Updated: Aug 28, 2020
By N. Saravana Kumar, P. Sarath, Adithyan G.S and Viduthalai Virumbi B
Image Courtesy: Pixabay
The World Health Organization (WHO) declared novel coronavirus disease (COVID-19) a pandemic on 11 March 2020. COVID-19 soon become a serious global public health crisis with almost all countries struggling to combat the epidemic; also, with few successful examples. It has infected over 10 million people in more than 200 countries resulting in more than half a million deaths.Currently, as the pandemic is emerging, many new insights and strategies are evolving from the best practices and innovations carried out by many countries. This article discusses selected global best practices carried out by the affected countries in combating the COVID-19 pandemic
As many nations struggle to keep the COVID-19 infections under control through tough public health measures, Taiwan presents an example of how to be prepared in the event of a pandemic. Located less than 150 kilometres from the original viral source – China, Taiwan has a much lower infection rate. Taiwan Government was swift in taking decisive actions as soon as the news of a virus emerged from the Chinese city of Wuhan. The Taiwanese government quickly put together a four-pronged approach such as early border control, proactive case finding and containment, resource allocation, reassurance and education of the public to combat the spread of coronavirus. A notable best practice is the Government’s decision to take control of face mask distribution, ensuring that there is no hoarding of supplies or exploitative pricing, as had happened in other places such as Hong Kong. The Government instituted price caps on face masks to maximize the number of people wearing them. Measures such as mandatorily measuring the temperature of people as they enter public buildings, helped the country avoid an extensive lock-down. "Electronic Fence" strategy that utilizes location-tracking services in mobile phones to ensure people who are quarantined stay in their homes, helped contain the spread of disease. ‘Cohorting’ (Grouping of workers) among the workplace within medical facilities allow for greater control over the spread of infection among medical fraternity while keeping treatment standards intact. This increase the effectiveness of altering the normal shift schedules of staff by making sure that groups of workers are always assigned to the same shifts with the same co-workers. The National Health Command Center (NHCC) Taiwan which was established after the 2002 SARS outbreak in the country also played a crucial role in coordinating the response mechanisms across multiple agencies and regions.
Within the country’s nationalised healthcare system, every citizen and every resident are assigned a health card, embedded with a computer chip reflecting their identity and medical history. This has enabled hospitals to quickly and efficiently control visitor entrance and report on patient symptoms. Sharing test data and results diligently, allowing a broad collaborative effort to find the best ways to fight the virus was much appreciated.
Thus far, Taiwan’s biggest success can be attributed to the readiness of the country and its hospitals were from ‘Day-One’. However, willingness and effectiveness with which doctors and medical officials have worked cooperating with each other and the public is a testament to the country’s smart and rational approach to healthcare and disease prevention.
Thailand was dealing with the third-highest number of confirmed coronavirus infection cases after China and Singapore, within four weeks of reporting its first confirmed case of the COVID-19. The Thai government had announced a partial lock-down and taken a number of fiscal and non-fiscal measures to contain the impact on the well-being of its people as well as its economy. They put into effect an aggressive strategy of contact tracing, quarantining those tested positive, hospitalizing those with serious symptoms, and requiring international travelers arriving from “dangerous communicable disease areas” to self-isolate or, in some cases, be confined to government quarantine centers. A critical role was played by village health volunteers (VHVs) in flattening the spread of COVID-19 at the community level. They monitored people’s movement in and out of their villages; visited homes to check the temperature; shared health information about COVID-19 and how to prevent it, recorded household health information, and reported their data to the provincial health office and then the central government afterward.
Culturally sensitive hygienic practices and community enforced government advisories were strongly influential in reducing the spread of infection in Thailand.The universal healthcare program which was in existence for 18 years in the country has become the foundation of the relationship of trust between the health system and the people in effectively controlling the epidemic.
To a large extent the political leadership was superfluous. Voluntary compliance of citizens, voluntary service of grassroots public health activists, cooperation and planning among the institutions and civil societies were the cornerstones for the prevention of Covid-19 in Thailand.
Japan being the 11th most populous country in the world with elderly citizens (above 60 years of age) constituting almost a third of the total population has prevented the spread of covid-19 in a successful manner within a short span of time. Without imposing a complete lockdown, the country has avoided an explosion of cases and attained very low mortality rate. Their approach was restricted with “Three C’s” - avoiding Closed spaces, Crowded spaces and Close-contact settings.Japan has followed stringent testing strategy; only the people those who experienced severe symptoms were tested and hospitalized. More than 50,000 experienced public health nurses were put for strict contact tracing. They also focused on tackling with clusters, or groups of infections from a single location such as clubs or hospitals and to contain the cases before they become super spreader.
The Government promoted their traditional customs to follow basic hygiene practices such as hand-washing, gargling and maintaining social distancing as part of their everyday life. For example, greetings are usually done with bowing instead of handshaking, and if someone is sick with a cold or flu, they wear surgical masks.
So, it does not require special effort from the government in imposing such preventive practices to deal with the pandemic. Employers were encouraged for remote work, shifting the commute time, and sick leaves were given for those even with mild symptoms.
Although Australia recorded its first confirmed Covid19 case as early as 25th January 2020, the nation appears to have managed to contain the spread of the virus effectively. With a low incidence and case fatality rate, the success is mainly attributed to the way the authorities acted swiftly, started mass testing, conducted contact tracing, shut the international borders and brought guidelines to quarantine the infected. Effective social distancing guidelines were also put in place. The Government also announced welfare schemes for individuals and businesses (For example, the job keeper scheme, childcare scheme, etc.) to limit the economic effect of the pandemic within the society. Their notable approach to the pandemic is based on mathematical models of infectious diseases which represents the way infections spread between individuals, in households, and through society.Another significant policy decision that Australia took in the early days of COVD-19 that helped in its containment was to form a ‘national cabinet’ comprising of the leaders of the federal government and of the ruling parties in the various states and territories. Australia’s federal structure, similar to that in India and the USA, allows the states to be in charge of decision-making in their respective jurisdictions (the federal government has limited power) in enforcing decisions related to COVID-19.
Quite early in this crisis, the National Cabinet was formed, and all the decisions were collectively taken, thus, avoiding the possibility of disagreements between the states and the federal authorities. Whatever disagreements arose, these were ironed out behind closed doors so that the public saw a unified authority acting similar to a war cabinet. One did not, therefore, witness, the public bickering between the regional and national leaders that one saw in India and the USA.
The situation is being reviewed continuously by experts and the Prime Minister, Scott Morrison, regularly updates the nation on the virus spread, prevention, economic measures, social welfare etc. The Australian story is a collaborative effort of the work done by health officials, government, economic experts and most importantly, the people, who supported the cause.
South Korea provides another example of how the state’s administrative machinery effectively made use of its Information Communication Technology (ICT) management capabilities in combating the pandemic. They had followed 3T’s Strategy: Test, Trace and Treat. Confirmed cases are being tracked by a fusion of credit card purchases, smartphone location tracking, and CCTV footage, presumably analysed by facial recognition algorithms. It has tested more than a quarter-million people for the virus; there are over 600 testing sites nationwide, with a capacity to test up to 20,000 people each day. Results are released, on average, within 6 hours via text. Tracking and publishing the movements of virus carriers is being done even before they show symptoms. The South Korean government announced it will cover all medical costs associated with COVID-19 treatment for its citizens and others living in the country.
The government developed and distributed a self-health check mobile app to track the movements of overseas visitors; the ministry of health reports usage rates of the app in excess of 90%. Health administration authorities have developed mobile apps to track and monitor those under quarantines as well as the capabilities to use drones to disinfect large public areas.
South Korea’s ICT capabilities were developed partly because of the country’s sensitive geopolitical location and its tense history with North Korea. The Korea Centre for Disease Control and Prevention (KCDC) also played a pivotal role by imbibing lessons from the SARS and MERS epidemic. The KCDC has strengthened its risk communication and assessment strategy after the MERS and also increased the number of professional epidemiological investigators in its team.
South Korea’s experience highlights the importance of cutting the chain of infection in the country by supplying the hospitals and medical personnel with proper equipment and gear, testing and isolating infected citizens from the general population, and encouraging the practice of wearing masks and proper social distancing. In addition, the government has made a conscious effort to create a sense of trust by being transparent and bearing the financial burdens associated with treatment.
During the COVID-19 outbreak, Singapore has won praise for its ‘gold standard’ response. Singapore established a multi-agency task force chaired by two ministers (health and national development) with representation across the entire public service including ministers in charge of trade, manpower, education, and communication, even before the first case was reported in Singapore. With its previous experience of SARS, Singapore had put all contingency efforts to use such as government-owned holiday chalets and once it became fully occupied, university hostels were made available for quarantine activities. The Government also motivated people to come for testing and they announced that all medical expenses related to testing and treatment would be covered, and that S$100 per day would be provided to compensate for any loss of income while quarantined. Singapore announced heavy penalties for defying quarantine and isolation orders. In a widely publicized case, it took away permanent residency status from a resident who had breached a ‘stay-home notice’ and permanently barred him/her from re-entry.
Expertise from Singapore’s National Biomedical Sciences Initiative was quickly brought together and organized early on, leading to the early development of diagnostic kits, serological tests and the ability to trial novel drugs for therapy.
Singapore has adopted high-tech surveillance tools, including a smartphone app that tracks users' location and proximity to other people using Bluetooth, alerting those who come in contact with someone who has tested positive or is at high risk for carrying the coronavirus.
Germany is often referred to as a positive example on how to manage the COVID-19 pandemic, owing to its properly funded health system, technological edge, and decisive leadership. But beyond all these, the hallmark of the German system was a strong commitment to building public trust. They were successful in preventing the overburdening of the health system. The curve of infections is clearly flattening and the proportion of severe cases and fatalities is lower in Germany than in many other countries currently.
Notable best practice was the pooled testing method developed by the German Red Cross Blood Donor Service in Frankfurt. It involves simultaneously testing a combined sample from multiple people from a household or a local cluster to widen reach and speed up results that are suitable for expanded testing in larger population groups. In the case of a positive mini-pool result, individual testing is carried out in previously reserved samples. In the case of a negative result, all included samples have a reliable negative result. It was earlier used during large outbreaks and invisible community transmission, such as HIV.
Another important approach is being Corona taxis: Medics equipped in protective gear, driving around the empty streets to check on patients who are at home to see if anyone requires immediate hospitalization or not, by checking biochemical parameters. Germany's federal agency responsible for disease control and prevention, the Robert Koch Institute, has teamed up with the health technology start-up Thryve to develop an app called Corona-Datenspende (data donation) that works with a variety of smartwatches and fitness wristbands. The app is designed to use the device's sensors to collect user data and includes algorithms to it to spot symptoms linked to COVID-19 and help predict the spread and containment of the virus.
Germany has not shut down daily life either; only food and entertainment outlets have been closed since the end of March. They have been conducting intensive testing and strictly quarantines sick people and their contacts. It has also made its medical system ready for a pandemic.
On March 25, New Zealand implemented a nationwide lockdown, just three days after officials confirmed community transmission, with only 102 cases in the country. Moreover, New Zealand carried out one of the strictest lockdowns in the world. Shortly before the strict lockdown, the government also sent emergency text messages to all its residents.
New Zealand’s followed only the classic pattern with a strong administrative will- they prevented external travelers to arrive in the country, strengthened the health system to combat the epidemic by procuring adequate drugs, diagnostics and PPE, strengthening testing capacity, contact tracing and strict isolation of tested positives.
Most of all they also gained public confidence in practicing social distancing and adhering to lock down policies sternly.The geography of New Zealand was an added advantage; the fact that it is a relatively isolated island has greatly helped New Zealand’s pandemic response. It has more control over who can enter than other countries with large land borders. It also has a relatively low population density, meaning the virus cannot travel as easily through the population, as fewer people encounter each other.
Currently, there is no new COVID 19 case in New Zealand and they have lifted back all domestic restrictions and started all economic activities in full fledge even though the borders remain closed to all other than returning residents who mandatorily has to go for quarantine upon arrival.
China was the country where COVID-19 originated, and therefore the country that had the least amount of time to prepare for this pandemic, especially given its late initial response. But China overcame these significant handicaps and managed to reduce new domestic cases to nearly zero over the span of two months. China’s approach focused on identifying and controlling the source of the infection using testing, isolation, and social distancing. China was quick in conducting etiological and epidemiological investigations when the cases of pneumonia due to unknown etiology arose in Wuhan city and released the genome sequence of the novel coronavirus. In the initial month itself Wuhan went for a complete lockdown and no residents were allowed to leave and non-residents were not allowed to enter the province.
Early detection, reporting, quarantine and treatment with a focus on the four categories of vulnerable people (confirmed cases, suspected cases, febrile patients who might be carriers, and close contacts) were the hallmark of China’s response strategy. Wuhan carried out nearly two rounds of community-based mass screening of its 4.21 million households through pooled testing strategy.
A community grid-based screening was carried out across the country and all residents were requested to report their health condition on a daily basis in this. Community workers also visited the households and triangulated this information. Temperature checking was also made a routine at all places.New hospitals were built and the number of beds were increased in existing hospitals in record time. An excellent example is the newly built Huoshenshan and Leishenshan Hospitals, which offer 2,600 beds in total. The Chinese Government also repurposed major stadiums and exhibition centers as quarantine facilities and temporary treatment centers. Robots were also used for carrying out disinfection activities in big hospitals.
China also applied a region-specific, multi-level approach to epidemic prevention and control i.e. each region was classified based on risk analysis and different approaches were carried out based on the risk assessment.
In India, the first case of COVID-19 was reported on January 30th, 2020, followed by two similar cases on February 2nd and 3rd. All three had a travel history to Wuhan, China. A month later, on March 2nd, two new cases were reported – one each from New Delhi and Hyderabad. A sharp increase in numbers then followed. To contain the spread, the Ministry of Health and Family Welfare (MoHFW) and various State Governments took steps to combat the pandemic. India’s preparedness and response to COVID-19 have differed at the state level depending on their individual capacities to handle the outcomes. Some of the best practices were initiated at the state level and followed across the country. Few notable models include Bhilwara Model-Rajasthan, Break the Chain – Kerala, Intensive Testing Strategy – Tamil Nadu, The Dharavi example- Maharashtra.
Kerala has drawn on its experience with the Nipah virus in 2018 to use extensive testing, contact tracing, and community mobilization to contain the virus and maintain a very low mortality rate. A large number of Non-Resident Keralites returning daily is a worrisome factor for the state at present.
The Kerala model emphasises on public action through a clear focused awareness campaign, effective roping in of Panchayat Raj institutions & grassroots structures and collaboration with line departments and an effective public health approach.
The Bhilwara Model (Rajasthan) includes six major steps which include-Isolating the district; mapping the hotspots; door-to-door screening; aggressive contact tracing; ramping up quarantine and isolation wards; and readying a monitoring mechanism for rural areas. Even with the strict containment the district administration also took care of the basic needs of all people in the district and supplied all essentials services at doorsteps.
The Dharavi (largest slum of South Asia) containment story also can be considered as the best practice. The ‘chasing the virus’ strategy employed a door-to-door screening of all slum dwellers (temperature and oxygen saturation levels), accessible fever clinics at slum level, organized lifting of suspected people to quarantine facilities, and strong community involvement.
The Tamil Nadu government took effective action by excessive testing (the first state to cross 1 million testing by 26th June 2020), early identification and proper clinical management.
Hence, India has the opportunity to reverse disease predictions with stringent containment measures, social distancing, increasing case detection, isolation and quarantining the contacts and learning from these best practices.
Other few examples: Vietnam, Mongolia, Cuba, and Nordics
Vietnam, a nation of around 95 million population confirmed its first COVID-19 cases on 23 January 2020.
Early response and action without any strict lockdown measures proved successful in Vietnam’s case.
Vietnam has so far reported only 328 cases with zero deaths and 307 recoveries. Early awareness of the pandemic, appropriate, drastic and people-centric measures, as well as public support, are the main factors behind the success of Vietnam. The Government has implemented a strict 14 days quarantine for all foreign arrivals. The local administration meticulously traced every single person who may have been infected with the virus and quarantine entire streets as well as villages. Vietnam also developed its own testing kits for COVID-19 as early as January and managed to improve it to provide results within an hour with 90% accuracy, according to the ministry of health. The testing kits were developed by Military medical university and Viet-A company with funding from the Ministry of Science and Technology.
Mongolia was also very swift in action and was able to achieve zero deaths and also have zero local transmissions. On January 22nd, the Mongolian health ministry held a press briefing with the WHO and started all preventive activities (masking, social distancing) prior before any case got reported. They began screening of all travelers from mid-January and quarantining them cautiously.When the first case in Mongolia was reported on March 10th, 2020, which was an imported case, they isolated the entire office area and quarantined the entire district and shut down all public transport in the district. They also did a mass decontamination of the entire area.
Cuba was slow in closing its borders. But by late March, they focussed on actively screening all households through their health workforce. Cuba with a strong public health system was able to do a unified strategy with much coordination as compared to many other nations. Everybody who tests positive on the island got hospitalised and those suspected of carrying the virus are put into state-run “isolation centers”, usually for 14 days. Cuba also did extensive contact tracing and antibody testing was done among asymptomatic contacts and RT-PCR for further confirmation.
Cuba, which has the highest doctor-to-patient ratio in the world was also able to send its health manpower to many countries to contain the spread of the virus.
The Nordics (Denmark, Iceland, Finland, Sweden, and Norway) have made the best use of integrated healthcare IT platforms during crisis management very effectively. The digital innovation and integrated data solutions were central to the health system of these countries and they were able to handle the pandemic by making the best out of it.
Even now it’s premature to brand certain countries efforts as best practice since it’s an evolving epidemic and the strategies are also getting evolved. The best practices of the countries mentioned should be co-related with the context- health system, social and political. There are also criticisms to many of these models (eg: India, China) which also needs to be further evaluated and documented.
The 3T practices, coupled with technology and data analytics, institutional quarantine, training, decentralised planning and response, enforcement and community mobilization hold the key to the success of any nation’s containment activity. Earlier the country starts preparing to combat the COVID-19, the containment measures proves successful. Experiences from earlier pandemics and using the existing health system infrastructure augments the response strategies, especially use of technology in implementing control and preventive measures. The vision of COVID-19 containment measures has to be aligned from national to community level for implementing the global and national best practices which are suitable for the local context.
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Table 1: Summary of global best practices
Table 2: Disease status from select countries (as of 29 June 2020)
All the authors are public health professionals currently working in Tamil Nadu. The views are personal.