Prevention

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By Stefano Lazzari

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Introduction

In the absence of an effective vaccine or antiviral treatment, prevention through public health measures remains the mainstay of SARS-COV-2 infection control and pandemic impact mitigation. Effective preventive measures for respiratory infections have been standard practices for many years. However, uncertainties still exist about the role and importance of different transmission routes in the spread of SARS-COV-2 (See chapter on Transmission). This complicates the choices in terms of the most efficient and effective mix of public health measures to be implemented and the correct prevention messages to be communicated to the public.

The basic COVID-19 preventive strategies include: the identification and isolation of infectious cases and quarantine for suspected cases and close contacts; changes in individual behaviors including physical and social distancing, use of face masks and hand hygiene; travel restrictions, bans on mass gatherings and localized or nationwide lockdowns when the other measures prove ineffective in halting the spread of the virus. Specific prevention measures can be simple recommendations left to the decision of the individual, or mandatory measures to be implemented under control by the public health authorities. Preventive measures can therefore be applied at the personal, community and societal level.

In this chapter we will review the available scientific evidence on the effectiveness of these measures in reducing the spread of SARS-COV-2.

Prevention at the personal level

Good respiratory hygiene/cough etiquette.

Good respiratory hygiene refers to measures aimed at containing respiratory secretions and reducing their spread in the environment or to other people. (Chavis, 2019) Traditionally, they include:

  • Covering your mouth and nose with a tissue or with your elbow when coughing or sneezing; and safe disposal of the tissue once used.
  • Use of a surgical or tissue face mask.
  • Perform hand hygiene often, and always after contact with potentially contaminated objects/materials.

Good respiratory hygiene and cough etiquette are usually recommended for individuals with signs and symptoms of a respiratory infection. However, given the established risk of SARS-COV-2 infection from asymptomatic individuals, public health authorities all over the world have recommended these measures for everybody when in public places. This is not without controversy, in particular on the use of masks in the absence of symptoms.

Face masks

The use of face masks to reduce the risk of infection is an established medical and nursing procedure. It is therefore surprising that it has created such a debate in the context of COVID-19.  The initial recommendation by WHO and other health authorities that masks should only be used by health workers and symptomatic patients resulted in controversy among the experts and widespread confusion among the public. This was contradictory with the images of people wearing masks in all settings from countries in Asia that successfully managed to contain the pandemic.  In addition, the existence of different types of masks greatly complicated communication efforts.

Face masks can prevent transmission of respiratory viruses in two ways:

  1. when worn by healthy individuals they are protecting them from infection by reducing the exposure of the mouth and nose to viral particles present in the air or on contaminated hands;
  2. when worn by an infected person they perform source control, by reducing the amount of virus dispersed in the environment while coughing, sneezing or talking.

Different types of masks perform these tasks differently, which also dictates the situations in which they should be used.  Type of masks currently used include:

  • N95 (or FFP2) masks, designed to block 95% of very small particles. They reduce the wearer’s exposure to particles including aerosols and large droplets. They also reduce the patient or other bystanders’ exposure to particles emitted by the wearer (unless they are equipped with a one-way valve to facilitate breathing).
  • Surgical masks only filter effectively large particles.  Being loose fitted, they will reduce only marginally the exposure of the wearer to droplets and aerosols. They do, however, limit considerably the emission of saliva or droplets by the wearer, reducing the risk of infecting other people.
  • Cloth masks will stop droplets that are released when the wearer talks, sneezes, or coughs. As recommended by WHO, they should include multi-layers of fabric.  When surgical or N95 masks are not available, cloth masks can still reduce the risk of SARS-COV-2 transmission in public places.

If masks are protective, why they were not widely recommended at the beginning of the pandemic? Whether due to poor communication, fear of shortage of essential medical supplies or under-appreciation of the role of asymptomatic carriers in spreading the virus, the initial reluctance in promoting mask use and the resulting controversy was not helpful in combating the pandemic and contributed to a general undermining of the credibility of public health authorities.

It was only on 5 June, months into the pandemic, that WHO released updated guidance on the use of masks, recognizing the role that face masks can play in reducing transmission from asymptomatic carriers in particular settings.  This was a few days after the publication of a comprehensive review and meta-analysis of observational studies showing a significant reduction in risk of infection with all types of masks (Chu 2020).  Surgical masks were also shown to work in a hamster model (Chan JF 2020). Other authors, based on reviews or modelling, recommend wearing suitable masks whenever an infected persons may be nearby (Meselson 2020, Prather 2020, Zhang 2020). (See also the discussion on droplets and aerosol, page xxx.)

Meanwhile the controversy on the use of masks continues, including on the potential negative effects of wearing masks on health, for example on cardiopulmonary capacity (Fikenzer, 2020). Regardless of the controversy and the mounting “No-Mask” movements, face masks are “here to stay”.  The sight of people wearing face masks in public, which in the past surprised and amused Western travelers to Asian countries, will be a common sight worldwide for months and maybe for years to come.

Hand Hygiene

The role of fomites in transmission of SARS-CoV-2 remains unclear but cannot be excluded. (Although objects can be easily contaminated by infected droplets and contaminate hands, it is extremely challenging to prove such transmission.) In any case, frequent handwashing is known to disrupt the transmission of respiratory diseases. Since people routinely make finger-to-nose or finger-to-eye contact (Kwok, 2015), handwashing of 30 seconds with ordinary soap is always recommended when there is a contact with a potentially infected item and regularly whenever possible (ex. when returning home). If water and soap are not available (ex. in public places), use of hydroalcoholic solutions or gel is recommended. These solutions have been shown to efficiently inactivate the SARS-COV-2 virus in 30 seconds (Kratzel, 2020) and can be home-made using a WHO recommended formulation. Hand-hygiene has the added advantage of preventing infections from many other respiratory pathogens. Unfortunately, both water for handwashing and hydroalcoholic solutions are often not available in resource-poor settings (Schmidt, 2020)

Physical/Social distancing and avoiding crowded conditions

Physical distancing means keeping a safe distance from others. The term is often confused with the more common “social distancing”, usually imposed during lockdowns, that means reducing social contacts as much as possible by staying home and keeping away from others to prevent the spread of COVID-19.

Social distancing has been unequivocally shown to reduce the spread of SARS-CoV-2 – in Wuhan and Shanghai, daily contacts were reduced 7-8-fold during the social distancing period, with most interactions restricted to the household (Zhang J 2020b, Du Z 2020). Social distancing can be an individual choice, but it is usually imposed by health authorities during “Lockdowns” or “stay-at-home orders”. We will expand on the issues related to lockdowns and social distancing in the sections below.

With the end of lockdowns and the restart of economic and social activities, physical distancing in public places will become an important behavioural aspect of everyday life and an essential measure to reduce the spread of SARS-COV-2.  Keeping a safe distance from others seems like a straightforward recommendation but defining what can be considered a “safe distance” is in fact quite complicated. In a published meta-analysis (Chu, 2020), the authors estimated that the risk of being infected with SARS-COV-2 is reduced to 13% for those standing at 1 m, further reduced to only 3% beyond that distance.  Based on this evidence, the WHO and ECDC recommend a minimum inter-personal distance of 1 m, although other agencies and countries suggest 1.5 m (Australia, Italy, Germany), 1.8 m (US CDC), or even 2 meters (Canada, China, UK). (BBC News, 2020)

Some authors suggest that even 2 meters might not be sufficient and that being “safe” would depend on multiple factors related to both the individual and the environment. These could include infecting viral load, duration of exposure, number of individuals present, indoor versus outdoor settings, level of ventilation, and whether face coverings are worn or not. (Qureshi, 2020, Jones 2020). In crowded conditions, including public transport (e.g. trains, buses, metros),  physical distancing is often impossible and the use of a protective mask is increasingly becoming mandatory.

 

Source :  Jones NR,et al. Two metres or one: what is the evidence for physical distancing in covid-19? BMJ. 2020 Aug 25;370:m3223.

 

Speak quietly, don’t shout (or sing)!

Traditionally, visible droplets produced during coughing and sneezing are considered the main carriers of respiratory viruses. It has only recently emerged that normal speech also yields large quantities of particles that are too small to be visible, but are large enough to carry a variety of communicable respiratory pathogens and can remain airborne for longer periods. The rate of particle emission during normal human speech is positively correlated with the loudness (amplitude) of vocalization, ranging from approximately 1 to 50 particles per second (0.06 to 3 particles per cm3), regardless of the language spoken (English, Spanish, Mandarin, or Arabic) (Asadi 2019). However, a small fraction of individuals behaves as “speech superemitters,” consistently releasing many more particles than their peers.

These data may help explain the occurrence of some super-spreaders events (e.g. choirs, parties and festivals, slaughterhouses, sport events, religious celebrations, family gatherings, etc.) that are disproportionately responsible for outbreaks of COVID-19 (See Epidemiology section).  While research will continue to study super-spreaders events, people should abide to a simple rule: Regardless of physical distancing, speak quietly, don’t shout!

 

Household hygiene

Several studies suggest the possibility of aerosol and fomite transmission of SARS-CoV-2, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (Doremalen 2020, Chin 2020). Though transmission of SARS-COV-2 from contaminated surfaces has not been clearly documented, traditional good home hygiene measures like cleaning floors and furniture, keeping good ventilation and the general disinfection of frequently used objects (e.g. door and window handles, kitchen and food preparation areas, bathroom surfaces, toilets   and   taps,   touchscreen   personal   devices,   computer keyboards, and work surfaces) are recommended to prevent transmission, particularly where confirmed or suspected COVID-19 cases are present. (CDC 2020, WHO 2020)

SARS-COV-2 is sensitive to ultraviolet rays and heat. Sustained heat at 56°C for 30 minutes, 75% alcohol, chlorine-containing disinfectants, hydrogen peroxide disinfectants and chloroform can effectively inactivate the virus.  Common detergents and sodium hypochlorite (bleach) can also be used effectively. To avoid poisoning, disinfectants should be used at the recommended concentrations, wearing appropriate PPE and should never be mixed. US CDC reported a substantial increase in calls to the poison centers in March 2020 associated with improper use of cleaners and disinfectants; many cases were in children <5 years old. (MMWR 2020)

Chemoprophylaxis (not there yet!)

In the future, antiviral drugs may be used to reduce viral shedding in suspected cases and as a prophylactic treatment of contacts.  As for now, unfortunately, no such drugs are available.

Prevention at the community/societal levels

Widespread testing, quarantine, and intensive contact tracing

Tedros Adhanom Ghebreyesus didn’t get everything right in the SARS-CoV-2 pandemic, but he was right when he recommended: “Test! Test! test!” (WHO, 16 March 2020). Indeed, identification, and testing of suspected cases, isolation and care for those confirmed, and tracing, testing and quarantine of close contacts are critical activities to try to break the chain of transmission in any epidemic. They worked well, for example, in responding to the 2003 SARS outbreak and many countries in Asia successfully applied them to COVID-19 (Li 2020, Lam 2020, Park 2020). The South Korea experience has been nicely summarized in an article in The Guardian.

However, despite the early availability of sensitive PCR tests (Sheridan 2020), many countries in Europe and elsewhere were caught by surprise.  Unprepared, they struggled initially to provide sufficient testing, isolation and contact tracing capacities to keep up with the pace of spread of SARS-COV-2. In Italy, the lack of laboratory capacities led to limiting PCR tests to symptomatic patients only, missing many asymptomatic cases.  Other countries, like Germany, fared better in diagnostics but implementing contact tracing proved difficult everywhere when the epidemic reached its peak, due to the large number of potential contacts of asymptomatic cases and their relatively long incubation period.

Ensuring sufficient testing capacities paired with the development of new rapid diagnostic tests (see section on Diagnosis) will be essential in facing future COVID-19 clusters or the feared “second wave” of infections. Advanced pooled testing strategies (Mallapaty, 2020) and the use of saliva samples could facilitate the task by allowing the rapid testing of large number of people, as China has done by testing all the population of Wuhan (more than 10 million people) in less than 2 weeks.

Isolation (separation of ill or infected persons from others) and quarantine (the restriction of activities or separation of persons who are not ill, but who may be exposed to an infectious agent or disease) are essential measures to reduce the spread of COVID-19. Unless a patient is hospitalized, quarantine and isolation are usually done at home or in dedicated facilities like hotels, dormitories, or group isolation facilities. (CDC 2020) Given the uncertainty about the infectivity of the suspected individual, preventive measures are similar for both isolation of confirmed cases and quarantine of contacts. Basically, you are required to stay at home or in the facility and avoid non-essential contacts with others, including household members, for a set period to avoid spreading the infection.

The long incubation and high pre-symptomatic infectivity of COVID-19 puts family members of infected individuals at particular risk (Little 2020). The infection rate found for household members varies between 11% and 32% (Bi Q 2020, Wu J 2020). These differences are probably due to different isolation measures implemented inside the family homes. Ideally, people in isolation should have access to a separate bedroom (and bathroom), personal protection equipment (PPE) and should not have contacts with people at high risk of serious COVID-19 disease.

The period of isolation and quarantine required before suspected or confirmed cases can be considered no more infectious remains controversial. Initially, the requirement for a confirmed case was to have clinically recovered and to have two negative RT-PCR results on sequential samples taken at least 24 hours apart. (WHO 2020) This second criteria proved challenging in countries with limited testing capacities and even when tests are available, some patients can continue to have positive PCR results for weeks or months after the cessation of symptoms, leading to prolonged isolation periods.

Updated WHO criteria were published in May 2020. Based on data showing the rarity of the presence of vital virus after 9 days from symptom onset (Cevic 2020), the new recommendation is to limit the isolation period to:

  • 10 days after symptom onset, plus at least 3 additional days without symptoms for symptomatic patients.
  • 10 days after positive test for SARS-CoV-2 for asymptomatic cases.

However, several countries, (e.g. Italy), continue to apply the earlier testing criteria including a negative PCR test, which can result in individual being kept in isolation for several weeks or even months.

Recommended quarantine period for contacts and for travelers has not changed and remains set at 14 days.

Contact tracing can be effective in reducing the risk of spread of the virus (Keeling 2020) but is a complex and resource intensive exercise. It is most effective when implemented early in the outbreak, before there is sustained community transmission. Once cases are soaring, identifying and monitoring all the potential contacts using only the public health resources becomes close to impossible and additional measures like physical distancing, face masks and localized lockdowns become necessary (Cheng 2020). WHO has published detailed guidance on contact tracing for COVID-19 and alternative approaches to contact tracing that results in resource-saving measures have recently been suggested. (ECDC, April 2020)

As stated by several authors, (Steinbrook, 2020, Salathé 2020) in countries that have managed to bring the pandemic under control a necessary step in “reopening” society is to have sufficient testing and contact tracing capacities to successfully contain the outbreaks that will inevitably occur as social restrictions are removed or relaxed. The coming winter months will show which countries will have learned this important lesson.

Tracking apps

Mobile phone data reveal astonishing details about population movements. According to an analysis by Orange, a French phone operator, data from its telephone subscribers revealed that 17% of the inhabitants of Grand Paris (Métropole du Grand Paris, 7 million people) left the region between March 13 and 20 – just before and after the implementation of the French lockdown measures (Le Monde, 4 April 2020). Again, mobile phone data from individuals leaving or transiting through the prefecture of Wuhan between 1 January and 24 January 2020 showed that the distribution of population outflow from Wuhan accurately predicted the relative frequency and geographical distribution of SARS-CoV-2 infections throughout China until 19 February 2020 (Jia JS 2020).

Numerous countries have tried to harness the power of the smartphone to design and target measures to contain the spread of the pandemic (Oliver 2020). In addition to the dissemination of COVID-19 information and prevention messages, the use of smartphones in support to contact tracing has been promoted widely. This contact tracing system (better named “exposure notification”) would basically use an application to detect if the phone has come in close distance from another phone of a person diagnosed with SARS-COV-2 and potentially infectious. It will then give a warning message prompting the owner to seek medical assistance, self-isolation, and testing.

The deployment of these tracking applications has faced several hurdles, including the need for inter-operability across platforms (Google, Apple) and across countries (unfortunately, each European country has developed its own app); the possibility of false-positive alerts; and the need for a majority of the population to download and regularly activate the app to be truly effective. The need to preserve the privacy of the users forced less performing technical solutions (e.g. decentralized data systems with data only stored in each phone vs centralized database; preference for less-accurate Bluetooth connection over GPS geo-localization; voluntary decision required on the sharing of data; ensuring time-limited storage of collected data, etc.) For example, in June, Norway’s health authority had to delete all data gathered via its Covid-19 contact-tracing app and suspend its further use following a ruling by the Norwegian Data Protection Authority.

A few months into their introductions, most COVID-19 tracking apps have failed to deliver as expected. In almost all countries only a small proportion of the population have downloaded the app (only Qatar, Israel, Australia, Switzerland, and Turkey have seen downloads above the minimum threshold of 15% of the population) and probably even less people are regularly activating it. More importantly, the success of a tracking application should  not be measured by the number of downloads but by the number of contacts detected, which so far have been relatively few (due to privacy concerns, the total number of  contacts is not available in countries where information is decentralized).

Maybe, with additional improvements, these tracking applications will become more efficient and effective in future, though they will probably only be only a support rather that a replacement for a traditional “manual” contact tracing system.

 

Mandatory use of face masks

Wearing a face mask to protect self and others from SARS-COV-2 infection may be an individual choice (see above).  However, as of 6 May 2020, more than 120 countries have made wearing a mask in some settings a mandatory requirement as a collective preventive public health measure. Mandatory settings range from “everywhere in public” to all indoor public places, public transportation, shops, workplaces, schools, etc. Children and people with breathing difficulties are often exempted from the mandatory use of face masks. (US CDC 2020, WHO 2020, ECDC 2020) As a result, the global number of people regularly wearing masks in public has soared, reaching the peak of 80-90% of the population in most countries in Asia but also in Italy, France, and Spain. Surprisingly, mask acceptance has increased to the point of being branded as a fashion items.

As shown in the chart, authorities in Asia have mandated the use of face masks in public at the early stages of the pandemic, which contributed to reduced spread and the sharp drops in infections. As mentioned earlier, in many other parts of the world, conflicting advice with misleading or incomplete information about the usefulness of masks has caused confusion among the population and a late adoption of this preventive measure. In addition, a growing “no-Masks” movement has gathered momentum, staging rallies in several countries.  Regardless, as new infections have started to increase again following the summer reopening, mandatory mask requirements are being introduced again in many European countries and becoming a norm in most public places.

 

Source: YouGov.com

 

Ban on mass gatherings

Recognizing their potential role in generating explosive clusters of SARS-COV-2 infections, (McCloskey 2020, Ebrahim 2020) most countries have implemented nationwide bans of mass gathering like sporting and cultural events, concerts, religious celebrations, rallies and political demonstrations, etc. Several important international mass gatherings events have been cancelled or postponed, including  the Tokyo 2020 Olympic Games, Euro 2020 football championship, Formula  1  Grand  Prix  races, the Eurovision Song Contest 2020, 2020 Geneva Motor Show, Christian Holy Week events in Rome, Umrah pilgrimage to Mecca, and many others.

It is currently uncertain under which conditions cultural events that require closeness of spectators (e.g. cinema, theatre, opera, etc.), religious ceremonies, political rallies, and other social events that require the contemporaneous presence of large numbers of clients in a restricted, closed space (discos, bar, etc.) can be resumed without  the risk of resulting in a super spreader event. The limited reopening of these premises during the summer holidays has recently been associated with a resurgence of the spread of the virus observed in Greece, Spain, France, and Italy. Most sport events have resumed, but without public. WHO has recently published key recommendations for mass gatherings in the context of COVID-19. Unless the risk of SARS-COV-2 spread is reduced significantly, postponing or cancelling of planned large event is likely to continue in the months to come.

 

Localized and nationwide Lockdowns

Lockdowns (or “stay-at-home orders”) are restrictions of movements of the whole population, ordered by a government authority to suppress or mitigate an epidemic or pandemic. They differ from quarantine in that all residents are supposed to stay at home, except for those involved in essential tasks, while quarantine is usually limited to people suspected to be infected.

Lockdowns and social distancing have been used for centuries in the fight against epidemics, as famously illustrated in the Decameron, a book by Bocaccio, an Italian writer, which contains tales told by a group of young people sheltering in a villa outside Florence to escape the Black Death of 1348. However, the 2020 nationwide lockdowns which ordered almost 4 billion people in 90 countries to stay at home were unprecedented in human history. (see also Chronology) For the first time, lockdowns were imposed initially in a whole city of 10 million people (Wuhan), then to 60 million people in the whole province of Hubei, finally to a whole country (Italy, followed by most other European countries.)  Though countries opted for more (China) or less (Europe) strict confinement measures, lockdowns were clearly effective in decreasing a hypothesized infection rate of 60% to 70% to less than 10%. (Cowling 2020)

How strict such measures can be has been shown in Hong Kong (Normile 2020). The recipe: hospitalize all those who test positive, regardless of whether they have symptoms, order two weeks of self-quarantine to all close contacts, introduce electronic wristbands, etc. A website even displays the location of infected people in Hong Kong at all times: https://chp-dashboard.geodata.gov.hk/covid-19/en.html. Such strict measures can be very effective but would not be acceptable or feasible in most countries.  Indeed, one of the limitations of lockdowns is that they can never be 100% complete. People occupied in essential services (e.g. health, security, transport, communication, food production and delivery, etc.) will need to be allowed to move and work, and sick people will need to continue to access health services.

Generalized lockdowns are blunt prevention tools, affecting the whole healthy population to reduce the risk of transmission from the relatively few potentially infectious individuals. (Hsiang 2020) They impose a major economic and social burden on the affected populations, while also preventing at times access to prevention and treatment for other health conditions. (Charlesworth 2020) Various authors (Marshall 2020, Pierce 2020, Williams 2020, Galea 2020) have emphasized the combined impact of the pandemic, social distancing and closures on the mental health of the population. In addition, implementing generalized lockdowns in low-income countries is particularly difficult. People in the informal economy without social net benefits would be forced to choose between the risk of infection and risking of falling into poverty and hunger. (ILO, 2020)

In fact, widespread testing, isolation and quarantine,  combined with population behavioral changes (physical distancing, use of masks, hand hygiene) – that have a less disruptive social and economic impact – have been shown to meaningfully contain COVID-19 if applied widely and consistently (Cowling 2020). A key metric for their success is whether critical care capacities are exceeded or prolonged or whether intermittent social distancing will be necessary into 2022 (Kissler 2020).

In summary, the tighter you control the infected and trace and isolate the close contacts, the less restriction you will have to impose on the uninfected. Hopefully countries will have learnt the lesson and, being better prepared, will be able to avoid in future the need for generalized lockdowns to respond to COVID-19 (and other epidemics).  However, until an effective vaccine becomes available, localized temporary lockdowns might still be required in the fight against this pandemic.

Travel bans/border closures

It has been long recognized that both land, sea and air travel can be efficient and rapid routes for the international spread of a pandemic virus. (Hufnagel 2004, Hollingsworth 2007) The conditions for restricting movements of people and goods between countries in case of a public health emergency are therefore regulated by the WHO International Health Regulations adopted by all WHO member states in 2005 (IHR 2005).

As of 18 June 2020, almost all (191) countries have taken some measures that restrict people’s movement since the COVID-19 pandemic began. Measures range from control of entry onto the territory of a State to control of movement within a territory, comprising of partial or total border closures (161 countries) and international flight suspensions (154 countries).

As pointed out by some authors (Habibi 2020), these measures are in breach of the IHR 2005, as they do not seem grounded on “scientific principles, scientific evidence, or advice from WHO” as required by IHR. (WHO 2005) This position is based on several scientific studies that have shown how the imposition of travel bans and border closures can be only partially effective in slowing down the introduction and spread of an epidemic or pandemic virus (like influenza or Ebola) while being potentially damaging and even counterproductive. (Brownstein 2006Mateus 2014, Poletto 2014)

 

In fact, widespread travel restrictions and border closures have not prevented SARS-COV-2 from reaching quickly just about every country on the planet (see section on Epidemiology). Though Italy was the first in Europe to impose a travel ban on China, it was also the first European country to experience a major COVID-19 outbreak. Australia has imposed a total travel ban since 24 March that contributed initially to stop the spread of the virus but did not prevent returning citizens and poorly-trained quarantine guards to break the rules and cause the ongoing major outbreak in Melbourne. One reason why travel bans are usually ineffective is that you cannot prevent everybody from entering a country. Some people (e.g. Citizens, long-term residents, diplomats, air or ship crews, health personnel, sometimes businessmen, etc.) are often exempted and able to travel under national or international agreements. Others (e.g. illegal migrants) can cross borders unofficially.

 

Some authors have also pointed out how the travel bans and border closures can restrict the movement of vital health equipment and supplies (e.g. medicines, PPEs, testing reagents and equipment) and also essential personnel, particularly needed in countries with limited resources (Devi 2020). Others suggest that early detection, hand washing, self-isolation, and household quarantine will likely be more effective than travel restrictions at mitigating this pandemic. (Chinazzi 2020)

 

On the other hand, the economic damage of travel bans has been substantial. The activities of airlines, airports, travel agents, hotels and resorts has basically come to a halt at the peak of the pandemic.  Eurocontrol has recorded a 90% drop in air passenger in Europe at the end of April; the figure has improved with the reopening of borders but is still at -50% compared to 2019 as of mid-July.  In May, the UN World Tourism Organization (UNWTO) projected the potential economic loss for the tourist industry worldwide at US$ 910 billion to US$ 1.2 trillion, with 100-120 million jobs at risk.

 

Like generalized lockdowns, generalized travel bans and border closures are blunt tools and can result in an erroneous and dangerous false sense of security in the population and in the authorities. While they might be partially effective in at least slowing down the introduction of a pathogen, they will eventually end up being breached one way or the other. Their impact on the life of many people, the economy and the trade is substantial and strict screening and quarantine measures can be as effective in avoiding transmission of the virus by imported cases. Most likely,  as countries will increasingly learn how to deal with the risk of COVID-19 in more efficient and effective ways, international travel will  finally  be allowed to resume in a safe environment.

Containment or mitigation of COVID-19?

Public health interventions to control an outbreak or an epidemic aim at achieving two separate but linked objectives (Zhang 2020, OECD 2020):

  • To contain the spread by minimizing the risk of transmission from infected to non-infected individuals, eventually suppressing transmission and ending the outbreak.
  • To mitigate the impact by slowing the spread of the disease while protecting those at higher risk. While not halting the outbreak, this would “flatten the epidemic curve”, reduce disease burden and avoid a peak in health care demand. In case of new emerging pathogens, it would also buy time to develop effective treatments or vaccines. (Djidjou-Demasse 2020)

Containment strategies rely heavily on case detection and contract tracing, isolation, and quarantine. They are usually applied most successfully in the early stages of an outbreak or epidemic, when the number of cases is still manageable by the public health system. (Hellewell 2020) When containment measures are insufficient or applied too late, mitigation becomes the only option, usually through the imposition of generalized preventive measures like closing of non-essential activities, social distancing, mandatory mask use, or lockdowns. (Parodi 2020, Walker 2020)

During the first months of the COVID-19 pandemic, several countries (China, Vietnam, South Korea, Australia, New Zealand) have shown how the implementation of a well-timed, comprehensive package of aggressive containment and mitigation policies can be effective in suppressing the COVID-19 epidemic, at least in the short-term. Other countries (most countries in Europe), have not been able to suppress transmission but have managed to mitigate the impact and bring the spread of SARS-COV-2 down to acceptable levels, while in others the pandemic is still raging with no  end in sight (e.g., US, Brazil, most of Latin America.)  However, as long as the virus is actively spreading anywhere in the world, no country can feel safe (as shown by the recent outbreaks in Victoria, Australia and in New Zealand).

Conclusion

While the quest for an effective vaccine or antiviral treatment continues, countries are still struggling to find the right mix of preventive measures (and the right balance between health and socio-economic priorities) to build an effective response to the COVID-19 pandemic.

Finding the right prevention mix means identifying what are the most cost-effective measures that can be widely implemented to reduce or halt the transmission of the virus. For this, we need a better understanding of how this virus spreads and how effective the different preventive measures are. Only more research and better science will provide this information.

However, finding the right balance also means recognizing that some measures can be effective, but at a very high social, economic, political, educational, and even health costs. These are political decisions. For example, it is unlikely that many European countries will accept to impose again strict generalized lockdowns, border closures or travel bans. These measures are simply too costly for society to be acceptable.

The most likely scenario is that to respond to new cluster of cases or the acceleration of the spread of the virus, perhaps due to “superspreaders” events or a relaxation of individual preventive measures, localized time-limited public health measures will need to be imposed, their effectiveness judged by better monitoring of the spread of the virus.  It is not ideal, it is not being “back to normal”, but in the absence of a “silver bullet” it is probably the best option we have right now to contain this pandemic.

References

Prevention at the personal level

Good respiratory hygiene/cough etiquette.

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Face masks

Hand Hygiene

Physical/Social distancing and avoiding crowded conditions

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  • Alagoz O, Sethi A, Patterson B, et al. Impact of Timing of and Adherence to Social Distancing Measures on COVID-19 Burden in the US: A Simulation Modeling Approach. MedRxiv 2020 doi: https://doi.org/10.1101/2020.06.07.20124859  [published Online First: 9th June, 2020]
  • WHO Considerations for public health and social measures in the workplace in the context of COVID-19 Published online 10 May 2020 https://www.who.int/publications/i/item/considerations-for-public-health-and-social-measures-in-the-workplace-in-the-context-of-covid-19
  • Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ; COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020 Jun 27;395(10242):1973-1987. PubMed: https://pubmed.gov/32497510. Full-text: https://doi.org/10.1016/S0140-6736(20)31142-9
  • Nazrul Islam, Stephen J Sharp, Gerardo Chowell, Sharmin Shabnam, Ichiro Kawachi, Ben Lacey, Joseph M Massaro, Ralph B D’Agostino Sr, Martin White. Physical distancing interventions and incidence of coronavirus disease 2019: natural experiment in 149 countries BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2743  (Published 15 July 2020)
  • Zeshan Qureshi, Nicholas Jones, Robert Temple, Jessica PJ Larwood, Trisha Greenhalgh, Lydia Bourouiba. What is the evidence to support the 2-metre social distancing rule to reduce COVID-19 transmission? CEBM,  Published Online June 22, 2020
  • Jones NR, Qureshi ZU, Temple RJ, Larwood JPJ, Greenhalgh T, Bourouiba L. Two metres or one: what is the evidence for physical distancing in covid-19? BMJ. 2020 Aug 25;370:m3223. PubMed: https://pubmed.gov/32843355. Full-text: https://doi.org/10.1136/bmj.m3223

 

Speak quietly, don’t shout (or sing)!

 

Household hygiene

  • van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020 Apr 16;382(16):1564-1567. PubMed: https://pubmed.gov/32182409. Full-text: https://doi.org/10.1056/NEJMc2004973
  • Alex W H Chin; Julie T S Chu; Mahen R A Perera; Kenrie P Y Hui; Hui-Ling Yen; Michael C W Chan; et al. Stability of SARS-CoV-2 in different environmental conditions Lancet 2020:April 02, 2020DOI: https://doi.org/10.1016/S2666-5247(20)30003-3
  • Radhika Gharpure; Candis M. Hunter; Amy H. Schnall; Catherine E. Barrett; Amy E. Kirby; Jasen Kunz; Kirsten Berling; Jeffrey W. Mercante; Jennifer L. Murphy; Amanda G. Garcia-Williams. Knowledge and Practices Regarding Safe Household Cleaning and Disinfection for COVID-19 Prevention — United States, MMWR Morb Mortal Wkly Rep. May 2020 Early Release / June 5, 2020 / 69 https://www.cdc.gov/mmwr/volumes/69/wr/mm6923e2.htm?s_cid=mm6923e2_w
  • Chang A, Schnall AH, Law R, et al. Cleaning and Disinfectant Chemical Exposures and Temporal Associations with COVID-19 – National Poison Data System, United States, January 1, 2020-March 31, 2020. MMWR Morb Mortal Wkly Rep. 2020 Apr 24;69(16):496-498. PubMed: https://pubmed.gov/32324720. Full-text: https://doi.org/10.15585/mmwr.mm6916e1

 

Chemoprophylaxis

Post exposure prophylaxis (PEP) with antiviral drugs after documented exposure can reduce the risk of infection. In the future, SARS-CoV-2-PEP could be used to reduce viral shedding in suspected cases and as a prophylactic treatment of contacts.

 

Prevention at the community/societal levels

Widespread testing, quarantine and intensive contact tracing

 

Quarantine and isolation of suspected or confirmed cases

  • Muge Cevik, Matthew Tate, Oliver Lloyd, Alberto Enrico Maraolo, Jenna Schafers, Antonia Ho SARS-CoV-2, SARS-CoV-1 and MERS-CoV viral load dynamics, duration of viral shedding and infectiousness: a living systematic review and meta-analysis medRxiv 2020.07.25.20162107; doi: https://doi.org/10.1101/2020.07.25.20162107

 

Test. Treat. Track.

 

Tracking apps

  • Jia JS, Lu X, Yuan Y, Xu G, Jia J, Christakis NA. Population flow drives spatio-temporal distribution of COVID-19 in China. 2020 Apr 29. PubMed: https://pubmed.gov/32349120. Full-text: https://doi.org/10.1038/s41586-020-2284-y
  • Mobile phone data for informing public health actions across the COVID-19 pandemic life cycle By Nuria Oliver, Bruno Lepri, Harald Sterly, Renaud Lambiotte, Sébastien Deletaille, Marco De Nadai, Emmanuel Letouzé, Albert Ali Salah, Richard Benjamins, Ciro Cattuto, Vittoria Colizza, Nicolas de Cordes, Samuel P. Fraiberger, Till Koebe, Sune Lehmann, Juan Murillo, Alex Pentland, Phuong N Pham, Frédéric Pivetta, Jari Saramäki, Samuel V. Scarpino, Michele Tizzoni, Stefaan Verhulst, Patrick Vinck Science Advances05 Jun 2020 : eabc0764
  • Ferretti L, Wymant C, Kendall M, et al. Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing. 2020 May 8;368(6491):eabb6936. PubMed: https://pubmed.gov/32234805. Full-text: https://doi.org/10.1126/science.abb6936

 

Mandatory face masks

 

Ban on mass gatherings

 

Localized and nationwide Lockdowns

 

Travel bans/border closures

 

Containment and mitigaton of COVID-19

  • Xiaoyan Zhang, Yuxuan Wang. Comparison between two types of control strategies for the coronavirus disease 2019 pandemic. J Infect Dev Ctries 2020 14(7):6 96-698. doi:10.3855/jidc. 12899
  • OECD Flattening the covid-19 peak: Containment and mitigation policies Published online 24 March 2020  https://www.oecd.org/coronavirus/policy-responses/flattening-the-covid-19-peak-containment-and-mitigation-policies-e96a4226/
  • Joel Hellewell, Sam Abbott, Amy Gimma, Nikos I Bosse, Christopher I Jarvis, Timothy W Russell, James D Munday, Adam J Kucharski, W John Edmunds. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. Lancet Glob Health 2020; 8: e488–96Published OnlineFebruary 28, 2020 https://doi.org/10.1016/S2214-109X(20)30074-7
  • Parodi SM, Liu VX. From Containment to Mitigation of COVID-19 in the US. JAMA. 2020;323(15):1441–1442. doi:10.1001/jama.2020.3882
  • Patrick G. T. Walker, Charles Whittaker, Oliver J. Watson, Marc Baguelin, Peter Winskill, Arran Hamlet, Bimandra A. Djafaara, Zulma Cucunubá, Daniela Olivera Mesa, Will Green, Hayley Thompson, et al. The impact of COVID-19 and strategies for mitigation and suppression in low- and middle-income countries  Science 24 Jul 2020 : 413-422 https://science.sciencemag.org/content/369/6502/413
  • Ramses Djidjou-Demasse, Yannis Michalakis, Marc Choisy, Mircea T. Sofonea, Samuel Alizon. Optimal COVID-19 epidemic control until vaccine deployment. medRxiv. 2020.04.02.20049189; doi: https://doi.org/10.1101/2020.04.02.20049189

 

Environmental hygiene and disinfection

 

Vaccinate for seasonal influenza and for COVID-19 (not yet available)

DOI: 10.1126/sciadv.abd0086 https://advances.sciencemag.org/content/early/2020/05/28/sciadv.abd0086

 

Hospitals and other health care settings

 

Nursing facilities

 

Long-term Care Institutions

  • Yen MY, Schwartz J, King CC, Lee CM, Hsueh PR; Society of Taiwan Prevention and Control. Recommendations for protecting against and mitigating the COVID-19 pandemic in long-term care facilities. J Microbiol Immunol Infect. 2020 Apr 10;53(3):447-53. PubMed: https://pubmed.gov/32303480. Full-text: https://doi.org/10.1016/j.jmii.2020.04.003
  • Lai CC, Wang JH, Ko WC, et al. COVID-19 in long-term care facilities: An upcoming threat that cannot be ignored. J Microbiol Immunol Infect. 2020 Apr 13;53(3):444-6. PubMed: https://pubmed.gov/32303483. Full-text: https://doi.org/10.1016/j.jmii.2020.04.008

 

Workplaces

 

Schools

 

Prisons

 

Homeless shelters