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Viewpoint
February 24, 2020

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

Author Affiliations
  • 1Chinese Center for Disease Control and Prevention, Beijing, China
JAMA. 2020;323(13):1239-1242. doi:10.1001/jama.2020.2648

The Chinese Center for Disease Control and Prevention recently published the largest case series to date of coronavirus disease 2019 (COVID-19) in mainland China (72 314 cases, updated through February 11, 2020).1 This Viewpoint summarizes key findings from this report and discusses emerging understanding of and lessons from the COVID-19 epidemic.

Among a total of 72 314 case records (Box), 44 672 were classified as confirmed cases of COVID-19 (62%; diagnosis based on positive viral nucleic acid test result on throat swab samples), 16 186 as suspected cases (22%; diagnosis based on symptoms and exposures only, no test was performed because testing capacity is insufficient to meet current needs), 10 567 as clinically diagnosed cases (15%; this designation is being used in Hubei Province only; in these cases, no test was performed but diagnosis was made based on symptoms, exposures, and presence of lung imaging features consistent with coronavirus pneumonia), and 889 as asymptomatic cases (1%; diagnosis by positive viral nucleic acid test result but lacking typical symptoms including fever, dry cough, and fatigue).1

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    10 Comments for this article
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    Smoking History Linked to Mortality?
    Thomas Ferber, Dr. | Oncoletter.ch
    In all the epidemiological studies about the novel coronavirus outbreak there is no differentiation between smokers and non-smokers. Does smoking and preexisting lung disease influence morbidity and mortality?
    CONFLICT OF INTEREST: None Reported
    Date of Onset of Symptoms in the First Patient And Supposed Source of Infection
    Giuliano Ramadori, Professor of Medicine | University Clinic Göttingen Germany
    I am grateful for the enormous amount of work done by the authors in reporting as precisely as possible the numbers and characteristics of patients demonstrated (or supposed to have been) infected by a variant of the coronavirus.

    In the report, however, I do not find a demonstration concerning the hypothesized "zoonotic spillover" as the cause of human infection. In public imagination this assumption turns the viral infection into a much stronger threat than it is.

    According to Chaolin Huang et al.(1), "the symptom onset date of the first patient identified was Dec. 1,2019."
    Therefore this date
    should be added to the very important and comprehensive epidemic curve (Figure 1) and to the timeline comparing the SARS and the COVID-19 outbreaks (Figure 2) in this report.

    REFERENCE

    1. Chaolin Huang et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan,China. The Lancet, January 24, https://doi.org/10.1016/50140-6736(20)30183-5
    CONFLICT OF INTEREST: None Reported
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    Data Missing on Sex and Professions
    Hedley Quintana, MD, MSc, PhD | Gorgas Memorial Institute for Health Studies
    This article lacks data on sex and profession! Are they considered relevant regarding COVID-19 infectivity and mortality?
    CONFLICT OF INTEREST: None Reported
    Age as a Risk Factor
    Toufique Hussain, MPH | Sindh Institute of Ophthalmology and Visual Sciences, Hyderabad Pakistan
    The authors have complicated interpretation of their data in the age group 30 to 79 years. It is a wide span that obscures different populations, and the authors should report more age groups (eg 30-45, 46-65, 66-79) to understand if any of these more precisely defined age groups is at greater risk.
    CONFLICT OF INTEREST: None Reported
    Outbreak
    Irfan Malik, FCPS Pulmonology | Post Graduate Medical Institute, Lahore General Hospital, Lahore Pakistan
    Very important lessons and experiences shared in this short viewpoint report regarding COVID-19, a recent horrible outbreak of viral infection in China. Detailed data is shared related to this disease like age, sex and epidemiological distributions which are very informative for understanding the severity of this viral infection. Though many people suffer from this infection, mortality is not high. This report also shows that a large number of healthcare workers (HCWs) were affected in this viral outbreak, which is an eye opener for HCWs to be vigilant in treating people and to follow infection prevention and control standard precautions. />
    This report also highlights the active precautionary measures which took place in response to this contagious disease in China. It would be challenging to enact the same measures in developing countries like Pakistan. China is a developed country and took all these precautionary measures in a very short period. In contrast, resources in developing countries like Pakistan are limited, and it would be difficult to take comparable precautionary measures against contagious infectious illnesses in the same period of time. China as a nation is so united it’s a lesson for other countries to face critical public health situations with similar unity.
    CONFLICT OF INTEREST: None Reported
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    Follow-up Data Missing on Discharged Patients
    Zhiyan Liu, PhD | Peking University First Hospital
    As of February 27, 36117 cases had been cured and discharged in China. The follow-up data of cured patients were not reported and analyzed, including the positive rate of nucleic acid test and clinical symptoms within 14 days.
    CONFLICT OF INTEREST: None Reported
    False Diagnoses and Reinfection
    Michael McAleer, PhD (Econometrics) | Asia university
    This highly informative viewpoint cannot cover all issues, so two queries are as follows:

    1. What is the possibility of having false positives or false negatives arising from checks for COVID-19?

    2. Is there any possibility of reinfection after purported recovery and, if so, how soon can this occur?
    CONFLICT OF INTEREST: None Reported
    Occurrence of Infections and Mild and Subclinical disease
    Victor Cardenas, MD, MPH, PhD | University of Arkansas for Medical Sciences Fay W. Boozman College of Public Health
    I have read with great interest the report on behalf of the Chinese CDC team, and I am puzzled by the low frequency of reports of cases among children. I believe age-specific rates would have been more informative. A burning question before us is whether or not there are cases of mild acute respiratory infections (ARI) in children, possibly not severe enough to merit a visit to an emergency room? One quick look at the reported figures of office visits for ARI would be valuable, to see whether the figures have remained stable in the affected provinces. In your report I could not find out if there has been a systematic effort to investigate the occurrence of any respiratory symptoms including mild disease among contacts of cases. Since it is unlikely that children are not susceptible to the SARS-2 virus, and in some instances recent cases in the US seemed to have no obvious source case among contacts, the possibility of some spread through asymptomatic carriers or persons with mild disease could play role in the transmission. More population-based epidemiological and laboratory-based research possibly in households is needed to answer the question of why the risk among children seems small.
    CONFLICT OF INTEREST: None Reported
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    Where are Clinically Diagnosed Cases Now?
    Padmanabhan VT, Master Community Health | Freelancer
    Regarding the clinically diagnosed cases in Hubei province, the authors do not explain as to why “no test was performed but diagnosis was made based on symptoms, exposures, and presence of lung imaging features consistent with coronavirus pneumonia.” In fact the clinically diagnosed group was mentioned only once in the report from the Health Commission of Hubei province on 11 Feb 2020. NHC or CDC did not mention this group in any report. According to the CDC report, on March 07, 2020 there were 80,651 confirmed cases and 502 suspected cases.

    The clinically
    diagnosed group disappeared because they were added to the confirmed list during 12-15 Feb 2020.

    The WHO’s situation reports for 12 to 16 Feb 2020 did not include these cases. The situation report for 16 Feb had 51,174 laboratory confirmed cases in China and on 17 Feb 2020 there were 70,635 confirmed cases in China, which included the clinical cases also. The WHO now reports cases in China as confirmed and cases from rest of the world as laboratory-confirmed.

    The WHO’s definitions of confirmed and probable cases of COVID-19 are reproduced below:

    Confirmed case: A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms.

    Probable case: A suspect case for whom testing for COVID-19 is inconclusive. • Inconclusive being the result of the test reported by the laboratory.

    Detailed report at:

    https://www.researchgate.net/publication/339746617_final_2A1
    CONFLICT OF INTEREST: None Reported
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    Paciente Asintomático
    David Ezequiel Garcia, Licenciado en enfermería | Hospital general de occidente.
    Los paciente asintomaticos mencionados en la estadistica fueron positivos a RT-PCR?

    Were the asymptomatic patients mentioned in the reporting of patients positive for RT-PCR?
    CONFLICT OF INTEREST: None Reported
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