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First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessmentKathy Leung et al. Lancet. 2020.
. 2020 Apr 25;395(10233):1382-1393. doi: 10.1016/S0140-6736(20)30746-7. Epub 2020 Apr 8. AffiliationsItem in Clipboard
AbstractBackground: As of March 18, 2020, 13 415 confirmed cases and 120 deaths related to coronavirus disease 2019 (COVID-19) in mainland China, outside Hubei province-the epicentre of the outbreak-had been reported. Since late January, massive public health interventions have been implemented nationwide to contain the outbreak. We provide an impact assessment of the transmissibility and severity of COVID-19 during the first wave in mainland Chinese locations outside Hubei.
Methods: We estimated the instantaneous reproduction number (Rt) of COVID-19 in Beijing, Shanghai, Shenzhen, Wenzhou, and the ten Chinese provinces that had the highest number of confirmed COVID-19 cases; and the confirmed case-fatality risk (cCFR) in Beijing, Shanghai, Shenzhen, and Wenzhou, and all 31 Chinese provinces. We used a susceptible-infectious-recovered model to show the potential effects of relaxing containment measures after the first wave of infection, in anticipation of a possible second wave.
Findings: In all selected cities and provinces, the Rt decreased substantially since Jan 23, when control measures were implemented, and have since remained below 1. The cCFR outside Hubei was 0·98% (95% CI 0·82-1·16), which was almost five times lower than that in Hubei (5·91%, 5·73-6·09). Relaxing the interventions (resulting in Rt >1) when the epidemic size was still small would increase the cumulative case count exponentially as a function of relaxation duration, even if aggressive interventions could subsequently push disease prevalence back to the baseline level.
Interpretation: The first wave of COVID-19 outside of Hubei has abated because of aggressive non-pharmaceutical interventions. However, given the substantial risk of viral reintroduction, particularly from overseas importation, close monitoring of Rt and cCFR is needed to inform strategies against a potential second wave to achieve an optimal balance between health and economic protection.
Funding: Health and Medical Research Fund, Hong Kong, China.
Copyright © 2020 Elsevier Ltd. All rights reserved.
FiguresFigure 1
Timeline of events between Jan…
Figure 1
Timeline of events between Jan 23 and Feb 17, 2020 (A) The number…
Figure 1Timeline of events between Jan 23 and Feb 17, 2020 (A) The number of confirmed cases reported outside Hubei province in mainland China. (B) Cities in mainland China that have implemented any lockdowns by Feb 10, and cities (blue) and provinces (green) included in the estimation of the instantaneous reproduction number (Rt). Semi-lockdown was defined as public health control measures that did not quite reach the intensity and comprehensiveness as those implemented in Wuhan. Complete lockdown was defined as measures that were comparable to those implemented in Wuhan (since Jan 23). Wartime measures was defined as residents being unable to get in or out of buildings that come under full closed management. Islands in the South China Sea are not shown (appendix p 15).
Figure 2
Estimates of R t in…
Figure 2
Estimates of R t in Beijing, Shanghai, Shenzhen, and Wenzhou (A) The daily…
Figure 2Estimates of Rt in Beijing, Shanghai, Shenzhen, and Wenzhou (A) The daily number of symptom onsets in Beijing (411 cases), Shanghai (337 cases), Shenzhen (417 cases), and Wenzhou (504 cases), stratified by local cases (blue), imported cases from Wuhan or Hubei (red). The epidemic curves were estimated from cases reported on or before Feb 29, 2020. The daily number of symptom onsets observed or estimated from reported cases between Feb 29 and March 16, are shown, but not included in the analysis. Imported cases from overseas were reported in Beijing, Shanghai, and Shenzhen since March 1 (green). The date of symptom onset was available for 186 of 212 cases who were reported in Beijing on or before Feb 2, 2020, and for each case in Shenzhen and Wenzhou. The date of symptom onset was not available for the remaining 225 cases in Beijing, and all cases in Shanghai. Therefore, we estimated the date of onset for the 225 cases in Beijing and all cases in Shanghai based on their date of reporting and Beijing's distribution of the time between onset and reporting (which was estimated from the 186 cases reported by Feb 2, in Beijing). (B) The estimates of Rt by date of symptom onset on sliding weekly windows between late January, and Feb 19, 2020, for Beijing and Shanghai, and between mid-January, and Feb 25, 2020, for Shenzhen and Wenzhou (eg, the estimate on Feb 25 was for the week of Feb 22–28). We estimated Rt until Feb 19, because few cases reported in the week of Feb 22–28, and the estimation of the onset dates of these cases was not accurate. Dots show the posterior mean and bars show 95% credible intervals. Rt=instantaneous effective reproduction number.
Figure 3
Estimates of R t of…
Figure 3
Estimates of R t of Guangdong, Henan, Zhejiang, Hunan, and Anhui (A) The…
Figure 3Estimates of Rt of Guangdong, Henan, Zhejiang, Hunan, and Anhui (A) The epidemic curves by estimated date of illness onset stratified by reported cases (blue) and estimated cases not reported yet due to the time delay between onset and reporting (yellow). We assumed the distribution of the time between onset and reporting in all provinces was the same as Beijing, with a mean of 4·9 days. The epidemic curves were estimated from cases reported on or before Feb 29, 2020. The Shilifeng prison cluster (red) reported on Feb 21 in Zhejiang was not included in the Rt estimation. (B–E) The estimates of Rt assuming the daily proportion of imported cases from Hubei was the same as Beijing, Shanghai, Shenzhen, and Wenzhou.
Figure 4
cCFRs in Beijing, Shanghai, Shenzhen,…
Figure 4
cCFRs in Beijing, Shanghai, Shenzhen, and Wenzhou and in provinces outside Hubei cCFR…
Figure 4cCFRs in Beijing, Shanghai, Shenzhen, and Wenzhou and in provinces outside Hubei cCFR in Qinghai and Tibet were not shown because the 95% CIs were wide due to the small number of confirmed cases. cCFR=confirmed case-fatality risk. Ex-Hubei=all provinces outside Hubei.
Figure 5
The effect of relaxation of…
Figure 5
The effect of relaxation of interventions for different scenarios of reproduction numbers R…
Figure 5The effect of relaxation of interventions for different scenarios of reproduction numbers R2 and R4 refer to the reproduction number when stage 2 and 4 began, respectively. (A) Relative case count compared with no relaxation of interventions. (B) The duration of aggressive interventions required to push prevalence back to pre-relaxation level (T4) relative to the duration of interventions relaxation (T2).
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