Essential actions to "Box in" the Virus

To guide our thinking about epidemic preparedness and response, Exemplars in Global Health applies a four-part framework based on the framework developed by the Global Health Security Index, which includes prevention, detection, containment, and treatment. The foundation for all of these is an enabling environment that promotes strategic decision making and effective implementation.

In regard to COVID-19, we focused our research specifically on detection and containment, because they are the keys to reopening societies around the world as quickly as possible.

The COVID-19 pandemic is among the most complex public health problems the world has ever faced. Leaders in every country must create appropriate strategies based on the local context. They must monitor not only on their citizens’ health but also economic outcomes and civil liberties. Meanwhile, countries must make plans for the future based on imperfect and incomplete information due to gaps in data and knowledge.

Emerging success stories in early COVID-19 management have been identified in South Korea, Vietnam, and Germany - each implementing this framework differently depending on factors such as transmission rates, resources available, and social norms. However, our observations suggest that countries who are most successful in containing the disease have displayed strong leadership and respect for human rights and science. In addition, they prioritize:

• Data-driven decision making—collecting and analyzing data from a variety of sources to enable countries to assess priorities and test whether interventions are working
• Adaptation—being flexible, learning from setbacks, and iterating continually to inform better results in a rapidly evolving environment
• Communication—clear and consistent engagement with communities to build trust and increase the likelihood that people will understand and comply with the recommendations of public health authorities

With this context in mind, we worked to showcase a flexible framework for detection and containment specific to COVID-19. While sheltering in place reduces transmission, it does not alter the underlying conditions that can allow COVID-19 to spread explosively if we resume normal activities. The following set of essential actions will help us move beyond sheltering in place and is based on what is working in countries with early positive outcomes.

Expand and Prioritize Testing

Testing is the fundamental tool for providing reliable information, but this information is only useful when countries can effectively gather, assess, and use it to inform public health decisions. Different tests are used for different purposes and contexts, and the role of testing will change depending on what stage of containment we are in. Best practices in testing can help countries determine their testing strategy—that is, which groups of people a country prioritizes for testing—while recognizing there is no one-size-fits-all approach.

To control the COVID-19 pandemic, we first need to know who is infected. To do so at scale will require more diagnostic tests, faster processing speed,  and prioritization of who is tested. Governments need to ensure that enough tests are produced, and both public and private labs need to accelerate processing. In addition, best practices are needed as to the appropriate application of serological testing, which identifies antibodies showing that a person has been infected in the past.

We need the capacity to test all people with suspected COVID-19 disease, everyone hospitalized for any reason, and those working in health care or other essential roles. Where this is not possible due to resource constraints or context, testing can be targeted to identify higher-risk groups. These groups include sick health care workers, sick people in shared housing facilities (e.g., nursing homes, jails, refugee camps, and shelters), and every one of their contacts, as well as every person in a disease cluster who could be infected with COVID-19. 

Ultimately, we must test even more broadly to learn more about presymptomatic and asymptomatic transmission and establish national surveillance systems to monitor the disease. We also need to provide repeat testing of cases and contacts to identify when it is safe for people to return to society. A voluntary registry could be established (similar to immunization registries) to identify people who have recovered or who have sufficient antibodies and therefore may be able to help with the response. 

Isolate Infected Patients

We must isolate people infected with COVID-19 to reduce transmission and prevent introduction into high-risk environments such as clinics, hospitals, and shared housing facilities. This includes isolating people presumed to have the disease while confirmatory testing is being conducted, thereby restricting the movement of those who could be entering the most infectious period of their potential illness. In the United States, during the first two months of the pandemic, at least 10,000 health care workers fell sick, more than 2,500 nursing homes reported cases, and more than 500 detainees and correction officers in a single jail in Illinois had tested positive.¹ As of early May, more than half of the deaths in Canada, France, Ireland, and Spain had occurred in nursing homes.²

Hospitals must rapidly identify and effectively isolate all infected patients. Nursing homes and other shared housing facilities with large populations of high-risk people should adopt strict physical distancing, restrict access to visitors and non-essential personnel, train staff on infection prevention and audit their performance, and screen staff and residents regularly for illness.

People with COVID-19 whose symptoms do not merit hospitalization should isolate at home if they can do so safely. For those who live with other family members, however, isolating at home may not be the best option. Each community must therefore provide facilities for isolation that are safe and pleasant.

Trace Contacts

Everyone who has been in contact with an infected person must be identified and notified quickly. For this to occur, a massive expansion of contact tracing capacity is needed in most countries. Contact tracing is extremely resource-intensive.

In an epidemic, an infection is not passed on from one person to another in a simple chain; it spreads more like a web. If just one chain of transmission in this web is missed, the virus can continue to spread through the community.

Although the idea of contact tracing is simple, implementing it is not. Contact tracing requires technical knowledge, people skills, access to resources, and supportive, expert supervision. It involves conducting detailed interviews with every confirmed or presumptive case of COVID-19, detailing their activities hour by hour throughout the entire infectious period, and recalling everyone they were in contact with during that time. Those people must then be contacted, interviewed, and tested if necessary. If those contacts are infected, then their contacts must in turn be identified and interviewed. This process continues until the end of any possible transmission chain has been reached.

Political and cultural leaders should support this process by communicating clearly with the public to explain why contact tracing is necessary, fight any stigma associated with being identified as a traced contact, and allay fears about civil liberties restrictions. When done correctly, contact tracing addresses confidentiality and privacy concerns while allowing governments to take appropriate protective action.

Quarantine Contacts

To control COVID-19, we must ensure that people who have been in contact with infected people (confirmed or suspected) are quarantined. The average incubation period for COVID-19 is five days, but symptoms can take as long as two weeks to develop.³ COVID-19, unlike SARS, is spread by infected people who are presymptomatic or asymptomatic.^4 5

It is essential to make services and support available to people in quarantine so they can adhere to prescribed guidelines. The details will vary greatly by context, but services and support can include delivering food and hygiene products, providing help with childcare or eldercare, and offering a hotline for psychological counseling.

People who are in quarantine need immediate access to telehealth services and care, with immediate testing and isolation available if the quarantined person or anyone else in the household develops COVID-19 symptoms. 

Emerging Success Stories

The objective of Exemplars in Global Health is to identify countries that have excelled in certain areas of global health and analyze their performance to highlight best practices that may be adapted to other countries. Although the world is still in the process of responding to COVID-19, several countries stand out as emerging successes, offering lessons about how to test, isolate, trace, and quarantine effectively.

Testing:

Germany leveraged its strong health system and private laboratory capacity to test large numbers of people earlier than any other European country. Now it is testing at one of the highest per capita rates in the world. Germany’s strategy is not just a story of success by numbers. Its intentional approach to testing includes testing people with minimal or no symptoms as well as those with more severe illness, and the country is beginning to explore antibody testing.⁶ South Korea, which experienced both the SARS and MERS outbreaks, invested heavily in epidemic preparedness and was able to get large-scale testing off the ground quickly. Vietnam used data effectively to prioritize who should be tested first to maximize impact, and it currently has the highest rate of tests per case in the world, suggesting that its testing strategy succeeded.

Isolation:

Singapore has protected health care workers from infection, thanks to smart policies dating back to the outbreak of SARS in 2003. At that time, health care workers accounted for 41 percent of Singapore’s infections, so the country first published its Influenza Pandemic Readiness and Response Plan in 2005 and regularly trains its hospital staff for this type of scenario. The country also built a stockpile of personal protective equipment, and health care workers scrupulously adopted the use of surgical masks, hand hygiene, and other standard procedures.⁷ Furthermore, during the response to COVID-19, hospitals reorganized into modular teams that rotate together, reducing exposure among them. ^8 9 Through April, the country reported only a handful of infections among its health care workers, and most or possibly all of these may have occurred in the community, outside of health care facilities. South Korea had a similar experience with MERS in 2015, which disproportionately affected health care workers. After the MERS outbreak, the country implemented more frequent training and designated facilities for use in the event of future respiratory outbreaks. During the COVID-19 pandemic, South Korea effectively prevented health care worker infections by separating COVID-19 patients from other care-seekers through the use of designated COVID-19 facilities, centrally triaging beds and supplies, and aggressively testing and screening health care workers.¹⁰

Contact Tracing:

Germany  meticulously traced contacts in the first cluster of cases (the “Munich cluster”), which helped authorities understand the spread of the disease and draw up a strategy. Germany is also currently rolling out digital tools to increase the efficiency of contact tracing. South Korea  used GPS and other records to improve its contact tracing. It also made patient trajectories public so that citizens could identify whether they may have been in contact with an infected person. Based on its experience with SARS, Vietnam conducted contact tracing for people up to three degrees removed from an infected person,¹¹ which led to mass testing, isolation, and quarantine.¹²

Quarantine Contacts:

Singapore  and South Korea have established strong support systems for people in quarantine.¹³ Some governments have set policies to support home delivery services for people quarantining at home, including engagement with neighborhood committees and volunteer groups. In South Korea, provinces and cities designate lodgings or other facilities as “living and treatment support centers” for isolation of individuals with suspected symptoms.¹⁴ Vietnam  used empty military barracks and school dormitories to create quarantine centers that could collectively hold thousands of people, and where international travelers are required to spend 14 days upon entering Vietnam to avoid any potential exposure to household members.¹²

Conclusion

Despite the devastation the pandemic has caused, we cannot yet say what portion of the population has been exposed, and the picture around immunity is unclear. Regardless, with strategic, swift, large-scale action consistent with the framework to test, isolate, trace contacts, and quarantine, we can get ahead of the virus and take the offensive. 

Although the framework identifies what countries need to accomplish, it does not explain how they might accomplish it. To help illustrate the pathways for action, we worked with partners to create more detailed case studies of South Korea, Vietnam, and Germany, paying particular attention to how they approached testing, isolation, contract tracing, and quarantine.

We selected the three countries through a rigorous quantitative selection process. We started with a group of countries with a population larger than 5 million people, a significant number of COVID-19 cases, and credible testing data. Then, using our epidemic preparedness and response framework and working with data partners, we chose three indicators for the detection phase, four indicators for the containment phase, and one indicator for the treatment phase. The countries that performed the best across all the indicators in each phase rose to the top of the list. We finalized the list by qualitatively screening for the countries whose experiences were most generalizable.

Having a clear framework and early success stories to learn from helps but does not diminish the difficulty of responding to this evolving and complex challenge. We need to invest in real-time, accurate data to track the virus. We need to enlist people to find and respond to cases, clusters, and outbreaks, and we need to train and supervise them well. This will require leadership, resources, and a global effort. Public health professionals have the tools to stem this crisis and guide us toward a safer world with stronger global collaboration and solidarity.