Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.

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April 14, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 13 reports 1,773,084 confirmed cases (76,498 new) and 111,652 deaths (5,702 new). The WHO also reported that 2 clinical trials are underway to evaluate the effect of the Bacille Calmette-Guérin (BCG) vaccine on preventing SARS-CoV-2 infection. At this time, there is no evidence of efficacy, and the WHO does not recommend the vaccine’s use for SARS-CoV-2. Interest in the vaccine stems from several (preprint) reports that found lower reported COVID-19 incidence in countries where the vaccine is used routinely in infants; however, the WHO notes that these types of studies are often subject to a variety of biases and confounding factors.

Russia reported a total of 21,102 cases (2,774 new; 15% increase) and 170 deaths. Pakistan reported 342 new cases on April 13, its highest daily incidence outside the large spike on April 5-6 (577 cases). Independent of the April 5-6 spike, Pakistan’s daily COVID-19 incidence has increased relatively steadily since mid-March, indicating that its epidemic is accelerating. Much of the increased incidence has been reported in the Punjab province, Pakistan’s most populous province, which borders India. Pakistan reports a total of 5,716 cases and 96 deaths (3 new). India reported 10,815 confirmed cases and 353 deaths (29 new). India has doubled its national incidence since April 8 , including more than double the cases in Maharashtra, nearly 3 times the number in Delhi, and nearly 4 times the number in Gujarat since that time.
Correction: We indicated yesterday that Pakistan reported 122 new cases on April 13, but this was only a partial day’s value. Pakistan reported 342 new cases on April 13.

Spain reported 3,405 new cases, totaling 169,496 cases and 17,489 deaths (567 new). With the exception of a few days of elevated incidence, Spain’s daily incidence is steadily declining, down from a peak of 8,809 new cases on March 30 . Italy reported 2,972 new cases, its lowest daily total since March 13. Daily incidence continues to fluctuate, but it appears to be gradually decreasing over time, down from a peak of 6,557 new cases on March 21. In total, Italy reported 162,488 total cases and 21,067 deaths (602 new). 

Indonesia reported a total of 4,839 (282 new) confirmed cases and 459 deaths (60 new). Daily incidence rose relatively steadily from mid-March to a high of 399 new cases reported on April 12, but daily incidence decreased for the second consecutive day. Singapore reported 386 new cases of COVID-19, including 222 new cases associated with a “foreign worker dormitory” (586 confirmed cases linked to that cluster). More than 10 new cases were also reported in 3 additional clusters linked to lodges or dormitories (14, 22, and 77 new cases, respectively). In total, Singapore reported 2,918 confirmed cases and 9 deaths

The US CDC reported 554,849 cases (29,145 new) and 21,942 deaths (1,456 new) on April 12. In total, 19 states have reported more than 5,000 cases, and there are currently 29 states, plus Guam, reporting widespread community transmission. In addition to states and territories, the Indian Health Service (IHS) is publishing COVID-19 data reported by tribal partners. The IHS reported 1,037 total cases (52 new), with more than half reported among the Navajo Nation (579 cases). The Johns Hopkins US COVID-19 dashboard * is reporting 572,689 US cases and 23,134 deaths as of 11:45am on April 14.
*The Johns Hopkins University Coronavirus Resource Center now publishes US-specific data, at the county level, on a dedicated dashboard.

US SOCIAL DISTANCING Governors from several states on the east and west coasts have begun coordinating plans to relax social distancing measures . The states include New York, New Jersey, Connecticut, Pennsylvania, Rhode Island, Delaware, and Massachusetts on the east coast and California, Oregon, and Washington on the west coast. These efforts will aim to rely on available data and expert input in order to determine the best approach to relaxing social distancing measures. States in the eastern coalition announced they would have a council that will involve public health and economic experts from each state, in addition to the governors. At the federal level, US President Donald Trump is expected to announce a council that will advise him on planning for resuming normal business and community activity, which could include members representing a variety of perspectives, potentially including some state governors.

Tornadoes and storms across portions of the southeastern United States caused destruction and led to more than 30 deaths across several states, including Mississippi, South Carolina, and Georgia. Response efforts have been complicated by the COVID-19 pandemic, as emergency response agencies must work to rescue families affected and provide shelter for communities in ways that also mitigate the risk of virus transmission. Stay-at-home measures have also impacted hurricane preparedness measures, such as community advisory meetings. Some disaster-prone states, such as California, are working to incorporate natural disaster preparedness into their pandemic response plans, as the shifting dynamics of compounding emergencies can complicate coordination between officials and agencies that are responsible for various aspects of simultaneous responses.

Some US states, particularly those with large rural areas, have elected not to implement more aggressive statewide social distancing measures, citing economic and social concerns. South Dakota Governor Kristi Noem is among the governors that have not yet implemented a statewide “stay-at-home” order to enforce or promote social distancing measures. She has reportedly stated that individuals should make their own decisions regarding their actions in response to COVID-19 and commented that such an order would need to remain in place through October to be effective. South Dakota has reported a sizable COVID-19 outbreak linked to a meat processing plant in Sioux Falls, which recently shut down indefinitely as a result of the outbreak. Some local leaders, including Sioux Falls Mayor Paul TenHaken , have implemented their own efforts to promote social distancing, but these measures do not apply beyond the boundaries of individual jurisdictions. Mayor TenHaken has reportedly called on the state to implement broader social distancing measures to mitigate inconsistencies between local jurisdictions, and the South Dakota State Medical Association also published a letter to Governor Noem calling on her to issue a statewide stay-at-home order.

A study published by the US CDC’s COVID-19 Response Team —in collaboration with the Georgia Tech Research Institute and local health departments in New York, Louisiana, Washington state, and California—evaluated the timing and implementation of large-scale social distancing efforts in several areas of high SARS-CoV-2 transmission. The study found that social distancing efforts progressed incrementally in New Orleans, New York City, San Francisco, and Seattle, increasing from emergency declarations to stay-at-home orders—and in the case of parts of New Orleans, up to mandatory curfew orders. The community mobility in these cities decreased as the number of restrictions increased. Emergency declarations did not appear to drive sustained changes in the public’s activity level; however, limits on the size of gatherings, school closures, and stay-at-home orders (as well as the White House’s 15-day plan) coincided with incremental decreases in community mobility. The study also provides preliminary evidence that these policies, and associated decreases in community mobility, may correspond to decreased transmission; however, additional study is needed to better characterize this relationship.

GLOBAL RESPONSE Stigmatization of individuals quarantined or isolated as a result of COVID-19 is reportedly hindering public health response efforts in Iraq . Stigmatization during infectious disease emergencies occurs around the world for a myriad of events, but a lack of trust in government and underlying religious or cultural beliefs may be hindering Iraq's COVID-19 response. Reports indicate that individuals may be afraid to be tested for SARS-CoV-2 or otherwise be associated with infected individuals, which is complicating public health measures such as contact tracing. Additionally, some individuals have been hesitant to seek care, which could contribute to further transmission and potentially more severe disease or death. Additionally, the stigmatization is compounded for women out of fear that they could be separated from the rest of their families if found to be infected.

Several countries in the Middle East have experienced challenges addressing the housing needs of migrant workers. Countries such as the United Arab Emirates, Saudi Arabia, and Bahrain rely heavily on laborers from Asia, many of whom live in crowded labor camps that provide ideal conditions for communicable disease outbreaks, including COVID-19. Other migrant workers may live in densely populated low-income housing. Charity organizations have been working to provide food and shelter to foreign workers, and to isolate those who are infected and sanitation programs are being implemented to improve living conditions and reduce transmission risk. Some workers may not be permitted to return to their home country due to travel restrictions related to the pandemic, which could potentially strain international relationships in the future.

More than a third of Singapore’s 2,918 confirmed COVID-19 cases have been reported among clusters associated with migrant worker dormitories . These outbreaks have largely fueled recent rapid growth of Singapore’s COVID-19 epidemic, which has nearly tripled in size since April 1 . The Singapore government recognized the challenges associated with these facilities and implemented response measures to protect the workers who live there . The Ministries of Health and Manpower, among other government agencies, have formed a task force dedicated to addressing these COVID-19 outbreaks. The task force is coordinating with the companies operating these dormitories to establish medical treatment and triage facilities and provide essential services and supplies, including food and internet access, to the workers who live there and improve hygiene and sanitation processes. All workers living at the affected facilities are prohibited from going to work, but the government is coordinating with employers to ensure they continue to be paid while under quarantine.

US CONSUMER SPENDING Analysis conducted by The New York Times looked at changes in how Americans are spending money as a result of the COVID-19 pandemic and associated social distancing measures. The study compared the volume of spending for a number of commercial sectors—ranging from grocery stores to restaurants to clothing stores to entertainment—to identify nationwide spending trends. Not surprisingly, travel, transportation, and restaurants were among the sectors experiencing the largest negative impact. Grocery sales increased substantially in March, but they appear to have declined toward the end of the month, potentially returning to relatively normal levels now that many households have stockpiled essential items. Overall, the “shopping” and “entertainment” sectors experienced sizable decreases in spending; however, this was not evenly distributed across the entire sector. While portions that rely heavily on in-person purchases, such as clothing/apparel and movie theaters, saw major spending decreases, spending on online services—including e-commerce, video and audio streaming, and gaming—increased.