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

The Center for Health Security is analyzing and providing update on  the emerging novel cor on avirus. If you would like to receive these daily  update s, please  sign up here and select COVID-19. Additi on al resources are also available  on  our  website .
April 27, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 26 reports 2.80 million confirmed cases (84,900 new; 260,004 since Friday’s briefing) and 193,722 deaths (6,018 new; 18,028 since Friday’s briefing).

In addition to updating how confirmed COVID-19 cases are reported (i.e., limiting them to positive PCR test results), Spain also updated their dashboard display to reflect that change. Spain continues to report only new PCR positive cases on the dashboard, and it updated the total cases to utilize the same case definition. Spain reported 209,465 cases (1,831 new) on April 26, and its daily incidence appears to be steadily decreasing since early April. Spain stopped publishing specific numbers for positive serological tests in its daily situation reports, but the data for both PCR and serological tests is available via a link on the dashboard page to download the data.

After 6 days of decreased numbers of active daily cases, Italy reported a slight increase on April 26, but the total decreased again on April 27. Italy continues its overall decline in daily incidence, which has persisted for more than 5 weeks. Austria’s reported COVID-19 incidence appears to be remaining at a low level, and Germany continues its trend of declining daily incidence. Russia has reported approximately 6,000 new cases per day over the past several days. As of today, Russia surpassed China in terms of reported COVID-19 cases with 87,147. Belarus continued its elevated daily COVID-19 incidence

India appears to be holding relatively steady at approximately 1,500-1,700 new cases per day, although there may still be a slight increase over the longer term. Pakistan continued to report elevated daily incidence over the weekend, posting its second and third highest daily totals on April 24 and 25, indicating that Pakistan’s COVID-19 epidemic continues to accelerate.

Singapore reported 799 new COVID-19 cases, including 764 among dormitory residents. Migrant workers living in these dormitory facilities continue to drive Singapore’s accelerating COVID-19 epidemic, representing 84.4% of all COVID-19 cases reported in Singapore (12,183 out of 14,423 total cases), including 95.1% reported in the past week (6,099 out of 6,409 cases). While reported “community cases” remain low, there is potential for transmission to reach beyond the migrant worker community. Indonesia reported 2 days of significantly lower daily incidence (214 on April 27, fewer than half of the daily total on April 25); however, considering these were over the weekend, it is unclear whether this could signal further decreases in the future. Bangladesh reported 497 new cases today its second highest daily total continuing its steady acceleration.

After 4 consecutive days of increasing daily incidence, New York state reported a decrease on April 25 (5,902). On April 24, the state reported its fifth highest daily total (10,553 new cases). Additionally, New York City also reported increasing daily incidence through April 24, followed by a decrease on April 25 (3,145 new cases). The daily incidence for both New York City and state continue to largely correspond to trends in the number of tests performed.

Georgia and Texas both appear to be remaining relatively steady in terms of daily incidence. Georgia has reported approximately 600-800 new cases per day over the past several weeks, and Texas has reported approximately 800-1,000 new cases per day over a similar period. Georgia’s Department of Public Health reports significantly fewer daily cases over the past week, but the data is displayed by symptom onset rather than report date, which could explain the disparity with the New York Times data, a popular data resource. Trends in daily incidence will warrant close monitoring over the next several weeks as Georgia, Texas, and other states begin to ease statewide physical distancing measures.

On Friday, April 24, the US CDC reported 37,144 new cases, the country’s highest daily total since the onset of the pandemic. On April 26, the CDC reported 928,619 total cases (32,853 new from the previous day; 2,663 probable) and 50,439 deaths (2,020 new from the previous day; 5,402 probable). In total, 18 states reported more than 10,000 cases (no change), including New York with more than 200,000; New Jersey more than 100,000; and Massachusetts more than 50,000. In total, 35 states (decrease of 2) are reporting widespread community transmission. Based on recent daily incidence trends, the United States could reach 1 million cases in 2-3 days.

The Johns Hopkins CSSE dashboard is reporting 972,969 US cases and 55,118 deaths as of 12:30pm on April 27.

CANADA RESPONSE Canadian Prime Minister Justin Trudeau announced a new rent subsidy program which would provide financial resources to property owners and businesses to cover rent payments. The program would pay 50% of the rent for 3 months to the building owners, but it requires them to reduce the rent cost and refrain from evicting tenants. The businesses themselves would be required to cover the remaining rent. Like some other countries, Canada is facing the challenge of maintaining vaccination coverage for children during the COVID-19 pandemic. The Canadian Paediatric Society emphasized the importance of maintaining vaccination schedules, particularly as vaccination requirements to enter child care and schools are not being enforced while they are closed. Last week, Canada reportedly received 1 million KN95 respirators from China , but the masks did not comply with government standards for use in healthcare settings. The Canadian government has authorized these types of respirators for use in healthcare settings; however, the items tested did not meet the minimum standards. The Canadian government is determining whether the respirators are suitable for use in other settings.

CALL CENTERS National and local health officials in South Korea published a case study of a COVID-19 outbreak at a call center . The cluster of COVID-19 cases was originally reported in early March, in a “commercial-residential mixed-use building,” and the outbreak resulted in 97 confirmed cases at the time of the investigation. Notably, the building consists of office spaces on floors 1-11 and residential apartments on floors 13-19. Of the 97 cases, 94 were detected among employees of a call center on the 11th floor. The epidemiological investigation determined that there was little mixing between employees on different floors. In total, there were 922 employees and 203 residents in the building (plus an additional 20 visitors during the investigation period), but only 216 employees worked in the 11th floor call center (attack rate of 43.5%), most of which worked in a single room. The investigation did not identify an index case for this outbreak. This outbreak illustrates the potential for SARS-CoV-2 transmission among individuals with prolonged close contact, such as in office settings.

NPR published a detailed overview of the impact of India’s national “lockdown” measures on the country’s call centers, a major commercial sector in the country. India provides much of the world’s customer service and technical support via call centers located nationwide, including for communication and banking companies as well as hospitals, police, and other first responders. More than 4 million individuals across India are employed at these call centers. After India initially announced the national lockdown, these workers were classified as essential, but there have been delays in communicating that to local governments and in transitioning employees to work remotely. Additionally, the shift raises concerns about the security of personal information (e.g., medical records, credit card numbers) for employees working from home using their own personal computers.

COVID-19 DOWNSTREAM IMPACT- WHO GUIDANCE The April 26 WHO COVID-19 Situation Report included links to several documents related to potential downstream health impacts of the COVID-19 pandemic. First, the WHO emphasized the importance of maintaining malaria prevention and treatment programs, particularly in sub-Saharan Africa. WHO analysis indicates that a worst-case scenario, involving a total interruption of insecticide-treated mosquito nets and a 75% decrease in available antimalarial drugs, could potentially result in twice the number of malaria deaths compared to 2018, “a return to malaria mortality levels last seen 20 years ago.” The Pan-American Health Organization (PAHO) also emphasized the importance of malaria prevention and treatment, particularly in protecting progress toward elimination in several countries over the past several years. The WHO and PAHO published guidance regarding malaria control efforts in the midst of the COVID-19 pandemic. Of particular note is the recognition that there may be shortages of the antimalarial drug chloroquine due to increased demand as a potential treatment option for COVID-19. PAHO also published an article discussing the importance of continued routine vaccination, including for seasonal influenza, and highlighting novel solutions and innovative approaches utilized by several countries to maintain national vaccination programs during the pandemic. Finally, the WHO European Regional Office issued a statement regarding the need to develop “sustainable people-centered long-term care in the wake of COVID-19.” The statement emphasized that recent indications of success (e.g., decreasing daily incidence or active cases) does not signal success against the COVID-19 pandemic. Additionally, the statement calls attention to the elevated risk at long-term care facilities and calls for countries across the continent to revisit the operation of long-term care facilities to reduce the vulnerability of high-risk populations for COVID-19 and future health emergencies.

UNITED STATES As states continue to develop and implement plans to relax physical distancing measures, several modeling efforts indicate that most US states do not have sufficient testing capacity in place to begin moving forward with those plans. In collaboration with STAT News , researchers at Harvard’s Global Health Institute analyzed the number of tests per day that would be required in each state by May 1 in order to effectively inform decisions regarding social distancing. The researchers then compared that volume to testing capacity data published by the COVID Tracking Project to evaluate where individuals states stand. They found that the vast majority of states fell well short of where they would need to be to effectively monitor and track new cases. Another effort by Washington University’s Institute for Health Metrics and Evaluation (IHME) took a different approach, aiming to estimate the date on which SARS-CoV-2 transmission could fall within states’ existing capacity. The IHME model was based on the assumption that states could likely handle approximately 1 new case per million people, based on existing testing and contact tracing capacity. The researchers then analyzed trends in reported COVID-19 cases to estimate when daily incidence could be expected fall to that level in each state. The IHME modeling effort estimates that only 5 states will reach that point by May 10, and 20 states and Washington, DC, will reach that point on June 1 or later.

EUROPE The WHO European Regional Office (EURO) published guidance for countries regarding the process to ease social distancing measures. The guidance includes 6 principal criteria for countries to consider before relaxing social distancing: (1) evidence that COVID-19 is coming under control, (2) national testing and contact tracing capacity, (3) “minimized” risks to vulnerable populations, (4) workplace physical distancing and hygiene measures, (5) mitigated risk of imported cases, and (6) community engagement before and during the transition. The EURO guidance also emphasizes 4 key components for decision-making : (1) evidence-based process, (2) healthcare capacity for both routine services and COVID-19 response, (3) social and behavioral considerations, and (4) social and economic support for individuals and communities.

JAPAN The Japanese island of Hokkaido may offer some insight into the potential effects of lifting social distancing measures prematurely. TIME published an article discussing the island’s decisions to relax physical distancing measures and the spike in COVID-19 incidence that followed. After several dozen COVID-19 cases were detected following a major festival that took place in late January, the government declared a state of emergency and requested that residents and businesses adhere to “lockdown” recommendations. After several weeks of lockdown—and associated decreases in COVID-19 incidence and severe economic effects—the government lifted the state of emergency to allow residents to resume businesses and other activities, while keeping some government facilities and schools closed. According to the report, normal social activity—including travel from other parts of Japan—resumed almost immediately. Three weeks later, Hokkaido reported its highest daily incidence. Several days later, the island reported an 80% increase in COVID-19 cases compared to the total when the lockdown was lifted, and the local government issued a second emergency declaration. The local outbreak had increased by another 70% over the following week. The rapid return to normal social interaction may have fueled a substantial resurgence of SARS-CoV-2 transmission, which potentially prolonged the economic and social impact of the lockdown. Many factors contribute to both the health and economic effects of implementing and lifting physical distancing measures; however, this case study could provide insight into these mechanisms as other locations begin developing and evaluating their own plans.

AFRICA The BBC published an overview of varying social distancing and lockdown approaches implemented by countries in Africa . Despite a recent surge in cases across the continent , some countries in Africa are evaluating if and how to begin easing these restrictions. National measures range from prohibitions on large public gatherings to closing schools to city lockdowns and restrictions on travel within countries. Like other parts of the world, lockdowns and other social distancing measures are having significant economic impact, particularly for lower-income individuals. While some countries are maintaining their restrictions, others are beginning to lift some. For example, Ghana reportedly lifted some restrictions on businesses but kept schools closed and maintained bans on public gatherings . The BBC is also maintaining a tracker for COVID-19 incidence and social distancing programs implemented in Africa , including the degree of lockdown (e.g., national, partial, curfew) and start and end dates for each country.

IMMUNITY CERTIFICATES & PASSPORTS As serological testing capacity increases worldwide, countries and businesses are developing plans to implement broader testing programs and evaluating mechanisms to use the available data. One particular tool that has been mentioned by health and elected officials in multiple countries is “immunity passports/certificates” that could enable those with antibodies to SARS-CoV-2 to resume normal activities; however, this concept presents a myriad of technical, social, ethical, and legal challenges. The WHO published a statement regarding the use of serological tests for this purpose. The WHO notes that there is not currently sufficient evidence to determine whether individuals who have been previously infected with SARS-CoV-2 are immune to future infections. Based on a review of a number of studies, most identified antibodies in individuals who recovered from the infection, but none have yet determined that the presence of these antibodies confers protection against future infection or at what level this would occur. Additionally, the available serological tests need to be validated in order to understand their accuracy and limitations. The WHO encourages the continued use of serological tests to evaluate the scope and severity of the pandemic at the population level—including high-risk populations, such as healthcare workers—but it warns against the use of that data to predict individual immunity. It also emphasizes that the use of “immunity passports/certificates” could actually result in increased SARS-CoV-2 transmission resulting from susceptible individuals who believe they are immune and therefore relax precautions.

TOCILIZUMAB- PRELIMINARY DATA Researchers at the Assistance Publique-Hôpitaux de Paris (AP-HP) published preliminary results from a study of tocilizumab, a monoclonal antibody utilized for the treatment of rheumatoid arthritis. In a randomized clinical trial, 65 COVID-19 patients were treated using standard care and tocilizumab, and 64 patients were treated using standard care only. The drug was evaluated as a potential treatment to mitigate the “cytokine storm” that is believed to contribute to acute respiratory failure and death in COVID-19 patients. According to a press release published by AP-HP, the patients that received the drug were significantly less likely to die or require mechanical ventilation over a 14-day period. The study has not yet undergone peer review, and no further information regarding the study methodology or data is presented. The press release emphasizes that additional study is required to confirm the results.

UK PRIME MINISTER RETURNS TO WORK UK Prime Minister Boris Johnson returned to work, several weeks after being diagnosed with and hospitalized for COVID-19. He addressed the country from 10 Downing Street, thanking first responders and citizens for their dedication, support, and cooperation. He emphasized that, while the economic and other hardships resulting from social distancing are difficult, the UK must resist the urge to resume normal activities too soon. He noted that the existing social distancing measures have prevented the worst-case outcomes nationwide and that continued adherence will help mitigate the risk of a resurgence in transmission and further associated economic impact.