Lancet Respiratory Medicine
Apr 2020 Volume 8 Number 4 p321-422, e14-e26
COVID-19: delay, mitigate, and communicate
The Lancet Respiratory Medicine
On March 11, 2020, WHO declared COVID-19 a pandemic and has called for governments to take “urgent and aggressive action” to change the course of the outbreak. As of March 12, 2020, the USA has suspended all travel from 26 European countries, and Italy is the latest country to enforce widespread lockdown measures to curb the spread of the virus. Robust plans and policies to avoid the disease trajectories seen in the worst-hit countries are urgently needed. These responses must be proportionate to each country’s situation and communicated in a clear and balanced way to avoid spreading fear and panic.
The UK preparedness plan for tackling COVID-19, informed by WHO guidance and launched on March 3, 2020, includes four phases: containment, delay, mitigation, and, alongside these, research to better understand the disease and its effects, and to address the challenges of imperfect diagnostic approaches and absence of proven treatments or a vaccine. Containment measures, aimed at preventing the disease from taking hold, are broadly in line with those of other European countries at a similar stage in the outbreak, encompassing early detection, isolation, and care of people already infected, with careful tracing and screening of their contacts. These measures might have staved off a sharp rise in cases, as seen in Italy, for now but case numbers are inevitably climbing. Although the controversial containment measures used in China have bought some time for other regions of the world, such strategies are unlikely to be replicated in Europe. The example of Singapore could be informative for many countries: having learned lessons from the severe acute respiratory syndrome epidemic of 2002–03, Singapore has so far managed the outbreak well, with rapid testing of suspected cases, clear public health messages from the outset, and by individuals taking action to protect themselves and others.
With cases approaching 500, the UK has now moved to the delay phase, a decision that has been criticised for coming too late. The delay phase aims to slow the spread and push the peak impact away from the winter season to reduce pressure on an already overstretched NHS. Social distancing strategies, some of which are already in place in other European countries, such as the cancellation of conferences and other large gatherings, reducing non-essential use of public transport, and closure of schools, are under consideration but yet to be implemented in the UK. Rather, simple but important containment measures such as handwashing are being promoted, as is self-isolation for 7 days for those with symptoms, which is thought to be more effective than school closures and bans on mass gatherings. Although the list of countries imposing tight restrictions on people who have travelled from regions with high caseloads is growing, the UK is unlikely to follow suit, and WHO does not recommend large-scale international travel restrictions or closure of borders owing to the major implications for trade, international collaboration, and supply chains for food and resources, including medical equipment. Decisions about delay strategies must be scientifically based and clearly justified to the public—via all communication platforms, including social media—to counter misinformation and avoid fuelling panic.
Mitigation planning for widely established infection—as seen in China, Italy, Iran, and South Korea—is essential to enable optimum care for patients, maintenance of essential hospital services, and provision of ongoing support for infected people in the community to minimise disruption to society, public services, and the economy in the event of a prolonged pandemic. The higher rates of severe or fatal cases in Italy compared with other countries with major outbreaks (eg, South Korea) might reflect the older population in affected regions of Italy and highlight the need to tailor mitigation plans to local demographics. Many health systems will be stretched beyond capacity by the demands of increasing COVID-19 caseloads. In the UK, for example, intensive care unit (ICU) bed numbers per person are already worryingly low compared with those of other European countries, so thorough surge capacity planning is needed. Interim strategies with makeshift intensive care facilities outside ICU settings could be provided to care for less severely affected patients, but such an approach would not be sustainable in the long term. Support for health-care professionals on the frontline should also be prioritised.
All governments must now take decisive action to more aggressively combat the outbreak. COVID-19 represents a substantial risk to large sections of the population, and especially elderly people and those with pre-existing health conditions. As the outbreak progresses, balanced, coherent, and consistent public health communication, based on science, will be essential.