Is there any successful control of Covid-19 without a lockdown?

When Covid-19 is spreading in a community, there seem to be 3 ways to break the chain of transmission

• Trace and isolate all those infected so that they do not come into contact those who are not sick

• Isolate every one irrespective of whether they are sick or not.  This is the lockdown strategy

• No need to isolate anyone.  Instead, ask everyone to keep a certain distance from each other and/or wear protective gear if you cannot keep the distance

The first method works if the number of infected is small.

But when the numbers of infected in the community are large, then many countries have resorted to the second method.

Some have even tried the third. 

 

I keep hearing stories about how Sweden tried the third approach and I want to know whether this can be a successful method generally.

To get a sense of whether it is possible, I looked at the countries which have not instituted any lockdown.

Actually, it was not as straight forward as I thought as there are different shades of lockdown. 

According to a VOX article citing Lindsay Wiley, a health law professor at the Washington College of Law "lockdown" isn't a technical term used by public-health officials.

It can refer to anything from mandatory geographic quarantines to non-mandatory recommendations to stay at home, closures of certain types of businesses, or bans on events and gatherings.

Secondly, there is still debate about whether a lockdown works. Wikipedia has the following conclusion:

• Several analyses have concluded that lockdowns did save lives in the aggregate, although admitting that data is insufficient to know how much of the reduction came from voluntary social distancing. 

• Other epidemiologists have asserted that generalized lockdowns were enacted without reliable supporting data. Empirical studies have questioned whether lockdowns actually saved lives since they did not target the most vulnerable and elderly populations yet risked new “deaths of despair” from unemployment and poverty.

To get have a more objective view of the success of controlling the virus without a lockdown, I looked at a number of indicators for those countries that have not had any lockdown based on Wikipedia listing.

  

There were 10 countries that were listed as not having any lockdown.  For these I looked at the following:

• Whether the number of daily cases is increasing or declining

• Where it is ranked in terms of the total number of cases 

• The number of cases per million population 

• The mortality per million population 

• The Malaysian GCI ranking

• The Oxford Stringency Index – a higher score meant more stringent measures were imposed.  So for those without any lockdown, I would expect a relatively lower score

If a country was successful in controlling the virus without any lockdown, I would expect

• A declining number of daily cases

• Low ranking in terms of the total number of cases

• A relatively lower number of cases and mortality per million population

• High GCI rank

• Low Stringency score

The table summarizes the results.  

I have added Brazil – although this was not in the Wikipedia list, I have come across a few news sites that have classified Brazil as one of the countries not having a lockdown.

I have also added Malaysia to serve as a “control”. 

I have classified the countries into 2 groups

• Those with a low or declining number of cases

• Those with an increasing number of cases

Countries  (a)	Covid Trend 16 Jul	Ranking (b)	No of cases per m pop	No of deaths per m pop	Oxford Index 6 Jul	GCI rank 16 Jul
Timor-Leste	Low	197	18	0	19	53
Taiwan	Low	158	19	0.3	19	6
South Korea	decline	65	265	6	57	5
Nicaragua	decline	102	475	15	11	68
Iceland	decline	116	5,599	29	0	11
Belarus	decline	29	6,945	51	11	71
Sweden	decline	27	7,572	552	41	175
Malaysia		77	270	4	51	7
Malawi	increase	108	137	2	57	136
Japan	increase	56	178	8	28	30
Brazil          (c)	increase	2	9,270	355	81	138
USA	Increase	1	10,929	423	69	130

Note

a) Source:  Wikipedia unless stated otherwise

b) Worldodomer at 16 Jul

c) Business Insider 8 Jul

Declining cases

I think it is fair to say that if the number of cases is declining, it must mean that the virus is under control.  Look at their Oxford Stringency Index score - except for South Korea, they are all lower than that for Malaysia.

I think there are 3 sub-groups here

• For Taiwan (with 454 total cases) and Timor-Leste (24 total cases), it does not make sense to lock down the country with such low cases.  If there was a lesson here, it is that a country should go all out (before the lockdown) to have the number of cases low.  

• The other sub-group is Nicaragua (3,147 total cases) and South Korea (13,672 total cases) showing that it is possible to bring it under control without a nationwide lockdown even if the total numbers a bit high.  Note that technically, Korea did “lockdown” the area where the virus first surged. 

• The final sub-group is Belarus, Iceland and Sweden. For these, the question becomes whether the “no lockdown” has come at a significant cost as measured in terms of the number of cases, mortality and economic performance. 

In my 11 July post, I have a comparison between Sweden and its 2 Scandinavian neighbors to show that Sweden did not have any economic advantage for bearing the high number of cases and mortality. 

The economic indicators for Belarus and Iceland relative to Sweden as per the table below suggest that they seem to have the same economic performance as Sweden meaning that they are not necessarily better off without the lockdown.  To be fair, Belarus' unemployment is much better than for Sweden. 

Economic indicators	Belarus (a)	Iceland (b)	Sweden
GDP growth in 2020	(6.0)	(7.2)	(6.8)
Unemployment rate %	2.3	8	10.1

Source: Nordeatrade.com from IMF

Note

a) As a small, open, commodity-exporting economy, Belarus is heavily exposed to the deep ongoing contractions in its main trading partners (Russia and the EU), the collapse of global oil prices and global financial volatility caused by the COVID-19 pandemic 

b) As a small and highly open economy with a sizeable concentration in tourism and commodity exports, Iceland is exposed to the economic shock with a severe recession, widening budget deficits, and a significant rise in government debt. 

Increasing cases

For the increasing cases, the jury is still out whether they can bring it under control without any lockdown in the coming future. 

• Brazil and the US already have high Oxford index scores.  So if they have lockdown it will mean higher scores in the future. But have you noticed that their Oxford index scores are higher than that for Malaysia?   More stringent measures but poorer results c/w Malaysia.  

• Japan with the low Oxford score meant that there are other measures it could still try before the lockdown

• Malawi got its 50th case around mid-May so it is currently in the second odd month of the virus with 2,700 odd total number of cases.  I don know enough about what is happening there but it does not look as if the virus is under control. 

For the US and Brazil, the number of cases in both countries is such that they cannot point to Taiwan, Timor-Leste, Nicaragua and South Korea as examples of controlling the virus without a lockdown.

The best is for them to point to Belarus, Iceland and Sweden (which has a 4 digit number of cases per million population) as their role model.  

But if Belarus, Iceland and Sweden are not likely to get any economic gain for the “no lockdown” why would the US and Brazil be different economically?

All I can say is that I am glad I am not in Brazil or the US – you suffer both the virus and a longer economic disruption.

Conclusion - Can you successfully control Covid-19 without a lockdown.  

• YES by nipping in the bud early

• Even if the country fails to nip it early, there is still hope provided it is not so widely spread as shown by South Korea

• But if it is widely spread, like Belarus, Iceland and Sweden, it is still possible to control the virus without a lockdown but I think you need disciplined citizens.  But while you can control it, the cost both in terms of cases and mortality as well as economic may not be attractive

But I think that if the cases have gone into really exponential growth ie very widely spread, I am not sure whether it can be controlled without a lockdown.  

So especially for the US and Brazil where there is no clear cut strategy of lockdown or self-control, I suspect the virus will just run wild.  

I am looking at the US and Brazil with interest as the only hope for them is the vaccine. OR there is a change in leadership.   

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PS: This blog is for me to better understand COVID 19 as this will impact my investments. If you are also into equities, follow me at i4value.asia.

Disclaimer:  I am not an epidemiologist, healthcare worker, pharmacist, or staff in the Ministry of Health, but rather is someone with a strong interest in numerical analysis.  The content is an attempt to understand what is happening in the battle against COVID 19 from a data-based perspective. The opinions expressed here are based on information extracted from readily available public sources but I do not warrant its completeness or accuracy and should not be relied on as such. 

Will opening of the causeway lead to more risks?

Malaysia and Singapore have agreed to implement Reciprocal Green Lane (RGL) and Periodic Commuting Arrangement (PCA) travel, allowing citizens from either side of the Johor Strait to cross the border for work or official purposes, beginning Aug 10.

1) The RGL scheme will enable cross-border travels for essential business and official purposes.

• Eligible travelers will have to abide by prevailing Covid-19 prevention and public health measures including PCR swab tests.

• They will also be expected to submit to the relevant authorities of the receiving country a controlled itinerary and adhere to this during their visit.

• Initially, 400 Malaysians and Singaporeans would be allowed under this scheme

2) For the PCA scheme, it would allow Singapore and Malaysia residents, who hold long-term immigration passes for business and work purposes in the other country, to enter that country for work.

• After at least three consecutive months in their country of work, they may return to their home country for short-term home leave, and thereafter, re-enter their country of work to continue working for at least another three consecutive months.

• These travelers will also have to abide by the prevailing Covid-19 prevention and public health measures.

• Initially, some 2,000 Malaysians and Singaporeans would be allowed under this scheme. 

If the initial phase works, then it would be extended to cover the daily crossing of between 200,000 to 250,000 Malaysians and Singaporeans and the full opening of the borders. 

I think there are 2 questions to be raised

• Are we able to monitor those coming from Singapore under both the above schemes? 

• Will there be additional risks from Singaporeans coming into Malaysia and/or Malaysians coming back into Malaysia?  In other words, is the risk of infection in Singapore worse than in Malaysia?

Monitoring

I don’t know whether you saw the news the day before about the Russian Novgorod cluster

• One student coming back from Russia was found positive during screening at the airport

• His friend on the same flight was screened negative and allowed to go home for self-quarantine

• A few days later this friend fell sick with Covid-19

• The worst part is that he has infected his father and another 

• To date there are 5 cases from this cluster and all those close contacts are under observation

I have earlier voiced my concern about our self-quarantine process and I think this is a good example of what could go wrong.   I don’t think it would be so different for many families who have some self-quarantine member ie they are likely to get into close contact with the quarantined person.

The other interesting news is that our Defence Minister has threatened to take stern action against the 255 people who had self-quarantined but still refused to get their 2nd Covid-19 test. 

It clearly shows that not everyone will follow SOP (and assuming that the SOP are tight enough to prevent the transmission of the virus)

So now we will have these thousands of Malaysians coming back from Singapore regularly.

  

Do you have confidence in all of them following the SOP?

I think the only protection we have is if there is very little chance of getting infected when in Singapore.  To answer this question, we have to look at how the virus has been spreading in Singapore. 

Singapore Covid-19 status

The Covid-19 situation in Singapore can be summarized by the table below that shows the cumulative number of cases as of 13 Jul 2020 (Source: Singapore MOH press release).

13 Jul 2020	Singapore Permanent Residents	Long-term and work pass holders	Visitors	Sub-total
Imported	431	133	52	616
Community	1,290	764	9	2,063   (a)
Dormitories	NA	43,604	NA	43,604
Sub-total	1,721	44,501	61	46,283

Note

(a) Of the 2,063 cases, 1,310 or 63 % are linked cases (ie clusters)

As can be seen, the majority of the cases are due to migrant workers staying in the dormitories. Over the period from April to Jul, the growth in cases can be summarized as

• 48 imported cases equivalent to about 0.5 cases daily

• 1029 local and/or community spread equivalent to about 11 cases daily

• 42,288 cases from those in the dorms

Why are the cases in the dorm still so high?  Yes, it is declining from 

• 723 daily cases from April to May
• 478 daily cases from May to June
• 193 daily cases from June to Jul

But it begs the question that it is more than 3 months since the spike in cases among the migrant works and so whatever index cases would have recovered.  

I take it to mean that the current cases are due to those from the other generations ie the people in the dorm are spreading it amount themselves.

I am curious why they are spreading because we have similar situations in Malaysia with our EMCIO areas eg One City, Selangor Mansion.  

We EMCO these areas and while initially there are increases in the number of cases, within a couple of weeks, the cases from these EMCO areas dropped dramatically.

To be fair, I do not have any picture of what the conditions in the Singapore dorms are like or what Singapore authorities are doing in the dorm.  

But from what I have read, it appears that those in the dorm are isolated from the rest of the community and it does sound like our EMCO. 

If so, how come the number of cases from the dorms is not dropping at a rate like what Malaysia had with our EMCO areas.  

I hope our Singapore readers can fill in the blanks.

Non-dorm cases

Leaving aside this question on why it is taking so long to control it among the dorm residents, the other question is whether there has been any “leakage” ie transmission between those in the dorm and the general public.

I am presuming that there is hardly any spread between the dorm workers and those in the general community as I have not seen such reports.

So the local/community spread is among the non-dorm people. 

If you look at the local/community spread it is 276 cases from 13 Jun to 13 Jul for Singapore. In comparison for the same period, Malaysia had 

• 86 cases (excluding imported ones and foreign workers). 

• 228 cases including foreign workers (but excl imported). Note that there is no detention cluster during this period to skew the figures

I would say that leaving aside the dorms, Singapore actually had 20% more cases and is in a more densely populated area whereas, for Malaysia, our numbers are for the whole country.

If you look at the pattern of the daily number of cases for the past 2 weeks for the 2 countries, you can see that the incidence in Singapore is higher. 

I would conclude that the risk of infection in Singapore is higher than the risk of infection in Johore (where the causeways are located). 

Conclusion: I do expect more cases to be reported in the Johore areas when the border is opened as

• There will not be 100 % SOP compliance

• The risk of infection is still higher in Singapore c/w Malaysia. 

I do hope that the Malaysian MOH is prepared for such contingencies eg having more random sampling on the causeway crossings. 

Appendix

For those interested, the tables below show the breakdown of the cases in Singapore for the past 4 months.

Malaysia has a different reporting format than Singapore so in order to have an apple to apple comparison between Singapore and Malaysia, I think that the dorm cases are equivalent to 5those in our EMCO areas.

I estimated that we have about 1,000 cases from the EMCO areas which comes to about 12% of the total Malaysian cases c/w Singapore dorm cases of 94 %. 

About 60 + % of Singapore community cases are linked cases (ie clusters).  There are about 40 clusters in Malaysia and we have a higher % linked to clusters c/w Singapore.

Singapore’s pace of imported cases from Jun to Jul is much smaller than Malaysia's.  But I think this is related to Malaysia’s policy of allowing students to come home so I wouldn’t read too much into these.  

At this stage, I have not seen reports of the local cases that are due to transmission by imported ones so I don’t know whether the size for such transmission in either Singapore or Malaysia. 

13 Jun 2020	Singapore Permanent Residents	Long-term and work pass holders	Visitors	Sub-total
Imported	411	118	51	580
Community	1,188	591	8	1,787   (a)
Dormitories	NA	37,830	NA	37,830
Sub-total	1,599	38,539	59	40,197

 Note

(a) Of the 1,787 cases,  1,157 or 65 % are linked cases (clusters) 

13 May 2020	Singapore Permanent Residents	Long-term and work pass holders	Visitors	Sub-total
Imported	410	119	51	580
Community	1,093	657         (a)	8	1,758   (b)
Dormitories	NA	23,008	NA	23,008
Sub-total	1,503	23,784	59	25,346

 Note

(a) This included 434 work pass holders residing outside the dorm

(b) Of the 1,758 cases, 1058 or 60 % are linked cases (clusters)

 

13 Apr 2020   (a)	Singapore Permanent Residents	Long-term and work pass holders	Visitors	Sub-total
Imported				568
Community				1,034
Dormitories	NA	1,316	NA	1,316
Sub-total				2,918

Note: This table was re-constructed based on MOH reporting format then

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Be fearless to get more to Stay Safe, Share this Blog

PS: This blog is for me to better understand COVID 19 as this will impact my investments. If you are also into equities, follow me at i4value.asia.

Disclaimer:  I am not an epidemiologist, healthcare worker, pharmacist, or staff in the Ministry of Health, but rather is someone with a strong interest in numerical analysis.  The content is an attempt to understand what is happening in the battle against COVID 19 from a data-based perspective. The opinions expressed here are based on information extracted from readily available public sources but I do not warrant its completeness or accuracy and should not be relied on as such.