What measures have been put into place in different countries and the evidence behind them?
Updated: Jun 8, 2020
Since the beginning of this outbreak in December, 151 countries have had confirmed cases of the COVID-19 virus. Since then, the epicentre of the pandemic has spread from the Western Pacific area to Europe.
Seeing daily news updates of measures implemented in various countries to combat the virus, as well as talking to friends living in Europe, has highlighted to me the differences in the management of this pandemic globally.
The current aim of most countries inflicted by the virus appears to be the same and is depicted by the graph above (BBC). The graph demonstrates this aim: to flatten the infection curve to ensure that there is a gradual number of cases over a longer time period rather than a spike in cases over a short time frame which would overwhelm the healthcare infrastructure.
However, the way in which the United Kingdom (UK) is going about this appears to be different from its neighbours. That said, the UK appears to be scaling up measures gradually.
At the time of writing this blog, the current UK guidance is for anyone who has a new persistent cough or high fever to self-isolate for 7 days. If they live with anyone, they too should self-isolate for 14 days if they are asymptomatic.
I have divided the rest of the blog into a few measures implemented in other countries compared to in the UK. It should be said, that the aim of this blog is not to criticise different methods, rather to compare the differences in approach and investigate why such differences may exist.
Testing in the community
Given that the WHO director general Tedros Adhanom Ghebreyesus recently said “You cannot fight a fire blind. Test, test, test” made me wonder why then the United Kingdom has not been focussing on testing for the virus in the community setting.
Many mathematical models have been created to help monitor future trends of the virus. One such example was in a study by Ruiyun Li et al, which looked into the effect of undocumented cases of the virus versus confirmed cases in China. In the article, undocumented cases refers to those who are able to infect others but experience mild or no symptoms and therefore go unrecognised. This increases the risk of them being exposed to a greater number of individuals than they would have been had they shown symptoms.
This was particularly interesting to me as I can imagine that within the UK there is a high rate of undocumented infections given the fact that there is currently no testing being done in the community setting. In this model, they found that from the 10th January to the 23rd, only 14% of cases of total infections were reported. This means that 86% of the cases were undocumented. This model found that without transmission from undocumented infections, the reported infections during this same time period were reduced by 78.8% across all of China. This highlights that undocumented infections contributed to the increasing spread of the virus within China.
One could argue that the same would stand true in the United Kingdom. Therefore, why is testing the community not being carried out? The reasoning for this is that with limited resources, Public Health England the NHS England Department and Social Care have decided to prioritise testing for those most at risk of severe illness. This includes (taken from the gov.uk website): all patients in critical care or requiring hospital admission for pneumonia, acute respiratory distress syndrome or flu-like illness or where an outbreak has occurred in a residential or care setting.
School, bar and sporting event closures
Singapore has not implemented school closures and has managed to successfully curb the number of cases of the virus. From February 5th to 18th2020 Singapore had the highest number of cases outside of China. It rapidly curbed the spread of the virus via multiple measures including via strict surveillance and contact tracing.
That said, in China and Hong Kong, school closures where implemented. These two countries also had an overall successful response to the pandemic, once measures were implemented.
This suggests that there are multiple ways in which one can tackle a pandemic. In fact, the majority of cases in children have been mild and there would be implications for working parents if schools are closed. This would be particularly difficult on the NHS if staff are unable to come into work due to lack of childcare.
That said, over the course of writing this blog, the UK government announced that schools would be closing nationwide to slow the spread of the virus. However, schools will be making provision for children of keyworkers, such as NHS staff, and vulnerable children. At the time of writing the blog, there was no further clarification on what this would mean.
The UK has not yet closed restaurants or pubs, contrary to other countries such as Italy and Greece. Interestingly, contrary to the government’s advice, the prime minister’s own father has stated that “of course I’ll go to a pub if I need to go to a pub.” This introduces the issue of compliance to advise given by the government.
The UK is one of the only European countries who has not imposed travel restrictions. The Foreign Office has only advised UK nationals against all but essential travel.
In January 23rd 2020, Wuhan City was in lockdown. A study by Chad R Wells et al calculated that by 15th February 2020, the lockdown on travel had reduced the rate of disease exportation by 81% compared to if they had had no border restrictions! This suggests that border control measures have the potential to delay the early spread of the disease.
The USA has introduced airport screening of individual wishing to enter into the states. However, the evidence of the effectiveness of this is slim. The same paper mentioned above found that about 64% of infected individuals travel during the incubation period of the disease (i.e. the period in which they are infectious but have not yet shown symptoms). Therefore, screening at the airports may not be that effective in detecting cases.
Other Draconian approaches
Many countries have been described as taking Draconian approaches- the UK is surprisingly, not in the category. The reasoning behind advising rather than not implementing comes from this idea of behaviour fatigue. This is the worry that individuals will tire of the limitations of social contact and revert to prior behaviour. A recent open letter (which I have linked below) signed by multiple behavioural scientists, outlines the limited evidence base for this concept.
On searching for evidence myself, behavioural fatigue appears to have been an issue in previous epidemics, supporting the notion of compliance being proportional to the perceived threat.
However, the arguments against this are that, the perceived threat in this case is substantially higher than threats from previous flu epidemics.
There are also other countries, for instance, China and South Korea, who have successfully implemented such measures without behaviour fatigue.
However, one should take into account the cultural differences. In China, the idea of social responsibility is a lot more heavily ingrained into society than in the UK.
Greece closed all restaurants and pubs to help curb the spread of disease. However, the locals started going to the beach to socialise there instead. Soon after, all organised beaches and ski resorts were closed. This suggests that severe implementations do not necessary mean people will abide by them. It also demonstrates the complexity of public policy and having to not only take into account the behaviour of the virus but also the behaviours of the local target population.
It is important to note that the UK government guidance online does state that recommendations may evolve to keep up with new discoveries of the virus. I think this is the fundamental message: the whole world is still learning about this novel virus. No matter how many models are made which predict future events with or without certain measures, due to uncertainty of the behaviour of the virus itself as well as the behaviour of the target population, it is difficult to make a plan. That too, when there are multiple opinions to take into account across multiple disciplines. The impact of this virus is yet to reach its peak. Therefore, in the interim, continue to abide by national policy and I hope that you are staying safe!
Provides updated information on the number of cases per day, deaths and the countries affected.
An interesting article explaining the different case curves
An article modelling the impact restricting travel has on preventing the number of cases- measuring country-level exportation risks
An article using mathematical modelling to assess the impact of undocumented cases
This is the open letter mentioned in the text
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