COVID-19: operationalization of the global response strategy in the WHO European Region: September 2020

COVID-19 Operationalization of the Global Response Strategy in the WHO European Region September 2020 © Times of Malta ©WHO Acknowledgements The Incident Management Support Team (IMST) in the WHO Regional Office for Europe developed this document under the supervision of Dr Dorit Nitzan, Regional Emergency Director. The document is the result of the contributions from across all the divisions in the Regional Office for Europe, working together in support of the Member States response to COVID-19. © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Designed by: www.freightdesign.co.uk Document number: WHO/EURO:2020-1073-40819-55167 COVID-19 Operationalization of the Global Response Strategy in the WHO European Region About this document 6 Current situation and key insights in the WHO European Region 7 European regional strategy to respond to COVID-19 9 Working together as one 10 National strategies to respond to COVID-19 11 National operational plans for responses 11 Engage and mobilize communities to limit exposure 12 Find, isolate and test cases; track and quarantine contacts to control transmission 13 Provide clinical care and maintain essential health services to reduce mortality 14 Adapt strategies to national and local contexts based on risk, capacity and vulnerability 15 Prevent and suppress community transmission 15 Transition and maintain a steady state of low-level or no transmission 16 Adapt to low-capacity settings 17 Humanitarian settings, vulnerable and high-risk groups 18 International community’s response to COVID-19 20 Coordinate support for countries and monitor country preparedness and response 20 Understand the regional epidemiology, develop regional analytics and conduct 20 ongoing risk assessments Coordinate supply chain management across the Region 21 Accelerate research, innovation and knowledge sharing 22 Strengthen preparedness for future emergencies 23 Annex 25 Annex 1: Adaptation of response measures based on scale of transmission 25 Annex 2: Adaptation of response measures based on health system capacity, 30 resourcing and context COVID-19 Strategy for the WHO European Region 5 6 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 7 The COVID-19 pandemic has been exacting an enormous toll on individuals, families, communities and societies across the globe. Since mid-February, COVID-19 has quickly spread across Europe and has profoundly impacted the societal and economic situation, even in countries with the most robust and sophisticated health systems in the WHO European. This document outlines the WHO European Regional strategy to respond to COVID-19 and its consequences, based on WHO’s global strategy update for COVID-191, covering the period February -December 2020. The estimated funding needs of the WHO European Region, for this period, amount to US$ 175 million.2 This strategic document is relevant to the diverse contexts that exist across the WHO European Region, and to countries implementing a wide range of national and subnational responses. The strategy is flexible and adaptable to national and subnational contexts and guides countries in rapidly bringing COVID-19 cases under control, and in preparing for a phased transition from a widespread transmission to a steady state of low-level or no transmission. This strategy considers the needs of the WHO European Region (Member States and Secretariat) to prepare for a new operating norm in which the COVID-19 virus is taken into account in decision- making across the whole of society and the whole of government until such a time that transmission of the virus can be suppressed nationally and globally. It highlights the coordinated support that is required from the international community and complements other plans (including the Global Humanitarian Response Plan (HPRP)).3 1 WHO. COVID-19 strategy update, 14 April 2020. Geneva: World Health Organization; 2020. (https://www.who.int/publications/i/item/covid-19-strategy-update-13-april-2020, accessed 11 May 2020). 2 COVID-19 WHO Appeal, updated 24 May 2020, Geneva World Health Organization, 2020 (https://www.who.int/publications/m/item/covid-19-who-appeal, accessed 14 July 2020) 3 The HPRP addresses COVID-19 response in humanitarian and fragile settings. For the Global Humanitarian Response Plan, see: UN. Global humanitarian response plan COVID-19. New York: United Nations; 2020. (https://www.unocha.org/sites/unocha/files/Global-Humanitarian-Response-Plan-COVID-19.pdf, accessed 11 May 2020). Every country needs to implement a comprehensive set of measures according to their own capacity and contextual specificities in order to slow down transmission and to reduce the morbidity and mortality associated with COVID-19, while maintaining comprehensive health care services along the continuum of care and life- course, public health services and maintaining civil liberties as much as possible, with the ultimate aim of reaching and/or maintaining a no transmission status. Practical guidance on adaptations of response measures, based on transmission scenarios and health system capacities, is provided in Annex 1 and 2 of this document. About this document © WHO © WHO/Tunc Ozceber 6 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 7 Current situation and key insights in the WHO European Region COVID-19 is a new disease and, although many gaps in knowledge remain, much has been learned about its characteristics and impact on health during the response. The COVID-19 virus spreads rapidly and can quickly overwhelm health systems while also placing societies under significant strain. Governments, WHO and partners have been working urgently to save lives through the development of public health and clinical countermeasures.4 At present, there are no specific treatments for COVID-19, though early evidence indicates that dexamethasone may reduce mortality in severely ill patients. According to data from countries affected early in the pandemic, about 40% of cases experience mild disease, 40% have moderate disease, 15% of cases suffer from severe disease, and 5% of cases require intensive and critical care. Over 26 million cases of COVID-19 have been seen worldwide, with deaths exceeding 863,020 (as of 4 September 2020). The most recent situation update can be found on our website.5 WHO’s risk assessment of the situation is being regularly reviewed as the emergency evolves, and the current level of risk to public health associated with COVID-19 is considered globally as very high risk. 4 WHO. A coordinated global research roadmap. Geneva: World Health Organization; 2020. (https://www.who.int/publications/m/item/a-coordinated-global-research-roadmap, accessed 11 May 2020). 5 WHO. Coronavirus disease (COVID-2019) situation reports [website]. Geneva: World Health Organization. (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/ situation-reports, accessed 11 May 2020). 6 The analysis of this data has been conducted based on the information available on the case forms reported so far to the WHO Regional Office for Europe. It is relevant to note that not all case reporting forms include complete data; for example, the existence of underlying conditions or on whether the patient is a health care worker. Countries are encouraged to continue sending their case reporting forms to inform this regional analysis. Since late February 2020, the pandemic has evolved extremely rapidly, first in the WHO European Region, then in the Regions of the Americas, the Eastern Mediterranean and South-East Asia, with most countries in the European Region reporting community transmission. Based on the available information,6 (11 March 2020 to 26 June 2020) in the WHO European Region: • 21% of all reported infections were in health care workers. • 89% of deaths were in people aged 65 years and older. • 95% of deaths were in people who had at least one underlying condition, with cardiovascular disease the leading comorbidity (66%). • 46% of all cases and 57% of all deaths were among males. 27% of cases required hospital admission and 2% of laboratory-confirmed cases were admitted to intensive care units (ICUs). • 76% of intensive care unit admissions were in persons aged 50–79 years of age, with 70% of all ICU admissions in men. Countries are at different stages in the evolution of their national outbreaks with significant variations observed at subnational levels. © WHO Several lessons have already been identified • Political leadership and strong governance, with effective structures and participatory mechanisms to incorporate the whole of government and whole of society, are needed for preventing, preparing for, responding to and recovering from the spread of the virus. • Early and comprehensive public health measures, including case identification, isolation, testing, contact tracing and quarantine can prevent explosive transmission, allowing health systems to cope with the demand. • Removal of barriers to access free testing and health services is critical to preventing spread and protecting health care workers and communities, particularly those at higher risk of exposure and in situations of vulnerability. • The health workforce must be protected at all levels of care, including in social and care services. • Protecting older people and other vulnerable populations is key, in particular those with underlying health conditions, such as noncommunicable diseases (diabetes, cardiovascular diseases, cancer and severe obesity). • Having access to real-time health information for decision-making at all levels of the health system is crucial in guiding an effective, timely and targeted response, including for the allocation of vital equipment and resources needed to mobilize and coordinate response. efforts. • Communicating risks effectively, promoting health-seeking behaviours, and encouraging community engagement enable individuals and communities to make informed choices to stay safe and healthy, prevent the further spread of the virus and contribute to the response. • Identifying and activating surge capacities at all levels of clinical care, public health and social services is needed as the disease spreads. • Physical distancing measures are necessary when community transmission is widespread and should be complemented with health promoting strategies around mental health, nutrition, physical activity, and tobacco and alcohol consumption. • Ensuring excluded communities or communities at greater risk of vulnerability, such as the homeless, refugees and migrants, those at risk of domestic violence, single parents, people with pre-existing conditions or those at risk of isolation, children living in poverty and relying on school meals are supported through community- based or local government initiatives is essential to the response. • Effectively leverage and integrate different data and information systems, at national and subnational levels, can facilitate data-driven decisions to achieve desired outcomes. © Baku Media Center 8 COVID-19 Strategy for the WHO European Region Response principles: data-focused; balanced; agile; flexible; context-appropriate; time-sensitive; participatory; preparedness-driven. The overarching goal of the regional strategy is for all countries to slow and stop transmission, preventing outbreaks and delaying the spread of COVID-19; to reduce mortality and morbidity by providing optimized care for all patients, especially the seriously ill; and minimize the impact of the pandemic on health systems, social services, communities and economies. Simultaneously, this plans looks to identify ways in which the continuity of essential health services can be maintained, with the ultimate objective of ensuring overall sustainability of the health system. The strategic objectives of the regional strategy are to: • Mobilize and engage all sectors and communities to ensure that every sector of government and society takes ownership of and participates in the response. • Identify and control sporadic cases and clusters and prevent community transmission by rapidly finding and isolating all suspected cases and/or those with suspected symptoms though large-scale decentralized testing; providing them with appropriate care; and tracing, quarantining and supporting all contacts. 7 WHO. Vision and strategic directions: Why is united action for better health needed? [website]. Copenhagen: WHO Regional Office for Europe; 2020. (https://www.euro.who.int/en/about-us/regional-director/vision-and-strategic-directions, accessed 11 May 2020). • Prevent and suppress community transmission through context-appropriate infection prevention and control measures, physical distancing measures and appropriate and proportionate restrictions on non-essential domestic and international travel, while minimizing the impact of the pandemic on social services and economic activity. • Ensure continuity of essential, people-centred health and social services. • Learn from the European experience and innovate for the development of safe and effective vaccines, therapeutics and technologies that can be delivered at scale, with equitable access and an approach based on global solidarity. • Leverage effective partnerships to mitigate the socioeconomic impact of COVID-19 response measures. • Build resilient health systems with emphasis on the essential public health operations, to advance universal health coverage, including preparedness capabilities to withstand epidemic shocks. While this objective will require medium- and long-term actions, efforts to suppress the pandemic today may lead the way for building the resilient, integrated and person-centred health and long-term care systems of tomorrow. The WHO Regional Office for Europe COVID-19 strategy is in line with and will contribute to the European Programme of Work (EPW) towards “United Action for Better Health”7 being presented for discussion and adoption by the WHO Regional Committee for Europe in September 2020. European regional strategy to respond to COVID-19 © WHO COVID-19 Strategy for the WHO European Region 9 It will also support the implementation of the Thirteenth General Programme of Work (GPW13)8 and achievement of the Strategic Development Goals (SDGs).9 The activities are built around a comprehensive strategy to prevent the spread of the pandemic, save lives and minimize impact, by targeting four areas: prepare and be ready; detect, protect and treat; reduce transmission; innovate and learn. Working together as one The international community has been working together across borders and at the country level through the “one UN approach” when applicable. WHO representatives have been leading the health response in collaboration with UN Resident Coordinators (UNRCs) and all members of the UN Country Teams (UNCTs), while contributing to the public health implications of the broader socioeconomic response to the pandemic led by UNRCs. WHO is providing, and will continue to provide, substantial technical and operational support to countries in the areas of operational planning, laboratory support, health systems preparedness and hospital readiness, surveillance, infection prevention and control, clinical management, essential medicines and packages of care, public health services and risk communication and community engagement. Support to countries is delivered through WHO Country offices, in coordination with the Incident Management Support Team (IMST) at the WHO Regional Office for Europe and in collaboration with operational partners, including the Global Outbreak and Response Network (GOARN) 10 8 WHO. Thirteenth General Programme of Work 2019–2023. Geneva: World Health Organization; 2019. (https://www.who.int/about/what-we-do/thirteenth-general-programme-of- work-2019---2023, accessed 11 May 2020). 9 UN. Transforming our World: the 2030 Agenda for Sustainable Development. New York: United Nations (https://sustainabledevelopment.un.org/post2015/transformingourworld, accessed 11 May 2020). 10 For more information about GOARN, see: GOARN: Global Outbreak and Response Network [website]. Geneva: World Health Organization. (https://extranet.who.int/goarn, accessed 11 May 2020). 11 For more information about EMTs, see: WHO. Emergency medical teams and World Health Organization [website]. Geneva: World Health Organization. (https://www.who.int/ emergencies/partners/emergency-medical-teams, accessed 11 May 2020). 12 WHO. Partnerships. In: Sustainable Development Goals [website]. Copenhagen: WHO Regional Office for Europe (https://www.euro.who.int/en/health-topics/health-policy/ sustainable-development-goals/partnerships-and-intersectoral-action, accessed 11 May 2020). 13 WHO. Global action plan for healthy lives and well-being for all. In: Global Action Plan [website]. Geneva: World Health Organization. (https://www.who.int/sdg/global-action-plan, accessed 11 May 2020). 14 SEEHN. South-Eastern Europe Health Network [website]. (https://www.euro.who.int/en/about-us/networks/south-eastern-europe-health-network-seehn, accessed 11 May 2020). 15 WHO. WHO European Healthy Cities Network [website]. Copenhagen: WHO Regional Office for Europe. (https://www.euro.who.int/en/health-topics/environment-and-health/ urban-health/who-european-healthy-cities-network, accessed 11 May 2020). and the Emergency Medical Teams (EMTs).11 WHO is also making use of mechanisms such as the Regional Issue-based Coalition for Health (IBC),12 bringing together 14 UN agencies and other development partners and the Global Action Plan for Health.13 Professional networks of experts in respiratory pathogens have also been leveraged to support countries. In addition, GOARN, IFRC, UNICEF and WHO coordinate technical and operational support on risk communication, with a special focus on highly vulnerable populations. WHO is collaborating with the European Centre for Disease Prevention and Control (ECDC), regional networks and counterparts, to update and enhance surveillance strategies. Together with humanitarian partners, support is being provided for the implementation of public health measures in over-crowded environments, such as refugee and migrant camps, detention centres and prisons. As many European countries have become the pathfinders of the current global response, different regional platforms are being used to further disseminate the know-how and to share experiences and expertise (including the Commonwealth of Independent States (CIS), the South-Eastern European Health Network (SEEHN)14, the European Union, WHO’s Small countries initiative, WHO’s Regions for Health Network15, the WHO European Healthy Cities Network, the Schools for Health in Europe network, and the Partnership for Health in the Criminal Justice System). 10 COVID-19 Strategy for the WHO European Region Each country should continue implementing its Country Preparedness and Response Plan (CPRP) and associated operational plans, based on whole-of-government and whole-of-society approaches, and a realistic appraisal of what is feasible to achieve in terms of slowing down transmission and reducing mortality. Plans must be flexible and adaptable to respond rapidly to changes in epidemiological situations and take into account the local contexts and capacities to respond.16 The core pillars of an effective national response have been set out in detail in the Strategic Preparedness and Response Plan (SPRP February 2020) and their practical implementations are outlined in Annexes 1 and 2. The International Health Regulations (IHR) 200517 remain the legal and technical basis for all country- level and international preparedness and response efforts. They are the normative basis for all actions undertaken to prepare for, respond to and recover from this pandemic. IHR core capacities are being put to the test: gaps are being revealed even in the most robust public health and health care systems, and the lessons of COVID-19 are being documented so that they can be applied in future joint efforts to strengthen health systems, including the essential public health operations, and reinforce health security. Every national strategy plays a crucial part in meeting the regional and global objectives in the response to the pandemic, and must, at a minimum, set out the basis for: • Leadership and coordination of the national and subnational responses. • Engagement, empowerment and mobilization of communities. 16 For current WHO guidance, see: WHO. Critical preparedness, readiness and response actions for COVID-19 [website]. Geneva: World Health Organization. (https://www.who.int/publications/i/item/critical-preparedness-readiness-and-response-actions-for-covid-19, accessed 14 July 2020). 17 WHO. International Health Regulations. Geneva: World Health Organization; 2008. (https://www.who.int/ihr/publications/9789241596664/en/, accessed 11 May 2020). • Implementation of context-appropriate public health measures to slow transmission and control sporadic cases. • Preparation of the health system to reduce COVID-19-associated mortality, adapt its capacity to the increased burden of cases, maintain essential services, protect health workers and be ready for the next emergency. The following sections provide strategic direction for national authorities to take immediate action. National operational plans for responses Successful implementation of adaptive COVID-19 preparedness and response strategies will depend on the whole-of-society being engaged in the plan, and strong national and subnational coordination mechanisms being in place, with well-managed command- and-control structures implemented, when necessary. Many countries have activated national public health and disaster/crisis management policies, empowering authorities to prepare, plan and respond to COVID-19, such as the Pandemic Influenza Preparedness plans (PIPs). These plans should be adapted to the COVID-19 context and include capacity assessments and risk analyses to identify high-risk and vulnerable populations. Where appropriate, plans should include local government, not-for-profit providers such as those working with the homeless, civil society, faith-based organizations and nongovernmental organizations (NGOs) to extend the reach of public health and socioeconomic interventions. National strategies to respond to COVID-19 © WHO COVID-19 Strategy for the WHO European Region 11 The coordinated management of COVID-19 preparedness and response should include the engagement of all levels of government and relevant ministries, such as health, agriculture, education, environment, finance, public works, social protection, transport, travel and tourism, and water and sanitation, to ensure a coordinated whole-of-government approach and to mitigate the social and economic impacts. WHO, together with the UN and its partners and all national and regional health sector partners, will act in coordination, to ensure that the best support possible is provided to national and local authorities and communities affected by COVID‐19. Engage and mobilize communities to limit exposure Stopping the transmission of COVID-19 and protecting people will require the participation of communities, including those at risk and most affected. Informed and empowered populations can protect themselves by taking measures at the individual and community level that will reduce the risk of transmission. It is therefore essential that international, national and local authorities engage through participatory two- way communication efforts proactively, regularly, transparently and unambiguously with all those affected, while acknowledging the uncertainty of the outbreak evolution, with a view to harnessing community resilience and social solidarity. Ensuring that global and regional recommendations and communications are tested and adapted to local contexts, and that messages and public health advice are based both on the risk assessment and the risk perception, is an essential part of helping countries to empower communities to own the response and control the COVID-19 pandemic. Risk communication and community engagement (RCCE) are integral parts of the WHO European Region COVID-19 readiness and response strategy and are public health interventions in themselves. At the country level, the overall RCCE goal is to ensure that people comply with health protection measures recommended by the health authorities and adopt protective behaviours that contribute to the control of the COVID-19 pandemic nationally and globally. 18 WHO. WHO tool for behavioural insights on COVID-19. In: Coronavirus disease (COVID-19) outbreak [website]. Copenhagen: WHO Regional Office for Europe; 2020. (http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/technical-guidance/who-tool-for-behavioural-insights-on-covid-19) The role and importance of trust is central to this: essential factors contributing to trust are timely, accurate and transparent communications, coordination and consistency, relevant and tailored messages based on risk perception and delivered through effective channels and key influencers. Engaging communities and empowering stakeholders to find and implement the solution is at the core of an effective response. This also includes establishing mechanisms to gather risk perception and behavioural insights of segmented population groups as the basis of RCCE strategies. Strong coordination between national and subnational stakeholders and across sectors is essential to establishing authority and trust. One of the objectives of the RCCE strategy is to establish an RCCE working group, engaging all response authorities centrally and locally to ensure the development and implementation of a nationally coordinated communication strategy and plan across all transmission scenarios. Participatory community engagement interventions should include accurate information on risks, what is still unknown, what is being done to find answers, what actions are being taken by health authorities, and what actions those at risk can take to protect themselves. Nonmedical sectors need to be engaged to ensure availability of hygiene measures, water, hygiene articles, soap and disinfectants, to allow implementation of guidance at all levels of society. Action at the community level is also essential to addressing other health consequences of response measures to the pandemic, such as the impact on mental health or on gender-based violence (GBV). The emphasis for engagement should be on vulnerable people and populations. The WHO Regional Office for Europe will continue supporting countries with RCCE guidance and strategies along the various scenarios. To manage rumours and respond to the infodemic, WHO monitors communication about COVID-19 at the regional and country levels and support countries establishing agile risk perception mechanisms through the Behavioural Insight tool18. 12 COVID-19 Strategy for the WHO European Region Trusted channels of communication and information, through resources, such as global and regional COVID-19 dashboards, global WHO social media chatbots and EPI-WIN, and the regional HealthBuddy,19 Global ShaperS20 and the RCCE topic webinars, play critical roles in meeting information needs. Find, isolate and test cases; track and quarantine contacts to control transmission Mild cases continue to be the driver for the pandemic. Stopping the spread of COVID-19 requires finding, isolating and testing all suspected cases/symptomatic patients so that they are promptly isolated, tested, receive care and their contacts are identified and quarantined for the duration of the incubation period. Suspected cases should be isolated and tested. Within 48 hours of symptom onset. It is essential to identify and trace contacts of every confirmed or probable case, and quarantine them for 14 days. This ensures that even asymptomatic cases that may arise do not mix with the general population. As per obligations under IHR (2005), every effort must be made to support individuals undergoing quarantine, including through the provision of psychosocial support, ensuring continuity of any routine medication and health care as needed. Countries and communities must strengthen their capacity to find suspected cases of COVID-19 in the general population. Repurposing proven surveillance systems already active in the WHO European Region and rolled-out in close collaboration with the ECDC for respiratory diseases is essential. This includes indicator‐based surveillance, community event‐based surveillance and sentinel surveillance (e.g. severe acute respiratory infection and influenza‐like illness), and active case-finding at points of entry, health facilities and in communities. Countries may need to rapidly scale-up their workforces to find cases, including by looking outside traditional public 19 WHO. HealthBuddy. In: Coronavirus disease (COVID-19) outbreak [website]. Copenhagen: WHO Regional Office for Europe; 2020. (https://www.euro.who.int/en/health-topics/ health-emergencies/coronavirus-covid-19/healthbuddy, accessed 19 May 2020). 20 WHO. COVID-19: WHO joins forces with young Global Shapers to disseminate health advice. In: Coronavirus disease (COVID-19) outbreak [website]. Copenhagen: WHO Regional Office for Europe; 2020. (https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/5/covid-19-who-joins-forces-with-young-global- shapers-to-disseminate-health-advice, accessed 19 May 2020). health systems to train non-public health professionals and volunteers, and using novel technologies where possible. During periods of sustained community transmission, diagnostic capacity may be limited and it may be necessary to prioritize testing of: vulnerable populations, including those at risk of developing severe disease; symptomatic health workers and essential staff; those needing additional measures in order to receive testing, such as the homeless or undocumented migrant populations; and the first symptomatic individuals in closed settings (e.g. schools, long-term living facilities, prisons, hospitals, camps etc.) to identify and control outbreaks. © WHO © WHO COVID-19 Strategy for the WHO European Region 13 In these contexts, where widespread testing is not possible or is limited, a syndromic approach to COVID-19 case detection based on reported symptoms or signs can be applied to identify and isolate suspected cases. All COVID-19 suspected cases should be safely and rapidly isolated (whether confirmed through testing or based on symptoms or signs) to prevent onward transmission in the community. They can be isolated in households or, if it is possible and feasible, in dedicated facilities. In either case, all isolated confirmed cases should be provided with appropriate care and support. The WHO Regional Office for Europe will continue supporting countries with guidance for finding, isolating and testing as well as strengthening their capacity to find suspected cases and contacts to COVID-19 cases. Provide clinical care and maintain essential health services to reduce mortality One of the defining features of COVID-19 is the burden placed on health systems and health workers by the large proportion of patients who require safe and effective clinical care. Many patients with severe disease need help to breathe, with outbreaks placing strain on staffing levels, availability of equipment, and crucial supplies such as medical oxygen and personal protective equipment (PPE). Establishing effective pathways for COVID-19 and non-COVID-19 cases along the continuum of care, through early detection, screening, triage, transitions, targeted referral, early planned discharge, among other community care and general practice, is essential in all settings of care. The use of digital technologies, such as telemedicine, mobile health, and other innovative approaches that facilitate access to remote care and monitoring, should be explored and incorporated into mainstream care pathways. This burden on the health systems, combined with the disruptive impact on widespread control measures, must be mitigated in order to minimize 21 WHO. Guidance on routine immunization services during COVID-19 pandemic in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2020. (https://www.euro.who.int/__data/assets/pdf_file/0004/433813/Guidance-routine-immunization-services-COVID-19-pandemic.pdf, accessed 11 May 2020). 22 WHO. Strengthening the health system response to COVID-19. Recommendations for the WHO European Region. Policy brief (1 April 2020). Copenhagen: WHO Regional Office for Europe; 2020. (http://www.euro.who.int/__data/assets/pdf_file/0003/436350/strengthening-health-system-response-COVID-19.pdf?ua=1, accessed 11 May 2020). 23 WHO. Strengthening the health systems response to COVID-19: Technical guidance #1, 18 April 2020. Copenhagen: WHO Regional Office for Europe; 2020. (https://www.euro. who.int/en/health-topics/Health-systems/pages/strengthening-the-health-system-response-to-covid-19/technical-guidance-and-check-lists/strengthening-the-health-systems- response-to-covid-19-technical-guidance-1,-18-april-2020, accessed 11 May 2020). 24 WHO. Surge planning tools [website]. Copenhagen: WHO Regional Office for Europe. (https://www.euro.who.int/en/health-topics/Health-systems/pages/strengthening-the- health-system-response-to-covid-19/surge-planning-tools, accessed 11 May 2020). the negative health impacts of COVID-19 on individuals who depend on essential, non-COVID- 19-related services. It is crucial to ensure the continuity of emergency and essential care services, such as vaccinations,21 for children, pregnant women, older people and for people living with and affected by noncommunicable diseases and mental health conditions (e.g. cancer, diabetes, hypertension, asthma, depression, dementia and alcohol or drug-use disorders) along the continuum of care, from prevention, early detection, diagnosis, treatment, management, rehabilitation and palliation. The Policy Brief22 and interim technical guidance on health system strengthening for the COVID-19 response23 developed by the WHO Regional Office for Europe, and the three surge planning tools24 should be used by Member States to plan and ensure surge capacities for all health system functions. Innovative solutions to increase health care capacity, including for non-COVID-19 cases, will be required, such as repurposing existing public and private facilities to provide safe areas for emergency case management, quarantine and isolation – this should be feasible even in remote and low resource areas. Rapid expansion of clinical capacity for life- saving measures should be focused on care for most patients through simple treatments such as providing oxygen. It is also likely there will be substantial number of individuals with long-term sequelae (e.g. lung fibrosis) which will need follow- up. Continuity of care should be coupled with an international research agenda that provides evidence for treatment as well as modifications to health services to address new needs. Maintaining population trust in the capacity of health services and the health system to safely meet essential needs and to control infection risk in health facilities is key to ensuring appropriate care-seeking behaviour and adherence to public health advice. 14 COVID-19 Strategy for the WHO European Region The WHO Regional Office for Europe will continue supporting countries to provide safe and effective clinical care and maintenance of essential health services through technical assistance, support and supplies together with evidence-based guidance that can be tailored to each country’s needs, level of outbreak and settings. Adapt strategies to national and local contexts based on risk, capacity and vulnerability Adaptation of strategies should be governed by evidence-based criteria using continuous monitoring of the situation and based on the precautionary principle. The ability of countries to engage and mobilize communities; find, isolate and test cases; provide effective clinical care; and maintain essential health services will differ according to their specific context, including their capacities to respond to the diverse levels of risk exposure, intensity and prevalence of COVID-19 transmission, and the pre-existing and emerging or developing situations of vulnerability in communities. Every country must put in place comprehensive public health and primary health care measures to maintain a sustainable steady state of low-level or no transmission and have the capacity to rapidly control sporadic cases and clusters of cases to prevent community transmission from occurring. This approach needs to be applied at the lowest administrative level possible in each country to ensure a tailored and appropriate response depending on the situation and local capacities. In addition, public health and primary health care services will need to be guided and supported while preparing to respond to non-COVID-19 critical needs of the community. The WHO Regional Office for Europe will support countries in adopting and adapting WHO normative guidance to local contexts and conditions, taking factors such as feasibility, equity and acceptability into consideration, in view of facilitating and scaling-up the implementation of evidence-based strategies and interventions. Prevent and suppress community transmission While countries must find, isolate and test suspected cases; track and quarantine contacts to control transmission, in countries and/or subnational regions where there is a risk of community transmission becoming established, authorities must immediately adopt additional physical distancing measures and movement restrictions (see Annex 1, Part 3 Prevent, suppress and slowdown transmission). Targeted and time-limited implementation of these measures will potentially reduce morbidity and mortality by slowing the transmission of COVID-19 and relieving some pressure on clinical care services. However, these measures should be based on a thorough risk assessment, proportionate to the public health risk, be time-limited and reconsidered regularly, as well as implemented with the understanding, consent and participation of communities, and based on the principle of doing no harm. Support systems must be in place to ensure communities are able to comply with these measures. Individuals, especially the most vulnerable, must also be supported (and be provided with refuge or safe spaces and supplies where necessary) through coordinated economic and social measures that provide incentives to participate, and which mitigate negative social and economic consequences. Food security, mental health, and gender safeguarding issues, including the need to protect women and children from an increased risk of domestic abuse, are areas of particular concern. The precise nature and feasibility of implementing these measures will be heavily dependent on the context in which affected communities live. Measures for humanitarian settings, vulnerable and high-risk groups and low-capacity settings are detailed below. The WHO Regional Office for Europe stands ready to provide the guidance and support needed for countries to find the best ways to implement these measures in each setting. COVID-19 Strategy for the WHO European Region 15 Transition and maintain a steady state of low-level or no transmission For many countries and subnational authorities and communities, managing a controlled transition from a scenario of community transmission to a sustainable, steady state of low-level or no transmission is the best-case outcome in the short and medium term in the absence of safe and effective pharmaceutical solutions and a vaccine. For countries yet to report community transmission, preventing the escalation of transmission and maintaining a steady state of low-level or no transmission may be feasible. Achieving either of these aims will hinge on the ability of national and/or subnational authorities to ensure that six key criteria are satisfied: 1. COVID-19 transmission is controlled. Ideally, there would be at most sporadic cases, all from known contacts or importations; at a minimum, new cases would be reduced to a level that the health system can manage based on clinical care capacity. 2. Sufficient health system capacities are in place. Three key capacities would need to be in place to contain all new cases and transmission chains, whether due to indigenous cases (including asymptomatic cases) or importations: • isolation of cases and quarantine (and support) of traced contacts for 14 days; • case investigation and contact tracing for confirmed cases, or cases with COVID-19 compatible symptoms; and • large-scale decentralized testing of suspected cases and/or symptom-based case-finding. 3. Outbreak risks in special settings are minimized. All major drivers and/or amplifiers of COVID-19 transmission would be identified, with appropriate measures in place to minimize the risk of new outbreaks (e.g. appropriate infection prevention and control in health care facilities, long-term care facilities and other residential care settings, prisons and other places of detention, universities and trade schools, bars and restaurants, places of worship, etc.). 4. Workplace preventive measures are established to reduce risk, including the appropriate directives and capacities to promote and enable standard COVID-19 prevention measures in terms of physical distancing, hand washing, respiratory etiquette and, potentially, temperature monitoring. © WHO 16 COVID-19 Strategy for the WHO European Region 5. Importation risks can be managed. The likely origin and routes of importations would be understood, and measures would be in place to rapidly detect and manage suspected cases among travellers at points of entry, health care facilities and communities (including the capacity to quarantine with possible contacts or those individuals arriving from countries with community transmission). 6. Communities are engaged in the transition. Communities are an integral part of the transition phase and contribute to it by continuing to adhere to guidance. This includes embracing a “new normal” in which prevention measures would be maintained, and playing their role in enabling and in some cases implementing new control measures. Decisions about when and where to attempt the transition to a steady state of low-level or no transmission must be entirely evidence-based and data driven. No decision of this nature should be contemplated without real-time, accurate data on the testing of suspected cases, the nature and isolation status of all confirmed cases, the number of contacts per case and completeness of tracing, and the dynamic capacity of health systems to deal with COVID-19 cases. The WHO Regional Office for Europe is developing guidance to countries for transitioning in and out of such measures and this guidance will accompany this strategy.25 The risk of re-introduction and resurgence of the disease will continue and will need to be sustainably controlled through the rigorous application of public health and primary health care interventions as the virus circulates between and within countries. A balance needs to be struck between the effect of the virus on the community and the effect of the control measures in terms of limiting human rights, economic damage with secondary effects of poverty, social isolation, lack of continuity of education and adverse impacts on mental health and well-being. Communities and affected 25 WHO. WHO/Europe publishes considerations for gradual easing of COVID-19 measures, 24 April 2020 [website]. Copenhagen: WHO Regional Office for Europe. (https://www. euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/4/whoeurope-publishes-considerations-for-gradual-easing-of-covid-19-measures, accessed 11 May 2020). 26 For all current WHO guidance on preparing for and responding to COVID-19 in humanitarian operations, camps and other fragile settings, see: WHO. Coronavirus disease (COVID-19) technical guidance: Humanitarian operations, camps, and other fragile settings as well as refugees and migrants in non-humanitarian and non-camp settings [website]. Geneva: World Health Organization. (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/humanitarian-operations-camps-and- other-fragile-settings, accessed 11 May 2020). populations need to have a say in how they value these factors over the duration of the pandemic. The WHO Regional Office for Europe will continue supporting countries with tailored guidance and technical support. It is also engaged in the processes relating to the development and delivery of a safe and effective vaccine, or vaccines, and therapeutics that may enable a transition away from some of the measures necessary to maintain this state of low-level or no transmission. The principal role of the WHO Regional Office in vaccine development and roll-out will be on preparing for safe and equitable vaccination and deployment when the vaccine is available. Adapt to low-capacity settings Countries with comparatively weak health and social care systems, and limited capacity to offset economic and social costs, including some countries with marked health system fragility and high levels of populations who live in vulnerability, are now reporting sporadic cases, clusters of cases and community transmission.26 The window for containment at the subnational and national level is closing in many countries. The impact of outbreaks in these facilities/settings will depend not only on how effectively health system capacity can be increased and public health measures implemented, but also on the complex interplay of demographics, the prevalence of underlying conditions associated with poor COVID-19 outcomes, the frequency of infections which have similar presentations to COVID-19 (such as bacterial pneumonia and tuberculosis), the relative importance of social, religious and cultural gatherings that have been shown to be important drivers of COVID-19 transmission in other contexts, and the local capacity to provide sustained support to national and subnational authorities in their response efforts. COVID-19 Strategy for the WHO European Region 17 18 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 19 There is a great diversity of vulnerabilities among the countries and populations within the WHO European Region and the COVID-19 pandemic adds to the ongoing responses to emergencies in the Region (Whole-of-Syria, Ukraine, Region-wide measles outbreak and a series of earthquakes) while also having the potential to have both direct and indirect effects across the Region. Moreover, support to implement effective responses and save lives in politically contested areas should be continued and reinforced in the context of COVID-19. It is essential to consider the need for measures tailored specifically to humanitarian settings and high-risk groups, such as people living in informal settlements, prisons and youth detention centres and residents of refugee, migrant and internally- displaced people (IDP) camps, and high-risk groups, including people who use drugs and people with substance-use disorders. Significant mortality from COVID-19 has been reported in long-term care facilities in a number of countries; residents of these facilities – mainly older people, many living with a cognitive, psychosocial or physical disability – therefore constitute a highly vulnerable group. The outbreak may exacerbate circumstances in these settings and deepen social inequality among certain categories of populations. Not dedicating enough resources to these vulnerable groups may also prolong the pandemic as these groups may have a role in driving community transmission. Residents of high-density settings will find it especially hard, or impossible, to effectively comply with physical distancing measures and movement restrictions as envisaged in other contexts, while health facilities in these contexts are unlikely to cope. Widespread testing, contact tracing, treatment, isolation and quarantine measures may also not be feasible without major and rapid coordinated capacity strengthening. In addition, within these contexts, groups such as elderly people, people with disabilities, people in poverty and people with comorbidities have an increased risk of severe outcomes from COVID-19. © UNODC/Maxim Shubovich © WHO Humanitarian settings, vulnerable and high risk groups 18 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 19 Protecting high-risk groups effectively from COVID-19 will require specific planning and implementation from the national level down to the neighbourhood level. As national governments act rapidly to protect their most vulnerable populations, WHO has partnered with the UN Office for the Coordination of Humanitarian Affairs (OCHA) to produce a COVID-19 Global Humanitarian Response Plan (GHRP; issued on 25 March 2020).27 The GHRP sets out the most urgent health and humanitarian actions required to prepare and respond to COVID-19 in these contexts. In Ukraine and Turkey, the GHRP stresses that countries should ensure core support is maintained to the programmes for the most vulnerable, including through UN-coordinated humanitarian and refugee response plans, rather than diverted to fill gaps in the COVID-19 response plans. 27 For the Global Humanitarian Response Plan see: UN. Global humanitarian response plan COVID-19. New York: United Nations; 2020. (https://www.unocha.org/sites/unocha/files/ Global-Humanitarian-Response-Plan-COVID-19.pdf, accessed 11 May 2020). © Syria Relief and Development © Press Centre, Ministry of Health, Kyrgyzstan 20 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 21 The scale of the COVID‐19 pandemic has required an extraordinary shift in the international system to support countries to plan, finance and implement their responses. Countries need authoritative real‐ time information on the evolving epidemiology and risks; timely access to essential supplies, medicines and equipment; the latest available technical guidance and examples of good practices; rapidly accessible and deployable technical expertise; access to an adequately-resourced emergency health workforce and medical teams; and equitable access to newly developed vaccines, therapeutics, diagnostics and other innovations. Particular attention and support from donors, the UN and NGOs will be needed in countries with low‐capacity and humanitarian settings, which are ill-equipped to cope due to weak health systems. Coordinate support for countries and monitor country preparedness and response The WHO Regional Office for Europe will continue focusing all its resources and repurposed staff to support the response within the Region. WHO Country Offices are fully focused on leveraging resources, expertise and networks, including technical expertise, in support of country operations, readiness and response to COVID-19. WHO support is being implemented through global, regional and country-level activities and is being allocated based on needs, assessments and availability of funds. This categorization28 will be updated regularly based on the evolving COVID-19 situation in each country to identify changes in needs. 28 WHO country preparedness and response status for COVID-19 is regularly maintained and available in the public domain, see: WHO. Updated country preparedness and response status for COVID-19 as of 1 June 2020 [website]. Geneva: World Health Organization (https://www.who.int/publications/i/item/updated-country-preparedness-and- response-status-for-covid-19-as-of-1-june-2020, accessed 14 July 2020). 29 WHO. COVID-19 situation in the WHO European Region dashboard [database]. Copenhagen: WHO Regional Office for Europe. (https://who.maps.arcgis.com/apps/ opsdashboard/index.html#/ead3c6475654481ca51c248d52ab9c61, accessed 14 July 2020). Member States have been actively engaged in the response and the WHO Regional Director for Europe will continue providing the highest possible level of leadership, representation, advice and support to all requests from Member States, donors, partners, as well as other multilateral organizations. The WHO Regional Office for Europe activated its Incident Management Support Team (IMST) in early January 2020 to initially monitor and then to swiftly respond to the growing needs of our Region. The IMST coordinates WHO’s response in the Region, and comprises technical experts and functional teams covering critical incident management functions and response pillars. It is country-focused and also includes the WHO Health Emergencies Programme (WHE) Hub-Coordinators and their teams in priority countries. The IMST will continue supporting all countries in the Region, including those countries without WHO Country Offices. The IMST is based in the Regional Office in Copenhagen, under the leadership of the Regional Emergencies Director (RED) and reports to the WHO Regional Director. Understand the regional epidemiology, develop regional analytics and conduct ongoing risk assessments Comprehensive and verified surveillance data about COVID-19 is being collected from all countries, territories and areas. This data is accessible through multiple channels, including a dynamic regional dashboard,29 as well as downloadable data extracts. Challenges in some cases remain, such as delays in receiving data, lack of integration and interoperability between the International community’s response to COVID-19 © WHO 20 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 21 different data and health information systems, and deficiency of trained people to manage and use these data. Regional channels for sharing health information under the IHR (2005) and risk assessments for the WHO European Region are well-established and the associated reporting capacities are tested annually by IHR Exercise JADE30. WHO is collaborating with the European Centre for Disease Prevention and Control (ECDC), regional networks and counterparts, to update and enhance surveillance strategies. To support surveillance activities with national authorities, the WHO Regional Office for Europe, together with ECDC, disseminates case definitions and communicates changes when needed. This includes remote support and advice to authorities on the implementation of surveillance strategies to monitor and report disease trends, disease severity and impacts on health and other systems. WHO is working to support and strengthen national laboratory capacities, and to ensure rapid and effective testing and reporting capabilities in all countries to test suspect cases using WHO case definitions and symptomatic contacts. Furthermore, WHO will continue to work to ensure access to reagents, supplies and laboratory protocols. Technical assistance from experts, both remotely and deployed, complements material support and provides advice on the adaptation of published protocols to the platforms in the laboratories, on the validation of the assays and on biosafety, quality or specimen sharing. This also includes facilitating shipment of specimens to WHO-appointed international COVID-19 referral laboratories. Social science and community insights, including perception surveys and feedback from communities affected by physical distancing and movement restrictions, are being rapidly synthesized and will be employed to ensure that future response measures are informed by and calibrated according to the ongoing experiences of affected communities. 30 WHO. Exercise JADE report, 2019. Copenhagen: WHO Regional Office for Europe; 2020. (https://extranet.who.int/sph/exercise-jade-2019-en, accessed 11 May 2020). 31 WHO. Taxonomy and glossary of public health and social measures that may be implemented to limit the spread of COVID-19. Geneva: World Health Organization; 2020. (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/phsm, accessed 18 May 2020). In addition, the WHO Regional Office for Europe is routinely collecting information on public health and social measures,31 implemented at national and international levels, for analysis of their effectiveness and appropriateness to inform the response as the pandemic evolves. This includes the regular monitoring and reporting of international restrictions on travel and trade and their public health rationales reported by IHR National Focal Points (NFPs) to WHO or published on official government websites, and shared by the Secretariat through the restricted platform for IHR NFPs, the Event Information Site (EIS). Coordinate supply chain management across the Region The COVID-19 pandemic has led to an acute shortage of essential supplies, including personal protective equipment (PPE), disinfectants, diagnostics and medical products. Essential health commodities (including vaccines when available, pharmaceuticals, health technologies and diagnostics) are goods that are desperately in need across the WHO European Region, especially in countries that have seen a high number of cases. In addition, supply chains for products and services needed for existing conditions, such as access to antiretroviral therapy and direct acting antivirals, opioid substitution therapy for people who use drugs, or other chronic disease interventions recommended by WHO, need to be sustained. Ensuring sustainable access to essential supplies and health commodities during this period will be challenging. Within each country, it will be important that an effective and collaborative supply process is maintained. Communication channels should be established between all those involved, including between ministries of health, national medicines agencies, procurement agencies and those involved in distribution and logistics. Good communication, including with the private sector, is essential to maintain supplies to the population. Country procurement of essential supplies and health commodities for use in non-COVID-19 patients should be based on estimates of previous consumption. Stockpiling in large quantities will exacerbate the global situation. Requests from countries are processed through the global supply chain, and the WHO Regional Office has established specific logistics capacity for the Region within the framework of WHO’s Global Logistics strategy. The WHO Regional Office for Europe will continue to identify needs, work to fulfil requests and facilitate the delivery of critical items for COVID-19 to countries. The WHO Regional Office for Europe will continue to provide technical assistance to countries to increase their capacity for the domestic production of supplies and commodities for COVID-19 while ensuring a high degree of quality assurance to international standards. Accelerate research, innovation and knowledge sharing The Global Research Forum has developed32 an initial COVID-19 Global Research Roadmap to guide a united COVID-19 agenda for research and development. This region was at one time the epicentre of the pandemic, and now represents a centre of continued learning regarding the virus and thus is generating, and will be sharing, knowledge on interventions and innovations. Consistency and quality of WHO Regional Office for Europe guidance documents is maintained through a technical review team within the IMST and is in line with the global mechanisms. As part of the knowledge generation activities for COVID-19, the WHO Regional Office for Europe will conduct operational research at the international level and support national governments in conducting after-action reviews (AARs) to analyse and share lessons learned from response interventions. Regional and national analyses and reviews of responses to ongoing and previous outbreaks are critical to institutionalize good 32 For more on research and development, see: WHO. Global research on coronavirus disease (COVID-19) [website]. Geneva: World Health Organization; 2020. (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov, accessed 11 May 2020). 33 WHO. HealthBuddy. In: Coronavirus disease (COVID-19) outbreak [website]. Copenhagen: WHO Regional Office for Europe; 2020. (https://www.euro.who.int/en/health-topics/ health-emergencies/coronavirus-covid-19/healthbuddy, accessed 19 May 2020). 34 WHO. WHO tool for behavioural insights on COVID-19. Copenhagen: WHO Regional Office for Europe; 2020. (https://www.euro.who.int/en/health-topics/health-emergencies/ coronavirus-covid-19/technical-guidance/who-tool-for-behavioural-insights-on-covid-19, accessed 11 May 2020). 35 WEF. Who are the Global Shapers? In Agenda [website]. Cologny: World Economic Forum; 2020. (https://www.weforum.org/agenda/2011/10/who-are-the-global-shapers/, accessed 11 May 2020). practices and share solutions with other affected countries and the wider public health community. Innovative ways to communicate risks and engage communities Innovative solutions are also being leveraged for risk communication and community engagement (RCCE). The role of the public in stopping the virus transmission is at the core of the response of the Regional Office. Our success in tackling the new coronavirus depends on people being informed, willing and enabled to take the right public health action. As part of the WHO RCCE response, several innovative flagship projects have been implemented in the Region: 1. HealthBuddy33 HealthBuddy is a joint UNICEF ECARO–WHO/Europe chatbot that answers users’ questions about the COVID-19 virus and protection measures against it and track risk perception. This tool is available to be deployed on countries authorities’ websites to support their RCCE for COVID-19 to their citizens, health care workers and other audiences in local languages and according to local information. 2. Behavioural insight tool34 Rapid, simple and flexible to use, the new WHO Regional Office for Europe behavioural insights tool offers countries the opportunity to gather invaluable information on people’s perceptions and behaviours to support and guide their COVID-19 response activities. The tool is offered to national and local authorities developing and coordinating interventions, policies and messages for the COVID-19 response. 3. Global Shapers35 The Global Shapers are an independent youth group born out of the World Economic Forum. Global Shapers Europe’s hubs engage in the COVID-19 response in the WHO European Region, led by the WHO Regional Office for Europe, by fighting the “infodemic” through accurate messaging distribution and sharing rumours, photo stories and general perceptions of mood from residents in the WHO European Region. 22 COVID-19 Strategy for the WHO European Region Digital health Digital health has been widely employed as part of national efforts in the Member States of the WHO European Region to respond to COVID-19 pandemic. The use of digital technologies has been applied in different preventative, service delivery and care contexts in meeting a range of urgent and critical functions. While the demand for digital health has accelerated the adoption of existing solutions (for example, the delivery of primary care), it has also sparked the development of new innovations. These innovations have enabled remote diagnosis, treatment and monitoring of suspected or confirmed COVID-19 cases and provided entirely new approaches for contact tracing, disseminating health information to the public and for supporting accelerated testing and clinical trials. Digital innovations have also extended into hospital settings as staff have adjusted to meet requirements for caring for COVID-19 patients through surge capacity modelling and the use of robotics technologies for disinfection, isolation ward communication and medical waste transfer. However, Member States have acknowledged difficulties associated with having accurate, real- time data to inform decision-making and guide COVID-19 response actions. More investments in national health information systems and the application of standards for the exchange of health information are required. These investments will strengthen public health response capacity, facilitate research and support adaptive health policy. Strengthen preparedness for future emergencies COVID-19 is a global, regional and individual crisis. It threatens human life, livelihoods and the way of life of every individual in every society in the Region. However, COVID-19 also provides an opportunity to strengthen overall resilience and capacities for health security at country level. Investments for COVID-19 should ensure support to “no regrets policies” and allow for longer-term health, environmental and societal benefits allowing countries to “build back better” and support our communities, societies and countries to be more resilient and prepared, in line with national and regional needs. Health system strengthening during this pandemic can further strengthen Member States’ abilities to prevent, detect and respond to future waves of the ongoing pandemic, future outbreaks and other public health events. The WHO Regional Office for Europe will continue providing short-, medium- and long-term opportunities to share knowledge, know-how and experiences so that the challenges of today can result in better prepared and more resilient systems and societies of tomorrow. Through solidarity, perseverance and patience, we will defeat this virus together.” “ Dr Hans Henri P. Kluge, WHO Regional Director for Europe Source: Media Statement 03 June 2020, Copenhagen, Denmark COVID-19 Strategy for the WHO European Region 23 © WHO / Blink Media – Martyn Aim 24 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 25 Preparedness and response measures No cases Sporadic cases and transmission chains Clusters of cases Community-wide transmission 1. Prepare, protect and be ready Initiate emergency mechanisms for national and local alert, response and coordination. This includes reviewing and testing capacity through simulations depending on context and stage of outbreak Activate emergency response36 mechanisms Enhance emergency response mechanisms Scale-up emergency response mechanisms Scale-up emergency response mechanisms Establish and rapidly expand capacity for case-finding, contact tracing and laboratory testing Identify additional workforce and train Train workforce and deploy, scale-up reserves Scale-up workforce, train and deploy Scale-up workforce, train and deploy Increase rapidly hospital and health care facility capacity to meet expected management needs Train staff in infection prevention and control (IPC)37 and clinical management38 specifically for COVID-19 Train staff in IPC and clinical management specifically for COVID-19 Train staff in IPC and clinical management specifically for COVID-19 Retrain staff in IPC and clinical management specifically for COVID-19 Prepare for health care surge Prepare for surge in health care facility needs, including respiratory support and PPE Prepare for surge in health care facility needs, including respiratory support and PPE. Identify facilities that can care for mild cases Advocate for home care for mild cases,39 if health care systems are overwhelmed, and identify referral systems for high-risk groups Rapidly implement health facilities surge plans Protect and enhance resilient supply chains for essential medical supplies and PPE Yes Yes Yes Yes 36 WHO. Strengthening health security by implementing the International Health Regulations (2005). Geneva: World Health Organization. (https://www.who.int/ihr/ publications/9789241565134_eng/en/, accessed 11 May 2020). 37 WHO. Infection prevention and control (IPC) for novel coronavirus (COVID-19). In: OpenWHO [website]. (https://openwho.org/courses/COVID-19-IPC-EN, accessed 11 May 2020). 38 WHO. Clinical Management of COVID-19. In: OpenWHO [website]. (https://openwho.org/courses/severe-acute-respiratory-infection, accessed 11 May 2020). 39 WHO. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts. Interim guidance, 17 March 2020. Geneva: World Health Organization; 2020. (https://www.who.int/publications/i/item/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms- and-management-of-contacts, accessed 13 July 2020). Annex 1 Adaptation of response measures based on scale of transmission 24 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 25 Communicate effectively and build trust with members of society and communities Actively communicate with and engage communities40 Actively communicate with and engage communities Actively communicate with and engage communities Actively communicate with and engage communities Share key data and information with WHO and other countries, to provide and receive information Yes Yes Yes Yes 2. Find, test and isolate all suspect cases and contacts Reporting of suspect COVID-19 as an immediately notifiable disease Yes Yes Yes Yes Active case-finding Conduct active case- finding,41 contact tracing and monitoring; quarantine of contacts42 and isolation of cases Enhance active case-finding, contact tracing and monitoring; quarantine of contacts and isolation of cases Intensify case-finding, contact tracing, monitoring, quarantine of contacts, and rapid isolation of cases and quarantine of contacts Continue active case- finding, continue contact tracing where possible, especially in newly infected areas, quarantine of contacts and isolation of cases. Apply self- initiated isolation for symptomatic individuals Immediate testing of all suspect cases on day of detection and conduct Enhanced surveillance to detect additional cases Test all individuals meeting the suspected case definition.43 Test a subset of samples from SARI/ ILI surveillance for COVID-19 Test patients with unexpected clinical presentation or an increase in hospital admissions in a specific demographic group that could be COVID-19 Test all individuals meeting the suspect case definition.44 Clinical management of severe acute respiratory infections when novel coronavirus is suspected.45 SARI/ILI surveillance for COVID-19 and reporting46 Test all individuals meeting the suspected case definition. Clinical management of severe acute respiratory infections when novel coronavirus is suspected. SARI/ILI surveillance for COVID-19 and reporting If diagnostic capacity is insufficient, prioritize testing: people who are at risk of developing severe disease and vulnerable populations; symptomatic health workers and the first symptomatic individuals in a closed setting (e.g. schools, long-term living facilities, prisons, hospitals) to quickly identify outbreaks and ensure containment measures 40 WHO. Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response. Interim guidance, 16 March 2020. Geneva: World Health Organization; 2020. (https://www.who.int/publications/i/item/risk-communication-and-community-engagement-(rcce)-action-plan-guidance, accessed 13 July 2020). 41 WHO. Surveillance strategies for COVID-19 human infection. Interim guidance, 10 May 2020. Geneva: World Health Organization; 2020. (https://www.who.int/publications/i/item/ surveillance-strategies-for-covid-19-human-infection, accessed 13 July 2020). 42 WHO. Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19). Interim guidance, 19 March 2020. Geneva: World Health Organization; 2020. (https://www.who.int/publications/i/item/considerations-for-quarantine-of-individuals-in-the-context-of-containment-for-coronavirus-disease-(covid-19), accessed 13 July 2020). 43 WHO. Global Surveillance for human infection with coronavirus disease (COVID-19). Interim guidance, 20 March 2020. Geneva: World Health Organization; 2020. (https://www.who.int/publications/i/item/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov), accessed 13 July 2020). 44 WHO. Considerations in the investigation of cases and clusters of COVID-19,Interim guidance, 2 April 2020. Geneva: World Health Organization; 2020. (https://www.who.int/publications-detail/considerations-in-the-investigation-of-cases-and-clusters-of-covid-19, accessed 11 May 2020). 45 WHO. Clinical management of severe acute respiratory infection when COVID-19 is suspected. Interim guidance, 13 March 2020. Geneva: World Health Organization; 2020. Clinical management of COVID-19 interim guidance, 27 May 2020. Geneva: World Health Organization; 2020. (https://www.who.int/publications/i/item/clinical-management-of- covid-19, accessed 11 May 2020) 46 WHO. Operational considerations for COVID-19 surveillance using GISRS: interim guidance, 26 March 2020. Geneva: World Health Organization; 2020. (https://www.who.int/ publications/i/item/operational-considerations-for-covid-19-surveillance-using-gisrs-interim-guidance, accessed 11 May 2020) 1. Prepare, protect and be ready continued Preparedness and response measures High-capacity settings Mid-capacity settings Low-capacity settings Humanitarian settings 26 COVID-19 Strategy for the WHO European Region Aggressively identify all cases and effectively isolate confirmed cases as quickly as possible to limit the potential of transmission to other people and ensure compliance Prepare health care facilities Isolate suspected cases in health care facilities and other facilities (mild patients) Isolate suspected cases in HCFs and other facilities (mild patients) Isolate suspected cases in HCFs and other facilities (mild patients) or at home Perform case investigation to identify and quarantine contacts and follow-up for 14 days Prepare quarantine capacities and guidelines All contacts Prioritize close contacts Close contacts Find cases and conduct enhanced surveillance Consider testing for COVID-19 using existing respiratory disease surveillance systems and hospital- based surveillance Implement COVID-19 surveillance using existing respiratory disease surveillance systems and hospital- based surveillance Expand COVID-19 surveillance using existing respiratory disease surveillance systems and hospital- based surveillance Adapt existing surveillance systems to monitor disease activity (e.g. through sentinel sites) 3. Prevent, suppress and slowdown transmission Prevent community level transmission/ superspreading events through individual distancing, personal hygiene and limiting public gatherings, concerts and religious gatherings Reinforce basic measures Consider closing mass gatherings such as concerts, religious events, sports events, theatres, cinemas to reduce the potential for inter-household spread Consider closing leisure venues (bars, restaurants, theatre, cinemas, religious events, sports events, clubs) in areas where transmission is suspected/ occurring to increase distance between household and reduce the potential for superspreading events Close leisure venues (bars, restaurants, theatre, cinemas, religious events, sports events, clubs) to increase distance between household and reduce the potential for superspreading events Prevent community level transmission through individual distancing, personal hygiene and limiting public gatherings, concerts and religious gatherings Reinforce basic measures and physical distancing Reinforce basic measures and physical distancing for all. Restrict gatherings to <100 people Reinforce basic measures and physical distancing for all. Restrict gatherings to <50 people Reinforce basic measures and physical distancing for all. Restrict gatherings to <10 people Prevent transmission in education facilities by closing universities, trade schools, as well as pre-schools, primary and secondary schools and adopting distance- learning strategies Reinforce basic measures Close if cases. Adopt distance- learning strategies47 Only close in areas with cases or clusters. Enact distance- learning strategies Close. Enact distance-learning strategies Prevent global spread through conducting risk assessments for global mass gatherings Conduct risk assessment Conduct risk assessment. Postpone or cancel Conduct risk assessment. Postpone or cancel Conduct risk assessment. Postpone or cancel 47 WHO. Considerations for school-related public health measures in the context of COVID-19, Annex to guidance, 10 May 2020. Geneva: World Health Organization; 2020. https://www.who.int/publications/i/item/considerations-for-school-related-public-health-measures-in-the-context-of-covid-19 2. Find, test and isolate all suspect cases and contacts continued Preparedness and response measures High-capacity settings Mid-capacity settings Low-capacity settings Humanitarian settings COVID-19 Strategy for the WHO European Region 27 Prevent transmission in workplaces by reducing non-essential business and industries while ensuring essential services48 Reinforce basic measures Targeted closures ensure essential services including through staggered shift working, home working or other strategies If cases ensure appropriate work conditions, social distancing, ensure essential services continue as safely as possible including through staggered shift working, home working or other strategies Stop/close all shared workspaces, mandate home working and ensure essential services continue as safely as possible Restrict movement in and out of care facilities,49 institutions and camps to protect high-risk groups Reinforce basic hygiene and IPC measures and physical distancing. Stop sick people from visiting Stop non-essential movement in targeted facilities Stop non-essential movement in affected areas Stop all non-essential movement Limit international and national travel and restrict movement within a city, area or outside households n/a Prohibit all travel/ movement of cases and contacts and ensure isolation at home or designated facilities Consider geographically targeted restrictions if escalating clusters/ spread. This may include isolation of incoming travellers Consider full movement restrictions if uncontrolled spread 4. Provide safe and effective clinical care Implement strict infection prevention and control in hospitals and health care facilities Always Always Always Always Expand clinical care capacity and dedicated facilities to effectively isolate all COVID-19 cases Urgently Urgently Urgently Yes Ensure the central system is not overloaded to prevent nosocomial transmission. Manage clinical pathways and referral systems so that those most at risk can access live saving care Set up screening and triage protocols at all points of access to the health system. Prepare to treat COVID-19 affected patients. Set up COVID-19 hotline and referral system. Ready hospitals for potential surge Screen and triage patients at all points of access to the health system. Care for all suspected and confirmed patients according to disease severity and acute care needs. Ready hospitals for surge. Ready communities for surge, including by setting up community facilities for isolation of mild/moderate cases Screen and triage patients at all points of access to the health system. Care for all suspected and confirmed patients according to disease severity and acute care needs. Activate surge plans for health facilities Screen and triage patients at all points of access to the health system. Care for all suspected and confirmed patients according to disease severity and acute care needs. Scale-up surge plans for health facilities and ad hoc community facilities, including enhancement of COVID-19 referral system Deliver maximum standard of care for all severe and critical patients Always Always Always Always 48 WHO. Considerations for public health and social measures in the workplace in the context of COVID-19. Geneva: World Health Organization; 2020. (https://www.who.int/ publications/i/item/considerations-for-public-health-and-social-measures-in-the-workplace-in-the-context-of-covid-19, accessed 19 May 2020). 49 WHO. Infection prevention and control for long-term care facilities in the context of COVID-19. Interim guidance, 21 March 2020. Geneva: World Health Organization; 2020. (https://apps.who.int/iris/handle/10665/331508, accessed 11 May 2020). 3. Prevent, suppress and slowdown transmission continued Preparedness and response measures High-capacity settings Mid-capacity settings Low-capacity settings Humanitarian settings 28 COVID-19 Strategy for the WHO European Region Train, equip and protect health care workers Immediately Scale-up Scale-up and provide adequate shift/rest periods Scale-up and provide adequate shift/rest periods Maintain COVID-19 essential medical supplies through effective supply chain management Yes Yes Yes Yes Ensure post-COVID-19 care for individuals with sequelae and contribute to efforts to characterize residual morbidity n/a Always Always Always 5. Maintain core health services and systems Establish simplified purpose-designed governance and coordination mechanisms to complement response protocols Develop and test plans Ensure plans are ready for deployment Start to activate Activate Identify context- relevant core services Yes Yes Yes and assess Yes and continually assess Optimize service delivery settings and platforms Develop plans Consider options as part of planning. This may include use of other facilities, dividing facilities into COVID-19 and non-COVID-19 with separate entrances and staff Activate plans Activate plans Establish effective patient flow (screening, triage, and targeted referral) at all levels Develop and trial plans Screening and triage ready Screening and triage Screening and triage Rapidly re-distribute health workforce capacity including by re-assignment and task sharing Develop plans Monitor Monitor and be ready to activate Activate Identify mechanisms to maintain availability of essential medications, equipment and supplies Develop plans and guidelines Monitor and ensure systems are ready for activation Monitor and ensure systems are ready for activation Activate plans 4. Provide safe and effective clinical care continued Preparedness and response measures High-capacity settings Mid-capacity settings Low-capacity settings Humanitarian settings COVID-19 Strategy for the WHO European Region 29 30 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 31 Preparedness and response measures High-capacity settings Mid-capacity settings Low-capacity settings Humanitarian settings 1. Prepare, protect and be ready Initiate emergency mechanisms for national and local alert, response and coordination Yes. Knowledge sharing among countries and regions to support best practice Yes, with support from partners as needed Yes, with support from international partners as needed Yes, with support through the UN Regional Coordinator Establish and rapidly expand capacity for case-finding, contact tracing and laboratory testing Yes Yes, with support through local, regional or international networks as needed Yes, with support through regional or international networks as needed Yes, with support through regional or international networks as needed Increase rapidly hospital and health care facility capacity to meet expected management needs Yes. Knowledge sharing among countries and regions to support best practice Yes, with support from partners as appropriate to context. This may include engagement with the private sector and civil society organizations Yes, with support from partners as appropriate to context. This may include engagement with the private sector and civil society organizations Yes, with support from partners including humanitarian partners such as Médecins Sans Frontières, IFRC, Save the Children and other partners Protect and enhance resilient supply chains for essential medical supplies and PPE Yes Yes, including through scale-up of local production Yes, with support from regional and international partners Yes, with support from partners Communicate effectively and build trust with members of society and communities Yes. Work with local civil society organizations, religious institutions and community and youth leaders. Use tools to understand community views and perspectives and use to adapt the response Yes. Work with local civil society organizations, religious institutions and community and youth leaders. Use tools to understand community views and perspectives and use to adapt the response Yes. Work with partners including the IFRC and UNICEF to develop social mobilization and community engagement plans Yes. Work with national and international partners including the IFRC and UNICEF to develop social mobilization and community engagement plans Share key data and information with WHO and other countries, to provide and receive information Yes Yes Yes Yes 2. Find, test and isolate all suspect cases and contacts Declaration of suspect COVID-19 as an immediately notifiable disease Yes Yes Yes Yes Enhanced surveillance to detect all suspect cases Yes Yes Yes Yes Annex 2 Adaptation of response measures based on health system capacity, resourcing and context 30 COVID-19 Strategy for the WHO European Region COVID-19 Strategy for the WHO European Region 31 Immediate testing of all suspect cases on day of detection Test all suspect cases Test all suspected cases If diagnostic capacity is insufficient, prioritize testing: people who are at risk of developing severe disease and vulnerable populations. Symptomatic health workers and the first symptomatic individuals in a closed setting (e.g. schools, long-term living facilities, prisons, hospitals) to quickly identify outbreaks and ensure containment measures If diagnostic capacity is insufficient, prioritize testing: people who are at risk of developing severe disease and vulnerable populations. Symptomatic health workers and the first symptomatic individuals in a closed setting (e.g. schools, long-term living facilities, prisons, hospitals) to quickly identify outbreaks and ensure containment measures Aggressively identify all cases and effectively isolate confirmed cases as quickly as possible to limit the potential of transmission to other people and ensure compliance Prepare health care facilities, designated areas for isolation and care Isolate confirmed cases in health care facilities (HCFs) and other facilities/designated areas (mild patients) Isolate confirmed cases in HCFs and other facilities/designated (mild patients) Isolate confirmed cases in HCFs and other facilities (mild patients) or in designated areas Perform case investigation to identify and isolate contacts and follow-up for 14 days Prepare quarantine capacities All close contacts Close contacts Closest contacts 3. Prevent, suppress and slowdown transmission Prevent global spread through conducting risk assessments for global mass gatherings Conduct risk assessment. Postpone or cancel public or private events. Reinforce public health messages on physical distancing Conduct risk assessment. Postpone or cancel. Reinforce public health messaging Conduct risk assessment (e.g. ensure physical distancing and control for all activities). Reinforce public health messaging Conduct risk assessment (e.g. ensure crowd control for all activities). Reinforce public health messaging Prevent community level transmission through individual distancing, personal hygiene and limiting public gatherings, concerts and religious gatherings Reinforce basic measures Restrict or ban gatherings including concerts, religious events, sports events, theatres, cinemas to reduce the potential for spread Restrict or ban gatherings including concerts, religious events, sports events, theatres, cinemas to reduce the potential for spread Restrict or ban gatherings including concerts, religious events, sports events, theatres, cinemas to reduce the potential for spread Prevent transmission in education facilities by closing universities, trade schools, as well as pre-schools, primary and secondary schools Reinforce basic measures. Adopt teleworking and other workplace strategies; lift gradually where there are no cases Only if cases (usually teachers). Adopt distance-learning/ alternative learning strategies Only those with cases or clusters. Adopt distance-learning/ alternative learning strategies Close or limit the size depending on the context. Enact distance-learning/ alternative learning strategies Prevent transmission in workplaces by reducing non-essential business and industries while ensuring essential services Reinforce basic measures Targeted closures and ensure essential services If cases restricted to <50 people and ensure essential services Stop/close all workspaces and ensure essential services 2. Find, test and isolate all suspect cases and contacts continued Preparedness and response measures High-capacity settings Mid-capacity settings Low-capacity settings Humanitarian settings Restrict movement in and out of care facilities, institutions and camps to protect high-risk groups Protect health facilities and vulnerable groups. Support community care Stop non-essential movement in targeted facilities Stop non-essential movement in affected areas Stop all non- essential movement, ensure continuity of essential services and medication Limit international and national travel and restrict movement within a city, area or outside households Adapt social measures to protect access to food supply, essential services and protect income Prohibit all travel/ movement of cases and contacts. Consider measures to protect access to food supply, essential services and protect income Consider geographically targeted restrictions if escalating clusters/ spread. Consider measures to protect access to food supply, essential services and protect income Consider full movement restrictions if uncontrolled spread. Consider measures to protect access to food supply, essential services, continuity of medication and livelihood protection Communicate effectively and build trust with members of society and communities Yes Yes Yes Yes Limit international travel with border measures, and/or screening of travellers Yes, including use of quarantine of travellers from high-risk countries Yes, including use of quarantine of travellers from high-risk countries Yes, including use of quarantine of travellers from high-risk countries Yes, including use of quarantine of travellers from high-risk countries 4. Provide safe and effective clinical care Implement strict infection prevention and control in hospitals and health care facilities Reinforce measures and use appropriate PPE Reinforce measures and use appropriate PPE Reinforce measures and use appropriate PPE Reinforce measures and use appropriate PPE Expand clinical care capacity and dedicated facilities to effectively isolate all COVID-19 cases Prepare public and private health care facilities (HCFs) and other facilities HCFs and other facilities. This includes engaging the private sector HCFs and other facilities including the private sector HCFs, other facilities and designated areas Ensure the central system is not overloaded to prevent nosocomial transmission. Manage clinical pathways and referral systems so that those most at risk can access life-saving care Application of guidelines to prevent nosocomial transmission. This includes clear IPC protocols and ensuring adequate supplies of PPE Application of guidelines to prevent nosocomial transmission. This includes clear IPC protocols and ensuring adequate supplies of PPE Application of guidelines to prevent nosocomial transmission. This includes clear IPC protocols and ensuring adequate supplies of PPE Application of guidelines to prevent nosocomial transmission. This includes clear IPC protocols and ensuring adequate supplies of PPE Deliver maximum standard of care for all severe and critical patients Increased oxygen and ventilator capacity Increased oxygen and ventilator capacity International partnership to support scale-up and delivery of care as needed International partnership to support delivery of care as needed through activation of the Inter- Agency Standing Committee protocols50 50 IASC. Interim guidance on public health and social measures for COVID-19 preparedness and response operations in low capacity and humanitarian settings. Inter-Agency Standing Committee. (https://interagencystandingcommittee.org/health/interim-guidance-public-health-and-social-measures-covid-19-preparedness-and-response-0, accessed 11 May 2020). 3. Prevent, suppress and slowdown transmission continued Preparedness and response measures High-capacity settings Mid-capacity settings Low-capacity settings Humanitarian settings 32 COVID-19 Strategy for the WHO European Region Train, equip and protect health care workers and frontline workers including non-health Yes Yes Yes Yes Maintain COVID-19 essential medical supplies through effective supply chain management Yes Yes Yes Yes 5. Maintain core health services and systems Establish simplified purpose-designed governance and coordination mechanisms to complement response protocols Yes Yes Yes Yes Identify context- relevant core services Yes Yes Yes Yes Optimize service delivery settings and platforms Yes Yes Yes Yes Establish effective patient flow (screening, triage, and targeted referral) at all levels Yes Yes Yes Yes Rapidly re-distribute health workforce capacity including by re-assignment and task sharing Yes Yes Yes Yes Identify mechanisms to maintain availability of essential vaccines, medications, equipment and other supplies Yes. This might include alternative means of delivering or distributing medicines, giving larger amounts of regular medicines such as for HIV (i.e. 6 months rather than 3 months). Look for community service options Yes. This might include alternative means of delivering or distributing medicines, giving larger amounts of regular medicines such as for HIV (i.e. 6 months rather than 3 months). Look for community service options Yes. This might include alternative means of delivering or distributing medicines, giving larger amounts of regular medicines such as for HIV (i.e. 6 months rather than 3 months). Look for community service options Yes. This might include alternative means of delivering or distributing medicines, giving larger amounts of regular medicines such as for HIV (i.e. 6 months rather than 3 months). Look for community service options 4. Provide safe and effective clinical care continued Preparedness and response measures High-capacity settings Mid-capacity settings Low-capacity settings Humanitarian settings COVID-19 Strategy for the WHO European Region 33 Notes 34 COVID-19 Strategy for the WHO European Region World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark TEL +45 45 33 70 00 FAX +45 45 33 70 01 EMAIL eurocontact@who.int WEB www.euro.who.int The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Document number: WHO/EURO:2020-1073-408190-55167