COVID-19 response and recovery: What are we missing?

COVID-19 response and recovery: What are we missing?

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Time article published on March 19 offered five important lessons from the 2014-2016 Ebola crisis, an epidemic that resulted in massive loss of life and economic disruption in West Africa, in order to offer critical guidance on the current COVID-19 crisis. In the few days since that article was published, we have seen nations and localities take up these suggestions in an attempt to contain and quell the public health impact of the virus, with varying degrees of success. We also have witnessed a growing tension between the public health response to reduce infection rates and the economic ramifications of stay-at-home (or shelter-in-place with exceptions) and other social distancing directives.
As public health and development researchers, and members of a team that evaluated select Ebola post-response recovery activities in West Africa, we are offering additional considerations for response and recovery, based on our subject-matter expertise and what we learned from that evaluation. Given that we are in the midst of a dynamic public health emergency, it is challenging to strategize about much more than the health issue at hand. However, we are calling on local, national, and multinational policymakers around the world, in the health, economic, and development sectors, to reflect on some longer-term ideas, because prospective thinking is critical for an effective and comprehensive management of, and recovery from, this growing pandemic. This is particularly true given the staggered nature of COVID-19’s outbreak timelines around the world and the potential for successive waves of infection.
Lesson 1 – At-scale identification of active infections and survivors is needed for disease containment, the management response, and system recovery. 
 
Many have underscored the importance of testing and the ability to bring tests to the community, particularly to facilitate disease containment. Rapidly mobilized, frequent, and widespread testing is a driver of South Korea’s successful outbreak response, which has dramatically lowered its infection rate in a matter of weeks.
However, testing capacity has lagged elsewhere. In the US, despite progress to scale-up, continued critical shortage of tests and testing supplies has led some hard-hit localities to forgo tests unless doing so would alter the course of an individual’s treatment. In India, the world’s second most populous country, approximately 20,000 tests have been administered to date, leaving some experts concerned that inadequate testing may be creating a false sense of the extent of community spread. In Nigeria, Africa’s most populous country, fewer than 200 tests had been administered as of March 22 — one month after confirming its index case.
Taking a longer view, we anticipate early and effective identification of COVID-19 survivors to be a critical component of future waves of the response and of the post-response recovery. Thus, not only should testing expand to identify symptomatic and asymptomatic active infections but, as antibody tests are developed, they too should be widely used to retroactively identify survivors who may have been unable to obtain a test during the early shortages and who now might safely engage without risk of reinfection.
Survivor identification can help to lessen impact on the economy and prevent additional community spread if survivors are among the first to be put back to work.  Allowing survivors back into the workforce as soon as possible also can restimulate the non-essential service economy. In West Africa, Ebola survivors were redeployed to their work posts or other essential services as possible, which helped lessen the negative impact of the disease on severely affected communities. Survivors of COVID-19 could also  safely provide non-technical medical support to hospital teams, restock stores, and provide customer facing services (e.g., serve as cashiers, deliver food and supplies to home-bound patients, etc). The strategies used by communities should be adjusted to their specific situations.
We caveat these ideas with an acknowledgement that the microbiology and epidemiology of COVID-19 differ in many key ways from Ebola, as well as from COVID-19’s close relatives SARS, MERS, and the other coronaviruses that cause the common cold. As information about COVID-19 rapidly evolves, so too does understanding of the duration of infectivity in symptomatic and asymptomatic patients and the period of immunity following infection — fundamental insights on which hinge the potentiality of some of our ideas.
Lesson 2 – A common learning agenda and a system for monitoring and evaluating the response can better prepare us for the post-response recovery.
 
The COVID-19 emergency will eventually give way to a post-response recovery, to address the mid- and long-term needs of affected communities and strengthen preparedness for potential outbreak cycles, which epidemiologists warn are likely. To this end, prospectively identifying the learning and information needs for the post-response recovery is critical. In addition, an investment must be made in designing and deploying a strong monitoring, evaluation and learning (MEL) system to predict secondary outbreak waves and inform adaptive management during the recovery.
Early in the 2014-2016 Ebola epidemic, traditional epidemiological approaches were used to forecast changes in infection rates and geographic spread. Big data subsequently were used with the hope of containing the outbreak, albeit with limited effect due to faulty assumptions about the meaning behind the data. The post-response recovery was initially challenged by an inundation of implementing partner data of varied quality and delivered in Excel-based templates, which was burdensome to analyze and difficult to use for adaptive management.
Across localities and countries, current COVID-19 data collection efforts are primarily oriented towards establishing basic facts such as the number of confirmed cases and known outcomes in terms of recoveries and deaths by location. In addition, clinical datasets contain information on symptom onset and risk factors, and some countries have collected vast troves of data through contact tracing. Others are undoubtedly tapping big data in the hopes of answering urgent questions. But, rather than haphazardly collecting and processing vast amounts of data, a more coordinated approach would deliver relevant, trustworthy and right sized data that can produce meaningful and action-oriented insights.
We need a common learning agenda that will drive data collection, while the emergency response is unfolding, which will put us in a position to manage the response and recovery better. For example, to predict where the potential seasonal resurgence of the virus might have the highest impact, what do we need to collect now? What kinds of data are necessary to inform the recovery strategy and its implementation? Should we be collecting population data on immunity? Now is the time to identify and prioritize what we will need to know, for what purpose, and where to find the answers.
Lesson 3 – Early identification and deployment of support services, including a focus on stigma reduction, is necessary to address the existing and emergent recovery needs. 
 
In West Africa, registered Ebola survivors, their families and other affected individuals benefited from having access to a range of health, psychosocial, and economic recovery services, which could similarly be envisioned for COVID-19. For example, survivors of moderate to severe COVID-19 illness may have permanent disability due to the disease itself or its aggressive treatment, necessitating varying degrees of follow-up medical care and livelihood support services. We must rapidly begin identifying the range of support needs that survivors might require and determine the extent to which existing service providers will be able to absorb these new cases or whether new interventions and programs are needed. A robust referral mechanism would enhance service uptake and long-term outcomes. As tens of thousands of severe cases are presently in recovery globally, the need already exists.
Additionally, the United States Centers for Disease Control and Prevention recognizes the potential for this public health emergency to catalyze social stigma directed towards various subgroups, which may differ by location. Survivor stigma was a prominent feature of the Ebola epidemic, prompting a variety of efforts to reduce internalized and enacted stigma in the community and in healthcare settings during the post-response recovery. Survivor stigma also was recognized in the SARS and MERS epidemics, affecting survivor attempts to work, attend school, maintain interpersonal relationships, and use services.
The extent to which COVID-19 survivors may face stigma remains unknown, but proactive anti-stigma efforts could help to avert long-term negative impacts on survivors’ mental health and general wellbeing — and, ultimately, their ability to effectively engage in the restimulation of the economy. The World Health Organization has issued guidance for government, media, and local organizations to prevent and address COVID-19-related social stigma. In addition to knowledge campaigns, other interventions may be required to target the specific needs of individuals, such as individualized counseling, peer support, or interpersonal group psychotherapy.

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