Epidemic Prevention in Wuhan: How to Make Good Use of Available Resources?
Originally published in Sanlian Lifeweek(三联生活周刊) on Jan. 28th, 2020
By Jan 28th, according to the National Health Commission, nearly 6,000 medical staff have been dispatched to Hubei province to support the prevention and treatment of the outbreak there. Nationwide medical personnel and resource support is gradually changing the situation of Wuhan's response. Wuhan is also continuously summarizing and adjusting its strategies to the outbreak. As the number of imported cases increases everywhere, the practical experiences and lessons learned in Wuhan's epidemic prevention may serve as a reference for other regions.
In the opinion of Miao Xiaohui, a clinical consultant on public health from Shanghai, it is of course important for Wuhan to build new hospitals and to enlarge the area for medical treatment. But it is even more important to ensure a good allocation of available resources and a prompt response.
Journalists | Wang, Haiyan (王海燕); Wan, Shan (王珊)
Translation | Chengji Translation Team
The Challenge for Hospitals at Every Level
On Jan 24th, at noon, the COVID-19 Prevention and Control Headquarter in Wuhan announced the implementation of the graded treatment policy for the novel pneumonia. Patients with a fever will be first sent to the community health care center for screening and categorization, and then sent to higher-level hospitals. But for some patients, the problem becomes even more difficult.
Xu Cai lives in the Jun'an Community in the street of Tazi Lake, which is located in Jian'an District, Wuhan City. Her parents-in-law and her husband started to have an elevated temperature on Jan 10th and Jan 15th, respectively. Since then they have been staying in a hospital, taking infusions and waiting for CT examinations, which showed that all of them had lung infections. Possibilities of Influenza A, Influenza B, and ordinary pneumonia had been ruled out. But they were not diagnosed as patients of COVID-19. Since the lockdown of Wuhan on Jan 23rd, public transportation in the city also stopped running. Xu Cai's family does not own a car, so the patients began to walk to the hospital and then back home. Xu Cai's parents-in-law needed 2 hours to finish the distance of 2 kilometers because they already had some slight breathing difficulties.
On the afternoon of Jan. 25th, Xu Cai's husband started to have a fever. Following the graded treatment policy, Xu Cai called her community center but the line was busy all day. Also, there was no one answering the phone at the community hospital. It was not until 10 pm that the community center contacted Xu Cai. They advised her to overcome it by herself. But at that time Xu Cai's husband had long been having a high fever, and the antipyretics did not help either.
Xu could only leapfrog her community and call the ambulance directly. At 3 a.m., on Chinese New Year's Day, Xu Cai finally found an ambulance to pick her husband up after calling the emergency number for more than 2 hours together with her friends. Her husband was first sent to Wuhan Tianyou Hospital, which was a newly designated hospital for the outbreak. But after the ambulance arrived there, they were informed that the hospital was still preparing the beds and could not take any patients. The ambulance could only take him to the No. 11 Hospital, which was just the designated hospital where Xu's husband had the infusions. Later the CT results of his lung showed that his infection was getting worse.
But the No. 11 Hospital could not arrange hospitalizations for him. First, there was no vacant bed. Second, according to the new graded treatment policy, hospitalization could only be uniformly arranged after receiving the report from the community and concrete diagnosis of the patient. Xu Cai and her friends networked in many ways, but they got similar feedback from several hospitals. Xu Cai could only urge the community center again and again. But the only feedback the community could give was that they already reported, but had no idea when a response would come.
Photo by Yuan Zheng.
On the morning of Jan 26th -- namely, two days after the graded treatment policy was announced, our reporters randomly dialed 10 community centers in multiple districts. Half of them were unavailable. Two of them could arrange transportations and report the case to hospitals. Another two said they were in charge of reporting the graded treatment information, but could not provide vehicles. Our reporters also called 10 community hospitals and neighborhood committees. Three of them answered the phone. 2 of them said they got vehicles and can finish the procedures of graded treatment. The other one said they themselves were quite confused about the situation.
There was already a set of graded treatment procedures before this community graded treatment. In the old version, patients with a fever admitted to general hospitals should be transferred to designated hospitals, where diagnosed patients with severe conditions would be taken to Jinyintan Hospital. It was also rather difficult to get through each of these steps here. A doctor from a top-level hospital told us that "After the announcement of designating hospitals for the outbreak, the designated hospital in my district set up a criterion, namely for patients to be transferred they must be diagnosed first. The chance of having a diagnosis with the test kit is quite limited. According to that criterion, many of our patients had no choice but to stay here for a while. But we contributed some doctors to help other hospitals, while we also took in some patients from other departments of the designated hospital. Now we can only strive to ensure the normal operation of the hospital. "
Designated hospitals also had their difficulties. Li Tong, a nurse at a designated hospital, told us that the respiratory department of her hospital began to fill up in late December. In early January this year, the hospital set aside several floors of wards for the treatment of fever patients. On the evening of January 21, the hospital was informed that it became a designated hospital for the COVID-19. More patients immediately swarmed in, forming a long line outside the gate, which was hundreds of meters long and was difficult for the hospital to digest.
Jinyintan Hospital, which is currently the end hospital of the procedure, requires concrete diagnosis and transfer procedures for patients to be admitted. Due to this strict requirement, the number of patients is relatively under control. The problem there was a severe shortage of medical personnel. Lin Bai works as a nurse at Jinyintan Hospital. She and her colleagues were from various hospitals in Wuhan City and volunteered to join the nursing work. There are nearly 40 patients on every floor. In the daytime, there are only 8 nurses and only 3 at night. They are responsible for everything, from infusion to the dining, drinking, defecation, and hygiene of the patients. The nurses in the critical ward, in addition to the full-body protective clothing, also carries around a ventilation system weighing up to 5 kilograms. They can only stay there for about three hours at a time, or there will be a risk of shock.
There's no place for medical staff to have a rest in Jinyintan Hospital. Medical staff who have close contact with severely ill patients every day, could only go back home after work. A complete quarantine could not be ensured. In order to increase their immunity, Lin Bai and her colleagues take traditional Chinese medicine and thymosin daily. Thymosin is a medicine that mediates the immune system with unclear mechanisms. Because Jinyintan Hospital has a priority for supplies, the protective equipment for Lin Bai and her colleagues is sufficient so far.
Became a Designated Hospital in a Sudden
Hospitals at all levels were faced with a huge shortage of supplies due to a sharp increase in the number of patients as well as a lack of preparation. Li Tong remembers that their hospital was suddenly named as a designated hospital on January 22nd. Li Tong was not in the Respiratory Department but they had already admitted several patients who were highly suspected cases of COVID-19. At that time, all the medical staff in Li Tong's department had no protection except ordinary facial masks. They were all in an unprotected situation. By Jan 17th, there had been several suspected cases among the medical staff. They strongly applied for protective equipment but got no feedback. It took a few days or so before the nurses' cloth caps were finally replaced with disposable caps, around Jan 20th.
The news that their hospital became a designated hospital, hit Li Tong and the patients almost at the same time. This means that as endless feverish patients swarmed to the gate, the hospital was still installing isolation doors and remodeling wardrobes in a hurry. They only had a buffer of two days. Within the two days, Li Tong needed to discharge patients from the hospital or transfer them to another hospital. She only managed to find time for the only training available and learned to put on and take off the protective suit. Finally, the protective equipment arrived on the evening of Jan 23rd.
The hurried response has brought the medical staff risks. Li Tong's hospital provided a blood test for all the medical staff on Jan 23rd. It turned out that several people needed to be quarantined at home, merely in Li Tong's department. In the whole hospital, dozens of medical staff needed to stay in the hospital for treatments, which made the lack of personnel even worse. When we interviewed them, one of Li Tong's colleagues had been working continuously for 18 hours.
Wu Hong is the manager of a 'third level A' hospital in Wuhan. He said that after the lockdown of the city, the government did not make any arrangements for medical staff. Wu Hong lives far away from his hospital and usually takes a bus to go to work. On the first day of the lockdown, he spent more than one hour merely getting into a taxi. Among his colleagues, some people who do not live that far away could only ride a bicycle to work. The hospital did not even have transportations for protective equipment and basic living materials. It was after many hospitals appealed that a specific transportation route was opened.
Similar to most hospitals, Wu Hong's hospital was in an acute lack of masks. He made an example that if a hospital has 500 staff, who need 1 mask per day per person, then 5000 masks would be run out within only 10 days." But how can we only use 1 mask per day per person? How could we make the doctors use the same mask for multiple surgeries in one day?" In order to minimize the consumption of masks, the hospital could only try their best to arrange shifts for the medical staff and to reduce the working durations of ordinary departments. However, this will add to the scarcity of medical resources in return.
The lack of protective equipment was largely due to the soar of consumption and the closure of factories during the Chinese New Year. Hospitals rarely put a great amount of protective equipment in stock during normal times. However, as far as Wu Hong knew, the city government had its own stock. The reason why they did not distribute their equipment was that they wanted to ensure the need for the newly built "Xiaotangshan Hospital" in the Wuhan version. At present, all the major hospitals are trying to use their own connections to raise donations of protective equipment from society. Wu Hong said that "As for raising donations, the government should have shared their stock first. If it is still not enough, we then raise from society. Now it is all the other way around."
On the evening of Jan 24th, the third press conference for the outbreak in Hubei was held, on which Hubei Medical Products Administration announced that they will "visit factories and business which produces or sells masks, thermometers, and antiviral drugs, in order to ensure the quality and the supplies of drugs and medical devices which are needed for containing the outbreak."
Xiantao City, which is only 100 kilometers from Wuhan, is a nationwide known production base for disposable cloth masks. Wang Ming, the manager of a mask factory in Xiantao City, told us that there is no need to stock masks. He mentioned that ordinary masks and medical masks share the same procedures of production. They can be produced quite quickly as long as the filter material is available. Wang Ming's factory mainly exported masks abroad, and their highest production could reach up to 30 million per month. At present, they have a stock of raw materials to produce several hundred thousand medical masks, or 7 million ordinary masks (which can block saliva).
The factory stopped running for the holiday one week before the Chinese New Year. Prior to the holiday, he and other surrounding mask factories received orders from Hong Kong and Macau. One of the customers even made an individual order of 2 million masks. Wang Ming's factory received its latest expedited order in early January. After the outbreak, Wang Ming and his peer factories have been constantly watching to see if it is possible to continue the production. They asked the National Health Commission and confirmed that if medical companies are buying their products, they can get a license for production. But Wang Ming was more concerned about the problem of raw materials. Their stock could only support the production for a few days. The raw materials are not classified as medical protective equipment and cannot be issued a license. It is still unknown how to import raw materials from other places.
Miao Xiaohui is a clinical consultant on public health from Shanghai who fully participated in SARS prevention in Shanghai and Beijing Xiaotangshan Hospital in 2003. He was very confused when he noticed that Wuhan was planning to build two temporary hospitals. He told us that after 2003, big cities all over the country have built specific hospitals in response to potential public health emergencies. Taking the existing lung hospital into account, there are at least two hospitals that can take patients of COVID-19. Especially, the newly built epidemic hospital with governmental funding after 2003 is absolutely able to and must play the role of Xiaotangshan Hospital during the SARS outbreak.
In his points of view, it is important for Wuhan to build new hospitals and to enlarge the area for medical treatment of course. But it is even more important to ensure a good allocation of available resources and a prompt response. As a matter of fact, some medical staff from Jinyintan Hospital told us that they had some vacant wards until Jan 25th, mainly because of a lack of medical personnel.
Avoid Panic Visits to Hospitals
Looking back on the timeline, Zhong Nanshan had an interview with CCTV on Jan 20th; Hubei Province started a Level 2 Response to Public Health Emergency, which was upgraded to Level 1 two days later and was followed by many other provinces. Within a week, the entire Chinese population had undergone a dramatic emotional change. Wuhan people, who live "in the center of a hurricane", may have an even stronger feeling.
Gao Lanlan lives in Qingshan District, Wuhan City. She suspected that her father had a fever only because of the panic. She was one of the small percentages of people who knew about the outbreak from friends in the medical system and became highly alarmed since late December. She bought masks a long time ago and warned her friends of the disease. However, her father was always very calm. Till Jan 23rd when Wuhan went into the lockdown, he still reminded Gao Lanlan 'not to create or spread rumors' when Gao discussed the outbreak with her friends.
The abrupt change of his mood occurred on the morning of Jan 24th, when the husband of Gao Lanlan's friends was quarantined and Gao was notified. One day ago, an old man from Gao's neighbor's family died. Although it was proved to be a flu, people were all suspicious that it could be the COVID-19. What's more, after watching videos in the WeChat groups that the medical staff was experiencing an emotional breakdown, the blood pressure of Gao's father soared. After taking some pills, it went back to normal, but he was always feeling sick and had some palpitations.
He began to have a fever on Jan 25th, with his body temperature ranging from 37.3C and 37.4C. Gao Lanlan's first response was to call the community and wanted to go through the graded treatment procedures. However, she was told that community workers were not doctors and they didn't have any protections for themselves, so they could not help. They advised her to take her father to the designated hospital in Qingshan District, namely the No. 9 Hospital, or she can directly call an ambulance. They also emphasized that "He can surely be admitted into the hospital if you call an ambulance."
Gao Lanlan was really hesitant. She would like to quarantine her father at home, but all the pharmacies nearby had been closed. If she decided to go to the hospital, she knew that the designated No. 9 Hospitals had been quite crowded with patients. At last, a friend of hers, who was a civil servant, told her that s/he went to clear beds for a large Level 3 hospital located near Gao's home, so the friend advised her to go there to have a try. After taking her father there, Gao Lanlan realized only then that the fever clinic was always open there. Except for ambulances running in and out, the whole hospital looked quite empty. There were only 3 patients in front of her father.
Photo by Yuan Zheng.
Gao's father was examined for Influenza A and Influenza B at the hospital. He also had a CT imaging taken of his lungs. Finally, the doctor diagnosed that he did not have any problems except for a little bronchitis. He didn't need to take any medications for the moment. On the morning of Jan 26th, his body temperature became normal. However, no matter how Gao Lanlan comforted him, he was always in a panic, thinking that he was in the incubation period of COVID. There might be a lot of people who went to see doctors because of panic just like Gao Lanlan's father. When they were at the hospital, a woman in front of them had already come to the hospital 3 times that week. The doctor repeatedly asked her not to come again. The doctor also said if she were to take more CT examinations, she would get sick although she was healthy then.
This is also why it is crucial to build a solid base at the community level in response to such a complicated outbreak, besides saving patients in hospitals, according to Miao Xiaohui. But 'building a base at the community level' does not mean letting the community decide on the screening and the distribution of patients. It is difficult to operate, and will not gain trust from the people. Instead, community workers should be well equipped with protective facilities, and visit the neighborhood one by one, helping the government on epidemic survey, psychological support and knowledge propagation. "They need to work on some detailed and professional tasks, which challenges the intelligence of the local government", said Miao Xiaohui.
As far as we learned, a part of neighborhood committees and community hospitals still had not sent out any notices by Jan 26th, let alone receiving medical training and preparing protective equipment. This means that community centers and community hospitals, as the most basic and the most important step in the graded treatment policy for COVID, can only actually do a limited amount of work, apart from waiting for the patients and reporting them to higher-order hospitals.
As to now, public transportation in Wuhan has been basically suspended. Wu Hong estimates that with these measures, the increase of infected patients will drop very soon. But since the incubation period of the virus can be as long as 2 weeks, we could only consider whether to remove some measures after a watching period of 2 weeks.
As a young person sensitive to online information, Gao Lanlan was quite worried in early January. But most people around could not understand her at that time. Jan 23rd, the day that Wuhan was locked down, at 3 am, her good friend called her to ask if she were to buy flights and flee away from Wuhan together. Looking at her kid beside her, thinking of her father next door, and remembering her happy life in Wuhan for over 30 years, she finally gave up the flight, on which there were still some seats available.
Different from the silence before the storm one week ago, she is now exposed to a huge amount of information every day, which includes negative news about the outbreak and the shortage of supplies, but also positive stories that people stay strong together and help each other. Every piece of the news reveals some truth to her. She became calm instead and also persuaded her father to trust in the power of the collective.
(Great thanks to Pianpian's support at Wuhan, Wu Hong, Li Tong, Gao Lanlan and Lin Bai are aliases. Interns Yang Yue and Zhang Jiaqian also contributed to this report.)
Further progress: On the evening of Jan 26th, with the access provided by the community, a bed in hospital was finally allocated for Xu Cai's husband. The bed slot happened to come from the Level 3 hospital near Gao Lanlan's home. On Jan 28th, Xu Cai's parents-in-law were also admitted to the hospital after a long waiting period.
During the most difficult time, some friends sent her husband to the hospital and then took him back, some netizens she did not know dropped protective facilities and groceries at her door. A lot of neighbors also helped her together to find access to the hospital. When her parents-in-law were not accepted by the hospital, someone suggested that she takes them to the community center and just stays there. But she dismissed this suggestion. No matter how hard it was, she didn't hope that her family becomes a source of transmission.