key: cord-298918-o1bmulz3
authors: Khosrawipour, Veria; Lau, Hien; Khosrawipour, Tanja; Kocbach, Piotr; Ichii, Hirohito; Bania, Jacek; Mikolajczyk, Agata
title: Failure in initial stage containment of global COVID‐19 epicenters
date: 2020-04-28
journal: J Med Virol
DOI: 10.1002/jmv.25883
sha: 
doc_id: 298918
cord_uid: o1bmulz3

With multiple virus epicenters, COVID‐19 has been declared a pandemic by the World Health Organization. Consequently, many countries have implemented different policies to manage this crisis including curfew and lockdown. However, the efficacy of individual policies remains unclear with respect to COVID‐19 case development. We analyzed available data on COVID‐19 cases of eight majorly affected countries, including China, Italy, Iran, Germany, France, Spain, South Korea, and Japan. Growth rates and doubling time of cases were calculated for the first 6 weeks after the initial cases were declared for each respective country and put into context with implemented policies. Although the growth rate of total confirmed COVID‐19 cases in China has decreased, those for Japan have remained constant. For European countries, the growth rate of COVID‐19 cases considerably increased during the second time interval. Interestingly, the rates for Germany, Spain, and France are the highest measured in the second interval and even surpass the numbers in Italy. Although the initial data in Asian countries are encouraging with respect to case development at the initial stage, the opposite is true for European countries. Based on our data, disease management in the 2 weeks following the first reported cases is of utmost importance.

The current COVID-19 outbreak with multiple global epicenters has attracted worldwide attention. Thus, with continuously rising numbers of confirmed cases, COVID-19 has been declared a pandemic on March 11th, 2020 by Tedros Ghebreyesus, the World Health Organization's (WHO) Director-General. 1 have been insufficient. 8, 9 The aim of this study is to evaluate and compare case development, growth rate and doubling time during the initial phase of COVID-19 exposure for each respective country. The total number of confirmed COVID-19 cases for Asia (China, South Korea, and Japan), Europe (Italy, Germany, France, and Spain), and Iran were obtained from the COVID-19 situation reports made publicly available by the WHO. The present study included F I G U R E 1 Cumulative development of COVID-19 cases in China, South Korea, Japan, Italy, Germany, France, Spain, and Iran according to WHO data. Data for the months of January, February and March and magnification of latest case developments outside of China F I G U R E 2 Cumulative development of COVID-19 cases in China, South Korea, Japan, Italy, Germany, France, and Spain within the first and second 3-week intervals. Projections of the calculated exponential growth within both intervals for each respective country data from January 20th, 2020 to March 13th, 2020 as reported by the WHO (see Figure 1 ). 1 

The first 6 weeks after initial reports of COVID-19 cases in Italy, France, Spain, Iran, South Korea, Japan, Germany, and China were subject to analysis. This time span of 6 weeks was divided into two intervals: (a) a first 3-week interval and (b) a second 3-week interval.

We chose an observation period of 6 weeks as most initial worldwide cases occurred within a 6-week time span (Figure 1 ).

For these two intervals, we measured the doubling time (d) in days and the corresponding growth rate (g). An exponential growth curve with least squarer regression analysis was estimated for both 3-week time intervals for each respective each using the following model:

. in Japan was similar between the first (6.90, 95% CI: 5.53-8.85) and

second-time interval (6.54, 95% CI: 6.09-7.03) (Figure 4 ). Similarly, the data for Iran is probably biased and incomplete for analysis. 10 This finding may be a strong indicator that detection of COVID-19 occurred at later stages with a more large-scale virus spread. This underreporting and insufficient disease detection is a source of continuous concern. 11 The overall international COVID-19 case development remains concerning and a significant trend of initial underreporting must be assumed. This is a negative development and indicates the possibility of further COVID-19 spread, especially as most countries still report very few initial cases. As many counties are at different stages of the COVID-19 epidemic, the question arises as to how reinfection can be avoided once curfew and lockdown measures are lifted. Our data support the effectiveness of current containment and testing efforts. 12 However, short-time curfew might not be an alternative to long-term containment and testing measures. The concept of wave patterns has been previously described for other pandemic outbreaks. These waves can be experienced for many months. [13] [14] [15] Limitations of this study include the quality of provided case numbers, as they might be subject to bias and underreporting. It remains challenging to distinguish the effect of different measures due to a lack of testing kits, insufficient detection, and varying containment policies.

The extent of overall testing seems to correlate with the awareness of serious health risks in the observed countries. As official case numbers have increased with the onset of containment measures, one can assume that testing is itself part of the containment strategy. 8, 16 In fact, evaluation of individual strategies is not possible as only the totality of combined effects and policies of each country regarding quarantine, regional lockdowns, travel restriction, testing, and social distancing can be evaluated.

This problem has already been recognized in the evaluation of single containment measures. 12, 17 With respect to these considerations, this study focuses on the combination of all measures taken by a country to evaluate the quality of the initial response to this outbreak.

Following the analysis of different European and Asian countries heavily affected by COVID-19, our data indicate significant differences in initial growth rates and doubling time. According to our data, European countries seem to have missed effective measures to contain COVID-19 at the beginning of the crisis compared to their counterparts in Asia. This is further substantiated by continuously, rapidly increasing COVID-19 case numbers in European countries, which call for more draconic containment measures.

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The authors declare that there are no conflict of interests.

VK: data acquisition, data interpretation, final analysis, drafting of the manuscript, final approval for publication. HL: data acquisition, analysis, and interpretation, drafting of the manuscript, final approval for publication. TK, PK, and HI: data interpretation, drafting of the manuscript, final approval for publication. JB and AM: data interpretation, conception, and design of the work, critical revision for important intellectual content, final approval for publication.

http://orcid.org/0000-0003-0233-551X