Restaurants, bars and shopping centers reopen in Geneva, Switzerland

Preliminary results from a Swiss study found that the prevalence of antibodies against SARS-CoV-2, the virus that causes COVID-19, in children ages 5 to 9 years old is 68% lower than the seroprevalence in adults aged 20 to 49 years old. 

The study, titled SEROCoV-POP, reported seroprevalence results from almost 2800 participants followed from April 6 to May 9, the first five weeks of a 12 week followup period. A previous paper posted in the preprint server MedRxiv, which analyzed data from the first three weeks of the study period, found that there was no significant difference in the seroprevalence in children compared to adults. Both studies found that older adults had a lower seroprevalence.

The most recent analysis found only about 11% of the Swiss population has antibodies against SARS-CoV-2, slightly higher than the 9.7% seroprevalence estimated in the previous paper.

“Our results highlight that as the end of the epidemic curve in Geneva approaches, the immunological landscape has not substantially changed since before the pandemic, with most people having no evidence of past infection,” wrote the authors, representing Geneva University Hospitals and the Johns Hopkins Bloomberg School of Public Health. 

They also noted that the Geneva study represents one of the most high quality, representative seroprevalence studies to date. Existing sero-surveys from the USA, Brazil or Denmark don’t ‘accurately reflect’ the true proportion of the population with antibodies, because study participants were likely to be healthier than the average person, or were recruited from less affected areas.

The serosurvey results come as a Lancet Correspondence from Thursday claims that there is “little evidence” to support herd immunity – A controversial theory that assumes exposing an entire population to a disease will eventually lead most to develop immunity. Experts from the World Health Organization have repeatedly cautioned against assuming that herd immunity will protect against further waves of the virus. 

The cumulative mortality rate per capital has plateaued at different levels in different countries, and countries that went into lockdown early experienced fewer deaths, indicating that public health measures, and not herd immunity, were responsible for reductions in mortality.

“Under herd immunity, the cumulative mortality rate due to COVID-19 per million of the population would be expected to plateau at roughly the same level in different countries (assuming similar basic reproduction numbers). This is not what the data show,” the authors of the Commentary wrote. 

The Lancet Correspondence, which was submitted by the UK’s MRC Centre, Imperial College London and Oxford University, analysed cumulative per-capita COVID-19 mortality data from a number of countries, as well as seroprevalence studies.

US Chamber Of Commerce Spokesperson Supports Transparency Around COVID-19 Vaccine
Spike glycoproteins decorating SARS-CoV-2’s membrane surface; highlighted in red is a potential neutralization site, which is a protein sequence that might be used as a target for vaccines.

A spokesperson for the United States Chamber of Commerce, the largest trade lobbying group in the country, has supported increased transparency for a COVID-19 vaccine, according to the Independent. 

However, finer details of the Chamber’s endorsement is still unclear, and does not extend to supporting voiding of intellectual property and patent rights. 

“The short answer is yes [more transparency is needed]. But we don’t have a clear-cut US Chamber position on that,” Patrick Kilbride, a senior vice president of the US Chamber’s Global Innovation Policy Centre (GIPC), told The Independent. 

The US Chamber’s tepid support comes amidst repeated calls from global leaders, including France’s President Emmanuel Macron and Germany’s Chancellor Angela Merkel, for any COVID-19 vaccine developed to be a ‘global public good.’ 

AstraZeneca, along with Johnson & Johnson and Glaxosmithkline (GSK) announced In late May that they were taking a ‘not-for-profit’ approach for vaccine development. But access advocates have argued that further transparency and disclosure around costs of production are needed in order to ensure true ‘no-profit’ prices.

“This is a unique situation and I feel comfortable saying that a higher level of transparency is warranted, especially given the unusual public sector contribution to some of the efforts that are ongoing,” said Kilbride.

“There’s this enormous and unprecedented mobilisation of R& D by business, and to a certain extent added to by government and various other non-governmental organisations,” Robert Grant, director of international policy at the GIPC. “It really is a considerable collective effort that is typically much less common in non-crisis times.”

For example, Pfizer, which announced in late May they were moving towards Phase 3 clinical trials in July, has received funding from the United States Health and Human Services Biomedical Advanced Research and Development Authority department for clinical trials. AstraZeneca is closely working with Oxford University on their vaccine candidate. 

See the full story on The Independent.

Image Credits: S. Lustig Vijay/HP-Watch, National Institutes of Health/David Veesler, University of Washington.

A severe disruption of reproductive and children’s health services during the pandemic could cause more deaths in women, children, and adolescents than COVID-19 itself,  according to World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus.

“The indirect effects of COVID19 on this group may be greater than the number of deaths due to the virus itself,” warned Dr Tedros. “Because the pandemic has overwhelmed health systems in many places, women may have a heightened risk of dying from complications of pregnancy and childbirth.”

As health facilities pivot towards providing COVID-19 care, reports of women unable to reach childbirth facilities have emerged in countries like Peru. Many maternity hospitals have also shut down.   

“Maternity and child health services are not functioning, or only partially functioning in over 150 locations around the world. Many thousands could die from preventable complications in childbirth and pregnancy,” said Executive Director for the UN Family Population Fund (UNFPA) Natalia Kanem.

Amidst the scarcity of health services, unintended pregnancies and child marriages could shoot up, as women, children, and adolescents lose access to health programmes. For every six months of lockdown, some 47 million women could lose access to contraception, leading to 7 million more unintended pregnancies. 

With people stuck at home during lockdowns, domestic violence has also shot up, as survivors quarantine with their abusers. 

“It’s truly an emergency pandemic within the pandemic,” said Kanem. “We are joining WHO to sound a ‘red alert’ to stop gender based violence – to offer timely assistance to women and girls who are now trapped in abusive situations.”  

Image Credits: Twitter: @Atayeshe.

Roberto Azevêdo (left) meets with the United States President, Donald Trump, at the World Economic Forum Annual Meeting in Davos, Switzerland.

The early resignation of Roberto Azevedo from the post of Director General (DG) of the World Trade Organization (WTO), sets the stage for a highly politicized competition over his successor – who will face a major challenge in demands to reshape the WTO in the wake of repeated US complaints about its trade dispute rulings and policies with an alleged pro-China tilt.

Azevedo announced in May that he would be resigning from the position as of 31 August 2020, a year before his term formally ends. Azevedo, a seasoned and well-regarded member of Brazil’s diplomatic corps before taking on the role of WTO DG, presided over a period when the WTO’s effectiveness as a negotiating forum was eroded. Political conflict between economically powerful Members, most recently precipitated by the United States, brought its highly regarded dispute settlement system to a standstill. Now, as the COVID-19 crisis has sent global trade into a tailspin, the question is who – if anyone – can revitalize the Organization and reassert its preeminence in trade governance.

The new Director General will face a range of sharp debates around trade issues that are critical to health – including the need to ensure wide global access to new COVID-19 medicines and vaccines. But beyond the current pandemic, the WTO may also play a lead role on other critical  policies that affect health as well as broader economic well-being, including: import and export barriers affecting fragile economies; policies around trade in agriculture and food products; and ever more urgent questions surrounding trade, climate and sustainability.

The Candidates
(left-right) formally nominated WTO DG candidates; Jesús Seade Kuri, Ngozi Okonjo-Iweala, Abdel-Hamid Mamdouh

So far, four candidates have been formally nominated: Jesús Seade Kuri, Mexico’s chief negotiator for the ‘New NAFTA’; Abdel-Hamid Mamdouh, former director of the Trade in Services Division of the WTO; and Ngozi Okonjo-Iweala, board chair of Gavi, the Vaccine Alliance and former Nigerian Finance Minister, who also spent 25 years in Washington, DC with the World Bank. The Republic of Moldova’s Minister of Foreign Affairs, Tudor Ulianovschi, also had his name thrown in the ring on June 16.

On Tuesday, June 9, European Trade Commissioner Phil Hogan told reporters that he was also considering a bid to become WTO Director General. At a meeting with European Union trade ministers he identified trade and health issues, and the urgency of addressing the COVID-19 crisis, as priorities. Hogan also suggested that the European Union should put forward a single candidate, saying: “The EU has very strong multilateral credentials and is recognized as a force that could shore up the WTO and protect the multilateral trading system. This puts the EU in a legitimate position to offer a Director General to the WTO.” The Croatian Foreign Minister confirmed that EU members would discuss whether to unify around a single EU candidate during the next month.

The fact that Phil Hogan has put his name forward does not assure his position as the EU nominee. Other Europeans also reported to have expressed interest include: Arancha González-Laya, Spain’s Minister of Foreign Affairs and a former WTO Chief of Staff; and; Sigrid Kaag of The Netherlands, currently Dutch Trade Minister, formerly UN Under-Secretary-General, with experience at UNICEF and UNDP. (An interesting – if perhaps academic – question: The EU has exclusive authority over trade matters for its member states, while the EU and each of its member states are Members of the WTO, with a unique voting arrangement. If the EU nominates a DG candidate, does that preclude individual member states from nominating their own candidates?) Peter Mandelson, of the United Kingdom (now no longer EU!), but a former EU Trade Commissioner and UK Secretary of State for Trade and Treasury, has signaled interest too. While there is a long history of European heads of the WTO antecedent, the General Agreement on Tariffs and Trade, whether this argues for or against a new DG from Europe is not clear.

Jockeying between the power blocs
Two workers pin rolls of fabric in a large clothing factory in Cape Town, South Africa.

Appointments to leadership posts at multilateral organizations take account of the merits of the candidates, but realistically they must be viewed through the lens of political gaming and the exercise of power. Neither China nor the United States have as yet nominated a candidate, and perhaps neither country will because of the almost-certain divisiveness this would evoke. But it would be a mistake to think that either Beijing or Washington view this appointment exercise as one of identifying the smartest trade expert in the room. The recent battle over the appointment of a Director General for the World Intellectual Property Organization (WIPO) was hard-fought between US and China-sponsored candidates. With the US having prevailed, China will be looking again to assert its growing power. And, we have not yet heard from India.

Also, tradition holds that the leading positions in the United Nations and other multilateral organizations are divided up between regions – and that balance will play a role in the debate over whether a candidate from Asia, Africa, Europe or the Americas will succeed.

A candidate from Africa, such as Ngozi Okonjo-Iweala, might seem a “neutral” prospect as compared to candidates from one of the major trading powers. Okonjo-Iweala, who studied at Harvard and earned a PhD from MIT, might also be someone who the Americans would support. Kenya’s Amina Mohamed, former Ambassador and Permanent Representative for Kenya in Geneva, served as the first woman to chair the WTO General Council and as chair of the 10th WTO Ministerial Conference in Nairobi, and is certainly qualified, as is Abdel-Hamid Mamdouh of Egypt. Yonov Fredrick Agah, of Nigeria, currently a WTO Deputy Director-General, and previously Nigeria’s Ambassador to the WTO is said to have expressed interest, along with Eloi Laourou, of Benin, currently Ambassador and Permanent Representative of Benin to the UN in Geneva.

In terms of UN agency heads, Dr. Tedros Adhanom Ghebreyesus of Ethiopia is currently leading the WHO and Mukhis Kituyi of Kenya is leading UN Conference on Trade and Development (UNCTAD). Viewed through the lens of regional diversity, this might seem an obstacle to appointment of another Geneva DG from Africa. (Asia is poised at the top of WIPO, with Daren Tang of Singapore elected to succeed Francis Gurry.) Through a wider UN and global lens, however, the UN (António Guterres) and the International Monetary Fund (Kristalina Georgieva) Secretariats are headed by Europeans, and an American (David Malpass) is leading the World Bank. Seen from that perspective, the prospects for a third African Geneva leader may look brighter.

In years past, despite their differences, the United States and European Union were allies with shared trading system interests that would ultimately cooperate over the selection of a WTO (or former GATT) Director General, even if each had a candidate in the running. However, the Trump Administration has done everything it can to blow up the US relationship with the EU, so a prospective alliance over the choice of a candidate for WTO right now is in doubt.

As if to illustrate that doubt, following a recent statement by EU Trade Commissioner Phil Hogan that the US trade representative (USTR) Robert Lighthizer supported a WTO DG candidate from a developed country, USTR Lighthizer’s office responded saying, “Ambassador Lighthizer does not support any candidate at this time, nor does he feel that a candidate must necessarily be from a developed country.”

The Selection Process
Pepper farming in India

This is not the best time to be “counting chickens” as we still are at relatively early days in the nominating process – which is scheduled to run until 8 July 2020.

Following that, candidates “will have a period of time to make themselves known to members,” according to the process outlined by WTO. That is to include a special meeting of the WTO’s General Council, which includes all WTO member states, “where the candidates will be invited to make presentations, followed by the consensus-building phase devoted to selecting and appointing one of the candidates.”

However, the final appointment date remains unclear. General Council Chair, Ambassador David Walker (New Zealand) has said only that he will be “will be consulting with members in order to establish expedited deadlines for the post-nomination phases so that members may have clarity on the timeline for the appointment process by the end of the nomination period.”

In theory, then, the DG appointment could also be delayed beyond the US Presidential elections scheduled for November.

Public Health and the WTO

The choice of WTO DG is important to the future of public health. Through the implementation of the Agreement on Trade-Related Aspects of Intellectual Property Rights (“TRIPS Agreement”), the WTO sets the ground rules for the granting and use of intellectual property rights, including patents, for  diagnostics, medicines, treatments and vaccines. The TRIPS Agreement embodies important “flexibilities” that allow governments to take measures to promote and protect public health, including to grant compulsory patent and government use licenses for the generic production or import of patented drugs, and to make use of other exceptions to IP rights. Historically, the exercise of these flexibilities has provoked controversy. The COVID-19 crisis, whereby hundreds of existing and new drug formulations, as well as vaccines, are currently being trialed in combat against the virus, is expected to further test those WTO TRIPS flexibilities – and the ability of WTO to support comprehensive and equitable distribution of health products.

The new WTO Director General will thus be called upon to reassure member states that they can provide for vital national health needs – without facing undue pressure over Intellectual property interests or issues.

COVID-19 In the shadow of the HIV Legacy 
fixed-dose, antiretroviral HIV treatment

The new WTO director will be confronting COVID-19 in the shadow of the historic dispute over access to medicine that raged while the HIV-AIDS epidemic grew unchecked in the mid- and late-1990s. At that time, the government of South Africa came under intense pressure from the United States, the European Union and the innovator pharmaceutical industry based on unsupported allegations that South Africa’s 1997 health legislation amendments, permitting measures such as the parallel import of patented HIV/AIDS drugs, violated the TRIPS Agreement. Collapse of the industry case was followed by adoption of the WTO Doha Declaration on the TRIPS and Public Health along with the TRIPS Article 31bis amendment on compulsory patent licensing predominantly for export. This further clarified the rights of countries to produce or import generics of vitally needed health products in times of need.

Throughout the saga, either one of the two successive WTO Director General’s, including Renato Ruggiero (to September 1999) or Mike Moore (to September 2002), could have issued a clear public statement that the South African legislation did not violate the TRIPS Agreement, a fact which no serious trade and IP expert doubted (and which has been confirmed not only by the Doha Declaration, but even by the US Supreme Court).

Had they done so, the pharmaceutical industry would have had a very difficult time justifying its litigation, and the EU would also have been under considerable pressure to withdraw its trade threats (which the US did earlier on). But neither Director General spoke out. Not only did the failure to support  South African prolong insecurity in South Africa’s health system, but it damaged the public perception of the WTO as an institution, because the basic charge of the pharmaceutical industry was “we have these patent rights given to us by the WTO that are under threat”, while in fact WTO rules allocated no such rights.

Pandemic Will Test Mettle of WTO Flexibilities

In case you were on the recent space shuttle mission, and missed entirely the start of the COVID-19 pandemic, international interest in the legal mechanisms that will be used to develop and distribute vaccines, treatments, diagnostics and medical devices to address the pandemic is at a historic high – and WTO once again has an important role to play.

In fact, several governments, several governments – including France and Germany — already have modified their legislation to facilitate the compulsory licensing of patented health products to address the pandemic.  Israel has issued a compulsory license.

Along with the much-touted WHO-supported voluntary COVID-19 patent pool launched two weeks ago, proposals for compulsory patent pools are in the works, as are suggestions for taking advantage of the TRIPS Article 31bis provision allowing compulsory licensing predominantly for export. So, the mettle of WTO rules regarding intellectual property are likely to be tested again, perhaps even more severely than before, as the current pandemic has touched rich and poor countries alike in the greatest global public health crisis of a century. The new WTO DG will thus be called upon to provide leadership in assuring that TRIPS Agreement and other WTO flexibilities are respected.

In addition, there are critical health-related issues involving export restrictions on critical health products, subsidies to the pharmaceutical sector, and others that involve complex questions of WTO law and will need to be addressed. Again, a strong DG voice at the WTO may be important.

Economic well-being is also a health issue
Restaurants, bars and shopping centers reopen in Geneva, Switzerland after two months of lockdown

Finally, economic well-being is a major determinant of health, and the WTO has an important role to play in assuring that its Members are able to continue to export and import to support their fragile economies. The new DG will confront serious obstacles as he or she seeks to counterbalance the current trend towards higher national barriers in international trade.

The COVID-19 pandemic has had devastating economic consequences everywhere; but developing countries have been hit particularly hard because of the inherent vulnerability of their economies, and jobs dependent on international trade.

The consequences of sharply falling income, particularly among economically vulnerable groups, can be as severe as a deadly virus.

The fact that some middle- and high-income countries have started to “pull up the drawbridges” and to re-shore production will have significant consequences for developing countries. One task of the WTO DG will be to help remind and persuade developed country political constituencies that trade is not a zero-sum game, in which export success by one country means that other countries are losing. At the same time, the WTO DG must help address unfair trading practices, that damage the system and consequently hurt all participants in the long run.

Trade and Sustainability
Commercial fishing boat

And at the same time, in an era when climate has been described as the next global health crisis, the WTO and its Director General may be asked to re-examine longstanding WTO rules and frameworks that ignore the oft-heavy carbon costs of international trade, and thereby hinder the development of sustainable, local industries.

For example, the WTO Appellate Body ruled that India’s legislative preference for locally-produced solar panels was inconsistent with WTO national treatment rules. The Appellate Body correctly interpreted existing WTO law. But from a policy standpoint telling India to buy its solar panels from China (or the United States) when India faces tremendous requirements for new energy supplies, as well as wide underemployment, was not good climate or development policy. Particularly in light of the fact that the main alternative to solar power is massive new coal power plant construction. The WTO needs to adjust its rules to accommodate the large-scale changes in energy supply needed to reduce carbon output and promote development.

WTO negotiations on fisheries subsidies which are critical to reducing overfishing of depleted fish stocks are stalled. This represent another important area where leadership of the new WTO DG may be important.

Changes to government policies that encourage transition to sustainable agricultural practices, that facilitate the development of industries transitioning away from reliance on fossil fuels, and that recognize the damage done by industries employing outsize carbon intensity should be pursued under the direction of new WTO leadership.

Does it Really Matter? The Director General’s Authority
World Trade Organization building in Geneva, Switzerland

As the electioneering commences, the WTO is at a critical, nearly life-or-death, juncture.

Yet in the final analysis, the WTO Director General has rather limited “actual authority” – rather like the head of the World Health Organization. The constitutional document of the WTO,  the 1995 Agreement Establishing the World Trade Organization, provides that the WTO Secretariat will be headed by a Director General, appointed by the Ministerial Conference (of member states), which will also “adopt regulations setting out the powers, duties, conditions of service and term of office”.

Significantly, WTO members never adopted the called-for regulations setting out the powers and duties of the DG, although they have established the term of office and conditions of employment.

Even so, along with staff appointments and budget management, a recurring and significant role of the Director General involves the appointment of expert panelists at the first level of WTO dispute settlement proceedings, should disputing parties fail to agree.

The Director General traditionally has also played a major role in the negotiation of new WTO (and former GATT) agreements. The DG has acted as Chair of the Trade Negotiations Committee that coordinates the proposals and drafts of the agreements that are ultimately presented to the Members for adoption, and through that function, past Director Generals have played a critical role in facilitating compromise texts and solutions to disagreements between member states. The DG brings interested groups of WTO delegates together for face-to-face discussions as they address issues in various negotiating contexts.

Yet with these things said, the WTO DG is mainly a political figure at the head of the institution who gives the appearance of “leading”. The extent to which that leadership is taken seriously by WTO Members or the wider public may also depend on the personal character and charisma of the individual. He or she – bearing in mind there has never been a female Director General at the WTO – can only persuade. The DG does not issue orders, other than to the Secretariat staff.

Efforts to accommodate what may be some legitimate US concerns are problematic because President Trump appears to have no real interest in “solving” the technical problems with the way the WTO works. He requires some grand gesture for which he can claim victory — or to use his current jargon “total domination”.

Grand gestures are all the more important to Trump as the DG appointment process coincides with the lead-up to the US presidential elections in November.  While a new DG should, in theory, be put into place by 1 September, it’s not at all clear that will happen in the current environment.

Selection of a strong and charismatic figure to “right the ship” of the WTO is thus important for many reasons, including for public health. Developing economies remain dependent on an open international trading system, and the health of people around the world is certainly affected by their economic conditions. As discussed, there are specific WTO rules that may have a significant impact on health affairs, and how the WTO manages its rule system makes a difference. But multilateral cooperation in economic affairs, as in other spheres, is important not only for the particular end that an institution seeks to achieve, but also to avoid devolution of international relations that ultimately might come to a bad end.

It is far from clear that any single individual will be able to pull the WTO out of its current difficulties. But the right appointment is likely to have meaningful consequences in terms of giving the organization a fighting chance. And the next WTO DG must be committed to improving standards of living, including standards of healthcare, for all. The world could use a WTO DG who can actually help make that happen.

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Frederick Abbott, Professor of International Law at Florida State University College.

Frederick M. Abbott is Edward Ball Eminent Scholar Professor of International Law at Florida State University College of Law, USA. He has served as expert consultant and legal representative for numerous international organizations, governments and NGOs, mainly in the fields of trade, intellectual property, public health, technology transfer, and sustainable development. He served as Rapporteur for the International Trade Law Committee of the International Law Association (ILA) (1993-2014) and presently is Co-Chair of the ILA Committee on Global Health Law. He has served as counsel in dispute settlement at the WTO, and has advised governments on TRIPS-related negotiations and implementation. He is on the Board of Editors of the Journal of International Economic Law (Oxford), and of the WIPO-WTO Colloquium Series. http://frederickabbott.com

Image Credits: World Trade Organization, WTO, King & Spalding Law, World Trade Organization, Bread for the World, Government ZA/GCIS, S. Lustig Vijay/HP-Watch, World Trade Organization, World Trade Organization.

Cumulative cases of COVID-19 in Africa as of June 11 2020 8:00PM CET. Numbers change rapidly

African countries are lifting lockdowns even as COVID-19 cases across the continent reached a grim new milestone, topping 200,000 cases.

The pandemic took only 19 days to reach 200,000 cases in Africa, while it took 98 days to reach the first 100,000 cases.

Yet carefully easing lockdown orders in Africa may be the right move according to former United States CDC director Tom Frieden, who is currently president and chief executive officer of Resolve to Save Lives, an Vital Strategies initiative.

“There’s a real risk that lockdowns could kill many more people than the COVID-19 epidemic would, if it was spreading,” said Frieden in response to a query from Health Policy Watch. “That means that countries need to find the balance.”

Many African countries, such as South Africa, were early adopters of stay-at-home orders and physical distancing measures when COVID-19 cases were detected within their borders. Yet the heightened risk of food insecurity, and disruption of essential health services for other killers such as malaria and tuberculosis, have led many countries to begin reopening their economies.

“The need to balance between saving lives and protecting livelihoods is a key consideration in this response, particularly in Africa,” said WHO Africa Regional Director Dr Matshidiso Moeti in a press release. “Stay-at-home orders and closing of markets and businesses have taken a heavy toll, particularly on the most vulnerable and marginalized communities.”

South Africa, along with Nigeria, Sudan, Egypt and Algeria, have the highest number of coronavirus deaths in the African continent – but the figures still pale in comparison to the death toll in the United States and Europe.

How Lifting Lockdowns Could Help Africa

COVID-19 responders dressed in personal protective equipment

While lockdowns in North America and Europe have prevented many deaths from the coronavirus, Frieden says that the same moves may exacerbate conditions in Africa.

“Africa, and other parts of the world including lower income parts of Asia, have several features that make the calculation [around enacting lockdowns], very different,” said Frieden.

For example, populations in Africa are on average younger than populations in North America or Europe, so the risk of dying from COVID-19 is lower in those populations.

“The strongest risk factor for death in COVID-19 is age,” said Frieden. “In the US in some communities, 24% of our population are over 60 or 65 years of age. In Africa, it can be 3% to 5%. That means the number of people at risk for dying is dramatically lower in society.”

Additionally, said Frieden, the risk of dying from other conditions, such as HIV/AIDS, tuberculosis, or malaria, due to the disruption of essential health services, is much higher in the Africa region.

“The competing mortality… from other stuff you might die from is much more likely,” said Frieden. “Your risk of dying if you don’t get health care for malaria, for measles, for tuberculosis, in lower income countries is quite high.”

In such cases, controlled of easing lockdown restrictions, while making sure testing and treating capacities are in place to detect new cases, may be a beneficial move.

South Africa Lifts Lockdown Amid Pandemic Acceleration

South African President Cyril Ramaphosa, wearing a mask, bumps elbows with a representative of Naspers South Africa

South Africa, one of the countries hit hardest by the pandemic on the continent, is making difficult decisions to lift lockdown measures even as case numbers continue climbing.

“They’ve said we’re going to loosen up on some of the physical distancing interventions because people need to get health care, they need work, they need food,” said Frieden.

The country was among the first to detect COVID-19 in the Region, and also the first to enact stay-at-home orders to slow the spread of the virus.

The lockdowns were used mainly to slow the spread of the virus so that the health system could prepare for a peak in cases, penned South African President Cyril Ramaphosa in his weekly letter to the public.

The country, which reports 25% of the continent’s cases, entered Phase 3 of reopening on June 1st, allowing limited religious gatherings including funerals, school attendance, some work meetings, non-contact sports, and alcohol sales to resume.

Citizens are urged to stay home as much as possible, and wearing a mask while out in public is required.

And amidst an alarming uptick of cases in the Eastern and Western Cape, Ramaphosa reminded citizens that non-essential travel between provinces is still restricted.

Image Credits: WHO Africa Regional Office, Africa CDC, Government ZA/GCIS.

Dr Tedros at the June 10 WHO COVID-19 press briefing

Asymptomatic transmission is possible, but the World Health Organization is still unsure as to what extent asymptomatic COVID-19 infections contribute to the spread of the virus, according to WHO Director-General Dr Tedros Adhanom Ghebreyesus on Wednesday.

“Since early February, we have said that there are asymptomatic people that can transmit COVID-19. But we need more research to establish the extent of asymptomatic transmission, and that research is ongoing,” said Dr Tedros.

The WHO Director-General attempted to clarify seemingly contradicting statements made by WHO COVID-19 Technical Lead Maria Van Kerkhove on Tuesday and Monday regarding asymptomatic transmission, the onwards spread of COVID-19 by an infected person who never develops symptoms.

Van Kerkhove had on Monday said that transmission of COVID-19 by asymptomatic people was “very rare,” according to reports from countries doing detailed contact tracing 

“We have a number of reports from countries who are doing very detailed contact tracing. They’re following asymptomatic cases, they’re following contacts and they’re not finding secondary transmission… It is very rare,” said Van Kherkhove at WHO’s regular press briefing on Monday. “From the data we have it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual.”

The comment seemed to contradict United States Centers for Disease Control guidelines that advise pandemic preparedness teams to assume that 35% of all COVID-19 infections are asymptomatic, and asymptomatic persons are just as likely to transmit the infection as symptomatic persons. The modeling guidelines are based on COVID-19 estimates from the US CDC, and US Health and Human Services Office of the Assistant Secretary for Preparedness and Response (ASPR).

WHO COVID-19 Technical Lead Clarifies “Rare” Asymptomatic Transmission Comment After Concerns 

WHO COVID-19 Technical Lead Maria van Kerkhove attempts to clear up confusion around claim that asymptomatic transmission of COVID-19 is ‘rare’

Van Kerkhove walked back on her comments on Tuesday, after receiving backlash from scientists concerned that WHO was writing off the threat of asymptomatic transmission.

She clarified that her comment designating asymptomatic transmission as “rare” was based on a small subset of 2 to 3 studies following asymptomatic people and their contacts, and the true extent of asymptomatic transmission was still unknown.

“”The majority of transmission that we know about is that people who have symptoms transmit the virus to other people through infectious droplets. There are a subset of people who do not develop symptoms,” said Van Kerkhove at a Twitter livestream on the issue on Tuesday. “To truly understand how many people don’t develop symptoms – we don’t have that answer yet.

“I wasn’t stating a policy of WHO or anything like that, I was just trying to articulate what we know. In that, I used the phrase ‘very rare’ – and I think that’s misunderstanding to state that asymptomatic transmission globally is very rare.”

Van Kerkhove highlighted that due to the many unknowns, infectious disease modeling groups have used their own estimates of the contribution of asymptomatic transmission.

“What I didn’t report yesterday, was because this is a major unknown, some modeling groups have tried to estimate what is the proportion of asymptomatic people that may transmit,” she said. “And there is a big range, depending on how the models are done, from which country…They can be [quite high].

“Some estimates are around 40% of transmission may be due to asymptomatic [infections],” said Van Kerkhove, a potential nod to the CDC modeling guidelines.

Photo Credit: Marco Verch

In what he described as a great “public health victory,” the World Trade Organization has ruled that Australia’s plain packaging requirements for tobacco products did not infringe on international trade, said the World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus on Wednesday.

The decision by the WTO on Tuesday comes just as it also opened nominations for the selection of its next Director General, following an earlier announcement by Roberto Azevedo that he would resign from his post on August 31st.

So far, three candidates have been formally nominated, including chair of Gavi, the Vaccine Alliance’s Board Ngozi Okonjo-Iweala; Mexico’s chief negotiator for the ‘New NAFTA’, Jesús Seade Kuri; and former director of the Trade in Services Division of the WTO, Abdel-Hamid Mamdouh.

The decision on the case against Australia, the first country to introduce mandatory ‘plain packaging’ for tobacco products in 2012, was described as the final nail in the coffin of the tobacco industry’s nearly decade-long campaign against plain packaging, which has now completely run out of international avenues to appeal such laws.

“This WTO ruling means the tobacco industry has run out of options to challenge plain packaging internationally,” said Dr Tedros in a press briefing.

The WTO decision upheld a 2018 ruling that Australia’s plain packaging laws did not violate WTO rules. That decision was appealed by Honduras and the Dominican Republic on behalf of a bloc of countries, leading to a final ruling on Tuesday that ended the international litigation against Australia.

“This is a fantastic win not just for Australia, but for governments around the world who want to reduce the terrible toll of sickness and death caused by smoking,” Australian Health Minister Greg Hunt said in a statement released Wednesday.

Appellate Body Rules ‘Plain Packaging’ Laws Do Not Violate International Trade Agreements

Australia’s ‘plain packaging’ laws require the display of graphic public health warnings on tobacco products

An WTO Appellate Body ruled Tuesday that the bloc of countries opposing Australia’s laws “had not succeeded in establishing that Australia’s tobacco plain packaging measures are inconsistent with the provisions of the covered [trade] agreements at issue.” 

Therefore, the committee made no recommendations to change Australia’s plain packaging laws.

“This WTO ruling reaffirms that this legislation is within the international trade rules,” said Australia’s Federal Trade Minister Simon Birmingham.

Australia’s precedent-setting ‘plain packaging’  law for tobacco products, adopted in 2012, bars tobacco packaging from using prominent logos or promotional text, and requires the display of graphic public health warnings.

The WHO has said that there is evidence that such packaging, combined with other interventions recommended by the WHO Framework Convention for Tobacco Control (FCTC), helps reduce demand for tobacco products. Smoking is a leading risk factor of deadly non-communicable diseases like heart disease, lung cancer, and chronic obstructive pulmonary disorder (COPD). 

Other countries that have since adopted similar ‘plain packaging laws,’ include France, Ireland, Northern Ireland, and the United Kingdom. Singapore, New Zealand, and more are now in the process of introducing such laws.

Honduras first submitted a request to the WTO to challenge the Australian laws in April 2012, under the claim that the ‘plain packaging’ requirements put up barriers to international trade as outlined under the WTO Agreement on Trade Related Aspects of Intellectual Property (TRIPS Agreement) and the corresponding Technical Barriers to Trade Agreement. 

Image Credits: Flickr: Marco Verch Professional Photographer and Speaker, Twitter: @FCTCofficial.

Switzerland is now the world’s safest country since the pandemic started, followed by Germany and Israel, according to a Regional Safety Assessment of 200 territories and regions during the COVID-19 pandemic.

Overall, Asia and Europe were the regions most successful in fighting the coronavirus although there were wide variations within Europe in terms of how countries really performed, according to the report by Deep Knowledge Group, an international consortium of commercial and non-profit organizations that applies progressive data-driven solutions to healthcare.

Said the report: “On average, Asia and Europe appear to be maintaining regional safety more efficiently than the rest of the world.” 

The study offers policymakers an opportunity to assess and improve their COVID-19 responses by learning from their neighbours, and reveals why some countries fared better than others in the worldwide scramble to curb the pandemic.

Most Critical Finding – Avoid Reckless Reopenings

The quality of specific governmental policies designed to combat the pandemic were a bigger key to success than the quality of its healthcare system in ‘non-pandemic times’, the study found.

The ‘most critical’ finding of the study is that countries should avoid reckless reopenings in the name of short-term economic recovery, or “all the sacrifices” made will have been meaningless”, the reports authors also warned.   

By compiling some eleven thousand data points from over 500 reputable, publicly available sources of data, researchers created a Regional Safety Index – A composite index that ranked, categorized and analyzed health system preparedness of about 200 regions.

The Regional Safety Index is based on a range of social, economic and health indicators, as well as six categories, including – quarantine efficiency; government efficiency of risk management; monitoring and detection; health readiness; regional resilience; and emergency preparedness. 

Switzerland, Germany and Israel ranked ‘exceptionally high’ in the risk assessment, with scores hovering around 750, in comparison to the USA, the UK and France – which performed “much less favourably” than expected given the sophistication of their health systems, at about 530 on the Regional Safety Index.

Sophisticated Healthcare Systems Not Necessary To Effectively Curb Outbreaks – But Timely Policies Are Crucial 

Strikingly, while the European and Asian countries that scored well on the index all have good healthcare systems, the sophistication of the health system was less a predictor of success than might be expected. What was ‘critical’, the study reported, was  timely adoption of evidence-based policies:

“One of the most critical factors impacting regional safety and stability is not the general level of healthcare sophistication in non-pandemic times, but the specific governmental crisis management strategies and policies used to combat pandemics.”

But countries that successfully curbed the pandemic shared a handful of common features, mainly health systems that operate with high levels of emergency preparedness, which enabled: early and proactive government responses; quick and efficient testing, tracing and isolating efforts to prevent overburdening of healthcare systems; and rapid resource mobilization. Such countries include Switzerland, Germany, Israel, Singapore and Japan.

Another similarity between high-performing countries on the Index was a ‘cautious’, evidence-based unfreezing of lockdowns without sacrificing public health and safety.

In contrast, while technological and economic superpowers like the United Kingdom, the United States and France have very sophisticated healthcare systems, they were ‘surprising outliers’ faring much worse in the ratings “than expected by any basic logic”, the study reported:

“We do see a number of so-called outliers in the [European] region as well, i.e., countries who should score well given their generally high degrees of healthcare robustness, such as France and especially the United Kingdom, but which do not,” said the authors. These countries also were among those that suffered from “the highest infection spread and mortality rates, which is a surprising result.”

Significantly, some lower-middle and middle-income ranked better than others as well.  For instance, South Africa and India, as well as Argentina, Uruguay and Ecuador, in Latin America, ranked higher than other neighbours in their region of similar socio-economic levels.

Countries that scored badly on the Index tended to lack whole-government approaches, leading to considerable delays in physical distancing measures and limited COVID-19 testing.

The “Most Critical Risk” – Hasty Economic Recovery Will Make All Efforts ‘Meaningless’

Countries that were battered by the coronavirus have also started to unfreeze lockdowns too fast, warned last week’s study – The “most critical risk” is reckless prioritization of economic concerns over healthcare priorities without the necessary increases in testing, tracing and isolation:

“Above all else, regions should not put economic recovery above public health and safety…or all the sacrifice and joint work of citizens, governments and organizations will have been meaningless,” states the report.  

While countries such as the United Kingdom have erred more on the side of caution since Prime Minister Boris Johnson himself was briefly hospitalized in an intensive care ward for COVID-19 in early April, US President Donald Trump has been adamant about reopening business across the United States, regardless of infection trends, in an attempt to revive the economy.

Image Credits: Deep Knowledge Group .

Shoppers in Wuhan, China, post-COVID-19 lockdown

A novel study published in preprint form by Harvard University suggests that cases of the novel SARS-COV-2 virus that has caused a global pandemic may have begun appearing in Wuhan hospitals as early as August 2019 – several months before China officially admitted that a new coronavirus was circulating.

The study Tuesday found an unusual uptick in traffic at several Wuhan hospitals in the late summer and early fall 2019, as compared to the year before, as well as a significant increase in online searches in China for diseases related to “cough” as well as “diarrhoea” – the latter symptom a distinctive feature of early COVID-19 onset.

Analysis of hospital traffic in Wuhan China indicates shows high number of visitors, compared to the same time, in the year before

“We observe an upward trend in hospital traffic and search volume beginning in late Summer and early Fall 2019. While queries of the respiratory symptom “cough” show seasonal fluctuations coinciding with yearly influenza seasons, “diarrhea” is a more COVID-19 specific symptom and only shows an association with the current epidemic.

“The increase of both signals precede the documented start of the COVID-19 pandemic in December, highlighting the value of novel digital sources for surveillance of emerging pathogen,” says the preprint study, published on Harvard’s DASH repository, and authored by four experts in computational epidemiology and biomedical informatics at Harvard Medical School, Boston University School of Public Health and Boston Children’s Hospital.

Study Strengthens Theory That Virus Emerged From Source Outside Wuhan Seafood Market

The authors said that their findings strengthen the theory that the novel coronavirus may have already been circulating in Wuhan, a city of 10 million people, prior to the identification of a large cluster of infected people associated with the Hunan Seafood Market.

While it has been suggested that the original source of the virus was a wild animal in the market, where mammals, reptiles and other animals were kept in crowded, contained spaces in close proximity to market workers and shoppers, no direct connection to the market has been found for the first 14 individuals who became infected with the virus.  Nor have virology samples taken from wildlife at the market been linked to SARS-COV2,  the study notes, “leaving open the possibility of alternate points of origin and infection.”

“Here we consider that SARS-CoV-2 may have already been circulating in the community prior to the identification of the Huanan Market cluster. This hypothesis is supported by emerging epidemiologic and phylogenetic evidence indicating that the virus emerged in southern China, and may have already spread internationally, and adapted for efficient human transmission by the time it was detected in late December.”

Hospital traffic and Covid-19 symptoms search queries both rise sharply in autumn, 2019

The study examined satellite images of traffic patterns at six Wuhan hospitals as well as several other control sites, to draw its conclusions.  Along with that it searched terms in the Chinese “Baidu” search engine, noting that the same method has been used to estimate influenza trends in China.

Between September and October 2019, 5 of the 6 hospitals studied show their highest relative daily volume of traffic in the series of images that were analysed, the study found. “coinciding with elevated levels of Baidu search queries for the terms “diarrhea and cough”. While searches for cough alone are typical of the influenza season, diarrhea has been one of the more distinctive symptoms marking onset of Covid-19.

Chinese Officials Reject Findings of Study – Still in Preprint
Hua Chunying, China Foreign Ministry Spokeswoman

Speaking at a press briefing on Tuesday, China’s foreign ministry spokeswoman Hua Chunying rejected the study’s findings, saying, “I think it is absurd, actually extremely absurd, to draw this kind of conclusion based on superficial observations such as traffic volume.”

Other experts also urged caution in interpreting the study’s results: “It’s important to remember that the data are only correlative and (as the authors admit) cannot identify the cause of the uptick,” said Paul Digard, a virologist professor at the University of Edinburgh. “By focusing on hospitals in Wuhan, the acknowledged epicentre of the outbreak, the study forces the correlation. It would have been interesting (and possibly much more convincing) to have seen control analyses of other Chinese cities outside of the Hubei region,” he said.

The study is still in its preprint form, and had not undergone peer review, they also noted.  This seemed apparent from one obvious error in the preprint PDF, which refers to a:  “large decrease in hospital [traffic] voume and search query data, following the public health lockdown of Wuhan on January 23, 2019”  – an apparently erroneous reference to the lockdown of January 23, 2020.

 

Image Credits: José Mauquer , Nsoesie, Elaine Okanyene et al. Harvard University Pre-print Repository, , Analysis of hospital traffic and search engine data in Wuhan China indicates early disease activity in the Fall of 2019.

Shoppers mob malls in Geneva, Switzerland after restaurants and stores reopened on 6 June – following nearly two months of lockdown

Stay-at-home orders and lockdown measures helped greatly limit the spread of coronavirus in 11 European countries from the start of the epidemic to May 4th, according to a new modeling paper published in Nature on Monday. 

Some 3.1 million deaths were averted across the study countries thanks to “non-pharmaceutical measures” such as lockdowns and social distancing policies, according to the study.

Meanwhile, the World Health Organization said that the disease was accelerating in South Asia and Latin America, even as European countries saw declines and began lifting lockdown measures. Switzerland, which reported only 20 new cases on Sunday, reopened restaurants, nightclubs, and red-light district services on June 6, and allowed mass demonstrations of up to 300.

“Yesterday, more than 136,000 cases were reported, the most in a single day so far. Almost 75% of yesterday’s cases come from 10 countries, mostly in the Americas and South Asia,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus.

“We’re seeing acceleration of disease now in Central and South America,” said WHO Health Emergencies Executive Director Mike Ryan. “And we’re seeing a similar acceleration and path for South Asia.”

In his strongest statement to date, the WHO Director-General also expressed support for worldwide demonstrations against police brutality and racism, sparked by the death of a black man, George Floyd, after an officer put him in a knee hold in the United States.

“WHO fully supports equality and the global movement against racism. We reject discrimination of all kinds. We encourage all those protesting around the world to do so safely, as much as possible,” said Dr Tedros, the first African leader of the UN’s health agency.

“As much as possible, keep at least 1 metre from others, clean your hands, cover your cough and wear a mask if you attend a protest. We remind all people to stay home if you are sick and contact a health care provider,” he added.

As the US entered its third week of protests, countries around the world have rallied in support of the movement. Similar demonstrations drew masses of people in Switzerland, the United Kingdom, the Republic of Korea, Spain, and other countries.

US Embassy issues alerts on planned demonstrations on “racial discrimination” in Geneva, Switzerland

Nature Paper Finds Non-Pharmaceutical Interventions Lowered Reproductive Number, R0

Only 3.2-4.0% of the total population, or between 12 to 15 million people, were estimated to be infected in 11 countries from the beginning of the epidemic in Europe until May 4th, according to the Nature study.

“Our results show that major non-pharmaceutical interventions and lockdown in particular have had a large effect on reducing transmission. Continued intervention should be considered to keep transmission of SARS-CoV-2 under control,” the authors, a group of researchers from Imperial College London and Oxford, wrote in the analysis.

Empty streets in Italy during lockdown

Non-pharmaceutical measures were able to successfully lower the reproduction number R0, which estimates the average number of susceptible people that will contract the disease from one infected person. When the R0 drops below 1, the epidemic will decline. 

 “Current interventions have been sufficient to drive the reproduction number R0 below 1, and achieve epidemic control,” according to the authors. 

The analysis found that the average R0 was reduced by 82% across the 11 countries, dropping to 0.66 compared to 3.8 at the beginning of the study period, before any “non-pharmaceutical interventions” were put in place. R0 values in individual countries ranged from 0.44 in Norway to 0.82 in Belgium.

The authors used death data from the European Centers for Disease Control to estimate infections across Austria, Belgium, Denmark, France, Germany, Italy, Norway, Spain, Sweden, Switzerland, and the United Kingdom.

Pandemic Hotspots Shift From Europe + US to Latin America + South Asia

Active cases of COVID-19 world wide as of 8 June 2020 evening. Numbers change rapidly

New infections are growing at an alarming rate in several countries in South America. The trends are real, not just due to increased testing and better surveillance, according to Mike Ryan.

In the past day, about 70% of COVID-19 deaths were in the Americas. Brazil overtook the United States in recording the highest number of new cases late last week, and 60% of the world’s new cases were reported in the Americas.

“I would say right now the epidemic in Central and South America is the most complex of all of the situations we face globally.. We’re seeing from Mexico all the way to Chile is an increasing pattern across the Americas across Latin America, with some notable exceptions,” said Ryan on Monday. “I think it’s a time of great concern.

“It’s not one country, it’s many many countries experiencing very severe epidemics [similar to] what we saw in Europe and North America….There’s been an increase of about 50% of cases in Guatemala over the last week, with a worrying over 100% increase in the number of fatalities [for example].”

“The pandemic epicentre moved from China & East Asia to Europe & North America, now to South Asia & Latin America. [We’re] still in the growth phase in many countries,” tweeted  Devi Sridhar, Professor & Chair of Global Public Health at University of Edinburgh.

Locals gather outside public office in Hyderabad, Pakistan

Pakistan, now reporting the highest number of new cases per day in WHO’s Eastern Mediterranean region, reported 4,960 new cases on Sunday.

Some 70% of new cases in WHO’s Southeast Asian Region were recorded in India, now hosting the 6th highest number of COVID-19 cases. The country reported 11,000 new cases in the past 24 hours, some 500 more than the previous day.

The New Delhi’s Department of Health, Family and Welfare overrode a controversial order restricting hospital services for COVID-19 to residents of Delhi on Monday. The order, published on Sunday, limited hospital services for COVID-19 to “bona fide residents of the National Capital Territory of Delhi” – leaving Indian migrants in the capital. About 40% of New Delhi’s population are migrants, and the capital has the highest concentration of inter-state migrants compared to any other region in India.

In the WHO European region, half of Sunday’s new cases were in the Russian Federation, which reported 9000 cases. New cases in Russia have plateaued around 8,000-9,000 per day since mid-May. 

Still, the Russian Federation plans to lift its months-long lockdown starting Tuesday, said Moscow’s Mayor Sergei Sobyanin on Monday. “Moscow can practically get back to its usual rhythm of life,” said Sobyanin on his personal blog.

On Monday, New Zealand Prime Minister Jacinda Ardern declared the country ‘virus-free’, and announced that virtually all COVID-19 restrictions will be dropped reported Reuters. New Zealand last reported new cases of COVID-19 on 19 May, but the country has still taken a cautious approach to reopening, which has been largely supported by the public. 

Image Credits: S. Lustig Vijay/HP-Watch, Flickr: Nicola, Johns Hopkins CSSE, Tasleem Ul Haq.

Peaceful protestors in front of the Brooklyn Public Library in New York City

In the wake of widespread demonstrations in the United States against police brutality, catalyzed by the death of George Floyd while being pinned under an officer’s knee, the World Health Organization has urged protestors to protect themselves against COVID-19.

“We have certainly seen a lot of passion this week, we’ve seen people who’ve felt the need to be out and express their feelings, but we ask them to remember: still protect yourself and others, the coronavirus is all around, protect yourselves and others while expressing yourselves,” said WHO spokesperson Margaret Harris at a briefing in Geneva. “So, all the things we have been saying (still) apply.

“The best precaution is being able to stay one metre away from each other, being able to wash your hands, being able to ensure that you don’t touch your mouth, nose and eyes.”

Meanwhile, in a separate press briefing, WHO also released updated guidance on June 5 for the use of masks to prevent COVID-19 transmission in the general public and healthcare settings.

April Baller, infection prevention & control expert in WHO’s Health Emergencies team, shows how to properly wear a mask – making sure to cover the nose, mouth, and chin.

Governments in areas with widespread COVID-19 transmission should encourage the use of non-medical masks on public transport, in shops and in other locations where physical distancing is difficult, WHO recommends in updated guidance published on Friday.

Additionally, people over 60, or who have underlying health conditions, should wear medical masks in these settings, while all workers in clinical areas of health facilities should also use them – not just those who deal with COVID-19 patients.

For the first time, WHO also released instructions on how to make fabric masks for use by the general public that would provide adequate protection against onwards transmission of the virus, based on scientific research commissioned by the agency.

“What is really new in the guidance, is the research that we requested to be done on looking at which types of materials can actually be used in making these non-medical fabric masks,” said WHO COVID-19 Technical Lead Maria Van Kerkhove.

Masks should consist of an inner layer of absorbent material like cotton, a middle layer of non-woven materials such as polypropylene – a filtering material, and a non-absorbent outer layer made of a polyester or a polyester blend, said Van Kerkhove.

“WHO has developed this guidance through a careful review of all available evidence and extensive consultation with international experts and civil society groups,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “I wish to be very clear that the guidance we’re publishing today is an update of what we have been saying for months – that masks should only ever be used as part of a comprehensive strategy. Masks on their own will not protect you from COVID-19.”

WHO Director-General introducing new mask guidelines at the 5 June WHO COVID-19 press briefing

The slow move towards issuing specific guidelines for the broader use of facial coverings comes after an independent Strategic Technical Advisory Group for Infectious Hazards (STAG-IH) released a note supporting the broader use of masks in the community. Earlier in the week, the Lancet had also published a WHO-sponsored meta-analysis that found mask use decreased the risk of infection, although this reduced risk applied only to the use of N95s, surgical masks, and 12-16 layer cloth masks.

Still, WHO experts emphasized that masking will be an important tactic as countries begin to lift stay-at-home orders.

“In many urban areas in India, it’s impossible to maintain physical distancing, and therefore it will be very important that people wear appropriate face coverings when they are out and about, in office settings where physical distancing cannot be maintained, in public transport, and in educational institutions as some states are thinking about opening,” said Soumya Swaminathan, WHO chief scientist. Swaminathan was formerly director-general of the Indian Council of Medical Research.

Masks are mainly used as a form of “source control,” said WHO Health Emergencies Executive Director Mike Ryan. Ryan emphasized that the proper use of masks is mainly recommended to help prevent an asymptomatic or presymptomatic persons from transmitting the virus to others.

WHO Updates Guidance For Surgical Mask Use In Healthcare Settings, But No Changes In N95 Use Recommendations

In areas with widespread transmission, WHO recommended that any person working in a clinical, be it healthcare worker, janitor, or administrative staff, should wear a medical mask at all times, even while working in wards with no COVID-19 patients.

However, the use of N95 masks should still be restricted to use by healthcare workers conducting aerosolizing procedures.

“Evidence shows that there might be a greater reduction in risk by respirators, but this is still limited evidence, with many limitations due to the fact that these are only observational and small studies,” said Benedetta Allegranzi, coordinator of WHO’s infection prevention global unit. “Respirators may also have more side effects than surgical masks, such as skin lesions or difficulty breathing, etc. Also, assessing recommendations for the global level, [we have] to consider many different contexts in different countries where it’s important to assess resource availability… and equitable access.

“All together, these elements led our experts to consider that there is no strong reason for changing our recommendations [for N95 use].”

Benedetta Allegranzi speaking at the June 5 WHO COVID-19 press briefing
How To Mask Properly, According to the WHO

WHO had previously released lukewarm recommendations supporting countries’ public masking policies in areas where physical distancing is not possible.

But the new recommendations are much more specific, including guidance for different age groups, settings; instructions on how to DIY a fabric mask using materials around the house; and instructions on how to properly use and maintain a fabric mask.

“People can potentially infect themselves if they use contaminated hands to adjust a mask or to repeatedly take it off and put it on, without cleaning hands in between,” said Dr Tedros.

A properly worn mask should cover the nose, mouth, and chin. Care to only touch the earloops when removing a mask will help prevent contamination of the hands, and hands should always be washed before putting a mask on and after taking one off, according to a new instructional video featuring WHO expert on infection prevention and control, April Baller.

WHO experts also emphasized that wearing fabric masks is not protective in itself against getting infected. Maintaining physical distancing and frequent handwashing is important to protect oneself against the virus, said larger public health measures such as contact tracing, quarantining and treating cases, and isolating suspected cases must not be abandoned, said Ryan.

“Wearing a mask in a community level is more about protecting others if you happen to be infected rather than protecting yourself. So it’s an altruistic act,” said Ryan. “[We need a] well educated, empowered community, caring for their own personal hygiene and protection, caring for the rest of their community in terms of protection.

“[They need to be] supported by a public health service that’s capable of finding the virus, isolating and quarantining cases, and health system that’s capable of treating people successfully.

“And all of that in the context of good coordination, good governance being implemented. Then [add] the appropriate and targeted use of masks at community level, in order to reduce transmission within the community in areas where physical distance cannot be maintained.”

 

Image Credits: GF Ginsberg/HP-Watch.