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

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April 17, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 16 reports 1,991,562 confirmed cases (76,647 new) and 130,885 deaths (7,875 new). Assuming that the total reaches 2 million cases in this afternoon’s Situation Report, it will have taken 13 days to go from 1 million cases to 2 million. By comparison, it took 8 days to go from 500,000 cases to 1 million and 7 days to go from 250,000 cases to 500,000. On a global scale, the doubling time is slowing (at least in terms of reported cases), but the pandemic is still growing steadily. Notably, in the 13 days it took to double from 1 million to 2 million cases, the number of reported deaths increased 130% (from 56,986).

China’s National Health Commission reported a major revision to COVID-19 deaths in Wuhan . After a review of patient data, Chinese health officials identified an additional 1,290 COVID-19 deaths in the city of Wuhan. The new addition raises Wuhan’s total from 2,579 to 3,869, a 50% increase. The new deaths would raise China's national total from 3,342 deaths to 4,632, a 38.6% increase. China also reported an additional 325 cases in Wuhan. The NHC attributes the underreporting to the large surge of cases early in the epidemic hindering data collection efforts. In particular, the notice references inadequate testing, overwhelmed healthcare capacity (leading to patients dying outside of healthcare settings), and healthcare facilities not being able to utilize the central reporting system.

Pakistan reported 497 new cases on April 16, its third highest reported daily total. Overall, Pakistan’s epidemic appears to continue its acceleration. Prior to April, Pakistan’s highest daily total was 236 new cases, but it has exceeded that number on 12 of the 16 days so far in April. In total, Pakistan reported 7,025 cases and 135 deaths (11 new). Nearly half of Pakistan’s cases have been reported in the Punjab province (3,276 cases; 46.6%). India reported 13,385 confirmed cases (1,445 new) and 452 deaths (60 new). Today’s daily total is more than 3 times what was reported yesterday; however, yesterday’s value was half of what was reported the previous day, which indicates that yesterday’s low number may have been a reporting aberration.

Spain has reported elevated daily COVID-19 incidence for 3 consecutive days, with 5,252 new cases reported today. Spain had been exhibiting a steady decline in daily incidence since the beginning of April; however, 3 consecutive days of increasing incidence is potentially concerning. Spain also reported 899 new deaths, considerably more than the 551 deaths reported yesterday and closer to the 1,000 new deaths reported on Wednesday. In total, Spain reported 188,068 cases and 19,478 deaths. Italy reported 3,786 new cases on April 16, ending 4 days of decreasing daily incidence. As we have noted previously, Italy’s COVID-19 reporting has involved a number of peaks and valleys over the past several weeks, but it is exhibiting an overall slow decline since the peak of 6,557 on March 21. In total, Italy reported 168,941 cases and 22,170 (525 new). 

Indonesia reported a total of 5,923 confirmed cases (407 new) and 520 deaths (24 new). This is the third consecutive day that Indonesia’s daily incidence has increased. It appears that Indonesia’s COVID-19 epidemic is continuing on an accelerating trajectory. Singapore reported 623 new cases of COVID-19, continuing its recent elevated incidence. Among these new cases, 558 (89.6%) were reported among residents of migrant worker dormitories, a significant driver of Singapore’s growing epidemic. Outside of the cases associated with the dormitories, Singapore reports that cases reported in the broader community have decreased since the “circuit breaker” social distancing measures were implemented 11 days ago. Singapore’s COVID-19 Situation Report has not yet been updated; however, the national total is expected to be 5,050 confirmed cases and 10 deaths (zero new). 

The US CDC updated its COVID-19 reporting website this week. On April 15, the CDC added demographic data for reported COVID-19 cases, and yesterday it included data on both confirmed and probable cases and deaths. Additionally, the CDC updated its map display to re-categorize states by total incidence (now separating states with 5,001-10,000 cases and 10,001 cases or more). The CDC reported 632,548 total cases (27,158 new; 632,220 confirmed; 348 probable) and 31,071 total deaths (6,489 new; 26,930 confirmed; 4,141 probable) on April 16. In total, 14 states reported more than 10,000 (zero new), and 34 states (1 new), plus Guam, are reporting widespread community transmission.The Johns Hopkins CSSE dashboard * is reporting 672,303 US cases and 33,898 deaths as of 12:45pm on April 17.
*The Johns Hopkins CSSE also publishes US-specific data , at the county level, on a dedicated dashboard.

New York state reported 222,284 cases (8,505 new), including 12,192 deaths (606 new). New York City reported 117,565 cases (6,141 new), including 8,893 deaths (988 new). The Indian Health Service (IHS) reported 1,212 total cases (88 new), with more than half reported among the Navajo Nation (693 cases).

US RESPONSE The United States continues to report high rates of COVID-19 incidence and deaths nationally. Yesterday, US President Donald Trump announced new guidance regarding future efforts to relax existing social distancing measures. Earlier this week, there appeared to be disagreement regarding the relative authority of the federal and state governments with respect to implementing and relaxing these measures. The plan outlined yesterday seems to direct governors to make decisions based on transmission, risk, and resources on a state-by-state basis. In particular, the plan outlines 3 phases, in which social distancing measures can be relaxed incrementally, as well as guidance on considerations and conditions that should be in place before transitioning to each phase. The principal “gating criteria” before moving into the first phase include a “downward trajectory” for influenza-like illnesses, syndromic COVID-19 surveillance reports, confirmed COVID-19 cases, and percent of SARS-CoV-2 tests that are positive over a 14-day period. Additionally states should have sufficient healthcare capacity to treat all COVID-19 patients and a “robust testing program” for healthcare workers and “emerging antibody testing.”

Several groups of US States have made plans to coordinate regional roll backs of social distancing measures, including existing coalitions on the east and west coasts. Yesterday, a group of 7 Midwestern states—Illinois, Michigan, Ohio, Wisconsin, Minnesota, Indiana, and Kentucky— announced that they are similarly coordinating a regional plan to relax social distancing measures and “reopen the regional economy.” Governors in some of these states have dealt with public opposition to statewide “stay at home” orders—mostly, in the form of small organized protests rather than broad disregard for the policies—which may be contributing to pressure for the region to develop a course of action. The group plans to focus on 4 factors in their decision to relax social distancing across the region: epidemic control, testing capacity, healthcare capacity, and social distancing best practices in businesses and workplaces. The group did not announce a set date for a planned roll out of these procedures, but Ohio Governor Mike DeWine announced yesterday Ohio will begin this process on May 1. 

US COVID-19 TESTING From the beginning of the US COVID-19 epidemic, the United States has struggled to deploy sufficient testing capacity. Nationwide capacity has increased significantly over the past several weeks, but questions still remain about both quantity and quality of US SARS-CoV-2 tests. STAT News published a report on a high number of false negative results for a particular rapid test. The tests, developed by Abbott Laboratories, can provide results in as few as 13 minutes and have reportedly been used to process “hundreds of thousands” of tests across the country. The test appears to work well for patients with high viral load; however, patients with low viral load may be receiving false negative results. The issue may potentially be due to the process utilized to collect the samples. Samples placed in viral transport media, which can allow samples to be stored longer, have higher rates of false negative tests compared to those that test swabs directly. Abbott has updated its guidance for processing specimens, and the company is coordinating the the US Food and Drug Administration (FDA) to make the necessary changes to the instructions included with the test kits.

Analysis published in The Atlantic attempts to provide insight into the true burden of COVID-19 in the United States. Because the US has struggled to deploy sufficient testing capacity, it is difficult to know how many actual cases (and asymptomatic infections) there have been. One potential option, described by Jason Andrews from Stanford University, is to extrapolate based on the percentage of SARS-CoV-2 tests that are positive—the test-positivity rate. With expanded testing, it would normally be expected that test-positivity rate would decrease (due to testing more non-cases); however, this has not happened in the US. Nationally, the US test-positivity rate is approximately 20%, much greater than other countries that have implemented aggressive testing strategies. This suggests that there may still be many more COVID-19 cases in the US that are going undetected.

UK EXTENDS SOCIAL DISTANCING The United Kingdom’s Foreign Secretary Dominic Raab—who is still largely performing the duties as Prime Minister while Boris Johnson recovers from his ICU admission for COVID-19—announced that the UK will extend existing social distancing measures for at least the next 3 weeks. He noted that prematurely relaxing social distancing measures “would risk a significant increase in the spread of the virus,” “threaten a second peak,” and “substantially increase the number of deaths.” He also outlined 5 criteria that will drive the UK government’s decision regarding when and how to relax social distancing: (1) sufficient healthcare capacity, (2) sustained decrease in mortality, (3) manageable level of community transmission, (4) sufficient supply of test kits and personal protective equipment (PPE), and (5) confidence that any measures “will not risk a second peak...that [could] overwhelm the NHS.”

COVID-19 & ANTIBIOTIC RESISTANCE A new article published in Science outlines how complications from COVID-19 could potentially fuel antimicrobial resistance (AMR). Although SARS-CoV-2, the pathogen responsible for COVID-19, is a virus, the disease can lead to conditions that necessitate antibiotic treatment, including bacterial pneumonia. In fact, one study found that 15% of a COVID-19 cohort in China acquired bacterial infections. In severe cases, it can be difficult to determine if pneumonia in a COVID-19 patient is viral or bacterial in nature, and the severity of the condition may require urgent action. The incorrect administration of antibiotics is secondary to the main goal of saving lives, but some AMR experts are highlighting this as a growing concern. A myriad of complex factors could impact AMR in the United States and around the world, potentially including a steep decline in elective surgeries, but proactive attention and considering of the potential impacts of the COVID-19 pandemic can ensure that we monitor these changes in real time. 

FINDING EFFECTIVE TREATMENT FOR COVID-19 A Viewpoint article published in the Journal of the American Medical Association ( JAMA ) outlines the need for processes to properly evaluate the benefits and risks of novel or candidate therapeutics, particularly in the context of Emergency Use Authorizations (EUAs). The article argues that while EUAs can certainly provide benefit during health emergencies, their inappropriate as a tool to increase the availability or use of unproven drugs can erode confidence in regulatory authorities and place patients at risk. The pressure of the COVID-19 pandemic has already led to decisions that have increased the use of untested experimental treatments, potentially without providing the data necessary to evaluate their efficacy. The authors provide 3 potential courses of action to correct these steps and provide safe and effective treatment of COVID-19 patients: (1) use randomized controlled trials (RCTs) to evaluate safety and efficacy of candidate drugs, (2) optimize treatments that do exist such as supportive care, and (3) maintain the trust and integrity of regulatory bodies. 

US HOSPITALIZED COVID-19 PATIENTS The US CDC implemented the COVID-19–Associated Hospitalization Surveillance Network (COVID-NET) surveillance system in March to provide insight into hospitalized COVID-19 patients in the United States. The system, built on existing framework utilized by the Influenza Hospitalization Surveillance Network (FluSurv-NET) (4) and the Respiratory Syncytial Virus Hospitalization Surveillance Network (RSV-NET), collates epidemiological and clinical data on hospitalized COVID-19 patients across the country. A study of hospitalized cases reported in March provides preliminary insight into the clinical features among hospitalized patients early in the US epidemic. Among 1,482 hospitalized COVID-19 patients, nearly 75% were aged 50 years or older, and hospitalization rates increased with age. These are both consistent with previously presented data from many countries. Only 178 patients had available data on underlying health conditions, but among these patients, “the most common were hypertension (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%), and cardiovascular disease (27.8%).”

COVID-19 HEALTHCARE WORKER INFECTIONS Two articles published in the US CDC’s Morbidity and Mortality Weekly Report provide analysis of healthcare worker infections in the United States. The first provides an overview of COVID-19 cases healthcare workers (HCWs) in the US. During the period February 12-April 9, the US reported 315,531 COVID-19 cases. Of that total, 49,370 had associated employment data, and 9,282 (19%) of those were reported as a HCW. Among the HCW COVID-19 cases, the median age was 42 years and 73% were female, which the authors believe to likely reflect the distributions in the broader HCW workforce. The racial/ethnic distribution among HCW COVID-19 patients is also believed to reasonably reflect the distribution within the HCW population. Of those with data on potential exposure to SARS-CoV-2, 55% of HCWs reported exposure to COVID-19 patients only in healthcare settings. Approximately 8-10% of HCW COVID-19 patients were hospitalized, and increased age was associated with increase risk of severe disease and death —although both were reported in all age groups .

The second article documents HCW exposure to a patient with undiagnosed COVID-19 and provides insight into the risk of SARS-CoV-2 transmission in the healthcare setting. A patient hospitalized in Solano County, California, in February did not report relevant travel or contact with symptomatic individuals and was not initially suspected of being infected with SARS-CoV-2. The patient was hospitalized for 4 days at one hospital before being transferred to a second hospital, where he/she was confirmed to be infected with SARS-CoV-2. During the patient’s hospitalization at the first facility, the HCWs utilized standard infection control precautions, but the patient underwent several aerosol-generating procedures before being transferred. Ultimately, 43 of the 121 HCWs exposed to the patient (35.5%) developed COVID-19 symptoms within 14 days of treating the patient, and 3 (2.5%) tested positive for SARS-CoV-2 infection. Based on interviews with 37 of the HCWs, including the 3 who tested positive, “performing physical examinations and exposure to the patient during nebulizer treatments were more common” among those who tested positive than in those who did not. Additionally, the HCWs who tested positive “also had exposures of longer duration to the patient.”