If there is a country in the world that currently has the greatest knowledge and experience of the Covid-19 coronavirus, it is undoubtedly China.
China (especially Hubei province) is the place where the virus emerged. 83% of the more than 90.000 cases known so far have been recorded there. And it is there that doctors and health authorities fought the epidemic for two months by adopting unprecedented public health measures, including sanitary cordons and blockades that affected millions of people.
In recent weeks the number of new infections and deaths reported in China has been declining, which suggests that the spread of the virus may have peaked and is slowing down.
It is now imperative that the rest of the world learn as much as possible from China's efforts to limit the spread of the virus.
Meanwhile, cases are increasing in many other countries, with serious outbreaks in South Korea, Italy and Iran, and an increasing number of cases in the USA.
A recent World Health Organization (WHO) mission to China observed a factual reality. “China's bold approach to contain the rapid spread of this new respiratory pathogen has changed the course of a fast-growing and deadly epidemic.”
What can the world learn from the Chinese response to coronavirus? Here are the answers given by the expert epidemiologist Bruce Aylward who led the WHO mission in China.
The WHO has suggested the world should follow China's lead, but there are concerns about the human rights effects of restrictions on freedom of movement.
The majority of the response in China, in 30 provinces, concerned the search for cases and contacts and the suspension of public meetings, common measures used anywhere in the world to manage the spread of diseases.
The most important human rights blocs have focused on Wuhan and two or three other cities where the virus has exploded. These are places that got out of control early on which required extreme measures.
What worked best?
The factor that China teaches us is speed. The faster you can find cases, isolate them and keep track of their close contacts, the greater the success.
How did they do it? Can this model be replicated?
First of all, we need to start from the basics. If we want to achieve a speed of response, the population must know as much as possible about this disease. The entire West must know the signs to pay attention to.
The two initial symptoms are commonly fever and dry cough.
Many still think they are a runny nose and chills. The population is the real surveillance system. Everyone has a smartphone, everyone can have a thermometer. This is the surveillance system. And you have to be ready to quickly evaluate who really has those symptoms, test those people and, if necessary, isolate and trace their contacts.
In China they have adapted (to Wuhan even created) a gigantic network of hospitals just for fever. In some areas, a team can come to you, swab you and give you an answer in 4 hours. But we need to set up this system: speed is everything.
In summary:
- Inform the population well and practically;
- Have the population use assessment tools;
- Prepare infrastructures dedicated to rapid response to signals arriving from the population.
This is 90% of the Chinese coronavirus method.
How do we know if contact search was more important than closing cities?
Let's think about the virus. Where is the virus and how is the virus contained? The virus is in individual cases and their close contacts. That's where most of the focus should be.
China has done many things quickly, and other countries may have to do them too. But the key is always the same. Public information must get an informed population that reports cases quickly and intelligently. Those cases are found and quickly isolated. Their close contacts are also isolated: between 5 and 15% of those contacts are certainly infected. And again, it is the close contacts, those who have spent some time with the infected person, not all.
China reports collateral damage cases caused by this outbreak. For example, HIV patients have not received the usual treatments due to the restrictions. What can we learn from China to minimize this type of damage?
China made a quantum leap when they realized they had to repurpose large chunks of their hospital system to deal with the epidemic. First of all they made the testing free and the treatment free.
In this sense, there are huge obstacles in the West. In the USA, for example, you can take the test, but you may be negative and have to pay the bill. In China they realized that these were barriers for people seeking treatment, so as a state they covered expenses for people whose insurance plans weren't enough. They have mitigated these barriers.
The other thing they did: normally a doctor's prescription in China cannot last for more than a month. They increased the duration to three months to make sure people don't rush to the doctor to get their prescription refilled. And they have established a delivery system for medications for affected populations.
China seems to have conveyed the idea that the spread of this virus is primarily driven by families. It is true?
Bruce Aylward: “You look at the long lists of all the cases and try to investigate what types of clustering happen: in hospital, in hospices, in theaters, in restaurants? We found that it was mostly in families. It's no big surprise: China had closed many other ways for people to congregate. And family groups were obviously the most exposed.
Something we still don't understand, however, is how little virus there was in the much larger community. Wherever we went, we tried to find and understand how many tests had been done, how many people had been tested and who they were. In Guangdong province, for example, 320.000 tests were done in people who came to fever clinics, outpatient clinics. And at the height of the epidemic, 0,47 percent of those tests were positive. People keep saying the cases are just the tip of the iceberg. But we were unable to find this iceberg. And this is different from the flu. With influenza you will find this virus throughout the child population, and through blood samples in 20 to 40% of the population.”
If this “iceberg” of cases in China has not been found, what could be the real mortality rate of the virus?
The average death rate is 3,8% in China, but much of that is driven by the initial outbreak in Wuhan, where the numbers were highest. Outside Hubei province the death rate is just under 1%. This is the mortality rate in China: they find cases quickly, isolate them, treat them and support them quickly. The second thing they do is use assisted ventilation massively. They use extracorporeal oxygenation (the ECMO which I talked about at length here), a sophisticated and expensive system. This is why the survival rate is higher. I would say that elsewhere in the world the mortality range may be lower than Hubei's 3,8% (not by much, if there are no serious measures) but certainly higher than 1%. It's much more than a flu.
But panic and hysteria are not appropriate: this disease resides in the infected and in close contacts. It is not an enemy hiding in a bush. Get informed, organized, disciplined and resolve.
How should countries look for coronavirus?
Bruce Aylward: “Initially, I was a big believer in the idea that we should swab millions and see what's happening. A bit of Italy's approach in the first hour. But the data from China made me rethink. What could be done instead is that every hospital should test people with atypical pneumonia and flu-like symptoms. Stop. We have a lot of surveillance systems for influenza around the world, trying to pick up the big one and we should be using these systems to test for Covid.”
Can we trust China's data?
The big question is: are they hiding things? The WHO looked at a lot of different things to try to confirm the decline in infections. Even with small interviews in clinics. Fever clinics went from seeing 46.000 people a day to 1.000 now. So yes, there really was a huge drop in numbers. Another strong indication is the actual presence of free beds, registered by the WHO.
What is the greatest danger to countries outside of China?
We need beds. In China, they have closed entire wings of hospitals, sealed them up to make them a specific treatment area. They worked on a large scale. They bought a bunch of assisted ventilation systems to keep people alive. They made sure they had plenty of high-flow oxygen, tomographs and labs. This is, and is needed soon: beds, ventilation, oxygen, tomographs, laboratories.
While deaths occur at higher rates in older people, there have also been reports of death in otherwise healthy young people. Is it true that pollution and smoking can contribute?
Smoking certainly does this because coronavirus comorbid conditions worsen. In the long term, we know that smokers suffer from cardiovascular and lung disease, and these are all co-factors in terms of a higher likelihood of mortality. From that point of view, we know it's a problem. In some mortality studies we see a higher mortality rate in males than females. There is a suspicion that it could be a function of differences in smoking patterns: there are very high smoking rates among men in China compared to women.
How can we explain the high mortality rate of the coronavirus in the elderly? Is it about the deterioration of the immune system with age or the greater probability of developing other diseases that become a contributing cause of death?
Bruce Aylward: “I think it's the latter. These people are dying of an inflammatory process in their lungs. It is not an infectious process, like a bacterial or viral infection. It is inflammatory, as we see with SARS. We are not sure of the mechanism. We know that the percentage of people dying who had cancer was half that of hypertension and cardiovascular disease.”
Why do children seem to have been spared from the coronavirus so far? What's the best guess?
It's a million dollar question. There are several possibilities: the most accepted is that children become infected (and are also a possible vehicle) but have a low expression of the disease. We should do an antibody test to test the population for antibodies against the virus, and to find out if children are unwittingly driving the epidemic (to tell the truth, today's news is that in France 21% of those infected have less than 18 years old) but this is not the time to do so.
