Prominent Croatian scientist Igor Rudan writes exclusively for Vecernji list on the 18th of March, 2020 about coronavirus, and in his latest article, he discusses how the Chinese are managing the coronavirus epidemic so well.
We are transmitting Igor Rudan's latest article in full:
''In my article on the spread of COVID-19 written for Vecernji list three days ago, I tried to explain the danger we're facing.
I've clarified the two main ways that the virus can put us at a greater risk - its rapid spread in the community and hospital outbreaks. I also explained behaviours that should help in both cases. I concluded that Croatia had well prepared defense lines, which in the first weeks, had yielded measurable results in relation to the environment. However, I also emphasised in this text that "... with epidemics, things can quickly turn against us just because of a little carelessness or the irresponsibility of individuals, and in just 48 hours, from a successful country, because of just a few incidents, things can change.'' and then every country quickly starts being followed case by case.
Unfortunately, three days later [after that article] we're witnessing just how important this warning was. Doctors at several leading Zagreb hospitals are now infected with coronavirus. More than a hundred health professionals and their contacts, are therefore isolated. Several Croatian broadcasters have mentioned individual negligence as a possible cause, although all epidemiologists have been calling for caution for at least a month, and all of our doctors are well aware of the risks of viral outbreaks. Thus, despite several weeks of professional efforts, the start of the fight against coronavirus in Croatia could be marked by hospital outbreaks. Obviously, the words of the 19th-century Prussian military strategist Helmuth von Moltke, who taught us that "no war plan will survive its first contact with an adversary,'' are still true to this day.
It's less evil at least that such a failure occurred at such an early stage. Now, clinicians in hospitals will also raise the level of severity to that shown by public health professionals for weeks. In addition, hospitals are still not significantly burdened with infected patients. Furthermore, sending more than a hundred health professionals into self-isolation will allow them to rest well, so we'll also get a backup squad. This may be absolutely necessary in just two weeks, provided that the number of cases of new patients continues to increase significantly in Croatia and that the frontline doctors themselves become infected.
At present, however, the issue of how many patients in hospitals may have been infected is of the greatest concern. We'll know this within a few days, when their incubation period is over and some may develop COVID-19 symptoms. Infected Zagreb hospital patients could become the first Croatian cases to create a more severe clinical picture, but still a curable one. Hopefully, there will be as few of them as possible, and that everyone will learn valuable lessons from this early incident.
By now, coronavirus has spread to so many countries that some entry and defense models are beginning to crystallise - such as the Chinese, South Korean, Singaporean, Iranian, Italian, German, French, Spanish and American ones. In the past few days, I've often wondered which of these models will most closely resemble the situation in Croatia, in order to contact my global health colleagues there and seek their advice, since they are all ahead of Croatia in terms of the epidemic.
We can see now that the onset in Croatia could be marked by the initial spread of contagion in major hospitals in the capital. This situation is most similar to what was happening in Wuhan, where the pandemic started. So I called a few colleagues from China, leading global health experts there, to ask them to recall all the contingencies and "bottlenecks" they had to deal with while fighting the Wuhan epidemic. I told them that the Croatian, ie the Dubrovnik invention from the end of the fourteenth century - quarantine - saved Wuhan and China from COVID-19 in the 21st century, and that it would be nice if their experiences would help us here in Croatia now. So, I'll relay their story of Wuhan, which may also carry some useful advice for us.
In November or December 2019, somewhere around Wuhan, a new coronavirus managed to transfer over from a small mammal, a bird or a bat, to a human, and then spread for some time to the local population. After several hundred infected people, severe cases of pneumonia occurred, predominantly among older men. They ended up being treated at the hospitals of Wuhan, with eleven million residents.
Nobody even noticed those isolated first cases as something special. It was only between December the 26th and the 28th that the first group of patients with this unusual pneumonia appeared in the same hospital. It was the "Hubei Hospital for Integrated Traditional Chinese and Western Medicine" (HICWM). All of the patients had stories that were in some way related to the Huanan Fish Market. It was then that the doctors at that hospital first suspected that it could be a new pathogen. But the doctors were already infected by then.
Moreover, they infected many of their colleagues at a rapid speed, and they in turn infected their patients. Many patients were already seriously ill, those who were old and those with compromised immune systems. Everyone was aware that a new contagion was spreading, but its symptoms were generally mild in doctors and younger patients, but more severe in the elderly. Lung inflammation would occur relatively infrequently, and no one knew what was causing it, but it was extremely dangerous for the elderly and the sick. On the last day of 2019, the Chinese authorities informed the World Health Organisation in Geneva of the situation and closed the fish market on the first day of 2020.
However, it took time to isolate the virus from the blood of those infected. The virus was discovered on January the 7th, 2020 and was immediately recognised as a new, seventh human coronavirus, somewhat similar to SARS. It was shared on the 12th of January, 2020, with the whole world. On this basis, diagnostic tests were available as early as the next day, and we were finally recognising who was infected. The problem with the new coronavirus was that it spread rapidly and successfully among people in the phase until the infected showed symptoms, so it was clear that an explosive epidemic across Wuhan was inevitable.
During that time, between December the 26th, 2019, and January the 12th, 2020, the coronavirus epidemic spread rapidly across Wuhan, and a large number of doctors in hospitals became infected with the virus. Although their clinical picture was neither problematic nor personally threatening, they wanted to continue helping their patients, but they shouldn't have done so. Specifically, they were able to transmit the infection to people in much worse shape than them. Entire medical teams had to go home to get over COVID-19 or quarantine their colleagues' contacts. In those days, when there weren't enough doctors in Wuhan's hospitals and the epidemic spread among severe hospital patients, most people died in Wuhan. The death rate among the already old and severely ill patients was, of course, much higher than it would be among the healthy population outside the hospital.
Around January the 15th, the number of newly infected people in Wuhan was already close to 500, and on January the 19th, it was close to 1000, reaching 2200 on January the 22nd. But the problem with the outbreaks is that these patients went to hospitals and were tested there days later. Thus, epidemiologists were only able to notice this "jump" from 100 to 200 newly infected people in hospitals on January the 22nd.
This was a sure sign that the epidemic was already spreading rapidly among the population. This is important to remember, because it means that when around 200 infected people are tested today Europe, it means that the actual number of newly infected individuals among the population on that day is probably already ten times higher. With all these adversities, for travel related to the Chinese New Year celebration, travellers from Wuhan transmitted this new coronavirus to just about every Chinese province where the first cases were recorded.
The very next day, on January the 23rd, all of Wuhan was urgently put into quarantine. A day later, fifteen more surrounding cities were shut down. The effects of quarantine measures on reducing the number of positive test results were only noticed two weeks later, but thereafter - it declined steadily. In the Hubei province, therefore, the new coronavirus also first entered the major hospitals of the capital, Wuhan, and put enormous pressure on them. It was at a time when many infected doctors were in isolation.
My Chinese colleagues recalled a series of decisions that then had to be made, procedures and bottlenecks that they simply couldn't have foreseen. First, their situation in Wuhan and Hubei province on January the 23rd was a "perfect storm." A large number of infected doctors were in isolation when the main wave of severe Wuhan patients were rushed into the hospitals. This is where China was fortunate to be such a populous country. All other provinces of China then sent, by emergency flights, a large number of doctors and nurses to each of the sixteen quarantined cities, with hundreds of artificial respirators shipped to them by the military.
So, they managed to bridge the shortage of health care staff and equipment until the infected doctors from the Hubei province recovered and were able to return to work. The first task for teams coming to Wuhan was to physically separate infected patients from uninfected patients in hospitals. Now they already had tests, so they could test all patients daily and know who was infected and who wasn't. One option was to move all patients uninfected with the virus somewhere else, and leave all those who were infected in the hospitals. But, uninfected patients also needed sophisticated hospital equipment. They couldn't transport them all to other provinces because for many it would be too risky. Alternatively, some Wuhan hospitals could be declared infected and others uninfected. But with these relocations around the city, the fear was that there would be chaos and eventually this virus would be introduced into all the hospitals.
Owing to that, a pragmatic decision was made clear to the rest of the world: in just a few days, two brand new hospitals would be built, and they were for the infected only. They'd be supplied with hundreds of respirators and intensive care units. This radical decision was one of the best, as it suppressed the further spread of the pathogen among hospital patients, which contributed very significantly to the total number of deaths.
Another "bottleneck" has become contagion suits for the doctors and nurses. They thought they had enough, but when Wuhan's doctors returned to work and the imported medical teams were still there, it was evident that there were simply never enough protective suits. Some factories were then ordered to mass produce protective clothing. In addition, it's important not only to have suits, but also to carry out sufficiently high-quality training among doctors and nurses on how to use them properly.
Having learned from the experience of the infection of entire medical teams at first, the directors of the large hospitals in Wuhan divided their staff into teams large enough to cope with entire wards. Such teams were no longer allowed to be in the hospital at the same time, nor were they permitted to socialise or to get in touch privately. Thus, it was ensured that if some of the medical staff were already ill, not everyone became ill.
Another practical problem was that doctors weren't allowed to take off those suits all day, so they couldn't deal with the emergencies. A large amount of adult diapers had to be purchased, which health professionals had to carry all day in their shifts. Another unforeseen problem is that the doctors in those suits couldn't breathe. After a few days, they would start developing very unsightly and painful rashes. It was necessary to mobilise entire teams of dermatologists to treat these rashes for their colleagues at the end of their shifts so that they could work again the next day.
In addition, Wuhan's hospitals were already so overcrowded with patients and doctors that it was necessary to double or triple the production and supply of food and drink for all of these people. Furthermore, the doctors had to watch over patients all day and night. Because of this, practical questions began to arise - does it make sense that they return to their homes at all during the epidemic? Most of them chose to stay and sleep in the hospital to protect their families from infection.
Others rented temporary apartments near the hospital so that they could sleep properly and not endanger their families. The third sent their families to relatives. I believe that my colleagues in Croatia, many of them my former students, are thinking about these issues now, so I'd like to offer them some ideas from Wuhan.
Finally, after suppressing coronavirus hospital outbreaks in this way, the out-of-hospital epidemic among the population in Wuhan needed to be suppressed. This could only be done by the mass testing of all suspected infected people. It was the flu and cold season of January and February, so many people were coughing anyway. It was necessary to see who was coughing because of the flu or a cold and who was coughing because of COVID-19. The Chinese then organised thousands of small epidemiology teams to report and go around the apartments, measure temperatures and test people.
Just as they had to move all infected patients from existing hospitals to two newly built hospitals, in the same way, all infected people with a milder form of the virus had to be put into isolation. They used stadiums and empty schools for this. A large number of infected people were thus moved into isolation and monitored until they were better and no longer showed any trace of the virus. So, between January the 23rd and March the 7th, Wuhan was able to completely suppress the massive coronavirus epidemic, which peaked at about 3750 confirmed infections in a single day, in just six weeks. An analogy of this for Croatia would be 1364 newly confirmed cases per day for comparison. And they were able to quarantine it within six weeks.
Lastly, I asked them how they managed to keep eleven million people in their homes so successfully. My colleagues told me that when they closed down Wuhan, the government brought together leading Chinese judicial experts.
As early as February the 6th, two weeks after the Wuhan shutdown, they enacted a "Criminal Justice Punishment Act aimed at preventing the spread of a new coronavirus that causes pneumonia." Any person who had been quarantined and intentionally violated that would be punished with "between 10 years' imprisonment and the death penalty," depending on the consequences, according to Articles 114 and 115 of the Chinese Penal Code.
If they breached the quarantine provision by accident, he would be imprisoned for a month to three years. And anyone who by any means, negligently and contrary to the instructions of the coronavirus prevention staff, contributed to the spread of the virus, would be punished with 3 to 7 years in prison. Obviously, these are penalties that were compelling enough to allow eleven million people to be kept in strict quarantine. Only one household member, every three days, was allowed to go out to get groceries for the others. Before going out, he had to call one of those small epidemiology teams to get his temperature measured.
The Wuhan/Hubei quarantine were the first mega-quarantine experiments in human history, locking 56 million people inside their households. This has shown us that the COVID-19 epidemic can be effectively suppressed. All over China, with its one billion and four hundred million inhabitants, only about twenty new cases a day have been being recorded. Most of these new cases are now coming from overseas, and the total number of deaths in China shouldn't exceed 5,000.
If the epidemic returns again with a smaller focal point, there's no doubt that China will be able to extinguish such a focal point, after such an experience. Two very difficult questions for all Western leaders today are: can they achieve the same result, and do they want to achieve it? Because months of quarantine of a lesser severity than China's will severely hurt their economies. It will leave countless people jobless.
In addition, flu caused by the influenza virus can take up to 650,000 lives worldwide annually, although vaccines are available for it. But there is almost no public awareness or fear about the threat of the flu. Perhaps a better example is pneumonia in poor children across the world, mainly caused by pneumococcus, type B hemophilus, respiratory syncytial virus and the influenza virus.
They continue to take one million children's lives per year. This is 2,739 deaths of the world's poor children every day, completely invisible and unknown to the public, due to the same medical cause that COVID-19 is now threatening us with. The West is now deciding whether to suppress COVID-19 with discipline and strict quarantine, like the Chinese, or turn it into a "creeping epidemic", so that they live in milder quarantines for months until people just get used to COVID-19 and stop it having so much of an effect.''
This text was written by Igor Rudan and translated by Lauren Simmonds
For rolling information and updates in English on coronavirus in Croatia, as well as other lengthy articles written by Croatian epidemiologist Igor Rudan, follow our dedicated section.
