COVID-19
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 s  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 28, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 27 reports 2.88 million confirmed cases (85,530 new) and 198,668 deaths (4,982 new) worldwide. The Situation Report notes the recent change in Spain’s COVID-19 reporting (PCR positive only) that we have covered in recent briefings and includes an update on Emergency Medical Teams, the Global Health Cluster, the Global Outbreak Alert and Response Network (GOARN), and Risk Communication and Community Engagement activities.

Spain continued its steady decline in daily incidence. Italy continues its decline in active cases—down more than 3,000 cases (2.8%) from the peak on April 19—as well as its overall decline in daily incidence, which has persisted for more than 5 weeks. The UK COVID-19 epidemic appears to be on the decline as well. While the epidemic curves are displayed by specimen date (as opposed to report date), last week (April 19-25) is on pace to be the second consecutive week of declining daily incidence.

Russia continues to report more than 6,000 new cases per day. The daily incidence may still be increasing, but not nearly as rapidly as in early April. Today , Russia surpassed Iran in terms of reported COVID-19 cases with 93,558. Belarus reported 919 new cases, continuing its acceleration . 

India appears to be holding relatively steady at 1,500-1,700 new cases per day. Pakistan continued to report elevated daily incidence, posting its 5 highest daily totals over the past 8 days. Pakistan’s epidemic doubled in size over the last 11 days, and it continues to accelerate.

Singapore reported 528 new COVID-19 cases, 511 (96.8%) of whom are residents of migrant worker dormitories. Migrant workers living in these dormitory facilities continue to drive Singapore’s accelerating COVID-19 epidemic. After 2 days of significantly lower daily incidence, Indonesia reported 415 new cases, its third-highest daily total. It appears as though Indonesia’s outbreak continues to accelerate. Bangladesh reported 549 new cases today, its highest daily total since the onset of the epidemic.

New York state and New York City both reported their second consecutive day of decreasing daily incidence and their lowest daily totals since March 20. The daily incidence for both New York City and state continue to largely follow trends in the number of tests performed. In New York City, 21.2% of tests performed yesterday were positive, and 16.9% were positive outside of New York City (19.0% positive statewide).

The US CDC reported 957,875 total cases (29,256 new; 4,999 probable) and 53,922 deaths (3,483 new; 6,142 probable) as of April 26. This appears to be a new record high for daily reported deaths (excluding the day New York City first reported probable COVID-19 deaths [April 14]), exceeding the previous high by more than 650 (23.6%). Notably, the United States represents a third of the global cases and more than a quarter of the global deaths. 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, 36 states (increase of 1), plus Guam (added again), are reporting widespread community transmission. Based on recent daily incidence trends, the United States could reach 1 million cases in 2 days.

The Johns Hopkins CSSE dashboard is reporting 994,625 US cases and 56,749 deaths as of 12:30pm on April 28.

SPAIN INVESTIGATES SEROPREVALENCE Spain is launching a nationwide seroprevalence study , including 36,000 randomly selected households. The study will attempt to sample between 60,000 and 90,000 individuals across the country with the goal of achieving a representative sample based on regional population size. Two different serology tests will be performed for each participant: a finger-stick rapid test and a laboratory-based test. Participants will also be asked to take a questionnaire with questions such as previous diagnosis with COVID-19 or other possible exposures. The study recruitment and sampling period will last until May 10. 

NEW ZEALAND CONTAINS COVID-19 New Zealand has had success in controlling the spread of SARS-CoV-2 due in part to its rapid response, strict enforcement of border closures and social distancing, and testing capacity. Other contributors to New Zealand’s success could include its relative isolation as an island nation, its low population density, and its higher socioeconomic resources. The R0 is currently estimated at 0.4 and recent daily incidence has been below 10 in recent days (1 case reported on April 27). The rate at which tests return positive is less than 1%, and more than 100,000 tests have been administered nationwide. On April 27, New Zealand’s Prime Minister Jacinda Ardern stated “There is no widespread undetected community transmission in New Zealand. We have won that battle. But we must remain vigilant if we are to keep it that way.” New Zealand has now transitioned its response to “ Alert Level 3 ,” which includes lifting some of the strictest movement measures and allows certain businesses to reopen. One of the main goals of Alert Level 3 is to achieve COVID-19 elimination. 

US TESTING STRATEGY US President Donald Trump revealed the Blueprint For Testing Plans And Rapid Response Programs , which outlines plans to increase testing capacity to 2 million tests per week across the country. The Blueprint delineates roles and responsibilities of the federal government, state/local/tribal governments, and the private sector in order to reach this goal. While the Blueprint does not call specific actors or companies to action, pharmacy chain CVS said in response that it will partner with the federal government to provide drive-through testing at its facilities, among other potential activities. Scaling up testing capacity is a major factor in many plans to safely reopen parts of the economy in the coming weeks and months. The Blueprint highlights several areas in which capacity could be scaled, including expanding the number of testing platforms, enhancing sample collection, and maximizing laboratory capacity.

US COVID-19 FUNDING The US government has announced and implemented cuts to funding for a variety of activities associated with the COVID-19 pandemic. Notably, President Trump said that he intends to suspend US government funding for the WHO while the federal government investigates the organization’s response to the COVID-19 pandemic. This effort has prompted opposition from elected officials and health experts around the world. Yesterday, US Representative Eliot Engel , Chair of the House Committee on Foreign Affairs, initiated an investigation into the circumstances surrounding President Trump’s decision. In a letter to US Secretary of State Mike Pompeo, Chairman Engel notes that the White House’s justification for the decision does not provide a factual basis for the decision and does not indicate how “suspending funds for the WHO will save lives here at home or around the world.” The letter also requests a variety of documents and communications over the past several months pertaining to the US COVID-19 response.

The US government continues to evaluate options to provide financial support for US businesses and individuals to offset the economic impact of the COVID-19 pandemic and associated social distancing measures. Today, US Secretary of the Treasury Steven Mnuchin announced that the US government will audit companies that received loans of more than $2 million from the Paycheck Protection Program. The economic stimulus effort was designed to provide financial support for small businesses during the COVID-19 response; however, reports have emerged since the initiation of the program of larger companies—including nationwide restaurant and hotel chains and the Los Angeles Lakers basketball team (which returned the loan)—receiving sizable loans while some small businesses have been unable to access the emergency funding. The Small Business Association has made changes designed to limit the loans to small businesses, but these audits would provide additional oversight for the program.

EASING SOCIAL DISTANCING
UNITED STATES US states continue to develop and implement plans to relax social distancing measures, with the aim of increasing economic activity while mitigating SARS-CoV-2 transmission risk. Yesterday, President Trump reportedly discussed reopening schools on a call with state governors—he also mentioned it during the White House COVID-19 briefing . President Trump emphasized the need to proceed with any plans with safety as a priority.

Several states, including Ohio and Texas , announced detailed plans to initiate efforts to relax statewide social distancing measures. The guidance for both states include a number of restrictions that will remain in place as nonessential businesses reopen, including limiting the maximum occupancy, physical distancing, face mask use, enhanced hygiene, and temperature/symptom monitoring. Certain aspects of businesses, such as buffets and salad bars at restaurants, will be prohibited, even for businesses that reopen. Additionally, some elective healthcare services will be permitted to resume, but capacity must be reserved for COVID-19 response.

UNITED ARAB EMIRATES The United Arab Emirates is beginning to relax social distancing measures despite recent increases in reported cases. The UAE epidemic has nearly doubled over the past 10 days , but the country is beginning to resume activity at shopping malls, markets, and other businesses. The changes include limiting the previously-imposed movement restrictions to 10pm to 6am, resuming public transit, and reopening a variety of nonessential businesses, such as restaurants, shopping malls, and retail stores. “Family entertainment centers, cinemas, changing rooms and prayer rooms” will not be permitted to reopen at this time, and restrictions will limit businesses’ capacity, both for visitors and employees. Additionally, some businesses may implement fever screening and disinfecting units, in which individuals move through a “fog of disinfectant” to kill virus on their clothing and skin. The Ministry of Health and Prevention also unveiled a smartphone app that aims to support contact tracing efforts. The app will use short-range Bluetooth signals to determine if an individual was in close contact with an identified COVID-19 case. Using the app appears to be voluntary.

COLOMBIA Colombia will reportedly extend its national social distancing measures —including school closures, restrictions on restaurant operations, and a prohibition on mass gatherings—order until May 11, but the government will begin allowing construction and manufacturing workers to return to work on April 27. Mass transit services may not exceed 35% capacity until further notice. Colombia has shown signs of progress in controlling their epidemic, with Minister of Health Fernando Ruiz recently stating that Colombia’s R0 is currently close to 1.5, compared to 2.5 early in the epidemic. Efforts to relax some of the social distancing measures at the national level have received pushback from some local elected officials. Most notably, Mayor of Bogotá Claudia Lopez , spoke out against reopening certain areas of the economy too soon, because of the potential for disproportionate impact on the citizens of Bogotá.

CHILE Chilean President Sebastián Piñera unveiled the country’s Plan for Safe Return to gradually and flexibly return Chileans to work. The plan outlines 3 main components: returning civil servants to public jobs, returning private industry workers to their jobs, and returning students to schools. The country currently has different levels and duration of quarantine enforcement in different zones of the country, with quarantine in some areas ending on May 7 and others ending earlier in April. 

ECUADOR Ecuador is among most severely affected countries in the PAHO region, but the government is beginning to assess ways to relax social distancing measures. Ecuador’s Committee of Emergency Operations has classified each city/province with a “red", "yellow, or "green” designation to signify the current level of transmission risk. The entire country will observe social distancing measures through May 4, but local governments will be responsible for decisions regarding when and how to to begin relaxing these measures. Local authorities, such as mayors, will be in charge of these initiatives within their localities once they have reached those levels. For example, while telecommuting is still highly encouraged, “yellow” cities can allow 50% of their public and private workforce to return to work. “Green” cities can allow 70% of their public and private workforce to return.

COVID-19 EXCESS DEATHS Analysis conducted by researchers at the Yale School of Public Health with The Washington Post , evaluated the number of excess deaths reported in the United States during the COVID-19 epidemic. This study aimed to determine the number of reported deaths nationwide above what would be expected under normal circumstances. The researchers found that an additional 15,400 deaths (i.e., above the expected total) were reported nationwide from March through April 4. This total includes both reported COVID-19 deaths and deaths due to other causes. Notably, through April 4, only 8,128 COVID-19 deaths had been reported in the United States. The additional 7,000+ excess deaths could include COVID-19 deaths that were not detected, deaths resulting from individuals delaying or not being able to obtain necessary care for other conditions, and other causes. This analysis does not provide detailed information on the exact cause of the excess deaths, but it provides insight into the broader health impact of the COVID-19 pandemic, beyond just direct cases and deaths. The number of COVID-19 deaths alone does not fully capture the pandemic’s impact.

SARS-CoV-2 HOUSEHOLD TRANSMISSION A study published in The Lancet: Infectious Diseases analyzes SARS-CoV-2 transmission characteristics based on cases and contacts monitored in Shenzhen, China. The study included 391 COVID-19 cases and 1,286 contacts monitored by the Shenzhen Center for Disease Control as part of China’s epidemic response. The researchers found that household contacts of COVID-19 cases and individuals traveling with cases were both at elevated risk of infection. Additionally, the secondary “attack rate” (percentage of contacts who tested positive for SARS-CoV-2 infection) among household contacts was at least 11.2%. While attack rates were higher among older adults, the value for children—7.4% and 7.1% for children aged 0-9 years and 10-19 years, respectively—was higher than in younger and middle-aged adults—4.9%-6.1% for adults aged 20-29 years, 30-39 years, and 40-49 years. Individuals aged 0-39 years exhibited lower risk of severe COVID-19 than adults aged 40 years and older.

TURKEY SENDS SUPPLIES TO UNITED STATES Turkey sent a military cargo plane loaded with personal protective equipment and other supplies to support the US COVID-19 response. The shipment included 500,000 surgical masks; more than 500 gallons of disinfectant; 400 N95 respirators; and 500 face shields, among other supplies. Turkey’s COVID-19 epidemic has been on the decline since early April, and the Turkish government has sent similar shipments to at least 55 countries. Distribution of the supplies in the United States will be coordinated by the Federal Emergency Management Agency.

KEVZARA A number of drugs that are traditionally used to combat autoimmune diseases are being evaluated as potential treatment options for COVID-19. Because “cytokine storm” (an overwhelming immune response so severe that it damages the body) is believed to contribute to acute respiratory failure and death, these drugs are being evaluated as a potential mechanism to modulate the body’s immune response. The drug Kevzara (sarilumab) is a monoclonal antibody that is typically used to treat rheumatoid arthritis. A randomized control trial of the drug was reportedly terminated after enrolling 276 patients, because it did not demonstrate efficacy in treating “severe” COVID-19 patients (requiring low-flow oxygen). A study will continue in “critical” COVID-19 patients (requiring high-flow oxygen or mechanical ventilation), as preliminary data demonstrated a potential benefit for patients who received a high dose of the drug. Additional data is required to characterize Kevzara’s efficacy in these patients.