Tackling COVID-19: A Global Effort
Over the last few weeks we have spent many of these updates discussing the lack of action, coordination, and response to the COVID-19 pandemic in the United States. The actions in the U.S. have cost many lives, and while the situation in Europe has come and gone in waves, we can not deny the stark contrast in response strategies. We have seen the investment in public health and science, the collaboration between countries, and the unification of strategies on future vaccine dissemination. The EU has set an example that the US must consider following.
Investing in Public Health and Science
In March, when COVID-19 was officially declared a pandemic disease by the WHO (World Health Organization), European countries quickly implemented public health control measures and invested in science. Countries issued stay-at-home orders. They invested in and implemented widespread testing and contact tracing. They also worked collectively to mobilize life-saving resources such as PPE and medical equipment (a complete timeline of EU COVID actions from January to present can be found here). Compared to the United States, where citizens had to determine for themselves which news sources were trustworthy due to the lack of a coordinated national response, the EU was miles ahead.
Unification of Future Vaccine Dissemination Strategies
The movement to combat the pandemic has continued full steam ahead ever since; the EU has created a vaccine strategy, disseminated a plan to protect at-risk populations, and relied on evidence-based medicine to determine the most effective diagnostics and treatments. They have even begun to think about what life may look like post-COVID and are planning accordingly by creating an in-depth recovery plan and updated extended budget through 2027.
Responding to the Ups and Downs of the Coronavirus
In spite of being quick to act and remaining well-prepared, the situation in Europe today is vastly different from several months ago when countries were revered for their steadily declining incidence rates. Today, there are more than 9M cases in Europe (for daily COVID-19 updates worldwide check the ECDC website). New regulations, social-distancing and harsh restrictions (like night curfews) are being introduced across multiple European countries to halt the second wave of coronavirus spread. Nonetheless, the pandemic is accelerating across the continent: the countries reporting the most cases are: Russia (1,547,774), France (nearly 1,2 M), Spain (1,116,738), United Kingdom (917,575), Italy (564,778), Germany (465,780) and Belgium (347,289).
The Reality Is That We Still Know Little About COVID-19
Due to the novelty of COVID-19, country-specific disease rates across the world are changing daily. As information about the disease and its implications are discovered, best practices and regulations continue to be revised. This update was written on October 29th, 2020, but new data will most likely be available by the time it is being read. Because of this, it is vital COVID-19 is continuously monitored globally.
As a global society we must learn from the success stories. No lives lost are acceptable. Even as we continue to learn about COVID-19 we must implement the best public health strategies possible.
Global Epidemiological Update
As of October 29, 2020
Since December 31, 2019 and as of October 29, 2020, 44,574, 981 cases of COVID-19 (in accordance with the applied case definitions and testing strategies in the affected countries) have been reported, including 1,175, 279 deaths. (ECDC)
Cases have been reported from:
Africa: 1,750,331 cases; the five countries reporting most cases are South Africa (719,714), Morocco (207,718), Egypt (107,030), Ethiopia (94,820) and Nigeria (62,371).
Asia: 13,286,655 cases; the five countries reporting most cases are India (8,040,203), Iran (588,648), Iraq (463,951), Bangladesh (403,079) and Indonesia (400,483).
America: 20,218,716 cases; the five countries reporting most cases are the United States (8,858,024), Brazil (5,468,270), Argentina (1,130,520), Colombia (1,041,935) and Mexico (906,863).
Europe: 9,277,726 cases; the five countries reporting most cases are Russia (1,563,976), France (1,235,132), Spain (1,136,503), United Kingdom (942,275) and Italy (589,766).
Oceania: 40,857 cases; the five countries reporting most cases are Australia (27,554), French Polynesia (6,493), Guam (4,466), New Zealand (1,593) and Papua New Guinea (588).
Other: 696 cases have been reported from an international conveyance in Japan.
Deaths have been reported from:
Africa: 42,175 deaths; the five countries reporting most deaths are South Africa (19,111), Egypt (6,234), Morocco (3,506), Algeria (1,941) and Ethiopia (1,451).
Asia: 236,920 deaths; the five countries reporting most deaths are India (120,527), Iran (33,714), Indonesia (13,612), Iraq (10,770) and Turkey (10,027).
America: 634,871 deaths; the five countries reporting most deaths are the United States (227,700), Brazil (158,456), Mexico (90,309), Peru (34,315) and Colombia (30,753).
Europe: 260,260 deaths; the five countries reporting most deaths are the United Kingdom (45,675), Italy (37,905), France (35,785), Spain (35,466) and Russia (26,935).
Oceania: 1,046 deaths; the five countries reporting most deaths are Australia (907), Guam (77), French Polynesia (26), New Zealand (25) and Papua New Guinea (7).
Other: 7 deaths have been reported from an international conveyance in Japan.
International Update
Europe
European Commission Vaccine Strategy
A comprehensive vaccine strategy released in June focused on “accelerating the development, manufacturing, and deployment” of vaccines for COVID-19. The Commission reports an expected timeframe of 12-18 months, emphasizing that although time is of the essence a vaccine will only be released after going through strict authorization procedures and adhering to robust safety standards. The Strategy outlines key elements to consider regarding vaccination, including increasing the capacity of health systems to deliver vaccines and clearly communicating any benefits and risks, and stresses that special consideration should be given to health care workers or individuals at high risk once a vaccine is available. Most importantly the Commission has announced that all Member States will have access to COVID-19 vaccines at the same time, fostering collaborative efforts. Recently, the European Commission has signed agreements to secure vaccines with the following companies: AstraZeneca, SAnofi-GSK, Johnson&Johnson and is in exploratory talks with BioNTech-Pfizer, Moderna and CureVac.
EMA (European Medicines Agency) Treatments and Vaccines for COVID-19
The European Medicines Agency (EMA) is interacting with developers of potential COVID-19 treatments and vaccines to enable promising medicines to reach patients as soon as possible. It is also making use of real-world data to monitor the safety and effectiveness of medicines used for patients with COVID-19. EMA has been in discussion with the developers of 39 potential COVID-19 vaccines and 163 potential COVID-19 treatments. These include immunomodulators, antivirals and hyperimmune serums. EMA has also finalised 30 scientific advice procedures to provide developers with direction on the most appropriate methods and study designs for potential COVID-19 medicines. A further 21 such procedures are ongoing.
Council Recommendation on a Coordinated Approach to the Restriction of Free Movement in Response to the COVID-19 Pandemic
To limit the spread of the coronavirus outbreak, the EU’s 27 Member States have adopted various measures, some of which have had an impact on citizens’ right to move freely across the European Union, such as requirements to undergo quarantine or coronavirus testing.
Every Thursday the ECDC publishes countries maps in support of the EU Institutions. On October 13, EU Member States adopted the Council Recommendation on a coordinated approach to the restriction of free movement in response to the COVID-19 pandemic.
While the measures are intended to safeguard the health and wellbeing of citizens, they have had serious consequences for the economy and citizens’ rights. The right of European citizens to move and reside freely within the European Union is one of the most cherished achievements of the European Union, as well as an important driver of its economy.
The Recommendation sets out four key areas where Member States will coordinate their efforts:
1. Common criteria: the notification rate; the test positivity rate and the testing rate
2. A common map
3. A common approach to travel
4. Clear and timely information to the public about any restrictions
European Commission Invested €459 Million in Coronavirus Projects So Far in 2020
By September 2020, the EU invested €459 million from Horizon 2020 in grants for 103 new research projects targeting the pandemic: diagnostics, treatments, vaccines, epidemiology, preparedness and response to outbreaks, behaviour and socioeconomics, manufacturing, medical and digital technologies, as well as the infrastructures and data resources that enable this research. By the end of 2020, the EU will invest €1 billion into research and innovation to tackle COVID-19 and its consequences.
European Leaders Reach a Deal on the Recovery Plan and European Long-Term Budget 2021-2027
In August, EU leaders successfully agreed on the recovery plan for Europe. More than 50% of the long-term EU budget and Next Generation EU – a total of some €1.8 trillion - will support modern policies and set Europe on path to a sustainable and resilient recovery. President von der Leyen said: “The agreement is a strong signal of trust and a historic moment for Europe.”
EASL - ESOT - ELITA - ILTS* Joint initiative on liver transplantation. Survey launched in September.
Recently EASL, ESOT, ELITA and ILTS made a joint initiative on the impact of COVID-19 on liver transplantation, aiming to explore how patients, healthcare professionals, and liver transplant centres across the world are affected – in their clinical care and waiting-list management.
To this end, a survey launched in September 2020 has been sent to more than 470 transplant centres in Europe, Australia, Asia, USA, and South America, to collect and analyse regional practices. The survey requests data on: processes; therapy; living donors; and the procurement of organs. Once processed, the results of this survey will be disseminated, including in a peer-reviewed publication and a multi-society, open-access webinar.
*EASL, the European Society for Organ Transplantation (ESOT) with the European Liver and Intestine Transplantation Association (ELITA), and the International Liver Transplantation Society (ILTS).
ECDC’s (European Centre for Disease Prevention and Control) Rapid Risk Assessment and Recommendations for EU Countries
In its most recent COVID-19 Risk Assessment, published on October 23, the ECDC has developed epidemiological criteria to categorise the epidemiological situation in countries as being ‘of concern’ (Germany) or ‘of serious concern”. According to the data, the countries whose rates and/or trends cause them to be categorised as of “serious concern” include: Austria, Belgium, Bulgaria, Croatia, Czechia, Denmark, France, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania, Slovenia, Slovakia, Spain, Sweden and the United Kingdom. These countries have been categorised as ‘of serious concern’ on account of having high or increasing case notification rates and/or test positivity ≥3%, as well as high notification rates in the older age groups and/or high mortality rates.
Oxford - Advent - Astrazeneca COVID-19 Vaccine
One of the world's leading COVID-19 experimental vaccines developed by the University of Oxford’s Jenner Institute and Oxford Vaccine Group (ChAdOx1 nCoV-19 and also known as AZD1222) is now undergoing Phase III clinical trials. The vaccine has already undergone rigorous testing to ensure the highest standards of quality and safety. The vaccine produces an immune response in young adults and an even larger response in elderly persons. It also triggers lower adverse responses among the elderly.
IRBM’s Advent, a global leader in viral vector manufacturing, based in Italy (Pomezia) has made thousands of doses of a novel COVID-19 vaccine, (AZD1222) to be used by the University of Oxford and AstraZeneca in clinical trials in the UK, Brazil and South Africa.
Russia
This week, Russia has applied to the World Health Organization for accelerated registration and prequalification of its Sputnik V coronavirus vaccine. The Russian Direct Investment Fund (RDIF), which finances the vaccine, said that accelerated registration would make the Russian vaccine available globally quickly. Some Western scientists have expressed concern over the Russian vaccine, with some warning that moving too quickly could be dangerous. Earlier this month, President Vladimir Putin announced that Russia had registered its second coronavirus vaccine, EpiVacCorona. Nevertheless, mass vaccinations against the coronavirus disease will commence in December-January in Moscow.
International
UN General Assembly Resolution on COVID-19
On September 11th, the 75th session of the UN General Assembly (UNGA75) adopted the Omnibus Resolution on a “Comprehensive and coordinated response to the coronavirus disease (COVID-19) pandemic”.
Following here some of its key points which calls on the Member States to:
Adopt a whole of government and a whole of society response, maintain health systems and strengthen primary healthcare, recognising the importance of increased domestic financing and development assistance in achieving UHC.
Include persons with disabilities in all stages of policy and decision-making related to COVID-19 response and recovery.
Strengthen efforts to address communicable diseases, including HIV/AIDS, tuberculosis, malaria and hepatitis, as part of universal health coverage as well as for noncommunicable diseases (NCDs) and mental health.
Strengthen efforts to address NCDs as a part of UHC and to recognize that people living with NCDs are at higher risk of developing severe COVID-19 symptoms and are among the most impacted by the pandemic.
Prevent, monitor, and address the impact of the pandemic on older persons to ensure the highest attainable standard of physical and mental health.
Enable all countries to have unhindered timely access to quality, safe, efficacious and affordable diagnosis, therapeutics, medicines and vaccines, and essential health technologies, and their components as well as equipment for the COVID-19 response.
Recognise the role of extensive immunization against COVID-19 as a global public good for health in preventing, containing and stopping transmission in order to bring the pandemic to an end once safe, quality, effective, accessible and affordable vaccines are available.
Reaffirm the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement) as amended, and also reaffirming the 2001 WTO Doha Declaration on the TRIPS Agreement and Public Health, which recognizes that intellectual property rights should be interpreted and implemented in a manner supportive of the right of Member States to protect public health and to promote access to medicines for all.
Remove unjustified obstacles in order to ensure the universal, timely and equitable access to, and fair distribution of, all quality, safe, efficacious and affordable essential health technologies and products required to tackle COVID-19.
Ensure protection for those most affected women, children, youth, persons with disabilities, older persons, indigenous peoples, refugees, internally displaced persons, migrants and the poor, vulnerable and marginalised segments of the population and prevent all forms of discrimination.
Africa
The World Health Organization (WHO) has pointed to a recent resurgence in COVID-19 infections in Africa. Until two weeks ago, Africa had the lowest rates of COVID-19 infections globally. Since the beginning of October, the number of new cases was 14% higher than the previous week and there was an 8% increase in new deaths, according to the Africa Centres for Disease Control and Prevention (Africa CDC). The largest percent increase in cases were in Tunisia, Ethiopia, Libya and Morocco.
There could be a number of explanations for this recent rise in case numbers in specific countries. The Africa CDC's John Nkengasong says the recent rise in numbers of reported deaths could be due to an improvement in some countries' ability to document deaths from coronavirus. There is evidence for this in South Africa, where an on-going audit of COVID-19 deaths has reported additional deaths, which were not previously accounted for. However, the reported death rate per capita on the continent has been low compared with other parts of the world, despite the poor health infrastructure in many African countries. The continent, which has a population of more than 1 billion, has had about 1.7 million cases.
Africa’s figures are far lower than those in Asia, the Americas and Europe, so, what are the reasons for Africa's relatively low death rate? Experts find 5 main reasons: 1) Quick action: since the first case in Egypt was discovered, the Government adopted drastic public health measures: including avoiding handshakes, frequent hand-washing, social distancing and wearing of face masks. 2) Public Support: a survey conducted in 18 countries in August by PERC highlighted that public support for safety measures was high - 85% of respondents said they wore masks. 3) Young population and few old-age homes. 4) Favourable climate: a study conducted by researchers in the University of Maryland in the US found a correlation between temperature, humidity and latitude, and the spread of COVID-19. 5) Good community systems. The COVID-19 pandemic came at a time when the Democratic Republic of Congo was dealing with its biggest outbreak of Ebola yet. Neighbouring states were on high alert, and the health screening of travellers for Ebola was extended to include COVID-19.
Several West African states, which battled the terrible outbreak of Ebola (in 2013-2016), had also mastered the public health measures that have been used to prevent COVID-19, including isolating the infected, tracing their contacts, and then getting them quarantined while they were tested. Furthermore, in Africa's most populous state, Nigeria, teams that had been going into villages to vaccinate children against polio were quickly re-purposed to educate communities about the new pandemic.
Asia and Oceania
According to some recent studies, based primarily on each Asian country’s cumulative death toll and health policy measures adopted by governments to prevent the spread of the virus, the countries who have handled COVID-19 the best are: Vietnam, Taiwan, Iceland, New Zealand, Singapore and China. Nearly all of them are in the continent of Asia with the exception of Iceland and New Zealand. What kind of measures did these countries adopt? The first aspect seems to be “timing,” followed by: travel restrictions, closely monitored and eventually increased testing, quarantining at borders, schools closures, and vast and labour-intensive contact tracing operations. Governments quickly built a team of contact tracers, tracing suspected cases as well. They also maintained a stockpile of face masks, medical officers and lab capacity to handle any outbreaks prior to the coronavirus pandemic.
In January, the New Zealand Ministry of Health set up the National Health Coordination Centre (NHCC) to respond to the outbreak. An Infectious and Notifiable Diseases Order was issued, which required health practitioners to report any suspected cases under the Health Act 1956. This was the first barrier of protection. Travel restrictions to and from other countries were imposed as early as February, and on 23 March, New Zealand committed to an elimination strategy (despite the fact that the country was reporting 102 cases and 0 deaths) when Prime Minister Jacinda Ardern announced that New Zealand was going to rapidly escalate levels of social distancing and travel restrictions, reaching the level of a full national lockdown on 26 March.
Singapore’s response to COVID-19 has been a model for other countries despite its human rights price. Its Government invested a fortune over the past months to pioneer a slate of COVID-19 responsiveness measures that are perhaps the most rigorous in the world in order to help Singapore rebound as quickly as possible. A huge contact tracing programme began and a national coronavirus-tracing app was rolled out. Public cautions were increased and clearly communicated. Harvard epidemiologists called Singapore's system the "gold standard of near perfect detection". Another important aspect of its plan is the SG Clean, a programme that encourages companies to meet specific hygiene and safety standards by certifying compliant venues. Finally, contactless check-in systems, traffic patrol, and hospitality robots in the retail-and-entertainment space were increased and a partial lockdown adopted. However, many of Singapore's lowest earners (migrants) remained indoors, facing uncertainty because of a crisis building, unseen by most of the population. Since mid-April, the government has released two distinct daily figures - the cases amongst the local community and the cases in the migrant dormitories. The authorities decided that the dormitories would have to be sealed off. Around 10,000 healthy migrant workers in essential services were relocated to other accommodation. Last month, the government declared that all workers living in dormitories had recovered or were tested COVID-19 free. Prime Minister Lee Hsien Loong has admitted that the government's response to the threat to dormitories was "not without shortcomings” and promised to further improve conditions for migrant workers by 2020.
An article recently published on The Lancet highlights “China’s successful control of COVID-19” following the praise of Mike Ryan, executive director of the WHO Health Emergencies Programme, who offered “deepest congratulations to the front-line health workers in China and the population who worked together tirelessly to bring the disease to this very low level”. How has China managed to control the pandemic? The main reasons identified by The Lancet and by the Dubai Medical Journal are: a centralised epidemic response system (most Chinese adults remember SARS-CoV and the high mortality rate that was associated with it); the speed of the response (the first reported cases of the disease were reported in late December 2019 and China released the genomic sequence of the virus on Jan 10, 2020); early reporting and situation monitoring, large-scale surveillance and preparation of medical facilities (14 COVID-19 hospitals were built in few weeks) and supplies, were all successful in reducing the epidemic. Moreover, very little of the elderly population live in care homes (3%); a strict and long lockdown was adopted, public transport was suspended and high compliance from all the population were also key factors. Finally, drones equipped with echoing loudspeakers rebuked Chinese citizens who were not following the rules.
China’s most important action is probably its Large-Scale Surveillance system. As for infected patients, clinical case identification was provided by WHO China and CDC China to have clear criteria for identifying cases under the outbreak investigation. The national authorities later placed public health strategies and follow-ups for cases and contacts, and more than 1,800 teams of epidemiologists were assigned to trace tens of thousands of people a day in Wuhan. In addition, a community-wide temperature screening was implemented through “installing infrared thermometers in airports, railway stations, long-distance bus stations, and ferry terminals”. Thousands of health and quarantine stations were set up in national service areas and in stations. The search was later expanded to include screening people at work, in shops and on streets in the country. The Chinese government has been investing a lot in new high technology tracking systems such as the smartphone application and the street cameras. The smartphone app is based on a health code color system that categorizes individuals into 3 color groups (from green to red) based on their health status and travel history, and then determines whether they need to be quarantined.
However, as Han Fu, from the Imperial College points out: “In China, you have a combination of a population that takes respiratory infections seriously and is willing to adopt non-pharmaceutical interventions, with a government that can put bigger constraints on individual freedoms than would be considered acceptable in most Western countries”.
