Groundwork for a global campaign
Enormous efforts are underway everywhere to contain the spread of the virus and limit its impact: intensified action is needed among poorer people and nations yet there are marked shortages of resources in multiple settings.
1 A series of disease outbreaks caused by a dangerous virus that is here to stay
The virus is here to stay and is dangerous. It particularly affects poor people in poor countries. It occurs in multiple localised outbreaks some of which are described as spreader events because of the large numbers of people affected. There are increasing reports of long-duration COVID among as many as 5% of those who are recovering. Children are infected but the consequences of that infection are unclear. Leaders in local authorities, national governments, business, professional organizations, civil society, science and the media seek help with difficult decisions. The overarching objective is to preserve people’s health and well-being with minimal disruption to economic and social activity in rapidly changing situations. People must be involved: the capacities of government at local and national level are needed to support people as they d this and to encourage recovery of economies and societies. Reopening schools and universities, and keeping them open, is seen as an important next step but has to be done in ways that take account of the local-level incidence.
2 Establishing strategic principles for an effective response
There is growing recognition that Lockdowns have some, but limited, value: they freeze the virus in place and slow spread but do not suppress outbreaks. For societies everywhere to get ahead of the virus a comprehensive set of strategic principles should be pursued. These are based on the WHO strategic guidance of mid-April 2020. They include:
Engage people fully in universal precautions that limit opportunities for the virus to spread through a combination of:
Ensure well-functioning public health services to find cases, interrupt transmission, contain and suppress outbreaks promptly and support those who are vulnerable.
Physical distancing (at least one and ideally 2 metres);
Personal Hygiene and cough etiquette;
Wearing face coverings [well-fitting, functional and effective);
Self-isolating when symptomatic.
Encourage integrated local-level action by ALL in society, focusing especially on people at greater risk in settings with higher likelihood of transmission. Pay special attention to ventilation in confined locations.
Invest in what is needed for essential health and other services to continue to function including for people who do not have COVID, especially those who are poor.
Pay special attention to the needs of all those who provide care ensuring they are protected (eg ward attendants, dentists as well as doctors and nurses).
Focus on communicating clearly and consistently, encouraging two-way dialogue everywhere.
Use meaningful metrics to demonstrate the performance of responses to COVID at local and national level in the full range of settings and use them transparently to help with decision-making.
The strategic principles are adapted in local settings. They are challenging in settings where resources are extremely limited eg refugee settings or very poor countries.
A key requirement for adapting the principles is that data are available to reveal the patterns of outbreaks spikes and surges. They should help identify which people are most at risk and which places are most likely to see outbreaks. There must be emphasis is on people who are in crowded workplaces and residential setting sespecially those who are poor and have limited options to change the ways in which they work and live. Men are more at risk of death: women face hardship.
There is a need for clarity on the performance of different response elements. The required data used go beyond case numbers and include indicators that show the level of performance, for example, on risk management procedures, public engagement, testing regimes, contact tracing, patient care outcomes and so on. As a result of Singapore’s experience seven performance indicators have been proposed: these could be adapted in different circumstances (see below).
3 Adaptive informed concerted prevention, alert and response by multiple actors who are involved collectively at the local level – despite the uncertainties …
There are at least five elements to this:
I Detective work: Work out what is going on, the pattern of infection, who is involved, how they are connected;
II Cluster-busting: Establish what will break the pattern, who must be involved, how to reach them; enable them to act and to be credited for acting;
III Including everyone: Use all available resources … national and local; sate, private, community and religious, engage the media
IV Ensuring meaningful connections and trust at interfaces: Think about how groups are connected, whether there are challenges and mistrust at interfaces; invest in making interactions smooth and functional.
V Over-arching theme: The virus is the problem, people are the solution; we are all most effective when we work together for common purpose.
Indeed, things do work best if businesses, community organizations, institutions and religious groups engage with local administrations and public health authorities in in locally integrated prevention, alert and response activities. This should be done in ways that are well organized, rigorous, and focused on safety of citizens, clientele, workforces, and members. It is important that employees are part of the solution – for example that they do not feel penalized for expressing anxieties about coming to work, and are incentivised to self-isolate at home if they have COVID-19 symptoms or believe that they may have been exposed.
There are still multiple uncertainties that beset us as we move forward. We learn more about this virus every day : we must not lower our guard and instead we should stay mobilized and tuned to the science. Hence information sharing, careful coordination and collective action are key. Even the best world experts may not be right first time, and the greatest of them are known for their humility. So here are my big five:
- How important is airborne transmission? The virus is primarily transmitted by droplets in expired air projected 1 – 2 metres but spreading can occur through smaller particles in aerosol form in confined and ill-ventilated areas (manufacturing plants, dormitories; ships crew quarters,…) with a transmission distance of 5 8 metres. I think this type of transmission is most likely in chilled environment where ventilation is poor and people are obliged to shout because of noise (eg : meat, fish, vegetable processing plants).
- How valuable are face protections? Mask efficacy is difficult to assess. Some specialists say they are useless, others are saying that masking is key. WHO believes that face masks are really important given that there is significant asymptomatic spread of COVID19. If they have an impact (and I believe they do) they ought to be mandatory at least for now.
- How many people have COVID19 and can spread the virus without symptoms? Current view: a significant number of people can have COVID and spread it before they have symptoms or even without. There are huge variations in places where it has been studied studies (cruise ships VS NYC and London).
- What is the duration of immunity after a person has had (and recovered from) COVID19? An infected person develops immunity in two ways – through producing antibodies that neutralize the virus and through priming T cells so that they kill the virus if exposed to it again. It will not necessarily be a full immunity. Evidence to date suggests that the levels of antibodies in individuals vary a lot post-COVID19 and tend to fall the longer the interval after infection. It may be that the priming of T cells lasts for longer meaning that cell mediated Immunity is more durable. My view is that people who have severe COVID19 are more likely to have substantial immunity than those who have it mildly, but the duration is super-variable from person to person. This will be an issue that could affect vaccine efficacy.
- What is the role of children in COVID19 transmission? How should schools react to the threat of COVID19? This needs to be thought about from the perspectives of school children themselves, of adults in and around schools, and the other members of the household in which the child lives. Do not think about schools in isolation without also considering what is happening with regard to COVID19 in the local communities. If there is a lot of transmission in the community then the school is likely to be a site of transmission too. Here is what the science tells us: a) the impact of COVID19 on young children is still under study: some think that they are, in general, unharmed by the virus. Not everyone agrees. Certainly schools are places where adults can pass COVID19 on each other. However, there are very few examples of children infecting others in the home: this is also the subject of ongoing research. My view is that what happens in schools will be important in the efforts to stay ahead of COVID19. Schools must be considered in context: localized school closing will have to be considered (on a temporary basis) if there are spikes of cases in the local community.
4. Accelerating equitable access to diagnostics, therapies and vaccines
As COVID-19 spreads among poor communities in poor countries, it is increasingly evident that response strategies need to take account of the increased risks faced by poorer people and THEIR communities. The strategies should ensure that those who have clear needs, but access limited essential resources, are able to access them as required. Therefore special attention is needed to ensuring access to PPE, oxygen, essential medicines and testing reagents. This is the rationale behind the Access to COVID-19 Tools ACT) accelerator being coordinated by the World Health Organization. This will prioritize the accepted procedures for validating newly developed tools (ensuring efficacy, reliability and safety) and for ensuring that they are accessible to those who need them.
5 Responding to the Challenge of getting COVID-ready and geared up for equitable responses
People, local institutions, authorities and business leaders are understandably unsure about how to move forward with managing fear of COVID-19, threats to their health, chains and clusters of infection and, in some cases, surges of disease. It will be helpful if a campaign for “Keeping Safe Amid the COVID-19 Threat” with clear messages is embraced by multiple leaders (including influencers) and broadcast widely by all involved in public health action. There need to be an overarching non-branded networked systems-leadership approach for the campaign (with the focus on ensuring the resilience of leadership in the face of opposition).
The Response to the COVID-Ready and Equitable Response Challenge could include:
I Applying Comprehensive Precautions Everywhere
Widespread engagement of communities everywhere so that they take responsibility for adoption of physical distancing, face protection, personal and institutional hygiene, as well as self-isolation when symptomatic in ways that are adapted to context
II Ensuring locally-adapted community-based public health responses
Well-functioning and inclusive arrangements for engaging local actors so they respond to local needs at the local level with an emphasis on interoperability and functionality at interfaces for interrupting transmission and suppressing outbreaks early with minimal economic and social consequences
III Maintaining Essential Health Services for All
Access to essentials and well-being of care providers with an emphasis on ensuring care for non-COVID illness
IV Prioritizing the Needs of Poor People (in access to elements needed for prevention, care, support, vaccines and treatment)
This goes beyond the health sector, means addressing the inequities revealed by COVID and tackling the systemic inequalities that increase their risks of more serious consequences as a result of infection, disease and containment strategies (including poverty, malnutrition, discrimination)
V Maintaining public dashboards that show performance of responses
The dashboard should convey information about the potential triggers for adapting the strategic principles in different settings. Information should be provided in ways that help local authorities, governments, and others to move forward with keeping their economies and education systems functioning.
VI Doing everything possible to ensure equitable access to diagnostics, protective equipment, treatments and vaccines Focusing on widespread participation in the WHO ACT Accelerator and the vaccine pillar CoVax.
If you haven’t already watched our first Being COVID-Ready reel, here it is!
Video production: A very special thanks to Arti Jain, BJ Golnick, Jeffrey Daniels, Derek Owen, Undivided Attention, Brothers Golnick Productions.
With much appreciation to the 4SD community and friends for support in providing subtitles especially our multilingual collaboration with MultiPOD Mentoring.