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China's aggressive measures have slowed the coronavirus. They may not work in other countries – Science Magazine

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Other countries can take lessons from China’s handling of the COVID-19 epidemic, the World Health Organization’s Bruce Aylward told reporters in Beijing on 24 January.

Xinhua/Xing Guangli via Getty Images

Chinese hospitals overflowing with COVID-19 patients a few weeks ago now have empty beds. Trials of experimental drugs are having difficulty enrolling enough eligible patients. And the number of new cases reported each day has plummeted the past few weeks.

These are some of the startling observations in a report released on 28 February from a mission organized by the World Health Organization (WHO) and the Chinese government that allowed 13 foreigners to join 12 Chinese scientists on a tour of five cities in China to study the state of the COVID-19 epidemic and the effectiveness of the country’s response. The findings surprised several of the visiting scientists. “I thought there was no way those numbers could be real,” says epidemiologist Tim Eckmanns of the Robert Koch Institute, who was part of the mission.

But the report is unequivocal. “China’s bold approach to contain the rapid spread of this new respiratory pathogen has changed the course of a rapidly escalating and deadly epidemic,” it says. “This decline in COVID-19 cases across China is real.”

The question now is whether the world can take lessons from China’s apparent success—and whether the massive lockdowns and electronic surveillance measures imposed by an authoritarian government would work in other countries. “When you spend 20, 30 years in this business it’s like, ‘Seriously, you’re going to try and change that with those tactics?’” says Bruce Aylward, a Canadian WHO epidemiologist who led the international team and briefed journalists about its findings in Beijing and Geneva last week. “Hundreds of thousands of people in China did not get COVID-19 because of this aggressive response.”

 “This report poses difficult questions for all countries currently considering their response to COVID-19,” says Steven Riley, an epidemiologist at Imperial College London. “The joint mission was highly productive and gave a unique insight into China’s efforts to stem the virus from spread within mainland China and globally,” adds Lawrence Gostin, a global health law scholar at Georgetown University. But Gostin warns against applying the model elsewhere. “I think there are very good reasons for countries to hesitate using these kinds of extreme measures.”

There’s also uncertainty about what the virus, dubbed SARS-CoV-2, will do in China after the country inevitably lifts some of its strictest control measures and restarts its economy. COVID-19 cases may well increase again.

The report comes at a critical time in what many epidemiologists now consider a pandemic. Just this past week, the number of affected countries shot up from 29 to 61. Several countries have discovered that they already have community spread of the virus—as opposed to cases only in travelers from affected areas or people who were in direct contact with them—and the numbers of reported cases are growing exponentially.

The opposite has happened in China. On 10 February, when the advance team of the WHO-China Joint Mission began its work, China reported 2478 new cases. Two weeks later, when the foreign exerts packed their bags, that number had dropped to 409 cases. (Yesterday, China reported only 206 new cases, and the rest of the world combined had almost nine times that number.) The epidemic in China appears to have peaked in late January, according to the report.

Ambitious, agile, and aggressive

The team began in Beijing and then split into two groups that, all told, traveled to Shenzhen, Guangzhou, Chengdu, and the hardest hit city, Wuhan. They visited hospitals, laboratories, companies, wet markets selling live animals, train stations, and local government offices. “Everywhere you went, anyone you spoke to, there was a sense of responsibility and collective action, and there’s war footing to get things done,” Aylward says.

The group also reviewed the massive data set that Chinese scientists have compiled. (The country still accounts for more than 90% of the global total of the 90,000 confirmed cases.) They learned that about 80% of infected people had mild to moderate disease, 13.8% had severe symptoms, and 6.1% had life-threatening episodes of respiratory failure, septic shock, or organ failure. The case fatality rate was highest for people over age 80 (21.9%), and people who had heart disease, diabetes, or hypertension. Fever and dry cough were the most common symptoms. Surprisingly, only 4.8% of infected people had runny noses. Children made up a mere 2.4% of the cases, and almost none was severely ill. For the mild and moderate cases, it took 2 weeks on average to recover.

A critical unknown is how many mild or asymptomatic cases occur. If large numbers of infections are below the radar, that complicates attempts to isolate infectious people and slow spread of the virus. But on the positive side, if the virus causes few, if any, symptoms in many infected people, the current estimated case fatality rate is too high. (The report says that rate varies greatly, from 5.8% in Wuhan, whose health system was overwhelmed, to 0.7% in other regions.)

To get at this question, the report notes that so-called fever clinics in Guangdong province screened approximately 320,000 people for COVID-19 and only found 0.14% of them to be positive. “That was really interesting, because we were hoping and maybe expecting to see a large burden of mild and asymptomatic cases,” says Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. “That piece of data suggests that’s not happening, which would imply that the case fatality risk might be more or less as we currently have.” But Guangdong province was not a heavily affected area, so it is not clear whether the same holds in Hubei province, which was the hardest hit, Rivers cautions.

Much of the report focuses on understanding how China achieved what many public health experts thought was impossible: containing the spread of a widely circulating respiratory virus. “China has rolled out perhaps the most ambitious, agile, and aggressive disease containment effort in history,” the report notes.

The most dramatic—and controversial—measure was the lockdown of Wuhan and nearby cities in Hubei province, which has put at least 50 million people under a mandatory quarantine since 23 January. That has “effectively prevented further exportation of infected individuals to the rest of the country,” the report concludes. In other regions of mainland China, people voluntarily quarantined and were monitored by appointed leaders in neighborhoods.

Chinese authorities also built two dedicated hospitals in Wuhan in just over 1 week. Health care workers from all over China were sent to the outbreak’s center. The government launched an unprecedented effort to trace contacts of confirmed cases. In Wuhan alone, more than 1800 teams of five or more people traced tens of thousands of contacts.

Aggressive “social distancing” measures implemented in the entire country included canceling sporting events and shuttering theaters. Schools extended breaks that began in mid-January for the Lunar New Year. Many businesses closed shop. Anyone who went outdoors had to wear a mask.

Two widely used mobile phone apps, AliPay and WeChat—which in recent years have replaced cash in China—helped enforce the restrictions, because they allow the government to keep track of people’s movements and even stop people with confirmed infections from traveling. “Every person has sort of a traffic light system,” says mission member Gabriel Leung, dean of the Li Ka Shing Faculty of Medicine at the University of Hong Kong. Color codes on mobile phones—in which green, yellow, or red designate a person’s health status—let guards at train stations and other checkpoints know who to let through.

“As a consequence of all of these measures, public life is very reduced,” the report notes. But the measures worked. In the end, infected people rarely spread the virus to anyone but members of their own household, Leung says. Once all the people in an apartment or home were exposed, the virus had nowhere else to go and chains of transmission ended. “That’s how the epidemic truly came under control,” Leung says. In sum, he says, there was a combination of “good old social distancing and quarantining very effectively done because of that on-the-ground machinery at the neighborhood level, facilitated by AI [artificial intelligence] big data.”

Deep commitment to collective action

How feasible these kinds of stringent measures are in other countries is debatable. “China is unique in that it has a political system that can gain public compliance with extreme measures,” Gostin says. “But its use of social control and intrusive surveillance are not a good model for other countries.” The country also has an extraordinary ability to do labor-intensive, large-scale projects quickly, says Jeremy Konyndyk, a senior policy fellow at the Center for Global Development: “No one else in the world really can do what China just did.”

Nor should they, says lawyer Alexandra Phelan, a China specialist at Georgetown’s Center for Global Health Science and Security. “Whether it works is not the only measure of whether something is a good public health control measure,” Phelan says. “There are plenty of things that would work to stop an outbreak that we would consider abhorrent in a just and free society.”

The report does mention some areas where China needs to improve, including the need “to more clearly communicate key data and developments internationally.” But it is mum on the coercive nature of its control measures and the toll they have exacted. “The one thing that’s completely glossed over is the whole human rights dimension,” says Devi Sridhar, an expert on global public health at the University of Edinburgh. Instead, the report praises the “deep commitment of the Chinese people to collective action in the face of this common threat.”

“To me, as somebody who has spent a lot of time in China, it comes across as incredibly naïve—and if not naïve, then willfully blind to some of the approaches being taken,” Phelan says. Singapore and Hong Kong may be better examples to follow, Konyndyk says: “There has been a similar degree of rigor and discipline but applied in a much less draconian manner.”

The report doesn’t mention other downsides of China’s strategy, says Jennifer Nuzzo, an epidemiologist at the Johns Hopkins University Bloomberg School of Public Health, who wonders what impact it had on, say, the treatment of cancer or HIV patients. “I think it’s important when evaluating the impact of these approaches to consider secondary, tertiary consequences,” Nuzzo says.

And even China’s massive efforts may still turn out to have only temporarily slowed the epidemic. “There’s no question they suppressed the outbreak,” says Mike Osterholm, head of the Center for Infectious Disease Research and Policy at the University of Minnesota, Twin Cities. “That’s like suppressing a forest fire, but not putting it out. It’ll come roaring right back.” But that, too, may teach the world new lessons, Riley says. “We now have the opportunity to see how China manages a possible resurgence of COVID-19,” he says.

Aylward stresses that China’s successes so far should give other countries confidence that they can get a jump on COVID-19. “We’re getting new reports daily of new outbreaks in new areas, and people have a sense of, ‘Oh, we can’t do anything,’ and people are arguing is it a pandemic or not,” Aylward says. “Well, sorry. There are really practical things you can do to be ready to be able to respond to this, and that’s where the focus will need to be.”

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Nunavut admits to large tuberculosis outbreak in Pangnirtung months later – The Globe and Mail

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St. Luke’s Mission Hospital, in Pangnirtung. The Nunavut Department of Health said on May 26 that 139 cases of TB have been identified in Pangnirtung in the past 18 months.Pat Kane/The Globe and Mail

Pangnirtung, a small hamlet on Baffin Island, is grappling with the largest tuberculosis outbreak in Nunavut since 2017, according to data the territorial government released on Thursday after refusing for months to reveal the extent of the disease’s spread.

The Nunavut Department of Health said on Thursday that 139 cases of TB have been identified in Pangnirtung in the past 18 months, 31 of which were active, meaning the patients were sick and infectious. The rest were cases of latent or “sleeping” TB, an asymptomatic version of the bacterial infection that isn’t contagious, but that puts patients at risk of developing active TB in the future.

The Globe and Mail travelled to Pangnirtung earlier this month as part of a continuing investigation into health care in Canada’s youngest territory. In interviews, community leaders have expressed frustration at the lack of official information about the TB outbreak, which Michael Patterson, the territory’s chief public-health officer, first declared on Nov. 25 without providing a tally of cases.

The size of the outbreak came as a surprise to Pangnirtung Mayor Eric Lawlor who, along with the rest of the hamlet’s elected council, wasn’t privy to official statistics on the ballooning health problem in his own community.

“The information should have been provided to us regularly to begin with,” Mr. Lawlor said on Thursday. “This is more concerning than COVID, actually. With the numbers being so high, it’s kind of worrisome and bothersome that we haven’t been addressing it more seriously from the government side.”

The Nunavut Department of Health published the figures in a news release a week after receiving a list of questions from The Globe about the ongoing tuberculosis outbreak in Pangnirtung, a community of about 1,600 people an hour’s flight north of Iqaluit, the territorial capital.

“I don’t know why they’re so secretive,” said Madeleine Qumuatuq, Pangnirtung’s community wellness co-ordinator. “You can’t be secretive and then do prevention. I mean, they’ve got to be truthful to us.”

Ms. Qumuatuq was one of several Pangnirtung residents who raised concerns about the pace of the government’s response to the TB outbreak. She pointed out that the health department rented the community hall – one of Pangnirtung’s few public spaces – beginning March 1 for a satellite TB clinic that still isn’t up and running.

“We’re missing out on a lot of age groups that would normally be coming here to play checkers, pool, whatever it might be. And the teenagers hang out here,” she said. “All that is taken away because they’ve rented the space. But they’re not even here yet.”

Danarae Sommerville, a spokesperson for the Nunavut Department of Health, said by e-mail that the delay has been caused by a shortage of skilled workers “required to ensure the Hamlet building has the appropriate wiring and network to set up workstations for staff.” Those workers were waylaid responding to the aftermath of a fire that consumed a government building in another hamlet, she added.

In responses to earlier questions about the outbreak, she pointed out that the Department of Health sent extra nurses and other front-line staff to Pangnirtung to help manage the outbreak – no easy feat during a national nursing shortage exacerbated by the pandemic.

Active tuberculosis infections, which are caused by bacteria that spread through the air and usually lodge in the lungs, can cause fever, weight loss, night sweats, fatigue and a chronic, sometimes bloody cough. Antibiotics can cure active TB and prevent latent cases from turning into serious disease. The infection can be fatal if left untreated.

Tuberculosis is a disease that most Canadians think of as a scourge of the past. But it remains a scourge of the present in Indigenous communities, particularly Inuit communities, where deep-seated poverty, overcrowded housing and limited access to medical care make residents particularly vulnerable.

The federal Liberal government, along with Inuit Tapiriit Kanatami, a national Inuit organization, promised in 2018 to eliminate TB in Inuit communities by 2030.

The most recent data from the Public Health Agency of Canada show there were 72.2 active cases of TB per 100,000 population among Inuit people in 2020, compared with a national case rate of 4.7 per 100,000.

Despite being 15 times higher than the national average, the TB rate among Inuit in 2020 was down significantly, from 188.7 cases per 100,000 in 2019 and from a 10-year annual average of 184.14 per 100,000 from 2010 to 2019. The decline likely reflects cases of TB going undiagnosed in the first year of the pandemic, experts on the disease have said.

Nunavut, which is home to the majority of Inuit in Canada, recorded 34 active cases across the territory in 2020, or 86.40 per 100,000, down from an average of 66 active cases per year territory-wide over the previous four years.

In February, Nunavut’s privacy commissioner ruled in The Globe’s favour after the newspaper appealed the territorial government’s refusal to release TB case counts by community, age and gender.

But privacy commissioner decisions aren’t binding in Nunavut. Health Minister John Main rejected the call to release community-level data, saying at the time that doing so could risk identifying patients and stigmatizing entire communities.

Neither Mr. Main nor Dr. Patterson were available for interviews Thursday.

Chris Puglia, another spokesperson for the Nunavut Department of Health, said in an e-mail that the department doesn’t plan to release TB data by hamlet, except during outbreaks. “Community level data outside an outbreak does not offer additional protection to public health and could further stigmatize the disease and create hesitancy in people seeking testing,” he wrote.

He added that Dr. Patterson’s office decided to compromise in the case of Pangnirtung and release updates every three months that “might assist in outbreak management.” The Department of Health released community-level data during Nunavut’s last major TB outbreak, in Qikiqtarjuaq in 2017-2018. A 15-year-old girl died in that outbreak.

Nunavut Privacy Commissioner Graham Steele said the government should go further and follow his ruling on TB data.

“I continue to believe that the law requires that community-level numbers be released, and not only at a time and place selected by the government,” he said Thursday. “It’s hard to hold the government to account for tuberculosis policy when it holds all the numbers in secret.”

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Monkeypox stigma can spread ‘like a virus,’ LGBTQ advocates say – Global News

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Advocates warn that stigma could pose a public health threat as a cluster of monkeypox cases stokes concern in the queer community.

Health authorities are investigating more than two dozen confirmed monkeypox cases in Canada as part of an unprecedented outbreak of the rare disease that seldom spreads outside Africa.

Twenty-five infections have been confirmed in Quebec, in addition to one in Ontario, the Public Health Agency of Canada said Thursday, predicting the tally will rise in coming days.

Read more:

Montreal sauna suspected origin of Canada’s monkeypox outbreak: doctors

While everyone is susceptible to the virus, clusters of cases have been reported among men who have sex with men, officials say.

For some LGBTQ advocates, this raises the spectre of sexual stigmatization that saw gay and bisexual men scapegoated for the rise of the HIV-AIDS epidemic.

Others say the early detection of the monkeypox cases by sexual health clinics shows how the queer community has mobilized to dismantle shame and promote safe practices.


Click to play video: 'Quebec confirms 25 cases of monkeypox, plans to administer vaccine'



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Quebec confirms 25 cases of monkeypox, plans to administer vaccine


Quebec confirms 25 cases of monkeypox, plans to administer vaccine

Canada’s deputy chief public health officer said he’s mindful of the potential for stigma and discrimination, reiterating that the virus’s spread isn’t limited to any specific group or sexual orientation.

But as early signs suggest that the virus is circulating in certain communities, authorities are working to raise awareness among those at elevated risk of exposure, Dr. Howard Njoo told a news conference Thursday.

The disease can be contracted through close contact with a sick person, including but not limited to sexual activity, said Njoo. Scientists are still working to determine what’s driving cross-border transmission of the virus.

Read more:

Physical distancing recommended amid monkeypox spread in Canada, Njoo says

Aaron Purdie, executive director of the Health Initiative for Men in B.C., said he worries that the spread of fear and stigma could present a greater threat than the disease itself.

“Stigma spreads like a virus,” Purdie said. “Yes, it’s treatable. Yes, it’s containable. But it spreads nonetheless.”

Stigma can be a major hurdle to effective disease prevention and treatment, particularly for gay men who have suffered systemic discrimination by the health-care system, said Purdie.

Dane Griffiths, director of the Gay Men’s Sexual Health Alliance of Ontario, said silence tends to perpetuate stigma, so one of the best strategies to combat it is to provide timely and accurate information without “shame or blame.”

The identification of monkeypox cases in men who have sex with men speaks to the success of community-led efforts to improve access to sexual health testing and care, said Griffiths.

“There are gay and bisexual men who have been showing up around the world at clinics and doctor’s offices and are being seen and therefore counted,” said Griffiths. “That’s a good thing, and it’s actually to be encouraged within our community.”

© 2022 The Canadian Press

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Monkeypox: Canada likely to see more cases – CTV News

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With 26 confirmed cases of monkeypox in Canada, health officials warn there will likely be more cases reported in the coming days and weeks. However, one expert says the outbreak can be stopped if the country works quickly to get it under control.

Infectious disease expert Dr. Isaac Bogoch says that Canada will “definitely” see more cases of the virus in the “few days and weeks ahead.”

“This outbreak is going to crumble along unfortunately for a bit of time,” Bogoch told CTV’s Your Morning on Friday.

However, if health officials act quickly, Bogoch said the outbreak in Canada can be stopped.

“Currently, there’s only 26 people in a country of 38 million people and the risk of the general population today is extremely, extremely small. But let’s play our cards right. Let’s deal with this quickly and effectively so that no one else needs to get this infection and that we just get this under control,” he said.

The Public Health Agency of Canada announced on Thursday there are now 25 confirmed cases of monkeypox in Quebec, and one confirmed case in Ontario. However, the health agency says several suspected and probable cases are still being investigated.

Prior to this month, monkeypox had never been detected in Canada.

Despite the unexplained rise in cases in Canada, and a growing number in other countries such as the U.S., Spain, Portugal, and the U.K., Bogoch says Canada has the tools to “quell this quickly,” if federal and provincial health officials take a co-ordinated approach to vaccinating those at high risk.

“We have an outbreak of this right now, but there’s no reason to let this run amok and there’s no reason to have this infect many people,” he said.

PHAC said they are focusing on a “targeted approach to vaccination and treatment” amid the current outbreak, and do not believe a mass vaccination campaign is necessary.

There is no proven treatment for the virus infection, but the smallpox vaccine is known to also protect against monkeypox, with a greater than 85 per cent efficacy. Because the smallpox vaccine eradicated the disease, however, routine smallpox immunization for the general population ended in Canada in 1972.

PHAC has already supplied Quebec with 1,000 doses of the smallpox vaccine Imvamune from Canada’s National Emergency Strategic Stockpile. Because of the limited supply, it is not yet clear who will be eligible for the vaccines, but Bogoch said they will likely be reserved for close contacts and health-care workers.

Bogoch said if vaccines are issued to high-risk groups quickly, officials “can certainly prevent the spread of this and fewer Canadians need to be impacted.”

WHAT TO KNOW ABOUT MONKEYPOX

First discovered in 1958, monkeypox is a rare disease caused by a virus that belongs to the same family as the one that causes smallpox. The disease was first found in colonies of monkeys used for research.

The disease has primarily been reported in central and western African countries, with the first case outside the continent reported in 2003 in the United States.

The virus is transmitted through contact with an infected animal, human or contaminated material. Transmission between people is thought to primarily occur through large respiratory droplets, which generally do not travel far and would require extended close contact. Transmission from an animal can happen through bites or scratches, contact with an animal’s blood or body fluids.

Monkeypox symptoms are similar to those for the smallpox, but generally milder. The first signs are fever, headache, muscle aches, backaches, chills, and exhaustion.

The incubation period — the span of time between initial infection and seeing symptoms — for monkeypox is generally 6-13 days, but can range to as many as 21 days, according to PHAC.

The “pox” develops after the onset of a fever and usually occurs between one to three days later, sometimes longer. A rash usually begins on the face and spreads to other parts of the body, developing into distinct, raised bumps that then become filled with fluid or pus.

Dr. Howard Njoo, Deputy Chief Public Health Officer, said Canadians should be aware of these symptoms, and seek medical attention particularly if they have an unexplained rash.

He added that people can avoid infection by “maintaining physical distance from people outside their homes.”

“As well, wearing masks, covering coughs and sneezes, and practicing frequent handwashing continues to be important, especially in public spaces,” Njoo said.

While the overall risk of monkeypox to the general public is low, Njoo said it is important to remember that everyone is susceptible, despite most cases in the country and others appearing to be spread through sexual contact between men.

He added that more guidance on case identification and contact tracing, along with infection prevention, will be released shortly.

Monkeypox is endemic in animals in regions in Western Africa, and while cases have popped up in countries where it is not endemic before, the cases typically involved people who recently travelled from a country in Africa.

What is unusual right now is that officials in numerous countries that don’t usually deal with monkeypox are seeing cases where the patient has no travel history, Njoo said.

Due to the unexpected nature of the current outbreak, Njoo said health officials in Canada and abroad are looking at whether there are any changes from what was previously known about the rare illness, including incubation period and method of transmission.

He said global cases are “not all similar in how they’re presenting,” and said milder cases may even go undetected.

“Our understanding of the virus is still evolving, but I want to emphasize this is a global response,” Njoo said.

With files from CTVNews.ca’s Alexandra Mae Jones and Solarina Ho

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