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Germany which handled the first wave of the coronavirus better than France or Spain with better testing and contact tracing is now facing the second wave. Following the reopening Germany went back to normal with fewer restrictions. Some Germans ignored restrictions and Germans travelled to other countries. German students in Croatia in summer tourism are reported to be part of the 21 million tourists in the country in summer that failed to follow any restrictions. The result is that Germans now fear the second wave is beginning to hit Germany.

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As the pandemic continues to spread and numbers grow with reopening of the economy the question remains -what can we learn from other countries positive experience in controlling spread? Here the Times provides the example of German contact tracing- chancellor Merkel has emphasized that a lot depends on "total" contact tracing, and contact tracing "above all else." Germany's experience is that even if you don't get everything right, you make an honest effort with everything you've got and do it early it makes a real difference. Some of the offices across Germany are stretched and short of staff but they have been working since the beginning of March, sometimes in the early days 7 days a week. Only 33% or one third of the offices throughout Germany for contact tracing have the required 5 person team for every 20,000 people, and 35% are overstretched or at their limit, according to one survey. No apps, just a low tech effort with people from the state administrations who were not working during lockdown trying doing something else, or volunteers. Mainly using the phone, talking to people and tracing the contact chain of people testing positive. Putting this information on the computer with a central database.  The Berlin office has 115 workers and has tracked down every one of 666 virus cases it was given. Because of privacy concerns at the Munich office sometimes even the patient's name is not given and office staff have to locate the name and the person. It requires dedication, flexibility and above all resilience, says Harold Rau, the deputy Mayor of the Cologne office, cited in this Times report. The doctor alerts the local office with a test result. The office calls the person and finds out who he has been in contact with for the last 14 days. Then the people who were in contact with are grouped based on the directness of contact, face to face, so on. These people are asked to quarantine for 14 days, sometimes with the rest of their household. They get daily call to find out how their doing for symptoms. The effort goes back to Robert Koch in the 1892 cholera epidemic in Hamburg. Robert Koch, microbe hunter in Germany, was called in after the epidemic spread from Moscow. It devastated Moscow and Tokyo, but Hamburg suffered far less about 8605 deaths as a result of the contact tracing and strict closing off quarantining of affected chains after isolating them, closing off affected parts of the city. Bit by bit the cholera epidemics sparks were put out before turning into flames, says Koch. In the current pandemic Germany has suffered 8241 deaths and 178,000 confirmed cases. So far this is in line with the cholera epidemic in Hamburg 1892, and this for all of Germany. And it is not just affluent nations that can do this. where there is a will there is a way. In Kerala state in southwestern India, similar efforts have worked to limit spread  with even better results than Germany. ...

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Health authorites in Italy, France, Britain India and the U.S, have hesitated in reopening schools. Germany and Denmark have reopened schools with no increase in infections with schools following specific policy including mandatory masks, air circulation rules, and careful preparation of schools to ensure social distancing rules are respected. Other countries reopening schools are Austria, Norway, Finland, Australia, New Zealand.

Schools in German states are reopen for about 1 month now, with a positive experience after careful preparation. Italy faces difficulty reopening its economy as people going back to work find it difficult, particularly women,with childcare provided by grandparents no longer an option, and lack of daycare. Opening of schools in Italy would help in reopening the economy, as well as provide relief to parents and children, when done carefully.

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Merkel say to Gemany in a weekly video message that "the danger posed by coronavirus remains serious. "Take it seriously because the situation is serious." It requires everyone to act responsibly. "By following the rules for social distancing, hand hygiene, facial coverings, every one of us contributes to our shared destiny, " she said. It is a message that should resonate in the U.S. India, Brazil and other countries hit hard by the virus. Germany's cases are approaching 200,000 with fresh outbreaks in some areas. Reopening everywhere creates new risks, vigilance is essential.

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Parents and teachers in Germany are skeptical of school reopening because of the lax rules for mostly unvaccinated children. Teachers are not required to be vaccinated and show digital certificate of vaccination as is the case in Italy. Teachers and parents see the return to normalcy not lasting long  with the relaxed rules. Britain is also following school reopening with relaxed rules going so far as to not require social distancing or masks. Health experts question this policy.

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The British government is considering effectively preventing two households from meeting indoors by limiting the number of people meeting indoors to 6 from the 30 now in place. Experts believe a second wave of infections is a distinct possibility if nothing is done especially with higher infections among younger people in Europe after reopening. People are seen as relaxing too much. Young people in Spain and other European countries are a big part of the problem today. In Germany the incidence of cases for 15-24 years is fifteen times the number of cases for 70-79 years in the first week of September, showing how completely reversed the situation has become with young people acting as spreaders of the pandemic. The incidence of new cases is 30 per 100,000 in Germany for 15-24 years compared to just 2 for the 70-79 years. In Berlin it is as high as 43 for 15-24 years and the Health Minister is concerned because in contrast to local groups these individuals can spread it throughout Berlin.  School reopenings in Europe and in America are a distinct danger so that colleges in the U.S are switching back to remote learning because of improper behaviour of young people including parties and gatherings. Tougher restrictions are seen as necessary to get people to pay attention to social distancing that was practiced earlier in April. This is true of Europe, America, and Asia. Even curfews are now being considered. ...

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Other European nations and the U.S. will be watching Germany's opening of small shops and small retail business under 800 square metres of space on April 20, followed by other business on May 4, in a gradual partial reopening of the economic activity

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As 22 million Americans go on unemployment benefits some Americans protest in states such as Michigan and North Carolina, Virginia. Even though Michigan was hard hit the western part of the state is quite different from the south east and Detroit which were hit hard. As the situation is different in each state and also by county president Trump has made it clear that it is the governors of the states who will decide and also the reopening could be varied by county. President Trump is also looking at other countries which are reopening in phases such as Germany where April 20, May 4, are dates for phases of reopening starting April 20 with small shops less than 800 square meters in space. European Union is similar to the U.S. in size. Germany went in front, but France like New York is coming in the back of this. France hit hard, has extended the lockdown till May 11.

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The deputy chief medical officer, Dr. Jenny Harries, asks people in Britain to limit themselves to what is sensible and not what is possible, to use common sense, so that reopening works. The Housing Secretary, Mr. Jenrick says the room for maneouvre is limited with the reproduction R ratio for Britain at somewhere between 0.7 and 0.9. There is also a lag period for data making it so that the current situation is not known. Germany's after reopening is now estimated by Robert Koch Institute at 1.14 so that there is some shift to be expected as the opening happens, the idea being to limit this to around the 1.0 figure. Britain reopens cautiously and in  in a patchy way with primary schools reopened, and people from different households allowed to meet in groups of six as long as they stay 2 metres apart. Outdoor markets and car showrooms are also reopening. Also stated is the need to be sensitive to geography as areas such as London which were hit early and with severity are now better off than areas in the north of England. ...

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German chancellor Merkel met with leaders of Germany's 16 federal states to come up with an exit plan for reopening the economy from the lockdown in phases. In the first phase shops with up to 800 square metres of space will reopen on April 20. Bookshops, libraries, car dealers, bicycle shops, and museums will open too. Larger retailers will wait till May 4 to reopen. On May 4 school children in primary school can attend school and teenagers can take exams. Germany has 133,000 infected cases, 3592 deaths. Merkel warned that the performance with coronavirus was "fragile and provisional success" and the need for social distancing measures. A ban on gatherings of more than 2 people from separate households will remain in place till May 1. The government will strongly recommend that face masks be worn in public and in shops, public transport. Mass events will be prohibited till September. Bars clubs and restaurants will remain closed at least till May 3, or beyond. ...

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Reports from Europe that a V shaped recovery is happening in the economy. Andy Haldane the chief economist of the Bank of England says roughly half of the 25% lost output in the economy in the lockdown in April and May has been gained back in UK. This is good news for Europe after the bad hit it took from the pandemic since March. The reopening of the economy in Germany, France, Italy, Spain and Britain is taking place with greater reassurance as the curve is flattening out at low levels of cases in July and people are generally following rules for prevention.

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Italy faces tighter restrictions and a national lockdown at Easter for the coronavirus, Italians who were the first to go into lockdown on March 10, 2020, now think they will be the last to exit lockdowns. The mood in Europe is of frustration with the slow vaccination drive and the failure to procure enough vaccine supplies and to approve vaccines in time. The US and Britain have vaccination drives that are moving rapidly leading to a reduction in cases and deaths. In Europe new cases are rising since mid February 2021, and there is the spread of the new variant first detected in the UK.  The variants make up 70% of new cases in France says Health Minister Olivier Veran. ICU's in France are 80% full. Elections in France in 2022 and in Germany in September 2021 are leading to government reluctance to impose tighter restrictions. The government strategy is now being questioned. Only 30% of Germans now have confidence in chancellor Merkel's ability to make competent decisions. The CDU's partner in the government, the SDU socialists have even less trust with SDU getting less than 10%. There are signs of a third wave of coronavirus in Germany resulting from variants of the virus, slow vaccinations, and reopenings. ...

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Requests, consensus, and social pressure played a bigger role than just strict rules and penalties in controlling the virus in Japan. By contrast in Germany states imposed strict rules and fines, some consensus, a better equipped hospital system, added contact tracing, to limit the spread. More than 100 industries in Japan have drawn up new guidelines for reopening to minimize risks. Prime minister Abe said recently " Now we are going to venture into a new arena. Therefore we need to create a new lifestyle from now on. We need to change our way of thinking." The new social consensus on the best way to behave outdoors and at work is the way Japan is tackling reopening.  The effort is focused on avoiding high risk situations the 3 C's crowded, closed spaces, and close contact, close conversations. Japan started with a fumbled response but gradually the right spirit and social distancing caught on. The universal health care system helped Japan detect cases early, even in the remote rural areas. ...

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On May 11, NYT shows the rail network in India opening with the first trains taking 45 million migrants to homes in all parts of the country. Australia calls for an international inquiry into the cause of the coronavirus pandemic and its origins in China. Russia begins a cautious reopening with the governors of provinces having powers for reopening based on local conditions. In Spain restrictions are gradually being lifted but the major cities of Barcelona and Madrid are still in lockdown. And as Germany the first country to reopen opens up its business and schools the crucial R ratio of reproduction of the virus -with 1 being the number at which it grows again and below 1 showing control of spread- moves up to above 1.

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Public health experts warn that it is essential that countries reopening their economy have a reproduction ratio of much less than 1.0 so that the rate of increase is under control. Germany's Robert Koch Institute which advises the German government says the reproduction ratio which was 0.70 in mid April is now up to 0.96 after creeping back up. This is based on a mathematical model and extrapolated from infection numbers several weeks back.  It doesn't reflect the change by recent easing of lockdown measures starting with reopening smaller stores. This validates the careful approach adopted by France which was put forward by prime minister Edouard Philippe in his address to the National Assembly. The Assembly approved the plan 368 to 100. More legislation will back up the French government's authority to ban non essential travel between French departments and the creation of a large brigade to perform contract tracing. That involves finding testing and isolating everyone potentially infected, using dedicated locations. Detailed restrictions on travel, work and gatherings will take effect when France reopens partially on May 11.  France is also putting resources behind its testing program to test every person having coronavirus symptoms, and all they are in contact with. That means about 700,000 tests a week. Officials will generate a color coded map from this with red areas facing more restrictions than green areas. Student size is capped at 115 per class. Cafes, restaurants, movie theatres and large museums will remain closed. Gatherings of more than 10 banned. Those who can work from home asked to do so. Public transit users will be required to use masks, and marks on platforms will indicate the social distance required. Only essential travel is allowed more than 62 miles from home. These rules remain till June 2, when new ones will be set. Large music festivals and sporting events are canceled till the fall. Mr. Philippe says "these efforts will not be in vain and should allow us to arrange for a better summer season." ...

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Lessons can be learned about careful reopening in fighting the coronavirus from other countries. Here the Netherlands experienced a rise of cases by 500% within two weeks of reopening after some poor decisions. The Mark Rutte government decided to open all bars and nightclubs resulting in a twelve fold surge in these locations in one week. Most of the new coronavirus cases were in people 18-29. Data from Dutch public health institute shows 4 out of 10 new cases linked to bars and nightclubs with 262% surge in cases for young people 18-24 years. This goes to show that with the vaccination drive what we see is the cases shifting to younger people, the unvaccinated, and to activities like nightlife. People going to work, or doing hybrid remote work with trips to the office, workers in factories, people doing essential shopping, are not causing the rise in cases. Much can be learned from these examples in working out reopening that does not lead to new crises with surging cases in new waves of coronavirus. Earlier in 2020 summer tourists who ignored mask and social distancing restrictions in Croatia brought on a post summer coronavirus wave to Germany and Austria. This time Greece and Portugal are introducing restrictions. Greece plans to make vaccine health pass required effective July 21 to go into restaurants. Another lesson from Netherlands this week is that a 20,000 person music event of 2 days in Utrecht where QR codes were required showing vaccination or PCR tests failed. About 1000 cases were attributed to the Utrecht event alone. Reasons given are that people faked the QR codes, or that the covid testing system produced too many false results as much as 20%. The same QR code system was followed at nightclubs resulting in big problems. One can never be sure that things work as expected and the risks are great as this adds up. Even vaccines offer limited protection and only if fully vaccinated depending on the type of vaccine. One dose of the vaccine is simply inadequate, and obesity, other morbidities can lead to problems. Withdrawing the mandatory use of face masks in most situations is also a risky decision of the Dutch government. Face masks offer the added protection at a time of variants that spread quckly, and when large parts of the population have only one dose of the vaccine, some elderly are still not vaccinated, and young people have not been vaccinated in large numbers. ...

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This Times leading article on UK government's coronavirus policy says it is inconsistent, and a muddled effort just as the third wave is accelerating. It asks the public to be cautious when going outside and still opens nightclubs with covid passports not required till the end of September. By August cases could reach 100,000 say experts so that the nightclub and bars reopening can only fuel the rise in cases. The British government must be aware that the Netherlands opened nightclubs and bars in June and this led to a sudden jump in cases with 40% of new cases coming from nightclubs.  The policy is undermining public confidence. It is doing this at the same time as it is asking people to self isolate for 10 days. The policy also does not require covid vaccination pass for all events and for shops and restaurants as is being done in France and in other countries on a regional basis as in Germany. 

 

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Germany has shown that low tech contact tracing efforts work- no apps needed, a phone, a desktop computer with a centralized database, and most important the human relations skills of the person doing the calls. The  sensitivity to the situation facing each person being called, being able to talk to the person in the language they speak in a multilingual environment such as California, is shown here. A 40 person team operates in San Francisco consisting of public health officials, clinicians, medical students and librarians. They call the contacts of people with coronavirus, arrange tests, and as needed send packages of food and medicines to hotel rooms or homes. Every call is expected to last 15 minutes but all sorts of questions are handled.  English and Spanish are used. Here one of the persons doing the contact tracing says she does not use apps, just an open source software used in the fight against Ebola. Definitely low tech, no waiting, get going is the message to every city in the world. She says apps software such as what Google and Apple are putting out can tell you whether the person went to some place, but cannot tell you more about that person, cannot tell you about problems the person is having being tested, and how they are having difficulty providing for families. One of the big lessons from Germany and efforts such as this one in San Francisco, and in other places such as Paris, Singapore, Taiwan, is that there is a complex nature to contact tracing that cannot be solved by tech. In fact the best thing to do is to get started immediately, with a phone and a database on a computer, as long as you have a person who has the motivation and skills, empathy with people, a lot can be done. Waiting for apps is a dangerous waste of time is shown by the low tech German experience, and the experience in other places. Most important is starting immediately. The example shown here of working with migrant workers in contact tracing shows in the most vulnerable places it is these human relations skills that count, that no tech app can do. It requires detective skills to find out and get people to share their history of movements and contacts for 14 days . In Singapore crowded dormitories house 300,000 of 1.4 million migrant workers. Singapore using an app also but its use is secondary. Apps don't work in many situations but fail in the most critical situations such as these dormitories and other eccentric or atypical situations such as faced by South Korea with religious groups and gay communities, elderly people in Europe, that generate the worst dangers of spread and need to be cluster isolated quickly. Human contact tracing has a history of being an effective method and was used in China and South Korea during the 2003 SARS epidemic. More countries need to adopt the method used in Asia and in Germany, particularly Britain, the U.S., France and India. It is OK that Britain's NHS and India's national government with Aarogya Setu app have put out their own apps which balance privacy concerns with the need to act immediately and cover the entire country, but the hard slog of human contact tracing teams in each district is indispensable. This is why the former Health minister in Britain calls it Britain's national mission to do this. Speed is key- putting together teams across the country in every district from skilled volunteers or government workers, and pulling together the phone and a centralized database on a computer as basic equipment. The fact that this is easily doable and people with human skills needed can always be recruited as they have been in Germany- from public officials in local government who are less busy in lockdowns, medical students, clinicians, volunteers, people from different professions- makes it inexcusable not to learn from others experience and get going. Just Do It. You want to reopen business, professions, offices and public services- Just Do It, it makes this possible. You want to prevent spread of the virus- Just Do It, it makes this possible. You want to limit damage to the economy and get the recovery going- Just Do It, it makes this possible. People of all shades of opinion can agree on this- its the only thing that works, even when there is a lack of enough proper accurate testing. ...

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The critical variable in knowing whether lockdowns of cities and countries are working is called the coronavirus RO, or reproduction ratio. This ratio measures the average number of people infected by a carrier A. It could be that he infects 1 person at work and transport call it B people , or in large gatherings call it C people he infects 2 persons, or in other surroundings such as restaurants he infects 1 person call it D people. The people A has infected B+C+D are the ones now not infected by A with the lockdowns such as in New York, Italy, Germany, UK and France. It is determined by global health experts that the number of B+C+D is about an average of 4 persons infected by 1 person A with coronavirus, though it may be much higher in practice in some areas. The natural rate of RO or reproduction ratio is considered by the European Centre for Disease Prevention and Control to be 3.86 or about 4, if no lockdown or social distancing or other prevention is practiced. This in a situation where people behaved as before unaware that the virus was around them. Governments such as New York and France, UK, Germany are including this key variable in their determination of how long a lockdown lasts, and for determining if the reopening is not going the right way or failing. In such situations the lockdown would be reinstated, or if it is a phased reopening such as in the U.S. and other countries go back to the previous phase. In Italy and Germany the RO reproduction ratio for coronavirus is estimated by official experts at 0.8. Germany's RO estimated by the Robert Koch Institute and Italy's by Franco Locatelli, scientific advisor to the government. In New York the margin is thin- with RO of 0.9, estimate from the state's governor. In France which has one of the tightest lockdowns of all with a document required to go outside it is at 0.6, the figure coming from the prime minister Mr. Philippe. In the UK it is below 1.0 but no accurate figure is reported. As Dr. Birx- leading the coordinated response in the U.S. - emphasizes over and over again this is a very contagious virus, about which not much is known. Social distancing, wearing masks, basic prevention measures such as frequent handwashing, and not gathering in large numbers of people, is essential for defeating this virus. This has to be followed up with extensive testing and contact tracing to win this fight.   ...

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Concern about the spread of the pandemic in the U.S. with the upcoming Thanksgiving holiday and travel to visit family and friends. Seen from Australia and other countries American fatigue with staying at home is cause for concern. Yet this is not entirely American as governments in France plan to have a phased reopening by Christmas, with phase 2 partial lifting of restrictions of the lockdown on December 15. Austria has turned down German requests to close Austrian ski resorts that have cause spread in Europe. The Swiss have also kept ski resorts open. During the summer Croatia and parts of Spain kept open tourist spots to help the economy recover creating the conditions for spread as tourists went back home. 

Beyond this there a complex web of choices. From mental health to hospitals filling up, from jobs and income for service workers to people in nursing homes, all calling for different responses. 

 

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A look at countries in Europe shows different strategies for tackling coronavirus Delta variant as schools reopen in September 2021. Italy requires all teachers to carry a covid digital certificate that shows vaccination or PCR test results. France, Germany and Spain do not require vaccination for teachers to go to schools, and rely mostly on social distancing and mask requirements in schools. Britain not only does not require vaccination digital certificate, but also has not made masks and social distancing mandatory. Health experts say there are serious risks in this approach with mass return to schools and offices after August 2021, and the fall weather with more time indoors. This could lead to a surge in coronavirus as in the US where the reopening of schools and Delta variant has led to surge particularly in states such as Texas, Florida, California. In UK 65% of total population is now fully vaccinated, in Italy 62%. Teachers in Italy fully support the new rules. In Lombardy region with Milan as the capital, only 300 out of 300,000 workers returned to schools without the green pass, according to regional officials. Britain remains an outlier says this report in the WSJ, taking more risks than is proper at this time, and simply hoping for the best. Not the best strategy in this situation.   ...

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European Union countries, Britain and the US face the risk of a resurgence of coronavirus through the Delta variant and other variants. The Delta variant detected in India is 40% to 80% more transmissible than the Alpha variant detected in the UK, with the Alpha variant 50% more transmissible than the original coronavirus that originated in Wuhan.    Virologists in Italy feel they are flying blind at this time because of the lack of genetic sequencing in Italy, Spain, France and across most European Union countries. The UK has done genetic sequencing on 27% of recent covid positive tests. The figure drops to 1% for Italy and is tiny for most of the EU countries including Spain and France. Without genetic sequencing it is hard to predict and take steps. Another problem in the EU is that the southern economies Spain, Portugal, Greece, Italy, Croatia are dependent on summer tourism for the economy. The UK economy can handle a delay to a full opening for 6 weeks without serious impact to the economy, says WSJ. Southern European economies can afford only short delays to full reopening. Croatia acted as a door to spread of coronavirus into central Europe when Germans and Austrians went to vacation spots in Croatia in summer 2020. This situation could be happening again in 2020 with British and other tourists visiting vacation areas in Portugal, and Germans visiting Greece and other summer tourism spots. Portugal's national health institute says the Delta variant represents 60% of new cases in the area around Lisbon based on early data. The government of Portugal is facing criticism for letting a Champions League soccer final to take place in Porto, Portugal between two English teams. Thousands of English fans watched the game at the stadium. Other problems are in relaxing of mask rules in France and Italy, last week in France and in the coming week in Italy. French nightclubs open July 9 without mask requirement. Germany is maintaining some social distancing measures and this includes mandating medical masks in closed public spaces and on public transport. Half of French, Italians, Germans are vaccinated and quarter fully vaccinated. Yet the gaps of unvaccinated people is large enough to cause serious concern of another wave. The relaxation of mask rules- the entire stadium in Budapest was packed for a recent game between Hungary and Italy for a soccer Euro 2021 game with no masks to be seen. Stadiums played a key role for the spread of the original coronavirus in Italy with a game in Bergamo, Italy, in the area near Milan. All this makes health officials concerned about the risks of still another wave of the coronavirus.   ...

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This video shows Dr. Birx explaining the three Phases for reopening the U.S. economy. Each state's governor would decide when a state thinks it is safe to move to the first phase. States which have not been affected much and fewer cases in the western part of the U.S. such as Idaho, North Dakota, Iowa could open earlier. Texas could start in May. California would have to do more testing before it starts Phase 1. New York, New Jersey, Michigan and Massachusetts, would come later because of the severity of the crisis. Each phase criteria are carefully set out and parameters set down for social distancing rules to be followed, number of people, locations, how offices open, how stores open, how hospitals open. Germany and the U.S. have set out detailed guidelines and phases. A state in the U.S. could even move back in phases if data shows it is doing badly. Hotspots would continue to be tracked and resources shifted from the federal government quickly to these new hotspots now that medical supplies, medical personnel and other shortages such as testing are being aggressively addressed. ...

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This analysis from The Times of London provides critical information on the strategy for successfully tackling the coronavirus following the example of South Korea and progress in Britain.

The random community testing is key to getting an idea of the scale of infections in the community at large. The critical ratio called reproduction ratio tell one if the virus is under control and how lockdowns can be lifted. For Britain this 0.7 estimated by Imperial College. It has a 2 week lag. 1.0 or close to 1.0 is not good. Germany after being at about 0.7 has moved up to 1.0 with 2 week lag in information says the Robert Koch Institute. This means a lot of work ahead, it won't be easy.