COVID-19
Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.

The Center for Health Security is analyzing and providing update s  on  the emerging novel cor on avirus. If you would like to receive these daily  update s, please  sign up here and select COVID-19. Additi on al resources are also available  on  our  website .
April 15, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 14 reports 1,844,863 confirmed cases (71,779 new) and 117,021 deaths (5,369 new). Yesterday’s WHO Situation Report explicitly notes that reported COVID-19 incidence “reflects national laboratory testing capacity and strategy,” so these factors should be considered when interpreting the incidence data.

Pakistan reported 272 new cases on April 14—slightly fewer than the previous 2 days—bringing the national total to 5,988 cases and 107 deaths (11 new). India reported 11,933 confirmed cases (1,118 new) and 392 deaths (39 new). India has more than doubled its national incidence since April 9 , including more than double the cases in Maharashtra and Delhi and nearly 4 times the number in Gujarat since that time.

Spain reported 4,978 new cases, an increase of more than 1,500 (46%) compared to the day before. Spain also reported 1,090 new deaths, nearly double from the day before. These substantial increases could potentially result from reporting delays. In total, Spain reported 177,633 cases and 18,579 deaths. 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 2,627 new cases, a third consecutive day of decreased incidence and Italy’s lowest daily total since March 13 and down from a peak of 6,557 new cases on March 21. In total, Italy reported 165,155 total cases and 21,645 deaths (578 new). 

Indonesia reported a total of 5,136 confirmed cases (297 new) and 468 deaths (9 new). The daily incidence increased slightly from the previous day. Singapore reported 334 new cases of COVID-19 on April 14 (including 198 linked to “foreign worker dormitories”) and 447 new cases on April 15 (this number is included in the daily update headline , but the document is not yet available to provide more detail). In total, Singapore has reported at least 3,252 confirmed cases (through April 14) and 10 deaths (1 new). 

The US CDC reported 579,005 cases (24,156 new) and 22,252 deaths (310 new) on April 14. In total, 19 states have reported more than 5,000 cases, including 13 states with more than 10,000. New York state reported 202,208 cases (7,177 new), including 10,834 deaths, and New York City reported 107,263 cases, including 7,905 deaths. Additionally, there are currently 30 states (1 new), 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 1,124 total cases (87 new), with more than half reported among the Navajo Nation (636 cases). The Johns Hopkins CSSE dashboard * is reporting 610,774 US cases and 26,119 deaths as of 12:00pm on April 15.
*The Johns Hopkins CSSE now publishes US-specific data , at the county level on a dedicated dashboard, but it has not been updated since yesterday.

SINGAPORE SOCIAL DISTANCING Singapore enhanced its ongoing “circuit breaker measures” (i.e., community-level physical distancing), which have been in place nationwide since April 7. Singapore’s government announced that mask use will now be mandatory in public spaces. The country has deployed 3,000 enforcement officers from dozens of government agencies to monitor for compliance with the physical distancing directives. The officials can issue warnings and fines for violations—$300 for the first offense and $1000 for a second offense. The announcement notes that public transit use is down more than 70% since the “circuit breaker” measures were implemented, and nearly 80% of workers are now working from home. Additionally, the government estimates that only 30-40% of the population is out in public during the week and only 20-30% on weekends, providing evidence that physical distancing efforts are effectively reducing public interactions.

TEMPORAL DYNAMICS OF VIRAL SHEDDING A Brief Communication article published in Nature presents analysis on temporal trends in viral shedding in COVID-19 patients. The study included data from 94 laboratory-confirmed COVID-19 patients in Guangzhou, China—including 414 total throat swabs taken as long as 32 days after symptom onset—to analyze trends in SARS-CoV-2 viral load.The study also included information on 77 identified transmission events, from both inside and outside China, to analyze SARS-CoV-2 transmission dynamics. The researchers observed high viral load in COVID-19 patients immediately after symptoms presented, which tapered off over a period of approximately 21 days. The researchers concluded that the viral load could potentially peak around the time symptoms present, or possibly slightly earlier. Based on the viral load data and case data from the 77 transmission events, the researchers estimated that 44% of the transmissions occurred during the index case’s pre-symptomatic period and that COVID-19 patients become infectious 2.3 days before symptom onset, with a peak in infectiousness around 0.7 days before symptom onset. The study does not evaluate transmissibility of individuals with asymptomatic infection, and the viral load data may not directly correlate to an individual’s degree of infectiousness. Additionally, the article notes that clinical treatment could affect viral load in COVID-19 patients.

US TO SUSPEND WHO FUNDING US President Donald Trump announced that he has directed his administration to suspend US government funding for the WHO in the midst of the COVID-19 pandemic. President Trump has been critical of the WHO’s role in the pandemic response and suggested that the WHO participated in a cover-up regarding the spread of COVID-19 early in the pandemic. In particular, President Trump expressed displeasure with the WHO’s opposition to travel restrictions early in the pandemic, including those imposed by the US government on travelers from China. The White House presented a video at the April 13 Coronavirus Task Force briefing that addressed US government actions in response to COVID-19; however, the video raised questions regarding what measures the US government took during the period immediately after the travel restrictions on China were implemented.

Following President Trump’s announcement, UN Secretary General emphasized that now is “not the time to reduce the resources” for the WHO, but he did not explicitly refer to the United States or President Trump. The announcement also garnered opposition from health experts in the United States and elsewhere, including the American Medical Association . WHO Director-General Tedros Adhanom Ghebreyesus commented that President Trump’s decision was regrettable, but he emphasized that the United States has been a longstanding partner of the WHO and that the WHO endeavours to “improve the health of many of the world’s poorest and most vulnerable people” with the “support from the people and government of the United States.” Some supporters of President Trump have agreed with the decision, and efforts are reportedly underway in the US Congress to investigate some of the associated claims regarding the WHO’s handling of the global response. It is unclear at this point how much of US government funding to the WHO will be suspended or how the suspension would be implemented.

US VENTILATOR CONTRACT The US Department of Health and Human Services announced that it finalized contracts with several companies to produce mechanical ventilators for the national COVID-19 response. Contracts with 5 companies were issued under the Defense Production Act (DPA), and 2 additional contracts were issued outside the scope of the DPA. Combined with previous federal ventilator contracts, US companies have committed to producing 6,190 ventilators by May 8; 29,510 by June 1; and 137,431 by the end of 2020. These units will be allocated to the Strategic National Stockpile which will then distribute them to support state-level responses. The 7 new contracts total more than US$1.4 billion.

GENDER EQUALITY IN THE WORKPLACE An article published in the Lancet notes how measures such as closing schools may disproportionately affect women and how care-taking roles may influence risk of infection with SARS-CoV-2. An opinion piece published by the British Medical Journal documents changes in work patterns and care within households, including a disproportionate effect on women. The piece highlights how transitions to remote work have illustrated challenges in balancing work and personal responsibilities. These articles suggest that acknowledging these burdens and proactive effort is needed to mitigate associated stress and negative impacts, including physical and mental health effects, that may result from some social distancing measures. Policies such as flexible work hours could mitigate some of these challenges, and they may be needed as social distancing is relaxed in the future, both to reduce overall effects, but particularly to address inequalities that exist between genders in the workplace. 

COVID-19 IMPACT ON KIDNEY FUNCTION There is growing evidence that COVID-19 can have serious effects on organs far beyond the lungs . Respiratory distress and failure is perhaps the most recognized clinical presentation in severe COVID-19 patients, but patients are also experiencing damage to the heart, kidneys, central nervous system, and other parts of the body. In particular, kidney failure among COVID-19 patients resulting in increased demand for dialysis and continuous renal replacement therapy. This could be due to a variety of factors, including the treatments used to care for COVID-19 patients or a “cytokine storm” (i.e., overwhelming immune response that can also damage organs and tissues), but there is also preliminary evidence that the damage could be caused by the disease itself. Additional data and research are needed to fully characterize the clinical progression and manifestation of COVID-19, but it appears that the SARS-CoV-2 virus can infect a variety of cells and result in a broad scope of symptoms and damage.

IMPACTS OF BORDER CLOSURES IN EUROPE A number of countries around the world have implemented border and travel restrictions in response to the COVID-19 pandemic, including at the US-Canadian border. Within the European Union (EU), borders have been relatively open. However, recent restrictions on border crossings between EU countries are posing challenges for both the economy and COVID-19 response. In Europe, some border crossings have been closed entirely, and others enforce restrictions on non-essential travel. In many places, particularly cities near national borders, workers that used to cross the border daily, living and working in different countries, are finding the journey difficult or even impossible under the new restrictions. In one example, a laundry service that cleans linens for local hospitals in Germany is reportedly struggling to keep up with demand due to the loss of workers who live across the border in Poland. Some countries have implemented programs to ease the process for healthcare workers, but sectors beyond health care can potentially impact hospital operations and other aspects of the response.