The European Union’s health agency has called on member states that are seeing an increase in cases of coronavirus to reinstate control measures, as it warned of a “true resurgence” in several countries.
In a “rapid risk assessment” published on Monday, the European Centre for Disease Prevention and Control (ECDC) warned of a “risk of further escalation of Covid-19” across the continent.
The Stockholm-based agency said that the Covid-19 pandemic continued to “pose a major public health threat”, in spite of a recent decline in cases. Since the relaxation of movement restrictions and other measures, the spread of the virus had resumed, it said.
“Further increases in the incidence of Covid-19, and associated hospitalisations and deaths, can be mitigated if sufficient control measures are reinstalled or reinforced in a timely manner,” the agency said.
The recent spike in cases around Europe is presenting new risks. While the term ‘second wave’ wasn’t used, the risk assessment presents the risks unless serious mitigation measures are implemented. These include increased testing, social distancing measures and strengthen healthcare services.
The European Centre for Disease Prevention and Control stated that as of 2 August 2020, ten countries had 14-day incidence of reported cases greater than 20 per 100 000 population. Among these, six countries (Belgium, Czechia, Luxembourg, Malta, Romania and Spain) reported an increase of 30% or more and two countries (Portugal and Sweden) reported a decrease of 30% or more compared to the 14-day incidence of reported cases as of 19 July.
In three countries (Luxembourg, Romania and Spain) the rate was higher than 60 per 100 000 population.
Malta is among the countries with the highest rate of testing. Luxembourg has the highest testing rate for week 30, followed by Denmark, Malta, the UK, Cyprus, Austria, Ireland and Portugal. Countries with low testing rates and test positivity above 2% for week 30 were Croatia, Romania, Bulgaria, Spain, Czechia, Belgium, Poland and Slovenia.
The ECDCs warned that in countries where there is evidence that is suggestive of increasing transmission, as demonstrated by a recent increase in cases and no increase in hospitalisations but where there has been an increase in test positivity rates (if they have sufficient testing capacity and intensity of testing has remained stable), the risk of further escalation is high. For those countries, the risk is very high if they do not implement or reinforce multiple measures, including physical distancing and contact tracing.
Age Distribution
The age-distribution was different when comparing the periods of January – May and June – July. Between January and May 2020, 40% of cases were aged 60 years or above and the largest proportion of cases were reported among 50-59 year-olds (18.7%). In contrast, in June and July, persons aged 60 years or above accounted for 17.3% of cases and the largest proportion of cases were reported among 20-29 year-olds (19.5%). The proportion of cases diagnosed among children and youths aged below 20 years also increased from 4.2% of cases between January and May to 12.8% in June and July. The median age decreased from 54 years in January – May to 39 years in June – July. The proportion of mild-cases overall increased between the two periods (+11.9%), with the biggest increase among persons aged 70-79 years (+7.3%), 60-69 years (+6.8%) and children below 10 years of age (+6.3%). Among other age-groups, the proportion of mild cases changed by less than 5%. These changes could be related in part of the expansion of testing over time, leading to more testing of milder cases, particularly among younger persons, as well as potentially increased transmission among younger people once public health measures were lifted.
The age-distribution of mild (non-hospitalised) cases changed over time, with the median age decreasing from 46 years in January – May to 35 years in June – July. Hospitalised cases also tended to be younger in June and July compared to previous months (median age: January – May: 67 years; June – July: 57 years). The median age of cases admitted to intensive care or who required respiratory support remained stable over time (January – May: 65 years; June – July: 64 years) although 20.4% of cases admitted to intensive care or requiring respiratory support were below 50 years of age in June and July compared to 14.2% between January and May (Figure 8(i)). Almost all deaths were among persons aged 60 years or over in both periods, however there was a lower proportion of deaths among 60-79 year olds in June and July compared to January to May (January – May: 26.3%; June – July 20.0%) and a higher proportion of deaths among persons aged 80 years or over (January May: 58.4%; June – July 66.2%).
The proportion of imported cases among these 15 countries changed over time: in January and February, when overall case numbers were low, 26 out of 51 reported cases were imported (51%). The proportion of imported cases decreased in March to 15.3%, however the absolute number of imported cases was highest in March (5 634 cases). As lockdowns and travel restrictions were introduced, the proportion (and number) of imported cases decreased to 1.5% in April and reached a minimum of 1% in May when 241 cases out of 24 024 were reported to be imported. The number and proportion of imported cases then increased in June and July to reach 3.6% of reported cases (616 out of 16 905 cases).
Defining Vulnerable Categories
Medically and socially vulnerable groups are at increased risk of severe disease and death due to the public health measures in place to reduce the spread of COVID-19. The medically vulnerable include older adults, people with underlying health conditions and the socially vulnerable: those with long-term physical, mental, intellectual or sensory impairments, homeless people, people living in abusive household settings, sex workers, and others who face challenges due to their belonging to two or more categories of social vulnerability.
Residents in long-term care facilities (LTCF) are also a vulnerable population group for COVID-19 and are particularly at risk when transmission rates are high within the general community. Many LTCFs across the region and globally have reported COVID-19 outbreaks, with high rates of morbidity and case fatality among residents [7]. In some countries, a high proportion of all the deaths reported at the national level have been among residents of such facilities. The transmission dynamics of COVID-19, combined with a previously low availability of testing are considered to have fuelled a rapid spread within and between facilities. A further contributing factor has been asymptomatic transmission among cases in both staff and residents [7].
People in prisons are another vulnerable group due to the many environmental factors that may increase risk of COVID-19 transmission, such as overcrowding and unsanitary facilities, and the demographic profile of the prison population, including the proportion of the population belonging to risk groups for developing severe disease [8]. Outbreaks in prison settings can be a serious challenge for public health as they can quickly overburden prison and community health services and, given the high turnover in many prisons, can result in increased transmission within, or reintroduction into, marginalised communities.
Environmental factors such as overcrowding in reception and detention centres may increase exposure to SARS- CoV-2 among the migrants and refugees living there [8]. Outbreaks in reception and detention centres can spread quickly in the absence of adequate prevention measures.
Risk Factor
The risk of further escalation of COVID-19 is high in countries that have also had an increase in hospitalisations, providing a strong indication that there is a genuine increase in transmission occurring. For these countries, the overall risk of escalation is very high if they do not implement or reinforce multiple measures, including physical distancing measures and contact tracing, and have sufficient testing capacity.
The risk of further escalation of COVID-19 is high for the countries reporting no increase in hospitalisations but having seen an increase in test positivity (if testing capacity is sufficient and intensity has remained stable), suggesting increasing levels of transmission. For these countries, the overall risk of escalation is very high if they do not implement or reinforce multiple measures, including physical distancing measures and contact tracing.
The risk of further escalation of COVID-19 is moderate-to-high for those countries reporting no increase in hospitalisations or test positivity (if testing capacity is sufficient and intensity has remained stable). The countries that have multiple physical distancing measures in place should conduct local risk assessments to better understand the groups or settings driving the increase in cases and to determine which measures should be in place or strengthened.
Recommendations
The key priorities to consider in order to optimise testing strategies:
- Ensure all people with symptoms, even very mild symptoms are tested.
- Ensure testing is easily accessible for everyone, including populations such as migrants, seasonal workers and travellers.
- Promote testing and ensure that people with symptoms are tested as soon as possible after symptom onset.
- Ensure sufficient laboratory capacity exists to be able to deliver results in a timely manner, ideally within 24 hours of sample collection.
- Ensure robust follow-up systems for case management, rapid contact tracing and quarantining.
- Further options to consider as part of an effective testing strategy include testing of asymptomatic persons such as:
- Those who have had a high-risk exposure to a confirmed case (close contacts) [28] .
- Those working with vulnerable populations.
- Those in high-risk settings such as prisons and long-term care facilities [7].
- In the context of clusters or outbreaks.
- In the context of screening populations at higher risk of infection, such as travellers returning from high- transmission settings [29] or persons working in occupations with high risk of exposure.
ECDC / The Guardian
