WHO Refrains From Public Mask Recommendation – Health Workers Need Them First; Intensity of Virus Exposure May Drive More Serious COVID-19 Disease
Volunteer assembles 3D- printed face shields in NYC. The face shields are donated to and sanitized before use at local hospitals facing protective equipment shortages.

WHO deferred any broad recommendation to the public on the use of face masks, even as more countries were recommending some kind of a face cover or protective mask to reduce COVID-19 transmission.

World Health Organization Director General Dr Tedros Adhanom Ghebreyesus stressed that health workers need to remain the key priority for the use of medical masks.

Dr Tedros spoke at a press briefing on Monday, where Lady Gaga also made a special appearance to announce plans for a mass virtual concert, “One World – Together At Home” on Saturday April 18th, involving dozens of celebrity stars such as Sir Elton John and Paul McCartney.

The event, in collaboration with Hugh Evans of Global Citizen,  aims to raise money for the WHO’s COVID-19 Solidarity Response Fund, particularly for test kits and protective gear to shield health workers in low- and middle-income countries from infection.

In other key comments, WHO’s head of Emergencies Mike Ryan said there is growing evidence of a strong correlation between the “dose” of viral infection to which an individual is exposed and the severity of disease that they develop, but those questions need to be explored further by researchers.

“We need to look at who is getting sick and is the type of exposure they are getting different?” said Ryan at the press briefing. “It’s not just looking at who is infected, but whether there are specific exposures that cause more severe infection. We need to have the serological-epidemiological studies to find out what the infectious dose is, and the dose of exposure, and severity of infection.

If someone is exposed to a high dose from another individual directly, or a surface that’s heavily contaminated, is that significant in terms of driving infection? We have seen that in many many other diseases in the past including cholera, Ebola and others.”

Cloth Masks & Face Covers ? WHO Refrains From Comment 

Dr Tedros said that WHO would be issuing updated guidance on masks, which so far only recommends them for health workers; people who know they are sick; or people caring for the sick.

“Use of general masks in the general population could exacerbate the supply for those who need it most. These shortages are putting health workers in real danger in some countries”, he said.

However, he noted that in some crowded, low-income settings, where other social distancing and sanitation measures are difficult to maintain, then public mask use might be more justified, adding, “What is clear is that there is limited research in this area. We encourage countries that are considering the use of masks for the general population to study their effectiveness so we can all learn. Most importantly, masks should only ever be used as part of a comprehensive package of interventions.”

The WHO Director-General offered no direct comment on the recommendations issued last week by the US Centres for Disease Control calling on the general public to wear cloth masks or other non-medical face covers. Israel also has called on the public to wear simple surgical masks, cloth masks, or cloth face covers when outside of the home, while Hungary and  Austria made wearing of masks mandatory in supermarkets.  

Public health authorities in those countries say the universal wearing of masks seems to have been a factor that helped reduce high rates of disease transmission in countries like China, the Republic of Korea, and Singapore. 

As growing evidence seems to support the fact that people who are either pre-symptomatic or asymptomatic may be unknowingly transmitting the virus, the Center for Disease Control (CDC) last week recommended wearing cloth face coverings in public settings, especially in places where adhering to social distancing guidelines are challenging, such as grocery stores and pharmacies. 

As part of the new CDC move, the US Surgeon General issued guidance on You Tube, explaining to the public how to make their own protective masks.

The CDC recommendation exempts young children under age of 2, people with trouble breathing, or people who are unconscious, incapacitated or otherwise unable to remove a face covering without assistance. And while it is hoped that the pervasive use of face coverings would slow the spread of the virus by carriers who are unaware that they are infected, masks will only be effective when supplemented by frequent hand cleaning with alcohol-based hand sanitizer or soap and water, CDC stressed. 

As shortages in medical supplies continue, experts stressed that medical masks, particularly high-performance N-95 masks should be mainly reserved for the healthcare workers who are on the frontlines of the pandemic.

In that vein, New York City authorities have been sending SMS messages to city residents that read: “New Yorkers: Wear a face mask when you go outside and near others. It can be a scarf, a bandana or one you make at home” However, the messages added the caveat: “The city urges you to save medical masks for our healthcare workers and first responders who truly need them.” 

Yet the new US recommendations were not without dissonance, reflecting the hesitations that some members of the public also might have over mask use, beginning with the President himself. “With the masks, it is going to be a voluntary thing. I am choosing not to do it,.” Donald Trump remarked in a press briefing after the White House issued its own recommendation echoing that of the CDC. 

Lockdowns Proving Effective for COVID-19 Control- But Exit Strategies Key to Economies

As regards lockdowns, the main disease control tool being used, Ryan said “lockdowns in many situations are proving effective in dampening outbreak, but those lockdowns are causing economic hardships. [We need ] a more sustainable way.”

He stressed, however, that any effort to lift lockdowns will require a “stepwise approach” by governments, with careful consideration of those restrictions that can safely be lifted without recharging the infection cycle. 

Among the parameters that are important to consider are hospital capacity;  the “doubling rate” – that is the number of days over which the cumulative number of COVID-19 cases are doubling; as well as the proportion of COVID-19 test sample that are testing positive.

“You need to look at doubling rate and positivity rate,” said Ryan, citing as one example of the latter, Korea, where 2-6% of samples are testing positive and restrictions on economic activity and public movements are relatively relaxed, as compared to New York City, where 37% of testing samples are turning out to be positive. 

“A carefully calibrated stepwise approach is the safe path out of lockdown.”

And once lockdowns are lifted, other tactics will become all the more important, he stressed. Those include: “active case finding, testing, isolation of cases, quarantine and strong community education around physical distancing.” 

WHO Welcomes Costa Rica Overture on Patents Pool for COVID-19 Therapies
Carlos Alvarado Quesada, President of Costa Rica

In his remarks on Monday, Dr Tedros also said that he “supported” the proposal by the President of Costa Rica, Carlos Alvarado, to create a global pool of rights to COVID-19 therapies, and would be working to finalize its details.

The WHO Director General had responded positively to the overture last week in a Tweet, but this was the first time that he made a more formal comment on the developing initiatives around an international patent pool by Costa Rica, which was also backed last week by the UN-supported Medicines Patent Pool.

“I want to thank the Medicines Patent Pool and UNITAID for the initiative they announced last Friday to include medicines and diagnostics for COVID-19 in their licensing pool,” he said.

In a parallel move, the International Federation of Pharmaceutical Manufacturers (IFPMA) and Associations on Monday released a statement responding favorably to the Medicines Patent Pool’s move.

“While we are not aware of any instance to date where intellectual property management has been an impediment in the global response to this pandemic, proposals for voluntary pooling of intellectual property assets, including the decision of the Medicines Patent Pool (MPP) to temporarily expand its mandate to include health technologies related to COVID-19, adds to the arsenal of options available to companies when establishing access to any potential COVID-19 product,” said Thomas Cueni, director-general of IFPMA.

Cueni added that the biopharma industry “recognized there was no ‘one-size fits all’ approach” to supporting research and development, and access efforts. Thus, the industry was “open to explore innovative approaches and partnerships to facilitate further R&D to develop new medicines and vaccines for patients suffering from COVID-19 and to expand access.”

Dr Tedros also thanked the President of Costa Rica, Carlos Alvarado, and Health Minister Daniel Salas for submitting the proposal to create a pool of rights to diagnostics, treatments and vaccines, with free access or licensing on “reasonable and affordable terms.”

“Muchas gracias, Mr President. I support this proposal, and we are working with Costa Rica to finalize the details,” added the WHO Director-General.

“More than 70 countries have joined WHO’s Solidarity Trial to accelerate the search for an effective treatment. And about 20 institutions and companies are racing to develop a vaccine. WHO is committed to ensuring that as medicines and vaccines are developed, they are shared equitably with all countries and people,” he added.

India bans Hydroxychloroquine Exports – Following Despite US Efforts to Access Supplies  

Despite the calls for global solidarity, individual countries continued moves to restrict exports of certain supplies and medicines viewed as potentially critical. Over the weekend, India banned all export of the drug hydroxychloroquine, a drug currently approved for the treatment of immune disorders such as lupus, but also viewed as a potential remedy for COVID-19.

The Indian limitation on exports followed a new, and unprecedented recommendation by a National Task Force for COVID-19, led by the Indian Medical Research Council, on the use of hydroxychloroquine as a prophylactic for asymptomatic healthcare workers involved in the care of suspected or confirmed cases of COVID-19, as well as for asymptomatic houseold contacts of laboratory confirmed COVID-19 cases. 

Over the weekend, the Indian Ministry of Health and Family Welfare issued a more formal guidance permitting the off-label use of hydroxychloroquine with the antibiotic azithromycin in COVID-19 for patients in intensive care or with severe respiratory disease

“The export of hydroxychloroquine and formulations made from hydroxychloroquine shall remain prohibited, without any exception,” stated the order by India’s Directorate General of Foreign Trade in the wake of the national policy directives.  

The Indian export ban was imposed despite US President Trump’s call this weekend with Indian PM Narendra Modi during which Trump urged the release of “the amounts that we ordered”.

Although hydroxychloroquine’s safety and efficacy for treating COVID-19 have not been demonstrated, various countries, including India and the US, have incorporated the antimalarial drug into their national containment plans.

The pharmaceutical industry is not waiting for the final evidence either. It has already made commitments to ramp up production of the drug. Pharmaceutical giants like Novartis, Bayer, Teva and Mylan NV, amongst others, have all pledged to contribute some 220 million tablets, by mid-May, more than half of which will be donated by the Swiss-based pharma firm Novartis.

New York may be Reaching Plateau – Africa doing “Well” So Far In Response

In terms of pandemic trends worldwide, it appeared that New York may be near the apex of its infection wave, or already plateauing, New York Governor Andrew Cuomo said on  Sunday. New York City’s daily number of deaths dropped for the first time in weeks from 630 on Saturday to 594 on Sunday, and the number of new hospitalizations was halved overnight.

“The number of deaths over the past few days has been dropping for the first time. What is the significance of that? It’s too early to tell”, Cuomo said in yesterday’s speech.

“Three or four days” may be needed to see whether the death rate is actually decreasing. Some 4,150 people have died among the 122,031 confirmed cases in the USA’s epicentre, the Governor said. 

However, cases are rising fast elsewhere in the US – and President Trump is facing mounting pressure from healthcare groups to put a national shelter-in-place order. So far, stay at home orders have been up to state governors’ discretion. Yesterday, Texas officials installed COVID-19 Checkpoints at the border with Louisiana. Vehicles are screened at all roadways crossing into Texas including interstates .Commercial motor vehicle traffic will not be obstructed, says Louisiana’s State Police. Louisiana’s case count shot up, almost doubling over the past weekend.

Africa has been doing “well in the outbreak response so far,” said Mike Ryan, WHO Executive Director of the Health Emergencies Programme, at today’s press conference. Even so, the number of cases in the African region have doubled over the past last week, with a total of some 9 200 cases as of Monday. 

There were even more worrisome trends in some countries; the number of infected people in Guinea, Niger and Cameroon doubled over the past 2-3 days, a faster pace of growth than most other countries today. South Sudan also reported cases of COVID-19 for the first time, according to the latest WHO Situation Report.

Still, some African countries still only have imported cases, leaving a window to contain further disease expansion, said Maria Van Kerkhove, WHO’s Technical Lead for the COVID-19 outbreak, at Monday’s press briefing.

Responding to a journalist’s suggestion in a TV interview last week that Africa could be the ideal test ground for a possible COVID-19 vaccine, Dr Tedros said, “Africa can’t and won’t be a testing ground for any vaccine.”

He described the remarks as a “hangover from a colonial mentality.”

“It was a disgrace, appalling, to hear during the 21st Century, to hear from scientists, that kind of remark. We condemn this in the strongest terms possible, and we assure you that this will not happen,” he added.

The offensive remarks were made during a discussion on French TV channel LCI, as Camille Locht, head of research at Inserm Health Research group, talked about a possible vaccine trial in Europe and Australia.

Jean-Paul Mira, head of intensive care at Cochin hospital in Paris, then said: “If I can be provocative, shouldn’t we be doing this study in Africa, where there are no masks, no treatments, no resuscitation?

“A bit like it is done elsewhere for some studies on AIDS. In prostitutes, we try things because we know that they are highly exposed and that they do not protect themselves.”

Mr Locht nodded in agreement at this suggestion, and said: “You are right. We are in the process of thinking about a study in parallel in Africa.”

Cochin later apologized for the remark.

There is still a window of time in Africa, as some countries only have imported cases, rather than local transmission.
Spain & Italy Stabilizing – UK Public Warned to Prepare for Worst

In the United Kingdom, the public was warned to prepare for the worst as cases were still rapidly increasing, and Prime Minister Boris Johnson was moved to the intensive care unit  Monday night, following ten days of COVID-19 self-quarantine and a deterioration in his health status. Concurrently,  Queen Elizabeth II addressed the nation in a rare, and well-received speech on Sunday.

Spain’s cases and deaths continue to fall for the fourth day in a row, as the Spanish government continued to bolster its efforts on testing, including with the rollout of new rapid tests.

“Throughout the day, the first part of a million rapid tests will be received by the Autonomous Communities,” said Spanish Health Minister Salvador Illa. In an effort to counter the economic effects of the Covid-19, the Spanish government also announced plans to guarantee a universal basic income to all citizens.  

Italy’s infections rates also seemed to be finally declining, after the numbers first began to plateau over the past week. With the flattening of Italy’s curve following a month of lockdown, the Italian authorities were debating if and how to let some members of the workforce return to work, focusing first on people who could be tested and found to have antibodies against COVID-19.

Lately, Belarus has witnessed the most rapid growth of coronavirus in Europe, with cases having doubled in only three days. There is no need to stop normal daily life, said the Belarusian President Alexander Lukashenko president in an interview with The Times, who even recommended a glass of vodka for lunch to citizens. The Eastern European country has not imposed a lockdown and has not closed its borders. Belarus currently has some 560 cases.

Today, Japan announced a national state of emergency after the country experienced the  highest daily jump in cases on Sunday, with numbers soaring to 1000 cases. Many of Tokyo’s cases are untraceable, said Governor Yuriko Koike said in a livecast YouTube video on yesterday, according to a report from Reuters. 

Total cases of COVID-19 as of 6:55 PM CET, with active case distribution globally. Numbers change rapidly.

Image Credits: HP-Watch/G Ren, Africa CDC.