‘China Box’: Buried WHO Report Of Italy’s COVID-19 Response Cited ‘Inconvenient Facts’ On Pandemic’s Initial Spread in Asia Analysis 23/12/2020 • Elaine Ruth Fletcher & Nicoletta Dentico Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to email this to a friend (Opens in new window)Click to print (Opens in new window) Wuhan residents lining up outside a drugstore to buy masks in January. From the beginning of the outbreak, masks were required by Chinese authorities to reduce person-to-person transmission – WHO only issued a recommendation months later. The redacted WHO report on Italy’s pandemic response, “An Unprecedented Challenge” contained a brief timeline of events in the early days of the SARS-CoV-2 outbreak in China, which a number of WHO officials sought to amend or suppress even before the entire report was recalled. In fact, the so-called “China box” on the outbreak’s early days, which had been vetted by several experts, contained a narrative of sensitive key events – including the fact the genome sequence was posted publicly by scientists the week before the official report by Beijing of the genome sequence to WHO – which have either been omitted or muted in the official WHO timeline of the COVID-19 pandemic, which was updated just last week. Straightforward Narrative – With Bombshell Implications – Ruffling Feathers In Beijing or Washington? The intent of the “China box” – the name gaven to a box-out in the report – of no more than 300 words, was straightforward: to present a terse, factual narrative of the pandemic’s onset in Wuhan and beyond. However, just ahead of the report’s publication, a controversy over the fine print of the “China box” text erupted among WHO officials, Health Policy Watch has learned. And it was in fact concerns over that box, which directly led to the report’s withdrawal from the WHO website on 14 May, a day after it had been published online. The chain of events raises further questions over whether the entire document’s recall may not only have been linked to the feathers it might ruffle in Rome, but also those in Beijing. China Box Timeline Drawn From Original WHO Reports – Which Were Later ‘Amended’ The China box: excerpted from the suppressed WHO report, “An unprecedented challenge” The report’s “China box” provided a cursory, but unvarnished narrative of the early days of the SARS-Cov-2 virus spread, which was based on initial WHO epidemiological reports from January 2020 and other expert sources. But that WHO narrative has since seen several major revisions – including on 27 April, 29 June, and again on 15 December. As a result, some of the facts to which the “China box” briefly refers – and verified by outside sources – have since been muted or even removed from the official WHO record. Examples include: the circumstances around the initial SARS-Cov2 genome sequencing; WHO statements downplaying the possibility of human-to-human virus transmission in connection with the first reported cases in Wuhan; and the first case reported outside of China in Thailand on 13 January- in someone with no link to the Wuhan seafood market – providing evidence of human to human transmission. Here below are the details of the “China box” account of events – and the revisions the record has since undergone: First Case Reports & WHO Statement on “No Evidence” Of Human to Human Transmission The China box states that “As of 3 January, 2020 China had reached 44 cases, including 11 with severe systems; the Wuhan City Health Committee confirmed that 121 close contacts were under observation. WHO was told that there was no evidence of human to human transmission.” Indeed, WHO repeatedly referred to the lack of any evidence, or any clear evidence, of human-to-human transmission in the first three weeks of January, at WHO press conferences as well as in tweets, such as one on January 12. Only in the latter part of January, shortly before declaring a public health emergency of international concern, did WHO finally begin to concede that human to human transmission was occurring. The “China Box” narrative refers bluntly to this “inconvenient” fact of WHO’s earlier communications which downplayed transmission risks – communications that are now muted in the official WHO account. WHO Timeline Revisions: WHO “updates” of the pandemic timeline, in April, June and December, omit reference to WHO’s initial dismissals of human to human transmission risks. The latest WHO timeline, updated on 15 December 2020, begins the narrative on the transmission risks with a tweet from 19 January 2020, by WHO’s Western Pacific Regional Office, stating; “According to the latest information received and @WHO analysis, there is evidence of limited human-to-human transmission of #nCOV.” According to the latest information received and @WHO analysis, there is evidence of limited human-to-human transmission of #nCOV.This is in line with experience with other respiratory illnesses and in particular with other coronavirus outbreaks. — World Health Organization Western Pacific (@WHOWPRO) January 19, 2020 A little more than a week later, on 30 January, WHO declared the new coronavirus a public health emergency of international concern. The initial number of cases that had been reported in Wuhan as of 3 January 2020 (44 ill, 11 seriously)- are not explicitly mentioned in the most recent 15 December timeline update either; the timeline refers simply to a “cluster of cases”. The case numbers are, however, still available online in the 5 January 2020 WHO Disease outbreak news. Publication Of the SARS-CoV-2 Genome Sequence The China Box states: “On 7 January, the causative agent was identified by China as a novel strain of coronavirus and the genetic sequence was quickly made available.” Early WHO accounts acknowledge that the virus had been isolated in the week of 7 January. A WHO disease outbreak report from 12 January stated: “The Chinese authorities identified a new type of coronavirus (novel coronavirus, nCoV), which was isolated on 7 January 2020.” A 10 December post on virological.org, by an Australian researcher from the University of Sydney “on behalf of the consortium led by Professor Yong-Zhen Zhang, Fudan University, Shanghai” note that the sequence was available on an open-source data base called GenBank. This is echoed by direct postings from the University of Minnesota’s prestigious Center for Infectious Disease Research and Policy. However, the fact that the virus sequence had first been posted independently online by a group of Chinese researchers before it was shared by China officially with WHO on Saturday, 11 January became a subsequent point of political embarrassment. It is among the issues that has been raised by WHO critics, who say that there was intense backroom coordination between WHO and Beijing over the course of the pandemic narrative. Either way, the updated WHO timelines contain no reference to any independent sharing of the sequence by researchers in the week of 7 January – and the fact that the virus sequence was already available on an open source database by Friday, 10 January. Rather, the official WHO timeline begins with 11 January in one tweet, headlined “Breaking” noting that the virus had been made available to WHO. An earlier WHO report in “Disease Outbreak News, which has since been removed from the record, cites 12 January as the date in which the genetic sequence was officially shared by Chinese government officials. The fact that the “China box” suggests that the virus was sequenced and publicly available earlier in that week – resurrects a politically sensitive issue that WHO and Beijing would both rather forget. That is the fact that China may have dallied in sharing the vital information with the global body – possibly doing so only after it had been made available ad-hoc by a group of Chinese researchers. BREAKING: WHO has received the genetic sequences for the novel #coronavirus (2019-nCoV) from the Chinese authorities. We expect them to be made publicly available as soon as possible. pic.twitter.com/h1w7A0jBm2 — World Health Organization (WHO) (@WHO) January 11, 2020 First Case Report Outside China – Growing Evidence of Human-to-Human Transmission The China box states: “The first case outside of China was reported on 13 January in Thailand. There was a link to Wuhan, but not to the market in question, suggesting human-to-human transmission.” The fact that the Thai case was the first abroad, and it also had no apparent link to the Wuhan seafood market, were both facts widely reported in the media as mounting evidence of the virus spread, and likely human-to-human transmission – including in this paper, which led a story on Wednesday, 15 January, stating “Human Transmission of New Coronavirus May be Occuring.” Further evidence of human-to human transmission was indeed evident by Wednesday, as second case was reported in Thailand, as well as another infection in Japan – the latter in a man who had never visited the Wuhan seafood market thought to be the center of the outbreak. In addition, a commission of technical experts from Hong Kong, Macao and Taiwan, visited Wuhan on 13-14 January, confirming that they had found two family clusters of the virus, including a spouse who had not visited the market recently. Chinese links to the original Wuhan government report about the experts’ visit, as well as the statement by Wuhan authorities about the woman who may have been infected by her husband, which were linked to the Health Policy Watch story of 15 January, have since been deleted. In a WHO press briefing on 14 January, WHO’s Maria Van Kerkhove, admitted that “from the limited information that we have, it is possible that there is limited human-to-human transmission, especially among families who have close contact with one another. However, the official, updated, WHO timeline account remains silent about the ways in which the Japanese and Thai cases had heightened concerns over human-to-human transmission – and ambivalent about those risks overall. A 14 January tweet by WHO continued to maintain that “Chinese authorities have found no clear evidence of human-to-human transmission of the novel #coronavirus (2019-nCoV) identified in #Wuhan, #China.” WHO’s official Disease Outbreak Report, posted 14 January. also maintained that: “To date, China has not reported any cases of infection among healthcare workers or contacts of the cases. Based on the available information there is no clear evidence of human-to-human transmission.” That same disease outbreak report also sounded another note of false reassurance, stating that: “No additional cases have been detected since 3 January 2020 in China.” Cases Increasing Exponentially & Health Workers Dying WHO statements to the contrary – cases were increasing exponentially in Wuhan in that period – but under the international health radar. And health workers were falling ill – including the Chinese whistleblower, Li Wenliang, who had alerted colleagues to the new infectious virus in a medical chat group on 30 December 2019, was hospitalized on 13 January, and died February 7. At the same time in mid-January when WHO Director General was repeatedly praising China for its fast and efficient response, Wenliang and other Chinese doctors trying to get a grip on the emerging virus were being reprimanded and detained by authorities. Li Wenliang, doctor at Central Hospital of Wuhan, was one of the 8 people detained by police for spreading “rumors” about the new viral disease – from which he died on 7 February. Even so, WHO resisted acknowledging the human to human transmission was occurring until a WHO mission visited China in the last part of January. On 19 January, WHO’s Western Pacific Regional Office (WPRO), which is responsible for China, tweeted that “there was evidence of limited human to human transmission” On 21st January WHO/WPRO tweeted that “it is now clear that there is at least some human to human transmission”. It wasn’t until 22 January that the WHO mission which had rushed to China issued a statement saying that “Data collected through detailed epidemiological investigation and through the deployment of the new test kit nationally suggests that human-to-human transmission is taking place in Wuhan” The WHO Mission added, however, that “more investigation was needed to understand the full extent of transmission of human-to-human transmission.” On the same day, WHO’s Second Situation Report on the novel coronavirus, reported a total of 314 cases, of which 270 were in Wuhan, 39 elsewhere in China, and four abroad in Thailand, Japan and South Korea. WHO’s Emergency Committee met and on 23 January failed to agree on declaring a public health emergency of international concern (PHEIC). Just one week later on 30 January, the number of confirmed cases globally had increased 25 fold to 7818, including 82 cases in 18 countries outside of China; no one could doubt that human-to-human transmission was occuring. And WHO would finally declare a Public Health Emergency of International Concern, this critical point of human transmission was still up for debate. China Box Became a Lightning Rod For WHO Political Concerns Ultimately, insiders say, the China box became a lightning rod for the full set of WHO political concerns that were weighing down on the document. Key WHO China experts also were afraid that geopolitical sensitivities would be aroused by the facts that it cited – which were in the process of being buried by WHO official records, sources say. “Kindly pull the document off the web immediately. Consider this an emergency,“ said one internal email, seen by Health Policy Watch. One key correction was needed, in fact: unlike the narrative implied by WHO’s initial alert about the outbreak, in its 5 January 2020 “Disease Outbreak News” account, the Chinese authorities had not directly “informed” WHO’s China Country Office on 31 December 2019 about the outbreak; rather WHO learned about it from a Wuhan Municipal Health Commission press release. After the exact circumstances of the first alert were aired widely by media, WHO amended the account in its official timeline. But there were yet other, more politically-tinged objections to the text – including objections to a reference that the 13 January report of the infected person in Thailand was “suggesting human-to-human transmission.” While this, too, was widely reported in the media as one of the first examples of human-to-human transmission (the person in question had not been at the Wuhan Seafood Market), the text was perceived as “contradicting” 14 January statements by Director General Dr Tedros Adhanom Ghebreyesus downplaying the risks, the team was told. The fact that official WHO statements downplayed the human-to-human transmission risk in that period is very clear, as described in the official outbreak news reports and Twitter chains cited here. The record of Dr Tedros’s own statements is more elusive. A google search turned up a single tweet by @DrTedros on 5 January acknowledging the outbreak and noting WHO was in contact with Chinese authorities; another tweet 20 January announces the IHR Emergency Committee’s meeting. Dr Tedros’ first official statement on the WHO record about the novel coronavirus dates to 22 January, 2020, when he convened the IHR Emergency Committee. Good to receive updated information from #China on #pneumonia of unknown cause in Wuhan City. @WHO remains in close touch with 🇨🇳 authorities as they work to identify the cause. https://t.co/USteczAV1m — Tedros Adhanom Ghebreyesus (@DrTedros) January 5, 2020 Text Revisions lead to Report Suppression Whether the issues raised by the China box touched on facts, political sensitivities – or a combination of both – the report’s lead coordinator, Francesco Zambon, based in WHO’s Venice Office, was asked to make textual revisions – and told he should also talk to the WHO Legal Department. In fact, it is WHO Legal – and not only the scientists – who have a final word on the elements of the coronavirus narrative that are published in WHO’s name – and those that are muted or ignored. Rather than see the objections proliferate further, the report’s lead author, Wim Van Lerberghe, who was focused on portraying the account in Italy and not in China, quickly offered to remove the sensitive box from the document altogether. Zambon and the writing team, at the WHO Venice Office, which was in charge of the publication, agreed. The team was particularly eager to resolve the issues over China – insofar as these were coming on top of objections raised by WHO’s Assistant Director General Ranieri Guerra, a former Italian Ministry of Health official, to the detailed Italy narrative that was the heart of the report. Guerra, according to the emails and testimonies reported by Health Policy Watch on 15 December, wanted to remove or tone down phrases in the report that he perceived as shedding negative light on the Italian government response or even, as insiders say, on him personally. Notably, the record shows that Guerra wanted to amend a reference in the report to Italy’s national pandemic preparedness plan, so as to suggest that the 2006 plan had been updated in 2016 – when in fact it had not been. In this same period he was in charge of the Ministry’s prevention initiatives -which should have included updating the decade-old plan. On 14 May, the day after the report’s publication, it was removed from the WHO website – so that an amended version without the China box could be uploaded again – a process that was supposed to happen the same day. But the report on Italy’s pandemic response – An Unprecedented Challenge – never was republished. WHO’s official response 14 December states that: “Following publication, factual inaccuracies were found in the text and the WHO Regional Office for Europe removed the document from the website, with the intent to correct errors and republish it. “By the time corrections were made, WHO had established a new global mechanism – called the “Intra-action Review” – as a standard tool for countries to evaluate their responses and share lessons learned. The original document (“An unprecedented challenge”) was therefore never republished.” In fact, the corrections to the China box were only supposed to take a couple of hours; the WHO Intra-action review process guidance to countries for conducting their own pandemic response reviews, was published over two months later – on 23 July, 2020. Asked on by Health Policy Watch to explain what factual inaccuracies at stake, a WHO spokesperson declined to comment, saying, “We are not going to discuss factual inaccuracies.” WHO Responds To China Box Story In a response following the publication of this article, a WHO spokesperson provided Health Policy Watch with the following clarifications about the issues surrounding the China box controversy, and the WHO narrative around the early days of the outbreak: “Regarding the issue itself of China box: The Italy report was removed to address concerns expressed by WHO’s China country office about ‘Box 1: How it started.’ “The report was never re-published, however, upon the decision of the WHO Regional Office for Europe for reasons unrelated to the China box. There are several inaccuracies in the China box in relation to the reporting of the outbreak and the characterization of human to human transmission: “Having made a request to the authorities on 1 January 2020, WHO’s China country office received information on the cluster of cases of ‘viral pneumonia of unknown cause’ identified in Wuhan directly from Chinese officials on 3 January 2020 – not 31 December 2019 as the ‘How it started’ box says. “WHO did learn of the outbreak on 31 December 2019 through its monitoring in two ways. Its Country Office in China picked up a media statement by the Wuhan Municipal Health Commission. WHO’s Epidemic Intelligence from Open Sources (EIOS) platform also picked up a media report on ProMED (a programme of the International Society for Infectious Diseases). “The box says that “WHO was told that there was no evidence of human-to-human transmission” but our Disease Outbreak News from 5 January importantly nuances this statement with the word ‘significant’: ‘Based on the preliminary information from the Chinese investigation team, no evidence of significant human-to-human transmission and no health care worker infections have been reported.’ The box surfaces human-to-human transmission (H2H) as an issue but does not reference relevant and important WHO documents and statements from January, including: 10 January: Guidance on infection prevention and control 14 January: Press conference, which recognised H2H as a possibility; WHO tweet that preliminary investigations by the Chinese authorities had found “no clear evidence of human-to-human transmission”; WHO’s own risk assessment saying that additional investigation was needed into H2H. 19 Jan: WHO Western Pacific Regional Office tweet that there was evidence of limited H2H. WHO continues to refine the timeline of its activities from Day 1 of the outbreak. The interactive and text timelines are regularly updated to add recent activities and also amend earlier listings. We aim to state clearly when we have made a material change in a timeline. The interactive timeline remains our main reference piece.” ________________________________________________ -Updated 29 December 2020 Third in a series. First two stories include: World Health Organization’s Censorship Of Report On Italy’s Pandemic Response Sets Dangerous International Precedent – Critics Say WHO Playbook For Responses To Media Queries On Suppressed Italian COVID-19 Report – Raises More Questions than Answers Image Credits: Flickr/Nicolò Lazzati, China News Service／中国新闻网, An unprecedented challenge, WHO 2020, Nandu News. 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