A Comparative Retrospective Study of COVID-19 Responses in Four Countries

Objective This study compared the government policies and non-pharmaceutical interventions adopted by South Korea, Japan, India, and China in response to COVID-19 during 2020-2021. We hope that our study would propose policies for future COVID-19 waves and provide lessons for future responses to similar infectious diseases. Methods We made a retrospective study by analyzing the government policies and non-pharmaceutical interventions in these four countries. Results From January 2020 to May 18, 2021, South Korea and Japan experienced three waves of COVID-19 epidemic, but the number of daily new conrmed cases per million people was relatively small in both countries, and South Korea had fewer daily new conrmed cases per million than Japan. Following the COVID-19 outbreak in Wuhan in late 2019, China successfully contained the rst wave of the outbreak and is not currently experiencing a large-scale resurgence of the epidemic. India is experiencing a grim second wave of the epidemic, with far more daily new conrmed cases per million people than South Korea and Japan. Throughout 2020, the number of COVID-19 deaths per million population remains low in South Korea, Japan, and China, while India has seen an upward trend in deaths per million population since July. As of May 18, 2021, the number of total tests per thousand people in South Korea, India, and Japan was 230.65, 181.23, and 99.59, respectively. South Korea and India both have more than twice as total tests per thousand people as Japan. Conclusion Successful practices in China and South Korea show that--case identication and management, coupled with close contact tracing and isolation, is a powerful strategy. The lessons of Japan and India show that social distancing is an effective measure, but only if it is rigor and persistent. Finally, in both developed and developing countries, the development of health care systems and coordinated government leadership play a key role in overcoming epidemics.


Introduction
Labeled as a black swan event, the coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) has emerged in Wuhan, China in December 2019.
As COVID-19 continues to diffuse and affect the lives of people around the world, on January 31, 2020, the World Health Organization (WHO) declared COVID-19 a Public Health Emergency of International Concern. [1] The ongoing COVID-19 has already affected over 160 million people, claiming more than 3 million lives in over 200 nations all over the world as of May 18, 2021. [2] In response to " atten the curve", various nations have tried different approaches to COVID-19 such as social distance, travel restrictions, lockdown city, and quarantine. While some countries are still struggling with the COVID-19 pandemic, others are progressing well and rapidly returning to relative normalcy.
The rst case of COVID-19 death was reported in China on January 10, 2020. Japan, a neighboring country of China, reported the rst case of COVID-19 on January 15. After that, South Korea followed suit on January 20 and India reported on January 30. [3,4] Although Asian countries were hit by the epidemic earlier, the epidemiological impact of COVID-19 has been relatively moderate in most countries except India.
Four representative Asian countries have been selected for analysis, given their relatively similar cultures and nationalities. We selected two developed countries, Japan and South Korea, and two developing countries, China and India, for comparison. This study compared the government policies and nonpharmaceutical intervention measures taken by these four countries to respond to the highly infectious virus during 2020-2021. Countries with varying national economic income can be used as a means of demonstrating this theme in the COVID-19 outbreak response. A study published in Science by the Harvard School of Public Health suggests that the vaccine we have high hopes for will likely do very little.
Because the antibodies produced by infected humans may only be effective for 40 weeks (< 300 days), shorter than even the development cycle of a vaccine. [5] The future is uncertain, and the practice and lessons learned by governments in combating COVID-19 remain invaluable. We hope that our study would propose policies for future COVID-19 waves and provide lessons for future responses to similar infectious disease outbreaks.

Methods
We made a retrospective case study by analyzing the government policies and non-pharmaceutical intervention measures of four representative Asian countries ( COVID-19 con rmed cases and deaths were obtained from Johns Hopkins University (JHU), accessed through the Our World in Data database. [6] Total tests per thousand people and the positive rate were also accessed through the Our World in Data database. The case fatality rate is the number of con rmed deaths divided by the number of con rmed cases. Based on epidemiological data we were able to draw various gures by Microsoft Excel. As this case study focuses on the COVID-19 pandemic during 2020-2021, all the epidemiological data presented are dated between January 2020 and May 2021 3. Results

Presentation
General Description in South Korea, Japan, India, and China Located across the sea from the Chinese city of Qingdao, South Korea is an East Asian country of 51.6 million inhabitants, with half of the population concentrated in the capital city of Seoul and its metropolitan area. The country has 15.5% of people over the age of 65. According to the Organization for Economic Cooperation and Development (OECD), South Korea is a wealthy and developed country with a per capita GDP of 42 700 US$. [7] South Korea's healthcare system is considered one of the best in the world, with a Computed Tomography (CT) Scanners count of 39 per 1 million inhabitants and 12.4 hospital beds per 1,000 inhabitants in 2018. [8] Japan, China's neighbor, is a developed country with 127 million inhabitants residing in 364555 km 2 , most of the residents live in urban areas (91.8%). [9] According to the OECD, Japan's GDP in 2019 was per capita 42239 US$. [10] Japan is an aging country, with 28% of the total population over 65 years old. [11] Japan's healthcare system undoubtedly ranks among the best in the world. Japan's total health expenditure in 2019 was 4823 US$, which was 11.1% of GDP. General government expenditure on health is 20.28 % of total government expenditure in 2014. [12,13] China and India are both developing countries and the most populous countries in the world. However, India's population density is almost three times that of China, and urban slums may have a population density of more than 250 000/km 2 . [14] India's GDP in 2016 was per capita 5901 US$, and China's GDP in 2017 was per capita 14306 US$. According to the OECD, India's health system is relatively weak, with only 0.5 hospital beds per 1,000 inhabitants in 2017. General government expenditure on health accounted for only 5.05 % of total government expenditure in 2014. [15] After the lessons learned from SARS in 2003, China has been enhancing its healthcare system. Given the size of the population, China's per capita health resources are also inadequate. Health expenditure per capita in China in 2017 was only 440.83 US$. [16] General government expenditure on health accounted for 10.43 % of total government expenditure in 2014. [13] Epidemiological Situation of the four Country Regarding COVID-19 Figure 1 shows the comparison of the daily new con rmed COVID-19 cases per million people in India, Japan, South Korea, and China as of May 18, 2021. The gure was produced and published by Our World in Data. From January 2020 to May 18, 2021, South Korea and Japan experienced three waves of COVID-19 epidemic, but the number of daily new con rmed cases per million people was relatively small in both countries, and South Korea had fewer daily new con rmed cases per million than Japan. Following the COVID-19 outbreak in Wuhan in late 2019, China successfully contained the rst wave of the outbreak and is not currently experiencing a large-scale resurgence of the epidemic. India is experiencing a grim second wave of the epidemic and has far more daily new con rmed cases per million than South Korea and Japan. Figure 2 shows the timeline comparing the cumulative con rmed deaths per million people of COVID-19 in India, Japan, China, and South Korea. Throughout 2020, the number of COVID-19 deaths per million population remains low in South Korea, Japan, and China, while India has seen an upward trend in deaths per million population since July. Japan's number of deaths per million population increases gradually into 2021, and is higher than that of Korea and Japan, while India's number of deaths per million population continues to increase, far exceeding that of Japan, Korea, and China.
Testing is our window into the pandemic and how it spreads, and the positive rate shows the level of detection relative to the size of the outbreak. Figure 3 shows the comparison of the total tests per thousand people and the positive rate for COVID-19 in India, Japan, and South Korea. (Relevant data for China are not fully disclosed) As of May 18, 2021, the number of total tests per thousand people in South Korea, India, and Japan was 230.65, 181.23, and 99.59, respectively. South Korea and India both have more than twice as total tests per thousand people as Japan.
According to the standards published by the WHO in May 2020, a positive rate of COVID-19 less than 5% indicates that the epidemic situation in a country is under control. We can see that the positive rate of COVID-19 in South Korea is 2.2%, which is lower than the standard announced by the WHO, indicating that the epidemic in South Korea is well controlled. The positive rate in Japan is 6.9%, which is slightly higher than the standard positive rate, while the positive rate in India is 17%, which is much higher than the standard positive rate. The task of epidemic prevention and control is still arduous in India.

Management And Outcome
"Non-pharmaceutical interventions (NPIs)" are social interventions, including isolation, management of sources of infection, social distancing, and so on, aimed at reducing contact rates in the population and thus reducing the spread of the virus. [17] The major measures taken by South Korea and Japan in response to COVID-19 were summarized in Table 1 from the government infectious disease risk alert approach, immigration, screening, surveillance, healthcare, and society. Table 2 shows the major measures taken by India and China in response to COVID-19. A. Japanese Ministry of Foreign Affairs gradually raised the risk alert for the epidemic level.
B. The Ministry of Health, Labor, and Social Affairs, with the Government's aid, set up a cluster response team along with 536 consultative centers.

Immigration and Screening Measures
A. In the early stages of the epidemic, the government focused on special entry procedures, mandatory "Self-Check" Mobile APP and other monitoring measures to track and monitor the health status of inbound travelers upon arrival.
B. Mandatory COVID-19 testing and two-week quarantine for inbound travelers.
C. In late June, country-speci c restrictions began, suspending visa issuance and unscheduled ights and requiring submission of negative PCR-test results when issuing tickets to South Korea.
D. For travelers with A1, A2 and A3 visas and essential travelers will be tested for COVID-19 upon arrival. They will be actively monitored for 14 days if the test is negative.
A. The government reinforced travel restrictions to and from China, South Korea, and other countries.
B. Returning residents and long-term pass holders with travel history to these affected regions is subject to 14-day quarantine.
C. Japan gradually relaxed immigration restrictions starting on October 1, 2020.

Responses
South Korea Japan 3.KCDC rapidly scaled up the diagnostic capacity within South Korea. Laboratory test for COVID-19 was initially performed at KCDC and then became available at 17 regional laboratories throughout the nation, on 24 January 2020.

B. Tracing
The Korean government utilized advanced digital technology to track people who came into close contact with the con rmed cases, and place them under self-quarantine.
A. Testing 1.The need for PCR testing was downplayed, and extensive testing was rejected by the government's scienti c advisers in the early stage.
2. PCR testing start to increase from July 2020.
B. Tracing 1.The authorities used retrospective monitoring methods to nd closer links to an infected person. The basic policy was to early detect the source of an infected individual, follow all the people in the cluster who are highly transmissible, test and isolate them immediately and treat them rather than general testing of the country's entire population.
2. On June 19, 2020, the government released a tracing app named "COCOA". D. Early patient diagnosis and enhancement of intensive care and the securing of a medical service system for the severely ill.

Government policies and Non-pharmaceutical interventions in response to COVID-19 in South Korea and Japan
The rst wave of COVID-19 in South Korea was a cluster of outbreaks linked to a religious group in the city of Daegu and northern Gyeongsang province. The rst wave peaked at 813 new cases on February 29, 2020, after which the number of new cases began to gradually decrease. [18] This was followed by a sustained outbreak in small clusters and an increasing number of imported cases from outside Korea. A retrospective look at the ght against the COVID-19 from 2020 to late May 2021 shows that South Korea did not resort to blockades and suspension of public transport to restrict people's movement, even at the height of the outbreak. The core of Korea's response to COVID-19 is massive and rapid testing to identify positive cases, along with meticulous tracing and quarantine of all contacts. To provide safe and effective screening for COVID-19, the Drive-Through and Walk-Through Screening Centre have been implemented in Korea. In addition, effective mitigation strategies such as mask-wearing campaigns, social distancing, avoiding crowds, and frequent hand and face washing were implemented.
To avoid the overwhelming of medical resources, Korea prepared for other types of care centers beyond hospital beds. KCDC converted public facilities and residential facilities provided by the volunteer into isolation-and-care facilities and named Life Treatment Centers (LTCs). [19] LTCs can prevent asymptomatic or mildly ill patients from infecting family members. The latest digital technology is also key to the control of COVID-19 in Korea. The Korean government developed Self-Diagnosis Mobile Application to monitor the health of inbound passengers and patients in LTCs. The Korean government has temporarily allowed doctors to engage in telemedicine activities, which can avoid hospital infections and cross-contamination during patient visits. [20] Japan was the third country to have the rst COVID-19 case in January 2020 after Thailand. From January 2020 to May 2021, three waves of COVID-19 outbreaks surfaced in Japan. COVID-19 is a disease that mainly threatens the elderly, and Japan has more elderly people per capita than any other country. The rst wave of outbreak control focused on avoiding medical resource shortages and reducing deaths due to COVID-19. The Japanese government adopted a strategy of hospitalizing serious patients and isolating the mildly at home. [21] The main measures of the Japanese government were to close schools at the end of February 2020 and to urge the public to wear masks, telecommute, work shifts, not hold events, and avoid contact with others to reduce transmission. [22] Instead of massive testing, the Japanese Government declared a state of emergency on April 17, 2020. [23] Many restaurants and companies reduced the time people spent outside their homes by reducing business hours and shifting to teleworking.
Japan initially adopted a strategy that focused primarily on symptomatic patients, controlling clusters and seeking ways to coexist with the virus rather than eradicating it. However, after the rst wave of the outbreak, socio-economic activities quickly resumed and the epidemic resurfaced. Although the peak period of the second wave of infections was larger than that of the rst wave, the number of infections declined in the absence of measures such as a state of emergency. However, during the second wave of the outbreak, Tokyo increased the number of testing. Since early November 2020, the number of infections has started to increase again, and Japan has entered the third wave of the outbreak. The government did not declare a state of emergency, and local governments only called for reduced business hours and limited activities in December 2020. [24] The third wave of the outbreak in Japan is ongoing.

Government policies and Non-pharmaceutical interventions in response to COVID-19 in India and China
India reported the rst case of COVID-19 on 30 January 2020. The international community is concerned about India's control strategy and capacity due to high population density, socioeconomic inequalities, and low health care resources. India's robust response began at the outset of the pandemic. Border controls such as fever screening, travel history, identi cation of disease symptoms, and airport screening began in late January 2020. A national lockdown that began on March 24 impacted 1.3 billion individuals. Public health measures such as social distance, hand hygiene, mask use, and telecommuting were also widely practiced. India made every effort to increase health resources, converted train cars into isolation beds. The Government also introduced a mobile phone application named Aarogya Setu for contact tracing and aiding in quarantine. Testing numbers have also increased rapidly, with 553 government labs and 231 private labs nationwide having expanded. [25] Despite a robust response at the outset of the pandemic, India has the world's fastest-growing in absolute numbers as of May 2021. WHO has stated that the "future of the pandemic will depend on how India handles it." [26] From June 2020, India has already gradually relaxed the lockdown measures. With the gradual socio-economic recovery and continued relaxation of restrictions, a second wave of the outbreak emerged in India in February 2021 and gained momentum.
As the country that rst identi ed the COVID-19 outbreak, China took the lead in initiating an unprecedented lockdown. From January 23 to April 8, 2020, Wuhan, the source of the outbreak, suspended all tra c in and out of the city. The central thrust of China's efforts to control the rst wave of the outbreak was to actively identify and manage cases, track, and isolate close contacts, and severely restrict or control population movements when feasible and appropriate. [27] The main response policies of the Chinese government include the following levels. Mobility restrictions: Except for the lockdown of where the epidemic occurred, has completed nucleic acid testing and screening. It is also the decisive actions and strict measures that have allowed China to control the rst wave of epidemics so far, except for sporadic epidemics and imported cases.

Discussion
COVID-19 is a novel, highly destructive virus with a high basic reproductive number (R0), and can be transmitted during the asymptomatic phase of infection. A Nature survey shows many scientists think that the coronavirus will become endemic-meaning that it will continue to circulate in pockets of the global population for years to come. Control of COVID-19, while di cult, does have some countries with successful experiences. Global vaccination is ongoing, but it remains to be seen how effective the vaccine will be in reducing the severity of infection. Reducing transmission through non-pharmaceutical measures will remain critical in the next year or two. In the analysis of COVID-19 response strategies in four representative Asian countries during 2020-2021, we have summarized some effective strategies and identi ed some shortcomings.

Aggressive Case Identi cation And Quarantine
Case identi cation and management, coupled with close contact tracing and isolation, is a powerful strategy. Both China and South Korea, which have achieved better results in COVID-19 control, attach great importance to case identi cation and quarantine. A model evaluating the effectiveness of NPIs in China showed that without these interventions, COVID-19 cases may increase 67-fold and that early detection and isolation of cases was the most effective measure. [28] Korea's rapid containment of transmission in the rst wave of the epidemic, along with the implementation of less stringent social distancing measures, led to widespread international attention to their "test, track, isolate" strategy. However, other countries should note in replicating the measure that the rst wave in South Korea was a small cluster of outbreaks. China also locked down the source of the outbreak at the outset, mobilized national health resources to focus on large-scale testing and screening, detected and treated all cases, and isolated close contacts. Aggressive case identi cation and quarantine measures may be more appropriate to suppress outbreaks promptly at the initial outbreak or when small clusters occur. This may be di cult when the epidemic is larger and spread to a wider area. [29] 4.2 Social Distance By appealing or forcing residents to maintain social distance is a potent measure chosen by most countries in the world. However, the enforcement of social distance in countries is decreasing as the outbreak prolongs. Japan's response to COVID-19 was unique in that the authorities did not impose the same rigorous lockdown measures as China and India, nor did they carry out massive testing and screening as in South Korea. Figure 3 shows that Japan's total tests per thousand people are lower than South Korea and India. The state of emergency declared by the Prime Minister and the avoidance of the "3C Plus" relied more on the voluntary behaviors of the residents. Instead of quarantining all con rmed patients, the main focus was on treating serious cases and recommending home quarantine for patients with mild symptoms. A study of voluntary behavioral changes during the early stages of the COVID-19 outbreak in Japan showed that a signi cant portion of the Japanese population voluntarily changed their behavior. [30] Although the rst wave was controlled mainly by residents' good hygiene habits and compliance with social distance measures, after Japan launched the "Go To" campaign to revitalize the economy in July 2020, with the increase in population mobility, the second and third wave of epidemics also followed.
India's early response to COVID-19 was very strict, and a widespread lockdown of the country was initiated as soon as possible, but India's lockdown was seriously awed. India's 140 million people are daily-paid migrant laborers; with the imposition of a national lockdown, they are forced to ock back to their villages, unable to comply with the government's advice to maintain social distance. [ China has addressed the problem of health resource availability in this COVID-19 outbreak through rapid action and a unique nationwide joint prevention and control system. India has a weak public sector in the health care system, with a large, unregulated private sector. Due to the varying public health services across Indian states, the response and effectiveness of the outbreak varied considerably. Although the healthcare infrastructure has been urgently strengthened and the export of PPE such as masks and protective clothing was banned by the Indian authorities in February 2020, the shortage of doctors will not be remedied overnight. Healthcare personnel was also stigmatized by the general public for having contracted COVID-19 due to inadequate protection. Only the requisitioning of private facilities to support patient care in this situation will increase India's ability to respond to emergencies. [32]

Government Leadership
A pandemic is a war-like crisis. The powerful government plays a key role in the war. As we can see from the results of the current outbreak response in the four representative Asian countries selected for this study, a strong government does play an important role in outbreak control. The Korean government adhered to the "one team" principle after the outbreak began; it delegated the control and management of infectious diseases to the head of the KCDC by deploying national manpower and medical resources, which allowed for the consistent and systematic command and control throughout the country. China quickly launched a joint prevention and control mechanism to respond to COVID-19; the NHC took the lead in setting up a leading group to analyze and judge the situation of the epidemic and provide uni ed guidance to local governments in handling the outbreak.
The Japanese government failed to adequately re ect on the lessons of the rst wave of the outbreak and instead clung to the notion of exceptionalism. Instead of investing in public health, logistics, addressing social and health inequalities, and improving communication with the public, the government prioritized rescuing the restaurant and tourism industries to revive the economy, all of which led to prevention fatigue and reduced public adherence, accelerating the second and third waves of the epidemic. [33] And back in September 2020, a Lancet editorial noted that the Indian government was creating a climate of fatalism and false optimism, with excessive optimism hindering vital public health initiatives. The message to countries is that policymakers should respect scienti c evidence and follow the advice of epidemiologists rather than blind con dence and false optimism. As early as September 2020, a Lancet editorial noted that the Indian government was creating a climate of fatalism and false optimism and that excessive optimism hindered vital public health initiatives. [34] The enlightenment for all countries is that policymakers should respect scienti c evidence and follow the advice of epidemiologists instead of blindly self-con dent and falsely optimistic.

Conclusion
COVID-19 is a new, extremely complex, and highly destructive virus. Although global vaccination is underway, we should not take it lightly. Successful practices in China and South Korea show that case identi cation and management, coupled with close contact tracing and isolation, is a powerful strategy.
The lessons of Japan and India show that social distancing is an effective measure, but only if it is rigor and persistent. Finally, in both developed and developing countries, the development of health care systems and coordinated government leadership play a key role in overcoming epidemics.