The major differences in evaluation and testing criteria in the guidelines across the six countries centered around the priority of testing for COVID-19 in the population, which strongly depended upon each country’s healthcare capacity, including accessibility to healthcare providers, having enough testing kits and reagents, availability of hospital beds, etc. The most similar recommendations in the evaluation and testing criteria from each government were those pertaining to the clinical signs and symptoms, such as fever and respiratory symptoms, as the priority criteria to initiate COVID-19 testing.
There was, at the time of writing, no specific antiviral recommended for the treatment of COVID-19, and no vaccine for COVID-19 available. Therefore, early detection and diagnostic testing for COVID-19 were vital to tracking the virus, understanding epidemiology, informing case management, and suppressing transmission [11]. The government guidelines concerning screening criteria and capacity for screening – including screening centers, and laboratory testing for COVID-19 in suspected or confirmed cases –were crucial factors in protecting the public from the virus. The WHO criticized countries that had not prioritized testing for COVID-19, and Tedros Ghebreyesus, the chief executive of WHO, emphasized the importance of testing by stating, “The most effective way to prevent infections and save lives is breaking the chains of transmission. You cannot fight a fire blindfolded, and we cannot stop this pandemic if we don't know who is infected. We have a simple message for all countries: test, test, test, test” [12]. However, lack of reagents and/or testing capacity for the SARS-CoV-2 virus challenged all nations included in the study, at least at the beginning of the pandemic. The US, UK, Haiti, and Brazil in particular experienced problems with shortages of testing kits for SARS-COV2 due to rapidly increasing demand compounded by national supply chains under stress and national laboratories with limited experience in COVID-19 virus testing [13, 14]. This had a negative impact by potentially obstructing the expansion of COVID-19 testing criteria, resulting in narrowing the range of people undergoing COVID-19 testing, which may have led to increases in the actual number of cases and overall risk of death by COVID-19, but falsely decreased the number of confirmed cases and deaths reported in the nations’ statistics.
According to the UK’s National Health Service, (NHS) testing priority was given to 1) patients with suspected COVID-19 in intensive care units (ICU), 2) patients with severe respiratory illness including pneumonia, 3) isolated cluster outbreaks such as care homes, and 4) random testing for surveillance purposes carried out by over 100 general practices [15, 16].
The first 2 confirmed cases occurred in the UK on January 31, 2020 and the first COVID-19 victims died on March 7, 2020 (see Figur 1). After 20 days, although the UK only tested people who were admitted to a hospital, the number of confirmed cases and disease-related deaths dramatically increased (confirmed cases: 14,745, deaths: 1,163) [17]. By April 7, 2020, one month after the first victims died of COVID-19, more than 1000 people were dying every day due to viral infection (see Figure 1). In April 9, 2020, despite the thousands of citizens dying each day due to COVID-19 related causes, the UK government launched massive COVID-19 testing centers prioritized for processing samples from health-care providers who were currently self-isolating, in order to allow them to return to work [16]. Therefore, people who were not considered a priority, such as non-health care providers or community members with mild respiratory symptoms, were never given access to testing. The limited scope of the UK’s testing approach for acute respiratory syndrome with COVID-19 was due to a “capacity problem” following a nationwide consolidation in the number of pathology laboratories. Many laboratories were centralized, which resulted in the possibility that each hospital would not necessarily be equipped with a fully functioning lab. This systemic capacity problem may have increased the risk of spread by free movement of people who were suspected of having the disease, since testing was unavailable to those individuals to enforce a stay-at-home order. As of the 24th of March, 90,000 people in the UK had been tested for COVID-19 (around 1300 tests per million people). This was a higher proportion than in some nations such as US (around 74 per million as of the 16th of March) but far behind South Korea (5200 per million as of the 17th of March) [18, 19].
Initially, the US’s CDC recommended testing only those who had a fever and/or lower respiratory symptoms and had traveled to China or had been in contact with a suspected or confirmed COVID-19 case. However, in late February, after a patient was infected despite a lack of travel history or known exposure, the CDC modified its testing guidelines to include anyone with a fever who was hospitalized with a respiratory illness. This change broadened the spectrum of patients being tested, which quickly increased the demand for testing.
In February 2020, the CDC acquired, developed, and distributed COVID-19 testing kits to nearly one hundred state and local laboratories. The majority of the laboratories using these kits experienced a number of issues, including the failure of negative controls and receiving inconclusive results. On February 12, 2020, the CDC officially announced that the problem was the result of a faulty reagent. The agency assured healthcare professionals they would solve the problem by re-manufacturing the faulty component and distributing the newly developed reagent to the public health labs. Ultimately, however, the lack of CDC test kits at this crucial time prevented wider-scale testing early in the outbreak.
Furthermore, although the number of confirmed cases and death rate significantly increased each day after March, 20, 2020 in the US (confirmed cases per day around 15,000, deaths per day around 1000), the total number of public health laboratories (PHL) that had completed verification and were offering testing was 97 on May 6, 2020 [20]. As further evidence of inadequate testing capability, the CDC announced that “although supplies of tests are increasing, it may still be difficult to find a place to get tested.”
The capacity for widespread testing together with prepared health facilities were key to controlling the spread of COVID-19, as evidenced by South Korea. South Korea reported its first coronavirus case (confirmed 7 cases) on January 31, 2020. In the month following, the number of daily reported cases remained low (confirmed cases: 100, deaths: 1) until a super spreader event was initiated on February 29, 2020. This event led to a daily case number spike for nine days, with each day the country's epidemic curve resembling a steep staircase as infections climbed (see Figure). However, South Korea quickly implemented large-scale COVID-19 testing, which allowed health officials to identify and notify potentially infected people, and to then send them into quarantine as a preventative measure. By March 25, 2020, more than 357,000 Koreans had been tested. The country reported about 10,804 total coronavirus cases and 254 deaths as of May 1, 2020. This was the lowest death rate among the countries examined [3, 21].
Having previously dealt with the 2015 outbreak of the Middle East Respiratory Syndrome (MERS), South Korea continued to refine its response system to better address potential outbreaks of large-scale epidemics, including installing negative pressure rooms in hospitals in 2018. The large-scale availability of COVID-19 testing locations, such as K-Walk-Thru and Drive-thru testing stations, were developed for the first time in the world to quickly and safely collect samples for COVID-19. These centers helped minimize the risk of cross infections at the in-hospital testing centers while maximizing daily testing capacity amid rapidly rising rates of new cases and received international attention and acclaim [22].
Still, exponential escalation in the number of daily confirmed cases placed enormous strain on national medical systems, leaving limited or no beds available for treating COVID-19 patients, even in the hospitals designated for viral treatment. Therefore, the US, the UK, South Korea, Brazil, and Haiti decided that patients with mild to moderate COVID-19 symptoms should be observed at home and remain in “Home Isolation." This approach was an important alternative to hospital isolation, as it required individual behavior change but no additional infrastructure investment.
Interestingly, the Chinese government decided against Home Isolation of patients with mild to moderate COVID-19. This policy was initiated in Wuhan, the city where COVID-19 emerged in late January 2020 and which accounted for more than 60% of all confirmed cases in China in March 27, 2020 (see Figure 1). The city opened three ‘Fangcang Shelter Hospitals’ on Feb 5, 2020, by converting exhibition centers and stadiums. Over the following weeks, Wuhan opened an additional 13 Fangcang shelter hospitals. Early epidemiological evidence showed that more than half of all Chinese patients with COVID-19 had at least one family member with the disease, with 75–80% of all clustered infections diagnosed within families, suggesting high rates of intrafamily transmission [23, 24]. Quickly emerging alternative hospitals, such as the Fangcang Shelter Hospitals, for testing and admission of the all COVID-19 patients may have led to a reduction in the spread of the virus into the community, thereby decreasing the number of new cases during the pandemic.
By January 22, 2020, the WHO announced the presence of travel-related cases linked to Wuhan City, human-to-human transmission, and reported that COVID-19 had been observed outside of China. The WHO strongly advised that individuals report their travel history to their health care providers [25]. However, the UK did not track travel history as it was not considered valuable information in the testing criteria. This was problematic since people who traveled to COVID-19 occurring areas could have been potential carriers of the virus to their respective communities and families, which might have had a strong influence on the increasingly steep confirmed case curves. Neither the American, Brazilian nor Haitian governments considered a history of travel to a region or country of high incidence of COVID-19, to be a high priority for testing or to be an important criterion for suspected cases. Those with a travel history to high spread areas were only encouraged to seek testing if they developed a fever or respiratory symptoms. In direct contrast, the Chinese guidelines suggested that any travelers who traveled to a region or country with occurrence of COVID-19 must be tested, regardless of whether they had developed symptoms.
Not enough was known about the epidemiology of COVID-19 to draw definitive conclusions about the full clinical features of disease, but the main clinical signs and symptoms reported in this outbreak include fever (>38 ℃), difficulty breathing, and chest radiographs showing bilateral lung infiltrates [11, 26]. For this reason, most countries considered fever, respiratory symptoms, and pneumonia as clinical justification for initiating diagnostic testing. Although there was enough evidence for human-to-human transmission, the US and UK did not include contact with confirmed or suspected cases as screening criteria. The absence of this criteria may have led to an increased risk of spreading the virus. In contrast, South Korea implemented a well-organized contact-tracing program: After laboratory testing confirmed a positive case, officials used interviews, GPS phone tracking, credit-card records, and video surveillance to trace an infected person's travel history. The South Korean government then published anonymized data detailing where each patient went, prior to diagnosis on a public website so others could determine whether they had been near a positive patient. Though effective, there were concerns regarding individual privacy.
Recognizing that the global spread of COVID-19 had dramatically increased the number of suspected cases and the breadth of geographic areas affected, it became increasingly evident that implementing screening criteria to better cope with each country’s capacity for screening, and laboratory testing was needed. However, beyond supply chain issues with provision of testing kits, there were significant limitations of the government guidelines for COVID-19 testing in several domains.
National health systems and coverage of COVID-19 medical expenses were vital to fostering a sense of financial certainty and a safe environment for those who were infected. Testing and treatment support came mainly or totally from the government in South Korea, the UK, China and Brazil. All US citizens were covered for FDA-approved COVID-19 testing, regardless of private or federal insurance status, however, treatment was subject to the insurer’s policy. Despite the larger role the governments took in the other countries examined, Haiti’s COVID-19 health care response was financially supported primarily by the private sector (60%). Hospitals and newly established screening clinics from the private sector worked together with the Haitian Ministry of Health to screen Haitians, however, health care facilities from the private sector were not regulated by government officials (hence the paucity of government screening guidelines) [27].
As an example of the increased preparedness the WHO called for, the South Korean government created temporary ‘Public Relief Hospitals’ which provided segregated treatment for non-respiratory and respiratory patients to ensure safe medical services to general patients and to prevent the viral spread. Public Relief Hospitals were divided into two types: Type A and Type B. Type A hospitals had separate outpatient treatment areas for general patients and respiratory patients, while Type B hospitals did not only provide separate outpatient areas for respiratory patients, but also had testing centers for COVID-19 and dedicated wards for respiratory patients. The Korean government also permitted non-respiratory patients to receive counseling and prescriptions by phone or by proxy, so as to prevent infection within healthcare institutions. This approach was also utilized in the US and UK. Non-respiratory patients, such as cancer patients or patients with heart problems, were directed to the general outpatient area at a Public Relief Hospital. Patients with mild respiratory symptoms were directed to see a doctor nearby or to go to the respiratory outpatient area at a Public Relief Hospital. Suspected patients or PUI who developed COVID-19 symptoms were advised to attend a screening center after receiving guidance from a competent clinic or the 1339 call center. Using this triage workflow, hospital systems were better able to prevent internal spreading of the COVID-19 virus in the hospital setting and potentially reduced a higher infection-related risk of mortality across the population. The South Korean death rate provided evidence to support this hypothesis, showing that although they had a high rate of confirmed cases (10,780), the total number of deaths was only 250. Most of those who died were admitted to the hospital due to chronic health conditions and were infected with the virus during their hospitalization.
Even though the US’s federal guidance on hospital visitation seemed more liberal than other countries, especially when contrasted with South Korea, more restrictions were adopted depending on the local circumstances. For example, although limiting visitors was not advised by the US CDC until April, several hospitals in New York city restricted visitor access as early as March.
Community guidelines:
Theme: Prevent getting sick
Despite being consistently recommended for use by symptomatic individuals and those in health-care settings, discrepancies were observed in the recommendations regarding the use of face masks in the general public and community settings. The WHO consistently maintained that the benefits of healthy people using masks in the community setting was not supported by the current evidence, and additionally could contribute to uncertainties or create critical risks [26]. This advice to decision makers remained in place up until the time of this paper submission in May 2020.
Several nations, such as the US and Brazil, changed their face cover recommendations as new studies were conducted that supported the use of face masks as an effective means to limit viral spread. Some studies may under-estimate their protective effects, while observational studies exaggerate them [28]. However, with the emerging evidence of asymptomatic or presymptomatic COVID-19 transmission, the authors note that the community guidance regarding utilizing a face mask and not sharing personal items could significantly prevent potential asymptomatic or presymptomatic transmission, which corroborates other publications [14]. Mask shortages were prevalent across countries in their early stage of use. For example, in the early stages of the COVID-19 pandemic, masks were in short supply in South Korea as citizens crowded the pharmacies to stock up in preparation. The South Korean government encouraged mask companies to increase their production rates and then ensured the newly manufactured masks were directly allocated to pharmacies, where a limited number of masks could be sold to each citizen. To prevent citizens from lining up outside pharmacies, and violating physical distancing measures, the government and private sector partners created apps to display the number of masks available at nearby locations. The number of masks bought by each citizen was then tracked through the National Health Insurance Service database.
The general guidance across nations about avoiding infection by washing hands or using alcohol-based hand sanitizer frequently, performing respiratory etiquette when coughing or sneezing, and avoiding touching the face corroborated the WHO guidelines [29].
Despite physical distancing being vital to mitigating the spread of coronavirus, political beliefs affected compliance with COVID-19 social distancing orders. In general, in the US, people who held contrasting political beliefs to the resident state governing body were less responsive to stay at home orders. For example, Republican counties were less likely to stay at home after a Democratic state order had been implemented, relative to those in Democratic counties. In a similar fashion, Democrats were less likely to respond to a state-level order when it was issued by a Republican governor [30].
On that point, it is worth noting that although the countries examined all referred to the government issued COVID-19 notices as ‘guidelines,’ these notices were not enforceable equally across countries. As an example, in the US, the CDC’s guidance acted as a framework that could be adapted for use by individual hospitals or by local/state governments for legislative purposes. However, in South Korea the guidelines essentially acted as enforceable legislation with serious financial repercussions.
Another important political development to note occurred in Brazil, when the Ministry of Health included a video on their website focused on clarifying “fake news” about the coronavirus. The video requested that users confirm whether information presented in various medias was true before sharing that information with others. It also suggested individuals consult with an official number via WhatsApp for information clarification and communication.
An additional concern was raised regarding the use of health-tracking apps. Various countries used voluntary health-tracking apps to manage the COVID-19 pandemic either for informational, health vigilance, or contact tracing purposes. However, a unique aspect of the South Korean response was to mandate all Koreans and long-term expatriates install a health tracking app for contact tracing purposes. Privacy concerns were raised by several publications, some of whom referenced the possibility of preserving data protection [31], while others reflected on the legal implications and the need to refine the data into an aggregate, rather than individual-level data, to better deter the misuse of the data [32].
The countries’ guidelines on how to care for people infected with COVID-19 experiencing mild symptoms at home aligned with the WHO guidance [33]. According to the WHO, ensuring the sick person used a separate room and bathroom in the home would be essential to containing the virus, however, only the US, South Korea, and Brazil made this recommendation to their respective communities. Haiti, the UK, and China did not mention this recommendation in their guidelines. Although those suspected of having coronavirus were requested to stay at home in the UK, limited information was provided to guide the home care process, such as how to disinfect the ill person’s room or how to handle sharing household items in the home. In China, all people suspected of having the coronavirus were instructed to seek testing at a testing center, and were admitted to ‘Fangcang Shelter Hospitals.’ Therefore, it was not necessary to provide information on how to deal with sick people at home to the community. The decision to advise all people suspected of having the coronavirus to go directly to the hospital is at odds with at least one study, which proposed that instead of guiding the COVID-19 patient to seek healthcare facilities, it would be preferable to provide at-home testing and monitoring [34]. However, while staying at home it is critical to carefully monitor worsening symptoms since medical care is not necessarily immediately available.
The symptom thresholds to contact healthcare providers varied between countries, with a wider array of symptoms (beyond the respiratory types) being included by countries that had dealt with the epidemic for longer periods of time. Clearly there was a great deal of clinical judgement necessary in monitoring the disease progression, which meant acting in a timely manner to differentiate a more serious case of COVID-19, which could be fatal.
Finally, the guidelines on transportation to healthcare facilities varied in emphasis between governments. A publication from China indicated that imported cases via public transportation played an important role in the spread of COVID-19, finding a significant and positive association between the frequency of flights, trains, and buses from Wuhan in the daily, as well as the cumulative, numbers of COVID-19 cases in other cities [35].
Limitations:
These findings are related to the guidelines for healthcare facilities and communities, as updated until April 20, 2020, however some guidelines may have been continuously updated beyond this date. In Haiti, because of the low prevalence of COVID-19 (total confirmed case: 100, deaths: 8 as of May 1, 2020), some information was unable to be obtained from the government guidelines, even though it was provided by news outlets or other medias, which were not included here. This study only used government guidelines accessible by the public, which may have limited the scope of the study’s usable information.