RESEARCH ARTICLE Open Access

Comparative analysis of COVID-19guidelines from six countries: a qualitativestudy on the US, China, South Korea, theUK, Brazil, and HaitiJi Youn Yoo1*†, Samia Valeria Ozorio Dutra2†, Dany Fanfan3, Sarah Sniffen4, Hao Wang5, Jamile Siddiqui6,Hyo-Suk Song7, Sung Hwan Bang8, Dong Eun Kim9, Shihoon Kim10 and Maureen Groer1

Abstract

Background: In late January, a worldwide crisis known as COVID-19 was declared a Public Health Emergency ofInternational Concern by the WHO. Within only a few weeks, the outbreak took on pandemic proportions, affectingover 100 countries. It was a significant issue to prevent and control COVID-19 on both national and global scalesdue to the dramatic increase in confirmed cases worldwide. Government guidelines provide a fundamentalresource for communities, as they guide citizens on how to protect themselves against COVID-19, however, theyalso provide critical guidance for policy makers and healthcare professionals on how to take action to decrease thespread of COVID-19. We aimed to identify the differences and similarities between six different countries’ (US, China,South Korea, UK, Brazil and Haiti) government-provided community and healthcare system guidelines, and toexplore the relationship between guideline issue dates and the prevalence/incidence of COVID-19 cases.

Methods: To make these comparisons, this exploratory qualitative study used document analysis of governmentguidelines issued to the general public and to healthcare professionals. Documents were purposively sampled(N = 55) and analyzed using content analysis.

Results: The major differences in the evaluation and testing criteria in the guidelines across the six countriescentered around the priority of testing for COVID-19 in the general population, which was strongly dependent on eachcountry’s healthcare capacity. However, the most similar guidelines pertained to the clinical signs and symptoms ofCOVID-19, and methods to prevent its contraction.

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* Correspondence: jiyounyoo@usf.edu†Ji Youn Yoo and Samia Valeria Ozorio Dutra contributed equally to thiswork.1College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd,Tampa, FL 33612, USAFull list of author information is available at the end of the article

Yoo et al. BMC Public Health (2020) 20:1853 https://doi.org/10.1186/s12889-020-09924-7

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Conclusion: In the initial stages of the outbreak, certain strategies were universally employed to control the deadlyvirus’s spread, including quarantining the sick, contact tracing, and social distancing. However, each country dealt withdiffering healthcare capacities, risks, threats, political and socioeconomic challenges, and distinct healthcare systemsand infrastructure. Acknowledging these differences highlights the importance of examining the various countries’response to the COVID-19 pandemic with a nuanced view, as each of these factors shaped the government guidelinesdistributed to each country’s communities and healthcare systems.

Keywords: COVID-19, Coronavirus, Government guidelines, Outbreak COVID-19, Pandemic

IntroductionThe recent outbreak of COVID-19 has led to a majorconcern of increased mortality in the world. The firstoutbreak of COVID-19 was reported in Wuhan city, thecapital of China’s Hubei Province, in late December,2019 [1]. Only a few months later, on March 11, 2020,the World Health Organization (WHO) designated theCOVID-19 outbreak a pandemic and provided guide-lines for COVID-19 case management in the health fa-cility and community. Globally, approximately 3,506,577confirmed cases of COVID-19 have been reported, in-cluding over 247,467 deaths (Johns Hopkins University,May 03, 2020) [2, 3]. The fast spread of the virus reflectshow health is connected globally and the necessity ofinvesting in global research efforts to explore, clarify,and address global health emergencies.When the first COVID-19 outbreak was reported in

China, the Chinese government established guidelinesthat recommended keeping social distance in publicplaces, staying at home, and isolating infected popula-tions to contain the epidemic. After a month, SouthKorea was assailed by a COVID-19 outbreak. Both gov-ernments’ early actions were aggressive in an attempt tostop the virus from spreading, involving both widespreadtesting for the virus and contact tracing. The COVID-19response in China and South Korea provided the modelfor other countries where COVID-19 was just beginningto expand. While it was uncertain whether other coun-tries could implement or adapt the stringent measuresendorsed by China and South Korea, the heterogeneousnature of the virus worldwide warranted further investi-gation into the healthcare and community responsesfrom governments across many nations.Considering how each country had different capacities,

risks, threats, political and socioeconomic challenges, aswell as different health care systems, it was unsurprisingthat each country responded to this threat with differentmeasures and different timings. However, it is alsoclearly critically important to look at how differentcountries addressed the first pandemic of coronavirus.Thus, we compared six different countries’ guidelines toinvestigate their management, incidence, and prevalenceof COVID-19 cases. Additionally, we explored the

relationship between the guidelines’ issue dates and theprevalence-incidence curves of the different countries.

ObjectiveThe objective was to compare government guidelines onCOVID-19 by six different countries (The United States(US), China, South Korea, The United Kingdom (UK),Brazil and Haiti). This included general public guidelinesand healthcare professionals’ (medical institutions)guidelines. We aimed to identify differences and similar-ities between the countries’ community and healthcareprofessional guidelines and additionally to explore therelationship between guidelines issue dates and theprevalence/incidence of the COVID-19 cases. This is sig-nificant because we can examine how various countriesresponded to COVID-19 and identify best practices.This approach also allows us to understand how health-care system and policy capacities shape COVID-19 re-sponses and to share this information to improveresponses to COVID-19.

MethodsResearch designOur study used document analysis, a standard qualitativeresearch method for evaluating communication and pol-icy research, to explore the differences and similaritiesbetween government COVID-19 guidelines from sixcountries [4, 5]. The following steps were included inthe analysis: (i) establishing the document inclusion cri-teria, (ii) gathering documents, (iii) analyzing key areas,(iv) coding the document, (v) verification, and (vi) ana-lysis [6]. In this approach, the investigators are the pri-mary means of data selection and analysis. This studyused purposive sampling to recruit investigators inter-nationally by email and/or phone.

Country selectionCOVID-19 is a global pandemic warranting a cross-national perspective from countries differing on severallevels (e.g., geographic region, health and economic re-sources, stage of COVID-19 spread and response) tomaximize range and diversity when exploring the scopeof COVID-19-related community and healthcare system

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guidelines. When selecting the six countries, the follow-ing were considered: 1) COVID-19 starting and spikingperiod, 2) geographic proximity to China, where theCOVID-19 spread began, 3) population size, 4) gross do-mestic product (GDP) status, and 5) eligibility of a bilin-gual expert in the public health field. For instance, thefirst COVID-19 outbreak occurred in China in Decem-ber 2019. Outbreaks in other countries like South Korea,the US, and the UK soon followed in January and Febru-ary 2020. Finally, in March 2020, Brazil and Haiti notedincreased incidence and deaths from the virus. By April2020, China and South Korea were in the recovery stageof the pandemic while the spread of COVID-19 intensi-fied in countries such as the US, UK, Haiti and Brazil.Geographical differences in the selected countriesreflected geographic proximity to China (Korea), largestpopulation in North America (the US), largest popula-tion in South America (Brazil), and island countries withsignificant geographic distance from China (Haiti andthe UK). Furthermore, the countries’ population sizeswere strongly related to the effectiveness and widespreaddissemination of information regarding COVID-19guidelines [6]. Additionally, the countries’ GDP repre-sented their resources, ability, and strategies employedin response to COVID-19. For instance, at the start ofthe COVID-19 spread in the UK and Haiti, both coun-tries had very little available resources for COVID test-ing. With Haiti’s fragile health care system, Haiti did nothave the infrastructure to fight the spread of the virus,warranting economic support from other countries. Fi-nally, it was necessary to collaborate with authors whomet the following inclusion criteria in order to facilitatedocument analysis of different countries’ governmentguidelines: hold a graduate degree, have experience withhealthcare material, are fluent in English and have nativelanguage fluency (Chinese, Korean, Portuguese, andFrench/ Haitian Creole) in at least one of the six coun-tries selected.

Document inclusion/exclusion criteriaSix members of the research team, which consisted ofmultidisciplinary, cross-cultural researchers, collectedthe data. The research team only reviewed documentsfrom publicly available government websites for eachcountry (see Additional file 1). Guidelines from govern-ment websites were available in different formats, in-cluding action and response plans, healthcare andgeneral population guidelines, prevention measures/rec-ommendation flyers, videos, government memos andwebpages. Documents or information from nongovern-ment websites, social media, online newspapers/edito-rials, peer-reviewed articles, and heath institutionguidelines were excluded from the study.

Data collectionTo guide document selection among investigators, a code-book was developed which highlighted the informationnecessary for each theme (see Additional files 2 and 3).Each document for each country was reviewed to deter-mine the extent to which the document provided answersto at least one of the pre-identified themes (i.e. areas ofanalysis). The team reviewed government websites weeklyfor approximately 6 weeks from March 2020–May 2020 toobtain information from government guidelines, and toascertain whether any new documents were published, orwhether old guidelines had been updated. A total of 55documents (e.g., government guidelines, flyers, memo,webpages) were reviewed to extract data (10 for the US, 3for China, 10 for South Korea, 8 for the UK, 13 for Brazil,11 for Haiti) (see Additional file 1). Texts from COVID-19general public guidelines and government health promo-tion materials relevant to each pre-identified theme werecopied verbatim in their original language and added toan excel spreadsheet. Extracted verbatim texts written in alanguage other than English (Portuguese, Chinese, Korean,and Haitian Creole/French) were translated to English bybilingual members of the research team and added to theexcel spreadsheet to allow for review and analysis of theinformation as a group (see Additional file 3). Text trans-lation focused primarily on maintaining meaning consist-ent with health care language rather than culturalnuances, thus, formal translation procedures (e.g., forwardand back translation) were not completed. The authorsevaluated the English translations, providing constructivefeedback about the translation, and confirmed their valid-ity through governmental and professional guidelines andarticles.

Data analysisKey areas of analysis were articulated in the codebook,which provided a list of codes (e.g., themes and sub-themes) and included six basic components: the code, abrief definition, a full definition, guidelines for when touse or not use the code, and examples of the code. Ex-plicitly, the codebook helped the research team deter-mine the meanings of themes and provided clarity aboutwhat to look for within the text of the guidelines. Thecodes’ sensitivity and specificity were used as a tool formeasuring the adequacy of answers to research ques-tions. Data analysis entailed appraising and synthesizingtexts from guidelines, which were then organized intomajor themes and sub-categories through content ana-lysis [7]. Content analysis within the research team wasfacilitated through online meetings, which were conveni-ent and removed geographic barriers. Researchersassessed the data for coding patterns (e.g., similarity, dif-ferences, frequency) across different countries regardingtheir government guidelines for the general public and

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healthcare professionals. All texts from guidelines wereallocated deductively to the a priori themes (deductivecodes). During the iterative content analysis process,new themes also emerged (inductive codes). When dis-agreement ensued during data analysis, the researchteam recoded, or the primary coder sought advice fromanother team member for verification and clarification[7]. The original data of the confirmed and deaths caseswere downloaded from the Johns Hopkins UniversityCenter for Systems Science and Engineering [3]. Tab-leau, a well-known website for analyzing big data, wasused to clean and reshape the data for sharing with thepublic. The data was then converted to excel files andused to create figures (see Additional file 4) [8].

Trustworthiness of the dataWe established trustworthiness of the data by: 1) focus-ing on government guidelines, as they are a crediblesource of information (credibility), 2) using informationfrom guidelines, which maintain dependable and consist-ent patterns over time and are periodically updated toreflect the evolving understanding of the coronavirus(dependability), 3) using government guidelines, whichlimited the research team’s bias at the data collectionand interpretation level, and improved accuracy with theuse of a well-developed codebook (confirmability), and4) analyzing the guidelines of six countries experiencingthe coronavirus pandemic at the same time but withindifferent contextual realities (transferability) [9, 10].

ResultsTheme: Evaluation and testingSub-them: Screening criteriaWhen comparing the different government guidelineson screening for signs and symptoms in suspectedCOVID-19 cases, all countries listed respiratory symp-toms as a criterion and the majority – Brazil being theexception – emphasized fever, as well. Interestingly, theUS and UK did not list travel history as a criterion. Wealso noticed that the US and Brazil did not categorizepneumonia as a screening criterion, whereas SouthKorea, the UK and Haiti emphasized unknown case ofpneumonia, clinical or radiological evidence of pneumo-nia, and bronchopneumonia. A major distinction the au-thors noted was that only China and the UK specifiedthe detection of suspected COVID-19 cases within thehospital through either radiological evidence via chestX-ray and thoracic Computed Tomography (CT) orlymphocyte counts. Haiti, as of April 20, 2020, expandedthe screening criterion from ‘have a fever greater than38°C within the last 10 days’ to ‘anyone with fevergreater than or equal to 38 °C (see Additional file 3).’Haiti’s screening criteria also included body aches, sud-den changes in taste (ageusia) or smell (anosmia),

possibility of coming in contact with a healthcare profes-sional diagnosed with COVID-19, or being an occupantof a high risk area while experiencing symptoms com-patible with COVID-19 (see Table 1).Although information about contact with suspected

and/or confirmed cases was vital for screening criterionin most countries, the US and UK did not include this.Furthermore, specifically examining symptomatic pa-tients aged over 65 or who had underlying conditionswas only found in the US guidelines (see Table 1). Ofnote, South Korea created a new category in addition tothe suspected cases called the Patient Under Investiga-tion (PUI) on April 03, 2020. A PUI is a person who hasan epidemiologic link to a collective outbreak ofCOVID-19 in an area, or a possible contact to aCOVID-19 positive person. The US used the term PUIto describe people who exhibit symptoms, or wereotherwise suspected of having COVID-19, but had notyet been confirmed via laboratory testing.

Theme: Evaluation and testingSub-theme: Screening center typesAcross different countries, we identified three differenttypes of screening centers: healthcare facilities, drive-through screening clinics, and walk-through screeningclinics. While walk-through screening clinics were avail-able in South Korea, healthcare facilities were the onlyscreening centers available in Brazil and Haiti. Interest-ingly, Brazil and China did create other satellite facilitiesfor treatment, even though they did not create separatefacilities for screening. The US, UK and South Koreaconducted drive-through screening clinics.In particular, South Korea took a distinctly different

approach to managing suspected COVID-19 cases. Pa-tients with respiratory symptoms that fit the COVID-19suspected case criteria were blocked from entering thedesignated healthcare facilities (called the Public ReliefHospital System) and were redirected to other COVID-19 screening/test centers, or if the hospital was a screen-ing center itself, the patient suspected of havingCOVID-19 was directed to use a specific entrance forCOVID-19 screening before entering the main hospitalbuilding. The purpose of establishing the Public ReliefHospital System was to provide safe hospital environ-ments protected against COVID-19 spread. In otherwords, this was an attempt to block patients withCOVID-19 from spreading the virus to general patientswho did not have COVID-19.

Theme: Infection controlSub-theme: General outpatient guidanceOutpatients are patients outside of the hospital whoneed periodical medical attention due to other morbid-ities (hypertension, cancer, HIV/AIDS, etc.). In South

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Korea, outpatients who require healthcare service due tonon-COVID-19 diseases were directed to the Public Re-lief Hospital for follow-up or to see a doctor. These out-patients were strictly separated from patients with anyrespiratory symptoms.In Brazil and the US, outpatients were advised to call

ahead of their appointment time and were askedwhether they had experienced symptoms of respiratoryinfection. The UK and Haiti avoided treating outpatientsin their healthcare facilities. Still, the UK continued withoutpatient appointments either through video or phoneclinics. Chinese patients, on the other hand, could makean appointment via the phone or online and could thencomplete their appointment in the hospital as long asthe patient made the appointment with a specialist andavoided using the emergency room (ER) or fever clinicswhere COVID-19 patients had been treated. Haiti didnot provide recommendations regarding whether outpa-tients should make appointments with clinics, and out-patient services were unavailable to the generalpopulation. However, Haiti did provide some guidancefor those with HIV/AIDS, as Haiti has a high number ofindividuals suffering from HIV/AIDS. The US updatedtheir guidelines in April 13, 2020, advising healthcare fa-cilities to implement alternatives to face-to-face triage

and visits, and instructing patients to utilize cloth facecoverings regardless of symptoms upon entry to ahealthcare facility. However, the guideline did not spe-cify what alternatives were implemented.

Theme: Cost supportSub-theme: Cost supportFinancial support for testing and treatment was providedmainly or totally by the government in South Korea, theUK, and Brazil. In Haiti, the Haitian government, theUS, and the World Bank’s Board of Executive Directors,in conjunction with several international and private or-ganizations, donated money to cover the cost of thecountry’s COVID-19 response. In China, an individual’smedical cost was subsidized based on the subsidy policyof the local area if the patient was suspected of havingCOVID-19. However, once the patient received confirm-ation of COVID-19 infection, the medical cost was sub-sidized by the authorities. The cost of the clinic visit andtesting was made free for all US citizens regardless of in-surance status, per The Families First Coronavirus Re-sponse Act, which required private and federal insuranceto pay for Food and Drug Administration (FDA)-ap-proved testing, and for testing to be free to those whowere uninsured. The extent to which the COVID-19

Table 1 Evaluation & testing; COVID-19 symptoms screening criteriaCountries Fever Respiratory

symptomsPneumonia Clinical evidence Contact with

confirmedcases

Contactwithsuspectedcases

Travel history Patientsaged over65 withsymptoms

Patients withunderlyingconditions

US >100.4 °F/ 38 °C

Cough, difficultybreathing

N/A N/A N/A N/A N/A Withsymptoms

Withunderlyingconditions

China Fever Any respiratorysymptoms

Multiple patchyshadows andinterstitial changesat the lungs

CT imaging featuresof COVID-19 / eitherWBC or lymphocytecount decreases

Within 14 daysbefore theonset of thedisease

Within 14days beforethe onset ofthe disease

Within 14 daysbefore theonset of thedisease

N/A N/A

SouthKorea

≥37.5 °C Coughing, difficultybreathing

Unknow case ofpneumonia

N/A Within 14 dayswith respiratorysymptoms

Within 14days withrespiratorysymptoms

Within 14 dayswithrespiratorysymptoms

N/A N/A

UK (Onlyforinpatients)

≥37.8 °C Persistent cough (withor without sputum),hoarseness, nasaldischarge orcongestion, shortnessof breath, sore throat,wheezing, sneezing

Clinical orradiologicalevidence ofpneumonia

Acute respiratorydistress syndromeor influenza

N/A N/A N/A N/A N/A

Brazil N/A Coughing, runny nose,difficulty breathing

N/A N/A *** Possiblepatients

Travel abroadin the last 14days

N/A N/A

Haiti ≥38 °C Cough with or withoutrespiratory difficulties,headache, body aches,sudden changes intaste and smell

Acute upperrespiratoryinfection with atendency todevelop pneumoniaor broncho-pneumonia

N/A Possibly havinghad contactwith aconfirmedCOVID-19

Contactwith a sickperson

Within 14 dayswith flusymptoms

N/A N/A

All the information was only extracted from the government’s guidelines. Information from public news or other heath institution guidelines were excludeThe terms were extracted directly from the government guidelines. N/A represents the information did not indicate in the guidelines*** The Brazil government considers that contact with possible patients would include contact with confirmed cases

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treatment was covered differed between insurancecompanies.

Theme: Evaluation and testingSub-theme: Confirmation of COVID-19All six countries performed real time PCR to confirmCOVID-19 cases. Uniquely, the UK did not provide test-ing for COVID-19 to the community (at the time ofwriting), and instead reserved testing for National HealthService (NHS) staff, their relatives and – later in thepandemic – select essential workers. Some unique typesof confirmatory lab tests were via virus isolation inSouth Korea, virus gene sequencing in China, and sero-logical examination in Brazil, Haiti, and the US.Brazil made the decision to include epidemiological

criteria, meaning a confirmed case could be included ifthe individual met clinical criteria and epidemiologicalevidence, despite a lack of confirmatory laboratory test-ing for COVID-19. The US, however, made the distinc-tion that an individual who met those guidelines wasconsidered a probable case. The US also described prob-able cases as a person meeting the presumptive labora-tory evidence and either the clinical criteria or theepidemiological evidence. Finally, an individual could beconsidered a probable case by the US if their vital re-cords, as in their death certificate, indicated the persondied of causes related to COVID-19, despite not havinga confirmed laboratory test result.

Theme: Triage protocolsSub-theme: Hospital admission criteriaAll countries’ hospitalization decisions were made on acase-by-case basis. While Haiti’s hospitalization criteriawere not specified by the government, Brazil relied onpost-collection medical evaluation for hospitalization de-cisions. The Chinese guideline did not indicate hospitaladmission criteria. The US recommended hospitalizationof people with severe symptoms: septic shock, sepsis,pneumonia, hypoxemic respiratory failure, acute respira-tory distress syndrome (ARDS), and cardiomyopathy,etc. The UK required either clinical evidence of pneu-monia or radiological evidence with a high suspicion forCOVID-19, with ARDS-like or influenza-like symptomsfor hospitalization.Uniquely, South Korea created three different categor-

ies, ranging from moderate, severe, to extremely severefor hospitalization. Asymptomatic COVID-19 positiveindividuals or those with mild symptoms were sent tothe Living Treatment Center, a facility that monitoredsymptoms twice a day and transferred support to thehospital in the event of a worsening of symptomseverity.

Theme: Infection controlSub-theme: Healthcare triage isolationAll six countries developed an isolated area for screeningand follow up for symptomatic patients in order to iso-late suspected cases. Brazil and the US advised health-care facilities to place suspected cases in well ventilatedspaces that allowed sufficient space between patients.South Korea, Haiti, and China organized their healthcarefacilities into different levels of care according to the ab-sence or presence of respiratory symptoms. More specif-ically, China categorized triage isolation areas into thosefor confirmed, suspected, or non-COVID-19 patients.

Theme: Infection controlSub-theme: Visitor access to healthcare facilitiesIn China, visitors were prohibited from accessing health-care facilities, whereas the UK and South Korea madeexemptions for seriously ill patients receiving end-of-lifecare, who were allowed one visitor per ward patient.Brazil and Haiti limited the number of visitors to theminimum amount possible, but only Haiti required thatall visitors entering the hospital wear a face mask. Al-though earlier in the pandemic the US made no recom-mendations regarding visitor access, by April the USCenter for Disease Control and Prevention (CDC) ad-vised hospitals to limit the number of visitors allowed.Except for China’s guidelines, all countries took extra

precautions towards visitors, establishing protocols forvisitors regarding proper Personal Protective Equipment(PPE) and hygiene. Although the US CDC guidelineswere not as restrictive as other countries regarding vis-itor limitations, the US guidelines suggested activelyscreening visitors for fever and COVID-19 symptomsupon entry to healthcare facilities. If COVID-19 symp-toms were present, the guidelines advised that the visitornot be allowed entry to the facility. Similarly, Brazil sug-gested avoiding entry of visitors with respiratory symp-toms. The US CDC and the Brazilian government alsorecommended posting visual alerts advising visitors towash their hands frequently, limiting visitors to the mostvulnerable patients (i.e. oncology and transplant awards),encouraging the use of videocall applications in place ofin-person visits, and recommending visitors leave the pa-tient during aerosol generating procedures or other spe-cimen collection procedures. Lastly, Brazil and the USinstructed visitors to only visit the patient’s room, notany other locations in the facility.

Community guidelinesTheme: Prevent getting sickSub themes: Prevent getting sickMost recommendations to the community on preventinggetting sick were similar between the six different coun-tries. In order to explore the major differences, the sub-

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themes were organized according to singular actions (i.e.total time washing hands, covering cough and sneezes,face-cover recommendations, etc.).Generally, face-cover recommendations changed

throughout the pandemic, however South Korea andChina recommended the use of face masks in publicplaces from the beginning of the pandemic, even if theindividual was not sick. The UK did not indicate clearguidance on this matter. The US, Brazil, and Haiti didnot initially recommend wearing a face covering, how-ever, the guidelines were updated by the US CDC onApril 4th, 2020, by the Brazilian Health Ministry onApril 5th, 2020, and by Haiti in the middle of April 2020to indicate that all people, regardless of whether theywere sick, should wear a cloth face covering in public.However, medical grade face masks were still not recom-mended for the community, as they were to be reservedfor health care workers due to shortages.South Korea, Brazil, Haiti, the US and the UK did not

provide guidance on the sharing of personal items in thegeneral community guidelines regarding the preventionof getting sick. China was the only country who men-tioned not sharing any personal items to the communityas a method for preventing contraction of COVID-19.Even though most community guidelines on prevent-

ing illness recommended maintaining 1.8–2.0 m of phys-ical distance between people to avoid viral transmission,Haiti’s guidance on physical distancing initially recom-mended staying two steps away from other individuals.Haiti updated their recommendation to staying threesteps away from others on April 20th.

As of April 8th, 2020, as a unique measure to preventviral spread, the South Korean government made itmandatory for all Koreans and long-term stay foreignerswho entered South Korea to (1) be tested for COVID-19, (2) install an application on their cell phones: theSelf-quarantine Safety Protection App, and (3) abide bythe guidelines for self-quarantined persons, includingconducting self-diagnosis for a period of 14 days (seeTable 2).

Theme: If you are sickSub theme: What to do if you are sickBased on the guidelines, we were able to extract 8 im-portant terms, including avoid using public transportand crowded places, isolation days and next steps, facemask or cloth face covering, use a separate room or bath-room, sharing household items, sick room ventilation,cleaning instructions, call center for COVID-19 (seeTable 3). These terms were ascertained from at least twocountries’ guidelines.Five of the countries recommended people with re-

spiratory symptoms stay at home for certain periods,whereas the Chinese guidelines advised sick people toimmediately go to a designated medical care institutionfor testing, and to then follow the quarantine protocolsrequested. Each country designated different isolationperiods and procedures. As reported by the US and theUK governments, people with respiratory symptomswere to isolate at home and only stop home isolationunder the following conditions; no fever for at least 72 hwithout the use of medications that reduced fever,

Table 2 Prevent getting sick

Countries Total timeof washinghands

Handwashing

Cover coughsand sneezes

Social distance Face cover/gloves Avoid touching face withunwashed hands

US 20 s (until dryif using handsanitizer

Soap, handsanitizer (>60% alcohol)

Elbow or tissue,Immediately washyour hands or use handsanitizer afterward

6-ft Cloth face cover (Updateon April 4, 2020)

Avoid touching your eyes,nose, and mouth withunwashed hands

China Keep goodhand hygiene

Soap, alcohol-based handsanitizer

Elbow N/A Disposable medicalfacemask, Surgical mask,Gloves are recommended

Avoid touch face with handswhen you uncertain abouthands’ cleanness.

SouthKorea

More than 30s

Soap Elbow 2-m Facemask Do not touch your eyes, nose,or mouth with unwashedhands

UK 20 s Soap, handsanitizer

Tissue, wash yourhands

2-m (6-ft) N/A Do not touch your eyes, nose,or mouth

Brazil 40–60 s withsoap, 20–30 swith alcohol

Soap, 70%alcoholicpreparation

Tissue or arm 2-m Face cover (Update onApril 5, 2020)

Avoid touching your eyes,nose, and mouth with yourunwashed hands

Haiti N/A Soap Elbow or disposablehandkerchief

2 steps, (Updatedon April 20, 2020)3 steps

Facemask Remember to always washyour hands before touchingyour mouth, eyes and nose

All the information was only extracted from the government’s guidelines. Information from public news or other heath institution guidelines were exclude. Theterms were extracted directly from the government guidelines. N/A represents the information did not indicate in the guidelines.

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Table 3 What to do if you are sickCountries US China South Korea UK Brazil Haiti

Avoid using publictransport andcrowded places

Stay home except toget medical care.Do not visit publicareas.Avoid publictransportation, ridesharing, or taxis.

Immediately go tothe designatedmedical careinstitution for havingspecimen collectionand lab analysis andfollow thequarantine protocolsas requested.Avoid using publictransportations anddo not go tocrowded places

Do not go to school orwork avoid outdooractivities

Stay at home and donot meet up with otherpeople,Only go outside for food,health reasons or work(but only if you cannotwork from home)

Avoid physicalcontact with otherpeople, especiallythe elderly andchronically ill andstay home until youget better

Symptoms of acuterespiratory infectionshould be placedunder observationor quarantineresidential orinstitutionalquarantine

Isolation daysand next steps

If have had no feverfor at least 72 hwithout use of feverreducing medication,other symptomsimproved, and atleast 7 days havepassed sincesymptoms firstappeared.OR if no longer havea fever, othersymptoms haveimproved, andreceive 2 negativetests in a row, 24 hapart

All family membersand close contactsrequired to take 14-day quarantine

Take a rest at home andmonitor the symptomsfor 3-4 daysConsult with KCDC Callcenter at 1339, a localcode+ 120 or a localhealth center (visit atriage health centerwhen fever (38 °C)continues, or othersymptoms get worse

Stay home 7 days ifyou have Coronavirussymptoms.After 7 days, if you feelbetter, you can start yourusual routine again.

All residents are inisolation for 14 days

Symptoms of acuterespiratory infectionshould be placedunder observationor quarantineresidential orinstitutionalquarantine.

Face mask or clothface covering

[Sick person] shouldwear a cloth facecovering, over yournose and mouth ifyou must be aroundother people even athome.The caregiver shouldwear [for cleaningthe sick person’sbathroom] a mask/cloth face coveringand wait as long aspossible after thesick person has usedthe bathroom

All family membersshould wear adisposable medicalface mask

If necessary [to contactfamily or others] wear amask

N/A The infected person:Wear a mask at alltimes

Recommended foreveryone leavingtheir home (Updateon April 06, 2020)

Use a separateroom or bathroom

You should stay in aspecific “sick room”if possible.Use a separatebathroom if available

N/A Separate self from othersas much as possible. Usea separate bathroom ifavailable (If it isnecessary to use acommon bathroom,disinfect after use)

N/A A room Used forisolation.In houses with onlyone room, otherresidents must sleepin the living room,away from theinfected patientIn the room used forinsolation, keep thewindows open forair circulation. Thedoor must be closedfor the duration ofthe insolation.

N/A

Sharing householditems

Avoid sharingpersonal householditems: Do not sharedishes, drinkingglasses, cups, eatingutensils, towels, orbedding with otherpeople in your home

N/A Avoid sharing personalhousehold items (dishes,drinking glasses, utensils,towels, bedding) andwash Used itemsthoroughly after use

N/A The waste producedby the contaminatedpatient needs to beseparated anddisposed. Bathtowels, forks, knives,spoons, glasses andother objects usedby the patient. Sofasand chairs cannot beshared either.

N/A

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improvement of other symptoms, and the passage of atleast 7 days since symptom onset. Brazil and China ad-vised that, in addition to the person with respiratorysymptoms, all family members or fellow residents wereto be quarantined for 14 days. In South Korea, any per-son who had COVID-19 symptoms was mandated tostay at home for at least 3 to 4 days and was then calledand given advice by the Korea Centers for Disease Con-trol and Prevention (KCDC) call center.To prevent the spread of the virus between family/

household members, the US, South Korea, and Brazilrecommended the ill person be confined to a separateroom and bathroom and avoid sharing personal house-hold items. Haiti, China, and the UK did not provideguidance on providing a separate room/bathroom or onsharing personal items.Isolation room ventilation, such as keeping the win-

dow open for air circulation or closing the door, werementioned in the South Korean and Brazilian guidelines.

Cleaning instructions for containing the virus were indi-cated in different ways in each country, except for in theUK and Haiti. Call centers for COVID-19 were con-ducted in South Korea, Haiti, and Brazil in the very earlystages of the pandemic.

Theme: If you are sickSub theme: Threshold to contact a healthcare providerAcross the countries examined, the threshold symptomsfor when to contact healthcare providers varied. SouthKorea advised sick people to contact a healthcare pro-vider if the person had a fever (37.5 °C) or if symptomsworsened. Brazil recommended seeking help if the illperson experienced shortness of breath. The US advisedindividuals to get medical attention if they experiencedpersistent pain, chest pressure, cyanosis on lips or face,new confusion, or if unable to be awakened. Haiti men-tioned contacting a healthcare provider if the individualhad respiratory symptoms. Besides the usual respiratory

Table 3 What to do if you are sick (Continued)Countries US China South Korea UK Brazil Haiti

Sick roomventilation

N/A N/A The isolation room mustclose the door and openwindow for ventilation

N/A In the room used forinsolation, keep thewindows open forair circulation. Thedoor must be closedfor the duration ofthe isolation.

N/A

Cleaninginstructions

Wash [household]items thoroughlyafter use (with soapand water or put inthe dishwasher).Clean high-touchsurfaces in yourisolation area (“sickroom” andbathroom) everyday; let caregiverclean and disinfecthigh-touch surfacesin other areas of thehome. If a caregiverneeds to clean anddisinfect a sickperson’s bedroomor bathroom, theyshould do so on anas-needed basis. Thecaregiver shouldwear a mask/clothface covering andwait as long aspossible after thesick person hasUsed the bathroom.Clean and disinfectareas that may haveblood, stool, or bodyfluids on them

[Confirmed COVID-19 person’s]residence, supplies,cloth, beddings,tableware and otherbelongings have totake the procedureof final disinfection,for future reuse.

If it is necessary to use acommon bathroom,disinfect after use.Wash used [household]items thoroughly afteruse.

N/A Clean the handle [ofthe door to theroom used forisolation] frequentlywith 70% alcohol orbleach.Household furnitureneeds to be cleanedfrequently withbleach or 70%alcohol.After using thebathroom, never[skip] washing yourhands with soap andwater and alwaysclean the toilet, sinkand other surfaceswith alcohol orbleach to disinfectthe environment.

N/A

Call center forCOVID-19

N/A N/A KCDC Call center at 1339,a local code+ 120

N/A TeleSus 136 Call the Ministry ofPublic Health’ scenter ofepidemiologyat 4343 3333

All the information was only extracted from the government’s guidelines. Information from public news or other heath institution guidelines were exclude. Theterms were extracted directly from the government guidelines. N/A represents the information did not indicate in the guidelines.

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acute signs (fever, shortness of breath), China also men-tioned acute digestive tract symptoms as a reason toreach out to a healthcare facility. In the UK, if a person’ssymptoms worsened to the point where they were hav-ing difficulty breathing, they were advised to go to thehospital by ambulance facilitated by the online NHSservice.

Theme: If you are sickSub-theme: Transport to healthcare facilitiesThe US, South Korea, and China recommended usingpersonal vehicles and to avoid using public transporta-tion to reach healthcare facilities, however South Koreaand China specified that individuals should cover theirface with a face mask before reaching healthcare facil-ities. Five of the countries allowed ambulance transport,with the exclusion of China.

DiscussionWHO acknowledged and announced the impact ofCOVID-19 on both public health and economic sectorsvia two interim guidelines published in late March 2020.WHO also emphasized the importance of preparednessfor the COVID-19 pandemic, accounting for the coun-tries’ health care capacities [11, 12]. The six countriestend to align with the WHO interim guideline, howeverthere are some differences in the response to the pan-demic in each country.The major differences in evaluation and testing criteria

in the guidelines across the six countries centeredaround the priority of testing for COVID-19 in thepopulation, which strongly depended upon each coun-try’s healthcare capacity including accessibility to health-care providers, having enough testing kits and reagents,availability of hospital beds, and so on. The most similarrecommendations in the evaluation and testing criteriafrom each government were those pertaining to the clin-ical signs and symptoms, such as fever and respiratorysymptoms, as the priority criteria to initiate COVID-19testing.During the writing of this paper, there were no known

vaccine or antiviral therapies for COVID-19. Therefore,early detection and diagnostic testing for SARS-CoV-2were vital to reducing transmission, managing activecases, contact tracing, and understanding epidemiology[13]. The government guidelines concerning screeningcriteria and capacity for screening – including screeningcenters, and laboratory testing for COVID-19 in sus-pected or confirmed cases –were crucial factors in pro-tecting the public from the virus. The WHO criticizedcountries that had not prioritized testing for COVID-19.Tedros Ghebreyesus, the chief executive of WHO, em-phasized the importance of testing by stating, “The mosteffective way to prevent infections and save lives is

breaking the chains of transmission. You cannot fight afire blindfolded, and we cannot stop this pandemic if wedon’t know who is infected. We have a simple messagefor all countries: test, test, test, test” [14]. However, lackof reagents and/or testing capacity for the SARS-CoV-2virus challenged all nations included in the study, atleast at the beginning of the pandemic. The US, UK,Haiti, and Brazil, in particular, experienced problemswith shortages of testing kits for SARS-COV2 due torapidly increasing demand compounded by national sup-ply chains under stress and national laboratories withlimited experience in COVID-19 virus testing [15, 16].This had a negative impact by potentially obstructingthe expansion of COVID-19 testing criteria, resulting ina narrowed range of people undergoing COVID-19 test-ing, which may have led to increases in the actual num-ber of cases and overall risk of death by COVID-19, butfalsely decreased the number of confirmed cases anddeaths reported in the nations’ statistics.According to the UK’s NHS, testing priority was given

to 1) intensive care unit patients with suspected corona-virus, 2) patients with severe respiratory illness includingpneumonia, 3) isolated cluster outbreaks, and 4) randomtesting for surveillance purposes [17, 18]. The first 2confirmed cases occurred in the UK on January 31, 2020and the first COVID-19 victims died on March 7, 2020(see Fig. 1). After 20 days, although the UK only testedpeople who were admitted to hospitals, the number ofconfirmed cases and disease-related deaths dramaticallyincreased (confirmed cases: 14,745, deaths: 1163) [19].By April 7, 2020, 1 month after the first COVID-19deaths, more than 1000 people were dying every day dueto viral infection (see Fig. 1). In April 9, 2020, despitethe thousands of citizens dying daily due to COVID-19related causes, the UK government launched largeCOVID-19 testing centers which prioritized processingsamples from health-care workers in self-isolation,allowing them to go back to work [18]. Therefore,people who were not considered a priority, such as non-health care providers or community members with mildrespiratory symptoms, were not given access to testing.The limited scope of the UK’s testing approach forCOVID-19 was due to a capacity problem, resultant tothe consolidation in the number of pathology laborator-ies nationwide [18]. Many laboratories were centralized,which led to the possibility that each hospital would notnecessarily be equipped with a fully functioning lab. Thissystemic capacity problem may have increased the riskof spread by free movement of people who were sus-pected of having the disease, since testing was unavail-able to those individuals to enforce a stay-at-homeorder. In the UK, 90,000 people were tested as of the24th of March - around 1300 COVID-19 tests per mil-lion people. Although it was a higher portion than some

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nations, including the US (around 74 per million as ofthe 16th of March), it was far behind South Korea (5200per million as of the 17th of March) [20, 21].Initially, the US’s CDC included fewer testing criteria

than the WHO guidelines. The CDC guidelines recom-mended testing individuals with a body temperatureabove 38 °C (fever) and lower respiratory symptoms,those who had a fever and a travel history to China, orthose who had a fever and were possibly exposed to asuspected or confirmed COVID-19 case. However, oncea patient who did not have any travel history or expos-ure to any confirmed COVID-19 cases was reportedCOVID-19 positive, the CDC expanded their testing cri-terion to include any individuals admitted to a hospitaldue to lower respiratory symptoms and fever. Thisaddition broadened the spectrum of patients beingtested, but also led to rapid increase in the demand fortesting.In February 2020, the CDC acquired, developed, and

distributed COVID-19 testing kits to laboratories nation-wide, almost one hundred of which reported experien-cing several issues with the testing kits. These issuesincluded the failure of negative controls and presenta-tion of inconclusive results. After an internal investiga-tion on February 12, 2020, the CDC reported a faultyreagent as the issue. The CDC immediately recalled allunreliable testing kits and promised to re-manufacturethe faulty component and distribute the newly developedreagent to the public health labs as soon as possible. Ul-timately, the shortage of COVID-19 test kits at this crit-ical time point possibly interfered with the prevention ofincreasing confirmed cases early in the outbreak. Fur-thermore, although the number of confirmed cases anddeath rate significantly increased each day after March,20, 2020 in the US (confirmed cases per day around 15,000, deaths per day around 1000), only 97 public healthlaboratories finished verification and were offering test-ing on May 6, 2020 [22]. As further evidence of inad-equate testing capability, the CDC announced that“although supplies of tests are increasing, it may still bedifficult to find a place to get tested” [22].Together, the capacity for widespread testing and pres-

ence of prepared health facilities were key to controllingthe dissemination of coronavirus, as evidenced by SouthKorea. The first COVID-19 incident in South Korea wasannounced on January 31, 2020, with 7 confirmed cases.The daily confirmed cases remained low for the follow-ing month (confirmed cases: 100, deaths: 1) until a superspreader event was initiated on February 29, 2020. Eachday for 9 days afterward, the country’s epidemic curveresembled a steep staircase as infections climbed, result-ing in dramatically increased confirmed cases and deaths(see Fig. 1). However, by implementing large-scale gov-ernmental COVID-19 testing, health officials were able

Fig. 1 COVID-19 Cases in six countries

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to effectively contact trace and send potentially infectedpeople into quarantine as a preventative measure. ByMarch 25, 2020, more than 357,000 Koreans had beentested. The country reported 10,804 total coronaviruscases and 254 deaths as of May 1, 2020. This was thelowest death rate among the countries examined [3, 23].Having previously dealt with the Middle East respiratorysyndrome (MERS) in 2015, South Korea had already pre-pared for potential outbreaks of large-scale epidemics,for example by installing negative pressure rooms inhospitals in 2018. Additionally, the country rapidly de-veloped large-scale availability of COVID-19 testing lo-cations, such as K-Walk-Thru and Drive-thru testingstations. These were the first testing centers of their kindin the world and facilitated the quick and safe collectionof samples for COVID-19 testing. These unique centershelped not only reduce the risk of cross infections at thein-hospital testing centers, but also increased daily test-ing capacity amid rapidly rising rates of new cases [24].WHO emphasized the prioritization of isolated care

for patients with higher risk of infection, such as severeand critical illness patients aged over 60 years, and thosewith underlying medical conditions [25]. Still, exponen-tial escalation in the number of daily confirmed casesplaced enormous strain on national medical systems,resulting in limited or total lack of beds for COVID-19treatment. Therefore, the US, UK, South Korea, Brazil,and Haiti decided patients with mild to moderate cor-onavirus symptoms should be observed in “Home Isola-tion”. This approach was a crucial option that onlyrequired modification in individual behavior withoutsupplementary expenditure.Interestingly, China opposed observing mild to moder-

ate coronavirus cases at home, instead directing all po-tentially infected persons to designated medical careinstitutions. This policy was initiated in Wuhan, the citywhere COVID-19 emerged in early February 2020 [26].On March 27, 2020, more than 60% of coronavirus casesin the country were at Wuhan (see Fig. 1). The city con-verted exhibition centers and stadiums into shelter hos-pitals within mere weeks. Epidemiological evidence atthe beginning of the pandemic revealed high intrafamilytransmission, with 75–80% of all clustered infections di-agnosed within families [26, 27]. Quickly emerging alter-native hospitals, such as the Fangcang Shelter Hospitals,dedicated to testing and admitting only COVID-19 pa-tients may have led to a reduction in the spread of thevirus in the community, thereby decreasing the numberof new cases during the pandemic.On January 22, 2020, the WHO announced the pres-

ence of travel-related cases linked to Wuhan City,human-to-human transmission, and reported COVID-19had been observed outside of China. The WHO stronglyadvised individuals to report their travel history to their

health care providers [28]. However, the UK did nottrack travel history as it was not considered valuable in-formation in their testing criteria. This was problematicsince people who traveled to COVID-19-occurring areascould have potentially acted as carriers of the virus totheir respective communities and families, which mighthave strongly influenced the increasingly steep con-firmed case curves. Neither the American, Brazilian norHaitian governments considered a history of travel to aregion of high COVID-19 incidence to be a high priorityfor testing, or to be an important criterion for suspectedcases. Those with a travel history to high spread areaswere only encouraged to seek testing if they developed afever or respiratory symptoms. In direct contrast, theChinese guidelines suggested that any travelers whotraveled to a region or country with occurrence ofCOVID-19 must be tested, regardless of whether theyhad developed symptoms.Although WHO provided a definition of symptoms

observed in suspected cases that warranted further sur-veillance [11], it was a challenge to define the full clinicalcharacteristics of COVID-19. Fever (> 38 °C), breathingproblems, and chest radiographs showing bilateral lunginfiltrates were the main clinical signs and symptoms re-ported during the outbreak [13, 29]. For this reason,most countries considered fever, respiratory symptoms,and pneumonia as clinical justification for initiatingdiagnostic testing. Although by March/April 2020, theUK and US countries were defined as ‘countries experi-encing larger outbreaks’ (as referred to in Group 4 of theWHO guidelines), they did appear to be largely acting inaccordance with WHO advice at that point in time, des-pite not acting on the previous advice regarding thescreening of travelers [11].Although there was ample evidence of human-to-

human transmission, the US and UK did not includecontact with confirmed or suspected cases as screeningcriteria very early in the pandemic. The absence of thiscriteria early in the pandemic may have led to increasedrisk of viral spread. In contrast, South Korea undertookan intense contact-tracing program: upon confirmationof a COVID-19 case through laboratory testing, theSouth Korean government conducted interviews withthe infected person, traced their travel history, used GPSphone tracking, and checked their credit-card history.The anonymized data detailing the travel history beforediagnosis was published on a public website by theSouth Korean government. This allowed government of-ficials to quickly release information about potentialCOVID-19 exposed locations and help people who mayhave been near those locations make quick decisions onwhether they needed to be tested. Though effective,there were and continue to be concerns regarding indi-vidual privacy.

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With the global spike of COVID-19 and consequentsurge in suspected cases and geographic areas affected,the need for implementing screening criteria to bettercope with each country’s capacity for screening and la-boratory testing became increasingly evident. However,beyond supply chain issues with provision of testing kits,there were significant limitations of the governmentguidelines for COVID-19 testing in several domains. Na-tional health systems and coverage of COVID-19 med-ical expenses were vital to fostering a sense of financialcertainty and a safe environment for those who were in-fected. Testing and treatment support came mainly ortotally from the government in South Korea, the UK,China, and Brazil. All US citizens were covered for FDA-approved COVID-19 testing, regardless of private or fed-eral insurance status, however, treatment coverage wassubject to the insurer’s policy. Despite the larger role thegovernments took in most of the countries examined,Haiti’s COVID-19 health care response was primarily fi-nancially supported by the private sector (60%). Hospi-tals and newly established screening clinics from theprivate sector worked together with the Haitian Ministryof Health to screen Haitians, however health care facil-ities from the private sector were not regulated by gov-ernment officials (hence the paucity of governmentscreening guidelines) [30]. Given these limitations intesting capacity, WHO launched the ‘COVID-SolidarityResponse Fund for WHO’ to support COVID-19 rapidtests for low and middle-income countries [31].In March 19, 2020, WHO recommended that “when

symptomatic, patients are required to wait, ensure theyhave a separate waiting area” [32]. As an example of theincreased preparedness the WHO called for, the SouthKorean government created temporary ‘Public ReliefHospitals’ which provided isolated treatment rooms forpatients with respiratory and non-respiratory symptomsto ensure safe medical services to general patients and toprevent viral spread. Public Relief Hospitals were dividedinto two types: Type A and Type B. Both had separateoutpatient treatment zones for patients without respira-tory symptoms and for patients with respiratory symp-toms but differed in whether their testing centers werecontained within the hospital. The Korean governmentalso permitted patients who have a chronic disease, butdid not have any respiratory symptoms, to receive coun-seling and prescriptions by telephone or by proxy, there-fore decreasing the risk of internal cross-infection withinhealth care facilities for higher-risk patients. This ap-proach was also utilized in the US and UK. In SouthKorea, non-respiratory patients, such as cancer patientsor patients with heart problems, were directed to thegeneral outpatient area at a Public Relief Hospital. Pa-tients with mild respiratory symptoms were directed tosee a doctor nearby, or to go to a respiratory outpatient

area at a Public Relief Hospital. Suspected patients orPUI who developed COVID-19 symptoms were referredto a COVID-19 testing center after receiving guidancefrom a competent clinic or the 1339 call center. Usingthis triage workflow, Korean hospital systems were bet-ter able to prevent internal spreading of the COVID-19virus in the hospitals and potentially reduced a higherinfection-related risk of mortality across the population.The South Korean death rate provided evidence to sup-port this hypothesis, showing that although they had ahigh rate of confirmed cases (10,780), the total numberof deaths was only 250.WHO recommended healthcare facilities limit the

number of visits to suspected or confirmed COVID-19patients by health care providers, family members, andvisitors while being treated in health care facilities.WHO also suggested maintaining a record of all staffand visitors who entered suspected or confirmedCOVID-19 patients’ rooms [32]. Even though the US’sfederal guidance on hospital visitation seemed more lib-eral than other countries, especially when contrastedwith South Korea and the UK, more restrictions wereadopted depending on the local circumstances. For ex-ample, although limiting visitors was not advised by theUS CDC until April, several hospitals in New York cityrestricted visitor access as early as March. Brazil’s gov-ernment strongly recommended individuals with flu orrespiratory symptoms are not allowed entry to the hospi-tals. The government also recommend the hospitals re-duce visitor numbers, which, while not mandatory, washeavily implied to be. Although limitations of visitorswere not mandatory, wearing a face mask wasmandatory for all visitors in Haiti.The figure illustrates the incidence of confirmed cases

and deaths in six countries from January to April.

Community guidelinesTheme: Prevent getting sickDespite being consistently recommended for use bysymptomatic individuals and those in health-care set-tings, discrepancies were observed in the recommenda-tions on wearing face masks in the general public andcommunity settings. The WHO consistently maintainedthat the benefits of healthy people using masks in thecommunity setting was not supported by the currentevidence, and additionally could contribute to uncertain-ties or create critical risks [29]. This advice to decisionmakers remained in place up until the time of this papersubmission in May 2020.Several nations, such as the US and Brazil, changed

their face cover recommendations as new studies wereconducted that supported the use of face masks as an ef-fective means to limit viral spread. Some studies mayunder-estimate their protective effects, while

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observational studies exaggerate them [33]. However,with the emerging evidence of asymptomatic or pre-symptomatic COVID-19 transmission, the authors notethat the community guidance regarding utilizing a facemask and not sharing personal items could significantlyprevent potential asymptomatic or presymptomatictransmission, which corroborates other publications[16]. Mask shortages were prevalent across countries intheir early stage of use. For example, at the beginning ofthe pandemic, there was a mask shortage in South Koreadue to mass panic-induced purchases by citizens. TheSouth Korean government requested manufacturers in-crease mask production, and then ensured the newlymanufactured masks were directly allocated to pharma-cies where only a limited number of masks could be pro-vided to individuals. The number of available masks wasdisplayed in government- and private sector-createdapps to prevent citizens from lining up outside pharma-cies, which could have resulted in violating physical dis-tancing measures. Additionally, the National HealthInsurance Service database showed how many maskswere sold to individuals per week.Generally, the guidance provided across the six nations

regarding avoiding infection by washing hands or usingalcohol-based hand sanitizer frequently, performing re-spiratory etiquette when coughing or sneezing, andavoiding touching the face corroborated the WHOguidelines [34].Despite physical distancing being vital to mitigating

the spread of the novel coronavirus, political beliefs affectedcompliance with COVID-19 social distancing guidelines.This was especially evident in the US, where, in general,people who held contrasting political beliefs to the residentstate governing body were less responsive to stay-at-homeorders. For example, Republicans did not fully respect andreact to stay-at-home orders when Democratic counties an-nounced the order. In a similar fashion, Democrats wereless likely to respond to stay-at-home orders when a Re-publican governor issued the decree [35].On that point, it is worth noting that although the

countries examined all referred to the government is-sued COVID-19 notices as ‘guidelines,’ these noticeswere not enforceable equally across countries. As an ex-ample, in the US, the CDC’s guidance acted as a frame-work that could be adapted for use by individualhospitals or by local/state governments for legislativepurposes. However, in South Korea the guidelines essen-tially acted as enforceable legislation with serious finan-cial repercussions.Another important political development to note oc-

curred in Brazil, when the Ministry of Health included avideo on their website focused on clarifying “fake news”about the coronavirus. The video requested users con-firm whether information presented in various medias

was true before sharing that information with others. Italso suggested individuals consult with an official num-ber via WhatsApp for information clarification andcommunication.An additional concern was raised regarding the use of

health-tracking apps. Various countries used voluntaryhealth-tracking apps to manage the COVID-19 pan-demic either for informational, health vigilance, or con-tact tracing purposes. However, a unique aspect of theSouth Korean response was the mandate for all Koreansand long-term expatriates to install a health tracking appfor contact tracing purposes. Privacy concerns wereraised by several publications, some of whom referencedthe possibility of preserving data protection [36], whileothers reflected on the legal implications and the needto refine the data into an aggregate, rather thanindividual-level data, to better deter the misuse of thedata [37].The countries’ guidelines on how to care for people in-

fected with COVID-19 experiencing mild symptoms athome aligned with the WHO guidance [38]. Accordingto the WHO, ensuring the sick person used a separateroom and bathroom in the home would be essential tocontaining the virus, however, only the US, South Korea,and Brazil made this recommendation to their respectivecommunities. Haiti, the UK, and China did not mentionthis recommendation in their guidelines. Although thosesuspected of contracting the coronavirus were requestedto stay at home in the UK, limited information was pro-vided to guide the home care process, such as how todisinfect the ill person’s room or how to handle sharinghousehold items in the home. In China, all people sus-pected of having the coronavirus were instructed to seektesting at a testing center and were admitted to ‘Fang-cang Shelter Hospitals.’ Therefore, it could be argued itwas not necessary to provide information to the commu-nity on how to deal with sick people at home. The deci-sion to advise all people suspected of having thecoronavirus to go directly to the hospital is at odds withat least one study, which proposed that instead of guid-ing the COVID-19 patient to seek healthcare facilities, itwould be preferable to provide at-home testing andmonitoring [39]. However, while staying at home it iscritical to carefully monitor worsening symptoms sincemedical care is not necessarily immediately available.The symptom thresholds to contact healthcare pro-

viders varied between countries, with a wider array ofsymptoms (beyond the respiratory types) being includedby countries that had dealt with the epidemic for longerperiods of time. Clearly a great deal of clinical judge-ment was necessary for monitoring disease progression,since acting in a timely manner to differentiate a moreserious case of COVID-19 was crucial to limitingfatality.

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Finally, WHO provided information regarding thetransportation of patients with confirmed and suspectedCOVID-19 to referral health care facilities, however,WHO did not give any information regarding transportmode to individuals with suspected COVID-19 [40]. Theguidelines on transportation to healthcare facilities var-ied in emphasis between governments. A publicationfrom China showed key involvement of public transpor-tation in the dissemination of coronavirus. According tothe study, the daily frequency of public transportationentrance and exit from Wuhan was significantly relatedto the number of COVID-19 cases in other cities [41].When traveling to a hospital due to the presence of po-tential COVID-19 symptoms, wearing a face mask, usinga personal vehicle, avoiding public transports and/orcalling an ambulance were recommended by the Korean,US, and Chinese government’s guidelines. The UK andHaiti advised such patients utilize ambulance transportwhen heading to the hospital. The Brazilian governmentdid not provided advice regarding transport mode.

LimitationsThese findings are related to the guidelines for health-care facilities and communities, as updated until April20, 2020, however some guidelines may have been con-tinuously updated beyond this date. In Haiti, because ofthe low prevalence of COVID-19 (total confirmed case:100, deaths: 8 as of May 1, 2020), some information wasunable to be obtained from the government guidelines,even though it was provided by news outlets or othermedias, which were not included here. This study onlyused government guidelines accessible by the public,which may have limited the scope of the study’s usableinformation.

ConclusionIn summary, all six countries updated their guidelines,especially screening criteria, as the incidence of COVID-19 increased to take more aggressive actions against theprogression of COVID-19 spread and to help “flatten thecurve,” thus easing some of the burden on the respectivehealthcare systems. In the initial stages of the outbreak,certain strategies were universally employed to controlthe deadly virus’s spread, including quarantining thesick, contact tracing, and social distancing. However,these measures would have limited value if the peoplesuspected of contracting the disease were not tested. Itis difficult, if not impossible, to identify any one factor asthe greatest cause for coronavirus dissemination, but bycomparing these countries’ approaches it is possible toidentify multiple factors that contribute to an overall ef-fective strategy for reducing its spread. Additionally,there are multiple characteristics that influence theprevalence and incidence of COVID-19, including

population density, differences in healthcare infrastruc-ture, and primary means of transportation. Future stud-ies should focus in more detail on these factors and theirinfluence on the prevalence and incidence of COVID-19.

Supplementary InformationThe online version contains supplementary material available at https://doi.org/10.1186/s12889-020-09924-7.

Additional file 1. The governments information sources.

Additional file 2. Codebook.

Additional file 3. Themes list.

Additional file 4. Confirmed and Deaths Data.

AbbreviationsCOVID-19: Coronavirus disease; CT: Computed Tomography; CDC: Center forDisease Control and Prevention; ER: Emergency room; FDA: Food and DrugAdministration; HIV/AIDS: Human Immunodeficiency Virus/AcquiredImmunodeficiency Syndrome; ICU: Intensive care unit; KCDC: Korea Centersfor Disease Control and Prevention; MERS: Middle East respiratory syndrome;NIH: National Health Service; PUL: Patient Under Investigation; PPE: PersonalProtective Equipment; US: United States; UK: United Kingdom; WHO: WorldHealth Organization

AcknowledgementsSamia Valeria Ozorio Dutra acknowledges support from the Brazilian FederalAgency for Support and Evaluation of Graduate Education (CAPES) forgraduate education.

Authors’ contributionsJYY and SVOD equally contributed to the manuscript. Please, indicate co-firstauthorship in the fine print of the published paper. Conceptualization: JYY,SVOD, DF, SS, HW, JS. Data Collection and Methodology: JYY, SVOD, DF, SS,HW, JS, SHK. Writing the Manuscript: JYY, SVOD, DF, SS, HW, JS. Reviewing andEditing: JYY, SVOD, DF, SS, HW, JS., HSS, SHB, DEK, SHK, MG. The author(s) readand approved the final manuscript.

FundingNo funding was received.

Ethics approval and consent to participateNot applicable

Consent for publicationNot applicable

Competing interestsThe authors declare that they have no competing interests.

Author details1College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd,Tampa, FL 33612, USA. 2College of Nursing, University of Tennessee –Knoxville, 1200 Volunteer Blvd, Knoxville, TN 37902, USA. 3College of Nursing,University of Florida, Health Professions, Nursing, Pharmacy Building, 1225Center Dr, Gainesville, FL 32603, USA. 4Morsani College of Medicine,University of South Florida, 12901 Bruce B. Downs Blvd., MDC 78, Tampa, FL33612, USA. 5Department of Chemical and Biomedical Engineering,University of South Florida, 4202 E. Fowler Ave, ENB118, Tampa, FL 33620,USA. 6Canon Medical Systems Ltd., Boundary Court, Gatwick Road, CrawleyRH10 9AX, UK. 7Department of Emergency Medical Service, Daejeon HealthInstitute of Technology, 21 Chungjeong St., Dong-gu, Daejeon 34504,Republic of Korea. 8Department of Special Warfare MedicalNon-Commissioned Officer, Daejeon Health Institute of Technology, 21Chungjeong St., Dong-gu, Daejeon 34504, Republic of Korea. 9Department ofDisaster Construction Safety, Daejeon Health Institute of Technology, 21Chungjeong St., Dong-gu, Daejeon 34504, Republic of Korea. 10Department

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of Public Health, Konyang University, 158, Gwasnjeoddong-ro, Seo-gu,Daejeon 35365, Republic of Korea.

Received: 20 May 2020 Accepted: 18 November 2020

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