Convalescent plasma from recovered patients may help treat COVID-19`

There is insufficient evidence that treating people hospitalized for COVID-19 with blood plasma from recovered patients is safe and effective – and more randomized clinical trials are thus needed, warned the World Health Organization on Monday. 

Evidence overall remains “inconclusive,” said WHO chief scientist Soumya Swaminathan at a WHO press conference on Monday. 

She spoke just a day after the United States Food and Drug Administration (FDA) issued an emergency authorization for use of the antibody-rich cocktail from the plasma of recovered coronavirus patients in people hospitalized with COVID-19.

Swaminathan added that while blood plasma has been used to treat a variety of infectious diseases for over a century, it is still an “an experimental treatment” for SARS-CoV-2, the virus that triggers COVID-19.  

In the US, over 71,000 hospitalized COVID-19 patients have already received convalescent plasma as part of the nation’s Expanded Access Program. However, evidence supporting its use is still “inconclusive” and “very low quality”, said the Organization.

WHO chief scientist Soumya Swaminathan

“There are a number of clinical trials going on around the world looking at convalescent plasma compared to standard of care, and only a few of them have actually reported results, and the results are not conclusive,” said WHO Chief Scientist Soumya Swaminathan, at a press conference on Monday, in response to a question from Health Policy Watch. “The trials have been fairly small [and while some] trials report some benefit…[the evidence] is still very low quality.”

“The most important question really is about its efficacy and safety being proven and randomised trials, and I hope that we get that evidence in the coming weeks.” 

“At the moment, it is still a very low quality of evidence.. So we recommend that convalescent plasma is still an experimental therapy. It should be continued to be evaluated in well-designed randomized trials.

“Of course countries can do emergency use listings, if they feel that the benefits outweigh the risks,” she added, in a nod to the US FDA move. “But that’s usually done while you’re waiting for more definitive evidence.” 

US President Trump Calls Plasma “Beautiful Ingredient” – Others Less Sure 

Despite the expert reservations, Sunday’s FDA authorization of the treatment was trumpeted at a White House press conference, where US President Donald Trump hailed the plasma as a ‘beautiful ingredient’ that would be a game-changer for COVID patients. 

US Health and Human Services Secretary Alex Azar called it a “milestone achievement” while FDA Commissioner Stephen Hahn, FDA Commissioner, said that data from some 70,000 people pointed to as much as a 35% reduction in mortality.  

The largest such study of some 35,000 people, undertaken by Minnesota’s Mayo Clinic, suggests that people given plasma treatment within 3 days of being hospitalized had somewhat better survival rates than others, as did people who received plasma with higher levels of SARS-CoV-2 antibodies.  This was according to preliminary data published on medrxiv.org, which has not been peer-reviewed yet.

“We dream in drug development of something like a 35 percent mortality reduction. This is a major advance,” Azar. 

However, a number of leading US health experts, including Dr Antony Fauci, one of Trump’s top COVID advisors, last week had urged the FDA to hold off on its emergency approval of the plasma treatment, saying that existing data was still not strong enough to support wider plasma use. 

Notably, the Mayo clinic data was gathered only from “observational” studies and not from randomized controlled studies that are the gold standard for evaluating treatment efficacy. 

In a Twitter blast last week, Trump had impatiently blamed the “deep state” for delaying approval of COVID-19 vaccines and therapeutics.  And speaking at Sunday’s press conference, Trump made it clear that he saw the FDA approval as an election issue – suggesting that the authorization might initially have been delayed for political reasons.  

Critics Say Hasty Approval Threatens FDA’s Credibility

After the FDA issued the emergency use authorization anyway on Sunday, some health policy experts blasted it as a move that had been expedited due to politics, not health concerns, in a week where Trump is heading into the Republican National Convention and wants to show fast results in the COVID battlefront. 

The FDA approval threatens to “further damage” the Agency’s credibility at a crucial time, said Rachel Sachs, Associate Professor of Law at Washington University. 

“Given the explicitly political pressure on the FDA to rush the approval of COVID-19 products, authorizing a new product 1) without publishing the evidence and 2) without a supporting randomized trial risks further damage to public trust in the agency.”

“To be clear, some data from observational studies have been released. But because randomized trials have not yet shown a benefit, it’s not clear than opposing observational data can support an emergency use authorization. It will be critical to see more randomized clinical trials.”

Convalescent plasma isn’t the first product to receive emergency approval despite a shaky evidence base. The antimalarial hydroxychloroquine received emergency approval in late March, after it was widely touted by Trump; its emergency use was later revoked in mid-June after the treatment failed to deliver results in patients. 

Convalescent Plasma May Trigger Side Effects And Could Be Difficult To Scale-Up

Although convalescent plasma has been used against infectious diseases for almost 100 years, it is not risk-free, and may not be suitable in all contexts, added WHO experts at Monday’s press conference. 

Most notably, the actual levels of antibodies received cannot be well-controlled since each plasma portion has different antibody titres, said Swaminathan. So even if convalescent plasma proves to be effective and safe, it may be ‘very difficult’ to deliver a standardized therapy to patients.

“One of the challenges with convalescent plasma is each individual may have different titles of neutralizing antibodies after recovery, and it’s very difficult to standardize that”, Swaminathan observed.

She also added that scaling-up convalescent plasma therapy may be difficult in countries or hospitals that lack the necessary facilities to screen, extract and store plasma from the blood of recovered patients.

Given that convalescent plasma contains a range of different antibodies – including the highly specific neutralizing antibodies – it may result in side-effects like mild chills and fevers, as well as “more severe” lung-related injuries, or even circulatory overload, noted Bruce Aylward, WHO’s Senior Advisor to the Director-General. According to the FDA, circulatory overload is the second leading cause of death in people that receive transfusions.

“For that reason, clinical trial results [for convalescent plasma therapy] are extremely important to know that we have here demonstrated efficacy” and safety, he added.

Convalescent Plasma Versus Monoclonal Antibodies  

Usually, extraction of plasma from the blood requires continuous centrifugation and subsequent freezing within a day of collection. Also, any convalescent plasma sample must be screened for blood-borne infectious diseases – like human immunodeficiency virus (HIV), hepatitis B or C, or even syphilis – and clinicians must match suitable blood types together to prevent adverse immune reactions. 

Given the drawbacks of convalescent plasma, some scientists have instead been suggesting that there may be greater potential for developing more specific and standardized monoclonal antibody treatments, as per their use in past outbreaks, such as Ebola. 

“There’s a lack of willingness, so there isn’t enough [convalescent plasma] around, but I think the most important question really is about its efficacy and safety being proven and randomised trials, and I hope that we get that evidence in the coming weeks,” said Swaminathan.

Image Credits: Sarah Chapman / Evidently Cochrane, WHO.

Some 101 public health organizations have called on the International Automobile Federation (FIA) to put an end to all tobacco advertising in connection to the world-famous Formula 1 (F1) races that FIA sponsors. The organizations issued the call in an open letter to FIA President Jean Todt, released by the tobacco industry watchdog STOP last week.

The call follows on the heels of a call by the World Health Organization last year for sporting bodies, including Formula 1, to adopt stringent polices to prevent participants from receiving any sponsorship through tobacco companies, in line with the WHO Framework Convention on Tobacco Control (FCTC).

Currently, the door remains open for tobacco companies to market their products to Formula 1 fans, despite claims by FIA, Formula 1’s lead sponsor, that its organization is FCTC compliant.

In fact, Phillip Morris International (PMI) and British American Tobacco (BAT) spent US $110 million on Formula 1 sponsorships in 2019. A recent report estimated that the two companies will spend over US $115 million on F1 sponsorships in 2020.

Tobacco marketing expenditures were not mentioned in the new Concorde Agreement, the contract between FIA, Formula 1 and all F1 teams wishing to compete, which sets guidelines for the sport through the next five years, including for the recruitment and allocation of advertising revenues.

“The sport represents one of the last vestiges of Big Tobacco’s global marketing to lure young people into addiction through sports,” the open letter stated. ” Continued tobacco sponsorship in Formula 1, and the promotion of tobacco company’s brands, either directly through brand stretching and extensions, on and off the track is a violation of public health laws and United Nations (UN) norms. Federation Internationale de l’Automobile’s (FIA’s) continued tolerance of this situation defies good governance and is inconsistent with the commitments the FIA has made to UN global road safety and climate change initiatives,” states the open letter.

“While it committed to removing tobacco from the sport, under its watch the industry’s spending is on the increase. FIA cannot claim to be the regulator if it cannot control its races and shirk its responsibility by giving excuses,” said Mary Assunta, from Global Center for Good Governance in Tobacco Control, a partner in STOP, in a press release. “FIA represents the last major hurdle to complete a sweeping change that shows tobacco has no place in sports.”

The organizations accuse tobacco companies of taking advantage of Formula 1’s fast growing fanbase under the age of 25 and marketing tobacco products to youth, which is illegal under the WHO’s FCTC. The Convention has been ratified by 182 countries.

The letter also criticizes the FIA Foundation for claiming that it supports the WHO FCTC, as well as participating in a range of other formal UN-sponsored initiatives, while ignoring WHO’s calls for Formula 1 to end tobacco sponsorship.

“FIA’s continued failure to take responsive action to prevent violations could make it complicit with the tobacco industry,” the letter states.

FIA has made official commitments to both UN global road safety and climate change initiatives, and is officially listed on the WHO website as a partner in the “Friends of the Decade of Action for Road Safety 2011-2020. FIA President, Jean Todt, is also the UN Special Envoy for Road Safety.

“FIA’s commitment to protect the planet and promote safety is a sham if it continues to be a vehicle for tobacco sponsorships that contribute to killing people and destroying the planet.” the open letter added.  “Even if FIA manages to reduce Formula 1’s 256,551 tons of carbon footprint (2019), it continues to contribute 845,000 tons of cigarette butts per year. This staggering amount of waste kills animals, pollutes land and sea, slows sustainable consumptionand undermines the basic principles of the UN framework.”

Todt’s own role as a UN Special Envoy for road safety creates a further conflict of interest, the tobacco control groups say.

“There is a conflict between Mr. Todt’s role as President of the FIA, the governing body of a sport that is promoting tobacco industry interests, and his public health commitments as a UN representative. FIA’s claims about being ‘PurposeDriven’ ring hollow when you look at its resistance to ending tobacco industry involvement in the sport,” said Phil Chamberlain from the University of Bath, a partner in STOP, in a separate press release.

“The tobacco industry is a major driver of disease and death; it targets youth, women, minorities and other vulnerable groups; it profits from the exploitation of vulnerable workers in tobacco farming, and it harms the environment.”

Image Credits: Flickr: Indrid_Cold.

The World Health Organization and UNICEF have issued new age-specific mask guidance for children, recommending looser masking protocols for younger children.

The agency’s new guidance comes the week after a new study from researchers at the Massachusetts General Hospital found that children infected with COVID-19 had higher virus levels in their nose and throats than adults, despite showing less severe or no symptoms. The findings suggest that children may be “silent spreaders” of the virus, expelling more virus than infected adults despite being less prone to getting symptoms of COVID-19 themselves.

“[Based on preliminary studies] there appears to be a difference in transmission by age group, with the younger children able to transmit less than teenagers, for example, but this data is really limited,” Maria Van Kerkhove, WHO technical lead for COVID-19, told reporters Friday.

Children under the age of 5 should not be required to wear masks, according to the new guidance.

The guidance takes a “risk-based” approach to recommendations for kids between the ages of 6 to 11 years old. They should wear masks if they have adequate adult supervision, they’re able to safely don and doff a mask themselves, or they reside in areas of high COVID-19 transmission. Those 6 to 11 years old should also wear masks if they are interacting with people who have a higher risk of developing severe COVID-19 disease, such as people over the age of 65 or those with preexisting conditions.

Children older than 12 should wear fabric masks under the same conditions as adults – in areas of high transmission, where maintaining physical distancing is impossible, or confined and crowded environments.

“What we understand about transmission in children is still limited,”  Van Kerkhove admitted.

But with the upcoming fall semester beginning all over the world, understanding the role of children in COVID-19 transmission is even more urgent as countries grapple with the decision to reopen classrooms, or pursue remote learning.

Schools are debating between reopening classrooms or continuing remote learning in the fall.

While the risk of severe disease in children is low, public health officials are concerned that children who get infected at school could bring the virus home, potentially exposing older family members or those with preexisting conditions.

Ultimately, the success of controlling the spread of the virus in schools is dependent on controlling the virus’ transmission in the larger community.

“Schools do not operate in isolation. They operate in communities and… if there’s widespread transmission in those communities or intense transmission is possible, the virus can enter the school system,” said Van Kerkhove.

“Just because kids or others have masks does not mean we can forget about the other measures,”  added WHO Health Emergencies Executive Director Mike Ryan. “Wearing a mask is not an alternative to physical distancing. It’s not an alternative to hand washing, and it’s not an alternative to decompressing classes.”

WHO’s current guidance for masking in classroom settings recommends that schools develop a policy on wearing masks or face coverings in line with national or local recommendations.

Children With Few Or No Coronavirus Symptoms May Carry More Virus Than Hospitalized Adults

In a study of 192 pediatric patients at Massachusetts General Hospital and Mass General Children’s Hospital, researchers found that infected children had significantly higher levels of virus in their airways than infected adults.

Levels of virus in the children’s noses and throats were highest in the first two days of symptoms – significantly higher than viral loads in hospitalized adult patients experiencing more severe symptoms.

“I was not expecting the viral load to be so high,” said lead author Lael Yonker in a press release. “You think of a hospital, and of all of the precautions taken to treat severely ill adults, but the viral loads of these hospitalized patients are significantly lower than a ‘healthy child’ who is walking around with a high SARS-CoV-2 viral load.”

The higher the level of virus in the airways, the more likely it is for a patient to transmit the virus onwards. Coupled with the fact that children generally tend to have more mild COVID-19 disease, the study findings imply that children could be a major, unmeasured source of the virus’ spread.

“During this COVID-19 pandemic, we have mainly screened symptomatic subjects, so we have reached the erroneous conclusion that the vast majority of people infected are adults. However, our results show that kids are not protected against this virus. We should not discount children as potential spreaders for this virus,”  said Alessio Fassano, director of the Mucosal Immunology and Biology Research Center at MGH and senior author on the paper.

“Kids are a possible source of spreading this virus, and this should be taken into account in the planning stages for reopening schools,” Fassano added.

Out of the cohort of patients in Massachusetts, some 49 children tested positive for SARS-CoV-2, but only 25 had a fever. Many of the children presented with non-specific symptoms such as a cough or congestion.

The Massachusetts study’s results are more damning than the results of a preliminary report published by the Centers for Disease Control, conducted by researchers at the University of Geneva in Switzerland. The Geneva study compared 12 pediatric patients’ samples to adult samples and found that levels of virus in children and adults were comparable. Still, the Geneva researchers write, their results also show that infected children can transmit the disease.

This story was updated 24 August to reflect new masking guidelines.

Image Credits: Flickr: Jill Carlson, Flickr: Ivan Radic.

House in Bikoro, Équateur, is disinfected following the discovery of a confirmed Ebola case

The Democratic Republic of Congo (DRC) requires “critical” support to fend off a growing Ebola outbreak in the western Province of Équateur, warned WHO’s Regional Director for Africa Matshidiso Moeti on Friday.

Her warnings came as Équateur’s Ebola cases have almost doubled to one hundred in the past five weeks, of which 96 are confirmed and four are suspected.

Only US$6 million of the $40 million required for the Ebola response has been pledged so far, as international donors remain distracted by the COVID crisis. The DRC government has committed $4 million, and WHO has pledged $2 million. 

“Without extra support the teams on the ground will find it harder to get ahead of the virus,” said Moeti. “COVID-19 is not the only emergency needing robust support. As we know from our recent history we ignore Ebola at our peril.”

Since the DRC’s eleventh outbreak was declared on 1 June 2020, it has spread to 11 of the province’s 17 health zones, and claimed the lives of forty-three people, said the WHO Regional Office for Africa in a press release.

Healthcare Worker Strike Complicates Efforts
Ebola vaccination campaign in
Mbandaka, Équateur Province (DRC)

In addition to the havoc triggered by COVID-19, a health worker strike in the area has limited the response.

“The situation has been further complicated by a strike by health workers, which is affecting activities, including vaccination and safe burials. DRC has the best trained workforce in the world of for Ebola – this situation needs to be resolved as soon as possible,” WHO Director-General Dr Tedros Adhanom Ghebreyesus told reporters on Friday. 

Healthcare workers in the Ebola response entered a three day strike last week, demanding the government pay and raise their salaries in light of the dangers of facing the virus. Healthcare workers have experienced a high risk of infection and death in previous Ebola outbreaks, including in the 2014-2016 West Africa outbreak.

However, part of the strike involved blocking off access to Ebola testing laboratories, according to Mory Keita, a WHO Ebola incident manager. A number of samples collected two days prior to the strike were unable to be processed.

“When health workers protest or strike, it should be done in a way that doesn’t affect the service they provide to those who need it most,” said Dr Tedros on Friday.

Significant Logistical Challenges Delay Identification Of New Cases
House in Equateur Province gets disinfected following discovery of confirmed Ebola case.

And responders are grappling with ‘significant logistical challenges’ to respond to the ongoing Ebola outbreak. Not only has Ebola spread across a whopping 300 km area both from east to west and from north to south, most affected communities also live in remote, densely forested areas that take ‘days’ to reach by river boat, increasing the time it takes to identify potential cases.

“There is currently a delay of about five days from the onset of symptoms to when an alert about a suspected case is raised. This is concerning, because the longer a patient goes without treatment, the lower their chances of survival, and the longer the virus can spread unseen in communities,” said Dr Tedros.

“The virus is spreading across a wide and rugged terrain which requires costly interventions and with COVID-19 draining resources and attention, it is hard to scale-up operations”, added Moeti. “With 100 Ebola cases in less than 100 days, the outbreak in Équateur Province is evolving in a concerning way.” 

Since the outbreak began, the DRC Government has led the ring vaccination of over 22,600 people at high risk of contracting the deadly virus. It has also screened about 640,000 across 40 points of control, in collaboration with 90 WHO experts on the ground and about 20 partner organizations.

Image Credits: WHO/Junior D. Kannah, WHO/Junior D. Kannah, WHO.

The World Health Organization Headquarters in Geneva, Switzerland

Germany and France are proposing sweeping reforms to strengthen the World Health Organization and ramp up funding for the agency.

A draft paper circulated by the two countries outlines ten key reforms to boost the WHO’s legal authority and funding, while also increasing oversight of the agency’s emergency operations, according to Reuters, which obtained a look at the document.

“Not only during the current pandemic, it has become clear that the WHO partly lacks the abilities to fulfill its mandate,” the document said. The reforms are clearly “pro-WHO,” a diplomat in Geneva familiar with the negotiations told Reuters.

One key proposed reform is the creation of an independent expert committee to assess WHO’s operations in emergency situations as they unfold.

In previous years, WHO has undergone extensive independent reviews only after pandemics have been beaten back. The ongoing independent review of the agency’s COVID-19 response, headed by former Liberian President and Nobel Prize winner Ellen Johnson Sirleaf and former New Zealand Prime Minister Helen Clark, is the first such review to take place as an emergency is unfolding.

While leaders and Health Ministers of both France and Germany have been upfront about their criticism of the WHO, both countries have also steadfastly stood behind the agency as it has weathered repeated attacks regarding its handling of the coronavirus crisis.

And unlike the United States, which followed up its strong criticism of the agency by withholding funding and announcing its intent to withdraw from the WHO, France and Germany are looking to prop up the Organization. Both countries have upped their contributions to the agency following the US’ withdrawal.

In fact, the draft document appeared to recommend giving the WHO more power to autonomously and independently investigate reports of new outbreaks. Currently, WHO must be invited into a country to investigate any outbreaks, WHO Director-General Dr Tedros Adhanom Ghebryesus previously told reporters.

Additionally, the document urges Member States to provide more unspecified funding to the agency, which currently runs on a shoestring budget of about US$5 billion a year, approximately the same budget size as a large, sub-regional hospital.

More than 80% of the agency’s current budget is also earmarked for specific programs, meaning WHO only has about US $1 billion a year to deploy rapidly in the case of unpredicted emergencies.

Ramping up un-earmarked contributions will give the agency more flexibility to respond to outbreaks of novel diseases early, rather than spend time raising money for an emergency response, according to the document.

The proposed reforms could be discussed at the WHO as soon as mid-September, according to Reuters.

A WHO spokesperson declined to comment on the document.

Image Credits: U.S. Mission Geneva/ Eric Bridiers.

Antoine Flahault, director of the Institute of Global Health at the University of Geneva

Six months into the pandemic, the rapidly evolving science behind COVID-19 has complicated efforts to clamp down on the virus’ rampage around the world. Geneva Solutions asked Antoine Flahault, director of the Institute of Global Health at the University of Geneva, and leading voice on COVID-19 science in the region, how we can take swift action to save lives when science hasn’t yet provided definitive answers.

When we don’t have evidence, scientists need to be transparent, he says. In the meantime, masks for everyone, everywhere, and all the time, are vital to fend off the pandemic.

Geneva Solutions: Earlier this year, you advocated homemade masks out of toilet paper on Twitter, even though there was no scientific backing for your claim. Why?

Professor Antoine Flahault: It’s true that in late January when COVID-19 began its rampage around the globe, there wasn’t enough evidence to suggest that homemade masks actually worked. I made an assumption that any physical barrier was better than no protection at all. Some of my colleagues said it was irresponsible to make claims on homemade masks without scientific data to back them. At the same time, my colleagues weren’t providing any alternatives to fend off the virus, and there was a massive shortage of surgical masks.

 

During a crisis, doing something is better than doing nothing. In the case of masks, wearing a mask is a really low-risk action that has a huge potential benefit in preventing onwards transmission. When the evidence isn’t there, we need to be transparent and mention the lack of scientific evidence and use our gut feeling because the data may take time to collect — and in that time, lives can be saved. And we shouldn’t be stubborn when the evidence comes our way. We should follow it. In the case of masks, evidence eventually came that masks provide very useful and effective protection against the coronavirus.

However, we wouldn’t want to follow our gut in other instances. For instance, we cannot trust that an untested vaccine works. However, in the case of masks, there is very little risk associated with mask-wearing, and a very large potential benefit, but this is not the case with an untested vaccine, which could have dangerous side effects.

GS: There’s a similar lack of clarity on aerosol transmission of COVID-19. Some scientists think aerosols are primary drivers of transmission, while others — including the WHO — maintain that they are not a primary route of transmission. What should we do when the science is unclear?

AF: Aerosols are small viral particles that float around in the air. We think they’re produced when people speak, sing, cough, sneeze or exhale, but the data is still limited. However, our lack of solid evidence shouldn’t nullify the aerosol hypothesis. Maybe aerosols are not the major route of transmission of COVID-19, but we just don’t know yet.

What we can do now is to protect ourselves with masks in closed spaces that lack ventilation. Keeping distance may simply not be sufficient. We need to be sensible and do the best we can with the tools we have — and that means wearing masks.

Masks should be worn everywhere, all the time, and by everyone – including pupils in classrooms.
GS: We are approaching the fall start of schools. Is there a risk that opening up schools could endanger children?

AF: The latest science tells us that pupils, and anyone below the age of 40, is at a very low risk of becoming critically ill and dying from COVID-19, so opening schools will not endanger children themselves. Rather, the issue is that children could transmit the virus to others in their surroundings, particularly vulnerable groups like older people, those with underlying conditions or even school teachers and staff.

GS: Could schools become a breeding ground for COVID-19 transmission?

AF: Definitely. Given that classrooms in schools are often enclosed and poorly ventilated, schools have potential to turn into clusters of transmission that could spill over into the community.

Some epidemiological findings also suggest that children — and even young children — may transmit the virus as well as adults. This is based on evidence that children carry similar quantities of the virus as adults in their noses and throats. However, we’re still not totally sure whether that means they can transmit as well as adults. Given the data is not well ascertained, we need to stay cautious, and take appropriate measures to mitigate the spread of the virus.

GS: Do you see concrete good practice examples that countries could emulate — in Europe and beyond — with regards to smaller class sizes, masks, remote learning, or other measures, to curb the risk of transmission in schools?

AF: There are three measures we can take to win against this virus and allow schools to stay open for as much as possible throughout the year:

  1. The most important measure we can take is to wear masks in schools throughout the day. Wearing masks is possible for any child older than 3 years of age
  2. We need to improve ventilation in schools, and we also need to promote alternative methods of teaching to reduce the number of students in one space at any point in time. We can achieve the latter by spreading out lunch breaks throughout the day so that kids aren’t all eating at the same time. We could even spread out the time for going to school — not for primary schools because younger children are less autonomous, but maybe for children in secondary schools. This may also take the edge off of overcrowded public transportation, and contribute to dampening down transmission.
  3. We could also implement distance learning or mixed approaches in secondary schools. However, we need to stay cautious, because not all parents will be able to stay at home to supervise their children’s learning. Also, not every family will have computers at home, so we need to take the context into account. There’s also the issue of meals at schools. We need to bear in mind that schools may offer more nutritious meals than at home. That’s why we need to carefully consider the context and work accordingly, and to ensure the strategies we adopt are sensible and appropriate.
Remote learning may help curb COVID-19, but it won’t be appropriate in all contexts.
We are seeing a slow, but steady rise in new COVID-19 cases in Switzerland from 100 per week a less than a month ago to over 200 new cases in the past week. Is there anything Switzerland could do to further curb transmission?

There are several measures Switzerland can adopt today, and that’s to recommend wearing masks in all indoor settings, not only in public transportation, but also in workplaces and businesses in the whole nation. These are the next breeding grounds for transmission.

The second measure we can take is to learn from countries like Australia, Taiwan and Japan. They took very targeted approaches to COVID-19 screening. Instead of randomly testing the entire population, their testing is precise, agile and swift. They took a proactive approach to identify superspreaders and clusters of COVID-19 cases. Once they found a cluster, they very quickly started testing and tracing before the cluster went out of hand and spread across the region.

Targeted screening approaches will be particularly important during the cold season, which will bring many people with mild symptoms to hospitals. If we don’t take more targeted approaches, it will be difficult to tease out COVID-19 symptoms from common colds caused by respiratory viruses other than COVID-19.

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Health Policy Watch is partnering with Geneva Solutions, a new non-profit journalistic platform dedicated to covering Genève internationale. In the midst of the Coronavirus pandemic, a special news stream is published at heidi.news/geneva-solutions, providing insights into how the institutions and people in Geneva are responding to this crisis. The full Geneva Solutions platform and its daily newsletter will launch 24 August. Follow @genevasolutions on Twitter for the latest news updates.

Image Credits: Antoine Flahault, UNICEF, Nenad Stojkovic.

UK Health Secretary Matt Hancock announces that Public Health England will be replaced with a new institute.

United Kingdom Secretary of State for Health Matt Hancock’s announcement to replace Public Health England (PHE) with a new agency focused on biosecurity and infectious disease threats has drawn widespread criticism from health experts.

The Health Secretary announced that PHE will be replaced with a new National Institute for Health Protection (NIHP) in a speech on Tuesday, following widespread media reports hinting at the move on Sunday. Ministers, including Prime Minister Boris Johnson, have supposedly been unhappy with the PHE’s handling of the pandemic for weeks.

The NIHP will merge the PHE, the National Health Services’ Test & Trace program, and the Joint Biosecurity Centre (JBC) into a single organization, modeled after Germany’s Robert Koch Institute and focused on protecting the United Kingdom from “new” and “external” infectious threats, according to Hancock.

But critics have called the move a dangerous and distracting play in the middle of the pandemic. They have also questioned how PHE’s other responsibilities, such as managing environmental health or non-communicable diseases, will be taken into account in this reshuffle.

“Where is the evidence, the independent review that has informed such a significant organisational change to the national public health response for England at such a critical time? It takes time to build an organisational culture and the way the tired, hardworking PHE staff heard via a leak at the weekend is shocking,” wrote Gail Carson, deputy chair of the Global Outbreak and Response Network (GOARN).

“Now is not the time to replace Public Health England. The pandemic may have shown us that some changes are needed, but they need to be made at the right time. PHE is playing a key role in keeping the country going, and we really don’t need the upheaval that this move is going to create,” said Andrew Goddard, president of the Royal College of Physicians, in a statement.

Many Uncertainties Remain About New Institute’s Leadership & Responsibilities

In particular, Hancock’s decision to place fellow Conservative Dido Harding, the current head of the widely criticized NHS Test & Trace program, at the helm of the NIHP has sparked ire. Many critics have pointed to the lack of transparency behind Harding’s appointment.

“I was looking forward to applying for the role of Chair of the UK’s National Institute of Health Protection, but somehow I missed the open transparent recruitment process,” Richard Horton, chief editor of the global health journal the Lancet, tweeted.

Similarly, it’s unclear how PHE’s responsibilities in carrying out programs outside the realm of pandemic threats will be managed in the wake of the agency’s dissolution. Outside of COVID-19, PHE managed programs for a variety of health-related issues, including programs focused on curtailing smoking and the harmful use of alcohol, reducing obesity, improving maternal and child health, and managing sexually-transmitted diseases.

“We shouldn’t forget that the overwhelming burden of death and disease in this country is not caused by ‘external threats’ as Matt Hancock put it, such as infections and biological weapons. Instead it is caused by chronic diseases – cancer, cardiovascular disease, diabetes, dementia and others. A significant proportion of these diseases are preventable and Public Health England plays a central role in that through its health improvement functions,” said Linda Bauld, a professor of public health at the University of Edinburgh. “There is a real risk that reorganisation threatens these functions. We don’t yet know how or where they will continue to be delivered.”

And for a coalition of organizations battling a decades-long epidemic at home in the UK, the  institute’s focus on “new” and “external” threats brings out concerns that longstanding domestic health issues will be ignored.

“The announcement made today focuses on “new” and “external” health threats while not acknowledging the public health emergencies that already exist in the UK,” wrote a coalition of UK-based HIV organizations, in a statement. “While attention has rightly been given to the ongoing COVID-19 pandemic, focus must not be lost in tackling long-standing HIV and STI infection rates and reversing sexual health inequalities.

“The Secretary of State’s speech today leaves us with more questions than answers…a knee-jerk restructure of the public health system which is non-transparent, ill-thought through and leads to more fragmentation in accountability structures risks holding us back.”

Receiving a shot of insulin to help control diabetes.

COVID-19 infection may be associated with an increased risk of Type I diabetes in children, according to a new study published by researchers from Imperial College Healthcare NHS Trust.

Diabetes emerged as a high risk factor for severe COVID-19 disease in the early days of the pandemic. But the new study, published in the Diabetes Care Journal, seemed to imply that the opposite relationship could also exist, and that coronavirus infection may be associated with a risk of developing diabetes.

“It appears that children are at low risk of developing serious cases of COVID-19. However, we do need to consider potential health complications following exposure to the virus in children,” said Karen Logan, a clinical nurse specialist at Imperial College Healthcare NHS Trust, and supervising author on the study.

Children have been largely spared from the worst effects of the COVID-19 pandemic, which has hit older people and those with preexisting chronic conditions hard. However, keen clinicians have linked rare complications in children to COVID-19 infection in the past, as in the case of an uncommon, Kawasaki disease-like syndrome that causes inflammation of the blood vessels.

Although the diabetes study only followed a cluster of hospitals in northwest London, some 30 children in hospitals across five paediatric inpatient unites presented with new-onset type I diabetes between 23 March and 4 June, the peak of the pandemic in London. Type I diabetes occurs when damage to the pancreatic cells renders them unable to produce insulin, a hormone that is required to help the body process sugars.

The increase in new type I diabetes cases was highest in two of five paediatric inpatients units, which both saw 10 cases of new-onset type I diabetes during the study, compared to an average of 2-4 cases during the same time period in previous years.

Five out of the 30 children had tested positive for either active or previous COVID-19 infection, although 14 children were not tested in all.

“We believe this study is the first to show a potential link between COVID-19 and the development of type 1 diabetes in some children,” added Logan. However, she noted that the study was limited to only one region in the UK, and more research is required to establish whether there is a definitive link between COVID-19 and new onset Type I diabetes.

Additionally, testing was limited during the peak of the pandemic, so not all the children in the cohort were able to be tested for COVID-19, according to Rebecca Unsworth, lead author on the study.

“In the meantime we hope clinicians will be mindful of this potential link,”  said Logan.

A shot containing insulin, used to control type I diabetes

Strong Link Between Diabetes & Death By COVID-19

Meanwhile, a massive study recently published in the Lancet found a strong link between type I diabetes, type 2 diabetes and risk of COVID-19 related death.

Conducted by researchers at Public Health England and the NHS, the study analyzed data from over 6 million patients registered with general practitioners, and 23,698 COVID-19 hospital deaths. The researchers found that over a third of coronavirus deaths between 1 March and 11 May occurred in people with a previous diabetes diagnosis.

“To our knowledge, this is the largest COVID-19-related population study, covering almost the entire population of England, and is the first study to investigate the relative and absolute risks of death in hospital with COVID-19 by type of diabetes,” the authors wrote.

While previous studies have already established that people with diabetes are at increased risk of experiencing severe COVID-19 disease or death, the new study found that the mortality rate was highest in patients with Type 2 diabetes.

However, after adjusting for demographic factors – such as age, sex and poverty – the study found that those with type I diabetes had 3.51 times the odds of dying by COVID-19 compared to patients without diabetes. Patients with type 2 diabetes had 2.03 times the odds of dying by COVID-19 compared to those without diabetes.

Patients with diabetes who were under the age of 40 had a lower risk of dying by COVID-19. However, the study did not analyze deaths in care homes, which accounted for approximately 70% of COVID-19 deaths in England during the study period.

Image Credits: WHO, Flickr: Jill Brown.

Lab technician processes sample for COVID-19 test

An breakthrough new COVID-19 saliva test, named SalivaDirect, received emergency use approval from the US Food and Drug Administration, potentially opening the door to broader testing. 

The new FDA-approved test, developed by researchers from the Yale School of Public Health, is about as sensitive as a traditional COVID-19 test, but is less invasive to perform, easier to store, and compatible with a variety of platforms. It could also be priced as low as $10 per test. 

FDA Commissioner Stephen M. Hahn called the test “groundbreaking” in a press release.

“Providing this type of flexibility for processing saliva samples to test for COVID-19 infection is groundbreaking in terms of efficiency and avoiding shortages of crucial test components like reagents,” he said. 

To collect a test sample, people are asked to think about a favorite food or upcoming meal to generate saliva, then simply spit into a sterile tube. The process is much less invasive than a traditional COVID-19 test, which requires trained professionals to stick swabs far up the nose and down the throat to collect samples.  

And unlike previously approved COVID-19 saliva tests, the samples for this test don’t need to be refrigerated, nor do they require many reagents. This cuts down the cost of the materials needed for the test to under US $5 per test. 

“We simplified the test so that it only costs a couple of dollars for reagents, and we expect that labs will only charge about $10 per sample,” said Nathan Grubaugh, whose lab developed the Yale test. “If cheap alternatives like SalivaDirect can be implemented across the country, we may finally get a handle on this pandemic, even before a vaccine.” 

Traditional COVID-19 tests collect samples by swabbing the back of the nose and throat.
From The National Basketball Association To The FDA

Yale’s breakthrough saliva diagnostic was tested first on samples from an unusual cohort of people – players in the US National Basketball Association (NBA).

NBA players had previously been using a saliva test developed by Rutgers University that cost anywhere from US $60 to $150 per test. However, in a trial sponsored by the NBA and the National Basketball Players Association, the Yale test yielded similarly accurate results for less than a fifth of the price. 

The Yale test circumvents one key step that other tests on the market take – it doesn’t use expensive reagents to stabilize the sample and extract the virus’ genetic material. Instead, the Yale test relies on cheaper reagents and a heating step to separate the virus’ genetic material from the rest of the sample. While this causes the test to be slightly less sensitive, it makes the test much cheaper than most widely used alternatives. 

And while the test has been used so far in NBA players, the Yale researchers hope it can quickly be adapted for broader use. Grubaugh and his co-authors have said they do not wish to commercialize the test. 

The test works with a variety of commonly available reagents and platforms, and the protocol for running the test has been made publicly available.  

Image Credits: Flickr: Penn State Health, Flickr: Prachatai.

WHO recommends postponing routine dentist visits in areas with high community transmission of COVID-19.

The World Health Organization recommended postponing routine dental visits in areas with community transmission of COVID-19 in new guidelines released last week. 

Many dental procedures can generate aerosols, or tiny solid or liquid particles that contain disease-causing pathogens. If dentists were unknowningly treating coronavirus infected patients, aerosols laden with SARS-CoV-2, the virus that causes COVID-19, could contaminate other surfaces, or infect staff or other patients if inhaled.

To minimize the risk of COVID-19 spreading in dental care settings, WHO recommended that patients avoid seeking non-emergency oral care, such as routine check-ups or aesthetic treatments. Routine visits can resume once community transmission is controlled, and only clearly traceable clusters of infection are present in the community

In the meantime, service providers can offer phone or virtual consultation services for patients experiencing mild symptoms, including prescription of analgesics and antibiotics.

However, patients should still seek their dentist’s care in the case of dental emergencies, such as severe swelling, bleeding or intense pain. Seeking emergency oral care at the dental office can free up general emergency rooms for those with COVID-19 specific complications. Patients should call their clinics ahead of time, and confirm that they do not have COVID-19. 

Dental Workers Should Take Extra Precautions

Healthcare workers should take extra precautions to wear proper protective equipment and adhere to cleaning and hygiene protocols. Dental workers should wear respirators and full protective gear when performing aerosol-generating procedures. 

The guidance has encouraged installation of exhaust fans and whirlybirds or high-efficiency particulate air (HEPA) filters to purify the air and maintain safe ventilation throughout the clinic. It warned against warned using air recirculation devices such as split conditioners, which can disperse droplets or aerosols containing the virus throughout a room. 

Appointments should be adequately spaced out, and patients should arrive alone, wear a mask, and keep at least 1 metre apart from other patients in the waiting room. 

Before starting any procedure, the patient should gargle with 1% hydrogen peroxide or 0.2% povidone iodine for 20 seconds and spit in a disposable cup instead of spittoon. All surfaces should be cleaned, and instruments should be sterilized and disposed after each clinic visit. 

WHO recommends that patients who have confirmed COVID-19 or COVID-19 symptoms seek care for dental emergencies in care centers trained to safely care for coronavirus patients.

Image Credits: Flickr: locomomo.