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

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April 8, 2020

EPI UPDATE The WHO COVID-19 Situation Report for April 7 reported 1,279,722 confirmed COVID-19 cases (68,766 new) and 72,614 deaths (5,020 new).

The Russian Ministry of Health reported a total of 8,672 cases (1,175 new), an increase of 16% since the previous day. Iran reported 64,586 confirmed cases of COVID-19 (1,997 new), including 3,993 deaths (121 new), continuing its slow decline in daily incidence. Pakistan reported 4,072 confirmed cases (208 new) and 58 deaths (4 new), considerably lower than the previous 2 days, which both exceeded 400 new cases.

After a week of decreasing daily COVID-19 incidence, Spain reported elevated numbers on consecutive days—5,478 new cases yesterday and 6,180 new cases today , bringing the national total to 146,690 cases and 14,555 deaths (757 new). Italy ’s decline in daily COVID-19 continues. From a hig h of 6,557 new cases on March 21 , Italy is down to 3,039 on April 7, its lowest daily total since March 13. Italy is reporting a total of 135,586 confirmed cases, and 17,127 deaths.

The US CDC reported 374,329 cases (43,438 new) and 12,064 deaths (3,154 new) on April 7. These are both a substantial increase over the previous day; however, it is potentially the result of delays in reporting over the weekend. As of yesterday, 14 states have reported more than 5,000 cases (1 new), and 30 states have reported widespread community transmission (1 new). The Johns Hopkins CSSE dashboard is reporting 401,166 US cases and 12,936 deaths as of 10:30am on April 8.

ALTERNATIVE MEDICAL CARE FACILITIES As cities around the country and around the world scramble to bolster health system capacity to handle existing or anticipated surge in COVID-19 patients, many are looking toward alternate medical care facilities like temporary hospitals to supplement existing capacity. Eric Toner and Richard Waldhorn, from the Johns Hopkins Center for Health Security, published a commentary to discuss recommendations for establishing and using these types of facilities. Alternate care sites can take many forms, including retrofitting existing facilities, utilizing available spaces such as gymnasiums or convention centers, or establishing field hospitals using tents. The authors recommend that communities across the country initiate efforts to establish them, including areas not yet severely affected by the growing US epidemic. Staffing these facilities will likely remain a challenge for many communities, which could factor heavily into decisions regarding the purpose of alternative care sites.

WHO MASK GUIDANCE The WHO published guidance for the use of face masks , including by the general public in the community. The guidance indicates that there is sufficient evidence that proper face mask use by infected individuals can reduce the risk of transmission for influenza-like illnesses, including coronaviruses. WHO recommends that individuals exhibiting COVID-19 symptoms wear a mask to reduce the amount of virus expelled into the environment. The WHO emphasizes, however, that there is no evidence that wearing a mask by healthy individuals in the community setting reduces their risk of SARS-CoV-2 infection. The guidance includes considerations for policymakers regarding universal mask use among the public, including the level of existing community transmission, population density, vulnerability of specific populations (e.g., older individuals, those with underlying health conditions), and the feasibility of implementing large-scale mask use (including mask availability). The WHO notes that universal mask use in community settings could potentially reduce the risk of transmission by “infected person[s] during the "pre-symptomatic’ period.” Potential risks exist as well, including self-contamination by touching a contaminated mask, increased risky activity due to a false sense of security, and the diversion of medical masks from healthcare workers.

FACE MASK POLICIES Mayor of Los Angeles Eric Garcetti issued an emergency order requiring employees working at business or organizations that are designated as “essential services”—as well as their customers—to wear face coverings to reduce SARS-CoV-2 transmission. Business owners are responsible for supplying masks for their employees. The order emphasizes this order does not refer to non-medical masks or respirators (which should be reserved for healthcare workers); rather, the coverings include cloth masks, scarves, or bandannas. Multiple other cities in California and elsewhere in the United States are also mandating mask use in the community. The US CDC guidance recommends mask use by the public, particularly when maintaining proper social distancing is not possible, but the CDC guidance emphasizes that the measure is voluntary.

Several countries and international cities have also issued mandatory orders for mask use by the general public. Austria is scheduled to be one of the first European countries to begin scaling back nationwide social distancing measures, permitting small non-essential businesses to resume operating on April 14 . The government will also expand existing requirements for mask use in supermarkets to businesses that reopen and public transit. In India, masks may be required in individual cities and states, including Mumbai . Additionally, the Indian state of Uttar Pradesh reportedly implemented a full "lockdown" for 15 highly affected districts . During the lockdown, residents are not permitted to leave their homes for any reason, and the government will deliver essential goods and services to the affected populations. The government will also require mask use across the state for all residents. A number of other countries and cities have reportedly implemented similar requirements for mask use.

ITALY COVID-19 PATIENT DATA  A study published in the Journal of the American Medical Association ( JAMA ) characterizes the clinical manifestations of COVID-19 in 1,591 patients admitted to an intensive care unit (ICU) in Lombardy, Italy. The patients’ SARS-CoV-2 infections were confirmed through real-time RT-PCR testing. The median age was 63, with higher mortality occurring in older patients compared to younger age groups. Among all patients, 68% had at least one underlying health condition, with nearly half carrying a diagnosis of hypertension. Other comorbidities included cardiovascular disease, hypercholesterolemia, and type II diabetes. Nearly every single patient (99%) required respiratory support of some nature, including 88% that required invasive mechanical ventilation. This study found a 26% mortality rate among individuals with known outcomes; however, 920 of the patients were still admitted to the ICU at the conclusion of the study, so this number could change. Notably, 82% of the patients were male, which is a higher proportion than what has been reported in previous studies. 

VENTILATOR AVAILABILITY & ALLOCATION As cities around the world face increasing COVID-19 patient surge at healthcare facilities, many are already struggling with a shortage of mechanical ventilators needed to treat the most severe patients. US cities, states, and hospitals are working to generate guidance and policies for how to allocate these scarce resources in the midst of the growing pandemic. A number of ethical principles and practical constraints factor into these difficult decisions, as there may not be enough ventilators to treat every patient who needs one. The policies prioritize different groups, including vulnerable patients and those at elevated risk for severe complications, frontline healthcare workers, and those most likely to survive. Each state, city, or hospital may ultimately identify and use different priorities, which could result in inconsistent allocation of ventilators among COVID-19 patients.

In addition to developing policies to allocate scarce ventilators, other efforts are ongoing to increase supply and mitigate some of the demand for ventilators among COVID-19 patients. According to a recent media report, some hospitals in New York are implementing plans to provide temporary respiratory support for patients by sharing a single ventilator for 2 patients . While not a permanent solution, it could potentially provide time to allow for the arrival of additional ventilators. An article by STAT News suggests that ventilators could be overused for COVID-19 patients. Some critical care physicians have suggested that some patients could be treated with “less intensive respiratory support” and that ventilator use may not be providing added benefit for some patients. If this is the case, other respiratory support options could free up additional ventilators for use by patients with more severe COVID-19 symptoms, making more efficient use of the available resources. Additionally, efforts are ongoing in the United States and around the world to scale up production of ventilators to increase the available inventory. The US government recently invoked the Defense Production Act in order to secure additional production from a number of companies, including General Motors (GM), and the US Department of Health and Human Services announced this morning that the government finalized a $500 million contract with GM to produce 30,000 ventilators to support the US response.

AIR TRAVEL As the volume of air travel continues to decline, airlines are taking additional actions to scale back operations. The US Transportation Security Administration (TSA) published updated information on air travel volume in the United States. The number of passengers screened at US airports has decreased considerably compared to this time last year. On March 1, passenger volume was approximately equal to 2019; however, a steady decline due to the COVID-19 pandemic has dropped the volume to only 4.6% of the 2019 daily total on April 7, at fewer than 100,000 passengers nationwide compared to more than 2 million in 2019. As we noted yesterday, major airlines are dramatically scaling back service, particularly to highly affected cities like New York, and aircraft manufacturers are suspending operations at major production facilities for commercial aircraft.

Lufthansa, the world’s third largest airline (and largest outside of the United States), announced major changes yesterday with respect to its current and future service. Forecasting a prolonged and slow recovery for the airline industry, Lufthansa announced that it will decommission 18 aircraft in anticipation of protracted decreases in travel demand and volume as well as temporary removal of an additional 11 aircraft from service. The airline will also remove aircraft from service in its subsidiary carriers Eurowings and Lufthansa Cityline, and it will discontinue service through its Germanwings carrier entirely. The airline indicated that it aims to retain as many affected employees as possible, but the restructuring aims to streamline Lufthansa’s operations to account for the long-term effects of the COVID-19 pandemic.

RACIAL DISPARITIES IN COVID-19 IMPACTS Over the past few days there has been increased recognition of disparities in COVID-19 impacts, with African Americans bearing a substantial burden of the deaths compared to other populations in the US. A similar phenomenon was observed during the 2009 H1N1 influenza pandemic , during which racial and ethnic minorities were disproportionately affected. In Chicago , African American residents have approximately a 6 times higher mortality rate than Caucasian residents. Additionally, 68% of COVID-19 deaths have been reported in African Americans, despite only representing 30% of the population. The distribution of cases and death from COVID-19 highlights differential access to resources and poignant inequities between communities. Affected communities in Chicago have higher rates of underlying health conditions including hypertension, diabetes, and lung disease such as asthma and chronic obstructive pulmonary disease, which could factor into the disproportionate COVID-19 impact. Additionally, individuals who live in high-density housing, use public transportation, and are employed in jobs that are not conducive to social distancing are likely at elevated risk. There is a need for actions to be taken to mitigate these impacts and identify appropriate protections to disproportionately affected populations. 

UNDERREPORTING COVID-19 DEATHS There is growing concern that the number of reported COVID-19 deaths is underestimating the scale and severity of the pandemic. We have previously reported challenges associated with reporting COVID-19 cases, in particular due to limited testing and a focus on the most severe cases. It has largely been assumed, however, that surveillance systems were accurately capturing COVID-19 deaths due to severe cases seeking care. Reports are emerging from around the world—including China , Ecuador , the United Kingdom , and the United States —that many potential COVID-19 patients may be dying without a proper diagnosis. In some cases, testing may not be available to test suspected cases after they die, and in others, patients may not be able to seek care due to overwhelmed local health systems. There are reports in many countries that patients are simply dying at home, and many of those victims may not be accounted for in the COVID-19 surveillance data. 

WUHAN ENDS LOCKDOWN Wuhan, China, the city where the novel coronavirus outbreak was first documented, lifted travel restrictions today, removing some of the most restrictive measures implemented during the city’s widely publicized “lockdown” that started more than 2 months ago. The city had been largely cut off from the outside world, stranding many individuals within its borders as health officials and clinicians scaled up response activities to contain the local COVID-19 epidemic. The intense social distancing measures largely confined individuals to their homes and placed significant restrictions on travel into or out of the city. The city was already in the process of slowly reopening local businesses and industry, but today, public transit resumed , as did rail service , flights , and automobile traffic , allowing individuals to exit the city. Despite relaxing the travel and movement restrictions, a number of social distancing and other public health interventions remain in place, including maintaining separation from others in public and routine fever screening. Additionally, travel is still restricted to individuals with a “ green code ,” which is assigned based on responses to a brief health survey through WeChat smartphone app used nationwide as a form of COVID-19 screening. Wuhan is one of the first major cities hit by COVID-19 to relax lockdown measures to this extent, and the situation will warrant close monitoring for increased SARS-CoV-2 transmission in the future.