Brief History of the First Three Weeks of the COVID-19 Pandemic

The COVID-19 outbreak appears to have originated in the Wuhan area of Hubei Province in China in November or December of 2019. Although information about the outbreak was initially suppressed by Chinese officials (link), by December 30, 2019, various Chinese media reports publicly emerged about a “viral pneumonia” occurring in the area (link). The first major public tracking effort of this pandemic started at FluTrackers.com. In a thread started by penguinsix on December 31, 2019, members of FluTrackers.com, a volunteer organization tracking infection diseases around the world, began compiling media reports about the spread of this novel disease outbreak (link).

On December 31, 2019, the Centre for Health Protection in Hong Kong noted that they were monitoring an outbreak of 27 cases of pneumonia in Wuhan, China (link). On January 1, 2020, Chinese authority shut down the Huanan Seafood Wholesale Market where it was believed that the virus made the jump to humans from an animal species in the market (link). By January 3, the Hong Kong Centre for Health Protection was monitoring 44 cases of this novel disease (link, link). Within a few days, China officially reported 44 case-patients with pneumonia of unknown etiology to the World Health Organization (link) as required by International Health Regulations, Article 6.

On January 6, the Center for Disease Control and Prevention in the United States issued a Level 1, travel warning to the Wuhan area of China (link). On January 7, Chinese scientists determined that a new type of coronavirus (SARS-CoV-2) was causing this outbreak of viral pneumonia (link, link). Three days later, on January 10, the genome of this novel coronavirus was made publicly available (link, link). By January 8, the number of cases in Wuhan area climbed to 59 (link). On January 9, China reported its first official death from the coronavirus, a 61-year-old male who frequented the Huanan Seafood Wholesale Market (link).

A few days later, the first laboratory-confirmed case of COVID-19 was detected outside of China in Thailand (link). On January 13, the Ministry of Public Health in Thailand reported that an infected 61-year-old Chinese woman was detected by surveillance at the Bangkok airport. The woman was a resident of Wuhan, China, and was apparently ill for several days before her arrival at the Thailand airport on January 8.

Three days later, on January 16, the Japanese Ministry of Health, Labour, and Welfare, announced the detection of the first COVID-19 case in Japan (link). The individual was a Japanese resident in his 30s from the Kanagawa prefecture who tested positive after returning from a visit to the Wuhan area in China (link). Japan became the second county outside of China to report a COVID-19 case.

The following day, January 17, the Japanese Ministry of Health, Labour, and Welfare reported a second confirmed COVID-19 cases to the World Health Organization (link). A man, living in Japan, had traveled to Wuhan, China, in early January where he developed symptoms, but tested negative for influenza when he returned to Japan. After returning, he continued to have symptoms and was hospitalized. Public official conducted two separate tests on January 14 and determined he had been infected with the coronavirus that causes COVID-19.

Three days later, on 20 January 2020, public health officials in the Republic of Korea (South Korea) reported the first case of novel coronavirus in the that county. The case was a 35-year-old female, Chinese national residing in Wuhan, China, who started exhibiting symptoms on the January 18 in China (link). The symptomatic individual was detected when she arrived at the Incheon International Airport on January 19, and was confirmed on January 20.

By January 20, four deaths had been attributed to COVID-19 infections in China, all from Hubei Province. The reported cases in China reached a total 291; Hubei Province 270, Guangdong 14. Beijing 5, and Shanghai 2 (link). The four reported cases from outside of China were Thailand 2, Japan 1, and Republic of Korea 1, all occurring as imported cases.

On January 21, The World Health Organization began publishing its daily situation report on this new disease (link). Also, on January 21, a team from Johns Hopkins University set up one of the first internet websites for live tracking the global outbreak of COVID-19 (link). According to World Health Organization by the end of the day on January 21, there were 314 confirmed COVID-19 cases, 309 from China, 2 from Thailand and 1 each from Japan, South Korea, and Taiwan (link).

The following day, on January 22, the United States of America became the fourth country in the world to report a confirmed COVID-19 case according to the World Health Organization.¹ The individual was a 35-year-old male who had spent several months travelling in the Wuhan area before returning to the United States. On January 15 he returned to his home in Snohomish County, Washington, and the next day started exhibiting symptoms. Test by the Center for Disease Control and Prevention on January 20 determined that this individual was infected with COVID-19 (link, link). He became the first COVID-19 case in the United States.

A few days later on January 25, the World Health Organization reported a worldwide total of 1320 confirmed COVID-19 cases. Besides China, Thailand, Japan, South Korea, and the United States, first confirmed cases of COVID-19 were reported from five additional countries, Viet Nam, Singapore, Australia, Nepal, and France (link).

And by the end of that week, the coronavirus outbreak was the lead story of international news around the world. It was not a “Wuhan Flu” or the “Chinese virus” and it was no longer just a Chinese problem. The entire world was in danger. On February 11, the World Health Organization named the disease COVID-19 (link) and a month later on March 11, 2020, the World Health Organization declared a worldwide COVID-19 pandemic (link). That was only the beginning.

Notes

1. By January 22, Macao and Taiwan had reported cases, but the World Health Organization considers these area as administrative regions associated with the Peoples Republic of China.

Edited March 24, 2020 to add information to note that FluTrackers.com was the first organization to note and track the beginning of this pandemic.

Three Things All Governments Should Do to Confront a Pandemic

There are 3 important things that any government must do if it wishes to survive a pandemic.

1. Provide Accurate and Truthful Information

Any government should provide accurate, current, and truthful information about the pandemic. Certainly, as a pandemic unfolds the situation changes rapidly. Government agencies and spokespeople should acknowledge the fluidity of the situation. Providing conflicting information from various agencies will lead to confusion among the general population. Covering up or misleading the public will lead to distrust of official announcements and recommendations. Dismissing or downplaying the serious potential of a pandemic can lead to fear and general anxiety. Failure of the government to provide truthful and accurate information can lead to panic and possibly mass hysteria. 

What can be done?

Provide a unified voice from the government by public health officials who understand what is going on and have credibility with the public.  Let these public health officials speak freely and honestly about the parameters of the pandemic. Provide a daily update to the public by these individuals.

A government should set up a national hotline with knowledgeable government employees taking calls and responding to any and all questions relating to the pandemic. Nothing can be more reassuring than talking to another human being about concerns and actions to take as a pandemic progresses.

2. Provide Supplies and Protection for Health Care Workers

A pandemic is a foreign invader, it cannot be stopped by soldiers or generals. The front-line defense against a pandemic are all of the healthcare workers and their support staff. These individuals include doctors, nurses, medical technicians, laboratory support staff, first responders, and the support and maintenance staff of health facilities.  

Healthcare staff and facilities around the world are working at capacity even before a pandemic begins. Healthcare staff of all specialties will be pressed into service to aid in treatment of pandemic cases. A pandemic will overwhelm staff and facilities. Just because there is a pandemic, regular medical issues will not go away. In addition to treating the influx of pandemic patients, other medical aspects such as caring for acute trauma, monitoring chronic conditions, assisting in births, etc. will continue to be necessary. 

What can be done?

The government should be responsible for making sure that adequate supplies such as masks, gowns, gloves, are available to all staff. Ample supplies of medications and tests should also be available. These health care workers need to be assured that they have all the resources they need to treat patients and not get sick themselves.

Health care workers should not be burdened by paperwork exercises, filling out forms, and looking up insurance codes. They should be 100% focused on taking care of sick people. 

Healthcare workers are the soldiers of a pandemic crisis. They can be subject to anxiety and psychological stress such as PTSD just like any other soldier. The government should do all it can to lessen the physical and psychological pressures and provide extensive crisis management for these healthcare workers.  

3. Have a Clear Pandemic Plan 

The government needs to have a clear public plan in place for dealing with the myriad of problems that accompany a pandemic. Does the government have a rational plan for quelling concerns among the population? Is it ready to bolster weak links in the supply chain to ensure that critical infrastructure remains intact? Will adequate supplies of food, water, electricity, gas, and oil be properly delivered to people who are in desperate need?

What can be done?

The government needs to have a coherent communication plan in place if various avenues of official news and information are disrupted.  One thing the government can do minimize the effect of a pandemic is to make sure that all treatment for the disease is free, no one should have to pay for treatment. Everyone should have equal opportunity for treatment and recovery. Any vaccination, when it becomes available, should be free to every citizen. 

A pandemic will eventually end. At that time the government will be responsible for bringing the broken pieces of the economy and society back together again. The government will need to have a massive deficit spending plan to jump start the economy once the pandemic is over. Extensive spending will be necessary to put people back to work and to bolster the supply chain and infrastructure in order return to a semblance regular life. Only then will the populations have the faith that things will eventually return to normal.

Any government that does not address these 3 issues will not instill confidence in the general public. It would demonstrate that the government is incapable of managing a pandemic crisis. Failure to manage a pandemic crisis could result in more infections, poorer treatment, greater loss of life, and perhaps  even a permanent lowering of the standard of living.

Rapidly spreading 2019 nCoV outbreak

The 2019-nCoV outbreak is rapidly spreading across China. There have been more than 2000 cases reported among almost all the provinces in China since mid-January.  At least 54 confirmed cases have been imported into 14 other countries or administrative regions.  Five of these cases have been imported into 5 different counties in the United States. See maps below.

The Third Major Novel Coronavirus Outbreak This Century (2019-nCoV)

The Third Major Novel Coronavirus Outbreak This Century (2019-nCoV)

Once again for the 3^rd time in this century, public health officials are battling a novel coronavirus (2019-nCoV) that originated in China in December 2019.  In 2003 the Severe Acute Respiratory Syndrome (SARS) outbreak was attributed to a coronavirus that originated in bats but was apparently passed from civets to humans in Guangdong Province in China. During that outbreak more than 7,500 people from 17 countries were infected with about 775 deaths blamed on SARS.

In 2012 a novel coronavirus began infecting people on the Arabian Peninsula. The Middle East Respiratory Syndrome (MERS) was eventually attributed to camels as an intermediate host passing on the MERS coronavirus to humans.  Since 2012 more than 2500 people have been infected with more than 850 associated deaths. While the SARS coronavirus has not infected anyone during the past 15 years, MERS is still circulating and continues to cause human illness and death. As noted by Kayvon Modjarrad (link) in 2016, treatment options for SARS  were never clearly defined so that when MERS appeared treatment options were limited as well.

In December 2019 a novel coronavirus began infecting people in Wuhan, Hubei province, in China. This coronavirus outbreak originated as the preceding two this century. A few cases here and there become sick exhibiting symptoms similar to pneumonia. Eventually local public health officials noticed a pattern in the symptoms of sick individuals who worked at or shopped in a wet market in the City of Wuhan where a variety of animals were processed and sold. Suspicion soon focused on coronaviruses because they are found in many animal species and can occasionally infect humans.

Within a few weeks Chinese researchers had isolated a new coronavirus called 2019-nCoV (2019 novel CoronaVirus) from sick individuals. The scientist quickly developed a test to rapidly identify the presence of this coronavirus in a sick individual.

During the initial days of this outbreak, there was uncertainty about whether or not all of the human cases resulted from exposure to infected animals. However, the rapid growth in confirmed cases in China demonstrates that human-to-human transmission is now the main source of the spread of this disease. Since the 11^th of January, the number of reported, confirmed cases has risen about 20-fold. The chart below shows the growth of confirmed cases in the past 13 days from about 40 cases to more than 860 cases. This rate of infection, if it is unimpeded, could see the number of cases rise to 1500 tomorrow and 2500 the day after. These are only crude estimates, but there is little reason to suspect that number of confirmed cases in going to start declining precipitously in the near future.

The Spread of H7N9 in China

Hong Kong’s Centre for Health Protection weekly Avian Influenza Report published on August 1 is the first weekly report in 2017 with no reported human H7N9 cases from the Republic of China. The last weekly Avian Influenza Report with no reported H7N9 cases was previously published on December 1, 2016. In the intervening 8 months more than 750 human H7N9 cases were reported from China. This is an extremely large number of human infections in a short time period.

Human cases of H7N9 were first identified and reported from China late in the 2012-2013 influenza season. Since then, there have been several waves of human H7N9 infections generally corresponding with seasonal influenza outbreaks. Although human cases of H7N9 have been sporadically reported over the past four years, the 750+ cases reported in the last eight months represent about 49% of all reported H7N9 cases. To date, all human infections have occurred in China although some individuals infected in China were identified in other countries. 

   Chart: Number of human H7N9 cases by influenza season.

As depicted in the maps below, between 13 and 16 provinces, autonomous areas, or municipalities were reporting H7N9 cases during these previous waves on a seasonal basis. This recent wave with over 750 cases, the 2016-2017 influenza season, struck China particularly hard. All provinces, autonomous areas, municipalities, or special administrative regions in China with the exception of Hainan, Heilongjiang, Qinghai, and Ningxia Hui reported at least one human H7N9 case during the past influenza season.

Map: Distribution of human H7N9 cases in China in early 2013.

Map: Distribution of human H7N9 cases in China in the 2013-2014 influenza season.

Map: Distribution of human H7N9 cases in China in the 2014-2015 influenza season.

 Map: Distribution of human H7N9 cases in China in the 2015-2016 influenza season.

Map: Distribution of human H7N9 cases in China in the 2016-2017 influenza season.

Almost all of these recent H7N9 infections are attributed to contact with infected poultry; human to human transmission is apparently very rare. There is very little public information about the distribution of low pathogenicity avian influenza (LPAI) H7N9 among domestic poultry in China. However, we can deduce from the extensive geographic distribution of human H7N9 in China this past season, that H7N9 is wide spread and perhaps endemic in poultry flocks in China.

Domestic poultry may soon be infected in adjoining countries of Myanmar, Laos, and Vietnam.  Human cases from these countries in the future would not be surprising. With the next influenza season officially starting in a few weeks, we can anticipate that additional human H7N9 cases will be reported from China in the upcoming influenza season.

The Current Status of the 2016 – 2017 H7N9 Outbreak in China as of March 1, 2017 (Is the Outbreak Just About Over?)

For the purposes of this discussion the current outbreak of H7N9 began November 1, 2016 and is still continuing. More than 460 human cases have been reported from China. Of these cases, 426 have symptom onset dates reported by the World Health Organization (WHO) for cases with onset before February 10, 2017.

Graphing the symptom onset dates for these H7N9 cases provides a count of new daily infections of H7N9. Also included in the graph are the remaining 37 cases based on their reporting date rather than symptom onset date which is not available at this time for cases reported after February 11. The graph, an epidemic curve, shows that the greatest number of H7N9 infections occurred on February 1, 2017, based on a five day moving average.

Even if The 37 cases for which symptom onset dates are not available are distributed over the 17 days following February 11, they are an insufficient number of new cases to exceed the five-day moving average which peaked above 10 cases per day on February 1, 2017. The number of human H7N9 infections in this outbreak now seems to be declining. The decline in human cases can be attributed to closing of some local poultry markets by Chinese authorities. Hopefully, the number of H7N9 infections will continue to decrease.

While there is little evidence of human-to-human transmission in this outbreak, every human H7N9 infection is a potential opportunity for the influenza virus to reassort and become transmissible between humans.