I was the Australian doctor on the WHO’s COVID-19 mission to China. Here’s what we found about the origins of the coronavirus

Dominic Dwyer, University of Sydney

As I write, I am in hotel quarantine in Sydney, after returning from Wuhan, China. There, I was the Australian representative on the international World Health Organization’s (WHO) investigation into the origins of the SARS-CoV-2 virus.

Much has been said of the politics surrounding the mission to investigate the viral origins of COVID-19. So it’s easy to forget that behind these investigations are real people.

As part of the mission, we met the man who, on December 8, 2019, was the first confirmed COVID-19 case; he’s since recovered. We met the husband of a doctor who died of COVID-19 and left behind a young child. We met the doctors who worked in the Wuhan hospitals treating those early COVID-19 cases, and learned what happened to them and their colleagues. We witnessed the impact of COVID-19 on many individuals and communities, affected so early in the pandemic, when we didn’t know much about the virus, how it spreads, how to treat COVID-19, or its impacts.

We talked to our Chinese counterparts — scientists, epidemiologists, doctors — over the four weeks the WHO mission was in China. We were in meetings with them for up to 15 hours a day, so we became colleagues, even friends. This allowed us to build respect and trust in a way you couldn’t necessarily do via Zoom or email.

This is what we learned about the origins of SARS-CoV-2.

Animal origins, but not necessarily at the Wuhan markets

It was in Wuhan, in central China, that the virus, now called SARS-CoV-2, emerged in December 2019, unleashing the greatest infectious disease outbreak since the 1918-19 influenza pandemic.

Our investigations concluded the virus was most likely of animal origin. It probably crossed over to humans from bats, via an as-yet-unknown intermediary animal, at an unknown location. Such “zoonotic” diseases have triggered pandemics before. But we are still working to confirm the exact chain of events that led to the current pandemic. Sampling of bats in Hubei province and wildlife across China has revealed no SARS-CoV-2 to date.

We visited the now-closed Wuhan wet market which, in the early days of the pandemic, was blamed as the source of the virus. Some stalls at the market sold “domesticated” wildlife products. These are animals raised for food, such as bamboo rats, civets and ferret badgers. There is also evidence some domesticated wildlife may be susceptible to SARS-CoV-2. However, none of the animal products sampled after the market’s closure tested positive for SARS-CoV-2.

We also know not all of those first 174 early COVID-19 cases visited the market, including the man who was diagnosed in December 2019 with the earliest onset date.

However, when we visited the closed market, it’s easy to see how an infection might have spread there. When it was open, there would have been around 10,000 people visiting a day, in close proximity, with poor ventilation and drainage.

There’s also genetic evidence generated during the mission for a transmission cluster there. Viral sequences from several of the market cases were identical, suggesting a transmission cluster. However, there was some diversity in other viral sequences, implying other unknown or unsampled chains of transmission.

A summary of modelling studies of the time to the most recent common ancestor of SARS-CoV-2 sequences estimated the start of the pandemic between mid-November and early December. There are also publications suggesting SARS-CoV-2 circulation in various countries earlier than the first case in Wuhan, although these require confirmation.

The market in Wuhan, in the end, was more of an amplifying event rather than necessarily a true ground zero. So we need to look elsewhere for the viral origins.

Read more:
Coronavirus: live animals are stressed in wet markets, and stressed animals are more likely to carry diseases

Frozen or refrigerated food not ruled out in the spread

Then there was the “cold chain” hypothesis. This is the idea the virus might have originated from elsewhere via the farming, catching, processing, transporting, refrigeration or freezing of food. Was that food ice cream, fish, wildlife meat? We don’t know. It’s unproven that this triggered the origin of the virus itself. But to what extent did it contribute to its spread? Again, we don’t know.

Several “cold chain” products present in the Wuhan market were not tested for the virus. Environmental sampling in the market showed viral surface contamination. This may indicate the introduction of SARS-CoV-2 through infected people, or contaminated animal products and “cold chain” products. Investigation of “cold chain” products and virus survival at low temperatures is still underway.

Read more:
Could frozen food transmit COVID-19?

Extremely unlikely the virus escaped from a lab

The most politically sensitive option we looked at was the virus escaping from a laboratory. We concluded this was extremely unlikely.

We visited the Wuhan Institute of Virology, which is an impressive research facility, and looks to be run well, with due regard to staff health.

We spoke to the scientists there. We heard that scientists’ blood samples, which are routinely taken and stored, were tested for signs they had been infected. No evidence of antibodies to the coronavirus was found. We looked at their biosecurity audits. No evidence.

We looked at the closest virus to SARS-CoV-2 they were working on — the virus RaTG13 — which had been detected in caves in southern China where some miners had died seven years previously.

But all the scientists had was a genetic sequence for this virus. They hadn’t managed to grow it in culture. While viruses certainly do escape from laboratories, this is rare. So, we concluded it was extremely unlikely this had happened in Wuhan.

Read more:
British people blame Chinese government more than their own for the spread of coronavirus

A team of investigators

When I say “we”, the mission was a joint exercise between the WHO and the Chinese health commission. In all, there were 17 Chinese and ten international experts, plus seven other experts and support staff from various agencies. We looked at the clinical epidemiology (how COVID-19 spread among people), the molecular epidemiology (the genetic makeup of the virus and its spread), and the role of animals and the environment.

The clinical epidemiology group alone looked at China’s records of 76,000 episodes from more than 200 institutions of anything that could have resembled COVID-19 — such as influenza-like illnesses, pneumonia and other respiratory illnesses. They found no clear evidence of substantial circulation of COVID-19 in Wuhan during the latter part of 2019 before the first case.

Where to now?

Our mission to China was only phase one. We are due to publish our official report in the coming weeks. Investigators will also look further afield for data, to investigate evidence the virus was circulating in Europe, for instance, earlier in 2019. Investigators will continue to test wildlife and other animals in the region for signs of the virus. And we’ll continue to learn from our experiences to improve how we investigate the next pandemic.

Irrespective of the origins of the virus, individual people with the disease are at the beginning of the epidemiology data points, sequences and numbers. The long-term physical and psychological effects — the tragedy and anxiety — will be felt in Wuhan, and elsewhere, for decades to come.

Read more:
Yes, we need a global coronavirus inquiry, but not for petty political point-scoring

The Conversation

Dominic Dwyer, Director of Public Health Pathology, NSW Health Pathology, Westmead Hospital and University of Sydney, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Why the coronavirus has become a major test for the leadership of Xi Jinping and the Communist Party

Wu Hong/EPA

Yun Jiang, Australian National University and Adam Ni, Macquarie University

Last week, the World Health Organization (WHO) declared coronavirus a global health emergency. In the same statement, the agency said it

welcomed the leadership and political commitment of the very highest levels of Chinese government, their commitment to transparency and the efforts made to investigate and contain the current outbreak.

Indeed, Chinese authorities have put in place unprecedented measures to slow the spread of coronavirus, including quarantining Wuhan and surrounding cities, home to over 45 million people.

While some have praised Chinese authorities for these tough measures, others have criticised the local and central governments for cover-ups, a lack of transparency, being slow to react and mishandling the early stages of the outbreak.

For some, China’s authoritarian political system is to blame for making the situation worse and delaying action until it was too late.

Now, the crisis is being seen as a key test of President Xi Jinping’s leadership and the ability of the Communist Party to effectively respond to and manage a health emergency.

There wasn’t national attention on the outbreak until late January, weeks after the government reported the first cases to the WHO.
Alex Plavevski/EPA

Too slow to react

Suspicions of the new virus first emerged in early December. But it wasn’t until the end of the month that the Chinese government reported 27 cases of pneumonia to the WHO. The state media mentioned this only briefly.

A day later, police in Wuhan detained eight doctors for spreading “rumours” about a new outbreak of suspected SARS.

China reported the first death from the outbreak on January 11, but without accompanying warnings to the public to take extra precautions. No new infections were reported until January 20, when Xi issued a directive for party committees and governments at all levels to take effective measures to combat the outbreak.

Read more:
Fear spreads easily. That’s what gives the Wuhan coronavirus economic impact

During this time, it was business as usual in Wuhan, with the government organising a New Year banquet for 40,000 families.

By the time Xi issued his directive, it had been seven weeks since the virus was first recorded and three weeks since it was reported to the WHO.

Crucially, it was also 10 days after the official start of the Spring Festival (Lunar New Year) travel period, the largest annual human migration in the world.

At this point, the central government finally sprang into action, locking down Wuhan, shutting down public transport, building new hospitals and giving more leeway to the media to report on the unfolding crisis.

But it may have been too late. According to some estimates, five million people had already left Wuhan before these measures took effect.

Silence, followed by censorship

The initial reaction of the Chinese authorities to the outbreak was to rely on traditional forms of censorship rather than transparency.

This is clear from the initial suppression of whistleblowers – the detention of the eight doctors for spreading “rumours” – as well as the subdued reporting from the state media before January 20.

One possible reason for the silence is Beijing believed it could contain the outbreak without any extra measures, particularly at the start, when the nature of the virus was uncertain. The authorities may have believed mass panic would do more harm than the virus itself.

Read more:
Coronavirus fears can trigger anti-Chinese prejudice. Here’s how schools can help

But after containment appeared unlikely, the central government wasted crucial time deciding what to do. Without clear direction from Beijing, the authorities in Wuhan chose not to act, which allowed the infection to spread.

Media coverage of the outbreak finally exploded after Xi’s January 20 directive, including by non-state media. However, strict censorship returned after two weeks, ostensibly to combat misinformation.

Playing the blame game

As anger deepens over how the crisis has been handled, the public will want to see officials lose their jobs and even be prosecuted.

The process of finding people to blame has started within the Communist Party. And already, we are seeing local government officials being sacked.

But the central government’s role should also be scrutinised. Beijing must have known about the outbreak by December 31, when it reported the cases of pneumonia to the WHO. Serious questions need to be asked, then, about why the central government chose not to respond publicly for another three weeks.

When things go right in a dictatorship, the credit goes to the leader. But when things go wrong, the blame can also rise to the top.

Read more:
Xi Jinping’s grip on power is absolute, but there are new threats to his ‘Chinese dream’

In the late 1950s and early 1960s, the party was able to push the blame for the Great Leap Forward and the subsequent Great Famine onto local cadres. However, Mao’s prestige within the party also suffered greatly as a result.

Xi has followed Mao’s leadership style in many aspects, not least the cult of personality he has built around himself. He has also been consolidating power since he became party general-secretary in late 2012.

Sensing the potential political damage from the current crisis, the state media is now trying to shield Xi from direct criticism and blame.

Instead, it is focusing on the responses of other top leaders, particularly Premier Li Keqiang. In fact, for nearly a week from late January to early February, Xi did not appear on the front page of the party mouthpiece, People’s Daily, in stories related to the outbreak.

Premier Li Keqiang was mocked online for leading workers in a cheer when he visited Wuhan.
Shepherd Zhou/EPA

Propaganda and trust

All propaganda must have heroes and villains. The virus is the villain in this story, and the biggest heroes are the front-line doctors who are working long hours in dangerous conditions to fight it. The people, government and party have also been cast as heroes, united against a common threat.

The party knows the public has low trust of authorities when it comes to transparency, as it has an extensive history of cover-ups of everything from natural disasters to accidents to outbreaks of other diseases like SARS.

It hopes the focus on unity and heroes, coupled with more timely updates, will restore people’s trust in the government’s handling of this outbreak.

However, this is unlikely given the scale of public anger at the moment. This, in turn, may explain the state media’s search for other villains, particularly the US and other western countries that are shutting their borders to China.

A key test for the party

The party’s prestige and legitimacy are both on the line. Crises like this are a serious test of the party’s assertions about the inherent superiority of China’s political system.

Ultimately, the Chinese people are likely to judge the party harshly, despite its efforts at narrative control.

One thing is for certain: the unfolding crisis is a human catastrophe, and Beijing has much to answer for.The Conversation

Yun Jiang, Senior Research Officer, Australian National University and Adam Ni, China researcher, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

How does the Wuhan coronavirus cause severe illness?

Allen Cheng, Monash University

We usually think of viral respiratory infections, like the common cold, as mild nuisances that pass in a few days. But the Wuhan coronavirus has proven to be different. Of those infected, around 2% are reported to have died but the true mortality is unknown.

There’s much we’re yet to learn about this new virus, but we know it often causes pneumonia, an infection of the lungs which produces pus and fluid and reduces the lungs’ ability to absorb oxygen.

Of the first 99 people with severe infection, three-quarters had pneumonia involving both lungs. Around 14% appeared to have lung damage caused by the immune system, while 11% suffered from multi-organ system failure, or sepsis.

Others are at risk of complications from being treated in hospitals, such as acquiring other infections.

Read more:
How contagious is the Wuhan coronavirus and can you spread it before symptoms start?

At this stage, we know some people develop only a mild infection, while others become critically ill, but the exact proportion of each is not yet clear.

Overall, there are four key ways the Wuhan coronavirus can cause severe disease – and some can occur at the same time.

1. Direct viral damage

For the SARS (severe acute respiratory syndrome) coronavirus, direct viral damage was probably the most common way the infection caused disease. This is likely the case with the Wuhan coronavirus.

Early studies have found the Wuhan coronavirus attaches to a particular receptor found in lung tissue. This is like a lock and key mechanism allowing the virus to enter the cell, and is the same receptor the SARS coronavirus used.

Viruses “hijack” the host cell’s mechanisms to make more copies of itself. Damage results from either viruses taking over the cell completely and causing it to die, or immune cells recognising the viral infection and mounting a defence, triggering cell death.

If large numbers of cells die, then the affected organ can’t function effectively.

Studies from patients who died from SARS coronavirus showed the virus caused damage to not only the lungs, but also other organs in the body. Early research suggests the Wuhan coronavirus can also damage other organs, including the kidneys.

2. Pneumonia

While we’re still piecing together the relationship between the Wuhan coronavirus and pneumonia, there’s much we can learn from influenza.

Influenza is a virus but it commonly leads to bacterial pneumonia – this is what’s known as a secondary infection.

It’s thought the influenza virus weakens the usual protective mechanisms of the lung, allowing bacteria to establish and multiply. This is especially true in children, older people and those with compromised immune systems.

Secondary bacterial pneumonia is more severe than influenza alone – in hospitalised patients, around 10% of those with influenza and pneumonia die, compared to around 2% of those who don’t have pneumonia.

The Wuhan coronavirus appears to cause pneumonia in two ways: when the virus takes hold in the lungs, and through secondary bacterial infections, however, the first way appears to be more common.

3. Sepsis

Sepsis is a serious condition that can be caused by many infections.

When we get an infection, we need to mount an immune response to fight off the pathogen. But an excessive immune response can cause damage and organ failure. This is what happens in the case of sepsis.

Read more:
What is sepsis and how can it be treated?

Although it can be difficult to determine whether organ damage from the Wuhan coronavirus is a result of direct viral infection or indirect “collateral damage” from the immune system, initial reports suggested around 11% of people severely ill with the Wuhan coronavirus experienced sepsis with multi-organ failure.

So far no drugs or interventions have been able to dampen this immune response. Although several treatments have been proposed for Wuhan coronavirus, none have yet been shown to work.

4. Complications of hospital care

Finally, patients who require hospital care may have complications. These include infections from intravenous lines (for drips/medication) or urinary catheters (flexible tubes inserted into the bladder to empty it of urine), pneumonia, or non-infectious complications such as falls or pressure sores.

Studies have found 10% of patients in hospital have some sort of health care-acquired infection, and around 5% have a pressure sore.

Hospitals work hard to try to prevent these complications, by making sure health care workers disinfect their hands and other equipment. However, complications still occur, particularly in patients who are debilitated from long hospital stays.

Read more:
1 in 10 patients are infected in hospital, and it’s not always with what you think

While most respiratory viral infections are mild, some can trigger serious complications, either directly or indirectly. It’s too early to tell how often this occurs with the Wuhan coronavirus. While we have initial data on those who were severely affected, many others may not have required medical care.The Conversation

Allen Cheng, Professor in Infectious Diseases Epidemiology, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.