AFEW International signed “Civil Society Statement on COVID-19 and People who use Drugs”

INPUD, in collaboration with International Drug Policy Consortium and Harm Reduction International, developed a statement ‘In the time of COVID-19: Civil Society Statement on COVID-19 and People who use Drugs’.

Organizations are asking for the international community, including international donors, to act immediately to ensure, through policy guidelines and financial and political support, that national, regional and global responses to the pandemic respect the fundamental rights of all.

The deadline for sign on is Monday, 6 April, by noon (12:00 – London time).

To  sign the statement, please use this link.

The statement

In the time of COVID-19: Civil Society Statement on COVID-19 and People who use Drugs

We, as community and civil society organisations working in drug policy reform and harm reduction, urge the international community to take proactive and coordinated action to protect the health and human rights of people who use drugs in light of the COVID-19 crisis.COVID-19 infection does not discriminate, but magnifies existing social, economic and political inequities. People who use drugs are particularly vulnerable due to criminalisation and stigma and often experience underlying health conditions, higher rates of poverty, unemployment and homelessness, as well as a lack of access to vital resources – putting them at greater risk of infection. The crisis must be an occasion to rethink the function of punishment, to reform the system and to work towards ending the war on drugs. If we are to ‘flatten the curve’, the health of the most marginalised in society must also be protected as an urgent priority.

In times of crisis, uncertainty and upheaval it is imperative that human rights act as an anchor point. Careful and vigilant attention must be paid to non-discriminatory access to health care, human dignity and transparency. Multiple governments emphasise that we are fighting a ‘war’, the use of such terminology justifying a militarised approach that allows for the suspension of rights and freedoms. History shows that extraordinary powers are routinely deployed against the most persecuted in society, who risk being scapegoated in the name of infection control. As states of emergency are declared, the international community must urge caution on the creation of a ‘new normal’ where States derogate from their obligation to serve and protect all persons.

Failure to effectively steer and manage the COVID-19 response will have disastrous consequences. The international community, including international donors, must act immediately to ensure, through policy guidelines and financial and political support, that national, regional and global responses to this pandemic take the needs of people who use drugs into account and respect the fundamental rights of all. We therefore suggest the following recommendations:

1. Protect the right to health: During times such as these, governments have an obligation to ensure that a public health crisis does not become a human rights crisis due to lack of access to adequate health care. In the wake of COVID-19, however, there is great concern that harm reduction services are being closed, not adapting sufficiently rapidly to changing legal and health contexts and that essential resources will be diverted to the COVID-19 response at the expense of equally life-saving work. Inappropriate and restrictive regulations banning or limiting take-home doses and other supplies make complying with lockdowns and social distancing rules extremely difficult. Harm reduction workers report unease about scarcity of resources, lack of coherent policies and programme guidelines on COVID-19, and potential disruptions to global supply chains of essential medicines and equipment, including methadone, buprenorphine, naloxone, needles and syringes, disinfectant, masks and gloves.

The international community must act swiftly to ensure States meet their international obligations to protect the right to life and health. This can be done by issuing strong political statements and clear and comprehensive technical guidance, building on WHO and UNODC  guidelines and national COVID-10 regulations, which unequivocally calls to:

– Declare harm reduction programmes as life-saving services that must stay open. The closure of harm  reduction centres would deprive service users from accessing life-saving interventions and would ultimately lead to over-crowding of centres that remain open, increasing risk of infection.
– Immediately amend restrictive legal and regulatory policies that ban or limit take-home doses due to fear of diversion and that restrict the provision of take-home naloxone to prevent overdoses.
– Enhance service accessibility, develop and implement safety and hygiene protocols and coordinate efforts within the health system to allow for the effective distribution of resources.
– Recognise harm reduction workers as critical healthcare workers so that they can access government stocks of protective clothing.
– Protect and expand the operation of low-threshold services, including outreach, as well as provide housing and shelter for those facing housing insecurity.
– Adequately fund harm reduction services, particularly low-threshold services.

2. Ensure safe supply: Border closures and travel bans around the world will impact the future supply of unregulated substances such as heroin and cocaine. This will have a range of repercussions, including an increase in demand for opiate substitution therapy (OST). Of particular concern is that synthetic drugs such as fentanyl, which are easier to produce and transport, could replace bulkier substances such as heroin, the corollary of this being an exponential increase in overdose deaths.

In light of the above, international and regional bodies must work with member states to:

– Monitor trends of illicit drug markets to provide a rapid response to dangerous and emerging trends, such as increased risk of overdose deaths.
– Ensure increased access to OST to respond to changes in drug supply, through accelerated and flexible entry procedures.
– Deprioritise the enforcement of supply-side control in order to retain some stability in illicit drug markets and prevent market saturation with synthetic drugs.
– Respond to potential disruptions in the production of methadone and buprenorphine and step in when early signs of issues with supply chain management are detected.

3. Protect the right to be free from arbitrary detention: The COVID-19 crisis has spotlighted the public health dangers of overcrowding in prison and detention facilities which are traditional hotbeds for infectious diseases. According to UN data, at least 470,000 persons are incarcerated worldwide for drug use and possession only, while an additional 1.7 million people are incarcerated for other drug offences, many of which are non-violent. In addition, across East and South-east Asia, hundreds of thousands of people who use drugs are detained in compulsory drug detention facilities, with tens of thousands more detained in private drug treatment centres, often against their will, across Asia and Latin America. In such contexts, COVID-19 prevention measures, such as physical distancing, cannot be implemented effectively. Further restrictions on family visits and supervised releases increase isolation and stress during a time of fear, leading to an increase in violence, riots and assault.

The UN High Commissioner for Human Rights has urged governments to reduce the number of people in detention, particularly those without sufficient legal basis. In view of this, the international community must ensure States take action to:

– Decriminalise drug use and possession for personal use as promoted by the UN system and outlined in the UN Common Position on Drugs.
– Reduce the prison population through early release, pardons, amnesties and non-coercive alternatives to incarceration for people detained for drug-related non-violent offences, particularly those on remand, and those most-at-risk individuals, including people living with HIV, TB and COPD, as well as older people.
– Immediately release people who use drugs from compulsory drug detention centres and from private drug treatment centres that apply coercive measures, including involuntary detention.

4. Protect civil and political liberties: Many governments, as part of COVID-19 containment measures, are restricting civil liberties in unprecedented ways, through mass surveillance, including tracking mobile phone data, restricting movement and banning public assembly. Authorities such as police and army personnel are permitted to stop anyone on the street, increasing the chance of hostile interactions with people who use drugs, particularly when they need to purchase drugs or travel for health appointments. The potential misuse of personal data, particularly when it comes to criminalised populations, is of acute concern.

In a joint statement, UN experts have urged States, in accordance with the Siracusa Principles, to exert caution when applying COVID-19 related measures and restrictions that may impinge on human rights, as well as to limit their duration and subject them to regular review. Based on this, we urge the international community to:

– Ensure that emergency declarations and broader extraordinary powers granted under COVID-19 responses are not used to target specific populations or deployed to silence and repress human rights defenders.
– Establish rights-based legal safeguards to govern the appropriate use and handling of personal data to  protect privacy and confidentiality.
– Ensure that exorbitant fines and imprisonment should only be used as a last resort and personal circumstances taken into account, in the event of breaches to protective measures.

5. Protect community and civil society organisations: The COVID-19 pandemic has showed the critical role of communities in the response, as they can react quickly and reach those who are otherwise unreachable, easing the burden on the healthcare system. Furthermore, communities play important watchdog functions when it comes to government transparency and accountability. UN and donor agencies must act to:

– Protect human rights defenders, communities and civil society organisations during this crucial time, by highlighting their critical role in public statements and in their interaction with governments.
– Ensure governments do not impose disproportionate restrictions or obstructions on the work of community  and civil society organisations.
– Establish mechanisms for monitoring human rights compliance, with a particular focus on populations whose rights are commonly violated.

Global problems such as the COVID-19 pandemic require global solutions. We urge the international community to take urgent action to ensure the inherent rights and dignity of people who use drugs are respected and defended in the time of COVID-19. The pandemic has laid bare the failures within our societies. Undoubtedly a serious challenge, COVID-19 must not be exploited by governments to suspend basic rights and freedoms indefinitely, but be a wake-up call to change and repair a broken system that has been overly focused on the punishment of people who use drugs, a policy that is now exacerbating the dangers of COVID-19. The failed war on drugs must end, and health and political systems must be reformed to ensure the health and wellbeing of all.

#Strongertogether. The EU’s response to the coronavirus pandemic in the Eastern Partnership

As part of its global response to the coronavirus outbreak, the European Commission is mobilising an emergency support package for Armenia, Azerbaijan, Belarus, Georgia, the Republic of Moldova, and Ukraine: €140 million for immediate needs; up to €700 million for the short and medium term to support the social and economic recovery of the region.

Responding to immediate needs includes:

  • Support to the health sector (€30 million)
  • Working with the WHO to supply medical devices and personal equipment such as ventilators, laboratory kits, masks, goggles, gowns, and safety suits.
  • Training medical and laboratory staff, and raising awareness across the six countries.

 

  • Support for the most vulnerable groups in society (€11.3 million)
  • Grants of up to €60,000 to civil society organisations to respond to immediate needs, such as supporting local schools with distance learning – already available through the EU’s regional “Rapid Response Mechanism”.
  • Launch of the “Eastern Partnership Solidarity Programme” to target the most affected parts of the populations, with sub-grants to smaller, local organisations.

Limiting the social and economic impact

Working closely with International Financial Institutions (IFIs) and financing institutions from EU Member States to provide a coordinated European response as TEAM EUROPE:

  1. New €100 million support programme to help SMEs, including self-employed and others to easily access credit and boost their businesses after the crisis.
  2. €200 million of existing credit lines and grants to SMEs in local currency through the EU4Business Initiative.
  3. €500 million available for the EU’s Neighbourhood through the EU’s major de-risking instrument, the European Fund for Sustainable Development (EFSD) to rapidly provide liquidity across the region.

What is the EU already doing for the Eastern Partnership to face the coronavirus emergency?

Armenia

  • Over 3,000 vulnerable households, with elderly people and people with disabilities and large families in Shirak, Tavush and Lori regions will receive humanitarian aid packages thanks to the support of the European Union.

Azerbaijan

  • With EU funds, the Ganja Vocational Education and Training school will purchase equipment machinery to produce masks for the Ganja area.

Belarus

  • Thanks to EU cross-border cooperation projects linking communities in Belarus, Ukraine and Poland, emergency medical services such as ambulances and respirators are available in the hospitals to help doctors fight against the coronavirus pandemic.

Georgia

  • A Georgian producer of medical textiles has produced 40,000 medical gowns within a week after he was able to purchase 12 additional sewing machines thanks to a micro-grant provided by the EU.

Republic of Moldova

  • EU projects in Moldova are already working to provide protection sets such as gloves and masks for vulnerable people and medical staff, as well as sterilizers for equipment across the country.

Ukraine

  • The EU supports the building of community resilience through assistance to vulnerable people, transition to online education, fighting disinformation and strengthening cultural diversity and creativity online.

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#StaySafe with Teenergizer

Teenergizer, a movement that has united teenagers from the region of Eastern Europe and Central Asia, launched the #StaySafe online campaign aimed at teens and young people from EECA countries to help them feel strong and protected during the unstable time of the coronavirus pandemic.

Teenergizer engages stars to promote key campaign ideas about the importance of following quarantine rules during an epidemic. For more about free online consultations, see the video from Teenergizer family!

EACS & BHIVA Statement on risk of COVID-19 for people living with HIV

COVID-19 & HIV

So far there is no evidence for a higher COVID-19 infection rate or different disease course in people living with HIV (PLWH) than in HIV-negative people.

Current evidence indicates that the risk of severe illness increases with age, male sex and with certain chronic medical problems such as cardiovascular disease, chronic lung disease and diabetes. Although people living with HIV who are on treatment with a normal CD4 T-cell count and suppressed viral load may not be at an increased risk of serious illness, many people living with HIV have other conditions that increase their risk.

Indeed, almost half of people living with HIV in Europe are older than 50 years and chronic medical problems, such as cardiovascular and chronic lung disease, are more common in people living with HIV. It has to be assumed that immune suppression, indicated by a low CD4 T-cell count (<200/µl), or not receiving antiretroviral treatment, will also be associated with an increased risk for a more severe disease presentation. For patients with low CD4-counts (<200/ml), or who experience a CD4-decline during a COVID-19 infection, remember to initiate opportunistic infection (OI) prophylaxis. More information regarding recommendations for prophylaxis and treatment of specific opportunistic infections can be found in the BHIVA and EACS guidelines for the treatment of HIV/AIDS. Smoking is a risk factor for respiratory infections; smoking cessation should therefore be encouraged for all patients. Influenza and pneumococcal vaccinations should be kept up to date.

First reports from China suggest a growing evidence for potential COVID-19 vertical transmission [1]. So far clinical outcome of the newborn however, has been very good. Existing national guidelines should be followed in terms of reducing risk and managing symptoms; examples are listed below [2-4].

COVID-19 treatment: antiretrovirals & further options

Expedited research and publication are welcomed with the caveat that results may be disseminated pre-publication and/or published without usual peer review. There is ongoing discussion and research around some HIV antiretrovirals which may have some activity against COVID-19. The first randomised clinical trial with lopinavir/ritonavir demonstrated no benefit over standard care in 199 hospitalised adults with severe COVID-19 [5]. There is no evidence to support the use of other antiretrovirals, including protease inhibitors; indeed, structural analysis demonstrates no darunavir binding to COVID-19 protease. A recent case series on hydrochloroquine, with or without azithromycin, was not able to demonstrate a clear clinical benefit, despite in vitro inhibition of SARS-CoV-2, due to methodological issues [6]; although the same group has postulated an infection control benefit of more rapid viral clearance there was a lack of control arm for comparison [7]. One small RCT demonstrated trends for reduced time to clinical recovery and short-term radiological improvement for hydroxychloroquine [8], though another showed no benefit in terms of viral clearance, clinical or radiological endpoints [9]. Despite lack of evidence, indeed no acute viral infection has ever been successfully treated with either product [10], the FDA has issued an Emergency Use Authorisation to allow hydroxychloroquine and chloroquine products to be used for certain hospitalised patients with COVID-19 [11] while awaiting results from randomised trials. A further potential drug candidate for treatment of COVID19 is remdesivir which was originally developed for Ebola therapy. Remdesivir has broad in vitro antiviral activity against SARS-CoV-2 [12]. First cases where COVID19 patients were treated with remdesivir suggest potential clinical benefit. The results from ongoing clinical trials are eagerly awaited.

Currently no evidence is available to justify switching a patient from their usual antiretroviral therapy. Additionally there is no evidence to support HIV-negative people taking antiretrovirals outside the context of pre-exposure prophylaxis (PrEP) to prevent HIV acquisition – PrEP should be taken as directed and there is no current evidence that PrEP is effective against COVID-19.

COVID-19 data collection & resources

A COVID-19 drug interactions website (www.covid19-druginteractions.org) has been developed for the experimental drugs being trialed to treat COVID-19 in different parts of the world. EACS and BHIVA are happy to announce that they have agreed to financially support this very useful website.

We would like to highlight two resources for reporting COVID-19 cases:

  • The NEAT ID Foundation has developed a ‘data dashboard’ to monitor COVID-19 case numbers, hospitalisations and mortality in people living with HIV at European and country level. The data will be available for public viewing via ww.NEAT-ID.org and if your centre has not signed up, you can do so via this link.
  • The Lean European Open Survey on SARS-CoV-2 Infected Patients (LEOSS) launched by the German Society for Infectious Diseases (DGI) and ESCMID’s Emerging Infections Task Force (EITaF) an open register based on anonymous questionnaires and they are keen to collaborate with other registries. See https://leoss.net, contact them by email at info@leoss.net and the register can be accessed here https://leoss.net/statistics

The coronavirus outbreak is rapidly evolving. EACS and BHIVA will continue to share any updates to specific guidance for people living with HIV. Wishing you all well. Stay healthy.

 

References

  1. Zeng L, et al. Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr 2020; DOI: 10.1001/jamapediatrics.2020.0878.
  2. www.rki.de
  3. https://www.cdc.gov/coronavirus/2019-ncov/index.html
  4. https://www.gov.uk/government/collections/wuhan-novel-coronavirus
  5. Cao B, Wang Y, Wen D et al. A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19. N Engl J Med 2020; doi: 10.1056/NEJMoa2001282.
  6. Gautret P et al. Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: an observational study. Int J Antimicrob Agents. 2020 Mar 20:105949. doi:10.1016/j.ijantimicag.2020.105949.
  7. https://www.mediterranee-infection.com/wp-content/uploads/2020/03/COVID-IHU-2-1.pdf; accessed 31st March 2020
  8. Chen Z, Hu J, Zhang Z et al. Efficacy of hydroxychloroquine in patients with COVID-19: results of a randomized clinical trial. medRxiv 2020.03.22.20040758; doi: https://doi.org/10.1101/2020.03.22.20040758
  9. Chen J, Liu D, Li L et al. A pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease-19 (COVID-19). J Zhejiang Univ. 2020; Mar. (DOI 10.3785/j.issn. 1008-9292.2020.03.03
  10. Guastalegname M, Vallone A. Could chloroquine /hydroxychloroquine be harmful in Coronavirus Disease 2019 (COVID-19) treatment? Clin Infect Dis. 2020 Mar 24. pii: ciaa321. doi: 10.1093/cid/ciaa321.
  11. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-daily-roundup-march-30-2020; accessed 21st March 2020
12. Wang M, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020 Mar;30(3):269-271

 

COVID-19: Advice for People who Use Drugs

In collaboration with EuroNPUD, INPUD have developed “COVID-19: Advice for People who Use Drugs” leaflet.

This resource is intended to provide both general harm reduction practices and information on available local services provided by communities of people who use drugs. The English language version below is set up for Bath and North East Somerset, and co-branded with the local drug user organisation West Country Respect

Read here 

Interim Guidance. COVID-19: Focus on persons deprived of their liberty.

IASC – Inter-Agency Standing Committee published Interim Guidance. COVID-19: Focus on persons deprived of their liberty.

COVID-19 has been declared a global pandemic and as it is spreading, identified vulnerabilities such as the situation
of persons deprived of their liberty in prisons, administrative detention centres, migration detention centres and drug rehabilitation centres, require a specific focus.
Persons deprived of their liberty might face higher vulnerabilities as the spread of the virus can expand rapidly due to
the usually high concentration of persons deprived of their liberty in confined spaces and to the restricted access to
hygiene and health care in some contexts. International standards highlight that states should ensure that persons in
detention have access to the same standard of health care as is available in the community, and that this applies to all
persons regardless of citizenship, nationality or migration status.
Maintaining health in detention centres is in the interest of the persons deprived of their liberty as well as of the staff of the facility and the community. The state has the obligation, according to international human rights law1, to ensure the health care of people in places of detention. If the risks related to the virus in places of detention are not addressed, the outbreak can also spread to the general public.
The series of messages below aim at assisting OHCHR and UNCT/HCT in addressing the specific issues of persons
deprived of their liberty with the responsible services and ministries (Ministry of Justice/Ministry of Interior/Ministry of Health/Agencies in charge of migration and rehabilitation centres, etc).

Read the guidance 

Statement of principles relating to the treatment of persons deprived of their liberty

The Council of Europe’s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) has published a statement of principles relating to the treatment of persons deprived of their liberty in the context of the coronavirus disease (COVID-19) pandemic.

“The Coronavirus disease (COVID-19) pandemic has created extraordinary challenges for the authorities of all member States of the Council of Europe”, says Mykola Gnatovskyy, President of the CPT. “There are specific and intense challenges for staff working in various places of deprivation of liberty, including police detention facilities, penitentiary institutions, immigration detention centres, psychiatric hospitals and social care homes, as well as in various newly-established facilities/zones where persons are placed in quarantine. Whilst acknowledging the clear imperative to take firm action to combat COVID-19, the CPT must remind all actors of the absolute nature of the prohibition of torture and inhuman or degrading treatment. Protective measures must never result in inhuman or degrading treatment of persons deprived of their liberty.”

In the CPT’s view, the following principles should be applied by all relevant authorities responsible for persons deprived of their liberty within the Council of Europe area.

Read Statement of principles 

What people living with HIV need to know about HIV and COVID-19?

UNAIDS developed a guidelines for people who live with HIV.

Read it here

What UNAIDS recommends:
1. HIV services must continue to be made available for people living with and at risk of HIV. This includes ensuring the availability of condoms, opioid substitution therapy, sterile needles and syringes, harm reduction, pre-exposure prophylaxis and HIV testing.
2. To prevent people from running out of medicines and to reduce the need to access the health system, countries should move to the full implementation of multimonth dispensing of three months or more of HIV treatment.
3. There must be access to COVID-19 services for vulnerable people, including a targeted approach to reach those most left behind and removing financial barriers, such as user fees.

Harm Reduction Must Go On: Position of European Harm Reduction Networks on COVID-19

The Correlation European Harm Reduction Network and the Eurasian Harm Reduction Association published a joint position on the continuity of harm reduction services during the COVID-19 crisis.

People Who Use Drugs (PWUDs) can be considered as a risk group in the COVID-19 epidemic. They often live in the margins of society with low or no access to housing, employment, financial resources, social and health care, and face systematic discrimination and criminalisation in majority of countries. Many of them have multiple health problems, which can increase the risk of a (fatal) COVID-19 infection (including long-term diseases such as COPD, HIV, TB, cancer, and other conditions which reduce the immune system). Harm reduction services are often the one and only contact point for PWUDs to access the health service. They provide health and social services as well as other basic support, and function as an essential link to other live-saving services.

We call on local and national governments and international organisations introducing safety measures and to:

1. Ensure the continuity and sustainability of harm reduction and other lowthreshold services for PWUDs during the COVID-19 epidemic. This includes in particular Opiate Substitution Treatment (OST), Heroin Assisted Treatment (HAT), Needle and Syringe Programs (NSP), naloxone provision, and continued access to Drug Consumption Rooms (DCRs). In addition, essential basic services need to be provided, including day and night shelter, showers, clothing, food, and other services. This is of particular importance to those who experience homelessness and/or live on the streets.

2. Provide adequate funding for harm reduction and other low-threshold service providers, and supply them with adequate equipment to protect staff and clients from infections (soap, hand sanitiser, disposable face-masks, tissues etc.).

3. Acknowledge the important and critical role of harm reduction and other low-threshold services in the COVID-19 pandemic and address the specific vulnerable situation of PWUDs and other related groups.

4. Develop specific guidelines and regulations for harm reduction services, with respect to the vulnerable situation of PWUDs and related target groups. These guidelines should be developed in close cooperation with involved staff and the affected communities, and build on international WHO guidelines, recommendations, and evidence and/or national COVID-19 regulations.

More specifically we call for the following:

5. OST and HAT should be maintained and take-home regulations should be established or extended for patients to have opportunity to come for treatment rarely then ones a week. Access through pharmacies should be ensured.

6. NSP should provide PWUDs with larger amounts of needles, syringes, and other paraphernalia to minimise the number of contacts. Special bins for needles and syringes should be provided to collect used material at home.

7. Harm reduction services should provide COVID-19 prevention material and information for staff, volunteers, and service users, including soap, alcohol-based hand sanitisers that contain at least 60% alcohol, tissues, trash baskets, and disposable face-masks (if this is requested by national regulations), for people who show symptoms like fever, coughing, and sneezing.

8. Drop-in services, day shelters, and DCRs should advise and support PWUDs in preventing COVID-19 infections. Visitors should be made to sanitise their hands when entering and should stay no longer than is absolutely necessary. Kitchens can prepare take-away food to be eaten outdoors. All necessary measures should be made to increase social distancing among visitors/ staff with all possible means, and rooms should be ventilated. Overcrowding in harm reductions services, shelters, and DCRs should be avoided, by establishing safety measures, e.g. minimising the duration of stay, maximum number of visitors, entering only once per day. People with permanent housing should be encouraged to stay at home and come only to pick up needles and other harm reduction paraphernalia and tools.

9. The health situation of PWUDs should be monitored closely. If someone shows symptoms, such as fever and coughing, face-masks should be provided and a medical check-up should be ensured. Cooperation agreements with public health services, related health units, and hospitals need to be established to ensure direct medical support, follow up care, and treatment.

10. Night shelters need to be made available for people experiencing homelessness, with a separation in place between those who are not infected and those who are infected and need to be quarantined, but do not need specific medical care and treatment in hospitals. Night shelters have to comply with the overall safety regulations for COVID-19, and people should not be exposed to additional risks for infection through overcrowding and insufficient health care.

11. Group-related services, such as meetings and consultations, should be cancelled and postponed until further notice or organised as online services. New treatment admissions should be temporarily suspended. Coercive measures (e.g treatment referrals made by court/prosecutor/ police, probation officer visits etc.) should be suspended. Mandatory urine sampling should be abolished.

12. Harm reduction services should establish a safe working environment and make sure that staff are well informed and protected against infection. Service providers should identify critical job functions and positions, and plan for alternative coverage by involving other staff members in service delivery.

PDF version of the statement

Mental Health and Psychosocial Considerations During COVID-19 Outbreak

WHO and public health authorities around the world are acting to contain the COVID-19 outbreak. However, this time of crisis is generating stress in the population. WHO’s Department of Mental Health and Substance Use developed mental health considerations as messages targeting different groups to support for mental and psychosocial well-being during COVID-19 outbreak.

General population
1. COVID-19 has and is likely to affect people from many countries, in many geographical locations. Do not attach it to any ethnicity or nationality. Be empathetic to all those who are affected, in and from any country. People who are affected by Covid-19 have not done anything wrong, and they deserve our support, compassion and kindness.
2. Do not refer to people with the disease as “COVID-19 cases”, “victims” “COVID-19 families” or the “diseased”. They are “people who have COVID-19”, “people who are being treated for COVID-19”, “people who are recovering from COVID-19” and after recovering from COVID-19 their life will go on with their jobs, families and loved ones. It is important to separate a person from having an identity defined by COVID-19, to reduce stigma.
3. Minimize watching, reading or listening to news that causes you to feel anxious or distressed; seek information only from trusted sources and mainly to take practical steps to prepare your plans and protect yourself and loved ones. Seek information updates at specific times during the day, once or twice. The sudden and near-constant stream of news reports about an outbreak can cause anyone to feel worried. Get the facts; not the rumors and misinformation. Gather information at regular intervals, from WHO website and local health authorities platforms, in order to help you distinguish facts from rumors. Facts can help to minimize fears.
4. Protect yourself and be supportive to others. Assisting others in their time of need can benefit the person receiving support as well as the helper. For example, check-in by phone on neighbors or people in your community who may need some extra assistance. Working together as one community can help to create solidarity in addressing Covid-19 together.
5. Find opportunities to amplify positive and hopeful stories and positive images of local people who have experienced COVID-19. For example, stories of people who have recovered or who have supported a loved one and are willing to share their experience.
6. Honor caretakers and healthcare workers supporting people affected with COVID-19 in your community. Acknowledge the role they play to save lives and keep your loved ones safe.

Healthcare workers
7. For health workers, feeling under pressure is a likely experience for you and many of your health worker colleagues. It is quite normal to be feeling this way in the current situation. Stress and the feelings associated with it are by no means a reflection that you cannot do your job or that you are weak. Managing your mental health and psychosocial wellbeing during this time is as important as managing your physical health.
8. Take care of yourself at this time. Try and use helpful coping strategies such as ensuring sufficient rest and respite during work or between shifts, eat sufficient and healthy food, engage in physical activity, and stay in contact with family and friends. Avoid using unhelpful coping strategies such as tobacco, alcohol or other drugs. In the long term, these can worsen your mental and physical wellbeing. This is a unique and unprecedent scenario for many workers, particularly if they have not been involved in similar responses. Even so, using strategies that have worked for you in the past to manage times of stress can benefit you now. You are most likely to know how to de-stress and you should not be hesitant in keeping yourself psychologically well. This is not a sprint; it’s a marathon.
9. Some healthcare workers may unfortunately experience avoidance by their family or community due to stigma or fear. This can make an already challenging situation far more difficult. If possible, staying connected with your loved ones including through digital methods is one way to maintain contact. Turn to your colleagues, your manager or other trusted persons for social support- your colleagues may be having similar experiences to you.
10. Use understandable ways to share messages with people with intellectual, cognitive and psychosocial disabilities. Forms of communication that do not rely solely on written information should be utilized If you are a team leader or manager in a health facility.
11. Know how to provide support to, for people who are affected with COVID-19 and know how to link them with available resources. This is especially important for those who require mental health and psychosocial support. The stigma associated with mental health problems may cause reluctance to seek support for both COVID-19 and mental health conditions. The mhGAP Humanitarian Intervention Guide includes clinical guidance for addressing priority mental health conditions and is designed for use by general health workers.

Team leaders or managers in health facility
12. Keeping all staff protected from chronic stress and poor mental health during this response means that they will have a better capacity to fulfil their roles. Be sure to keep in mind that the current situation will not go away overnight and you should focus on longer term occupational capacity rather than repeated short-term crisis responses.
13. Ensure good quality communication and accurate information updates are provided to all staff. Rotate workers from higher-stress to lower-stress functions. Partner inexperienced workers with their more experienced colleagues. The buddy system helps to provide support, monitor stress and reinforce safety procedures. Ensure that outreach personnel enter the community in pairs. Initiate, encourage and monitor work breaks. Implement flexible schedules for workers who are directly impacted or have a family member impacted by a stressful event. Ensure you build in time for colleagues to provide social support to each other.
14. If you are a team leader or manager in a health facility, facilitate access to, and ensure staff are aware of where they can access mental health and psychosocial support services. Managers and team leaders are also facing similar stressors as their staff, and potentially additional pressure in the level of responsibility of their role. It is important that the above provisions and strategies are in place for both workers and managers, and that managers can be a role-model of self-care strategies to mitigate stress.
15. Orient responders, including nurses, ambulance drivers, volunteers, case identifiers, teachers and community leaders and workers in quarantine sites, on how to provide basic emotional and practical support to affected people using psychological first aid
16. Manage urgent mental health and neurological complaints (e.g. delirium, psychosis, severe anxiety or depression) within emergency or general health care facilities. Appropriate trained and qualified staff may need to be deployed to these locations when time permits, general health care staff capacity in mental health and psychosocial support should be increased (see mhGAP Humanitarian Intervention Guide)
17. Ensure availability of essential, generic psychotropic medications at all levels of health care. People living with long-term mental health conditions or epileptic seizures will need uninterrupted access to their medication, and sudden discontinuation should be avoided.

Care providers for children
18. Help children find positive ways to express feelings such as fear and sadness. Every child has their own way to express emotions. Sometimes engaging in a creative activity, such as playing, and drawing can facilitate this process. Children feel relieved if they can express and communicate their feelings in a safe and supportive environment.
19. Keep children close to their parents and family, if considered safe for the child, and avoid separating children and their caregivers as much as possible. If a child needs to be separated from their primary caregiver, ensure that appropriate alternative care is provided and that a social worker, or equivalent, will regularly follow up on the child. Further, ensure that during periods of separation, regular contact with parents and caregivers is maintained, such as twice-daily scheduled phone or video calls or other age-appropriate communication (e.g., social media depending on the age of the child).
20. Maintain familiar routines in daily life as much as possible, or create new routines, especially if children must stay at home. Provide engaging age appropriate activities for children, including activities for their learning. As much as possible, encourage children to continue to play and socialize with others, even if only within the family when advised to restrict social contract.
21. During times of stress and crisis, it is common for children to seek more attachment and be more demanding on parents. Discuss COVID-19 with your children using honest and age-appropriate way. If your children have concerns, addressing those together may ease their anxiety. Children will observe adults’ behaviors and emotions for cues on how to manage their own emotions during difficult times. Additional advice available here
Older adults, care providers and people with underlying health conditions
22. Older adults, especially in isolation and those with cognitive decline/dementia, may become more anxious, angry, stressed, agitated, and withdrawn during the outbreak/while in quarantine. Provide practical and emotional support through informal networks (families) and health professionals.
23. Share simple facts about what is going on and give clear information about how to reduce risk of infection in words older people with/without cognitive impairment can understand. Repeat the information whenever necessary. Instructions need to be communicated in a clear, concise, respectful and patient way. It may also be helpful for information to be displayed in writing or pictures. Engage their family and other support networks in providing information and helping them practice prevention measures (e.g. handwashing etc.)
24. If you have an underlying health condition, make sure to have access to any medications that you are currently using. Activate your social contacts to provide you with assistance, if needed.
25. Be prepared and know in advance where and how to get practical help if needed, like calling a Taxi, having food delivered and requesting medical care. Make sure you have up to 2 weeks of all your regular medicines that you may require.
26. Learn simple daily physical exercises to perform at home, in quarantine or isolation to maintain mobility and reduce boredom.
27. Keep regular routines and schedules as much as possible or help create new ones in a new environment, including regular exercising, cleaning, daily chores, singing, painting or other activities. Help others, through peer support, neighbor checking, and childcare for medical personnel restricted in hospitals fighting against COVID-19 when safe to do so. in accordance with previous ones. Keep regular contact with loved ones (e.g. via phone or other accesses).

People in isolation
28. Stay connected and maintain your social networks. Even when isolated, try as much as possible to keep your personal daily routines or create new routines. If health authorities have recommended limiting your physical social contact to contain the outbreak, you can stay connected via e-mail, social media, video conference and telephone.
29. During times of stress, pay attention to your own needs and feelings. Engage in healthy activities that you enjoy and find relaxing. Exercise regularly, keep regular sleep routines and eat healthy food. Keep things in perspective. Public health agencies and experts in all countries are working on the outbreak to ensure the availability of the best care to those affected.
30. A near-constant stream of news reports about an outbreak can cause anyone to feel anxious or distressed. Seek information updates and practical guidance at specific times during the day from health professionals and WHO website and avoid listening to or following rumors that make you feel uncomfortable.