key: cord-298682-5heb9biz authors: Stephen, Shine; Issac, Alwin; Jacob, Jaison; Vijay, VR; Radhakrishnan, Rakesh Vadakkethil; Krishnan, Nadiya title: COVID-19: Weighing the Endeavors of Nations, with Time to Event Analysis date: 2020-08-17 journal: Osong Public Health Res Perspect DOI: 10.24171/j.phrp.2020.11.4.02 sha: doc_id: 298682 cord_uid: 5heb9biz The cataclysmic COVID-19 pandemic erupted silently causing colossal impact worldwide, the repercussions of which indicated a lackadaisical vigilance in preparation for such a pandemic. This review assessed the measures taken by nations to contain this pandemic. A literature review was conducted using Medline, Google Scholar, Science Direct, Scopus, and WHO website. There were 8 nations (selected from the GHS index list) appraised for containment strategies. This was achieved by using mortality rate (per million) as the primary endpoint. The nations which were proactive, initiated scientific strategies earlier with rigor, appeared to have succeeded in containing the pandemic, although it is still too early to arbitrate a verdict. The so called “pandemic war” mandates international, interdisciplinary, and interdepartmental collaboration. Furthermore, building trust and confidence between the government and the public, having transparent communication, information sharing, use of advanced research-technology, and plentiful resources are required in the fight against COVID-19. Corona Virus Disease-2019 (COVID-19) has spread to most nations. Migration, climate change, urbanization, and international mass displacement are some prevailing factors that are ideal for a virus to cause a pandemic [1] . The initial infection was reported in Wuhan, China in late 2019, and rapidly spread worldwide thereafter [2] . On March 11 th 2020, based on "alarming levels of spread and severity, and a worrisome level of inaction," COVID-19 was announced as a pandemic by the Director-General of World Health Organization (WHO) [3] . Screening, surveillance, quarantine, lockdown, testing, isolation, and treatment were the approaches adopted by most nations to contain the pandemic. Some nations prudently executed most of these approaches early, whereas, some nations precariously delayed implementation and the outcomes have been very discernible, although it may be too early to arbitrate the success of these strategies. implementation of lockdown, public relations, and restricted travel). Since mortality is a precise appraisal of the progression and outcome of a pandemic [4] , with which the management strategy of a nation can be evaluated, the death rate (per million population) was fixed as the primary endpoint for evaluating the outcome of measures taken by these 8 selected nations. According to the WHO, all individuals who had come in contact with a COVID-19 positive patient needed to be in quarantine for a fortnight (incubation period of COVID-19), starting from the last day they had contact with the patient [5] . Those infectious would be isolated (to curb further spread) and social distancing (more than 1 meter and no group gathering) norms would be followed. In the United States (US), a returnee from Wuhan tested positive for COVID-19 on January 20 th . A surge in the number of patients was observed initially due to the delay in commencement of COVID-19 testing [6] . Many of the testing kits developed by the US were reported to be erroneous [7] . On January 29 th , the White House coronavirus taskforce was set up to organize and oversee efforts to contain and palliate the spread of coronavirus in the US. Two days later, a public health emergency was declared, which barred entry to foreign nationals who had visited COVID-19 affected nations (China, Iran, United Kingdom, Ireland, or the 26 European countries) in the past 2 weeks. US nationals returning home after travelling through COVID-19 affected countries had to undergo a compulsory health screening and be quarantined for a fortnight. Non-essential travel to COVID-19 affected nations was banned, yet a nationwide lockdown was not imposed. A national emergency was announced on March 13 th [8] . By April 11 th , all public events were cancelled and schools were closed ( Figure 1 ). On January 31 st , the first case of COVID-19 was reported in York, England, in an infected Chinese national. As soon as the case was confirmed, a public health information campaign that resembled a previous "Catch it, Bin it, Kill it" campaign was initiated, to educate the public on reducing the risk of spreading the virus [9] . Public Health England (PHE) was slow to enact action. Though most countries focused on "containment policy," the UK was led by the scientists to believe in "herd immunity" and the control measures appeared not to be stringent enough. Schools were all shut down by March 20 th (Figure 1 ). The Coronavirus Act 2020 was enacted by government on March 19 th , which offered discretionary powers to the government in areas of schooling, health care organizations, border force, and courts. The UK was forced into lockdown on March 23 rd due to a drastic increase in the number of cases [9] . Australia reported its first case on January 25 th . On the 13 th February, the government barred entry of tourists arriving from mainland China, and advised returning residents to self-quarantine for a fortnight upon arrival, and warned that noncompliance would warrant a fine. On March 15 th the National Cabinet announced that gatherings of more than 500 people should be called off with exceptions for schools, universities, workplaces, and public transport [10] . This proved insufficient, and they expanded their testing to the vulnerable, health care workers, anyone exhibiting mild symptoms of COVID-19 and even asymptomatic cases [10] . A human bio-security emergency was declared on March 18 th owing to the hazard to human health caused by COVID-19, and stringent measures were imposed with the shutting down of non-essential services, urging vulnerable people to stay indoors, social distancing rule of 4 square meters per person in an enclosed space (which was later modified to include only 2 people who could meet in public places). People were permitted to go outdoor to purchase essential items, for medical or humane needs, exercising (in line with the limitation of 2 people meeting in public), and for job or educational activities. A mobile application (app) "COVIDSafe" that uses Bluetooth technology was developed to show contact between people when they come within 1.5 meters of each other [11] . The index case for Canada's COVID-19 epidemic was reported on January 27 th , in Toronto. A stringent border access ban was put in place and the Quarantine Act was invoked that warranted all persons (excluding essential workers) entering the country to self-isolate themselves for a fortnight, prohibited those with symptoms from using public transit, and barred self-isolation in settings where they may come in contact with vulnerable people [12] . Global Affairs Canada provided consular support to Canadians stranded in other countries affected by COVID-19 and numerous educational resources about coronavirus management were circulated amongst the public. International passenger flights were allowed to land only in 4 designated airports to ensure vigilant and coordinated screening of the passengers [13] . The government believed that broader testing was the key to reopening the country and thereby paced their testing capacity through an interim order. The Federal government activated their emergency operations center on January 15 th , and the Government's pandemic response was based on the Canadian pandemic influenza preparedness planning guidelines and the Federal/provincial/territorial public health response plan for biological events [14, 15] . On March 12 th the government ordered the shutdown of schools (Figure 1 ), bars, restaurants, cinema halls, non-essential businesses, and public gatherings; community transmissions were reported by mid-March, which forced the country to declare a state of emergency ( Figure 1 ) [13] . Canada, having a universal health care system, enabled the public health authorities to commandeer the hospital system. A smart-phone app that notifies the users if they have been in the proximity of a person who has tested positive for COVID-19, will be launched in July [13] . Even before Thailand reported their initial COVID-19 case, passengers from China were screened at the airports. Thailand was the first country to report a COVID-19 case outside China. On January 8 th , a Chinese tourist who had flown from Wuhan to Bangkok (Thailand) was identified using thermal surveillance and tested positive for COVID-19, 4 days later [16] . Owing to the nation's weaker economy, mass screening was not affordable and so contact tracing was initiated early. On January 23 rd , the government issued a decree barring all non-essential travel to China, and a curfew was imposed from 10 pm to 4 am. By mid-March all non-essential businesses were shut down along with schools, entertainment venues, and public gatherings were While the government declared a state of emergency, the fight against the pandemic was driven by public health authorities deploying a policy of prompting people to use face masks, hand sanitizers, practice social distancing, and staying at home. Visual and audio reminders were omnipresent in public places and shopping centers [17] . Culturally transmitted norms of personal hygiene, voluntary abidance to government recommendations, volunteers from hundreds of thousands of grass-root public health activists, and collaboration among the public health authorities, paved the way for their success at keeping COVID-19 transmission to a minimum [18] . By mid-June the country had resumed its normalcy, though preventive measures such as wearing a face mask, and social distancing were still being followed. Sweden is a prominent country in Europe that marked a On February 17 th , the government put a travel ban in place to Hubei province and advised against non-essential travel to grossly affected nations [19] . The public health agency of Sweden was entrusted to advise and monitor the action plan to contain virus spread. The primary aim was to curb the spread of COVID-19 to limit the demand on the health services, such that it didn't overwhelm the country's hospital capacity. General containment strategies were employed where social distancing was advised for vulnerable people especially the elderly, and people with respiratory illness were told to isolate. There was no nationwide lockdown in Sweden because the government was not eager to curb movement for their citizens. on January 20 th in South Korea [20] . Korea's response was 4-pronged: test, track, trace, and treat. Testing was not limited to symptomatic patients or those from the afflicted regions, even asymptomatic people were tested. Owing to the high proportion of cashless transactions, phone ownership rates, and density of surveillance technology, health officials retraced patient's movements using security camera footage, credit card records, and GPS data from their cars and cell phones [21] . A travel ban was imposed to affected countries, a partial lockdown in Daegu (the city which was affected the most), and shutdown of educational institutions were in place by February 19 th (Figure 1 ). Drive-through testing centers were functional by March 13 th . Soon after the virus was isolated in China, Korea Centers for Disease and Prevention (KCDC) produced testing kits (100,000 kits per day) and conducted 29,619 tests per million population (Figure 2) . A local surveillance team called in twice a day to ensure the traced person remained isolated, and even people with mild or no symptoms were isolated [22] . international travel bans long before their 100 th case. The initial transmission was rapid in the US and UK as it took less than 10 days to reach the national toll to 1,000 cases from the 100 th case, while other nations took nearly 2 months. Though it took less than 2 weeks for every nation to record the 1,000 th case from the 100 th case, Australia and South Korea required 115 days and 37 days to reach 10,000 tallies from the 1,000 th case, whereas Thailand and Finland have still not crossed the 10,000 mark, reflecting tightened reigns over the disease spread. and Severe Acute Respiratory Syndrome) has led the US not being prepared. Regardless of the availability of the virus genomic sequence from January 11 th , the US failed to produce enough testing kits. Rather, many of the available testing kits proved to be defective. There was no specific testing strategy, which might have led to many probable cases being missed. Insufficient supply of personal protective equipment for health care providers also worsened the situation. The assumption that only the aged and vulnerable population were at risk also proved to be fatal [27] with a mortality of 450 per million population ( implementation was delayed and overwhelmed the National Health Service with a case toll of 298,681 and a death toll of 674 per million population as on July 25 th (Figure 2 ). Nonadherence to the "track and trace" instructions (of WHO to identify and isolate cases), a limited PPE supply to health care workers, implementation of late lockdown, and unorganized testing added to the surge in case toll. There was no effective system to report recovered cases [30] . Most of the nations followed traditional measures of containment of an epidemic including screening, surveillance, quarantine, lockdown, testing, and isolation. Some nations prudently executed them earlier, whereas some delayed and the outcomes are very discernible, although outcomes of these strategies will be measured over time. Biological threats like the COVID-19 pandemic are inevitable and every nation must expect them to pose a great challenge to global health and security. There is an alarming need for every nation to be prepared and capable to swiftly respond to such public health emergencies. Confidence needs to be provided to neighboring countries that the outbreak can be prevented if there is a future global pandemic. Moreover, world leaders and international agencies must bear a collective responsibility to ensure a coordinated response. • Each country should develop health intelligence teams capable of giving early warning of a health emergency. • Epidemic preparedness plans and standard operating protocols for each nation should be designed and updated periodically. • Policies for judicial use of available resources during a disease outbreak should be developed and implemented. • Measures to gain the confidence of the public, like transparent information sharing to be established. • Centralized administration to monitor and oversee sustainable action plans during a disease outbreak is crucial to coordinate national efforts. • Recruitment, pre-preparedness, and continuous training of the workforce for epidemic/pandemic control. • Investing more in infectious disease prevention, control, and related research. • Developing precise and sophisticated technology in surveillance, control, and preventive methods. Limitations of this review are that it did not address the preparedness of nations and the factors associated with mortality of COVID-19. However, this was a meaningful appraisal about top-rated GHS index nations handling of the COVID-19 epidemic across key containment and combating strategies. The measures different countries adopted for COVID-19 were similar, but their timing and rigor in implementation made a huge impact upon how the country fared concerning case fatality per head of population. Although the picture is still evolving, and no country was fully equipped to respond to COVID-19, countries with a centralized and governmentdominated healthcare system responded better in terms of adapting to absorb the surge in cases, provided the response was guided and backed by well-timed political will. Moreover, early implementation of stringent containment strategies have reduced transmission rates in many countries. 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