Non-pharmaceutical interventions for containment, mitigation and suppression of COVID-19 infection

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Abstract

Background:

The best scientific evidence is required to design effective Non-pharmaceutical interventions to help policymakers to contain COVID-19.

Aim:

To describe which Non-pharmaceutical interventions used different countries and a when they use them. It also explores how Non-pharmaceutical interventions impact the number of cases, the mortality, and the capacity of health systems.

Methods:

Result:

Some countries are focused on establishing travel restrictions, isolation of identified cases, and high-risk people. Others have a combination of mandatory quarantine and other drastic social distancing measures. The timing to implement the interventions varied from the first fifteen days after detecting the first case to more than 30 days. The effectiveness of isolated non-pharmaceutical interventions may be limited, but combined interventions have shown to be effective in reducing the transmissibility of the disease, the collapse of health care services, and mortality. When the number of new cases has been controlled, it is necessary to maintain social distancing measures, self-isolation, and contact tracing for several months. The policy decision-making in this time should be aimed to optimize the opportunities of saving lives, reducing the collapse of health services, and minimizing the economic and social impact over the general population, but principally over the most vulnerable. The timing of implementing and lifting interventions could have a substantial effect on those objectives.

Keywords: COVID-19, Coronavirus, Review, Public Health, Quarantine, Health Impact Assessment

Remark

1) Why was this study conducted?

To know what non-pharmaceutical interventions (Non-pharmaceutical interventions) have different countries adopted for containment, mitigation, or suppression of COVID-19 pandemic and at what time they were implemented. To review the evidence on the impact of Non-pharmaceutical interventions on containment, mitigation, or suppression of the pandemic.

2) What were the most relevant results of the study?

Some countries are mainly focused on establishing travel restrictions, isolation of identified cases, and high-risk people. Others have a more intense combination of drastic social distancing measures like mandatory quarantine measures for the entire population and closure of all educational centers. Some of the countries have implemented drastic social distancing measures in the first fifteen days after detecting the first case, other countries have taken more than 30 days. The effectiveness of isolated Non-pharmaceutical interventions may be limited, but combined interventions have shown to have a high impact in reducing the transmissibility of the disease, the collapse of health care services, and mortality. When the number of new cases has been controlled, it is necessary to maintain social distancing measures. Testing, contact tracing, and quarantine of suspected cases could be the main strategies after the relaxation of drastic social distancing Non-pharmaceutical interventions

3) What do these results contribute?

The evidence synthesized might inform the policy decision-making regarding the control of COVID-19 disease.

Introduction

Coronavirus disease 2019 (COVID-19) is a new, rapidly emerging infectious disease, which constitutes a major global health threat ¹ . On January 30th, 2020, the World Health Organization (WHO) declared the outbreak a global health emergency ² , while Colombia did it on March 12th ³ .

The virus SARS-CoV-2 appears to have high transmissibility, the basic reproduction number (R0) range from 2.8 to 5.5, in the absence of full quarantine and social distancing measures, in comparison to the average R0 for seasonal influenza viruses which is about 1.8 ⁴ .

In past experiences, like the 1918-19 H1N1 influenza pandemic, no effective interventions or vaccines were available to treat or prevent the disease; this has taught us that in these circumstances, a variety of non-pharmaceutical interventions (Non-pharmaceutical interventions) are successful at reducing case numbers ⁴ . Non-pharmaceutical interventions include isolating ill persons, contact tracing, quarantine of exposed persons, social distancing, travel restrictions, school, churches and workplace closure, and cancellation of mass gathering events ⁴ ^- ⁹ . Those interventions have shown to be effective ways to respond to the outbreak when implemented early in the epidemic (4-6). Past epidemics have also shown that while the interventions remained in place, mortality is reduced; however, “transmission rebounded once controls are lifted” ⁴ .

Three groups of Non-pharmaceutical interventions strategies have been recognized, 1) containment, 2) mitigation, and 3) suppression ⁶ ^, ⁷ . Containment interventions are those implemented when the first cases are detected in order to interrupt the transmission of the disease, prevent its spread and give time to the healthcare system to make the preparations for attending patients, and waiting for the development of vaccines and effective interventions ⁹ . Mitigation interventions are used when the number of cases increases and the possibility of finding a relationship between cases is complicated, mitigation is not aimed to interrupt transmission completely, but to reduce the health impact of an epidemic over the mortality and the collapse of the health system ⁴ ^, ¹⁰ . And suppression is intended to reduce the average number of secondary cases each case generates ⁴ .

According to the Imperial College, suppression carries enormous social and economic costs, which may themselves have a significant impact on health and well-being in the short and longer-term. Mitigation will never be able to protect those at risk from severe disease or death entirely, and the resulting mortality may, therefore, still be high ⁴ .

In China, three major Non-pharmaceutical interventions have been implemented to control the spread and reduce the outbreak size of COVID-19 ⁹ . First, inter-city travel bans and the establishment of a cordon sanitaire of Wuhan and surrounding cities in Hubei Province ⁹ ^, ¹¹ ^- ¹³ . Second, measures for improving the screening, contact tracing, identification, diagnosis, isolation, and reporting of suspected ill persons and confirmed cases ⁹ ^, ¹⁴ . And third, implementing inner-city travel and contact restrictions, which included limiting individual social contact, using personal hygiene and protective measures, and increasing the physical distance between those who have COVID-19 and those who do not ⁹ ^, ¹⁵ . The Chinese government also encouraged people to stay at home as much as possible, canceled or postponed large public events and mass gatherings, and closed libraries, museums, and workplaces ⁸ ^, ⁹ .

The progressive spread of the disease has allowed many countries to anticipate that a pandemic is approaching ⁹ ^, ¹⁶ . In the case of Colombia, some local governments, as well as the national government, rapidly and drastically implemented a quarantine in all the national territory, as well as other Non-pharmaceutical interventions aimed at the contention, suppression, and mitigation of the COVID-19 disease.

The best available scientific evidence is required to design effective Non-pharmaceutical interventions and disseminate the knowledge urgently to help policymakers assess the potential benefits and costs of Non-pharmaceutical interventions to contain COVID-19 outbreaks. It is essential to describe how different countries implement Non-pharmaceutical interventions, and at what point of the epidemic. It is also necessary to explore how those Non-pharmaceutical interventions have impacted the number of cases, the mortality, and the capacity of health care facilities to deliver healthcare services. There are still crucial knowledge gaps on the effectiveness of different interventions to adequately justify the preparation, implementation, or cancellation of various Non-pharmaceutical interventions, policymakers across the World need evidence as to the combination and timings of each, which remains lacking.

Materials and Methods

A rapid evidence synthesis focused on identifying Non-pharmaceutical interventions implemented in the city of Wuhan and 19 countries (i.e., Argentina, Australia, Brazil, Canada, Chile, China, Colombia, Cuba, Germany, Iran, Italy, Japan, Mexico, Norway, Russia, South Korea, Spain, United Kingdom, and the United States) was carried out. Three criteria were applied to select the countries and territories, 1) a comparatively high number of cases, 2) a political or social particularity that allows the understanding of different types of Non-pharmaceutical interventions or different pace in their implementation; and 3) balance between countries in Europe, Asia, and North, Central, and South America.

Eight web pages of transnational organizations, 17 webpages of international magazines and newspapers, and 99 webpages of governmental institutions in the 19 countries included were searched from January 1^st to March 25^th, 2020. Additionally, the databases Medline and Embase were searched for studies evaluating the effectiveness of Non-pharmaceutical interventions for the containment, suppression, and mitigation of COVID-19 (Appendix 1with the search sources).

Official documents and media articles were used to determine the date when different countries implemented Non-pharmaceutical interventions. The eligibility criteria of academic papers were that the article was focused on exploring the effectiveness and impact of Non-pharmaceutical interventions on the containment, suppression, or mitigation of COVID-19, with no language, neither study design restrictions. Eligible studies included observational studies (cohorts, time series, series report), simulations studies, and health system or political system guidance.

Quality assessment of observational studies was performed with the Johana Briggs criteria for appraisal. In contrast, simulation studies were not formally quality assessed. Still, a judgement was provided according to the completeness of variables to perform the simulation, the strength of the assumptions, and the quality of the description of the statistical procedure. All stages of the review process were performed by one researcher and checked by a second.

Information about the number of new cases and new deaths caused by COVID-19 in the countries and territories chosen was reached from the John Hopkins Center for Systems Science and Engineering after realizing that its dashboard has more updated information than the situation reports of WHO ¹ . The first case reported in each country was documented from official sources or from WHO, with this information, we determined how many days elapsed between the first case reported and the NPI decision taken by the government. The number of days to make the decision was used to develop a timeline of events, a heat map, and a joint figure that represents new cases day by day and the point in which the Non-pharmaceutical interventions were decided. The heat map was developed with R software ¹⁷ .

Results

All countries have implemented several Non-pharmaceutical interventions to control COVID-19 infection. However, there is variability in the amount and type of interventions. In countries like Brazil, Canada, Mexico, and Russia, we identified few interventions, and none of them were among the most drastic measures of social distancing, for example, Mexico has only implemented the closure of schools and colleges ¹⁸ . These countries have focused mainly on avoiding the entry of cases by using travel restrictions and isolating the identified cases and high-risk people.

Another group of countries applied several interventions, including one of the drastic social distancing ones. South Korea, United Kingdom, and the United States, for example, have implemented more drastic social distancing interventions combined with rules of detection, contact tracing, and isolation of cases and contacts. Notably, South Korean is recognized for the rapid implementation of a mass case detection strategy ¹⁹ , while recently in some of the States in the United States have begun the implementation of social distancing measures ²⁰ .

The third group of countries has applied an intense combination of drastic interventions for containment, mitigation, and suppression of infection. Argentina, Chile, China, Colombia, Italy, Spain, all implemented mandatory quarantine for the entire population, after closing schools and universities, canceling all events that concentrated more than 200 people and suspending public transportation for all who do not carry out essential work for infection control. In addition, they have also employed case isolation and contact tracing, borders closings, and some are implementing mass case detection.

Regarding the pace for implementing the strategies, some countries such as Argentina, Chile, and Colombia, which reported the first case in March, implemented interventions in the early fifteen days after the detection of the first case (Table 1 for further details), or even before the notification of the first case, as it is the case of Chile. Argentina, Chile, and Colombia have had the opportunity to anticipate and learn from the policy decision made in other countries, such as China and South Korea, affected as early as December 2019 and January 2020 (Figure 1 that exhibits a heat map of the time to implement the interventions). Countries such as Italy, Spain, and the United States, took more than 30 days to implement drastic measures of social distancing, and they are displaying an extreme situation of the collapse of their health systems. These experiences have served to apprentice countries to making decisions early after the first case is reported (Figure 2 for information about the moment in which some countries have implemented some decisions and the number of new cases they had at that time).

Table 1. Non-pharmaceutical interventions and number of days to implement them after the first case of COVID-19 (as march 28 of 2020).

Countries/first case date	Hubei	China	Japan	Korea	United States	Australia	Canada	Germany	Spain	Italia	Russia	United Kingdom	Iran	Brazil	Norway	México	Chile	Argentina	Colombia	Cuba
Countries/first case date	31/12/19	31/12/2019	15/01/20	20/01/20	21/01/20	26/01/20	27/01/20	27/01/20	31/01/20	31/01/20	1/02/20	1/02/20	20/02/20	26/02/20	27/02/20	29/02/20	3/03/20	3/03/20	6/03/20	13/03/20
Measures
Emergency declaration		23		13	52	53			43			9		25			-24	9	6
Population level social distancing
Quarantine	23	24		62*	59					38		52					18	16	16
Closing schools and universities	23	48	43						41	30			5		14	14	12	12	10	11
Canceling of large events	20					54		43	39	39					14		15	14	6
Suspension of public transportation	23								41	51			35					14
Isolation of cases and contacts
Isolation of travelers from china		20	50	2		34								-18			-41	-26	4
Isolation of travelers from other countries				62		49	58			33	34				15		3	3	4	7
Isolation of high-risk population					46	34	53		38			49			18	16	19	14	12	-45
Isolation of cases or symptomatic people	31				46							40		14	18		-41	8
Travel restrictions
Entry restrictions for foreigners (China)			19	2	10	54	49			30	-1				14	-46	14	9	9
Entry restrictions for foreigners (Others)			61	59	39	54	49	43	39		27			22	16	15	14	12	9
Closure of borders					57	54	51		51		44			26	14		15	13	10	7
International travel restrictions			54	58	58	54		48	39	38	32	46	25		16		15	9
Inter-city travel restrictions	31	31				54			48	38		41	25				17	14	16
Early case detection and contact tracing
Intensive early case detection	20	21	6	6				19			44		5				8	-32		5
Contac tracing	20	21	33	6									10				-41	10

Other Non-pharmaceutical interventions implemented by the countries analyzed include interventions to improve the infrastructure of the health system and strength the human resources capacity (e.g., expand the capacity of beds, enable the use of stadiums and other spaces), strategies aimed at populations at risk (e.g., special measures for the people deprived of liberty), social support interventions (e.g., tax relieves), strategies to support the production of goods and services (e.g., facilitate loans to companies), and strategies for accurate information, timely communication, and support for social distancing (Appendix 2).

Impact of Non-pharmaceutical interventions

In exploring the effectiveness of non-pharmaceutical interventions on containment, suppression, and mitigation of COVID-19 infection, we included nine over 34 studies identified (one policy guidance, one rapid systematic review, two cohort studies, one time series study, and four simulations) ⁴ ^- ⁶ ^, ¹¹ ^- ¹³ ^, ²¹ ^, ²² . Appendix 3 summarizes the findings of these studies.

The effectiveness of any isolated Non-pharmaceutical interventions may be limited, but combined interventions have shown to be effective and have a high impact in reducing the transmissibility of the disease, the collapse of health care services, and mortality. Seven of nine studies included explicitly suggest the early implementation of combined and strict interventions; mainly, quarantine, social distancing, suspension of public transportation, early detection of cases and home isolation of mild cases ⁴ ^, ⁵ ^, ⁹ ^, ¹² ^, ¹³ ^, ²¹ ^, ²² (Table 2).

Table 2. Impact of non-pharmaceutical interventions for the control of COVID-19 infection.

No-Pharmaceutical Intervention	Impact	# of studies addressing the intervention	Type of study
Combination of interventions	High	7	1 policy guidance
			2 cohort studies
			1 rapid systematic review
			1 time series study
			2 simulations
Isolation of cases	High	3	1 policy guidance
Isolation of cases	High	3	2 simulations
Early detection of cases	High	2	1 policy guidance
Early detection of cases	High	2	1 simulation
Contact tracing	High	1	1 simulation
Quarantine of contacts	High	2	1 cohort study
Quarantine of contacts	High	2	1 policy guidance
Suspension of public transportation	High	2	1 rapid systematic review
Suspension of public transportation	High	2	1 cohort study
Canceling of large events	High	2	1 rapid systematic review
Canceling of large events	High	2	1 cross-sectional study
Maintaining social distancing interventions for at least 6 months after the outbreak	High	2	2 simulations
Self-isolation of symptomatic people	Moderately high	2	1 policy guidance
Self-isolation of symptomatic people	Moderately high	2	1 simulation
Isolation of people older than 70 years	Moderate	1	1 simulation
Work at home strategies	Moderate	1	1 policy guidance
Social distancing	Moderately low	3	2 simulations
Social distancing	Moderately low	3	1 rapid systematic review
Inner-city travel restrictions	Moderately low	2	1 policy guidance
Inner-city travel restrictions	Moderately low	2	1 simulation
Inter-city travel restrictions	Moderately low	3	1 policy guidance
			1 cohort study
			1 cross-sectional study
Closure of schools and daycares	Moderately low	2	1 policy guidance
Closure of schools and daycares	Moderately low	2	1 simulation
Quarantine of people traveling from territories affected	Low	1	1 cohort study
Contact reduction	Low	1	1 simulation
Closure of borders	Low	1	1 policy guidance
Procedures for detecting cases in the airports	Low	1	1 policy guidance

Without the implementation of Non-pharmaceutical interventions, one study in China claims that the number of COVID-19 cases would have a 51-fold increase in Wuhan, a 92-fold increase in other Hubei cities, and a 125-fold increase in other provinces ⁹ . Combined Non-pharmaceutical interventions might reduce the maximum demand for medical care and mortality by half or even two thirds ⁴ . A simulation study for the United Kingdom and the United States shows that, in an uncontrolled epidemic, demand for intensive care beds is predicted to exceed as early as the second week of April, with peak demand for care beds of more than 30 times the maximum supply in both countries ⁴ .

After the peak of the disease, and when the number of new cases has been controlled, it is necessary to maintain social distancing measures, control of public transportation, work-at-home strategies, case detection and isolation, and contact tracing. Contact tracing and case isolation are suggested to be highly effective in controlling a new COVID-19 outbreak. However, the probability of control decreases with 1) long delays from onset of symptoms until deciding isolation, 2) few contacts tracked per case, and 3) when the transmission before symptoms increases ²² . In most of the simulation scenarios and from the public health experience of previous epidemics, it is identified that, if the social contact resumes to normal levels, the contagions could increase again. Therefore several Non-pharmaceutical interventions, including social distancing, should be continued for several months, ⁹ it is even proposed that restrictive measures should be maintained until a vaccine is available (potentially 18 months or more) since it is predicted that transmission will recover quickly if interventions are relaxed ⁴ .

When the number of new cases demonstrates the control of the disease, evidence suggests that measures that can be lifted first are border closures, case detection procedures at airports, and the closings of schools and daycares. The evidence also suggests that both the establishment and removal of Non-pharmaceutical interventions depend on several political, social, and cultural factors, not only on the behavior of the disease ⁵ ^, ⁹ ^, ²¹ .

Discussion

Summary of the main findings

We consulted eight web pages of transnational organizations, 17 of international media, 99 of government institutions in the 19 countries included, and besides, we included nine studies (out of 34 identified) that met inclusion criteria. We found that some countries are mainly focused on establishing travel restrictions, isolation of identified cases, and high-risk people. Others have a more intense combination of mandatory quarantine for the entire population, closure of all educational centers, and suspension of public transportation for all those who do not perform essential work. Some of the countries have implemented interventions in the first fifteen days after detecting the first case, while others have taken more than 30 days to implement drastic measures of social distancing. The effectiveness of isolated Non-pharmaceutical interventions may be limited, but combined interventions have shown to be effective and have a high impact in reducing the transmissibility of the disease, the collapse of health care services, and mortality. When the number of new cases has been controlled, it is necessary to maintain social distancing measures, public transportation control, work at home strategies, case detection, self-isolation, and contact tracing for several months.

Comparison with other studies

A modeling study made in Colombia to predict the impact of the COVID-19 pandemic according to mitigation measures that have been implemented in the country resonates with our findings that combined interventions could be effective and have a high impact on reducing the transmissibility of the disease. The study of González-Jaramillo et al. ²³ , concludes that the combination of mitigation strategies taken by the Colombian government could reduce the number of patients that would require intensive care units from 36,782 in the scenario of no intervention to 1,176 in the scenario that combines case isolation, home quarantine, and social distancing of people over 70 years old.

Our finding of the need to maintain social distancing measures, control of public transportation, work-at-home strategies, case detection and isolation, and contact tracing has also been supported in the literature. The model developed by Prem et al., suggests that the sudden lifting of interventions could lead to an earlier secondary peak, which could be prevented by relaxing the interventions gradually ¹⁴ . In this regard, Colburn suggests that testing, contact tracing, and quarantine of suspected cases could be the main strategies after the relaxation of drastic social distancing Non-pharmaceutical interventions to prevent healthcare system overload. Colburn calls for the incorporation of these strategies into models to allow countries to have a better picture of the testing capacity they will need and to decide if such policies could be successful in suppressing COVID-19 spread in a given country ²⁴ .

Non-pharmaceutical interventions also have adverse effects on individuals, communities, and the national economy. A recent rapid review reported that quarantine could have harmful psychological effects such as post-traumatic stress symptoms, confusion, and anger, which can lead to adverse long-term psychological effects ²¹ ^, ²⁵ . Many articles have highlighted the economic implications that quarantine interventions might have over the economy in 2020; however, the goal at this moment is saving as many lives as our resources allowed ⁴ ^, ⁵ ^, ⁸ ^, ⁹ ^, ¹² ^, ¹³ ^, ²¹ ^, ²⁶ .

Limitations of this review

Given the time constraints imposed by the ongoing coronavirus outbreak, we made some critical methodological decisions that need to be considered. The inclusion criteria and the extraction of information of the studies included in this synthesis were applied by one reviewer. In addition, simulation studies were not formally quality assessed.

Conclusion

The policy decision-making in this time should be aimed to optimize the opportunities of saving lives, reducing the collapse of health services, and minimizing the economic and social impact over the general population, but principally over the most vulnerable. The timing of implementing and lifting interventions is likely to have a substantial effect on those objectives.

Acknowledgements

The authors want to thank Ivan Dario Flórez and Gabriel Jaime Otálvaro for their important comments and suggestions. They also thank Cristian David Santa Escobar for his contribution in the graphic representation of the results.

Appendix 1. Search sources.

WHO PAHO. WHO Situation Dashboard. https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd

WHO. 2019 Novel Coronavirus (2019nCoV): Strategic preparedness and response plan. 03 de Febrero. https://www.who.int/docs/default-source/coronaviruse/srp-04022020.pdf

Enfermedad por el Coronavirus ‎‎(COVID-19)‎. https://www.paho.org/es/temas/coronavirus/enfermedad-por-coronavirus-covid-19

UNION EUROPEA

Eurosurvelliance. https://www.eurosurveillance.org/content/eurosurveillance/browse

EU Commision COVID-19 Coronavirus data. https://data.europa.eu/euodp/en/data/dataset/covid-19-coronavirus-data/resource/62eb477f-be00-462a-831a-594095f7306a

Politico. Coronavirus in Europe https://www.politico.eu/coronavirus-in-europe/

ECDC. European Centre for Disease Prevention and Control https://www.ecdc.europa.eu/en

IATA. International Air Transport Association. Government Measures Related to Coronavirus (COVID-19). https://www.iata.org/en/programs/safety/health/diseases/government-measures-related-to-coronavirus/

Johns Hopkins University and Medicine. Coronavirus Resource Center. Interactive maps and news https://coronavirus.jhu.edu/

COVID-19 Expert Reality Check. Johns Hopkins Bloomberg School of Public Health. https://www.globalhealthnow.org/2020-02/coronavirus-expert-reality-check#quammen

Worldometer owned by Dadax. https://www.worldometers.info/coronavirus/

Evidence Aid https://www.evidenceaid.org/coronavirus-resources/

Otros medios de comunicación

Science Magazine. Mass testing, school closings, lockdowns: Countries pick tactics in ‘war’ against coronavirus. By Jon Cohen, Kai KupferschmidtMar. 18, 2020 , 11:30 AM. https://www.sciencemag.org/news/2020/03/mass-testing-school-closings-lockdowns-countries-pick-tactics-war-against-coronavirus

The Economist. The politics of pandemics. All governments will struggle. Some will struggle more than others. https://www.economist.com/leaders/2020/03/12/the-politics-of-pandemics

Prospect Magazine UK. Coronavirus: Why scientists are divided over the effectiveness of the UK’s strategy by Philip Ball / March 16, 2020. https://www.prospectmagazine.co.uk/science-and-technology/coronavirus-uk-herd-immunity-boris-johnson-government-plan-cure

StateNews. Understanding what works: How some countries are beating back the coronavirus by Helen Branswell March 20, 2020. https://www.statnews.com/2020/03/20/understanding-what-works-how-some-countries-are-beating-back-the-coronavirus/

The NY Times. The Coronavirus Outbreake https://www.nytimes.com/news-event/coronavirus?action=click&pgtype=Article&state=default&module=STYLN_coronahub&variant=show&region=header&context=menu

Wikipedia . Resumen de decisiones de los gobiernos. https://en.wikipedia.org/wiki/National_responses_to_the_2019%E2%80%9320_coronavirus_pandemic

International restrictions. https://en.wikipedia.org/wiki/Travel_restrictions_related_to_the_2019%E2%80%9320_coronavirus_pandemic

BBC News. Coronavirus pandemic. https://www.bbc.com/news/explainers

The Guardian. Coronavirus Outbreak. https://www.theguardian.com/world/coronavirus-outbreak

The Washington Post. Coronavirus news and maps. https://www.washingtonpost.com/world/2020/03/27/coronavirus-latest-news/

Aljazeera. Coronavirus Pandemic News. https://www.aljazeera.com/topics/events/coronavirus-outbreak.html

El Espectador. Coronavirus hoy: ¿Qué están haciendo otros países de América Latina para contener la pandemia?. https://www.elespectador.com/noticias/el-mundo/coronavirus-hoy-que-estan-haciendo-otros-paises-de-america-latina-para-contener-la-pandemia-articulo-910367

¿Qué está haciendo cada país de América Latina para frenar el nuevo coronavirus?. https://rpp.pe/mundo/actualidad/coronavirus-covid-19-que-esta-haciendo-cada-pais-de-america-latina-para-frenar-el-nuevo-coronavirus-noticia-1252868

Semana. Semana Tendencias Coronavirus. https://www.semana.com/noticias/coronavirus/126948

El Colombiano. Coronavirus en Colombia contra el miedo. https://www.elcolombiano.com/coronavirus-en-colombia-contra-el-miedo

Europapres. Agencia Europa Press https://www.europapress.es/

RFI. Noticias Coronavirus http://www.rfi.fr/es/tag/coronavirus/

CNN Noticias Coronavirus CNN https://cnnespanol.cnn.com/category/coronavirus.

Note: The following official sources and other media were consulted between March 16 and March 27 to identify the actions and strategies defined by the countries.

ALEMANIA

Fuentes Oficiales

Federal Ministry of Health. https://www.bundesgesundheitsministerium.de/en/press/2020/coronavirus.html#c17182

Robert Koch Institute. https://www.rki.de/EN/Home/homepage_node.html

The Federal Government. Together against Corona. https://www.zusammengegencorona.de/

Chancellor and Federal Government. https://www.bundesregierung.de/breg-en/search/998964!search

Otros medios de comunicación

Deutsche Welle. Coronavirus. https://www.dw.com/en/top-stories/coronavirus/s-32798

Coronavirus en Alemania: últimas noticias. https://www.deutschland.de/es/news/coronavirus-en-alemania-actualizaciones

Noticias Bundesliga. https://www.bundesliga.com/es/bundesliga/noticias/noticias-informacion-actualidad-liga-alemana-3034-2316

Pressemitteilungen. https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/krisenstab-bmg-bmi-sitzung-5.html

Bundesministeriums für Verkehr und digitale Infrastruktur. https://www.bmvi.de/DE/Ministerium/Minister-Staatssekretaere/minister-staatssektretaere.html

Coronavirus: Jens Spahn trifft Gesundheitsminister der Länder. https://www.youtube.com/watch?v=nm5l-uxSeeM&feature=youtu.be

Statement von Jens Spahn bei Pressekonferenz vom 19.03.2020. https://www.youtube.com/watch?v=9dQKFImYaY0&feature=youtu.be

ARGENTINA

Fuentes Oficiales

Ministerio de Salud. Coronavirus. https://www.argentina.gob.ar/salud/coronavirus-COVID-19

Gobierno Nacional. Resumen de medidas. https://www.argentina.gob.ar/coronavirus/medidas-gobierno

Otros medios de comunicación

El Clarin. Coronavirus en Argentina: piden donaciones para ayudar a los que menos tienen. https://www.clarin.com/sociedad/coronavirus-argentina-piden-donaciones-ayudar_0_9O4v1s5nJ.html

Infoabae. Argentina solo recibió ayuda de China para enfrentar la pandemia del coronavirus. https://www.infobae.com/politica/2020/03/22/la-argentina-solo-recibio-ayuda-sanitaria-de-china-para-enfrentar-la-pandemia-del-coronavirus/

RSE Presente. En épocas de coronavirus una ONG contagia solidaridad. https://presenterse.com/en-epocas-de-coronavirus-una-ong-que-contagia-solidaridad/

AUSTRALIA

Fuentes Oficiales

Coronavirus: COVID-19: Western Australian Government response. https://www.wa.gov.au/organisation/department-of-the-premier-and-cabinet/coronavirus-covid-19-western-australian-government-response

Safe Work Australia. https://www.safeworkaustralia.gov.au/doc/coronavirus-covid-19-advice-employers

COVID-19 (Coronavirus) and the Australian border. https://www.homeaffairs.gov.au/news-media/current-alerts/novel-coronavirus

COVID-19 Coronavirus Information for Public Sector Employers. https://www.commerce.wa.gov.au/labour-relations/covid-19-coronavirus-information-public-sector-employers

Departamento de salud Gobierno de Australia. https://www.health.gov.au/news

Health information for western Australia. https://www.healthywa.wa.gov.au/Articles/A_E/COVID-clinics

Conferencia de prensa primer ministro de Australia. https://www.pm.gov.au/media/transcript-press-conference

Actualización medidas primer ministro. https://www.pm.gov.au/media/update-coronavirus-measures

Circular 5/2020 - Licencia COVID-19 y otras flexibilidades laborales. https://www.commerce.wa.gov.au/sites/default/files/atoms/files/pslr_circular_04_2020.pdf

BRASIL

Fuentes Oficiales

Agencia Nacional de Vigilancia Sanitaria. http://portal.anvisa.gov.br/

Ministerio de salud. https://www.saude.gov.br/noticias

Otros medios de comunicación

Infoabae. Brasil cerró sus fronteras a europeos y asiáticos por el coronavirus. https://www.infobae.com/america/america-latina/2020/03/20/brasil-cerro-sus-fronteras-a-europeos-y-asiaticos-por-el-coronavirus/

CANADÁ

Fuentes Oficiales

Public Health Agency of Canada. https://www.canada.ca/en/public-health/services/diseases/coronavirus-disease-covid-19.html

Página oficial Primer ministro. https://pm.gc.ca/

Página oficial- Gobierno de Canadá. https://www.canada.ca/

CHINA Y HUBEI

Fuentes Oficiales

Chinese Center for Disease Control and Prevention. http://www.chinacdc.cn/en/COVID19/

National Health Commission of the People's Republic of China. http://en.nhc.gov.cn/antivirusfight.html

CHILE

Fuentes Oficiales

Plan de Acción Coronavirus. https://www.gob.cl/coronavirus/

Ministerio de Salud. Seguimiento de casos. https://www.minsal.cl/nuevo-coronavirus-2019-ncov/casos-confirmados-en-chile-covid-19/

Ministerio de Relaciones Internacionales. Medidas. https://chile.gob.cl/chile/medidas-de-prevencion-ante-el-nuevo-coronavirus

Servicio Informativo del Instituto de Previsión Social. Ministerio del Trabajo. https://www.chileatiende.gob.cl/coronavirus

Fuentes Oficiales

Ministerio de Salud y Protección Social. Coronavirus. https://d2jsqrio60m94k.cloudfront.net/

Ministerio de salud. https://www.minsalud.gov.co/

Instituto Nacional de Salud. https://www.ins.gov.co/Noticias/Paginas/Coronavirus.aspx

Presidencia de la República. https://id.presidencia.gov.co

Ministerio de Transporte. https://www.mintransporte.gov.co

Aeronáutica Civil de Colombia. http://www.aerocivil.gov.co/

COREA DEL SUR

Korean Centers for Disease Control and Prevention. http://www.cdc.go.kr/board.es?mid=a30402000000&bid=0030

CUBA

Fuentes Oficiales

Presidencia de Cuba. Noticias y medidas. https://www.presidencia.gob.cu/es/noticias/

Ministerio de Comercio. Medidas coronavirus. https://www.mincin.gob.cu/content/medidas-de-protecci%C3%B3n-tomadas-en-el-sector-del-comercio-para-prevenir-cualquier-contagio-0

Ministerio Relaciones Internacionales. Medidas coronavirus. http://misiones.minrex.gob.cu/es/coronavirus

Ministerio de Salud Pública de la República de Cuba. https://salud.msp.gob.cu/

Otros medios de comunicación

Cibercuba. Mapa del Coronavirus en Cuba. https://www.cibercuba.com/tags/coronavirus-cuba

Infomed, Portal de la Red de Salud de Cuba. http://www.sld.cu/

ESPAÑA

Fuentes Oficiales

Alertas en Salud Pública de actualidad. MinSalud España. https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov-China/home.htm

Instituto de Salud Carlos III. Situación de COVID-19 en España. https://covid19.isciii.es/

Portal de La Moncloa. https://www.lamoncloa.gob.es/Paginas/buscadoravanzado.aspx

Instituto de Mayores y Servicios Sociales. https://www.imserso.es/imserso_02/actualidad/2020/marzo/IM_130154

Ministerio del Interior no a Penitenciarias. www.interior.gob.es

Otros medios de comunicación

Lista de Medidas del gobierno de El Diario. https://www.eldiario.es

ESTADOS UNIDOS

Fuentes Oficiales

Centers for Disease Control and Prevention. https://www.cdc.gov/

Página oficial del coronavirus de CDC. https://www.coronavirus.gov

White house. https://www.whitehouse.gov/

Departamento de Estado. https://travel.state.gov/

Departamento de defensa. https://www.defense.gov/

Asociación de médicos de los Estados Unidos. https://www.ama-assn.org

Gobierno de los Estados Unidos. https://www.usa.gov/

ITALIA

Fuentes Oficiales

Ministero della Salute. Nuovo coronavirus. http://www.salute.gov.it/nuovocoronavirus

Ministero della Salute. Situazione in Italia. http://www.salute.gov.it/portale/nuovocoronavirus/dettaglioContenutiNuovoCoronavirus.jsp?lingua=italiano&id=5351&area=nuovoCoronavirus&menu=vuoto

Protezione Civile. Emergenza Coronavirus. http://www.protezionecivile.gov.it/

Instituto Superiore di Sanitá. http://www.iss.it/coronavirus

Trova norme salute. http://www.trovanorme.salute.gov.it/norme/dettaglioAtto?id=73532

Guida per prevenire e affrontare lo stigma sociale. http://www.salute.gov.it/imgs/C_17_notizie_4149_0_file.pdf

Aeroporti di Roma. http://www.adr.it/it/web/guest/coronavirus

Governo Italiano Presidenza del Consiglio dei Ministri. http://www.governo.it/it/articolo/comunicato-stampa-del-consiglio-dei-ministri-n-33/14204

L'epidemiologia per la sanità pubblica Istituto Superiore di Sanità. https://www.epicentro.iss.it/

IRÁN

Fuentes Oficiales

Ministry of Health and Medical Education. News. http://irangov.ir/cat/509

Ayatollah Khamenei. Official website. http://english.khamenei.ir/

Otros medios de comunicación

Islamic Republic News Agency. https://en.irna.ir/ y https://es.irna.ir/

Iran Daily. http://www.iran-daily.com/

JAPÓN

Fuentes Oficiales

Ministry of Health, Labour and Welfare. About coronavirus Disease 2019. https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/newpage_00032.html

Prime Minister of Japan and His Cabinet. Basic responses to COVID2019. http://japan.kantei.go.jp/ongoingtopics/coronavirus_info_e.html

MÉXICO

Fuentes Oficiales

Gobierno de México. Comunicados y decisiones. https://coronavirus.gob.mx/noticias/

Dirección General de Epidemiología. Mapa de casos. http://ncov.sinave.gob.mx/mapa.aspx

Sistema de Información de la Secretaría de Salud. http://sinaiscap.salud.gob.mx:8080/DGIS/

Instituto Mexicano del Seguro Social. http://www.imss.gob.mx/

Otros medios de comunicación

Diario AS México. Covid-19. https://mexico.as.com/tikitakas/tag/covid_19/a/

NORUEGA

Fuentes Oficiales

Norwegian Institute of Public Health. https://www.fhi.no/en/id/infectious-diseases/coronavirus/

Ministry of Health and Care Services. https://www.regjeringen.no/en/dep/hod/id421/

REINO UNIDO

Fuentes Oficiales

Government UK. Coronavirus. https://www.gov.uk/coronavirus

Coronavirus (COVID-19): UK government response. https://www.gov.uk/government/topical-events/coronavirus-covid-19-uk-government-response

The Health Protection (Coronavirus) Regulations 2020. http://www.legislation.gov.uk/uksi/2020/129/contents/made

Public Health England. https://www.gov.uk/government/organisations/public-health-england

Departamento de salud pública Inglaterra. https://www.gov.uk/government/organisations/department-of-health-and-social-care

Oficina del primer ministro. https://www.gov.uk/government/organisations/prime-ministers-office-10-downing-street

Ministerio de comunidades y gobierno local. https://www.gov.uk/government/organisations/ministry-of-housing-communities-and-local-government

Departamento de trabajo y pensiones. https://www.gov.uk/government/organisations/department-for-work-pensions

Departamento de negocios, energía e industria. https://www.gov.uk/government/organisations/department-for-business-energy-and-industrial-strategy

http://www.legislation.gov.uk/ukpga/1984/22

Foreign Travel Advice. https://www.gov.uk/foreign-travel-advice

Foreign & Commonwealth Office. https://www.gov.uk/government/organisations/foreign-commonwealth-office

Noticias gobierno de UK. https://www.gov.uk/government/news/

Statutory Sick Pay. Pago estatutario de enfermedad. https://www.gov.uk/statutory-sick-pay

Portal de noticias NHS. https://www.england.nhs.uk/2020/03/nhs-111-online-to-help-people-with-coronavirus/

Appendix 2.

Appendix 2. Non-pharmaceutical interventions and number of days in which they were implemented (as March 28, 2020).

Country/First case date	Hubei	China	Japan	South Korea	United States	Australia	Canada	Germany	Spain	Itally	Russia	United Kingdom	Iran	Brazil	Norway	Mexico	Chile	Argentina	Colombia	Cuba
Country/First case date	31/12/2019	31/12/2019	15/01/2020	20/01/2020	21/01/2020	26/01/2020	27/01/2020	27/01/2020	31/01/2020	31/01/2020	1/02/2020	1/02/2020	20/02/2020	26/02/2020	27/02/2020	29/02/2020	3/03/2020	3/03/2020	6/03/2020	13/03/2020
Strategies
Declaration of emergency		23		13	52	53			43			9		25			-24	9	6
Social distancing at population level
Mandatory quarantine throughout the territory (or part of it)	23	24		62	59					38		52					18	16	16
Suspension of face-to-face classes in kindergartens, schools or universities	23	48	43						41	30			5		14	14	12	12	10	11
Closure of cinemas, restaurants, and other social-meeting places	23							55		37		48			14		17	14	12
Closure of public parks (museums included)	20								41	49			5		14		14	12
Suspension of gatherings	20					54		43	39	39					14		15	14	6
Suspension of non-essential activities																	14	14
Prohibition of mobility in public or private means of transport	23								41	51			35					14
Social distancing of cases or contacts
Isolation for 14 days because of attending places with high influx of people																			4
Isolation because of coming from China		20	50	2		34								-18			-41	-26	4
Isolation because of coming from another country				62		49	58			33	34				15		3	3	4	7
Isolation because of living with a possible positive case														14			-41	14
Isolation because of being a person at high risk of contracting the virus					46	34	53		38			49			18	16	19	14	12	-45
Isolation because of presenting symptoms or being a positive case	31				46							40		14	18		-41	8
Travel restrictions
Entry restrictions for foreigners (China)			19	2	10	54	49			30	-1				14	-46	14	9	9
Entry restrictions for foreigners (other countries)			61	59	39	54	49	43	39		27			22	16	15	14	12	9
Border closure for non-essential Traffic					57	54	51		51		44			26	14		15	13	10	7
Restrictions on international travels			54	58	58	54		48	39	38	32	46	25		16		15	9
Restrictions on domestic air travel	31	31				54			48	38		41	25				17	14	16
Restrictions on cruise ships			36			54			41			40					12	12	6
Case tracking and detection
Intensive case search (in port of entry and in all territorial entities/provinces)	20	21	6	6				19			44		5				8	-32		5
Contact tracking	20	21	33	6									10				-41	10
Use of technology to detect cases, track contacts, and notify (e.g., thermometers, drive-through, apps)	14	14		6				43			47	34					-41	15
Labs or additional capabilities	27	34	21		56	44					44	6		5		18	-4	15
Infrastructure of the health and human resource system
Expanding the capacity of beds	34	34								46	41			19		-1	4	15		6
Enabling the use of stadiums and other spaces	34	34								46	44						4	14	16
Increasing supplies (masks, ventilators)					56		51		40	46	32			2	16		-24	7		1
Investment in vaccines and research			28				39		46		46	34						15		6
Increasing care staff (volunteers, students, retirees, foreigners, humanitarian aid)								46	44	46		47		19		-2	-24
Training for doctors										22	44
Incentives (monetary) for care staff								52			47								17
Strategies for population at risk
Special conditions for over 70 years old people or children			41			45			38	36							12	12	12
Special measures for population deprived of liberty									41								18		18
Raising isolation measures for cases of domestic violence										40									17
Limiting access to care facilities or hospitals for the elderly						54				49	46		10		18		12
Social support
Direct support with financial resources (bonds or other measures)					50	53	51		41	32		48					15	14	18
Tax or credit relief					50		51		41	46	48	48					15	14	12	11
Food support or other supplies for vulnerable people							51		45	51		48					15	14	12
Labor or tenant protection measures (in order to avoid layoffs and evictions)						42			46			46			18		15	17
Improving payment conditions due to sickness or disability						50			41			32			18			3
Coordination of donations										49								15
ONG participation										41								-347
Interventions to endorse goods and services production
Direct support with financial resources for companies			55		63	53	51		46			40			18		15	21
Tax and credit reliefs and facilitating loans to companies			55		50	53	51			46	47	48			18		15	21
Economic plans			55				51	56		46	48				18		15	21
Food and drug supply plans									40		45						15	14
Regulation of medicine retail price									41									21
Information, communication, and endorsement to social distancing
Mobile apps with information												30				6	16	20	4	-15
Daily media reports				6				53		49		43					-24	-32	6
Educational campaigns		21		42		48			44	30		32	14				-24	-32
Publiccation of plans, decrees, recommendations on specific							53	43	38	28							-41	-32		-7
National increase in internet speed for all users																	17
Enabling free call lines for nationals abroad													5				14	10
Promoting remote working or telemedine					55	42			38								15	13	8

Appendix 3.

Appendix 3. Key findings of studies that addressed the impact of non-pharmaceutical interventions.

Non-pharmacological interventions	Impact	Findings
Combination of measures	High	Two modeling studies (SIR) of COVID-19 infection stablished that strict prevention and early control measures, such as quarantine, social distancing or detention of public transportation service, reduce the infection’s contact rate and efficiency, and therefore, are the key on the outbreak. (11)
		Non-pharmacological measures such as restriction of travels between cities, social distancing and contact reduction, as well as early detection and isolation, have made a substantial reduction of the COVID-19’s transmission in Chine. It is estimated that early detection and isolation of the positive cases prevent more infection than restriction in traveling and contact reduction (5 5 versus 2.6 times), but non-pharmacological measures all integrates made the strongest and fastest effect. (12)
		Without the implementation of non-pharmacological measures, case numbers of COVID-19 would have increased rapidly in China, 51 times in Wuhan, 92 times in other cities from Hubei and 125 times in other provinces. (12)
		Implementation times of intervention are also critical. Case’s numbers can be drastically reduced in 66%, 86% and 95%, respectively, if NPI could be driven in a week, two week and three weeks before the real time in which they were implemented on the whole country. Also, geographic range of affected areas can be reduced from 308 to 192, 130 and 61 cities, respectively. (12)
		On most scenarios, tracking of contacts is highly effective and the isolation of positive cases it’s enough to control new outbreaks for COVID-19 in three months. Control probability decreases with long delays from the beginning of symptoms to isolation, can determined less cases from contact tracking and increases the transmission before symptoms. (13)
		The effectiveness of any isolated intervention can be limited, which requires combination of multiple interventions to have a substantial impact on transmission. (10)
		Optimal mitigation policies (which combine home isolation of suspicious cases, home quarantine of the people who live in the same place as the suspicious case and social distancing of elderly and people at higher risk of severe illness) may reduce the maximum demand of medical care and mortality between 2/3 and a half However, resulting mitigated pandemic probably would lead to hundreds of thousands of deaths and collapsed health services. (10)
		In total, on a non-mitigated pandemic, we can predict approximately 510.000 deaths in UK and 2.2 million in USA, without taking into account the possible negative effects of a collapsed health system. (10)
		For a non-controlled epidemic, we can predict that the demand of ICU beds will be exceeded from the second week of April, with a peak in demand 30 times higher than de maximum offer in both countries. (10)
		Cities that implement any combination of control measures preventively, before any case of COVID-19, informed 33.3% (IC 95%: 11.1-44.4%) less cases confirmed by laboratory during the first week of (13.0, IC 95%: 7.1-18.8, n = 125), compared with cities who started control measures later (20.6 cases, IC 95%: 14.5-26.8, n = 171; difference between groups, U = 8197 z = -3.4, P <0.01). (14)
		Inside the specific control measures, cities who suspended public transportation within the city and/or closed entertaining places and forbidden public reunions, and made it before, informed less cases during the first week of outbreak. (14)
Case isolation	High	It is estimated that early detection and isolation of cases prevent more infection tan traveling restriction and contact reduction (5 vs 2.6 times), but non-pharmacological measurements all together have a stronger and faster impact. (12)
Early detection of cases	High	It is estimated that early detection and isolation of cases prevent more infection tan traveling restriction and contact reduction (5 vs 2.6 times), but non-pharmacological measurements all together have a stronger and faster impact. (12)
Contact tracking	High	On most scenarios, tracking of contacts is highly effective and the isolation of positive cases is enough to control new outbreaks for COVID-19 in three months. Control probability decreases with long delays from the beginning of symptoms to isolation, can determined less cases from contact tracking and increases the transmission before symptoms. (13)
Quarantine of contacts	High	Four cohort studies and 15 modeling studies of SARS (Severe acute respiratory syndrome) and MERS (Middle east respiratory syndrome) confirmed the effectiveness of quarantine on individuals that have had close contact with confirmed cases. (11)
		Only three studies considered the effectiveness of quarantine on hypothetical examples that also modeled the pre-symptomatic infectiousness. The studies are consistent on identifying that quarantine effectiveness depends on a critical way from the biological dynamics of the infectious disease (for example, latent periods and infectious periods) and transmissibility. When the transmissibility is relatively low (basic reproductive number <2.5), the quarantine may control a disease, even when the infectiousness precedes the symptoms for several days. When transmissibility is high and symptoms come many days after infectiousness, quarantine may be enough. (11)
		The related evidence with flu pandemics indicates that quarantine of exposed people may delay the peak on local epidemics during the first stages of it, which helps reducing the disease load and also delays the propagation. ECDC
		A 14 days quarantine is considered enough to control contact cases of COVID-19, quick identification of cases increases the effectiveness of quarantine measurement. (15)
Public transportation suspension	High	In Wuhan, if they haven’t stablished any traveling restriction on January 23th, cases may have been increased in 118 % (91% -172%), which leads to 13,857 more cases (10,920-20,574), if the prohibition haven’t been decreed three days before, it may have reduced cases in 47% (26% -58%), which involves 3,103 less cases (1,732-3,820), cases would have been reduced on a 83% (78% -89%) if this measure would have been taken a week before. (16)
Cancelling public meetings	High	Data from seasonal influenza models and pandemic influenza models indicates that, during mitigation stage, cancelling public massive meetings before the epidemic peak may reduce virus transmission. (15)
Cancelling public meetings	High	A systematic review from 24 studies found Little but consistent evidence on the fact that influenza transmission occurs among pilgrims on main religious events. Main sports events such as Olympic Games and World Football Cup, detected a marginal increase on incidence of all the infectious diseases, including the flu, with infections limited to competitors and the staff, instead of the crowds or the general community. (17)
Maintenance of social distancing measures, (at least six months after outbreak)	High	If the contact with the population resume to normal levels observed on previous years, the suspension on traveling restriction may produce an increasing on the epidemic. Thus, the social distancing may continue during several months. (12)
	High	The main challenge in the suppression is that the package of intensive intervention, or something equivalent, effective to reduce the transmission, may be maintained until a vaccine is available (potentially 18 months or so), because it has been predicted that transmission may recover fast if we relax the measures. (10)
Self-isolation of symptomatic patients	Moderate-High	Self-isolation of individuals with respiratory infection symptoms in one of the most important measures to reduce transmission of diseases and limit the spread of virus on the community during an epidemic. (15)
Social distancing of people older than 70 years	Moderate	Studies have always considered the contact reduction along with other non-pharmacological measures, (12)
Working areas measurements	Moderate	Measures on workplaces (flexible work schedules/shifts for employees, telecommuting, physical distancing) are recommended on people with acute respiratory diseases. (15)
Social distancing	Low- Moderate	Studies have always considered social distancing along with other non-pharmacological measurements. (10-12)
Restriction of travels between cities	Low- Moderate	Warnings to not travel during epidemics have the goal of reducing the number of infected people during the trip to areas or countries where community transmission is in progress: reducing import risk from affected countries and reducing the transmission among travelers (for example, the line son airport and on airplanes) (15)
Restriction of domestic flights	Low- Moderate	General restrictions of domestic travels can have a small positive impact on delaying an epidemic, only if they are implemented on early stages. Such restrictions may be considered only during contention stage of a high severity epidemic. (15)
		While we couldn’t contain a higher propagation f COVID-19, attributed measures to Hubei blocking helped reduced the infection speed and reduce the correlation of national air traffic with COVID-19 cases within China, while interpreting changes observed in time of duplication, may be considered all measures imposed at Wuhan. Data cannot make difference between which strict measures succeeded the most, because the analysis only evaluated the effectiveness of the whole measures. All measures were partially successful and have resulted on delayed propagation of COVID-19 in China. (18)
		Travel ban from Wuhan delayed the arrival time of COVID-19 to other cities in an average of 2.91 days (IC 95%: 2.54-3.29 days). More than 130 cities, covering more than half of China's geographic area and population, benefited from the delay. This delay provided additional time to prepare for the arrival of COVID-19 in China but would not have stopped transmission after the infection was exported to new locations from Wuhan. (14)
Closing day-cares and schools (low impact)	Low- Moderate	Proactive school and daycare closing may be associated with significate cost to society and economy. During contention stage, school closing is not justified. There is no data that back up decision making on proactive school closing in terms of anticipated effectiveness to mitigate COVID-19 epidemic, due to de unknown transmission level of this virus on children. (15)
Quarentine of travelers from affectes areas	Low	Infection and death numbers avoided with quarantine of travelers from countries with declared outbreaks is substantially lower than quarantine of suspicions or contact cases. (11)
Quarentine of travelers from affectes areas	Low	A retrospective cohort study and three modeling studies addressed the effectiveness of quarantine to reduce the transmission from individuals who travelled from high transmission rate areas One of the studies considered evidence of SAR outbreak on 2003 in Taiwan. Results of model show that in the hypothetical scenario where no one would have been quarantined after arriving from a high transmission rate region, there would be 511 additional SARS cases and 70 additional deaths. On data bases, they could track 17 imported cases not quarantined (lost cases and cases before the quarantine implementation). If these 17 imported cases would have been quarantined, 280 SARS cases and 48 deaths may have been avoided. Of the more than 95,000 people in quarantine, only two developed SARS. If these two individuals would have not been quarantined, it may have produced 29 additional cases and 5 deaths. (11)
Contact reduction	Low	LStudies always considered the reduction of contact along with other non-pharmacological (12)
Border closure	Low	According to evidence from modeling studies, mainly related with influenza pandemic, border closure may delay the introduction of virus to a country only if they are full and quickly implemented during early stages, which is only plausible on specific contexts (for example, on small nations, isolated and islands). Therefore, available evidence does not back up the border closure measure that may cause important secondary effects social and economic disorders. (15)
Airport case detection procedures	Low	Even though some imported cases of COVID-19 have been detected through airport detection procedures, available evidence from all the reviewed publications and the unpublished modeled work made on the ECDC suggests that border control measures are not effective to delay or mitigate a pandemic. This due to the low sensibility of used systems to detect infections lowly symptomatic and its inability to detect cases during incubation stage. (15)

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Colomb Med (Cali). 2020 Jun 30;51(2):e4266. [Article in Spanish]

Contribución del estudio

1) ¿Por qué se realizó este estudio?

Para saber qué intervenciones no farmacológicas (INFs) han adoptado diferentes países para la contención, mitigación o supresión de la pandemia de COVID-19 y en qué momento se implementaron. Para revisar la evidencia sobre el impacto de las intervenciones no farmacológicas en la contención, mitigación o supresión de la pandemia.

2) ¿Cuáles fueron los resultados más relevantes del estudio?

Algunos países se centran en establecer restricciones de viaje, aislamiento de casos identificados y personas de alto riesgo. Otros tienen una combinación más intensa de medidas drásticas de distanciamiento social, como medidas de confinamiento obligatorias para toda la población y cierre de todos los centros educativos. Algunos de los países han implementado medidas drásticas de distanciamiento social en los primeros quince días después de la detección del primer caso, otros países han tardado más de 30 días. La efectividad de intervenciones no farmacológicas aisladas puede ser limitada, pero la combinación de intervenciones ha demostrado tener un alto impacto en la reducción de la transmisibilidad de la enfermedad, el colapso de los servicios de atención médica y la mortalidad. Cuando se ha controlado el número de casos nuevos, es necesario mantener medidas de distanciamiento social. La realización de pruebas, el rastreo de contactos y la cuarentena de los casos sospechosos podrían ser las principales estrategias para realizar después de que se hayan relajado las intervenciones no farmacológicas de distanciamiento social drástico.

3) ¿Qué aportan estos resultados?

La evidencia sintetizada podría informar la toma de decisiones políticas con respecto al control de la enfermedad COVID-19.

Introducción

La enfermedad por coronavirus 2019 (COVID-19) es una nueva enfermedad infecciosa que emergió rápidamente y que constituye una importante amenaza para la salud global ¹. El 30 de enero de 2020, la Organización Mundial de la Salud (OMS) declaró el brote como una emergencia de salud global ², mientras que Colombia lo hizo el 12 de marzo ³.

El virus SARS-CoV-2 parece tener una alta transmisibilidad, en ausencia de cuarentena completa y medidas de distanciamiento social el número de reproducción básica (R0) varía de 2.8 a 5.5, en comparación con el R0 promedio para los virus de influenza estacional que es en promedio 1,8 ⁴.

En experiencias pasadas, como en la pandemia de influenza H1N1 de 1918-19, no se tenía disponibilidad de intervenciones efectivas o vacunas para tratar o prevenir la enfermedad; Esto nos enseñó que, bajo estas circunstancias, una variedad de intervenciones no farmacológicas (INFs) tienen éxito en la reducción del número de casos ⁴. Las INFs incluyen el aislamiento de personas enfermas, el rastreo de contactos, la cuarentena de personas expuestas, el distanciamiento social, las restricciones de viaje, el cierre de escuelas, iglesias y lugares de trabajo, y la cancelación de eventos de reunión masivos ⁴^-⁹. Estas intervenciones han demostrado ser formas efectivas de responder al brote cuando se implementan temprano en la epidemia ⁴^-⁶. Las epidemias pasadas también han demostrado que, si las intervenciones se mantienen, la mortalidad se reduce; sin embargo, "la transmisión se recupera una vez que se levantan los controles" ⁴.

Se han reconocido tres grupos de estrategias de intervención no farmacológicas, 1) contención, 2) mitigación y 3) supresión ⁶^,⁷. Las intervenciones de contención son aquellas implementadas cuando se detectan los primeros casos con el fin de interrumpir la transmisión de la enfermedad, prevenir su propagación y dar tiempo al sistema de salud para hacer los preparativos para atender a los pacientes y esperar el desarrollo de vacunas e intervenciones efectivas ⁹. Las intervenciones de mitigación se utilizan cuando aumenta el número de casos y la posibilidad de encontrar una relación entre los casos es complicada, la mitigación no tiene como objetivo interrumpir la transmisión por completo, sino reducir el impacto en la salud de una epidemia sobre la mortalidad y el colapso del sistema de salud. ⁴^,¹⁰. Y la supresión tiene la intención de reducir el número promedio de casos secundarios que cada caso genera ⁴.

Según el Imperial College, la supresión conlleva enormes costos sociales y económicos, que pueden tener por si mismos un impacto significativo en la salud y el bienestar a corto y largo plazo. La mitigación nunca podrá proteger por completo a las personas en riesgo de enfermedad grave o muerte y, por lo tanto, la mortalidad resultante puede seguir siendo alta ⁴.

En China, se han implementado tres importantes intervenciones no farmacológicas para controlar la propagación y reducir el tamaño del brote de COVID-19 ⁹. Primero, las prohibiciones de viajes entre ciudades y el establecimiento de un cordón sanitario en Wuhan y las ciudades circundantes de la provincia de Hubei ⁹^,¹¹^-¹³. En segundo lugar, medidas para mejorar la detección, el rastreo de contactos, la identificación, el diagnóstico, el aislamiento y la notificación de personas con sospecha de enfermedad y casos confirmados ⁹^,¹⁴. Y tercero, la implementación de restricciones de viaje y de contacto al interior de la ciudad, las cuales incluyeron limitar el contacto social individual, el uso de medidas de higiene personal y de protección, y el aumento de la distancia física entre los que tienen COVID-19 y los que no ⁹^,¹⁵. El gobierno chino también incito a las personas a quedarse en casa tanto como fuera posible, canceló o pospuso grandes eventos públicos y reuniones masivas, y cerró bibliotecas, museos y lugares de trabajo. ⁸^,⁹.

La propagación progresiva de la enfermedad ha permitido a muchos países anticipar que se aproxima una pandemia ⁹^,¹⁶. En el caso de Colombia, algunos gobiernos locales, así como el gobierno nacional, implementaron rápida y drásticamente un confinamiento obligatorio en todo el territorio nacional, así como otras intervenciones no farmacológicas dirigidas a la contención, supresión y mitigación de la enfermedad COVID-19.

Se requiere la mejor evidencia científica disponible para diseñar intervenciones no farmacológicas efectivas y difundir el conocimiento de manera urgente para ayudar a los tomadores de decisión a evaluar los posibles beneficios y costos de las intervenciones no farmacológicas para contener los brotes de COVID-19. Es esencial describir cómo diferentes países implementan intervenciones no farmacológicas y en qué punto de la epidemia. También es necesario explorar cómo esas intervenciones han impactado el número de casos, la mortalidad y la capacidad instalada de atención médica para prestar servicios de salud. Sin embargo, todavía hay brechas en el conocimiento sobre la efectividad de las diferentes intervenciones para justificar adecuadamente la preparación, implementación o cancelación de varias intervenciones no farmacológicas.

Materiales y métodos

Se realizó una síntesis rápida de evidencia enfocada en identificar las intervenciones no farmacológicas implementadas en la ciudad de Wuhan y 19 países (Argentina, Australia, Brasil, Canadá, Chile, China, Colombia, Cuba, Alemania, Irán, Italia, Japón, México, Noruega, Rusia, Corea del Sur, España, Reino Unido y Estados Unidos). Se aplicaron tres criterios para seleccionar los países y territorios, 1) un número comparativamente alto de casos, 2) una particularidad política o social que permita la comprensión de diferentes tipos de intervenciones no farmacológicas o un ritmo diferente en su implementación; y 3) un equilibrio entre países de Europa, Asia y América del Norte, Central y del Sur.

Se realizaron búsquedas en ocho páginas web de organizaciones transnacionales, 17 páginas web de revistas y periódicos internacionales y 99 páginas web de instituciones gubernamentales en los 19 países incluidos entre el periodo del 1 de enero al 25 de marzo de 2020. Además, se realizaron búsquedas en las bases de datos Medline y Embase de estudios que evaluaran la efectividad de las intervenciones no farmacológicas para la contención, supresión y mitigación de COVID-19 (Anexo 1 con las fuentes de búsqueda).

Se utilizaron documentos oficiales y artículos de medios de comunicación para determinar la fecha en que diferentes países implementaron las intervenciones no farmacológicas. Los criterios de elegibilidad de los artículos académicos fueron que el artículo se enfocara en explorar la efectividad y el impacto de las intervenciones no farmacológicas en la contención, supresión o mitigación de COVID-19, sin restricciones en lenguaje, o diseño del estudio. Los estudios elegibles incluyeron estudios observacionales (cohortes, series de tiempo, reportes de series), estudios de simulación y guías del sistema de salud o del sistema político.

La evaluación de la calidad de los estudios observacionales se realizó con los criterios de evaluación de Johana Briggs. En contraste, la calidad de los estudios de simulación no fue evaluada formalmente. Aun así, se emitió un juicio de acuerdo con la pertinencia de las variables utilizadas para realizar la simulación, la solidez de los supuestos y la calidad de la descripción del procedimiento estadístico. Todas las etapas del proceso de revisión fueron realizadas por un investigador y verificadas por un segundo investigador.

La información sobre el número de nuevos casos y muertes causadas por COVID-19 en los países y territorios elegidos se obtuvo del John Hopkins Center for Systems Science and Engineering después de notarse que sus tablas tienen información más actualizada que los informes de situación de la OMS ¹. El primer caso reportado en cada país fue documentado de fuentes oficiales o de la OMS, con esta información, determinamos cuántos días transcurrieron entre el primer caso reportado y la decisión de la INF tomada por el gobierno. El número de días para tomar la decisión se utilizó para desarrollar una línea de tiempo de eventos, un mapa de calor y una figura conjunta que representa los nuevos casos día a día y el punto en el que se decidieron las intervenciones no farmacológicas. El mapa de calor se desarrolló con el software R ¹⁷.

Resultados

Todos los países han implementado varias intervenciones no farmacológicas para controlar la infección por COVID-19. Sin embargo, existe una variabilidad en la cantidad y tipo de intervenciones. En países como Brasil, Canadá, México y Rusia, identificamos pocas intervenciones, y ninguna de ellas estaba entre las medidas más drásticas de distanciamiento social, por ejemplo, México solo ha implementado el cierre de escuelas y universidades ¹⁸. Estos países se han centrado principalmente en evitar la entrada de casos utilizando restricciones de viajes y aislando los casos identificados y las personas de alto riesgo.

Otro grupo de países ha aplicado varias intervenciones, incluyendo alguna de las medidas drásticas de distanciamiento social. Corea del Sur, Reino Unido y Estados Unidos, por ejemplo, han implementado intervenciones de distanciamiento social más drásticas combinadas con realización de pruebas de detección, localización de contactos y aislamiento de casos y contactos. Cabe destacar que Corea del Sur es reconocida por la rápida implementación de una estrategia de detección de casos en masiva ¹⁹, mientras que solo recientemente en algunos de los estados de Estados Unidos se ha comenzado a implementar medidas de distanciamiento social ²⁰.

El tercer grupo de países ha aplicado una combinación intensa de intervenciones drásticas para la contención, mitigación y supresión de la infección. Argentina, Chile, China, Colombia, Italia, España, todos implementaron confinamiento obligatorio para toda la población, después de cerrar escuelas y universidades, cancelar todos los eventos que concentraran a más de 200 personas y suspender el transporte público para todos los que no realizan trabajos esenciales para el control de la infección. Además, también han empleado aislamiento de casos y rastreo de contactos, cierre de fronteras y algunos están implementando la detección masiva de casos.

Con respecto al ritmo de implementación de las estrategias, algunos países como Argentina, Chile y Colombia, que reportaron el primer caso en marzo, implementaron intervenciones en los primeros quince días después de la detección del primer caso (Tabla 1 para más detalles), o incluso antes de la notificación del primer caso, como es el caso de Chile. Argentina, Chile y Colombia han tenido la oportunidad de anticipar y aprender de las decisiones políticas tomadas en otros países, como China y Corea del Sur, afectados desde diciembre de 2019 y enero de 2020 (Figura 1 que muestra un mapa de calor del momento para implementar las intervenciones). Países como Italia, España y Estados Unidos tardaron más de 30 días en implementar medidas drásticas de distanciamiento social y están mostrando una situación extrema de colapso de sus sistemas de salud (Figura 2 información sobre el momento en el cual algunos países han implementado algunas decisiones y la cantidad de casos nuevos que tenían en ese momento).

Tabla 1. Intervenciones no farmacologicas y número de días para implementarlas después del primer caso de COVID-19 (hasta el 28 de marzo de 2020).

Paises/ fecha primer caso	Hubei	China	Japón	Corea del Sur	Estados Unidos	Australia	Canadá	Alemania	España	Italia	Rusia	Reino Unido	Irán	Brasil	Noruega	México	Chile	Argentina	Colombia	Cuba
Paises/ fecha primer caso	31/12/19	31/12/2019	15/01/20	20/01/20	21/01/20	26/01/20	27/01/20	27/01/20	31/01/20	31/01/20	1/02/20	1/02/20	20/02/20	26/02/20	27/02/20	29/02/20	3/03/20	3/03/20	6/03/20	13/03/20
Medidas
Declaración de emergencia		23		13	52	53			43			9		25			-24	9	6
Distanciamiento social a nivel poblacional
Cuarentena obligatoria en todo el territorio	23	24		62*	59					38		52					18	16	16
Suspender clases presenciales	23	48	43						41	30			5		14	14	12	12	10	11
Suspender concentraciones de personas	20					54		43	39	39					14		15	14	6
Suspensión del transporte público	23								41	51			35					14
Aislamiento de casos o contactos
Aislamiento por llegar desde China		20	50	2		34								-18			-41	-26	4
Aislamiento por llegar desde otro país				62		49	58			33	34				15		3	3	4	7
Aislamiento por ser persona de alto riesgo					46	34	53		38			49			18	16	19	14	12	-45
Aislamiento por tener síntomas o ser un caso	31				46							40		14	18		-41	8
Restricciones de viaje
Restricciones de entrada a extranjeros (China)			19	2	10	54	49			30	-1				14	-46	14	9	9
Restricciones de entrada a extranjeros (otros)			61	59	39	54	49	43	39		27			22	16	15	14	12	9
Cierre de frontera para tráfico no esencial					57	54	51		51		44			26	14		15	13	10	7
Restricciones de viajes internacionales			54	58	58	54		48	39	38	32	46	25		16		15	9
Restricciones a viajes aéreos domésticos	31	31				54			48	38		41	25				17	14	16
Detección y rastreo de casos
Búsqueda intensiva de casos (En puerto de entrada y en territorios/provincias)	20	21	6	6				19			44		5				8	-32		5
Rastreo de contactos	20	21	33	6									10				-41	10

Otras intervenciones no farmacológicas implementadas por los países analizados incluyen intervenciones para mejorar la infraestructura del sistema de salud y fortalecer la capacidad de recurso humano (p. ej., ampliar la capacidad de camas, habilitar el uso de estadios y otros espacios), estrategias dirigidas a las poblaciones en riesgo (p. ej., medidas especiales para las personas privadas de libertad), intervenciones de apoyo social (p. ej., ayudas tributarias), estrategias para apoyar la producción de bienes y servicios (p. ej., facilitar préstamos a empresas) y estrategias de información precisa, comunicación oportuna y apoyo para el distanciamiento social (Anexo 2).

Impacto de las intervenciones no farmacológicas

Al explorar la efectividad de las intervenciones no farmacológicas para la contención, supresión y mitigación de la infección por COVID-19, incluimos nueve de 34 estudios identificados (una guía de política, una revisión sistemática rápida, dos estudios de cohortes, un estudio de series de tiempo y cuatro simulaciones) ⁴^-⁶^,¹¹^-¹³^,²¹^,²². El anexo 3 resume los hallazgos de estos estudios.

La efectividad de cualquier intervención no farmacológica aislada puede ser limitada, pero las intervenciones combinadas han demostrado ser efectivas y tienen un alto impacto en la reducción de la transmisibilidad de la enfermedad, el colapso de los servicios de atención médica y la mortalidad. Siete de nueve estudios incluidos sugieren explícitamente la implementación temprana de intervenciones combinadas y estrictas; principalmente, cuarentena, distanciamiento social, suspensión del transporte público, detección temprana de casos y aislamiento domiciliario de casos leves ⁴^,⁵^,⁹^,¹²^,¹³^,²¹^,²² (Tabla 2).

Tabla 2. Impacto de las intervenciones no farmacológicas para el control de la infección por COVID-19.

Medida no farmacológica	Impacto	Número de estudios que abordan la medida	Tipo de estudio
Combinación de medidas	Alto	7	1 guía de política
			2 estudios de cohorte
			1 revisión sistemática rápida
			1 estudio de serie de tiempo
			2 simulaciones
Aislamiento de casos	Alto	3	1 guía de política
Aislamiento de casos	Alto	3	2 simulaciones
Detección temprana de casos	Alto	2	1 guía de política
Detección temprana de casos	Alto	2	1 simulación
Rastreo de contactos	Alto	1	1 simulación
Cuarentena de contactos	Alto	2	1 estudio de cohorte y 1 guía de política
Suspensión del transporte público	Alto	2	1 revisión sistemática rápida
Suspensión del transporte público	Alto	2	1 estudio de cohorte
Cancelación de grandes reuniones	Alto	2	1 guía de política
Cancelación de grandes reuniones	Alto	2	1 estudio transversal
Sostenimiento de medidas de distanciamiento (al menos seis meses después del brote)	Alto	2	2 simulaciones
Autoaislamiento de personas sintomáticas	Moderado-alto	2	1 guía de política
Autoaislamiento de personas sintomáticas	Moderado-alto	2	1 simulación
Distanciamiento social de los mayores de 70 años	Moderado	1	1 simulación
Medidas en el lugar de trabajo	Moderado	1	1 guía de política
Distanciamiento social	Bajo-Moderado	3	2 simulaciones
Distanciamiento social	Bajo-Moderado	3	1 revisión sistemática rápida
Restricción de viaje entre ciudades	Bajo-Moderado	2	1 guía de política
Restricción de viaje entre ciudades	Bajo-Moderado	2	1 simulación
Restricciones de viajes domésticos	Bajo-Moderado	3	1 guía de política
			1 estudio de cohorte
			1 estudio transversal
Cierres de escuelas y guarderías (bajo impacto)	Bajo-Moderado	2	1 guía de política
Cierres de escuelas y guarderías (bajo impacto)	Bajo-Moderado	2	1 simulación
Cuarentena de viajeros provenientes de zona afectada	Bajo	1	1 estudio de cohorte
Reducción de contacto	Bajo	1	1 estudio de simulación
Cierres de fronteras	Bajo	1	1 guía de política
Procedimientos de detección de casos en aeropuertos	Bajo	1	1 guía de política

Un estudio en China afirma que, sin la implementación de intervenciones no farmacológicas, el número de casos de COVID-19 habría aumentado de 51 veces en Wuhan, 92 veces en otras ciudades de Hubei y 125 veces en otras provincias ⁹. Las intervenciones no farmacológicas combinadas podrían reducir la demanda máxima de atención médica y la mortalidad a la mitad o incluso a dos tercios ⁴. Un estudio de simulación para el Reino Unido y los Estados Unidos muestra que, en una epidemia no controlada, la demanda de camas de cuidados intensivos se prevé que se vea excedida a partir de la segunda semana de abril, con una demanda máxima de camas de más de 30 veces el máximo suministro en ambos países ⁴.

Después del pico de la enfermedad, y cuando se ha controlado el número de casos nuevos, es necesario mantener medidas de distanciamiento social, control del transporte público, estrategias de trabajo en el hogar, detección y aislamiento de casos y rastreo de contactos. Se sugiere que el rastreo de contactos y el aislamiento de casos son altamente efectivos para controlar un nuevo brote de COVID-19. Sin embargo, la probabilidad de control disminuye con 1) largos retrasos desde el inicio de los síntomas hasta decidir el aislamiento, 2) pocos contactos rastreados por caso y 3) cuando aumenta la transmisión antes de los síntomas ²². En la mayoría de los escenarios de simulación y de la experiencia de salud pública de epidemias anteriores, se identifica que, si el contacto social se reanuda a niveles normales, los contagios podrían aumentar nuevamente. Por lo tanto, varias intervenciones no farmacológicas, incluido el distanciamiento social, deben continuarse durante varios meses, ⁹ incluso se propone que se mantengan medidas restrictivas hasta que haya una vacuna disponible (potencialmente 18 meses o más) ya que se predice que la transmisión se recupere rápidamente si se flexibilizan las intervenciones ⁴.

Cuando el número de casos nuevos demuestra el control de la enfermedad, la evidencia sugiere que las medidas que se pueden levantar primero son el cierre de fronteras, los procedimientos de detección de casos en los aeropuertos y el cierre de escuelas y guarderías. La evidencia también sugiere que tanto el establecimiento como la eliminación de intervenciones no farmacológicas dependen de varios factores políticos, sociales y culturales, no solo del comportamiento de la enfermedad ⁵^,⁹^,²¹.

Discusión

Resumen de los hallazgos principales

Consultamos ocho páginas web de organizaciones transnacionales, 17 de medios internacionales, 99 de instituciones gubernamentales en los 19 países incluidos, y, además incluimos nueve estudios (de 34 identificados) que cumplían con los criterios de inclusión. Encontramos que algunos países se centran en establecer restricciones de viaje, aislamiento de casos identificados y personas de alto riesgo. Otros tienen una combinación más intensa de confinamiento obligatorio para toda la población, cierre de todos los centros educativos y suspensión del transporte público para todos aquellos que no realicen trabajos esenciales. Algunos de los países han implementado intervenciones en los primeros quince días después de detectar el primer caso, mientras que otros han tardado más de 30 días en implementar medidas drásticas de distanciamiento social. La efectividad de las intervenciones no farmacológicas aisladas puede ser limitada, pero las intervenciones combinadas han demostrado ser efectivas y tener un alto impacto en la reducción de la transmisibilidad de la enfermedad, el colapso de los servicios de atención médica y la mortalidad. Cuando se ha controlado el número de casos nuevos, es necesario mantener medidas de distanciamiento social, control del transporte público, estrategias de trabajo en el hogar, detección de casos, autoaislamiento y rastreo de contactos durante varios meses.

Comparación con otros estudios

Un estudio de simulación realizado en Colombia para predecir el impacto de la pandemia de COVID-19 de acuerdo con las medidas de mitigación que se han implementado en el país concuerda con nuestros hallazgos de que las intervenciones combinadas podrían ser efectivas y tener un alto impacto en la reducción de la transmisibilidad de la enfermedad. El estudio de González-Jaramillo et al. ²³, concluye que la combinación de estrategias de mitigación adoptadas por el gobierno colombiano podría reducir el número de pacientes que requerirían unidades de cuidados intensivos de 36,782 en el escenario de no intervención a 1,176 en el escenario que combina aislamiento de casos, cuarentena domiciliaria y distanciamiento social de personas mayores de 70 años.

Nuestro hallazgo de la necesidad de mantener medidas de distanciamiento social, control del transporte público, estrategias de trabajo en el hogar, detección y aislamiento de casos y rastreo de contactos también ha sido respaldado en la literatura. El modelo desarrollado por Prem et al. ¹⁴, Sugiere que el levantamiento repentino de las intervenciones podría conducir a un pico secundario más temprano, que podría evitarse relajando las intervenciones gradualmente. En este sentido, Colburn sugiere que la realización de pruebas, el rastreo de contactos y la cuarentena de casos sospechosos podrían ser las estrategias principales después de la relajación de las intervenciones no farmacológicas de distanciamiento social drástico para prevenir la sobrecarga del sistema de salud. Colburn ²⁴ llama a la incorporación de estas estrategias en modelos que permitan que los países tengan una mejor idea de la capacidad de realización de pruebas que necesitarán y a decidir si dichas políticas pudieran tener éxito en la supresión de la propagación de COVID-19 en un determinado país.

Las intervenciones no farmacológicas también tienen efectos adversos en los individuos, las comunidades y la economía nacional. Una revisión rápida reciente informó que la cuarentena podría tener efectos psicológicos nocivos, como síntomas de estrés postraumático, confusión e ira, que pueden conducir a efectos adversos psicológicos a largo plazo ²¹^,²⁵. Muchos artículos han destacado las implicaciones económicas que las intervenciones de cuarentena podrían tener sobre la economía en el año 2020; sin embargo, el objetivo en este momento es salvar tantas vidas como lo permitan nuestros recursos ⁴^,⁵^,⁸^,⁹^,¹²^,¹³^,²¹^,²⁶.

Limitaciones de esta revisión

Dadas las limitaciones de tiempo impuestas por el brote actual de coronavirus, tomamos algunas decisiones metodológicas críticas que deben considerarse. Un solo revisor aplicó los criterios de inclusión y la extracción de información de los estudios incluidos en esta síntesis. Además, la calidad de los estudios de simulación no fue evaluada formalmente.

Conclusión

En este momento la toma de decisiones políticas debe tener como objetivo optimizar las oportunidades de salvar vidas, reducir el colapso de los servicios de salud y minimizar el impacto económico y social sobre la población en general, pero principalmente sobre los más vulnerables. Es probable que el momento de implementar y levantar las intervenciones tenga un efecto sustancial en estos objetivos.

Anexo 1. Recursos de búsqueda.

WHO PAHO.

WHO Situation Dashboard. https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd