April: A global snapshot of COVID-19 (updated)

​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!

COVID-19 Update: United States of America
Sheri Sellmeyer, Freelance Healthcare Business Writer, Analyst & Consultant

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

COVID-19 Update: Canada
Shannon Lee, Independent Market Access Consultant & Pharmacist

As of April 29th, there are 50,016 confirmed COVID-19 cases, 19,203 resolved cases, and 2,859 deaths in Canada. In the province of Ontario, health officials announced on April 20th the community spread of COVID-19 had peaked and there were 247 people in intensive care compared to the previous estimate of 1,200. COVID-19 lockdown measures began mid-March and are currently still in place. The majority of provinces have ordered the closure of “non-essential” businesses, schools, and parks and playgrounds. More contentious is the establishment of dedicated phonelines to report people or businesses they suspect of social distancing violations across the country.  

​To help workers who lost their income due to COVID-19, the government is offering $2,000 every four weeks. As of April 24th, more than a third of the number of Canadians who had a job in mid-March have filed for the benefit. For small businesses, the government has been criticized for being slow to act. However, a bright light that emerges is the resilience of the small and independent businesses. They have had to quickly change their operating model from an in-store to online focus. Such as the owner of a children's clothing boutique with no online shop, offering video calls to provide a personal shopping experience; the manufacturer of barbeque products and meats for restaurants, making the shift to an e-commerce business and offering consumers an alternative to going to grocery stores. Despite the challenges imposed by the lockdown measures, the small businesses are maximizing what resources and manpower they can afford to ensure their businesses will succeed.  

Sources: 
https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection.html
https://nationalpost.com/news/covid-19-pandemic-in-ontario-peaks-early-fewer-people-dying-than-feared

COVID-19 Update: Brazil
Wilson Follador, Founder & ED, Sano-Efiko

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/

COVID-19 Update: Argentina
Eleonora Aiello, Independent Healthcare Consultant Market Access & HEOR

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

COVID-19 Update: United Kingdom
Victoria Wooldridge, FINGERPOST

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

COVID-19 Update: France
Nicole Drake-Boven, Independent Healthcare Insights Consultant

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

COVID-19 Updated: Germany
Neil Grubert, Global Market Access Consultant, Trainer and Writer

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

COVID-19 Update: Spain
Elsa Faria-Billinton, ​Freelance Market Access Consultant at Enara Consulting Ltd

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

COVID-19 Update: Italy
Katia Acella, Independent Healthcare Consultant

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.
​
Sources:
http://opendatadpc.maps.arcgis.com/apps/opsdashboard/index.html#/b0c68bce2cce478eaac82fe38d4138b1
https://www.statista.com/statistics/785104/elderly-population-in-italy/

COVID-19 Update: Sweden
Ann-Sofie Brandt, Freelance Consultant, Market Access Sweden

'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. 
​
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

COVID-19 Update: Portugal
​​Elsa Faria-Billinton, ​Freelance Market Access Consultant at Enara Consulting Ltd

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

COVID-19 Update: Netherlands
Nicole Drake-Boven, Independent Healthcare Insights Consultant

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

COVID 19 Update: Serbia
Vladimir Guzvic, Independent Consultant & Head of Clinical Pharmacology ​at Health Insurance Fund of Republic of Srpska

At the beginning of March in Serbia, the first patients with COVID-SARS 2 virus infection were detected. After initially denying the seriousness of the infection in the early stages, the Government then introduced probably the toughest quarantine measures in Europe.  

On 15th March the Serbian President declared a “State of Emergency’’ for the whole country as the number of confirmed infections reached 48.  Included in these measures were the closure of shops, and cancellation of sport activities, social events and public transportation.  Later in March, a so called ‘’police hour’’ was introduced, and all citizens were forbidden to leave their houses between 17:00 PM and 05:00 AM next day. During the weekend these hours were extended from Friday 17:00 PM until Monday 05:00 AM (during Orthodox Easter it was from Thursday until Monday, an 80-hour long complete lockdown). 

The elderly (defined as those aged 65 in the cities and 70 outside of cities) were not allowed to leave their houses at any time, except on Friday morning, from 04:00 AM until 07:00 AM, to buy necessary groceries.  On other days of the week deliveries to the elderly have been organized by volunteers.  

Loosening of the quarantine started on 27th April 2020 and was also quite radical.  Most of the shops are now open, and complete opening is planned as per a step by step approach by the middle of the May depending on the continued spread of infection.

By 28th April in Serbia (population 6.5 million), 8,275 citizens have been confirmed as infected, with 162 COVID-19 related deaths (1.96% mortality rate), and 1,209 cured so far. The number of performed tests  is currently 67,917.  

Source: https://covid19.rs/ 

COVID-19 Update: United Arab Emirates (UAE)
Lavni Varyani, Founder & Principal Consultant at Pharma Business Partners

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

COVID-19 Update: Australia
Sharon Leadbitter, Principal Consultant at TACS Healthcare

​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. 
​
Source:
​https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers

COVID-19 Update: New Zealand
Sharon Leadbitter, Principal Consultant at TACS Healthcare

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

30th April 2020: new cases current status

Further Resources

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.