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

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April 20, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 19 reports 2.24 million confirmed cases and 153k deaths. That is 81k new cases and 6.5k new deaths from the previous day and 250k cases and 22k deaths since our Friday briefing. The European Region reached 100k total COVID-19 deaths. Europe accounts for half of the total global reported cases but two-thirds of the reported deaths.

Russia’s COVID-19 epidemic continues to accelerate, doubling approximately every 4-5 days. Official daily incidence from previous days is not available on the Russia MOH website; however, the WHO COVID-19 Situation Reports indicate steadily increasing daily incidence over the past 2 weeks, from 583 new cases on April 5 to 6,060 new cases on April 19 . Russia officially reported 47,121 confirmed cases nationwide, including 405 deaths.

Pakistan reported 8,418 confirmed cases and 176 deaths on April 19—425 new cases and 17 new deaths from the previous day and 1,402 cases and 41 deaths since Friday’s briefing. Pakistan’s epidemic continues to accelerate, with 5 consecutive days of more than 400 new reported cases. Punjab province continues to represent a sizable portion of Pakistan's COVID-19 cases (3,721 cases; 44.2%), but the percentage is decreasing. India reported 17,656 confirmed cases and 559 deaths—4,271 new cases and 107 new deaths since Friday’s briefing. India’s COVID-19 epidemic appears to be accelerating, despite nationwide “lockdown” measures.

After several days of elevated COVID-19 incidence, Spain reported decreased daily totals over the weekend—but not as low as the daily totals reported early last week. In total, Spain reported 200,210 cases (4,266 new since the previous day) and 20,852 deaths—12,142 new cases and 1,374 deaths since Friday’s briefing. Italy reported 3,047 new COVID-19 cases on April 19, continuing its overall slow decline since its daily peak of 6,557 new cases on March 21. In total, Italy reported 178,972 cases and 23,660 deaths—10,031 cases and 1,470 deaths since Friday’s briefing. 

Indonesia reported only 185 new cases today, fewer than half of the daily total reported on Friday. This is the third consecutive day that Indonesia’s daily incidence has decreased. Indonesia’s COVID-19 epidemic had been growing overall in recent weeks, but it is unclear whether the recent decline signals the beginning of a longer-term trend. In total, Indonesia reported 6,760 confirmed cases and 590 deaths.

Singapore reported 2,964 new cases since Friday’s briefing, a 59% increase in total cases over the weekend. Residents of dormitories for migrant worker continue to drive Singapore’s epidemic. Detailed information on the 1,426 cases reported today is unavailable (although the preliminary press release indicates that “the vast majority” are dormitory residents); however, more than 70% of all cases reported in Singapore through April 19 were dormitory residents. Singapore’s COVID-19 Situation Report has not yet been updated; however, the national total is expected to be 8,014 confirmed cases and 11 deaths (1 new).

Japan has reported elevated COVID-19 incidence since approximately the beginning of April. The increase began in late March, from fewer than 50 new cases per day to a high of 385 new cases on April 6. With the exception of weekends, Japan has reported more than 200 cases nearly every day in April—with many greater than 300 cases. In total, Japan reported 10,751 confirmed cases (361 new) and 171 deaths (9 new).

The US CDC reported 720.6k total cases (1.3k probable) and 37.2k deaths (4.2k probable) on April 19. This represents 29.9k new cases since the previous day and 88k cases and 6.1k new deaths since our Friday briefing. In total, 16 states reported more than 10,000 cases (2 new since Friday’s briefing), and 26 states, plus Guam, are reporting widespread community transmission. Notably, 8 fewer states reported widespread transmission than did so in Friday’s briefing. The Johns Hopkins CSSE dashboard * is reporting 762k US cases and 40.7k deaths as of 11:30am on April 20.
*The Johns Hopkins CSSE also publishes US-specific data , at the county level, on a dedicated dashboard.

New York state reported 222k cases and 14k deaths—6k new cases from the previous day and 20.5k new cases and 1.7k new deaths since Friday’s briefing. New York state has reported declining daily incidence for 4 consecutive days, down from its high of 11.6k new cases on April 14. New York City reported 117.6k cases and 10k deaths—12.2k new cases and 1.1k new deaths since Friday’s briefing. The Indian Health Service reported 1,212 total cases (384 new since Friday’s briefing), with 75% reported among the Navajo Nation (908 cases).

RELAXING SOCIAL DISTANCING Following US President Donald Trump’s unveiling of the federal government’s plan to relax social distancing —and associated tweets to “liberate” the states of Minnesota , Michigan , and Virginia —groups of protesters gathered in states across the country in opposition to existing physical distancing measures. The protesters assembled to call for governors to lift “stay at home” orders, including reopening non-essential businesses and permitting large gatherings. In Denver, Colorado, some protestors were met by local healthcare workers who stood in intersections wearing hospital scrubs and N95 respirators . Yesterday, President Trump stated that he supported the protestors, arguing that “some governors have gone too far” in their efforts to enforce physical distancing. Several state governors , both Republican and Democrat, raised concern about President Trump’s comments and highlighted the need to relax physical distancing measures in a way that mitigates the risk of increased transmission. Additionally, Dr. Anthony Fauci expressed his opposition to the protests, noting that prematurely relaxing physical distancing could “backfire” and cause increased transmission, which could further delay economic recovery.

The Johns Hopkins Center for Health Security, in collaboration with former FDA Commissioner Scott Gottlieb, published a guidance document to support governors’ efforts to determine when and how to relax existing physical distancing measures appropriately. This document builds on recommendations included in a previously published Road Map to Reopening , which included 4 phases and associated capacities and triggers. The current document emphasizes that each state is different and that a single approach will not address the unique needs, capabilities, and situations for all states. Regardless, governors should take an evidence-based approach, evaluating the current and projected COVID-19 epidemiology, testing and healthcare capacity, and other factors to develop their own risk assessments. The document includes high-level assessment transmission risk at non-essential businesses, schools, mass gatherings, and other settings, including the expected intensity of close contact, the size of the population, and the potential to modify operations to mitigate transmission risk. These types of analysis should factor into decisions regarding when and how to relax physical distancing measures and begin to resume public activity.

US SARS-CoV-2 TESTING As US states begin planning to relax physical distancing measures, testing capacity could once again be a limiting factor in the US COVID-19 response. One of the key components in the White House’s guidance to states is to establish sufficient testing capacity to implement effective surveillance and contact tracing efforts as physical distancing measures are lifted. Since the announcement, a number of governors have called for additional support from the federal government to increase testing capacity to a level that would support efforts to resume public activity. President Trump intends to invoke the Defense Production Act to increase production of swabs to support testing efforts nationwide, and Vice President Mike Pence announced that the federal government will provide additional information and support for state governments to ensure the availability of testing supplies and capacity to scale up SARS-CoV-2 appropriately to support relaxing physical distancing around the country.

In addition to diagnostic tests, serological testing is a growing priority, both for assessing population-level prevalence of SARS-CoV-2 infection and determining individual-level exposure and risk. At this time, the US FDA has only issued Emergency Use Authorization for a small handful of serological tests; however, others have been developed and are available without FDA authorization. Some of these tests have been purchased for use by health departments, health systems, and others for use in determining individual exposure or to conduct community serological surveys, but there remains uncertainty regarding their reliability. Officials at the Association for Public Health Laboratories and other experts have expressed concern about the availability of SARS-CoV-2 serological tests without sufficient data to demonstrate their reliability.

GLOBAL RESPONSE Germany has reportedly begun reopening businesses after approximately a month of “lockdown”. Public health officials have recommended that people should wear face masks when riding on public transportation and in stores or other enclosed spaces, and some German states have made mask use mandatory. German Chancellor Angela Merkel urged people to follow guidance in order to avoid an increase in disease incidence, and she noted that it could take 14 days to evaluate the effects of resuming public activity on SARS-CoV-2 transmission. While some businesses have reopened, schools and certain businesses like hair salons are currently scheduled for opening May 4. Schools will reportedly prioritize final year students. While Germany contains the fifth-highest number of cases in the world, its number of deaths has remained relatively low, potentially a function of its extensive testing strategy. 

While African countries have reported lowered COVID-19 incidence and many have implemented contact tracing and other containment measures, the continent remains vulnerable to substantial morbidity and mortality from COVID-19. Many low-income countries have severe resource constraints, which can hinder public health and healthcare response to health emergencies such as pandemics. For example, a number of countries in Africa reportedly have fewer than 10 ventilators nationwide , and 10 have no ventilators at all. Even more concerning, only 15% of the population in Sub-Saharan Africa has access to clean water and soap. Higher-resource countries, such as South Africa, have greater supply of medical resources needed to treat COVID-19 patients, highlighting considerable disparities within the continent. Certain organizations and philanthropists have worked to donate or coordinate resources, including ventilators, to be sent to affected countries. Some countries have reported difficulties ordering supplies and equipment, because they are often unable to effectively compete against wealthier nations. A perspective article in The New England Journal of Medicine highlighted that “coordinated global support is essential” to combat COVID-19, particularly in terms of providing support for lower-resource nations, and explicitly called on countries to provide support for COVID-19 response in Africa. 

Some scientists in Indonesia are criticizing their government for a lack of coordination and transparency in its COVID-19 response strategy. Modeling estimates indicate that there could be extensive underreporting of cases in Indonesia, and there has been a reported spike in funerals (suggesting excess mortality) in March. Government officials have downplayed the severity of the pandemic; however, Indonesia’s Ministry of Health implemented social restrictions and “partial lockdowns” for certain affected regions. Like many other countries, testing capacity remains limited, and there have been challenges in establishing lab infrastructure to implement a broad, large-scale testing strategy.

MASS VACCINATION Faculty from the Johns Hopkins Center for Health Security published a commentary in Vaccine on the importance of modernizing and optimizing vaccine manufacturing, distribution, and administration in the context of COVID-19. According to the WHO , nearly 70 COVID-19 vaccine candidates are currently in development, with several undergoing early-stage clinical trials. Several candidates are using novel platforms, and others are using non-traditional methods of administration, including oral tablets and microneedle patches. The commentary highlights several key aspects and considerations for rapid vaccine manufacturing and calls for geographically distributed manufacturing capacity. Additionally, the authors describe potential benefits and considerations for next-generation vaccine administration approaches in order to streamline vaccine administration and expedite immunization coverage. 

CHINESE GOVERNMENT CALLS FOR STRONGER TESTING As China becomes one of the earliest countries to gradually ease physical distancing restrictions, including lockdowns of major cities, the government has called for more rigorous testing to prevent a resurgence of cases, from either travelers or from local transmission as well as an increasing number of COVID-19 clusters . The government specifically identified Guangdong and Heilongjiang provinces as areas where greatest improvement was needed, as there has been an influx of Chinese citizens returning to those regions from abroad. An article published last week demonstrated the challenges of easing restrictions, as clusters have emerged in recent weeks, connected to imported cases, asymptomatic transmission, and local dinner parties and other social gatherings. As China begins to relax social distancing measures nationwide, it could provide key lessons for other countries that are anticipating similar efforts in the coming weeks and months.

SWEDISH “HERD IMMUNITY” According to news media reports, a Swedish health officials claimed that infection rates in Stockholm are slowing and that parts of the country could achieve “herd immunity” in the next several weeks. According to Dr. Anders Tegnell, Sweden’s national epidemiologist, epidemiological models indicated that data are showing decreased transmission in some cities, including Stockholm, and that there could be enough infected individuals in the city to make a substantial impact by May. He acknowledged that the models could be incorrect. The announcement comes amid reports of increased deaths in Sweden, which Dr. Tegnell attributed to a failure to protect high-risk populations rather than elevated levels of community transmission. Sweden has taken a rather unorthodox approach to responding to COVID-19, compared to other countries, resisting efforts to implement more aggressive social distancing measures. Swedish officials have emphasized that they are not attempting to develop herd immunity, but rather, they are not implementing formal “lockdown” like other countries. Despite the less aggressive distancing measures, Sweden has reported an increase in unemployment to 8%.