COVID-19 cases in Wuhan, China

Once COVID-19 outbreak has been contained in China but exploded in many European countries and the US since late Feb, the Western media and governments have been accusing China of “hiding something”.  While this “hiding something” is too vague to be meaningful, a more specific question has been raised lately about the accuracy of COVID-19 cases and deaths in Wuhan.  News on Yahoo.com on April 1 (is this an April fool’s joke?) reported that the US intelligence believed China intentionally underreported Wuhan cases, citing recent scenes at cremation services in Wuhan, or maybe an early order to destroy samples in Wuhan, and that a Dr somebody thinks most Wuhan residents have been infected.  An underlying theme is that China can’t possibly do better than Western countries, so it must be lying.  Politics aside, this question deserves analyses in depth.

The first, overarching notion that must be universally established is that all confirmed cases and deaths are just documented numbers, not “real” cases and deaths.  This applies to all countries, not just China.  To get the “real” numbers, one has to test everybody, everyday.  You may be negative today, but who can say you won’t be positive tomorrow, or were yesterday?  Unless you do this impossible task, you are literally “hiding something”.  Even that, you still have to contend with false positives and false negatives in tests.  Thus, nobody, including in China, takes the documented numbers as more than what they are.  The “real” numbers, is the documented numbers times a factor.  

This factor depends on how well you find and test everybody and how good the test is.  Even if tests in China, many developed in a rush early on, might not be as sensitive as the latter versions in some countries, because typically a person under medical observation is tested at least twice, on separate days, one can consider testing in China reliable.  Any country can test only those it has reasons to screen or those coming in for testing.  So if China is lying about cases, what China or Wuhan must do is to test somebody, find a positive, but nevertheless declares a negative.  But this is never the case. 

 

The Chinese National Health Commission has released multiple official guidelines regarding COVID-19, sometimes more than once a week, since Jan 2020.  They are all publicly available.  Most instructions are consistent and pretty much of common sense, but there are also changes, updating understanding of the diseases at the time.  COVID-19 containment would include five categories: confirmed cases, suspected, recovered, death, and closely monitored.  The last category are those who have had close contact with confirmed and suspected cases but no symptoms.   Its numbers are huge and swing sometimes widely, as expected, and not always as readily available as other categories (no other countries do this, either).  But these people are not released; instead, they are under observation for at least 14 days.  If during this period of time they show symptoms, or are tested positive, they become suspected or confirmed cases.  Even if they are declared OK after 14 days, they are still advised to stay at home for two more weeks.   If sick any time later, they will go back.

Nothing in those numbers and guidelines, absolute numbers or trends, suggests China or Wuhan is hiding something from Jan to now.  The only “oddity” in the official numbers was on Feb 12 when the newly confirmed cases in Wuhan jumped by more than 10K.  This is only because of changes in the official guideline.  Because a lot of suspected cases in Wuhan were tested RNA negative, some repeatedly, but had clinical symptoms, e.g., from CT scans, on Feb 12 all such cases were included as confirmed based mainly on CT results.  The rest of China did not follow the same criterion, as the confirmed and suspected cases were low, so it didn’t make much difference anyway.  After Feb 12, newly confirmed cases dropped back to the previous level, and later guidelines reversed to using RNA instead of CT results.

This bump in numbers on Feb 12 or no subsequent bumps, is hardly sinister.   RNA result is the gold standard everywhere.  Relying only on CT scan likely introduced more false positives than the false negatives RNA test would have allowed.  The goal really was to treat as many patients the same as possible.  Once you moved almost all the suspected cases to confirmed, you likely didn’t have that many to replenish.   

 

Should one believe the numbers?  No and yes.  No because one can never get the “real” numbers because of the reasons given above.  Yes because those numbers were given in real time, and how they were obtained were explained in all the official guidelines, never controversial in any scientific way.  If one wants to hide something to have an impact, he had to do it from day 1, do it consistently, and coordinate within Wuhan, rest of Hubei, and other provinces in China, since numbers from so many different places are reported independently, everyday.  Clearly a mountain of work, tons of risks, but no benefits, for lying.  Because on Feb 20, when the clearest sign COVID-19 was finally contained in China emerged, the confirmed cases and deaths in China were at least 100 times higher than any other country (Japan without the ship).  Nobody would have thought any country could ever topped China then.  Is the number of 75K not enough to demonstrate seriousness of COVID-19, or only when some countries have more cases on April 1 do they think China should have reported 750K instead of 75K on Feb 20?  

Another allegation is Wuhan ordered destroying viral samples early on.  There are multiple problems with it.  First is we don't even know if it is true.  Did such an order even exist?  What did it say in its entirety?  Did it give a justification?  But a fatal problem is: what did it aim to achieve even if true?  Did it prevent pathogen identification?  If not (samples had been distributed to various places in China, and virus sequenced within 10 days), then the usefulness of the samples was minimal.  What is more, you can destroy patient samples, but can you destroy patients (dozens of cases then, well reported by the media)?   There can simply be no possible legitimate explanations, so the allegation is a red herring or just a rumor.   

At this point the only thing critics can cling on scientifically is: How about the asymptomatic?  Frankly, China first discovered the problem with asymptomatic infections in late Jan and has updated and published numerous guidelines and papers on the subject (along with almost all the other information about COVID-19 now every country is using).    Asymptomatic now means somebody with a positive RNA test but exhibits no symptoms.  It is ambiguous whether it should be included as confirmed or not in medicine (WHO seems to think so): for example, if you are HBV positive but otherwise healthy, are you considered having hepatitis or other liver problem?  But in any case, an asymptomatic is also under medical observation and quarantine, according to China's official guidelines.  He may develop symptoms within 14 days and change status to confirmed, or not, in which case he is released and quarantined for two more weeks.  In other words, it is not that these people are deliberately ignored, not counted, not supervised, or not treated.  For the latest China is now listing asymptomatic in a separate category, although this is merely to subdivide previous classifications.  It is about 1500, including imported cases.  The number is not large and hardly changes anything.  Asymptomatic cases do pose a problem with disease containment, but with better surveillance, diagnosis, and quarantine policies now in place, people should be able to live with small pockets of COVID-19. 

But how about the jammed cremation service places in Wuhan recently, when people are taking their love ones’ ashes?  It has a simple explanation: people couldn’t get out since Jan 23 and are only able to move more freely in the past week.  This actually shows COVID-19 in Wuhan is truly under control.  According to data, Wuhan has about 50K confirmed case, 2500 deaths from COVID-19.  But in a normal year Wuhan also has about 5000 deaths per month.  So two months’ time plus COVID-19 will give you 12.5K deaths, all needed to take care of after the lockdown is relaxed.  I would suspect the actual death is more than 12.5K, but not in the way Western media prefer to portray.  Since the lockdown, deaths from traffic and violent crimes are likely down, but from heart diseases, cancers, digested systems, nervous systems (e.g., depression), etc, likely up, due to much or most medical resources been diverted to COVID-19.  This should lead to more “normal” deaths than 5000 per month.  This is one reason against Wuhan lockdown from my Jan 26 and Feb 9 blogs.  But an even deadlier problem for the conspiracy theorists is that now is almost April 4, the traditional Tomb Sweeping Day.  Urns can be stored for months before pickup, and pickup right before April 4 is preferred and scheduled for many families.  So might include deaths in Dec 2019 or even earlier.  Then the number can be many more than 12.5K, making a "smoking gun" going up in complete smoke.  

Then there is this Dr somebody thinking that most Wuhan residents have been infected.  There could be people, among them some British doctors, believing Wuhan’s numbers too good to be true.  But let’s do some math.  There are 9-10 million people in Wuhan, if most infected, assume 5 million infected.   The official fatality rate in Wuhan is 5% (2500 deaths/50K cases), China outside Hubei is 1%.  So 5 million cases in Wuhan means 50K to 250K deaths.  In fact, one could even propose that with 5 million cases in Wuhan the whole medical system would have crashed, making it more like Italy or Spain, with 10% fatality, or 500K deaths.  There is absolutely zero evidence for even the 50K deaths, and how many beds would Wuhan need, for even 10% of the 5 million cases in two months?   But if we accept the 2500 deaths and 5 million case number, we will have a fatality rate of 0.05%, then COVID-19 is like flu, not bad at all, right, particularly considering Wuhan medical system would had been decimated (much worse than Italy)?   Furthermore, with so much focus on Wuhan at the time, 20-30K doctors and nurses and many more volunteers working hard, only to find 50K cases out of 5 million, COVID-19 must be one of the wimpiest viruses ever, not the globe trotting killer it is right now!  And why stop there, why not most Chinese are infected, because lockdowns in other places were less stringent than in Wuhan, and the whole country follows the same medical guidelines and protocols?  Even with a lowballed 50% infection and 1% fatality rate, 1.4 billion Chinese, it is 7 million deaths in two months.  Seriously???  The only explanation left for these "academics" is COVID-19 had circulated for a long time, maybe years, in Wuhan.  In that case, rest of China, perhaps much of the world, must already have developed herd immunity, too, like the UK originally wanted to do.  This absurdity has no boundary.  For reasons given earlier, it is almost a truism that documented numbers undercount, with innocuous explanations, but there is just no evidence the “real” numbers being significantly different, certainly not by a factor of 100 or even 10.    

An additional piece of strong evidence against China hiding something is the extent of scientific publishing by Chinese scientists and doctors since Jan 2020.  Essentially all current knowledge of the disease and virus, including transmission, diagnosis, clinical manifestations, treatment, most case studies, was first published by the Chinese, and most results have been confirmed by subsequent studies.  Information like the virus sequences, transmission routes, latency, duration, fatality rates in different age groups, and the well-known 14-day rule.   The only major things left to discover are vaccines, cures or better treatments.  If China really wants to hide something, why do Chinese doctors publish those largest case studies thus far as well as many other papers?    

On Feb 20, nobody would have believed any country could ever surpass China in COVID-19 cases, even with the then Chinese numbers.  But now many people need to account for how this happens, and a jerk-knee answer is: well, we didn’t, because China’s real numbers are much higher.   But the real, important question is: is COVID-19 contained in China now, and it doesn’t take any intelligence services more than reading China’s online, newspaper, TV reports since Jan 23, 2020 to understand how.  China’s response is well in the open, updated and explained daily, and consistent.  Medical doctors and researchers are conducting interviews and answering questions (and publishing scientific papers), while governments officials doing policies but hardly dealing with medical specifics.  The Wuhan lockdown on Jan 23 was much harsher than any other lockdowns in the world.  Most people were immediately confined to their local communities, often in their homes.  Temperature was taken twice daily, and people worn masks outside and avoided others.  Whenever possible, symptomatic people were admitted or quarantined.  Community transmission was shut off right away.  Only familiar transmission was possible, which was handled with additional measures later.  Unlike lockdowns in a few other countries, where people still go out for various activities for days or weeks.  Based on the eventual, confirmed cases in Wuhan, in Hubei outside Wuhan, and other places in China, one can calculate how many COVID-19 cases from Wuhan prior to Jan 23, e.g., in my Feb 23 2020 blog.  The results, likely overestimates, are fairly consistent: one case in several hundred people before Jan 23.  If Wuhan residents, with initially one infection for a few hundred people, largely and quickly stopped interacting with others after Jan 23, the only people they can infect are family members, assuming 2 more people, and then the transmission chain stops.  This comes out to about 1 infection per 100 at the end.  There are 9-10 million residents in Wuhan, so 100K total infected, maybe an overestimation because many patients were identified before infecting family members.  The official number is 50K.  For a back-of-the envelope calculation, this is perfect.  Adding asymptomatic or other factors doesn’t change the overall picture.

Because numbers of cases and deaths change daily, this kind of consistency rules out significant manipulation.  To achieve that, one had to know on Jan 23 what data would need to look like on April 1.  And he has to know what the data look like in other countries as well, whose COVID-19 outbreak was not a given even by Feb 20.   The death rate in China outside Hubei is 1%, similar to those in South Korea and Germany, which are reported later and still ongoing.  In Wuhan it is much higher, 5%, closer to Italy, consistently with my contention that lockdown induced panicking and overwhelmed medical services there.  If one accepts the data in China outside Hubei, he has to accept the data in Wuhan as well.  These numbers are consistent and self coherent.  They can be explained through time and space.  The only question is whether you choose to believe evidence and science, or your imagination.   

Note 1: In terms of lockdown measures, at the national level, India now has a harsher policy than China had, at least on paper.  But at the local level, Wuhan during Feb was still more restrictive: most people were confined to their homes.  Doors were "taped", food, shopping, and trash handled by community services or volunteers.   

Note 2:  COVID-19 deaths have received relatively little attention, albeit not without its own counting issues.  This report (https://www.inquirer.com/health/coronavirus/coronavirus-covid19-cause-death-certificate-pcom-20200401.html) summed up the potential variations around the world.  Also in the US: https://www.nytimes.com/2020/04/05/us/coronavirus-deaths-undercount.html.  As the NYT story pointed out, it often take months, years, or decades to know the true extent of deaths (likely cases as well) in history.  The US and and every other country are underreporting, but it is just due to the limitation in resources and time.  So it is a farce to hold China's figures to the higher standard than the rest, when China had the tightest time.   Inconsistencies should never be considered a sign of cover up.  In any case, they don't make much a difference in the current fight. 

Note 3: This report details the Chinese response to COVID-19: https://news.sina.com.cn/zx/2020-04-06/doc-iimxyqwa5378257.shtml.  Not a nimble exercise, as too much, some irrelevant information is included.  But it is a good summary of what happens and consistent with all the media reports since late Dec 2019, if one follows the Chinese news online and offline.  There are two points "missing" in it though.  First is WHO was notified officially on Jan 3, but "unofficially" on Dec 31, per other reports and interviews of the WHO representative in China.  Second is that viral sequences were obtained earlier than the official publication of full virus seq.  Such sequences were likely partial, and it needed time to verify the virus was truly responsible for COVID-19 and then assemble partial sequences into a full virus map. 

Note 4: Here is a story comparing different countries: https://www.businessinsider.com/how-long-took-spain-italy-france-lockdowns-to-slow-coronavirus-2020-4.  These are different countries, obviously with different patient populations, government policies and enforcement.  But the case numbers are overtly comparable, with Wuhan having only 10 million residents.  The tends of new cases over time look similar in all places.  Time will tell if trends of deaths will be alike.  Remember the Wuhan and China data were published daily and much earlier.  So if someone had done fishy stuff, he must have had a very good crystal ball.