World Needs Mindset Shift On COVID-19: Head Of WHO Delegation Issues Call For Aggressive Action Upon Return From China
WHO’s Bruce Aylward shows a graph of the epidemic curve in China, showing how rate of new infections has decreased due to China’s strict outbreak response measures.

COVID-19 can be beaten – but it will take a big mindset shift on the part of the global community to achieve what China has done – which is dramatically curb transmission of the new, mysterious and deadly coronavirus using traditional public health measures for digilent tracing of contacts, isolating those found to be ill; and providing intensive care, including advanced respiratory treatment, for the 20% of serious cases.

That was a key message from Bruce Aylward, the head of a WHO-convened independent commission of experts that just returned from a 10-day trip to China studying the massive public health effort now underway there.

Aylward spoke as new cases in China continued a generally downward trend, with 523 new cases and 71 deaths in the past 24 hours, but cases elsewhere in the world were now exploding.

The latest count included 2573 cases in 39 countries, an overnight increase of 292 infections. The biggest hotspots continue to be: Korea with 977 infections and 10 deaths; Italy, with  322 cases and 11 deaths; and in Iran, 93 cases including the infection of Iran’s deputy health minister, and 16 deaths.  In Switzerland, a 71 year old man was the first to be diagnosed with COVID-19 after visiting Lombardy, Italy 10 days ago for a conference. The fact that the case reports have increased so rapidly in all three countries over just the past few days suggests that other infected people may also be circulating undiscovered and infecting others, repeating a pattern that occured in the first weeks of the coronavirus emergency in China.

“What has China down and how they have done it is extremely important,” said Aylward, speaking to journalists on Tuesday, just hours after his return. “We have escalating outbreaks [even] in industrialized countries.  We have got to try to respond.”

In an unusually fresh, if sometimes rambling, account by a WHO official, Aylward called on countries to undergo a “shift in mindset.”  He used wartime terminology to describe the public health battle that countries will need to mount to effectively fight the virus, while describing the R&D effort required as a modern-day “Manhattan project.”

Aylward also painted a stark picture of the alternative – exponentially expanding infections and health systems becoming overwhelmed and even collapsing with the weight of treating so many seriously ill patients, often requiring advanced respiratory care.

Yet, too many public health officials remain both unprepared and fatalistic about the virus – approaches that will be devastating when cases finally appear on their doorstep.

Health checks at the “Milano Malpenza” airport in Milan, Italy.

“Is this a pandemic or not? Folks this is a rapidly escalating epidemic in different places that we have to tackle really fast.  But what China demonstrates is where this goes is within our control,” said Aylward.

“For the rest of the world, there has to be a shift in mindset. Around the world, people are thinking ‘how do we live with this, and manage all this disaster’, instead of saying: ‘This virus is going to come, we are going to find every case, isolate it, find every contact.’

“Countries have got to be shifting to a rapid response type of thinking. You can change the shape of this, but it takes a very aggressive and tough programme. In 30 years of doing this business, I have not seen this before,” he said, of the Chinese response.

An expert report outlining key findings and recommendations was being submitted Tuesday to WHO’s Director General Dr. Tedros Adhanom Ghebreyesus, Aylward said.  He described it as a consensus product of the 13 international disease control experts who participated in the mission, from institutions and countries as diverse as Nigeria CDC, the United States Centers for Disease Control, and Germany’s Robert Koch Institute.  Recommendations were made by the experts as individuals, and not on behalf of their institutions, he added.

Main Finding- Tough Chinese Measures Averted Hundreds of Thousands More Infections

While oft-criticized as draconian, Aylward said that the commission found the tough Chinese measures were proving to be effective, and so other countries need to study them and learn their lessons:

“It is the unanimous assessment of the team that they have changed the course of this outbreak. It was a rapidly escalating outbreak.. It has plateaued and is coming downward sooner than expected,” said Aylward.

“Hundreds of thousands of people in China did not get COVID-19 because of the aggressive response… and they also reduced the probability of this going elsewhere.”

He said that the strict quarantine, isolation and contact tracing measures were justified in the name of saving lives, and avoiding the swamping of health systems with seriously ill cases that even developed country health systems often lack capacity to treat.

“You are at war here. Is this a dangerous virus or a serious virus, bottom line is that this virus kills people, it kills older people it kills vulnerable. And young people die too. And they die in industrialized countries.”

“Instead of debating if COVID19 is a pandemic or not, countries need to ask themselves:  ‘Do you have your isolation beds ready for people that will need to be hospitalized? Do you know who your thousand contact tracers are? There are really practical things to be done?

“Countries need to keep in mind: People who get sick remain in hospital from 2-6 weeks so its a long time in hospital/isolation center.

80% of cases are mild, but with regards to more severely ill, there is the “sheer weight of numbers.. that’s really important, you have got to plan, how many beds… etc.

“How many countries are planning hospital beds, ventilators. lab supplies to be able to manage this? “You are going to need beds to isolate people and quarantine really close contacts. You have got to be able to accommodate those people, you have got to have enough ventilators for the serious cases, you have got to be able to transport people, have the lab capacity.”

“People are talking about [whether this is more like] SARS or flu, as soon as we get stuck with the two binary approaches we are not preparing for novel coronavirus.”

Nurse wearing a specialized mask, cap, gown and gloves measures the body temperature of a coronavirus patient in Hubei TCM Hospital. Such gear is vital to protect health workers from infection.

Using Old Fashioned Public Health Tools – And Mobilizing All Government Sectors   

China took a “very pragmatic approach” and decided to aim for the containment of the virus, using this set of traditional public health tools – including finding cases, contact tracing and rapid hospitalization of those who were seriously ill, but also the quarantine of mildly ill cases to stop the transmission chain; and even the isolation of close contacts and suspected cases.

Aylward said that the visiting experts sometimes wondered, “‘Is this real, this extraordinary mobilization to implement fundamental public health principles and approaches in the absence of a vaccine. Can this bring it down? Yes it can.””

“It was a science-driven” effort, agile response but deployed with extraordinary rigour, says Aylward, noting that clear guidelines for managing cases were issued and revised rapidly in line with new developments. Big data was deployed to find cases, and their contacts and to isolate them.

At the same time, the response was not monolithic, he stressed. Uniform guidelines were applied in a “differentiated” manner, across different provinces, depending on the level of infections.

“The fundamentals were always the same but the degree of application was different. There was a  differentiated approach when there were zero cases, sporadic cases or community transmission like they had in Wuhan.”

Aylward said that the differentiation allowed more efficient use of resources so that the national response effort was not exhausted. “A lot of people have said we can’t do this at scale because you will exhaust your response. The Chinese said ‘not if you tailor this properly.’

And at local level “There was a lot of latitude.. big rules were in place but provinces, towns, communities could adapt them to make it work for them, ” he said.

While hospital infection control failures in the first weeks of the coronavirus epidemic led to many health workers becoming ill and even dying, measures are now well in place for managing “clean and dirty channels” of hospital systems, and health workers now appear to be adequately equipped with personal protective gear. These, however, are key challenges that health systems elsewhere now need to prepare to meet.

Another secret to the success of the effort so far, has been the way all government sectors, from transport to agriculture, were mobilized to the public health mission at hand, Aylward said.

“They repurposed the machinery of government – all of government – to fight the virus,” he said, noting that transport services were rerouted not only to skip communities where the infection toll was high, but also ensuring wide spacing between passengers in areas where trains and metros were running normally.

“Food supplies were channeled to ensure that areas under lockdown had adequate provisions. And prepared meals were arranged and served in such as way as to minimize food-borne transmission of the infection, including by seating members of the expert team at separate tables at the China CDC cafeteria.

“We talk about all of government responses, but usually it doesn’t have much meaning,” Aylward said, adding that in the case of the Chinese battle against COVID-19, it did. “Everyone has a role that has been repurposed to fit this machinery.”

Public Support For Aggressive Containment Is Key

Another one key aspect of the China effort was the way in which massive public support was recruited at every level of society.

“They [China] mobilized a phenomenal collective and cooperative action,” said Aylward, saying that the level of commitment exceeded anything that could be simply imposed from above by an authoritarian government.

“It’s never easy to get the kind of passion, commitment and individual sense of duty.

“…We spoke to hundreds of people on planes, trains outside the system, they all shared this responsibility to be part of this.”  Over and over, said Aylward, “we also heard people say, ‘It’s our responsibility to do this for the world.’ ”

Public health officials elsewhere have to think about how to build similar awareness and social solidarity around a critical global public health battle.

“To accept quarantine, to accept rapid isolation there are going to be challenges for people to accept that. And are we ready to quarantine and isolate that number of people?  There are mindset issues. But we have got to overcome them,” said Aylward.

Face mask use across  the Middle East increases as new cases appear linked to travel in Iran. (Photo Credit: Farsnews/Sajad Toloui)

Access China Expertise & Launch “Manhattan Project” For Coronavirus Research 

Aylward also said that Chinese expertise could now be critical in helping other countries fight the virus, and he urged other public health systems to access Chinese experts.

“They have done this at scale. They are really good at it. They are ready to help,” he said.

He noted that rich and poor countries alike need help in preparing for the virus.  Rich countries may have hospital beds, but lack appropriate isolation facilities.  They may have respiratory units, but those may be inadequate to meet the scope of the new virus. And they also need to be identified and mobilized for any area where clusters of illness occur.

At the same time, poor countries lack capacity for treating severe cases, and that also needs to be addressed, he said.

“I also worry that when this gets into lower capacity health facilities, they don’t have ventilators, they don’t have the capacity to keep people alive.”

Ultimately, said Aylward, health authorities need to ask tough questions now, such as:  “Are we ready to manage these people?”

“This is not flu, it is a more SARS-like pathology.  Are we ready to manage that.. to go after the transmission of this thing. Don’t accept the inevitability that you cannot control this virus.”

Research can help to provide longer-term solutions, he added, although there too, a massive response will be needed. “You want a Manhattan Project on your top vaccine candidates and top therapeutics,” he said, for a disease that currently has no effective drug remedies or cures.

“Rapid diagnostics are urgently needed as are seroimmunity studies to see if a much wider population may be silently exposed and developing some protection to the virus, as are household studies to better understand the mechanisms of transmisison. “In terms of research, use the time well,”he advised. “Research saves lives.”

Watch the entire press conference here:

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

 

Image Credits: Dipartimento Protezione Civile, China News Service, FarsNews/Sajad Toloui.