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

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April 2, 2020

EPI UPDATE With the rapid global escalation in COVID-19 incidence, including the number of priority countries we track, the Epi Update section of our daily COVID-19 briefing has become too lengthy. We will continue to report the global totals from the WHO COVID-19 Situation Reports as well as the US totals reported by the CDC and the Johns Hopkins CSSE dashboard, but we will not necessarily be including case counts for individual regions or countries. We recommend using Ministry of Health, Centers for Disease Control, or other national public health agency websites for the most current national-level COVID-19 incidence data.

The WHO COVID-19 Situation Report for April 1 reported 823,626 confirmed COVID-19 cases (72,736 new) and 40,598 deaths (4,193 new) globally, and 3 new countries reported COVID-19 cases. If the recent trend continues, the pandemic could reach 1 million cases and 50,000 deaths in the next 3 days. The WHO Situation Report emphasizes that the ultimate goal is for countries to be able to “walk back” their respective epidemics from community transmission to clusters to sporadic transmission and ultimately to no cases, and the WHO intends to publish guidance for countries in their efforts to scale back social distancing and other community mitigation measures once transmission decreases.

The Russian Ministry of Health reported a total of 3,548 cases (783 new), an increase of 28% from the previous day. Iran reported 50,468 confirmed cases of COVID-19 (2,875 new), including 3,160 deaths (124 new). Iran’s COVID-19 reported incidence is growing steadily, but it appears to be closer to linear at this point than exponential. Pakistan reported 2,291 confirmed cases on April 2 (252 new). Spain has reported more than 25,000 cases in the last 3 days—9,222 on March 31 ; 7,719 on April 1 ; and 8,102 on April 2 —second only to the United States in terms of daily incidence over that time. Spain is now reporting a total of 110,238 cases and 10,003 deaths.

The US CDC reported 186,101 cases (22,562 new) and 3,603 deaths (743 new) on April 1. Of these cases, fewer than 2.5% have an identified exposure—travel-related or close contact of a known case. As of yesterday, 8 states have reported more than 5,000 cases (1 new), and 25 states have reported widespread community transmission (5 new). The Johns Hopkins CSSE dashboard is reporting 217,263 US cases and 5,151 deaths as of 11:00am on April 2.

The New York Times is compiling national-level COVID-19 incidence data to track the epi curves in real time.

US RESPONSE US government officials, including representatives from the Department of Homeland Security and US President Donald Trump, have confirmed that the Strategic National Stockpile (SNS) is running low on supplies and equipment. The SNS maintains inventory of a myriad of supplies and equipment—including pharmaceuticals, personal protective equipment (PPE), and ventilators—for rapid deployment during emergencies; however, it “was never...designed to fight a 50-state pandemic.” While products are being shipped to states and health systems directly from manufacturers and distributors in the commercial market, states are still struggling to obtain necessary supplies and equipment. There are numerous reports that states are bidding against each other, as well as foreign competitors, to secure materiel to support their response activities, and multiple governors have called on the federal government to provide additional support. The US government has reportedly shipped millions of pieces of equipment and other supplies nationwide, but it appears that the available inventory has been insufficient, and domestic production has not scaled up quickly enough to meet the existing demand. As the US epidemic continues to grow, so too, will the demand, which will inevitably place even more strain on existing resources.

Unconfirmed reports are circulating that the United States could be suspending overseas aid shipments in an effort to secure sufficient domestic supply of critical supplies and equipment. Reportedly, the US government has been working with a number of other countries to obtain much needed supplies, including PPE; however, the US Agency for International Development (USAID) has been shipping similar supplies to other countries, including some of the same countries from which US officials were seeking support. Several US government sources reportedly confirmed the suspension, but President Trump denied it as yesterday’s White House Coronavirus Task Force briefing. 

PRIVATE TESTING BACKLOG The Atlantic published an investigative piece on delays in SARS-CoV-2 testing at private sector laboratories . Since a myriad of early delays, the United States has steadily increased testing capacity during the COVID-19 response, building capacity to more than 100,000 tests per day nationwide. Despite these increases, numerous reports indicate that there are still struggles to test patients , including lengthy delays in obtaining test results and an inability to access supplies needed to conduct the tests. The Atlantic report describes testing delays at private laboratory companies that have contracted to provide affordable and rapid testing across the country. Despite the availability of test kits and supplies, even these large companies have been unable to scale up capacity to support the testing throughput necessary to keep up with demand, resulting in delays in completing tests and returning results.

Test kits, supplies, and capacity are not the only challenges facing the SARS-CoV-2 tests. A report published in The New York Times describes challenges with false negative test results —ie, negative test results in patients actually infected with the virus. According to the report, the SARS-CoV-2 tests have a high rate of false negatives, which could result in individuals believing they are not infected but still transmitting the virus to others. Additionally, because these cases go unreported, they negatively impact disease surveillance efforts and, ultimately, our understanding of the scope and severity of the pandemic. The article notes that data on SARS-CoV-2 test sensitivity is lacking, but it cites preliminary data ( preprint ) from China that indicates false negative rates of nearly 30%. Additionally, some companies are making false claims about testing capabilities, including marketing unlicensed at-home test kits . One company in California is advertising FDA-approved home test kits for purchase, but the FDA has not authorized any such tests, including this one. An earlier report circulated about the existence of a 2-minute serology test kit that received an Emergency Use Authorization (EUA), based on a press release by the company, but this also proved to be false .

On March 31, Becton, Dickinson and Co. (BD) announced the release of its new serological test , in partnership with BioMedomics and Henry Schein, Inc. The test aims to detect SARS-CoV-2 antibodies at the point of care within 15 minutes, to detect current or past infection. The press release notes that the test has not been evaluated by the FDA, but it is being distributed under existing public health emergency provisions.

EMERGENCY COVID-19 HOSPITALS We have covered a number of stories in recent weeks detailing plans to expand health system capacity to manage the surge in COVID-19 patients, including US military hospital ships and temporary field hospitals. Over the weekend, the US Army Corps of Engineers completed its conversion of the Jacob K. Javits Convention Center in New York City into a temporary 2,000-bed hospital, and patients were admitted starting on March 30. Similar to the hospital ships, this facility will not treat COVID-19 patients, but rather, it will provide care for other patients in order to free up additional capacity at nearby hospitals. One of the outstanding questions about these facilities is how they will deal with COVID-19 patients who are identified there—ie, patients that seek care for other conditions but ultimately test positive for SARS-CoV-2—and how they will protect staff and patients against transmission within the facility.

US CDC RESPIRATOR DECONTAMINATION The US CDC published preliminary guidance regarding the decontamination and reuse of respirators during the COVID-19 response. The guidance explicitly notes that respirators are not approved for decontamination and reuse under normal standards of care; however, during crises, like the current pandemic, it may be necessary to mitigate shortages. The guidance indicates that masks decontaminated using available procedures—from the manufacturer or a third party—can be reused for any patient care activities. The guidance includes information on a variety of decontamination strategies and techniques, but based on the available evidence, the CDC identified vaporous hydrogen peroxide (VHP), ultraviolet germicidal irradiation (UVGI), and moist heat as the preferred decontamination methods.

US UNEMPLOYMENT CLAIMS The US Department of Labor published updated data on unemployment claims nationwide. The number of initial claims continued to spike, jumping from a weekly total of 3.3 million to 6.6 million. The report attributed the surge largely to the COVID-19 pandemic, with a broad range of sectors impacted. Most notably, the food service and hotel industries have been particularly affected, but many others also faced setbacks, including health care, manufacturing, retail, and construction. The CARES Act , signed into law last week, includes direct benefits to workers as well as support for small businesses in an effort to keep individuals employed. Analysis by The New York Times illustrates that the current spike in unemployment is orders of magnitude greater than the peak during the 2008 global recession and the all-time weekly record of 695,000 in 1982.

DEBATE OVER SHIFTING US MASK POLICIES AMID SHORTAGES Following recent announcements that the US CDC is considering recommendations for the general public to wear masks or face coverings, the Center for Infectious Disease Research and Policy (CIDRAP) published a commentary written by two doctors from the University of Illinois at Chicago that discourages universal mask use for the general public. The authors identify several potential pitfalls for such a policy without sufficient benefit. They argue that there is insufficient evidence these masks reduce transmission among the general public, that such recommendations could reduce healthcare worker access to surgical masks, and that wider use of masks could lead the general public to relax social distancing measures unnecessarily due to a false sense of security from the masks. The article comes amid media reports that some hospitals are discouraging or prohibiting personnel from wearing masks and other PPE when not treating patients, due in part to ongoing supply shortages. These policies have received pushback from some clinicians who feel they require the additional protection while at work, and other hospitals have implemented mandatory universal mask policies .

PANAMA IMPLEMENTS GENDER-SPECIFIC SOCIAL DISTANCING In an effort to further enforce nationwide social distancing measures, Panama recently announced that it is implementing gender-specific rules for when people can leave their homes. Women will be allowed to be outside on Mondays, Wednesdays, and Fridays, and men will be allowed on Tuesdays, Thursdays, and Saturdays. On Sundays, everyone must remain indoors. The restrictions will reportedly last for at least 15 days. Officials implemented the additional gender-specific restrictions after observing high rates of noncompliance with the previous policies. These rules will be enforced based on the sex specified on individuals’ national identification cards. Additionally, the announcement stated that Panama has also been invited to participate in the SOLIDARITY Trial , led by the WHO, which aims to assess COVID-19 treatment options.

ITALY EXTENDS NATIONAL LOCKDOWN Italy, one of the first European countries to introduce social distancing restrictions in response to COVID-19, has extended its national "lockdown" to April 13. While the country has recently reported a gradual decrease in new cases and deaths per day, the nation’s health systems are still experiencing significant COVID-19 impact. Government leaders stated that the country’s epidemic is far from over and that social distancing measures would need to continue. Those violating the social distancing measures face fines of more than US$200. The announcement follows reports that UK officials indicated that some form of required social distancing measure could be in place in their country for approximately 6 months, with gradual easing when the time is appropriate.

INDIA DISCUSSES STAGGERING MOVEMENT POST-LOCKDOWN Approximately one week after India implemented a nationwide 21-day "lockdown" across its population of 1.3 billion people, the government has reportedly begun discussing how to stagger movement after the lockdown period ends. The news follows a recent spike in cases, which has been partially attributed to a recent large religious gathering in Delhi. Efforts to ease the movement restrictions will focus on avoiding another spike in cases as social distancing measures are relaxed and public activity and interaction increases. The rapid implementation of lockdown measures has led to concerns of supply chain disruptions, as delivery drivers and other essential workers have reduced their work and many face challenges in accessing food due to the restrictions.

PROTESTS IN MIGRANT DETENTION CENTER AND PRISONS In a migrant detention center in Mexico , a Guatemalan migrant died and another 14 people were injured during recent riots and protests. Those detained in the center were, in part, protesting overcrowding and unsanitary conditions that they argue could elevate their risk of SARS-CoV-2 transmission. There are also increasing reports of unrest in prisons in other countries, including Colombia and Italy . The living conditions in these facilities have prompted discussions in the United States and elsewhere regarding how to prevent COVID-19 outbreaks in incarcerated populations. Several countries , particularly in Europe and North America, have released some individuals detained for non-violent crimes or nearing the end of their sentences, in an effort to reduce prison crowding. 

CHINESE OFFICIALS DENY COVID-19 UNDERREPORTING The Chinese Ambassador to France reportedly told French news media that China has not underreported deaths due to COVID-19. The statement comes amid reports that US intelligence agencies determined that China underreported COVID-19 incidence and mortality. Like many other countries, including the United States, China faced shortages of diagnostic tests and overwhelmed health systems during the peak of the country’s COVID-19 epidemic, which could contribute to surveillance and reporting challenges. 

EMA URGES RESTRAINT IN USING CHLOROQUINE The European Medicines Agency (EMA), Europe’s drug regulatory authority, urged countries to only use chloroquine and hydroxychloroquine to treat COVID-19 as part of a clinical trial or in “national emergency programs.” Assertions that the drugs could possibly be effective, as well as the initiation of clinical trials to assess their efficacy, has prompted widespread demand and subsequent shortages for both drugs, despite a lack of safety and efficacy data as a COVID-19 treatment. Both drugs are used for other conditions, including as a treatment for malaria and lupus, and they can cause serious side effects.