Spain & Italy
Spain & Italy
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and organisational structure to deal with infectious diseases that may spread across borders quickly and dangerously is out of date.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.
COVID-19 is not the first pandemic, nor will it be the last. The WHO was also criticised after the 2014 Ebola epidemic.
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.
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.
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.
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.
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.
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.
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.
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.
Papua New Guinea
Readily available drugs, which dampen the runaway inflammatory response in patients severely ill with COVID-19, save lives, according to evidence released this week.
An analysis by the World Health Organisation (WHO), which drew together results from several studies, confirms the benefit of this group of anti-inflammatory steroid drugs, known as corticosteroids.
While earlier studies showed the apparent benefit of one of these drugs, dexamethasone, this latest evidence goes further.
It shows other cheap and readily available corticosteroid drugs, including hydrocortisone, could benefit patients at the life-threatening stages of coronavirus infection.
Corticosteroids have been used for decades to treat a variety of inflammatory conditions. These include severe forms of lung inflammation, such as pneumonia, shock due to infection, and severe respiratory syndromes. They are also used to treat more common conditions, including asthma and eczema.
These medicines are on the WHO list of essential medicines, meaning they are widely available (usually at low cost).
In June, early release of results from the RECOVERY trial showed dexamethasone reduced the risk of death by up to a third in people hospitalised with COVID-19 who needed a ventilator to help them breathe.
Despite the early release of the trial results, and limited details at the time, the findings were compelling and clinical practice changed.
Several other trials were stopped. All patients switched to receive active treatment with a corticosteroid.
The results of the RECOVERY trial have since been formally peer reviewed and published.
The WHO drew together results from seven randomised clinical trials, including data from 1,703 critically ill patients with COVID-19.
This is a powerful and compelling way to combine information and truly address the question of whether these medicines benefit people in hospital critically unwell with COVID-19.
The study, which included patients from Australia and New Zealand, found almost 33% of people treated with corticosteroids died within 28 days of treatment. This was compared with 41% of patients who received supportive care (or placebo). Corticosteroid treatment helped patients whether or not they needed ventilation or oxygen.
Importantly, the analysis also concluded the benefits were not specific to one corticosteroid drug but were the same for dexamethasone and hydrocortisone.
Corticosteroids can also have an impact on the immune system. So the researchers looked at the risk of infection from other causes, for example bacterial pneumonia, and found it was not a major concern.
The weight of evidence has led WHO guidelines this week to strongly recommend using corticosteroids to treat people with severe or critical COVID-19.
It is important to remember these findings only apply to using corticosteroids in critically ill people hospitalised with COVID-19. There is currently limited information to suggest these medicines are appropriate for people with mild COVID-19.
While corticosteroids help treat the body’s response to the coronavirus infection, they are not antiviral drugs. They do not inhibit the virus itself, so they are not a cure.
Usually, several clinical trials on a common theme are published over a series of years. Then a meta-analysis draws together their results, publishing these combined results much later.
But the amazing thing about this latest evidence is the meta-analysis included data from clinical trials published at the same time. This shows a degree of co-operation and collaboration between researchers to share data to urgently address important research questions that guide clinical care.
Evidence to guide the best treatments and management for people with COVID-19 continues to emerge. You can follow the evidence and how it’s applied in Australia here.