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Fangcang Shelter Hospitals: a Novel Concept for Responding to Public Health Emergencies

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Fangcang Shelter Hospitals: a Novel Concept for Responding to Public Health Emergencies Health Policy Fangcang shelter hospitals: a novel concept for responding to public health emergencies Simiao Chen*, Zongjiu Zhang*, Juntao Yang, Jian Wang, Xiaohui Zhai, Till Bärnighausen†, Chen Wang† Fangcang shelter hospitals are a novel public health concept. They were implemented for the first time in China in Published Online February, 2020, to tackle the coronavirus disease 2019 (COVID-19) outbreak. The Fangcang shelter hospitals in China April 2, 2020 were large-scale, temporary hospitals, rapidly built by converting existing public venues, such as stadiums and https://doi.org/10.1016/ S0140-6736(20)30744-3 exhibition centres, into health-care facilities. They served to isolate patients with mild to moderate COVID-19 from *Co-first authors their families and communities, while providing medical care, disease monitoring, food, shelter, and social activities. †Co-senior authors We document the development of Fangcang shelter hospitals during the COVID-19 outbreak in China and explain Heidelberg Institute of Global their three key characteristics (rapid construction, massive scale, and low cost) and five essential functions (isolation, Health, Faculty of Medicine triage, basic medical care, frequent monitoring and rapid referral, and essential living and social engagement). and University Hospital, Fangcang shelter hospitals could be powerful components of national responses to the COVID-19 pandemic, as well as Heidelberg University, future epidemics and public health emergencies. Heidelberg, Germany (S Chen ScD, Prof T Bärnighausen MD); 5,6 Introduction or critical disease. Health workers at Fangcang shelter Chinese Academy of Medical Fangcang shelter hospitals were developed and used for hospitals can transfer patients to higher-level hospitals for Sciences & Peking Union 6 Medical College, Beijing, China the first time in China to tackle the coronavirus disease more complex treatment if their conditions worsen. 1 (S Chen, Prof T Bärnighausen, 2019 (COVID-19) outbreak. The term Fangcang, which Fangcang shelter hospitals can also offer emotional and Prof C Wang MD); National sounds similar to Noah’s Ark in Chinese, was borrowed social support to help patients recover and thrive during Health Commission of the from military field hospitals,2,3 but it refers to a novel an otherwise disruptive period in their lives.6 In this People’s Republic of China, concept: large, temporary hospitals built by converting report, we document the conception and dev elop ment Beijing, China (Z Zhang BS); State Key Laboratory of public venues, such as stadiums and exhibition centres, of Fangcang shelter hospitals during the COVID-19 Medical Molecular Biology, into health-care facilities to isolate patients with mild to outbreak in China, describe their key characteristics Institute of Basic Medical moderate symptoms of an infectious disease from their and essential functions, discuss critical issues for the Sciences, Chinese Academy of familes and communities, while providing medical care, success of Fangcang shelter hospitals, and consider Medical Sciences & Peking Union Medical College, Beijing, disease monitoring, food, shelter, and social activities. applications of the concept as part of the COVID-19 public China (J Yang PhD); National The experience with Fangcang shelter hospitals during health response in other countries. Center for Medical Service the COVID-19 outbreak in China suggests that they could Administration, Beijing, China be powerfully employed in future public health emer- Development of Fangcang shelter hospitals in (J Wang BS, X Zhai MS); Department of Global Health gencies, in particular other epidemics, but also during Wuhan and Population, Harvard T H other events involving illness or injury on a large or rapidly Wuhan, the capital city of Hubei province in China, Chan School of Public Health, growing scale, such as mass poisonings or natural disas- was the epicentre of the COVID-19 pandemic. As of Boston, MA, USA ters. The Fangcang shelter hospitals, which can be rapidly March 27, 2020, confirmed cases of COVID-19 in Wuhan (Prof T Bärnighausen); National Clinical Research Center for 4,5 established, can provide large numbers of hospital beds accounted for more than 60% of all confirmed cases in Respiratory Diseases, Beijing, and appropriate care for patients who do not have severe China.7 The surge of infections placed huge pressure China (Prof C Wang); Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China–Japan Friendship 10 000 Hospital, Beijing, China (Prof C Wang); and Chinese Academy of Engeering, Beijing, 5000 China (Prof C Wang) Correspondence to: 0 Prof Chen Wang, Chinese Academy of Medical Sciences & Peking Union Medical College, –5 000 Beijing 100730, China [email protected] –10 000 Number of patients in Fangcang shelter hospitals Number of vacant beds in Fangcang shelter hospitals or Number of cumulative transfers to higher-level designated hospitals Number of cumulative discharges Dr Juntao Yang, State Key Laboratory of Medical Molecular Feb 6 Feb 7 Feb 8 Feb 9 Biology, Institute of Basic Feb 10 Feb 11 Feb 12 Feb 13 Feb 14 Feb 15 Feb 16 Feb 17 Feb 18 Feb 19 Feb 20 Feb 21 Feb 22 Feb 23 Feb 24 Feb 25 Feb 26 Feb 27 Feb 28 Feb 29 March 1March 2March 3March 4March 5March 6March 7March 8March 9 March 10 Medical Sciences, Chinese Date Academy of Medical Sciences & Peking Union Medical College, Figure 1: Fangcang shelter hospital patient flows during the coronavirus disease 2019 outbreak in Wuhan, China Beijing 100005, China All dates are in 2020. [email protected] www.thelancet.com Published online April 2, 2020 https://doi.org/10.1016/S0140-6736(20)30744-3 1 Health Policy on the city’s medical system.7 At the beginning of Wuhan subsided and bed occupancy moved towards February, 2020, Wuhan had no beds available for zero, the Fangcang shelter hospitals were successively COVID-19 patients in the hospitals designated for suspended. The first hospital closed on March 1, 2020; treating the virus.8 Thousands of patients with mild to by March 10, all Fangcang shelter hospitals had been moderate COVID-19 had to be sent home for isolation suspended.10,11 and observation. With a shortage of hospital beds, Wuhan Home isolation is an important alternative to hospital needed an approach to rapidly and massively scale its isolation, which requires behaviour change but no capacity to isolate and care for patients with mild to additional infrastructure investment. Chinese policy moderate COVID-19. As the outbreak in Wuhan reached makers decided against home isolation of patients with its most severe point, with thousands of new infections mild to moderate COVID-19 for a number of important per day, the city opened three Fangcang shelter hospitals reasons.12,13 First, home isolation puts patients’ family on Feb 5, 2020, by converting exhibition centres and members at risk. Early epidemiological evidence in stadiums. Over the following weeks, Wuhan opened an China showed that more than half of all patients with additional 13 Fangcang shelter hospitals.9 Figure 1 shows COVID-19 had at least one family member with the the progression of bed capacity and occupancy of the disease, and 75–80% of all clustered infections were Fangcang shelter hospitals over time. As the epidemic in within families, suggesting high rates of intrafamily Clean Semi- Contaminated zone zone clean zone Escape passage Passage for Passage for health workers patients Escape passage Passage for patients Passage for health workers Escape passage Passage for patients Passage for health workers Figure 2: Zones and passages in a Fangcang shelter hospital in Wuhan, China Adapted with permission of ThePaper.29 2 www.thelancet.com Published online April 2, 2020 https://doi.org/10.1016/S0140-6736(20)30744-3 Health Policy transmission.14–18 Second, patients can find home workers put on and take off their protective suits, isolation psychologically taxing, because they know that and a clean zone where supplies are received—and they are putting those they care about most at risk of two passages, one for patients and the other for health contracting the disease.19,20 Third, home isolation is workers. Although Fangcang shelter hospitals have unlikely to be fully effective because it cannot be strictly some historic precedents, such as makeshift hospitals, enforced. Patients might break with the mandated emergency field hospitals, emergency shelters, and behaviour to stay at home and go outside for errands, hospital isolation wards,30–32 they have three distinct entertainment, or exercise. Lastly, it is difficult to organise characteristics and five functions that set them apart medical care, frequent monitoring of disease progression, from facilities that have previously been used for the and timely referral to hospital care for thousands of control of public health emergencies. patients in home isolation.21 COVID-19 can deteriorate from mild or moderate to severe illness, requiring rapid Three key characteristics of Fangcang shelter referral to hospital care.16–18 In home isolation in Wuhan, hospitals before the introduction of the Fangcang shelter hospitals, Fangcang shelter hospitals have three characteristics the time from onset of severe symptoms to admission to that make them particularly well suited to address public a tertiary hospital for intensive care was up to 10 days.8,22 health emergencies, such as the COVID-19 outbreak The Fangcang shelter hospitals substantially reduced in Wuhan (figure 3).33 The first characteristic
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