Media briefing on COVID-19 - 07/12/2020

00:00:25 FC Hello, all. I am Fadela Chaib speaking to you from WHO headquarters in Geneva and welcoming you to our global COVID-19 press conference today, Monday 7th December. Present in the room are WHO Director-General, Dr Tedros, Dr Mike Ryan, Executive Director, Health Emergencies, Dr Maria Van Kerkhove, Technical Lead for COVID-19, and Dr Mariangela Simao, Assistant Director-General, Access to Medicines and Health Products. Joining us remotely are Dr Soumya Swaminathan, our Chief Scientist, Dr Kate O'Brien, Director, Immunisation, Vaccines and Biologicals, Steve Solomon, Principal Legal Officer. Welcome, all. As usual we have simultaneous interpretation in the six official UN languages plus Portuguese and Hindi. Now without further delay I would like to hand over to Dr Tedros for his opening remarks. Dr Tedros, the floor is yours. TAG Shukran, Fadela. Good morning, good afternoon and good evening. Last week I spoke about the importance of testing, which is vital for knowing where the virus is but it's also important to know where the virus has been and how many people might have been infected without showing symptoms or being diagnosed by testing. 00:02:02 To do that seroprevalence studies are important, which look for antibodies in the blood of individuals to evaluate the extent of infection in different populations. Hundreds of seroprevalence studies have been done around the world, which vary in quality, methods and the type of tests used. Some follow people or populations over time to show how an antibody response in the individual or seroprevalence in populations changes over time. Despite their limitations their results are fairly consistent. They tell us that most of the world's population remains susceptible to infection with the COVID-19 virus. We're still learning how strong immune responses are in different populations and for how long this immune response lasts. In January WHO launched the Unity studies, a global effort to standardise seroprevalence studies and the use of serological tests. 00:03:10 So far more than 60 countries including more than 40 low and middle-income countries are conducting one or more of these studies using WHO's protocols. We're providing technical, financial and operational support and building research capacities for these studies. We continue to work with our global networks to better understand the proportion of the world's population that has been exposed to this virus and how long immunity lasts in people who have been infected. Seroprevalence studies can help us to understand how long immunity from natural infection lasts, which could also help us to understand how long immunity from vaccination might last. As countries plan to roll out vaccines in the coming weeks and months we urge them to prioritise vaccinating those most in need based on the values framework and population prioritisation roadmap issued by WHO's strategic advisory group of experts on immunisation. This document provides recommendations on who should be considered for vaccination first and lays out the values that inform those recommendations. These are not easy decisions. Vaccinating health workers who are at high risk of infection will help to protect them and the health system. 00:04:45 People at highest risk of severe disease or death as a result of age are also a high-priority group because protecting them will reduce severe disease and death and protect the burden of health systems. As supply increases the next groups would include those who have higher risk of severe disease because of their underlying conditions and marginalised groups at higher risk. In the initial stages of roll-out with only a small proportion of a country's population immunised it's vital that governments, communities and individuals continue using proven public health tools. Shortly after my election as Director-General in 2017 we analysed WHO's funding situation and showed that the organisation was too reliant on a handful of major donors. In May of 2018 we announced our plans to establish a foundation to reduce that reliance by generating funding from new sources. In May of this year I announced the creation of the WHO Foundation, a new independent body to generate resources for the work of WHO from source we have not accessed before. 00:06:14 Today the WHO Foundation announced the appointment of Anil Soni as its first Chief Executive Officer from the beginning of next year. Anil is an experienced global health expert with experience in the public, private and non-profit sectors. His previous role was at Viatris, a pharmaceutical company, where he was head of global infectious diseases. He has also held senior leadership roles at the Clinton Health Access Initiative and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Anil will play a vital role at a vital time in supporting the WHO Foundation to achieve its goal of raising $1 billion for global health over the next three years. The Foundation will also become a key partner of the COVID-19 Solidarity Response Fund, which has so far raised US$238 million from more than 650,000 individuals, companies and philanthropies. I would like to thank the United Nations Foundation and the Swiss Philanthropy Foundation for their partnership in the success of the Solidarity Response Fund so far and I would like to congratulate Anil Soni and we look forward to this exciting new era and to implement the strategic solution that can bring better resources to WHO. I thank you. 00:07:55 FC Thank you, Dr Tedros. I will now open the floor to questions from journalists. I remind you that you will need to use the raise your hand function in order to get in the queue and please unmute yourself. I would like now to invite Carmen from Politico to ask the first question. Carmen, can you hear me? CA Yes, I can, Fadela. Thank you so much for giving me the question. I have a question about the WHO Foundation and I was wondering, does the WHO framework for engagement with non-state actors apply to the WHO Foundation and where is the money coming from for the initial set-up of the foundation, who has financed it so far so it can get on track? Thank you. FC Thank you, Carmen. I think we can also... Dr Tedros would like to say something. TAG Yes, thank you. Thank you so much. I think, as I said in my speech, maybe I can go back to how it all started. We did a diagnosis of the problems WHO has been facing, especially in 2017 and 2018, as part of our transformation. 00:09:39 We have concluded that from some of the problems many of the problems, especially the financing part, could challenge WHO's sustainability in terms of funding. As you know from the volunteers, most of the money, 80% comes as volunteer financing and it comes from few donors. During that analysis what we thought was, if any of these donors withdrew its funding WHO could get into shock which it cannot absorb. So the strategic solution we proposed at that time was for WHO to broaden its base of donors but at the same time find new areas of resources and that's why we developed the first ever investment case, the first resource mobilisation framework and also the first partners' forum, which was held in Sweden last year, and also we decided to have the establishment of the WHO Foundation. WHO Foundation was one of the solutions so based on the first three I think there are strategic areas that have been already covered and this will focus - the WHO focuses new areas of resources. So the money will come from areas where WHO cannot mobilise directly and where, like the principles we have in FENSA, there could be a conflict of interest. 00:11:42 So the WHO Foundation can mobilise resources without really direct involvement of WHO so the relationship between WHO and what the WHO Foundation makes is not direct. So one thing I would like to assure you is that we have done all the assessments and based on FENSA the foundation's establishment is clear so it's based on FENSA that the foundation itself was established. But I just wanted to use this opportunity to tell you that WHO Foundation is one of the strategic solutions among others. Thank you. FC Thank you, Dr Tedros. I would like now to invite Bianca Rothier from Globo to ask the next question. Bianca, can you hear me? BI Hi, Fadela. Yes, can you hear me? FC Yes, very well. Go ahead, please. 00:12:45 BI Thanks. My questions' to Globo. I'm a correspondent here in Switzerland for Globo. It's about schools because contrary to what we have seen in most European countries during the second wave some cities in Brazil - Hijadel [?] for example - are closing schools again while shipping centres can still be open 24 hours a day. What are the WHO recommendations for schools in countries facing a level of spread like Brazil is facing now again and what have the most recent studies shown, what is the role of children in transmission; how about the teachers and other staff, parents when they are going to pick them up? How important is this risk? Thanks a lot. FC Thank you, Bianca. Dr Van Kerkhove will take this question. MK Thanks, Bianca, for this question. WHO advises taking a risk-based approach as it relates to schools and considerations for schools and education systems, whether they remain open or closed. I think universally everyone understands the critical importance of schools and education for children and young adults, especially the youngest kids. 00:14:11 So in our guidance which we've jointly issued with UNICEF - we're grateful for our partners at UNICEF and our global network, our strategic advisory group that helps advise us on educational settings - is to take this risk-based approach and first and foremost schools operate in communities and if the virus is circulating in the communities and there's intense transmission in the communities it's possible that the virus will enter into the school because individuals who work at the school, who attend the school live in those communities where the virus is circulating. So the first thing that needs to be done is to focus on reducing transmission in the communities and there are a number of steps that you've heard us outline over time. But on the schools themselves we also outlined guidance on what type of plans schools need to have in place in terms of the policies and plans for identifying cases, if they were to have a case how they would carry out contact tracing, having certain environmental cleaning within the school, make sure there's disinfection that's happening, certain physical barriers and distancing of desks for example to ensure that children remain apart. 00:15:18 Age-appropriate use of marks, making sure that there's good ventilation and ensuring that there's good natural ventilation and fresh air coming into the schools and making sure that part of those plans include communication; good communication with not only the students themselves who want to know what's happening and who are very, very smart but also the parents of those schools and what role they can play in this. So we've outlined an approach to help schools in taking the decisions of when t open and when to close, if they need to move to a distance-based learning application or virtual-type schooling. So we've helped countries and decision-makers with taking those decisions at the most local level possible because the virus doesn't spread uniformly, there're different levels of intensity. So that is something that's been issued and that's what countries are following. There's a lot of research now that's happening and looking at children and COVID-19 and the infection among children and we do see some age differences in terms of the amount of infection identified in kids as measured by seroprevalence, as the Director-General was talking about earlier in his speech. There seem to be lower levels of seroprevalence in the youngest age groups as compared to older children and teenagers and we do also see differences in the rates of transmission amongst the youngest children, which seems to be lower compared to older children and teenagers who can spread more than the youngest kids. 00:16:50 But we still have quite a lot to learn. Still we do see overall that children when they are infected tend to have more mild disease and asymptomatic infection and that is something that has held true through the more and more research that is being published but it isn't universal so we do have some children who have developed severe disease and we have had some children die. So it is really important that we take a risk-based approach, we look at schools as part of communities because it's not only the children, it's the people who work there. But there are many places all over the world who have open schools and who have prioritised keeping schools open while keeping transmission low. FC Thank you very much. I would like now to invite Emma Farge from Reuters to ask the next question. Emma, can you hear me? 00:17:42 EM Yes, I can. Thank you for taking my question. It's regarding the Biden health team which is coming together now. I'm wondering if the WHO has had any discussions with the incoming administration and whether specifically you can update us on those discussions; did they lead to anything significant on funding or even a possible late inclusion of the US into the COVAX scheme? Thanks. FC Thank you, Emma. TAG As you know, they're in transition and the team is not formed in full so there cannot be formal or organised discussions when they're doing their transition. So we will let you know when we have contacts, when we have formal engagements but so far we haven't done any discussion with the group as a group. As you know, some of them were just announced a few hours ago. Thank you. FC Thank you, Dr Tedros. I'd like now to invite Bloomberg to ask the next question; Corinne Gretlet. Corinne, can you hear me? Corinne? I can't hear you, Corinne. Okay. If not I will go to the next journalist, Gunila Van Hal, Swedish journalist. Gunila, can you hear me? 00:19:43 GU Yes, I can hear you. Can you hear me? FC Yes, very well. Go ahead, please, Gunila. GU Thanks for taking my question. It concerns vaccine hesitancy now, when we have the vaccines here or very close. How worried are you, how concerned are you about this and the fact that maybe too few people will vaccinate themselves to have a real impact on stopping the virus? If I may ask a question concerning that connected to Sweden where we have experience through the swine flu and the vaccinations that led to the life-long disease of narcolepsy for hundreds of young people, how to address vaccine hesitancy that actually comes from a negative experience of mass vaccinations and also from a vaccine that was developed extremely fast and keeping in mind that the pharmaceuticals do not know anything about the long-term side-effects. Thanks. FC Thank you, Gunila. I'd like to invite Dr Kate O'Brien to take this question. Kate. 00:20:51 KOB Thank you. This is an extremely important issue and I'm really glad you raised it. The vaccines that are demonstrating efficacy and are reaching authorisation for use in countries - and we expect that we will see more of these - are not going to be useful unless people actually become vaccinated. The vaccine that sits on the shelf in a refrigerator or a freezer is going to confer no benefit to people. The issue of vaccine hesitancy and certainly the questions about the vaccine are really legitimate questions and we do want people to be informed about the science, we want people to be fully informed about the evidence that regulators and policy recommending bodies are reviewing in order to make the recommendations and the decisions that are being made. I think one of the things that really helps communities and people, individuals who have to make decisions about being vaccinated is the trust that they have in where the information is coming from. Information really does need to come from the most local level possible; from trusted providers, from people's physicians or the nurse that they go to or the voice of public health people in the community. 00:22:26 So sharing the information and the transparency that we have through the regulatory process and through the policy recommending process is really important so that there's accuracy in what people understand about the vaccines. Each individual will make a decision for themselves about the value that they place on the vaccine and especially in this time where so many people, millions of people have suffered and the deaths that have occurred. I think this assessment that people will make about their understanding of the benefits of the vaccine is going to be a critical mixed phase in the pathway towards having these vaccines be critical tools in the toolbox of the interventions that we have. As Mike and Maria have emphasised so often, having vaccines is not going to be a switch, it's not going to be just going from not having vaccines to having them. We're going to have to continue with the public health interventions for some time yet because of vaccine supply and because of the ramp-up of people getting vaccinated. 00:23:42 What I really want to emphasise here is that there's a very robust, a very strong safety monitoring system that is in place and that system is in place in countries that will be starting vaccines, in all countries around the world. As WHO - and perhaps Mariangela can speak to this a little bit more - that safety system is switched on fully for full co-ordination across all of the different groups - the regulators, the manufacturers, WHO - to be looking at the data in real time. But if there are any signals of concerns around the vaccine we have the ability to look at that, to investigate it and to really understand if there's any issue. But in the clinical trials - which have been very large in nature - the safety evidence is the critical piece of evidence that is being assessed by regulators looking very carefully at the safety profile. As you've seen in the trials that have been reported - in the press releases at least - there are tends of thousands of people who have been enrolled in the trials and each of them is randomised so approximately half of them have received the vaccine. 00:25:09 So I think we have standards around safety, we have large clinical trials that have been done, we have a system in place to monitor for rare or unusual potential outcomes from the vaccine and assess whether they were related to the vaccine or not. I think where people really need to spend their time and their energy is on really being sure that the information that they're receiving is information that is based on the science. I wonder if Mariangela wants to say anything more about the safety part or anybody else to come in here. Thank you. FC Thank you, Dr O'Brien. I think that was a very comprehensive answer. I hope that Gunila was happy. I would like now to invite NPR, Jason Bobian from NPR, to ask the next question. Jason, can you hear me? JA Yes, I can, thank you. The CDC updated what they're calling a close contact and they're now adding anyone who had direct physical contact of a person; before it was anyone who's been within six feet of someone for 15 minutes, masked or unmasked. 00:26:35 I think there's still a little bit of confusion. What is your view of whether or not... They mentioned hugging, that if someone had hugged a person that person would then be considered a close contact and should quarantine. What would be your take on a short interaction like that, just a hug, would that be considered close contact? MK Thanks for the question. It's a good one because there are lots of different definitions out there for contacts. The reason we have the definition of contacts is because of the way the virus spreads. It's a respiratory pathogen and so the virus can be released from your mouth and your nose when you talk or cough or sing but it can also be passed if people have direct contact with one another. What we learn about through these studies is to really get much more detail around what that contact entails. What we know is that most transmission is happening among people who tend to spend a lot of time together. They happen in households, they happen in workplaces and so you have more than just a passing or a brief exchange between individuals. 00:27:50 So when you have a household contact you may hug that person, you may spend long periods of time in the same room together, you may sleep in the same bedroom together, you may share meals together. So when transmission happens in those households it's very difficult to disentangle how transmission actually occurred and the instant of transmission. But we know that long periods of time together, the intensity of that type of interaction, meaning the closeness of it, the direct contact, the direct nature of that contact and the type of setting in which that type of transmission takes place; if it happens in a closed setting with poor ventilation for example that is a situation where transmission can be facilitated more readily. So we define a contact; we use a time frame, we do give a 15-minute window in terms of that amount of time spent with someone. But countries and institutions and agencies need to take decisions about how they define contacts based on the experience that they're seeing in their countries, based on the studies that are being conducted, the details of those outbreak investigations. 00:28:54 This is why these outbreak investigations are so critical for us; because you get to that level of detail that really disentangles how transmission is happening because there are different ways in which transmission can take place. So it is important the time element, the type of contact; if you're hugging for someone, if you're kissing someone, if you're caring for someone, especially if they're sick. Those are really important to define contacts. Also, having said that, we try to outline what would be considered a higher-risk contact versus a lower-risk contact and that relates to the amount of exposure, the duration and the time of exposure because when you're carrying out contact tracing sometimes those numbers of contacts become very high and you do prioritise who you follow up so we recommend following up the highest-risk contacts, those who have the most exposure to someone who is a case. MR Thank you, Maria. I think Maria's spot-on with that. Also just for ordinary people out there, it's like looking at your skin in the sun. Some people can develop a cancerous growth. Nobody knows which specific event caused that. What we do know is if you spend longer in the sun there's more of a chance that you will but it's very difficult to associate a specific day or time at which that sun might cause that cell to change but we do know it's bad to be out in the sun with unprotected skin. 00:30:25 It doesn't mean that sunlight is bad; it means that overexposure to sunlight can lead to that outcome. In the same way we don't know what specific event causes the transfer of the virus to humans. It could be a hug but it's much more likely to occur in a situation where you're in the same space as somebody else for a long time because there are more opportunities during that period for the virus to jump. I think it's difficult right now for the likes of CDC in Atlanta; the US is accounting for a third of all world cases at the moment over the last number of weeks. The epidemic in the US is punishing, it's widespread. It's quite frankly shocking to see one to two persons a minute die in the US, a country with a wonderful, strong health system and amazing technological capacities. So I believe that the CDC are doing their job; they're trying to identify each and every possible significant contact, they're really reaching out to try and get people to stay the course and to use the hope of vaccines but just to remember, there are a number of months to go in which everyone is going to have to unfortunately avoid those hugs. 00:31:41 Maybe because we're here talking today about hugs and about how much we would like those hugs over the holiday period and just how getting that close to people in a situation with intense community transmission can be so tragically dangerous; that's, I think, the awful, brutal dilemma that we all face. It's a horrible thing to think that we would be here as the World Health Organization saying to people, don't hug each other. It's terrible but that is the brutal reality in places like the United States right now and I commend the CDC for doing everything they can. Definitions are definitions. At one level they're arbitrary; who is a contact, who is not. What CDC are trying to do is pick out as many of the significant contacts as they can so that people can protect themselves, get the diagnosis they need, get into treatment early. They're trying to make sure that people are detected and get access to care, they're trying to break the chains of transmission and I commend them as a strong federal agency and as an agency that sends light to the world through its science for doing what they're doing. 00:32:54 FC Thank you. I would like to call again Corinne Gretler from Bloomberg news, our second attempt. Corinne, can you hear me? CO Yes, I can. Can you hear me? FC Corinne? CO Hello, can you hear me? FC Yes, very well. Go ahead, please. CO I may have missed this in previous briefings but I was wondering whether the WHO is advising member states to make the vaccine mandatory. What's your general stance on that and if not countries would it maybe make sense for companies to make it mandatory for employees? FC Thank you, Corinne. Dr Simao. MS Let me start and colleagues can complement. Actually there are very few cases where vaccines are mandatory in countries because countries have different regulations and they usually refer to vaccination in children. 00:34:00 We don't have that experience with adults so far but we do believe that it's much better to work on information campaigns, on making the vaccine accessible to those priority groups who need to be vaccinated first as we don't have enough vaccine next year to vaccinate the entire population. So it will be up to countries to decide but the position is that the way it works better is to make sure that people who are in the priority populations should be vaccinated first, that they have the right information and that they can make an informed choice regarding getting the vaccine. FC Thank you, Dr Simao. I think Dr O'Brien would like also to comment. Dr O'Brien. KOB Yes, I also just wanted to add to what Mariangela has just said is that there is only one vaccine, the yellow fever vaccine, that has any requirement regarding international travel and obviously international travel is not a mandate to be vaccinated, it's an underpinning of that travel requirement. 00:35:20 Just on the issue of mandatory vaccination I fully agree with what Mariangela has had to say; there are some examples of countries for the purpose of paediatric vaccinations that have had success in ensuring that children have high coverage with vaccination in a setting where there are school-related requirements for attendance. But we do think that it is a much better position to actually encourage and facilitate the vaccination without those kinds of requirements. Really one of the limitations for vaccination is availability of vaccines and that doesn't just mean in a country itself but in a time and a place that is convenient for people to go and get vaccinated and with facilities that are of high quality, that provide a positive environment for people to come and be vaccinated. So there are many ways in which we can facilitate people coming to get the vaccines that they want to get and that they know are for their health and their safety. I think the other thing to say is that there may be some countries or some situations in countries where there are professional circumstances where it would be required to be vaccinated or where it would be highly recommended to be vaccinated. 00:36:55 One can imagine certain professional jobs in hospitals - respiratory technicians, intensive care unit physicians and nurses - where for the safety of the staff and the patients there would be a very strong recommendation to be vaccinated. So I don't think we envision any countries creating a mandate for vaccination but there certainly are situations where that strong recommendation - or perhaps on the part of an employer - would decide that that would be a requirement. FC Dr Ryan. MR Yes, I agree with very much of what Kate said. I think the issue and the discussion we need to have amongst ourselves, with ourselves is the issue of what is personal responsibility versus what is a requirement of law and what are you as an individual willing to do to protect yourself and those people around you. If I lived on a desert island would I necessarily want to have COVID vaccine? I don't know. But if I was going to visit my 80-year-old mother - she's not in the nursing home but if she was - if vaccine was available would I be responsible in going in there, visiting lots of older people without being vaccinated if a vaccine was available to me? 00:38:27 So I think we all have to ask ourselves those questions and when you ask yourself those questions you tend to come up with the right answers and then you avoid questions about law and mandatory nature of vaccines. I think the other thing that Maria reflected to me earlier was, the reality is most people want these vaccines. This is a massive potential breakthrough for global health. People are demanding these vaccines, people want these vaccines. They want these vaccines to be rolled out carefully and safely and Mariangela, Soumya, Kate and some of the others - Ana Maria - are working so hard here and around the world to ensure that process and give people the necessary reassurances. But the reality is the vaccine story is a good news story. It is the victory of human endeavour potentially over a microbial adversary, as the DG has called it many, many times and there's hope with that. Yes, we have to continue to bring people along on that journey but I don't think we should necessarily focus on the negative aspects here. 00:39:29 We need to convince people and we need to persuade and we need to dialogue on this issue. I'm not a great believer... I agree with Kate; there are specific circumstances in which governments may have to require a specific mandate for vaccination but I think all of us who work in public health would rather avoid that as a means of getting people vaccinated. I think we are much better served to present people with the data, to present people with the benefits and let people make up their own minds, obviously within reason because there are certain circumstances, as I've alluded to, where I would believe that the only responsible thing would be to be vaccinated, in future when the vaccine is fully available. FC Thank you. Kate, do you have something to add? KOB Yes, I just wanted to add on the comment that I made that there are some countries, a limited number of countries that do have requirements for school attendance for children to verify the vaccination status. 00:40:35 I'd like to also just comment that mandates have another side to them which is that they're also examples where when countries thought that this would be a means to improve the coverage of vaccination in the country it just went in the opposite direction. So just really reinforcing what I said before and what Mike said, that this is not a tool that has strong evidence behind it that it results in higher coverage. In each circumstance where it has been tried the evidence is that it actually goes in both directions. So especially in the circumstance that we're in - and as Mike has said and Maria has said - the substantial majority of people - and people are really eager to have these vaccines available and to move along with vaccination and access to vaccines so I don't think that mandates are the direction to go in here, especially for these vaccines. Thank you. FC Thank you all. I would like now to invite Kumar Bian, Indian media, to ask the next question. Kumar, can you hear me? KU Yes. Can you hear me? 00:42:00 FC Very well. Go ahead, please. KU From the beginning the WHO has been saying - the DG in particular - that the vaccine is very unpredictable, it behaves differently with different people. In this context I would like to ask whether the WHO is looking at different vaccines for different ages groups and geographies because elders have different symptoms, children have different symptoms. I myself have come out of COVID very recently. My age group will have different symptoms. What's your take on it, WHO? FC Thank you, Kumar. Dr O'Brien, can you take this question, please? KOB Sure. We have been emphasising that in the evaluation of the vaccines it is important that the trials are of large enough size and are of diverse enough populations that we can get some answers to questions about whether or not there is a difference in the efficacy of the vaccines according to different subgroups. Age is one particular attribute; that there is a high interest in knowing whether or not the vaccines perform in the same across different age groups. I want to emphasise that the data that has been made public at this point is from press releases. We're very eager to see the details of the data from these clinical trials. 00:43:37 Some of the clinical trials are large enough and enrolled in a a way that they are able to look at the efficacy of the vaccines according to some of the different age strata of interest, in particular older adults. But none of the trials enrolled people who were over 80 years of age so we don't have information among the very oldest in our communities. What is available from some of the press releases are statements in the press release that the efficacy in older age groups was very similar if not the same as among the groups in the younger age groups. So what we really need to wait for is to see the data go through the regulatory process and through the public processes where the data is provided. There are scientific reasons to ask a question about whether or not there could be differences of performance of vaccines in different age groups or underlying medical conditions. 00:44:45 There are a number of areas in which one might expect that there could be differences in the performance of the vaccine and as vaccines become used in communities there will be ongoing evaluations of those vaccines as people become vaccinated to identify whether one or more of the vaccines has better performance or less good performance in some subgroups of people. It's also the reason why we need to continue the research on vaccines, that the story isn't over with the first vaccines coming to authorisation and there are a large number of vaccines in the pipeline and it really is important that as we focus on ramping up both the manufacturing and the delivery as vaccines come through and are assessed for authorisation from a regulatory perspective that we don't stop with the research. Because for most vaccines there has been ongoing development of them and the ones that we started with at the beginning were improved upon over time. So as much as we want the vaccines that are coming through now I do want to emphasise the importance of the ongoing research. Thank you. FC Thank you, Dr O'Brien. I would like to invite Ana Maria Henao Restrepo, Dr Ana Maria, to respond also to this question. 00:46:19 AMR Yes, I just want to echo some of the points that Kate has highlighted. We have been discussing with chemical trialists and vaccine experts and, as Kate says, we are very pleased to have the third term information on the efficacy of these three vaccines but all the experts agreed that we require to have additional evidence. Placebo-controlled trials are the gold standard of obtaining information on the efficacy, the safety, the duration of the protection and the occurrence of serious adverse events. This is why we are communicating to all the researchers around the world who are doing the trials to continue the trials as per the protocols. Second, as he was saying, randomised evidence is the best opportunity we have to evaluate the additional vaccines and to know if these additional vaccines in the pipeline - we have almost 150 candidate vaccines all with different attributes. Some require one dose, some have different routes of administration, some are more suitable for certain contexts. 00:47:28 We want to test all of them because maybe there will be the solution for countries or for certain locations. Thirdly we of course understand that at some point we are going to move into observational data. The randomised placebo-controlled trials will not be possible any longer but we have to enter into this phase understanding that this kind of a study doesn't have the same attributes as the mass clinical trials, that even if they are very well conducted they are subject to bias and interpretation is going to be more complex. So we need to look at that; having close marketing surveillance, having case controlling studies, having cohort studies is a good idea but we need to deliver data. We are in the process of organising consultations to deliberate on what are the best contexts and the best approaches to conduct such studies so that we don't get the wrong answers. FC Thank you. I would like just to give you the title of Dr Ana Maria Henao Restrepo. She's Co-Lead, Research and Development Blueprint at WHO. Thank you so much for your answer. I would like now to invite the next journalist, NSK Shoko [?]. NSK, can you ask your question, please? 00:48:54 SH Hello, Fadela, can you hear me? Hello? FC Yes, I can hear you. Go ahead, please. SH Okay, thank you for taking my question. Tomorrow marks a year since the first patient was detected in Wuhan in China. Can you please give us an update on when WHO is planning to send the international experts to China? Does it take place by the end of this year or rather the beginning of next year or even later? Thank you. TAG Yes, thank you so much. We're planning and we're hoping to be to the ground as soon as possible. Thank you. FC Thank you. I would like now to invite Maya Klans from the UN Brief to ask the next question. Maya, can you hear me? MA Thank you very much, Fadela, for taking our question. My question is regarding the foundation. I know you have spoken already about it but I would like to know what's in the pipeline for the coming year, for its very first year. 00:50:17 FC Thank you so much. The board is established now and we have our CEO, as I have announced today, and we have already started and the foundation have already started taking the next steps, meaning raising the funding as operational cost for the foundation. While raising that funding of course it will trigger the ambitious three-year plan the foundation has. So while the immediate funding will be the US$40 million for the operation of the foundation then the plan is to mobilise US$1 billion in the next three years. Thank you. MR If I could just add - and this is more aspirational in terms of the foundation because I've had the great pleasure of working on behalf of Dr Tedros on the Solidarity Fund for COVID-19 which is the precursor in a way of some of the hopes that we have for the foundation. It's been very, very empowering this year to see how funding coming from sources other than traditional has funded so many amazing efforts in terms of the Solidarity Fund. It's invested in youth organisations for COVID-19 messaging, it's invested in oxygen solutions, in emergency medical team training and subregional centres in Ethiopia. 00:52:05 It's evolved funding our partners outside WHO more than our partners inside including UNICEF, the World Food Programme, UNROA, the UNHCR and others who are doing health-related activities in the field. So it is our hope, Dr Tedros, that the foundation will be, as you have laid out, a way in which WHO can leverage increased investment in health. I think Tedros always says that; that this isn't about necessarily just increased investment in WHO. It's about leveraging more funding into the global cycle for health and driving partnership and innovation throughout the world. I think we've started well with the Solidarity Fund and we hope that the foundation will have that same impact and I'm sure it will. TAG Thank you, Mike. You have reminded me of one thing. When we propose these strategic solutions for WHO it's not just to raise funding only. It could improve the amount of funding, it could improve the quality of funding; that's one. 00:53:15 But at the same broadening our base and moving into additional resources which doesn't have any strings attached means improving also WHO's independence. So it's not about funding only; it's also an independence issue. With long-term multi-tier [?], broad-based funding comes independence also so it's not just finance, it's also ensuring and securing the independence of the organisation and that's why I say this is a strategic solution that addresses some of the systemic problems that we have. Thank you. FC Thank you, Dr Tedros. I would like now to invite Kostas from ERT Greece to ask the next question. Kostas, can you hear me? KO Can you hear me? FC Very well. KO Thank you for taking my question. I would like to ask you about the origin of the coronavirus. Do you agree with the scientific opinion of several virologists in the last days who claim that the virus did come from China but mutated in Italy and then became more contagious and deadly than the original virus in Wuhan? Thank you. 00:54:51 FC Thank you, Kostas. Dr Ryan. MR We can pass to Maria for more specific comment but there are many, many hypotheses as to the origins, the evolution and the spread of COVID-19. They all make for great stories but at the moment there is no proof that any of the hypotheses for generation or for transmission are so. But it is important that we continue to create those hypotheses and then test those against the data that we know. That's part of the reason why Dr Tedros has pushed so hard to work with our Chinese colleagues on understanding the origins of the human disease in Wuhan. But we also have other data that we're looking at very closely for early transmission potentially in Europe and also we've seen the human-to-mink-to-human transmission. So what we see here is a very dynamic interface between animals and humans. We see evolution of the virus within human populations and potentially even faster evolution within small animal populations that are densely packed together. 00:56:01 So it is difficult to come up with a single hypothesis that explains transmission and there is no question that there was very explosive transmission in Wuhan in the early part of the epidemic and clearly in northern Italy a similar explosion of transmission at that time and Italy suffered greatly for that and then we saw the subsequent transmission in other countries. So it is an interesting observation around those effectively two epicentres and how they were related but there are no answers to those questions but we're really interested and we're working with both colleagues in Italy and other countries in Europe - and Denmark. We're working with our colleagues in China and we would hope to build up a much more definite picture on that so please keep sending us your hypotheses but every hypothesis needs to be tested against the data that we actually have. Maria. MK Thanks. Just to support what Mike has said, the studies that need to take place in Wuhan looking at the first cases that were detected are really, really critical in terms of those epidemiologic investigations and really understanding the time that the virus was detected. 00:57:11 Those need to take place and those are taking place and that's the main mission of the China international team and that's ongoing, as the Director-General has said and as Mike has said. But we are a scientific organisation, we are an evidence-based organisation, we follow the science, we follow all of the research that is ongoing globally and there are research groups that are looking at past serologic samples, sera from 2019 and for all of those examples we will follow up and we're following up a recent publication from Italy and those samples are being tested by a partner lab. All of the sequencing that has been made available and again it's incredible that more than 200,000 full genome sequences have been shared globally and these have been shared on publicly available platforms like GISAID. It's really incredible; we need more sequences to be shared so thank you to colleagues for doing that. 00:58:09 Looking at the most common ancestor, any evidence that points to a late November/early December most common ancestor. We're looking also at some countries that are looking at stored waste water samples and following up any indication of RNA testing and making sure that it's a real finding or it might be contamination. We're looking at countries that are going back into their labs and looking at stored clinical samples from 2019 and so all of these avenues are followed up but again - and the Director-General has made very clear and so has Mike and so have I - these studies will begin in Wuhan and it's really, really critical from the public health point of view to understand the events that took place because of the public health importance. What is really critical is that we understand the intermediate host or hosts because that is the important animal or animals that the virus can pass between and we want to make sure that that doesn't continue to happen or doesn't happen again. FC Thank you so much. I would like to invite Peter Kidi from Anadolu news agency to ask the last question. Peter, you have the floor. 00:59:28 PE Thank you for taking my question. Can you hear me? FC Yes, go ahead, please. PE Thank you. With all the growing optimism from vaccine development there's also quite a lot of talk about the thorny issue of intellectual property rights and sharing of knowledge and data. I know that South Africa and India have proposed to the WTO that they should choose whether to grant or enforce patents and other intellectual property related to COVID-19 and to share data. The industry says with all the innovation it's pushed forward such fast development of data. Can you say what the WHO has to say about this? Thank you. FC Thank you, Peter. Dr Simao. MS Thank you for the question; it has been coming up quite frequently lately because these discussions are ongoing in the Trips Council, which is managed by WTO, as you know well. WHO of course welcomes all measures that countries can make in order to address any barriers to access to safe and effective products. That's the spirit behind this process that's happening at the WHO. 01:00:59 On the other hand WHO's Director-General together with the President of Costa Rica has launched at the end of May the COVID Access Technology Pool which is aiming at increased sharing of knowledge and scientific information but also increased pooling of patents, pooling of licences through the medicines patent pool. We believe very much that for next year as we are facing a situation where we will have scarce products, scarce manufacturing capacity in countries and that short-term we need to deal with the affordable access, equitable access to these products that prove to be safe and effective. In the mid and long term we need to increase capacity for, for example, local production or technology transfer and that's where the CTAP, which is this platform, can play a very important role through a voluntary mechanism where manufacturers and researchers, academics and institutions in general can deposit and make available the pertinent licensing or scientific knowledge that can help us face the pandemic at the end of 2021, into 2022 and 23. 01:02:33 I'm saying this particularly because we have situations where we may have for example biotherapeutics that could be useful to fight COVID but they are also being developed for other disease but for which - for example monoclonal antibodies - there is a very, very limited manufacturing capacity concentrated in some multinational companies at the moment. We need to increase the willingness to do technology transfer and also to do the pooling of licensing so that we do not only address the COVID needs but we also address other conditions like oncological products and HIV products for example. Thank you. MR Thank you, Mariangela. I fully agree with your points but just from the perspective as we enter many holiday seasons - Mariangela's right - the technology transfer can take time and it can be done over many products but what we need now globally is not to enter the land of empty promises in terms of supporting the ACT Accelerator. 01:03:51 The structure is there, the partnership is there, the means to do this, allocation fairly and equitably is there. We've never had that in place previously but what's not in place is the financing to make that happen in 2021. I'm not directly and daily involved with the ACT so I'm speaking as an advocate for my colleagues who've given every ounce of their energy across multiple organisations on this project over months. Quite frankly right now there's too much of a gap between the rhetoric and the reality of what the Director-General and other leaders have at their disposal in order to make the ACT Accelerator deliver on a fair and equitable result for people around the world. Equity and fairness is still an aspiration, it's a dream, there's a plan. We have the architectural drawings for this moon shot but I think the DG will agree, we still don't have the financing to make that happen. So I do think as we approach the time of giving it's really important that countries that speak to the idea of fairness and equity, countries that want that to the a reality and have the financial power, the donors that have the power, be they philanthropic or be they government or other or private sector, that we actually make that happen. 01:05:19 Anyway, that for me is going to be the essence of creating equity. It's not just about the technology, it's about financing the ACT Accelerator, particularly the COVAX facility, in order to make this happen. FC Thank you so much. We have gone over one hour since we started this press conference. I would like to invite Dr Tedros for any final comments. Over to you, DG. TAG Thank you so much, Fadela, and thank you all for joining us. See you in our upcoming presser. Thank you. Have a nice week. FC Thank you, DG. I would like to remind journalists that we will be sending the DG's opening remarks and the audio file after this press conference. The full transcript will be available tomorrow on the WHO website and as usual don't hesitate to contact the media team for any follow-up questions. Thank you and see you on Friday. 01:06:22

Characteristics and outcomes of COVID-19 patients in New York City's public hospital system.

BACKGROUND: New York City (NYC) bore the greatest burden of COVID-19 in the United States early in the pandemic. In this case series, we describe characteristics and outcomes of racially and ethnically diverse patients tested for and hospitalized with COVID-19 in New York City's public hospital system. METHODS: We reviewed the electronic health records of all patients who received a SARS-CoV-2 test between March 5 and April 9, 2020, with follow up through April 16, 2020. The primary outcomes were a positive test, hospitalization, and death. Demographics and comorbidities were also assessed. RESULTS: 22254 patients were tested for SARS-CoV-2. 13442 (61%) were positive; among those, the median age was 52.7 years (interquartile range [IQR] 39.5-64.5), 7481 (56%) were male, 3518 (26%) were Black, and 4593 (34%) were Hispanic. Nearly half (4669, 46%) had at least one chronic disease (27% diabetes, 30% hypertension, and 21% cardiovascular disease). Of those testing positive, 6248 (46%) were hospitalized. The median age was 61.6 years (IQR 49.7-72.9); 3851 (62%) were male, 1950 (31%) were Black, and 2102 (34%) were Hispanic. More than half (3269, 53%) had at least one chronic disease (33% diabetes, 37% hypertension, 24% cardiovascular disease, 11% chronic kidney disease). 1724 (28%) hospitalized patients died. The median age was 71.0 years (IQR 60.0, 80.9); 1087 (63%) were male, 506 (29%) were Black, and 528 (31%) were Hispanic. Chronic diseases were common (35% diabetes, 37% hypertension, 28% cardiovascular disease, 15% chronic kidney disease). Male sex, older age, diabetes, cardiac history, and chronic kidney disease were significantly associated with testing positive, hospitalization, and death. Racial/ethnic disparities were observed across all outcomes. CONCLUSIONS AND RELEVANCE: This is the largest and most racially/ethnically diverse case series of patients tested and hospitalized for COVID-19 in New York City to date. Our findings highlight disparities in outcomes that can inform prevention and testing recommendations.

Real-world outcomes in thoracic cancer patients with severe Acute respiratory syndrome Coronavirus 2 (COVID-19): Single UK institution experience.

BACKGROUND: UK COVID-19 mortality rates are amongst the highest globally. Controversy exists on the vulnerability of thoracic cancer patients. We describe the characteristics and sequelae of patients with thoracic cancer treated at a UK cancer centre infected with COVID-19. METHODS: Patients undergoing care for thoracic cancer diagnosed with COVID-19 (RT-PCR/radiology/clinically) between March-June 2020 were included. Data were extracted from patient records. RESULTS: Thirty-two patients were included: 14 (43%) diagnosed by RT-PCR, 18 (57%) by radiology and/or convincing symptoms. 88% had advanced thoracic malignancies. Eleven of 14 (79%) patients diagnosed by RT-PCR and 12 of 18 (56%) patients diagnosed by radiology/clinically were hospitalised, of which four (29%) and 2 (11%) patients required high-dependency/intensive care respectively. Three (21%) patients diagnosed by RT-PCR and 2 (11%) patients diagnosed by radiology/clinically required non-invasive ventilation; none were intubated. Complications included pneumonia and sepsis (43% and 14% respectively in patients diagnosed by RT-PCR; 17% and 11% respectively in patients diagnosed by radiology/clinically). In patients receiving active cancer treatment, therapy was delayed/ceased in 10/12 (83%) and 7/11 (64%) patients diagnosed by RT-PCR and radiology/clinically respectively. Nine (28%) patients died; all were smokers. Median time from symptom onset to death was 7 days (range 3-37). CONCLUSIONS: The immediate morbidity from COVID-19 is high in thoracic cancer patients. Hospitalisation and treatment interruption rates were high. Improved risk-stratification models for UK cancer patients are urgently needed to guide safe cancer-care delivery without compromising efficacy.

Comparative efficacy and safety of pharmacological interventions for the treatment of COVID-19: A systematic review and network meta-analysis.

BACKGROUND: Numerous clinical trials and observational studies have investigated various pharmacological agents as potential treatment for Coronavirus Disease 2019 (COVID-19), but the results are heterogeneous and sometimes even contradictory to one another, making it difficult for clinicians to determine which treatments are truly effective. METHODS AND FINDINGS: We carried out a systematic review and network meta-analysis (NMA) to systematically evaluate the comparative efficacy and safety of pharmacological interventions and the level of evidence behind each treatment regimen in different clinical settings. Both published and unpublished randomized controlled trials (RCTs) and confounding-adjusted observational studies which met our predefined eligibility criteria were collected. We included studies investigating the effect of pharmacological management of patients hospitalized for COVID-19 management. Mild patients who do not require hospitalization or have self-limiting disease courses were not eligible for our NMA. A total of 110 studies (40 RCTs and 70 observational studies) were included. PubMed, Google Scholar, MEDLINE, the Cochrane Library, medRxiv, SSRN, WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov were searched from the beginning of 2020 to August 24, 2020. Studies from Asia (41 countries, 37.2%), Europe (28 countries, 25.4%), North America (24 countries, 21.8%), South America (5 countries, 4.5%), and Middle East (6 countries, 5.4%), and additional 6 multinational studies (5.4%) were included in our analyses. The outcomes of interest were mortality, progression to severe disease (severe pneumonia, admission to intensive care unit (ICU), and/or mechanical ventilation), viral clearance rate, QT prolongation, fatal cardiac complications, and noncardiac serious adverse events. Based on RCTs, the risk of progression to severe course and mortality was significantly reduced with corticosteroids (odds ratio (OR) 0.23, 95% confidence interval (CI) 0.06 to 0.86, p = 0.032, and OR 0.78, 95% CI 0.66 to 0.91, p = 0.002, respectively) and remdesivir (OR 0.29, 95% CI 0.17 to 0.50, p < 0.001, and OR 0.62, 95% CI 0.39 to 0.98, p = 0.041, respectively) compared to standard care for moderate to severe COVID-19 patients in non-ICU; corticosteroids were also shown to reduce mortality rate (OR 0.54, 95% CI 0.40 to 0.73, p < 0.001) for critically ill patients in ICU. In analyses including observational studies, interferon-alpha (OR 0.05, 95% CI 0.01 to 0.39, p = 0.004), itolizumab (OR 0.10, 95% CI 0.01 to 0.92, p = 0.042), sofosbuvir plus daclatasvir (OR 0.26, 95% CI 0.07 to 0.88, p = 0.030), anakinra (OR 0.30, 95% CI 0.11 to 0.82, p = 0.019), tocilizumab (OR 0.43, 95% CI 0.30 to 0.60, p < 0.001), and convalescent plasma (OR 0.48, 95% CI 0.24 to 0.96, p = 0.038) were associated with reduced mortality rate in non-ICU setting, while high-dose intravenous immunoglobulin (IVIG) (OR 0.13, 95% CI 0.03 to 0.49, p = 0.003), ivermectin (OR 0.15, 95% CI 0.04 to 0.57, p = 0.005), and tocilizumab (OR 0.62, 95% CI 0.42 to 0.90, p = 0.012) were associated with reduced mortality rate in critically ill patients. Convalescent plasma was the only treatment option that was associated with improved viral clearance rate at 2 weeks compared to standard care (OR 11.39, 95% CI 3.91 to 33.18, p < 0.001). The combination of hydroxychloroquine and azithromycin was shown to be associated with increased QT prolongation incidence (OR 2.01, 95% CI 1.26 to 3.20, p = 0.003) and fatal cardiac complications in cardiac-impaired populations (OR 2.23, 95% CI 1.24 to 4.00, p = 0.007). No drug was significantly associated with increased noncardiac serious adverse events compared to standard care. The quality of evidence of collective outcomes were estimated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The major limitation of the present study is the overall low level of evidence that reduces the certainty of recommendations. Besides, the risk of bias (RoB) measured by RoB2 and ROBINS-I framework for individual studies was generally low to moderate. The outcomes deducted from observational studies could not infer causality and can only imply associations. The study protocol is publicly available on PROSPERO (CRD42020186527). CONCLUSIONS: In this NMA, we found that anti-inflammatory agents (corticosteroids, tocilizumab, anakinra, and IVIG), convalescent plasma, and remdesivir were associated with improved outcomes of hospitalized COVID-19 patients. Hydroxychloroquine did not provide clinical benefits while posing cardiac safety risks when combined with azithromycin, especially in the vulnerable population. Only 29% of current evidence on pharmacological management of COVID-19 is supported by moderate or high certainty and can be translated to practice and policy; the remaining 71% are of low or very low certainty and warrant further studies to establish firm conclusions.

Clinical Manifestation of Patients Who Died Due to COVID-19; A Retrospective Study from Qom-Iran.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has become a pandemic health problem worldwide. In this study, we attempted to explain the clinical and laboratories characteristics of non-surviving patients, to identify the probable factors affecting disease progression. METHODS: In a retrospective study, we assessed the data from dead adult patients who were hospitalized and laboratory diagnosed with COVID-19 during March 2020. The data were obtained from electronic medical records. Moreover, a checklist including demographic, clinical, laboratorial, imaging, and treatment data was completed for each one of the patients. In case of lack of information, a member of the research team contacted the first-degree relatives via phone. RESULTS: Totally, 50 patients were enrolled in this study. The mean age was 68.0 ± 14.1 years. Of them, 29 (58%) patients were male. Notably, the median (IQR) hospitalization time was 4.0 (2.7-6.2) days and the duration between the first symptoms to death was 10.0 (5.0-14.5) days. Also, pre-existing morbidity was reported in 42 (84%) patients, and hypertension was the most common one with 28 (54%) patients. Interestingly, body temperature more than 37.5°C was reported in only 20 (40%) patients. Nevertheless, neutrophilia (≥7109/L) and lymphopenia (<1.0 109/L) were observed in 27 (54%) and 29 (58%) patients, respectively. Also, elevated levels of creatinine, lactate dehydrogenase (LDH), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were common, which may be indicators of aggravation of the patients' status. CONCLUSION: Besides age and underlying diseases, elevated creatinine level, neutrophil count, and the inflammatory indices along with the reduced lymphocyte count can be considered as indicators of disease progression. Hence, they should be considered for admission and surveillance of patients.

Promoting Public Engagement during the COVID-19 Crisis: How Effective Is the Wuhan Local Government's Information Release?

During times of public crises (such as COVID-19), governments must act swiftly to release crisis information effectively and efficiently to the public. This paper provides a general overview of the way that the Wuhan local government use Weibo as a channel to engage with their citizens during the COVID-19 pandemic. Based on the media richness, dialogic loop, and a series of theoretically relevant factors, such as content type, text length, and information source, we try to examine how citizen engage with their local government. By analyzing the data mining samples from Wuhan Release, the official Sina Weibo account of Wuhan's local government, results show that, despite the unstable situation COVID-19 over the crisis, there exist three stages of a crisis on the whole. Combining the behavior of the government and the public, duration from 31 December 2019 to 19 January 2020 could be seen as the development period, then the outbreak period (30 January 2020 to 28 February 2020), and a grace period (29 February 2020 to19 April 2020). Public attention to different types of information changes over time, but curbing rumors has always been a priority. Media richness features partially influent citizen engagement. Text length is significantly positively associated with citizen engagement through government social media. However, posts containing information sources have a negative impact on citizen engagement.

COVID-19 disease-Temporal analyses of complete blood count parameters over course of illness, and relationship to patient demographics and management outcomes in survivors and non-survivors: A longitudinal descriptive cohort study.

BACKGROUND: Detailed temporal analyses of complete (full) blood count (CBC) parameters, their evolution and relationship to patient age, gender, co-morbidities and management outcomes in survivors and non-survivors with COVID-19 disease, could identify prognostic clinical biomarkers. METHODS: From 29 January 2020 until 28 March 2020, we performed a longitudinal cohort study of COVID-19 inpatients at the Italian National Institute for Infectious Diseases, Rome, Italy. 9 CBC parameters were studied as continuous variables [neutrophils, lymphocytes, monocytes, platelets, mean platelet volume, red blood cell count, haemoglobin concentration, mean red blood cell volume and red blood cell distribution width (RDW %)]. Model-based punctual estimates, as average of all patients' values, and differences between survivors and non-survivors, overall, and by co-morbidities, at specific times after symptoms, with relative 95% CI and P-values, were obtained by marginal prediction and ANOVA- style joint tests. All analyses were carried out by STATA 15 statistical package. MAIN FINDINGS: 379 COVID-19 patients [273 (72% were male; mean age was 61.67 (SD 15.60)] were enrolled and 1,805 measures per parameter were analysed. Neutrophils' counts were on average significantly higher in non-survivors than in survivors (P<0.001) and lymphocytes were on average higher in survivors (P<0.001). These differences were time dependent. Average platelets' counts (P<0.001) and median platelets' volume (P<0.001) were significantly different in survivors and non-survivors. The differences were time dependent and consistent with acute inflammation followed either by recovery or by death. Anaemia with anisocytosis was observed in the later phase of COVID-19 disease in non-survivors only. Mortality was significantly higher in patients with diabetes (OR = 3.28; 95%CI 1.51-7.13; p = 0.005), obesity (OR = 3.89; 95%CI 1.51-10.04; p = 0.010), chronic renal failure (OR = 9.23; 95%CI 3.49-24.36; p = 0.001), COPD (OR = 2.47; 95% IC 1.13-5.43; p = 0.033), cardiovascular diseases (OR = 4.46; 95%CI 2.25-8.86; p = 0.001), and those >60 years (OR = 4.21; 95%CI 1.82-9.77; p = 0.001). Age (OR = 2.59; 95%CI 1.04-6.45; p = 0.042), obesity (OR = 5.13; 95%CI 1.81-14.50; p = 0.002), renal chronic failure (OR = 5.20; 95%CI 1.80-14.97; p = 0.002) and cardiovascular diseases (OR 2.79; 95%CI 1.29-6.03; p = 0.009) were independently associated with poor clinical outcome at 30 days after symptoms' onset. INTERPRETATION: Increased neutrophil counts, reduced lymphocyte counts, increased median platelet volume and anaemia with anisocytosis, are poor prognostic indicators for COVID19, after adjusting for the confounding effect of obesity, chronic renal failure, COPD, cardiovascular diseases and age >60 years.

Clinical characteristics and outcomes of critically ill patients with COVID-19 admitted to an intensive care unit in London: A prospective observational cohort study.

BACKGROUND: Cohorts of severely ill patients with COVID-19 have been described in several countries around the globe, but to date there have been few published reports from the United Kingdom (UK). Understanding the characteristics of the affected population admitted to intensive care units (ICUs) in the UK is crucial to inform clinical decision making, research and planning for future waves of infection. METHODS: We conducted a prospective observational cohort study of all patients with COVID-19 admitted to a large UK ICU from March to May 2020 with follow-up to June 2020. Data were collected from health records using a standardised template. We used multivariable logistic regression to analyse the factors associated with ICU survival. RESULTS: Of the 156 patients included, 112 (72%) were male, 89 (57%) were overweight or obese, 68 (44%) were from ethnic minorities, and 89 (57%) were aged over 60 years of age. 136 (87%) received mechanical ventilation, 77 (57% of those intubated) were placed in the prone position and 95 (70% of those intubated) received neuromuscular blockade. 154 (99%) patients required cardiovascular support and 44 (28%) required renal replacement therapy. Of the 130 patients with completed ICU episodes, 38 (29%) died and 92 (71%) were discharged alive from ICU. In multivariable models, age (OR 1.13 [95% CI 1.07-1.21]), obesity (OR 3.06 [95% CI 1.16-8.74]), lowest P/F ratio on the first day of admission (OR 0.82 [95% CI 0.67-0.98]) and PaCO2 (OR 1.52 [95% CI 1.01-2.39]) were independently associated with ICU death. CONCLUSIONS: Age, obesity and severity of respiratory failure were key determinants of survival in this cohort. Multiorgan failure was prevalent. These findings are important for guiding future research and should be taken into consideration during future healthcare planning in the UK.

Corticosteroid use in COVID-19 patients: a systematic review and meta-analysis on clinical outcomes.

BACKGROUND: In the current SARS-CoV-2 pandemic, there has been worldwide debate on the use of corticosteroids in COVID-19. In the recent RECOVERY trial, evaluating the effect of dexamethasone, a reduced 28-day mortality in patients requiring oxygen therapy or mechanical ventilation was shown. Their results have led to considering amendments in guidelines or actually already recommending corticosteroids in COVID-19. However, the effectiveness and safety of corticosteroids still remain uncertain, and reliable data to further shed light on the benefit and harm are needed. OBJECTIVES: The aim of this systematic review and meta-analysis was to evaluate the effectiveness and safety of corticosteroids in COVID-19. METHODS: A systematic literature search of RCTS and observational studies on adult patients was performed across Medline/PubMed, Embase and Web of Science from December 1, 2019, until October 1, 2020, according to the PRISMA guidelines. Primary outcomes were short-term mortality and viral clearance (based on RT-PCR in respiratory specimens). Secondary outcomes were: need for mechanical ventilation, need for other oxygen therapy, length of hospital stay and secondary infections. RESULTS: Forty-four studies were included, covering 20.197 patients. In twenty-two studies, the effect of corticosteroid use on mortality was quantified. The overall pooled estimate (observational studies and RCTs) showed a significant reduced mortality in the corticosteroid group (OR 0.72 (95%CI 0.57-0.87). Furthermore, viral clearance time ranged from 10 to 29 days in the corticosteroid group and from 8 to 24 days in the standard of care group. Fourteen studies reported a positive effect of corticosteroids on need for and duration of mechanical ventilation. A trend toward more infections and antibiotic use was present. CONCLUSIONS: Our findings from both observational studies and RCTs confirm a beneficial effect of corticosteroids on short-term mortality and a reduction in need for mechanical ventilation. And although data in the studies were too sparse to draw any firm conclusions, there might be a signal of delayed viral clearance and an increase in secondary infections.

[Preliminary study of the antibody level in confirmed patients with COVID-19 after discharge].

Objective: To analyze the antibody levels and dynamic changes in patients infected with 2019-novel coronavirus(2019-nCoV). Methods: The average age of 72 corona virus disease 2019 (COVID-19) patients was (45.53±16.74)years(median age:47 year), including (44.88±17.09) years(median age:46 year) for 38 males and (46.32±16.52)years (median age:46 year) for 34 females in Loudi City, Hunan Province. There is no significant difference in genders between the severe and mild groups (χ²=0.916, P>0.05). There is a significant difference in the age between the severe and mild groups (F=3.315, P<0.05). The blood samples of 72 discharged patients were collected and the consistence of IgM and IgG antibodies were detected by chemiluminescence method. SPSS25.0 was used for gender, age, case type and antibody analysis of variance, χ2 test and other analysis. Results: The average time of the serum samples collection of 72 patients was (34.89±9.02)days (median time: 34 days) from onset of COVID-19, and (14.53±8.35) days (median time: 14 days) from discharge. The positive rate of IgM or IgG was 97.22% (70/72), and the positive rate of IgM and IgG was 48.61% (35/72) and 97.22% (70/72) respectively. Serum COVID-19 antibodies were detected in 72 patients from 1st to 40th days after discharge. The average concentration of IgM in 1-7 days, 8-14 days, 15-21 days, 22-28 days, above 29 days were 21.91(7.07-52.84)AU/ml, 14.16(6.19-32.88)AU/ml, 11.36(6.65-42.15)AU/ml, 8.15(3.66-30.12)AU/ml, 2.98(0.46-6.37)AU/ml. There was no significant difference in the time of IgM antibody concentration (H= 8.439, P>0.05). The average concentrations of IgG in 1-7 days, 8-14 days, 15-21 days, 22-28 days, 29 days and above were 169.90 (92.06-190.91) AU/ml, 163.89 (91.19-208.02) AU/ml, 173.31 (95.06-191.28) AU/ml, 122.84 (103.19-188.34) AU/ml, 101.98 (43.75-175.30) AU/ml, respectively, (H=2.232, P>0.05). The IgM becomes negative after the 3rd week of discharge and decreases rapidly with time. The IgG concentration higher than IgM during the same period, and keep at high level without any change, and decrease in the fourth week. Among them, 5 cases developed "re-infection" within 1-3 weeks after discharge, and the rate of "re-infection" was 6.94% (5/72 cases). Conclusions: After the COVID-19 patients are discharged from the hospital, the level of antibodies produced varies greatly among individuals, but the overall changes in antibodies have a certain pattern. It is recommended to strengthen the antibody monitoring during hospitalization and after discharge from the hospital to reduce the "re-infection" rate and potential risk of infection.

Media briefing on COVID-19 - 27/11/2020

00:00:20 MH Hello, everybody. This is Margaret Harris in WHO headquarters, Geneva welcoming you to our global press conference on COVID-19 today, Friday November 27th. We have with us in the room our WHO Director-General, Dr Tedros. We also have Dr Mike Ryan, Executive Director of our Emergencies Programme, Dr Maria Van Kerkhove, Technical Lead for COVID-19, and also Dr Hanan Balkhy, our Assistant Director General for Antimicrobial Resistance, and Dr Peter Ben Embarek, a scientist specialising in zoonosis and food safety, and we also have next to me here Dr Kate O'Brien, our Director of Immunisation, Vaccines and Biologicals. They will all be here to answer your questions so please think about your questions now and get them ready. As usual we are translating this simultaneously into the six official languages plus Portuguese and Hindi and we'll be posting the Director-General's remarks and an audio file of the press conference on the web as soon as possible. Transcripts will be available later. Now without further delay I will hand over to Dr Tedros to give us his opening remarks. Dr Tedros, you have the floor. 00:01:46 TAG Thank you, Margaret. Good morning, good afternoon and good evening. COVID-19 is an uneven pandemic. All countries have been affected but not all countries have been affected equally. 70% of cases and deaths are in just four countries and there are many countries all over the world that have shown COVID-19 can be controlled with existing tools. One of the things all these countries have in common is an emphasis on testing. Since the beginning of the pandemic WHO has emphasised the importance of testing and provided the tools for countries to do it. On 13th January in collaboration with the experts we work with we published the first instructions for producing tests, just two weeks after the first cases were reported. Since then we have shipped millions of tests and other diagnostic products all over the world and we have also worked with countries to increase testing capacity. For example at the start of the pandemic just two African countries had lab testing capacity for COVID-19. By the end of February 32 countries in Africa had testing capacity and now all countries can test for COVID-19. 00:03:17 But we continue to need more and better tests that are easy to use, cheap, reliable and fast so patients can be cared for and contacts can be traced. In September WHO published our target product profiles for diagnostics, which outline the features needed for new tests. Many manufacturers around the world have been working to develop these tests. Through the diagnostics pillar of the Access to COVID-19 Tools Accelerator WHO, FIND, the Global Fund and other partners are working together to evaluate more than 50 diagnostics including self-administered tests. Once these tests are validated and approved they can be incorporated into national strategies. In September WHO issued the first emergency use listing for an antigen-based rapid diagnostic test which can return a result in just 15 minutes, along with guidance on where best to use these rapid tests. Together with our partners we also announced an agreement to purchase 120 million of these tests for 68 low and middle-income countries in all regions of the world. We're now shipping these tests around the world. Last week WHO and FIND also launched a comprehensive training package for health workers on the use of rapid antigen tests. But nearly two months later we still face a funding gap of US$500 million to maximise the use of rapid tests. 00:05:14 As vaccines are rolled out testing will continue to play a vital role. Initially health workers, older people and other at-risk groups will be prioritised for vaccination. That will still leave the virus with a lot of room to move and testing will remain a vital tool for controlling the pandemic. If you don't know where the virus is you can't stop it. If you don't know who has the virus you can't isolate them, care for them or trace their contacts but testing must be strategic, in support of clear public health objectives. Everyone who needs a test should get a test. WHO's guidance outlines how countries can test strategically based on their transmission scenario. It's also important to remember that although testing is vital it's only part of the strategy. Testing is the spotlight that shows where the virus is. Investments in testing must be matched by investments in isolation facilities, clinical care, protecting health workers, contact tracing, cluster investigation and supported quarantine. 00:06:39 WHO is continuing to support countries in different transmission scenarios to use testing strategically to bring outbreaks under control. Finally this week WHO published new guidelines on physical activity and sedentary behaviour. Physically activity is essential for physical and mental health throughout life but one in four adults and four in five adolescents don't get enough physical activity. The new guidelines recommend between 150 and 300 minutes of moderate to vigorous activity per week for all adults and an average of 60 minutes per day for children and adolescents. COVID-19 has resulted in restrictions of many types but everyone can remain active whether that's doing a work-out at home or going out for a walk, a run or a ride. It's one way all of us can add years to life and life to years. Every move counts. I thank you. MH Thank you very much, Dr Tedros. I will now open the floor to questions. I should let you know that I omitted to mention that we also have joining us remotely Dr Mariangela Simao, our Assistant Director-General for Access to Medicines and Health Technologies, Dr Bruce Aylward, Senior Advisor to the Director-General, who leads on the ACT Accelerator, and Dr Soumya Swaminathan, our Chief Scientist so once again remember you have a wealth of expertise here to answer your questions. 00:08:30 It will be an hour so if I do not get to everybody I apologise in advance. We will start the questions with Simon Ateba from Today News Africa. Simon, please unmute yourself and go ahead. SI Thank you, Margaret, for taking my question. This is Simon Ateba from Today News Africa in Washington DC. Pfizer has applied for emergency use of its COVID-19 vaccine from the FDA here in the USA and is likely to be approved soon but the Pfizer vaccine has to be kept at -70 degrees Celsius and needs special storage requirements not found in many hospitals even here in the USA. With Africa having other problems such as lack of constant electricity in many hospitals what needs to be done between now and then for the Pfizer vaccine to be shipped to African countries or is it even realistic to distribute that vaccine in countries such as Nigeria where there's never been constant electricity in the past 50 years? Thank you. 00:09:48 MH Thank you, Simon. Dr Kate O'Brien will answer first and maybe others will join. KOB Thanks for that question. The Pfizer vaccine, as you indicated, does require what we refer to as an ultra-cold chain so very cold temperatures and we do have one other vaccine that has required that degree of very cold temperature and that's the Merck Ebola vaccine so we do have experience in a number of countries, specifically in Africa, being able to deploy a vaccine with that ultra-cold chain requirement. It has not been deployed across every country in the world of course so as we anticipate the use of the Pfizer vaccine the intention is certainly to be able to use it along with other vaccines because no one vaccine is going to have adequate supply nor will any one vaccine necessarily have suitable operational characteristics to meet all of the needs. But specifically on the Pfizer vaccine, Pfizer has developed a special shipper for the vaccines and even without the use of in-country ultra-cold chain freezers that shipper can actually maintain the temperature of the vaccine for a substantial number of days, in the range of ten to 15 depending on how often you open the box. 00:11:14 Furthermore the Pfizer vaccine can be maintained at refrigerated temperatures for five days prior to the final use of the vaccine. In addition to that we do have technology that can help with the delivery of ultra-cold chain. There are portable freezers referred to as Arctech [?] and other products that don't require electricity and that can maintain the temperature of the vaccine at this -70 degrees for a period of days. Finally with the use of dry ice there are ways that we can maintain vaccines at this low temperature but you do make a very important point which is this is not a strategy that's in place already in countries including high-income countries so every country is going to have to work very hard and is going to have to innovate around systems to actually deliver vaccines that do have an ultra-cold chain. Part of the approach that many countries may take is to choose to use vaccines that require an ultra-cold chain for only certain portions of the population that need to be vaccinated; for example using that vaccine among healthcare workers where facilities might be the place where immunisation would take place and therefore installation of a -70 freezer would be more simple, recognising also the need that you described for electricity to be maintained in those facilities. 00:12:53 So I think the main message is that we do have technology, there is demonstrated experience of delivering ultra-cold chain vaccines even in some of the most difficult and remote areas but that has also taken enormous resources to do that. So what we need is a variety of vaccines that have different characteristics and, as you know, in the past several weeks have been through press release, the release of efficacy data on other vaccines that are either kept at -20 or at refrigerated temperatures, which will certainly ease the distribution and use of vaccines so I hope that answers your question. MH Thank you. I'm looking in the room to see if there's anyone else who wants to add anything. I think not. Do we have anyone on the line who would like to add? No so we'll go to the next question which is from Helen Branswell. Helen, could you unmute yourself and ask your question. 00:13:55 HB Hi, thanks for taking my question. Hello to you all. Can I ask about vaccines and herd immunity? [Unclear] get a sense of how efficacious these vaccines could be, are we able to calculate how many people in a population would need to be vaccinated to get to herd immunity? Is it something that is achievable at this point? KOB Another great question. The concept of herd immunity of course is the idea that there can be people who have the appearance of immunity, in other words are protected against disease, but themselves are not actually vaccinated and the way that that happens is that at some point the number of people around them in the community are themselves immune and as a result the non-immune people are protected because the virus or the pathogen simply has very limited ability to move around in the community so just for those who maybe aren't familiar with what herd immunity is I'll just clarify that. 00:15:11 Helen, the point about herd immunity is really what is the performance and the ability of the vaccines or frankly natural infection to protect against future infection and therefore acquisition and transmission to somebody else. What we really need to know is what the vaccines are being developed, each of them; what their ability is to interrupt the acquisition of infection but it's not the only way that herd immunity can be achieved. We do want to know about whether there's a reduction in people getting infected in their nose, in their respiratory tract even without getting disease; but also do the vaccines change the amount of time that you're actually infected, does it change the density of the infection and does it change the transmissibility to another person? Those are all really important characteristics. We don't know the proportion of the population that would need to be immunised because we haven't observed that yet but the answer to that can come from modelling studies that tell us under certain conditions what proportion of the population would need to be immunised. A number of those modelling studies have been done and under a variety of conditions have concluded that somewhere around 60 to 70% of the population would need to be immune - presumably through immunisation - in order to achieve a reduction or an interruption in transmission of the virus. 00:16:52 That's of course predicated on what the performance of the vaccine would be so it's really important that we start to get more information about what the vaccines do not just for preventing disease but for actually preventing the acquisition of the virus, an infection and the characteristics of that infection. MR Thanks, Kate; really clear. Just maybe to add that we also need to continue our understanding of the transmission dynamics of the virus because it clearly does not spread through a community in a common linear way and herd immunity concepts are built around that idea, that the disease spreads evenly through the community and that everyone's absolute risk of being infected is about the same. Then if you have lots of protected people surrounding those who are unprotected then effectively there's a barrier, there's a firewall around someone who's not vaccinated, a firewall of vaccinated people and therefore you can achieve control and eradication sometimes without vaccinating everybody. That's the principle, I think, of herd immunity. 00:18:05 But what we've seen with this virus is - I won't define it as cleverness but the virus is very opportunistic and we've seen that the virus can spread in particular circumstances. We've seen in many clusters that only 20% of the cases go on to transmit to others, 80% don't transmit to anybody else. We've seen super-spreading events, certain contexts and certain groups who mix and the disease can explode. So it may be that it will take some very clever vaccination strategies to highly target people in our society who are more likely to carry, transmit and super-spread with this virus. So just using an absolute number, Helen, may not be the best way. I think we'll need some numbers to guide us in terms of policy but I think we'll need to be much more surgical and precise in exactly who we target for vaccination. It may be much more important to target certain sections of the community than it will be necessarily to target some others who may not be participating in transmission as much. So I think the answers will come based on what Kate has said but we also, I think, need to remain vigilant. As long as there's a potential for super-spreading events there's always the chance that a very small incidence can lead to a large cluster of cases even in the context of high levels of vaccination. 00:19:27 I think we will need to be very, very careful to make sure we send the right messages to people. Vaccination will have a major impact on mortality, we hope. We hope it will have a very major impact on transmission and control but I don't think anyone can promise eradication of this virus until we understand much more about the vaccine and much more about how the vaccines work in the real world and until we understand much more about the details of transmission of this virus. KOB That's such a great point, Mike. I just want to give an example to bring it to life a little bit. Last year in 2019 we had a terrible years of measles outbreaks around the world and many of those outbreaks were happening in countries that had very high measles vaccine coverage but it wasn't the whole country's coverage that was important; it was about the sub-communities, the subnational coverage. 00:20:24 So you absolutely can have lower vaccine coverage in a community that is a big enough community where a virus can spread so I think Mike's made a really good point, that we shouldn't be anchoring on a hypothetical number from modelling that somehow is going to be the whole country's coverage but it's really about where is the virus at any given time and how much of a firewall is there for the virus in that community at that time when there are infectious people in the community. I hope that gives an example of what Mike was trying to explain. MH Thank you, Dr O'Brien. I think Dr Soumya Swaminathan would like to add something as well. SS I wanted to make a very quick point, Helen, because we were talking about vaccines with over 90% efficacy here. That's what we've seen from a couple of the early results. Just to point out that MRNA vaccines are particularly good at stimulating innate immunity and so what you see in the short term - we've only got data for two months of follow-up - could be the effect of a non-specific innate immune response plus specific immunity. So while we hope that these vaccines do have over 90% efficacy it would be wise to wait a little bit to look at the follow-up results from people in this trial and that's why it's so important that the trials are continued, that they continue as placebo-controlled, double-blinded trials as long as possible, as long as it's ethically and practically feasible to do that because there are a lot of questions that we still need to understand particularly, as I said, about duration of protection, about the impact on severe illness and on transmission of infection and about the efficacy in different sub-populations including the older-age adults. 00:22:29 Just something to keep in mind especially when we see these very, very high efficacy read-outs is that we do need data over longer periods of time to make sure that those are actually the long-term protective effects. I just wanted to say that in addition to what's been said by Mike and Kate. Thanks. MH Thank you, Dr Swaminathan. Our next question comes from Jamil Chaid from Brazilian media. Jamil, unmute yourself please and ask your question. JA Thank you, Margaret. Thank you for taking my question. This is a question to Dr Ryan. Could you tell us a little bit of the scenario for Brazil at this current stage? Can we talk about a second wave already in terms of Brazil or has the first wave never ended for us to be calling it a second wave? What lessons from Europe could Brazil learn in this potential second wave? Thank you. 00:23:46 TAG Yes, I think there are lessons there for all of Central and South America. Most of Central and South America went through a very tough time in terms of cases and deaths and the numbers have progressively fallen in most countries over a couple of months but now we see the prospect of numbers increasing again. I think there are lessons to be learned from North America, lessons to be learned from Europe. I think what we've seen is where countries have taken decisive action to try and reduce community transmission they've managed to turn that curve around but that's taken quite a deal of co-operation from people in terms of understanding the need to do more physical distance and to really focus on mask-wearing, to focus on hygiene and in some cases to accept restrictions; restrictions of movement and so-called lock-downs. That's a very difficult thing to enact, particularly in highly populated areas where many people are dependent on going to work and on day salaries, where poverty is an issue and it's very hard to expect people to give up their only access to socio-economic gain by staying home. 00:25:02 So I think the lessons we're seeing now in Europe certainly is countries that act early and act decisively get a benefit and that the transmission turns around relatively quickly once you're able to make a community-based intervention and particularly when the community come on board with that. We've seen a significant shift in behaviour in countries towards people really working not only on avoiding transmission in large settings or in the public environment but really looking at transmission in the household and trying to reduce the risk of secondary transmission at home, which has become a major factor in Europe and in North America for transmission; focusing on protecting yourself and protecting others, that individual education, individual knowledge transfer and getting that clear and consistent messaging out. I think Europe this time around has done a much better job in having consistent processes across all of - let's look at the European Union; the member states of the European Union have aligned better on the types of measures, they've looked the same in how they've approached things much, much more. 00:26:18 There's been a consistency in that messaging and if you see the European Union as a federation of states and you look at a very large country like Brazil or other large federated states that ability to negotiate with and reach consensus with subnational entities and find consensus on how to move forward together so that populations get clear and consistent messaging, clear decisions on public health action, clear decision on mandates that are to be implemented by government; I think that's what we've seen. We've also seen previously for example, the Brazilian health service reacted wonderfully to the last surge in cases and certainly so many brave front-line health workers in Brazil but they were pushed to the very limits of their capacities both in terms of equipment and their own fatigue. Therefore it's going to be very important as numbers increase that they are protected, that the health system is protected from a large surge of cases. You cannot assume that a health system can take the same beating a second time around and what we have seen too as case fatality rates have dropped in every age group is higher recovery rates for all age groups over the summer. 00:27:38 That's been very much down to doctors and nurses having more time with patients, having more time to give clinical care. If we get back to a situation where intensive care units are overwhelmed we will see the death rates rise again unnecessarily so all of the things we've said before; what we need now is to do it quicker, to do it more consistently in a more co-ordinated way because we've learned what works. There is an excuse the first time around; we're all learning, we're all adapting, we're all testing what our populations will accept or won't accept. A second time around you need to have done that learning and understand how to do better this time. I think countries in Europe have really tried to look at how they can improve what they are doing and I think they have improved this time around and hopefully there are lessons there and learnings there for countries who may now be entering a second surge or a second phase. Maria. 00:28:37 MK Yes, I'd like to add to what Mike has said there. As he said, there're a lot of lessons to learn. I think one of the messages we need to continue to say is even as case numbers are coming down all countries need to remain vigilant. You've heard us say this before but we really need to emphasise this again; do not let your guard down. It is good to see the measures taking effect and transmission going down but it is not time to let up and it's time to even scale up. In situations where you're bringing this under control it is time to scale up your public health infrastructure still; work on making sure that you have adequate workforce to do active case finding, to conduct those tests, to use those tests strategically, as you've heard us say many times and the Director-General emphasise again today; to work to have your health systems be ready for any potential resurgence. That includes making sure you have ample hospital beds, ICU beds, supplies, PPE for your staff. It is still time to scale up. I know that probably sounds like it doesn't make sense; the case numbers are going down, why do I need to scape up? It's just using the time appropriately to prepare and to revise. As Mike has said, we're learning and so you can tailor your approach to be more agile, to where it's needed and need those resources best if you have any resurgence and be very quick and decisive when there is a resurgence. 00:30:13 So the earlier action you have, if you have that resurgence, the quicker you can prevent cases becoming clusters and clusters turning into community transmission. But what we don't want to see is situations where you're moving from a so-called lock-down state to bringing the virus under control to moving to a so-called lock-down state. It's really important at that time when transmission is brought under control that we don't give up, we don't let our guard down. We still need to ensure that everyone remains vigilant, everybody knows that this is not yet over. We're working towards bringing this over altogether but we still need to think about what we do every day, we still need to take a risk-based approach throughout the actions that we have every day until this pandemic is over. 00:31:03 I think that we just need to make sure that we just don't let up and I think that's something that we have to hammer in because there is no reason to have a second surge, there is no reason to have another wave or another surge. It is within our power to be able to keep transmission low and we've seen dozens of countries show us that it can be brought under control and it can stay under control. MH Thank you very much, Dr Ryan and Dr Van Kerkhove. The next question goes to Bayram from Anadolu. Bayram, can you unmute yourself and please ask your question. BA Thank you, Margaret, for taking my question. According to certain sewage samples in Marseilles, France, it seems cases of COVID-19 already started to die [?] before France put the country into lock-down, which could mean that the lock-down was not really efficient. Some specialists even said getting people confined in close settings at home increased the cases after the start of lock-downs and that is also visible in sewage samples. Do you have any comment on that? Thank you so much. 00:32:20 MH Your question was about whether or not lock-downs work and do they exacerbate transmission by confining people. Is that correct, Bayram? BA It is correct, yes. MK Thanks for that question. It's a very important one because if people are asked to stay at home and there are stay-at-home orders and there is virus circulating in the community if there is somebody who is infected and they're put in the home there's the possibility that the virus can transmit within the home. That's why one measure alone is not enough. We need to make sure that in addition to any measures that are put in place we still are conducting strategic testing for any cases who are suspect cases; they receive a test and then the public health actions are followed. So if a case is identified make sure that they are isolated in a medical facility and all cases need to be isolated in a medical facility or at home away from others. 00:33:18 In the situation where people are going home all at once we need to make sure that if we're feeling unwell we stay away from others in our home, we wear a mask in the home and others in the home wear masks, especially people who are feeling unwell. But there is a risk that by putting people all at home you can put the virus there and it can spread but again we need to make sure that these confinement measures or these stay-at-home measures are not used in isolation. They have to be used with other measures as well. The stay-at-home measures do take the heat out of transmission in some respects in terms of transmission in the community but it is possible that it brings it home so you have to take the precautions at home as well. MH Thank you very much, Dr Van Kerkhove. The next question is from Shane Ju from CCTV. Shane, could you unmute yourself and please go ahead. SH Okay. Thank you, Margaret. My question is for Dr Ryan. It's a follow-up question about his comments last time on the virus origin. Dr Ryan, as you mentioned during the previous briefing there is increasingly more and more evidence of the existence of this virus in other species and in waste water or patients around the world. 00:34:32 You also mentioned some cases were not directly linked to Wuhan seafood market in the first [?] outbreak and... not sure yet where the first case of breaching the species barrier... and maybe the market was only the place for amplification. There is also new evidence, they say, suggesting that the virus existed long before the outbreak in Wuhan. For example the Italian researchers found the virus in samples from last September. Does that mean that the case zero or several cases zero could be outside of Wuhan, outside of China and is there a possibility that the virus already circulated in humans outside of China before the outbreak in Wuhan but without being noticed? Thank you. MR Thank you. Yes, I think we need to be careful with our speculation here. There are lots of different observations that have occurred around the world but the idea that humans can infect minks and minks can infect humans is very clear but there's no evidence that mammals in a European environment were the source of this disease originally for humans or outside China. 00:35:44 The issue for us and from our perspective - and again Dr Tedros, myself and others have been clear on this from the beginning and this is why we sent an advance team to China; this is why we've been discussing this issue since February, since the first research and development roadmap where the animal origins studies were seen as a top priority; this is why the World Health Assembly discussed this and issued a World Health Assembly resolution 73.1 identifying the origin studies as a very important issue, which was consensus between all member states. This is why we sent an advance team to China, to look at the issues and negotiate on the best possible way to move forward with studies. We identified in the terms of reference two phases of studies. Phase-one studies really identify many of the questions you've laid out there or laid out within the phase-one studies that we've agreed with our Chinese colleagues. We've had a high level of engagement with those colleagues at a virtual level. Peter Ben Embarek is here and I've asked Peter to give you an update on the nature of those discussions but it is clear from a public health perspective that you start your investigations where the human cases first emerged. 00:37:00 In that regard and the first cluster of cases - and again the astute clinicians in Wuhan picked up a cluster of unusual, atypical pneumonia and to an extent probably because there was an association in time and a geographic association with the market it triggered in their minds a suspicion and they reported that disease to the appropriate authorities and then there was a subsequent investigation. So from that perspective that was the event which triggered the response and the investigation and that's very important and the physicians and others and the people involved in that initial detection deserve credit. The question then is what was the original origin of the virus and nobody has that answer and that is what the phase-one studies were to be about and are about and there's a series of phase-two follow-up studies planned once we have the answers to those questions. 00:38:01 So we believe we need to make progress on those studies and understand what our Chinese colleagues have investigated, the results of those investigations and we are working with them to send a team to the ground to both review the results of the phase-one trials and look at other studies that may need to be done. After that the evidence should take us where we need to go but to speculate on where the virus emerged precisely without starting where the human disease emerged for us doesn't represent the best way forward. However at the same time we are working with scientists all over the world, we are open, we receive information. There are publications being made almost every week on animal studies and we will continue to track that and we will take every detection in France, in Spain, in Italy very seriously and we will examine each and every one of them. We have taken action directly with researchers - Maria may speak to that and how we've engaged with researchers who've published unusual results from other countries to try and validate those results as well. 00:39:09 So I think it's highly speculative for us to say that the disease did not emerge in China. What we do know is the first clusters of human cases that were detected were in Wuhan in China. There was a massive response to contain that disease there and we look forward to working with our Chinese scientific colleagues to understand better the origins of the virus within China or beyond China, wherever that leads. Peter. PBE Yes, as you said, the international team has started to work with their counterparts in China updating each other in existing and past studies and ongoing studies and we are starting now to discuss the famous phase-one studies, the studies that need to be conducted in and around Wuhan to look at what happened back in late 2019. We need to push back our understanding of what happened before the detection of the initial cases. We have to make the link between that event and the original animal that was the source of this virus. We know that the virus belongs to a group of viruses that have their natural niche in bats, in certain families of bats but between bats and the event in Wuhan we have a big gap and that's the purpose of all theses studies, to fill that gap and understand what happened between these two events and where it happened. 00:40:52 But for the time being we have to start where we have the first solid clues and these are the first detected human cases in Wuhan in late 2019. MK Thanks. Just a couple of comments to add on to what Mike and Peter have said. There is some additional work that is ongoing as well looking at some waste water studies. Some countries have looked at retrospective samples of waste water. There was a study that hasn't been published that had one sample, that they found RNA but that hasn't published. There are other studies that found RNA in December in Europe, in Italy. There's one study that was published very recently, a serologic study, seroassay study looking at some samples from Italy from a cancer screening institute in the fall. They found seropositive samples in December using an Eliza test and in October using microneutralisation. We have reached out to these researchers and they have generously offered to work with us and to collaborate with us on some further studies looking at those samples, just making sure that we can do some further studies with samples from that cancer institute. 00:42:14 In addition to that there are a lot of analyses that are ongoing looking at genetic sequences so as you know there are more than 200,000 full-genome sequences that have been made available. This is an incredible global collaboration of researchers all over the world. We still need more so please continue to share those sequences. Then there are phylogenetic analyses and there are really incredible scientists that are looking at these to look at how this helps shape our understanding of this virus and the way that this virus moves. So there are a lot of sources of information but as Mike and Peter have pointed out studies need to begin where the first cases were detected, in Wuhan where those first cases were detected in December and then we follow the science wherever the science leads us in terms of further investigations and studies that need to be undertaken. 00:43:07 But there's a wonderful global collaboration that is ongoing and these studies will be conducted. MH Thank you, Dr Van Kerkhove. One more. Sorry, Dr Tedros. TAG On the study of the origin of the virus one thing that has to be clear is the study will start from Wuhan in China, where the first report came from and then from there based on the findings we can go anywhere so I think it's better to really underline that. Thank you. MH Thank you, Dr Tedros. The next question goes to Stephanie Nebahe from Reuters. Stephanie, please unmute yourself and go ahead. ST Thank you. Thanks for taking my question. I wondered if either Kate O'Brien or Dr Soumya would like to comment on the AstraZeneca results and the idea of needing further... a new trial in effect to check the findings of the lower dosage, the efficacy of the lower dosage, that first part. I wondered if you think that is necessary and whether the current results are reliable enough to give regulators a full picture. Thank you. KOB I can start and then pass over to Soumya. I think the first thing to say is what we've seen is a press release and what is really the next most important step is that the data really needs to be evaluated based on more than a press release. First of all there's only a limited amount that can be said in a press release and secondly it really needs to be reviewed in terms of the data and questions asked about the data that may come up in the course of the review so it's difficult to weigh in on this. 00:45:29 I think what we can emphasise though is that from what we understand about the press release there is certainly something interesting that has been observed but there are many reasons that could underlie the differences that were observed. So certainly more information is needed and that includes evaluations of the immune response in the trial as well. So I think it's too early for us to say anything about what we make of the data and what is needed next. What we really need to see is more than a press release; to really see the data and have a chance to ask the questions that are needed. I'll pass it over to Soumya. SS Thanks, Kate. Just to add to that, again what we know is what we've seen from the press release and it appears that fewer than 3,000 people were given the schedule with the half dose followed by the full dose of the vaccine and we also understand that those people were all under 55 so they didn't have anyone over 55 in that group. 00:46:44 Whereas the other group of about 8,000-plus people who were given the full dose and the full dose; there were larger numbers and it also included different age groups so it's very hard to compare these two groups and I would say the numbers are still small to really come to any definitive conclusions. Of course the advantage of using a smaller dose, particularly if you're getting a higher efficacy, is great as you can save on the vaccine and at the same time you're benefiting from higher efficacy. But I think it would be speculation at this point and we've heard from AstraZeneca that they would like to do a full trial of this schedule because the other trials that are ongoing now are the two full doses. So if we are to explore this hypothesis of having perhaps a better efficacy with a lower dose then it would need a trial. The last point I'd make is that this is the reason that WHO actually convened experts very early on in the pandemic to really start thinking about what should be the benchmarks, the target product profiles for a good vaccine and also thinking about what would be a good trial design really to answer the questions around efficacy and prevention of severe disease and prevention of infection as a secondary endpoint. 00:48:13 We worked with statisticians, with experts to really come up wit what a trial design would look like and I must say that it's been very encouraging to see that many of the manufacturers and developers have actually published their protocols so you can see exactly how they're going to do it, what they're going to do, at what steps they're going to do the interim analysis, when they're going to unblind the data and what the primary and secondary endpoints are both for efficacy and safety. So I think that transparency and sharing is extremely important for scientists to evaluate, to compare also between different vaccines because let's not forget, we have dozens of vaccines in the pipeline and we are going to be in a situation where we might have a variety of different vaccines with a variety of different results and people are going to have to make decisions and choices. 00:49:13 So it's really good to have apples to compare with apples and therefore for all trialists - and perhaps this is a plea to those who haven't yet published their protocols and made them available. It's easy for the regulatory agencies as well. It's good for organisations like the WHO that have to make decisions based on comparisons and it's good for citizens also in that it generally builds a trust in the process of vaccine development. Thank you. MH Thank you, Dr Swaminathan and Dr O'Brien. The next question goes to Shoko from NHK. Shoko, can you unmute yourself and ask your question. SH Hello, Margaret. Can you hear me? MH Very well. Please go ahead. SH Thank you for taking my question. Dr Tedros just mentioned the study of the origin of the virus will start in China but is the international mission going into the field in Wuhan? Thank you. TAG Yes, that's correct. It will travel to Wuhan. Thank you. MH Thank you. That was an easy question. The next question goes to Musa from Al-Mayadin TV. Musa, please unmute yourself, go ahead and ask your question. 00:50:47 MU Are you listening? MH Very well. Please go ahead. MU My question is in Arabic, please. TR The question is for the Director-General. You always ask for vaccines to be spread out fairly, to be distributed fairly. Are you asking for help for poor countries from rich countries or from industries that produce the vaccines? Is the WHO able to offer all or part of these vaccines freely to poor countries? A question for Ms O'Brien; what about the Russian vaccine compared with other vaccines? Do you have any data on the Russian vaccine? Thank you very much. MH Thank you. Yes, this sounds like a question. The first question's about COVAX really, about distribution of vaccines and the second one is specifically for Dr O'Brien. Dr Aylward, are you online? If not we can start with Dr O'Brien and then move over to Dr Aylward. How about that? Dr Mariangela Simao will be able to speak to that as well, I think. We'll start with Dr O'Brien. 00:52:12 KOB Thank you. I'll start with some comments on the fair allocation of vaccines. There is, as I think people are aware... WHO has through the ACT Accelerator and the COVID vaccine component of the ACT Accelerator... and is a partner in the COVAX facility which is the global mechanism for all countries around the world to aggregate demand and the financing for vaccines and to assure that there is fair and equitable access through the WHO fair and equitable access mechanism, which can be then applied to those vaccines that are procured through the COVAX facility. That facility has a component of the facility for the 92 countries that will be supported for the procurement of vaccine and it also includes a part of the facility where countries who are wealthier countries would themselves pay for vaccines that are procured through the facility. So there is a mechanism for all countries to have fair and equitable access and for those countries that are not able to themselves afford vaccines to be supported to do that. That support is coming from overseas official development assistance and from contributions from other sources and there is of course a relationship for entering into contracts with manufacturers and those discussions with manufacturers are well underway for the facility with a number of agreements made already and others that are fully being developed at this point. 00:54:09 Perhaps Mariangela would like to say a little bit more about the allocation. We have developed an allocation mechanism that Who has led and that really is about allocating vaccine in a fair and equitable way across all of the countries. For the first 20% all countries would receive vaccine in an equal rate and following that for vaccines beyond the 20% of the population, for countries that want to go beyond that level there may be consideration if we're still in supply shortage about... The pace that countries would get vaccines would account for vulnerability and the threat of COVID but I'm sure Mariangela may want to say more about that. On the issue of the Russian vaccine, the Gamelaya vaccine, again we've had a press release from the Gamelaya vaccine in the past several days, reporting very high efficacy from this viral vector vaccine. This is also very welcome news along with the other three manufacturers that have reported efficacy data but I want to emphasise again what we emphasised before. 00:55:29 These are data that have been reported through press releases and what is really important and critical at this point is for those data to be reviewed by regulators and reviewed at WHO also for policy reasons and for regulatory reasons, for WHO pre-qualification or emergency use listing and for those data to be in the public domain through the usual mechanisms that are used, which is through the peer-reviewed publication process. So we're really eager to see the results of all of the reports and of any vaccine that is able to report results from phase-three clinical trials on the prevention of disease. I don't know if Bruce is on the line or if Mariangela would like to join in or Soumya. Thank you. MH Dr Mariangela's on the line, I believe, so over to you. MS Thank you and thank you, Kate, for a very... I almost have nothing else to add except on the allocation because I think Dr O'Brien has explained quite well. But I would like to add regrading the vaccines, the Russian vaccine and... because - have mentioned in weeks before - WHO has issued an expression of interest to assess for emergency use listing candidate vaccines in phase 2B and phase three and this expression is still open. 00:57:03 There are several of the advance candidates in phase three that have expressed interest and are in discussions with WHO, exchanging information. As Dr O'Brien has mentioned, we still have to see not only the clinical data but also the good manufacturing practices data that are part of when a country does an emergency use authorisation or WHO does an emergency use listing. It's based on a series of important information, non-clinical, clinical and referring to manufacturing practices. This is work ongoing and I think Dr O'Brien has explained quite well the allocation. Thank you, Kate. MH Thank you very much. Dr Tedros has something to add. TAG Yes, thank you. With regard to vaccines, when we started the ACT Accelerator we had two objectives. The first one is accelerating or speeding up development of products and the second objective fair distribution. 00:58:15 Based on that we have been working and now there are three critical elements for the success of the ACT A; one, finance and I think we have said it many times. We need US$4.5 billion immediately. Second it's political commitment. Probably you have followed the G20 summit and the UN General Assembly. Many countries are committing to use vaccines for COVID as global public good, meaning to share it fairly so the political commitment is important. We have it now, of course a pledge but that has to be translated into action because we're going to have the vaccines now so the political commitment will be real when we see it in action; that's second. Third, we have to prepare countries for vaccination and strengthening the infrastructure will be important. As one of the journalists asked, some of the vaccines need -70 degrees centigrade refrigeration so we may have those vaccines; we may have other vaccines that could be refrigerated between two and eight degrees. 00:59:42 But we have to prepare the system for any eventualities or the infrastructure of countries and that's why we have co-signed a letter with the World Bank, UNICEF and the Global Fund to our country offices to prepare and support countries for vaccination. These are the critical issues; finance, political commitment that can be translated into action and preparing the infrastructure. This will result in sharing. Sharing of the vaccines fairly means faster recovery for the world. This is in the interests of each and every country. It's only together that we can recover faster. It's through sharing that we can recover faster and it's only through sharing that we can take care of lives and livelihoods. Thank you. MR I'd add one thing, something, Dr Tedros, I think we should say because in my experience in emergency response and in other infectious diseases in situations like this we tend to be unfair first, inequitous [sic] and then eventually the glaring gap is so big and with activists from community level and others the world has to turn around and find a way to be fair. 01:01:17 In my professional experience this is the first time that fairness and equity were built into this project from day one and that was under the leadership of Dr Tedros and other leaders who came together and implemented by people like Dr Mariangela and others and a wonderful team. But that would not have happened unless someone had stood and said, no, this will be done but it will be done with fairness and equity as its central tenet. In my view that has then created and driven one of the most effective public/private partnerships in the history of science when you think about where we were ten months ago and we're not there yet. As Soumya says, we're at the base camp and we have to climb the mountain. But the very fact that we have the opportunity to climb that mountain and bring everyone with us is incredible and we thank you for your leadership, Dr Tedros, and for the way in which you've reached out to partners all over the world to deliver this. In addition, as someone who works in humanitarian response, this is definitely the first time, in addition to that fair distribution, that there's a specific allocation of 5% for the humanitarian situations in which we may not be able to access people through normal programmes. 01:02:26 That has never happened before because it is the refugees and the displaced of the world who are the most forgotten and it is just wonderful for me as someone who works in the humanitarian space and I thank you on behalf of all of those people we serve for that being at the forefront of the decision-making in that regard. So thank you, Dr Tedros, for your leadership. MH Thank you. On that note this is the moment to close the press conference. I think a very, very important point has been made here. I would like to thank everybody. Those who did not get questions, please contact us via media enquiries and we will of course post all the audio file, the transcript and everything else on the web as soon as possible. I'll now just hand back to Dr Tedros to say goodbye. MH Thank you, Margaret. In my statement earlier I said COVID-19 is an uneven pandemic and 70% of cases and deaths are in just four countries but I would like to correct this and I would like to thank Kai for keeping us on our toes. What I should have said is that almost half of all cases and deaths are in just four countries and almost 70% of cases and deaths are in the top ten countries so apologies for the error. I'm really sorry for any confusion we caused but thank you, Kai, for keeping us on our toes. Thank you and I would like to also thank all our colleagues here, starting with our interpreters and also to the media who have joined today. Thank you so much and see you in our upcoming presser. Thank you. 01:04:29

Media briefing on COVID-19 - 23/11/2020

00:00:18 MH Hello, everybody. This is Margaret Harris at WHO headquarters, Geneva, welcoming you to our global press conference on COVID-19 today, Monday November 23rd. We have with us as always in the room the WHO Director-General, Dr Tedros, Dr Mike Ryan, Executive Director of our Emergencies Programme, and Dr Maria Van Kerkhove, our Technical Lead for COVID-19. We will also be joined remotely by a number of people including some special guests whom Dr Tedros will introduce. On the line to answer your questions will be Dr Mariangela Simao, our Assistant Director-General for Access to Medicines and Health Technologies, Dr Bruce Aylward, Senior Advisor to the Director-General, who leads on the ACT Accelerator, and Dr Soumya Swaminathan, our Chief Scientist. As usual we are translating this simultaneously into the six official UN languages plus Portuguese and Hindi. We will be posting the Director-General's remarks and an audio file of the press conference on the web as soon as possible and transcripts will also be available later. Now without further delay I will hand over to Dr Tedros to give us his opening remarks. Dr Tedros, you have the floor. 00:01:33 TAG Thank you. Thank you, Margareta, and welcome. I would also like to use this opportunity to thank Fadela, who has been moderating until today. Good morning, good afternoon and good evening. With the latest positive news from vaccine trials the light at the end of this long, dark tunnel is growing brighter. There is now real hope that vaccines in combination with other tried and tested public health measures will help to end the pandemic. The significance of this scientific achievement cannot be overstated. No vaccines in history have been developed as rapidly as this. The scientific community has set a new standard for vaccine development. Now the international community must set a new standard for access. The urgency with which vaccines have been developed must be matched by the same urgency to distribute them fairly. Every government rightly wants to do everything it can to protect its people but there is now a real risk that the poorest and most vulnerable people will be trampled in the stampede for vaccines. That's why in April with support from multiple partners WHO established the Access to COVID-19 Tools Accelerator. The ACT Accelerator has supported the fastest, most co-ordinated and successful global effort in history to develop vaccines, diagnostics and therapeutics. More than 50 diagnostic tests are being evaluated and new rapid antigen diagnostics are being made available for low and middle-income countries. Life-saving dexamethasone treatments are being rolled out and new medicines including monoclonal antibodies are being tested. 187 countries are now participating in the COVAX facility to collaborate on the procurement and roll-out of vaccines, ensuring the best possible prices, volumes and timing for all countries. Importantly COVAX is also analysing and supporting the systems for delivering vaccines and other COVID-19 tools which have been mapped in four regions and we're rolling out other tools like the WHO Academy's new augmented reality course for health workers on the correct use of personal protective equipment. However only a fundamental change in funding and approach will realise the full promise of the ACT Accelerator. US$4.3 billion is needed immediately to support the mass procurement and delivery of vaccines, tests and treatments. A further US$23.8 billion will be needed next year. 00:05:01 This isn't charity. It is the fastest and smartest way to end the pandemic and drive the global economic recovery. The International Monetary Fund estimates that if medical solutions can be made available faster and more widely it could lead to a cumulative increase in global income of almost US$9 trillion by the end of 2025. The real question is not whether the world can afford to share vaccines and other tools. It's whether it can afford not to. At the G20 leaders' summit on Saturday it was very encouraging to hear world leaders expressing their support for WHO and their commitment to the ACT Accelerator. Thank you. In September WHO established a facilitation council for the ACT Accelerator to leverage high-level political commitment to put the tools to defeat COVID-19 in the hands of the people who need them most. Today we're honoured to be joined by the two co-chairs of the ACT Accelerator facilitation council, His Excellency, Dag-Inge Ulstein, Minister of International Development of Norway - takk sa mye, takk skal du ha - and Dr Zweli Mkhize, Minister of Health of South Africa. 00:06:44 Minister Dag-Inge Ulstein, welcome and you have the floor. Takk skal du ha again. DIU Thank you so much and good evening, Dr Tedros. By the time I have presented my speech today many people will have received a positive COVID-19 test. Others will have been told that their loved ones did not make it. As of today there are more than 55.5 million confirmed cases, more than one million deaths. Every second matters. This pandemic is not going away if we sit still and do nothing. Moreover it is not going away if some countries are only taking a my-nation-first approach. Such vaccine nationalism is not only morally reprehensible, it is also a stupid thing to do because, as already heard many times, we are not safe until we are all safe. Our economies will continue to bleed money if countries with a large number of cases lack in obtaining the vaccine and other medicines. We are in this together and the solution is only achievable if we work as one team and, yes, time is running out. 00:08:06 This is not only a health crisis. It is an economic crisis, it is a nutrition crisis, it is a protection crisis, it is a humanitarian crisis. I could have gone on and on and on. The real-world ramifications of the pandemic are all too clear to see. Every day jobs are being lost. The ILO estimates that 495 million full-time jobs will be lost in the second half of 2020. Every day people are being pushed into extreme poverty. The World Bank estimates that this could be the case for an overwhelming 150 million people, 150. Every day children around the world are sitting at home as their schools are closed in an attempt to contain the global pandemic. This has taken 1.6 billion students out of classrooms around the globe. For millions of girls and young women, particularly those in the world's least-developed countries school shutdowns bring other risks such as domestic violence and sexual abuse. This pandemic affects us all but it does not affect us all equally. UN Chief Antonio Guterres warns that the impacts of the COVID-19 pandemic are falling disproportionately on the most vulnerable; people living in poverty, the working poor, women and children, persons with disabilities and other marginalised groups. 00:09:39 This is easy to forget as we are all faced with COVID fatigue. So now is not a time to feel sorry for movie time lost, parties not attended or dinner parties postponed. We owe the most vulnerable that we do whatever we can to end this pandemic. The human costs of not acting are obvious. So are the economic consequences. We heard some of the numbers. The IMF foresees $11 trillion will be lost in GDP in 2021. Behind these forecasts lie businesses, jobs, local communities, families and individuals. As economies bleed money futures are stolen and the occasional opportunities lost. Mental health issues are rising. The sooner we get the pandemic under control the sooner we can reopen societies and get the global economy back on track. To stop the pandemic we need to ensure that effective diagnostics, therapeutic drugs and vaccines are not only developed. To stop the pandemic we need to ensure these tools are distributed to people around the world. If we are to succeed in this we need to engage with civil society, humanitarian organisations and the private sector and, yes, there is hope. We have tests that provide results in less than 30 minutes now. 00:11:06 We have better knowledge of how to treat the disease. We have a wide portfolio of vaccine candidates on the cusp of finalising phase three trials. We need to make sure that we do not end up with having these tools but not the infrastructure to make them available to all. Fortunately there is a clear path forward and that is the Access to COVID-19 Tools Accelerator, ACT A. This initiative was set up to promote equitable global coverage of vaccines, tests and treatments and strengthen the health systems. In just six months ACT Accelerator partners have compiled the world's largest portfolio of these tools. To continue rolling out rapid testing, evaluating new treatments and ensuring access to vaccines as soon as they are licensed the ACT Accelerator urgently needs 4.3 billion and a further 23.9 billion in 2021. So we have a problem; we have a solution; now we only need to make it work. 00:12:19 I would argue that this is a no-brainer for the world leaders. $23.9 billion sounds a lot yet the total need is less than 0.1% of global GDP. In other words if G20 countries were to devote just 1% of their current stimulus spending on the efforts to alleviate the economic consequences of the pandemic globally they would actually more than cover the needs of the ACT Accelerator. I would argue that this is a small price to pay to get the world back on track. Once full travel and trade are restored that investment would be repaid in as little as 36 hours. I think we all know that the cost of inaction far outweighs the cost of action so this is the best business case ever and it is the only way. There is no plan B so each dollar, pound, euro, yuan and yen spent on the accelerator is underwriting future demands for goods and services so that global trade and growth can bounce back. In a letter sent last week from South Africa, Norway, the European Commission and WHO we called on the G20 countries to consider support to the global COVID-19 response as part of their domestic stimulus spending and to contribute substantial amounts to fully fund the ACT Accelerator. 00:13:50 As the G20 summit in Saudi Arabia closes I think we can say that we are being hurt. The 20 biggest economies vote [?] to spare no effort to supply COVID-19 drugs, tests and vaccines to all people. Yes, we still have a long way to go and the pledging marathon will continue. However I think the recent news about coronavirus vaccines and the strong support from the G20 meeting addressing the need for solidarity and multilateral co-operation makes me truly believe that we can allow optimism to fuel our next steps. Yet only a fundamental change in funding and approach will turn new hope of technological achievements into an effective weapon against the virus and allow us to change the course of the pandemic. I trust that every world leader will see that this problem is not solvable if we don't collaborate. The cost of inaction and the human consequences of prolonging this pandemic should be incentive enough. So to end, it's amazing what we have actually achieved so far. Despite many ongoing conflicts in the world, despite difficult topics all countries are somehow united in this. Yes, when it comes to the ACT Accelerator we are still sitting around the same table yet we come to the table with different perspectives and different needs. 00:15:21 But so far everyone has been willing to listen, to stretch to try to understand and meet each other because we understand how closely interwoven our countries and people actually are. The ultimate goal becomes so much more important than just launching the best and right solution for ourselves. With that said, back to you, Dr Tedros. Thank you. TAG Thank you. Thank you so much, Minister Ulstein, for your support and commitment. As you said, I fully agree; the best case ever and it has to be supported. Thank you so much again. It's now my great honour to introduce Dr Zweli Mkhize, Minister of Health of South Africa. Your Excellency, welcome and you have the floor. Thank you so much for your support also. Thank you. ZM Thank you very much, Dr Tedros, the Director-General of the WHO and all the members of the WHO team, my colleague, the Co-Chairperson, Minister Dag-Inge Ulstein. Thank you very much for the opportunity to be part of this very special occasion, this briefing. If there was ever a case for solidarity and global co-operation this COVID pandemic has demonstrated why. 00:16:48 The crisis is hitting the world hard and our most fragile regions harder, affecting income, health, education and other parts of our socio-economic lives. COVID-19 does not respect national boundaries and as long as it exists anywhere it is a threat everywhere. No-one is safe until everyone is safe. Global solidarity isn't just the right thing to do; it's the smartest thing to do. Ensuring that tools are allocated equitably, not based on income but based on universal protection against COVID-19 is the fastest and most effective way to defeat the pandemic and get our lives and our economies back to normal again. We must treat Access to COVID-19 Tools as a global public health initiative. Collective efforts to stamp out the virus now would also mean that future deadlier strains or mutations that are more difficult to treat could be avoided. It is clear that every country will need to play a part in financing an end to this crisis and every leader has a political choice to make. 00:18:04 But the lack of adequate financing for our global exit strategy, the ACT Accelerator, is an existential threat to the economic and health security of all countries and their citizens. Speaking from the perspective of the African continent it has now recorded over two million cases with 49,000 deaths, which accounts for 2.5% of the global caseload. There are signs of resurgence in 18 countries which is 38%. More than 20% increase is recorded in the numbers in the last seven days when compared to the previous seven days. It's also not certain how a resurgence on the African continent will evolve and therefore any equal access to vaccines and therapeutics will be critically mitigating the threat posed by the resurgence on the continent. As part of these preparations President Ramaphosa, His Excellency, Chair of the African Union established a COVID-19 African vaccine acquisition task team to lead this effort. In addition to equitable access to COVID-19 tools we also need to pay attention to the strengthening of health systems. The ACT Accelerator offers a clear way forward for ending the crisis through global co-operation that will deliver. All countries need to end the acute phase of the pandemic, restoring economic vitality and averting catastrophe. 00:19:43 Whilst the pace of scientific research and development into effective vaccine therapeutics and diagnostics is unprecedented its true value will only be realised if countries can access these tools and are prepared for their use. Every country has work to do to ensure that once ready these tools can be rapidly deployed. This includes ensuring that capacities and infrastructure that need to be rapidly scaled or upgraded to deploy COVID-19 tools are ready and working. Bottlenecks in key areas of health systems such as data, workforce, clinical care, supply chains as well as access to key commodities such as PPEs and oxygen remain limiting factors to effective deployment and use of COVID-19 tools in many countries. The health system connect, a pillar of the ACT Accelerator, is a critical mechanism to support countries to bolster and strengthen through a tailored approach that uses global knowledge to address local problems. 00:20:50 Countries' readiness is an absolute prerequisite to the equitable scale-up of the COVID-19 tools. It is a hurdle we must clear if we are to win this race and this is one time when we all need each other and every country matters and therefore we need to make sure that we focus on more and more partnership, solidarity and global co-operation. Thank you very much, Dr Tedros, for inviting us. Thank you. TAG Thank you. Thank you very much, Minister Mkhize, for your support and commitment and I look forward to working with both of you in this very critical period to realise the promise of the ACT Accelerator. Thank you so much again and I hope you will stay with us for a few more minutes to answer questions from the media if we have them. With that, back to you, Margaret. MH Thank you very much, Dr Tedros. Yes, we will now open the floor for questions. I probably don't need to remind you you need to use the raise your hand icon to get in the queue. We already have a large number of you in the queue so I ask that you restrict yourselves to one question. Remember we also have our experts on the line and in the room so indicate clearly what your question is. 00:22:22 We have limited time so please keep your questions short. I will stop talking now and give you a chance to ask your question. The first one goes to Corinne from Bloomberg. Corinne, could you unmute yourself and please ask your question. CO Hi, thanks for taking my question. It'd be great to get your take on the AstraZeneca vaccine results, especially since it said that they're going to try to get a quick recommendation from the WHO and it seems the results are not that straightforward. MH That question, I think, will go to Dr Soumya Swaminathan. Dr Soumya, are you on the line? SS Yes, I am, Margaret. Thank you for that question. First of all I'm sure the person who asked the question, like all of us, is very encouraged by the news that we got today with the preliminary results that have been released from the clinical trial of the AstraZeneca vaccine, following on from the encouraging results from the two earlier vaccine, the Pfizer and the Moderna, both of which are MRNA vaccines, the AstraZeneca vaccine being a viral vector vaccine. 00:23:42 So I think the good news is that vaccines for COVID-19 are possible to make and it's possible that we will have a number of different vaccine candidates that can be used in the fight against this disease. As we're discussing the ACT Accelerator today I think this I very relevant because we would like to provide access to as many efficacious and safe vaccines as possible so we can cover the population around the world. Remember we have to cover a huge number of people, billions and billions of people. This is unprecedented and we will need all the manufacturing capacity in the world to be able to do that. On the AstraZeneca results themselves we've heard only the preliminary results about the vaccine trials that were done in the UK and Brazil looking at two slightly different dosing schedules. The schedule that had the same dose given two times had a slightly lower efficacy but still it was about 62%, which is above the benchmark that we had set but the schedule which gave a smaller dose followed by a larger dose; the efficacy seems to have been higher, up to 90%. 00:25:01 But again this is based on rather small numbers and I think we need to wait to see the results both of the efficacy and the safety. The AstraZeneca vaccine is also being currently trialled in many other countries and eventually we should have data in about 60,000 patients or so. That will enable us to take a much more informed decision. So we await discussions with the company and they're already talking with our pre-qualification programme on how they will go about it and Dr Simao's available to answer more questions on that. Thanks. MH Thank you, Dr Swaminathan. Over to Dr Simao for some added points. MS Thank you very much, Margaret, and thank you, Corinne, for the question. Actually we have already had several discussions with AstraZeneca following the expression of interest WHO issued for the emergency use listing and pre-qualification of the vaccines so we are very hopeful and we are about to receive more clinical data in the next week. 00:26:13 We are also aware that AstraZeneca is also submitting the dossiers to the European Medicines Agency and we do have very close collaboration. There are actually eight sites; some of them are manufacturing sites so we will be analysing this data very carefully but very much welcome the results so far. We expect that we should finalise the assessment in the beginning of next year. Thank you. SS If I could just add, Margaret; I forgot to mention the advantage of this vaccine is that it can be stored at ordinary refrigerator temperatures of two to eight degrees and is stable at that temperature. That of course has huge logistical advantages for transporting and delivering this vaccine to cities, towns, villages and rural areas around the world. We hope there will be more vaccines like that which are more heat-stable and we have to also continue to encourage all the other developers who are doing clinical trials and who are in early phases of development because we do need a variety of vaccines out there that will target different groups better, that will have different storage conditions. Also the issue of affordability is important to keep in mind. Thanks. MH Thank you, Dr Swaminathan and Dr Simao. There do not seem to be any comments in the room so I will take the next question from Gunila, the Geneva correspondent for Swedish media. Gunila, please unmute yourself and go ahead. 00:28:05 GU Can you hear me? MH Yes. Please go ahead. GU Thanks for taking my question. It is very promising that a vaccine candidate is coming but first we have Christmas and Christmas is now about one month away. Countries have started to give advice; in the UK they said we can have an exception of three households celebrating Christmas together, which could be a lot of people. In Sweden meanwhile the Prime Minister yesterday said there should be one family staying inside for the time being. I'm wondering, would you be able to give advice, recommendations for how countries should deal with celebrations around Christmas, especially in Europe, which now still have a very high community transmission? 00:28:57 MR I can start. Maria will follow up. I think first of all it's important that we separate the science of COVID-19 from what are the policies that surround that science because governments have to make choices and they have to decide on the local epidemiology of the disease, they have to decide what the tolerance level of the population has been, how long people have been in lock-down or not in lock-down, what level of control they have, how strong their public health architecture has become over the last number of weeks, have they expanded their capacity to test, trace, quarantine and isolate those people who are actually sick or carrying the virus. are they able to protect vulnerable populations. So the decisions to ease restrictions coming towards a holiday period - and there are many countries heading towards holiday periods; we've seen the most recent holiday period in Canada, their Thanksgiving; they did see an increase in transmission after that period because people come together, they mix, they travel. It's inevitable that in the presence of community transmission if you further release the opportunity for the virus it will find opportunities to transmit. But there is the trade-off, the economic and social trade-off in that so I think it's really important that we're not trying to bend science in this. The science is straightforward. If there is significant community transmission in your country and you don't have the necessary public health architecture to track and trace and isolate and quarantine contacts then further opening up will result in increased transmission. 00:30:39 There's no question of that. The question is, have you got the disease under enough control to start with and can you in a sense allow people a little bit more freedom over the Christmas period, which generates a sense of confidence and a sense of joy in the community, which people need right now, without letting the virus let rip again within our communities? This is a very important trade-off and it's a trade-off between those two issues. The science is clear. The policy is what's not clear and each government will have to decide on its policy based on those trade-offs between the epidemiologic risk versus and economic and social risk of continuing to have people in a restricted situation over a holiday period, which will generate genuinely a lot of frustration, further fatigue and a lot of push-back. 00:31:34 Maria may comment on the technical aspects of this but I certainly hope that we're not going to enter into a period where we're trying to come up with a formula which says, this is how much you can open up and this is how many days of Christmas we have by some scientific formula that says, this is safe and this is not safe. There is no safe or unsafe decision. There is only higher and lower risk of the situation getting better or worse depending on what you do. MK Thanks, Mike. Yes, I think the point is that there's no zero risk here right now. We are in the middle of a pandemic and many countries unfortunately are in a very difficult situation with increasing case numbers, with hospitals full and with ICUs full. As Mike has said, there's lower risk or higher risk but there is risk. This virus needs us, it needs people to spread between and if we allow it to we could be that individual that brings that virus into someone's home. What we have outlined to support countries in making those policies is a risk-based approach in terms of what is the situation in the areas where you live, where people need to travel from, where they need to travel to. 00:32:46 You as individuals need to take decisions about, how will I celebrate these holidays that are coming up, that have happened, am I going to be visiting a family that has vulnerable individuals that live in that family and what is the possibility that I could potentially bring that virus into that home where someone who lives there has a higher risk of developing severe disease and a higher risk of dying. So there are a lot of things that we outlined; who will you be visiting, what will that situation look like, can you have that holiday indoors or outdoors, how crowded will it be? There are ways in which you can reduce the risk but there is no zero risk unfortunately in this situation. I do think I agree with Mike and all of you who understand that this is incredibly difficult because especially during holidays, especially during birthdays, especially during these family celebrations we really want to be with family. 00:33:43 But in some situations the difficult decision not to have that family gathering is the safest bet so everyone will need to take that decision based on your current situation, based on your family, based on where you need to travel. We hope everyone will have happy holidays and find ways to connect. Fortunately many people around the world have access to the ability to connect virtually and I think that that may be the way that many areas need to go. But I do want to say that even if you can't celebrate together this year you can find ways to celebrate when this is all over. We are doing that within our own family. We are going to have one heck of a celebration when this is all over regardless of when that is and that is something that helps personally myself and my family get through because we know that eventually we'll be able to celebrate with our loved ones. MH Thank you very much, Dr Van Kerkhove. The next question goes to Nina Larson of AFP. Nina, could you unmute yourself and please go ahead. NI Hi, can you hear me? MH Yes, Nina. Please go ahead. 00:34:56 NI Thank you for taking my question. I understand that you've held a briefing for diplomats on the progress on the independent international investigation into the origins of COVID-19 and that some concerns were raised about the lack of transparency in negotiating the terms of reference for the mission and also over the amount of time it's taking to send a team to China. I was hoping you could provide us with more information on the terms of the agreement with Beijing and also say when you expect them to go to China. It would be good to know who's on the list or how many people are on the list. Thank you. MK Thanks for the question. I can start and maybe Mike would like to supplement. We have actually released the terms of reference for the mission online. We have also released the names of those who are on the international mission online and so that is completely transparent for you to see. As you know, we sent a pre-team of WHO staff to China over the summer to discuss with counterparts the nature in which the studies needed to take place. We've outlined phase-one and phase-two studies. It's all in the terms of reference and you can see that; where those initial phase-one studies need to take place in Wuhan, looking at the earliest cases that were reported and identified in Wuhan, looking at the epidemiologic studies that were done. There're a number of studies that are underway that need to be conducted by Chinese counterparts. 00:36:30 The international team has met and is meeting with Chinese counterparts to see how that could be supported through global collaborations. This is very technical and very science-oriented and very research-oriented because there are many, many studies that need to be undertaken. The international team will travel to China. That is being discussed amongst the international team and the Chinese counterparts and that will be arranged in due time. MR Just to add, certainly with regard to the mission briefings - and remember, we have weekly briefings with our member states at mission briefings and are engaged in very open and transparent dialogue with our member states every single week and we discuss every issue from vaccines to the ACT Accelerator last week, to the animal/human origin studies all the way through to surveillance, to contact tracing. 00:37:33 We have the member states presenting on their own case studies, on their own experience. We exchange that information and the DG has led from the front in engaging directly with our member states on a weekly basis on all matters of importance. On the issues of the progress with the animal studies in fact quite the opposite; the member states who spoke - and there were many - all expressed appreciation for the progress that was being made, for the terms of reference and asked obviously for further progress to be made in the phase one and two. We explained to our member states the content of the phase-one studies and the hopes for phase-two. One member state did express some concerns regarding the phase-one studies and ensuring that they were completed as quickly as possible. We reassured that member state that that would happen and again we did release to the member states the names of the international team members. 00:38:33 Again the international team has been brought together. We were in the process of finalising the legal documentation to be members of this group and as soon as we have been able to confirm all of that we will put the names of the team up on the list. I must also express, the international team themselves have expressed their own concerns. There has been a level of attack and abuse to people involved in international science. It is not an easy space to be in right now; let me be plain about that. We have all received our fair share of hate mail and threats and everything else right through this process and it is important that we as an organisation protect the space of science and protect those scientists. We would like to thank them for their openness and transparency and for allowing us to release their names. That's not an easy choice when you're trying to do your best for your own system and for the international system so we thank them not only for their scientific leadership but for their courage in doing that and it's a strange thing to have to say in this world today that it takes courage to be a scientist. I used to think it only took brains but now you need to be brave and courageous as well to do science in the face of the anti-science movements that we see and the ideologic politics that has come into this process. 00:39:54 We're very, very pleased with the reaction of our member states. We're particularly encouraged by the way in which so many countries are supporting everything that we're trying to do. Imperfectly as we do it, our member states recognise the massive effort that this secretariat is making with our collaborating centres and scientific partners to fight this pandemic. We look forward to making progress on the animal/human origin studies and again I made it very clear at that briefing that we are pushing for co-operation from all countries and especially from our colleagues in China who have identified a very strong Chinese scientific team and we're working very closely with that. We expect openness and transparency from all our member states when it comes to scientific collaboration and we trust we will continue to receive that from our scientific colleagues in China. 00:40:49 MH Thank you very much, Dr Ryan and Dr Van Kerkhove. The next question will go to Michael from CNN. Michael, please unmute yourself and go ahead. MI Thank you for taking my question. Can you hear me? MH Yes. Please go ahead. MI As a follow-up to the last question, it's hard to believe but we're almost at a year from when case zero or the index case for coronavirus was identified. However all we seem to know according to state documents reported on by the South China Morning Post is that it was a 55-year-old male but he can't be identified or no-one can trace him. How important is it in your investigation to find the origins of the coronavirus who case zero or the index case was? Just quickly also the wet market where the virus is believed to have originated; that's been cleaned up and closed off. How will that be an impediment to your investigation? Thank you. MR We could end up in a lot of detail. Your questions are well asked. Identifying case zero is a very important aspect of all epidemic investigations. There may be more than one case zero in some situations because there may be more than one species breach. 00:42:15 We're increasingly seeing that SARS-CoV-like viruses have been identified in many different countries; in fact in horseshoe bats most recently in the last few days. We've seen other potential intermediate hosts identified in various settings so there's no question that this virus has an actual home, probably somewhere in the bat community; some intermediate hosts who we haven't fully identified yet. How that disease then breached that barrier into the human species may have been a single event, it may have been multiple events. Those events may have occurred in one particular time or over a range of different times because if the virus is present in the animal kingdom or in wild animals then the chances of multiple introductions - and we've seen that; for example if you look at the recent human-to-mink and mink-to-human. We've seen multiple reintroductions into the human population from the mink population; it wasn't just one exposure back. The natural history of these things is at least one case zero, probably more. 00:43:19 The DG has always said and was very, very strong on this from the very beginning; we need to start where we found the first cases and that is in Wuhan in China and then we need to follow the evidence after that wherever that leads. With regard to the Wuhan seafood market, in fact one of the interesting findings is while there was most certainly a temporal and geographic cluster associated with the market not all of the cases in that initial cluster can be linked directly to the market. So the market is likely to have been a point of amplification. As we've seen for example in the event in Shanghai [?], we had a similar event. We don't know whether it was a human that drove the amplification event at the Wuhan market; was it animal; was it environmental contamination; we don't know that. But certainly it's clear that there were cases that preceded that event at the Wuhan market so the real question is, the original species barrier breach; where did that occur? That is still unknown and it is extremely important and the terms of reference for the investigation clearly lay out in phase one the necessary epidemiologic and clinical and serologic and retrospective studies that need to be done to establish whether or not there's any evidence trail that will lead back. 00:44:43 It is remarkably difficult. It is like looking for a needle in a haystack sometimes for an individual event, to look for that single event. I've been doing that in Ebola for the last 25 years and we've never hit the mark except on one occasion where we could actually identify the actual event where the disease crossed the species barrier. So this is not easy to achieve. We will pursue those investigations over the next couple of months in phase one and hopefully move on to phase two. I think, Maria, there was a second part if you want to come in, on the markets. I think it's important. MK Yes, as Mike has said, there are a lot of studies that need to be underway to find the initial case wherever they may be and look at the conditions in which they were infected so this case zero that you mentioned may not be in fact case zero. There could have been other cases that existed that weren't detected because they weren't picked up through a current surveillance system. 00:45:45 That's not a criticism; that's just a possible fact, that we need to look back, we need to look retrospectively to see what happened. The amplification event at the market in Wuhan certainly is what triggered more transmission and the conditions by which that happened are the focus of some study as well, looking at the animals that were there, that were sourced at that market, where those animals came from, where those animals were sold onward, looking at environmental samples that were collected there. There were a number of environmental samples that were collected in that initial market from animals but also from surfaces around different parts of the market and those results the Chinese colleagues have presented to the international team so there are some results from there. But all of these are clues, if you will, that help lead to the next question. As far as any answers that we get from any studies, they lead to a number of additional studies so as Mike has just said and as the DG has outlined, we follow the science. We're also working with a large number of people across the world looking at retrospective analyses in different countries. 00:46:56 You've heard of studies of waste water, studies that have looked at samples from 2019. We're working with our seroepi networks on looking at stored clinical samples and sera from 2019 to see if any of those test positive but all of these really help us to piece together how this unfolded. Just to point out, for MERS coronavirus it took us almost a year to find the intermediate host for the MERS coronavirus which is the dromedary camel, the one-humped camels. Those came from detailed epidemiologic investigations at the animal/human interface with people who were caring for camels, testing the animals, testing the camels, looking at sequences and being able to match and see that there was transmission that had happened between the humans and the camels. It does take time and we know everyone is really anxious to get these answers and those studies are underway. We need the science to unfold, we need those studies to be done carefully and thoughtfully and thoroughly and we will be there across the world with our international partners to support that every step of the way. 00:48:03 MR Can I just add to be clear again on the journalist's question, we fully expect that we will have a team on the ground. We need to be able to have the international team join our Chinese colleagues and go onto the ground and look at the results and the outcomes of those phase-one studies and verify these data on the ground. This is extremely important and we are continuing to expect that that be the case and we would like to have that team deployed as soon as possible. So we're building the relationship between the Chinese counterparts and the international team. We have regular Zoom calls between the two groups and we fully expect and have reassurances from our Chinese Government colleagues that the trip to the field part of the mission will be facilitated and as soon as possible in order that the international community can be reassured of the quality of the science. Again the Chinese colleagues have done a tremendous amount of scientific investigation and in fact, I think, have published hundreds and hundreds of papers regarding the situation in China and the learnings they have done. 00:49:10 But clearly we all need to understand the origin of the virus, we all need to understand where it has come from, not least to understand where it may re-emerge in the future and I believe our Chinese colleagues are just as anxious to find those answers as we are. MH Thank you very much, Dr Ryan and Dr Van Kerkhove. The next question goes to Emilio Divinito from El Pais. Emilio, please unmute yourself and ask your question. EM Hello. Good afternoon. I'm going to make it a very short question but is it true? We've heard Dr Tedros and Mr Ulstein talking about how important it is to make sure that the poor countries are going to receive their share of the new developments; I'm thinking about the vaccines. I want to ask them how realistic it is to think that they are going to receive them on time or are they going to be the last ones in the queue. I'm thinking now that we know the plans for Spain or in Germany and in other countries, the plans that they have to vaccinate their own people where they have to prioritise amongst the populations. 00:50:32 So I don't know if it's realistic to think that these countries are going to give part of the vaccines... so how are you going to do it, make sure that the poor ones are going to receive their share? Thank you. MH Thank you. Our Minsters, our guests would like to respond to that question. DIU Thank you so much. Thank you for that question. I think this is the most important thing because it's not enough to develop vaccines. It's all about the last lap and that is why my colleague from South Africa and I have been so clear on our mission also. It's about creating equitable access for all and to make sure that vulnerable groups and critical health workers in all countries... I know that it's very much in Dr Tedros' heart and mind also because we really need to make sure that the logistics, that the infrastructure that we have, shared knowledge and trained enough healthcare workers in all countries to make sure that it's possible actually to roll out and to use those tests and to make sure that the medicine will be available and that we make sure that the infrastructure for the vaccines is in place. 00:51:58 So it will not be easy, it will be really, really difficult and that's why I am so clear that we need to first make sure that the finance gap, not only the urgent gap of 2020 but we make sure that we mobilise as much money as possible also for the gap in 2021 right now because this will not be easy, it will be really, really difficult. So we need to make sure that we use the momentum and that will not be easy but we will do whatever it takes to make sure that we will have fair and equitable access to all. That's why we also wrote the letter to G20 countries and I really hope we will have some substantial answers with new, fresh money also into the portfolio. But over to my colleague. ZM Thank you very much, Minister. I think we all agree that the approach has to be that of equitable access and the issue has to be that there should be no-one left behind in each country that requires to be assisted does get assisted. On that basis we believe that some of the discussions on the COVAX facility will take us to a point where there is a way of being able to assist those who can't fund themselves to get the basic [inaudible] to start and then the support, to be assisted as well. 00:53:29 So the general message that we're all sending across basically says that we need to focus on the... Everyone needs to be safe on the basis of having some access to a vaccine. Then of course the more vulnerable would need to be targeted first so that with time as the volumes start to increase we're able to reach out to members of society right across. But it would be quite risky to have one side covered because they can afford it and then some other member states not covered simply because they cannot afford it. That still creates a risk of a resurgence of the pandemic. So our approach is more or less the same. TAG Yes, I think the Ministers have said it very well. Maybe to stress, I think there are three important issues here. One is the political commitment to share and second is the financing. Third is preparing the infrastructure of countries. On the political commitment and financing, as the Ministers said, we have brought it to the attention of the G20 and hopefully others outside the G20 will also give their political support and also, we hope, will give their financial support. 00:55:09 It won't be easy, it's going to be tough but at the same time we have now the facilitation council and the facilitation council is chaired by Norway and South Africa. Its objective is to make sure that the political commitment and also the financing is ensured. On the third, preparing infrastructure, the World Bank, UNICEF, WHO, Global Fund have already sent a letter to our country offices to work with countries to prepare the infrastructure for vaccination, to identify gaps and fix and prepare it. That will include training of health workers and so on. All agencies relevant for this are also working on preparing the countries and that's very important, the preparation of countries. One country which we have seen really very advanced is Ecuador in terms of preparing for vaccination. I had the opportunity to speak to the Health Minister and the Foreign Minister last week and they have a very good model. 00:56:30 I think identifying best practices of countries and sharing it with countries to use will be very important. Thank you. MH Thank you so much, Dr Tedros and Honourable Ministers. We're really coming up to the hour but we're going to take one last question from Morocco and that is from Abdullah Hussan from Morocco News. Abdullah, could you unmute yourself and go ahead. I think you may be asking in Arabic. TR Yes, I have a question. Those vaccines that have been readied, that are being prepared; are they effective? Will they be provided to African countries, especially those which come from Pfizer and Sanofi? Thank you very much. MR I think the question is about vaccines. Alaikum-salaam to you. I think Soumya can come in. You asked the question whether the vaccines are effective. I think three of the vaccines have clearly demonstrated efficacy in the trials so far. That data is being put forward to various regulatory authorities over this week and next week and probably in the coming weeks and certainly that data, we hope, will also be provided directly to WHO so WHO can make decisions about emergency use listings and other things. 00:58:28 The question you have regarding providing of vaccine to Africa; I think that is really what the COVAX initiative is about; ensuring that an initiative covers 80% of the world's population and the vast majority of the population of Africa. I don't know if Bruce is online but if he is he can speak to just how many countries in Africa are actually signed up to the COVAX initiative which actually, I think, covers the vast majority of countries on the continent. Bruce. MH Dr Aylward, go ahead. BA Hi, Mike, and greetings, all. I think it's been covered already. The majority of countries on the African continent are signed up to the COVAX facility. It's actually over 45 countries now on the African continent that have actually joined and the remainder are still considering. There're issues, fiduciary and others, that need to be considered but clearly people see this as the key, as Minister Ulstein and Minister Mkhize said; the COVAX facility is key to the equitable allocation of vaccine globally and to ensuring that all countries get some product rather than some countries all product. This is absolutely crucial to getting the world out of the economic/societal health crisis that it's in today. 00:59:51 To the specific question that was asked, yes, it is absolutely possible to see an equitable allocation. This is a function, as Minister Ulstein and Minister Mkhize said, of political choices with respect to financing and to the timing and use of products. But increasingly there's very, very clear recognition globally that this is the best possible way out of this crisis. MS Can I complement? Just to say, as we heard before when the question came about AstraZeneca, it's very important that we have different vaccines and different platforms being developed because some of them, like the Pfizer vaccine, need an ultra-cold chain which brings logistic problems. There are not only challenges for countries in Africa; there are challenges for all low and middle-income countries and some of the high-income countries as well. So we see the portfolio including the other vaccines beyond the MRNA vaccines like Pfizer and Moderna as a very good point ahead in ensuring that there will be access to alternatives as the platforms are easier to use at country level. That's, in a nutshell, how we are seeing it. 01:01:19 It's very important to ensure equitable access but we need to take into account also the characteristics of each vaccine and the [unclear] environment that will make the availability at country level more challenging. Thank you. MH Thank you, Dr Simao. I'd like to ask the Minister for Health from South Africa, Dr Mkhize, if he would like to add something. ZM Yes, thank you very much. I think, following on the response that has been given, just to bring to the attention of the person that asked the question that from the African Union's perspective there's been a task team that's been set to help to co-ordinate the access to vaccine together with the member states, also working together with the COVAX facility, GAVI and the other partners. In this process the African Centre for Disease Control is the one that's at the centre, co-ordinating, looking at the numbers, the needs and so on so that in addition to whatever the WHO and all the other players are doing there is adequate support from the African Union member states. 01:02:42 This is building on the work that was done during the difficult days of the early COVID pandemic where the assistance, the support, the donations, the needs, the new tools for acquisition had to be co-ordinated through the Africa CDC. So they have actually engaged a number of manufacturers and they've engaged COVAX just to be able to understand so that everything is aligned. I think the key issue is also to say, we need to look beyond the point of the public's process in terms of what else needs to be done to reach out to the largest numbers of people who still need to be assisted. So there's quite a bit of work that's being done at that level and certainly we don't believe that the African continent, the member states will actually be left behind so there is lots of work being done at that level. Thank you very much. MH Thank you so much, Minister, and thank you very much to all journalists who joined. Your questions were excellent today. We really appreciate it. We have to finish here now but I'll hand over to Dr Tedros for a few more words. 01:03:54 TAG Yes, thank you. I think they always ask excellent questions. This Wednesday marks the International Day for the Elimination of Violence Against Women. Around the world nearly one in three women have experienced physical or sexual violence, mostly by intimate partners. As countries have implemented stay-at-home orders and other measures to prevent transmission of COVID-19 reports from women experiencing violence at home have increased. At the same time services for survivors have been disrupted. Violence against women is never acceptable. We're calling on governments to include services for women affected by violence in every country's package of essential health services and to allocate the resources to make them accessible. We're calling on health providers to pay more attention to identifying women who experience violence and provide first-line support and we're calling on everyone to show their solidarity with women affected by violence by raising their voices and by wearing something Orange this Wednesday - the day after tomorrow - as a symbol of solidarity and hope. Thank you and see you on Friday. I would like again to thank Minister Mkhize and Minister Ulstein for joining today and also for your leadership of the facilitation council of the ACT Accelerator. Thank you, Norway. Thank you, South Africa. 01:05:42

Corticosteroid treatment in severe COVID-19 patients with acute respiratory distress syndrome.

BACKGROUNDCorticosteroids are widely used in patients with COVID 19, although their benefit-to-risk ratio remains controversial.METHODSPatients with severe COVID-19-related acute respiratory distress syndrome (ARDS) were included from December 29, 2019 to March 16, 2020 in 5 tertiary Chinese hospitals. Cox proportional hazards and competing risks analyses were conducted to analyze the impact of corticosteroids on mortality and SARS-CoV-2 RNA clearance, respectively. We performed a propensity score (PS) matching analysis to control confounding factors.RESULTSOf 774 eligible patients, 409 patients received corticosteroids, with a median time from hospitalization to starting corticosteroids of 1.0 day (IQR 0.0-3.0 days) . As compared with usual care, treatment with corticosteroids was associated with increased rate of myocardial (15.6% vs. 10.4%, P = 0.041) and liver injury (18.3% vs. 9.9%, P = 0.001), of shock (22.0% vs. 12.6%, P < 0.001), of need for mechanical ventilation (38.1% vs. 19.5%, P < 0.001), and increased rate of 28-day all-cause mortality (44.3% vs. 31.0%, P < 0.001). After PS matching, corticosteroid therapy was associated with 28-day mortality (adjusted HR 1.46, 95% CI 1.01-2.13, P = 0.045). High dose (>200 mg) and early initiation (≤3 days from hospitalization) of corticosteroid therapy were associated with a higher 28-day mortality rate. Corticosteroid use was also associated with a delay in SARS-CoV-2 coronavirus RNA clearance in the competing risk analysis (subhazard ratio 1.59, 95% CI 1.17-2.15, P = 0.003).CONCLUSIONAdministration of corticosteroids in severe COVID-19-related ARDS is associated with increased 28-day mortality and delayed SARS-CoV-2 coronavirus RNA clearance after adjustment for time-varying confounders.FUNDINGNone.

Low-dose chest CT for diagnosing and assessing the extent of lung involvement of SARS-CoV-2 pneumonia using a semi quantitative score.

OBJECTIVES: The purpose is to assess the ability of low-dose CT (LDCT) to determine lung involvement in SARS-CoV-2 pneumonia and to describe a COVID19-LDCT severity score. MATERIALS AND METHODS: Patients with SARS-CoV-2 infection confirmed by RT-PCR were retrospectively analysed. Clinical data, the National Early Warning Score (NEWS) and imaging features were recorded. Lung features included ground-glass opacities (GGO), areas of consolidation and crazy paving patterns. The COVID19-LDCT score was calculated by summing the score of each segment from 0 (no involvement) to 10 (severe impairment). Univariate analysis was performed to explore predictive factor of high COVID19-LDCT score. The nonparametric Mann-Whitney test was used to compare groups and a Spearman correlation used with p<0.05 for significance. RESULTS: Eighty patients with positive RT-PCR were analysed. The mean age was 55 years ± 16, with 42 males (53%). The most frequent symptoms were fever (60/80, 75%) and cough (59/80, 74%), the mean NEWS was 1.7±2.3. All LDCT could be analysed and 23/80 (28%) were normal. The major imaging finding was GGOs in 56 cases (67%). The COVID19-LDCT score (mean value = 19±29) was correlated with NEWS (r = 0.48, p<0.0001). No symptoms were risk factor to have pulmonary involvement. Univariate analysis shown that dyspnea, high respiratory rate, hypertension and diabetes are associated to a COVID19-LDCT score superior to 50. CONCLUSIONS: COVID19-LDCT score did correlate with NEWS. It was significantly different in the clinical low-risk and high-risk groups. Further work is needed to validate the COVID19-LDCT score against patient prognosis.

Adaptation of Clinical Laboratories to COVID 19 Pandemic: Changes in Test Panels, Overcoming Problems and Preparation Suggestions for Future Pandemics Adaptation of Clinical Laboratories to COVID 19 Pandemic.

BACKGROUND: For Coronavirus Disease 2019 (Covid-19) infection, clinical laboratories provide essential contributions in the diagnosis of infection, stage prognostication, and evaluation of disease severity. We aimed to show laboratory problems including changes of test numbers, changes of test panels, and differences of preanalytical errors during Covid-19 pandemic and, in the current study, we also intended to give solutions for the obstacles to guide other possible pandemics. METHODS: Our study was based on data between January 10, 2020, and May 10, 2020. The first Covid-19 case of the Republic of Turkey was seen March 10, 2020, which was determined as the threshold date for comparisons. This was a single center, data mining, retrospective study. RESULTS: The number of patients admitted to hospital were 34,260 and 15,573, the number of total tests were 66,263 and 42,066 before and after pandemic, respectively, for the two-month interval. Test percentage changes were increased for D-dimer 136%, fibrinogen 3,113%, troponin 6%, and LDH 17%. Test percentage changes were decreased for CBC 37%, sedimentation 45%, aPTT 30%, PT 37%, CRP 28%, ProCT 10%, ferritin 29%, CK-MB 27%, blood gases 47%, ALT 43%, AST 42%, urea 42%, creatinine 42%, triglycerides 45%, sodium 42%, potassium 41%, chloride 21%, urine culture 58%, and blood culture 44%. When preanalytical sources of errors were investigated no differences were found. CONCLUSIONS: Laboratories must take quick action and be prepared for changes in patient services during pandemics. The most reliable ways for this are past experiences, statistical analysis, co-operation with administrations, high quality communication skills, and a risk-based management system.

Evaluating Clinical Course and Risk Factors of Infection and Demographic Characteristics of Pregnant Women with COVID-19 in Hamadan Province, West of Iran.

BACKGROUND: COVID-19 is a new viral disease with a rapid outbreak. Pregnant women are at a higher risk of contracting viral infections including COVID-19. We aimed to evaluate the clinical course and risk factors of pregnant women diagnosed with COVID 19 in Hamadan Province, west of Iran. STUDY DESIGN: A retrospective cohort study. METHODS: The convenience sampling was performed using 50 papers and electronic files of pregnant women diagnosed with COVID-19 according to the WHO's temporary guidelines. They were hospitalized in health centers and clinics of Hamadan Province. The data-collecting tool employed was a researcher-made questionnaire. The data were analyzed via SPSS software version 19. RESULTS: The mean age of pregnant women with COVID 19 was estimated to be 29.20 ± 5.8 yr and their average gestational age estimated to be 28.8 ± 8.20 weeks. About 32% of them had an underlying disease, 32% a history of influenza, and 40% recently traveled to infected areas. The most common findings were CT scans and multiple mottling and ground-glass opacity chest radiology. The most common symptoms were fever, cough, and shortness of breath. About 8% of the women required ICU hospitalization and the average length of hospital stay was 4.04 ± 2.38 and 29% had premature births. Moreover, 28% of infected mothers had a normal delivery and 20% had a cesarean section. CONCLUSION: Early diagnosis of Covid-19 disease is essential in pregnant women. Because there is a possibility of worsening complications in the mother and fetus.

Umbilical cord blood-derived mesenchymal stem cells in treating a critically ill COVID-19 patient.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic is spreading rapidly. Critically ill cases of COVID-19 can rapidly progress to acute respiratory distress syndrome and multiple organ failures. However, no effective drugs have been available till now, leading to more than 300,000 deaths up to 29 April 2020. Here, we present a critically ill case utilizing umbilical cord blood-derived mesenchymal stem cells (UCB-MSCs). CASE PRESENTATION: A 72-year-old man was admitted, with the diagnosis of COVID-19, ARDS, type-2 diabetes, diabetic nephropathy, renal insufficiency, and hypertension. His clinical condition continually developed to be life-threatening even receiving various treatment options including antiviral therapy and extracorporeal membrane oxygenation. Between 28 February and 8 March 2020, the patient was given 5-time intravenous infusions of UCB-MSCs. His hematological and biochemical indexes, including lymphocytes and renal function improved. Pulmonary static compliance increased significantly and PaO2/FiO2 ratio maintained stable. On March 10, he received lung transplantation. CONCLUSIONS: Our current findings suggested that UCB-MSCs therapy may show some positive effect in treating critical COVID-19 to some extent, for its delaying deterioration of the disease and efficacy in respiratory and renal function, though limited.

Should we remain hopeful? The key 8 weeks: spatiotemporal epidemic characteristics of COVID-19 in Sichuan Province and its comparative analysis with other provinces in China and global epidemic trends.

BACKGROUND: The COVID-19 spread worldwide quickly. Exploring the epidemiological characteristics could provide a basis for responding to imported cases abroad and to formulate prevention and control strategies in areas where COVID-19 is still spreading rapidly. METHODS: The number of confirmed cases, daily growth, incidence and length of time from the first reported case to the end of the local cases (i.e., non-overseas imported cases) were compared by spatial (geographical) and temporal classification and visualization of the development and changes of the epidemic situation by layers through maps. RESULTS: In the first wave, a total of 539 cases were reported in Sichuan, with an incidence rate of 0.6462/100,000. The closer to Hubei the population centres were, the more pronounced the epidemic was. The peak in Sichuan Province occurred in the second week. Eight weeks after the Wuhan lockdown, the health crisis had eased. The longest epidemic length at the city level in China (except Wuhan, Taiwan, and Hong Kong) was 53 days, with a median of 23 days. Spatial autocorrelation analysis of China showed positive spatial correlation (Moran's Index > 0, p < 0.05). Most countries outside China began to experience a rapid rise in infection rates 4 weeks after their first case. Some European countries experienced that rise earlier than the USA. The pandemic in Germany, Spain, Italy, and China took 28, 29, 34, and 18 days, respectively, to reach the peak of daily infections, after their daily increase of up to 20 cases. During this time, countries in the African region and Southeast Asian region were at an early stage of infections, those in the Eastern Mediterranean region and region of the Americas were in a rapid growth phase. CONCLUSIONS: After the closure of the outbreak city, appropriate isolation and control measures in the next 8 weeks were key to control the outbreak, which reduced the peak value and length of the outbreak. Some countries with improved epidemic situations need to develop a continuous "local strategy at entry checkpoints" to to fend off imported COVID-19.

Cardiac Injury and Clinical Course of Patients With Coronavirus Disease 2019.

Background: Cardiac injury is recognized as one of the most common critical complications during exacerbation of coronavirus disease 2019 (COVID-19). This study aimed to investigate the effect of cardiac injury on the clinical course of COVID-19 and to examine its potential mechanism and treatments. Methods and Results: A total of 222 hospitalized patients with COVID-19 from Wuhan were selected for the study during February 10 to March 28, 2020. Demographic, laboratory, and clinical data on admission and during hospitalization were compared between patients with COVID-19 with or without cardiac injury. On admission, cardiac injury (n = 29) was associated with advanced age, more underlying coronary artery disease, and a lower Pao2. Troponin levels were correlated with inflammatory markers (C-reactive protein: r = 0.348, P < 0.001; interleukin 6: r = 0.558, P < 0.001) and d-dimer levels (r = 0.598, P < 0.001). During hospitalization, another six patients suffered from cardiac injury and cardiac injury (n = 35), resulting in higher rates of ventilation (invasive: 51.4 vs. 1.6%, P < 0.001; non-invasive: 31.4 vs. 1.1%, P < 0.001) and mortality (54.3 vs. 1.1%, P < 0.001). Cardiac injury on admission was a predictive factor for mortality (adjusted hazard ratio = 4.73, 95% confidence interval = 1.35-16.63, P = 0.015). Receiver operating characteristic curve analysis showed that, on admission, a troponin level of 36.35 pg/mL was predictive for mortality with a sensitivity of 73.7% and a specificity of 92.1%. Conclusions: Cardiac injury complicates the disease course and increases the mortality rate of COVID-19. Troponin levels should be checked at admission and during hospitalization for triage, better monitoring, and managing those with COVID-19, especially in the most severe patients. Condensed Abstract: Cardiac injury is not uncommon in COVID-19. In a cohort of 222 patients with COVID-19, cardiac injury was found in 29 patients on admission and in another 6 patients during hospitalization. The admission level of troponin was well-correlated with inflammatory factors and d-dimer levels and strongly predicted mortality. Cardiac injury is a manifestation secondary to hypoxia and systemic infection, but which nevertheless further complicates the disease course and increases the mortality rate. Troponin levels should be checked at admission and during hospitalization for triage, better monitoring, and managing those with COVID-19, especially in the most severe patients.

Early cases of SARS-CoV-2 infection in Uganda: epidemiology and lessons learned from risk-based testing approaches - March-April 2020.

BACKGROUND: On March 13, 2020, Uganda instituted COVID-19 symptom screening at its international airport, isolation and SARS-CoV-2 testing for symptomatic persons, and mandatory 14-day quarantine and testing of persons traveling through or from high-risk countries. On March 21, 2020, Uganda reported its first SARS-CoV-2 infection in a symptomatic traveler from Dubai. By April 12, 2020, 54 cases and 1257 contacts were identified. We describe the epidemiological, clinical, and transmission characteristics of these cases. METHODS: A confirmed case was laboratory-confirmed SARS-CoV-2 infection during March 21-April 12, 2020 in a resident of or traveler to Uganda. We reviewed case-person files and interviewed case-persons at isolation centers. We identified infected contacts from contact tracing records. RESULTS: Mean case-person age was 35 (±16) years; 34 (63%) were male. Forty-five (83%) had recently traveled internationally ('imported cases'), five (9.3%) were known contacts of travelers, and four (7.4%) were community cases. Of the 45 imported cases, only one (2.2%) was symptomatic at entry. Among all case-persons, 29 (54%) were symptomatic at testing and five (9.3%) were pre-symptomatic. Among the 34 (63%) case-persons who were ever symptomatic, all had mild disease: 16 (47%) had fever, 13 (38%) reported headache, and 10 (29%) reported cough. Fifteen (28%) case-persons had underlying conditions, including three persons with HIV. An average of 31 contacts (range, 4-130) were identified per case-person. Five (10%) case-persons, all symptomatic, infected one contact each. CONCLUSION: The first 54 case-persons with SARS-CoV-2 infection in Uganda primarily comprised incoming air travelers with asymptomatic or mild disease. Disease would likely not have been detected in these persons without the targeted testing interventions implemented in Uganda. Transmission was low among symptomatic persons and nonexistent from asymptomatic persons. Routine, systematic screening of travelers and at-risk persons, and thorough contact tracing will be needed for Uganda to maintain epidemic control.