key: cord-1007318-qbtprbvm
authors: Triukose, S. D.; Nitinawarat, S. D.; Satian, P.; Somboonsavatdee, A. D.; Chotikarn, P. D.; Thammasanya, T.; Wanlapakorn, N.; Sudhinaraset, N. D.; Boonyamalik, P. D.; Kakhong, B.; Poovorawan, Y.
title: Effects of Public Health Interventions on the Epidemiological Spread During the First Wave of the COVID-19 Outbreak in Thailand
date: 2020-09-03
journal: nan
DOI: 10.1101/2020.09.01.20182873
sha: 7cdf2a6963a95481c52398e5ed3cca774a4057fe
doc_id: 1007318
cord_uid: qbtprbvm

A novel infectious respiratory disease was recognized in Wuhan (Hubei Province, China) in December 2019. In February 2020, the disease was named "coronavirus disease 2019" (COVID-19). COVID-19 became a pandemic in March 2020, and, since then, different countries have implemented a broad spectrum of policies. Thailand is considered to be among the top countries in handling its first wave of the outbreak -- 12 January to 31 July 2020. Here, we illustrate how Thailand tackled the COVID-19 outbreak, particularly the effects of public health interventions on the epidemiological spread. This study shows how the available data from the outbreak can be analyzed and visualized to quantify the severity of the outbreak, the effectiveness of the interventions, and the level of risk of allowed activities during an easing of a "lockdown." This study shows how a well-organized governmental apparatus can overcome the havoc caused by a pandemic.

A novel coronavirus disease is officially recognized in Wuhan, China, in December 2019 section) and the point at which Thailand had no local infectious report for 67 consecutive days.

Classification of the five time periods 127 In reflecting the dynamics of the first wave COVID-19 epidemic and its relationship to 128 corresponding interventions in Thailand, the first-wave period was classified into five epidemic The Early stage (A) started from 12 January to 5 March 2020. The first imported and 137 local cases were identified on 12 January and 31 January 2020, respectively. On 1 March 2020, 138 Thailand had the first patient who died from COVID-19. During this stage, the total number of 139 COVID-19 cases was below 100 cases, and there was no strong public health intervention. 140 However, Thais were quite active in wearing facial masks due to the PM2.5 crisis during that 141 time.

The Spreading stage (B) was from 6-14 March 2020. This stage was a short period but 143 contained two "super-spreading" events in Bangkok: at the Lumpini boxing stadium on 6 March 144 2020 and an entertainment venue in the Thong Lo area on 9 March 2020. These events 145 contributed to the outbreak in Thailand [9] . After this stage, the number of total COVID-19 146 confirmed cases was higher than 100 cases, and Thailand entered the critical period of infectious 147 disease. The critical period (from 15 March to 14 April 2020 in the case of Thailand) is defined 148 as a 30-day duration from the first time at which the number of total confirmed cases is higher 149 than 100 cases [13] . It is believed to be an extremely crucial moment in combating an epidemic 150 because actions during this period dictate if the outbreak will be in or out of control. March 2020, the Bangkok mayor shut down the city, resulting in the suspension of many jobs. 161 Unfortunately, the leaked news of the shutdown led to a massive migration of workforces in 162 Bangkok back to their hometown just before the actual shutdown. This was the key event that 163 caused the outbreak to spread countrywide. Therefore, the Intervention II stage, from 3 April to 2 164 May 2020, involved additional policies to control the route of transmission. A nationwide curfew 165 was implemented on 2 April 2020, and the Civil Aviation Authority of Thailand (CAAT) banned 166 all international flights to Thailand starting from 6 April 2020. A mandatory state quarantine was 167 established on 3 April 2020, for everyone traveling to Thailand. Alcohol sales were prohibited 168 from 12 April 2020, throughout the Intervention II period [9] . 169 At the end of the critical period, public health intervention policies that local and 170 Government executed during the Intervention I and Intervention II stages were successful: the 171 number of daily confirmed cases in Thailand returned to the same level before the critical period.

Therefore, Thailand entered the Easing stage (E) from 3 May to 31 July 2020. In this stage, 173 restrictions correlated to the lower infectious risk were lifted and observed for 14 days before 174 proceeding to the next level, which eased the policies with higher contagious risk. In addition, 175 we compared the trade-off of the two different COVID-19 handling approaches on health and 176 economics by selecting two neighbours in Scandinavian, Sweden, Denmark, and Thailand as 177 subjects of our analysis. Sweden has been one of the countries that adopt the herd immunity 178 strategy. In contrast, Denmark and Thailand have used lockdown and social distancing measures 179 to limit local cases.

The number of daily confirmed cases is the total new laboratory-confirmed cases on a 182 particular day. It is interesting to note that the Government initially used a stringent criterion for 183 the case to be confirmed, requiring each individual to be approved by the two assigned national 184 laboratories. Later, on 22 March 2020, the criterion was changed, and a new case was confirmed 185 using just one national laboratory result, instead of two [14] .

Unless specified otherwise, all the data clean up, transformation, and calculation were 188 done using R and Python languages. The epidemic curves were generated by Tableau software. 60-69 9 (10) 1 (3) 132 (7) 72 (7) 0 (0) 214 (7) 70-79

This section reports Thailand's geographic information for the average daily number of 227 confirmed cases. Fig 3 shows how COVID-19 spread across the country in five epidemic stages.

In the Early stage, the COVID-19 was mostly limited to Bangkok (Fig 3A) , in which the average 229 daily number of confirmed cases was less than 1. ). The highest average daily number of confirmed cases, found in Bangkok, was less than 10.

In the Intervention I stage (Fig 3C) Samutprakan, and Pattani) had the average daily number of confirmed cases between 1 to 10.

Lastly, in the Easing stage, the average daily number of confirmed cases dropped to zero 248 almost nationwide ( Fig 3E) . The new confirmed cases came from nine provinces: Ang Thong, 249 Bungkan, Chainat, Kamphaengphet, Nan, Pichit, Ranong, Singburi, and Trat. 

The results from Thailand (Fig 4A) , Bangkok (Fig 4B) , and Phuket ( Fig 4C) We believe that these measures, imposed for every patient, and VHVs' network 332 contributed greatly to the excellent outcome of handling the COVID-19 outbreak in Thailand. March 2020, was approximately 14 days after the two super-spreading events.

In handling the outbreak, two critical executive decisions played a major part during the 339 Intervention I stage to get Thailand past the outbreak peak before the end of the critical period.

At the end of the critical period (14 April 2020), the number of daily confirmed cases was 33, whereas 32 cases were at the beginning.

The first important decision was enforcement of a set of policies to reduce and prohibit were introduced to reduce the frequency of contact and prevent SARS-CoV-2 from spreading to 362 Thailand. At the end of the Intervention II stage, the number of daily confirmed cases was stable and very low. After Thailand had the number of daily confirmed cases below 10 cases for seven 364 consecutive days, the Thai Government announced the Easing stage and began relaxing 365 restrictions imposed during the Intervention I and II stages.

As a positive side-effect, the changes in human behavior (awareness in handwashing, 367 facial mask-wearing, and social distancing) during the COVID-19 outbreak may contribute to the 368 decreased transmission of other respiratory tract infections, such as influenza [9] .

Easing periods 370 After the number of daily confirmed cases was lower than 10 cases for seven consecutive 371 days, the Thai Government started to relax the public health policies.

The Easing stage is from 3 May 2020 to 31 July 2020, where the restrictions 373 corresponding to the lower infectious risk were lifted and observed for 14 days before 374 proceeding to the next level, which eased the policies related to a higher infectious risk. The

Easing stage was classified into five easing phases, and Thailand was in the fifth easing phase by 376 the end of the first wave. After all, we observe that these two approaches yield a similar projection on the Gross 410 Domestic Product (GDP) as shown in Table 3 . Although Sweden's economics seem to be slightly better than Denmark in the first quarter of 2020, 0.1 percent versus -2.1 percent, respectively, the 412 International Money Fund (IMF) predicts the GDP of Sweden and Denmark for the entire 2020 413 as -6.8 and -6.5 percent respectively. In addition, IMF predicts the unemployment rate, another 414 key measure on economics, of Sweden and Denmark for the entire 2020 as 10.1 (increased from 415 6.8% in 2019) and 6.5 (increased from 5% in 2019) percent, respectively. Essentially, Sweden has more than five times higher mortality rate than Denmark. In the short 427 run, the strict public intervention policies seem to be in favor; however, the impacts, in the long 428 run, will remain to be seen. mistakes (such as its inability to stop the massive migration that happened two weeks after its 467 inception), the CCSA learned from its mistakes, adapted, improved, and became more effective 468 afterward. The Thai Government will continue to have a significant role in managing the 469 pandemic.

In terms of observation on the economic impact, trying to intervene slightly can slow 471 down the GDP to decline momentarily. Using herd immunity or lockdown approaches to handle 472 the COVID-19 outbreak seem to bear similar impacts on the economy; however, adopting more 473 potent public health interventions leads to more survival.

If the second wave of the COVID-19 outbreak hits Thailand, the Thai Government needs 475 practical tools for preventive policy planning. These tools should be data-driven, in real-time, 476 and aid decision-making rapidly. We used some of these data-driven tools to form visual and 477 measurement analytics (Fig 3, Fig 4, and Table 2 ). We plan to utilize these tools or develop new 478 data-driven tools with good predictive power to help tackle a second outbreak of COVID-19 in 479 Thailand. Available from: https://ourworldindata.org/grapher/total-confirmed-cases-of-covid-19-560 per-million-people?year=2020-07-31 

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