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

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April 24, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 23 reports 2.54 million confirmed cases (73,657 new) and 175,694 deaths (6,689 new). Additionally, the WHO Situation Report comments that “all available evidence for COVID-19 suggests that SARS-CoV-2 has a zoonotic source” and that genomic analysis “does not support that SARS-CoV-2 is a laboratory construct.” Additional details are provided in a “Subject in Focus” on the origins of SARS-CoV-2.

Spain appears to be updating its COVID-19 reporting methods. On its COVID-19 dashboard, the cases reported in the past 24 hours now refer only to those confirmed with a PCR test, which appears to be a change. Previously, Spain did not specify how many cases fell under this category, and after a review of other daily reports, it seems as though Spain has been including individuals with positive serological tests since approximately April 15. We have noted in previous COVID-19 briefings that Spain’s reported daily incidence has not been decreasing like we have observed in some other European countries. If these recent reports included positive serological tests (whereas previously reported data did not), it could potentially explain why the daily incidence was not decreasing as expected. Spain’s April 24 daily report shows 202,990 confirmed cases (PCR test), including 2,796 new cases. This is considerably fewer new cases than have been reported over the past several weeks. Additionally, the daily report shows 219,764 total cases—including both PCR and serological tests—which matches the total cases reported on the dashboard. The change in total cases reported on the dashboard from the previous day is 6,740 new cases, but it seems that this would include new positive serological tests as well. As of today, the dashboard appears to include a mix of data for both types of test in the total reported cases and just the PCR test for new cases, and it is unclear how Spain will proceed with its COVID-19 reporting in the future.

Italy continues its overall decline in daily incidence as well as decrease in active cases—851 fewer active cases than the previous day. Austria’s reported COVID-19 incidence appears to be remaining at a low level, and Germany continues its trend of declining daily incidence. After several days of relatively consistent daily incidence, Russia reported 5,849 new cases today . It appears that this would be Russia’s second highest daily total since the onset of the pandemic; however, the daily growth rate for Russia’s epidemic is less than 10%, compared to 16-18% in previous weeks. Belarus continued its elevated daily COVID-19 incidence, reporting 751 new cases, which appears to be elevated compared to daily incidence reported over the previous week

India reported 1,752 new cases, approximately equal to yesterday's daily total but still higher than previous days, despite ongoing national “lockdown” measures. Yesterday, we mistakenly reported the partial daily incidence for Pakistan , which explains why it was so much lower than other recent reports. Pakistan reported 742 new cases on April 22 and 642 new cases on April 23. Pakistan has reported its 3 highest daily totals (and 4 of the top 5) over the past 4 days. While its daily growth remains below 10%, Pakistan’s COVID-19 epidemic continues to accelerate.

Singapore reported 897 new COVID-19 cases, including 853 among migrant worker dormitory residents. Migrant workers living in these dormitory facilities continue to drive Singapore’s accelerating COVID-19 epidemic, representing 82% of all COVID-19 cases reported in Singapore (9,929 out of 12,075 total cases), including 95% reported in the past week (6,660 out of 7,025 cases). While reported “community cases” remain low, there is potential for transmission to reach beyond the migrant worker community into the broader public, especially considering the current high rate of transmission. Indonesia reported its highest daily incidence (436 new cases), but daily fluctuations make it difficult to anticipate the longer-term trajectory. Bangladesh also reported its highest daily incidence (503 new cases), continuing its acceleration. After updating its reporting criteria for COVID-19 deaths to include probable/suspected deaths, Japan reported 19 new deaths today. With the exception of the 91 new deaths reported on the first day Japan made that change, the recent daily number of new deaths have been closer to 10.

New York state reported increased daily incidence for the second consecutive day, following nearly a week of decline. Additionally, New York City reported its third consecutive increase. Notably, both the city and state reported significant increases in testing as well.

The US CDC reported 828,441 total cases (25,858 new; 4,211 probable) and 46,379 deaths (1,804 new; 5,922 probable*) on April 23. After 2 consecutive days of elevated daily death totals, yesterday’s update was approximately 1,000 fewer than each of the previous 2 days. In total, 18 states reported more than 10,000 cases (1 new), and 37 states (10 new) are reporting widespread community transmission. Based on recent trends, the United States could reach 1 million cases by the end of April, and it could exceed 50,000 deaths later today.
* 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 890,112 US cases and 50,114 deaths as of 1:00pm on April 24.
** The Johns Hopkins CSSE also publishes US-specific data , at the county level, on a dedicated dashboard.

NEW YORK SEROLOGICAL STUDY New York Governor Andrew Cuomo reported preliminary results from a serological study conducted in New York state. The study tested 3,000 individuals across 19 counties statewide. A fact sheet about the test linked in the press briefing describes it as having a specificity of 93-100%; however, additional details about the test are not provided. The preliminary study results found that nearly 14% of New York residents may have been previously infected with SARS-CoV-2. These results are weighted heavily by the New York City area, with much lower estimates for the rest of the state. Like many other serological studies currently being implemented, additional information on the test is necessary to fully analyze the serological test data and characterize the scope of transmission in a given community.

STAT News provides a good overview of the limitations, expectations, and other considerations that to keep in mind when evaluating serological survey results. We will continue to see serological tests conducted in the United States and other countries, using a variety of tests. Serological data will be critical to understanding both the scale and severity of the COVID-19 pandemic—which will inform decisions regarding response operations and policies, including social distancing—so it is important to account for the limitations of tests used in these studies.

COVID-19 TREATMENTS Evidence from a clinical trial for remdesivir , an antiviral drug, conducted by Gilead Sciences in China reportedly did not demonstrate sufficient efficacy as a COVID-19 treatment. Data from the study was inadvertently published on the WHO website and obtained by STAT News before it was removed. A WHO spokesperson indicated that the study is currently undergoing peer review. A press release from Gilead Sciences stated that the results were published prematurely by accident and that the associated post on the WHO site contained “inappropriate characterizations” regarding the results. The statement noted that the study “terminated early due to low enrollment and, as a result, it was underpowered to enable statistically meaningful conclusions.” The study was initially meant to enroll 453 patients in a double-blind randomized clinical trial, but the initial report reflected findings from only 158 patients who received remdesivir and 79 patients who received a placebo. While the published results did not demonstrate a statistically significant effect, the statement by Gilead Sciences indicates that “trends in the data suggest a potential benefit for remdesivir, particularly among patients treated early in disease.” Additional study will be required to further characterize any benefits associated with the use of remdesivir in COVID-19 patients.

A recent correspondence published in Nature reported that researchers were able to successfully isolate human monoclonal antibodies to the SARS-CoV-2 spike protein that could block the binding of the protein to the ACE-2 receptor, providing a potential mechanism to develop a COVID-19 therapeutic. The researchers identified spike protein IgG antibodies, specifically antibodies to the SARS-CoV-2 receptor binding domain, in the blood serum from most of the 26 COVID-19 patients involved in the study. The investigators then assessed whether these antibodies could block the binding of SARS-CoV-2 receptor binding domain to the ACE2 receptor using an ELISA-based inhibition assay. While a large proportion of the patients mounted antibody responses, results indicated that only 3 of the 26 patients had antibodies that could effectively block the SARS-CoV-2 receptor binding domain to ACE2. The researchers were able to clone 2 sets of functional antibodies from these patients. This study provides preliminary indication that this process could yield monoclonal antibodies that could be leveraged for future prophylaxis or therapies in other patients. 

GLOBAL SOCIAL DISTANCING Yesterday marked the first day of Ramadan, a holy month for Muslims during which many people visit holy sites, including the Grand Mosque in Mecca and the Prophet’s Mosque in Medina (Saudi Arabia). Unfortunately, COVID-19 physical distancing measures have forced these holy sites to close. Religious leaders have adopted new procedures, including a live-streaming religious ceremonies, to provide key religious services during this time. The WHO published guidance for individuals celebrating Ramadan to mitigate SARS-CoV-2 transmission risk. The guidance emphasizes the importance of hygiene, physical distancing, and cleaning/sanitizing places of worship. Additionally, the WHO notes that no studies have been conducted regarding COVID-19 risks associated with fasting; however, COVID-19 patients should discuss decisions about fasting with their doctor.
* This newsletter has been updated to correct a typo in the spelling of Ramadan.

The New York Times published a report that looks at the practice of home isolation of COVID-19 patients in Italy and the associated challenges and transmission risk. Italian public health officials have identified person-to-person transmission among individuals living in the same home as one of the drivers of their country’s COVID-19 epidemic. The decision to isolate a sick family member at home could have cascading effects beyond the public health benefit, potentially including elevated risk of transmission for members of the same household. The article outlines the challenges that Italy has faced isolating members of “tight-knit” families, raising concerns about the expectations for public adoption of certain public health behaviors, given the wide range of cultural norms in a global response. Communities in other countries, including the United States, face similar challenges. Public health interventions, including social distancing measures and home isolation must be considered in the context of social and cultural norms and other factors in order to identify and implement effective responses to health emergencies.

EUROPE COVID-19 ECONOMIC RECOVERY Leaders of the European Union (EU) have yet to come to an agreement on a recovery program to help member states rebuild their economies in the wake of the COVID-19 pandemic. The EU member countries convened virtually yesterday to review a number of proposals, including increases to the EU budget and bond sales to increase available funds, that aim to stabilize Europe's bloc economy while also providing support for domestic economies in countries that the pandemic has hit the hardest. While the group did not reach an agreement during this call, several political leaders said that the coalition made significant progress toward an agreement.  

WHO ANNOUNCES GLOBAL COVID-19 DRUG COLLABORATION Today, the WHO announced the initiation of a global collaboration to promote the rapid development of vaccines and therapeutics for COVID-19 as well as a commitment to ensure equitable access for all. The effort, labeled the Access to COVID-19 Tools (ACT) Accelerator , aims to speed global research and production efforts for critical COVID-19 “drugs, tests, and vaccines.” Additionally, the program emphasizes the importance of ensuring access to the pharmaceutical products around the world, not just for countries and individuals who can afford them. Funding is needed to implement the effort, and the program hopes to secure an initial sum of US$8.1 billion; however, European Commission President Ursula von der Leyen noted that this is only a first step. A representative from the US Mission is Geneva, Switzerland, reportedly stated that the United States will not be a formal member of the partnership , but it will support international efforts to develop and produce a vaccine. French President Emmanuel Macron commented that he hoped to bring the United States and China onboard to support the effort.

MISINFORMATION & FRAUD Misinformation, including the misinterpretation and misrepresentation of information—about COVID-19 and associated personal protective equipment , test kits , and vaccines or treatments continue to persist as the pandemic grows. The US Department of Justice announced earlier this week that it has disrupted hundreds of COVID-19 scams, including fraudulent websites seeking donations to the American Red Cross or soliciting personal information as well as websites for legitimate companies that were used to distribute malware. Earlier this month, the US FDA also published a warning regarding the sale and use of chlorine dioxide products which when mixed with other chemicals can become bleach —as a prevention or treatment for COVID-19.

ESTIMATING COVID-19 INCIDENCE IN CHINA A study published by the Lancet evaluated the effect of evolving COVID-19 case definitions in China on the number of detected and reported cases. The researchers identified 7 different versions of COVID-19 case definitions published by China’s National Health Commission. Based on analysis of updated case definitions, as well as changes in COVID-19 reporting associated with the changes to the case definition and control measures such as the “lockdown” of affected areas, the researchers developed a model to estimate the total COVID-19 incidence that could have been detected if the most inclusive version—final version—of the case definition been used from the onset of the epidemic. The authors found that using the final case definition from the outset would have resulted in 253,000 cases detected by February 20, compared to 55,508 cases reported at that time. While this study focuses on case definition and reporting in China, other countries faced similar challenges. As we have covered in recent briefings, the identification of several COVID-19 deaths from early February in California indicates that the narrow case definition in place in the United States at that time likely resulted in the inability to detect ongoing community transmission for weeks before it was first reported. Case definitions for novel diseases and emerging outbreaks often evolve as additional information becomes available.

DOCTOR SPOT Brigham and Women’s Hospital in Boston, Massachusetts (US), is using a robot dog to help clinicians screen patients. The robot, designed and built by Boston Dynamics, is similar to their Spot robots (and their cousin the Cheetah) made famous via online videos , but it can do far more than run , jump , and dance . The robot is now being used to help emergency department physicians handle potential COVID-19 patients remotely. Doctors can move the robot and communicate via video chat on a tablet in order to evaluate incoming patients without risking potential exposure to the SARS-CoV-2 virus. The robot’s ability to operate on a variety of surfaces enables it to function effectively wherever hospitals establish triage areas, including parking lots or grassy lawns. The robot allows clinicians to interact with prospective patients, including delivering supplies and potentially advanced remote diagnostic equipment, without the need for doctors and nurses to don PPE, providing the capability to safely interview, evaluate, and triage patients without using limited PPE or risking unnecessary exposure.