China has reported it’s lowest level of new COVID-19 infections in a month, with just 327 cases over the past 24 hours.  At the same time, cases abroad exploded overnight with 1,000 more people reported to be infected with the virus in some 49 countries. Most f new cases were heavily concentrated in the emerging global hotspots of: Korea, which saw 732 new cases since Thursday evening; Iran, 143 new cases and 8 deaths; and Italy, where new cases appeared to decline then spike against a cumulative total of 888 cases and 21 deaths, according to Italian national authorities.

Italy and Iran were also proving to powerful vectors of exported cases to other countries – reflecting how effectively the virus moves along with international travel.

“Since yesterday, Denmark, Estonia, Lithuania, Netherlands and Nigeria have all reported their first cases. All these cases have links to Italy,” said WHO’s Director General Dr Tedros Adhanom Ghebreyesus in a Friday press briefing.  “24 cases have been exported from Italy to 14 countries, and 97 cases have been exported from Iran to 11 countries.

“The continued increase in the number of cases, and the number of affected countries over the last few days, are clearly of concern… and we have now increased our assessment of the risk of spread and the risk of impact of COVID-19 to very high at a global level,” said Dr. Tedros.

Tough Message from Report of WHO-China Joint Mission

The assessment came as the report of a WHO-convened international team to China was released, containing tough messages to global health policymakers about what countries need to do to contain the epidemic, and the worldwide risks in the event of failure.

“The COVID-19 virus is unique among human coronaviruses in its combination of high transmissibility, substantial fatal outcomes in some high-risk groups, and ability to cause huge societal and economic disruption,” the report concludes. “The COVID-19 virus must be considered capable of causing enormous health, economic and societal impacts in any setting. It is not SARS and it is not influenza. Building scenarios and strategies only on the basis of well-known pathogens risks failing to exploit all possible measures to slow transmission of the COVID-19 virus, reduce disease and save lives.”

The report finds that the decline in cases in China, even in the absence of effective vaccines and drugs, is “real,” virtually unprecedented, and provides “vital lessons” for the global response.

“In the face of a previously unknown virus, China has rolled out perhaps the most ambitious, agile and aggressive disease containment effort in history. The strategy that underpinned this containment effort was initially a national approach that promoted universal temperature monitoring, masking, and hand washing. However, as the outbreak evolved, and knowledge was gained, a science and risk-based approach was taken to tailor implementation. Specific containment measures were adjusted to the provincial, county and even community context.”

“China’s uncompromising and rigorous use of non-pharmaceutical measures to contain transmission of the COVID-19 virus in multiple settings provides vital lessons for the
global response. This rather unique and unprecedented public health response in China reversed the escalating cases in both Hubei, where there has been widespread community transmission, and in the importation provinces, where family clusters  appear to have driven the outbreak.”

However the experts warn that: “Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China.”

And that is despite the fact that, “These are the only measures that are currently proven to interrupt or minimize transmission chains in humans. Fundamental to these measures is extremely
proactive surveillance to immediately detect cases, very rapid diagnosis and”immediate case isolation, rigorous tracking and quarantine of close contacts, and an exceptionally high degree of population understanding and acceptance of these measures.

The experts outline, however, a set of far-reaching recommendations for what countries need to prepare for, or carry out in the case of those already facing outbreaks, including:

• Active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantine of close contacts;
• Expanded surveillance and sceening of people with symptoms of atypical pneumonia;
• Public education;
• Involvement of all government sectors in the response effort.

In the even more dramatic means are needed, the mission report advises countries to conduct “simulations for the deployment of even more stringent measures to interrupt transmission chains as needed (e.g. the suspension of large-scale gatherings and the closure of schools and workplaces).

The Joint Mission consisted of 25 national and international experts from China, Germany, Japan, Korea, Nigeria, Russia, Singapore, the United States of America and the World Health
Organization (WHO). The Joint Mission was headed by Dr Bruce Aylward of WHO and Dr Wannian Liang of the People’s Republic of China.

WHO Recommends No Travel Restrictions: No WHO Comment On Masks For Vulnerable Groups or in COVID-19 Hotspots 

Despite the increasingly clear association between disease spread and international travel from hot spots,  WHO’s top emergency response officials, including WHO Emergencies Head Mike Ryan and the Director General himself, have continued to speak out against restrictions on international travel.  Rather than barring any incoming travelers from any particular countries or hotspots, the inherent risks need to be “managed” by preparing health facilities in countries to detect, quarantine and treat incoming cases of virus transmission, they have repeatedly said.

“WHO advises against the application of any restrictions of international traffic based on the information currently available on this event,” states the most recent WHO guidance on international travel, from 27 January. Although China sharply restricted its own outgoing travel from its country to get a handle on the epidemic, it is a contradiction WHO officials have never sought to explain.

WHO has  also generally recommended against the widespread use of face masks outside of health care settings, describing it as largely unecessary, even though this was another key element of China’s containment policy, as noted by the Joint Mission.

Even for at-risk groups such as older people living in epidemic hotspots; for border police and airport workers working face to face with travelers; or for older and at-risk commuters moving about in outbreak areas in crowded conditions, there is virtually no WHO recommendation to don a mask.

Rather, WHO recommendations state that masks should be reserved almost exclusively for people who are themselves ill, or for health care settings:

• “If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.”
• “Wear a mask if you are coughing or sneezing.”

Otherwise, however, the messages issued by top WHO leadership over the past week have largely echoed those of the Joint Mission report.

In the Friday briefing, both Dr Tedros and Ryan said that national disease strategies should continue to focus on “containment” of COVID-19 transmission, as compared to “mitigation”  – noting that without containment measures, health systems even rich countries could be quickly overwhelmed by a surge of seriously ill patients requiring respiratory treatment and critical care, which they would be ill-prepared to provide.

“What we see at the moment are linked epidemics of COVID-19 in several countries, but most cases can still be traced to known contacts or clusters of cases. We do not see evidence as yet that the virus is spreading freely in communities,” said Dr Tedros.

One exception to that has been the United States, where the Centers for Disease Control and Prevention (CDC) on Friday confirmed COVID-19 in California resident who has no at-risk travel history or exposure to another known patient.  The case has raised alarm bells that other COVID-19 infections may have passed under the radar in the US, where testing has been limited by the rigid CDC protocols and many state labs lacked training or capacity properly use the CDC test kits that they received.

However, infections with no prior source of COVID-19 contact remain the exception rather than the rule, said Dr Tedros, at the briefing.

“As long as that’s the case, we still have a chance of containing this virus if robust action is taken to detect cases early, isolate and care for patients and trace contacts,” he said. “As I said yesterday, there are different scenarios in different countries, and different scenarios within the same country.

“The key to containing this virus is to break the chains of transmission.”

This story was updated on 29 February 2020 to accurately reflect the cases of COVID-19 in Italy.

Image Credits: South Korea National Fire Agency, DXY, John's Hopkins CSSE.