize” the way it’s used.

Dr Tedros also paid tribute to Nicola Magrini, outgoing secretary of WHO’s EML Committee, who was tapped in January to replace Luca Li Bassi as the head of the Italian Medicines Agency.

He called Magrini’s departure from WHO “bittersweet,” and said the electronic EML was launched quickly in February partially as “a token of appreciation” for the secretary’s work.

The list, which provides guidance on the most crucial medicines for countries to have in supply, has been revised every two years by a group of WHO experts since 1977, and has previously only been published in print or PDF format.

Countries received a paper or PDF copy of the list, and manually searched through the many pages to find guidance on specific compounds to update their own national lists – which dictated which medicines to procure for the health system.

The new electronic format makes the WHO’s EML list more accessible and easily searchable on smartphone and computer screens. Users can search by medicine name or health issue, and filter results by target population, dates medicines were added to the list, and section of the EML. The customized lists are exportable to Excel or Word.

More than 150 countries currently use the WHO list to work out which medicines best meet their national health contexts and priorities, so they can compile their own national essential medicines lists.

Countries at all income levels rely on the list – including Canada, which is currently using the EML to design its own national list. According to Dr Tedros, the EML is one of WHO’s “most important products.”

“Of course placing medicines on a list does not on it’s own guarantee patient access,” said Dr. Tedros. But, the list still represents an important “first step in the policy process towards ensuring access to these medicines.”

Image Credits: Thiru Balasubramaniam.

For the second day in a row, new COVID-19 cases outside of China exceeded those inside the country on Thursday. According to the latest data Thusday evening, there were now 4,053 cases in 44 countries outside of mainland China, and at least 54 deaths.

The biggest hotspots remained Italy, Iran and Korea, but shifting numbers in those countries throughout the day made tallies more difficult. Korea, with the largest case tally, reported another 449 new cases Thursday morning, while a 6 p.m. bulletin noted that there had been another 171 cases since the morning.  That made for a total of 1,766 cases in the country.

And over the past 24 hours, seven more countries reported cases for the first time: Brazil, Georgia, Greece, North Macedonia, Norway, Pakistan and Romania.

“We are at a decisive point,” said Dr Tedros Adhanom Ghebreyesus in a daily WHO press briefing on the COVID-19 crisis. “My message to each one of these countries is: This is your window of opportunity.  If you act aggressively now, you can contain this virus. You can prevent people from getting sick. You can save lives. So my advice in these countries is to move swiftly.”

While the virus is more contagous than other recently emerged pathogens such as Ebola or SARS, a recent seroimmunological study in China’s Guangdong indicates that it still is not being transmitted as widely or as easily as seasonal flu or the common cold, the WHO Director General noted.

In the study, scientists tested more than 320,000 blood samples from community members, and found that only .14% were positive for COVID-19 antibodies.

“The evidence we have is that there does not appear to be widespread community transmission,” said Dr Tedros. “This suggests that containment is still possible. Indeed, there are many countries that have done exactly that. There are several countries that have not reported a case for more than two weeks,” he said, noting that those included: Belgium, Cambodia, India, Nepal, Philippines, the Russian Federation, Sri Lanka and Viet Nam.

“No country should assume it won’t get cases. That could be a fatal mistake, quite literally.”

Wellcome Trust Calls for US$ 10 Billion Investment By World Bank To Support Low-Income Countries  

In London, meanwhile, the director of the Wellcome Trust, one of the world’s largest funders of public health research, called upon the World Bank to open up $10 billion in funds from its Pandemic Emergency Finance Facility, to make critical investments in diagnostics and therapeutics needed by low-income countries to combat the virus.

Jeremy Farrar, Director of Wellcome, also called upon the International Monetary Fund and Regional Development Banks to step up to the bat with funding. Until now, the global development banks have been largely silent regarding the crisis.

“An urgent commitment of $10 billion, with more to follow as needed, is essential from the World Bank to underpin the public health measures in low- and middle-income countries, coordinated by the WHO alongside critical investment in diagnostics, therapeutics and vaccines,” said Farrar, in a press release. “Anything less leaves us at risk of much greater costs later and long-term catastrophe. The sums are considerable. The decision to release funds should not be taken lightly, but the stakes could not be higher.

“The continued rapid spread of this virus is extremely challenging to control and poses an unprecedented global challenge – to health systems, economies and to societies around the world,” Farrar added.  “Researchers around the world are increasing our understanding of this virus at an incredible pace. The World Health Organization and governments around the world have stepped up their response, implementing crucial public health measures which have undoubtedly reduced the impact and bought everyone critical time, we must use this window of opportunity.

“But now, what we are really missing, is tangible, high-level funding and support from global financial institutions including the World Bank, Regional Development Banks and the International Monetary Fund. The possible impact of this coronavirus is far beyond a health emergency – it’s a global crisis with potential to reach the scale of the global financial crisis of 2008. These institutions, designed to act as the world’s insurance policy, were quick to act then and can no longer stand by in the face of a crisis that is no less threatening.

“By instigating a bigger and more united multilateral effort, we can ensure no country is left behind, in particular those with fragile health systems in low and middle income countries.”

WHO Director General Dr Tedros Adhanom Ghebreyesus at Thursday press briefing.

Virus Does Not Respect Borders – Key Measures Countries Should Take  

“This virus does not respect borders. It does not distinguish between races or ethnicities. It has no regard for a country’s GDP or level of development,” added Dr Tedros.  “Our message is that this has pandemic potential… But we are not hopeless. We are not defenseless. There are things every country and every person can do.”

He said key measures countries should be prepared to take include readiness to:  

  • Detect cases early, isolate patients, and trace contacts;
  • Provide quality clinical care to the 20% of people who become seriously ill, including medical oxygen, ventilators and other equipment critical for respiratory care;
  • Prevent hospital outbreaks of infection;
  • Raise awareness and prevent further community transmission;
  • Ensure surveillance and monitoring, including at airports and border crossings, as well as reliable reporting.

“There are some vital questions that every country must be asking itself today,” said Dr Tedros. “Are we ready for the first case? What will we do when it arrives? Do we have an isolation unit ready to go? Do we have enough medical oxygen, ventilators and other vital equipment? How will we know if there are cases in other areas of the country?”

“Is there a reporting system that health facilities are all using, and a way to raise an alert if there is a concern? Do our health workers have the training and equipment they need to stay safe? Do our health workers know how to take samples correctly from patients?

“Do we have the right measures at airports and border crossings to test people who are sick? Do our labs have the right chemicals that allow them to test samples? Are we ready to treat patients with severe or critical disease? Do our hospitals and clinics have the right procedures to prevent and control infections? Do our people have the right information? Do they know what the disease looks like?  … These are the quesitons that every health minister must be ready to answer now.”

So far, he said, WHO had shipped testing kits to 57 countries and personal protective equipment for health workers to 85 countries that needed such supplies.  More than 80,000 health workers have undergone training with online WHO courses.

“Once again, this is not a time for fear. This is a time for taking action now to prevent infections and save lives now,” the Director-General said.

Some Countries Outside China See Disproportionately High Fatality Rates 

While the fatality rate for the virus has averaged around 2% inside China, some countries outside of China have seen far higher death rates.

Iran’s Foreign Ministry Spokesman, Abbas Mousavi, announces pending arrival of 20,000 COVID-19 test kits from China.

In Iran, notably, some 26 people are reported to have died as of Thursday out of a total of 245 infections.  That 10% average may, however, be indicative that “the extent of infection may be broader than what we are seeing,” said WHO’s Emergency Head, Mike Ryan.

China was set to ship some 20,000 COVID-19 test kits to the Islamic Republic to bolster its testing facilities, announced the Ministry of Foreign Affairs Spokesman Abbas Mousavi, on Thursday. Meanwhile, however, authorities also banned the entry of Chinese nationals into Iran, in an apparent effort to reduce any influx of new cases from abroad.

Iran has temporarily shut down schools, universities and cancelled mass cultural and sports gatherings across the country, in and effort to curb the disease.

Japan, the country with the fourth largest case load of COVID-19 infections, meanwhile, announced that it was closing all of its universities as well as schools and high schools until March 2 in order to contain further spread.

Meanwhile, in the United States, where Vice President Mike Pence was named Wednesday by President Donald Trump to lead national coronavirus response, Pence appointed US Global AIDS Coordinator, Debbie Birx, as White House Coronavirus Response Coordinator.

Trump, who on Wednesday, declared at a COVID-19 press conference that “the risk to the American people remains very low,” on Thursday was reported by the New York Times to have told all of the top health officials involved in COVID-19 response that any statements they made had to be cleared with the White House.

 

 

 

Image Credits: Johns Hopkins CSSE , @WHO, IRNA , @TheWhiteHouse.

Governments around the world are ramping up COVID-19 containment measures as new infections outside of China surged by 497 cases over the past 24 hours, outnumbering those inside the country for the first time ever during the epidemic.

The increase abroad was largely linked to an acceleration of COVID-19 outbreaks in Italy, Iran, and South Korea, which also were spilling over into other countries, in Europe and the Middle East.  Officials were aggressively restricting movement in areas with confirmed local transmission in an effort to curb person-to-person spread of the contagious virus.

On a more positive note, nine countries with COVID-19 cases had not reported any new cases in two weeks, including Belgium, Cambodia, Finland, India, Nepal, Philippines, the Russian Federation, Sri Lanka, and Sweden.

“The primary objective of all countries with cases must be to contain the virus,” said World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus in his opening remarks at a WHO briefing to UN Missions in Geneva on the emergency.  “I read the list of 9 countries who have not reported cases for two weeks. We should do the same: try to contain.”

Map shows growing case numbers in Italy, Iran, and South Korea. (Source: Johns Hopkins CSSE Global Map of COVID-19 Cases)

As of 4:30PM CET, China continued reporting a downwards trend in new cases, with 416 infections and 52 deaths by COVID-19 over the past 24 hours, for a cumulative total of 78195 cases and 2718 deaths since the epidemic began. Around the world, there have now been a total of 81,265 cases and 2770 deaths.

The highest overnight increase in cases was in South Korea, which reported 368 new infections and 4 new deaths in the past 24 hours. The country, now the largest center of an outbreak outside of China, has reported a total of 1261 cases and 12 deaths. Iran, meanwhile, reported 46 new infections, for a total of 139 cases and 19 deaths, making it the country with the highest number of deaths from the virus outside China. Italy saw an increase in 52 infections, to 374 total cases and 12 deaths.

Across all three countries, authorities have undertaken aggressive measures to lock down cities and communities with the highest concentration of cases.  Classes suspended in schools and universities; local public transportation was shut down, mass gatherings were canceled, and community members were strongly encouraged to stay home.

Despite the escalation of cases in multiple countries, the WHO director-general emphasized that, for the moment, the COVID-19 emergency had not reached “pandemic status” as there was no “sustained and intensive community transmission” of the virus, nor was there “large-scale severe disease or death.”

However, he underlined that all countries, whether they have cases or not, must prepare for a “potential pandemic”.  

Officials Pursue Containment of Outbreak in Italy and Iran

Officials across Europe were ramping up measures to stop the virus in its tracks, as cases linked to Italy were confirmed in Austria, Croatia, Germany, Spain, and Switzerland. An Italian adult who arrived in Algeria on 17 February became the second confirmed case of COVID-19 on the African continent on Tuesday, and a 61-year old patient in Brazil who had recently traveled to Italy was confirmed by the Brazilian Ministry of Health as the first case on the South American continent.

“In the European Union we are still in the containment phase, it is important to underline this,” Stella Kyriakides health commissioner of the European Center for Disease Control (ECDC) said at a press briefing in Rome at the conclusion of a joint WHO-ECDC mission to Italy.

However, “given how quickly the situation can change, even if we are currently in the containment phase, our public health care response across the EU must be ready to deal with increased numbers of COVID-19 infections,” she stressed. EU member states are currently reviewing pandemic plans, health care capabilities, and capacities for tracking contacts of infected individuals, diagnosing and testing cases, and treating acute respiratory illnesses.

Kyriakides praised countries for keeping borders with Italy open rather than “resorting to what at this point could be considered disproportionate and inefficient measures.” In Italy however, train service had been interrupted and there were barriers on roads around the 11 towns in Lombardy and Venetto at the center of Italy’s outbreak. Residents remained largely confined to their homes as authorities try to track down all suspected cases of COVID-19.

Health officials in Algeria discuss the country’s first COVID-19 case

Meanwhile, Algeria confirmed its first case of COVID-19 on Tuesday, just days after Dr Tedros met with African Ministers of Health at an emergency meeting on the coronavirus outbreak on 22 February. A WHO survey previously had determined that the African regional readiness level for COVID-19 was about 66% of what should be full preparedness capacity. Algeria was among 13 countries on the continent initially identified as “high priority” due to direct links and a high volume of travel to China, although the first confirmed case was in an Italian adult.

“The window of opportunity the continent has had to prepare for coronavirus disease is closing,” said Dr Matshidiso Moeti, WHO’s Regional Director for Africa in a press release. “All countries must ramp up their preparedness activities.”

WHO will be sending a team of experts to assist the response in Algeria in the coming days to assist in response efforts.

This upcoming weekend, the agency is also sending a team of experts to Iran, where numbers of cases and fatalities have climbed rapidly as officials tracked down suspected cases. Following in the footsteps of other countries with larger outbreaks, Iran has begun to limit large gatherings and public events, including suspending classes at 10 universities across the country by the end of the week, including schools in Qom where Iran’s first cluster of COVID-19 cases, rapidly followed by an out-sized number of deaths, was detected.

US CDC Warns Communities To Prepare For Community Spread

Across the Atlantic in the United States, US Centers for Disease Control officials warned journalists at a press briefing on Tuesday to “ultimately expect” to see community spread of the virus and prepare for “severe” disruption to everyday life.

The messaging represents a huge shift in tone for the US, which had up until then been largely focused on “largely successful” existing quarantine measures.”  There are currently 54 confirmed cases and no deaths in the country.

Nancy Messonier, director of the National Center for Immunization and Respiratory Diseases at the US CDC said that the country is now pursuing a “dual strategy” of continuing measures to contain the disease, while preparing “strategies to minimize the impact on communities.” She added that if communities experienced local transmission, the government may enact measures such as “school closures and dismissals,” encourage businesses to allow workers to telecommute, and postpone or cancel mass gatherings – similar to the strict measures China has taken to attempt to curb the outbreak.

“CDC is concerned about the situation… And now is the time for businesses, hospitals, community schools, and everyday people to begin preparing as well,” said Messonier.

COVID-19 response planning at the US CDC’s Emergency Operations Center.

Image Credits: European Center for Disease Control, Johns Hopkins CSSE, WHO AFRO, US Centers for Disease Control and Prevention.

Luca Li Bassi holds his transparency award

Former general director of the Italian Medicines Agency (AIFA) Luca Li Bassi was awarded the 2019 “International Transparency in Medicines Policies Awards” by the French civil society watchdog group l’Observatoire Médicaments Transparences (the Observatory for Transparency in Medicines), for his efforts in negotiating a milestone World Health Assembly resolution in May 2019 supporting more public disclosure of medicines costs by countries, which are now generally obliged to keep their purchase contracts with pharma suppliers secret under non-disclosure agreements. French MP Caroline Fiat was awarded the French national prize by the NGO for her efforts to encourage price transparency in the parliament.

Li Bassi navigated the draft resolution on “Improving the transparency of markets for medicines, vaccines, and other health products,” through a complex set of technical barriers and member state objections to final approval during the seventieth-second World Health Assembly.

Following on the WHA resolution, Li Bassi drafted and won Italian government approval for a decree requiring pharma companies to disclose any public contributions that they had received for R&D costs of new drugs, as part of their portfolio submissions for drug reimbursements by the national health system. While the decree was signed by both Ministers of Health and Finance in August 2019, Li Bassi was replaced as head of AIFA in a government reshuffle in last autumn, and the decree is yet to be published in the national gazette, when it would then officially take effect.

“Scientists, policy makers and the public all need to have more and clearer information on the life-cycle of medicines if we all are committed to achieve universal access to treatments,” Li Bassi told Health Policy Watch, regarding his efforts on the transparency issue. “The current asymmetry of information is not helping society to assess the efficiency and effectiveness of the current system and to explore ways to improve it.”

Caroline Fiat holds her transparency award

Caroline Fiat, a Member of the French Parliament for the political party La France Insoumise, was recognized by the Observatory for leading the charge on an amendment to the French Bill on Social Security Funding for 2020, that would require pharmaceutical disclosure of public contributions to R&D costs.

After bouncing back and forth between the National Assembly and the Senate, the amendment was finally adopted in the final version of the Bill, only to be blocked by the French Constitutional Council on a procedural technicality. The legal objection centered around the fact that French Minister of Health Olivier Véran initially had rejected all transparency amendments in the first reading of the bill. That led to the Council’s censoring of the final amendments, even after Véran joined the transparency bloc to co-write the amendment that was adopted by both houses of French legislators. Fiat has continued to push forward the issue by submitting public questions on the implementation of the amendment to the Ministry of Health, which has the authority to override the constitutional objections.

In an oblique reference to Véran’s inaction so far, representatives of the Observatory said in a press release that they are waiting on Véran to publicly confirm his support for the transparency amendment, and “hope to award him with this prize” in the future.

Skyrocketing medicines prices around the world have put transparency higher on the global health agenda, as proponents argued that the secrecy around disclosure of medicines prices and R&D costs puts public health systems at a disadvantage when negotiating medicine prices – combatting pharma industry claims that the information is proprietary and confidentiality is needed to encourage costly medicines R&D.

In its press release, the Observatory said the awards to “pay tribute to critical individual and courageous actions” and “shed light on people occupying institutional positions” that push forward initiatives on transparency in many aspects of their work.

Transparency Legislation Recognized As Team Effort

In his comments to Health Policy Watch, Li Bassi’s view said his reward represented “the result of the efforts made by many delegates at the last World Health Assembly to take a milestone step for global health.”

“While it was indeed challenging to arrive to a consensus on a very contentious topic, the efforts made to reach an agreement were fueled by an incredible motivation in all delegates to do something concrete to improve access to medicines and other health products,” he added. 

The Observatory also paid tribute to all the countries who “co-sponsored” the resolution on transparency, against stiff opposition from a handful of governments. That included Lenias Hwenda, representative of Zimbabwe and vice-chair of the negotiating group, as well as other representatives of countries.

In France, a number of politicians across seven different political parties have supported the transparency amendment. Fiat has also aligned her efforts with hospital and emergency care health workers in France who have been protesting against cuts to public hospitals in staffing, funding, and equipment.

“Major progresses in health policies cannot be attributed to individuals alone,” said the Observatory press release. “Democratic life needs such strong, courageous and concrete actions, from various stakeholders, and cannot content itself with lukewarm actions.”

Image Credits: l'Observatoire Médicaments Transparences.

WHO’s Bruce Aylward shows a graph of the epidemic curve in China, showing how rate of new infections has decreased due to China’s strict outbreak response measures.

COVID-19 can be beaten – but it will take a big mindset shift on the part of the global community to achieve what China has done – which is dramatically curb transmission of the new, mysterious and deadly coronavirus using traditional public health measures for digilent tracing of contacts, isolating those found to be ill; and providing intensive care, including advanced respiratory treatment, for the 20% of serious cases.

That was a key message from Bruce Aylward, the head of a WHO-convened independent commission of experts that just returned from a 10-day trip to China studying the massive public health effort now underway there.

Aylward spoke as new cases in China continued a generally downward trend, with 523 new cases and 71 deaths in the past 24 hours, but cases elsewhere in the world were now exploding.

The latest count included 2573 cases in 39 countries, an overnight increase of 292 infections. The biggest hotspots continue to be: Korea with 977 infections and 10 deaths; Italy, with  322 cases and 11 deaths; and in Iran, 93 cases including the infection of Iran’s deputy health minister, and 16 deaths.  In Switzerland, a 71 year old man was the first to be diagnosed with COVID-19 after visiting Lombardy, Italy 10 days ago for a conference. The fact that the case reports have increased so rapidly in all three countries over just the past few days suggests that other infected people may also be circulating undiscovered and infecting others, repeating a pattern that occured in the first weeks of the coronavirus emergency in China.

“What has China down and how they have done it is extremely important,” said Aylward, speaking to journalists on Tuesday, just hours after his return. “We have escalating outbreaks [even] in industrialized countries.  We have got to try to respond.”

In an unusually fresh, if sometimes rambling, account by a WHO official, Aylward called on countries to undergo a “shift in mindset.”  He used wartime terminology to describe the public health battle that countries will need to mount to effectively fight the virus, while describing the R&D effort required as a modern-day “Manhattan project.”

Aylward also painted a stark picture of the alternative – exponentially expanding infections and health systems becoming overwhelmed and even collapsing with the weight of treating so many seriously ill patients, often requiring advanced respiratory care.

Yet, too many public health officials remain both unprepared and fatalistic about the virus – approaches that will be devastating when cases finally appear on their doorstep.

Health checks at the “Milano Malpenza” airport in Milan, Italy.

“Is this a pandemic or not? Folks this is a rapidly escalating epidemic in different places that we have to tackle really fast.  But what China demonstrates is where this goes is within our control,” said Aylward.

“For the rest of the world, there has to be a shift in mindset. Around the world, people are thinking ‘how do we live with this, and manage all this disaster’, instead of saying: ‘This virus is going to come, we are going to find every case, isolate it, find every contact.’

“Countries have got to be shifting to a rapid response type of thinking. You can change the shape of this, but it takes a very aggressive and tough programme. In 30 years of doing this business, I have not seen this before,” he said, of the Chinese response.

An expert report outlining key findings and recommendations was being submitted Tuesday to WHO’s Director General Dr. Tedros Adhanom Ghebreyesus, Aylward said.  He described it as a consensus product of the 13 international disease control experts who participated in the mission, from institutions and countries as diverse as Nigeria CDC, the United States Centers for Disease Control, and Germany’s Robert Koch Institute.  Recommendations were made by the experts as individuals, and not on behalf of their institutions, he added.

Main Finding- Tough Chinese Measures Averted Hundreds of Thousands More Infections

While oft-criticized as draconian, Aylward said that the commission found the tough Chinese measures were proving to be effective, and so other countries need to study them and learn their lessons:

“It is the unanimous assessment of the team that they have changed the course of this outbreak. It was a rapidly escalating outbreak.. It has plateaued and is coming downward sooner than expected,” said Aylward.

“Hundreds of thousands of people in China did not get COVID-19 because of the aggressive response… and they also reduced the probability of this going elsewhere.”

He said that the strict quarantine, isolation and contact tracing measures were justified in the name of saving lives, and avoiding the swamping of health systems with seriously ill cases that even developed country health systems often lack capacity to treat.

“You are at war here. Is this a dangerous virus or a serious virus, bottom line is that this virus kills people, it kills older people it kills vulnerable. And young people die too. And they die in industrialized countries.”

“Instead of debating if COVID19 is a pandemic or not, countries need to ask themselves:  ‘Do you have your isolation beds ready for people that will need to be hospitalized? Do you know who your thousand contact tracers are? There are really practical things to be done?

“Countries need to keep in mind: People who get sick remain in hospital from 2-6 weeks so its a long time in hospital/isolation center.

80% of cases are mild, but with regards to more severely ill, there is the “sheer weight of numbers.. that’s really important, you have got to plan, how many beds… etc.

“How many countries are planning hospital beds, ventilators. lab supplies to be able to manage this? “You are going to need beds to isolate people and quarantine really close contacts. You have got to be able to accommodate those people, you have got to have enough ventilators for the serious cases, you have got to be able to transport people, have the lab capacity.”

“People are talking about [whether this is more like] SARS or flu, as soon as we get stuck with the two binary approaches we are not preparing for novel coronavirus.”

Nurse wearing a specialized mask, cap, gown and gloves measures the body temperature of a coronavirus patient in Hubei TCM Hospital. Such gear is vital to protect health workers from infection.

Using Old Fashioned Public Health Tools – And Mobilizing All Government Sectors   

China took a “very pragmatic approach” and decided to aim for the containment of the virus, using this set of traditional public health tools – including finding cases, contact tracing and rapid hospitalization of those who were seriously ill, but also the quarantine of mildly ill cases to stop the transmission chain; and even the isolation of close contacts and suspected cases.

Aylward said that the visiting experts sometimes wondered, “‘Is this real, this extraordinary mobilization to implement fundamental public health principles and approaches in the absence of a vaccine. Can this bring it down? Yes it can.””

“It was a science-driven” effort, agile response but deployed with extraordinary rigour, says Aylward, noting that clear guidelines for managing cases were issued and revised rapidly in line with new developments. Big data was deployed to find cases, and their contacts and to isolate them.

At the same time, the response was not monolithic, he stressed. Uniform guidelines were applied in a “differentiated” manner, across different provinces, depending on the level of infections.

“The fundamentals were always the same but the degree of application was different. There was a  differentiated approach when there were zero cases, sporadic cases or community transmission like they had in Wuhan.”

Aylward said that the differentiation allowed more efficient use of resources so that the national response effort was not exhausted. “A lot of people have said we can’t do this at scale because you will exhaust your response. The Chinese said ‘not if you tailor this properly.’

And at local level “There was a lot of latitude.. big rules were in place but provinces, towns, communities could adapt them to make it work for them, ” he said.

While hospital infection control failures in the first weeks of the coronavirus epidemic led to many health workers becoming ill and even dying, measures are now well in place for managing “clean and dirty channels” of hospital systems, and health workers now appear to be adequately equipped with personal protective gear. These, however, are key challenges that health systems elsewhere now need to prepare to meet.

Another secret to the success of the effort so far, has been the way all government sectors, from transport to agriculture, were mobilized to the public health mission at hand, Aylward said.

“They repurposed the machinery of government – all of government – to fight the virus,” he said, noting that transport services were rerouted not only to skip communities where the infection toll was high, but also ensuring wide spacing between passengers in areas where trains and metros were running normally.

“Food supplies were channeled to ensure that areas under lockdown had adequate provisions. And prepared meals were arranged and served in such as way as to minimize food-borne transmission of the infection, including by seating members of the expert team at separate tables at the China CDC cafeteria.

“We talk about all of government responses, but usually it doesn’t have much meaning,” Aylward said, adding that in the case of the Chinese battle against COVID-19, it did. “Everyone has a role that has been repurposed to fit this machinery.”

Public Support For Aggressive Containment Is Key

Another one key aspect of the China effort was the way in which massive public support was recruited at every level of society.

“They [China] mobilized a phenomenal collective and cooperative action,” said Aylward, saying that the level of commitment exceeded anything that could be simply imposed from above by an authoritarian government.

“It’s never easy to get the kind of passion, commitment and individual sense of duty.

“…We spoke to hundreds of people on planes, trains outside the system, they all shared this responsibility to be part of this.”  Over and over, said Aylward, “we also heard people say, ‘It’s our responsibility to do this for the world.’ ”

Public health officials elsewhere have to think about how to build similar awareness and social solidarity around a critical global public health battle.

“To accept quarantine, to accept rapid isolation there are going to be challenges for people to accept that. And are we ready to quarantine and isolate that number of people?  There are mindset issues. But we have got to overcome them,” said Aylward.

Face mask use across  the Middle East increases as new cases appear linked to travel in Iran. (Photo Credit: Farsnews/Sajad Toloui)

Access China Expertise & Launch “Manhattan Project” For Coronavirus Research 

Aylward also said that Chinese expertise could now be critical in helping other countries fight the virus, and he urged other public health systems to access Chinese experts.

“They have done this at scale. They are really good at it. They are ready to help,” he said.

He noted that rich and poor countries alike need help in preparing for the virus.  Rich countries may have hospital beds, but lack appropriate isolation facilities.  They may have respiratory units, but those may be inadequate to meet the scope of the new virus. And they also need to be identified and mobilized for any area where clusters of illness occur.

At the same time, poor countries lack capacity for treating severe cases, and that also needs to be addressed, he said.

“I also worry that when this gets into lower capacity health facilities, they don’t have ventilators, they don’t have the capacity to keep people alive.”

Ultimately, said Aylward, health authorities need to ask tough questions now, such as:  “Are we ready to manage these people?”

“This is not flu, it is a more SARS-like pathology.  Are we ready to manage that.. to go after the transmission of this thing. Don’t accept the inevitability that you cannot control this virus.”

Research can help to provide longer-term solutions, he added, although there too, a massive response will be needed. “You want a Manhattan Project on your top vaccine candidates and top therapeutics,” he said, for a disease that currently has no effective drug remedies or cures.

“Rapid diagnostics are urgently needed as are seroimmunity studies to see if a much wider population may be silently exposed and developing some protection to the virus, as are household studies to better understand the mechanisms of transmisison. “In terms of research, use the time well,”he advised. “Research saves lives.”

Watch the entire press conference here:

See Open WHO knowledge base with emergency resources for policymakers, professionals and researchers here.

 

Image Credits: Dipartimento Protezione Civile, China News Service, FarsNews/Sajad Toloui.

Health checks at the “Guglielmo Marconi” airport in Bologna, Italy

With spiraling outbreaks of COVID-19 in 3 countries, Iran, Italy, and Korea, WHO officials warned Monday of growing risks that the epidemic could become a full-fledged pandemic – although Dr Tedros Adhanom Ghebreyesus stepped back from the brink, telling a press briefing on Monday: “Does this virus have pandemic potential? Absolutely it has. Are we there yet? Not yet.”

“We have hope, courage and confidence that this virus can be contained,” he added, speaking at a daily press briefing. “We are not witnessing the uncontained global spread of the virus with significant deaths.”

In a visit to Geneva, UN Secretary General Antonio Guterres called on UN member states to “do everything they can to contain the disease” warning that if even a few countries fail, the epidemic will veer “out of control, with dramatic consequences to global health and global economy.”

According the latest official Chinese data, the trend showing a decline in new cases in China continued on Monday, with only 423 fresh reports of infection over the past 24 hours, leaving a total of 77,269 cases, and 2,596 deaths. Abroad, however, the story was of a percolating  crisis with 2,281 cases and 32 deaths reported as of Monday afternoon.

Italy, Iran and Korea – New Virus Test Grounds

In Italy, one of the newest epicenters, some 230 cases and six deaths were reported as of Monday afternoon. That was as compared to 16 cases on Friday according to the Ministry of Health.

Some 11 towns – 10 in the Lombardy region just south east of Milan, Italy’s financial nerve center, were under a strict quarantine. Schools were shut, train service suspended, and police barricaded main roads around the communities where at least 163 people were infected. The Ministry of Health on Sunday expanded strict measures region to Italy’s Veneto region too.

Austria temporarily suspended train service from Italy on Sunday, and announced that the country was reconsidering the reintroduction of border controls. But Switzerland and other neighboring European Union countries left their borders open. European Union Health and Food Safety Commissioner Stella Kyriakides told reporters Monday that the WHO had not recommended imposing travel restrictions across the EU’s open “Schengen” “zone . The European Centers for Disease Control meanwhile announced  that a group of European experts were being sent to Italy to assist in the response and further develop recommendations for coordinated action.

Said Kyriakides, “We all need to take this situation very seriously, but without giving in to panic, even more importantly, to disinformation.”

Iranian officials, meanwhile, were still scrambling to determine the chains of transmission behind the cases in the country, even as the outbreak spilled over into neighbors. At least 10 countries tightened border controls and enacted travel restrictions in response to the Iranian outbreak, where at least 61 cases and 12 deaths have now been reported, according to WHO’s Eastern Mediterannean Regional Office. The outbreak has left Iran with the highest death toll from the virus of any country outside of China.

Commuter in Iran wears face mask as COVID-19 cases climb (Photo Credit: Farsnews)

Many of the 10 countries that had imposed travel restrictions  tightened border controls after confirming their own cases of COVID-19, linked not to travel in China, but to travel in Iran. Just Monday morning, Oman also suspended flights to and from Iran indefinitely after the country’s first two COVID-19 cases were confirmed in two Omani women who had recently returned from Iran.

Meanwhile the South Korean government raised the level of the response to “red” – the highest possible level – as cases quadrupled from 204 infections Friday to 833 confirmed cases and 7 deaths as of 8:00AM CET Monday, according to the Korean Center for Disease Control.

Among the new Korean cases confirmed over the weekend, 18 people had just returned from an eight-day religious pilgrimage to Israel on 16 February. That left Israel scrambling to identify local contacts of the pilgrims for followup, while also turning back all but 11 of 188 passengers on board another Korean airliner that landed in Tel Aviv on Sunday, due to infection fears. The return of the Korean passenger plane triggered diplomatic protests from Korea.

In Korea’s Daegu, where an explosion of cases was linked to the Shincheonji Church, Korean authorities have obtained an entire list of the church’s membership for follow-up, and to encourage members to self-quarantine.

Mixed Messages on Outbreak Containment Measures

WHO and other UN officials, however, continued to project mixed messages about what containment measures countries should follow – praising tough Chinese steps as effective, on the one hand, but also discouraging other countries from taking similar measures.

The praise came at a press briefing in Beijing. There, a group of WHO-convened international experts led by WHO’s Bruce Aylward, who had been on a weeklong mission, expressed support for the country’s unprecedented containment efforts.

Those measures effectively put Wuhan, the city of 11 million people at the epicentre of the outbreak, under quarantine, as  mass events and meetings were canceled, commercial and entertainment centres were closed, and the movement of millions more across the country was restricted.

Even in Tianjin and Shanghai, far from the epicentre, some apartment complexes are under virtual lockdown, with only one family member allowed to leave the complex per day to buy food, local sources have told Health Policy Watch. 

Aylward highlighted that new cases had dropped so low in China that a Chinese researcher had trouble enrolling new patients into a clinical study for remdesivir, the only antiviral that “may have real efficacy” against the new virus.

The WHO team’s assessment has been that the measures taken in China averted the more rapid spread of the disease elsewhere. Guterres echoed those remarks in his Geneva briefing today, telling reporters that the world owes a debt of thanks to the Chinese:

“My message to all of those in China, who are deprived of a many aspects of a normal life, is a message of gratitude because it is the sacrifices of those who are deprived of those positive aspects of life, so as to avoid the propagation of the disease, who are rendering a service to humanity,” Guterres said, speaking in French.

He added, “All countries must do everything to be prepared, and all countries must do everything – respecting naturally the principle of non-discrimination, without stigmatization and respecting human rights – do everything they can to contain the disease.”

“This disease is still possible to be contained but if some fail, if some do not do everything that is needed, this can still become out of control, with dramatic consequences to global health and global economy.”

However, an hour earlier at a WHO press briefing, Emergencies head Mike Ryan was more ambivalent about the degree to which other affected countries, such as Italy and Iran, should imitate China’s tough measures – which have included the mass cancellation of public events, as well as the strict curtailment of entertainment, business and commercial activities, even in lesser affected cities, such as Shanghai.

“The natural transmission dynamics if you look at most cases, including in China are in family clusters,” said Ryan. “That has been driving the epidemic. Then there are very then particular circumstances… We need to understand the exact dynamics of what has been happening in Iran. Clearly there have been gatherings for religious festivals, people coming and moving on afterwards.

“We are reaching out to all affected countries to ensure that they have the necessary technical  assistance.  But I caution everybody, please don’t extrapolate from one individual country experience, each country is different.”

As for the outbreak in northern Italy, Ryan expressed strong opposition to travel restrictions, saying. “The European Union and Switzerland and other countries have been working together to maintain their open borders and to manage this risk collectively.”

He added, “There is no zero risk. This is about good risk management. It’s about good communication between states.  It’s about management and early detection of cases and their appropriate isolation and treatment.  It’s not about shutting borders; it’s about coherent coordinated public health actions of of a number of member states that share borders to manage the public health consequences.”

Iranian officials are still scrambling to determine the chains of transmission behind the cases in the country, even as the outbreak spilled over into neighboring countries. At least 10 countries have enacted travel restrictions for people transiting through Iran, reaching 61 cases and 2 deaths according to data from WHO’s Eastern Mediterannean Regional Office.

The 10 countries with travel restrictions on Iran include Turkey, Georgia, Jordan, Saudi Arabia, Lebanon, Iraq, Egypt, Kuwait, Bahrain, the United Arab Emirates, Afghanistan, and Pakistan. Many of the same countries tightened border controls after confirming their own cases of COVID-19, linked not to travel in China, but to travel in Iran. Oman became the latest country, suspending flights to and from Iran indefinitely after the country’s first COVID-19 cases were confirmed in two Omani women recently returned from Iran.

Trucks pile up at Bazargan, Iran border crossing, closed by Turkey since early Monday morning due to coronavirus fears.

Donors Dramatically Step Up Funding Support

With the virus accelerating on European shores, the EU today announced a €232 million package for the coronavirus emergency, one-third of the US $675 million requested by the WHO to fund the global response.

France, Germany, and Sweden have also contributed funding to the global response efforts. Germany today announced a €3 million infusion for the response today, following on Sweden’s commitment of SEK 40 million (€3.8 million) earlier Monday.

In terms of the EU commitment:

  • €114 million will support the World Health Organization (WHO), in particular the global preparedness and response global plan. This money would boost public health emergency preparedness and response work in countries with weak health systems and limited resilience. Part of this funding is subject to the agreement of the EU budgetary authorities.
  • €15 million would be allocated directly to African institutions, including to the Institut Pasteur in Dakar, Senegal to support strengthened capacity for undertaking rapid diagnosis and epidemiological surveillance.
  • €100 million will support development of new health products and tools, including up to €90 million in funds to public-private partnerships with the pharmaceutical industry and €10 million directly spent for research on disease epidemiology, diagnostics, therapeutics and clinical management of containment and prevention.
  • €3 million will be allocated to the EU Civil Protection Mechanism for repatriation flights of EU citizens from Wuhan, China.

Guterres, at the WHO briefing called on countries worldwide to step up to the bat regarding WHO’s appeals for funding to confront the outbreak.

“If there is something stupid one can do in today’s world it is to not fully fund WHO appeals,” he said. “My appeal to all donors is to make sure that WHO appeals in relation to this virus, but also to other commitments around the world are fully funded.”

Image Credits: Dipartimento Protezione Civile, Farsnews.com, Twitter: @IrnaEnglish.

Pilgrims visit the Holy City of Qom in Iran. (Photo Credit: Pierre Le Bigot)

Containing an explosion of COVID-19 cases in Korea and Iran have become top priorities for global health officials battling to prevent the epidemic from growing into a worldwide pandemic. While new lab-confirmed cases in China on Friday numbered 896, more than double the day before, that was still part of an generally downward trend as compared to the two weeks before. But expanding clusters of cases in prisons, including one in the eastern Chinese province of Shandong, elevated concerns about Chinese hotspots outside of Wuhan, the epicentre of the outbreak.

Early Friday evening, meanwhile, Italian health officials announced a cluster of 8 new cases in the northern Italy town of Codogno, five among medical staff at the local hospital, where 3 infected patients who had contracted the virus, were already being treated. The new reports brought Italy’s total of confirmed cases to 16.

The Italian, Korean and the Iranian cases illustrate how seemingly random events involving just a few individuals can drive much larger outbreaks of the highly contagious virus. In South Korea, just one woman has infected dozens of other fellow members of her church in the city of Daegu.

In the case of Iran, a mysterious series of geographically dispersed clusters led to reports of some 18 infections as of Friday, four deaths in the pilgrimage city of Qom, and onwards transmission of the virus by two infected travelers who were identified upon arriving in Canada and Lebanon.

“The window of opportunity may be closing,” said Dr Tedros Adhanom Ghebreyesus in a press briefing on Friday. “Although the total number of cases outside China remains relatively small, we are concerned about the number of cases with no clear epidemiological link, such as travel history to China or contact with a confirmed case.”

Origins of Iran’s COVID-19 Cases Unclear 

While most of the cases outside of China have until now been linked to travel to the epicenter of the outbreak or known contacts of confirmed cases, the transmission patterns in Iran are so far unclear. Reports of cases in Lebanon and Canada, linked to recent travel from Iran, but not to China, were later confirmed by health officials in both countries.

An Iranian Ministry of Health official told CNN news that it was “possible” more cases existed in cities across the country, and speculated that the virus was possibly imported by Chinese workers living in Qom, an important center of Shiite Muslim pilgrimage. China has continued to do business with the Islamic Republic in defiance of US sanctions. However, a Ministry of Health official told Iranian News Agency IRNA on Thursday that two patients who had died of COVID-19 in Qom had not reported any contact with foreigners or Chinese nationals, and their families had not yet been subjected to quarantine.

“We’re getting information [from Iran], but we need to engage with them more,” said Tedros. “These dots or trends are very concerning and we’re working with the government to fully understand the transmission dynamics.”

Meanwhile, cases in South Korea shot up by 100 new cases in the past 24 hours to a total of 204 confirmed cases, making South Korea the country with the highest number of cases outside China. According to the Korean Centers for Disease Control, at least 129 of those cases are members of the Shincheonji church, a Christian organization considered cult-like by many mainstream churches. Most cases related to the church have been clustered in Daegu, although cases in church members have also been reported in Seoul and Gwangju.

Sweeping Closure of Commercial Activities & Public Events In Italy’s Lombardy Region 

In response to outbreak in northern Italy, Minister of Health Roberto Speranza announced a sweeping series of measures in Codogno and about ten other surrounding towns, including: suspension of all public events, commercial activities, schools and day care centers, municipal works, public transport services, and recreation services.

The total number of people infected in the Lombardy region now stands at 14, said the minister and other health officials at a press conference Friday.  The officials’ descriptions of the infection chain illustrates how very casual contacts played a role in the expanding outbreak. The first person to be infected was a 38-year-old man who had become ill after meeting a friend recently returned from China.  He then infected his wife, and a running group acquaintance. They were all hospitalized. Three older friends of the runner, who all frequented the same bar, were then infected, followed by the five health workers at the local hospital, who were treating the initally infected patients, and several others.  There are reportedly two other COVID-19 cases in Italy’s Veneto region.

Despite the fast-changing path of the virus, WHO’s Director General said he still believed that the outbreak could potentially be contained, if countries step up preparedness measures.

“The window of opportunity is still there but [it] is narrowing, and that is why we call on the international community to act, including the financing, and that is not what we see.”” said Dr. Tedros.

China Changes Reporting Protocol Again Amid New Spread In Prisons

As of 5:30pm CET, there were 896 new cases of the virus in China according to official Chinese data, higher than the increase of 404 cases recorded yesterday, but much lower than the 2,000-3,000 new cases reported almost daily in the previous week. Total cases in China were 75,571, while abroad the total number of cases exceeded 1,225 in 27 countries, late Friday afternoon, as Israel also reported its first coronavirus case – in a passenger returning from the Diamond Princess cruise ship.  That latest count did not include the late breaking reports of infections in Italy.

The significant decline in new confirmed Chinese cases may indicate that authorities there are finally getting the infection more under control.  But it is also partly due to another change in the way China reports numbers. After adding over 14,000 clinically diagnosed cases to the number of confirmed cases in Hubei province on Wednesday last week, authorities have reverted back to only including lab diagnosed cases in the count, WHO officials said today at the press briefing. They said that the zig zag was due to the fact that with less pressure on health systems, most suspected cases were now being rapidly lab confirmed.

In a place with the lab capacity to test every suspected case for the virus, the “recommended approach” is to classify lab-confirmed cases as confirmed, and other cases as “suspected,” explained Tedros. “We’re glad China has gone back to this approach, we think it will bring more clarity.”

In response to concerns about the confusing changes in reporting measures, WHO’s director of epidemic and pandemic diseases Sylvie Briand stressed, “As long as we understand the situation, it helps us. Surveillance or monitoring disease is about taking the best possible decision and collecting numbers for action, not numbers for numbers… Beyond the numbers what’s important is trends.”

“Understanding the definition” rather than where the numbers are reported is the basis for decisions, she added. “At the end of the day, as long as the decision behind the numbers is a good decision, that is what matters most.”

WHO Director General Expresses “Concern” Over Increase of Cases In Shandong Province – Reference to Prison Hotspot   

WHO’s Tedros also said that WHO was “concerned about an  increase in the number of cases in Shandong province.” According to a local news station Qilu Evening News, 200 of the 202 new cases reported in Shandong Thursday night occurred in Rencheng prison. Some 207 cases have been reported in total from the prison, including 7 prison guards and 200 prisoners.

The reports were confirmed by state owned news agency Xinhua on Friday, which reported that the index case was a prison guard who was diagnosed on 12 February. However, proper infection prevention control measures were not taken until much later, leading to a dramatic overnight rise in confirmed cases in the prison. The debacle led to the national government launching a formal investigation into the handling of the outbreak, which resulted in the replacement of the director of the Provincial Justice Department and sacking of a number of prison officials, including the director of Rencheng prison, according to Xinhua.

But the South China Morning Post reported that there have been a number of other prisons in China where outbreaks are flourishing in confined and closed conditions. These include a Wuhan Woman’s Prison, which has reported some 230 cases, and smaller clusters in Shayang Hanjin prison in Hubei province and Shilifen Prison in Zhejiang province.

Reports about the contagious virus’ spread in prisons mirror the growing concern around transmission of the virus in so-called “re-education” centres in Xinjiang province, where China has reportedly detained 1-1.5 million ethnic Muslim Uyghurs in overcrowded facilities with limited access to medical care, contact with friends and family, according to a report by the UN’s Office of the High Commissioner for Human Rights (OHCHR).

So far, WHO has not made any public comment on the potential transmission of the virus in the camps, which have been criticized by the OHCHR as “amounting to detention centres” due to their “coercive nature.”

Updated Saturday 22 February 

Image Credits: Flickr: Pierre Le Bigot.