Recovery, Renewal, Resilience

Vaccine programmes will need to source sufficient vaccine, notify recipients of their eligibility, and arrange processes to administer the vaccine. Vaccine wastage, recipient confusion over invitations, and inefficient processes will risk undermining the programme's efficacy. To build early confidence in vaccine programmes:

• Agree the current aim for the vaccine programme e.g. to reduce immediate risk to life
• Identify the priority groups to vaccinate to achieve the current aim
• Identify individual citizens who belong to those priority groups
• Disseminate public information on current priority groups to manage expectations
• Explain to agencies that lobby for their staff to be given higher priority why they are currently prioritised as set out in the priority groups - and explain how this achieves the current aim
• Establish a national register of healthcare staff who are qualified to administer the vaccine -including volunteers and other staff who have been recently trained and approved
• Identify suitable facilities that can act as vaccine centres e.g. doctor surgeries, schools, public buildings, mass vaccine centres
• Identify the demand for vaccine at each vaccine centre (based on estimated throughput) and ensure that sufficient supply is available when it is needed
• Identify how the vaccine will be transported to centres and stored appropriately
• Maintain close communication with each vaccine centre to share information, for example, on:
  • Stock levels, delivery schedules, and projected demand
  • Which patients have received the vaccine
  • Which patients have been refused the vaccine and for what reason
• Track the performance of vaccine centres to analyse programme risks and capacities, for example, implement an inventory management system to reduce vaccine waste such as by tracking expiry dates (continued)
• Consider future aims for later in the vaccine programme and the timing of vaccinating different priority groups to achieve those aims e.g. to re-open non-essential business
• Seek process-related advice from countries that have already established vaccine centres e.g. Germany

COVID-19 vaccination rollout is taking place in many countries, with many more planning to implement mass vaccination strategies for in the near future. The widespread nature of the pandemic has meant that huge numbers of people require vaccination, and a result, demand for vaccines currently far outstrips supply in some countries[1]. Fear surrounding COVID-19 has led to criminals utilising black markets to develop and sell fake vaccinations on the dark web[2]. The demands on government vaccination programmes has also promoted the online sale of other fake medicines such as the malaria drug hydroxychloroquine and the steroid dexamethasone[3] as these have been associated with COVID-19 treatment. In other cases, some online vendors were claiming to sell vaccinations or medicines that would have never been shipped to buyers[4],

And in the UK, there were incidents of scammers turning up at people’s doorsteps offering a vaccine for payment, following a spate of fake text messages[5].

Vaccines are a financially lucrative commodity, and while the pharmaceutical industry is prepared with regular audits and vetting of supply chains, minimising human contact, stops and handovers during distribution, and real-time digital devices which measure temperature and location, there are other risks. Some of those at risk include:

• Desperate consumers believing they can purchase the vaccine online
• Hospitals and healthcare facilities that have been hit with a barrage of phishing and ransomware attacks which can try to sell fake vaccines
• Vaccination centres which may be points of vulnerability; one supply chain security expert stated “we need to tell people at the vaccine centres that they carry gold”[6].

The rise in fake vaccines and medications requires approaches that protect people, and infrastructure.

Protecting people

• Widespread information campaigns that advise people not to buy any vaccines online, with particular focus on informing people with pre-existing health conditions or those in certain vaccine priority groups as these groups may feel an urgency to be vaccinated
• Remind people that they should consult their registered doctor about vaccination, and only be vaccinated at an official vaccination point[7] and that NHS England will never ask for bank details, Pin numbers or passwords, when contacting you about a vaccination
• Monitor online chatrooms and forums that may be regularly used by vulnerable groups to scan for attempts to sell fake vaccines and medications
• Set up and regulate certification organisations which undertake due diligence on sources of drugs (e.g. pharmacies) and medications e.g. pharmacychecker.com to create a transparent solution for the public to check the sources of their online medications to ensure their legitimacy and safety
• Work with healthcare professionals to build trust in vaccinations. The spread of fake vaccines may deter people from legitimately being vaccinated

Protecting infrastructure

• Regularly assess cyber security and train staff in recognising and reporting any phishing scams or malware attacks
• Train staff and volunteers administering vaccinations in the safe and careful disposal of empty vaccine vials which could be stolen and used to package fake vaccines that look authentic[8]
• If required, consider security at vaccination centre sites, especially those which have been set up in temporary locations or do not have adequate security systems

References:

[1] https://www.swissinfo.ch/eng/swiss-regulator-warns-of-fake-covid-19-vaccines-online/46279734

[2] https://www.japantimes.co.jp/news/2020/11/27/asia-pacific/covid-19-vaccine-china-black-market/

[3] https://iea.org.uk/will-there-be-a-black-market-in-covid-vaccines/

[4] https://www.ft.com/content/8bfc674e-efe6-4ee0-b860-7fcb5716bed6

[5] https://www.bbc.co.uk/news/uk-england-london-55577426

[6] https://www.ft.com/content/8bfc674e-efe6-4ee0-b860-7fcb5716bed6

[7] https://www.swissinfo.ch/eng/swiss-regulator-warns-of-fake-covid-19-vaccines-online/46279734

[8]https://www.dw.com/en/officials-warn-of-fake-covid-19-vaccines/a-56123830

There is much concern about the combination of coronavirus with winter flu and the effects on transmission rates and a recent report outlines concerns and plans. It recommends to plan for coronavirus during winter months by:

• Analysing current COVID-19 data to develop prevention and mitigation strategies for winter, considering the rise in other illnesses during colder weather
• Considering how mitigation strategies should protect, and pose no further disadvantages to high risk patients or communities
• Engaging with patients, carers, public and healthcare professionals with enhanced coordination, collaboration and data sharing between central and local initiatives

It also suggests considering:

• Minimising community SARS-CoV-2 transmission and impact through:
  • developing effective policies to maximise population engagement in essential control measures e.g. participation in test, trace and isolate (TTI)
  • extensive autumn public information campaigns co-produced by communities and professional organisations
  • guidance for commercial, public and domestic properties on temperature, humidity and ventilation to reduce virus transmission indoors
  • consideration of those most vulnerable to COVID-19 who are least able to heat their homes adequately in winter
• Maximise infection control and ensure that COVID-19 and routine care can take place in parallel by:
  • prioritising system-wide infection prevention and control measures
  • o providing training to use personal protective equipment (PPE) and other infection prevention and control measures
  • maximising remote consultations for hospital and community care
  • testing and quarantining patients being discharged into the community or care
  • prioritising the backlog of clinical care by clinical need, not waiting times
• Improving public health surveillance for COVID-19, influenza and other winter diseases through:
  • comprehensive, population-wide, near-real-time, health surveillance systems
  • conducting large-scale population surveys comparable data collected from hospitals and the community
  • overseeing and coordinating data centrally
• Minimise influenza transmission and impact by maximising influenza vaccination uptake

Test and trace systems have been implemented worldwide to try to track and contain the transmission of COVID-19. While these efforts have been broadly successful, there are some communities in which the test and trace process is inefficient due to limited uptake[1]. This has been particularly relevant in communities where there are language barriers[2], and in work environments in which sharing colleague’s information may be difficult because a positive result could mean unpaid sick days[3]. Commonly, such occupations include those with a large number of migrant workers, or where workers are employed through agencies and staff members are inconsistent or turnover is high[4]. In these cases alternative mechanisms such as mass swabbing through mobile testing units have been employed to try to boost the number of people tested, including those who may be asymptomatic[5]. Taking swabs can be unpleasant, however, using saliva samples can be less invasive, more reliable than nasal swabs, and can be done more frequently, even once a week which would help mitigate the false negatives swabs can produce[6].

Targeted mass swabbing is currently being undertaken in some countries such as Canada, where there have been outbreaks and deaths of those working in agriculture due to poor living and working conditions5. The vulnerability of these groups to COVID-19 was addressed in The Manchester Briefing 13 where it addressed localised spikes in COVID-19 transmission as a result of poor working conditions in food and garment industries.

Mass swabbing could help to mitigate the lack of reporting to contact tracers, improve the transparency of information within the health system, and improve the efficiency of testing[7]. Efficient mass testing should consider:

• Effectively mapping all existing testing and laboratories capabilities including those in health services, research centres[8], and scientific institutes to reduce the risk of running parallel systems with the private sectors which may encourage competition for supplies and potentially reduce the capacity of existing systems13
• Use existing capacities to help develop important localised approaches to improve the coordination of mass testing through involvement with local authorities and industries13
• Develop partnerships with life science industries to build resources and capacity for mass testing14 that should account for, and complement, existing local capacity
• Be mindful of how targeted mass testing may (further) stigmatise certain communities. Careful consideration should be given to the location of testing centres so not to create an association between a particular community and the virus
• Ensure there is clear and simple dissemination of public information in areas in which mass testing takes place. This should include sensitivity to the local conditions including languages, culture and the level of community (dis)harmony

Increasing effective capacity for mass testing, especially in high risk populations, is central to limiting the spread of COVID-19. Developing an integrated localised system that is capable of regular, repeat testing may not only help stem the spread of the virus, it may also help support other sectors adversely affected by COVID-19. For example, this type of testing may help mitigate the issue of quarantine after travel as the virus can be more closely monitored, even in asymptomatic patients. In addition, particularly vulnerable groups may be protected through close observation, including those who work in jobs where there is a high risk of infection, and those who may feel forced to go to go to work due to financial insecurity.

[1] https://www.theguardian.com/world/2020/aug/04/four-key-failings-of-england-covid-19-test-and-trace-system

[2] https://www.theguardian.com/world/2020/aug/04/four-key-failings-of-england-covid-19-test-and-trace-system

[3] https://www.theglobeandmail.com/canada/article-ontario-pivots-on-testing-strategy-for-migrant-workers-to-contain/

[4] https://www.iheartradio.ca/am800/news/mass-testing-planned-after-24-year-old-migrant-worker-dies-of-covid-19-1.12612356

[5] https://windsor.ctvnews.ca/mass-testing-for-migrant-workers-planned-following-death-of-24-year-old-man-1.4972533?cache

[6] https://www.newscientist.com/article/2246880-city-in-uk-takes-steps-to-test-entire-population-for-coronavirus/

[7] https://www.bma.org.uk/news-and-opinion/a-hidden-threat-test-and-trace-failure-edges-closer

[8]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878121/coronavirus-covid-19-testing-strategy.pdf

To read this case study in its original format, follow the source link below to TMB Issue 20 (p.22-23).

The health impacts of COVID-19 such as organ scarring, and long-term lung problems are gradually coming to light. However, wider implications from lockdown on working socialising and living in small spaces is less understood. Consider the impacts of this and the steps that can be taken to address them:

• Eye strain. Consider the amount of time being spent on online calls e.g. on Zoom or Skype:
  • Where possible replace Zoom with phone calls
  • Make meetings shorter and limit them to 40 minutes
  • Use the 20/20/20 rule. In a 40 minute meeting, take a mid-time break to rest your eyes and look at something 20 feet away for 20 second
• Back pain. Consider impacts of home working environments on back pain such as working from the sofa:
  • Ensure employees have a set-up that's fit for purpose like they do at their office
  • Do not stay seated all day as the spine is out of alignment - set reminders to walk every hour for a few minutes or do simple stretches
• Circulation. Improve awareness of the risk from poor circulation as a result of moving less:
  • Look for signs of varicose veins such as aching legs, swollen ankles, and red or brown stains around the ankles
  • Keep hydrated and mobile to decrease the risk of deep vein thrombosis (DVT), or clotting in the deep veins of the legs
• Maintain contact with your doctor as DVT is associated with underlying health issues that may go undiagnosed

When the intensity of the crisis reduces, there is more opportunity for targeted measures that limit virus transmission. Testing should be pro-active and strategically targeted. Consider establishing 3 categories of people and places, and create suitable testing guidelines for each one, including:

People with symptoms. Consider testing this group immediately:

• Establish a system with quick consultation, diagnosis and testing (upon medical advice)
• Use antigen tests as results are available quickly
• Conduct antigen tests via saliva samples to minimize the risk and burden on patients and medical staff

People without symptoms, who have been assessed with a high pre-test risk of infection, and/or who work in high-risk areas. Consider testing this group pro-actively:

• Consider places that require close physical contact such as hospitals, senior-care facilities, or nightlife/entertainment-related industries
• Because of the high risk of infection and high pre-test risk of infection, consider thorough and rapid testing for this group

People without symptoms, who have been assessed with a low pre-test risk of infection, and who work in low-risk areas. Build consensus regarding action for this group:

• Include people who, for peace of mind, want to be tested in order to conduct societal, economic, cultural activities etc.
• Consider that testing is not perfectly accurate and only reflects a person's condition at one point in time. Continuous testing would be required to fully monitor the condition of an individual

The basic idea of pooled testing is that instead of testing samples from individuals one at a time, samples from multiple individuals (pools) would be mixed together at a testing facility, and tested as one sample. If the test comes back negative the whole pool is clear. If the test is positive, the pool can be tested individually instead. Pooled testing is a means to test more people faster, using few tests, and for less money, and has long been used to test large asymptomatic populations for disease e.g. to screen for sexually transmitted diseases, and to test donated blood for Hepatitis B and C, Zika virus and HIV. Consider:

• The cost saving benefits of pooled testing over testing each individual - schools and businesses saddled with testing costs could lower costs by as much as 75%
• The scalability of pooled testing - batched testing of pools can provide data covering large areas such as schools and businesses
• Pooled testing could ramp up the number of coronavirus tests while lowering testing costs, especially in low-prevalence areas

The Mental Health Commission of Canada has developed three programmes: Caring for Yourself/Caring for your Team, and Caring for Others:

• Caring for Yourself/Caring for your Team - Participants learn how to better understand their own mental wellness, and that of their team. They learn to notice if they might be moving into unwell areas, use practical actions to help with stress, and know when to reach out to get professional help, and learn tips to support team members
• Caring for Others - Participants focus on how to create a safe space to have conversations about mental health and/or substance use problems, and the skills required to respond to a mental health crisis until professional help arrives. This prepares participants to have conversations confidently about mental health during a crisis, with their family, friends, communities, and in their workplaces

A number of track and trace mechanisms to support treatment have been credited with supporting the response in Korea[1]. These include: Self-diagnosis Apps for in-bound travellers; the self-quarantine Safety APP; contact tracing and epidemiological investigations.

Self-diagnosis Apps for in-bound travellers

This self-diagnosis mobile application has been available to in-bound travellers at airports and harbours. The apps:

• Have been developed by the government to monitor symptoms of inbound travellers and provide them with prompt medical advice.
• Are downloaded onto a mobile device and:
  • Is required at entry by all inbound travellers since 1st April 2020.
  • Is available through the URL and QR codes available around the airport or harbour immigration gates and on special arrival cards.
• Require the in-bound traveller to:
  • Install the app and use it to submit passport information, nationality, name, address and other necessary information for quarantine.
  • Connect directly to a call centre and social media channels and provides medical answers against suspected symptoms to enable early treatment.
  • Report their health condition (body temperature, cough, sore throat, or difficulty breathing) through the application once a day during their 14 days of quarantine.
  • Seek medical advice if they are showing symptoms. This can be done through call centres operated by the Korea Centres for Disease Control and Prevention (KCDC), or at COVID-19 screening centres.
• Collect data entered by the user during the self-diagnosis which:
  • Is checked against immigration data before being sent to the public health clinics under jurisdiction of local governments.
  • Is transferred to local governments so that the corresponding public health clinics can provide medical advice, testing and instructions on how to receive care. This is done for travellers reporting symptoms for more than 2 days.

Self-quarantine Safety APP

This is a voluntary application for residents of Korea. The app:

• Has three functions to:
  • Conduct a self-diagnosis for the users to conduct and submit the results with the assigned government officers
  • Provide necessary information including self-quarantine guidelines and the contact info of the assigned government case officers.
  • Ensure that self-quarantine orders are kept by setting off a GPS-based location tracking alarm whenever a user ventures out from the designated quarantine area - to prevent possible violation of orders. A case officer is also notified when quarantine is disobeyed; the case officer takes appropriate measures to have the subject return to the quarantine area.
• Has two types of application available:
  • One for the users under self-quarantine – they use the application twice a day to monitor themselves for four symptoms: fever, cough, sore throat, and respiratory difficulties.
  • One for the assigned government case officers – once submitted, the self-diagnostic data will automatically be shared with an assigned case officer, who will be notified if the user does not submit the self-diagnostic data or becomes symptomatic.
• Has been effective in monitoring those under self-quarantine and making sure that they stay in designated locations. The alarm function of the application has demonstrated to encourage the quarantined to follow regulations.

Contact tracing and epidemiological investigations

The COVID-19 Data Platform supports investigators as they trace infected people. The app:

• Is designed to:
  • Support epidemiological surveyors to quickly identify the transmission routes and places that the infected person has visited
  • Use real-time analysis of data through location tracking, card transactions, and CCTV recordings for accurate tracing of routes and places
• Takes users through a process of using the app as:
  • Citizens voluntarily record their whereabouts on their smartphones using Google Timeline
  • Using a ‘My Timeline’ function on Google Map application, the user whereabouts and routes are recorded automatically.
  • Data on Google Timeline can be captured as screenshots and shared with epidemiological investigators, who will use the data to trace contacts and patient routes.
• Supports health officials in:
  • Confirming the interview results of patient transmission routes with data on the system.
  • Allowing big data analysis from real-time data feeds on COVID-19 patients, including their whereabouts and the time spent on each location.
  • Using these multiple data points, so that the system can detect incidents of cluster infection and show the source of transmission.
  • Enabling prompt data-driven COVID-19 epidemiological investigations.

Further details on the apps are available[2],[3].

References:

[1] Flattening the curve on COVID-19: How Korea responded to a pandemic using ICT http://www.undp.org/content/seoul_policy_center/en/home/presscenter/articles/2019/flattening-the-curve-on-covid-19.html

[2]http://ncov.mohw.go.kr/upload/ncov/file/202004/1587521842434_20200422111722.pdf

[3]http://ncov.mohw.go.kr/upload/viewer/skin/doc.html?fn=1587107400738_20200417161001.pdf&rs=/upload/viewer/result/202005/

Councils maintain crucial services, have set up community hubs, and established local teams for tracing and tracking. Councils provide food and shelter to people at risk, help local businesses stay afloat and have mobilised volunteers and therefore know their communities in depth which can support trace and track. Councils:

• Are naturally placed to respond quickly to the distinct needs, challenges and infection rates of their own area
• Are equipped with their own teams of public health professionals

While volunteers can help bolster these provisions, local government should be wary of levels of training, qualification and experience to reduce poor services and inefficient use of resources.