In the wake of Taiwan, South Korea and China, which seem to have found a "new normal" in the aftermath of the coronavirus, restrictions are being loosened by several European countries. Let's figure out what parameters the new modes of life are guided by and how priorities differ from one state to another.
On April 24, the regional office of the World Health Organization in Europe published the criteria by which countries can assess their readiness to relax quarantine measures (if they were, of course, introduced). You can also briefly familiarize yourself with them in the Russian-language infographics. Despite well-founded claims to the actions of WHO at the first stage of the epidemic - for example, it ignored reports of human-to-human transmission of the virus until official China reported this - the organization remains the most qualified and authoritative source of information about the pandemic. It has significant expertise and aggregates and analyzes data across countries. Therefore, you should be interested in her recommendations.
The communiqué emphasizes that this problem is complex and for it there is no universal - one fits all - solutions. Countries are encouraged to act individually, paying particular attention to clear communication with the population so that people understand and comply with the constraints.
“The purpose of this document is to provide countries with key principles for lifting restrictive measures and moving to the“new normal”. Everyone wants to return to economic activity, but it must be clearly understood that this will be a gradual process, requiring organized monitoring and, possibly, a local return to quarantine where there are more cases of the disease,”said Dr. Hans Henry Kluge, WHO Regional Director for Europe …
WHO identifies six criteria, compliance with which will mean readiness to exit quarantine:
- There is evidence that transmission of the virus has been brought under control;
- Public health and healthcare systems have the capacity to identify, isolate, test and treat all people with Covid-19, and to track and quarantine everyone who comes in contact with them;
- The risks of an outbreak are minimized in settings with a high level of vulnerability, such as long-term care facilities (for example, nursing homes for the disabled and the elderly, rehabilitation centers and psychiatric hospitals), as well as in crowded areas;
- Workplaces have the necessary preventive measures, including physical distancing, hygienic handwashing equipment, respiratory etiquette and possibly body temperature checks;
- Controlling the risks of import and export of infection from regions with a high risk of virus transmission;
- Local communities have a voice and the right information, they are interested in and participate in the transition process.
“The situation with Covid-19 is very uneven, countries are at different stages. Some are beginning to lift restrictions, while others remain in strict quarantine,”the WHO said.
Criteria in detail
The most common metric of life out of quarantine and the transition to it is based on the definition of the so-called effective reproductive number.This concept was perfectly explained by Angela Merkel in one of her speeches, answering the question about the duration of the quarantine. Base reproductive number R0 - the characteristic of the infection and is the number of people that one carrier of the infectious agent infects.
The effective reproductive number R characterizes the epidemiological situation in a particular community: how many new patients are there for one existing one. It is easy to understand that at R> 1 the epidemic grows - Merkel illustrates this by predicting overcrowding in hospitals in the event that quarantine is lifted "right now." To get out of quarantine and live outside of it, you need to be sure that the outbreak is extinguished - that is, the effective reproductive number does not exceed 1, and ideally less than one. This is a numerical expression of the first WHO criterion - the spread of the virus is taken under control.
The first criterion is closely related to the second in terms of tracking, testing and isolation. R can be reliably determined, obviously, only by knowing the total number of cases: it was the imperceptible spread of the virus at the beginning of the year that brought humanity to where we are now. Therefore, it is important not only to identify new cases of infection by symptoms, but also to test the maximum number of contacts of this patient and quarantine those who pass a positive test for the virus, even if this person does not have clinical manifestations of the disease. This is the only way to prevent local outbreaks from growing uncontrollably.
As soon as the number of cases begins to increase, it is necessary to return to local restrictive measures again, emphasizes the WHO.
In addition, the organization insists on the gradual lifting of restrictions, this is due to two factors. First, the virus can have a long incubation period, up to 10-14 days. Until that time has passed, it is impossible to know reliably whether the lifting of restrictions has led to a sharp increase in the incidence. The second reason is that we still do not know exactly in which situations the virus is transmitted more easily, and in which it is less likely (although we will discuss some of this kind of data below). Therefore, it is important to rank measures: for example, the first indulgences concern walking and exercise in the open air. This should be the safest - and you can find out for sure by looking at the test results after two weeks.
WHO also draws attention to the need to restructure health care: the organization uses the term “dual health management system”. On the one hand, health care must remain highly prepared to provide assistance to those infected with coronavirus, to examine and test them. On the other hand, it is necessary not only to resume admission of patients on non-urgent issues in the usual way, but also, if possible, compensate for the forced downtime in medical care in recent months, while ensuring the epidemiological safety of all patients.
In addition, the organization focuses on two more closely related aspects: establishing communication with the population and measures to overcome the negative social consequences of the epidemic.
Without economic assistance, people will not respond to communication, and without clear and transparent communication, medical measures will not work.
When researching reports from different countries, it turned out that in life everything is not as simple as in the WHO document. Someone does not have time to wait for the outbreak to fade - or quarantine does not allow it to be extinguished, that is, in fact, it does not work. Someone is in a hurry to open up and pay attention to certain factors, and in many countries the procedure for lifting quarantine is described chaotically, and it is extremely difficult to trace the motivation and reasons for making certain decisions.
In Italy - March 8
Italy became the main - after China - center of the coronavirus epidemic in late February - early March, but now it has left the front pages of newspapers and the first lines of ratings for the number of patients: the situation has stabilized.On May 7, 1401 new cases were detected in Italy, and at the peak, on March 21, there were 6,500 of them. Approximately so many patients were found in the country exactly two months ago, on March 8 - 1492. On March 9, the first government order on a nationwide quarantine was signed. The Italian quarantine was one of the most stringent in the world and was second only to Wuhan.
Italians could go out exclusively one at a time: to work in production (for three weeks - only to life support), to shops and pharmacies, as well as on matters of emergency. Even physical activity was limited to 200 meters around the house. In April, all businesses were completely restarted and bookstores opened, and on May 4, a noticeable movement began: people were allowed to walk on the street. Why was it necessary to close on March 8, with 1400 new patients, and to open on May 8? It's about dynamics and detectability. In the beginning, the number of patients grew - on average, 25-30% more new cases were found every day. Now the number of new patients is steadily decreasing. But, even worse, in this growing trend, the country had a very weak idea of how many people were sick.
For example, on March 9, about 4,000 tests were done - and almost half of them were positive. Such a high detection rate reflects low powers: then only people with severe symptoms and confirmed contact with Covid-positive were tested (as we remember, it was very difficult to confirm your Covid status).
As of May 6, more than 70,000 tests a day were carried out - and even on weekends the number of tests does not fall below 30,000. Only 2-3% of them turn out to be positive - this is what the tracking system described by WHO looks like in practice. Corriere della Sera tells in detail about this system: an operational test of a patient within 24-48 hours, testing at home or contactlessly those who interacted with him, including colleagues at work, the introduction of a mobile application through which doctors will be able to notify the population.
Italy opens very slowly and gradually: libraries were followed by children's clothing stores, restaurants began to sell take-away, and home goods stores will open. Churches have been opened - but a limited number of people can attend Mass. Although it should be said that the masses in non-cathedral churches on non-holidays and before quarantine could not boast of being full, so it will not be so difficult for the Church to follow the precautions.
In general, almost all trade is taken away. The ban on any gatherings remains: you can only visit relatives. The museums will open on May 18 - those that can provide distance between visitors. Hairdressers, beauty salons and restaurants will be the last to open from June 1, and there will be no foreign tourists in Italy this summer. Social distancing is still prescribed for everyone; in many regions, wearing masks is mandatory even on the street.
Prime Minister Giuseppe Conte did not succeed in explaining the importance of a phased opening for controlling the epidemiological situation: it seemed to many that the procedure for opening businesses was determined arbitrarily, as if they were pulling a loto - social networks were filled with memes on this topic.
Despite the jokes, the strategy as a whole looked quite sensible: the outbreak in Italy was large-scale, so the number of new cases does not allow talking about a return to the "old life", but it is economically difficult to continue quarantine. So Italy will have to rely on testing and tracking and hope that the outbreak will slowly fade away as a result of social distancing measures. The Italian quarantine was initially one of the most severe, and it is being lifted gradually. Schools will not open until September (the same decision was made by Spain).
France and Spain are catching up
A similar situation is developing in Spain, but there the outbreak began later - and there are still up to 3,000 new patients a day. However, the authorities allowed walks with the children.Spaniards can gather in groups of up to 10 people, restaurants open summer terraces (only half of the seats can be taken), hotels are allowed to resume work (however, travel is possible only within the province of residence).
Even cultural events are being resumed: indoors - up to 30 people with a 30% occupancy rate, in the open air - up to 200 people. It should be noted that not the whole country is moving to weakening measures (the first phase of lifting quarantine). In phase zero - quarantine - Madrid, Barcelona and several other cities particularly affected by the epidemic in different parts of the country remain.
In France, which entered the massive phase of the epidemic following Italy and Spain at the end of March, the outbreak was also largely extinguished. Every day, on average, no more than a thousand new infections are found - most in Paris and in the east of the country, on the German border.
The easing of quarantine began on May 11, while efforts are focused on restarting production and ensuring transport safety. The opening of schools remained at the mercy of local authorities, travel is limited to a hundred-kilometer radius from the place of residence. The borders remain closed.
Scandinavia without Sweden
Norway and Denmark - and with them Finland - are examples of successful early suppression of an outbreak. After discovering a massive importation of the coronavirus in mid-March - mainly from ski resorts in the Alps - countries launched mass testing and quickly introduced quarantines. As a result, the outbreaks did not enter a phase of explosive growth, and no country experienced an overburdened health care system. In Norway, for several weeks, the number of new patients has been at around 30 people a day, in Denmark and Finland - about 100 people a day.
This amount is feasible for tracking deployed testing facilities. The quarantine itself was initially very mild: economic activity was limited, schools were closed, but people walked calmly. Apparently, the governments realized that they could afford it due to the relatively low number of cases. In Denmark, a general quarantine was introduced until May 10, but kindergartens and elementary schools opened on April 14. In Norway, kindergartens opened on April 20 and primary school on the 27th.
Germany is a big champion
Like the Scandinavian countries, Germany managed to work proactively and prevent the collapse of hospitals, which had a beneficial effect on mortality rates: if in Italy and Spain more than 500 people per million of the population died, in Germany - only 90. Now the number of new infections is kept at below a thousand a day. The severity of quarantine in Germany differed depending on the region: the rules were stricter in the outbreaks in Bavaria, North Rhine-Westphalia and Baden-Württemberg, while in other regions the rules were initially more liberal. Restrictions affected the industry less: there the focus shifted to ensuring production safety. Also, more shops remained open - for example, construction shops along with grocery ones.
Now all retail outlets will be able to open - the only condition will be to ensure hygiene and distance for customers. Wearing masks is compulsory in the shop and on public transport. Schools will open their doors to elementary grades and students who need to take exams. In a full-fledged mode, offline learning should be restored gradually during the summer semester (it lasts in Germany until August). Berlin also announced the opening of restaurants - but with an incomplete occupancy and subject to an order in its own name for notification in case of contact with a sick person.
However, the main news of the lifting of quarantine in Germany is the resumption of Bundesliga matches. The footballers have already started training, the first matches will be held (of course, with empty stands) on May 16.
The measures to lift the quarantine have now been officially approved by the government of the country, and specific decisions have been transferred to the land level (although Angela Merkel noted that the "emergency brake" can be applied at any time if the situation worsens again). Regional regulation is easier given to Germany with its strong federal structure, while it is more natural for unitary France, Italy and Spain at the level of political culture to take uniform measures for the whole country - which is not always reasonable in the context of a pandemic.
When the quarantine was triggered
Almost all European countries have submitted plans to lift quarantine: the coronavirus outbreak has subsided. This applies to both the Netherlands and Belgium, where the incidence was quite high and led to a large number of victims, and the countries of Central Europe and Greece, where quarantine was introduced in advance and the number of cases was not large. Belgium and the Netherlands are focusing on opening schools - as is the culturally close Northern Europe. It is noted that the poorest pupils and children from difficult families suffer the most without schools: they receive food and protection at school.
Poland will open large shops, hotels and museums at once from May 4. Austria opens schools during May and promises to provide access to attractions from the end of the month. Ireland is also lifting the quarantine, but slowly: most of the changes are scheduled for July, only the stores will open on June 8.
Slovakia lifted several bans at once on May 4, and this is one of the few countries that clearly formulates the criteria for the success of quarantine. Prime Minister Igor Matovic explained that social distancing measures should act in such a way that during each week the average number of new patients per day does not exceed 100.
Greece, which has successfully suppressed the outbreak, has gone further and plans to open up to tourists this summer. The country's beaches have been available to residents since May 4, and the efforts of local scientists are aimed at understanding how to ensure the safety of guests in conditions of viral risk.
No major changes
A special category is countries that initially introduced quarantine in a mild form or with a delay and, instead of a peak of new infections, reached a plateau. These are the United States (about 30,000 cases per day since the beginning of April and more than 80,000 deaths), Great Britain (four to five thousand new patients per day since mid-April, the second largest number of deaths in the world - more than 32,000) and Sweden (about 700 new patients per day since early April).
In the United States, the pandemic is extremely politicized: rallies are being held against quarantine, and President Donald Trump has long denied its necessity. The problem of disunity was superimposed by a month's delay in the start of mass testing. As a result, the strategy to combat the epidemic was left at the mercy of local authorities.
In some states - California and Washington in the northwest of the country - governments have been able to take early pre-emptive action and suppress the outbreak without heavy casualties. The disease curve also went down in New York, although there measures were taken late and led to a collapse: the whole world was covered with images of field hospitals in Central Park.
However, the increase in incidence is now provided at the expense of other states, and some - for example, Georgia - are in a hurry to remove restrictions, although experts unequivocally say that testing capacity in the United States is now not enough to safely exit quarantine with such an increase in patients.
The situation with testing in the UK is also unsatisfactory, but there Boris Johnson is not yet talking about canceling quarantine. The fears of experts are not unfounded: coverage of testing and tracking of new cases are the main points of the WHO recommendations for getting out of the restriction regime.
As for the strategy of Sweden, it raises more and more questions not only from experts, but also from the people of the country themselves.Although the imposed restrictions are more serious than it might seem from the outside, now the comparison between Sweden and its neighbors in Denmark and Norway does not favor those who chose the no-quarantine scenario. 75% of Swedes are already in favor of stricter quarantine.
Instead of output
Countries emerging from quarantine are following WHO guidelines with varying degrees of success, and comparisons should be made with great caution. So, it is not enough to normalize test coverage for the population of the country: you need to calculate how many tests are there for one Covid-positive. The number of cases and deaths per million population provides an estimate of the complexity of the situation, but the readiness for containment is determined by how many new patients are registered each day.