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Coping with the Coronavirus in China

What We Know Changes Daily

By Tom Ulmet, ACAMIS

03/26/2020

Coping with the Coronavirus in China
On 31 January, the world looked on with amazement as China announced it was taking massive measures to protect the country from the rapid spread of the newly identified novel coronavirus, now officially classified by the World Health Organization as COVID-19. When the speed of transmission resulted in long lines at medical centers and rising fatality rates, Hong Kong and Macao quickly followed suit.

These unprecedented emergency measures were implemented during one of the largest annual mass migrations in China—the Chinese Lunar New Year holiday, which occurs over a 15-day timeframe in January and prompts many Chinese to return home to visit with family. This year, experts predicted the occasion would attract the largest number of travelers ever, with over 440 million railway travelers expected within China and 79 million air travelers, about 7 million of whom were traveling from abroad. [reference]

Noting the severity of the virus outbreak that coincided with this migration, the government moved swiftly to enact multiple measures to contain the spread, with so many people traveling back to the major cities. These included instituting a complete lockdown of Wuhan, the epicenter, shuttering all places of work in all major cities, screening every port of entry—via rail, road, and air—and immediate testing of people upon request to see if they carried the virus.

All shops and restaurants were temporarily closed or had restricted hours for food delivery and all public gatherings were cancelled. Screening stations were set up at the borders of cities and provinces. As schools were not in session over the holiday, it was later announced that all educational institutions would be closed until further notice and online instruction was put in place.

This response protocol had been planned in advance based on lessons learned from previous outbreaks, such as SARS, Swine Flu, Avian Flu, and MERS, which have occurred about every four years.

Imagine the shock for those returning from holiday to see once bustling and traffic-filled streets deserted, with public transport reduced to a trickle. Fourteen-day quarantines were put in place for anyone returning from outside the country, as residents were asked to remain in their homes and visitors in hotels.

Individuals’ movements were tracked by monitors in each housing area. Although major stores remained open for shortened days, stocks of key goods—such as face masks, toilet paper, and tissues—were completely exhausted for long periods of time.

The sheer magnitude of the measures taken is mind boggling. All universities and schools remained closed after the holiday and, as of 13 March, are still not open. Consider the size of this order, where nationwide there are about 514,000 schools, including undergraduate universities, 260 million students, and about 15 million teachers. This year, all schools have been asked to conduct online learning in some fashion. What a massive undertaking! [reference]

In addition, the international community—consisting of international business representatives, specialists, and diplomats from over 100 nationalities—is supported by two types of private schools: those designed to serve local students and foreigners and Schools for Children of Foreign Nationals that are not allowed to enroll local students without written permission from the government.

The Association of China and Mongolia International Schools (ACAMIS) consists of 77 members across China that serve the educational needs of the international population and to enhance the economic development of each region. Approximately 63,800 students and 8,200 teachers are part of this professional affiliation.

Although structured differently by host governments in other countries, these are the types of constituents around the world served by The International Educator (TIE). Their campuses in China have been closed since 31 January and have been offering remote learning.

To compound the situation, most international school teachers had scattered around the world for the holiday and face a two-week self-quarantine upon returning to China. Still, thanks to experience gained through previous health emergencies, most ACAMIS member schools were well prepared to implement online study.

What have we learned from this type of rapidly spreading virus?

• Education and information are key factors in the management of infectious disease. The distinction between the disease and the epidemic is key. Controlling the spread of the virus is the focus, but also controlling anxiety through reassurance and information honestly and openly is the biggest challenge. [reference]

To understand what governments need to do in order to stop the uncontrolled spread of infectious disease, this article by Dr. David Owens available online at www.otandp.com is a must-read, as it affects us all: "COVID-19: to contain or delay and mitigate, which is the best strategy?" [reference]

• Containment and prevention are essential. China moved swiftly to contain the transmission of the virus, but the rest of the world is not as well prepared to undertake this kind of massive action.

Consider that in Wuhan, a city of about 12 million that came to a complete standstill, 1,800 trained teams of epidemiologists with a minimum of five people per team were deployed to track contacts of those infected (over 10,000 per day) to conduct medical observation and refer those with symptoms for testing and appropriate medical care, depending on severity.

Some countries ignored the danger at first, with a "what’s all the fuss" attitude, as if this were just another form of influenza and would soon pass. China discovered that human-to-human transmission of the COVID-19 virus is largely occurring in families. In other countries, transmission tends to occur within social clusters and spreads within families. Health care workers, despite their protective gear, were among the hardest hit. "As of 20 February 2020, there were 2,055 COVID-19 laboratory-confirmed cases reported among health care workers from 476 hospitals across China with the majority in Wuhan." This largely occurred at the very start of the outbreak, before the nature of the virus was identified. [reference]

Who does it affect the most?

Highest fatality rates are for people over 80, which is the same for all infections. As of 28 February, there have so far been no fatalities in children and for those under 40 years of age the mortality is 0.2 percent.

The high mortality rate among health care workers is likely to be explained by high viral load. Health care workers have always died during epidemics. They are working with the sickest people; in many outbreaks, an individual’s level of exposure can correlate to the severity of their case.

Men are at a higher risk than women, with the highest risk being among older males. This may be due to smoking (about 50 percent of males in China smoke, in comparison to 3 percent of females). Part of the public health response to this crisis should include advocating healthy living, including exercise, a healthy diet, and no smoking. [reference]

Global spread

The virus is now spreading globally, and most countries are neither prepared for it, equipped to handle its treatment, nor ready to take the dramatic actions China took to contain the virus.

As of 15 March, 143 countries (nine additional since the last report) have reported confirmed cases involving 153,517 cases and 5,735 deaths. The countries with more than 100 confirmed/new cases can be found in the daily WHO Situation Reports. In almost all of these cases there was an original link to someone in China. The spread inside countries is now via social clusters and within family units, but it remains controllable at this time if contained and if people who become ill are aware of the possibility of infection, notify their recent contacts, and seek help as soon as possible. Human nature suggests this is a lot to expect, but this approach is working in China. [reference]

Why close schools?

To date, the few children who contracted the virus were part of a family cluster. If there are no fatalities among children, why close schools? Dr. David Owen of OT&P Healthcare, an expert in Hong Kong on infectious diseases, states, "It is important to appreciate that in epidemics we do not close schools specifically because we fear for the impact of the disease on our children. Fortunately, early data suggests that the complications of COVID-19 are not affecting children. School closures work by reducing the spread of mild illness and other disease which makes it less likely that any epidemic will grow." [reference]

"The relevance of school terms is important but unknown for the SARS-CoV-2. Few children have been identified as cases. This may mean they do not get easily infected and don’t do much transmitting. Or it may mean only that they don’t get severe symptoms when they are infected, and transmit nonetheless. Or something in between. Understanding this is key if we want to know whether school closures can help control COVID-19 spread, as well as to anticipate how much summer vacation may help reduce spread." [reference]

Will the coronavirus slow down in the warmer months, as with flu season?

Four types of coronaviruses circulate annually. Interestingly, it showed that viruses do not totally die out, but that immune systems function much better in warm weather and humans are not as susceptible, except those in certain groups such as the aged, ill, infirm, smokers, and those with other diseases. This research of COVID-19 compared with other bat viruses showed most similarity to SARS. Although different, the make-up of this coronavirus is a 79 percent match with SARS and the genome sequence has a 93 percent match. In five gene regions (E, M, 7, N, and 14), the sequence identities were greater than 90 percent, with the highest being 98 percent in the E gene. [reference]

This similarity to SARS suggests that the study of temperature related to the spread of SARS may be useful in predicting how COVID-19 will behave as temperatures increase. A similar study of MERS showed an increase of cases in lower temperatures and a decrease in spread in higher temperatures. For example, "an increase of 1°C in air temperature was associated with an average reduction of 3.6 (sic) cases.

This article concludes that "Air temperature might be a very important factor in the emergence and elimination of SARS." And indeed it was, with SARS and MERS as well. This provides hope that warmer temperatures will see a great decline in numbers of cases. However, cases have already been imported to countries in the southern hemisphere where it is summer. If those cases are not contained now in the southern hemisphere, the virus may be able to transmit within social clusters very rapidly as temperatures decrease. [reference]

The latest WHO Situation reports show that containment has been effective in China to date. In China there is great hope that the virus will not transmit well in summer.

"Based on the analogy of pandemic flu, we expect that SARS-CoV-2, as a virus new to humans, will face less immunity and thus transmit more readily even outside of the winter season. Changing seasons and school vacation may help, but are unlikely to stop transmission."[a href="https://ccdd.hsph.harvard.edu/will-covid-19-go-away-on-its-own-in-warmer-weather/"> [reference]

Conclusions

Major measures by government in China and Hong Kong (SAR) have been very effective in reducing transmission. China was prepared for this, as a result of experiencing previous infectious events. Instituting such extensive measures may not be possible in other countries, where the needed skilled healthcare workers and epidemiology expertise is lacking. At this point, during the first pass, children do not appear to be easily infected and may not do much transmitting, but this could change with time. The average person’s immune system is worse in winter.

It is possible that transmission may decrease during warmer weather, but the coronavirus can still be spread from cooler climates to warm ones through travel. As this virus is new to humans, it may take 12–18 months for the spread to make the first pass. Seasonality in the northern and southern hemispheres will make little difference as this virus can be carried and transmitted back and forth between seasons. Most affected are the susceptible hosts—the aged, infirm, smokers, and those will other illnesses, particularly those above age 60.

This suggests that we must try to protect those people by encouraging them to limit broad social contact until conditions improve, which could take more time than first thought. If the spread is not contained, there is a danger that the medical community will become overloaded and overworked.

International schools all over the world should expect to be affected in some way at some point.

Be patient, be confident, be strong, be informed, be a good listener, be safe!

Tom Ulmet is the Executive Director of the Association of China and Mongolia International Schools (ACAMIS) since 2014. Before taking this role, he was Founding Chair of Shanghai International Schools Association (SISA) (during SARS in 2003) and was a member of the ACAMIS Board for five years. He served as Superintendent of Yew Chung International Schools in China (YCIS) for 12 years and in the YCIS Foundation Headquarters in Hong Kong for two years.

References

The ACAMIS Model Infectious Disease Preparation Check List for International Schools

2019-2020 US Flu Season: Preliminary Burden Estimates, Center for Disease Control, February 22, 2020

COVID-19: The Distinction Between a Disease and an Epidemic, Updated, OT and P Healthcare, Owens, Feb 28, 2020

Coronavirus Disease 2019 (COVID-19), Situation Report-55, World Health Organization (WHO), March 15, 2020

COVID-19: why do we close schools, OT and P Healthcare; Owen, Jan 28, 2020

Environmental factors on the SARS epidemic: air temperature, passage of time and multiplicative effect of hospital infection
Education in China: A Snapshot, 2016

Genomic Characterisation and Epidemiology of 2019 Novel Coronavirus: Implications for Virus Origins and Receptor Bindings"; Lu, Zhao, Li, Niu, Yang, Wu; The Lancet: V 395, Issue 10224, Feb 22, 2020

Seasonality of SARS-CoV-2: Will COVID-19 go away on its own in warmer weather?, Marc Lipstitch, Harvard School of Public Health, Winter 2020

Understanding the Risk of Catching COVID-19, OT& P Healthcare; Owen, Feb 21, 2020

"What is the Latest on the COVID-19", OT and P Healthcare, Owens, Feb 28, 2020

"Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), 16-24 February 2020"




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