RKI and WHO Euro carry out a first virtual country mission in the Republic of Armenia for COVID-19 response

Participants on the first day of the virtual mission (Source: WHO Euro)

The global spread of the COVID-19 has affected many areas of work for the Robert Koch Institute (RKI) and its partners. One of the greatest effects of the pandemic has been its impact on international travel. With serious restrictions that result in closed borders and cancelled flights, to be able to conduct projects that usually require an on-site presence means that global health experts have to find innovative ways to cooperate and support the outbreak response in other countries remotely.

Facing these challenges, the RKI and the WHO Regional Office for Europe (WHO Euro) have joined forces to pilot the first virtual country mission to Armenia. In response to the request from the Armenian Ministry of Health (MoH) and the Presidential Office of the Republic of Armenia, RKI and WHO Euro put together an expert delegation to consult Armenian colleagues about the response measures to the COVID-19 outbreak. Over 400 participants attended a total of nine online sessions between 29.04 and 07.05.2020. Eleven colleagues from the Centre for International Health Protection and Department for Epidemiology of Infectious Diseases of the RKI supported the joint mission.

The joint mission's overall goal was to rapidly provide Armenia's national government with feedback on their COVID-19 response efforts and offer recommendations regarding the implementation of additional measures.

The mission

The online sessions during the mission were organised around the response pillars of surveillance and epidemiology, laboratory diagnostics, risk communication and community engagement (RCCE), clinical management and infection prevention and control (IPC). Additionally, issues particularly relevant in the context of the current outbreak appeared on the agenda, such as the production of ventilators, response to COVID-19 in special settings including prisons and care facilities and continuity of essential health care services throughout the pandemic.

The virtual mission began with a high-level meeting between the joint expert team and the Armenian MoH representatives on 29.04. During this session, a "helicopter view" discussion took place to better understand the COVID-19 situation in the Republic of Armenia, with a focus on the preparedness and response activities implemented so far by the government. As a result of the discussion, the participants determined the main objectives of the mission.

In the next two days, seven deep dive technical discussions were arranged and attended by the experts from the RKI, WHO Euro and their counterparts from the Armenian MoH. Each session started with a technical presentation on the part of the MoH and was followed by a question and answer (Q&A) session. Working in coordination with the Armenian colleagues, members of the mission identified strengths and weaknesses of the response activities and based on this issued a set of suggestions and recommendations. These were presented during a closing debriefing to the Deputy Minister of Health of the Republic of Armenia.

The team has recommended maintaining focus on containment measures across the country. The suggestion was made to prioritise the expansion of case finding and proactive testing of certain high-risk groups, such as healthcare personnel and residents of long-term care facilities. To have a clearer picture of the COVID-19-related mortality, members of the mission advised reviewing all-cause mortality data for excess deaths in the country.

With regard to the management of COVID-19 in special settings, experts pointed out the need to find the balance between isolation measures and maintaining quality of life for residents of long-term care facilities. The implementation of stronger IPC measures was emphaised as being crucial to reducing the incidence of infection.

In the course of discussion on risk communication activities, the participants raised the critical issue of "fatigue" among the population, which must be considered during the transition phase involving lifting of restrictions. Initially, there was a high degree of compliance with implemented protective measures in the country, given the high level of trust towards the government and the transparency it pursued in its communication strategy. However, the reluctance to follow the rules on hygiene and physical distancing has been increasing due to the long duration of the crisis. The team endorsed more formative research into people's attitudes to better understand the dynamics of the fatigue and the barriers to continuing compliance with the guidance.

Concerning the transition, the experts noted that Armenia has sufficient public health and health system capacities to identify, isolate, test and treat all cases as well as to trace and quarantine contacts. As the country enters the transition phase, it is recommended that the lifting of restrictions follows evidence-based planning and happens gradually.

Feedback on the new format of the virtual mission

During a facilitated internal discussion between the RKI and WHO Euro, most participants agreed that the virtual mission has considerable limitations compared to a conventional country mission. In particular, team members pointed out that site visits cannot be reconstructed during a virtual country visit. There is also an indisputable value to the direct face-to-face exchange between participants over longer periods, some of which is lost in the format of an online session.

However, it must be noted that virtual missions have great potential when actual travel is severely restricted for all or some participants. They offer a low-cost opportunity to bring people together and engage experts in a targeted manner. Rather than having to allocate several days to a trip, the participants can selectively attend the relevant online sessions dedicated to their area of work.

Upon completion of the first virtual country mission, the team members from the RKI and the WHO Euro office agreed to continue exploring and improving this format, at least for the duration of the ongoing COVID-19 outbreak.

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