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      Are high-performing health systems resilient against the COVID-19 epidemic?

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          Abstract

          As of March 5, 2020, there has been sustained local transmission of coronavirus disease 2019 (COVID-19) in Hong Kong, Singapore, and Japan. 1 Containment strategies seem to have prevented smaller transmission chains from amplifying into widespread community transmission. The health systems in these locations have generally been able to adapt,2, 3 but their resilience could be affected if the COVID-19 epidemic continues for many more months and increasing numbers of people require services. We outline some of the core dimensions of these resilient health systems 4 and their responses to the COVID-19 epidemic. First, after variable periods of adaptation, the three locations took actions to manage the outbreak of a new pathogen. Surveillance systems were readjusted to identify potential cases while public health staff identified their contacts. National laboratory networks developed diagnostic tests once the COVID-19 genetic sequences were published 5 and laboratory testing capacity was increased in all three locations, although expansion of the diagnostic capacity to university and large private laboratories in Japan is still ongoing. In Hong Kong, initially, only pneumonia patients without a microbiological diagnosis were tested, but surveillance has been broadened to include all inpatients with pneumonia and a purposively sampled proportion of outpatients and emergency attendees totalling about 1500 per day (Leung GM, unpublished). Japan's testing strategy has also evolved with diagnostic tests now offered to all suspected cases irrespective of their travel history; however, there are reports of cases that should have been tested but were not. Different strategies were used to selectively control travellers entering these locations. In Singapore, there was a stepwise series of decisions to restrict entry for anyone from mainland China and, more recently, from northern Italy, Iran, and South Korea. Hong Kong has imposed mandatory 14-day quarantine for everyone who enters from the mainland, and denies entry to non-local visitors from South Korea and Iran as well as the most affected parts of Italy. In Japan, there were travel restrictions on citizens from Hubei and Zhejiang provinces, and cruise ships with cases of COVID-19 were quarantined. Second, intragovernmental coordination was improved because health authorities drew on their experiences of severe acute respiratory syndrome during 2002–03 in Hong Kong and Singapore, H5N1 avian influenza in 1997 in Hong Kong, and the 2009 influenza H1N1 pandemic in all three locations. Hong Kong and Singapore began interministerial coordination within the first week, whereas Japan did this in early February when the operation to quarantine passengers on the Diamond Princess cruise ship was heavily criticised as inadequate, resulting in the widespread infections among crew and passengers. Third, all locations adapted financing measures so that all direct costs for treating patients are borne by the governments. In Singapore, the government pays the cost of hospitalisation, irrespective of whether the patient is from Singapore or abroad. In Japan, funding has been provided through routine financing and contingency funds. Meanwhile, Hong Kong is using routine financing that already pays for all such care. Fourth, the three health systems developed plans to sustain routine health-care services, but the integration of services has been problematic. In Japan, as the capacity at designated hospitals becomes overstretched, the coordination between hospitals and local government will be a major challenge. In Singapore, at the beginning of the outbreak, there were difficulties with disseminating information to the private sector. In all locations, intensive-care unit bed capacity is limited. © 2020 Roslan Rahman/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Fifth, in all locations, critical care treatment and medicines have been available for patients with COVID-19, but adequate supplies of personal protective equipment in hospitals and face masks in the community are a key concern. In Japan and Hong Kong, hospital supplies are running low but have not yet impacted clinical management. In all locations, pressure on critical care treatment is likely if there is a sustained increase in cases of COVID-19. Sixth, in all three locations training and adherence to infection prevention and control measures in hospitals have largely been appropriate, but Japan could face a shortage of infectious disease specialists. Health-care staff are stretched in all localities, especially in selected designated hospitals. Long-term escalation in the need for health services will place pressures on health-care workers, and could at some point compromise the clinical management of people with COVID-19 and other patients. Seventh, management of information systems is comprehensive in all locations. In Singapore, there are almost daily meetings between Regional Health System managers, hospital leaders, and the Ministry of Health. However, in Japan information sharing across prefectures could be improved. The interoperability of systems between the government health department and public hospitals in Hong Kong is not optimal. Timely, accurate, and transparent risk communication is essential and challenging in emergencies because it determines whether the public will trust authorities more than rumours and misinformation. 6 Singapore health authorities provide daily information on mainstream media, the Ministry of Health has Telegram and WhatsApp groups set up with doctors in the public and private sectors where more detailed clinical and logistics information is shared, and authorities use websites to debunk circulating misinformation. Risk communications to establish trust in authorities has been less successful in Japan and Hong Kong. Finally, the political environment and differences in communities and their moods and values are important. The ongoing social unrest in Hong Kong has led to a breakdown of public trust with the government 7 and affected front-line health-care staff and the reception and acceptance of government information. 8 In Hong Kong and Singapore, rumours led to panic purchasing to the extent that shops ran out of some food and supplies. 9 In Japan, concerns related to the Diamond Princess cruise ship and the sudden announcement of school closures fuelled increased public anxiety. The three locations introduced appropriate containment measures and governance structures; took steps to support health-care delivery and financing; and developed and implemented plans and management structures. However, their response is vulnerable to shortcomings in the coordination of services; access to adequate medical supplies and equipment; adequacy of risk communication; and public trust in government. Moreover, it is uncertain whether these systems will continue to function if the requirement for services surges. Three important lessons have emerged. The first is that integration of services in the health system and across other sectors amplifies the ability to absorb and adapt to shock. 2 The second is that the spread of fake news and misinformation constitutes a major unresolved challenge. Finally, the trust of patients, health-care professionals, and society as a whole in government is of paramount importance for meeting health crises.

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          Genomic characterization of the 2019 novel human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting Wuhan

          ABSTRACT A mysterious outbreak of atypical pneumonia in late 2019 was traced to a seafood wholesale market in Wuhan of China. Within a few weeks, a novel coronavirus tentatively named as 2019 novel coronavirus (2019-nCoV) was announced by the World Health Organization. We performed bioinformatics analysis on a virus genome from a patient with 2019-nCoV infection and compared it with other related coronavirus genomes. Overall, the genome of 2019-nCoV has 89% nucleotide identity with bat SARS-like-CoVZXC21 and 82% with that of human SARS-CoV. The phylogenetic trees of their orf1a/b, Spike, Envelope, Membrane and Nucleoprotein also clustered closely with those of the bat, civet and human SARS coronaviruses. However, the external subdomain of Spike’s receptor binding domain of 2019-nCoV shares only 40% amino acid identity with other SARS-related coronaviruses. Remarkably, its orf3b encodes a completely novel short protein. Furthermore, its new orf8 likely encodes a secreted protein with an alpha-helix, following with a beta-sheet(s) containing six strands. Learning from the roles of civet in SARS and camel in MERS, hunting for the animal source of 2019-nCoV and its more ancestral virus would be important for understanding the origin and evolution of this novel lineage B betacoronavirus. These findings provide the basis for starting further studies on the pathogenesis, and optimizing the design of diagnostic, antiviral and vaccination strategies for this emerging infection.
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            Towards an understanding of resilience: responding to health systems shocks

            Health Policy and Planning, doi: 10.1093/heapol/czx183. The authors wish to inform readers that one source of funding (Wellcome Trust grant number 102919/Z/13/Z) was originally omitted from this article’s funding statement. This has now been corrected online.
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              The COVID-19 Outbreak Has Shown We Need Strategies to Manage Panic during Epidemics

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                Author and article information

                Contributors
                Journal
                Lancet
                Lancet
                Lancet (London, England)
                Elsevier Ltd.
                0140-6736
                1474-547X
                6 March 2020
                14-20 March 2020
                6 March 2020
                : 395
                : 10227
                : 848-850
                Affiliations
                [a ]Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
                [b ]Asia Pacific Observatory on Health Systems and Policies, World Health Organization Regional Office for South-East Asia, New Delhi, India
                [c ]WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
                [d ]Tohoku University School of Medicine, Sendai, Japan
                [e ]School of Public Health, University of Hong Kong, Hong Kong Special Administrative Region, China
                [f ]Institute for Population Health, King's College London, London, UK
                [g ]London School of Hygiene & Tropical Medicine, London, UK
                Article
                S0140-6736(20)30551-1
                10.1016/S0140-6736(20)30551-1
                7124523
                32151326
                1e355d8f-f1e0-4278-80e3-9d78135e9552
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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