Published: February 28, 2020 From WHO
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 Liang of the People’s Republic 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 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 this report are based on the Joint Mission’s 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.
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.
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
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 intraalveolar spaces, showing viral cytopathic-like changes. No obvious intranuclear or intracytoplasmic viral inclusions were identified.
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 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 are generated using China’s National 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
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:
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.
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).
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%.
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.
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.
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:
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
Given Wuhan’s transport hub status and 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.
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:
(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 longterm 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.
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 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.
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.
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.
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’s issuing, on 8 February 2020, of The Notice on Orderly Resuming Production and Resuming Production in Enterprises, which indicated that China’s national 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 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 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.
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.
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 period, provided the vital evidence base for China’s strategy, gaining invaluable time for the response.
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 China’s 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-long ‘stay at home’ 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. China’s bold approach to contain the rapid spread of 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 team’s work there were 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 scale and impact of China’s COVID-19 operation has been remarkable, it has also highlighted areas for improvement in public health emergency response capacity.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, riskinformed 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 endorses China’s working assumption that 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-19 in the country. China’s rapid return to 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 to China’s experience in responding to COVID-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 applied non-pharmaceutical, public health measures to interrupt chains of human-tohuman 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. China’s uncompromising and rigorous use of non-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 megacities in the north and south of the country, to remote communities. However, the rapid adaptation and tailoring of China’s strategy demonstrated that containment can be adapted and successfully operationalized in a wide range of settings.
China’s experience strongly supports the efficacy and effectiveness of anchoring COVID-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.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 middleincome 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 history of the disease, and the virus’s transmission dynamics. However, the urgency of 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.
Link : https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf