COVID-19: Successful management strategies worldwide
Paul
SIX months after the initial reports of the COVID-19 outbreak from China, the SARS-COV2 virus has been reported in most countries worldwide.
Most governments have responded with measures aimed at preventing disease spread, morbidity, and mortality in their respective countries. The results of the control measures have differed greatly but have generally been accompanied by severe economic dislocation in most countries. As countries try to move beyond purely managing COVID-19 disease and trying to resume economic activity, we will identify some of the factors which successful countries have employed.
WINNERS AND LOSERS
Several countries have done well in controlling the spread of the SARS-COV-2 virus, and as a result have had relatively low levels of infection and death. We in the Caribbean should take a victory lap as new COVID-19 infections have been either in the single digits or lower for most of our nations. The middle- and high-income countries of Asia do appear as a region to be doing relatively well in containing the pandemic. Countries such as Thailand have had new cases in the low single digits for several weeks; other countries in the region have new cases that are in the range of 10’s to hundreds of new cases daily which is relatively low when population sizes of tens of millions are considered.
The Oceana region including Australia and New Zealand is another in which the spread of the SARS-COV-2 virus seems to be well controlled.
The European continent had an explosive outbreak early on, particularly in Spain and Italy, but have displayed significant improvement over the past few weeks with falling death rates and rates of new infections.
China has also been doing well, although with some worrying clusters located in Beijing, which has required areas of lockdown and quarantine. Many African countries have also done significantly better that predictive models suggested, and this may be related to prior experience in fighting periodic infectious epidemics like Ebola and Lassa Fever.
The United States of America, Brazil, India, and Russia have been experiencing rapid growth in patient numbers, hospitalisation, and deaths suggesting continued community spread in these nations. South America, the Middle East, and other Asian countries are other areas of continuing spread and increasing impact from the pandemic.
WHAT FACTORS DETERMINE OUTCOMES FOR NATIONS?
There are several factors that appear to play a prominent role in the differing outcomes in various nations.
An important issue appears to be a strong coordinated health care response. Many of the successful countries have been able to organise a country-wide response, where testing strategies, social distancing polices, human and health care resources are developed and applied with variations as needed for peculiar local conditions. This coordination may be born of experience, particularly in the Asian continent where several recent respiratory viral epidemics have occurred over the past two decades (SARS, H5N1). This experience with rapidly spreading infectious epidemics has led to improvements in public health infrastructure, including surveillance methods, public education, contact tracing, and policies for country response. The United States and Brazil are two countries in which health care is delivered autonomously at State and local levels thus hampering efforts at a unified national response or guidelines. These countries have had difficulties with a coordinated federal response.
A unified and centrally coordinated public health and governmental preparedness and response result in the ability to mount an early and aggressive response to prevent the entry of and limit the spread of the SARS-COV-2 virus. Such a coordinated national response has proven useful for centrally run national health systems as evident in many small countries in the Caribbean including Jamaica.
Measures such as testing and contact tracing are most useful early in the course of the disease spread, when identification and quarantine of infected people can stop the epidemic. Closing borders in this context can be an effective strategy for island nations. It is in this area that Caribbean island nations, including Jamaica, have performed admirably, demonstrating the effectiveness of our public health systems despite manpower and resource limitations not seen in more developed nations.
Border closure as we have experienced does have significant negative impacts for tourism and trade-dependent economies, as well as human costs for families who have members living in other countries. However, for island nations for whom the only method of entry of the SARSCOV-2 virus is by infected travellers it is an important method of control.
An early and aggressive response to the COVID-19 epidemic has taken different forms in various countries. In China, where the COVID-19 epidemic originated, a quarantine was imposed in the city of Wuhan. People were not allowed in or out of the city. Infected individuals were removed from their homes and kept in quarantine facilities until they tested negative. Doubtless, these measures would not be possible in most other countries. However, this did provide a relatively rapid control of the disease. Other countries used less aggressive methods requiring home, hotel, or hospital quarantine, depending on a variety of factors. It does seem clear that the ability to keep infected people away from the general population can be important in limiting disease spread. Jamaica has clearly adopted a creative controlled re-entry programme with the innovative JAMCOVID app and the structured re-entry process that ensures protection of both the travellers and the community.
In a similar vein, the use of social distancing was also important. Given that the predominant method of spread is person to person, not being in contact with others outside your household is effective in disease control. Most countries practised social distancing in which people were encouraged to stay at home. The severity and enforcement varied from country to country. In many countries, most non-essential businesses and activities were ordered to close.
In Italy and Dubai, during the epidemic peak, people were only allowed to leave home for shopping or medical care. Other countries such as England and the United States allowed exceptions for exercise. It does appear that countries that started social distancing early and maintained this policy until community spread stopped had better results than other countries. The experience of Sweden when compared to its Northern European neighbours being a case in point. The United States experience would suggest that prematurely stopping social distancing in the presence of continued community spread may lead to a rebound in SARS-COV-2 spread, particularly if people place themselves in high-risk, crowded situations, such as beaches or bars. This is also compounded by mixed messages from political and civic leaders that create confusion and doubts in the minds of citizens with respect to proven and effective prevention strategies.
Effective testing has emerged as an important issue. The ability to test symptomatic people with possible COVID-19 disease or asymptomatic people, who may have been exposed, facilitates the segregation of infected individuals from the general population, thus lowering the chances of continued disease spread. It appears countries such as South Korea and Germany did well from this point of view. The late development of testing infrastructure or the inability to develop this due to resource constraints poses a significant problem for control of disease spread. Knowledge of where clusters of infections are located and the rate of increase of COVID-19 cases remain critical for disease control.
The rate of use of masks does appear to decrease the risk of spread of the SARS-COV-2 virus. The reasons for using masks are based on the mechanism of disease spread. We do not currently have (nor are likely to have) randomised control trials looking at this issue. However, studies have demonstrated efficacy in mask usage in preventing the passage of virus particles at various levels of efficacy, depending on the type of material used. Epidemiologic evidence suggests that regions with high rates of mask usage such as South East Asia appear to do better.
HOW DO SOCIO-ECONOMIC AND CULTURAL FACTORS AFFECT RESPONSE?
The last issue that we shall consider are social, economic, health, and cultural factors. The baseline socio-economic factors do play a role in the difficultly of controlling SARSCOV-2 virus spread. Countries that have a large proportion of the population who are at social or economic disadvantage will have greater challenges. These people often live in small multigenerational homes where crowding is almost universally present. They often do not have the luxury of remaining home during an epidemic as they depend on daily income for continued existence. Similar crowded conditions are noted in expatriate worker housing in countries in the Middle East or migrant worker housing in the United States and Canada.
Baseline health characteristics of the population are also important. Countries with populations with high rates of co-morbidities and poor population health will have greater challenges. Lastly, culture is an important factor. An example is that of mask-wearing which is more of a cultural norm in the Asian continent, but which seems to be a political statement in much of the United States. Finally, the United States experience has been significantly complicated by the politicisation of the pandemic and the demonisation of science by some politicians to the detriment of population health.
WHAT LESSONS HAVE WE LEARNED?
There have been different levels of success among different countries. What lessons can we take for our country? First, we must continue to build upon the successes that we have achieved. Our public health systems have performed relatively well despite resource constraints;efforts at contact tracing and disease surveillance will need to continue. As a more normal life resumes and we welcome back visitors and returning residents to our shores, continued vigilance remains extremely important. We should continue to practise hand-washing, mask-wearing, and to social and physical distancing as far as is practical.
Dr Ernest Madu, MD, FACC; and Paul Edwards, MD, FACC are consultant cardiologists at the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. Correspondence to emadu@caribbeanheart.com or call 876-906-2107