What is the risk, as of 22 April 2020, of severe disease associated with SARS-CoV-2infection in the general population in the EU/EEA and UK?

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Risk assessment on COVID-19, 23 April 2020

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What is the risk, as of 22 April 2020, of severe disease associated with SARS-CoV-2infection in the general population in the EU/EEA and UK?

  • The risk of severe disease in the EU/EEA and UK is currently considered low for the general population in areas where appropriate physical distancing measures are in place and/or where community transmission has been reduced and/or maintained at low levels.
  • The risk of severe disease in the EU/EEA and UK is currently considered moderate for the general population in areas where appropriate physical distancing measures are not in place and/or where community transmission is still high and ongoing.

This assessment is based on the following factors:

  • Most EU/EEA countries have observed decreases in the daily number of newly reported cases in the last two weeks. As of 22 April, 20 countries had decreasing 14-day incidence, with 19 countries reporting a current 14- day incidence below 50 cases per 100 000 population. Although the composition and intensity of implementation vary, all EU/EEA countries and the UK have introduced a range of non-pharmaceutical interventions such as ‘stay-at-home’ policies (recommended or enforced) alongside other community and physical distancing measures such as the cancellation of mass gatherings and closure of educational institutions and public spaces to reduce transmission. While uncertainty remains about the extent to which the combination and intensity of these measures impacts on transmission, in several countries such measures are associated, at least temporarily, with decreases in the number of newly reported cases at population level. In addition, transmission rates within countries are heterogeneous and even in countries with high incidence of COVID-19, there are areas where sustained community transmission has been halted or strongly reduced. In countries with appropriate measures in place as well, as in areas where transmission has declined or remained low, the probability of infection with COVID-19 is currently assessed as low.
  • However, several countries appear to have not yet reached a peak and the current 14-day incidence is currently the highest observed. As of 22 April, five countries, including Spain, that show a clear decreasing trend still have a 14-day incidence >100 cases per 100 000 population. In these countries, the implemented control measures may not yet be showing the desired effect. In these settings, the probability of infection with COVID-19 is currently assessed as very high.
  • The analysis of data from TESSy shows that the risk of hospitalisation increases rapidly with age already from the age of 30, and that the risk of death increases from the age of 50, although the majority of hospitalisations and deaths are among the very oldest age groups. Older males are particularly affected, being more likely than females of the same age to be hospitalised, require ICU/respiratory support, or die. All-cause excess mortality from EuroMOMO, particularly at this time when competing drivers (influenza and high/low temperatures) are largely absent, shows considerable excess mortality in multiple countries, affecting both the 15-64 and 65+ years age groups in the pooled analysis. Once infected, no specific treatment for COVID-19 exists, however early supportive therapy, if healthcare capacity for this exists, can improve outcomes. In summary, the impact of severe disease of COVID-19, if acquired, is assessed as moderate for the general population.

What is the risk, as of 22 April 2020, of severe disease associated with SARS-CoV-2 infection in populations with defined factors associated with elevated risk for COVID-19 in the EU/EEA and UK?

  • The risk of severe disease in the EU/EEA and UK is currently considered moderate for populations with defined factors associated with elevated risk for COVID-19 in areas where appropriate physical distancing measures are in place and/or where community transmission has been reduced or maintained at low levels.
  • The risk of severe disease in the EU/EEA and UK is currently considered very high for populations with defined factors associated with elevated risk for COVID-19 in areas where appropriate physical distancing measures are not in place and/or where community transmission is still high and ongoing.

This assessment is based on the following factors:

  • The probability of infection in the different areas has been assessed above and is the same for populations with defined factors associated with elevated risk for COVID-19 (low to very high depending on the implementation of appropriate physical distancing measures and the level of community transmission). The probability of infection is particularly high for individuals in closed settings such as LTCFs due to the potential for rapid spread associated with incorrectly applied IPC measures and/or lack of PPE.
  • The analysis of TESSy data shows that persons over 65 years of age and/or people with underlying health conditions, when infected with SARS-CoV-2, are at increased risk of severe illness and death compared with younger individuals. These vulnerable populations account for the majority of severe disease and fatalities to date. Older males are particularly affected, being more likely than females of the same age to be hospitalised, require ICU/respiratory support, or die. Long term care facilities which are home to frail elderly people with underlying conditions, have had a large impact on the overall reported mortality in many EU/EEA countries and the UK. A rapid spread of the disease in these facilities has been observed causing high morbidity in the residents and staff as well as high mortality in the elderly residents. The number of fatal cases from LTCFs contribute substantially to the overall reported COVID-19 mortality in countries, in some cases by more than 60%. Although strict physical distancing measures, hand hygiene and use of face masks together with closing these facilities for visitors minimises the risk of disease introduction, the high proportion of asymptomatic cases among staff, staff working in several facilities, lack of PPE and other essential medical supplies as well as lack of training of staff have contributed to the spread of the disease. In summary, the impact of COVID-19 is assessed as very high for elderly and individuals with defined risk factors.

What is the risk of resurgence of sustained community transmission in the EU/EEA and the UK in the coming weeks, as a consequence of phasing out ‘stay-at-home’ policies and adjusting community level physical distancing measures without appropriate systems and capacities in place?

  • The risk of resurgence of sustained community transmission in the EU/EEA and the UK is currently moderate if measures are phased out gradually and accompanied by appropriate monitoring systems and capacities, with the option to reintroduce measures if needed, and remains very high if measures are phased out without appropriate systems and capacities in place, with a likely rapid increase in population morbidity and mortality.

 This assessment is based on the following factors:

  • The effect of testing strategies, healthcare capacities and environmental conditions has not been fully disentangled when evaluating the role played by the community and physical distancing measures implemented in different EU/EEA countries and the UK. However, the temporal relationship between application of such measures and changes in morbidity and mortality rates, and the results of modelling studies, suggest that it is very likely that those measures, and particularly the ‘stay-at-home’ policies, have played an important role in reducing transmission and, in some subnational areas, have led to a strong reduction in the rate of disease incidence and mortality. The available information from the first seroepidemiological studies indicates the population immunity is still low (in most cases <10%). Phasing out measures may cause a rapid resurgence of transmission unless:
    • measures are phased out after a clear indication that the spread of the disease has substantially decreased for a sustained period of time and health system capacities have fully recovered;
    • a robust surveillance strategy, extended testing capacities, and a robust framework for contact tracing are in place.
    • clear strategies are in place for adjusting community level physical distancing measures in a way that allows their effectiveness to be evaluated, taking into account local differences in transmission rates, and being ready to refine and re-implement measures based on the evolution of transmission patterns.
  • In the absence of a vaccine or an effective treatment and because of the still low population immunity level, rapid resurgence of sustained community transmission may occur, which can lead to very high population morbidity and mortality. This can be directly related to disruption of healthcare services, as happened in March 2020 in several EU/EEA countries and the UK, but also to the high mortality associated with outbreaks in LTCFs residents and in other populations with defined factors associated with elevated risk for severe COVID19, if these are not appropriately shielded. In summary, the impact could be very high, not only from a public health perspective, but also because COVID-19 outbreaks can cause huge economic and societal disruptions.

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