The global response: How cities and provinces around the globe tackled Covid-19 outbreaks in 2021

Abstract

Background: Tackling the spread of COVID-19 remains a crucial part of ending the pandemic. Its highly contagious nature and constant evolution coupled with a relative lack of immunity make the virus difficult to control. For this, various strategies have been proposed and adopted including limiting contact, social isolation, vaccination, contact tracing, etc. However, given the heterogeneity in the enforcement of these strategies and constant fluctuations in the strictness levels of these strategies, it becomes challenging to assess the true impact of these strategies in controlling the spread of COVID-19.

Methods: In the present study, we evaluated various transmission control measures that were imposed in 10 global urban cities and provinces in 2021- Bangkok, Gauteng, Ho Chi Minh City, Jakarta, London, Manila City, New Delhi, New York City, Singapore, and Tokyo.

Findings: Based on our analysis, we herein propose the population-level Swiss cheese model for the failures and pitfalls in various strategies that each of these cities and provinces had. Furthermore, whilst all the evaluated cities and provinces took a different personalized approach to managing the pandemic, what remained common was dynamic enforcement and monitoring of breaches of each barrier of protection. The measures taken to reinforce the barriers were adjusted continuously based on the evolving epidemiological situation.

Interpretation: How an individual city or province handled the pandemic profoundly affected and determined how the entire country handled the pandemic since the chain of transmission needs to be broken at the very grassroot level to achieve nationwide control.

Funding: The present study did not receive any external funding.

Keywords: COVID-19; Cities; Delta variant; Global response; Management; Provinces; Swiss Cheese; Testing; Transmission.

Figure 1

Trend graph showing the daily confirmed COVID-19 cases from January 2021 to October 2021 for cities/provinces with major outbreaks (green) and controlled outbreaks (yellow) with the red line indicating 7-day moving average. The peak highest daily number of confirmed cases is highlighted in the graph. (a) Bangkok; (b) Gauteng; (c) Ho Chi Minh City; (d) Jakarta; (e) London; (f) New Delhi; (g) New York City; (h) Tokyo; (i) Manila City and (j) Singapore. Note that the X-axis shows the date in DD.MM.YYYY format whilst the Y-axis shows the number of confirmed daily positive cases.

Figure 2

The Population-level Swiss Cheese Model for COVID-19 transmission. Each cheese slice indicates specific barriers for protection and prevention with holes representing breaches (or failures) in the implementation of the specific barrier - (1) Planning, swiftly acting, and adapting to outbreaks; (2) Rapid enforcement of public health measures (like mask wearing, social distancing); (3) Sufficient testing capacity; (4) Proper isolation of the confirmed patients; (5) Robust identification and isolation measures for close contacts (contact tracing); (6) Cluster identification and mitigation to prevent high co-worker and household transmission rates; (7) Sufficient healthcare resources (like beds, oxygen, respirators); and (8) Vaccination promotion. Some of the barriers are co-enforceable like contact tracing and cluster identification (blue arrow). With widespread breaches in multiple barriers, the risk of viral transmission increases manyfold (black arrow), which allows for easy spread of the virus amongst the community (red arrow); ultimately leading to loss of lives and livelihood.