Croakey is closed for summer holidays and will resume publishing in the week of 18 January 2021. In the meantime, we are re-publishing some of our top articles from 2020.
This article was first published on March 11, 2020
A quick tour around the world shows countries are in various stages of preparing for and experiencing the COVID-19 pandemic, with the health impacts to arise from massive economic and social disruption, stress on health systems and healthcare workers, as well as the direct effects of the infection itself.
Meanwhile, today’s announcement by the Australian Government of a package of measures, including funding for telehealth, aged care and a national communications campaign, has been broadly welcomed, following widespread concerns about mixed messages and inadequate communications, reports Melissa Sweet.
To date, 119,476 confirmed cases of COVID-19 have been reported globally, with 4,291 deaths, and 65,900 people recovered, according to real-time online mapping of the outbreak by John Hopkins University Center for Systems Science and Engineering, as of AEDT on 11 March, 2020.
On 11 March, the World Health Organization declared a pandemic, the first caused by a coronavirus.
Melissa Sweet writes:
In England, a Health Minister, Nadine Dorries, is in isolation after contracting the novel coronavirus and, according to the BBC, other health ministers and government officials who have been in contact with her are now also being tested.
Spain has closed one of its houses of Parliament after a member was diagnosed with the virus, while in the United States, several members of Congress have put themselves into quarantine, and questions are being raised about whether Congress should take a break.
Meanwhile, the world’s eyes are on Italy, where more than 60 million people are subject to an unprecedented, nationwide lock-down to slow Europe’s worst outbreak of COVID-10. The Atlantic (which is making its coronavirus coverage freely available) describes this as “the most stringent restrictions on freedom of movement imposed in Europe since the Second World War”.
Escalating demand on Italy’s intensive care resources has led to rationing; Associated Press reports that the Italian Society of Anesthesiology and Intensive Care published 15 ethical recommendations to consider when deciding on ICU admissions during the crisis, with criteria including age of the patient and their probability of survival, and not just “first come first served.”
In Iran, where another health minister also contracted the virus, thousands of prisoners have been released temporarily to combat its spread in jails, according to Reuters.
In Ireland, the Government has cancelled St Patrick’s Day parades, and is scaling up health services to deal “with a population impact over the coming months which could produce service demand beyond anything previously experienced”. Measures include freeing up as much space as possible in hospitals, and ensuring maximum capacity in intensive care and high-dependency units.
Ireland has also announced income support measures, including an increase to the personal rate of Illness Benefit from €203 per week to €305 per week for a maximum period of two weeks of medically certified self-isolation, or for the duration of a person’s medically-certified absence from work due to COVID-19 diagnoses. Self-employed people will be entitled to receive either illness benefit or non-means tested supplementary welfare allowance. Iceland is reportedly also paying people for being in quarantine.
Israel is requiring all citizens who return from abroad to self-quarantine for 14 days as a precaution against the spread of coronavirus, and will admit foreigners only if they can prove they have the means to self-quarantine.
Conference cancellations
In Australia and other places, health and medical conferences and other events are being cancelled. International climate negotiations are also affected – the United Nations Framework Convention on Climate Change (UNFCC) has announced its secretariat will not hold any physical meetings in Bonn or elsewhere between 6 March and the end of April.
Canada has developed a risk assessment tool to guide planning of large gatherings during the COVID-19 outbreak, and the World Health Organization (WHO) also has related resources for event organisers and workplaces.
Unprecedented times
As the University of Sydney’s Faculty of Medicine and Health said in an email to staff yesterday, advising of a ban on work-related international travel, “these are unprecedented times”.
Anxiety levels are high, especially for those who are in or who have loved ones in aged care and other vulnerable situations.
Many healthcare workers have also been sharing their frustration and anxiety in grappling with uncertainty, concerns about their personal safety, and inadequate communications and systems.
Misinformation is also a critical concern; in the United States, President Trump has been a thorn in public communication efforts, while in the UK, the Government has set up a unit to counter coronavirus-related disinformation, including from Russia and China, The Guardian reports.
As well, the NHS is working with Google, Twitter, Instagram and Facebook to counter coronavirus fake news, and on 10 March unveiled a package of measures to help the public avoid myths and misinformation.
The WHO is also liaising with Facebook, as the Director-General, Dr Tedros Adhanom Ghebreyesus, reported yesterday.
Meanwhile, University of Canada researchers investigating censorship of COVID-19 information on Chinese social media platforms YY and WeChat reported that the blocking of messages may have restricted “vital communication related to disease information and prevention”. It is suggested that one consequence of the outbreak will be to further entrench mass surveillance of Chinese people.
Australian responses
The Australian Government today announced a $2.4 billion COVID-19 package, with measures including:
- $100 million for a new Medicare telehealth service for people in home isolation or quarantine due to the coronavirus, to receive health consultations via the phone or video such as FaceTime or Skype. These services will be bulk-billed at no cost to patients, available from 13 March, and provided by doctors, nurses and mental health allied health workers. It will also be available for non-coronavirus consultations for people aged over 70, people with chronic diseases, Aboriginal and Torres Strait Islander people aged over 50, people who are immunocompromised, pregnant people and new parents with babies as these people are at greater risk from the virus and treatment home will minimise their exposure risk.
- $25 million for home medicines services to enable PBS prescriptions to be filled online or remotely, and medicines delivered to their home. This service will be available for people in home isolation and for vulnerable patient groups. All pharmacies with e-prescribing will be eligible to participate in the home medicines services and patients will continue to retain choice in their preferred community pharmacy.
- $5 million to fast track the rollout of electronic prescribing.
- $50.7 million to expand the national triage phone line, so this free-call hotline operates 24/7 to advise people on the best course of action depending on their symptoms and risks. Medical staff will direct people to the nearest hospital or respiratory clinic, or advise them to stay home and self-monitor, or contact their GP. People who are not severely ill with COVID-19 will be directed to GPs or a network of well-resourced GP-led respiratory clinics.
- $206.7 million for up to 100 dedicated respiratory clinics. The Primary Health Networks (PHNs) will co-ordinate with the AMA, RACGP and states and territories to identify areas of need. The clinics will be a one-stop-shop for people who are concerned they may have the virus, to be tested and isolated from other patients.
- $58.7 million to support people living and working in remote locations, in particular Aboriginal and Torres Strait Islander communities, including tools to proactively screen visitors and fly-in, fly-out workers, additional support to evacuate early cases if required, and mobile respiratory clinics to quickly respond to outbreaks where there is no hospital or available health service. wil
- $170.2 million for dedicated Medicare funded and bulk billed pathology tests for the virus and flu. Pathology testing will be funded in aged care facilities.
- $101.2 million to educate and train aged care workers in infection control, and enable aged care providers to hire extra nurses and aged care workers for both residential and home care. Additional aged care staff will be available for deployment to facilities as needed, where an urgent health response is required and to provide extra support for staff and training. Extra funding for the Aged Care Quality and Safety Commission to work with providers on improving infection control.
- The Government is providing half of all additional costs incurred by states and territories in diagnosing and treating patients with COVID-19, or suspected of having the disease, and efforts to minimise the spread of the disease, covering activities both within and outside hospitals. The funding will be uncapped and demand driven.
- $30 million from the Medical Research Future Fund will be allocated for vaccine, anti-viral and respiratory medicine research.
- $1.1 billion funding so patients and critical health care staff have face masks, and other protective equipment such as surgical gowns, goggles and hand sanitiser for health professionals. Antibiotics and antivirals will be bought for the National Medical Stockpile, so that patients who experience secondary infection as a result of COVID-19 can be treated quickly.
- $30 million for a new national communications campaign – across all media – to provide practical advice on how people can play their part in containing the virus and staying healthy. The campaign will keep the health and aged care industry informed, including providing up to date clinical guidance, triaging and caring for patients, development of an app and advice to workers in looking after their own safety. The information will be based on the most up to date medical advice and will be targeted at the entire community as well as high risk groups and in up to 20 languages.
The Chief Medical Officer Professor Brendan Murphy has also promised to improve communications to primary care, through twice-weekly newsletters to all GPs and regular webinars. His first missive, on 9 March, acknowledged there had been “some confusion and a perception of inconsistency of information/information gaps”.
He warned of the “very real possibility” of larger scale community outbreaks occurring across Australia, placing a significant burden on the health system, and also acknowledged that some GPs had been concerned about the availability of personal protective equipment (PPE), especially surgical masks.
He said:
A further 260,000 masks from the national medical stockpile were announced this weekend on top of the 750,000 already distributed to PHNs and we will work closely with PHNs to ensure appropriate supply arrangements.
We appreciate that it can be frustrating if only small numbers of masks are distributed at any one time. Masks are in very short supply worldwide and we need to conserve them at this time until our emergency procurement plan delivers a significantly enhanced stockpile in coming weeks. We recognise the need to supply GPs who are assessing potential COVID-19 patients and are focusing our efforts there.”
Murphy also acknowledged that more work is needed in the residential aged care sector and for Aboriginal and Torres Strait Islander peoples and other at-risk groups.
NACCHO has reported on a range of developments, including the appointment of an Aboriginal and Torres Strait Islander advisory group on COVID-19.
A communique from the group’s second meeting, on 10 March, discussed the importance of involving all community service organisations, such as Local Councils, Land Councils, schools and not just health services, in the development of local COVID-19 preparedness and response management plans in remote communities.
Responses
Consumer and medical groups have broadly welcomed the Government’s package, with the Consumers Health Forum of Australia describing it as “an impressive and wide-ranging response that prepares Australians and health services well to counter the threat of a pandemic”.
Shadow Health Minister Chris Bowen said gaps needed addressing, including:
- limited eligibility for patients to access COVID-19 telehealth services. Labor believes that given the intent of the package is to not only treat, but to contain the virus, such services should be more widely available.
- delay of pop up clinics to be operational when the health system is under strain. The Government has indicated these clinics may take up to six weeks to be operational, and there are already hundreds of patients waiting for hours to be tested at existing facilities.
- delay and continued confusion on resourcing health professionals with personal protective equipment including masks
- confusion around circumstances in which health professionals should be tested for the disease, noting the Australian Health Protection Principal Committee (AHPPC) is still considering this issue
- lack of clarity around support for innovative pathology models, such as visits to homes and aged care facilities.
Others have also raised concerns about the wait for COVID-19 clinics.
On telehealth, check this Twitter thread by Professor Trisha Greenhalgh from the University of Oxford, covering research, clinical, technical, strategic and operational issues for healthcare providers on video consultations as a partial solution to the COVID-19 pandemic (compiled here).
Urgent communications
The Australian Medical Association stressed the importance of getting “clear and comprehensive public health messages and information to the general public and frontline health workers as a matter of urgency”.
President Dr Tony Bartone said:
There is a lot of information flowing from the Federal and State and Territory Governments, and from Chief Medical Officers and Chief Health Officers and Health Departments, but the AMA is hearing that the messaging has been inconsistent, and sometimes conflicting.
Local GPs in suburbs and towns are telling us that the flow of quality information is sometimes poor, and the supply of protective equipment is inadequate in places.
We need to see clear and instructional education and information material, in many languages, at every airport, railway station, bus stop and station, doctor’s surgery, shopping centre, office blocks, schools, post offices, everywhere where people gather.
Posters, signs, and ads must be splashed across print, radio, television, cinemas, digital channels, and social media very soon.
COVID-19 is a national emergency, and we must all respond accordingly. Education about how to avoid contracting this deadly virus is crucial to stop its spread.”
This is also important for “flattening the curve” – slowing the spread of infections so that health systems are not overwhelmed by an unmanageable peak in demand.
See this article recommended by Professor Trish Greenhalgh calling for urgent action to flatten the curve. “Countries that are prepared will see a fatality rate of 0.5-0.9%. Countries that are overwhelmed will have a fatality rate of 3-5%”. 
The image above is from a paper by public health experts from the University of Newscastle, the University of Sydney and Australian National University, that has made a splash internationally, with the self-explanatory title of “Pre-emptive low cost social distancing and enhanced hygiene implemented before local COVID-19 transmission could decrease the number and severity of cases”.
The authors say:
Early interventions to reduce the average frequency and intensity of exposure to the virus might reduce infection risk, reduce the average viral infectious dose of those exposed,and result in less severe cases who are less infectious. A pre-emptive phase would also assist government, workplaces, schools, and businesses to prepare for a more stringent phase.
Countries, and subregions of countries without recognised COVID-19 transmission should assume it is present and consider implementation of low cost enhanced hygiene and social distancing measures.”
Their recommendations follow below. 
Wider national action
Prime Minister Scott Morrison is due to release a multi-billion dollar stimulus package tomorrow, and the ABC reports that it is expected to include a one-off payment for welfare recipients, including pensioners and those on Newstart. Some states are also planning packages.
In a speech in Sydney on 10 March, Morrison said a whole-of-government response was underway, now that Australia had entered the phase of community transmission.
For the first time, the Emergency Response Plan for Communicable Diseases Incidents of National Significance had been activated, and the Australian Health Sector Emergency Response Plan had been fast tracked to prepare for a more rapid spreading of COVID-19 within Australia.
The Government had also stood up the National Coordination Mechanism within the Department of Home Affairs to support pandemic preparedness beyond the health system. This body would coordinate activities across the Commonwealth, state and territory governments, beyond the health response, as well as industry to ensure a consistent national approach to provide essential services across critical sectors and supply chains.
This week, the Attorney General and Minister for Industrial Relations, Christian Porter, held a joint industry-trade union roundtable focusing on workforce and industrial relations implications, and the Minister for Industry, Science and Technology, Karen Andrews, held an industry roundtable on emerging supply chain impacts. The Council of Australian Governments (COAG) will meet on Friday, 13 March.
The Prime Minister said:
Whatever you thought 2020 was going to be about. Think again.
We now have one goal, together, this year – to protect the health, the wellbeing and livelihoods of Australians through this global crisis, and to ensure that when the recovery comes, and it will, we are well positioned to bounce back strongly on the other side.
All Australians have a role to play, in Australia successfully moving through this crisis.
The range of possible economic outcomes will depend on the spread, severity and duration of this health crisis and its interaction with demand-side and supply-side effects. Now that means, to fix our problem, our health response must be the primary response.”
Global perspectives
With more than 119,000 reported cases of COVID-19 in 100 countries, Dr Tedros told a 9 March media briefing that the threat of a pandemic had become “very real”. Many experts in the field have already been using this term.
He noted that more than 70 percent of the 80,000 reported cases in China had recovered and been discharged.
WHO is now providing guidance for countries in four categories: those with no cases; those with sporadic cases; those with clusters; and those with community transmission.
On 11 March, Dr Tedros announced a pandemic had been declared. He said:
Pandemic is not a word to use lightly or carelessly. It is a word that, if misused, can cause unreasonable fear, or unjustified acceptance that the fight is over, leading to unnecessary suffering and death.
Describing the situation as a pandemic does not change WHO’s assessment of the threat posed by this virus.
It doesn’t change what WHO is doing, and it doesn’t change what countries should do.”
He urged all countries to activate and scale up emergency response mechanisms:
Communicate with your people about the risks and how they can protect themselves – this is everybody’s business;
Find, isolate, test and treat every case and trace every contact;
Ready your hospitals;
Protect and train your health workers.
And let’s all look out for each other, because we need each other.”
Lessons and questions
Writing in The Lancet (9 March), Professor Sir Roy Anderson from Imperial College, London, and colleagues said they believed COVID-19 was now a pandemic, with small chains of transmission in many countries and large chains resulting in extensive spread in a few countries, such as Italy, Iran, South Korea, and Japan.
China had shown that quarantine, social distancing, and isolation of infected populations can contain the epidemic but it was unclear whether other countries can implement such stringent measures.
However, Singapore and Hong Kong provide hope and many lessons to other countries. In both places, COVID-19 had been managed well to date, despite early cases, by early government action and through social distancing measures taken by individuals.
The researchers say key unknowns include:
- the case fatality rate
- whether infectiousness starts before onset of symptoms
- whether there are a large number of asymptomatic cases of COVID-19. Estimates suggest that about 80 percent of people with COVID-19 have mild or asymptomatic disease, 14 percent have severe disease, and 6 percent are critically ill
- the duration of the infectious period for COVID-19
- the effect of seasons on transmission of COVID-19 is unknown.
Mitigation measures included voluntary plus mandated quarantine, stopping mass gatherings, closure of educational institutes or places of work where infection has been identified, and isolation of households, towns, or cities.
School closure, a major pillar of the response to pandemic influenza A, was unlikely to be effective given the apparent low rate of infection among children, they said. Concerns about the social and economic impacts of pre-emptive school closures have also been highlighted by the University of Sydney’s Professor Julie Leask.
Anderson and colleagues say individual behaviour will be crucial to control the spread of COVID-19:
Personal, rather than government action, in western democracies might be the most important issue.
Early self-isolation, seeking medical advice remotely unless symptoms are severe, and social distancing are key. Government actions to ban mass gatherings are important, as are good diagnostic facilities and remotely accessed health advice, together with specialised treatment for people with severe disease.
How individuals respond to advice on how best to prevent transmission will be as important as government actions, if not more important.
Government communication strategies to keep the public informed of how best to avoid infection are vital, as is extra support to manage the economic downturn.”
Also writing in The Lancet, researchers from Singapore investigate lessons from Hong Kong, Singapore, and Japan, and highlight the importance of “timely, accurate, and transparent risk communication”, because it determines whether the public will trust authorities more than rumours and misinformation.
Singapore health authorities provide daily information on mainstream media, the Ministry of Health has Telegram and WhatsApp groups set up with doctors in the public and private sectors where more detailed clinical and logistics information is shared, and authorities use websites to debunk circulating misinformation. Risk communications to establish trust in authorities has been less successful in Japan and Hong Kong.
“The ongoing social unrest in Hong Kong has led to a breakdown of public trust with the government and affected front-line health-care staff and the reception and acceptance of government information,” the researchers report.
They conclude that “the trust of patients, health-care professionals, and society as a whole in government is of paramount importance for meeting health crises”.
Researchers have also called for a gender-lens to be applied to COVID-19 responses, warning that women have disproportionately borne the burden of previous outbreaks because their needs and experiences were not factored into policy making.
“Despite the WHO Executive Board recognising the need to include women in decision making for outbreak preparedness and response, there is inadequate women’s representation in national and global COVID-19 policy spaces, such as in the White House Coronavirus Task Force,” they say.
Further reading
The psychological impact of quarantine and how to reduce it (a rapid review of the evidence in The Lancet).
On a knife’s edge of a COVID-19 pandemic: is containment still possible? Amongst other things, Professor Raina MacIntyre highlights the need for attention to the challenges posed by cruise ships:
Unless we develop clear cross-national management plans for treatment, isolation, quarantine and evacuation of global citizens, cruise ships may be the weak link that results in sustained community transmission in other countries.
Advice to Australians to avoid cruises in the Asia-Western Pacific region at this time may be prudent.”
The argument for social distancing measures, a view from the US. By Dr Tom Inglesby.
On the difference between quarantine, isolation and social distancing.
Watch this interview with infectious diseases researcher and paediatrician Dr Asha Bowen and Professor Allen Cheng from Monash University.
Resources from Prevent Epidemics.
A final thread from public health communications scholar Professor Jennifer Manganello thanking everyone working hard to minimise the toll of COVID-19. The discussion has a United States focus, but you get the picture.
