No time for complacency on COVID-19 in Europe

While the world is transitioning out of the emergency phase of the COVID-19 pandemic,1WHOStatement on the fifteenth meeting of the IHR (2005) Emergency Committee on the COVID-19 pandemic.https://www.who.int/news/item/05-05-2023-statement-on-the-fifteenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemicDate: May 5, 2023Date accessed: May 14, 2023Google Scholar new surges of COVID-19 continue to occur across Europe because of persistent viral circulation and the regular emergence of new subvariants of omicron.2Lenharo M WHO declares end to COVID-19's emergency phase.Nature. 2023; (published online May 5.)https://doi.org/10.1038/d41586-023-01559-zCrossref Google Scholar New infections occur even during the summer months, a notable difference with influenza virus or other seasonal respiratory infections.3Gavenčiak T Monrad JT Leech G et al.Seasonal variation in SARS-CoV-2 transmission in temperate climates: a Bayesian modelling study in 143 European regions.PLoS Comput Biol. 2022; 18e1010435Crossref PubMed Scopus (2) Google Scholar The breadth of the most recent COVID-19 waves remains difficult to assess, because of a steep reduction in diagnostic testing across the continent. None of the waves of COVID-19 since the spring of 2022 overwhelmed health-care systems in Europe, or warranted new restrictions from December, 2022. Yet, excess mortality, although not only attributable to COVID-19, has been and remains unacceptably high.4EuroMOMOEuroMOMO Bulletin, week 17, 2023.https://www.euromomo.eu/Date: 2023Date accessed: May 7, 2023Google Scholar COVID-19 claimed the lives of 467 921 people in Europe during 2022.5Our World in DataCoronavirus (COVID-19) deaths.https://ourworldindata.org/covid-deathsDate: 2023Date accessed: April 25, 2023Google Scholar Hospital admissions of new patients with COVID-19 continue; infections persist in immunocompromised people; and vulnerable individuals with comorbidities remain at high risk of severe COVID-19. Persisting symptoms are also associated with 3–20% of affected people suffering from Long Covid.6Office for National StatisticsPrevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 30 March 2023.https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/30march2023Date: 2023Date accessed: April 25, 2023Google Scholar, 7US Centres for Disease Prevention and ControlNearly one in five American adults who have had COVID-19 still have “Long COVID”.https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/20220622.htmDate: 2023Date accessed: April 25, 2023Google Scholar Persisting absenteeism from work linked to COVID-19 and to other circulating respiratory viruses since the lifting of public health measures has had negative effects on European economies.8Lovett S Colds and flu causing more work absence than Covid. The Daily Telegraph, Dec 17, 2022https://www.telegraph.co.uk/global-health/science-and-disease/britain-now-losing-working-days-flu-related-infections-covid/Date accessed: May 15, 2023Google Scholar These impacts of COVID-19 are likely to continue in the coming years if more efforts are not made to decrease the circulation of SARS-CoV-2 and mitigate its impact on public health. Options are readily available to reduce the burden of SARS-CoV-2 and other endemic respiratory pathogens. We thus question the current high level of political and societal complacency towards COVID-19 in Europe. Much more strategic attention and investments are needed now to more effectively manage COVID-19 and develop greater resilience to future respiratory pathogens. COVID-19-related control measures are not on any public health agenda in Europe at this time. Governments should, however, carefully consider which non-pharmaceutical interventions (NPIs) to relinquish and when. Furthermore, PCR tests are no longer accessible or available for free in most European countries and, since antiviral agents need to be administered within a few days after SARS-CoV-2 infection,9Li G Hilgenfeld R Whitley R De Clercq E Therapeutic strategies for COVID-19: progress and lessons learned.Nat Rev Drug Discov. 2023; (published online April 19.)https://doi.org/10.1038/s41573-023-00672-yCrossref Scopus (2) Google Scholar vulnerable people who may need treatment are typically unable to access testing in a timely way to receive the relevant treatment. Additionally, across Europe COVID-19 antigenic tests are no longer being made easily available or used at the same scale to diagnose infection, a measure which allows for the reduction of transmission risk by individuals' behaviour. Broad access to vaccines and bivalent COVID-19 vaccine boosters in Europe, including among older people, together with acquired immunity through infection, has resulted in predominantly milder forms of COVID-19.10Arbel R Peretz A Sergienko R et al.Effectiveness of a bivalent mRNA vaccine booster dose to prevent severe COVID-19 outcomes: a retrospective cohort study.Lancet Infect Dis. 2023; (published April 13.)https://doi.org/10.1016/S1473-3099(23)00122-6Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar Over the past year in Europe, there has been a major reduction in COVID-19 hospitalisations and deaths compared with the first 18 months of the pandemic.11EurostatCountry overview report: week 17 20. European Commission, 2023https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Weekly_death_statisticsDate accessed: May 7, 2023Google Scholar However, the high transmissibility of subvariants of omicron has led to more infections and cases than with the initial strains, so that the absolute number of deaths in Europe remained high.12Mohsin M Mahmud S Omicron SARS-CoV-2 variant of concern: a review on its transmissibility, immune evasion, reinfection, and severity.Medicine (Baltimore). 2022; 101e29165Crossref PubMed Scopus (28) Google Scholar The public health focus has now moved away from using NPIs that could effectively reduce the circulation of SARS-CoV-2 and other respiratory agents in the population. In Europe only minimal NPIs are typically used in higher risk settings, such as health-care facilities, where rates of nosocomial transmission of SARS-CoV-2 remain high.13Knight G Mui T Stimson J et al.The contribution of hospital-acquired infections to the COVID-19 epidemic in England in the first half of 2020.BMC Infect Dis. 2022; 22: 556Crossref PubMed Scopus (11) Google Scholar, 14Read JM Green CA Harrison EM et al.Hospital-acquired SARS-CoV-2 infection in the UK's first COVID-19 pandemic wave.Lancet. 2021; 398: 1037-1038Summary Full Text Full Text PDF PubMed Google Scholar, 15Pople D Monk EJM Evans S et al.Burden of SARS-CoV-2 infection in healthcare workers during second wave in England and impact of vaccines: prospective multicentre cohort study (SIREN) and mathematical model.BMJ. 2022; 378e070379PubMed Google Scholar, 16Wee LE Conceicao EP Aung MK et al.Nosocomial SARS-CoV-2 transmission in multi-bedded hospital cubicles over successive pandemic waves: lower mortality but wider spread with Omicron despite enhanced infection-prevention measures.Infect Dis Health. 2023; 28: 81-87Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 17Ramos-Rincon JM Lopez-Sampalo A Cobos-Palacios L et al.Nosocomial COVID-19: a nationwide Spanish study.Gerontology. 2023; 69: 671-683Crossref PubMed Scopus (2) Google Scholar, 18Skagseth H Jørgensen SB Reilly J Kacelnik O A new method for near real-time, nationwide surveillance of nosocomial COVID-19 in Norway: providing data at all levels of the healthcare system, March 2020 to March 2022.Euro Surveill. 2023; 282200493Crossref PubMed Scopus (1) Google Scholar Improving ventilation and indoor air quality is a crucial intervention to reduce risk of respiratory infections and evidence suggests it is both cost-effective and brings wider benefits for health and wellbeing.19Royal Academy of EngineeringInfection resilient environments, 2022.https://nepc.raeng.org.uk/infection-resilient-environmentsDate: 2023Date accessed: April 25, 2023Google Scholar, 20Morawska L Allen J Bahnfleth W et al.A paradigm shift to combat indoor respiratory infection.Science. 2021; 372: 689-691Crossref PubMed Scopus (132) Google Scholar More efforts should be developed to protect older and immunocompromised populations to reduce their risk of exposure to SARS-CoV-2 and other respiratory viruses, identifying their infection early, assessing the role of nosocomial transmissions, and treating cases in a timely way. Clinical collaborative research that involves those most at risk is important to test optimised treatment in vulnerable patients, including drug combinations or longer duration of antiviral therapies, such as the randomised controlled trial Optimisation of Antiviral Therapy in Immunocompromised COVID-19 Patients (OPTICOV) in Switzerland and France (NCT05587894). Almost all European countries have stopped providing a reliable surveillance system to monitor the circulation of SARS-CoV-2 and other respiratory viruses and its population impact. Testing and sequencing are no longer undertaken in community settings and hospitals across most regions of the continent. One can regret that close to 4 years into the pandemic, we still lack consolidation of epidemiological data related to hospitalisations and deaths associated with COVID-19 and other viral respiratory disease and disintegrated data on causes of excess mortality across almost all European countries. Revisiting the surveillance and monitoring of respiratory infectious diseases in Europe has become imperative. Europe needs to be moving towards integrated respiratory virus surveillance, building on the lessons and innovations seen during the pandemic.21WHOFrom emergency response to long-term COVID-19 disease management: sustaining gains made during the COVID-19 pandemic.https://www.who.int/publications/i/item/WHO-WHE-SPP-2023.1Date: May 3, 2023Date accessed: May 15, 2023Google Scholar Robust surveillance for respiratory diseases involves strategic investments, such as wastewater and syndromic surveillance, and update of pandemic preparedness plans.22WHO Regional Office for EuropeEuropean Centre for Disease Prevention and ControlOperational considerations for respiratory virus surveillance in Europe.https://www.ecdc.europa.eu/sites/default/files/documents/Operational-considerations-respiratory-virus-surveillance-euro-2022.pdfDate: July 18, 2022Date accessed: May 15, 2023Google Scholar, 23WHOWHO policy brief: COVID-19 surveillance, 11 April 2023.https://www.who.int/publications/i/item/WHO-2019-nCoV-Policy_Brief-Surveillance-2023.1Date: 2023Date accessed: May 15, 2023Google Scholar, 24WHOWHO launches new initiative to improve pandemic preparedness.https://www.who.int/news/item/26-04-2023-who-launches-new-initiative-to-improve-pandemic-preparednessDate: April 26, 2023Date accessed: May 15, 2023Google Scholar The European region cannot afford to be complacent in its response to COVID-19. Health authorities, research institutions, and the population still need to mitigate the impact of respiratory pathogens on public health in Europe. Governments must improve protection of vulnerable people, urgently invest in improving ventilation and indoor air quality in health-care and other settings, and revisit surveillance and monitoring systems to ensure that we are prepared to respond to future pandemics. Longer-term strategies are also needed, such as developing pandemic prevention and preparedness plans, strengthening health systems, including public health functions, improving risk communication and community engagement, and ensuring adequate human resources planning and training to counteract staff shortages across social and health systems.25European Centre for Disease Prevention and ControlLessons from the COVID-19 pandemic.https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-lessons-learned-may-2023.pdfDate: 2023Date accessed: May 7, 2023Google Scholar Europe needs to develop resilience in our public health systems for future emerging pathogens and get better prepared for other potential future health hazards responsible for public health crisis. Failure to take these steps now will result in more deaths due to COVID-19 and other respiratory pathogens and mean that we are not well prepared to respond to future public health threats. AF is Chair of and AC, DC, OD, IE, HJL, HL-Q, CN, and MK are members of the High-Level Expert Group for COVID-19 that has advised Hans Kluge since 2021. HK is the Regional Director of the WHO Regional Office for Europe. AC report grants from ViiV Healthcare, Gilead Sciences, and MSD and is the principal investigator of the OPTICOV trial. DC report institutional grant from Janssen and honoraria for lectures from Gilead and Pfizer. HJL reports grants from GSK, Merck, and a MacArthur Award for the Vaccine Confidence Project and honoraria for lectures from UNC and NYU. HL-Q was a member of the Secretariat of the Independent Panel for Pandemic Preparedness and Response. CN reports grants from the Engineering and Physical Sciences Research Council, the UK Department of Health and Social Care, the Natural Environment Research Council, NHS Scotland, and the UK Government for various projects on transmission of COVID-19; is a member of the UK Government SAGE Committee, Co-Chair of SAGE Environment and Modelling group, is a member of multiple UK and Scottish Government and NHS working groups on COVID-19, is a member of WHO ECAP, and a member of the Royal Academy of Engineering and Academy of Medical Sciences working groups on COVID-19 mitigation. MK is an independent Board member of ExevirBio, a biotechnology company designing therapeutic monoclonal antibodies against SARS Cov2. We declare no other competing interests. We thank Catherine Smallwood, Gerald Rockenschaub, and Richard Pebody, from the WHO Regional Office for Europe, for their participation in reviewing and their helpful contributions to this Comment.