This series of articles is not to be regarded as a running commentary on the progression of the COVID-19 virus. Instead, it explores the possible trajectories of COVID-19 and its immediate outcomes and implications. The articles also focus on Crisis and Emergency Risk Communication practices, what we can learn from how health authorities have so far handled this crisis, as well as previous disease outbreaks.

This article focuses on:

- China’s domestic measures to contain COVID-19

- The international spread of COVID-19.

From cover-up to unprecedented action

Responding to virus outbreaks is speed-crucial, not only in terms of containment decisions, but also how health authorities communicate health messages to the public. With the outbreaks of SARS (2003), Ebola (2014) and Zika (2016), too much time had passed between outbreak, detection and official action. This meant that containment in each case became more challenging.

During the SARS epidemic, the Chinese government engineered a sustained cover-up of the spread of the virus across all channels of conventional media. This silence was only broken by a retired Chinese doctor, who alerted the international scientific community by email about the outbreak of a new coronavirus that was killing around 10% of those infected. At the time, email was a relatively new channel for professional communication and possibly flew under the radar of censors. By the time this information was leaked, it is probable that the official cover-up of SARS contributed to the spread and death toll of the virus.

After the SARS outbreak, the Chinese scientific community implemented a robust disease-monitoring network to detect new types of coronavirus strains. At the year’s close, 30th -31st December 2019, when doctors in Wuhan, Hubei Province, China, spotted a cluster of cases of pneumonia that were linked to a new kind of coronavirus, they followed this established protocol. It emerged that the new virus displayed symptoms that resemble flu and can include pneumonia. Around 20% of cases require hospital care and has a fatality rate of 2%, a similar rate to influenza. Like SARS, it is a zoonotic virus, jumping from bats to humans, most probably via pangolins imported from Malaysia, sometime in mid-to-late December 2019. The virus was traced to the Wuhan seafood market, although it is now thought that it could have been germinating elsewhere in Wuhan for weeks before cases were detected.

It took scientists years to sequence the genome of HIV/AIDS and weeks to sequence SARS. Once COVID-19 was identified on January 7th, scientists were able to sequence the genome of the new virus within a matter of days and shared it with the international scientific community. Diagnostic kits were able to be developed in many countries. These actions have helped other countries, such as the UK, to be prepared for a possible pandemic.

The seafood market was closed down and disinfected as soon as it was identified as a possible source. Health professionals started sharing experiences of how to prevent and treat COVID-19. By January 13th, COVID-19 had already travelled to other parts of China and was present in Thailand and Japan.

Measures and containment within China

While the scientific community acted fast, the official response was initially slow. Instead, it downplayed initial cases, gave mixed messages about the nature of transmission of COVID-19, censored information flow and arrested whistle-blowers. The late Dr Li Wenliang, victim of the new virus, was amongst those early arrests, for sounding the alarm early and explicitly describing COVID-19 as a new SARS-like coronavirus.

During the SARS outbreak, the official cover-up went to such extremes as hospital staff hiding infected patients in ambulances out of the sight of observers from the World Health Organisation (WHO). Mindful of this, Xi Jinping warned that anyone found covering up info ‘will be nailed on the pillar of shame for eternity’. Using the language of combat, Mr Xi claimed that China was fighting ‘a people’s war’ against the virus, throwing the entire apparatus of the Chinese state behind the fight.

China immediately swung into action: by 23rd January, the city of Wuhan, a city of 15 million people, and the wider province of Hubei (60 million), were in lockdown and quarantine – the largest quarantine in history. Two new hospitals were constructed 10 days. Health professionals were drafted in from the military and other provinces to bolster health care provision in Wuhan. The military enforced lockdown in Wuhan. These were amongst many other measures that focused on containment, detection and treatment of new cases, rather than prevention of viral transmission.

While the global community sees these measures as positive action to contain and delay a global pandemic, mistakes have also been made:

Two days before lock-down, the Mayor of Wuhan allowed a ‘pot-luck’ meal to go ahead that involved 40 000 families sharing home-cooked meals on the streets of the city to celebrate the Lunar New Year. It is unknown how widespread the virus was by then, how many of the infected prepared meals or how many people were infected as a result of this celebration. By January 27th, two days after lock-down and four days after the event, hospitals in Wuhan were overwhelmed with new cases.
In a lockdown situation, while an important step in stemming the flow of the virus, it is not possible to stop flow of people entirely. The lockdown of Wuhan was not enacted until hours after it was announced. It is estimated that up to 1 million people left Wuhan during this time. The number of infected people who left before lockdown enforcement is unknown.
In an outbreak, transparency of information is key to safeguarding public health. In the first weeks of the virus, Chinese authorities put the wheels of censorship in motion: deleting both overt and veiled criticisms of the government’s handling of the crisis on Chinese social media, arresting people, including doctors, for spreading falsehoods, only to admit certain rumours were true hours later. For example, officials initially denied that human-to-human transmission was possible and, even when cases were appearing all over China, as well as Thailand and Japan, were still insisting that the virus was confined to Wuhan.
The logic of censorship in an outbreak situation is to prevent panic and hysteria, but in early days of the COVID-19 outbreak, initial government downplaying and denial of facts led to a space that was filled by rumour, conjecture and misinformation.
COVID-19 is 96% similar to a virus detected in bats in 2013 that was discovered could infect and thrive in human cells. By 2016, Chinese virologists warned that this virus could emerge in humans. A failure to take this seriously has been described as a missed opportunity to protect Chinese and global public health.

The spread of COVID-19

At the time of writing, in China itself abroad, there have been over 80 000 cases of COVID-19 and 2595 deaths. Eighty percent of these cases have been mild, while 4.7% have been critical. The death rate is estimated at 2.3% and most at risk are the very old and those with pre-existing chronic illnesses. There is a slow-down in the number of new cases, which suggests that containment measures within China could be working.

Outside of China, the virus has been detected in 35 countries. Possible super-spreading events have created clusters of infection in South Korea, Italy and Iran, where the Iranian Ministry of Health believes that COVID-19 could be present in all Iranian cities. Italy itself has seen 200 cases and 8 deaths in the past week. On February 20th, the World Health Organisation (WHO) expressed concern that cases emerging outside of China with no clear epidemiological link, such as travel to or from infected areas, or contact with people from infected areas, i.e. no ‘Patient Zero’ in those clusters, such as in Italy, has been identified.

WHO recognises, albeit cautiously, that the world could be on the verge of a pandemic.

The next article focuses on what is being done to develop treatments and vaccines to fight COVID-19, as well as what public health measures are in place around the world.

By Mark Gibson, Health communication specialist, UK, 23rd February 2020.

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COVID-19: emergence, detection and action