TODAY’S UPDATED MEDICAL INFORMATION AND ACTION RECOMMENDATIONS REGARDING THE COVID-19 PANDEMIC

JULY 10th, 2020, 16H30 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 yet complete information update with an analysis focused on information regarding COVID-19 and recommendations regarding the management of its impacts.

Sources:  the most reputable international sources such as WHO, Chinese CDC, CDC, international media, medical institutions and journals etc. and government websites.

Target: Generali Global Assistance/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 23^rd 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 11^th. 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, while maintaining precautions in place.  Local small outbreaks after deconfinement 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 general director of WHO’s Eastern Mediterranean region, which includes Western Asia made a stern warning on June 10^th 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 then. Pakistan, Iran and Saudi Arabia alone accounted for more than 50% of the regional cases and the director insisted on the necessity to maintain social distancing and other preventive measures. Dr. Tedros, the head of the WHO, earlier this week warned again about 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 over 11 million total cases have occurred in the Americas, a quarter of the world cases are in the USA, which reported their highest number of new cases, over 53 thousand late last week, by far not only a reflection of the number of tests, but of the high level of transmission. WHO Director General Dr. Tedros has emphasized on July 2nd “the importance of focusing on a comprehensive approach to respond to the pandemic, not testing alone, not physical distancing alone, not contact tracing alone, or no masks alone, but doing all of those.” On July 9^th he announced that an independent commission led by Ms. Clark, former prime minister of New Zealand and Ms. Sirleaf, former president of Liberia, would examine the performance of the WHO in responding to the COVID-19 crisis.

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, 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, and at a higher risk with underlying diseases such as diabetes, chronic pulmonary diseases and cardiovascular diseases. On May 10^th, 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 27^th 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 13^TH 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 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 Generali Global Assistance/Europ Assistance 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 rooms. Access 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. It must be noted that the termination announced July 4^th of the Solidarity study on hydroxychloroquine and lopinavir / ritonavir concerns only the in-hospital branch. The outpatient and prevention branches are still ongoing. 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 in June 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 GENERALI GLOBAL ASSISTANCE/EUROP ASSISTANCE, 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 14H00 July 10th Beijing time, from the Chinese CDC and from the WHO, July 9th 2020, 10H00 CEST, a total of 12394974 cases and 557505 deaths have been identified worldwide, a continued marked increase that shows that the problem remains 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. In Africa, which had been quiet so far, a 25% increase was documented in the last week. Some fear that the start of the fall in the southern hemisphere will be detrimental.

Europe 

Italy, with 242363 cases and  34926 deaths, Spain (300136 and 28401), France (170094 and 29979), Germany (199198 and 9125), the UK (287621 and 44602) and now Russia (707301 and 10843) 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 85447 cases and 4648 deaths, Asia has resisted quite well with the early exception of Iran, which accounts for 250458 cases and 12305 deaths and a bit of a worrying growth in Turkey (209962 cases and 5300 deaths). Israel has a high number of cases, 34825 given its small size but a remarkably low number of deaths, 348. South Korea has a comparatively low number of cases, 13293, very few of them recent except for a very recent small cluster, but few deaths (287) as has Japan (20371 and 981). This is probably due to the strong health infrastructure response and access to easy screening as in Japan and SE Asia. India has been hit much harder recently. It has 795605 cases and 21632 deaths.

The Americas

The Americas overall have more than half the worldwide cases and deaths. The USA is the country with the most cases, 3219999 as well as the most deaths 135822, 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 that has lasted since. 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 (1759103 cases and 69254 deaths), Peru (316448 cases and 11314 deaths), and Chile (306216 cases and 6682 deaths) have high numbers, and Mexico is growing as well, with 282283 cases and 33526 deaths. 

Africa

Africa still has a relatively low but growing number of cases and 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. The 25 % increase in the overall number of cases for the continent in the last week is a source of concern. So far South Africa is reporting the highest figures (238339 cases and 2844 deaths). The continent as a whole has 49313 cases.

Generali Global Assistance/Europ Assistance Recommendations 

In these circumstances Generali Global Assistance/Europ Assistance 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 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 working 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.

Generali Global Assistance/Europ Assistance 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 and reducing physical contact, and even reducing usual means of showing friendship such as handshakes and hugs. 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. It is important to also encourage the strict adherence to these measures outside of the work environment.

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. Generali Global Assistance/Europ Assistance 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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