Not Again: China Imposes New Coronavirus Lockdown - Fears Grow for Devastating Second Wave

With over 4.5 billion people under some form of lockdown, business organisation is mounting nearly the economical, social and adverse wellness effects resulting from these restrictions, including disruption in not-COVID-19 related health care and an increasing number of families beingness thrown into poverty [1,2]. Policymakers need to balance the clear benefits of lockdown measures in containing manual of SARS-CoV-two confronting growing concerns nigh their negative effects.

The current Great britain lockdown measures began on 23 March 2020, following which emergency legislation was passed past the U.k. Government and its devolved administrations [3]. These regulations are subject to regular review and were extended on 16 Apr 2020 for a farther three weeks [4]. On 17 Apr 2020, the UK Government outlined 5 criteria that would need to be met before lockdown measures could be lifted (see Box i). The first ii of these criteria have arguably been met every bit evidenced past the new Nightingale Hospitals remaining largely empty and a turn down in the number of daily reported COVID-19 deaths. The remaining three criteria are vaguely articulated, but regardless these take not however been met. A key omission when compared to the criteria proposed past the World Health Arrangement (WHO) is the failure to make whatsoever mention of active surveillance, tracing and isolation capacity [5].

Box 1

U.k. Regime criteria for lifting lockdown measures [4].

ane. The NHS must exist able to cope.

2. Sustained and consistent falls in daily death rates.

three. Reliable evidence of infection rates decreasing to manageable levels.

iv. Confidence that there is sufficient testing capability and personal protective equipment (PPE).

5. Confidence that lifting restrictions will not consequence in a second top.

Of prime importance to governments and the public is how and when lockdown tin be lifted. Attempts to infer from previous pandemics (eg, H1N1, SARS) are fraught with challenges given standing uncertainties about parameters equally key as the charge per unit of manual (R or more accurately R_t, the effective reproduction number) and case fatality rate [half-dozen]. Both figures are very difficult to estimate reliably given the lack of a truthful denominator of the number of cases in the Great britain [7-9].

To bring clarity for future decisions, we have identified and mapped the range of approaches that are either actively beingness explored or accept been implemented internationally ( Tabular array 1 ). The objectives of these approaches are either to: i) promote natural herd immunity; ii) release lockdown measures once a handling or vaccine become available; three) effort to completely eliminate the virus; or four) notice ways of relaxing lockdown whilst still containing virus transmission through a 'exam, trace, isolate' strategy. Such measures would demand to proceed until an effective treatment is available or herd amnesty (whether naturally or through mass vaccination) develops. We briefly consider each of these approaches in turn.

Table 1

Potential COVID-xix lockdown get out strategies

Strategy	Description	Pros and cons	Countries	Supporting evidence
Natural herd immunity	Depending on the truthful R0, this would require between approximately 58%-82% of the population to recover from infection with sufficient levels of antibodies to attain herd immunity.	Pros: Maintains societal functioning.	Sweden	[10]
		Cons: Reliant on the supposition that long-term amnesty is possible despite some evidence of possible reinfections. Big number of deaths in elderly and the vulnerable (akin to 'survival of the fittest'). Need to stay within health services capacity. Social unrest if individuals unable to access medical services.
Lockdown till cure or vaccination herd immunity	This option maintains the lockdown indefinitely until a therapeutic is found or a vaccine has been adult, tested, mass-produced and deployed at sufficient levels to achieve herd immunity.	Pros: If maintained, highly likely to prevent transmission.	Current default for many countries
		Cons: Highly unlikely to exist maintainable given social, wellness & economic consequences. Furthermore, no guarantee that a therapeutic or vaccine will exist found.
Try to eliminate the virus	The "test, trace, isolate" strategy advocated by WHO, which aims to fully contain and suppress the epidemic and then reopen club.	Pros: WHO advocated arroyo with some evidence of success. Keep society and economic system running past just removing those carrying virus and breaking bondage of manual.	Communist china, Czechia, Faroe Islands, Germany, Iceland, Singapore, South Korea, Vietnam, Hellenic republic, New Zealand, Australia	[11]
		Cons: Insufficient surveillance, testing, tracing and isolating capability in the UK. Demand for border control to catch imported cases.		[12]
Containment measures (many of which are likely to be used in combination):
Gradual release	Gradual release of lockdown restrictions informed by the areas which are responsible for most economic productivity whilst nonetheless existence able to adhere to physical distancing measures (eg, construction workers). Needs shut monitoring of the number of new cases generated as a result of the release, which would inform whether further loosening or tightening of restrictions is required.	Pros: Allows an assessment of what impact lockdown relaxation measures are having.	Austria, Czech Republic, Denmark, Germany, Italy, Republic of ireland, Norway, Espana	[13]
				[14]
		Cons: May outcome in actual or perceived inequity leading to social unrest.		[fifteen]
Population scheduling	Splits the population into groups and just allows these groups out at certain days/times. This can allow for the resumption of economic activity whilst helping to maintain physical distancing.	Pros: Allows an assessment of what impact lockdown relaxation measures are having.	Panama; being considered in Croatia, Peru and Kingdom of spain	[16]
		Cons: May consequence in actual or perceived inequity leading to social unrest.
Geographical partitioning	Involves dividing the state into distinct geographical regions and implementing strategies at these regional levels. Could be used selectively to isolate hot spots to prevent widespread transmission through strict enforcement of lockdown measures. Conversely, areas with low manual would be costless to travel inside their geographical boundaries.	Pros: Allows an assessment of what impact lockdown relaxation measures are having.	Argentina, Australia, Prc, Germany, Israel, Italian republic, Kuwait, Russia, Saudi Arabia, UAE	[17]
		Cons: May issue in actual or perceived inequity leading to social unrest. Could lead to motility within countries towards regions with less restrictive policies.		[xviii]
PPE for the full general public	Strongly encouraging or mandating the wearing of PPE in public spaces such as face masks.	Pros: May offering some protection confronting manual in areas where concrete distancing cannot be maintained such as public transport, shops and workplaces.	China, Singapore Republic of korea, Scotland, UAE United states	[19]
		Cons: Global PPE shortage then may divert essential supplies from the front-line. Face masks should be dwelling house-made and cloth-based		[twenty]

ICU-Intensive care unit, PPE-Personal protective equipment, R₀ – basic reproduction number, R_t – effective reproduction number, UAE-United Arab Emirates, Usa – Unites States of America, WHO – World Health Arrangement

Photo: Liverpool Street Station, London. By Ben Garratt via Unsplash.

The UK, Dutch and Swedish governments initially pursued the idea of promoting herd immunity, simply the UK and Dutch have subsequently abandoned this strategy in light of mounting public concerns virtually the demand to infect 60%-80% of the population and revised modelling, which indicated that health systems would be over-whelmed and this could not be pursued as a feasible public health policy [21]. Sweden is in dissimilarity still broadly pursuing this arroyo with merely minimal enforced restrictions on physical movements. Its case is however somewhat singular as a big proportion of its population ( ~ 40%) alive in single person households, it has a highly skilled workforce which enables many people to work from home, and the high levels of education have led to full general compliance with messaging almost maintaining concrete distancing leading to relatively low levels of infection (estimated at ~ 7%) [22]. It is as yet an unproven assumption that long-term immunity is possible despite some testify of potential reinfections and curt-lasting immunity from other coronaviruses [23]. Of note, Sweden'south approach has resulted in significantly more deaths than comparable Nordic countries [24].

Considering the second selection, optimistic estimates advise that a vaccine will not exist bachelor for at to the lowest degree 12-eighteen months and fifty-fifty and so it is unknown how safety, effective, available or accessible such a vaccine would be [25]. Given the decimating wellness, economic and social impacts of lockdowns, information technology is practically inconceivable that widespread lockdowns can continue fifty-fifty beyond the next 4-six months. That said, this cannot be a license to recklessly lift lockdown restrictions as well early on every bit, for example, the Mayor of Las Vegas was considering [26].

A 'test, trace and isolate' strategy is the cornerstone of managing epidemics, and has been repeatedly emphasized by the WHO. Countries such as China (in item Hubei Province), Hong Kong, South korea, Taiwan and Vietnam have pursued such approaches achieving substantial command of the disease. Importantly many of these countries had previous experiences of dealing with SARS and MERS, which enabled them to understand the magnitude of the potential challenge very early on and mount effective nationally coordinated multi-sectoral responses. In contrast, the Great britain and many other Western nations were delayed in instituting their responses, which immune the numbers of cases to rise very rapidly. Too of relevance in this respect is that these Asian countries in that location has been active surveillance and enforced isolation of suspected and confirmed cases. Such approaches are far less socially adequate in Western European contexts. The success of such approaches is also highly dependent on the calibration of testing and contact tracing achievable and the efficiency with which test results are turned around. In that location are therefore a number of substantial challenges that need to exist overcome to effectively implement 'examination, trace and isolate' strategy in the context of the United kingdom [27].

In the Uk, the window of opportunity has passed for quick emptying of the virus, given active community transmission likewise equally the absenteeism of surveillance, testing and tracing capacity. If sufficient political will is found and public wellness infrastructure is created, information technology could become a route in the medium- to longer-term. This would however require public acceptance of some of the privacy infringements that contact tracing and an active quarantining approach rely on, which have been employed in a number of other countries. For case, it is estimated that ten 000 new symptomatic cases per twenty-four hour period would require 140 000-390 000 contacts to exist quarantined/d [28]. Given these requirements, it is currently not feasible to pursue elimination every bit this would involve maintenance of tight lockdown, vast armies of contact tracers as well every bit a huge increase in examination kits to allow for population testing and extensive quarantining capacity or monitoring of cases.

The last option is we believe the most credible for the United kingdom of great britain and northern ireland in the brusque-term. In essence, this involves finding ways of living with the virus by gradually relaxing some of the lockdown measures whilst simultaneously pursuing ambitious development of active surveillance, testing, tracing and quarantining capacity. These are interim interventions to comprise the spread of the disease, keep daily new cases low and minimise its impact until a vaccine, effective treatment, or more data on immunity becomes available. This is likely to involve the conscientious, gradual opening of segments of social club – for example, beginning with predominantly outdoor workers who can maintain physical distancing and/or geographical areas of the country where there is the prospect of eliminating the disease (eg, Scotland'southward island communities). This could be followed by a careful phased re-opening of schools with reduced class sizes, desks at 2m distances, face up masks for older pupils, frequent hand washing; and the gradual re-opening of non-essential businesses whilst maintaining physical distancing measures. We envisage certain sectors such every bit bars and restaurants volition not open until much later. British Columbia is, for example, considering easing lockdown measures guided by modelling that predicts that increasing social interactions from the current 30% to forty%-60% would not result in a 2d outbreak [29].

The idea of 'bubbles' has been floated whereby each household has interactions with a limited number of others. Recent research has suggested that express, repeat contacts inside the aforementioned group may be an constructive way of allowing express socialisation whilst still keeping cases downwards [30]. This approach does however have the potential to trigger family discord and also has the claiming of being very hard to monitor and enforce.

Whatsoever lockdown relaxation measures need to be considered aslope provision of personal protective equipment (PPE) for those nearly at take a chance of acquiring or transmitting the virus and standing to shield the most vulnerable members of social club, including those in care homes. The impact of such changes in policy will need to be continuously monitored using real-time, multi-modal data with a willingness to (temporarily) tighten controls when necessary. Germany recently began to cautiously ease its lockdown measures, a federal rather than national decision, and has very chop-chop seen a rise in R_t from 0.vii to ane, leading to considerations to retighten the restrictions.

What is articulate is that there is no straightforward manner out and that moving forward will be a frail balance involving difficult merchandise-offs. Whichever approach is taken, transparency and clear communication with the public is essential as well every bit recognition that anticipation might exist to re-engaging with aspects of public life [31].

Acknowledgments

Disclaimer: These views should non in any manner be seen as representing the views of the Scottish Government.

Authorship contributions: Donkey, ZS & SD jointly drafted the manuscript. AzS & DS conceived this newspaper and commented critically on drafts of the manuscript. All authors approved the terminal version of the manuscript.

Competing interests: AzS & DS are both members of the Scottish Government COVID-nineteen Principal Medical Officer's Informational Group. The authors have completed the ICMJE COI form (available upon request from the corresponding writer), and declare no farther conflicts.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296206/

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