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.

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.