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The kind of early effort needed to control the public health crisis of the coronavirus. Steps taken in Washington State on social distancing and action underway in the U.S. so that a proactive approach takes place, acting early and decisively.

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The knowledge that the virus  caused human to human transmission and that it spreads to wide parts of the population very quickly were critical pieces of information that remained with Chinese epidemiologists, doctors and medical researchers, and were suppressed by local authorites in Wuhan.  Yet China's version of the U.S. CDC, China's Centre of Disease Control and Prevention, modeled on the U.S. control efforts worked effectively to identify the problem. Virologist Gao Fu, heads China's CDC. This report in Germany's Der Spiegel says Mr. Fu made it a habit to scan China's internet before bedtime for any signs of possible disease outbreaks. On the night of December 30 he came across rumors of an internal memo from the Wuhan Health Commission of an outbreak of a vaguely worded lung disease. When he called the Wuhan health authority he found their answers to be evasive which alarmed him. The next morning December 31 Mr. Fu sent the first of three teams to Wuhan which is how China was able to identify the problem, in the sense that Chinese authorites in Beijing were to rely on Dr Gao Fu to overcome the problem of Wuhan provincial authorites. He informed the World Health Organization Beijing office on that day. The Der Spiegel report says "shortly afterward," the Seattle Times in its report says this was about New Years Day 2020- Mr Fu made a call to Dr. Redfield, head of the U.S. Centre for Disease Control, who was on vacation. Redfield is deeply disturbed on hearing this from Fu and they have conversations over the next few days to the point that Dr. Gao Fu is in tears about what has happened. On January 1 Taiwanese public health authorites shared the information with WHO that the cornonavirus was a human to human transmission, would the Taiwanese authorites not have shared it with the U.S. the same week during calls from the U.S. CDC or other public health authorites alarmed about the situation. (The WHO was proving useless by Jan 14 when it contradicted Taiwan's more reliable assessment  on Jan 14 going by the letter from president Trump to WHO). On January 6 a few days later Dr Redfield and Dr. Azar head of Health and Human Services ask China for permission to send a team of CDC U.S. experts to China. This is cited in the U.S. letter to the World Health organization- the lack of human to human transmission information being given to the U.S. officially early by China. A risk that could have been a topic of conversation between the U.S. and China heads of CDC. That letter from president Trump also points out that the team of experts the U.S. planned to send was not accepted by China till Feb 16, one and half months after that series of conversations between Dr. Gao Fu of China CDC and Dr. Redfield of U.S. CDC in an alert message.  In effect removing one of the key defences for the U.S. and Europe in making their own defensive actions and plans, laying the basis of the worldwide coronavirus pandemic affecting millions of people. Dr Redfield is a AIDS researcher at the University of Maryland who spent most of his life trying to control spread of HIV and was appointed by president Trump to head CDC agency in 2018. He set a goal of eliminating AIDS by 2030 and is more comfortable with aids patients and research than the bureaucratic nature of agencies- CDC has about 11,000 employees. Once it was clear that a team of U.S. experts was not given permission to make its own assessment in Wuhan in the few days after January 6 offer to sent the team to China by Redfield of U.S. CDC and Dr. Azar, would it have alerted the U.S. that something was seriously heading the wrong way for a epidemic risk. That letter of president Trump cites how the head of WHO during the first SARS crisis in 2003, Dr. Harlem Brundtland acted when she faced China's lack of cooperation during that crisis by saying openly that this was a danger to world public health and millions. Could CDC in the U.S. and the other connected health authorites have taken the responsibility and filled Dr Brundtland's role in this crisis, that the WHO failed to perform?    ...

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Asymptomatic people infected by coronavirus are acting as spreaders of the coronaavirus making it more essential than ever that everyone wear masks. This is a widely accepted practice in Asia- wearing masks to prevent others from getting a virus. This now needs badly to become the practice in the U.S. and Europe. The longer it is delayed the worse the crisis can get and the longer it takes to eradicate it. Even low grade cotton masks are useful as is the practice in Asian countries. It is now part of the new guidelines of the Centers for Disease Control in the U.S. This needs to be adopted as safe practice everywhere.

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A NYT video simulation that shows how early action is critical with decisive steps for quarantine and lockdown with enforcement, to control the spread of coronavirus. It shows the spread along a timeline of the coronavirus in the U.S.

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Maps of U.S. coronavirus by state as of April 1, 2020, that reached 189,000. How coronavirus is surging worldwide with 75,000 added on March 31 to reach 874,000 coronavirus cases detected worldwide. China's numbers have not included coronavirus cases that are asymptomatic. 

China continues to see coronavirus cases with 166 new cases on March 31, showing that it public health authorites have to be vigilant about a restart of the epidemic once it comes under control.

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About 80% of Russia's business is state owned or state run business. Small business is about 20%. Steps taken so far now protect state run business workers. All state run or state owned businesses will give employees one months salary and ask workers to stay home as a way to control coronavirus. Most regions and big cities in Russia have self isolation measures to control spread of coronavirus as infections increase to 4000.

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China's new approach to keep strict control over who goes in and out of affected areas in and near Wuhan where the coronavirus originated. This covers several cities and is being expanded as it spreads to limit how much it affects other parts of China and the world.

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This BBC report looks at how doctors, nurses, police, railway employees, and sanitation workers in India are tackling the job of preventing the spread of coronavirus as India goes into a complete lockdown. The lockdown and quarantine are intended to slow the epidemic for enough time to enable bringing it under control.

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Researchers at Gottingen University in Germany analyzing data from a study published in the Lancet Infectious Diseases monthly journal say countries around the world have only discovered on average about 6% of all coronavirus infection cases. The true total of infections could be tens of millions worldwide. Why this is important- the recurrence of the virus is a real danger even after it appears that it is under control, making relaxation of essential guidelines for prevention very risky.

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Pfizer coronavirus vaccine is shown to be 90% effective in results from Phase 3 trials. The findings come from a preliminary look at the first 94 infections in a group of 44,000 people in the trial. The vast majority of the cases received a control instead of vaccine. A vaccine is considered effective if it works on 50% of cases. The Pfizer vaccine is based on an experimental "mRNa" technology.

Britain has ordered 5 million till the end of 2020 and another 20 million for 2021. In total Pfizer plans to make a billion doses of the vaccine by 2021.

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After China's economy shrank by 6.8% in the first quarter the outlook is looking increasingly uncertain. Premier Li Keqiang stated at the start of an annual parliament meeting that China will now scrap the annual economic target due to the huge uncertainty from the coronavirus, and the world economic and trading environment. New tensions over Hong Kong's autonomous status are adding to the trade tensions between the U.S. and China, and tensions over early handling of coronavirus by China. China recently announced new national security legislation for Hong Kong, and Mr. Trump says the U.S. would act "very strongly" against any effort to gain more control over Hong Kong.

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A draft decree in the prime minister's office shows a plan to place quarantine covering the Lombardy region of Italy and nearby provinces, including the cities of Milan, Venice and Modena. The population in this region of 10 million people will face restrictions on mobility. The draft decree says transit in and out of the quarantine zones will be granted only in the event of "grave situations." It urges people to stay inside their homes and not travel. A similar quarantine in China around the Wuhan region helped limit the spread of coronavirus and bring it under control. Today the worst hit and not yet under control are Iran and Italy.

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By the end of the week March 8,, India will have 34 labs testing for coronavirus. About 600,000 people were tested at 21 airports and 77 seaports. A million people have been tested in border regions next to Nepal. A screening lab is being setup In Iran to test returnees.

A communicable diseases expert says doing quick diagnostics is quite doable. The control effort is based on prompt detection and effective triage.

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The instinct and habit of looking for the solution that is guaranteed to work for the patient, or the flawless solution is counterproductive and can be our worst enemy in fighting the coronavirus says this infectious disease specialist in the NYT.  What is needed to fight the virus is speed and scale he says. 

He says comprehensive use of even moderately effective treatments and solutions is the answer to get infections and deaths down substantially in the next few weeks. The widespread implementation of imperfect prevention measures therapies and treatments is important to get it under control.

 

 

Dr. Schiffer is an Associate Professor at the DIvision of Infectious Diseases, University of Washington, Seattle.

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India reports over 300,000 cases for the fourth day in a row. German chancellor Merkel passes legislation that gives the federal government the power to set curfews to control the spread of coronavirus. Cases reach 166 per 100,000 in Germany and the government sees lockdowns to be in place till the end of May. Streets in Dusseldorf and other German cities are shown deserted at night.  The European Union deal signed with Pfizer for 1.8 billion doses including booster doses of the Pfizer vaccine, provides new hope for the vigorous vaccination drive needed in Germany and the rest of Europe. 

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The head of South Korea's Disease Control committee says that patients with coronavirus can't relapse. About 277 patients tested positive after recovery. Looking at this the scientists found that there were harmless traces that were incorrectly detected by the RNA test which are not live so that patients are still in good health with no relapse. This is a very important bit of information for reopening different countries to modified normal life.

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It took a week longer for each country to impose a lockdown. In China first Wuhan then the whole country went into lockdown and quarantine. The same process is repeated in Europe and in America as authorites see numbers of infections increasing rapidly without strict controls. First the Lombardy region in Italy around Milan, then the provinces in Northern Italy, followed by a complete lockdown in the country on March 10 as infection spread faster without lockdown and enforcement of lockdowns. Germany and Britain follow Spain and Italy on March 20. France followed Spain in the days after Italy's complete lockdown. Macron ordered the lockdown on March 16 with stringent enforcement. Infectious Disease specialists at Imperial College warned of "unintended consequences for the entire nation" if a lockdown of Britain did not take place. The goal is to limit the spread of infections from rapid to slow as public health systems and economic measures are ramped up in preparation for the crisis. Most countries were lacking the preparatory steps having lost time waiting to see what happens next or analyzing data in the vain hope the virus does not spread.  Bad economic results of lockdowns were initially a concern, but this concern became less important as the coronavirus spread rapidly in Europe. Decision makers in Europe decided that not acting forcefully would lead to equally or worse economic outcomes. Public health systems overwhelmed would diminish public confidence rapidly and lead to equally bad or much worse economic outcomes. The European Union executive body has supported state aid, stimulus action and border controls in this crisis. In America and in Europe the hope is that shoring up the safety net with massive aid to businesses and households would buy time to tackle and overcome the coronavirus through a combination of lockdowns, quarantines, contact tracing, large scale testing and medical technology measures. The examples of China, South Korea, Taiwan showed this pathway exists for phased control and reducing fatalities to zero. ...

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The mistakes  and the right action done in Italy that the world can learn from as Italy tackles the coronavirus. The coronavirus is a dangerous pandemic yet there is one part of it that can be used to take the right action. The timeline of countries affected early in January and February and early March with information from these countries on what worked very effectively and what did not work with bad results is available. The mistakes were made in Bergamo, a town in Lombardy region of northern Italy with the highest number of infections and deaths in Italy. Bergamo had limited testing, no rigorous attitude for quarantining those who had come in contact with people testing positive, and lack of contact tracing. In Vo another town in northern Italy the situation is a complete contrast with resort to mass testing and isolation of clusters which has reduced infections to zero and made it a safe place. Vo is a small rural town 85 miles east of Bergamo in the Veneto region. This was the method used in South Korea, China, Taiwan and other Asian countries that have overcome the virus. Bergamo is an example of what failed in Italy with the worst number of fatalities. The health crisis worldwide has shown this  method of first general quarantine to buy time to build capabilities for testing  and preventing things spiralling out of control,  then mass testing, contact tracing and isolating the people who test positive, and repeating this process again and again till infections are way down,  is the only way to control this crisis. In the early days massive quarantine or stay at home strictly enforced is the best solution till production of tests accelerates to permit mass testing and isolating the clusters of infections. This mass quarantine buys time for accelerated production of tests and building up the capabilities of labs to process these tests, including use of a central national lab centre with national data on computers for microbiologists to monitor the entire country. This was done in South Korea reports in WSJ show. This is vital for everyone involved in the effort to control the virus to understand based on the experience of  countries that have successfully overcome coronavirus. It is the experience in South Korea and Italy that the U.S. White House response coordinator Dr. Brx is looking at and learning from as she and the White House team in the U.S., governors of all 51 states, health officials including CDC, are looking at as they execute their action plan in phases.  ...

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China has used the quarantine and strict measures to contain the coronavirus. After being taken by surprise in the way the coronavirus developed in Wuhan region China shifted to large scale containment and quarantine. To do this China used technology, mobile carrier information, volunteers going from door to door and enforced quarantine action. Other countries in Europe, including Italy, are adopting measures such as quarantine and appeals to the public for cooperative behaviours.

The entire approach is new yet shows how government and citizens can work together to contain epidemics of this kind in the modern world of urbanized areas and close contact in subways, streets, and stadiums. The approach in democratic countries may vary from China yet essentially strong bold action has proved to be the way to go, not vacillating and acting one step at a time till things are out of control. 

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India imposes a travel ban for 30 days for visitors and overseas citizens of India in an effort to control spread of the coronavirus. The rule goes into effect on March 13, Friday. Visitors to India will face a quarantine of 14 days. The ban was announced on the same day that the U.S. president Trump announced a travel ban for 26 European countries for 30 days.

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Colleges and universities are preparing to reopen and investing in the changes required for coronavirus prevention and control. Installing plexiglass, hand sanitizer stations, and ensuring availability of face masks on campus, arranging for labor to do the hourly wipedown of door knobs and for taking student temperatures, are steps colleges are taking to reopen. Some universities expect to reopen with 30% of classes in face to face settings.

Other planning includes installing upgraded ventilation systems, retrofit doors for motion sensor technology or foot operated openers. Also included infrared technology to detect temperatures and ultraviolet lighting disinfection technologies.

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 South Korea has run about 300,000 coronavirus tests, double that in Italy and ten times that in the U.S., says this report in the WSJ. This report shows how the South Korean testing works and the workday of Lee Hyuk-min, a clinical microbiologist at a testing lab of Yonsei University Health System Severance Hospital in Seoul, who is working from 4.45 am to 11 pm. South Korea's effectiveness in controlling the spread is based on a strategy of efficient testing that enables isolating quickly people and areas. South Korea's testing network is a legacy of the MERS coronavirus outbreak in 2015, and the government failure at that time to control it.  It brings together doctors, medical staff, labs, and political leaders in roles following the protocols established since then. Dr Lee and others are the final checkpoint in the system which coordinates a diagnostic operation that combines together 633 test sites and 100 labs. The protocol includes a uniform setup- same testing equipment, same training, same decision making process. At 8 am each day all labs upload results to a shared database, which allows public and private hospitals to monitor patient results and report them to Korea Centers for Disease Prevention and Control. Hospitals upload testing details to an online directory. This surveillance allows South Korea to predict where to concentrate its efforts for controlling spread, says Dr Lee who advises the South Korean government on lab testing issues. Action plan took 2 years for the new rules to be implemented following MERS in 2015. The plan included accelerated bio testing company approval for tests. The first company got approval on Feb 4, followed by 4 other firms. Dr Lee says testing is only part of the equation as labs are needed to process and confirm results. Another key is innovation. South Korea setup testing in drive thru locations, that limit contact and speed up testing, which the U.S. is adopting. Dr Lee says early identification is key, and identifying the first coronavirus patient which was done in South Korea on January 20. Other countries including the U.S. took too long to identify the first patient, says Dr. Lee. ...

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South Korea has tested about 300,000 people for coronavirus. About 20,000 can be tested daily for coronavirus through 40 drive thru locations. South Korea invented this method of testing. Another feature of the South Korean method is the tracking down of people who have come into contact with those testing positive for coronavirus. The South Korean government is able to do this because it can access the credit card and cell phone information of people in the country. This is possible through laws that were passed after the failures during a previous epidemic of MERs. The government then tracks down and isolates the people who came into contact with infected persons. This includes people who show no symptoms, an important aspect of the South Korean program which needs to be adopted in other countries once the production of test kits and testing is ramped up. The reason is that about 30% of people who tested positive in South Korea were not showing any symptoms but acted as silent carriers. This is similar to the figures for people in the Wuhan region of China. This testing capability is one of South Korea's key strengths, though Germany's Robert Koch Institute says it has a similar capability to test 160,000 people a week. The U.S. has tested about 30,000 people by comparison. The U.S. government is procuring 60,000 test kits under the Defense Production Act. South Korea also enforces social distancing though a $2500 fine and a 1 year prison sentence. Germany now has a 2500 euros fine in some states for curfew violations.  By comparison the fine in Britain is insignificant.  Another difference between China and South Korea with Germany and the rest of Europe, the U.S., is that in China and South Korea self-isolation is monitored, tightening the control over coronavirus spread at every turn.   ...

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This analysis from The Times of London provides critical information on the strategy for successfully tackling the coronavirus following the example of South Korea and progress in Britain.

The random community testing is key to getting an idea of the scale of infections in the community at large. The critical ratio called reproduction ratio tell one if the virus is under control and how lockdowns can be lifted. For Britain this 0.7 estimated by Imperial College. It has a 2 week lag. 1.0 or close to 1.0 is not good. Germany after being at about 0.7 has moved up to 1.0 with 2 week lag in information says the Robert Koch Institute. This means a lot of work ahead, it won't be easy.