Published February 17th, 2020
The purpose of this bulletin is to provide our clients, with a current summary and analysis of information available both in general media and especially from Chinese and international scientific sources regarding the coronavirus outbreak in and disseminated from Wuhan to other Chinese cities, as well as to foreign countries, and to make specific recommendations for each of the client groups, national travelers, expatriates in the targeted areas, and corporate travelers and tourists.
This bulletin is important as the Chinese authorities have gradually enforced strict measures to reduce contacts between people, among others by restricting transport and extending holidays till February 9th included, first in Wuhan and Hubei province, then nationwide. People have been back at work this week, with efforts at maximizing work at home and preventative precautions. Travel to and from China is more and more restricted, as for instance major airlines have stopped flights to and from China, and several countries such as for instance the USA, the UK and Italy plus neighboring countries have put limitations on travel by Chinese citizens to and from their countries, despite the WHO position in that regard. In addition several countries including the USA, Korea, Japan, Germany, Canada, Belgium and France among others have provided repatriation flights from Wuhan to their citizens.
This outbreak started officially on 31st December in a live animal and fish market in Wuhan and is thought to originate from the Chinese horseshoe bat. It initially caused relatively few cases, was managed with energetic isolation measures, and showed no evidence of human to human contagion. Recommendations were therefore limited to avoiding contacts with animals and patients, and no travel restrictions were advised by either Chinese or international authorities.
A significant deterioration of the situation was reported by the media over the weekend of 18th January and confirmed early last week by the Chinese authorities, including the transmission, probably through droplets, between human beings. The disease is highly contagious but less severe than SARS at this stage although the proportion of severe cases seems to be increasing.
Deaths occur mostly in people with underlying diseases. The symptoms to watch for are first of all contact with a proven or potential case, then respiratory symptoms like cough and dyspnea/shortness of breath, and feeling sick. Fever is often but not always present. The incubation is usually 3 to 7 days, rare cases are transmitted from symptom free patients, and the maximum is currently thought to be 14 days although there may be cases exceeding this length.
The World Health Organization (WHO) on Thursday January 23rd after two days of meetings recognized the severity of the outbreak but did not declare yet a public health emergency of international concern. Their Emergency Committee welcomed the efforts made by China and an official visit to China was made by the WHO director. The committee met again January 30th and did make the recommendation to support the director general’s decision to declare a Public Health Emergency of International Concern in view of the growth in the numbers and the restrictions applied by China and many countries. It supported the Chinese initiatives but strongly argued against the global spread of any measure to restrict travel as economically unsound. This remained the WHO’s core concern in their February 4thand 6th communication, focusing on the need for prevention, isolation and appropriate handling of cases and contacts. The WHO cooperates with IATA to standardize precautions onboard airlines.
On February 11th 2020 to be coherent with international virus and disease naming rules the International Committee on the Taxonomy of Viruses renamed the virus SARS-CoV-2 and the WHO named the disease COVID-19.
The CDC also published a document on 23rd January. They consider the public health threat serious but state it is too early to predict the evolution. They strongly recommend to avoid travelling to China unless one has a critical reason to go. Most foreign cases did originate from Wuhan initially but transmission of the virus outside of China has started occurring. The CDC stated that given the release of the full genome of the “2019-nCoV” they have the tools required for case detection. They have begun entry screening of passengers coming from China to the main airports of entry in the US. Their focus is on the use of proper prevention measures. The CDC also produces specialized advice for the likes of businesses or ships.
Elective but not systematic 14 days isolation is practiced on arrival except on cases repatriated by many countries. This type of screening was extended to other arrival points and also undertaken under a variety of formulas by many countries.
The Chinese authorities have decided to modify the way cases are classified in Hubei province, essentially adding a clinical diagnosis category not requiring laboratory confirmation, which increased the number of cases. At this stage the latest modified data available, as of 15H00 February 13th China time, the total volume of confirmed cases in China was 59888 (60378 globally), 8204 of them critical, and 1368 deaths had occurred (1310 of them still in Hubei province, 1 outside China). There are 16067 suspicious cases, and 490 cases have been identified abroad (408 in Asia, including 247 in Japan, many on a cruise ship offshore, 46 in Europe, 21 in North America and 15 in Australia).
The decision to isolate Wuhan and several other cities in the region and to enforce increased surveillance and prevention measures including a delay of return to work till at least February 9th in the whole of China may have an impact on reducing contagion. The reduction measures may be negatively impacted by among others the serious lack of supplies even country-wide of notably soap and masks, including protective devices for hospital use.
For expatriates in Wuhan, in Hubei and now in the rest of China there is no special regulation scheduled for foreign patients who need to be medically assessed for respiratory symptoms with fever. If they have symptoms, they have to follow the public system at this stage. Some international / VIP clinics in China might refuse to accept consultation with suspicious cases and their resources are limited under the current threatening environment. There are 9 designated hospitals in Wuhan for fever patient consultations, but the government plans to open more hospitals and beds for patient accommodation. They are actually building a brand new prefabricated hospital of a 1000 beds for early February to meet the demand. So far there is a significant shortage of ward beds for admission of patients. Facilities such as hotels have been requisitioned to increase the ability to isolated cases.
General Recommendations
In these circumstances it is recommended – taking into account the unavoidable increase of in-country travel during the Chinese New Year festivities – to first and foremost avoid any contact with patients with Wuhan flu, and more generally with patients with cough and fever. This is also recommended to national clients. Of course the usual hygiene precautions should remain a priority considering that regular handwashing, disinfection and adequate use of mask wearing, especially in public transports and crowded places, are part of these essential hygienic attitudes. In addition for expatriate patients planning to remain in the country one would suggest to avoid exposure to mass transport, visits to hospitals and clinics, as well as to markets with live fish and animals.
Clients in the isolated zone of Wuhan cannot travel unless they are involved in government authorized evacuations. There is no necessity to leave the country as long as prevention measures are adhered to but it may make the concerned individuals feel more at ease. There are medical evacuation schemes in place, but these are voluntary and organized by national authorities not private concerns. Any decision to travel out of the country, in anticipation of potentially broadened isolations or hard to apply safety measures remains a personal choice. Should people arrive from China to their country of destination they should declare any symptoms of fever or cough having appeared during the flight to the airline and airport staff. They should remain isolated for the 14 days after arrival and report symptoms to the designated institution by phone and follow instructions and not go to health care providers or emergency rooms.
For those outside China planning to travel back there may be charter flights organized by the Chinese authorities if they are Chinese citizens. For expatriates wishing to travel back and for travelers the individual decision should take into account the measures in place in China, the travel restrictions issued by several governments, and the fact that many airlines have temporarily suspended flights. Clearly any travel undertaken have formal restrictions were announced could be challenged cover wise. For non-essential travel to China the sensible individual decision may be to delay travel for several days until the information regarding this epidemic is more reliable. These considerations concern only China as there are no medical reasons to restrict travel anywhere in Asia or the world because of the Novel Coronavirus epidemic.
The current bulletin will be updated regularly until the situation stabilizes.