Face virus and epidemic prevention
Many understandings accumulated through more than two years of practice
Need to be reexamined
How does the city pass the pass against Omikron
Our reporter/Huo Siyi and Peng Danni intern/Yu Haoqing
Published on China Newsweek, Issue 1037, 2022.3.28
Omikjon, who is spreading very fast, is breaking a lot of "common sense".
In previous rounds of the epidemic, China has accumulated a lot of experience in epidemic prevention and control. For example, we should make full use of nucleic acid detection to achieve "early detection" and cut off the transmission chain through traceability as soon as possible; Nucleic acid positive persons should be immediately transferred to designated hospitals for isolation and treatment in a closed loop to achieve social clearance at the fastest speed; At the same time, hospitals should have enough beds and ventilators, especially for severe and critical patients, to receive timely treatment; Finally, in terms of the overall strategy, we should make precise prevention and control, and try not to upgrade the control measures. When all these can be achieved, the epidemic situation can be basically controlled within half a month, and the epidemic situation in various places can range from hundreds to single digits.
However, in the latest outbreak of fermentation since the beginning of March, people soon found that these experiences did not seem to be as useful as before. As of March 19, the epidemic situation throughout the country is still in the development stage, and more than 29000 cases of COVID-19 have been reported accumulatively, affecting 28 provinces, including Jilin Province, which has reported more than 10000 cases accumulatively, and 4 provinces, which have reported more than 1000 cases accumulatively. The single day increase in several cities is still in the climbing period, breaking 100 every day. All this happened within 20 days. Previously, in the whole two years after the outbreak, the total number of confirmed cases reported nationwide had just exceeded 10000.
At 17:00 on March 17, Nanchang City, Jiangxi Province started the nucleic acid detection work in the central urban area. People lined up at 303 Green Center Square to wait for the verification. Figure/Zhongxin
Even Shanghai, which has always been known as the "textbook" of precise prevention and control, experienced some confusion in the early response period. Zhang Wenhong, director of the National Medical Center for Infectious Diseases of China and director of the Infection Department of Huashan Hospital affiliated to Fudan University, said on his microblog on March 14 that due to the large number of cases in the short term, it is inevitable that all parts of the country will appear a little flustered, and Shanghai is no exception. Precise prevention and control in Shanghai At the time of the spread of Omicron BA. 2, due to the sudden occurrence, late start, and fast virus, it is still in the phase of running with the virus, and I feel very hard.
According to the definition of the State Council, cities with a permanent resident population of more than 5 million in urban areas are called megacities. There are at least 15 such cities in China. They are geographical spaces with dense population, frequent personnel mobility and high difficulty in social governance. So far, Wuhan, Xi'an, Nanjing, Shanghai and Shenzhen are the mega cities or megacities that have experienced large-scale COVID-19 outbreaks.
The possibility and frequency of large-scale outbreaks at a single point have been greatly increased by the Omikjon mutant with stronger transmission power and more concealed symptoms. In the face of this new situation, what emergency preparedness should our medical system, communities and even the whole city do to ensure an orderly response and avoid rush?
How to do nucleic acid detection?
Why do a large number of cases suddenly appear in a short time? Huang Senzhong, a professor of the School of Statistics and Data Science of Nankai University, explained to China Newsweek that the existing epidemic monitoring system is difficult to detect in time because of the more cunning Omikjon. The monitoring system mainly has two "eyes": First, report through the hospital; Second, regular screening of key populations and places.
If a person with cough, fever and other symptoms goes to the fever clinic of the hospital to take the initiative to see a doctor, after the nucleic acid is positive, the hospital will immediately start epidemic prevention through a 24-hour epidemic reporting system.
However, because Omikron is not only more contagious, but also more insidious, and more than 95% of infected people are mild and asymptomatic, the period of patients from infection to symptoms after taking the initiative to seek medical advice has been lengthened, which used to be 5-7 days, but now it will be extended to 10-14 days. "In addition, the infectivity of Omikjon is very strong, and it is usually too late to find it. As long as one case is found, it means there is still a large number of cases behind," said Huang Senzhong.
In Huang Senzhong's view, with the spread of Omikjon, the concept of epidemic scale needs to be redefined in the future. In the past, they found that those with fewer than 100 cases can be regarded as "small scale", while those with more than 100 cases and less than 500 cases can be regarded as "medium scale". But now, the number of cases below 500 is small, and the number of cases below 4000 is medium. It is hard to say how large the number will be. When the new diagnosis goes from hundreds to thousands in just one week, people's understanding of viruses and epidemic prevention, which has been accumulated through more than two years of practice, needs to be reexamined.
In terms of screening of key groups, units and places, the country has long had detailed regulations. In the new version of the protection guidelines issued in August 2021, the protection requirements for 10 types of places, such as docks, ports, chess and card rooms (mahjong halls), cruise ships (sightseeing boats) and milk tea shops, have been added, and more stringent epidemic prevention measures have been proposed for key groups.
On March 18, in Harbin Mobile Laboratory in Heilongjiang Province, testers debugged the detection system to prepare for a new round of nucleic acid detection. Figure/Zhongxin
However, Huang Senzhong pointed out that although there are provisions, the implementation of these provisions varies from place to place, and the monitoring role played by them also varies greatly. In this round of epidemic in Jilin, in schools and other places that should be monitored, in the new semester starting after the Spring Festival, there have been students in Jilin Agricultural Science and Technology College who have cough and other symptoms, but the school has not been vigilant. The sick and the not sick still live together. The first confirmed case was not "identified" until March 7, and within five days thereafter, It was found that more than 70 people had been infected.
In the existing protection guidelines, it is required to do a good job of health monitoring for students and teaching staff, but the specific implementation is "completely conscious". For example, students are required to measure and record their body temperature every day, and when there are fever, cough and other suspicious symptoms, they should take the initiative to report in time. Huang Senzhong suggested that under the new epidemic prevention situation, the regular screening frequency of schools, isolated hotels and other key places should be increased. For example, nucleic acids should be given to students every two weeks. Local governments should also consider introducing more targeted and detailed measures to improve the implementation of policies.
Wu Zunyou, chief epidemiologist of China Center for Disease Control and Prevention, pointed out at the press conference on March 19 that the difficulty of current prevention and control work is how to find all infected people in time. First, we must stop the virus before it spreads; The second is "all". In the whole transmission chain, all people who may be infected should be traced back to avoid any omission. The omitted cases may become the source of the new transmission chain.
In the face of Omikjon, the early preventive containment measures have partially failed, and if they are not "timely", "all" is even more important. However, the "all" strategy emphasized by Wu Zunyou here is not the whole city wide nucleic acid detection, but targeted at local areas. He said that it is best to complete a round of inspection within 1 to 3 days, and the speed must be fast. Each round of testing must complete the screening of all people within the determined local scope. "Pay attention to prevent any omission. If there are omissions in every round, there may be cases that infected people at the social level find out after seven or eight rounds or eight or ten rounds of nucleic acid testing," he said.
In short, large-scale screening should be carried out when the tracking of infected persons and contacts is not effective. According to the model of Huang Senzhong's team, it is assumed that in a city with a permanent population of about 6 million, before the discovery of the epidemic, Omikjon had spread in the community for 10 days, perhaps for 3 to 4 generations. At this time, it will be very difficult to trace the source and tune. He pointed out that if the strategy of all staff nucleic acid once a day is adopted throughout the city, on the one hand, because the infection base exceeds the previous rounds of epidemic, it will bring great pressure to the nucleic acid work at the grass-roots level; On the other hand, the effect of improving screening efficiency is limited. A better strategy is to carry out full staff nucleic acid screening in key areas, that is, to transition from full staff in the whole area to full staff in local areas.
On the evening of March 20, Fujian Quanzhou Fangcang Hospital was officially put into use after two days and nights of rush construction. The shelter hospital is located in the badminton hall and basketball hall of Quanzhou Strait Sports Center. It is divided into Zone A and Zone B, and can accommodate 1039 beds. It is mainly used to receive patients with mild illness and asymptomatic infections. Figure/Zhongxin
He explained that only about 5% of the people infected with Omikjon are ordinary people with obvious symptoms, which is highly infectious, so nucleic acid screening should focus on these 5% of the diagnosed people. The scope of key areas can be defined according to about 10 times the diffusion influence, and all the people in key areas can be tested once a day, Nucleic acid can be measured once every 3-4 days in non key areas.
Shanghai has given a more straightforward name to this "partial full staff nucleic acid": "grid nucleic acid screening." Wu Jinglei, director of the Shanghai Municipal Health Commission, once explained that grid is different from the previous screening model of "full staff multiple rounds of nucleic acid", but in view of the risk situation in different regions, it implements hierarchical prevention and control and delimits several key areas, We will promote "block and grid" nucleic acid screening. In the key areas, all personnel shall keep relatively still in place and need to conduct two full staff nucleic acid screening within 48 hours. Then, according to the number of cases and asymptomatic infected persons screened in the region, age distribution, population distribution, etc., especially in combination with epidemiological investigation to judge the possibility of spread risk, dynamically adjust the next epidemic control measures. In other words, "dynamic adjustment" is a very important part of grid management.
Practice shows that the adjustment of Shanghai's thinking of "focusing on key points" is an effective way to deal with Omikjon. At present, Shanghai has carried out a round of nucleic acid screening for all staff in key areas from March 16 to 17, and conducted a nucleic acid screening for personnel in non key areas in three days from March 18 to 20, with a total of more than 30 million people screened. Wu Jinglei said that through the analysis of the screened positive infected persons, we found that the detection rate of positive infected persons in key areas was higher than that in non key areas, and there was a spot like regional clustering phenomenon.
Huang Senzhong also said that due to the particularity of the epidemic, the idea of the current investigation should also be adjusted. For example, Shanghai has the largest current investigation team, about 3000 people. Even so, according to the current scale of the epidemic, if the number of new cases in a single day is more than one hundred, plus close contact and sub close contact, these people are simply not busy, And the number of people who need to be transferred is accumulating. In other cities with a population of more than 5 million, there are only a few hundred migrant workers. "Recently, some grassroots flow investigators have almost collapsed, and everyone has to deal with one or two hundred pieces of information a day.". Therefore, in the early stage of flow survey, we should first focus on tracking the 5% of ordinary and severe patients, and initially screen out those who are more likely to be infected as soon as possible. After the goal adjustment, "the pressure of flow survey teams around the country should be able to reduce a lot". In addition, many places have developed their own streaming applet to improve the efficiency of streaming through big data.
On the evening of January 27, 400 buses were dispatched from Hangzhou, Zhejiang, to transfer the residents of the Yangtze River Community as a whole to the centralized isolation point. Figure/People's Vision
On March 22, the National Health Commission issued the third edition of the Guidelines for the Implementation of Regional New Coronavirus Nucleic Acid Testing Organizations. Compared with the previous edition, the new edition changed "all staff" to "regional". According to the official information of the Health Commission, the area may be as small as a building, or as large as the whole city. The details should be determined by the local epidemic prevention and control headquarters on the basis of scientific research and judgment, according to the actual needs of epidemic prevention and control, and adjusted dynamically. In addition, the new version of the Guide adds antigen detection as a supplementary means of regional nucleic acid detection, and proposes to promote the monitoring mode of "antigen screening and nucleic acid diagnosis".
Jiao Yahui, the director of the medical administration and medical administration bureau of the National Health Commission, explained that the previous "all staff" was easy to misunderstand that it was to carry out large-scale testing and flood irrigation throughout the city. This time, we changed it to "region", emphasizing more on scientific and accurate delineation of nucleic acid detection scope, and emphasizing that all regions should conduct accurate nucleic acid detection more quickly and effectively. Liang Wannian, the leader of the expert group of the epidemic response and disposal leading group, stressed that the general policy of "dynamic zeroing" should still be adhered to at present, but precise prevention and control is the essence of "dynamic zeroing".
How to ensure medical redundancy?
On March 9, 2022, the epidemic situation in Jilin City will appear for about a week, and the number of confirmed cases and asymptomatic infections on that day will be 295 and 269 respectively. According to the official report, Jilin has two new designated hospitals with 552 beds. According to media reports, within a few days after the outbreak of the epidemic, there has been a shortage of beds in the city.
In Wuhan, the "Central Medical Capital" with rich medical resources, according to 2018 data, there are 81700 hospital beds in the city, but infectious disease beds are seriously insufficient. When Wuhan was virtually "closed" on January 20, 2020, there were only about 800 beds in the city that could be opened to patients with COVID-19. In addition, there were still shortcomings in the department of critical care and graded diagnosis and treatment. At that time, Wuhan's medical system was faced with collapse.
Zhang Wenhong, director of the National Medical Center for Infectious Diseases and director of the Infection Department of Huashan Hospital, said at the press conference on March 17 this year that in the face of Omikjon, who has a significantly stronger ability to spread, it is necessary to continue to improve the vaccination rate, strengthen the reserves of new crown treatment drugs, and at the same time, it is necessary to ensure sufficient medical resources to keep the mortality rate at a low level.
Zhu Jinghai, professor of the School of Public Health of China Medical University and executive director of China Urban Planning Society, pointed out that in public health emergencies, the challenges faced by medical resource supply focused on two aspects: the coordination between the basic medical system and the emergency medical system, and the shortage of space supply for the isolation and treatment of a large number of patients. How to ensure the normal operation of the basic medical system and buffer the pressure of designated hospitals is an important issue in the construction of the resilient medical system.
How many isolation wards, sickbeds and corresponding personnel and medical supplies should be prepared for a city of a specific size when facing an epidemic of what degree of prevalence? There seems to be no standard answer to these questions. According to the requirements, each city at or above the municipal level should designate a designated treatment hospital. Wang Guiqiang, chairman of the Infectious Diseases Branch of the Chinese Medical Association and director of the Infectious Diseases Department of Peking University First Hospital, told China Newsweek that once the epidemic broke out, the designated hospitals would certainly not be enough. From local experience, in the epidemic situation, if more than 60% of the beds in the infectious diseases specialty hospital were used, the standby hospital would start to be started, Because the number of patients will rise quickly.
"We feel that if we can find out the medical resources in each city and draw an early warning line for medical runs, we can take a faster and more accurate hierarchical management of treatment when the epidemic situation is close to the early warning line." A public health scholar told China News Weekly that people pay more attention to this research, but there are few reliable research results, The main reason is that the current amount of medical resources in a city is not very clear, and these data are still dynamic, considering the domestic capacity for rapid mobilization and construction.
Zhu Jinghai and others specifically suggested that megacities, megacities and provincial capital cities should further enhance the treatment capacity of existing infectious disease hospitals and build a large public health clinical center according to the needs and urban capacity. Non provincial capital cities with a permanent population of 1 million to 5 million in urban areas should focus on strengthening the treatment capacity of one or two specialized infectious disease hospitals, and should also properly allocate several emergency medical reserve centers as auxiliary facilities.
A specialized infectious disease hospital should be built in medium-sized cities and small cities. At the same time, some large comprehensive hospitals with strong strength should be selected as emergency backup hospitals. Beds should be opened to ordinary patients at ordinary times, and used for centralized treatment of infectious disease patients during the epidemic. Other economically underdeveloped cities can rely on the existing general hospital infection department for reconstruction and expansion. In addition to these permanent and semi permanent new construction and expansion, in key epidemic areas, temporary rapid expansion can be carried out through new Xiaotangshan model hospital, reconstruction of the original hospital, construction of shelter hospital, etc.
At the beginning of February 2020, there was a run on the designated hospital for newly infected people in Wuhan, and a large number of infected people could not be admitted. Within three weeks, Wuhan rebuilt 16 shelter hospitals from the existing buildings, providing about 13000 beds for the treatment of mild diseases and suspected cases. Among them, the shelter hospital of Hongshan Stadium was completed in only 37 hours.
The shelter hospital accommodates about 20% of the newly crowned patients with severe and critical diseases in Wuhan, while ensuring that 80% of the light and ordinary patients can receive appropriate medical care. Its function is not only to treat, but also to isolate the infected. On or about February 24, 2020, Wuhan achieved "full collection of accounts receivable", becoming a key turning point for epidemic control.
Based on the data of the epidemic situation in Wuhan in early 2020, Wang Hongwei, director of the Management System Engineering Research Center of Huazhong University of Science and Technology, and others calculated the impact of hospital bed expansion on the development of the epidemic situation through the model. The results showed that if there were no 13000 beds in the shelter hospital and 11505 beds in the fourth and fifth batch of designated hospitals, the total number of patients with the epidemic would increase by 10.7% and 8.3% respectively, and the duration of the epidemic would extend by 9 days and 7.4 days respectively.
In January 2022, a total of 297 people attended the annual meeting of Hangzhou Huierte Company, of whom there were confirmed cases. Therefore, the residential quarters involved with the relevant staff of the annual meeting will be transferred to the centralized isolation point as a whole, and the first batch of isolation will be nearly 10000 people. Therefore, Huang Senzhong said that at present, isolation shelters have been built in advance in some areas, which is a good practice. He suggested that in the future, all regions could build some shelters for standby. "In a city with a population of 6 million, building a spare shelter with a capacity of about 20000 can meet the basic needs."
However, Tang Jinling, Professor Rongxiu of Epidemiology at the Chinese University of Hong Kong, also made a preliminary calculation and found that if the epidemic situation rises rapidly, a city's isolation capacity may reach the upper limit in less than a week. The centralized isolation capacity of most inland cities can cope with sporadic and sporadic outbreaks, but most of them cannot withstand the impact of outbreaks.
He assumed that in a city with a population of 17 million, the number of rooms available for centralized isolation of patients is 40000, and there are 15 secret contacts behind each infected person who also need to be isolated. If at the beginning, the number of infected people in this city was 50, and the number of infected people increased at a rate of 30% every day, then infected people and close contacts would occupy 40000 isolation rooms in 10 days, and more than 150000 isolation rooms would be needed in 15 days. Therefore, under the current general goal, a city needs a large centralized isolation capacity, which should be far greater than the actual treatment capacity.
Jiao Yahui said on March 22 that all provinces should now build or come up with construction plans according to the epidemic situation to ensure that each province can have at least 2-3 shelter hospitals. Ensure that the shelter hospital can be built and put into use within two days when it needs to be used.
Why is there always a shortage of emergency supplies? What about drills?
According to the research of Zhu Jinghai and others, China's emergency system is insufficient, and more targeted measures should be taken to deal with the crisis to avoid waste, while systematizing the experience of dealing with the crisis.
More than two years after the outbreak of the epidemic, the shortage of materials still exists. In this round of epidemic in Jilin Province, the Red Cross Society of Jilin Province issued a proposal for donation on March 15. The donation materials include medical surgical masks, protective clothing, protective masks, disinfectant, etc. The staff of Jilin Charity Federation said in an interview with the media that volunteers and medical staff involved in nucleic acid sampling need at least one set of protective clothing, four pairs of gloves and two N95 masks a day, and the existing epidemic prevention materials can only last for two to three days. At about the same time, Yangxin County, Binzhou City, Shandong Province also sent a message of medical supplies for help.
On March 15, the police of Hulunbeier Border Management Detachment on duty collected and delivered living materials for residents in a closed community in Manzhouli City, Inner Mongolia. Figure/Zhongxin
In the face of the lack of medical materials, Jilin Province has launched the "daily dispatching" mechanism of key epidemic prevention medical materials, dispatching the production capacity, reserves, consumption and other conditions of epidemic prevention medical materials in the whole province every day, and assigning special personnel to connect the demand for epidemic prevention medical materials with Changchun, Jilin, Siping, Liaoyuan, Tonghua, Songyuan, Yanbian, Meihekou and other regions, And timely coordinate with the production and circulation enterprises of medical materials to ensure that epidemic prevention medical materials can be delivered in place on time. At the same time, all regions of the province also immediately carried out the supply of medical supplies for epidemic prevention.
In the handling of public health emergencies, the support capacity of emergency supplies is an important link. Especially in the response to the epidemic, masks, protective clothing, etc. are strategic supplies. According to the emergency plan, all regions should have sufficient reserve capacity. Generally speaking, the material warehouse at the municipal level will have some reserves, and all hospitals will have corresponding reserves.
In Huang Senzhong's view, the "lack of supply" in Jilin Province also has its reasons. Because according to the original prevention and control experience, the medical strategic materials in various regions are basically prepared according to the "epidemic scale of about 1000 people", and no one can predict that this round of local epidemic will be tens of thousands. In the future, with the spread of Omikjon, there will be greater uncertainty and contingency in the scale of the epidemic. Therefore, there will be great uncertainty about how much strategic medical supplies should be stored and what standards to refer to, which will also bring challenges to future epidemic prevention and urban emergency management.
In Jilin City, where the epidemic is most serious, in addition to basic medical protective articles such as masks and protective clothing, the core material weakness is nucleic acid detection reagents. Due to the lack of local nucleic acid production capacity, Jilin Province has dispatched 39 mobile nucleic acid detection vehicles and 600 nucleic acid detection teams for support. In the past half month, the nucleic acid detection capacity of Jilin City has continued to increase from 45000 tubes per day to 285000 tubes, but still far below many cities.
In comparison, the single tube nucleic acid detection capacity of Nanjing has reached 1 million tubes per day, and the permanent population of Nanjing is more than 9 million. If the "ten in one" or "five in one" mixed detection is adopted, it is enough to support the whole city to complete a round of nucleic acid detection in 2-3 days. Nanjing also plans to centrally purchase and build 12 shelter laboratories by the end of March, which is expected to increase the detection capacity of 180000 tubes per day. After the outbreak of a new round of epidemic in Xi'an in December 2021, the government dispatched medical personnel from 131 medical institutions to set up a 14400 municipal nucleic acid emergency sampling team. At the same time, it organized 19 third-party laboratories in the city, supporting 5 urban nucleic acid detection bases, and urgently called 33 shelters, 6 air membranes, and 10 detection vehicles, with a daily detection capacity of 1.6 million tubes. There are 164 nucleic acid testing institutions in Shanghai, and the maximum daily nucleic acid testing capacity can reach more than 1.9 million copies per person per tube. At the beginning of March, the number was 1.028 million copies.
It can be found that in these million or ten million level cities with sufficient experience in epidemic prevention, their own nucleic acid detection capability is only one aspect. More importantly, they can quickly mobilize resources to improve their nucleic acid detection capability in a very short time in the face of emergencies.
The second edition of the Implementation Guidelines for All Staff New Coronavirus Nucleic Acid Testing Organizations, released in September 2021, stipulates that in the event of an epidemic, all regions can rapidly dispatch nucleic acid testing forces equivalent to completing single tube testing of 10%~15% of the actual management population to meet the needs of large-scale nucleic acid testing across the region. In addition, cities with a population of more than 5 million should reserve more than 5 laboratories or areas that can be reconstructed for use by nucleic acid detection support teams. Each laboratory or area that can be reconstructed should accommodate at least 5 detection teams, of which each team can detect at least 10000 tubes per day, and generally at least 20-25 people should be equipped with new coronavirus nucleic acid detection personnel. However, according to Huang Senzhong, there are still many cities that cannot reach this "redundancy" reserve.
On March 17, in Shenzhen, Guangdong, Hubei Primary School in Luohu District provided warm services such as overnight stay for delivery workers and couriers. Due to the temporary closure of some communities in Shenzhen, some delivery workers could not return to their homes for rest and chose to spend the night in public places. Picture/Surging Image
In August 2021, Gao Fu, director of the Chinese Center for Disease Control and Prevention, Shi Zhengli, a researcher at the Wuhan Institute of Virology, Chinese Academy of Sciences, and others published an opinion article entitled "Lessons learned from the COVID-19 pandemic". Gao Fu and others pointed out that although the pandemic is unpredictable in nature, proper planning and preparation in advance will help to better respond.
After the SARS epidemic in 2003, China has gradually established an emergency management system based on "one case, three systems". "One case" refers to the emergency plan, and "three systems" include the comprehensive coordination system with the emergency office of the general office (office) of the government as the hub, the response mechanism with prevention preparation, monitoring and early warning, information reporting, etc. as the content, and the legal system including a series of laws and regulations.
Wang Guiqiang pointed out that each place should not only have a reserve hospital for treatment, but also need a fast and smooth starting mechanism. Whether a rescue hospital is ready and can be used at any time depends on whether its space and physical conditions are consistent with the treatment of respiratory infectious diseases, how its ability to treat severe diseases is, and the basic hospital sense training of medical personnel, which is not temporary.
Although infectious disease hospitals of different echelons are being built all over the country, Wang Guiqiang feels that the convergence of various processes is not smooth. He has participated in the treatment of COVID-19 epidemic in many places, and found that there were problems of coordination between departments at the beginning. The diversion of infected persons, the management of close contacts, and the hierarchical treatment were not good. "The plan is available, but the drill is insufficient".
Take Jilin and Shanghai for example recently. When infected people appear in hospitals and other closed places, patients are not diverted at the first time. In one city, although there is a designated hospital specially open to "yellow code" patients with abnormal health codes, it is reported publicly that pregnant women have miscarried because they were not treated in time.
Therefore, Wang Guiqiang said that it is more important to do a good job in the plan and actual combat drills, to refine the degree of how long the ward can be vacated in case of an epidemic. Some links did not expect to go wrong, but it may be found that there are real problems in the drill. In this way, after the infected person is really sent to the hospital, there will be no "chaos". Moreover, hospital drills alone are not enough. This should be a set of coordination mechanisms led by the government. Hospitals, communities, material security and other departments should repeatedly practice and run in.
Tang Jinling also suggested that the medical system should be prepared and adjusted in advance to deal with the outbreak, and that sand table exercises can be carried out step by step. For example, if the medical resources can only allow 1% of patients to be admitted, what about 99% of them? If most patients can only be isolated at home, how to know if an infected person's condition is getting worse, how to deal with it, who can send him to the shelter hospital or designated hospital, and how to send him?
How to meet the medical needs of patients who are not newly crowned?
"When an epidemic breaks out in every city, the patients who need hemodialysis are very upset." Zhian, the initiator of the uremic patient platform "People Like Kidney", told China Newsweek that patients and their families in the city where the epidemic occurs will find them in various ways, fearing that their travel and treatment will be affected. At the most helpless time, some patients said that they wished they were infected with COVID-19 now, at least they could be sent to the hospital.
In Wuhan, a city with a population of more than 10 million, at the beginning of 2020, the sudden outbreak of the epidemic caused some hospitals to quickly close their hemodialysis rooms. Some hospitals were understaffed due to the transfer of medical staff or infection, while others were unable to go out because of the closure of the community... In chaos, thousands of patients in Wuhan who needed hemodialysis had nowhere to go.
On January 28, 2020, Wuhan Municipal Health Commission designated several hospitals in Wuhan as designated hospitals for patients with COVID-19 who need dialysis. However, at the beginning of the process, confusion was caused due to the tight allocation of dialysis machines, insufficient and excessive fatigue of medical staff, and waiting for the transformation of new dialysis rooms. Later, the epidemic headquarters gradually expanded the number of such designated hospitals from 2 to 6 and then to 16, and the problem was gradually solved.
Zhi'an's rescue platform mainly assisted patients in three cities during the epidemic: Wuhan, Lanzhou and Xi'an. During the epidemic in late December of last year, many hospitals in Xi'an with a large number of dialysis beds stopped diagnosis "to meet the needs of epidemic prevention and control". Some people who needed dialysis were once unable to go out for medical treatment because of the closure of the community, even if they had a green code.
On January 19, in Xi'an, Shaanxi, under the control of the epidemic situation, the community was closed and managed. The couriers sorted the goods outside the isolation barrier of the community to facilitate the property management staff to sort and classify. Figure/People's Vision
Hemodialysis, which is carried out regularly every few days, is one of the renal replacement treatments for patients with chronic renal failure, and is the key to maintaining the life of this group. In fact, the dialysis problem of uremic patients is only one of the treatment needs that cannot be ignored in the emergency state. Other patients who cannot afford to wait include patients with myocardial infarction, pregnant women, tumor patients who need regular chemotherapy, etc. At present, because of the lack of emergency plans, the medical security of this part of the population often depends on private forces. Zhian's platform has also helped AIDS patients in epidemic cities to obtain drugs.
Huang Yuguang, member of the Beijing Municipal Committee of the CPPCC and chief physician of the Department of Anesthesiology of Peking Union Medical College Hospital, also said that during the epidemic period, it was difficult for non COVID-19 patients to enter the hospital area when they went to see a doctor, and they needed to carry 48 hour nucleic acid reports, which caused obstacles for those with acute and critical diseases who went to see a doctor specially. Because of the complex diagnosis and treatment process, the emergency department of most hospitals often has a large number of patients staying, especially some emergency and severe patients.
Traditionally, hospitals should focus on the "4S" framework for emergency response during the pandemic: materials, personnel, space and systems. However, Jeremy Kahn, a doctor in the emergency department of the University of Pittsburgh, and others wrote in the Journal of the American Medical Association (JAMA) last July that these elements are necessary, but not enough, A comprehensive perspective is to investigate the organizational resilience of hospitals.
One of the manifestations of resilient hospitals is that they should ensure the treatment of non infected people, including tumor patients, patients who need emergency cardiac surgery and surgical trauma treatment, while responding to the outbreak of the epidemic. This depends on a number of factors, including flexible electronic health records, inter hospital collaboration, regional referral network, etc.
For example, during the epidemic, the Arizona Department of Health Services and hospital managers jointly established an emergency scheduling system called "Surge Line" to coordinate the participation of more than 100 hospitals in the state, achieve rapid placement of newly crowned patients, and balance patients and medical resources, such as ICU beds, ventilators and medical care.
A hemodialysis doctor analyzed in an interview with the media that the number of dialysis machines and the medical staff in the hemodialysis room in Wuhan were originally sufficient. Disorder and closure of the dialysis room were the root causes of "insufficient capacity". What needed to be done under the epidemic was the rational allocation of resources. If there is a plan and experts participate in decision-making, some arrangements can be made in advance to reduce disorder.
In Zhian's view, when the epidemic did not occur, an urban area should be aware of the number of patients requiring long-term treatment, the types of diseases and the hospitals for routine treatment in its own jurisdiction. In addition, it also includes the medical resources in the region. Based on this, an emergency plan should be developed in advance, so that patients can be re matched with medical resources when the epidemic occurs.
At the Beijing CPPCC meeting in January this year, Huang Yuguang suggested that a triage mechanism should be established to improve the "green channel" for emergency and critical care for special populations. At the same time, designated hospitals and special clinics for emergency and critical care for non newly crowned patients should be established in all districts to fully mobilize the existing collaborative mechanism of hierarchical diagnosis and treatment and medical consortium, so as to link referral.
Also, public policy makers gave more detailed suggestions from the perspective of patients, for example, to ensure that patients with sudden diseases (such as stroke) who need to be admitted to hospital can get the test results in the shortest time; When patients from medium and high risk areas go to hospitals in low risk areas for medical treatment, the hospital should allow patients to be qualified to register after arriving in the city where the hospital is located. During the 14 day isolation period, they can first conduct remote video and telephone inquiries with doctors to determine the next possible treatment steps and plans.
But that is not enough. Zhian said that in the prevention and control of the epidemic in many cities, there are actually policies for the treatment of pregnant women, hemodialysis patients and other special groups, as well as emergency and critical patients. However, there is a lack of practical details in the implementation. For example, he recently met a dialysis patient with a private car, nucleic acid report and dialysis certificate, but the community must follow the policy and require the patient to find 120 ambulances, which is difficult during the epidemic.
Therefore, Zhian believes that the government should also give terminal executors a loose authority to allow them to adjust flexibly according to the actual situation. "A resilient medical system should have greater freedom, allowing institutions to consider a series of solutions for a single problem, and quickly turn when the pre planned solutions do not work." Jeremy Kahn, a doctor in the emergency department of the University of Pittsburgh, and others wrote.
How to ensure the basic life of citizens?
With the expansion of the scope of nucleic acid screening in Shanghai, a number of Shanghai residents in Fengkong Community reported to reporters that when placing orders on e-commerce platforms such as Hema and Meituan recently, they sometimes "failed to get the goods". "You must start buying at six in the morning. Sometimes you can buy it, sometimes you can't buy it. After seven o'clock, you can't buy it." A Shanghai citizen who has been closed down for management told China News Weekly. However, she said that before being sealed off, the community would notify them 1 to 2 days in advance to purchase materials.
In response to the phenomenon that some supermarkets are out of stock and the speed of online shopping and delivery is slow, Liu Min, Deputy Director of Shanghai Municipal Commission of Commerce, said on March 13 that e-commerce platforms and supermarket stores are actively guaranteeing supply, and some enterprises provide point-to-point services for residents in closed communities through online and offline linkage. At present, the average stock volume of the just needed categories of e-commerce platforms in Shanghai's front warehouses has reached 1.5 to 2 times the daily level, and the supply of goods in most regions is sufficient. In addition, a list of supply guarantee enterprises such as key wholesale markets, supermarket stores and e-commerce platforms has been established. Together with relevant departments, we will accelerate the establishment of inter provincial and intra city logistics and transportation green channels, give priority to the nucleic acid testing of relevant practitioners, and ensure the stable and orderly supply of main and non-staple food markets.
On March 21, an "empty city" appeared in Shanghai under the epidemic. In the past, the Bund and Nanjing Road pedestrian streets were crowded one after another, with few tourists, almost no one. Picture/Surging Image
At present, the pause button has been pressed for daily life in many cities. In order to deal with Omikjon, many areas with serious epidemic situation have adopted temporary traffic control+community closure. In this context, the challenges faced by these cities are similar to those faced by Wuhan and other places in the early stage of the epidemic. In terms of material supply, logistics support and other emergency contents, the test is not only the hardware resources of a city, but also its refined governance capability, especially the governance capability of the grass-roots level.
In the last round of epidemic in Xi'an, which broke out at the end of 2021, Xi'an implemented the "most active" epidemic prevention control after the epidemic in Wuhan and Shijiazhuang. After December 22, 2021, almost all citizens in the city will be sealed in the community, unable to move. At that time, it was difficult to buy food and get medical treatment in Xi'an.
In retrospect, it was difficult to supply living materials in Xi'an in a timely manner, not because the supply of goods was insufficient, but because of the lack of "delivery boys" and transport vehicles, many people were "sealed" in the community and could not work normally. Take Hema as an example. Due to the tight transportation capacity, only three batches of online orders were opened every day at 0:00, 8:00, and 12:00. A delivery platform station originally had 70 delivery staff, but after the "closure", the number quickly dropped to 20, and later to 7. After the "closure of the city", under the one size fits all policy of "staying at home", the delivery staff, couriers, nurses, drivers and volunteers were trapped in their own communities. They are the capillaries that maintain the basic operation of a city.
In order to solve these problems, Xu Mingfei, Vice Mayor of Xi'an, pointed out on December 31, 2021 that the government started to strengthen the supply guarantee from three aspects: at the front end, organize five large-scale vegetable wholesale markets to increase the supply of goods and ensure market supply; In the middle end, open a green channel for vegetable transportation to ensure the normal operation of logistics enterprises and smooth vegetable distribution; At the end, the supermarket, logistics, distribution and other staff should be determined to return to their posts as soon as possible without risk, and cooperate with community front-line staff "internally and externally".
In Jilin, in order to ensure the supply and guarantee of all kinds of living materials, the system of "Jilin Province Emergency Material Pass for Epidemic Prevention and Control" and "Emergency Transport Pass" has been established locally, and the application process of important material transport vehicles has been clarified. Up to now, 15986 ordinary trucks, 244 dangerous goods trucks, 148 tractors and 48 cold chain cars have been dispatched in the province, ready to carry out emergency material transportation in various places.
However, the reporter found in the interview that even with the support of these mechanisms, grass-roots practice still faces many difficulties in the "last hundred meters" of security services. For example, in the Xi'an epidemic last year, many residents of a control building reported to China Newsweek that it was difficult to buy vegetables, and contacted the community several times, which was not solved. The community staff explained to China News Weekly that after residents of Fengkong Building bought vegetables on e-commerce, the takeout would be delivered downstairs, and each building had a butler who would uniformly "deliver". If residents have any demand, it can be reflected in the owner group, and the housekeeper will solve it "point-to-point". But the problem is that there are more than 1000 people in each building, and there is only one building manager in each building, who should not only help organize nucleic acids, but also be responsible for docking material needs.
Therefore, having sufficient community workers is an important part of solving this problem. In the evening of March 5, Dongjing Town, Songjiang District, Shanghai suddenly received a notice that due to the abnormal nucleic acid of residents in Runjingyuan Community of Pingyang Community under its jurisdiction, it was necessary to seal, control and manage, involving 7000 people from 2198 households. Therefore, the community organized Dingdong to buy vegetables overnight to "pack" living materials, one for each household, including pork, chicken, potatoes, carrots, vegetables, etc., which were sent to the closed community early the next morning, all free of charge. "Because the community was closed in an emergency, we were worried that some families did not have food reserves, so we temporarily prepared a material for them for emergency use." A staff member of the Dongjing Town Government in Shanghai explained to China News Weekly.
It is understood that the deliveryman and driver should wear protective clothing in the isolation area outside the community before entering, and put food in the designated delivery area outside each unit. The community is equipped with 2~6 volunteers for each unit building, mainly composed of cadres who have sunk to the grass-roots level. If there are positive key sealing and control units, the volunteers in isolation suits will deliver the goods to the door in person. If there are ordinary sealing and control units, the community will organize residents to go downstairs in batches to do nucleic acid and pick up the goods and materials. For some elderly people with inconvenient legs, Volunteers also provide on-site services.
Zhang Yi, Vice President of Dingdong Shopping, told China Newsweek that after the grid governance in Shanghai, some employees were "sealed" in the community and could not be delivered. In order to solve the problem of transportation capacity, the Shanghai Municipal Commission of Commerce issued a guarantee certificate for Dingdong to buy vegetables. With this "red headed document", and under the unified leadership of the Shanghai Municipal Commission of Commerce, one-on-one communication with the district commissions of commerce was conducted to open a "green channel" for the sealed employees. Employees can be "liberated" from the closed community by presenting the supply guarantee certificate+work certificate, and then relying on the 48 hour nucleic acid negative report. After that, Ding Dong will separately arrange unified accommodation for these employees to solve the travel obstacles during the closure period. After coordination from top to bottom, hundreds of employees returned to work from the closed control area. However, in some areas with more enclosed areas, such as Pudong, Xuhui and Minhang, the transport capacity is still relatively tight.
However, Zhang Yi also said that in the process of coordination with governments at all levels, there are sometimes some problems that need coordination at all levels, from the district level to towns and streets. She hopes that when major public health events occur again in the future, governments at different levels can better unify their statements or improve the efficiency of information transmission in terms of coordinating the supply of enterprises. "However, compared with many places, Shanghai has done a very good job in this area. At least, I can find a leading department in the city, and after communication, I can respond and coordinate," she said.
Wei Sheng, professor of the Department of Epidemiology and Health Statistics of the School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, pointed out to China Newsweek that the reason for the problem of material supply and logistics under the epidemic is that the "last kilometer" was interrupted, which is not a shortage of materials, nor just a traffic barrier after the city was suspended. In the final analysis, It is a problem of community governance.
"Therefore, the most important thing is to have an emergency plan. The government department should have a plan, and the community should also have a plan. For example, when the community is suddenly closed, how to collect the residents' material needs in the shortest time, and then transmit them to the relevant departments, who will arrange scheduling, who will be responsible for procurement, who will be responsible for transportation, and how to mobilize more manpower when the community is short of staff. Generally speaking, the civil affairs and commercial departments are jointly responsible for ensuring supply, and a security group should be established between the community and the supply guarantee department. The epidemic often comes in a hurry. If a detailed emergency plan is not prepared in advance, even in areas with good urban governance such as Shanghai and Shenzhen, there will be confusion at the beginning. " He said.
Is epidemic prevention strategy enough?
As of March 20, although the epidemic situation in some parts of China has eased, it is still on the rise nationwide. According to the data from the National Health Commission, 1947 new local cases were reported nationwide from 0:00 to 24:00 on March 20. The number of new cases in Jilin Province remained high at 1542. The epidemic situation in Fujian developed rapidly, with 154 new cases added in a single day. The epidemic situation in Hebei, Guangdong, Shanghai and other places is still fermenting.
Liang Wannian, the leader of the expert group of the leading group for epidemic response and disposal of the National Health Commission, interpreted the two meanings of "dynamic zeroing" on the 20th: first, the ideal state, there is no patient in society, but the uniqueness of COVID-19 determines that we cannot do it for the time being; The second meaning is that once an epidemic situation occurs, it can be quickly identified and handled, cut off the transmission chain, and the social aspect will gradually move towards dynamic zero clearing. "If we do not pursue dynamic zeroing, social communication will continue to connect and form a large-scale rebound," Liang Wannian said.
In Huang Senzhong's view, this is not only a choice of epidemic prevention strategies, but also an epidemiological problem, and also a social problem. It involves the game and balance of science, resources, mechanisms, human resources, finance and concepts. The answers given by different cities reflect the comprehensive governance level of a city.
"In fact, all regions have their own emergency plans, but in some places they are useless, some are unable to keep up with the governance capacity, some are lack of vigilance against the epidemic, and some may be due to financial constraints," he said.
He also pointed out that this plan does not correspond to a single response strategy, but to different development situations of the epidemic, different strategies should be adopted, such as when to "stop", and whether there is a scientific basis or quantitative indicators for reference. From the epidemiological point of view, we can conduct large-scale research and judgment through data simulation, and then provide basis for decision-making. But in reality, "foot ban" is a difficult decision.
When China News Weekly asked Gao Fu, the director of the China Center for Disease Control and Prevention, "How should we respond to a virus strain of high transmission power like Omikjon once a local outbreak occurs on a large scale? Has the industry studied the plan or conducted sand table exercises?" He only answered four words: "Good question."
Editor on duty: Wang Lin
