Loopholes Revealed in Virus Response System
By GT staff reporters
Global Times
2020/2/28 0:48:40
A laboratory technician conducts HIV tests at the Disease Control and Prevention Center of Handan, North China's Hebei Province, on November 30, 2018. Photo: VCG
While China's epidemic control work has made progress in preventing the further spread of the coronavirus, the central government's top medical adviser said the situation should have been better if control measures were taken earlier, underscoring some of the major shortcomings in the country's heavily-invested disease prevention system set up following the SARS outbreak.
Several top-down authorities, constantly shifting blame on each other for mishandling the outbreak earlier, have now been engulfed in a public opinion crisis, with the public urging an improved decision-making process in the country's healthcare system.
Zhong Nanshan, a leading epidemiologist who was also among those in the expert groups dispatched by the central government to the epicenter Wuhan, Central China's Hubei in January, said three major coronavirus-related epidemics in the 21st century - SARS, MERS and COVID-19 - had offered a lesson that countries should act quickly to prevent its further spread.
"The epidemic would have been much less severe if we took strict control measures in early December, even early January," Zhong said at a press conference on Thursday. "We estimated that numbers of patients would surge to more than 100,000 if we took measures [such as city lockdown] after January 25."
Missing the window of opportunity has become a major regret amid the COVID-19 outbreak not only for the veteran medical adviser, but also for many frontline doctors and officials inside the central and regional centers for disease control and prevention (CDC), as a more timely response to the outbreak as soon as the virus had been detected would have led to a different outcome, given the highly contagious disease has caused more than 78,000 infections nationwide and death to 2,747 in the mainland.
"We have to take immediate action as soon as we detect the virus. This is a lesson we must learn," Zhong said.
At the Thursday's press briefing, Zhong also noted that in China, the CDC system is just a "technical department" with limited standing when he mentioned the shortcomings exposed amid the outbreak. And the CDC should be given more authority and its importance should be further highlighted.
Standing at the frontline of alarming the public on possible major public health crises, CDC, as an affiliate of the National Health Commission (NHC), should do research and offer advice, but ultimately it is not a policymaking organ in China, unlike the top and regional health commissions, according to analysts. And it is urgent to figure out how the CDC could play a bigger role in public health matters or have "a bigger say" in alerting the Chinese people about potential epidemic risks and sending out warnings instead of only focusing on doing research or publishing papers in medical journals.
Mechanism failure
After the SARS outbreak from 2002 to 2003 that caused over 5,000 infections and killed 349 nationwide, China set up a top-down direct reporting system on infectious diseases and critical public health events, which reportedly cost 730 million yuan ($104 million), with the aim of reporting and examining any epidemic quickly after receiving information about confirmed and suspected patients at hospitals. This massive information-gathering system should have technically covered the whole country, to which even county-level health clinics have access and could share the information with health authorities at a higher level.
The first confirmed case of then "unknown pneumonia" occurred on December 8 in Wuhan, while the first result of a pathogen sample, collected from a 65-year-old male, proved that the "unknown pneumonia" discovered in the city was caused by a coronavirus, which is 80 percent similar to the SARS virus, media reported.
And another sample tested by a Beijing-based biotechnology company, as third-party companies cooperate with hospitals in doing gene sequencing, showed inaccurate results and was described as a SARS coronavirus.
Shortly after, Li Wenliang, a local doctor in Wuhan considered the "whistleblower" of the looming crisis, shared the information about the "SARS-like coronavirus" found in Wuhan hospitals on social media, which became the first warning from the healthcare system to the public in a non-official capacity.
The third sample was examined in a lab of the Shanghai Public Health Center, which is cooperating with Wuhan Central Hospital and Wuhan CDC. The result suggesting an unknown virus of the same family as the SARS coronavirus was reported to Shanghai and national health commissions on January 5, media reported.
From the first confirmed case in Wuhan to the official warning about human-to-human transmissions of COVID-19, it took over a month before vigorous measures are adopted. However, a city lockdown implemented in the epicenter was considered a delayed response, raising questions on the loopholes in China's health emergency response system and why this heavily-invested direct reporting system did not work.
A respiratory medical expert and a frontline doctor from a Wuhan hospital who requested anonymity told the Global Times that medics dared not talk about the disease publicly as they would be investigated as "rumormongers."
Whether hospitals or local governments in Wuhan and Hubei deliberately concealed the outbreaks at the very early stage remains a major question. However, some analysts suggested such cover-ups if there are any were based on economic interests.
"Once hospitals reported infectious diseases, local health organs have to inform the public. Hospitals feared that patients would not come if they knew their hospitals received confirmed infectious disease patients.
The government feared public panic and a loss of investment, not to mention the need to maintain social stability for the provincial "two sessions," annual meetings of Hubei's legislature and political advisory body starting January 11, the expert said.
Some frontline doctors even had little understanding about this so-called top-down reporting system when they were asked by the Global Times on Thursday.
A frontline doctor in Wuhan told the Global Times on Thursday that local doctors only heard about its existence. "It's more like an ornament without any practical use."
"Only confirmed infectious disease cases are reported through the system, but at the end of December, it was very difficult to confirm a case as we were told verbally that we could only apply for nucleic acid test kits with the approval of at least two medical experts," the doctor said.
Also, the standards in defining a confirmed case at an early stage were too strict, even rigorous and stubborn, some doctors were quoted as saying in media reports. For example, a patient with coronavirus-like symptoms should have gone to the Huanan seafood market where the virus was believed to occur before the patient was confirmed with COVID-19 infection. The first batch of experts dispatched by NHC including experts from CDC, arrived at Wuhan on December 31, who received some reports about the unidentified pneumonia cases.
The national CDC reportedly raised its alert level to the second highest on January 6. However, most Chinese people did not get a warning on the seriousness of the disease until January 20 as Zhong, who was also among the experts sent by central authorities to Wuhan, publicly revealed human-to-human transmission in a TV interview.
A Beijing-based public health expert told the Global Times on Thursday that CDC experts in Wuhan failed to judge the situation beforehand and offer an accurate advice on prevention and control measures when there was already evidence of strong infectiousness and human transmissions.
"Though these experts studied the virus samples, they lack epidemiological investigations and understanding to detect the situation at the early stage of the outbreak," the expert said.
The situation is in line with some media reports suggesting that central and regional health commissions - important government organs in releasing critical information to the public - are not usually chaired by officials with a medical background. But those officials usually play a major role in the decision-making process, the expert said.
Limited executive power in decision-making and a lack of understanding on the disease have become major hurdles for CDC to advise NHC more timely, giving accurate advice for effective prevention and control measures.
However, whether the heath commissions at the regional level in Hubei and Wuhan would adopt those measures also became another question as there have been divergences in how to handle the matter among local health officials, mayors and experts.
The shortcomings exposed within the CDC system also hinder its capacity to report to authorities at a higher level as its consultancy may not directly be linked to the central government while its suggestions could not be adopted by provincial governments as the CDC is on a lower executive level, which limits its power inside the CDC system, analysts said.
"A reform in this top-down disease reporting and warning system is necessary," the expert said, noting that the system should allow relevant authorities to issue alerts, regardless of its executive power, by telling the public to get prepared, as limited information leads to panic and rumors.
Global Times
2020/2/28 0:48:40
A laboratory technician conducts HIV tests at the Disease Control and Prevention Center of Handan, North China's Hebei Province, on November 30, 2018. Photo: VCG
While China's epidemic control work has made progress in preventing the further spread of the coronavirus, the central government's top medical adviser said the situation should have been better if control measures were taken earlier, underscoring some of the major shortcomings in the country's heavily-invested disease prevention system set up following the SARS outbreak.
Several top-down authorities, constantly shifting blame on each other for mishandling the outbreak earlier, have now been engulfed in a public opinion crisis, with the public urging an improved decision-making process in the country's healthcare system.
Zhong Nanshan, a leading epidemiologist who was also among those in the expert groups dispatched by the central government to the epicenter Wuhan, Central China's Hubei in January, said three major coronavirus-related epidemics in the 21st century - SARS, MERS and COVID-19 - had offered a lesson that countries should act quickly to prevent its further spread.
"The epidemic would have been much less severe if we took strict control measures in early December, even early January," Zhong said at a press conference on Thursday. "We estimated that numbers of patients would surge to more than 100,000 if we took measures [such as city lockdown] after January 25."
Missing the window of opportunity has become a major regret amid the COVID-19 outbreak not only for the veteran medical adviser, but also for many frontline doctors and officials inside the central and regional centers for disease control and prevention (CDC), as a more timely response to the outbreak as soon as the virus had been detected would have led to a different outcome, given the highly contagious disease has caused more than 78,000 infections nationwide and death to 2,747 in the mainland.
"We have to take immediate action as soon as we detect the virus. This is a lesson we must learn," Zhong said.
At the Thursday's press briefing, Zhong also noted that in China, the CDC system is just a "technical department" with limited standing when he mentioned the shortcomings exposed amid the outbreak. And the CDC should be given more authority and its importance should be further highlighted.
Standing at the frontline of alarming the public on possible major public health crises, CDC, as an affiliate of the National Health Commission (NHC), should do research and offer advice, but ultimately it is not a policymaking organ in China, unlike the top and regional health commissions, according to analysts. And it is urgent to figure out how the CDC could play a bigger role in public health matters or have "a bigger say" in alerting the Chinese people about potential epidemic risks and sending out warnings instead of only focusing on doing research or publishing papers in medical journals.
Mechanism failure
After the SARS outbreak from 2002 to 2003 that caused over 5,000 infections and killed 349 nationwide, China set up a top-down direct reporting system on infectious diseases and critical public health events, which reportedly cost 730 million yuan ($104 million), with the aim of reporting and examining any epidemic quickly after receiving information about confirmed and suspected patients at hospitals. This massive information-gathering system should have technically covered the whole country, to which even county-level health clinics have access and could share the information with health authorities at a higher level.
The first confirmed case of then "unknown pneumonia" occurred on December 8 in Wuhan, while the first result of a pathogen sample, collected from a 65-year-old male, proved that the "unknown pneumonia" discovered in the city was caused by a coronavirus, which is 80 percent similar to the SARS virus, media reported.
And another sample tested by a Beijing-based biotechnology company, as third-party companies cooperate with hospitals in doing gene sequencing, showed inaccurate results and was described as a SARS coronavirus.
Shortly after, Li Wenliang, a local doctor in Wuhan considered the "whistleblower" of the looming crisis, shared the information about the "SARS-like coronavirus" found in Wuhan hospitals on social media, which became the first warning from the healthcare system to the public in a non-official capacity.
The third sample was examined in a lab of the Shanghai Public Health Center, which is cooperating with Wuhan Central Hospital and Wuhan CDC. The result suggesting an unknown virus of the same family as the SARS coronavirus was reported to Shanghai and national health commissions on January 5, media reported.
From the first confirmed case in Wuhan to the official warning about human-to-human transmissions of COVID-19, it took over a month before vigorous measures are adopted. However, a city lockdown implemented in the epicenter was considered a delayed response, raising questions on the loopholes in China's health emergency response system and why this heavily-invested direct reporting system did not work.
A respiratory medical expert and a frontline doctor from a Wuhan hospital who requested anonymity told the Global Times that medics dared not talk about the disease publicly as they would be investigated as "rumormongers."
Whether hospitals or local governments in Wuhan and Hubei deliberately concealed the outbreaks at the very early stage remains a major question. However, some analysts suggested such cover-ups if there are any were based on economic interests.
"Once hospitals reported infectious diseases, local health organs have to inform the public. Hospitals feared that patients would not come if they knew their hospitals received confirmed infectious disease patients.
The government feared public panic and a loss of investment, not to mention the need to maintain social stability for the provincial "two sessions," annual meetings of Hubei's legislature and political advisory body starting January 11, the expert said.
Some frontline doctors even had little understanding about this so-called top-down reporting system when they were asked by the Global Times on Thursday.
A frontline doctor in Wuhan told the Global Times on Thursday that local doctors only heard about its existence. "It's more like an ornament without any practical use."
"Only confirmed infectious disease cases are reported through the system, but at the end of December, it was very difficult to confirm a case as we were told verbally that we could only apply for nucleic acid test kits with the approval of at least two medical experts," the doctor said.
Also, the standards in defining a confirmed case at an early stage were too strict, even rigorous and stubborn, some doctors were quoted as saying in media reports. For example, a patient with coronavirus-like symptoms should have gone to the Huanan seafood market where the virus was believed to occur before the patient was confirmed with COVID-19 infection. The first batch of experts dispatched by NHC including experts from CDC, arrived at Wuhan on December 31, who received some reports about the unidentified pneumonia cases.
The national CDC reportedly raised its alert level to the second highest on January 6. However, most Chinese people did not get a warning on the seriousness of the disease until January 20 as Zhong, who was also among the experts sent by central authorities to Wuhan, publicly revealed human-to-human transmission in a TV interview.
A Beijing-based public health expert told the Global Times on Thursday that CDC experts in Wuhan failed to judge the situation beforehand and offer an accurate advice on prevention and control measures when there was already evidence of strong infectiousness and human transmissions.
"Though these experts studied the virus samples, they lack epidemiological investigations and understanding to detect the situation at the early stage of the outbreak," the expert said.
The situation is in line with some media reports suggesting that central and regional health commissions - important government organs in releasing critical information to the public - are not usually chaired by officials with a medical background. But those officials usually play a major role in the decision-making process, the expert said.
Limited executive power in decision-making and a lack of understanding on the disease have become major hurdles for CDC to advise NHC more timely, giving accurate advice for effective prevention and control measures.
However, whether the heath commissions at the regional level in Hubei and Wuhan would adopt those measures also became another question as there have been divergences in how to handle the matter among local health officials, mayors and experts.
The shortcomings exposed within the CDC system also hinder its capacity to report to authorities at a higher level as its consultancy may not directly be linked to the central government while its suggestions could not be adopted by provincial governments as the CDC is on a lower executive level, which limits its power inside the CDC system, analysts said.
"A reform in this top-down disease reporting and warning system is necessary," the expert said, noting that the system should allow relevant authorities to issue alerts, regardless of its executive power, by telling the public to get prepared, as limited information leads to panic and rumors.
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