COVID-19 Country-Specific Responses

COVID-19 best papers & country
response summaries
Table of Contents
Overall summary 2
Country-Specific Responses 2
1. Taiwan 2
Summary 2
Epidemic curve 2
Data reliability 4
Policies pursued 4
Policies not pursued 6
Context and other actions 6
2. South Korea 7
Epidemic curve 7
Data reliability 9
Policies pursued 10
Appendix 1 13
Appendix 2 14
3. Singapore 16
Epidemic curve 17
Data reliability 17
Policies pursued 18
4. Japan 19
Epidemic Curve 19
Data reliability 21
Policies pursued 22
5. Hong Kong 26
Summary 26
Epidemic curve 26
Data reliability 27
Policies pursued 28
6. China 32
Epidemic Curve 32
Data reliability 34
Policies pursued 35
Appendix 38
7. Italy 41
Summary 41
Epidemic curve 41
Data reliability 43
Policies pursued 43
8. Spain 46
Summary 46
Epidemic curve 47
Data reliability 48
Policies pursued 49
9. Kuwait 51
Summary 51
Epidemic curve 52
Data reliability 52
Policies pursued 53
Notes and collated best papers 60

Non-pharmaceutical interventions 60
Healthcare system/clinical 61
Diagnostics 64
Epidemiology/modelling 64
Other country-specific papers 65
This document contains translated information from original articles, not all of which
have been verified. Also note that different sections of this document were written at
different times, and some information may be out of date.
Overall summary
COVID-19 is being successfully contained in South Korea, and mostly contained in Taiwan
and Singapore. None of these countries have required lockdowns, instead relying on
extensive testing and contact tracing, travel restrictions, and likely public hygiene measures.
1
The UK and US have too many cases for those measures alone to be practical right now,
but after a period of 'lockdown' and reduced transmission, such nations may be in a position
to adopt similar policies to prevent a second wave of COVID-19.
This pandemic may currently be largely contained in Hong Kong and Japan, but we are
concerned about under-testing and under-counting of cases in these nations as outlined
below, so cannot draw strong conclusions. These countries deserve further study.
Italy and Spain have faced a very difficult pandemic scenario and a significant minority of the
countries may have been infected. However, nearly three weeks after imposing a nation-
wide lockdown, they have started experiencing a reduction in the growth rate of new cases
and deaths.
Kuwait has fared reasonably well under increasingly intense suppression methods, including
strict curfews, although the growth rate of confirmed cases has risen significantly in April.
Demography, geography, climate and other contextual factors are likely to have played
important roles in Kuwait’s experience.
Country-Specific Responses
How are other countries faring, and how are they doing it?
1. Taiwan
A) Summary
Taiwan, despite being very closely linked to China, seems to have mostly controlled
COVID19, with a possible small resurgence in the last few days. This may be because of
early adoption of high rates of testing, tracking of travel history, border restrictions,
mandatory home quarantine, potentially the widespread use of masks, and other measures
listed below and outlined in this paper.
B) Epidemic curve
Context: "The island of 23 million is just 81 miles from mainland China ... Taiwan had 2.7
million visitors from China last year." (March 10 article)
As of March 29 confirmed cases remain few in Taiwan and their growth rate is slowing.
There have been just 3 recorded deaths.
2
Initially Taiwan had many times the density of confirmed cases — 5-10x as that in the UK —
but as of March 17 was far below the UK level:
C) Data reliability
3
It may be reasonable to assume 10-100x infected persons for every confirmed case in some
countries. However, the Taiwanese have been conducting a vast number of tests relative to
the number of identified cases — 18,812 tested for just 80 confirmations by 17 March.
This is a confirmation rate of only 0.4%, far lower than Spain (>50%), Italy (20%), Japan
(5%), the UK (4%), and even South Korea (3%) around the same date. So they may be
capturing a substantially larger fraction (see testing), conceivably more than half.
Testing seems to have been fairly constant in rate, maybe even dropping off somewhat. It's
possible they took their foot off the gas because they seemed to have it under control for a
while. Quote from a March 13 Guardian article:
"Chan, from National Taiwan University, agrees more needs to be done […] Taiwan,
with a population of almost 24 million, currently conducts only around 800 screenings
a day and not everyone under quarantine is tested."
D) Policies pursued
The best source is an academic paper from March 3. It includes a table of Taiwanese
government actions Dec 31 to Feb 21.
In summary: Taiwan immediately mobilized its National Health Command Center, set up a
Central Epidemic Command Center (CECC), and started testing after the first signs of the
outbreak in China (often by symptoms, and testing for flu first). It used emergency powers to
identify high-risk people by travel and medical history and restrict movement. From
December 31 2019 there were already passengers from Wuhan being temperature
screened, and by 29 January 2020 there was electronic monitoring of quarantined
individuals.
Production of PPE has been ramped up since January, with 15 million facemasks being
produced per week as of March 18.
Timeline (from academic paper link above)
● Dec 31 • Officials board and inspect passengers for fever or pneumonia symptoms
on direct flights from Wuhan
● Jan 5 • Taiwan CDC notified if passenger from Wuhan has fever and/or URTI (table)
● Jan 20, the Taiwan CDC announced that the government had under its control a
stockpile of 44 million surgical masks, 1.9 million N95 masks, and 1100 negative-
pressure isolation rooms. (accompanying paper)
● Jan 22 • Entry permits canceled for 459 tourists from Wuhan set to arrive later in
January
● Jan 23 • Wuhan residents banned from entering
● Jan 29 • Electronic monitoring of quarantined individuals via government-issued cell
phones
4
● Feb 2: Government drew up a budget of NT$200 million (US$6.6 million) to build 60
additional surgical mask production lines. Each machine can manufacture 100,000
surgical masks per day. Goal to raise output to 10 million masks a day. Soldiers
added to factories.
● Feb 5 • Cruise ships with suspected cases in past 28 days are banned • Cruise ships
with previous dockings in China, Hong Kong, or Macau in past 14 days are banned
● Feb 6 • Tours to Hong Kong and Macau suspended until Feb 29 • Chinese nationals
are banned • All international cruise ships are banned • Contacts traced for Diamond
Princess cruise ship passengers who disembarked in Taiwan on Jan 31 (table)
Facemask rationing system introduced
● Feb 7 • Foreign nationals with travel to China, Hong Kong, or Macau in the past
14-days are banned • Foreigners must see an immigration officer and cannot use e-
Gate (quick entry) • Couple fined NT$300,000 (USD $10,000) for breaking 14-day
home quarantine rule
● Feb 11 • Most residents of Hong Kong and Macau are banned
● Feb 12 • Government declared that violators of home isolation regulations will be
fined up to NT$300,000 (USD $10,000); violators of home quarantine regulations will
be fined up to NT$150,000 (USD $5,000)
● Feb 12 • Cases of severe influenza that tested negative for influenza since Jan 31 to
be retested for COVID-19 (table)
● Feb 18 • Taiwanese passengers on Diamond Princess cruise ship returning to
Taiwan must use charter flight arranged by the CECC and be quarantined • All
hospitals, clinics, and pharmacies have access to patients’ travel histories
● Feb 23 • Healthcare professionals banned from overseas travel
● Feb 25: Following bill passes: Special Act on COVID-19 Prevention, Relief and
Restoration
○ NT$60 billion ($2 billion USD) special budget, $19.6 billion for disease
prevention, rest for economic relief.
● March 5: Ministry plans to increase mask production with a further 32 lines and has
budgeted NT$90 million up to the end of March. The hope is to raise daily production
to 12 million masks.
● Enabled purchase of masks online through pre-purchase trial, first round between
March 12 and March 18 for quantities between March 26 to April 1 for pick up at
designated supermarkets (March 11 press release - in Chinese; March 13 article).
● Not sure when started or if had ended, but the minister of health has given daily
press briefings and VP of Taiwan broadcast PSAs online from the office of the
president.
● “They incentivized people to be truthful” on their health declaration forms, says
Wang. “If you are placed in the high risk group, the government will help you get
care. If you get sick by yourself, you’ll have to wander around the hospital trying to
get help.” (March 12 article)
● Soldiers were sent to work at mask factories to ramp up production (March 12
article).
● Note they were not part of WHO emergency meetings about COVID-19 due to
political issues with China. Taiwanese experts were allowed to participate online in a
WHO forum on Covid-19 on 12 February in their professional capacities (March 13
article).
● March 14: Travelers from Europe need to quarantine 14 days.
5
● March 18: HTC will design automated system through the LINE Bot system platform,
allowing home quarantines to actively report their health status through the Bot and
obtain Help information about epidemic prevention and share the workload of
frontline care staff (March 18 press release - in Chinese)
● March 19: Entry Ban on all foreign nationals.
E) Policies not pursued
● Schools
○ These were initially closed but reopened on Feb 25.
○ The Ministry of Education announced on Feb 20 that an individual class must
be closed if there is one confirmed case, and the school must be closed if
there are 2 confirmed cases (Official link), and courses will change to online-
learning (Mandarin Chinese).
○ Teachers and students (High school, junior high school and primary school)
are not allowed to go abroad until the end of the semester (Official link).
● Businesses
○ Open, but must if they have a confirmed case must close facilities for
disinfection. The employees must work from home for 14 days. (News -
translated from Mandarin Chinese)
● Travel
○ Domestic travel remains unrestricted (Official link - Mandarin)
○ Travel industry temporarily suspends international group tours to foreign
countries until April 30. (Official link - Mandarin)
F) Context and other actions
● SARS prepared everyone; National Health Command Center had already been set
up.
○ Activated and leading from early stage of the outbreak
● There is a widespread culture of mask-wearing (evidence of mask wearing
effectiveness is poor but improves if adherence/proper use is high, and cultural
acceptance of mask-wearing eg. CDC article: face mask use for reducing respiratory
virus transmission)
○ “adherent use of P2 or surgical masks significantly reduces the risk for ILI
infection, with a hazard ratio equal to 0.26 (95% CI 0.09–0.77; p = 0.015)”
● There may be a greater culture of doing what authorities say. Privacy may be less of
a concern, as they were pulling detailed travel histories early on. As a package the
measures were popular:
○ "the minister of health and welfare received approval ratings of more than
80% for his handling of the crisis, and the president and the premier received
an overall approval rating of close to 70%"
● Perversely, the proximity to Hubei may have helped by generating alarm in the
country early on. At the same time, being an island, Taiwan is more able to regulate
its borders.
6
● The vice president of Taiwan is a prominent epidemiologist — maybe some kind of
cultural indication, and could have assisted their policy response.
2. South Korea
Note: Subsections A and B were updated on 2 May, but the rest was written in mid-March
Context: Chinese visitors represented 31.1% of all arrivals to South Korea in October [of
2018], with more than 475,000 entering the country." (5.7 million per year) (The Moodie
Davitt report, 2018)
A) Epidemic curve
Key statistics as of 2 May:
Confirmed cases to date 10,780
Case density ~3,000 per million
Deaths to date 250
Case fatality risk 2.3% (with no lag)
Tests to date ~623,000
Testing density ~12.2 per thousand
Confirmation ratio ~1.7%
After its first case on 18 February, infections rose rapidly to a peak of more than 1,000 per
day on the 29th. By mid-March, however, numbers had dropped to less than 100 per day,
7
and were in the single digits by the end of April.
Its case density has always been higher than Taiwan’s, but was surpassed by the UK in late
May and Singapore in early April.
B) Data reliability
Scaled to population, South Korea has not carried out an unusually high number of tests as
of early May – fewer than Singapore and only a little more than the UK. However, testing
8
was far more widespread than these countries at the beginning of the pandemic, even taking
into account the earlier arrival of the first case, and has remained high relative to cases. This
suggests the official case figures are likely to be accurate.
C) Policies pursued
In brief: South Korea has carried out early and extensive testing — more per capita than
any other country aside from Bahrain — driven by fast and reliable test kits coupled with
surveillance and public information sharing (e.g. Corona Map which shows where confirmed
COVID-19 carriers have been recently, illustrated below).
Examples (Full list in Appendix 2)
Surveillance technology:
9
● Government uses debit/credit cards, CCTV footage, and mobile phone GPS data to
trace confirmed patients’ movements.
○ Uses this information to trace contacts (and offer them free testing).
● Government released “Corona Map” (updated in real time), which allows users to see
locations visited by individuals later to test positive for COVID-19 within the past 24
hours / 4 days.
● Patient whereabouts1 disseminated through text message alerts (Mar 11 article) and
on the Corona-100 app, which notifies residents when they are within 100 metres of
someone with a confirmed case (Mar 20 article).
● All travelers go through “special immigration procedures” — providing contact
information and report their symptoms daily for the next 14 days via a self-diagnosis
app on their mobile device (Mar 19 CDC Press Release, Mar 12 article).
Allows users to see locations visited by individuals later to test positive for COVID-19 within
the past time period (24 hours, 4 days, 9 days).
Testing:
● As of March 17, South Korea tested 286,716 people (5,566 per million people).
Testing available free to any contacts of confirmed cases and pneumonia patients.
Available to everyone else who wants it for ~$134 (Mar 11 article, Mar 14 article).
● Achieved through >40 drive-through facilities (Mar 10 article) and 500 designated
testing clinics (Mar 11 article).
● See details of testing below.
Mandatory quarantine:
● Citizens who have had ‘routine contact’ with confirmed cases must self-quarantine for
a mandatory period of 14 days (Feb 3 CDC Press Release).
○ Patients under mandatory quarantine monitored using phone apps with GPS
(Mar 19 article).
○ Quarantine violators fined $2,500 (Mar 17 article).
Social distancing:
● Seoul bans mass gatherings in three major public squares, with fines of up to $2,490
USD .
● Hospitalized patients transferred to isolation hospitals.
1 Acquired through surveillance (i.e. whereabouts traced using credit card use, CCTV footage and
mobile phone tracking)
10
● Government recommends ‘social distancing’ (first time this phrase is used) (Feb 29
KCDC Press Release).
Sanitation:
● Feb 24: disinfecting surfaces in most public places (Mar 4 article, Feb 24 KCDC
Press Release).
D) Policies not pursued
● No lockdowns as of March 19 (Mar 19 article).

● No office closures (though companies encouraged working from home; RSupport,
which offers remote-working support, offering free services for several months) (Mar
4 article).
● No comprehensive ban on entry from China (Mar 4 article).
● All travelers monitored but not restricted (March 19 CDC Press Release).
● No regional or national closing of businesses (aside from a few churches where there
were outbreaks).
○ That said, over 12,000 businesses have applied for government subsidies to
pay their employees while they close temporarily (voluntarily) (Mar 14 article).
E) Context and other actions

● Lessons learned after MERS outbreak:
○ South Korea did not have enough test kits during the 2015 MERS outbreak.
After MERS the outbreak was eventually contained, South Korea created a
system for rapid approval of virus test kits. As a result, firms were accredited
to develop and sell test kits within weeks (normally a year) (March 4 article).
○ Legislation passed after the MERS outbreak also gave the government
permission to access citizens’ credit card and mobile data — which is what
has enabled the tracing of patients’ recent contacts and whereabouts
● Extensive testing
○ may account for low case numbers and lower CFR
○ early diagnosis allows for early treatment (March 4 article)
○ asymptomatic cases detected (Mar 11 article)
● As of March 19, 58.7% of cases linked to the religious sect, Shincheonji, members of
which may have refused to get testing, citing religious beliefs (Mar 19 KCDC Press
Release)
○ Most members are young women — may contribute to low CFR (Mar 11
article)
● “Disciplined civil society” led to higher compliance with government advice to stay
indoors and avoid interpersonal contact (Mar 11 article).
● Culture of mask-wearing (evidence of mask wearing effectiveness is poor but
improves if adherence/proper use is high, and cultural acceptance of mask-wearing
eg. CDC article: face mask use for reducing respiratory virus transmission)
○ “adherent use of P2 or surgical masks significantly reduces the risk for ILI
infection, with a hazard ratio equal to 0.26 (95% CI 0.09–0.77; p = 0.015)”
11
● South Korea’s smaller geography (the size of the state of Indiana) allowed them to
track down cases and contacts quickly and easily (Mar 19 article)
● South Korea has triple the number of hospital beds relative to the UK (Mar 20 article)
● Inside the South Korean Labs Churning Out Coronavirus Tests
● Coronavirus: South Korea’s success in controlling disease is due to its acceptance of
surveillance
● South Korea turns to tech to take on Covid-19
Appendix 1
In brief: Emergency-response legislation passed after the 2015 MERS outbreak allowed for
the rapid development (using AI) and approval of test kits by private biotech firms. As of
March 19, there are at least 5 test kits approved for use — some of which are being
exported to as many as thirty other countries. Perhaps because test kits are being
manufactured in-country, South Korean firms have been better able to keep up with kit
demands than other countries.
Which test kits are they using?
Test Kit Producer Approved Tests for2 Results Weekly Weekly Approach
in SK in supply diagnostic
capability
Powercheck Kogene Feb 4 ● E gene 10,000 250,000 RT-PCR

2019-nCoV Biotech ● RdRP gene kits
RT PCR kit
Allplex 2019- Seegene Feb 12 ● E gene <4 1,000 kits 25,000- RT-PCR,
nCOV Assay ● RdRP gene hours 30,000 automatic
● N gene pipetting and
mixing3
DiaplexQ N Solgent Feb 27 ● E gene <2 1,000 kits 50,000 RT-PCR

Coronavirus ● RdRP gene hours
Detection kit
Standard M Sd Feb 27 ● E gene 2,000 kits 100,000 RT-PCR

nCoV RT Biosensor ● RdRP gene
Detection kit
I think there’s
at least one
more now
In addition to these test kits, as of March 17, an additional 45 kits are under review by the
South Korean government:
● 29 are under document review
● 8 awaiting clinical evaluations
2 Tests that can test for 3 genes reportedly faster than those that test for just 2.
3 Seegene hypothesizes that other countries are slow because of manual testing instead of automatic
testing (scientist pipetting to put the assay kit onto the sample, as opposed to pipetting by a robot arm
+ mechanized mixing of solutions). Automatic testing is 4X faster than manual testing (Mar 13 article).
12
● 8 requiring additional data
How did they develop them so fast?
● In 2016, after the MERS outbreak, South Korea passed legislation that allowed for
the rapid development and approval of kits that test for novel diseases contagious
enough to cause widespread outbreaks. Approval takes as little as a week,
compared to 8-18 months under normal circumstances.
○ Four-step process: 1) documents review, 2) clinical performance evaluation,
3) Korean Society for Laboratory Medicine review and 4) MDFS approval at
KCDCP’s request
● Before there were any cases in South Korea, private biotech firms had already been
approved to develop test kits.
● Government also authorized large private hospitals to assist in diagnostic testing and
mandated training of hospital staff in the operation of diagnostic machinery. As a
result, the South Korean government could enlist 100 facilities to process diagnostic
tests early on.
● Biotech firms used artificial intelligence/big data to develop accurate tests in a matter
of weeks rather than months (additional benefit of low staff requirements) (Mar 13
article)
How did they roll them out so fast?
● Seegene reportedly had all of its 395 employees (including its most senior
researchers) in its production lines (Mar 13 article)
● As of March 19, South Korea’s 5(?) test kit suppliers used different materials despite
employing the same testing method (RT PCR), reducing material shortages like
those experienced in e.g. the US
● Private-run labs are flexible enough to transition most of their efforts to processing
diagnostic kits (Mar 20 article)
Appendix 2
● Jan 19: First patient entered South Korea from China (JKMS)
● Jan 19: All contacts of each confirmed case tracked down and offered free testing
(Mar 11 article)
● Jan 20: Korean government raised “alert level” from blue to yellow (JKMS)
● Jan 27: Korean government raised “alert level” from yellow to orange (JKMS)
● Jan 28: Total “inspection” of travelers from mainland China (a health questionnaire;
fine of $10,000 for false information) (Jan 28 KCDC Press Release)
● Jan 28: 3,023 travelers from Wuhan investigated. Korean residents with fever or
respiratory symptoms quarantine and tested (Jan 28 KCDC Press Release)
○ 65% classified as suspected cases, being monitored as of Jan 29 (Jan 29
KCDC Press Release)
● Jan 29: New genetic diagnostic test validated; tests go from taking 24 hours to get
results to taking just 6 hours (Jan 29 CDC Press Release)
13
● Feb 4: Citizens who have ‘routine contact’ with confirmed cases must self-quarantine
for a mandatory period of 14 days (Feb 3 CDC Press Release)
● Feb 4: Entry restriction for those coming from Hubei (JKMS)
● Feb 7: PCR tests available in 46 labs (JKMS)
● Feb 12: KCDC expands strict quarantine screening to Hong Kong and Macao (Feb
11 CDC Press Release)
● Feb 18: KCDC triggers community surveillance for early detection of cases (Feb 17
KCDC Press Release)
○ Patient whereabouts4 disseminated through text message alerts and on
government websites (Mar 11 article).
● Feb 19: Special task force released to Daegu — task force “closely monitors” people
who have attended Shincheonji services (Feb 19 KCDC Press Release)
● Feb 20: First death (JKMS)
● Feb 20: Military personnel in Daegu banned from leaving bases (Feb 20 article)
● [more information needed]
● Feb 20: Stopped enlisting military draftees
● Feb 21: Seoul bans mass gatherings in three major public squares, with fines of up to
$2,490 USD (Feb 21 article)
● Feb 21: Seoul mayor closed Shincheonji churches (Shincheonji religious group
associated with rapid spread) (Feb 21 article)
● Feb 21: Closed over 3,000 social welfare facilities (Feb 21 article)
● Feb 21: Hospitalized patients transferred to isolation hospitals
● Feb 23: Korean government raised “alert level” from orange to red (JKMS)
● Feb 23: Korean government delayed school start by one week (JKMS)
● Feb 24: disinfecting surfaces in most public places (Mar 4 article, Feb 24 KCDC
Press Release)
● Feb 25: Shincheonji mobile phones tracked (Feb 25 KCDC Press Release)
● Feb 26: Testing achieved through drive-through facilities (40) (Mar 10 article)
○ and 500 designated testing clinics (Mar 11 article).
● Feb 27: Training to local government to improve “epidemiological investigation
capacities” (Feb 27 KCDC Press Release)
● Feb 29: Government focuses test and treatment efforts on those aged over 65 (Feb
29 KCDC Press Release)
● Feb 29: Government recommends ‘social distancing’ (first time this phrase is used)
(Feb 29 KCDC Press Release)
● Mar 2: Korean government delays school start by additional two weeks (JKMS)
● Mar 2: New protocol introduced [more information needed]
● Mar 5: Government bans exportation of face masks, requires mask produces to
report sales to government (to prevent price-gouging) (Mar 10 article)
○ Max prices fixed at ~$1 USD (limited to five per customer)
● Mar 11: KCDC recommends that people work at home or keep distance from co-
workers (March 11 KCDC Press Release)
● Mar 16: KCDC strongly recommends that all close-contact indoor gatherings be
cancelled(March 19 CDC Press Release)
4 Acquired through surveillance (i.e. whereabouts traced using credit card use, CCTV footage and
mobile phone tracking)
14
● Mar 16: All travelers go through “special immigration procedures” — providing
contact information and report their symptoms daily for the next 14 days via a self-
diagnosis app on their mobile device (March 19 CDC Press Release)
● Mar 17: South Korea offers subsidy of ~£313 per month to those who are self-
isolating (Mar 20 article)
Dates unknown
● Patients under mandatory quarantine monitored using GPS (Mar 19 article)

● Quarantine violators fined $2,500 (Mar 17 article)
● Free testing then offered to everyone who had contact with the patient (Mar 11
article), while it costs $134 per test for those not linked to confirmed cases (Mar 11
article)
● Tests get faster — take just 10 minutes for patients, one day result turnaround (Mar
13 article)
● Government released “Corona Map” (updated in real time), which allows users to see
locations visited by individuals later to test positive for COVID-19 within the past 24
hours / 4 days
● Screening for all patients with pneumonia (Mar 14 article)
● South Korea encourages undocumented immigrants to get tested; public health
officials not obligated to report undocumented status (Mar 13 article)
● South Korea developed an app, “Corona-100,” which notifies residents when they are
within 100 metres of someone with a confirmed case (Mar 20 article)
● Suspected cases allowed to vote on national election (April 15) from home (BIT
Slides
3. Singapore
A) Summary
Singapore managed to keep its economy and society open for longer than most countries.
This was due in part to its relatively thorough contact tracing and testing processes in the
early stages of the pandemic.
However, Singapore entered lockdown in early April following outbreaks in densely-packed

migrant worker dormitories. This failure was largely because of delays in implementing travel
restrictions from places other than China, but its slow adoption of universal mask-wearing
and reliance labour-intensive contact tracing methods also played a role.
Context: Singapore was affected by SARS and has done a great deal to prepare itself for
future pandemics. It is a famously well organised city and the country with the second
highest population density in the world.
14 million international visitors came to Singapore in 2017, more than 2x its local population,
– a very high rate of tourists per capita. Of those, 18% or so are from mainland China.
15
B) Epidemic curve
Singapore managed to avoid exponential growth throughout February and March. But the
rate of new infections sharply increased in early April, reaching nearly 1,500 new cases on
the 20th. According to official statistics, these are primarily among young and middle-aged
male Bangladeshi and Indian migrant workers living in crowded dormitories. The UK and
USA were the largest sources of original infections.
As of 21 April there have been:
C) Data reliability
In March Singapore’s confirmation rate was apparently lower than most other countries,
suggesting high levels of testing: "Singapore is very liberal with our testing. Less than 1% of
our tests are positive, so that reflects just how many tests we are doing." (Source, March
18.)
On 17 March, the chief of research at the National Healthcare Group said that the Ministry of
Health had carried out more than 21,000 tests thus far (Source, March 17.) This is 3,700 per
16
million people, below South Korea (6,000), but far ahead of the UK, US, Japan, or Taiwan
(1,000).5
Media reports suggest 2,800–3,000 tests per day between mid-March and late April, which
implies a rapidly increasing confirmation rate, and perhaps a declining case detection rate.
D) Policies pursued
Singapore attempted to avoid “lockdown”. Measures included:
● Travel bans from Hubei (29 Jan); China (1 Feb); Korea, Iran, Northern Italy (4
March); Italy, France, Germany, Spain (16 March); all short-term visitors (23 March)
● 14 day quarantine for all arrivals (20 March)
● Screening, contact tracing and isolation
● Suspension of large gatherings
● “Safe distancing” measures in public places (e.g. mobile ordering and payment;
spacing in restaurants, malls)
● Safe distancing, screening, hygiene, and other “business continuity” measures at
workplaces
However, this ultimately failed and a four-week “circuit breaker” (temporary lockdown to
break transmission) was announced on 3 April. This included:
● Closing non-essential businesses and public services (7 April)
● Closing schools (8 April)
● Closing recreation facilities (7 April)
● Only take-away or delivery from restaurants, cafes, etc. (markets, supermarkets,
convenience stores, etc remain open)
● Enhanced safe distancing measures for essential services (each company to submit
plans by 13 April)
● People to “remain largely within their place of residence. They can still go out to buy
meals or other essentials, or procure essential services, but should otherwise
minimise the time they spend outside.”
● Masks mandatory in public places
○ Reusable masks distributed to all residents (5-12 April).
● Extra precautions at dormitories
○ All foreign workers to remain within the premises.
○ Extra measures to reduce transmission, e.g. less intermixing between blocks
On 21 April, the government’s Multi-Ministry Taskforce extended the circuit breaker to 1

June and introduced additional safeguards.
● Closing standalone outlets selling only beverages, snacks and desserts.
● Closing hairdressers and barber services.
● Opticians by appointment only.
● Pet supplies stores and laundry services online sales and delivery only.
● Temperature screening at all supermarkets and malls; customers required to give
details for contact tracing.
5 Back on Feb 27 it was reported they had conducted at least 1,200 tests with 93 confirmed
cases, a 7.7% confirm rate. (Source.) The 1200 figure could be an error, or out of date, or
testing figures may have increased a great deal.
17
● More workplace measures, e.g. all employees wear masks; more safe distancing
measures; better data gathering to aid contact tracing; safe housing options for
foreign workers (no daily movement in and out of dormitories)
● Financial support for affected workers and businesses.
This table gives a day-by-day response summary of what Singapore pursued prior to
lockdown.

According to Tomas Pueyo, the failure to avoid lockdown was for three reasons:
1. Delay in banning travel from places other than China.
2. Inadequate contact tracing
a. Low take-up of the TraceTogether app (<20% by mid-April)
b. Mostly done manually, unlike South Korea and Taiwan
3. Low mask usage until April 3.
4. Japan
A) Epidemic Curve
Japan continues to report a gradual growth in cases and deaths:
18
B) Data reliability
Japan has completed far fewer tests per capita than South Korea (130 vs. 5,500 tests
per million people). Japan has received some criticism for only using around 1/6th of
their testing capacity and rejecting some requests for testing.
19
Source (all updated March
17)
Number of People Tested 16,484 Our World in Data
Number of Tests Per 130 Our World in Data

Million People
Confirmation rate 5% Values above

(Confirmed Cases/Number
of People Tested)
“Nationwide capacity for the polymerase chain reaction (PCR) test has grown to 7,500 a
day, on track to reach 8,000 a day target by the end of the month.
But the number of tests conducted has been on average 1,190 a day over the past month,
totaling 32,125, according to health ministry data. That compares with more than the
200,000 tests conducted in South Korea and 80,000 in Italy.” — From Reuters 18 March
C) Policies pursued
16 January First case in Japan
20
28 January PM Abe Designated Coronavirus a
quarantinable infectious disease, allowing
the government to order suspected cases to
undergo diagnosis, hospitalization,
treatment and quarantine.
29 January Start of repatriation of citizens from Hubei

province
30 January Start of inter-ministerial coordination of the

government response.
3 Feb Travel restrictions on travelers and citizens

from Hubei.
5 Feb PM Abe ordered quarantine of Diamond

Princess Cruise ship.
12 Feb Travel restrictions on travelers and citizens

from Zhejiang.
Extended testing to patients with symptoms,

beyond those with travel history to Hubei.
MoH contracts a company to do PCR

testing.
500 billion yen secured to help small and

medium enterprises.
15.3 billion yen set aside “to facilitate the

donation of isolated virus samples to
relevant research institutions across the
globe.”
14 Feb Established 536 consultation centres to give

information about how to get tested at a
specialized outpatient ward.
25 Feb Released a uniform policy for Coronavirus

control, announced focus on prevention of
large-scale clusters.
Suspended large gatherings, closed

schools. Announced policy to keep patients
with minor symptoms from going to the
hospital and encourage them to take time
off work. Recommendation that people at
high risk avoid hospitals where possible.
Allowed general medical facilities (rather

than just specialized clinics) to test and treat
suspected patients.
Established a “Cluster Response Section to
21
ID and contain small-scale clusters.
26 Feb Recommended cancelling, delaying, scaling

down large events.
27 Feb Plans for tests to be covered through

national health insurance insurance system.
1 March Invoked emergency measure so that face

mask manufacturers sell to the government
then the government distributes them.
2 Mar Start of school closures, planned until early

April
5 March Quarantining visitors from China and S.

Korea.
Announced an emergency package using a
270 billion yen ($2.5 billion) reserve fund for
virus containment and economic support.
16 March Expanded entry restrictions for visitors from

Spain, Italy, Switzerland, and Iceland.
Did not ramp up testing:
Only using ~1/6th of stated capacity, no drive-through testing centres - conducting far fewer
tests than SK.
No legal actions to lockdown cities:
“Can the government order city lockdowns to deal with the coronavirus outbreak?
According to Hyogo-based lawyer Koju Nagai, who is well versed in disaster prevention
laws, the short answer is no.
The closest Japan has at the moment, he said, is a law enacted in 2012 to battle a novel
influenza virus that became a pandemic in 2009. The law spells out a raft of measures that
can be taken by governors to restrict the movement of people.
But even so, municipal leaders can merely request that residents under their jurisdiction stay
indoors as much as possible and that schools and other public facilities temporarily shut or
scale back their businesses. Should the requests be disobeyed, governors can take it up a
notch and issue something that amounts to an order, although failure to comply entails no
penalties, Nagai said.” (Source: Japan Times)
Cultural norm against sounding the alarm may have led to a delayed response:
22
NYT Op-Ed by Political Scientist Koichi Nakano
“As some observers have pointed out, a measure of denial and inertia is at play. The
Japanese bureaucracy is notoriously dominated by a culture of “kotonakare shugi” (literally,
“no-problem-ism”), which prioritizes stability and conformity, and shuns anything that might
rock the institutional boat. Sound the alarm about an impending crisis and you might be
blamed for causing it."
Lack of extensive and clear risk communication
“Timely, accurate, and transparent risk communication is essential and challenging in

emergencies because it determines whether the public will trust authorities more than
rumours and misinformation. Singapore health authorities provide daily information on
mainstream media, the Ministry of Health has Telegram and WhatsApp groups set up with
doctors in the public and private sectors where more detailed clinical and logistics
information is shared, and authorities use websites to debunk circulating misinformation.
Risk communications to establish trust in authorities has been less successful in
Japan and Hong Kong.”
…
“In Japan, concerns related to the Diamond Princess cruise ship and the sudden
announcement of school closures fuelled increased public anxiety.” Lancet Article
Delayed interministerial coordination relative to SK and HK
“Second, intragovernmental coordination was improved because health authorities drew on

their experiences of severe acute respiratory syndrome during 2002–03 in Hong Kong and
Singapore, H5N1 avian influenza in 1997 in Hong Kong, and the 2009 influenza H1N1
pandemic in all three locations. Hong Kong and Singapore began interministerial
coordination within the first week, whereas Japan did this in early February when the
operation to quarantine passengers on the Diamond Princess cruise ship was heavily
criticised as inadequate, resulting in the widespread infections among crew and
passengers.” - Lancet Article
Cultural norms
“A population ready to comply with strict controls has also been key for Japan in
containing coronavirus. The government’s handling of the failed quarantine on the
Diamond Princess cruise ship and its policy of testing relatively few people have come under
heavy criticism. But experts say social and cultural norms that impose self-discipline and
obedience to official guidance are one of the reasons Japan has so far managed to limit the
number of infections.
23
“There is a social norm that you should not cause trouble to other people,” says Kazuto
Suzuki, an expert on international politics at Hokkaido University. “If you don’t take care of
yourself and become ill, that is taken as causing problems for other people.” The coronavirus
outbreak has resulted in the rigorous use of hand sanitisers and washing of hands, while not
wearing a mask on the train would attract immediate disapproval.
…
Japan’s obsession with wearing masks predates Covid-19. Sales exploded during the
2009 H1N1 swine-flu outbreak…” — Containing coronavirus: lessons from Asia
Flu cases have been unusually low in January and February, perhaps as a result of
voluntary hygiene and social distancing measures. These may also have slowed the spread
of COVID-19.
5. Hong Kong
A) Summary
Hong Kong has contained the outbreak relatively well. There has been public support for
strict measures. Experience with SARS contributed to eagerness for strict containment,
perhaps tolerance of strict enforcement, and a culture of hygiene. Lots of events were
canceled early on.
24
B) Epidemic curve
The pandemic is growing in Hong Kong, but slowly compared to many other countries
around the world, such as the UK:
Note that testing was probably way ahead in HK than in the UK near the beginning,
suggesting a shallower increase in true cases for the UK than the graph suggests.
Since March 20 the rate of increase in cases as been growing but HK still only reports 4
deaths:
There was a large increase on March 20. 36/48 of the new cases were apparently from
people who had traveled abroad. 50/57 of the cases in "recent weeks" from March 17 were
apparently from abroad.
For latest updates: Hong Kong government dashboard
25
C) Data reliability
HK government dashboard: This appears to show 641 confirmed cases on 5,798 tests, a
confirmation rate of around 11%.
This appears to indicate a low testing rate, at only 1000 tests per million residents, and could
suggest significant undercounting.
By contrast Our World in Data reports that by March 5, there had been 5,271 tests
performed. Using the OWID number, the positive rate for tests as of March 5 was ~2%,
indicating growth in the confirmation rate.
D) Policies pursued
The information gathering and reporting Hong Kong reports seems better than average --
they report details on particular cases, and give a breakdown of where they might have
come from, as well as running information on the government dashboard . They also have
running information on buildings where cars have been identified, etc on the government
dashboard about buildings with confirmed cases of COVID in the last 14 days, quarantine
centers, etc.
26
The Hong Kong government also shortened visitor hospital visits and made it a requirement
for visitors to wear face masks. Screening was tightened at airports and train stations with
connections to Wuhan.[2] In the first week of 2020, 30 unwell travellers from Wuhan were
tested.
● Jan 8: Hong Kong's Centre for Health Protection (CHP) added

"Severe respiratory disease associated with a novel infectious
agent" to their list of notifiable diseases to expand their authority on
quarantine.
● 30 unwell travellers from Wuhan were tested.
● The Hong Kong government also shortened hospital visits and
First week made it a requirement for visitors to wear face masks. Screening
of Jan was tightened at airports and train stations with connections to
2020: Wuhan.
At some point in January the government released this Preparedness and
Response Plan for Novel Infectious Disease of Public Health Significance
(2020)
Includes "three-tier response level system with each level representing a
graded risk of the novel infectious disease affecting Hong Kong and its
health impact on the community; key factors to be considered in the risk
assessment; activation and standing down mechanism; public health
actions to be taken at each response level; and key Bureaux and
Departments to be involved."
1/22/20
1/23/20 Formed a quarantine centre.
1/24/20
1/25/20 Hospital called police on people with covid that tried to escape
1/26/20 Amusement parks closed
1/27/20
● Chinese New Year Holiday extended to Feb 17. Closure later
extended to March 16, then April 20.
1/28/20 ● Museums, libraries close indefinitely
Government employees besides emergency/essential services to work
1/29/20 from home (extended to Feb 16, likely again)
1/30/20 Rail and ferry services suspended.
1/31/20
● BY feb 1 travel restrictions on passengers coming from the
mainland
2/1/20 ● Medical worker strike threatened
2/2/20
2/3/20
2/4/20
Medical worker strike starts. Demands: all non-HK residents should be
2/5/20 denied entry and all HK residents should be quarantined on entrance.
2/6/20
2/7/20 Medical strike ends
27
2 week quarantine mandated for travelers from Mainland China (excepting
essential workers, who are monitored), with 3,2000 USD fine for violations,
stay at hotels at their own expense or centers; flights separated;
Work from home for gov't eployees extended to feb 16 (but when did it
2/8/20 start?)
2/9/20
2/10/20
2/11/20
2/12/20
2/13/20
2/14/20
2/15/20
2/16/20
2/17/20
2/18/20
2/19/20
2/20/20
2/21/20
2/22/20
2/23/20
2/24/20
● gov't declares state of emergency
● schools close, set to open Feb 17 (but they don't)
2/25/20 ● lunar new year events canceled (may have been before this date).
2/26/20
2/27/20
2/28/20
2/29/20
3/1/20
3/2/20
3/3/20
3/4/20
3/5/20
3/6/20
3/7/20
Since March 8, 2020, all inbound travellers via Hong Kong International
3/8/20 Airport are required to submit health declaration form.
3/9/20
3/10/20
3/11/20
3/12/20
28
3/13/20
3/14/20
"The government also told Hong Kong residents to avoid all non-essential
travel and issued its second-highest red outbound travel alert to all
3/15/20 countries and territories except for mainland China, Macao and Taiwan."
3/16/20
"members of the public are strongly urged to avoid all non-essential travel
outside Hong Kong," the city's Center for Health Protection said in a
3/17/20 statement." (March 18 article)
Macao blocking entry by anyone except people from mainland China,

3/18/20 Hong Kong or Taiwan.
all visitors under a two-week quarantine and medical surveillance

New arrivals will be issued with an electronic wristband that monitors
3/19/20 whether they violate quarantine.
3/20/20
"No leniency for breaching quarantine" - Violators face up to six months in

jail and fines as high as 3,220 USD
3/21/19 "Gov't to ensure safe exams"

Some people have criticized the government for delays:
● "Lam only gradually closed border crossings [...] rejected demands to temporarily bar
arrivals from mainland China and called the move “discriminatory"" - 2 week
quarantine on mainland travelers happened later than many wanted, after strike
(which ended Feb 7). (source seems somewhat editorial)
● Rail passengers not required to fill out health declaration forms until confirmed cases
in Hong Kong (i.e., Jan 23 - above source says Jan 30)

● SARS in 2003 killed 299 people in Hong Kong (out of ~800 worldwide), and infected
close to 2000.
29
● This has led to a culture of relatively extreme public hygiene, including hand sanitizer
stations around the city, two sets of chopsticks at restaurants (one for communal
dishes), protective coverings at Karaoke bars. "The precautions have been so
effective, [David Hui] says, that the city’s annual flu season has been dramatically
reduced."
○ Use of public shaming? Sign at bar: "everyone knows you so if you are meant
to be in isolation, do not come into Hemingway's. If we see you, we will send
our CCTV footage to the authorities. YOU HAVE BEEN WARNED."
● Some Hong Kongers angry at Mainland authorities underreporting SARS initially
● "One of the world's best" public health systems
● Tried to ban face masks at public gatherings in October to deter protests
● Hong Kong has a mobile population working on either side of the border
● Tensions with Mainland China continue, now over COVID-19 too.
○ E.g., some Hong Kongers worry about Mainland Chinese crossing the border
for better medical treatment; resent spread of virus from Mainland and
possible cover-up.
6. China
Context: COVID-19 commenced in Wuhan, Hubei Province in China in early December.
A) Epidemic Curve
Sources: Our World in Data
China, with a population of 1.4 billion has had 81,748 confirmed cases.
The first case of COVID-19 was detected in Wuhan, China on Dec 8, 2019. Confirmed cases
rose drastically between the end of January and the end of February, but have since slowed.
The number of daily new confirmed cases has remained below 1,000 since Feb 20.
If Chinese data are to be believed, there are almost no new local transmission of COVID-19
within China at the current time.
30
To date, there have been 3,283 deaths — a case fatality rate of 4.02%, roughly equivalent to
the worldwide CFR of 4.33%. Daily deaths are stable and increasing only slowly:
The UK has already well exceeded China in terms of the density of confirmed cases:
31
B) Data reliability
We have not been able to find data on ongoing testing rates in China. This is somewhat
worrying, as low confirmed case figures could reflect a lack of testing.
The only testing figure we found was 320,000 people in Guangdong having been tested in
late February. This would in fact represent a fairly high test rate for that time, of ~3000 per
million residents. Guangdong province had the second highest number of COVID-19 cases
in China, though far fewer than Hubei.
"Within the fever clinics in Guangdong, the percentage of samples that tested positive for
the COVID-19 virus has decreased over time from a peak of 0.47% positive on 30 January
to 0.02% on 16 February. Overall in Guangdong, 0.14% of approximately 320,000 fever
clinic screenings were positive for COVID-1."
A WHO mission to China in February appeared to believe the pandemic had been brought
under control at that time. We worry that the positivity of this report could be in part politically
motivated or to encourage other countries.
Whether one trusts the Chinese figures is down to individual judgement. On the one hand
the failure to release testing figures is worrying. On the other, it would be peculiar for the
Chinese government to allow the disease to re-emerge through lack of testing after having
paid such a huge price to control it in the first place.
Read more: Hidden infections challenge China’s claim coronavirus is under control
32
C) Policies pursued
In brief: China’s COVID-19 containment strategy centered around city-wide lockdowns and
blanket home confinement. China achieved high compliance through a combination of
surveillance and fines, as well as economic and technological measures — for example,
stipends for those in quarantine and contactless grocery shopping and delivery.
On top of this, China has also harnessed its manufacturing capabilities to build new
makeshift hospitals and retrofit factories to be able to produce face masks, gloves, and test
kits. Details below:
Enforced quarantine:
● City lockdowns
○ Travel to and from Wuhan by airport, train, ferry, or motor vehicle
prohibited
○ Suspension of public transportation systems
○ Some provinces require temperature screen upon entry
● Closure of non-essential businesses
○ Business closures
○ School suspension, followed by online learning only
● Mandatory blanket quarantine (affecting half of the population of China)
○ From Feb 1, blanket house confinement in Wuhan: only one member per
household on street to make necessary purchases every two days
○ Mass gatherings (e.g. Lunar New Year celebrations, sports events) cancelled
○ Public spaces closed
○ Non-essential vehicles banned from roads
○ Weddings cancelled (suspension of marriage registration)
Construction and manufacturing:
● Construction of makeshift laboratory that can process 10,000 test kit samples
per day
● Construction of two makeshift hospitals in Wuhan, and conversion of existing
hospitals to emergency treatment hospital (Feb 4 article)
● Construction of new face mask factory, plus retrofitting of factories to produce
facemasks and other medical supplies (Feb 20 article)
● Amazon-esque marketplace established to connect suppliers of critical
medical equipment to hospitals
Use of technology:
● To identify the sick

○ All residents required to measure temperature twice daily, report
measurements exceeding 37.3C (99.1F) through an app
○ JD launched JD health (China Resources Medical) within an APP to
connect volunteer doctors with patients virtually (Feb 20 article)
33
● To meet residents’ basic needs
○ Sinopec’s fuelling stations, with attached convenience stores (like 7-11),
offered touch-free service while customers refuel their vehicles
(Customers pre-order or order groceries via Sinopec’s APP, choose
pick-up point, Sinopec staff prepare the package and deliver app-
ordered groceries to car trunks) (Feb 18 article)
○ Schooling moved to apps
○ Local governments launched chat bots to answers COVID-19 questions (Feb
23 article)
● To enforce quarantine
○ Use of Health QR code, which serves as an entry card for citizens to
visit public venues (Feb 18 article)
Economic stimulus, deregulation, and subsidies:
● Import tariffs/duties suspended for materials donated for epidemic

prevention/control
● Financial institutions ordered to help those affected postpone loan
repayments, etc. (overdue payments not included in credit history)
● Two stimulus packages:$170 billion USD, then 71 billion USD
● Government offers daily stipend of 300 yuan (36 GBP) for confirmed cases or direct
contacts of confirmed cases
Testing and forced hygiene:
● Wuhan claims to have tested all patients with fever or close contact to
confirmed cases
● Wuhan claims to have tested all inpatients at hospitals
● £70 reward offered to people with fevers who volunteer to be tested
● Cash from affected areas stored before entering market
● Public required to wear face masks
34
● Public bikes disinfected
A full list of measures taken is listed in the appendix.
● Epidemiologists say China’s mammoth response had one main flaw: it started too
late.
○ A model simulation by Lai Shengjie and Andrew Tatem, emerging-disease
researchers at the University of Southampton, UK, shows that if China had
implemented its control measures a week earlier, it could have prevented
67% of all cases there. Implementing the measures 3 weeks earlier, from the
beginning of January, would have cut the number of infections to 5% of the
total.
● Cities that suspended public transport, closed entertainment venues and banned
public gatherings before their first COVID-19 case had 37% fewer cases than cities
that didn’t implement such measures, according to a preprint by Dye on the
containment measures used in 296 Chinese cities.
● Didn’t pursue a exceptionally high testing rate like, for example, South Korea
● Restrict internal travel from the outbreak region: five million people had left the city of
Wuhan before the shutdown began.
● Keep the public well-informed. China initially tried to silence the spread of information
about the virus.
● School contact tracing measures. Schools were kept open in Singapore and at the
Saw Swee Hock School of Public Health, at the start of each class, a picture would
be taken of the classroom, so that if any student became ill, there would be a record
of who had been in close contact with him or her. (David Heymann in STATnews)
● Counting: counting cases of people who were positive but had not been admitted to
hospital, or did not show any symptoms of the disease, or counting re-infections as
new cases. China is not doing this.
● Governors were disincentivized from reporting cases — especially early on — as

high case numbers could result in being fired after the outbreak. This was partly
responsible for China’s slow response.
● Beginning of Chunyun — the celebration of the Chinese New Year (largest migration
in the world) — led to mass movements of people that likely accelerated the spread
early on
● China faced international scrutiny following its response to the 2003 SARS epidemic
(slow response and cover ups). It’s been argued that this motivated Chian to improve
its response in the wake of COVID-19
● “Disciplined civil society” led to higher compliance with government advice to stay
indoors and avoid interpersonal contact
● Culture of mask-wearing
35
● Local residents complained that restrictions later imposed on traffic made it difficult
for people to get to work and seek medical assistance, perhaps hindering prevention
efforts rather than helping them. (source NYT)
● Local hospitals ran out of supplies and had to ask for donations on social media
(source NYT)
Appendix
Date Description
Dec 8 First case
Closure of Huanan Seafood Market (inspection and collection of samples by health
Jan 1 agency workers in hazmat suits)
Beginning of Chunyun — the celebration of the Chinese New Year (largest
Jan 10 migration in the world)
Jan 12 Scientists announce new coronavirus
Wuhan's Municipal Health Commission reported that investigation showed no

Jan 15 evidence of human-to-human transmission
Jan 19 40,000 Wuhan families attend potluck banquet to celebrate Kitchen God Festival
Jan 20 Confirmation of human-human transmission
Jan 20 Command for Epidemic Control (CEC) formed
Jan 23 Construction of makeshift Huosheshan Hospital
Jan 23 Lockdown
Jan 24 Lockdown in neighboring provinces (affecting 40 million residents)
Jan 24 135 medical workers from Shanghai and 128 from Guangdong sent to Wuhan
138 medical workers from Sichuan, 135 from Zhejiang, 138 from Shandong, and
Jan 25 147 from Jiangsu sent to Wuhan
Jan 25 Construction of makeshift Leishenshan Hospital
Jan 25 Cases peaked

Government offers daily stipend of 300 yuan (36 GBP) for confirmed cases or
Jan 30 direct contacts of confirmed cases
Jan 30 Government offers daily stipend of 200 yuan (25 GBP) for all medical personnel
Import tariffs/duties suspended for materials donated for epidemic
Feb 1 prevention/control
Waste water treatment measures (supervision, regulation, sterilization, disinfection)
Feb 1 to prevent spread through feces
Feb 1 Marriage registration suspended
Feb 1 House confinement (only one member per household on street to make purchases
36
every two days)
Feb 1 Businesses and start of new school semester suspended
Feb 1 Primary schools closed until Feb 17, secondary schools closed until Feb 24
Feb 1 Medical Center converted to emergency treatment hospital (+1000 beds)
Feb 1 Companies in Hubei no longer have to pay listing fee to stock exchange
Feb 1 Apple closes stores
Feb 1 Entertainment industry ordered to pause filming, etc.
Feb 1 All deceased must be cremated at nearest facilities (no farewell ceremonies, etc.
Feb 1 Badminton Masters tournament postponed
People's Bank orders financial institutions to help those affected postpone loan
Feb 1 repayments, etc. (overdue payments not included in credit history)
Feb 2 Fangchang hospitals launched
House confinement (only one member per household on street to make purchases
Feb 2 every two days)
Feb 2 Completion of Huoshenshan hospital
Feb 2 Disinfecting of shared bikes
Feb 2 Imported masks allowed to be sold in Hubei markets
Feb 2 New makeshift laboratory constructed, can process 10,000 samples per day
Wuhan imposes enforced quarantine on all suspected cases and those with
Feb 2 contact with confirmed cases
Feb 2 New mask factory
Feb 3 Extending Chinese New Year holiday
Feb 3 Chinese stimulus package — $170 billion USD
Feb 4 Another Chinese stimulus package — $71 billion USD
Feb 5 Hubei subsidies for new treatment sites
Feb 6 Semesters postponed
Feb 6 Economic stimulus
Feb 6 China halves tariffs on goods imported from US
Hangzhou imposed a temporary ban on retail pharmacies selling fever and cough
Feb 7 medicines, asking citizens with the symptoms to see a doctor instead
Feb 8 Economic subsidies
Feb 8 Leisheshan hospital opens
Feb 8 Business resumed everywhere but Hubei
Feb 8 Apple extends store closures
Feb 10 Tibetan New Year activities cancelled
Feb 11 Ban on trading and eating wildlife
37
Feb 11 Relief for small and medium-sized businesses
Feb 12 Railway limits train occupancy
Feb 13 Masks sold for 1 yuan each
Feb 13 Business and school suspended until Feb 20
Feb 13 Schools closed through Mar 1
Feb 13 Residents not allowed to leave neighborhoods for non-medical reason
Feb 13 People entering Wuhan required to self-quarantine for 14 days
Feb 14 Tutoring/training online only
Feb 14 March exams cancelled
Feb 15 Outside vehicles prohibited from entering
Feb 15 Cash from quarantined areas stored before entering market
Feb 16 Hard quarantine
Feb 16 Public spaces closed, gathering forbidden
Feb 16 Normal traffic resumed
Feb 16 Telemedicine hospitals open
Feb 16 Real-name public transport system
Feb 16 £70 reward offered to people with fevers who volunteer to be tested
Feb 17 Lockdown, violators subject to <10 day detention
Feb 17 Normal traffic resumed
Feb 18 QR code required for entering public spaces and transport services
Feb 18 Yiwu trade city re-opened for business
Feb 18 Online education
Feb 19 Domestic traveler screenings (new vehicles)
Feb 19 Businesses closed until Mar 10
Feb 19 Non-essential vehicles banned from roads

All residents must measure temperature twice daily, report measurements
Feb 20 exceeding 37.3C (99.1F)
Feb 21 Completes testing of all patients with fever or close contact to confirmed cases
38
Feb22 14-day quarantine for discharged covid-19 patients
Feb 25 Testing all inpatients for covid-19
Feb 25 Mandated quarantine of foreign travelers from covid-19 locations for 14 days
Date Requisitioned taxis. Free taxi services given to community managers to offer
unknown food/medicine to households unable to access it
Date 2500 factories converted to produce 116 million facemasks per day (up from 10
unknown million masks)
Date
unknown Public required to wear facemasks in public places
Date
unknown Travel arrangements made flexible, refunds offered
7. Italy
A) Summary
Italy confirmed it’s first two cases on January 31 in two Chinese citizens on holiday. Since
then, Italy has recorded the highest number of confirmed SARS-CoV-2 infections outside of
China, and has surpassed the number of deaths in China. Given its relative progression into
the outbreak, Italy has become a case study for other European countries and perhaps the
US to try and predict the course of their own outbreaks.
B) Epidemic curve
Italy probably has among the highest density of COVID-19 in the world, but the rate of
growth in cases and deaths is slowing, 2-3 weeks after the country was placed on lockdown.
39
C) Data reliability
40
As of 19/03/20, 182,777 tests had been conducted in Italy (source Dipartimento della
Protezione Civile).
At that time Italy had a positive test rate of 20%, among the highest in the world. This
suggests case numbers are likely much higher than those being measured.
With a total population of 60,550,075, 182,000 tests represents 0.30% of the population
having been tested. A mean of 3,797 tests were conducted daily between 24/2/2020 and
10/3/2020 before testing rates were increased, to a daily mean of 13,097 from 10/3/2020 to
18/3/2020.
A trial in the town of Vò was conducted by the University of Padua. A confirmed cluster was
identified in the town and subsequently all 3,300 Vò residents were tested. Of 6,800 swabs,
1.7% were confirmed positive. All positive cases were quarantined. This epidemiological
study will be used for outbreak investigation by the University of Padua. According to news
reports, so far there have been no new cases recorded in the town since the trial began.
D) Policies pursued
Italian Council of Ministers appointed Angelo

Borrelli, head of the Civil Protection, as Special
1/2/2020 Commissioner for the COVID-19 emergency
2/2/2020
3/2/2020
4/2/2020
5/2/2020
6/2/2020
41
7/2/2020
8/2/2020
9/2/2020
Italy becomes first EU country to ban flights to and
10/2/2020 from China (source)
11/2/2020
12/2/2020
13/2/2020
14/2/2020
15/2/2020
16/2/2020
17/2/2020
18/2/2020
19/2/2020
20/2/2020
First cases detected in ‘Lombardy Cluster’ and
21/2/2020 ‘Veneto Cluster’ - the initial main clusters.
Certain towns in Northern Italy enter lockdown
(closures of schools, businesses, and restaurants.
Cancellation of sporting events and religious
22/2/2020 services.) (source)
23/2/2020
Ministry of health engages 31 laboratories to carry
24/2/2020 out analysis of test swabs (source)
25/2/2020
Director of Higher Health Council Franco Locatelli
announced that swabbing would only be
performed on symptomatic patients, as 95% of the
swabs previously tested were negative (source)
26/2/2020 All schools closed in Palermo and Naples (source)

27/2/2020
Veneto governor Luca Zaia orders all 3,300 Vò
residents to be tested. Of 6,800 swabs, 1.7% were
confirmed positive. This epidemiological study
would be used for outbreak investigation by the
28/2/2020 University of Padua.
29/2/2020
Council of Ministers approved a decree to
organise the containment of the outbreak. In the
decree, the Italian national territory was divided
into three areas: red, yellow, and ‘the rest of Italy’,
with various levels of control measures in each
1/3/2020 (source)
2/3/2020
42
3/3/2020
Nationwide closure of all schools and universities.
4/3/2020 All sporting events played behind closed doors.
5/3/2020
6/3/2020
7/3/2020
Restricted movement (‘lockdown’) within
8/3/2020 Lombardy and 14 other northern provinces.
9/3/2020 All sporting events cancelled.
Lockdown extended to whole of Italy - incl. Travel
restrictions and ban on public gatherings.
All businesses closed except pharmacies, grocery
10/3/2020 stores, and banks.
Government allocated 25 Billion euros for the
emergency (source). All commercial and retail
businesses except those providing essential
services, like grocery stores and pharmacies,
11/3/2020 closed down
12/3/2020
13/3/2020
14/3/2020
Strict quarantine introduced in Ariano Irpino
15/3/2020 (Avellino) (source)
Strengthened quarantine to the municipality of
Medicina, near Bologna, which was the epicentre
of a very developed outbreak. People were not
allowed to enter or exit from the town for any
16/3/2020 reason (source)
17/3/2020
18/3/2020
Despite the lockdown, there are news reports of people still being outside, given that the
governmental decree does not explicitly prohibit movement in public unless a person has
tested positive for the virus or has come into contact with someone who is infected.
An advisory group from China criticised the weak enforcement of the lockdown in Milan.
Mass screenings haven’t been seriously considered beyond the town of Vo (Mar 18 article)
Doctors are being encouraged to work unless they show symptoms or test positive.
43
Flavia Riccardo, a researcher in the Department of Infectious Diseases at the Italian National
Institute of Health told TIME magazine: “The virus had probably been circulating for quite
some time. This happened right when we were having our peak of influenza and people
were presenting with influenza symptoms.” (How Italy became the ground zero of Europe’s
coronavirus crisis)
Widespread reports from medical staff of overstretched healthcare systems/not enough

ventilators, forcing difficult triage decisions.
8. Spain
A) Summary
Spain confirmed its first case on January 31st 2020 when a German tourist tested positive
for SARS-CoV-2 in La Gomera, Canary Islands. Since then Spain has recorded the second
highest number of confirmed SARS-CoV-2 deaths and Madrid became one of the worst
affected regions in the world. The epidemic has already caused five times more deaths than
the 2019 flu. Spain instituted a national lockdown on March 15th (44 days after 1st confirmed
case, 17 days after confirmed cases surpassed 10) and has recently (as of 10 April) begun
to see a reduction in the rate of new deaths – though it is possible counting of deaths is not
keeping up with reality. Spain intends to allow non-essential economic activity to resume
from April 13th (29 days after national lockdown).
B) Epidemic curve
The rate of new deaths is slowing 2-3 weeks after the national lockdown was imposed.
44
45
Onset of symptoms data reports suggest the number of cases with onset of symptoms (blue)
began to decline after the “lockdown” began on March 15th.
C) Data reliability
Spain is not reporting testing figures publically. Latest figures from unattributed sources in
media articles suggest 5,522 tests per million (El Pais 31 March)
Infections detected are only a fraction of the total, perhaps less than 10% ( I , II ) but
perhaps as high as 15% (ICL 30 March). Numbers hospitalized and in ICU are a better guide
because likely only ~5.3% of all cases were being reported previously (Russel et al, 22
March;El Pais 28 March). True cases were estimated to be 150,000 to 900,000 (El Pais 25
March) and there appear to be vast differences in how Covid-19 deaths are counted in
Europe (El Pais 30 March). A good portion of deaths outside of hospitals are not included in
official statistics.
46
D) Policies pursued
Summary: Spain was slow to restrict travel from affected European countries and institute a
national lockdown, but perhaps not significantly slower than comparable countries. Internal
travel from Madrid before the lockdown may have contributed to the spread of the virus.
Waiting a weekend after closing schools to impose a lockdown meant many in Madrid had
travelled to other areas of the country to their second homes. A lack of PPE due to a decade
of austerity cuts led to many healthcare workers (~10%) becoming sick, and the failure to
quickly acquire rapid testing kits meant many were stuck in quarantine waiting for a result.
Actions on Border Control, Travel Restrictions, and Case Finding

Date Policy and/or Action
The Spaniards returning from Wuhan, will spend the first 14 days on
Jan 29 their return to Spain in isolation at the Gómez Ulla hospital in Madrid.
1st case (this came from a German. Following cases were related to
Jan 31 Italy and France, not China)
Director of the Centre for Coordination of Health Alerts and
Emergencies of the Ministry of Health, Fernando Simon, dismissed the
gravity of the situation as a distant dilemma which would only provoke
Feb 9 ‘a handful of cases’ in Spain.
Feb 12 Barcelona Mobile World Congress Cancelled
Feb 13 1st death
2,500 Valencia football fans congregated with 40,000 Italian Atalanta
Feb 19 supporters, at a Champions League game in Bergamo
Feb 28 WHO classes Spain as “local transmission”
Suspension of all non-sports indoor events such as news
Feb 28 conferences
Mar 6 Remove holy water from churches, stop hand shaking in churches
International Women’s Day March: 120,000 people came together to
Mar 8 march on the streets of Madrid, in addition to 76 other events.
Closed educational institutions in Madrid city
Businesses to shift to digital wherever possible
Vulnerable people and people with symptoms asked to remain at
Mar 9 home
Cancelled direct flights from Italy.
School closures in Basque region
Activities in closed spaces that gather more than 1,000 people
Mar 10 are suspended in Madrid, La Rioja, Vitoria and Labastida
Mar 11 School closures in Madrid and La Rioja regions
Nationwide closure of schools
Mar 12 (Thursday) Major sport and event cancellation
The Prime Minister announces he will take emergency measures,
Mar 14 but waits 24 hours to impose them.
47
Nationwide lockdown (all stores except groceries and
pharmacies)
all groupings are prohibited
Closure of restaurant, bars, shopping centres, cultural
Mar 15 (Sunday) establishments and alike
Mar 17 International travel ban at land borders
Mar 19 210 million EUR for the support of regional responses
Closure of borders is extended to ports and airports.
Central government revokes the President of the Region of Murcia’s
Mar 22 orders of the cessation of all non-essential economic activities
The Government requests Congress to extend the state of alarm until
April 11.
Mar 24 Hotels and short-term stays required to close
The Cabinet temporarily restricted layoffs while the state of alarm lasts
Mar 27 (El Pais 27 March)
The prime minister ordered all non-essential workers to stay at home
Mar 28 from 30 March to 9 April to bend the curve and contain the epidemic.
Mar 30 Prohibits funerals and restricts funeral ceremonies
Apr 6 Released an app for self-evaluation
Planned return of non-essential services & activities:
Remote work should prevail whenever possible and keep shops and
leisure establishments where people congregate closed, but restart
industrial and labor activities (from a factory to a law firm).
Apr 13 Planned government distribution of masks on public transport
● No mass screening and testing

● No alert levels
● No mobile phone tracking
● No GPS monitoring of quarantined
● No Corona Map of cases
● No text message alert when near a confirmed case nor when state of emergency
declared
● No mask wearing guidance until April 10
● Health Ministry recommendations still don’t actually recommend social distancing in
their “How to protect myself” infographic.
● Madrid had 2,100 more beds and 2,200 more healthcare professionals in 2008 than
2020, due to health care cuts by governments over the last decade (El Pais 13
March, & Munater & Mckee 2020)
48
● Prime Minister Pedro Sánchez, weak after forming a minority government, likely
didn’t want to risk his fragile hold on power by banning large gatherings, and avoided
sweeping measures that could spook people (and the markets) until after March
13th.
● Before the lockdown, many people living in Madrid, along with their children, made
trips to holiday homes in other regions of the country – spreading the virus even
further.
● Not much prior pandemic experience: Only 1 case of SARS, 2 cases of MERS,
1,194 cases of 2009 Swine Flu.
● Spain is a popular travel destination for many Europeans. It is notable that the
first cases in Spain were from Europeans, not those connected to China.
● Warm temperatures in the months of February and early March invited Spanish
residents to take to the streets and socialise. Before the lockdown cinema box office
numbers appeared unaffected in Spain and this smartphone location report shows
most movement remained unchanged until the national lockdown was imposed and
visits to parks were actually above baseline the days before the lockdown.
● There were reports of people discharging themselves from hospitals, gyms secretly
remaining open, bars still serving customers (El Pais 24 March; EFE 23 March;
Correo Del Sur 24 March);
● The vast majority of people live in apartment buildings. (The Local.es/EuroStat 2015)
● A culture where people always shake hands, or hug, or kiss each other, when they
meet.
● Part of the problem is that while Spain has a national health care system, each of the
17 regions actually administer it separately. The central government tried to address
this disconnect by temporarily nationalizing all the country’s private hospitals.
● Private old people’s homes must turn a profit while charging people prices they can
afford – which may be a basic pension of just over €9,000 ($9,900/£8,200). As a
result, these were understaffed, unprepared and quickly overwhelmed, with death
rates of up to 20%. (The Guardian 26 March)
9. Kuwait
A) Summary
As of 11 April, Kuwait has fared reasonably well, with just 1 death and ~1,300 confirmed
cases – although the rate of growth increased markedly in early April. One major factor in its
apparent success is the government response, which seems to have been generally rapid,
transparent, and competent (e.g. screening arrivals, quarantining contacts, limiting travel and
public gatherings). But it has probably been helped a lot by contextual and circumstantial
factors, such as a small population and geographical area (4.25 M people in an area smaller
than Wales/New Jersey); a very young population (just 2% over 65); wealth (4th highest
GDP per capita in the world); limited use of public transport (most people drive); and
perhaps its relatively hot, sunny climate.
B) Epidemic curve
Sources: The following is based primarily on daily updates provided through an official
COVID-19 website and the Ministry of Health Twitter feed. Testing numbers are from a
49
contact in the Ministry of Defence (MoD) who is involved in the COVID-19 response (though
the MoH is leading the overall effort).
Key stats on 11 April:

● Cases to date: 1,287 (0.03%; 302 per million; 1 per ~3,307)
○ Doubling time: 6 days
● Deaths to date: 1
○ Case fatality risk: 0.16% (with 7 day lag)
● Recovered to date: 136 (10.6% with no lag)
● Critical (ICU) to date: 31
○ ICU admission risk: 2.4% with no lag; 5.6% with 7 day lag
● Active cases: 1,150
● Tests to date: ~30,000 (0.7% of population)
○ Confirmation rate: 4.3% (up from ~1% throughout March)
The first cases (24 Feb) were in travellers from Iran (many Kuwaitis have Persian ancestry).
There are still a significant number of new cases associated with travel abroad (Kuwait is
gradually repatriating around 60,000 nationals), but it appears that most cases are now due
to community transmission; for example, just 31 of 161 new cases on 11 April were in
travellers. The MoD contact said the increase is among blue-collar migrant workers, with
transmission remaining steady among Kuwaiti nationals, but this has not been independently
verified.
C) Data reliability
The MoD contact and contacts in neighbouring countries believe the official figures are likely
to be accurate (e.g. no intentional underreporting, and few unreported confirmed cases or
deaths). Testing is carried out in various locations but all are processed in one central
laboratory, which may improve the accuracy of record keeping.
Nevertheless, it is hard to determine the actual incidence of COVID-19 given current

information. The MoH does not routinely publish the number of tests done, though news
articles reported 6,620 by 11 March and over 14,000 by 18 March, while the MoD contact
said nearly 17,000 by 23 March, and nearly 30,000 by 11 April. This implies a rapid increase
50
in the confirmation rate from below 1% in Feb-March to over 8% in April. Since the number
of confirmed cases also rose sharply in April, it is unclear whether the rate of transmission
increased or the testing was better targeted (or both). This could potentially be clarified with
further investigation.
D) Policies pursued
Summary: Key strategies for containing the virus have included:
● Quarantine of arrivals: initially from high-risk countries (Iran, Italy, etc), then from all
countries (except for repatriation of nationals). Many quarantine sites specially built.
● Suspension of international travel: again, beginning with high-risk places then
universal.
● Testing, contact tracing, and isolation of high-risk individuals.
● Boosting capacity of the health system: production and stockpiling medical
supplies; early qualification of medical doctors; recruitment of clinicians from private
sector; recruitment of volunteers.
● Banning public gatherings: initially large ones (schools, weddings, conferences,
sporting events, etc); followed by all non-essential services (e.g. barbers, cafes,
restaurants).
● Curfew: initially 5pm–4am; extended to 6am.
● Complete lockdown of ‘hotspots’.
● Sanitation: disinfecting public areas and bins.
Sources: Most of the following information was taken from the Kuwait News Agency, which
seems to report all official announcements (and little else), so there is some chance of bias
(e.g. it did not report that the imported test kits were not accurate enough to use). Some was
provided or confirmed by the contact in the MoD.
Key actions are in bold (highly subjective selection)
Date Action
24 Feb ● First 3 cases, from Iran

● 14-day quarantine for arrivals from Iran
● Announces campaign to educate students and teachers on prevention
● Bans ships and flights to/from Irag
25 Feb ● Suspends flights to South Korea, Thailand, Italy

● Ports closed to foreign ships from Republic of Korea, Italy, Thailand,
Singapore, Japan, China, Hong Kong but “in order to maintain efficient
trade [they] will be allowed to berth with the emphasis of prohibiting
direct contact with the crew and preventing them from disembarking
from the ship. The period they have specified is two weeks of their
departure from the affected ports.”
● Al-Khiran resort turned into quarantine
● Kuwaiti citizens warned against travel to covid-hit countries
● Threatens legal action against those “spreading rumours” about covid
26 Feb ● Cabinet meeting:
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○ Tells Kuwait Supply Company to produce enough face masks
○ Assigns Social Affairs Ministry to make sterlization products
available
○ Establishes a system to brief lawmakers about anti-covid
measures
○ Urges everyone to avoid gatherings and ignore rumours
● Cooperates with cooperative societies to ensure access to masks,
sanitizer, etc
● Shuts down 14 pharmacies for increasing price of masks (and more
later)
● Gives hygiene kits to mourners
27 Feb ● Urges Kuwaitis abroad to return
28 Feb ● Medical teams board ships to screen for covid

● “Work in the public sector is proceeding normally” - no special
measures
29 Feb ● Meets regional director of WHO

● Gives special assistance to disabled people for covid prevention
● Claims masks available for distribution
1 March ● Passengers from Egypt and Syria to be screened both before

boarding the plane and on arrival in Kuwait
2 March ● Schools, colleges, unis closed till March 12

● Imports 3.6 M face masks
3 March ● Passengers from 10 countries must produce certificates issued

by Kuwaiti embassy confirming they are covid-free
4 March ● Bank of Kuwait cuts discount rates from 2.75 to 2.50% “in anticipation
of coronavirus-related fallouts”
5 March ● Special Cabinet meeting makes 9 decisions, e.g.

○ Anti-monopoly pricing of masks
○ MoFinance to ensure funding is available
○ “Financially honour” anti-covid workers
○ Stockpiling and distributing “preventive supplies”
6 March ● Suspends flights to/from India, Bangladesh, Philippines, Sri

Lanka, Syria, Lebanon, Egypt
7 March ● Compulsory home quarantine for all arrivals from India,

Bangladesh, Philippines, Sri Lanka, Syria, Lebanon, Egypt.
8 March ● Minister of Social Affairs meets local charities to coordinate efforts

● Government agencies banned from allowing quarantined staff to work.
Quarantined staff (Kuwaiti and foreign) get full pay and keep their jobs.
● MoE distributes thermometers, pamphlets, etc to schools
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9 March ● Extends closure of schools, unis, colleges till 26 March
● Suspends issuing of all entry visas
● New arrivals:
○ 14-day institutional quarantine for arrivals from China, South
Korea, Hong Kong, Italy, Iran, Iraq.
○ 14-day home quarantine for arrivals from Singapore, Japan,
Thailand, Bangladesh, India, Philippines, Sri Lanka, Egypt,
Syria, Lebanon, Azerbaijan.
○ Health monitoring for arrivals from Germany, France,
Sweden, Spain, USA, Netherlands, Norway, UK, Belgium,
Switzerland
● Limits public gatherings
○ Closes all cinemas, theaters, wedding receptions
○ Funerals organized by government with preventive measures in
place
○ Stops sporting activities
● 157 billboards to educate people on how to avoid infection
10 March ● MoH and Red Crescent Society launch awareness campaign among
volunteers
● Cabinet to meet daily to discuss covid
11 March ● Gatherings at restaurants and coffee shops banned

● Starts screening all expats who arrived since 27 Feb
○ Screening centre set up in a fairground
12 March ● Public holiday begins

○ banks, offices etc closed until 29 March
○ public transport stopped
● Call for volunteers in the Civil Defense Department
● Disinfection of ~40k public waste containers
● Ministry of Information: “No leniency for rumourmongers” (vague)
● Shipping: No vessels allowed from Iran until further notice
● Land borders with Saudi Arabia and Iraq closed
13 March ● Suspends all commercial flights except for arriving Kuwait

citizens and immediate relatives/domestic helpers, excl cargo
● Mosques closed
14 March ● Shops (excl. food stores), malls, hairdressers, arcades, child

entertainment centers to be closed (but cooperative societies and
ration centres to remain open)
● 13-bed ward of Al-Ahmadi Hospital reserved for quarantine as a
“backup” in case the main centre at Jaber Hospital fills up
15 March ● MoD transforms army camp into field hospital for coronavirus
quarantine
● PM: Government is “committed to transparency and honesty”
53
16 March ● Cabinet approves draft law for $1.6bn covid-19 fighting fund
● Agrees to the revision of another bill
○ punishing deliberate transmission of covid-19 with up to 5y
imprisonment and/or fines
○ punishing violations of preventive health measures with up to 3
months in prisons and/or fines
● Interior minister threatens curfews and deportations if people go
outside unnecessarily
17 March ● Mandatory 14 day quarantine for arrivals:

○ Institutional quarantine if they visited China, Hong Kong,
Egypt, France, Germany, Iran, Iraq, Italy, South Korea, Spain,
the United Kingdom, or the United States during the two weeks
prior to entering Kuwait
○ Home self-isolations if they visited any other country
● Charges 14 website admins for violating e-media regulations by
spreading misinformation about covid
● Donates $40 M to WHO to fight covid
18 March ● Bans wedding receptions and other social gatherings

● MoH claims >14,000 “swipe tests” (PCR) have been conducted so far,
including >1,000 “yesterday alone”.
● 400k rapid test kits arrive, but the MoD contact says they were too
inaccurate to use
● Suspends employment of hourly domestic workers
● Forms teams to enforce home quarantine and punish violators
19 March ● Closure of schools, universities, colleges extended till 4 Aug
20 March ● MoH receives medical equipment and supplies from China
22 March ● Begins partial curfew (5pm–4am) and instructs people to stay

home if possible even outside curfew.
○ Punishment for breaching curfew is up to 3 years in jail and
fines up to US$32,000.
○ Enforced in part by the National Guard.
○ Exemptions allowed for certain reasons; elderly and people
with disabilities prioritised
23 March ● 9 expats arrested for breaching curfew; and another group of 3

Kuwaitis and 2 foreigners
● Fire service and MoH to deliver medicine during curfew
● Health minister says they have procured malaria and HIV medicines to
suppress symptoms, and will use a vaccine when available
● Health minister expects crisis will worsen for two months then start
improving
24 March ● 14 day institutional quarantine for arrivals from all countries
25 March ● People urged to disregard rumours and abstain from excessive

shopping and consumption of food “until the situation improves”.
● Returnees from Lebanon, Egypt and Bahrain quarantined on arrival by
National Guard.
● Kuwait “leads the region” in sequencing of SARS CoV-2 genome
54
26 March ● Minister of Information stresses role of mass media in refuting COVID-
19 rumours.
27 March ● Kuwaitis repatriated from Barcelona, Rome and London

● Ministry of Social Affairs launches COVID-19 donation campaign.
28 March ● All cafes closed; deliveries allowed outside curfew

● Only relatives of deceased allowed at funerals, and burials only
allowed 8am–3pm
29 March ● Repatriations from Iran, Germany, France, USA, UK – end of first

phase of repatriation plan.
30 March ● Final year medical students’ exams brought forward to allow them
to register as doctors and fight COVID-19.
31 March
1 April
2 April ● MoE says private schools should pay teachers’ wages till schools
reopen
● 462 entities (e.g. barbers, gyms, shops) were closed in March for
violating COVID-19 preventive measures.
3 April ● Large sanitisation campaign (spraying public areas)

● MoD completes quarantine zone and hands to MoH
4 April
5 April
6 April ● Curfew extended by two hours (5pm–6am)

● Complete lockdown in two areas (Mahboula and Jleeb Al-Shuyoukh)
to allow more testing after several infections found
○ Food baskets later delivered to areas
7 April
8 April ● Plane with medical supplies arrives from China
9 April ● Database created of citizens abroad who wish to return, including

medical information
● Private sector clinicians allowed to work for MoH
10 April
11 April ● Plane with Indian medical supplies and medics arrives

● 12 contracts for quarantine sites approved
● Surveillance limited
○ No tracking of mobile phone, credit cards, CCTV footage
55
○ No GPS monitoring of quarantined
○ No Corona Map of cases
○ No text message alerts when near a confirmed case
● Testing not that widespread aside from in travellers?
○ Not all pneumonia cases screened
○ No drive-through clinics
○ Tests seemingly not available to buy privately
○ No screening for fever in public places
○ No cash incentive to be tested (as in Wuhan)
● Seemingly no alert levels

Note: This is mostly quite speculative
Things that have likely reduced the impact

● Size: Small country (=Wales/New Jersey) so easier to control/monitor. Just 4.25 M
inhabitants, 90% of whom live in one city.
● Wealth: 4th highest GDP per capita in the world, which makes most things easier.
● Very young population: Just 8% ≥55yo and 2% ≥65. (USA = 29% and 16%. Italy =
35%; 22%. China = 23%; 9%). Reduces severity of illness and risk of death.
● Healthy worker effect / healthy migrant effect? 70% of the population is non-
native, mostly migrant workers. Both migrants and workers tend to be healthier than
average (because working and travelling are hard when you’re ill). But unclear if this
applies to migrant workers in Kuwait, given that they tend to be from poor countries
like India and often live in bad conditions.
● Transport: Most people travel by car; buses only used by blue-collar workers, which
limits social contact.
● Hygiene practices?: Most wash at least 5x a day before prayer (though not always
with soap)
● More time to prepare? First cases on 24 Feb (Taiwan 21 Jan; Spain/Italy 31 Jan;
Egypt 14 Feb; Iran 19 Feb)
● Good governance?: Considered one of the more competent, transparent,
democratic countries in the region
Things that have likely exacerbated the impact

● Physical contact/social mixing: Within genders, people hug and kiss a lot. Large
extended families living together. Migrant workers live in crowded conditions.
● Population ~60% male: Men are possibly more likely to get severe symptoms.
Things with unclear effect

It is possible that Kuwait’s climate has either helped or (perhaps less likely) hindered efforts.
The evidence on the role of these factors seems not to have been settled, but there is
preliminary evidence (April 7 article) that temperature in particular may play a role.
● Temperature: Temperatures around 5C seem optimal for the virus, whereas Kuwait
is 13-19C in Feb-March, with highs over 20C (graph). In April it rises to 25C average
56
and highs of 30C, but the rate of confirmed cases increased markedly during this
period.
● Humidity: Kuwait’s Feb–April humidity of 60-70% is fairly high (graph), and there is
some evidence that the virus prefers lower humidity.
● Precipitation: Rainfall is pretty low (10-15 mm/month) even in winter (graph) and
viruses generally prefer dry weather.
● Sunshine: Kuwait seems to be fairly sunny year round (3,000 hours per year; >200+
hrs per month in winter). There is some evidence that UV light can sterilise surfaces.
57
Notes and collated best papers
Non-pharmaceutical interventions
1. Lai S, Ruktanonchai NW, Zhou L, Prosper O, Luo W, Floyd JR, et al. Effect of non-
pharmaceutical interventions for containing the COVID-19 outbreak: an observational
and modelling study. medRxiv. 2020;
https://www.medrxiv.org/content/10.1101/2020.03.03.20029843v3.full.pdf
● Analysis of travel restrictions and social distancing
● Estimate that compared with no non-pharmaceutical interventions (NPIs)
would have a 67x increase in cumulative COVID-19 cases
○ Higher in other provinces (125x) outside of Hubei
● Highest impact intervention was early case detection + swift isolation
● Combined NPIs had greatest effect
● Speed of intervention made large difference in reduction in case numbers
● Advises prevention of seeding outbreak in new regions/containing local
transmission in new locations early
● Seems to conclude that China has contained the outbreak/does not mention
rebound when NPIs are relaxed and social behavior returns to normal
2. Chinazzi M, Davis JT, Ajelli M, Gioannini C, Litvinova M, Merler S, et al. The effect of
travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak.
Science. 2020;
https://science.sciencemag.org/content/early/2020/03/05/science.aba9757
● Broadly agrees with previous travel restriction modelling studies that not
much benefit incurred: travel restrictions cause a slight/modest delay with
stringent measures applied, but that this does not significantly alter epidemic
progression/final epidemic size
● Wuhan travel quarantine only delayed outbreak by 3-5 days in mainland
China
● Case exports from Wuhan reduced to some areas up to 80%
● “The simulated scenarios show that even in the case of 90% travel reductions
(Fig. 4D), if transmissibility is not reduced (r = 1), the epidemic in Mainland
China is delayed for no more than 2 weeks.”
● “The model also indicates that even in the presence of the strong travel
restrictions in place to and from Mainland China since 23 January 2020, a
large number of individuals exposed to the SARS-CoV-2 have been traveling
internationally without being detected. Moving forward we expect that travel
restrictions to COVID-19 affected areas will have modest effects, and that
transmission-reduction interventions will provide the greatest benefit to
mitigate the epidemic.”
3. Keeling MJ, Hollingsworth TD, Read JM. The Efficacy of Contact Tracing for the
Containment of the 2019 Novel Coronavirus (COVID-19). medRxiv. 2020;
https://www.medrxiv.org/content/10.1101/2020.02.14.20023036v1
● Note, in China 11-12 contacts were traced per case according to National
Health Commission of the PRC daily data releases
58
● Contact tracing requirements are resource intensive, requiring a mean 36
contact traces/case
● Contact tracing sensitivity/specificity changes depending on definition
○ Current PHE definition of 15 minutes within 2 metres (large # of
contacts for some individuals)
○ No outbreak control if >4 hours required to be counted as a contact
● Note, study doesn’t account for asymptomatic transmitters
4. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-
based mitigation measures influence the course of the COVID-19 epidemic? The
Lancet. 2020; https://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(20)30567-5/fulltext
● Shortening the time from symptom onset to isolation vital – same result
robustly found in SARS studies
● Superspreading events could overwhelm contact tracing
Healthcare system/clinical
1. Li R, Rivers C, Tan Q, Murray MB, Toner E, Lipsitch M. The demand for inpatient and
ICU beds for COVID-19 in the US: lessons from Chinese cities. medRxiv [Internet].
2020 Jan 1;2020.03.09.20033241.
http://medrxiv.org/content/early/2020/03/16/2020.03.09.20033241
● Strict public health interventions 6 weeks post-sustained local transmission
● Used Wuhan-style outbreak applied to US scenario with statrum-specific
critical care rate (age, main comorbidity used: hypertension)
● Exceeding ICU/healthcare system capacity – 259/1 million population
requirements at peak
● Only have 36-53/1 million population empty, staffed ICU beds
● “Our findings show that combined NPIs, inter-city travel restrictions, social
distancing and contact reductions, as well as early case detection and
isolations, have substantially reduced COVID-19 transmission across China.”
● Good plain language summary for policymakers
2. Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19.
JAMA [Internet]. 2020 Mar 11; https://doi.org/10.1001/jama.2020.3633
● Median duration between symptom onset and ICU admission: 9-10 days
● Evidence-based treatment guidelines for ARDS should be followed, including
○ conservative fluid strategies for patients without shock following initial
resuscitation
○ empirical early antibiotics for suspected bacterial co-infection until a
specific diagnosis is made
○ lung-protective ventilation
○ prone positioning
○ consideration of extracorporeal membrane oxygenation (ECMO)
● Caution with HFNC or noninvasive ventilation
● Need to protect healthcare workers - greater than 3,300 Chinese healthcare
workers infected so far (4% of all cases)
59
3. Yang X, Yu Y, Xu J, Shu H, Liu H, Wu Y, Zhang L, Yu Z, Fang M, Yu T, Wang Y.
Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in
Wuhan, China: a single-centered, retrospective, observational study. The Lancet
Respiratory Medicine. 2020 Feb 24. https://www.thelancet.com/lancet/article/s2213-
2600(20)30079-5
● 15% of intubated survivors still being mechanically ventilated at 28 days
○ Significant implication for prolonged care required for anyone
intubated and mechanically ventilated
4. Liew MF, Siow WT, MacLaren G, See KC. Preparing for COVID-19: early experience
from an intensive care unit in Singapore. Critical Care. 2020;24(1):1–3.
https://www.ncbi.nlm.nih.gov/pubmed/32151274
5. Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP. Effect of Noninvasive
Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal
Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized
Clinical Trial. JAMA [Internet]. 2016 Jun 14;315(22):2435–41.
https://pubmed.ncbi.nlm.nih.gov/27179847
● Could be worth exploring as a non-aerosol generating non-invasive
ventilation
● This may be able to prevent the need for some severe/critically unwell
patients to need to be intubated and mechanically ventilated, which is very
resource intensive (including nursing staff, O2, propofol and other sedating
drugs, nasogastric feeding, etc)
6. Frat J-P, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-Flow Oxygen
through Nasal Cannula in Acute Hypoxemic Respiratory Failure. New England
Journal of Medicine [Internet]. 2015 May 17;372(23):2185–96.
https://doi.org/10.1056/NEJMoa1503326
● FLORALI study has shown robust evidence relevant to COVID-19:
● Positive benefit of HFNC and significant reduction in the need to intubate
patients with acute respiratory failure
● We could try to estimate the number of averted intubations if supplemental
oxygen (especially HFNC) is preferentially used
○ Also compare possible nosocomial infections from HFNC vs.
CPAP/BiPAP vs. helmet (above) due to difference in aersolisation
7. Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al. Pathological findings of
COVID-19 associated with acute respiratory distress syndrome. The Lancet
Respiratory Medicine. 2020;
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext
8. Bernheim A, Mei X, Huang M, Yang Y, Fayad ZA, Zhang N, et al. Chest CT findings
in coronavirus disease-19 (COVID-19): Relationship to duration of infection.
Radiology. 2020; https://pubs.rsna.org/doi/10.1148/radiol.2020200463
● hallmarks of COVID-19 infection on imaging were bilateral and peripheral
ground-glass and consolidative pulmonary opacities
● CT chest findings most extensive on day 10 of infection
9. Cortegiani A, Ingoglia G, Ippolito M, Giarratano A, Einav S. A systematic review on
the efficacy and safety of chloroquine for the treatment of COVID-19. Journal of
60
Critical Care. 2020;
https://www.sciencedirect.com/science/article/pii/S0883944120303907
● Old malaria drug, proven safety profile
● Efficacy shown in systematic review
● Could trial as a prophylactic for healthcare workers to reduce transmission
and severity & duration of infection if they become infected
● Should ensure supply chain regardless even if just for treatment of patients -
is it possible to manufacture this drug in the UK?
10. Liu, J., Cao, R., Xu, M. et al. Hydroxychloroquine, a less toxic derivative of
chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell Discov 6, 16
(2020).https://www.nature.com/articles/s41421-020-0156-0
● Derivative of choloroquine
● Hydroxychloroquine is a less toxic/less side effect profile of chloroquine
● We have more stores of it and it's safer
○ Cholorquine market supply and production has gone down over years
○ Hydroxycholorquine is widely used to treat autoimmune diseases like
rheumatoid arthritis, so more supply available
● This study shows direct antiviral activity of hydroxycholorquine
○ Seems to also prevent cytokine storm through anti-inflammatory
properties -- cytokine storms kills many critically ill COVID-19 patients
● Could consider as a trial as a prophylactic drug - similar to how oseltamivir
(tamiflu) is used for influenza outbreaks as a treatment & prophylactic
11. Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19
Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency
Response. JAMA. Published online March 13, 2020.
https://jamanetwork.com/journals/jama/fullarticle/2763188
● Need to combine increasing ICU capacity with public health containment
measures concurrently and early
● Highlights the need for accurate forecasting of ICU needs
● Showcases the need to test even if epidemiological risk factors are not
present (in case there are undetected transmission chains with disease
‘generation gaps’ in testing)
● Similar ICU bed numbers and occupancy to UK
● Forecasting ICU need and pre-planned for adjustments based on exceeding
capacity
● Cohorting COVID-19 patients away from non-COVID-19 patients (crude step
1 cohort)
● Triage of new patients for 1) mechanical ventilation needs and 2) dividing new
patients into COVID-19/not COVID-19 streams
● Were able to increase ICU beds by 67% (added 482 to 720).. with 90%
occupancy of the 720 due to other conditions (648) this mean that effectively
there were 554 beds for COVID-19 if background ICU bed needs stayed
constant
● Need to start planning/creating ICU beds now, opposed to when reaching/at
capacity given exponential/sub-exponential growth in cases
● Diagnostics are vital – if we cannot diagnose patients requiring mechanical
ventilation we cannot triage/cohort and forecasting of the likely length of
critical care needs etc becomes difficult
61
Diagnostics
1. Fang Y, Zhang H, Xie J, Lin M, Ying L, Pang P, et al. Sensitivity of chest CT for
COVID-19: comparison to RT-PCR. Radiology. 2020;
https://pubs.rsna.org/doi/full/10.1148/radiol.2020200432
● RT-PCR sensitivity is 71% [95%CI 56-83%]
● CT Chest performs better but limited availability + not feasible to do for
diagnostic purposes in mild/moderate cases
2. Wang M, Fu A, Hu B, Tong Y, Liu R, Gu J, Liu J, Jiang W, Shen G, Zhao W, Men D.
Nanopore target sequencing for accurate and comprehensive detection of SARS-
CoV-2 and other respiratory viruses. medRxiv. 2020;
https://www.medrxiv.org/content/medrxiv/early/2020/03/06/2020.03.04.20029538.full.
pdf
● Whole genome sequencing of SARS-CoV-2
3. Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, Tao Q, Sun Z, Xia L. Correlation of
chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a
report of 1014 cases. Radiology. 2020 Feb 26:200642.
https://pubs.rsna.org/doi/abs/10.1148/radiol.2020200642
● Of 1014 patients, 59% (601/1014) had positive RT-PCR results, and 88%
(888/1014) had positive chest CT scans. The sensitivity of chest CT in
suggesting COVID-19 was 97% (95%CI, 95-98%, 580/601 patients) based on
positive RT-PCR results. In patients with negative RT-PCR results, 75%
(308/413) had positive chest CT findings; of 308, 48% were considered as
highly likely cases, with 33% as probable cases. By analysis of serial RT-PCR
assays and CT scans, the mean interval time between the initial negative to
positive RT-PCR results was 5.1 ± 1.5 days; the initial positive to subsequent
negative RT-PCR result was 6.9 ± 2.3 days). 60% to 93% of cases had initial
positive CT consistent with COVID-19 prior (or parallel) to the initial positive
RT-PCR results. 42% (24/57) cases showed improvement in follow-up chest
CT scans before the RT-PCR results turning negative.
Epidemiology/modelling
1. Lipsitch M, Swerdlow DL, Finelli L. Defining the epidemiology of Covid-19—studies

needed. New England Journal of Medicine. 2020;
https://www.nejm.org/doi/full/10.1056/NEJMp2002125
2. Bai Y, Yao L, Wei T, Tian F, Jin D-Y, Chen L, et al. Presumed asymptomatic carrier
transmission of COVID-19. Jama. 2020;
3. Liu Y, Gayle AA, Wilder-Smith A, Rocklöv J. The reproductive number of COVID-19
is higher compared to SARS coronavirus. Journal of travel medicine. 2020;
https://academic.oup.com/jtm/advance-article/doi/10.1093/jtm/taaa021/5735319
4. Zhan C, Chi KT, Lai Z, Hao T, Su J. Prediction of COVID-19 Spreading Profiles in
South Korea, Italy and Iran by Data-Driven Coding. medRxiv. 2020;
62
5. Wong JEL, Leo YS, Tan CC. COVID-19 in Singapore—current experience: critical
global issues that require attention and action. JAMA. 2020;
6. Danon L, Brooks-Pollock E, Bailey M, Keeling MJ. A spatial model of CoVID-19
transmission in England and Wales: early spread and peak timing. medRxiv. 2020;
Other country-specific papers
1. Tariq A, Lee Y, Roosa K, Blumberg S, Yan P, Ma S, et al. Real-time monitoring the

transmission potential of COVID-19 in Singapore, February 2020. medRxiv. 2020;
2. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? The Lancet. 2020;
https://www.thelancet.com/lancet/article/S0140-6736(20)30627-9
63

COVID-19 Country-Specific Responses

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COVID-19 best papers & country

Notes and collated best papers 60

Timeline (from academic paper link above)

E) Policies not pursued

F) Context and other actions

Confirmed cases to date 10,780

Case density ~3,000 per million

Deaths to date 250

Case fatality risk 2.3% (with no lag)

Tests to date ~623,000

Testing density ~12.2 per thousand

Confirmation ratio ~1.7%

Examples (Full list in Appendix 2)

D) Policies not pursued

● No lockdowns as of March 19 (Mar 19 article).

E) Context and other actions

Which test kits are they using?

Powercheck Kogene Feb 4 ● E gene 10,000 250,000 RT-PCR

DiaplexQ N Solgent Feb 27 ● E gene <2 1,000 kits 50,000 RT-PCR

Standard M Sd Feb 27 ● E gene 2,000 kits 100,000 RT-PCR

How did they develop them so fast?

How did they roll them out so fast?

● Patients under mandatory quarantine monitored using GPS (Mar 19 article)

However, Singapore entered lockdown in early April following outbreaks in densely-packed

As of 21 April there have been:

On 21 April, the government’s Multi-Ministry Taskforce extended the circuit breaker to 1

E) Policies not pursued

Japan continues to report a gradual growth in cases and deaths:

Number of People Tested 16,484 Our World in Data

Number of Tests Per 130 Our World in Data

Confirmation rate 5% Values above

16 January First case in Japan

29 January Start of repatriation of citizens from Hubei

30 January Start of inter-ministerial coordination of the

3 Feb Travel restrictions on travelers and citizens

5 Feb PM Abe ordered quarantine of Diamond

12 Feb Travel restrictions on travelers and citizens

Extended testing to patients with symptoms,

MoH contracts a company to do PCR

500 billion yen secured to help small and

15.3 billion yen set aside “to facilitate the

14 Feb Established 536 consultation centres to give

25 Feb Released a uniform policy for Coronavirus

Suspended large gatherings, closed

Allowed general medical facilities (rather

Established a “Cluster Response Section to

26 Feb Recommended cancelling, delaying, scaling

27 Feb Plans for tests to be covered through

1 March Invoked emergency measure so that face

2 Mar Start of school closures, planned until early

5 March Quarantining visitors from China and S.

16 March Expanded entry restrictions for visitors from

D) Policies not pursued

Did not ramp up testing:

No legal actions to lockdown cities:

Lack of extensive and clear risk communication

“Timely, accurate, and transparent risk communication is essential and challenging in

Delayed interministerial coordination relative to SK and HK

“Second, intragovernmental coordination was improved because health authorities drew on

E) Context and other actions

For latest updates: Hong Kong government dashboard

● Jan 8: Hong Kong's Centre for Health Protection (CHP) added