Today’s Updated Medical Information and Action Recommendations Regarding the Covid-19 Pandemic
20 March 2020Generali Global Assistance/Europ Assistance is issuing the following medical advice
In order to support readers of this notice, we have highlighted (in bold) the changes from the last edition March 18th 2020.
MARCH 20th 2020, 17H00 Paris time – Dr M. Kalina, EA Group Medical Director, F. Tits, RN, EA Group Sr Project Manager and J. Heywood, EA Group communication and CSR,
The purpose of this bulletin is to provide all the entities of Generali Global Assistance/Europ Assistance (EA), GEB and GGH, to the Generali Group Management, and all their clients, with a current summary and analysis of information available both in general media and especially from Chinese and international scientific sources regarding the coronavirus outbreak in and disseminated from Wuhan to other Chinese cities, and then to many countries around the world, and to make specific recommendations for each of the client groups, national travelers, expatriates in the targeted areas, and international travelers, both corporate and leisure, as well as to EA’s own staff.
Overview
This outbreak started officially December 31st 2019 in a live animal and fish market in Wuhan and is thought to originate from the Chinese horseshoe bat. It initially caused relatively few cases, was managed with energetic local isolation measures, and showed no evidence of human to human contagion. Recommendations were therefore limited to avoiding contacts with animals and patients, and no travel restrictions were advised by either Chinese or international authorities. A significant deterioration of the situation in China was reported by the media over the January 18th weekend and has been increasing ever since, first in China and then worldwide. It was confirmed the following week by the Chinese authorities, including the transmission, probably through droplets, between human beings. The disease is highly contagious but appears less severe than SARS or MERS at this stage. The proportion of severe cases has stabilized around 15% of the total number of cases. Deaths, at 3 to 4 % overall but with wide variation between high (Iran, Italy) and low (Germany, Korea), occur mostly in older people’ above 70 years of age, most with underlying diseases such as diabetes, chronic pulmonary diseases and cardiovascular diseases. 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 dyspnea/shortness of breath and feeling sick. Fever is often but not always present. The incubation is usually 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.
The World Health Organization (WHO) has congratulated the Chinese authorities for their efforts in the fight against this outbreak and their contribution to research. It declared a Public Health Emergency of International Concern on January 30th 2020 in view of the growth in the numbers and the restrictions applied by China and many countries. It supported the Chinese initiatives but strongly argued against the global spread of any measure to restrict travel as economically unsound. The WHO cooperated with IATA to standardize precautions onboard airlines and has worked with ICAO to make joint recommendations. 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. The March 3rd edition is important because it reminds all of the definition of cases. A suspect case either has a combination of fever and one respiratory symptom and a history of travel to or contact with a source of COVID or a patient with severe respiratory illness and no other etiology. The case becomes confirmed with a positive test irrespective of symptomatology. On March 5th the WHO’s director general made a strong appeal to all countries to take the situation seriously and to put in place measures to reduce the transmission of the disease. He warned against misinformation related to media spreading too many uncontrolled news and insisted on the importance of balance and coherent communications. The February 29th travel recommendations have remained unchanged, but the March 10th situation report clearly and rightly warns against any limitations in international travel not objectively founded on the reduction of infection transmission.
On March 11th the WHO’s Director General declared that this outbreak now qualified as a PANDEMIC. The next day he declared that this pandemic must be considered CONTROLLABLE. ICAO and the WHO have issued a joint statement to support guidelines to mitigate risks in the travel industry, but there is no statement regarding the maintenance or not of air travel capabilities. The focus of the recommendations remains on decreasing contacts likely to increase contamination and early access to formal isolation and proper treatment for positive cases. On March 18th the WHO’s DG Dr. Ghebreyesus, highlighted the need to insist on the focus on the four key priorities, isolate, test, treat and trace. He congratulated Korea for succeed in one month to reduce cases from 800 to 90.
Most governments are now advising that anyone showing symptoms related to COVID-19 is asked to remain isolated and to contact the emergency services (112 or the equivalent). 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 need for avoidance of contact to reduce contamination has led many countries to enforce house confinement measures similar to the ones seen in China a month and a half ago.
Travelers and expatriates have to realize that several countries have seriously reduced access to activities in their countries. When possible accelerated return to the home countries is an appropriate strategy especially if the situation at home is less challenging than at the client’s current location. First and foremost are the cancellation of any crowd event, including sport competitions and the closing of schools, but several countries have gone beyond this and reduced access to shops, to elective health care, to restaurants and early return home may have to be considered if flights are still available, sometimes through modified itineraries. Increased testing may have added value as well as improved availability of protection devices- especially masks – and essentially for caregivers and COVID-19 + patients.
Current global situation
At this stage the latest modified data available, as of 14H00 March 20th China time, the total volume of confirmed cases in China was 81337, of which 71292, a remarkable figure, had recovered and 3254 deaths had occurred. A total of 164326 cases and 6793 deaths have been identified outside of China, a continued marked increase that shows that the problem is global and currently most acute in Western Europe. The general situation of the epidemic is improving in China and the confirmed case volume is continuing to decrease as more and more healed cases, over 75% of the total cases, emerge. New cases, few of them (only 34 yesterday), continue to occur mainly at entry points like international airports. There have been no new local cases in China for two days, a legitimate source of pride and an encouragement for other countries.
Initially many countries implemented travel restrictions to and from China, but the number of affected countries has increased significantly, and many measures have been taken by many countries to reduce or forbid access to their territory to anyone directly or indirectly coming from a high contamination risk country. Therefore, it has become imperative for people to enquire about any limitations with the EA entity they are contracted with. The EA entity will contact the one in the country concerned or the agent to ensure that accurate and up to date information is provided in addition to adapted assistance services, always aligned to government advice. The number of such cases is expected to decrease as very few travelers remain and even many expatriates have left.
Europe
Italy (now the second hardest hit country with 41035 cases and 3405 deaths), Spain (18077 and 831), Germany (15320 and 44) and France (10995 and 372) have high rising number which challenge the capability of the overwhelmed health care delivery systems in many areas. The variation in the death rate may in part be linked to differences in the availability of resources.
The week of 16 March has seen the situation dramatically evolving in Europe as cases escalate. Italy took further steps to lock down the entire country and currently all travel into or out of is banned unless there are urgent reasons to do so and most governments have recommended a halt to all travel to Italy, with subsequent mass cancellation of flights. Italian citizens are being urged to remain at home unless they have an urgent health or work reason or purchase food and household cleaning products or medicine. Shops and restaurants, schools and universities are closed. Some Italian regions have also started to close down parks and ban jogging outside.
Subsequently, action has followed across the rest of Europe. The measures taken vary country per country however most countries have adopted the closure of schools and universities, sporting events and mass gatherings while others have gone further to issue travel restrictions and in the case of several countries strong measures on border control to limit entry to nationals and sometimes control health status in addition. In all cases the evolution is toward home confinement as is already the case in China, Italy, France, Belgium and Portugal.
Asia
Although it was hit early, right after China, Asia has resisted quite well with the exception of Iran, which accounts for 18407 cases and 1284 of the continents 34301 cases and 1488 deaths. Korea has a large number of cases (8413) but relatively few deaths (29). This is probably due to the strong health infrastructure response as in Japan and SE Asia. India remains a question mark. There is a rise in cases in the border regions between India and Pakistan.
The Americas
The USA now have 14340 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. The number in South America is spread out and totals 1918 cases. A number of South American countries have restricted flights to Europe while Peru and Ecuador have enforced a lockdown, similar to those seen in Europe.
Oceania
Similarly to South East Asia, Oceania has relied on the strong public health response, with a relatively low number of cases 868, with only 7 deaths so far.
Africa
Africa has a low number of cases, 799 and 20 deaths but is doing its best together with international organizations to prepare as the impact could be severe given the relatively weak public health infrastructures.
Generali Global Assistance/Europ Assistance Recommendations
In these circumstances Generali Global Assistance/Europ Assistance recommended, to first and foremost avoid any contact with patients with COVID-19, and more generally with patients with cough and fever. This is also recommended to national clients. Of course, the usual hygiene precautions should remain 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. In addition, for expatriate patients planning to remain in these countries one would suggest avoiding exposure to mass transport, visits to hospitals and clinics, as well as to markets with live fish and animals. In addition, a worldwide push to reduce social interaction between people to reduce contamination is supported by Generali Global Assistance/Europ Assistance, all the way to and including confinement for periods of weeks. We also support access to proper hospital beds, masks and testing.
For those seeking to enter or exit countries or regions with government-imposed restrictions will face severe travel distribution. Expatriate wishing to travel back, and travelers should take into account the measures and travel restrictions issued by several governments, and the fact that many airlines have temporarily suspended flights. Clearly any travel undertaken have formal restrictions were announced could be challenged cover wise. For non-essential travel to China the sensible individual decision may be to delay travel for several days until the information regarding this epidemic is more reliable. These considerations concern China, Korea, Iran and Italy as there are no medical reasons to restrict travel anywhere in Asia or the world because of the COVID-19 epidemic. There is an increasing risk that countries, Thailand, Israel, Czech Republic, Denmark or Morocco being examples, put restrictions in place for travelling visitors from affected countries thus reducing access to care even to people with no COVID-19 issue.
Our internal procedures are until further advise to ensure negative test for COVID-19 has been carried out for any EA patient with respiratory disease, who travels by air (air ambulance or commercial carrier) from any affected country to any other country. Patients no matter where they are must monitor signs of infection, fever and respiratory symptoms and follow local rules after calling their EA platform before seeking care. In general, if positive they will be asked to remain in isolation for 14 days if not very sick, or to be cared for locally.
Overall the transport of clients and the transport of patients back to their home countries has become very difficult because of both markedly reduced numbers of flights and frequently stringent restrictive regulations. The complications are even worse when the client is a patient accompanied by a nursing or medical also submitted to tight confinement rules. This even applies to air ambulance flights and the assistance staff must spend much more time and effort to reorganize flights. Regarding COVID patients the general principle is that they must treated where they are, both for their own sake and to reduce contamination risks at home. It is true that a couple of air ambulance providers have successfully managed the transfer of patients across continents, but these are very exceptional cases. We should not promote this as a regular solution.
Generali Global Assistance/Europ Assistance has provided detailed information with simple prevention measures for employees, partners and corporate clients. These will be centered on minimizing contacts by increasing work at home, reducing physical meetings, and even reducing usual means of showing friendship such as handshakes and kisses. It emphasizes the need for frequent handwashing with soap and water, plus, 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 marginally useful otherwise to protect healthy people from getting the virus.
We encourage our readers to nevertheless consider the situation as one that will be overcome, especially if 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. Generali Global Assistance/Europ Assistance cares for its clients and its employees and will do everything to help.
The current bulletin will be updated regularly until the situation stabilizes.