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Open in new tab Report of the WHO-China Joint Mission
on Coronavirus Disease 2019 (COVID-19)
16-24 February 2020
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Table of Contents
I. THE MISSION
GOAL AND OBJECTIVES
MEMBERS & METHOD OF WORK
II. MAJOR FINDINGS
THE VIRUS
THE OUTBREAK
THE TRANSMISSION DYNAMICS
THE SIGNS, SYMPTOMS, DISEASE PROGRESSION AND SEVERITY
THE CHINA RESPONSE
KNOWLEDGE GAPS
III. ASSESSMENT
THE CHINA RESPONSE & NEXT STEPS
THE GLOBAL RESPONSE & NEXT STEPS
IV. MAJOR RECOMMENDATIONS
FOR CHINA
FOR COUNTRIES WITH IMPORTED CASES AND/OR OUTBREAKS OF COVID-19
FOR UNINFECTED COUNTRIES
FOR THE PUBLIC
FOR THE INTERNATIONAL COMMUNITY
ANNEXES
A. WHO-CHINA JOINT MISSION MEMBERS
B. SUMMARY AGENDA OF THE MISSION
C. DETAILED TECHNICAL FINDINGS
RESPONSE MANAGEMENT, CASE AND CONTACT MANAGEMENT, RISK COMMUNICATION AND COMMUNITY
ENGAGEMENT
CLINICAL CASE MANAGEMENT AND INFECTION PREVENTION AND CONTROL
LABORATORY, DIAGNOSTICS AND VIROLOGY
RESEARCH & DEVELOPMENT
D. KNOWLEDGE GAPS
E. OPERATIONAL & TECHNICAL RECOMMENDATIONS
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I. The Mission
Goal and Objectives
The overall goal of the Joint Mission was to rapidly inform national (China) and international
planning on next steps in the response to the ongoing outbreak of the novel coronavirus
disease (COVID-191) and on next steps in readiness and preparedness for geographic areas
not yet affected.
The major objectives of the Joint Mission were as follows:
• To enhance understanding of the evolving COVID-19 outbreak in China and the
nature and impact of ongoing containment measures;
• To share knowledge on COVID-19 response and preparedness measures being
implemented in countries affected by or at risk of importations of COVID-19;
• To generate recommendations for adjusting COVID-19 containment and response
measures in China and internationally; and
• To establish priorities for a collaborative programme of work, research and
development to address critical gaps in knowledge and response and readiness tools
and activities.
Members & Method of Work
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. The full list of members and their
affiliations is available in Annex A. The Joint Mission was implemented over a 9-day period
from 16-24 February 2020. The schedule of work is available in Annex B.
The Joint Mission began with a detailed workshop with representatives of all of the principal
ministries that are leading and/or contributing to the response in China through the
National Prevention and Control Task Force. A series of in-depth meetings were then
conducted with national level institutions responsible for the management, implementation
and evaluation of the response, particularly the National Health Commission and the China
Centers for Disease Control and Prevention (China CDC). To gain first-hand knowledge on
the field level implementation and impact of the national and local response strategy, under
a range of epidemiologic and provincial contexts, visits were conducted to Beijing
Municipality and the provinces of Sichuan (Chengdu), Guangdong (Guangzhou, Shenzhen)
and Hubei (Wuhan). The field visits included community centers and health clinics,
country/district hospitals, COVID-19 designated hospitals, transportations hubs (air, rail,
road), a wet market, pharmaceutical and personal protective equipment (PPE) stocks
warehouses, research institutions, provincial health commissions, and local Centers for
1 In the Chinese version of this report, COVID-19 is referred to throughout as novel coronavirus pneumonia or
NCP, the term by which COVID-19 is most widely known in the People’s Republic of China.
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Disease Control (provincial and prefecture). During these visits, the team had detailed
discussion and consultations with Provincial Governors, municipal Mayors, their emergency
operations teams, senior scientists, frontline clinical, public health and community workers,
and community neighbourhood administrators. The Joint Mission concluded with working
sessions to consolidate findings, generate conclusions and propose suggested actions.
To achieve its goal, the Joint Mission gave particular focus to addressing key questions
related to the natural history and severity of COVID-19, the transmission dynamics of the
COVID-19 virus in different settings, and the impact of ongoing response measures in areas
of high (community level), moderate (clusters) and low (sporadic cases or no cases)
transmission.
The findings in this report are based on the Joint Mission’s review of national and local
governmental reports, discussions on control and prevention measures with national and
local experts and response teams, and observations made and insights gained during site
visits. The figures have been produced using information and data collected during site
visits and with the agreement of the relevant groups. References are available for any
information in this report that has already been published in journals.
The final report of the Joint Mission was submitted on 28 February 2020.
II. Major findings
The major findings are described in six sections: the virus, the outbreak, transmission
dynamics, disease progression and severity, the China response and knowledge gaps. More
detailed descriptions of technical findings are provided in Annex C.
The virus
On 30 December 2019, three bronchoalveolar lavage samples were collected from a patient
with pneumonia of unknown etiology – a surveillance definition established following the
SARS outbreak of 2002-2003 – in Wuhan Jinyintan Hospital. Real-time PCR (RT-PCR) assays
on these samples were positive for pan-Betacoronavirus. Using Illumina and nanopore
sequencing, the whole genome sequences of the virus were acquired. Bioinformatic
analyses indicated that the virus had features typical of the coronavirus family and belonged
to the Betacoronavirus 2B lineage. Alignment of the full-length genome sequence of the
COVID-19 virus and other available genomes of Betacoronavirus showed the closest
relationship was with the bat SARS-like coronavirus strain BatCov RaTG13, identity 96%.
Virus isolation was conducted with various cell lines, such as human airway epithelial cells,
Vero E6, and Huh-7. Cytopathic effects (CPE) were observed 96 hours after inoculation.
Typical crown-like particles were observed under transmission electron microscope (TEM)
with negative staining. The cellular infectivity of the isolated viruses could be completely
neutralized by the sera collected from convalescent patients. Transgenic human ACE2 mice
and Rhesus monkey intranasally challenged by this virus isolate induced multifocal
pneumonia with interstitial hyperplasia. The COVID-19 virus was subsequently detected
and isolated in the lung and intestinal tissues of the challenged animals.
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Whole genome sequencing analysis of 104 strains of the COVID-19 virus isolated from
patients in different localities with symptom onset between the end of December 2019 and
mid-February 2020 showed 99.9% homology, without significant mutation (Figure 1).
Figure 1. Phylogenetic analysis of the COVID-19 virus and its closely related reference
genomes
Note: COVID-19 virus is referred to as 2019-nCoV in the figure, the interim virus name WHO announced early in the
outbreak.
Post-mortem samples from a 50-year old male patient from Wuhan were taken from the
lung, liver, and heart. Histological examination showed bilateral diffuse alveolar damage
with cellular fibromyxoid exudates. The lung showed evident desquamation of
pneumocytes and hyaline membrane formation, indicating acute respiratory distress
syndrome (ARDS). Lung tissue also displayed cellular and fibromyxoid exudation,
desquamation of pneumocytes and pulmonary oedema. Interstitial mononuclear
inflammatory infiltrates, dominated by lymphocytes, were seen in both lungs.
Multinucleated syncytial cells with atypical enlarged pneumocytes characterized by large
nuclei, amphophilic granular cytoplasm, and prominent nucleoli were identified in the intra-
alveolar spaces, showing viral cytopathic-like changes. No obvious intranuclear or
intracytoplasmic viral inclusions were identified.
The outbreak
As of 20 February 2020, a cumulative total of 75,465 COVID-19 cases were reported in
China. Reported cases are based on the National Reporting System (NRS) between the
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