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February 13, 2020

EPI UPDATE  China’s National Health Commission reported a total of 59,804 cases of COVID-19, including 1,367 deaths. A total of 5,911 patients have been discharged, and an additional 13,435 suspect cases remain. The new total incidence is a notable increase compared to other recent reports. On Friday, February 6, the NHC published updated guidance for reporting cases , which added a new category for “Clinical diagnosis” for Hubei Province only. The extent to which this change is responsible for the increased daily incidence is not wholly clear at this time, but Hubei Province reported 14,840 new cases (including 13,436 in Wuhan) on February 12, representing nearly 98% of the newly reported cases nationwide.

The addition of a “Clinical diagnosis” category could potentially mitigate reporting delays in Hubei Province that result from limitations in testing capacity, but it adds additional complexity to tracking the epidemic. For example, it is unclear when these new cases were identified, as it is possible that some (or many) of these cases were identified in recent days and simply did not yet have confirmatory diagnostic tests. Additionally, some (or many) individuals in the “Clinical diagnosis” category could be removed if SARS-CoV-2 diagnostic tests are negative or if other diagnoses (eg, influenza) are confirmed. Further, we understand that patient recovery and discharge in China requires a negative laboratory diagnostic test, and it is unclear if limitations in testing capacity will impact the determination or reporting of discharged “Clinical diagnosis” patients in future reports. This situation will merit close monitoring in the coming days and weeks.

The WHO Situation Report for February 12 reports 441 total confirmed COVID-19 cases outside of China, including 46 newly reported cases and 1 death. No new countries reported cases of COVID-19. The WHO activated a Crisis Management Team (CMT) to coordinate response activities, led by Dr. Mike Ryan, Director of WHO’s Health Emergencies Programme. The CMT includes the WHO, UN Office for the Coordination of Humanitarian Affairs (OCHA), International Maritime Organization (IMO), UN Children’s Fund (UNICEF), International Civilian Aviation Organization (ICAO), World Food Programme (WFP), Food and Agricultural Organization (FAO), World Bank, and “several departments of the UN Secretariat.”

The US CDC confirmed the 14 th COVID-19 case in the United States. The individual is part of a group that recently returned from Wuhan on a flight chartered by the US State Department . All individuals on the flight are currently under federal quarantine at Marine Corps Air Station Miramar in California. US CDC officials report that there is no indication of person-to-person transmission at the quarantine facility.

The Japanese Ministry of Health reportedly confirmed the country’s first death in a COVID-19 patient. At a press conference held late last night, Japan’s Minister of Health, Katsunobu Kato, indicated that the victim was a woman in her 80s who lived in Kanagawa Prefecture, outside Tokyo. He emphasized that it is unclear at this time whether the death is attributable to COVID-19. This is the third death outside China—Hong Kong and the Philippines previously reported deaths—and it is not included in the most recent WHO Situation Report. We have not yet found an official announcement from Japan’s MOH; however, Japan did announce the country’s 27th and 28th cases of COVID-19 this morning.

The Singapore Ministry of Health reported 8 new confirmed cases of COVID-19, bringing the country’s total to 58. None of the newly reported cases have a reported travel history to China, and Singapore health officials identified epidemiological links for all new cases to previously identified COVID-19 patients. The Singapore MOH also provided additional details on epidemiological links for a number of previously identified cases. Singapore has identified several clusters of COVID-19 cases, including 2 clusters associated with churches (5 and 7 cases, respectively), a Chinese medicine clinic (9 cases), a hotel (3 cases), and a construction site (4 cases).

PROBLEMS WITH US TEST KITS The US CDC announced that some states reported issues with the SARS-CoV-2 test kits they received. The issues were identified during normal quality assurance procedures at the state laboratories, and the CDC is working to identify which states can continue using the test kits and which states need replacement supplies. The issue appears to be with the reagents used during the test, which resulted in inconclusive results in the affected states.

COVID-19 RESEARCH PRIORITIES The WHO, in partnership with the Global Research Collaboration for Infectious Disease Preparedness, convened major research funders and more than 300 scientists and researchers from around the world to discuss research priorities for COVID-19/SARS-CoV-2 . The meeting is taking place over 2 days, and the participants will determine which research topics are most necessary to support the response to the emerging epidemic. Potential topics include the virus’ history, transmission (including effective infection control practices), epidemiology, and diagnosis; animal and environmental research; COVID-19 clinical presentation and treatment; novel therapeutics and vaccines; and ethical considerations in research. The findings from this meeting will inform a forthcoming research roadmap, which will aim to guide future research on the SARS-CoV-2 virus and COVID-19 disease and make efficient use of available research funding.

INTRAUTERINE TRANSMISSION RISK After reports last week of SARS-CoV-2 infection in a newborn infant, a new study published in The Lancet aimed to characterize the possibility of intrauterine vertical transmission (ie, from mother to fetus during pregnancy). The study evaluated medical records, including laboratory results, for 9 pregnant women with laboratory-confirmed COVID-19 pneumonia and SARS-CoV-2 infection. The patients were all treated at Zhongnan Hospital in Wuhan, China from January 20-31. Amniotic fluid, cord blood, and breast milk from the mothers were tested for the presence of SARS-CoV-2 as well as neonatal throat swabs from the newborns. All collected specimens were negative for SARS-CoV-2, suggesting that there is “currently no evidence for intrauterine infection” in pregnant women who develop COVID-19 pneumonia late in their pregnancy.

SARS-CoV-2 PRESENCE IN SALIVA Researchers in Hong Kong published results of a study in the journal Clinical Infectious Diseases that demonstrates the consistent presence of SARS-CoV-2 in patients’ saliva. In the study, researchers analyzed self-collected saliva specimens from laboratory-confirmed COVID-19 patients and performed viral culture to identify the presence of SARS-CoV-2. The patients were asked to “cough out saliva into a sterile container” to obtain the specimens, obtained at a median of 2 days after hospitalization (range 0-7 days). The viral culture was performed in a BSL-3 laboratory. Of the 12 participating patients, SARS-CoV-2 was detected in 11 saliva samples (91.7%). The only patient with a negative test provided the sample on the day of admission to the hospital (ie, day 0). Current diagnostic tests require specimens to be taken from the upper respiratory tract (eg, by nasopharyngeal or oropharyngeal swabs). These procedures are relatively invasive and require close contact between patients and healthcare workers, which can present risk of transmission. Conversely, saliva samples can be provided by patients without the increased transmission risk. This study demonstrates relatively consistent presence of SARS-CoV-2 in patients’ saliva, which suggests the possibility of developing less-invasive testing procedures that could reduce the risk of nosocomial transmission of SARS-CoV-2.

TAIWAN COVID-19 CASE REPORTS Clinicians in Taiwan published a brief case report for 2 COVID-19 cases as a Letter to the Editor in The New England Journal of Medicine . The first patient was a 52-year-old woman who returned from Wuhan to Taiwan on January 20, and the second patient was her 50-year-old husband who had no relevant travel history. Both patients sought care on January 25, and it is believed that the woman transmitted the infection to her husband shortly after her arrival in Taiwan. The case report provides details on the disease progression and course of treatment for both patients.

THE WHO COMBATS MISINFORMATION WHO Director-General Dr. Tedros Adhanom Ghebreyesus and Dr. Alex Ng, member of the WHO’s Digital Health Technical Advisory Group, published an op-ed in the South China Morning Post to address challenges posed by misinformation in the midst of the COVID-19/SARS-Cov-2 epidemic response. They note that “this ‘infodemic’ is hindering efforts to contain the outbreak [and] spreading unnecessary panic and confusion.” In addition to publishing updates via the WHO’s website and social media accounts—including in multiple languages—the WHO is also partnering with major companies around the world to spread positive, accurate information. For example, Google is prioritizing WHO information in search results and branding YouTube videos about SARS-CoV-2 or COVID-19 with a banner directing viewers to the WHO website. Misinformation is not limited to the ongoing coronavirus epidemic, however, and other health events and topics, including polio eradication and rising vaccine hesitancy, are facing similar threats. Drs. Tedros and Ng call on governments and tech companies alike to do their part to combat the deliberate spread of misinformation (ie, disinformation). And they call on everyone to be vigilant and responsible when sharing information about health emergencies and other topics to ensure that it is accurate and reliable.