[This article has been written by Carlos Chaccour and Adelaida Sarukhan, in collaboration with Joe Brew and Pau Rubio]
Over the last weeks, the COVID19 epidemic has become a pandemic, spreading outside of China and causing a worryingly large —and growing— number of cases and deaths in several countries in Asia, the Middle East, the US, and Europe (particularly Italy and Spain).
This is resulting in striking differences in the epidemiological curve unfolding in each country, as well as on the societal and economic costs of the response.
Although many biological, clinical and epidemiological uncertainties remain with regards to this new virus, what is already clear is that each country has responded —or is responding— to the same threat with different measures and/or with different timing. Just as clearly this is resulting in striking differences in the epidemiological curve unfolding in each country, as well as on the societal and economic costs of the response.
China: Early Lockdown and Forced Quarantine
As the place where the epidemic originated and the country with the highest number of cases (over 80,000 cases and 3,213 deaths for the moment), all eyes initially were focused on China and its unprecedented public health response: it promptly forced a lockdown on Hubei province, (on January 24, around three weeks after realizing that it was dealing with a new disease), placing 60 million people in forced quarantine; it restricted inter- and intra-city movement; it imposed severe restrictions on hundreds of millions of citizens, enforced through the use of health QR codes on mobile phones; it performed building and street sterilizations several times daily; it isolated all suspected cases in facilities; and it increased its bed capacity to over 50,000 beds in order to test, admit and treat all patients.
The results of these early and drastic measures are already visible. They helped delay the spread of the virus from Hubei to other provinces, which have experienced a much “flatter” epidemiological curve. Currently, less than two months after the lockdown, China is reporting 20 new cases per day, instead of the 4,000 cases per day reported at the peak of the epidemic. This radical approach had the advantage of enforcing cooperation and quickly reducing pressure on the health system. These measures, however, have high economic and societal costs related to the isolation of all positive cases in facilities and the severe restriction of individual freedom of movement. Furthermore, they require detailed and up-to-date population data and strong data management capacities, neither of which may be available in many other countries. It is still not clear what will occur once restrictions are lifted and normal activities resume, or if it will be necessary to impose multiple lockdowns should subsequent outbreaks occur.
South Korea: Trace, Test and Treat
South Korea, which has also managed to bend the epidemiological curve despite having reached a high number of cases (over 8,000), has used a quick, transparent and pre-emptive approach. In contrast to China, it did not implement lockdowns or restrictions to movement and no travel bans were enforced, only “special immigration procedures”. Its strategy has relied on active, free and massive screening (including drive-through tests) for symptomatic individuals, case contacts or travellers (up to 15,000 tests per day, with over 250,000 tests performed by March 13). Masks and hand sanitizer were used massively, and social distancing measures (school closures, teleworking and no large gatherings) were implemented. Clinical beds were only offered to those in need, while those with mild symptoms were sent home. Last but not least, daily television messages and government briefings provided timely information to the population, while a website and automated SMS to inform about potential contact with infected individuals. Such measures have succeeded in reducing the daily number of cases from 600 on March 3 to 130 one week later. By March 13, the number of recovered patients exceeded the number of new cases.
One major advantage of this strategy is that it provides mass data for cluster identification, facilitates rapid self-quarantine, and increases the denominator (number of cases), hence reducing the estimated case fatality rate. Overall, it seems to have reduced the societal and economic impact across early and late stages of the epidemic. However, cultural traits inherent to Korean society likely made a major contribution to this achievement, and sustaining such an approach outside of South Korea could be problematic.
Italy and Spain: Less Restrictive Lockdowns
The measures in Italy and in Spain have been somewhat mixed. Containment measures (contact and cluster tracing) were not sufficient, leading to an escalation of restrictive measures aimed at mitigating the epidemic and “flattening the curve”. Massive gatherings have been prohibited, schools have closed, only some work can be done outside of the home, and travel has been partly restricted. Unlike China and South Korea, Spain has not used tracing technology as of March 17. The curve may just be starting to bend in Italy, where a first lockdown of the Northern provinces was announced on March 7, followed shortly by a national lockdown. This was more than one month after the first cases were reported on January 29, although the virus is thought to have circulated since mid-January. It is still too early to start seeing an impact of the lockdown in Spain, which started on March 14 (a month and a half after the first cases were detected in the Canary Islands) – it takes five to seven days (the median incubation time) to start seeing an effect on the number of cases and about 14 to 20 days to start seeing an effect on deaths.
This milder and stepwise response may have delayed the economic impact at the early stage of the epidemic while promoting cooperation with law enforcement. However, it has also led to the overloading of the health systems as shown by mortality rates that are higher than those in China and South Korea. Furthermore, restricted testing will lead to overestimates of case fatality rates and limit the value of available epidemiological information. How long these lockdowns can be maintained, and how a second peak of cases will be prevented once they are lifted, remain open questions.
United Kingdom: Contain, Delay, Research, Mitigate
The United Kingdom is implementing an approach based on a continuum across these four stages, whereby specific measures are more or less emphasised according to the situation. Schools have remained open as of this writing, with the rationale being that children usually have milder disease. Restrictive measures have been announced one-and-a-half months after the first cases were reported, but they target only the most vulnerable: the elderly and individuals with comorbidities may need to remain confined for up to four months. This strategy also assumes that some deaths will be inevitable, and bets on the build-up of herd immunity to avoid a second winter peak later in 2020.
The advantage is that the delayed restrictions may flatten the societal and economic costs, and authorities have postulated that the containment measures could buy time to improve health system capacity. However, this strategy requires an almost surgical precision for implementing or removing restrictive measures, which may not be feasible, and also requires a high degree of public cooperation. Otherwise, the risk of overloading health services and of experiencing a spike in deaths among the most susceptible is high. The strategy also relies on the development of protective immunity among all infected individuals, whether they have developed symptoms or not, which is a great unknown at the moment.
South Africa, Ghana, Kenya, Botswana: Strong Border Protection
Several countries in Africa are betting on containing the virus by strengthening their borders, restricting flights based on origin and flight path, denying visas based on the nationality of applicants, and asking foreigners to self-quarantine for 14 days. Schools and universities are closed, mass gatherings are prohibited, and anyone with symptoms is referred to the hospital. As in many other countries, mass use of hand sanitizer in public spaces and cashless payment are being encouraged.
These measures can be effective at the very early stages of the epidemic with limited societal and economic costs. However, they might turn out to be counterproductive if they push the peak of the epidemic into the austral winter (in the case of countries in the Southern hemisphere) and if they affect trade, which can indirectly increase deaths. They might also foster discrimination against foreigners, which in turn might undermine the efforts of foreign organisations and personnel to carry out relief work. It is still not clear whether the higher temperatures and younger populations may help decrease the spread and impact of the epidemic in Africa.
Each country must adapt its response according to its health system capacities, its economic resources and infrastructure, and the degree of individual and collective responsibility
In conclusion, there is not a single “one-size-fits-all” approach that allows to respond effectively to the ongoing and rapidly evolving situation. Each country needs to tailor its response in accordance with the capacities of its health systems, its economic resources and infrastructure, and the degree of collective and individual responsibility and compliance with recommendations issued by the authorities. The next generation of health professionals will look back at the different responses to COVID-19 described above and hopefully draw lessons for future infectious disease epidemics.
Photo by Adli Wahid on Unsplash