“The world is inching towards a pandemic,” admitted WHO Director General Dr Tedros Adhanom Ghebreyesus in a WHO media briefing Monday, which saw COVID-19 cases more than double over the weekend in France, Germany and Spain, as well as the USA.  In an unprecedented move, Italy’s Prime Minister put the entire country under emergency lockdown Monday night after cases soared from 3860 Friday to 9,172 people infected Monday. Over 100 countries around the world were now reporting infections.   

“But it would be the first pandemic we could control,” Dr Tedros added.

“Of all cases reported 93% come from just four countries,” he said, referring to Italy, Iran and South Korea, which have seen exponential increases in recent days, while cases in China decline.

Other countries and regions, were beginning to respond as they saw case numbers spiral in now predictable ways as the outbreak caught hold. Italy’s Prime Minister Guiseppe Conte expanded the lockdown over Lombardy region to the entire country Monday evening as the country reported another 1797 new cases – closing schools until April 3rd, canceling all sporting events and other mass gatherings, and restricting movement across the country.

“Italy’s future is in our hands. We all do our part, giving up something for the good of the community. At stake is the health of our loved ones, our parents, our children, our grandparents,” Conte tweeted just after signing the ministerial decree.

New York State declared a “disaster emergency” on Sunday, following on from the examples of the states of Washington, California and Maryland, the states that have been driving the increases in cases in the United States where 707 cases have now been reported, likely an underestimate since the national rollout of tests had been delayed both by inadequate tests as well as a severe shortage testing kits.

“Countries that continue finding & testing cases & contacts can affect their countries and what happens globally,” Dr. Tedros said, noting that the Republic of Korea now seems to be on the verge of containing the virus.  Singapore and Japan also seem to have turned the corner, following the experience of China, which has managed to beat back the infection, registering only 84 new cases over the past 24 hours.

The WHO Director-General praised examples such as the Korean “drive through” testing model, which allows easy access to tests for people suspecting that they may have been infected, with little risk to them or health care workers.  He said that the “drive-through” model was helping to “widen the net and catch cases that might otherwise be missed.”

At the same time, WHO Emergencies Head Mike Ryan told the press briefing that the world may only be in the early phases of an erupting epidemic, and so the curve of new cases would likely rise further before it starts to decline.

“We are at the beginning or middle of fighting this virus,” Ryan said. “We are very much in the ‘up’ cycle. But it’s up to us to turn this around,” he said, adding that, “the way in which China, Singapore, Korea and Japan are on the verge of turning a corner gives me hope,” he said. He added that there has also been some speculation that warmer weather might potentially help beat back the virus, but that can’t be relied upon since so little is known about the virus behaviour. Comparatively fewer cases have been seen in some parts of the southern hemisphere, which is in its summer seasons, although the pattern has been inconsistent. 

People 80+ have 20% Fatality Rate – New Recommendations Likely On Avoiding Travel & Mass Gatherings  

Meanwhile even as case totals and death rise daily, failing to fight for strong containment measures will effectively sacrifice the lives of millions of older people, as well as people with underlying health conditions, the WHO officials stressed.

The most recently available data from China indicates that COVID-19 fatality rates for people over the age of 80 is above 20%, and that data is still not fully up to date, said Maria Van Kherkove, WHO Emergencies Technical Lead.

Similarly, people with underlying conditions have an outsized fatality rates – averaging around 13% for those who fall ill and have cardiovascular disease, for example, and about 7.5% for those with cancer, she said, citing the findings of a recent WHO-Joint Mission Report.

It would be a lapse in “morality” to abandon wholesale such groups, said Dr Tedros. “Not taking the death of the elderly, our senior citizens, is a serious issue, and even a moral decay. Every human being matters – it pains us when some want to move into mitigation [as compared to containment of the epidemic] because the virus kills seniors or elderly only.”

Added Ryan, public health professionals need to be committed to fighting on behalf of the vulnerable. “When people talk about just letting the wave pass, remember that there are many vulnerable people, for whom this won’t go away. Our elderly, people on cancer chemotherapy are precious members of society.. N=1  – every person matters,” he said.

But Ryan conceded that WHO may need to provide more pinpoint advice to countries for guidance about measures that older people should take – so far it has not.

“Maybe we need to push forward our advice to that elderly group about travel, mass gatherings and meetings,” Ryan said.

However, recommendations to practice “social distancing” should not just be for the “elderly” said Dr Tedros; it should be for all groups, and particularly for people living in countries and regions that are experiencing widespread community transmission of the virus – from contacts that are difficult or impossible to trace.

The United States Centres for Disease Control is already recommending at national level that older adults and other “high risk” groups stock up on supplies, practice social distancing measures and “stay at home as much as possible,” in light of their greater vulnerability.

Seattle Hospital Sets Up “Drive-Through” Testing – But Many FDA Testing Barriers Remain

States and cities in US hotspots were finally ramping up diagnostic test capacity, after four state governors declared “states of emergency” in their jurisdictions over the weekend. Overall, the number of US cases more than doubled from 239 on Friday to a total of 566 cases by Monday.

The change came after days of pushing the Federal Drug Administration – the US’s governing body for regulating drugs and diagnostics – to allow local testing and bypass the US CDC’s limited testing capacity. As of March 5, a total of just 1583 patient samples had been tested through the CDC.

The loosening of restrictions saw initial use of successful tools like Korea’s model of “drive-through” testing. The University of Washington’s Hospital – at the center of the US’s first outbreak hotspot in Seattle – followed in South Korea’s footsteps and set up a “drive through” diagnostic center where hospital staff with potential COVID-19 symptoms, or contact with confirmed cases, could pull up and get tested, without leaving their car. The “drive through” testing is so far restricted so far only to healthcare workers. According to an article in Nature, however, the virology lab at the University is now testing hundreds of samples a day from healthcare facilities around the state since the federal government allowed academic centers to test for the virus.

At the other end of the scale, however, Northwell Health Center in the New York City area, was still under an FDA limit to perform manual testing of only 75-80 samples a day as state health officials waited for the FDA to allow Northwell to perform automatic testing in order to scale up to testing 1000-1500 samples a day.

New York’s governor Andrew Cuomo followed in the footsteps of Saturday’s declaration’s by Washington State, California, and Maryland declaring a “disaster emergency” on Sunday. This allows state governments to speed up medical supplies procurement, hiring of medical personnel, transfer of suspected patients to quarantine facilities other than hospitals, and allow medical personnel other than doctors and nurses to test for COVID-19.

The declaration also allows the governor to investigate cases of potential price gouging as prices for cleaning products and hand sanitizer soared last week.

However, an emergency room healthcare worker from a New York City public hospital told Health Policy Watch that there does not yet seem to be a clear protocol for public hospitals that primarily serve underprivileged or uninsured communities – hospitals that are already operating above  capacity.

To order a test for COVID-19 in one particular New York City hospital, for example, the patient must first be cleared of having the flu or any other common respiratory virus – then the test can only be ordered after a consultation with an infectious disease specialist.

Patients often wait to be tested in crowded emergency room waiting areas, where they could expose health care workers or other critically ill people to the virus, said the source. Getting test results still takes a couple days, and the 80% of mild cases of COVID-19 that do not require hospitalization are sent home to self-quarantine, where they might still infect others if the proper precautions aren’t taken.

Another problem faced by hospitals is the lack of systems to test and manage health care workers who may have been exposed to the virus over the past several weeks, when testing was largely unavailable. Healthcare facilities, such as University of California-Davis Medical Center, are asking staff to self-quarantine for two weeks if they have been exposed to the virus. However, experts are concerned that will result in a shortage of healthcare workers during the most critical peaks of the outbreak – particularly if many of those staff ultimately test negative.

“It’s just not sustainable to think that every time a health care worker is exposed they have to be quarantined for 14 days. We’d run out of health care workers,” Jennifer Nuzzo, a senior scholar in Johns Hopkins Health Security Program told National Public Radio.

Africa Region Shifts From “Readiness to Response”

See here Open WHO knowledge base with emergency resources for policymakers, professionals and researchers.

Grace Ren contributed to this story.

This story was updated 10 March 2020.

Image Credits: Wikimedia Commons/Amarvudol, John's Hopkins CSSE, Kevin P. Coughlin / Office of Governor Andrew M. Cuomo.