Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.
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March 23, 2020

EPI UPDATE With the rapid global escalation in COVID-19 incidence we have moved away from including case counts for all regions or countries. 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 22 reported 292,142 confirmed COVID-19 cases and 12,784 deaths globally. This represents 82,303 new reported cases and 4,006 new deaths since the March 19 Situation Report.

The number of reported COVID-19 cases in Pakistan has more than doubled since last Thursday. As of today’s Daily Situation Report , the Pakistan Ministry of National Health Services reported 784 confirmed cases, compared to 302 on March 19 . Pakistan reported 159 new cases on March 20 , 34 new cases on March 21 , 185 new cases on March 22 , and 138 new cases today. As we reported previously, there is concern about importing COVID-19 cases arriving from Iran. Pakistan has screened more than 1 million total travelers arriving in the country and identified 217 suspected cases through these efforts.

The US CDC reported 15,219 total (confirmed and presumptive) COVID-19 cases and 201 deaths nationwide. This represents a 45.7% increase in reported cases and a 34% increase in deaths from Thursday to Friday*. Of these cases, 95.6% do not have an identified exposure—travel-related or close contact of a known case—and are still under investigation. The Johns Hopkins CSSE dashboard is reporting 35,345 US cases and 473 deaths as of 10:30am on March 23. This would put the United States at #3 worldwide in terms of national COVID-19 incidence, behind only China (81,496 cases) and Italy (59,138).
* Reminder: The US CDC does not provide official updates over the weekend. The COVID-19 data will update today at noon.

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

US RESPONSE Yesterday, the White House issued a memorandum to governors announcing the federal government’s intention to provide 100% cost sharing—via FEMA—for National Guard units activated by states in response to the COVID-19 pandemic. The National Guard units will still support state governments (i.e., will not be federalized), but this measure is intended to make it more financially feasible for states to activate them to support local response activities.

Efforts to finalize an economic stimulus package to mitigate COVID-19’s financial impact on US businesses and individuals stalled yesterday, as the Senate failed to pass the bill in its current form. There are conflicting reports regarding how close Republicans and Democrats in the Senate are to negotiating a solution. Reportedly, differences remain with respect to how funding is allocated for businesses. Additionally, bipartisan efforts in both the House of Representatives and Senate to implement policies that would allow Representatives and Senators to vote remotely have failed to make progress. This issue is increasingly gaining attention as members of of Congress have tested positive for SARS-CoV-2 and several others have self-quarantined due to potential exposures, all of whom are unable to vote in person.

US President Donald Trump delegated as much as $50 billion from the Exchange Stabilization Fund to Treasury Secretary Steven Mnuchin to inject much-needed stability for various aspects of economic markets and industries in the United States. Among the top priorities is the airline industry , which has taken a historic financial hit as travelers across the country cancel flights over concerns about COVID-19.

US CDC GUIDANCE The US CDC published updated guidance for several aspects of the COVID-19 response. On Friday, the CDC issued interim guidance for independent living facilities (ILFs; eg, retirement communities) that aims to protect residents and staff. The CDC had previously issued recommendations for long-term care facilities , which operate more like healthcare facilities. At a high level, the new ILF guidance recommends cancelling group events, disinfecting common areas daily, limiting non-essential visitors, and screening staff and visitors for signs of the disease.

The CDC also provided parents and guardians with some recommendations for keeping children safe and healthy while schools are closed . In addition to guidance on hygiene and general social distancing, the CDC offers information targeted specifically at children. The CDC emphasizes that social distancing is appropriate for children as well as adults (with an emphasis on protecting older and other high-risk individuals) and recommends that parents/guardians revise or postpone travel plans, including for spring break. The CDC also notes that children congregating in other locations while schools are closed (e.g., parties, shopping malls) can facilitate community transmission of SARS-CoV-2, which limits the impact of school closures. The guidance also includes information about promoting learning and healthy activity while children are at home in order to mitigate the impact of school closures on their learning and development.

Finally, the CDC published information about several investigational COVID-19 treatment products , along with references to previously reported data and information on how to access the drugs. Remdesivir is not currently licensed by the FDA for any purpose, but COVID-19 patients may be able to access it through one of 3 ongoing clinical trials in the United States or via compassionate use in areas where trials are not taking place. Chloroquine and hydroxychloroquine are both authorized by the FDA for treating malaria, rheumatoid arthritis, and lupus. Clinical trials are currently underway for hydroxychloroquine as pre- and post-exposure prophylaxis and treatment for a range of COVID-19 disease severity. The CDC notes that hydroxychloroquine has demonstrated higher in-vitro activity and is more widely available than chloroquine in the United States, and it does not explicitly mention any ongoing chloroquine trials. The CDC also notes that other drugs, including lopinavir and ritonavir are under investigation as well, including in clinical trials under the WHO, but it does not include information on any specific ongoing clinical trials in the United States for these drugs.

“STAY AT HOME” ORDERS Following closely on the heels of California, New York Governor Andrew Cuomo issued an executive order on Friday, directing that “100% of the workforce must stay home, excluding essential services” such as “shipping, media, warehousing, grocery and food production, pharmacies, healthcare providers, utilities, banks and related financial institutions.” The New York COVID-19 website describes it as: “ New York State on PAUSE .” Previously—on March 18 and March 19 —Governor Cuomo issued executive orders to direct businesses statewide that provide non-essential services to reduce the non-essential workforce by 50% and 75%, respectively. Additionally, “non-essential gatherings,” including parties or other social events, are cancelled or postponed, regardless of size. When people do go into public, they “must practice social distancing of at least six feet from others,” and they should limit their use of public transportation to the extent possible. The current executive order extends the restrictions to April 19. New York published detailed guidance on what qualifies as essential businesses and services , which includes bars, restaurants, liquor stores, breweries, distilleries , and other establishments that produce or sell alcohol. Despite efforts to keep restaurants viable during the COVID-19 crisis, there are reports that some (or possibly many) have already determined that maintaining limited operations for takeout of delivery is not feasible and closed their doors and laid off their entire staff.

Illinois , Connecticut , New Jersey , Ohio , Delaware , Louisiana , and Massachusetts each also issued statewide “stay at home” orders, as did a number of cities, including Philadelphia . All of the orders generally include similar provisions. Individuals are directed to stay at home to the extent possible, but they are permitted to leave their homes to shop for groceries and other supplies; seek medical, dental, or veterinary care; provide care for others; exercise or engage in other outdoor activities; work at essential businesses; and utilize other essential services (e.g., post office, laundry). When people do need to go into public, the orders direct them to maintain social distancing, including staying 6 feet away from others and reducing public transit use, if possible. Some states require written documentation for essential workers to be carried while they are in public. Additionally, the orders direct restaurants, bars, and other eating establishments to operate only for drive-thru, takeout, or delivery, and the orders may place restrictions on other types of public spaces, like playgrounds, beaches, and parks.

DECONTAMINATING RESPIRATORS The University of Nebraska Medical Center (UNMC) published its internal procedures for utilizing ultraviolet germicidal irradiation (UVGI) to decontaminate N95 respirators . UNMC developed the procedures as a way to extend its inventory of N95 respirators during the COVID-19 response. Based on existing research illustrating both the effectiveness of UVGI on inactivating viruses (including other coronaviruses and on N95 respirators) and the minimal impact of the irradiation on the performance of the respirators, UNMC is implementing this program for high-demand areas of the hospital (e.g., emergency department and COVID-19 ward) and aims to expand it more broadly. Programs like this could potentially mitigate the burden of continued respirator use on existing health system inventory/stockpiles resulting from the COVID-19 response while production companies increase supply in the coming weeks and months. Separately, the Department of Health and Human Services is finalizing guidance to hospitals intended to inform operations while supplies of personal protective equipment, such as masks and respirators, are limited. 

ALLOCATION OF SCARCE RESOURCES A new commentary published in the The New England Journal of Medicine looks at how scarce medical resources should be allocated during the COVID-19 pandemic. The authors identify 4 ethical values that should be considered in developing scare resource allocation plans: “maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.” They then make a series of recommendations based on an application of these values. Their principal recommendation is that the principle of maximizing the benefits of scarce medical resources is the most important consideration. They also recommend that available resources be prioritized for those who become ill in the course of their professional duties (e.g., doctors, nurses, researchers), because they provide direct contribution to the pandemic response. Importantly, they note that no ethical allocation protocol should include ability to pay as a factor in decision-making. Finally, the authors suggest that the decision-making process around allocation should ideally include a triage officer, or a medical authority not directly involved with patient care, in an effort to relieve clinicians of the burden of these decisions.

OLYMPICS FATE UNCLEAR The International Olympic Committee (IOC) reiterated its commitment to hosting the 2020 Summer Olympics in Tokyo, Japan. Yesterday, the IOC Executive Board announced that it is increasing “scenario-planning” efforts to ensure the safety of the athletes and visitors, including modifying operational practices and potentially postponing the event. Notably, the Canadian Olympic Committee announced that it will not send athletes to the 2020 games over concerns about the COVID-19 pandemic and called on the IOC and WHO to postpone the event until 2021. The Australian Olympic Committee published a notice to its athletes saying that they “should prepare for a Tokyo Olympic Games in...2021,” noting the comments by the IOC about potentially postponing the games. Japanese Prime Minister Shinzo Abe reportedly addressed the issue in remarks to the Japanese Parliament, stating that if a full version of the Olympics could not be held as scheduled, Japan would work with the IOC to identify more suitable dates rather than cancel the games entirely.

CHLOROQUINE POISONING The drug chloroquine, currently being investigated as a potential treatment for COVID-19, resulted in multiple overdose deaths in Nigeria. In the short period after the drug was touted by US President Donald Trump, prices reportedly skyrocketed by more than 400% in some locations due to increased demand, despite a dearth of evidence indicating that it is effective against COVID-19. Over the weekend, Nigeria reported several deaths due to “chloroquine poisoning." In response, Lagos State Health Commissioner Akin Abayoi published a video via the Lagos State Ministry of Health Twitter account warning against the unlicensed use of chloroquine and emphasizing that it has yet to demonstrate efficacy against COVID-19, and Nigeria’s Minister of Health Osagie Ehanire echoed the need for additional data in a statement posted on the Nigeria Ministry of Health website.

GERMAN CHANCELLOR IN QUARANTINE German Chancellor Angela Merkel is undergoing voluntary quarantine after one of her physicians recently tested positive for SARS-CoV-2. Reportedly, the doctor administered a vaccination to Chancellor Merkel on Friday and then tested positive. At an address yesterday, Chancellor Merkel announced that Germany will implement further restrictions in order to curb the spread of COVID-19. The biggest changes include closing non-essential businesses and restricting gatherings of more than 2 people, excluding families.

LOCUST SWARMS In addition to the growing COVID-19 pandemic, several countries in East Africa are battling the worst locust infestation in 70 years . Ideal breeding conditions in countries like Ethiopia, Kenya, and Somalia could enable locust populations to swell by a factor of 400, which could devastate crops across the region. The agricultural industry in East Africa accounts for approximately one-third of the gross domestic product and nearly two-thirds of jobs. The economic impact of the locust swarms has been compounded as restrictions are implemented by countries trying to contain COVID-19. Additionally, reduced trade demand from China could further compound economic losses, and it may be even more difficult for affected countries to identify supplemental trade partners as more national-level restrictions are implemented by countries around the world.