In May this year, a new definition of HTA was announced following a collaboration co-led by the International Network of Agencies for HTA (INAHTA) and HTA International (HTAi).
​
This is important as it provides insight into how the members of INAHTA and HTAi, as well as the other collaborations noted, are viewing the evolution of HTA. Previously, the various groups had their own definitions, now they are moving forward with the same focus, in the same direction.

The joint task group conducted three rounds of consultation to reach a consensus. Discussion focused on whether:

• the definition of a health technology needed updating (no);
  
• to include improving health outcomes as an aim, in addition to informing health policy and decision making (no);
  
• removal of jargon and simplification (yes); and
  
• how to express the concept of value (considered context-related). 
  

The change from ‘all available evidence’ to ‘best available evidence’ acknowledges that decisions must be made and pragmatism may be required.
​
The general nature of the definition is meant to “reflect different decision contexts in low-, middle-, and high-income countries, such as: formulary coverage or reimbursement decisions (including disinvestment); clinical practice guideline development; defining emergency kits, disaster planning, (basic) benefit packages, and essential medicine lists; medical device and equipment procurement planning; negotiating prices for health technologies, and other decision contexts at the national, regional, or local levels, including hospitals”.

HTA is a versatile tool, and even though the definition may be quite general and succinct, how it came about says a lot.

Note 1: A health technology is an intervention developed to prevent, diagnose or treat medical conditions; promote health; provide rehabilitation; or organize healthcare delivery. The intervention can be a test, device, medicine, vaccine, procedure, program, or system.

Note 2: The process is formal, systematic, and transparent, and uses state-of-the-art methods to consider the best available evidence.

Note 3: The dimensions of value for a health technology may be assessed by examining the intended and unintended consequences of using a health technology compared to existing alternatives. These dimensions often include clinical effectiveness, safety, costs and economic implications, ethical, social, cultural and legal issues, organizational and environmental aspects, as well as wider implications for the patient, relatives, caregivers, and the population. The overall value may vary depending on the perspective taken, the stakeholders involved, and the decision context.

Note 4: HTA can be applied at different points in the lifecycle of a health technology, that is, pre-market, during market approval, post-market, through to the disinvestment of a health technology.
​
Reference: O’Rourke B, Oortwijn W, Schuller T, the International Joint Task Group (2020). The new definition of health technology assessment: A milestone in international collaboration. International Journal of Technology Assessment in Health Care 36, 187–190.  https://doi.org/10.1017/S0266462320000215
​

Over the past five years, a number of 'big brand' biologics have gone off patent and have been replaced with biosimilars. This remains a challenge for any biologic nearing the end of the lifecycle, no doubt pushing prices up to achieve maximum return on investment for the short time available on the market. At FingerPost, we have been involved with a number of research projects looking at the impact of biosimilars - both from the perspective of the biologics nearing the end of their patent, and from the perspective of new biosimilars preparing to launch. We thought it would be interesting to review the current biosimilar situation in Australia and Canada, particularly as trust in biosimilars has grown amongst payers and healthcare professionals with increasing experience over the past few years.

As of 1 July 2020, the Sanofi Lantus® brand of insulin glargine is no longer reimbursed to treat diabetes on the national Pharmaceutical Benefits Scheme (PBS). The first biosimilar brand of insulin glargine, Semglee® (Alphapharm) was PBS listed in October 2019. 

Commencing in 2015, the Australian Government has introduced successive initiatives to encourage prescribing and dispensing of biosimilar brands of biological medicines. The Semglee® brand of insulin glargine was assessed by the Therapeutic Goods Administration (TGA) to be highly similar, based on the FDA definition, to the reference brand Lantus®.  Such assessments are then translated into opportunities for substitution.

These are signalled on the PBS by the practice of flagging: 
 ‘a’ flagging denotes that: 

• Brand substitution may be undertaken by pharmacists at the point of dispensing without difference in clinical effect or health outcomes. 
• Brand substitution by pharmacists is permitted without reference to the prescriber when the following conditions apply: the patient agrees to the substitution; and the prescriber has not indicated on the prescription form that substitution should not occur by ticking the box labelled ‘brand substitution not permitted’. 

 While ‘b’ flagging denotes that:  

• the brand is equivalent to the reference brand but it is not known if there is equivalence to the ‘a’ flagged brand. 
• All medicines flagged ‘b’ are substitutable by the pharmacist when the patient agrees to substitution and the prescriber has not indicated on the prescription form that substitution should not occur. 

The Education arm of the Australian Generic and Biosimilar Medicines Association (GBMA) received a grant of AU 5 million dollars (US 3.5 million) from the Australian Government in April 2018 to increase confidence in the use of biosimilars via peer-to-peer health communication activities. A further driver is the October 2019 introduction of active ingredient prescribing regulations. These require prescribers to include the active ingredient on all PBS prescriptions. A brand name can be included after the active ingredient where doing otherwise may pose a patient safety risk. Prescribing software must be updated to reflect these requirements. There are concerns that prescribers will be unable to identify products by brand.   

Insulin glargine 100 units/mL listings on the PBS now include the following note:
Biosimilar prescribing policy 
Prescribing of the biosimilar brand, Semglee, is encouraged for treatment naive patients. Encouraging biosimilar prescribing for treatment naive patients is Government policy. A viable biosimilar market is expected to result in reduced costs for biological medicines, allowing the Government to reinvest in new treatments. Further information can be found on the Biosimilar Awareness Initiative webpage (www.health.gov.au/biosimilars). 
 
​So back to Lantus®, Sanofi introduced the Optsulin® brand (available overseas) in January 2020, under the same PBS code 9039R, as the formulation, excipients and manufacturing process are the same. It is ‘a’ flagged. Through a partnership with the Australian Diabetes Educators Association, Sanofi's insulin patients were able to call toll-free and speak with a Credentialled Diabetes Educator (CDE) about the transition. The commercial reason behind the re-branding exercise is unclear as the effective price of 100 units/mL has not changed. Special pricing arrangements (meaning a difference between the published and effective price) continue to apply to the Sanofi Toujeo Solostar® brand of insulin glargine 300 units/mL.

British Columbia:
British Columbia was the first province to initiate biosimilar switching policies. On May 27, 2019, BC PharmaCare launched the Biosimilars Initiative with the objective of switching patients using Enbrel®, Remicade®, and Lantus® for certain indications to their biosimilar versions by November 25, 2019. The second phase (September 5, 2019 – March 5, 2020) consisted of patients being switched from Remicade® for gastrointestinal (Crohn’s disease or ulcerative colitis) to a biosimilar version. The three biologic drugs selected for biosimilar switching were among the highest drug expenditures in BC, totalling $125 million in 2018. During the first phase of the initiative, 73% of 20,780 patients using the reference biologics were switched to biosimilars. During the second phase, based on initial partial numbers, 78% of patients on infliximab reference product were switched to biosimilars.

Alberta:
In Alberta, the government introduced the Alberta Biosimilar Initiative on December 12, 2019. This initiative requires adult patients currently on an originator biologic drug to switch to a biosimilar version, if available for their medical condition, in order to maintain drug coverage through the government sponsored drug plan. The products included in the Biosimilar Initiative are:

• Remicade® (all indications)
• Enbrel® (all indications except plaque psoriasis and pediatric juvenile idiopathic arthritis)
• Lantus® (all indications)
• Neupogen® (all indications)
• Neulasta® (all indications)
• Copaxone® (all indications)

Alberta spent over $238 million in the 2018 to 2019 fiscal year on biologics and with this initiative, the government anticipates saving approximately $30 million annually. The switching requirement was initially scheduled for July 1, 2020 but due to the COVID-19 pandemic, it was postponed to January 15, 2021.

Ontario:
On January 1, 2020, the Ontario Ministry of Health published a policy directive addendum to the Ontario Guidelines for Drug Submission and Evaluation which simplified requirements for biosimilar drug product submissions. The simplified submission no longer requires the biosimilar manufacturers to provide scientific evidence of clinical similarity between the biosimilar and its originator product – the rationale being that Health Canada does this assessment before approving the biosimilar. As a result, the biosimilar listing process on the public drug plan would be considerably quicker. In a report published by the Ontario Drug Policy Research Network (ODPRN) titled “Current and Prospective Utilization of Innovator Biologics and Biosimilars in Ontario,” a total of $1.1 billion was spent on biologic medications through the Ontario public drug program in 2018. The report found that biosimilar uptake in Ontario was low, with less than 1 in 5 biologic users accessing the available biosimilars.

Canadian Agency for Drugs and Technologies in Health (CADTH):
The Canadian Agency for Drugs and Technologies in Health published a report in January 2020 titled "Utilisation of Innovator Biologics and Biosimilars for Chronic Inflammatory Diseases in Canada: A Provincial Perspective." The report addressed the findings of the ODPRN report and provided possible cost-containment mechanisms or strategies to optimize the benefits associated with biosimilar drugs alongside innovator biologics. The proposed possible approaches provided include:

• Controlled substitution of innovator biologics for biosimilars
• Reimburse biosimilars for newly diagnosed persons only – persons already being treated with an innovator biologic drug may remain on that treatment if their disease is stable
• Tiered reimbursement for innovator or biosimilar biologics – “tiers” would be based on the medicines’ relative value for money, with the most cost-effective options classified in the first reimbursement tier
• Prescribing quotas to incentivize use of biosimilars
• Provide access to biosimilars using tendering procedures

 
Physicians and Patients:
Lastly, what is the perspective of physicians and patients with regard to the biosimilar initiatives? The Canadian Association of Gastroenterology and Crohn’s Colitis Canada published the "Joint Canadian Association of Gastroenterology and Crohn’s Colitis Canada Position Statement on Biosimilars for the Treatment of Inflammatory Bowel Disease"

Included in their recommendations:

• A biosimilar may be started in patients who are naive to anti-TNF therapy rather than starting with the biologic originator but this is contingent on the price differential of the two drugs. If the price differential is modest, then the biologic originator should be used.
• Nonmedical switching from the originator biologic to biosimilar in patients whose disease is stable with treatment is not recommended.

Biosimilar policies will continue to evolve across Canada as public payers must balance managing their drug plan budgets while meeting  patient needs. Adding further complexity to this issue is the COVID-19 pandemic, the long-lasting impact of which remains unknown.

At the end of April, we published a summary of the global response to COVID-19 as written by a selection of FingerPost's Global Associates who specialise in Market Access across different countries. The summary (available here) provided a brief overview of the statistics as they were at the end of April, measures implemented to reduce the outbreak and any other impact (political, economic or social) on each market as a result of the pandemic. This was a valuable snapshot ahead of the first steps taken to ease 'lockdown' measures across Europe and the US. However, this was far from the end of the pandemic and there was still a lot of uncertainty surrounding when and where  'second wave' outbreaks would occur. 

Two months on, we have now published a follow up to the report to capture the continued impact of the pandemic. During this time, we have seen widespread outbreaks of COVID-19 shift from Europe and North America, through to Latin America, India and Pakistan. Brazil, in particular, is one of the worst hit with no sign that the pandemic has reached its peak. Meanwhile, widespread resurgences of the virus have also been documented in the US and Asia, as per the predictions for 'second wave' outbreaks. Local surges have also been documented in most of the countries 'recovering' from the initial outbreak but these are being managed via local restrictive measures, as well as nationalised tracing programs. 

Various regulations have been relaxed to help ensure rapid access to medicines, devices, healthcare apps and personal protective equipment to help treat those with COVID-19, protect healthcare workers and prevent or identify further outbreaks. For example, in Spain protective masks that do not bear the appropriated CE mark (NIOSH or KN95) can now be commercialised. Many countries have also centralised pricing and supply/distribution systems to ensure an adequate supply of medicines.

Remdesivir has now received EMA and FDA marketing authorisation for COVID-19, and will be distributed by Gilead for patients on government-sponsored insurance in the US and other countries with national healthcare systems. In India and 126 other low- and middle-income countries, four Indian companies have been granted non-exclusive licences to produce remdesivir for distribution. 

As the pandemic shows no sign of slowing on a global level, there are strong hopes for the 17 candidate vaccines in clinical evaluation and 132 in pre-clinical evaluation. AstraZeneca has already started to manufacture a vaccine that has been co-developed with scientists at Oxford University, which will be supplied to low- and middle-income countries via a licensing agreement with Serum Institute of India (SII). This is a big risk as they won't know until August whether the AZD1222 vaccine will be effective. Similarly, in the United Arab Emirates, the Abu-Dhabi-based Group 42 (G42) are partnering with the Chinese pharmaceutical giant Sinopharm China National Biotec Group (CNBG) to commercialise and develop a vaccine. And in Germany, €750 million has been allocated by the government to go towards vaccine development and to aid the international Coalition for Epidemic Preparedness Innovations. 

Despite the COVID-19 pandemic, there is still a need to keep bringing other medicines to market. This is recognised by the majority of health technology assessment (HTA) agencies, who have continued to evaluate new treatments throughout the various 'lockdowns'. However, the Scottish Medicines Consortium (SMC) have experienced some delays and now expect to resume their meetings in August. Likewise, in Canada, the pan-Canadian Pharmaceutical Alliance (pCPA) have indicated that some negotiatons may be temporarily put on hold or delayed.

At FingerPost, we anticipate a more challenging Market Access environment over the next few years. Firstly, a number of 'non-urgent' medical appointments (e.g. cancer screening, minor surgeries, GP appointments) have been postponed throughout the pandemic. This is likely to have long-term consequences for the management of chronic conditions.  Secondly, those who have 'recovered' after receiving intensive care for COVID-19 symptoms are likely to require long-term support to manage the damage left by the virus, the extent of which is largely unknown. And finally, financing COVID-19 is likely to take it's toll on global healthcare systems, exerting additional pressure on pricing and reimbursement negotiations to reduce the cost of medicines. 

If you'd like to read more about the global impact of COVID-19 as of the 30th June 2020, you can download our latest 'Global snapshot of COVID-19' report below for free. The report contains summaries for 22 different global markets, with key insight from the FingerPost team and our Global Associates. I'd like to say a big thank you to all of the authors who contributed content to this report and hope you find the summaries as interesting as I did.

The highlight of the first quarter of 2020 was the bi-annual revision of National Health Insurance (NHI) prices and of medical fees, announced in March and coming into effect on April 1. Key changes included:

• The impact of the revised prices was an average reduction of 4.38% of the price paid by the NHI, with large differences by product.
• The repricing of 17 products, mostly due to sales having exceeded the initial estimates which the manufacturers presented at the time of the first pricing decision. Among them, Faslodex (-25%), Dupixent (-20.2%), Keytruda (-20.9%), Lixiana (-25%).
• A new re-pricing rule was created to hit Xolair (-37.3%) after its approval for allergic rhinitis, a much larger indication than the earlier indication for asthma, resulted in reimbursement at a lower NHI price than asthma, and – going forward –  further tweaking of the repricing of products having already been re-priced, to cut deeper.
• On a positive note, three drugs could mitigate re-pricing with a post-launch premium for “true clinical effectiveness”: dapagliflozin (Forxiga), canagliflozin (Canaglu) and alirocumab (Praluent). Six others gained a premium for an additional pediatric indication.
• Minor adjustments were also made to the standard values and rates (eg profit ratio) used in the cost calculation method.

[To read more about the methods used to determine reimbursement price, please click 'read more' below.]

Besides price revisions and special re-pricing, the Central Social Insurance Council, known as Chuikyo, approved the reimbursement of over 30 new products from January to the end of May.  These decisions are summarized below:

• January: two anti-virals for HIV were approved, Dovato (dolutegravir/lamivudine) and Pifeltro (doravirine). Anti-viral drugs are usually reimbursed the moment they are approved, bypassing the quarterly listing and qualifying for the so-called Price Maintenance Premium. Both were priced by Cost Comparison Method I (standard) and Method II (no innovation).
• End of April: Nine new products, in 14 product presentations, joined the NHI price list. The Cost Comparison Method was used to evaluate five products, and the Cost Calculation Method for the other four. Only two obtained a premium, at the lowest possible rate of 5%. Of these nine new products, Noxafil (MSD) will have to submit a CEA dossier (estimated peak sales are 10% above the threshold).
• May 8: Remdesivir was approved to treat severely ill COVID-19 patients under an expedited review process but Gilead have not yet applied for reimbursement. Avigan (the 'national champion') was also anticipated to obtain PMDA approval for COVID-19 as an additional indication, but this wasn't the case as further trials were deemed necessary. 
• End of May:  A larger group of 18 new products (28 product presentations) was listed. The methods used to evaluate the products for reimbursement included the Cost Comparison for nine of them, Cost Calculation for another five, Combination price for three and New Formulation for one. A premium was awarded to eight of them, including three sakigake (pioneer) premiums of 10% to Nippon Shinyaku’s DMD treatment vitolarsen, Merck Biopharma c-MET inhibitor tepotinib and Stella Pharma’s borofalan (Steboronine). Steboronine is a nuclear medicine boron compound for head & neck cancer, used in conjunction with Boron Neutron irradiation (called BNCT), a new procedure recently approved in Japan. It obtained a price of 444,215 yen per unit, a premium of 35% for Usefulness I, to which 10% for sakigake was added. Combined, the treatment with Steboronine (3 units) and the BNCT procedure will cost about 3.7 million yen but they were not retained for CEA. Cabometyx and Enhertu have to submit a CEA dossier (see further below).

Not all approved products obtained reimbursement. Eli Lilly’s glucagon nasal powder Baqsimi, approved in March 2020 and, again, Zeria’s Ferinject, an injectable iron preparation used in dialysis and approved in March 2019, was still unable to obtain reimbursement.

In 2019, 51 new pharmaceutical products were listed on the NHI reimbursement list. Including Kymriah, classified as a regenerative medicine product, six of them have to submit a Cost-Effectiveness Analysis (CEA) dossier:

1. The triple combination, Trelegy (Chronic Obstructive Pulmonary Disorder, COPD)
2. Tisagenlecleucel (Kymriah, Acute Lymphoblastic Leukemia)
3. Ravulizumab (Utomiris, Paroxysmal Nocturnal Hemoglobinuria)
4. Another triple combination for COPD, Breztri Aerosphere. NB: no formal analysis required as it was priced in comparison to Trelegy
5. Vortioxetine (Trintellix, depression)
6. Ivabradine (Coralan, Coronary Heart Failure)

 
Out of over 30 new products listed this year until May, four additional CEA dossiers were required.

1. Posaconazole (Noxafil tablets, aspergillus and candida. NB: the injection is not subject to CEA)
2. Cabozantinib (Cabometyx, Renal Cell Carcinoma)
3. Trastuzumab deruxtecan (Enhertu, Breast Cancer),
4. Onamasemnogen abeparvovec (Zolgensma, Spinal Muscular Atrophy )

​In FINGERPOST’s March newsletter, Wilson our associate in Brazil, provided a Covid-19 update from his home country.  The article received  positive feedback as an interesting insight into a country that readers, in the UK especially, haven’t heard too much about in the news and media.  This response prompted us to change tact slightly for our April blog/newsletter and instead of publishing a global round-up of HTA decisions as usual, we decided a Covid-19 round up from a cross-section of countries globally would be more apt this month.  

Summarised by a selection of FINGERPOST's Global Affiliates who are either based in, and/or are market experts on the country they write about, we present a brief overview of the current statistics, measures implemented to reduce the outbreak and any other impact (political, economic or social) on the market as a result of the pandemic.

This blog provides an abridged version of the pieces our colleagues submitted, however, we have collated their full contributions (including links, images and references) into a report which can be downloaded from the link below. 

It has been a really interesting and collaborative exercise to collate the insights from 15 countries across the world. Whilst lockdown and social distancing are common practice with recurrent themes across all the cited countries, the leniency of these measures vary greatly, as do the statistics associated with the disease, the general management of the situation and population response. We'd like to say a big thank you to all of the authors who contributed content to this blog (see below) and hope you find the summary as interesting as we do!

The number of COVID-19 cases passed the one million mark in the United States on April 28th. More than 55,000 U.S. residents have died from complications resulting from COVID-19.

Most of the country remains under stay-at-home measures, with only essential businesses open. Without consistent and widespread diagnostic testing, state governors are uncertain when it will be safe to lift restrictions. The U.S. conducted 1.6 million tests last week but needs to be doing at least twice as many, according to the Covid Tracking Project. 

While most states are being cautious, a dozen are beginning to ease social distancing measures. Texas, the country’s second-largest state by population (29 million), has announced that stores, movie theaters, restaurants and malls will be allowed to reopen on a limited basis on Friday, May 1st. 

Besides issues with diagnostic testing, the United States is struggling to provide sufficient antibody testing to determine how far the virus has spread. The FDA is allowing private companies to conduct their own validation, but that has resulted in a lack of consistently reliable tests. Part of the problem is the United States’ fragmented healthcare system that hampers its ability to systematically conduct tests, assure adequate supplies, and share information across hospital systems and clinics.  

​Source: https://covidtracking.com/data

Since my last bulletin for the FINGERPOST newsletter, certain things have changed in Brazil. Namely, the Brazilian President has changed the Minister of Health, who is now an experienced oncologist, Nelson Teich.
 
The COVID-19 epidemic is still showing growing numbers in Brazil. The last bulletin from the Brazilian government, issued yesterday (28th April 2020), shows 71,886 confirmed cases  and 5,017 deaths, with a general mortality rate of 7%.
 
As predicted, the disease initially affected people who had better purchasing power, possibly because this group were exposed to the virus earlier (e.g., due to the frequency of international travel). However, the incidence is now much more intense in low-income populations, mainly because this group is less able to maintain social isolation practices for a long time. The number increase in this low-income demographic is also evident in mortality rates, as this population is totally dependent on the public health system, which is becoming dangerously overburdened.
 
A major problem in Brazil has been the identification of COVID-19 cases. The overload of the health system, coupled with the low availability of laboratory tests for the disease, has led to the perception that under reporting is very high.

Source: https://covid.saude.gov.br/

On March 19th, the Argentinean President passed a decree (Nr. 297/2020) on Preventive and Compulsory Social Isolation (lockdown), although some activities are being progressively released. The decree mandated that all people who live in the country or are in it temporarily must remain in their usual homes or where they were at 00:00 on March 20, 2020. 

Until May 10th inclusive (last update), people must refrain from attending their workplaces and may not circulate on routes, roads and public spaces. Only minimum and essential trips to stock up on cleaning supplies, medicines and food are allowed. During the term of the isolation, educational, cultural, recreational, sports, religious or any other type of events that involve the attendance of people may not be held. 

As of 29th April, the total number of confirmed cases in Argentina is 4,127 (50.2% women, 49.8% men), of which 207 have died. Regarding the confirmed cases, 909 (22%) are imported, 1,766 (42.8%) are close contacts of confirmed cases, 984 (23.8%) are cases of community circulation and the rest are under epidemiological investigation. To date, the total number of discharges is 1,192 patients. 

On the 28th April, 2,458 new samples were tested and since the beginning of the outbreak 56,058 diagnostic tests have been carried out for the disease overall, which is equivalent to 1,235.4 samples per million inhabitants. ​

Sources:
www.argentina.gob.ar
www.indec.gob.ar

The first confirmed cases of COVID-19 were identified in the UK on 29th January 2020, initially associated with individuals returning from overseas.  A month later, on 28th February, the UK’s first confirmed case in a British national who had not travelled outside of the UK was confirmed.  On the same day, the first Covid-19 death in the UK occurred in a British Citizen who had contracted the virus aboard a cruise ship.  The UK Government gradually began to encourage social distancing measures, however as the confirmed cases and fatalities grew, schools were closed on Friday 20th March and the country went into formal lockdown from Monday 23rd March 2020. 

The lockdown here has seen more leniency by comparison to some of our European neighbours.  

There is information this week to suggest that the UK has ‘passed its peak’ but these assertions are still to be monitored and still very much rely on the population continuing to comply with lockdown and social distancing rules.  Our current lockdown phase is due to end on 5th May, but it is widely regarded this will be extended further, especially as at the time of writing we have once again seen a significant rise in daily figures published (although this is attributed to the figures coming from Care Homes being included in the totals for the first time). 

The current figures as of Thursday 30th April 2020 in the UK are: 687,369 tested, 171,253 confirmed cases, 26,771 confirmed deaths.*
​
*Source: Public Health England: https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public#number-of-cases-and-deaths

As of 29th April 2020, France has over 130,442 confirmed cases of COVID-19, with 24,087 deaths. The strict confinement measures implemented in mid-March appear to be working, as the number of new cases and deaths each day are declining. 

On 12th March 2020, the government began implementing a lock-down where nearly all public establishments were closed with only "essential services (food shops, pharmacies, banks, newsagents, petrol/service stations…) and essential public services" being authorized to remain open.  On 23rd March, a further measure was implemented whereby all people were required to complete and carry an attestation form when leaving their homes.  Essential journeys include shopping for food, travelling to work (if unable to work from home), accessing healthcare, and exercising within 1 km from home for up to 1 hour. 

Presently, testing is only conducted on an order from a GP for patients with breathing difficulties, chronic illnesses, symptomatic elderly people, symptomatic health professionals, organ, cell, tissue donors and pregnant women.  The government's objective is to be able to carry out 700,000 tests per week at the time of deconfinement, in order to test all people with symptoms and those who have been in contact with a COVID-19 patients. 
​
On 28th April 2020, after being under strict confinement for 6 weeks, the details of a plan for a phased deconfinement were communicated.  Deconfinement will being on May 11th, the extent of which will vary by department.  In general, young children will return to school and stores and public services will reopen.  In early June additional measures (e.g. opening restaurants, high schools, etc.) may be relaxed if all goes well during the first phase with regards to the control of the disease.  ​

Source: Source: https://www.gouvernement.fr/info-coronavirus/carte-et-donnees

The first cases of COVID-19 in Germany were recorded in January 2020. As of April 29, 2020, 157,641 cases of the disease had been confirmed by laboratory test, of which 6,115 had died.
The states with the highest incidence of the disease, expressed as cases per 100,000 inhabitants, were Bavaria (320), Baden-Württemberg (283), Saarland (254) and Hamburg (246)—among the most-affluent areas of the country. Incidence was much lower in the states in the east of the country (the former German Democratic Republic)—just 43 cases per 100,000 inhabitants were recorded in Mecklenburg-Vorpommern, for example.

Two-thirds of COVID-19 patients were aged 15-59. Nineteen per cent of patients were aged 70 or older, but 87% of deaths were in this age cohort. 

An estimated 120,400 patients had recovered from the illness. 

Self-isolation has been generally well supported across Germany and the country has not had to adopt measures as extreme as those of some of its neighbours in Europe.
State administrations have considerable autonomy in determining policy, but the federal government was able to command a broad consensus throughout the early stages of the pandemic.

On 20th April, however, Angela Merkel, the Chancellor, warned against what she called Öffnungsdiskussionsorgien (orgies of discussion about reopening).
​
At a stormy meeting on 6th May, the federal government agreed to allow states to begin reopening shops, restaurants and hotels, and to resume professional football (behind closed doors). Social distancing requirements will remain in place and an "emergency brake" will allow for the reimposition of stricter controls if necessary.

Source: 
https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/2020-04-29-de.pdf

Spain has been one of the countries worst affected by the COVID-19 outbreak. The first case was confirmed on the 31st January and the first death was reported on the 4th of March. Since then there have been 236,899 confirmed cases and 24,275 confirmed deaths, i.e. 515 deaths per million population (data from 29th of April 2020).   

To combat the spread of the virus, Spain implemented one of the toughest lockdowns on 14th of March, however, this Tuesday (28th April) Prime Minister Pedro Sánchez announced plans to begin relaxing the lockdown over the next two months and bringing in a shift towards a “new normality”. This shift is anticipated to take place over four stages, which will vary by province: 

• Phase 0 (start 4th May) - restaurants able to open for takeaway service 

• Phase 1 (start 11th May in mainland Spain) - restaurants allowed to open outside terraces, hotels and places of worship allowed to open, all restricted to a maximum of 30% occupancy 
• Phase 2 - restaurants able to open indoor dining areas, cinemas, theatres and exhibitions able to resume business all restricted to a maximum of 1/3 of their capacity 
• Phase 3 – occupancy/capacity criteria would be relaxed, but continued social distancing of about two metres required 

Schools will generally not return until September. 
​
Progress will be determined by epidemiological, transport and socio-economic data, and the capacity of the Spanish healthcare system, in terms of primary care and intensive care beds. 

Sources: 
​https://coronavirus.jhu.edu/map.html 
 ​​https://www.ine.es/
 https://elpais.com/sociedad/2020/04/09/actualidad/1586437657_937910.html
https://www.eldiario.es/politica/Pedro-Sanchez-anuncia-desescalada_0_1021548525.html
 https://www.ft.com/content/c03f61a9-2d16-47cc-8289-0c732a782dda

April 29th, 2020: The country has been under lockdown measures since early March to tackle the spread of the virus; nearly eight weeks later, Italy has reported 27,359 fatalities.

The third-largest economy in the eurozone is suffering the highest recorded death toll in Europe and its economy is about to collapse.

The government together with several committees are now planning and co-ordinating the next phase of the lockdown relaxation. COVID-phase 2 is expected to start on 4th May. Phase 2 will gradually lift some lock-down measures; certain activities, shops, businesses and factories will be allowed to re-open under strict safety measures. With less than one week to go, phase 2 is still unclear and contradictory and it is causing further distress and uncertainty about the future.  

Based on the current understanding of the COVID-19 virus, the Italian Government is trying to assess, manage and balance the risk related to a potential second wave. This could once more hit the ageing Italian population, (23.1%* are over 65 years) and the already exhausted medical staff, hospitals, and ICUs.
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Sources:
http://opendatadpc.maps.arcgis.com/apps/opsdashboard/index.html#/b0c68bce2cce478eaac82fe38d4138b1
https://www.statista.com/statistics/785104/elderly-population-in-italy/

'Same but different' is a relevant phrase to describe life in Sweden. Restaurants are open, public transport is running, and the majority of children are at school. Yet, there is a feeling of uneasiness as the nation keeps updated on the latest numbers.  

At the time of writing (29th April) there have been  2,462 confirmed deaths linked to corona virus which ranks  Sweden as 11th highest deaths per million of population (225), significantly higher than neighbouring Denmark at only 76.  While testing hasn't been widespread, the trend regarding daily deaths suggests that Sweden has at least reached the peak.  Health resources have been put under pressure but have not yet reached capacity. In fact, the additional 'field hospital' that has been built outside of Stockholm has yet to receive a patient. Therefore, it could be concluded that the voluntary measures to flatten the curve have worked sufficiently for Sweden's infrastructure to cope. 
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While media outlets have suggested the Swedish approach is a gamble and irresponsible vs the lockdown measures in other nations, the majority of Swedes support the government's decision  to stand behind the  data driven recommendations of the Swedish Public Health Agency, headed by Anders Tegnell.  More importantly, the data suggest that the Swedish people are adhering to the guidance by working from home, travelling less and social distancing. While much has been made of the open bars and restaurants, measures have been taken to mitigate risk. Hand sanitizer is everywhere, capacity has been halved and it’s table service only. ​

​Source: https://www.folkhalsomyndigheten.se

Even though around 22% of Portugal’s 10.3 million people are 65 or older, making them particularly vulnerable to coronavirus, there have so far been fewer infections and deaths than in neighbouring countries. On the 29th of April 2020 there had been 24,505 confirmed cases and 973 confirmed deaths (94.5 deaths per million population).  

The main reasons for the lower infection and death rates are believed to be: 

• Time to prepare - being behind other countries in the spread of the virus allowed the country and hospitals to get ready and increase capacity in ICUs, and learn from other countries’ experience 
• Acting early - Portugal introduced lockdown measures e.g. school and universities closures on the 12th of March before any fatalities had occurred, and declared a state of emergency shutting most non-essential services and travel six days later (only two days after the first COVID-19 death) 

• Centralised healthcare system - allowed quick implementation of measures compared to more regionalised systems 

Portugal also has one of the highest testing rates worldwide, with >37,000 tests per million population carried out by 29th of April. 

This Tuesday (28th April), President Marcelo Rebelo de Sousa announced that the state of emergency would end at midnight on the 2nd of May. He warned that this will not be a return to normality and that activities will be resumed slowly and gradually while monitoring a range of indicators. Nurseries will open on the 18th of May and pre-schools will open on the 1st of June; further details are anticipated on the 30th of April. ​

Sources:
https://www.ine.pt/xportal/xmain?xpgid=ine_main&xpid=INE&xlang=p ​https://coronavirus.jhu.edu/map.html
https://www.theguardian.com/world/2020/apr/19/swift-action-kept-portugals-coronavirus-crisis-in-check-says-minister
https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=354227526&DESTAQUESmodo=2&xlang=pt
https://www.statista.com/statistics/1104645/covid19-testing-rate-select-countries-worldwide/
https://pt.euronews.com/2020/04/28/fim-do-estado-de-emergencia-em-portugal-no-dia-2
https://www.publico.pt/2020/04/29/sociedade/noticia/creches-abrem-ja-18-maio-preescolar-1-junho-1914472

As of 27th April 2020, the Netherlands has 38,424 confirmed cases of COVID-19 with 4,677 deaths. Measures to limit personal contact implemented in mid-March appear to be working, as the number of new cases and deaths each day are declining. 

The first patient in the Netherlands was diagnosed with COVID-19 on 27th February 2020, having contracted the disease during a trip to Italy. Seeing the spread of the virus in its southern European neighbours, and also within the country itself, on 12th March the Dutch government began imposing measures to limit personal contact.  It was explicitly stated that the government chose not to resort to confinement measures, reasoning that the virus is here to stay, so that the preferred approach was to tackle the epidemic by building population immunity.  With that said, social distancing (1.5m) was enforced with fines, schools were closed, along with cafés, restaurants, sports clubs, saunas, sex clubs, and coffee shops.  While stores were never forced to close, many chose to do so as they could not guarantee the safety of their staff. The same was true for some public services like libraries.  Masks were never mandatory, as the Dutch feel that they cannot be effectively used by the public, only by medical personnel. 

Testing is only for vulnerable groups (e.g.: elderly, patients with comorbidities) and healthcare workers. The testing capacity in the Netherlands is currently around 17,500 tests per day, which can be increased to around 29,000 if necessary, especially following the return of children to school and opening testing up to teachers. 

The government announced on April 15th that all current measures will remain in place although beginning on 28th April, children may return to participating in outdoor sports, though no parents may be present, and 12-18 y/o children must maintain the 1.5m distancing.  On 11th May elementary schools will re-open and on 2nd June middle and high schools are scheduled to open.  Following this announcement, many stores that had voluntarily closed in March, made the decision to re-open on 30th April.  ​

Source:  https://www.rivm.nl/coronavirus-covid-19/grafieken

New cases in the UAE started to plateau on the 23rd April, with newly diagnosed patients ranging between 518 and 549 per day. In total, there have been 105 deaths, and 2,429 recovered patients. 

Restrictions in the UAE started differently to Europe, with initial restrictions only in the form of a curfew between 8PM and 6AM. These restrictions were called out as a ‘disinfection program’. This was further extended to a 24 hour stay indoors order, whereby permits were required to leave the house for essential services or medical emergencies.
 
Since the start of Ramadan on 24th April, restrictions were loosened once more to a curfew between 10PM – 6AM. Restaurants and businesses are able to operate at 30% capacity, whereas social distancing measures are still recommended and masks are required to be worn at all times.
 
Whilst the UAE authorities have mentioned that all citizens and residents will be tested, the plans on execution are not yet clear, although there are some drive through facilities in Abu Dhabi where citizens are able to get free tests (ex-pats are able to get tested for $100 if they do not have symptoms). 

Source:
​https://www.mohap.gov.ae/en/AwarenessCenter/Pages/COVID19-Information-Center.aspx

​Population 25 million
Total cases 6,746 (19 new in past day) with 89 deaths.
Total tests conducted 544, 410.
(As at 28th April 2020)
 
More than 600 cases and at least 21 deaths have been linked to the cruise ship, Ruby Princess. All 2,700 passengers were controversially allowed to disembark without health checks when it docked in Sydney a month ago. It the single biggest source of COVID-19 infections in Australia.
 
Despite lockdown laws requiring people to stay at home except for essential tasks and exercise, keeping Australians off the beach has been difficult. This photo is from last weekend when beaches were re-opened. Restrictions were re-introduced soon after influx and lack of social distancing! 

A COVID Safe app has been released with approximately 10% of the population downloading it in the first day. The Government says that to be beneficial in controlling outbreaks, at least 40% coverage is required.
 
People are also being encouraged to have the flu vaccination as winter approaches. The aim is to avoid simultaneous COVID-19 and influenza spikes. Despite this lockdown restrictions are starting to be loosened as the crisis seems to have passed but ‘normal service’ with shops, restaurants, gyms and public places re-opening is a long way off. 
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Source:
​https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers

Population 5 million
Total cases 1,474 (2 new in past day) with 19 deaths.
Total tests conducted 128,703
(As at 28th April 2020)

New Zealand’s decisive action on March 25th to move directly to the strictest “Level 4” (eliminate) lockdown restrictions has been hailed as a standout in leadership by Prime Minister, Jacinda Arden.

Even as cases declined in early April, border restrictions were tightened so that all citizens and permanent residents arriving in New Zealand were required to spend two weeks quarantined in an approved facility rather than at home.

The New Zealand Government announced earlier this week that it had effectively “eliminated” the coronavirus and moved to ease restrictions to “Level 3” (restrict). Some non-essential business, healthcare and education activity will be able to resume, but most people will still be required to remain at home at all times and avoid all social interactions.
 
Modelling has indicated that New Zealand could have had more than 1,000 cases a day if it had not brought in the lockdown so early. Reports are that Queen Elizabeth called Jacinda Arden to congratulate her and have a chat!

Source: 
​https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases

To view current updates on global statistical information relating to COVID-19, please visit: https://coronavirus.jhu.edu/map.html and ​https://www.ft.com/coronavirus-latest. If you would like to read more about the COVID-19 impact in each market, please email cbacon@fingerpostconsulting.com for a copy of the full report.