To evaluate COVID-19 containment performance impartially, we developed and tested a comprehensive evaluation method that accounts for GP&HE indicators, VH&SE measures, and vaccination. LE captures a nation’s effectiveness in enacting measures according to recent incidence. As variants continue to emerge, a new normal, in which pharmaceutical and non-pharmaceutical interventions are considered should be established. Because it is unreasonable to expect life to normalize completely in the short term, we did not include the global normalcy index19 in our analyses.
Our sensitivity analysis showed that inclusion of the Google Trends indicator altered the overall rankings of the 50 examined countries and territories slightly. We included it for three reasons: Google Trends data reflect health literacy and impacts on mental health7,8; none of the global institutions assessing COVID-19 containment effectiveness have included public responses in their evaluation criteria; and we believe that public response is important for transmission control.
Prior to vaccine allocation, some countries and territories in Asia and Oceania were more successful at suppressing COVID-19 outbreaks than their European and American counterparts. They exhibited a relative weakening of containment performance after inclusion of the vaccine indicator (since December 2020), likely due, at least in part, to their lower vaccination coverage (Supplementary Information 12, Fig. 4).
New Zealand and Singapore emerged as the most stable performers. New Zealand has been steadfast in its fight against the vexatious COVID-19, increasing its LE to overcome spikes in infection (March/April 2020) and in fatality (May 2020). Successful containment has contributed to their economic stability during the first phase of pandemic (Supplementary Information 12). After New Zealand was invaded by the Delta variant in August 202120, the number of confirmed cases and infection rates increased, and New Zealand responded with an accelerated vaccination strategy (Supplementary Information 12).
Although Singapore did not control rapid viral spread initially, they recovered from outbreaks well. Following a 5-month period of rising cases (April–August 2020), the Singapore government improved its health-system policies and LE, leading to decreased case numbers thereafter. Since January 2021, Singapore has been administering vaccines efficiently, making it a model nation for curbing COVID-19 (Supplementary Information 12). However, the surge in coronavirus infections and confirmed cases in Singapore since September 2021 may be related to Singapore’s “coexisting with COVID-19” strategy and the Delta variant outbreak21,22. Whether Singapore can achieve the goal of “live with the virus” has become the focus of global attention.
Changes in containment performance scores of six locations associated with notable performance, activities, or policies are shown in Fig. 1. Denmark and the UK have high vaccination coverage23. Denmark lifted restrictions on September 10, 202124. Starting on July 19, 2021, the UK lifted most of its restrictions and removed social distancing recommendations25. In all US regions, restrictions have eased and people have returned to generally normal life26. The 2020 Olympic and Paralympic Games took place in Tokyo, Japan from July 23 to August 8 and from August 24 to September 5 of 2021, respectively27. Vietnam was Asia’s top-performing economy in 202028. Taiwan has been praised for its 253-day streak without local infections29.
Denmark’s infection growth increased rapidly from September 2020 to January 2021, though their fatality rate remained low. Transmission was mitigated through strict health-system policies, improved LE, and mass vaccinations. Although the number of confirmed cases increased after May 2021, the fatality rate was low. The pandemic within Denmark appeared to be under stable control, but at the end of the study Denmark faced another new wave of outbreaks, the development of which remains to be seen (Fig. 1, Supplementary Information 12).
Containment performance in the UK was not satisfactory in phase one. The UK improved LE and health-system policies while administering vaccinations on a massive scale. These efforts enabled a gradual containment of COVID-19 transmission, which was suppressed by March 2021. There was a case/infection growth surge in June 2021 (Fig. 1, Supplementary Information 12).
The USA did not control infection well in the first phase, but its containment performance improved in the second phase. They have endured large numbers of confirmed cases with cascading regional surges (Fig. 1, Supplementary Information 12).
Japan adopted inclusive health-system policies. Although their confirmed cases increased during the 2021 Olympics, Japan had several prior waves of increased case numbers, including two in 2021 (January and May). Whether the increase in confirmed cases during the Olympics can be attributed to Olympic event gatherings remains to be clarified (Supplementary Information 12).
Vietnam performed well in early but experienced a short-term containment performance decline in August 2020. Vietnam controlled an outbreak that emerged in February 2021 successfully. Infection growth in Vietnam has been relatively high since May 2021, and was only slightly contained until October, but then increased again in November. Transmission in late summer 2021 may reflect Delta variant invasion under low vaccination coverage (Fig. 1, Supplementary Information 12).
Taiwan is an exemplary case. COVID-19 transmission was suppressed early owing to a rapid response by Taiwan’s Central Epidemic Command Center with cooperation from local government agencies and the public30. Taiwan suffered a case surge under low vaccine coverage in May and June 2021. The Central Epidemic Command Center responded with intensive data gathering, expansive testing, quarantines, and stringent non-pharmaceutical policies31. Faced with the highly transmissible Delta variant, Taiwan suppressed case numbers within 2 ~ 3 months (Fig. 1, Supplementary Information 12).
While countries seek to increase vaccination coverage, vaccine effectiveness has been tested by the Delta variant and breakthrough infections. In addition to vaccination, non-pharmacological interventions, such as handwashing, masking, and physical distancing, remain important for preventing transmission.
Public health implications
Our research suggests that the top performing nations tend to enact rigorous health system policies and locally-appropriate lockdown measures, especially early in the pandemic (Supplementary Information 12, and Supplementary Table S11). Asian countries’ border control policies were implemented earlier than non-Asian countries. In Asian and non-Asian countries, the median times to any border closure from the first reported case in China were 24.50 and 67.50 days, respectively (P = 0.0003), and the median times to any border closure from the first domestic case within each country were -10.50 and 8.00 days, respectively (P = 0.0027) (Supplementary Table S50, Supplementary Information 15). Notwithstanding, stringent lockdown measures should not be enacted without careful consideration, and lockdown policies should be adjusted in response to recent incidence. Flexibility in their implementation can yield containment with minimal harm to societies, economies, and mental health.
Limitations
Several methodological limitations should be noted. First, we include unemployment rate and GDP loss, but not international aid, economic stimulus packages, or other fiscal measures. Second, Google Trends data do not represent a random sampling and may exclude vulnerable groups without internet access or those not actively searching. Third, ideally, only local infection rates should be considered to obtain precise LE measurements. However, because daily local case data are not fully available, we used incidence data inclusive of imported cases to determine LE scores. Therefore, minor inaccuracies in our LE data are expected (Supplementary Information 5).
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