China’s Response to the COVID-19 Outbreak: A Model for Epidemic Preparedness and Management

Coronaviruses are a family of contagious viruses that can cause a range of mild to severe respiratory illnesses. These viruses can mutate rapidly and form new types of coronaviruses such as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) identified in 2019 in China, which is responsible for the current pandemic of COVID-19 disease.

China has a history of fighting against coronaviruses, as seen in SARS and MERS outbreaks. Late in 2002, China suffered from a SARS outbreak, one of the contagious coronaviruses that resulted in 8,098 infections and 774 deaths from 32 countries [1]. Although SARS was effectively contained, preparations of China and other countries were insufficient for the epidemic at that time in terms of late reporting to health officials, inadequate quarantine and isolation measures, poor hygiene precautions, and vulnerability of healthcare workers [1].

Wuhan city, also known as the “Chicago of China”, is the capital and largest city in Hubei province in central China. It has a population of over 11 million and is considered a major industrial and economic part of central China. In December 2019, several cases of the emerging coronavirus, previously called 2019-nCoV, were reported in Wuhan [2]. These cases, presenting with pneumonia, were thought to have one of the countless viruses that can create the same symptoms. Later on, in early and mid-January 2020, more cases started to appear in other provinces due to the population movement during the Chinese New Year holidays, and in other countries such as Thailand, USA, South Korea, and Japan due to international travel. This escalation in the number of infected cases in China and globally, and the reporting of deaths, made the Chinese authorities sense the abnormal situation and take immediate measures.

The emergence of any infection within a community can threaten public health security as it might cause serious health impacts and has the potential to interfere with international travel and trade. COVID-19 has gained global attention by the global health organizations and health regulatory authorities since its discovery. The main issue with COVID-19 disease is the high rate of human-to-human transmission as the number of confirmed cases has reached 1,133,758 confirmed cases and 62,784 deaths over a 3-month period [3]. The basic reproductive number for virus transmutability was calculated in different studies using different models and each provided different estimations. Liu et al. [4] reviewed all the reproductive number value estimations reported from different studies and reported an average estimation of 3.28, a value that is higher than the value reported by the World Health Organization (WHO) which is 1.95. The global case fatality rate (CFR) for MERS, SARS, and COVID-19 is 34.4, 9.6, and 4.6%, respectively [5]: “Although CFR for SARS and MERS was higher, COVID-19 has led to more total deaths due to the large number of infected cases.”

Many challenges and consequences for communities in terms of health, social, and economic aspects can emerge as a result of outbreaks. In order to reduce some of the consequences, Sigfrid et al. [6] emphasized the importance for countries to “address political, economic, administrative, regulatory, logistical, ethical, and social challenges when it comes to strengthen global preparedness to emerging epidemics.” The Centers for Disease Control and Prevention (CDC) emphasized the importance for each community to have mitigation strategies in place in order to slow down the transmission when a virus with pandemic potential emerges. As each community is unique, these strategies must be based on local factors such as epidemiology, community characteristics, healthcare and public health capacities [7]. The strategies adopted by the Chinese government and discussed in this paper are a successful example as they demonstrated their efficacy in controlling and reducing the disease transmission.

This paper is a narrative review of the literature where a comparison of the Chinese response to the SARS outbreak and the current COVID-19 outbreak was conducted using various databases. Epidemic preparedness and management strategies under comparison, such as the country’s epidemic response capacity, case identification and surveillance, healthcare facilities, and medical team preparation, were selected based on CDC and WHO frameworks, regulations, and guidelines on the implementation of mitigation strategies for communities responding to epidemics. Reported cases were also reviewed from WHO situation reports from December 2019 to April 2020.

China’s government has been working on strengthening and improving their epidemic response capacity for future outbreaks, and the results are visible when comparing the response to SARS and COVID-19 outbreaks. A study by Wu and McGoogan [5] shows the timeline of the important events for SARS and COVID-19 diseases. According to them, there was a delay in notifying WHO about the SARS outbreak as 300 cases and 5 deaths had already occurred compared to 27 cases and zero deaths in COVID-19. The first official confirmation for COVID-19 came on December 31, 2019, when the WHO China Country Office was informed about a cluster of 27 pneumonia cases of unknown etiology detected in Wuhan, Hubei province, China [8]. Investigations began and traced the outbreak to a seafood market were live bats were sold and believed to be the origin of the virus [9]. The Chinese authorities immediately closed the market on January 1, 2020, as a method to terminate all meat trades, and then started environmental assessment to confirm the association and to prevent further transmission [8]. On January 3, 2020, 3 days after the first notification, the national authorities of China reported another 44 cases, while the causative agent was still unknown. Concerned authorities immediately started epidemiologic and etiologic investigations, which led the authorities to identify and isolate a new type of coronavirus on January 7, to report and detect a novel coronavirus (2019-nCoV) as the causative agent on January 9, and to make novel coronavirus genome sequencing publicly available for countries on January 10 [8]. The country exerted great efforts to improve their laboratory capacities as well, since the time taken to identify the virus was 2 months for SARS compared to 1 week for COVID-19 [9]. In addition, Chinese scientists have compiled a massive data set that gives the best available picture of the disease [10]. The advances in viral diagnostic methods, the bioinformatic capabilities to analyze the data, and the speed by which genome sequencing and data were obtained were very helpful in developing diagnostic kits and taking fast precautionary measures [11].

To look for the infection source, authorities started their surveillance with investigating food markets other than Huanan Seafood market. As for infected patients, clinical case identification was provided by WHO China and CDC China to have clear criteria for identifying cases under the outbreak investigation. The national authorities later placed public health strategies and follow-ups for cases and contacts, and more than 1,800 teams of epidemiologists were assigned to trace tens of thousands of people a day in Wuhan [12]. In addition, a community-wide temperature screening was implemented through “installing infrared thermometers in airports, railway stations, long-distance bus stations, and ferry terminals” [8]. Thousands of health and quarantine stations were also set up in national service areas and in entrances and exits for passengers at stations [12]. The search was later expanded to include screening people at work, in shops and on streets. Furthermore, the government followed more aggressive ways of health checking by sending officials to residents’ houses and forcing ill people to be isolated [13].

The Chinese government has been investing in new high technology tracking systems as well. One example is the smartphone application which is based on a health code color system that categorizes individuals into three color groups based on their health status and travel history, and then determine whether they need to be quarantined [10, 14]. Another measure that helped in disease surveillance and controlling is the street camera system that can catch and fine individuals walking publicly without a mask and identify those showing symptoms. This system is known to be effective as it was previously used during the SARS outbreak but recently updated to include facial recognition and to cover all areas in China [14].

As of January 22, the total number of confirmed cases had reached 581 globally; there were 571 cases reported in China, 375 of which were reported in Hubei province [12]. After many studies in the country reported human-to-human transmission [9, 15, 16], and due to the rapid spreading of SARS-CoV-2 within Hubei province, the Chinese authorities expanded the range of its preventive measures and announced a lockdown in Wuhan and Hubei province cities on January 24, by closing the airports and suspension of all public transportations to prevent anyone from entering and leaving [17]. This announcement was made one day before the Spring Festival in China in order to reduce the very high population movement at this time, thus reducing the spread of the disease. In addition, shops were all shut except those providing food and medicine, and very tight restrictions were placed on people to force quarantine. The government also cancelled activities with large crowds and postponed the reopening of schools and collages by extending the holiday [10]. Moreover, massive disinfection campaigns were launched in public facilities, and education was provided with a focus on populations with higher risk.

This large-scale quarantine and social distancing that locked millions of people and cost huge human and economic costs has never been applied to this extent before, which made epidemiologists skeptical of whether it would work or not. Yuan [18] assessed the effect of Wuhan lockdown during COVID-19 epidemic and reported that “cities lock-down combined with nationwide traffic restrictions and Stay At Home Movement are all public health interventions that changed the fast-rising curve of newly diagnosed cases and helped in controlling the epidemic.” As for the increase in the number of cases after the lockdown, Zhong et al. [17]reported strong correlation between the 5 million people who traveled from Wuhan within Hubei province and other provinces before January 24, 2020, and the extent of amplification of the outbreak of COVID-19 in China.

Another measure taken is generating daily reports for the newly suspected, diagnosed, and asymptomatic cases and deaths. As soon as a COVID-19 case is diagnosed or suspected, the responsible doctor is required to report the case electronically, where statistics will be generated for the total number in each area [11]. These reports are generated through China’s National Infectious Disease Information System (IDIS) developed in 2004 after the SARS outbreak, and are based on the National Disease Reporting System (NDRS) between the National and Provincial Health Commissions, which covers the entire population of China [12]. Each province is required to submit its report on a daily basis, where epidemiological curves will be generated for the whole country and for each province separately. These epidemic curves, in addition to the published literature and on-site visits to the affected areas, helped the epidemiologists in China to make epidemiological observations about the disease’s demographic characteristics, zoonotic origins, transmission dynamics, and progression. The country also used these data to identify and focus on areas that have more cases and require further measures.

Given the trend of daily increase in the number of reported cases in China in January 2020, it was a clear sign for the government that patients would soon overwhelm the country’s hospitals. As with the Xiaotangshan Hospital that was built during the SARS outbreak to relieve the overstressed medical system, China decided to replicate the old experience and immediately started building new hospitals in Wuhan and preparing the available ones to receive COVID-19 patients. The decision was made on January 24 to build Huoshenshan Hospital in Wuhan city, a brand-new facility that is fully equipped and has the capacity to treat 1,000 COVID-19 patients at once [19]. The building of the 269,000-square-foot hospital was completed within 10 days and started receiving patients on February 3. During the same period, the Leishenshan Hospital project with a 1,500-bed capacity was announced and completed on February 5 [19].

Xiaotangshan was the model for the new coronavirus hospitals built, but some notable differences in China’s actions can be seen. The first is the decision time for building the hospitals as Xiaotangshan construction began 6 months after the announcement of the SARS outbreak while Huoshenshan Hospital construction started less than 2 months after the reporting of COVID-19 cluster cases and just days after the seriousness of the outbreak became clear. Secondly are the larger construction areas with strategic locations and larger capacities to accommodate patients in the new hospitals [20]. Many other hospitals, medical centers, and quarantine facilities were built as well across the country to accommodate all patients [19]. As many of the deaths were from the older age groups, China focused on building special centers to treat old and critically ill patients where the principle of “Four Concentrations” was implemented with a focus on concentrating on the patients, medical experts, resources, and treatment [12].

As for the healthcare team, more than 40,000 healthcare workers were deployed and medical resources were mobilized from across the country to support the response in Wuhan [10, 12]. In addition, China’s National Health Commission worked on surveillance of COVID-19 among healthcare workers, revision of protection standards and specifications, and strengthening prevention and control measures against the disease in hospitals [21, 22]. Due to all of these measures being taken, transmission within healthcare settings does not appear to be a major transmission feature of COVID-19 in China, unlike in SARS and MERS outbreaks where the majority of cases were healthcare-associated transmissions [15].

Fighting and containing an outbreak of a novel pathogen with person-to-person transmission and in this highly mobile world is a challenging task [23]. Despite that, China’s government and people were up for the challenge and were able to contain the outbreak within their country borders. After all the measures taken and people’s commitment, a decline in the number of new cases and deaths was observed by the end of February and is still ongoing. The country has succeeded in reducing the numbers to hundreds and tens compared to thousands in previous months [24, 25]. This improvement can also be noticed in the very high recovery rate as more than 95% of the infected cases have recovered [26].

Health authorities have reported zero new local COVID-19 cases in Wuhan and Hubei provinces for 4 consecutive days from March 19 to March 22 [27]. The city has been able to close all temporary corona virus hospitals, and lockdowns to control the disease spreading are slowly being lifted. After more than 2 months and with all the situation improvements happening, China announced the removal of the lockdown and the travel restrictions on Wuhan and restarting of the economy on April 8 [27]. Although the results reflect the tremendous work and success of China in terms of preparedness, response, and service availability, health officials warned of a relapse as the pandemic is still ongoing in other countries and as 80% of infected cases have mild to moderate symptoms but are still infectious [27].

Meanwhile, the pandemic is spreading rapidly elsewhere around the world. Countries like the USA, Italy, and Spain have become the new virus epicenters with a higher number of infected cases and deaths reported [28]. China has contributed by sending their medical team and protective supplies from Wuhan to some of the European countries mostly affected by the outbreak, such as Italy, in order to assist in fighting against the ongoing daily battle.

China provides hope for the rest of the world and reminds other countries that even the most severe situations can be turned around. Their response to the COVID-19 epidemic and the high level of collective action in a modern city with more than 11 million people are to be appraised and have stunned the whole world. Although some will say this might seem easy in a society or political system as that available in China, it is actually not easy to get this kind of passion, commitment, interest, and an individual sense of duty. There is currently controversy regarding China’s decision to remove the lockdowns, but the results will become clearer after its application and are dependent on the precautionary measures taken by the government.

Countries need to learn from China’s response to COVID-19 and start implementing prevention and control strategies immediately as each one is at risk of becoming the new virus epicenter. Considering that each community is unique, assessment should be done of the possible benefits and negative consequences of each strategy adopted. In addition, countries should work on enhancing their systems and personnel in order to be more prepared for future outbreaks and reduce consequences when they strike.

The author declares no conflict of interest.

The author has no funding sources to declare.