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      Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe

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          The COVID-19 pandemic is an unprecedented global crisis. 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 Health Policy paper uses an adapted framework to examine the approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (ie, Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (ie, Germany, Norway, Spain, and the UK). This comparative analysis presents important lessons to be learnt from the experiences of these countries and regions. Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations who are at risk, and suppress transmission to save lives.

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          Most cited references 9

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          Institutional, not home-based, isolation could contain the COVID-19 outbreak

          In the absence of vaccines, non-pharmaceutical interventions such as physical distancing, intensive contact tracing, and case isolation remain frontline measures in controlling the spread of severe acute respiratory syndrome coronavirus 2. 1 In Wuhan, China, these measures were implemented alongside city lockdown, mass quarantine, and school closure during the coronavirus disease 2019 (COVID-19) outbreak in January and February, 2020. 2 Critical to Wuhan's success, cases identified through liberal testing, regardless of symptom profile, were immediately isolated in purpose-built shelters, as delays in isolation from symptom onset increase transmission risk substantially. 3 European countries and the USA have mostly followed these measures, except, in most cases, only people with severe symptoms are being admitted to hospital, whereas people with mild symptoms are asked to self-isolate at home. Test kit shortages and limited health-care facility capacity have also led to unconfirmed cases self-isolating at home. Compliance with home isolation, however, is partial. In Israel, 57% of people with unconfirmed infection did not self-isolate because they were not financially compensated 4 and because the lay public is not informed on how to keep strict isolation measures at home. We modelled and compared two types of isolation measures: institution-based isolation and home-based isolation. The former is modelled after China, with isolation of confirmed cases in quarantine facilities 5 resulting in no further onward within-household transmission, and the quarantining of contacts with legal enforcement. Once quarantined, contact rates are reduced by 75% in the household and by 90% in the community. We contrasted this with home-based isolation, modelled after Europe and the USA, where home isolation of confirmed cases is the current policy. This approach is assumed to cause a 50% reduction in contact within the home and a 75% reduction in contact in the community. Contact cases have an overall reduced interaction at an assumed contact rate of 50%. No reduction in transmission is assumed to occur for asymptomatic infections because asymptomatic cases are not being identified and isolated. We used GeoDEMOS-R, 6 an agent-based respiratory illness simulation model that estimates the total number of infections through time and measures the effects of quarantining, physcial distancing, and school closure on a city population. A different calibration procedure, 7 however, was used to estimate the number of infections over time. We assumed a basic reproduction number of 2 for the initial 4-week phase of the COVID-19 epidemic, with a subsequent decrease in the effective reproduction number due to the implementation of physical distancing control measures. The model represents a large city of 4 million residents, modelled upon the city-state of Singapore. Relative to the baseline with no control measures (figure ), our models showed that home-based isolation causes an 8-day delay (IQR 5–11) in the epidemic peak, with a corresponding reduction of 7100 cases (IQR 6800–7400) at this peak and 190 000 cases averted throughout the epidemic (IQR 185 000–194 000). Institution-based isolation created a peak delay of 18 days and a reduction of 18 900 cases (18 700–19 100). A total of 546 000 cases (IQR 540 000–550 000) are averted throughout the epidemic, representing roughly a 57% reduction in comparison to 20% reduction through home-based isolation. Figure Number of new infections (A) and cumulative infections (B) within 7 months under the baseline control measures (black), home-based isolation (blue), and institution-based isolation (red) These results show the need for institution-based isolation to reduce household and community transmission. They also provide theoretical support for the approach successfully implemented in Wuhan, where fangcang isolation shelters were established for all infected and potentially exposed individuals. 5 These shelters provided triage, basic medical care, frequent monitoring, rapid referrals, and essential living and social engagements for the wellbeing of those isolated. Crucially, the fangcang obviated most of the risk of within-household transmission, which frequently occurs as viral loads can be high for mild infections. 8 Home-based isolation, which is reliant on personal compliance, will therefore inevitably lead to increased transmission. Although cities within Europe and the USA might not be able to create make-shift isolation centres similar to those in Wuhan, due to a lack of social acceptability or negative public perceptions, other strategies should be considered to reduce transmission, such as repurposing hotels or dormitories. We urge policy makers in countries with or facing overburdened health-care facilities 9 to consider such measures as countries emerge from lockdowns.
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            Responding to the COVID-19 outbreak in Singapore: Staff Protection and Staff Temperature and Sickness Surveillance Systems

            Abstract Background Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by novel coronavirus (SARS-CoV-2), and first reported in Wuhan, China, in December 2019. Since the severe acute respiratory syndrome (SARS) outbreak in 2003, Tan Tock Seng Hospital (TTSH) in Singapore has routinely fit-tested staff for high filtration N95 respirators, and established web-based staff surveillance systems. The routine systems were enhanced in response to Singapore’s first imported COVID-19 case on January 23,2020. Methods We conducted a cross-sectional study, from January 23,2020 to February 23,2020, among healthcare workers to evaluate the effectiveness of the staff protection and surveillance strategy in TTSH, a 1600-bed multidisciplinary acute-care hospital co-located with the 330-bed National Centre for Infectious Diseases (NCID). As of February 23,2020, TTSH/NCID has managed 76% of confirmed COVID-19 cases in Singapore. The hospital adopted a multi-pronged approach to protect and monitor staff with potential COVID-19 exposures:(1) Risk-based personal protective equipment, (2) Staff fever and sickness surveillance, and (3) Enhanced medical surveillance of unwell staff. Results A total of 10,583 staff were placed on hospital-wide fever and sickness surveillance, with 1,524 frontline staff working in COVID-19 areas under close surveillance. Among frontline staff, a median of eight staff illness episodes was seen per day, and almost 10% (n=29) resulted in hospitalization. None of the staff was found to be infected with COVID-19. Conclusions A robust staff protection and health surveillance system that is routinely implemented during non-outbreak periods and enhanced during the COVID-19 outbreak is effective in protecting frontline staff from the infection.
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              South Korea is reporting intimate details of COVID-19 cases: has it helped?

               Mark Zastrow (2020)

                Author and article information

                Lancet (London, England)
                Elsevier Ltd.
                24 September 2020
                24 September 2020
                [a ]Saw Swee Hock School of Public Health, National University of Singapore, Singapore
                [b ]Department of Nursing and Health Sciences, University of South East Norway, Drammen, Norway
                [c ]Medical Faculty, University of Maribor, Maribor, Slovenia
                [d ]College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
                [e ]LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
                [f ]Institute for Population Health, King's College London, London, UK
                [g ]Asia Pacific Observatory on Health Systems and Policies, World Health Organization Regional Office for South-East Asia, New Delhi, India
                [h ]College of Medicine, Seoul National University, Seoul, South Korea
                [i ]ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
                [j ]Centro de InvestigaÇão em SaÚde de ManhiÇa, Maputo, Mozambique
                [k ]Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
                [l ]Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
                [m ]Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
                [n ]Centre for International Health Protection, Robert Koch Institute, Berlin, Germany
                [o ]The Helen Clark Foundation, Auckland, New Zealand
                Author notes
                [* ]Correspondence to: Dr Helena Legido-Quigley, Saw Swee Hock School of Public Health, National University of Singapore, Singapore 117549

                Joint first authors

                © 2020 Elsevier Ltd. All rights reserved.

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