WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19
WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 © World Health Organization 2020 ISBN 978 92 9061 915 4 Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence Photo credits Cover: ©WHO/Yoshi Shimizu CONTENTS Introduction 1 Purpose 1 Background 1 Scope and target audience 2 Goal 2 Objectives 2 Priority areas 1. Incident management, planning, administration and coordination 3 2. Strategic communications 5 3. Community engagement 7 4. Non-pharmaceutical public health measures 9 5. Care pathways 11 6. Health-care delivery 13 7. Surveillance and risk assessment 15 8. Laboratory 17 9. Operational logistics 18 10. Health-care costs and financial protection 19 Pacific approach 20 Background 20 Pacific priority actions 20 Performance framework 24 Resource requirements 26 References 27 ii 1WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 INTRODUCTION Purpose This Regional Action Plan has been developed by the World Health Organization (WHO) Regional Office and country offices of the Western Pacific to guide WHO and partner actions in supporting countries and areas in the Region to mitigate the public health impact of large-scale community outbreaks of coronavirus disease 2019 (COVID-19). Background Since 2005, Member States of the Western Pacific Region have strengthened national health system capacities to detect and respond to emerging infectious diseases, guided by the Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (APSED III) (1). Strengthening these core capacities – as mandated by the International Health Regulations, or IHR (2005) – has enabled the Region to be more prepared to manage the challenges posed by public health emergencies. These capacities and the systems they support will be tested in the months to come as the world prepares to manage large-scale community outbreaks of COVID-19. On 7 January 2020, authorities identified a novel coronavirus from a cluster of pneumonia cases of unknown etiology in Wuhan, the capital city of Hubei province in Central China. On 30 January 2020, WHO declared the COVID-19 outbreak a public health emergency of international concern. By early March, unprecedented physical distancing measures and other non-pharmaceutical interventions had largely brought the spread of the virus under control in China. However, COVID-19 continues to spread in other countries around the world, many of which are not prepared or lack resources to respond to the same degree. Measures to control initial cases and localized outbreaks of COVID-19 involve active surveillance, contact tracing, isolation, quarantine and laboratory confirmation of each case. These measures are intense and challenging to sustain over time, particularly in resource-limited settings. If the virus has spread widely in the general community, control measures are no longer practical. Instead, authorities should focus resources on non-pharmaceutical interventions to reduce transmission and measures aimed at mitigating the impact on health-care systems and societies. The 2014 outbreak of Ebola virus disease in West Africa highlighted the need for response plans to change if initial cases or localized outbreaks develop into large-scale community outbreaks. In this scenario, initial intense control efforts must shift – quickly – to longer-term interventions that reduce the impact on health and social services and emphasize the engagement of communities in a sustained response. This type of situation requires a coordinated approach with countries and areas, WHO, the United Nations and other partners in the Western Pacific Region working together in a collaborative, all-of-society response. WHO’s response to COVID-19 is a major test of the Organization’s transformed emergency response structure, which has incorporated lessons from the Ebola outbreak. It is also an opportunity to put into practice the global WHO Thirteenth General Programme of Work 2019−2023 (2) and the Western Pacific Region’s shared vision for the coming years as articulated in For the Future: Towards the Healthiest and Safest Region (3). This will be achieved by ensuring that short-term emergency response goals also contribute to long-term strategic priorities, including addressing health emergencies, improving access to universal health coverage and strengthening health systems. 2INTRODUCTION This Regional Action Plan is based on the foundations laid by APSED III and designed to support implementation of the WHO guidance on preparing for large-scale community transmission of COVID-19 in countries and areas in the Western Pacific Region (4). This Plan is also aligned with the global Strategic Preparedness and Response Plan (5), WHO guidance on responding to the community spread of COVID-19 (6), and relevant international principles and initiatives, including the Sendai Framework for Disaster Risk Reduction 2015–2030 (7). Scope and target audience This Regional Action Plan is intended for use by WHO and partners to support Member States across the Western Pacific. It may also be used as a reference by Member States to inform national planning for large- scale community outbreaks of COVID-19 in accordance with their national contexts. This Plan specifically addresses the public health response actions needed once large-scale community outbreaks are established in a country and measures to mitigate the impact of a long-term COVID-19 epidemic. Pacific island countries and areas (PICs) face unique health system challenges, including logistical complexities, limited infrastructure, and relatively small populations and economies of scale. The priority areas and actions outlined in this Plan will be adapted to fit the Pacific context to meet specific needs and challenges in facing potential outbreaks of COVID-19. Goal To support countries and areas in the WHO Western Pacific Region in mitigating the public health impacts of large-scale community outbreaks of COVID-19, over a projected period of six months (March–August 2020). Objectives 1. Minimize illness and deaths caused by COVID-19 and reduce transmission of the virus. 2. Reduce stress on health services and protect those delivering care. 3. Engage communities to drive and sustain the response. 4. Protect vulnerable and hard-to-reach populations. 5. Work in partnership with governments, community partners, international and United Nations agencies and donors to deliver a coordinated, multisectoral public health response. 6. Strengthen overall health systems and contribute to long-term health priorities in the Region. Priority areas Actions to mitigate the impact of large- scale community outbreaks of COVID-19 are outlined in 10 priority areas: 1. Incident management, planning, administration and coordination 2. Strategic communications 3. Community engagement 4. Non-pharmaceutical public health measures 5. Care pathways 6. Health-care delivery 7. Surveillance and risk assessment 8. Laboratory 9. Operational logistics 10. Health-care costs and financial protection WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 3 National public health emergency management mechanisms will be activated to provide coordinated management of the COVID-19 response, including incident management systems, emergency operations centres, multisectoral coordination mechanisms and public health emergency plans. Country support C.1 National COVID-19 response plans Support countries to implement national COVID-19 response plans. Response plans developed for public health emergencies or pandemic influenza can be adapted to COVID-19. Plans should establish clear roles, responsibilities and collaboration mechanisms. This information should be widely disseminated to relevant actors. Plans should contain monitoring, evaluation and revision mechanisms to ensure adaptation to the evolving situation. Plans should also ensure inclusivity and equity, and protection of vulnerable groups including health-care workers, older people, the chronically ill and people with limited access to health care. C.2 Event management Support countries to implement a national incident management system (IMS) and functional emergency operations centre (EOC) for event management. C.3 Administration and finance Support countries to implement human, financial and material resource management processes within the national IMS to enable the COVID-19 response. Support planning processes, development of resource estimates, preparation of budget requests to finance ministries and proposals to potential donors. Coordinate operational logistics to facilitate surge staff deployments and ensure supply chain management of essential and emergency supplies and equipment. C.4 Multisectoral coordination Support countries to implement multisectoral mechanisms to coordinate response activities and whole-of-society participation. Managed by national emergency platforms, coordination actions should strengthen collaboration across the entire health system (including national, subnational and community levels; public, private and informal facilities), across multiple sectors (such as financial, education, transportation, tourism, culture, development, nongovernmental organizations and business) and across society (including vulnerable groups and hard-to-reach communities). INCIDENT MANAGEMENT, PLANNING, ADMINISTRATION AND COORDINATION 1. 41. INCIDENT MANAgEMENT, PLANNINg, ADMINISTRATION AND COORDINATION Regional support R.1 International partnerships and coordination Support the development of whole-of-society, innovative and community-based solutions from the ground up. Promote the health sector as a driver and facilitator of growth and development, and work with partners in and outside the health sector to address the role of improved health security in global social and economic development. Coordinate with global and regional partners, stakeholders and donors to share information, convene expertise, and mobilize technical support and resources. Facilitate access to donors and other funding sources for WHO country offices and Member States. Coordinate participation in research initiatives and contribute to international research and development priorities. R.2 Research and innovation Collect and share examples of good practices and innovation at the country level to respond to COVID-19, particularly community-based solutions from the ground up. Contribute to the regional research agenda in the areas of community engagement, non-pharmaceutical public health measures, development of care pathways and health service delivery. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 5 Strategic communications – both risk and leadership communications – are critical components of any emergency response. Risk communication is the real-time exchange of information, advice and opinions between health experts and people who face a risk to their survival, health or socioeconomic well- being. Timely, responsive, transparent, empathetic and consistent messaging is key to maintaining trust. It is critical to communicate to the public what is known, what is unknown or uncertain, what is being done to respond to the situation and what people can do to protect themselves and others. Leadership communications focus on the timely sharing of accurate updates on the situation, the actions being taken by WHO, Member States and partners to address COVID-19, and their impact. These communications reinforce trust in the response, ensure that recommendations are implemented, strengthen working partnerships, and keep the public and other stakeholders well informed. Country support C.1 National risk communication plans Support adaptation and implementation of national risk communication plans for public health emergencies (or similar) for COVID-19 response. C.2 Technical content and advice for public communications Provide technical content and advice to government counterparts for press releases, briefings and national media enquiries. Participate in media and partner briefings when invited. Support national authorities to develop, adapt, translate and disseminate information, education and communication (IEC) materials for target groups and the general public. Put COVID-19 messages in the context of relevant messages for overall health promotion (such as good handwashing practices, respiratory etiquette) and psychosocial support (such as promoting mental health). C.3 Listening and feedback loops Support countries to gather information on community perceptions (such as through social media monitoring, surveys or feedback) and incidents of social stigmatization and discrimination. This information should be used to respond to public concerns, questions, rumours and misinformation and to update risk communication messaging and materials. C.4 Coordination of risk communication activities across partner agencies Coordinate with other in-country United Nations agencies and partners to ensure consistent messaging and efficient utilization of the strengths and resources of each agency to reach a broader audience. STRATEGIC COMMUNICATIONS 2. 62. STRATEgIC COMMUNICATIONS Country support C.5 Leadership communications Share credible, understandable, timely, accessible and actionable information on the evolving situation, WHO’s role in the response and its impact. Use strategic engagement with media and other stakeholders, and develop and disseminate a range of communications products. Regional support R.1 Regional social listening Conduct regional media surveillance (traditional and social) to understand the perceptions of target audiences and to detect and respond to rumours, misinformation and stigmatization. Media surveillance includes social media listening, polling and research, and monitoring and evaluation. R.2 Coordination of risk communication activities across partner agencies Coordinate with other United Nations agencies and partners to ensure consistent messaging and efficient use of the strengths and resources of each agency to reach a broader audience. Establish partnerships for information dissemination with media platforms. R.3 Communication on the situation, response and impact Communicate on the COVID-19 situation, response and impact of interventions with different audiences including the media, the public, donors and partners. Ensure timely internal communication within WHO on all levels. R.4 Technical support Develop, adapt and disseminate guidance, resources and lessons learnt on risk communication in emergency settings. Translate science and guidance into actions. Support countries to adapt, translate and produce communication materials. Provide technical assistance and training to countries based on regional support plans and assessed need. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 7 Strategies to prepare for a successful response to COVID-19 require effective and timely community engagement to support local meaning-making, self-organization and resilience. Communities in urban, rural and remote settings must be willing to prepare for adjustments in social and economic life that may be required to limit the spread of COVID-19. Communities, especially those farthest from specialist health care, also must plan and prepare to recognize symptoms of mild or severe disease, prevent further infection and access needed health-care services. Country support C.1 Network mapping and development Work with countries and partners to map, utilize and build upon existing networks and structures to engage communities and hard-to-reach populations in planning the response to COVID-19. Networks can include disease control volunteers from existing programmes (immunization, tuberculosis, malaria, HIV), nongovernmental organizations, medical associations, unions, community or religious leaders, women’s groups and organizations that work with vulnerable groups. Engage with influential community leaders to mobilize community-owned preparedness and response. Structures include formal and non-formal mechanisms of organization and decision- making that exist at national, local and community levels. C.2 Enhancing engagement at interfaces Support countries and areas to identify critical interface points between community members and public health and/or care delivery (such as clinics, hospitals and social care). Develop mechanisms to monitor, assess and strengthen the quality of interactions at these points, particularly where poor interaction could lead to loss of community trust and confidence (such as triage and referral). Ensure that staff at these interfaces have the training and relational skills to interact with communities in ways that address fears/concerns, build trust, reduce anxiety and communicate correct information. C.3 Engagement and feedback Support countries and areas to define key principles for community engagement during the response that will form the foundation for trust during recovery and after the outbreak. Draw upon nationally and regionally available expertise to support the development and implementation of context-specific engagement strategies with at- risk and affected communities and to facilitate community-based approaches to the COVID-19 response from the ground up. Engagement should be genuine and two-way, enabling communities to offer feedback and local solutions. COMMUNITY ENGAGEMENT3. 83. COMMUNITy ENgAgEMENT Regional support R.1 Community engagement package Compile and disseminate guidance, resources and lessons on community engagement, appropriate to a scenario of large-scale community outbreaks of COVID-19. R.2 Coordinate with key partner agencies Coordinate with other United Nations agencies, international agencies and partners to support community engagement activities, and ensure that the strengths and resources of each agency are used effectively to support country responses. R.3 Technical support Support countries to implement key community engagement processes and interventions in coordination with partners. Provide technical assistance and training to countries based on regional support plans and assessed need. Evaluate implementation of community engagement action plans and document lessons learnt, in coordination with national programmes and partners. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 9 NON-PHARMACEUTICAL PUBLIC HEALTH MEASURES 4. Strategies to reduce the level of COVID-19 transmission will largely rely on non-pharmaceutical public health measures, as there are currently no vaccines or specific therapeutics available. Such measures include personal protective, physical distancing, travel-related and environmental measures. Each planned measure should have a clear objective informed by a risk assessment of the current or projected situation, defined triggers to start and stop, and be coordinated with all relevant sectors. Measures should also be carefully evaluated for economic and social impact. Country support C.1 Planning Support countries to identify and plan appropriate non-pharmaceutical public health measures, involving all relevant sectors through multisectoral coordination mechanisms. For each planned measure, define the public health objective and rationale, trigger criteria and period for implementation, and evaluate the public health benefit versus social and economic costs. Conduct multisectoral scenario planning and simulations to test implementation and communications. Review and strengthen any regulatory and legal frameworks needed to support planned measures. C.2 Multisectoral implementation Support countries to coordinate multisectoral implementation of non-pharmaceutical public health measures. Engage communities and civil society groups to implement measures and mitigate social impacts (such as engaging communities to help with home care, childcare or psychosocial support). C.3 Communication and community engagement Coordinate with risk communication and community engagement teams to prepare messages and information materials for affected people, the public and other stakeholders. Support countries to engage communities and civil society groups to develop local adaptations or solutions to planned measures, in order to reduce the social or economic impacts and increase compliance and sustainability. C.4 Monitoring and evaluation Establish metrics and monitoring and evaluation systems to assess the real-time effectiveness and impact of planned measures, in order to inform decision-making to continue, adapt or stop. 10 4. NON-PHARMACEUTICAL PUBLIC HEALTH MEASURES Regional support R.1 Monitoring and evaluation Establish monitoring and evaluation systems to assess the effectiveness and impact of implemented measures and to make recommendations to continue, adapt or stop. R.2 Technical support Develop, adapt and disseminate guidance on relevant non-pharmaceutical public health measures. Provide technical advice and assistance to countries based on regional support plans and assessed need. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 11 A care pathway outlines each step a person takes over the course of an illness from the first contact with primary health-care services to outpatient management or hospitalization, community or home care, and recovery or death. It also encompasses the clinical care expected at different points on the pathway. During widespread community outbreaks, clear care pathways are needed for people with suspected COVID-19, people requiring critical routine care and people requiring emergency care for other health conditions to ensure that large numbers of patients can be managed safely. Mapping patient journeys through the care pathway enables more effective resource allocation between different levels of the health system, better clinical outcomes and standardized quality of health care across facilities. In the context of COVID-19, this will also enable services and referral arrangements to be reorganized to meet the changing health- care needs of the response. Country support C.1 Care pathways Support countries to plan care pathways for people with suspected COVID-19, people requiring critical routine care and people requiring emergency care for other health conditions. For people with suspected COVID-19, care pathways should identify systems and capacities to be established at first contact points (such as staffed hotlines or ambulance), presentation to health facilities (such as clinics or triage counters before entry to facility) and other health services (such as hospital wards that do not care for patients with COVID-19). Care pathways should include primary care settings, rural health posts, non-health facilities, community settings and home care, as well as access to psychosocial and mental health support mechanisms. Care pathways for patients requiring critical routine care and emergency care for other health conditions should identify modified arrangements during a period of large- scale community outbreaks of COVID-19. Support countries to communicate new and modified care pathways to health facilities, health workers, other stakeholders and the public. Include nongovernmental, faith-based and other civil society organizations that may provide care to vulnerable and hard-to-reach populations including migrants, remote rural, cultural or ethnic groups. C.2 Clinical management Support countries to review, disseminate and train health-care workers in national guidance for clinical management of COVID-19 and management of patients with co-morbid conditions and risk factors. Engage communities and civil society groups to develop and implement guidance for community and home care of mild cases. Training strategies should include special considerations for health workers in remote locations and those providing care to marginalized and hard-to-reach communities. Consider establishing a clinical professional network to share expertise and lessons in managing patients with COVID-19. CARE PATHWAYS5. 12 5. CARE PATHWAyS Country support C.3 Infection prevention and control guidance Support countries to review and update national infection prevention and control (IPC) guidance for COVID-19 in line with existing policies and procedures, disseminate this guidance to hospitals and health-care facilities, and train staff in implementation. Support countries to translate, adapt and disseminate IPC guidance for home and community care providers and other relevant facilities (such as elderly homes, long- term care facilities and points of entry). guidance should reflect locally accessible resources. C.4 Patient payments Support countries to develop patient payment options and initiatives to reduce financial barriers and out-of-pocket payments people may face in accessing health care for COVID-19. C.5 Potential use of therapeutics and vaccines Review risk group prioritization and mechanisms for the use of off-license or experimental therapeutics and vaccines for compassionate use and/or clinical trials, when available. Regional support R.1 Regional networks Coordinate a regional clinical expert network to address uncertainties around the clinical management of COVID-19 and patients with co-morbid conditions and risk factors. Establish methods to share updated knowledge (such as videoconferences and bulletins). Establish a regional knowledge and response network for mental health and psychosocial support. R.2 Technical support Develop, adapt and disseminate guidance, tools, protocols and algorithms for clinical management, triage, referral criteria, community-level care and psychosocial support, including adaptations for low-resource settings. Adapt and disseminate IPC guidance for COVID-19 for facility, community and home care settings. Provide technical assistance and training to countries based on regional support plans and assessed need. Support and promote the use of innovative approaches for triage and health- care delivery (such as telemedicine, e-health and augmented diagnosis). WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 13 HEALTH-CARE DELIVERY6. Health facilities and systems will need to be reorganized to enable safe and effective care pathways for patients with COVID-19 and people requiring urgent routine and emergency care. This includes three elements: 1) leveraging existing health system capacity; 2) adjusting for COVID-19-specific care; and 3) enhancing capacity with training and additional resources. Health facilities will be required to reconfigure service delivery and prepare for surge capacity through actions to manage patient flow, hospital beds and routine/emergency service provision and to strengthen workforce capacities, IPC and business continuity. Country support C.1 Designated clinical services for COVID-19 Support countries to identify designated hospitals and transport services for patients with COVID-19 across different levels of health care (primary and hospital) and to designate trained staff to provide care. Ensure triage, referral and case management mechanisms are coordinated with designated hospitals and transport services. C.2 Facility-level planning Support countries to develop facility-level plans (from primary to tertiary) to triage and treat severe and high-risk cases of suspected COVID-19 through facility configuration, patient distribution and transfer mechanisms, equipment and resources (including personal protective equipment (PPE) and hand hygiene consumables). Identify ways to increase bed capacity if needed (such as utilizing long-term care wards for acute care). Support countries to address specific service delivery challenges, such as service delivery to remote islands and areas. C.3 Planning and delivery of essential routine and emergency care Support countries to develop national and subnational plans to continue delivery of essential routine care (such as births and chronic disease management) and emergency care (such as trauma and heart attacks). This should include plans to designate specific facilities for these services, to deliver routine care online or by telephone (such as repeat prescription needs), and to bring elective surgeries forward (before anticipated large-scale community outbreaks) or postpone them. C.4 Health workforce Support countries to protect health workers and to strengthen their capacity for stronger service delivery overall. Establish staff health and welfare policies (workload, compensation, sick leave, protection from abuse, psychosocial support, etc.), provide necessary training and technical support, and ensure adequate IPC measures. Support countries to recruit and train surge staff if needed (including volunteers, retirees and emergency medical teams). 14 6. HEALTH-CARE DELIVERy Country support C.5 IPC in health facilities Support countries to strengthen and apply standard precautions for all patients, additional contact and droplet precautions for suspected and confirmed COVID-19 patients, and airborne precautions for health workers performing aerosol-generating procedures. Access to and appropriate use of PPE and hand hygiene consumables are essential. Support countries to develop adequate isolation capacity. Ensure that health facility and patient transport infrastructure meet IPC standards, including adequate ventilation, bed spacing, designated areas for donning and removing PPE, hand hygiene, waste management, environmental cleaning and disinfection. Support countries to ensure sustainable IPC infrastructure and activities in health facilities (IPC committee, reviewing existing PPE stockpiles, estimating future needs, facilitating procurement, monitoring and evaluation, etc.). C.6 Business continuity Support countries to ensure overall business continuity of health facilities. Establish mechanisms to assess the burden on local health systems, and the capacity to continue health service delivery in hospitals and primary care facilities for patients with and without COVID-19. C.7 Medicines, supplies and medical devices Support countries to identify items and quantities of medicines, supplies and medical devices needed to provide treatment for COVID-19 and maintain essential health services at each level of care. Develop plans for medical supply chain management, taking potential supply and transport disruptions into consideration. (Also see 9. Operational logistics) C.8 Excess mortality Support countries to develop mortuary plans to manage increased numbers of corpses due to COVID-19 deaths and to review guidelines for post-mortem care if COVID-19 caused or contributed to death. Regional support R.1 Regional networks Establish a regional network of hospital administrators to exchange experiences and expertise and to provide support. Establish a regional IPC expert network to coordinate and facilitate the exchange of technical expertise, knowledge and potential deployments. R.2 Technical support Develop and disseminate models and tools to support facility-level planning. Provide technical assistance and training to countries based on regional support plans and assessed need. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 15 SURVEILLANCE AND RISK ASSESSMENT 7. During large-scale community outbreaks, surveillance will focus on monitoring trends for geographical spread, transmission intensity, affected populations, virological features and impacts on health-care services. These multiple sources inform ongoing risk assessments for deciding appropriate public health measures. Country support C.1 Case definitions, surveillance strategies and systems Support countries to develop and update national case definitions and surveillance strategies and systems to support the objectives of the COVID-19 response, based on updated WHO guidance. In the early stages of the spread of the virus, surveillance strategies may focus on control activities, including case identification and contact tracing. In case of large- scale community outbreaks, surveillance strategies should focus on monitoring disease trends and impact. Existing surveillance systems for respiratory illnesses and notifiable diseases1 can be used for COVID-19 and supplemented with ad hoc indicators,2 if needed. C.2 Health information management and reporting Support countries to report the first case of COVID-19 to WHO within 24 hours of confirmation as per IHR (2005) requirements. Support countries to report early cases of COVID-19 to WHO via IHR reporting mechanisms. If widespread community outbreaks are occurring, support weekly reporting of aggregated epidemiological and virological data to WHO via the FluMart platform.3 Promote the collection of disaggregated data (by gender, socioeconomic status, etc.) to analyse disparities in risk and access to health care. C.3 Risk and severity assessment Support countries to conduct continuous systematic risk and severity assessments, and to use assessment findings to review and inform response measures. 1 For instance, event- and indicator-based surveillance for influenza-like illness (ILI), severe acute respiratory illness (SARI), acute febrile illness and pneumonia, notifiable disease surveillance system. 2 For instance, school absenteeism at sentinel sites, sales of over-the-counter medications. 3 For more information on FluMart, see https://www.who.int/influenza/resources/flumart/en/. 16 7. SURVEILLANCE AND RISk ASSESSMENT Regional support R.1 Regional surveillance and risk assessment Conduct regional COVID-19 surveillance and risk assessment using multiple sources to inform decision-making on appropriate response measures and public health interventions. R.2 Situation reports and analysis Produce and disseminate regular briefings, standardized situation reports (“sitreps”) and epidemiological analysis to inform operations. R.3 Technical support Develop, adapt and disseminate guidance, protocols and algorithms for COVID-19 case definitions, surveillance and risk assessment. Provide technical assistance and training to countries based on regional support plans and assessed need. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 17 Countries will require access to large-scale laboratory testing for COVID-19 – domestically or through arrangements with international reference laboratories. Laboratories should implement testing strategies to monitor the intensity of transmission as well as surge plans to manage increased volume. Country support C.1 Testing strategies Support countries to establish sampling strategies for virological testing to monitor transmission intensity in coordination with surveillance and clinical management focal points. Ensure that national reference laboratories report virological data through appropriate channels. C.2 National laboratory system and surge plans Support countries to identify national laboratories with the capacity to test for COVID-19 or, if domestic capacity does not exist, to establish arrangements with an international reference laboratory. Establish surge plans (including staffing, equipment, reagents and other consumables) to manage increased demand for testing and to return results in a timely manner. C.3 Laboratory equipment and supplies Support countries to source and procure diagnostic kits, laboratory equipment, reagents, packing supplies and other laboratory consumables. C.4 Biosafety and biosecurity Support countries to ensure that staff are trained in and implement COVID-19 laboratory testing procedures and biosafety protocols. C.5 Specimen shipment Support countries to ensure that staff are trained in and implement protocols to pack, store and ship specimens according to national regulations. If samples are sent to international reference laboratories, staff must also be trained in and implement international sample transport regulations. Regional support R.1 Quality assurance Implement an external quality assessment (EQA) programme for regional laboratories testing for COVID-19. R.2 Technical support Develop, adapt and disseminate guidance, protocols and algorithms for COVID-19 laboratory testing. Provide technical assistance and training to countries based on regional support plans and assessed need. LABORATORY8. 18 WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 Logistical arrangements to support event management and operations should be reviewed. Measures should be put in place to strengthen and ensure supply chain delivery to rural, remote and urban areas. Expedited procedures may be required in key areas (such as surge staff deployments, procurement of essential supplies and staff payments). Country support C.1 Resource and supply mapping Support countries to map available resources and supply systems in health and other sectors. In health facilities, include facility-level inventory reviews of supplies based on the WHO COVID-19 Disease Commodity Package.4 C.2 Procurement processes Support countries to review and strengthen procurement processes (including importation and customs) for medical and other essential supplies. C.3 Supply chain management Support countries to strengthen supply chain and management systems (stockpiling, storage, security, transportation and distribution) for medical and other essential supplies. Ensure that supply chain management extends to rural and remote areas as well as urban centres. Regional support R.1 Procurement, stock management and distribution Coordinate procurement, stock management and distribution to ensure countries have stocks of essential response equipment and supplies. R.2 Support staff deployments Deploy support staff to countries on request (such as technical experts and emergency medical teams). R.3 Technical support Develop, adapt and disseminate guidance, quantification tools and resources for operational logistics. Provide technical assistance and training to countries based on regional support plans and assessed need. 4 See https://www.who.int/publications-detail/disease-commodity-package---novel-coronavirus-(ncov). OPERATIONAL LOGISTICS9. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 19 Ensuring adequate and timely financing will be a critical part of the response to large- scale community outbreaks of COVID-19. Sources of finance may include domestic and international sources, development partners and multilateral development banks. Describing what health ministries expect to achieve with resources requested to respond to the outbreaks, as well as long-term benefits that will accrue from stronger health systems, is crucial to developing credible, compelling and costed budget requests. This includes putting in place measures to ensure that people can access testing and treatment without risk of financial impoverishment. Country support C.1 Costing health-care needs Support countries to frame and obtain inputs to cost required health-care needs to prepare for large-scale community outbreaks of COVID-19. C.2 Financial source identification Support countries to identify potential domestic and international funding streams to finance the COVID-19 response. Provide support to identify and address specific funding preconditions and requirements. C.3 Funding requests Support countries to develop and present robust funding requests to domestic and international funders. Provide guidance on outputs and outcomes related to public financial management (PFM) and linkages to PFM instruments, such as medium-term budget and expenditure frameworks. Regional support R.1 Technical support Develop, adapt and disseminate guidance and tools for health-care financing. Provide technical assistance and training to countries based on regional support plans and assessed need. HEALTH-CARE COSTS AND FINANCIAL PROTECTION 10. 20 WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 PACIFIC APPROACH Background The Pacific region includes 21 unique countries and areas spread across a vast expanse of ocean with an extremely diverse population in terms of ethnicity, culture, economy and health. Compared to the rest of the Western Pacific Region, however, they share similar health system challenges arising from small population sizes, geographic isolation, fragile infrastructure and limited resources. A sustained response to large-scale community outbreaks of COVID-19 will be an extreme challenge for many Pacific islands. In addition to health system and capacity issues, Pacific island countries and areas also face: • High rates of noncommunicable diseases (NCDs), including cardiovascular diseases, diabetes, cancer and chronic respiratory diseases, which represent the single largest cause of premature mortality in the Pacific. Together with older people, people with underlying medical conditions such as these are most at risk of severe illness from COVID-19 infection. • Disrupted transport routes and reduced volume of commercial flights due to travel restrictions aimed at stopping the importation of COVID-19 cases. Restrictions are also causing significant disruptions to the supply of essential items and medical supplies, to access to timely laboratory testing and overseas medical referral systems, and to deployments of international humanitarian staff, technical experts and emergency medical teams to the Pacific. Pacific priority areas The types of risk will vary across Pacific island countries and areas, and country-level risk assessments will be required to guide national actions and WHO support. As these risk assessments evolve, specific activities within this Regional Action Plan will be prioritized for different countries and areas. 1. Incident management, planning, administration and coordination National COVID-19 response plans. Support countries and areas to develop and implement national COVID-19 response plans. Event management and coordination. Support countries and areas to implement robust systems for event management and coordination with other government sectors, international agencies and partners. Administration and finance. Support countries and areas to implement administration and financial management of the COVID-19 response. 2. Strategic communications National risk communication plans. Support adaptation and implementation of national risk communication plans for public health emergencies (or similar) for the COVID-19 response. Advice for public communications. Provide technical content and advice to government counterparts for press releases, briefings and media enquiries. Listening and feedback loops. Support countries and areas to gather information on community perceptions and incidents of stigmatization and discrimination to respond to public concerns, rumours and misinformation and update messaging and communication materials. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 21 3. Community engagement Network mapping and development. Work with countries and areas to map, utilize and build upon existing networks and structures to engage communities and hard-to-reach populations in planning the response to COVID-19. Enhancing engagement at interfaces. Support countries and areas to identify critical interface points between community members and public health/ care delivery and to strengthen the quality of interactions at these points, particularly where poor interaction could lead to loss of community trust and confidence (such as triage and referral). Engagement and feedback. Support countries and areas to define key principles for community engagement during the response that will form the foundation for trust during recovery and after the outbreak. Develop and implement context-specific engagement strategies with at-risk and affected communities and to facilitate community- based approaches to the COVID-19 response from the ground up. 4. Non-pharmaceutical public health measures Planning. Support countries and areas to identify and plan appropriate non-pharmaceutical public health measures with the involvement of all relevant sectors. For each planned measure, define the public health objective and rationale, trigger criteria and period for implementation, and evaluate the public health benefit against social and economic costs. Communication and community engagement. Coordinate with communication and community engagement teams to prepare messages and information for affected people, the public and other stakeholders. Support countries and areas to engage communities and civil society groups in developing local adaptations or solutions to planned measures. Monitoring and evaluation. Establish metrics and monitoring and evaluation to assess the real-time effectiveness and impact of planned measures to inform decision-making to continue, adapt or stop. 5. Care pathways Care pathways. Support countries and areas to plan care pathways for people with suspected COVID-19, people requiring critical routine care and people requiring emergency care for other health conditions and to communicate this information to the public. Care pathways should include primary care settings, rural health posts, non-health facilities, community settings and home care, as well as access to psychosocial and mental health support mechanisms. Clinical management of COVID-19. Support countries and areas to review, disseminate and train health workers in national guidance for clinical management of COVID-19 and management of patients with co-morbid conditions and risk factors. Training strategies should include special considerations for health workers in remote locations or those providing care to marginalized and hard-to-reach populations. Engage communities and civil society groups to implement guidance for community and home care of mild cases. IPC guidance for COVID-19. Support countries and areas to review and adapt IPC guidance for COVID-19, disseminate this guidance to health-care facilities, and train staff in implementation. Translate, adapt and disseminate IPC guidance for home and community care providers and other relevant facilities. guidance should reflect locally accessible resources. Patient payments. Support countries and areas to develop patient payment options and initiatives to reduce financial barriers and out-of-pocket payments that people may face in accessing health care for COVID-19. 22 PACIFIC APPROACH Potential use of therapeutics and vaccines. Review risk group prioritization and mechanisms for the use of off- license or experimental therapeutics and vaccines for compassionate use and/or clinical trials, when available. 6. Health-care delivery Designated clinical services for COVID-19. Support countries and areas to designate facilities for patients with COVID-19, and train staff to provide appropriate care. Ensure triage, referral and case management mechanisms are coordinated with designated facilities. Facility-level planning. Support countries and areas to develop plans at each health-care facility to triage, isolate and treat severe and high-risk cases of suspected COVID-19. Identify ways to increase bed capacity, if possible, and address service delivery needs of remote islands and areas. Planning and delivery of essential routine and emergency care. Support countries and areas to develop national and facility-level plans to continue delivery of essential routine care (such as births and chronic disease management) and emergency care (such as trauma and heart attacks). Health workforce. Support countries and areas to protect health workers and strengthen their capacity for service delivery overall. Establish staff health and welfare policies (compensation, sick leave, psychosocial support, etc.), provide necessary training and technical support, and ensure adequate IPC measures. Support countries and areas to recruit and train surge staff, if needed (including volunteers, retirees and emergency medical teams). IPC in health-care facilities. Support countries and areas to strengthen IPC practices and environments, and ensure sustainable IPC infrastructure in health facilities. Access to and appropriate use of PPE and hand hygiene consumables are essential. Ensure health facilities have adequate isolation capacity and patient transport infrastructure that meet IPC standards including adequate ventilation, bed spacing, designated areas for donning and removing PPE, hand hygiene, waste management, environmental cleaning and disinfection. Business continuity. Support countries and areas to ensure overall health facility business continuity. Regularly assess the burden on local health systems and capacity to continue health service delivery to patients with and without COVID-19. Medicines, supplies and medical devices. Support countries and areas to identify items and quantities of medicines, supplies and medical devices needed to provide COVID-19 treatment and maintain essential health services. Develop plans for medical supply chain management, taking potential supply and transport disruptions into consideration. (Also see 9. Operational logistics) Excess mortality. Support countries and areas to develop mortuary plans to manage increased numbers of corpses due to COVID-19 deaths and to review guidelines for post-mortem care if COVID-19 caused or contributed to death. 7. Surveillance and risk assessment Case definitions, surveillance strategies and systems. Support countries and areas to update case definitions and enhance surveillance strategies and systems to support the objectives of the COVID-19 response. Health information management and reporting. Support countries and areas to report early cases of COVID-19 to WHO via IHR reporting mechanisms. In the event of widespread community outbreaks, support weekly reporting of aggregated epidemiological and virological data to WHO. Promote the collection of disaggregated data (by gender, socioeconomic status, etc.) to 23 WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 analyse disparities in risk and access to health care. Risk and severity assessment. Support countries and areas to conduct continuous systematic risk and severity assessments, and use assessment findings to review and inform response measures. 8. Laboratory Testing strategies. Support countries and areas to establish sampling strategies for laboratory testing to monitor transmission intensity in coordination with surveillance and clinical management focal points. National laboratory system and surge plans. Support countries and areas to establish COVID-19 testing arrangements with an international reference laboratory. Specimen shipment. Support countries and areas to ensure that staff are trained in and implement protocols to pack, store and ship specimens according to national and international sample transport regulations. Support access to accredited transport to ship specimens to reference laboratories. Laboratory equipment and supplies. If available, support countries and areas to procure mobile laboratory equipment, diagnostic kits, reagents, packing supplies and other testing consumables. 9. Operational logistics Resource and supply mapping. Support countries and areas to map available resources and supply systems. Procurement processes. Support countries and areas to review and strengthen procurement processes (including imports and customs) for medical and other essential supplies. Supply chain management. Support countries and areas to strengthen supply chain management for medical and other essential supplies, including to remote areas. 10. Health-care costs and financial protection Costing health-care needs. Support countries and areas to cost and budget required health-care needs to prepare for large-scale community outbreaks of COVID-19. Financial source identification. Support countries and areas to identify potential funding streams to finance the COVID-19 response and to address any requirements to access funds. Funding requests. Support countries to develop and present robust funding requests to domestic and international funders. 24 WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 PERFORMANCE FRAMEWORk The indicators listed below are a sample of the indicators that will be used to monitor implementation of the Regional Action Plan. A framework will be developed in collaboration with national governments and implementing partners to monitor key performance indicators at country and regional levels on a regular basis. Where appropriate, indicators will be aligned with those used in national plans and the WHO Strategic Preparedness and Response Plan to streamline reporting. Priority area Sample indicator Proposed target Rationale 1. Incident management, planning, administration and coordination Proportion of countries and areas with a COVID-19 national preparedness and response plan 100% Planning is critical to help mitigate the impact of community outbreaks. Countries and areas with a plan will have better knowledge and capacities for timely response. Proportion of countries and areas with a functional multisectoral, multipartner coordination mechanism for COVID-19 preparedness and response 100% Coordination is critical for an effective response. The activation of a functional emergency operations centre or other relevant coordination system is evidence of the presence of coordination. 2. Strategic communications Proportion of countries and areas that have developed or adapted a risk communication plan for COVID-19 > 80% Existence and application of a plan is likely to facilitate improved risk communication to mitigate the impact of community outbreaks. Proportion of countries and areas that have communicated COVID-19 prevention and preparedness messages to the population > 80% Effective messaging helps transform and deliver public health policies and scientific knowledge so they are understood by, accessible to and trusted by populations and communities. 3. Community engagement Proportion of countries and areas with a COVID-19 community engagement plan > 60% Existence and application of a plan is likely to facilitate improved community mobilization and commitment to a sustained response. 4. Non-pharmaceutical public health measures Proportion of countries and areas with defined objectives and triggers developed for proposed physical distancing measures > 80% Physical distancing measures are important tools to control transmission, given that pharmaceutical interventions for COVID-19 are still in development. Developing objectives and triggers for each planned measure will facilitate rational and clear implementation. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 25 Priority area Sample indicator Proposed target Rationale 5. Care pathways Proportion of countries and areas with a clinical referral system to care for COVID-19 cases > 80% Clinical referral systems will be required to enable severe and high-risk cases to be appropriately managed by health-care facilities under pressure. 6. Health-care delivery Proportion of countries and areas with an infection prevention and control (IPC) programme > 80% To minimize the risk of onward transmission, clinical care should adhere to optimum IPC practices, managed by an IPC programme aligned with WHO guidelines. 7. Surveillance and risk assessment Proportion of countries and areas with a surveillance strategy in place to monitor disease trends and impact during large-scale community outbreaks of COVID-19 100% During large-scale community outbreaks, surveillance should focus on monitoring disease trends and impacts on health systems to inform risk assessments and guide response measures. Proportion of countries and areas with COVID-19 event-based surveillance > 80% Event-based surveillance will be an important component of a multisource surveillance approach to monitoring disease trends and impacts. 8. Laboratory Proportion of countries and areas that have COVID-19 laboratory testing capacity or access to a reference laboratory 100% Access to large-scale laboratory testing will be required to monitor the intensity of transmission – either domestically or through arrangements with international reference laboratories. 9. Operational logistics Proportion of countries and areas receiving stocks of requested supplies (for example, personal protective equipment (PPE), laboratory consumables) N/A Capacity to procure and deploy supplies to countries and areas will support effective national responses. 10. Health-care costs and financial protection Number of countries and areas supported to develop health-care costings and funding requests N/A Ensuring adequate and timely financing will be a critical part of the COVID-19 response. 26 WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 RESOURCE REQUIREMENTS Priority area Country support (US$) Regional support (US$) Total estimated requirement (US$) 1. Incident management, planning, administration and coordination 2 800 000 750 000 3 550 000 2. Strategic communications 4 400 000 370 000 4 770 000 3. Community engagement 5 300 000 260 000 5 560 000 4. Non-pharmaceutical public health measures 1 700 000 90 000 1 790 000 5. Care pathways 3 600 000 270 000 3 870 000 6. Health-care delivery 39 000 000 450 000 39 450 000 7. Surveillance and risk assessment 3 200 000 150 000 3 350 000 8. Laboratory 9 300 000 140 000 9 440 000 9. Operational logistics 900 000 270 000 1 170 000 10. Health-care costs and financial protection 640 000 25 000 665 000 WHO incident management 3 590 000 5 035 000 8 625 000 Total 74 430 000 7 810 000 82 240 000* * Requirements may change during the response, given the rapidly evolving nature of the COVID-19 situation globally and within individual countries. WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 27 REFERENCES 1. Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (APSED III). Manila: WHO Regional Office for the Western Pacific; 2017 (https://iris.wpro.who.int/ handle/10665.1/13654). 2. Thirteenth general Programme of Work 2019–2023. geneva: WHO; 2019 (https://www.who. int/about/what-we-do/thirteenth-general-programme-of-work-2019---2023). 3. For the future: towards the healthiest and safest region. Manila: WHO Regional Office for the Western Pacific; 2020 (https://iris.wpro.who.int/handle/10665.1/14476). 4. Preparing for large-scale community transmission of COVID-19: guidance for countries and areas in the WHO Western Pacific Region. Manila: WHO Regional Office for the Western Pacific; 2020 (https://iris.wpro.who.int/handle/10665.1/14493). 5. 2019 novel coronavirus (2019-nCoV): strategic preparedness and response plan [draft]. geneva: WHO; 2020 (https://www.who.int/docs/default-source/coronaviruse/srp-04022020. pdf). 6. Responding to community spread of COVID-19: interim guidance. geneva: WHO; 2020 (https://www.who.int/docs/default-source/coronaviruse/20200307-responding-to-covid-19- communitytransmission-final.pdf). 7. Sendai Framework for Disaster Risk Reduction 2015-2030. geneva: United Nations Office for Disaster Risk Reduction; 2015 (https://www.undrr.org/publication/sendai-framework- disaster-risk-reduction-2015-2030).