at Dadhaleh Institute

Research on Forecasting Peak Transmission and Health System Utilization

Short-term forecasts of COVID-19 deaths in multiple countries Imperial College London, 8 April 2020 https://sangeetabhatia03.github.io/covid19-short-term-forecasts/index.html This weekly [ ... ]

The ongoing global protests against police brutality in the United States and the structural racism that enables it, remind us that racism is detrimental, and deadly. As such, racism and structural manifestations are a major public health concern and compound with other issues like COVID-19 to magnify negative impacts on dignity, and on morbidity and mortality.

A recent study by the U.K. Government shows how the risk of death from COVID-19 for ethnic minorities is 10-50% higher risk. The WHO expressed support of the global movement and clarified that attending a mass gathering did not necessarily require more restrictive measures. Instead, WHO officials urged protesters to follow local guidelines in maintaining safe practices, including physical distancing, masks and hand washing.

Updates on COVID-19 clinical trials

The pace of research and development for treatments and vaccines for the novel Coronavirus has intensified, with dozens of clinical trials underway around the world. Several papers were published over the weekend with preliminary findings on the two largest studies that were both stopped for different reasons.

In the New England Journal of Medicine, researchers reported on a randomized double-blind study for remdesivir by the U.S. CDC that was stopped prematurely due to positive preliminary results. For patients hospitalised with COVID-19, the antiretroviral appears to reduce the recovery time (by four days) and mortality (from 12% to 7%), while presenting no additional adverse events. While this is promising, the results appear to be worse for visible minorities (a group that has been disproportionately impacted by the pandemic). Researchers have also been surprised that patients treated sooner after symptom onset may not have markedly better outcomes than those treated later in the course of disease.
A paper in the Lancet, meanwhile, presents on the WHO Global COVID-19 Solidarity Trail on chloroquine and hydroxychloroquine. Based on the advice of the WHO Executive Group – comprised of experts from ten countries involved in the trial – the observational study was stopped as preliminary findings suggest the possibility of higher mortality rates. The WHO Chief Scientist committed to a comprehensive analysis of all emerging clinical trial data globally to consider benefit and harm, acknowledging that unlike randomized controlled trials, observational studies have been known to yield misleading results. Expertshave also critiqued the failure of the study to adequately adjust for the fact that many of the patients in the trial are more likely to be severely ill and already at increased risk of death.

Ethics of controlled Coronavirus infection

An article in Science this week also expresses concern in the growing trend of researchers pursuing, and thousands of people expressing interest in participating in, controlled human infection (CHI) studies, i.e. deliberately exposing healthy people to COVID-19 to study infection and treatment efficacy. The authors present an ethical framework for CHIs that emphasizes “social value” as fundamental in justifying these studies. The proposed Ethical Framework for SARS-CoV-2 CHI considers six additional criteria, including: Reasonable Risk-Benefit Profile, Context-Specific Stakeholder Engagement, Suitable Site Selection, Fair Participant Selection, Robust Informed Consent, and Proportionate Payment.

Everyone in the (patent) pool

More than 100 former heads of government and leading scientists have urged all COVID-19 related research and intellectual property to be shared freely, and for the equitable distribution of vaccines. An editorial this week in Nature laments that the growing concern of “techno-protectionism” necessitates such a letter, while highlighting the remarkable speed of advancements as a result of global consortia of researchers (“Work that would normally have taken months, possibly years, is completed in weeks”). The Nature article focuses particularly on the patent pool model that is was popularized by the UNITAID Medicines Patent Pool that was successful in bringing antiretrovirals to market.

The World Health Assembly Resolution last week made explicit reference to IP rights flexibilities with respect to R&D, manufacturing and distribution of COVID-19 vaccines. Support was not unanimous, however, as some countries (notably the U.S. and the U.K) and research consortia (including the Coalition for Epidemic Preparedness Innovations) expressed their preference for conventional models where vaccine developers retain the IP rights that they may sub-license and their determined price. An article in the Harvard Business Review drew attention to the dangers of this form of ‘vaccine nationalism’, particularly as the underlying research thus far has been pooled and governments around the world have shouldered much of the risk in funding the vaccine effort.

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According to the latest report by UNDP, global human development is projected to decline for the first time since the UN defined and began measuring the concept in 1990. Unlike other crises over the past three decades, the “triple hit to health, education and income” as a result of COVID-19 has been reported globally. The UNDP warns that developing countries that are less able to cope with the pandemic’s social and economic fallout remain acutely vulnerable. The report urges countries to focus on equity in order to limit these impacts. Closing the digital divide by providing more equitable internet access, for example, is estimated to cost less than 1% of the fiscal support packages but could result in a two-thirds reduction of the impact of school closures that currently leave 60% of children globally without access to education.

WHO COVID-19 Strategic Preparedness and Response Plan

The WHO published a Strategy Update to the COVID‐19 Strategic Preparedness and Response Plan of the emerging epidemiological situation in order to support countries preparing for a phased transition from widespread transmission to a steady state of low‐level or no transmission. The Strategy Update emphasizes a whole-of-UN approach, and provides practical guidance for whole‐of‐society strategic action that can be adapted to local conditions and capacities. Countries have been asked to identify the lead coordinator of multiagency COVID-19 plans, map existing preparedness and response capacities and gaps, engage key technical and operational partners to identify appropriate coordination mechanisms and mobilize resources and capacities, and to establish monitoring mechanisms and operational reviews to track progress and adjust strategies.

An accompanying COVID‐19 Monitoring & Evaluation Framework was developed to support countries, listing key public health and health systems indicators for countries to monitor their preparedness and response to the pandemic. The M&E Framework is organized across three dimensions: Geographical Scope (global, all countries, priority countries); Planning and Monitoring Needs (informing strategic planning, operational tracking, evidence‐based decision‐making, as well as advocacy and transparency between donors, UN agencies, and partners); and across 9 Pillars (Country‐level coordination/planning/monitoring, Risk communication/community engagement, Surveillance/rapid response teams, Points of entry/travel/transport, National laboratories, Infection prevention & control, Case management, Operational support & logistics, Maintaining essential health services & systems).

World Economic Forum’s COVID-19 Risks Outlook

The World Economic Forum, which publishes the annual Global Risks Report, released two new reports that map the global risks, challenges and opportunities that COVID-19 presents. Adopting a complex systems approach, the reports highlight the interdependencies within and across borders but also health, economic, environmental, social, geopolitical systems. At the same time, the emphasis in both documents tilts towards the Great Transformation that will be needed. These include the need to reframe essential public services, notably health but also education, care and social safety nets. The factors that promote and inhibit solidarity and compassion are also raised, alongside needed behavioural shifts towards more sustainable consumption and mobility habits.

Global fiscal support during the COVID pandemic

The monthly IMF Fiscal Monitor adjusted the estimated fiscal support by countries around the world to US$9 trillion as a result of COVID-19. This was roughly divided between public sector loans (and other equity injections) as well as direct budgetary support. The IMF reports that a second wave of government measures to address the economic impact of the pandemic this past month accounted for the $1 trillion increase in the overall figure.

The G20 account for most of this sum ($8 trillion), reinforcing global inequities in the distribution of resources and fiscal support capacities. Developing countries, meanwhile, are also anticipating a “hidden debt risk” due to the unprecedented synchronization of fiscal stresses. Including currency depreciation, capital outflows and foreign-currency borrowing.

Dynamic intervention to relax lockdowns and school closures

A study in the European Journal of Epidemiology modelled dynamic interventions (i.e. cycles of lockdown to reduce R0 to below 1, and intervals of relaxed social distancing) across 16 distinct countries globally. The authors conclude that a ‘rolling schedule’ of 50 days of lockdown followed by 30 days of relaxation could reduce transmission levels and keep ICU demands below national capacities. The model furthermore suggests that adopting such dynamic suppression measures over 18 months could lead to significant reductions of new infections and deaths, particularly in developing countries. Since each model was only run one time per country, one study limitation is testing underlying factors at one fixed value rather than a range of possible outcomes from multiple runs, introducing uncertainty.

The SAGE group in the U.K. also released a report last week that modelled the impact of eight scenarios of school re-opening on community transmission of COVID-19. Between the two extremes of staying closed and fully opening, the most promising scenario was breaking classes into two cohorts and alternating between ‘two weeks on / two weeks off’ over academic year. The authors acknowledge the uncertainties associated with the model, but nevertheless suggest that the impact of school re-opening is likely to be relatively small compared to maintenance of other social distancing measures in the broader community.

[post_title] => COVID-19: A Magnifying Glass for Inequalities [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => covid-19-a-magnifying-glass-for-inequalities [to_ping] => [pinged] => [post_modified] => 2020-08-13 22:29:04 [post_modified_gmt] => 2020-08-14 02:29:04 [post_content_filtered] => [post_parent] => 0 [guid] => https://covid19.dighr.org/developments/covid-19-a-magnifying-glass-for-inequalities/ [menu_order] => 0 [post_type] => development [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 2397 [post_author] => 1 [post_date] => 2020-05-10 16:11:22 [post_date_gmt] => 2020-05-10 20:11:22 [post_content] =>

An article in The Lancet (Has COVID-19 subverted global health?) emphasize the importance of context and equity as key principles of global health. In light of limited financial aid from wealthier countries, the authors urge developing countries to adopt policies that reflect their local context that focus on what is possible, acceptable, just, and sustainable.

What accounts was South Korea’s COVID Secret? Fast Testing, High-Tech Tracing, Zero-Tolerance Isolation (Atlantic)

Lockdown Is a Blunt Tool, We Have a Sharper One: Contact Tracing (NYT)

WHO issues a Technical Guidance on Contact Tracing for COVID-19 in Africa (WHO)

The U.S. can expect a series of ‘mini-epidemics’, as the flattening curve is misleading, as the CIDRP outlines three potential futures: recurring small outbreaks, monster wave, persistent crisis (NYT)

Where the latest models think we are headed and why they disagree (FiveThirtyEight)

Reopening some states can heighten risk of or recurring second waves in others (STAT)

Simulation: Ending restrictions earlier is associated with higher projected cases and deaths, but also quicker economic recovery according to a RAND Corporation online tool

In the New England Journal of Medicine, the authors provide two lessons in the Italian response to the pandemic, highlighting the important of testing of health care workers, and how “urgent and decisive” lockdown of the region earlier could have contain the epidemic (Adaptations and Lessons in the Province of Bergamio)

National Geographic reviews the lessons learned from national responses to the COVID-19 pandemic, including the spread of social mitigation, the effectiveness of travel restrictions, testing and the impact of speed of response on outbreak trajectory (How to measure your nation’s response to coronavirus).

It took the U.S. only seven days to exceed projected COVID-19 deaths for August (Newsweek)

A new paper in the Journal of Risk Research (Resilience in the face of uncertainty) describe how political interference undermined the ability of the U.K. National Health Service with COVID-19 preparedness and response. Similar to the Bank of England, the authors argue that national emergency preparedness requires greater independence.

While the full impact of the pandemic on food security remains unknown, Dr. Rhonda Ferguson (DIGHR Research Fellow) argues that the displacement of localized food systems require transformation in trade to protect the estimated 265 million people threatened by famine (Coronavirus: Another chance to transform the global food trade)

COVID-19 and Globalization (One Health)

Could COVID-19 mark a ‘turning point’ in the climate crisis? (WEF)

Effective transmission across the globe: the role of climate in COVID-19 mitigation strategies (Lancet Planetary Health)

Iran’s locust threats grow amid coronavirus pandemic, sanctions (New Humanitarian)

As the number of cases in Iran top 100,000, the spokesperson for the Health Ministry expressed concern in the “rising trend” over the least three days (Daily Star Lebanon)

Public Health Emergency of International Concern (PHEIC) Declaration for COVID-19 extended (WHO)

Why we can’t compare country responses to COVID-19: death rates, data and geography (WEF)

[post_title] => Snapshot of the State of the Pandemic [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => snapshot-of-the-state-of-the-pandemic [to_ping] => [pinged] => [post_modified] => 2020-08-13 22:35:42 [post_modified_gmt] => 2020-08-14 02:35:42 [post_content_filtered] => [post_parent] => 0 [guid] => https://covid19.dighr.org/developments/snapshot-of-the-state-of-the-pandemic/ [menu_order] => 0 [post_type] => development [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 2394 [post_author] => 1 [post_date] => 2020-05-03 16:02:23 [post_date_gmt] => 2020-05-03 20:02:23 [post_content] =>

The doubling rate of confirmed COVID-19 cases dropped to once every 21 days from a high of once every 7 days on April 1. As some countries experience stabilizing or declining national death tolls, it has prompted attempts to loosen lockdown measures. This includes France, Italy and Spain, three of the world’s hardest hit countries (accounting for 20% of cases and a third of all COVID-related deaths worldwide). Germany is begun to relax lockdown measures, as face masks have become mandatory in public. The National Health Service of the United Kingdom set out a six-week plan to ‘return to normal’ following projections that the U.K. has ‘likely survived the first wave’ of the pandemic and will get close to testing targets. Despite a record daily increase in confirmed cases,South Africa restarted some mining operations, as India has also begun to ease lockdown measures following a drop in reported

As some Asian-Pacific countries such as Singapore experience major outbreaks in the second wave of transmission, hospitals across Europe have raised concerns. The WHO noted that many states also do not have adequate testing capacity needed to support a safe reopening strategy that can detect, trace and isolate new COVID transmission. China has meanwhile provided a guide on how countries can prevent a second wave, including compulsory masks in public, fines for failure to exercise public hygiene practices, as well as public markings for social distancing lanes.

The LSHTM is gathering data on hundreds of intervention measures from around the world to determine factors contributing to disease outbreak as well as relative effectiveness of control strategies. For example, to date, Hong Kong’s swift surveillance, quarantine and social-distancing measures – such as the use of face masks and school closures – helped to cut Coronavirus transmission with only 4 deaths in a (urban) population of 7.5 million. The LSHTM platform is being developed to support the WHO’s technical support to member states, and includes more than 1,100 volunteers, multiple universities, public health organizations and non-profits, including ACAPS which analyses humanitarian crises.

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Ten countries have now confirmed more than 1,000 COVID-related deaths, with 14 countries reporting more than 10,000 cases. With less than 17% of all confirmed cases globally, Italy and Spain continue to account for more than 35% of all reported deaths (21,645 and 19,130, respectively). Both countries are experiencing a slow-down in the rates of transmission, however, and while Spain is beginning to relax control measures, Italy has extended lockdown measures until May.

Sweden (12,540) is the latest country to exceed 10,000 cases, as the number of deaths doubled in less than a week, which has been blamed on its controversial voluntary public health measures. France (147,863) and Turkey (69,392) continue to experience significant daily increases in confirmed cases and deaths, while the U.K. is expected to see a drop in new cases and hospitalization, despite surpassing 10,000 deaths and approaching 100,000 cases. The U.K. Prime Minister Boris Johnson was moved out of Intensive Care over the weekend, noting “I owe (NHS staff) my life.”

Transmission rates in Russia have also raised concerns, as daily reported cases continue to surge 20% for a second consecutive day, approaching 28,000 cases and 232 deaths. As the number of COVID-related deaths in Belgium surpass China, Germany is reporting an increase of COVID-related outbreaks in nursing homes and hospitals, where the elderly account for only 17% of cases but 86% of all deaths.

Many European countries are also reporting high CFR near or above 10%, including Italy, Spain, France, the U.K., Netherlands, Belgium, and Sweden. This has been partly attributed to selective testing strategies, as a paper this week in BMJ suggests early and widespread testing may be contributing to Germany’s relatively low CFR (2%). The European CDC has recommended that countries scale up testing and surveillance systems to guide and monitor the escalation and de-escalation of mitigation strategies.

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Short-term forecasts of COVID-19 deaths in multiple countries

Imperial College London, 8 April 2020

https://sangeetabhatia03.github.io/covid19-short-term-forecasts/index.html

This weekly report by Imperial College London presents forecasts of transmission and mortality estimates over the coming week for 42 countries with active transmission, accounting for the impact of control measures. The caveat with these forecasts is that accuracy varies with the quality of surveillance and reporting, i.e. presenting likely underestimates for countries with poor reporting. That said, based on transmissibility estimates, the COVID-19 epidemic is expected to demonstrate:

Stabilizing patterns in 14 countries (including Italy, Iran, Iraq, South Korea);
Slow-growth transmission (1<Rt<2) in Spain and Netherlands; and
Rapidly growing transmission (Rt>2) across 26 countries (including Algeria, Brazil, Canada, China, Egypt, France, Germany, India, Japan, Peru, Turkey, U.K. and U.S.).

Based on central forecasting trends, reported deaths in the coming week are expected to be:

Relatively small (<100) and large (100-1000) in 29 countries;
Large (1,000-5,000) in 8 countries (including Algeria, Brazil, Germany, Iran, and Turkey); and
Very large (5,000+) in 5 countries (France, Italy, Spain, U.K. and U.S).

New COVID-19 forecasts for Europe: Italy & Spain have passed the peak of their epidemics; UK, early in its epidemic, faces a fast-mounting death toll

Institute for Health Metrics and Evaluation, 7 April 2020

http://www.healthdata.org/news-release/new-covid-19-forecasts-europe-italy-spain-have-passed-peak-their-epidemics-uk-early-its

New COVID-19 forecast from IHME found that among European nations, the peak daily death rate from the pandemic will occur during the third week of April, with the pandemic spreading from Southern Europe. According to current trajectories, 151,680 COVID-19 deaths could occur during the “first wave” of the pandemic in Europe, while the U.S. is expected to face 81,766 deaths. Declines in deaths are now occurring in Italy and Spain as most regions in the two countries have passed their peaks in the number of deaths, while other nations are approaching their peaks and still others facing peak mortality later in April. The death toll in many countries is compounded by demand for hospital resources well in excess of what is available. Predicted peaks in daily COVID-19 deaths appear to be highly variable among EEA countries, likely reflecting the equally variable ways that the novel coronavirus initially spread and then continued to affect Europe.

Projecting hospital utilization during the COVID-19 outbreaks in the United States

Moghadas et al, National Academy of Sciences, 3 April 2020

https://www.pnas.org/content/117/16/9122

Findings

Without isolation and with R0 = 2.5, treatment of critically ill patients at the outbreak peak would require 3.8x more ICU beds than exist in the U.S. (or 2x if R0 = 2). With self-isolation by 20% of cases within 24 hours of symptom onset, the outbreak trajectory would delay and flatten, and the number of ICU beds needed at the peak would reduce by 48.4% (or 73.5% if R0 = 2).

Interpretation

Hand washing and self-isolation is shown to significantly contribute to reducing the rate of spread of COVID-19, and therefore reducing the number of ICU beds needed at any one time. This could facilitate emergency mobilization to expand mobilization of critical care capacity to handle the burgeoning outbreak.

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The total number of cases continue to increase by at least 10% for a second day to 1,039,158, and 55,000 confirmed deaths, as of 3 April 2020 (9:25am EST).

Although the U.S. and Europe constitute over 70% of confirmed cases, the rapid increase of local clusters across low- and middle-income countries has emerged as a major concern.

CFR figures (in order of countries with the highest number of deaths)

Italy (11.4%)
Spain (8.7%)
Iran (6.5%)
U.K. (8.2%)
France (6.8%)
China (4.1%)
US (1.9%)
Netherlands (8.3%)

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As of April 3, Italy and Spain together make up almost half of all confirmed deaths globally (13,915 and 10,348, respectively), while each country has also surpassed 110,000 confirmed cases. Across Europe, ten countries are reporting more than 10,000 cases, while seven countries have reported over 1,000 deaths. Many European countries are also reporting alarmingly high Case Fatality Rates over 5%. Including Italy (12%), Netherlands and Spain (9.1%), UK (8.7%), France (7.1%), Belgium (6.6%), and Sweden (5.2%). This has been partly attributed to selective testing strategies in these countries, while widespread testing is likely contributing to relatively low CFR rate in countries like Germany (1.2%) and Austria (1.4%). The European CDC has nonetheless warned that current testing capacity and if countries do not enact mitigation strategies, Europe could see a scenario similar to China by the middle of April.

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Countries are increasingly adopting the WHO’s main advice to “test, test, test,” with total number of tests performed increasing 42% over the past week, as of April 1. Limited availability of diagnostic kits and laboratories in many low- and middle-income countries remain a critical concern and is almost certainly masking more widespread local transmission.

Similar to prior pandemics, high initial Case Fatality Rates for COVID-19 are expected to trend downwards over time as countries adopt more wide-spread population testing (i.e. recording those dying with as opposed to from the virus). This is reflected in these CFR figures (in order of countries with the highest number of deaths), as of 3 April: Italy (12%), Spain (9.1%), U.S. (2.4%), France (7.1%), China (4.1%), Iran (6.3%)

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