Warsaw, 13 April 2020
Mrs Jadwiga Emilewicz
Deputy Prime Minister, Minister of Development
Ministry of Development
Pl. Three Crosses 3/5
Cc: Minister Łukasz Szumowski
COVID-19 – what's next with epidemic?
What's next with social life and economy?
Expert manifesto of doctors, managers and entrepreneurs
Reverend Deputy Prime Minister,
We are an apolitical group of doctors, entrepreneurs and managers. We understand the human, health, systemic and economic challenges associated with the COVID-19 pandemic. We represent various sectors of the economy, we have gone through several crises (Internet from 2000, terrorist 9/11, financial from 2008). We are also ordinary citizens of Poland, Europe and the world. We understand what it means to lose a steady income or bankrupt a company built for decades. We have families and together with them we think about our future and that of our children, parents and friends. We care about our common good - Poland.
We feel obliged to take part in the discussion on what to do next. Being stuck, like many other countries, in a state of "freezing", every week we become more convinced that the epidemic will be stopped. At the same time, we are increasingly convinced that our lives will be different from those we remember from the first months of this year. We feel that we must prepare for the next step. But how?
We want to speak up on this. We want to make concrete recommendations. We declare our readiness to work pro bono, across political divides, to implement them.
A little context
The whole world is struggling with the COVID-19 pandemic, and Europe, next to the USA, is now its most important epicenter. Doctors, nurses and other healthcare professionals are fighting for the lives of patients. Experts assume that we have up to two years of constant struggle ahead of us. The disease will never cease (as was the case with the virus that caused the SARS epidemic in Asia in 2003). Vaccines that are currently in clinical trials will not be available on a mass scale until next year and may not be as effective as those against influenza (50-60%). Similarly with medicines - unless one of the already authorised medicines proves to be effective, new medicines still require years of clinical research.
To control virus transmission, all countries have implemented restrictions, freezing economies and restricting citizens' freedom of movement. The measures implemented by the Polish government are necessary and right. One can argue about the appropriateness of individual detailed solutions, but in our opinion this is a marginal issue in view of the gravity of the situation.
The brake is effective and necessary to control the epidemic, but it has serious consequences. It "freezes" the economy and social life. We see whole sectors disappearing - tourism, passenger transport, hotels, catering, non-food trade. Entrepreneurs count the days separating them from declaring insolvency. In the United States, 10 million people lost their jobs during the first 2 weeks of the freeze, that is, as many as they normally do for one year! We know that the first wave of redundancies in Poland took place at the end of March. Families of people who are unable to earn their living start to face basic problems. How to pay the next rent installment? What to buy food for?
Isolation has its impact on social life. For the first time we spent Easter among our household members only. There was no ordination of food, no meetings between grandchildren and grandparents. Weeks of remote work from home, when children demand constant attendance and care, intensifies emotional tension. Social isolation is particularly acute for people already struggling with depression or other mental illnesses. We are likely to see an increase in suicides, domestic violence and crime resulting from the marginalization of many social groups.
Freezing has serious negative health consequences as it significantly deteriorates the availability of medical care for people suffering from diseases other than COVID19. Doctors of various specialities - due to the closure of schools, for example - had to take advantage of care allowance. Non-communicable hospitals have limited scheduled admissions in order not to expose patients and staff to the risk of coronavirus infection. Overnight oncological patients began to struggle with access to doctors, chemotherapy and diagnostics.
The key question - when can we gradually give up the restrictions? Can we afford to wait a year for a vaccine or an effective drug? No! We must urgently prepare the next step. This is beyond discussion.
The most important question is what to do to get out of the freeze and what should this "new normality" look like during the further smouldering COVID-19 epidemic.
Action will only be possible if we control our fear. We have to be sure that going out on the streets will not cause another wave of the epidemic to break out. This will be a different normality from the one we remember before March. The virus is circulating and will continue to circulate. So how do we prepare to live with the coronavirus?
De-frosting of the economy and the social life
We have prepared a set of six recommendations for the "de-frosting" of the economy. These are based on the experience of other countries in the fight against various pandemics, including the current COVID19. We tried to balance epidemiological, medical, social and economic issues in order to prepare Poland and Poles for the "new normality". Our overriding goal is to protect life - there can be no compromises here.
The recommendations we have presented are as good as the knowledge we currently have about COVID-19. Therefore, they can, and probably will, evolve as our understanding of the pandemic expands. It will take months, maybe years, to defrost the economy and create a new reality. Perfect preparation and disciplined implementation of all six elements of our recommendations is essential to start defrosting the economy. Successful implementation of the de-freeze phase will be a huge logistical, process and management challenge. Much more difficult than the current freeze, which has been successfully introduced by mainly top-down administrative decisions. In a moment we may witness drastic social scenes, which history has so far spared an absolute majority of us.
1. Mass diagnostics
In order for healthy people to be able to walk on the streets, infected people must be isolated. For infected people to be isolated, we need to know who is infected. To know who's infected, we need to make a broad diagnosis. That's it.
WHO recommends diagnostics as a key element in controlling a pandemic. Model countries (e.g. Iceland, Norway, Hong Kong, Singapore) that have applied mass diagnosis have a lower mortality rate due to COVID-19. Diagnosis must be fast and mass. It must also be carried out according to a pragmatic protocol that takes into account the sensitivity and specificity of each type of test.
The only tests currently recommended by the WHO are tests for the presence of virus genetic material through RT PCR laboratory tests. This is a standard used in Poland and most countries. At the same time, it should be remembered that such a test has its limitations - its sensitivity depends on the correctness of the nasopharyngeal swab, conditions and time of transport from the place of collection to the laboratory and will never be used in mass testing because it is time-consuming and requires considerable human resources. Therefore, as a priority we should focus on mass availability for risk groups and all willing parties already available commercially fast (15-minute) antigen tests (protein on the virus envelope) that are as sensitive as the laboratory test, but can be performed under field conditions.
Although serological tests for IgM and IgG antibodies are used en masse in several countries, they are of limited epidemiological importance. They indicate the presence of natural (early or immune) anti-SARS-CoV-2 antibodies, i.e. they identify individuals who are in the active phase of infection (but only 7-10 days after exposure) or have acquired immune antibodies. Unfortunately, at this stage of knowledge it is not certain whether people who have developed COVID19 acquire permanent immunity as with chickenpox or not - as with flu.
Mass testing will require a central register of all tested persons, together with a system reminding them to perform possible repeat tests and an application storing the result of an individual test as a QR code. It is also possible to imagine that all public places (offices, shopping malls, stations, airports, etc.) will be equipped with QR code scanners and entry to such places will be possible only if they have the appropriate code.
We need to create an infrastructure for mobile blood or swabs, ensure the availability of tests, a data storage platform, an application to store individual QR codes, scanners. It will probably be possible to partially use existing IT systems such as the Individual Patient Account (IPC).
Mass testing is crucial in order to keep the epidemic under control and at the same time to return to social and economic activity.
2. Contact tracing
Once a new infected person has been identified, we need to identify all persons with whom he has had close contact in the last 14 days. All these people should in turn be tested for coronavirus. This can be done using technologies operating in other countries (e.g. Singapore) and ensuring full protection of personal data. Many companies are already outperforming each other in creating new applications for smartphones or smartphones, which enable safe and effective contact monitoring. Recently, Apple and Google joined forces to develop contact monitoring applications that work interchangeably on both operating systems. This app will help to collect anonymous data, so modern Artificial Intelligence algorithms can better determine who should be quarantined and where the virus is most frequently transmitted in the long term.
As experts, we realize that we need to balance epidemiological protection with privacy - we need to make sure that monitoring contacts (and other activities) do not endanger our common privacy.
3. Absolute quarantine of suspects and their relatives
As the test will never be able to be carried out using the app on your phone, it is important that all people with suspicious symptoms (dry cough and fever) immediately quarantine themselves and their relatives for 14 days. These people should immediately report the event to the central system, which will automatically send the appropriate number of self-tests to their address. If the test is negative, these persons could leave the quarantine.
4. Protection of the most vulnerable persons
Children and young people most often have a mild SARS-CoV-2 infection. On the other hand, the elderly and chronically ill people are the most vulnerable to the severe course of COVID19. The groups at higher risk are: people over 65 years of age, suffering from chronic lung diseases regardless of age (asthma, chronic obstructive pulmonary disease), cardiovascular diseases, diabetes, oncological patients, people taking drugs inhibiting the immune system (after transplantation, autoimmune diseases).
We should protect these people at all costs. They should particularly respect the principles of social isolation. We must prepare rules for all these people and work out models of both social isolation and their support. A system of neighbourhood care could be created for them and military services could be used to distribute food and basic goods for them (perhaps for free). In some countries, seniors have been given the opportunity to stay in hotels (which are empty anyway), which have been specially prepared for this circumstance (i.e. only people with a confirmed negative test for the presence of the virus may stay in the hotel).
5. protective masks and disinfectants for all
The issue of the effectiveness of protective masks in preventing infections in healthy people has been and still is controversial. But now the whole world is moving towards mandatory protective masks worn by all. This is due to the fact that many people can be infected without knowing it. In addition, masks prevent the face from being touched with hands, and this is a common mechanism for transmitting the virus.
In Singapore, at the time of the outbreak, each household received four N95 masks from the government. In Hubei Province, China, it is currently impossible to leave the house without an N95 mask. For the abolition of universal self-isolation to be safe, we must implement the obligation to wear a protective mask every time we leave home. The Polish government is introducing an obligation to cover the mouth and nose in public places - it seems to be necessary, also for psychological control over the fear of infection.
6. Strengthening resources, infrastructure and procedures in health care
Healthcare workers are the most valuable resource during an epidemic. Protecting them from infection and ensuring their comfort is key to controlling the epidemic. Past experience in managing health care during a pandemic indicates 4 key needs for change.
1) Securing all health care workers, especially in infectious hospitals. This means the availability of sufficient personal protective equipment and continuous testing (at least once a week, and in some hospitals perhaps even daily) to avoid nosocomial infections (currently over 30% of all diagnosed patients!). We should also better prepare a system of shift work in infectious diseases hospitals to provide full 24-hour care while minimising the time of uninterrupted work by individuals. Staff fatigue reduces immunity and increases the risk of infection.
2) Secure continuity of care for non-COVID patients19. Remember that every year we have nearly one hundred thousand acute coronary syndromes, more than one hundred thousand newly diagnosed cancer patients, thousands who contract other infectious diseases, and millions who have chronic diseases or need permanent or periodic rehabilitation. We need to take care of them and make sure that human resources, infrastructure, drug delivery logistics work efficiently and patients have continuity of care. Hospitals and clinics should be given clear guidelines to protect patients and staff from possible infections. This probably also means preventive testing of all staff and all patients wishing to receive medical services.
3) Securing health care for patients in quarantine or isolation. It is particularly important to take care of people who are isolated because they belong to a high-risk group. Most of these people are already chronically ill and need access to diagnosis and treatment. It seems advisable to systematically implement procedures allowing for remote diagnostics (e.g. blood collection at home by community nurses) or, for example, for the supply of medicines at home.
4) Secure safe hospitalisation of patients and safe resumption of planned operations and procedures. This will require a managerial effort to reduce the number of staff dealing with one patient, drastically shorten the length of stay in the hospital, only one operating team for each patient. Simple, but requiring huge and immediate changes in the daily work of medical teams.
We strongly believe that we need to get out of the social and economic freeze as soon as possible. We can already see the dramatic consequences of this phase, and each week will deepen these consequences. Nevertheless, human life is at stake, the lives of many thousands of Poles. That is why thinking about unfreezing the economy should begin by answering the question to what extent the six elements described above are "under control". We need to have a perfectly prepared, tested plan for the implementation of the recommendations before we announce all the progress for the economy. We must also have an excellent system for monitoring implementation and compliance with these elements. We need to have a daily, even hourly, system for reporting key measures so that we can react immediately at any time, not only at the central but also at the regional level, so that we can take active measures to limit and relax restrictions not only at the national level. An effective fight against Covid-19 must be carried out voivodeship by voivodeship, county by county, and the measures applied may vary in different areas of Poland.
This is our "new reality". We are convinced that as Poles we will accept it with understanding to safely rebuild our social life and economy.
We know that effective implementation of the "de-freeze program" requires precision, excellent operating procedures, logistic systems, knowledge, experience and independence from politics. We offer our experience in crisis management and pro publico bono assistance. In the name of the good of us all. Beyond divisions.
dr Adam Kruszewski, MBA
dr n. med. Jarek Oleszczuk
Dr Bogdan Biarda
Dr Stefan Bogusławski
Dr Michał Boni
Prof. zw. dr hab. Marcin Czech
Dr n. med. Jakub Gierczyński
Dr Igor Gnot
Dr Ligia Kornowska
Dr Adam Kruszewski
Prof. dr hab. Jarek Leszczyszyn
Dr n. med. Tomasz Maciejewski
Dr n. med. Jarek Oleszczuk
Prof dr hab. Witold Orłowski
Dr n. med. Piotr Romanowski
Dr Jan Skowroński
Prof Jakub Swadzba
Dr Robert Szymański
Dr Paweł Urbański
Dr Marcin Zawadzki