3 March 2020, COVID-19 Narrative Two

By Dr David Nabarro, Strategic Director of 4SD, Special Envoy of World Health Organization Director-General on COVID-19 and Co-Director of the Imperial College Institute of Global Health Innovation at the Imperial College London

In the light of the heightened state of alert announced by WHO today, readiness planning must focus urgently on the Integrated Management of COVID-19 Outbreaks. There are four components: engagement of people, organization of public health services, planning provision of clinical care, and preventing societal disruption.

Developments over the last week lead us to expect an increasing number of COVID-19 outbreaks to emerge around the world over the coming weeks and months. We want to do whatever is possible to enable local and national authorities to prevent outbreaks from becoming established. We are most concerned by the larger outbreaks with intense transmission between people, where there are many chains of transmission.

An individual with COVID-19 can infect several other people each day: outbreaks grow surprisingly rapidly. They can – and must – be contained. This means that everyone who suspects that they might have COVID-19 must be isolated promptly and receive attention quickly. When people understand what is expected of them, and work with the authorities to ensure wellorganized and effective action, containment efforts will be successful. The longer the interval between symptoms starting and care being provided, the more likely it is that the outbreak will intensify.

Individuals with COVID-19 may turn up anywhere at any time. This can happen even in settings where strenuous efforts are made to block the entry of people who have travelled from places where there are people known to be infected with COVID-19. Authorities need to be organized and ready to provide Integrated Management of COVID-19 outbreaks (IM).

IM must be ready for implementation rapidly and at scale, with open sharing of information among all concerned and seamless adaptation in the light of changing situations. The focus is on containment of the outbreak at the local level and clear direction from national administrations, with a single and clearly identified point of authority. It is essential that confusion (about who does what and where) is avoided as much as possible. Communications channels must be established in advance and clearly understood by all.

There are four components of IM:

a. ENGAGEMENT OF PEOPLE: Engaging and involving all people as partners with a focus on personal hygiene and social distancing;

b. ORGANIZATION OF PUBLIC HEALTH SERVICES: Well-organized public health services (case detection, comfortable isolation, contact tracing, surveillance and reporting);

c. PLANNING THE PROVISION OF CARE: Repurposed health services ready to receive and provide quality medical care for large numbers of persons with severe illness;

d. PREVENTING SOCIETAL DISRUPTION: Contingency planning for maintaining access to essential services and ensure essential supplies (food, energy, water).

IM is concerned with detecting people with COVID-19, preventing outbreaks from becoming established, as well as delaying them and containing them as they do occur. It also focuses on the functioning of health services and ensuring the continuity of people’s livelihoods. It means a COVID-ready mindset, engagement of all people and some repurposing of functions within local and national authorities. IM involves a concerted effort to repurpose action across all sectors within national and local governments, with the Ministry of Health providing central and vital services. This will require a major cross-government and whole-of-society effort: the key is for all concerned to work together in a highly- coordinated manner, sharing experiences at local, national and international levels.

For those that are involved in COVID-19 outbreaks, the present time feels like the calm before the storm: it may not last long. If current containment efforts are unsuccessful, intense outbreaks may emerge within days, in several locations simultaneously, throughout the world. This will lead to widespread, world-wide, COVID-19 incidence with significant human, economic and societal consequences.

The World Health Organization (WHO) maintains that such a global tragedy can be prevented but only if everyone gets ready to offer IM. They should do this together so that they can act together, and all know what needs to be done, when and by whom. Working together involves families, neighbours and communities, businesses and civil society, schools and universities, cities and provinces, sectors within governments, different sciences and professions, international media and more.

(a) People must have access to the most reliable information about COVID-19 and ways to minimise risks of infection: this must be updated regularly in line with the evolving science (we have only known this new virus for 7 weeks) with clear explanations as to its significance.

(b) The WHO Director-General is leading by providing detailed daily briefings which are reported by the world‘s media. He has developed guidance (see below) that is relevant to everyone and should be regularly shared now with all people, through professionally developed public information videos presented by familiar and trusted figures. These should be made available in all broadcasting as well as in social media.

(c) The guidance can be made available through businesses, especially those that connect directly with the public (through product wrappers, point of sale publicity and advertising). It can also be circulated among schools and universities.

(d) Dialogue about ways in which people can engage in COVID-19 management should be encouraged everywhere, especially when it comes to exploring behaviours that increase the risk of an individual becoming infected, and action to be taken if symptoms develop.

Heads of State and Government are becoming increasingly involved. Some initially questioned whether the issue is as serious and urgent as the WHO maintains. However, most are now engaging with their people and making sure they have information. They are ensuring readiness and good coordination. The WHO Director-General, Regional Directors and six special envoys on COVID-19 have established direct channels for communicating with the offices of Heads of State and Government. International bodies, notably the WHO, are also preparing for rapidly increasing levels of demand both to track the outbreaks and respond to questions about risks and opportunities.

There is a need for efficient, rapid and dependable means for enabling poorer nations to access the finance they need to rapidly scale up readiness in line with IM. This will need to be established as a special mechanism by leaders who have experience of mobilizing and deploying finance for international health programmes. There is useful experience available from the resource mobilization efforts during and after the West Africa Ebola outbreak of 2014-15, particularly on support for quick disbursement to enable rapid scale-up of essential action with due diligence and accountability but minimal bureaucracy.

Some response plans are based on linear extrapolations of what is happening at this time. This may lead to a false sense of security as the scale of the outbreak appears to advance at an exponential rate, doubling every 3 to 5 days. Readiness must be reassessed at daily intervals in the light of the evolving picture, with time and effort being invested in actions needed to prevent societal disruption as a result of both the impact of disease on people, and the consequences of containment and control measures. Those involved in readiness planning and assessment will need to take account of different scenarios for the evolution of the COVID-19 outbreaks.

Together, we are powerful. Containment starts with us.

The WHO Director-General’s 10-point guidance

– First, as we keep saying, clean your hands regularly with an alcohol-based hand rub, or wash them with soap and water. Touching your face after touching contaminated surfaces or sick people is one of the ways the virus can be transmitted. By cleaning your hands, you can reduce your risk.
– Second, clean surfaces regularly with disinfectant – for example kitchen benches and work desks.
– Third, educate yourself about COVID-19. Make sure your information comes from reliable sources – your local or national public health agency, the WHO website, or your local health professional. Everyone should know the symptoms – for most people, it starts with a fever and a dry cough, not a runny nose. Most people will have mild disease and get better without needing any special care.
– Fourth, avoid traveling if you have a fever or cough, and if you become sick while on a flight, inform the crew immediately. Once you get home, make contact with a health professional and tell them about where you have been.
– Fifth, if you cough or sneeze, do it into your sleeve, or use a tissue. Dispose of the tissue immediately into a closed rubbish bin, and then clean your hands.
Sixth, if you are over 60 years old, or if you have an underlying condition like cardiovascular disease, a respiratory condition or diabetes, you have a higher risk of developing severe disease. You may wish to take extra precautions to avoid crowded areas, or places where you might interact with people who are sick.
– Seventh, for everyone, if you feel unwell, stay at home and call your doctor or local health professional. He or she will ask some questions about your symptoms, where you have been and who you have had contact with. This will help to make sure you get the right advice, are directed to the right health facility, and will prevent you from infecting others.
– Eighth, if you are sick, stay at home, and eat and sleep separately from your family, use different utensils and cutlery to eat.
– Ninth, if you develop shortness of breath, call your doctor and seek care immediately.
– Tenth, it’s normal and understandable to feel anxious, especially if you live in a country or community that has been affected. Find out what you can

On 21 February 2020, Dr David Nabarro, Strategic Director of 4SD and Co-Director of the Imperial College Institute of Global Health Innovation at the Imperial College London, was appointed as a World Health Organization (WHO) Director-General Special Envoy on COVID-19. In this role, David and five other special envoys are providing strategic advice and high-level political advocacy and engagement in different parts of the world to help WHO coordinate the global response to the epidemic. David joins special envoys Professor Dr Maha El Rabbat, former Minister of Health of Egypt; Dr John Nkengasong, Director of the African Centres for Disease Control and Prevention; Dr Mirta Roses, former Director of the WHO Region of the Americas; Dr Shin Young-soo, former Regional Director of the WHO Region of the Western Pacific and Professor Samba Sow, Director-General of the Center for Vaccine Development in Mali in this collective effort.

Please visit: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 for official guidance from the World Health Organisation on the virus. These Narratives are being written and shared by David for those who want more information and to help raise awareness and readiness of all actors.

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