Covid-19 – the China Syndrome

Today’s Guardian quotes Anthony Costello, former director of the World Health Organization:

The key principles from WHO are intensive surveillance. You test the population like crazy, find out where the cases are, immediately quarantine them and do contact tracing and get them out of the community. This deals with family clusters. That’s the key bedrock of getting this under control.

This was how South Korea, China, Japan, Hong Kong and Taiwan had brought their case numbers down. You can really take people out of the population and make sure they are quarantined. That is vital.

A twenty-five strong WHO Joint Mission was sent to China in late February. It was made up of:

25 national and international experts from China, Germany, Japan, Korea, Nigeria, Russia, Singapore and the USA, and headed by Dr Bruce Aylward of WHO and Dr WannianLiang of the People’s Republic of China.

Here are the key findings – full report here – as compiled on Reddit:

• When a cluster of several infected people occurred in China, it was most often (78-85%) caused by an infection within the family by droplets and other carriers of infection in close contact with an infected person. Transmission by fine aerosols in the air over long distances is not one of the main causes of spread. Most of the 2,055 infected hospital workers were either infected at home or in the early phase of the outbreak in Wuhan when hospital safeguards were not raised yet.

• 5% of those diagnosed with Covid require artificial respiration. Another 15% need to breathe in highly concentrated oxygen – and not just for a few days. The duration from start of the disease until recovery is 3 to 6 weeks on average for these severe and critical patients (compared to only 2 weeks for the mildly ill). The mass and duration of the treatments overburdened the existing health care system in Wuhan many times over. The province of Hubei, whose capital is Wuhan, had 65,596 infected persons so far. A total of 40,000 employees were sent to Hubei from other provinces to help fight the epidemic. 45 hospitals in Wuhan are caring for Covid patients, 6 of which are for patients in critical condition and 39 are caring for seriously ill patients and for infected people over the age of 65. Two makeshift hospitals with 2,600 beds were built within a short time. 80% of the infected have mild disease, ten temporary hospitals were set up in gymnasiums and exhibition halls for those.

• China can now produce 1.6 million test kits for the novel coronavirus per week. The test delivers a result on the same day. Across the country, anyone who goes to the doctor with a fever is screened for the virus: In Guangdong province, far from Wuhan, 320,000 people have been tested, and 0.14% of those were positive for the virus.

• The vast majority of those infected sooner or later develop symptoms. Cases of people in whom the virus has been detected and who do not have symptoms at that time are rare – and most of them fall ill in the next few days.

• The most common symptoms are fever (88%) and dry cough (68%). Exhaustion (38%), expectoration of mucus when coughing (33%), shortness of breath (18%), sore throat (14%), headaches (14%), muscle aches (14%), chills (11%) are also common. Less frequent are nausea and vomiting (5%), stuffy nose (5%) and diarrhoea (4%). Running nose is not a symptom of Covid.

• An examination of 44,672 infected people in China showed a fatality rate of 3.4%. Fatality is strongly influenced by age, pre-existing conditions, gender, and especially the response of the health care system. All fatality figures reflect the state of affairs in China up to 17 February, and everything could be quite different in the future elsewhere.

• Healthcare system: 20% of infected people in China needed hospital treatment for weeks. China has hospital beds to treat 0.4% of the population at the same time – other developed countries have between 0.1% and 1.3% and most of these beds are already occupied with people who have other diseases. The fatality rate was 5.8% in Wuhan but 0.7% in other areas of China, which China explained with the lack of critical care beds in Wuhan. In order to keep the fatality rate low like outside of Wuhan, other countries have to aggressively contain the spread of the virus in order to keep the number of seriously ill Covid patients low and secondly increase the number of critical care beds until there is enough for the seriously ill. China also tested various treatment methods for the unknown disease and the most successful ones were implemented nationwide. Thanks to this response, the fatality rate in China is now lower than a month ago.

• Pre-existing conditions: The fatality rate for those infected with pre-existing cardiovascular disease in China was 13.2%. It was 9.2% for those infected with high blood sugar levels (uncontrolled diabetes), 8.4% for high blood pressure, 8% for chronic respiratory diseases and 7.6% for cancer. Infected persons without a relevant previous illness died in 1.4% of cases.

• Gender: Women catch the disease as often as men. But only 2.8% of Chinese women who were infected died from the disease, while 4.7% of the infected men died. The disease appears to be not more severe in pregnant women than in others. In 9 examined births of infected women, the children were born by caesarean section and healthy without being infected themselves. The women were infected in the last trimester of pregnancy. What effect an infection in the first or second trimester has on embryos is currently unclear as these children are still unborn.

• Age: The younger you are, the less likely you are to be infected and the less likely to fall seriously ill if you do get infected

• The new virus is genetically 96% identical to a known coronavirus in bats and 86-92% identical to a coronavirus in pangolin. Therefore, the transmission of a mutated virus from animals to humans is the most likely cause of the appearance of the new virus.

• Since the end of January, the number of new coronavirus diagnoses in China has been steadily declining (shown here as a graph) with now only 329 new diagnoses within the last day – one month ago it was around 3,000 a day. “This decline in COVID-19 cases across China is real,” the report says. The authors conclude this from their own experience on site, declining hospital visits in the affected regions, the increasing number of unoccupied hospital beds, and the problems of Chinese scientists to recruit enough newly infected for the clinical studies of the numerous drug trials. Here is the relevant part of the press conference about the decline assessment.

• One of the important reasons for containing the outbreak is that China is interviewing all infected people nationwide about their contact persons and then tests those. There are 1,800 teams in Wuhan to do this, each with at least 5 people. But the effort outside of Wuhan is also big. In Shenzhen, for example, the infected named 2,842 contact persons, all of whom were found, testing is now completed for 2,240, and 2.8% of those had contracted the virus. In Sichuan province, 25,493 contact persons were named, 25,347 (99%) were found, 23,178 have already been examined and 0.9% of them were infected. In the province of Guangdong, 9,939 contacts were named, all found, 7,765 are already examined and 4.8% of them were infected. That means: If you have direct personal contact with an infected person, the probability of infection is between 1% and 5%.

A few direct quotes from the report:

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. In the face of a previously unknown virus, China has rolled out perhaps the most ambitious, agile and aggressive disease containment effort in history. China’s uncompromising and rigorous use of non-pharmaceutical measures to contain transmission of the COVID-19 virus in multiple settings provides vital lessons for the global response. This rather unique and unprecedented public health response in China reversed the escalating cases in both Hubei, where there has been widespread community transmission, and in the importation provinces, where family clusters appear to have driven the outbreak.

Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China. These are the only measures that are currently proven to interrupt or minimize transmission chains in humans. Fundamental to these measures is extremely proactive surveillance to immediately detect cases, very rapid diagnosis and immediate case isolation, rigorous tracking and quarantine of close contacts, and an exceptionally high degree of population understanding and acceptance of these measures.

COVID-19 is spreading with astonishing speed; COVID-19 outbreaks in any setting have very serious consequences; and there is now strong evidence that non-pharmaceutical interventions can reduce and even interrupt transmission. Concerningly, global and national preparedness planning is often ambivalent about such interventions. However, to reduce COVID-19 illness and death, near-term readiness planning must embrace the large-scale implementation of high-quality, non-pharmaceutical public health measures. These measures must fully incorporate immediate case detection and isolation, rigorous close contact tracing and monitoring/quarantine, and direct population/community engagement.