The Chinese doctor who tried to warn others about coronavirus

Dr Li Wenliang, who was hailed a hero for raising the alarm about the coronavirus in the early days of the outbreak, has died of the infection.

His death was confirmed by the Wuhan hospital where he worked and was being treated, following conflicting reports about his condition on state media.

Dr Li, 34, tried to send a message to fellow medics about the outbreak at the end of December. Three days later police paid him a visit and told him to stop. He returned to work and caught the virus from a patient. He had been in hospital for at least three weeks. He posted his story from his hospital bed last month on social media site Weibo.

“Hello everyone, this is Li Wenliang, an ophthalmologist at Wuhan Central Hospital,” the post begins.

It was a stunning insight into the botched response by local authorities in Wuhan in the early weeks of the coronavirus outbreak.

Dr Li was working at the centre of the outbreak in December when he noticed seven cases of a virus that he thought looked like Sars – the virus that led to a global epidemic in 2003. The cases were thought to come from the Huanan Seafood market in Wuhan and the patients were in quarantine in his hospital.

On 30 December he sent a message to fellow doctors in a chat group warning them about the outbreak and advising they wear protective clothing to avoid infection.

What Dr Li didn’t know then was that the disease that had been discovered was an entirely new coronavirus.

In his Weibo post he describes how on 10 January he started coughing, the next day he had a fever and two days later he was in hospital. His parents also fell ill and were taken to hospital.

It was 10 days later – on 20 January – that China declared the outbreak an emergency. Dr Li says he was tested several times for coronavirus, all of them came back negative.

On 30 January he posted again: “Today nucleic acid testing came back with a positive result, the dust has settled, finally diagnosed.”

He punctuated the short post with an emoji of a dog with its eyes rolled back, tongue hanging out.

Not surprisingly the post received thousands of comments and words of support.

“Dr Li Wenliang is a hero,” one user said, worrying about what his story says about their country. “In the future, doctors will be more afraid to issue early warnings when they find signs of infectious diseases.”

“A safer public health environment… requires tens of millions of Li Wenliang.”

How worried should we be?

A virus – previously unknown to science – is causing severe lung disease in China and has also been detected in other countries.

People are known to have died from the virus, which appeared in the city of Wuhan in December.

The disease has been spreading and experts expect the number of people infected will keep rising.

A new virus arriving on the scene, leaving patients with pneumonia, is always a worry and health officials around the World Health Organization has declared a global emergency. Can this outbreak be contained or is this something far more dangerous?

What is this virus?

Officials in China have confirmed the cases are caused by a coronavirus. These are a broad family of viruses, but only six (the new one would make it seven) are known to infect people.

Severe acute respiratory syndrome (Sars), which is caused by a coronavirus, killed 774 of the 8,098 people infected in an outbreak that started in China in 2002.

“There is a strong memory of Sars, that’s where a lot of fear comes from, but we’re a lot more prepared to deal with those types of diseases,” says Dr Josie Golding, from the Wellcome Trust.

How severe are the symptoms?

It seems to start with a fever, followed by a dry cough and then, after a week, leads to shortness of breath and some patients needing hospital treatment. Around one-in-five cases are thought to be severe.

Notably, the infection rarely seems to cause a runny nose or sneezing. The coronavirus family itself can cause symptoms ranging from a mild cold all the way through to death.

“When we see a new coronavirus, we want to know how severe are the symptoms. This is more than cold-like symptoms and that is a concern but it is not as severe as Sars,” says Prof Mark Woolhouse, from the University of Edinburgh.

How deadly is it?

While the ratio of deaths to known cases appears low, the figures are unreliable.

It is far too simplistic to divide the number of deaths by the number of cases to calculate the death rate to get a figure of around 2% at this stage of the outbreak.

Thousands of patients are still being treated and we do not know if any of those cases will die – so the death rate could be higher. And it is unclear how many unreported cases there are – so the death rate could also be lower.

Where has it come from?

New viruses are detected all the time. They jump from one species, where they went unnoticed, into humans.

“If we think about outbreaks in the past, if it is a new coronavirus, it will have come from an animal reservoir,” says Prof Jonathan Ball, a virologist at the University of Nottingham.

Many of the early coronavirus cases were linked to the South China Seafood Wholesale Market, in Wuhan. But the earliest documented case, which has been traced back to 1 December, had no connection to the market.

Sars started off in bats and then infected the civet cat, which in turn passed it on to humans.

And Middle East respiratory syndrome (Mers), which has killed 858 out of the 2,494 recorded cases since it emerged in 2012, regularly makes the jump from the dromedary camel.

Which animal?

Once the animal reservoir (where the virus normally camps out) is detected, then the problem may become easier to deal with.

While some sea-going mammals can carry coronaviruses (such as the Beluga whale), the South China Seafood Wholesale Market also has live wild animals, including chickens, bats, rabbits, snakes, which are more likely to be the source.

The new virus is closely related to one found in Chinese horseshoe bats. However, this does not mean wild bats are the source of the outbreak – they could have passed the virus onto another species sold at the market.

Why China?

Prof Woolhouse says it is because of the size and density of the population and close contact with animals harbouring viruses.

“No-one is surprised the next outbreak is in China or that part of the world,” he says.

How easily does it spread between people?

At the beginning of the outbreak, the Chinese authorities said the virus was not spreading between people – but now, such cases have been identified.

Scientists say each infected person is passing the virus on to between two and three people.

This figure is called the virus’ basic reproduction number – anything higher than 1 means it’s self-sustaining. This is not a virus that will burn out on its own and disappear.

Only the decisions being made in China – including shutting down cities – can stop it spreading. Those figures are constantly being revised, but put the novel coronavirus in roughly the same league as Sars.

When are people infectious?

Chinese scientists say people are infectious even before their symptoms appear. The time between infection and symptoms – known as the incubation period – lasts up to 14 days.

Sars and Ebola are contagious only when symptoms appear. Such outbreaks are relatively easy to stop: identify and isolate people who are sick and monitor anyone they came into contact with.

Flu, however, is the most famous example of a virus that you spread before you even know you’re ill.

Prof Wendy Barclay from the department of infectious disease at Imperial College London said it was common for lung infections to spread without symptoms.

The virus is “carried into the air during normal breathing and talking by the infected person,” she explained.

“It would not be too surprising if the new coronavirus also does this.” We are not at the stage where people are saying this could be a global pandemic like swine flu.

But the problems of stopping such “symptomless spreaders” will make the job of the Chinese authorities much harder. What is not known is how infectious people are during the incubation period.

How fast is it spreading?

It might appear as though cases have soared. But this is somewhat misleading. Many of these seeming new cases will have come to light as a result of China improving its ability to find infected people.

Estimates by the University of Hong Kong suggest the true total number of cases could be far higher than official figures suggest. Their mathematical models of the outbreak suggest more than 75,000 people may have been infected in the Chinese city of Wuhan alone. Multiple groups have estimated the number of cases is doubling every week.

Why a global emergency?

The World Health Organization (WHO) says the virus is a public health emergency of international concern – as it did with swine flu and Ebola.

It said it has done so in order to provide extra support to lower and middle-income countries with weaker health systems that might not be able to spot or isolate cases of coronavirus.

Could the virus mutate?

Yes, you would expect viruses to mutate and evolve all the time. But what this means is harder to tell. China’s National Health Commission has warned the coronavirus’s transmission ability is getting stronger, but they were unclear on the risks posed by mutations of the virus. This is something scientists will be watching closely.

How can the outbreak be stopped?

We now know the virus will not stop on its own; only the actions of the Chinese authorities can bring this epidemic to an end. The only option is to prevent people who have become infected from spreading the virus to others.

That means:

*limiting people’s movement

*encouraging hand-washing and other forms of infection control

*treating patients in isolation with healthcare workers wearing protective gear

A massive feat of detective work will also be needed to identify people whom patients have come into contact with to see if they have the virus.

Are there any vaccines or treatments?

No. However, the work to develop them is already under way. It is hoped that research into developing a vaccine for Mers, which is also a coronavirus, will make this an easier job. And hospitals are testing anti-viral drugs to see if they have an impact.

A combination of two drugs – lopinavir and ritonavir – was successful in the Sars epidemic and is being tested in China during this outbreak. Treatment at the moment relies on the basics.

Patients are kept in isolation so they do not spread the virus; breathing support is given to people with the worst lung disease; and doctors manage the other conditions the patients have.

How have Chinese authorities responded so far?

China has done something unprecedented anywhere in the world – by effectively putting entire cities into quarantine.

The central province of Hubei, where nearly all deaths have occurred, is in a state of lockdown.

The province of 60 million people is home to Wuhan, the heart of the outbreak. The city has effectively been sealed off and China has put numerous transport restrictions in place to curb the spread of the virus. Some mass gatherings have been banned and tourists sites, including part of the Great Wall, have been closed.

And a ban on the sale of wildlife, a possible source of the infection, has been imposed.

In Wuhan – the centre of the outbreak – two new hospitals have been built with beds for a total of 2,300 people.

How worried are the experts?

Dr Golding says: “At the moment, until we have more information, it’s really hard to know how worried we should be.

“Until we have confirmation of the source, that’s always going to make us uneasy.”

Prof Ball says: “We should be worried about any virus that explores humans for the first time, because it’s overcome the first major barrier.

“Once inside a [human] cell and replicating, it can start to generate mutations that could allow it to spread more efficiently and become more dangerous.

“You don’t want to give the virus the opportunity.”

Wuhan: The London-sized city where the virus began

Wuhan may not be a well-known Chinese mega-city like Beijing or Shanghai.

But the place where the coronavirus outbreak emerged is, in fact, a crowded metropolis with connections to every part of the globe.

Estimates vary on the exact size of the population, with local government officials putting the figure at 11 million, though UN data from 2018 says 8.9 million people live in the central Chinese city.

Either way, the city is around the same size as London, but much bigger than Washington DC.

One estimate makes it the 42nd biggest city in the world, and the seventh biggest in China.

And it’s the size – and economic clout – of Wuhan that explains why the virus has travelled quickly across Asia, and even to the US.

In short, the virus has spread so widely because lots of people visit Wuhan and take the virus home with them.

Wuhan international airport handled 20 million passengers in 2016, and offers direct flights to London, Paris, Dubai, and other cities around the world.

The city is built along the Yangtze river and, according to its website, it is a “foundation of in both hi-tech manufacturing and traditional manufacturing”.

It has a series of industrial zones, 52 “institutions of higher learning”, and claims more than 700,000 students – including, reportedly, the largest number of undergraduates in the country.

Some 230 of the world’s 500 biggest companies (as measured by the Fortune Global list) have invested there.

There is also notable investment from France – which had a foreign concession in Hankou, in today’s Wuhan, between 1886 and 1943. More than 100 French firms have invested in the city and Peugeot-Citroen has a Chinese joint-venture plant there.

Wuhan can also serve as a gateway to the Three Gorges – a tourist region and home to a huge hydroelectric dam.

So, although the coronavirus originated in a local seafood market, the flow of people in and out of Wuhan has ensured its spread.

The US patient, for example, had recently visited Wuhan, as had both Japanese patients. The Korean patient lived there. The case in Thailand is a Chinese tourist from Wuhan.

The huge flow of people in and out of Wuhan will only increase as Chinese New Year approaches, and millions of people return home to celebrate.

China’s National Health Commission said travellers should avoid Wuhan, and that Wuhan residents should not leave the city.

But Wuhan’s status as one of the biggest – and most connected – places in the world means international cases will almost certainly continue to emerge.

Pic cap 6: The Institut Pasteur de Dakar, in Senegal, is one of the laboratories that has the reagents needed to test samples

Are African countries ready?

Africa is one of only two continents with no confirmed cases of coronavirus, however, experts have warned that it may not be long before the first case is confirmed, given its increasingly close ties to China.

At least 565 people have died with more than 28,000 confirmed cases around the world, most of them in China.

Last week the World Health Organization (WHO) declared the coronavirus outbreak a global health emergency – largely because of fears that poorer countries might not be able to cope with an outbreak.

“The main reason for this declaration is not what is happening in China but what is happening in other countries. Our greatest concern is the potential for the virus to spread to countries with weaker health systems,” said WHO chief Tedros Adhanom Ghebreyesus, who is from Ethiopia.

The health systems in many African countries are already struggling with the existing workload, so can they deal with another outbreak of a highly infectious disease?

Michael Yao, WHO’s head of emergency operations in Africa, notes that some countries on the continent “have the minimum to start with – they’re not starting from scratch”.

“We know how fragile the health system is on the African continent and these systems are already overwhelmed by many ongoing disease outbreaks, so for us it is critical to detect earlier so that we can prevent the spread.”

What facilities are there at the moment to treat it?

Until early this week, there were only two laboratories in Africa – one in Senegal and the other in South Africa – which had the reagents needed to test samples. They have been working as referral laboratories for countries around the region.

One of the laboratories, Institut Pasteur de Dakar, in Senegal has long been on the front line in medical innovation in Africa, including in yellow fever research.

However this week Ghana, Madagascar, Nigeria and Sierra Leone have announced they can also conduct tests.

The WHO is also sending kits to 29 laboratories on the continent to ensure they have the capacity to deal with the virus and also help test samples from other countries if needed.

However it’s hoped that by later this month at least 36 African countries will be equipped to carry out tests specific to the coronavirus.

The ability of African nations to properly diagnose cases “depends on the new reagents being made available from China and Europe,” says Dr Yao.

The Nigerian Red Cross Society says it has placed one million volunteers on alert. Its Secretary General, Abubakar Ahmed Kende, said the measure was to prevent the possible spread of the virus into the country and also contain the spiraling outbreak of Lassa fever across the country.

In Tanzania, Health Minister Ummy Mwalimu announced that isolation centres in the north, east and west of the country had been identified. Thermometers have been stockpiled and more than 2,000 health workers have been trained.

Several countries including Kenya, Ethiopia, Ivory Coast, Ghana and Botswana have dealt with suspected cases, placing them in quarantine while tests were carried out. So far, all have tested negative for the virus.

Uganda’s health ministry confirmed it had quarantined more than 100 people who have arrived at Entebbe International Airport. Some of the people have been quarantined at two hospitals in Entebbe and Kampala, while others have been asked to stay in their homes.

Have any lessons been learned from Ebola?

Dr Yao was involved in dealing with the outbreaks of Ebola in West Africa in 2014-2016 and more recently in the east of the Democratic Republic of Congo. He said he was concerned that there was not enough capacity to treat critical cases of coronavirus.

“We’re advising countries to at least detect cases early to avoid spreading the new virus within the community – that will be difficult to manage,” he says.

On a positive note, many African countries are already screening passengers arriving at their ports of entry for Ebola. Countries that dealt with the Ebola outbreak still have the isolation facilities and expertise in controlling infectious diseases.

But when it comes to detection, Ebola is different from the coronavirus. Ebola only became infectious when symptoms showed however there have been reports that in some cases, the coronavirus may have been transmitted before patients were showing symptoms.

What about travel between the continent and China?

Increasingly close trade links between China and African countries have heightened concerns that the virus could spread.

China is Africa’s biggest trade partner and around 10,000 Chinese firms are currently operating throughout the continent. According to Chinese state media, more than one million Chinese nationals live in African countries.

There are also more than 80,000 African students in China, often attracted by government scholarships, reports the Guardian. A 21-year-old student from Cameroon was reported to have contracted the virus after a trip to Wuhan and is being treated in hospital. Chinese students are also travelling to the continent, attracted again by government scholarships. BBC