Comments on key documents from the early weeks of SARS-CoV-2

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By Daniel R. Lucey MD, MPH, FIDSA

The purpose of this blog is to provide comments on reporting of some of the key COVID-19 events from 23 Chinese publications dated Dec. 31, 2019, until Feb. 17, 2021. Except for the five from the China CDC Weekly website, most are no longer online; however, I saved hard copies as I read them in real time starting Dec. 31, 2019.

Readers can reconstruct China’s reported trajectory of patient numbers, e.g., the significance of the 153 new patients confirmed Jan. 17-19 (17 + 59 +77 on those three successive days) when only 45 total cases (41 + 4) had been reported in China as of Jan. 16.

Health care providers will also immediately understand the significance of the China CDC publication on Feb. 17, 2020 reporting that from Jan. 1-31 a total of 1,366 health workers had been confirmed to be infected overall in China (albeit some retrospectively, once laboratory testing became available to do so during January 2020).

Importantly, in the China CDC Weekly publication posted online Jan. 22, readers can find the China CDC joint team’s initial surveillance definition and also probable case definition for cases of “Viral Pneumonia of Unknown Etiology (VPUE)” as of Dec. 31, 2019. This VPUE surveillance system was created in 2004 in response to the 2003 SARS epidemic. It had been used 2004-2019, e.g., for avian influenzas H5N1, H7N9 and H5N6 and then for the novel coronavirus pneumonia later named SARS-CoV-2/COVID-19.

This blog is divided into three sets of documents:

  • 15 from Wuhan Municipal Health Commission: Dec. 31, 2019-Jan. 24, 2020.
  • 3 from China National Health Commission (in Beijing): Jan. 11, 19, 20.
  • 5 from China CDC Weekly (in Beijing): Jan. 21, 22, 30, Feb. 1, 17.

Wuhan Municipal Health Commission: 15 Documents from Dec. 31, 2019-Jan. 24, 2020

1) Date: Dec. 31, 2019.
Document: “Wuhan Municipal and Health Commission’s briefing on the current pneumonia situation in our city.”
Key Takeaways: 27 cases viral pneumonia, “many” related to “South China Seafood City.” Consulting with Tongji Hospital, Provincial Hubei CDC, Wuhan CDC, Wuhan Infectious Disease Hospital, Wuhan Institute of Virology, more.

2) Date: Jan. 3, 2020.
Document: “Wuhan Municipal and Health Commission’s report on unexplained viral pneumonia.”
Key Takeaways: 44 cases; “… no clear evidence of human-to-human transmission and no medical staff infections.” “The State and Provincial Health and Health Commission … sent work groups and expert teams to Wuhan to guide the local epidemic response and disposal work.”

3) Date: Jan. 5.
Document: Wuhan Municipal and Health Commission’s report on unexplained viral pneumonia.
Key Takeaways: 59 cases, earliest onset Dec. 12 and latest Dec. 29. “Some” patients linked to Wuhan South China Seafood Wholesale Market. “… no clear evidence of human-to-human transmission and no medical staff infections … influenza, SARS and MERS have been excluded. Pathogen identification and cause tracing are still underway.”

4) Date: Jan. 11.
Document: “Experts explain the latest bulletin of unknown cause of viral pneumonia.”
Key Takeaways and Questions: How was this outbreak diagnosed? What are clinical manifestations? Details on the one death? What does it mean that there are no new cases since Jan. 3 (earliest case Dec. 8, 2019 and latest Jan. 2)? How should we understand “No clear evidence of human-to-human transmission”? “… all close contacts, including medical staff, have so far not detected any related cases.”

5) Date: (Also) Jan. 11.
Document: Wuhan Municipal and Health Commission’s report on unexplained viral pneumonia.
Key Takeaways: 41 cases of pneumonia with a “new type of coronavirus based on “nucleic acid testingas of Jan. 10. “… with support of the state and Hubei Province, Wuhan has … cooperated to carry out in-depth epidemiological investigations … On January 1, 2020, the South China Seafood Wholesale Market has been closed and measures taken to strengthen the prevention of disease and environmental hygiene in public places in the city, especially the farmers’ market.” … “At present, no medical staff infections have been found, and no clear evidence of human-to-human transmission has been found.” … “If you have fever, respiratory infection symptoms, especially persistent fever, go to a medical institution in time.”

6) Date: Jan. 14/15.
Document: “Experts from Hong Kong, Macao, and Taiwan visited our city.”
Key Takeaways: A team of experts from these three places visited Wuhan Jan. 13-14. They “conducted face-to-face-exchanges and consultations with national, provincial, and municipal experts … and visited the laboratories of disease control institutions …”

7) Date: (Also) Jan. 14/15.
Document: “Questions and answers on pneumonia outbreak of new coronavirus infection.”
Key Takeaways and Questions: The first case in Thailand ex-Wuhan reported Jan. 13; how to detect new cases? (“After the outbreak, the city quickly carried out screening of relevant cases in all medical institutions in the city.”) “Existing survey results show that clear human-to-human evidence has not been found, and the possibility of limited human-to-human transmission cannot be ruled out, but the risk of continued human-to-human transmission is low.” “Among the 41 cases currently diagnosed, one was found to be clustered in the family. The husband was employed at the South China Seafood Market but his wife denied any exposure to the Market.” Define close contacts, why the 14-day observation period, and what if fever and cough develop? “What is the development trend of the epidemic?” “…most of the cases are related to the South China Seafood Wholesale Market exposure, a few cases deny a history of …Market exposure, and some cases have been exposed to similar cases. No community transmission has been identified.”

8) Date: Jan. 16.
Document: “Wuhan Municipal Health and Health Commission’s report on pneumonia of new coronavirus infection.”
Key Takeaways: Still 41 cases; “all patients received isolation treatment at designated medical institutions in Wuhan.” A second death, 69-year-old man ill on Dec. 31, transferred to Wuhan Jinyintan Hospital Jan. 4 with severe myocarditis, multiorgan failure. “A total of 763 close contacts have been tracked, 644 medical observations have been lifted, and 119 medical observations are still underway. Among the close contacts, no related cases were found.”

9) Date: Jan. 17/18.
Document: “Wuhan Municipal Commission of Health and Health on pneumonia of new coronavirus infection.”
Key Takeaways: “4 new cases … being transferred to Jinyintan Hospital. Onset Jan. 5-8. One case in Japan as well as Thailand.” Total 45 cases; “as of now … among close contacts, no related cases were found.”

10) Date: (Also) Jan 17/18.
Document: “About the situation of prevention and control of pneumonia caused by new coronavirus infection in our city.”
Key Takeaway: “The sanitary killing of the South China Seafood Wholesale Market and other agricultural fairs in the city and … will continue.”

Jan. 17-19 Friday-Sunday, a total of 153 new patients reported:

  • Jan. 17: 17 new cases
  • Jan 18: 59 new cases
  • Jan. 19: 77 new cases

11) Date: Jan. 18.
Document: “About the new cases of pneumonia of new coronavirus infection in Wuhan.”
Key Takeaways: “Jan. 17 national and provincial experts screened cases of unexplained pneumonia at community health centers on the city … the positive result of the novel coronavirus nucleic acid detected by the subsequent detection kit … and 17 cases” were diagnosed. Ages 30-79 years. Onset before Jan. 13. Transferred to Jinyintan hospital except 2 cases with severe disease unstable for transfer. “In the next step, the city will continue to expand the search scope …”

12) Date: Jan. 18/19.
Document: “Wuhan Municipal Commission of Health and Health on pneumonia of new coronavirus infection.”
Key Takeaways: As of Jan. 17, a cumulative total of 62 cases (41 as of Jan. 15 + 4 on Jan. 16 + 17 on Jan. 17). “… a total of 763 close contacts have been tracked, 681 observations have been lifted, and 82 people are still receiving medical observation. Among close contact, no related cases were found.”

13) Date: Jan. 19/20
Document: “Wuhan Municipal Commission of Health and Health on pneumonia of new coronavirus infection.”
Key Takeaways: On Jan. 18, 59 new cases were diagnosed. On Jan. 19, 77 new cases were diagnosed. Of these 136 new cases Jan. 18-19, ages 25-89 years all with onset before Jan. 18. “According to the newly revised diagnosis and treatment plan, patients were classified according to their severity and criticality, including 100 mild, 33 severe, and 3 critical (one death). A total of 817 close contacts tracked … No related cases were found among the close contacts.”

14) Date: Jan. 20.
Document: “Wuhan sets up a list of outpatient medical institutions and designated medical institutions.”
Key Takeaways: See 4 pages of detailed lists across Wuhan of “61 hot clinics in the city … There are 9 designated medical institutions …” (including Wuhan Children’s Hospital).

15) Date: Jan. 24.
Document: “Ma Guoqiang deploys Wuhan’s epidemic prevention and control work to concentrate all efforts to resolutely curb the spread of the epidemic.”
Key Takeaways: “On Jan. 22 Ma Guoqiang, deputy secretary of the Provincial Party Committee … presided over a meeting … emphasizing the need to carefully study and understand the spirit of General Secretary Xi Jinping’s important instructions, and resolutely implement the decisions and deployments of the Party Central Committee and the State Council.” … “guide the masses to take the initiative to reduce or cancel New Years’ Eve dinners …”

National Health Commission: 3 Publications from Jan. 11-20

1) Date: Jan. 11, 2020.
Document: “Notification of Wuhan Municipal Health Commission on Unexplained Viral Pneumonia” (from Health Emergency Office, Beijing).
Key Takeaways: “All 739 close contacts, including 419 medical staff, have been under medical observation and no relevant cases have been found … no clear evidence of human to human transmission has been found.”

2) Date: Jan. 19.
Document: “National Health and Health Commission actively carries out prevention and control of pneumonia epidemic of new coronavirus infection” (from Health Emergency Office).
Key Takeaways: “On January 1, 2020, the Commission set up a leading group for epidemic response and disposal, with Director Ma Xiaowei as the team leader … to guide and support Hubei province and Wuhan City …

“The Committee first organized the China CDC, the Chinese Academy of Medical Sciences … the Military Medical Research Institute of the Academy of Medical Sciences to conduct parallel testing of case samples. On January 8, 2020, a new coronavirus was initially identified as the pathogen of the epidemic.”

“A national televised conference of the national health system was held …”

3) Date: Jan. 20.
Document: “Announcement of the National Health Commission of the People’s Republic of China” (from Bureau of Disease Control and Prevention).
Key Takeaways: Legal basis for quarantine and classifying this novel coronavirus as “Class B infectious disease” and “take preventive and control measures for Class A infectious diseases.”

China CDC Weekly: 5 Selected Publications from Jan. 21-Feb. 17**

1) Date: Submitted Jan. 19; online Jan 21.
Publication: “A Novel Coronavirus Genome Identified in a Cluster of Pneumonia Cases—Wuhan, China 2019-2020.” Authors include Drs. Wenji Tan, George Fu Gao. China CDC Weekly 2020, 2(4): 61-62.
Key Takeaways: “The origin of the 2019-nCoVs is still being investigated. However, all current evidence points to wild animals sold illegally in the Huanan Seafood Wholesale Market.The disease has been named “Novel coronavirus-infected pneumonia (NCIP).”

2) Date: Submitted Jan. 20. Online Jan. 22.
Publication: “An Outbreak of NCIP (2019 nCoV) Infection in China—Wuhan, Hubei Province, 2019-2020.” By the “Outbreak Joint Field Epidemiology Investigation Team, Qun Li.” China CDC Weekly 2020, 2(5): 79-80.
Key Takeaways: Important chronology Dec. 29-Jan. 3, and also important initial surveillance case definition for “Viral Pneumonia of Unknown Etiology (VPUE)” and “probable case” definition that includes epi-link to EITHER Seafood Market or another case of VPUE.

Dec. 29: “A hospital in Wuhan admitted four individuals with pneumonia and recognized that all four had worked in the Huanan Seafood Wholesale Market which sells live poultry, aquatic products, and several kinds of wild animals to the public. The hospital reported this occurrence to the local center for disease control (CDC), which lead Wuhan CDC staff to initiate a field investigation with a retrospective search for pneumonia patients potentially linked to the market. The investigators found additional patients linked to the market, and on …

Dec. 30: “Heath authorities from Hubei province reported this cluster to China CDC. The following day…”

Dec. 31: “China CDC sent experts to Wuhan to support the investigation and control efforts. Samples from these patients were obtained for laboratory analyses.”

“To identify potential cases, a temporary surveillance case definition for the VPUE (Viral Pneumonia Unknown Etiology) was established at that time that was consistent with previous “pneumonia of unknown etiology” definitions: an illness of unknown etiology with:

      • fever with or without a recorded temperature
      • radiographic evidence of pneumonia
      • low or normal leukocyte count or low lymphocyte count during the early stage
      • no improvement or worsening symptoms after 3 to 5 days of antimicrobial treatment per standard clinical guidelines.

A ‘probable case’ of VPUE was defined as a surveillance case or an illness of unknown etiology fulfilling the first three surveillance VPUE case criteria with a history of exposure to the Huanan Seafood Wholesale Market in Wuhan OR any other VPUE case.

“On January 3, 2020, the sequence of novel B-genus coronaviruses (2019-nCoV) was determined from specimens determined from specimens collected from patients in Wuhan by scientists of the National Institute of Viral Disease Control and Prevention (IVDC), and three distinct strains have been established.

“On January 7, this novel coronavirus was confirmed to be the cause of the VPUE cluster, and the disease was designated NCIP (Novel Coronavirus Infected Pneumonia).”

NOTE: “Huanan Seafood Wholesale Market has western and eastern sections and 15 environmental specimens collected in the western section were positive for 2019-nCoV virus through RT-PCR testing and genetic sequencing analysis. Despite extensive searching, no animal from the market has thus far been identified as a possible source of infection.” (p. 79 bottom right with my underline for emphasis).

“As of January 19, 198 cases of NCIP have been reported in Wuhan … age range 26-89.”

“A total of 817 close contacts of cases have been placed under quarantine … NO CASES OF NCIP HAVE BEEN FOUND AMONG CLOSE CONTACTS …

“A total of 16 health care workers (HCWs) are believed to have been infected while caring for patients from the outbreak …”

“Two clusters containing two cases and three cases, respectively, were identified among the confirmed cases. Human-to-human transmission appears to have occurred in the two-person cluster.”

During the investigation, the following was concluded:

      • recently reported, confirmed cases have had no history of exposure to the Huanan Seafood Wholesale Market;
      • human-to-human transmission has occurred;
      • HCWs have been shown to have been infected by the novel coronavirus;
      • “BASED ON THIS INFORMATION, TRANSMISSION WITHIN COMMUNITIES IS BELIEVED TO BE TAKING PLACE IN WUHAN.”

3) Date: Submitted Jan. 24. Accepted Jan. 29. Online Jan. 30.
Publication: “Description of the First Strain of 2019-nCoV, C-Tan-nCoV Wuhan Strain—National Pathogen Resource Center, China, 2020.” China CDC Weekly 2020, 2(6): 81-82.
Key Takeaways: “Isolation date: Jan. 6.” “Risk level “BSL-3.” “Name: C-Tan-nCoV Wuhan Strain.”

4) Date: Submitted Jan. 29. Online Feb. 1, 2020.
Publication: “Epidemic Update and Risk Assessment of 2019 Novel Coronavirus—China, January 28, 2020.” CCDC Weekly 2020, 2(6): 83-86.
Key Takeaways: “The results of the field investigation, laboratory testing, and knowledge of other known coronaviruses indicates that the 2019-nCoV originated in wild animals, even though the host animal(s) are still under investigation. Whether the spillover from animals to humans and the completion of adaptive mutation of the virus occurred in HN market remains to be confirmed, HN market has been identified as the main source of infection for early cases of this epidemics … The virus is highly contagious … To date, there is no reliable evidence from field investigations that the disease is contagious during the incubation period. (p. 84)

5) Date: Online Feb. 17.
Publication: “The Epidemiologic Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19)—China, 2020.” CCDC 2020: 2(8): 113-122.
Key Takeaways: Essential Reading: 9-page paper on 72,314 patients (44,672 (61.8%) confirmed; 16,186 (22.4%) suspected cases, 10,567 (14.6%) CLINICALLY DIAGNOSED CASES (HUBEI PROVINCE ONLY), 889 ASYMPTOMATIC cases (1.2%).

NOTE: See Figure 4: 3,019 cases among health care workers from Jan. 1 to Feb. 11.

See Table 2: Before Dec. 31, zero health care workers confirmed to be infected.

      • Jan. 1-Jan. 10: Total of 20 confirmed health care worker infections in China overall.
      • Jan. 11-20: 310 new confirmed HCW infections in China overall.
      • Jan. 20-31: 1,036 new confirmed HCW infections in China overall.
      • After Feb. 1 (until ~Feb. 10): 332 new confirmed HCW infections in China (1,688 total since Jan. 1).

**Correction: Due to a copyediting error, the subheading “China CDC Weekly: 5 Selected Publications from Jan. 21-Feb. 17” originally read “China CDC Weekly: 5 Selected Publications from Jan. 21-March 19.” Science Speaks regrets the error.

Dr. Daniel Lucey

Daniel Lucey, MD, MPH, FIDSA, FACP, is a Clinical Professor of Medicine at Dartmouth Geisel School of Medicine, Infectious Disease adjunct Professor at Georgetown Medical Center, senior scholar at Georgetown Law, Anthropology Research Associate at the Smithsonian Museum of Natural History and a member of the Infectious Diseases Society of America Global Health Committee. He served as a volunteer to outbreaks overseas including hands-on Ebola patient care in Sierra Leone and Liberia (Doctors without Borders) 2014, MERS 2013, SARS 2003, as well as HIV, H5N1, Zika, yellow Fever, and pneumonic plague 2017 (with WHO/USAID/CDC). Since Jan. 6, 2020 he has contributed more than 100 posts to Science Speaks on COVID-19 and traveled to China in February 2020. He initially proposed, then fundraised and helped design the content for 2018-2022 Smithsonian Exhibition on Epidemics due to zoonotic viruses. From 1982-1988 he trained at University of California San Francisco and Harvard and was an attending physician at the NIH (NIAID) in the 1990s while in the U.S. Public Health Service.

 

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