Today's Updated Medical Information and Action Recommendations Regarding the Covid-19 Pandemic

July 1, 2020

JULY 1st, 2020, 18H00 Paris time – Dr M. Kalina, EA Group Medical Director, F. Tits, RN, EA Group Sr Project Manager, C.Jannuzzi and J. Heywood, EA Group communication team.


The purpose of this bulletin is to provide a crisp, quick information update with an analysis focused on information regarding COVID-19 and recommendations regarding the management of its impacts.


Where is the information sourced from:  the most reputable international sources such as WHO, Chinese CDC, CDC, international media, medical institutions and journals etc. and government websites.


Who is this bulletin prepared for: GMMI, Europ Assistance and Generali employees, managers, clients, insurers, travelers, expatriates, partners and … anyone interested! 


Overview / Historic reminder 


In December 2019 a cluster of an apparently new kind of viral infection was first recognized in a Wuhan market, initially transmitted from animals (most probably a bat according to the WHO’s April 23rd report) to man but man to man transmission quickly developed with a rapid deterioration into a local epidemic in Hubei province. While there have been allegations that the virus could originate from a research laboratory, there is no objective evidence in this regard. The unfortunate coincidence with the Chinese New Year and a large number of Chinese people travelling both in country and abroad contributed to the rapid spread of this novel virus. The outbreak deteriorated in China in mid-January and forced the Chinese authorities to take stringent measures to confine the people and reduce transport, first in Wuhan and Hubei province and then in the whole country. Exported cases started to be reported at the end of the month in countries such as South Korea and Japan, and individual cases, initially often of Chinese origin or having travelled to China, were notified in several countries. The situation evolved rapidly, and restrictions in air travel began to be imposed. On January 30th the WHO declared a Public Health Emergency of International concern. On February 11th 2020 to be coherent with international virus and disease naming rules the International Committee on the Taxonomy of Viruses renamed the virus SARS-CoV-2 and the WHO named the disease COVID-19. In late February and early March new major outbreaks occurred in Iran and Italy, seeing a huge growth in the epidemic, which was now affecting over one hundred countries and territories. The WHO declared a PANDEMIC on March 11th. At that time, and as the situation in China was starting to improve, many countries in Europe introduced lockdown measures starting by Italy, extending rapidly in Western Europe and on most continents including countries like India or more recently in the USA, South America and Africa. In recent weeks the USA have remained a major area of growth of the numbers of affected people and deaths, with Russia and  South America, mainly Brazil and now Peru, recently becoming a very serious concern, while eastern Asia first and now Western Europe are starting gradual deconfinement and resuming activities, including the resumption of football matches, while maintaining precautions in place.  Local small outbreaks after deconfinement in South Korea, Germany and Wuhan, and since last week in Beijing, are useful warnings that all protection measures are still very important to follow. So far there have not been any reports of significant recurrences after deconfinement was initiated but authorities are carefully monitoring numbers, and lots of local outbreaks have been documented. The director general of WHO’s Eastern Mediterranean region, which includes Western Asia made a stern warning on June 10th about the worsening situation in his region. The number of cases has grown very steeply in the last three weeks to 670000 along with 15000 deaths in the region. Pakistan, Iran and Saudi Arabia alone account for more than 50% of the regional cases and the director insisted on the necessity to maintain social distancing and other preventive measuresThe current outbreak of 184 cases in Beijing must be considered as a local resurgence that will be controlled and not as a second wave, as criteria – so far at least - are not met. Dr. Tedros, the head of the WHO, yesterday warned againabout not being overly optimistic, especially in countries in Asia and Europe who are beginning to further loosen restrictions. The pandemic is still ACCELERATING. Half of the 10 million total cases have occurred in the Americas, a quarter of the world cases are in the USA, and many countries reported their highest number of new cases yesterday.

 

Clinical picture  


The disease is highly contagious although it appears that it may be less severe than other coronavirus diseases such as SARS or MERS at this stage.  Lockdown measures have been shown to reduce contagiousness: a French study showed that it reduced the reproductive number (the number of people infected by each case) from 3.3 to 0.5 (84% reduction). The proportion of severe cases has stabilized at around 15% of the total number of cases. Deaths, at around 4% to 5 % overall initially but now just below 7 %, and with wide variation between high (UK, France, Italy, Spain) and low (Germany, Austria, South Korea, Japan), occur mostly in older people above 70 years of age, and at a higher risk with underlying diseases such as diabetes, chronic pulmonary diseases and cardiovascular diseases. On May 10th, The WHO reported a possible increase of the risk of worsened outcome in patients ACE (angiotensin converting enzyme) inhibitors. The WHO also reported on May 27th that outcomes in smokers could be worse than in non-smokers, contrarily to what had been initially thought by some. The signs and symptoms to watch for are first of all contact with a proven or potential case or environment, then respiratory symptoms like cough and shortness of breath, and feeling sick, with often head and muscle aches. Fever is very often but not always present. The WHO is stating that cases are the most infectious in the first three days of the symptoms. A significant incidence of anosmia (loss of smelling sensation) is also reported. The incubation period usually lasts 3 to 7 days, rare cases are transmitted from symptom free patients, and the maximum is currently thought to be 14 days although there may be cases exceeding this length. In cases requiring admission to the intensive care unit for assisted ventilation, and often for ECMO (extra-corporeal membrane oxygenation), the duration of stay is usually long, between two and three weeks (sometimes even more), and is followed by a need for rehabilitation.  Some people retain chronic symptoms. During the unlocking phase protection measures must be in place. The WHO has published guidelines regarding unlocking, and in particular on re-opening of schools May 13TH and the need for a balance between protection against COVID and attention to potential social and educational losses.


Key protection measures  


The key preventive measures are targeted towards avoidance of contact with potential sources of contamination, hygiene and strictly restricting diagnosis and treatment to facilities designated by the authorities.  The key measures are to decrease contacts; therefore, travel has decreased over 90% and countries have introduced lockdowns that lasted or should last at least two months in most cases. Maintaining social distancing – especially during the unlocking phase - and isolation at home are key measures to reduce contagion. In addition, hand washing, disinfection and wearing masks for care and service providers, as well as for the public when in contact with others, are the key. Wearing masks in public places and good availability of testing have been associated to better resistance to the spread and impact of the epidemic. The same is true of the rapid identification and isolation and care of contacts.


Treatment 


Access to regular treatment of usual diseases is limited and a lot of elective interventions have been cancelled during lockdowns. There is also a concern regarding the decrease in accessibility to regular vaccination programs, which enhances threats such as for instance measles. This may have been a source of increased morbidity and mortality. If someone feels symptoms possibly related to COVID-19 they should use the local public designated numbers. They can also access help lines like the ones provided by GMMI for their employees. Some people will need to be examined and tested. Examination by family doctors and house call doctors are always preferable to attempting to visit crowded clinics, hospitals or emergency roomsAccess to testing is currently variable between countries, with some restricting the tests to public institutions, some to PR only and others more liberal and showing an opening to serology testing as well. Serological tests enabling the detection of antibodies are now being added and will help to determine immunity status. Access to tests and masks is increasing after initial shortages. Similarly, several scientific studies are underway to investigate the objective value of several treatment modalities such as antiviral drugs, or hydroxychloroquine.So far there is no clear evidence that any treatment works well enough to be recommended as a standard. The only exception is cortisone in the very acute phase, which has been supported this week by the WHO on the basis of mainly British evidence. Similarly, many groups are conducting research on vaccines, and a few early successes have been mentioned. This said no vaccine should be available before the very end of this year at the earliest. Obviously due to the huge decrease of flight availability not only tourists and expatriates have trouble returning home, but also providing a challenging environment for assistance companies such as GMMI, specializing in repatriations. Exceptional evacuation of even COVID cases from isolated places or overwhelmed regions happens occasionally using air ambulances. Several companies offer specialized transport units, but clearly such evacuations are very complex to organize and expensive. Of course, sadly, the repatriation of mortal remains has also been a complicated task. The cases admitted to hospital can normally be offered especially oxygen supplementation and tight surveillance, but many have to be admitted to intensive care. The duration of the stay as already mentioned is up to two or three weeks with heavy physical and psychological rehabilitation needs.

 

Current global situation      


At this stage the latest modified data available, most as of 16H00 July 1st Beijing time, from the Chinese CDC and from the WHO, June 30th 2020, 10H00 CEST, a total of 10599631 cases and 514292 deaths have been identified worldwide, a continued marked increase that shows that the problem remains truly a pandemic and is currently still quite acute in the United States, now mostly in southern states, which accounts for almost a third of all cases in the world but is active on all continents and especially worrying in South America and the Middle East today. As warned earlier the pandemic is accelerating worldwide and our full attention is required. China is now mainly concerned about imported cases especially along its north-eastern border at this stage and has stopped allowing foreigners to enter the country. The beginning of a post crisis situation is also noticed in Korea and some European countries, notably Austria. A “high plateau” situation followed by a steady decrease of cases is currently observed in western Europe including Italy, France and Spain. Several countries in Asia and Western Europe have initiated gradual deconfinement measures. As mentioned earlier local clusters even in highly performing countries like South Korea or Germany serve as a reminder that a high level of caution is still required.  At the same time South America and the Middle East are hit hard. Some fear that the start of the fall in the southern hemisphere will be detrimental.


Europe


Italy, with 240578 cases and  34767 deaths, Spain (296351 and 28355), France (164801 and 29843), Germany (195832 and 9052), the UK (312694 and 43730) and now Russia (654405 and 9536) have high numbers which have challenged the capability of the overwhelmed health care delivery systems in many areas before the current improvement. Unfortunately, many senior homes have in particular become clusters for death cases in many countries.


Asia


Although it was hit early, right after China, which has reported 85232 cases and 4648 deaths, Asia has resisted quite well with the early exception of Iran, which accounts for 227662 cases and 10817 deaths and a bit of a worrying growth in Turkey (199906 cases and 5131 deaths). Israel has a high number of cases, 25244 given its small size but a remarkably low number of deaths, 320. South Korea has a fairly large number of cases, 12800, very few of them recent except for a very recent small cluster, but few deaths (282) as has Japan (18593 and 972). This is probably due to the strong health infrastructure response and access to easy screening as in Japan and SE Asia. India and the South Asia region have been hit harder recently. India has 585792 cases and 17410 deaths.


The Americas


The USA is the country with the most cases, 2727996 as well as the most deaths 130123, and the government has acknowledged the extent of the challenge and began to restrict travel into the country, with week March 16 seeing the introduction of a travel ban to a number of European countries. California was the first state to introduce a lockdown, followed by others including New York, which was the hardest hit state in the country but is now under control. Florida is currently hit hard as are Texas and California. Some states are already loosening their lockdown despite high numbers and deaths every day. The numbers in South America are uneven but Brazil (1408485 cases and 59656 deaths), Peru (285213 cases and 9677 deaths), and Chile (279393 cases and 5688 deaths) start having large numbers, and Mexico is growing as well, with 226089 cases and 27769 deaths. 


Africa


Africa has a low but growing number of cases but is doing its best together with international partners and NGO’s to prepare as the impact could be severe given the relatively weak public health infrastructures. So far South Africa is reporting the highest figures (151209 cases and 2657 deaths). The continent as a whole has 297290 cases.


GMMI Recommendations 


In these circumstances GMMI recommends to:


1)   First and foremost, realize that this pandemic is a very damaging worldwide phenomenon and the more all of us take it seriously the lesser the worldwide health, sociological and economic impacts. Worldwide the problem is still growing.

2)   Avoid any contact with patients with COVID-19, travelers from regions with a high incidence of COVID 19, and more generally with patients with cough and fever. When contact is required for help, protection by distance and if available masks is important.

3)   Follow the usual hygiene precautions as a priority considering that regular handwashing, disinfection and adequate use of mask wearing, especially in public transport and crowded places, are part of these essential hygienic attitudes. The cleaning of facilities, including air conditioning systems is essential. The use of masks in crowded public places and especially public transport is more and more an approach country favor with now scientific support.

4)   Accept the need for a worldwide push to reduce social interaction between people including long distance transportation to reduce contamination. From the corporate and company standpoint maximization of work at home is the key action when feasible. Workplaces and schedules have to be adapted to increase this in order to reduce on site contamination by reducing both the density of workers at any time. Going forward a balance between office and home-work will be required.

5)     Accept the current drastic reduction in access to travel means when not required for functions such as international health programs.

6)     Plan to maintain the current restrictions at least partially over time and take home the lessons learned regarding contagious disease prevention for the future

7)     Support our local health care system and facilities helping fragile people such as the old people homes.

8)     Maintain communications with colleagues, friends and families to reduce the risk of depressive reactions to the situation.

9)  Carefully design deconfinement plans that should be gradual and supported by much increased preventive measures and carefully monitored. The use of both PCR and serological tests to at least selected segments of the population may be an asset.


GMMI has provided detailed information with simple prevention measures for employees, partners and corporate clients. These are centered on minimizing contacts by increasing work at home, reducing physical contact, and even reducing usual means of showing friendship such as handshakes and kisses. It emphasizes the need for frequent handwashing with soap and water, and, wherever appropriate alcoholic disinfectant. These should be provided at offices. Masks should be used by anyone dealing with potential patients, people living in the same room as suspect cases, and of course people with symptoms. They are useful otherwise to protect healthy people from getting the virus in crowded environments including meetings, are very efficient to prevent infected people from contaminating others and are seen as a strong signal to enhance the efficacy of other measures. Frequent team e-contacts allow the maintenance of professional activities, team spirit and morale. Establishing access to psychological support is a useful component of a COVID centered service package. Deconfinement and the return to office work must be carefully planned with reduced attendance, flexible schedules, redesigned safe spaces and strict enforcements of procedures. 


We encourage our readers to nevertheless consider the situation as one that will be overcome, especially if personal hygiene and governmental restrictions are adhered to, and to remember that most people affected will not be seriously ill. The key is adherence to public health advice. GMMI cares for its clients and its employees and will do everything to help. We want to thank all of you who are providing care and assistance to the most fragile people in our communities.


The current bulletin will be updated regularly until the situation stabilizes.

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