COVID-19
Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.
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March 30, 2020

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 necessarily be including case counts for individual regions or countries 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 29 reported 634,835 confirmed COVID-19 cases (63,159 new) and 29,891 deaths (3,398 new) globally. Global reported COVID-19 cases have nearly doubled (and deaths more than doubled) since March 23 —332,930 cases and 14,509 deaths—less than a week ago.

Russia’s Ministry of Health reported 1,523 COVID-19 cases, a nearly 50% increase in cases since Friday, March 27. Russia’s MOH also reports that more than 260,000 tests have been administered nationwide.

Iran reported 41,495 confirmed cases of COVID-19 (3,186 new), including 2,757 deaths. Like many countries, Iran is struggling to balance pandemic response measures, including strict social distancing, against the economic impact of the response. Iran’s national economy was already under strain , due in part to US sanctions, and Iranian President Hassan Rouhani has called for relief from the sanctions and requested a US$5 billion loan from the International Monetary Fund. Despite the economic effects, President Rouhani reportedly stated that the social distancing measures are “the new way of life” and that they could remain in place for a prolonged period of time.

The US CDC is now updating its reported COVID-19 cases over the weekend. The CDC reported 122,653 total (confirmed and presumptive) COVID-19 cases and 2,112 deaths nationwide on March 29. Today, the CDC reported 140,904 cases (18,251 new) and 2,405 deaths (293 new). Of these cases, 97.7% do not have an identified exposure—travel-related or close contact of a known case—and are still under investigation. The United States now has the most reported COVID-19 cases of any country, followed by Spain (85,195 cases) and Italy (75,528 cases). The United States has reported approximately 50% more cases than China , but only 64% of the deaths (81,470 cases and 3,304 deaths in China). The Johns Hopkins CSSE dashboard is reporting 144,672 US cases and 2,575 deaths as of 12:00pm on March 30.

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

US RESPONSE On Friday, March 27, US President Donald Trump signed the CARES Act , the “phase 3” COVID-19 response and funding package containing economic stimulus measures. The package includes $1,200 “tax rebates” for individuals (with additional $500 rebates for dependents), suspension of payments for federal student loans, tax relief for businesses, additional funding for the healthcare system, and regulatory changes to promote testing and authorization of investigative pharmaceuticals.

Yesterday, President Trump announced that the national guidelines regarding social distancing measures would remain in effect until the end of April . What was announced initially as the White House’s “15-Day Plan” was set to expire today, but after evaluating the US epidemic, the White House determined that the measures needed to remain in place in order to slow transmission across the country. A number of states and cities have implemented more restrictive and mandatory social distancing programs, but the national guidelines provide a minimum standard for individuals, families, and businesses nationwide.

The US government invoked the Defense Production Act (DPA) for the first time, reportedly after negotiations with General Motors to produce ventilators stalled last week. Reportedly, General Motors was already in the process of transitioning production lines to manufacture the ventilators, so it is unclear whether invoking the DPA will speed the delivery of ventilators. Additionally, President Trump delegated additional authorities under the DPA to the Secretaries of Homeland Security and Health and Human Services, including the ability to provide loans necessary to increase production of necessary resources and authority to coordinate the nationwide production and distribution of medical resources, including materials and services available “in the civilian market.” States have reported barriers to obtaining necessary supplies , including bidding against each other and losing contracts to the federal government, so centralized control of nationwide distribution could potentially provide more efficient use of limited resources.

President Trump also issued an executive order to activate some members of the US military reserve to support COVID-19 response efforts. Additionally, FEMA will provide funding to Florida, Louisiana, Maryland, Massachusetts, New Jersey, Guam, and Puerto Rico to cover 100% of COVID-19 response activities conducted by National Guard units as well as additional operational support for those activities.

US STATE TRAVEL RESTRICTIONS & GUIDANCE The US CDC has not historically issued travel advisories for travel within the United States ; however, it issued a travel advisory over the weekend for New York, New Jersey, and Connecticut. Most travel guidance issued by the US CDC includes recommendations for US travelers who may be traveling to an affected area (eg, considerations for deciding whether or not to travel, precautions to take while traveling), but the coronavirus-related guidance for these 3 states take a different approach. This travel advisory “urges residents of New York, New Jersey, and Connecticut to refrain from non-essential domestic travel for 14 days,” essentially asking residents of this affected area to avoid traveling elsewhere. The CDC guidance followed a series of statements by President Trump regarding the possibility of instituting a federal quarantine on New York tri-state area, which prompted opposition from New York Governor Andrew Cuomo and others.

In addition to the federal travel guidance, several states have implemented their own travel restrictions for affected areas. Florida Governor Ron DeSantis issued several executive orders requiring all travelers arriving from New York, New Jersey, Connecticut , and Louisiana to isolate or quarantine themselves for 14 days after entering Florida. Florida will not bear any costs associated with the quarantine or isolation of these individuals. The executive order pertaining to Louisiana also includes provisions for establishing “checkpoints on the roadways for those persons and vehicles entering the State of Florida,” at which Florida officials will require written documentation of travelers’ purpose and destination in Florida. Reportedly, the traffic at one checkpoint on I-95 entering from Georgia was so bad this weekend that the checkpoint was closed for several hours to allow the congestion to subside. Governor DeSantis expressed concern about the volume of travelers arriving from the New York area seeking reprieve from the strict social distancing measures. Notably, Florida has reported 4,768 COVID-19 cases, more than the 3,540 reported by Louisiana . The local government in the Florida Keys is also prohibiting the entry of visitors and other non-residents and operating checkpoints to enforce the order.

In Rhode Island, Governor Gina Raimondo issued executive orders requiring 14-day quarantine for all travelers arriving from outside the state, including establishing checkpoints along the state’s southern border with Connecticut, which will divert all vehicles with out-of-state license plates for screening and instruction. It is unclear if or how this policy will address Rhode Islanders (or others with Rhode Island license plates) who are returning from out-of-state travel or travelers crossing the Massachusetts border. Beyond the screening checkpoints, local law enforcement and the Rhode Island National Guard will be going “door to door” in some communities in search of travelers who arrived from New York and issuing them quarantine orders. The National Guard is also stationed at airports and train stations to identify arriving travelers and issue quarantine orders. The state-specific restrictions have prompted opposition from the American Civil Liberties Union (ACLU) over concerns about due process for New Yorkers and other travelers. Rhode Island’s initial focus on travelers from New York prompted New York Governor Andrew Cuomo to threaten to file a lawsuit against Rhode Island over its policies.

Texas Governor Greg Abbott expanded previously issued travel restrictions (originally for the New York tri-state area) to include mandatory quarantine for all travelers from New Orleans, Louisiana, and all travelers arriving by air from California; Louisiana; Washington; Atlanta, Georgia; Chicago, Illinois; Detroit, Michigan; and Miami, Florida. Other states are also recommending against travel to areas with higher reported transmission or considering their own travel restrictions. Kentucky Governor Andy Beshear , for example, called on Kentuckians to avoid unnecessary travel across the border to Tennessee, particularly for the purpose of participating in activities that are prohibited in Kentucky but not Tennessee.

In addition to interstate travel restrictions, states continue to issue “stay at home” orders to enforce social distancing practices.

IMPERIAL COLLEGE NPI MODELING Researchers at Imperial College London , a WHO Collaborating Center for Infectious Disease Modeling, published findings from a study that aimed to evaluate the impact of nationwide non-pharmaceutical interventions (NPIs; eg, social distancing) in Europe on SARS-CoV-2 transmission and mortality. The model utilizes reported deaths as the underlying data, accounting for reporting delays and other barriers to effective surveillance and reporting, to estimate the actual number of deaths across 11 countries as well as the expected number of deaths without the national measures in place. The NPIs included self-isolation, government-encouraged social distancing, banning public events and gatherings, school closures, and mandatory “lockdown.” The model estimates that these nationwide efforts could have averted 59,000 deaths across the 11 countries and that the national policies could have potentially driven the R0 value to below 1. The study modeled the pandemic through the end of March.

ROAD MAP TO REOPEN THE US The American Enterprise Institute published a report outlining a series of steps that can be taken nationally and regionally as the US COVID-19 epidemic is brought under control. The report—led by former US FDA Commissioner Scott Gottlieb and with support from JHCHS Senior Scholars Caitlin Rivers and Crystal Watson, among others—evaluates potential future changes to social distancing and other response measures that could be implemented or relaxed over the coming months as well as metrics to indicate when it would be appropriate to do so. The report emphasizes the need for improved surveillance and testing, increased public health and health system capacity, and the availability of vaccines and therapeutics in order to facilitate these changes and “gradually move away from a reliance on physical distancing as our primary tool” for combating the pandemic. The “stepwise approach” outlined in the report presents 4 phases for relaxing national social distancing measures: slowing SARS-CoV-2 spread, relaxing physical distancing state by state, establishing immune protection (eg, via vaccination) and wholly lifting physical distancing, and rebuilding readiness for future pandemics.

ORIGINS OF SARS-CoV-2 There has been a push to better understand the origins of SARS-CoV-2 in order to anticipate and reduce future zoonotic spillover events and transmission. A study published in Nature details the identification of viruses related to SARS-CoV-2 in Malayan pangolins. This animal has been under consideration as an intermediate host of SARS-CoV-2, potentially providing the bridge between primary host animal reservoirs (eg, bats) and humans. Identification of pangolins is important, considering that they are the mammal illegally trafficked most often, for both food and medicinal purposes. The coronavirus genomes isolated from pangolins have between 85.5% and 92.4% similarity to the genome of the SARS-CoV-2 virus circulating in humans however, further study is required, particularly in wild pangolin populations, before making any determination . 

COVID-19 AND LOSS OF TASTE & SMELL A loss of taste and smell —hypogeusia and hyposmia, respectively—has been reported as a potential early symptom of SARS-CoV-2 infection. This phenomenon is consistent with case reports of individuals infected with other coronaviruses. While it has not been widely documented in the scientific literature, there have been reports of patients exhibiting neurological symptoms, including hyposmia and hypogeusia, in Wuhan, China. A more complete understanding of how and why this phenomenon takes place could potentially enable its use in interpreting clinical progression of COVID-19. A study conducted at the Harvard Medical School ( preprint ) identified a pathway that could potentially explain these symptoms. Two genes required for SARS-CoV-2 cell entry are expressed by olfactory epithelial and stem cells but not olfactory sensory neurons, which could challenge the hypothesis that there is a neurological basis for the phenomenon. 

INTERNATIONAL RESPONSE EFFORTS  Globally, nations are implementing a variety of measures to reduce transmission of SARS-CoV-2. In Israel , foreign nationals are not permitted from entering the country and now individuals cannot go more than 300 feet outside their home. There have reportedly been challenges implementing these measures in certain communities. Orthodox Jewish communities, for example, tend to be tight-knit, and slower implementation of the mitigation measures has increased concern about transmission in these communities. Jordan , has reportedly initiated a large-scale “lockdown” of Irbid, its second largest city, after dozens of guests at a recent wedding tested positive for SARS-CoV-2. The restrictions essentially enforce a domestic travel ban and prevent individuals from leaving their homes, even to obtain critical supplies. The city is under “military control,” and the government will be responsible for ensuring the availability of food and water to the affected population. Similarly, the nationwide “lockdown” in India has reportedly had a significant impact on migrant worker populations, who are now without access to work, critical supplies, and shelter.