DISCUSSION
The COVID 19 pandemic showed quite unexpected results considering the
level of health care systems, organization and the economic power of
different states, so many states that considered their health system to
be quite well organized experienced such a sharp increase in seriously
ill patients so their health systems became overloaded and could not
meet the needs of the population. It is very valuable to objectively
study the factors that led to this consequence, concerning the health
systems themselves or, more likely, the epidemiological measures
implemented by the state apparatus. In the media, one could often hear
at least doubts about the pandemic response that Sweden implemented, as
very liberal and unjustifiably optimistic, to condemn the drastic
measures seen in China, which allegedly concerned unnecessary and as
inappropriate restriction of personal freedoms. Besides the level of the
introduced measures, there is also the question of their timeliness.
Scientists were aware that without causal treatment and in the absence
of a vaccine, the spread of the infection could not be prevented, but
measures were prescribed as a national epidemiological priority, which
should have as a goal a ”flattened curve” of the spread of the disease
in order to prevent such a rapid spread of disease that could lead to
overloading of national health systems and their collapse [14].
China has imposed a state of emergency with significant military and
police engagement, so by January 29, the entire province of Hubei was in
isolation [14]. It was a period when Europe and the USA observed the
situation and hoped that the epidemic would remain at the local level
and soon be overcome as SARS 2003, but unfortunately, very important
differences between SARS Cov and SARS Cov 2 were not known. In many
ways, Wuhan had a predisposition for further spread of the infection. It
is a very large city with over 11 million inhabitants, with the largest
airport and railway station, important industrial plant, with traffic
that has multiplied in previous years while population density has even
tripled in the last decade. Also, the spread of the infection was
favored by a large celebration of the lunar New Year just before the
introduction of epidemiological measures. Infection was disseminated
despite enormous efforts and strict epidemiological measures that were
introduced relatively quickly [15].
On January 31, the Italian government suspended air traffic with China
as a known source of infection, and then in early February, 11
municipalities in the northern part of the country were quarantined.
Soon quarantine extended to the entire country, with the suspension of
all industries that are not essentia [16]. On February 24, there was
a sharp increase in the number of patients reaching a peak within 20
days with about 6,000 patients in one day [17]. The Spanish
government started a series of epidemiological measures on March 14,
with the suspension of all non-essential activities. It is important to
mention that before the beginning of what soon became known as the
”Italian and Spanish scenario”, a big football match, which can be
characterized as an epidemiological incident, was played between the
Italian and Spanish rivals with about 40,000 spectators in the region
that soon became the epicenter of the infection [18]. This is a
probable reason and explanation why there was a significantly higher
number of patients and deaths in Italy and Spain compared to Sweden.
France introduced a state of
emergency on March 17, but the first round of municipal elections was
held in France on March 15, which certainly had an impact on the further
course of the epidemic in the country [19, 20]. USA declared a state
of emergency on March 13. The increase in the number of patients was
quite large and sudden, so even an economic power such as the USA soon
faced the situation that there was not enough medical equipment,
hospital facilities, personal protective equipment, as well as tests,
despite mass production and reorientation of certain industries on
production of medical supplies. Comparing the number of patients and
deaths from COVID-19 infection in Sweden and the USA, we concluded that
the difference in the number of patients is statistically significant,
but not mortality [11].
The state of emergency was introduced in Serbia on March 17, with
movement bans for people over 60 (65) years of age [21]. Strict
restraint measures were also strictly implemented for persons under
house observation and quarantine. Compared to Sweden, there were
statistically significantly fewer patients and deaths from COVID-19
infection in Serbia, in spite of over 30,000 temporary workers abroad
who returned to Serbia at the very beginning of the epidemic.
In United Kingdom, On March 23, a state of emergency is imposed, with
the suspension of many industries, economic disciplines, gathering
places, while the population is banned from ”irrelevant” travel and
contacts except with family members. Social distance was ordered and the
broad permission were given to police to implement epidemiological
measures [11].
Germany is a country with a traditionally strong health system. Upon
arrival of the first cases, moderate epidemiological measures are
recommended. On March 13, measures, which included closing schools and
kindergartens, stopping higher education and banning visits to nursing
homes because it was already known that the elderly population is more
susceptible to severe clinical picture if they become ill. Shortly
afterwards, the borders with the surrounding countries were closed, and
within Germany some areas introduced different levels of epidemiological
measures with a state of emergency, while others introduced strict
social distance [22]. Croatia On March 24 introduced very strict
measures to control the infection, which, together with the early
detection of the trajectory of the infection, good information and
cooperation of the population, led to a very good control of the disease
[23, 24]. Sweden is a country that has introduced a fairly liberal
system of epidemiological measures relying on the health education of
the population. Recommendation of the Public Health Agency were
continuation of the work of primary schools, avoiding of trips that are
not necessary, to work remotely, not to gather more than 50 people,
respecting physical distance and for people over the age of 70 to stay
at home as long as possible. Swedish government considered that
well-informed and motivated persons understand and follow the given
recommendations, and that personal responsibility is better than
coercive measures. For people with symptoms suspicious of COVID-19, the
advice was to stay at home. Thus, they soon reached the level of 30%
fewer vehicles and 70% of pedestrians active in Stockholm, and that
over 50% of classes take place at a distance. It was also believed that
in this way a wider ”controlled infection” of the population will be
achieved in order to acquire collective immunity [25]. Norway is a
country that is very similar to Sweden in size, population, geographical
position and mentality. Unlike Sweden, Norway has introduced a number of
much stricter epidemiological measures, and the results indicate that
Norway has a lower incidence rate and a significantly lower number of
deaths from COVID-19 infection [26].
Unfortunately, as in previous cases with SARS and MERS, we do not have
an antiviral drug or vaccine, so classic epidemiological measures such
as active detection and isolation of cases, tracking infection,
quarantine, social distance and hygiene measures are the only weapons to
combat COVID-19. Although our experiences from the SARS and MERS
epidemics are very important, it is essential to understand that there
are also very important differences [4]. In addition to the economic
strength and quality of the health care system in each country, a very
important factor is represented by social events, the way of behaving
the population, epidemiological measures implemented by the state
apparatus according to the advices of experts and also timing of all
measures. There are several objective reasons that have contributed to
the rapid and massive spread of the disease concerning the nature of the
virus itself, such as the large number of asymptomatic or subclinical
carriers of the virus, which was not common for SARS and MERS. Another
possible cause would be the higher virulence of this virus compared to
SARS and MERS, despite lower mortality. The third reason might be
existence of different subtypes of the virus that have a somewhat
different clinical picture and disease outcome. Also, there is a
possibility that the virus experienced some kind of attenuation by
passing through the human population. According to early reports from
China, on February 11, 72,314 cases were registered with only 889 (1%)
asymptomatic carriers of the virus. Subsequent reports from Europe
indicated that there were many more asymptomatic cases that posed the
main epidemiological danger because the carrier is not aware of it at
the time of infection, realizing multiple contacts and contributing to
the rapid dispersal of the disease [3]. In addition to the reasons
concerning the virus itself, the discipline of a nation and its
government, as well as the introduction of appropriate epidemiological
measures, which should be not only sufficient but also timely, also play
an important role. In any case, until a vaccine or possibly an antiviral
drug would be developed, we are left with only epidemiological
protection measures, so the fight against COVID-19 will probably
continue with occasional fluctuations, new outbreaks and residues of
infection and conditions of new patterns of ”normal” behavior in
epidemiological terms.