Tag: Health

Engaging the Community to Defeat COVID-19 in the PRC

A volunteer registers information for a resident at a COVID-19 testing site in Jilin city, Northeast PRC's Jilin province, 18 March 2022. [Photo/Xinhua]

Rainbow community, Huiji district, Zhengzhou city, Henan province

In the People’s Republic of China (PRC), the community is the critical battlefield for preventing and controlling the coronavirus disease (COVID-19). Early detection, early reporting, and reduction of transmission risk are the community’s weapons. Community engagement is key to “turning off the tap” of COVID-19. Rainbow, a community of 5,655 households, embodied these good practices.

On 24 January 2020, the eve of Chinese New Year, millions were on the road rushing to family reunions. That was when the news broke: a lot of COVID-19 cases had been found in Wuhan and the city was locked down from the evening of 23 January 2020. Rainbow’s New Year preparations came to a halt, and the fight against the pandemic started and has continued since then.

Community mobilization

“Protect neighborhoods for our communities, protect communities for our city.” ~ Community branch secretary

Rainbow’s leadership immediately mobilized residents into joint working groups and set up a data platform and a health communication network. “We declared war on COVID-19,” said the community branch secretary. “Our duty is to control it.”

Strengthening community leadership and organization

Community leaders called emergency meetings. They formed a joint prevention and control leadership working group, with representatives from the community committee, health sector, grid team, and residents. They set up a communication and information exchange mechanism among local organizations and formed working groups for the neighborhood committee, health care, volunteers, and residents (Figure 1).

Figure 1. Rainbow Community Response and Working Groups for Community Engagement

Building community information database

The joint team built an information database to understand residents’ baseline conditions. Committee members conducted a diagnosis and needs assessment in the first 2 weeks. Community workers went door to door to survey households. They screened those who had returned from Wuhan and other high-risk areas. They collected households’ health management information, including personal information, work settings, travel history, and so on, and stored it in the database to guide the groups’ work.

Public health education and health promotion

Committee members launched health information and education drives. Mobile loudspeakers made the rounds to remind people to wear face masks, wash their hands, practice social distancing, ensure their rooms’ natural ventilation, observe cough etiquette, among others. Health workers put up more than 3,000 posters containing key health messages in neighborhoods and handed out brochures about how residents could protect themselves.

The residents’ representatives were key. They compiled residents’ concerns and inquiries for public opinion monitoring, which shaped key messages and information. They documented rumors and misinformation so that community health workers could counter them with the help of health education professionals. The residents’ representatives closely followed official social media accounts and forwarded the latest information, announcements, and knowledge to everyone in their social media networks.

Community participation and involvement

The residents were the backbone of COVID-19 prevention and control (Figure 2).

Management workers of residential buildings (i) sent out epidemic notifications, government policies, and updates via residents’ networks and WeChat groups; (ii) called on everyone to take action and do their share by not traveling, for example, or gathering or going out; and (iii) quickly notified the health-care working group of high-risk people arriving from abroad or high-risk areas.

Community singing and dance groups shared health education information with their members every day. “Everyone’s more aware of how to prevent and control COVID-19,” Yi Wang, the community dance team leader, said proudly. “They stay home, easing the checkpoint personnel’s work.”

Figure 2. Community volunteers guarding the entrance of a residential complex, where they asked visitors and residents about their travel history, took their body temperature, and provided them with face masks, health education leaflets, disinfection services, among others. Source: Meipan.cn

The 1-2-3-4 model for managing home quarantine

Rainbow strictly implemented the 1-2-3-4 model to manage home quarantine. With the virus spreading and more people returning from Wuhan and other high-risk areas, home quarantine was an important deterrent against COVID-19. Rainbow recruited volunteers for the Little Red Elephant team to bring support services to quarantined people 24/7.

The 1-2-3-4 model was carried out as follows:

  1. Community grid team members inspected quarantined households every day to ensure people did not go out. Team members asked questions such as, “Did anyone of you travel for the Spring Festival or other reason? Does anyone here have flu symptoms?” They also instructed household members to monitor their body temperature.
  2. Community health workers were responsible for two things: (i) visiting people’s homes to monitor the body temperature and symptoms of those in quarantine and (ii) providing them with psychological counseling and teaching them to protect themselves and disinfect their homes.
  3. Community volunteers collected household garbage every day for centralized disinfection.
  4. Community volunteers delivered vegetables and other necessities to those in quarantine, shopped for them, and gave them packs containing a thermometer, a face mask, a registration form, disinfectant, and health education materials. All goods ordered by those in isolation were delivered to the entrance of the neighborhood. Then community workers and volunteers instructed residents to get them in batches according to a schedule, avoiding direct contact with anyone and maintaining social distance. Community workers and volunteers also helped patients with chronic diseases buy medicine or visit hospitals for check-ups.

Menglan Zhang, a resident, was grateful to the community workers and volunteers. “When I ran out of food, they brought me food. When I needed something, I called them and they shopped for me. They even sent us yuanxiao (glutinous-rice balls) for the Lantern Festival even though we didn’t ask for them.”

Author
Xuefeng Zhong

Xuefeng Zhong

Public Health Specialist (Consultant)

Good Practice: Health Education to Promote COVID-19 Vaccination in the PRC

A woman receives a booster dose in Chaoyang district of Beijing on 13 July 2022. [Photo/Xinhua]

The PRC has fully vaccinated 90% of its 1.413 billion people. Health education and promotion have been crucial to achieving such a high rate of protection.

Background

The success of coronavirus disease (COVID-19) vaccine development has been key to ending the pandemic. The vaccines have not only prevented transmission but also reduced the rates of severe COVID-19 and mortality. To build herd immunity, the PRC has vaccinated almost everyone since four vaccines were conditionally approved on 31 December 2020.1 Although the vaccines have controlled the pandemic and their benefits have been clearly demonstrated, a significant proportion of people still refuse to be vaccinated. A well-designed health education approach to overcome vaccine hesitancy is important to improve vaccination rates.

The PRC’s vaccination strategy

The national vaccination strategy has three steps:

  • Vaccinate populations at higher risk of infection, such as health-care professionals, customs staff, airport employees, teachers, community health workers, and others whose work puts them at risk.
  • Vaccinate the elderly (60 years or older), adults with medical conditions, and those over 18.
  • Vaccinate the whole population, including children and adolescents, as vaccine supply is guaranteed.

Source: Z. An, F. Wang, A. Pan, Z. Yin, L. Rodewald, and Z. Feng. 2021. Vaccination Strategy and Challenges for Consolidating Successful Containment of COVID-19 with Population Immunity in China. BMJ. 1 (375): e066125.

Health education strategy

Because the COVID-19 vaccine was an innovation, many people took a wait-and-see attitude toward vaccination.

A Beijing Municipality survey in May 2020 found that about 70% of the respondents were willing to be vaccinated.2 The most cited reasons for refusing the vaccine were that (i) production was rushed and thus the vaccine was dangerous, (ii) the vaccine was useless because COVID-19 was “harmless,” (iii) the vaccine’s efficacy was doubtful, (iv) respondents believed they were already immune, and (v) the vaccine’s provenience was uncertain.3

To increase vaccine coverage, health workers and other responsibility bearers should improve people’s vaccine knowledge and attitudes. Health education and health promotion include policy advocacy, social mobilization, community engagement, communication and dissemination of health information, and effective evaluation.

Policy advocacy and social mobilization. The government released policies and regulations early on to make vaccination accessible and safe. The measures covered equitable access, vaccination location and scheduling, vaccine supply with cold chain infrastructure, health-care service staff training in vaccination, and vaccination management.4 The government formed joint working teams from multiple sectors to expedite vaccination.

Dissemination of vaccination knowledge and information. The government developed and distributed health education and information material targeting different groups. Agencies used various channels or media, such as government press conferences, government websites, TV, radio, posters, leaflets, question-and-answer kits, and social media platforms such as WeChat official accounts and WeChat videos. The aim was to spread knowledge on the COVID-19 vaccine: why it was important to get vaccinated, the benefits of vaccination, how to make a vaccination appointment, and who were eligible for a vaccination, among others.

Community engagement. Community organizers aimed to encourage residents, especially older adults, to get vaccinated. Community engagement not only provided health education for target groups but also organized residents to make appointments and provided transport to vaccination sites, including community health service centers, centers for disease control (CDCs), hospitals, and clinics.

Community health education included (i) delivery of key health messages through banners, announcements (vaccination rates and numbers on neighborhood boards), and community WeChat groups; (ii) community lectures by professional and technical personnel, followed by questions and answers and discussions; (iii) counseling on vaccination through a hotline; and (iv) health education and counseling during home visits by community health workers and volunteers.

Organization involvement. Organizations, including institutes, enterprises, schools, and companies, were among the best promoters of health education. Their activities included mobilization meetings, posting information on websites, and announcements on public boards. To expedite vaccination, for example, organizations scheduled their workers’ shots in the workplace.

Vaccinating older adults

Vaccinations are one of the most widely accepted preventive services in the PRC. Vulnerable populations such as elderly adults and people with underlying chronic diseases need them most. In March 2021, Beijing became the first city to vaccinate those 60 years and older. However, the elderly vaccination rate is lower than in Europe, the United States, and other Asian countries because elderly Chinese know less about vaccination and are more hesitant to get vaccinated. Awareness of COVID-19 vaccines must be raised and public confidence in vaccines heightened. Take what Beijing authorities did as an example:

What did the elderly need? Health workers assessed the needs of the elderly through home visits and community meetings. The Beijing CDC used the results to develop a health education plan:

Key point for health education 1

Assess needs to understand the target group, what factors influence its members’ decision on vaccination, including barriers and facilitating factors (who, what, why).

Who was the target group? Those aged 60 years and older.

Why didn’t people want to be vaccinated? They (i) believed that vaccines were not safe, (ii) were uncertain of the vaccine’s effectiveness, and (iii) thought staying home meant no risk of infection.5

What content should be delivered? Based on the needs assessment, health education professionals summarized the concerns that must be tackled when disseminating information about vaccination:

Six key questions that need to be answered about the COVID-19 vaccine

  1. Why do the elderly need to be vaccinated?
  2. What if the elderly have side effects?
  3. Why do the elderly need three doses of the vaccine?
  4. If the unvaccinated elderly stay home, are they safe?
  5. Is the vaccine safe for the elderly suffering from hypertension, diabetes, and coronary heart disease?
  6. Why should the elderly be observed for half an hour after vaccination?

Key point for health education 2

Design dissemination methods based on the best way to reach target groups (when, where, how).

Designing dissemination methods

Those reaching out to target groups must understand when, where, and how to deliver health messages.

When. Health educators must know when to release scientific data. Evidence from Hong Kong, China demonstrated that of those who died at a median age of 86 years, 92% had had a long history of illness and 72% had not been vaccinated.6 The Beijing Health Commission used published and reported data on Hong Kong, China to promote vaccination among the elderly. Health educators used scientific data when publishing in official webchat accounts and websites. Counseling of the elderly on vaccination increased.

Where. WeChat became the most popular channel for getting information, messages, and knowledge to people. Health education materials were published by the Beijing CDC WeChat account and posted by district CDCs and others on their websites.

How. The needs assessment showed that the elderly got health information mainly from family members, TV, posters, and WeChat videos and that they trusted health experts and key opinion leaders.

Posters showing the elderly being vaccinated. Health educators designed posters using images of elderly advocates or endorsers getting vaccinated.7

Posters promoting vaccination of older adults

Posters showing key opinion leaders’ answers to questions. The top national experts are the most respected and trusted by the elderly. Posters used such an expert for posters showing Six Questions and Answers on vaccination.8 Dr. Guiqiang Wang is a famous chief physician of infectious disease, a member of the National Expertise Team on COVID-19 Prevention and Control, and director of the Infection Department of the First Affiliated Hospital, Peking University. The posters were published in People’s Daily WeChat, the most respected and trusted official account.

Six Key Questions and Answers by Dr. Guiqiang Wang

BTV WeChat video. Yang-Sheng-Tang [养生堂, How to Stay Healthy and Live Long] is a highly popular TV show among the elderly. A mini video was shown on the Beijing Satellite TV official WeChat.

Mini video: Vaccination, to protect yourself and the people you love most 

Effectiveness

By April 2022, the elderly vaccination rate had reached 80% in Beijing.9 By August, a total of 3.43 billion doses of the vaccine had been administered in the PRC, and 1.27 billion or 89.9% of the total population had been fully vaccinated. A total of 239 million people over the age of 60 (90.24% of all elderly) had been vaccinated and 226 million (85.33%) had completed the full course. A total of 176 million elderly had received booster shots.10

1 Press conference by the Joint Prevention and Control Mechanism of the State Council, 31 December 2020.
2 R. Ma, L. Suo, L. Lu, et al. 2021. Willingness of the General Public to Receive the COVID-19 Vaccine During a Second-Level Alert—Beijing Municipality, China. CCDC Weekly. 3 (25):7. 
3 G. Troiano and A. Nardi. 2021. Vaccine Hesitancy in the Era of COVID-19. Public Health. 194 (2).
4 COVID-19 Vaccine Technical Working Group. 2021. Technical Vaccination Recommendations for COVID-19 Vaccines in China. CCDC Weekly. 3 (21).
5 R. Ma, L. Suo, L. Lu, et al. 2021. Willingness of the General Public to Receive the COVID-19 Vaccine During a Second-Level Alert—Beijing Municipality, China. CCDC Weekly. 3 (25): 7.
6 Government of the Hong Kong Special Administrative Region of the People’s Republic of China. Together, We Fight the Virus!
7 Beijing CDC WeChat official account.
8 People’s Daily WeChat official account.
9 Baidu. 2022. 北京60岁及以上人群新冠病毒疫苗接种率超80% [Over 80% of people aged 60 and over in Beijing have been vaccinated against COVID-19]. 13 April.
10 Press conference of the Joint Prevention and Control Mechanism of the State Council, 8 July 2022.

Author
Xuefeng Zhong

Xuefeng Zhong

Public Health Specialist (Consultant)

Risk Communication in the PRC:
Good Practices in Zhejiang Province

Doctors offer services to residents at a community in Nanhu district of Jiaxing, East PRC's Zhejiang province, 11 January 2023. [Photo/Xinhua]

Risk communication is “the real-time exchange of information, advice and opinions between experts, community leaders or officials and the people who are at risk, which is an integral part of any emergency response.” 1

Risk communication aims to provide scientifically accurate, adaptable messages to help people be prepared and stay informed. It involves risk assessment, risk awareness, knowledge dissemination, and community intervention.2During the coronavirus disease (COVID-19) pandemic, people relied on accurate, timely communication to prevent misinformation and to guide them to respond appropriately. Effective practices of various aspects of COVID-19 risk communication in Zhejiang are summarized below.

1. Risk assessment

Risk assessment is the first step in understanding the scope of risk and the influencing factors, thus enabling decision making on adequate prevention and control measures. Key to developing an effective risk communication plan and implementation strategy are what (key messages), whom (target groups), who (organizations or professionals to deliver key messages to target groups), when (time of delivery), and how (methods and channels to communicate with target groups).

On 26–28 January 2022, a total of 44 confirmed cases of COVID-19 were reported in Hangzhou City, with 12 in Xiaoshan District, 21 in Binjiang, 1 in Xihu, 2 in Shangcheng, 6 in Fuyang, and 2 in Gongshu. They included the latest 18 confirmed cases detected among close contacts at centralized isolation sites.

The provincial government strengthened risk communication mechanisms to respond to the COVID-19 outbreak. The Zhejiang Provincial Center for Disease Control and Prevention (CDC) immediately assessed the public health risk.

1.1. Assessment of risk scope and influencing factors

Outbreak period. The first confirmed COVID-19 case was reported on 26 January 2022, after which new cases were identified and reported daily. The outbreak happened 1 week before Chinese New Year (1 February 2022). Prevention and control of the pandemic urgently needed risk management, including risk communication.

Social-psychological factors. Zhejiang is one of the most developed provinces in the PRC. Many people from all over the country migrate to Zhejiang to work. Hangzhou, the capital of Zhejiang, is a popular tourist spot. The city faced two challenges, both risk factors for the spread of the virus: (i) some migrant workers would go back to their hometown for Chinese New Year family reunions, and (ii) many tourists would visit Hangzhou for Chinese New Year

Rumors and misinformation. People living in high-risk communities, where new cases and close contacts had been identified, were scared and worried. Rumors and misinformation were spreading.

2. Risk awareness

The best way to prevent and slow the transmission of the COVID-19 pandemic is through risk awareness, which is achieved by communicating risk assessment and is an important measure to control the infodemic.3

Risk awareness relies on trust, timely release of information, transparency, and advance planning.

Government and health institutes are trusted sources of data and information. The government must announce COVID-19 information and prevention measures daily through mass media such as TV, radio, newspapers, and government social media accounts.

2.1. Daily news release mechanism established to publish vital information

The Information Office of the Zhejiang provincial government held a press conference every day to announce the latest number of confirmed cases, the general situation of the COVID-19 pandemic, and prevention and control measures, among other matters (Figure 1). The governor and health experts answered reporter’s questions, which were of great public concern. Live broadcasts provided updates on the latest developments and tackled public concerns at home and abroad.

Figure 1. Zhejiang Provincial Government Information Office Press Conference, 29 January 2022

Source: Zhejiang Center for Disease Control and Prevention.

2.2. Daily reporting system launched to provide accurate and comprehensive data

The Provincial Health Commission announced on its website and other platforms daily updates on the latest numbers of newly confirmed cases, suspected cases, those on quarantine, close contacts under medical observation, and asymptomatic cases.

The epidemic map was updated in real time to display infection figures. All regions could refer to it, which was supported by big data technology, for the precise location and number of cases in a specific community to allow health authorities to quickly respond and promptly formulate prevention measures.

2.3. Health education plan developed

The Zhejiang CDC developed a work plan for health education to guide and expedite risk communication with target groups. The plan included key messages, health education methods, and media platforms:

  • Key messages for different target groups were developed.
  • Key target groups were identified as migrant workers, students, and residents in high-risk communities.
  • Key settings were workplaces with a significant number of migrant workers, schools, transport stations, communities with confirmed new cases and close contacts, and public places such as shopping centers and restaurants.

For migrant workers. Key messages on prevention and control for migrants returning to their hometowns for Chinese New Year were developed through sample questions and answers (Figure 2). The messages were delivered through posters, flyers, the provincial CDC WeChat account, workplaces, and enterprises.

Figure 2. Q&A on Preventive Measures for Migrant Workers Traveling during Chinese New Year

Source: Zhejiang Center for Disease Control and Prevention.

For students. Health education professionals developed “The First Class” for the new semester. It was taught by CDC staff in one school and broadcast live online to all other schools. It imparted knowledge, attitudes, and skills to prevent COVID-19 (Figure 3).

Figure 3. The First Class in the New Semester

Source: Zhejiang Center for Disease Control and Prevention.

At 3 PM, on 24 February 2020, health education expert Qi Zhang, associate physician of Zhejiang CDC, held “The First Class” at Yucai-Jinhang Elementary School in Hangzhou. The topic was COVID-19 protection guidelines for students. “The First Class” was streamed, allowing more than 7,000 students in other schools to attend.

To further strengthen health education in schools, the Health Education Institute of Zhejiang CDC will continue to use media platforms to create more online, live, high-quality courses.

For residents in communities. Since the COVID-19 outbreak was reported in Hangzhou on 26 January 2020, communities and workplaces have been divided into zones for containment, control, and prevention, following national and provincial policies:

  • Containment zones. People stayed home and community workers provided door-to-door service.
  • Control zones. No one could go out or gather.
  • Prevention zones. People were advised to stay in the area and not gather.

Zhejiang CDC developed key messages for residents in the zones and produced and handed out posters and flyers carrying the key messages (Figure 4).

The coverage of the three zones was adjusted quickly depending on the risk after cases at isolation sites reached zero. On 10 February 2020, the containment, control, and prevention zones were opened.

Figure 4. Key Messages for the Community

Source: Zhejiang Center for Disease Control and Prevention.

For all residents. On Chinese New Year’s Eve in 2022, Zhejiang CDC published an open letter on the Spring Festival Initiative on Epidemic Prevention. It admonished people to (i) be aware of the risks; (ii) monitor their temperature, cough, and other symptoms; (iii) stay home; (iv) cooperate with health workers in investigation, nucleic acid testing, and disinfection; (v) not believe or spread rumors; and (vi) immediately report epidemic risks (Figure 5).

Figure 5. Open Letter on the Spring Festival Initiative on Epidemic Prevention

Source: Zhejiang Center for Disease Control and Prevention.

3. Knowledge dissemination

Zhejiang CDC’s practical prevention and control tips, key messages, and guidelines were delivered through posters, flyers, and professional social media accounts. The measures covered self-protection, disease prevention under specific conditions, travel, family, public places, public transport, and medical observation at home. Zhejiang CDC developed a question-and-answer manual for rural residents.

Key opinion leaders played a major role in raising public awareness of scientific disease prevention and control. Famous doctors and public experts from provincial health organizations and research institutions regularly expressed their professional opinions and suggestions via press conferences, interviews, and the internet, and widely promoted simple but effective self-protection measures such as wearing face masks, washing hands regularly, and ventilating rooms.

News and mainstream media were the vehicles for mass dissemination of knowledge, policies, updates, and inspiring stories about the fight against the pandemic.

  • Knowledge, key messages, and guidelines were developed and disseminated through different channels by Zhejiang CDC. Daily news and updates were released via the popular Zhejiang Health Education WeChat account.
  • Key opinion leaders were interviewed in the health section of a weekly local TV program that discussed issues concerning the public.
  • A health hotline provided the public with health advice and guidance on where to access nucleic acid testing and COVID-19 vaccines, and answered questions about individual and family preventive measures, medical observation at home, and medical treatment. The hotline also provided psychological counseling 24 hours a day. All CDCs (provincial, city, county, and district) in Zhejiang disseminated the health hotline number (Figures 6 and 7).
  • News and mainstream media, including digital media, widely disseminated knowledge, policies, updates, and inspiring stories about the fight against the pandemic. They helped allay people’s anxiety and fears, identified problems, and helped solve them. A good number of media outlets dedicated space for epidemiological updates and analytics on the COVID-19 situation and for countering of rumors and dis- and misinformation.

4. Community-based intervention

The community is crucial in risk communication. Community-based management has been key in curbing the spread of the virus. A report on the PRC’s fight against COVID-19 puts it clearly: “As an extension of governance for social management, 4 million community workers, together with volunteers, visited 650,000 urban and rural communities across the country to communicate epidemic prevention knowledge, offered psychological counseling and helped households receive daily necessities. They helped provide dragnet screening of potential virus carriers, made sure every corner was disinfected, and helped millions of households with difficulties in making a living.”4

Zhejiang CDC worked with community committees and other partners to mobilize community resources (health workers, neighborhoods, volunteers, grid workers, and residents’ representatives) for risk communication. They developed key messages that targeted gaps in information, awareness, and understanding about how to protect individuals and the community, especially the most vulnerable. Community involvement helped stop stigma, rumors, and misinformation. It was particularly useful in rapid information sharing; mobilization of community resources for prevention, care, and support; and regular collection of feedback from the entire community.

1 World Health Organization (WHO). 2017. Communicating Risk in Public Health Emergencies: A WHO Guideline for Emergency Risk Communication (ERC) Policy and Practice. Geneva. 
2 S. Du, A. Mao, K. Wang, Y. Meng, Y. Yang, M. Zhao, W. Qiu [都率, 毛阿燕, 王坤, 孟月莉, 杨玉洁, 赵敏捷, 邱五七]. 2021. 风险沟通原则在我国新型冠状病毒肺炎（COVID-19）疫情防控中的实践 [Practice of Risk Communication Principles in the Prevention and Control of the COVID-19 in China]. Soft Science of Health. 7 (35). pp. 90–92.
3 R. Chaterjee et al. 2020. COVID-19 Risk Assessment Tool: Dual Application of Risk Communication and Risk Governance. Progress in Disaster Science. 7. 
4China Daily. 2021. China’s Fight against COVID-19. 

Author
Xuefeng Zhong

Xuefeng Zhong

Public Health Specialist (Consultant)

Adapting and Innovating to Control Tuberculosis in the PRC: Resilience during the COVID-19 Pandemic

Yu Ma, 89, chief physician of the Capital Medical University's Beijing Chest Hospital, reads CT scans. (China Daily)

The coronavirus disease (COVID-19) pandemic threatened to reverse the recent gains made in tuberculosis (TB) control in the People’s Republic of China (PRC). The pandemic and the public health measures enforced to contain it adversely affected TB service provision and uptake, especially in high-burden countries. The PRC has the third-highest TB burden and the second-highest burden of multidrug-resistant TB (MDR-TB) globally—the number of TB cases diagnosed decreased sharply during intensive implementation of public health interventions against COVID-19. 1 2

The fall in number of people diagnosed with TB was attributed mainly to (i) disruptions in TB service delivery because workers were reassigned to centers for disease control and prevention (CDCs) and primary health-care units (PHCs) to fight the COVID-19 epidemic, the temporary closure of TB outpatient clinics, and the designation of TB hospitals as COVID-19 hospitals to handle the pandemic surge, which affected care-seeking behavior; and (ii) lack of access to TB care as most counties restricted intercity and intra-county travel, making it difficult to visit health facilities and seek medical care.3 4

The TB control network is composed of CDCs, TB-designated hospitals, and PHCs in each county. 5 With most prefecture and provincial TB hospitals designated as COVID-19 hospitals, hospital-based services had to be modified to maintain continuity of essential TB care services during the pandemic. The adjustments included changes in hospitalization and treatment-monitoring policies, approaches to TB patient support, and infection prevention and control protocols. 6

Hospitalization and treatment. During the pandemic a number of TB hospitals set stricter criteria for hospitalization. Longer-term prescriptions were widely used to lessen the number of outpatient visits while ensuring that TB patients had enough TB medicines. Most hospitals provided 2–3 months’ supply of TB medicines during the pandemic, while some provided enough for a month, compared with 1–2 weeks’ supply before the pandemic. Ensuring that TB patients would adhere to treatment was a challenge, which health-care providers faced by sending them regular follow-up instant messages. Hospitals switched from injectable treatments to oral regimens for patients with MDR-TB, not only reducing the frequency of patient visits but also minimizing the risk of exposure to the virus. Hospitals started delivering medication to patients to make it easier for them to continue their treatment without putting their health at risk. 7

Patient support. TB patients became more anxious during the pandemic and needed counseling and mental health support. Given the limited in-person interactions with health-care workers and increasing patients’ unease caused by COVID-19, patient support was important to ensure continuity of TB care. The TB hospitals adopted multiple interventions, including access to patient-friendly web- and paper-based educational materials on TB and COVID-19. A hospital developed a mobile application for personal consultation. 8

Infection prevention and control. Consistent with World Health Organization (WHO) guidelines, all TB patients were screened for COVID-19 through a triage system. Those negative for COVID-19 were sent directly to TB services, while those positive were segregated in a COVID-19 investigation area. All patients and hospital visitors were required to wear a surgical mask. All hospitals strengthened their environmental disinfection and ventilation systems. Some hospitals reduced the use of bronchoscopy for TB patients. 9

Accessible cutting-edge diagnostic technologies and standardized treatment procedures have significantly improved TB diagnosis and treatment. By training health-care providers and closely monitoring TB clinical services, provinces that strengthened project-based TB control and systems have seen significant improvements in the quality of TB and MDR-TB diagnosis and treatment. 10

Innovation and adaptation are proving to be effective in the fight against TB. The WHO found that the PRC was one of the few high-burden countries where monthly TB case notifications in 2020 had recovered from the initial decline caused by the pandemic. 11 Of the 30 high TB burden countries, The PRC continued to be among those with the highest levels of treatment coverage in 2020 and 2021. 12 By embracing new technologies and approaches, the PRC is turning the tide against TB.

1 WHO. 2020. Global Tuberculosis Report 2020. Geneva.
2 Fei Huang et al. 2020. The Impact of the COVID-19 Epidemic on Tuberculosis Control in China. The Lancet Regional Health, Western Pacific.
3 Ibid.
4 Y. Pang et al. 2020. Impact of COVID-19 on Tuberculosis Control in China.
5 Fei Huang et al. 2020.
6 X. Shen et al. 2020. Continuity of TB Services during the COVID-19 Pandemic in China in the COVID-19 Era. Preprint.
7 Ibid.
8 Ibid.
9 Ibid.
10 Long Qian et al. 2021. Scale-Up of a Comprehensive Model to Improve Tuberculosis Control in China: Lessons Learned and the Way Forward. Infectious Diseases of Poverty. 10 (41).
11 WHO. Global Tuberculosis Report 2020. p. 17
12 WHO. 2021. Global Tuberculosis Report 2021. Geneva. p. 15; and WHO. 2022. Global Tuberculosis Report 2022. Geneva. p. 20.

Authors
Najibullah Habib

Najibullah Habib

Senior Health Specialist, East Asia Department, ADB

Pedrito B. dela Cruz

Pedrito B. dela Cruz

Project Coordinator (Consultant), ADB

Buses Help Bring COVID-19 Jabs to the Masses in the PRC

A mobile vaccination vehicle in Haidian District of Beijing, capital of PRC, 11 April 11 2021. (Xinhua/Ren Chao)

They look like sleek, bright tour buses, some vaguely insect-like with long-necked rearview mirrors. But the people lined up outside them in the People’s Republic of China (PRC) aren’t sightseers. From Beijing in the north to Haikou in the southern island of Hainan; from Shanghai on the east coast to Xidu, Hunan and Wuhan, Chongqing, and Wuxi in the interior; and in many other towns and cities, the buses bring COVID-19 vaccinations to people who can’t easily make the trip to sometimes inaccessible vaccination centers. It’s not just people living in remote mountainous areas such as Ouhai in Wenzhou, Zhejiang who benefit but also urban office workers, who don’t have to take time off to get their shots, and the elderly and handicapped.

The buses are kitted out with vaccination stations, smart medical refrigerators that keep temperatures at 2°C–8°C and send an alert to the Chinese Center for Disease Control and Prevention if they deviate, and first-aid facilities in case of an adverse reaction. Vaccinated people are screened, registered, inoculated, and observed after. Regulators can monitor the information remotely.

The buses speed up inoculation, efficiently bringing millions of doses to downtown neighborhoods and remoter locales. The PRC has reason to make haste. Its population of about 1.4 billion is spread across more than 9.3 million square kilometers, including coasts and mountains and everything in between and some regions that are harder to get to than others.

In April, Nature reported that the PRC was vaccinating about 5 million people a day on average. In June, for more than a week, that number swelled to 20 million a day on average. As of 6 June, the journal stated, 778 million doses had been administered. In the first week of October, according to Reuters, the average daily number of doses administered was about 1.42 million. A total of at least 2,218,826,000 doses, enough for about 79.4% of the population, have been administered. The news outlet said that the PRC has had 96,374 infections and 4,636 COVID-19–related deaths since the pandemic began in late 2019. New infections reportedly average 24 a day, or 1% of the highest daily average reported in February 2021.

The remarkable feat of vaccinating more than a billion people in less than 2 years was made possible by the PRC’s decision to produce its own vaccines rather than rely on other countries and by getting the vaccines to its people efficiently. The vaccination buses are part of this logistically extraordinary achievement.

Health facilities have often been stretched to capacity, transport can be inefficient, and vaccination centers can be difficult to reach and expensive to build.

Some other parts of Asia have been using vans and buses for health work. In the Philippines, for example, mobile x-ray machines serve tuberculosis patients, family-planning caravans have delivered contraception to communities, and now mobile clinics bring COVID-19 vaccination to cities and villages. In September, Thailand rolled out its first vaccination bus, in Bangkok, which needs only six people to operate it and to inoculate 1,000 people a day. Pekanbaru, Indonesia launched its vaccination buses on 1 June and doubled their number to 10 within 2 weeks. In July, the Cambodia government delivered 10 vaccination vans to the defense ministry, which was already inoculating people, and promised one or two vans each to the provinces, depending on their population. In India, the Karnataka government and the private sector launched the 4–6-month Vaccination on Wheels in August. In Fiji, Rights, Empowerment and Cohesion for Rural and Urban Fijians (REACH) Project buses started bringing vaccines to communities in early 2020.

Some of the least developed developing member countries might not have the high technology that the PRC does, but they use the technology on hand to get the job done. Health workers can use cellphones to inform residents of mobile clinic arrivals, register vaccinees, remind them of vaccination schedules, and transmit information to government agencies. Smart refrigerators might not always be an option, but solar panels can keep the cold chain going.

The World Health Organization (WHO) and United Nations (UN) Secretary-General António Guterres appealed to the leaders attending the 76th UN General Assembly, held in September, to ensure that poor and rich countries have equitable access to COVID-19 vaccines. An impassioned secretary-general called vaccine equity “the biggest moral test before the global community.”

Continuing imbalanced access means not only that not enough vaccines are reaching the least developed countries but also that their health systems are deficient. Even if the countries were to receive more vaccines than they are, of what use would they be if they expire in warehouses or at ports because they cannot be distributed?

To reach levels of success seen in the PRC, developing member countries need stronger health systems, more vaccines, and greater vaccine outreach.

WHO and the UN are right to be alarmed. Only 47.7% of the world’s population has received at least one dose of the COVID-19 vaccine but only 2.5% of people in low-income countries. Vaccination buses are just one solution and an effective one. They do traverse some countries, but not enough of them and in not enough countries. Imagine what fleets of them could do.

Author
Najibullah Habib

Najibullah Habib

Senior Health Specialist, East Asia Department, ADB

Fangcang Hospitals: Essential to Battle Disease and Disaster

Staff members clean up a makeshift hospital converted from a sports venue following its closure as its last batch of cured COVID-19 patients were discharged in Wuhan, central PRC's Hubei Province, 8 March 2020. (Xinhua/Xiao Yijiu)

In February 2020, millions watched videos showing gyms, a stadium, and other buildings in Wuhan, PRC transformed into makeshift treatment centers. Timelapse videos captured the Huoshenshan and Leishenshan hospitals being assembled in 10 days like giant Lego structures. Known even outside the PRC as fangcang hospitals, 12 were fully operational in February, with 13,348 beds. Some were set up in school dorms, vacant factories, warehouses, and passenger terminals. By March, 16 facilities were serving the city of 11 million.

Since December 2019, the coronavirus disease (COVID-19) had sickened thousands in the city, overwhelming traditional hospitals. Wuhan fought back with fangcang hospitals.

The PRC is no stranger to public health crises. It had endured the SARS epidemic of 2002–2003, for example, and set up a fangcang hospital in Yushu, Qinhai after the 2010 earthquake. But the scale of the COVID-19 pandemic was unprecedented and required extraordinary measures.

Fangcang hospitals are like military field hospitals, which follow armies into battle. And Wuhan was at war with the pandemic, with casualties as bad as those seen in combat. By March 2020, about 2,500 in the city had died and 50,000 had fallen ill.

While military field hospitals treat all the wounded, however, fangcang hospitals treated only those mildly and moderately infected (80% of all cases) who could not quarantine at home or be trusted to stay home. The fangcang hospitals freed up general hospitals to care for only severe cases and designated hospitals to treat only critical cases. The fangcang hospitals also allowed other hospitals to resume treating patients with other serious ailments in need of specialized care.

Fangcang hospitals can be built rapidly on a massive scale and at low cost. Their functions are isolation; triage; basic medical care (including mental health counselling); frequent monitoring and rapid referral; and essential living and social engagement (including food, hygiene, emotional support, and mood-lifting activities such as dancing). And running them is inexpensive: they need fewer doctors and nurses as all the patients have the same illness, reducing the complexity of care.

The images of the pandemic are harrowing, including long lines of the sick outside hospitals in many countries. Those who could not be hospitalized stayed home, where they might worsen and could not be monitored, and infected their families. Or they moved about, risking infecting the public. Wuhan shows that fangcang hospitals should be in countries’ public health arsenal against not just COVID-19 but also future epidemics and emergencies.

In ADB developing member countries that lack health-care facilities and health human resources, especially during crises or disasters, fangcang hospitals are a powerful weapon. They don’t need enormous amounts of time or money or highly advanced technology to be set up.

The Philippines had 10 fangcang hospitals by April 2020. One, in a convention center in Manila, had almost 300 beds, learned from the Wuhan experience and worked with PRC medical teams. Outside Manila, local governments retrofitted existing public facilities, where the mildly and moderately infected could isolate and be cared for and monitored. In July 2020, on the day that India reported its biggest spike in infections, it opened the world’s largest single temporary hospital, with 10,000 beds. In Tajikistan, in May 2020, new state buildings were turned into four temporary hospitals, two of which had ICUs and ventilators, and a mobile hospital for quarantine was assembled in a stadium using 144 containers provided by the Government of Uzbekistan.

Hospitals in Indonesia sometimes set up tents in their parking lots to manage the number of people seeking help. An unused luxury hotel in Cambodia was turned into a 500-room COVID-19 hospital in March 2021. The 300-bed fangcang hospital in Lao People’s Democratic Republic closed in June 2021 after cases dropped but is prepared to reopen. In the Kyrgyz Republic, the pandemic peaked in July 2021 and a dozen “pop-up” hospitals opened in Bishkek’s gyms, hotels, and restaurants, and night-time temporary hospitals treated 9,203 patients.

Even the United Kingdom and the United States resorted to using fangcang hospitals at the height of the pandemic.

The market for fangcang hospital equipment is expected to grow in 2021–2027, with the PRC, Japan, the Republic of Korea, India, Australia, Indonesia, Thailand, Philippines, Malaysia, and Viet Nam constituting an important segment.

A study on Wuhan concluded that traditional hospitals saved the lives of patients with severe COVID-19, but it was the fangcang hospitals that helped slow and stop the pandemic. If the fangcang hospitals had been opened a day later, COVID-19 cases would have totaled more than 7.4 million instead of 50,844, about 1.4 million instead of 5,003 would have died, and the epidemic would have lasted 179 days instead of 71.

The world will face other pandemics and natural disasters. The lesson of COVID-19 is that countries must be prepared. Developing countries’ health systems, however, will continue to be inadequate for a long time. The lesson of Wuhan is that fangcang hospitals can fill in the gaps.

Authors
Najibullah Habib

Najibullah Habib

Senior Health Specialist, East Asia Department, ADB

Muriel Ordoñez

Muriel Ordoñez

Writer and Editor (Consultant)

The Path to Healthy Aging in the PRC

The rapidly aging Chinese population is posing severe economic and societal challenges. To deal with these challenges, it is crucial the population ages healthily. Prof. Yaohui Zhao, National School of Development, Peking University will discuss major findings and policy recommendations from the recently released Peking University-Lancet Commission on “The Path to Healthy Aging in the PRC”. The commission reviewed evidence on health statuses and their determinants among older Chinese, current healthcare, and aged care policies in the PRC, and provided recommendations for future policy making.

Supporting Health-Care Financing Reform in Mongolia: Experiences, Lessons Learned, and Future Directions

Virtual Tour of the Community Care Center

Enjoy the tour of two community care centers ADB help renovate and refurbish. The centers are a part of ADB’s Yichang Elderly Care Demonstration Project.

Related event: Elderly Care System Development Forum

Interview with Project Management Office Staff

What is the role played by the Yichang Elderly Care Demonstration Project’s management office staff? What challenges do they face? Listen to how the Yichang project strengthen their capacity.

Related event: Elderly Care System Development Forum

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