Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.
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March 17, 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 UPDATE The WHO COVID-19 Situation Report for March 16 reported 167,511 confirmed COVID-19 cases and 6,606 deaths across 152 countries/territories/areas, an increase of 13,903 cases, 862 deaths, and 4 countries from the previous day. The Iranian Ministry of Health website is unavailable this morning, but the WHO reports 14,991 cases (2,262 new) and 853 deaths (245 new). The European CDC reported 61,098 cases across Europe, including 2,740 deaths. Spain’s Ministry of Health reported 11,178 confirmed cases and 491 deaths. The WHO Regional Office for Africa reported 417 confirmed cases and 7 deaths across 29 countries on the continent. The South Korea CDC reported 8,320 confirmed COVID-19 cases, including 81 deaths. China’s National Health Commission reported 21 new confirmed cases of COVID-19 and 13 new deaths nationwide, bringing the national total to 80,881 cases and 3,226 deaths. Notably, only 1 of the cases was the result of domestic transmission (in Wuhan), and the other 20 cases were imported. China’s NHC also reported 157 cases in Hong Kong, 11 in Macau, and 67 in Taiwan.

Italy’s National Institute of Health is publishing daily COVID-19 data updates. The March 16 update reports 25,058 cases—including 2,339 healthcare workers—and 1,697 deaths nationwide. The case fatality ratio for individuals 90 years and older is 21.6%, 18.8% 80-89 years, 11.8% for 70-79 years, and 3.2% for 60-69 years. The CFR is 1% for individuals 50-59 years and 0.3% or less for all younger age ranges. Notably, nearly 75% of reported cases are individuals over the age of 50, including 37.4% over the age of 70. Only 1.1% of cases have been reported in individuals 18 years and younger. Based on data from 8,802 of Italy's cases, 6.5% were reported as asymptomatic and a total of 58.8% had mild or very mild disease or no symptoms.

The US CDC reported 4,226 total (confirmed and presumptive) COVID-19 cases and 75 deaths across 49 states and Washington, DC; Puerto Rico, Guam, and the US Virgin Islands. This is more than double the 1,629 cases reported on Friday, March 13. Of these cases, only 474 have an identified source (travel-related or close contact of another identified case) and 3,752 cases (88.8%) are still under investigation. The Johns Hopkins CSSE dashboard is reporting a total of 5,204 COVID-19 cases and 92 deaths in the United States as of 12:15pm on March 17.

**March 16 Correction: Yesterday, we incorrectly reported that there were 6,507 COVID-19 deaths in the Europe/UK region. That number was reported by ECDC as the global total. The correct number of deaths in Europe/UK yesterday was 2,316.

US RESPONSE Yesterday, US President Trump announced a series of guidelines as part of a 15-day plan to slow the growing COVID-19 epidemic in the United States. In addition to existing guidance regarding improved hygiene, self-isolation for those that feel ill, and generally reducing public interaction, particularly for older and other high-risk individuals, the plan promotes more aggressive social distancing actions. The President recommended remote work and school “whenever possible”; using drive-thrus, takeout, or delivery instead of eating in restaurants and bars; avoiding “discretionary travel”; and not visiting nursing homes or other long-term care facilities where there are older, high-risk individuals. Perhaps the biggest policy change was the President’s recommendation to avoid social gatherings of more than 10 people. Many states have restrictions or recommendations in place for much larger gatherings (eg, 100 or 250 people), and this is significantly more restrictive than the existing CDC guidance, which lists 50 or 250 people (in various locations on the CDC website). The President’s guidance also recommends schools should be closed in and around areas with evidence of community transmission and that “bars, restaurants, food courts, gyms, and other indoor and outdoor venues where groups of people congregate” should be closed in states with evidence of community transmission.

The San Francisco Bay area in California instituted a “shelter in place” starting at 12:01am this morning in order to enforce enhanced social distancing measures. The shelter in place order was jointly issued by Health Officers in San Francisco, Marin, San Mateo, Santa Clara, Contra Costa, and Alameda Counties as well as the City of Berkeley, and it is currently scheduled to end on April 7 (3 weeks) unless otherwise extended or terminated early. The order directs residents of the San Francisco Bay area to remain in their homes, except for designated “essential activities,” and it aims to build on more traditional social distancing measures. The associated FAQ page emphasizes that provisions of the shelter in place order are mandatory, as opposed to previous voluntary social distancing measures, and that violations will be treated as misdemeanor criminal offenses. The order aims to “minimize social interactions,” but residents will be permitted to go out in public to buy groceries or other supplies, for medical or veterinary appointments, or even just to get some fresh air (as long as they remain 6 feet apart from each other). Those who perform designated essential functions in the community (e.g., healthcare workers and first responders, government agencies and postal service, grocery stores, gas stations) are permitted to continue working, and food delivery services will remain in operation. As of 10am on March 16, San Francisco had reported 40 cases of COVID-19 and zero deaths .

GERMANY RESPONSE German Chancellor Angela Merkel announced that Germany will implement “radical measures” in an effort to combat COVID-19. Non-essential shops, restaurants and bars, movie theaters, and other businesses will be closed , and domestic and international tourist travel will be restricted . Each of the 16 German states will determine when and how to implement these measures, but a government spokesperson indicated that the states were coordinating to implement a consistent approach nationwide.

WHO TECHNICAL MISSION TO IRAQ A technical mission from the WHO completed its visit to Iraq to support ongoing COVID-19 response activities. The visit prioritized establishing an Emergency Operations Center to support the national response response. Most cases reported in Iraq so far are linked to travel, particularly from Iran; however, there is growing concern about community transmission. In an effort to reduce infections, schools have been closed and public gatherings have been canceled. Iraq also announced new COVID-19 response measures , including a 1-week curfew for Baghdad, suspending flights for 1 week, and banning domestic travel between Iraqi provinces.

NIH CLINICAL VACCINE TRIAL A phase I trial has begun to investigate the safety and efficacy of the mRNA-1273 vaccine developed by the National Institutes of Allergy and Infectious Disease Clinical Research Consortium and Moderna, Inc. The vaccine has "shown promise" in animal trials, but this will be the first time is has been tested in humans. The trial ( NCT04283461 ) is a phase I open-label, dose-ranging study. It will enroll 45 healthy adult patients ages 18-55 at the Kaiser Permanente Washington Health Research Institute in Seattle. The study will evaluate both safety for varying doses of the vaccine as well as its ability to induce an immune response. The trial is estimated to be completed in June 2020. 

RESPONSE MEASURES IN AFRICA The WHO Regional Office for Africa has reported 417 COVID-19 cases across 29 countries on the continent of Africa. Several new countries confirmed their first cases of COVID-19: Liberia , Tanzania , and Eritrea . Liberia’s first case is the head of the country's Environmental Protection Agency, who tested positive after recent travel to Switzerland.

In an effort to prevent SARS-CoV-2 transmission, Ghana has instituted nationwide social distancing measures, including school closures, cancellation of all public gatherings (for the next 4 weeks), enhanced hygiene and sanitation in public spaces like restaurants and supermarkets, and enhanced hygiene for public transportation vehicles and terminals. Private funeral/burial services will be permitted, but no more than 25 people can attend. Ghana’s President Nana Addo Dankwa Akufo-Addo also emphasized the importance of scaling up domestic manufacturing and production capacity , including for products like masks and hand sanitizer, to ensure Ghana’s self-sufficiency during this and future responses. Also, the Ghana Health Service published a travel advisory , which discourages foreign travel to Ghana until further notice. Any foreign national arriving from a country that has reported more than 200 COVID-19 cases will not be permitted to enter Ghana. Those who are permitted to enter Ghana, including citizens or residents, will be required to undergo 14-day self-quarantine.

Similarly Kenyan President Uhuru Kenyatta announced that Kenya will suspend the entry of all travelers arriving from countries that have confirmed cases of COVID-19 for the next 30 days. Additionally, anyone who arrived in Kenya in the last 14 days must undergo quarantine. Schools and universities are also suspended nationwide, and businesses are directed to support remote work where possible. President Kenyatta also encouraged Kenyans to use credit cards and mobile pay to reduce the use of cash and to avoid gatherings, including religious services, weddings, and funerals.

BORDER CLOSURES IN SOUTH AND LATIN AMERICA Guatemala has reportedly closed its borders entirely to prevent further SARS-CoV-2 introduction and transmission. Guatemala’s President Alejandro Giammattei addressed the nation yesterday, stating that the country would “be cut off from the rest of the world.” The borders will be closed for 15 days. We have not yet identified official government information about the border closure there. Guatemala has reported 5 confirmed cases and 1 death .

Chile joins Guatemala in significantly restricting international travel. Chilean President Sebastián Piñera announced that Chile’s land and maritime borders will be closed to foreign nationals beginning on March 18, and Chilean citizens and permanent residents arriving from high-risk areas will be required to undergo mandatory 14-day quarantine upon arrival. The travel restrictions will not impact the import or export of goods, and the Chilean government emphasized that citizens do not need to stockpile supplies. At the time of the announcement, Chile had reported 155 cases of COVID-19. 

CIVIL DISRUPTION In Afghanistan, 38 individuals, including at least 1 confirmed COVID-19 case, reportedly escaped from a quarantine facility yesterday. The individuals were undergoing quarantine in the border province of Herat after arriving from neighboring Iran, where the COVID-19 epidemic is growing rapidly. In Sao Paulo, Brazil, hundreds of prisoners across 4 jails reportedly escaped after the state government rescinded temporary release over concerns that the inmates could become infected with SARS-CoV-2 and bring it back to the prisons. The Sao Paulo government has not confirmed the total number of escapees, but local media has estimated as many as 1,000 prisoners fled. The temporary release was originally scheduled for 34,000 prisoners.

NON-PHARMACEUTICAL INTERVENTIONS Researchers from Imperial College London published findings from a modeling study on the potential effects of several non-pharmaceutical interventions in the United Kingdom and United States . The researchers concluded that efforts to mitigate the effects of the COVID-19 epidemic in each country—defined here as slowing transmission to reduce the peak of the epidemic—would be expected to still result in hundreds of thousands of deaths and overwhelmed health systems. Subsequently, they argue that efforts to suppress the epidemics—defined here as lowering transmission to bring R0 less than 1—are necessary to ensure the continued functioning of health systems. These measures, however, would likely need to be implemented for 18 months or longer. The study considered multiple interventions, both alone and combination with others: case isolation at home, voluntary quarantine of those living with cases, social distancing for individuals over the age of 70, social distancing of the entire populations, and school closures. The model indicates that a combination of these measures would be sufficient to suppress the epidemic and preserve the health system, but the disease would be expected to “quickly rebound” after the interventions are lifted. In order to maintain their impact, the measures would essentially need to be maintained until a vaccine becomes available, which could be 18 months or longer.

PEDIATRIC COVID-19 PATIENTS Researchers from multiple medical and public health institutions in China published (pre-print) detailed epidemiological data from a cohort of pediatric COVID-19 patients . The study included 2,143 pediatric patients (731 confirmed and 1,412 suspected) from across China reported between January 16 and February 8, 2020. Among the 731 laboratory-confirmed infections, 94 (12.9%) were asymptomatic. Of the total cases, 1,185 (55.3%) were either asymptomatic infections or mild cases, and another 831 (38.8%) were moderate cases. Of the 125 severe or critical cases, 76 (60.8%) were 5 years or younger, including 41 (32%) under the age of 1. Because many of the cases were not confirmed via laboratory diagnostics, it is possible that they could have been suffering from other diseases with similar symptoms. This study suggests that children are generally at lower risk than adults for severe disease, but younger children may be at higher risk than other pediatric COVID-19 patients. The study does not provide data regarding the extent to which pediatric cases contribute to community transmission of SARS-CoV-2.

BLOOMBERG DONATES US$40 MILLION Bloomberg Philanthropies announced this morning that it will donate US$40 million to support preparedness and response activities in low- and middle-income countries, with a particular focus on African nations. The funding will be allocated to provide support for COVID-19 prevention and detection efforts, training for frontline healthcare workers, establishing laboratory networks and specimen transportation, evaluating community containment strategies such as school closures, and public communication as well as providing subject matter expertise to regional and international organizations. Bloomberg Philanthropies will partner with the WHO and Vital Strategies—including Resolve to Save Lives CEO and former US CDC Director, Dr. Tom Frieden—to implement these programs.