Volume 6, Issue 3 (Spring 2021)                   Health in Emergencies and Disasters Quarterly 2021, 6(3): 147-160 | Back to browse issues page

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Rafieepour A, Masoumi G, Dehghani A. Health Responses During the COVID-19 Pandemic: An International Strategy and Experience Analysis. Health in Emergencies and Disasters Quarterly 2021; 6 (3) :147-160
URL: http://hdq.uswr.ac.ir/article-1-344-en.html
1- Department of Occupational Health, Student Research Committee, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
2- Department of Health in Emergencies and Disasters, School of Health Management and Information Services, Iran University of Medical Sciences, Tehran, Iran.
3- Department of Health in Emergencies and Disasters, Student Research Committee, School of Public Health and Safety, Shahid-Beheshti University of Medical Sciences, Tehran, Iran. , dehghani.am64@gmail.com
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1. Introduction
The COVID-19 was first detected in December 2019 in Wuhan, China. The virus caused a type of viral pneumonia with the ability to spread rapidly from person to person, which is due to the characteristics of its genome structure. It was classified as Acute Respiratory Syndrome (SARS-2002) and the Middle East Respiratory Syndrome (MERS-2012) [1, 2]. 
The COVID-19 spread rapidly worldwide and was identified by the WHO as a significant public health concern [3] as of September 15, 2020, 12:02 GMT. It has infected 29475633 people in 215 countries, of whom 933444 died [4]. The death rate from the COVID-19 in most countries was estimated at 3.61% [5], which was more prevalent among the elderly or those with underlying diseases such as diabetes, cardiovascular disease, chronic respiratory disease, blood pressure, and cancer [1]. 
Over time, examining hospitalized cases showed that children and younger people are also more likely to be infected with the COVID-19 [6, 7]. Furthermore, involvement of the kidneys and other organs in patients with the COVID-19 has also been reported by some researchers [8]. In addition, the cardiovascular system in patients with COVID-19 is severely affected by the virus or drug treatments, and as a result, the mortality rate due to cardiac arrest has increased during the outbreak of the disease [9]. Therefore, efforts to control the disease and prevent its spread are on the agenda of governments; thus, several measures have been taken.
Efforts to reduce the disease transmission have been significantly effective with taken measures such as quarantine, reduction of displacement, increasing social distance, and strict adherence to basic hygiene principles [10, 11]. However, the rapid spread of COVID-19 infection is associated with fundamental changes in the health care system [12]. The high cost of caring for people with COVID-19, the provision of beds, ventilators, and concerns about staff health and personal protective equipment have posed challenges to each country’s health and economic system [13]. 
Many countries take measures such as building new hospitals (China) [1], designing and using a patient tracking application (Singapore) [14], designing and operating a corona screening system (Iran) [15], and implementing quarantine operations along with increasing the capacity of the hospitals (Italy) [16] to minimize the challenges of the treatment system. In addition, new vaccines were designed and tested for the COVID-19 in various countries worldwide [17]. But what is important here is to share successful experiences fighting the virus to disrupt the epidemic chain as soon as possible.
Hick and Biddinger argued that countries should not act as an island in the face of epidemics and pandemics and should take steps to prevent the spread of disease by sharing health data [18]. However, learning from the measures taken in different countries is a relatively new subject that can effectively achieve the right policy to deal with future epidemics. In 2015, the World Health Organization (WHO) launched the Global Learning Laboratory (GLL) to be used as a space for sharing lessons and tools focused on Universal Health Coverage [19]. Therefore, in this article, we decided to review the measures taken in selected countries to combat the COVID-19 and analyze international policies and experiences to develop appropriate health guidelines to deal with the inevitable health threats of the future.

2. Materials and Methods
A comparative study method was used to evaluate and explain the experiences of COVID-19 disease management in selected countries of the world. The study population includes Canada, Japan, Germany, Korea, Turkey, and Iran, which are not only among the leading countries in the management of COVID-19 disease but also have been affected mainly by this disease. In selecting these countries, we attempted to study at least one country from each continent. Initially, 10 effective indicators in the management of COVID-19 epidemic disease were extracted using literature review and interviews with professors and epidemiology management experts. Then, the outcome of the indicators was done to extract the differences and similarities between health systems strategies in different countries. Thus, the differences and similarities between different countries were compared and applied in the next step.
The study data were collected from articles published in scientific databases (Google Scholar, PubMed, Web of Science, and Scopus databases) or online reports of government agencies or COVID-19 disease management bodies and based on specified search strategies. The data from each country were collected based on the indicators of current research in the management of COVID-19 and were written separately for each country. The inclusion criteria were experiences based on defined indicators and access to information, and exclusion criteria were complete lack of access to information or information in languages other than English and Persian. The matrix content analysis method was used to analyze the obtained data. In this method, content analysis was conducted with indicators, and the models obtained from the studies were placed in the designed matrix. Finally, the extracted indices were analyzed.

3. Results

 Germany, with more than 83 million population (September 15, 2020, 12:34 GMT), with 263407 infected, 9437 dead, and 237550 recovered, ranked 22nd in the world in terms of COVID-19, and only 1% of their patients have been reported in critical condition [20]. Germany responded to the COVID-19 outbreak by implementing a national program at the federal level by the Robert Koch Institute (RKI). The low rate of fatalities versus the high rate of infected patients indicates the successful policies of the country’s health system, which includes rapid measures such as a large number of screening tests (500000 tests per week), rapid implementation of social prevention methods, high bed-to-patient ratio (56000 beds for people with coronary artery disease), € three billion budget allocation to 1000-bed hospital by the German army and forced to wear a mask. Other practical measures of the German health system included initial contact with a family doctor or 115 emergencies and providing medical information, if necessary, initial examination and quarantine of the patient at home or hospitalization, and use of innovative facilities of drive-through testing.

A country with more than 84 million population (September 15, 2020, 12:34 GMT) is ranked 12th globally in terms of COVID-19 disease, with 407353 infected, 23453 dead, 349984 recovered, and 11% have reported comorbid malignancies [20]. Iran, by creating the National Headquarters for Corona, took health-oriented decisions in various areas of the country, and by stopping unnecessary services in hospitals (selective surgeries) and allocating IRR 1000 billion budget for the credit of the treatment system in the first phase be ready, as well as increasing the capacity of hospitals to provide services, took adequate steps to combat the spread of the disease. On the other hand, measures such as screening at the entrances of cities by Red Crescent volunteer forces, minimizing hospital visits, setting up a telemedicine system to care for patients and necessary treatment measures, plasma therapy, appointing a spokesperson for the National Corona Management Headquarters, launching Hot Line 4030, to answer frequent questions about the corona, launched the Corona Disease Self-Assessment System, developed and launched the Tuck application (nutrition, safety, and corona) to diagnose the disease in the shortest possible time.

Turkey, with more than 84 million population, was ranked 19th in the world for COVID-19 on September 15, 2020, at 12:34 GMT. To date, 292878 people have been infected, 7119 have died, and 260058 have recovered [20]. Despite the similarity between Turkey’s population and cultural structure with Iran, the overall number of patients with this disease is less reported than in Iran [20]. Observing social distance and banning traffic in the city and canceling all scientific, cultural, artistic, and sports events in the country, and starting online education in schools and universities have been among the measures taken by Turkey to manage this disease.

Japan, with a population of 126 million (as of September 15, 2020, 12:34 GMT), is ranked 44th globally regarding the number of people with COVID-19, with 75657 infected 1442 dead, 67242 recovered, and 2% have reported comorbid malignancies. However, Japan has a minimal number of patients whose reasons can be attributed to the proper functioning of the government and the country’s health system, including the early cancellation of all cultural, social, political, sports, and artistic events, the closure of educational centers, the production of diagnostic equipment and its pilot use at airports. In addition, for short-term quarantine of incoming passengers from infected areas, a new test method was implemented to speed up the detection of COVID-19 in 30 minutes by the State Research Institute. Also, the country established a policy to protect against the spread of the coronavirus, such as asking people with mild symptoms to stay home until they recover and asking companies to promote telecommuting and variable opening hours.

With more than 60 million people (September 15, 2020, 12:34 GMT), Italy reported about 288761 infected, 35624 deaths, and 213950 cases recovered. At the time of the study, it was ranked 20th regarding COVID-19 disease globally [20]. The most crucial action of the Italian health system in the face of COVID-19 disease was using local health authorities in developing health instructions appropriate for each region. Also, the closure of religious places and the use of virtual medicine in providing services to patients to prevent congestion in medical centers was another effective measure in this country.

South Korea
Using the lessons learned from the 2015 MERS outbreak, South Korea could (on September 15, 2020, 12:48 GMT) become 77th in the world with a population of more than 51 million, due to the infection of 22391 people and the death of 367 people and the recovery of 18878 people from COVID-19 disease [20]. Furthermore, the country enhanced its capacity to monitor and deal with the rapid adoption of laws and developing a comprehensive framework for dealing with infectious diseases. Also, it established specialized departments for risk assessment, emergency operations, crisis communication, and increasing the capacity of hospitals to prevent and control infectious diseases to manage this disease very well. 
South Korea has begun operations with 532 treatment centers for people infected with the COVID-19. As a result, it has the highest rate of COVID-19 testing in the world. On the other hand, hospitals conducted remote diagnostics for patients with mild symptoms and helped medical professionals to focus on people with more severe symptoms. They created a smartphone app to warn mobile users of places where people are infected and provide the possibility of announcing the health conditions of people with the authorities. These measures were taken to detect the disease at its early stage. In addition, a five-division system was developed to allow the general use of the mask, allowing each person to purchase two masks per person during the working days of each week, determined by the last digit of each person’s year of birth. And if they do not buy the mask on the specified days, they can buy their quota on the weekend of the same week.

4. Discussion
The prevalence of COVID-19 in 215 countries worldwide has prompted governments to develop national strategies tailored to their social, political, economic, cultural, and religious conditions and adhere to international strategies and implement them to manage this disease optimally. Considering the type of crisis, the necessary actions of any government are in health system services management, which can help improve the current challenging conditions of societies by slowing down the epidemic process. In this regard, in this study, 10 essential health measures indexes to manage the COVID-19 crisis in 6 countries were compared. The results showed that some health management programs could be effective in reducing morbidity and mortality. Furthermore, learning from successful global strategies and customizing them can strengthen countries’ preparedness for the inevitable crises ahead.
The World Health Organization (WHO) recommends that the efforts and programs of all countries involved in the corona crisis be reviewed and its results used to strengthen the health system [76]. However, studies show that countries do not use other countries’ lessons learned and experiences. A workshop after the influenza pandemic organized by the WHO in 2005 with the participation of the European Center for Disease Control and Prevention emphasized that the development and revision of pandemic preparedness programs should be facilitated by the transfer of information and best practices from other countries and all countries should share these experiences. Using this lesson also helps other health-threatening situations and enables International Health Regulation (IHR) [77]. 
Successful pandemic management systems include the Thai Ministry of Health, which, using the experience of Australia, Hong Kong, and China, has been able to improve its programs in influenza pandemic management (2009) [78]. Awareness of what has been learned helps countries be prepared to deal with other emergencies threatening health. The Chinese government has improved its capacity to respond to epidemics since 2003, following the SARS outbreak and addressing its challenges. This experience helped China successfully manage COVID-19 despite its initial emergence [79], demonstrating the importance of using the lessons learned in epidemics and disasters.
Following the outbreak of COVID-19, the WHO declared a state of emergency and set up an international committee of 15 members, urging countries with poor health to respond quickly to the disease and take effective measures in its proper management according to the local conditions [76]. 
The review of management measures in the present study also showed that most of the prosperous countries in the field of the COVID-19 crisis had taken steps to establish a National Corona Countermeasures Headquarters in the very first days of the epidemic, in addition to optimal policy in the field of health measures. They intended to have adequate supervision over the proper implementation of these guidelines (Tables 1 and 2).

The National Corona Headquarters were set up in Korea and Germany with the lowest number of infected and dead people in a health research center attended by scientists in disease management [21]. This experience shows that the presence of health professionals can be effective in the success of strategies adopted in the management of a disease.
According to the WHO, one of the most important measures in the management of COVID-19 disease is the early diagnosis and screening of this disease. By activating the maximum laboratory capacity, Korea could achieve a special place in the success of COVID-19 management [76]. A review of country documents shows that KCDC (Korea Centers for Disease Control and Prevention) in Korea has used emergency methods to track tests quickly. They performed 18000 diagnostic tests per day, used innovative drive-through testing in disease screening, and encouraged people to take the test to prevent the spread of disease [80]. In addition, awareness of contaminated areas through the design and use of a traffic routing application for infected people in Korea is another successful experiment in reducing the spread of the disease that can be localized and used by other countries [70].
Other essential measures in the management of COVID-19 disease were the protection of medical personnel and the prevention of the financial and workload of hospitals [81]. One successful strategy for controlling the health care wave is “forward triage” or patient classification before entering the emergency department. Remote diagnosis and treatment or virtual medicine is another method that effectively screened the disease or applied home quarantine while maintaining the health of the patient and the treatment staff [82]. Italy has taken appropriate measures to screen patients and reduce unnecessary referrals to medical centers using telemedicine [83]. Keeping people away from significant sources of infection, such as hospitals and providing services at home, is another effective measure that can reduce the incidence of the disease. Therefore, having similar technologies in other countries is recommended to deal with the spread of epidemics.
Protecting the health of medical staff against infectious diseases is another issue that can help meet the challenge of reducing the number of specialists in disease control. Protecting the health of medical staff is an essential issue that the WHO also addressed its importance as a prerequisite for patient safety in the slogan of the World Patient Safety Day on September 17, 2020 [84]. In this regard, personal protective equipment and training on how to use it properly can help reduce the risk of infection to a great extent. However, studies show that only 15% of physicians have received complete and sufficient training to use personal protective equipment [85]. Early in the outbreak of COVID-19, in some countries, such as Italy, there were problems with the supply of medical equipment, in which a large number of medical staff were infected and required to use personal protective equipment by local health authorities. However, the disagreement of some famous Italian leaders over the requirement to use personal equipment created some problems [86, 87]. 
In Iran, by concluding memoranda of understanding with the textile industry and knowledge-based companies, extensive measures have been taken in the production of personal protective equipment, and with the increase in production capacity, activities were carried out in the field of limited export of personal protective equipment to some countries in the crisis of shortage of this equipment. Also, effective measures were taken at the national level to teach the correct method of using personal protective equipment, and similar measures were taken in other countries studied in this study. Furthermore, utilizing existing potentials to increase the production capacity of equipment needed to deal with a crisis and cross-sectoral cooperation and procedural unity is another practical factor that can effectively reduce constraints. 
According to WHO, the convents with three main features (rapid construction, large-scale, and low cost) and five essential functions of quarantine (triage, primary medical care, frequent and rapid monitoring, and providing social services) to implement the predominant strategy will be very effective to cope with the COVID-19 crisis [42]. Thus, many advanced countries have set up convalescent homes in field hospitals, nursing centers, or allocation of hotels, airports, and other public centers to temporary care centers, or, like Italy, they have benefited from home quarantine and telemedicine services. Moreover, managing patients with contagious infections and providing timely medical services until a complete cure can effectively prevent the spread of the disease can be considered in the management of subsequent crises.
With the daily increase in the number of patients with COVID-19 disease and the illness of medical staff, the capacity to provide services in hospitals decreased, so no guidelines and instructions were provided to establish a dedicated hospital. On the other hand, this measure is not cost-effective and is less effective because there is contamination in all medical centers due to the presence of asymptomatic carriers [88]. But China and Italy built a specialized hospital, and Iran evacuated some of its hospitals and turned it into a dedicated hospital for COVID-19 patients, which returned to its original condition after two weeks due to ineffectiveness. COVID-19 disease, as a long-standing pandemic, has many economic dimensions and poses a significant threat to the achievement of the United Nations Sustainable Development Goals (SDGs). One of the goals of sustainable development is fair and universal access to health services [89]. 
The study showed that all countries have paid for the diagnosis and treatment of COVID-19 through insurance coverage or the services of government agencies, sponsors, and donors. Having the same health services for people with different economic backgrounds is an effective way to control epidemic diseases that can effectively manage health crises.
The COVID-19 disease has a wide range of dimensions and effects, the most important of which is to increase the burden of hospital services and the disease of medical staff. Volunteers can be a good help in managing hospital services [90]. Because most hospitals need expert personnel familiar with medical sciences, most countries in this study invited the nursing and medical volunteers, retired medical staff, and students to provide support services in the field of treatment or to provide educational, health, and screening services in the field of health. The use of volunteers and the invitation of health retirees is an effective measure to reduce the service load of the treatment system, which can be considered an efficient process in emergencies of epidemics.
The diverse outcomes of COVID-19 required different indices to evaluate health system. This study only reviewed 10 indicators of the response phase of the COVID-19 crisis, which is one of the limitations of this study. Also, the selection of countries according to the authors’ nationality, the country’s success in health and disease management, and the availability of information in Persian or English are other limitations of this study and require further research.

5. Conclusion
A pandemic of viral diseases such as COVID-19 is one of the world’s challenges at various intervals. Because of emerging diseases, epidemics, and pandemics worldwide, it is necessary to use the lessons learned to manage these diseases. In epidemics, prevention is an essential step because the disease is emerging, and treatment is impossible in the first weeks and months of the outbreak.
Therefore, training and employing health personnel to promote culture and public health literacy are among the measures that can effectively control diseases. Disseminating the teachings of these events and using them for education in schools and the general public can reduce the severity of unavoidable future events. Establishing infectious disease centers and using their knowledge, scientific and skill capacity in disease management is another factor that will lead to a unified procedure in formulating and implementing preventive laws away from political issues and is therefore essential. Also, implementing new technological and electronic facilities during all phases of crisis management of infectious diseases, such as risk reduction (education), preparedness, response, rehabilitation, and recovery, can control this disease more effectively. It is consistent with new and widely used methods of obtaining information. Prompt action to control an epidemic is like preventing a fire from spreading to nearby buildings, thus preventing the spread of the disease. Therefore, it is recommended that countries act honestly (away from political disputes) in presenting their strengths and weaknesses in providing health services and establish a unified system for learning from experiences gained to provide valuable and practical guidelines for dealing with subsequent crises.

Ethical Considerations
Compliance with ethical guidelines

This article was approved by the Vice-Chancellor of the Iran University of Medical Sciences (Code: IR.IUMS.REC.1400.087).

This research was supported by the Iran University of Medical Sciences (Research Project: 087). 

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

The authors would like to thank the Vice-Chancellor for Research of the Iran University of Medical Sciences for approving the research project.

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Type of Study: Research | Subject: General
Received: 2020/11/12 | Accepted: 2021/02/10 | Published: 2021/04/1

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