China’s changed how it counts virus cases three times now. Here’s why

Weeks after the novel coronavirus crisis began in December, there is still widespread confusion over the exact number of cases reported in China and whether the epidemic is finally stabilizing at the outbreak’s epicenter of Hubei province.

On Thursday, China announced just 394 new confirmed cases, the lowest number of daily infections reported in weeks. But on Friday, the confirmed number of cases in mainland China increased to?889, according to the country’s National Health Commission.

This fluctuation could be partly down to a change this week in what is counted as a “confirmed case” in Hubei province, the epicenter of the global outbreak.

Here’s what we know.

How has China changed its method?

Last week, Hubei province announced it would count “clinically diagnosed” cases in its numbers. These were patients who demonstrated all the symptoms of Covid-19 but either had not been able to get a test or were believed to have falsely tested negative.

TOKYO, JAPAN - JANUARY 31: A passenger receives a temperature check before taking a flight bound for Wuhan at Spring Airlines' check-in counter at Haneda airport on January 31, 2020 in Tokyo, Japan. The Chinese government arranged a charter flight operated by Spring Airlines for tourists from Wuhan to return to the city first time since the center of the outbreak of a new coronavirus has been under lockdown. The number of those who have died from the Wuhan coronavirus, known as 2019-nCoV, in China climbed to over 213 on Friday and cases have been reported in other countries including the United States, Canada, Australia, Japan, South Korea, India, the United Kingdom, Germany, France and several others. (Tomohiro Ohsumi/Getty Images)

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Hubei doctors could use CT scans to confirm such coronavirus infections without a test.

That decision saw confirmed cases in Hubei province soar, with more than 15,152 new infections announced in mainland China on February 12 alone.

Officials said the move to include clinically diagnosed patients was intended to help clear a backlog of suspected cases in Hubei.

But on Thursday the government guidelines changed and “clinically confirmed” were excluded from the tally of confirmed cases.

Now patients must have a positive lab test result to be counted in the tally. Other cases will be listed as “suspected.”

The World Health Organization (WHO) reacted to the change in their Friday situation report, noting: “Some previously reported ‘clinically diagnosed’ cases are thus expected to be discarded over the coming days as laboratory testing is conducted and some are found to be Covid-19-negative.”

Adding to the confusion is that on Friday, Hubei health authorities announced another new development.

Tu Yuanchao, deputy director of Hubei Health Committee, said at a press conference that the provincial government has banned the practice of reducing the number of already confirmed cases.

Tu said that all the cases that were confirmed but then retroactively dismissed as they no longer fitted the reporting requirements would be added back to the total tally.

“These adjustments in numbers have attracted huge public attention, caused some doubts about the data. As a result, Ying Yong, secretary of the provincial Party committee, attached great importance to this issue. He explicitly ordered that no subtraction be allowed for already-confirmed cases and all subtractions be added back,” Tu said.

Why has China done this?

China cited improved testing capacity of the novel coronavirus as the reason for changing the way confirmed cases are counted in Hubei province, officials said Thursday.

Wang Guiqiang, director of the Society of Infectious Diseases of the Chinese Medical Association, said: “In order to resolve the conflict between diagnosis and treatment, in Hubei, such clinical diagnosis was introduced to enable timely treatment of possible patients and reduce fatality rate.

“But now that the situation in Hubei has changed. The nucleic acid testing capability has been greatly improved. And now all suspected cases or unconfirmed cases can be tested for nucleic acids quickly. Nucleic acid testing is no longer an issue.”

Nucleaic acids – such as DNA – are the main information-carrying molecules of the cell. Nucleic acid tests analyze swabs taken from a patient’s saliva or mucus and look for the genetic materials of the virus.

However, scientists have pointed to problems with the nucleic acid test producing false negatives, meaning infected patients could be going undetected.

There are also reports in parts of China that a shortage of testing kits and inaccurate results are leading to long delays in the diagnosis and treatment of coronavirus patients.

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A pedestrian walks a dog through a quiet street in New York on March 17.

People gather to collect free face masks in New Delhi on March 17.

Dermot Hickey, left, and Phillip Vega ask a pedestrian in New York to take their picture on a thinly trafficked Fifth Avenue on March 17. Many streets across the world are much more bare as people distance themselves from others. In the United States, the White House has advised people not to gather in groups of more than 10.

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Two nuns greet neighbors from their balcony in Turin, Italy, on Sunday, March 15.

Pope Francis, inside the Church of San Marcello in Rome's city center, prays at a famous crucifix that believers claim helped to save Romans from the plague in 1522.

Passengers wait for their flights at Marrakesh Airport in Morocco on March 15.

US Vice President Mike Pence takes a question during a White House briefing about the coronavirus on March 15.

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People wait in line to go through customs at Dallas/Fort Worth International Airport on March 14. Travelers returning from Europe say they were being made to wait for hours at US airports, often in close quarters, as personnel screened them for the coronavirus.

Hundreds of people lined up to enter a Costco in Novato, California, on March 14. Many people have been stocking up on food, toilet paper and other items. As a response to panic buying, retailers in the United States and Canada have started limiting the number of toilet paper that customers can buy in one trip.

A member of the White House physician's office takes a media member's temperature in the White House briefing room on March 14. It was ahead of a news conference with President Donald Trump and Vice President Mike Pence.

Reporters in Arlington, Virginia, sit approximately 4 feet apart during a briefing by Marine Corps Gen. Kenneth F. McKenzie on Friday, March 13.

People walk past a closed Broadway theater on March 13 after New York canceled all gatherings over 500 people.

Body temperatures are scanned as people enter the Buddhist temple Wat Pho in Bangkok, Thailand, on March 13.

A Costco customer stands by two shopping carts in Richmond, California, on March 13.

A teacher works in an empty classroom at the Pompeu Fabra University in Barcelona, Spain.

A woman looks at an empty bread aisle in Antwerp, Belgium, on March 13.

Employees of the Greek Parliament wear plastic gloves ahead of the swearing-in ceremony for Greek President Katerina Sakellaropoulou.

A motorcyclist drives through disinfectant sprayed in Jammu, India, on March 13.

Workers prepare to construct an additional building on a hospital on the outskirts of Moscow.

Paul Boyer, head equipment manager of the NHL's Detroit Red Wings, wheels out equipment bags in Washington on Thursday, March 12. The NHL is among the sports leagues that have suspended their seasons.

Students leave Glacier Peak High School in Snohomish, Washington, on March 12. Beginning the following day, schools in the Snohomish school district planned to be closed through April 24.

An Uber Eats delivery biker stands at a deserted Piazza di Spagna in Rome.

People at a railway station in Seoul, South Korea, watch a live broadcast of US President Donald Trump on March 12. Trump announced that, in an effort to slow the spread of the coronavirus, he would sharply restrict travel from more than two dozen European countries.

Workers in protective suits disinfect Istanbul's Dolmabahce Palace on March 11.

A person wearing a face mask walks outside of a shopping mall in Beijing on March 11.

Police officers restrain the relative of an inmate outside the Sant'Anna jail in Modena, Italy, on March 9. Riots broke out in several Italian jails after visits were suspended to curb the spread of the coronavirus.

Medical staff in Wuhan, China, celebrate after all coronavirus patients were discharged from a temporary hospital on March 9.

Traders work on the floor of the New York Stock Exchange on March 9. Stocks plummeted as coronavirus worries and an oil price race to the bottom weighed on global financial markets.

Rescuers search for victims at the site of a collapsed hotel in Quanzhou, China, on March 8. The hotel was being used as a coronavirus quarantine center.

The Grand Princess cruise ship, carrying at least 21 people who tested positive for coronavirus, is seen off the coast of San Francisco on March 8. The ship was being held at sea.

Sumo wrestlers attend a tournament in Osaka, Japan, that was being held behind closed doors because of the coronavirus outbreak.

A couple rides a bicycle at a park in Seoul, South Korea, on March 7.

A volunteer from Blue Sky Rescue uses fumigation equipment to disinfect a residential compound in Beijing on March 5.

Airmen from the California National Guard drop coronavirus testing kits down to the Grand Princess cruise ship off the coast of California on March 5.

Municipal workers are seen at the Kaaba, inside Mecca's Grand Mosque. Saudi Arabia emptied Islam's holiest site for sterilization over coronavirus fears, an unprecedented move after the kingdom suspended the year-round Umrah pilgrimage.

Passengers react as a worker wearing a protective suit disinfects the departure area of a railway station in Hefei, China, on March 4.

Teachers at the Nagoya International School in Japan conduct an online class for students staying at home as a precaution against the spread of coronavirus.

Soldiers spray disinfectant throughout a shopping street in Seoul.

A Muslim worshipper attends a mass prayer against coronavirus in Dakar, Senegal, on March 4. It was after cases were confirmed in the country.

People wear face masks in New York's Times Square on March 3. New York reported its first case of coronavirus two days earlier.

A security guard stands on the Shibuya Sky observation deck in Tokyo on March 3.

US President Donald Trump, flanked by Vice President Mike Pence, left, and Health and Human Services Secretary Alex Azar, speaks during a meeting with pharmaceutical executives and the White House coronavirus task force on March 2. Throughout the meeting, Trump was hyperfocused on pressing industry leaders in the room for a timeline for a coronavirus vaccine and treatment. But experts at the table -- from the administration and the pharmaceutical industry -- repeatedly emphasized that a vaccine can't be rushed to market before it's been declared safe for the public.

Medical staff stand outside a hospital in Daegu, South Korea, on March 1.

Healthcare workers transfer a patient at the Life Care Center in Kirkland, Washington, on March 1. The long-term care facility is linked to confirmed coronavirus cases.

British Prime Minister Boris Johnson visits a London laboratory of the Public Health England National Infection Service.

Tomoyuki Sugano, a professional baseball player on the Yomiuri Giants, throws a pitch in an empty Tokyo Dome during a preseason game on February 29. Fans have been barred from preseason games to prevent the spread of the coronavirus.

Commuters wearing masks make their way to work during morning rush hour at the Shinagawa train station in Tokyo on February 28.

Medical staff transport a coronavirus patient within the Red Cross hospital in Wuhan on February 28.

Inter Milan plays Ludogorets in an empty soccer stadium in Milan, Italy, on February 27. The match was ordered to be played behind closed doors as Italian authorities continue to grapple with the coronavirus outbreak.

A bank clerk disinfects banknotes in China's Sichuan province on February 26.

A child wearing a protective face mask rides on a scooter in an empty area in Beijing.

A Catholic devotee wears a face mask as he is sprinkled with ash during Ash Wednesday services in Paranaque, Philippines, on February 26.

People disinfect Qom's Masumeh shrine in Tehran, Iran, on February 25.

A worker in Daegu stacks plastic buckets containing medical waste from coronavirus patients on February 24.

Paramedics carry a stretcher off an ambulance in Hong Kong on February 23.

People attend a professional soccer match in Kobe, Japan, on February 23. To help stop the spread of the novel coronavirus, the soccer club Vissel Kobe told fans not to sing, chant or wave flags in the season opener against Yokohama FC.

A team of volunteers disinfects a pedestrian bridge in Bangkok, Thailand.

A man rides his bike in Beijing on February 23.

Hospital personnel in Codogno, Italy, carry new beds inside the hospital on February 21. The hospital is hosting some people who have been diagnosed with the novel coronavirus.

Doctors look at a CT scan of a lung at a hospital in Xiaogan, China, on February 20.

A sales clerk wears a mask as she waits for customers at a hat shop in Beijing on February 18. Small companies that help drive China's economy are worried about how much damage the coronavirus outbreak will cause to business.

Buses carrying American passengers arrive at the Haneda Airport in Tokyo on February 17. The passengers were leaving the quarantined Diamond Princess cruise ship to be repatriated to the United States.

A medical worker rests at the isolation ward of the Red Cross hospital in Wuhan on February 16.

Authorities watch as the Westerdam cruise ship approaches a port in Sihanoukville, Cambodia, on February 13. Despite having no confirmed cases of coronavirus on board, the Westerdam was refused port by four other Asian countries before being allowed to dock in Cambodia.

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Beds are made in the Wuhan Sports Center, which has been converted into a temporary hospital.

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A police officer, left, wears protective gear as he guards a cordon at the Hong Mei House in Hong Kong on February 11.

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A shopper walks past empty shelves at a grocery store in Hong Kong on February 9. China's Ministry of Commerce encouraged supermarkets and grocery stores to resume operations as the country's voluntary or mandatory quarantines began to take an economic toll.

A worker wearing a protective suit uses a machine to disinfect a business establishment in Shanghai, China, on February 9.

Workers in protective gear walk near the Diamond Princess cruise ship docked in Yokohama on February 7.

People in Hong Kong attend a vigil February 7 for whistleblower doctor Li Wenliang. Li, 34, died in Wuhan after contracting the virus while treating a patient.

A woman grieves while paying tribute to Li at Li's hospital in Wuhan on February 7.

The Anthem of the Seas cruise ship is seen docked at the Cape Liberty Cruise Port in Bayonne, New Jersey, on February 7. Passengers were to be screened for coronavirus as a precaution, an official with the Centers for Disease Control and Prevention told CNN.

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Passengers are seen on the deck of the Diamond Princess cruise ship, docked at the Yokohama Port on February 7.

Flight attendants wearing face masks make their way through Don Mueang Airport in Bangkok on February 7.

Workers check sterile medical gloves at a latex-product manufacturer in Nanjing, China, on February 6.

A woman wears a protective mask as she shops in a Beijing market on February 6.

This aerial photo shows the Leishenshan Hospital that is being built in Wuhan to handle coronavirus patients.

A passenger shows a note from the World Dream cruise ship docked at the Kai Tak cruise terminal in Hong Kong on February 5.

A mask is seen on a statue in Beijing on February 5.

An ambulance stops at a traffic light in front of the Grand Lisboa Hotel in Macao. The virus turned China's gambling mecca into a ghost town.

A dog in Beijing wears a makeshift mask constructed from a paper cup.

Striking hospital workers in Hong Kong demand the closure of the border with mainland China on February 4.

The Diamond Princess cruise ship sits anchored in quarantine off the port of Yokohama on February 4. It arrived a day earlier with passengers feeling ill.

A medical worker wearing protective gear waits to take the temperature of people entering Princess Margaret Hospital in Hong Kong on February 4.

Medical workers in protective suits help transfer patients to a newly completed field hospital in Wuhan.

People wearing protective overalls talk outside a Wuhan hotel housing people in isolation on February 3.

A man stands in front of TV screens broadcasting a speech by Hong Kong Chief Executive Carrie Lam on February 3. Lam said the city would shut almost all border-control points to the mainland.

A colleague sprays disinfectant on a doctor in Wuhan on February 3.

Commuters in Tokyo walk past an electric board displaying dismal stock prices on February 3, the first business day after the Chinese New Year. Asia's markets recorded their worst day in years as investors finally got a chance to react to the worsening coronavirus outbreak.

Medical workers move a coronavirus patient into an isolation ward at the Second People's Hospital in Fuyang, China, on February 1.

Children wear plastic bottles as makeshift masks while waiting to check in to a flight at the Beijing Capital Airport on January 30.

Passengers in Hong Kong wear protective masks as they wait to board a train at Lo Wu Station, near the mainland border, on January 30.

A volunteer wearing protective clothing disinfects a street in Qingdao, China, on January 29.

Nanning residents line up to buy face masks from a medical appliance store on January 29.

Lyu Jun, left, a member of a medical team leaving for Wuhan, says goodbye to a loved one in Urumqi, China, on January 28.

A charter flight from Wuhan arrives at an airport in Anchorage, Alaska, on January 28. The US government chartered the plane to bring home US citizens and diplomats from the American consulate in Wuhan.

South Korean President Moon Jae-in wears a mask to inspect the National Medical Center in Seoul on January 28.

Hong Kong Chief Executive Carrie Lam, center, attends a news conference in Hong Kong on January 28. Lam said China will stop individual travelers to Hong Kong while closing some border checkpoints and restricting flights and train services from the mainland.

Workers at an airport in Novosibirsk, Russia, check the temperatures of passengers who arrived from Beijing on January 28.

Alex Azar, the US Secretary of Health and Human Services, speaks during a news conference about the American public-health response.

Two residents walk in an empty park in Wuhan on January 27. The city remained on lockdown for a fourth day.

A person wears a protective mask, goggles and coat as he stands in a nearly empty street in Beijing on January 26.

Medical staff members bring a patient to the Wuhan Red Cross hospital on January 25.

People wear protective masks as they walk under Lunar New Year decorations in Beijing on January 25.

Construction workers in Wuhan begin to work on a special hospital to deal with the outbreak on January 24.

Dr. Allison Arwady, commissioner of the Chicago Department of Public Health, speaks to reporters on January 24 about a patient in Chicago who had been diagnosed with the coronavirus. The patient was the second in the United States to be diagnosed with the illness.

A couple kisses goodbye as they travel for the Lunar New Year holiday in Beijing on January 24.

Workers manufacture protective face masks at a factory in China's Hubei Province on January 23.

Shoppers wear masks in a Wuhan market on January 23.

Passengers are checked by a thermography device at an airport in Osaka, Japan, on January 23.

People wear masks while shopping for vegetables in Wuhan on January 23.

A militia member checks the body temperature of a driver in Wuhan on January 23.

Passengers wear masks as they arrive at the Ninoy Aquino International Airport in Manila, Philippines, on January 23.

A customer holds boxes of particulate respirators at a pharmacy in Hong Kong on January 23.

Passengers wear masks at the high-speed train station in Hong Kong on January 23.

A woman rides an electric bicycle in Wuhan on January 22.

People in Guangzhou, China, wear protective masks on January 22.

People go through a checkpoint in Guangzhou on January 22.

Medical staff of Wuhan's Union Hospital attend a gathering on January 22.

Health officials hold a news conference in Beijing on January 22.

In pictures: The novel coronavirus outbreak

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What experts say

The WHO has previously voiced support for the way China is counting coronavirus infections, and said Thursday it was encouraged by the drop in reported cases.

Some experts, however – including a former US Food and Drug Administration commissioner – have expressed skepticism over taking China’s figures at face value, given the government’s track record of suppressing information about this epidemic and previous ones.

But David Fisman, a professor of epidemiology at the University of Toronto, said the way that officials define cases of a virus often evolves as their understanding of the illness develops.

Tugboats guide a container ship of Maersk Line at the Yangshan Deepwater Port, operated by Shanghai International Port ( Group) Co., Ltd. (SIPG), on October 4, 2019 in Shanghai, China.

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“One could change a case definition for sort of nefarious reasons to create the illusion that the epidemic is getting better. In this case, China did exactly the opposite,” he said. “They broadened their case definition when they needed to, in order not to miss cases, and now that things are under control they’re narrowing it down again to make it consistent to easier to keep track of what’s really going on.”

But Eric Feigl-Ding, an epidemiologist and visiting scientist at the Harvard T.H. Chan School of Public Health, said to change track twice in one week was “very unusual.”

“It’s very confusing to see true trends and makes elucidating them complicated,” Feigl-Ding continued. “Did (the cases) really decrease or is it because you’ve been not reporting this the last few days?”

Experts have also questioned the reliability of China relying solely on the lab test.

“There’s evidence that people don’t test positive until much later in the in the disease course,’ said Feigl-Ding.

Asymptomatic cases not counted in China

China’s decision to not count patients who have tested positive in the lab but haven’t shown any symptoms has also raised eyebrows.

This differs from the reporting practice of countries around the world, said Feigl-Ding.

For example, 11 Americans who were flown back to the US from Japan last week tested positive for the virus but showed no symptoms. Those asymptomatic patients are counted as confirmed cases in the US, but if they were in China they would not be.

“It’s extremely frustrating,” said Feigl-Ding, who said attempting to count the number of global cases with such a discrepancy, “becomes an apples and oranges situation.”

He urged China to report how many lab-positive asymptomatic patients it has, as failing to do so prevent “for international comparisons.”

The US Centers for Disease and Control has said that asymptomatic patients can still be contagious and spread the virus.

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02:26 - Source: CNN

Is the outbreak under control?

At a press conference on Thursday, the WHO’s director-general, Tedros Adhanom Ghebreyesus, said that although data from China showed a decline in new infections, this was no time for complacency.

Experts have warned there could be a renewed increase in cases once China properly returns to work – hundreds of millions of people around the country have been on lockdown for weeks now.

Smaller outbreaks continue to expand elsewhere, including on the Diamond Princess cruise ship in Japan, where two deaths were confirmed Thursday, the first from the hundreds of cases on the ship, which has begun disembarking passengers after a 14-day quarantine this week. There have been 78 cases confirmed with no connection to the ship, raising concerns of a self-sustaining outbreak in the country.

On Friday, South Korea recorded an additional 52 additional cases overnight, bringing its total to 156.

In Singapore the infection rate continues to climb, with 85 confirmed cases. Similarly, in Hong Kong, there are 68 confirmed cases, and two deaths.

CNN’s Steven Jiang, Shanshan Wang, Claudia Otto, Frederik Pleitgen and Jacqueline Howard contributed to this report.