2019-nCoV Outbreak in China

Country’s Response

February 20, 2020

 Outline

• Epidemic

• Responses

• Challenges

2
 COVID-19 Cases in China
(as of Feb 18, 2020)
Data source: China Information System for Disease Control and Prevention

31 provinces, autonomous regions and

municipalities reported 80,396 COVID-19 cases:
- 53,183 confirmed cases
- 1,793 deaths
- 19,263 clinically diagnosed
- 426 deaths
- 6,359 suspected cases
- 100 deaths
- 1,591 asymptomatic
Crude case fatality: 2.88%

Hong Kong, China: 60 (1 death)

Macao, China: 10
Taiwan, China: 22
 Geographic Distribution of confirmed COVID-19 cases
in China (as of Feb 18, 2020）

As of Feb 18, 2020, in 31 provinces and

1553 Counties. Top 5 provinces:
- Hubei 40725 confirmed cases 75%
- Guangdong 1328 confirmed cases 3%
- Henan 1257 confirmed cases 3%
- Zhejiang 1185 confirmed cases 2%
- Hunan 1007 confirmed cases 2%
 Onset distribution of COVID-19 cases in China
(by different types of cases, as of Feb 18, 2020 ）
确诊病例 阳性检测 临床诊断病例 疑似病例
Confirmed Asymptomatic Probable Suspected Jan.23. travel ban in
6000
Jan 7, announced Jan 20. Wuhan, 16 cities in Hubei
causative pathogen was Incorporated as a until Jan.26
identified as a novel notifiable disease
5000 coronavirus China

Dec 31, alert issued by the Jan 10. China CDC

Wuhan Municipal Health publicly shared complete
4000
Commission about the cluster of gene sequence
PUE

病 30 Jan 11. PCR

例 3000 25
diagnostic
数 20
15 Jan 1, Huanan reagents
10 Seafood Market provided to
5 Wuhan
2000 0 closed
2019年
12
月
1000
1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728293031

0
2019

2020

年 年
12 1
Spring 2
月 月
Festival月

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7发病日期
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Prolonged vacation
 Number of cases

1000
1500
3500
4000

2000
2500
3000

500

0
12/8

10
30
40

20
50
60

0
12/10
12/8
12/12
12/10
12/14 12/12
12/16 12/14
12/16
12/18
12/18
12/20 12/20

12/22 12/22
12/24
12/24
12/26
12/26 12/28
12/30
12/28
1/1
12/30 1/3
1/1
1/3
1/5
1/7
Wuhan

1/9
1/11
1/13
1/15
Date of Onset

1/17
China (Excluding Hubei)
Hubei (Excluding Wuhan)

1/19
1/21
(as of Feb 18, 2020)

1/23
1/25
1/27
1/29
1/31
2/2
2/4
2/6
2/8
2/10
2/12
2/14
2/16
Onset distribution of confirmed COVID-19 cases in China
 病例数 病例数
2000
3000
4000

1000
1500
2500
3500

500
0

1000
2000
3000
4000

0
12/8 12/8
12/10 12/…
12/12 12/…
12/14 12/…
12/16 12/…
12/18 12/…
12/20 12/…
12/22 12/…
12/24 12/…
date of onset

12/26 12/…
Confirmed case

Suspected case
date of onset
12/28 12/…
12/30 12/…
1/1 1/1
1/3 1/3
1/5 1/5
date of report

1/7 1/7
date of report

1/9 1/9
1/11 1/11
1/13 1/13
1/15 1/15
1/17 1/17
1/19 1/19
by dates of onset and report

1/21 1/21
1/23 1/23
1/25 1/25
1/27 1/27
1/29 1/29
1/31 1/31
2/2 2/2
2/4 2/4
2/6 2/6
2/8 2/8
2/10 2/10
2/12 2/12
2/14 2/14
2/16 2/16
(as of Feb 18, 2020）
Time distribution of confirmed and suspected cases
 COVID-19 epidemics in Hubei Province
and Wuhan City
5000 Confirmed Asymptomatic Probable Suspected
确诊病例 阳性检测 临床诊断病例 疑似病例

4000
Hubei Province
3000
Confirmed and probable cases

2000
病
例
数1000

1
4
7

3
6
9

2
5
8
10
13
16
19
22
25
28
31

12
15
18
21
24
27
30

11
14
17
12月 1月 2月

2019年 2020年
发病日期

Confirmed Asymptomatic Probable Suspected

确诊病例 阳性检测 临床诊断病例 疑似病例

4000
3500
3000
病 2500
例 2000
Wuhan City
数 1500
1000
500
0

1
4
7

3
6
9

2
5
8
10
13
16
19
22
25
28
31

12
15
18
21
24
27
30

11
14
17
12月 1月 2月

2019年 2020年 8
发病日期
 Features of Confirmed Cases in China
Data source: 43,113 confirmed cases from China Information System for Disease Control and Prevention
• Asymptomatic cases 2% （n=724）
-laboratory testing positive but without symptoms
• Mild cases 81% （n=34869）
-including non-pneumonia cases and mild pneumonia cases
• Severe cases 14% (n=6210)
- Difficulty in breathing, respiratory rate ≥ 30 times/min, Oxygen
saturation ≤ 93%, PaO2/FiO2≤300, the area of diffuse patchy infiltration
greater than 50% of the lungs in 24 to 48h.
• Critical cases 3% (n=1310)
- Respiratory failure, septic shock, MODS/MOF
• Elderly, patients with underlying diseases, obesity or a decreased
lymphocyte count face poor prognosis
 Case fatality analysis of COVID-19
Data source: 44,672 confirmed cases from China Information System for Disease Control and Prevention
as of Feb. 11, 2020
Confirmed cases and deaths by age groups Confirmed cases and deaths by provinces
Characters Confirmed cases Deaths Crude case Characters Confirmed Deaths Crude
fatality cases mortality

Sum 44,672 1,023 2.3% Sum 44,672 1,023 2.3%

Hubei 33,367 (74.7%) 979 (95.7%) 2.9%
0- 416 0 0 Others 11,305 (25.3%) 44 (4.3%) 0.4%
10 - 549 1 0.2%
Confirmed cases and deaths by clinical classification
20 - 3,619 7 0.2% Characters Confirmed Deaths Crude
cases mortality
30 - 7,600 18 0.2% Sum 44,672 1,023 2.3%
40 - 8,571 38 0.4% mild/moderate 36,160 (80.9%) 0
severe 6,168 (13.8%) 0
50 - 10,008 130 1.3%
critical 2,087 (4.7%) 1,023 (100%) 49%
60 - 8,583 309 3.6% unkown 257(0.6%) 0

70 - 3,918 312 8.0% Confirmed cases and deaths by sex

 80 1,408 208 14.8% Characters Confirmed
cases
Deaths Crude
mortality
Sum 44,672 1,023 2.3%
male 22,981 (51.4%) 653 (63.8%) 2.8%

% in columns of “confirmed cases and “deaths”: constituent ratios female 21,691 (48.6%) 370 (36.2%) 1.7%
Responses
 Firm political resolution of Chinese Government
• Dec 31th, 2019, National Health Commission dispatched a working group to Wuhan to learn about the epidemic
situation.
• Jan 14th, National Health Commission held a video-conference to assign and deploy the prevention and control
nationwide in health system.
• Jan 19th, Chinese President and Premier made important instructions on disease prevention and control, and urged
resolute efforts to contain the spread of pneumonia cases caused by novel coronavirus (2019-nCov).
• Jan 20th, video conference held by the State Council，the national prevention and control was deployed.

• Jan 25th, President Xi Jinping chaired a meeting of the standing committee of the Political Bureau of the CPC
Central Committee to discuss the prevention and control of the epidemic.
• Jan 26th, Premier Li Keqiang chaired a meeting of the leading group to further deploy efforts to prevent and control
the epidemic.
• Jan 27th, Premier Li Keqiang visited Wuhan, Hube, to guide the prevention and control of the epidemic, and Vice
Premier Sun Chunlan led the central steering group to guide the prevention and control of the epidemic in Hubei.
• Jan 28th, Chinese President Xi Jinping met with Tedros Adhanom Ghebreyesus, the Director-General of the World
Health Organization exchange views on the epidemic.
 Strong Measures in Response to the Epidemic Nationwide
• Launching a cross-sectoral joint prevention and control mechanism, with 32 departments involved.
• Including the 2019-nCoV Infectious Disease Prevention Act as a statutory infectious disease, and Frontier
Health and Quarantine Law as a quarantinable infectious disease.
• Adopting strict traffic control measures in Wuhan and surrounding cities to cut off the source of the infection
and the transmission.
• Strengthening the national transportation management to minimize the flow of people. Public transportation
vehicles were disinfected, and body temperature monitoring in all public places were strengthened.

• It take the initiative to cancel mass gathering activities during the Spring Festival, reduce public gatherings,
reduce the risk of transmission.

• Extending the national Spring Festival holiday of 2020. Colleges and universities, primary and secondary schools,
and kindergartens around the country have postponed the start of school.
• Strengthening inspection and quarantine of wild animals, prohibit the transfer and trafficking of wildlife, and
strengthen control at source.
• Continue to increase the financial commitment of special funds in response to the epidemic , and have allocated
nearly 5 billion yuan from the central government budget.

• So far, 31 provinces have declared themselves on level-one alert in response to major public health
emergencies.
 Issuing Comprehensive Technical Guidelines on Prevention & Control
in Timely Manner
• The country has formulated a series of prevention and control guidelines including
diagnosis and treatment procedures which have been updated in line with the changing
situation and research progress. And it has developed technical standards in case detection,
case reports, epidemiological investigation, close contacts management, laboratory tests,
medical treatment and hospital control, transportation, and disinfection in public places
provide instruction nationwide.
– Case detection: Patients with fever, cough and shortness of breath found in the fever clinic were asked
whether there was a history of travel to Wuhan contacts with confirmed patients 14 days before the
onset of the disease.
– Case report: Report directly to the National Notifiable Disease Report System(NNDRS) in 2 hours.
– Epidemiological investigation: Epidemiological investigations be required to complete within 24 hours for
suspected cases, confirmed cases, mild cases and asymptomatic infected persons.
– Launched a national system of daily report adopting “zero report” standard on epidemics.
– Carry out comprehensive screening, follow-up and other health management on outbound personnel
from Wuhan city and surrounding areas.
– Formulated guidelines for emergency psychological crisis to reduce the negative psychological impact
caused by the epidemic and promote social stability.
– Develop public prevention guidelines and disseminate them widely by traditional and social media.
 Highlighting Prevention & Control at Community Level
Strategies for different communities
• Jan 25th, the National Health Commission has
Epidemic Strategy Measures
issued a notice to strengthen the community
prevention and control of the new coronavirus Communities with prevention for 1.Community mobilization;
pneumonia no confirmed import 2.Health education;
cases 3.Informing;
– Give full play to the communities to mobilize and
implement grid and carpet management
4.Management of
returning personnel from
– implement the prevention and control measures the epidemic areas;
by mobilizing grassroots level organizations and 6.Preparation of supplies
communities while maintaining social stability
Communities with prevention from 1-6 listed above;
– "Early detection, early reporting, early isolation, confirmed cases spreading in the 7.Management of close
early diagnosis, early treatment“ measures or outbreaks community and contacts;
applied Exporting the
8.Disinfection.
epidemic
– Prevent the import, spread and export of the
cases to curb the spread of the disease Communities with prevention for 1-8 listed above;
spreading of continuing 9. Epidemic area lock
epidemic spreading and down;
export the
10.Limitation for gathering.
epidemic
 Strengthen Actions in Wuhan and Hubei
• 尽快实现及时收治 Timely hospitalization and medical treatment
– 减少家庭传播 Reduce family transmission
– 降低病死率 Reduce mortality
– 缓解和避免患者、家庭和社会无助失望情绪 Relief and avoid helplessness and
disappointment of patients, families and society
• 努力降低医院感染 Reduce infection in hospitals
– 控制医务人员感染 Control infection of healthcare workers
– 降低民众就医过程感染 Reduce infection during the medical care seeking of
patients
• 加强社会（社区）支持（服务） Strengthen social (community) support
(service)
• 解决关键物资供应保障 Solve the supply guarantee of key materials
 Challenges
• To further understand the virus itself and the infection pattern of the
epidemic
• It is the critical stage for prevention and control as the epidemic
situation remains serious and complex.
• The complete disease spectrum has not been obtained yet, and
further investigation is needed after the development of antibody
diagnostic reagent.
• There are no specific therapies targeted the disease.
• Vaccine research and development takes time.
• It takes time to see the full effect of the measures.
 Continue to Strengthen International Cooperation with ASEAN
• We work closely with ASEAN, implementing consensus of the 10+1 Summit and ACHMM.
➢ Sharing Information through ASEAN Secretariat in a transparent and timely manner.
➢ Since Jan. 3rd, 2020
➢ On daily basis
➢ On Jan 12th, China shared the genome sequence with the world through GISAID, any county can download it.
➢ On 13th January , MBDS Board meeting in Beijing.
➢ Delegates from Cambodia, Thailand, Lao PDR, Vietnam, China and secretariat attended the meeting.
➢ delegates from Thailand (staff from MoPH Thailand) exchanged information about the first imported case to
Thiland of 2019 n-Cov.
➢ On Jan 21st, China shared nucleic acid test primers and probe sequences with the world
➢ Technical exchange through FETN
➢ On Feb 3rd , ASEAN+3 SOMHD Special Video Conference on COVID-19. ASEAN+3 have in-depth exchange and
discussion on the prevention and control of COVID-19.
➢ Sharing technical guidelines regarding diagnosis and treatment, prevention and control, lab test, surveillance,
epidemiological investigation, risk assessment, management of clost contacts

18
 Proposed Cooperation for next steps
➢ Establish China-ASEAN EOC network
➢ Strengthen cooperation and collabration with ASEAN EOC network.
➢ Strengthen information reporting, information sharing and policy coordination
➢ The Sub-forum of the 3rd China-ASEAN Health Cooperation Forum in
September 2020 in China.
➢ Conclusion discussion on this outbreak
➢ Exchange experience, best practice and lessons learnt

➢ Human resource development cooperation in Health Emergency &

Response.
➢ Workshop on Health Emergency& Response held in China the first half of this year
➢ to share data, knowledge and experience.
Diagnosis and Treatment
 Diagnosis and treatment of new coronavirus pneumonia
(version 6)
Epidemiological characteristics
(I) the source of infection.
• At present, the main source of infection is the new coronavirus infection patients.
Asymptomatic infections can also be a source of infection.

(2) transmission channels.

• Respiratory droplets and close contact are the main routes of transmission. Aerosol
propagation is possible under the condition of long exposure to high concentrations
of aerosols in a relatively closed environment

(iii) susceptible groups.

• People are generally susceptible.
 Clinical manifestations
• The incubation period: the incubation period is 1-14 days, mostly 3-7 days.
• Clinical Features:
– Fever, dry cough, fatigue as the main performance.
– A small number of patients have symptoms such as stuffy nose, runny nose, sore throat, myalgia
and diarrhea.
– In severe cases, dyspnea and/or hypoxemia usually occur one week after the onset of the
disease, and dyspnea and/or hypoxemia may rapidly progress to acute respiratory distress
syndrome, septic shock, metabolic acidosis that is difficult to correct, bleeding and coagulation
dysfunction, and multiple organ failure.
• The patients with severe or critical illness may have moderate or low fever, or even
no significant fever.
• The mild patients showed only low fever, mild fatigue, and no pneumonia.
• Most patients have a good prognosis, a few patients are in critical condition. The
elderly and those with chronic underlying diseases have poor prognosis.
 Laboratory test
• In the early stage of the disease, the total number of white blood cells in the
peripheral blood was normal or decreased, while the lymphocyte count was
decreased.
• Elevated troponin is seen in some critically ill patients. In most patients, C-reactive
protein (CRP) and erythrocyte sedimentation rate (ESR) were elevated, and
procalcitonin was normal. In severe cases, D-dimer increased and peripheral
lymphocyte cells progressively decreased. Severe and critical patients often have
elevated inflammatory factors.
• The new coronavirus nucleic acid can be detected in nasopharyngeal swabs, sputum
and other lower respiratory secretions, blood, feces.
– In order to improve the positive rate of nucleic acid detection, it is suggested that sputum should
be retained as far as possible, and lower respiratory secretions should be collected from patients
with endotracheal intubation, and samples should be submitted for examination as soon as
possible after collection.
 Chest imaging

• In the early stage, there were multiple spotted shadows and interstitial changes,
which were obvious in the extraneous lung.
• Further, multiple ground-glass shadows and infiltration shadows were found in both
lungs.
• Lung consolidation was found in severe cases, and hydrothorax was rare.
 Diagnostic criteria

(1) suspected cases.

• Combined with the following epidemiological history and clinical manifestations of
comprehensive analysis:
• epidemiological history
(1) travel history or residence history in wuhan and its surrounding areas within 14 days before the
onset of the disease, or in other communities where cases have been reported;
(2) a history of contact with new coronavirus infection (positive nucleic acid detection) within 14
days before the onset of the disease;
(3) patients with fever or respiratory symptoms who came into contact with patients from wuhan
and surrounding areas or from communities with case reports within 14 days prior to the onset of
the disease;
(4) aggregation.
•
 Diagnostic criteria

(1) suspected cases.

• Clinical manifestations
(1) fever and/or respiratory symptoms;
(2) imaging characteristics of the above novel coronavirus pneumonia;(3) the total number of white
blood cells in the early stage of the disease was normal or decreased, and the lymphocyte count was
decreased.

It has any one of the epidemiological history and conforms to any two
of the clinical manifestations. If there is no clear epidemiological
history, it conforms to 3 clinical manifestations.
(2) confirmed cases.
1. Real-time fluorescence rt-pcr was used to detect positive nucleic acid
of novel coronavirus;
2. Viral gene sequencing, highly homologous with new coronaviruses
 Clinical Types
(1) Mild: The clinical symptoms were mild, and there was no sign of pneumonia on
imaging.
(2) Moderate: Have fever, respiratory symptoms, imaging manifestations of
pneumonia.
(3) Severe. In accordance with any of the following:
1. Shortness of breath (RR 230 times/min);
2. In resting state, oxygen saturation <93%;
3· partial arterial oxygen pressure (Pao2)/oxygen absorption concentration (Fi0,) <300mmlg
4. Pulmonary imaging showed significant progression of > within 24 to 48 hours.
(4) Critical: One of the following:
1. Respiratory failure, requiring mechanical ventilation;
2. Shock;
3. Combined with other organ failure, intensive care unit is required.Differential diagnosis
 Differenciation Diagnosis
• The mild manifestations of novel coronavirus infection should be differentiated from
upper respiratory tract infections caused by other viruses.

• The novel coronavirus pneumonia is mainly differentiated from influenza virus,

adenovirus, respiratory syncytial virus and other known viral pneumonia and
mycoplasma pneumoniae infection. In particular, methods including rapid antigen
detection and multiple PCR nucleotide detection should be adopted for suspected
cases to detect common respiratory pathogens as far as possible.
• With non - infectious diseases, such as vasculitis, dermatomyositis and pathogenesis
 Treatment

To determine treatment sites according to the condition.

• Suspected and confirmed cases should be isolated for treatment in designated
hospitals with effective isolation conditions and protective conditions. Suspected
cases should be isolated for treatment in a single room.
• Critical cases should be admitted to ICU for treatment as soon as possible.
 General treatment.

• Bed rest, strengthening supportive treatment and ensuring sufficient calories;Pay

attention to the balance of water and electrolysate to maintain the stability of
internal environment.Closely monitor vital signs and oxygen saturation etc.
• Monitor blood routine, urine routine, CRP, biochemical indicators (liver enzyme,
myocardial enzyme, kidney function, etc.), blood coagulation function, arterial blood
gas analysis, chest imaging, etc.Cytokine detection is feasible for those with
conditions.
• Timely and effective oxygen therapy, including nasal catheter, mask and transnasal
high-flow oxygen therapy.
• Antiviral treatment: can try a interferon (adult 5 million U every time or when the
dose, 2 m1 join sterilizing water for injection, atomization inhalation) 2 times a day,
that horse /, the wei (adult 50 mg / 200 mg/grain, every time 2 grain, 2 times daily,
cure process of no more than 10 days)
 Antiviral treatment

• Interferon, and ribavirin

• Lopinavir and Ritonavir
• Chloroquine phosphate (adult 500 mg, 2 times daily, not more than 10 days
• Abby dole
• To further evaluate the efficacy of the drugs in clinical application. It is not
recommended to use three or more antiviral drugs at the same time, and should
stop using related drugs when there are intolerable side effects.
 treatment of severe and critical cases.

• 1. Treatment principle: on the basis of symptomatic treatment, actively prevent and

treat complications, treat basic diseases, prevent secondary infections, and provide
timely organ function support.
• 2. Respiratory support:
• (1) oxygen therapy: severe patients should receive nasal catheter or mask oxygen,
and timely assess whether the respiratory distress and/or hypoxemia is relieved.
• (2) high-flow nasal-catheter oxygen therapy or noninvasive mechanical ventilation:
consider high-flow nasal-catheter oxygen therapy or noninvasive ventilation when
the patient's respiratory distress and/or hypoxemia cannot be relieved after
standard oxygen therapy.Endotracheal intubation and invasive mechanical
ventilation should be performed promptly if the condition does not improve or even
worsen within a short time (1-2 hours).
 treatment of severe and critical cases.

• (3) invasive mechanical ventilation: a protective lung ventilation strategy, namely

neap volume (4-8m1/kg ideal rest weight) and low inspiratory pressure (platform
pressure <30cmH20), was adopted for mechanical ventilation to reduce ventilator
related lung injury.More patients have man-machine differences. Sedatives and
muscle relaxants should be used promptly.
• (4) salvage treatment: pulmonary reconstruction is recommended for patients with
severe ARDS.In the case of adequate human resources, ventilation in the prone
position should be performed for more than 12 hours a day. If the effect of
ventilation in the prone position is poor, ECMO should be considered as soon as
possible, if conditions permit.
• 3. Circulation support: on the basis of sufficient fluid resuscitation,
improve microcirculation, use vasoactive drugs, and conduct
hemodynamic monitoring when necessary.
• 4. Plasma therapy for convalescent patients: it is suitable for patients
with rapid disease progression, severe and critical type.Reference for
usage and dosage: prescription for convalescent plasma clinical
treatment of convalescent patients with xinguan pneumonia (trial
edition 1)
• For oxygenation index progressive deterioration, imaging progress quickly, the
body's inflammatory reaction excessive activation of the state of the patients, take
into consideration the short term (3 to 5) use of glucocorticoid induced,
recommended dose not more than the equivalent of methyl prednisolone 1 ~ 2
mg/kg/day, should pay attention to the larger doses glucocorticoid due to immune
inhibition, delay of coronavirus cleared; Intravenous administration of xuebijing
100m1/ time, twice daily;Intestinal microecological regulator can be used to
maintain intestinal microecological balance and prevent secondary bacterial
infection. For critically ill patients with high inflammatory response, plasma
exchange, adsorption, perfusion, blood/plasma filtration and other off-site blood
purification techniques can be considered if conditions permit.
• Patients often have anxiety and fear, should strengthen psychological counseling.
• TCM treatment.
•
This disease belongs to traditional Chinese medicine "epidemic" disease category,
disease because feel "epidemic geng" of gas, each place can according to disease
condition, local climate characteristic and different constitution wait for a
circumstance, consult below

The treatment was based on syndrome differentiation. The use of

superpharmacopoeial doses should be directed by a physician.
1. Clinical manifestations during medical observation 1: fatigue accompanied by
gastrointestinal discomfort
Recommended Chinese patent medicine: huoxiang zhengqi capsule (pill, water, oral
liquid)
Thanks for your attention!