China's Response to the COVID-19 Outbreak: A Model for Epidemic Preparedness and Management
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Review Article
Dubai Med J Received: April 7, 2020
Accepted: May 6, 2020
DOI: 10.1159/000508448 Published online: May 19, 2020
China’s Response to the COVID-19
Outbreak: A Model for Epidemic
Preparedness and Management
Nourah S. AlTakarli
Prevention and Control of Infection, Medical Fitness Department, Dubai Health Authority,
Dubai, United Arab Emirates
Keywords taken by the Chinese government to stop COVID-19 spread-
Coronavirus · COVID-19 · Epidemic preparedness · Epidemic ing by comparing the country’s response to SARS and CO
management · Outbreak response VID-19 outbreaks, which will provide an example for the
communities, health managers, and leaders of countries to
follow on how to prepare, detect, and respond to potential
Abstract outbreaks. Method: For this article, epidemic preparedness
Background: As we live in an interconnected globalized and management strategies under comparison were de-
world, people and the diseases they carry can be easily trans- rived from the Centers for Disease Control and Prevention
mitted to any place in a matter of hours. SARS-CoV-2 began (CDC) and World Health Organization (WHO) frameworks
like all new viruses with an ordinary moment when a cluster and guidelines. Other data related to COVID-19 and reported
of patients admitted to a hospital with pneumonia turned cases were taken from more than 25 official public health
out to have a new strain of coronavirus. The virus’s high organization reports and relevant articles using various da-
transmissibility made the epidemic in China turn into a glob- tabases (e.g., Google Scholar, PubMed and Science Direct).
al pandemic with an ongoing daily reporting of new cases Results: Working on developing resilient systems against in-
and deaths. However, as fast as viruses spread, the detection fectious diseases should be one of the top priorities of any
of pandemics and taking early measures has become much country. China embraced resilience in its battle against CO-
easier due to the advancement of science in today’s world. VID-19 and proved its capability to cope with the outbreak
The early responses and measures adopted by China, such crisis. Despite succeeding in altering the course of the out-
as early reporting and situation monitoring, large-scale sur- break, healthcare experts warned about possible epidemic
veillance, and preparation of medical facilities and supplies, recurrence and stressed the need for caution as the pandem-
were all successful in reducing the epidemic in China gener- ic is still ongoing and most of the infected cases are present-
ally and in the epicenter Wuhan specifically. The purpose of ing with only mild symptoms. © 2020 The Author(s)
this review is to focus on the effectiveness of the measures Published by S. Karger AG, Basel
© 2020 The Author(s) Nourah S. AlTakarli
Published by S. Karger AG, Basel Prevention and Control of Infection
Medical Fitness Department, Dubai Health Authority
karger@karger.com This article is licensed under the Creative Commons Attribution-
NonCommercial-NoDerivatives 4.0 International License (CC BY- Al Tawar 1, Dubai (United Arab Emirates)
www.karger.com/dmj n.saltikarly @ gmail.com
NC-ND) (http://www.karger.com/Services/OpenAccessLicense).
Usage and distribution for commercial purposes as well as any dis-
tribution of modified material requires written permission.Introduction studies and reported an average estimation of 3.28, a val-
ue that is higher than the value reported by the World
Coronaviruses are a family of contagious viruses that Health Organization (WHO) which is 1.95. The global
can cause a range of mild to severe respiratory illnesses. case fatality rate (CFR) for MERS, SARS, and COVID-19
These viruses can mutate rapidly and form new types of is 34.4, 9.6, and 4.6%, respectively [5]: “Although CFR for
coronaviruses such as the severe acute respiratory syn- SARS and MERS was higher, COVID-19 has led to more
drome coronavirus 2 (SARS-CoV-2) identified in 2019 in total deaths due to the large number of infected cases.”
China, which is responsible for the current pandemic of Many challenges and consequences for communities
COVID-19 disease. in terms of health, social, and economic aspects can
China has a history of fighting against coronaviruses, emerge as a result of outbreaks. In order to reduce some
as seen in SARS and MERS outbreaks. Late in 2002, Chi- of the consequences, Sigfrid et al. [6] emphasized the im-
na suffered from a SARS outbreak, one of the contagious portance for countries to “address political, economic,
coronaviruses that resulted in 8,098 infections and 774 administrative, regulatory, logistical, ethical, and social
deaths from 32 countries [1]. Although SARS was effec- challenges when it comes to strengthen global prepared-
tively contained, preparations of China and other coun- ness to emerging epidemics.” The Centers for Disease
tries were insufficient for the epidemic at that time in Control and Prevention (CDC) emphasized the impor-
terms of late reporting to health officials, inadequate tance for each community to have mitigation strategies in
quarantine and isolation measures, poor hygiene precau- place in order to slow down the transmission when a virus
tions, and vulnerability of healthcare workers [1]. with pandemic potential emerges. As each community is
Wuhan city, also known as the “Chicago of China”, is unique, these strategies must be based on local factors
the capital and largest city in Hubei province in central such as epidemiology, community characteristics, health-
China. It has a population of over 11 million and is con- care and public health capacities [7]. The strategies ad-
sidered a major industrial and economic part of central opted by the Chinese government and discussed in this
China. In December 2019, several cases of the emerging paper are a successful example as they demonstrated their
coronavirus, previously called 2019-nCoV, were reported efficacy in controlling and reducing the disease transmis-
in Wuhan [2]. These cases, presenting with pneumonia, sion.
were thought to have one of the countless viruses that can
create the same symptoms. Later on, in early and mid-
January 2020, more cases started to appear in other prov- Method
inces due to the population movement during the Chi-
nese New Year holidays, and in other countries such as This paper is a narrative review of the literature where a com-
parison of the Chinese response to the SARS outbreak and the cur-
Thailand, USA, South Korea, and Japan due to interna- rent COVID-19 outbreak was conducted using various databases.
tional travel. This escalation in the number of infected Epidemic preparedness and management strategies under com-
cases in China and globally, and the reporting of deaths, parison, such as the country’s epidemic response capacity, case
made the Chinese authorities sense the abnormal situa- identification and surveillance, healthcare facilities, and medical
team preparation, were selected based on CDC and WHO frame-
tion and take immediate measures.
works, regulations, and guidelines on the implementation of miti-
The emergence of any infection within a community gation strategies for communities responding to epidemics. Re-
can threaten public health security as it might cause seri- ported cases were also reviewed from WHO situation reports from
ous health impacts and has the potential to interfere with December 2019 to April 2020.
international travel and trade. COVID-19 has gained
global attention by the global health organizations and
health regulatory authorities since its discovery. The Epidemic Response Capacity
main issue with COVID-19 disease is the high rate of hu-
man-to-human transmission as the number of confirmed China’s government has been working on strengthen-
cases has reached 1,133,758 confirmed cases and 62,784 ing and improving their epidemic response capacity for
deaths over a 3-month period [3]. The basic reproductive future outbreaks, and the results are visible when com-
number for virus transmutability was calculated in differ- paring the response to SARS and COVID-19 outbreaks.
ent studies using different models and each provided dif- A study by Wu and McGoogan [5] shows the timeline of
ferent estimations. Liu et al. [4] reviewed all the reproduc- the important events for SARS and COVID-19 diseases.
tive number value estimations reported from different According to them, there was a delay in notifying WHO
2 Dubai Med J AlTakarli
DOI: 10.1159/000508448about the SARS outbreak as 300 cases and 5 deaths had Thousands of health and quarantine stations were also set
already occurred compared to 27 cases and zero deaths in up in national service areas and in entrances and exits for
COVID-19. The first official confirmation for COVID-19 passengers at stations [12]. The search was later expanded
came on December 31, 2019, when the WHO China to include screening people at work, in shops and on
Country Office was informed about a cluster of 27 pneu- streets. Furthermore, the government followed more ag-
monia cases of unknown etiology detected in Wuhan, gressive ways of health checking by sending officials to
Hubei province, China [8]. Investigations began and residents’ houses and forcing ill people to be isolated [13].
traced the outbreak to a seafood market were live bats The Chinese government has been investing in new
were sold and believed to be the origin of the virus [9]. high technology tracking systems as well. One example is
The Chinese authorities immediately closed the market the smartphone application which is based on a health
on January 1, 2020, as a method to terminate all meat code color system that categorizes individuals into three
trades, and then started environmental assessment to color groups based on their health status and travel his-
confirm the association and to prevent further transmis- tory, and then determine whether they need to be quar-
sion [8]. On January 3, 2020, 3 days after the first notifica- antined [10, 14]. Another measure that helped in disease
tion, the national authorities of China reported another surveillance and controlling is the street camera system
44 cases, while the causative agent was still unknown. that can catch and fine individuals walking publicly with-
Concerned authorities immediately started epidemiolog- out a mask and identify those showing symptoms. This
ic and etiologic investigations, which led the authorities system is known to be effective as it was previously used
to identify and isolate a new type of coronavirus on Janu- during the SARS outbreak but recently updated to in-
ary 7, to report and detect a novel coronavirus (2019- clude facial recognition and to cover all areas in China
nCoV) as the causative agent on January 9, and to make [14].
novel coronavirus genome sequencing publicly available
for countries on January 10 [8]. The country exerted great
efforts to improve their laboratory capacities as well, since City Lockdown and Social Distancing
the time taken to identify the virus was 2 months for SARS
compared to 1 week for COVID-19 [9]. In addition, Chi- As of January 22, the total number of confirmed cases
nese scientists have compiled a massive data set that gives had reached 581 globally; there were 571 cases reported
the best available picture of the disease [10]. The advanc- in China, 375 of which were reported in Hubei province
es in viral diagnostic methods, the bioinformatic capa- [12]. After many studies in the country reported human-
bilities to analyze the data, and the speed by which ge- to-human transmission [9, 15, 16], and due to the rapid
nome sequencing and data were obtained were very help- spreading of SARS-CoV-2 within Hubei province, the
ful in developing diagnostic kits and taking fast Chinese authorities expanded the range of its preventive
precautionary measures [11]. measures and announced a lockdown in Wuhan and Hu-
bei province cities on January 24, by closing the airports
and suspension of all public transportations to prevent
Case Identification and Large-Scale Surveillance anyone from entering and leaving [17]. This announce-
ment was made one day before the Spring Festival in Chi-
To look for the infection source, authorities started na in order to reduce the very high population movement
their surveillance with investigating food markets other at this time, thus reducing the spread of the disease. In
than Huanan Seafood market. As for infected patients, addition, shops were all shut except those providing food
clinical case identification was provided by WHO China and medicine, and very tight restrictions were placed on
and CDC China to have clear criteria for identifying cas- people to force quarantine. The government also can-
es under the outbreak investigation. The national author- celled activities with large crowds and postponed the re-
ities later placed public health strategies and follow-ups opening of schools and collages by extending the holiday
for cases and contacts, and more than 1,800 teams of epi- [10]. Moreover, massive disinfection campaigns were
demiologists were assigned to trace tens of thousands of launched in public facilities, and education was provided
people a day in Wuhan [12]. In addition, a community- with a focus on populations with higher risk.
wide temperature screening was implemented through This large-scale quarantine and social distancing that
“installing infrared thermometers in airports, railway sta- locked millions of people and cost huge human and eco-
tions, long-distance bus stations, and ferry terminals” [8]. nomic costs has never been applied to this extent before,
China’s Response to COVID-19 Outbreak Dubai Med J 3
DOI: 10.1159/000508448which made epidemiologists skeptical of whether it would hospitals in Wuhan and preparing the available ones to
work or not. Yuan [18] assessed the effect of Wuhan lock- receive COVID-19 patients. The decision was made on
down during COVID-19 epidemic and reported that “cit- January 24 to build Huoshenshan Hospital in Wuhan
ies lock-down combined with nationwide traffic restric- city, a brand-new facility that is fully equipped and has
tions and Stay At Home Movement are all public health the capacity to treat 1,000 COVID-19 patients at once
interventions that changed the fast-rising curve of newly [19]. The building of the 269,000-square-foot hospital
diagnosed cases and helped in controlling the epidemic.” was completed within 10 days and started receiving pa-
As for the increase in the number of cases after the lock- tients on February 3. During the same period, the Leish-
down, Zhong et al. [17] reported strong correlation be- enshan Hospital project with a 1,500-bed capacity was
tween the 5 million people who traveled from Wuhan announced and completed on February 5 [19].
within Hubei province and other provinces before Janu- Xiaotangshan was the model for the new coronavirus
ary 24, 2020, and the extent of amplification of the out- hospitals built, but some notable differences in China’s
break of COVID-19 in China. actions can be seen. The first is the decision time for
building the hospitals as Xiaotangshan construction be-
gan 6 months after the announcement of the SARS out-
National Reporting System break while Huoshenshan Hospital construction started
less than 2 months after the reporting of COVID-19 clus-
Another measure taken is generating daily reports for ter cases and just days after the seriousness of the out-
the newly suspected, diagnosed, and asymptomatic cases break became clear. Secondly are the larger construction
and deaths. As soon as a COVID-19 case is diagnosed or areas with strategic locations and larger capacities to ac-
suspected, the responsible doctor is required to report the commodate patients in the new hospitals [20]. Many oth-
case electronically, where statistics will be generated for er hospitals, medical centers, and quarantine facilities
the total number in each area [11]. These reports are gen- were built as well across the country to accommodate all
erated through China’s National Infectious Disease In- patients [19]. As many of the deaths were from the older
formation System (IDIS) developed in 2004 after the age groups, China focused on building special centers to
SARS outbreak, and are based on the National Disease treat old and critically ill patients where the principle of
Reporting System (NDRS) between the National and Pro- “Four Concentrations” was implemented with a focus on
vincial Health Commissions, which covers the entire concentrating on the patients, medical experts, resources,
population of China [12]. Each province is required to and treatment [12].
submit its report on a daily basis, where epidemiological As for the healthcare team, more than 40,000 health-
curves will be generated for the whole country and for care workers were deployed and medical resources were
each province separately. These epidemic curves, in addi- mobilized from across the country to support the re-
tion to the published literature and on-site visits to the sponse in Wuhan [10, 12]. In addition, China’s Nation-
affected areas, helped the epidemiologists in China to al Health Commission worked on surveillance of CO-
make epidemiological observations about the disease’s VID-19 among healthcare workers, revision of protec-
demographic characteristics, zoonotic origins, transmis- tion standards and specifications, and strengthening
sion dynamics, and progression. The country also used prevention and control measures against the disease in
these data to identify and focus on areas that have more hospitals [21, 22]. Due to all of these measures being
cases and require further measures. taken, transmission within healthcare settings does not
appear to be a major transmission feature of COVID-19
in China, unlike in SARS and MERS outbreaks where
Healthcare Facilities and Medical Team Preparations the majority of cases were healthcare-associated trans-
missions [15].
Given the trend of daily increase in the number of re-
ported cases in China in January 2020, it was a clear sign
for the government that patients would soon overwhelm Situation Improvements
the country’s hospitals. As with the Xiaotangshan Hospi-
tal that was built during the SARS outbreak to relieve the Fighting and containing an outbreak of a novel patho-
overstressed medical system, China decided to replicate gen with person-to-person transmission and in this high-
the old experience and immediately started building new ly mobile world is a challenging task [23]. Despite that,
4 Dubai Med J AlTakarli
DOI: 10.1159/000508448China’s government and people were up for the challenge Conclusion
and were able to contain the outbreak within their coun-
try borders. After all the measures taken and people’s China provides hope for the rest of the world and re-
commitment, a decline in the number of new cases and minds other countries that even the most severe situations
deaths was observed by the end of February and is still can be turned around. Their response to the COVID-19
ongoing. The country has succeeded in reducing the epidemic and the high level of collective action in a modern
numbers to hundreds and tens compared to thousands in city with more than 11 million people are to be appraised
previous months [24, 25]. This improvement can also be and have stunned the whole world. Although some will say
noticed in the very high recovery rate as more than 95% this might seem easy in a society or political system as that
of the infected cases have recovered [26]. available in China, it is actually not easy to get this kind of
Health authorities have reported zero new local CO- passion, commitment, interest, and an individual sense of
VID-19 cases in Wuhan and Hubei provinces for 4 con- duty. There is currently controversy regarding China’s de-
secutive days from March 19 to March 22 [27]. The city cision to remove the lockdowns, but the results will be-
has been able to close all temporary corona virus hospi- come clearer after its application and are dependent on the
tals, and lockdowns to control the disease spreading are precautionary measures taken by the government.
slowly being lifted. After more than 2 months and with all Countries need to learn from China’s response to CO-
the situation improvements happening, China an- VID-19 and start implementing prevention and control
nounced the removal of the lockdown and the travel re- strategies immediately as each one is at risk of becoming
strictions on Wuhan and restarting of the economy on the new virus epicenter. Considering that each community
April 8 [27]. Although the results reflect the tremendous is unique, assessment should be done of the possible ben-
work and success of China in terms of preparedness, re- efits and negative consequences of each strategy adopted.
sponse, and service availability, health officials warned of In addition, countries should work on enhancing their sys-
a relapse as the pandemic is still ongoing in other coun- tems and personnel in order to be more prepared for future
tries and as 80% of infected cases have mild to moderate outbreaks and reduce consequences when they strike.
symptoms but are still infectious [27].
Meanwhile, the pandemic is spreading rapidly else-
where around the world. Countries like the USA, Italy, Disclosure Statement
and Spain have become the new virus epicenters with a The author declares no conflict of interest.
higher number of infected cases and deaths reported [28].
China has contributed by sending their medical team and
protective supplies from Wuhan to some of the European Funding Sources
countries mostly affected by the outbreak, such as Italy, in
order to assist in fighting against the ongoing daily battle. The author has no funding sources to declare.
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