Staff members administering vaccinations at Kabuga Health Center in the Gasabo district of Kigali (Rusororo sector), Rwanda on June 28, 2018.

As the explosive impact of COVID-19 ripples globally, there’s a clear plea from many regions and countries: stay home and help “flatten the curve” of infection. People from China to Italy have seen the consequences of the virus spreading too quickly with hospitals overwhelmed and doctors forced to make heartbreaking decisions about who lives and dies.

It’s natural to hear these stories and blame a lack of pandemic preparedness. But emergency response can only go so far if the health system’s first line of defense – primary health care – isn’t up to the task.

Experts have already called attention to gaps in front line health supplies, such as masks, hand sanitizer, testing kits and vaccines. In the U.S., where we live, these gaps mean we’re now fighting a steep uphill battle in containing the virus. But few are talking about shortcomings of the primary health care system, which is about far more than just supplies. Strong primary health care looks like a trusted nurse or doctor, who is always there and trained to answer your questions. It means comprehensive quality care – in one place – tailored to your health needs. It means confidence that your local health center is safe and ready with quality medicines and supplies, regardless of outbreaks or changes in the world around you.

Whether or not a crisis is looming, primary health care should be the first place everyone turns for health services or information, using hospitals only when truly necessary.

For most people worldwide, though, access to quality primary health care depends on where you live or how much money you have. In fact, primary health care is chronically underfunded and deprioritized in rich and poor countries alike.

COVID-19 has made it painfully clear that we can’t afford to have weak primary health care continue as our reality. In the U.S., fragmented care and lack of clear communication from experts has left people anxious about where to turn, making unnecessary visits to emergency rooms. In Italy, where the health care system has experienced cuts in funding over the past decade, we’re seeing the dire consequences of having too few staff and supplies. And across Africa, where the virus is rapidly spreading, misinformation and mistrust of health systems could keep people from seeking care – as we saw in Liberia and other West African countries during the 2014-2016 Ebola outbreak.

This doesn’t have to be the case. There are clear steps the world can take to fully unlock the potential of primary health care, both to help us respond to the current pandemic and prepare for disease outbreaks we’ll inevitably face in the future.

In the short-term, primary care providers should be considered central partners and first responders in this crisis, helping to test and triage the most at-risk patients, and reducing the burden on already-overwhelmed hospitals. Leaders owe them reliable information and tools, including additional support for logistics and staffing and critical supplies such as rapid test kits and personal protective equipment. Such approaches have paid off in a big way in countries like Singapore, where they’ve been able to mobilize a trusted and well-resourced primary health care workforce.

Trusted primary care providers can also play a key role disseminating prevention messages to the public and high-risk groups, and encouraging social distancing by offering telehealth services for people with COVID-19 symptoms and chronic disease patients alike.

In the weeks and months ahead, countries and donors should also resist the urge to earmark all response funds for coronavirus-specific care. As health systems approach breaking point, flexible funds for primary health care can aid the response and prevent disruptions to essential daily life-saving services, from delivering babies to treating chronic conditions. This approach will also help head off future epidemics, rather than promote a continuous cycle of “Band-Aid” investments that ignore the root of the problem.

In the long term, governments must significantly increase spending on quality primary health care to make sure it’s well-resourced and affordable – so that no one has to choose between seeking care and paying their bills. The World Health Organization estimates that it will take an additional $200 billion annually to fund quality primary health care for all; well-spent, this could save 60 million lives in low- and middle-income countries alone.

Finally, we can’t fix problems that we can’t diagnose. Countries desperately need better ways to take the temperature of their primary health care systems. At the Primary Health Care Performance Initiative, a partnership of country policymakers, health systems managers and advocates, we’re working with governments around the world to collect more and better data, equipping leaders to pinpoint weaknesses and improve health systems before the next pandemic hits. Counting treatments or people infected is not enough – we need to know if people trust and value their care; if health workers are trained, resourced and motivated; and if clinics are safe, clean and well-managed.

We are only as prepared as the world’s weakest health system. The world has repeatedly failed to learn this before. We must do better beginning today, or this won’t be the last time we pay the price.

______________________________________________________________________________

Dan Schwarz, MD MPH is the Director of Primary Health Care at Ariadne Labs and an Adviser to the WHO and the Lancet Commission on Noncommunicable Diseases and Poverty, with over a decade of experience in global healthcare delivery. 

 

 

 

Beth Tritter is the Executive Director of the Primary Health Care Performance Initiative (PHCPI). PHCPI was founded in 2015 by the Bill & Melinda Gates Foundation, the World Health Organization and the World Bank Group, and now including UNICEF, in collaboration with Ariadne Labs and Results for Development. She previously served in the U.S. government as the Millennium Challenge Corporation’s Vice President for Policy and Evaluation.

Image Credits: Bill & Melinda Gates Foundation/Samantha Reinders.

Gianni Infantino (left) and Dr Tedros (right) sit at least 2m apart from each other at the WHO COVID-19 Press Briefing

A World Health Organization – Fédération Internationale de Football Association (FIFA) joint campaign was launched on Monday to “kick out coronavirus” as global confirmed cases of COVID-19 soared past 350,000 Monday afternoon. 

“Football can reach millions of people, especially younger people, that public health officials cannot,” he added.

It took 67 days to reach the first 100,000 cases, 11 more days to surpass 200,000 cases, and only 4 days to reach the 300,000 benchmark, noted Dr Tedros soberly in a press briefing. 

Alisson Becker, WHO Ambassador and Liverpool’s goalkeeper, joined Tedros via video chat and told the public, ”Health comes first in this moment. It’s time, like in football, to have teamwork.

“That means everybody does their own job – that includes being safe, staying at home, following the local authorities’ advice…We can’t forget that for now we need to work as a team.”

Gianni Infantino, president of FIFA, said that FIFA’s 211 member countries will be rolling out the “kick out coronavirus” campaign in the next few days.

 

Still, Dr Tedros told reporters that such physical distancing measures were “defensive” and not enough to quash the virus alone.

“You can’t win a football game only by defending. You have to attack as well,” said Tedros.

“To win, we need to attack the virus with aggressive and targeted tactics –  testing every suspected case, isolating and caring for every confirmed case, and tracing and quarantining every close contact.”

Technician in Indonesia runs a test on a GeneXpert machine (Source: USAID)

US Food & Drug Administration authorization of a rapid COVID-19 test on the GeneXpert platform, one of the most widely-used TB diagnostic tools in the world, could be the first crack in the doorway to wider testing capacity in low- and middle-income countries, leading TB advocates told Health Policy Watch. 

There are some 23,000 GeneXpert devices worldwide, including an estimated 7000 -10,000 instruments scattered across Africa, Latin America and South-East Asia. While not a high-throughput device, the GeneXpert technology produced by the California-based firm Cepheid, can process nose swab samples in a mere 45 minutes.

Cepheid received the US FDA emergency use authorization on Friday, March 20th  for its new Xpert® Xpress SARS-CoV-2 diagnostic that can be processed on the GeneXpert platform. 

“The GeneXpert® platform could fill a crucial need, especially in low- and middle-income countries,” said Paula Fujwara, Scientific Director of the International Union Against Tuberculosis and Lung Disease (The Union). “The need for testing is immense as we still don’t know the true number of people who are infected in the world,” she added, and adapting the GeneXpert platforms in low- and  middle-income countries to COVID-19 testing coud be “easily and rapidly done,” since the technology is already well-known.

However, she called on Cepheid to reduce the price of the COVID-19 test cartridges, which are reportedly set to sell for US$20 initially, to US$5 each, in order to make them more widely affordable in low- and middle-income countries. 

Many other pathogens, including HIV and hepatitis C, are also tested on GeneXpert, at a cost of between $US 9 – $US 20, to some 145 low- and middle-income countries that are eligible to procure the diagnostics at concessionary prices.

In December 2019, Médecins Sans Frontières/Doctors Without Borders called upon Cepheid to reduce the costs of all its test cartridge to US$5, including service and maintenance, eligible countries.  

GeneXpert was widely deployed about decade ago to rapidly detect tuberculosis, including multi-drug resistant strains; it has since been adapted to enable rapid testing of many her pathogens, including not only HIV and hepatitis C, but also influenza, Ebola and sexually transmitted infections. 

Thanks to longstanding investments in TB infrastructure by The Global Fund, among others, the GeneXpert instruments are widely available in WHO’s Africa Region, which has now reported 1,396 confirmed COVID-19 cases across 43 countries. For instance, there were approximately 150 machines installed and running in the Democratic Republic of Congo, and ‘several “hundreds in nearby countries”, according to a 2018 report from Nature.

GeneXpert tests are a “point-of-care” option that allows  hospitals and clinics to perform diagnostic tests in-house, rather than sending them to outside labs. Additionally,  the machine’s “automated systems do not require users to have specialty training to perform testing — they are capable of running 24/7,” Cepheid President Warren Kocmond also noted in a press release.

“During this time of increased demand for hospital services, Clinicians urgently need an on-demand diagnostic test for real-time management of patients being evaluated for admission to health-care facilities,” said  David Persing, Chief Medical and Technology Officer at Cepheid.

“An accurate test delivered close to the patient can be transformative — and help alleviate the pressure that the emergence of the 2019-nCoV outbreak has put on healthcare facilities that need to properly allocate their respiratory isolation resources.”

The new COVID-19 tests for the system will be shipped out from the Sunnyvale, California production facility starting this week.

The first diagnostic tests appear to be destined for US domestic use, where there are approximately 5,000 machines, a source with another TB advocacy group told Health Policy Watch.

“It appears that Cepheid is not yet positioning the COVID test for wide -scale use in low-income countries, where it could have the greatest impact,” the source said.

Still, there is a “strong case” for activists to push “for ramping up global production to meet the testing needs of many low-income countries,” where GeneXpert networks are already in place.

Usability In Rough Field Settings Still A Concern

While automated, and designed for point-of-care testing, GeneXpert requires controlled, air-conditioned temperatures, so it’s not suitable for rough field conditions.  However, it is still widely available in district health facilities and TB clinics across many low-income countries.

“The advantage of GeneXpert is that testing can be done closer to the point of care (rather than only in centralized laboratories), which theoretically would improve turn-around times for test results as compared to laboratory instruments,” the source told Health Policy Watch.

Ultimately, instrument-free immunoassays would be even cheaper and more appropriate for community-level testing. There are a number rapid tests in the pipeline, but  none so far have been approved. 

In arrangements made a decade ago, prices for the GeneXpert device, which normally costs about US$17,000, as well as cartridge prices were reduced, for 145 eligible low- and middle-income countries. In 2016 alone, 6.9 million cartridges were procured in the public sector under the concessionary pricing arrangements. 

Tsering Llamo and Grace Ren contributed to this story

Updated 24 March, 2020. 

Image Credits: Trishanty Rondonuwu, USAID Challenge TB.

New York Army National Guard members dressed in protective equipment. The photo contrasts sharply with reports of paltry protective equipment available in New York City hospitals.

Manufacturing of personal protective equipment (PPE) for the COVID-19 pandemic response should be scaled up by 80 to 100 times to meet the projected needs of the healthcare workforce, the World Health Organization said on Friday.

Amid a growing PPE shortage crisis in hotspots like Italy, the United States, and Iran, some 26 million healthcare workers around the world who may have to engage with COVID-19 patients could be in need of personal protective equipment, WHO projected.

“The greatest tragedy is the prospect of losing a great part of our healthcare workforce that may lose their lives [to care for those who are sick],” WHO’s Executive Director of health emergencies, Mike Ryan, told reporters Friday.

Ryan added that WHO was working on directing medical supplies into a “protected supply chain for health workers,” but at the moment the organization was also facing issues with transporting existing stock to countries in need.

“We’re having issues with flights, issues with moving material around” due to some international travel restrictions, said Ryan. “We’re going to need to set up air bridges to bring staff and stuff to countries to help assist them.”

WHO’s Director-General Dr Tedros Adhanom Ghebreyesus additionally added that the shortage of PPE could not be addressed “without political commitment of our leaders.”

According to Dr Tedros countries should be taking three key steps:

  1. Increase production of protective equipment;
  2. Support cross-border mobility and lift export restrictions on protective equipment;
  3. Focus on equitable distribution, as all countries may not have access based on needs.

Down at the community level, Maria Van Kerkhove, WHO’s technical lead on the COVID-19 crisis, said individuals who are not caring for a sick COVID-19 patient or sick themselves should not use masks in order to keep the supply available for healthcare workers.

“There’s very serious discussions about use of masks – if you do not need to wear a mask, don’t hoard those masks. Make sure they are available for healthcare workers,” she said.

“They’re making very difficult decisions about extended use or repeated use.”

US Healthcare Workers Plead For More Government Support As PPE Stocks Run Low

Amidst the global PPE shortage, healthcare staff around the United States are pleading with the federal government for assistance procuring personal protective equipment. 

Additionally, in some hospitals in the epicentres of US outbreaks, resident doctors are being refused COVID-19 tests unless they themselves show severe symptoms.

One resident at a large hospital in New York City posted on social media that the new hospital policy is that a resident should continue working, even if they have mild upper respiratory infection symptoms.

“We are being refused COVID tests as doctors. We are only deemed eligible if we develop [further] respiratory symptoms,” added the resident in their post.

Another resident in New York City confirmed that this was a new policy at a different hospital, as New York City shifted from testing and tracing all suspect cases, to reserving COVID-19 tests for severe cases on Wednesday as cases surged. On Tuesday, a federal official told the Washington Post that there were reports of more than 60 health workers infected with COVID-19 in the US. 

However, US President Donald Trump told reporters in a press briefing Thursday that the federal government has yet to take action under the “Defense Production Act” invoked on Tuesday to direct American manufacturing towards producing supplies for the COVID-19 response. Vice President Mike Pence insisted that “35 million masks” manufactured by 3M, a major respirator production company “were immediately available” for hospitals to purchase, although social media reports from healthcare providers indicated a severe shortage on the ground.

Desperate healthcare workers are calling on the US government to step up. Said the NYC resident, “there has been no government-issued PPE provided to any hospital as of yet… we also need help from the government.”

The US CDC loosened PPE guidance to recommend “facemasks as an acceptable alternative when the supply chain of respirators cannot meet the demand.” Respirators, masks which filter inspired air rather than just protecting against splashes and sprays, offer a higher level of protection against droplet and aerosol transmission than surgical masks. 

A widely circulated petition submitted by three physicians on Change.com, which has gathered more than 700,000 signatures in 48 hours, pleaded “Recommendations to protect healthcare workers should not be based on what’s available; availability should be based on what is necessary.”

According to the petition, some hospitals have taken the CDC’s advice to mean that surgical facemasks are the preferred PPE, and are thus rationing N95 respirators only for ‘aerosol-generating procedures’ such as intubation procedures required to place patients on ventilators. 

Sources told Health Policy Watch that some hospitals in the Tri-State area, which encompasses New York, Connecticut, and New Jersey, have begun collecting used N95 respirators to sanitize and reuse. 

But the concerns do not apply to New York City alone. The authors of the petition, who hail from San Diego, California, wrote “We urge the government to access the Strategic National Stockpile, [the federal government’s stock of emergency medical supplies], and to utilize both the public and private sector to immediately increase production of PPE supplies.”

Active cases around the world as of 2:43PM CET 20 March. Right column shows cumulative case count. Numbers are rapidly changing.

WHO Director-General Tells Young People “You Are Not Invincible” As Data Indicates Severe Disease In Those Under 50

As confirmed COVID-19 cases around the world rose to 246,276, and total deaths surpassed 10,000, Dr Tedros put out an urgent message to young people to treat the virus with greater caution, amidst an ongoing narrative that the virus is mostly serious in those above the age of 65 and with preexisting conditions.

“You are not invincible,” said the WHO Director-General. “This virus could put you in hospital for weeks, or even kill you.

“Even if you don’t get sick, the choices you make about where you go could be the difference between life and death for someone else.”

Approximately two-thirds of cases in intensive care units in Italy, which now has 41,035 confirmed cases and 3,405 deaths, are under the age of 50, said Ryan. Cases across Europe increased to 99,302 cases and 5,174 deaths, increasingly placing health systems under strain.

Swiss authorities warned on Friday that along with a shortage of diagnostic tests, parts of the country including Ticino canton in the south faced a looming shortage of hospital beds, according to the Local. With one of the highest case to population ratios in Europe, Switzerland has reported 4,164 cases and 43 deaths, according to the Swiss Federal Office of Public Health.

Spain was battling the second largest outbreak In Europe with 18,077 cases and 833 deaths; followed by Germany with 16,290 cases and 44 deaths, and France with 10, 891 cases and 371 deaths.

Across the Atlantic in the United States, some 38% of patients hospitalized for COVID-19 are under the age of 55, according to data released by the US CDC on Wednesday. Among 121 patients admitted to the intensive care unit, 48% were under the age of 65. The case count in the US rose to 14,250 confirmed cases and 250 deaths as outbreaks accelerated in New York State, California, and Washington State.

In Iran, where the epidemic bloomed to 18,407 cases and 1,284 total deaths,  Iranian Ministry of Health spokesman Kianush Jahanpur said that the coronavirus disease is currently killing one person every 10 minutes and some 50 people become infected with the virus every hour. The government urged people to stay home on Friday for Nowruz, the Persian New Year.

More than 700 cases have been confirmed across WHO’s Africa region by Friday, when just one week ago the case count stood at 147 confirmed cases. With local transmission settling into twelve countries in the African region including South Africa, which has 202 confirmed cases, South African Health Minister Zweli Mkhize warned the country to scale up preparedness efforts for when the outbreak starts “affecting poor communities where families do not have enough rooms or spaces to quarantine those affected.”

In Latin America, Brazil and Chile have the highest number of reported cases so far, with 428 and 342 cases respectively according to WHO’s Pan-American Regional Office. On Friday, Brazilian officials announced a ban on entry of all foreigners from Europe for a month, starting 23 March. On the same day, Argentina, with 128 cases, began a “preventative and compulsory” lockdown. Peruvian president Martín Vizcarra announced an investment of US $28 million to help ramp up diagnostic capacity in the country, which currently has 234 cases and just reported its first death.

In one bright spot, Wuhan, the Chinese city at the center of the epidemic merely six weeks ago, reported no new cases of COVID-19 for the first time since the beginning of the outbreak.

“Of course, we must exercise caution – the situation can reverse. But the experience of cities and countries that have pushed back this virus give hope and courage to the rest of the world,” said Dr Tedros.

“Wuhan provides hope for the rest of the world, that even the most severe situation can be turned around.”

Svet Lustig and Zixuan Yang contributed to this story.

Image Credits: New York City Nation Guard, Johns Hopkins CSSE.

Covid-19 laboratory test kit (Reverse-Transcriptase Polymerase Chain Reaction) developed by the USA’s Center for Disease Control (CDC)

New high-throughput test technologies that can process thousands of COVID-19 samples a day are coming online. But the CEO of Roche Pharmaceuticals, which recently gained US Food and Drug Administration approval for a new high-volume test, asserted Thursday that “broad-based testing is simply not feasible.”

Severin Schwan, Roche CEO, was speaking at a press conference of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), where he also serves as vice-president.

“Testing is very important to help isolate infected patients, to flatten the curve to help health systems cope with capacity,” Schwan said. “Whilst industry has been ramping up production, still the demand is by far outstripping the supply. Tests should be targeted to patients at risk. Broad-based testing is simply not feasible.”

His comments came as countries rushed to obtain COVID-19 diagnostics, while gaps appeared to be widening between different health systems’ abilities to secure and run tests – and not always along the lines of wealthier and poorer countries. The USA, Germany, and Israel, to name some examples have rapidly accelerated mass testing after Korean and Singaporean examples, to head off wider transmission of the virus in line with WHO Director General Dr Tedros Adhanom Gheyebresus’ recommendation Monday to “test, test, test.”

But as the number of cases continued to grow throughout Africa and Latin America, health policymakers are increasingly worried about how they could secure tests needed to reduce tranmission to maneagable levels. And in Europe, the new virus epicentre, some of its most affluent nations, including Switzerland which is home to Roche, have said that they are reserving tests for only seriously ill and at risk patients, as a result of the overall shortfall in tests, reagents or other resources.

The Canton of Berne was forced to put plans to create a “drive-in” testing sites, imitating a successful Korean model, on hold because of the lack of available tests, Swiss public health officials conceded in a press briefing on Thursday.

“There has been an increase in testing, and this has stretched the availability of tests to their limits,” said Daniel Koch, director of communicable diseases in the Swiss Office of Public Health, in a press conference convened by Federal authorities in Switzerland, where 3,888 cases have now been confirmed.  Speaking in a televised interview, he added, “Initially you test as broadly as possible. But this phase is over in Europe. It is impossible at the moment to test everyone who might have been infected.”

Koch called upon citizens to remain secluded and avoid social contact in order to reduce further transmission, “it’s the last moment. If everyone doesn’t make an effort, we are going to face a catastrophe.”

He remarks came against a continued worldwide increase in infections by at least 20,000 new cases overnight, mostly driven by infections in western Europe which is the new epidemic epicentre. Italy was now reporting over 5,000 new cases overnight for a total of 41,035, according to national data. Spain and Germany were reporting over 30,000 cases combined, followed by the United States and France with about 9,415 and 9,058 cases each.

The concerns over testing also have been heightened by the recent surge of infections in Latin America (1397), Africa (733), as well as South-East Asia (497) where public health authorities are scrambling to contain outbreaks, and prevent spread in mega-cities.  In Lagos, which has so far seen only 8-12 reported cases, Nigerian officials ordered schools closed on Thursday as a pre-emptive move.

Global tracking of active cases. Numbers change rapidly. Italy was reporting 41,035, total cases, 5,023 new on other sites.

Thermofisher and Roche To Produce Millions of COVID-19 Tests on High Throughput Platforms 

Recently, the US-based ThermoFisher, one of the largest scientific instrument manufacturers in the world, announced plans to produce up to 5 million testing kits for its Applied Biosystems 7500 Fast Dx Real-time PCR instrument. That represents a more than three-fold increase over the 1.5 million tests currently available on their platforms.  

“The authorization of our diagnostic test for COVID-19 will help to protect patients and enable medical staff to respond swiftly to treat those who are ill and prevent the spread of infection,” said Marc Casper, the chairman, president and CEO of Thermo Fisher, in a statement.

The Swiss-based Roche also plans to produce millions of diagnostic tests, which run on its Cobas 6800/8800 automated diagnostic systems, following US FDA Emergency authorization of the tests. Globally, Roche has installed some 842 Cobas systems, a Roche spokeswoman told Health Policy Watch. That includes 136 units of the larger Cobas 8800, and 706 units of the smaller COBAS 6800, a Roche spokesperson said.  She said that Roche would be partnering with “local affiliates as well as customers, nonprofits, and governments” to harness that testing capacity.   

The Cobas 8800, Roche’s larger automated diagnostic system, is capable of delivering up to 4128 tests over a period of 24 hours, and 400,000 tests a week.  This is ten-times faster than Roche’s existing test, which runs on their MagNA Pure 24 and the LightCycler 480 devices.

This suggests that the Cobas 8800 automated diagnostic systems alone could more than double the USA’s current test capacity (of about 182 000 a week), according to a scientific site monitoring COVID-19 test capacity. 

“We are increasing the speed definitely by a factor of 10”, said Thomas Schinecker, head of the Roche’s diagnostics unit in an interview with Bloomberg News.  “Capacity is ramping up as we speak. Millions of tests are available a month but demand is also going up,” added Schwan in the Thursday press briefing.

USA doubles testing capacity in five days 

According to reports by scientists monitoring the landscape, the USA has already doubled its testing capacity over the past five days, largely as a result of expanded use of the so-called “low-throughput” manual diagnostic assays developed by individual hospitals, universities and private laboratories.

Once the new high-throughput systems come on line that should expand even more – at least in high income countries. The USA, for instance, currently has 110 COBAS 6800/8800 automated diagnostic systems on hand, according to media reports.  

Roche does not divulge, however, the global distribution of its equipment, although presumably the automated instruments are primarily available in countries with well-equipped health systems. In low- and middle-income regions, meanwhile, hopes for improving testing capacity may hinge on the development of new rapid, low-cost tests, WHO officials say. 

In the Africa region, WHO has already distributed some 200,000 test kits, as well as building up laboratory capacity to manage the tests from just two countries, South Africa and Senegal, in early February to 40 countries presently. However, WHO’s Regional Director for Africa, Matshidiso Moeti is anticipating that those initial test stocks could quickly be drained once the virus hits the continent with full-force as it may when the winter season arrives in southern and eastern Africa. 

“As regards the test kits and the global challenges in their availability, we would like to encourage a very focused screening and case finding strategy where those who have symptoms and their close contacts would be tested,” she said, speaking at a WHO African Region press briefing on COVID-19 Thursday.

“We are aware there is a challenge,” she said, adding, “We are very keen to explore test kits and testing approaches that will be carried out  in as minimal a demanding a way, and as broadly as possible, so that they can be carried out before or right when people start showing symptoms.” 

Source: @Covid2019tests

Price and Patents Could Create Barriers to Wider Testing – Say Access Advocates

Even in well-resourced Europe, however, there are also growing concerns that available diagnostics are too expensive for the volumes now required.  This is despite the fact that traditional low-throughput laboratory tests are freely available from public sources since the main patents on reverse-transcriptase Polymerase Chain Reaction (rt-PCR) technology required to conduct the tests have expired,

WHO has estimated the cost of those tests as US$ 30-$US60.  However, some countries, such as France, also seem to be paying even more.

“It is unclear why the set price for a Covid-19 test is 135 Euros, given that the production price is estimated at 12 Euros,” says Pauline Londeix co-founder of the French Observatory for Medicines Transparency in a recent post. “We are asking the [French] Minister of Health …to implement a policy of transparency regarding the price of diagnostics and to regulate them, as was the case with the price of alcoholic gel [hand sanitizer]. Leaders in the diagnostics market exist in France. Their production units must be requisitioned to enable us to produce the tests we urgently need.” 

In an open letter Thursday evening to French Prime Minister Edouard Philippe, the group further alleged that the current French Health Ministry policies limiting COVID-19 testing to higher risk and more symptomatic cases “contradict” the recent WHO recommendations to test aggressively, and also ignore the examples of Germany and the Republic of Korea which have seen a correlation between widespread testing and reduced COVID-19 mortality.

In Thursday’s press conference today, Roche CEO Schwan deferred from discussing the per-unit price of the COBAS tests.  But he asserted that expansion of testing infrastructure and lab capacity are the real barriers – not costs.

“Cost is not the issue,” said Roche CEO Schwan, “The issue is capacity and access,” he said, “The problem is you need to install highly sophisticated systems in hospitals, you need personnel to ramp up testing. The priority has been to provide those labs with existing infrastructure. These are not tests that you can run at home. We need educated staff for this.

“In emerging markets, we have to work with low throughput systems at this stage,” he added, saying.  “In parallel, we need to bring additional instruments to labs that have infrastructure where the need is biggest so that we can increase capacity. So cost is not the bottleneck, infrastructure and personnel is the bottleneck.”

Still, some access advocates say that without a transparent market in COVID-19 diagnostics – including publicly available data on high- and low-throughput technologies, and their prices, it will be difficult, if not impossible, for global health leaders and national policymakers to rationally plan their strategies, fill stocks and adequately respond to growing demands.

“Policymakers should have a clue what it costs to manufacture and deliver diagnostic tests, and by that, I mean, what is the cost to suppliers,” said Knowledge Ecology International’s Jamie Love. “Testing should be done for lots of people and some people will need lots of tests. Prices matter. There needs to be complete transparency of costs and prices for the whole value chain, and this is also consistent with the 2019 World Health Assembly Resolution on transparency.  

“In an emergency like this, having accurate and relevant information is important. I think everyone knows that, but it is surprisingly how little we know about testing costs right now. For large scale testing, we should see prices between $1 and $5 per test. But we are way off that now.  

In cases where diagnostics patents have not expired, legal battles could also threaten rapid scale-up of some technologies, observers add.

In one such example, Labrador Diagnostics last week filed a lawsuit against BioFire Diagnostics and the French-based BioMerieux S.A. in a US District Court in Delaware for allegedly infringing on its patents linked to its FilmArray System. The BioFire FilmArray Pneumonia Panels System is especially helpful for diagnosing lower respiratory infections, including those created by COVID-19. Should Labrator’s injuction be approved, use of these FDA-approved diagnostics to slow down the outbreak in the USA could be seriously hindered.  

Image Credits: NIAID-RML, Wikimedia Commons: US CDC, @COVID2019tests.

Electron microscope image of SARS-CoV-2, the virus that cause COVID-19

The World Health Organization announced on Wednesday a global “SOLIDARITY Trial” to generate a large, robust study comparing potential treatments for COVID-19. Currently there are 522 trials listed on WHO’s Clinical Trial registry under “COVID-19.”

“Multiple small trials with different methodologies may not give us the clear, strong evidence we need about which treatments help to save lives,” WHO Director General Dr Tedros Adhanom Ghebreyesus told reporters Wednesday.

“WHO and its partners are therefore organizing a study in many countries in which some of these untested treatments are compared with each other.”

So far, Argentina, Bahrain, Canada, France, Iran, Norway, South Africa, Spain, Switzerland and Thailand have confirmed they will join the trial, and the Director-General expressed hope that others would soon join.

According to Ana Maria Henao Restrepo, medical officer in the Department of Immunization Vaccines and Biologicals at WHO, countries will be able to choose from 5 treatment arms:

  1. Standard of care available in the country, which will serve as a ‘control’ arm that the efficacy of other treatments will be compared with.
  2. Remdesivir, an antiviral drug with activity against Ebola, highlighted as one of the most promising potential treatments
  3. Lopinavir/ritonavir, a combination of two common HIV/AIDS antivirals
  4. Lopinavir/ritonavir and the anti-inflammatory drug interferon beta
  5. Chloroquine, an antimalarial drug, or its less toxic derivative, hydroxychloroquine

The large, international study will hopefully “generate the robust data we need to show which treatments are the most effective,” said Dr Tedros.

This story was updated 21 March 2020.

Image Credits: NIAID-RML.

Public health laboratory in Pennsylvania, USA extracts COVID-19 samples for testing

A worldwide shortage of chemical reagents needed for COVID-19 testing has emerged, World Health Organization officials admitted on Wednesday – even as the number of confirmed cases of the novel coronavirus worldwide surpassed the 200,000 mark.

Reports of shortages come days after WHO’s Director General Dr Tedros Adhanom Ghebreyesus issued an urgent appeal to countries worldwide to accelerate diagnostic testing in order to get the pandemic under control.

“There have been shortages of ancillary materials used in PCR (Polymerase Chain Reaction) reactions, which is the most common way to diagnose coronavirus,” said Mark Perkins, WHO lead for laboratory networks for infectious disease management, speaking at Wednesday’s press briefing.

“Some important chemistries [reagents] you cannot find anywhere other than diagnostic manufacturers. And a lot of the diagnostic manufacturing has been done in China; with the outbreak in China, it decimated the workforce – and that has made them difficult to procure.”  

To make up for the gap, some 200 PCR tests have also been created and are being manufactured locally by different national, regional and local laboratories or private firms, he noted. “The vast number of diagnostic companies are scaling up their own capacity to produce reagents, so I think we are getting over that hump.”

However, having a “plethora” of choices is also creating new issues, he admitted.  “Sorting out which ones work and meet which needs is the next step.”

Additionally, tests on their own are not a panacea, stressed Maria Van Kerkhove, WHO’s Health Emergencies technical lead. What is required is a multi-pronged approach: increasing the number of tests; the number of labs that can run the tests; and the number of qualified technicians.

Testing alone is not enough either, stressed Mike Ryan, WHO Emergencies Head. To slow or interrupt transmission, not only do people found to be positive for the virus need to be isolated, but their close contacts as well: “The difficult part is contact tracing – countries need to mobilize a large public health mechanism needed behind to identify and isolate contacts of cases.”

Aggressive Testing Helps Reduce Germany’s Death Rates 

Even so, Germany’s aggressive early testing strategy may help explain why the country has so far managed to to keep disease death rates low, added Ryan. “They have had a very aggressive testing programme, and so far confirmed over 6000 cases with just 13 deaths.” The testing dragnet captures milder cases and also allows people to get treatment faster, reducing the overload on health systems. 

In contrast, Italy has experienced an 11% death rate from the virus.  However no one factor alone can explain the variations, the WHO officials stressed. Italy’s high death rate is likely also due to the older average age of its population; the fact that the epidemic cycle is more advanced; as well as the fact that health systems were caught by surprised and overwhelmed at the outset of the epidemic, also reducing the ability to treat serious cases.

“We see a pattern of long hospital admission,” Ryan observed.  “Italy, having experiencing the first wave, and a number of people reach a point when they can no longer be saved in the clinical system. We have to look at where each country is in the epidemic cycle.”

“We also have to look at demographics Italy has a much older profile. Italy has been a panacea for healthy people living to old age, but unfortunately in this case, the fatality rate may appear higher because of age distribution. 

“And there may be technical reasons as well in ability to provide care,” he added, noting that the country has seen over 1200 COVD-19 patients in intensive care simultaneously. “Anyone who has worked in the front lines of emergency, knows that when numbers begin to overwhelm, standards of care cannot be maintained.” 

At the same time, Van Kerkhove emphasized that it remains difficult to define and compare mortality rates, since in some countries many milder cases may be flying under the radar.

Also, the notion that the disease mainly affects older people, can be misleading, she added.

“Almost 20% of their [Republic of Korea] deaths have occurred in people under the age of 60,” Van Kerkhove said. “The idea that this kills only elderly is dangerous. This isn’t just a disease of the elderly – young people may have higher rates of mild disease. Otherwise healthy adults can develop a serious form of the disease.

“We haven’t seen how it will behave in vulnerable populations, HIV-positive and malnourished children, and that’s what we need to prepare for.”

Active cases of COVID-19 (middle) around the world as of 6:53 PM CET 18 March, Numbers change rapidly.

Europe Hits 80,000 Cases – Equal To China’s Cumulative Total  

Europe, now has over 80,000 confirmed cases and close to 3,500 deaths, Johns Hopkins University – making it the full-fledged epidemic epicentre.  In comparison, China has had over 81,000 confirmed cases but only 8,183 still remain active. 

Italy continued to be the hardest country hit, with a cumulative total of 31,506 confirmed infections and 2503 deaths, followed by Spain with 13,910 cases and 623 deaths; France with 7661 cases and 148 deaths; and Germany with 10,082 cases and only 27 deaths. Switzerland has reported 2772 cases – while the UK has reported 1966 cases and 72 deaths. 

In a bid to contain transmission, the European Union (EU) has banned travellers from outside the bloc for 30 days – these measures also apply to Iceland, Liechtenstein, Norway and Switzerland, however travelers from the UK are unaffected. The travel ban will affect all non-EU nationals from visiting the bloc, except long-term residents, family members of EU nationals and diplomats, cross-border and healthcare workers, and people transporting goods. 

In Spain authorities were maintaining a partial lockdown on 47 million people, while in France people must carry a document detailing the reasons for leaving home, and face a €135 fine for non-essential travel. In the UK, in contrast, only voluntary measures are being used; the public has been told to avoid social contact, work from home and avoid all non-essential foreign travel. Germany has banned religious services and asked the public to cancel all domestic and international travel.

The Swiss government on Monday declared an “extraordinary situation” over the coronavirus, instituting a ban on all private and public events and closing restaurants and bars in a bid to harmonise policies nationwide; the new measures are in place until April 19. Some cantons have instituted even more stringent measures. Geneva, for instance, banned all gatherings of more than five people. 

In a World War II era move, US President Donald Trump on Wednesday announced he was invoking the “Defense Protection Act” in an effort to redirect American industries to produce more medical supplies amidst a growing shortage of protective equipment in healthcare facilities. Some 7769 cases have been reported in the US, with 118 deaths.

In WHO’s Eastern Mediterranean Region, Iran and other neighboring states continued to post the highest number of cases, with over 16,000 cases in Iran, 442 in Qatar and 100-200 cases each scattered across Bahrain, Egypt, Iraq, Kuwait, Lebanon, Saudi Arabia and the United Arab Emirates.

Health worker at Bole Chefe in Ethiopia wears protective gear to treat suspect cases of COVID-19

Latin America, South-East Asia and Africa Bracing For Next Wave  

Meanwhile, Latin America appeared to be poised to absorb the next wave of infections, with some 973 confirmed cases with 6 deaths; Brazil and Chile account for the most cases with 291 and 201 reported infections, respectively. In Venezuela, President Nicolás Maduro announced a nationwide quarantine amid deep concern about the havoc the coronavirus could cause in a nation where the health system’s collapsed and there’s a massive shortage of doctors, equipment and medicine. 

Colombia and Argentina have closed their borders to arriving foreigners; Chile followed suit Wednesday. Ecuador and Paraguay have established night time curfews.  And in Brazil, firemen using megaphones were patrolling beaches in Rio de Janeiro, asking people to go home. Rio’s famed Sugarloaf Mountain has been closed to the public.

WHO’s Africa Region, reporting 477 cases and South-East Asia with about 480 cases, were also trying to beef up their preparedness.

WHO’s Southeast Asia Regional Director Poonam Khetrapal Singh issued an urgent call Tuesday to all Member States in the region to “scale-up aggressive measures” for COVID-19 preparedness, as new cases trickled in and more clusters were confirmed. 

Looking at the numbers, some countries are clearly heading towards community transmission of COVID-19, said Singh in a press release. “The situation is evolving rapidly. We need to immediately scale up all efforts to prevent the virus from infecting more people,” added Singh, calling on countries to ramp up testing and contact tracing, social distancing, as well as preparing networks of health facilities to triage a potential surge in patients.

In India, the total number of confirmed cases has risen to 151 with 3 deaths. The government on Tuesday banned the entry of passengers from Afghanistan, The Philippines and Malaysia.  Travelers arriving from the European Union, Turkey and the United Kingdom, including both foreign citizens and Indian nationals, are also barred from entering the country until March 31. 

As for Africa, WHO has equipped laboratories in countries across the continent with tens of thousands of tests, trained technicians, and distributed personal protective equipment to support COVID-19 surveillance, early detection and treatment. Some political leaders have also made personal appeals to their citizens to adopt preventive measures, such as social distancing and handwashing practices, including online challenges to promote good practices by Paul Kagame, President of Rwanda, and Abiy Ahmed Ali, Prime Minister of Ethiopia.  And many countries have also put into place unprecedented travel restrictions on visitors from Europea and the United States. 

Still, in the WHO briefing on Wednesday, officials said that the measures taken have been insufficient. In particular, they urged countries with reports of cases to consider bans on mass gatherings where the virus could be easily transmitted.

“Certainly at this time, all countries with disease inside their borders should limit contact between individuals, particularly during large gatherings, particularly large, religious type gatherings that bring people from very far away into close contact.”

Dr Tedros, formerly Health Minister of Ethiopia, made a personal plea, saying: “Africa should wake up. My continent should wake up,” 

-Gauri Saxena contributed to this article 

Image Credits: Governor Tom Wolf, Johns Hopkins CSSE, WHO/ Otto B..

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.