Published March 24th, 2020
The current bulletin will be updated regularly until the situation stabilizes. Find more articles about COVID19 in our blog.
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 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 and increasing ever since.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 around 4 % overall but with wide variation between high (Iran, Italy) and low (Germany, Austria, South 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. A significant incidence of anosmia (loss of smelling sensation) is now also reported. 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 cooperates with IATA to standardize precautions onboard airlines. 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.
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 positive patients. Given reduced air traffic and increased administrative restrictions at borders, travel is more and more difficult for clients even returning home in good health. These constraints are even worse for escorted commercial flights as escorts run the risk of being quarantined, and the risk exists as well for air ambulances. Transport of COVID positive cases although reported in very rare cases must not be considered as an option at all. Local care in suitable facilities is by far preferred.
Current global situation
At this stage the latest modified data available, as of 14H00 March 23rd China time, the total volume of confirmed cases in China was 81649, of which 72847, a remarkable figure, had recovered and 3276 deaths had occurred. A total of 257700 cases, only 25229 healed and 11437 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, continue to occur mainly at entry points like international airports. There have been no new local cases in Hubei province, the starting point of the epidemic, yesterday, a legitimate source of pride for China 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 travellers remain and even many expatriates have left.
Europe
Italy (now the second hardest hit country with 59138 cases and 5476 deaths), Spain (28768 and 1772), Germany (24852 and 94) and France (16018 and 674) have high rising numbers 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 but the interpretation must be careful as there may well be differences in the way the numerator is calculated.
The week of March 16th 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.
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, and many other countries. Several countries and regions have added curfews to further reduce transmission potentials.
Asia
Although it was hit early, right after China, Asia has resisted quite well with the exception of Iran, which accounts for 21638 cases and 1685 deaths of the continents 42005 cases and 2008 deaths. South Korea has a large number of cases (8961) but relatively few deaths (111). 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 35211 cases as well as 509 deaths, 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, followed by others including New York. The number in South America is spread out and totals 4186 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 1770, and with only 7 deaths so far. New Zealand will enter into a European style lockdown, closing all non-essential activity within the next 48 hours.
Africa
Africa has a low but growing number of cases, 1459 and 49 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.
GENERAL RECOMMENDATIONS
Of course the usual hygiene precautions should remain a priority considering that regular handwashing, disinfection and adequate use of mask wearing, especially in public transports and crowded places, are part of these essential hygienic attitudes. In addition for expatriate patients planning to remain in these countries one would suggest to avoid exposure to mass transport, visits to hospitals and clinics, as well as to markets with live fish and animals.
For those seeking to enter or exit countries or regions with government imposed restrictions will face severe travel distribution. For expatriates wishing to travel back and for travelers the individual decision 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.