Miraal Mavalvala, Gabrielle Appleford
Alas – the coronavirus has made its way to the small Pacific nation of Vanuatu, a country that enjoyed being “covid-free” for almost a year since the emergence of the novel virus in December 2019. Vanuatu recorded its first case on 10 November 2020 – a 23-year-old, asymptomatic man who returned from the US on a strictly controlled repatriation flight and tested positive on the fifth day of quarantine. Official reports state complete adherence to personal protection measures from the time of take-off to reaching the quarantine facility followed by patient isolation and contact tracing. [1]
The “border case” as labelled by Vanuatu Public Health falls under Scenario 2A of the country’s COVID-19 Preparedness and Response Plan directing government measures towards hand hygiene while allowing schools and workplaces to remain open. [2,3] While a national action plan for COVID-19 exists, together with a COVID-19 task force, there is much to learn from best practices employed by a handful of countries in the early stages of their epidemics. This blog highlights effective COVID-19 response strategies of countries that were better able to contain the virus, namely Singapore, South Korea, Taiwan and Thailand.
Institutions, frameworks and responsibilities
A well-coordinated COVID-19 response necessitates a national public health body to serve as a ‘central leader’ for coordination between agencies and dissemination of information.
A ‘whole-of-nation’ approach underpinned national response strategies of all four countries featuring public-private partnerships and coordination frameworks. The Singapore Ministry of Health (MOH) served as central leader for the COVID-19 response and employed the Disease Outbreak Response System Condition framework that provided guidance on outbreak severity and corresponding public actions. [4] South Korea ensured a data-driven response to the crisis, facilitated by assigning a health systems researcher as Chief Secretary for the President. [5] Taiwan’s Ministry of Health (MOH) established the ‘Central Epidemic Command Centre’ (CECC) merely three days after Wuhan went into lockdown, which has three divisions (intelligence, logistics and operations) each staffed by appropriate personnel from institutions such as the Centers for Disease Control (CDC), Ministry of Foreign Affairs, Industrial Development Bureau, and Ministry of Economic Affairs. [6]
Data sharing
All four countries demonstrated well-coordinated data sharing processes particularly between scientists and policymakers for evidence-based decision making.
Epidemiological updates were relayed by Thailand’s Department of Disease Control (DDC) Situation Awareness Team to the Centre for COVID-19 Situation Administration (CCSA) ensuring timely policy decisions. The integrated information system of Taiwan’s command centre gathered real-time information from multiple government databases such as the National Health Institute (NHI), stockpile systems and the National Infectious Disease Statistics System and media reports. [7] The Taiwanese and South Korean governments shared real-time data on face mask stockpiles with the public. This facilitated the development of mobile apps by private entities which provided information to consumers on the availability and pick-up locations of masks, while allowing officials to monitor the flow of supplies.
Screening, testing and isolating
Strong public-private partnerships in the selected Asian countries led to well-coordinated case-based measures from the point of screening to potential hospitalization.
Individuals were screened at Public Health Preparedness Clinics (PHPCs) in Singapore, which served as intermediaries between communities and hospitals, before being sorted into risk categories and if necessary, transferred to specialized Infectious Disease (ID) hospitals. ‘PHPC-like wings’ housing negative pressure rooms and quarantine rooms could be set up in regular clinics and repurposed according to the need.
Vigorous testing and contact tracing were the cornerstone for outbreak control in the Asian countries, as exemplified by Singapore which reported a testing rate of over 57,000 per million population in June 2020.[8] Testing in Thailand involved strong public-private partnerships with the establishment of the COVID-19 lab network housing over 200 laboratories that performed PCR-testing. Regular proficiency assessments of the laboratories conducted by Thailand’s National Institute of Health (NIH) ensured standardized quality of testing.
Isolation facilities were set up across the countries to avoid spread of infection at the household level. The Thai MOH together with Ministries of Interior and Defense and the Thai Army led state-wide quarantine procedures, while private hospitals and hotels established Alternative State Quarantine (ASQ) facilities in major hubs. [9]
Contact tracing
Digitized contact tracing tools greatly facilitated aggressive contact tracing efforts of the selected countries to curb virus transmission.
Examples of such tools include the Bluetooth-operated ‘TraceTogether’, an open source and free to use platform in Singapore, and ‘TRACE’ in Taiwan. [7,8] South Korea went a step further by tracking case movement routes through credit cards, cellphone GPS, and security camera records, providing real-time monitoring and reduced workloads. Singapore’s MOH partnered with the Armed Forces and Police Force for tracing contacts, while Thailand mobilized Village Health Volunteers at the community level and South Korea employed temporary ‘Epidemiological Intelligence Service’ officers (repurposed government health officers trained in standardized contact tracing protocol). Existing policies allowed governments to take measures that raised privacy concerns, though efforts were made to pacify the population on the appropriate use of their data. Future recommendations to address privacy concerns include establishing an independent community advisory board for data governance.
Widespread production and distribution of masks
A distinct feature of all selected country responses was the widespread usage of masks in the early phase of the crisis, while many other countries debated their effectiveness.
The governments of South Korea and Taiwan exemplified best practices by centralizing the sale of masks and rationalizing their distribution. The Taiwanese government purchased all locally manufactured masks at an increased price, thus establishing a system wherein local producers were motivated to ramp up production in light of confirmed demand. [10] Mask distribution was rationalized through local pharmacies, convenience stores and governmental subsidiaries: in South Korea citizens could buy 2 masks per week on designated days based on their birth year, while in Taiwan each individual could purchase 3 masks per week. [10] Taiwan’s government leveraged technological tools to avoid price gouging and mask hoarding by using “Face Mask System 2.0”, a pre-ordering system through which one could purchase masks online. This was completed by ‘“Health Care Express eMask” a mobile app through which customers could pre-specify the day and convenience store for mask collection.
Risk Communication
Consistency, transparency and creativity underpinned the risk communication strategies of all four countries.
Singapore provided regular situation updates via traditional and modern media outlets and developed the caricature series called “COVID-19 chronicles” which provided simplified yet robust public health information on the virus. The Thai government partnered with ThaiHealth to establish several platforms for risk communication under the name “Thai Roo Soo COVID” including social media giants TikTok and Instagram. [9] A single representative of Thailand’s health sector at the national level delivered COVID-19 related messaging at regular CCSA press briefings which was relayed to Village Health Workers for dissemination at the community level. Information dissemination by a single body enables unified messaging, while using traditional and new media sources ensures equitable access to information.
References:
Vanuatu records first COVID-19 case in man who returned from US. (2020). https://www.aljazeera.com/news/2020/11/11/vanuatu-records-first-covid-19-case-in-man-who-returned-from-us
Vanuatu Ministry of Health (2020). COVID-19 Transmission Scenarios & Recommended Measures. https://covid19.gov.vu/images/Scenario/COVID-19_Transmission_Scenarios_English.pdf
Vanuatu Ministry of Health (2020). COVID-19 Health Sector Preparedness and Response Plan. (2020). https://covid19.gov.vu/images/To_Know/MOH_COVID_HSPRP_2.pdf
Chua, A. Q., Tan, M. M. J., Verma, M., Han, E. K. L., Hsu, L. Y., Cook, A. R., … & Legido-Quigley, H. (2020). Health system resilience in managing the COVID-19 pandemic: lessons from Singapore. BMJ global health, 5(9), e003317. https://europepmc.org/article/med/32938609
Oh, J., Lee, J. K., Schwarz, D., Ratcliffe, H. L., Markuns, J. F., & Hirschhorn, L. R. (2020). National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Systems & Reform, 6(1), e-1753464. https://covid19.elsevierpure.com/ca/publications/national-response-to-covid-19-in-the-republic-of-korea-and-lesson
Summers, J., Cheng, H. Y., Lin, H. H., Barnard, L. T., Kvalsvig, A., Wilson, N., & Baker, M. G. (2020). Potential lessons from the Taiwan and New Zealand health responses to the COVID-19 pandemic. The Lancet Regional Health-Western Pacific, 100044. https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(20)30044-4/fulltext
Jian, S. W., Cheng, H. Y., Huang, X. T., & Liu, D. P. (2020). Contact tracing with digital assistance in Taiwan’s COVID-19 outbreak response. International Journal of Infectious Diseases, 101, 348-352. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537669/
Kuguyo, O., Kengne, A. P., & Dandara, C. (2020). Singapore COVID-19 pandemic response as a successful model framework for low-resource health care settings in Africa?. OMICS: A Journal of Integrative Biology, 24(8), 470-478. https://www.liebertpub.com/doi/full/10.1089/omi.2020.0077
The World Health Organization and Thai Ministry of Health (2020). Joint Intra-Action Review of the Public Health Response to COVID-19 in Thailand https://www.who.int/docs/default-source/searo/thailand/iar-covid19-en.pdf
Yuen Wai Hung, Marina Cortes, and Mara Hansen Staples, “Creative public-private collaborations in Taiwan and South Korea bolster the fight against coronavirus,” Stanford Social Innovation Review, April 17, 2020. https://ssir.org/articles/entry/creative_public_private_collaborations_in_taiwan_and_south_korea_bolster_the_fight_against_coronavirus