Scepticemia

Lessons from International Efforts to Control COVID-19

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Disclaimer: This post represents my personal opinion. This does not represent the opinion or policy position of my employer or any organization or agency or group that I am affiliated with.

China:

The principal mitigation strategy in China has been unprecedented degrees of lockdown between and within Chinese metropolitan cities. At one point of time, almost half the country was under some degree of restriction of movement, with around 50 million people experiencing severe restrictions. Mathematical modeling has shown that the median daily reproduction number declined from 2.35 (95% CI: 1.15-4.77) one week before travel restrictions were introduced on 23rd January to 1.05 (95% CI: 0.413-2.39) one week after.[1]

While it is being postulated that if China had better testing data, and a more accurate sense of the progress of the epidemic, such measures could have been placed earlier, enabling better control. However, it remains to be noted that the stringent measures adopted by China may not be implementable in many other countries. It is also unclear as to the long-term impact of such stringent control measures. Whether there is an asymptomatic reservoir of the virus, which spurs a subsequent rise in cases, once the restrictions are lifted, needs to be seen.

Hong Kong:

Contiguous with China, Hong Kong contributed a major chunk to the deaths and casualties in the wake of the 2003 SARS outbreak. Hong Kong initiated port-of-entry screening in late January, when the world was waking up to the COVID-19 outbreak. The SARS response in 2003-2004 prepared Hong Kong to invest in infrastructure and policy responses to outbreaks across the country. Hong Kong initiated early travel restrictions but since it shares a border with China, it focused more intensely on preventing community transmission of illness and case management. The country managed to leverage 40,000 beds, with around 1,000 of them having negative pressure beds.

Based on its recent brushes with an upsurge in cases of influenza, Hong Kong also considered the option shutting down schools. This has been previously administered, with some degree of success.[2]

Taiwan:

Taiwan’s central command center for epidemics, constituted following the 2003 SARS outbreak, listed a 124-item action agenda, which included items like border controls, school and work policies, public communication plans and resource assessments of hospitals.[3] Taiwan also mobilized a US$2 bn bursary to support businesses adversely affected by the epidemic. Taiwan initiated port-of-entry screening as early as January 5, 2020.Taiwan, a nation with a population of approximately 25 million people, managed to bring together a central stockpile of 44 million surgical masks, 1.9 million N95 masks, and 1100 negative-pressure isolation rooms by January 20, a time when most countries were not even cognizant of the risk posed by COVID-19. On January 29, Taiwan initiated electronic monitoring of quarantined individuals via government-issued cell phones. Punitive measures (fines of US$10,000) set up and implemented against offenders breaching home quarantine. Subsidies, financial assistance to furloughed workers, and additional PPEs provided to families which have been financially affected by COVID-19.

Taiwan’s prompt response can be tied to the years and years of investment made in preparedness and dangerous pathogen outbreak response. Customizable microplans, action item lists, and time-bound policy action packages have been developed beforehand so that they may be adopted and used in times of outbreak containment. However, the challenge in most countries, irrespective of their LMIC-status, is to develop, deploy and sustain comprehensive systems. A legacy of the 2003 SARS epidemic, the responsive public health system has managed to protect Taiwan from a tougher outcome with COVID-19.

Singapore:

In mid-February, Singapore featured prominently in the tally of cases outside mainland China, with over 80 cases. However, this was ascribed to the sensitive surveillance system in place in Singapore, which has a 2.5 times higher ability to detect cases than the global standard.[4] This has been combined with a very active contact tracing and quarantine program, which offers additional quarantining sustenance (equivalent to US$73 per day) to protect self-employed and small businesses. Additionally, Singapore has ensured that there is no cost associated with testing and management of COVID-19, to spare the financial burden on the country.

In Singapore, the authoritarian approach to ensure social distancing has been possible owing to the unique political and legislative structure of the country. Such an extent of government control may not be feasible in many countries with democratically elected governments. One key moment of leadership has emerged in Singapore, when the Prime Minister appeared on mass media to deliver an address to quell public anxiety. This address took place in the aftermath of panic purchase of groceries, and led to immediate effects as such hoarding behavior was seen to abate immediately.

United Kingdom:

Initially, the UK strategy was to cocoon the elderly people at a higher risk of contracting severed COVID-19, whilst allowing the disease to spread in a controlled manner, allowing “herd immunity” to emerge, and thus stunt the putative second peak in the fall and winter later this year. This controversial action plan was met with a lot of indignation and models suggested that even if the strategy proceeded exactly as planned, at the peak of the epidemic in UK, 8,610 people aged 20-40 years would need ICU beds, which is more than twice the number of ICU beds (4,100) available across the UK.[5] In addition, other modeling efforts have shown that in an unmitigated epidemic, there would be at least 510,000 deaths, in addition to the overwhelming of the existing healthcare facilities due to the rising needs for ICUs and ventilators.[6] The existing ICU capacity would be overwhelmed by early April, and at the peak of the epidemic, the needs could rise to as high as 30 times the existing capacity.[6] The initial UK policy was also countered by estimates noting that even after the subsidence of the epidemic in Wuhan, China, almost 95% of the population was not infected with COVID-19, a condition which would render the herd immunity theory moot.[1]

In the face of growing concern about this controversial approach, the UK government recent changed tack, and started emphasizing on the need for self-isolation, social distancing, and prevention of mass gatherings. UK has also ramped up testing for COVID-19 to detect and isolate cases, identify and follow up contacts, and initiate management for symptomatic patients.

UK had the benefit of a delayed onset of the COVID-19 epidemic, which was frittered away by a controversial policy stance. However, with cases still remaining low, the UK has now started to focus on messages of social distancing and other containment principles which are being followed globally.

United States:

The US was also slow off the blocks to acknowledge the threat posed by the COVID-19 situation. Initially, testing was being done using limited, quality assured testing kits, under the control of the CDC, but this has since been expanded. The case count remained low for a long time, since not enough tests were being conducted, and once the states and private institutions were authorized to conduct their own testing, more and more cases began to emerge. This resulted in the declaration of emergency against COVID-19 in many states. Subsequently, this was also declared as a national emergency, and the messaging related to social distancing was significantly ramped up.

However, once the decision to make a concerted policy response to mitigate the COVID-19 threat in the US was taken, immediate steps were taken. Congress approved over US$8 bn in a COVID-19 response package, focusing on funding the interventions needed to prevent, detect, control, treat and contain the virus.[7]

The ambivalent policy making steps in the initial days of the COVID-19 threat, along with the reinforcement of the perception that the disease threat was not a major issue has delayed the policy response from the US. This delay is likely to result into additional cases in the thousands, and massive losses in terms of economic impairment.

South Korea:

At one point, after China, the epidemic had its deepest roots in South Korea. However, a concerted effort was initiated, including massive roll out of testing facilities, with almost 10,000 people being tested every day at the height of the epidemic. South Korea conducted over 250,000 tests, and had stringent measures on isolation and quarantine in place for the test positive individuals and their contacts. The government injected US$25 billion into supporting measures to contain the epidemic.

The South Korea model represents, aside from the Chinese model of state-sanctioned restrictions on a grand scale, the only other strategy which can be studied over a period of time ultimately culminating into decline of the epidemic. Compared to China and South Korea, where the epidemic is declining every day, most other countries are either in exponential or pre-exponential phase of the growth of the epidemic.

South Korea not only ramped up testing and response activities, but also focused on improving the volume of clinical services made available to manage the severe cases. The immediate and transparent response to COVID-19, based on testing-generated evidence, was transformative. For many LMICs, it would be difficult to generate the resources needed to successfully implement the South Korea strategy. It appears that the US is now adopting their strategy for testing as much of the at risk groups as possible, and the Director General of WHO has also stressed on the need to make testing the foundation stone of an evidence based response to COVID-19.

Sweden:

The Swedish government has endorsed and enforced the social distancing message, especially for people at risk, such as those with a recent history of foreign travel. Self-deferral and self-quarantine by the individuals, at their homes, has also been successfully undertaken. This degree of self-determination is perhaps difficult to expect in nations with less efficient social support systems in place. Testing has been limited to the vulnerable groups, in need of hospitalization and tertiary care.

The Swedish government has earmarked an additional SEK 41 million for the Public Health Agency of Sweden, and SEK 20 million for the National Board of Health and Welfare. Appropriations for sick pay, quarantine allowance, and other social support systems have also been made to ensure that the COVID-19 response does not add to the economic pressure on the people.

Germany, France & Spain:

With the decline of new cases in China and South Korea, the epicenter of the COVID-19 pandemic has now shifted to Europe. In Europe, there are two groups of policy approaches, broadly speaking. The first is in the countries like Germany, France and Spain, where a significant number of cases have emerged, but the national governments have mobilized dedicated resources to contain and mitigate the threat. In the second group are countries like Italy, where the epidemic has raged on, unaddressed, and now significant restrictive steps are being taken, like closure of international borders, restrictions on trade and traffic, and other coercive measures to enforce social distancing and cut down on infection transmission.

Germany, France and Spain have all advocated for stringent measures of social distancing, including closure of international borders, shutting down of schools and malls, and limiting individual freedom of movement. Government resources are also being kicked in to support the small businesses and individuals who need financial sustenance while the social distancing is being implemented.

The whole strategy is backed up by extensive availability, accessibility and affordability of testing, to ensure that whoever is at risk, can get tested.

Summary

There have been broadly three approaches to managing the COVID-19 threat. First, social distancing, with or without widespread testing and response; second, coercive and state mandated quarantine and isolation, including border lock down, and shut down of domestic mobility; and third, self-deferral for testing and isolation, supported by direct transfer of benefits or provision of sustenance.

Many countries have responded to the emergent threat very slowly, resulting in subsequent explosive growth of the epidemic. In the US, the epidemic is doubling every 4 days now. The long initial tail of the case counts is followed by an explosive rise in the number of cases, which may end up overwhelming the available healthcare facilities in country.

Coordinated policy response, identifying which pathway works best, and if needed, adopting a blended strategy could also be explored as potential policy responses.

References:

1. Kucharski AJ, Russell TW, Diamond C, et al. Early dynamics of transmission and control of COVID-19: a mathematical modelling study. Medrxiv 2020;:1–12. doi:10.1101/2020.01.31.20019901
2. Ali ST, Cowling BJ, Lau EHY, et al. Mitigation of influenza B epidemic with S school closures, Hong Kong, 2018. Emerg Infect Dis 2018;24:2071–3. doi:10.3201/eid2411.180612
3. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan. JAMA Published Online First: 2020. doi:10.1001/jama.2020.3151
4. Niehus R, Salazar PM De, Taylor A, et al. Quantifying bias of COVID-19 prevalence and severity estimates in Wuhan, China that depend on reported cases in international travelers. medRxiv 2020;:2020.02.13.20022707. doi:10.1101/2020.02.13.20022707
5. Jenkins HE, Leavitt S V, Bushman ME, et al. The direction of the UK government strategy on the COVID-19 pandemic must change immediately to prevent catastrophe. PrePrint. 2020;:1–3.https://www.dropbox.com/s/d5jqdmsxgwrjz6v/ICU_beds.pdf (accessed 19 Mar 2020).
6. Ferguson NM, Laydon D, Nedjati-Gilani G, et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. doi:10.25561/77482
7. World Health Organization. COVID-19 Strategic Preparedness and Response Plan: Operational planning guidelines to support country preparedness and response. Geneva: 2020. https://www.who.int/docs/default-source/coronaviruse/covid-19-sprp-unct-guidelines.pdf (accessed 19 Mar 2020).

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