Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.
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March 20, 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 With the rapid global escalation in COVID-19 incidence, including the number of priority countries we track, the Epi Update section of our daily COVID-19 briefing has become too lengthy. We will continue to report the global totals from the WHO COVID-19 Situation Reports as well as the US totals reported by the CDC and the Johns Hopkins CSSE dashboard, but we will not be including case counts for all regions anymore. We recommend using Ministry of Health, Centers for Disease Control, or other national public health agency websites for the most current national-level COVID-19 incidence data.

The WHO COVID-19 Situation Report for March 19 reported 209,839 confirmed COVID-19 cases (16,556 new) and 8,778 deaths (828 new) across 168 countries/territories/areas (7 new).

The US CDC reported 10,442 total (confirmed and presumptive) COVID-19 cases and 150 deaths nationwide. This represents a 48.3% increase in reported cases and a 54.6% increase in deaths from the previous day. Of these cases, 94.3% do not yet have an identified exposure. The Johns Hopkins CSSE dashboard is reporting 14,250 US cases and 150 deaths as of 11:15am on March 20.

Notably, Italy has overtaken China with respect to the number of reported COVID-19 deaths. Yesterday, Italy reported a total of 3,405 deaths compared to 3,248 reported deaths in China ; however, China’s 80,967 cases remains the highest national total, and Italy is second with 33,190. Additionally, Spain reported more than 1,000 COVID-19 deaths .

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

US RESPONSE Yesterday afternoon, US President Donald Trump and members of the White House Coronavirus Task Force announced that the Federal Emergency Management Agency (FEMA) would be taking over as leader for the national COVID-19 response . FEMA is currently activated at Level 1 for the COVID-19 response, its highest level for a national emergency. Following the press briefing, President Trump and Vice President Pence held a teleconference at FEMA headquarters with governors from across the United States. During that call, the President re-emphasized FEMA’s new leadership role for the federal coronavirus response and urged governors to coordinate directly with their respective FEMA Regional Offices. The shift in response leadership away from the HHS has raised questions about the future of the US government’s response operations. Some have noted that high-profile and senior CDC officials have not been visible or available recently and that there have been contradictions between CDC and White House COVID-19 recommendations, including the maximum size of gatherings. Some experts argue that the CDC is the lead government agency for infectious disease response and that CDC officials need to provide information and guidance directly to the public. It is unclear at this point if or how the roles of the CDC, FEMA, and other government agencies will change in the coming weeks as FEMA takes the lead.

Yesterday, the US Senate unveiled an initial draft of a US$1 trillion economic stimulus package that aims to mitigate the financial impact of the COVID-19 pandemic on individuals, companies, and industries in the United States. This “phase 3” package includes US$300 million in loans to support small businesses, US$200 million for the most-affected industries (e.g., airlines), and direct payments to individuals. The direct payments could be on the order of $1,200 per person for adults, with additional smaller payments for children, and they aim to supplement lost income due to the pandemic. The current draft also proposes moving the income tax filing deadline from April to July. The proposal also reportedly includes provisions for additional healthcare resources and addressing student loans and business taxes. Negotiations between Republicans and Democrats are just getting underway, but there appears to be initial opposition to some of the bill’s provisions. The previous 2 legislative efforts to address the COVID-19 response have involved a good deal of bipartisan cooperation and support, so hopefully, that trend continues now and in the future.

CALIFORNIA “STAY AT HOME” ORDER Yesterday, California Governor Gavin Newsom issued a statewide “stay at home” order in response to the COVID-19 pandemic. The order, similar to the “shelter in place” order recently implemented in the San Francisco Bay area, directs all California residents to “stay home or at their place of residence,” except for essential tasks. The Governor’s priorities for issuing the order include ensuring the continuity of operations for essential infrastructure sectors , as outlined by the federal government, and protecting the health of high-risk individuals. California’s COVID-19 website provides additional clarification, noting that individuals will be permitted to leave their homes for things such as purchasing gasoline, shopping for food and other supplies (including farmers markets, food banks, and restaurant takeout/delivery), banking, or doing laundry. Additionally, essential state and local government functions will continue, including law enforcement.

DEFENSE PRODUCTION ACT US President Donald Trump confirmed at a press conference yesterday that no action has yet been taken under the Defense Production Act , which he enacted on Wednesday.He commented that the Act was invoked so that it would be available if it is needed, but the country is not yet to that point. On a subsequent call with state governors , multiple governors noted significant challenges accessing supplies, including personal protective equipment and testing kits (and reagents to conduct tests), which raises concerns that the country is already to the point at which the Defense Production Act could provide substantial benefit. There are also reports that sectors of the health system beyond direct clinical patient care are being affected as well, including pharmacists that prepare medication .

COLOMBIA BORDER CLOSURE Colombia announced that it will suspend all inbound international passenger air travel to the country for 30 days , beginning on March 23. Until that time, only Colombian citizens and permanent residents are permitted to enter the country, and all arriving travelers will be required to undergo a mandatory 14-day quarantine. Reportedly, Colombian President Ivan Duque indicated in a speech yesterday that the travel restrictions will apply to all travelers, including citizens and permanent residents , once they take effect. The complete suspension will aim to ensure the country can effectively implement the 14-day quarantines before admitting any more arriving travelers. Colombia recently deported 4 individuals as a result of their failure to comply with quarantine orders.

IRAN, PAKISTAN & AFGHANISTAN It is difficult to gain insight into the ongoing COVID-19 epidemic and response in Iran , but media reports paint a concerning picture. Reportedly, Iranian doctors have indicated that surveillance and reporting at the national level significantly underestimate the scale of the epidemic, and healthcare facilities may be rationing care for only the sickest patients. Additionally, Iran's neighbors Pakistan and Afghanistan are struggling to screen individuals crossing the border from Iran. A “quarantine camp” established in Pakistan appears to be ideal conditions for transmitting SARS-CoV-2 (e.g., poor hygiene conditions, densely populated). With low testing capacity at the camp, many of the cases associated with the camp —which represents more than half of all cases in Pakistan are only identified after they have been released to other parts of the country. A similar situation may exist in Afghanistan, where migrant workers and refugees are screened as they arrive from Iran. One health official acknowledged, however, that it was “inevitable” that infections will evade the screening and enter the country. The combination of struggling healthcare and public health systems, low testing capacity, and high population movement place this region at high risk for rapid spread of SARS-CoV-2.

SEROLOGICAL TESTING As diagnostic testing for SARS-CoV-2 infection ramps up in the United States, many questions remain regarding the number of cases and asymptomatic infections that are going undetected, both in the United States and around the world. The PCR tests currently used to diagnose COVID-19 patients are effective at identifying active infections by detecting virus currently present in the specimens, but they are not able to determine whether an individual was previously infected after the patient has recovered. For this, serological tests are needed. Serological tests identify the presence of antibodies, which were generated as a result of prior infection. A study published on March 18 (pre-print) describes the development and initial testing of an ELISA serological test by researchers at the Icahn School of Medicine at Mount Sinai, in collaboration with colleagues from multiple international institutions. Based on tests using human samples from both uninfected individuals and recovered COVID-19 patients, their preliminary findings indicate that the new serological test can effectively detect the target antibodies. Additionally, the researchers note that the test “do[es] not require handling of infectious virus” and that production is “amenable to scaling,” which could allow for rapid production in order to conduct larger population surveys.

At yesterday’s White House briefing , Dr. Deborah Birx, White House Coronavirus Task Force Coordinator, reported that that approximately 10-11% of all SARS-CoV-2 tests in the United States have positive results, potentially indicating that the majority of individuals with COVID-19 symptoms have other diseases (eg, seasonal influenza). But additional information is still required to understand the number of mild cases or asymptomatic infections in the community, particularly as they may not have warranted testing or even sought care. Serological testing, using products such as the test discussed above, could allow broader surveys to be conducted to more accurately characterize the scale of the pandemic, and the infection fatality ratio as well as screen individuals (e.g., healthcare workers) to identify those with immunity to the virus.