Public health physician Gauden Galea, the WHO representative in China, expects the coronavirus pandemic to last several months. He weighs in on Malta’s efforts so far. Kristina Abela has more...
Is Malta being prudent in imposing a partial lockdown?
Malta has 30 reported cases (at the time of writing).
Testing has increased considerably and there are plans to further increase the amount of tests done. A testing centre has been set up. Active contact tracing is being conducted. Cases are being isolated and contacts quarantined.
Quarantine is being enforced for returning Maltese and for visitors.
These are all good practices and consistent with what has been learned in China as well as with WHO recommendations.
Active identification of cases, contact tracing, isolation and quarantine are established public health interventions that will help stop or slow virus transmission by effectively identifying potentially infected people and taking them out of circulation until there is a high degree of certainty that they are not infectious.
It is good to start these measures early. The increased surveillance will result in early detection of outbreaks and breaking the chains of transmissions... this should theoretically be easier in an island population.
Couldn’t a partial lockdown, of schools, child centres, etc, be futile? Parents of children are still working and coming into contact with people after all.
It is indeed a good idea to control population movement at least for a period long enough to ascertain that there is no community transmission.
In China, after a period of prolonged shutdown of the schools and workplaces, provinces judged to be at low risk are slowly opening again with careful vigilance to catch any new outbreaks in the bud.
The virus is too new and its transmission dynamics are not fully known. For instance it is not known how infectious children will be when they congregate in schools – it is currently known that children do get the infection but in general manifest only mild disease.
On the other hand, it is not known how that will change when children get together after school re-opening.
It is important, of course, that the population understands that school shutdown is not a holiday, and families should take the hint: children should not congregate elsewhere.
Until community transmission has been ruled out by sufficient testing, and at least two weeks have passed to cover any cases currently in the incubation period, it would be ideal to opt for the greatest amount of social distancing possible. This will help to slow or stop any spread that is taking place undetected in the community.
Should a total lockdown be imposed on the country?
Total “lockdowns” such as we saw in Wuhan, Hubei province, are not intended as preventive measures for the population being locked down but rather to protect others.
It is good to assume that there already is infection in the community and to go for stringent controls
Wuhan’s lockdown was a sacrifice at a great cost to the people of the city. It was the price paid to buy time for the rest of China and for the rest of the world to prepare for the epidemic that was coming.
Control of population movement, beyond the isolation of cases and quarantine of contacts and potentially exposed people, should be based on a careful risk assessment and should not be the reflex action.
The level of infection in the community will be an important deciding factor. How much of a shutdown and, for how long, depends on this risk assessment.
The battle will be a long one, since Europe as a whole is headed for an epidemic that is many months long and the economy would be severely affected by such a period of lockdown.
Nevertheless, at the beginning, it is good to assume that there already is infection in the community and to go for stringent controls on work, school and mass gatherings, and then to ease off as the testing and case finding allow for a lowering of the risk assessment.
This is the example that has been set by those provinces in China that had only a few cases and successfully kept the epidemic at a low level. This balancing of movement restriction and risk assessment of community spread needs to be evidence based using the data from widespread testing.
How to control an outbreak
WHO lists nine areas of preparation for controlling a large-scale community outbreak. Gauden Galea said he was pleased to see that action was being taken on all these fronts in Malta.
• Incident management and planning system;
• Surveillance and risk assessment;
• Laboratory capacity;
• Clinical management and health care services;
• Infection prevention and control systems;
• Non-pharmaceutical public health measures (such as quarantine and movement restrictions);
• Risk communication;
• Screening systems at points of entry;
• Operational logistics.