To understand the spread of COVID-19, the pandemic is more usefully viewed as a series of distinct local epidemics. The way the virus has spread in different countries, and even in particular states or regions within them, has been quite varied.
A New Zealand study has mapped the coronavirus epidemic curve for 25 countries and modelled how the spread of the virus has changed in response to the various lockdown measures.
The research, which is yet to be peer-reviewed, classifies each country’s public health response using New Zealand’s four-level alert system. Levels 1 and 2 represent relatively relaxed controls, whereas levels 3 and 4 are stricter.
By mapping the change in the effective reproduction number (Reff, an indicator of the actual spread of the virus in the community) against response measures, the research shows countries that implemented level 3 and 4 restrictions sooner had greater success in pushing Reff to below 1.
An Reff of less than 1 means each infected person spreads the virus to less than one other person, on average. By keeping Reff below 1, the number of new infections will fall and the virus will ultimately disappear from the community.
Conversely, the larger the Reff value, the more freely the virus is spreading in the community and thus the faster the number of new cases will rise. This means a higher number of cases at the peak of the epidemic, a greater risk of the health system becoming overwhelmed, and ultimately more deaths.
Here are some of study’s findings from states and nations around the world:
The effect of Australia’s strict border control measures, implemented relatively early in the pandemic, can clearly be seen in the graph below. Federal and state governments introduced strict social distancing rules; schools, pubs, churches, community centres, entertainment venues and even some beaches were closed.
This prompted the Reff value to drop below 1, where it has stayed for some time. Australia is rightly regarded as a success story in controlling the spread of COVID-19, and all states and territories are now mapping their paths towards relaxing restrictions in the coming weeks.
Italy was relatively slow to respond to the epidemic, and experienced a high Reff for many weeks. This led to an explosion of cases which overwhelmed the health system, particularly in the country’s north. This was followed by some of the strictest public health control measures in Europe, which has finally seen the Reff fall to below 1.
Unfortunately, the time lag has cost many lives. Italy’s death toll of over 27,000 serves as a warning of what can happen if the virus is allowed to spread unchecked, even if strict measures are brought in later.
The UK’s initial response to COVID-19 was characterised by a series of missteps. The government prevaricated while it considered pursuing a controversial “herd immunity” strategy, before finally ordering an Italy-style lockdown to regain control over the virus’s transmission.
As in Italy, the result was an initial surge in case numbers, a belatedly successful effort to bring Reff below 1, and a huge death toll of over 20,000 to date.
New York City, with its field hospital in Central Park resembling a scene from a disaster movie, is another testament to the power of uncontrolled virus spread to overwhelm the health system.
Its Reff peaked at a staggeringly high value of 8, before the city slammed on the brakes and went into complete lockdown. It took a protracted battle to finally bring the Reff below 1. Perhaps more than any other city, New York will feel the economic shock of this epidemic for many years to come.
Sweden has taken a markedly relaxed approach to its public health response. Barring a few minor restrictions, the country remains more or less open as usual, and the focus has been on individuals to take personal responsibility for controlling the virus through social distancing.
This is understandably contentious, and the number of cases and deaths in Sweden are far higher than its neighbouring countries. But Reff indicates that the curve is flattening.
Singapore is a lesson on why you can’t ever relax when it comes to coronavirus. It was hailed as an early success story in bringing the virus to heel, through extensive testing, effective contact tracing and strict quarantining, with no need for a full lockdown.
But the virus has bounced back. Infection clusters originating among migrant workers has prompted tighter restrictions. The Reff currently sits at around 2, and Singapore still has a lot of work to do to bring it down.
Individually, these graphs each tell their own story. Together, they have one clear message: places that moved quickly to implement strict interventions brought the coronavirus under control much more effectively, with less death and disease.
And our final example, Singapore, adds an important coda: the situation can change rapidly, and there is no room for complacency.
The antibiotic resistance threat is real. In the years to come, we will no longer be able to treat and cure many infections we once could.
We’ve had no new classes of antibiotics in decades, and the development pipeline is largely dry. Each time we use antibiotics, the bacteria in our bodies become more resistant to the few antibiotics we still have.
The problem seems clear and the solution obvious: to prescribe our precious antibiotics only when absolutely needed. Implementing this nationally is not an easy task. But Australia could take cues from other countries making significant progress in this area, such as Sweden.
Antibiotic use was rising steadily in Sweden during the 1980s and 1990s, causing an increase in antibiotic resistant bacteria. A group of doctors mobilised to tackle this threat, and brought together peak bodies across pharmaceuticals, infectious diseases and other relevant areas to form a national coalition.
The Swedish Strategic Programme Against Antibiotic Resistance (Strama) was founded in 1995.
Since then, Strama has been working on a national and regional level to reduce antibiotic use. Between 1992 and 2016, the number of antibiotics prescriptions decreased by 43% overall. Among children under four, antibiotics prescriptions fell by 73%.
Levels of antibiotic use and resistance in Sweden are now among the lowest of all OECD countries, both in humans and animals.
In 2017, Australia’s chief medical officer sent a letter to all high-prescribing general practitioners. Over the following six months, this resulted in around a 10% reduction in antibiotic prescriptions among those GPs.
While an excellent start, this is just one of several interventions needed to avert the looming antibiotic crisis.
Audit and feedback
The idea of audit and feedback sees GPs provided with a summary of their antibiotic prescribing rates over a specified period of time.
In Australia, antibiotic prescribing data are currently collected by the Pharmaceutical Benefits Scheme (PBS) and periodically used by the National Prescribing Service (NPS MedicineWise) to provide feedback to some GPs.
In Sweden, regular meetings between local Strama members and primary health care clinics serve to reinforce treatment guidelines. Strama representatives review individual doctors’ antibiotic prescribing as well as trends across the area, and discuss targets for optimal prescribing.
This results in some decrease in antibiotic use; a small but desirable effect if combined with other interventions.
Restrict access to specific antibiotics
The Australian Commission on Safety and Quality in Health Care keeps a list of antibiotics that should only be used as a last line of defence. An example is meropenem, which is commonly used to treat infections with multidrug-resistant organisms such as septicaemia.
Current restrictions stipulate these antibiotics can only be used in hospitals under the supervision of a hospital antimicrobial stewardship team. This team usually consists of an infectious disease specialist, a microbiologist and a pharmacist. The team reviews the request and either approves it or recommends using another antibiotic.
Strama takes a similar approach.
But the way this is enforced differs between Australian hospitals. We may need to strengthen these restrictions if resistance continues to increase.
Stop default repeat prescriptions
Prescriptions which include a “repeat” could leave patients believing another course of antibiotics is needed, when this is not always the case. They may hold on to the prescription with a “just in case” attitude to take when they feel it’s necessary, or even give the prescription to someone else.
In Sweden, there are no default repeat prescriptions for antibiotics and this is reinforced by appropriate package size.
Pleasingly, Australia’s Pharmaceutical Benefits Advisory Committee has recently recommended the removal of default repeat options for a range of common antibiotics in high usage, where no repeats are deemed clinically necessary.
Delayed prescribing is when a GP provides a prescription during the consultation, but advises the patient to see if the symptoms will resolve first before using it (a “wait-and-see” approach).
GPs use delayed prescribing in situations of uncertainty as a safety measure, or when patients appear anxious and require additional assurance antibiotics are accessible in case the infection gets worse.
A systematic review found delayed prescribing resulted in 31% of people taking the course of antibiotics compared to 93% who were prescribed them normally.
In Sweden, national treatment guidelines for common infections in primary health care support GPs delaying antibiotic prescribing.
To change public attitudes around antibiotic use and preservation, it’s important to communicate the negative effects of the unnecessary use of antibiotics and the risk of antibiotic resistance for the individual as well as the community.
Continuous awareness campaigns are essential (for example, via the media) to keep the public tuned in to the issue. The French campaign “antibiotics are not automatic” is a good example.
Further, enabling patients to be involved in the decision of whether to use antibiotics or not encourages discussion between the doctor and the patient around the benefits and harms of potential treatments. Using shared decision making in consultations has proven effective in reducing antibiotic prescribing by about one-fifth.
Each of these strategies contributes a small amount to improving antibiotic usage. Like the Swedish Strama program, the combination will need to be sustained and reinforced over many years to reach levels of antibiotic use comparable to the lowest prescribing OECD countries, like Sweden.
Mina Bakhit, Postdoctoral Research Fellow, Bond University; Chris Del Mar, Professor of Public Health, Bond University, and Helena Kornfält Isberg, MD, General practitioner, PhD-student, Lund University
Julian Assange, the Australian cofounder of Wikileaks, was arrested on April 11 by British police at the Ecuadorian embassy in London, where he had been claiming political asylum for almost seven years.
He has faced a range of criminal charges and extradition orders, and several crucial aspects of his situation remain to be resolved.
What are the British charges against Assange, and what sentence could be imposed?
Assange moved into the Ecuadorian embassy in London in June 2012 after losing the final appeal against his transfer to Sweden on a European Arrest Warrant (EAW). He was then charged with failing to surrender to the court.
While in the embassy, Assange could not be arrested because of the international legal protection of diplomatic premises, which meant police could not enter without Ecuador’s consent. On April 11, British police were invited into the embassy and made the arrest. On the same day, Assange was found guilty, and awaits sentencing. The charge of failing to surrender to the court carries a jail term of up to 12 months.
What are the US charges against Assange?
Also on April 11, the United States government unsealed an indictment made in March 2018, charging Assange with a conspiracy to help whistleblower Chelsea Manning crack a password which enabled her to pass on classified documents that were then published by WikiLeaks. The US has requested that the UK extradite Assange to face these charges before a US court.
What were the Swedish charges, and could they be revived?
In 2010, a Swedish prosecutor issued the EAW requesting Assange’s transfer to Sweden to face sexual assault allegations, which he denies. In 2016, Assange was questioned by Swedish authorities by video link while he remained in the Ecuadorian embassy. In 2017, they closed their investigation.
After Assange was arrested and removed from the embassy, the lawyer for one of the complainants indicated she would ask the prosecutor to reopen the case, as the statute of limitations on the alleged offence does not expire until 2020. As of April 12, Sweden’s Prosecution Authority is formally reviewing the case and could renew its request for extradition.
What are Britain’s legal obligations to extradite to Sweden or the US?
The UK, as a member of the European Union (for now!), is obliged to execute an EAW. The law on EAWs is similar to extradition treaties. However, the law also says it is up to the UK to decide whether to act first on the EAW from Sweden or the US extradition request.
Bilateral extradition treaties are usually based on identical reciprocal obligations. But the current UK-US extradition treaty, agreed in 2003, has been criticised for allowing the UK to extradite a person to the US solely on the basis of an allegation and an arrest warrant, without any evidence being produced, despite the fact that “probable cause” is required for extradition the other way.
The relative ease of extradition from the UK to the US has long been one of the concerns of Assange’s legal team. The treaty does not include a list of extraditable offences but allows for extradition for any non-political offence for which both states have criminalised the behaviour, which carries a sentence of at least one year in prison.
Espionage and treason are considered core “political offences”, which is why the US request is limited to the charge of computer fraud. Conspiracy to commit an extraditable offence is covered in the US-UK treaty, as it is in the EAW (and in the US-Australia extradition treaty).
Assange may legally challenge his extradition either to the US or to Sweden (as he previously did). Such challenges could take months or even years, particularly if Assange applies to the European Court of Human Rights arguing that an extradition request involved a human rights violation.
Given Assange’s previous conduct, and the likelihood that he will be sentenced to prison for failure to surrender to court, he will probably remain in a UK prison until all legal avenues are exhausted.
What are Australia’s obligations to Assange?
As an Australian citizen, Assange is entitled to consular protection by the Australian government, which means staff from the Australian High Commission in London will provide support for him in the legal process. The extent of that support is not set in stone, however, and both Foreign Minister Marise Payne and Prime Minister Scott Morrison have declined to provide detail on the basis that the matter is before the courts.
One possibility is that Assange will serve his sentence for failing to surrender to the court, after which the UK will deport him to Australia. At that point, it is possible the US could request extradition from Australia, and the US-Australian extradition treaty would apply. The US charges would most likely be covered although not specifically mentioned in the treaty.
As with the UK-US treaty, political offences are excluded, and an extradited person can only be tried for the offence in the extradition request or a related offence, and in any event not for an offence not covered by the treaty. In addition, the treaty specifies that neither Australia nor the US is obliged to extradite its own nationals, but may do so. The fact that Australia has the option to refuse extradition purely on the ground of Assange’s nationality could lead to intense pressure on the government to do just that.
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