correspondence

the ‘prevention, containment or treatment’ Second, to strengthen crisis Anna Mia Ekström 1 ✉ , Camilla Berggren2, of COVID-19, when India and South preparedness4 and make the response Göran Tomson2,3, Lawrence O. Gostin4, Africa proposed that the World Trade less blunt and more evidence-based, Peter Friberg2,5 and Ole Petter Ottersen3 Organization temporarily suspend Trade coordinated and effective, the existing 1Department of Global Public Health, Karolinska Related Aspects of Intellectual Property gaps in infrastructure, technology and Institutet, Stockholm, Sweden. 2Swedish Institute 7 Rights rules . information must be reduced. The for Global Health Transformation, Royal Swedish Already in 2019, a Lancet Commission WHO warns that lockdown-induced Academy of Sciences, Stockholm, Sweden. 3President’s recommended increased utilization of disruption (e.g., of childhood immunization Ofce, Karolinska Institutet, Stockholm, Sweden. legal mechanisms to advance global health and essential care) could cause greater 4O’Neill Institute for National and Global Health 8 10 through justice systems and to harness death and suffering than COVID-19 itself . Law, Georgetown University, Washington, DC, USA. the power of law to promote global health As LMICs embark on an unprecedented 5Department of Public Health and Community and sustainable development, calling upon vaccination scale-up, substantial investment medicine, Sahlgrenska Academy, Gothenburg governments, the WHO and United Nations is needed to prevent redistribution of scarce University, Gothenburg, Sweden. organizations to make necessary legal health personnel that further undermines ✉e-mail: [email protected] reforms to translate vision into action. routine immunization. Future plans must The current crisis is a salient opportunity have a clear health-systems dimension Published online: 11 March 2021 for strengthening the global response to and must include social mobilization https://doi.org/10.1038/s41591-021-01288-8 upcoming pandemics. With the belief that and strategies for fighting vaccine 7 vaccines against COVID-19 are a global misinformation . References common good and that allocation should Third, as shown by COVID-19, updated 1. Nat. Med. 27, 1 (2021). be based on need, we make the following global governance mechanisms are needed 2. Launch & Scale Speedometer. https://launchandscalefaster.org/ COVID-19 (2021). recommendations. that better reflect the contemporary 3. Emanuel, E. J. et al. Science 369, 1309–1312 (2020). First, a global legal framework is needed geopolitical order and truly encourage 4. Ottersen, O. P. & Engebretsen, E. Nat. Med. 26, 1672–1673 (2020). to regulate the commercial determinants international collaboration across sectors, 5. Ottersen, O. P. et al. Lancet 383, 630–667 (2014). 6. COVAX. Gavi, the Vaccine Alliance https://www.gavi.org/sites/ of health and to secure universal fair access through political and legal solutions rooted default/fles/covid/covax/COVAX_Principles-COVID-19- to essential technologies and vaccine in commitments to justice and shared global Vaccine-Doses-COVAX.pdf (2020). production. This may be financed through responsibility5,8. We call for a 21st-century 7. Deutsche Welle. https://www.dw.com/en/rich-countries-block- india-south-africas-bid-to-ban-covid-vaccine-patents/a- existing alliances (such as COVAX, or Gavi, Bretton Woods–type conference, similar to 56460175 (2021) the Vaccine Alliance) or by new G7 or G20 that of 1944, when states met to improve 8. Gostin, L. O. et al. Lancet 393, 1857–1910 (2019). standing funds for vaccine development global economic interaction, secure 9. Gostin, L.O., Friedman, E.A. & Moon, S. Foreign Afairs 9 https://www.foreignafairs.com/articles/world/2021-01-19/ and allocation . In times of emergency, the peace and provide assistance to countries wealthy-countries-should-share-vaccine-doses-it-too-late (2021). World Trade Organization should also grant devastated by World War II, which resulted 10. World Health Organization. https://www.who.int/news/item/ temporary waivers for Trade Related Aspects in new global governance structures such 15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations- of Intellectual Property Rights rules for \as the International Monetary Fund and during-covid-19 (2020). governments to produce their own vaccines the World Bank. or, if necessary, to exercise compulsory Using the dynamics of one acute Author contributions All authors contributed to the writing of this manuscript; licensing powers for a third party to produce crisis to build resilience against the next A.M.E. drafted the first version and edited the final version a patented technology. Ideally, perceived could also serve a greater good in line on the basis of feedback from all co-authors; and all authors legal risk could facilitate the negotiation of with the growing notion of the United have seen and approved the submitted version. purchase transparency, voluntary licensing Nations Security Council that health, arrangements and patent sharing while poverty mitigation, security and peace Competing interests committing the industry to global justice. are interlinked. ❐ The authors declare no competing interests.

Comprehensive large-scale nucleic acid– testing strategies support ’s sustained containment of COVID-19

To the Editor—Since identification and was associated with economic loss: China’s has high socioeconomic value: economic initial characterization of COVID-19 in first-quarter gross domestic product fell 6.8% activities recovered rapidly, with an increase late December 2019 and early January compared with that in the first quarter of in gross domestic product of 3.2% during 2020, China’s containment goal has been 2019 (ref. 2). Since containment, there have April through June 2020, and of 4.9% during complete interruption of local transmission been numerous outbreaks in China caused by July through September 2020 (ref. 2); the of the coronavirus SARS-CoV-21. The imported viruses with local spread, varying government’s response to the pandemic was nationwide epidemic wave centered on in size from several cases to about 1,000 perceived positively by the Chinese public4. was contained by April 2020 with cases, all stopped with non-pharmaceutical In this Correspondence, we describe two non-pharmaceutical interventions alone but interventions alone3. Sustained containment large-scale PCR-based testing strategies that

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500 Ürümqi city Xinjiang autonomous region 16 Jul–18 Aug Imported cases 450 Cases: 1,064 Local cases

Outbreak events 400

350

300

Beijing city Dalian city 11 Jun–5 Jul Liaoning province Kashgar city Cases: 366 250 22 Jul–5 Aug Xinjiang autonomous region Harbin city Cases: 135 24 Oct–7 Nov Heilongjiang province Cases: 430

Reported cases 8–25 Apr 200 Cases: 89 Suifenhe city Heilongjiang province Tiānjīn city 16–30 Apr 8–20 Nov 150 Cases: <100 Shulan city Cases: 11 Jilin province Manchuria city 7–25 May Inner Mongolia Cases: 49 Shenzhen & Shanwei cities 21 Nov–9 Dec 100 Guangdong province Qingdao city Cases: 29 14–22 Aug Shandong province Cases: 9 11–16 Oct Shanghai city Cases: 12 9–23 Nov 50 Cases: 6

0 4/1 4/8 5/6 6/3 7/1 7/8 8/5 9/2 9/9 4/15 4/22 4/29 5/13 5/20 5/27 6/10 6/17 6/24 7/15 7/22 7/29 8/12 8/19 8/26 9/16 9/23 9/30 10/7 11/4 10/14 10/21 10/28 11/11 11/18 11/25 11/30

Testing begun on Testing strategy for incoming Shenzhen & Shanwei cities, Guangdong province Shanghai city incoming travelers travelers revised as testing at 15–16 Aug, 0.12 million people screened 10 and 21–23 Nov, 44,000 people days 1 & 13 of quarantine period Screening strategy: high-risk places and screened personnel screened by the cases’ activities Screening strategy: residents in villages Wuhan city, province with cases reported and personnel in 14 May–1 Jun, 9.9 million people screened high-risk places screened Qingdao city, Shandong province Screening strategy: all city residents Ürümqi city, Xinjiang autonomous region 11–16 Oct, 10.9 million people screened ≥6 years of age 17–23 Jul, 2.3 million people screened Tianjin city Screening strategy: residents of the entire 1:1 or 5:1 pooled testing Screening strategy: residents in the high-, moderate- 21–23 Nov, 2.5 million people and low-risk areas city screened by risk level screened 3:1 or 5:1or 10:1 pooled testing Screening strategy: all residents of Beijing city Binhai New Area screened 11 Jun–14 Jul Dalian city, Liaoning province 11.9 million people screened 26–31 Jul, 4.5 million people screened Kashgar city, Xinjiang autonomous region Screening strategy: residents in the Screening strategy: residents of the entire city 24–27 Oct, 4.7 million people screened Manchuria city, Inner Mongolia 'high-, moderate- and low-risk areas, screened by risk level Screening strategy: residents of the entire 22 Nov–5 Dec, 0.2 million people screened including , cases reported, 5:1 or 10:1 pooled testing city screened by risk level Screening strategy: residents of the entire communities, etc. 1:1 or 5:1 pooled testing city screened by risk level

Fig. 1 | Local and imported COVID-19 cases from 1 April 2020 to 30 November 2020. Light blue wide bars indicate outbreaks (key) and adjacent labels indicate mass PCR testing strategies.

have played critically important roles in Outbreak investigations in Beijing and PCR. This screening strategy has identified sustaining containment since April 2020 in Dalian found that food contamination index cases of several outbreaks: the Xinfadi mainland China: routine, active, PCR-based could potentially transmit SARS-CoV-26,7. market in Beijing; Dalian; Pudong airport8; screening, and mass PCR testing during the Isolation of viable virus in the outer Qingdao9; and Manchuria. outbreak response. packages of imported seafood in Qingdao Routine testing requires many PCR tests. With almost all of China’s population strengthened the evidence for such Laboratories combine five or ten specimens being susceptible to SARS-CoV-2 before transmission. Workers handling imported and test the combination for SARS-CoV-2 the induction of any vaccine-induced goods are now required to be tested weekly RNA as an efficiency and cost-saving population immunity5, imported viruses for SARS-CoV-2, which has prevented measure. If the combination tests have a posed an enormous threat to containment. several importation-related outbreaks—for positive result, people whose samples were All incoming international travelers, example, four dockworkers were found to combined are tested separately to identify workers handling imported goods, have become infected in December 2020 the infected person (or people). With a 10:1 medical-center outpatients with fever or in Dalian, and an outbreak investigation pooled sampling approach, the average cost respiratory symptoms, and medical staff in Kashgar, Xinjiang, found importation per person tested is approximately 9 RMB caring for patients with fever or infectious of SARS-CoV-2 via a contaminated yuan (US$ 1.50) in China. diseases are actively screened with PCR to cross-border truck. Routine PCR testing is augmented with determine if they are infected. Incoming Fever clinics have long been established testing of all close contacts of an infected travelers have been required to quarantine at in secondary and tertiary hospitals. person. Since September 2020, all close designated hotels for 14 days after entry into Anyone with fever seeking healthcare contacts of infected people have been China, during which time they are tested at is screened by PCR. Medical facilities required to be tested three times during a least twice. As of 30 November 2020, 3,866 admit anyone with suspected COVID-19, 14-day centralized quarantine period: at day SARS-CoV-2-infected travelers had been unexplained pneumonia, or severe, acute 1 or 2; 1 day later; and at day 14. diagnosed, which prevented seeding of the respiratory-tract infection, and they test Mass, community-wide PCR testing virus in susceptible communities (Fig. 1). the patients and accompanying people by during or after an outbreak response has

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proven to be a useful strategy for identifying for outpatients, inpatients, caregivers, of Surveillance and Early Warning on Infectious infected people, including those with no close contacts of confirmed cases and Disease, Chinese Center for Disease Control and symptoms, and for determining whether people residing in high-risk areas in a local Prevention, Beijing, China. 2WorldPop, School of a community is free of SARS-CoV-2. outbreak setting are to be reported within Geography and Environmental Science, University Once a local outbreak is identified, 12 hours. Results for patients in fever clinics of Southampton, Southampton, UK. 3Chinese Center geographic jurisdictions are classified and emergency departments are to be for Disease Control and Prevention, Beijing, China. by epidemiologists into regions at low, reported within 6 hours. 4CAS Key Laboratory of Pathogenic Microbiology moderate or high risk of transmitting the In China’s ‘new-normal’ situation, and Immunology, Institute of Microbiology, Chinese virus. People in high-risk settings are tested comprehensive, active and innovative PCR Academy of Sciences, Beijing, China. 5Tese authors individually. In moderate-risk areas, a 5:1 testing strategies are performed for targeted contributed equally: Zhongjie Li, Fengfeng Liu. 6Tese or 10:1 pooled sampling approach is used to groups and in outbreak settings; this ensures authors jointly supervised this work: George F. Gao reduce the number of tests. timeliness of early case detection and and Zijian Feng. The first city-wide mass screening interruption of local outbreaks—essential ✉e-mail: [email protected] was performed between 14 May and ingredients in the prevention and control 1 June 2020 in Wuhan city; nearly 10 strategy. Maintenance of containment has Published online: 15 April 2021 million people were tested by PCR, and greatly reduced the impact of COVID-19 https://doi.org/10.1038/s41591-021-01308-7 300 asymptomatically infected people in terms of suffering, lives lost and were identified for quarantine. The socioeconomic progress. References testing results were used to support The introduction of vaccines against 1. Li, Z. et al. Lancet 396, 63–70 (2020). 2. National Bureau of Statistics of China. http://www.stats.gov.cn/ full reopening of local socioeconomic COVID-19 globally and in China will tjsj/zxf/202010/t20201020_1794939.html (accessed 16 February 10 activities . Large screening programs have undoubtedly improve epidemiological 2021). been implemented following local case situations. PCR testing strategies will be 3. Zheng, C. et al. China CDC Weekly 2, 902–905 (2020). 4. Lazarus, J. V. et al. PLoS One 15, e0240011 (2020). reports that indicated possible community adjusted to fit the changing epidemiological 5. Li, Z. et al. Lancet Reg. Health West. Pac. 8, 100094 (2021). transmission. For instance, during the situation in China—probably one in 6. Pang, X. et al. Natl. Sci. Rev. 7, 1861–1864 (2020). outbreak in Beijing’s Xinfadi market, 11.9 which few or fewer non-pharmaceutical 7. Zhao, X. et al. China CDC Weekly 2, 658–660 (2020). 8. Fang, F., Song, Y., Hao, L., Nie, K. & Sun, X. China CDC Weekly million people were tested between 11 June interventions will be needed for effective 47, 910–911 (2020). and 14 July 2020; in Dalian, 4.5 million epidemic control. Inexpensive, readily 9. Xing, Y., Wong, G.W.K., Ni, W. & Hu, X. Xing. Xing. N. Engl. J. people were tested between 26 July and available and rapid PCR testing will continue Med. 383, e129–e129 (2020). 31 July 2020; and in Qingdao, 10.9 million to be essential for sensitive surveillance 10. Cao, S. et al. Nat. Commun. 11, 5917–5917 (2020). people were tested between 11 October of SARS-CoV-2 well into the future. and 16 October 2020 (ref. 9). These Throughout 2020, PCR testing served the Acknowledgements risk-based, large-scale, population-wide public well, helping to make and keep China We thank L. Rodewald for contributions to the content and screenings contributed to case finding and nearly free of SARS-CoV-2, and providing improvement to the text of this Correspondence. rapid control of epidemics and provided socioeconomic space and time for vaccine evidence for the government to reopen development and long-term prevention and Author contributions ❐ Z.L., Z.F. and G.F.G. designed and supervised the study; economic activities. control of COVID-19. Z.L. and F.L. wrote the manuscript; J.C. designed and The timeliness of PCR test results varies drew the figure; Z.P., Z.C., Q.C. and L.W. participated in by testing purpose and epidemiological Zhongjie Li1,5, Fengfeng Liu1,5, literature review and data collection; and S.L. and G.F.G. situation. For members of the public Jinzhao Cui1, Zhibin Peng1, Zhaorui Chang1, commented on and revised drafts of the manuscript. who request PCR testing but have no Shengjie Lai 2, Qiulan Chen1, Liping Wang1, symptoms or exposure history, results are George F. Gao3,4,6 and Zijian Feng3,6 ✉ Competing interests to be reported within 24 hours. Results 1Division of Infectious disease, Key Laboratory The authors declare no competing interests.

Open letter to international funders of science and development in Africa

To the Editor—Recently there was an for decision-making in malaria control be led from Africa by African scientists, announcement1 of a US$30 million grant and elimination. partnering with Western institutions where awarded to the nonprofit health organization Not one African institution was named appropriate, especially where capacity has PATH by the US government’s President’s in the press release. The past year has been been demonstrated. Malaria Initiative (PMI). The grant funded a full of calls from staff and collaborators of We write this letter to the major consortium of seven institutions in the USA, various public-health entities for equality international funders of science and the UK and Australia to support African and inclusion, so one might imagine that development in Africa as African scientists, countries in the improved use of data such a partnership to support Africa should policy analysts, public-health practitioners

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