key: cord-288616-7i1kukmn
authors: Wan, Kelvin H.; Huang, Suber S.; Ko, Chung-Nga; Lam, Dennis S.C.
title: The end of cordon sanitaire in Wuhan: the role of non-pharmaceutical interventions
date: 2020-05-14
journal: Public Health
DOI: 10.1016/j.puhe.2020.05.007
sha: 
doc_id: 288616
cord_uid: 7i1kukmn

Abstract The effectiveness of the non-pharmaceutical interventions implemented in Wuhan are described and discussed. In the absence of vaccine and proven specific safe and effective treatments, the experience and results achieved by Wuhan could serve as a good reference for leaders and policymakers around the world in formulating their strategies and policies in fighting against COVID-19.

Wuhan, the initial epicenter of Coronavirus Disease 2019 (COVID-19), has lifted its cordon sanitaire on 8 April, 2020 after being in place for 76 days. However, epidemics are getting very serious in some countries such as America and Italy. Soon after the start of the outbreak, when the transmission dynamics and epidemiology had become a little bit clearer, the Chinese government has reacted swiftly with liberal testing, immediate case isolation, rigorous contact tracing and quarantine, social distancing, community containment, and mass masking.

"Desperate times call for desperate measures", said by Hippocrates, the famous ancient Greek physician describes vividly the decision to lockdown the Wuhan city on 23 January 2020. This was a major decision that needs much political will and wisdom. The Report of the WHO-China Joint Mission on COVID-19 concluded that "such an approach is warranted to save lives and to gain the weeks and months needed for the testing of therapeutics and vaccine development." 1 The effectiveness of these non-pharmaceutical interventions have now become evident and can serve as an important reference in managing COVID-19 pandemic.

Temperature checking stations were set up across transportation hub, designated fever clinics and wards were established in hospitals for suspected cases. Different tiers of healthcare facilities were established in anticipation of the overwhelming number of new cases. Sports stadiums and convention halls were converted into makeshift hospitals to relieve the pressure in hospital for mild COVID-19 cases. Huoshenshan and Leishenshan, the two dedicated hospitals with 2,600 beds for treating the seriously-or critically-ill patients were completed in 2 weeks. Over 42,000 medical personnel from all over China were deployed to the epicenter soon after the outbreak. 

For isolation to be effective in preventing transmission, patients should be detected ideally before the onset of viral shedding. Transmission from asymptomatic patients has made temperature and symptom-based screening less effective. 4 In China, testing for the coronavirus is free and easily accessible; 320,000 tests have been performed in the Guangdong province alone in just over 2 weeks. 1 One reason that has attributed to the reduction of new cases in South Korea has been its widespread testing together with a digital crowdsourced contact tracing strategy; they have performed over 608,000 tests as of 28 April, 2020. 5 Testing must be widely available and hurdles to get tested must be reduced. Rapid testing protocols also ensure the optimal use of isolation room and other facilities at the hospitals. Through widely available testing and contact tracing, followed by isolation and quarantining, this will be a part of the strategy of breaking the transmission chains. Companies across the world are developing and manufacturing diagnostic kit to increase the abundance of testing kits.

The use of facemask as part of the respiratory hygiene is ubiquitous in Southeast Asian countries such as China, South Korea, and Japan. Many provinces in China made it mandatory by law to wear a facemask in public during COVID-19. In contrast, citizens are advised to wear facemask only when they are ill in most non-Asian countries. Some opposing parties believe that the limited supply of facemask should be reserved for healthcare workers. This has led to racial stigmatism and aggravation among mask wearers in some of the countries in the current pandemic. As a public health intervention, mass masking protects the wearer but also each 5 other, and would eliminate discrimination. There is limited evidence, but not evidence of absence, on whether mask masking is effective in protection against coronavirus infection. 6 An adequate supply of medical masks to the public is likely to be a key bottleneck that determines whether such a strategy could be implemented as one of the non-pharmaceutical interventions in a country.

Real-time information was broadcasted by the Chinese government through popular instant messaging apps such as WeChat and Weibo. Various IT platforms have increased the accessibility to information, health services, and minimized fake news. Video conferencing and telemedicine platforms reduced exposure to healthcare workers. Wuhan Wuchang Smart Field

Hospital, one of the makeshift hospitals, was staffed with robots. Robots were equipped with infrared thermometry; they delivered meals and medications and disinfected areas. Smart bracelets and rings worn by patients monitored their vitals with data fed to remote medical staffs.

Unmanned aerial drones transported supplies to those under quarantine; they also replaced police officers in patrolling areas to enforce quarantine restriction. These innovative technologies reshape how we can protect medical personnel and care for our patients during health emergencies.

China enforced unprecedented public health efforts such as surveillance, prompt isolation of patients, quarantine close contacts, social distancing, and community quarantine. A modeling 6 study showed that changes to contact patterns via workplace and school closure significantly delayed the epidemic peak and flattened the curve of Wuhan. 7 Another model revealed that larger travel restriction of >90% together with a strong transmissibility reduction delays the epidemic growth such that the daily incidence does not exceed 1 case per 1000 in China. 8 The series of multifaceted public health measures led to a reduction in R t to less than 1.0 on 6

February and to below 0.3 on 1 March, 2020 in Wuhan. 9 These encouraging results highlight the importance of the synergistic effect of all public health measures. Such measures allow the healthcare system to better prepare their capacity to respond to an overwhelming influx of patients, minimize the morbidity and mortality, while hoping for an effective vaccine or antiviral to come. WHO Director-General commented that the "Chinese government is to be congratulated for the extraordinary measures it has taken to contain the outbreak." 10 

Report of the WHO-China Joint Mission on Coronavirus Disease

Early dynamics of transmission and control of COVID-19: a mathematical modelling study

Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand

Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany

The updates on COVID-19 in Korea as of

Respiratory virus shedding in exhaled breath and efficacy of face masks

The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in 8

China: a modelling study. The Lancet Public Health

The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak

Association of Public Health Interventions With the Epidemiology of the COVID-19 Outbreak inWuhan, China

WHO Director-General's statement on IHR Emergency Committee on Novel Coronavirus

Patient and other consents: Not applicable, not required Acknowledgments: None