Public health response in China
As of 26 January 2020, in China, 30 provinces initiated a level-1 public health response to control COVID-19. As described by Deng (J ClinMed 2020, see below), level-1 response means that during the occurrence of a particularly serious public health emergency, the provincial headquarters shall organize and coordinate the emergency response work within its administrative area according to the decision deployment and unified command of the State Council.
Fever observation rooms were to be set up at stations, airports, ports, and so on to detect the body temperature of passengers entering and leaving the area and implement observation/registration for the suspicious patients. The government under its jurisdiction, in accordance with the law, is to take compulsory measures to restrict all kinds of the congregation, and ensure the supply of living resources. They also ensure the sufficient supply of masks, disinfectants, and other protective articles on the market, and standardize the market order. The strengthening of public health surveillance, hygiene knowledge publicity, and monitoring of public places and key groups is required.
Comprehensive medical institutions and some specialized hospitals are to be prepared to accept COVID-19 patients to ensure that severe and critical cases can be differentiated, diagnosed, and effectively treated in time. The health administration departments, public health departments, and medical institutions at all (province, city, county, district, township, and street) levels, and social organizations function in epidemic prevention and control and provide guidance for patients and close contact families for disease prevention.
Chen, Yang et al. (Lancet 2020, see below) also underlined the importance of the social distancing measures that were applied during the Chinese Lunar New Year holiday in China. People in China are indeed estimated to make close to 3 billion trips over the 40-day travel period, or Chunyun, of the Lunar New Year holiday. As part of these social distancing policies, the Chinese Government encouraged people to stay at home; discouraged mass gatherings; cancelled or postponed large public events; and closed schools, universities, government offices, libraries, museums, and factories.
Only limited segments of urban public transport systems remained operational and all cross-province bus routes were
taken out of service. As a result of these policies and public information and education campaigns, Chinese citizens started to take measures to protect themselves against COVID-19, such as staying at home as far as possible, limiting social contacts, and wearing protective masks when they needed to move in public. The Chinese Government even extended the Lunar New Year holiday, so that the duration of the holiday would be sufficiently long to fully cover the suspected incubation period of COVID-19.
China took draconian measures to contain the outbreak, including the quarantine of at least 30 million residents of Wuhan and neighbouring cities (Kickbusch British Med J 2020, see below). Countrywide interventions include delaying resumption of school after the spring festival holiday, encouraging citizens to work from home and stay at home, using personal protective equipment such as face masks, and cancelling all mass gatherings. Vehicular traffic in Wuhan was banned. Authorities closed public transit and cancelled outbound transportation (air, train, and long-haul buses). China also imposed a ban on overseas travel with tour groups and suspended sale of flight and hotel packages. Authorities cancelled Lunar New Year gatherings in Beijing as well as intraprovince bus service into the nation’s capital. China's Finance Ministry announced ¥1 billion (U.S. $145 million) to fund the response as well as the rapid construction of 2 hospitals in Wuhan to treat those affected (Phelan JAMA 2020, see below).
Most districts of Hangzhou announced in a statement that every community would be kept under closed management, and only one family member was allowed to leave his house and buy daily living supplies outdoors every two days (Diao Infect Control Hosp Epidemiol 2020, see below). Furthermore, "non-contact delivery", a new delivery method, was adopted by many express delivery companies, which could reduce contagion risk. Fourth, in order to reduce the concentration of personnel to avoid the risk of cross-infection, online working and network teaching were encouraged for workers and students, respectively, which were supported by mobile technology companies. Fifth, to meet the need of resumption of production and curb the transmission of the virus as far as possible, Hangzhou arranged chartered transportation to help numbers of migrants return to workplaces. Lastly, in cooperation with Alipay, Hangzhou adopted the health QR code system on February 11, 2020, which were designated by green, yellow or red.
People who wanted to get into Hangzhou needed to submit their travel history and health information online in advance. Residents with a green code indicated they had a low current risk of being infected, while residents with yellow or red codes were quarantined for seven or fourteen days and required to report their health condition every day to exclude infection before the codes turned green.
The strong public health response in China could not prevent the spread of COVID-19 to other countries, causing a worldwide public health crisis. Shangguan (Int J Environ Res Public Health 2020, see below) analysed the various reasons why China could not contain the outbreak. The authors suggested that the country should adopt a Singaporean-style public health crisis information management system to ensure information disclosure and information symmetry and should use it to monitor public health crises in real time. They added that the central government should adopt the territorial administration model of a public health crisis and increase investment in public health in China.
Public health response in other countries
The first COVID-19 case outside China is said to have been reported on January 13 2020: a patient in Thailand was said to have visited the Huanan Seafood Wholesale Market (Bruinen de Bruin Saf Sci 2020, see below). Due to the absence of a cure or a vaccine, controlling the infection to prevent the spread of COVID-19 was correctly seen as the only intervention that could be used. Risk mitigation measures were soon implemented on other areas and countries such as Hong Kong, Taiwan, South Korea and Mongolia. One of them consisted of contact tracing and recommending a set of precautions. In the United States, on January 20, state and local health departments, in collaboration with teams deployed from CDC, began identifying and monitoring all persons considered to have had close contact with patients with confirmed COVID-19 (Burke MMWR Morb Mortal Wkly Rep 2020, see below). The aims of these efforts
were to ensure rapid evaluation and care of patients, limit further transmission, and better understand risk factors for transmission.
Tanne, Hayasaki et al. (BMJ 2020, see below) provided a rapid overview of how selected countries (USA, Canada, Australia, India, Japan, South Korea, Italy, Spain, France, Germany, Iran) were tackling the epidemic in March 2020).
Hong Kong declared its highest-tier emergency, curtailed public events, and barred travellers from Hubei Province.
Travelers from mainland China had to complete health declarations. Hong Kong has also rapidly closed schools and universities. Governments have not banned travel from China, with 2 exceptions: North Korea prohibited entry of all Chinese travellers and Kyrgyzstan closed its border with China. Multiple countries (e.g., Australia, Thailand, South Korea, Japan, India, Italy, Singapore, Malaysia, and Nigeria) implemented temperature screening, symptom screening, and/or questionnaires for arriving passengers from China. The U.S. Centers for Disease Control and Prevention launched enhanced, non-invasive screening of travellers from Wuhan at 20 major airports, while the U.S. State Department issued its highest-level travel advisory for Hubei Province: level 4, “do not travel.”
Legido-Quigley (Lancet 2020, see below) analysed the response in Hong Kong, Singapore and Japan. The three locations introduced appropriate containment measures and governance structures; took steps to support health-care delivery and financing; and developed and implemented plans and management structures. However, their response was found vulnerable to shortcomings in the coordination of services; access to adequate medical supplies and equipment; adequacy of risk communication; and public trust in government. Three important lessons emerged. The first is that integration of services in the health system and across other sectors amplifies the ability to absorb and adapt to shock. The second is that the spread of fake news and misinformation constitutes a major unresolved challenge. Finally, the trust of patients, health-care professionals, and society as a whole in government is of paramount importance for meeting health crises.
The response of Singapore to contain the epidemic was also described in a publication by Lee (J Trav Med 2020, see below).
From January 30, the Italian Government implemented extraordinary measures to restrict viral spread, including interruptions of air traffic from China, organised repatriation flights and quarantines for Italian travellers in China, and strict controls at international airports’ arrival terminals (Spina Lancet 2020, see below). Local medical authorities adopted specific WHO recommendations to identify and isolate suspected cases of COVID-19. Such recommendations were addressed to patients presenting with respiratory symptoms and who had travelled to an endemic area in the previous 14 days or who had worked in the health-care sector, having been in close contact with patients with severe respiratory disease with unknown aetiology. Suspected cases were transferred to preselected hospital facilities where the SARS-CoV-2 test was available and infectious disease units were ready for isolation of confirmed cases. Since the first case of SARS-CoV-2 local transmission was confirmed, the Emergency Medical System in the Lombardy region (reached by dialling 112, the European emergency number) represented the first response to handling suspected symptomatic patients, to adopting containment measures, and to addressing population concerns. The Emergency Medical System of the metropolitan area of Milan instituted a COVID-19 Response Team of dedicated and highly qualified personnel, with the ultimate goal of tackling the viral outbreak without burdening ordinary activity. More details on the consequences of the COVID-19 outbreak on critical care capacity were provided by Grasselli (JAMA 2020, see below).
Johnson (Euro Surv 2020, see below) characterised three sequential scenarios for the spread of SARS-CoV-2 in the EU/EEA, with the third scenario divided in two sub-scenarios based on impact on the healthcare system. The scenarios were: (1) short, sporadic chains of transmission, (2) localised sustained transmission, (3a) widespread sustained transmission with increasing pressure on the healthcare system and (3b) widespread sustained transmission with
overburdened healthcare system. These scenarios were presented together with suggested control measures to limit the impact of the epidemic. At different points in time, it was expected that different countries may find themselves in different scenarios.
Bruinen de Bruin (Saf Sci 2020, see below) collated and clustered (using harmonised terminology) the risk mitigation measures taken around the globe in the combat to contain, and since March 11 2020, to limit the spread of the SARS-CoV-2 virus. Figure 21 describes the timeline of events up to end of March 2020.
Figure 21 Time line of events and application of COVID-19 risk mitigation measures (from Bruinen de Bruin Saf Sci. 2020)
A WHO report dated August 20 2020 provided information on pandemic preparedness and response in Malaysia (https://www.who.int/publications/m/item/malaysia-strong-preparedness-and-leadership-for-a-successful-covid-19-response). Another report issued on September 30 2020 described how the strong health system in Thailand fights the pandemic (https://www.who.int/publications/m/item/thailand-how-a-strong-health-system-fights-a-pandemic).
Of note, a convenient platform has been created for access to detailed information on how different countries respond to the pandemic (see: https://www.covid19healthsystem.org/mainpage.aspx).