Overview

Early Insights & Past Epidemics

In May 2020, the COVID-19 pandemic was just beginning. It was too early to declare exemplars...

but countries such as South Korea, Vietnam, and Germany were already proving to be comparatively successful at controlling the outbreaks within their borders. Exemplars in Global Health wanted to know what accounted for this early success. We worked with a broad set of collaborators to find out, compiling a set of resources to help learn from past epidemics and outbreaks and make sense of the COVID-19 pandemic as it was unfolding. Together we defined the essential public health actions needed to control COVID-19; examined the early available data to identify positive outliers in the early phase of the pandemic; and studied the three emerging COVID-19 success stories in detail.

Contents

Early Insights

We started with the four phases of epidemic preparedness and response as defined by the Global Health Security Index project in 2019. Each phase—(1) prevent, (2) detect, (3) respond: contain, and (4) respond: treat—comprises its own set of key actions; at the same time, the four phases are inextricably linked, because success or failure in one phase determines the priorities for subsequent phases. In general, the shape of a country’s epidemic curve depends on its performance during each phase of its response.

As the COVID-19 pandemic continued, with multiple surges in cases and deaths in many countries, it became clearer than ever that the four phases are sequential but not linear: countries can move through them in either direction. As part of Exemplars’ ongoing work on COVID-19 response, we are elaborating a more explanatory conceptual framework that accounts for other contextual and systems factors and interventions, including public-health and other social measures. The new framework will help illustrate how these factors contribute to the outcomes we are using to define “success” in controlling the pandemic and mitigating against its indirect effects; it will also allow us to begin to quantify how much of these outcomes can be attributed to particular components of the framework.

Essential Actions to "box in" the virus

COVID-19 Essential Actions

Countries with a strong, enabling environment that successfully test, isolate infected people, trace contacts, and quarantine contacts can “box in” the virus.

Until an effective COVID-19 vaccine is available, countries need to focus on detecting and containing the disease to reopen society safely. There are four essential actions to strengthen detection and containment: (1) widespread testing to know who is infected, (2) complete isolation of people who are infected, (3) comprehensive tracing of those who were in contact with infected people, and (4) quarantine those contacts to prevent transmission. Using public health measures that already exist, it is possible to keep the pandemic under control, and we highlight several countries that appear to have done so. To implement these measures effectively, countries need to build trust, communicate clearly, and strengthen the enabling environment for public health. All countries need to commit to adapting these proven strategies to their local context.

Authors: Resolve to Save Lives (an initiative of Vital Strategies), & Exemplars in Global Health 
Box it in
How experts use data to identify emerging COVID-19 success stories

Finding COVID-19 Success Stories

Analysis of emerging data suggests which countries are achieving positive results in detecting, containing , and treating COVID-19. This pandemic is unfolding and there is much that remains unknown. Without the benefit of hindsight, we cannot definitely declare exemplars, but we can learn valuable lessons from countries' actions in the initial phase of the pandemic. 

Total confirmed COVID-19 cases, per million people

The basis of Exemplars in Global Health (EGH) is learning lessons from countries that excel in key areas of global health. In a complex, ongoing pandemic such as COVID-19, however, identifying positive outliers can be challenging. Using the epidemic preparedness and response framework, a methodology was devised for understanding, with appropriate rigor and sophistication, which countries are performing well at detecting, containing, and treating COVID-19. Several graphs were included as part of this methodology, and a brief analysis of each graph is provided to describe what it does and does not reveal about the success of the COVID-19 response in a given country.

Authors: UK-Public Health Rapid Support Team, Our World in Data, & Exemplars in Global Health

EMERGING COVID-19 SUCCESS STORY

South Korea Learned the Lessons of MERS

Health system reform in the wake of the MERS epidemic in 2015 put South Korea in a position to act quickly and effectively.

When the COVID-19 pandemic arrived, South Korea quickly established 600 screening centers, transformed public facilities into isolation wards, hired and trained hundreds of epidemiologists and contact tracers, and used technology effectively to contain the disease. With the recent MERS epidemic in mind, the population was especially willing to wear masks, cooperate with contact tracers, and listen to public health officials. In addition, reforms enacted in the wake of MERS gave epidemiological intelligence officers access to much more data, which enabled them to plan and execute a better response.

Authors: Ariadne Labs, Seoul National University College of Medicine, & Exemplars in Global Health
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EMERGING COVID-19 SUCCESS STORY

Vietnam's Commitment to Containment

Vietnam’s intensive test-and-trace strategy in areas with confirmed cases is one reason the country has maintained extraordinarily low case counts.

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Vietnam’s government started responding to COVID-19 even before the country reported its first case. Although it had a strong public health infrastructure already, Vietnam is not engaging in broad testing; however, if even a single case is reported, it does extensive testing and contact tracing in the area, followed by quarantines. From the beginning, the government has communicated clearly and powerfully with the population about what they can do to contain the virus. Though Vietnam has a population of nearly 100 million, the country reported only 35 deaths from COVID-19 in 2020.

Authors: Oxford University Clinical Research Unit Hanoi, Vietnam’s Ministry of Health, National Institute of Hygiene and Epidemiology in Hanoi, The Partnership for Health Advancement in Vietnam, & Exemplars in Global Health

EMERGING COVID-19 SUCCESS STORY

Germany’s Push to Maintain Progress

Germany early response to COVID-19 was strengthened by a highly effective health system, although it has faced challenges in maintaining its early success.

German researchers developed one of the first COVID-19 diagnostic tests and the country’s laboratories scaled up quickly, leading to high testing capacity throughout the country. Germany’s Robert Koch Institute has gathered detailed epidemiological data which is shared publicly to aid in decision-making. The country’s federal system of government gives significant power to individual states, so the response strategy has varied from state to state. After the country reopened throughout the spring and summer, there was a large surge in cases that started to come under control as of January 2021.

Authors: Robert Koch Institute, Health Protection Authority City of Frankfurt, & Exemplars in Global Health
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Learning from past outbreaks and epidemics

While the effects of previous outbreaks of other diseases have not been nearly as extensive as those from the COVID-19 pandemic, we can learn relevant lessons from each of them—and from the countries that successfully controlled them. EGH and its partners worked to identify those lessons, along with the ways in which individual countries have applied them to truncate or mitigate the COVID-19 pandemic. For example, the reforms and measures South Korea and Vietnam implemented in response to the MERS and SARS epidemics respectively have served them well during the COVID-19 pandemic.

Trajectories of past epidemics

Partner Case Studies

Preventing Ebola in Uganda

A case study from the Makerere University School of Public Health and the Johns Hopkins Center for Health Security

The Kivu Ebola epidemic began on August 1, 2018, when four cases were confirmed in North Kivu Province in eastern Democratic Republic of the Congo (DRC). To date, the epidemic has led to over 3,400 confirmed and suspected cases in the DRC and over 2,200 deaths. Because there is frequent movement from North Kivu across the border into Uganda, including a regular influx of refugees, the Ugandan government and its partners put themselves on high alert and mobilized resources to prevent the importation of cases, detect imported disease quickly, contain the spread of imported disease, and treat sick people appropriately.

In June 2019 the virus reached Uganda, but only four imported cases have been reported as of May 2020 and no in-country transmission has occurred. Uganda has focused on preventing an outbreak and detecting cases. Prevention activities included assembling a multisectoral team and establishing robust coordinating mechanisms, running simulation exercises to assess the country’s readiness, and implementing a prophylactic vaccination effort among frontline workers and contacts of suspected cases. Detection activities included health communications and messaging and cross-border surveillance in collaboration with officials from the DRC.

These accomplishments, despite foundational challenges facing Uganda’s health system, prompted Makerere University School of Public Health and the Johns Hopkins Center for Health Security to conduct this study, based on an in-depth gray literature review and key informant interviews.

Surveillance Technology in Thailand, Cambodia, and Tanzania

A case study from Ending Pandemics

San Francisco-based nonprofit Ending Pandemics works with partners in lower-income countries using innovative methods to prevent, detect, and contain disease outbreaks. Its collaborations take a “One Health” approach, which starts from the evidence that because three in four emerging infectious diseases arise in animals before spreading to humans, detecting disease in animals faster can prevent outbreaks in humans. This approach enables early detection of and rapid response to outbreaks in human populations.

Working with local organizations, Ending Pandemics supports the development of technology-enabled surveillance systems that rely on community input. These systems include mobile applications in Tanzania and Thailand and a digital hotline in Cambodia. In both cases, Ending Pandemics and its partners hosted in-country EpiHacks (epidemiology hack-a-thons) to engage local software developers in the challenge of building efficient, robust surveillance systems. These sessions also generated buy-in from local health professionals, communities, and the private sector- generating early buy-in from the key stakeholders. As implementation partners continued fine-tuning the technology, they began recruiting community volunteers and raising citizen awareness to empower people to use the systems to the greatest effect.

Thailand’s Participatory One Health Disease Detection (PODD) project launched in 2015 and Cambodia’s 115 Hotline launched in 2016. Both systems have effectively reduced detection and response time and limited the spread of animal disease, clearly establishing that user-friendly technology alongside community mobilization can facilitate successful “bottom-up” disease surveillance.

The two systems have since been adapted to serve other public health purposes, including early warning of weather shocks and, more recently, COVID-19 surveillance. With continued support from Ending Pandemics and buy-in from other local governments, they are being extended and replicated in other countries. In Tanzania, a project built on the PODD experience and led by the SACIDS Foundation at Sokoine University of Agriculture is demonstrating promising early results.

Additional Resources

H1N1

Response to the First Wave of Pandemic (H1N1) 2009: Experiences and Lessons Learnt from China

W. Liang, L. Feng, C. Xu, N. Xiang, Y. Zhang, Y. Shu, H. Wang, H. Luo, H. Yu, X. Liang, D. Li, C.-K. Lee, Z. Feng, Y. Hou, Y. Wang, Z. Chen, W. Yang

From SARS in 2003 to H1N1 in 2009: Lessons Learned from Taiwan in Preparation for the Next Pandemic

M.-Y. Yen, A.W.-H. Chiu, J. Schwartz, C.-C. King, Y.E. Lin, S.-C. Chang, D. Armstrong, P.-R. Hsueh

SARS

Epidemiology and Control of SARS in Singapore 

Kee-Tai Goh, Jeffery Cutter, Bee-Hoon Heng, Stefan Ma, Benjamin KW Koh, Cynthia Kwok, Cheong-Mui Toh, Suok-Kai Chew

From SARS in 2003 to H1N1 in 2009: Lessons Learned from Taiwan in Preparation for the Next Pandemic

M.-Y. Yen, A.W.-H. Chiu, J. Schwartz, C.-C. King, Y.E. Lin, S.-C. Chang, D. Armstrong, P.-R. Hsueh

Lack of SARS Transmission among Public Hospital Workers, Vietnam

Le Dang Ha, Sharon A. Bloom, Nguyen Quang Hien, Susan A. Maloney, Le Quynh Mai, Katrin C. Leitmeyer, Bach Huy Anh, Mary G. Reynolds, Joel M. Montgomery, James A. Comer, Peter W. Horby, and Aileen J. Plant

SARS Transmission among Hospital Workers in Hong Kong

Joseph T.F. Lau, Kitty S. Fung, Tze Wai Wong, Jean H. Kim, Eric Wong, Sydney Chung, Deborah Ho, Louis Y. Chan, S.F. Lui, and Augustine Cheng

MERS

Zero Transmission of Middle East Respiratory Syndrome: Lessons Learned From Thailand

Surasak Wiboonchutikul, Weerawat Manosuthi, and Chariya Sangsajja

Imported Case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection from Oman to Thailand, June 2015

T Plipat, R Buathong, S Wacharapluesadee, P Siriarayapon, C Pittayawonganon, C Sangsajja, T Kaewpom, S Petcharat, T Ponpinit, J Jumpasri, Y Joyjinda, A Rodpan, S Ghai, A Jittmittraphap, S Khongwichit, DR Smith, VM Corman, C Drosten, T Hemachudha

Ebola

Nigeria’s Ebola Outbreak Response: Lessons for Future Epidemic Preparedness

Emmanuel Musa, Abdulsalam Nasidi, and Faisal Shuaib

Managing Ebola from Rural to Urban Slum Settings: Experiences from Uganda

Sam I Okware, Francis Omaswa, Ambrose Talisuna, Jacinto Amandua, Jackson Amone, Paul Onek, Alex Opio, Joseph Wamala, Julius Lubwama, Lukwago Luswa, Paul Kagwa, Thorkild Tylleskar

An Account of the Ebola Virus Disease Outbreak in Nigeria: Implications and Lessons Learnt 

Akaninyene Otu, Soter Ameh, Egbe Osifo-Dawodu, Enoma Alade, Susan Ekur, and Jide Idris

Our Collaborators

 

Exemplars in Global Health COVID-19 Webinar

On July 20, Exemplars in Global Health co-hosted its inaugural webinar in partnership with Amref Health Africa, the Center for Global Development, and the Center for Strategic and International Studies. The conversation featured global experts discussing best practices in COVID-19 response, takeaways from the collective response to date, and how critical learnings from successful country responses to COVID-19 and prior disease outbreaks could shape future response efforts.
Highlights from the full webinar can also be viewed on the Exemplars YouTube channel.

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