2019–20 coronavirus outbreak

The 2019–20 coronavirus outbreak is an ongoing outbreak of coronavirus disease 2019 (COVID-19) that has spread to multiple world regions. It is caused by the SARS-CoV-2 virus, first identified in December 2019 in Wuhan, Hubei, China. As of 29 February 2020, more than 85,000 cases have been confirmed in 62 territories, of which 8,000 were classified as serious. At least 2,900 deaths have been attributed to the disease and more than 39,000 people have recovered. The risk of it spreading further is very high. The virus primarily passes from one person to others via respiratory droplets produced from the airways during coughing or sneezing. The time between exposure and symptom onset is typically between two and fourteen days, with symptoms having included fever, cough, and breathing difficulties, and complications including pneumonia and acute respiratory distress syndrome. There is currently no vaccine or specific antiviral treatment; as research is still ongoing; efforts have been aimed towards managing symptoms and supportive therapy. Advice from health bodies have recommended preventative measures such as hand washing and maintaining distance from people showing signs of symptoms, and monitoring and self-isolation for two weeks if individuals suspect that they have contracted the disease. The outbreak has been defined by the World Health Organization (WHO) as a Public Health Emergency of International Concern. Public health responses in China and around the world have included travel restrictions, quarantines, and curfews. These have included the lockdown of Hubei and various curfew measures in China; a voluntary curfew in Daegu, South Korea; as well as lockdowns in Italy. Some airports and train stations have instituted various screening methods. Several countries, including the United States, Canada, and the United Kingdom, have issued warnings with regards to non-essential travel to regions where the disease is occurring. Reports indicate that the Iranian government has been covering up the extent of their outbreak, surpressing information, and refusing to quarantine. There are many outstanding allegations that the country's government is covering up mass graves and continues to deny the spread of the disease. Over ten countries have traced their cases back to Iran signifying Iran has been a new epicenter of the outbreak and indicates the extent of the crisis is far more severe than the Iranian government has let on. Wider concerns about consequences of the outbreak include political and economic instability. They have also included xenophobia and racism against people of Chinese and East Asian descent, and the spread of misinformation about the virus, primarily online. Epidemiology: As of 29 February 2020, more than 85,000 cases have been confirmed worldwide; more than 92.5% of them have been in mainland China. SARS-CoV-2 was first detected by health authorities in Wuhan, Hubei Province, People's Republic of China, after forty-one patients presented with symptoms of pneumonia of unknown etiology. Phylogenetic analysis of the SARS-CoV-2 genome has demonstrated that the human disease originated in a single zoonotic event on or before Dec. 1, 2019 and possibly as early as Oct. 2019, followed by human to human transmission (Dec. 1 was the date the first symptomatic case was identified, though at that time the etiology was unknown). Subsequently, two similar viruses were identified in bats, but not similar enough to implicate bats as the reservoir animals. Researchers conclude that the virus must have passed to humans via an intermediate animal or that some other animal entirely (but not snakes), harboring a more similar virus, is the natural reservoir. Researchers indicate that the virus is not recombinant, which would rule out its origin in a laboratory. The earliest cases all initially sought medical help after December 8, but one patient reported onset of symptoms as early as late November. Most of the earliest cases were linked to the Huanan Seafood and Wholesale Market, however some researchers believe that the other cases, which were not linked to the wet market, point to a different initial transmission location. During the early stages, the number of cases doubled approximately every seven and a half days. In early and mid-January 2020, the virus spread to other Chinese provinces, helped by the Chinese New Year migration ,as Wuhan is a transport hub in China and the infected individuals quickly spread throughout the country.On 20 January, China reported nearly 140 new patients in a day, including two people in Beijing and one in Shenzhen. Later official data shows that 6,174 SARS-CoV-2-infected patients had already developed symptoms by 20 January 2020. The virus spread to other countries and regions. In chronological order, these were Thailand, Japan, Macau, South Korea, Taiwan, United States, Hong Kong, Singapore, France, Nepal, Vietnam, Australia, Malaysia, Canada, Cambodia, Germany, Finland, Sri Lanka, United Arab Emirates, India, Italy, the Philippines, the United Kingdom, Russia, Sweden, Spain, Belgium, Egypt, Iran, Israel, Lebanon, Afghanistan, Bahrain, Kuwait, Iraq, Oman, Algeria, Austria, Brazil, Croatia, Switzerland, Greece, Pakistan, North Macedonia, Georgia, Norway, Romania, Denmark, Estonia, Northern Ireland, San Marino, Netherlands, Nigeria, Belarus, Lithuania, New Zealand, Mexico, Azerbaijan, Iceland, Monaco, Qatar, Ecuador and Ireland. On 26 February 2020, WHO reported that, as new cases reported dropped in China but suddenly increased in Italy, Iran, and South Korea, the number of new cases outside China had exceeded the number of new cases in China for the first time on 25 February 2020. Deaths: As of 29 February 2020, more than 2,900 deaths have been attributed to COVID-19. According to China's NHC, most of those who died were older patients – about 80% of deaths recorded were from those over the age of 60, and 75% had pre-existing health conditions including cardiovascular diseases and diabetes. The first confirmed death was 9 January 2020 in Wuhan. The first death outside China occurred in the Philippines, and the first death outside Asia was in Paris. As of 28 February 2020, outside of mainland China, more than a dozen deaths have been recorded in each of Iran, South Korea, and Italy. Signs and symptoms: Most infected people have initially shown clinical symptoms, often described as flu-like symptoms, such as fever, coughing, breathing difficulties, fatigue, and myalgia. Further development can lead to severe pneumonia, acute respiratory distress syndrome, sepsis, septic shock, and death. Upper respiratory symptoms, such as sneezing, a runny nose and sore throat, are less frequent. Some of those infected may be asymptomatic, returning test results that confirm infection but show no clinical symptoms, so researchers have issued advice that individuals with close contact to confirmed infected patients should be closely monitored and examined to rule out infection. The incubation period (the time between infection and symptom onset) ranges from one to 14 days, though is most commonly five days. However, one case is reported as having an incubation period of 27 days. Cause- Transmission: The primary mode of transmission is through human-to-human transmission via respiratory droplets produced when people exhale (such as coughing or sneezing). The WHO is assessing whether asymptomatic transmission and fecal transmission are important transmission modes. Droplets transmitting coronaviruses only stay suspended in the air for a short time. Details for SARS-CoV-2 are not available as of 26 February 2020, and it is assumed that they are similar to other coronaviruses, which may stay viable and contagious on a metal, glass or plastic surface for up to nine days at room temperature. Disinfection of surfaces is possible with substances such as 62–71% ethanol applied for one minute. There have been estimates for the basic reproduction number (the average number of people an infected person is likely to infect), ranging from 2.13 to 4.82. As of 24 January 2020 the virus was reported to have been able to transmit down a chain of up to four people. This is similar to severe acute respiratory syndrome-related coronavirus (SARS-CoV). There are disputed reports that some of the infected may be super-spreaders. The WHO furthermore writes that though history with SARS and MERS show that transmission through food does not happen, the possibility remains open and that meat and animal products should be cooked thoroughly as a rule of thumb. Virology: SARS-CoV-2, a novel severe acute respiratory syndrome coronavirus first isolated from three people with pneumonia connected to the cluster of acute respiratory illness cases reported in Wuhan, is the cause of coronavirus disease 2019 (COVID-19). SARS-CoV-2 is closely related to SARS-CoV-1 (75% to 80% identical). It is thought to have a zoonotic origin based on probable epidemiological links to the Huanan Seafood Market. Genetic analysis has revealed that the coronavirus genetically clusters with the genus Betacoronavirus, in lineage B of the subgenus Sarbecovirus together with two bat-derived strains. It is 96% identical at the whole genome level to other bat coronavirus samples (BatCov RaTG13). In February 2020, Chinese researchers found that there is a 99% similarity in genome sequences between the viruses found in pangolins and those from human patients, suggesting that the animal may be an intermediary host for the virus, but did not release evidence. At least five genomes of the novel coronavirus have been isolated and reported. Diagnosis: The WHO has published several testing protocols for SARS-CoV-2. Testing uses real time reverse transcription polymerase chain reaction (rRT-PCR). The test can be done on respiratory or blood samples. Results are generally available within a few hours to days. A person is considered to be at risk of having COVID-19 if they have travelled to an area with ongoing community transmission within the previous fourteen days or has had close contact with an infected individual. Common key indicators include fever, coughing and dyspnea. Other possible indicators include fatigue, myalgia, anorexia, sputum production and sore throat. An alternative method of diagnosis is based on clinical presentation such as looking for visual signature patterns of COVID-19 in CT scans of the lungs. Signs of pneumonia may precede confirmation of SARS-CoV-2 through RT-PCR. Prevention: To reduce the chances of becoming infected, health organisations recommend avoiding close contact with sick individuals; frequently washing hands with soap and water; not touching the eyes, nose, or mouth with unwashed hands; and practising good respiratory hygiene. Those who may already be infected are advised to stay at home except to get medical care, call ahead before visiting a healthcare provider, wear a face mask (especially in public), cover coughs and sneezes with a tissue, regularly wash hands with soap and water, and avoid sharing personal household items. No vaccine currently exists. A number of governments advise against all non-essential travel to countries and areas affected by the outbreak. The Government of Hong Kong warned anyone travelling outside the city to not touch animals; to not eat game meat; and to avoid visiting wet markets, live poultry markets, and farms. There is no evidence that pets, such as dogs and cats, can be infected. The Government of China has banned the trading and consumption of wild animals. For health care providers taking care of someone who may be infected standard precautions, contact precautions, and airborne precautions with eye protection are recommended. Contact tracing is an important method for health authorities to determine the source of an infection and to prevent further transmission. Rinsing the nose, gargling with mouthwash, and eating garlic are not effective. Hand washing: Hand washing with soap and water (especially after coughs, sneezes, nose blowing, before meals, after using bathrooms, or if hands are visibly dirty) has been recommended by the CDC, as well as use of hand sanitizer with at least 60% alcohol: The CDC, the National Health Service (NHS), and the WHO have also advised against touching the eyes, nose, or mouth with unwashed hands. Respiratory hygiene: Health bodies recommended that individuals cover their mouth and nose with a tissue when coughing or sneezing (which should then be disposed of immediately), or with a sleeve if a tissue is not available. The use of surgical masks by those who suspect they are infected has also been recommended, as they can limit the volume and travel distance of expiatory droplets dispersed when talking, sneezing, and coughing. The WHO issued best practices for the use of masks in home and health care environments, including that they be securely tied to the face to minimize gaps, that masks should be replaced when they become damp or humid, that the user should not touch the front of the mask when removing it, the immediate disposal of single-use masks upon removal, and hand washing or sanitizing after removal or if a used mask is touched. Masks have also been recommended for use by those taking care of someone who may have the disease. Furthermore, health care professionals were advised to wear respirators at least as protective as NIOSH-certified N95, EU standard FFP2, or equivalent, in addition to other personal protective equipment. There is no evidence to show that the wearing of surgical masks by uninfected persons at low risk is effective, and wearing them may create a false sense of security. Only China has recommended the use of masks by healthy members of the public, while face masks are widely used by healthy people in Hong Kong, Japan, Singapore, and Malaysia. Self-isolation: In addition to the aforementioned guidance on hand washing and respiratory hygiene, public health bodies have also advised that individuals who suspect they may have contracted coronavirus should restrict activities outside the home, except for getting medical care (for which patients should call ahead): The most commonly-used length of these periods have been 14 days (two weeks), as it is also an estimated timeframe between infection and the onset of symptoms. Vaccine research: Several organisations around the world are developing vaccines. In China, the Chinese Center for Disease Control and Prevention (CCDC) has started developing vaccines against the novel coronavirus. Also, a team at the University of Hong Kong announced that a new vaccine is developed, but needs to be tested on animals before conducting clinical tests on humans. The U.S. National Institutes of Health (NIH) is hoping for human trials of a vaccine by April 2020. The Norwegian Coalition for Epidemic Preparedness Innovations (CEPI) is funding three vaccine projects and hopes to have a vaccine in trials by June 2020, and approved and ready in a year. Management: There are no specific medications for SARS-CoV-2, though development efforts are underway. Attempts to relieve the symptoms include taking regular (over-the-counter) flu medications, drinking fluids, and resting. Depending on the severity, oxygen therapy, intravenous fluids, and breathing support may be required. Some countries require people to report flu-like symptoms to their doctor, especially if they have visited mainland China. On 18 February 2020, the Chinese National Medical Products Administration approved the antiviral drug favipiravir for treatment of COVID-19. The drug, previously approved for treatment of influenza, had shown early efficacy against COVID-19 in human trials in China. Bruce Aylward, an assistant director-general of the World Health Organization (WHO), has stated "there is only one drug right now that we think may have real efficacy and that's remdesivir." Trials are in progress, and results could be available within weeks of 24 February. History: In late December, a cluster of pneumonia cases of unknown cause was reported by health authorities in Wuhan, Hubei Province, People's Republic of China. The initial cases mostly had epidemiological links to the Huanan Seafood Wholesale Market and consequently the virus is thought to have a zoonotic origin. The virus that caused the outbreak is known as SARS-CoV-2, a new virus which is closely related to bat coronaviruses, pangolin coronaviruses and SARS-CoV-1. The earliest reported symptoms occurred on 1 December 2019, in a person who had not had any exposure to the Huanan Seafood Wholesale Market or to the remaining 40 of the first cluster detected with the new virus. Of this first cluster, two-thirds were found to have a link with the market, which also sold live animals. China has since banned the trade and consumption of wild animals. The WHO declared the outbreak to be a Public Health Emergency of International Concern on 30 January. The WHO's director, Tedros Adhanom, has maintained praise in China's response to the virus as of 24 February 2020, "to avoid a significant number of cases", despite the disease's potential to have sustained community transmission in other world regions. National responses: As of 29 February, apart from China, the outbreak has spread to three other countries around the world, South Korea, Italy, and Iran, which have subsequently all become new hotspots for the coronavirus. National response measures has included containment measures such as lockdowns, quarantines, and curfews. Domestic responses in China: The first person known to have fallen ill due to the new virus was in Wuhan on 1 December 2019. A public notice on the outbreak was released 30 days later by Wuhan health authority on 31 December 2019; the initial notice informed Wuhan residents that there was no clear evidence of human-to-human transmission of the virus, that the disease is preventable and controllable, and that people can wear masks when going out. WHO was informed of the outbreak on the same day. On 7 January 2020, the Chinese Communist Party Politburo Standing Committee discussed novel coronavirus prevention and control. On 20 January, Zhong Nanshan, a scientist at China's National Health Commission who played a prominent role in the SARS epidemic, declared its potential for human-to-human transmission, after two cases emerged in Guangdong of infection by family members who had visited Wuhan. This was later confirmed by the Wuhan government, which announced a number of new measures such as cancelling the Chinese New Year celebrations, in addition to measures such as checking the temperature of passengers at transport terminals first introduced on 14 January. A quarantine was announced on 23 January 2020 stopping travel in and out of Wuhan. On 25 January, Chinese authorities banned the use of private vehicles in Wuhan. Only vehicles that are transporting critical supplies or emergency response vehicles are allowed to move within the city. On 26 January, a leading group tasked with the prevention and control of the novel coronavirus outbreak was established, led by Chinese Premier Li Keqiang. The leading group decided to extend Spring Festival holiday to contain coronavirus outbreak. China Customs started requiring that all passengers entering and exiting China fill in an extra health declaration form from 26 January. The health declaration form was mentioned in China's Frontier Health and Quarantine Law, granting the customs rights to require it if needed. On 27 January, the General Office of the State Council of China, one of the top governing bodies of the People's Republic, officially declared a nation-wide extension on the New Year holiday and the postponement of the coming spring semester. The Office extended the previously scheduled public holiday from 30 January, to 2 February, while it said school openings for the spring semester would be announced in the future. Some universities with open campuses also banned the public from visiting. On 23 January, the education department in Hunan, which neighbours the centre of the outbreak Hubei province, stated it would strictly ban off-school tutors and restrict student gatherings. Education departments in Shanghai and Shenzhen also imposed bans on off-school tutoring and requested that schools track and report students who had been to Wuhan or Hubei province during the winter break. The semi-autonomous regions of Hong Kong and Macau also announced adjustments on schooling schedules. Hong Kong's Chief Executive Carrie Lam declared an emergency at a press conference on 25 January, saying the government would close primary and secondary schools for two more weeks on top of the previously scheduled New Year holiday, pushing the date for school reopening to 17 February. Macau closed several museums and libraries, and prolonged the New Year holiday break to 11 February for higher education institutions and 10 February for others. The University of Macau said they would track the physical conditions of students who have been to Wuhan during the New Year break. After the Chinese New Year on 25 January, there would be another peak of people travelling back from their hometowns to workplaces as a part of Chunyun. Several provinces and cities encouraged people to stay in their hometowns and not travel back. Eastern China's Suzhou also encouraged remote working via the Internet and further prolonged the spring festival break. The Civil Aviation Administration of China and the China State Railway Group, which regulate China's civil aviation and operates rail services, announced on 24 January that passengers could have full refunds for their plane and train tickets without any additional surcharges, regardless of whether their flight or train will go through Wuhan or not. China's Ministry of Culture and Tourism ordered travel agencies and online tourism firms to suspend package tours and stop offering "flight+hotel" bundles. Additional provinces and cities outside Hubei imposed travel restrictions. Beijing suspended all intercity bus services on 25 January, with several others following suit. On 1 February 2020, Xinhua News reported that China's Supreme People's Procuratorate (SPP) has "asked procuratorates nationwide to fully play their role to create a favourable judicial environment in the fight against the novel coronavirus outbreak." This includes severe punishments for those found guilty of dereliction of duty and the withholding of information for officials. Tougher charges were proscribed for commercial criminal activities such as "the pushing up of prices, profiteering and severely disturbing market order" along with the "production and sale of fake and shoddy protective equipment and medicines." Prosecuting actions against patients who deliberately spread the infection or refuse examination or compulsory isolation along with threats of violence against medical personnel were also urged. The statement also included urging to prosecute those found "fabricating coronavirus-related information that may lead to panic among the public, making up and spreading rumors about the virus, sabotaging the implementation of the law and endangering public security" and also stressed "harshly punishing the illegal hunting of wildlife under state protection, as well as improving inspection and quarantine measures for fresh food and meat products." Museums throughout China are temporarily closed. The National Cultural Heritage Administration (NCHA) asked museums around the country to move their exhibits and galleries temporarily online via a program that the NCHA is launching. Quarantines: On 23 January 2020, a quarantine on travel in and out of Wuhan was imposed in an effort to stop the spread of the virus out of Wuhan. Flights, trains, public buses, the metro system, and long-distance coaches were suspended indefinitely. Large-scale gatherings and group tours were also suspended.[143] By 24 January 2020, a total of 15 cities in Hubei, including Wuhan, were placed under similar quarantine measures.[174] On 27 and 28 January 2020, Xiangyang closed its railway stations and suspended all ferry operations, after shutting down its airport and intercity bus services earlier. Thus, the entire Hubei province entered a city-by-city quarantine, save for the Shennongjia Forestry District. Before the quarantine began, some in Wuhan questioned the reliability of the figures from the Chinese government as well as the government response, with some calling for quarantine, and a post also showed sick people and three dead bodies covered in white sheets on the floor of a hospital on 24 January, although many such posts in Weibo about the epidemic have since been deleted. Due to quarantine measures, Wuhan residents rushed to stockpile essential goods, food, and fuel; prices rose significantly. 5,000,000 people left Wuhan, with 9,000,000 left in the city. On 26 January, the city of Shantou in Guangdong declared a partial lockdown, though this was reversed two hours later. Residents had rushed to supermarkets to stock food as soon as the lockdown was declared, until the authorities reversed their decision. Caixin said, that the wording of Shantou's initial declaration was "unprecedentedly strict" and will severely affect residents' lives, if implemented as-is. Shantou's Department for Outbreak Control later clarified that it would not restrict travelling, but would sterilise vehicles used for transportation. Local authorities in Beijing and several other major cities, including Hangzhou, Guangzhou, Shanghai, and Shenzhen, announced on 26 January, that these cities will not impose a lockdown similar to those in Hubei province. Rumours of these potential lockdowns had spread widely prior to the official announcements. A spokesperson of Beijing's Municipal Transportation Commission claimed that the expressways, highways, subways, and buses were operating normally. To ease the residents' panic, the Hangzhou city government stressed that the city would not be locked down from the outside world, and both cities said that they would introduce precautions against potential risks. On 2 February 2020, the city of Wenzhou in Zhejiang also implemented a partial lockdown, closing 46 of the 54 highway checkpoints. On 4 February 2020, two more cities in Zhejiang province restricted the movement of residents. The city of Taizhou, three Hangzhou districts, and some in Ningbo began to only allow one person per household to go outside every two days to buy necessities, city officials said. More than 12 million people are affected by the new restrictions. By 6 February 2020, a total of four Zhejiang cities—Wenzhou, Hangzhou, Ningbo, and Taizhou—were under the "passport" system, allowing only one person per household to leave their home every two days. These restrictions apply to over 30 million people. Outside Mainland China, some cruise ships were quarantined after passengers developed symptoms or tested positive for SARS-CoV-2. The Costa Smeralda was quarantined on 30 January off Civitavecchia in Italy, after passengers developed flu-like symptoms – the quarantine was lifted when tests for the virus came back negative. Two further ships were quarantined on 5 February: Diamond Princess in the Port of Yokohama, Japan and World Dream, which returned to Hong Kong after being refused entry to Kaohsiung, Taiwan. In both cases, passengers and crew tested positive. On 10 February passengers were allowed to disembark the World Dream "without the need to self-quarantine after leaving." The Diamond Princess remains quarantined with 136 confirmed cases as of 10 February. Although the quarantine has not been completely lifted, around 500 passengers that were not diagnosed with the virus were allowed to leave on 19 February 2020. In addition, although not quarantined the MS Westerdam has been refused entry by several ports after departing Hong Kong on 1 February. Outdoor restrictions: On 1 February, Huanggang, Hubei implemented a measure whereby only one person from each household is permitted to go outside for provisions once every two days, except for medical reasons or to work at shops or pharmacies. Many cities, districts, and counties across mainland China implemented similar measures in the days following, including Wenzhou, Hangzhou, Fuzhou, Harbin, and the whole of Jiangxi. Speciality hospitals: A speciality hospital named Huoshenshan Hospital has been constructed as a countermeasure against the outbreak and to better quarantine the patients. Wuhan City government had demanded that a state-owned enterprise construct such a hospital "at the fastest speed" comparable to that of the SARS outbreak in 2003. On 24 January, Wuhan authorities specified its planning, saying they planned to have Huoshenshan Hospital built within six days of the announcement and it will be ready to use on 3 February. Upon opening, the speciality hospital has 1,000 beds and takes up 30,000 square metres. The hospital is modelled after the Xiaotangshan Hospital, which was fabricated for the SARS outbreak of 2003, itself built in only seven days. State media reported that there were 7,000 workers and nearly 300 units of construction machinery on the site at peak. On 25 January authorities announced plans for Leishenshan Hospital, a second speciality hospital, with a capacity of 1,600 beds; operations are scheduled to start by 6 February. Some people voiced their concerns through social media services, saying the authorities' decision to build yet another hospital in such little time showed the severity of the outbreak could be a lot worse than expected. On 24 January 2020, the authority announced that they would convert an empty building in Huangzhou District, Huanggang to a 1,000-bed hospital named Dabie Mountain Regional Medical Centre. Works began the next day by 500 personnel and the building began accepting patients on 28 January 2020 at 10:30 pm. In Wuhan, authorities have seized dormitories, offices and hospitals to create more beds for patients. Interprovincial medical aid: As of 16 February 2020, 217 teams of a total of 25,633 medical workers from across China went to Wuhan and other cities in Hubei to help open up more facilities and treat patients. Censorship and police responses: The first known infection by a new virus was reported in Wuhan on 1 December 2019. The early response by city authorities was accused of prioritising a control of information on the outbreak. A group of eight medical personnel, including Li Wenliang, an ophthalmologist from Wuhan Central Hospital, who in late December posted warnings on a new coronavirus strain akin to SARS, were warned by Wuhan police for "spreading rumours" for likening it to SARS. By the time China had informed the World Health Organization of the new coronavirus on 31 December 2019, The New York Times reported that the government was still keeping "its own citizens in the dark". While by a number of measures, China's initial handling of the crisis was an improvement in relation to the SARS response in 2003, China has been criticised for cover-ups and downplaying the initial discovery and severity of the outbreak. This has been attributed to the censorship institutional structure of the country's press and Internet, with Nicholas Kristof of The New York Times and Jude Blanchette of the Center for Strategic and International Studies suggesting that it was exacerbated by China's paramount leader Xi Jinping's crackdown on independent oversight such as journalism and social media that left senior officials with inaccurate information on the outbreak and "contributed to a prolonged period of inaction that allowed the virus to spread". On 20 January, Chinese Communist Party General Secretary Xi Jinping made his first public remark on the outbreak and spoke of "the need for the timely release of information". Chinese premier Li Keqiang also urged efforts to prevent and control the epidemic. One day later, the CPC Central Political and Legal Affairs Commission, the most powerful political organ in China overseeing legal enforcement and the police, wrote "self-deception will only make the epidemic worse and turn a natural disaster that was controllable into a man-made disaster at great cost," and "only openness can minimise panic to the greatest extent." The commission then added, "anyone who deliberately delays and hides the reporting of cases out of self-interest will be nailed on a pillar of shame for eternity." Also on the same day, Xi Jinping instructed authorities "to strengthen the guidance of public opinions", language which some view as a call for censorship after commentators on social media became increasingly pointedly critical and angry at the government due to the epidemic. Some view this as contradictory to the calls for "openness" that the central government had already declared. Statements issued by Xi Jinping on 3 February declared the need for an emphasis by state media on "telling the moving stories of how people on the front line are preventing and fighting the virus" as a priority of coverage, while top official Zhang Xiaoguo said that his department would "treat propaganda regarding the control and prevention measures of the virus as its top priority". For instance, state media organisations People's Daily and Global Times, along with deputy director of information Zhao Lijian from the Ministry of Foreign Affairs, have been observed to be publishing effusive praise on Beijing's response to the epidemic, such as extensive coverage of the accelerated construction of the new hospitals in Wuhan (which Zhao claimed was completed in 16 hours), the lock down of Wuhan with its population of 11 million, and the "unprecedented" quarantine of Hubei province. Though such efforts had a questional effect on the epidemic, as the new hospitals were operating at under half-capacity due to shortages of beds and medical resources while the lock down of Wuhan came too late to be effective as millions had left, the Financial Times and others noted that such widely publicised actions were a "PR coup" showing that the "overbearing, centralized government" of China was particularly suited to dealing with the outbreak, creating the impression as if Beijing had directly intervened at Xi Jinping's request. Observers have warned that while "admiration of the front-line medical workers is widespread and sincere," the state media should also be highlighting the reality that many of those workers "lack protective gear" and that over 3000 have been infected since the outbreak so that media attention may bring them public support to obtain some much needed equipment. The New York Times has noted that such government propaganda attempts to control the narrative has been viewed with distrust among the younger individuals, who unlike older people depend less on state media and instead have sought "firsthand info and in-depth media studies concerning the epidemic on the web", suggesting that the central government was out of touch with the younger population. As part of the central government's "bifurcated approach to diffuse discontent", while the propaganda machinery was going into "overdrive...to protect Xi Jinping's reputation", citizens were permitted to criticise local officials so long as they did not "question the basic legitimacy of the party". The Cyberspace Administration (CAC) declared its intent to foster an "good online atmosphere," with CAC notices sent to video platforms encouraging them to "not to push any negative story, and not to conduct non-official livestreaming on the virus." Censorship has been observed being applied on news articles and social media posts deemed to hold negative tones about the coronavirus and the governmental response, including posts mocking Xi Jinping for not visiting areas of the epidemic, an article that predicted negative effects of the epidemic on the economy, and calls to remove local government officials. Chinese citizens have reportedly used innovative methods to avoid censorship to express anger about how government officials have handled the initial outbreak response, such as using the word 'Trump' to refer to Xi Jinping, or 'Chernobyl' to refer to the outbreak as a whole. Younger individuals have also been creating digital archives of media concerning the epidemic - which is prone to deletion by censors - and posting them on the exterior web. While censorship had been briefly relaxed giving a "window of about two weeks in which Chinese journalists were able to publish hard-hitting stories exposing the mishandling of the novel coronavirus by officials", since then private news outlets were reportedly required to use "planned and controlled publicity" with the authorities' consent. On 30 January, China's Supreme Court, delivered a rare rebuke against the country's police forces, calling the "unreasonably harsh crackdown on online rumours" as undermining public trust. In what has been called a "highly unusual criticism" by observers, supreme court judge Tang Xinghua said that if police had been lenient against rumours and allowed the public to have taken heed of them, an earlier adoption of "measures like wearing masks, strictly disinfecting and avoiding wildlife markets" might have been useful in countering the spread of the epidemic. The Human Rights Watch reported that "there is considerable misinformation on Chinese social media and authorities have legitimate reasons to counter false information that can cause public panic," but also noted censorship by the authorities on social media posted by families of infected people who were potentially seeking help as well as by people living in cordoned cities who were documenting their daily lives amidst the lockdown. After the death of Li Wenliang, who was widely hailed as a whistleblower in China on 7 February, some of the trending hashtags on Weibo such as "Wuhan government owes Dr Li Wenliang an apology" and "We want freedom of speech" were blocked. While media outlets were allowed to report his death, the nature of the doctor's censorship which produced widespread public anger in the aftermath, in what has been described as "one of the biggest outpourings of online criticism of the government in years," was not a topic that was permitted for coverage. One such media outlet even sending notices to editors, and leaked to reporters, asking them to refrain from "commenting or speculating" and giving instructions to "not hashtag and let the topic gradually die out from the hot search list, and guard against harmful information." After attempts to discourage the discussion on Dr. Li's death further escalated online anger, the central government has been accused of reportedly attempting to co-opt the incident by "casting Dr. Li's death as the nation's sacrifice – meaning, the Chinese Communist Party's own". A group of Chinese academics including Xu Zhangrun of Tsinghua University signed an open letter calling for the central government to issue an apology to Dr. Li and to protect freedom of speech. Professor Zhou Lian of Renmin University has observed that the epidemic has "allowed more people to see the institutional factors behind the outbreak and the importance of freedom of speech". Domestic responses in South Korea: The first confirmed case of the coronavirus was identified with a 35-year-old Chinese woman on 20 January. The first South Korean national to be infected occurred three days later was a 55-year-old man who worked in Wuhan and returned for a checkup with flu symptoms. The two infection reports were publicly released on 24 January. The sixth patient was the first case in South Korea who had never visited Wuhan. The 56-year-old man caught the virus when visiting a restaurant with the third patient. A woman, who had returned from Thailand after a five-day vacation, was tested positive and confirmed as the sixteenth case on 4 February. Three more cases were confirmed on 5 February, bringing the total case count to 19. The seventeenth and nineteenth patients had attended a conference in Singapore and been in contact with an infected individual there. The very same day the Centers for Disease Control and Prevention Korea (KCDC) announced that the second patient had been released from hospital after being tested negative in consecutive tests, becoming the country's first coronavirus patient to fully recover. On 19 February, the number of confirmed cases increased by 20. On 20 February, 70 new cases were confirmed, giving a total of 104 confirmed cases, according to the Centers for Disease Control and Prevention Korea (KCDC). According to Reuters, KCDC attributed the sudden jump to 70 cases linked to "Patient No. 31", who had participated in a gathering in Daegu at the Shincheonji Church of Jesus the Temple of the Tabernacle of the Testimony. On 20 February, the streets of Daegu were empty in reaction to the Shincheonji outbreak. A resident described the reaction, stating "It's like someone dropped a bomb in the middle of the city. It looks like a zombie apocalypse." The first death was reported in a mental ward of Cheongdo Daenam Hospital in Cheongdo County. According to the mayor of Daegu, the number of suspected cases as of 21 February was 544 among 4,400 examined followers of the church. The hospital was suspected as the source of the present outbreak after it was visited by a woman who became the second fatal case of Korea on that day. The infection spread outside via a funeral ceremony attended by members of the church. All South Korean military bases were on lockdown after tests confirmed that three soldiers were indeed positive for the virus. Airlines cut connections and cultural schedules were being canceled due to fears of further spread. United States Forces Korea raised the alert level from low to moderate and cut off non-essential travel to and from USFK Daegu. USFK Daegu's school facilities were closed and non-essential personnel were ordered to stay at home while any visitors going there were not allowed to enter. USFK announced that the widow of a retired soldier who was in Daegu was diagnosed to be positive for the virus on 24 February. Camp Humphreys enacted virus detection protocols, including temperature checks and raised the alert level to high. On 26 February, an American soldier based at Camp Carroll was diagnosed to be positive and was quarantined away from bases via off-base housing unit with contact tracing done that showed his movements to Camp Walker. As of 22 February, among 9,336 followers of the church, 1,261 reported symptoms. At the time, 169 confirmed cases involved the church and another 111 came from the Cheongdo Daenam Hospital. 23 February saw another 123 cases with 75 being from Shincheonji and 24 February saw 161 additional cases with 129 being from the religious group. Over 27,000 people have been tested for the virus with 19,127 negative results. On 24 February, 15 countries imposed travel restrictions to and from South Korea. It was also reported that a senior health official overseeing the COVID-19 efforts in Daegu tested positive and was also a member of Shincheonji. Within a few days, a petition to the nation's president urging for the disbandment of the church had over 750,000 signatures. Their headquarters in Gwacheon was raided by law enforcement and government officials said all 245,000 members of the religious group would be found and tested.[327] On 28 February, over 2,000 confirmed cases were reported. Domestic responses in Italy: The outbreak was confirmed to have spread to Italy on 31 January 2020, when two Chinese tourists tested positive for SARS-CoV-2 in Rome. In response, the Italian government suspended all flights to and from China and declared a state of emergency, with Prime Minister Giuseppe Conte stating that Italy is the first EU country to take this precautionary measure. On 31 January 2020, the Italian Council of Ministers appointed Angelo Borrelli, head of the Civil Protection, as Special Commissioner for the COVID-19 Emergency. A unassociated cluster of COVID-19 cases was later further detected starting with 16 confirmed cases in Lombardy on 21 February, an additional 60 cases on 22 February, and Italy's first deaths reported on the same day. The Ministry of Health announced new guidelines for reporting cases on 27 February in response to the previous blanket testing that caused case numbers to surge and inflamed public panic. It would no longer report asymptomatic cases (swabs taken from patients which tested positive but were not showing symptoms) which counted as 40 to 50% of all reported cases at the time. These people would undergo isolation at home and would be followed up with new tests until they were negative. Quarantines: On 21 February, at least ten towns in the Lombardy and Veneto regions of Italy, with a total population of 50,000, were locked down in quarantine procedure following an outbreak in the town of Codogno in Lombardy. Police mandated a curfew closing all public buildings and controlling access through police checkpoints to the so-called 'red zone' which is enforced by penalties for violations ranging from a €206 fine to three months of imprisonment against trespassers who are not health or supply workers. The government of Italian Prime Minister Giuseppe Conte vowed that sending in "the armed forces" to enforce the lockdown was within possibility. The governor of Basilicata, Vito Bardi, instituted a mandatory 14-day quarantine for people arriving from areas in Northern Italy affected by the outbreak on 24 February. Additionally on the same day, 500 additional police officers were assigned to patrol the quarantined areas in Lodi and Veneto. Domestic responses in Iran: Iran reported its first confirmed cases of SARS-CoV-2 infections on 19 February 2020 in Qom, where according to the Ministry of Health and Medical Education stated that both had died later that day. The Ministry of Islamic Culture and Guidance, announced the cancellation of all concerts and other cultural events for one week. The Ministry of Health and Medical Education also announced the closure of universities, higher educational institutions and schools in several cities and provinces. The Ministry of Sports and Youth took steps to cancel sporting events, including football matches. The Ministry of Defense and Armed Forces Logistics created first COVID-19 test kit on 23 February. Management and Planning Organization announced government has allocated 5 trillion rials to combat the virus. President Hassan Rouhani ordered the Ministry of Roads and Urban Development to make decisions about public commuting and the Ministry of Industry, Mine and Trade to build the required medical equipment. President Rouhani, however, said on 26 February 2020 that there are no plans to quarantine areas affected by the outbreak, and only individuals would be quarantined. Nevertheless, Iran's Health Ministry said that Friday prayers will not be held in Tehran and areas affected by the outbreak that week. On 20 February, according to a letter of Iran’s health ministry to the governor of Qom, a request was made to "limit the number of pilgrims at the Shrine to Fatima Masumeh and other religious sites". However, Shia shrines in Qom, the city most affected in Iran, remained open for pilgrims to congregate. International responses: Since 31 December 2019, some regions and countries near China tightened their screening of selected travellers. The Centers for Disease Control and Prevention (CDC) of the United States later issued a Level 1 travel watch. Guidances and risk assessments were shortly posted by others including the European Centre for Disease Prevention and Control and Public Health England. An analysis of air travel patterns was used to map out and predict patterns of spread and was published in the Journal of Travel Medicine in mid-January 2020. Based on information from the International Air Transport Association (2018), Bangkok, Hong Kong, Tokyo, and Taipei had the largest volume of travellers from Wuhan. Dubai, Sydney and Melbourne were also reported as popular destinations for people travelling from Wuhan. Bali was reported as least able in terms of preparedness, while cities in Australia were considered most able. As a result of the outbreak many countries and regions including most of the Schengen area, Armenia, Australia, India, Iraq, Indonesia, Kazakhstan, Kuwait, Malaysia, Maldives, Mongolia, New Zealand, Philippines, Singapore, Sri Lanka, Taiwan, Vietnam, and the United States have imposed temporary entry bans on Chinese citizens or recent visitors to China, or have ceased issuing visas and reimposed visa requirements on Chinese citizens. Samoa even started refusing entry to its own citizens who had previously been to China, attracting widespread condemnation over the legality of such decision. El Salvador banned visitors coming from Italy and South Korea following the outbreak in those countries. Hong Kong, Mongolia, Nepal, North Korea, Russia, and Vietnam have also responded with border tightening/closures with mainland China. On 22 January 2020, North Korea closed its borders to international tourists to prevent the spread of the virus into the country. Chinese visitors make up the bulk of foreign tourists to North Korea. Also on 22 January, the Asian Football Confederation (AFC) announced that it would be moving the matches in the third round of the 2020 AFC Women's Olympic Qualifying Tournament from Wuhan to Nanjing, affecting the women's national team squads from Australia, China PR, Chinese Taipei, and Thailand. A few days later, the AFC announced that together with Football Federation Australia they would be moving the matches to Sydney. The Asia-Pacific Olympic boxing qualifiers, which were originally set to be held in Wuhan from 3–14 February, were also cancelled and moved to Amman, Jordan to be held between 3–11 March. On 27 January 2020, the United States CDC issued updated travel guidance for China, recommending that travellers avoid all nonessential travel to all of the country. The CDC directed US Customs and Border Protection to check individuals for symptoms of the coronavirus. On 29 January 2020, British Airways, Lufthansa, Lion Air, and Air Seoul cancelled all their flights to mainland China. The same day, the Czech Republic stopped issuing Schengen visas to Chinese citizens. On 30 January 2020, Egyptair announced a suspension of flights between Egypt and Hangzhou starting 1 February 2020 while those to Beijing and Guangzhou will be suspended starting 4 February 2020 until further notice. On 31 January 2020, Italy suspended all passenger air traffic to Italy from Mainland China, Hong Kong, Macau, and Taiwan. The Italian Civil Aviation Authority NOTAM says that effective 31 January, all passenger flights from China, including the special administrative regions of Hong Kong and Macau, and Taiwan, are suspended until further notice, on request of the Italian health authorities. Aircraft that were flying to Italy when the NOTAM was published, were cleared to land. Qatar Airways took the decision to suspend flights to mainland China from 3 February until further notice, due to significant operational challenges caused by entry restrictions imposed by several countries. Qatar Airways is the first carrier in the Middle East to do so. An ongoing review of operations will be conducted weekly with the intention to reinstate flights as soon as the restrictions are lifted. Though some of the airlines cancelled flights to Hong Kong as well, British Airways, Finnair and Lufthansa have not, and American Airlines continues operating a limited service to the area. Hong Kong's four airlines halved the flights to mainland China. A large number of airlines have reduced or cancelled flights to and from China. On 31 January 2020, the United States declared the virus a public health emergency. Starting 2 February, all inbound passengers who have been to Hubei in the previous 14 days will be put under quarantine for up to 14 days. Any US citizen who has travelled to the rest of mainland China will be allowed to continue their travel home if they are asymptomatic, but will be monitored by local health departments. On 2 February 2020, India issued a travel advisory that warned all people residing in India to not travel to China, suspended E-visas from China, and further stated anyone who has travelled to China starting 15 January (to an indefinite point in the future) could be quarantined. New Zealand announced that it will deny entry to all travellers from China and that it will order its citizens to self-isolate for 14 days if they are returning from China. Indonesia and Iraq followed by also banning all travellers that visited China within the past 14 days. On 3 February 2020, Indonesia announced it would ban passenger flights and also sea freight from and to China starting on 5 February and until further notice. Live animal imports and other products were banned as well. Turkey announced it would suspend all flights from China till the end of February and begin scanning passengers coming from South Asian countries at airports. Australia released its Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19) on 7 February 2020. It states that, although much is yet to be known about COVID-19, "Australia has taken a precautionary approach in line with preparedness and response guidance for a pandemic, working collaboratively with state and territory and whole of government partners to implement strategies to minimise disease transmission through strong border measures and widespread communication activities." On 22 February, the Italian Council of Ministers announced a new decree law to contain the outbreak, including quarantining more than 50,000 people from 11 different municipalities in Northern Italy. Prime Minister Giuseppe Conte said "In the outbreak areas, entry and exit will not be provided. Suspension of work activities and sport events has already been ordered in those areas." Punishments for violating of the lockdown range from a fine of 206 euros to 3 months imprisonment. Italian military and law enforcement agencies were instructed to secure and implement the lockdown. Evacuation of foreign citizens: Owing to the effective lockdown of public transport in Wuhan and Hubei, several countries have planned to evacuate their citizens and diplomatic staff from the area, primarily through chartered flights of the home nation that have been provided clearance by Chinese authorities. Canada, the United States, Japan, India, France, Australia, Sri Lanka, Germany and Thailand were among the first to plan the evacuation of their citizens.[404] Pakistan has said that it will not be evacuating any citizens from China. On 7 February, Brazil evacuated 34 Brazilians or family members in addition to four Poles, a Chinese and an Indian citizen. The citizens of Poland, China and India got off the plane in Poland, where the Brazilian plane made a stopover before following its route to Brazil. Brazilian citizens who went to Brazil were quarantined at a military base near Brasilia. On 7 February 215 Canadians (176 from the first plane, and 39 from a second plane chartered by the U.S. government) were evacuated from Wuhan, China, to CFB Trenton to be quarantined for two weeks. On 11 February, another plane of Canadians (185) from Wuhan landed at CFB Trenton. Australian authorities evacuated 277 citizens on 3 and 4 February to the Christmas Island Detention Centre which had been "repurposed" as a quarantine facility, where they remained for 14 days. United States announced that it will evacuate Americans currently aboard the cruise ship Diamond Princess. On 21 February, a plane carrying 129 Canadian passengers evacuated from the Diamond Princess landed in Trenton, Ontario. International aid: On 5 February, the Chinese foreign ministry stated that 21 countries (including Belarus, Pakistan, Trinidad and Tobago, Egypt, and Iran) had sent aid to China. The United States city of Pittsburgh announced plans to promptly send aid to Wuhan, with mayor Bill Peduto stating that "Our office has reached out to the mayor of Wuhan, which is our sister city" and promising that "over the next two days we should be able to have a care package that has been put together." He speculated that the contents of such a package will be coordinated with the consultation of medical experts, but that it will likely consist of "face masks, rubber gloves and other material that could be hard to find in the future". Additionally, the University of Pittsburgh Medical Center (UPMC) announced plans to provide help, with UPMC spokesman Paul Wood stating that "UPMC has a significant presence in China and has been in contact with our partners there," also declaring that "we stand ready to assist them and others in China with their unmet humanitarian needs." Some Chinese students at other American universities have also joined together to help send aid to virus-stricken parts of China, with a joint group in the Greater Chicago Area reportedly managing to send 50,000 N95 masks and 1,500 protection suits to hospitals in the Hubei province on 30 January. The humanitarian aid organisation Direct Relief, in co-ordination with FedEx transportation and logistics support, sent 200,000 face masks along with other personal protective equipment, including gloves and gowns, by emergency airlift to arrive in Wuhan Union Hospital, who requested the supplies by 30 January. The Gates Foundation stated on 26 January that it would donate US$5 million in aid to support the response in China that will be aimed at assisting "emergency funds and corresponding technical support to help front-line responders". On 5 February, Bill and Melinda further announced a $100 million donation to the World Health Organization, who made an appeal for funding contributions to the international community the same day. The donation will be used to fund vaccine research and treatment efforts along with protecting "at-risk populations in Africa and South Asia." Japan, in the process of co-ordinating a plane flight to Wuhan to pick up Japanese nationals in the city, has promised that the plane will first carry into Wuhan aid supplies that Japanese foreign minister Toshimitsu Motegi stated will consist of "masks and protective suits for Chinese people as well as for Japanese nationals". On 26 January, the plane arrived in Wuhan, donating its supply of one million face masks to the city. Also among the aid supplies were 20,000 protective suits for medical staff across Hubei donated by the Tokyo Metropolitan Government. Support efforts have sprung across Japan to help aid residents in Wuhan. On 27 January, the city of Ōita, a sister city to Wuhan for 40 years, sent 30,000 masks from its own disaster relief stockpile to its sister city through the Red Cross network with boxes labelled "Wuhan Jiayou!," meaning "Hang in there, Wuhan!" in Chinese. Its International Affairs Office division head, Soichiro Hayashi, said that "The people of Wuhan are like family" and expressed hopes that "people can return to their ordinary lives as quickly as possible". On 28 January, the city of Mito donated 50,000 masks to its sister-city of Chongqing, and on 6 February, the city of Okayama sent 22,000 masks to Luoyang, its own sister-city. The ruling Liberal Democratic Party on 10 February made a symbolic deduction of 5,000 yen from the March salary of every LDP parliamentarian, a total of 2 million yen, to donate to China, with the party's secretary-general, Toshihiro Nikai, stating that "For Japan, when it sees a virus outbreak in China, it is like seeing a relative or neighbour suffering. Japanese people are willing to help China and hope the outbreak will pass as soon as possible." Peace Winds Japan has declared it will send a staff member to China to help distribute the face masks and other goods that the NGO will send to the country. A number of other countries have also announced aid efforts. Malaysia announced a donation of 18 million medical gloves to China, The Philippine Red Cross also donated $1.4 million worth of Philippine-made face masks, which were shipped to Wuhan. Turkey dispatched medical equipment, and Germany delivered various medical supplies including 10,000 Hazmat suits. On 19 February, Singapore Red Cross announced that they will send $2.26 million worth of aid to China, which they declared would consist of "purchasing and distributing protective equipment like surgical masks for hospital staff and other healthcare workers." It will also be used to "buy and distribute hygiene items and conduct health education in seven welfare homes in Tianjin and Nanning." WHO response measures: The World Health Organization (WHO) has commended the efforts of Chinese authorities in managing and containing the epidemic, with Director-General Tedros Adhanom Ghebreyesus expressing "confidence in China's approach to controlling the epidemic" and calling for the public to "remain calm". The WHO noted the contrast between the 2003 epidemic, where Chinese authorities were accused of secrecy that impeded prevention and containment efforts, and the current crisis where the central government "has provided regular updates to avoid panic ahead of Lunar New Year holidays". On 23 January, in reaction to the central authorities' decision to implement a transportation ban in Wuhan, WHO representative Gauden Galea remarked that while it was "certainly not a recommendation the WHO has made," it was also "a very important indication of the commitment to contain the epidemic in the place where it is most concentrated" and called it "unprecedented in public health history". On 30 January 2020, following confirmation of human-to-human transmission outside China and the increase in number of cases in other countries, the WHO declared the outbreak a Public Health Emergency of International Concern (PHEIC), the sixth PHEIC since the measure was first invoked during the 2009 swine flu pandemic. Tedros clarified that the PHEIC, in this case, was "not a vote of no confidence in China," but because of the risk of global spread, especially to low- and middle-income countries without robust health systems. In response to the implementations of travel restrictions, Tedros stated that "there is no reason for measures that unnecessarily interfere with international travel and trade" and that "WHO doesn't recommend limiting trade and movement". On 5 February, the WHO appealed to the global community for a $675 million contribution to fund strategic preparedness in low-income countries, citing the urgency to develop those countries which "do not have the systems in place to detect people who have contracted the virus, even if it were to emerge." Tedros further made statements declaring that "We are only as strong as our weakest link" and urged the international community to "invest today or pay more later." On 11 February, the WHO in a press conference established COVID-19 as the name of the disease. In a further statement on the same day, Tedros stated that he had briefed with UN Secretary General Antonio Guterres who agreed to provide the "power of the entire UN system in the response." A UN Crisis Management Team was activated as a result, allowing co-ordination of the entire United Nations response, which the WHO states will allow them to "focus on the health response while the other agencies can bring their expertise to bear on the wider social, economic and developmental implications of the outbreak". On 14 February, a WHO-led Joint Mission Team with China was activated to provide international and WHO experts to touch ground in China to assist in the domestic management and evaluate "the severity and the transmissibility of the disease" by hosting workshops and meetings with key national-level institutions to conduct field visits to assess the "impact of response activities at provincial and county levels, including urban and rural settings." On 25 February, the WHO declared that "the world should do more to prepare for a possible coronavirus pandemic," stating that while it was still too early to call it a pandemic, countries should nonetheless be "in a phase of preparedness." In response to a developing case of outbreak of the coronavirus in Iran, the WHO has sent a Joint Mission Team there on the same day to assess the situation in the country. On 28 February, WHO officials said that the coronavirus threat assessment at the global level will be raised from "high" to "very high," its highest level of alert and risk assessment. Mike Ryan, executive director of WHO’s health emergencies program, warned in a statement that "This is a reality check for every government on the planet: Wake up. Get ready. This virus may be on its way and you need to be ready. You have a duty to your citizens, you have a duty to the world to be ready," urging that the right response measures could help the world avoid “the worst of it." Ryan further stated that the current data does not warrant public health officials to declare a global pandemic, saying that the declaration would mean "we’re essentially accepting that every human on the planet will be exposed to that virus." Appreciation of Chinese responses: China's response to the virus, in comparison to the 2003 SARS outbreak, has been praised by some foreign leaders. US president Donald Trump thanked Chinese President Xi Jinping "on behalf of the American People" on 24 January 2020 on Twitter, stating that "China has been working very hard to contain the Coronavirus. The United States greatly appreciates their efforts and transparency" and declaring that "It will all work out well." Germany's health minister Jens Spahn, in an interview on Bloomberg TV, said with comparison to the Chinese response to SARS in 2003: "There's a big difference to SARS. We have a much more transparent China. The action of China is much more effective in the first days already." He also praised the international co-operation and communication in dealing with the virus. In a letter to Xi, Singapore President Halimah Yacob applauded China's "swift, decisive and comprehensive measures" in safeguarding the health of the Chinese people, while Singapore Prime Minister Lee Hsien Loong remarked of "China's firm and decisive response" in communities affected by the virus. Similar sentiments were expressed by Russian President Vladimir Putin. At a Sunday mass at St. Peter's Square in Vatican City on 26 January 2020, Pope Francis praised "the great commitment by the Chinese community that has already been put in place to combat the epidemic" and commenced a closing prayer for "the people who are sick because of the virus that has spread through China". Criticism of responses- Hubei and Wuhan government: Local officials in Wuhan and the province of Hubei have faced criticism, both domestically and internationally, for mishandling the initial outbreak. Allegations included insufficient medical supplies, lack of transparency to the press and censorship of social media during the initial weeks of the outbreak. On 1 January 2020, the Wuhan police interviewed eight residents for "spreading false information" (characterising the new infection as SARS-like). The Wuhan police had originally stated through a post on its official Weibo account that "eight people had been dealt with according to the law," later clarifying through Weibo that they had only given out "education and criticism" and refrained from harsher punishments such as "warnings, fines, or detention". One of the eight, a doctor named Li Wenliang who informed his former medical school classmates of the coronavirus in a WeChat group after examining a patient's medical report with symptoms of the illness, was warned by the police on 3 January for "making untrue comments" that had "severely disturbed the social order" and made to sign a statement of acknowledgment. It was reported on 7 February 2020 Li had died after contracting the disease from a patient in January 2020. His death triggered grief and anger on the social media, which became extended to demands for freedom of speech in China. China's anti-corruption body, the National Supervisory Commission, has initiated an investigation into the issues involving Li. Local officials were criticised for hiding evidence of human-to-human transmission in early January, and suppressing reports about the disease during People's Congress meetings for political reasons. Criticism was directed at Hubei Governor Wang Xiaodong after he twice claimed at a press conference that 10.8 billion face masks were produced each year in the province, rather than the accurate number of 1.8 million. Wuhan Police detained several Hong Kong media correspondents for over an hour when they were conducting interviews at Wuhan's Jinyintan Hospital on 14 January. Reports said the police brought the correspondents to a police station, where the police checked their travel documents and belongings, then asked them to delete video footage taken in the hospital before releasing them. Authorities in Wuhan and Hubei provinces have been criticised for downplaying the severity of the outbreak and responding more slowly than they could have. The Beijing-based media journal, Caixin noted that Hubei did not roll out the first level of "public health emergency response mechanism" until 24 January, while several other provinces and cities outside the centre of the outbreak have already done so the day before. John Mackenzie, a senior expert at WHO, accused them of keeping "the figures quiet for a while because of some major meeting they had in Wuhan," alleging that there was a "period of very poor reporting, or very poor communication" in early January. In 19 January, four days before the city's lockdown, a wan jia yan (Chinese: 万家宴; literally: 'ten-thousand family banquet') was held in Wuhan, with over 40,000 families turning out; this attracted retrospective criticism. The domestic The Beijing News argued that the local authorities should not have held such a public assembly while attempting to control the outbreak. The paper also stated that when their journalists visited the Huanan Seafood Wholesale Market where the coronavirus likely originated, most residents and merchants there were not wearing face masks. Zhou Xianwang, the mayor of Wuhan, later spoke to China Central Television, explaining that the banquet was held annually, that it is a "sample of the people's self-autonomy," and that the decision was made based on the fact that scientists then wrongly believed that the virus's ability to spread between humans was limited. Meanwhile, on 20 January, Wuhan's municipal department for culture and tourism gave out 200,000 tickets valid for visiting all tourist attractions in Wuhan to its citizens for free. The department was later criticised for disregarding the outbreak. Tang Zhihong, the chief of the health department in Huanggang, was fired hours after she was unable to answer questions on how many people in her city were being treated. Central government of China: In contrast to the widespread criticism of the local response, the central government has been praised by international experts and state media for its handling of the crisis. This has led to suggestions, in particular by the international press, that it is an attempt by the state media to shift public anger away from the central government and towards local authorities. It has been noted historically that the tendency of provincial governments to minimise reporting local incidents have been because of the central government directing a large proportion of the blame onto them. Critics, such as Wu Qiang, a former professor at Tsinghua University, and Steve Tsang, director of the China Institute at the University of London, have further argued the same point, with the latter suggesting that it was also exacerbated through local officials being "apprehensive about taking sensible preventive measures without knowing what Xi Jinping and other top leaders wanted as they feared that any missteps would have serious political consequences," a sentiment that Tsang argued was difficult to avoid when "power is concentrated in the hands of one top leader who is punitive to those who make mistakes". Wuhan mayor Zhou Xianwang defended himself, referring to those suggestions by publicly blaming regulatory requirements that require local governments to first seek Beijing's approval, which delayed disclosure of the epidemic. He stated in an interview that "as a local government, we may disclose information only after we are given permission to do so. That is something that many people do not understand." In Xi's place, Premier Li Keqiang was dispatched to oversee epidemic control and prevention, with some suspecting that Li was a convenient "political scapegoat". This led to suggestions that the ruling party and state media were attempting to limit the risk of political fallout to Xi during this crisis. The governing party's censorship and propaganda have fueled mistrust on their handling of the outbreak, particularly among young individuals. The Chinese government has also been accused of rejecting help from the CDC and the WHO. Insiders at the US Centres for Disease Control and Prevention complained that China would not agree to on-site visits, while it took two weeks for Chinese authorities to approve an international mission team led by Dr. Bruce Aylward but the team composition and scope of work was still yet to be determined. Japanese government: Japan's Ministry of Health, Labour and Welfare has been criticised for a perceived delayed response. Critics have observed that while Japan announced the first case of infection on 28 January, it took until 17 February for the Health Ministry to inform the public on how to reach public screening centres and 25 February for the government to issue a "basic policy" on outbreak response. The overdue response times of the government has led critics to accuse Japanese Prime Minister Shinzo Abe of "callous indifference in the face of an unfolding disaster" and the government as a whole as being "out of touch with the lives of ordinary people that they seem genuinely uninterested in their plight". The Japanese government has been criticised for its quarantine measures on the cruise Diamond Princess after the ship proved a fertile breeding ground for the virus. Kentaro Iwata, a infectious disease professor at Kobe University Hospital, said that the condition aboard was "completely chaotic" and "violating all infection control principles". A preliminary report by Japan's National Institute of Infectious Diseases (NIID) estimated that most of the transmission on the ship had occurred before the quarantine, although it was based on the first 184 cases. On 22 February, the Health Ministry admitted that 23 passengers were disembarked without being properly tested for the virus. On 23 February, a Japanese woman who tested negative before disembarking from the cruise ship later tested positive after returning to her home in Tochigi Prefecture. However, she was not among the 23 passengers. The strict constraints on testing for the virus by Japanese health authorities has drawn accusations from critics such as Masahiro Kami, a physician and director of the Medical Governance Research Institute, towards Shinzo Abe of wanting to "downplay the number of infections or patients because of the upcoming Olympics." Reports that only a small select number of public health facilities were authorised to test for the virus, whereafter the results could only be processed by five government-approved companies, has created a bottleneck where clinics have been forced to turn away even patients who had high fevers. This has led some experts to question Japan's official case numbers, with Tobias Harris, of Teneo Intelligence in Washington stating "You wonder, if they were testing nearly as much as South Korea is testing, what would the actual number be? How many cases are lurking and just aren’t being caught?" South Korean government: The Ministry of Health and Welfare has been criticised for unilaterally implementing telephone consultation and prescription without discussing with the Korea Medical Association, and for not restricting traffic from China despite several warnings from the association and a petition proposed by the society. On 22 February, the South Korean government apologised for calling the virus "Daegu Corona 19" in an official report. The term has been widespread on social medias and raises concerns about discrimination. Iranian government: According to Radio Farda, despite an announcement by Iran's vice-president on 31 January of the Iranian government's willingness to stop flights from China, a report on 24 February claimed that Mahan Airline, a company related to the IRGC, kept operating its flights between China, Iran and Turkey, but it was denied consistently by Iranian officials. Iranian officials said they have ceased all flights to and from China, except a few evacuation flights and cargo flights, all of which had been thoroughly cleaned or quarantined. Iranians criticised government authorities for proceeding with elections while the disease was spreading and closing secular spaces while keeping shrines open, especially in the Shia holy city of Qom. Others, including Qom member of parliament Ahmad Amirabadi Farahani, claimed that the numbers of infections and deaths had been understated. Scrutiny has also been targeted at the government's unwillingness to implement similar area-wide quarantine measures implemented by China and Italy, with Iranian officials calling quarantines "old-fashioned." Iran's deputy health minister, Iraj Harirchi, in a conference on the same day denied that those allegations of understated numbers were valid, although he admitted a day after that he had tested positive for the virus.[500] Another government official, Masoumeh Ebtekar, Vice-President for Women and Family Affairs, reported she had tested positive on 27 February. There have been concerns that the Iranian government's official counts were an underestimation. Mike Ryan of the WHO has said that the "extent of infection may be broader than what we may be seeing" given that the "disease came unseen and undetected into Iran." BBC Persia conducted an independent count by asking "Iranian hospitals one by one," finding 210 fatalities on 28 February while the official number for the day was 34, from which the report suggests that "there were several thousand infections either undetected or unacknowledged." Iranian officials have denied the report's accuracy. Italian government: Italy's government has drawn criticism from scientists and WHO, for its decision to suspend direct flights to mainland China that while sounding "tough" on paper, was ineffective as "people can still arrive from risk areas via indirect routes." Walter Ricciardi, professor of Hygiene and Public Health at the Università Cattolica del Sacro Cuore in Rome and a member of the European Advisory Committee on Health Research has said "Italy was wrong, closing flights from China is of no use when there are indirect ones." Criticism followed disclosures by Italian Prime Minister Giuseppe Conte that protocols had not been followed at the hospital in Codogno, Lombardy that treated "patient 1" which "certainly contributed to the spread" of the virus in Italy, with Conte responding to inquiries by journalists on what protocol was broken with "This is not the time for controversy." In response to a statement by Conte that the central government may need to "revoke regional health policy powers," Lombardy governor Attilio Fontana pushed back on the remark with a colleague calling Conte's statement "fascist" and "talking nonsense." United States government: The Trump administration has come under criticism for its cuts of $15 billion in overall health funding in 2018, including those for an Obama-era global health security task force that would have been focused on pandemic response. In 2018, the Centers for Disease Control was forced to slash 80% of its global disease outbreak program as CDC funding was cut. Created in 2014, the program operated in 49 countries, but the CDC planned to reduce or eliminate operations in 39 of those countries. In its fiscal 2020 budget, the Trump administration proposed eliminating funding for epidemiology and laboratory capacity at state and local levels. An additional $30 million 'Complex Crises Fund' had also been cut entirely, which would have allowed the State Department to fund deployment of disease experts in the event of outbreaks. In May 2018, Trump's national security advisor John Bolton disbanded a National Security Council global health security team that was responsible for leading the American response to a pandemic. While the CDC has announced plans to screen people for the coronavirus, only three of the 100 public health labs were reported to be fitted for that role even after delays, which has been credited to the agency's funding cuts. President Trump has been further criticised for proposing further cuts to the CDC and National Institute of Health budgets, pegged at 16% and 10% respectively in a released 2021 white paper, seemingly during the midst of the outbreak on 11 February 2020. The proposed budget also called for a $65 million cut to the US' contribution to funding for the WHO. In response to the criticisms of the administration's handling of the crisis, Mick Mulvaney, the White House's acting Chief of Staff in a speech to a conservative audience event accused the US media of being overly-critical and plotting to "stoking virus fears" in hopes that "this is going to bring down the president." On February 28, Trump asserted Democrats were promoting a "new hoax" to harm him politically and that the press was in "hysteria mode," while attempting to link the outbreak to Democratic immigration policies. WHO: The WHO and Chinese authorities have received criticism for their delayed reporting and handling of the epidemic, leading to scrutiny of the relationship between the two entities amid allegations of a cover-up. A United Nations diplomat who spoke on the condition of anonymity said that the "World Health Organization is so much in thrall to China's influence, they have felt compelled to stay close to China's line on this crisis...to downplay this virus...until its position became untenable". Initial concerns included the observation that while WHO relies upon data provided and filtered by member states, China has had a "historical aversion to transparency and sensitivity to international criticism". While the WHO and some world leaders have praised the Chinese government's transparency in comparison to the 2003 SARS outbreak, others including John Mackenzie of the WHO's emergency committee and Anne Schuchat of the US' Center for Disease Control and Prevention have shown scepticism, suggesting that China's official tally of cases and deaths may be an underestimation.[citation needed] Other experts, including David Heymann, professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine, have said in response that "China has been very transparent and open in sharing its data … they’re sharing it very well and they opened up all of their files with the WHO present." Responding to criticism of his earlier approval of China's efforts, WHO Director-General Tedros stated that China "doesn't need to be asked to be praised. China has done many good things to slow down the virus. The whole world can judge. There is no spinning here," and further stating that "I know there is a lot of pressure on WHO when we appreciate what China is doing but because of pressure we should not fail to tell the truth, we don't say anything to appease anyone. It's because it's the truth." Tedros also suggested that the WHO would later assess whether China's actions were evidence-based and reasonable, saying "We don't want to rush now to blaming, we can only advise them that whatever actions they take should be proportionate to the problems, and that's what they assured us." In what was described as a "diplomatic balancing act" between "China and China's critics," some observers have framed the WHO as being unable to risk antagonising the Chinese government, as otherwise the agency would not have been able stay informed on the domestic state of the outbreak and influence response measures there, after which there would have "likely have been a raft of articles criticizing the WHO for needlessly offending China at a time of crisis and hamstringing its own ability to operate." Through this, experts such as Dr. David Nabarro have defended this strategy in order "to ensure Beijing's co-operation in mounting an effective global response to the outbreak". Osman Dar, director of the One Health Project at the Chatham House Centre on Global Health Security defended the WHO's conduct, stating that the same pressure was one "that UN organisations have always had from the advanced economies." The WHO's daily situation reports recognise Taiwan as a part of China, with the result of Taiwan receiving the same "very high" risk rating as the mainland by the WHO despite only a having a relatively small number of cases on the ROC-governed island. This has led to Taiwan receiving travel bans from other countries. Further concerns regarding Taiwan's non-member status in the WHO has been on the effect this has on increasing Taiwan's vulnerability in the case of a outbreak in the state without proper channels to the WHO. Taiwan president, Tsai Ing-wen, called on the WHO to allow Taiwanese experts to participate in the dialogue and for the WHO to share data on the virus even if it was not possible admit Taiwan as a member state. In response, the WHO has said that they "have Taiwanese experts involved in all of our consultations so they're fully engaged and fully aware of all of the developments in the expert networks." After urging from Japan, the US and the UK, Taiwan was granted participation with China's agreement, who deemed it "necessary under the circumstances to let Taiwan participate in sharing information on the virus." Taiwan has called the move a "meaningful development" in response. Misinformation: After the initial outbreak, conspiracy theories and misinformation spread online regarding the origin and scale of the Wuhan coronavirus. Various social media posts claimed the virus was a bio-weapon, a population control scheme, or the result of a spy operation. Google, Facebook, and Twitter announced they will crack down on possible misinformation. In a blogpost, Facebook stated they would remove content flagged by leading global health organisations and local authorities that violate its content policy on misinformation leading to "physical harm". On 2 February, the WHO declared there was a "massive infodemic" accompanying the outbreak and response, citing an over-abundance of reported information, accurate and false, about the virus that "makes it hard for people to find trustworthy sources and reliable guidance when they need it." The WHO stated that the high demand for timely and trustworthy information has incentivised the creation of a direct WHO 24/7 myth-busting hotline where its communication and social media teams have been monitoring and responding to misinformation through its website and social media pages. A group of scientists from outside China have released a statement to "strongly condemn" rumours and conspiracy theories about the origin of outbreak. On 22 February, US officials said that they discovered state sponsored disinformation campaign from Russia, deliberately promoting anti-American anti-CIA conspiracy theories on social media. U.S. President Donald Trump, Trump's top economic adviser Larry Kudlow and some members of the United States Congress have been accused of spreading misinformation about the coronavirus. Xenophobia and racism: Since the outbreak of COVID-19, heightened prejudice, xenophobia and racism against peoples of Chinese and East Asian descent has arisen as a result, with incidents of fear, suspicion and hostility being noted across various countries. Although there has been support from Chinese both on and offline towards those in virus-stricken areas, many residents of Wuhan and Hubei have reported experiencing discrimination based on their regional origin. Citizens in numerous countries such as Malaysia, New Zealand, Singapore, and South Korea have signed petitions lobbying their government to ban Chinese from entering the country. In the Russian cities of Moscow and Yekaterinburg, people of Asian appearance are targeted by quarantine enforcing campaigns, as well as police raids, which were condemned as racial profiling. On 30 January, WHO's Emergency Committee issued a statement advising all countries to be mindful of the "principles of Article 3 of the IHR," which cautions against "actions that promote stigma or discrimination," when conducting national response measures to the outbreak. Open access science: Owing to the urgency of the epidemic, many scientific publishers made scientific papers related to the outbreak available with open access. Some scientists chose to share their results quickly on preprint servers such as BioRxiv, while archivists created an illegal open access database of over 5,000 papers about coronaviruses, which they downloaded from Sci-Hub. Socio-economic impact: The outbreak has had further reaching consequences beyond the disease and efforts to quarantine it. There have been widespread reports of supply shortages of pharmaceuticals and manufactured goods due to factory disruption in China, with certain localities (such as Italy and Hong Kong) seeing panic buying and consequent shortages of food and other essential grocery items. The technology industry in particular has been warning about delays to shipments of electronic goods. A number of provincial-level administrators of the China Communist Party were dismissed over their handling of the quarantine efforts in Central China, a sign of discontent with the political establishment's response to the outbreak in those regions. Some commentators have suggested that outcry over the disease could be a rare protest against the CCP. Additionally, protests in the special administrative region of Hong Kong have strengthened due to fears of immigration from Mainland China. Taiwan has also voiced concern over being included in any travel ban involving the People's Republic of China due to the "one-China policy" and its disputed political status. As Mainland China is a major economy and a manufacturing hub, the viral outbreak has been seen to pose a major destabilising threat to the global economy. Agathe Demarais of the Economist Intelligence Unit has forecast that markets will remain volatile until a clearer image emerges on potential outcomes. Some analysts have estimated that the economic fallout of the epidemic on global growth could surpass that of the SARS outbreak. Dr. Panos Kouvelis, director of "The Boeing Center" at Washington University in St. Louis, estimates a $300+ billion impact on world's supply chain that could last up to two years. Organization of the Petroleum Exporting Countries reportedly "scrambled" after a steep decline in oil prices due to lower demand from China. Global stock markets fell on 24 February 2020 due to a significant rise in the number of COVID-19 cases outside Mainland China. The epidemic coincided with the Chunyun, a major travel season associated with the Chinese New Year holiday. A number of events involving large crowds were cancelled by national and regional governments, including annual New Year festivals, with private companies also independently closing their shops and tourist attractions such as Hong Kong Disneyland and Shanghai Disneyland Many Lunar New Year events and tourist attractions have been closed to prevent mass gatherings, including the Forbidden City in Beijing and traditional temple fairs. In 24 of China's 31 provinces, municipalities and regions, authorities extended the New Year's holiday to 10 February, instructing most workplaces not to re-open until that date. These regions represented 80% of the country's GDP and 90% of exports. Hong Kong raised its infectious disease response level to the highest and declared an emergency, closing schools until March and cancelling its New Year celebrations. The demand for personal protection equipment has risen 100-fold, according to WHO director-general Tedros Adhanom. This demand has lead to the increase in prices of up to twenty times the normal price and also induced delays on the supply of medical items for four to six months. On 27 February, due to mounting worries about the coronavirus outbreak, various US stock indexes including the NASDAQ-100, the S&P 500 Index, and the Dow Jones Industrial Average posted their sharpest falls since 2008, with the Dow falling 1,191 points, the largest one-day drop since the Financial Crisis. All three indexes ended the week down more than 10 percent.