As Greece is approaching the opening up phase, we must look at what has occurred in other countries more advanced in the epidemic curve than we are. We must examine the sequence of events as they have opened up and try to follow the best lessons from some and avoid the pitfalls of others.

The lesson from what we have seen in many countries appears to be that, if you leave it too late then everything becomes so much harder to do, because there are so many simultaneous cases. When reacting quickly, one has two choices, intensive testing with localised isolation or total lockdown. The experience of China must have been the clue to the decisions of individual countries. Although rumours about a terrible new disease taking place in China were circulating in the social media, including terrifying videos with people collapsed on the ground, the first report from WHO, the World Health Organisation came out on 20 January 2020, which related 278 cases in China, with an already ominous number of 6 deaths and  12 in critical condition. It also reported cases abroad, 2 in Thailand, 1 in Japan and 1 in South Korea. The first case in the US would appear on the 21st and the first case in Singapore the next day. France and Italy would be hit two days later. Two days after the virus genome sequence had been determined, on the 12th of January, China shared with all countries. Probably, because of their proximity to China, some took more measure of the threat than others.

Three countries have been cited as examples on how to cope with the crisis: Korea, Singapore, and Japan.

Korea and Singapore having each lost 33 people in respiratory syndrome epidemics respectively to MERS in 2015 and to SARS in 2003, immediately reacted in an all government approach, whereas Japan relied on its antiquated health system, delegating many responsibilities to local prefectures. Whereas Korea has just achieved the milestone of having no indigenous new cases, the other two, in the past few weeks, have been unexpectedly affected by a second wave, which they are struggling to contain. It is interesting to contrast the different methodologies of these governments.

In contrast with Greece that was hit, more than a month later, on the 27th of February, they all had their first case within a week: Japan on the 16th of January, Korea on the 20th and Singapore on the 23rd.

In order to appreciate the different evolutions of the infections across the three countries, we reproduce below the number of positive cases reported in WHO situation reports at various dates.

Whereas the containment methods in Korea  seemed to have worked perfectly, as the number of infections  has dwindled to a trickle, the  mounting figures in both Japan and Singapore indicate that, when a second wave occurred, the controls initially put in place to contain the epidemic were no longer sufficient or had loosened. We have adjusted the numbers in function of the population relative to that of United States. Whereas the numbers for Korea and Japan would appear relatively low, the latest figures of 18,778 for Singapore, when adjusted for population are not far from the total US current figures.

The Korean philosophy was that through early patient detection with accurate tests followed by isolation, the mortality rate could be lowered, and the virus prevented from spreading. Within 17 days after the CDC campaign strategy was agreed, South Koreans managed to design and create a test, set up a network of labs across the country and have a coherent system ready to work. The preventative measures taken by Korea involved no lockdowns, no roadblocks, and no restriction on movement. However, schools were closed, offices were instructed to encourage people to work from home and large gatherings were discouraged. The triple T (Test, Trace, and Treat) became the marching order. They relied on the natural civil obedience of the people to fully cooperate and they appear to have done so, apart from some religious sects that contributed to the formation of large clusters forcing the isolation of specific areas.

With a well-rehearsed response plan as a result of their SARS experience, Singapore carried out extensive testing of every suspected case; tracked down with  a detective methodology anyone was thought to have  come into contact with a confirmed case; and confined with strict control those contacts to their homes until they were cleared. For weeks, Singapore managed to keep its numbers low and trackable, with only small, easily contained hots spots, without interfering with the economy. The system worked until mid-March, until the state of the pandemic became alarming and thousands of citizens came back home, with an estimated 500 undetected at the airport health checks that involuntarily brought back  the virus with them Although the returnees were quarantined at home for two weeks, the other members of the households were free to carry on with their lives outside. This probably there that the safety control chain broke down and the sudden increase in cases made it impossible, because of insufficient personnel for the tracking system to operate. This was worsened by the discovery of cluster of cases in dormitories for foreign workers.

By contrast Japan, which did not suffer the epidemics of MERS or SARS kept to its ancient health care system where the testing is the responsibility of local health centres and not on a national government level  which meant that local centres were  not equipped with the resources both in terms of personal or equipment to cope with testing on a major scale. Further the government thought massive testing was a waste off resources. Preoccupied with the Olympics, they resisted the idea of a general emergency and opted for the policy of introducing progressive measures. At the end of February schools were closed and only the Hokkaido Prefecture imposed a voluntary lockdown. At that time, only 239 cases were reported. However at the beginning of March , infections starting mounting rapidly on march 5th  (349 cases on March 5th ) prompting  quarantine restrictions for all visitors arriving from China and South Korea. By the 10th as cases had reached 568, an historical “emergency situation” was declared. By the 16th they expanded the entry restrictions to foreign citizen arriving from Spain, Italy, Switzerland and surprisingly Iceland. Whether it was from Hokkaido or elsewhere, the virus started spreading particularly in the Toyo and neighbouring Chiba prefectures. Even the Hokkaido island that had lifted the lockdown on March 19 was hit by the second wave. Eventually the whole country was put on a state of emergency.

Interestingly the epidemic in Japan and Singapore probably because both were islands, was initially well contained more by favorable circumstances than by thorough preparation. Having avoided it for months, Singapore is now under a partial lockdown, with schools and non-essential businesses closed, and people urged to stay at home. Will they now consider massive testing? Even now, more than three months after Japan recorded its first case, it is still only testing a tiny percentage of the population. It seems Korea got it right with massive testing.

As we are to reopen the Country, we are no doubt going to be faced with similar problems. As we do not appear to have the massive testing infrastructure of Korea, we will have to resort to the Singapore approach. As long as our borders are closed, it will probably work. IF we open for tourism, we must build up the necessary testing infrastructure.

By Digenis4th May 2020

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