Active cases of COVID-19 around the world as of 5:00PM CET 13 March, vividly display Europe as new epicentre. Numbers change rapidly.

Europe has now become the epicenter of the COVID-19 pandemic, with more cases and deaths than the rest of the world combined, apart from China, said WHO Director General Dr Tedros Adhanom Ghebreyesus.

Even more worrisome, there are now more new cases being reported everyday in Europe, which has a population of about 741 million people, than were reported among China’s 1.4 billion people at the height of its epidemic, Dr Tedros Adhanom Ghebreyesus said Friday at a press briefing.

Around the world, 8,527 new cases of COVID-19 were reported in the last 24 hours, for a total of 137,385 cumulative cases. In the United States, another evolving epicentre, some 1,268 cases were being reported, and US President Donald Trump was set to appear on national television today to declare a State of Emergency, major media was reporting.

New Roche Test Offers Possibility of Testing “Millions” – Opening Way to More Rapid Treatment or Quarantine 

But as cases skyrocketed around the world, there was one new bright light on the emerging drugs, diagnostics and vaccines scene.

A new test by the Swiss-based Roche pharmaceuticals, approved for emergency use on Friday by the US Food and Drug Administration, could be a game-changer on the diagnostics – the first step to combatting the disease. The newly-approved test could lead to a rapid scale up of COVID-19 testing by millions of new tests a month, based on an automated technology.

According to a press release from Roche, the widely-available Roche’s Cobas 6800/8800 automated diagnostic systems, will be used to perform the  test for the SARS-CoV-2 virus that causes COVID-19. It can provide a total of 1,440 test results with the 6800 System and 4,128 results for the Cobas 8800 System over a period of 24 hours. The can be run simultaneously with other assays provided by Roche for use on the high-throughput Cobas 6800/8800 Systems.

About 96 tests can be run in a batch, with results delivered in 3.5 hours.

Roche Cobas 6800 Diagnostic system

A Roche spokesperson told Health Policy Watch that the company would now begin ramping up a plan to deploy the tests in eligible sites, in line with the emergency FDA authorization.

“We are prioritizing those customers and laboratories with the highest ability to implement routine testing (for example, those with the necessary instruments in place for successful testing and consumable products needed to run the tests) combined with the highest market need. We will be working with customers, nonprofit and government organizations and regulatory bodies to ensure that tests make the greatest patient and community impact,” said Karsten Kleine.

“At our current rate, we can supply approximately millions tests/month on the Cobas 6800/8800 instruments globally. We are working around the clock to increase that quantity as we recognize the importance that patients need access to these critical tests,” she said.

The breakthrough is  significant because the more rapidly and easily testing can be performed, the more easily health systems can either hospitalize or quarantine people who test positive for COVID-19, avoiding further spread of the virus, as well as serious disease progression and acute respiratory distress syndrome, which requires intensive care.

The severe shortages of test capacity in the United States has received widespread attention there. However, test shortages are also plaguing European countries from Switzerland to Norway – creating a playground where the virus can replicate. Whether due to necessity or choice, some European countries are thus deliberately choosing to test only cases among high risk and highly symptomatic groups. Now it remains to be seen if policies in such countries will change – if mass testings olutions become more widely available.

WHO experts have warned that limited testing is not the right approach. Speaking at today’s press briefing, WHO’s technical Emergency lead Maria Van Kerkhove issued a plea to governments.

“Please look for cases so we can turn the tide,” she said. “If case numbers increase because countries are aggressively testing, we should support that.

Testing must, however be part of an integrated strategy, nontheless, said Dr. Tedros. “Our message to countries continues to be you must take a comprehensive approach. Not testing alone, not contact tracing along, not quarantine alone. Not social distancing alone. Do it all,” he urged.

Attendee of the 43rd Session of the UN Human Rights Council in Geneva, wears a face mask. The Human Rights Council is ongoing, but in reduced format with additional precautionary measures.

United Kingdom and Europe See Tremendous Virus Acceleration

In less than two weeks cases in the European Union and the United Kingdom have shot up to at least 29,404 infections in 32 countries.

Italy remains the epicenter of Europe’s epidemic, with a total of 15,113 confirmed cases and 1,016 deaths. But the outbreak is spreading amongst Italy’s neighbors – Spain has the second largest outbreak in Europe with 4,334 cases and 122 deaths, Germany the third largest with 3,156 cases and 7 deaths, France has reported 2882 cases and 61 deaths, and Switzerland has confirmed 1125 test-positive cases and 7 deaths as of Friday afternoon.

Meanwhile in China, only 8 new cases were reported on Friday – the country’s lowest daily figure on record since January. South Korea reported a further decline in new cases (110) after a brief spike with an outbreak in Seoul yesterday. The country has reported a total of 7979 cumulative cases and 66 deaths.

With the outbreak accelerating and decelerating in different countries around the world, WHO scientist Maria Van Kerkhove told journalists, “We will not be able to predict what will happen. We need to prepare for every scenario… the trajectory is dependent on the country.”

Another hotspot of the pandemic is Iran; the Islamic State is also taking drastic new measures to contain the virus, ordering most people to stay home and announcing a plan to test every one of its 80 million citizens for the virus.

“Iran’s strategies and priorities to control COVID-19 are evolving in the right direction… but more needs to be done,” Richard Brennan, regional director of Emergencies for WHO’s Eastern Mediterranean Region in a press release Thursday, following the conclusion of a WHO mission to Iran, and shortly before the new measures were announced.

“We are all still students of this new virus, so we need to track its spread closely and quickly apply proven public health measures… More work also needs to be done to protect health workers,” said

Switzerland Closes Border with Italy  – First Time Since Schengen Zone Creation in 1985

Meanwhile in Berne, the Swiss Federal Council announced a series of unprecedented measures, including limits on any kind of mass gathering to 100 people; a shift of education to virtual school platforms; and the closure of its border with Italy – for the first time since the European Union’s Schengen zone of free area movement was created in 1985.

According to the Federal Council announcement, the measures restrict the entry into Switzerland of people from “high-risk” countries and regions, which also share a border with Switzerland.

“At present Italy is designated a high-risk country,” the announcement stated. “People from Italy will be refused entry to Switzerland. Exceptions are possible, for example for people who live or work in Switzerland. Anyone wishing to enter Switzerland despite the entry ban must prove that one of the exceptional conditions is met. These measures are intended to assure the provision of adequate care and therapeutic products to members of the public,” said the statement.

Speaking at a press conference, Confederation President Simonetta Sommaruga said, “The situation is difficult, but we have the means and we are ready to confront this, both in terms of our health system and financially.”

Alain Berset, head of the Federal Department of Health, said: “We now have positive tests for 1,125 people.  The situation changes all of the days, but the strategy lines that we are pursuing remains the same. The principle objective is to protect the population, with measured, considered steps.

Berset said, “The measures that have been taken include to reinforce protections for the most vulnerable and to also prevent a surcharge of hospital cases.

“We are running this with calm and determination. There will never be one measure taken for all times, that will solve the problem. We are going to have to continuously adapt. So there is no particular reason to be afraid. It’s serious, but we need to be led by calm and determination,” Berset added.

He said that not only sites such as museums, but also ski stations and swimming pools would be restricted to accommodating 100 people at a time.  Education will be shifted to virtual platforms, firstly for university and high schools. Primary and secondary schools will also be asked to develop distance or individualized education solutions for high schools and elementary schools that avoid bringing large groups together. The press conference also included Swiss Vice President Guy Parmelin, Department of Justice and Peace head, Karin Keller-Sutter, in a display of unity across Swiss agencies as well as political ranks.

WHO Headquarters in the Epicentre – Staff Fears & Frustrations Growing With No Clear Move to Teleworking

Despite the nationwide Swiss shift to an emergency footing, WHO’s Administration seem to be hesitant about making its own sweeping internal shift to teleworking at the Geneva Headquarters, despite mounting staff fears and a trend to teleworking across the rest of Geneva’s global health hub agencies and NGOs.

Concerns peaked after a WHO staff member collapsed and was rushed to the hospital on Thursday by ambulance. The staff member’s partner had reportedly already been under quarantine due to his contact with a COVID-19 case at his workplace in neighbouring France, staff members, who requested anonymity, told Health Policy Watch.

So far WHO’s Aministration has told staff that there are no “confirmed” cases among staff at the Geneva headquarters, and it has made no internal or public comment on suspected cases either.

Frustration and anger was growing among the grim and worried WHO staff  over the fact that teleworking for most staff remains limited to just four days a month, even in light of the expanding pace of infection in Switzerland and the Geneva area.

“The new rules say that ‘If you are over 65 or someone with pre-existing medical conditions, which you have to have a certificate, or if you are pregnant, you can go to Staff Health and Welfare and ask for a consultation, and then Staff Health and Welfare might give you a recommendation for teleworking,” observed one staff member.

“Well, WHO doesn’t have any people over 65, that is the mandatory age of retirement…They did say they are working a system for getting teleworking approved by emails. It still is the same old, same old. The message is that teleworking is not the norm.”

A mass teleworking drill was initiated on Friday for purposes of “continuity planning”. But as of Friday afternoon staff were still being told to return to their office workstations, as usual, on Monday.

Overall, the Organization’s top leadership seemed unclear about how to respond to the unique situation of a pandemic literally at its doorsteps, rather than in a remote Asian or African country, noted the staff members who requested anonymity.

“Teleworking will be adopted either when the Swiss government forces them to, or staff revolts,” said one staff. “Until then, staff are risking getting infected while commuting, potentially exposing themselves, colleagues and others in their social circle if infected, added the source.

“We are still operating in the dark ages, we haven’t adapted,” said another at-risk staff member, echoing complaints that paperwork for expanded teleworking permissions remains onerous even for those with a pre-existing condition.

For the first time since the crisis began, however, WHO’s media briefing was conducted on Friday only by virtual format.  Over the past 6 weeks, since daily briefings began, some 20-30 journalists and staff had been crowding together every afternoon in a tiny, airless “SHOC” emergency nerve center at WHO headquarters for the events, while hundreds also watched online.

“WHO has shifted to an online format – we are only having journalists online today to pilot a teleworking format,” said Tarik Jaresevic, a WHO spokesman.

Zixuan Yang contributed to this story.

 

Image Credits: Johns Hopkins CSSE, Roche Pharmaceuticals , UN Photo / Jean Marc Ferré.

UN Headquarters in Geneva: Participant in 43rd Session of the UN Human Rights Council dons mask to protect herself from COVID-19. All parallel sessions and side events have been cancelled.

With escalating COVID-19 outbreaks in Europe, the Middle East, and the United States, some countries are heeding the World Health Organization’s advice and ramping up containment measures, while others, including Switzerland, home to WHO’s Geneva Headquarters, appeared more resigned to the uncontrolled spread of the disease in the wake of yesterday’s declaration of a COVID-19 pandemic.

Denmark and Austria joined Italy, France, Germany and Spain in far-reaching measures to contain the virus, such as: tightening travel restrictions; closing education facilities in affected areas; cancelling large events; and closing some public institutions such as museums, libraries and concert halls. US President Donald Trump announced a temporary 30 day travel ban on all people entering the US from 29 European countries, as the outbreak escalated within US borders to 1,323 cases, and US Centres for Disease Control officials accelerated nationwide COVID-19 testing.  

But in Switzerland, Federal Health authorities  have said that only people with serious symptoms or at “high-risk” and displaying respiratory symptoms were to be tested. A communique circulated to parents of children at one of Geneva’s leading international schools warned that the Swiss testing protocols meant that “cases of COVID-19 which may occur among the healthy population will not be confirmed by testing.”

Although Swiss authorities have now banned events of more than 100 people, the policy to limit COVID-19 testing seemed to run counter to WHO advice that aggressive testing was key to early identification and quarantine or treatment, so as to prevent a surge of serious cases that overwhelm hospitals and health workers.  In a press briefing Wednesday, WHO Emergencies Head, Mike Ryan said that he recommended against a “diagnostic algorithm that only allows testing on only a small number of people.”

In the wake of the confusion, some are calling on WHO to provide more clear guidance on which containment strategies countries should be using.

“Where is the conductor?” Antoine Flahault, co-director of the Swiss School of Public Health in Zurich and director of Global Health at the University of Switzerland Medical School, tweeted Thursday. “There is a set of 4 major non-pharmaceutical interventions: school close, gathering ban, population transport restrictions, cordons sanitaires.

“We expect from WHO to provide clear recommendations on when, how and for how long to implement them.”

Critics are also calling for better guidance on reporting and managing COVID-19 cases in the workplace. In Geneva, home of many global health agencies and NGO headquarters, organizations were rapidly shifting their staff to teleworking as cases began to be confirmed inside their institutions, or nearby.

Those included Medicines for Malaria Venture, Gavi the Vaccines Alliance, The Global Fund, and the International Committee of the Red Cross (ICRC). WHO has not yet begun any mass transition to remote working, although staff were nervously anticipating that such a move might soon be on the horizon following reports that ambulances had been dispatched to WHO headquarters on Thursday to respond to emergency calls on behalf of two sick staff members, one of whom had collapsed at work due to unknown causes. WHO did not reply to queries from Health Policy Watch about the incident, or its own workplace protocols on reporting COVID-19 cases to staff.   

Meanwhile, universities around the world were also taking matters into their own hands. The Graduate Institute in Geneva announced that all courses will be moved to an online format starting on 23 March. Across the Atlantic, Harvard University, Yale University, Columbia University, and Cornell University have all begun plans to shift classes online. However in the United Kingdom, while five Oxford University community members have tested positive for COVID-19, the university continued activities as normal while monitoring the situation with the aid of public health authorities.

Switzerland’s initial cases were largely imported from northern Italy to the Italian-speaking Swiss canton of Ticino, but the Federal Health authorities now say that the virus spread is country-wide, and even with restricted testing, there were 858 cases reported as of Thursday afternoon. Italy, meanwhile, saw another increase in some 1,872 cases in the last 24 hours, and now had 12,462 cases and 827 deaths as of Thursday afternoon. France saw 497 new cases for 2,281 in total, although Germany, which had  had closed schools in affected regions, reported no new cases on Thursday.

Pandemic Spread; Active Cases Worldwide

Time is of Essence for Containment of COVID-19

WHO has frequently stressed that time is of the essence, in enacting containment measures.

A new study by researchers at the University of Southampton underlined that.  It found that in the case of China’s outbreak, enacting strong “non-pharmaceutical interventions” even one week earlier could have prevented almost two-thirds of COVID-19 cases in the epicentre of, Wuhan, a city of 11 million people.

The problem now is that worldwide, the same measures, including: monitoring and tracing contacts; restricting travel; closing schools and public institutions; as well as fencing off and limiting movement in areas with sustained community transmission – are now being adopted at different times and to differing degrees in other countries, as the outbreak hotspots shift to Europe, the Middle East, and North America.

Alarmed by some countries’ delays, experts are urging their governments to act fast.

Former US Commissioner for the US Food & Drug Administration Scott Gottlieb warned Thursday that the US faces “two alternative but hard outlooks with COVID-19.” 

“The virus is firmly rooted in our cities. We’re losing time,” Gottlieb tweeted. “We [can] follow a path similar to South Korea or one closer to Italy. We probably lost the chance to have an outcome like South Korea. We must do everything to avert the tragic suffering being borne by Italy,”

“Every day we delay hard decisions, every day leaders don’t demand collective action, the depth of epidemic will be larger. We must act now. We have narrow window to avert a worse outcome.”

Travelers donned in protective plastic jackets at Hong Kong airport; Hong Kong has ‘bent the curve’ of the outbreak with large-scale protective measures.

Action One Week Earlier Could Have Prevented 71% of Cases in Hubei and 78% in Rest Of China 

Chinese authorities enacted a cordon sanitaire of Wuhan on January 23 along with strict restrictions on inner-city travel, strategies that were quickly expanded to the rest of Hubei Province, and then the rest of China.

The Southamptom study, published in pre-print on MedRxiv estimated that enacting such “non-pharmaceutical interventions” even one week earlier could have prevented up to 71% of cases in Hubei Province, and 78% of cases in the rest of China, as well as 61% of cases in Wuhan – by preventing a large migration of people right before Lunar New Year on 25 January. Taking action two weeks earlier could have prevented 84% of the cases in Wuhan, 90% of the cases in Hubei Province, and 91% of cases in other provinces.

On the flip side, the researchers also estimated that if Chinese authorities had moved even one week slower, the case load of COVID-19 may have doubled in the country. Two weeks slower, and the case load could have increased by 5.8 times.

Given the modeled scenarios,  the authors recommended that “countries facing potential spread of COVID-19 should consider proactively planning NPIs and relevant resources for containment, given how the earlier implementation of NPIs could have lead to significant reductions in size of the outbreak in China.”

Th authors used population movement data from Baidu, China’s Google search engine equivalent, and modeled the effects of three buckets of containment strategies on the spread of COVID-19 in China:

1. Inter-city travel bans and restrictions, including the unprecedented cordon sanitaire of Wuhan – the Wuhan lockdown effectively fenced off the epicenter of the outbreak to the rest of the world.

2. Screening, contact tracing, identification, diagnosis, isolation and reporting of suspected ill persons and confirmed cases – in wuhan, citizens were required to report their temperature daily via an online app, and mild and symptomatic cases were quarantined away from crowded apartment complexes at makeshift hospitals in stadiums and conference centers

3. Restricting contact and inner-city travel even for healthy people – As part of “social distancing” policies, the Chinese government encouraged people to stay at home as much as possible; cancelled or postponed large public events and mass gatherings; shuttered public institutions, schools, and workplaces; and extended the Lunar New Year holiday for anywhere from 2 weeks to over a month in different provinces depending on COVID-19 caseload.

Image Credits: UN Photo / Jean Marc Ferré, Johns Hopkins CSSE.

Iranian healthcare workers in personal protective equipment

As cases of COVID-19 surpassed 120,000 around the world, the World Health Organization on Wednesday declared a pandemic – a move the organization stressed was intended to “trigger” even more aggressive action from governments against the virus rather than surrender to its rapid spread.

In line with current trends, numbers of COVID-19 cases, deaths and number of affected countries will “climb even higher,” Dr Tedros Adhanom Ghebreyesus warned on Wednesday, before they decline.

However, WHO sees this as a “call to action” to spur countries to scale up efforts to contain the virus and slow the spread, and prepare their health systems for an influx of patients, said WHO’s Head of Emergencies Mike Ryan.

“Declaration of a pandemic is not an “escape clause” to mitigation – a strategy focused only on saving lives when uncontrollable spread of a disease is inevitable, Ryan said. “There is a strong element of controllability in this disease.…We have a real chance to bend the curve – and give the health system a chance to save more lives.”

Dr Tedros added that the dramatic decline in new cases in certain countries, and the low numbers of cases in others means that governments still have the chance to stop the virus from spreading further.

“Eighty-one countries have no cases – they should not give any ground for this virus to set foot in their country. Fifty-seven countries have less than 10 cases – they can cut it from the bud,” he said.

‘Bending the Curve’ of Rising COVID-19 Cases

The Republic of Korea has already ‘bent the curve’  of the epidemic with an aggressive testing and containment strategy. In what was two weeks ago the largest outbreak outside of China, the daily new case count has fallen to approximately 30 – 40 per day compared to a peak of over 500 a day just last week.

Increasingly governments across the WHO European region are taking an iron fist to the virus as well, replicating tracts that have succeeded in China, Singapore and the Korea. Italy has locked down the entire country; school classes and mass gatherings across France and Germany are suspended. In Spain – now the country in Europe most affected outside of Italy – daycare centers and schools in key affected areas are closed, flights between Italy and Spain are suspended, and large sporting events have been cancelled.

In the most assertive preemptive moves so far outside of China and the Republic of Korea, Israel announced this week that it will place all Israeli citizens re-entering the country under 14 days of self-quarantine regardless of where they are coming from, and bar the entry of foreign tourists altogether.  So far Israel has reported just 76 cases, mostly among Israelis or tourists arriving from abroad, while there are 26 cases in the Israeli-occupied Palestinian territories; In contrast, Switzerland, a country of approximately the same size, now has 645 people who have tested positive.

Meanwhile, WHO was recommending that countries around the world take a ‘blended’ approach to the battle against the virus – bolstering the capacity of hospitals and health care facilities to prepare for a surge in patients while at the same time, continuing to make containment “the major pillar” of the response, said Tedros.

The trade-offs are challenging. Tracking down contacts of cases and enforcing quarantine measures to slow down transmission of the virus could slow the surge of patients that require hospital care. At the same time, they can be complex and costly to carry out.

“The difficulty is that if you do not try to suppress this, it could be very straining to your health system,” said Ryan. In Italy, for example, some 900 patients were have been hospitalized within intensive care units, who also need to be continuously monitored by health workers wearing full protective gear.

“We’ve had lots of people talking about containment vs mitigation – countries should focus on containing where there is opportunity, and preparing the health system to reduce the impact,” said Ryan.

“There’s a shortage of ventilators, a shortage of oxygen… ” he added, noting that “the caseload, the demand on the healthcare workers, and the risks that come with the fatigue and the shortage of personal protective equipment,” are overwhelming for health systems,  said Ryan. “We need to focus on getting them equipment, supplies, and the training that they need to do the job.

Pandemic Spread; Active Cases Worldwide

European Countries Declaring Emergencies – But Responses Still Lagging Behind Outbreak Curve

European governments are enacting emergency executive powers as the outbreak explodes across the continent – just days after the Prime Minister of Italy locked down the country, applying travel restrictions on its citizens that were unprecedented since the end of World War II.

Along with Italy, Switzerland, Spain, and Israel have activated national emergency rules, which allow federal powers to control aspects of daily life in order to slow the spread of COVID-19.

Spain, which is now the country with the fifth highest number of cases, has taken a “whole of society approach” to the virus – all schools, daycares and university classes are suspended in La Rioja, Basque, and Madrid, while the national government shut down all flights to Italy and canceled sporting events.

Even so, those measures may not be sufficient, Ryan warned, saying: “Countries in the EU and Western Europe should assess whether efforts are good enough to suppress the virus.”

As of noon Wednesday, 645 people in Switzerland have tested positive for the disease, and events of more than 100 people were banned by Swiss Government authorities – striking at the core of Geneva’s economy, host to dozens of UN agencies, the world’s largest global health hub, and among the world’s most popular venues for related international events..

As the case count crept higher, Geneva’s UN agencies and affiliates, as well as other global health and development organizations and non-profits, rolled out aggressive screening measures, policies on telecommuting, and new protocols for potentially sick employees.

Shortage of Hospital Equipment In Iran

Meanwhile in Iran, local and central governments have improved coordination of COVID-19 efforts, said Ryan.

Schools and universities across the country are closed until after Nowruz, the Iranian New Year that falls this year on 20 March. Opening hours of large tourist attractions have been limited, and checkpoints have been established in major cities such as Tehran according to the official state news agency IRNA.

Right now, “the concern is a shortage of ventilators and oxygen” for treating severe cases, said Ryan.

“We’ve seen this in Italy. What happens at this stage is that it generates a lot of cases, that requires a huge effort by health workers,” he added.

Data from The WHO-China Joint Commission report on COVID-19 showed that approximately 14-20% of critical or severe cases will require hospitalization. Patients can require ventilator support for more than two weeks, and must be attended by at least two healthcare workers wearing full personal protective gear at all times.

WHO and China are still supplying the country with diagnostic supplies and protective equipment. WHO shipped 140,000 diagnostic tests to Iran today, following a shipment of 7 tons of personal protective equipment along with other outbreak response supplies sent last week.

Iranian officials are now aggressively tracing contacts and testing suspect cases, as the outbreak escalated to 9000 total cases and reached the highest echelons of government. Some 24 Iranian government officials and Members of Parliament have died from the disease, and many are reportedly ill.

According to Al Jazeera more than 70,000 prisoners were released following reports of a COVID-19 cases in overcrowded prisons with inadequate isolation facilities. Those sentenced for less than five years for non-violent crimes are subject to release.

Image Credits: Twitter: @WHOEMRO.

[Medicines for Malaria Venture]

Geneva and Liverpool (8 March 2020) – A new collaboration announced on International Women’s Day 2020 aims to help establish pregnancy registries in malaria-endemic countries in Africa to help fill the data gap on the use of antimalarials in one of the most vulnerable populations to malaria.

The study, led by Medicines for Malaria Venture (MMV) and the Liverpool School of Tropical Medicine (LSTM), will set up pregnancy registers to capture data through a prospective observational study on the real-life use of ACTs during all stages of pregnancy, including the first trimester. The study will be conducted in three countries across Africa with the goal of collecting enough safety and exposure data that, if positive, would allow for policy change on the use of ACTs in the first trimester of pregnancy.

“Pregnant women are disproportionately affected by malaria – 29% of all pregnancies in sub-Saharan Africa were infected in 2018,” said Dr David Reddy, MMV’s CEO. “Yet their needs have not been fully addressed. We are delighted to be collaborating with LSTM to establish a pregnancy registry – a clear first step towards collecting the data necessary to support the medical needs of women suffering from malaria, during every stage of pregnancy.”

Artemisinin-based Combination Therapies (ACTs) are the standard of care for malaria, and are recommended by the World Health Organization (WHO) for children and adults including pregnant women who are in their second and third trimester. Even though they are recommended by the WHO, limited data are available in second and third trimester for the more recently approved ACTs. In addition, ACTs are currently not recommended in the first trimester of pregnancy owing to a historic lack of safety data. However, there is evidence that a significant proportion of women seeking treatment for malaria in early pregnancy are treated with ACTs either because they do not know, or are unable to declare that they are pregnant.

The effort will also contribute to healthcare systems strengthening and capacity building, and encourage a sustainable pharmacovigilance culture in resource-constrained healthcare systems. Furthermore, in partnership with researchers and local regulatory authorities that are responsible for pharmacovigilance, a longer-term goal of the project is to develop a standard protocol and a network of sites that will collect safety data for all antimalarials and medicines for infectious diseases (e.g. HIV, TB) circulating in relevant endemic regions.

Professor Feiko ter Kuile, Head of the Malaria Epidemiology Unit at LSTM, said: “This new collaboration with MMV will give us the opportunity to gather much-needed data and provide a robust framework from which policy makers can make informed decisions that will benefit women when they are at particular risk of malaria, during pregnancy. The work will build on our extensive research and clinical experience in the field, and this pregnancy registry should allow us to gather safety data, not only on anti-malarials, but for drugs for the treatment of other infectious diseases that affect pregnancy.”

For more information, see the press release at MMV.

Image Credits: Elizabeth Poll/MMV.

Babies are particularly vulnerable to complications from malaria.

[Medicines for Malaria Venture]

  • EDCTP grants the PAMAfrica research consortium €21.9 million over a 5 year period; MMV, Novartis and other partners will provide an additional €22 million.
  • The PAMAfrica consortium brings together a global medicines company, a not-for-profit product development partnership and leading academic institutions in Africa and Europe. PAMAfrica aims to develop new medicines for both severe and uncomplicated malaria, designed to combat emerging artemisinin resistance.
  • The projects will include development of the first new malaria treatment for babies under 5kg, a new fast-acting medicine for the treatment of severe malaria, and new combinations to treat drug-resistant uncomplicated malaria. 

The Hague, the Netherlands; Geneva and Basel, Switzerland (3 March 2020) – The European & Developing Countries Clinical Trials Partnership (EDCTP) awarded a new grant to the new PAMAfrica research consortium led by Medicines for Malaria Venture (MMV). The consortium will support the development of new treatments for malaria in the most-at-risk populations, including babies, patients with severe malaria, and those with drug-resistant infections. The EDCTP grant of €21.9 million is to be matched by funding from MMV, Novartis and partners. Over a period of 5 years, the grant will support the development of a portfolio of projects executed under the umbrella of the PAMAfrica research consortium. Clinical trial capabilities in Africa will also be strengthened to ensure each site involved can effectively operate to ICH-GCP regulatory standards. The consortium includes seven research organizations from Burkina Faso, Gabon, Germany, Mozambique, Spain and Uganda. In addition to Novartis, other pharmaceutical company partners may join the consortium.

The PAMAfrica research consortium will conduct three clinical trials, supporting efforts to build clinical capacity and train scientists across Africa. One trial will explore new combinations of compounds, including new chemical classes, for the treatment of uncomplicated malaria in adults and children. These compounds are all known to be fully active against all drug-resistant strains, including the artemisinin-resistant Kelch13 strains. The second trial will evaluate a new generation, rapid-acting treatment for severe malaria, cipargamin, also known as KAE609, which is being developed by Novartis, supported by a grant from the Wellcome Trust. In the third study, a novel formulation/ratio from Novartis of the current gold standard treatment artemether-lumefantrine will be tested in newborn infants weighing less than 5 kg or who are malnourished.

Dr Timothy Wells, Chief Scientific Officer of MMV and the coordinator of the PAMAfrica group, said: “All three of these research projects address areas of urgent need in malaria treatment. Antimalarial drug resistance, originally seen in Southeast Asia, is being reported in Africa and may threaten current treatments. It is important to have new therapies that are active against this emerging threat of resistance. The work on newborn infants and in severe malaria is groundbreaking in bringing medicines to this neglected group. Thanks to this critical support from EDCTP we are not only able to bring together the necessary African and European expertise to conduct these projects to address unmet needs, but in doing so, we are also able to support the training and development of the next-generation of leaders in clinical malaria research in Africa.”

Dr Michael Makanga, Executive Director of EDCTP, said: “Malaria continues needlessly to take 405,000 lives a year and must remain a global and national priority in endemic countries. We hope our funding for PAMAfrica will contribute to the development of successful new treatments that will support malaria eradication, while supporting the development of African research capacity.”

Caroline Boulton, Global Program Head, Malaria, Novartis, said: “Despite advances in malaria control, we still have a long way to go. New antimalarials are urgently needed to tackle rising parasite resistance to current therapies. In response, Novartis has committed to advance research and development of a number of next-generation antimalarial treatments. Partnerships play a critical role in helping to bring these novel agents forward and we sincerely appreciate the crucial support of EDCTP to this process.”

Image Credits: Jaya Banerji/MMV.

UNFPA distributes clean baby delivery kits to women in Kasaï province, Democratic Republic of the Congo.

[UN News]

(3 March 2020) – In an emotional ceremony on Tuesday, the last Ebola patient in the DRC – a woman called Masiko – was discharged from the treatment centre in Beni, the World Health Organization reported.

“There are currently zero cases of Ebola in DRC after over a year of fighting this outbreak”, WHO Regional Director Dr. Matshidiso Moeti said in Tweet sharing a video of Masiko leaving the facility to the cheers of a waiting crowd.

“So proud of all involved in the response. We are hopeful, yet cautiously optimistic that we will soon bring this outbreak to an end”.

Dr Tedros in a daily briefing on Ebola added that no new Ebola cases had been reported in the past two weeks.”

The milestone comes as countries increasingly report cases of respiratory disease caused by a new strain of the coronavirus, which first appeared in the Chinese city of Wuhan late last year.  To date, more than 60 additional countries have been affected.

Africa Prepares for COVID-19

Following the virus’s spread to the continent, the African Union and the Africa Centres for Disease Control and Prevention organized an emergency ministerial meeting last month where the DRC was identified among 13 countries most at risk of coronavirus disease 2019 (COVID-19) due to their direct travel links with China.

“Some countries in Africa, including DRC, are leveraging the capacity they have built up to test for Ebola, to test for COVID-19”, WHO Director-General Tedros Adhanom Ghebreyesus told the meeting. “This is a great example of how investing in health systems can pay dividends for health security.”

WHO’s Africa office this week held an emergency partnership meeting on coronavirus , aimed at boosting engagement and developing an effective preparedness and response plan for countries in the region.

Organizations in attendance included fellow UN agency the UN Population Fund (UNFPA), which believes that compared to countries with little experience in large-scale infection prevention and control, the DRC may be better positioned to prevent the spread of the coronavirus because of the Ebola measures already implemented.

Lessons :earned from the Ebola outbreak

UNFPA health workers have been supporting Ebola response in the DRC: the tenth such outbreak in the country’s history. It has occurred against the backdrop of one of the world’s most protracted crises and in a region of the country that has been scarred by deadly armed group attacks. Overall, nearly 16 million Congolese citizens require support, including 3.5 million women and girls of reproductive age: that is between 15-49 years old.

Workers disposing of Ebola-contaminated materials

While all people living in affected areas are at risk of contracting Ebola, UNFPA explained that  health workers face increased risk due to frequent contact with infected persons, their biological fluids and contaminated objects. They also risk spreading the disease to other patients and practitioners during care. More than five per cent of Ebola victims in DRC were health workers who contracted the disease through contact with an infected patient’s bodily fluids, according to the agency.

Midwife Rachelle Mbavindi was infected with Ebola while working in the Mangina Referral Health Centre, which was renovated by UNFPA. Located in North Kivu province, it is at the epicentre of the humanitarian crisis and Ebola outbreak.

Rachelle and nine colleagues spent 90 days in quarantine and treatment after contracting the disease. Despite the difficulty of her experience, Rachelle returned to work following her release.

“After my experience with Ebola, I felt born again,” she said, “and I carry out my work with great caution and attention.”

UNFPA expanding interventions

As a midwifery supervisor, Rachelle trains her colleagues in the proper implementation of practices that can make the difference between life and death in the prevention of fatal diseases. These steps include proper hand hygiene, face protection and clothing, prevention of injuries causing open wounds, respiratory hygiene: that is, preventing viral spread through coughing, systematic cleaning of rooms and linens, and appropriate management of biological wastes.

Rachelle is applying her personal and professional experience with Ebola to prepare for the potential spread of coronavirus.

“Thanks to the Ebola training provided by UNFPA, I feel reassured that my maternity ward can prevent and control a new epidemic, including the coronavirus”, she said.

“In addition to the training and related supervision, UNFPA provides maternity wards with essential equipment to ensure full implementation of the infection prevention and control measures”, said Dr. Polycarpe Takou, UNFPA humanitarian coordinator for Ebola response.

UNFPA regional and country offices are now working to expand such interventions in preparation for the potential spread of COVID-19.

Image Credits: UNFPA DRC, UN News.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Treatment of Seriously Ill – Big Confounder for Health Systems

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Officials Pursue Containment of Outbreak in Italy and Iran

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

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

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

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

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

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

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

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

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

US CDC Warns Communities To Prepare For Community Spread

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

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

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

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

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

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

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

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

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

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

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

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

Origins of Iran’s COVID-19 Cases Unclear 

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

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

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

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

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

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

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

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

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

China Changes Reporting Protocol Again Amid New Spread In Prisons

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

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

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

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

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

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

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

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

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

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

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

Updated Saturday 22 February 

Image Credits: Flickr: Pierre Le Bigot.