Long-term strategies to control COVID-19 in low and middle-income countries: an options overview of community-based, non-pharmacological interventions

Abstract

In low and middle-income countries (LMICs), strict social distancing measures (e.g., nationwide lockdown) in response to the COVID-19 pandemic are unsustainable in the long-term due to knock-on socioeconomic and psychological effects. However, an optimal epidemiology-focused strategy for ‘safe-reopening’ (i.e., balancing between the economic and health consequences) remain unclear, particularly given the suboptimal disease surveillance and diagnostic infrastructure in these settings. As the lockdown is now being relaxed in many LMICs, in this paper, we have (1) conducted an epidemiology-based “options appraisal” of various available non-pharmacological intervention options that can be employed to safely lift the lockdowns (namely, sustained mitigation, zonal lockdown and rolling lockdown strategies), and (2) propose suitable application, pre-requisites, and inherent limitations for each measure. Among these, a sustained mitigation-only approach (adopted in many high-income countries) may not be feasible in most LMIC settings given the absence of nationwide population surveillance, generalised testing, contact tracing and critical care infrastructure needed to tackle the likely resurgence of infections. By contrast, zonal or local lockdowns may be suitable for some countries where systematic identification of new outbreak clusters in real-time would be feasible. This requires a generalised testing and surveillance structure, and a well-thought out (and executed) zone management plan. Finally, an intermittent, rolling lockdown strategy has recently been suggested by the World Health Organization as a potential strategy to get the epidemic under control in some LMI settings, where generalised mitigation and zonal containment is unfeasible. This strategy, however, needs to be carefully considered for economic costs and necessary supply chain reforms. In conclusion, while we propose three community-based, non-pharmacological options for LMICs, a suitable measure should be context-specific and based on: (1) epidemiological considerations, (2) social and economic costs, (3) existing health systems capabilities and (4) future-proof plans to implement and sustain the strategy.

The effect of COVID-19 on the economy: evidence from an early adopter of localized lockdowns

“…As countries begin to reopen and ease mobility restrictions, localized lockdowns are increasingly considered a critical element of a non-pharmaceutical toolkit to control COVID-19 resurgence [6,7,19,28,29]. In contrast to nation-wide lockdowns, localized lockdowns are implemented over a limited geographical area, ranging from a neighborhood to a city, including suburbs, districts, or towns.…”

SARS-CoV-2 virus outbreak and the emergency public health measures in Bosnia and Herzegovina: January – July, 2020

“…. In addition, other strategies proposed recently for developing countries, such as zonal and dynamic blocs, can be considered [12,13]. Finally, coordination and collaboration with neighboring countries and the wider global community will be the key to reducing virus resurgence risks while minimizing travel and trade disruptions.…”

Viruses That Can and Cannot Coexist With Humans and the Future of SARS-CoV-2

“…It is possible to contain the outbreak at local level; some countries or regions were able to reduce their new cases to almost zero by extensive measures such as "lockdown" and strict "border control" (Baker M. et al, 2020;Erkhembayar et al, 2020;Wang C. J. et al, 2020;Wu and McGoogan, 2020). However, these interventions cannot be sustained for months or years worldwide (Chowdhury et al, 2020;Weill et al, 2020). Existence of asymptomatic and presymptomatic transmission makes public health intervention difficult (Fraser et al, 2004).…”