Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.
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March 13, 2020

Note: although we include case counts to help provide situational awareness to our readers, the numbers are constantly changing. Please refer to the WHO or the public health agencies of affected countries for the latest information.

EPI UPDATES  The WHO COVID-19 Situation Report shows a total of 125,048 confirmed cases (4,613 deaths) worldwide. There have been 6,729 new cases in the past 24 hours. French Polynesia, Turkey, Honduras, and Cote d’Ivoire have all reported their first COVID-19 cases in the last day. The Johns Hopkins Center for Systems Science and Engineering (CSSE) dashboard is reporting 137,066 cases and 3,337 total deaths as of noon today. Iran’s Ministry of Health reported 1,289 new cases of COVID-19 and 85 new deaths, bringing the total there to 11,364 cases and 514 deaths. The Italian Ministry of Health reported a total of 12,839 cases and 1,016 deaths. The Singapore Ministry of Health reported 200 total cases, of which 103 are currently hospitalized and 11 are in critical condition. Spain reported a total of 4,209 cases and 120 deaths . The US CDC reported a total of 1,215 cases and 36 deaths across 42 states and Washington, DC. Of those cases, 125 are travel-related, 102 are close contacts of known cases, and 988 are still under investigation.

The South Korean CDC reported a total of 7,979 confirmed COVID-19 cases, including 67 deaths. Epidemiological links have been identified for 79.8% of cases. The most recent report provides an updated breakdown of cases by region, sex, and age group, providing additional insight into the ongoing epidemic. Females represent 61.9% of cases but only 41.8% of deaths. The unadjusted case fatality ratio for individuals aged 80 years and older is 8.30% (21 deaths out of 253 cases), and it is 4.74% for those 70-79 years old and 1.42% for those 60-69 years old. For cases under the age of 60, the case fatality ratio is only 0.12%. Notably, there have been only 2 deaths below the age of 50, despite 4,712 confirmed cases. The epidemic in South Korea has been driven largely by the community around the Shincheonji religious group (4,780 cases; 59.9% of all cases).

REPORTS OF HEALTH SYSTEM BURDEN IN ITALY The New York Times reported that Italy’s health system has become rapidly overwhelmed in just 3 weeks, leading to severely limited availability for ventilators and necessitating difficult decisions regarding how ration medical care among patients. The rapid spread and increase in the number of severe cases prompted Italy to enforce radical social distancing measures and to strongly encourage other countries to rapidly implement these measures as well. As reported yesterday, Italy implemented strict quarantine measures nationwide, including closing many businesses . People will still be able to access public areas under certain conditions, but they are encouraged to remain at home and avoid non-essential gatherings. A pre-print recent report from faculty here at the Johns Hopkins Center for Health Security and collaborators also addresses the need for rapid implementation of social distancing measures to slow the spread of epidemic and mitigate health system burden. 

SINGAPORE ANNOUNCES NEW RESTRICTIONS Singapore recently expanded its travel restrictions to include visitors with travel history to Italy, France, Spain, and Germany in the last 14 days. These individuals will not be allowed entry or transit through the country, and those already in the country with travel history from those countries will receive stay-at-home notices. Singapore already had travel restrictions in place for China, Iran, and South Korea. 

US RESPONSE The US Senate will cancel the recess scheduled to begin today in order to remain in session to draft and debate legislation related to the US COVID-19 response. Senate Majority Leader Mitch McConnell was under pressure, including from fellow Republican Senators, to keep the Senate in session in order to finalize coronavirus legislation. The US House of Representatives and the White House are still negotiating a legislative package that aims to address economic and other effects of the COVID-19 epidemic in the United States. Reportedly, the bill is close to being finalized, with hopes that the House of Representatives could vote on it today. Key issues include free coronavirus testing, paid sick leave for COVID-19 patients, and increased support for states to address funding for unemployment and food assistance programs.

According to NPR , the Office of Personnel Management now requires agencies to incorporate telework into their continuity of operations plans, reversing a trend of scaling back telework infrastructure among government employees in recent years. 

ECONOMIC DECLINES CONTINUE TO BEAR MARKET NPR reported that recent wide-scale stock sell-offs have now led to the start of a “bear market,” which could potentially forecast an impending recession. The Dow Jones Industrial Average has dropped 28% since its high point on February 12. The South China Morning Post also reported similar declines in Asian financial markets.

US SCHOOL CLOSURES AND SOCIAL DISTANCING MEASURES Note: for the most up to date information about individual communities, please visit the relevant jurisdiction's website directly. Ohio Governor Mike Dewine announced that all K-12 schools will be closed through April 3, and the state banned all mass gatherings of more than 100 people. Michigan Governor Gretchen Whitmer also announced that all K-12 schools will be closed through April 5. Notably, Governor Whitmer also expanded access to telemedicine statewide, and she called for President Trump to initiate a special enrollment period for the ACA to ensure access to healthcare during the COVID-19 pandemic. Maryland Governor Larry Hogan announced closure of all schools through March 27 as well as a series of other response measures, including a ban on gatherings larger than 250 people, the closure of cruise ship terminal in Baltimore, and the activation of the Maryland National Guard to support the response. The announcement comes on the heels of Maryland detecting its first reported instance of community SARS-CoV-2 transmission . Washington, DC, public schools will be closed from March 16 - March 31. Spring Break for these schools has been rescheduled for March 17-23 (formerly scheduled for April), and students will participate in distance learning from March 24-31. Meals will be made available for all students during that period at designated schools throughout the District.

In addition to Ohio, Michigan, Maryland, and Washington, DC, several other states have closed schools in certain higher-risk areas. Washington Governor Jay Inslee ordered K-12 schools closed in King, Pierce, and Snohomish counties through April 24, affecting 600,000 students in high-risk areas. Schools in San Francisco and part of nearby Contra Costa County  in California are also closed, but the state has not mandated closures statewide. Pennsylvania Governor Tom Wolfe announced that schools in Montgomery County (13 reported cases) will be closed for 2 weeks. Pennsylvania is also mandating remote work for state employees, and the state is implementing a 10-day paid leave policy for individuals who cannot work remotely. The governors in Georgia and Kentucky both recommended that schools consider closing, but they did not mandate closures.

Many government agencies are recommending or mandating that people avoid crowded spaces and large gatherings, particularly if they are exhibiting COVID-19 symptoms, but this may be more difficult (or impossible) for individuals experiencing homelessness . In Washington, DC, the Department of Health Services (DHS) is coordinating with homeless shelters and local healthcare systems to provide support for these individuals who may need to undergo quarantine. DHS Director Laura Zeilinger said that individuals who seek care for symptoms would not be returned to shelters or other congregate settings. DHS is also providing additional assistance to increase access to hand sanitizer and improve hygiene and sanitation at shelters and locations where food is served.

Considering the elevated risk to older individuals , some adult long-term care facilities (e.g., nursing homes) are taking additional measures to protect their residents and patients. As seen in Seattle , nursing homes can be high-risk environments for spreading SARS-CoV-2 among a particularly vulnerable population. Nursing homes are beginning to screen and limit visitors in order to reduce their residents’ risk of exposure, and efforts are ongoing to increase the quality and effectiveness of disinfection and hygiene efforts to reduce the risk of transmitting within facilities. Concerns remain, however, about the toll of prolonged isolation from friends and family for residents of these facilities.

The NCAA announced yesterday that all remaining winter and spring sports championships, including the Men’s and Women’s basketball national championships (also known as March Madness), are cancelled due to concerns about coronavirus. The NHL announced yesterday that it is suspending the 2019-20 season indefinitely. Major League Baseball , Minor League Baseball , and Major League Soccer all announced a range of cancelations, restrictions, or suspensions in response to COVID-19 as well. Additionally, officials from the Boston Athletic Association and Boston Mayor Martin Walsh announced that the Boston Marathon will be postponed until September 14.

CLINICAL COURSE OF COVID-19 A study published on March 11 in The Lancet provides analysis of the progression of the COVID-19 disease in survivors and non-survivors. The study involved 191 hospitalized COVID-19 patients (54 deaths, 137 discharged) in Wuhan, China. Notably, the study describes the timing of various aspects of disease progression in hospitalized patients, including the time from first symptom onset to the onset of various symptoms/conditions, including dyspnoea, sepsis, and ARDS as well as their duration. The article also reports the time to and duration of ICU admission. The study found an increase in the odds of death with increased age, and the mean duration of viral shedding was 20 days from symptom onset in survivors and continuously until death in non-survivors (maximum duration: 37 days). The study found no evidence that antiviral treatment reduces the duration of viral shedding.

SPOUSE OF THE PM OF CANADA TESTED POSITIVE Prime Minister Justin Trudeau’s wife, Sophie Grégoire Trudeau , tested positive for SARS-CoV-2, according to a statement by the Prime Minister’s Office. At this time, her symptoms do not appear to be serious, and she will be self-isolating for at least 14 days. Prime Minister Trudeau will not be tested at this time because he is not exhibiting symptoms, but he will self-quarantine for 14 days as well. He does not expect this to affect his duties as Prime Minister. There are growing reports of political leaders from various countries becoming infected or exposed to COVID-19.