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.

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.”

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.