key: cord-0879026-cakz4l9c authors: Xu, Weiwei; Wu, Jing; Cao, Lidan title: COVID-19 pandemic in China: Context, experience and lessons date: 2020-08-27 journal: Health Policy Technol DOI: 10.1016/j.hlpt.2020.08.006 sha: 77b322a28bd81dac41021e8bd9026279fcd34153 doc_id: 879026 cord_uid: cakz4l9c The first cluster of COVID-19 cases was reported in Wuhan, China on December 29(th), 2019. Since then, China has experienced a pandemic of COVID-19. Objective: This study aims to present the context in which the pandemic has evolved, the government's response and the pandemic's impact on public health and national economy. Methods: A review was conducted to collect relevant data from press releases and government reports. Results: COVID-19 posed a major public health threat on China with a cumulative number of cases over 89,000 (data cut-off date: August 9(th), 2020). Between January and February 2020, China implemented a series of escalating policies (including a stringent nation-wide lockdown) to combat the pandemic. Therefore, it has been to a large extent limited to the Wuhan region. Social media such as WeChat and SinaWeibo played a crucial role in disseminating government information and public campaigns during the pandemic. Technologies were adopted to enable contact tracing and population travel patterns. The Chinese central government mobilized healthcare resources including healthcare personnel and medical materials to Wuhan in a highly effective way. Both central and regional governments launched financial policies to stimulate the economy, including special loans, tax extension, reduction or waiver. Nevertheless, the economy in China was significantly impacted especially during the lockdown period. Conclusions: China has responded to the COVID-19 epidemic in a highly centralized and effective way. Balancing the needs to prevent a future pandemic and to boost economic recovery remains a challenge. On December 29 th 2019, a cluster of four novel coronavirus-infected pneumonia cases were reported in (2) On January 23 rd 2020, the Chinese government implemented a stringent lockdown of Wuhan city, followed shortly after by other areas. Since mid-March the incidence of COVID-19 has been below 100 cases per day, with the majority of such cases being "imported" from other countries.(3) Today, China has gradually relaxed the measures within the country but has kept its borders shut. In the meantime, COVID-19 has developed into a global pandemic with a tremendous impact. Before the availability of an effective vaccine(s), COVID-19 would most likely coexist with the human society. There is no single global strategy against this pandemic. For example, some countries rely on "Hammer" measures such as (almost) complete lockdown, mandatory school closure, among other measures; other countries adopt "Dance" strategies by promoting social distance, wearing face masks, etc. Since we still are in the middle of this pandemic, it is crucial to view these measures in the context of each country. The objective of this study is to present, in the context of China, how the pandemic evolved, the government's response over time, and its impact on population health and national economy. In section 2, we give a description of the Chinese society from a population and healthcare system point of view; section 3 Chinese. Chronic obstructive pulmonary disease and asthma have a prevalence rate of 13.6% and 4.2%, respectively. (14, 15) Lung cancer is the most common cancer type (with age-standardized incidence rate of 36 .71 per 100,000 population in 2014 (16) ) and the leading cause of cancer mortality in China. (17) China is a highly centralized country. The central government is empowered to enable country-wide resource re-allocation in various circumstances. On the national level, the health authority, namely the National Health Commission (NHC), has a broad scope of responsibilities including national health policy, public health, healthcare service provision and health emergency management. Other ministerial authorities, such as National Development of Reform Commission, Ministry of Civil Affairs and National Healthcare Security Administration, collaborate with the NHC by fulfilling their duties in planning, funding and insurance management in the health system. The Chinese health system consists of four levels, including national, provincial, municipal and county-level authorities. (18) The total health expenditure (THE) of China has increased dramatically in the past decades, with a 27.4 folds increase from 1995 (215.51 billion CNY, equals to 30.79 billion USD) to 2018 (5,912.2 billion CNY, equals to 844.59 billion USD). In the meantime, THE as a percentage of GDP has increased from 3.51% to 6.57%.(19) In 2018, health expenditure per capita was 4,237 CNY (605.6 USD).(19) Tax-based governmental funding, social health insurance and private out-of-pocket payment are the three main sources of healthcare financing, representing a contribution of 27.7%, 43.7%, and 28.6%, respectively. (18) The Chinese healthcare insurance system has the main characteristics of social health insurance. In the past two decades, China has established an universal health insurance system with social health insurance as the basis, supplemented by private health insurance and other social schemes for specific vulnerable groups (e.g. low-income population, disabilities, etc. Healthcare facilities in China consist mainly of hospitals (providing emergency care and in-and outpatient services), clinics (providing outpatient services) and public health institutes (infectious disease control). Hospitals, even public ones, were funded by a mixture of government subsidies (10%) and service-based revenues (90%) in 2018. (22) Since January 23 rd 2020, the COVID-19 epidemiological data has been released daily by the NHC and by some regional health authorities with relatively high incidence (e.g. Wuhan and a few other cities in the Hubei Province). Daily provincial data release by some provincial health authorities followed shortly after since the majority of cities in China launched Public Health Emergency Response Level II and/or above. Municipallevel data release was not consistent across the country: the decisions on whether data was to be released as well as on the frequency of data release were largely made at a city-level. Data was published on government websites and widely disseminated by various social media channels such as WeChat (similar to Facebook) and SinaWeibo (similar to Twitter). Published data generally included the number of suspected cases, confirmed cases, COVID-19 related deceased cases, cured cases and active cases (the latter is the number of cured and deceased cases subtracted from that of confirmed cases). Information regarding ventilator use, hospitalization and ICU use was not reported. So far, there have been three data correction rounds (on February 13 th , February 23 rd and April 16 th ) to remove double counting, missed reporting, and statistical errors. For example, on April 16 th , the number of cumulative confirmed cases was corrected to 50,333 (instead of 50,008 as originally reported), the number of cumulative deceased cases was corrected to 3,869 (instead of 2,579) and the number of recovered cases was corrected to 46,335 (instead of 47,300) in Wuhan. Details of data correction were not published. According to all seven versions of clinical guidelines published by the NHC, suspected cases were defined based on contact history and symptoms (with minor variations across different versions). Confirmed cases were defined based on confirmed pathogen among suspected cases. When interpreting the epidemiological data, it is important to note a major change in the definition of confirmed case, which took place in the week between February 12 th and 19 th . During this week, suspected cases with image-confirmed pneumonia were reported as confirmed cases regardless of the results of pathogen tests. (24) (25) (26) There has been no official definition of COVID-19 related death in the reported data so far. It is not known whether the definition was a death resulting directly or indirectly (or both) from an infection of COVID-19. Furthermore, it is also unclear what data correction procedures took place to deal with the data during the week when the definition of confirmed cases changed. Figure 1A shows the daily number of newly confirmed cases in China since Jan 23 rd 2020. Due to the-above mentioned reasons, the peak of this curve (the period between February 12 th and 19 th ) was mainly driven by the different diagnostic criteria and cannot be directly compared with the other data points. On February 5 th , 14 days after lockdown in Wuhan, the number of daily new confirmed cases reached its peak, followed by a slow but steady decrease.(26,27) Since mid-June, a few local outbreaks were reported in various cities, including Beijing (Xinfadi outbreak). These outbreaks were controlled in a timely manner with relatively small number of daily newly diagnosed cases. There was a substantial difference between the Wuhan region and the rest of China in terms of the pandemic's severity. Wuhan, a city with a population of 11 million (28), was without doubt the centre of the pandemic and a key driver to the total number of new confirmed cases nationwide ( Figure 1B ). During the peak period, Wuhan reported 1,985 (7.7/100,000 population) daily new confirmed cases on February 7 th 2020. The rest of China reported 1,993 (0.14/100,000 population) on February 3 th 2020 ( Figure 1B The number of new confirmed cases has been low in China since mid-March. In the meantime, COVID-19 has become a global pandemic. Import of active cases from abroad has been a threat to China since March 4 th ( Figure 3 ). Stringent measures have been implemented both to restrict the inflow of overseas cases and to control the spreading. Imported cases were first identified mainly in port cities such as Beijing and Shanghai. Then later in a few northern cities on the Russia-China border. [ Figure 3 about here] COVID-19 related hospitalization, ventilator use, and ICU use were only reported in a few scattered reports in China. It was reported that COVID-19 caused 19,425 hospitalizations (24.5 per 10,000 adults) in Wuhan by mid-February, among which 9,689 (12.2 per 10,000 adults) were in serious condition and 2,087 (2.6 per 10,000 adults) with intensive care use. (29) Stratified epidemiological data by age or by occupation was not routinely reported. According to a retrospective study published by the Chinese Centre for Disease Control and Prevention (CDC), % of cases were above 60 years old.(30) Compared with other age groups, patients between 50 and 60 years old reported the largest share of confirmed cases (22.4%). Patients in the age group of 70 -80 reported the highest mortality (30.5% of all deceased cases). Healthcare personnel was also reported as a high risk group.  In other areas, similar measures were enforced but to a less extent and for a shorter period. For example, no mandatory lockdown was enforced in Shanghai. Instead, health declaration and body temperature inspections were mandated at all major transportation ports (e.g. airport, railway station, coach station, high-way entrance port). A real-name system in public transport (except bus, metro and taxi) has been implemented in China for decades. Together with information dissemination on social media, contact tracing of travelers was enabled and implemented even before the report of the first case in Shanghai. As a mandatory measure, exits and entrances to communities and villages were under control (to a less extent compared to those in Wuhan). Similar to Wuhan, the government announced closure of schools and all non-essential companies, non-essential public transports, retails and parks.  Stage 3: Careful exit. China has removed the restrictions step by step since the second half of March, starting from areas with low incidence rate during the pandemic and later in the Wuhan area Implementation of minimal social distance in China has been recommended, but not mandated largely due to the high population density in the urban areas. [ Figure 4 about here] The above-mentioned measures were enforced/implemented with the support of technologies: As mentioned above, China is a highly centralized country in many aspects. With the launch of Public Health Emergency Response Level I, the central government is legitimized to respond to this pandemic in a timely and powerful way by mobilizing healthcare and other relevant resources across different regions within the whole country. Routine healthcare service was with no doubt disrupted by the COVID-19 pandemic. Reasons for the disruption varied between Wuhan (and Hubei Province) and the rest of China. Sitting at the centre of the pandemic, Wuhan and Hubei Province experienced in the beginning an abrupt, heavy demand in healthcare resources, which over-loaded the healthcare system within a few weeks. In other regions, healthcare disruption was mainly caused by measures taken to prevent and control the epidemic, such as lockdown and social distancing. Between the end of January and mid-March, healthcare services (except emergency care) were largely paused. With the development of the pandemic over time, healthcare service provision has gradually recovered. By All patients with confirmed COVID-19 diagnosis were institutionalized in China. This led to high pressure being applied on the Chinese healthcare system, especially at the beginning of the pandemic and in regions with a high number of cases (such as Wuhan). At the beginning of February, there were 28 designated hospitals for treating COVID-19 patients in Wuhan, providing 8,000 to 10,000 sickbeds. By mid-March, 42,600 healthcare professionals from other regions in China were "relocated" to Wuhan to support the local health staff (45) By the end of February, 48 hospitals (including two newly-built hospitals specifically for COVID-19) with over 26,000 beds were designated for COVID-19 treatment. (46, 47) Furthermore, temporary hospitals (Fangcang) with over 13,000 beds were setup to isolate confirmed patients with mild symptoms. (47) Over 18,000 ventilators, including 3,000 invasive ones have been produced and delivered to the Wuhan region between January and early April. Table 2 . [ Table 2 about here] Investor confidence dropped substantially.(51) Figure 5 reflects the reactions of two major stock market indices in China (SSE50 and SZCOMP) to the COVID-19 epidemic. [ Figure 5 about here]  Mandatory use of tracing technologies without much restrictions. In western countries, privacy has been a major issue surrounding the implementation of tracing technologies, which has led to many debates. However, few debates regarding privacy took place in China, at least in the public domain. In the Chinese culture, life weights more over privacy. This allowed a smooth implementation of mandatory tracing. When looking at this experience, each country needs to investigate its own political and societal culture and environment to assess the potential of such measures. Both the central and regional governments launched financial policies to stimulate the economy, including special loans, tax extension, reduction or waiver. 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