What are National Societies required do to combat resurging COVID-19 and potential second waves?
Maintaining public health epidemic control measures is essential
Ongoing reductions in cases and transmission are achieved precisely because of effective epidemic control measures — maintaining them is crucial to preventing further waves of cases.
Prioritizing any single public health intervention to the exclusion of others is unlikely to be effective. Experience from the response to COVID-19 so far shows that multiple coordinated interventions are needed to systematically reduce risk, reduce transmission, detect and isolate cases, and trace contacts. Second waves can be avoided by identifying and learning what has been effective so far and ensuring these critical measures are continued, delivered on the necessary scale, and that they reach all affected and at-risk populations.
National Societies (NS) are well placed to continue and enhance support to community-level public health measures. Many already having extensive experience in epidemic control, are trusted voices in their communities to listen to, engage and educate people, and have a mandate to provide prevention and response measures.
NS activities to prevent further waves include:
- Ensure continued close engagement and coordination with relevant health authorities at all levels.
- Continue support to health authorities to detect, test, isolate and treat every case and trace every contact through community-based surveillance, auxiliary support to mass testing, contact tracing, and support to quarantine and isolation facilities.
- Help schools, markets, health facilities and other essential facilities establish preventive measures such as handwashing points and patient flows to improve physical distancing.
- Promote hand hygiene.
- Support screening at key locations e.g. international arrival airports
- Engage communities. People have a lot of questions and uncertainty and need to understand that life will not return to pre-COVID “normal” for many months, but be reassured that they can take actions to reduce their risk. Communities must be engaged in designing and implementing the measures that will prevent a second wave. Specific guidance for planning safe community engagement activities is available here, with other materials also available through the Community Engagement Hub and Go Platform
- Continue widescale risk communication and hygiene promotion before, during and after suppression measures are relaxed. Acknowledge government mandated restrictions are being lifted, but that this should not be misunderstood as COVID-19 being over. Emphasise that personal preventative behaviours remain a crucial responsibility for all. Some evidence shows focussing on the benefits and responsibility to the wider community is more effective than focussing on benefits to the individual e.g. “Don’t spread COVID-19” is a more effective message than “Don’t catch COVID-19”.
- Advocate for carefully planned and phased approaches to the end of lockdowns and transmission suppression measures.
- Promote seasonal influenza vaccination among vulnerable groups.
How does this fit with the overall strategy to combatting COVID-19?
There are two broad approaches to epidemic response: First, a suppression strategy aiming to eliminate human-to-human transmission. This approach requires intensive and sustained interventions, with a focus on identifying, isolating and treating all cases, and identifying all contacts or people at risk of exposure. These public health measures need to be maintained for as long as the virus is circulating, or until an effective vaccine is available. While maintained, they can have significant social and economic impacts, and require a significant scale-up of health systems’ capacities.
Second, a mitigation approach seeks to slow but not stop the spread of the virus, with the goal of reducing the demand on health systems and protecting the most vulnerable people (e.g. older people and those with underlying health conditions). The disruption to health, social and economic systems over this time period is likely to be profound. Where mitigation strategies are adopted, significant death and health system impacts – albeit at a lower level than would occur had they not been adopted – must still be expected. The ‘mitigated’ epidemic is still likely to overwhelm the health system with many times more cases than can be properly cared for, resulting in many avoidable deaths. However, this approach may be the only option in countries where health systems have limited capacity.
There is not yet enough evidence or experience to fully understand the long-term viability, limitations, or future impacts of either approach, but both strategies are expected to be needed, in various modalities, for a minimum of 12-18 months.
At the national and local level, the WHO has divided the COVID-19 outbreak into four distinct phases:
- No cases (preparedness phase)
- Imported or locally detected cases (sporadic cases)
- Clusters of cases over time or in different areas of the country (clusters)
- Larger-scale outbreaks with local transmission (community transmission)
What does this mean for National Societies responding to COVID-19?
National Societies can support critical public health, clinical, and health system activities during each phase, whether suppression or mitigation approaches are chosen, and support vulnerable communities by helping to mitigate the impact the outbreak has on health, social and economic systems.
Below are some evidence-informed health activities that National Societies can support. For each National Society these activities will be delivered alongside others depending on the context. It is important that National Societies review, prioritise, plan and adapt their activities to ensure they are able to maintain lifesaving humanitarian services throughout the epidemic.
Preparedness
Support health authorities and at-risk communities to prepare to respond to first cases (detect, isolate, and treat, trace contacts and screen, as appropriate); promote effective behaviour change and hygiene practices, engage communities and address misinformation and rumours; adapt community and clinical programming to be ready to effectively respond and limit risks to personnel; assess NS auxiliary roles and institutional capacities for public health and clinical responses.
Institutional readiness and coordination
– Establish institutional readiness (business continuity planning; identification of programming changes needed for appropriate outbreak response; institutional linkages to Ministry of Health, Emergency Operations Centres, WHO country offices, Humanitarian Country Teams, and other relevant stakeholders and partners)
– Define the auxiliary mandate of NS with authorities and partners, ideally within a National Response Plan, and prepare for designated outbreak response activities (e.g. support to quarantine, contact tracing, point of entry screening)
– Ensure plans take into account and, as far as possible, mitigate for possible impacts on staff and volunteers of COVID-19, these include ensuring measures are in place to reduce the risk of transmission of COVID-19 between staff, volunteers and community members; preparing for a likely reduction in human resources available due to staff and volunteers potentially catching the disease, quarantining, isolating, or caring for family members; mitigating against the risk of overwork and burnout among staff and volunteers due to increased demand on services and shortages in workforce; and promoting self-care and providing adequate psycho-social support services for all staff and volunteers – more information on this can be found on the webpage of the IFRC’s PS Centre.
Community-based actions to support health
- Identify and access the most vulnerable communities and systems.
- Identify the barriers which are preventing people and organisations from adopting safer behaviours which would prevent transmission.
- Enhance NS staff and volunteer capacity to prepare and respond to epidemics and enable community-led planning and action e.g. community-based health and wash activities, adaptation of existing community-facing programming.
- Continue Risk Communication, community engagement, and health promotion, in coordination with key stakeholders
Prepare for clinical actions based on the existing mandate of the NS
– Assess overall clinical capacity of the health system to respond; clearly identify and define the role of the NS in clinical service provision, including level of care (primary vs prehospital vs tertiary, community vs inpatient) to be provided and ability to respond to increased demand.
– Preposition appropriate PPE for healthcare activities, adapt facilities to allow for isolation activities and correct patient flow, identify clinical referral pathways, train clinical staff on latest COVID-19 clinical guidelines and IPC policies.
Who is most vulnerable to COVID-19?
As well as consistent underlying health-based vulnerabilities to COVID-19, there are many social, economic and contextual factors affecting who is most vulnerable to COVID-19. In addition, the socio-economic conditions being created as a result of the COVID-19 pandemic pose significant knock-on threats to people’s health, safety and wellbeing. National Societies must ensure they are aware of the factors affecting the vulnerability of people in their communities, where gaps in support and services exist, and adapt their activities accordingly to ensure support is reaching those who are most at risk.
Issues commonly exacerbating vulnerability include:
- Age. Many COVID-19 deaths so far have occurred in older people, particularly in those with existing medical conditions. Older people may also be at higher risk of various types of abuse from caregivers (in assisted living facilities, for example), isolation, lack of access to information, and limited access to health care.
- Existing medical conditions. People with existing medical conditions and non-communicable diseases such as heart disease, diabetes, cancer etc. These not only make people more vulnerable to the effects of COVID-19, but disruption to routine health services for their prevention, monitoring and treatment mean they are increasingly proving fatal.
- Economic Hardship. People may be lacking resources to be able to access basic healthcare, or buy items recommended to provide protection. Socio-economic factors may also see people living in conditions with poor sanitation, or which are overcrowded, two key factors affecting people’s risk of developing the disease. Dependence on the informal economy, is another factor in people’s vulnerability, particularly for women.
- Access to information. People with limited or no access to communication and information channels, including language minorities, people with sensory impairments, and people with low literacy, are all at greater risk from the disease.
- Gender. Women of all ages face an increased risk of contracting COVID-19 due to often being the primary caregivers for people who are already sick. People who are part of sexual or gender minorities face barriers such as shame, stigma and social gender expectations that may prevent them from seeking or receiving help.
- Disability. People living with disabilities are likely to face reduced access to information or disruption to the specialized services they may rely on.
- Migration. Due to their legal status, migrants may experience isolation, interruption to dedicated services and assistance, limited or no access to information or employment, and discrimination in accessing health care.
- Existing Humanitarian Issues. Alongside existing humanitarian vulnerabilities, people living in humanitarian settings – for example in camps or informal shelters and settlements – will also experience increased vulnerability to COVID-19.
National Societies should continue to:
Ensure that community-based health services and support, including social and legal services, and PSS support to caregivers in homes and communities, are maintained
- Deliver critical risk communication, with those that communication and behaviour change activities are aimed at included in their design and implementation. Stigmatisation of any groups or individuals must be actively avoided and combatted.
- Inform people of the critical health risks posed by COVID-19, and steps people can take to protect themselves and their loved ones, including recommendations for people living with Non-Communicable Diseases, caregivers, family members and the broader public (healthy diet, physical activity, healthy behaviours, managing stress).
- Promote the necessity of self-care, provide needed health and social services, and psychosocial support for people living with chronic health conditions, disabilities, and mental health challenges.
- Strengthen services to prevent and protect vulnerable people from any form of violence and abuse, such as domestic violence or neglect.
- Assess the secondary needs and impacts of COVID-19 on people, particularly in relation to physical and mental health. Address these and ensure universal access to healthcare and statutory benefits.
- Advocate for participation modalities at all levels to strengthen the participation of vulnerable people in decision and policy making.
- Plan and implement community-based activities in partnership with those people who are most affected and at risk – a fundamental factor in ensuring an effective response.
- Advocate and lobby for provision of essential health services for people living with Non-Communicable Diseases and other underlying conditions as an investment in Health, in building strong, resilient communities, and as a commitment to Universal Health Coverage
- Disseminate information in accessible formats, bearing in mind the needs and preferences of those the information is intended for e.g. visuals (pictures or posters, use of larger fonts), languages, audio options (e.g. radio), sign language, electronic, online, social media, or physical print formats etc.
- Coordinate with service providers to keep referral mechanisms updated and disseminate information accordingly.
What about COVID-19 related protection issues?
The prolonged lockdown and related economic impacts are causing people to lose their livelihoods, driving uncertainty about work and income, and causing the exhaustion of individual and family resources. This exposes people to severe pressure, creating conditions where people are more likely to adopt coping mechanisms that place them at risk of exploitation and abuse. Protection risks are also heightened, including for early marriage, forced labour, child labour, and people-trafficking. Sexual and Gender Based Violence (SGBV) and violence against children may also increase due to the inability of survivors to access services and safety nets or to be able to distance themselves from perpetrators.
In response to this, National Societies should:
- Inform all community members, and especially those at risk, of protection support and services available to them. Ensure appropriate channels and formats are used that are accessible to people with specific needs and preferences.
- Apply a diversity lens to analyze the impact of COVID-19, identifying the impact of the outbreak on different groups. Identify and capture risks of exclusion and barriers to accessing information, assistance, health care and services.
- Consider increasing or starting livelihoods programmes and share information about support for loss of earnings for people (especially women) who have been economically affected.
- Develop specific messages to explain the risks for older people and how to care for them. Target family members, health care providers, and caregivers.
- Include Prevention and Response to Sexual Exploitation and Abuse (PSEA) in your feedback and complaints mechanisms
- Ensure that all community-level activities are dignified, person-centred and adapted and accessible to everybody, considering especially the needs and preferences of people who have been marginalised.
- Consider which groups within the community are likely to be hardest hit by impacts on livelihoods and provide psycho-social support, information, and referral to relevant state or civil society services.
How should we respond to the wider socio-economic impacts of COVID-19?
The possibility of a second wave of COVID-19 and another round of sweeping lockdowns, represents a serious threat to the lives and livelihoods of already vulnerable people. The current increase of cases in several countries in the region will renew pressure on health care systems, and interrupt recoveries. Secondary impacts of the pandemic on labour markets will further exacerbate the poverty and vulnerability of populations already at risk and increase social tensions. This is particularly true for people working in informal sectors who depend on daily incomes and are often excluded from social safety nets. Daily workers in services or agriculture, women-headed households, migrants, Internally Displaced People (IDPs) and others already suffering from the current situation will all see their economic conditions worsen.
As poverty rates increase, National Societies should prepare to assist more people to meet their basic needs:
- Continue food assistance. Wherever possible avoid stopping food programmes, they already serve those who are most in need in situations which could be worsened by unexpected increases in COVID-19.
- Anticipate reductions in food production especially in agriculture and provide assistance to secure the upcoming harvests
- Expand cash assistance, including to small businesses to avoid debts and use of harmful coping strategies
- Advocate with institutions to support food security, livelihoods protection, and livelihoods recovery
- Advocate for strengthening and flexibility of social safety nets to include those who are currently excluded
- Coordinate livelihoods and basic needs interventions to guarantee that people at risk of SGBV or exploitation have access to economic opportunities. Livelihoods/cash programming can be a similarly important entry point for both information dissemination about protection and SGBV response services, and the collection of feedback about safe and accessible assistance.
Useful links
COVID-19 Health Help Desk – A comprehensive tool kit of guidance resources, direct technical guidance on different topics and much more!
https://www.preparecenter.org/toolkit/healthhelpdesk/
IFRC Go COVID-19 Emergency page – Please log in to view all documents and resources (i.e. field reports, situation updates, NSs activity tracking)
https://go.ifrc.org/emergencies/3972#details
World Health Organization – Technical guidance and resources
https://www.who.int/emergencies/diseases/novel-coronavirus-2019
This document has been developed by the IFRC Europe COVID-19 response team