In her latest edition of the COVID-19 Wrap, public health researcher Alison Barrett reports on the mental health impacts of quarantine, research evaluating public health interventions, and the World Health Organization’s update of its 2019 Novel Coronavirus Preparedness and Response plan.
Lockdown is the world’s biggest psychological experiment – and we will pay the price
Van Hoof, E, World Economic Forum, 9 April 2020
Approximately one-third of the world’s population are currently in some form of quarantine or lockdown to manage the COVID-19 pandemic. Psychologist Dr Elke Van Hoof says “this is arguably the largest psychological experiment ever conducted”.
As found in a systematic review published in February 2020 in The Lancet, periods of time in quarantine can result in negative psychological outcomes, including insomnia, depression, anxiety, post-traumatic stress, and emotional exhaustion.
The scale of the COVID-19 lockdown is enormous and it is vital that governments and NGOs implement psychological interventions now to help mitigate the emotional toll that are likely to occur.
Van Hoof says that if not addressed, the quarantine and lockdowns in place now “will result in a secondary epidemic of burnouts and stress-related absenteeism in the latter half of 2020”. This has been seen in health care professionals responding to Ebola, SARS and MERS epidemics.
She says it is important to respond to both medical and psychological outcomes of trauma from a crisis, similar to the French Medical and Psychological emergency units developed to respond to the aftermath from terrorist attacks and disasters. At present, the world-wide response has been largely medical and limited measures are in place to support people with the psychological impacts.
In Belgium, an online tool, Everyone OK, has recently been launched to help people cope emotionally during the current pandemic. Applying Recent Traumatic Episode Protocol and Group Traumatic Episode Protocols, the tool aims to improve mental resilience and help individuals deal with acute stress during the COVID-19 crisis.
In conclusion, Dr Van Hoof says that, “when it comes to offering psychological support to their populations, most countries are late to react, as they were to the novel coronavirus”.
She suggests the following recommendations to help mitigate the psychological impact of COVID-19 lockdown:
- Implement self-help interventions that can address the needs of large populations
- Education about the expected psychological impact and reactions to trauma, ensuring people understand that having a psychological reaction is normal
- Develop websites to address psychosocial issues
- Ensure people with acute issues can find help they need.
Association of public health interventions with the epidemiology of the COVID-19 outbreak in Wuhan, China
Pan, An et al., JAMA, 10 April 2020
In the absence of vaccination against or medical treatments for COVID-19, non-pharmaceutical interventions (NPIs), such as handwashing and social distancing, are the best ways to manage the pandemic and help limit infections.
Researchers evaluated the implementation of NPIs in Wuhan, China over five time periods during the COVID-19 outbreak and found that these measures were associated with a reduction in confirmed cases and transmission rates.
During the first two periods evaluated in the study, 8 December 2019 to 10 January 2020 and 10 January to 22 January, there were no specific interventions in place in Wuhan, with large travel movements occurring for Chinese New Year.
These time periods saw an increase in daily confirmed cases, from two cases per million people in the first period to 45.9 cases per million people in the second. Hospitals started to become overcrowded with patients experiencing fever or respiratory symptoms.
The daily confirmed cases grew to 162.6 cases per million people in the third period, 23 January to 1 February 2020.
Public health measures were implemented in Wuhan in the third period, including banning of outbound travel and traffic within the city, stopping public transport and cancelling mass gatherings. Also during this period, many confirmed or assumed cases of COVID-19 quarantined at home.
During the fourth period, 2-16 February, confirmed cases decreased to 77.9 cases per million people. During this period medical resources were improved with centralising quarantine in designated facilities and implementation of stay-at-home policies for all residents of Wuhan.
In the fifth period, from 17 February to 8 March 2020, thousands of community workers screened individuals at their homes through a government-initiated door-to-door program.
The daily confirmed cases decreased to 17.2 cases per million people during the fifth period.
As per the daily confirmed cases, the researchers found an initial growth in the rate of transmission increasing to 3.82 by 24 January and then subsequently decreasing. On 1 March 2020, the rate of transmission was below 0.3.
These findings indicate that public health measures (travel restrictions, stay-at-home policies) implemented in Wuhan, China were associated with improved control of the COVID-19 outbreak.
They are supported by findings in a recent study published in The Lancet measuring the impact of NPI measures in Hong Kong between 17 January and 31 March 2020. This study also found an association between public health measures and reduced rate of transmission of COVID-19 cases.
While these findings indicate an association between public health interventions and reduced rates of COVID-19 transmissions, it is important to highlight some limitations in these studies.
Information wasn’t available for all variables (such as incubation period, time to hospitalisation and discharge). Also, due to multiple interventions being implemented at the same time, it is difficult to evaluate individual strategies and determine the effect of one intervention over another.
In summary, while taking into consideration the study limitations, the findings may help to inform the implementation of public health measures to manage the COVID-19 pandemic in other countries.
2019 Novel Coronavirus (2019-nCoV): Strategic preparedness and response plan: Strategy update 14 April 2020
World Health Organization, 14 April 2020
On 14 April, the World Health Organization (WHO) published an update to their 2019 Novel Coronavirus Preparedness and Response plan.
During the COVID-19 outbreak, health systems have been overburdened, and numerous social and economic disruptions have occurred in an effort to manage the spread of the novel coronavirus.
WHO Director-General Dr Tedros Adhanom Ghebreyesus says: “One of the main things we’ve learned is that the faster all cases are found, tested and isolated, the harder we make it for this virus to spread. This principle will save lives and mitigate the economic impact of the pandemic.”
The preparedness and response plan was developed to provide guidance for public health measures to be implemented in response to the COVID-19 pandemic.
Current situation and key insights
COVID-19 is a novel coronavirus in the same family as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). There are currently no treatments or vaccinations against the virus.
People infected with SARS-CoV-2 experience symptoms ranging from mild to severe, and people with pre-existing medical conditions have an increased risk of severe symptoms.
Countries and regions that have implemented public health measures early in the outbreak have managed to keep the number of cases below their health system’s capacities, and therefore prevented high mortality rates.
One of the main public health measures implemented is population-level physical distancing to limit contact between people to decrease the spread of COVID-19.
These measures have a greater impact on vulnerable groups, including people experiencing poverty, homelessness and refugees, as these people often have limited access to basic resources and live in conditions more susceptible to spreading disease.
Some countries are at, or close to, the next phase of the pandemic, where a well-planned strategy is required to transition away from strict physical distancing measures and enable the return of some economic and social activities.
“The world stands at a pivotal juncture in the course of this pandemic,” the authors state, and extensive public health measures need to be implemented quickly.
Global strategy to respond to COVID-19
The global strategic goals are to:
Mobilise everyone to participate in the response by preventing cases through hygiene, handwashing and physical distancing at an individual-level.
Control cases and community transmission by testing, isolating, contact tracing and quarantining all infected individuals.
Suppress community transmission through physical distancing measures at a population-level, and applying appropriate bans on non-essential travel.
Reduce mortality by ensuring those affected by COVID-19 are provided relevant health care and that health workers are protected.
Develop safe and effective vaccines and therapeutics to be delivered wide-spread and accessible to all who need.
WHO says collaborative approaches involving everyone from individuals to private companies are the best way to slow the spread of COVID-19; however, it is important that each country ensures approaches are appropriate and feasible for them.
National strategies to respond to COVID-19
WHO recommends that each country implement a National Action plan to firstly, slow down infections and reduce mortality; and secondly, maintain low levels of transmission when social and economic activities return.
Each national strategy should aim to meet the global strategic goals outlined above, and implement plans to:
Coordinate and prepare the whole of society to respond to the COVID-19 strategy by engaging multiple sectors (health, education, finance, water and sanitation) in public health emergency measures. National COVID-19 plans should include identification of vulnerable populations and methods to reach them, ensuring the strategies are equitable.
Engage and mobilise communities to limit exposure to COVID-19. Slowing down COVID-19 infections relies on everyone, in particular those most vulnerable, undertaking individual hygiene and handwashing measures. For this to work, it is vital that authorities communicate in a proactive and appropriate manner.
Find, test, isolate and care for cases and quarantine contacts to control transmission of COVID-19. To do this, countries need to increase their surveillance capacity, including enabling individuals to self-report if symptomatic and get tested. If confirmed, individuals should be quarantined to prevent further transmission in the community. As part of this strategy, contact tracing must occur to identify, test and isolate additional confirmed cases.
Provide clinical care and maintain essential health services to reduce mortality. As COVID-19 places a great burden on health systems, it is important that hospitals have the appropriate medical equipment in place in order to provide sufficient care to patients. This includes ventilators and personal protective equipment (PPE). It may be necessary to have strategies in place to repurpose the health sector to respond in situations where the health systems become overwhelmed; and also ensure that those that need medical treatment for non-COVID-19 related services can access it.
Adapt strategies based on risk, capacity and vulnerability of each country; the public health measures implemented will be dependent on community transmission and level of clustered and sporadic cases and the capacity of the public health system to respond.
Suppress community transmission by implementing population-level physical distancing measures if community outbreaks occur. As these measures have such a huge impact on social and economic functions, they must be communicated appropriately to the public.
Transition to and maintain a steady state of low-level or no transmission. In the absence of a vaccine against COVID-19, countries should aim to transition to a manageable state of low-level or no transmission.
To do this, WHO advises the following six criteria need to be met:
- COVID-19 transmission is controlled to a level of sporadic or cluster of cases from known contacts, and incidence of new cases maintained at a level the health system can manage.
- Sufficient health system and public health capabilities are in place to identify and isolate all cases of COVID-19.
- Outbreak risks in high-vulnerability settings are minimised.
- Workplace preventive measures are established, including physical distancing, handwashing, and respiratory etiquette.
- Risk of imported cases managed by analysing origin of cases, and quarantining measures.
- Communities are fully engaged and understand the transition requires individuals to maintain physical distancing and hygiene measures.
The decision to transition must be based on evidence, accurate data and implemented in a phased approach to minimise the risk of a resurgent in cases.
Epidemiological risks and socioeconomic benefits must be assessed before lifting restrictions on workplaces, educational institutions and social activities. A minimum of two weeks between each phase is preferred, to allow enough time to understand any risks of new outbreaks.
Consider the needs for measures to be tailored specifically to low-capacity and humanitarian settings. This may include adapting living conditions, if feasible, to enable more distance between people; having good surveillance systems in place; and strong communication about infection prevention.
International community’s response to COVID-19
Coordination and monitoring of country preparedness and response
The large scale of the COVID-19 pandemic “requires the international community to reach out beyond its own capacity” in response.
This includes engaging the private sector, humanitarian systems, member state groups (i.e. European Union, G7 and G20), World Bank Group and International Monetary Fund with WHO in the response to the crisis.
Epidemiological analysis and risk assessment
It is vital for global surveillance data about COVID-19 and risk assessments to continue at local, national and global levels. Open source epidemic data platforms are being created to enable the sharing of public health data globally; this will help develop a better understanding of epidemiologic features of the current outbreak and predict future outbreaks.
Risk communication and community engagement
Due to the overwhelming amount of information being communicated about COVID-19, it is a challenge for people to find reliable sources of information when they need it, thus hindering public health responses.
To manage misinformation, WHO has partnered with various sectors (travel, sports, education) to provide reliable information on their Information Network for Epidemics.
Coordinated global supply chain management
The COVID-19 pandemic has resulted in a shortage of essential health and medical supplies, including PPE, medications and diagnostic tools. In response to this shortage, the United Nations (UN) has established a Supply Chain Task Force with an emergency supply chain system to enable provision of essential supplies to countries.
Technical expertise and health emergency workforce
To ensure emergency health workforce are kept up-to-date on latest evidence to prepare for and respond to COVID-19, WHO have published a set of technical guidance that is updated regularly as new evidence becomes available. They also provide online training on OpenWHO.org.
Accelerating research, innovation, and knowledge sharing
Global collaboration will be required to ensure vaccines and therapeutics to fight COVID-19 are effective and accessible to everyone. WHO are coordinating the Solidarity Trial which, as of 21 April, had over 100 countries collaborating to find effective treatments.
Strengthening pandemic preparedness for the future
WHO’s preparedness and response plan strategy update ends by stating “with the world facing an unprecedented threat, there is an opportunity to emerge with stronger health systems, and improved global collaboration to face the next threat.”
However, we must learn from the COVID-19 pandemic and ensure that the world’s response leaves a positive legacy.
A useful resource
New South Wales Health Critical Intelligence Unit shares daily summaries of new evidence, a useful resource which can be found here.
Croakey thanks and acknowledges Alison Barrett for providing this column as a probono service to our readers.
Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public health, rural health and health inequities. Follow on Twitter: @AlisonSBarrett
See previous editions
- Sleep, wastewater, drugs and tests
- Providing shelter, understanding transmission, messaging matters, learning from China, and a show not to miss
- Smoking, kids, communities and cruise ships
- Ranking global health, impact of quarantine, rural and remote health concerns, outbreak investigations, and reasons for humility