COVID-19 pandemic prevention & control: innovations based on past experiences

Speaker: Guang Zeng, High-level Expert Group of the National Health Commission of China and the former Chief Scientist of Epidemiology of the Chinese Center for Disease Control and Prevention

Translater: Xuan Li

Lecture Outline

Advantages of whole-of-society approach to COVID-19 prevention and control

2. The COVID-19 prevention and control: heritage as is, with significant innovative developments

3. The new normal of the COVID-19 prevention and control: to eradicate COVID-19 cases at all costs

Main points

1. Pandemic control requires the combination of theoretical research with real-world experience. The keys to victory lie in the availability of real-world experience. China's fight against the COVID-19 was directly taken from the rich heritages from fighting SARS and influenza A. Most other countries do not have such experience.

2. Pandemic prevention and control require a strategy that unfolds not along a plane, but along a timeline, which was not encapsulated in past mechanisms and institutions.

3. The new normal of COVID-19 prevention and control is to eradicate the confirmed cases at all costs. The serious attitude toward a local case is necessary for the safety of the whole nation.

I. Advantages of a whole-of-society approach to COVID-19 prevention and control

First, I will briefly talk about the National Whole-Of-Society Approach of Epidemic Prevention and Control System gradually established from SARS to COVID-19.[1] Then, I will talk about the key points of pandemic prevention and control under the new normal of the COVID-19 pandemic.

It has been less than a year since COVID-19 broke out in Wuhan, but the world has been changed drastically[2]. In the early days of the pandemic, there were few cases of COVID-19 abroad, and all the pressure to fight the pandemic was on China, with Wuhan taking the biggest hit. Despite being the first place to be hit by COVID-19, how has China managed to wrest control of its pandemic while the global COVID-19 is raging? For example, there is a big gap between our clinical treatment and the ones in Europe and the United States. Medical facilities, especially the reserve of negative pressure ICU ward, are also stretched to the limit. Besides, China does not have advantages in basic medical research where the U.S. has a strong research capacity of the National Institutes of Health (NIH) and it is unmatched by any other countries in the world.

Also, we have seen several U.S. biopharmaceutical companies show great strength in the current vaccine development process. No need to mention public health and epidemiology - the U.S. has the Center for Disease Control and Prevention (CDC) with over 26,000 employees, while the field epidemiology training in China was only founded in the U.S. in 2001. I was the founder of this curriculum and personally brought in instructors from the US CDC, who have helped us train many excellent students. Indeed, these instructors contributed a lot. In addition, China lacks the originality of theoretical research in emergency management, and its applied theories are mainly from Europe and the US.

How could China remain stable in coping with the epidemic when we are disadvantaged in pandemic prevention and control? Let me give you some analysis from my personal experience. During my 19 years as the Chief Expert of the Chinese CDC, I have participated in and consulted on a series of major public health events, so I have a deeper understanding and a lot of personal insights about China's public health strategies.

Figure 1. Health Emergency and Disaster Risk Management (EDRM) Framework3

I believe that the fight against the pandemic needs to be carried out in two separate directions: theoretical study and practical experience. We need to research the theory. WHO Director-General declared that the outbreak constitutes a Public Health Emergency of International Concern (PHEIC), and there is an international emergency management framework (EDRM) for such events[3], which is the institutional, legal, and institutional mechanisms in the diagram. But theoretical analysis alone is not enough, because theory cannot keep up with practice. Therefore, the existing public health emergency management system (see Figure 1) does not explain the question I raised - why China has an effective response to the COVID-19, while those developed countries are experiencing problems? If the above theory has kept up with practice, it must be able to answer the raised question.

I participated in the fight against SARS in 2003, the prevention and control of influenza A in 2009, and the COVID-19 pandemic this year. My experience is that the very key point to achieve victory is whether there is the experience in real combat and whether there is a wartime system. We and the virus are like two armies facing each other - when the enemy comes, what kind of command do we have? How’s our staff? How do our intelligence and logistics departments interface with each other? These are very practical questions.

Like fighting a war, pandemic prevention and control requires a strategic approach. But I think the previous mechanisms and systems do not include such a strategy. It is important to emphasize that prevention and control strategies do not unfold along a plane but along a timeline. At each point in time, what are the key issues? What countermeasures should be taken? What kind of recommendations should be made? Where are the key battles? How can these key battles be fought? Just like playing ping pong - the first three boards should solve the problem. Besides, we must avoid the pitfalls.

In the past, Western countries had applied a whole-of-society approach to responding to pandemics, mainly during the Spanish Flu in 1918-1919.[4] According to WHO estimates, 50 million people died from the Spanish Flu worldwide. Since then, Western countries have not experienced such a large-scaled pandemic. But this is not the case for China. During the past 20 years, we have dealt with two major infectious disease epidemics, SARS in 2003 and influenza A in 2009, and the COVID-19 is the third.

We have accumulated abundant experience in a short time through the SARS epidemic. I summarized these experiences, including first, national response, using a public health prevention and control strategy based on public health prevention and control; second, joint prevention and control in the State of War, in the form of command and staff, etc. The usual administrative boundaries, such as departmental coordination and hierarchical reporting, are all broken in the State of War. Thirdly, the natural history of field epidemiological investigation reins. 2003, although China's public health capacity is backward, I led the field flow disease training program has enrolled two students, these "student soldiers" after the time to become the pioneer of the flow disease investigation. Some other experiences include rule of law construction, management of category B infectious diseases according to category A, centralized isolation of close contacts; free treatment, combining Chinese and Western medicine; scientific research and vaccine research; national participation in community prevention and control; lock-down of some hospitals with serious hospital infections and establishment of Xiaotangshan Hospital; close cooperation with WHO; and experts and officials directly facing the media and the public. All these experiences originated from SARS, as well as cadre accountability and civil-military cooperation.

There was a key battle during SARS - the lock-down of Peking University People’s Hospital and the establishment of Xiaotangshan Hospital. At that time, the pandemic in Beijing was much more serious than the one in Guangdong, where it originated, and hospital infections occurred. The main reason was that the hospital was rushed to receive patients without preparations, the medical staff was not well protected, and nosocomial infections were serious. The delayed availability of diagnostic reagents also caused some ethical problems. The most typical one is the Peking University People's Hospital (Figure 2), which is the opposite door to the Ministry of Health. At that time, there was no way to receive patients into the wards because the hospital wards were already overcrowded, so they had to establish wards outside the regular wards, and even the boiler room and laundry room were built as wards. At that time, I was a consultant of the SARS Prevention and Control Command in the capital. I went to the Peking Hospital to investigate and found that the situation was very serious, and immediately proposed to close the Peking Hospital.

What happens to the patients after the hospital is closed? I suggested moving to the suburbs. One thing that impressed me at that time was that the advice of experts was immediately translated into action by decision-makers - I think this is very important. So, in seven days, the Xiaotangshan Hospital was established, which is the hospital pictured here (Figure 3). This hospital looks simple, but it is a specialized hospital for infectious diseases: each isolation area, contaminated area, buffer area, and clean area are well-defined, and each suspected SARS patient can stay in a ward, which eliminates hospital infection.

On April 28, 2003, the Ministry of Health of China dispatched me to introduce the scientific prevention and treatment of infectious atypical pneumonia to the Central Politburo, headed by Hu Jintao, and I spoke mainly about public health countermeasures. Before this countermeasure was clarified, the country put a lot of attention on high technology, while the public health prevention and control strategy did not form as a national policy, and the investment was far from adequate. It was at this meeting that the leaders accepted the concept of public health prevention and control, after which they began to launch public health anti-pandemic activities throughout the country, doing their best to bring out the advantages of public health prevention and control in China.

It can be said that the SARS pandemic broke out in China and ended in China. We had no experience in fighting the pandemic at the beginning, and the battle against the pandemic was very hard. In addition, our concept of fighting the pandemic was backward at that time, and we were still unfamiliar with the pandemic prevention and control techniques and guidance strategies. But eventually, we also adjusted in a short period of time.

In 2009, we confronted another outbreak of influenza A. Because we had suffered from SARS, we worked extra hard on the prevention and control of influenza A. We combined prevention and control at the ports of entry with prevention and control into the mainland and quarantined close contacts as soon as a diagnosis was confirmed. As a result, we effectively contained the spread of influenza A within three months.

We later referred to this three-month period as the "China Platform" (see Figure 4). During this three-month period, China developed a vaccine and vaccinated 130 million people. In addition, through the fight against influenza A in 2009, we also built confidence in the fight against the pandemic. In the past, people said that social prevention and control were ineffective for an influenza pandemic and that it was costly to the people. One of the rewards of our social control practice in 2009 was the confidence we gained in preventing and controlling pandemic respiratory infectious diseases. With the experience of SARS prevention and control and the confidence of influenza A prevention and control, we went into this COVID-19 pandemic.

Unfortunately, we did not seriously summarize the lessons learned in time in 2003, but only focused more on the later public health construction and the development of emergency plans. The SARS pandemic was concentrated in the Chinese community, although it also spread abroad, the cases were not many, so those countries did not use a whole-of-society approach to control SARS and did not seriously study the experience brought by SARS to China and lessons learned.

Since 2003, China has established the Pneumonia of Unknown Etiology (PUE) Surveillance System [5]. The vast majority of countries in the world do not have this system because they have not experienced SARS It is because China has this system that this COVID-19 outbreak was brought to the attention of our clinicians at an early stage. In the absence of this system, pneumonia is generally treated by clinical doctors who make a rough classification to determine whether the pneumonia is viral or bacterial, and then treat it. Over 99% of pneumonia around the world is treated in this way, and it is impossible to find out all the causes by clinical diagnosis alone. Thanks to the PUE surveillance system established after SARS, we received a report of pneumonia of unknown etiology in 2005, and I led a team to participate in this investigation, which eventually revealed a pneumonic plague outbreak[6]. Without this system, we would not have been able to detect the outbreak and remove the potential for the pneumonic plague epidemic.

Figure 2 Picture of Peking University People’s Hospital[7].

Located in Xiaotangshan, 30 kilometers north of Beijing．It is a tertiary level general hospital in Xiaotangshan Township, which is known for the hot spring resources. Yet, it’s the “Xiaotangshan Hospital”, designated as a hospital for SARS patients 13 years ago that made it famous around the country in the world. This temporary complex had taken in one in seventh of total SARS patients. It was built within seven days, which has never been accomplished in the world history. The hospital occupies approximately 33 hectares of land with over 1000 hospital beds. Usually, it would take two years to build an infectious hospital with over 500 beds.

Located in Xiaotangshan, 30 kilometers north of Beijing．It is a tertiary level general hospital in Xiaotangshan Township, which is known for the hot spring resources. Yet, it’s the “Xiaotangshan Hospital”, designated as a hospital for SARS patients 13 years ago that made it famous around the country in the world. This temporary complex had taken in one in seventh of total SARS patients. It was built within seven days, which has never been accomplished in the world history. The hospital occupies approximately 33 hectares of land with over 1000 hospital beds. Usually, it would take two years to build an infectious hospital with over 500 beds.

Figure 3. Beijing Xiaotangshan Recovery Hospital (also known as Xiaotangshan Hospital)[8]

Figure 4. Number of reported cases of influenza A in 2009[9]

Although the COVID-19 prevention and control started in Wuhan, it is becoming clearer that I can say with certainty that Wuhan is the "discovery site" but not the origin of the outbreak. There are now many reports from abroad claiming to have found a novel coronavirus earlier than December of 2019. Italy, for example, reported the detection of a novel coronavirus in specimens from September last year[10], and there are even local reports that scientific teams have detected the coronavirus in earlier water samples. If Wuhan is the origin of the virus, then the above foreign findings do not fit the basic chronology of epidemiological causality. The current outbreaks in Dalian, Qingdao, and Beijing do not exclude the possibility that they were triggered by cold food from abroad entering our country, and Wuhan cannot exclude this possibility either.

How exactly the SARS-Cov-2 virus arose requires global attention and research.

II. The COVID-19 prevention and control: heritage as is, with significant innovative developments

In response to the COVID-19 pandemic, we have fully received and harnessed the heritage of the fight against SARS, which is reflects the continuity of the Chinese system. It is crucial but has not received much attention, officials, journalists, clinical doctors, and the public see this as natural. We directly followed the division of labor for SARS prevention and control in the fight against the COVID-19, eliminating the need to figure out the process from scratch.

We have done better than SARS in many aspects, for example, in terms of information sharing we informed the World Health Organization and the international community promptly. China has led in the process of identifying and isolating SARS-Cov-2, publicizing the SARS-Cov-2 genome sequencing, and developing the diagnostic kits. Also, I think it was a brilliant move by the Beijing leadership to send a high-level expert group to Wuhan. Our high-level expert group only stayed in Wuhan for a short time, but, in the chaotic situation, Wuhan needs someone to call upon and break the dilemma, and the most suitable one for this task is the high-level expert group. With Zhong Nanshan as the leader, our expert group, six in total, had two significant accomplishments: 1) affirmed the person-to-person transmission of the SARS-Cov-2; 2) earned public understandings and acceptance pf the Wuhan lockdown. The critical measure was the lockdown of Wuhan – we, the expert group, have proposed the measure based on the lessons learned from past epidemics in China.

In 1967, an outbreak of cerebrospinal meningitis spread throughout China, which affected more than 3 million people and killed 164,000.[11] As a front-line expert, I was very familiar with that outbreak. It was during the "Cultural Revolution" period, when free meals, commutes, and lodging were available, resulting in packed trains, with people lying under the seats, standing in the corridors, and even on the luggage racks. And the dense crowds aggravated the pandemic. At that time, a professor named Hu Zhen, who was also my graduate mentor, suggested suspending the Great Exchange of Revolutionary Experiences in the Cultural Revolution to quell the pandemic, and this suggestion was later adopted by the central government.

When our expert group arrived in Wuhan this year, there were not yet many COVID-19 cases, but the celebration of the Spring Festival had begun. Our epidemiological concern was not only the existing confirmed COVID-19 cases, but also the iceberg hidden under the sea level - how many COVID-19 infection cases were still in the incubation period, how many people had just developed the disease and had not yet gone to the hospital, how many people had not yet reached the conditions for confirming the COVID-19 after consultation, and how many people had not yet reported upward after being diagnosed. At that time, Neoplasm was not a legally mandated infectious disease, so we determined that the number of Neoplasm infections was more than 10 times the number of known cases at that time.

The expert group returned to Beijing the next morning to the State Council and used the example of the meningitis outbreak. In the afternoon of that day, facing the national reporters, I proposed on behalf of the experts group: people should try not to go to Wuhan if they are currently outside of Wuhan, and people in Wuhan should try not to come out if possible. At that time, this was only a suggestion from the experts, not an official directive. However, I did not expect that the proposal made by the expert group in the afternoon of January 20th would be adopted by the central government on the 22nd and implemented on the 23rd. One day delay in the loch-down of Wuhan was a disaster. This was because the number of confirmed cases was rising rapidly each day. The pandemic in Wuhan has laid down the fundamentals of the pandemic spread scale on the mainland.

I think that the timely adoption of the experts' suggestions by the central government was fundamental determinacy in China's victory against the COVID-19 pandemic.

III. the new normal of the COVID-19 pandemic prevention and control: zeroing out cases at all costs

Our new norm of the COVID-19 pandemic prevention and control starts with zeroing out cases in China. The strength of pandemic prevention and control in mainland China is to treat the confirmed patients when they are found and to do so at all costs. As you can see, the COVID-19 is attacking foreign countries like nobody's business. But in mainland China, it is our defeated enemy. After the last COVID-19 patient was cured in Wuhan on March 18, new cases still have been reported intermittently in Heilongjiang, Jilin, Yunnan, Urumqi, Beijing, Dalian, Qingdao, and many other places. However, we are able to detect them early and to treat them in time.

Some people think that we have been too serious about the local COVID-19 areas and say that this is an “overkill”. However, from a holistic perspective, localized seriousness is necessary to serve the bigger picture. Once the transmission breaks out again in one area, the whole country will be affected immediately. So, our current disease control work is still on thin ice.

The other point I want to make is herd immunity. Herd immunity in the situations of natural infections is not justified. None of the measles, pertussis, diphtheria, and many other infectious diseases that have plagued mankind for thousands of years, have been successfully eradicated with the approach of herd immunity. You cannot just calculate, and model based on numbers. The population is not normally distributed. The adoption of the strategy of herd immunity is likely, even inevitable, to result in cohort infections of the vulnerable groups, such as the elderly and people with chronic disease. The strategy of herd immunity will eventually cause a massive death among these vulnerable groups. The road to herd immunity is paved with the cost of fresh life and blood.

To summarize, I think the advantages of China's whole-of-society approach include: first, we gained valuable experience through dealing with several epidemics, which go beyond the existing theory of emergency management and response. Second, the incident command system (ICS) of joint prevention and control has played an important role.[12] National support, especially at the decision-making level, enables timely adoption of scientists' recommendations and swift transition of professional proposals into national policies. Other key points include the victory of crucial battle, the seamless functioning of the government agencies and the consistency of China’s policy, which carry forward the lessons and experience from previous infectious disease prevention and control events. Lastly, I must highlight - we are walking on the thin ice. Thus, we must maintain cautious and avoid the pitfalls or misconceptions.

Question and Answer Session

Q1: What is the next focus of the outbreak prevention and control? What are the changes to expect in the prevention and control strategy?

Zeng Guang: Universal vaccination is a very daunting process.

1. In the process of universal vaccination, vaccination and pandemics will exist simultaneously. Therefore, our past prevention and control requirements such as wearing masks, washing hands regularly, and keeping social distance cannot be abandoned, and large-scale crowd gathering should still be appropriately restricted.

2. After the completion of universal vaccination: it is possible that global prevention and control will enter a new phase. For example, countries can open their borders, and various industries and people's lives around the world will gradually get on the right track. After all adults are vaccinated, there will be vaccines designed for newborns in the future.

The timing of universal vaccination may vary. For example, in the U.S., universal vaccination will be completed by March or April next year. But globally, I think it will take at least one more year, because many developing countries will not have universal coverage so soon.

So, here's another question that hasn't been mentioned: How can developing countries enjoy the results of vaccines? This is a big deal, and if the pandemic does not die down in developing countries, it will not completely die down in other countries where vaccination is already universal. It is necessary to hold an international summit on global vaccine rolling out, with politicians and scientists as consultants, so that the worldwide vaccination rate can reach 60 to 70 percent or even higher in a relatively short period of time.

Q3: How can information technology and digital connectivity empower public health? Can it achieve the real-time infection monitoring, tracing, and alertness?

Zeng Guang: At the national level, we have been building an information system-based infectious disease emergency as well as Early Warning and Response (EWAR) since the SARS period, where every hospital can report an outbreak directly to the National Center for Disease Control and Prevention. Next, we will try to reduce the reporting approval process and multi-point trigger so that epidemics can also be reported up faster.

Q5: What are the next challenges facing our public health and preventive medicine?

Zeng Guang: This is a rather big question, but it is also something I have been thinking about for more than a decade.

First, we cannot ignore the long-accumulated problems in China's public health system just because China has achieved a periodic victory in fighting the COVID-19 pandemic. Rome is not built in one day.

Second, public health in China is in dire need of reform. For example, the concept of public health in China is ambiguous. The idea of “general public health” is reflected in the prevention and control process of the COVID-19 pandemic, especially in public healthcare and public safety. However, in the past, our public health schools did not teach preventive medicine curriculum.

Third, public health education needs to combine theory and practice, as clinical medicine does, to indeed train people who can serve the CDC system.

Fourth, the remuneration of staff in the CDC system needs to be improved. The current situation in China is that 95% of the graduates from the first-class public health colleges are not willing to work in the CDC system because of the low remuneration.

Fifth, our public health reform should not be blind. President Xi Jinping put it very well when he said that we should "make an integrated plan to reshape the system and make complete improvements. It would be very immature to reform immediately without understanding the three fundamental questions - what is public health, what is the history of public health development in China, and what is the current state of public health development in the world.

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