Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.
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March 19, 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 18 reported 191,127 confirmed COVID-19 cases and 7,807 deaths across 161 countries/territories/areas, an increase of 15,123 cases, 786 deaths, and 1 country from the previous day. The WHO also reports COVID-19 data by region: Western Pacific 91,845 cases and 3,357 deaths; Europe 74,760 cases and 3,352 deaths; South-East Asia 538 cases and 9 deaths; Eastern Mediterranean 18,060 cases and 1,010 deaths; Americas 4,979 cases and 68 deaths; Africa 233 cases and 4 deaths. It appears that much of the data from the Americas did not update, so it is likely that the cases will increase substantially in the next Situation Report. 
Correction: Yesterday, we mistakenly reported 873 deaths for both the Eastern Mediterranean and Americas regions. This was the correct value for Eastern Mediterranean, but the Americas should have been reported as 68 deaths.

We were unable to access the Iranian Ministry of Health website, but the WHO Situation Report reports 16,169 confirmed cases, including 988 deaths—1,178 new cases and 135 new deaths since Iran’s previous report. The Italian National Institute of Health’s reported 31,772 cases (3,479 new), including 2,898 healthcare workers (269 new), and 2,390 deaths (387 new) nationwide. Spain’s Ministry of Health reported 17,147 confirmed cases (3,431 new) and 767 deaths (169 new). Public Health France reported 9,134 confirmed cases and 244 deaths. Germany’s Robert Koch Institute reported to 8,198 confirmed cases (1,042 new) and 12 deaths. The South Korean CDC reported 8,565 confirmed COVID-19 cases (152 new), including 91 deaths (7 new). Pakistan’s Ministry of National Health Services reported 302 confirmed cases (61 new), including its first 2 deaths. Canada reported 690 confirmed cases (121 new; 21.2% increase), including 1 death.

WHO’s Africa Regional Office (AFRO) dashboard reports 357 confirmed cases in African Region countries and 635 cases across the entire continent (129 new). Most of the cases have been reported in Egypt (196), South Africa (116), and Algeria (72), but 34 countries across the continent have reported cases. AFRO also published its weekly External Situation Report . In the past week, 18 new countries have reported COVID-19 cases. Notably, the index case in every country in the African Region had recent travel, including to Europe, the United States, Japan, and Iran. Twelve countries have reported local transmission. The Situation Report also provides information on preparedness and response activities in Africa, including WHO training, building laboratory capacity, risk communication, and supply logistics (e.g., for personal protective equipment).

For the first time since the onset of the COVID-19 epidemic, China’s National Health Commission reported no new domestic cases. There were 34 new reported cases, but all were imported from other countries. China has reported a total of 80,928 confirmed cases, including 3,245 deaths (8 new). A total of 7,263 active cases remain, including 6,744 in Wuhan. Hong Kong reported 192 confirmed cases (25 new). Of the 25 newly reported cases , 22 had recent travel history outside Hong Kong. Hong Kong has previously reported 4 COVID-19 deaths. Taiwan CDC reported 108 total cases (8 new), including 29 domestic and 71 imported, and 1 death.

The US CDC reported 7,038 total (confirmed and presumptive) COVID-19 cases and 97 deaths across all 50 states as well as Washington, DC; Puerto Rico; Guam; and the US Virgin Islands. This represents a 66.5% increase in reported cases and a 29.3% increase in deaths from the previous day. Of these cases, only 545 have an identified source (travel-related or close contact of another identified case) and 6,493 cases (92.2%) are still under investigation. The Johns Hopkins CSSE dashboard is reporting a total of 9,415 COVID-19 cases and 150 deaths in the United States as of 7:30am on March 19.

The New York Times is compiling national-level COVID-19 incidence data to track the epidemic curves in real time.

US RESPONSE At a press conference yesterday, US President Donald Trump and senior officials from US government agencies announced a series of measures aimed to bolster the domestic COVID-19 response. Perhaps the biggest announcement was that President Trump is invoking the Defense Production Act in order to increase production of critical supplies and equipment to support the US COVID-19 response. The Defense Production Act enables the federal government to compel private companies to manufacture materials, supplies, and equipment during crises. In this instance, the Act will be used to increase the supply of personal protective equipment, such as masks, respirators, and gloves, and ventilators needed to treat COVID-19 patients. President Trump authorized Secretary of Health and Human Services Alex Azar to coordinate nationwide production and distribution of critical supplies, equipment, and services.

The White House also announced that the US Department of Defense would increase support for the domestic COVID-19 response. The increased support will include the deployment of hospital ships USNS Mercy and Comfort to provide additional hospital capacity for New York and California as well as field hospitals. The military will also distribute 2,000 ventilators and various personal protective equipment (including 5 million N95 masks) to hospitals nationwide. Also, the US Department of Defense will soon certify its 16th laboratory to perform SARS-CoV-2 testing, which will provide additional testing capacity to support the domestic response.

The Centers for Medicare and Medicaid Services (CMS) issued guidance that all elective surgeries and procedures, including medical and dental, be postponed nationwide. This recommendation aims to mitigate the burden on health systems due to increasing COVID-19 incidence and make necessary equipment, supplies (including personal protective equipment), and personnel available to treat these patients. Additionally, the guidance notes that dental procedures pose a high risk for transmission due to the close proximity of providers and patients. CMS presents a tiered framework for determining whether procedures should be performed.

President Trump signed the “ Families First Coronavirus Response Act ,” which will provide additional support for the domestic COVID-19 response. The bill includes provisions for establishing a federal emergency paid leave program for individuals unable to work as a result of the COVID-19, expanding state unemployment benefits, requiring employers to provide paid sick leave, providing SARS-CoV-2 diagnostic testing free of charge to consumers, and providing liability protection for “respiratory protective devices” used as part of the COVID-19 response. The bill is reportedly “phase 2” of US legislative efforts to bolster the response, and “phase 3”, which is currently estimated to total $1 trillion , will address an economic stimulus package proposed by the US Department of the Treasury.

US COVID-19 TRANSMISSION & SEVERITY The US CDC COVID-19 Response Team published preliminary data on the severity of COVID-19 cases in the United States. The study considers clinical data from the COVID-19 cases reported in the United States from February 12 through March 16. Of the 4,226 reported cases, patient age was recorded for 2,449. The data largely supports previous reports that older individuals are at elevated risk for severe disease and death; however, it does show that younger individuals are still at some risk for severe outcomes. More than 60% of the cases were reported between March 12 and March 16, so most have incomplete clinical data. Also, the US has largely limited testing to hospitalized patients, which could bias the data. While further data collection and analysis—including on pre-existing health conditions—is required to better characterize the disease, this provides some insight into COVID-19’s severity in US patients early in the epidemic.

Health officials in Washington state and at the US CDC published a study of a COVID-19 outbreak associated with a long-term care skilled nursing facility in King County, Washington. An epidemiologic investigation identified 129 COVID-19 cases among residents (81 cases), staff (34 cases), and visitors (14 cases), including 23 deaths. This outbreak illustrates that SARS-CoV-2 can spread rapidly through these types of facilities, including among older individuals and those with underlying health conditions as well as staff. The outbreak prompted health officials to investigate other long-term care facilities in King County, and the study identified several common risk factors among facilities reporting COVID-19 cases: staff members working while symptomatic, staff members working at multiple facilities, inadequate infection prevention practices (including supplies and usage of personal protective equipment), and delayed identification and reporting of cases.

INEQUITIES IN US SARS-CoV-2 TESTING Diagnostic testing for SARS-CoV-2 in the United States has been a recognized problem from the onset of the COVID-19 pandemic. As testing capacity and community transmission increase, so are reports on traditional and social media of high-profile public figures getting tested while others wait. A number of notable celebrities, including some without known exposure or symptoms, have reportedly been tested for SARS-CoV-2, but many clinicians and patients continue to lament the lack of sufficient testing capacity for suspected cases and high-risk patients. Prior to the Families First Coronavirus Response Act (discussed above), there was no guarantee that patients could receive the test free of charge, which could potentially further limit access to the test for low-income individuals. Even with expanded access to testing, some health systems are still limiting testing to patients who require hospitalization, and they are instructing patients with mild symptoms to self-isolate without testing in order to make the most efficient use of available capacity.

US MEMBERS OF CONGRESS TEST POSITIVE Reports are emerging about the first 2 reported cases of COVID-19 in members of US Congress . Representatives Mario Diaz-Balart (Florida) and Ben McAdams (Utah) both tested positive for SARS-CoV-2 after exhibiting symptoms. Both individuals are self-isolating at their homes, and multiple other members of Congress will reportedly self-quarantine due to having contact with them.

WHO LAUNCHES MULTINATIONAL TRIAL FOR COVID-19 TREATMENTS The WHO announced that it will soon launch a major trial of prospective COVID-19 treatments . The trial, referred to as the SOLIDARITY trial, will assess possible therapies to treat COVID-19 infections across at least 10 countries. Trial countries include Argentina, Bahrain, Canada, France, Iran, Norway, South Africa, Spain, Switzerland, and Thailand. Four trial arms consisting of drugs or combinations of drugs will be tested against a control arm consisting of standard supportive care. The trial arms will consist of remdesivir; a combination of lopinavir and ritonavir; lopinavir, ritonavir, and interferon-beta; and chloroquine. All 4 options have shown some evidence of effectiveness against SARS-CoV-2 in either in vitro or animal models. After the announcement, research was published that indicates studies in China that assessed lopinavir-ritonavir treatment combinations did not find strong results in the study population. 

GLOBAL SOCIAL DISTANCING Social distancing measures vary considerably by country, but their implementation has increased globally, including among countries and regions that have not yet reported many cases. Several African countries, including Sierra Leone, Uganda, Kenya, and South Africa, have instituted restrictions on movement and travel and other social distancing measures, including banning large gatherings. Ensuring compliance and feasibility of these measures can be challenging, especially as exceptions have been granted in some countries for some large gathers, including services and markets. Conveying the importance of these measures has been challenging in some African countries that have not yet reported many cases. At a press conference yesterday, WHO Director-General Tedros Adhanom Ghebreyesus called on Africa to “wake up” to the threat posed by COVID-19, despite the currently low number of reported cases. The WHO recommends avoiding mass gatherings to slow the spread of SARS-CoV-2.

The Indian government announced that no international flights will be allowed to land in the country for one week, and Prime Minister Narendra Modi urged teleworking nationwide and called for individuals under 10 years old or older than 65 to stay at home. Some areas of the country are restricting public transit and limiting the size of public gatherings (e.g., no more than 20 people). The Pakistani government also implemented a range of social distancing measures, including school and business closures, after a recent surge in reported cases. Religious gatherings will be permitted to continue; however, the government directed that their duration be shortened and that larger congregations be broken into smaller “shifts” to reduce the number of people gathering at once. Like many countries, regional governments are implementing their own social distancing measures, which may not match the national guidelines or other regions. Prime Minister Imran Khan acknowledged that widespread closures and social distancing measures in the country may not be feasible or practical to implement, especially for vulnerable populations. 

US ECONOMIC IMPACT The US stock market continues to fall rapidly, down approximately 30% from its high several weeks ago, raising questions about the prospect for a rebound. While the US economy appears to be in a much more stable position than it was when the Great Recession hit, a prolonged pandemic could make recovery more difficult, particularly if there are lingering health effects or continued social distancing efforts that limit the workforce or consumer spending.

In the United States, enhanced social distancing measures are could signal far-reaching effects beyond the directly affected populations. For example, the “shelter in place” order in the San Francisco Bay area has resulted in the shutdown of the Tesla car manufacturing plant in Fremont, California, which illustrates the potential for similar shutdowns if other cities implement similar measures. If factories and other production facilities are not prioritized as essential operations, even temporary shutdowns could have substantial impact on national and global supply chains. The world continues to struggle with the downstream supply chain disruptions due to large-scale quarantine efforts in China.

We reported yesterday that US Treasury Secretary Steven Mnuchin commented that unemployment in the United States could climb to 20% without rapid efforts to stimulate the economy. The United States is nowhere near that level yet, but there are reports that applications for unemployment across the country are climbing as workers are laid off or working significantly reduced hours due to social distancing efforts and other impacts of the COVID-19 pandemic. According to one report, states are seeing dramatic increases in applications. In Ohio, 78,000 people filed for unemployment in a 3-day period after Ohio instituted statewide social distancing measures, compared to only 6,500 for the entire previous week. The volume of applications in New York, New Jersey, and Oregon was so great that it crashed the states’ computer servers. The service industry, including restaurants, and tourism industry appear to be among the hardest hit as people increasingly avoid public spaces.

WHO CRITICIZES STIGMATIZING LANGUAGE At yesterday’s WHO COVID-19 press conference, a senior WHO official denounced the use of stigmatizing language and terminology with respect to COVID-19 and other diseases. Mike Ryan, Executive Director of the WHO’s Health Emergencies Programme, noted the importance of adhering to the accepted and appropriate terminology for infectious diseases in order to reduce the stigma and negative connotations for individuals and populations associated with slang terms. The comments follow recent pushback against the repeated use of unofficial and stigmatizing terms , including by US President Donald Trump. The official and accepted terms are SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) when referring to the virus or infection and COVID-19 (coronavirus disease 2019) when referring to the disease or symptoms. These terms were selected based on existing WHO guidance , which aims to reduce stigma associated with a particular place, group of people, animal, or others that was common under historical virus and disease naming practices that often referred to how or where they were first discovered.