No one knows the true number of coronavirus infections in China, but it could be up to 4 million a day. Experts fear that new variants could emerge undetected that may prove dangerous for the rest of the world. Time is ticking.
Ravindra Gupta, an internationally recognized coronavirus expert from Cambridge, UK, is worried by what he can't see.
“We are unfortunately blind to what is happening there right now.” The what and the there Gupta is referring to is the rapid spread of COVID-19 in China. In his lab, Gupta researches how viruses develop under certain conditions. In order to better understand how new coronavirus variants evolve, he incorporates new mutations into so-called pseudo-viruses, then analyzes what these changes mean from a medical perspective.
In this way, he was able to predict that the dangerous Delta variant that first appeared in India in 2021 would spread across the world so quickly.
And now? “The Chinese government is not only preventing us from knowing the transmission pattern and death rate of the outbreak there.," Gupta says. "We are also not receiving any representative data about the variants in circulation.”
Over the past four weeks, only 388 coronavirus genome sequences have been entered into the international data bank GISAID from “mainland China”. If there had really been only a few thousand new infections per day in China, as officials claim, that would be a useful data set from which to draw conclusions. But that is not the case.
Hiding the truth
China – a country with a population of 1.4 billion – is clearly hiding the true figures: since Christmas, no new figures have been reported. The most recent was around 4,500 new infections per day, whereas eyewitnesses in all provinces report that half the population is ill.
Evolution is a numbers game.
English health analytics firm Airfinity estimates the true infection rate to be a thousand times the one reported: 4 million new infections per day. They say that over the past four weeks, there could have been hundreds of millions of cases.
“This means that having 388 genome sequences to analyze is as useless as having none,” explains Gupta. “There could be viruses that we don’t know about still mutating in the rest of the population, changing faster and learning how to deal with human immune responses more effectively, and unfortunately there could be worrying mutations piling up.”
Evolution is first and foremost a numbers game.
Airport toilet analysis
Some countries around the world are taking action, implementing some new travel restrictions. Others, like Germany, are also starting to monitor the situation in China themselves. For example, at Frankfurt Airport, the toilet tanks from planes arriving from China are being analyzed for viruses using a special PCR test.
Since Thursday, however, Chinese nationals will only be able to enter Germany if they show proof of a negative COVID test, which will reduce the efficacy of this monitoring: if scientists are unable to find any viruses, it could be difficult to collect enough samples to draw any valid conclusions.
The German government is advising citizens against any unnecessary travel to China, and on Monday the Robert Koch Institute (RKI) classified the country as an “area with dangerous virus variants”.
A lab technician at a factory in Beijing of Youcare Pharmaceutical Group Co., Ltd.
Artyom Ivanov/TASS via ZUMA
Changes to a virus’s genetic make-up can occur when it multiplies in its host cell; they are caused by replication errors or created when the blueprints for different viruses mix together. Most mutations produce virus cells that are unable to function, but sometimes they make a virus stronger.
In China, the population is largely unprotected.
Because these mutations happen by chance – although with a certain frequency – the infection rate within a specific time period makes a difference. In China the population is largely unprotected, which means more people are becoming infected within a shorter time period, and their immune system takes longer to rid them of the virus – so it has more time to replicate itself.
The sheer scale of the current outbreak makes it more likely that we will see the emergence of a new variant that could have a much higher death rate for those infected.
Almost all samples that have emerged from China so far have belonged to the Omicron group, a “mixture” of very similar viruses. These typically have a very high infection rate and cause relatively mild symptoms. They are a second-generation coronavirus and are seen as a new strain because they are able to produce an unusually high number of mutations. These characteristics are all adaptations to the human body that likely came about through chronic infections of immunocompromised patients.
China’s population is old, so it has a high rate of chronic illnesses such as diabetes and renal failure, which increase the chances of a patient suffering a chronic COVID infection. What could make the situation far worse is that in China there are around 1 million or more people who are HIV-positive.
Again, according to Western observers, China’s official figures on HIV are unreliable. The real number could be much higher, and it is possible that most of those infected have no access to HIV drugs, are seriously immunocompromised and therefore represent a high-risk group for coronavirus mutations.
These antiviral treatments also influence the evolution of SARS viruses. So far there has been no serious consideration of how that could impact on containment strategies. Governments that provide good care for HIV patients in their country are reducing the opportunities for coronaviruses to develop. However, those nations that freely prescribe broad-spectrum SARS-virus treatments to COVID patients are creating an environment in which dangerous variants could emerge.
Delta origins in India
Virologists like Gupta believe that the Delta variant was able to develop in India because hydroxychloroquine was widely used: the malaria treatment also blocks one of the receptors that allows SARS-CoV-2 to enter human cells, especially in the upper respiratory tract. They think that at some point a mutated virus was able to use another entry point, probably in the lungs, and that is most likely how Delta came into being, through selection pressure.
Scientists have long been aware of the problem of viruses responding to medical treatments by mutating quickly and becoming more aggressive. The solution is also common knowledge: using compound preparations (custom formulations of medication).
The COVID treatment molnupiravir relies on a single active ingredient, but this also lead to mutations. It impairs the virus’s ability to replicate itself in humans, but in rare cases it can also lead to new genetic mutations. This means it is all the more important to monitor the virus in places where the treatment is used. In late December China approved its use in emergency cases.
The size and spread factor
China is not the only country where the COVID situation is unclear. Most parts of the world don’t do enough sequencing, according to Gupta. He says that poorer countries don’t have the necessary labs, while rich countries underestimate the dangers of the virus.
But what makes the situation in China especially dangerous is the sheer size of the country.
But what makes the situation in China especially dangerous is the sheer size of the country, and its links to the rest of the world. “What emerges in China can quickly spread to the rest of the world.”
In our interview, Gupta seems resigned. Over the past 12 months he has worked hard with his team, trying to use biotechnology to give the world a head-start on the possible evolution of the virus. It now takes around four weeks to assess the risk posed by new mutations.
“If a more deadly variant should appear, this means we would still have time to step up protection measures around the world – and theoretically even to adapt vaccines,” Gupta explains. “But if that happens now in China, we will certainly be too late.”