Introduction
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. Fluctuations in the number of tests, positive cases, and case fatality rate (CFR) are the probable outcomes of a country showcasing their preparedness and timely containment measures.
This article aimed to examine COVID-19 containment strategies for nations which rank highly in the Global Health Security (GHS) index. The GHS index was a joint project of the Nuclear Threat Initiative and the Johns Hopkins Center for Health Security, and was developed with the Economist Intelligence Unit. The GHS index ranked 195 countries based on their health security, preparedness against epidemics, and related capabilities. Interestingly, the 8 nations selected for this review were amongst the top ranked countries of the GHS index, however, their performance and outcomes for COVID-19 containment measures were incongruous with their respective GHS index scores.
The toll of COVID-19 positive cases and deaths are escalating swiftly and the current situation drives each nation to learn from the successes and failures of other countries during this pandemic.
Discussion
Much evolved state-of-the-art technology aided expeditious identification of the novel coronavirus and updated the information to the entire globe. Novel technology merged with conventional methods, case detection, isolation, contact tracing, quarantine, and infection control measures were employed to counter the pandemic. It’s too early to judge the efficacy of measures taken by different nations, although a few countries kept the pandemic in check. Control measures executed by the nations scrupulously resemble each other and are in accordance with the WHO recommendations.
It is imperative to note that COVID-19 transmission occurred across nations at varying timelines depending on the connectivity, initiation of early mitigation measures, trade relations, deployment of containment strategies, and various socio-behavioral aspects. As depicted in
Figure 1, Thailand, South Korea, and US registered their index COVID-19 case 13 to 20 days after the Wuhan outbreak, owing to their close trade relations with China. Whereas European countries took almost a month to have their maiden case. Thailand took 62 days to mark its 100
th case from the index case while other nations crossed the same benchmark between 31 to 45 days. Importantly, South Korea and the US employed early 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.
The early grip for these nations can be attributed to their swift border closures and travel restrictions, suspension of educational institutions, closure of public events, and meticulous testing and contact tracing from an early time point. The nations like US, UK, and Canada needed just 9, 12, and 22 days respectively to climb 10,000 cases and witnessed an exponentially rapid spread in the following days. Notably, the US and UK delayed the implementation of stringent lockdowns, a public transport ban, and event cancelation compared with other nations, which later proved fatal. However, the UK and Canada managed to regain control over the spread of disease, while the US succumbed to COVID-19 and witnessed over 4 million cases and is still facing an active pandemic.
Cases in the US have skyrocketed suggesting the inefficiency and flaws in their pandemic management strategies. The US dominates globally with a case toll of more than 4 million (
Figure 2). The lack of previous experience in managing viral outbreaks (e.g., Zika, Ebola, Middle East Respiratory Syndrome, 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 (
Table 1). The approach of viewing COVID-19 like a seasonal flu, despite medical knowledge warning to the contrary, proved detrimental [
28] with the lowest recovery response (RR) among the nations studied in this review of 8 countries in the top GHS index (47.57%;
Table 1). Ignoring ominous signs, the US administration focused on saving the economy rather than saving lives [
29]. Having a decentralized public health system, coordination became arduous and early advisory warnings from nodal agencies like the Centers for Disease Control and Prevention (CDC) were not heeded. All of these factors made for a chaotic situation.
Even though the UK ranked 2 in the GHS index, the response towards COVID-19 was questionable. Having a National Health Service, stringent action plans against COVID-19 were not enacted, which attributed to a swift surge in cases by the end of March. Though the UK developed specific laboratory tests and coronavirus action plans to combat the disease, its 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). Non-adherence 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]. The CFR of 15.4 % (
Table 1) showed poor COVID-19 containment in the UK [
31].
Australia displayed commendable efforts to tame the viral spread to a state of single-digit cases per day since its index case in late January, though it’s now battling with a second wave of disease transmission. Early success in taming the outbreak was not only due to early closure of national borders, social distancing, quarantine and contact tracing of the infected, and cancellation of public events, but also partly attributed to transparent information sharing, escalated approach of imposing restrictions, swift testing of suspected infection cases and their contacts, and all high-risk individuals in hotspots. The government also focused on safeguarding economic ventures to continue business and released economic stimulus packages to their citizens. Importantly, the nation’s CFR was 1 out of 13,948 infected (
Table 1) which is well below the global average reflecting another facet of containing the pandemic in long run. The key to Australia’s success at reducing COVID-19 transmission was attributable to its public acceptance of spatial distancing and wide access to tele-health.
Canada couldn’t protect their elders in long-term care which increased their CFR (7.9%) and diminished RR (87.31%;
Table 1). A report by the Royal Society of Canada reported COVID-19 as a “shock wave” which revealed numerous long-standing deficiencies in the health care system which grossly affected their senior citizens [
32]. Access to primary health care was limited due to the shortage of registered nurses and other health care facilities. The government had to recall retired medical practitioners to meet the increased health care needs of the country [
33]. If a system of early warnings about the pandemic was in place, they could have brought the situation under control [
34].
Thailand’s centralized level of governmental administration made it easy to enact rules regarding the containment of an epidemic. The role played by employed village health volunteers in containment and mitigation measures was commendable. Moreover, Thai citizens adhered to governmental advice regarding the pandemic. Recent data showed that about 95% of Thais wore masks during the epidemic, which is highest in Southeast Asia [
35]. All these measures facilitated the containment of the epidemic which resulted in a case toll of 3,282 and CFR 1.8% (
Table 1) despite being the first country to report a COVID-19 case outside China.
With the 7
th position in the GHS index, Sweden followed a unique way of dealing with COVID-19. Instead of complete lockdown, limited movement restriction was imposed. The public maintained social distancing [
36]. The death per million population in Sweden was 564 (
Table 1), which is quite high compared with similarly GHS index ranked nations. The healthcare capacity in terms of bed numbers and infrastructure was far lower than other developed countries. The health care system focused on protecting the aged and the vulnerable population to reduce the spread of the virus, but this was ineffective in safeguarding the nation. The focus was to prevent over congestion of the health care system. Due to the congested healthcare system, the citizens with symptoms had to stay at home, which augmented fatalities. The way Sweden dealt with the epidemic invited much criticism from many corners of the world [
19].
South Korea’s response proved that they were well prepared for the epidemic even though it ranked 9
th in the GHS index. The screening program for COVID-19 was initiated well before the reporting of its index case. Mass testing was planned and executed along with large scale production of testing kits. Effective contact tracing was carried out using digital technology. Timely implementation of drive-through screening centers, widespread use of masks, and testing of asymptomatic individuals made Korea free from community transmission of COVID-19. 1 in every 100 citizens were tested, which was a high benchmark whilst combating COVID-19. The administrator’s accuracy in data sharing of the key features of the outbreak prevented ambiguity and confusion among the public. Moreover, Korea had formal standard operating procedures to be followed regarding the containment of epidemics [
37]. These measures helped them to limit the number of cases to 14,092 with a commendable recovery response (RR) of 91.30% [
33] (
Table 1).
Finland relied on a hybrid strategy to contain the virus spread which ensured normal living while still employing containment measures. The disease curve flattened from the early weeks of April which initiated the gradual lifting of imposed restrictions including travel bans, re-opening educational institutes, and business endeavors to minimize public life and economy from succumbing to the pandemic. Reciprocal support between the public and private sectors to prepare and stockpile the needed supplies and equipment for health care helped them in this emergency. The nation’s strong base in numerous human development indices, and timely streamlined containment strategies, coupled with strong legislation from governmental agencies, along with public support flattened the outbreak curve in April 2020, with 7,388 cases as of July 25
th in a population of nearly 5.6 million. The Finnish strategy highlights the need to balance the containment measures for disease outbreak and national sentiment. They brought the pandemic under control with the highest RR of 93.67% among the nations studied (
Table 1).
SARS-CoV-2 infection, which was initially thought to be spread through contact, is now proved to be disseminated by airborne droplets, although the complete picture is still evolving [
38]. The threat posed by the viral disease escalated and triggered global solidarity to work towards a definitive treatment regime or vaccine [
39]. To date, no specific treatment or clinical guidelines proved effective despite several randomized clinical trials, where efforts are continuing. Furthermore, numerous pharmaceutical companies and national laboratories are in the process of vaccine development which are in various stages of development and testing, with none approved for prophylaxis. As a general agreement, a SARS-CoV-2 vaccine is the ultimate solution to reduce the mortality and morbidity associated with the disease [
40].
1. Lessons from well-controlled nations
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.
Transparency in sharing the available information related to the disease outbreak and related epidemiology, widespread testing of suspected cases and contacts assisted the Australians to flatten the disease curve. Coordinated efforts by the health workers, responsible public actions, and centralized rules enactment by the Thailand administration facilitated them to curb the spread of infection. The MERS outbreak of 2015 enabled South Korea’s development of standard operating procedures to be followed during an epidemic. Their widespread testing and effective case isolation helped to bring the infection under control. Coordinated efforts through public-private partnerships at different phases of containment along with citizen cooperation aided a low rate COVID-19 infection in Finland.
2. Modifications and reformations for future pandemics
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.