LONDON – It has gone from “pneumonia of unknown cause” affecting 44 patients in Wuhan, China, on Jan. 5, 2020, to spark a global health alert, with the World Health Organization (WHO) now looking likely to declare the outbreak of the novel coronavirus, 2019-nCoV, a public health emergency of international concern (PHEIC) less than four weeks later.
Returning from a fact-finding mission to China on Wednesday Jan. 29, WHO Director General Tedros Adhanom Ghebreyesus announced he is reconvening the WHO Emergency Committee to advise him if the epidemic constitutes a PHEIC.
Last week, after long deliberation, the answer to the question was no. Ghebreyesus said he made the decision to reconsider because of new cases of human-to-human transmission in three countries outside China. “This potential for further global spread is why I called the emergency committee,” he said.
Most of the 6,000-plus confirmed cases of 2019-nCoV are in China, with just 1%, or 68 cases to date, in 15 other countries. Those cases are mainly in people with a history of travel in China, or who had contact with people who have been in the country. The 132 patients who have died of the infection were all in China.
It is clearly still a very active outbreak and clearly still centered in China. However, new evidence of person-to-person transmission of 2019-nCoV outside China is of “great concern” in terms of the evolution of the epidemic, said Michael Ryan, WHO executive director for health emergencies, who accompanied Ghebreyesus on the visit.
“The whole world needs to be alert now,” said Ryan. The Emergency Committee “will consider the merits of declaring an emergency so all member states act in a coordinated manner,” he said.
Countries with “imported” cases of 2019-nCoV already are at full alert. Countries with no cases need to be fully prepared, and WHO is working with member states that have fragile health care systems to ensure they can diagnose and isolate any cases.
The epidemic is “at an important juncture,” but through proper control measures, “we believe these chains of transmission can be interrupted,” Ryan said.
Given the scale of the epidemic around Wuhan, the fact that to date there have been only 68 cases outside China, and no deaths, is testament to the measures China has taken to prevent the export of 2019-nCoV. That is something the country is doing “at the expense of its economy,” Ghebreyesus said.
On Jan. 28, Ghebreyesus met China’s president Xi Jinping, with whom he had a series of “very candid discussions” on continued collaboration, containment measures, the public health response, conducting future studies into the severity of the disease, and sharing data and biological material.
“I was very impressed by the president’s knowledge of the outbreak and his involvement in dealing with the epidemic,” said Ghebreyesus. The measures being taken to manage the outbreak at its epicenter are not only good for China, but also for the rest of the world, he said.
Xi agreed with Ghebreyesus that WHO can send an expert mission to China to work alongside local scientists and public health officials to try and understand more about 2019-nCoV. WHO is now having internal discussions to decide what skills are needed.
Also on Jan. 28, U.S. health secretary Alex Azar told a press briefing he has had no response to an offer made three weeks ago to send a U.S. team to China to assist with the epidemic. Azar said “more cooperation and transparency” are the most important steps to take for an effective response.
Ghebreyesus said that if other countries want to get involved alongside WHO’s international mission, the best way to do so would be through “bilateral arrangements.” He also challenged the assertion that China is not cooperating and being fully transparent, citing cases of 2019-nCoV that have been confirmed in Germany.
The source of infection was a woman from China traveling there for work, who was asymptomatic during her stay in Germany. “She was found to be positive on her return. The Chinese authorities immediately notified counterparts in Germany,” Ghebreyesus said. “This is a good illustration of how China is engaging with WHO and other countries.”
Early data on the epidemiology are beginning to be published. The latest analysis by Chinese researchers, published in The Lancet on Jan. 29, 2020, includes 99 patients with laboratory-confirmed 2019-nCoV who were transferred to Jinyintan Hospital, an adult infectious disease hospital admitting the first 2019-nCoV cases from hospitals across Wuhan, between Jan. 1 and Jan. 20.
Most patients were middle-aged and male, and around half had a history of exposure to the Huanan seafood market, where the infection is thought to have transferred from animals to humans. A total of 46 patients worked at the market.
Patients were treated with antivirals, antibiotics and oxygen therapy, with most having a good prognosis. However, 17 patients developed acute respiratory distress syndrome, 11 of whom died of multiple organ failure. Fifty-seven patients are still in the hospital.
A second report by Chinese researchers, also in The Lancet, of the analysis of 10 genome sequences of 2019-nCoV from nine patients in Wuhan, found the virus is most closely related to two SARS (severe acute respiratory syndrome) coronaviruses that originated in bats.
Although that suggests bats might be the original host of the virus, the researchers say an animal sold at the Huanan seafood market, where “a number of non-aquatic animals such as birds and rabbits were also on sale before the outbreak,” might have been an intermediate host, enabling the emergence of the virus in humans.
Eight of the patients had visited the market. One patient had never visited the market, but had stayed in a hotel near the market before the onset of their illness.
The researchers found 2019-nCoV in all 10 samples taken from the patients, including eight complete genomes and two partial genomes. The genetic sequences of the samples were nearly identical, sharing more than 99.98% of the same genetic sequence. That indicates a very recent emergence of the virus into humans, the researchers say.
The first report of the transmission dynamics of 2019-nCoV was posted to the preprint server bioRxiv on Jan. 26, 2020, in advance of peer review.
Researchers at the Guangdong Provincial Center for Disease Control and Prevention, in Guangzhou, China, concluded on the basis of 830 confirmed cases that the average incubation period was 4.8 days, while the average time from onset of symptoms to isolation of patients was 2.9 days.”
Based on that, the researchers noted 2019-nCoV “may have a higher pandemic risk” than the SARs outbreak of 2003. While the public health efforts have significantly decreased the pandemic risk of the new virus, more rigorous control and prevention measures are needed to constrain its further spread, they conclude.
Another paper on transmission dynamics, published in the Jan. 29, 2020, online issue of The New England Journal of Medicine, also came to the conclusion that the virus has a high pandemic risk – in this case, based on estimates that the reproductive number of the virus has been 2.2 (meaning that each infected person goes on to infect 2.2 others on the average) and that the epidemic has been doubling every 7.4 days.
The authors of the NEJM paper concluded that “considerable efforts to reduce transmission will be required to control outbreaks if similar dynamics apply elsewhere.”
See BioWorld’s complete coverage of the ongoing 2019-n-Cov outbreak.