Country-led control measures to contain the spread of the novel coronavirus, COVID-19, have been diverse. Originating in Wuhan, China, in December, 2019, the COVID-19 outbreak was declared a pandemic by WHO on March 11, 2020. In recognition of the severity of the outbreak, and having the longest shared border with China, the Government of Mongolia activated the State Emergency Committee in January, 2020, on the basis of the 2017 Disaster Protection Law. As a result, various public health measures have been taken that led to delaying the first confirmed case of COVID-19 until March 10, 2020, and with no intensive care admissions or deaths until July 6, 2020. These measures included promoting universal personal protection and preventions, such as the use of face masks and handwashing, restricting international travel, suspending all training and educational activities from kindergartens to universities, and banning major public gatherings such as the celebration of the national New Year holiday. These measures have been accompanied by active infection surveillance and self-isolation recommendations. The Mongolian case shows that with robust preventive systems, an effective response to a pandemic can be mounted in a low-income or middle-income country. We hereby examine the emergency preparedness experience, effectiveness, and challenges of the early outbreak policies on COVID-19 prevention in Mongolia, as well as any unintended consequences.

With the global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in early 2020, Mongolia implemented rapid emergency measures and did not report local transmission until November 2020. We conducted a national seroprevalence survey to monitor the burden of SARS-CoV-2 in Mongolia in the months surrounding the first local transmission. During October-December 2020, participants were randomly selected using age stratification and invited for interviews and blood samples at local primary health centres. We screened for total SARS-CoV-2 antibodies, followed by two-step quantitative SARS-CoV-2 IgG serology tests for positive samples. Weighted and test-adjusted seroprevalences were estimated. We used chi-square, Fisher's exact and other tests to identify variables associated with seropositivity. A total of 5000 subjects were enrolled. We detected SARS-CoV-2 IgG antibodies in 72 samples. Crude seroprevalence of SARS-CoV-2 antibodies was 1·44% (95%CI,1·21-1·67). Population weighted and test-adjusted seroprevalences were 1·36% (95%CI,1·11-1·63) and 1·45% (95%CI,1·11-1·63), respectively. Age, sex, geographical, and occupational factors were not associated with seropositivity (p>0·05). Symptoms and signs within past 3 months and seropositivity were not associated at the time of the survey (p>0·05). SARS-CoV-2 seroprevalence in Mongolia was low in the first year of the pandemic potentially due to strong public health measures, including border restrictions, educational facilities closure, earlier adoption of mask-wearing and others. Our findings suggest large-scale community transmission could not have occurred up to November 2020 in Mongolia. Additional serosurveys are needed to monitor the local pandemic dynamic and estimate how far from herd immunity Mongolia will be following-up with vaccination programme in 2021 and 2022. World Health Organisation, WHO UNITY Studies initiative, with funding by the COVID-19 Solidarity Response Fund and the German Federal Ministry of Health (BMG) COVID-19 Research and development. Cyrillic and Traditional Mongolian translation of abstract is available on appendix section.

Various psychological, biological, and social factors make people vulnerable to mental health problems. These precursory factors as mental distress, are not sufficient alone for diagnosing a mental disorder but are recognised as risks to mental health. There has been no screening tool available in Mongolia that is adequately validated for mental health screening and neuropsychiatric functions of the brain. Therefore, we aimed to translate and validate the hospital anxiety and depression scale (HADS) to identify potential mental distress in healthy people. The HADS is reliable, valid, and practical for identifying the most common psychological disturbances. This nationwide comparative observational study for the validity of a self-reported measure was conducted between June and December 2020. One thousand ninety-four participants were randomly selected, aged 13-75, mean age was 37.7±13.7 years old, 60.9% were females, 63.9% were married. HADS total score was 13.0±5.7, HADS anxiety (HADS-A) score was 6.8±3.6, and HADS depression (HADS-D) score was 6.0±3.1 for the original two-factor model. The external reliability was good in the whole scale, and both subscales using the Intraclass Correlation Coefficient (0.872, 0.837, and 0.801 for the HADS-T, HADS-A, and HADS-D, respectively). Cronbach's alpha value was 0.776, 0.756, and 0.582, respectively, for the HADS-T, HADS-A, and HADS-D, indicating an acceptable internal consistency for the entire scale but marginal reliability for the HADS-D subscale. The reliability of both the two-factor and three-factor structures of the HADS was confirmed using confirmatory factor analysis with a satisfactory model fit on a separate sample. In conclusion, the Mongolian version of the HADS can be considered a valid and reliable measurement tool for various scientific and clinical practices in the general population.

Public health systems reported low mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in East Asia, in low-income countries, and for children during the first year of the SARS-CoV-2 pandemic. These reports led commentators to suggest that cross-reactive immunity from prior exposure to other pathogens reduced fatality risk. Resolution of initial infection waves also contributed to speculation that herd immunity prevented further waves prior to vaccination. Serology instead implied that immunity was too limited to achieve herd immunity and that there was little impact from cross-reactive protection. Paediatric deaths exceeded those from influenza, with higher age-specific fatality risk in lower-income nations and similar fatality risk in East Asia compared with demographically similar regions. Neither pre-outbreak exposure to related pathogens nor immunity induced by initial infection waves are necessarily a reliable response to future pathogen outbreaks. Preparedness for future pathogen outbreaks should instead focus on strategies such as voluntary behavioural changes, nonpharmaceutical interventions, and vaccination.

Practice pointsGlobally, medical professionals are shortaged. Despite being the most dispersedly populated country, Mongolia has trained sufficient number of medical doctors with local medical educ...

The COVID-19 pandemic has global impacts but is relatively understudied in developing countries. Mongolia, a lower-middle-income country, instituted strict control measures in early 2020 and avoided widespread transmission until vaccines became available in February, 2021. Mongolia achieved its 60% vaccination coverage goal by July 2021. We investigated the distribution and determinants of SARS-CoV-2 seroprevalence in Mongolia over 2020 and 2021. We performed a longitudinal seroepidemiologic study aligned with WHO's Unity Studies protocols. We collected data from a panel of 5000 individuals in four rounds between October 2020 and December 2021. We selected participants through local health centres across Mongolia by age-stratified multi-stage cluster sampling. We tested serum for the presence of total antibodies against SARS-CoV-2 receptor-binding domain, and levels of anti-SARS-CoV-2 spike IgG and neutralising antibodies. We linked participant data with national mortality, COVID-19 case, and vaccination registries. We estimated population seroprevalence and vaccine uptake, as well as unvaccinated population prior-infection prevalence. At the final round in late 2021, 82% (n = 4088) of participants completed follow-up. Estimated seroprevalence increased from 1.5% (95% CI: 1.2–2.0), to 82.3% (95% CI: 79.5–84.8) between late-2020 and late-2021. At the final round an estimated 62.4% (95% CI: 60.2–64.5) of the population were vaccinated, and of the unvaccinated population 64.5% (95% CI: 59.7–69.0) had been infected. Cumulative case ascertainment in the unvaccinated was 22.8% (95% CI: 19.1%–26.9%) and the overall infection-fatality ratio was 0.100% (95% CI: 0.088–0.124). Health workers had higher odds for being COVID-19 confirmed cases at all rounds. Males (1.72 (95% CI: 1.33–2.22)) and adults aged 20 and above (12.70 (95% CI: 8.14–20.26)) had higher odds for seroconverting by mid-2021. Among the seropositive, 87.1% (95% CI: 82.3%–90.8%) had SARS-CoV-2 neutralising antibodies by late 2021. Our study enabled tracking of SARS-CoV-2 serological markers in the Mongolian population over one year. We found low SARS-CoV-2 seroprevalence in 2020 and early 2021, with seropositivity increasing over a 3-month interval in 2021 due to vaccine roll out and rapid infection of most of the unvaccinated population. Despite high seroprevalence in Mongolia amongst both vaccinated and unvaccinated individuals by end-2021, the SARS-CoV-2 Omicron immune escape variant caused a substantial epidemic. 10.13039/100004423 World Health Organization , WHO UNITY Studies initiative, with funding by the COVID-19 Solidarity Response Fund and the German Federal Ministry of Health (BMG) COVID-19 Research and development. The Ministry of Health, Mongolia partially funded this study.