COVID-19 technical mission of experts to Tajikistan: 1–11 May 2020

COVID-19 technical mission of experts to Tajikistan: 1–11 May 2020 2 Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Marmorvej 51 DK - 2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2020 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. 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Document number: WHO/EURO:2020-1083-40829-55183 3 Contents Executive summary .................................................................................................................. 4 Background ...................................................................................................................................... 4 Key observations and recommendations for Tajikistan ..................................................................... 4 Summary ......................................................................................................................................... 6 Mission recommendations ....................................................................................................... 7 National coordination ...................................................................................................................... 7 Short term (urgent) ............................................................................................................................................... 7 Risk communication and community engagement (RCCE) ................................................................ 7 Short term (urgent) ............................................................................................................................................... 7 Epidemiology and surveillance ......................................................................................................... 8 Short term (urgent) ............................................................................................................................................... 8 Medium term ........................................................................................................................................................ 8 Points of entry ................................................................................................................................. 8 Short term (urgent) ............................................................................................................................................... 8 Medium term ........................................................................................................................................................ 8 National laboratories ....................................................................................................................... 8 Short term (urgent) ............................................................................................................................................... 8 Medium term ........................................................................................................................................................ 9 Long term .............................................................................................................................................................. 9 Infection prevention and control (IPC) .............................................................................................. 9 Short term (urgent) ............................................................................................................................................... 9 Medium term ...................................................................................................................................................... 10 Long term ............................................................................................................................................................ 10 Case management .......................................................................................................................... 11 Short term (urgent) ............................................................................................................................................. 11 Medium term ...................................................................................................................................................... 11 Long term ............................................................................................................................................................ 11 Operational support and logistics ................................................................................................... 11 Short term (urgent) ............................................................................................................................................. 11 Post WHO COVID-19 technical mission follow-up................................................................... 12 4 Executive summary The observations and recommendations in this report are based on the review of normative and technical documents provided by the Government of Tajikistan and, specifically, the Ministry of Health and Social Protection of Population, site visits, meetings and discussions conducted during the 10-day WHO technical mission. Background A pneumonia with an unknown origin was detected in Wuhan, China and reported to the WHO Country Office in China on 31 December 2019. WHO declared the COVID-19 outbreak a Public Health Emergency of International Concern on 30 January 2020, and a global pandemic on 11 March 2020. The strategies of early detection, isolation, laboratory confirmation, contact tracing and quarantine, along with physical distancing, have been shown to be critical elements in stopping or slowing disease transmission. Countries are experiencing different scenarios, so tailored responses are required. WHO nevertheless recommends all countries to adopt a comprehensive, blended strategy for controlling their epidemics and decreasing the burden on their health systems and economies. Following an invitation from the Minister of Health and Social Protection of Tajikistan, the COVID-19 Incident Management Support Team in the WHO Regional Office for Europe deployed a team of technical experts to the country from 1–11 May 2020. The objectives of the mission were to understand the response measures currently being taken to manage the outbreak and provide guidance on actions needed as the outbreak evolves. During the mission, the team met with the Prime Minister, the Minister of Foreign Affairs and representatives from the Ministry of Health and Social Protection, Committee of Emergency Situation and Civil Defence, Committee on Religion, Regulation of Traditions, Celebrations and Ceremonies, Committee for Protection of State Borders, United Nations agencies, the Red Crescent Society of Tajikistan, development partners and civil society groups. The team focused on the following areas of the outbreak response: epidemiology, surveillance, diagnostic testing, laboratory capacity and data systems; health- care system preparedness, clinical case management, and infection protection and control; and risk communication. The team visited health-care facilities, public health centres, laboratories, orphanages, points of entry, care facilities for older people, migrant observation facilities and quarantine areas at national, regional (oblast) and city levels in Dushanbe, Sughd and Khatlon oblasts and, remotely, with the Gorno-Badakhshan Autonomous Oblast (GBAO). Key observations and recommendations for Tajikistan Tajikistan reported its first cases of COVID-19 on 30 April 2020. Cases continued to be reported over the duration of the WHO technical COVID-19 mission from 1–11 May 2020. With cases reported throughout the country, Tajikistan has entered a phase of community transmission, with case counts doubling every 2–3 days. The epidemiology milestones from the first reported cases to the end of the mission are shown in Table ES.1. 5 Table ES.1. Epidemiology – milestones Date Event 30 April 2020 Tajikistan confirms its first 15 cases of COVID-19 2 May 2020 Tajikistan confirms its first two deaths attributed to COVID-19 3 May 2020 Tajikistan confirms a total of 128 cases and four deaths attributed to COVID-19 5 May 2020 Tajikistan confirms a total of 293 cases and nine deaths attributed to COVID-19 7 May 2020 Tajikistan confirms a total of 461 cases and 16 deaths attributed to COVID-19 9 May 2020 Tajikistan confirms a total of 561 cases and 19 deaths attributed to COVID-19 11 May 2020 Tajikistan confirms a total of 669 cases and 21 deaths attributed to COVID-19 On 2 February, the Government designated that the Ministry of Health and Social Protection of Population would provide the initial coordination for the COVID-19 outbreak response. On 18 March, the Government established a national multisectoral COVID-19 task force chaired by the Prime Minister, and on 19 March, the COVID-19 Preparedness and Response Plan was approved. A national Public Health Emergency Operation Centre should be established to coordinate between the Ministry of Health and Social Protection of Population and WHO and international partners that are providing outbreak response support. This would facilitate the operationalization of the Ministry of Health and Social Protection of Population’s actions in the Preparedness and Response Plan. The Government is finalizing the national COVID-19 risk-communication and community-engagement plan with assistance from the United Nations Children’s Fund and WHO. This plan needs to be rapidly implemented and continuously adapted to the evolving situation. COVID-19 response measures and health advice need to be accurately and clearly communicated on a regular basis. They should take into consideration community perceptions and concerns and appeal to the greater responsibility of all in stopping the spread of COVID-19. The Ministry of Health and Social Protection of Population approved the COVID-19 guidelines for prevention, diagnosis and treatment on 1 February. These were then distributed throughout the country. Existing surveillance, epidemiology and laboratory systems need to be tailored to the COVID-19 response to focus on finding and testing suspected cases and isolating those who test positive and their contacts. This requires expansion of protocols and increases in the number of laboratories testing for COVID-19 nationally and locally. Treatment protocols for severe, moderate and mild cases should be revised and updated on a regular basis to reflect current global best practices. Reorganization of health-care facilities and staff at all levels of the health system is a critical step the Government is taking to respond to the COVID-19 outbreak. It includes repurposing health-care facilities and training health-care workers. Patient care and infection prevention and control measures need to be standardized across all health-care facilities and personal protective equipment for health-care personnel needs to be made available through national and regional (oblast) stockpiles. As the response to COVID- 19 expands, a system to maintain essential health services for chronic diseases, immunization and maternal health needs to be in place. Providing operational and logistic support to Tajikistan is a significant challenge due to the lack of regular international flights. To support the national COVID-19 response and maintain essential medical services, the movement of people and commodities needs to be supported by establishing land and air humanitarian corridors. 6 Summary Tajikistan has entered a phase of community transmission of COVID-19. The situation is concerning and warrants rapid implementation of a comprehensive blended strategy.1 It is a pivotal moment in the outbreak response that requires the immediate implementation of additional inventions. Establishment of the Public Health Emergency Operation Centre is an urgent need that initially will be supported by WHO and international partners before being transitioned fully to the Ministry of Health and Social Protection of Population. The WHO COVID-19 mission has enabled a better understanding of the situation in Tajikistan and confirms the importance of a tailored multisectoral approach to the pandemic. These experiences will benefit not only the development of the next phases of the response in Tajikistan, but also efforts in central Asia, the WHO European Region and globally to combat the virus. WHO reiterates its commitment to supporting Tajikistan and is prepared to extend its efforts in the current COVID-19 response to the next phase. As an important first step, WHO will enhance its presence in Tajikistan with additional staff and consultants to ensure the necessary technical support is available to the Ministry of Health and Social Protection of Population to better meet the evolving needs of the people of Tajikistan. 1 WHO (2020). Critical preparedness, readiness and response actions for COVID-19. Geneva: World Health Organization (https://www.who.int/publications-detail/critical-preparedness-readiness-and-response-actions-for-covid-19, accessed 16 May 2020). 7 Mission recommendations National coordination Short term (urgent) • A national Public Health Emergency Operation Centre (PH-EOC) should be established to operationalize the Ministry of Health and Social Protection of Population’s responsibilities outlined in the National COVID-19 Preparedness and Response Plan and coordinate WHO and international partners’ support. Risk communication and community engagement (RCCE) Short term (urgent) • An operational Risk Communication and Community Engagement (RCCE) working group should be activated under the Deputy Prime Minister or the National COVID-19 Committee, involving all key players at central level (including United Nations organizations and development partners) and in coordination with local level. This will strengthen RCCE coordination, with clear accountability lines, and will ensure unified communication by all entities and optimization of existing resources in an emergency context. RCCE capacities in the country should be mapped and investment made in surge capacity as needed. • The RCCE strategy and plan should be updated and consolidated by emergency scenarios in a concise document to ensure that people comply with health protection measures recommended by health authorities and adopt protective behaviours that contribute to the control of the COVID-19 pandemic nationally and globally. This includes: o mapping RCCE capacities and allocating training resources; o increasing trust in response institutions; o embedding RCCE in the overall response to ensure that recommended measures are scientifically accurate and communicated in terms that can be understood and applied by citizens; o ensuring access to timely, transparent, accurate and coherent information based on risk perception; and o monitoring and evaluating outcomes and impacts. • Existing mechanisms should be strengthened to establish a multi-level system (national and subnational) information-gathering process (formative research, media and social media monitoring, hotlines, etc.) that provides insight into the knowledge, beliefs, risk perception, habits, practices and feelings of a target audience in the context of COVID-19 and monitor their evolution over time. With support from the United Nations Office for the Coordination of Humanitarian Affairs, the United Nations Children’s Fund and WHO, this can inform the RCCE strategy and tailor messages to stakeholders’ perceptions to foster acceptability and uptake of protective behaviours. • Messages should be developed and targeted to different population groups based on audience segmentation (affected and at-risk people, older people and people with chronic conditions, health- care workers, vulnerable groups, etc.) and according to the various phases of the outbreak evolution. Effective channels (strengthening media relations and using online channels) and trusted influencers should be selected to reach these groups. 8 Epidemiology and surveillance Short term (urgent) • The regular availability of epidemiology, surveillance and laboratory data should be ensured with support from the PH-EOC. Metrics and variables that support the tracking of the COVID-19 outbreak, such as the number of individuals tested and the number of tests conducted per individual, should be presented through a platform that can be updated rapidly and can provide a breakdown of information by regions (oblasts). • A robust contact-tracing programme should be developed with support from the PH-EOC to ensure that cases and potentially infected individuals are monitored and have proper clinical follow-up. • Tracking of COVID-19 in health-care workers, including doctors, nurses and support staff, should be ensured. Health-care workers are critical to the COVID-19 response in Tajikistan and represent one of the high-risk and vulnerable groups that need to be monitored throughout the outbreak response. Medium term • A regular process for updating and revising the national COVID-19 guidelines for prevention, diagnosis and treatment should be developed to ensure the most current best practices are reflected in national documents and protocols. Points of entry Short term (urgent) • Standardized entry screening, COVID-19 testing, contact-tracing and 14-day quarantine should be in place for all travellers arriving at international points of entry, including the international airport in Dushanbe and land crossings with Afghanistan, China, Kyrgyzstan and Uzbekistan. Medium term • Regular coordination and collaboration should be continued through the national COVID-19 task force to ensure that updated public health measures are shared. National laboratories Short term (urgent) • Support should be requested from the Global Outbreak Alert and Response network for rapid response mobile laboratories (RRMLs) and international laboratory experts to deploy to Sughd, Khatlon and GBAO oblasts to scale up operational and testing capacity and train local staff. • Diagnostic capacities in the Dushanbe region and oblasts should be expanded to increase testing volume across the country. • RRMLs should be refurbished and deployed and HIV/AIDS laboratories in all regions of the country engaged. In Sughd and Khatlon oblast, the existing polymer chain reaction (PCR) test equipment is sufficient to organize COVID-19 testing. Utilization of the HIV/AIDS facilities can and should be organized to extend their testing capacity for COVID-19 without disrupting testing for HIV and viral hepatitis. • Test kits and consumables should be resupplied urgently to cover the planned increased testing capacity, with a three-month supply at minimum. 9 Medium term • National laboratory capacity should be enhanced and strengthened with additional equipment – PCR machines, laminar hoods and PCR boxes should be distributed to national and regional (oblast) laboratories. This measure will extend the COVID-19 testing capacity of fixed laboratories and existing RRMLs and improve the resilience of the laboratory network. It would allow any COVID-19 testing in HIV/AIDS laboratories to shift exclusively to COVID-19-designed laboratories. The experience gained by the HIV/AIDS laboratories would enable additional secondary surge capacity if needed. • Staff and capacity for COVID-19 testing should be increased through training and on-site laboratory coaching, with support from international laboratory experts to be redeployed. • A national sero-surveillance programme should be developed under the National Prophylactic Medical Institute in Dushanbe to coordinate plans for antibody testing to support estimates of herd immunity and preparation for any deployment of COVID-19 vaccine. Long term • Existing testing facilities, especially PCR laboratories, should be renovated to extend the testing capacity in Tajikistan to meet modern biosafety and good laboratory practice requirements, including the National Prophylactic Medical Institute and public health laboratories at the Khatlon oblast and GBAO. Infection prevention and control (IPC) Short term (urgent) • A request for support should be made to the Emergency Medical Team Initiative Secretariat at WHO headquarters to provide technical assistance to selected hospitals involved in COVID-19 response activities in Dushanbe, Sughd oblast, Khatlon oblast and GBAO. The support would be provided through: o shadow support to local health-care workers in sampling and treatment of patients in COVID19 hospitals (including intensive care units) in line with WHO recommendations and national treatment guidelines; o on-the-job COVID-19 training (based on WHO recommendations and national guidelines) for health-care workers in the following areas of work: case management, including ICU management; IPC; patient testing (in collaboration with RRMLs and national Tajik laboratories); triage procedures; and isolation; and o support to the Ministry of Health and Social Protection of Population in repurposing the health-care workforce for COVID-19 management and revising hospital admission protocols. • Staff responsible for IPC should be designated at national (ministry), regional (oblast) and health- care facility levels. • IPC focal points should be familiar with national and WHO guidance on infection prevention and control. • Areas for non-suspected (green), yellow (suspected) and red (confirmed) cases should be designed and introduced in all health-care facilities in the country. Health-care workers must be informed and trained on how to use the triage system. 10 • Actions to separate patient flows with and without acute respiratory infection symptoms and fever should be implemented in all health-care facilities – outpatient centres, multidisciplinary hospitals and polyclinics. • Training on hand hygiene should be provided for health-care workers in all health-care facilities. Supplies for hand hygiene should be available at point of care. • Mechanisms for monitoring, evaluating and feeding back on hand-hygiene and personal protective equipment (PPE) practices should be implemented urgently. A buddy system (in which peers support each other to comply with hand-hygiene practices and correct use of PPE) should be created to ensure sustainability. Results of observations should be informed to hospital administration. • Health-care workers at all facilities should be trained on rational and correct PPE use (the infection prevention and control focal point should support development of PPE distribution plans by ward/units). • All hospitals should be provided with adequate quantities of medical masks, eye protectors (goggles or face shields), impermeable gowns, N95/FFP2 respirators, gloves, alcohol-based hand disinfectants, supplies for environmental cleaning and disinfection, and supplies for cleaning, disinfection and sterilization of medical equipment. • For COVID-designated hospitals, standard operating procedures based on WHO recommendations should be developed for extended use of medical masks, N95/FFP2 respirators and gowns in case of shortages. • Additional IPC guidance and training should be provided for staff and residents in facilities with high-risk and vulnerable populations, particularly long-term-care facilities such as homes for older people, orphanages and quarantine zones. Medium term • Nationwide assessments of IPC programmes should be conducted at hospital level. • Regular activities to inform and train health-care workers about the structure and functions of COVID-19-designated hospitals and IPC strategies should be maintained. • Working groups responsible for periodic assessment of IPC measures should be organized in all COVID-19-designated facilities. • Regular evaluations of compliance with IPC recommendations (including adherence to standard and transmission-based precautions, environmental cleaning and patient flow) should be conducted in all areas of hospitals, including emergency departments, general and surgical wards, operating theatres, sterilization services, nutrition services and radiology departments. Long term • A certified hospital infection epidemiology training programme should be organized for nurses and physicians and an infection prevention and control group created in each hospital and one for every two polyclinics. • Permanent hospital epidemiologist positions should be created in all hospitals, prioritizing infectious diseases hospitals. 11 Case management Based on the observations made during the mission, the recommendations have been divided into three phases. Short term (urgent) • A working group to review and revise treatment protocols on a regular (monthly) basis should be organized under the supervision of the Ministry of Health and Social Protection of Population and in consultation with WHO. • Pharmaceutical and other therapeutic treatment protocols should be reviewed. Currently, there are no proven pharmaceutical treatments available for COVID-19, so all pharmaceutical interventions (including antivirals) should be provided in the context of a clinical trial. WHO is coordinating the SOLIDARITY trial, a large, international study designed to generate the robust data needed to identify the most effective treatments. Tajikistan should consider participating in the SOLIDARITY trial and adopting relevant standard disease-characterization data collection.2 • Fifty per cent to 60% of bed capacity should have direct oxygen lines; according to the current protocol, only severely ill patients are hospitalized. • Supplies of ventilators with positive end-expiratory pressure capacity with high-flow oxygen therapy of 20–30% should be increased. • National webinars on clinical management, triage, diagnostics and treatment of patients with COVID-19 should be organized, reflecting regularly updated protocols for children and adults for health-care workers in different specialties – paediatrics, infectious disease, pulmonology, general practice and intensive care. Medium term • A short-term training programme for physicians and nurses for re-certification for pulmonary and intensive care specialists should be organized. • Implementation of national case-management protocols should be monitored on a regular basis, with regular review and revision of case management and provision of training for health-care workers on the treatment protocols. Long term • Modern infectious disease hospitals (possibly prefabricated) that meet modern requirements for infectious disease control, oxygen supply, isolation and critical care should be constructed in Dushanbe and each region. Operational support and logistics Short term (urgent) • Regular humanitarian corridors should be established by land and air to ensure rapid support for the COVID-19 response and maintenance of essential medical services in Tajikistan with the movement of people and goods. 2 WHO (2020). “Solidarity” clinical trial for COVID-19 treatments. In: World Health Organization [website]. Geneva: World Health Organization (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial- for-covid-19-treatments, accessed 16 May 2020). 12 Post WHO COVID-19 technical mission follow-up The WHO COVID-19 technical mission to Tajikistan was unable to complete all the tasks that were planned. The following areas will need follow up as part of the implementation phase of the WHO COVID-19 support to Tajikistan: • meet with the Ministry of Justice to review the COVID-19 procedures and protocols for people incarcerated in temporary or long-term facilities (prisons); and • visit GBAO and Khorog to assess health-care facility and laboratory capacity; the team had planned a visit to Khorog but were unable to travel due to weather conditions – the team nevertheless had a teleconference to discuss some of the current COVID-19 health concerns with government and health officials, but additional follow up is needed. 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