Now published: Middleton J, Lopes H, Michelsen K, Reid J. Planning for a second wave pandemic of COVID-19 and planning for winter. Int J Public Health (2020).
DOI: https://doi.org/10.1007/s00038-020-01455-7

A second wave of COVID-19?

There is no clear definition of a ‘second wave’ of  COVID-19 pandemic.(1) Many countries are now grappling with resurgences in different forms.(2) ASPHER suggests a true second wave could be defined as a resurgence of the incidence rate during a pandemic, which cumulatively presents:

1. An exponential increase in the number of cases of the disease in a given time period and specific territorial zone.

2. This exponential increase follows from:

a. the disappearance or near disappearance of cases of the disease;

b. may be influenced by a new behavioural characteristic of the infectious agent, or a modified characteristic from another already known.

Hope for the best, plan for the worst

ASPHER believes northern hemisphere countries should expect a second wave of the COVID pandemic, from the autumn.(3,4) Its impacts will be made worse by other economic, social and health service conditions.(4)

We should make the following worse-case assumptions:

• that a second COVID-19 pandemic wave will arrive across whole countries as local lock-down approaches to containment and control are unable to prevent widespread transmission;(3)
• respiratory viruses spread more easily in enclosed spaces and coronaviruses are no exception;(5)
• that we cannot expect there to be broad community protection based on previous exposure to the virus, ‘so called herd immunity’, as shown by low levels of exposure in national serological studies;(6,7,8)
• that a successful vaccine and anti-viral treatments will not be produced or widely available or rolled out in the population;(9)
• that seasonal respiratory infections will rise despite the continuance of some levels of physical distancing measures, and we should expect flu to be more severe than in recent years;(3,4,10) there is the potential for pandemic flu in the foreseeable future;(11)
• that health and social care systems will not have recovered over the summer and that population unmet health needs from the first wave have not been caught up;(14, 12-16)
• that some countries will have severe winter weather leading to cold-related deaths and illness;(17)
• that social and ethnic minorities and vulnerable populations remain at higher risk both to a second wave and more typical winter hazards;(4, 17-19)
• that there will be little appetite, politically, and room for manoeuvre, socially and economically,  for a programme of lockdowns such as we have seen in the first part of 2020, leading to continuing spread and major mortality, morbidity and impacts on health and social care systems. 

Countries should be particularly concerned about the interaction of six main factors:

1. Second wave COVID-19

Countries will need to deliver pandemic non-pharmaceutical measures at a scale and intensity not previously achieved. All of the well rehearsed non-pharmaceutical measures which have been applied across the globe need to be part of the armoury-enhanced localised surveillance, test and trace, face masks, physical distancing, shielding of vulnerable individuals, bans on mass gatherings. Adequate stockpiles of personal protective equipment (PPE) are needed for health and care systems.(4)

2. Planning for a severe flu season

Countries will need to plan to deliver an enhanced programme of flu vaccination to protect vulnerable patients, in the expectation of severe seasonal flu. Children’s immunisation programmes must achieve high coverage.(4,10,20) Health and care staff must be vaccinated to protect themselves and their patients.(20,21)

3. The recoiled spring of unmet health needs

Countries will need to address what ASPHER is calling ‘the spring effect’. A spring is squeezing tighter with the impact of new, previously unrecognised disease, and untreated and uncontrolled existing long-term conditions and conditions requiring surgical treatment over the pandemic period. At some point the spring will open violently impacting massively on already exhausted health services. Health services must take advantage of current decreases in COVID-19 cases requiring hospitalization to use capacity to address the backlog in regular care.(4, 12-16) Strong priority over the summer, should be given to:

• procedures that may involve the production of aerosols such as endoscopy and colonoscopy; 
• diagnosing cancer;
• serious cardiac disorders;
• delayed essential surgical procedures;
• review of patients with severe mental illness;
• cancer screening catch-up programmes;
• Immunisation catch-up programmes.

4. Lockdown illnesses - physical, mental and social

There will be added tension to the spring, from new cases of illness brought about through inactivity, processed food consumption, alcohol, overcrowding, mental distress, loneliness and domestic abuse during lockdowns.(14-16,22,23)

5. The impact of health and care staff burnout, post-traumatic experiences and exhaustion

Health workers are being confronted with depression, anxiety, stress, burnout, emotional distress, or another mental health condition relating to or made worse by their work, these had got worse during the pandemic. Health systems will need to develop their support mechanisms, including occupational health and counselling services to support health care staff in the next phase of the pandemic.(24,25)

6. Economic and social  intervention

Deepening economic recession will lead to increasing unemployment and  adverse effects on health, multiplying the effects of the virus and  seasonal flu.

Governments should apply economic and social measures that reduce inequalities in health and give protection to their communities,(26,27) including:

• Protecting household incomes, providing social security for the whole population, including disadvantaged, but also self-employed allowing maximal participation in economic activities;(27,28,29) and facilitating flexible working hours;(30,31) Protecting workplaces by support for returning to work, and enhancing regulatory health and safety services;(32) Measures reaching out to homeless, the hidden poor, and undocumented migrants. (18,33)
• Changes to transport systems to promote mobility, access and active travel.(34,35,36)
• Housing improvements to reduce overcrowding and promote affordable warmth.(17,37)
• Protecting children’s health and wellbeing, facilitating the maintenance of education;(14) and addressing unequal access to digital resources (the digital divide).(38)
• Strengthening adult education as a vital element of pandemic control, general health improvement and reducing inequalities.(39)

Governments should also facilitate other economic measures for the protection of their citizens (27, 40-42):

• Preventing gaps in supply (economic goods and services) especially food,(43) water and electricity.
• Maintaining a strong public sector with adequate finances.
• Strengthen international cooperation / cross border mobility of goods and services not only, but especially regarding medical products / devices and services.(40)

Leisure and tourist industries face particular problems, across Europe.(44) A crash out Brexit will have huge impact on the UK economy but will also impact on major EU trading partners.(45) 

Policies by consent, understood and supported by the people

Ineffective policies will produce harm, and harmful consequences of infection control policies have the potential to reduce their effectiveness, e.g. in case of denial or resistance. Policies must not be directed against people, but based in community cooperation and be community led wherever possible. They must support communities to promote their capabilities to reduce own infection risks, to reduce infection risks for others, to deal with disease in case of infection, and to organize the daily life with family, social networks and in line with working lives and economic requirements.(46,47)

Planning for a second wave, planning for winter 

In summary, ASPHER recommends the following four priorities for detailed winter preparedness during July to September 2020:

1. Engage widely now with excluded and vulnerable groups to prepare for a winter second wave.

2. Re-establish and reinforce essential health and social services, to catch-up over summer and autumn, and to preserve their function during the second winter wave.

3. Instigate social and economic policies to underpin good quality of life during the economic downturn from the first or second wave.

4. Reduce excess mortality and keep older people and all others with Long-Term Conditions safer this winter.

Detailed actions that ASPHER recommends are set out in detail here.

Conclusion

COVID-19 is here to stay, unless governments take concerted international efforts to curtail it. Short of this, the future course of the pandemic will play out different scenarios such as:

• a disastrous uncontrollable second wave this winter in Europe;
• local outbreaks or ongoing infections on a small scale;
• continuing multiple outbreaks;
• or low-grade continuing infectivity.

Most of the new outbreaks in Europe currently (July 2020) are due to previous social problems. In other words, Europe does not have a pandemic problem, but a social problem that reflects into the pandemic.

We should extract something positive from this social experience. These kind of measures could improve the sense of common citizenship, social participation and mutual responsibilities among people from all social backgrounds, within countries, and internationally.

As WHO EURO Director Hans Kluge has said,(48) reflecting on the apparent respite most European countries are experiencing from COVID-19, ‘we should not use this time to celebrate, but to plan’. In the best traditions of emergency preparedness, we should ‘hope for the best, but plan for the worst’. We are not seeing sufficient evidence that governments are indeed planning to meet these needs in a new and more challenging phase of the pandemic. 

John Middleton, Henrique Lopes, Kai  Michelsen, John Reid
July 20^th 2020 

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