Could cause panic.” “Will not help end the crisis.” “Could backfire.”
When the Chinese government blocked most travel into and out of the city at the center of the Covid-19 outbreak in late January, many public health experts took to social media and op-ed pages to decry the measure as not only draconian and a violation of individual rights but also as ineffective: This largest quarantine in history — the city, Wuhan, has a population of 11 million, and the lockdown has been expanded — would have little effect on the course of the epidemic, they argued.
As the U.S. and other countries imposed travel restrictions, even the World Health Organization questioned whether they were a good idea. But early evidence is causing some disease fighters to reconsider.
The last few days have seen a perceptible flattening in growth of Covid-19 cases in China, raising hopes that the epidemic has peaked. (Though there are doubts about the accuracy of China’s count.) That supports the emerging consensus on the Wuhan quarantine in particular: that, at minimum, it bought China and the world time to prepare. Crucially, the time lag allowed public health agencies to devise and distribute a diagnostic test that hospitals can use to identify patients ill with the novel coronavirus.
“Measures on movement restriction have delayed the dissemination of the outbreak two or three days within China and a few weeks outside China,” Sylvie Briand, director of Infectious Hazard Management at the WHO, told reporters this week. “Those measures, if well implemented, could have an impact on the propagation of the outbreak.”
Scientists are still gathering data on the effect of travel restrictions and the historic quarantine — and, in particular, whether they reduced total cases and deaths or just postponed many of them without lowering the eventual cumulative toll. The answer will have broad consequences for future outbreaks, perhaps putting large-scale quarantines back on the list of health officials’ epidemic countermeasures, including in countries that value individual liberties more than China does.
“We should do what we can to understand their effectiveness, because [quarantines and travel restrictions] may be considered again in this epidemic and in future epidemics,” said preparedness expert Tom Inglesby, director of the Center for Health Security of the Johns Hopkins Bloomberg School of Public Health. “It’s important to know not only if they worked in some way but also to gauge if they did harm.”
There have, in fact, been numerous, and in some cases fatal, unintended knock-on effects of the quarantine, as critics warned. People were unable to reach sick, elderly parents in Wuhan, let alone take them out of the city for treatment of heart disease, cancer, diabetes, and other illnesses. This week, UNAIDS announced that one-third of people in China who are living with HIV reported that because of lockdowns and travel restrictions they were at risk of running out of their HIV medications within days. And China’s economy has slowed to a crawl.
The impact of the movement restrictions extends beyond Wuhan, to other areas in China as well as other countries getting a trickle of cases early this month rather than the flood they likely would have if Wuhan residents and visitors had been able to leave the city. As a result, they have been able to deploy countermeasures with deliberation and not in a rushed panic.
The quarantine “let countries field the fly balls coming at them one by one by one and not drop them,” said David Fisman of the University of Toronto, a leading epidemic modeler. “The fact that Wuhan got sealed off made the numbers something other countries could handle. They’ve been able to figure out things like how to identify cases and what to do with them. I think that made a huge difference.”
If thousands of infected people had traveled from Wuhan starting in late January, Fisman said, “every place new cases landed would have had the potential to be another Wuhan,” whose Hubei province is approaching 2,000 deaths.
Instead, health care systems in countries that have had cases (1,073 and counting outside China, according to WHO) had time to prepare, said Alexandra Phelan of Georgetown University’s Center for Global Health Science and Security: “Delays can be a really useful tool, and maybe one of the only tools you have, to implement screening and training for health care workers, and essentially get your house in order.”
Hospitals could have used the time to give their staffs refresher courses in infection control and practice using respiratory gear, said Inglesby (though it’s not clear how many in which countries did so). Agencies such as the U.S. Centers for Disease Control and Prevention had time to update and disseminate technical information, including the use of diagnostic kits.
“The ability to test for the virus has been distributed pretty widely,” including by the CDC to U.S. states and cities, Inglesby said. Testing capacity grew outside the U.S., too, he said: “Certainly more countries can test for the virus now than three weeks ago,” when without the Wuhan quarantine they might have faced a flood of cases, both suspected and real.
With the breathing room the quarantine provided, China has been able to plan or begin about 120 clinical trials of potential Covid-19 treatments, Inglesby added: “There has been time to acquire data on what medications might work,” including those currently in use for other diseases and therefore relatively available.
U.S. travel restrictions (barring most foreign nationals who have been in China recently from entering, requiring Americans returning from China to be quarantined or self-isolate) were, like the Wuhan quarantine, “really meant to slow down the spread” of the coronavirus, Health and Human Services Secretary Alex Azar, told reporters this month. “It’s not meant to hermetically seal the United States from the virus, but rather to allow us to focus our resources,” including by setting up the quarantine centers. “It’s about slowing spread.”
“I think most health officials agree that at best [quarantine or travel restriction] delays and … kind of pauses things,” Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told reporters. “What we needed was a delay to essentially prepare better.”
Experts are divided, however, on whether the Wuhan quarantine not only resulted in what the WHO’s Briand called “postponing the peak” of the epidemic — the time when the number of new cases tops out — but also in reducing the total number of cases and deaths.
“I haven’t seen anything that says the overall number of people infected in the world will be less” than without the Wuhan quarantine, Inglesby said.
The reason for pessimism is that although the quarantine reduced the rate of transmission and therefore the number of cases in any given time period, normal commercial activity and travel in China “has to resume at some point, so it’s hard to argue that the disease wouldn’t resume its trajectory,” Inglesby said. “No one has put forth the case that what China has done will eliminate this virus from Earth.” Sustained transmission, however, might look more like bad colds (as other coronaviruses cause) than like severe seasonal flu.
Experts who take a more sanguine view believe that slowing the spread and buying time for countermeasures did have a permanent effect on the epidemic, not only postponing what would have been today’s cases into next week but preventing some of those cases forever. If so, then the eventual toll would be less than without the Wuhan quarantine.
That and other control measures changed how many cases each infected person causes “big time,” Fisman said. The lower this “reproductive number,” the lower the total case count. The Wuhan quarantine, he said, “reduced the likelihood of people in Wuhan coming into contact with people not in Wuhan. The rate of transmission is now pretty flat. This is coming under control in other cities [outside Hubei] in China.”
Fisman’s and other mathematical models of the epidemic’s trajectory, however, are undermined by the fact that key numbers in the equations describing disease transmission (a “model” is essentially a group of equations solved by computers) are uncertain.
For instance, the time between when one infected person becomes ill and when someone he infects does was thought to be five to seven days. But an analysis led by Hiroshi Nishiura of Japan’s Hokkaido University suggests this “serial interval” is only four days.
That could be bad news because half the people who get sick do so less than four days after exposure to the virus that causes Covid-19. “A substantial proportion” of transmission may therefore occur before people show symptoms, Nishiura and his colleagues warned. “Pre-symptomatic transmission … may even occur more frequently than symptomatic transmission,” confounding control measures: If people can spread disease before they’re sick, then isolating only sick people won’t stop transmission.
In fact, physicians in China reported this week in the New England Journal of Medicine that a symptom-free individual had just as much virus (according to nose and throat swabs) as patients with symptoms — all set to be sneezed or coughed onto other people.
Although diseases that can be spread by people who aren’t sick are harder to control, there are hints that the worst of the Covid-19 outbreak in China is nevertheless past. Like several other models, three by researchers at Georgia State University School of Public Health projecting Covid-19 cases suggest that the outbreak is losing steam. Total cases in China outside Hubei should stay below 15,000 through the end of February, with little increase after that, the models say. (Projections for Hubei got scrambled when China changed the case definition for Covid-19, producing a sharp one-time uptick in case totals last week.)
As of Thursday, there were 12,644 Covid-19 cases in China outside Hubei.
“For all other provinces, the models are on track,” said mathematical epidemiologist Gerardo Chowell of Georgia State. “The containment strategies implemented in China are successfully reducing transmission,” he and his colleagues wrote in a paper published last week in Infectious Disease Modeling. “The epidemic growth has slowed.”
Chowell inclines toward optimism, he said: “I think that we’ll control this,” especially if the Covid-19 virus (like influenza and other viruses) doesn’t survive or spread as well in warm, humid conditions.
Barring secondary outbreaks (as happened with SARS, a coronavirus that spread around the globe in 2003), Chowell said, the Covid-19 epidemic in China might be over in three weeks. This pathogen might join the other four coronaviruses that give millions of people colds and, in some cases, pneumonia every year.
If it falls well short of an uncontrollable pandemic, quarantines and other measures widely viewed as ineffective and even counterproductive could well join the bag of tools used in future viral outbreaks.
Andrew Joseph contributed reporting.
The author’s opinions are valuable in terms of how to prepare for possible outbreak of the coronavirus in anywhere outside China, where painful lessons were learnt.
This article seems to be out of date within 24 hours of being published. Numbers are out of control in Italy, Iran and in South Korea.
The Chinese government did do that much. They deserve commends for their efforts; because they are the ones that are taking the biggest losses financially and otherwise from their decision. Which is more than I can say for the CDC/WHO. We need reliable kits – we need to be quarantining people at the very least to the 20 day mark. We need to have testing performed at all hospitals where flu tests came back negative. We need a more solid response to something this serious, and not be downplayed by the professionals (don’t worry about coronavirus – worry about the flu) .. We need to stop self-quarantining because people are f**k**g selfish and self centered when it comes to what they want. All countries need to have complete and full transparency in order to fight this as a collective race of beings. And we need governments to stop playing patty-cake with a virus that doesn’t care about borders or boundaries. Sure the US is trying to take precautions – China is as well and look how things quickly got out of control for them. Same thing is now happening in S. Korea .
COVID-19 is probably going to become a pandemic/endemic at some point. It looks like purely containment strategies are not going to work. It may be time to focus more on vaccine/treatment. Although like many other corona viruses, it may be more easily said than done.
Bo, It’s already a worldwide Pandemic by WHO and CDC standards! The Governments just want to keep it at a lower tone to prevent the public from freaking out!
Do not let them in! Evacuating them will only cause a bigger spread across the world. I don’t know who is making the decisions but they are a f****** idiot! Here’s an example; the cruse ship. Hmmm let’s bring the Americans back to the US. We have made sure that no one contracted the virus. Funny because 14 of them have the virus and I bet many more of them have it as well. What if someones immune system doesn’t react to the virus until day 15? Ever thought about that? You let them out and now they are spreading it! I thought that being quarantined meant that no one gets in or out. If you let a population of 11 million f****** people go all over the world you are going to have a BIGGRR pandemic than what it is NOW. When there is a deadly virus going on our US citizenship should not matter. The best we can do is support China and who ever else needs it. I think you people need to start asking the public what WE THINK because who ever is calling the shots doesn’t know what the f*** they are doing! Go ahead and take the travel restrictions off and see what happens. See what f****** happens!
Support China? You go right ahead and do that Sasha.
It seems the State Department and the CDC are committing one blunder after another.
1. The CDC’s defective test kit that got sent to 30 countries and several states. Imagine the infected people that got release back to community to continue infecting others because of the defective test kit.
2. The State department overriding CDC and bringing back the infected patient from Diamond Princess back to the US. Politician should not make important epidemic decisions, look what happened to Wuhan. Trying to look good can cost someone to pay a high price.
3. The US government interceding in Cambodia to allow the MS Westerdam to disembark when they are only 2 days away from the 14 days of quarantine period.
At first I have confidence, but as I keep on reading blunders after blunders by both the CDC and the State government, one can’t help but start to worry.
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Firstly I believe absolutely NOTHING our government says about this particular outbreak and secondly I believe absolutely nothing any government says about it. To acknowledge it would be to admit they’re incompetent fools who should never be in charge of anything. That’s never going to happen so there’s no reason to believe anything they say. /end rant
There can be no doubt that the unprecedented Chinese government restrictions bought the rest of the world time at the cost of additional suffering in Hubei. Imagine if the CCP listened to doctors warning of the virus rather than jailing them?
Never trust politicians to make important medical decision. Just look at State Department over riding CDC in bringing the Diamond Princess passenger that tested positive back to the US.
Imaging the stupid US ambassador in Cambodia that even brought his family to MS Westerdam for publicity and allowing those passenger to disembark when they are so close to 14 days quarantine. One passenger tested positive in Malaysia’s airport.
Mike, subsequently in late-January, the Supreme People’s Court publicly praised the doctors’ contributions, and urged Wuhan officials to learn “a profound lesson”. An unusual event. In China and in many parts of the World, Science and scientists are not receiving the respect they should.
Were they not arrested, it would have a been much better experience for the doctors. Sure. But I have doubts whether the outcome would be much different for the World as a whole.
You see, despite being jailed, the doctors DID get their messages out. Who knows, by getting arrested they might have garnered even more public attention than otherwise. And it really took some time, some more cases, more data points (more people falling ill), in order to have sufficient data; and they may have taken some time pondering before taking the drastic actions. So even if the doctors were not arrested, the government probably need to see a more developed pattern before recognizing the situation. The difference might have been a few days, rather than weeks.
It was not “the CCP” who arrested the doctors. The CCP is not one thing, it is composed of many many different individuals. It was some Wuhan police, and I’d say not “all” of Wuhan police. Sometimes, actions by a few individuals do have significant consequences. But it would be an exaggeration to conclude that as the CCP’s doing. They certainly didn’t have a meeting about it to decide what to do with the doctors.
People love to hate the CCP. The media love to train people to hate the CCP. But they don’t really know anyone in the CCP. Funny.
@Gerald: Sounds like you’re a budding little communist! The first step toward becoming the enemy is respecting the enemy.
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