US and Europe may act too slowly in introducing robust anti-COVID-19 measures

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The World Health Organisation has praised the “early and robust” control measures that appear to have curbed COVID-19 in China, writes MedicalBrief. But some experts fear it unlikely that the necessary suspension of public transport, closing of entertainment venues, and banning of public gatherings will occur in time, in democratic societies.

Back in 2015, Bill Gates published an editorial in the New England Journal of Medicine warning that the world would likely see a pandemic in the next 20 years. Quilette reports that he was writing in the aftermath of the Ebola outbreak in Guinea, Sierra Leone and Liberia, and argued that while the world had an effective system for containing Ebola, it did not have adequate preparation for dealing with a disease with a substantially higher transmission rate. “(O)f all the things that could kill more than 10m people around the world, the most likely is an epidemic stemming from either natural causes or bio-terrorism.”

Gates likened preparation for dealing with epidemics to preparation for another global threat – war.

Two years later, at a global summit in Switzerland, Gates again warned leaders about their lack of readiness for a pandemic, emphasising that it was a global problem requiring countries to work together. “Epidemics don’t respect borders. And so, whether you’re looking at it from a humanitarian lens or a domestic lens, these are investments that should be made.”

The report says in 2018, Gates made another warning. Noting that people can now travel across the globe in a matter of hours, he said that a pathogen similar to SARS could kill 30m people in six months.

The report says while COVID-19 has spread to all corners of the globe, China appears to have recently seen a plateau, and possible decline in new cases. While we don’t know if all the numbers coming from the Chinese government are accurate, if it is the case that new cases have plateaued, it may be due to the rapid strategies deployed by the Chinese government to contain the outbreak.

A recent study led by Huaiyu Tian, associate professor at Beijing Normal University, has attempted to assess the effectiveness of transmission control measures used by China in response to the outbreak. Their analysis of 296 cities found that those which implemented control measures pre-emptively – before their first case of COVID-19 was reported – had 37% fewer cases of the disease compared with cities that took action after the first reported case.

What were these control measures? The suspension of public transport, closing of entertainment venues, and banning of public gatherings.

The report says such measures are unlikely to be introduced in democratic societies. Writing in 2015, Gates noted that future epidemics would be harder to stop in liberal societies: “Because democratic countries try to avoid abridging individuals’ rights to travel and free assembly, they might be too slow to restrict activities that help spread disease.”

Yet, the report says, past pandemics that have affected democratic nations can teach us lessons. In early October 1918, when the Spanish flu hit the East Coast of the US, the health commissioner of St Louis, Max Starkloff, ordered the closure of schools, movie theatres, saloons, sporting events and other public gathering spots. While the measures were protested by some citizens, the quarantine went ahead. A month later, as the pandemic raged on, he ordered the closure of all business, with a few exceptions, such as banks.

While drastic quarantine measures were being implemented in St Louis, the health commissioner of Philadelphia, Wilmer Krusen, gave permission for a parade for the war effort to go ahead in his city. It is reported that within 72 hours of the parade, every bed in Philadelphia’s 31 hospitals was filled, and in the week ending 5 October 1918, 2,600 people in Philadelphia had died, with the figure almost doubling a week later. At the end of the outbreak, St Louis had the lowest recorded death rate in the US, while in Philadelphia mortuaries overflowed and “bodies (were) piled up on sidewalks.”

Such measures are unlikely to be introduced in democratic societies. Writing in 2015, Gates noted that future epidemics would be harder to stop in liberal societies: “Because democratic countries try to avoid abridging individuals’ rights to travel and free assembly, they might be too slow to restrict activities that help spread disease.”

The World Health Organisation (WHO) has recommended that early robust control measures are the key to saving lives and halting transmission of COVID-19. Worryingly, Robert Nelson, MD and co-founder of ARCH Venture Partners, a biotech venture capital firm located in Seattle, San Francisco and Chicago, is quoted in the report as saying that, in some places in the US, it may already be too late:

“These bureaucrats and politicians who think panic is lines at Costco and angry parents when a school is closed, may find out that panic is when you are taking mom to the emergency room and she dies in the parking lot because no one can see her. I hope this does not happen and we get lucky, but all signs point the other direction.”

As a venture capitalist, Nelson’s job is to make bets on the future. With expertise in biomedicine his firm has invested in over one hundred companies, 27 of which are valued in excess of $1bn. On COVID-19, he said: “The HUGE error now in (the) US is being made by state and local health departments – they fear panic, so they are afraid to cancel public events and close schools. They are still waiting for symptomatic cases to act when we know there is huge asymptomatic spread. This is folly, and the expansion in places like Seattle will likely be uncontrollable. We must take more decisive action at state and local levels to immediately close schools and large gatherings and use social distancing, in order to flatten the curve. The reason that is so urgent is there is no way for our system to handle the critical and acute care burden unless we flatten the curve.”

The report says asked what would happen to acute and critical care facilities if local governments did not get ahead of the virus, Jeffrey Flier, former dean of Harvard Medical School said: “It’s all a matter of numbers—how many infected and how severe the consequent infections. At highest levels of both (still unclear where these will land), system could be overwhelmed, due to maxing out acute beds, illness of healthcare personnel, general supply disruption etc. and of course we have no therapy or vaccine yet. In that event, non-pandemic healthcare would be disrupted and/ or postponed for some period.”

The report says several CEOs in the tech industry are not waiting for local government leadership to implement self-distancing and are taking their own pre-emptive measures. Twitter CEO, Jack Dorsey, has ordered his 5,000 employees to work from home, while announcing that the company is suspending all non-critical business travel and events. Stripe CEO, Patrick Collison, has similarly encouraged, and in some cases mandated, remote work for his company’s employees. Just last month, the venture capital firm Andreessen Horowitz was criticised in the US press for discouraging handshakes inside its office, yet three weeks later the US military urged its own personnel to do the same.

A few days ago, Gates published another editorial in the NEJM. Its message was clear: “In the past week, COVID-19 has started behaving a lot like the once-in-a-century pathogen we’ve been worried about. I hope it’s not that bad, but we should assume it will be until we know otherwise.”

The report says in light of what we know – and acknowledging that our current information is still incomplete – our leaders must implement self-distancing policies now. While we must remain calm the situation demands strong leadership and decisive action.

Meanwhile, Chinese hospitals overflowing with COVID-19 patients a few weeks ago now have empty beds. Trials of experimental drugs are having difficulty enrolling enough eligible patients. And the number of new cases reported each day has plummeted the past few weeks. Science reports that these are some of the startling observations in a report released on 28 February from a mission organised by the WHO and the Chinese government that allowed 13 foreigners to join 12 Chinese scientists on a tour of five cities in China to study the state of the COVID-19 epidemic and the effectiveness of the country’s response. The findings surprised several of the visiting scientists.

“I thought there was no way those numbers could be real,” says epidemiologist Tim Eckmanns of the Robert Koch Institute, who was part of the mission.

But the report is unequivocal. “China’s bold approach to contain the rapid spread of this new respiratory pathogen has changed the course of a rapidly escalating and deadly epidemic,” it says. “This decline in COVID-19 cases across China is real.”

The question now is whether the world can take lessons from China’s apparent success – and whether the massive lockdowns and electronic surveillance measures imposed by an authoritarian government would work in other countries. “When you spend 20, 30 years in this business it’s like, ‘Seriously, you’re going to try and change that with those tactics?’” says Bruce Aylward, a Canadian WHO epidemiologist who led the international team and briefed journalists about its findings in Beijing and Geneva last week. “Hundreds of thousands of people in China did not get COVID-19 because of this aggressive response.”

“This report poses difficult questions for all countries currently considering their response to COVID-19,” says Steven Riley, an epidemiologist at Imperial College London. “The joint mission was highly productive and gave a unique insight into China’s efforts to stem the virus from spread within mainland China and globally,” adds Lawrence Gostin, a global health law scholar at Georgetown University. But Gostin warns against applying the model elsewhere. “I think there are very good reasons for countries to hesitate using these kinds of extreme measures.”

There’s also uncertainty about what the virus, dubbed SARS-CoV-2, will do in China after the country inevitably lifts some of its strictest control measures and restarts its economy. COVID-19 cases may well increase again.

The report comes at a critical time in what many epidemiologists now consider a pandemic. Just this past week, the number of affected countries shot up from 29 to 61. Several countries have discovered that they already have community spread of the virus – as opposed to cases only in travellers from affected areas or people who were in direct contact with them – and the numbers of reported cases are growing exponentially.

The opposite has happened in China. On 10 February, when the advance team of the WHO-China Joint Mission began its work, China reported 2478 new cases. Two weeks later, when the foreign exerts packed their bags, that number had dropped to 409 cases. The epidemic in China appears to have peaked in late January, according to the report.

The team began in Beijing and then split into two groups that, all told, travelled to Shenzhen, Guangzhou, Chengdu, and the hardest hit city, Wuhan. They visited hospitals, laboratories, companies, wet markets selling live animals, train stations, and local government offices. “Everywhere you went, anyone you spoke to, there was a sense of responsibility and collective action, and there’s war footing to get things done,” Aylward says.

The group also reviewed the massive data set that Chinese scientists have compiled. (The country still accounts for more than 90% of the global total of the 90,000 confirmed cases.) They learned that about 80% of infected people had mild to moderate disease, 13.8% had severe symptoms, and 6.1% had life-threatening episodes of respiratory failure, septic shock, or organ failure. The case fatality rate was highest for people over age 80 (21.9%), and people who had heart disease, diabetes, or hypertension. Fever and dry cough were the most common symptoms. Surprisingly, only 4.8% of infected people had runny noses. Children made up a mere 2.4% of the cases, and almost none was severely ill. For the mild and moderate cases, it took 2 weeks on average to recover.

A critical unknown is how many mild or asymptomatic cases occur. If large numbers of infections are below the radar, that complicates attempts to isolate infectious people and slow spread of the virus. But on the positive side, if the virus causes few, if any, symptoms in many infected people, the current estimated case fatality rate is too high. (The report says that rate varies greatly, from 5.8% in Wuhan, whose health system was overwhelmed, to 0.7% in other regions.)

To get at this question, the report notes that so-called fever clinics in Guangdong province screened approximately 320,000 people for COVID-19 and only found 0.14% of them to be positive. “That was really interesting, because we were hoping and maybe expecting to see a large burden of mild and asymptomatic cases,” says Caitlin Rivers, an epidemiologist at the Johns Hopkins Centre for Health Security. “That piece of data suggests that’s not happening, which would imply that the case fatality risk might be more or less as we currently have.”

But Guangdong province was not a heavily affected area, so it is not clear whether the same holds in Hubei province, which was the hardest hit, Rivers cautions.

Much of the report focuses on understanding how China achieved what many public health experts thought was impossible: containing the spread of a widely circulating respiratory virus. “China has rolled out perhaps the most ambitious, agile, and aggressive disease containment effort in history,” the report notes.

The most dramatic – and controversial – measure was the lockdown of Wuhan and nearby cities in Hubei province, which has put at least 50m people under a mandatory quarantine since 23 January. That has “effectively prevented further exportation of infected individuals to the rest of the country,” the report concludes. In other regions of mainland China, people voluntarily quarantined and were monitored by appointed leaders in neighbourhoods.

Chinese authorities also built two dedicated hospitals in Wuhan in just over 1 week. Health care workers from all over China were sent to the outbreak’s centre. The government launched an unprecedented effort to trace contacts of confirmed cases. In Wuhan alone, more than 1800 teams of five or more people traced tens of thousands of contacts.

Aggressive “social distancing” measures implemented in the entire country included cancelling sporting events and shuttering theatres. Schools extended breaks that began in mid-January for the Lunar New Year. Many businesses closed shop. Anyone who went outdoors had to wear a mask.

Two widely used mobile phone apps, AliPay and WeChat – which in recent years have replaced cash in China – helped enforce the restrictions, because they allow the government to keep track of people’s movements and even stop people with confirmed infections from traveling. “Every person has sort of a traffic light system,” says mission member Gabriel Leung, dean of the Li Ka Shing faculty of medicine at the University of Hong Kong. Colour codes on mobile phones – in which green, yellow, or red designate a person’s health status – let guards at train stations and other checkpoints know who to let through.

“As a consequence of all of these measures, public life is very reduced,” the report notes. But the measures worked. In the end, infected people rarely spread the virus to anyone but members of their own household, Leung says. Once all the people in an apartment or home were exposed, the virus had nowhere else to go and chains of transmission ended. “That’s how the epidemic truly came under control,” Leung says. In sum, he says, there was a combination of “good old social distancing and quarantining very effectively done because of that on-the-ground machinery at the neighbourhood level, facilitated by AI (artificial intelligence) big data.”

How feasible these kinds of stringent measures are in other countries is debatable. “China is unique in that it has a political system that can gain public compliance with extreme measures,” Gostin says. “But its use of social control and intrusive surveillance are not a good model for other countries.” The country also has an extraordinary ability to do labour-intensive, large-scale projects quickly, says Jeremy Konyndyk, a senior policy fellow at the Centre for Global Development: “No one else in the world really can do what China just did.”

Nor should they, says lawyer Alexandra Phelan, a China specialist at Georgetown’s Centre for Global Health Science and Security. “Whether it works is not the only measure of whether something is a good public health control measure,” Phelan says. “There are plenty of things that would work to stop an outbreak that we would consider abhorrent in a just and free society.”

The report does mention some areas where China needs to improve, including the need “to more clearly communicate key data and developments internationally.” But it is mum on the coercive nature of its control measures and the toll they have exacted. “The one thing that’s completely glossed over is the whole human rights dimension,” says Devi Sridhar, an expert on global public health at the University of Edinburgh. Instead, the report praises the “deep commitment of the Chinese people to collective action in the face of this common threat.”

“To me, as somebody who has spent a lot of time in China, it comes across as incredibly naïve – and if not naïve, then wilfully blind to some of the approaches being taken,” Phelan says. Singapore and Hong Kong may be better examples to follow, Konyndyk says: “There has been a similar degree of rigor and discipline but applied in a much less draconian manner.”

The report doesn’t mention other downsides of China’s strategy, says Jennifer Nuzzo, an epidemiologist at the Johns Hopkins University Bloomberg School of Public Health, who wonders what impact it had on, say, the treatment of cancer or HIV patients. “I think it’s important when evaluating the impact of these approaches to consider secondary, tertiary consequences,” Nuzzo says.

And even China’s massive efforts may still turn out to have only temporarily slowed the epidemic. “There’s no question they suppressed the outbreak,” says Mike Osterholm, head of the Centre for Infectious Disease Research and Policy at the University of Minnesota, Twin Cities. “That’s like suppressing a forest fire, but not putting it out. It’ll come roaring right back.” But that, too, may teach the world new lessons, Riley says. “We now have the opportunity to see how China manages a possible resurgence of COVID-19,” he says.

Aylward stresses that China’s successes so far should give other countries confidence that they can get a jump on COVID-19. “We’re getting new reports daily of new outbreaks in new areas, and people have a sense of, ‘Oh, we can’t do anything,’ and people are arguing is it a pandemic or not,” Aylward says. “Well, sorry. There are really practical things you can do to be ready to be able to respond to this, and that’s where the focus will need to be.”

Full Quilette report

New England Journal of Medicine perspective

Full Science report

WHO COVID-19 China situation report

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