IANPHI Europe Hosts COVID-19 Webinar on Lockdown De-escalation Strategies


As part of our ongoing COVID-19 webinar series, IANPHI organized a discussion on May 13, 2020 to hear from European members about their lockdown de-escalation strategies.

The event featured presentations from Dr. Johanna Hanefeld, scientific director and head of department at the Centre for International Health Protection (ZIG) of Germany’s Robert Koch Institute (RKI), and from Dr. Frode Forland, specialist director of infectious diseases and global health at the Norwegian Institute of Public Health (NIPH).

Dr. Jeffrey Koplan, former director of the U.S. CDC and co-founder of IANPHI, moderated the session and Dr. Quentin Sandifer, IANPHI European Network chair and executive director of public health services at Public Health Wales, featured as a discussant.

During the webinar, the panelists shared their country’s considerations for easing lockdown measures and on the role of national public health institutes (NPHI) at national, regional and local levels.

Five key takeaways from the webinar include:

  • Monitoring de-escalation of lockdowns should not solely rely on national-level thresholds, such as the R0 (reproductive number)
  • Local implementation and monitoring are essential components of de-escalation strategies
  • Increasing capacity for contact tracing and testing requires investments in infrastructure and health workers
  • Organizing parts of society into small groups, for example cohorts of school children, may be a means to control lockdown measures at a micro level
  • National strategies should also aim to support international capacity building and coordination

Dr. Johanna Hanefeld presented RKI’s considerations on de-escalation measures and the governance of public health in Germany:

As a Federal Republic, Germany’s Ministries of health at state level are each responsible for public health. This includes developing the implementation of state-level de-escalation strategies and implementation plans. The Robert Koch Institut advises the federal government with science-based evidence and provides guidance and support to public health institutes at the state and local levels, where requested RKI’s Centre for International Health Protection has continued supporting partners across the world during the COVID-19 situation, currently on a virtual basis.

In considering de-escalation measures, RKI shared a number of principles that they considered important. De-escalation should not be considered before there is relatively great chance that there will be no need to re-instate measures, there will be sufficient healthcare capacities and there will be no uncontrollable community transmission. De-escalation should ideally only be implemented once at the national level. Where re-escalation is necessary, it should be as confined/local as possible. Finally, de-escalation measures should go hand in hand with maintaining universal precautions such as hand hygiene, physical distancing and community masks applied to the whole society including as a means to shield vulnerable populations.

To monitor de-escalation, one could think about three indicators in line with WHO guidance; transmission dynamics, the severity of illness and the impact on health and public services. Each indicator should be monitored at the closest levels in relation to new cases without wholly relying on national thresholds. Germany at the moment considers a 7-day incidence per 100,000 in a Landkreis (local counties) with a threshold of 50/100,000 35/100,000 in cities after which counties have to confer with states about what they are doing.

Dr. Forland outlined Norway’s strategy to ease the lockdown and shared thoughts on why COVID-19 responses require engagement from the whole of society at national and global levels:

In Norway’s re-opening strategy, communication aims to raise critical awareness among the whole of society that daily routines must adapt in the medium term.

The current phase allows for groups of up to 50 people to meet at a distance of one meter at least. Moreover, quarantine has been reduced from 14 to 10 days to reflect a more accurate time for the incubation period, and the amount of time it would take for tracers to contact the associated suspected cases.

Though contingency plans have been developed for re-escalation of lockdown measures, a significant second wave is not expected. Rather, increased testing capacity and coordination at the local level are strategies to react to smaller bumps of outbreaks in the coming months.

The Norwegian Public Health Institute has been directly involved in advising all parts of government to supporting the whole of society. Global solidarity features as a priority for the current re-opening phase of Norway’s strategy in line with the WHO’s International Health Regulations (2005).

Dr. Quentin Sandifer shared his perspective on the distinct methods used at country level to respond to similar issues. Moreover, he praised certain institutes in the IANPHI Europe Network who have increased testing and tracing capacities quickly, often where existing infrastructure could be mobilized.

In a Q&A session, the following topics were discussed by both panelists:

Contact Tracing

For Germany, investing in the public health infrastructure at the local level has been an essential undertaking. This has included recruiting containment scouts (in large part medical students) to increase contact tracing capacity in a short time.

In Norway, contact tracers already existed within the public health structures of the 356 municipalities. The District Health Information System, an open source software platform for reporting, analysis and dissemination of data for all health programs, whose use is supported by NIPH in a number of developing countries, may also be rolled out in Norway at the local level to increase tracing capacity.

In both countries, mobile tracing apps are in the process of being developed.

Schools

In Germany, schools are beginning to open with a “shift” system to reduce the size of classes. It is still unknown how this measure will affect outbreak levels.

In Norway, children are returning to schools in “cohorts”, or small groups who do not mix. The strategy would enable Norway to control outbreaks at a cohort level without having to close schools. The infection rate has remained stable since the reopening of schools.

Monitoring and Testing

Both panelists stressed that relying on single indicators should be avoided. Rather, it was strongly recommended to favor indicators at a local level, including the number of new cases each day.

In Germany and Norway, testing strategies and capacities have widened to include mild symptoms beyond respiratory infections. In Germany, symptoms indicative of COVID-19 are updated as they become known. Testing in Norway can now be done through saliva samples which has increased speed and safety levels for health workers.

Modeling

Panelists shared a cautious view on modeling, which has become widespread. While models may be an effective way to communicate messages at the political level, modeling must be accompanied by public health analysis and new information being integrated over time.

For further information and resources from Norwegian Institute of Public Health, Santé publique France and other IANPHI members, visit our COVID-19 resource page.

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