The most important strategy to combat a pandemic is to prevent it from even happening. This means that the spread of a virus needs to be countered as early as possible. The COVID-19 epidemic curves and major intervention measures that were implemented in China are shown in. Here is a description of the timeline.
On December 31, 2019, the Wuhan Municipal Health Commission revealed a cluster of cases of pneumonia of unknown etiology. The Chinese CDC sent experts to Wuhan to support the investigation and control effort.12
On January 3, 2020, the first genomic sequence of the novel β-genus coronaviruses, now known as SARS-CoV-2, was determined by scientists of the National Institute of Viral Disease Control and Prevention.13China informed the WHO.
On January 10, 2020, the whole genome sequence of the SARS-CoV-2 was shared with the WHO. Several rapid and sensitive detection tests were developed by the China CDC.
On January 16, 2020, the National Health Commission (NHC) issued the first of 7 versions of the protocol for the diagnosis and treatment of COVID-19.
On January 20, 2020, the NHC upgraded the management of the COVID-19 to the highest level pertaining to class A infectious diseases.
On January 21, 2020, the NHC officially started to release daily disease information on the government website.
On January 23, 2020, the Chinese government began to limit movement of people in and out of Wuhan and announced that all public transportation, including city buses, subways, ferries, long-distance coaches, outbound channels at airports, and railway stations in Wuhan had been suspended or closed.
On January 24, 2020, the local government planned 2 new quarantine hospitals with 1000 and 1600 beds to be constructed within 10 days. By March 8, 2020, 42,600 health professionals from outside Hubei and 1,800 epidemiologic teams participated in battling COVID-19 in Hubei.14
On January 27, 2020, the Chinese government announced the extension of the Lunar New Year holidays, and postponement of reopening of schools and factories.
On January 29, 2020, all 31 provinces on the Chinese mainland had activated a level 1 public health emergency response, the highest in the country, to prevent further spread.
On February 3, 2020, public facilities such as conference venues and sports stadiums were converted into makeshift hospitals to isolate patients with mild to moderate COVID-19 from their families and communities, while providing medical care, disease monitoring, food, shelter, and social activity.15As of March 10, 2020, more than 12,000 patients had recovered and all makeshift hospitals were temporarily closed.16
On February 7, 2020, the Chinese government announced that all medical expenses of confirmed patients would be covered by health insurance or financial compensation.
On February 8, 2020, the Chinese central and local governments began to take measures to ensure the orderly resumption of production by companies to provide material support for the control of the epidemic. These included offering free health check-ups and arranging chartered buses, trains, and airplanes to send migrant workers back to resume work in other regions.
Quarantine Strategies
Quarantine and surveillance are still the most effective means of controlling the spread of infectious diseases. Some of the strategies and tactics are described below.
1)
Limiting migration—Wuhan city announced a citywide lockdown on January 23, 2020. Subsequently, the Chinese government banned all domestic travel, extended the Lunar New Year holidays, and postponed reopening of schools and factories to reduce the nationwide migration of the population.
2)
Designated hospitals—In Wuhan, to consolidate patients, medical experts, resources, and treatment, there were 45 COVID-19–designated hospitals: 6 for critical patients and 39 for severe patients and patients > 65 years of age. All regional hospitals established standardized fever clinics to timely screen for fever and strengthen isolation management. Designated hospitals were increased as needed by conversion of public and nonpublic hospitals.
3)
Community isolation—Travelers from Wuhan and other epidemic areas were required to register at their destination along with their travel history with the use of smartphones and to self-quarantine for 2 weeks to prevent community transmission. Only 1 family member could leave the house to purchase daily living supplies every 2 days.
4)
Maintaining adequate supply of essential items and revamping supply chains—Express delivery companies conducted “noncontact delivery” in communities. Shelves in stores were kept stocked by criminalizing price gouging and preventing hoarding. Opening green channels and coordinating transportation of supplies helped to ensure the safe delivery of key supplies. In the early stages of the COVID-19 outbreak, there was a shortage of personal protection equipment (PPE), which was mitigated by the use of reserve supplies, acquiring donations, and increases of production (Supplemental Appendix S1;Supplemental Fig. S1).
5)
Testing—Early testing provided the basis for tracking and isolation in Wuhan to identify persons who could potentially spread the disease. The numbers of tests performed in Wuhan are shown in.
6)
Tracking—A major part of the success in controlling the spread of COVID-19 was rooted in the tracking strategy. All patients testing positive for COVID-19 were tracked and their contacts isolated. Big data and artificial intelligence (AI) were used to strengthen contact tracing and the management of priority populations.
7)
Temperature screening—Temperature screening checkpoints were established at supermarkets, residential area entrances, and transportation hubs. Everyone was screened for temperature when entering public areas. Temperature screening is a cheap, easily implemented, and rapid method of screening large numbers of the population for possible COVID-19. Fever is the most common symptom in patients with COVID-19. Persons who had traveled to Hubei or had close contact with COVID-19 patients in the preceding 14 days were required to undergo temperature checks.10
8)
Personal protection—All residents were required to wear medical surgical masks or N95 masks when accessing public places. The internet and media were leveraged to publicize the correct knowledge of protection and prevention of spread, such as using masks, daily disinfection, and washing hands correctly.
9)
Controlling cross-infection—Hospitals offered online consultation and medical services to reduce the frequency that patients visited hospitals. Online work and learning were used to avoid cross-infection.
Managing Human and Equipment Resources
Physician scheduling was optimized.17This scheduling is shown inSupplemental Table S1. Emergency staffing was arranged as needed within half an hour.
Nurses 1-3 jointly completed all of the nursing work for patients, including daily care, disinfecting the isolation areas, etc. Nurse 4 was the team leader, who was mainly responsible for counting supplementary materials, delegating resources, and completing nursing records.
Workflow was optimized and the correct use of protective equipment, cleaning, and disinfection measures was ensured.18
During the outbreak, many elective surgeries were not performed. In addition, surgery may accelerate and exacerbate disease progression of COVID-19.19
Treatment of COVID-19
Suspected and confirmed patients were quarantined and treated in designated hospitals. High-risk patients were hospitalized to proactively prevent complications and secondary infections, treat underlying diseases, and provide organ function support according to the patients’ conditions.10
Clinical classification
Physicians classified the disease severity of patients with SARS-CoV-2 infection according to the “Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia” issued by NHC (trial version 7)20or “Clinical Management of Severe Acute Respiratory Infection When Novel Coronavirus (2019-nCoV) Infection Is Suspected” from WHO.21The severity definitions in the Chinese guidance were more widely used in clinical practice in China owing to its simplicity. According to the Chinese guidelines,20,89the clinical classification of COVID-19 patients includes 4 levels of severity: mild, moderate, severe, and critical (). So far, there is no special COVID-19 clinical classification criteria for pregnant women, which may be due to the fact that clinical characteristics of COVID-19–infected pregnant women are generally similar to those of nonpregnant women with COVID-19 infection.22
Nonpharmacologic Treatment—Supportive and Symptomatic Care
General treatment
Symptomatic and supportive treatment is essential and the main treatment for COVID-19.20General supportive measures for SARS-CoV-2–infected patients include bed rest, adequate nutrition, water and electrolyte balance, and intensively monitoring vital signs (blood pressure, respiratory rate, heart rate, and oxygen saturation). Laboratory markers of disease progression and clinical outcomes, such asd-dimer, C-reactive protein, procalcitonin, neutrophil count, lymphocyte count, and inflammatory cytokines, were monitored.1,23,24,25
Symptomatic therapy
Fever is the most common symptom of SARS-CoV-2 infection.1,23,24,25Continuous high fever may cause metabolic disorders and system dysfunction. Therefore, WHO guidance advocates the use of antipyretics and cooling measures.21Multiple studies have shown that COVID-19 patients have underlying diseases, including hypertension and diabetes, leading to higher mortality.1,26For these patients, blood pressure and blood sugar must be monitored, and if abnormal, it should be promptly treated. The onset of severe disease leading to liver, kidney, or cardiac injury should be anticipated and treated appropriately.
Respiratory support
Studies have shown that in severe cases, 66.7% of patients (124/186) received oxygen therapy, 44.7% (63/141) received high-flow nasal cannula (HFNC), 39.4% (108/274) received noninvasive mechanical ventilation, and 24.1% (66/274) required invasive mechanical ventilation. Only 6.2% (17/274) patients received extracorporeal membrane oxygenation (ECMO) ().1,23,24,27,28
In a study of 1099 patients in China, 41.3% of confirmed COVID-19 patients (454/1099) and 35.7% of nonsevere patients (331/926) received oxygen therapy.1WHO guidelines recommend that supplemental oxygen therapy be given to patients with severe acute respiratory infection (SARI), respiratory distress, hypoxemia, or shock.21However, there are no restrictions on which patients can receive supplemental oxygen therapy in the Chinese guidelines,20which may have resulted in the overuse of oxygen therapy. In general, patients with blood oxygen saturation (SPO2) ≥ 93% do not require supplemental oxygen, and hyperoxemia may induce further respiratory injury and even higher mortality.29The indications for supplemental oxygen should be carefully applied in patients with COVID-19.21
High-flow nasal cannula oxygen therapy and noninvasive mechanical ventilation
HFNC and noninvasive positive-pressure ventilation (NIPPV) was used as step-up therapy in patients who failed to improve on supplemental oxygen.20A Chinese expert consensus released in 2019 recommends that physicians can consider providing HFNC to mild or moderately ill patients (arterial oxygen partial pressure [PaO2]/fractional inspired oxygen [FiO2] 100-300 mm Hg). The clinical application of NIPPV on hypoxemic respiratory failure caused by severe pneumonia has long been controversial.30,31WHO21and Chinese20guidelines both recommend using HFNC and NIPPV with extreme care and closely monitoring the condition of patients treated with HFNC or NIPPV for deterioration. Failure of a short trial (1 hour) of NIPPV may require proceeding to invasive mechanical ventilation.
Invasive mechanical ventilation
According to Guan et al.,114.5% of severe patients (25/173) received invasive mechanical ventilation and 32.4% (56/173) received noninvasive mechanical ventilation. If standard oxygen therapy fails, Chinese guidelines recommend a trial of HFNC or noninvasive ventilation, but WHO guidelines recommend escalating to invasive mechanical ventilation.21It is generally accepted that timely use of invasive mechanical ventilation is an important component of the treatment of severe respiratory failure and acute respiratory distress syndrome (ARDS).32Based on a Chinese expert consensus,33it is recommended that invasive mechanical ventilation be the first choice for moderate or severe ARDS patients (PaO2/FiO2≤ 150 mm Hg)34or for patients after failure of HFNC and NIPPV. Lung-protective ventilation strategy, ie, low tidal volumes (6-8 mL/kg of predicted body weight) and low inspiratory pressures (platform pressure < 30 cm H2O) should be incorporated to prevent ventilator-related lung injury.32
Extracorporeal membrane oxygenation
ECMO is a form of extracorporeal life support for very ill patients that circulates blood flow through an artificial lung for gas exchange and then back into the bloodstream. It provides a period of pulmonary rest, artificially supports critical ill patents while their heart or lungs recover, and plays a role in the care of heart or lung transplant patients. ECMO has rarely been used in China owing to limited resources.1,23Moreover, there are no published studies about the efficacy and safety of ECMO with severely ill COVID-19 patients. Previously, the experience of using ECMO in Middle East Respiratory Syndrome (MERS) and influenza has been controversial.35
Pharmacologic agents
We summarize the treatment of 327 pooled cases of severe cases with COVID-19 in.1,23,24,27,28In severe cases, 87.3% of patients (254/291) received antibiotic treatment, 61.5% (201/327) received antiviral treatment, 53.8% (176/327) received corticosteroid treatment, and 41.3% (115/278) received intravenous immunoglobulin. Only 8.4% of patients (23/274) received continuous renal replacement therapy. The mortality rate of the 327 pooled severe cases was 25.4% (83/327) ().
Despite the use of various medications, the consensus of Chinese experts is that neuraminidase inhibitors (oseltamivir, peramivir, zanamivir, etc) and ganciclovir are not generally recommended. Routine prophylactic antibiotics, especially combined wide-spectrum antibiotics, are also not typically recommended.33However, because of the widespread use of the medications, as indicated in the previous paragraph, ongoing trials are being conducted to clarify which medications may or may not be helpful in treating COVID-19.
Antiviral treatment
At present, there is no evidence to support the effectiveness of antiviral drugs for COVID-19, although these are commonly used in the treatment of COVID-19 in China. The guidelines of the NHC recommend interferon-α2b inhalation, lopinavir/ritonavir, ribavirin, chloroquine, and arbidol as antiviral therapy and does not recommend using more than 2 antiviral drugs at the same time ().10,36
Xu et al. reported that of 55 of 62 confirmed COVID-19 patients in Zhejiang province received antiviral treatment. Twenty-one patients (34%) received lopinavir/ritonavir and interferon-α2b inhalation, 17 (28%) received arbidol and lopinavir/ritonavir, and 8 (13%) received interferon-α2b by inhalation.37Chen et al. reported that 75 of 99 confirmed patients in Wuhan received antiviral treatment, including oseltamivir, ganciclovir, and lopinavir/ritonavir.38The duration of antiviral treatment was 3-14 days.38However, the results of a clinical trial of lopinavir/ritonavir in China showed no clear benefit beyond standard care in hospitalized adult patients with severe COVID-19.39Remdesivir may have the greatest potential for the successful treatment of SARS-CoV-2, but efficacy and safety in COVID-19 need further evaluation.40,41Remdesivir has been studied in clinical trials to treat COVID-19 in China.
Favipiravir was approved for treatment of influenza on February 15, 2020, in China and is being studied in COVID-19 clinical trials. The preliminary results indicate that favipiravir has significantly more potent antiviral action and fewer adverse effects than lopinavir/ritonavir (P< 0.001).42One of the clinical trials was conducted in Shenzhen, and the results showed that the median time to viral clearance was 4 days in the favipiravir treatment group compared with 11 days in the lopinavir/ritonavir treatment group (P< 0.001). In terms of chest imaging, the improvement rates of the favipiravir treatment group and the lopinavir/ritonavir treatment group were 91.4% and 62.2%, respectively. No significant adverse reactions were noted in the favipiravir treatment group, and there were significantly fewer adverse effects than in the lopinavir/ritonavir group.43
In earlyin vitrostudies, chloroquine and hydroxychloroquine were found to inhibit SARS-CoV-2 infection efficiently,40,44and several clinical trials have been quickly conducted in China to evaluate the efficacy and safety of chloroquine and hydroxychloroquine. Gao et al. summarized that compared with the control treatment, chloroquine phosphate was effective in inhibiting the exacerbation of pneumonia, improving lung imaging findings, promoting a virus-negative conversion, and shortening the disease course.45The expert consensus on chloroquine phosphate recommends 500 mg twice daily for 10 days for patients diagnosed with COVID-19. Adverse effects of chloroquine and hydroxychloroquine must be carefully monitored.46
Zhou et al. proposed that hydroxychloroquine could serve as a better therapeutic agent than chloroquine, owing to reduced toxicity, fewer side-effects, lower cost, and relative safety in pregnancy.47Yao et al. used physiologically based pharmacokinetics models and found that hydroxychloroquine was more potent than chloroquine at inhibiting SARS-CoV-2in vitro. They recommended 400 mg hydroxychloroquine sulfate twice daily for 1 day, followed by 200 mg twice daily for 4 days to treat SARS-CoV-2 infection.48The efficacy and safety data of chloroquine or hydroxychloroquine from high-quality clinical trials are urgently needed.
Glucocorticoid therapy
Russell et al. recommended that corticosteroids should not be used in SARS-CoV-2–induced lung injury or shock.49However, Shang et al. suggested using short courses (≤ 7 days) of corticosteroids at low to moderate dose (≤ 0.5-1 mg/kg/d methylprednisolone or equivalent) for critically ill patients with COVID-19.50According to a Chinese experts’ consensus statement, the following criteria should be met before using corticosteroids in patients with COVID-19: 1) adults (≥ 18 years old), 2) laboratory-confirmed cases, 3) symptoms occurring within 10 days, 4) radiographic imaging consistent with COVID-19 pneumonia and progressing rapidly, and 5) SPO2≤ 93%, shortness of breath (respiratory rate ≥ 30/min), or oxygenation index ≤ 300 mm Hg at rest and with no oxygen therapy.51
A retrospective study found that low- to moderate-dose glucocorticoid therapy had no effect on the time to viral clearance in patients with COVID-19. Glucocorticoids are not recommended in mild cases, because there was no improvement in the rate of radiographic recovery.52However, a single center in Wuhan shared that early low-dose and short-term corticosteroids (1-2 mg/kg/d for 5-7 days) was associated with a faster improvement of clinical symptoms and absorption of focal lung lesions in severe cases of COVID-19.53Another study analyzed 15 critical cases and suggested that a low dose and short duration of corticosteroids (methylprednisolone < 1 mg/kg, < 7 days) may be beneficial for critically ill patients with COVID-19.54Zhou et al. analyzed 10 patients with COVID-19 who received corticosteroids and found that short-term moderate-dose corticosteroids (160 mg/d) plus immunoglobulin (20 g/d) were effective for reversing the continued deterioration of COVID-19 patients who failed to respond to the low-dose therapy (40-80 mg/d corticosteroids and 10 g/d immunoglobulin).55An open-label randomized controlled trial has been conducted to investigate the effectiveness of glucocorticoid therapy in patients with severe COVID-19.56
Convalescent plasma
Previous studies in MERS suggested that convalescent plasma may be effective.57Mair-Jenkins et al. further suggested that convalescent plasma may reduce mortality in patients with SARI of viral etiology.58The NHC (trial version 2) includes convalescent plasma as a potential treatment in severe cases, critical cases, and cases of rapidly worsening clinical status.59Donors and recipients should be carefully selected, and serum-specific IgG antibodies for SARS-CoV-2 should be tested to guarantee the quality of convalescent plasma. Critical patients who received convalescent plasma showed significant improvement in clinical symptoms and laboratory findings.60Multiple clinical trials have been registered in the Chinese Clinical Trial Registry to study the safety and efficacy of convalescent plasma treatment in COVID-19 patients.61
Intravenous immunoglobulin
In Guan et al.’s study1of 173 severe COVID-19 cases, 58 patients (33.4%) received intravenous immunoglobulin treatment (IVIG). IVIG was considered as a potential therapy for immunologic injury in COVID-19 in clinical practice because of its antiinflammatory action in treating conditions such as hemophagocytic lymphohistiocytosis and cytokine storm. Similarly, two reviews recommended IVIG based on mechanisms of SARS-CoV-2–mediated inflammatory responses.62,63However, further investigation and more clinical studies are needed.
Biologic modulators
The results of laboratory findings of COVID-19 patients in China showed an increase in plasma inflammatory cytokine levels, especially interleukin (IL) 6.23,38Therefore, the anti-IL6 monoclonal antibody tocilizumab was considered as a potential drug for some COVID-19 cases with extensive lung lesions and elevated IL-6 levels.20Three clinical trials have been initiated and registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn/index.aspx), but no results or data have been released at this time.
Other pharmaceutical measures
Traditional Chinese medicine treatment
The potentially beneficial role of traditional Chinese medicine is described in the guidelines of the NHC, and some Chinese patent medicines (CPMs) have been used to treat COVID-19.10However, the experience with most of these treatments is anecdotal. Gu et al. reviewed 93 Chinese medicine prescriptions and 157 forms of constituent medicines for COVID-19 treatment and found that they may be effective in reducing fever, mucous production, cough, and asthma symptoms.64Yan et al. discovered that 10 antiviral components from CPMs can directly bind to both host cell target angiotensin-converting enzyme (ACE) 2 receptor and viral target main protease, suggesting their potential for COVID-19 treatment.65
Other treatment measures
According to the guidelines of the NHC,10vasoactive drugs may be required to supplement fluid resuscitation and to improve microcirculation. Continuous renal replacement therapy has been used in acute kidney injury.66Apheresis methods, including plasma exchange, adsorption, perfusion, and filtration, were used in critical cases with severe inflammatory reactions.67
In addition to the treatment of the patients’ physical condition, psychologic support was provided to address the anxiety and fear that occurs in patients who are suffering from COVID-19 as well as in their loved ones and health workers. During the quarantine, mental health intervention provided online was especially recommended. According to Hu et al., the use of hypnotics can significantly improve clinical outcomes of COVID-19 patients. These improvements may be attributable to decreased oxygen consumption resulting from reduced periods of anxiety and improved immunity from experiencing high-quality sleep.68
Vaccine development
The development of a vaccine for SARS-CoV-2 has been accelerated as a priority project. On January 23, the Coalition for Epidemic Preparedness Innovations (CEPI) announced a $12.5 million grant to fund vaccine development by Queensland University in Australia, the National Institutes of Health in the United States, and the pharmaceutical companies Inovio and Moderna. On January 24, a virus strain of SARS-CoV-2 was successfully isolated from patients’ samples in China to provide the basis for vaccine development.69On February 3, CEPI and GlaxoSmithKline announced collaboration to strengthen the global effort to develop a vaccine. Vaccine safety is a priority. Currently, strategies for SARS-CoV-2 vaccine development include recombinant proteins, DNA vaccines, mRNA vaccines, traditional live vaccines, and recombinant adenovirus vaccines. These are in various phases of development, ranging from nonhuman animal studies to clinical trials.3,70,71On March 13, mRNA-1273 vaccine clinical trials began in the United States.70On March 16, recombination vaccines for SARS-CoV-2 entered into phase I clinical trials.71Although these are significant strides, the prospects for a commercially available vaccine are at least 6 months away, and probably much longer.
Respiratory nursing support
Studies have shown that prone positioning was associated with improved oxygenation and a decrease in CO2retention, leading to reduced mortality, in patients with influenza, MERS, or ARDS.72,73As a result, a Chinese expert consensus recommends that patients be prone for ≥ 12 hours a day when PaO2/FiO2< 150 mm Hg.74Before placing the patient in prone position, oral secretions should be suctioned regularly to help keep the artificial airway open. In addition, COVID-19 patients suffer from copious proteinaceous exudates in their lungs and airways.75,76Aspiration of sputum can help to keep the airway intact and potentially improve sample collection and the accuracy of SARS-CoV-2 nucleic acid detection.77The patient’s position should be assessed and changed regularly to avoid decubitus skin injury. Elevating the head of the bed 30-45 degrees,78suctioning out oropharyngeal secretions, and monitoring the pressure of a rebreathing bag can help to prevent ventilator-associated pneumonia.
Cardiac complications
Cardiac abnormalities were found to be present in a high proportion of patients who died of COVID-19 and may be more associated with severe disease. Based on current studies, COVID-19 patients with cardiovascular diseases are more likely to develop into critical cases and have higher mortality.1,23,24,38,79Clinicians should be alert to the manifestations of heart injury by closely monitoring patients’ vital signs (blood pressure and heart rate), laboratory tests including creatine kinase, lactate dehydrogenase, high-sensitivity cardiac Troponin I, creatine kinase MB, B-type natriuretic peptide (BNP) and N-terminal proBNP, and electrocardiography. Antiviral drugs, such as ribavirin and lopinavir/ritonavir, have been widely used in cardiac patients, although there no well-designed trials to support that. The hypothesis that COVID-19 directly causes myocardial injury may support the usage of antiviral drugs, but the side-effects of these drugs on the cardiovascular system, such as sudden cardiac death and bradycardia, should be carefully considered.80
Owing to the fact that cardiac insufficiency can lead to a coagulation disorder and that severe COVID-19 patients were reported to have increased level ofd-dimer, low-molecular-weight heparin was recommended to treat COVID-19 patients in the early phase of disease.62As with SARS-CoV, ACE2 has been identified as the receptor for SARS-CoV-2 to enter cells.81The use of ACE inhibitors (ACEIs) may not be of any benefit, because they does not bind to the ACE2 receptor. This also means that discontinuing ACEIs in patients with COVID-19 is not necessary. Regarding angiotensin receptor blockers (ARBs), there is evidence that ARBs could lead to increased expression of ACE2, thus worsening disease, but this remains controversial. There is no current recommendation to discontinue ARBs during treatment of COVID-19 in China. Monteil et al. found that SARS-CoV-2 infection in engineered human blood vessel organoids and human kidney organoids could be inhibited by human recombinant soluble ACE2.82Further investigations are required to shed light on the role of ACE2 in cardiac manifestations of COVID-19.
Regarding acute myocardial infarction in COVID-19 patients, Peking Union Medical College Hospital and Zhongnan Hospital of Wuhan University provided the following experience.83,84For acute ST-segment-elevation myocardial infarction (STEMI) in patients with confirmed COVID-19, strict isolation should start immediately and thrombolytic contraindications should be evaluated. Patients with thrombolytic contraindications should be transferred to the local infectious disease specialist hospitals immediately for further treatment. Patients without thrombolytic contraindications should first be started on intravenous thrombolysis and then transferred to the local infectious disease specialist hospitals for further treatment.83Considering the increased risk of exposure due to the lack of negative-pressure catheterization chambers and shortages of PPE, and the greater difficulty of finely manipulating the guidewires under level 3 protection, fibrinolysis is preferred when both percutaneous coronary intervention (PCI) and fibrinolysis are available. Once PCI is required, all medical workers should be under level 3 protection and thorough environmental disinfection must be given after each PCI.84
Effectiveness and Importance of Public Health Interventions
The WHO-China joint mission report reported that China’s vigorous public health measures to prevent the COVID-19 are the most “ambitious, agile, and aggressive disease containment effort in history.”85The drastic measures taken are listed in. If not for a national strategy that incorporated all of these measures simultaneously, it was estimated there would have been 744,000 COVID-19 cases outside Wuhan on day 50 of the epidemic, compared with the actual number of fewer than 20,000.86
As of April 13, 2020, COVID-19 has spread to 6 continents and 212 countries and regions. We compare the epidemiologic characteristics among China, Italy, South Korea, and the United States in. The data from China show that the daily number of infected patients has been less than 50 for the past week. However, there are a steady daily number of imported cases. Similarly, in South Korea, the strategy that worked also included early testing, tracking, and isolation. Unfortunately, lessons learned in China have not been universally adopted, and the numbers of cases in many countries are rapidly increasing.
