key: cord-0717569-2mjkbxzw
authors: Alshammari, Thamir M.; Alenzi, Khalidah A.; Alnofal, Fatemah A.; Fradees, Ghada; Altebainawi, Ali F.
title: Are countries’ precautionary actions against COVID-19 effective? An assessment study of 175 countries worldwide
date: 2021-04-20
journal: Saudi Pharm J
DOI: 10.1016/j.jsps.2021.03.011
sha: 29ca3c843d10d06eb90c353718120cb6bb12d752
doc_id: 717569
cord_uid: 2mjkbxzw

Background The coronavirus disease 2019 (COVID-19) pandemic has affected many countries negatively, particularly in terms of their health care and financial systems. Numerous countries have attempted to employ precautions to address this pandemic. This study was aimed at exploring and assessing the early precautionary actions taken by 175 countries on six continents to prevent the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods An observational study utilizing available public data was conducted on the basis of data collected from December 31, 2019 until the end of April 2020 and then compared with data in January 2021. Several data were extracted, including information related to the date of the first reported case of SARS-CoV-2, total confirmed cases, total active cases and more. In addition, seven validated indicators were used to assess the countries’ preparedness and precautionary actions. Results A total of 175 countries were included in the study. The total COVID-19 infection rate increased exponentially and rapidly in North America and Europe from March to April. The application of precautions (indicators) varied between countries. School closures, quarantines and curfews were the most-applied indicators among all countries. As for the relationship between the indicators and their effects on the infection rate, Italy and Spain were the top countries in Europe and adopted all the indicators. Nevertheless, they faced high infection rates: 239,639 and 205,463 COVID-19 cases in Spain and Italy, respectively. Conclusion The precautionary actions might have played a role in limiting the spread of COVID-19 in several countries. However, many countries might not benefit from applying these indicators.

During the last 20 years, there have been several epidemics associated with viruses, including SARS-associated coronavirus, H1N1 influenza and Middle East respiratory syndrome coronavirus (MERS-CoV), and all these epidemics have imposed a humanistic and economic burden on several countries (Cascella et al., 2020) . The first cases of coronavirus disease 2019 were reported to the World Health Organization (WHO) in December 31, 2019.

The WHO initially believed COVID-19 would be limited to China. However, given the increased number of cases and countries that have been affected, it was considered a high-level epidemic (Cascella et al., 2020) . On March 11, the WHO declared COVID-19 a pandemic because it had spread to most countries, and millions of patients were affected by the disease worldwide (WHO, 2020a).

All data showed that even in countries with a well-developed public health system, COVID-19 imposes a considerable burden not only on health care but also at the country level. Countries such as Italy, Spain and the United States of America (USA), which are known to have good health care systems, have experienced huge numbers of cases and deaths. In particular, the USA and United Kingdom (UK) account for a large percentage of deaths worldwide (Worldometer, n.d.) .

These countries' death rates between March and April of 2020 ranged from 12.9% to 14.2%, which is considered high ("CoronaTracker," n.d.; Worldometer, n.d.) . These challenges make dealing with COVID-19 very difficult and could lead to huge burdens on the health care system.

The main difficult issues facing the health system in addressing COVID-19 include the fact that there was no available vaccine for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) until recently. However, there is still an issue with the supply chain, which will take longer to cover all countries. Furthermore, several medications were used in an off-label manner for COVID-19. There were hopes that hydroxychloroquine and chloroquine would be used to treat patients with COVID-19 following a study by Philippe Gautret These actions are believed to delay the spread of SARS-CoV-2 (Dong et al., 2020) . Moreover, the best indicators that might prevent or delay the spread of SARS-CoV-2 were taken by some countries as precautions before any cases occurred (Alshammari et al., 2020).

Many countries took precautionary measures and actions aimed at reducing contact rates within the population and thereby reducing transmission of the virus. These actions included school and workplace closings, workforce reductions, public event cancelations, public transportation closures, public information campaigns, international travel restrictions and quarantines and curfews intended to limit the spread of the virus . It is thought that containment indicators for COVID-19 may only slow its spread and that the virus is now entering a stage of unprecedented threat in terms of its global impact (CEPI, n.d.). However, these indicators are likely to be implemented to varying degrees depending on the countries in question and their strategies . The major challenge is maintaining the precautions and interventions (Cauchemez et al., 2008) . Therefore, this study is aimed at exploring the early precautionary activities and patterns of 175 countries from six continents worldwide intended to address and prevent the spread of COVID-19.

An observational epidemiological study was conducted on the basis of data collected from all validated resources worldwide. The study included 175 countries from 6 continents worldwide (i.e., Asia, Africa, Europe, North America, Oceania and South America). In addition, it compared the numbers of infected cases in different countries with the current situation during January 2021 to yield knowledge on the importance of continuing with precautionary actions.

The study was conducted during the period from December 31, 2019 to the January 2021 All countries' information was searched, selected manually by the research team and divided by continents. After collection, the data were double-checked by the research team (each member checked the other members).

The country list was obtained utilizing the data from the WHO official page on the novel SARS-CoV-2 (WHO, 2020b). For each selected country, specific data related to SARS-CoV-2 and its indicators were collected. This included information related to the date of the first reported case, total confirmed cases, total active or suspected cases, total serious cases, total recovered cases, total deaths and deaths per million people starting from the beginning of the virus' spread to the end of March 2020. In addition to total confirmed cases and deaths per million people, data such as death rates and the numbers of confirmed, recovered and serious cases were also collected for April to compare the two months (April 2020 and January 2021).

Validated indicators were used to assess the countries' preparedness and precautionary actions. 

A total of 175 countries were included in the study. Of these, 42 were located in Africa, 43 were in Asia, 5 were in Oceania, 47 were in Europe, 26 were in North America and 12 were in South America. All included countries applied at least one of the precautionary indicators.

Infection rates were highest in Europe, followed by in North America. Furthermore, Europe had the highest death rate at 6,524 deaths per million people, whereas Oceania had the lowest at 8 deaths per million people.

Worldwide, a maximum of 7 indicators were applied by governments. Figure A Among these, 1 country applied 1 indicator, 2 applied 2 indicators, 1 applied 3 indicators, 1 applied 5 indicators, 1 applied 6 indicators and 6 applied 7 indicators. Most countries (11) closed schools, and the majority (9) closed workplaces, imposed international travel restrictions and established quarantines and curfews. Seven countries closed public transportation and used public information campaigns, and 7 canceled public events.

Another important factor was the total death rate in the studied countries. Figure In January 2021, the number of cases in Europe had slightly increased compared to in the April 2020 situation, except in some countries such as Russia, the United Kingdom and Ukraine (see The infected cases in Africa reported in January 2021 were comparable to the number of cases registered last April (see Graphs 3-G).

There were no great increases in the rate of infection in Asia compared to the rate during the last April, except in India, where the number of cases increased by three times (see Graphs 4-G). We also notice as much in the continent of South America, except in Brazil, where there was an increase in the number of infected cases (see Graphs 5-G).

In North America is January 2021, the infected cases were close to what were recorded the April before, except in the United States (see Graphs 6-G). This study examined the actions taken by 175 countries on 6 continents. We aimed to cover most regions worldwide and investigate the patterns among these countries. Thus, there were no specific exclusion criteria for countries, but inclusion depended on the availability of and access to data. Although COVID-19 originated from China, the highest death rate was in Europe, not Asia (Yuan et al., 2020). This may have occurred for many reasons. The number of COVID-19 cases was high during the study period, and Europe's elderly population is quite large; furthermore, most COVID-19 deaths occurred among elderly people due to weak immune systems (Rothan and Byrareddy, 2020; Wang et al., 2020) or due to environmental and social weaknesses. (Coccia, 2020) In addition, a lack of some important medical equipment-such as test kits, personal protective equipment, ventilators and available beds in intensive care units-in some countries, especially those with very high numbers of COVID-19 cases, might be another reason for the high death rate in Europe (Rubino et al., 2020) . In contrast, Oceania had the lowest rate at 8 deaths per million people. This might be due to the distance between the continent's islands, its low population and the early precautionary actions on the part of some of countries in Oceania, which limited the number of COVID-19 cases in those countries. New Zealand is a successful example of controlling the COVID-19 pandemic.

The number of tests conducted indicates that testing was performed more than once ("COVID-19 -current cases in New Zealand, Ministry of Health -Manatū Hauora," n.d.), and seven indicators were used to assess the country's activities and preparedness to fight SARS-CoV-2.

Only 15% of countries applied all 7 indicators, whereas the largest proportion applied only 2 indicators (22%). However, this pattern is different for Africa, South America and Oceania. Fewer indicators were applied by a couple of countries in Oceania. Thus, that continent had both the lowest rate of COVID-19 pandemic infection and the lowest average number of indicators. governmental indicators. This does not indicate that these indicators had no effect, however. These results could have occurred for several reasons: 1) applying some indicators such as quarantines and school closures early, 2) closing the country by preventing international travel to and from some countries and 3) Oceania's location, which, unlike Europe's, makes travel between countries difficult because of their sea borders ("COVID-19current cases in New Zealand, Ministry of Health -Manatū Hauora," n.d.). These reasons could also be why the spread of SARS-CoV-2 was lowest in Oceania. When comparing cases at the end of March to those at the end of April, we found that the rate increase in Oceania was only 36%, compared to 74% worldwide. Similarly, the death rate increased by about the same percentage.

However, cases differed across other continents, where SARS-CoV-2 spread more when governments applied fewer indicators. This is clearly shown in data for continents such as South America, Africa and North America, where the rate of spread was higher than the worldwide rate. Asia and Europe were comparable, and the rate of spread on both continents was lower than the worldwide rate, possibly due to their extensive efforts in applying most indicators to limit the spread of SARS-CoV-2.

The spread of SARS CoV-2 among the studied countries might have been affected by the applied indicators; this was seen in various countries. In Oceania, the more indicators governments applied, the fewer COVID-19 cases they reported. For example, in New Zealand and Fiji, this trend continued for both months (i.e., March and April). Several other continents' countries, such as Kenya, Saudi Arabia, Japan, Austria, Switzerland, Bermuda, Canada, Bolivia and Argentina, exhibited the same pattern. However, this was not always the case because some countries applied more indicators but still faced high numbers of infections, as in China, South Africa, Spain, Italy and the USA. This might have occurred because these indicators were not followed well, were applied late after many cases had already occurred or were not well recognized as being of considerable importance, especially during the early period of the pandemic, as in China (Aleta and Moreno, 2020; Sebastiani et al., 2020) . This is consistent with a simulation study conducted in Wuhan, which found that if precautionary actions (social distancing in the general community and school and workplace closures) would be applied well, the pandemic would vanish by end of April; however, the countries are still suffering from it . A study by Atalan conducted on 49 countries found that lockdowns have reduced the number of COVID-19 infections, but cases in Italy and Spain were not affected by lockdowns, which consists with our study (Atalan, 2020) .

In a comparison of the indicators or actions used by continents with the mortality rate at the end of the first month, in Africa, most countries that applied more indicators, such as Kenya, Mauritania, Angola and Cote d'Ivoire, had lower mortality rates. However, results were different in Algeria, which had a high mortality rate despite applying 6 of the 7 indicators. The only indicator Algeria did not apply was a public information campaign, which might indicate that educational materials and information about SARS-CoV-2 played a major role in counteracting this pandemic. Similarly, in Europe, Switzerland and Germany had low fatality rates, and both countries applied a high number of these indicators (Huber and Langen, 2020).

However, countries such Spain and Italy applied high numbers of indicators but still had high mortality rates. This might be due to late application or lack of seriousness in applying these indicators by these countries (Peiyu Liu, Sha He, 2020; Saez et al., 2020). However, a longer period of lockdown does not significantly reduce the fatality rate. (Coccia, 2021a ). In addition, as mentioned earlier, demographics and aging might have played roles in these countries (Rubino et al., 2020) . These results are consistent with a study conducted by Coccia M et al., which found that a longer lockdown (> 1 month) compared to a shorter one (maximum 15 days)

is not associated with a reduction in COVID-19 cases (Coccia, 2021b) . Furthermore, a study conducted in Italy found that these increases in cases might have owed to the air pollution and high population density in the affected cities (Coccia, 2021c (Coccia, , 2021d ). Nevertheless, a study by Tobias A conducted in Italy and Spain for a month found that there was a reduction in the number of cases after the lockdowns; however, the study was started in February where cases were already very high (Tobias A., 2020). Moreover, another study that assessed the effect of non-pharmaceutical interventions on COVID-19 in Europe found that there was a reduction in the transmission of COVID-19, but the study lasted until May, at which point cases had started to decline (Flaxman et al., 2020) . Brauner When the mortality rate was compared among countries worldwide, most countries with higher fatality rates were in Europe. The country with the highest rate was San Marino, followed by Belgium, Andorra, Spain, Italy, the UK, France and Sweden. This might be because of the massive number of COVID-19 cases that occurred earlier in Europe, as hospitals might not have been ready to deal with such a high number of cases (Rubino et al., 2020) . Another explanation could be the aging population in these countries, especially considering that such individuals are part of the most-affected age group (Toshkov, Dimiter, 2020 ).

There were more serious COVID-19 cases in Europe than in comparable continents. This sharp increase in cases occurred mainly in Italy and Spain, possibly due to the unpreparedness of these countries' health care systems, especially when faced with a huge number of cases. Also, the late action by these countries in applying restrictions might be a reason, taking into consideration the high number of cases before March. In addition, these countries' populations contain more elderly people, and most of the people affected have been elderly; this could be another justification for such a high number of serious cases (Rubino et al., 2020; Toshkov, Dimiter, 2020) . A study conducted in Italy and Spain found that when the lockdown was applied, the number of cases dropped in March and April compared to in February. This might be because cases were already very high in February (Tobías, 2020) . Nevertheless, another study conducted in 50 countries found that rapid border closures and full lockdowns are not associated with reduction critical cases or mortality reduction (Chaudhry et al., 2020) . Some countries such as Singapore, Hong Kong and Taiwan relied more on early precautions because of their belief that prevention was the only option without an available vaccine or drugs at that time. Singapore was among the first countries to apply a travel ban from China at that time. In addition, daily testing of up to 2,000 people was conducted to check for SARS-CoV-2, and employees were asked to work from home due to mandatory quarantines in the country. In some continents-Asia and Africa-we found no increase in the infected cases. The reason may be the lack of reporting by the countries or of testing due to a state's economic situation or the unavailability of a COVID-19 test; thus, the number of cases might have been decreased.

This study has several advantages. To our knowledge, it is the first study to evaluate these 7 indicators as precautionary actions on the part of 175 countries worldwide. In addition, our study involved important indicators that cover the most of the actions taken by countries. It also included data such as the numbers of infections, serious cases, recovered cases and deaths, the death rate per million people and the number of indicators applied by each country. The study's limitations include that we lacked time series information (i.e., the number of infections or deaths for multiple time points) because some data were unavailable or difficult to acquire.

In addition, it is difficult to judge and compare the countries because of the unavailability of several factors needed for this comparison and the emergence of the new coronavirus variant in some countries.

It is clear that the COVID-19 pandemic will continue over time for at least a year from now, and there is a hope that the availability of vaccines will help to end it; however, there is no solid evidence on that point. Therefore, precautionary actions might be considered the best methods to prevent the transmission of COVID-19, although the issue is still debatable. Educational (i.e., schools) and workplace closures (using online methods instead), border closure, social distancing and hand and face washing seem to be actions that can be recommended. Nevertheless, these recommendations might differ from one country to another.

Most studied countries exhibited the same pattern in terms of increasing numbers of COVID-19 cases. This study showed that the precautionary indicators taken by various countries might have played a role in limiting the spread of COVID-19. This might be seen clearly at the point when some countries stopped these precautionary actions, as they now have a second wave of COVID-19. However, some countries might not benefit from applying these indicators. 

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