WHO acknowledged and announced the impact of COVID-19 on both public health and economic sectors via two interim guidelines published in late March 2020. WHO also emphasized the importance of preparedness for the COVID-19 pandemic accounting for the countries' health care capacities should consider accessibility (see additional file 8, 9). The six countries tend to align with the WHO interim guideline, however there are some differences in the response to the pandemic in each country.
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, and so on. 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.
During the writing of this paper, there were no known vaccine or antiviral therapies for COVID-19. Therefore, early detection and diagnostic testing for SARS-CoV-2 were vital to reducing transmission, managing active cases, contact tracing, and understanding epidemiology . 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. 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” . 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 [14, 15]. This had a negative impact by potentially obstructing the expansion of COVID-19 testing criteria, resulting in a narrowed 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) intensive care unit patients with suspected coronavirus, 2) patients with severe respiratory illness including pneumonia, 3) isolated cluster outbreaks, and 4) random testing for surveillance purposes[16, 17]. 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 Figure 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) . By April 7, 2020, one month after the first COVID-19 deaths, 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 large COVID-19 testing centers which prioritized processing samples from health-care workers in self-isolation , allowing them to go back to work . Therefore, people who were not considered a priority, such as non-health care providers or community members with mild respiratory symptoms, were not given access to testing. The limited scope of the UK’s testing approach for COVID-19 was due to a capacity problem, resultant to the consolidation in the number of pathology laboratories nationwide . 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. In the UK,90,000 people had been tested as of the 24th of March - which was around 1300 COVID-19 tests per million people. Although it was a higher portion than some nations, including the US (around 74 per million as of the 16th of March), it was far behind South Korea (5200 per million as of the 17th of March) [19, 20].
Initially, the US’s CDC included fewer testing criteria than the WHO guidelines. The CDC guidelines recommended testing individuals with a body temperature above 38 ℃ (fever) and lower respiratory symptoms, those who had a fever and a travel history to China, or those who had a fever and were possibly exposed to a suspected or confirmed COVID-19 case. However, once a patient, who did not have any travel history or exposure to any confirmed COVID-19 cases, was reported COVID-19 positive, the CDC expanded their testing criterion to include any individuals admitted a hospital due to lower respiratory symptoms and fever. This addition broadened the spectrum of patients being tested, but also led to rapid increase in the demand for testing.
In February 2020, the CDC acquired, developed, and distributed COVID-19 testing kits to laboratories nationwide, almost one hundred of which reported experiencing several issues with the testing kits. These issues included the failure of negative controls and presentation of inconclusive results. After an internal investigation on February 12, 2020, the CDC reported a faulty reagent as the issue. The CDC immediately recalled all unreliable testing kits and promised to re-manufacture the faulty component and distribute the newly developed reagent to the public health labs as soon as possible. Ultimately, the shortage of COVID-19 test kits at this critical time point possibly interfered with the prevention of increasing confirmed cases 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), only 97 public health laboratories (PHL) finished verification and were offering testing on May 6, 2020 . 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” .
Together, the capacity for widespread testing and presence of prepared health facilities were key to controlling the dissemination of coronavirus, as evidenced by South Korea. The first COVID-19 incident in South Korea was announced on January 31, 2020, with 7 confirmed cases. The daily confirmed cases remained low for the following month (confirmed cases: 100, deaths: 1) until a super spreader event was initiated on February 29, 2020. Each day for nine days afterward, the country's epidemic curve resembled a steep staircase as infections climbed, resulting in dramatically increased confirmed cases and deaths (see Figure 1). However, by implementing large-scale governmental COVID-19 testing, health officials were able to effectively contact trace and send potentially infected people into quarantine as a preventative measure. By March 25, 2020, more than 357,000 Koreans had been tested. The country reported 10,804 total coronavirus cases and 254 deaths as of May 1, 2020. This was the lowest death rate among the countries examined [3, 22].
Having previously dealt with the Middle East respiratory syndrome (MERS) in 2015, South Korea had already prepared for potential outbreaks of large-scale epidemics, for example by installing negative pressure rooms in hospitals in 2018. Additionally, the country rapidly developed and had the large-scale availability of COVID-19 testing locations, such as K-Walk-Thru and Drive-thru testing stations. These were the first testing centers of their kind in the world, and facilitated the quick and safe collection of samples for COVID-19 testing. These unique centers helped not only reduce the risk of cross infections at the in-hospital testing centers, but also increased daily testing capacity amid rapidly rising rates of new cases .
WHO emphasized the prioritization of isolated care for patients with higher risk of infection, such as severe and critical illness patients aged over 60 years and those with underlying medical conditions (see additional file 10). Still, exponential escalation in the number of daily confirmed cases placed enormous strain on national medical systems, resulting in limited or total lack of beds for COVID-19 treatment. Therefore, the US, the UK, South Korea, Brazil, and Haiti decided patients with mild to moderate coronavirus symptoms should be observed in “Home Isolation". This approach was a crucial option that only required modification in individual behavior without supplementary expenditure.
Interestingly, China opposed observing mild to moderate coronavirus cases at home, instead directing all potential infected persons to designated medical care institutions. This policy was initiated in Wuhan, the city where COVID-19 emerged in late January 2020. In March 27, 2020, more than 60% of coronavirus cases in the country were at Wuhan (see Figure 1). The city converted exhibition centers and stadiums into shelter hospitals within mere weeks. Epidemiological evidence at the beginning of the pandemic revealed high intrafamily transmission, with 75–80% of all clustered infections diagnosed within families [24, 25]. 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 in the community, thereby decreasing the number of new cases during the pandemic.
On January 22, 2020, the WHO announced the presence of travel-related cases linked to Wuhan City, human-to-human transmission, and reported COVID-19 had been observed outside of China. The WHO strongly advised individuals to report their travel history to their health care providers . However, the UK did not track travel history as it was not considered valuable information in their testing criteria. This was problematic since people who traveled to COVID-19-occurring areas could have potentially acted as carriers of the virus to their respective communities and families, which might have strongly influenced the increasingly steep confirmed case curves. Neither the American, Brazilian nor Haitian governments considered a history of travel to a region of high COVID-19 incidence 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.
Although WHO provided a definition of symptoms observed in suspected cases that warranted further surveillance (see additional file 8), it was a challenge to define the full clinical characteristics of COVID-19. Fever (>38℃), breathing problems, and chest radiographs showing bilateral lung infiltrates were the main clinical signs and symptoms reported during the outbreak [12, 27]. For this reason, most countries considered fever, respiratory symptoms, and pneumonia as clinical justification for initiating diagnostic testing. Although by March/April 2020, the UK and US countries were defined as ‘countries experiencing larger outbreaks’ (as referred to in Group 4 of the WHO guidelines), they did appear to be largely acting in accordance with WHO advice at that point in time, despite not acting on the previous advice regarding the screening of travelers (see additional file 8).
Although there was ample evidence of human-to-human transmission, the US and UK did not include contact with confirmed or suspected cases as screening criteria very early in the pandemic. The absence of this criteria early in the pandemic may have led to increased risk of viral spread. In contrast, South Korea undertook an intense contact-tracing program: upon confirmation of a COVID-19 case through laboratory testing, the South Korean government conducted interviews with the infected person, traced their travel history, used GPS phone tracking, and checked their credit-card history. The anonymized data detailing the travel history before diagnosis was published on a public website by the South Korean government. This allowed government officials to quickly release information about potential COVID-19 exposed locations and help people who may have been near those locations make quick decisions on whether they needed to be tested. Though effective, there were and continue to be concerns regarding individual privacy.
With the global spike of COVID-19 and consequent surge in suspected cases and geographic areas affected, the need for implementing screening criteria to better cope with each country’s capacity for screening and laboratory testing became increasingly evident. 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 coverage was subject to the insurer’s policy. Despite the larger role the governments took in the most countries examined, Haiti’s COVID-19 health care response was primarily financially supported 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) . Given these limitations in testing capacity, WHO launched the COVID-Solidarity Response Fund for WHO to support COVID-19 rapid tests for low and middle-income countries .
In March 19, 2020, WHO recommended that “when symptomatic, patients are required to wait, ensure they have a separate waiting area” (see additional file 11). As an example of the increased preparedness the WHO called for, the South Korean government created temporary ‘Public Relief Hospitals’ which provided isolated treatment rooms for patients with respiratory and non-respiratory symptoms 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. Both had separate outpatient treatment zones for patients without respiratory symptoms and for patients with respiratory symptoms. The difference between Type A hospitals and Type B hospitals was whether their testing centers were contained within the hospital. The Korean government also permitted patients who have a chronic disease, but did not have any respiratory symptoms, to receive counseling and prescriptions by telephone or by proxy, therefore decreasing the risk of internal cross-infection within health care facilities for higher-risk patients. This approach was also utilized in the US and UK. In South Korea, 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 a respiratory outpatient area at a Public Relief Hospital. Suspected patients or PUI who developed COVID-19 symptoms were referred to a COVID-19 testing center after receiving guidance from a competent clinic or the 1339 call center. Using this triage workflow, Korean hospital systems were better able to prevent internal spreading of the COVID-19 virus in the hospitals 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.
WHO recommended healthcare facilities limit the number of visits to suspected or confirmed COVID-19 patients by health care providers, family members, and visitors while being treated in health care facilities. WHO also suggested maintaining a record of all staff and visitors who entered suspected or confirmed COVID-19 patients' rooms (see additional file 11).
Even though the US’s federal guidance on hospital visitation seemed more liberal than other countries, especially when contrasted with South Korea and the UK, 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. Brazil's government strongly recommended individuals with flu or respiratory symptoms not be allowed entry to the hospitals. The government also recommend the hospitals reduce visitor numbers, which, while not mandatory, was heavily implied to be. Although limitations of visitors was not mandatory, wearing a face mask was mandatory for all visitors in Haiti.
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 of wearing 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 . 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 . 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 . Mask shortages were prevalent across countries in their early stage of use. For example, at the beginning of the pandemic, there was a mask shortage in South Korea due to mass panic-induced purchases by citizens. The South Korean government requested manufacturers increase mask production, and then ensured the newly manufactured masks were directly allocated to pharmacies, where only a limited number of masks could be provided to individuals. The number of available masks was displayed in government and private sector- created apps to prevent citizens from lining up outside pharmacies, which could have resulted in violating physical distancing measures. Additionally, the National Health Insurance Service database showed how many masks were sold to individuals per week.
Generally, the guidance provided across the six nations regarding 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 .
Despite physical distancing being vital to mitigating the spread of the novel coronavirus, political beliefs affected compliance with COVID-19 social distancing guidelines. This was especially evident in the US, where, in general, people who held contrasting political beliefs to the resident state governing body were less responsive to stay-at-home orders. For example, Republicans did not fully respect and react to stay-at-home orders when Democratic counties announced the order. In a similar fashion, Democrats were less likely to respond to stay-at-home orders when a Republican governor issued the decree.
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 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 the mandate for all Koreans and long-term expatriates to 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 , 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 .
The countries’ guidelines on how to care for people infected with COVID-19 experiencing mild symptoms at home aligned with the WHO guidance . 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 could be argued 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 . 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 a great deal of clinical judgement was necessary for monitoring disease progression since acting in a timely manner to differentiate a more serious case of COVID-19 was crucial to limiting fatality.
Finally, WHO provided the information regarding the transportation of patients with confirmed and suspected COVID-19 to referral health care facilities; however, WHO did not give any information regarding transport mode to individuals with suspected COVID-19 (see additional filed 12). The guidelines on transportation to healthcare facilities varied in emphasis between governments. A publication from China showed key involvement of public transportation in the dissemination of coronavirus. According to the study, the data on how frequently public transportation interacted with Wuhan daily was significantly related to an increase in the number of COVID-19 cases in other cities.. For transport to a hospital with COVID-19 suspicious symptoms, wearing a face mask, using a personal vehicle, avoiding public transports and call an ambulance were recommended by the Korean, US and Chinese government’s guidelines. The UK and Haiti advised such patients utilize ambulance transport when heading to the hospital. The Brazilian government did not provided advice regarding transport mode information.
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.