Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1090 (Published 18 March 2020) Cite this as: BMJ 2020;368:m1090Read our latest coverage of the coronavirus outbreak
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor
The second wave of the COVID-19 pandemic has had a devastating effect on India. The rapid and exponential growth of COVID-19 cases in India has overwhelmed the existing healthcare infrastructure and resources. There is an acute deficiency of hospital beds, essential drugs, oxygen supply, and ventilators for COVID-19 care [1]. Along with the rising caseload and crises of essential drugs, there is an unprecedented rise in the number of counterfeit medicines that have entered the market [2,3], touting claims of efficacy against COVID-19 Similar instances have been reported from other parts of the world during this COVID-19 pandemic [4].
From paracetamol to remdesivir, several useful drugs have been reportedly counterfeited and sold at a higher price. The offenders have been using several modes, including WhatsApp groups, to sell fake drugs by feeding on the panic and frenzy of the public who are desperately looking for solutions amidst the crisis and scarcity of supplies. If left unchecked, this could pose a serious risk to public health and have adverse economic effects. The government should play an active role through policymaking and monitoring to address potential threats in the counterfeit drug market. The media must create better awareness about the dangers of illicit drugs among the public.
Physicians should come forward to prevent the menace while communicating with the patients and the caregivers. All COVID-care medicines should be dispensed only by licensed pharmacists under any circumstances.
Further, the adoption of technology (e.g., TruScan) should be encouraged to minimize risks of counterfeiting and promote quality assurance.[5] Use of Quick Response (QR) code to identify counterfeit medicine should be encouraged at the consumer level. Political will and involvement of multiple stakeholders (e.g., Pharmaceutical industries, police, wholesalers, distributors, pharmacist, and patients) is needed [6]. Formulation of integrated networks involving stakeholders at the district, state, regional, national, and international levels to ensure monitoring and implementation of deterrent legislation could be an option.
References
1. Pandey V, Nazmi S. Covid-19 in India: Why second coronavirus wave is devastating. BBC News. 2021; published online April 21. https://www.bbc.com/news/world-asia-india-56811315 (accessed May 4, 2021).
2. Singh G. Counterfeit drugs: Threat to India’s reputation on Indian Self-Reliant Model. Health World. 2021; published online March 5. https://health.economictimes.indiatimes.com/news/pharma/counterfeit-drug... (accessed May 4, 2021).
3. The Hindu. Fake Remdesivir: One more medical representative held. The Hindu. 2021; published online April 27. https://www.thehindu.com/news/national/karnataka/fake-remdesivir-one-mor... (accessed May 4, 2021).
4 . Gnegel G, Hauk C, Neci R, et al. Identification of Falsified Chloroquine Tablets in Africa at the Time of the COVID-19 Pandemic. Am J Trop Med Hyg 2020; 103: 73–6.
5. Hall C. Technology for combating counterfeit medicine. Pathog Glob Health. 2012 May;106(2):73-6. doi: 10.1179/204777312X13419245939485. PMID: 22943539; PMCID: PMC4001489.
6. Shrivastava SR, Shrivastava PS, Ramasamy J. Public health measures to fight counterfeit medicine market. Int J Prev Med. 2014 Mar;5(3):370-1. PMID: 24829724; PMCID: PMC4018649.
Competing interests: No competing interests
Dear Editor
The response to the COVID-19 pandemic in complex humanitarian crises, such as Somalia, is a global health challenge, with poor governance, public distrust, and political violence undermining interventions in these settings.
On 9th of May 2020, Somalia registered 997 cases and 48 deaths, with a case fatality rate of 5%. However, according to the country’s COVID-19 task force, there is huge under-reporting of both the mortality and disease prevalence. According to The Guardian, funeral agencies in Mogadishu are now reporting 18 burials in a day compared to 2 in usual daily reported figures (1). Somalia has theoretically adopted a lock-down strategy, which does not seem promising as people in general ignored government’s instructions. Every country is required to conduct regular operational reviews to assess implementation success and epidemiological situation, and adjust operational plans accordingly (2). However, Somalia does not have research competencies necessary to assess the implementation success as well as what has worked and what has not.
The country has five federal member states (FMS), the capital (Mogadishu),and self-declared Somaliland with each having its own Ministry of Health that operates independently. Only Puntland, Somaliland, and Mogadishu (the capital) have slightly better healthcare systems, with the capacity to provide limited health services to its population. The ministries of health of the other four states are barely functional. As a result, the healthcare services in the country is overwhelmingly provided by private system and Non-governmental organizations such as WHO, UNICEF, UNFPA and others (3). The response to the pandemic is haphazardly fragmented. The Puntland, Somaliland and Mogadishu have implemented activities involving testing self-reported cases with suspected COVID-19 symptoms, providing care to the severely sick, and updating the public about the COVID-19 cases and fatalities. Further, the federal government (FG) and FMS alike have introduced measures such as; stay home, self-quarantine and social distancing, but people are not complying with instructions. Consequently, prayers in mosques, meeting in public spaces and all other prohibited social gatherings remain unchanged. Even though there is a curfew in place in Mogadishu from 8pm to 6am, people are congregating in Mosques for Ramadan night-prayers until midnight with authorities having no capacity to enforce the guidelines. For the same reasons, contact tracing of affected persons and subsequently quarantining them for 14 days became an impossible task, making the spread of the disease irrepressible and difficult to trace. It is worth noting that people over 60 years constitute only 3% of Somalia’s population (4), which provides an opportunity for an alternative strategy that is potentially more feasible than lockdown.
The unique vulnerability of Somali people to Covid-19 pandemic
Somali-speaking people inhabit the Horn of African countries -- namely, Somalia, the northeastern region of Kenya, the Eastern region of Ethiopia, and the Republic of Djibouti. Consequently, Somali people, whether they are in the Horn of Africa or in the Western world, are comparatively found to be more prone to COVID-19. Somalia and Djibouti have seen a rapid spike in coronavirus incidences, with the two nations having the highest reported cases of COVID-19 in East Africa. Similarly, Eastliegh state of Nairobi, where Somali people prevail, has been reported to be the hotspot of COVID-19 transmission in Nairobi.
In Scandinavian countries with substantial Somali immigrants, Somalia-born individuals overrepresented both the people infected and those being hospitalized for COVID-19. Out of 15 persons who died of COVID-19 in Stockholm, six were of Somali origin (5). In Finland, nearly 200 Covid-19 cases of Somali-born immigrants have been identified in Helsinki, which translates to an incidence of 1.8%, while the average incidence is 0.2% for all the residents in Helsinki (6). Further, of 829 covid-19 cases with immigrant background in Norway, 201 (24.3%) were Somalia-born individuals (7), though Somalis constitute only 3.4% of immigrants in Norway. Moreover, Somalis are overrepresented in people who have been hospitalized for COVID-19 in Norway. While the average age of hospitalization was 64 years in the country, was 51 years of age among Somalia–born individuals (7). Understanding the factors contributing to Somali community’s vulnerability to the pandemic is important not only for the immigrants-hosting countries but also for the Horn of Africa.
The literature documents two major reasons (8, 9).
First, Somali people barely understand the importance of disease prevention: they seek health care only when they experience symptoms that prompt them to seek care such as persistent cough and fever, severe headache, vomiting, etc. This attitude stems from the fact that Somalia has never had a functioning preventive health service; hence, people have no reference to the notion of disease prevention and hardly comply with preventive-instructions given by health authorities.
The second reason mentioned in the literature is the prevalent religious fatalism ideology among Somalis, which refers to the belief that disease prevention is beyond human control. Religious fatalism is generally correlated with lower perceived quality of healthcare (10). Since Somalis have had no access to preventive health services, they have developed the perception that if they become infected by Coronavirus, it will happen anyway, ignoring the Islamic religious duties of first applying the preventative measures.
Conclusions
Coordinated strategy between the FG and FMS has paramount importance in the efforts to contain the pandemic, while fragmented activities in different areas may complicate the situation. There is strong mistrust between the FG and the FMS. However, International Organizations such as WHO and other health partners are highly trusted by all parties. As travel of international staff is highly limited, the WHO and other international partners may help mobilize local researchers and provide them with the necessary training required to perform high quality epidemiological assessment of the pandemic, and subsequent adjustment of the response strategy in the country. As >60 age-group constitute only 3% in the country, an alternative strategy could be a community-led approaches to self-isolate older people, while the business community, the FG, FMS and Somali-diaspora may contribute the food, medicine, and other support required by the elderly. Nevertheless, the safety and feasibility of this strategy in Somalia should be tested prior to its application.
References
1. The Guardian. Somali medics report rapid rise in deaths as Covid-19 fears grow. 2nd May, 2020.
2. WHO. COVID-19 Strategic Preparedness and Response Plan. fEB. 2020. https://www.who.int/docs/default-source/coronaviruse/covid-19-sprp-unct-....
3. Gele AA, Ahmed MY, Kour P, Moallim SA, Salad AM, Kumar B. Beneficiaries of conflict: a qualitative study of people's trust in the private health care system in Mogadishu, Somalia. Risk management and healthcare policy. 2017;10:127-35.
4. Federal Government of Somalia/UNFPA Somalia. Somalia Demographic Health Survey. 2020. https://somalia.unfpa.org/en/publications/somali-health-and-demographic-....
5. Susanne Bejerot, Mats Humble. Inhabitants of Swedish-Somali origin are at great risk for covid-19. BMJ 2020;368:m1101. Available; https://www.bmj.com/content/368/bmj.m1101/rr-10.
6. Foriegner. Helsinki warns of increased Covid-19 cases among Somali community. 2020. Available; https://www.foreigner.fi/articulo/coronavirus/increase-in-covid-19-cases....
7. The Norwegian Institute of Public Health. COVID-19 Dagsrapport søndag 5. april 2020. Available here; https://www.fhi.no/contentassets/ca5914bd0aa14e15a17f8a7d48fa306a/vedleg....
8. Gele A. What works where in prevention of Covid-19: The case of Somalia. WHO Eastern Mediterranean Health Journal (EMHJ), Vol. 26 No. 5 – 2020.
9. Gele A, Abdiqani A Farah. Somalia: Response to Covid-19 in complex humanitarian setting. 2020. https://wardheernews.com/somalia-response-to-covid-19-in-complex-humanit....
10. Nageeb S, Vu M, Malik S, Quinn MT, Cursio J, Padela AI. Adapting a religious health fatalism measure for use in Muslim populations. PloS one. 2018;13(11):e0206898.
Competing interests: No competing interests
Dear Editor
Chaos, complexity and complex systems science should be able to help doctors and healthcare systems tackle the challenges of coronavirus worldwide described by Hopkins et al (1). The worldwide differences described emerged from their unique past, and will change, reflecting many influences, including how they respond to these complex challenges.
Complex systems reflect the science of chaos and complexity, with complex dynamic interactions of many interconnected and interdependent parts with feedback, adaptation and change, leading to sudden transitions, unpredictability, uncertainty, apparent randomness and novel outcomes with new features (2,3).
Viruses are complex adaptive systems (4), producing predictable and unpredictable effects from interaction and adaptation to different environments, creating a variety of challenges and outcomes as seen in this pandemic, requiring different responses at different phases (5).
We can learn from this worldwide experience, using chaos, complexity and complex systems thinking, with complexity considered the science for the 21st century by Stephen Hawking, and the science for a complex world by the Santa Fe Institute, and increasingly used to help manage the chaos caused by this virus.
These systems and challenges worldwide reflect complex dynamic political, policy, social, cultural, biological and other nonlinear interactions producing a variety of predictable and unpredictable outcomes, as in the differences described. They manifest at the bedside with rapidly changing novel situations, like unusual respiratory infections, highly unusual multi-organ thrombosis, novel ECG abnormalities, etc, as well as system challenges of bed, ventilator and PPE shortages, which all change outcomes, as well reported.
Complex systems call for different leadership, management and decision approaches at different stages, illustrated in a Cynefin model (5), with simple or obvious - straightforward responses, complicated – need technical expertise, complex – sense, try, feedback adaptation and change, and chaos - immediate decisive action plus feedback adapt and change to move from chaos to complex, used singly or in combination.
In the early phase of this pandemic, many countries in the East responded with definitive early and sustained preventive and other actions considered successful, many in the West with a mismatch - delay and unpreparedness, leading to costly failures. Continuing to track differences as reported, and learning from them are valuable.
A chaos, complexity and complex systems approach may help us to better understand and envisage worldwide differences, and help to tackle the ensuing multitude of challenges at the different stages of this pandemic, with a 21st century science based approach, likely producing better outcomes and saving lives.
1 Hopkins J, Hayasaki E, Zastrow M, et al. Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide.
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1090 (Published 18 March 2020) accessed April 20, 2020.
2 VS, Rambihar SP, Rambihar VS Jr. Tsunami Chaos and Global Heart: using complexity science to rethink and make a better world. 2005. Vashna Publications. Toronto, Canada. http://femmefractal.com/FinalwebTsunamiBK12207.pdf (accessed April 20, 2020).
3 Rambihar VS. Chaos, complexity and systems thinking to contain and manage COVID-19. CMAJ 6 April 2020. Available at https://www.cmaj.ca/content/chaos-complexity-and-systems-thinking-contai... (Accessed April 20, 2020).
4 Solé R, Elena SF. Viruses as Complex Adaptive Systems. 2019. Princeton University Press, Princeton, USA.
5 Snowden D, Boone M. A Leader’s Framework for Decision Making. Harvard Business Review Nov 2007. https://hbr.org/2007/11/a-leaders-framework-for-decision-making Accessed April 20, 2020.
Competing interests: No competing interests
Dear Editor
I hate to point this out and whilst every effort should clearly continue to produce a safe and effective vaccine as soon as possible the estimated 'best' timescale of 18-24 months may well mean that by that time most people will have had the disease or isolation measures have worked, making it largely defunct. Perhaps more effort and research might be directed at strategies in addition to those already recommended e.g. quitting smoking, reducing air pollution etc. that may have some scientific foundation as candidates to reduce disease severity. The following might be included:
CANDIDATES FOR IMPROVED RESISTANCE TO COVID-19
Vitamin D
https://www.ncbi.nlm.nih.gov/pubmed/19063829 : either as a supplement e.g. fish oil capsules or tablets or natural sunlight on the skin
Catching a rhinovirus cold
https://www.sciencedirect.com/science/article/abs/pii/S0306987711004749 : co-infection of more than one virus may reduce the severity of viral disease due to a phenomenon known as 'viral interference'
Quinine or hydroxychloroquine
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(03)00806-5/fulltext : perhaps even the small amounts of quinine in tonic water may have immunomodulatory effects
'Love'
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5223438/ : more specifically the so-called 'love hormone' oxytocin
Measures to encourage positive mental health
https://neurosciencenews.com/immune-system-mental-health-14737/ : mediated by the body's neuroendocrine system
Non-specific effects of non-COVID-19 vaccines
https://adc.bmj.com/content/102/11/1077 : studies have shown that vaccines may have impact beyond the direct protection against the infection for which they were designed
Competing interests: No competing interests
Hopkins and colleagues give a rapid review of the response of several health care systems across the world to the COVID-19 pandemic (1). The responses illustrate the differences between health systems, including the weak spots in some countries (2). We, as General Practitioners (GPs) from the frontline, present our observations about the coordination at primary care level – or lack of it in the early health system response and the bottom-up reaction from the frontline health workers in two neighboring countries, Belgium and the Netherlands.
The Netherlands has a central public health authority (RIVM) with decentralized municipal public health services (GGD). RIVM developed the national protocol for screening and case finding and public health measures, the GGD were appointed to implement the screening and case finding, for patients that did not need acute medical care. Although there is regional variation in the extent to which this happened, the GGD service was meant to support the General Practitioners (GPs) in the containment of COVID-19 spread through testing and direct expert advice. Belgium also has a central public health authority (Sciensano) that similarly developed national protocols, but it does not have decentralized preventive health services to support at operational level. Implementation of the protocol at the initial stage left to the health care workers, who had to include case detection, reporting and patient care in their routine services. In the absence of regional leadership, many GPs continued their primary task, taking care for their patients. While people with symptoms started to come, this posed operational challenges and pressure.
In both countries, out of hours services and the surrounding GP groups were at the center of local coordination to developing a first response to the increase of ill patients and diagnosis of COVID-suspect cases in the initial first two weeks on the epidemiologic curve. Many bottom-up approaches were organized with separate respiratory triage posts to diverse potential viral and COVID-19 cases from other patients. The rapid preparedness by many local GP groups for this public health emergency prevented chaos in the first two weeks of the pandemic.
In the subsequent stage of the pandemic, both governments are scaling up. National emergency plans for health care response are taking shape for organization of first line screening diagnosis, care and referral and coordination with hospitals and other services. The locus of coordination and the guidance towards health care providers is different in each country. We observe a majority of centralized approaches in the Netherlands with many regional 24/7 triage centers as an adjunct to hospitals, and regional coordination by the Regional Medical Service Organization (GHOR), a public committee responsible for coordination in crisis situation. In Belgium first line triage posts are getting better organized and scientifically and logistically supported. The medical professional organizations in Flanders, Wallonia and Brussels have taken up an active role to support organization of their members. GP groups (huisartsenkringen) remain leading in the organization of the local response. Increasingly, GP practices and health centers reorganize and take measures such as telephone triage, telemedicine and staggered consultations by appointment, to still guarantee the essential and urgent primary care and avoid collateral damage by the epidemic, such as diagnostic delay of other conditions. In the absence of a clearly delineated regional coordination committee, this leads to a more scattered pattern of triage posts, and variation in response, for instance in how triage posts are staffed.
Driver for the differences relate to the set-up of the health care system and the institutional context. The complex and decentralized organization of the Belgium health system with 9 ministers of health slows down central coordination of response, despite a strong unified response in the other policy measures such as the lock-down. The financing system of health care providers also influences the flexibility of health care workers to reorganize patient flow and take up new emergency duties. The gatekeeping role of the first line and the largely capitation-based funding of primary care in the Netherlands enabled regional organization, in collaboration with existing decentralized public health services.
The presence of strong professional GPs in both countries, and in many others, is the backbone of health system response, also in public health emergencies. Central governments and professional organizations need support this backbone by having process and structures in place for efficient coordination and implementation, from central to regional and local level.
This response was written by members of the Department of Primary Care of the University of Antwerp (UA): Josefien van Olmen (UA) and Roy Remmen (UA) are GPs practising in the border area of Belgium and Netherlands; Paul Van Royen, Hilde Philips and Veronique Verhoeven are GPs in Belgium; Sibyl Anthierens (UA) is a sociologist.
1. Hopkins Tanne J, Hayasaki E, Zastrow M, Pulla P, Smith P, Garcia Rada A, et al. Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide As coronavirus continues to spread, doctors and healthcare systems are facing a multitude of challenges at all stages of the pandemic. 2020 [cited 2020 Mar 24]; Available from: www.coronavirus.
2. Tamara Popic. European health systems and COVID-19: Some early lessons [Internet]. LSE politics and policy blog. 2020 [cited 2020 Mar 24]. Available from: https://www.printfriendly.com/p/g/8Vf4G7
Competing interests: No competing interests
Dear Editor
“Dúirt bean liom go ndúirt bean léi – a woman told me that a woman told her”
(old Irish proverb)
The Covid-19 pandemic is unprecedented in our lifetime. The general public has been overwhelmed with information related to the novel coronavirus. In 2020, information sources have expanded from conventional newsrooms and broadsheets to digital applications and social media. Some newer information outlets are not subject to rigorous fact-checking, facilitating propagation of ‘fake news’. The rapidly advancing knowledge base surrounding Covid-19 has compounded the problem.
In Ireland the medical community has noted a trend of messages containing incorrect information about Covid-19 spreading rapidly via social media and messaging applications. Misinformation is defined as false information that is communicated without deliberate malice, while disinformation is false information that is communicated with the intent to deceive. [1] The motivation behind creating these messages is unclear, but may relate to attention-seeking behaviour and conspiracist ideation. [2,3]
The false messages that we have seen tend to contain three common features.
• There is a claim that the source has inside information eg ‘a young researcher from Wuhan’, ‘a Taiwanese expert’, or ‘Dr Tim in Cork’. However no further reference is provided to support the alleged source.
• The nature is vague eg ‘doctors have said’ without providing definite details eg names, positions, or affiliations. The tone has been alarmist, suggesting that if the suggested action is ignored, serious consequences will occur eg ‘please do this before it’s too late’.
• The emotive effect is intended to trigger panic in the reader, and induce fear. This increases the likelihood that the message will be shared with family and close friends.
These false messages have predominantly compromised of text. However some images have been shared, with text describing information that is factually discordant with the image. For example, an image of the Irish Defence Forces assembling a Covid-19 testing centre in Dublin was shared with the message ‘army setting up camp on the quays… complete lockdown’. Voice notes have also been shared with false information, with local accents to increase credibility. One such voice message claimed that the Irish military would be used to patrol the streets imminently, enforcing a ‘status red lockdown’.
Misinformation has centred around four key themes: food and beverages as ‘cures’, hygiene practices, medicines, and government responses.
One message from ‘Japanese doctors’ suggested drinking hot water every 15 minutes as the heat would ‘kill the virus and pass the virus into the stomach’. Garlic, vitamin C, and zinc lozenges have been claimed as cures for Covid-19 due to antimicrobial activity, despite there being no evidence that they have protected people from the new coronavirus.
A message on Whatsapp stated that a hospital in Galway was ‘saying that the virus was mainly being spread via petrol pumps’. While the novel coronavirus can survive on surfaces for several hours or even days, the main route of transmission is person-to-person. Another message allegedly from South Korea advised using the non-dominant hands for tasks as ‘it is very difficult to touch your face with your non-dominant hand’. A more dangerous video suggested directing a hairdryer at maximum temperature upwards through the nasal airways to kill the virus.
Another Whatsapp message spread falsely stating that ‘four healthy young people were in serious condition with coronavirus’ in Cork following ingestion of ibuprofen. While a retrospective cohort study from Wuhan published in the Lancet showed that corticosteroid use was associated with increased mortality, [4] there is no evidence that non-steroidal anti-inflammatory drugs are problematic. As Covid-19 is almost universally a febrile illness, this would have serious implications for management for pyrexia. A post shared widely on Facebook suggested that being able to hold one’s breath for ten seconds meant that one could not have coronavirus.
Other messages falsely claimed that ‘the government was advising stockpiling food and supplies’, and that the government had ‘shut down off licences’ on St Patrick’s Day (when no alcohol is typically sold before 16.00).
We have seen implications of these fake messages in clinical practice in Cork. Patients have been unwilling to take ibuprofen, leaving non-Covid-19 illnesses untreated. Other patients with serious time-sensitive non-Covid-19 illnesses (such as stroke) have had delayed presentations, becoming critically unwell, due to concerns about contracting Covid-19 in hospital. [5] Furthermore, the false information in the messages has detracted from the evidence-based precautions that the health service is promoting, such as social distancing, and hand hygiene.
The World Health Organisation has confronted fake news by offering a WhatsApp service (+41798931892) for updates. There is evidence that healthcare professionals can stop the spread of false information by refuting or rebutting misleading health information on social media and by providing appropriate sources to accompany their refutation. [6,7] We exhort our international colleagues to support each other in combating fake information as part of the fight against Covid-19.
References
1 Journalism, 'Fake News' and Disinformation: A Handbook for Journalism Education and Training. UNESCO (2018). ISBN: 978-92-3-100281-6
2 Wang, Y.et al (2019). Systematic literature review on the spread of health-related misinformation on social media. Social Science & Medicine, 112552. doi:10.1016/j.socscimed.2019.112552
3 Weigmann, K. The genesis of a conspiracy theory: Why do people believe in scientific conspiracy theories and how do they spread?. EMBO reports vol. 19,4 (2018): e45935. doi:10.15252/embr.201845935
4 Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020 Mar 11. pii: S0140-6736(20)30566-3. doi: 10.1016/S0140-6736(20)30566-3. [Epub ahead of print]
5 https://twitter.com/ronancollins7/status/1239507193940058113
6 Chou, WY et al. (2018). Addressing Health-Related Misinformation on Social Media. JAMA. doi:10.1001/jama.2018.16865
7 Bode, L et al. (2017). See Something, Say Something: Correction of Global Health Misinformation on Social Media. Health Communication, 33(9), 1131–1140. doi:10.1080/10410236.2017.1331312
Competing interests: No competing interests
Dear Editor
As highlighted by the interview of Dr Giridhar Babu of Public Health Foundation in India in the article by Tanne and colleagues, the Indian response has, till recently, been perfunctory, dilatory and inadequate.[1]
To err is human, to dither in face of insurmountable evidence is folly. On 19th March 2020, the apex medical organization in-charge of managing COVID-19 in India, the Indian Council of Medical Research (ICMR), stated that there is no evidence of community transmission, based on 826 random samples tested, due to which mass public testing has not begun.[2] In a nation of 1.3 billion individuals, such conclusions from a small, non-representative sample fly in the face of numerous reports of people with suspected disease fleeing isolation nationwide.[3] These cases, moreover, had only begun to be documented when screening policies for all incoming travellers commenced on 4th March, prior to which incoming flyers from many currently affected countries had gone unscreened.[4] In addition, the Indian Railways, a critical transport system for people of low and middle socio-economic system, also found, on testing passengers of two trains, that COVID-19 positive cases had travelled by them prior to 19th March.[5] In light of the above facts, it is difficult to repose trust in the statement of ICMR, and thereby, the Indian response, wherein suppression of negative news seems to have been the mainstay till now. Additionally, the ICMR's approach of slow and selective testing has also publicly gone against the World Health Organization (WHO) recommendations, resembling prior handling of the severe acute respiratory syndrome (SARS) epidemic by Asian countries where public denial and administrative inaction resulted in an undue spread of the epidemic.[6,7]
Poor isolation, containment and handling facilities nationwide have resulted in a rapid on-ground spread of the infection, unfortunately still not being recognized officially, with treating physicians at my institution becoming infected.[8] Due to a nationwide lack of personal protective equipment (PPE), more such morbidity and mortality should be expected, as illustrated by the recent death of a frontline physician in Pakistan.[9,10]
While Italy, with the highest number of deaths, has faced significant challenges in resource allocation despite having a functioning healthcare system, the Indian system is already stretched thin with a ratio of one doctor per 11,600 individuals.[11] As stated well by one of the foremost epidemiologists of the country, India is likely to witness an upcoming explosion of COVID-19 cases.[12] Many of these may be anticipated to be fatal due to lack of ventilator beds; since ventilator bed occupancy has historically been over 90% in public hospitals even before the pandemic. This surge of cases, coupled with the pre-existing massive healthcare inequity, may result in the requirement of humanitarian aid. International aid agencies would do well to prepare to lend extensive support to developing countries, especially India.
References:
(1.) Tanne JH, Hayasaki E, Zastrow M, Pulla P, Smith P, Rada AG. Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide. BMJ. 2020:18;368:m1090. doi: 10.1136/bmj.m1090.
(2.) Tiwari S. As Government Denies Coronavirus Community Transmission, Experts Say Too Few Tested To Know. Bloomberg Quint [Internet] 2020 Mar 20 [cited 2020 Mar 23]; News:[about 4 screens]. Available from: https://www.bloombergquint.com/coronavirus-outbreak/as-government-denies...
(3.) Furquan Ameen. Why people are fleeing isolation units in India. The Telegraph [Internet] 2020 Mar 20 [cited 2020 Mar 23]; News:[about 5 screens]. Available from: https://www.telegraphindia.com/india/coronavirus-why-people-are-fleeing-...
(4.) Coronavirus: All international arrivals to India to share travel history at airports. The Economic Times [Internet] 2020 Mar 4 [cited 2020 Mar 23];News:[about 2 screens]. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/all-intern...
(5.) 12 passengers who travelled by two different trains test positive. ThePrint [Internet] 2020 Mar 21 [cited 2020 Mar 23];News:[about 2 screens]. Available from: https://theprint.in/india/12-passengers-who-travelled-by-two-different-t...
(6.) India's poor testing rate may have masked coronavirus cases. Al Jazeera [Internet] 2020 Mar 18 [cited 2020 Mar 23];News:[about 4 screens]. Available from: https://www.aljazeera.com/news/2020/03/india-poor-testing-rate-masked-co...
(7.) Jones DS. History in a Crisis - Lessons for Covid-19. N Engl J Med. 2020 Mar 12. doi: 10.1056/NEJMp2004361. [Epub ahead of print].
(8.) Lucknow doctor tests positive after coming in contact with 2 coronavirus patients.The Economic Times [Internet] 2020 Mar 18 [cited 2020 Mar 23];News:[about 2 screens]. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/lucknow-do...
(9.) Pakistan Doctor Dies Amid Strike Threat Over Lack of Protection. The New York Times. [Internet] 2020 Mar 22 [cited 2020 Mar 23];News:[about 4 screens]. Available from: https://www.nytimes.com/reuters/2020/03/22/world/asia/22reuters-health-c...
(10.) Aarefa Johari. Investigation: Crucial coronavirus gear supply clouded by allegations of government ‘malintention’. Scroll.in. [Internet] 2020 Mar 22 [cited 2020 Mar 23];Investigation:[about 8 screens]. Available from: https://scroll.in/article/956866/investigation-crucial-coronavirus-gear-...
(11.) Abantika Ghosh. One isolation bed per 84,000 people, 1 quarantine bed per 36,000: Govt data. The Indian Express. [Internet] 2020 Mar 22 [cited 2020 Mar 23];News:[about 3 screens]. Available from: https://indianexpress.com/article/coronavirus/one-isolation-bed-per-8400...
(12.) Arunabh Saikia. Interview: ‘Suppression won’t work in India. Slow down the coronavirus. This will be a long haul’. Scroll.in. [Internet] 2020 Mar 22 [cited 2020 Mar 23];Interview:[about 8 screens].https://scroll.in/article/956932/interview-suppression-wont-work-in-indi...
Competing interests: No competing interests
Dear Editor,
The Indian Government has launched extensive measures to tackle the transmission of COVID-19 among the people at large. Besides complete shutdown and invoking the Epidemic Diseases Act our Hon' ble Prime Minister has personally monitored and convened several meetings with stakeholders to respond to the occasion both in the public and private sector undertakings who are actively involved in the containment of the infection. Complete imposition of curfew under sec 144 of the Indian Penal Code has been issued in the majority of states, including Delhi, Uttar Pradesh, whereby except for people involved in essential services such as Health, Police, Administration, etc., there is restriction of aggregation of five or more persons at one place and penalization of those not following the order is in place.
However, several factors of concern are emerging. One such factor is hiding the travel history even after symptoms appear, which misleads the health care provider and exposes them to the susceptibility of infection. Further, affected individuals are careless in taking preventive and control measures and they do not restrict their travel, socialization, which further increases the chances of transmission of the infection. Such irresponsible behaviour should be condemned.
Another factor which is emerging is racial attacks. The incidence of expressing frustration and discrimination against individuals having a Mongoloid appearance are of concern since this only leads to a division and not a combined effort in putting the war against COVID-19 spread wholeheartedly by every citizen of India. Other instances of discrimination have been reported even among the crew members of Air India who had actively participated in the rescue process of Indians stuck abroad where there was infection galore. Some of them have been asked to leave their residence by neighbours or the colony where they reside. Such instances should be curbed immediately and each one of us should appreciate the efforts put by anyone who has contributed his/her bit in controlling the infection.
Contact tracing of affected persons remains a herculean task for the Indian Government. Despite keeping track, some of the affected individuals left the country or disobeyed isolation in the hospital and left the hospital uninformed, posing a risk to the society at large. Such irresponsible behaviour of the affected individuals needs to be curbed with strict implementation of orders on isolation and quarantine measures.
Health care providers - doctors, nurses, paramedics - are at risk of the infection due to the non availability of an adequate number of personal protective equipment. There is a shortage of masks and other personal protective measures. Government should provide these on an urgent basis. The susceptible public (close contacts, family members, friends) are at risk of exposure due to non availability of masks which despite Government orders, are not available in the chemist shops or cost an exorbitant price which prohibits a layperson to buy. Government should start surprise checks of the shops and penalize them for selling these items as on the black market.
The chances of community transmission of the infection have already been in place. Vulnerable populations are those staying in slums, congested urban areas where transmission of the infection is high due to their low socio-economic status, unavailability of materials for hand hygiene (especially water, soap, forget about hand sanitizers), illiteracy, overcrowding, poor cough hygiene practices, etc. These susceptible populations need close monitoring with facilitation of testing for those at risk, or with influenza-like illnesses, which can help in immediate institution of isolation measures.
Preparedness of the health infrastructure besides the prevailing health care facilities, including the provision of community halls, schools, public facilities, etc., for caring for patients in the event of a large scale outbreak should be in place. Existing health care staff might not be able to tackle the situation and need to prepare volunteers for such an eventuality.
Competing interests: No competing interests
Dear Editor
I am writing as a public health physician who is increasingly concerned about the apparent failure to implement fundamental public health measures to address the COVID-19 outbreak – specifically, community contact tracing, clinical observation, and testing – and about what seems to be one of the knock-on effects of this failure, namely the blanket closure of schools.
Tracing and clinical observation of contacts, isolation, and quarantine are the classic tools and approaches in public health to infectious diseases. According to the WHO [ https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mis... ], they have been painstakingly adopted in China in response to the COVID-19 outbreak, with a high percentage of identified close contacts completing medical observation; and they have been strongly recommended by the WHO for other countries.
In England, there are a lack of data – contact tracing appears to have been adopted only initially. According to modelling conducted by the authors of one of the papers published by the government last week, ‘The efficacy of contact tracing for the containment of the 2019 novel Coronavirus (COVID-19)’ (Keeling et al) [ https://doi.org/10.1101/2020.02.14.20023036 ] they expect that it would enable the outbreak to be contained:
“Aggregating across all individuals and under the optimistic assumption that all the contact tracing can be performed rapidly, we expect contact tracing to reduce the basic reproductive ratio from 3.11 to 0.21 – enabling the outbreak to be contained. Rapid and effective contact tracing can therefore be highly effective in the early control of COVID-19, but places substantial demands on the local public-health authorities.”
The basic reproductive ratio, R0, is a standard epidemiological construct [ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1578275/ ]for understanding the epidemic potential of an infection; the higher the ratio, the more difficult it will be to control its spread. Ideally, R0 should be 0. If R0 is less than 1, an infected person will on average transmit the infection to less than one other person, and so the epidemic potential is critically reduced. On the basis of this modelling, if contact tracing is not being rigorously conducted now, the possibility of critically reducing the epidemic would be missed. The Keeling paper, when taken together with the New England Complex Systems Initiative critique [ https://necsi.edu/review-of-ferguson-et-al-impact-of-non-pharmaceutical-... ] raises serious questions about the validity of Neil Ferguson’s model [ https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-... ], the apocalyptic numbers of which were used by the Westminster government to justify its approach.
I am truly concerned that contact tracing, clinical observation, appropriate testing, quarantine, and isolation have not been exhaustively carried out before taking the blanket decision to close all schools. I have sent the opposition spokespeople for health at Westminster some suggested parliamentary questions that my colleague Peter Roderick and I have drafted
[ https://www.allysonpollock.com/?page_id=2903 ].
It is important to note that many areas in Scotland, Wales, and parts of England have low numbers of cases and so at this stage, by taking an area approach to vigorous and meticulous contact tracing and clinical observation and testing, it should be possible to contain the disease – in Singapore, the BBC reports [ https://www.bbc.co.uk/news/world-asia-51866102 ] that the army has been called in to help with this. This would in time, with other measures, allow local areas on a school-by-school basis to safely consider reopening – and uphold each child’s right to education.
One of the major differences in this outbreak is that it is being centrally managed rather than centrally coordinated, with insufficient foot soldiers on the ground.
This pandemic is at different stages in the country. In England local authorities and directors of public health cannot tailor responses to the local situation and are subject to central policy decisions. My colleagues in public health in local authorities say they have received very little information. This, combined with the devastating cuts to community-based communicable disease control and the changes wrought by the Health & Social Care Act 2012, which carved out public health from health services in England and then further fragmented communicable disease control by removing it to Public Health England, have created a perfect storm.
I urge the Scottish and Welsh governments immediately to institute a massive centrally-coordinated, locally-based contact tracing and clinical observation and testing programme; and to discuss with local authorities, health boards, trade unions, public health and communicable disease control experts, and schools, colleges, and universities how this tried-and-tested classic approach would, with other measures, enable the blanket school closure decision to be modified in favour of a locally-based strategy.
Competing interests: No competing interests
Re: Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide
Dear Editor
Nepal is experiencing the second wave of COVID-19 since early April 2021 and as of 29 May the official figures are frightening with world’s second-highest bi-weekly growth in mortality at 291%, and the highest test positivity rate of 40% [1]. Nepal has one of the weakest and fragile health system of the world with poor human resources which makes Nepal one of the most vulnerable countries in this pandemic. The government has imposed various responses; however, these could have been done better.
1. Late lockdown
While during the first wave government had imposed nationwide lockdown even with few cases, this time government handed over the decision of lockdown to district administration office based on local cases. Lockdown in Kathmandu began since late April 2021 and now there is lockdown in almost all districts. This timing was late as India had already been facing second wave and Nepal having open border with India contributed in the surge of cases. Schools, colleges and public places were not closed till late April which also attributed to the fast spread.
2. Medical oxygen and Intensive Care Unit (ICU) crisis
The existing supply with oxygen cylinder crisis could not meet the sudden rise in demand of medical oxygen [2]. Most hospitals do not have oxygen plant and rely upon oxygen cylinders. The crisis was affected more by shortages of ICU. Although government had sufficient time in between the two waves to establish oxygen plants with alarming scenario in neighboring nation, the preparation was not done adequately. Nepal got some help from countries like India and China, but this was quite late when many lives were lost.
3. Political instability
During this time parliament house got dissolved due to failure of Prime Minister and opposition parties not being able to form the government. This was claimed to be unconstitutional and the hearing of this case is going on in Supreme Court. The government’s focus has shifted from managing pandemic to preventing its own fall. Instead of getting united, the clash escalated between political parties and government and impacted the response to COVID-19.
4. Testing, contact tracing and mask-wearing (TCTM)
TCTM measures have been inadequate [1]. Official COVID-19 figures are underestimates based on hospital deaths without testing daily caseload total. As actual toll help policymakers develop appropriate mitigation plans, real magnitude need to be determined by widening TCTM strategies.
5. Vaccination campaign
Nepal has vaccinated around 5% of its population [3]. Vaccination started on 27 January 2021 from India’s assistance. Later, while government bought some quantity from India, it received some doses from WHO and China’s assistance. Target groups for vaccinations were front-line workers, government employees, elderly and those with comorbidities. Though governmental and international efforts are commendable to start vaccination, it is not enough and the second wave could have been prevented if more people were vaccinated. This shows that Nepal needs to speed up vaccination to prevent further damage and prevent potential third wave.
6. Health budget
In 2019/20, Nepal allocated 4.9% budget in health, lesser than WHO recommendation [4]. This is one of the main reasons for poor infrastructure, insufficient manpower and inefficient healthcare system leading Nepal to more damage in this crisis. In 2020/21, Nepal increased health budget to 6% with ambitious plans including establishing 300-beded infectious disease hospital in Kathmandu, 50-beded hospitals in capital of all provinces and provide 250-ICU beds in state run hospitals [4]. However, poor implementation of these projects snatched the chance to save a lot of lives during second wave. Announced in 29 May 2021, health budget is focused in fighting pandemic with more ambitious projects. We hope for the effective implementation of these projects for better response to the pandemic.
7. COVID-19 crisis management ordinance
Government has brought ordinance in late May 2021 under which it can - declare health emergency, use private properties and people for COVID-19 management, punish those violating restriction protocols, and manage medicines and vaccines directly by negotiations through procurement rules.
8. Violence on frontline healthcare workers (HCWs)
Government declared special allowance to HCWs for their praise worthy efforts during first wave; however, it lacked in implementation which decreased their morale. Besides, they faced physical violence from relatives of deceased COVID-19 patients [5]. Additionally, absence of strict law against violence on HCWs decreases their confidence in fighting pandemic. To boost their morale, we strongly recommend government to bring strong law/ordinance to punish culprits inflicting such violence.
References
1. Dhital K. Nepal Covid19- impact worse than official figures. NEPALI Times. 2021; published online May 30. https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-offi... (accessed May 30, 2021).
2. Bhandari R, Petersen HE. ‘A hopeless situation’: oxygen shortage fuels Nepal’s COVID crisis. The Guardian. 2021; published online May 10. https://www.theguardian.com/world/2021/may/10/hopeless-situation-oxygen-... (accessed May 28, 2021).
3. Reuters. COVID-19 Tracker. Global. Asia and the Middle East. Nepal. 2021. https://graphics.reuters.com/world-coronavirus-tracker-and-maps/countrie... (accessed May 28, 2021).
4. Poudel A. Health sector gets 32 percent more budget compared to previous year. The Kathmandu Post. 2020; published online May 29. https://tkpo.st/3cjgBrW (accessed May 28, 2021).
5. Shahi I. Abuse and physical violence for frontline health care workers. The Record. 2021; published online May 28. https://www.recordnepal.com/abuse-and-physical-violence-for-frontline-he... (accessed May 29, 2021).
Competing interests: No competing interests