Vietnam and COVID-19

In addition to Taiwan and South Korea, Vietnam was another country with an exceptional record in fighting the virus. But it is neither a democracy nor a prosperous country like South Korea or Taiwan. It is both an authoritarian and a developing state. With 96 million people, it has almost twice the population of South Korea and four times that of Taiwan. Its medical and hospital system is not well-developed. In 2018, there were only 8.6 doctors per ten thousand inhabitants in Vietnam compared to 25.4 in Canada and 23.3 in South Korea. Vietnam also had the major disadvantage that it actually bordered onto China.

Around the world as a result of the COVID-19 virus, as of today (12 July), there have been almost 555,00 deaths, up from 300,000 on May 15. Of those, about one quarter are Americans. In contrast, Vietnam has had only 369 confirmed cases, up from 288 on 15 May, from a world total of 12.24 million, and not a single death. 350 of those 369 cases have recovered. What accounts for Vietnam’s success?

Like Taiwan, South Korea and the U.S., COVID-19 spread to Vietnam in January. The following summarizes the initial spread.

  • 22 January – first two cases, a Chinese man travelling from Wuhan to Hanoi to visit his son who also developed the disease
  • 24 January – on the basis of only those two cases and reports from Wuhan, Vietnam activated its Emergency Epidemic Preventive Centre and the Civil Aviation Administration which cancelled all flights to and from Wuhan 
  • In the very prestigious weekly, New England Journal of Medicine, Vietnamese physicians immediately described the coagulopathic and antiphospholipid antibodies developed in the 69-year-old Chinese man, his son and a third identified case; this was the first report in a prestigious medical academic journal of human-to-human transmission outside China
  • 29 January, the Ministry of Health in Vietnam established 40 – yes 40 – mobile emergency response teams on stand-by to help detect, quarantine and trace contacts of suspected cases
  • Before the end of the month, 3 other cases had been identified, all Vietnamese nationals who had returned from Wuhan
  • 1 February, a 25-year-old Vietnamese woman who had direct contact with the father and son became the first case of domestic transmission
  • 2 February, a Vietnamese-American girl had become infected in a two-hour layover at Wuhan Airport
  • 2-4 February, a 20-year-old female and a 30-year old male, part of the first training team, were diagnosed with the illness; shortly after, another 29-year-old trainee was diagnosed
  • 7 February, with only 13 cases, Vietnam had cultured and isolated the virus in a lab – thus far, only Singapore, Australia, Japan and China had managed to do so
  • The 15th case was a 3-month-old grandchild of someone who contracted the disease through a contact on Lunar New Year; this was the 10th of 15 cases identified, all in Vinh Phuc Province
  • Vietnamese leaders quarantined the whole village of 10,000 of Son Loi, dividing the village into groups of 50 or so households for close monitoring
  • 3 March, the quarantine was removed when, after 20 days, no new cases were reported in Son Loi, but schools that had been closed in February remained closed until the end of March
  • The same day, Assoc. Prof. Dong Van Quyen, Deputy Director of the Institute of Biotechnology of the Vietnam Academy of Science and Technology, announced the completion of research and development of the SARS-CoV-2 detection kit; two days later,  the Vietnam Ministry of Science and Technology announced that it had a second test developed by the Military Medical Academy and Viet A Technology JSC.
  • On 6 March, a 26-year-old female returning from travelling across Europe tested positive for COVID-19; 200 people were tracked who had contact with the patient
  • By 7 March, Vietnam had a total of 18 cases as a 27-year-old Vietnamese in Ninh Binh Province returning from Daegu, South Korea, was diagnosed with COVID-19 as well as 2 cases in Hanoi discovered as a result of contact tracing
  • Vietnam introduced three levels for isolating cases: 1) self-isolation at home; 2) isolation in a central facility; 3) hospitalization
  • By 9 March, 11 more cases were tracked; all were foreigners, that had contact with the patient returning from South Korea and were now spread throughout the country
  • the next day, the first Vietnamese=originated case was traced, a 24-year-old Vietnamese woman who had just returned from England; she as well as a  British man on the same flight and a 51-year-old businesswoman returning from the United States via Qatar and Korea tested positive
  • On 11 March, 4 Vietnamese who were part of the same contact group were diagnosed
  • On 12 March, a 29-year-old tour guide in the contact group was diagnosed, 3 more a day later, and 3 two days  later; tracing was working very fast to identify and isolate infected patients directly or indirectly in contact with infected foreigners, a Vietnamese returning from Paris, a Vietnamese student who had been travelling across Europe, and a Czech national
  • The risk was coming from returnees, the most dangerous, a Muslim from the Cham minority who had attended a religious event in Malaysia and then the Jamiul Muslimin Mosque in Ho Chi Minh City before returning home to Ninh Thuân; that led to the quarantine of  the whole province and the closure of the mosque
  • In the next few days, 2 more patients were identified, one returning from the same religious event and one in contact with the infected patient
  • By 26 March 26 additional cases, almost all of returnees, were identified
  • By 22 April, the authorities had got on top of the epidemic with no new cases the previous week; however, when one new case was identified in Dong Van town, the whole province was locked down  
  • There appeared to be the first death on 4 May, but the man died of liver disease and the initial diagnosis had been incorrect
  • On 15 May, Vietnam confirmed 24 new cases, all of them from a repatriating flight from Russia; they were immediately quarantined
  • With no new cases by the beginning of June, Vietnam Airlines opened domestic flights
  • By 15 June, two months had passed without a single new confirmed case as a result of local transmission
  • On 25 June, the flight from Vietnam to Tokyo was resumed.

In February, Bill Gates published an article in the New England Journal of Medicine warning of this once-in-a century pandemic to insist not only on saving lives but on developing a system to respond appropriately to pandemics. Vietnam did this; the U.S.A. did not. In March, in that same journal, Anthony Fauci, H. Clifford Lane and Robert Redfield, who would soon become well known to the American and world public, identified the COVID-19 virus as the latest threat to global health caused by a novel coronavirus that is structurally related to the virus that causes severe acute respiratory syndrome (SARS). Like SARS (2002 and 2003) and Middle East respiratory syndrome (MERS) (2012 to the present) — the Covid-19 outbreak, they warned, posed critical challenges for the public health, research, and medical communities of all countries. They pointed out that the median age of the patients was 59 years, with higher morbidity and mortality among the elderly and among those with coexisting conditions and that 56% of the patients were male.

But the learning curve about the virus is also apparent on re-reading the article today as these great authorities on infectious diseases noted that, “there were no cases in children younger than 15 years of age. Either children are less likely to become infected, which would have important epidemiologic implications, or their symptoms were so mild that their infection escaped detection, which has implications for the size of the denominator of total community infections.” As we now know, this eventually proved to be misleading.

Experts also reported a case fatality rate of less than 1% akin to severe seasonal influenza with a case fatality rate of approximately 0.1%, much lower than SARS or MERS with case fatality rates of 9 to 10% and 36%, respectively. As of today, the death rate of 133,000 of 3.1 million cases in the U.S., which had been 6% in mid-May, has now dropped to 4.2% with improved treatment. Clearly, the most expert voices in the world on infectious diseases were still underestimating the virulence of COVID-19. Further, the authors credited travel restrictions on China for helping slow the spread of the virus, though we now know that the first cases in the U.S. came from Europe, not China.  

The authors noted that, “Community spread in the United States could require a shift from containment to mitigation strategies such as social distancing in order to reduce transmission. Such strategies could include isolating ill persons (including voluntary isolation at home), school closures, and telecommuting where possible.” The authors did note that, “The Covid-19 outbreak is a stark reminder of the ongoing challenge of emerging and reemerging infectious pathogens and the need for constant surveillance, prompt diagnosis, and robust research to understand the basic biology of new organisms and our susceptibilities to them, as well as to develop effective countermeasures.” Unfortunately, the U.S. did not introduce constant surveillance, prompt diagnosis, robust research or a strategy of effective countermeasures. Vietnam, by contrast, did all of these.

The best illustration in Vietnam emerged in the second phase of the outbreak when community transmission became a prominent concern. On 6 March, a 26-year-old woman in Hanoi was diagnosed with the virus and immediately 200 persons who had close contact with the individual were traced, identified and tested. But most new cases remined those of returning travelers on flight VN0054. Most cases in the second phase were patients returning to Vietnam or in close touch with such returnees. Further, to demonstrate the concern and concentration of the government, the armed forces were deployed to patrol and enforce quarantine and other control measures so tracing and focus made up for Vietnam’s limited ability to undertake extensive testing.

There was no shutting down of the economy wiping out businesses and jobs. Instead, speed. A quick start, an even faster reaction time when cases were discovered, early development of detection kits, systematic tracing and identification, rigorous and thorough quarantining, isolation of hot spots or hot bubbles and the use of tweezers, large tweezers rather than a hammer, caution in opening schools and extreme caution in resuming international flights. Pluck carriers out of society, quarantine them and their contacts who were immediately traced and keep them at home or in isolation hotels. To repeat, emphasize science and scientific leadership, robust research, constant surveillance, prompt diagnosis, and a strategy of effective countermeasures.

Instead of underdetermination and granting license to individuals in the face of both a communal crisis and a challenge to which individuals were ill-equipped to make decisions, overdetermination and centralized planning, resource allocation and decision-making, decisions which erred always on the side of extreme caution. The strategy was not secret. Fast action. Effective action. Social distancing, limited testing, extensive tracing and the use of isolation. Swift, strict and focused responses. The political leadership was effective in implementation, communication and gaining the people’s trust.  

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