Planning for a second wave pandemic of COVID-19 and planning for winter : A statement from the Association of Schools of Public Health in the European Region.

A second wave of COVID-19?

There is no clear definition of a ‘second wave’ of COVID-19. Many countries are grappling with resurgences in different forms. ASPHER suggests a second wave could be defined as: a resurgence of the incidence rate during a pandemic, which cumulatively presents an exponential increase in the number of cases of the disease in a given time period and specific territorial zone. This exponential increase follows from the disappearance or near disappearance of cases of the disease and may be influenced by a new behavioural characteristic of the infectious agent or a modified characteristic from another already known (Middleton et al. 2020).

A perfect storm

ASPHER believes northern hemisphere countries should expect a second wave of the COVID-19 pandemic, from the autumn (IHME 2020; Academy of Medical Sciences 2020). Countries face a perfect storm of resurgences of COVID-19, a severe flu season, pandemic unmet long-term health needs, some induced by lockdown, additional deaths from cold-related conditions and additional disease related to severe economic breakdown. In planning for these problems, we must assume there is no political will for full lockdowns, no herd immunity and no effective widely available vaccines and antiviral treatments (Middleton et al. 2020).

Second wave COVID-19

Non-pharmaceutical measures which have been applied across the globe in the first wave will be the major part of our response including: enhanced localised surveillance, test and trace, face masks, physical distancing, shielding of vulnerable individuals, quarantine of affected persons and bans on mass gatherings. Adequate stockpiles of personal protective equipment (PPE) are needed for health and care systems (Academy of Medical Sciences 2020). All will need to be delivered at an intensity and scale not previously achieved.

Planning for a severe flu season

Countries need to plan to deliver an enhanced programme of flu vaccination to protect vulnerable patients, in the expectation of severe seasonal flu. Children’s immunisation programmes must achieve high coverage (Academy of Medical Sciences 2020; CDC 2020). Health and care staff must be vaccinated to protect themselves and their patients (Van Hems et al. 2011).

Planning for winter

There is excess winter mortality across Europe, not necessarily related to absolute temperature levels. Cold housing is present in many countries. Cold stress is amenable to public health intervention to provide affordable warmth and prevent exposure to cold, and public health authorities should plan accordingly (Fowler et al. 2015).

The recoiled spring of unmet health needs

Countries will need to address what ASPHER is calling ‘the spring effect’. (1) A spring is squeezing tighter with the impact of new, previously unrecognised disease and untreated and uncontrolled existing long-term conditions and conditions requiring surgical treatment over the pandemic period (Rosenbaum 2020). At some point, the spring will open violently impacting massively on already exhausted health services. Health services must take advantage of current decreases in COVID-19 cases requiring hospitalisation to use capacity to address the backlog in regular care. Strong priority should be given to procedures that may produce aerosols; diagnosing cancer; serious cardiac disorders; delayed essential surgical procedures; review of patients with severe mental illness; cancer screening catch-up programmes; and immunisation catch-up programmes (Middleton et al. 2020; Academy of Medical Sciences 2020).

Lockdown illnesses—physical, mental and social

There will be added tension to the spring, from new cases of illness brought about through inactivity, processed food consumption, alcohol, overcrowding, mental distress, loneliness and domestic abuse during lockdowns (Middleton et al. 2020).

The impact of health and care staff burnout, post-traumatic experiences and exhaustion

Health workers are being confronted with depression, anxiety, stress, burnout, emotional distress, acquired or made worse during the pandemic. Health systems need to develop support mechanisms, including occupational health and counselling to support healthcare staff (Middleton et al. 2020).

Economic and social intervention

Deepening economic recession will lead to increasing unemployment and adverse effects on health, multiplying the effects of the virus, the winter and seasonal flu. Governments should apply economic and social measures that reduce inequalities in health and give protection to their communities. Measures should include economic, transport and housing protections and pay particular attention to the educational and developmental needs of children, minorities, migrants, the homeless and hidden poor (Middleton et al. 2020; UNDP 2020).

Governments should also facilitate other economic measures for the protection of their citizens: preventing gaps in supply of goods and services especially food, water and electricity; maintaining a strong public sector with adequate finances; and strengthening international cooperation/cross-border mobility not only regarding goods and services, but especially regarding medical products/devices and services (Middleton et al. 2020; UNDP 2020).

Policies by consent, understood and supported by the people

Policies must not be directed against people, but based in community cooperation and be community-led wherever possible. They must support communities to use their personal capabilities and community assets (Middleton et al. 2020).

Planning for a second wave, planning for winter

ASPHER recommends the following four priorities for detailed winter preparedness: engage widely now with excluded and vulnerable groups to prepare for a winter second wave; re-establish and reinforce essential health and social services, to catch-up over summer and autumn and to preserve their function during the winter wave; instigate social and economic policies to underpin good quality of life during the economic downturn from the first or second wave; reduce excess mortality; and keep older people and all others with long-term conditions safer this winter (Middleton et al. 2020; Fowler et al. 2015; ASPHER 2020).

Conclusion: plan for the worst, while hoping for the best

COVID-19 is here to stay, unless governments commit to zero COVID-19 strategies. Short of this, the future course of the pandemic will play out different scenarios such as low-grade continuing infectivity, gradually infecting more younger people; local and multiple outbreaks on a small scale; or disastrous uncontrollable second waves in many countries.

The pandemic highlights pre-existing ill health due to social and economic inequalities. We do not have a pandemic problem, but a social problem that is reflected by the pandemic. We should extract something positive from this social experience. The measures taken could improve the sense of common citizenship, social participation and mutual responsibilities among people from all social backgrounds, within countries and internationally.

In this respite for many countries, ‘we should not use this time to celebrate, but to plan’ (Cole 2020). In the best traditions of emergency preparedness, we should ‘hope for the best, but plan for the worst’. We call on all governments to meet these needs in this new and more challenging phase of the pandemic.