Covid-19 and the Easing of Restrictions.  How can we Learn from Countries in Asia, Pacific and Europe?

An interesting article published on health policy in The Lancet September 24, 2020 by Han and others looks at this in great detail.

Many countries have implemented restrictions on population movement to slow the spread of severe acute respiratory syndrome Coronavirus 2 and prevent health systems from becoming overwhelmed;

Some have instituted full or partial lockdowns.

However, lockdowns and other extreme restrictions cannot be sustained for the long term in the hope that there will be an effective vaccine or treatment for Covid-19.

Governments worldwide now face the common challenge of easing lockdowns and restrictions while balancing various health, social, and economic concerns.

To facilitate cross country learning this heath policy paper used an adapted framework to examine the approaches taken by nine high income countries and regions that had started to ease Covid-19 restrictions: Five in the Asia Pacific region and four in Europe.  This comparative analysis presents important lessons to be learnt from the experience of these countries and regions.  Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations that are at risk, and suppress transmission to save lives.

There is an increasing realisation that removing Covid-19 restrictions is not about returning to the pre-pandemic normal but about gradually and cautiously transitioning to a new normal, while being ready to re-impose measures if, and when, necessary.

Nonetheless, countries have diverged in terms of the speed, scale, and intensity with which they have implemented similar interventions, and differences can be observed between Asia and Europe in this regard.

For example, many Asian countries, except Japan, promptly did extensive testing, tracing, and isolation of all cases, i.e. not just severe cases from the start of the outbreak, strengthened by innovative surveillance technology, whereas these processes have been considerably delayed in most of Europe, except Germany.

Furthermore, confirmed cases are mostly isolated in institutions in Asia rather than home, such as in Europe.

Wearing a face covering to protect others has also been adopted to a much greater extent in Asia than in Europe.

These differences should be regarded against the background of experiences with past pandemics and economic policies adopted in the years leading up to this current crisis.

In Europe, more than a decade of austerity measures have substantially weakened health systems and social protection in many countries.

By contrast, major epidemics, such as SARS in 2003, MERS in 2015, drove many Asian countries to invest in building robust healthcare and public health infrastructure that would be well equipped to handle the next outbreak.

The public has also been better conditioned to cooperate with strict rules and invasive surveillance in times of crisis compared with the public in countries without experience of major epidemics, with most people accepting a trade off between their personal rights and the public good.

Although the future of Covid-19 is unknown at present, countries should plan and prepare for the worst case scenario.  It is not too late for the following lessons to be learnt and applied now.

First, as described here, countries can move forward mainly on the basis of the epidemiology or on the epidemiology in combination with other considerations; however, a clear and transparent plan that prescribes which factors are being taken into account is essential.  Ideally these plans should explicitly state the levels or phases of easing restrictions, the criteria for moving to the next level or phase, and the containment measures that each level or phase entails.

Second, countries should not ease restrictions until they have robust systems in place to closely monitor the infection situation.  Although much has been said about the use of R as a decision making indicator, it requires data of high quality and real time and it needs to be interpreted in the context of a good understanding of the epidemiology.

For example, a small localised outbreak can increase the R value for the whole country, but it does not necessitate a nationwide lockdown.

Third, continued measures to reduce transmission will be needed for some time.  For example, decreasing interactions to a few repeated contacts create social bubbles, as pioneered by New Zealand can allow interaction while reducing transmission.  It is now accepted that the cloth face coverings can significantly reduce person to person transmission, with one German study reporting that the use of face coverings reduced the daily growth rate of reported Covid-19 infections by 40% to 60%. 

Crucially governments should educate, engage, and empower all members of society, especially the most vulnerable to participate in the pandemic response.  Rather than crafting these measures on the basis of assumptions about what can communities can or cannot accept, citizens should be directly involved in the process of co-producing tailored solutions appropriate for the local context.

Fourth, each country should have an effective find, test, trace, isolate and support system in place.  Preliminary data for testing suggests that identifying and isolating mild and asymptomatic cases can significantly reduce R, healthcare burden, and overall fatality.  The novel drive through a walkthrough screening model in South Korea encourages proactive testing of potential case contacts offers a safe and efficient way to expand and enhance case finding.  The modelling studies also suggested that institution based isolation, as adopted by some Asian countries, is more effective than home based isolation at reducing household and community transmission.

On contact tracing, at base tracing is estimated to stop transmission if there is a 56% uptake rate in the population, and can be effective at slowing transmission at lower uptake rates.

However, digital tracing cannot replace traditional manual tracing.

As more evidence becomes available, some of these strategies might be able to aid countries in maintaining viral suppression and avoiding return to a full lockdown.

Fundamentally, this find, test, trace, isolate, and support system needs to be supported by sustained investment in public health capacity and health system capacity in terms of facilities, supplies and workforce.

WHO and the International Monetary Fund have jointly appealed for governments to prioritise health expenditures, which should go hand in hand with training and retaining skilled workers to fuel economic recovery.

Finally, the argument is strong for countries adopting a so called zero Covid strategy which aims to eliminate domestic transmission.

The New Zealand experience shows that this strategy is challenging but is an important aspiration, not least as the growing burden of so called long Covid becomes apparent in people who have survived Covid-19 who continue to have symptoms for longer than expected.  As more countries start to reopen their borders, screening tools and quarantine measures become essential to identify potential cases and prevent further transmission in the community.  To ensure that control measures are adequate, it is important for countries to review and optimise these processes regularly.

In the spirit of international collaboration, this health policy paper has presented lessons that can be learnt from nine countries and regions about the complex and challenging task of easing Covid-19 restrictions.  As New Zealand’s experience shows, easing restrictions is something that should be managed with great care and continued vigilance, and, at the time of writing, Spain, Germany, and the UK have offered a reminder of the enormous potential for resurgence if comprehensive safeguards are not in place.  Given the rapidly evolving nature of the pandemic and the measures taken in response to it, this paper inevitably provides a provisional snapshot rather than a conclusive analysis, of the situation and strategies of various countries and regions.  Nonetheless, the comparative framework developed in this paper can continue to be used to facilitate cross country learning and guide future policy making.  We hope that countries will continue to share their experience, information and strategies as they respond to this virus that knows no borders.

Easing of restrictions requires:

  1. Knowledge of infection status.  It seems intuitive that a country should not open up until it has a surveillance system of high quality in place and has confirmed that infections are being suppressed.
  • Community engagement.  For societies to reopen safely, communities should be fully engaged and empowered to protect themselves from the virus and the effect of the crisis, especially the most vulnerable populations.
  • Public health capacity.  The core of any effective exit strategy for Covid-19 restrictions should be a surveillance system that includes active case finding, testing all people with suspected infection, tracing their close contacts, isolating people with a confirmed infection, and supporting them in isolation.  In the Asian countries and regions, all people with a confirmed infection are isolated and supported in hospitals or other facilities whereas in the European countries, patients who have mild symptoms are typically isolated at home.
  • Health system capacity.  An adequate health system capacity is crucial to cope with possible surges in infection after lockdowns are lifted.  This capacity includes having sufficient treatment facilities, medical equipment and healthcare workers.
  • Border control measures.  As countries and regions gradually reopen their borders, the inflow of travellers should be managed to reduce the risk of people with Covid-19 travelling into the area.  Five countries and regions in Asia Pacific have implemented strict border control measures, with Hong Kong, New Zealand, and Singapore keeping their borders closed to most visitors.

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