It is well recognised that travel can facilitate the spread of a virus and this has been previously identified during the emergence of SARS-CoV and MERS-CoV . Whilst local public health authorities and health care providers play the major role in combatting the evolution of a viral outbreak, the role delineation of International Medical Assistance companies is such that they also are involved in dealing with scenarios such as the current Public Health Emergency of International Concern declared by the WHO on 30 January 2020.
The role of International Medical Assistance companies is to assist travellers who have become sick/injured during their travels with a principal focus of ensuring that they are capable of receiving appropriate medical care at their current location. Importantly, if their needs exceed the local capabilities they coordinate and provide medical evacuation to the nearest centre of medical excellence [2,3].
Allianz Partners Medical Operations are present in 25 countries and assist 76 nationalities. Our first reported cases came from our Chinese Business Unit on 23 January 2020, with notification of several Chinese citizens becoming ill in Canada, Thailand, Australia and the USA. This was followed by our Canadian colleagues reporting cases of Canadian patients being identified in China and then progressively we received reports of patients from multiple nationalities and in multiple countries as the weeks progressed.
As of March 5, 74 suspect cases have been reported across our network. Of these, 21 have been confirmed positive for SARS-CoV-2 with 13 cured. Of the remainder, 46 have been ruled out as infected with SARS-CoV-2 and the remaining seven are still under investigation. The 21 confirmed cases were located in China, Japan, Malaysia, Thailand, Sri Lanka, Australia and the USA (Fig. 1). One was deemed critically ill. None died.
As several business units were involved and the situation was expected to continue developing over many weeks to months, Group Medical Operations (International Head Quarter in Paris) launched « MedCrisis », Allianz Partners proactive and comprehensive emergency operations plan designed to respond to potential or actual calamitous events. ‘MedCrisis’ is designed to support local health providers, help facilitate the optimisation of appropriate medical responses and initiate the early repatriation of patients in scenarios where an incident can overwhelm local resources. Every potential case worldwide has been reported to the ‘Medcrisis’ Team in Global Office which has closely monitored each of these until they have been considered as cured for patients positive for SARS-CoV-2 or until COVID-19 has been definitively ruled out.
The nature of this emerging coronavirus has meant a somewhat different principle was required in developing our strategy for the management of these cases. Because of the global imperative to interrupt human to human transmission and to decrease the spread of the disease, local authorities around the world have responded with varying levels of border closures and travel restrictions. This has left very little latitude for any medical repatriation and cross-border movement out of high-risk areas or in high-risk patients until the patient can either be considered not contagious or cured if previously positive for SARS-CoV-2. However, aligned with our mission to ensure that our patients receive appropriate care, exceptions to this new paradigm of limiting repatriation may still be required in situations where local facilities have exceptionally limited capacity or lack suitable medical resources and expertise to treat a specific and in particular life- or limb-threatening condition. In such circumstances, the patient would need to be medically evacuated using accredited Air Ambulance providers and employing appropriate isolation measures during transport. The threshold for undertaking such repatriation is inevitably now much higher than our usual baseline norm. This would require significant levels of coordination between our medical teams, our air ambulance providers and in particular local government authorities in the departing and receiving countries.
The « MedCrisis » standardised operating processes have already shown their effectiveness in previous mass patient events and the validity of this emergency operations plan is regularly challenged through debriefs after each activation as well as tested through regular emergency response exercises . Nevertheless, its core principal will always be the return of victims to their country of origin as early as possible after a calamitous event. This is because such events cause significant emotional distress for both patients and their families and even in countries with high-quality medical capabilities can quickly overwhelm local medical resources. For COVID-19 the key strategy of Public Health Authorities has been and continues at the time of writing to be containment, and as such we foresee having to deal with the medical, psychological and social aspects of this new repatriation paradigm for some time yet.
It should be noted that International Medical Assistance companies have significant expertise in regards to issues such as the spread of infectious agents, especially multidrug-resistant bacteria, during international inter-hospital air transport . They have also had significant experience in the management of emerging novel coronaviruses such as SARS-COV and MERS-CoV. They are well placed during an epidemic/pandemic to liaise with local health care providers and public health authorities, with patients and their families and with other levels of Government as well as being able to monitor new developments and updates from the WHO and other government and non-government organisations in relation to global objectives, case definitions, containment rules and travel restrictions. This requires constant adjustment of our emergency operations processes and plans as well as comprehensive, clear and daily communication with our teams across the world and our many related stakeholders.
Finally, it should be remembered that our usual non-COVID-19 operations continue with large numbers of patients getting sick/injured on a daily basis across every continent on the globe. Many of these patients would normally be transferred home after an initial period of stabilisation locally and many would continue their treatment in their home country. The majority would normally be able to return home on commercial flights with appropriate levels of support in place. Current constraints mean that patients in areas considered at high risk of SARS-CoV-2 transmission may find themselves unable to leave quarantine zones. It should also be noted that hospitals across the world are gearing up to manage an expected influx of COVID-19 cases and if true pandemic levels are reached, availability of hospital beds may become a critical issue.
In conclusion, the nature of international medical assistance is that we have to deal with expensive and complicated logistics but more importantly we have to manage medical risk for each patient with the intent of ensuring an optimal medical outcome. To achieve this our teams require very specific skills which include extensive knowledge of the international medical environment, experience in retrieval medicine, critical care and travel medicine as well as an understanding of the principles of aviation medicine and a capacity to navigate the interface between geopolitics and medicine. Whilst SARS-CoV-2 is a new virus this is not a new challenge.
Conflicts of interest
There are no conflicts of interest.
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