WHO and China in Jan 2020

An AP news piece (https://www.yahoo.com/news/china-delayed-releasing-coronavirus-frustrating-040707689.html) portrayed WHO was frustrated by China’s delayed release of virus info and not telling it human-to-human transmission until Jan 20, 2020.  The timeline is common knowledge; what is new is only the WHO reactions along the way.  AP would have done a much better service to the public if it had informed people how medicine and biology work.

First of the bat, every scientist will be frustrated by any slow pace of science.  It happens everyday to everybody, itself not a big deal at all.  But science has its own standards and own ways of progressing, and it takes time and efforts and evidence, but hindsight is the least of its concerns. 

In the field of infectious diseases, the gold standard is the Koch’s postulates: A pathogen must be found in all patients, and only the patients; everybody with the pathogen should get the disease; when introduced in a healthy person, it will cause the same disease.  They are overly strict by current thinking, but remain the guiding principles for every infectious disease worker. 

Now consider how quickly the Chinese could do.  The first patients were identified on Dec 26-27, 2019.  Samples were available only afterwards.  Sequencing was easier and faster, so the first research was sequencing the whole patient sample, which contained myriad genetic information: besides human DNA, all kinds of DNA from microorganisms including bacteria and viruses.  Sure, you could see the novel CoV, but you also saw many species of known and unknown bacteria and viruses and others in the sample.  Most of them were irrelevant, but you didn’t know, so which one was it?  At the same time researchers also likely sequenced many cold/flu patients of similar symptoms and found different pathogens, muddling the water even further.  It is easy to say on June 2, but not so on Jan 2.

There are a few more technical difficulties to consider.  Deep sequencing gave you only short stretches of DNA, usually <100 nt.  COVID-19 is 30k, so it was almost certain that the first sequencing results didn’t cover the whole genome.  From the raw data one might find a CoV, but 1. he had no idea which was responsible; 2. he likely did not have the whole genome at all.  And the most importantly, he needed to confirm with more patients.  One, two, or even three patients are not enough.  In early Jan there just weren’t that many available (dozens of patients, but not everyone’s sample was taken or usable). 

So the AP assertion that the Chinese sequenced the virus on late Dec or early Jan but didn’t inform WHO until Jan 11 was very misleading.  As there was likely nothing solid to tell yet.  The earliest evidence AP cited could never tell if the virus was responsible or even the complete genome was available.  It needs more time to fully assemble the genome info, and it needs additional patient confirmation.  You don’t tell the whole world based on flimsy evidence.  Chinese could deposit the sequence, but without knowing what it did this was useless, as thousands of sequences are deposited to GenBank everyday.  Case in point: in early 2003 a (in)famous Chinese scientist got embarrassed stating SARS was caused by a different pathogen other than a CoV.   So it was natural that a few Chinese universities and institutes received more samples to test, well-known in China and also reported in this AP story: the goal was to validate results.  When China released CoV seq, there were actually multiple for several patients, which left absolutely no doubt about the pathogen.

Chinese media reported ruling out all the common, known suspects in early Jan and then that it was a novel CoV around Jan 8.  This reference could be made by partial sequence information but must be supported by more patient data.  The whole world including WHO would know then.  Live virus must also have been isolated and amplified by then, but not much sooner.  Isolating viruses is harder than sequencing the whole sample mix, and getting enough viral particles takes days.  Importantly, following Koch’s principles, scientists need to isolate the same virus from multiple patients but not others, when one still didn’t know what the positive and negative looked like.  It was a tricky and time-consuming task.  Satisfying Koch used to take months and years.  Nowadays weeks, as there are still practicality limitations that humans can't magically waive, like the time a virus needs to replicate in a cell. 

Thus, late Dec to Jan 11, was it a long time from to identify a whole new disease in the midst of a cold/flu season, to nailing down the cause?  Not at all.  Western media should find an example in medical history that the same process took a shorter time.  Even a flu takes longer.  Until then there is no honest discussion.  Least not forget WHO was notified on Dec 31 and again on Jan 3 about the new disease, along with other countries.  By Jan 8 everybody knew it was a CoV.  China already told WHO about the disease, already told the world about a novel CoV, so what good did China get with this "delay"?  Maybe China was being cautious about getting it right, but not for any insidious reasons.  In fact, the only problem AP finds resulting from not knowing the whole genome sequence was not being able to diagnose a patient in Thailand.  But the patient was a tourist from Wuhan, and the whole world knew about Wuhan already!  One doesn’t need genome info all the time, otherwise how did humans deal with pandemics before DNA sequencing was invented in late 1970s?  Regardless, the genome info was published on the heels, and Thailand has controlled COVID-19 quite well.  Frankly, the whole viral genome thing is a red herring by AP, a sinking man gasping for air in the course of WCEV.

About the second, human-to-human transmission, it is like beating a dead horse.  See my blogs on 2/9, 3/16, 4/4, and 4/15/2020.  One needs test kits to tell who are infected and how, and the test kits came only after knowing the pathogen.  As previous blogs argued, one could surmise transmission simply based on the CoV finding, but many CoVs cause only mild symptoms, so they needed to know more.  Saying human-to-human transmission means little if you don’t know the consequence, because you don’t know what to do next: so many diseases transmit human-to-human, but humans hardly do anything about it.  The most maligned statement in 2020 which supposedly denied human-to-human transmission on Jan 14 was actually NOT.  What the doctors said precisely and multiple times was: human-to-human transmission can’t be ruled out, or there may be limited human-to-human transmission.  Entirely consistent with the cases known at the time.  Nobody at WHO could say they were not aware of that; in fact, the AP story never says so, only that WHO wanted more information.      

The rest of the timeline was very clear.  On Jan 19 the third teams of Chinese experts met in Wuhan and concluded human-to-human transmission.  That night they were summoned to Beijing to report.  The next day Dr Zhong Nanshan announced finding human-to-human transmission.  On Jan 23 Wuhan began lockdown. 

The AP story continues a political hack job.  So much was done to learn about COVID-19 during those 4 weeks, yet China simply needing more time and evidence to make it right was constantly twisted as hiding something.  If one wants to play video games with hindsight, sure, 4 weeks was slow.  But is there a historic case anything had happen faster before?  The whole AP news found only some nagging from WHO and blew the whole thing out of proportion.  Based on those records, WHO was actually not frustrated, just very eager to learn more, a reaction entirely natural and reasonable.  AP even fails to mention WHO got all the information it needed by Jan 20 and all the seriousness from China on Jan 23, leaving plenty of time for the world to prepare.  The fabled “6-day-delay” (4/15/20 blog), even if true, which was not, pales in comparisons to the real delays of weeks, months in a few other countries.  How WHO interacted with those countries from Jan 23 to March will be more revealing.  Good or bad is only meaningful when comparing to precedents and others’ actions.  In this light what China did can’t possibly be characterized as bad, incompetent, or hiding something.  

All this is not to say China responded perfectly.  With hindsight there are certainly areas in need of improvement.  The Wuhan Municipal Government might be paralyzed partially at first: it has been suggested that by Chinese laws only the Hubei Provincial Government was authorized to declare an endemic, but at the time known COVID-19 cases were in Wuhan only.  Whether this is the real reason one can’t say.  Arguably, Wuhan lockdown reflected panicking at all government levels and was not well planned, even though it sent the strongest message possible to the world, which some countries nonetheless failed to get.  The Chinese National Health Commission published 7 versions regarding the diagnosis, treatment, and control of COVID-19.  The first was on Jan 15 and likely set the bar of diagnosis too high, leading to some cases being missed in mid Jan 2020.   But remember at the time test kits were still being developed, and nobody realized asymptomatic transmission yet.  Well, COVID-19 is a new disease, and people make mistakes.  Let the one without mistakes cast the first stone.

Ironically, in hindsight the worst could be that China’s response is overall too strict: lockdowns too drastic, quarantine time too long, and lifting the restrictions on work, travel, school, business too late.  Most of the prevailing notions about COVID-19 and containment measures in China in June 2020 are still based on what we knew by the end of Feb and have not changed, even though much more has been learned in the past 3 months, in China and around the world.  COVID-19 is not that deadly, and it is controllable if you identify and trace early.  Extended quarantines are not necessary.  There have been at least one nurse and one doctor who died on the last days of their hotel quarantine after they finished their month-long COVID-19 shifts in China.  The cause was obviously exhaustion, but they were relatively young people, and the 14 day long quarantine must have been a contributing factor.  I don't even know why there isn't any way to test medical staff and let them free earlier.  If the time at hotels is shorter, or if they are allowed to stay home instead, maybe they are still alive.  In fact, there is no report of any of the medical staff getting infected in Feb, but ~ 10 have died from cardiac arrest or traffic accidents.  It is a great pity COVID-19 didn't kill you, but the work against COVID-19 did.   

Well, COVID-19 is a new disease, and people make mistakes.  Let the one without mistakes cast the first stone.

PS: One of the first COVID-19 deep seq data was not ready for prime time, and must be perfected by subsequent work, as standard procedures, and submitted on Jan 5, 2020 (Wu et al., Nature 579: 265–269, 2020).  The actual virus was first isolated on Jan 7, 2020.  Considering how experiments take time, frankly, what the hell is AP talking about?  If being cautious means coverup, everybody should run naked outside.