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

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April 3, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 2 reported 896,450 confirmed COVID-19 cases (72,839 new) and 45,526 deaths (4,924 new) globally. If the recent trend continues, the official count could reach 1 million cases in the next 2 days and 50,000 deaths by tomorrow. The WHO Situation Report includes a link to recent guidance regarding the “growing number of falsified medical products that claim to prevent, detect, treat or cure COVID-19.” Yesterday’s COVID-19 briefing included mention of several of these types of products in the United States, but they are a global issue. The Situation Report also includes an overview of the WHO’s current understanding of SARS-CoV-2 transmission routes, including symptomatic and pre-symptomatic cases as well as asymptomatic infections.

The Russian Ministry of Health reported a total of 4,149 cases (601 new), an increase of 17% from the previous day and more than double the number reported on March 30. Iran reported 53,183 confirmed cases of COVID-19 (2,715 new), including 3,294 deaths (134 new). Iran’s COVID-19 reported incidence is growing steadily. Pakistan reported 2,450 confirmed cases on April 3 (159 new). Despite the growing epidemic in neighboring Iran and concerns about a major epidemic in Pakistan, the data do not yet indicate that is occurring.

Spain continues to report high daily incidence, with another 7,472 new cases reported today—32,515 new cases since March 31 . Spain is now reporting a total of 117,710 cases and 10,935 deaths, which overtakes Italy for the second most cases, behind only the United States. Italy’s recent decline in daily incidence continues, reporting only 4,668 new cases in the past 24 hours (115,242 total cases); however, Italy still remains as the country with the most deaths (13,915).

The US CDC reported 213,144 cases (27,043 new) and 4,513 deaths (910 new) on April 2, continuing its accelerating trajectory. Of these cases, fewer than 2% have an identified exposure—travel-related or close contact of a known case. As of yesterday, 10 states have reported more than 5,000 cases (2 new), and 26 states have reported widespread community transmission (1 new). The Johns Hopkins CSSE dashboard is reporting 245,658 US cases and 6,058 deaths as of 10:45am on April 3.

US CDC UPDATED GUIDANCE The US CDC published updated versions yesterday for a broad scope of COVID-19 guidance and information. More than 20 COVID-19 pages on the CDC website received updates, including interim guidance for collecting and processing clinical specimens , handling the bodies of deceased persons under investigation (PUIs) , operating schools and childcare centers , and infection control for COVID-19 patients . The CDC also published updated information for vulnerable populations, including individuals with asthma and pregnant women , as well as updated information on caring for COVID-19 patients at home .

Notably, the CDC updated its information regarding SARS-CoV-2 transmission. In the previous iteration of this information , the CDC noted that individuals not currently experiencing symptoms could potentially transmit the infection to others, citing anecdotal reports, but this was not thought to be a main driver of disease spread. The current guidance reflects growing evidence that transmission by asymptomatic individuals—including during the incubation period before symptoms present and by infected individuals that never develop symptoms—is possible, based on “recent studies” demonstrating this capability. Additionally, the updated information r emoves a previous reference to “affected geographic areas” and acknowledges widespread community transmission in the United States and states that SARS-CoV-2 is transmitting more readily than influenza.

The CDC also made substantial updates to guidance regarding how to optimize the supply of personal protective equipment (PPE). Previously , the page simply included links to guidance for individual types of PPE and other products, such as ventilators. The new site adds high-level recommendations for healthcare facilities regarding the current state of shortages for a broad scope of products. The CDC recommends that “all U.S. healthcare facilities should begin using PPE contingency strategies now” in recognition of ongoing shortages across the country. Additionally, the CDC notes that “healthcare facilities experiencing PPE shortages may need to consider crisis capacity strategies”—including reusing PPE and cancelling elective clinical services—and instructs healthcare facilities to develop these plans in advance, including identifying alternative approaches in the event that PPE is unavailable from commercial sources.

DEFENSE PRODUCTION ACT Yesterday, US President Donald Trump invoked the Defense Production Act (DPA) twice, in order to secure production respirators and mechanical ventilators to support the COVID-19 response. President Trump invoked the DPA to increase the production of mechanical ventilators from 6 companies and again to ensure the supply of N95 respirators from 3M . Since initially authorizing the use of the DPA in response to the COVID-19 pandemic, President Trump has invoked it sparingly, prompting criticism over his seeming reluctance to use the Act to increase the availability of critical supplies and equipment that are in short supply nationwide, control prices of supplies and equipment in high demand, and coordinate national allocation.

TEMPORARY HOSPITALS Reports continue about the construction of temporary hospital facilities across the country, including retrofitting existing buildings, such as the Javits Convention Center in New York, or field hospitals, such as the one established in Central Park. On the West Coast, the US Army is establishing a 250-bed field hospital in Seattle , at the CenturyLink Event Center. Like many similar facilities in the United States, this hospital is not intended to treat COVID-19 patients. Rather, it will provide care for other conditions in an effort to make additional capacity available in the local health system for COVID-19 patients. This was the initial plan for the Javits Convention Center facility, but this recently changed to permit the admission of COVID-19 patients . Similar provisions may be implemented at similar facilities in Louisiana and Texas.

Multiple media reports indicate that the hospital ships USNS Comfort and Mercy —currently providing support to the New York and California COVID-19 responses, respectively—have treated very few patients . According to one report, the Comfort has treated 20 patients and the Mercy has treated 15, as of yesterday afternoon. One of the principal challenges appears to be strict limitations regarding the patients that the ships can accept. In particular, it is being widely reported that there are 49 medical conditions, including COVID-19, that the hospital ships will not accept (however, we have been unable to locate the list of specific conditions). Additionally, patients cannot be brought directly to the ships, requiring preliminary evaluation, including SARS-CoV-2 testing, at a local hospital before they can be transported to the ship. As noted above, New York Governor Andrew Cuomo received permission from President Trump to allow COVID-19 patients to be admitted to the temporary hospital established at the Javits Convention Center, but the policy remains in place for the Comfort .

DEATHS IN ECUADOR Reports are emerging that Ecuador is struggling to handle the bodies of suspected COVID-19 victims in Guayaquil, the country’s largest city. Reportedly, citizens under restrictive social distancing measures have been unable to obtain care for family members sick with the disease, and the police have been assigned to retrieve the bodies of COVID-19 victims who die outside of hospitals. Delays in retrieving some of the bodies have reportedly led families to place them outside on the sidewalk and in the street while they await pickup. One Ecuadorian official commented that the police “went from taking away 30 deceased per day to 150” in just a 3-day period, on top of those handled by traditional means such as funeral homes. The Ecuadorian Ministry of Health reports 3,163 confirmed cases and only 120 deaths; however, multiple media reports indicate that Ecuador has struggled to increase testing capacity and that the official data likely underestimates the actual state of the epidemic.

SURGICAL MASKS A collaboration between researchers at the WHO Collaborating Center for Infectious Disease Epidemiology and Control at The University of Hong Kong, Hong Kong hospitals, and Harvard University studied the impact of surgical masks on the transmission of respiratory viruses, including coronaviruses, when used by symptomatic individuals. The study, published in Nature Medicine , found that surgical masks reduced the emission of droplets and aerosols exhaled by symptomatic patients. The masks resulted in a significant reduction in coronavirus detected in aerosols and a “trend toward reduced detection” for respiratory droplets (i.e., observed reduction, but not statistically significant). Conversely, the study found a significant reduction in influenza detected in respiratory droplets, but no significant reduction for aerosols. The coronavirus in this study was a “seasonal” coronavirus, as opposed to SARS-CoV-2, but it provides further support for guidance that encourages symptomatic individuals to wear masks to reduce transmission.

US AIRCRAFT CARRIER CAPTAIN FIRED We reported several days ago on the growing COVID-19 outbreak on the USS Theodore Roosevelt and Captain Brett Crozier’s letter to senior US Department of Defense leadership calling for additional support to ensure the health and safety of the 5,000 Sailors and Marines onboard. It was reported yesterday that the US Navy relieved Captain Crozier of his command as a result of the letter. The Defense Department is no longer publishing official COVID-19 data for individual units or commands; however, the outbreak was reported to be 114 cases yesterday , and the majority of the crew is scheduled to be disembarked from the ship this week. A smaller contingent will remain onboard to continue necessary operations.

EQUITABLE DISTRIBUTION OF A COVID-19 VACCINE As vaccine candidates are rapidly evaluated for SARS-CoV-2, determination of how vaccine supply can be equitably and effectively distributed when it becomes available will be critical to containing the COVID-19 pandemic. A report published in the Harvard Business Review —co-authored by Seth Berkley, CEO of Gavi , and senior faculty at Harvard Medical School—details the importance of properly allocating available vaccine, rather than based solely on the ability to pay for them. The authors argue that, considering the global impact and tremendous scale of the pandemic, it will be critical to allocate vaccine strategically to ensure the biggest impact, particularly early on, when there will be limited supply of vaccine available. Funding will be needed to ensure that the vaccine is accessible to lower-resourced settings, which will not be as readily able to purchase vaccine as wealthier countries. Additionally, allocation decisions should consider the protection of healthcare workers to ensure both continued care for COVID-19 patients and the conduct of vaccination operations worldwide. Additionally, displaced and mobile populations (eg, migrants, refugees) may be challenging to reach, as many do not have formal identification paperwork or fixed locations. Data and other technological solutions can provide situational awareness in areas where there is a lack of individual-level health data, and international coordination will be paramount to achieving global protection via a COVID-19 vaccine. 

US UNEMPLOYMENT We reported yesterday on US Department of Labor data that showed a dramatic increase in the number of unemployment claims filed nationwide. Today, the Labor Department published its monthly “ jobs report ” for March, which presents additional data regarding the recent increase in unemployment. Nationally, the number of jobs decreased by more than 700,000—a stark contrast to the 273,000 jobs gained in the February report —and the unemployment rate jumped from a 50-year low of 3.5% to 4.4%, the highest since 2017. The data included in this report only cover February 12 through March 12, which does not account for recent business closures and layoffs resulting from social distancing measures implemented over the past several weeks. Some estimates forecast that the national unemployment rate could exceed 10% in the near future.

UK “IMMUNITY PASSPORTS” Yesterday, the United Kingdom’s Minister of Health, Matt Hancock, outlined th e roadmap for the UK to move beyond the current restrictive social distancing measures . The plan includes 5 pillars: scale up diagnostic testing to 25,000 per day for government and hospital laboratories; increase access to commercial diagnostic testing for healthcare workers and other critical infrastructure; develop and deploy serological tests to identify past infections and immunity; improve surveillance to improve situational awareness and support vaccine and therapeutic development; and develop a nationwide mass testing capacity. The plan also includes an effort to utilize serological tests to identify those with immunity, which can allow them to return to normal activity. This status will reportedly be documented in “immunity passports” to demonstrate their status.

GOOGLE COMMUNITY MOBILITY PLATFORM Through the use of platforms such as Google Maps, Google has created aggregate mobility reports for a number of countries and regions around the world. These data enable the visualization of the changes in population movement over the course of the COVID-19 pandemic, which can provide insight into the role of social distancing efforts and other impacts of the pandemic on population movement. Google states that the data includes sufficient resolution to illustrate “the change in visits to places like grocery stores and parks.”