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

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April 30, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 29 reports 3.02 million confirmed cases (66,276 new) and 207,973 deaths (5,376 new) worldwide. The Situation Report includes a link to a document highlighting the need to proactively consider the growing need for physical therapy and rehabilitation services for COVID-19 survivors.

Russia reported 106,498 confirmed cases (7,099 new) and 1,073 deaths (101 new). The daily incidence is noticeably more than in other recent updates , which have hovered around 6,000 new cases per day.

India reported 1,823 new cases, its second consecutive day with more than 1,800 new cases, which could signal a continued acceleration of India’s epidemic. Pakistan reported 874 new cases, the second consecutive day of setting a new high for daily incidence.

Singapore reported 528 new COVID-19 cases, 488 (92.4%) of whom are residents of dormitories. Migrant workers living in these dormitory facilities continue to drive Singapore’s accelerating COVID-19 epidemic; however, community transmission outside of these facilities remains low (9 new community cases reported). Indonesia reported 347 new cases. Indonesia’s daily incidence has fluctuated considerably over the past week, but the daily values have largely remained between 250 and 450 new cases per day since the middle of April. Bangladesh reported 564 new cases, its second highest daily total. Bangladesh has reported its 3 highest daily incidence over the past 3 days.

New York state reported a nearly 50% increase in cases from the previous day (4,585 new cases compared to 3,110), and New York City reported a 35% increase over the previous day (2,503 new cases compared to 1,849). This ended a streak of 3 consecutive days with decreasing daily incidence for both the city and state Notably, the percent of tests that are positive has decreased substantially compared to earlier in the epidemic. At the peak of New York City’s daily incidence (7,837 new cases on April 14), 48% of tests were positive, whereas only 18% were positive in the most recent data. Similarly, New York state reported 43% of tests positive at its peak on April 14 and only 17% positive according to the most recent data.

We are continuing to monitor COVID-19 incidence trends in states that have started easing social distancing measures; however, it could be several weeks before any effects begin to emerge in reported data.

The US CDC reported 1,005,147 total cases (23,901 new) and 57,505 deaths (2,247 new). Overall, daily incidence in the US has remained relatively steady since early April, but recent fluctuations make it difficult to forecast any longer-term trend. The past 2 days represent the 2 lowest daily incidence since the end of March (excluding reporting issues on April 3-5); however, daily incidence for the 4 days before that were elevated. In total, 11 states reported more than 25,000 cases (no change), including New York with more than 200,000; New Jersey more than 100,000; and Massachusetts more than 50,000. Additionally, 35 states (increase of 1), plus Guam, are reporting widespread community transmission.

The Johns Hopkins CSSE dashboard is reporting 1.05 million US cases and 61,288 deaths as of 12:30pm on April 30.

REMDESIVIR TRIALS Several news items regarding the antiviral drug remdesivir were released over the past day. Yesterday, Gilead Sciences , the manufacturer of remdesivir, issued a press release that included some results from a Phase III clinical trial comparing the efficacy of 5-day and 10-day treatment courses of the drug. The press release said that patients given the 5-day course had similar time to recovery as those treated with the 10-day course. Gilead also noted that the results “complement” forthcoming results from a placebo-controlled trial conducted by the National Institute for Allergy and Infectious Diseases (NIAID). If 5-day treatment courses have similar efficacy to 10-day courses, it could increase the number of patients able to be treated with the drug; however, the press release did not provide any information regarding whether remdesivir improved patient outcomes compared to a control group—e.g., with respect to the time to recovery or disease severity or mortality. The results of this study have not yet been peer reviewed, but Gilead indicated that it intends to submit them for publication in the near future.

Following the Gilead announcement, NIAID issued a press release regarding the results of the study alluded to by Gilead. The interim results from the NIAID study—a randomized control trial involving more than 1,000 patients—find that patients treated with remdesivir had a shorter time to recovery than those who received a placebo (median of 11 days compared to 15 days; 28% improvement). Dr. Anthony Fauci described the reduction in time to recovery as “highly significant.” Additionally, the data suggest that remdesivir could also potentially improve survival. The mortality risk was found to be 8% in patients treated with remdesivir, compared to 11% in the control group; however, the results were not statistically significant. The study is ongoing, and the results have not been peer reviewed.

Additionally, another remdesivir study was published in The Lancet . This study, an RCT conducted in China, did not find a statistically significant improvement in patients treated with the antiviral. The median time to clinical improvement in the treatment group was 21 days, compared to 23 days in the control group; however, the results fell short of statistical significance. The mortality risk in both groups were approximately equal—14% in the treatment group, compared to 13% in the control group. This study aimed to recruit 325 patients but was only able to include 237.

Dr. Fauci commented that the NIAID results demonstrate that “remdesivir has a clear-cut, significant, positive effect in diminishing the time to recovery.” The NIAID study suggests that remdesivir could potentially reduce mortality, but additional data is needed to further clarify the drug’s effect from that perspective. Dr. Fauci indicated that the NIAID study’s findings are so striking that there is a “new standard of care” for COVID-19 patients. This is the first data-supported indication for a treatment for COVID-19. In light of the new evidence, the US FDA is expected to issue an Emergency Use Authorization (EUA) for remdesivir.

Gilead has reportedly increased production of remdesivir, from 5,000 treatment courses available in January to more than 50,000 courses available now. Prior to the COVID-19 pandemic, Gilead was “not actively manufacturing” the drug, but now that it has demonstrated some efficacy in treating COVID-19, a significant surge in production will be needed to meet growing global demand. Under its existing timeline, Gilead aims to produce 500,000 treatment courses by October and 1 million by December.

WHO COVID-19 GUIDANCE FOR CITIES The WHO published a set of recommendations for improving COVID-19 preparedness in cities and urban environments . This guidance aims to provide support for local decision-makers in cities and “other urban settlements” to improve capabilities and capacity to combat the COVID-19 pandemic. Urban areas, including “megacities,” often have conditions that facilitate rapid communicable disease transmission, including high population density and areas of substandard living conditions. Additionally, many cities have extensive public transit systems and/or serve as transportation hubs for regional or international travel. Beyond traditional recommendations—such as multisectoral collaboration, protecting vulnerable populations, and evidence-based policy decisions—the guidance also addresses 4 focus areas in the context of COVID-19 preparedness: (1) coordinated local plans to address unique issues, characteristics, and capacities of individual cities; (2) risk communication and education to promote compliance with recommended actions, using media that can effectively reach target audiences; (3) contextually and culturally appropriate approaches to public health, including social distancing, enhanced hygiene, and respiratory etiquette; and (4) adequate access to care for COVID-19 and other essential health services, including prevent services like vaccination. The document also includes an annex with more specific details, considerations, and recommendations under each focus area.

FEMA PROVIDING PPE FOR NURSING HOMES The US Federal Emergency Management Agency (FEMA) is reportedly preparing to provide critical personal protective equipment (PPE) to nursing homes across the country. We reported yesterday on the disproportionate impact in nursing homes and other long-term care facilities during the US COVID-19 epidemic. One of the major challenges for these facilities is obtaining necessary supply of PPE, including surgical masks and gloves. In March, the US Department of Health and Human Services Inspector General initiated a national review of emergency preparedness at long-term care facilities, explicitly citing increased risk for infectious diseases like COVID-19, among others. Additionally, the American Health Care Association and the National Center for Assisted Living have called for increased testing capacity and funding for long-term care facilities to support staffing and other resource needs during the COVID-19 response.

COVID-19 ECONOMIC IMPACT Experiences from countries such as Singapore and Spain have highlighted that the COVID-19 pandemic and associated social distancing measures will likely have dramatic and lasting impact on the global economy. In an annual address , Singapore Prime Minister Lee Hsien Loong discussed how workers and employers should anticipate longer-term wage and economic impacts, despite economic response measures implemented by the government.

Spain’s economy , which relies heavily on tourism, has also taken a significant hit. The national economy shrunk by 5.2% in the first quarter of 2020 (similar to the 4.8% contraction reported in the United States). Some businesses are now beginning to reopen, but many restrictions remain on how they are permitted to operate. Under a recently announced 4-phase plan , Spain hopes to have many of the restrictions removed by June, which could enable the country’s beaches to open this summer.

Low- and middle-income countries are particularly vulnerable to economic disruption from the pandemic, and experts anticipate that global poverty will increase for the first time since 1998 as low-wage and migrant workers lose precious income. In recent decades, there has been a substantial reduction in the global population in poverty, decreasing from 36% in 1990 to approximately 10% in 2016, with some of the largest gains in countries like India and Bangladesh. Experts worry that progress may be reversed as the pandemic continues.

This week, the United States Department of Labor announced that an additional 3.8 million new unemployment insurance claims were filed last week. The new data lowers the 4-week average; however, the national unemployment total and rate both set historical records for the previous week—17,992,000 individuals and 12.4%, respectively. In total, Americans have filed more than 30 million new unemployment claims over the past 6 weeks. In a recent poll conducted by NPR, PBS, and Marist , half of the respondents reported that someone in their household lost their job or had hours decreased, more than double the percentage from the poll conducted in March. Additionally, The New York Times reported that a number of changes and restrictions on unemployment benefits implemented by states over the past several years are posing challenges for individuals seeking support during the COVID-19 pandemic. Some of these efforts include requirements to apply in person and document efforts to find employment, which may not be feasible or realistic under the current social distancing restrictions. While these efforts potentially eased some of the financial strain on state unemployment programs, putting them in a better position now to provide unemployment funding, the restrictions may be barriers for the people now navigating the unemployment system.

MIGRATION IN LATIN AMERICA FUELS COVID-19 CONCERNS In Peru , the second hardest-hit Latin American country behind Brazil, there is reportedly a major increase in migration from urban areas like Lima, where the majority of Peru’s COVID-19 cases have been reported, to rural areas. These relocations raise concern about the risk of spreading the epidemic to rural areas, particularly those with poor public health and healthcare infrastructure. Despite being reporting the most cases and deaths among all Latin American countries (and ranking #11 globally , behind China), Brazil has largely resisted travel restrictions and aggressive social distancing measures. The growing epidemic in Brazil has sparked concerns that continued travel or business could fuel transmission in neighboring countries. Paraguay, for example, reportedly dug a trench along a key highway crossing the border with Brazil in an effort to discourage people from walking alongside the road and crossing the border into Paraguay. 

“REINFECTIONS” MAY HAVE BEEN FALSE POSITIVE TESTS According to South Korean media , national health experts reported that more than 260 COVID-19 patients who tested positive for SARS-CoV-2 shortly after recovering were likely false positive tests rather than reinfections. The false positive test results are believed to have resulted from the test detecting the RNA of virus fragments. The PCR tests used to detect nucleic acids from clinical samples cannot distinguish between virus that is viable and not viable. When reports emerged several weeks ago about recovered COVID-19 patients testing positive, it raised concerns that individuals could be reinfected soon after recovering. At that time, some experts, including Dr. Keiji Fukuda , Director of Hong Kong University's School of Public Health, suggested that it was more likely that the tests were detecting viral fragments than the recovered patients being immediately reinfected.

OPERATION WARP SPEED The US government is reportedly initiating an effort called “Operation Warp Speed” to speed the development and production of medical countermeasures against COVID-19, including vaccines. According to media reports, the program will provide liability protection and funding for vaccine developers to facilitate expanded research and development operations. It is unclear how much money will be allocated for this program, and it is unclear whether this program will be a consolidation of existing efforts—e.g., under the Biomedical Advanced Research and Development Authority —or an entirely new program. The goal of the program is reportedly to manufacture hundreds of millions of doses by the end of 2020, which would dramatically shorten the timeline normally associated with novel vaccine development. Operation Warp Speed has not been officially announced by the US government.