Containing an explosion of COVID-19 cases in Korea and Iran have become top priorities for global health officials battling to prevent the epidemic from growing into a worldwide pandemic. While new lab-confirmed cases in China on Friday numbered 896, more than double the day before, that was still part of an generally downward trend as compared to the two weeks before. But expanding clusters of cases in prisons, including one in the eastern Chinese province of Shandong, elevated concerns about Chinese hotspots outside of Wuhan, the epicentre of the outbreak.

Early Friday evening, meanwhile, Italian health officials announced a cluster of 8 new cases in the northern Italy town of Codogno, five among medical staff at the local hospital, where 3 infected patients who had contracted the virus, were already being treated. The new reports brought Italy’s total of confirmed cases to 16.

The Italian, Korean and the Iranian cases illustrate how seemingly random events involving just a few individuals can drive much larger outbreaks of the highly contagious virus. In South Korea, just one woman has infected dozens of other fellow members of her church in the city of Daegu.

In the case of Iran, a mysterious series of geographically dispersed clusters led to reports of some 18 infections as of Friday, four deaths in the pilgrimage city of Qom, and onwards transmission of the virus by two infected travelers who were identified upon arriving in Canada and Lebanon.

“The window of opportunity may be closing,” said Dr Tedros Adhanom Ghebreyesus in a press briefing on Friday. “Although the total number of cases outside China remains relatively small, we are concerned about the number of cases with no clear epidemiological link, such as travel history to China or contact with a confirmed case.”

Origins of Iran’s COVID-19 Cases Unclear 

While most of the cases outside of China have until now been linked to travel to the epicenter of the outbreak or known contacts of confirmed cases, the transmission patterns in Iran are so far unclear. Reports of cases in Lebanon and Canada, linked to recent travel from Iran, but not to China, were later confirmed by health officials in both countries.

An Iranian Ministry of Health official told CNN news that it was “possible” more cases existed in cities across the country, and speculated that the virus was possibly imported by Chinese workers living in Qom, an important center of Shiite Muslim pilgrimage. China has continued to do business with the Islamic Republic in defiance of US sanctions. However, a Ministry of Health official told Iranian News Agency IRNA on Thursday that two patients who had died of COVID-19 in Qom had not reported any contact with foreigners or Chinese nationals, and their families had not yet been subjected to quarantine.

“We’re getting information [from Iran], but we need to engage with them more,” said Tedros. “These dots or trends are very concerning and we’re working with the government to fully understand the transmission dynamics.”

Meanwhile, cases in South Korea shot up by 100 new cases in the past 24 hours to a total of 204 confirmed cases, making South Korea the country with the highest number of cases outside China. According to the Korean Centers for Disease Control, at least 129 of those cases are members of the Shincheonji church, a Christian organization considered cult-like by many mainstream churches. Most cases related to the church have been clustered in Daegu, although cases in church members have also been reported in Seoul and Gwangju.

Sweeping Closure of Commercial Activities & Public Events In Italy’s Lombardy Region 

In response to outbreak in northern Italy, Minister of Health Roberto Speranza announced a sweeping series of measures in Codogno and about ten other surrounding towns, including: suspension of all public events, commercial activities, schools and day care centers, municipal works, public transport services, and recreation services.

The total number of people infected in the Lombardy region now stands at 14, said the minister and other health officials at a press conference Friday.  The officials’ descriptions of the infection chain illustrates how very casual contacts played a role in the expanding outbreak. The first person to be infected was a 38-year-old man who had become ill after meeting a friend recently returned from China.  He then infected his wife, and a running group acquaintance. They were all hospitalized. Three older friends of the runner, who all frequented the same bar, were then infected, followed by the five health workers at the local hospital, who were treating the initally infected patients, and several others.  There are reportedly two other COVID-19 cases in Italy’s Veneto region.

Despite the fast-changing path of the virus, WHO’s Director General said he still believed that the outbreak could potentially be contained, if countries step up preparedness measures.

“The window of opportunity is still there but [it] is narrowing, and that is why we call on the international community to act, including the financing, and that is not what we see.”” said Dr. Tedros.

China Changes Reporting Protocol Again Amid New Spread In Prisons

As of 5:30pm CET, there were 896 new cases of the virus in China according to official Chinese data, higher than the increase of 404 cases recorded yesterday, but much lower than the 2,000-3,000 new cases reported almost daily in the previous week. Total cases in China were 75,571, while abroad the total number of cases exceeded 1,225 in 27 countries, late Friday afternoon, as Israel also reported its first coronavirus case – in a passenger returning from the Diamond Princess cruise ship.  That latest count did not include the late breaking reports of infections in Italy.

The significant decline in new confirmed Chinese cases may indicate that authorities there are finally getting the infection more under control.  But it is also partly due to another change in the way China reports numbers. After adding over 14,000 clinically diagnosed cases to the number of confirmed cases in Hubei province on Wednesday last week, authorities have reverted back to only including lab diagnosed cases in the count, WHO officials said today at the press briefing. They said that the zig zag was due to the fact that with less pressure on health systems, most suspected cases were now being rapidly lab confirmed.

In a place with the lab capacity to test every suspected case for the virus, the “recommended approach” is to classify lab-confirmed cases as confirmed, and other cases as “suspected,” explained Tedros. “We’re glad China has gone back to this approach, we think it will bring more clarity.”

In response to concerns about the confusing changes in reporting measures, WHO’s director of epidemic and pandemic diseases Sylvie Briand stressed, “As long as we understand the situation, it helps us. Surveillance or monitoring disease is about taking the best possible decision and collecting numbers for action, not numbers for numbers… Beyond the numbers what’s important is trends.”

“Understanding the definition” rather than where the numbers are reported is the basis for decisions, she added. “At the end of the day, as long as the decision behind the numbers is a good decision, that is what matters most.”

WHO Director General Expresses “Concern” Over Increase of Cases In Shandong Province – Reference to Prison Hotspot   

WHO’s Tedros also said that WHO was “concerned about an  increase in the number of cases in Shandong province.” According to a local news station Qilu Evening News, 200 of the 202 new cases reported in Shandong Thursday night occurred in Rencheng prison. Some 207 cases have been reported in total from the prison, including 7 prison guards and 200 prisoners.

The reports were confirmed by state owned news agency Xinhua on Friday, which reported that the index case was a prison guard who was diagnosed on 12 February. However, proper infection prevention control measures were not taken until much later, leading to a dramatic overnight rise in confirmed cases in the prison. The debacle led to the national government launching a formal investigation into the handling of the outbreak, which resulted in the replacement of the director of the Provincial Justice Department and sacking of a number of prison officials, including the director of Rencheng prison, according to Xinhua.

But the South China Morning Post reported that there have been a number of other prisons in China where outbreaks are flourishing in confined and closed conditions. These include a Wuhan Woman’s Prison, which has reported some 230 cases, and smaller clusters in Shayang Hanjin prison in Hubei province and Shilifen Prison in Zhejiang province.

Reports about the contagious virus’ spread in prisons mirror the growing concern around transmission of the virus in so-called “re-education” centres in Xinjiang province, where China has reportedly detained 1-1.5 million ethnic Muslim Uyghurs in overcrowded facilities with limited access to medical care, contact with friends and family, according to a report by the UN’s Office of the High Commissioner for Human Rights (OHCHR).

So far, WHO has not made any public comment on the potential transmission of the virus in the camps, which have been criticized by the OHCHR as “amounting to detention centres” due to their “coercive nature.”

Updated Saturday 22 February 

Image Credits: Flickr: Pierre Le Bigot.