Policy and Measures to Prevent Infection of SARS-CoV-2 and the Spread of COVID-19 Cases
in the Absence of a Vaccine in 2020:
Country Studies of Belgium, Thailand and Vietnam
Yasushi Katsuma
†At the end of 2019, there was an outbreak of an emerging infectious disease (EID) in Wuhan, the capital of Hubei Province, China. Following that, the World Health Organization (WHO) announced the discovery of the novel coronavirus “SARS-CoV-2” on 12 January 2020. Human infection by this virus is called COVID-19. It has become a global pandemic, and there is as yet no end in sight. In this paper, first, the author will lay out the major features of COVID-19. Second, the mobility restriction policy formulated, as well as the measures taken, in Belgium and Vietnam will be compared. Third, the author will look at how behavior changes have been promoted among citizens to prevent infection of SARS-CoV-2 and the spread of COVID-19 cases in Belgium and Thailand. Finally, referring to the example of Thailand, the medium-term measures against EIDs in general will be discussed.
Key Words: COVID-19, mobility restrictions, EID, Belgium, Thailand, Vietnam
1. Background
At the end of 2019, there was an outbreak of an emerging infectious disease (EID) in Wuhan, the capital of Hubei Province, China. Following that, the World Health Organization (WHO) announced the discovery of the novel coronavirus “SARS-CoV-2” on 12 January 2020. Human infection by this virus is called COVID-19. It has become a global pandemic, and there is as yet no end in sight.
What makes COVID-19 different from other infectious diseases? What public policy options are there to prevent infection of SARS-CoV-2 and the spread of COVID-19 cases in the absence of a vaccine? What should we do in the medium-term to combat COVID-19 and other EIDs? The author became interested in exploring these questions, after spending time in Vietnam in December 2019 and February 2020, in Thailand in January 2020, and in Belgium in March 2020. The author was able to observe and experience personally some developments related to COVID-19 in those three countries.
In this paper, first, the author will lay out the major features of COVID-19. Second, the mobility restriction policy formulated, as well as the measures taken, in Belgium and Vietnam will be
† Professor, International Studies Program, Graduate School of Asia-Pacific Studies (GSAPS), Faculty of International Research and Education, Waseda University; Director, Department of Global Health Affairs & Governance, Institute for Global Health Policy Research (iGHP), the National Center for Global Health & Medicine (NCGM), Japan. 早稲田大学国際学術院（大学院 アジア太平洋研究科国際関係学専攻）教授；国立国際医療研究センター・グローバルヘルス政策研究所・グローバルヘルス外交 ガバナンス研究科長
compared. Third, the author will look at how behavior changes have been promoted among citizens to prevent infection of SARS-CoV-2 and the spread of COVID-19 cases in Belgium and Thailand.
Finally, referring to the example of Thailand, the medium-term measures against EIDs in general will be discussed.
2. Unique Features of COVID-19
First, COVID-19 is a global pandemic, with an extremely high number of human infection cases in general, as well as higher death rates among vulnerable groups, including elderly people and those who have underlying health problems. Since the first report in December 2019, COVID-19 has become a global pandemic across 223 countries and territories, with over 107 million confirmed infections and over 2.3 million confirmed deaths (as of 13 February 2021) [WHO 2021a].
One reason for a high number of infection cases is that asymptomatic or undiagnosed infected people may be spreading the virus. Second, as it is difficult to identify, isolate and quarantine asymp- tomatic infected people, general mobility restriction measures, including lockdowns, are important to prevent the spread of COVID-19 cases. However, mobility restriction policy, banning mass gathering events and regulating hospitality and service businesses, would damage the economy and cannot be continued for months.
The actual number of people infected by COVID-19 should be far more than the confirmed number. First, many are thought to become infected and recover with only mild or no symptom, going about their daily lives without ever being aware of the virus. Second, there are many cases where people with symptoms resembling COVID-19 go undiagnosed because Polymerase Chain Reaction (PCR) tests are unavailable, or not conducted quickly. Third, some researchers point out that asymp- tomatic infected people can still spread the virus to others. These factors make contact tracing extremely difficult.
Much is still unknown about this virus, and there is no end in sight to the pandemic. Although the world now is much different than it was 100 years ago, the scale of its spread invites us compare with the 1918‒20 Spanish flu (H1N1 type-A influenza virus). That virus is said to have infected 500 million and killed 50 million around the world [Jordan 2019].
However, SARS-CoV-2 is not an influenza virus but a coronavirus. SARS-CoV-2, causing COVID- 19, is the seventh coronavirus known to infect humans. Of the seven, four have spread globally, but cause mild to moderate symptoms only now (HCoV-OC43, HCoV-HKU1, HCoV-229E and HCoV- NL63) [ICTV 2019]. The first three cause common colds, as well as severe lower respiratory tract infections among the youngest and oldest age groups. The last one, HCoV-NL63, is an important cause of (pseudo) croup and bronchiolitis among children [ECDC 2020].
The other three, including COVID-19, can cause more severe and even fatal symptoms. The severe
over to humans from greater horseshoe bats. By July 2003, it had spread to over 30 countries and terri- tories, with confirmation of around 8,000 people infected and over 700 deaths [CDC 2004]. The Middle East respiratory syndrome (MERS-CoV), another coronavirus infection discovered in Saudi Arabia in 2012, is thought to have spilled over to humans from the Arabian camel [ECDC 2015]. By the end of 2019, it had spread to 27 countries, with confirmation of about 2,500 people infected and over 800 deaths.
WHOʼs International Health Regulations (IHR), agreed upon by member countries, allow the WHO to declare a “public health emergency of international concern (PHEIC).” Following the H1N1 flu (2009), wild poliovirus (2014), Ebola virus (2014), Zika virus (2016) and Ebola virus (2019), COVID-19 pandemic forced the WHO to declare the sixth PHEIC. This PHEIC declaration should allow the WHO to demonstrate global leadership in promoting international cooperation among the member countries to combat COVID-19.
International cooperation for access to personal protective equipment (PPE) and testing kits, as well as for research and development of treatments and vaccines, is extremely important. However, as the WHO faces difficulties in demonstrating global leadership, along with the “my country first” stance of many wealthy member countries, including the suspension of financial contribution by the United States of America in 2020, international cooperation to combat COVID-19 has been insufficient.
There are a number of emerging issues related to vaccines. Wealthy countries tend to hoard more vaccines than needed for their own priority groups, which is often characterized as “vaccine nation- alism.” In addition, some wealthy people who do not have immediate access to vaccination in their own countries may go abroad for “vaccine tourism.” In some cases, vaccine producing countries may use their vaccines for diplomatic negotiations with low-income countries, which is often called
“vaccine diplomacy.” As there are only a limited number of pharmaceutical companies producing vaccines against COVID-19, the cost is another factor that may limit access to vaccines for some coun- tries and people. Currently, at the World Trade Organization (WTO), a proposal for temporary intel- lectual property (IP) waiver in response to COVID-19 is discussed [WTO 2020]. These emerging issues need to be addressed in order to promote equitable access to quality vaccines at affordable costs, leaving no country and no one behind.
The WHO and other partners were able to launch the Access to COVID-19 Tools (ACT) Acceler- ator in April 2020 in order to promote global public-private partnerships in development, production and equitable access to new COVID-19 diagnostics, therapeutics and vaccines, while strengthening health system. As the vaccines pillar of the ACT Accelerator, the COVAX Facility was established as a global risk-sharing mechanism for pooled procurement and equitable distribution of COVID-19 vaccines. It is important that wealthy countries support the ACT Accelerator and the COVAX Facility in promoting international cooperation to combat COVID-19.
3. Vietnamʼs Policy and Measures against COVID-19
Vietnamʼs first COVID-19 case, a Chinese who traveled from Wuhan to visit his son living in Hanoi, was confirmed on 23 January 2020. On the following day, 24 January, the acting health minister ordered the establishment of an emergency infectious disease prevention center. On 1 February, four Vietnamese were found to be infected from the Chinese traveler, which was the first confirmed cases of domestic transmission, totaling to six cases including two Chinese. On the same day, Prime Minister Nguyen Xuan Phuc signed Decision No. 173.QD-TTg, declaring COVID-19 an epidemic in Vietnam. Border measures were taken on the same day, with the Civil Aviation Authority of Vietnam suspending approval of flights between Vietnam and China [VNA 2020]. In addition, ground trans- portation of people and things across the 1,400 km border with China was restricted.
Even after the end of the holiday season of Vietnamese lunar new year (Tet) on 25 January, the Ministry of Education & Training kept primary and secondary schools closed. In mid-February, universities and other tertiary institutions were also closed. The Ministry of Culture, Sports and Tourism advised that traditional events scheduled across the country during the new year holidays on 8 February be scaled down, postponed or canceled.
For inter-personal behavior, physical distancing is important to prevent SARS-CoV-2 infection. The WHO prefers that we use the term “physical distancing” instead of “social distancing,” as expressed in the briefing on 20 March 2020 [Kaur 2020]. Behavior at religious mass gathering events poses several delicate issues. From 27 February to 1 March, a Tablighi Jamaat religious mass gathering event was held at a mosque in Sri Petaling in the suburb of Kuala Lumpur, Malaysia, attracting approximately 16,000 (including around 1,500 non-Malaysian) followers. It became one of the largest COVID-19 clusters, spreading the virus to half a dozen countries in Southeast Asia [Beech 2020]. After returning home from Malaysia, some Vietnamese Muslims did not observe self-quarantine, and continued visiting mosques in Vietnam. The tension between public health and religious faith is a delicate issue, which religious leaders rather than medical scientists may have a more influential role to play.
Among behavior changes promoted to the public, efforts to establish a handwashing habit are espe- cially notable. The National Institute of Occupational and Environmental Health, an agency of the health ministry, recruited musicians to rearrange a hit song to promote proper handwashing to the public. The song with illustrative animation can be seen on YouTube [MIN 2020].
As of 13 February 2021, in Vietnam, 2,142 people have been confirmed to be infected with SARS-CoV-2, with 35 confirmed deaths [WHO 2021b]. Along with the Republic of Korea (South Korea), Taiwan and New Zealand, it is receiving attention for being relatively successful among Asia-Pacific countries and territories in containing the spread of COVID-19 cases.
4. Belgiumʼs Policy and Measures against COVID-19
acknowledged as a problem in Asia, not in Europe.
During the week beginning 22 February, there were carnivals in towns of Binche, Aalst and Malmedy, and therefore schools were closed for about a week in Belgium. After the holidays, some Belgian tourists returned from skiing in northern Italy, and six of them were confirmed to be infected on 2 March. Beginning in March, people began to realize the risk of transmission from neighboring European countries.
On 10 March, indoor mass gathering events of 1,000 or more participants were ordered to be canceled. After that, Belgiumʼs National Security Council declared a state of emergency, closing schools, discos, cafes and restaurants, as well as canceling sports and culture events from 13 March.
Many cafes and restaurants did not allow indoor dining, selling only for takeout. Next, on 17 March, non-urgent travels were prohibited, nonessential stores were closed, and gatherings were banned.
Further, on 20 March, the national borders were closed to nonessential travel.
In order to prevent the infection of SARS-CoV-2 and the spread of COVID-19 cases, the freedom of movement is often restricted. It is important to avoid human rights abuses being committed in the name of public health. The 1984 Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights (ICCPR) provide guidance, and describe the framework, under which restrictions may be imposed [OHCHR 2020].
To encourage behavior changes, a message to maintain 1.5 meters distance from others was repeat- edly promoted to citizens, using pictograms. This was a major change for a culture in which shaking
Photo 1. Pictogram Promoting Physical Distancing (© Yasushi Katsuma, Brussels/2020 March 19)
hands, hugging and kissing are part of everyday greetings.
As of 13 February 2021, Belgium had over 735,000 confirmed cases and over 21,000 confirmed deaths [WHO 2021b]. At least in the year 2020, around 40％ of deaths were reportedly happening at nursing homes.
5. Medium-Term Measures against EIDs: Lessons Learned from Thailand
The first issue is border control. Being an island country, it is also literally called “waterside measures” in Japan. Judging from the outcomes, the early and strict border control measures imposed by Vietnam seem to have succeeded in preventing SARS-CoV-2 from coming into the territory so far.
As its level of medical care is not the highest, preventing an influx of the virus has been a high priority, and Vietnam seems to have learned from its experience with SARS-CoV in 2003.
The lessons learned from the past were also effectively used in South Korea. South Korea seems to have learned from in-hospital transmission of MERS-CoV in 2012, and the system built then for PCR testing has been effective to combat COVID-19, allowing widespread testing and quarantine of the infected.
In contrast, Belgium advised that travels to China be postponed, but tourists brought the virus home from neighboring countries such as Italy. The headquarters of the European Union (EU), which works to integrate Europe, happens to be located in Brussels, and at the beginning, Belgium was not keen to impose border control measures on Schengen countries that have signed a treaty to remove border controls. There is a tendency to simplify procedures required for international mobility in globalism, but this is currently re-examined in an era of COVID-19.
The second issue is physical distancing. We may not revert to previous greeting customs, even after COVID-19 is gone. It may be an opportunity to conceive of a new “greeting culture.” A more sensitive issue is how to deal with religious mass gathering events. The action of some Muslims was seen as problematic in Vietnam. There were also cluster outbreaks from worship services of Christian groups in South Korea. There is a chance of similar outbreaks in other religious groups as well, making this an issue for religious leaders to consider how to balance public health and religious faith.
The third issue is “leaving no one behind,” one of the principles of the Sustainable Development Goals (SDGs). Many of the confirmed COVID-19 deaths in Belgium were people under care in nursing homes. Though there is a lack of information, the health of those who are incarcerated in prison may also be at stake. In Thailand, many initiatives are being implemented with support from the Thai royal family to improve the quality of life of inmates, which includes monitoring their health.
For instance, in cooperation with the nearby Bang Bo General Hospital, an onsite clinic has been set to treat inmates at the Samutprakan Central Prison in Bang Bo District of the Samutprakan Province. As such, an inter-ministerial collaboration between different government agencies is required so that
henipavirus and coronavirus, which can infect both humans and animals. It is thought that the increasing contact between humans and animals is one factor. Steps to protect animalsʼ health and their habitat will also be needed to ensure the worldʼs health and safety. The Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE) and the WHO already signed an agreement in 2010 to look at the interaction of animals, humans and their habitats, under the idea of “One Health.”
In Thailand, in search of food, the Lyleʼs flying fox is now seen gathering in suburban areas, such as the town of Phanat Nikhom in Chonburi province. A large number of bats have taken up residence in a temple where killing is prohibited. As villagers were not well aware, a health education program is implemented so that they understand the risk of infections to humans from excrement and partially eaten fruit dropped by the bats. In the medium-term, we must work to preserve the environment, since deforestation and other habitat changes are behind the bats coming to the towns in search of food.
Acknowledgement
This work was supported by Waseda University Special Research Project Grant number 2018K-397.
A shorter version of this paper, without technical details, was first published in Japanese language, as a report in “Waseda Online” within the Yomiuri Online on 30 April 2020. Its English version appeared in the homepage of Waseda University on 11 November 2020. This paper has been significantly modified and updated from those earlier shorter versions that appeared on the Internet.
Photo 2. Lyleʼs Flying Fox
(© Yasushi Katsuma, Phanat Nikhom/2018 January 31)
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