What measures did China take to suppress the epidemic and are they transferable? Let’s take a closer look.
In my series of articles on COVID-19 written for Croatia’s “Vecernji list” newspaper, I intended to address and explain various key aspects of the crisis as they were emerging. I tried to provide detailed and sufficient explanations in a way that would be popular and easily understandable to very large crowds. I did this under the influence of the late professor Andrija Stampar, a 20th-century pioneer of international public health, who was also a Croatian. This giant of preventive medicine taught us that, in the fight against infectious diseases, “finding ways to inform population is more important than passing any laws” and that “a good epidemiologist and physician must be a teacher of the nation”.
The interest in this topic became incredibly intense over the past two months. As a result, my series of articles, accompanied by short videos developed by “Vecernji list” and “24 sata”, that summarized key messages and were spread through social networks, gradually gained an audience of the size that I still cannot fully grasp. The most recent estimates are that my regular updates on the pandemic COVID-19 are reaching up to 3 million people in six countries of former Yugoslavia. This all emerged from a popular science series on Facebook which I started writing for my 10,000 followers in late January this year.
In the first article on the spread of COVID-19 that I wrote professionally for “Vecernji list” on the 15th of March, having migrated from my Facebook page to this well-known Croatia’s newspaper, I tried to explain the danger that we were facing. I’ve clarified the three main ways through which the virus can put us all at greater risk: (i) its rapid spread in the community that generates many severe cases at once, which overpowers our ability to provide intensive care to those affected; (ii) through outbreaks within hospitals, rehabilitation centers, and retirement homes, that affect the ailing and most susceptible and have high case-fatality rate; and (iii) through infecting medical professionals and closing hospitals wards, which worsens care for all other illnesses.
I also explained behaviors that should help us to prevent these problems. I concluded that Croatia had well-prepared defense lines, which in the first weeks, had yielded measurable results in relation to the environment. However, I also emphasized in this text that “… with epidemics, things can quickly turn against us just because of a little carelessness or irresponsible behaviors of individuals. In just 48 hours, from a successful country, as a result of only a few incidents, things can change and we could suddenly become ‘a case nation’ in the eyes of the international public.’’
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Unfortunately, only three days later after I wrote that article, we had a chance to witness that this warning was well-founded. We had early outbreaks at Zagreb hospitals with many doctors affected. More than a hundred health professionals and their contacts were isolated as a result. Several Croatian media have hinted individual negligence as a possible cause. This was in spite of all epidemiologists calling for caution for at least a month, and all of our doctors being well aware of the risks of viral outbreaks. Thus, despite several weeks of professional efforts, the start of the fight against coronavirus in Croatia was marked by hospital outbreaks. Obviously, the words of the 19th-century Prussian military strategist Helmuth von Moltke, who taught us that “no war plan will survive its first contact with an enemy,’’ are still true to this day.
The only silver lining may be that these incidents occurred at such an early stage. Now, clinicians in hospitals will also raise the level of discipline and awareness to that shown by public health professionals for weeks. In addition, hospitals are still not significantly burdened with infected patients. Furthermore, sending more than a hundred health professionals into self-isolation will allow them to rest well, so we’ll also get a backup squad in the time of greater need. This may be absolutely necessary in just two weeks, provided that the number of cases of new patients continues to increase significantly in Croatia and that the frontline doctors themselves become infected.
At present, however, the issue of how many patients in hospitals may have been infected is of the greatest concern. We’ll know this within a few days when their incubation period is over and some may develop COVID-19 symptoms. Infected hospital patients in Zagreb could become the first Croatian cases to create a more severe clinical picture, but still a curable one. Hopefully, there will be a few of them as possible, and that everyone will learn valuable lessons from this early incident.
By now, coronavirus has spread to so many countries that some entry and defense models are beginning to crystallize — such as the Chinese, South Korean, Singaporean, Iranian, Italian, German, French, Spanish, and American ones. In the early days of Croatia’s response to the pandemic, I’ve often wondered which of these models would most closely resemble the situation in Croatia. I then planned to contact my global health colleagues in that country and seek their advice, since they would be ahead of Croatia in terms of dealing with the epidemic.
As the onset of Croatia’s fight was marked by the initial spread of contagion in major hospitals in the capital, this situation was most similar to that in Wuhan, where the pandemic started. Therefore, I contacted a few colleagues in the field of global health from China, hoping that they would recall any contingencies and “bottlenecks” that they faced while fighting the Wuhan epidemic. I told them that it was the Croatian invention from the end of the 14th century — quarantine that was introduced in the medieval city of Dubrovnik — that saved Wuhan and China from COVID-19 in the 21st century. So, it would seem quite appropriate if their experiences from Wuhan could help us here in Croatia now. I then relayed the story of Wuhan, which should also be helpful to Croatia’s response.
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In November or December 2019, somewhere around Wuhan, a new coronavirus managed to transfer over from a small mammal, a bird or a bat, to a human and then spread for some time to the local population. After several hundred infected people, severe cases of pneumonia occurred, predominantly among older men. They ended up being treated at the hospitals of Wuhan, with eleven million residents.
Nobody even noticed those isolated first cases as something special. It was only between December the 26th and the 28th that the first group of patients with this unusual pneumonia appeared in the same hospital. It was the “Hubei Hospital for Integrated Traditional Chinese and Western Medicine” (HICWM). All of the patients had stories that were in some way related to the Huanan Fish Market. It was then that the doctors at that hospital first suspected that they may be dealing with an entirely new pathogen. But the doctors were already infected by then, too.
Moreover, they infected many of their colleagues at a rapid speed, and they, in turn, infected their patients. Unlike most doctors, the patients were already quite old, seriously ill and some also had compromised immune systems. Everyone was aware that a new contagion was spreading. Its symptoms were generally mild in doctors and younger patients, but more severe in the elderly. Pneumonia of unknown cause would occur relatively infrequently, but it was extremely dangerous for the elderly and the sick. On the very last day of 2019, the Chinese authorities informed the World Health Organisation in Geneva of the situation and closed the fish market on the first day of 2020.
However, it took time to isolate the virus from the blood of those infected. The virus was discovered on the 7th of January, 2020 and was immediately recognized as a new, seventh human coronavirus, somewhat similar to SARS. Its genetic code was shared with the rest of the world on the 12th of January, 2020. On this basis, diagnostic tests were available as early as the next day, and this allowed for the recognition of those who were infected. The problem with the new coronavirus was that it could successfully and rapidly spread among people in the phase before those affected showed any symptoms. Therefore, it was clear that an explosive epidemic across Wuhan was inevitable.
During that time, between the 26th of December and the 12th of January, 2020, the coronavirus epidemic spread rapidly across Wuhan. A large number of doctors and nurses in hospitals became infected with the virus. Although their clinical picture was generally neither problematic nor personally threatening, to the extent that some of them wanted to continue treating their patients, they couldn’t have done so because the clinical course among infected patients would typically be considerably more severe. Entire medical teams had to go home to get over the disease. Many had to be quarantined because their colleagues’ were infected and they were in contact. In those days, when there weren’t enough doctors in Wuhan’s hospitals and the epidemic spread among many severely ill patients, most deaths in Wuhan had occurred. The death rate among the ailing and old patients was, of course, much higher than it would have been among the healthy population outside the hospital.
Around the 15th of January, the total number of people who tested positive for the novel coronavirus in Wuhan was close to 500. On the 19th of January, it was close to 1000, reaching 2000 on the 22nd of January. But the problem with the outbreaks is that these patients who went to hospitals to get tested were infected days earlier, so the epidemiologists were seeing a picture that was delayed for an unknown amount of time. This amount of time is called the “incubation period” and it represents the time between the actual infection and the onset of first symptoms. In fact, the period of delay in diagnosis was actually even longer, because many reported to hospitals only days after their symptoms developed, but would not go away. Therefore, when a “jump” from 100 to 200 newly infected cases in a single day was noticed in hospitals on the 22nd of January, that was a result of the state of things a few weeks into the past. It was also a sure sign that the epidemic was already spreading rapidly among the population of Wuhan.
This is important to remember because it means that when around 200 people test positively for the novel coronavirus on the present day, it means that the actual number of newly infected individuals in the population on that day is probably at least ten times higher if no measures of physical distancing were introduced. With all these adversities in Wuhan, travelers from Wuhan transmitted the new coronavirus to just about every Chinese province through massive travel movements related to the Chinese New Year celebrations.
The very next day, on the 23rd of January, all of Wuhan was urgently put into quarantine. A day later, fifteen more surrounding cities were also shut down. Clearly, the first effects of quarantine measures on reducing the number of positive test results would only have been expected two weeks later. This did happen and the number of new infections declined steadily thereafter. In the Hubei province, the new coronavirus has also first become a problem in the major hospitals of the capital, Wuhan, and put enormous pressure on the local health system. It was at a time when many infected doctors were in isolation. This is why their experience may help the fight against COVID-19 in Croatia.
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Having suppressed the epidemic in Wuhan, Chinese doctors recalled a series of decisions that then had to be made, procedures and bottlenecks that they simply couldn’t have foreseen. First, their situation in Wuhan and Hubei province on the 23rd of January was a “perfect storm.” A large number of infected doctors were in isolation as the main wave of severe Wuhan patients were rushed into the hospitals. This is where China was fortunate to realize how populous it really was. All other provinces of China then sent, by emergency flights, a larger number of doctors and nurses to each of the sixteen quarantined cities. Hundreds of respirators were simultaneously shipped by the Chinese military to assist them.
In this way, China managed to bridge the shortage of health care staff and equipment until the infected doctors from the Hubei province were able to recover and return to work. The first task for the new teams coming to Wuhan was to physically separate all those infected from uninfected patients in Wuhan’s hospitals. Now that they had sequenced the genome of the novel coronavirus, they could test all patients and know who was infected. One option at that point was to move all uninfected patients somewhere else and leave all those infected in the hospitals. But, uninfected patients also needed sophisticated hospital equipment and continuous care. It would have been risky to transport them all to other provinces — both because their condition may worsen and there was a fear that this would spread the infection. Such a move would clearly be too risky. Alternatively, some Wuhan hospitals could be declared “for those infected with coronavirus” and others “for the uninfected”. But to arrange relocations of so many infected and uninfected patients around the city and ensure that Wuhan’s large hospitals would truly be protected would have been a formidable challenge. It was most likely that, through such move, the virus would eventually be introduced into all the hospitals.
Owing to that, a pragmatic decision was made, which really surprised the rest of the world. It was decided that, within just a few days, two brand new hospitals would be built. They were intended for the infected only. This actually made a lot of sense: whoever would test positive in any of the city’s existing hospitals would immediately be sent to the new ones. This was an effective way to keep the existing hospitals free of infection. The two new hospitals were built intentionally so that they were supplied with hundreds of respirators and intensive care units. This radical decision, the second one after quarantining 56 million people in 16 cities, was again a really good one. It effectively suppressed the further spread of the pathogen among hospital patients, which contributed very significantly to the total number of deaths.
Another “bottleneck” has become the shortage of protection suits for the doctors and nurses. The initial thought that there should be enough, but when Wuhan’s doctors returned to work after getting over the infection, he imported medical teams that were still there. It soon became apparent that there were simply never enough protective suits. Some Chinese factories were then asked to mass-produce protective clothing. In addition, it’s important not only to have suits but also to carry out sufficiently high-quality training among doctors and nurses on how to use them properly.
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Having learned from the initial experiences of the infection of entire medical teams, the directors of the large hospitals in Wuhan divided their staff into teams large enough to cope with entire wards. Such teams were no longer allowed to be in the hospital at the same time, nor were they permitted to socialize or to get in touch privately. Thus, it was ensured that if some of the medical staff were already ill, not everyone became ill.
Another practical problem was that doctors weren’t able to take off those protective suits all day, so they couldn’t really use the toilet when they needed to. A large number of adult diapers had to be purchased, which health professionals had to carry all day in their shifts. Another unforeseen problem is that the skin in those protective suits couldn’t breathe normally. Because of this, after a few days, medical personnel would start developing very unsightly and painful rashes. It was necessary to mobilize entire teams of dermatologists to treat these rashes for their colleagues at the end of their shifts so that they could work again the next day.
In addition, Wuhan’s hospitals were already so overcrowded with patients and doctors that it was necessary to double or triple the production and supply of food and drink for all of these people. Furthermore, the doctors had to watch over patients all day and night. Because of this, practical questions began to arise — does it make sense that they return to their homes at all during the epidemic? Most of them chose to stay and sleep in the hospital to protect their families from infection. Others rented temporary apartments near the hospital so that they could get a sufficient rest and avoid passing the infection to their families. The third sent their families to stay with relatives. I believe that my colleagues in Croatia, many of them my former students, are also thinking about these issues now, so I’d like to offer them some ideas from Wuhan.
Finally, after suppressing coronavirus hospital outbreaks in this way, the out-of-hospital epidemic among the population in Wuhan needed to be suppressed. This could only be done by the mass testing of all suspected infected people. It was still January and February when the events unfolded, so the season of flu and cold was still very much present. Many people were coughing and sneezing, but not all of them because of the new coronavirus. It was necessary to distinguish them and isolate the latter. The Chinese then organized thousands of small teams of epidemiologists to go around the buildings and apartments, measure temperatures and test people, and then isolate them in order to proactively identify the paths of the virus and block them.
Just as they had to move all infected patients from existing hospitals to two newly built hospitals, in the same way, all infected people with a milder form of the virus had to be put into isolation. The Chinese used stadiums and empty schools for this. A large number of infected people were thus moved into isolation and monitored until they were better and no longer showed any trace of the virus. So, between the 23rd of January and the 7th of March, Wuhan was able to completely suppress the massive coronavirus epidemic. The epidemic peaked at about 3750 confirmed new infections in a single day. An analogy of this for Croatia would be 1,364 newly confirmed cases per day, for comparison. Still, the Chinese were able to suppress the outbreak through an exceptionally stringent quarantine within six weeks.
Lastly, it is quite interesting how they managed to keep eleven million people in their homes so strictly and successfully. When they closed down Wuhan, the government brought together leading Chinese judicial experts.
As early as the 6th of February, which was only two weeks after the Wuhan shutdown, they enacted a “Criminal Justice Punishment Act aimed at Preventing the Spread of a New Coronavirus that Causes Pneumonia.” Any person who had been quarantined and intentionally violated that order would be punished with “between 10 years’ imprisonment and the death penalty,” depending on the consequences, according to Articles 114 and 115 of the Chinese Penal Code.
If they breached the quarantine provision by accident, they would be imprisoned for between one month and three years. Additionally, anyone who, by any means, negligently and contrary to the instructions of the coronavirus prevention staff, contributed to the spread of the virus, would be punished with 3 to 7 years of imprisonment. Clearly, these penalties were compelling enough to allow eleven million people to be kept in strict quarantine. Only one household member, every three days, was allowed to go out to get groceries for the others. Before going out, they usually needed to have their temperature checked by one of those small epidemiology teams.
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The Wuhan/Hubei quarantine was the first mega-quarantine experiment in human history, which practically locked 56 million people inside their households. This has shown us that the COVID-19 epidemic can be effectively suppressed. In all other provinces, the spread of infection was successfully stopped by testing, tracing and isolation, and the virus typically circulated within families. All over China, with its one billion and four hundred million inhabitants, only about twenty new cases a day were being reported after the successful suppression of the epidemic. Most of these new cases are now coming from overseas, and the total number of deaths in China shouldn’t exceed 5,000.
If the epidemic returns again with a smaller focal point, there’s no doubt that China will be able to extinguish sit, after this unusual experience. Two very difficult questions for all Western leaders today are: can they achieve the same result, and do they want to achieve it? Because months of quarantine of lesser severity than China’s will severely hurt their economies. It will leave countless people jobless.
In addition, seasonal flu that is caused by the influenza virus can still take up to 650,000 lives worldwide annually in a bad season, even though vaccines are readily available to protect from it but most people don’t even get vaccinated. In fact, there is hardly any public awareness or fear related to the threat of the flu today. Perhaps an even better example is pneumonia that affects poor children across the world. It is mainly caused by Streptococcus pneumoniae, Haemophilus influenze type B, Respiratory syncytial virus and the Influenza virus. They continue to take one million children’s lives each year. This is 2,739 deaths of the world’s children every day, mostly among those who are poor and neglected, which remain completely invisible and unknown to the public. However, those deaths are caused by the very same medical condition — pneumonia — that COVID-19 is now threatening with. The West will be deciding whether to suppress COVID-19 with discipline and strict quarantine, like the Chinese. It seems an unlikely option for most western democracies. An alternative to suppression will be mitigation — i.e., turning the outbreak into a “creeping epidemic”, so that the people of the western world would live in milder quarantines for months, going in and out of it and practicing physical distancing until either a vaccine is found to prevent the new disease, or a drug is developed to treat severe forms. In the meanwhile, it is likely that, in time, people will simply get more accustomed to living with the presence of the new coronavirus and fearing it a bit less.
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FACEBOOK: Professor Igor Rudan
English Translation Assistant: Lauren Simmonds
Image credit: Clay Banks, Unsplash.com