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February 14, 2020

EPI UPDATE China’s National Health Commission reports a total of 63,851 cases of COVID-19, including 1,380 deaths. A total of 6,723 patients in China have been discharged, and an additional 10,109 suspect cases remain. The NHC also reported 53 cases in Hong Kong, 10 in Macau, and 18 in Taiwan.

Notably, the NHC report indicates that 108 deaths were removed from the total as a result of accidentally counting these deaths twice in Hubei Province, which would decrease yesterday’s new reported deaths from 254 to 146—more in line with expected values. Additionally, the NHC reports that 1,043 cases in Hubei Province were removed after “verification.” Presumably, this refers to cases that were initially reported in the new “Clinical diagnosis” category and were removed after negative diagnostic tests. As noted in yesterday’s COVID-19 briefing, we expect that some (or many) of the “Clinical diagnosis” cases will be removed as they receive negative tests, so this is not unexpected.

WHO SITUATION REPORT The WHO Situation Report for February 13 reports 447 total cases across 24 countries outside China, including 6 new cases and 1 death; the death total does not include the reported death in Japan from yesterday. Considering the comments by Japan’s Minister of Health, Dr. Katsunobu Kato, emphasizing that the cause of death had not yet been determined , Japan may be awaiting confirmation that the death was attributable to COVID-19 before reporting it. No new countries reported COVID-19 cases, and the regional and global risk remains “high.” The WHO situation report also addresses the sharp increase in cases reported in Hubei Province yesterday, noting that the reporting criteria changed to include clinical diagnosis in Hubei Province. The WHO will continue to report only laboratory-confirmed cases to remain consistent with previous reports.

The situation report also includes an analysis of the COVID-19 cases reported outside China. Of the 447 cases, 170 have recent travel to China, and the “vast majority” of these (89%) are not known to have resulted in secondary transmission. Secondary COVID-19 cases have been linked to the other 19 cases. The report includes a brief overview of the secondary transmission associated with 4 of these cases (each linked to 9 or more secondary cases). 16 of the reported cases in 4 countries outside China have no known travel history or epidemiological link to other known cases, and investigations are ongoing to determine their source of exposure.

INTERNATIONAL UPDATES Japan’s Ministry of Health confirmed the country’s 38th case of COVID-19, up from 28 as of our briefing yesterday. Additionally, at least 174 individuals have tested positive for SARS-CoV-2 infection onboard the Diamond Princess cruise ship currently quarantined in Yokohama. These cases are in addition to the 38 cases reported by Japan’s MOH, which is the largest outbreak outside mainland China.

The US CDC confirmed the United States’ 15th COVID-19 case in an individual who was under federal quarantine at a military installation in Texas. The individual was part of a group of Americans that were repatriated from Wuhan, China, on a US State Department charter flight on February 7. All individuals on the flight remain under quarantine. US CDC officials emphasized that they expect to identify additional cases of COVID-19 in the United States, including among those that have recently returned from Wuhan. There is no reported evidence of transmission at the federal quarantine facilities at this time.

CHINA RESPONSE Provinces outside of Hubei continue to send healthcare personnel to support COIV-19 response activities. Shanxi Province recently deployed its 7th team to Hubei. The most recent team consists of 110 total personnel, adding to the nearly 700 personnel who have already deployed from Shanxi to assist.

China CDC published updated guidance on the use of ventilation and air-conditioning systems in offices and public spaces during the COVID-19 epidemic. The updated guidance emphasizes the circulation of fresh air from outside, rather than the recirculation of air from inside the structure. For systems that are unable to draw fresh air directly from outdoors (eg, window air-conditioning units), the guidance instructs users to open other windows and doors to allow fresh air to circulate inside the structure. For shopping malls, office buildings, and other locations with large numbers of people, ventilation should run continuously, even if air-conditioning is not used, and the ventilation should run for at least 1 hour after the building is empty. Doors and windows should be opened in densely populated areas to increase ventilation, and workers should wear masks for increased protection. If suspect or confirmed cases of COVID-19 are detected, the ventilation should be secured/stopped, and the system should be cleaned and inspected before resuming operation.

CRUISE SHIPS Passengers and crew of the Holland America cruise ship Westerdam that had been denied entry to multiple ports over concerns about SARS-CoV-2 were finally able to disembark the ship. The ship pulled into port in Sihanoukville, Cambodia, and passengers were allowed to depart the ship after screening. Health screenings took place while the ship was anchored , before pulling into port and mooring pierside on Thursday. Samples taken from the ship were processed at the Pasteur Laboratory in Phnom Penh, and all returned negative results for SARS-CoV-2. Despite having no identified cases of COVID-19 onboard, the ship had been denied entry to multiple countries, including Japan, the Philippines, Taiwan, Thailand, and the United States (Guam) over concerns about the disease. The ship had been underway since departing Hong Kong on February 1. Cambodian Prime Minister Hun Sen personally greeted passengers as they disembarked the ship.

Japan’s MOH announced that it has distributed smartphones to the passengers and crew onboard the Diamond Princess cruise ship, which remains quarantined due to concerns about cases of COVID-19 onboard. The phones include an app with the ability to request medications from an onboard pharmacist, chat with a nurse or psychologist, and schedule an appointment with a doctor as well as a Frequently Asked Questions (FAQs) page. As of February 12, 174 of the 492 people tested onboard were positive for SARS-CoV-2 infection. Japan is permitting some of the quarantined passengers to disembark the ship and be quarantined in a shoreside facility. The priority passengers over 80 years old as well as those with pre-existing health conditions that could place them at elevated risk of severe disease. Reportedly, older individuals—60 years and older— comprise approximately 80% of those onboard , including 216 people 80 years and older. These individuals will be tested for infection before being allowed to disembark, and anyone testing positive will be transported to a local healthcare facility for treatment and isolation.

CORONAVIRUS RESEARCH & PUBLICATIONS Public health law experts Larry Goston and James Hodge published a commentary in the Journal of the American Medical Association on recent measures taken by the US government, including the public health emergency declaration, travel warnings and restrictions, and mass quarantine through the lens of balancing public health benefit against civil liberties.

COVID IMAGING Radiologists from Wuhan, China published findings from a study on the progression of COVID-19 pneumonia based on a retrospective review of patient CT scans. The study involved 82 CT scans across 21 patients identified between January 12 and February 6. Patients with severe respiratory distress and those requiring oxygen were excluded from the study. Patients were hospitalized for a mean of 17 days (range: 11-26 days), and “maximum lung involved peaked at approximately 10 days” based on CT score. The study identified 4 distinct phases of disease, with peak in Phase 3. Descriptions and timeline of the phases are included in the article.

US INVESTIGATION US CDC officials published an overview of individuals evaluated for SARS-CoV-2 (then referred to as 2019-nCoV) infection in the United States in January. In total, the CDC responded to “inquiries regarding approximately 650 persons” in January 2020. Of these individuals, testing was conducted for 210 persons under investigation (PUIs). Among these PUIs, 6 were identified at airport screening, 178 were identified in healthcare settings, and 26 were identified through contact tracing efforts for other cases. All 210 PUIs were symptomatic—143 had a fever, and 189 had respiratory symptoms. Thirty of the PUIs tested positive for another viral respiratory pathogen (eg, influenza, respiratory syncytial virus). Forty-two of PUIs were hospitalized, including 2 that were admitted to an intensive care unit. Travel-related risk was identified for 148 PUIs, and 42 PUIs had close contact with laboratory-confirmed cases or other PUIs. In total, 11 of the PUIs tested positive for SARS-CoV-2 infection, 9 of which had traveled to Wuhan, China. The other 2 had close contact with laboratory-confirmed cases in the United States.

EFFECTIVENESS OF MOVEMENT RESTRICTIONS Researchers from Dalian, China; Hong Kong; Texas and Santa Fe (USA); and Institut Pasteur (France) published a commentary in the journal Emerging Infectious Diseases containing preliminary results from an effort to model the risk of transmission to cities in China before quarantine/ cordon sanitaire were established around Wuhan and other cities in Hubei Province. Based on epidemiological data from early in the Wuhan outbreak and transmission network data during the Lunar New Year holiday, they estimated the risk of SARS-CoV-2 introduction for cities across China. Based on their model, they identified 130 cities in China with at least a 50% chance of introduction before the quarantine/ cordon sanitaire was established on Wuhan. By January 26, 107 of these 130 cities had reported cases, providing some validation of the model’s results. Of the remaining cities, 5 were estimated to have greater than 99% probability of importation and populations exceeding 2 million people: Bazhong, Fushun, Laibin, Ziyang, and Chuxiong.