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

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April 21, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 20 reports 2.31 million confirmed cases (72,846 new) and 157,847 deaths (5,296 new).

Spain and Italy both continued their slow decline in daily incidence. Spain’s daily incidence is below 4,000 for the first time in nearly a week (3,968 new cases), and Italy reported its lowest daily total (2,256 new cases) since March 10. Austria’s reported COVID-19 incidence appears to be remaining at a low level, following initial steps to relax some social distancing measures.

India continued its recent elevated COVID-19 incidence, reporting 1,329 new cases, despite nationwide “lockdown” measures. Pakistan continues to exhibit a concerning acceleration, reporting its highest daily total (796 new cases). This spike does follow 2 days after Pakistan’s highest daily testing total, which could factor into the elevated incidence; however, the overall trend still appears to be increasing steadily.

Singapore reported 1,111 new cases, the “vast majority” of which are among residents of migrant worker dormitories. Singapore published additional details of the 1,426 cases reported yesterday , and 1,369 of them were dormitory residents. Through April 20 , 75.8% of all COVID-19 cases (6,075 out of 8,014) reported in Singapore are dormitory residents. Singapore’s epidemic more than doubled in the previous week, and 92.6% of the new cases were among dormitory residents. Indonesia rebounded after yesterday’s low incidence, reporting 375 new cases—more than double what was reported the previous day. Today’s report is in line with Indonesia’s increasing trend.

Yesterday, New York state reported its lowest daily incidence (4,726 new cases) since March 20. This is the state’s fifth consecutive day of declining case counts, but the number of tests performed is also declining—April 20 had the fewest tests performed of any day in April. Notably, New York City represents more than half of the new cases reported statewide (2,370 new cases), but the city has also reported 5 consecutive days of declining incidence.

The US CDC reported 746,625 total cases (25,995 new; 1,696 probable) and 39,083 deaths (4,752 probable*) on April 20. In total, 16 states reported more than 10,000 cases (zero new), and 27 states (1 new state; Guam removed) are reporting widespread community transmission. The United States appears to be exhibiting a slight overall decline in daily incidence. The values fluctuate daily, but they appear to be closer to 25-26,000 per day recently, compared to 27-28,000 per day in previous weeks. This is likely driven by recent declines in larger outbreaks rather than a nationwide trend, but it is a welcome sign nonetheless.

The Johns Hopkins CSSE dashboard ** is reporting 788,920 US cases and 42,458 deaths as of 10:30am on April 21.
* See the guidance regarding the reporting of probable COVID-19 cases for more information on the case definitions.
** The Johns Hopkins CSSE also publishes US-specific data , at the county level, on a dedicated dashboard.

SEROLOGICAL TESTING As serological testing continues to gain momentum as a means to evaluate population- and individual-level exposure and immunity to SARS-CoV-2, it is important to understand the current state of evidence and limitations of these tests as well as the body’s immune response to SARS-CoV-2 infection. First, while it is expected that SARS-CoV-2 infection, and the associated antibodies, will provide some level of immunity, it remains highly unclear how complete that immunity will be against the virus and how long it will last. Additionally, a positive serological test (i.e., demonstrating prior exposure) may not necessarily correlate with immunity to reinfection. As we have reported previously, the US FDA has not licensed any serological test for SARS-CoV-2, and only a few candidate tests have Emergency Use Authorizations . As we discussed in yesterday’s briefing, however, there are many other tests available on the private market that do not necessarily have data supporting their accuracy.

In one example, the Los Angeles County Public Health Department (California) partnered with the University of Southern California-Los Angeles to administer serological tests in the local community to evaluate the scale of local exposure. A press release about the study indicate that 4.1% of Los Angeles County residents could have been exposed to the virus. The formal scientific report was not available as of the time of this writing. If these findings hold true, that could mean that LA County could have 28-55 times the number of actual infections than are indicated by the number of confirmed COVID-19 cases. This could be very valuable information; however, its validity depends heavily on the quality of the test used in the study. According to the LA County press release, the test “was further assessed at...Stanford University,” but no additional information is provided regarding the test’s sensitivity and specificity. These types of studies will be critical for better characterizing the scope and severity of the COVID-19 epidemic in the United States and elsewhere, but additional information on the test itself and study methodology are needed to fully analyze the data and its implications.

IRAN BEGINS RELAXING SOCIAL DISTANCING Iranian President Dr. Hassan Rouhani announced on April 18 that he was directing relevant government agencies to develop plans to take further steps to relax national social distancing measures. Iran reportedly began opening some low-risk businesses a week ago, and additional activities resumed this week, including allowing some travel within the country and opening “medium-risk” businesses like bazaars and markets. President Rouhani also emphasized that reopening religious sites across the country will be a priority in the future. As Iran eases social distancing measures, businesses will be required to implement risk mitigation strategies to reduce SARS-CoV-2 transmission. Iran is among the countries hit hardest by COVID-19, still in the Top 10 globally and #1 in the Eastern Mediterranean Region—with nearly 10 times the number of cases as #2 Saudi Arabia. Iran’s Ministry of Health reported a total of 84,802 total cases yesterday, and Iran has consistently reported 1-2,000 new cases daily for the past several weeks. As the Iranian public resumes travel and community activities, Iran will need to remain vigilant for signs of increased transmission.

DOWNSTREAM HEALTH IMPACTS OF COVID-19 In addition to the direct health threats posed by COVID-19, there may be indirect health impacts on healthcare systems and patient health. There are reports that patients with previously-diagnosed health conditions are struggling to receive the care they need, particularly where healthcare systems are overwhelmed with COVID-19 patients. In preparation for surges in COVID-19 patients, health systems began to limit non-essential health services, cancelling elective procedures, and postponing routine health appointments and screenings, such as annual physicals and mammograms. While these actions have been important in freeing up both physical space to accommodate COVID-19 patients and preserving critical supplies as personal protective equipment, there will inevitably be downstream impacts on non-COVID-19 patients. Hospitals are also seeing decreased patient volume in emergency departments , which could be due to a variety of factors ranging from fewer automobile accidents (as a result of fewer people driving due to physical distancing) to patients putting off care for conditions that could worsen over time. The extent of these effects may not be fully understood for some time, and dedicated effort will be required to fully characterize the downstream health effects of COVID-19.

In contrast to urban health systems, where hospitals are facing surges of COVID-19 patients that threaten to overwhelm available resources, some rural hospitals have actually faced a decrease in overall patient load since the start of the US epidemic. Efforts to restrict elective procedures and decreased emergency department activity have reduced demand at these facilities. Many rural hospitals have struggled financially over the past several years, and reduced demand (and reduced revenue) have put some at risk for closing . Many rural parts of the country have limited access to hospitals, and the loss of a facility could significantly affect patient care capacity for broad geographic areas, particularly with the looming prospect of increased demand due to COVID-19. While many rural hospitals are not yet seeing a major patient surge, some are beginning to experience the effects of local COVID-19 outbreaks. It may not take outbreaks on the scale of New York or other major cities to overwhelm vulnerable rural healthcare capacity.

US STATES BEGIN EASING SOCIAL DISTANCING Following the announcement by US President Donald Trump regarding guidance for US states to begin easing physical distancing measures, several states have already initiated or announced the removal or relaxation of some of their statewide efforts. The governors of Georgia , South Carolina , Tennessee , and Texas all announced immediate or forthcoming changes to existing physical distancing measures. Each state is taking a different approach to identifying activities that are appropriate to resume, but all note that the efforts are designed to provide relief to economic burdens in the state while continuing to mitigate COVID-19 risk. Notably, available COVID-19 data do not necessarily indicate that these states have exhibited the recommended 14-day downward trends in COVID-19 activity as outlined in the White House guidance . Additionally, the extent to which these states have the testing and capacity in place to support the necessary contact tracing efforts necessary to monitor SARS-CoV-2 activity in the community is not immediately clear—although expanded testing programs have been reported. Some of the changes outlined by these governors apply statewide, and others are limited to areas with lower rates of community transmission, but each state includes specific requirements for businesses regarding risk mitigation measures that must be implemented in order to resume operations. As states look ahead to relaxing social distancing measures, it will be critical to closely monitor the associated effects on COVID-19 incidence.

MAJOR FESTIVALS CANCELLED IN EUROPE Two of the world’s most well-known celebrations were officially cancelled yesterday. In Spain, local officials announced that the San Fermin festival in Pamplona, perhaps best known for its annual running of the bulls , will be suspended due to concerns about SARS-CoV-2 transmission among the large crowds that attend each year. The festival draws tens of thousands of visitors each year from around the world to the small town in northern Spain. Munich’s annual Oktoberfest celebration —described as “the biggest and most beautiful beer festival in the world”—was also cancelled over COVID-19 concerns . Munich’s Oktoberfest was expected to draw 6 million visitors from around the world. At this time, Pamplona has not determined alternate dates for the 2020 San Fermin Festival, and it appears that Munich may not attempt to host Oktoberfest until the scheduled dates in 2021. These events are the latest in a long line of international events and festivals that have been cancelled or postponed, including the 2020 Olympics in Tokyo.