Urban Preparedness and Country Capacity to Prevent, Prepare, Respond and Recover from COVID-19

On Wednesday, May 13, Rabin Martin, as the Secretariat for the Private Sector Roundtable for Global Health Security (PSRT), hosted a twelfth call in a series on the latest health impacts of COVID-19. The call featured speakers from the World Health Organization’s (WHO) Health Security Preparedness Department. Ludy Suryantoro, Head of Unit, Multisectoral Engagement for Health Security, and Marc Ho, Technical Officer, discussed the imperative for urban preparedness and the need to build country capacity to prevent, prepare, respond and recover from COVID-19 and other health emergencies.

Suryantoro began by noting longstanding efforts to align national and local governments in response to health emergencies. Historically, public health crises have forced national and sub-national decision makers to come together to tackle key challenges, from the need to prioritize vaccine recipients for H1N1 to navigating concerns about convening non-traditional stakeholders during the Ebola outbreak and managing the military’s presence in favelas as part of the Zika crisis.

He reported that Dr. Tedros has emphasized the need to work proactively with cities – acknowledging that by 2030, more people will live in cities than rural areas – and added that urban settings have and will continue to play an increasingly important role in health emergencies. Suryantoro added: “There is a serious need for local authorities to engage with national authorities to ensure cities are protected but also ensure that cities are prepared.”

Ho described how cities have been coping with the current pandemic, noting that the WHO has developed interim guidance for local authorities to improve preparedness, readiness and response. Many cities remain at risk of high infection rates and mortality because their settings facilitate rapid disease spread, including multiple points of entry (land, sea and air); large numbers of people traveling  to cities for tertiary care; high population density; public transport that enables intra-city travel; infrastructure where people congregate, such as sports stadiums and museums; overcrowded living conditions; and substandard housing. Further, certain urban populations are more vulnerable to COVID-19, especially those living in informal settlements where clean water and good sanitation may not be readily available.

He provided examples of how cities and countries are experiencing COVID-19 differently, noting that in the U.S., nursing homes have been hot spots, but in Singapore, the country is finding outbreaks in worker dormitories, and in other regions there have been challenges in slum settings where hand washing is not the norm. In spite of these differences, he explained that, for the most part, cities across the world are facing similar problems and that WHO is seeking to share these experiences to provide learnings, especially in how to address the needs of vulnerable subpopulations.

While he commented that the WHO is not trying to be prescriptive, he said that they are providing guidance to cities on developing a strong approach to respond to health emergencies, including what to look out for – such as migration and mobility, mental health issues and impact on livelihoods.

Suryantoro described a new initiative – Global Cities Network for Health Security – to make sure cities and countries are protected. The network will serve as a platform for documentation, learning and sharing, with mayors and local authorities driving implementation, recognizing that responding to a pandemic often rests with the local leaders. He noted, “There are SOPs for situations like 9/11 but not for pandemics – and this needs to change. COVID-19 has taught us that this change needs to happen at the city level.”

Pandemic Spread

Worldwide, as of Thursday, May 14 at 11:30 am ET, the Center for Systems Science and Engineering at Johns Hopkins University reported 4,387,438 confirmed cases and 298,392 deaths attributed to COVID-19.

COVID-19 Global Cases (Center for Systems Science and Engineering at Johns Hopkins University

The epidemic in the U.S. is far from over, with 1,395,265 reported cases. Though transmission is slowing and even declining in densely populated areas like New York City and New Orleans, cases are rising in the majority of the country. In response to intense political pressure – and, in some cases, threats of and acts of violence –  41 states have begun to relax social distancing measures, leading many public health experts to predict that the U.S. will soon see hotspots spiking across the nation.

Analysis of new cases signals the epidemic is not slowing at a national level (New York Times)

In congressional testimony on Tuesday, May 12, Dr. Anthony Fauci, Director, National Institute of Allergy and Infectious Disease, warned that should the U.S. not enhance its testing, contact tracing, isolation and social distancing practices, a second wave would “have the deleterious consequence of more infections and more deaths.” Researchers at Columbia University Mailman School of Public Health estimated that areas will experience rebounds of new cases and deaths two to four weeks after states begin to reopen.

“If you think that we have it completely under control, we don’t.”

Anthony Fauci, Director, National Institute of Allergy and Infectious Disease

As more regions of the U.S. consider reopening, decisionmakers should look to countries such as China, South Korea and Germany. Initially, these countries were praised for their ability to stop the spread of the virus, but in recent weeks as restrictions have lifted and citizens have returned to their daily activities, each country has seen a spike in cases. Economic experts from the IMF warn reopening too quickly could erase the gains made in controlling transmission, resulting in a more sustained epidemic and greater human and economic costs.

Others warn of a more insidious “third wave” of COVID-19 deaths that arise from patients delaying care for other illnesses. In the early weeks of the pandemic, over-burdened health systems could not treat those needing non-COVID-19 emergency care, resulting in thousands of preventable deaths. While epidemic control measures have reduced the burden on health systems, allowing them to provide more routine care, patients continue to stay away. This third wave of deaths will include patients who did not receive care because they feared for their safety – not because of a lack of health care capacity. The full impact of this third wave may not be seen for many months, but early data suggest it will be significant.

Industry Developments

“We need to get a better system in place. If the government’s going to take control of the supply of these kinds of therapeutics – and they don’t necessarily have to do that; they chose to do that – they need to have a good system in place for allocation.”

Scott Gottleib, former commissioner, FDA

Following the emergency use authorization for remdesivir granted by the U.S. FDA on May 1, Gilead has struggled to figure out how to meet the demand for the new drug given current limited supplies and scarcity of the active pharmaceutical ingredient. In the FDA approval letter, the agency signaled the government’s intent to control the existing stock and to oversee its distribution. Since then, distribution has been uneven and, at times, illogical. While Massachusetts General Hospital was treating close to 400 COVID-19 patients when it was selected to receive an allocation of remdesivir, Melrose-Wakefield Hospital, another institution to receive the drug, was treating only 52 patients. At the same time, other hospitals in the Boston area each treating more than 200 patients were not set to receive any doses.On Tuesday, May 12, Gilead signed nonexclusive licensing agreements with five generic drug manufacturers to increase production of remdesivir. The five companies, Cipla, Mylan, Ferozsons Laboratories, Hetero Labs and Jubilant Lifesciences will supply generic versions of remdesivir to 127 countries, mostly low- and middle-income countries. The agreements allow the companies to produce remdesivir without paying Gilead royalties for the duration of the WHO-declared health emergency, or until another effective COVID-19 therapeutic is found.

  • The outlook for hydroxychloroquine dimmed even more last week when a study published in The New England Journal of Medicine showed no statistically significant patient improvement following hydroxychloroquine administration. The retrospective, observational study reviewed outcomes from 1,446 consecutive patients at New York-Presbyterian Hospital – Columbia University Irving Medical Center in New York City. While presenting disappointing findings, the authors called for randomized controlled trials to understand further the role of hydroxychloroquine in COVID-19 recovery.
  • Interest in remdesivir’s clinical application remains high as the National Institutes of Health launched the second iteration of the Adaptive COVID-19 Treatment Trial on Friday, May 8. The study will pair Gilead’s remdesivir with Lilly’s rheumatoid arthritis drug Olumiant to observe the combination therapy’s effect on outcomes in critically ill patients. The trial seeks to enroll more than 1,000 patients to examine the safety and efficacy of the paired combination.
  • In recent weeks, BioNTech and Pfizer have initiated Phase I/II clinical trials of their co-developed vaccine candidate in Germany and the U.S. Pfizer announced on Friday, May 8, that it is preparing for large-scale manufacturing of the vaccine, should it prove safe and effective, by shifting more routine medical production to contractors. The shift would allow Pfizer to devote more production capacity to its COVID-19 vaccine while maintaining the supply chain integrity for its other products.
  • On Monday, May 11, the Coalition for Epidemic Preparedness Innovations awarded its largest grant to date: $384 million to fund research into Novavax’s COVID-19 vaccine candidate. Novavax plans to use the grant to fund its research through Phase II trials (results from Phase I are expected in July) and to scale-up its manufacturing capacity. The company aims to produce 100 million doses of its vaccine by the end of 2020.

From the Experts

“We’re not reopening based on science. We’re reopening based on politics, ideology and public pressure. And I think it’s going to end badly.”

Thomas Frieden, former director, CDC
Monday, May 11

“If we skip over the checkpoints in the guidelines to ‘Open America Again,’ then we risk the danger of multiple outbreaks throughout the country. This will not only result in needless suffering and death, but would actually set us back on our quest to return to normal.”

Anthony Fauci, Director, National Institute of Allergy and Infectious Diseases
Monday, May 11

“It’s 36 months at best before we can all feel that we’ve got this virus licked.”

Laurie Garrett, author, The Coming Plague: Newly Emerging Diseases in a World Out of Balance
Monday, May 11

“[Interruptions to HIV care] could effectively set the clock back by more than a decade to 2008, when more than 950,000 AIDS deaths were observed in the region. Only together can we get through this pandemic. In national unity and global solidarity.”

Tedros Adhanom Ghebreysus, Director-General, WHO
Monday, May 11

“The dance to defeat COVID-19 ultimately must be a global production.”

Jamie Bay Nishi, Director, Global Health Technologies Coalition
Tuesday, May 12

Additional Resources

Reports from International Governments and Bodies

Funding and Policy Trackers

Resource Pages and Market Research Literature

Communications Toolkits

What We’re Reading

‘Finally, a virus got me.’ Scientist who fought Ebola and HIV reflects on facing death from COVID-19 – Dirk Draulans, Science

COVID-19 and Health Equity — Serving the Underserved, Poorly Served, and Never Served – Stephanie Miceli, The National Academies of Sciences, Engineering, and Medicine

Experts Warn Coronavirus Will Divert Resources from Killer Diseases – Andrew Jack and Neil Munshi, Financial Times

Emerging from the Great Lockdown in Asia and Europe – Changyong Rhee and Poul Thomsen, International Monetary Fund Blog

Even Finding a COVID-19 Vaccine Won’t Be Enough to End the Pandemic – Christopher Rowland, Carolyn Johnson and William Wan, The Washington Post