Managing Close Contacts of COVID-19 Confirmed Cases in Metropolitan Areas in China: A Community-Driven Preparedness Strategy
by Jing Ding, BM, MS; Wen-Jan Tuan, MS, MPH, DHA; and Jonathan L. Temte, MD, PhD
The novel coronavirus (COVID-19) outbreak has rapidly spread across the world since it was first reported in late December 2019 in the People’s Republic of China. The rapid and wide distribution of the disease has not only become a serious public health challenge but also has led to a global economic downturn. Virologists identified COVID-19 as a zoonotic coronavirus resulting in human respiratory infection similar to that of severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS). Unlike SARS and MERS, the COVID-19 outbreak has resulted in lower mortality yet higher prevalence, while sharing similar epidemiological characteristics to those of influenza pandemics in the last century. As our medical industry partners continue to develop vaccines and pharmacologic treatments, it is also important for public health implementation of non-pharmacologic interventions (NPI) that can effectively mitigate the risk of the fast-spreading disease across highly-populated residential areas, especially among individuals who have close contact with confirmed cases.
To strengthen our responses to control and manage the COVID-19 outbreak emergency in China, we introduced a community-driven preparedness strategy involving the collaboration of local health departments, public safety authorities, neighborhood councils, and community health centers (see Figure below). The partnership allows existing resources and coordination networks to be leveraged and utilized by populations at highest risk from the COVID-19 infection.
Because most people in China live in densely-populated metropolitan areas, the person-to-person spread of COVID-19 has been a major public health concern for individuals who are in close contact with one another. The Chinese Center for Disease Control and Prevention (CCDC) has required that all COVID-19 confirmed cases be recorded and documented in a national notifiable disease surveillance system (NDSS).
Essentially, individuals meeting COVID-19 screening criteria (eg, travel/contact history, temperature≥37.3°C, sore throat/cough) should be immediately seen at fever clinics which specialize in treating severe respiratory illness. When suspected cases are confirmed with COVID-19 through chest CT and/or polymerase chain reaction (PCR) testing, clinicians at the fever clinics must enter case information into the CCDC’s NDSS database* within 2 hours. After receiving reports newly confirmed cases, an epidemiological services team at CCDC or trained medical professionals at local clinical facilities start a contact investigation to compile a list of persons who had close contact with confirmed cases.
Those individuals with close contact then become persons under investigation (PUI) for probable cases.
To reduce the risk of community spread, individuals who have been exposed to COVID-19 must be notified or treated immediately. The CCDC disseminates the PUI list to both the district health department and the community health center (CHC) where the PUI resides. The district health department then informs the district administrative government and neighborhood councils about the PUI in the community. The district government also notifies neighborhood councils about the PUI. The neighborhood council will further share the PUI list with local police stations. The cross-agency notification process is designed to ensure that all the key healthcare or civil stakeholders have access to the PUI information through multiple channels.
The partnership among the CHCs, neighborhood councils, and police stations enables healthcare professionals, social workers, and law enforcement officials to quickly form a taskforce team and conduct home visits to the PUI. During a home visit, a CHC’s clinician performs the standard COVID-19 screening assessment for the PUI**/***. Any PUI showing SARS-COV-2-like symptoms is immediately transported by ambulance to a fever clinic for chest CT and/or PCR tests. The PUI who does not meet symptomatic criteria is provided with one of two NPI options. In principle, all persons under investigation should stay in designated quarantine facilities for 14 days, wherein clinicians continue to monitor the health status of the PUI.
To be sensitive to each person’s circumstance, however, individuals who have special medical needs and/or family obligations (eg, caring for family members) can opt for the personal NPI that requires the PUI to undergo a voluntary 14-day home quarantine. The recommendation is made by the joint assessment by CHC clinicians and other taskforce members regarding whether the PUI’s residential setting is appropriate for voluntary home quarantine. Clinicians at the CHC monitor the clinical condition of individuals in home quarantine. In addition, the neighborhood council is responsible for helping to provide home quarantined individuals with basic necessities for living, such as provision of food and garbage collection. For the PUI who refuses to comply with isolation requirements or who breaches quarantine regulations (eg, by leaving home before the end of the isolation period), the public security authority may take necessary measures to enforce quarantine compliance*. Employers are required to provide quarantined individuals special leave without using vacation or sick leave days.
The PUI is released after completing a 14-day isolation period. Individuals staying in quarantine facilities receive a discharge note issued by the doctor of the quarantine facility. Persons under home quarantine are provided with a discharge note by the doctor of the community health center. The PUI with a discharge note is permitted to go back to work or school. If SARS-COV-2 symptoms are detected during the quarantine period, the PUI is immediately transported to a fever clinic for chest CT and/or PCR testing. If the test result is negative, the PUI resumes the previous NPI and remains in quarantine.
If the result of the COVID-19 diagnostic test is positive, the PUI is immediately hospitalized for further tests and treatments. The confirmed case is also reported to the CDCC’s NDSS database*. After recovering from the disease and when free of the virus, the patient is released from the hospital with a discharge note issued by the doctor of the hospital. The health status of the patient is monitored by clinicians at the CHC for another 28 days.
This management plan briefly summarizes how governmental, healthcare, and community organizations in China collaborate to establish critical situational awareness and build a sustainable partnership in response to the COVID-19 outbreak. This partnership provides a means of pooling the abilities, expertise and resources of various stakeholders to positively affect community health, through political empowerment, capacity building, and social actions.
*Executive Committee of the National People’s Congress of the People’s Republic of China. Law of the People’s Republic of China on the prevention and treatment of infectious disease. http://www.chinacdc.cn/jkzt/crb/xcrxjb/201810/t20181017_195159.html. (Click to view PDF.)
**Chinese Thoracic Society, Chinese Society of General Practice, Chinese Association of Chest Physician, et al. Expert recommendations for the prevention and control of novel coronavirus infections in primary care (1st ed). Chin J Gen Pract. 2020;19. doi:10.3760/cma.j.issn.1671-7368.2020.00. (Click to view PDF.)
***National Health Commission. Diagnosis and Treatment Plan of Covid-19 (Trial 7th ed). Mar 04, 2020. http://www.nhc.gov.cn/yzygj/s7653p/202003/46c9294a7dfe4cef80dc7f5912eb1989.shtml. (Click to view PDF.)
Jonathan L. Temte, MD/PhD, is Associate Dean for Public Health and Community Engagement at the University of Wisconsin School of Medicine and Public Health and professor of Family Medicine. He served on the U.S. Advisory Committee on Immunization Practices and is a member of the CDC’s Board of Scientific Counselors.
Wen-Jan Tuan, MS, MPH, DHA, is a senior analyst at the University of Wisconsin School of Medicine and Public Health. Dr. Tuan has held various analytical and leadership roles in the state health agency, academic health centers, and private healthcare service firms during the past 20 years. His research has contributed substantially to enhancing the efficiency of health system management and operation processes. Dr. Tuan’s interests include patient risk stratification strategies and team-based care optimization by applying EHR-based big data analytics, including machine learning and natural language processing.
Jing Ding, BM, MS, is Deputy Director of Yuetan Community Health Service Center of Fu Xing hospital, Capital Medical University. She is an Associate Professor of College of General Medicine and Continuing Education of Capital Medical University, and a master instructor in major of general practice.