Risk of #COVID19 resurgence is never far away, but now we know how to target the virus instead of targeting society

Statement to the press by Dr Hans Henri P. Kluge, WHO Regional Director for Europe

20  August 2020, Copenhagen, Denmark

Good morning and welcome after a very busy summer.

The European Region has registered 3.9 million cases corresponding to 17% of the global total, that is approaching 22 million cases. The epicentre of the pandemic is now in the Americas but other regions are also seeing a steep rise in cases.

The European Region is on a trajectory of its own, showing a different trend compared to the rest of the world. The virus hit Europe early and hard. Countries made phenomenal efforts to stop the spread by locking down schools and non-essential businesses as part of a comprehensive set of measures. And this worked: between May and July many countries managed to suppress transmission. Where policy decisions were prompt and responsive, the response was effective. But the virus has been merciless where there was partisanship, disinformation and denial.

The risk of resurgence has never been far away. In the last two months, new cases have been steadily increasing every week in the Region. There were 40,000 more cases in the first week of August, compared to the first week of June, when cases were at their lowest. Every day now the European Region reports an average of over 26,000 new COVID-19 cases. This is due in part to the relaxation of public health and social measures, where authorities have been easing some of the restrictions and people have been dropping their guard.

The good news is that we now know much more about the transmissions of this virus, and in particular how it is spread indoors in poorly ventilated settings, and especially where large numbers of people are coming together and speaking loudly or singing. The challenge is that localized outbreaks and clusters are now occurring with greater frequency, often in closed settings, such as work places and care homes, or linked to specific events, social gatherings, communities, food production and other industrial facilities and travel. Recent outbreaks among vulnerable groups such as migrants and refugees illustrate how we cannot leave anyone outside of our protective efforts. The virus increases inequalities.

As summer turns to autumn, what challenges lie ahead? We must make sure that we adopt the right public health measures to enable the safe return to school, manage the approaching influenza season, sustain our economies, and address the increased health risks to older people at this time of year.

The COVID-19 pandemic has created the largest disruption of education systems in history, affecting nearly 1.6 billion learners in more than 190 countries, and our Region is no exception. Most countries in the Region closed schools at some point between February and July this year, as part of COVID-19- related public health and social measures.

The WHO European Regional Office is convening a virtual meeting for all 53 countries on re-opening of schools and COVID-19 on 31 August where concrete actions will be discussed to ensure children receive proper education in safe settings. Such options might include heightened hygiene and physical distancing in school settings for all, and the introduction of targeted measures quickly and effectively to suit local circumstances – open schools where virus levels are low; adjust school schedules and limit pupil numbers where cases are more widespread; and consider keeping schools closed temporarily in areas where community transmission is high.

I am grateful to the Minister of Health of Italy, Roberto Speranza, for being the catalyst for this initiative.

The next influenza season is also approaching fast. Now, it is critical that countries monitor flu activity and restore and reinforce routine sentinel surveillance to include both viruses, and that they promote flu vaccination for at-risk groups. This is even more important this year as we need to protect our hospitals and health workforce already coping with COVID-19, from being overwhelmed. This year, even more than previous years, we must support older people to get their flu jab early, in a safe environment.

We are not in February, we can manage the virus differently now than we did when COVID-19 first emerged.

Already in the past month, two thirds of countries in the Region have re-introduced restrictions on mass gatherings, weekend curfews and/or closure of certain non-essential businesses.

What is different is that many of these recent restrictions have been implemented locally, showing that we are learning how to apply smart, time-limited and risk-based measures, capable of reducing both the spread of COVID-19 and its impact on the wider society and economy. Today, with increased knowledge and experience we also know that some measures require nationwide and sustained implementation – including the extensive testing and isolation of all cases, and the tracing, quarantining and 14-day follow-up of contacts. With the basic nationwide and additional targeted measures – we are in a much better position to stamp out these localized virus flare ups. We can manage the virus and keep the economy running and an education system in operation.

We can save lives and livelihoods, it’s not a matter of one or the other.

Young people that they are at the forefront of the COVID-19 response and they have a powerful message to convey through their behavior and their communication.

To my daughters, to teenagers everywhere, to all of you at that exciting, adventurous point in your lives – thank you for the sacrifices you have made to protect yourselves and others from COVID-19. No youngster wants to miss a summer. But I am very concerned that more and more young people are counted among reported cases and among deaths. Low risk does not mean no risk.  No one is invincible and if you do not die from Covid, it may stick with your body like a tornado with a long tail. While young people are less likely to die than older people, they can still be very seriously affected. We are now seeing many more cases of what has been described as Long COVID, whose characteristics were summarized in a recent paper in the British Medical Journal. This affects organs throughout the body, but especially the lungs and heart, with some young and fit people, including elite athletes, suffering considerably.

The youth alike everyone has to play your part to limit the opportunity for the virus to spread by:

• Wearing a mask in situations when you will be interacting with other people – to protect them from getting infected;
• Avoiding crowds and large groups – staying away from crowded bars and big parties.
• Meet outdoors rather than inside, if possible.
• Whenever meeting in smaller groups – keep at least 1 metre apart.
• Always, always, wash your hands, and
• With any sign of symptoms – stay at home and seek testing.

To repeat my key messages:

1. We are not back in February, we know how to target the virus instead of targeting society. We became smarter.
2. To the younger members of society: spread fun, but do not spread the virus. Protect your parents and grandparents.
3. When we open society, we have to opens schools.

Thank you.

“Ten years of crisis, repeated attacks on health care, death and displacement of health-care workers, and an increase in hostilities towards the end of 2019 have all posed significant challenges for the ability of the health system in northwest Syria to respond to COVID-19,” says Dr Mohamed Altwaish, a dentist by training who serves as Public Health Coordinator for Hand in Hand for Aid and Development (HIHFAD), a WHO implementing partner in northwest Syria.

Since the first cases were identified on 9 July, COVID-19 has disproportionately impacted health-care workers, who comprise 23 (43%) of all 54 identified cases reported by WHO. This has placed significant pressure on the already fragmented health infrastructure across the region (nearly 30% of health facilities are considered nonfunctional), including in Idleb and Aleppo governorates, which have been strained by years of crisis.

He stresses the critical work spearheaded by local health-care workers to mobilize COVID-19 preparedness and response efforts in collaboration with the WHO Emergency Field Programme in Gaziantep, Turkey, and the coordination of the Turkey Hub Health Cluster’s COVID-19 Taskforce, established in March 2020.

“Even before there were cases identified in northwest Syria, health-care workers were technically and logistically mobilizing local response efforts to combat COVID-19,” says Dr Altwaish. HIHFAD worked closely with WHO to establish isolation and treatment centres for suspected cases of COVID-19, ensure access to proper personal protective equipment for health-care workers across health facilities, and scale up training for community health workers to disseminate public health advice.

Leading training efforts for community health workers is another of Dr Altwaish’s roles. “I provide 1-day trainings for community health workers to engage local communities in COVID-19 prevention efforts as well as provide them with the skills to train other non-medical staff in how to distribute and disseminate these messages.”

Health-care workers have played a vital role in fostering community awareness of the growing threat of COVID-19, which has been one of the most challenging parts of the preparedness and response effort in northwest Syria.

“Health-care workers have struggled a lot to gain the acceptance of the local community, particularly in wearing masks and practising social distancing,” Dr Altwaish says. “Stigma was an issue from the beginning, particularly when the first case was identified among a member of the health-care workforce. Individuals started to assume that if you are a health-care worker, then you must have COVID-19.” He emphasizes the resulting psychological stress and pressure on the health-care workers to ensure the safety of their patients while continuing to provide essential services.

The protection of health-care workers continues to be a priority for WHO and local implementing partners in northwest Syria. Attacks on health care – a hallmark of the conflict in Syria – have brought the number of health facilities down further and deprived civilians of basic access to medical care. Now, with COVID-19 on the rise, stigma and barriers to care have added new challenges for the health-care workforce.

“When a fellow member of the health-care workforce tested positive for COVID-19, the event was an alert to the entire community in northwest Syria to better prepare and plan and avoid this in the future.”

How does a better understanding of masculinity help us to create better mental health policies? How does a culture-centred approach to health literacy improve knowledge about sexual and reproductive health among Iranian and Afghan minority groups in Sweden? And why don’t enough people in Romania get vaccinated?

Behavioural and cultural insights are still relatively underutilized in global health. By drawing on fields outside of medicine such as the social sciences and health humanities (including anthropology, history, sociology and psychology), it is possible to develop more effective health interventions.

“Recognizing and understanding the rich and diverse social, cultural, political and historical dimensions that affect health in the WHO European Region is essential to provide actionable support to countries that is tailored to their needs,” said WHO Regional Director for Europe Dr Hans Henri P. Kluge. “The Insights Unit will help health authorities to improve how their services meet citizens’ expectations – delivering respectful and people-centred care,” he concluded.

A new unit at WHO/Europe

Recognizing that, in terms of health policies, a one-size-fits-all approach is not always the most effective, WHO/Europe identified behavioural and cultural insights as a flagship area for the Region in the coming years. It established the Insights Unit to collaborate with partners and across sectors, academic disciplines and technical areas. The Unit is guided by 4 key principles:

• evidence – draw on evidence, test and evaluate it, and disseminate good practices;
• context – generate socially nuanced, culturally sensitive, people-centred health insights;
• scale – support the scale-up of interventions with proven impact; and
• partnership – work with experts, transformers, colleagues and critics.

The Unit works to identify barriers to and drivers of healthy practices. There is ample opportunity to encourage national health programmes and health authorities to use these insights to design more effective health interventions by ensuring they are relevant to their populations.

Behavioural and cultural insights in practice

Across the European Region, there are many cases of behavioural and cultural insights being used in practice.

For example, Kyrgyzstan has experienced measles outbreaks among internal migrants with low vaccination rates. Research to identify the reasons behind these low rates showed that a legislative barrier faced by people migrating from rural to urban areas was preventing them from getting routine vaccinations – an issue that could be changed to improve vaccination coverage and prevent measles.

High rates of cervical cancer incidence and mortality in Romania also reveal how cultural contexts impact health behaviours. Historical and ethnographic research has looked at the lasting legacy of pronatalist policies introduced during the Ceaușescu regime (1966–1989) and how associations with these policies have led to considerable stigma against cervical cancer screening and human papillomavirus (HPV) vaccination. People-centred health promotion efforts that acknowledge this historical stigma are needed if policies are to succeed in bringing down cervical cancer rates in Romania.

Another example is WHO/Europe’s ongoing work to support Member States across the Region to conduct behavioural insights studies in the context of COVID-19. Knowledge about the public’s fears and worries, levels of trust and risk perceptions, as well as their views on restrictions, testing and tracing, and a future COVID-19 vaccine, helps governments shape their pandemic responses.

If you want the answers to the questions posed in the beginning of this article, listen to the Health in Europe podcast, where Katrine Bach Habersaat, Nils Fietje and Anastasia Koylyu explain examples of how behavioural and cultural insights have been used to reveal the impact of social expectations on mental health, improve health literacy and understand low rates of vaccination.

Flagship initiatives

The work of the Insights Unit contributes to one of WHO/Europe’s 4 flagship initiatives to complement the European Programme of Work, which sets out health priorities for the coming 5 years. These initiatives – the Mental Health Coalition, Empowerment through Digital Health, the European Immunization Agenda 2030, and Healthier Behaviours: Incorporating Behavioural and Cultural Insights – are intended as accelerators of change. They mobilize action on critical issues that feature prominently on the agendas of Member States and for which high-visibility, high-level political commitment can be transformative.