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US Intel Agencies Played Unsettling Role
in Classi5ed and “9/11-like” Coronavirus
Response Plan
As coronavirus panic grips the world, concern over government overreach is
growing given the involvement of US intelligence agencies in classi5ed
meetings for planning the U.S.’ coronavirus response.
by Whitney Webb

March 13th, 2020

By Whitney Webb Whitney Webb Follow

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A s the COVID-19 coronavirus crisis comes to dominate headlines, little

media attention has been given to the federal government’s decision to
classify top-level meetings on domestic coronavirus response and lean heavily
“behind the scenes” on U.S. intelligence and the Pentagon in planning for an
allegedly imminent explosion of cases.

The classification of coronavirus planning meetings was first covered by

Reuters, which noted that the decision to classify was “an unusual step that has
restricted information and hampered the U.S. government’s response to the
contagion.” Reuters further noted that the Secretary of the Department of
Health and Human Services (HHS), Alex Azar, and his chief of sta! had
“resisted” the classification order, which was made in mid-January by the
National Security Council (NSC), led by Robert O’Brien — a longtime friend and
colleague of his predecessor John Bolton.

Following this order, HHS o!icials with the appropriate security clearances held
meetings on coronavirus response at the department’s Sensitive
Compartmentalized Information Facility (SCIF), which are facilities “usually
reserved for intelligence and military operations” and — in HHS’ case — for
responses to “biowarfare or chemical attacks.” Several o!icials who spoke to
Reuters noted that the classification decision prevented key experts from
participating in meetings and slowed down the ability of HHS and the agencies
it oversees, including the Centers for Disease Control and Prevention (CDC), to
respond to the crisis by limiting participation and information sharing.

It has since been speculated that the decision was made to prevent potential
leaks of information by stifling participation and that aspects of the planned
response would cause controversy if made public, especially given that the
decision to classify government meetings on coronavirus response negatively
impacted HHS’ ability to respond to the crisis.

A"er the classification decision was made public, a subsequent report in

Politico revealed that not only is the National Security Council managing the
federal government’s overall response but that they are doing so in close
coordination with the U.S. intelligence community and the U.S. military. It
states specifically that “NSC o!icials have been coordinating behind the scenes
with the intelligence and defense communities to gauge the threat and prepare
for the possibility that the U.S. government will have to respond to much bigger
numbers—and soon.”
 Creative Coronavirus Responses Appear Across the World, but Not in
Trump’s America
Countries across the globe are coming up with clever methods of fighting the coron-
avirus, putting the US lackluster response to shame.
MintPress News | Alan Macleod | Mar 11

Little attention was given to the fact that the response to this apparently
imminent jump in cases was being coordinated largely between elements of
the national security state (i.e. the NSC, Pentagon, and intelligence), as
opposed to civilian agencies or those focused on public health issues, and in a
classified manner.

The Politico article also noted that the intelligence community is set to play a
“key role” in a pandemic situation, but did not specify what the role would
specifically entail. However, it did note that intelligence agencies would
“almost certainly see an opportunity to exploit the crisis” given that
international “epicenters of coronavirus [are] in high-priority
counterintelligence targets like China and Iran.” It further added, citing former
intelligence o!icials, that e!orts would be made to recruit new human sources
in those countries.

Politico cited the o!icial explanation for intelligence’s interest in “exploiting the
crisis” as merely being aimed at determining accurate statistics of coronavirus
cases in “closed societies,” i.e. nations that do not readily cooperate or share
intelligence with the U.S. government. Yet, Politico fails to note that Iran has
long been targeted for CIA-driven U.S. regime change, specifically under the
Trump administration, and that China had been fingered as the top threat to
U.S. global hegemony by military o!icials well before the coronavirus outbreak.

A potential “9/11-like” response

The decision to classify government coronavirus preparations in mid-January,
followed by the decision to coordinate the domestic response with the military
and with intelligence deserves considerable scrutiny, particularly given that at
least one federal agency, Customs and Border Patrol (CBP), will be given broad,
sweeping powers and will work closely with unspecified intelligence “partners”
as part of its response to a pandemics like COVID-19.

The CBP’s pandemic response document, obtained by The Nation, reveals that
the CBP’s pandemic directive “allows the agency to actively surveil and detain
individuals suspected of carrying the illness indefinitely.” The Nation further
notes that the plan was dra"ed during the George W. Bush administration, but
is the agency’s most recent pandemic response plan and remains in e!ect.

Though only CBP’s pandemic response plan has now been made public, those
of other agencies are likely to be similar, particularly on their emphasis on
surveillance, given past precedent following the September 11 attacks and
other times of national panic. Notably, several recent media reports have
likened coronavirus to 9/11 and broached the possibility of a “9/11-like”
response to coronavirus, suggestions that should concern critics of the post-
9/11 “Patriot Act” and other controversial laws, executive orders and policies
that followed.

While the plans of the federal government remain classified, recent reports
have revealed that the military and intelligence communities — now working
with the NSC to develop the government’s coronavirus response — have
anticipated a massive explosion in cases for weeks. U.S. military intelligence
came to the conclusion over a month ago that coronavirus cases would reach
“pandemic proportions” domestically by the end of March. That military
intelligence agency, known as the National Center for Medical Intelligence
(NCMI), coordinates closely with the National Security Agency (NSA) to conduct
“medical SIGINT [signals intelligence].”

The coming government response, the agencies largely responsible for cra"ing
it and its classified nature deserve public scrutiny now, particularly given the
federal government’s tendency to not let “a serious crisis to go to waste,” as
former President Obama’s then-chief of sta! Rahm Emanuel infamously
said during the 2008 financial crisis. Indeed, during a time of panic — over a
pandemic and over a simultaneous major economic downturn — concern over
government overreach is warranted, particularly now given the involvement of
intelligence agencies and the classification of planning for an explosion of
domestic cases that the government believes is only weeks away.

Feature photo | A Medical University of South Carolina public safety o!icer

walks by the hospital’s drive-through tent for patients who are being tested for
the COVID-19 coronavirus at the Citadel Mall parking lot, March 13, 2020, in
Charleston, S.C. Mic Smith | AP

Whitney Webb is a MintPress News journalist based in Chile. She has

contributed to several independent media outlets including Global Research,
EcoWatch, the Ron Paul Institute and 21st Century Wire, among others. She has
 made several radio and television appearances and is the 2019 winner of the
Serena Shim Award for Uncompromised Integrity in Journalism.

Republish our stories! MintPress News is licensed under a Creative

Commons Attribution-NonCommercial-ShareAlike 3.0 International License.

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Rick • an hour ago − ⚑

Kind of important articles from James Corbett and Douglas Valentine very relevant
today.
https://steemit.com/coronav...
https://www.lewrockwell.com...
△ ▽ • Reply • Share ›

bob > Rick • an hour ago − ⚑

 −
Only if you believe in silly conspiracy theories

I wonder how much money they're making from peddling all this blather???
△ ▽ • Reply • Share ›

Tiamat • an hour ago − ⚑

Fema coffins being delivered by the freemasons
https://www.youtube.com/wat...
FEMA COFFINS EXPOSED IN GEORGIA ...NEAR THE C.D.C.
https://www.youtube.com/wat...
DHS -> FEMA -> State Fusion Centers. Every state has their list of holding facilities
△ ▽ • Reply • Share ›

Tiamat • 2 hours ago − ⚑

Medical Martial Law https://www.corbettreport.c...
△ ▽ • Reply • Share ›

bob > Tiamat • an hour ago − ⚑

Fake news
△ ▽ • Reply • Share ›

Occams • 3 hours ago − ⚑

Amazing how ahead of the curve I've been in all of this - but that's just because I now
know what my government wants and will probably do. I told a female-friend that this
bullshit panic will most likely usher in some new Homeland Security Vaccine Dept and
some new Patriot Vaccine Act....

3 weeks ago.

I told her to get her shopping done, but she was "so sick of hearing about this" she
asked if we could change the subject.

I hope she enjoys her shopping. Tomorrow.

1△ ▽ • Reply • Share ›

bob > Occams • an hour ago − ⚑

You should go and live in Tehran,they'd simply jail you for what you've just
written

But its easy to talk BS conspiracy theories about your own government
△ ▽ • Reply • Share ›

Occams > bob • an hour ago • edited − ⚑

lol...Oh, wait; You're serious! Let me laugh even louder! What's your
favorite flavor of Kool-Ade!?
 When you have a clue of what you're even talking about (do you even
HAVE a passport?), then get back to us here.
1△ ▽ • Reply • Share ›

bob > Occams • an hour ago − ⚑

Go live there,then
△ ▽ • Reply • Share ›

Marko • 4 hours ago − ⚑

Trump's hands are tied. Even though it's ineffective , we have to keep treating
coronavirus patients with Brawndo , otherwise the stock will crash , making the
situation even worse.

He's no dummy. He watches movies :

"BRAWNDO stocks plummet - Idiocracy"

https://www.youtube.com/wat...
△ ▽ • Reply • Share ›

Commenter • 4 hours ago − ⚑

It is extremely suspicious and may be another 9/11. There are false narratives such as
the virus originating from bat soup which reminds one of the story of the monkey from
Africa causing HIV. Iran sure seems to have been targeted. The pandemic began when
the U.S. oligarchy was under attack by Sanders and millions of supporters.
1△ ▽ • Reply • Share ›

bob > Commenter • an hour ago − ⚑

Do you attend the David Icke Academy of conspiracy theories?
△ ▽ • Reply • Share ›

NobodysaysBOO • 5 hours ago − ⚑

massive DEPORTATIONS OF ALL ALIENS and H1B visa holders NOW !!!
Clean our streets.
Deport all foreign US gov't workers , and replace them with AMERICANS !
△ ▽ • Reply • Share ›

pinOKYO nOSE • 5 hours ago − ⚑

"a 9/11-like response to the wuhan virus"

simple par for the course when you consider that FEMA showed up and set up shop
for 9/11 an entire day early.
2△ ▽ • Reply • Share ›

−
 Anyone can publish on Medium per our Policies, but we don’t fact-check every
story. For more info about the coronavirus, see cdc.gov.

https://medium.com/six-four-six-nine/evidence-over-hysteria-covid-19-1b767def5894

Evidence over hysteria —

COVID-19
Aaron Ginn Follow
Mar 20 · 32 min read

After watching the outbreak of COVID-19 for the past two

months, I’ve followed the pace of the infection, its severity, and
how our world is tackling the virus. While we should be
concerned and diligent, the situation has dramatically elevated to
a mob-like fear spreading faster than COVID-19 itself. When 13%
of Americans believe they are currently infected with COVID-19
(mathematically impossible), full-on panic is blocking our ability
to think clearly and determine how to deploy our resources to
stop this virus. Over three-fourths of Americans are scared of
what we are doing to our society through law and hysteria, not of
infection or spreading COVID-19 to those most vulnerable.

The following article is a systematic overview of COVID-19 driven

by data from medical professionals and academic articles that
will help you understand what is going on (sources include CDC,
WHO, NIH, NHS, University of Oxford, Stanford, Harvard, NEJM,
JAMA, and several others). I’m quite experienced at
understanding virality, how things grow, and data. In my
vocation, I’m most known for popularizing the “growth hacking
movement” in Silicon Valley that specializes in driving rapid and
viral adoption of technology products. Data is data. Our focus
here isn’t treatments but numbers. You don’t need a special
degree to understand what the data says and doesn’t say.
Numbers are universal.

I hope you walk away with a more informed perspective on how

you can help and Wght back against the hysteria that is driving
our country into a dark place. You can help us focus our scarce
resources on those who are most vulnerable, who need our help.
 Note: The following graphs and numbers are as of mid-March
2020. Things are moving quickly, so I update this article
twice a day. Most graphs are as of March 20th, 2020.

Best,

Aaron Ginn

Table of Contents
1. Total cases are the wrong metric

2. Time lapsing new cases gives us perspective

3. On a per-capita basis, we shouldn’t be panicking

4. COVID-19 is spreading

5. Watch the Bell Curve

6. A low probability of catching COVID-19

7. Common transmission modes

8. COVID-19 is likely to burn o_ in the summer

9. Children and Teens aren’t at risk

10. Strong, but unknown viral e_ect

11. What about asymptomatic spread?

12. 93% of people who think they are positive aren’t

13. 1% of cases will be severe

14. Declining fatality rate

15. So what should we do?

16. Start with basic hygiene

17. More data

18. Open schools

19. Open up public spaces

20. Support business and productivity

21. People fear what the government will do, not infection

22. Expand medical capacity

23. Don’t let them forget it and vote

. . .

Total cases are the wrong metric

A critical question to ask yourself when you Wrst look at a data set
is, “What is our metric for success?”.

Let’s start at the top. How is it possible that more than 20% of
Americans believe they will catch COVID-19? Here’s how. Vanity
metrics — a single data point with no context. Wouldn’t this
picture scare you?
Look at all of those large red scary circles!

These images come from the now infamous John Hopkins

COVID-19 tracking map. What started as a data transparency
e_ort has now molded into an unintentional tool for hysteria and
panic.

An important question to ask yourself is what do these bubbles

actually mean? Each bubble represents the total number of
COVID-19 cases per country. The situation looks serious, yet we
know that this virus is over four months old, so how many of
these cases are active?

Immediately, we now see that just under half of those terrifying

red bubbles aren’t relevant or actionable. The total number of
cases isn’t illustrative of what we should do now. This is a single
vanity data point with no context; it isn’t information or
knowledge. To know how to respond, we need more numbers to
tell a story and to paint the full picture. As a metaphor, the daily
revenue of a business doesn’t tell you a whole lot about
proWtability, capital structure, or overhead. The same goes for the
total number of cases. The data isn’t actionable. We need to look
at ratios and percentages to tell us what to do next — conversion
rate, growth rate, and severity.
Time lapsing new cases gives us perspective
Breaking down each country by the date of the Wrst infection
helps us track the growth and impact of the virus. We can see
how total cases are growing against a consistent time scale.

Here are new cases time lapsed by country and date of Wrst 100
total cases.

Here is a better picture of US conWrmed case daily growth.

The United States is tracking with other European nations at
doubling every three days or so. As we measure and test more
Americans, this will continue to grow. Our time-lapse growth is
lower than China, but not as good as South Korea, Japan,
Singapore, or Taiwan. All are considered models of how to beat
COVID-19. The United States is performing average, not great,
compared to the other modern countries by this metric.

Still, there is a massive blindspot with this type of graph. None of

these charts are weighted on a per-capita basis. It treats every
country as a single entity, as we will see this fails to tell us what is
going on in several aspects.

On a per-capita basis, we shouldn’t be

panicking
Every country has a di_erent population size which skews
aggregate and cumulative case comparisons. By controlling for
population, you can properly weigh the number of cases in the
context of the local population size. Viruses don’t acknowledge
our human borders. The US population is 5.5X greater than Italy,
6X larger than South Korea, and 25% the size of China.
Comparing the US total number of cases in absolute terms is
rather silly.

Rank ordering based on the total number of cases shows that the
US on a per-capita basis is signiWcantly lower than the top six
nations by case volume. On a 1 million citizen per-capita basis,
the US moves to above mid-pack of all countries and rising, with
similar case volume as Singapore (385 cases), Cyprus (75 cases),
and United Kingdom(3,983 cases). This is data as of March 20th,
2020.

But total cases even on a per-capita basis will always be a losing

metric. The denominator (total population) is more or less Wxed.
We aren’t having babies at the pace of viral growth. Per-capita
won’t explain how fast the virus is moving and if it is truly
“exponential”.

COVID-19 is spreading, but probably not

accelerating
Growth rates are tricky to track over time. Smaller numbers are
easy to move than larger numbers. As an example, GDP growth of
3% for the US means billions of dollars while 3% for Bermuda
means millions. Generally, growth rates decline over time, but
the nominal increase may still be signiWcant. This holds true of
daily conWrmed case increases. Daily growth rates declined
over time across all countries regardless of particular policy
solutions, such as shutting the borders or social distancing.
The daily growth data across the world is a little noisy. Weighing
daily growth of conWrmed cases by a relative daily growth factor
cleans up the picture, more than 1 is increasing and below 1 is
declining. For all of March, the world has hovered around 1.1.
This translates to an average daily growth rate of 10%, with ups
and downs on a daily basis. This isn’t great, but it is good news as
COVID-19 most likely isn’t increasing in virality. The growth rate
of the growth rate is approximately 10%; however, the data is
quite noisy. With inconsistent country-to-country reporting and
what qualiWes as a conWrmed case, the more likely explanation is
that we are increasing our measurement, but the virus hasn’t
increased in viral capability. Recommended containment and
prevention strategies are still quite e_ective at stopping the
spread.
Cases globally are increasing (it is a virus after all!), but beware
of believing metrics designed to intentionally scare like “cases
doubling”. These are typically small numbers over small numbers
and sliced on a per-country basis. Globally, COVID-19’s growth
rate is rather steady. Remember, viruses ignore our national
boundaries.

Viruses though don’t grow inWnitely forever and forever. As with

most things in nature, viruses follow a common pattern — a bell
curve.

Watch the Bell Curve

As COVID-19 spreads and declines (which it will decline despite
what the media tells you), every country will follow a similar
pattern. The following is a more detailed graph of S. Korea’s
successful defeat of COVID-19 compared also to China with
thousands of more cases and deaths. It is a bell curve:

Here is a more detailed graph of S. Korea graphed against the

total number of cases.
Here is a graph from Italy showing a bell curve in symptom onset
and number of cases, which may point to the beginning of the
end for Italy —

JAMA — https://jamanetwork.com/journals/jama/pages/coronavirus-alert

Bell curves is the dominant trait of outbreaks. A virus doesn’t

grow linearly forever. It accelerates, plateaus, and then declines.
Whether it is environmental or our own e_orts, viruses accelerate
and quickly decline. This fact of nature is represented in Farr’s
law. CDC’s of “bend the curve” or “natten the curve” renects this
natural reality.

It is important to note that in both scenarios, the total number of

COVID-19 cases will be similar. “Flattening the curve”’s focus is a
shock to the healthcare system which can increase fatalities due
to capacity constraints. In the long-term, it isn’t infection
prevention. Unfortunately, “nattening the curve” doesn’t include
other downsides and costs of execution.

Both the CDC and WHO are optimizing virality and healthcare
utilization, while ignoring the economic shock to our system.
Both organizations assume you are going to get infected,
eventually, and it won’t be that bad.

A low probability of catching COVID-19

The World Health Organization (“WHO”) released a study on
how China responded to COVID-19. Currently, this study is one of
the most exhaustive pieces published on how the virus spreads.

The results of their research show that COVID-19 doesn’t spread

as easily as we Wrst thought or the media had us believe
(remember people abandoned their dogs out of fear of getting
infected). According to their report if you come in contact
with someone who tests positive for COVID-19 you have a 1–
5% chance of catching it as well. The variability is large
because the infection is based on the type of contact and how
long.

The majority of viral infections come from prolonged exposures

in conWned spaces with other infected individuals. Person-to-
person and surface contact is by far the most common cause.
From the WHO report, “When a cluster of several infected people
occurred in China, it was most often (78–85%) caused by an
infection within the family by droplets and other carriers of
infection in close contact with an infected person.

From the CDC’s study on transmission in China and Princess

Cruise outbreak -
 A growing body of evidence indicates that
COVID-19 transmission is facilitated in
con@ned settings; for example, a large cluster
(634 con@rmed cases) of COVID-19
secondary infections occurred aboard a
cruise ship in Japan, representing about one
@fth of the persons aboard who were tested
for the virus. This @nding indicates the high
transmissibility of COVID-19 in enclosed
spaces

Dr. Paul Auwaerter, the Clinical Director for the Division of

Infectious Diseases at Johns Hopkins University School of
Medicine echoes this Wnding,

“If you have a COVID-19 patient in your

household, your risk of developing the
infection is about 10%….If you were casually
exposed to the virus in the workplace (e.g.,
you were not locked up in conference room
for six hours with someone who was infected
 [like a hospital]), your chance of infection is
about 0.5%”

According to Dr. Auwaerter, these transmission rates are very

similar to the seasonal nu.

Air-based transmission or untraceable community spread is very

unlikely. According to WHO’s COVID-19 lead Maria Van
Kerkhove, true community based spreading is very rare. The data
from China shows that community-based spread was only a very
small handful of cases. “This virus is not circulating in the
community, even in the highest incidence areas across China,”
Van Kerkhove said.

“Transmission by @ne aerosols in the air over

long distances is not one of the main causes
of spread. Most of the 2,055 infected hospital
workers were either infected at home or in
the early phase of the outbreak in Wuhan
when hospital safeguards were not raised
yet,” she said.

True community spread involves transmission where people get

infected in public spaces and there is no way to trace back the
source of infection. WHO believes that is not what the Chinese
data shows. If community spread was super common, it wouldn’t
be possible to reduce the new cases through “social distancing”.

“We have never seen before a respiratory pathogen that’s capable of

community transmission but at the same time which can also be
contained with the right measures. If this was an in<uenza
epidemic, we would have expected to see widespread community
transmission across the globe by now and e@orts to slow it down or
contain it would not be feasible,” said Tedros Adhanom, Director-
General of WHO.

An author of a working paper from the Department of Ecology

and Evolutionary Biology at Princeton University said, “The
current scientiWc consensus is that most transmission via
respiratory secretions happens in the form of large respiratory
droplets … rather than small aerosols. Droplets, fortunately, are
heavy enough that they don’t travel very far and instead fall from
the air after traveling only a few feet.”

The media was put into a frenzy when the above authors released
their study on COVID-19’s ability to survive in the air. The study
did Wnd the virus could survive in the air for a couple of hours;
however, this study was designed as academic exercise rather
than a real-world test. This study put COVID-19 into a spray
bottle to “mist” it into the air. I don’t know anyone who coughs in
mist form and it is unclear if the viral load was large enough to
infect another individual As one doctor, who wants to remain
anonymous, told me, “Corona doesn’t have wings”.

To summarize, China, Singapore, and South Korea’s containment

e_orts worked because community-based and airborne
transmission aren’t common. The most common form of
transmission is person-to-person or surface-based.

Common transmission surfaces

COVID-19’s ability to live for a long period of time is limited on
most surfaces and it is quite easy to kill with typical household
cleaners, just like the normal nu.

COVID-19 be detected on copper after 4 hours and 24 hours

on cardboard.

COVID-19 survived best on plastic and stainless steel,

remaining viable for up to 72 hours

COVID-19 is very vulnerable to UV light and heat.

Presence doesn’t mean infectious. The viral concentration falls

signiWcantly over time. The virus showed a half-life of about 0.8
hours on copper, 3.46 hours on cardboard, 5.6 hours on steel and
6.8 hours on plastic.

According to Dylan Morris, one of the authors, “We do not know

how much virus is actually needed to infect a human being with
high probability, nor how easily the virus is transferred from the
cardboard to one’s hand when touching a package”

According to Dr. Auwaerter, “It’s thought that this virus can

survive on surfaces such as hands, hard surfaces, and fabrics.
Preliminary data indicates up to 72 hours on hard surfaces like
steel and plastic, and up to 12 hours on fabric.”

COVID-19 will likely “burn oG” in the

summer
Due to COVID-19’s sensitivity to UV light and heat (just like the
normal innuenza virus), it is very likely that it will “burn o_” as
humidity increases and temperatures rise.

Released on March 10th, one study mapped COVID-19 virality

capability by high temperature and high humidity. It found that
both signiWcantly reduced the ability of the virus to spread from
person-to-person. From the study,

“This result is consistent with the fact that

the high temperature and high humidity
signi@cantly reduce the transmission of
inZuenza. It indicates that the arrival of
summer and rainy season in the northern
 hemisphere can e\ectively reduce the
transmission of the COVID-19.”

The University of Maryland mapped severe COVID-19 outbreaks

with local weather patterns around the world, from the US to
China. They found that the virus thrives in a certain temperature
and humidity channel. “The researchers found that all cities
experiencing signiWcant outbreaks of COVID-19 have very similar
winter climates with an average temperature of 41 to 52 degrees
Fahrenheit, an average humidity level of 47% to 79% with a
narrow east-west distribution along the same 30–50 N” latitude”,
said the University of Maryland.

“Based on what we have documented so far,

it appears that the virus has a harder time
spreading between people in warmer,
tropical climates,” said study leader
Mohammad Sajadi, MD, Associate Professor
of Medicine in the UMSOM, physician-
scientist at the Institute of Human Virology
and a member of GVN.

In the image below, the zone at risk for a signiWcant community

spread in the near-term includes land areas within the green
bands.

Children and Teens aren’t at risk

It’s already well established that the young aren’t particularly
vulnerable. In fact, there isn’t a single death reported below the
age of 10 in the world and most children who test positive don’t
show symptoms. As well, infection rates are lower for individuals
below the age of 19, which is similar to SARS and MERS (COVID-
19’s sister viruses).

According to the WHO’s COVID-19 mission in China, only 8.1%

of cases were 20-somethings, 1.2% were teens, and 0.9% were 9
or younger. As of the study date February 20th, 78% of the cases
reported were ages 30 to 69. The WHO hypothesizes this is for a
biological reason and isn’t related to lifestyle or exposure.

“Even when we looked at households, we did

not @nd a single example of a child bringing
the infection into the household and
transmitting to the parents. It was the other
way around. And the children tend to have a
mild disease,” said Van Kerkhove.

According to a WSJ article, children have a near-zero chance of

becoming ill. They are more likely to get normal nu than COVID-
19.

A World Health Organization report on China concluded that

cases of Covid-19 in children were “relatively rare and mild.”
Among cases in people under age 19, only 2.5% developed
severe disease while 0.2% developed critical disease. Among
nearly 6,300 Covid-19 cases reported by the Korea Centers for
Disease Control & Prevention on March 8, there were no
reported deaths in anyone under 30. Only 0.7% of infections
were in children under 9 and 4.6% of cases were in those ages
10 to 19 years old
 Only 2% of the patients in a review of nearly 45,000
conWrmed Covid-19 cases in China were children, and there
were no reported deaths in children under 10, according to a
study published in JAMA last month. (In contrast, there have
been 136 pediatric deaths from innuenza in the U.S. this nu
season.)

About 8% of cases were in people in their 20s. Those 10 to 19

years old accounted for 1% of cases and those under 10 also
accounted for only 1%.

However even if children and teens are not su_ering severe

symptoms themselves, they may “shed” large amounts of virus
and may do so for many days, says James Campbell, a professor
of pediatrics at the University of Maryland School of Medicine.

Children had a virus in their secretions for six to 22 days or an

average of 12 days. “Shedding virus doesn’t always mean you’re
able to transmit the virus”, he notes. It is still important to
consider that prolonged shedding of high viral loads from
children is still a risky combination within the home since the
majority of transmission occurs within a home-like conWned
environment.

A strong, but unknown viral eGect

While the true viral capacity is unknown at this moment, it is
theorized that COVID-19 is more than the seasonal nu but less
than other viruses. The average number of people to which a
single infected person will transmit the virus, or Ro, range from
as low as 1.5 to a high of 3.0
Newer analysis suggests that this viral rate is declining. According
to Nobel Laureate and biophysicist Michael Levitt, the infection
rate is declining -

“Every coronavirus patient in China infected

on average 2.2 people a day — spelling
exponential growth that can only lead to
disaster. But then it started dropping, and
the number of new daily infections is now
close to zero.” He compared it to interest
rates again: “even if the interest rate keeps
dropping, you still make money. The sum
you invested does not lessen, it just grows
more slowly. When discussing diseases, it
 frightens people a lot because they keep
hearing about new cases every day. But the
fact that the infection rate is slowing down
means the end of the pandemic is near.”

What about asymptomatic spread?

The majority of cases see symptoms within a few days, not two
weeks as originally believed.

On true asymptomatic spread, the data is still unclear but

increasingly unlikely. Two studies point to a low infection rate
from pre-symptomatic and asymptomatic individuals. One study
said 10% of infections come from people who don’t show
symptoms, yet. Another WHO study reported 1.2% of conWrmed
cases were truly asymptomatic. Several studies conWrming
asymptotic spread have ended up disproven. It is important to
note there is a di_erence between “never showing symptoms” and
“pre-symptomatic” and the media is promoting an unproven
narrative. Almost all people end up in the latter camp within Wve
days, almost never the former. It is very unlikely for individuals
with COVID-19 to never show symptoms. WHO and CDC claim
that asymptomatic spread isn’t a concern and quite rare.

Iceland is leading the global in testing its entire population of

~300,000 for asymptomatic spread, not just those that show
symptoms. They randomly tested 1,800 citizens who don’t show
symptoms and, as far as they knew, were not exposed to positive
individuals. Of this sample, only 19 tested positive for COVID-19,
or 1.1% of the sample.

Obviously, this type of viral spread is the most concerning;

however based on the level of media attention and the global size
of positive infections, it seems more probable we keep looking for
a COVID-19 viral trait that doesn’t exist.

Another way of looking at virality and asymptotic spread is the

number of night attendants, airport sta_, or pilots that have
tested positive for COVID-19. Out of the thousands of nights since
November 2019, only a handful of airport and airline sta_ have
tested positive (such as AA pilot, some BA sta_, and several TSA
employees).

Outside of medical and hospital sta_, these individuals are in

greatest contact with infected persons in conWned spaces. Despite
having no protective gear and most likely these people were
asymptomatic, airline and airport sta_ aren’t likely to catch
COVID-19 compared to the rest of the population. Those
employed in the travel sector are infected at a lower rate than the
general population or healthcare workers.

“We still believe, looking at the data, that the

force of infection here, the major driver, is
people who are symptomatic, unwell, and
transmitting to others along the human-to-
human route,” Dr. Mike Ryan of WHO
Emergencies Program.

If the symptoms are so close to other less fatal coronaviruses,

what is the positivity rate of those tested?

93% of people who think they are positive

aren’t
Looking at the success in S. Korea and Singapore, the important
tool in our war chest is measurement. If we are concerned about
the general non-infected population, what is the probability those
who show symptoms actually test positive? What is the chance
that the cough from your neighbor is COVID-19? This
“conversion rate” will show whether or not you have a cold
(another coronavirus) or heading to isolation for two weeks.
Global data shows that ~95% of people who are tested aren’t
positive. The positivity rate varies by country.

UK: 7,132 concluded tests, of which 13 positive (0.2%

positivity rate).

UK: 48,492 tests, of which 1,950 (4.0% positivity rate)

Italy: 9,462 tests, of which 470 positive (at least 5.0%

positivity rate).

Italy: 3,300 tests, of which 99 positive (3.0% positivity rate)

Iceland: 3,787 tests, of which 218 positive (5.7% positive

rate)

France: 762 tests, of which 17 positive, 179 awaiting results

(at least 2.2% positivity rate).

Austria: 321 tests, of which 2 positive, awaiting results:

unknown (at least 0.6% positivity rate).

South Korea: 66,652 tests with 1766 positives 25,568

awaiting results (4.3% positivity rate).

United States: 445 concluded tests, of which 14 positive

 (3.1% positivity rate).

In the US, drive-thru testing facilities are being deployed around

the nation. Gov. Cuomo of NY released initial data from their
drive-thru testing. Out of the 600~ that was tested in a single
day, ~7% were positive. Tested individuals actively show
symptoms and present a doctor’s note. This result is similar to
public tracking on US nationwide positivity rate.

University of Oxford’s Our World in Data attempts to track public

reporting on individuals tested vs positive cases of COVID-19. For
the US, it estimates 14.25% of those tested are positive.

Last week, the US was signiWcantly behind in testing, near the

bottom of all countries worldwide. As of March 20th, a week
later, the US is much closer to other G8 and European countries,
but there is a long way to go.
Based on the initial results and the results from other countries,
the total number of positive COVID-19 cases will increase as
testing increases, but the fatality rate will continue to fall and the
severity case mix will fall.

In general, the size of the US population infected with COVID-19 will

be much smaller than originally estimated as most symptomatic
individuals aren’t positive. 93% — 99% have other conditions.
Globally, the US has a long way to go to catch up in testing. As
testing expands, the total number of cases will increase, but the
mild to severe case ratio will decline dramatically.

1% of cases will be severe

Looking at the whole funnel from top to bottom, ~1% of everyone
who is tested for COVID-19 with the US will have a severe case
that will require a hospital visit or long-term admission.

Globally, 80–85% of all cases are mild. These will not require a
hospital visit and home-based treatment/ no treatment is
e_ective.
As of mid-March, the US has a signiWcantly lower case severity
rate than other countries. Our current severe caseload is similar
to South Korea. This data has been spotty in the past; however,
lower severity is renected in the US COVID-19 fatality rates
(addressed later).

Early reports from CDC, suggest that 12% of COVID-19 cases need
some form of hospitalization, which is lower than the projected
severity rate of 20%, with 80% being mild cases.

For context, this year’s nu season has led to at least 17 million

medical visits and 370,000 hospitalizations (0.1%) out of 30–50
million infections. Recalling that only comparing aggregate total
cases isn’t helpful, breaking down active cases on a per-capita
basis paints a di_erent picture on severity. This is data as of
March 20th, 2020.
Declining fatality rate
As the US continues to expand testing, the case fatality rate will
decline over the next few weeks. There is little doubt that serious
and fatal cases of COVID-19 are being properly recorded. What is
unclear is the total size of mild cases. WHO originally estimated a
case fatality rate of 4% at the beginning of the outbreak but
revised estimates downward 2.3% — 3% for all age groups. CDC
estimates 0.5% — 3%, however stresses that closer to 1% is more
probable. Dr. Paul Auwaerter estimated 0.5% — 2%, leaning
towards the lower end. A paper released on March 19th analyzed
a wider data set from China and lowered the fatality rate to 1.4%.
This won’t be clear for the US until we see the broader population
that is positive but with mild cases. With little doubt, the fatality
rate and severity rate will decline as more people are tested and
more mild cases are counted.

Higher fatality rates in China, Iran, and Italy are more likely
associated with a sudden shock to the healthcare system unable
to address demands and doesn’t accurately renect viral fatality
rates. As COVID-19 spread throughout China, the fatality rate
drastically fell outside of Hubei. This was attributed to the
outbreak slowing spreading to several provinces with low
infection rates.
John P.A. Ioannidis is professor of medicine, of epidemiology and
population health, of biomedical data science, and of statistics at
Stanford University and co-director of Stanford’s Meta-Research
Innovation Center recently wrote about fatality rates and how our
current instrumentation is leading to faulty policy solutions:

“The one situation where an entire, closed population was tested was
the Diamond Princess cruise ship and its quarantine passengers. The
case fatality rate there was 1.0%, but this was a largely elderly
population, in which the death rate from Covid-19 is much higher.
Projecting the Diamond Princess mortality rate onto the age
structure of the U.S. population, the death rate among people
infected with Covid-19 would be 0.125%. But since this estimate is
based on extremely thin data — there were just seven deaths among
the 700 infected passengers and crew — the real death rate could
stretch from ^ve times lower (0.025%) to ^ve times higher
(0.625%). It is also possible that some of the passengers who were
infected might die later, and that tourists may have di@erent
frequencies of chronic diseases — a risk factor for worse outcomes
with SARS-CoV-2 infection — than the general population. Adding
these extra sources of uncertainty…”

“Reasonable estimates for the case fatality

ratio in the general U.S. population vary
from 0.05% to 1%.”

Looking at the US fatality, the fatality rate is drastically declining

as the number of cases increases, halving every four or Wve days.
The fatality rate will eventually level o_ and plateau as the US
case-mix becomes apparent.

4.06% March 8 (22 deaths of 541 cases)

3.69% March 9 (26 of 704)

3.01% March 10 (30 of 994)

2.95% March 11 (38 of 1,295)

 2.52% March 12 (42 of 1,695)

2.27% March 13 (49 of 2,247)

1.93% March 14 (57 of 2,954)

1.84% March 15 (68 of 3,680)

1.90% March 16 (86 of 4,503)

1.76% March 17 (109 of 6,196)

1.66% March 18 (150 of 9,003)

1.51% March 19th (208 of 13,789)

1.32% March 20th (256 of 19,383)

Source: Worldometers.info

Mapped against other countries, our fatality rate and case-mix

are following a similar pattern to South Korea which is a good
sign, a supposed model of how to manage COVID-19.
Here are deaths weighted by the total number of cases as of
March 20th, 2020. Ranked by the total number of cases, our
death rate is closer to South Korea’s than Spain’s or Italy’s.
The initial higher fatality rate for the US is trending much lower
than originally estimated. A study of about half deaths within the
US (154 of 264), almost all Wt a similar demographic proWle as
the other global ~11,000 fatalities.
Another analysis by Nature, comparing the fatality rate (since
revised down) and infectious rate of COVID-19 to other illnesses.
COVID-19 is now within range of its other sisters of less potent
coronaviruses.

As the global health community continues to gather and report

data, the claim that “COVID-19 isn’t just like the nu” (though still
severe) is looking less credible as fatality rates continue to decline
and measuring of mild cases increases.
It is important to consider case-mix when looking at fatality rates.
The fatality rate is signiWcantly higher for patients with an
underlying condition.

The fatality rates by underling condition mimics the rise in the

average fatality rate with those with underlying conditions who
get the seasonal nu.

Pneumonia and innuenza: 1.53% — 1.93%

Chronic lower respiratory disease: 1.48% — 1.93%

All respiratory causes: 3.04% — 4.14%

Heart disease: 3.21% — 4.4%

 Cancer: 0.68% — 1.05%

Diabetes: 0.26% — 0.39%

For all underlying conditions: 10.17% — 13.67%.

Comparing case-mix across countries with a wide range of

fatality (China and Italy) and those with low fatality rates (S.
Korea) reveals a stark di_erence in age; therefore, underlying
conditions also vary signiWcantly across countries. These two
factors contribute the most to a country’s fatality rate.

Source: Goldman Sachs

Divided by most at risk and low risk, Italy had signiWcantly more
cases of high at-risk patients than Germany or Korea
Source: https://medium.com/@andreasbackhausab/coronavirus-why-its-so-deadly-in-italy-
c4200a15a7bf

Based on an initial CDC study of 2,449 COVID-19 cases (almost

half of current US cases have missing demographic data), the
United States case-mix looks more like S. Korea and Germany
rather than China or Italy. Approximately 69% of COVID-19 cases
are in the lower at-risk population of under 65, while 31% are
older than 65 higher risk population. This suggests the US will
experience a declining fatality rate; however, the US has over 100
million adults with underlying and chronic illnesses that will
negatively impact our fatality rate.
An older population skew within the infected population explains
most of the disparity in fatality rates between high and low
countries. According to a study of the fatalities of COVID-19 cases
in Italy, 99% of all deaths had an underlying pathology. Only
0.8% had no underlying condition.
Most of those infected in Italy were over the age of 60, but the
median age of a fatality was 80. All of Italy’s fatality under the
age of 40 were males with serious pre-existing medical
conditions.

This doesn’t factor in a wide variance in healthcare capacity, such

as hospital beds per 1,000 citizens which could a_ect health
outcomes; however, this doesn’t seem to be highly correlated
with fatality rates at this moment.

S. Korea — 11.5

Germany — 8.3
 China — 4.2

Italy — 3.4

United States — 2.9

Singapore — 2.4

So what should we do?

The ^rst rule of medicine is to do no harm.

Local governments and politicians are innicting massive harm

and disruption with little evidence to support their draconian
edicts. Every local government is in a mimetic race to one-up
each other in authoritarian city ordinances to show us who has
more “abundance of caution”. Politicians are competing, not on
more evidence or more COVID-19 cures but more caution. As
unemployment rises and families feel unbearably burdened
already, they feel pressure to “Wx” the situation they created with
even more radical and “creative” policy solutions. This only
creates more problems and an even larger snowball e_ect. The
Wrst place to start is to stop killing the patient and focus on what
works.

Start with basic hygiene

The most e_ective means to reduce spread is basic hygiene. Most
American’s don’t wash their hands enough and aren’t aware of
how to actually wash your hands. Masks aren’t particularly
e_ective if you touch your eyes with infected hands. Ask
businesses and public places to freely distribute disinfectant
wipes and hand sanitizer to the customers and patrons. If you get
sick or feel sick, stay home. These are basic rules for preventing
illness that doesn’t require trillions of dollars.

More data
The best examples of defeating COVID-19 requires lots of data.
We are very behind in measuring our population and the impact
of the virus but this has turned a corner the last few days. The
swift change in direction should be applauded. Private companies
are quickly developing and deploying tests, much faster than CDC
could ever imagine. The inclusion of private businesses in
developing solutions is creative and admirable. Data will calm
nerves and allow us to utilize more evidence in our strategy. Once
we have proper measurement implemented (the ability to test
hundreds every day in a given metro), let’s add even more data
into that funnel — reopen public life.

Open schools
Closing schools is counterproductive. The economic cost for
closing schools in the U.S. for four weeks could cost between $10
and $47 billion dollars (0.1–0.3% of GDP) and lead to a
reduction of 6% to 19% in key health care personnel.
CDC’s guidance on closing schools speciWcally for COVID-19 -

Available modeling data indicate that early, short to medium

closures do not impact the epi curve of COVID-19 or available health
care measures (e.g., hospitalizations). There may be some impact of
much longer closures (8 weeks, 20 weeks) further into community
spread, but that modeling also shows that other mitigation e@orts
(e.g., handwashing, home isolation) have more impact on both
spread of disease and health care measures. In other countries, those
places who closed school (e.g., Hong Kong) have not had more
success in reducing spread than those that did not (e.g., Singapore).

Based on transmission evidence children are more likely to catch

COVID-19 in the home than at school. As well, they are more
likely to expose older vulnerable adults as multi-generational
homes are more common. As well, the school provides a single
point of testing a large population for a possible infection in the
home to prevent community spread.

Open up public spaces

With such little evidence of proliWc community spread and our
guiding healthcare institutions reporting the same results,
shuttering the local economy is a distraction and arbitrary with
limited accretive gain outside of greatly annoying millions and
bankrupting hundreds of businesses. The data is overwhelming
at this point that community-based spread and airborne
transmission is not a threat. We don’t have signiWcant examples
of spreading through restaurants or gyms. When you consider the
environment COVID-19 prefers, isolating every family in their
home is a perfect situation for infection and transmission among
other family members. Evidence from South Korea and
Singapore shows that it is completely possible and preferred to
continue on with life while making accommodations that are
data-driven, such as social distancing and regular temperature
checks.

Support business and productivity

The data shows that the overwhelming majority of the working
population will not be personally impacted, both individually or
their children. This is an unnecessary burden that is distracting
resources and energy away from those who need it the most. By
preventing Americans from being productive and specializing at
what they do best (their vocation), we are pulling resources
towards unproductive tasks and damaging the economy. We will
need money for this Wght.

At this rate, we will spend more money on “shelter-in-place” than if

we completely rebuilt our acute care and emergency capacity.

Source: https://www.macrobond.com/posts/blog-central-banks-go-big-covi-19-market-
crash-crisis/

Americans won’t have the freedom to go help those who get sick,
volunteer their time at a hospital, or give generously to a charity.
Instead, big government came barrelling in like a bull in a china
shop claiming they could solve COVID-19. The same government
that continued to not test incoming passengers from Europe and
who couldn’t manufacture enough test kits with two months'
notice.
Let Americans be free to be a part of the solution, calling us to a
higher civic duty to help those most in need and protect the
vulnerable. Not sitting in isolation like losers.

People fear what the government will do, not an infection

Rampant hoarding and a volatile stock market aren’t being driven
by COVID-19. An overwhelming majority of American’s don’t
believe they will be infected. Rather hoarding behavior strongly
demonstrates an irrational hysteria, from purchasing infective
household masks to buying toilet paper in the troves. This fear is
being driven by government action, fearing what the government
will do next. In South Korea, most citizens didn’t fear infection
but the government and public shaming. By presenting a
consistent and clear plan that is targeted and speciWc to those
who need the most help will reduce the volatility and hysteria. A
sign the logic behind these government actions aren’t widely
accepted, nor believed as rational by the American people is the
existence itself of the volatility and hysteria. Over three-fourths of
Americans are scared not of COVID-19 but what it is doing to our
society.

In CDC’s worst-case scenario, CDC expects more than 150–200

million infections within the US. This estimate is hundreds of
times bigger than China’s infection rate (30% of our population
compared to 0.006% in China). Does that really sound plausible
to you? China has a sub-par healthcare system, attempted to
suppress the news about COVID-19 early on, a lack of
transparency, an authoritarian government, and millions of
Chinese traveling for the Lunar Festival at the height of the
outbreak. In the US, we have a signiWcant lead time, several
therapies proving successful, transparency, a top tier healthcare
system, a democratic government, and media providing ample
accountability.

Infection isn’t our primary risk at this point.

Expand medical capacity

COVID-19 is a signiWcant medical threat that needs to be tackled,
both Wnding a cure and limiting spread; however, some would
argue that a country’s authoritarian response to COVID-19
helped stop the spread. Probably not. In South Korea and Taiwan,
I can go to the gym and eat at a restaurant which is more than I
can say about San Francisco and New York, despite a signiWcantly
lower caseload on a per-capita basis.

None of the countries the global health authorities admire for their
approach issued “shelter-in-place” orders, rather they used data,
measurement,and promoted common sense self-hygiene.

Does stopping air travel have a greater impact than closing all
restaurants? Does closing schools reduce the infection rate by
10%? Not one policymaker has o_ered evidence of any of these
approaches. Typically, the argument given is “out of an
abundance of caution”. I didn’t know there was such a law. Let’s
be frank, these acts are emotionally driven by fear, not evidence-
based thinking in the process of destroying people’s lives
overnight. While all of these decisions are made by elites isolated
in their castles of power and ego, the shock is utterly devastating
Main Street.

A friend who runs a guy will run out of cash in a few weeks. A
friend who is a pastor let go of half of his sta_ as donations fell by
60%. A waitress at my favorite breakfast place told me her family
will have no income in a few days as they force the closure of
restaurants. While political elites twiddle their thumbs with
models and projections based on faulty assumptions, people’s
lives are being destroyed with Marxian vigor. The best
compromise elites can come up with is $2,000.

Does it make more sense for us to pay a tax to expand medical

capacity quickly or pay the cost to our whole nation of a recession?
Take the example of closing schools which will easily cost our
economy $50 billion. For that single unanimous totalitarian act, we
could have built 50 hospitals with 500+ beds per hospital.

Eliminate arcane certiWcate of need and expand acute medical

capacity to support possible higher healthcare utilization this
season.

Don’t let them forget it and vote

These days are precarious as Governors noat the idea of martial
law for not following “social distancing”, as well as they liked
while they violate those same rules on national TV. Remember
this tone is for a virus that has impacted 0.004% of our
population. Imagine if this was a truly existential threat to our
Republic.

The COVID-19 hysteria is pushing aside our protections as

individual citizens and permanently harming our free, tolerant,
open civil society. Data is data. Facts are facts. We should be
focused on resolving COVID-19 with continued testing,
measuring, and be vigilant about protecting those with
underlying conditions and the elderly from exposure. We are
blessed in one way, there is an election in November. Never forget
what happened and vote.

. . .
You may ask yourself. Who is this guy? Who is this author? I’m a
nobody. That is also the point. The average American feels utterly
powerless right now. I’m an individual American who sees his
community and loved ones being decimated without given a
choice, without empathy, and while the media cheers on with
high ratings.

When this is all over, look for massive conWrmation bias and
pyrrhic celebration by elites. There will be vain cheering in the
halls of power as Main Street sits in pieces. Expect no apology,
that would be political suicide. Rather, expect to be given a Jedi
mind trick of “I’m the government and I helped.”

The health of the State will be even stronger with more

Americans dependent on welfare, another trillion stimulus Wlled
with pork for powerful friends, and a bailout for companies that
charged us $200 change fees for nearly a decade. Washington DC
will be Wne. New York will still have all of the money in the world.
Our communities will be left with nothing but a shadow of the
longest bull market in the history of our country.

Coronavirus Corona Covid 19 Politics Health

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About Help Legal

Report of the WHO-China Joint Mission
on Coronavirus Disease 2019 (COVID-19)

16-24 February 2020

1
Table of Contents

I. THE MISSION 3

GOAL AND OBJECTIVES 3

MEMBERS & METHOD OF WORK 3

II. MAJOR FINDINGS 4

THE VIRUS 4
THE OUTBREAK 5
THE TRANSMISSION DYNAMICS 9
THE SIGNS, SYMPTOMS, DISEASE PROGRESSION AND SEVERITY 11
THE CHINA RESPONSE 14
KNOWLEDGE GAPS 16

III. ASSESSMENT 16

THE CHINA RESPONSE & NEXT STEPS 16

THE GLOBAL RESPONSE & NEXT STEPS 18

IV. MAJOR RECOMMENDATIONS 21

FOR CHINA 21
FOR COUNTRIES WITH IMPORTED CASES AND/OR OUTBREAKS OF COVID-19 21
FOR UNINFECTED COUNTRIES 22
FOR THE PUBLIC 22
FOR THE INTERNATIONAL COMMUNITY 23

ANNEXES 24

A. WHO-CHINA JOINT MISSION MEMBERS 24

B. SUMMARY AGENDA OF THE MISSION 25
C. DETAILED TECHNICAL FINDINGS 27
RESPONSE MANAGEMENT, CASE AND CONTACT MANAGEMENT, RISK COMMUNICATION AND COMMUNITY
ENGAGEMENT 27
CLINICAL CASE MANAGEMENT AND INFECTION PREVENTION AND CONTROL 31
LABORATORY, DIAGNOSTICS AND VIROLOGY 33
RESEARCH & DEVELOPMENT 34
D. KNOWLEDGE GAPS 36
E. OPERATIONAL & TECHNICAL RECOMMENDATIONS 38

2
I. The Mission

Goal and Objectives

The overall goal of the Joint Mission was to rapidly inform national (China) and international
planning on next steps in the response to the ongoing outbreak of the novel coronavirus
disease (COVID-191) and on next steps in readiness and preparedness for geographic areas
not yet affected.

The major objectives of the Joint Mission were as follows:

To enhance understanding of the evolving COVID-19 outbreak in China and the
nature and impact of ongoing containment measures;
To share knowledge on COVID-19 response and preparedness measures being
implemented in countries affected by or at risk of importations of COVID-19;
To generate recommendations for adjusting COVID-19 containment and response
measures in China and internationally; and
To establish priorities for a collaborative programme of work, research and
development to address critical gaps in knowledge and response and readiness tools
and activities.

Members & Method of Work

The Joint Mission consisted of 25 national and international experts from China, Germany,
Japan, Korea, Nigeria, Russia, Singapore, the United States of America and the World Health
Organization (WHO). The Joint Mission was headed by Dr Bruce Aylward of WHO and Dr
Wannian ublic of China. The full list of members and their
affiliations is available in Annex A. The Joint Mission was implemented over a 9-day period
from 16-24 February 2020. The schedule of work is available in Annex B.

The Joint Mission began with a detailed workshop with representatives of all of the principal
ministries that are leading and/or contributing to the response in China through the
National Prevention and Control Task Force. A series of in-depth meetings were then
conducted with national level institutions responsible for the management, implementation
and evaluation of the response, particularly the National Health Commission and the China
Centers for Disease Control and Prevention (China CDC). To gain first-hand knowledge on
the field level implementation and impact of the national and local response strategy, under
a range of epidemiologic and provincial contexts, visits were conducted to Beijing
Municipality and the provinces of Sichuan (Chengdu), Guangdong (Guangzhou, Shenzhen)
and Hubei (Wuhan). The field visits included community centers and health clinics,
country/district hospitals, COVID-19 designated hospitals, transportations hubs (air, rail,
road), a wet market, pharmaceutical and personal protective equipment (PPE) stocks
warehouses, research institutions, provincial health commissions, and local Centers for

1
In the Chinese version of this report, COVID-19 is referred to throughout as novel coronavirus pneumonia or
NCP, the term by which COVID-19 is most widely known in the

3
 Disease Control (provincial and prefecture). During these visits, the team had detailed
discussion and consultations with Provincial Governors, municipal Mayors, their emergency
operations teams, senior scientists, frontline clinical, public health and community workers,
and community neighbourhood administrators. The Joint Mission concluded with working
sessions to consolidate findings, generate conclusions and propose suggested actions.

To achieve its goal, the Joint Mission gave particular focus to addressing key questions
related to the natural history and severity of COVID-19, the transmission dynamics of the
COVID-19 virus in different settings, and the impact of ongoing response measures in areas
of high (community level), moderate (clusters) and low (sporadic cases or no cases)
transmission.

The findings in review of national and local

governmental reports, discussions on control and prevention measures with national and
local experts and response teams, and observations made and insights gained during site
visits. The figures have been produced using information and data collected during site
visits and with the agreement of the relevant groups. References are available for any
information in this report that has already been published in journals.

The final report of the Joint Mission was submitted on 28 February 2020.

II. Major findings

The major findings are described in six sections: the virus, the outbreak, transmission
dynamics, disease progression and severity, the China response and knowledge gaps. More
detailed descriptions of technical findings are provided in Annex C.

The virus

On 30 December 2019, three bronchoalveolar lavage samples were collected from a patient
with pneumonia of unknown etiology a surveillance definition established following the
SARS outbreak of 2002-2003 in Wuhan Jinyintan Hospital. Real-time PCR (RT-PCR) assays
on these samples were positive for pan-Betacoronavirus. Using Illumina and nanopore
sequencing, the whole genome sequences of the virus were acquired. Bioinformatic
analyses indicated that the virus had features typical of the coronavirus family and belonged
to the Betacoronavirus 2B lineage. Alignment of the full-length genome sequence of the
COVID-19 virus and other available genomes of Betacoronavirus showed the closest
relationship was with the bat SARS-like coronavirus strain BatCov RaTG13, identity 96%.

Virus isolation was conducted with various cell lines, such as human airway epithelial cells,
Vero E6, and Huh-7. Cytopathic effects (CPE) were observed 96 hours after inoculation.
Typical crown-like particles were observed under transmission electron microscope (TEM)
with negative staining. The cellular infectivity of the isolated viruses could be completely
neutralized by the sera collected from convalescent patients. Transgenic human ACE2 mice
and Rhesus monkey intranasally challenged by this virus isolate induced multifocal
pneumonia with interstitial hyperplasia. The COVID-19 virus was subsequently detected
and isolated in the lung and intestinal tissues of the challenged animals.

4
Whole genome sequencing analysis of 104 strains of the COVID-19 virus isolated from
patients in different localities with symptom onset between the end of December 2019 and
mid-February 2020 showed 99.9% homology, without significant mutation (Figure 1).

Figure 1. Phylogenetic analysis of the COVID-19 virus and its closely related reference
genomes
Note: COVID-19 virus is referred to as 2019-nCoV in the figure, the interim virus name WHO announced early in the
outbreak.

Post-mortem samples from a 50-year old male patient from Wuhan were taken from the
lung, liver, and heart. Histological examination showed bilateral diffuse alveolar damage
with cellular fibromyxoid exudates. The lung showed evident desquamation of
pneumocytes and hyaline membrane formation, indicating acute respiratory distress
syndrome (ARDS). Lung tissue also displayed cellular and fibromyxoid exudation,
desquamation of pneumocytes and pulmonary oedema. Interstitial mononuclear
inflammatory infiltrates, dominated by lymphocytes, were seen in both lungs.
Multinucleated syncytial cells with atypical enlarged pneumocytes characterized by large
nuclei, amphophilic granular cytoplasm, and prominent nucleoli were identified in the intra-
alveolar spaces, showing viral cytopathic-like changes. No obvious intranuclear or
intracytoplasmic viral inclusions were identified.

The outbreak

As of 20 February 2020, a cumulative total of 75,465 COVID-19 cases were reported in

China. Reported cases are based on the National Reporting System (NRS) between the

5
National and Provincial Health Commissions. The NRS issues daily reports of newly
recorded confirmed cases, deaths, suspected cases, and contacts. A daily report is provided
by each province at 0300hr in which they report cases from the previous day.

The epidemic curves presented in Figures 2 and 3

Infectious Disease Information System (IDIS), which requires each COVID-19 case to be
reported electronically by the responsible doctor as soon as a case has been diagnosed. It
includes cases that are reported as asymptomatic and data are updated in real time.
Individual case reporting forms are downloaded after 2400hr daily. Epidemiologic curves
for Wuhan, Hubei (outside of Wuhan), China (outside Hubei) and China by symptom onset
are provided in Figure 2.

Figure 2 Epidemiologic curve of COVID-19 laboratory confirmed cases, by date of onset of

illness, reported in China, as of 20 February 2020

6
Figure 3 presents epidemic curves of laboratory-confirmed cases, by symptom onset and
separately by date of report, at 5, 12, and 20 February 2020. Figures 2 and 3 illustrate that
the epidemic rapidly grew from 10-22 January, reported cases peaked and plateaued
between 23 January and 27 January, and have been steadily declining since then, apart from
the spike that was reported on 1 February (note: at a major hospital in Wuhan, fever clinic
patients fell from a peak of 500/day in late January to average 50/day since mid-February).

Figure 3. Epidemic curves by symptom onset and date of report as of 5 February (top
panel), 12 February (middle panel) and 20 February 2020 (lower panel) for laboratory
confirmed COVID-19 cases for all of China

Based on these epidemic curves, the published literature, and our on-site visits in Wuhan
(Hubei), Guangdong (Shenzhen and Guangzhou), Sichuan (Chengdu), and Beijing, the Joint
Mission team has made the following epidemiological observations:

7
Demographic characteristics
Among 55,924 laboratory confirmed cases reported as of 20 February 2020, the median age
is 51 years (range 2 days-100 years old; IQR 39-63 years old) with the majority of cases
(77.8%) aged between 30 69 years. Among reported cases, 51.1% are male, 77.0% are from
Hubei and 21.6% are farmers or laborers by occupation.

Zoonotic origins
COVID-19 is a zoonotic virus. From phylogenetics analyses undertaken with available full
genome sequences, bats appear to be the reservoir of COVID-19 virus, but the intermediate
host(s) has not yet been identified. However, three important areas of work are already
underway in China to inform our understanding of the zoonotic origin of this outbreak.
These include early investigations of cases with symptom onset in Wuhan throughout
December 2019, environmental sampling from the Huanan Wholesale Seafood Market and
other area markets, and the collection of detailed records on the source and type of wildlife
species sold at the Huanan market and the destination of those animals after the market
was closed.

Routes of transmission
COVID-19 is transmitted via droplets and fomites during close unprotected contact between
an infector and infectee. Airborne spread has not been reported for COVID-19 and it is not
believed to be a major driver of transmission based on available evidence; however, it can
be envisaged if certain aerosol-generating procedures are conducted in health care facilities.
Fecal shedding has been demonstrated from some patients, and viable virus has been
identified in a limited number of case reports. However, the fecal-oral route does not
appear to be a driver of COVID-19 transmission; its role and significance for COVID-19
remains to be determined. Viral shedding is discussed in the Technical Findings (Annex C).

Household transmission
In China, human-to-human transmission of the COVID-19 virus is largely occurring in
families. The Joint Mission received detailed information from the investigation of clusters
and some household transmission studies, which are ongoing in a number of Provinces.
Among 344 clusters involving 1308 cases (out of a total 1836 cases reported) in Guangdong
Province and Sichuan Province, most clusters (78%-85%) have occurred in families.
Household transmission studies are currently underway, but preliminary studies ongoing in
Guangdong estimate the secondary attack rate in households ranges from 3-10%.

Contact Tracing
China has a policy of meticulous case and contact identification for COVID-19. For example,
in Wuhan more than 1800 teams of epidemiologists, with a minimum of 5 people/team, are
tracing tens of thousands of contacts a day. Contact follow up is painstaking, with a high
percentage of identified close contacts completing medical observation. Between 1% and
5% of contacts were subsequently laboratory confirmed cases of COVID-19, depending on
location. For example:
As of 17 February, in Shenzhen City, among 2842 identified close contacts, 2842
(100%) were traced and 2240 (72%) have completed medical observation. Among
the close contacts, 88 (2.8%) were found to be infected with COVID-19.

8
 As of 17 February, in Sichuan Province, among 25493 identified close contacts,
25347 (99%) were traced and 23178 (91%) have completed medical observation.
Among the close contacts, 0.9% were found to be infected with COVID-19.
As of 20 February, in Guangdong Province, among 9939 identified close contacts,
9939 (100%) were traced and 7765 (78%) have completed medical observation.
Among the close contacts, 479 (4.8%) were found to be infected with COVID-19.

Testing at fever clinics and from routine ILI/SARI surveillance

The Joint Mission systematically enquired about testing for COVID-19 from routine
respiratory disease surveillance systems to explore if COVID-19 is circulating more broadly
and undetected in the community in China. These systems could include RT-PCR testing of
COVID-19 virus in influenza-like-illness (ILI) and severe acute respiratory infection (SARI)
surveillance systems, as well as testing of results among all visitors to fever clinics.

In Wuhan, COVID-19 testing of ILI samples (20 per week) in November and December 2019
and in the first two weeks of January 2020 found no positive results in the 2019 samples, 1
adult positive in the first week of January, and 3 adults positive in the second week of
January; all children tested were negative for COVID-19 although a number were positive for
influenza. In Guangdong, from 1-14 January, only 1 of more than 15000 ILI/SARI samples
tested positive for the COVID-19 virus. In one hospital in Beijing, there were no COVID-19
positive samples among 1910 collected from 28 January 2019 to 13 February 2020. In a
hospital in Shenzhen, 0/40 ILI samples were positive for COVID-19.

Within the fever clinics in Guangdong, the percentage of samples that tested positive for the
COVID-19 virus has decreased over time from a peak of 0.47% positive on 30 January to
0.02% on 16 February. Overall in Guangdong, 0.14% of approximately 320,000 fever clinic
screenings were positive for COVID-19.

Susceptibility
As COVID-19 is a newly identified pathogen, there is no known pre-existing immunity in
humans. Based on the epidemiologic characteristics observed so far in China, everyone is
assumed to be susceptible, although there may be risk factors increasing susceptibility to
infection. This requires further study, as well as to know whether there is neutralising
immunity after infection.

The transmission dynamics

Inferring from Figures 2 and 3, and based on our observations at the national and
provincial/municipal levels during the Joint Mission, we summarize and interpret the
transmission dynamics of COVID-19 thus far. It is important to note that transmission
dynamics of any outbreak are inherently contextual. For COVID-19, we observe four major
types of transmission dynamics during the epidemic growth phase and in the post-control
period, and highlight what is known about transmission in children, as follows:

9
Transmission in Wuhan
Early cases identified in Wuhan are believed to be have acquired infection from a zoonotic
source as many reported visiting or working in the Huanan Wholesale Seafood Market. As
of 25 February, an animal source has not yet been identified.

At some point early in the outbreak, some cases generated human-to-human transmission
chains that seeded the subsequent community outbreak prior to the implementation of the
comprehensive control measures that were rolled out in Wuhan. The dynamics likely
approximated mass action and radiated from Wuhan to other parts of Hubei province and
China, which explains a relatively high R0 of 2-2.5.

The cordon sanitaire around Wuhan and neighboring municipalities imposed since 23
January 2020 has effectively prevented further exportation of infected individuals to the
rest of the country.

Transmission in Hubei, other than Wuhan

In the prefectures immediately adjoining Wuhan (Xiaogan, Huanggang, Jingzhou and Ezhou),
transmission is less intense. For other prefectures, due to fewer transport links and human
mobility flows with Wuhan, the dynamics are more closely aligned with those observed in
the other areas of the country. Within Hubei, the implementation of control measures
(including social distancing) has reduced the community force of infection, resulting in the
progressively lower incident reported case counts.

Transmission in China outside of Hubei

G population movement during the Chinese New
Year (chunyun), infected individuals quickly spread throughout the country, and were
particularly concentrated in cities with the highest volume of traffic with Wuhan. Some of
these imported seeds generated limited human-to-human transmission chains at their
destination.

Given the Wuhan/Hubei experience, a comprehensive set of interventions, including

aggressive case and contact identification, isolation and management and extreme social
distancing, have been implemented to interrupt the chains of transmission nationwide. To
date, most of the recorded cases were imported from or had direct links to Wuhan/Hubei.
Community transmission has been very limited. Most locally generated cases have been
clustered, the majority of which have occurred in households, as summarized above.

Of note, the highly clustered nature of local transmission may explain a relatively high R0 (2-
2.5) in the absence of interventions and low confirmed case counts with intense quarantine
and social distancing measures.

Special settings
We note that instances of transmission have occurred within health care settings prisons
and other closed settings. At the present time, it is not clear what role these settings and
groups play in transmission. However, they do not appear to be major drivers of the overall
epidemic dynamics. Specifically, we note:

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 (a) Transmission in health care settings and among health care workers (HCW) The
Joint Mission discussed nosocomial infection in all locations visited during the
Mission. As of 20 February 2020, there were 2,055 COVID-19 laboratory-confirmed
cases reported among HCW from 476 hospitals across China. The majority of HCW
cases (88%) were reported from Hubei.

Remarkably, more than 40,000 HCW have been deployed from other areas of China
to support the response in Wuhan. Notwithstanding discrete and limited instances
of nosocomial outbreaks (e.g. a nosocomial outbreak involving 15 HCW in Wuhan),
transmission within health care settings and amongst health care workers does not
appear to be a major transmission feature of COVID-19 in China. The Joint Mission
learned that, among the HCW infections, most were identified early in the outbreak
in Wuhan when supplies and experience with the new disease was lower.
Additionally, investigations among HCW suggest that many may have been infected
within the household rather than in a health care setting. Outside of Hubei, health
care worker infections have been less frequent (i.e. 246 of the total 2055 HCW
cases). When exposure was investigated in these limited cases, the exposure for
most was reported to have been traced back to a confirmed case in a household.

The Joint Team noted that attention to the prevention of infection in health care
workers is of paramount importance in China. Surveillance among health care
workers identified factors early in the outbreak that placed HCW at higher risk of
infection, and this information has been used to modify policies to improve
protection of HCW.

(b) Transmission in closed settings There have been reports of COVID-19 transmission
in prisons (Hubei, Shandong, and Zhejiang, China), hospitals (as above) and in a long-
term living facility. The close proximity and contact among people in these settings
and the potential for environmental contamination are important factors, which
could amplify transmission. Transmission in these settings warrants further study.

Children
Data on individuals aged 18 years old and under suggest that there is a relatively low attack
rate in this age group (2.4% of all reported cases). Within Wuhan, among testing of ILI
samples, no children were positive in November and December of 2019 and in the first two
weeks of January 2020. From available data, and in the absence of results from serologic
studies, it is not possible to determine the extent of infection among children, what role
children play in transmission, whether children are less susceptible or if they present
differently clinically (i.e. generally milder presentations). The Joint Mission learned that
infected children have largely been identified through contact tracing in households of
adults. Of note, people interviewed by the Joint Mission Team could not recall episodes in
which transmission occurred from a child to an adult.

The signs, symptoms, disease progression and severity

Symptoms of COVID-19 are non-specific and the disease presentation can range from no
symptoms (asymptomatic) to severe pneumonia and death. As of 20 February 2020 and

11
based on 55924 laboratory confirmed cases, typical signs and symptoms include: fever
(87.9%), dry cough (67.7%), fatigue (38.1%), sputum production (33.4%), shortness of breath
(18.6%), sore throat (13.9%), headache (13.6%), myalgia or arthralgia (14.8%), chills (11.4%),
nausea or vomiting (5.0%), nasal congestion (4.8%), diarrhea (3.7%), and hemoptysis (0.9%),
and conjunctival congestion (0.8%).

People with COVID-19 generally develop signs and symptoms, including mild respiratory
symptoms and fever, on an average of 5-6 days after infection (mean incubation period 5-6
days, range 1-14 days).

Most people infected with COVID-19 virus have mild disease and recover. Approximately
80% of laboratory confirmed patients have had mild to moderate disease, which includes
non-pneumonia and pneumonia cases, 13.8% have severe disease (dyspnea, respiratory
frequency 30/minute, blood oxygen saturation 93%, PaO2/FiO2 ratio <300, and/or lung
infiltrates >50% of the lung field within 24-48 hours) and 6.1% are critical (respiratory
failure, septic shock, and/or multiple organ dysfunction/failure). Asymptomatic infection
has been reported, but the majority of the relatively rare cases who are asymptomatic on
the date of identification/report went on to develop disease. The proportion of truly
asymptomatic infections is unclear but appears to be relatively rare and does not appear to
be a major driver of transmission.

Individuals at highest risk for severe disease and death include people aged over 60 years
and those with underlying conditions such as hypertension, diabetes, cardiovascular
disease, chronic respiratory disease and cancer. Disease in children appears to be relatively
rare and mild with approximately 2.4% of the total reported cases reported amongst
individuals aged under 19 years. A very small proportion of those aged under 19 years have
developed severe (2.5%) or critical disease (0.2%).

As of 20 February, 2114 of the 55,924 laboratory confirmed cases have died (crude fatality
ratio [CFR2] 3.8%) (note: at least some of whom were identified using a case definition that
included pulmonary disease). The overall CFR varies by location and intensity of
transmission (i.e. 5.8% in Wuhan vs. 0.7% in other areas in China). In China, the overall CFR
was higher in the early stages of the outbreak (17.3% for cases with symptom onset from 1-
10 January) and has reduced over time to 0.7% for patients with symptom onset after 1
February (Figure 4). The Joint Mission noted that the standard of care has evolved over the
course of the outbreak.

Mortality increases with age, with the highest mortality among people over 80 years of age
(CFR 21.9%). The CFR is higher among males compared to females (4.7% vs. 2.8%). By
occupation, patients who reported being retirees had the highest CFR at 8.9%. While
patients who reported no comorbid conditions had a CFR of 1.4%, patients with comorbid
conditions had much higher rates: 13.2% for those with cardiovascular disease, 9.2% for
diabetes, 8.4% for hypertension, 8.0% for chronic respiratory disease, and 7.6% for cancer.

2 The Joint Mission acknowledges the known challenges and biases of reporting crude CFR early in an epidemic.

12
Figure 4 Case fatality ratio (reported deaths among total cases) for COVID-19 in China over
time and by location, as of 20 February 2020

Data on the progression of disease is available from a limited number of reported

hospitalized cases (Figure 5). Based on available information, the median time from
symptom onset to laboratory confirmation nationally decreased from 12 days (range 8-18
days) in early January to 3 days (1-7) by early February 2020, and in Wuhan from 15 days
(10-21) to 5 days (3-9), respectively. This has allowed for earlier case and contact
identification, isolation and treatment.

Moderate

Figure 5. Pattern of disease progression for COVID-19 in China

Note: the relative size of the boxes for disease severity and outcome reflect the proportion of cases reported as of 20
February 2020. The size of the arrows indicates the proportion of cases who recovered or died. Disease definitions are
described above. Moderate cases have a mild form of pneumonia.

13
Using available preliminary data, the median time from onset to clinical recovery for mild
cases is approximately 2 weeks and is 3-6 weeks for patients with severe or critical disease.
Preliminary data suggests that the time period from onset to the development of severe
disease, including hypoxia, is 1 week. Among patients who have died, the time from
symptom onset to outcome ranges from 2-8 weeks.

An increasing number of patients have recovered; as of 20 February, 18264 (24%) reported

cases have recovered. Encouragingly, a report on 20 February from the Guangdong CDC
suggests that of 125 severe cases identified in Guangdong, 33 (26.4%) have recovered and
been released from hospital, and 58 (46.4%) had improved and were reclassified as having
mild/moderate disease (i.e. + milder pneumonia). Among severe cases reported to date,
13.4% have died. Early identification of cases and contacts allows for earlier treatment.

The China response

Upon the detection of a cluster of pneumonia cases of unknown etiology in Wuhan, the CPC
Central Committee and the State Council launched the national emergency response. A
Central Leadership Group for Epidemic Response and the Joint Prevention and Control
Mechanism of the State Council were established. General Secretary Xi Jinping personally
directed and deployed the prevention and control work and requested that the prevention
and control of the COVID-19 outbreak be the top priority of government at all levels. Prime
Minister Li Keqiang headed the Central Leading Group for Epidemic Response and went to
Wuhan to inspect and coordinate the prevention and control work of relevant departments
and provinces (autonomous regions and municipalities) across the country. Vice Premier
Sun Chunlan, who has been working on the frontlines in Wuhan, has led and coordinated
the frontline prevention and control of the outbreak.

The prevention and control measures have been implemented rapidly, from the early stages
in Wuhan and other key areas of Hubei, to the current overall national epidemic. It has
been undertaken in three main phases, with two important events defining those phases.
First, COVID-19 was included in the statutory report of Class B infectious diseases and
border health quarantine infectious diseases on 20 January 2020, which marked the
transition from the initial partial control approach to the comprehensive adoption of various
control measures in accordance with the law. The second event was the State Council
issuing, on 8 February 2020, of The Notice on Orderly Resuming Production and Resuming
Production in Enterprises, which indicated that epidemic control work had
entered a stage of overall epidemic prevention and control together with the restoration of
normal social and economic operations.

The first stage

During the early stage of the outbreak, the main strategy focused on preventing the
exportation of cases from Wuhan and other priority areas of Hubei Province, and preventing
the importation of cases by other provinces; the overall aim was to control the source of
infection, block transmission and prevent further spread. The response mechanism was
initiated with multi-sectoral involvement in joint prevention and control measures. Wet
markets were closed, and efforts were made to identify the zoonotic source. Information
on the epidemic was notified to WHO on 3 January, and whole genome sequences of the
COVID-19 virus were shared with WHO on 10 January. Protocols for COVID-19 diagnosis and

14
treatment, surveillance, epidemiological investigation, management of close contacts, and
laboratory testing were formulated, and relevant surveillance activities and epidemiological
investigations conducted. Diagnostic testing kits were developed, and wildlife and live
poultry markets were placed under strict supervision and control measures.

The second stage

During the second stage of the outbreak, the main strategy was to reduce the intensity of
the epidemic and to slow down the increase in cases. In Wuhan and other priority areas of
Hubei Province, the focus was on actively treating patients, reducing deaths, and preventing
exportations. In other provinces, the focus was on preventing importations, curbing the
spread of the disease and implementing joint prevention and control measures. Nationally,
wildlife markets were closed and wildlife captive-breeding facilities were cordoned off. On
20 January, COVID-19 was included in the notifiable report of Class B infectious diseases and
border health quarantine infectious diseases, with temperature checks, health care
declarations, and quarantine against COVID-19 instituted at transportation depots in
accordance with the law. On 23 January, Wuhan implemented strict traffic restrictions. The
protocols for diagnosis, treatment and epidemic prevention and control were improved;
case isolation and treatment were strengthened.

Measures were taken to ensure that all cases were treated, and close contacts were isolated
and put under medical observation. Other measures implemented included the extension
of the Spring Festival holiday, traffic controls, and the control of transportation capacity to
reduce the movement of people; mass gathering activities were also cancelled. Information
about the epidemic and prevention and control measures was regularly released. Public risk
communications and health education were strengthened; allocation of medical supplies
was coordinated, new hospitals were built, reserve beds were used and relevant premises
were repurposed to ensure that all cases could be treated; efforts were made to maintain a
stable supply of commodities and their prices to ensure the smooth operation of society.

The third stage

The third stage of the outbreak focused on reducing clusters of cases, thoroughly controlling
the epidemic, and striking a balance between epidemic prevention and control, sustainable
economic and social development, the unified command, standardized guidance, and
scientific evidence-based policy implementation. For Wuhan and other priority areas of
Hubei Province, the focus was on patient treatment and the interruption of transmission,
with an emphasis on concrete steps to fully implement relevant measures for the testing,
admitting and treating of all patients. A risk-based prevention and control approach was
adopted with differentiated prevention and control measures for different regions of the
country and provinces. Relevant measures were strengthened in the areas of
epidemiological investigation, case management and epidemic prevention in high-risk public
places.

New technologies were applied such as the use of big data and artificial intelligence (AI) to
strengthen contact tracing and the management of priority populations. Relevant health
insurance policies were promulgated on "health insurance payment, off-site settlement, and
financial compensation". All provinces provided support to Wuhan and priority areas in
Hubei Province in an effort to quickly curb the spread of the disease and provide timely
clinical treatment. Pre-school preparation was improved, and work resumed in phases and

15
 batches. Health and welfare services were provided to returning workers in a targeted and
one-stop manner. Normal social operations are being restored in a stepwise fashion;
knowledge about disease prevention is being popularized to improve public health literacy
and skills; and a comprehensive program of emergency scientific research is being carried
out to develop diagnostics, therapeutics and vaccines, delineate the spectrum of the
disease, and identify the source of the virus.

Knowledge gaps

Since the start of the COVID-19 outbreak, there have been extensive attempts to better
understand the virus and the disease in China. It is remarkable how much knowledge about
a new virus has been gained in such a short time. However, as with all new diseases, and
only 7 weeks after this outbreak began, key knowledge gaps remain. Annex D summarizes
the key unknowns in a number of areas including the source of infection, pathogenesis and
virulence of the virus, transmissibility, risk factors for infection and disease progression,
surveillance, diagnostics, clinical management of severe and critically ill patients, and the
effectiveness of prevention and control measures. The timely filling of these knowledge
gaps is imperative to enhance control strategies.

III. Assessment
The Joint Mission drew four major conclusions from its work in China and four major
conclusions from its knowledge of the broader global response to COVID-19.
Recommendations are offered in five major areas to inform the ongoing response globally
and in China.

The China Response & Next Steps

1. In the face of a previously unknown virus, China has rolled out perhaps the most
ambitious, agile and aggressive disease containment effort in history. The strategy
that underpinned this containment effort was initially a national approach that
promoted universal temperature monitoring, masking, and hand washing. However,
as the outbreak evolved, and knowledge was gained, a science and risk-based
approach was taken to tailor implementation. Specific containment measures were
adjusted to the provincial, county and even community context, the capacity of the
setting, and the nature of novel coronavirus transmission there.

While the fundamental principles of this strategy have been consistent since its launch,
there has been constant refinement of specific aspects to incorporate new knowledge
on the novel coronavirus, the COVID-19 disease, and COVID-19 containment, as rapidly
as that knowledge has emerged. The remarkable speed with which Chinese scientists
and public health experts isolated the causative virus, established diagnostic tools, and
determined key transmission parameters, such as the route of spread and incubation

the response.

16
 As striking, has been the uncompromising rigor of strategy application that proved to be
a hallmark in every setting and context where it was examined. There has also been a
relentless focus on improving key performance indicators, for example constantly
enhancing the speed of case detection, isolation and early treatment. The
implementation of these containment measures has been supported and enabled by the
innovative and aggressive use of cutting edge technologies, from shifting to online
medical platforms for routine care and schooling, to the use of 5G platforms to support
rural response operations.

2. Achieving exceptional coverage with and adherence to these containment

measures has only been possible due to the deep commitment of the Chinese people
to collective action in the face of this common threat. At a community level this is
reflected in the remarkable solidarity of provinces and cities in support of the most
vulnerable populations and communities. Despite ongoing outbreaks in their own
areas, Governors and Mayors have continued to send thousands of health care
workers and tons of vital PPE supplies into Hubei province and Wuhan city.

At the individual level, the Chinese people have reacted to this outbreak with courage
and conviction. They have accepted and adhered to the starkest of containment
measures whether the suspension of public gatherings, the month-
advisories or prohibitions on travel. Throughout an intensive 9-days of site visits across
China, in frank discussions from the level of local community mobilizers and frontline
health care providers to top scientists, Governors and Mayors, the Joint Mission was
struck by the sincerity and dedication that each brings to this COVID-19 response.

3. this new respiratory pathogen

has changed the course of a rapidly escalating and deadly epidemic. A particularly
compelling statistic is that on the first day of the advance
2478 newly confirmed cases of COVID-19 reported in China. Two weeks later, on the
final day of this Mission, China reported 409 newly confirmed cases. This decline in
COVID-19 cases across China is real.

Several sources of data support this conclusion, including the steep decline in fever clinic
visits, the opening up of treatment beds as cured patients are discharged, and the
challenges to recruiting new patients for clinical trials. Based on a comparison of crude
attack rates across provinces, the Joint Mission estimates that this truly all-of-
Government and all-of-society approach that has been taken in China has averted or at
least delayed hundreds of thousands of COVID-19 cases in the country. By extension,
the reduction that has been achieved in the force of COVID-19 infection in China has
also played a significant role in protecting the global community and creating a stronger
first line of defense against international spread. Containing this outbreak, however,
has come at great cost and sacrifice by China and its people, in both human and material
terms.

While the -19 operation has been remarkable, it has

also highlighted areas for improvement in public health emergency response capacity.

17
 These include overcoming any obstacles to act immediately on early alerts, to massively
scale-up capacity for isolation and care, to optimize the protection of frontline health
care workers in all settings, to enhance collaborative action on priority gaps in
knowledge and tools, and to more clearly communicate key data and developments
internationally.

4. China is already, and rightfully, working to bolster its economy, reopen its schools and
return to a more normal semblance of its society, even as it works to contain the
remaining chains of COVID-19 transmission. Appropriately, a science-based, risk-
informed and phased approach is being taken, with a clear recognition and readiness
of the need to immediately react to any new COVID-19 cases or clusters as key
elements of the containment strategy are lifted.

Despite the declining case numbers, across China every province, city and community
visited is urgently escalating their investments in acute care beds and public health
capacity. It is crucial that this continues. Fifty thousand infected COVID-19 patient are
still under treatment, across the country. However, the Joint Mission has come to
understand the substantial knowledge, experience and capacities that China has rapidly
built during this crisis. Consequently, it in
most provinces and municipalities it should soon be possible to manage a resurgence in
COVID-19 cases, using even more tailored and sustainable approaches that are anchored
in very rapid case detection, instant activation of key containment activities, direct
oversight by top leadership, and broad community engagement.

As China works to resume a more normal level of societal and economic activity, it is
essential that the world recognizes and reacts positively to the rapidly changing, and
decreasing, risk of COVID- full connectivity with
the world, and to full productivity and economic output, is vital to China and to the
world. The world urgently needs access -
19, as well as the material goods it brings to the global response. It is even more urgent
now, with escalating COVID-19 outbreaks outside of China, to constantly reassess any
restrictions on travel and/or trade to China that go beyond the recommendations of the
IHR Emergency Committee on COVID-19.

The Global Response & Next Steps

1. The COVID-19 virus is a new pathogen that is highly contagious, can spread quickly,
and must be considered capable of causing enormous health, economic and societal
impacts in any setting. It is not SARS and it is not influenza. Building scenarios and
strategies only on the basis of well-known pathogens risks failing to exploit all possible
measures to slow transmission of the COVID-19 virus, reduce disease and save lives.

COVID-19 is not SARS and it is not influenza. It is a new virus with its own
characteristics. For example, COVID-19 transmission in children appears to be limited
compared with influenza, while the clinical picture differs from SARS. Such differences,
while based on limited data, may be playing a role in the apparent efficacy of rigorously

18
 applied non-pharmaceutical, public health measures to interrupt chains of human-to-
human transmission in a range of settings in China. The COVID-19 virus is unique among
human coronaviruses in its combination of high transmissibility, substantial fatal
outcomes in some high-risk groups, and ability to cause huge societal and economic
disruption. For planning purposes, it must be assumed that the global population is
susceptible to this virus. As the animal origin of the COVID-19 virus is unknown at
present, the risk of reintroduction into previously infected areas must be constantly
considered.

The novel nature, and our continuously evolving understanding, of this coronavirus
demands a tremendous agility in our capacity to rapidly adapt and change our readiness
and response planning as has been done continually in China. This is an extraordinary
feat for a country of 1.4 billion people.

2. -pharmaceutical measures to contain

transmission of the COVID-19 virus in multiple settings provides vital lessons for the
global response. This rather unique and unprecedented public health response in
China reversed the escalating cases in both Hubei, where there has been widespread
community transmission, and in the importation provinces, where family clusters
appear to have driven the outbreak.

Although the timing of the outbreak in China has been relatively similar across the
country, transmission chains were established in a wide diversity of settings, from mega-
cities in the north and south of the country, to remote communities. However, the rapid

adapted and successfully operationalized in a wide range of settings.

-
19 readiness and rapid response plans in a thorough assessment of local risks and of
utilizing a differentiated risk-based containment strategy to manage the outbreak in
areas with no cases vs. sporadic cases vs. clusters of cases vs. community-level
transmission. Such a strategy is essential for ensuring a sustainable approach while
minimizing the socio-economic impact.

3. Much of the global community is not yet ready, in mindset and materially, to
implement the measures that have been employed to contain COVID-19 in China.
These are the only measures that are currently proven to interrupt or minimize
transmission chains in humans. Fundamental to these measures is extremely
proactive surveillance to immediately detect cases, very rapid diagnosis and
immediate case isolation, rigorous tracking and quarantine of close contacts, and an
exceptionally high degree of population understanding and acceptance of these
measures.

Achieving the high quality of implementation needed to be successful with such

measures requires an unusual and unprecedented speed of decision-making by top
leaders, operational thoroughness by public health systems, and engagement of society.

19
 Given the damage that can be caused by uncontrolled, community-level transmission of
this virus, such an approach is warranted to save lives and to gain the weeks and months
needed for the testing of therapeutics and vaccine development. Furthermore, as the
majority of new cases outside of China are currently occurring in high and middle-
income countries, a rigorous commitment to slowing transmission in such settings with
non-pharmaceutical measures is vital to achieving a second line of defense to protect
low income countries that have weaker health systems and coping capacities.

The time that can be gained through the full application of these measures even if just
days or weeks can be invaluable in ultimately reducing COVID-19 illness and deaths.
This is apparent in the huge increase in knowledge, approaches and even tools that has
taken place in just the 7 weeks since this virus was discovered through the rapid
scientific work that has been done in China.

4. The time gained by rigorously applying COVID-19 containment measures must be used
more effectively to urgently enhance global readiness and rapidly develop the specific
tools that are needed to ultimately stop this virus.

COVID-19 is spreading with astonishing speed; COVID-19 outbreaks in any setting have
very serious consequences; and there is now strong evidence that non-pharmaceutical
interventions can reduce and even interrupt transmission. Concerningly, global and
national preparedness planning is often ambivalent about such interventions. However,
to reduce COVID-19 illness and death, near-term readiness planning must embrace the
large-scale implementation of high-quality, non-pharmaceutical public health measures.
These measures must fully incorporate immediate case detection and isolation, rigorous
close contact tracing and monitoring/quarantine, and direct population/community
engagement.

A huge array of COVID-19 studies, scientific research projects and product R&D efforts
are ongoing in China and globally. This is essential and to be encouraged and supported.
However, such a large number of projects and products needs to be prioritized. Without
prioritizing, this risks compromising the concentration of attention and resources and
collaboration required to cut timelines by precious weeks and months. While progress
has been made, the urgency of the COVID-19 situation supports an even more ruthless
prioritization of research in the areas of diagnostics, therapeutics and vaccines.

Similarly, there is a long list of proposed studies on the origins of COVID-19, the natural

responding to cases and saving lives makes it difficult for policy makers to consider and
act on such comprehensive lists. This can be addressed by balancing studies with the
immediate public health and clinical needs of the response. Studies can be prioritized in
terms of the largest knowledge gaps that can be most rapidly addressed to have
greatest immediate impact on response operations and patient management. This
suggests prioritizing studies to identify risk factors for transmission in households,
institutions and the community; convenience sampling for this virus in the population
using existing surveillance systems; age-stratified sero-epidemiologic surveys; the
analysis of clinical case series; and cluster investigations.

20
IV. Major Recommendations

For China

1. Maintain an appropriate level of emergency management protocols, depending

on the assessed risk in each area and recognizing the real risk of new cases and
clusters of COVID-19 as economic activity resumes, movement restrictions are
lifted, and schools reopen;

2. Carefully monitor the phased lifting of the current restrictions on movement and
public gatherings, beginning with the return of workers and migrant labor,
followed by the eventual reopening of schools and lifting other measures;

3. Further strengthen the readiness of emergency management mechanisms, public

health institutions (e.g. CDCs), medical facilities, and community engagement
mechanisms to ensure sustained capacity to immediately launch containment
activities in response to any resurgence in cases;

4. Prioritize research that rapidly informs response and risk management decisions,
particularly household and health care facility studies, age-stratified sero-
epidemiologic surveys and rigorous investigation of the animal-human interface;
establish a centralized research program to fast-track the most promising rapid
diagnostics and serologic assays, the testing of potential antivirals and vaccine
candidates, and Chinese engagement in selected multi-country trials; and

5. As the country with the greatest knowledge on COVID-19, further enhance the
systematic and real-time sharing of epidemiologic data, clinical results and
experience to inform the global response.

For countries with imported cases and/or outbreaks of COVID-19

1. Immediately activate the highest level of national Response Management

protocols to ensure the all-of-government and all-of-society approach needed to
contain COVID-19 with non-pharmaceutical public health measures;

2. Prioritize active, exhaustive case finding and immediate testing and isolation,
painstaking contact tracing and rigorous quarantine of close contacts;

3. Fully educate the general public on the seriousness of COVID-19 and their role in
preventing its spread;

4. Immediately expand surveillance to detect COVID-19 transmission chains, by

testing all patients with atypical pneumonias, conducting screening in some
patients with upper respiratory illnesses and/or recent COVID-19 exposure, and
adding testing for the COVID-19 virus to existing surveillance systems (e.g.
systems for influenza-like-illness and SARI); and

21
 5. Conduct multi-sector scenario planning and simulations for the deployment of
even more stringent measures to interrupt transmission chains as needed (e.g.
the suspension of large-scale gatherings and the closure of schools and
workplaces).

For uninfected countries

1. Prepare to immediately activate the highest level of emergency response

mechanisms to trigger the all-of-government and all-of society approach that is
essential for early containment of a COVID-19 outbreak;

2. Rapidly test national preparedness plans in light of new knowledge on the

effectiveness of non-pharmaceutical measures against COVID-19; incorporate
rapid detection, largescale case isolation and respiratory support capacities, and
rigorous contact tracing and management in national COVID-19 readiness and
response plans and capacities;

3. Immediately enhance surveillance for COVID-19 as rapid detection is crucial to

containing spread; consider testing all patients with atypical pneumonia for the
COVID-19 virus, and adding testing for the virus to existing influenza surveillance
systems;

4. Begin now to enforce rigorous application of infection prevention and control

measures in all healthcare facilities, especially in emergency departments and
outpatient clinics, as this is where COVID-19 will enter the health system; and

5. Rapidly assess the general population -19, adjust

national health promotion materials and activities accordingly, and engage
clinical champions to communicate with the media.

For the public

1. Recognize that COVID-19 is a new and concerning disease, but that outbreaks
can managed with the right response and that the vast majority of infected
people will recover;

2. Begin now to adopt and rigorously practice the most important preventive
measures for COVID-19 by frequent hand washing and always covering your
mouth and nose when sneezing or coughing;

3. Continually update yourself on COVID-19 and its signs and symptoms (i.e. fever
and dry cough), because the strategies and response activities will constantly
improve as new information on this disease is accumulating every day; and

4. Be prepared to actively support a response to COVID-19 in a variety of ways,

the high-risk elderly population.

22
For the international community

1. Recognize that true solidarity and collaboration is essential between nations to

tackle the common threat that COVID-19 represents and operationalize this
principle;

2. Rapidly share information as required under the International Health Regulations

(IHR) including detailed information about imported cases to facilitate contact
tracing and inform containment measures that span countries;

3. Recognize the rapidly changing risk profile of COVID-19 affected countries and
continually monitor outbreak trends and control capacities to reassess any
additional health measures that significantly interfere with international travel
and trade.

__________

23
Annexes
A. WHO-China Joint Mission Members
Bruce AYLWARD Team Lead WHO-China Joint Mission on COVID-19, Senior Advisor to the Director-General,
World Health Organization, Geneva, Switzerland
Wannian LIANG Team Lead WHO-China Joint Mission on COVID-19, Head of Expert Panel, National Health
Commission
Xiaoping DONG Director and Researcher, Center for Global Public Health, Chinese Center for Disease Control
and Prevention
Tim ECKMANNS Head of Unit, Healthcare-associated Infections, Surveillance of Antibiotic Resistance and
Consumption, Robert Koch Institute, Berlin, Germany
Dale FISHER Professor of Medicine, Yong Loo Lin School of Medicine, National University of Singapore,
Singapore, Singapore
Chikwe Director General, Nigeria Centre for Disease Control, Nigeria Centre for Disease Control,
IHEKWEAZU Abuja, Nigeria
Clifford LANE Clinical Director, National Institute of Allergy and Infectious Diseases, US National Institutes
of Health, Bethesda, United States
Jong-Koo LEE Professor of Family Medicine, Seoul National University College of Medicine, Seoul, Republic
of Korea
Gabriel LEUNG Dean of Medicine, Helen and Francis Zimmern Professor in Population Health, The University
of Hong Kong, Hong Kong SAR, China
Jiangtao LIN Director and Professor, Department of Pulmonary and Critical Care Medicine, China-Japan
Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing
Haiying LIU Deputy Director and Researcher, Institute of Pathogen Biology, Chinese Academy of Medical
Sciences, Beijing China
Natalia Head of International Department and Consultant, Center of Infectious Diseases, National
PSHENICHNAYA Medical Research Center of Phthisiopulmonology and Infectious Diseases, Moscow, Russia
Aleksandr Deputy Director, Saint Petersburg Pasteur Institute, Saint Petersburg, Russia
SEMENOV
Hitoshi Senior Research Scientist, Influenza Virus Research Center, National Institute of Infectious
TAKAHASHI Diseases, Tokyo, Japan
Maria Head of Unit, Emerging Diseases & Zoonoses, Global Infectious Hazard Preparedness, World
VAN KERKHOVE Health Organization, Geneva, Switzerland
Bin WANG Deputy Team Leader, Deputy Director General, Disease Prevention and Control Bureau,
National Health Commission
Guangfa WANG Director, Department of Respiratory and Critical Care Medicine, Peking University First
Hospital
Fan WU Vice Dean, Shanghai Medical College, Fudan University
Zhongze WU Director, Compliance and Enforcement Division, Department of Wildlife Conservation,
National Forestry and Grassland Administration
Zunyou WU Chief Epidemiologist, Chinese Center for Disease Control and Prevention
Jun XING Head of Unit, Country Capacity for International Health Regulations, Health Security
Preparedness, World Health Organization, Geneva, Switzerland
Kwok-Yung YUEN Chair Professor and Co-Director of State Key Laboratory of Emerging Infectious Diseases,
Department of Microbiology, The University of Hong Kong
Weigong ZHOU Medical Officer, Influenza Division, National Center for Immunization and Respiratory
Diseases, US Centers for Disease Control and Prevention, Atlanta, United States
Yong ZHANG Assistant Director and Researcher, National Institute for Viral Disease Control and
prevention, Chinese Center for Disease Control and Prevention.
Lei ZHOU Chief and Researcher, Branch for Emerging Infectious Disease, Public Health Emergency
Center, Chinese Center for Disease Control and Prevention

24
B. Summary Agenda of the Mission

Dates Location Activities

10-15 February 2020 Beijing Advance Team and WHO Country team meetings with national
(Advance Team) counterparts and institutions
16 February 2020 Beijing Meeting with the full international team for briefing at the WHO
Country office
Beijing Workshop at the National Health Commission (NHC) with relevant
departments of the Joint Prevention and Control Mechanism of the
State Council
17 February 2020 Beijing Site visit to Beijing Ditan Hospital

Beijing Site visit to Anhuali community and health service station, Anzhen
street, Chaoyang District, Beijing
Beijing Workshop with Chinese Center for Disease Control and Prevention
18 February 2020 Shenzhen, Shenzhen customs at the airport
(Guangdong Team) Guangdong
Shenzhen,
Guangdong
Shenzhen, Shenzhen Center for Disease Control and Prevention
Guangdong
Shenzhen, Meeting at Tencent
Guangdong
19 February 2020 Shenzhen, Qiaoxiang community
(Guangdong Team) Guangdong
Shenzhen to Visit to Futian High-speed Train Station, and travel to Guangzhou by
Guangzhou train
Guangzhou Guangzhou Panyu Sanatorium

Guangzhou Guangdong Laboratory of Regenerative Medicine and Health

Guangzhou Guangzhou Tiyudongzhihui wet market

Guangzhou First Workshop with The People's government of Guangdong Province

20 February 2020 Guangzhou Guangdong Provincial Center for Disease Control and Prevention
(Guangdong Team)
Guangzhou Renmin road campus of Guangzhou Women and Children Medical
Center
Guangzhou The second Workshop with The People's government of Guangdong
Province
18 February 2020 Beijing to
(Sichuan Team) Chengdu
Sichuan Site visit to Chengdu Shuangliu International Airport

Site visit to Yong'an Township Central hospital with fever clinic

19 February 2020 Symposium with provincial and municipal authorities

(Sichuan Team)
Sichuan Center for Disease Control and Prevention

Site visit to West China Hospital- Designated COVID-19 hospital

20 February 2020
(Sichuan Team)
Site visit to Pharmaceutical Logistics center

Site visit to East Chengdu railway station

25
 Site visit to Chengdu Public Health Clinical Centre- Designated COVID 19
hospital
Sichuan and Guangdong teams reconvene in Guangzhou
21-24 February 2020 Analyze major findings; Meetings of the WHO-China Joint mission to
finalize the report
Feb 22 (Wuhan Team) Guangzhou to Select team members only
Wuhan
23 February Site visit to Guanggu Campus of Wuhan Tongji Hospital
(Wuhan Team)
Site visit to Mobile Cabin Hospital in Wuhan Sports Center
Workshop with relevant departments of the Joint Prevention and
Control Mechanism of Hubei Province
Feedback Meeting with Minister Ma, NHC at the Wuhan Conference
Center
24 February 2020 Guangzhou to Finalize report, WHO-Joint Press conference in Beijing
Beijing

__________

26
C. Detailed Technical Findings

Response management, case and contact management, risk communication and

community engagement

The response structures in China were rapidly put in place according to existing emergency
plans and aligned from the top to the bottom. This was replicated at the four levels of
government (national provincial, prefecture and county/district).

Organizational structure and response mechanism

Response activation at the national level: COVID-19 prevention and control mechanisms
were initiated immediately after the outbreak was declared and nine working groups were
set up to coordinate the response: a) Coordination b) Epidemic prevention and control c)
Medical treatment d) Research e) Public communication f) Foreign affairs g) Medical
material support h) Life maintenance supplies and i) Social stability. Each working group has
a ministerial level leader. Emergency response laws and regulations for the emergency
response to public health emergencies, prevention and control of infectious diseases have
been developed or updated to guide the response.

Response activation in provinces: Each province set up a similar structure to manage the
outbreak. The response is organized at the levels of national, provincial, prefecture,
county/district and the community. By 29 January, all provinces across China had launched
the highest level of response for major public health emergencies.

Response Strategy

A clear strategy was developed, and goals were well articulated and communicated across
the entire response architecture. This strategy was rapidly adapted and adjusted to the
outbreak, both in terms of the epidemiological situation over time and in different parts of
the country.

The epidemiological situation has been used to define location into four areas:
In areas without cases, the strategy in these areas is to "strictly prevent
introduction". This includes quarantine arrangements in transportation hubs,
monitoring for temperature changes, strengthening of triage arrangements, use of
fever clinics, and ensuring normal economic and social operations.
In areas with sporadic cases, the strategy is focused on "reducing importation,
stopping transmission and providing appropriate treatment".
In areas with community clusters, the strategy is focussed on "stopping transmission,
preventing exportation, and strengthening treatment".
In areas with community transmission, the strictest prevention and control
strategies are being implemented, the entry and exit of people from these areas has
been stopped and public health and medical treatment measures are
comprehensively strengthened.

27
Main control measures implemented in China

The main control measures implemented in China are as follows and are illustrated in
Figures 6A-6D, representing the national level response and examples of the response at the
Provincial and municipal levels:

Monitoring and reporting: COVID-19 was included in the statutory reporting of infectious
diseases on 20 January and plans were formulated to strengthen diagnosis, monitoring, and
reporting.

Strengthening ports of entry and quarantine: The Customs Department launched the
emergency plan for public health emergencies at ports across the country and restarted the
health declaration card system for entry and exit into cities as well as strict monitoring of
the temperature of entry and exit passengers.

Treatment: For severe or critical patients, the principle of "Four Concentrations" was
implemented: i.e. concentrating patients, medical experts, resources and treatment into
special centres. All cities and districts transformed relevant hospitals, increased the number
of designated hospitals, dispatched medical staff, and set up expert groups for consultation,
so as to minimise mortality of severe patients. Medical resources from all over China have
been mobilized to support the medical treatment of patients in Wuhan.

Epidemiological investigation and close contact management: Strong epidemiological

investigations are being carried out for cases, clusters, and contacts to identify the source of
infection and implement targeted control measures, such as contact tracing.

Social distancing: At the national level, the State Council extended the Spring Festival
holiday in 2020, all parts of the country actively cancelled or suspended activities like sport
events, cinema, theatre, and schools and colleges in all parts of the country postponed re-
opening after the holiday. Enterprises and institutions have staggered their return to work.
Transportation Departments setup thousands of health and quarantine stations in national
service areas, and in entrances and exits for passengers at stations. Hubei Province adopted
the most stringent traffic control measures, such as suspension of urban public transport,
including subway, ferry and long-distance passenger transport. Every citizen has to wear a
mask in public. Home support mechanisms were established. As a consequence of all of
these measures, public life is very reduced.

Funding and material support: Payment of health insurance was taken over by the state, as
well as the work to improve accessibility and affordability of medical materials, provide
personal protection materials, and ensure basic living materials for affected people.

Emergency material support: The government restored production and expanded

production capacity, organized key enterprises that have already started to exceed current
production capacity, supported local enterprises to expand imports, and used cross-border
e-commerce platforms and enterprises to help import medical materials and improve the
ability to guarantee supplies.

28
 A
China CDC publicly shared the gene sequence of the
novel coronavirus
A novel coronavirus was isolated by China CDC
NHC issued diagnosis and control technical protocols
Emergency monitoring, case investigation, close contact NCIP incorporated as a notifiable disease in the Infectious Disease Law and
management and market investigation initiated, Health and Quarantine Law in China
technical protocols for Wuhan released
NHC notified WHO and relevant countries and regions NHC started officially daily disease information release
Gene sequencing completed by China CDC State council initiated joint multisectoral mechanism
Wuhan implemented strict traffic restrictions
4000
Mild WHO announced PHEIC
Pneumonia
3500 Huanan seafood
Severe wholesale market Two new hospitals were established in Wuhan
Critical closed
3000 Enhanced admission and isolated
Unkonwn treatment of cases in Hubei
2500
Number of cases

Resumption of labor and rehabilitation

Outbreak announced by WHC.
2000 NHC and China CDC involved
in investigation and response Strategy and response adjustment

1500

1000

500

0
12/10
12/12
12/14
12/16
12/18
12/20
12/22
12/24
12/26
12/28
12/30
1/1
1/3
1/5
1/7
1/9

2/2
2/4
2/6
2/8
12/8

1/11
1/13
1/15
1/17
1/19
1/21
1/23
1/25
1/27
1/29
1/31

2/10
2/12
2/14
2/16
2/18
2/20
Date of onset

First Stage Second Stage Third Stage

(before Jan. 19, 2020) (Jan. 20-Feb. 7, 2020) (after Feb. 8, 2020)

29
 C

Figure 6. COVID-19 epidemic curves and major intervention measures in China as

implemented at a) the national level b) in Guangdong province, c) in Shenzhen
municipality and d) in Sichuan province

30
Risk communications (information release, public and media communications)

International and interregional cooperation and information sharing: From 3 January

2020, information on COVID-19 cases has been reported to WHO daily. Full genome
sequences of the new virus were shared with WHO and the international community
immediately after the pathogen was identified on 7 January. On 10 January, an expert
group involving Hong Kong, Macao and Taiwanese technical experts and a World Health
Organization team was invited to visit Wuhan. A set of nucleic acid primers and probes for
PCR detection for COVID-19 was released on 21 January.

Daily updates: The National Health Commission announces the epidemic situation every
day and holds daily press conferences to respond to emerging issues. The government also
frequently invites experts to share scientific knowledge on COVID-19 and to address public
concerns.

Psychological care: This is provided to patients and the public. Governments at all levels,
NGOs and all sectors of society developed guidelines for emergency psychological crisis
intervention and guidelines for public psychological self-support and counselling. A hotline
for mental health services has been established for the public.

IT platform: China has capitalized on the use of technology, big data and AI for COVID-19
preparedness, readiness and response. Authoritative and reliable information, medical
guidance, access to online services, provision of educational tools and remote work tools
have been developed in and used across China. These services have increased accessibility
to health services, reduced misinformation and minimized the impact of fake news.

Social mobilization and community engagement

Civil society organizations (community centers and public health centers) have been
mobilized to support prevention and response activities. The community has largely
accepted the prevention and control measures and is fully participating in the management
of self-isolation and enhancement of public compliance. Community volunteers are
organized to support self-isolation and help isolated residents at home to solve practical life
difficulties. Measures were taken to limit the movement of the population through home-
based support. Up to now, outside of Hubei, 30 provinces have registered and managed
more than 5 million people coming from Wuhan.

Clinical case management and infection prevention and control

The main signs and symptoms of COVID-19 include fever, dry cough, fatigue, sputum
production, shortness of breath, myalgia or arthralgia, sore throat, and headache. Nausea
or vomiting has been reported in a small percentage of patients (5%). On 14 February,
China CDC described the clinical features, outcomes, laboratory and radiologic findings of 44
672 laboratory-confirmed cases. Only 965 (2.2%) were under 20 years of age and there is
just one recorded death (0.1%) in this age group. Most patients (77.8%) were aged 30 to 69
years. Patients aged over 80 years had a CFR of 14.8%. The CFR was highest in those with

31
comorbidities including cardiovascular, diabetes, chronic respiratory disease, hypertension
and cancer.

As opposed to Influenza A(H1N1)pdm09, pregnant women do not appear to be at higher

risk of severe disease. In an investigation of 147 pregnant women (64 confirmed, 82
suspected and 1 asymptomatic), 8% had severe disease and 1% were critical.

Severe cases are defined as tachypnoea ( 30 breaths/ min) or oxygen saturation 93% at
rest, or PaO2/FIO2 <300 mmHg. Critical cases are defined as respiratory failure requiring
mechanical ventilation, shock or other organ failure that requires intensive care. About a
quarter of severe and critical cases require mechanical ventilation while the remaining 75%
require only oxygen supplementation.

China has a principle of early identification, early isolation, early diagnosis and early
treatment. Early identification of suspect cases is critical to containment efforts and occurs
via a process of temperature screening and questioning at entrances to many institutions,
communities, travel venues (airports, train stations) and hospitals. Many hospitals have
fever clinics that were established and maintained since the SARS outbreak. In China,
laboratory tests were originally requested according to the case definitions, which included
an epidemiological link to Hubei or other confirmed cases. However, more recently, a more
liberal clinical testing regimen allows clinicians to test with a low index of suspicion.

Suspect cases are isolated in normal pressure single rooms, wear a surgical mask (for source
control). Staff in China wear a cap, eye protection, n95 masks, gown and gloves (single use
only). In Wuhan it is necessary for most suspects to be cohorted in a normal pressure
isolation ward. Staff wear PPE continuously, changing it only when they leave the ward.

PCR test results are returned the same day. If positive, patients are transported to
designated hospitals (including negative pressure ambulances in some cities). All patients,
including the mild and asymptomatic, with a positive test are admitted. The designated
hospitals are known and are strategically placed with at least one per district/county.
Positive cases are cohorted by gender. Negative tested patients are managed based on
clinical needs. All patients are evaluated with a respiratory multiplex to look for other
diagnoses. This can add to the reassurance that a negative COVID-19 test reflects a lack of
infection with COVID-19.

In Wuhan, there are 45 designated hospitals, 6 of which are designated for critical patients,
and 39 for severe patients and/or any patients >65 years old. There are an additional 10
temporary hospitals reconstructed from gymnasium and exhibition centers, which are for
mild patients. Other surge measures undertaken in Wuhan include two new temporary
hospitals with 2600 beds, plus many makeshift hospitals to increase bed capacity. Bed
capacity within Wuhan has increased to >50,000.

Patients are treated according to the National Clinical guidelines (edition 6) released by the
China National Health Commission (NHC). There are no specific antiviral or immune
modulating agents proven (or recommended) to improve outcomes. All patients are
monitored by regular pulse oximetry. The guidelines include supportive care by clinical
category (mild, moderate, severe and critical), as well as the role of investigational

32
treatments such as chloroquine, phosphate, lopinavir/ritonavir, alpha interferon, ribavirin,
arbidol. The application of intubation/invasive ventilation and ECMO in critically ill patients
can improve survival. The Joint Mission Team was told of ECMO use in four patients at one
hospital with one death and three who appeared to be improving. Clearly, though ECMO is
very resource consumptive, any health system would need to carefully weigh the benefits.
There is widespread use of Traditional Chinese Medicines (TCM), for which the affects must
be fully evaluated.

Patients with COVID-19 are not permitted visitors. Staff use coveralls, masks, eye cover,
and gloves, removing PPE only when they leave the ward.

Patients are discharged after clinical recovery (afebrile >3 days, resolution of symptoms and
radiologic improvement) and 2 negative PCR tests taken 24 hours apart. Upon discharge,
they are asked to minimise family and social contact and to wear a mask. There are
expectations of clinical trial results within a matter of weeks, which will see further
opportunities for treatment.

There are guidelines for elderly care specifically targeting prevention in individuals and
introduction of COVID-19 to nursing homes.

Training programmes by video conference nationally are scaled up to inform staff of best
practice and to ensure PPE usage. Clinical champions are created to disperse knowledge
and provide local expertise.

Maintenance of usual healthcare activities is maintained by hospital zoning (e.g.

clean/contaminated sections of the healthcare facility).

Laboratory, diagnostics and virology

The virus found to cause COVID-19 was initially isolated from a clinical sample on 7 January.
It is notable that within weeks following the identification of the virus, a series of reliable
and sensitive diagnostic tools were developed and deployed. On 16 January, the first RT-
PCR assays for COVID-19 were distributed to Hubei. Real-time PCR kits were distributed to
all the provinces on 19 January and were provided to Hong Kong SAR and Macao SAR on 21
January. Information regarding viral sequences and PCR primers and probes was shared
with WHO and the international community by China CDC on 12 January 2020. To facilitate
product development and research on the new virus, COVID-19 virus sequences were
uploaded to the GISAID Database by China.

By 23 February, there were 10 kits for detection of COVID-19 approved in China by the
NMPA, including 6 RT-PCR kits, 1 isothermal amplification kit, 1 virus sequencing product
and 2 colloidal gold antibody detection kits. Several other tests are entered in the
emergency approval procedure. Currently, there are at least 6 local producers of PCR test
kits approved by NMPA. Overall, producers have the capacity to produce and distribute as
many as 1,650,000 tests/week.

33
Specimens from both the upper respiratory tract (URT; nasopharyngeal and oropharyngeal)
and lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or
bronchoalveolar lavage) are collected for COVID-19 testing by PCR.

COVID-19 virus has been detected in respiratory, fecal and blood specimens. According to
preliminary data from Guangzhou CDC as of 20 February, virus can initially be detected in
upper respiratory samples 1-2 days prior to symptom onset and persist for 7-12 days in
moderate cases and up to 2 weeks in severe cases. Viral RNA has been detected in feces in
up to 30% of patients from day 5 following onset of symptoms and has been noted for up to
4-5 weeks in moderate cases. However, it is not clear whether this correlates with the
presence of infectious virus. While live virus has been cultured from stool in some cases,
the role of fecal-oral transmission is not yet well understood. COVID-19 has been isolated
from the clinical specimens using human airway epithelial cells, Vero E6 and Huh-7 cell lines.

Serological diagnostics are rapidly being developed but are not yet widely used. Joint
Mission members met with local research teams at the China CDC, Guangzhou Regenerative
Medicine and Health Guangdong Laboratory. The teams reported on the development of
tests for IgM, IgG and IgM+IgG using rapid test platforms utilizing chemiluminiscence. ELISA
assays are also under development.

Research & Development

The government of China has initiated a series of major emergency research programs on
virus genomics, antivirals, traditional Chinese medicines, clinical trials, vaccines, diagnostics
and animal models. Research includes fundamental basic research and human subjects
research. For the purpose of this report, human studies are limited to those involving IRB
approval and informed consent. Other forms of human subjects investigations are included
in the sections on epidemiology in this report. Well-focused, robust research conducted in
the setting of an outbreak has the potential of saving many lives by identifying the most
effective ways to prevent, diagnose and treat disease.

Since the COVID-19 virus has a genome identity of 96% to a bat SARS-like coronavirus and
86%-92% to a pangolin SARS-like coronavirus, an animal source for COVID-19 is highly likely.
This was corroborated by the high number of RT-PCR positive environmental samples taken
from the Huanan Seafood Market in Wuhan.

At least 8 nucleic acid-based methods for direct detection of COVID-19 and two colloidal
gold antibody detection kits have been approved in China by the NMPA. Several other tests
are close to approval. It will be important to compare the sensitivities and specificities of
these and future serologic tests. Development of rapid and accurate point-of-care tests
which perform well in field settings are especially useful if the test can be incorporated into
presently commercially available multiplex respiratory virus panels. This would markedly
improve early detection and isolation of infected patients and, by extension, identification
of contacts. Rapid IgM and IgG antibody testing are also important ways to facilitate early
diagnosis. Standard serologic testing can be used for retrospective diagnoses in the context
of serosurveys that help better understand the full spectrum of COVID-19 infection.

34
A variety of repurposed drugs and investigational drugs have been identified. Screening
NMPA approved drug libraries and other chemical libraries have identified novel agents.
Hundreds of clinical trials involving remdesivir, chloroquine, favipiravir, chloroquine,
convalescent plasma, TCM and other interventions are planned or underway. Rapid
completion of the most important of these studies is critical to identifying truly effective
therapies. However, evaluation of investigational agents requires adequately powered,
randomized, controlled trials with realistic eligibility criteria and appropriate stratification of
patients. It is important for there to be a degree of coordination between those conducting
studies within and beyond China.

The development of a safe and effective vaccine for this highly communicable respiratory
virus is an important epidemic control measure. Recombinant protein, mRNA, DNA,
inactivated whole virus and recombinant adenovirus vaccines are being developed and
some are now entering animal studies. Vaccine safety is of prime concern in the area of
coronavirus infection in view of the past experience of disease enhancement by inactivated
whole virus measles vaccine and similar reports in animal experiments with SARS
coronavirus vaccines. It will be important that these vaccine candidates rapidly move into
appropriate clinical trials.

The ideal animal model for studying routes of virus transmission, pathogenesis, antiviral
therapy, vaccine and immune responses has yet to be found. The ACE2 transgenic mouse
model and Macaca Rhesus model are already used in research laboratories. Systematically
addressing which models can accurately mimic human infection is required.

There is a global rush for masks, hand hygiene products and other personal protective
equipment. The relative importance of non-pharmaceutical control measures including
masks, hand hygiene, and social distancing require further research to quantify their impact.

There are distinct patterns of intra-familial transmission of COVID-19. It is unclear whether

or not there are host factors, including genetic factors, that influence susceptibility or
disease course. COVID-19 has a varied clinical course and a precise description of that
course is not available. In addition, the long-term consequences of COVID-19 are unknown.
An observational cohort study of patients with COVID-19 enrolled from the time of
diagnosis (with appropriate controls) could provide in-depth information about clinical,
virologic and immunologic characteristics of COVID-19. Table 1 summarizes priority
research areas with immediate to longer term goals.

Table 1 Priority research areas with immediate, intermediate and longer-term goals
Immediate Goals
Diagnostics: RNA assays, antibody
& antigen assays, point of care
detection
Therapeutics: Remdesivir,
favipiravir, chloroquine, plasma,
TCM
Vaccines: Development of animal
models
Intermediate Goals
Diagnostics: Multiplex
diagnostic platforms
Therapeutics: intravenous
immunoglobulin (IVIg)
Vaccines: mRNA candidates
and candidate viral vectors
Long-term goals
Diagnostics: Prognostic markers
Therapeutics: Innovative approaches
(CRISPR-CAS; RNAi; Cell-based;
positive hits from library screening)
Vaccines: inactivated candidates and
subunit candidates

35
D. Knowledge Gaps

Knowledge gaps and key questions to be answered to guide control strategies include:

Source of infection
Animal origin and natural reservoir of the virus
Human-animal interface of the original event
Early cases whose exposure could not be identified

The pathogenesis and virulence evolution of the virus

Transmission dynamics
Modes of Transmission:
o Role of aerosol transmission in non-health care settings
o Role of fecal-oral transmission
Viral shedding in various periods of the clinical course in different biological samples
(i.e. upper and lower respiratory tract, saliva, faeces, urine)
o Before symptom onset and among asymptomatic cases
o During the symptomatic period
o After the symptomatic period / during clinical recovery

Risk factors for infection

Behavioral and socio-economic risk factors for infection in
o Households / institutions
o the Community
Risk factors for asymptomatic infection
Risk factors for nosocomial infection
o among health care workers
o among patients

Surveillance and monitoring

Monitoring community transmission through existing
o ILI surveillance
o SARI surveillance
The outbreak trend and intervention dynamics
o Basic reproduction numbers in various stages of the epidemic
o

36
Laboratory and diagnostics
Sensitivity and specificity of different nucleic acid (PCR, NAATs and rapid tests),
antibody and antigen tests
Post-infection antibody titers and the duration of protection
Sero-prevalence among
Health care workers
General population
Children

Clinical management of severe and critically ill patients

Value of ECMO in the management of critically ill patients
Best practice using mechanical ventilation in the management of critically ill patients
Re-evaluation of the role of steroids in the management of severe and critically ill
patients
Identification of factors associated with successful clinical management and
outcome
Determination of the effectiveness of Traditional Chinese Medicines (TCM)
Determination the effectiveness of additional investigational treatment options (e.g.
intravenous immunoglobulin/IVIg, convalescent plasma)

Prevention and control measures

Key epidemic indicators that inform evidence-based control strategy decision making
and adjustments
Effectiveness of infection prevention and control (IPC) measures in various health
care settings
Effectiveness of entry and exit screening
Effectiveness of the public health control measures and their socio-economic impact
o Restriction of movement
o Social distancing
o School and workplace closures
o Wearing mask in general public
o Mandatory quarantine
o Voluntary quarantine with active surveillance

__________

37
E. Operational & Technical Recommendations

Operational/programmatic recommendations
Reassess risk and capacities based on different stages of the outbreak; approve
different measures during the different phases of the response; assess different
stages of the response; reach a balance between response and social development
Initiate a timely scientific evidence based, efficient and flexible joint multi-sectoral
mechanism, which is driven by strong government leadership

Technical recommendations

Epidemiology and transmission

Continue enhanced surveillance across the country through existing respiratory
disease systems, including ILI, SARI or pneumonia surveillance systems
Prioritize early investigations, including household transmission studies, age-
stratified sero-epidemiologic surveys including children, case-control studies, cluster
investigations, and serologic studies in health care workers

Severity
Continue to share information on patient management, disease progression and
factors leading to severe disease and favorable outcomes
Review and analyze the possible factors associated with the disease severity, which
may include:
o natural history studies to better understand disease progression in mild,
severe and fatal patients
o medical chart reviews about disease severity among vulnerable groups, (e.g.
those with underlying conditions, older age groups, pregnant women and
children) to develop appropriate standards of care
o evaluation of factors leading to favorable outcomes (e.g. early identification
and care)

Clinical care and infection prevention and control

Suspect patients who have not yet been tested should be isolated in single normal
pressure rooms; cohorting of positive cases is acceptable
Physicians and all health care workers need to maintain a high level of clinical alert
for COVID-19
For affected countries, standardize training for clinical care and IPC and scale with
the development of local (e.g. district level) experts
Ensure concurrent testing for other viral pathogens to support a negative COVID-19
test
Ensure maintenance of usual and essential services during the outbreak

38
 Ensure processes are in place for infection prevention among the most vulnerable,
including the elderly
Ensure readiness to provide clinical care and to meet IPC needs, including:
a. anticipated respiratory support requirements (e.g. pulse oximeters, oxygen,
and invasive support where appropriate)
b. national guidelines for clinical care and IPC, revised for COVID-19
c. nationally standardised trainings for disease understanding and PPE use for
HCWs
d. community engagement
e. PPE and Medication stockpiles
f. early identification protocols; triage, temperature screening, holding bays
(triage, including pulse oximetry)
g. treatment protocols including designated facilities, patient transportation
h. enhanced uptake of influenza and pneumococcal vaccine according to
national guidelines
i. laboratory testing
j. rapid response teams

Laboratory and virology

Continue to perform whole genome analysis of COVID-19 viruses isolated from
different times and places, to evaluate virus evolution
Conduct pathogenesis studies using biopsy/post-mortem specimens of COVID-19
patients or infected animal models
Evaluate available nucleic acid PCR diagnostics
Rapidly develop and evaluate rapid/point-of-care diagnostics and serologic assays
Conduct further study to interpret the result of positive COVID-19 RNA detection in
feces in patients recovering from COVID-19
Enhance international cooperation, especially in terms of biosafety and information
sharing for increased understanding of the COVID-19 virus and traceability of the
virus
Consider monitoring proinflammatory cytokines via multiplex assays to predict the

Research and development

Additional effort should be made to find the animal source, including the natural
reservoir and any intermediate amplification host, to prevent any new epidemic foci
or resurgence of similar epidemics

39
Efforts should be made to consistently evaluate existing and future diagnostic tests
for detection of COVID-19 using a harmonized set of standards for laboratory tests
and a biorepository that can be used for evaluating these tests
Consider the establishment of a centralized research program in China to oversee
that portfolio and ensure the most promising research (vaccines, treatments,
pathogenesis) are adequately supported and studied first; program staff dedicated
to the clinical research would work at the clinical research site(s) to decrease the
research workload of the clinicians at the site
Consider including one or more sites within China in the ongoing and future multi-
center, international trials; Chinese investigators should be actively engaged in
international trials
Continue to develop additional animal models, making every effort to ensure these
mimic human infection and virus transmission as closely as possible
Conduct studies to determine which of the commonly used forms of PPE are most
effective in controlling the spread of COVID-19

__________

40
https://academic.oup.com/jtm/advance-article/doi/10.1093/jtm/taaa039/5804843

Interrupting transmission of COVID-19: lessons from containment efforts in Singapore

Vernon J Lee, PhD1,2, Calvin J Chiew, MPH1, Wei Xin Khong, PhD1
1
Ministry of Health, Singapore
2
Saw Swee Hock School of Public Health, Singapore

Corresponding author: Vernon J Lee, Communicable Diseases Division, Ministry of Health,

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Singapore, 12 College Road, Singapore 169852, Email: Vernon_LEE@moh.gov.sg

Highlight

Despite multiple importations resulting in local chains of transmission, Singapore has been able to
control the COVID-19 outbreak without major disruption to daily living. In this article, we describe
the combination of measures taken by Singapore to contain COVID-19 and share some early lessons
learnt from the experience.

Keywords:

COVID-19; outbreak; Singapore; coronavirus; mitigation; importation;

Introduction

As of Mar 9, 2020, more than 100,000 COVID-19 cases and 3,800 deaths have been reported
globally, including over 28,000 cases and 600 deaths in 100 countries or regions outside China.1
Countries are now facing emerging outbreaks that threaten to develop into local epidemics if not
well contained. China, which had initiated the largest community containment effort in history, has
been successful at containing the outbreak, and since mid-February the daily number of new COVID-
19 cases has been declining in China.2 In the Republic of Korea (ROK) with one of the highest number
of infections outside China, the outbreak also appears to have stabilized after application of rigorous
measures such as strict contact tracing and large-scale quarantine.

Singapore, a city-state and global travel hub in Southeast Asia, was one of the first countries to be
affected by COVID-19, and for a while was the country with the highest COVID-19 numbers outside
of China from Feb 5, 2020 to Feb 18, 2020. This was in part due to Singapore’s strategy of using a
comprehensive surveillance system to detect as many cases as possible, and to contain them at the
individual level. Despite early importations resulting in local chains of transmission, the rise in the
number of cases has been steady without the exponential growth observed elsewhere. This suggests
that this strategy, coupled with community-based measures proportionate to the transmission risk,
has been effective in containing spread, and could be considered in countries in the early stages of
the outbreak where it is not possible to mount massive community-wide containment efforts.

Singapo e s approach

Singapore was one of the worst affected areas in the 2003 SARS outbreak, and since then Singapore
has steadily built up its outbreak preparedness, including developing a national pandemic
preparedness plan based on risk assessment and calibration of response measures that are
proportionate to the risk. This includes holding regular exercises, and building the National Centre
for Infectious Diseases (NCID), a 330-bed purpose built infectious diseases management facility with
integrated clinical, laboratory and epidemiologic functions.
One of the lessons learnt from SARS is that clear leadership and direction is critical to ensure
coordinated response across all sectors. Therefore, a Multi-Ministry Task Force was set up before
Singapore had its first COVID-19 case to provide central coordination for a Whole-of-Government
handling of the crisis.

Surveillance and containment measures

Singapore’s surveillance for COVID-19 aimed to identify as many cases as possible using
complementary detection methods. First, a case definition to identify suspect cases, at healthcare

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facilities or through contact tracing, was established based on clinical and epidemiological criteria,
and evolved over time as more information became available. To identify cases in the community
that do not fulfill the case definition, an enhanced surveillance system was set up to detect COVID-
19 among all cases of pneumonia in hospital and primary care, severely-ill patients in hospital
intensive care units and deaths with possible infectious cause, and influenza-like illness (ILI) in
sentinel primary care clinics. Finally, doctors were also allowed to test patients whom they viewed
with suspicion for clinical or epidemiological reasons. To support the surveillance system, SARS-CoV-
2 RT-PCR laboratory testing capacity was scaled up rapidly to all public hospitals in Singapore, and is
able to handle 2,200 tests a day for a population of 5.7m. Similarly, ROK has also quickly expanded
testing capacities, including setting up drive-through testing stations, and has conducted over
200,000 tests to date.3

All suspected and confirmed cases were immediately isolated in hospital to prevent onward
transmission. Contact tracing was also initiated to determine their movement history 14 days prior
to symptom onset to isolation to determine possible sources of infection and also to prevent onward
transmission among close contacts. Any contact with current or recent symptoms after exposure to
the case was referred to hospitals for isolation and testing as part of active case finding. Close
contacts who were well were placed under mandatory quarantine for 14 days from their last date of
exposure, while other lower-risk contacts were put on phone surveillance.

As of Mar 10, 2020, over 4000 close contacts had been placed under quarantine, and 8 cases
developed symptoms while under quarantine and tested positive. To facilitate compliance and
reduce hardship, the Quarantine Order Allowance Scheme provides economic assistance. At the
same time, the Infectious Diseases Act provides legal power to enforce contact tracing and
quarantine, and to prosecute those who do not comply.

Healthcare measures

A network of more than 800 Public Health Preparedness Clinics (PHPCs) was activated to enhance
management of respiratory infections in the primary care setting, with subsidies extended to
Singapore residents to incentivize them to seek care at these PHPCs. As early COVID-19 disease is
mild and undifferentiated, medical practitioners were instructed to provide extended medical leave
of up to five days for patients with respiratory symptoms. This allowed possible COVID-19 cases to
self-isolate at home to reduce the number of undetected cases seeding community transmission.
Those with persistent or worsening symptoms are advised to return to the same doctor for
evaluation and referral for testing.

At the hospitals, infection control measures were strengthened, including strict visitor controls,
cohorting of patients with pneumonia or respiratory infection, and maintenance of strict infection
control practices across all settings with personal protective equipment levels appropriate for the
patient care setting. Movement of patients and doctors between healthcare institutions was also
limited to prevent multiple institutions from being affected at the same time.

Border control measures

Apart from detecting cases and containing spread, prevention of imported cases is important to
reduce the force of infection from external sources. In Singapore, temperature and health screening
of incoming travelers from Wuhan since Jan 3, 2020, and extended to all travellers since Jan 29,
2020, is in place at all ports of entry. Travelers who meet the suspect case definition are conveyed

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directly to hospital.

Singapore has, as of Mar 4, 2020, advised Singaporeans to defer non-essential travel to mainland
China, Republic of Korea (ROK), Northern Italy and Iran and imposed entry restrictions on visitors
from the same areas. Returning residents and long-term pass holders with travel history to these
affected regions are subject to a 14-day quarantine.

Community and social measures

The community-level approach in Singapore was focused on social responsibility while life continued
as usual with precautions. Public education is a key strategy to empower the public, and is done
through traditional print and broadcast media, as well as social media. This includes messages on
regular handwashing and seeking medical treatment early and staying at home when unwell. The
use of masks was only encouraged for ill persons to prevent them from infecting others, and the
government distributed four masks to every household. Detailed anonymised information on COVID-
19 cases is shared publicly to prevent speculation, while misinformation is quickly debunked and
clarified on a government website.

In the workplace, employees are encouraged to monitor their temperature and health regularly, and
institutions to step up their business continuity plans, including allowing employees to telecommute
where possible and having segregated teams. Advisories to avoid large-scale events of more than
1,000 people are in place, while ongoing events are advised to take precautions such as health
screening and turning away ill individuals. Schools have remained open, and have implemented
precautionary measures such as reduction of mass assemblies, inter-class and inter-school activities,
and staggered meal times. Mass fever screening through thermal temperature scanners is widely
instituted at entry to public buildings, such as offices, hotels, community centres and places of
worship.

Although these precautions are implemented, relative normalcy of day-to-day life has been
maintained in Singapore. Notably, Singapore has not implemented school closures or other major
social distancing measures, as there is no evidence of widespread community transmission, and
rates of COVID-19 infection among children remain low.4 School closures and social distancing have
been performed in China and Hong Kong, where containment is also successful. However,
Singapore’s experience suggests it is possible to avoid major social disruptions and contain the
spread of COVID-19, as a sustainable approach over the long term.

Success and Challenges

With the combination of measures, Singapore has been able to interrupt transmission to contain the
outbreak. The majority of cases were detected through application of the case definition at the point
of medical consult or through contact tracing.5 Statistical modeling of the effective reproduction
number has shown it to be consistently below 1, suggesting that containment efforts are successful
(Pung et al, unpublished data).

However, several challenges lie ahead. Firstly, the longer the outbreak persists, the more chains of
community transmission and missed cases are present, and the more difficult it will be to link cases
and contain spread. Contact tracing and quarantine are resource-intensive activities and may not be
sustainable in the long run. Secondly, some individuals who continue to work or attend social
functions while symptomatic are driving disease spread, leading to substantial community

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transmission. Thirdly, with global spread, the force of infection from imported cases will be
substantial, leading to new waves of infection.

As Singapore is a travel hub with high reliance on trade, sustained border control measures may not
be practical with global disease spread, and it may not be feasible to completely shut a country’s
borders for a prolonged duration. These factors may result in a rise in cases, and additional
measures will be required to achieve a balance between containing disease spread and reducing the
overall health and socioeconomic impact due to community transmission.

Conclusion

Early detection of cases through surveillance and aggressive contact tracing around known cases has
helped to contain spread of the outbreak in Singapore. Together with other healthcare, border and
community measures, they allow the COVID-19 outbreak to be managed without major disruption to
daily living. Countries could consider these measures for a proportionate response to the risk of
COVID-19.

Author contributions:

All authors contributed equally to the literature review, data collection and writing of the
manuscript.

Declaration of interests:

We declare no competing interests.

References

1. World Health Organization. Coronavirus disease (COVID-2019) situation report 49 (10 Mar 2020).
https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200309-sitrep-49-
covid-19.pdf (11 March, 2020, date last accessed).
2. Wilder-Smith A, Chiew CJ, Lee VJ. Can we contain the COVID-19 outbreak with the same
measures as far SARS? Lancet Infect Dis 2020. https://doi.org/10.1016/S1473-3099(20)30129-8.
3. Our World in Data. How many tests for COVID-19 are being performed around the world?
http://www.ourworldindata.org/covid-testing-10-march (11 March, 2020, date last accessed).
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characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua
Liu Xing Bing Xue Za Zhi 2020; 41(2):145-151.
5. Ng Y, Li Z, Chua YX et al. Evaluation of the effectiveness of surveillance and response measures
for the first 100 patients with COVID-19 in Singapore. MMWR Morb Mortal Wkly Rep 2020 (in
press).
6. World Health Organization. Coronavirus disease (COVID-19) technical guidance: Surveillance and
case definitions. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-
guidance/surveillance-and-case-definitions (11 March, 2020, date last accessed).
7. Public Health England. COVID-19: guidance for primary care.
www.gov.uk/government/publications/wn-cov-guidance-for-primary-care (11 March, 2020, date
last accessed).
8. Department of Health, Government of Australia. Letter to doctors from the Chief Medical Officer
about the response to COVID-19. http://health.gov.au.news/letter-to-doctors-from-the-chief-
medical-officer-about-the-response-to-covid-19 (11 March, 2020, date last accessed).
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control recommendations for patients with suspected or confirmed coronavirus disease 2019
(COVID-19) in healthcare settings. http://www.cdc.gov/coronavirus/2019-ncov/infection-

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https://www.osha.gov/Publications/OSHA2990.pdf (11 March, 2020, date last accessed).
Table: Summary of measures taken for COVID-19 in Singapore and other countries (as of Mar 10, 2020)

Measure Singapore Other Countries (selected)

Surveillance and containment measures
Case detection Case definition was established based on
clinical and epidemiological criteria, and
continuously updated as the COVID-19
situation evolved. Surveillance was
enhanced to test COVID-19 in all
pneumonia patients, ICU patients and
deaths from possible infectious cause, and
influenza-like illness (ILI) in sentinel
primary care sites. Doctors were also
allowed to test patients whom they
viewed with suspicion for clinical or
epidemiological reasons.
Quarantine & Symptomatic contacts were referred to
phone hospital. Asymptomatic close contacts
surveillance were placed under compulsory quarantine
for 14 days, while lower-risk contacts were
put on phone surveillance.
Laboratory PCR testing for COVID-19 is available at all
testing public hospital laboratories to increase
national diagnostic capacity, and other
healthcare institutions can send samples
for testing at these facilities. Serological
tests were used to investigate linkages
between cases and clusters.
Healthcare measures
Clinical Medical practitioners were instructed to
management in provide extended medical leave of up to
primary care five days for patients with respiratory
symptoms, and to refer them for further
testing if they do not recover. Patients
were advised to return to the same doctor
if symptoms persist.
Affected countries instituted various case
finding activities using WHO’s case definition
or a modified version.6 Malaysia, Republic of
Korea (ROK) and the United Kingdom
incorporated COVID-19 testing for severe
acute respiratory illness (SARI) and ILI
surveillances. In Japan, Republic of Korea
(ROK) and the United States (US), doctors
were allowed to test patients at their
discretion.
Mandatory quarantine was required by law
in several countries/regions, including
Brunei, Hong Kong, Israel, mainland China
and ROK.
In Japan and the United States (US), COVID-
19 testing was extended to non-public
health laboratories. Serological testing using
IgM and IgG antibodies was described in
mainland China.
In UK, primary care practitioners were
advised to avoid face-to-face assessment of
suspected cases. Instead, patients should be
immediately isolated and referred to the
7
local health authorities via a hotline.
General practitioners in Australia were
similarly advised to refer patients to
dedicated health services, undertake remote
telemedicine consultation or make safe
arrangements to assess possible COVID-19

Infection Infection control measures were
prevention and strengthened at healthcare institutions,
control including strict visitor controls, cohorting
of patients with pneumonia or respiratory
infection, and maintenance of strict
infection control practices across all
settings. Inter-institution movement of
patients and doctors was limited.
Healthcare Over 800 Public Health Preparedness
services Clinics (PHPCs) were activated to enhance
management of respiratory infections in
the primary care setting, with subsidies
extended to Singapore residents.
Designated Majority of cases were isolated and
hospital treated at the National Centre for
Infectious Diseases (NCID), a 330-bed
purpose built infectious diseases
management facility.
Border control measures
Temperature Temperature and health screening for
screening inbound travelers is being conducted at all
land, air, and sea checkpoints.
Travel advisories Singaporeans are advised to defer non-
& border essential travel to mainland China, ROK,
restrictions Northern Italy and Iran, and entry
restrictions are imposed on visitors from
these regions. Returning residents with
travel history to these areas are subject to
a 14-day quarantine.
Community and social measures
Schools Schools have remained open, but
implemented precautionary measures
such as reduction of mass assemblies,
inter-class and inter-school activities, and
staggered meal times.
Workplaces Employees are encouraged to monitor
their temperature and health regularly,
and institutions are encouraged to step up
their business continuity plans, such as
telecommuting where possible and having
segregated teams.
Public Public education was done through
communications traditional print and broadcast media, as
well as social media. Public are advised to
practise social responsibility while life
continues as usual with precautions.
Misinformation is debunked and clarified
on a government website.
Lockdown of No areas have been locked down to date.
affected areas
8
patients.
Infection control measures recommended
by the US Centers for Disease Control to
healthcare institutes included limiting points
of entry to facilities, prioritizing triage of
patients with respiratory symptoms,
exploring alternatives to face-to-face triage,
limiting visitor access and movement within
facility, and managing exposed healthcare
9
Downloaded from https://academic.oup.com/jtm/advance-article-abstract/doi/10.1093/jtm/taaa039/5804843 by guest on 22 March 2020
workers .
Australia and China set up “fever clinics” to
assess large volume of people for COVID-19
while minimizing risk of transmission to
other patients.
While most countries managed their cases in
existing hospitals, China established at least
14 temporary medical facilities designated
to treat COVID-19 patients. Two new
hospitals with at least 1,000 beds each were
also built in Wuhan city.
Countries including China are conducting
temperature screening of incoming
passengers at air, land and sea checkpoints.
At least 45 countries or regions issued
partial or complete travel bans on mainland
China, Iran, Italy, ROK or other countries.
Country/region-wide school closures were
announced in Albania, Bulgaria, Iran, Iraq,
Italy, Japan, mainland China, Hong Kong,
Saudi Arabia, Spain and ROK.
Hong Kong’s Centre for Health Protection
encouraged companies to develop
comprehensive policies that include
business continuity and operational plans to
10
maintain core services . In US, employers
were recommended to develop contingency
plans for situations that may arise during
outbreaks11.
Most countries delivered public-service
announcements promoting social
responsibility and set up telephone hotlines
for public enquiries. In mainland China,
several provinces mandated mask wearing in
public spaces.
Massive lockdowns were reported in
mainland China, Palestine, Saudi Arabia, and
Italy. Smaller scale lockdowns were reported
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The coronavirus pandemic is exacting a heavy toll on Italy, with hospitals overwhelmed
The coronavirus pandemic is exacting a heavy toll on Italy, with hospitals overwhelmed
and a nationwide lockdown imposed. But experts are also concerned about a seemingly

high death rate, with the number of fatalities outstripping the total reported in China.

Of the 47,000 people confirmed coronavirus patients in Italy, 4,032 so far have died - with
a record increase of 627 in the last 24 hours.

By contrast China has almost twice as many cases, 81,250, but 3,253 fatalities.

In very crude terms, this means that around eight per cent of confirmed coronavirus
patients have died in Italy, compared to four per cent in China. By this measure Germany,
which has so far identified 13,000 cases and 42 deaths, has a fatality rate of just 0.3 per
cent.

So why the disparity?

According to Prof Walter Ricciardi, scientific adviser to Italy’s minister of health, the
country’s mortality rate is far higher due to demographics - the nation has the second
oldest population worldwide - and the manner in which hospitals record deaths.

China Italy
4000
3405

3000 3245

2000

1000

“The age of our patients in hospitals is substantially older - the median is 67, while in
China it was 46,” Prof Ricciardi says. “So essentially the age distribution of our patients is
squeezed to an older age and this is substantial in increasing the lethality.”

A study in JAMA this week found that almost 40 per cent of infections and 87 per cent of
A study in JAMA this week found that almost 40 per cent of infections and 87 per cent of

deaths in the country have been in patients over 70 years old.

And according to modelling the majority of this age group are likely to need critical
hospital care - including 80 per cent of 80-somethings - putting immense pressure on the
health system.

But Prof Ricciardi added that Italy’s death rate may also appear high because of how
doctors record fatalities.

“The way in which we code deaths in our country is very generous in the sense that all
the people who die in hospitals with the coronavirus are deemed to be dying of the
coronavirus.

Coronavirus: ‘It’s just a build-up of dead people,’ says British nurse in Italy

“On re-evaluation by the National Institute of Health, only 12 per cent of death certificates
have shown a direct causality from coronavirus, while 88 per cent of patients who have
died have at least one pre-morbidity - many had two or three,” he says.

Other experts have also expressed scepticism about the available data. Martin McKee,
Other experts have also expressed scepticism about the available data. Martin McKee,
professor of European public health at the London School of Hygiene and Tropical
Medicine, says that countries do not yet have a good indication of how many mild
infections they have.

If further testing finds more asymptomatic cases spreading undetected, the mortality rate
will drop.
Coronavirus cases tracker
Known coronavirus cases
Known coronavirus deaths

1 10 100 1,000 10,000 81,321 (China)

Country Cases Deaths

China 81,321 3,260
Italy 53,578 4,825
USA 26,111 324
Spain 25,496 1,378
Germany 22,364 84
Iran 20,610 1,556
France 14,459 562
South Korea 8,799 102
UK 5,018 233

Source: WHO, CDC, ECDC, NHC, DXY. Last updated: 22/03/2020. Japan total excludes 712 cases from the Diamond Princess

“It’s too early to make a comparison across Europe,” he says. “We do not have detailed
“It’s too early to make a comparison across Europe,” he says. “We do not have detailed
sero-surveillance of the population and we do not know how many asymptomatic people
are spreading it.”

Prof McKee adds that testing is not currently consistent across the continent, or world.

“In Germany, epidemiological surveillance is more challenging - simply because of the

complexity of working in a federal state and because public health is organised very
much at the local level."

But there are other factors that may have contributed to Italy’s fatality rates, experts say.
This includes a high rate of smoking and pollution - the majority of deaths have been in
the northern region Lombardy region, which is notorious for poor air quality.

Workers stand next to coffins and remains of the coronavirus victims, in Bergamo, Italy CREDIT: FOTOGRAMMA/EPA-EFE

And there’s also no question that parts of Italy’s health system have been overwhelmed
with a surge of coronavirus patients and are struggling to cope.
“Doctors in Italy haven’t been dealing with one or two patients in care... but up to 1,200,”

says Dr Mike Ryan, health emergencies programme executive director at the World
Health Organization. “The fact they’re saving so many is a small miracle in itself.”

This pressure is likely to get worse as more healthcare workers are infected and have to
isolate - already, 2,000 have contracted the virus in Italy.

"Based on Italy’s experience, there is a real concern for the UK,” adds Prof McKee.
“Compared to almost every other European country we have a relative shortage of
ventilators and medical staff.”

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« An appearance on James Delingpole's podcast | Main

22 March 2020 12:29 AM

PETER HITCHENS: Is shutting down Britain – with unprecedented curbs on

ancient liberties – REALLY the best answer?

This is Peter Hitchens's Mail on Sunday column

Some years ago I had the very good luck to fall into the hands of a totally useless
doctor. It was hell, and nearly worse than that, but it taught me one of the most
important lessons of my life. He was charming, grey-haired, smooth and beautifully
dressed. He was standing in for my usual GP, a shabbier, more abrasive man.
I went to him with a troubling, persistent pain in a tender place. He prescribed an
antibiotic. Days passed. It did not work. The pain grew worse. He declared that in that case I needed surgery,
and the specialist to whom he sent me agreed with barely a glance. I was on the conveyor belt to the
operating table.
In those days I believed, as so many do, in the medical profession. I was awed by their qualifications. Yet the
prospect of a rather nasty operation filled me with gloom and doubt. As I waited miserably for the anaesthetist
in the huge London hospital to which I had been sent, a new doctor appeared. I braced myself for another
session of being asked ‘Does this hurt?’ and replying, between clenched teeth, that yes it blinking well did.
But this third man was different. He did not ask me pointlessly if it hurt. He knew it did. He was, crucially, a
thinking man who did not take for granted what he was told.
He looked at my notes. He actually read them, which I don’t think anyone else ever had. He swore under his
breath. He hurried from the room, only to return shortly afterwards to say I should get dressed and go home.
The operation was cancelled. All I needed was a different antibiotic, which he – there and then – prescribed
and which cured the problem in three days. He was furious, and managed to convey tactfully that the original
prescription had been incompetent and wrong.
The whole miserable business had been a dismal and frightening mistake. He was sorry. Heaven knows what
would have happened if Providence had not brought that third doctor into the room. I still shudder slightly to
think of it. But the point was this. A mere title, a white coat, a smooth manner, a winning way with long words
and technical jargon, will never again be enough for me.
It never, ever does any harm to question decisions which you think are wrong. If they are right, then no harm
will be done. They will be able to deal with your questions. If they are, in fact, wrong, you could save
everyone a lot of trouble.
And so here I am, asking bluntly – is the closedown of the country the right answer to the coronavirus? I’ll be
accused of undermining the NHS and threatening public health and all kinds of other conformist rubbish. But I
ask you to join me, because if we have this wrong we have a great deal to lose.
I don’t just address this plea to my readers. I think my fellow journalists should ask the same questions. I think
MPs of all parties should ask them when they are urged tomorrow to pass into law a frightening series of
restrictions on ancient liberties and vast increases in police and state powers.
Did you know that the Government and Opposition had originally agreed that there would not even be a vote
on these measures? Even Vladimir Putin might hesitate before doing anything so blatant. If there is no
serious rebellion against this plan in the Commons, then I think we can commemorate tomorrow, March 23,
2020, as the day Parliament died. Yet, as far as I can see, the population cares more about running out of
lavatory paper. Praise must go to David Davis and Chris Bryant, two MPs who have bravely challenged this
measure.
It may also be the day our economy perished. The incessant coverage of health scares and supermarket
panics has obscured the dire news coming each hour from the stock markets and the money exchanges. The
wealth that should pay our pensions is shrivelling as share values fade and fall. The pound sterling has lost a
huge part of its value. Governments all over the world are resorting to risky, frantic measures which make
Jeremy Corbyn’s magic money tree look like sober, sound finance. Much of this has been made far worse by
the general shutdown of the planet on the pretext of the coronavirus scare. However bad this virus is (and I
will come to that), the feverish panic on the world’s trading floors is at least as bad.
And then there is the Johnson Government’s stumbling retreat from reason into fear. At first, Mr Johnson was
true to himself and resisted wild demands to close down the country. But bit by bit he gave in.
The schools were to stay open. Now they are shutting, with miserable consequences for this year’s A-level
cohort. Cafes and pubs were to be allowed to stay open, but now that is over. On this logic, shops and
supermarkets must be next, with everyone forced to rely on overstrained delivery vans. And that will
presumably be followed by hairdressers, dry cleaners and shoe repairers.
How long before we need passes to go out in the streets, as in any other banana republic? As for the
grotesque, bullying powers to be created on Monday, I can only tell you that you will hate them like poison by
the time they are imposed on you.
All the crudest weapons of despotism, the curfew, the presumption of guilt and the power of arbitrary arrest,
are taking shape in the midst of what used to be a free country. And we, who like to boast of how calm we are
in a crisis, seem to despise our ancient hard-bought freedom and actually want to rush into the warm, firm
arms of Big Brother.
Imagine, police officers forcing you to be screened for a disease, and locking you up for 48 hours if you
object. Is this China or Britain? Think how this power could be used against, literally, anybody.
The Bill also gives Ministers the authority to ban mass gatherings. It will enable police and public health
workers to place restrictions on a person’s ‘movements and travel’, ‘activities’ and ‘contact with others’.
Many court cases will now take place via video-link, and if a coroner suspects someone has died of
coronavirus there will be no inquest. They say this is temporary. They always do.
Well, is it justified? There is a document from a team at Imperial College in London which is being used to
justify it. It warns of vast numbers of deaths if the country is not subjected to a medieval curfew.
But this is all speculation. It claims, in my view quite wrongly, that the coronavirus has ‘comparable lethality’ to
the Spanish flu of 1918, which killed at least 17 million people and mainly attacked the young.
What can one say to this? In a pungent letter to The Times last week, a leading vet, Dick Sibley, cast doubt
on the brilliance of the Imperial College scientists, saying that his heart sank when he learned they were
advising the Government. Calling them a ‘team of doom-mongers’, he said their advice on the 2001 foot-and-
mouth outbreak ‘led to what I believe to be the unnecessary slaughter of millions of healthy cattle and sheep’
until they were overruled by the then Chief Scientific Adviser, Sir David King.
He added: ‘I hope that Boris Johnson, Chris Whitty and Sir Patrick Vallance show similar wisdom. They must
ensure that measures are proportionate, balanced and practical.’
Avoidable deaths are tragic, but each year there are already many deaths, especially among the old, from
complications of flu leading to pneumonia.
The Department of Health and Social Care (DHSC) tells me that the number of flu cases and deaths due to
flu-related complications in England alone averages 17,000 a year. This varies greatly each winter, ranging
from 1,692 deaths last season (2018/19) to 28,330 deaths in 2014/15.
The DHSC notes that many of those who die from these diseases have underlying health conditions, as do
almost all the victims of coronavirus so far, here and elsewhere. As the experienced and knowledgeable
doctor who writes under the pseudonym ‘MD’ in the Left-wing magazine Private Eye wrote at the start of the
panic: ‘In the winter of 2017-18, more than 50,000 excess deaths occurred in England and Wales, largely
unnoticed.’
Nor is it just respiratory diseases that carry people off too soon. In the Government’s table of ‘deaths
considered avoidable’, it lists 31,307 deaths from cardiovascular diseases in England and Wales for 2013, the
last year for which they could give me figures.
This, largely the toll of unhealthy lifestyles, was out of a total of 114,740 ‘avoidable’ deaths in that year. To put
all these figures in perspective, please note that every human being in the United Kingdom suffers from a
fatal condition – being alive.
About 1,600 people die every day in the UK for one reason or another. A similar figure applies in Italy and a
much larger one in China. The coronavirus deaths, while distressing and shocking, are not so numerous as to
require the civilised world to shut down transport and commerce, nor to surrender centuries-old liberties in an
afternoon.
We are warned of supposedly devastating death rates. But at least one expert, John Ioannidis, is not so sure.
He is Professor of Medicine, of epidemiology and population health, of biomedical data science, and of
statistics at Stanford University in California. He says the data are utterly unreliable because so many cases
are going unrecorded.
He warns here
http://bit.ly/CoronaSense
‘This evidence fiasco creates tremendous uncertainty about the risk of dying from Covid-19. Reported case
fatality rates, like the official 3.4 per cent rate from the World Health Organisation, cause horror and are
meaningless.’ In only one place – aboard the cruise ship Diamond Princess – has an entire closed community
been available for study. And the death rate there – just one per cent – is distorted because so many of those
aboard were elderly. The real rate, adjusted for a wide age range, could be as low as 0.05 per cent and as
high as one per cent.
As Prof Ioannidis says: ‘That huge range markedly affects how severe the pandemic is and what should be
done. A population-wide case fatality rate of 0.05 per cent is lower than seasonal influenza. If that is the true
rate, locking down the world with potentially tremendous social and financial consequences may be totally
irrational. It’s like an elephant being attacked by a house cat. Frustrated and trying to avoid the cat, the
elephant accidentally jumps off a cliff and dies.’
Epidemic disasters have been predicted many times before and have not been anything like as bad as
feared.
The former editor of The Times, Sir Simon Jenkins, recently listed these unfulfilled scares: bird flu did not kill
the predicted millions in 1997. In 1999 it was Mad Cow Disease and its human variant, vCJD, which was
predicted to kill half a million. Fewer than 200 in fact died from it in the UK.
The first Sars outbreak of 2003 was reported as having ‘a 25 per cent chance of killing tens of millions’ and
being ‘worse than Aids’. In 2006, another bout of bird flu was declared ‘the first pandemic of the 21st
Century’.
There were similar warnings in 2009, that swine flu could kill 65,000. It did not. The Council of Europe
described the hyping of the 2009 pandemic as ‘one of the great medical scandals of the century’. Well, we
shall no doubt see.
But while I see very little evidence of a pandemic, and much more of a PanicDemic, I can witness on my daily
round the slow strangulation of dozens of small businesses near where I live and work, and the catastrophic
collapse of a flourishing society, all these things brought on by a Government policy made out of fear and
speculation rather than thought.
Much that is closing may never open again. The time lost to schoolchildren and university students – in debt
for courses which have simply ceased to be taught – is irrecoverable, just as the jobs which are being wiped
out will not reappear when the panic at last subsides.
We are told that we must emulate Italy or China, but there is no evidence that the flailing, despotic measures
taken in these countries reduced the incidence of coronavirus. The most basic error in science is to assume
that because B happens after A, that B was caused by A.
There may, just, be time to reconsider. I know that many of you long for some sort of coherent opposition to
be voiced. The people who are paid to be the Opposition do not seem to wish to earn their rations, so it is up
to the rest of us. I despair that so many in the commentariat and politics obediently accept what they are
being told. I have lived long enough, and travelled far enough, to know that authority is often wrong and
cannot always be trusted.
I also know that dissent at this time will bring me abuse and perhaps worse. But I am not saying this for fun,
or to be ‘contrarian’ –that stupid word which suggests that you are picking an argument for fun. This is not
fun.
This is our future, and if I did not lift my voice to speak up for it now, even if I do it quite alone, I should
consider that I was not worthy to call myself English or British, or a journalist, and that my parents’ generation
had wasted their time saving the freedom and prosperity which they handed on to me after a long and cruel
struggle whose privations and griefs we can barely imagine.
If you want to comment on Peter Hitchens, click on Comments and scroll down

March 22, 2020 Comments (363) Categories: Human Wrongs , Liberty | Permalink

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Are you not missing the point about the lack of immunity? We have immunity against flu- not against this. Without immunity the impact of spread is devastating.

Posted by: LD | 22 March 2020 at 11:42 AM

In 2008 many argued that the financial crisis should be allowed to wash through at whatever cost. The same argument could be made for the virus. I'm not sure if that is being advocated in this article.

The consequences - at my guess - would be 400,000 deaths over the next 4 months, with the majority dying untended at home, in the streets, in corridors. There would be civil unrest. Herd immunity would result.

The 'measures' are aimed at spreading the deaths, not limiting them, or not much, over 12 months.

There is a laissez-faire argument to be made. This article doesn't achieve it. Peter Hitchins was once given bad medical advice. So what?

Posted by: Paul Caister | 22 March 2020 at 11:40 AM

It is always admirable to want to save life and do the best one can for one's fellow yet not at the expense of every fellow.
The medical profession is doing the right thing in trying to find a vaccine and care for those incapacitated. In the meantime keep calm and carry on. "Don't panic Captain Mainwaring".
A humorous thought in a difficult time, yes. The current reaction is classic appeasement of the lowest common denominator which itself takes precedence over common sense. We are all going to die so face up to it. If
you have a underlying health condition then you have already had extra days of life thanks to the medical profession. Be thankful therefore that you had those extra days and let's not have the minority ruling the majority.

Posted by: Back Gammon | 22 March 2020 at 11:39 AM

Peter i salute you for writing this article and i actually think it takes some guts to write this in the current climate. but what you say is spot on.
you have an open mind that has not surrendered to the bombardment of propaganda that has been fed to the public. i always say if the mind is exposed to this often enough it starts to believe it. we are seeing signs of
George orwell's 1984 coming about.

Posted by: nick agnew | 22 March 2020 at 11:39 AM

Peter is usually correct in his comments, but this means that he will be shouted down as usual. Free speech = free thinking and we can't allow any of that.....!

Posted by: Steve | 22 March 2020 at 11:38 AM

Yes totally agree. We are trying to fight nature and we won't win. Those who have died from coronovirus would have probably died from something else and those who survive this will inevitably die from that something
else. These are facts of life. I am 66 keep fit don't smoke, drink too much, eat well and use the common sense I have gleaned from a life led. If that's not enough to survive well I've lived and am happy with my lot.

Posted by: Andrew Holmes | 22 March 2020 at 11:37 AM

 Help

JoinSign in

Timeline: The Regulations—and Regulators—That

Delayed Coronavirus Testing
There have been three major regulatory barriers so far.
Alec Stapp Mar 20 43 82

Addressing the media alongside the coronavirus task force on Thursday, Donald Trump
said he would “slash red tape like nobody has even done it before” to get approval for
coronavirus treatments.

That would be a welcome development indeed. What’s unfortunate is that there was no
similar push at the beginning of the crisis to expedite coronavirus testing. The U.S.
response to the pandemic has been hampered at every level due to insuDcient testing
capacity.

The Erst coronavirus case in the U.S. and South Korea was detected on January 21. Since
then, South Korea has eJectively contained the coronavirus without shutting down its
economy or quarantining tens of millions of people. Instead, the Korean government has
pursued a “trace, test, and treat” strategy that identiEes and isolates those infected with
the coronavirus while allowing healthy people to go about their normal lives. Hong Kong,
Singapore, and Taiwan have also managed to contain the virus via a combination of travel
restrictions, social distancing, and heightened hygiene.

Unfortunately, the United States has not made testing widely available and now various
regions are being forced to impose severe economic and social lockdowns. As of March 17,
the U.S. had tested only about 125 people per million. South Korea had tested more than
5,000 people per million. Between early February and mid-March, the U.S. lost six crucial
weeks because regulators stuck to rigid regulations instead of adapting as new information
came in. While these rules might have made sense in normal times, they proved disastrous
in a pandemic.

Under ordinary circumstances, the cost of using an imperfect diagnostic test oUen
outweighs the beneEt. But when public health oDcials need to contain a novel and highly
contagious disease, speed matters more than perfection. The lessons from this debacle are
clear: The FDA needs to have plans in place prior to a pandemic for public labs and private
companies to produce their own test kits. A distributed strategy would be much more
resilient to errors, in contrast to the single point of failure created by the FDA in this crisis.
Poor planning and mindless adherence to peacetime regulations led to this abysmal result:
Source: NYT

Source: NYT

How did the U.S. government only manage to produce a fraction as many testing kits as its
peer countries? There have been three major regulatory barriers so far to scaling up testing
by public labs and private companies: 1) obtaining an Emergency Use Authorization (EUA);
2) being certiEed to perform high-complexity testing consistent with requirements under
Clinical Laboratory Improvement Amendments (CLIA); and 3) complying with the Health
Insurance Portability and Accountability Act (HIPAA) Privacy Rule and the Common Rule
related to the protection of human research subjects. One the demand side, narrow
restrictions on who qualiEed for testing prevented the U.S. from adequately using what
capacity it did have.

It’s important to understand the broader context of the FDA regulatory process. It oUen
takes more than a decade for a new diagnostic test or therapeutic drug to earn FDA
approval. Fortunately, the FDA already has the ability to let public labs and private
companies circumvent the regular approval process under its Emergency Use
Authorization (EUA) authority. So, why was this emergency authority ineJective in scaling
up coronavirus testing? Here is a timeline of the most important events:

December 31: The WHO received reports of dozens of cases of pneumonia of unknown
cause in Wuhan City, Wubei Province, China.

January 9: China announced it has mapped the genome of the novel coronavirus.

January 21. The CDC conErmed the Erst case of coronavirus in the United States in the
state of Washington and announced it had Enalized its coronavirus testing protocol.

January 23: German researchers published the Erst paper describing a testing protocol for
the novel coronavirus. The WHO would later use this protocol as the basis for the millions
of tests it produced for less-developed countries.

January 30: The WHO declared a global health emergency.

January 31: HHS Secretary Alex Azar declared a public health emergency, which initiated a
new requirement—labs that wanted to conduct their own coronavirus tests must Erst
obtain an emergency use authorization (EUA) from the FDA. According to reporting from
Reuters, the emergency declaration made it more diDcult to expand testing outside the
CDC:

That’s because the declaration required diagnostic tests developed by individual labs,
such as those at hospitals or universities, to undergo greater scrutiny than in non-
 emergencies—presumably because the stakes are higher.

“Paradoxically, it increased regulations on diagnostics while it created an easier

pathway for vaccines and antivirals,” said Dr. Amesh Adalja, a senior scholar at the
Johns Hopkins University Center for Health Security. “There was a real foul-up with
diagnostic tests that has exposed a faw in the United States’ pandemic response plan.”

This was the moment when the wheels came oJ the bus. Keith Jerome, the lab director at
the University of Washington Virology Lab in Seattle, told The New Yorker how perverse
this heightened standard was from a public health perspective:

From the point of view of the academic labs, we look at it, like, when there’s any run-of-
the-mill virus that people are used to, they trust us to make a test. But when there’s a big
emergency and we feel like we should really do something, it gets hard. It’s a little
frustrating. We’ve got a lot of scientists and doctors and laboratory personnel who are
incredibly good at making assays. What we’re not so good at is Eguring out all the forms
and working with the bureaucracy of the federal government.

EUAs were intended to speed up the normal authorization process. But in this case, labs
that were already conducting their own coronavirus tests needed to cease operations until
they were granted an EUA. By declaring a public health emergency and not waiving EUA
requirements, the FDA was actually slowing down the testing process.

Obtaining an EUA is no quick task. The FDA requires new protocols to be validated by
testing at least Eve known positive samples from a patient or a copy of the virus genome.
Most hospital labs have not even seen coronavirus cases yet. An article in GQ magazine
detailed how Alex Greninger, an assistant director of the clinical virology laboratories at
the University of Washington Medical Center, was forced to navigate a regulatory morass:

AUer emailing his application to the FDA, Greninger discovered that it was incomplete.
It turned out that in addition to electronically Eling it, he also had to print it out and
mail a physical copy along with a copy burned onto a CD or saved to a thumb drive. That
package had to be shipped oJ to FDA headquarters in Maryland. It was a strange and
onerous requirement in 2020, but Greninger complied. He had no choice. On February
20, he overnighted the hard copies of his application to the FDA.

But submitting the physical application wasn’t the end of the process. Before granting the
EUA, the FDA wanted Greninger to run his testing protocol against the MERS and SARS
viruses:

Greninger complied. He called the CDC to inquire about getting some genetic material
from a sample of SARS. The CDC, Greninger says, politely turned him down: the genetic
material of the extremely contagious and deadly SARS virus was highly restricted.

“That’s when I thought, ‘Huh, maybe the FDA and the CDC haven’t talked about this at
all,’” Greninger told me. “I realized, Oh, wow, this is going to take a while, it’s going to
take several weeks.”

February 3: The FDA hosted a previously scheduled all-day conference at its headquarters
with regulators, researchers, and industry leaders to “discuss the general process for
putting diagnostic tests cleared under emergencies on the path to permanent approval by
the FDA,” according to reporting by Reuters. “Though coronavirus was now the hottest
topic in global medicine, a broadcast of the meeting conveyed little sense of urgency about
the epidemic sweeping the globe” and the virus was only mentioned “in passing.”

February 4: The FDA issued an emergency use authorization (EUA) for the CDC’s test to
be used at any CDC-qualiEed lab. Prior to issuing the CDC an EUA, all tests had been
collected in the Eeld and then shipped to CDC headquarters in Atlanta for analysis. During
this time period, the CDC was able to run only about 500 tests (12 of which came back
positive). To implement nationwide testing, the CDC would need to distribute its testing
kits to partner labs across the country.

In a declared emergency, the FDA has broad discretion about which laboratory-developed
tests will be permitted to be used. By only issuing a single EUA to the CDC, the FDA put
all its eggs in one basket. Alan Wells, the medical director for the University of Pittsburgh
Medical Center’s clinical laboratories, told the Wall Street Journal: “We had considered
developing a test but had been in communication with the CDC and FDA and had been
told that the federal and state authorities would be able to handle everything.”

February 5: The CDC began shipping test kits to about 100 state, city, and county public-
health laboratories across the country, which would have allowed 50,000 patients to be
tested. However, most of the partner labs ran into problems during the validation stage
(which is necessary to ensure the tests were functioning properly), according to a
ProPublica investigation:
 The [CDC] shunned the World Health Organization test guidelines used by other
countries and set out to create a more complicated test of its own that could identify a
range of similar viruses. But when it was sent to labs across the country in the Erst week
of February, it didn’t work as expected. The CDC test correctly identiEed COVID-19,
the disease caused by the virus. But in all but a handful of state labs, it falsely fagged the
presence of the other viruses in harmless samples.

The speciEc cause of these problems is still under investigation, but the initial Endings
suggest there were problems with one or more of the reagents used in the CDC testing kits.
The CDC paused testing at its partner labs and resumed exclusive — and very limited —
testing at its Atlanta headquarters.

February 10: The CDC notiEed the FDA about the reagent problems in the testing kits it
had shipped to its partner labs. By not allowing private companies or public labs to use
their own tests, the FDA had created a single point of failure and ultimately delayed large-
scale testing by weeks. Keith Jerome, the lab director at the University of Washington,
explained to The New Yorker why the FDA’s plan was vulnerable from the outset:

The FDA’s exclusive authorization to the CDC to conduct COVID-19 tests ended up
creating “what you’d think of as an agriculture monoculture. If something went wrong,
it was going to shut everything down, and that’s what happened.” Jerome said that his
lab has taken its own steps to mitigate this problem. “We’ve built three completely
independent testing pathways in our laboratory, so that if there’s a shortage of a reagent
or a bit of plastic, we have other ways to do the testing.”

February 21: Nancy Messonnier, the director of the National Center for Immunization and
Respiratory Diseases (NCIRD) at the CDC, told journalists that the issues with the reagents
were still not resolved.

February 24: An association of more than 100 state and local health laboratories sent a
letter to the FDA commissioner asking for “enforcement discretion” to use their own lab-
developed tests. The chief executive of the association that sent the letter called it a “Hail
Mary” pass and an act of desperation. The FDA directed the labs to submit an EUA
application instead.

Between mid-January and February 28, the CDC produced more than 160,000 tests but used
fewer than 4,000.
February 29: Facing a backlash to its rollout of testing, the FDA reversed its position and
removed the requirement that advanced laboratories obtain prior emergency use
authorization before using their own tests. At the time, this exemption applied only to
“laboratories that are certiEed to perform high-complexity testing consistent with
requirements under Clinical Laboratory Improvement Amendments.” One researcher
estimated 5,000 virology labs in the country met this standard. For context, U.S. testing
capacity includes approximately 260,000 laboratory entities.

March 3: Vice President Pence announced the CDC was liUing all federal restrictions on
who can be tested for COVID-19: “Any American can be tested, no restrictions, subject to
doctor’s orders.” Previously, testing was limited to only those who were exhibiting
symptoms and had recently traveled to China or had been exposed to a known case.
However, the supply of tests in particular regions would continue to be the most common
binding constraint.

March 12: The FDA issued an EUA to Roche. Paul Brown, the head of Roche’s Molecular
Solutions division, told The New Yorker, that “the company had been working on a test
since February 1st” and that “the new tests, which are mostly automated, can make it
possible for large testing companies such as Quest and LabCorp to test for COVID-19.”
The CDC and state and local public health labs have been running tests manually.
Reaching the scale of millions of tests will require automated tests on high throughput
machines at large testing companies.

March 13: President Trump declared a national emergency. The FDA issued an EUA to
Thermo Fisher.

March 15: HHS Secretary Azar waived sanctions and penalties against any covered hospital
that does not comply with various provisions of the HIPAA Privacy Rule related to patient
privacy and consent, including the need “to obtain a patient’s agreement to speak with
family members or friends involved in the patient’s care.” Previously, HIPAA privacy
provisions and the Common Rule were holding up testing and the dissemination of
information. According to an article in the New York Times, these kinds of requirements
prevented labs from conducting coronavirus tests on samples collected for research
purposes:

Federal and state oDcials said the fu study could not be repurposed because it did not
 have explicit permission from research subjects; the labs were also not certiEed for
clinical work. While acknowledging the ethical questions, Dr. Chu and others argued
there should be more fexibility in an emergency during which so many lives could be
lost. On Monday night, state regulators told them to stop testing altogether.

...

On a phone call the day aUer the C.D.C. and F.D.A. had told Dr. Chu to stop, oDcials
relented, but only partially, the researchers recalled. They would allow the study’s
laboratories to test cases and report the results only in future samples. They would need
to use a new consent form that explicitly mentioned that results of the coronavirus tests
might be shared with the local health department.

They were not to test the thousands of samples that had already been collected.

March 16: The FDA expanded the EUA exemption to all commercial manufacturers and
labs using new commercially developed tests, not just those that are certiEed to perform
high-complexity testing under CLIA. The FDA also devolved regulatory oversight of these
labs to the states. Wojtek Kopczuk, a professor of economics at Columbia University,
quipped that the “FDA sped up the process by removing itself from the process.” The FDA
also issued EUAs to Hologic and LabCorp. Co-Diagnostics, a molecular diagnostics
company based in Utah, already had a test available in Europe and claimed it could supply
50,000 coronavirus tests per day going forward under the new FDA exemption. On Monday,
government oDcials announced they were going to set up more drive-through testing
centers. By the end of the week, they said they expect to have 1.9 million tests available
thanks to high throughput automated machines at commercial labs.

Lessons learned.
In her call with reporters on February 21, Nancy Messonnier, who runs the CDC’s research
on immunization and respiratory diseases, said: “We are working with the FDA, who have
oversight over us, under the EUA, on redoing some of the kits. We obviously would not
want to use anything but the most perfect possible kits, since we’re making determinations
about whether people have COVID-19 or not.” This mentality is understandable coming
from a regulator under ordinary circumstances. In normal times, and with non-highly
contagious diseases, many of these regulations related to testing make sense. However,
during a global pandemic, the risk calculus shiUs. As Dr. Mike Ryan, executive director of
the WHO's health emergencies program, said in a press conference last week, when
battling a new virus, “speed trumps perfection.”

The FDA did the right thing when it expanded the EUA exemption to all labs and
manufacturers and devolved regulatory oversight to the states. The Department of Health
and Human Services did the right thing when it waived certain provisions of the HIPAA
Privacy Rule. But all of these actions were six weeks too late. Policymakers should consider
implementing an automatic trigger so these decisions are made immediately upon the
declaration of a public health emergency. COVID-19 will not be the last public health
emergency. Speed, not perfection must be the focus of government agencies who are
entrusted to protect the health of hundreds of millions of Americans. A distributed
approach would be much more resilient to the inevitable mistakes and accidents inherent
to pandemic response. Instead, in this crisis, the FDA bet big on a single testing protocol
from the CDC and burned its ships. And when the “perfect” test failed spectacularly,
everyone was leU wishing for a way to retreat.

Alec Stapp is the director of technology policy at the Progressive Policy Institute.

Photograph by Al Drago/CQ-Roll Call/Getty Images.

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Todd Baker Mar 20

When will the peddlers of bureaucracy finally realize that they are a very large part of the
problem? The motivations and ingenuity of the private sector and their nimble response are
what keep this country moving forward, often in spite of the technocrats that think they know
better. I saw a tweet from Sanders laying all of this at the feet of the greedy medical industry.
His willful ignorance from a position of "authority" is downright criminal.....and, unfortunately,
he is not alone.
7 Reply
Bronte Capital
The sometimes eccentric views of John Hempton

Thursday, March 19, 2020

Coronavirus – getting angry

I am going to give you a few stylised facts about severe acute respiratory syndrome coronavirus
2 and the data.

First – no matter what you say about the Chinese data – and the Chinese data was full of lies at
first – China has controlled the outbreak. Shanghai, Beijing, Chongqing are all functional mega-
cities with no obvious health catastrophes.
The virus has been managed to very low infection rates in Singapore and Taiwan. The numbers
(completely real) in Korea show a dramatic slowdown in infection.

Korea has not shut restaurants and the like. The place is functioning. But it has had rigorous
quarantine of the infected and very widespread testing. It has complete social buy-in.
China tests your temperature when you get on a bus or a train. It tests you when you go into a
classroom, it tests you when you enter a building. There is rigorous and enforced quarantine.

But life goes on – and only a few are dying.

In Singapore nobody has died (yet) though I expect a handful to do so before this over. This is
sad (especially for the affected families) but it is not a mega-catastrophe.
There is a story in the Financial Times about a town in the middle of the hot-zone in Italy where
they have enforced quarantine and tested everyone in the town twice. They have no cases.
The second stylized fact – mortality differs by availability of hospital beds
A. Coronavirus provided you do not run out of hospital beds probably has a mortality of
about 1 percent. In a population that is very old (such as some areas in Italy) the mortality
will be higher. In a population that is very young base mortality should be lower. Also co-
morbidities such as smoking matter.
B. If you run out of ICU beds (ventilators/forced oxygen) every incremental person who
needs a ventilator dies. This probably takes your mortality to two percent.
C. Beyond that a lot of people get a pneumonia that would benefit from supplemental
oxygen. If you run out of hospital beds many of these people also die. Your mortality edges
higher - but the only working case we have is Iran and you can't trust their data. That said
a lot of young people require supplementary oxygen and will die. If you are 40 and you
think this does not apply to you then you are wrong. Mass infection may kill you. Iran has
said that 15 percent of their dead are below 40.

I will put this in an American perspective with a 70 percent strike rate by the end.
 Option A: 2 million dead

Option B: 4 million dead

Option C: maybe 6 million dead.

By contrast, Singapore: a handful of dead.

China has demonstrated this virus can be controlled. The town in Italy has demonstrated it can be
controlled even where it is rife.

Life goes on in Singapore. Schools are open. Restaurants are open in Korea.

The right policy is not “herd immunity” or even “flattening the curve”. The right policy is to try to
eliminate as many cases as possible and to strictly control and test to keep cases to a bare
minimum for maybe 18 months while a vaccine is produced.
The alternative is literally millions of people dying completely unnecessarily.

What is required is a very sharp lockdown to get Ro well below one – and put the virus into
exponential decay.

When the numbers are low enough – say six weeks – you let the quarantine off – but with Asian
style monitoring. Everyone has their temperature measured regularly. Quarantine is rigid and
enforced. You hand your phone over if you are infected and your travel routes and your contacts
are bureaucratically reconstructed (as is done in Singapore). And we get through.
And in a while the scientists save us with a vaccine.
The economic costs will be much lower. Indeed life in three months will be approximately normal.

The social costs will be much lower.

Every crisis has its underlying source. And you want to throw as much resources (and then some)
close to the source. Everything else is peripheral.

The last crisis was a monetary crisis and it had a monetary solution.
This is a virus crisis and it has a virology solution.

Asian Governments are not inherently superior to ours – but they have done a much better job of
it than ours. The end death toll in China (probably much higher than stated) will wind up much
smaller than the Western death tolls. I do not understand our idiocy.

John
Who Got the Coronavirus Right?
Lessons From the People Who Were Right About the Latest
Global Crisis

Michael Tauberg Follow

Mar 21 · 5 min read

Photo by CDC on Unsplash

 Call it what you want, coronavirus, COVID-19, the “China” virus. No
matter the name, this viral pandemic represents the biggest global
event since 2008. In that great calamity, many modern-day
Cassandras made their name by being early to warn us. It got me
wondering, who got this crisis right? That is, who called it early and
is likely to see their credibility rise after this is all over. I have a few
ideas.
Read more stories this month when you create a free Medium account.

sonya, supposedly @sonyasupposedly · Mar 14, 2020

this coronavirus thing, like the 2008 financial crisis or Trump getting
elected, will lead to many personal epistemic wakeups. these
epistemic wakeups will 1) all rhyme in their anti-establishment
nature, 2) fracture and/or coalesce into handful of factions,
probably evolving out

Michael Tauberg
@MichaelTauberg

The financial crisis made many famous. Taleb, Roubini, michael

Lewis, Felix salmon etc. Any nominations for who wins big post-
corona?
2 8:51 PM - Mar 14, 2020

Scientists
The unsung heroes of any pandemic are undoubtedly the doctors and
scientists who Jght to understand the threat. There are many who
have warned for years about the kind of global shutdown that we are
experiencing. For my money though, the one who has communicated
the most clearly before and during this event is Scott Gottlieb.

Gottlieb has been consistent in his warnings, even as others were too
sanguine about this pandemic. Here he is on Face the Nation on
March 1, warning anyone that would listen about how grave the
virus threat is.

Conflits
@Conflits_FR

Epidémie de #coronavirus : "il pourrait y avoir plusieurs

centaines voire quelques milliers" de personnes infectées par le
#COVID2019 aux Etats-Unis, d'après @ScottGottliebMD. (CBS)
#CoronaVirusUpdate #USA

254 1:44 PM - Mar 1, 2020

Beyond communicating with the public, Gottlieb has also ampliJed

other scientiJc voices, even starting an online tracker to share lab
testing capacity with the public. This sort of constructive activity to
stop the virus is what makes scientists like Gottlieb the front line in
this war. Others like Sue Hellmann and Liz Specht have also been
amazing at both Jghting the virus and communicating their eTorts.
Investors
One surprise of this pandemic has been the prescience of silicon
valley VCs. Back in February, they were being mocked for avoiding
handshakes and wearing masks to work. Since then it’s been clear
that startup investors were one of the few groups who understood
the power exponential growth.

While Paul Graham, Sam Altman, Dave McClure, Naval Ravikant,

and other silicon valley legends were all early in warning about the
pandemic, there is one investor who stands above the others. For
months Balaji S. Srinivasan has been screaming from the rooftops
about this threat. Here he is in mid February warning that the
conditional probability of full-blown contagion was much higher
than most expected.

Balaji Srinivasan and Patrick Stanley chat COVID-19

Since then, his Twitter account has been bookmarked by any good
coronavirus obsessive. Every day he shares the latest scientiJc
information, as well as lessons that can be learned from other
countries that have successfully battled COVID-19.

Journalists
As in 2008, journalists largely failed to warn the public about this
crisis. For the most part, the big news outlets don’t like to challenging
institutional power, especially respected names like the FDA and CDC
(both were slow to ramp up testing). However, there are some major
exceptions.

Alexis Madrigal and the Atlantic staT have done a great job of taking
this catastrophe seriously, even in its early stages. Like most of us,
Madrigal somewhat underestimated the virus in his early January
columns. Since then, he has been a vital source of news about
pandemic. More importantly, he started the COVID19 Tracking
Project to collect reliable testing data across the United States. This
project scrapes state and local testing websites and compiles the
results in to a central database, re`ecting the true state of the
epidemic in the US. Where federal data on testing has been lacking,
this news source has been crucially important.

Other journalists who has proved indispensable during this crisis are
more surprising. Now long past his annoying bowtie days, Tucker
Carlson has emerged as one of the few sane voices in cable news.
Thankfully he also seems to have the ear of the president. This recent
story from Vanity Fair describes how Carlson `ew to Mar-a-Lago on
March 7 to personally impress on the president the seriousness of the
virus. A week later Trump had totally changed his messaging around
the crisis and had encouraged the entire nation to stay at home. Not
many will want to admit it, but I think Carlson is responsible for
saving many, many lives.

Politicians
The behavior of politicians during this pandemic has ranged from
unhelpful to downright treasonous. Still, not all Senators were
secretly dumping stock after being privately warned about
Coronavirus. Some like Senator Josh Hawley of Missouri have been
sounding the alarm for months.

Josh Hawley
@HawleyMO

It’s time for Senate hearings to find out how we allowed our
critical medical supply chains for antibiotics & other vital drugs to
become so dependent on #China & threatened now by
#coronavirus axios.com/coronavirus-th…

Coronavirus threatens shortages of about 150 prescription dr…

 Coronavirus threatens shortages of about 150 prescription dr…
China is a huge supplier of the ingredients used in many drugs.
axios.com

2,753 1:13 PM - Feb 23, 2020

After raising warnings about the fragility of our medical supply

chain, Hawley introduced legislation to reduce our dependence on
foreign nations for key medical supplies. In Senator Hawley, we see a
new breed of right-wing politician. Both a populist and nationalist,
Hawley supports massive federal aid to workers while pursuing
antitrust action against large corporations like Google. Just as
Alexandria Ocasio-Cortez rose to prominence on the back of the
Trump election, I expect to see senator Hawley’s star rise in the
aftermath of this crisis.

Academics
Many have criticized the decline of American academia, exempliJed
most by skyrocketing costs and aging administrators. Nevertheless,
there are still many beacons of wisdom and sanity in the ivory tower.
Nicholas Christakis has been one of the most persuasive people to
warn about the dangers of COVID-19. Every day for weeks,
Christakis has been tweeting the latest information about the virus
and urging essential measures like school closing and social
distancing. With a large online following, Chistakis is a bonaJde
member of “intellectual dark web”, having credibility with both
mainstream and fringe audiences. He has used that in`uence for
tremendous good.
Others
Mike Cernovich is not widely accepted as a journalists by
mainstream outlets. Despite helping to break the JeTrey Epstein
story (among others), Cernovich is regularly labelled a simple
“blogger”. Regardless of his proper title, Cernovich was early to alert
his half-million twitter followers of the need to prepare for the
consequences of the virus. In the time since, he has been a useful
source of news on the topic, especially for people who no longer trust
old-school news gatekeepers.

There are many other private individuals who defy easy description,
yet who have been consistently correct about the course of the
coronavirus. Among these, the most prominent is probably Nassim
Nicholas Taleb. Taleb has the rare honor of being correct both in
2008 and now in 2020. One could easily say that an expert on “Black
Swan” events is always prophesying doom. Still, I think that misses
the point. Taleb’s key insight is that the tails of real-life probability
distributions are much fatter than we realize. These catastrophic
events are more likely than we assume and so we must act with an
abundance of caution. His focus on the precautionary principle has
never been more explicitly mirrored in real life than now, with
society almost completely shut down. I don’t know when this
pandemic will end, but I’ll bet that copies of Taleb’s Incerto books
will sell better than ever when it’s over.

Final Thoughts
In my experience, crises closely follow the Kubler-Ross stages of
grief. We have already passed through denial and anger, and are now
moving through depression and perhaps bargaining. Once the
pandemic begins to recede, and we enter the acceptance phase, we’ll
look back at who was right and who was able to guide us wisely. I’ve
proposed a few names that might become more prominent after this
crisis, and I’m interesting in knowing who I’ve missed (feel free to
add them in the comments). One thing is certain, careers are made
in a catastrophe. Let’s hope this one doesn’t go to waste.

News Media Twitter Social Media Economics

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About Help Legal

https://watermark.silverchair.com/taaa036.pdf?
token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAA

Correlation between travellers departing from Wuhan before the Spring Festival and

subsequent spread of COVID-19 to all provinces in China

Ping Zhong MD1 * &, Songxue Guo MD2 &, Ting Chen MD3 &

1 BE and Phase I Clinical Trial Center, The First Affiliated Hospital of Xiamen University,

Downloaded from https://academic.oup.com/jtm/advance-article-abstract/doi/10.1093/jtm/taaa036/5808004 by guest on 22 March 2020

Xiamen, China.

2 Department of Plastic Surgery, The Second Affiliated Hospital Zhejiang University

School of Medicine, Hangzhou, China.

3 Department of Medical Examination and Blood Donation, Xiamen Blood Center,

Xiamen, China.

& The authors contributed equally to this work

Corresponding author:

Ping Zhong *

BE and Phase I Clinical Trial Center, The First Affiliated Hospital of Xiamen University,

NO.11 Hongdi Road, Xiamen, Fujian, 361022, People's Republic of China.

Email: jgszp2004@163.com

ORCID iD: https://orcid.org/0000-0002-4415-2992

Highlight:

We found a strong correlation between travel volumes departing from Wuhan, Hubei

Province before the Spring Festival and the extent of amplification of the outbreak of

COVID-19 in China in 2020, with 100 top cities. Almost 70% of exportations were within

Downloaded from https://academic.oup.com/jtm/advance-article-abstract/doi/10.1093/jtm/taaa036/5808004 by guest on 22 March 2020

cities in Hubei province.

Keywords Coronavirus; Public health emergency of international concern; 2019-nCov;

Migration; Containment; Quarantine; Travel

In December 2019, a cluster of pneumonia, now known as COVID-19, was reported in

Wuhan, Hubei Province, in the central part of China. As of 9 March 2020, more than

80,700 COVID-19 cases have been reported in China. Wuhan was the epicentre. Wuhan

is the capital city of Hubei Province, and is one of the well-developed cities in China.

Wuhan is also a major transportation hub in China, as it is located on the crossroads

between the railway line linking Beijing and Guangzhou and the Yangtze River linking

Chongqing and Shanghai. In response to the rapid spread within Hubei Province and

exportations to other countries1, the Chinese government implemented a lock-down of

Wuhan on 24 January, 2020, the day before Spring Festival. Population movement is

high during Spring Festival with about 2.97 billion passengers travelling during the

Spring Festival in 2019.2 As Wuhan is a major transportation hub in China, it is

estimated that about five million people left the city during the Spring Festival travel

rush before Jan 24, 2020. The aim of this essay is to explore the correlation between

travellers departing from Wuhan before the Spring Festival and the extent of

amplification of the outbreak of COVID-19 in China.

The data referring to population mobility were collected from the Baidu Migration

database (http://qianxi.baidu.com/), which is a non-profit project aimed to provide data

on population mobility during the Chinese Spring Festival rush. The database is able to

provide the overall proportion of travellers departing from one city during a certain

period. According to the instructions of the database, the proportion of travellers

Downloaded from https://academic.oup.com/jtm/advance-article-abstract/doi/10.1093/jtm/taaa036/5808004 by guest on 22 March 2020

departing from Wuhan to one city is calculated by n 1/n2, where n1 is defined as the

number of travellers departing from Wuhan to one selected city during a certain period

and n2 is the total number of travellers departing from Wuhan during a certain period.

For instance, the proportion of travellers departing from Wuhan to Beijing was 1%, if

the number of travellers departing from Wuhan to Beijing was 50, 000 during a certain

period and the total number of travellers departing from Wuhan was 5 million during

the same period. We extracted data between Jan 10, 2020 and Jan 24, 2020, on travellers

departing from Wuhan to other cities and calculated the proportions of travellers

departing from Wuhan to the top 100 cities in China.

All confirmed cases of COVID-19 and persons recovered from COVID-19 in the top 100

cities were aggregated from official announcements by searching the publicly available

sources. The deadline was at 11:59 p.m. Feb 11, 2020 (China standard time, CST).

According to the official announcements, all cases were applied with the same diagnostic

criteria based on the recommendation by the National Health Commission of China

(http://www.nhc.gov.cn/). No ethical approval was needed for this study. The

proportion of cases in a destination city was calculated by m 1/m2, where m1 is the

number of confirmed cases found in one selected city and m 2 is that found in China

outside of Wuhan. The recovery rate in each city was also recorded. Furthermore,

considering several socioeconomic factors had a potential impact in the spreading of

COVID-19, population, population density, regional income, and level of health care in

the top 100 cities were extracted from the National Bureau of Statistics of China

(http://data.stats.gov.cn/).
We used an analysis of correlation to evaluate the associations between the proportion

of travellers departing from Wuhan and four indexes of the extent of amplification of the

outbreak of COVID-19 in the top 100 cities. The proportions of travellers departing from

Downloaded from https://academic.oup.com/jtm/advance-article-abstract/doi/10.1093/jtm/taaa036/5808004 by guest on 22 March 2020

Wuhan in the top 100 cities were not normally distributed. Thus, a Spearman

correlation analysis was applied. Besides, the correlations between the socioeconomic

factors and two indexes of the extent of amplification of the outbreak of COVID-19 were

analyzed. In addition, we did the scatter plots and the regression curves. Considering the

health system for COVID-19 in Hubei Province differs from that in other areas and the

results may depend on data quality of district health systems, a subgroup analysis

according the district health systems was performed. The data were analyzed by SPSS

statistic 22.0 (SPSS Inc., Illinois, Chicago, USA). All statistical significance was defined as

P<0.05.

COVID-19 cases in top 100 cities in China

Up to Feb 11, 2020, 44, 653 confirmed COVID-19 infections in China mainland with a

total of 4740 recovered cases. Of these, a total of 25095 confirmed cases were reported

in China outside of Wuhan. The top 100 cities are located in four municipalities (i.e.

Beijing, Shanghai, Chongqing, Tianjin) and 16 provinces or autonomous regions in China.

Overall, a total of 21807 cases (86.9%) were reported in the selected top 100 cities with

13798 cases (54.98%) in 15 cities in Hubei Province. There are 15 cities except Wuhan

in Hubei Province. The hot spots of COVID-19 cases were the other 15 cities in Hubei
province and the cities in neighboring provinces including Henan, Hunan, Jiangxi, and

Anhui. Meanwhile, several well-developed areas, such as Beijing, Shanghai, Guangdong

Province, and Zhejiang Province also showed a high proportion of COVID-19 cases.

Downloaded from https://academic.oup.com/jtm/advance-article-abstract/doi/10.1093/jtm/taaa036/5808004 by guest on 22 March 2020

Comparisons between proportions of travellers departing from Wuhan and

proportions of cases in the top 100 cities in China

Figure 1A shows the comparison between the proportions of travellers departing from

Wuhan and proportions of cases in the selected top 100 cities in China. Between Jan 10,

2020 and Jan 24, 2020, 91.68% of all travellers departing from Wuhan travelled to the

top 100 cities, with 69.34% of them to other 15 cities in Hubei province. The areas with

a high proportion of travellers departing from Wuhan were correlated with a high

proportion of COVID-19 cases. Compared to the proportion of travellers departing from

Wuhan, most areas showed a lower proportion of cases. However, several

well-developed areas, such as Zhejiang Province, Guangdong Province, Shanghai, and

Beijing, showed a significantly higher proportion of cases compared to the proportion of

travellers departing from Wuhan. Meanwhile, the population mobility departing from

Wuhan before the Spring Festival in 2020 (yellow) and 2019 (white) is shown in Fig. 1B

(provided by Baidu Migration). Our data may be an underestimation as not all cases are

identified or are paucisymptomatic.3

Correlation between the proportion of travellers departing from Wuhan and four

potential risk factors in the top 100 cities

We did not find a correlation between number of cases and the population density (P =

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0.643), regional income (P = 0.617), or level of health care (P = 0.244). Meanwhile, there

were no correlations between recovery rate and the population (P = 0.926), population

density (P = 0.680), regional income (P = 0.073), or level of health care (P = 0.063).

There was a strong positive correlation between the proportion of travellers departing

from Wuhan and the number of cases (Spearman’s r = 0.773, P = 0.000, Fig. 2A) or the

proportion of cases (Spearman’s r = 0.773, P = 0.000, Fig. 2B) in the top 100 cities. In

addition, a strong positive correlation was also observed between the proportion of

travellers departing from Wuhan and the number of the recovered cases (Spearman’s r

= 0.704, P = 0.000, Fig. 2C). Conversely, the correlation between the proportion of

travellers departing from Wuhan and the recovery rate was negative in the top 100

cities (Spearman’s r = -0.209, P = 0.037, Fig. 2D). The correlation between the

proportion of travellers and the number of cases was positive, both in the subgroup of

cities outside Hubei (r = 0.553, P = 0.000) and in the subgroup of cities in Hubei (r =

0.930, P = 0.000).

Conclusions

The main destination cities of travellers departing from Wuhan before the Spring

Festival were other cities (n = 15) within Hubei province and the cities (n = 40) in the
neighboring provinces. We found a strong correlation between travellers departing from

Wuhan before the Spring Festival and the extent of amplification of the outbreak of

COVID-19 in China.

The timing of the outbreak before the Spring Festival, and the transportation hub

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located in Wuhan accelerated the spread of COVID-19. Our results indicated that 69.34%

of travellers departing from Wuhan travelled to other cities in Hubei Province. These

areas also reported the largest number of cases, with a proportion of 54.98%. Travellers

departing from Wuhan before the Spring Festival were the main infection source for

other cities in China.

.
Author statements

Authors' contributions

PZ conceived and designed the research; SG and TC performed the research; Data were

analyzed by PZ and TC. PZ and SG drafted the manuscript; PZ initiated and organized

this study. All authors reviewed and edited the manuscript and approved the final

version of the manuscript.

Funding

This work was supported by the following grants: National Natural Science Foundation

of China (NSFC) Grants 81671909, 81901958 and Zhejiang Provincial Natural Science

Foundation of China Grants: LY18H150004, LY19H150004, LY20H150010.

Conflicts of interest

The authors have declared no conflicts of interest.

References

1. Bogoch, II, Watts A, Thomas-Bachli A, Huber C, Kraemer MUG, Khan K. Potential

for global spread of a novel coronavirus from China. J Travel Med 2020.
2. Hu M. Visualizing the largest annual human migration during the Spring Festival
travel season in China. Environment and Planning A: Economy and Space; 2019:
1618-21.

Downloaded from https://academic.oup.com/jtm/advance-article-abstract/doi/10.1093/jtm/taaa036/5808004 by guest on 22 March 2020

3. Zhao S, Musa SS, Lin Q, et al. Estimating the Unreported Number of Novel
Coronavirus (2019-nCoV) Cases in China in the First Half of January 2020: A
Data-Driven Modelling Analysis of the Early Outbreak. J Clin Med 2020; 9(2).
Figure legends

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Figure 1 Comparison between proportions of travellers departing from Wuhan and

proportions of cases in the top 100 cities in China.

The areas with a high proportion of travellers departing from Wuhan (blue) also

companied with a high proportion of COVID-19 cases (red) (Fig. 1A). The travellers

departing from Wuhan before the Spring Festival (Jan 25) were far more than those

after the Spring Festival in 2020 (yellow) and 2019 (white) (Fig.1B).
 Downloaded from https://academic.oup.com/jtm/advance-article-abstract/doi/10.1093/jtm/taaa036/5808004 by guest on 22 March 2020
Figure 2 Scatter plots of the proportions of travellers departing from Wuhan and four

indexes of the extent of amplification of the outbreak of COVID-19 in the top 100 cities.
https://watermark.silverchair.com/taaa042.pdf?
Journal of Travel Medicine 1

Routes for COVID-19 importation in Brazil

Running title: COVID-19 importation in Brazil

Darlan Da S Candido, MSc1, Alexander Watts, PhD 2,3, Leandro Abade, DPhil 1, Moritz UG

Kraemer, DPhil 1,4,5, Prof Oliver G Pybus, DPhil 1,6, Prof Julio Croda, MD, PhD 7,8,9,

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Wanderson de Oliveira, PhD 7, Kamran Khan, MD, MPH 2,3, Prof Ester C Sabino, PhD 10,

Prof Nuno R Faria, PhD1,10

1. Department of Zoology, University of Oxford, United Kingdom.

2. Li Ka Shing Knowledge Institute, St. Michael s Hospital, Toronto, Canada.

3. Department of Medicine, Division of Infectious Diseases, University of Toronto, Canada.

4. Harvard Medical School, Harvard University, Boston, United States.

5. Computational Epidemiolog Group, Boston Children s Hospital, Boston, United States.

6. Department of Pathobiology and Population Sciences, The Royal Veterinary College,

London, United Kingdom.

7. Secretaria de Vigilância em Saúde, Coordenação Geral de Laboratórios de Saúde Pública,

Ministério da Saúde, Brasília-DF, Brazil.

8. Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados,

Dourados, Mato Grosso do Sul, Brazil.

9. Fundação Osvaldo Cruz Campo Grande, Mato Grosso do Sul, Brazil.

10. Instituto Medicina Tropical, University of São Paulo, Brazil.

This work was supported by a Medical Research Council and FAPESP CADDE partnership
award (MR/S0195/1) and a John Fell Research Fund (grant 005166). NRF is supported by a
Sir Henry Dale Fellowship (204311/Z/16/Z). DDSC is supported by the Clarendon Fund and
by the Oxford University Zoology Department.

Correspondence to Nuno Rodrigues Faria (nuno.faria@zoo.ox.ac.uk)

 2

Highlight

The global outbreak caused by the severe acute respiratory syndrome coronavirus-2 (SARS-

CoV-2) has been declared a pandemic by the WHO. As the number of imported SARS-CoV-

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2 cases is on the rise in Brazil, we use incidence and historical air travel data to estimate the

most important routes of importation into the country.

Main Text

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) was first detected in Wuhan,

Hubei province, China, on December 8th 2019. SARS-CoV-2 infection can cause coronavirus

disease (COVID-19) and can lead to acute respiratory syndrome, hospitalization and death.1

As of the 12th March 2020, the global SARS-CoV-2 outbreak has been declared a pandemic,

with 125,048 cases and 4,613 deaths have been notified by the World Health Organization

(WHO) in 117 countries/territories or areas worldwide (who.int/emergencies/diseases/novel-

coronavirus-2019/situation-reports). The first case in Latin America was confirmed on

February 26, 2020, in the São Paulo metropolis, the most populous city in the Southern

hemisphere (~11 million people Instituto Brasileiro de Geografia e Estatística,

www.ibge.gov.br). Self-declared travel history and subsequent genetic analyses confirmed

that this infection was acquired via importation of the virus from Northern Italy2. Since then

Brazil has reported the largest number of cases in Latin America (n=34, as of March 10,

2020). SARS-CoV-2 has been now detected in 7 (26%) of the 27 federal states of Brazil. So

far, transmission of SARS-CoV-2 appears to be primarily sporadic (85.3%, 29/34 are

imported cases). Here, we analyse data on airline travellers to Brazil in 2019, who departed

from countries that had reported local cases of COVID-19 transmission by March 5th 2020.

2
 Journal of Travel Medicine 3

This information provides insights into which Brazilian cities are most at risk for SARS-

CoV-2 importation.

We used travel data on all air journeys that had a Brazilian city as their final destination

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during February and March 2019 as a proxy for flight density during the 2020 COVID-2019

outbreak (see Supplementary Material). We focused on the data for 29 countries that had

reported SARS-CoV-2 cases by 5th March 2020. We collated the total number of passengers

flying to any Brazilian airport during this period, country population size for 2019 from the

United Nations World Population Prospects 2019 database, and the WHO-reported number

of COVID-19 cases (as of March 5th, 2020). We used these values to estimate the proportion

of infected travellers potentially arriving in Brazilian cities from each country and for each

route (additional information can be found in Supplementary Material). No air passenger data

from Iran to Brazil was available for our analysis.

Between February and March 2019, Brazil received 841,302 international passengers in a

total of 84 cities across the country (Figure 1). São Paulo, the largest city in the country, was

the final destination of nearly half (46.1%) of the passengers arriving to Brazil, followed by

Rio de Janeiro (21%) and Belo Horizonte (4.1%). More than half of the international

passengers started they journey in the USA (50.8%) followed by France (7.9%) and Italy

(7.5%). The air-travel routes to airports in Brazil with most passengers were USA-São Paulo

(23.3%), USA-Rio de Janeiro (9.8%) and Italy-São Paulo (3.4%).

 4

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Figure 1. Potential for COVID-19 importation to Brazil. A) Map of Brazilian federal states

and Federal District coloured according to COVID-19 notification status (as of March 10,

2020). Circles correspond to the estimated proportion of arrivals from the top 29 destinations

(except Iran) that had reported local COVID-19 by 5th March 2020. B) Percentage of

passengers for the top-20 routes to Brazilian airports from countries that had reported

COVID-19 cases by the 5th March 2020. C) Estimated percentage of importations for the top-

20 routes from countries that had reported local COVID-19 by the 5th March 2020.

To better understand the potential for SARS-CoV-2 introductions to Brazil, we estimate the

relative risk of COVID-19 introduction to Brazilian cities by taking into account SARS-CoV-

2 incidence per international traveller arriving at an airport in Brazil. We estimate that 54.8%

of all imported cases would be expected to come from travellers infected in Italy, 9.3% and

8.3% of the cases would be from travellers infected in China and France, respectively. The

route Italy-São Paulo was estimated to comprise 24.9% of total infected travellers travelling

4
 Journal of Travel Medicine 5

to Brazil during this period. Moreover, we estimate that Italy has been the source location for

five of the top 10 most importation routes for infected travellers into Brazil based on the

current epidemiological scenario (Supplementary Information). Consistent with this, at least

48% (n=14/29) of the reported imported cases in Brazil have a history of travelling to Italy

prior to onset of symptoms, as of 9th March 2020. Six (23.1%) of the confirmed cases that

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acquired the virus in Italy have been identified in São Paulo (Supplementary Information).

We find that the proportion of estimated imported cases by airport of destination is highly

correlated with the proportion of detected imported cases. Our study has several limitations.

Unfortunately, data from Iran was not available for this analysis. Moreover, our analysis

relies on incidence data, and thus the risk of importation will follow changes in epidemic

sizes at source locations. In fact, with the reduction in the number of flights leaving from

Italy and 51% of flights to Brazil depart from airports in the USA, we should anticipate for an

increasing proportion of infected travellers arriving from the USA. Moreover, the estimated

risk of importation from China is likely an overestimate as recent measures have extensively

decreased the flights to Brazil.

At a time when the number of SARS-CoV-2 cases are steadily growing in Brazil, our

findings highlight the high potential for the introduction of new cases in several cities of

Brazil, especially in Sao Paulo and Rio de Janeiro metropolises. Rapid identification of

locations where clusters of local transmission might first ignite is critical to better coordinate

preparedness, readiness and response actions.3,4 There is critical need for epidemiological,

human mobility and genetic data5 to understand virus transmission dynamics at local,

regional and global scales. Continued integration of these data streams should help guide

deployment of resources to mitigate COVID-19 transmission.

 6

Authors Statements

KK is the founder of BlueDot, a social enterprise that develops digital technologies for public

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health. KK and AW are employed at BlueDot. DSC, LA, MK, WO, JC, ECS, OGP, NRF

have no conflicts of interest to declare.

Authors Contributions

DSC, LA, NRF conceived the idea and wrote the manuscript. DSC, LA, NRF, KK, AW

conducted data analysis. DSC, NRF, LA, MUGK, WO, JC, ECS, OGP, AW, KK interpreted

data and contributed to writing.

Funding

This work was supported by a Medical Research Council and Fundação de Amparo à

Pesquisa do Estado de São Paulo CADDE partnership award (MR/S0195/1) and a John Fell

Research Fund (grant 005166). NRF is supported by a Sir Henry Dale Fellowship

(204311/Z/16/Z). DDSC is supported by the Clarendon Fund and by the Oxford University

Zoology Department.

References

1 Zhu, N. et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019.

The New England Journal of Medicine 382, 727-733, doi:10.1056/NEJMoa2001017

(2020).

6
 Journal of Travel Medicine 7

2 de Jesus JG et al. First cases of coronavirus disease (COVID-19) in Brazil, South

America (2 genomes, 3rd March 2020) (http://virological.org/t/first-cases-of-

coronavirus-disease-covid-19-in-brazil-south-america-2-genomes-3rd-march-

2020/409, Virological, 2020).

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3 Ministério da Saúde, B. Brasil amplia monitoramento do coronavírus. (2020).

4 WHO. Critical preparedness, readiness and response actions for COVID-19.

(Technical Guidance 2020, https://www.who.int/emergencies/diseases/novel-

coronavirus-2019/technical-guidance/critical-preparedness-readiness-and-response-

actions-for-covid-19).

5 Kraemer, M. U. G. et al. Reconstruction and prediction of viral disease epidemics.

Epidemiology and Infection, 1-7, doi:10.1017/S0950268818002881 (2018).

 https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-
the-coronavirus-pandemic-takes-hold-we-are-making-decisions-
1
without-reliable-data/
A fiasco in the making? As the coronavirus pandemic takes hold, we
are making decisions without reliable data

By John P.A. Ioannidis

March 17, 2020

A nurse holds swabs and a test tube to test people for Covid-19 at a drive-through station set up in the parking lot of
the Beaumont Hospital in Royal Oak, Mich. Paul Sancya/AP

The current coronavirus disease, Covid-19, has been called a once-in-a-century

pandemic2. But it may also be a once-in-a-century evidence fiasco.

At a time when everyone needs better information, from disease modelers and
governments to people quarantined or just social distancing, we lack reliable
evidence on how many people have been infected with SARS-CoV-2 or who
continue to become infected. Better information is needed to guide decisions and
actions of monumental significance and to monitor their impact.

Draconian countermeasures have been adopted in many countries. If the

pandemic dissipates — either on its own or because of these measures — short-
term extreme social distancing and lockdowns may be bearable. How long,
though, should measures like these be continued if the pandemic churns across the
globe unabated? How can policymakers tell if they are doing more good than
harm?

Vaccines or affordable treatments take many months (or even years) to develop
and test properly. Given such timelines, the consequences of long-term lockdowns
are entirely unknown.

Related: 3

We know enough now to act decisively against Covid-19. Social

distancing is a good place to start 3

The data collected so far on how many people are infected and how the epidemic
is evolving are utterly unreliable. Given the limited testing to date, some deaths
and probably the vast majority of infections due to SARS-CoV-2 are being
missed. We don’t know if we are failing to capture infections by a factor of three
or 300. Three months after the outbreak emerged, most countries, including the
U.S., lack the ability to test a large number of people and no countries have
reliable data on the prevalence of the virus in a representative random sample of
the general population.

This evidence fiasco creates tremendous uncertainty about the risk of dying from
Covid-19. Reported case fatality rates, like the official 3.4% rate from the World
Health Organization, cause horror — and are meaningless. Patients who have
been tested for SARS-CoV-2 are disproportionately those with severe symptoms
and bad outcomes. As most health systems have limited testing capacity, selection
bias may even worsen in the near future.

The one situation where an entire, closed population was tested was the Diamond
Princess cruise ship and its quarantine passengers. The case fatality rate there was
1.0%, but this was a largely elderly population, in which the death rate from
Covid-19 is much higher.

Projecting the Diamond Princess mortality rate onto the age structure of the U.S.
population, the death rate among people infected with Covid-19 would be
0.125%. But since this estimate is based on extremely thin data — there were just
seven deaths among the 700 infected passengers and crew — the real death rate
could stretch from five times lower (0.025%) to five times higher (0.625%). It is
also possible that some of the passengers who were infected might die later, and
that tourists may have different frequencies of chronic diseases — a risk factor for
worse outcomes with SARS-CoV-2 infection — than the general population.
Adding these extra sources of uncertainty, reasonable estimates for the case
fatality ratio in the general U.S. population vary from 0.05% to 1%.

Related: 4

Coronavirus model shows individual hospitals what to expect in the

coming weeks 4

That huge range markedly affects how severe the pandemic is and what should be
done. A population-wide case fatality rate of 0.05% is lower than seasonal
influenza. If that is the true rate, locking down the world with potentially
tremendous social and financial consequences may be totally irrational. It’s like
an elephant being attacked by a house cat. Frustrated and trying to avoid the cat,
the elephant accidentally jumps off a cliff and dies.

Could the Covid-19 case fatality rate be that low? No, some say, pointing to the
high rate in elderly people. However, even some so-called mild or common-cold-
type coronaviruses that have been known for decades can have case fatality rates
as high as 8%5 when they infect elderly people in nursing homes. In fact, such
“mild” coronaviruses infect tens of millions of people every year, and account for
3% to 11%6 of those hospitalized in the U.S. with lower respiratory infections
each winter.

These “mild” coronaviruses may be implicated in several thousands of deaths

every year worldwide, though the vast majority of them are not documented with
precise testing. Instead, they are lost as noise among 60 million deaths from
various causes every year.

Although successful surveillance systems have long existed for influenza, the
disease is confirmed by a laboratory in a tiny minority of cases. In the U.S., for
example, so far this season 1,073,976 specimens have been tested7 and 222,552
(20.7%) have tested positive for influenza. In the same period, the estimated
number of influenza-like illnesses is between 36,000,000 and 51,000,000, with an
estimated 22,000 to 55,000 flu deaths.

Note the uncertainty about influenza-like illness deaths: a 2.5-fold range,

corresponding to tens of thousands of deaths. Every year, some of these deaths are
due to influenza and some to other viruses, like common-cold coronaviruses.

In an autopsy series6 that tested for respiratory viruses in specimens from 57

elderly persons who died during the 2016 to 2017 influenza season, influenza
viruses were detected in 18% of the specimens, while any kind of respiratory
virus was found in 47%. In some people who die from viral respiratory pathogens,
more than one virus is found upon autopsy and bacteria are often superimposed. A
positive test for coronavirus does not mean necessarily that this virus is always
primarily responsible for a patient’s demise.

If we assume that case fatality rate among individuals infected by SARS-CoV-2 is

0.3% in the general population — a mid-range guess from my Diamond Princess
analysis — and that 1% of the U.S. population gets infected (about 3.3 million
people), this would translate to about 10,000 deaths. This sounds like a huge
number, but it is buried within the noise of the estimate of deaths from “influenza-
like illness.” If we had not known about a new virus out there, and had not
checked individuals with PCR tests, the number of total deaths due to “influenza-
like illness” would not seem unusual this year. At most, we might have casually
noted that flu this season seems to be a bit worse than average. The media
coverage would have been less than for an NBA game between the two most
indifferent teams.
Some worry that the 68 deaths from Covid-19 in the U.S. as of March 1610 will
increase exponentially to 680, 6,800, 68,000, 680,000 … along with similar
catastrophic patterns around the globe. Is that a realistic scenario, or bad science
fiction? How can we tell at what point such a curve might stop?

The most valuable piece of information for answering those questions would be to
know the current prevalence of the infection in a random sample of a population
and to repeat this exercise at regular time intervals to estimate the incidence of
new infections. Sadly, that’s information we don’t have.

In the absence of data, prepare-for-the-worst reasoning leads to extreme measures

of social distancing and lockdowns. Unfortunately, we do not know11 if these
measures work. School closures, for example, may reduce transmission rates. But
they may also backfire if children socialize anyhow, if school closure leads
children to spend more time with susceptible elderly family members, if children
at home disrupt their parents ability to work, and more. School closures may also
diminish the chances of developing herd immunity in an age group that is spared
serious disease.

This has been the perspective behind the different stance of the United Kingdom
keeping schools open12, at least until as I write this. In the absence of data on the
real course of the epidemic, we don’t know whether this perspective was brilliant
or catastrophic.

Flattening the curve13 to avoid overwhelming the health system is conceptually

sound — in theory. A visual that has become viral in media and social media
shows how flattening the curve reduces the volume of the epidemic that is above
the threshold of what the health system can handle at any moment.

Related: 14

The novel coronavirus is a serious threat. We need to prepare, not

overreact 14

Yet if the health system does become overwhelmed, the majority of the extra
deaths may not be due to coronavirus but to other common diseases and
conditions such as heart attacks, strokes, trauma, bleeding, and the like that are
not adequately treated. If the level of the epidemic does overwhelm the health
system and extreme measures have only modest effectiveness, then flattening the
curve may make things worse: Instead of being overwhelmed during a short,
acute phase, the health system will remain overwhelmed for a more protracted
period. That’s another reason we need data about the exact level of the epidemic
activity.

One of the bottom lines is that we don’t know how long social distancing
measures and lockdowns can be maintained without major consequences to the
economy, society, and mental health. Unpredictable evolutions may ensue,
including financial crisis, unrest, civil strife, war, and a meltdown of the social
fabric. At a minimum, we need unbiased prevalence and incidence data for the
evolving infectious load to guide decision-making.

In the most pessimistic scenario, which I do not espouse, if the new coronavirus
infects 60% of the global population and 1% of the infected people die, that will
translate into more than 40 million deaths globally, matching the 1918 influenza
pandemic.

The vast majority of this hecatomb would be people with limited life
expectancies. That’s in contrast to 1918, when many young people died.

One can only hope that, much like in 1918, life will continue. Conversely, with
lockdowns of months, if not years, life largely stops, short-term and long-term
consequences are entirely unknown, and billions, not just millions, of lives may
be eventually at stake.

If we decide to jump off the cliff, we need some data to inform us about the
rationale of such an action and the chances of landing somewhere safe.

John P.A. Ioannidis is professor of medicine, of epidemiology and population

health, of biomedical data science, and of statistics at Stanford University and co-
director of Stanford’s Meta-Research Innovation Center.
About the Author
John P.A. Ioannidis

jioannid@stanford.edu 15
@METRICStanford 16

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