These recommendations were written at the request of a very generous donor in Southeast Asia that was observing the same thing we see: many governments, at all levels, simply don’t know what they’re supposed to do right now. As a group, we have been tracking COVID-19 closely since mid-January. What’s written is a mix of best practices, mistakes made, lessons learned, and academic research.
We will update this page with feedback from more public health, policy, and medical experts and as we see which strategies do and don’t work. We will be launching an Asia-focused COVID19 platform soon at outbreak.asia.
We would recommend following the Australian government’s travel warnings and advise citizens to cancel non-essential travel everywhere in the world right now. COVID-19 is currently uncontainable and undetected. While inadequate testing in the United States is in the news, many countries lack the capacity to produce assays and test domestically. For inbound international travel, we would advise 14-day self-quarantine for all passengers arriving internationally regardless of nationality. Assume three out of four infected arrivals were not, and will not, be detected on entry.
Suspension of domestic travel out of cities where an uncontained community transmission has been detected should be strongly considered. This was the Philippines DOH threshold that was reached when President Duterte ordered these measures on Thursday. However, these domestic travel bans were announced with 24-48 hours notice in both Manila and Lombardy. Predictably, this led to an exodus of possibly infected non-residents to outer provinces and cities.
After already letting far too many Chinese New Year travellers out of Wuhan before the lockdown, the lockdowns that followed were generally only announced at the time the policy came into effect. If the outbreak is severe, a surprise announcement should be considered. There are contexts in which travel restrictions might do more harm than good if the outbreak already seems uncontained throughout the country.
We entered this epidemic with a pre-existing crisis in global leadership. Developing and middle income countries should be forcibly advocating for global and regional partnerships with traditional development partners to help them rapidly expanding their domestic testing capacity. It is in everyone’s interest to know where outbreaks are happening, assist other countries in discovering and containing their own outbreaks, and collect more data for systemic analysis.
Genetic data from test samples needs to be sent to GISAID as promptly as possible to detect new strains of COVID19 and understand the larger picture of this epidemic. It took the Hong Kong government a month to submit their data.
It is critical to know now whether warm weather slows the spread of this disease and/or by how much. Instead of waiting for warmer weather, testing capacity should be expanded rapidly in places like Philippines, Malaysia, Indonesia, and Egypt that are likely experiencing much larger outbreaks than the official numbers suggest. They likely require international, bilateral, or multinational assistance to do this as quickly as is necessarily.
Testing should be free. Anyone who matches the symptoms and tests negative for other respiratory infections should be tested. If not by a PCR or serological test, then a CT scan. Countries with limited testing capacity should consider letting doctors diagnose with CT scan imagery, if that option is available. In our view, the risk of false negatives far outweighs the risks of false positives that can be confirmed later with a test. Contact tracing to discover potential infection clusters is being dangerously delayed at present.
To minimize the risk of false negatives many of the testing products require two tests before giving the all clear, and PCR and serological tests may not work if samples are taken too early in the infection cycle, when the viral load is too low or if the person’s body hasn’t produced antibodies against the virus yet. This means sufficient time is required to be able to test people correctly.
Serological tests are only now being developed. They are much faster and easier to distribute, if less accurate. We recommend that government researchers should be encouraged to look at, and participate in, Protocols.io community of medical researchers that are developing non-proprietary public domain COVID19 testing protocols that can be easily replicated.
We feel the situation is so dangerous at the moment that every locale should ban mass public gatherings. We feel the numeric thresholds (i.e., >100 or >1000) are insufficient. Companies that can have their workers work remotely should be asked to do so. Any locale with >10 infections should consider suspending schools. Non-essential government services should be suspended when an uncontained community outbreak has been detected in a locale.
Citizens should be encouraged to wear reusable cloth face masks even if they are not sick. They should be discouraged from buying and hoarding surgical masks and N95 respirators. Expect N95 masks to become unavailable for frontline medical staff in the event of an outbreak. It is worth reading about Taiwan’s response at the onset of this epidemic in the form of nationalized mask production and distribution.
Locations with exponential case growth should be placed on some form of lockdown immediately. The longer a government waits, the larger the outbreak and longer the lockdown will last. Locking down Wuhan a week earlier might have meant the rest of China, and now everyone else, wouldn’t be in this position now.
There are various types of lockdowns that range in severity. What we mean is that, at minimum, people should be discouraged from going outside at all except when necessary. At one extreme this is a near-martial law curfew. At the other end, however, we’re talking about almost nobody going to work or school until the outbreak is contained. One way to avoid mandatory curfews is to encourage and even subsidize food, grocery, and medicine delivery.
We strongly advise governments everywhere, but especially governments in developing countries, to consider the impact a lockdown will have on the most vulnerable populations. You should be actively planning right now how to ensure food security and income stability for people with already precarious livelihoods. Consider policies like eviction bans and no-interest loans to mitigate the economic shock. There are many cities where a month-long lockdown might kill more people than letting the virus run uncontained. Thi
It was difficult for both the government and civil society to bring donated goods into Wuhan at the peak of the crisis there. Governments should be planning now to ensure safe logistic routes still exist after a lockdown order to deliver critical supplies into ‘hot zones.’ Highly monitored transit zones or cargo drop off points should be considered in the event that cities or provinces are preventing outside drivers and vehicles from entering.
Mass quarantine sites should be identified and ready to launch well before an outbreak reaches your locale. The experience in Hong Kong suggests that trusted politicians and medical experts should be sent early to ease community fears. Covered stadiums, gyms, and coliseums are ideal hospital overflow sites. Ensure now that frontline medical workers will have sufficient PPE gear and supplies and patients have adequate food and other necessities.
One under-recognized Chinese response to their outbreak was building more quarantine sites than were ultimately necessary. Cities across China built their own ‘ten day hospitals’ or were converting other buildings into quarantine sites that never wound up being used. A rule of thumb might be to always have one more facility being built than seems necessary right now.