Last week I was pointed at an interesting analysis of the global coronavirus approaches. The author, dr. Daxin Ni, a deputy director of the public health emergency center at the Chinese Center for Disease Control and Prevention (CDC) and former steering committee member of WHO’s Global Outbreak Alert and Response Network (GOARN), compared two general approaches: the SARSlike and pandemic flu-like approach. Although I want to emphasize this is not my analysis and I do not necessarily agree with all that he wrote, I found it insightful and with his permission, I hereby share it with you.
On 31 December 2019, an outbreak of pneumonia of unknown pathogen was discovered in Wuhan, China. On 7 January 2020, a new coronavirus was identified as the cause of the pneumonia. Since then, as the epidemic spread to other parts of China and some other countries of the world, it attracted high attention from the international community. On 30 January 2020, the World Health Organization declared the COVID-19 outbreak a public health emergency of international concern. After the outbreak detected, the Chinese government has taken active prevention and control strategies and measures. After more than two months of unremitting efforts, not only has the increase of new cases been effectively controlled, but also the local transmission has been tending to be completely contained by mid-March 2020. But at the same time, the international epidemic went from imported cases and limited local transmission in a few countries in January 2020, to rapid growth in a few countries including the Republic of Korea, Iran and Italy in February, then the global epidemic spread rapidly and accelerated in March. On 11 March 2020, the World Health Organization officially declared the COVID-19 outbreak a global pandemic.
With the spread of the epidemic around the world, different countries have adopted different strategies and measures, and the international academic community has never stopped arguing about how to control the epidemic of COVID-19, the World Health Organization’s recommendations have not been well implemented in many countries and areas, especially in countries like the United States of America and Europe, where the World Health Organization’s recommendations have almost been ignored. As of 16 March 2020, there were 86,429 confirmed cases and 3,388 deaths in 150 countries except China, including 13,874 new cases and 848 new deaths on March 16th only, and the number of countries with the first confirmed cases report reached seven on the day. However from global perspective, the COVID-19 epidemic is still in the early stage of the pandemic development, widespread community-based transmission has not yet occurred in most countries, and the global pandemic is still accelerating and there is still a long way to reach its peak.
In order to provide support to the prevent and control the global pandemic of COVID-19, this paper tries to analyze the strategies and measures of the prevention and control for the COVID-19 in the world.
1. Classification of the Strategies and Measures for the Prevention and Control of COVID-19
Taking a comprehensive view of the current international strategies and measures for the prevention and control of COVID-19, although there are differences in the specific measures in different countries, but according to the essential characteristics of the strategies and measures adopted, they can be simply classified into the following two categories.
The first category is the strategy and measures adopted by countries such as China, Singapore, Korea and Thailand, etc., which can be called “SARS-like prevention and control strategy and measures” , or Containment strategy, Blocking strategy, and hereafter will be called “SARS-like strategy” in this article .
The second category is the strategy and measures adopted by countries such as the United States of America, Japan, Italy, France and Switzerland, etc., which can be called “pandemic influenza prevention and control strategy and measures” , or mitigation strategy, and hereafter will be called the “Pandemic Flu-like strategy” in the article.
2. Differentiation and Analysis of the Differences between Two Kinds of Strategies and Measures
Through careful analysis and study of different national prevention and control strategies and measures based on their essential differences, the two types of prevention and control strategies and measures are mainly different in the following areas.
(1) Different Prevention and Control Goals
The prevention and control goals of the two strategies are different. The prevention and control goals of the SARS-like strategy are to control the epidemic, contain the spread completely and eliminate the harm. While the prevention and control goals of Pandemic Flu-like strategy are to control the spread, slow down the epidemic, and reduce the overall harm.
(2) Different Arguments
SASRS-like strategists believe that the main route of transmission of COVID-19 is through close contact and droplet by symptomatic individuals, and active investigation and control through SARS-like prevention and control, the transmission of latent and incubation infections can be interrupted by additional measures, proactive control strategies and measures should be adopted. While Pandemic Flu-like strategists consider that it is almost impossible to completely detect and manage all the source of transmission of the new coronavirus, which infection exists in the latent and incubation period of transmission. The transmission of COVID-19, just like that of an pandemic influenza, can only be slowed down and cannot be completely interrupted. Since it cannot be blocked, all people will sooner or later become infected, so it is better to adopt strategy and measures to slow its spread, and allow it to spread slowly and in a controlled manner until the population forms an adequate immune barrier or reach herd immunity, and then the intensity of the epidemic will be greatly reduced, making it a seasonal epidemic disease similar to seasonal influenza.
(3) Different Views on Cost-effectiveness
SARS-like strategists believe that, regardless the case-fatality rate of COVID-19 is high or low, since the virus can be effectively controlled and the transmission can be completely blocked by taking proactive prevention and control measures, so hard efforts should be made to minimize the incidence, severe cases and case fatality of the disease, it is worthwhile to pay a greater cost in the short term, and to avoid more significant overall health and socio-economic losses. While Pandemic Flu-like strategists argue that, about 80% of those infected with COVID-19 are mild cases, and the case fatality rate was only a slightly higher than that of the pandemic influenza, which much lower than that of SARS and MERS. At the same time, those infected with the COVID-19 has no specific medicine, and mild cases do not require hospitalization. So under the hypothesis that the transmission could not be interrupted, SARS-like prevention and control strategy and measures will cost too much, and the impact on normal social production and life and the loss for that are extremely heavy, so it is not worth of it, not in line with the cost-effectiveness principle.
(4) The Key Prevention and Control Measures are Different under the Guidance of the Two Strategies
Because of the different objectives, arguments and cost-effectiveness views, the key prevention and control measures under the guidance of the two strategies are remarkably different.
1. Key Prevention and Control Measures under SARS-like Strategy
Under the SARS-like strategy, in order to stop transmission and reduce health impact, it is necessary to realize “Five Early” , that is, “Early Detection, Early Reporting, Early Investigation, Early Isolation and Early Treatment” , so as to realize the strict management of the source of infection, and to block transmission gradually.
“Early Detection” , that is by improving the awareness and sensitivity of medical staff, early detection of suspected cases, rapid tests and diagnosis should be taken, so as to promote timely and effective management of all patients, which are the most important source of infection for COVID-19.
“Early Reporting” , that is, suspected patients and confirmed cases need to be reported to the health authority or disease control departments within a specified time, in order to start the investigation and response.
“Early Investigation”, that is after receiving reports of confirmed patients, suspected patients or positive tested persons, the department of disease control and prevention needs to send out the epidemiologists to investigate the patients’ exposure before the onset of illness and the persons getting contacted with him/her after getting ill, so as to find out the source of infection of the patient and all of the close contacts associated with him/her. Through in-depth “Early Investigation” to identify the transmission chain of each cases, it will be totally possible to achieve an overall identification and management of all possible patient-related infected persons.
“Early Isolation” , that is all confirmed cases should be treated in isolation, all suspected cases should be treated in isolation, and all close contacts should be placed under medical observation and isolation, or be quarantined. “Early Isolation” of confirmed and suspected cases would be effective in preventing transmission of the virus from COVID-19 patients to healthy individuals. “Early Isolation” of close contacts will help to detect new cases of infection including atypical mild cases at an early stage, as well as to ensure strict management of those with latent or incubation period infections, so that they could not spread the virus to other people. Through the single-room isolation of the suspected patients and close contacts, it can effectively prevent the possible cross-infection between these isolated patients or quarantined people.
“Early Treatment”, that is through the effective symptomatic treatment, support treatment and available anti-viral or traditional Chinese medicine treatment, efforts are made to prevent the progression of mild cases to severe or critical, and the severe cases to be given full care, all these efforts are trying to reduce case fatality. At the same time, through “Early Treatment” , it can also achieve the elimination of patients’ status as a source of infection.
Through “Five Early” , and to achieve the full hospitalization of all the confirmed cases, suspected cases and positive tested persons, to achieve the full management or quarantine of close contacts, which are called in China “Due Hospitalization, Due Management”, it will lead to the effective control of the further spread of the virus, and ultimately interruption of the virus transmission.
2. Key Measures under Pandemic Flu-like Strategy
Under the Pandemic Flu-like strategy, in order to achieve the goal of reducing health impact, the emphasis and the most critical measures are the treatment of severe cases. At the same time in order to avoid medical overload, if necessary, appropriate measures will be taken to increase social distance. However, no emphasis are placed on the early detection of all cases, the isolation of mild cases, or the tracing and management of close contacts.
Treatment of Severe Cases , that is to give priority to the case of severe, or cases with underlying illnesses for hospital treatment, mainly through active symptomatic, support treatment, to reduce the mortality. At present, there is no specific drug for the treatment of COVID-19 virus, so under the strategy of Pandemic Flu, it is generally to advocate mild cases to be observed at home, if not showing any severe symptoms like short of breath.
Because of the lack of emphasis on early case detection, the tests for new coronavirus is generally not recommended for atypical, mild patients and the close contacts.
When the number of cases increases rapidly or too fast in a region, the number of severe cases exceeds the capacity of the medical institutions, or severe cases crowding out of medical resources, measures may be taken to increase social distance, such as the prohibition or reduction of large-scale gatherings, school suspension, work stoppage, and even declared a state of emergency or a curfew, etc. just like what are happening now rather popularly in the countries with such kind of strategy.
3. Other Common Measures to Prevent and Control COVID-19
Based on the prevention and control practice of COVID-19 in various countries, other common prevention and control measures are as follows:
(1) Lockdown of cities, villages and roads, as well as closed management for institutions and communities.
(2) Suspension of work, school and production.
(3) Suspension of flights, ships, traffic, etc.
(4) Quarantine at Point of Entries, and traffic health check points.
(5) Mask wearing, hand hygiene, cough etiquette, etc.
(6) Disinfection measures.
All these measures are aimed either at controlling the flow of infectious sources, increasing social distance or protecting vulnerable populations in order to prevent or reduce the spread of the virus and reduce the incidence of the disease. These measures may be more or less adopted to prevent and control the epidemic of COVID-19 in both groups of strategic population, and at the same time, they may be different in each country according to the current epidemic situation, the concept of prevention and control, and cultural customs there. SARS-like strategy may pay more attention to and take more aggressive closure measures, such as in Wuhan, lockdown of the city was used to prevent further spread of new coronavirus infection, other types of closed management in other parts of China are also taken to prevent infection from spreading out or coming in. while Pandemic Flu-like strategy may place more emphasis on more modest measures to increase social distance, such as fewer gatherings and school suspension. But all of these measures are complementary to the key measures of both types of strategies and can only help or facilitate faster and better outcomes for key interventions.
5. Brief analysis of prevention and control strategies and measures in some countries
(1) China’s strategy and measures
China has adopted a SARS-like strategy, focusing on patient discovery and isolation, close contact investigation and strict management. In order to control the spread of infectious sources, the city of Wuhan, with a population of ten millions, was locked down. By adding fixed-point hospitals, building new isolation hospitals and building shelter hospitals, the problem of admission and treatment for huge number of patients in Wuhan was effectively solved, and the patients, the most important source of infection, were effectively under control. At the same time, through general mobilization throughout the country, other provinces and municipalities, while doing well their local prevention and control work, have provided adequate medical personnel, epidemiological investigators, rescue and protection equipment and facilities to Wuhan in the form of counterpart support, the goal of stopping the spread of the virus has been basically or initially achieved, and the higher case fatality rate in the early stage of the epidemic has been effectively controlled.
The key to the control of epidemic situation in China lies in the effective management of infectious resources, and at the same time, through the lockdown of Wuhan City, the spread of the virus to outside areas has been effectively blocked, which is crucial to the epidemic control of other areas in China, and also contribute to the control of the epidemic in the World at that time period. However, there is almost no widespread community transmission outside of Wuhan, so the various closure measures in these areas should only play an facilitating role in the control of the spread of this disease, meanwhile, the enormous impact of these measures on the social production and life may have caused a large number of unnecessary losses to the national economy and social development.
(2) Singapore’s strategy and measures
Although the Singapore government claims that the COVID-19 is just like a large influenza, in the specific prevention and control practice, it has focused on the detection and isolation of patients, and the follow-up investigation and management of close contacts. Therefore, in essence, the goal of prevention and control is to block the spread of the virus, the basic strategy and key measures are still similar to SARS prevention and control strategy and measures.
(3) Republic of Korea’s strategy and measures
The Republic of Korea is also implementing SARS-like prevention and control strategies and measures. After the epidemic rapidly increased and in the case of once-difficult admission of patients, although no drastic containment measures were taken, but the Republic of Korean government resisted huge pressure to increase the detection of suspected patients and close contacts, and their efforts were finally made to achieve the goal of managing all the patients and quarantine all the contacts, so the control results of the epidemic has already seen obviously, daily reported cases have fallen from a peak of more than 1,100 to the dozens now.
(4) Japan’s strategy and measures
Japan has adopted a typical pandemic flu-like strategy, with the government making it clear in the early days that it would only encourage hospital treatment for severe cases and home treatment for mild cases, and would not encourage new coronavirus testing for asymptomatic people. But thanks to Japan’s self discipline and high level of hygiene, the country has not seen the rapid increase in cases like what seen in European countries, making it one of the very unusual countries using the pandemic flu-like strategy. However, as its prevention and control strategy is unlikely to stop the spread of the epidemic, the recent COVID-19 in Japan is still in the process of a sustained slow rise.
(5) Iran’s strategy and measures
Iran’s original intention was to adopt SARS-like prevention and control strategy and measures, to vigorously strengthen the detection of suspected patients, to make efforts to investigate and manage contacts, and to solve the problem of patient admission, but due to long-term economic sanctions, the basic capacity or social economic support is weak, it has not really done the “Due Hospitalization, Due Management”, so Iran is not a complete SARS-like strategy country. As a result, although the number of cases has not continued to increase significantly recently, it has been in the peak phase of cases for a longer time, and the effect of future control depends on whether the hospitalization of cases can be effectively solved, and then to further strengthen the close contacts investigation and management.
(6) The United States of America’s strategy and measures
The United States of America has a strong Pandemic Flu-like strategy, so it has been strictly limiting the new coronavirus test for suspected cases and encouraging patients with mild illness to stay at home. Earlier outbreaks there rose more slowly than other countries when aggressive travel restrictions imposed by the United States of America on China, but because cases continue to spread slowly, the source of infection accumulate, new importation from Europe countries introduced, and more testing has recently been done, there has been a rapid increase in the number of cases and deaths. To this end, a number of states, and later on, the United States of America nationwide, have declared a state of emergency, and take a lot of measures to increase social distance.
(7) Italian strategy and measures
In spite of the lockdown imposed in the disease focus areas and even the final nationwide lockdown, and the relatively active testing of new coronavirus, Italy has emphasized the treatment of serious cases, home observation of mild cases was required, both in the focus areas and in other parts of the country. And at one point it was even announced that testing for mild cases would be reduced. So Italy’s strategy and measures are closer to those of the Pandemic Flu, which is why Italy has surpassed South Korea and then Iran to become the country with the highest number of cases outside China. And because community transmission has not been effectively controlled, with the increase in the total number of patients, severe cases have emerged to cause medical resources run-off phenomenon, medical staff have to face selective treatment of the “severe cases”, that is, priority is given to the treatment of severe cases with longer “life expectancy” rather than those with advanced age and severe underlying illnesses.
8) Strategy and measures of the United Kingdom and other European countries
The United Kingdom, as well as most European countries, are strong Pandemic Flu-like strategy, emphasizing that COVID-19 cannot be completely blocked, the treatment of severe cases is the main focus, and patients with mild cases require home observation, limiting new coronavirus testing in patients with mild illness. The United Kingdom, Switzerland, Sweden, and most other European countries, in face of the rapid rise in new cases of COVID-19, directly announced the abandonment of the detection of mild cases, and even said no longer announced the number of confirmed cases. The UK has even gone so far as to say publicly that it wants to natural immunize the population by giving it a 60 per cent or so infection rate, so it has tended to be conservative even in taking measures of increasing social distance, such as not actively enforcing school closures.
6. Analysis of the control effect of two kinds of strategies on COVID-19
(1) SARS-like strategy countries have achieved good results in controlling the epidemic situation
Countries and regions that adopted SARS-like strategies, whether the countries like China and Republic of Korea, where the COVID-19 epidemic was severe in the early stage, or Singapore, Thailand, Vietnam, Hong Kong SAR (China), etc. where the imported cases was the major problem, through actively adopted SARS-like prevention and control strategy and measures, the COVID-19 epidemic situation has been well controlled, even has realized successfully the elimination of local transmission. China, as the first country to find the COVID-19 epidemic this time, has experienced a high intensity and extensive community spread in Wuhan, but has successfully controlled the local spread by actively adopting SARS-like prevention and control strategy and measures, and is about to complete the interruption of local virus transmission. In the case of Republic of Korea, which experienced a sharp increase in the number of cases in the previous period and made it once the number of cases be second only to China, it insisted on the implementation of key measures and quickly reversed the epidemic. At present, the number of new cases has been successfully reduced to double digits, the control and containment of local transmission is within reach.
Countries that have adopted a SARS-like strategy have interrupted the chain of transmission of the virus because of the discovery of key sources of infection and the implementation of management measures. New cases have been effectively contained and the number of severe cases has been brought under control accordingly, the crude case fatality rate of most other countries or regions except Wuhan, China is relatively low, while the case fatality rate is high in Wuhan due to the medical resources run-off once upon a time.
In addition, the SARS-like strategy countries, exported less cases to other countries. Although imported cases from China were detected in more than 20 countries around the world in the early days of the Wuhan outbreak, with proactive and even aggressive prevention and control measures, other countries has reported very few new cases of COVID-19 imported from China since February 2020.
(2) Pandemic flu-like strategy countries continue increase or even very rapidly
In countries with pandemic flu-like strategy, community transmission continues to occur as a result of a lack of comprehensive and effective management of the source of infection, the level of transmission or the varies of increase rate from country to country affected mainly by differences in the ability to treat cases in different countries, the compliance of the population to treatment at home, the strength and consciousness to increase social distance measures, and the early or late the start of the epidemic. The Italian epidemic continues to rise, the epidemic in vast majority of European countries and the United States of America are soaring in the recent past, and the epidemic in Japan has been continuing to rise slowly.
With the spread of the disease and the increase in the number of cases in Italy, the number of severe cases has increased accordingly, which has exceeded the capacity of local medical institutions. Medical personnel are facing the dilemma of having to treat patients selectively, and the case fatality rate remains high, to become the world’s highest crude case fatality rate country. It remains to be seen whether other countries with pandemic flu-like strategy will experience a similar run on severe cases.
In the case of widespread community transmission and severe epidemic of the virus in Italy, no strict and genuine lockdown was imposed on the severe epidemic area and the country, the epidemic continues to spread inside the focus area, from the focus area to other parts of Italy, and then Italy has continued to spread to Europe and other countries around the world. For this reason, Italy has been the biggest exporter of cases to other countries, and in some ways it has been a major source of the new global pandemic. At the same time, with the number of new cases rapidly rising in most European countries and the United States, these countries have also become an important source of recent cases importation to other countries and act as a booster of the global pandemic.
7. Analysis of the Relationship between the Two Strategies and Suggestions for the Next Step Control Strategy
At present, the global pandemic is still in its early stage. So if the differences between the two strategies can be quickly resolved, and a global consensus, concerted action and robust joint measures can be reached and taken, among them the most important is that the SARS-like strategy could be promoted by all countries, it is still possible to influence and control the course of the global pandemic, and to halt the global spread of the new coronavirus.
(1) Analysis of the Relationship between the Two Types of Strategies
The fundamental differences between the two strategies are whether the new coronavirus can be completely contained, how to view the cost-effectiveness of prevention and control, and the understanding of containment measures.
A. The possibility of containment or blocking. Whether the new coronavirus can be completely blocked is now entirely possible. First, China, Singapore, Thailand, Vietnam and even the Republic of Korea’s control practices have fully explained this point, the China’s COVID-19 prevention and control field research report of World Health Organization also gave full recognition. Second, for the “leakage of infectious sources” caused by latent infectious, incubation period infectious and atypical cases problem which are concerned about by Pandemic flu-strategists, it is entirely possible that these problems can be well solved through the measures of “Five Early” and “Due Hospitalization, Due management”, which has also been proved in practice. The incubation infectious of COVID-19 is mainly at the end of the incubation period, and the rate of latent infection is low, it can realize the comprehensive detection and management of all atypical patients, latent infection and incubation period infection, thus effectively prevent the further spread of virus to other healthy people.
B. Cost-effectiveness. As long as people agree that new coronavirus transmission can be stopped, it will become very clear which of the two strategies is more cost-effective. The SARS-like strategy may control the incidence increase in a shorter time, block the spread of the virus, and greatly reduce the overall number of cases, severe cases and deaths, at the same time, it avoids the influence of social distance measures on social production and life for a much longer time. When look it at a global scale, based on a simple analysis of available data and extrapolation, it is much easy to see the cost-effectiveness and health benefits of the two strategies are not even comparable.
C. Understanding of the role and necessity of containment measures. According to the SARS-like strategy, it is necessary to take some measures to control the spread of COVID-19 virus in the intensive community transmission area, which can reduce the pressure of prevention and control in other areas. As even at the peak of the outbreak in China, and because of domestic management measures for those at risk of infection, limited exportation to the rest of the world were recorded at only earlier stage, and no exportation to Africa. However, after the recent increase of the epidemic in Italy, more European countries and the United Sates of America, due to the adoption of a pandemic-influenza like strategy there, those who may have been infected in the country have not been effectively detected and managed, as a result, more than 20 countries in Africa alone have recently seen imported confirmed cases in a very short time period, and even in some African countries, such as Egypt, Algeria and Senegal, have already led to local transmission, which will be a very worrisome situation. It can be seen that the adoption of SARS-like strategy and measures in areas with widespread community transmission not only has a fundamental impact on the control of the epidemic situation in the country or the region, but also it has a great impact on the world pandemic control, especially on countries with poor capacity and resources, such as Africa, which the epidemic losses there will be incalculable.
It is clear from the comparison of key control measures across the two global strategies, whether in high-prevalence areas where widespread community-based transmission has already occurred, or in low-prevalence areas where only imported cases or limited local transmission happened there, the key to control and contain the spread of new coronavirus lies in the implementation of “Five Early” and “Due Hospitalization, Due management”. And the earlier it is implemented, the easier it is to implement, and the less costly it will be. In contrast, the later it is implemented, the harder it is to implement, and the more costly it will be. The development of the epidemic is mainly affected by the above-mentioned key measures, rather than the lockdown or social distance measures which are considered most difficult to replicate in Western and pandemic flu-like strategy countries. We need to emphasize that these lockdown or social distance measures are necessary only under certain circumstances like massive local transmission. In addition, all these measures only play an facilitating role in controlling the epidemic situation. Even without it, the time for control and containment may be last somehow longer, but if the key control measures be taken timely and effectively, similar containment effect should be able to achieve, just like what we have seen in Singapore and in the Republic of Korea. Therefore, all countries in the world, when take measures to strengthen the treatment of severe cases, they can adopt the SARS-like strategy further, i.e. to implement key control measures to achieve the “Five Early” and “Due hospitalization, Due management”, it will effectively control the increase of disease incidence, and easily to reach the target of reduce case fatality rate, and ultimately contain the spread of new coronavirus. With such united efforts, we are still hopefully and able to interrupt the pandemic, to finally contain or block the new coronavirus transmission, and to make great contribution to the benefit of people in each country, and to the benefit of people around the world.
(2) Recommendations for the control strategy of next step
At present, the COVID-19 global pandemic is still at an early stage, the vast majority of countries have not yet emerged widespread community-based transmission. However, we are now also in a critical period of time for the pandemic, which will be much more difficult to control once the pandemic evolves further and spreads widely in the community in many more countries and regions. Since the outbreak of COVID-19, a large number of disease characteristics and studies have shown that COVID-19 cannot be compared with pandemic influenza in terms of its harm to health and potential harm to social development. At the same time, the transmission of the new coronavirus can be totally contained or blocked, compared with the influenza pandemic, which is almost impossible to do so. Therefore, in the face of this unprecedented challenge to all mankind, as a community of mutual influence on the fate of mankind, countries around the world need to put aside political and ideological differences, and quickly unite to take SARS-like prevention and control strategy and measures, and to act immediately to help without hesitation those countries with highest disease burden now and the countries with the epidemic but without enough resources and capacity, while each country should do best first to prevent and control the epidemic in their own countries, so that all countries can implement fully and as soon as possible the key measures of “Five Early” and “Due Hospitalization, Due management”. Based on these, all countries and regions can take supplementary measures such as lockdown or other social distance measures, in adaptation to the local situation of epidemic and cultural custom etc. In this way, people should have full confidence to make this pandemic the first in the history to be controlled and finally contained.
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【Written on 17 March 2020, in Zambia】