US, WASHINGTON (ORDO NEWS) — Following Taiwan, South Korea and China, which seem to have found a “new standard” of life after coronavirus, restrictions are loosening several European countries at once. We understand what parameters new life modes are oriented to and how priorities differ from one state to another.
On April 24, the regional office of the World Health Organization in Europe published criteria by which countries can assess their willingness to weaken quarantine measures (if, of course, they were introduced). You can briefly familiarize yourself with them in Russian-language infographics.
Despite well-grounded claims to the actions of WHO at the first stage of the epidemic – for example, it ignored reports of the transmission of the virus from person to person until official China informed about it – the organization remains the most qualified and authoritative source of information about the pandemic. It has significant expert power, and also aggregates and analyzes data for different countries. Therefore, its recommendations should be interested.
The communique emphasizes that this problem is complex and there is no universal — one fits all — solution for it. Countries are encouraged to act individually, with particular emphasis on clear communication with the public so that people understand and abide by the restrictions.
“The objective of this document is to provide countries with key principles for lifting restrictive measures and moving to the“ new norm ”. Everyone wants to return to economic activity, but you need to clearly understand that this will be a gradual process, requiring organized monitoring and, possibly, local return to quarantine where there are more cases,” said Dr. Hans Henry Kluge, WHO Regional Director for Europe .
WHO identifies six criteria, compliance with which will mean readiness to quarantine:
- There is evidence that indicates that the transmission of the virus was able to take control;
- Public health systems and medical facilities have the potential to detect, isolate, test and treat all Covid-19 patients, as well as to track and quarantine all who come into contact with them;
- Outbreak risks are minimized in facilities with a higher level of vulnerability, such as long-term care facilities (for example, boarding houses for the disabled and elderly, rehabilitation centers and psychiatric hospitals), as well as in crowded places;
- Necessary preventive measures are provided at workplaces, including physical distance, sanitary equipment for washing hands, respiratory etiquette and, possibly, checking body temperature;
- Controlling the risks of import and export of infection from regions with a high risk of transmission of the virus;
- Local communities have the right to vote and the necessary information, they are interested in and participate in the transition process.
“The situation with Covid-19 is very uneven, countries are at different stages. Some begin to remove restrictions, while others remain in strict quarantine, ”the WHO report says.
Criteria in detail
The most common metric of life outside quarantine and transition to it is based on the definition of the so-called effective reproductive number. This concept was perfectly explained by Angela Merkel in one of her speeches, answering the question about the duration of quarantine. The basic reproductive number R 0 is a characteristic of infection and represents the number of people that infects one carrier of the pathogen.
An effective reproductive number R characterizes the epidemiological situation in a particular community: how many new patients per one existing. It is easy to understand that at R> 1 the epidemic is growing – Merkel illustrates this with the forecast of hospital overcrowding in the event of quarantine removal “right now”. To get out of quarantine and live outside it, you need to be sure that the outbreak is fading – that is, the effective reproductive number does not exceed 1, and ideally less than one. This is a numerical expression of the first WHO criterion – the spread of the virus is taken under control.
The first criterion is closely related to the second in terms of tracking, testing and isolation. One can reliably determine R, obviously, only knowing the total number of cases: it was the imperceptible spread of the virus at the beginning of the year that brought mankind to where we are now. Therefore, it is important not only to identify new cases of infection by symptoms, but also to test the maximum number of contacts of this patient and quarantine those who pass a positive virus test, even if this person has no clinical manifestations of the disease. Only in this way can local flashes be prevented from growing uncontrollably.
Once the number of cases begins to increase, it is necessary to return locally to restrictive measures again, the WHO emphasizes.
In addition, the organization insists on the gradual removal of restrictions, this is due to two factors. First, the virus may have a long incubation period, up to 10-14 days. Before this time passes, it is impossible to know reliably whether the lifting of restrictions has led to a sharp increase in the incidence. The second reason is that we still do not know exactly in which situations the virus is transmitted more easily and in which it is less likely (although we will talk about some of this kind of data below). Therefore, it is important to rank measures: for example, the first exemptions relate to walks and exercises in the open air. This should be the safest – and you can find out for sure by looking at the test results after two weeks.
WHO also pays attention to the need to restructure healthcare : the organization uses the term “dual healthcare management system”. On the one hand, health care must remain highly prepared to provide assistance to infected coronaviruses, to examine and test them. On the other hand, it is necessary not only to resume the admission of patients on urgent matters in the usual mode, but also, if possible, to compensate for the forced downtime in medical care in recent months, while ensuring the epidemiological safety of all patients.
In addition, the organization focuses on two more closely related aspects: establishing communication with the public and measures to overcome the negative social consequences of the epidemic.
Without economic assistance, people will not respond to communication, and without clear and transparent communication, medical measures will not work.
When studying communications from different countries, it turned out that life is not so simple as in the WHO document. Someone does not have time to wait for the flash to decay – or quarantine does not allow it to be extinguished, that is, in fact it does not work. Someone is in a hurry to open up and pays attention to certain factors, and in many countries the procedure for removing quarantine is confused, and it is extremely difficult to trace the motivation and reasons for making certain decisions.
In Italy – March 8
Italy became the main – after China – the center of the coronavirus epidemic in late February – early March, but now it has left the front pages of newspapers and the first lines of the ratings of the number of patients: the situation has stabilized. On May 7, 1401 new infections were detected in Italy, and at the peak, March 21, there were 6,500. About as many patients were found in the country exactly two months ago, on March 8, 1492. On March 9, the first government decree was signed on a nationwide quarantine. Italian quarantine was one of the strictest in the world and was second only to Wuhan, perhaps.
The Italians could go out solely for one thing: to work in production (within three weeks – only in life support), in shops and pharmacies, as well as in cases of emergency. Even physical activity was limited to 200 meters around the house. In April, all enterprises completely restarted and bookstores opened, and on May 4, a noticeable movement began: people were allowed to walk on the street. Why, then, on March 8, with 1,400 new patients, it was necessary to close, and on May 8, to open? The point is dynamics and detectability. In the beginning, the number of patients grew – on average, 25-30% more new infections were found every day. Now the number of new patients is steadily declining. But, even worse, on this growing trend, the country had a very weak idea of how many people are sick.
For example, on March 9, about 4000 tests were done – and almost half of them were positive. Such a high percentage of detection reflects low powers: then only people with severe symptoms and confirmed contact with Covid-positive were tested (as we recall, it was very difficult to confirm their Covid status).
As of May 6, more than 70,000 tests were conducted per day – and even on weekends the number of tests does not fall below 30,000. Only 2-3% of them are positive – this is how the tracking system described by WHO looks in practice. Corriere della Sera talks in detail about this system: an operative test of the patient within 24-48 hours, testing at home or contactlessly those who interacted with him, including work colleagues, the introduction of a mobile application through which physicians can notify the population.
Italy opens up very slowly and gradually: children’s clothing stores followed the libraries, restaurants began to take away, home goods stores will open. Churches have been opened – but a limited number of people can attend masses. Although it is worth saying that masses in non-cathedral churches on non-holiday days and before quarantine could not boast of being full, so it would not be so difficult for the Church to follow precautions.
In general, almost all trade is carried away. There is a ban on any gatherings: you can only visit relatives. Museums will open on May 18 – those that can provide distance between visitors. The last to open are hairdressers, beauty salons and restaurants – from June 1, and there will be no foreign tourists in Italy this summer. Everyone is still prescribed social distance, in many regions wearing masks is mandatory even on the street.
Prime Minister Giuseppe Conte was not very good at explaining the importance of a phased opening for controlling the epidemiological situation: many thought that the procedure for opening businesses was determined arbitrarily, as if they were pulling lottos – social networks were filled with memes on this topic.
Despite the jokes, the strategy as a whole looked quite meaningful: the outbreak in Italy was widespread, so the number of new cases does not allow us to talk about returning to the “old life”, but it is economically difficult to continue quarantine. Therefore, Italy will have to rely on testing and tracking and hope that the outbreak will slowly fade as a result of social distance measures. Italian quarantine was initially one of the toughest and is being removed gradually. Schools will not open until September (Spain made the same decision).
France and Spain are catching up
A similar situation is developing in Spain, but there the outbreak began later – and up to 3,000 new patients per day still appear. Nevertheless, the authorities allowed walking with children. Spaniards can gather in groups of up to 10 people, restaurants open summer terraces (you can take only half of the places), hotels are allowed to resume work (however, travel is possible only within the province of residence).
Even cultural events are resumed: indoors – up to 30 people with 30 percent filling, in the open – up to 200 people. It is worth noting that not the whole country is moving to weakening measures (the first phase of quarantine removal). In the zero phase – quarantine – there remain Madrid, Barcelona and a few more particularly affected cities in different parts of the country.
In France, which entered the mass phase of the epidemic after Italy and Spain – at the end of March – the outbreak is also largely suppressed. Every day, on average, no more than a thousand new infections are detected – most in Paris and in the east, on the German border.
The weakening of quarantine began on May 11, while efforts are focused on restarting production and ensuring transport safety. The opening of schools remained at the mercy of local authorities, travel is limited to a hundred-kilometer radius from the place of residence. Borders remain closed.
Scandinavia without Sweden
Norway and Denmark – and Finland along with them – show an example of successful early outbreak suppression. Having discovered in mid-March a massive import of coronavirus – mainly from ski resorts in the Alps – countries launched mass testing and quickly introduced quarantine. As a result, the outbreaks did not enter the phase of explosive growth, and in no country did the situation of overloading the healthcare system arise. In Norway, for several weeks now the number of new patients has been at around 30 people a day, in Denmark and Finland – about 100 people a day.
Such an amount is feasible for tracking deployed testing capabilities. Quarantine itself was initially very soft: economic activity was limited, schools closed, but people walked quietly. Apparently, governments understood that they could afford it because of a rather low number of cases. In Denmark, general quarantine was introduced before May 10, but kindergartens and elementary schools opened on April 14. In Norway, gardens opened on April 20, and an elementary school on the 27th.
Germany is a big champion
Like the Scandinavian countries, Germany managed to prevent and prevent the collapse of hospitals, which had a beneficial effect on mortality rates: in Italy and Spain, more than 500 people per million people died, in Germany it’s only 90. Now the number of new infections is kept at level below a thousand a day. The stiffness of quarantine in Germany differed depending on the region: the rules were stricter in the outbreaks in Bavaria, North Rhine-Westphalia and Baden-Württemberg, and in other regions the rules were initially more liberal. Restrictions have less affected industry: there the focus has shifted to ensuring the safety of production. Also, more stores remained open – for example, construction along with grocery stores.
Now all retail outlets will be able to open – the only condition will be to ensure hygiene and distance for customers. Wearing masks is required in the store and public transport. Schools will open their doors to primary schools and students who need to take exams. In full mode, offline education should be restored gradually during the summer semester (it lasts in Germany until August). Berlin also announced the opening of restaurants – but with incomplete occupancy and subject to an order in its name to notify in case of contact with the sick.
However, the main news about quarantine removal in Germany is the resumption of the Bundesliga matches. The players have already begun training, the first matches will be held (of course, in the empty stands) on May 16.
Quarantine removal measures have now been officially approved by the government, and specific decisions have been transferred to the ground level (although Angela Merkel noted that the “emergency brake” can be applied at any time if the situation worsens again). Regional regulation is easier for Germany with its strong federal structure, while unitary France, Italy and Spain at the level of political culture are more likely to take uniform measures for the whole country – which is not always reasonable in the context of a pandemic.
When quarantine worked
Almost all European countries have submitted quarantine removal plans: the outbreak of coronavirus has waned. This applies both to the Netherlands and Belgium, where the incidence was quite high and led to a large number of victims, and to countries in Central Europe and Greece, where quarantine was introduced in advance and the number of cases was not large. Belgium and the Netherlands are focusing on opening schools – as is culturally close Northern Europe. It is noted that the poorest students and children from complex families suffer most without schools: they receive food and protection at school.
Starting May 4, Poland immediately opens large shops, hotels, and museums. Austria opens schools during May and promises to provide access to attractions from the end of the month. Ireland also quarantines, but slowly: most of the changes are scheduled for July, only stores will open on June 8.
Slovakia lifted several bans on May 4 at once, and this is one of the few countries that clearly articulates the criteria for successful quitting. Prime Minister Igor Matovich explained that social distance measures should be in place so that during each week the average number of new patients per day does not exceed 100.
Greece, which managed to effectively suppress the outbreak, has gone further and plans to open this summer for tourists. The beaches of the country are available to residents from May 4, and the efforts of local scientists are aimed at understanding how to ensure the safety of guests in viral conditions.
No major changes
A special category is the countries that initially introduced quarantine in a mild form or with a delay and instead of a peak of new infected people reached a plateau. These are the United States (about 30,000 cases a day since the beginning of April and more than 80,000 deaths), the United Kingdom (four to five thousand new patients a day from mid-April, the second largest number of deaths in the world – more than 32,000) and Sweden (about 700 new patients per day since the beginning of April).
In the United States, the pandemic issue is highly politicized: rallies are being held against quarantine, and President Donald Trump has long denied it. A month-long delay with the start of mass testing overlapped the problem of disunity . As a result, the strategy to combat the epidemic was left to the local authorities.
In some states — California and Washington in the north-west of the country — governments have been able to take early, proactive measures and suppress the outbreak without major casualties. The disease curve also went down in New York, although measures were taken there late and led to a collapse: images of field hospitals in Central Park circled around the world.
However, an increase in the incidence rate is now provided at the expense of other states, and some – for example, Georgia – are in a hurry to remove the restrictions, although experts unequivocally say that testing capacities in the USA are not enough now to safely quarantine such an increase in patients.
The testing situation is unsatisfactory in the UK as well , but Boris Johnson is not talking about quarantine cancellation there. Expert fears are not unfounded: testing coverage and monitoring of new cases are the main points of the WHO recommendations on how to exit the restriction regime.
As for the strategy of Sweden, it raises more and more questions not only among experts, but also among the inhabitants of the country . Although the restrictions imposed are more serious than it might seem from the outside, now a comparison of Sweden and its neighbors in Denmark and Norway does not speak in favor of those who choose a no-guarantee scenario. More than 75% of Swedes now advocate toughening quarantine .
Instead of output
Countries leaving quarantine follow WHO guidelines with varying degrees of success, and comparisons should be made with great care. So, test coverage is not enough to normalize to the country’s population: you need to calculate how many tests fall on one Covid-positive. The number of cases and deaths per million of the population allows us to assess the complexity of the situation, but the readiness to contain is determined by how many new patients are registered every day.
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