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.