ECDC Director Learning Pandemic Lessons

■Japanese: 将来のパンデミックに、私たちはどう備えるべきか　ヨーロッパからの視点

――There are various infectious diseases in the world. As an expert, please tell us what you feel about the global impact of this COVID-19 pandemic. Has that perception changed over time?

The ongoing COVID-19 pandemic has posed unprecedented public health challenges to Europe and the world. EU Member States have responded quickly by implementing tailored measures while drawing on the strong foundation of public health expertise in the region and collaborating through well-established networks. There has been an increasing number of reports of COVID-19 outbreaks in long-term care homes across Europe with high associated mortality, highlighting the extreme vulnerability of the elderly in this setting.

The absence of an effective treatment or a vaccine combined with an exponential growth in infections from late February led many countries to implement non-pharmaceutical interventions such as “stay-at-home” policies (recommended or enforced), jointly with other community and physical distancing measures such as the cancellation of mass gatherings, closure of educational institutions and public spaces. This approach has collectively reduced transmission and the 14-day incidence in the EU/EEA and the UK overall has declined by 66% since 8th April and as of 17 May. In 30 EU/EEA countries, it appears that the initial wave of transmission has passed its peak with a decline in the number of newly reported cases.

According to our latest Risk Assessment, in the current situation, a strong focus should remain on comprehensive testing and surveillance strategies (including contact tracing), community measures (including physical distancing), strengthening of healthcare systems and informing the public and health community. The promotion of mental wellbeing among people living under physical distancing measures is necessary to ensure that populations have the resilience to maintain adherence to these measures.

――I know it's a very nasty virus, but it took some time to spread from the epidemic in China to the epidemic in Europe. The WHO issued a warning at the end of January by proclaiming a public health emergency of international concern (PHEIC), but European society could not prevent an epidemic. Do you think it really was unavoidable? What are the lessons you have learned?

ECDC has been carefully monitoring COVID-19 since early January 2020 through global epidemic intelligence and the collection of comprehensive information on cases detected in EU/EEA countries.

From January to April, ECDC updated its assessment nine times. As it is a new virus, knowledge about its characteristics evolved over time. ECDC has been assessing the risks based on the evidence known at the time of publication of each assessment, and focusing on the current probability and likely impact of the disease in the context of different questions (from risk of spread in the EU from China to risk to EU/EEA citizens in areas with community transmission and risk of severe disease). The risk moved from low at the beginning, to moderate and very high in line with the evolution of the outbreak and relevance for Europe of each of the issues highlighted. In addition to the focus on current risk, ECDC has also identified and updated needs for responding to likely future progression, and already at the end of January, ECDC stressed that preparedness plans should be updated and that hospital preparedness needs to be increased. That recommendation was included in all ECDC assessments until beginning/mid-March, and it was supported with guidance documents.

The outbreak of COVID-19 has EU/EEA evolved dramatically and rapidly since January. At this time, our analysis indicated that prevention and control of COVID-19 was feasible, and indeed many cases were identified at that stage, and chains of transmission were interrupted. However, the epidemic has moved fast and the virus has spread fast, and most EU/EEA countries have since then moved toward a scenario of increasing community transmission with large numbers of cases infected. This rapid escalation of cases in countries such as Italy and Spain, UK, and some regions in France has placed an enormous pressure on the healthcare system and this has been a major challenge for local services. All countries in the EU have responded to the emerging situation through implementation of a comprehensive package of measures including surveillance, testing, case management and strategies to mitigate the impact of the pandemic such as physical distancing measures.

The current focus in the EU and EEA remains on coordinated and well-managed adjusting of COVID-19 containment measures. The Joint European Roadmap puts emphasis on the following overarching principles for such adjustment:

• Actions should be informed by science and have public health at its centre;
• Actions should be coordinated between the Member States;
• Respect and solidarity between Member States remain essential.

Lessons-learned activities are ongoing or being planned and will inform the future preparedness activities in Europe.

――To my understanding, the IHR2005 (International Health Regulations 2005) is based on the idea that it will not interfere with the flow of international people and cargo as much as possible, even during a pandemic. However, governments have in turn closed borders and blocked cities. It seemed like a kind of panic to my eyes. Especially in Europe, freedom of movement under the Schengen Agreement is the most basic idea. How did you see that situation? Did you recommend those measures? Do these benefits outweigh the costs?

In the EU legal framework in relation to health, and according to ECDC’s founding regulation, ECDC’s role is in risk assessment, while risk management i.e. decision about borders’ openings and travel restriction lies with the individual Member States and the European Commission. Healthcare is exclusively a member state responsibility. Our technical assessments should provide information to support risk management, prioritise resources and aid communication.

Given the current epidemiology and risk assessment, and the expected developments, ECDC listed in its assessment a series of public health measures to be put in place to mitigate the impact of the epidemic. Our latest risk assessment says that based on an assessment of the local situation a range of physical distancing measures should be implemented, and where necessary enforced, in order to mitigate the impact of the epidemic and to delay the epidemic peak. These include, for example, the isolation of infected persons, the suspension of large-scale gatherings, restrictions in travel, and the closure of schools and workplaces. This can interrupt human-to-human transmission chains, prevent further spread, reduce the intensity of the epidemic and slow down the increase in cases, while allowing healthcare systems to prepare and cope with an increased influx of patients.

We have seen that over the past few weeks, EU/EEA countries and the UK have indeed implemented a range of measures to reduce the transmission of the virus, focussing in particular on physical distancing to decrease the burden on healthcare services, protecting populations at risk of severe disease, and reducing excess mortality. The reduction in the rate of incident reported cases in many EU/EEA Member States is almost certainly due to the introduction of these stringent control measures. Modelling studies show that lifting interventions too rapidly will cause a sudden upsurge in case incidence. However, a progressive strategy to phase out measures, where an increasing proportion of the population returns to work, could mediate this effect, maintaining incidence at a rate within hospital capacity, and allowing monitoring systems to identify need for re-introduction of specific measures if there is a sharp resurgence.

――When and how should a country reopen its borders? You argued that travel restrictions will need to be enforced to protect the most vulnerable groups even after lockdowns are lifted. Should seniors give up travel for a while? 

In the EU legal framework in relation to health, and according to ECDC’s founding regulation, ECDC’s role is in risk assessment, while risk management i.e. decision about borders’ openings and travel restriction lies with the individual Member States and the European Commission. Healthcare is exclusively a member state responsibility. Our technical assessments should provide information to support risk management, prioritise resources and aid communication.

――Unfortunately, WHO has been accused of being close to China and does not seem to have enough leadership in this pandemic. U.S. President Donald Trump said that he was cutting off U.S. payments to WHO. Is there a need for WHO reform? 

ECDC is not in a position to comment on those statements. During the current pandemic we worked extensively with our international partners and stakeholders, including the World Health Organization (WHO).

――What is most important for human society to confront this COVID-19 and future emerging infectious diseases? What role should WHO and ECDC play in it? How about nation states?

While it is still too early to draw final conclusions on how such a situation could be more effectively managed, the current situation provides a very unique and important opportunity to learn lessons how countries could be better prepared to deal with any future pandemics.

Systematic and comprehensive evaluations involving all key stakeholders will be necessary to review the impact of different responses. These lessons learned will feed into improving preparedness for the COVID-19 pandemic and will be used by countries to revise and update their general pandemic preparedness plans. Pandemic plans should enable adaptive public health measures, secure surveillance and reporting as well as health care system capacity and capability, and consider preparedness in different settings (urban, health care facilities, vulnerable populations). Exchange of scientific knowledge and latest available evidence should be part of future preparedness planning to better support decision-making process.

While the pandemic is still ongoing, smaller-scale reviews, in the form of in-action reviews, can be a rapid approach to help crisis managers modulate their response in dealing with the current emergency. Evaluations and lessons learned activities can be undertaken at local, regional, national and international levels. Their purpose is to improve preparedness plans, strengthen readiness, and support recovery: “build back better”. All components of preparedness plans need to be regularly tested in the “inter-pandemic” period in accordance with the continuous quality improvement process.

In relation to the future role of ECDC, this is one of the questions that will need to be looked at closer once the acute phase of this pandemic is over. Importantly, strengthening EU competence in the health area is a matter that lies within the responsibility of the EU Member States.