Authors: Ranjeet Dhonkal (contact: Ranjeet.Dhonkal@haw-hamburg.de), John Middleton (United Kingdom), Ralf Reintjes (Germany), Laurent Chambaud (France), Alberto Fernandez (Spain), Jose M Martin-Moreno (Spain), Natia Skhvitaridze (Georgia)
ASPHER conclusions so far
In accordance with the WHO EURO and EU recommendations we believe there should be:
- Planned and gradual lifting
- Protection of groups of people needing special care
- Lifting measures should be divergent in approach
- Public gathering should be permitted
- Preventive measure should be sustained
- Proper monitoring of measures
- In addition, recovery of health and care services
Planned and gradual lifting
Essential and reasonable approach for planned and gradual lifting of coronavirus containment measures should be controlled, slow and in step wise manner. Sufficient time should be left between the steps considering one incubation period to identify and adverse effects. Time interval between relaxation may varies and can be more than one incubation period cycle as it strongly depends on the quality of surveillance system and countries capacity to measure the effects.
WHO and the EU also suggest the easing of restrictions in certain countries will have to be staggered over a period of time. Due to the nature of COVID-19, it is difficult to understand any adverse impact of easing of restrictions until 10–14 days have passed.
As restrictions are eased, it is important for countries to recognize that it may be necessary to reintroduce physical distancing measures to manage outbreaks at short notice. John Hopkins policy advisers recommend 'a state should revert to lockdown and continue “slow the spread” if a substantial number of cases cannot be traced back to known cases, if there is a sustained rise in new cases for five days, or if hospitals are no longer able to safely treat all patients requiring hospitalization’. WHO Europe calls this ‘bidirectional working’. Countries will need to be adaptable, and secure a high level of public understanding and support for further control measures if needed.
Target group needs special care
Protection of most vulnerable populations should be central in the decision to maintain or lift measures. People aged ≥70 and people of any age who have serious underlying medical conditions (for example - heart disease, hypertension, diabetes, chronic respiratory disease, cancer), at risk due to compromised immune system from medical condition or treatment (for example - chemotherapy) might be at higher risk for severe illness from COVID-19. People with mental illness are another possible risk group. People with either mild symptoms or severe should be advise to stay quarantine as will help the break the chain of transmission.
Lifting measures should be divergent in approach
Lifting measures should start with an approach targeting the local area first by allowing the functioning of the internal market and on free movement of the people. After careful observation and monitoring the measures gradual lifting should extend to broader geographical coverage. The travel restrictions should be lifted once physical distancing rules are widely and responsibly applied. External border reopening and access of non-EU residents to the EU should happen in later stages. The widely used 14 day quarantining of airline travellers on arrival into another country is a sensible precautionary measure.
Public gathering should be permitted on a staged basis
Public gathering should be progressively permitted. It is important to determine the appropriate sequence for reintroduction of gatherings. The EU road map describes such gatherings in terms of: (i) Schools and universities; (ii) Nonessential business; (iii) Social activities; (iv) Mass gathering.
The EU is silent on religious gatherings. For some this is the most heart-breaking problem of the pandemic- not being able to properly mourn the loss of their loved ones. For the present, assessment of conduct of ceremonies, births, marriages and funerals will need to be determined in the context of risk assessments. These are the same principles which apply to all public gatherings. It is important to recognise the impacts of public gathering beyond the confines of the facility in which the gathering is taking place - impacts for public transport, for car parking, for gatherings outside the facility, for hospitality facilities, for the length of time of the event and for the ease of access and egress. The potential for ticketing and reservations as a means to control numbers is another consideration. Potential use of remote technologies should also be considered. Another consideration is the capacity of the event organisation to provide, or police personal hygiene measures Detailed risk assessment is required in each case.
Preventive measures must be sustained
Health promotion and health awareness campaign should encourage people to maintain good hygiene practice ‘the new normal’ (use of sanitizers, washing of hands, coughing/sneezing etiquette, cleaning high-contact surfaces, etc.). In addition, employers should discourage the previous culture of ‘presenteeism’ in which employees were obliged to work, or colluded inworking, even if ill and especially when infectious to others. Through these awareness campaigns people should be provided with brief information regarding risk assessment. ASPHER recommends the use of non-surgical facemasks or face coverings in the community.This is especially the case when visiting busy, confined spaces, such as grocery stores, shopping centres, or when using public transport. The European Union has also adopted the recommendation as made by the European Centre for Disease Surveillance and Control.
Proper monitoring of measures.
WHO recommends a rigorous surveillance programme to identify, test and isolate all cases and to trace and quarantine their contacts is vital to ensure that localized outbreaks do not get out of control. ASPHER agrees and has set out its view on testing; nevertheless, there are concerns about the real world effectiveness of the tests in picking up true infections, and in over-estimating population exposure in mass serology.
In addition to testing regimes, novel and lateral sources of surveillance data should be used. These may be different from country to country. Under-reporting of COVID deaths may be off-set by use of the excess mortality indicators available for some countries. Other primary care data, COVID and respiratory data may be available and add to a picture of the state of the outbreak for particular countries.
When measures are eased, cases should not exceed a sustained reproductive factor of 1, and should ideally remain below 1. This means that a person with confirmed COVID-19 does not pass the disease on to more than 1 other person to keep the number of cases flat. For example, Germany used an R factor of 0.7 before reducing its restrictions.
Recovery of health and care services
We must recognise and celebrate health and care services workers; and we must mourn and honour the colleagues we have lost. We must also recognise and make provision for a level of mental distress, post traumatic stress disorder amongst health and care workers and recongise that restarting health and care services to full capacity will not be possible. We must also plan for a recovery of non urgent health care and some urgent and routine care which has been put on hold during the pandemic. We will also have built up waiting lists and demand for health services during the pandemic period and we may not have planned for lockdown induced illness, (e.g., domestic violence), economic inequality induced illness (unemployment related suicide) and vulnerability induced illness (care for homeless and migrant people). We should plan for full reinstatement of life saving preventive care, like the childhood immunisation programmes, maternal and reproductive health care, and long term conditions management in primary care.
Key references
ASPHER Statement on the streategic use of masks:
https://www.aspher.org/aspher-statement-masks.html
ASPHER Statment on the COVID-19 testing:
https://www.aspher.org/aspher-statement-covid-19-testing.html