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Thursday, April 23, 2020, 10:50
Professional’s reading of early case count shows no cover-up
By David T.Y. Lam
Thursday, April 23, 2020, 10:50 By David T.Y. Lam

Josephine Ma of the South China Morning Post wrote an article titled “Coronavirus: China’s first confirmed COVID-19 case traced back to November 17” on March 13. Sky News subsequently interviewed Ma and used only two sentences from the interview to make up a story that China covered up the outbreak of COVID-19.

The SCMP and Sky News have aroused a lot of concern that the Chinese government has been covering up the outbreak, at least in its early stages, and was likely underreporting the case numbers during subsequent months.

Ma reported that the first case in Wuhan probably occurred on Nov 17, well over a month before the first case as it was officially reported in late December. Bearing in mind that the pathogen was only identified in early January and the test was only available in mid-January, no one in November could have made a diagnosis of COVID-19. One might argue that the case should have sparked surveillance of the outbreak, but with one case? This is not the way epidemiologists work. You need a cluster (in time or in a locality) of cases to sound the alarm.

The cases were among a much greater number of flu pneumonia in a particularly rampant (according to the US CDC) flu season, amid an even much bigger population. The practice of medicine is judged by information available at the material time without the benefit of hindsight

Ma further reported that there have been one to five new cases each day through Dec 15, by which time there were 27 cases. The number has to be wrong since one case a day would add up to 29 cases by Dec 15, and a more plausible amount would have been zero to five cases a day, meaning not every day. The case number, according to Ma, rose to 27 by Dec 15, and 60 by Dec 20.

Is there a cluster now? Yes, there was a cluster by mid-December assuming Ma was correct, but this cluster of 60 in a city of 10 million would have been hidden among pneumonia cases during the flu season. Moreover, there was no test for SARS-CoV-2, nor was it known. Did we not recall that this flu season was particularly rampant according to US Centers for Disease Control and Prevention figures? It is doubtful if all suspected flu pneumonia cases were tested, for influenza at the material time (not all were tested even in Hong Kong, nor the United States), and if not, non-influenza viral pneumonia could have easily passed as flu-pneumonia. Did we not recall Dr Anthony Fauci of the US admitting that some COVID-19 deaths have been passed as influenza deaths until retrospective testing of saved samples for SARS-CoV-2 found out the real cause? This happens.

Even if some pneumonia cases tested negative for the flu, doctors should know (if laymen don’t) that atypical pneumonia with an unidentified pathogen is not unusual, and it becomes unusual only when it comes in clusters, which it did, by mid- to late December.

The clustering of cases among visitors to the South China Seafood Market (source apparent) alerted the Wuhan CDC to a non-flu outbreak. At the material time, one diagnostic criterion was a visit to the apparent source or their close contacts. The numbers must necessarily be reported in accordance with the diagnostic criteria. Typical computed tomography findings were not even known then, let alone the availability of reverse transcription polymerase chain reaction (RT-PCR).

Dr Zhang Jixian on Dec 27 told the health authority that there was an unusual clustering of atypical pneumonia cases, which could very well include some of the 60 cases Ma alluded to. And, of course, there was a week or so of delays in reporting, because Zhang could not possibly have predicted the clustering until he had seen them, had been treating them, and had been analyzing what was going wrong.

Wuhan and the Hubei provincial CDC announced an investigation into an unknown pneumonia outbreak on Dec 29. Looking at the authority’s very quick response after Zhang’s reporting, it is highly likely that the CDC was not acting in response to Zhang’s report alone, but it has been alerted to the situation and closely observing it for some time, perhaps since mid-December. It came to the conclusion of an outbreak by Dec 29 and took prompt action. The source apparent was swiftly closed and the China CDC joined within two days.

China informed the World Health Organization and internationally on Jan 3 of a new pathogen outbreak in Wuhan, and uploaded five sequences of the new viral genome to share internationally on Jan 11.

The first RT-PCR test for the new virus can only become available after the gene sequence is decoded, and it takes time to develop. The US CDC took (and lost) weeks even after the genome was known. It was late in February when Wuhan had enough tests for clinical use, and was retrospectively testing suspected cases that occurred the year before.

Critics say there was one case of COVID-19 in Wuhan on Nov 17, and China did not test it, it was a cover-up. There were 60 cases by mid-December and China did not test them, it was a cover-up. 

But there was no test. The cases were among a much greater number of flu pneumonia in a particularly rampant (according to the US CDC) flu season, amid an even much bigger population. The practice of medicine is judged by information available at the material time without the benefit of hindsight.

Before ending, let us sidetrack a little to the issue of human-to-human transmission. Again, there are allegations of cover-ups that China knew there was human-to-human transmissions long before Professor Zhong Nanshan announced this on Jan 20. Critics cite the cases of healthcare workers and also the contacts of infected patients. True, there were, but in small numbers. That was why Chinese health authorities announced earlier that there was evidence of human-to-human transmission under specific circumstances.

An article by Li Qun and others in the New England Journal of Medicine published on Jan 29 demonstrated that the new virus is transmissible from human to human, after analyzing the data up to Jan 23. Scientists do not act by betting, they go by evidence, which only became available when the data were analyzed. One might argue Zhong jumped the gun by warning the world of human-to-human transmissions nine days before the article was published and three days before the last data set was collected. There was no cover-up.

Ma’s article, if her figures are real, and read from a professional point of view rather than a layman’s perspective, attests to the faithful reporting of events announced by the Chinese government at the material time. The fact that the numbers are there for Ma to see testify to the fact that tests were done all the way to find out the facts retrospectively. This is exactly what a responsible government should do.

The author is a surgeon, chairman of Medical Conscience, a medical policy think tank and action group of medical doctors and healthcare professionals. This article represents the views of Medical Conscience. 

The author is also vice-president of the Hong Kong Medical Association. This article does not represent the view of the Hong Kong Medical Association. The views do not necessarily represent those of China Daily.

1. Josephine Ma: Coronavirus: China’s first confirmed Covid-19 case traced back to November 17: SCMP 13/3/2020;
2. SPECIAL REPORT: China’s deadly Coronavirus cover-up; Sky News, Australia:
3. 外交部發言人華春瑩主持例行記者會— 中華人民共和國外交部 2/4/2020:
4. Li Q, Guan X, Wu P et al: Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. NEJM 29/1/2020: DOI: 10.1056/NEJMoa2001316

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