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and organisational structure to deal with infectious diseases that may spread across borders quickly and dangerously is out of date.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.

How long are you infectious when you have coronavirus?



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Tambri Housen, Australian National University; Amy Elizabeth Parry, Australian National University, and Meru Sheel, Australian National University

As the coronavirus pandemic stretches on, a small proportion of Australians infected have now died, while most have either recovered, or are likely to recover over the next few weeks.

One thing many of us want to know is for how long people who have SARS-CoV-2, the virus that causes COVID-19, are able to pass it on to someone else.

Let’s look at what the science tells us so far.

How long does it take to get sick?

The “incubation period” is the time between being exposed to the virus and the onset of symptoms.

For COVID-19, the incubation period ranges from 1 to 14 days. But most people who develop COVID-19 symptoms do so 4 to 6 days after exposure.




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How long are you infectious?

The “infectious period” means the time you’re able to spread the virus to someone else.

For COVID-19, there is emerging evidence to suggest the infectious period may start 1 to 3 days before you develop symptoms.

The most infectious period is thought to be 1 to 3 days before symptoms start, and in the first 7 days after symptoms begin. But some people may remain infectious for longer.

Commonly reported symptoms for COVID-19 – such as fever, cough and fatigue – usually last around 9 to 10 days but this can be longer.


The Coversation, CC BY-ND

Why are some people infectious for longer?

Typically with viruses, the higher the viral load (the more virus circulating in the body), the higher the risk of transmission through known transmission pathways.

A study conducted in Hong Kong looking at viral load in 23 patients diagnosed with COVID-19 found higher viral loads in the first week of illness.

Another study from China looking at 76 hospitalised patients found that by 10 days after symptom onset, mild cases had cleared the virus. That is, no virus was detectable through testing.

However, severe cases have much higher viral loads and many continue to test positive beyond the 10 days after symptoms start.

So the more severe the illness and the higher the viral load, the longer you continue to shed the virus and are infectious.




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When are you no longer infectious?

If someone has been symptom-free for 3 days and they developed their first symptoms more than 10 days prior, they are no longer considered to be infectious.

But we’re not sure whether people are infectious when they have recovered but the virus can still be detected in their bodies.

One study from Hong Kong found the virus could be detected for 20 days or longer after the initial onset of symptoms in one-third of patients tested.

Another study from China found found the virus in a patients’ faecal samples five weeks after the first onset of symptoms.

But the detection of the virus doesn’t necessarily mean the person is infectious. We need more studies with larger sample sizes to get to the bottom of this question.

Should you get tested again before going back into the community?

Due to a global shortage of coronavirus tests, the Commonwealth and state governments have strict criteria about who should be tested for COVID-19 and when.




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Who can get tested for coronavirus?


People who have been self-quarantining, because they had contact with a confirmed case of COVID-19 and have completed their 14-day quarantine period without developing symptoms, can return to the community. There is no requirement to be tested prior to returning to the community. It is, however, recommended they continue to practise social distancing and good hygiene as a precaution.

The requirements are different for people who have been diagnosed with COVID-19.

At present, re-testing people who have experienced mild illness, and have recovered from COVID-19 is not recommended. A person is considered safe to return to the community and discontinue self-isolation if they are no longer infectious. This means they developed their first symptoms more than 10 days prior and have not experienced any symptoms for at least 3 days (72 hours).

For people who have been hospitalised with more severe illness, the testing requirements before discharge are different. They will have two swabs taken 24 hours apart to check if they have cleared the virus. If the swabs are both negative, they can be discharged and don’t require further self-isolation.

If one or both tests are positive but the person is well enough to go home, they must continue to self-isolate for at least 10 days since they were discharged from hospital and they have not experienced any symptoms for at least 3 days.

There are also different testing requirements for people working or living in high-risk settings. If you work or live in a high-risk setting you should consult with your health care provider on re-testing requirements.The Conversation

Tambri Housen, Epidemiologist | Senior Research Fellow, National Centre for Epidemiology and Population Health, Australian National University; Amy Elizabeth Parry, Epidemiologist | PhD Candidate, National Centre for Epidemiology and Population Health, Australian National University, and Meru Sheel, Epidemiologist | Senior Research Fellow, Australian National University

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

Egyptian Couple Shot by Muslim Extremists Undaunted in Ministry


Left for dead, Christians offer to drop charges if allowed to construct church building.

CAIRO, Egypt, June 9 (CDN) — Rasha Samir was sure her husband, Ephraim Shehata, was dead.

He was covered with blood, had two bullets inside him and was lying facedown in the dust of a dirt road. Samir was lying on top of him doing her best to shelter him from the onslaught of approaching gunmen.

With arms outstretched, the men surrounded Samir and Shehata and pumped off round after round at the couple. Seconds before, Samir could hear her husband mumbling Bible verses. But one bullet had pierced his neck, and now he wasn’t moving. In a blind terror, Samir tried desperately to stop her panicked breathing and convincingly lie still, hoping the gunmen would go away.

Finally, the gunfire stopped and one of the men spoke. “Let’s go. They’re dead.”

 

‘Break the Hearts’

On the afternoon of Feb. 27, lay pastor Shehata and his wife Samir were ambushed on a desolate street by a group of Islamic gunmen outside the village of Teleda in Upper Egypt.

The attack was meant to “break the hearts of the Christians” in the area, Samir said.

The attackers shot Shehata twice, once in the stomach through the back, and once in the neck. They shot Samir in the arm. Both survived the attack, but Shehata is still in the midst of a difficult recovery. The shooters have since been arrested and are in jail awaiting trial. A trial cannot begin until Shehata has recovered enough to attend court proceedings.

Despite this trauma, being left with debilitating injuries, more than 85,000 Egyptian pounds (US$14,855) in medical bills and possible long-term unemployment, Shehata is willing to drop all criminal charges against his attackers – and avoid what could be a very embarrassing trial for the nation – if the government will stop blocking Shehata from constructing a church building.

Before Shehata was shot, one of the attackers pushed him off his motorcycle and told him he was going to teach him a lesson about “running around” or being an active Christian.

Because of his ministry, the 34-year-old Shehata, a Coptic Orthodox Christian, was arguably the most visible Christian in his community. When he wasn’t working as a lab technician or attending legal classes at a local college, he was going door-to-door among Christians to encourage them in any way he could. He also ran a community center and medical clinic out of a converted two-bedroom apartment. His main goal, he said, was to “help Christians be strong in their faith.”

The center, open now for five years, provided much-needed basic medical services for surrounding residents for free, irrespective of their religion. The center also provided sewing training and a worksite for Christian women so they could gain extra income. Before the center was open in its present location, he ran similar services out of a relative’s apartment.

“We teach them something that can help them with the future, and when they get married they can have some way to work and it will help them get money for their families,” Shehata said.

Additionally, the center was used to teach hygiene and sanitation basics to area residents, a vital service to a community that uses well water that is often polluted or full of diseases. Along with these services, Shehata and his wife ran several development projects, repairing the roofs of shelters for poor people, installing plumbing, toilets and electrical systems. The center also distributed free food to the elderly and the infirm.

The center has been run by donations and nominal fees used to pay the rent for the apartment. Shehata has continued to run the programs as aggressively as he can, but he said that even before the shooting that the center was barely scraping by.

“We have no money to build or improve anything,” he said. “We have a safe, but no money to put in it.”

 

Tense Atmosphere

In the weeks before the shooting, Teleda and the surrounding villages were gripped with fear.

Christians in the community had been receiving death threats by phone after a Muslim man died during an attack on a Christian couple. On Feb. 2, a group of men in nearby Samalout tried to abduct a Coptic woman from a three-wheeled motorcycle her husband was driving. The husband, Zarif Elia, punched one of the attackers in the nose. The Muslim, Basem Abul-Eid, dropped dead on the spot.

Elia was arrested and charged with murder. An autopsy later revealed that the man died of a heart attack, but local Muslims were incensed.

Already in the spotlight for his ministry activities, Shehata heightened his profile when he warned government officials that Christians were going to be attacked, as they had been in Farshout and Nag Hammadi the previous month. He also gave an interview to a human rights activist that was posted on numerous Coptic websites. Because of this, government troops were deployed to the town, and extremists were unable to take revenge on local Christians – but only after almost the
entire Christian community was placed under house arrest.

“They chose me,” Shehata said, “Because they thought I was the one serving everybody, and I was the one who wrote the government telling them that Muslims were going to set fire to the Christian houses because of the death.”

Because of his busy schedule, Shehata and Samir, 27, were only able to spend Fridays and part of every Saturday together in a village in Samalut, where Shehata lives. Every Saturday after seeing Samir, Shehata would drive her back through Teleda to the village where she lives, close to her family. Samalut is a town approximately 105 kilometers (65 miles) south of Cairo.

On the afternoon of Feb. 27, Shehata and his wife were on a motorcycle on a desolate stretch of hard-packed dirt road. Other than a few scattered farming structures, there was nothing near the road but the Nile River on one side, and open fields dotted with palm trees on the other.

Shehata approached a torn-up section of the road and slowed down. A man walked up to the vehicle carrying a big wooden stick and forced him to stop. Shehata asked the man what was wrong, but he only pushed Shehata off the motorcycle and told him, “I’m going to stop you from running around,” Samir recounted.

Shehata asked the man to let Samir go. “Whatever you are going to do, do it to me,” he told the man.

The man didn’t listen and began hitting Shehata on the leg with the stick. As Shehata stumbled, Samir screamed for the man to leave them alone. The man lifted the stick again, clubbed Shehata once more on the leg and knocked him to the ground. As Shehata struggled to get up, the man took out a pistol, leveled it at Shehata’s back and squeezed the trigger.

Samir started praying and screaming Jesus’ name. The man turned toward her, raised the pistol once more, squeezed off another round, and shot Samir in the arm. Samir looked around and saw a few men running toward her, but her heart sank when she realized they had come not to help them but to join the assault.

Samir jumped on top of Shehata, rolled on to her back and started begging her attackers for their lives, but the men, now four in all, kept firing. Bullets were flying everywhere.

“I was scared. I thought I was going to die and that the angels were going to come and get our spirits,” Samir said. “I started praying, ‘Please God, forgive me, I’m a sinner and I am going to die.’”

Samir decided to play dead. She leaned back toward her husband, closed her eyes, went limp and tried to stop breathing. She said she felt that Shehata was dying underneath her.

“I could hear him saying some of the Scriptures, the one about the righteous thief [saying] ‘Remember me when you enter Paradise,’” she said. “Then a bullet went through his neck, and he stopped saying anything.”

Samir has no way of knowing how much time passed, but eventually the firing stopped. After she heard one of the shooters say, “Let’s go, they’re dead,” moments later she opened her eyes and the men were gone. When she lifted her head, she heard her husband moan.

 

Unlikely Survival

When Shehata arrived at the hospital, his doctors didn’t think he would survive. He had lost a tremendous amount of blood, a bullet had split his kidney in two, and the other bullet was lodged in his neck, leaving him partially paralyzed.

His heartbeat was so faint it couldn’t be detected. He was also riddled with a seemingly limitless supply of bullet fragments throughout his body.

Samir, though seriously injured, had fared much better than Shehata. The bullet went into her arm but otherwise left her uninjured. When she was shot, Samir was wearing a maternity coat. She wasn’t pregnant, but the couple had bought the coat in hopes she soon would be. Samir said she thinks the gunman who shot her thought he had hit her body, instead of just her arm.

The church leadership in Samalut was quickly informed about the shooting and summoned the best doctors they could, who quickly traveled to help Shehata and Samir. By chance, the hospital had a large supply of blood matching Shehata’s blood type because of an elective surgical procedure that was cancelled. The bullets were removed, and his kidney was repaired. The doctors however, were forced to leave many of the bullet fragments in Shehata’s body.

As difficult as it was to piece Shehata’s broken body back together, it paled in comparison with the recovery he had to suffer through. He endured multiple surgeries and was near death several times during his 70 days of hospitalization.

Early on, Shehata was struck with a massive infection. Also, because part of his internal tissue was cut off from its blood supply, it literally started to rot inside him. He began to swell and was in agony.

“I was screaming, and they brought the doctors,” Shehata said. The doctors decided to operate immediately.

When a surgeon removed one of the clamps holding Shehata’s abdomen together, the intense pressure popped off most of the other clamps. Surgeons removed some stomach tissue, part of his colon and more than a liter of infectious liquid.

Shehata could not eat normally and lost 35 kilograms (approximately 77 lbs.). He also couldn’t evacuate his bowels for at least 11 days, his wife said.

Despite the doctors’ best efforts, infections continued to rage through Shehata’s body, accompanied by alarming spikes in body temperature.

Eventually, doctors sent him to a hospital in Cairo, where he spent a week under treatment. A doctor there prescribed a different regimen of antibiotics that successfully fought the infection and returned Shehata’s body temperature to normal.

Shehata is recovering at home now, but he still has a host of medical problems. He has to take a massive amount of painkillers and is essentially bedridden. He cannot walk without assistance, is unable to move the fingers on his left hand and cannot eat solid food. In approximately two months he will undergo yet another surgery that, if all goes well, will allow him to use the bathroom normally.

“Even now I can’t walk properly, and I can’t lift my leg more than 10 or 20 centimeters. I need someone to help me just to pull up my underwear,” Shehata said. “I can move my arm, but I can’t move my fingers.”

Samir does not complain about her condition or that of Shehata. Instead, she sees the fact that she and her husband are even alive as a testament to God’s faithfulness. She said she thinks God allowed them to be struck with the bullets that injured them but pushed away the bullets that would have killed them.

“There were lots of bullets being shot, but they didn’t hit us, only three or four,” she said. “Where are the others?”

Even in the brutal process of recovery, Samir found cause for thanks. In the beginning, Shehata couldn’t move his left arm, but now he can. “Thank God and thank Jesus, it was His blessing to us,” Samir said. “We were kind of dead, now we are alive."

Still, Samir admits that sometimes her faith waivers. She is facing the possibility that Shehata might not work for some time, if ever. The couple owes the 85,000 Egyptian pounds (US$14,855) in medical bills, and continuing their ministry at the center and in the surrounding villages will be difficult at best.

“I am scared now, more so than during the shooting,” she said. “Ephraim said do not be afraid, it is supposed to make us stronger.”

So Samir prays for strength for her husband to heal and for patience. In the meantime, she said she looks forward to the day when the struggles from the shooting are over and she can look back and see how God used it to shape them.

“There is a great work the Lord is doing in our lives, we may not know what the reason is now, but maybe some day we will,” Samir said.

 

Government Opposition

For the past 10 years, Shehata has tried to erect a church building, or at a minimum a house, that he could use as a dedicated community center. But local Muslims and Egypt’s State Security Investigations (SSI) agency have blocked him every step of the way. He had, until the shooting happened, all but given up on constructing the church building.

On numerous occasions, Shehata has been stopped from holding group prayer meetings after people complained to the SSI. In one incident, a man paid by a land owner to watch a piece of property near the community center complained to the SSI that Shehata was holding prayer meetings at the facility. The SSI made Shehata sign papers stating he wouldn’t hold prayer meetings at the center.

At one time, Shehata had hoped to build a house to use as a community center on property that had been given to him for that purpose. Residents spread a rumor that he was actually erecting a church building, and police massed at the property to prevent him from doing any construction.

There is no church in the town where Shehata lives or in the surrounding villages. Shehata admits he would like to put up a church building on the donated property but says it is impossible, so he doesn’t even try.

In Egypt constructing or even repairing a church building can only be done after a complex government approval process. In effect, it makes it impossible to build a place for Christian worship. By comparison, the construction of mosques is encouraged through a system of subsidies.

“It is not allowed to build a church in Egypt,” Shehata said. “We can’t build a house. We can’t build a community center. And we can’t build a church.”

Because of this, Shehata and his wife organize transportation from surrounding villages to St. Mark’s Cathedral in Samalut for Friday services and sacraments. Because of the lack of transportation options, the congregants are forced to ride in a dozen open-top cattle cars.

“We take them not in proper cars or micro-buses, but trucks – the same trucks we use to move animals,” he said.

The trip is dangerous. A year ago a man fell out of one of the trucks onto the road and died. Shehata said bluntly that Christians are dying in Egypt because the government won’t allow them to construct church buildings.

“I feel upset about the man who died on the way going to church,” he said.

 

Church-for-Charges Swap

The shooters who attacked Shehata and Samir are in jail awaiting trial. The couple has identified each of the men, but even if they hadn’t, finding them for arrest was not a difficult task. The village the attackers came from erupted in celebration when they heard the pastor and his wife were dead.

Shehata now sees the shooting as a horrible incident that can be turned to the good of the believers he serves. He said he finds it particularly frustrating that numerous mosques have sprouted up in his community and surrounding areas during the 10 years he has been prevented from putting up a church building, or even a house. There are two mosques alone on the street of the man who died while being trucked to church services, he said.

Shehata has decided to forgo justice in pursuit of an opportunity to finally construct a church building. He has approached the SSI through church leaders, saying that if he is allowed to construct a church building, then he will take no part in the criminal prosecution of the shooters.

“I have told the security forces through the priests that I will drop the case if they can let us build the church on the piece of land,” he said.

The proposal isn’t without possibilities. His trial has the potential of being internationally embarrassing. It raises questions about fairness in Egyptian society during an upcoming presidential election that will be watched by the world.

Regardless of what happens, Shehata said all he wants is peace and for the rights of Christians to be respected. He said that in Egypt, Christians have less value than the “birds of the air” mentioned in the Bible. According to Luke 12:6, five sparrows sold for two pennies in ancient times.

“We are not to be killed like birds, slaughtered,” he said. “We are human.”

Report from Compass Direct News