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

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April 23, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 22 reports 2.47 million confirmed cases (73,920 new) and 169,006 deaths (6,058 new).

Spain again reported a slight increase in daily incidence. Overall, the epidemic has slowed since March. Italy reported increased daily incidence as well, but it also reported its third consecutive day of decreasing active cases, 10 fewer than the previous day. Austria’s reported COVID-19 incidence remains at a low level, and Germany continues its trend of declining case counts. After several weeks of consistently increasing daily incidence, Russia has reported several consecutive days of relatively steady incidence (4,774 new cases today ), but additional data is needed before analyzing longer-term trends. Belarus reported 741 new cases, which appears to be elevated compared to daily incidence reported over the previous week

India reported 1,716 new cases, a considerable increase over the previous day, despite ongoing national “lockdown” measures. Pakistan reported only 298 new cases yesterday, a substantial decrease from yesterday. This is its lowest daily total incidence since April 14; however, the previous 3 days represented 3 of the 4 highest days since the pandemic began, so today’s low total may be an anomaly.

Singapore reported 1,037 new COVID-19 cases, including 982 among migrant worker dormitory residents. Migrant workers living in these dormitory facilities continue to drive Singapore’s accelerating COVID-19 epidemic. While reported “community cases” remain low, there is potential for transmission to extend beyond the migrant worker community into the broader public, especially considering the current case counts. Indonesia continued its overall increase in daily incidence, but it still appears that it could potentially be starting to taper off slightly. Bangladesh continued its elevated daily incidence, reporting its third-highest daily total (414 new cases). According to the WHO Situation Report , Japan updated its reporting for COVID-19 deaths to include both confirmed cases and cases “whose data matching and verification are in progress”—which presumably corresponds to suspected or probable deaths. Japan reported 91 new deaths yesterday, increasing the national total by 49%, but the daily total was back down to 10 new deaths today .

New York state and New York City both reported an increase in new cases for the first time in nearly a week. The state reported 5,526 new cases, 32% more than the daily incidence reported yesterday, and New York City reported 3,107 new cases, a 23% increase over the daily incidence reported the previous day. Notably, the number of tests performed in New York City and statewide were both also greater than the previous day.

The US CDC reported 802,583 total cases (26,490 new; 3,981 probable) and 44,575 deaths (2,817 new; 5,862 probable*) on April 22. This is the second consecutive day that the CDC reported a record high for new deaths —excluding the day New York City first reported probable COVID-19 deaths (April 14). In total, 17 states reported more than 10,000 cases (no change), and 27 states (no change) are reporting widespread community transmission. Based on recent daily incidence trends, the United States could reach 1 million cases by the end of April and 50,000 deaths by April 24.
* Based on the provided guidance regarding the reporting of probable COVID-19 cases , it is unclear how there could be more probable deaths than there are probable cases.

The Johns Hopkins CSSE dashboard ** is reporting 843,981 US cases and 46,859 deaths as of 11:30am on April 22. The data for new daily cases reported yesterday was adjusted from the high value cited in yesterday’s briefing, and the updated value is consistent with other recent reports.
** The Johns Hopkins CSSE also publishes US-specific data , at the county level, on a dedicated dashboard.

US UNEMPLOYMENT Earlier today, the US Department of Labor released new information relating to the impact of COVID-19 on the US workforce. This report indicated that more than 4.4 million individuals filed initial claims for unemployment, owing largely to prolonged public health measures impacting companies’ ability to operate. While this number is a decrease from the previous week, it brings the national total to approximately 26 million new claims over the last 5 weeks, roughly 7.8% of the entire US population (not just those of working age). 

BELARUS After several weeks of an accelerating COVID-19 epidemic in Belarus the WHO deployed a team of experts to provide technical support and guidance for the country’s response. Belarus has already implemented a number of critical response measures, including testing, contact tracing, and isolating suspected cases. Additionally, the Belarusian government has engaged the private sector to increase production of supplies and equipment needed to support response activities. Beyond the current response measures, the WHO emphasized the importance of social distancing measures to reduce transmission in the community. The WHO recommended restricting large gatherings, quarantining contacts of confirmed patients, increasing remote work and education opportunities, and reducing non-essential movement and activities in the community. Belarusian President Alexander Lukashenko commented that he would take the WHO’s recommendations under advisement, but he will not be implementing nationwide measures at this time. He noted that the COVID-19 epidemic is not nationwide, so local measures are appropriate. This approach stands in contrast to many other European countries that elected to take national approaches to social distancing measures, some of which are now observing enough success that they are beginning to relax existing restrictions.

SWEDISH “HERD IMMUNITY” STUDY RETRACTED Closely following the debut of a report indicating high levels exposure to SARS-CoV-2 in Stockholm, the Swedish Public Health Agency retracted the report due to errors in the analysis. The initial announcement was widely covered by media around the world, as Swedish health officials forecasted that some parts of the country, including Stockholm, could achieve herd immunity by May. The model indicated that SARS-CoV-2 had spread far more widely among the public than would be indicated by other estimates, potentially including 600,000 people in Stockholm alone. In contrast, current WHO estimates suggest that only 2-3% of the global population has been infected by the virus. The Swedish government has resisted implementing the kind of aggressive nationwide social distancing measures used in other countries, and the report was used to justify this approach by suggesting that Sweden could achieve herd immunity with relatively few cases and deaths. Swedish officials have previously denied that herd immunity was the intent behind decisions against national social distancing restrictions. It is unclear at this time what errors were included in the report or whether a corrected version will be published publicly.

RACIAL DISPARITIES IN NEW YORK NURSING HOME DEATHS A report published by NPR looked at 78 nursing homes in New York in which at least 6 residents have died from COVID-19. The investigation found that 7 of the 11 nursing homes with the highest number of COVID-19 related deaths reported 46% or greater “non-white” residents. Nursing homes have played a major role in the spread of New York City’s COVID-19 outbreak, and residents are at elevated risk for severe disease and death. This report further highlights inequities and disparities in health outcomes for COVID-19 patients. It is essential that these inequities are further explored and addressed.

DEVELOPING CAPACITY FOR SEROLOGICAL TESTING A new report from the Johns Hopkins Center for Health Security outlines a potential path forward for a national strategy for antibody testing. The report urges the United States to increase access to validated, accurate serological tests for public health authorities, essential workers, and individuals who would use the test to assess their own risk of SARS-CoV-2 infection. In addition to this call to action, the report outlines key areas of importance for serological testing, particularly in the context of relaxed social distancing measures; technical, ethical, and legal challenges of “immunity certificates”; and the importance of managing uncertainty around serological test results as these tests are deployed more widely in the coming months. This report comes amid recent comments from pharmaceutical leaders and health experts regarding the current challenges that serological testing faces in the United States. 

NEW ACADEMIC ARTICLES The Journal of the American Medical Association ( JAMA ) journals published 3 articles pertaining to clinical features of COVID-19. The first article provides a detailed look at the COVID-19 epidemic in New York City. The study includes case series data from patients presenting at 12 different New York City hospitals, spanning the majority of the larger metropolitan area. The median age for patients was 63 years, and 60.3% of patients were male. Common comorbidities included hypertension (56.6%), obesity (41.7%), and diabetes (33.8%). Among the subset with documented outcomes by the end of the study, 14.2% were admitted to an intensive care unit, and 12.2% received mechanical ventilation. In total, 21% of patients with known outcomes died.

The second article , from JAMA Pediatrics , presents a systematic review of SARS-CoV-2 infections in children and adolescents. The paper reviewed 18 different studies that shared case details of a total 1,065 COVID-19 cases in children or adolescents. The paper found that the majority of pediatric patients presented with mild or no symptoms and that no child aged 0 to 9 died across the 18 studies. This paper reinforces the current understanding that children and adolescents are at lower risk for severe COVID-19 than older adults. 

The third article is a research letter regarding a study that aimed to explore smell or taste disturbances in COVID-19 patients, with a focus on the prevalence, timing of onset, and intensity of those symptoms. Interviews were conducted with 202 confirmed COVID-19 patients from a regional hospital in Northern Italy. The study participants had a median age of 56 years. The study found that 64.4% of participants reported altered sense of taste or smell. The median score for severity was a 4 (with 5 being the most severe change). Among those who provided information regarding the timing of their altered smell/taste, 19.4% indicated that it presented before other symptoms, 37.1% said it presented at the same time as other symptoms, and 43.5% said it presented after other symptoms presented.

SARS-CoV-2 COMMUNITY TRANSMISSION Researchers at Northeastern University developed a model that illustrates a scenario in which the SARS-CoV-2 virus could have circulated in the New York City area (and other major cities), reaching thousands of infections before it was first detected. The model also estimates that there were potentially 28,000 infections across several major US at a time when there were only 23 confirmed COVID-19 cases. There is considerable uncertainty inherent to any model, but even if the projected magnitude is higher than reality, there appears to be growing evidence that early screening, testing, and contact tracing efforts were unable to adequately detect community transmission early in the epidemic.

RELAXING SOCIAL DISTANCING As elected officials and health officials in the United States look ahead to relaxing social distancing measures, some initial decisions have been met with opposition, particularly because current epidemic conditions and response capacities (eg, diagnostic testing and contact tracing) have not met proposed thresholds for relaxing those measures. Earlier this week, Georgia Governor Bill Kemp issued an executive order that would ease existing statewide restrictions, including permitting some non-essential businesses to reopen as early as later this week. Yesterday, US President Donald Trump —in contrast to previous calls for states to “reopen”—stated that he disagreed with Governor Kemp’s decision. He emphasized that Georgia had not yet demonstrated the key criteria to enter “phase 1” and that businesses such as tattoo parlors and barber shops that pose elevated risk of transmission would be more appropriate to open in “phase 2.” Dr. Anthony Fauci also warned of the potential for SARS-CoV-2 transmission to “rebound” if social distancing measures are not eased in the appropriate manner.

In an interview yesterday with CNN’s Anderson Cooper, Las Vegas Mayor Carolyn Goodman commented that she would not issue guidance to local businesses—or casinos and hotels that are under the jurisdiction of the Nevada Gaming Commission or county government—regarding social distancing or other measures to augment the safety of employees or visitors. She emphasized the need to resume business operations, including drawing in visitors, due to the economic hardship imposed by existing restrictions, but she also noted that it would be the responsibility of individual businesses to develop and implement their own measures. Additionally, she stated that she had previously offered for Las Vegas to be a “control group” (ie, without social distancing measures in place) to provide baseline SARS-CoV-2 transmission data against which the effects of social distancing could be evaluated, but local health officials recommended against this approach. Some elected officials, union representatives , and others have criticized her remarks as reckless.

NEW YORK COVID-19 CONTACT TRACING New York Governor Andrew Cuomo and former New York City Mayor Mike Bloomberg announced the start of an ambitious COVID-19 contact tracing effort. The scale of the contact tracing effort is set to exceed that of any in New York’s history, with financial contributions and plans for recruitment already in progress. The program is set to launch immediately, but there is an expectation that it will take time before contact tracing operations can formally commence. Governor Cuomo has repeatedly emphasized the importance of contact tracing to New York State’s prolonged COVID-19 response, including efforts to relax social distancing, with the goal being to develop a system that can effectively “identify, contact, isolate” patients in a way that will limit spread of the disease. 

DOWNSTREAM COVID-19 IMPACTS Concern over COVID-19 and limited operations at healthcare and public health facilities, beyond the COVID-19 response, are resulting in individuals postponing care and other services. An article published by STAT News provides insight into patients who are electing to delay treatment, including going to the emergency department (ED) for emergent conditions. EDs across the country have reported significant decreases in normal patient load—including for injuries and trauma as well as strokes, appendicitis, and heart conditions—since the onset of the COVID-19 epidemic. There are a number of potential factors such as reduced pollution, reduced driving and fewer traffic accidents—however, some clinicians are reporting that the patients they are treating in the ED have more severe conditions, which could indicate that people are postponing needed care. Additionally, some clinicians expressed concern that patients may be dying of these conditions at home rather than risk exposure to the SARS-CoV-2 virus at the hospital.

Another article, published in The New York Times , addresses the impact of the COVID-19 epidemic on vaccination coverage and other preventive services as parents delay routine childhood care. Decreasing rates for routine childhood immunizations have received considerable attention over the past several years, as low vaccination coverage has resulted in increasing outbreaks (in both number and scale) for vaccine-preventable diseases, such as pertussis, mumps, and measles. One effort to evaluate the impact of COVID-19 on childhood vaccination coverage found that the number of vaccinations administered for measles, mumps, and rubella vaccine decreased by 50% for a week in early April. Additionally, vaccinations for diphtheria and pertussis (DTaP and Tdap vaccines) decreased by 42%, and vaccinations against the human papillomavirus (HPV) fell by 73%. The federal Vaccines for Children program also reported decreases in the number of vaccine doses distributed, including a 68% decrease in Massachusetts over 2 weeks in April. Around the world, national immunizations programs have been suspended in many countries, as public health assets are allocated for the COVID-19 response. Alternatives to traditional doctor’s appointments, including “house calls” and mo bile clinics, may be needed in order to mitigate risks due to delayed preventive and routine medical care, including vaccination.

JOHNS HOPKINS WEBCAST ON TAIWAN'S COVID-19 RESPONSE On Friday, April 24, Taiwan Vice President Chen Chien-jen will join Ellen J. MacKenzie, Dean of the Johns Hopkins University Bloomberg School of Public Health, for a webcast conversation about Taiwan’s early and effective response to the COVID-19 pandemic. They will discuss specific measures that Taiwan took to control the spread of the virus and how Vice President Chen’s public health training played a role.