Before the second wave


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Coronavirus cases have been on the rise in the world since August. Summer has brought new peaks in all our neighboring countries and last week, a serious increase of cases started in Georgia as well. Although the opening of borders did not lead to a significant increase in the number of foreign tourists, domestic tourism rise increased mobility at both sea and mountain resorts. With this background, the clusters of Svaneti and Kobuleti in August were followed by the clusters of Batumi ("Dona" confectionery shop) and Guria in early September. But the biggest local outbreak turned out to be the result of a wedding in Tbilisi, which was followed by the formation of clusters in Tsageri, Zugdidi and Kutaisi, and during the current week, the record daily new cases number, being only 42 since April 16, is updated almost every day reaching now 158. In addition to the exponential increase in daily cases, we are also witnessing the negative trend of active cases rise, as the new cases now strongly prevail over the number of recoveries.  
Georgia Indicators: Chart 1 (New daily cases of the last week) and Chart 2 (Active cases)



Why are coronavirus cases on the rise and what can be done to better control the pandemic?

There are several reasons for the global rise of new cases:

In Latin America (Brazil, Peru, Mexico, Colombia, Argentina, Chile), Africa (South Africa) and Asia (India, Bangladesh, Pakistan, Saudi Arabia, Philippines) the infection rates are very high in many countries. Also, the high rate remains stable in Russia and Iran (and we do not know how real these rates are, it is quite possible actual rates are even greater).

In many European countries, there has been a significant increase in cases during the summer. In some countries, even the record for daily spring rates was broken several times (France, Czech Republic, Israel, Poland, Ukraine), while in others it exceeded 50% of the first wave (UK, Germany, Italy, Belgium). French new daily anti-record - 9843 cases, in Spain - 12,183 new cases.

What is happening? - There are several reasons:

Weather effect? - As we thought, it was an illusion that the spread of the virus would decrease in summer due to the high temperature. The examples of Iran, Armenia, India, Saudi Arabia and the southern US states were enough to reject this assumption – heat does not terminate the coronavirus, although it still may have higher spread in cooler seasons. Although mortality has decreased, the spread of infection has not.

More testing - yes, there is a lot more testing now, and besides, now the testing profile is more universally covering population in many countries and is not focused on symptomatic patients arriving in hospitals - as it was typical in the spring. In fact, when we talk about setting new anti-records in most European countries, we do not take into account one important indicator - what is the positive tests rate. That is, what % of the current tests are positive. If we compare this figure, it turns out that in Germany and Scandinavia, although the number of confirmed cases has been growing significantly there since July-August, the positive tests are only 0.1% (significant drop from being from 1%-4% in May), while in other European countries there is an increase in the rate of positive tests:

In Belgium - 2.2% (in May - 2%),
In Romania - 5.8% (in May - 3.6%),
In the Czech Republic - 5.4% (in May - 1%),
In Spain - 9.4% (in May - 3%),
and in Ukraine - 10.6% (in May - 8%).

WHO believes that if the positive test rate is below 5%, this is valuable indicator that infection control is well managed in that country.

Currently the highest rates of positive tests are those in Mexico (47%), Argentina (53.7%), Bolivia (33%) and Paraguay (28%), indicating the need for expansion of testing. At such times, the dynamics of this indicator is more interesting - if it increases, it means that the actual circulation rate of the virus would be even higher if more testing were done than the daily infection rates show. And in most parts of Europe, increased daily cases numbers today do not mean an actual increase in infection - we just grasp the real picture much better now, otherwise the real incidence of infection is much lower than it was in Spring. In Georgia, too, the daily number of testing in March-April was 200-300, and now exceeds 7,000. Therefore, now 70-150 cases detected daily are only 1% -2% of test positivity, while in the spring the average of 5-10 cases was 2-4%. So in this case, the situation is still under control, though the trend of daily infections rise is alarming.

Mobile laboratories - earlier testing was mainly concentrated in large cities and indicators from remote regions were less known. Now in most European countries, testing has shifted to local hotspots, and mobile labs are working at full capacity, giving governments a better reflection of infection rates in different parts of the country. And as the population density at these points is much lower - the overall average of the country comes out lower than when 90% of all data was collected in big cities. At the same time, if  we control clusters faster, the time required to find contacts is reduced and the solution is better due to the reduction of delayed cases. It is  right decision to set up open-air testing tents in Batumi, Kutaisi, Ozurgeti - first in terms of accessibility, and also showing to the population that the problem is serious.

Infection outcome  - has improved significantly and that is evident in the example of Europe: in France the number of daily cases in March-April was 5,000-7,000, and the daily death rate - 1000-1400 (almost 10-20%)! Presently, with a 30% increase in daily cases, the daily mortality rates are only 25-80, or 20 times lower than the spring rates! However, it should also be noted that the increase  the fatalityof rate is usually 2-3 weeks behind the peak of cases. So, we have to watch the infection fatality rate closely during next weeks.

Tourism - Despite the boom in seaside resorts during the summer months, there is no unequivocal answer to the question of whether the risk of infection increases on crowded beaches. U.S. Centers for Disease Control usually advise everyone to be careful – maintaining 2 feet-away distancing, wearing facemasks (while on land) and use sanitizers. Only 6 of the 20 beaches in the UK have seen an increase in infection cases following a sharp increase in the number of holidaymakers. But aside of relaxing on the beaches, tourists flock to cafes, discos, restaurants, birthday-parties or for other reasons - even indoors, where there is a much greater chance of infection spread, especially as alcohol blunts vigilance while singing and dancing increases the risk of virus transmission. Georgia's tourist season also provides enough evidence for this - confectionery, weddings, birthdays, restaurants, as well as - various shops where rules and regulations are no longer followed ... That has turned out to be the most frequent reasons of new clusters. This is against the background of the fact that Britain and France have reintroduced strict restrictions on the number of people indoors, while in large cities in France it is necessary to wear facemasks outdoor as well. Israel is on the verge of complete quarantine of the whole country.

Young people - they still consider their risk of infection is low. This is true - if we compare the rates of infection among different age groups during the first wave of pandemic. However, during the summer, an elderly person who wears a mask and does not walk to crowded bars or weddings may have a much lower risk than a young person who refuses to wear a mask and distance himself. Summer brought some increase in infection rates among young people (20-39 years old) in Luxembourg, the United Kingdom, Canada, Spain and France. 75% of students and teachers at a teen summer camp in the state of Georgia became infected due to neglect of distancing and masks. It is true that only 5% of young people are admitted to the intensive care unit, however, French researchers also note that the mild manifestations of the infection among young patients may last longer - sometimes even up to three months and delayed effects of this long-COVID aren’t clear yet.

The illusion of "victory" - also weakens the enforcement of recommendations. In countries which were justifiably proud of the positive results achieved - Germany, the Czech Republic, Greece, Slovenia, Georgia - it has a paradoxical backlash to the attitude of a large part of the population - if all goes well, then why do we need those restrictions?!

The "relaxing" effect of the holiday season - as psychologists say, one of the most difficult problems of Covid-19 is psychological overburden - called Covid-fatigue. It was very difficult to get used to the fact that the usual rhythm of life is disrupted for such a long time – over half-a-year. One may think people shall be grateful for not being at work for extended amounts of time and spending days at home, working remotely and enjoying free time saved on commuting. But it turns out, that is not necessarily "rest". On the contrary, deprivation of usual social contacts, of variety of happenings, and monotony of being home especially non-voluntarily and unpredictably in length leads to prolonged "fatigue", causes emotional exhaustion and stress in many people (particularly – in youth). Previous lifestyle when work at workplace was alternating with relaxation at home is gone and replaced by home-converted-to-office without usual social connection, unusual time-space continuum. As Georgians say:  "Do not accustom me to the unusual and do not de-accustom me from the usual". However, the pandemic has dealt us this double blow - in addition to the fear of infection and death, a very strong stress factor turned out to be uncertainty. Against this background, returning to nature and real recreation - at sea, in the mountains, on hikes, at villages, fishing or hunting - turned out to be an amazing relief on the one hand - in terms of unwinding from negative emotions and returning to the old, longed-for reality. But the dizziness of returning to the old reality is at the same time dangerous - for ignoring the elementary precautions altogether, losing the vigilance…

Authorities around the world no longer wish to declare lockdowns, which are very heavy blow to the economy. Especially as the first economic deep wounds have not yet healed. The leaders of Germany, France and UK have made it clear that there will be no full-scale countrywide lockdowns. Considering the escalation of political tensions over the upcoming US elections and the serious efforts and arsenal of actors influencing this process through hybrid warfare and cyber threats, the same actors will gladly try to damage Georgia beforehand and during of polarized elections. Against this background, proper communication with the population and timely measures to prevent hybrid threats are of particular importance. The bottom line is this - much of the world and Georgia are now better prepared for the second wave of the pandemic. Early diagnosis, 10-20 times better potential for testing, positive effects of some drugs (e.g. dexamethasone), already proven communication lines with the population, better preparedness of experienced medical staff, better equipment, better communication between different sectors of, and prevalence of young people among infected with less complications and fatality expectations give some hopes that increased cases will not lead to the previous sharp rise of hospitalization.

But the virus is still around us, the vigilance of the population is diminished, the illusion has emerged that we have defeated Coronavirus, the people are tired due to Covid-fatigue, and the political polarization ahead of forthcoming elections increases chance of mixed reaction from the population both in terms of taking the new wave of Covid-19 and renewed threat seriously, as well as in terms of thorough adherence to epidemiological recommendations. 

Authorities first have to convince people through proper and effective communication in the need of restoration of unconditional compliance to epidemiological recommendations (masks, distancing, handwashing). For achieving that, it is necessary to appeal with objective data and share international experience of second wave management. An objective measurable dataset would be useful for follow-up observation – e.g., infection reproduction number (R), positive tests rate, number of infected medical personnel, new cases per population during last two weeks, infection fatality rate, etc. The need and scale of new restrictions, as well as their duration, shall be determined based on such dataset changes, along with consideration of international best practice.

Now that we know the virus better, we can count on more pinpoint, short-term, and localized restrictions. Georgia's successful experience of epidemiological surveillance,  contact finding and PCR testing to quickly identify clusters and shut little fires before massive engulfing one is a good foundation, but we need to build up a stockpile of tests for October, when flu outbreak may be added to Covid-19 (although existing mitigations might lead to relatively low flu-outbreak this year, but it will be difficult to differentiate between two viral infections). On one hand, improving and accessing online resources for psychological help (in addition to specialists, media and social networks should also be involved) and raising social responsibility - we need to make people aware that if they do not want to be locked up again - wear a mask, wash their hands often and distance themselves - It is the ultimate measure of self-insurance and protection of loved ones - not to rely solely on epidemiologists. That "loyalty" to mass parties, weddings, birthdays or funerals is the dangerous shortest way to the hospital. Recent cases assure us that neither politicians nor journalists are protected from the virus - on the contrary, their risk may be higher and therefore protection measures should be used more scrupulously.

The most difficult and vulnerable field is education. Just a week ago, I wrote that the restoration of traditional education in schools, especially in the lower grades, is an urgent need for children - this is what UNICEF and psychologists around the world call for and demand to avoid significant side effects of Covid-related long term home isolation on young generation’s mental and cognitive status. Moreover, access to online education is not yet guaranteed everywhere. Unfortunately, the rapid increase in cases last week has called into question this already announced tactic and the government has decided to switch to online education again for at least two weeks. The caution is justified, because unlike the Danes and Norwegians, who after lockdowns first and foremost resumed studies in the lower grades in May, it is hard to imagine what the reaction of Georgian society and parents to such experiment would be like, even if it is supported by scientific evidence – young children do have less Covid-infection and less complications. Also do not forget that we almost did not have the experience of in-person teaching during the pandemic, and this segment is the most terra incognita for us. - We do not know how the school administration will be able to start the process and successfully manage it at the stage when we have a rapid increase in cases. In much of Europe, schooling is still the norm. However, France closed schools again this week, as did South Korea (which has opened and closed several times already), some US states and some Canadian provinces, and Israel, while most US universities remaining in hybrid or online education. Hybrid education was considered a leading model until the vaccine becomes available. Most likely, it is expected in the spring of next year, or at best - in December 2020. If we can stop the increase in cases in the next two weeks and assess the skills of the school staff give us hope for more self-confidence, we can again think about resuming regular or hybrid teaching in schools.

As mentioned earlier, the coronavirus does not leave us with a great chance of maintaining a solid and unchanging strategy for long time. The situation can change rapidly, especially if we are reluctant to follow the regulations. It was justified that we would have to live by the method of trial and error, and move forward with such a principle - "two steps forward, stop, check the situation, and maybe, - a step back" and again from the beginning ...

Fortunately, while it is difficult to take the very first steps in the darkness, we are now quite adapted. So, we have to get back the prematurely forgotten habits - facemasks, social distancing, frequent hand washing, sanitizers – instead of relying only on the heroism of epidemiologists and doctors. We should  thank them that we no longer have "stay-home" order. Otherwise, it is clear that those who do not follow the rules, first of all hurt themselves, their families and their business ...

Cases of infection in medical staff are particularly noteworthy. Advanced and frequent testing alone will not help - it is necessary to once again conduct awareness and training for medical personnel to properly understand the dangers and to steadfastly defend the relevant skills.

Two months ago, the United Nations and the Swedish Development Agency (SIDA) announced an infection control training program to train 4,000 medical staff online as a future reserve for Covid-management. I wonder what is happening in this regard. The availability of beds, equipment and staff reserves should be guaranteed by the end of September instead of October. In spring Ministry of Health has announced that we could mobilize 3,600 beds and an agreement was reached with private sector hospitals. It is necessary to re-specify and agree on these plans along with medical personnel reserves and with proper distribution of cases between inpatient and outpatient care. We consider the decision of the minister to manage mild cases in Covid-hotels to be correct. Out of the current 550 active cases, inpatient care is expected to be required for only 20-30%. In most European countries, mild and light cases are mostly managed at home. However, under the condition of active remote monitoring by the primary health care system, and in case of complications, with timely transfer of patient to the hospital.

Finally, the Swedish approach to pandemic management around the world has been largely criticized. Yes, they made a mistake - they did not control well the staff and approaches, including relatives visits at the nursing homes, and also in the fact that they did not take into account that migrant population may not have habits to follow recommendations as thoroughly and as responsibly as native Swedes do. Now it is very important for us to be able to introduce Swedish self-control and thorough compliance with public health recommendations, to motivate and socially activate each other - doctors, the government and each member of the community, to share our responsibility and endure this prolonged coronavirus examen for a few more months so that the economy can survive...

The maturity of society is measured precisely during a serious crisis. Independence is manifested not only in drawing up the right plan for survival in times of crisis, but also in the unity of society for the realization of this plan, and the countries and people who failed to unite in times of crisis are neither independent ... or simply not existing ... already. Whatever hope we have for help from our strategic partners, our survival depends first and foremost on our own civic maturity and social responsibility.