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International
Protocol to response COVID-19
The Global Response
& Next Steps
1.
The COVID-19 virus is a new pathogen that is highly contagious, can
spread quickly, and must be considered capable of causing enormous health,
economic and societal impacts in any setting. It is not SARS and it is not
influenza. Building scenarios and strategies only on the basis of well-known
pathogens risks failing to exploit all possible measures to slow transmission
of the COVID-19 virus, reduce disease and save lives.
COVID-19 is not SARS and it is not
influenza. It is a new virus with its own characteristics. For example,
COVID-19 transmission in children appears to be limited compared with
influenza, while the clinical picture differs from SARS. Such differences,
while based on limited data, may be playing a role in the apparent efficacy of
rigorously 19 applied non-pharmaceutical, public health measures to interrupt
chains of human-tohuman transmission in a range of settings in China. The
COVID-19 virus is unique among human coronaviruses in its combination of high
transmissibility, substantial fatal outcomes in some high-risk groups, and
ability to cause huge societal and economic disruption. For planning purposes,
it must be assumed that the global population is susceptible to this virus. As
the animal origin of the COVID-19 virus is unknown at present, the risk of
reintroduction into previously infected areas must be constantly considered.
The novel nature, and our continuously evolving understanding, of this
coronavirus demands a tremendous agility in our capacity to rapidly adapt and
change our readiness and response planning as has been done continually in
China. This is an extraordinary feat for a country of 1.4 billion people.
2. China’s uncompromising
and rigorous use of non-pharmaceutical measures to contain transmission of the
COVID-19 virus in multiple settings provides vital lessons for the global
response. This rather unique and unprecedented public health response in China
reversed the escalating cases in both Hubei, where there has been widespread
community transmission, and in the importation provinces, where family clusters
appear to have driven the outbreak.
Although the timing of the outbreak in
China has been relatively similar across the country, transmission chains were
established in a wide diversity of settings, from megacities in the north and
south of the country, to remote communities. However, the rapid adaptation and
tailoring of China’s strategy demonstrated that containment can be adapted and
successfully operationalized in a wide range of settings. China’s experience
strongly supports the efficacy and effectiveness of anchoring COVID19 readiness
and rapid response plans in a thorough assessment of local risks and of
utilizing a differentiated risk-based containment strategy to manage the
outbreak in areas with no cases vs. sporadic cases vs. clusters of cases vs.
community-level transmission. Such a strategy is essential for ensuring a
sustainable approach while minimizing the socio-economic impact.
3.
Much of the global community is not yet ready, in mindset and
materially, to implement the measures that have been employed to contain
COVID-19 in China. These are the only measures that are currently proven to
interrupt or minimize transmission chains in humans. Fundamental to these
measures is extremely proactive surveillance to immediately detect cases, very
rapid diagnosis and immediate case isolation, rigorous tracking and quarantine
of close contacts, and an exceptionally high degree of population understanding
and acceptance of these measures.
Achieving the high quality of
implementation needed to be successful with such measures requires an unusual
and unprecedented speed of decision-making by top leaders, operational
thoroughness by public health systems, and engagement of society. 20 Given the
damage that can be caused by uncontrolled, community-level transmission of this
virus, such an approach is warranted to save lives and to gain the weeks and
months needed for the testing of therapeutics and vaccine development.
Furthermore, as the majority of new cases outside of China are currently
occurring in high and middleincome countries, a rigorous commitment to slowing
transmission in such settings with non-pharmaceutical measures is vital to
achieving a second line of defense to protect low income countries that have
weaker health systems and coping capacities. The time that can be gained
through the full application of these measures – even if just days or weeks –
can be invaluable in ultimately reducing COVID-19 illness and deaths. This is
apparent in the huge increase in knowledge, approaches and even tools that has
taken place in just the 7 weeks since this virus was discovered through the
rapid scientific work that has been done in China.
4.
The time gained by rigorously applying COVID-19 containment measures
must be used more effectively to urgently enhance global readiness and rapidly
develop the specific tools that are needed to ultimately stop this virus.
COVID-19 is spreading with astonishing speed;
COVID-19 outbreaks in any setting have very serious consequences; and there is
now strong evidence that non-pharmaceutical interventions can reduce and even
interrupt transmission. Concerningly, global and national preparedness planning
is often ambivalent about such interventions. However, to reduce COVID-19
illness and death, near-term readiness planning must embrace the large-scale
implementation of high-quality, non-pharmaceutical public health measures.
These measures must fully incorporate immediate case detection and isolation,
rigorous close contact tracing and monitoring/quarantine, and direct
population/community engagement. A huge array of COVID-19 studies, scientific
research projects and product R&D efforts are ongoing in China and
globally. This is essential and to be encouraged and supported. However, such a
large number of projects and products needs to be prioritized. Without
prioritizing, this risks compromising the concentration of attention and
resources and collaboration required to cut timelines by precious weeks and
months. While progress has been made, the urgency of the COVID-19 situation
supports an even more ruthless prioritization of research in the areas of
diagnostics, therapeutics and vaccines. Similarly, there is a long list of
proposed studies on the origins of COVID-19, the natural history of the
disease, and the virus’s transmission dynamics. However, the urgency of
responding to cases and saving lives makes it difficult for policy makers to
consider and act on such comprehensive lists. This can be addressed by
balancing studies with the immediate public health and clinical needs of the
response. Studies can be prioritized in terms of the largest knowledge gaps
that can be most rapidly addressed to have greatest immediate impact on
response operations and patient management. This suggests prioritizing studies
to identify risk factors for transmission in households, institutions and the
community; convenience sampling for this virus in the population using existing
surveillance systems; age-stratified sero-epidemiologic surveys; the analysis
of clinical case series; and cluster investigations.
For countries with imported cases and/or outbreaks of
COVID-19
1.
Immediately activate the
highest level of national Response Management protocols to ensure the
all-of-government and all-of-society approach needed to contain COVID-19 with
non-pharmaceutical public health measures;
2.
Prioritize active,
exhaustive case finding and immediate testing and isolation, painstaking
contact tracing and rigorous quarantine of close contacts;
3.
Fully educate the general
public on the seriousness of COVID-19 and their role in preventing its spread;
4.
Immediately expand
surveillance to detect COVID-19 transmission chains, by testing all patients
with atypical pneumonias, conducting screening in some patients with upper
respiratory illnesses and/or recent COVID-19 exposure, and adding testing for
the COVID-19 virus to existing surveillance systems (e.g. systems for
influenza-like-illness and SARI); and 22
5.
Conduct multi-sector
scenario planning and simulations for the deployment of even more stringent
measures to interrupt transmission chains as needed (e.g. the suspension of
large-scale gatherings and the closure of schools and workplaces).
For uninfected countries
1.
Prepare to immediately
activate the highest level of emergency response mechanisms to trigger the
all-of-government and all-of society approach that is essential for early
containment of a COVID-19 outbreak;
2.
Rapidly test national
preparedness plans in light of new knowledge on the effectiveness of
non-pharmaceutical measures against COVID-19; incorporate rapid detection,
largescale case isolation and respiratory support capacities, and rigorous
contact tracing and management in national COVID-19 readiness and response
plans and capacities;
3.
Immediately enhance
surveillance for COVID-19 as rapid detection is crucial to containing spread;
consider testing all patients with atypical pneumonia for the COVID-19 virus,
and adding testing for the virus to existing influenza surveillance systems;
4.
Begin now to enforce
rigorous application of infection prevention and control measures in all
healthcare facilities, especially in emergency departments and outpatient
clinics, as this is where COVID-19 will enter the health system; and
5.
Rapidly assess the general
population’s understanding of COVID-19, adjust national health promotion
materials and activities accordingly, and engage clinical champions to
communicate with the media.
For the public
1.
Recognize that COVID-19 is
a new and concerning disease, but that outbreaks can managed with the right
response and that the vast majority of infected people will recover;
2.
Begin now to adopt and
rigorously practice the most important preventive measures for COVID-19 by
frequent hand washing and always covering your mouth and nose when sneezing or
coughing;
3.
Continually update yourself
on COVID-19 and its signs and symptoms (i.e. fever and dry cough), because the
strategies and response activities will constantly improve as new information
on this disease is accumulating every day; and
4.
Be prepared to actively
support a response to COVID-19 in a variety of ways, including the adoption of
more stringent ‘social distancing’ practices and helping the high-risk elderly
population. 23
For the international community
1.
Recognize that true
solidarity and collaboration is essential between nations to tackle the common
threat that COVID-19 represents and operationalize this principle;
2.
Rapidly share information
as required under the International Health Regulations (IHR) including detailed
information about imported cases to facilitate contact tracing and inform
containment measures that span countries;
3.
Recognize the rapidly
changing risk profile of COVID-19 affected countries and continually monitor
outbreak trends and control capacities to reassess any ‘additional health
measures’ that significantly interfere with international travel and trade.
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