Updates on the Wuhan 2019-nCoV outbreak

The 2019-nCoV death toll surpassed 800 on Feb 9, making a prediction in the blog “Hyperbole, overreaction, and panicking in the Wuhan virus scare of 2020” wrong.  Between the Jan 26 blog and Feb 9, however, we have known a lot about the disease, initial cases, symptoms, Wuhan hospital and government responses, etc, based on real-time updates (https://news.sina.cn/zt_d/yiqing0121), media reports, and medical and scientific papers, and the principal ideas of the blog remain valid.

As of Feb 9, 2020, there are 37294 confirmed cases, 813 deaths.  Suspected cases (28942) might be less reliable because the criteria may have shifted, and the data collection too decentralized.   Quarantine numbers have been unavailable for days, because they are even more decentralized; estimates could be in hundreds of thousands but change every minute, with no meaningful standards.

In Wuhan, there are 14982 confirmed cases, 608 deaths, fatality rate is 4%.  In Hubei province outside Wuhan, about 12000 cases, 170 deaths, 1.5%.  Rest of China and the world, 10000 cases, 32 death, 0.3%.  Most cases obviously are people from Wuhan, so why the vast difference in mortality rates?  Reason #1 is that those patients (capable of) traveling out of Wuhan were less sick than those staying.  Reason #2 is that with the panicking in Wuhan and local hospitals flooded with patients, the healthcare system is overwhelmed, lowering the care for everybody.  One can assume that from Jan 20 to 26, hundreds of thousands of people went to the hospitals.  No city in the world can handle this.  Thus, it can be easily imagined that, say person A was just having a mild common cold, but because of nonstop, serious coverage of the virus and the lockdown, decided to go to a hospital to check.  There he joined hundreds or even thousands of similar patients, some with the 2019-nCoV, most without, in a crowded, closed environment.  After spending hours there, with all the blood work, CT, whatever, he was declared OK, but got infected with the virus on that day.  So he had a false sense of security with a “health certificate”, and went home to celebrate with family and friends.  Then several days later he developed symptoms, and many of his relatives and friends got infected.  This belief is not far-fetched: a JAMA paper (doi:10.1001/jama.2020.1585) showed that cases due to transmission in hospitals could be 40% (patient to patient 12%), during the earliest phase of the outbreak, when little was known, and protection was lacking.  Future analyses will determine the extent of this around Jan 23.  

The silver lining here is that with sufficient care, and treatment lessons learned, more cases will be confirmed but mortality rates in Wuhan will drop.  We also need to remember that throughout all history real infections are much higher than confirmed cases, as many people developed mild or no symptoms and did not check in.  While deaths could be undercounted as well, it is probable that some people had both common cold or seasonal flu, and 2019-nCoV, and it is the other infections that kill instead of 2019-nCoV.  In fact, having a 2019-nCoV epidemic doesn't mean the common cold/flu endemic is no more.  With the way people voluntarily or involuntarily check into Wuhan hospitals since the lockdown, one could die from a bad cold, or have a bad cold, contract the CoV at the hospital, and die, and both may count as death from CoV.  Since RNA test can yield false negatives, it is not essential in some diagnoses now.  If a suspected case dies quickly, he can be classified as a positive even without RNA test or time to confirm it.  And so far we haven't even mentioned the false positives.  Therefore, the death toll can be overcounted too.  

Another burning question is what Wuhan could have done better.  Based on the media reports and published articles in NEJM, Lancet, and JAMA, we have a clearer picture of what transpired in the early days.   The earliest case(s) could be traced back to early Dec 2019 or earlier, but the late Dec cluster cases (about 40) set off the alarms.  The first hospitals submitted the reports on Dec 26, Wuhan health authority warned all hospitals on Dec 30, national news (like Sina) reported it on Dec 31, WHO notified, a team of experts were sent from Beijing to Wuhan, and on Jan 1, 2020, the wet market in question was shut down.   In essence, within one week, a lot was done.  

The big problem, however, was we had a new virus.  Initial tests couldn’t find anything, not bacteria, known flu viruses, adenoviruses, or other coVs including SARS, MERS.   Moreover, we now know the incubation time for this virus can be long, and many patients don’t become sick for days, unlike SARS.  So the medical doctors and experts in Wuhan didn’t know what caused the diseases and who was infected unless he checked himself in.  At the time most quarantines, close relative of the patients showed no symptoms, so all the doctors could say was no apparent human-to-human transmission.  There are precedents: many bird flus go from birds like chickens to humans but not humans to human.  In fact, bird flus are often more dangerous than all the other viruses.  

The first problem was solved when the virus was sequenced: initial data was now known to be obtained on Jan 5, but they needed time to check data quality, confirmed in more samples, assembled and analyzed the data.  On Jan 7-8 WHO was notified, news reported that a new virus was identified. 

Finding a CoV should warn doctors about human-to-human transmission.  But at the time (Jan 8) it was still unclear what the virus could do.  For one thing, there weren’t known, secondary patients yet.  Another, unlike SARS and MERS, symptoms developed more slowly.  Lastly, there are other CoVs that present only mild problems.  So the doctors and experts were probably debating where the patients are and whether 2019-nCoV is like SARS, MERS, or the other CoVs.  Once the virus was known, PCR kits were designed to identify the infected.  Since it was new, detection was initially slow, taking 2-3 days out of town.  Unfortunately, there could still be false negatives: if you have mild symptoms, specimen may miss it.  These factors contributed to the undercounting of patients.    
     

But more patients eventually appeared: assuming the initial cases from late Dec 2019 infecting others in early Jan, and the latter started to show clear symptoms in mid Jan.  With more confirmed patients and better sampling and quicker PCR detection, the hospitals now had a sense of what really happened.  In mid Jan Wuhan stated could not rule out human-human spread, and on Jan 20 Dr Zhong Nanshan confirmed on major news human-human transmissions and advised travel freeze in Wuhan.  This sets the other responses in motion, and on Jan 23, lockdown began in Wuhan and elsewhere.

In retrospect, if the medical community had acted more forcefully once a CoV was identified, the situation might have been improved.  But a benefit of doubt is in order.  As mentioned, initially there were not many patients, how the symptoms evolved was unclear, the wet market was closed right away, secondary infections were not apparent for some time due to various reasons, CoV is not automatically very dangerous.  Based on sequence analyses alone, 2019-nCoV is 80% similar to SARS but believed likely less infectious or deadly.  All these influenced the thinking at the time and probably delayed a stronger recommendation or response.  This is really subjective, but I think sounding an alarm on Jan 15 is justified, but Jan 20 is understandable.  About a couple hundred of confirmed cases back then.

Sounding an alarm is, however, not the same as the subsequent lockdown, which is governments’ responsibility.  The lockdown as practiced is counterproductive.  It created panicking, likely leading to people getting unnecessarily infected and many more deaths in Wuhan.  In other places in China, it should reduce virus transmission, but there are other, less disruptive ways to do it.  The local measures are actually getting more extreme in recent days.  A few cities allow only one person from any family to get out shopping once every two days.  People buying OTC medicine for fever and cough may need registration.  You can’t visit any schools, residential areas of not your own.  There are instances of neighbors against neighbors, families against families, friends against friends.  Rumors are flying all over the place.  Stupidity and craziness are on full display.  These are completely self-harming and defeating.   

Perhaps panicking is inevitable, being on Jan 15 or Jan 23.  But the medical community and especially the governments should have done a better job discouraging or preventing mass hysteria.  For one thing, 80-90% of 2019-nCoV patients have only mild symptoms, 10-20% need ICU, but most make complete recovery with no residual effects.  Better life-supporting care should reduce the mortality rate further.   The virus is infectious, but not that bad compared to many other pathogens.  There are now 10 cases directly linked to air travel from China to the US.  During that period of time, there are over one hundred thousand passengers on the China to US flights.   In those ten flights there were maybe 3000 people packed in the environment.  Nobody else was infected.  It is not that a person can’t get infected through air or train transport or any other interactions with other people, but we need to remember the odd is low and can be lowered.  One can understand governments and airlines reducing flights, due to lower demands, but complete suspension is absolutely unjustifiable.  It feeds the worst of human nature, leading to xenophobia and racism.  Warren Buffett says: "Only when the tide goes out do you discover who's been swimming naked."  In the times of crises, you discover who's a bad human being.  There are a lot of them in the world.

Basic premises of the Jan 26 blog stand: Chinese governments’ response is really to fight a war against common cold and seasonal flu, not just 2019-nCoV, and many other governments’ are unreasonable.  The war can be won only when the nature helps (temperature increases) and the governments loosen the standards.  The virus will stay in the population for a while, even if not as an epidemic.  Later on, drugs and vaccines may be developed, which is the ultimate solution.  We are lucky that 2019-nCoV is no bird flu.