A policy review published in The Lancet identified five key factors for developing strategies to ease lockdown restrictions: knowledge of infection levels, community engagement, public health capacity, health system capacity, and border control measures.
Analysing the successes and failures of nine high-income countries and regions (Germany, Hong Kong, Japan, New Zealand, Norway, Singapore, South Korea, Spain, and the United Kingdom), the authors found an absence of clear and consistent strategies for exiting restrictions and identified key cross-country lessons that can be learnt.
Lead author, Associate Professor Helena Legido-Quigley said, “COVID-19 is a serious disease that will be with us for a long time. There is increasing realisation that easing of lockdown is not about returning to a pre-pandemic normal, and governments have to find strategies that will prevent rapid growth of infections in ways that are sustainable and acceptable to the public over many months.”
“Our review of international experiences identifies lessons governments can learn from each other’s successes and failures. We are not advising that the exact same measures should be replicated in different countries, but it is not too late for governments to consider novel policy solutions developed by other countries and adapt them to fit their own context,” said Assoc Prof Legido-Quigley.
Dean, Professor Teo Yik Ying, who was a co-author on the paper, said, “In reviewing international experiences, we were concerned about the large divergence in government preparedness. There is an urgent need to understand the contextual differences that have led to such contrasting results, and to identify common principles that governments can follow to protect their people and economy.”
The authors pointed out that responses so far have varied significantly across countries.
In particular, the methods and success of contact tracing and isolation have varied significantly across countries. Many Asian countries, except Japan, promptly did extensive testing, tracing and isolating of all cases (i.e., not just severe cases) from the start of the outbreak, strengthened by innovative surveillance technology, whereas these processes have been considerably delayed in most of Europe, except Germany (where existing resources were redeployed quickly). Furthermore, confirmed cases are mostly isolated at institutions in Asia rather than at home, such as in Europe.
Wearing of face coverings to protect others was, at least initially, adopted to a much greater extent in Asia than in Europe. This is partially to do with greater cultural acceptance. For example, in Hong Kong, Japan and South Korea, the habit of wearing face coverings was already widespread before the pandemic.
Experience with previous epidemics like SARS meant that many Asian countries had robust healthcare and public health infrastructure already in place. There has historically been a high level of public acceptance of strict rules in times of crisis, with the majority accepting a trade-off between their personal rights and public health.
The authors also identified key learnings from these countries’ experiences that have implications for lockdown exit strategies worldwide:
- A clear plan with a transparent decision-making process is essential, ideally explicitly stating the levels or phases of easing restrictions, the criteria for moving to the next level or phase, and the containment measures that each level or phase entails.
- Governments should have robust systems in place to closely monitor the infection situation before easing measures. The authors point out that the R value is important, but caution that this requires high-quality data in real time (like in Hong Kong) to be accurate and needs to be interpreted using epidemiological knowledge. For example, a small localised outbreak can drive a country’s R value up but does not require a national lockdown to be controlled.
- For communities to reopen safely, control measures to reduce transmission will be needed for some time, including face masks and social distancing. New Zealand’s social bubbles provide a successful example of sustainable measures, as they allow for social interaction while reducing transmission. For control measures to work, governments must educate and engage with the public, building trust and selecting appropriate measures that the public are willing to comply with. The public should be directly involved in the process of producing measures appropriate for the local context.
- Each country must have an effective find, test, trace, isolate and support system in place before easing lockdown restrictions. Drive-through and walk-through screening in South Korea encourages proactive testing of potential case contacts and offers an effective model for expanding case finding. Furthermore, any test, trace, isolate and support system needs to be supported by sustained investment in public health capacity and health system capacity including facilities, supplies and workforce.
- Finally, there is a strong argument for adopting a so-called ‘zero COVID-19’ strategy, like in New Zealand, which aims to eliminate domestic transmission, particularly considering emerging evidence on the effects of ‘long COVID’, which occurs in people who have survived the disease but continue to have symptoms for longer than expected.
Authors from SSHSPH include Assoc Prof Helena Legido-Quigley, Prof Teo Yik Ying, Assoc Prof Alex Cook, Assoc Prof Hsu Li Yang, Ms Melisa Tan Mei Jin (Research Associate and PhD student) and Ms Emeline Han (former Research Associate).
They worked with international experts, including Prof Gabriel Leung from The University of Hong Kong’s Li Ka Shing Faculty of Medicine, Prof David Heymann and Prof Martin McKee from London School of Hygiene & Tropical Medicine, and the Right Honourable Helen Clark from The Helen Clark Foundation and former Prime Minister of New Zealand.
Full text is available on The Lancet: Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe
Media coverage:
- Trust in government and well-funded health systems key to virus control, study finds, The Telegraph, 25 September 2020
- Countries should meet these five criteria before easing lockdowns, study says. Many aren’t even close, CNN, 25 September 2020
- Covid-19: Learn from other countries about easing lockdown, researchers urge, The BMJ, 25 September 2020
- Experts compare strategies for easing lockdown restrictions in Europe and Asia Pacific, Medical Xpress, 25 September 2020
- New Zealand’s ‘social bubbles’, Hong Kong’s real-time R rate, and South Korea style testing: The measures scientists say are needed to ease Britain’s lockdown, Daily Mail, 25 September 2020
- Five key factors for easing lockdown restrictions, NUS News, 30 September 2020