How have additional government measures differed in response to the recent emergence of variants of concern?

Cross-Country Analysis


How have additional government measures differed in response to the recent emergence of variants of concern?

Since the beginning of 2021, reports of the spread of genetic variants of the COVID-19 virus have increasingly shaped the evolution of the pandemic and countries’ response strategies across the WHO European Region.

It has become apparent that some of these variants of concern (VOC) differ in their behaviour compared to previously circulating SARS-CoV-2 viruses. Some are more transmissible, some likely cause more severe disease, and for some the vaccine response may be reduced.

Member States’ responses to the emergence and spread of the three most common VOC (at the time of writing) has varied depending on the epidemiological situation. However, general trends across the Region have become apparent. While the initial responses centred around travel restrictions to and from the countries of first detection and countries with enhanced spread of the variants, some countries started to adjust their mask policies in anticipation of the spread of potentially more transmissible variants. Initial clusters and local spread of the variants were often met with targeted, local restrictions, but as the variants defied regional measures and the VOC became the dominant strain of the virus in several countries, creating new waves of infections and increases in hospitalizations, a number of countries moved to broader, national measures and lockdowns. Strengthened laboratory testing and rapid characterization of viruses have also been of particular importance. This is being used in various ways such as implementing a surge in community testing in response to detection of clusters of VOC and enhancing contact tracing measures for certain VOC and variants under investigation. A number of countries have successfully suppressed surges in new infections fuelled by VOCs and resulting hospitalizations and deaths by imposing strict public health and social measures (PHSM), underlining the important role such measures play even with vaccination campaigns well underway.

This analysis examines the strategies implemented by countries across the European Region in response to the emergence and spread of newly detected VOC in other countries, as well as in their own country. Information was collected from open sources including media and government websites by the COVID-19 Incident Management Support Team of the WHO Regional Office for Europe and the COVID-19 Health Systems Response Monitor (HSRM) (up to 25 March 2021). Selected country examples are provided for Austria, Belgium, Croatia, the Czech Republic, France, Germany, Italy, Latvia, Luxembourg, Netherlands, Norway, Portugal, Slovakia, Switzerland, the United Kingdom. This analysis can help to inform the development of countries’ policies as VOC continue to emerge and spread across the Region.

Variants of concern pose a risk because they may be more contagious

When a virus replicates or makes copies of itself, the virus genome frequently changes a little bit. These changes are called “mutations” and are usually not significant. A virus with one or several new mutations is referred to as a “variant” of the original virus. Some changes can occasionally result in a virus variant that behaves differently in the human host. There have been hundreds of variations of SARS-CoV-2 identified worldwide and stakeholders including WHO, its partners and countries have been following them very closely. Although most variants of SARS-CoV-2 behave nearly identically to the original virus, for three recently detected VOCs, this appears to be different: preliminary signs indicate that they may be able to spread more easily between people. The three variants were first detected in: the United Kingdom (known as the B.1.1.7 variant), South Africa (known as 501Y.V2 variant), and Brazil (known as P.1 variant)1. These variants may also be associated with an increased risk of severe disease. Furthermore, the latter two VOCs may potentially result in an increased risk of infection in people who are already immune (either through previous infection or vaccination).

As of 16 April 2021, there have been over 520,000 confirmed cases of the B.1.1.7 reported in 51 countries of the WHO European Region with 38 countries having reported known community transmission (or are assumed to have community transmission of this variant). The 501Y.V2 variant has been reported among 35 countries and the P.1 variant in 21 countries or territories across the Region. As of 16 March 2021, the B.1.1.7 virus has become the dominant variant in 21 countries of the WHO European Region, outnumbering non-variant cases of the COVID-19 virus.

As a result, an increasing number of countries have named VOCs as the main reason for introducing, strengthening, or extending PHSM over concerns of increased transmissibility, potentially higher mortality and a possible impact on vaccine effectiveness. Figure 1 shows information on the detection of the first cases of the VOC in each country along with the PHSM Severity Index . The PHSM Severity Index captures the composite degree of stringency of a set of the most common public health and social measures for each country and Figure 1 portrays the colour-coded index values over time for each country, with darker shades indicating a higher degree of severity.

Figure 1. Date of detection of VOC with the PHSM Severity Index2

Many countries imposed travel restrictions as an initial response to VOCs

When reports of a potentially more transmissible variant emerged from the UK in mid-December 2020, many countries quickly responded by putting in place targeted travel restrictions as some of the first interventions in attempt to stop or slow the spread of the variant in the European Region. On 20 December 2020, the first countries to suspend travel with the UK were Croatia3, Italy, Latvia3, Luxembourg and the Netherlands. France took one of the most drastic steps by stopping all flow of people coming from the UK on 21 December 2020 for 48 hours, including accompanied freight, causing disruption to cross-channel trade and chaos at the British port of Dover. Most of these initial travel bans and flight suspensions were intended to only last for a period of 24 to 48 hours, while further investigation of the new variant was conducted. However, in most cases, they were either extended or replaced with stricter entry requirements for travellers from the UK, such as quarantine or testing requirements. The majority of other European countries followed suit within the next two weeks. By 7 January 2021, 29 Member States of the WHO European Region had suspended flights to and from the UK, and 12 countries had introduced quarantine or self-isolation requirements, ranging from 7 to 14 days for passengers arriving from the UK1.

Similar measures were taken by countries in response to the emergence of the 501Y.V2 and the P.1 variants, restricting travel to and from South Africa and Brazil, where these variants were first detected. The Netherlands and Switzerland3 were the first countries in the Region to suspend flights with South Africa on 21 December 2020. The UK was the first country to ban entry for travellers from Brazil and several other South American countries with strong travel links to Brazil on 15 January 2021 due to the detection of the P.1 variant. As the new variants began spreading in other countries in the beginning of 2021, Member States, such as Germany, increasingly restricted travel with destinations they considered “virus variant areas”. On 14 February 2021, Germany also closed its borders with the neighbouring Austrian state of Tyrol, where the 501Y.V2 variant had started to circulate and with the Czech Republic, where the B.1.1.7 variant was spreading widely.

The use of higher-grade masks was encouraged

Another common and early response to reports of the spread of new variants by a number of countries was through adjustments to their mask policies, with some countries imposing requirements for medical-grade masks wearing in public places. The Czech Republic and Germany moved away from basic cloth face coverings, instead requiring people to use at least medical grade masks, Austria, and later Slovakia, only allowed for FFP2/K95 or higher-level masks, all of them stating the spread of the VOCs as the reason for the change in policy. In January 2021, France recommended that all citizens wear FFP2 masks in public, but stopped short of making them mandatory, instead allowed the use of either surgical, FFP2 or cloth masks of level 1 standard, as the Minister of Health announced that home-made cloth masks were not sufficient to mitigate the spread of the new VOC.

Local restrictions were enacted to curb the spread of variant clusters

As countries started to detect clusters and local spread of variants in their own territories, many of them opted to enact local measures to mitigate the spread of VOC within the country. On 8 February 2021, Austria detected the largest outbreak of the 501Y.V2 variant in Europe thus far. A total of 293 confirmed cases and 200 suspected cases were detected in the federal state of Tyrol. After public discussion and political pressure about a possible confinement in the state of Tyrol, the government of Austria abstained from isolating the areas of concern, instead making a formal plea to reduce movement in and out of the region and encouraged individuals to go for testing after visiting the region. The following day, however, the government announced that from 12 February 2021 people would only be allowed to leave the state of Tyrol if they were able to produce a negative COVID-19 test result within the past 48 hours. The district of Schwaz in Tyrol, where the circulation of the 501Y.V2 variant was mainly concentrated, responded by testing the entire population of 84,000 inhabitants with a PCR test, intensified contact tracing, and kept high schools in distance learning for an additional two weeks, while students in the rest of the country returned to schools after the semester break. A similar exit testing requirement, as the one that was applied to the state of Tyrol, was later introduced for anyone exiting the district of Schwaz. In early March 2021, it was announced that the district of Schwaz would become part of a wider international research effort to investigate the effectiveness of vaccines on the 501Y.V2 variant. The European Commission, agreed to allocate an additional 100,000 doses of the Pfizer/BioNTech vaccine to Austria, making all adults in Schwaz eligible to get vaccinated immediately.

In late February 2021, France started to enforce local weekend confinements in areas that were heavily impacted by the more contagious B.1.1.7 variant. The affected areas were Dunkirk, in the north of France, where instances of the variant had reached 70% among positive tests checked for variants by mid-February, the Pas-De-Calais département and the Alpes-Maritimes region in the south of the country, including the city of Nice. On weekends, the confinement rules only allowed residents to leave the house under certain conditions and all shops, except those selling food, had to close in the affected areas. On 19 March 2021, the confinement was extended to 16 metropolitan departments and became applicable throughout the whole week for four weeks.

In the beginning of March 2021, Norway moved 6 municipalities to the highest response level (of the country’s tiered system for restrictions) due to the increase in infections with the B.1.1.7 variant and in mid-March one municipality was moved into the highest level due to ongoing outbreaks of the 501Y.V2 variant.

Countries have only used national measures and lockdowns as a last resort when VOCs were first detected

By the end of March 2021, the rapidly spreading B.1.1.7 variant has become the dominant strain in a number of countries, fuelling new waves of infections across the European Region. Often defying regional measures, this more transmissible variant has forced countries to impose far-reaching national measures and lockdowns. A few examples of such measures are described here.

At the end of 2020, the new B.1.1.7 variant began spreading rapidly across the UK. The variant grew quickly to become the dominant variant across the UK. As a consequence, the B.1.1.7 variant led to further surges in cases, hospitalisations and deaths. The UK government responded by reintroducing the stay-at-home order first in the regions most affected and then nationally across England. The devolved administrations took similar approaches. As a result of the strict lockdown since the beginning of January 2021, cases, hospitalizations and deaths have decreased significantly across the UK and at the end of February, England unveiled its four-step plan to ease its lockdown. Continued adherence to PHSM and increasing levels of vaccine coverage have allowed the UK to cautiously lift restrictions and (at time of writing) to complete step 2 of the roadmap according to plan without risking a new surge in new infections (see Figure 2).

Figure 2. Daily cases and PHSM in the UK4

In Portugal, the proportion of B.1.1.7 positive cases started to increase exponentially in the beginning of January 2021. In direct response, Portugal implemented a nationwide lockdown in mid-January. Travel between municipalities was prohibited, all non-essential businesses and schools closed, and night-time/weekend curfews were implemented with a recommendation for citizens to remain at home. As a result, a dramatic drop in new cases of COVID-19 could be observed starting at the end of January (see Figure 3).

Figure 3. Daily cases and PHSM in Portugal4

The sequencing of positive samples in early February showed that over 70% of cases in Slovakia were positive for the B.1.1.7 variant. The prevalence of the VOC and the speed of the spread led the government to impose a nationwide curfew, allowing only citizens who could present a negative COVID-19 test result to leave their homes.

In Belgium, the B.1.1.7 variant became the dominant strain by mid-February, continuously driving up cases and hospitalizations, which led the government to once again impose a four-week lockdown by the end of March. This included closing all schools, reducing the permitted social bubbles and making non-essential businesses only accessible by appointment.

Even with vaccination campaigns well underway, Public Health and Social Measures retain a vital role in curbing infection rates

The emergence of more transmissible VOCs and countries’ responses have demonstrated that PHSM remain critically important to curb the spread of SARS-CoV-2. Evidence from multiple countries with extensive transmission of VOCs has indicated that the implementation and strengthening of measures such as physical distancing and other PHSM have been effective in reducing COVID-19 case incidence5. The higher transmissibility of VOCs may require for PHSM to be implemented more consistently over longer periods of time. Even with vaccination campaigns well underway in many countries, with Israel and the UK leading the Region in coverage, it is still unclear when herd immunity will be reached. Until then, PHSM remain the most important tools to suppress the spread of circulating SARS-CoV-2 viruses. Adjustments to PHSM should continue to be informed by epidemiological tracking, irrespective of VOC circulation. All countries need to assess their level of local transmission and national and local authorities are encouraged to continue adjusting existing PHSM based on risk assessments6 as well as strengthening epidemiological surveillance, strategic testing, and systematic sequencing of SARS-CoV-2 where feasible.  

Christoph Wippel, Tanja Schmidt, Richard Pebody

References

  1. World Health Organization Regional Office for Europe. Factsheet February 2021 SARS-CoV-2 Variant of Concern (VOC). https://www.euro.who.int/__data/assets/pdf_file/0003/492177/SARS-CoV-2-VOC-factsheet-eng.pdf
  2. World Health Organization Regional Office for Europe. Underlying Methodology and Application of the PHSM Database and PHSM Severity Index. https://apps.who.int/iris/handle/10665/337686
  3. The Event Information Site (EIS) is a restricted platform developed by WHO to facilitate secure communications with IHR NFPs as part of the implementation of the IHR (2005). https://www.who.int/ihr/access/en/
  4. World Health Organization Regional Office for Europe. COVID-19. EURO Situation Dashboard. https://who.maps.arcgis.com/apps/opsdashboard/index.html#/ead3c6475654481ca51c248d52ab9c61
  5. World Health Organization. COVID-19 Weekly Epidemiological Update. https://apps.who.int/iris/bitstream/handle/10665/340087/nCoV-weekly-sitrep9Mar21-eng.pdf?sequence=1&isAllowed=y
  6. World Health Organization. Considerations for implementing and adjusting public health and social measures in the context of COVID-19. https://www.who.int/publications/i/item/considerations-in-adjusting-public-health-and-social-measures-in-the-context-of-covid-19-interim-guidance