Too late, already bolted: how a faster WHO response could have slowed COVID-19’s spread


Victor He/Unsplash

Michael Toole, Burnet InstituteUrgent global action is needed to end the COVID-19 pandemic and prepare for future threats, according to a new report by the Independent Panel for Pandemic Preparedness and Response.

The panel, co-chaired by former New Zealand prime minister Helen Clark and former Liberian president Ellen Johnson Sirleaf, criticises the World Health Organization (WHO) for its tardy actions during the first months of 2020.

The WHO was slow to warn of person-to-person transmission after it first received this information in Wuhan, China, in early January.

And it was slow to declare a public health emergency of international concern (PHEIC), which it did on January 30.

The WHO also opposed international travel restrictions that, if implemented earlier, might have slowed the international spread of the virus. By the time the PHEIC was declared, COVID-19 had spread to 18 countries outside China.

But WHO’s hands were tied

While this may appear just a scathing criticism of the world’s peak health body, the WHO had its hands tied by the international framework that governs the response to emerging infectious diseases and pandemics, the International Health Regulations (IHR).

These regulations were drafted in 2005 in response to the SARS (severe acute respiratory syndrome) and H5N1 (avian flu) pandemics and endorsed by member nations in 2007.

The regulations imposed new requirements that must be met before the WHO director general could act on emergencies, rather than enabling the WHO to act immediately and independently.

The regulations also prohibit international travel restrictions in public health emergencies.




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Many member nations failed to act

The report describes February 2020 as a “lost month”, referring to the time between the declaration of a PHEIC and the WHO statement on March 11 that characterised COVID-19 as a pandemic.

The panel found this was due to a lack of understanding that the PHEIC declaration was the loudest possible alarm open to the director general. The pandemic declaration was not based on International Health Regulation guidelines.

The panel found a number of countries took a wait-and-see attitude during February 2020, allowing the virus to spread uncontrollably.

Effective and high-level coordinating bodies were critical to a country’s ability to adapt to changing information. Yet only a few countries set in motion comprehensive and coordinated COVID-19 protection and response measures.

Of the 28 country responses the panel analysed in depth, only a handful adopted aggressive containment strategies, including China, New Zealand, South Korea, Singapore, Thailand and Vietnam.

Some others had uncoordinated approaches that devalued science, denied the potential impact of the pandemic, delayed comprehensive action and allowed distrust to undermine efforts. While not named, the United States and Brazil were probably among them.

The report praises the role of the African Union and the Africa CDC in leading a continent-wide coordinated response.

It also singles out research and development as a major achievement, especially in vaccine development.




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Preparation was inadequate

Despite the lessons learned from previous outbreaks of SARS, H1N1 (avian flu), Zika, MERS (Middle East respiratory syndrome) and Ebola, preparedness was vastly underfunded.

The US government, led by the Centres for Disease Control, established the Global Health Security Agenda, a group of 70 countries — including Australia – committed to building global capabilities to implement the International Health Regulations. But the Trump administration defunded most of the US CDC’s activities under the agenda.




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After the H1N1 pandemic, Australia reviewed its health sector response and made many recommendations for future preparedness. However, inaction followed. Australia has not run a large-scale pandemic simulation exercise since 2008.

Australia also dropped the ball on regional pandemic preparedness. After the SARS outbreak in 2003, the government developed a five-year regional emerging diseases and pandemics strategy, which received A$100 million from the Howard government. Yet the second five-year strategy attracted very little funding.

Fixing the global system

The panel urges immediate action to end the pandemic through:

  • accelerated vaccination
  • proven measures such as masks and social distancing
  • testing and contact tracing.

However, the focus of its recommendations is on future preparedness.

The panel is convinced a Global Health Threats Council at the most senior level is vital to future success. It would help secure high-level political leadership and ensure attention to pandemic prevention, preparedness and response is sustained over time. Such a body is long overdue.

To ensure the WHO is more agile, the panel recommends an increase in the proportion of funding that is unearmarked for specific programs and countries. This would allow for financial reserves to respond to sudden, unexpected events. It also needs an improved surveillance system, quicker alerts for emerging virus threats, and authority to publish information and dispatch expert missions immediately.

Transparency, speed, flexibility to act more independently and better resourcing are critical to the reforms proposed. Efforts to do this will need unqualified support from its member nations, starting at this month’s World Health Assembly.

After the disruptive years of the Trump presidency, the WHO needs restoration. Australia is influential and should be at the forefront of ensuring this happens.The Conversation

Michael Toole, Professor of International Health, Burnet Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

I was the Australian doctor on the WHO’s COVID-19 mission to China. Here’s what we found about the origins of the coronavirus


Dominic Dwyer, University of Sydney

As I write, I am in hotel quarantine in Sydney, after returning from Wuhan, China. There, I was the Australian representative on the international World Health Organization’s (WHO) investigation into the origins of the SARS-CoV-2 virus.

Much has been said of the politics surrounding the mission to investigate the viral origins of COVID-19. So it’s easy to forget that behind these investigations are real people.

As part of the mission, we met the man who, on December 8, 2019, was the first confirmed COVID-19 case; he’s since recovered. We met the husband of a doctor who died of COVID-19 and left behind a young child. We met the doctors who worked in the Wuhan hospitals treating those early COVID-19 cases, and learned what happened to them and their colleagues. We witnessed the impact of COVID-19 on many individuals and communities, affected so early in the pandemic, when we didn’t know much about the virus, how it spreads, how to treat COVID-19, or its impacts.

We talked to our Chinese counterparts — scientists, epidemiologists, doctors — over the four weeks the WHO mission was in China. We were in meetings with them for up to 15 hours a day, so we became colleagues, even friends. This allowed us to build respect and trust in a way you couldn’t necessarily do via Zoom or email.

This is what we learned about the origins of SARS-CoV-2.

Animal origins, but not necessarily at the Wuhan markets

It was in Wuhan, in central China, that the virus, now called SARS-CoV-2, emerged in December 2019, unleashing the greatest infectious disease outbreak since the 1918-19 influenza pandemic.

Our investigations concluded the virus was most likely of animal origin. It probably crossed over to humans from bats, via an as-yet-unknown intermediary animal, at an unknown location. Such “zoonotic” diseases have triggered pandemics before. But we are still working to confirm the exact chain of events that led to the current pandemic. Sampling of bats in Hubei province and wildlife across China has revealed no SARS-CoV-2 to date.

We visited the now-closed Wuhan wet market which, in the early days of the pandemic, was blamed as the source of the virus. Some stalls at the market sold “domesticated” wildlife products. These are animals raised for food, such as bamboo rats, civets and ferret badgers. There is also evidence some domesticated wildlife may be susceptible to SARS-CoV-2. However, none of the animal products sampled after the market’s closure tested positive for SARS-CoV-2.

We also know not all of those first 174 early COVID-19 cases visited the market, including the man who was diagnosed in December 2019 with the earliest onset date.

However, when we visited the closed market, it’s easy to see how an infection might have spread there. When it was open, there would have been around 10,000 people visiting a day, in close proximity, with poor ventilation and drainage.

There’s also genetic evidence generated during the mission for a transmission cluster there. Viral sequences from several of the market cases were identical, suggesting a transmission cluster. However, there was some diversity in other viral sequences, implying other unknown or unsampled chains of transmission.

A summary of modelling studies of the time to the most recent common ancestor of SARS-CoV-2 sequences estimated the start of the pandemic between mid-November and early December. There are also publications suggesting SARS-CoV-2 circulation in various countries earlier than the first case in Wuhan, although these require confirmation.

The market in Wuhan, in the end, was more of an amplifying event rather than necessarily a true ground zero. So we need to look elsewhere for the viral origins.




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Frozen or refrigerated food not ruled out in the spread

Then there was the “cold chain” hypothesis. This is the idea the virus might have originated from elsewhere via the farming, catching, processing, transporting, refrigeration or freezing of food. Was that food ice cream, fish, wildlife meat? We don’t know. It’s unproven that this triggered the origin of the virus itself. But to what extent did it contribute to its spread? Again, we don’t know.

Several “cold chain” products present in the Wuhan market were not tested for the virus. Environmental sampling in the market showed viral surface contamination. This may indicate the introduction of SARS-CoV-2 through infected people, or contaminated animal products and “cold chain” products. Investigation of “cold chain” products and virus survival at low temperatures is still underway.




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Extremely unlikely the virus escaped from a lab

The most politically sensitive option we looked at was the virus escaping from a laboratory. We concluded this was extremely unlikely.

We visited the Wuhan Institute of Virology, which is an impressive research facility, and looks to be run well, with due regard to staff health.

We spoke to the scientists there. We heard that scientists’ blood samples, which are routinely taken and stored, were tested for signs they had been infected. No evidence of antibodies to the coronavirus was found. We looked at their biosecurity audits. No evidence.

We looked at the closest virus to SARS-CoV-2 they were working on — the virus RaTG13 — which had been detected in caves in southern China where some miners had died seven years previously.

But all the scientists had was a genetic sequence for this virus. They hadn’t managed to grow it in culture. While viruses certainly do escape from laboratories, this is rare. So, we concluded it was extremely unlikely this had happened in Wuhan.




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A team of investigators

When I say “we”, the mission was a joint exercise between the WHO and the Chinese health commission. In all, there were 17 Chinese and ten international experts, plus seven other experts and support staff from various agencies. We looked at the clinical epidemiology (how COVID-19 spread among people), the molecular epidemiology (the genetic makeup of the virus and its spread), and the role of animals and the environment.

The clinical epidemiology group alone looked at China’s records of 76,000 episodes from more than 200 institutions of anything that could have resembled COVID-19 — such as influenza-like illnesses, pneumonia and other respiratory illnesses. They found no clear evidence of substantial circulation of COVID-19 in Wuhan during the latter part of 2019 before the first case.

Where to now?

Our mission to China was only phase one. We are due to publish our official report in the coming weeks. Investigators will also look further afield for data, to investigate evidence the virus was circulating in Europe, for instance, earlier in 2019. Investigators will continue to test wildlife and other animals in the region for signs of the virus. And we’ll continue to learn from our experiences to improve how we investigate the next pandemic.

Irrespective of the origins of the virus, individual people with the disease are at the beginning of the epidemiology data points, sequences and numbers. The long-term physical and psychological effects — the tragedy and anxiety — will be felt in Wuhan, and elsewhere, for decades to come.




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The Conversation


Dominic Dwyer, Director of Public Health Pathology, NSW Health Pathology, Westmead Hospital and University of Sydney, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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WHO reform: a call for an early-warning protocol for infectious diseases


Peter Gluckman and Alexander Gillespie, University of Waikato

The World Health Organization (WHO) has come in for its share of criticism for its handling of the COVID-19 pandemic. While some faults are the responsibility of the WHO, others were caused by member states, which did not always act as quickly as they should have.

In our opinion, the fundamental problem was that the WHO’s current information sharing, response and organisational structure to deal with infectious diseases that may spread across borders quickly and dangerously is out of date.

We argue the global population deserves a better model — one that delivers information about the risk of emergent infectious diseases faster and in a way that is transparent, verifiable and non-politicised.

Preparing for the next pandemic

More than one million people have died of COVID-19, and that number could double before the pandemic is brought under control.

COVID-19 is not the first pandemic, nor will it be the last. The WHO was also criticised after the 2014 Ebola epidemic.




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Global responses to such threats have precedents dating back to 1851 and the development of stardardised quarantine regulations. The international initiatives that have since followed, punctuated by the formation of leading international bodies such as the WHO in 1946, represent incremental progress. The most recent iteration of work in this area is the International Health Regulations of 2005.

We suggest a new protocol should be added to the WHO. We have drafted a tentative discussion document, which is available upon request, based on the following six broad ideas.




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1. The WHO remains the central decision-making body

We want to strengthen the collection and sharing of information related to infectious diseases, but we believe the WHO must remain the international entity that interprets the material, raises alerts for the global community and organises responses.

Despite retaining the centrality of the WHO, we suggest a new protocol to provide the basis for the independent collection, sharing and transfer of information between countries and with the WHO. Fundamentally, we want the early-warning science to be divorced from the policy responses.

2. Obligation to issue risk warning

A clear and binding legal principle needs to be explicitly written into international law: namely, that there is an obligation to pass on, as quickly as possible, information about a hazardous risk discovered in one country that could be dangerous to others.

The international community first saw this thinking in the 1986 Convention on Early Notification of a Nuclear Accident, developed after the Chernobyl incident. We believe the same thinking should be carried over to the early notification of infectious disease threats, as they are just as great.

3. Independence in science

We need legally binding rules for the collection and sharing of information related to infectious diseases. These rules must be detailed, but have the capacity to evolve. This principle is already developing, beginning with innovative solutions to problems like regional air pollution, which separates scientists from decision-makers and removes any potential for partisan advice.

The core of this idea needs to be adapted for infectious diseases and placed within its own self-contained protocol. Signatories can then continually refine the scientific needs, whereby scientists can update what information should be collected and shared, so decision-makers can react in good time, with the best and most independent information at their fingertips.

4. Objectivity and openness

We must articulate the principle that shared scientific information should be as comprehensive, objective, open and transparent as possible. We have borrowed this idea from the Intergovernmental Panel on Climate Change (IPCC) but it needs to be supplemented by the particular requirement to tackle emergent infectious disease risks.

This may include clinical and genetic information and the sharing of biological samples to allow rapid laboratory, medical and public health developments. Incomplete information should not be a reason to delay and all information should be open source. It will also be important to add a principle from international environmental law of acting in a precautionary manner.

In the case of early notification about infectious diseases, we contend that even if there is a lack of scientific certainty over an issue, it is not a reason to hold back from sharing the information.

5. Deployment to other countries

We realise information sometimes needs to be verified independently and quickly. Our thinking here has been guided by the Chemical Weapons Convention and the use of challenge inspections. This mechanism, in times of urgency, allows inspectors to go anywhere at any time, without the right of refusal, to provide independent third-party verification.

In the case of infectious diseases, a solution might be that in times of urgency, if 75% of the members of the new protocol agree, specialist teams are deployed quickly to any country to examine all areas (except military spaces) from where further information is required. This information would then be quickly fed back into the mechanisms of the protocol.

6. Autonomy and independent funding

We suggest such a protocol must be self-governing and largely separate from the WHO, and it is essential it has its own budget and office.

This will increase the autonomy of the early-warning system and reduce the risks of being reliant on the WHO for funding (with all the vagaries that entails). If well designed, the protocol should provide a better way for state and non-state actors to contribute.

The goodwill and financial capacity of international philanthropy, transnational corporations and civil society will need to be mobilised to a much greater degree to fund the new protocol.


The authors worked with Sir Jim McLay, whose leadership contribution and input on the proposed protocol has been integral to the project.The Conversation

Peter Gluckman, Director of Koi Tū, the Centre for Informed Futures; former Chief Science Advisor to the Prime Minister of New Zealand and Alexander Gillespie, Professor of Law, University of Waikato

This article is republished from The Conversation under a Creative Commons license. Read the original article.

WHO is right: lockdowns should be short and sharp. Here are 4 other essential COVID-19 strategies


Hassan Vally, La Trobe University

Last week the World Health Organisation’s special envoy on COVID-19, David Nabarro, said:

We in the World Health Organisation do not advocate lockdowns as the primary measure for the control of the virus.

This has created confusion and frustration, as many people have interpreted this as running counter to WHO’s previous advice on dealing with the pandemic. Haven’t most of us spent some or most of the past few months living in a world of lockdowns and severe restrictions, based on advice from the WHO?

Dig a little deeper, however, and these comments are not as contrary as they might seem. They merely make explicit the idea that lockdowns are just one of many different weapons we can deploy against the coronavirus.

Lockdowns are a good tactic in situations where transmission is spiralling out of control and there is a threat of the health system being overwhelmed. As Nabarro says, they can “buy you time to reorganise, regroup, rebalance your resources”.

But they should not be used as the main strategy against COVID-19 more broadly. And the decision to impose a lockdown should be considered carefully, with the benefits weighed against the often very significant consequences.

Lockdowns also have a disproportionate impact on the most disadvantaged people in society. This cost is greater still in poorer countries, where not going to work can mean literally having no food to eat.




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So if lockdowns are best used as a short, sharp measure to stop the coronavirus running rampant, what other strategies should we be focusing on to control the spread of COVID-19 more generally? Here are four key tactics.

1. Testing, contact tracing and isolation

The key pillars in the public health response to this pandemic have always been testing, contract tracing, and isolating cases. This has been the clear message from the WHO from the beginning, and every jurisdiction that has enjoyed success in controlling the virus has excelled in these three interlinked tasks.

No one disputes the importance of being able to identify cases and make sure they don’t spread the virus. When we identify cases, we also need to work out where and by whom they were infected, so we can quarantine anyone who may also have been exposed. The goal here is to interrupt transmission of the virus by keeping the infected away from others.

Time is of the essence. People should be tested as soon as they develop symptoms, and should isolate immediately until they know they are in the clear. For positive cases, contact tracing should be done as quickly as possible. All of this helps limit the virus’s spread.




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2. Responding to clusters

Responding to disease clusters in an effective, timely manner is also vitally important. We’ve all seen how certain environments, such as aged-care homes, can become breeding grounds for infections, and how hard it is to control these clusters once they gain momentum.

Bringing clusters under control requires decisive action, and countries that have been successful in combating the virus have used a range of strategies to do it. Vietnam, which has been lauded for its coronavirus response despite its large population and lack of resources, has worked hard to “box in the virus” when clusters were identified. This involved identifying and testing people up to three degrees of separation from a known case.




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3. Educating the public

Another crucial element of a successful coronavirus response is giving the public clear advice on how to protect themselves. Public buy-in is vital, because ultimately it is the behaviour of individuals that has the biggest influence on the virus’s spread.

Everyone in the community should understand the importance of social distancing and good hygiene. This includes non-English speakers and other minority groups. Delivering this message to all members of the community requires money and effort from health authorities and community leaders.

4. Masks

After some confusion at the beginning of the pandemic, it is now almost universally accepted that public mask-wearing is a cheap and effective way to slow disease transmission, particularly in situations where social distancing is difficult.

As a result, masks — although unduly politicised in some quarters — have been rapidly accepted in many societies that weren’t previously used to wearing them.




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The Conversation


Hassan Vally, Associate Professor, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.