4.1 Principle findings
In this study, we observed that the CC between TCC100 and CFR100 is 0.92(t=37.87) and CC=-0.02(t=-0.25) between TCC100 and CFR. The former is as expected due to the strong association between TCC and CFR though both were divided by a common value of 100, 000. The latter presents none relationship between TCC100 and CFR. That is the reason why we need to simultaneously examine these two for understand the COVID-19 hit to countries/regions in comparison,
Washington, USA was found to have the highest TCC100(=3498.15) and CFR100 (=16548.96) with CFR(=5%) in comparison to (1)Taiwan[TCC100(=1.65), CFR100 (=2.17), CFR(=1%)] , South Korea[TCC100(=20.34), CFR100 (=39.8), CFR(=2%)] ,and Vietnam[TCC100(=0.26), CFR100 (=0), CFR(=0%)] up until April 12,2020.
4.2 What this finding adds to what we already knew
Numerous documents have reported using CFRs to compare death tolls of specific diseases. The incidence rates and CFRs adjusted by a population of 100,000 can be reasonably compared with one other[6-10]. We made an effort to combine both CFR(or CFT100) and TCC100 on a dashboard, which is novel, innovative, and rarely seen in past literature. Such a design presents a new perspective on the current COVID-19 pandemic. For instance, Italy had a high CFR at 13% for COVID-19 up until April 12, 2020, but less than the state of Washington, USA, and other countries/regions in CFR100 if population density had been taken into account.
In addition, countries/regions that performed well on fighting against COVID-19 should be highlighted (e.g., see the left-hand bottom corner in Figures 2 and 3), namely Vietnam, Taiwan, Hawaii(US), or Fujian(China). The coordinate for entities will be automatically and immediately adjusted to an appropriate point on the dashboard once the data are updated.
4.3. What it implies and what should be changed
We illustrated Taiwan, one example of a success controlling the COVID-19 crisis, in Figures from 4 to 6. One article from NBC News suggested that Taiwan learned from the experience of the 2003 SARS outbreak and its government and people were well prepared for this current crisis.
Of the nearly 200 countries and regions affected, Taiwan has the lowest incidence rate — around 5 in every 100,000 people— for a place that is located so close to China and with so much travel to and from[37-39]. It is worth noting that the Taiwan government mandates hospitals to test for and report cases of COVID-19. Such policy helped the government identify those infected, trace their social contact history, and isolate those that were in contact. Taiwan's government’s measures to prevent community spread were steps ahead of the world, successfully containing the widespread of the disease, even well before Taiwan had its first confirmed case on Jan. 21, 2020[40-43].
Another noteworthy fact is that Taiwan’s Centers for Disease Control(CDC) set up the Central Epidemic Command Center on Jan. 20, 2020, which quickly rolled out a series of epidemic control measures. The command center not only investigates confirmed and suspected cases, but also works with ministries and local governments to coordinate the crisis response across Taiwan, such as allocating funds, mobilizing personnel and advising on disinfection policies in schools. On Jan. 26, 2020, Taiwan was the first country to ban direct flights from Wuhan and a handful of other Chinese cities. Five days after Taiwan confirmed its first case, the Taiwan government imposed border control restricting all non-citizens from entering via China[44-46], see Additional Files 2 and 3.
Moreover, the Taiwan health insurance system covering 99 percent of the country’s population has been crucial in fighting the spread of the outbreak. Such a system thus allows everyone to have access to necessary medical attention without the financial burden when the infection is suspected[47-48].
Similarly, Vietnam’s early preparation from the first days of the pandemic has resulted in its current success in containing the outbreak .
4.4. Strengths of this study
Three key features of this study are highlighted below: (1)both TCC100 and CFR100 can be complemental to the deficit of the traditional CFT used in the epidemiology of not taking the population density into account; (2) one-dimension category is verified with CC=0.92(t=37.87) comprising a total of 285 count data (i.e., 12, 225, and 48 dispersed on the Kano diagram), which makes comparing countries/regions on COVID-19 situations easy; (3) an app developed to display the CFR and TCC100 online, complements the traditional dashboards which do not consider population density.
4.5. Limitations and future studies
There are several limitations to our study. First, although the data were downloaded from Github on a daily basis, the criteria to determine confirmed cases may not be consistent around the globe, which may influence the CFR computations. For instance, he confirmed cases are from clinically diagnosed cases in Hubei since Feb. 14, 2020 .
Second, although we applied both CFR and TCC100 on a dashboard(Figure 3), the provisional CFRs merely were hidden behind their bubble sizes. A larger bubble stands for a higher CFR100, which might be complemental to the CFR in this matter.
Third, some biases may exist among the US regions. Original data were based on county and location(eg., such as Spokane County, WA(US), St. Louis County, MO(US), Suffolk County, NY(US), Ulster County, NY(US), Unassigned Location, VT(US), Volusia County, FL(US), Unknown Location, MA(US),etc.), all of which should be combined into their own corresponding States prior to computing the CFR100 and TCC100. Particularly, in the recent data from Github , many counties in the US were included separately, making the data arrangement more difficult.
Fourth, although we recommend using a population-based method (e.g., CFR100 and TCC100 in this study), the traditional CFR cannot be neglected because of its familiarity with the general public, despite the importance of infected population density being greater than total confirmed cases and CFR in nature. Finally, every government has its own strategy and policy against COVID19. We illustrated two examples(e.g., Taiwan and Vietnam), where successful measures were implemented to prevent the outbreak. Many other effective measures applied to fight against COVID-19, such as a need to limit human-to-human transmission, to rapidly identify, isolate, and provide optimized care for patients, to accelerate the development of diagnostics, therapeutics, and vaccines, should not be ignored. On the other hand, caution should be taken to minimize social disruption and economic impact through international, collaborative, and multisectoral approaches.