In an occasional series, public health researcher Alison Barrett reports on key public health and scientific publications and developments in the COVID-19 pandemic.
COVID-19 gives the lie to global health expertise
The Lancet, 26 March
“Global health will never be the same after COVID-19 – it cannot be,” states author, Sarah Dalglish, as she discusses different countries’ responses to the COVID-19 pandemic.
The Global Health Security Index compiled in 2019 shows ratings of 195 countries’ ability to respond to outbreaks of infectious diseases; USA and UK were at the top of the list (first and second respectively), indicating they were the countries ‘most prepared’ for an infectious disease outbreak.
By comparison, South Korea was ranked ninth, China 51st and Australia fourth.
As the global pandemic unfolds, it has become evident that the USA and UK “have provided among the world’s worst responses to the pandemic,” conducting limited testing and contact tracing; and with limited access for health workers to appropriate personal protective equipment; nor enough hospital beds for patients.
This is in contrast to countries, such as China (ranked 51st) and South Korea (ranked 9th), which have delivered quick and effective responses, largely due to their experience dealing with the Middle East respiratory syndrome and severe acute respiratory syndrome outbreaks.
Most African countries were ranked as ‘least prepared’ to respond to an infectious outbreak.
While it is too soon to tell how the pandemic will affect them, African countries, such as Uganda, Rwanda, Senegal and Nigeria, have implemented measures “worth imitating,” the author advises. These include proactive screening, handwashing stations at transport centres, WhatsApp chatbots delivering reliable communication, and celebrity campaigns and call centres to encourage sensible behaviour during the pandemic.
In summary, the author provides an interesting discussion on the notion that the current global health model has been largely based on the expertise, capabilities and technical assistance of rich countries, such as the USA and UK, whose response so far to the pandemic has been slow.
To move forward, it is vital conversations must occur to have a “more democratic, more multipolar, more networked, and more distributed understanding and operation of global health,” says Dalglish.
Meanwhile, the Somali Government is reported to have sent has sent 20 doctors to Italy, volunteers from the Somali National University, following an appeal from the Italian government for international help to contain the virus.
The psychological impact of quarantine and how to reduce it
The Lancet, 26 February
This rapid review of published studies explores the psychological impact of quarantine and if there are any contributing factors that may predict who is most likely to experience worse outcomes from a period in quarantine.
The key finding from the review of 24 studies is that quarantine can result in a considerable psychological impact and that the impact can be ongoing.
This is important for health officials to consider when determining appropriate measures to fight an infectious disease outbreak, such as COVID-19.
The studies included in the review explored the psychological impact of quarantine during SARS, Ebola, H1N1 influenza, Middle East respiratory syndrome and equine influenza outbreaks. They used a variety of measures to determine outcome, including interviews, focus groups, surveys and diagnostic scales such as the Generalised Anxiety Disorder 7-item (GAD-7) scale.
The reviewed studies found a range of psychological impacts from periods in quarantine, including post-traumatic stress, anxiety, alcohol abuse, avoidance behaviours, low mood, insomnia and exhaustion. A qualitative study found that “for some, the return to normality was delayed by many months”.
Evidence was mixed about what factors predicted adverse psychological impact of periods in quarantine.
While one study indicated that being a health care worker wasn’t linked to poor psychological outcomes, another found that those that had been quarantined, had higher levels of post-traumatic stress than people from the general public who had also been quarantined.
Stressors during and after quarantine included the length of quarantine, boredom and frustration, worry over infection in themselves or infecting others, challenges accessing basic supplies, insufficient provision of information and guidelines, financial burden and stigma.
Whilst quarantine may be an essential measure to prevent or slow the spread of infectious diseases, the poor psychological impacts identified by this review highlight a need for appropriate strategies to be implemented to alleviate the adverse effects.
Strategies suggested by the authors include limiting the length of quarantine periods as much as possible, providing extra support to health care workers and those who have pre-existing mental health issues, and improving public health communications.
The authors identify some limitations to their review: due to the limited time available to conduct the review, a critical appraisal was not performed and grey literature not searched. Except for one study, long-term outcomes were not measured.
In conclusion, while quarantine is likely to result in negative psychological outcomes for some people, the authors point out that the result of not quarantining people, in order to manage infectious diseases and letting the disease spread, might result in worse psychological outcomes.
Why we need better rural and remote health, now more than ever
Rural and Remote Health Journal, 24 March
Professor Paul Worley, National Rural Health Commissioner, discusses the COVID-19 pandemic in the context of rural and remote populations in Australia where access to critical health services, such as testing clinics, is limited.
In preparing rural health systems to meet the demands of COVID-19, Worley writes that a global community response is required to fight the COVID-19 pandemic, at “social, economic and health system levels”.
He suggests we learn from First Nations peoples and follow a “holistic approach that is grounded in an appreciation of the places in which we live and where we share both our history and future.”
Rural health systems would be better prepared if they adopted the principles of integration and generalism, he says.
The four levels of integration he suggests are:
- Across primary, secondary care and other social service sectors – it is more effective to service smaller rural communities with generalist GP models rather than “siloed specialist” models that are used in urban settings
- Across professions – teams of generalists with broad skills can rapidly change their practice patterns without the need to hire new clinicians
- Across towns and villages within regions – collaboration of services within rural regions is particularly critical when one health service is closed down for a period of time due to a natural or other disaster
- Across care, teaching and research – training of the next generation.
Integrating a generalist approach to rural health will result in resilient, responsive and responsible practitioners, and reassurance for patients that they can access care closer to home, Worley says.
Social, economic and health systems can be improved by sharing data, developing strong telehealth systems and understanding that preventative health is an asset to a society’s economic security.
Community mitigation strategies in a pandemic
BMJ, 17 March
With health systems overloaded and no vaccines or medication available, countries and communities need to implement systematic measures to alleviate the spread of COVID-19.
The key point from this editorial is that community interventions, such as measures already in place in Australia, like social distancing and travel restrictions, will be relied upon to ensure the health system is able to help all those in need during this pandemic.
Clear and transparent communication from health officials is vital, to ensure that misinformation, fake news and confusion are minimised and the public respond to intervention measures appropriately. This is a view supported by Victoria’s Chief Health Officer Professor Brett Sutton, who has provided honest and timely communication to the Australian public throughout the pandemic to date.
As places of work can contribute to the spread of respiratory infections, the authors recommend some workplace strategies to enable social distancing measures, such as enabling video conferencing and expanded leave policies for staff, and scheduling shifts to reduce the number of people in one location.
While acknowledging there is limited evidence about the spread of the novel coronavirus among children, the authors suggest there may be a risk of infection to adults who are in school environments and to children who may have pre-existing health conditions, and recommend the closure of schools as another social distancing strategy.
However, they advise that schools should not be closed unless remote learning is implemented and school meals are available for children in need.
Other community mitigation strategies the authors discuss are cancellation of events and large gatherings, strategies that have been gradually implemented in Australia over the previous two weeks, including cancellation of many events and the recent restriction for no more than two people allowed to gather together (with exceptions).
In summary, if the number of times and length of contact with other people is reduced by implementation of community mitigation strategies, this will decrease the transmission of the novel coronavirus; and thus, help medical staff respond more effectively to those patients who are infected.
A long-term care facility in King County, Washington
The New England Journal of Medicine, 27 March
As previously mentioned, older adults are at a higher risk of severe or fatal outcomes from COVID-19 than younger adults.
This article, a case study of a COVID-19 outbreak in King County, Washington, USA, provides additional evidence of this, and also highlights how rapidly outbreaks can occur in long-term care facilities (aged care/assisted living facilities).
In February-March 2020, the US Centers for Disease Control and Prevention (CDC) and Public Health department in Seattle and King County (PHSKC) investigated a cluster of COVID-19 cases that occurred in King County, finding that by 18th March 2020, 167 confirmed cases of COVID-19 had been linked to a long-term care facility.
Among residents of the facility, 101 positive results were confirmed out of 118 tests, while 50 healthcare personnel and 16 visitors linked to the same facility were also found positive.
The residents, with a median age of 83 years, had higher hospitalisation and fatality rates than staff and visitors; most of the residents had pre-existing health conditions. The authors also found that three other facilities in the county had confirmed cases linked to the first facility.
Surveys and on-site visits in the long-term care facilities found a few reasons for the number of linked cases; including staff that worked in multiple facilities, working while symptomatic, not being familiar with PPE, having limited access to PPE and testing, challenge in identifying potential cases and transferal of residents between facilities.
The authors identified some limitations in their investigation: testing and case identification increased after the outbreak was recognised in the first site, but it is unclear if infections had occurred in other facilities in the area prior to that; there was not a complete record of visitors to the first site, which may have resulted in some infections among visitors being missed; and not all residents and staff were tested and interviewed, so there may be an under-representation of infected people.
In summary, the investigation into this outbreak provides valuable insight into the impact of COVID-19 among residents and staff of long-term care facilities (or similar aged care/assisted living facilities in Australia), highlighting the importance of identifying infected people and implementing effective infection control measures.
The authors concluded:
The experience described here indicates that outbreaks of Covid-19 in long-term care facilities can have a considerable impact on vulnerable older adults and local health care systems. The findings also suggest that once Covid-19 has been introduced into a long-term care facility, it has the potential to spread rapidly and widely.
This can cause serious adverse outcomes among facility residents and staff, which underscores the importance of proactive steps to identify and exclude potentially infected staff and visitors, early recognition of potentially infected patients, and implementation of appropriate infection prevention and control measures.”
World Health Organization perspectives
Director-General statement, 27 March
Tedros Adhanom Ghebreyesus summarised key outcomes from a meeting of world health ministers, where China, Japan, Republic of Korea and Singapore shared their experiences and lessons learned from the pandemic in their country.
Some of the common practices that have worked for these countries include:
- Early detection and isolation of confirmed cases is important
- Contacts of confirmed cases need to be identified, followed up and also isolated
- Care needs to be optimised
- Communities need to be engaged in the fight.
The most urgent common challenge faced by many countries was the shortage of personal protective equipment (PPE) that is required to save lives.
Dr Tedros stressed the importance of not using medication or therapies that haven’t yet been deemed effective in treating COVID-19: “We must follow the evidence. There are no short-cuts.”
WHO’s ongoing response to the crisis includes the publication of guidance documents online, training health workers on OpenWHO, the COVID-19 Solidarity Fund, and WHO’s WhatsApp HealthAlert, which has 12 million users worldwide.
On 26 March, he told the leaders of G20 countries to use every resource possible to fight COVID-119, that countries should unite together during the pandemic, and that industry and innovation of G20 countries are important asset in producing and distributing required equipment.
Director-General statement, 30 March
Dr Tedros urged countries to ensure that essential health services continue, as previous outbreaks had shown that when health systems are overwhelmed, deaths due to vaccine-preventable and treatable conditions increase dramatically.
To help countries manage the surge in COVID-19 cases while maintaining essential services, WHO has also published a detailed, practical manual on how to set up and manage treatment centres for COVID-19, covering three major interventions:
- First, how to set up screening and triage at health facilities, using a repurposed building or a tent.
- Second, how to set up community facilities to care for mild patients;
- Third, how to set up a treatment centre, by repurposing hospital wards or entire hospitals, or by setting up a new hospital in a tent.
The manual also covers structural design, infection prevention and control measures, and ventilation systems.
In implementing measures that restrict the movement of people, he said countries must respect the dignity and welfare of all people.
It’s also important that governments keep their people informed about the intended duration of measures, and to provide support for older people, refugees, and other vulnerable groups.
Governments need to ensure the welfare of people who have lost their income and are in desperate need of food, sanitation and other essential services.
Countries should work hand-in-hand with communities to build trust and support resilience and mental health.
Dr Tedros explained that he sent the tweet above because:
COVID-19 is reminding us how vulnerable we are, how connected we are and how dependent we are on each other.
In the eye of a storm like COVID, scientific and public health tools are essential, but so are humility and kindness.
With solidarity, humility and assuming the best of each other, we can – and will – overcome this together.”
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 her previous compilation: COVID-19 wrap: smoking, kids, communities and cruise ships
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