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Association of Public Health Interventions With the Epidemiology of the COVID-19 Outbreak in Wuhan, China

Educational Objective
To understand the effect Public Health Interventions had on reducing COVID-19 Outbreaks in China
1 Credit CME
Key Points

Question  Was there an association of public health interventions with improved control of the COVID-19 outbreak in Wuhan, China?

Findings  In this cohort study that included 32 583 patients with laboratory-confirmed COVID-19 in Wuhan from December 8, 2019, through March 8, 2020, the institution of interventions including cordons sanitaire, traffic restriction, social distancing, home quarantine, centralized quarantine, and universal symptom survey was temporally associated with reduced effective reproduction number of SARS-CoV-2 (secondary transmission) and the number of confirmed cases per day across age groups, sex, and geographic regions.

Meaning  A series of multifaceted public health interventions was temporally associated with improved control of the COVID-19 outbreak in Wuhan and may inform public health policy in other countries and regions.

Abstract

Importance  Coronavirus disease 2019 (COVID-19) has become a pandemic, and it is unknown whether a combination of public health interventions can improve control of the outbreak.

Objective  To evaluate the association of public health interventions with the epidemiological features of the COVID-19 outbreak in Wuhan by 5 periods according to key events and interventions.

Design, Setting, and Participants  In this cohort study, individual-level data on 32 583 laboratory-confirmed COVID-19 cases reported between December 8, 2019, and March 8, 2020, were extracted from the municipal Notifiable Disease Report System, including patients’ age, sex, residential location, occupation, and severity classification.

Exposures  Nonpharmaceutical public health interventions including cordons sanitaire, traffic restriction, social distancing, home confinement, centralized quarantine, and universal symptom survey.

Main Outcomes and Measures  Rates of laboratory-confirmed COVID-19 infections (defined as the number of cases per day per million people), across age, sex, and geographic locations were calculated across 5 periods: December 8 to January 9 (no intervention), January 10 to 22 (massive human movement due to the Chinese New Year holiday), January 23 to February 1 (cordons sanitaire, traffic restriction and home quarantine), February 2 to 16 (centralized quarantine and treatment), and February 17 to March 8 (universal symptom survey). The effective reproduction number of SARS-CoV-2 (an indicator of secondary transmission) was also calculated over the periods.

Results  Among 32 583 laboratory-confirmed COVID-19 cases, the median patient age was 56.7 years (range, 0-103; interquartile range, 43.4-66.8) and 16 817 (51.6%) were women. The daily confirmed case rate peaked in the third period and declined afterward across geographic regions and sex and age groups, except for children and adolescents, whose rate of confirmed cases continued to increase. The daily confirmed case rate over the whole period in local health care workers (130.5 per million people [95% CI, 123.9-137.2]) was higher than that in the general population (41.5 per million people [95% CI, 41.0-41.9]). The proportion of severe and critical cases decreased from 53.1% to 10.3% over the 5 periods. The severity risk increased with age: compared with those aged 20 to 39 years (proportion of severe and critical cases, 12.1%), elderly people (≥80 years) had a higher risk of having severe or critical disease (proportion, 41.3%; risk ratio, 3.61 [95% CI, 3.31-3.95]) while younger people (<20 years) had a lower risk (proportion, 4.1%; risk ratio, 0.47 [95% CI, 0.31-0.70]). The effective reproduction number fluctuated above 3.0 before January 26, decreased to below 1.0 after February 6, and decreased further to less than 0.3 after March 1.

Conclusions and Relevance  A series of multifaceted public health interventions was temporally associated with improved control of the COVID-19 outbreak in Wuhan, China. These findings may inform public health policy in other countries and regions.

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Article Information

Corresponding Authors: Tangchun Wu, MD, PhD (wut@tjmu.edu.cn), and Sheng Wei, MD, PhD (shengwei@hust.edu.cn), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hongkong Rd, Wuhan 430030, Hubei, China; and Xihong Lin, PhD, Department of Biostatistics, Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Boston, MA 02115 (xlin@hsph.harvard.edu).

Accepted for Publication: April 3, 2020.

Published Online: April 10, 2020. doi:10.1001/jama.2020.6130

Author Contributions: Drs Wei and Wu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Joint first authors are Drs Pan, Liu, C. Wang, Guo, and Hao.

Concept and design: Pan, C. Wang, Wu.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Pan, C. Wang, Lin.

Critical revision of the manuscript for important intellectual content: Liu, Guo, Hao, Q. Wang, Huang, He, Yu, Lin, Wei, Wu.

Statistical analysis: Pan, Liu, C. Wang, Guo, Hao, Q. Wang, Huang, Lin, Wei.

Obtained funding: Wu.

Administrative, technical, or material support: He, Yu, Wu.

Supervision: C. Wang, Lin, Wu.

Conflict of Interest Disclosures: Dr Yu reported receiving grants from the National Natural Science Foundation of China, the Program of Shanghai Academic/Technology Research Leader, and the National Science and Technology Major Project of China during the conduct of the study; grants from Sanofi Pasteur, GlaxoSmithKline, Yichang HEC Changjiang Pharmaceutical Company, and bioMérieux Diagnostic Product (Shanghai) outside the submitted work. No other disclosures were reported.

Funding/Support: This study was partly supported by the Fundamental Research Funds for the Central Universities (2019kfyXMBZ015), the 111 Project (Drs Pan, Liu, C. Wang, Guo, Hao, Q. Wang, Huang, Wei, and Wu). Dr Lin is supported by Harvard University.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We are grateful to all staff at the national, provincial, and municipal Center for Disease Control and Prevention for providing the data and all medical staff members and field workers who are working on the frontline of caring for patients and collecting the data.

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