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COVID-19 lessons learned: a global perspective

COVID-19 lessons learned: a global perspective One June 15, 2021, infectious disease authorities from around the world participated in a joint webinar to share expe- riences and lessons learned in combatting the COVID-19 pandemic. One of the overriding goals of the conference “COVID-19 Lessons Learned: A Global Perspective” was to provide documentation of worldwide COVID-19 response strat- egies, in order to combat the plethora of misinformation and conspiracy theories that are being actively disseminated. This misinformation is having a profound negative impact on controlling the pandemic in many countries. Misinfor- mation which was addressed in the conference included challenging the seriousness of COVID-19 infections, a refusal to recognize aerosolization as the major mechanism of spread, a belief that schools can be opened safely without implementation of extensive control strategies, and that masks and vaccines are not effective. A second goal was the identification of common strategies between nations. Common strategies included the implementation of a range of closures, mask mandates, travel bans and the need for expanded testing. But of utmost importance there was recog- nition of the need to implement a coordinated national strategy, which is depoliticized and led by scientists. In Brazil, misinformation has been reported to be Introduction spread by politicians and preachers. This has allegedly Infectious disease authorities from around the world resulted in indigenous populations greeting public health presented and participated in a joint webinar on 15 June officials with bows and arrows [1]. In India, misinfor - 2021 to share experiences and lessons learned in combat- mation encouraged the public to search for ineffective ting the COVID-19 pandemic—See Table  1. It is hoped treatments and homeopathic medications not backed that a worldwide perspective will aid in adoption of effec - by evidence demonstrating efficacy in COVID-19 [2]. In tive strategies and to mitigate the epidemic of misinfor- Europe, a European Union document described a Rus- mation which is often predicated on local or regional sian disinformation campaign pushing fake news, making mistrust of government and politics. it harder for the Union itself to implement its pandemic response [3]. More recently, the United States identified Misinformation constraining pandemic responses and denounced a Russian disinformation campaign shed- One of the overriding goals of the conference “COVID- ding doubt over the effectiveness of vaccines [4]. 19 Lessons Learned: A Global Perspective” was to pro- Disinformation was often fanned by political rallies vide documentation of worldwide strategies to combat where public health advice was ignored and commu- the plethora of misinformation and conspiracy theories nity leaders set an example of not following COVID-19 which are being actively disseminated. In many coun- containment strategies, impeding their acceptance by tries, this misinformation is having a profound negative the general population. Such rallies were seen in many impact on controlling the pandemic. countries, including the United States, India, Brazil, Kenya and Spain. As evidenced in Spain and the United *Correspondence: kavanagh.ent@gmail.com 1 States, the focus of the rallies was the call of freedom. As Health Watch USA, P.O. Box 1403, Somerset, KY 42502, USA Full list of author information is available at the end of the article pointed out, “infringing on freedom has become the main © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kavanagh et al. Antimicrob Resist Infect Control (2021) 10:125 Page 2 of 6 Table 1 Speakers and countries represented at COVID-19 lessons those vaccinated [9], vaccination does not exempt one learned: a global perspective from compliance with advisements. For example, in Sin- gapore, starting after a case surge in May 2021, all hospi- Imogen Mitchell Australia tal staff were tested for COVID-19 every two weeks, and Sebastian Hoehl Germany all newly admitted patients were tested. Both Australia Vineeta Gupta India and Singapore have implemented the use of cell phone Paul Yonga Kenya apps for tracking of residents to facilitate case identifica - Matthias Maiwald Singapore tion [10–12]. Jesús Rodríguez-Baño Spain Many conspiracy theories are rooted in a nation’s cul- Stephanie Dancer United Kingdom ture, economics, or politics. However, it becomes more Kevin Kavanagh United States difficult for these theories to remain viable and attack Carolyn Clancy United States Dept. of Veterans Affairs national or regional advisements when the strategies Beth Taylor United States Dept. of Veterans Affairs being enacted are similar to those enacted by other coun- tries around the globe. point of attack on restrictions and regulations during the Covid-19 pandemic, but freedom is more than simply Common misinformation talking points which being able to do what we want” [5]. Of course, freedom have inhibited pandemic responses from public health strategies will too often usher in death Misinformation: SARS‑CoV‑2 is the flu or disability from Long Covid. This conspiracy theory stems from the fact that seasonal Some political rallies were held indoors. Others were influenza disappeared at about the same time COVID-19 mass outdoor gatherings. In the case of the United States, emerged. The premise is that SARS-CoV-2 is actually just pictures from a recent Independence Day celebration severe cases of the  seasonal flu which are misdiagnosed. showed tightly packed maskless individuals, including This argument may seem plausible in countries such as presumably unvaccinated young children. These events the United States, where COVID-19 cases surged and demonstrate that many, including political and other influenza disappeared, but the theory can easily be dis - leaders, are not taking the pandemic seriously [6]. proven by looking at data from Singapore. As described Baker et  al. classified a country’s COVID-19 response by Dr. Matthias Maiwald [13], Singapore instituted a strategies into five categories: [7] Exclusion Strategy stringent elimination strategy, resulting in both the less (some Pacific Islands), Elimination Strategy (Singapore infectious influenza virus and the highly infectious SARS- and Australia), Suppression Strategy (European Union CoV-2 virus to almost totally disappear. All respiratory and United Kingdom), Mitigation strategy (USA, Bra- viruses had a substantial decrease during Singapore’s zil, and India), and No Substantive Strategy.   The suc - lockdown period. Relaxation of strategies resulted in the cess of any chosen strategy generally depended upon the reappearance of some viruses. Approximately 13  weeks degree and uniformity of support the public held for pre- after reopening, rhinovirus and enteroviruses reap- ventative strategies. However, misinformation impedes peared. Later in 2020, adenoviruses reappeared but influ - this support. enza remained at almost non-existent levels throughout A mitigation strategy was adopted in large areas of the the remainder of the year [14]. United States, Brazil and India. In this strategy, attempts were made to try to flatten the case curve until herd Misinformation: fatality rates of SARS‑CoV‑2 are immunity was reached or a vaccine became available. The overestimated overarching goal, which was not always achieved, was to There is actually a denial of and underestimation of true prevent the healthcare system from being overrun  with deaths rather than an overestimation. For example, in COVID-19 patients. early June of 2021, the official death toll In India was just At the other end of the spectrum is an elimination over 350,000, but may actually have been as high as 4.2 strategy as adopted by Australia and Singapore. In this million individuals [15]. Many strategies can be enacted strategy, there is a zero tolerance for the SARS-CoV-2 to lower actual numbers, such as requiring a COVID-19 virus. In Australia, cities were closed even if there were test in a country with a fragmented and underdeveloped only 1 or 2 cases. In both countries, everyone entering healthcare system, or not counting patients with almost the country were required to quarantine. In a few coun- any co-morbidity for a virus which preys on the elderly. tries the Delta Variant prompted the quarantine time The latter strategy can reduce deaths by 50% to 80%. The period to be extended to 21  days [8]. With the Delta same was true in the United States where the  number Variant causing mild and asymptomatic infections in the of counted cases was approximately 600,000 but actual K avanagh et al. Antimicrob Resist Infect Control (2021) 10:125 Page 3 of 6 deaths using excess mortality data was estimated by the screening for COVID-19 [23]. On 19 Mar. 2021, the CDC Institute for Health Metrics and Evaluation to be over decreased the social distancing in schools from 6 to 3 950,000 [16]. feet [24]. A recommendation which appeared to be based upon droplet spread and lacked detailed recommenda- Misinformation: herd immunity can be achieved tions regarding aerosolization of the virus. without protective measures On 7 May 2021, the CDC recognized that aerosols are a Despite lack of any firm evidence for pandemic subsid - major mechanism of SARS-CoV-2 spread [25]. However, ence, herd immunity was advocated as an effective strat - too few school districts have upgraded their ventilation egy for poor countries [17] and was declared to have been systems. Currently, the CDC recommends “increased” reached by the Fall of 2020 [18–20]. However, a crush- and “improved ventilation” of schools but lacks specifics ing wave of COVID-19 affected the world over the win - for implementation [23]. ter holidays, followed in many countries by another wave Many school districts have not implemented manda- caused by the Delta Variant. tory systematic testing of all students and teachers. CDC The quest for herd immunity with or without a vaccine recommendations are to “offer” not “mandate” regular has been made almost non-achievable with the emer- testing in schools. Cited barriers include “privacy con- gence of the Delta Variant where the R0 is estimated to cerns, operational complexity, and financial concerns” be greater than twice that of the wild type of virus. This [23]. means that greater than 85% of the population would For both masks and testing interventions, the recom- have to be immune before herd immunity is achieved. mendations vary depending upon vaccination status, a In addition, SARS-CoV-2 is actively infecting the ani- distinction with questionable validity with the emergence mal population particularly cats, dogs, and minks. Zoos of the Delta Variant and the reports of vaccine break- are even starting to implement vaccination programs through infections. for large cats, apes, bears, and ferrets [21]. Misinformation: three to six feet away and you are safe Misinformation: we are overly concerned There has been a denial by many governments regard - regarding children and the opening of schools ing the airborne transmission potential for SARS-CoV-2. The excuse often given in many regions of the United This, in part, emanated from original guidelines pro - States is that other countries have shown that schools can duced by the World Health Organisation (WHO). Dr. be opened safely, and children are at low risk for the dis- Stephanie Dancer, NHS Lanarkshire, Scotland, aptly ease.  However, what is left out is that extensive strategies asserted that aerosolization is a major mechanism of to identify carriers and prevent spread were enacted to spread for SARS-C0V-2 and proper ventilation in build- allow the students to attend schools in as safe of an envi- ings is of utmost importance [26]. Viral particles and ronment as possible. Most countries recognize schools as small droplets can aerosolize with breathing and speech, an important source of SARS-CoV-2 spread. School clo- and float in the air, particularly in poorly ventilated envi - sures have been implemented in many countries, includ- ronments [27]. Viable SARS-CoV-2 have been cultured ing the United States, United Kingdom, Germany, Kenya, in the air 3 h after aerosolization. It should be noted that and Singapore. two other highly infectious airborne pathogens, tubercu- In Germany, there were school closures. When schools losis and measles have never been successfully cultured were reopened, there were mask mandates, social dis- in the air. The United States has been exceedingly slow to tancing and rapid antigen testing twice weekly for all stu- enact strategies regarding aerosolization and took until dents and teachers. A positive test was then confirmed early May in 2021 to recognize that aerosolization was a with PCR testing. Even with these interventions, there major factor of spread of SARS-CoV-2. were at least 86 outbreaks documented in daycare nurs- eries and schools. Misinformation: masks do not work Dr. Sebastian Hoehl presented data from the Robert This misinformation is based upon the fact that the Koch Institute which found that during Germany’s third SARS-CoV-2 virus is less than 1 micron in size and thus wave, there was a shift in the age distribution of cases to would not be effectively filtered using even an N-95 younger individuals. Patients between the ages of 5 and mask.  This argument asserts the ineffectiveness of mask 19  years old frequently became infected with SARS- recommendations but ignores the evidence that the CoV-2 [22]. transmitted particle size is most often much larger, in the In the United States, the CDC recommends a num- form of droplets.  ber of strategies which schools “might specifically All of the countries represented at the conference have implement”, such as social distancing, use of masks and mask mandates as part of their strategy, including Kenya, Kavanagh et al. Antimicrob Resist Infect Control (2021) 10:125 Page 4 of 6 Spain, Germany, Australia, Singapore, United Kingdom, officers to oversee and guide the emergency pandemic and the United States. Dr. Paul Yonga described how response. The UK formulated SAGE, an independent Kenya immediately implemented strategies to control committee of scientists to advise the government on pan- the spread of SARS-CoV-2. The country of Kenya even demic control strategies. mandated masks two weeks before their use was recom- Social disparities must also be addressed in a compre- mended by the WHO [28]. hensive pandemic response. It is not only a moral imper- Dr. Stephanie Dancer explained that there is a contin- ative, but those with a lower social economic status are uum of viral droplet particle sizes which are produced particularly vulnerable to infections by the virus. Low- by SARS-CoV-2 [26]. Those under 100 microns can form income migrant workers in Singapore became the sub- aerosols. These particles can be effectively filtered with jects of a fourth wave which hit the country. In Germany, N-95 masks but also well-constructed and well-fitted a major outbreak was associated with a meat processing cloth masks. Because of concerns of aerosolization, Ger- plant. As stated by Dr. Sebastian Hoehl, “This was one of many mandated the use of surgical or N-95 masks in the first times that we saw that those that are the most most “shops and public transport” [29]. Singapore man- affected by this cluster, this outbreak, were very low paid dated the public to wear at least surgical or cloth masks workers.” [22]. During the winter holiday surge, Germany since mid-April 2020 and had a pre-pandemic stockpile also recorded a “much higher” number of cases in lower of approximately three N-95 masks for every resident [13, income communities. In Kenya, as in most low-income 30]. countries, vaccines are lacking which not only places Universal use of masks are of utmost importance, since their citizens at greater risk for COVID-19 but also cre- as pointed out by Dr. Dancer, asymptomatic spread may ates a basis for the emergence of new variants. As stated account for over half of SARS-CoV-2 transmissions [26]. by Dr. Jesús Rodríguez-Baño “It is a global failure, is the way the vaccines have been distributed across the world. Once again, those of us who live in developed countries Misinformation: antivaxxers are lucky enough to have much more probabilities of The antivaxxer movement tends to downplay the serious - receiving the vaccines earlier than those living in low- ness of SARS-CoV-2 by using many of the above misin- income countries ….” [31]. formation strategies and to exaggerate the exceedingly Protecting hospital staff and patients is of utmost rare vaccine complications which have been reported. importance. NHS Lanarkshire in Scotland started to vac- Similar with most of the European Union and the United cinate their staff against SARS-CoV-2 in early Decem - States, the antivaxxer movement was a major concern ber 2020. The virus entered all three acute care hospitals in all countries, except Spain. Dr. Jesús Rodríguez-Baño “from the community via staff both asymptomatic and reported that greater than 75% of Spain’s population were pre-symptomatic.” Transmission then occurred between confident in the coronavirus vaccine and additional per - staff and patients, and from patients on one ward, and centages would become vaccinated anyway. In Kenya, then to other wards [26]. Naturally ventilated wards con- there is a critical vaccine shortage and supply does not tributed towards spread since it was winter, and staff even begin to meet demand. were reluctant to open windows. In Singapore, after case clusters occurred in hospitals, all staff were tested every two weeks, and if unvaccinated, every week. Pooled test- Overriding lesson learned—need ing was used to facilitate implementation of this strategy. for a comprehensive, coordinated national In the United States, healthcare-acquired infections are and world response effectively not tracked. The metric used in the United The second overriding message was the importance of States for hospital onset  SARS-CoV-2 infections, does having a coordinated national strategy and healthcare not require reporting unless the patient is currently hos- system. Several of the countries, including the United pitalized and the infection occurred 14 or more days after States, Spain and Australia are federated where govern- admission. In addition, patients “should not be counted” mental power is concentrated in Regions and States. if they become asymptomatic and are removed from iso- In the United States, pandemic response was largely lation precautions [32]. The average length of hospital directed by the States, with the Federal Government stay is 4.6  days [33]. Hence, a hospitalized patient who assuming an advisory role. In Spain, emergency pow- left the hospital at day 13 would not be counted as a Hos- ers initially placed pandemic governance at the federal pital Acquired Infection (HAI). This metric does not pro - level, but with later surges this shifted to regional deci- vide an adequate method for accurate accounting of HAI. sion making. In Australia, the country had an overarch- All front-line workers should be provided with ade- ing Australian Health Principle Protection Committee, quate PPE, including N-95 masks, and with a robust composed of the federal and jurisdictional chief health K avanagh et al. Antimicrob Resist Infect Control (2021) 10:125 Page 5 of 6 testing infrastructure. Increases in testing capacity for A robust system of genomic testing for variants COVID-19 screening in the workplace and schools is should be implemented in all nations. This includes the needed. Pool testing can be used to increase testing effi - testing of a substantial portion of randomly selected ciency and conserve resources. positive specimens, in order to enable effective tracking For example, Germany mandated testing of all stu- of community transmission. dents, teachers and industrial workers twice a week, and But above all, we must start to pay attention to respir- testing is recommended in all workplaces. Rapid antigen atory pathogens the same way we do for food, surface tests are used. They are relatively accurate during the and waterborne pathogens [34]. We must recognize the time period of symptom onset, when viral load is high. need and require upgraded indoor ventilation systems, In Australia, it became apparent that staff in designated air filtration and sanitization along with implementing quarantine hotels could become vectors for the disease stringent strategies to halt the transmission of SARS- and as a result, their movements are restricted, and they CoV-2. This will not be an easy task, as observed by Dr. are tested daily. Matthias Maiwald [14]. It was relatively easy for public Travel restrictions and bans are important strategies health strategies to cause the disappearance of almost which have been implemented by most nations. They are all respiratory viruses, including seasonal influenza. intended to limit the spread of variants, delaying entrance By way of logical extension, it may be concluded that into a country and hopefully allowing effective case SARS-CoV-2 must be extremely effective in transmis - tracking for the few cases which emerge. SARS-CoV-2 sion to be so persistent around the world. entered Germany on 17 January 2020, from an air trave- Videos and slides of the conference presentations, ler who flew into the country from China. Dr. Sebastian along with provisions for obtaining AMA Category I Hoehl presented extensive data regarding the ineffective - continuing education credits for physicians are avail- ness of symptom and temperature screening and stressed able free of charge at http:// healt hconf erence. org. the impact that asymptomatic carriage has on spread of the virus. Dr. Imogen Mitchell from Australia empha- Abbreviations sized the importance of controlling viral spread. Australia AMA: American Medical Association; CDC: Centers for Disease Control and banned cruise lines and advised against citizens traveling Prevention; NHS: National Health Service; PPE: Personal Protective Equipment; SAGE: Scientific Advisory Group for Emergencies; UK: United Kingdom; USA: overseas. Everyone entering the country would have to be United States of America; VA: United States Department of Veterans Affairs.; quarantined for 14 days, usually at designated hotel quar- WHO: World Health Organisation. antine facilities. During outbreaks, Australia also closed Acknowledgements borders and travel between states and territories to limit Paul Yonga, Jesús Rodríguez-Baño, Matthias Maiwald, Sebastian Hoelht, Imo- the spread of SARS-CoV-2. Singapore, a city-state, per- gen Mitchell, Stephanie Dancer, Vineeta Gupta, Beth Taylor and Carolyn Clancy formed similar bans and quarantines for persons entering for their presentations and review of the manuscript. the country. Authors’ contributions Of all of the industrialized nations, the United States KTK: First Draft of Manuscript, Conference Planning and Execution. CP, JP, LEC: appeared to have one of the most substantive deficits in Manuscript Review and Revision, Conference Planning and Execution. All authors read and approved the final manuscript. how the public healthcare system was able to address the pandemic, and the country lacked a national coordi- Funding nated response. To help alleviate this deficiency, Acting There was no outside funding for production of this manuscript. Deputy Secretary Carolyn Clancy and Undersecretary Availability of data and materials Beth Taylor described how the United States Depart- All presentations can be viewed at https:// healt hconf erence. org. ment of Veterans Affairs (VA) activated its Fourth Mis - sion. The Fourth Mission does not solely aid veterans, it Declarations is designed to aid the country in healthcare emergencies, Ethics approval and consent to participate including pandemics. During the COVID-19 pandemic, Not applicable. the VA hospitalized over 400 non-veterans at VA facili- ties and outsourced over 1000 healthcare staff to commu - Consent for publication All authors consented for publication and presenters allowed to comment nity nursing homes and non-VA facilities. With the VA and suggest changes to final manuscript. having the largest infrastructure of any healthcare system in the United States, many at the conference felt that the Competing interests The authors declare that they have no competing interests. VA could possibly serve as an infrastructure for develop- ment of a national public healthcare system, along with Author details 1 2 coordinating and delivering a unified national response Health Watch USA, P.O. Box 1403, Somerset, KY 42502, USA. 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Infect Everyone: How Herd Immunity Could Work for Poor lished maps and institutional affiliations. Countries. Bloomberg 22 Apr. 2020. https:// www. bloom bergq uint. com/ coron avirus- outbr eak/a- herd- immun ity- strat egy- could- actua lly- work- in- youth ful- india http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Antimicrobial Resistance & Infection Control Springer Journals

COVID-19 lessons learned: a global perspective

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10.1186/s13756-021-00992-x
Publisher site
See Article on Publisher Site

Abstract

One June 15, 2021, infectious disease authorities from around the world participated in a joint webinar to share expe- riences and lessons learned in combatting the COVID-19 pandemic. One of the overriding goals of the conference “COVID-19 Lessons Learned: A Global Perspective” was to provide documentation of worldwide COVID-19 response strat- egies, in order to combat the plethora of misinformation and conspiracy theories that are being actively disseminated. This misinformation is having a profound negative impact on controlling the pandemic in many countries. Misinfor- mation which was addressed in the conference included challenging the seriousness of COVID-19 infections, a refusal to recognize aerosolization as the major mechanism of spread, a belief that schools can be opened safely without implementation of extensive control strategies, and that masks and vaccines are not effective. A second goal was the identification of common strategies between nations. Common strategies included the implementation of a range of closures, mask mandates, travel bans and the need for expanded testing. But of utmost importance there was recog- nition of the need to implement a coordinated national strategy, which is depoliticized and led by scientists. In Brazil, misinformation has been reported to be Introduction spread by politicians and preachers. This has allegedly Infectious disease authorities from around the world resulted in indigenous populations greeting public health presented and participated in a joint webinar on 15 June officials with bows and arrows [1]. In India, misinfor - 2021 to share experiences and lessons learned in combat- mation encouraged the public to search for ineffective ting the COVID-19 pandemic—See Table  1. It is hoped treatments and homeopathic medications not backed that a worldwide perspective will aid in adoption of effec - by evidence demonstrating efficacy in COVID-19 [2]. In tive strategies and to mitigate the epidemic of misinfor- Europe, a European Union document described a Rus- mation which is often predicated on local or regional sian disinformation campaign pushing fake news, making mistrust of government and politics. it harder for the Union itself to implement its pandemic response [3]. More recently, the United States identified Misinformation constraining pandemic responses and denounced a Russian disinformation campaign shed- One of the overriding goals of the conference “COVID- ding doubt over the effectiveness of vaccines [4]. 19 Lessons Learned: A Global Perspective” was to pro- Disinformation was often fanned by political rallies vide documentation of worldwide strategies to combat where public health advice was ignored and commu- the plethora of misinformation and conspiracy theories nity leaders set an example of not following COVID-19 which are being actively disseminated. In many coun- containment strategies, impeding their acceptance by tries, this misinformation is having a profound negative the general population. Such rallies were seen in many impact on controlling the pandemic. countries, including the United States, India, Brazil, Kenya and Spain. As evidenced in Spain and the United *Correspondence: kavanagh.ent@gmail.com 1 States, the focus of the rallies was the call of freedom. As Health Watch USA, P.O. Box 1403, Somerset, KY 42502, USA Full list of author information is available at the end of the article pointed out, “infringing on freedom has become the main © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kavanagh et al. Antimicrob Resist Infect Control (2021) 10:125 Page 2 of 6 Table 1 Speakers and countries represented at COVID-19 lessons those vaccinated [9], vaccination does not exempt one learned: a global perspective from compliance with advisements. For example, in Sin- gapore, starting after a case surge in May 2021, all hospi- Imogen Mitchell Australia tal staff were tested for COVID-19 every two weeks, and Sebastian Hoehl Germany all newly admitted patients were tested. Both Australia Vineeta Gupta India and Singapore have implemented the use of cell phone Paul Yonga Kenya apps for tracking of residents to facilitate case identifica - Matthias Maiwald Singapore tion [10–12]. Jesús Rodríguez-Baño Spain Many conspiracy theories are rooted in a nation’s cul- Stephanie Dancer United Kingdom ture, economics, or politics. However, it becomes more Kevin Kavanagh United States difficult for these theories to remain viable and attack Carolyn Clancy United States Dept. of Veterans Affairs national or regional advisements when the strategies Beth Taylor United States Dept. of Veterans Affairs being enacted are similar to those enacted by other coun- tries around the globe. point of attack on restrictions and regulations during the Covid-19 pandemic, but freedom is more than simply Common misinformation talking points which being able to do what we want” [5]. Of course, freedom have inhibited pandemic responses from public health strategies will too often usher in death Misinformation: SARS‑CoV‑2 is the flu or disability from Long Covid. This conspiracy theory stems from the fact that seasonal Some political rallies were held indoors. Others were influenza disappeared at about the same time COVID-19 mass outdoor gatherings. In the case of the United States, emerged. The premise is that SARS-CoV-2 is actually just pictures from a recent Independence Day celebration severe cases of the  seasonal flu which are misdiagnosed. showed tightly packed maskless individuals, including This argument may seem plausible in countries such as presumably unvaccinated young children. These events the United States, where COVID-19 cases surged and demonstrate that many, including political and other influenza disappeared, but the theory can easily be dis - leaders, are not taking the pandemic seriously [6]. proven by looking at data from Singapore. As described Baker et  al. classified a country’s COVID-19 response by Dr. Matthias Maiwald [13], Singapore instituted a strategies into five categories: [7] Exclusion Strategy stringent elimination strategy, resulting in both the less (some Pacific Islands), Elimination Strategy (Singapore infectious influenza virus and the highly infectious SARS- and Australia), Suppression Strategy (European Union CoV-2 virus to almost totally disappear. All respiratory and United Kingdom), Mitigation strategy (USA, Bra- viruses had a substantial decrease during Singapore’s zil, and India), and No Substantive Strategy.   The suc - lockdown period. Relaxation of strategies resulted in the cess of any chosen strategy generally depended upon the reappearance of some viruses. Approximately 13  weeks degree and uniformity of support the public held for pre- after reopening, rhinovirus and enteroviruses reap- ventative strategies. However, misinformation impedes peared. Later in 2020, adenoviruses reappeared but influ - this support. enza remained at almost non-existent levels throughout A mitigation strategy was adopted in large areas of the the remainder of the year [14]. United States, Brazil and India. In this strategy, attempts were made to try to flatten the case curve until herd Misinformation: fatality rates of SARS‑CoV‑2 are immunity was reached or a vaccine became available. The overestimated overarching goal, which was not always achieved, was to There is actually a denial of and underestimation of true prevent the healthcare system from being overrun  with deaths rather than an overestimation. For example, in COVID-19 patients. early June of 2021, the official death toll In India was just At the other end of the spectrum is an elimination over 350,000, but may actually have been as high as 4.2 strategy as adopted by Australia and Singapore. In this million individuals [15]. Many strategies can be enacted strategy, there is a zero tolerance for the SARS-CoV-2 to lower actual numbers, such as requiring a COVID-19 virus. In Australia, cities were closed even if there were test in a country with a fragmented and underdeveloped only 1 or 2 cases. In both countries, everyone entering healthcare system, or not counting patients with almost the country were required to quarantine. In a few coun- any co-morbidity for a virus which preys on the elderly. tries the Delta Variant prompted the quarantine time The latter strategy can reduce deaths by 50% to 80%. The period to be extended to 21  days [8]. With the Delta same was true in the United States where the  number Variant causing mild and asymptomatic infections in the of counted cases was approximately 600,000 but actual K avanagh et al. Antimicrob Resist Infect Control (2021) 10:125 Page 3 of 6 deaths using excess mortality data was estimated by the screening for COVID-19 [23]. On 19 Mar. 2021, the CDC Institute for Health Metrics and Evaluation to be over decreased the social distancing in schools from 6 to 3 950,000 [16]. feet [24]. A recommendation which appeared to be based upon droplet spread and lacked detailed recommenda- Misinformation: herd immunity can be achieved tions regarding aerosolization of the virus. without protective measures On 7 May 2021, the CDC recognized that aerosols are a Despite lack of any firm evidence for pandemic subsid - major mechanism of SARS-CoV-2 spread [25]. However, ence, herd immunity was advocated as an effective strat - too few school districts have upgraded their ventilation egy for poor countries [17] and was declared to have been systems. Currently, the CDC recommends “increased” reached by the Fall of 2020 [18–20]. However, a crush- and “improved ventilation” of schools but lacks specifics ing wave of COVID-19 affected the world over the win - for implementation [23]. ter holidays, followed in many countries by another wave Many school districts have not implemented manda- caused by the Delta Variant. tory systematic testing of all students and teachers. CDC The quest for herd immunity with or without a vaccine recommendations are to “offer” not “mandate” regular has been made almost non-achievable with the emer- testing in schools. Cited barriers include “privacy con- gence of the Delta Variant where the R0 is estimated to cerns, operational complexity, and financial concerns” be greater than twice that of the wild type of virus. This [23]. means that greater than 85% of the population would For both masks and testing interventions, the recom- have to be immune before herd immunity is achieved. mendations vary depending upon vaccination status, a In addition, SARS-CoV-2 is actively infecting the ani- distinction with questionable validity with the emergence mal population particularly cats, dogs, and minks. Zoos of the Delta Variant and the reports of vaccine break- are even starting to implement vaccination programs through infections. for large cats, apes, bears, and ferrets [21]. Misinformation: three to six feet away and you are safe Misinformation: we are overly concerned There has been a denial by many governments regard - regarding children and the opening of schools ing the airborne transmission potential for SARS-CoV-2. The excuse often given in many regions of the United This, in part, emanated from original guidelines pro - States is that other countries have shown that schools can duced by the World Health Organisation (WHO). Dr. be opened safely, and children are at low risk for the dis- Stephanie Dancer, NHS Lanarkshire, Scotland, aptly ease.  However, what is left out is that extensive strategies asserted that aerosolization is a major mechanism of to identify carriers and prevent spread were enacted to spread for SARS-C0V-2 and proper ventilation in build- allow the students to attend schools in as safe of an envi- ings is of utmost importance [26]. Viral particles and ronment as possible. Most countries recognize schools as small droplets can aerosolize with breathing and speech, an important source of SARS-CoV-2 spread. School clo- and float in the air, particularly in poorly ventilated envi - sures have been implemented in many countries, includ- ronments [27]. Viable SARS-CoV-2 have been cultured ing the United States, United Kingdom, Germany, Kenya, in the air 3 h after aerosolization. It should be noted that and Singapore. two other highly infectious airborne pathogens, tubercu- In Germany, there were school closures. When schools losis and measles have never been successfully cultured were reopened, there were mask mandates, social dis- in the air. The United States has been exceedingly slow to tancing and rapid antigen testing twice weekly for all stu- enact strategies regarding aerosolization and took until dents and teachers. A positive test was then confirmed early May in 2021 to recognize that aerosolization was a with PCR testing. Even with these interventions, there major factor of spread of SARS-CoV-2. were at least 86 outbreaks documented in daycare nurs- eries and schools. Misinformation: masks do not work Dr. Sebastian Hoehl presented data from the Robert This misinformation is based upon the fact that the Koch Institute which found that during Germany’s third SARS-CoV-2 virus is less than 1 micron in size and thus wave, there was a shift in the age distribution of cases to would not be effectively filtered using even an N-95 younger individuals. Patients between the ages of 5 and mask.  This argument asserts the ineffectiveness of mask 19  years old frequently became infected with SARS- recommendations but ignores the evidence that the CoV-2 [22]. transmitted particle size is most often much larger, in the In the United States, the CDC recommends a num- form of droplets.  ber of strategies which schools “might specifically All of the countries represented at the conference have implement”, such as social distancing, use of masks and mask mandates as part of their strategy, including Kenya, Kavanagh et al. Antimicrob Resist Infect Control (2021) 10:125 Page 4 of 6 Spain, Germany, Australia, Singapore, United Kingdom, officers to oversee and guide the emergency pandemic and the United States. Dr. Paul Yonga described how response. The UK formulated SAGE, an independent Kenya immediately implemented strategies to control committee of scientists to advise the government on pan- the spread of SARS-CoV-2. The country of Kenya even demic control strategies. mandated masks two weeks before their use was recom- Social disparities must also be addressed in a compre- mended by the WHO [28]. hensive pandemic response. It is not only a moral imper- Dr. Stephanie Dancer explained that there is a contin- ative, but those with a lower social economic status are uum of viral droplet particle sizes which are produced particularly vulnerable to infections by the virus. Low- by SARS-CoV-2 [26]. Those under 100 microns can form income migrant workers in Singapore became the sub- aerosols. These particles can be effectively filtered with jects of a fourth wave which hit the country. In Germany, N-95 masks but also well-constructed and well-fitted a major outbreak was associated with a meat processing cloth masks. Because of concerns of aerosolization, Ger- plant. As stated by Dr. Sebastian Hoehl, “This was one of many mandated the use of surgical or N-95 masks in the first times that we saw that those that are the most most “shops and public transport” [29]. Singapore man- affected by this cluster, this outbreak, were very low paid dated the public to wear at least surgical or cloth masks workers.” [22]. During the winter holiday surge, Germany since mid-April 2020 and had a pre-pandemic stockpile also recorded a “much higher” number of cases in lower of approximately three N-95 masks for every resident [13, income communities. In Kenya, as in most low-income 30]. countries, vaccines are lacking which not only places Universal use of masks are of utmost importance, since their citizens at greater risk for COVID-19 but also cre- as pointed out by Dr. Dancer, asymptomatic spread may ates a basis for the emergence of new variants. As stated account for over half of SARS-CoV-2 transmissions [26]. by Dr. Jesús Rodríguez-Baño “It is a global failure, is the way the vaccines have been distributed across the world. Once again, those of us who live in developed countries Misinformation: antivaxxers are lucky enough to have much more probabilities of The antivaxxer movement tends to downplay the serious - receiving the vaccines earlier than those living in low- ness of SARS-CoV-2 by using many of the above misin- income countries ….” [31]. formation strategies and to exaggerate the exceedingly Protecting hospital staff and patients is of utmost rare vaccine complications which have been reported. importance. NHS Lanarkshire in Scotland started to vac- Similar with most of the European Union and the United cinate their staff against SARS-CoV-2 in early Decem - States, the antivaxxer movement was a major concern ber 2020. The virus entered all three acute care hospitals in all countries, except Spain. Dr. Jesús Rodríguez-Baño “from the community via staff both asymptomatic and reported that greater than 75% of Spain’s population were pre-symptomatic.” Transmission then occurred between confident in the coronavirus vaccine and additional per - staff and patients, and from patients on one ward, and centages would become vaccinated anyway. In Kenya, then to other wards [26]. Naturally ventilated wards con- there is a critical vaccine shortage and supply does not tributed towards spread since it was winter, and staff even begin to meet demand. were reluctant to open windows. In Singapore, after case clusters occurred in hospitals, all staff were tested every two weeks, and if unvaccinated, every week. Pooled test- Overriding lesson learned—need ing was used to facilitate implementation of this strategy. for a comprehensive, coordinated national In the United States, healthcare-acquired infections are and world response effectively not tracked. The metric used in the United The second overriding message was the importance of States for hospital onset  SARS-CoV-2 infections, does having a coordinated national strategy and healthcare not require reporting unless the patient is currently hos- system. Several of the countries, including the United pitalized and the infection occurred 14 or more days after States, Spain and Australia are federated where govern- admission. In addition, patients “should not be counted” mental power is concentrated in Regions and States. if they become asymptomatic and are removed from iso- In the United States, pandemic response was largely lation precautions [32]. The average length of hospital directed by the States, with the Federal Government stay is 4.6  days [33]. Hence, a hospitalized patient who assuming an advisory role. In Spain, emergency pow- left the hospital at day 13 would not be counted as a Hos- ers initially placed pandemic governance at the federal pital Acquired Infection (HAI). This metric does not pro - level, but with later surges this shifted to regional deci- vide an adequate method for accurate accounting of HAI. sion making. In Australia, the country had an overarch- All front-line workers should be provided with ade- ing Australian Health Principle Protection Committee, quate PPE, including N-95 masks, and with a robust composed of the federal and jurisdictional chief health K avanagh et al. Antimicrob Resist Infect Control (2021) 10:125 Page 5 of 6 testing infrastructure. Increases in testing capacity for A robust system of genomic testing for variants COVID-19 screening in the workplace and schools is should be implemented in all nations. This includes the needed. Pool testing can be used to increase testing effi - testing of a substantial portion of randomly selected ciency and conserve resources. positive specimens, in order to enable effective tracking For example, Germany mandated testing of all stu- of community transmission. dents, teachers and industrial workers twice a week, and But above all, we must start to pay attention to respir- testing is recommended in all workplaces. Rapid antigen atory pathogens the same way we do for food, surface tests are used. They are relatively accurate during the and waterborne pathogens [34]. We must recognize the time period of symptom onset, when viral load is high. need and require upgraded indoor ventilation systems, In Australia, it became apparent that staff in designated air filtration and sanitization along with implementing quarantine hotels could become vectors for the disease stringent strategies to halt the transmission of SARS- and as a result, their movements are restricted, and they CoV-2. This will not be an easy task, as observed by Dr. are tested daily. Matthias Maiwald [14]. It was relatively easy for public Travel restrictions and bans are important strategies health strategies to cause the disappearance of almost which have been implemented by most nations. They are all respiratory viruses, including seasonal influenza. intended to limit the spread of variants, delaying entrance By way of logical extension, it may be concluded that into a country and hopefully allowing effective case SARS-CoV-2 must be extremely effective in transmis - tracking for the few cases which emerge. SARS-CoV-2 sion to be so persistent around the world. entered Germany on 17 January 2020, from an air trave- Videos and slides of the conference presentations, ler who flew into the country from China. Dr. Sebastian along with provisions for obtaining AMA Category I Hoehl presented extensive data regarding the ineffective - continuing education credits for physicians are avail- ness of symptom and temperature screening and stressed able free of charge at http:// healt hconf erence. org. the impact that asymptomatic carriage has on spread of the virus. Dr. Imogen Mitchell from Australia empha- Abbreviations sized the importance of controlling viral spread. Australia AMA: American Medical Association; CDC: Centers for Disease Control and banned cruise lines and advised against citizens traveling Prevention; NHS: National Health Service; PPE: Personal Protective Equipment; SAGE: Scientific Advisory Group for Emergencies; UK: United Kingdom; USA: overseas. Everyone entering the country would have to be United States of America; VA: United States Department of Veterans Affairs.; quarantined for 14 days, usually at designated hotel quar- WHO: World Health Organisation. antine facilities. During outbreaks, Australia also closed Acknowledgements borders and travel between states and territories to limit Paul Yonga, Jesús Rodríguez-Baño, Matthias Maiwald, Sebastian Hoelht, Imo- the spread of SARS-CoV-2. Singapore, a city-state, per- gen Mitchell, Stephanie Dancer, Vineeta Gupta, Beth Taylor and Carolyn Clancy formed similar bans and quarantines for persons entering for their presentations and review of the manuscript. the country. Authors’ contributions Of all of the industrialized nations, the United States KTK: First Draft of Manuscript, Conference Planning and Execution. CP, JP, LEC: appeared to have one of the most substantive deficits in Manuscript Review and Revision, Conference Planning and Execution. All authors read and approved the final manuscript. how the public healthcare system was able to address the pandemic, and the country lacked a national coordi- Funding nated response. To help alleviate this deficiency, Acting There was no outside funding for production of this manuscript. Deputy Secretary Carolyn Clancy and Undersecretary Availability of data and materials Beth Taylor described how the United States Depart- All presentations can be viewed at https:// healt hconf erence. org. ment of Veterans Affairs (VA) activated its Fourth Mis - sion. The Fourth Mission does not solely aid veterans, it Declarations is designed to aid the country in healthcare emergencies, Ethics approval and consent to participate including pandemics. During the COVID-19 pandemic, Not applicable. the VA hospitalized over 400 non-veterans at VA facili- ties and outsourced over 1000 healthcare staff to commu - Consent for publication All authors consented for publication and presenters allowed to comment nity nursing homes and non-VA facilities. With the VA and suggest changes to final manuscript. having the largest infrastructure of any healthcare system in the United States, many at the conference felt that the Competing interests The authors declare that they have no competing interests. VA could possibly serve as an infrastructure for develop- ment of a national public healthcare system, along with Author details 1 2 coordinating and delivering a unified national response Health Watch USA, P.O. Box 1403, Somerset, KY 42502, USA. 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Journal

Antimicrobial Resistance & Infection Control – Springer Journals

Published: Aug 26, 2021

References

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    Baker, GM; Wilson, N; Blakely, T
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    Morawska, L; Allen, J; Bahnfleth, W