NAIROBI — The World Health Organization inched closer to declaring a pandemic Monday, after coming under fire for failing to do so even though COVID-19 cases have now been reported in more than 100 countries.
“Now that the virus has a foothold in so many countries, the threat of a pandemic has become very real,” said WHO Director-General Tedros Adhanom Ghebreyesus during a press conference.
The global spread of COVID-19, which originated in China, has picked up pace in recent weeks. Two weeks ago, there were 2,459 cases and 33 deaths outside of China. Now, there are 28,674 cases outside of China and 686 deaths. Over the weekend, the total case count surpassed 100,000.
Coronavirus around the world
WHO has hesitated to make the declaration as some countries, such as China and Singapore, have shown that aggressive containment measures can work to slow the spread of the virus.
Tedros added that it “would be the first pandemic in history that could be controlled.”
There is also fear that a pandemic declaration could provoke a change in mentality that leads to an abandonment of efforts to contain the virus, said Dr. Michael Ryan, executive director of the WHO Health Emergencies Programme.
“The word for us is not a problem. The issue for us is what the reaction will be. Will the reaction to the word be: Let’s fight? Let’s push this disease back? Or will the reaction to the word be: Let’s give up,” he asked.
COVID-19 vs. influenza
Declaring a pandemic is a rare event. During the 20th century, pandemics were declared only three times — the Spanish flu of 1918-19, the Asian flu of 1957-8, and the Hong Kong flu of 1968. The last global pandemic was the swine flu in 2009. In that case, WHO received criticism over whether the outbreak should have been labeled a pandemic — the agency had lowered the threshold for what defines a pandemic shortly before the declaration.
Outbreaks of influenza, which spread more easily than COVID-19, are easier to label as pandemics, WHO experts have repeatedly said.
“This virus is not influenza. We are in uncharted territory. We have never seen before a respiratory pathogen that’s capable of community transmission but at the same time, which can also be contained with the right measures,” Tedros said during a previous press conference last week.
If it were an influenza epidemic, he said, global widespread community transmission would have been expected to occur by now and efforts to slow its spread would not be possible. But, with COVID-19, containment is possible when countries use early, aggressive measures, he said.
However, COVID-19 is more concerning than influenza because there isn’t a vaccine or treatment, and there are questions surrounding transmission and case fatality, Ryan said during the press conference.
Cases, clusters, communities
More than two months into the outbreak, the majority of cases are still in China, and 93% are in just four countries — China, South Korea, Italy, and Iran. Of the 104 countries, territories, and areas that have reported cases, 51 still have fewer than 10 cases, and 40 still only have cases that were imported from other countries, rather than local transmission of the virus.
WHO has grouped countries into four categories: Those with no cases; those with sporadic cases, such as from travelers who arrived from other countries; those with clusters, which include cases that are associated with a certain setting, such as a workplace, place of worship or cruise ship; and those with community spread, when the virus begins to spread in an area and there are cases where it’s not always clear how individuals become infected.
Countries that have no cases, sporadic cases, or clusters should focus on finding, testing, treating, and isolating individual cases, as well as following their contacts, Tedros said.
When there is community transmission, testing and tracing all contacts becomes more challenging. In that case, actions should be taken to reduce transmission into manageable clusters, including considering closing schools and canceling mass gatherings.
There is proof that countries can properly manage the outbreak: Some have successfully gone from community transmission back down to clusters, said Dr. Maria Van Kerkhove, technical lead of the WHO Health Emergencies Programme, during the press conference. “There is no [inevitable] eventuality here,” she said.
Another major advantage of not giving up on an aggressive containment approach is that it gives time for weak health systems to prepare their response.
“At the very least, by doing that, we give all the health systems in the world a chance to prepare and potentially develop therapeutics and vaccines to prevent it. This is about containment and buying time and in doing that, we can save a lot of lives,” Ryan said during a previous press conference.
Containment in China and Singapore
WHO pointed to some countries where aggressive containment measures have been effective and present a justification for not declaring a pandemic.
“What we’ve seen in other countries — like Singapore, like China — demonstrates real success in turning the disease around,” Ryan said.
One of the lessons from these two countries is to “break down your problem.” This includes understanding when you have sporadic cases, clusters, and community transmission.
In China, the number of new cases per day peaked around mid-February. On Feb. 8, for example, there were 3,401 new cases reported in China in one day. On Monday, only 45 new cases were reported from China.
The country has taken drastic containment measures, such as quarantining Wuhan, the city at the center of the outbreak. But the government has also taken an evidence-based approach and has been diligently tracing contacts of people with cases, according to WHO experts.
As of the end of January, all provinces in China were at the highest level of risk. Since then, a majority of them have downgraded that risk, Ryan said.
Meanwhile, Singapore reported its first case on Jan. 23, and has since only reported 150 cases. It’s a good example of an “all of government approach,” Tedros said.
Its response included quickly scaling up contact tracing efforts and quarantining people who had close contact with confirmed cases, as well as travel advisories and entry restrictions.