Effect of non-pharmaceutical interventions for containing the COVID-19 outbreak in China
Authors: Lai Shengjie , Ruktanonchai Nick W , Zhou Liangcai , Prosper Olivia , Luo Wei , Floyd Jessica R , Wesolowski Amy , Santillana Mauricio , Zhang Chi , Du Xiangjun , Yu Hongjie , Tatem Andrew J 
Published: March 2020

AbstractBackgroundThe COVID-19 outbreak containment strategies in China based on non-pharmaceutical interventions (NPIs) appear to be effective. Quantitative research is still needed however to assess the efficacy of different candidate NPIs and their timings to guide ongoing and future responses to epidemics of this emerging disease across the World.MethodsWe built a travel network-based susceptible-exposed-infectious-removed (SEIR) model to simulate the outbreak across cities in mainland China. We used epidemiological parameters estimated for the early stage of outbreak in Wuhan to parameterise the transmission before NPIs were implemented. To quantify the relative effect of various NPIs, daily changes of delay from illness onset to the first reported case in each county were used as a proxy for the improvement of case identification and isolation across the outbreak. Historical and near-real time human movement data, obtained from Baidu location-based service, were used to derive the intensity of travel restrictions and contact reductions across China. The model and outputs were validated using daily reported case numbers, with a series of sensitivity analyses conducted.ResultsWe estimated that there were a total of 114,325 COVID-19 cases (interquartile range [IQR] 76,776 - 164,576) in mainland China as of February 29, 2020, and these were highly correlated (p<0.001, R2=0.86) with reported incidence. Without NPIs, the number of COVID-19 cases would likely have shown a 67-fold increase (IQR: 44 - 94), with the effectiveness of different interventions varying. The early detection and isolation of cases was estimated to prevent more infections than travel restrictions and contact reductions, but integrated NPIs would achieve the strongest and most rapid effect. If NPIs could have been conducted one week, two weeks, or three weeks earlier in China, cases could have been reduced by 66%, 86%, and 95%, respectively, together with significantly reducing the number of affected areas. However, if NPIs were conducted one week, two weeks, or three weeks later, the number of cases could have shown a 3-fold, 7-fold, and 18-fold increase across China, respectively. Results also suggest that the social distancing intervention should be continued for the next few months in China to prevent case numbers increasing again after travel restrictions were lifted on February 17, 2020.ConclusionThe NPIs deployed in China appear to be effectively containing the COVID-19 outbreak, but the efficacy of the different interventions varied, with the early case detection and contact reduction being the most effective. Moreover, deploying the NPIs early is also important to prevent further spread. Early and integrated NPI strategies should be prepared, adopted and adjusted to minimize health, social and economic impacts in affected regions around the World.FundingBill & Melinda Gates Foundation; EU Horizon 2020; National Natural Science Fund of China; Wellcome Trust.Research in contextEvidence before this studyThe COVID-19 outbreak has spread widely across China since December 2019, with many other countries affected. The containment strategy of integrated nonpharmaceutical interventions (NPIs) including travel bans and restrictions, contact reductions and social distancing, early case identification and isolation have been rapidly deloyed across China to contain the outbreak, and the combination of these interventions appears to be effective. We searched PubMed, Wanfang Data, and preprint archives for articles in English and Chinese published up to February 29, 2020, that contained information about the intervention of the COVID-19 outbreak. We found 15 studies that have investigated or discussed the potential effects of traveller screening, Wuhan’s lockdown, travel restrictions, and contact tracing in China or other countries. However, none of them comprehensively and quantitatively compared the effectiveness of various NPIs and their timings for containing the COVID-19 outbreak.Added value of this studyTo our knowledge, this is the most comprehensive study to date on quantifying the relative effect of different NPIs and their timings for COVID-19 outbreak containment, based on human movement and disease data. Our findings show that NPIs, inter-city travel restrictions, social distancing and contact reductions, as well as early case detection and isolations, have substantially reduced COVID-19 transmission across China, with the effectiveness of different interventions varying. The early detection and isolation of cases was estimated to prevent more infections than travel restrictions and contact reductions, but integrated NPIs would achieve the strongest and most rapid effect. Our findings contribute to improved understanding of integrated NPI measures on COVID-19 containment and can help in tailoring control strategies across contexts.Implications of all the available evidenceGiven that effective COVID-19-specific pharmaceutical interventions and vaccines are not expected to be available for months, NPIs are essential components of the public health response to the ongoing outbreaks.Considering the narrowing window of opportunity around the World, early and integrated NPI strategies should be prepared, deployed and adjusted to maximise the benefits of these interventions for containing COVID-19 spread.