Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.
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March 6, 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 the affected countries for the latest information.

EPI UPDATES The WHO COVID-19 Situation Report for March 5 reports 95,333 confirmed cases globally, including 3,282 deaths. There were 2,241 new cases and 84 new deaths reported yesterday. China’s National Health Commission reported a total of 80,522 cases (143 new) and 3,042 deaths (30 new) nationwide. Notably, Hubei Province reported no new cases outside of Wuhan. The NHC also reported a total of 104 cases in Hong Kong (2 deaths), 10 in Macau (zero deaths), and 44 cases in Taiwan (1 death; 2 new cases). South Korea’s CDC reported a total of 6,284 confirmed cases, including 42 deaths, an increase of 518 cases and 7 deaths. Of these cases, 62% of cases nationwide (3,917) have been linked to the Shincheconji religious group. The Iranian Ministry of Health reported a total of 4,747 cases nationwide (1,234 new), including 124 deaths (17 new). Italy’s Ministry of Health reported a total of 3,916 cases (620 new) and 197 deaths (49 new).

England’s Chief Medical Officer confirmed the country’s first COVID-19 death. The patient was older and had underlying health conditions; the person is believed to have been infected in England, and a case investigation is underway. Additionally, Public Health England confirmed that 2 British Airways baggage handlers tested positive for SARS-CoV-2; both individuals are currently isolated and recovering at home . Cameroon, Togo , and South Africa each reported the country’s first case, bringing the number of affected countries in Africa to 6. All 3 cases appear to be travel-related, and contact investigations are underway.

US EPI UPDATE In its March 5 update the US CDC confirmed 99 cases and 10 deaths across 13 states (data current through 4pm on March 4). Separately, the CDC also reported that an additional 49 repatriated travelers from the Diamond Princess cruise ship and Wuhan, China, have tested positive. The Johns Hopkins CSSE Department dashboard reported a total of 233 confirmed cases (as of 10am on March 6), reporting additional cases in Pennsylvania, Maryland, Texas, and Tennessee. State health departments have some of the most current information regarding confirmed cases within their states.

Pennsylvania has confirmed two presumptive positive cases, each from two separate counties in the state. Additionally, the Colorado State Health Department has confirmed two positive cases. Maryland has declared a state of emergency in response to announcing its first 3 cases. According to the Washington Post , all 3 case were on an overseas cruise and were not immediately tested for COVID-19 because they did not meet the testing guidelines in place at the time. Texas reported 4 additional travel-related cases in Harris County, bringing its total to 5 cases. The first presumptive case reported in Tennessee is an adult man who had recently traveled out of state. A total of 8 people have been tested in the state, and has capacity to test 85 people at this time. While the Nevada State Health Department has not officially reported cases, the Southern Nevada Health District reported yesterday its first presumptive case. 

The 3,533 passengers and crew onboard the Grand Princess cruise ship remain confined to the ship —currently off the coast of San Francisco, California—while SARS-CoV-2 testing is conducted for high-risk individuals onboard. According to Princess Cruise Lines , 45 specimens were collected for testing and flown to a laboratory in nearby Richmond, California. Operating under CDC guidance, all guests have been directed to remain in their staterooms until the testing is complete. Test results are expected sometime today, March 6.

CHINA RESPONSE China’s NHC reported that the demand for medical supplies and equipment in Hubei Province has been met. Considering the volume of international transmission, China is now encouraging domestic manufacturers of PPE (“protective suits”) to export products to support the COVID-19 response outside of China. China continues to import advanced equipment, including extracorporeal membrane oxygenation (ECMO) to treat severe cases. A health official in China reported that the government has delivered 67 ECMO machines to Hubei province, including 16 that arrived recently from manufacturers in Germany. China has also scaled up domestic production, providing more than 65,000 pieces of necessary equipment, including “14,000 noninvasive ventilators, 2,900 invasive ventilators and 15,000 ECG monitors” to support China’s response efforts.

China’s NHC also published national guidance regarding rehabilitation support for recovered COVID-19 patients . The guidance addresses, respiratory and other physical challenges in survivors as well as mental health issues, and it includes assessment methods for evaluating patients and guidance regarding rehabilitation therapy and exercises. With more than 50,000 recovered cases—which is increasing steadily every day—China will be critical to gaining insight into the longer-term effects of COVID-19 after the acute symptoms have subsided.

IRAN RESPONSE Iran’s Ministry of Health again called for reduction in unnecessary travel in order to mitigate the risk of SARS-CoV-2 transmission. Travel in some northern areas of the country remains heavy, and some provinces and cities may implement screening or restrict entry in order to curb unnecessary domestic travel. The government has directed residents of Guilan Province to remain in their homes , except for emergencies. The number of people in the public has reportedly decreased considerably, but not everyone is adhering to the guidance. Iran is also experiencing a shortage of PPE in Guilan Province, which is impacting clinical care for patients and healthcare worker safety. Iran is requesting that people in Guilan Province who develop systems should seek care at doctors’ offices and other health centers instead of going directly to the hospital. Hospitals are accepting coronavirus patients on referral only, in an effort to decrease patient surge as hospitals and reserve available resources for only those that require hospitalization. The Iranian government implemented measures to help ensure the availability of PPE nationwide. In this case, Iran directed the consolidation of national distribution of examination and surgical gloves to two designated companies and implemented government price controls on these products. Additionally, the exportation of gloves is prohibited, and importers are required to submit updates on supply inventory to a central government database.

THAILAND TRAVEL & ENTRY PROCEDURES There is reportedly some confusion about travel restrictions, screening, and quarantine for arriving international travelers in Thailand. According to several media reports , the Thai government posted conflicting messages, including via social media platforms, regarding quarantine and monitoring requirements for travelers arriving from countries affected by COVID-19. On Tuesday, Thailand’s Minister of Public Health announced via Facebook that travelers from “high-risk zones” would undergo mandatory self-quarantine for 14 days upon arrival, but that post was subsequently deleted. On Wednesday, officials from Thailand’s Tourism Authority published a Facebook post stating that they had received no official direction to implement quarantine for Singapore and that Thailand did “not recommend any travel or trade restrictions against China or other affected areas.” Today, Thai health officials announced that travelers arriving from mainland China, Hong Kong, Macau, South Korea, Italy, and Iran would require 14-day self-monitoring (including daily check-in and reports to health officials) but not quarantine; however, a subsequent tweet by the Thai government seemingly contradicted the previou announcement, resulting in further confusion. In Hong Kong, travelers en route to Thailand remained uncertain regarding quarantine and monitoring requirements, even as they boarded their aircraft, but they reportedly did not face mandatory quarantine upon their arrival. 

FUNDING BILL CNBC reported that President Trump signed a sweeping $8.3 billion spending bill to fund US response to COVID-19. The spending bill received wide bipartisan support with only three Congressmen opposing it. Other legislative issues, such as determining how US workers could receive paid time off, are still to be finalized. 

US NURSES CITE NEED FOR ADDITIONAL SUPPORT A New York Times article describes concerns among nurses about their safety and lack of available support as they treat possible COVID-19 patients. The article stated that nurses, particularly in California and Washington State where community transmission is recognized, have experienced challenges accessing N-95 masks, or have been forced to exit quarantine early so they can treat patients. A survey of nurses found that the majority work in hospitals that do not have plans for isolating COVID-19 patients and less than half have been provided guidance about how to handle the virus. 

US TESTING UPDATES A statement published by the California Nurses Association has highlighted limitations in testing capacity and criticized CDC’s process and shifting criteria to receive diagnostic testing. The critical statement by an anonymous nurse at a California Kaiser facility who is exhibiting symptoms and is in quarantine after caring for a COVID-19 positive patient. The author noted that despite requests from their physician and county health department, they are still awaiting permission from CDC to be tested. Furthermore, the statement alleges that CDC’s reasons for not testing this nurse have varied, ranging from testing being unnecessary due to the nurse’s use of appropriate personal protective equipment to prioritizing testing only among severe cases. Amid confusion and concern over testing, US officials have tried to increase testing capacity nationally. On Monday March 9, Quest Diagnostics will be allowed to launch its own diagnostic test, which can be used if physicians submit clinical samples to company labs. Currently, the CDC has reported that 5 states (Wyoming, Oklahoma, Ohio, West Virginia, and Maine) are currently not able to use COVID-19 diagnostic tests.

QUARANTINE MOTEL The government in King County, Washington (USA)—home to Seattle— purchased a local motel for the purposes of housing quarantined or isolated COVID-19 patients and persons under investigation (PUIs). The property reportedly cost the county government $4 million, and it is expected to be available for use in the next several days. The government purchased the motel to provide a space to house individuals who are not ill enough to require hospitalization but may not be able to isolate or quarantine themselves at home. Local government officials in the city of Kent (where the motel is located)—including city council members, the police chief, and the mayor—are protesting the purchase , because they do not want to actively bring COVID-19 patients to their city. The officials cited concerns about individuals under “voluntary quarantine” being able to leave the facility and spread disease in the community, among other concerns. King County is also reportedly establishing mobile quarantine/isolation sites to support individuals experiencing homelessness across the county.

SCHOOL, WORK & LANDMARK CLOSURES CONTINUE NPR has reported on several ways in which universities across the US have been responding to COVID-19 fears on campus. Many college campuses have taken actions such as developing plans to move classes online, cancel travel associated with college or state university systems, and issuing guidance. While not many colleges have reported cases, those with hospitals caring for COVID-19 cases have been on heightened alert. The New York Times has reported that although an employee at Dartmouth-Hitchcock Medical Center in New Hampshire was advised to stay home while awaiting test results, he went to a crowded public event at the school. Since then, a contact of this person has tested positive. School closures have resulted in nearly 300 million children globally staying home, resulting in adverse effects such as negatively affecting learning, reducing access to free or discounted meals for poorer students, and affected work schedules for parents who need to arrange care for their child. The Associated Press reported that the widespread school closures have led to elderly grandparents taking care of children and bringing them to playgrounds and parks, despite government requests to remain at home.  Teleworking has also been encouraged in affected countries, leading to a large rise in demand for food and service delivery companies, though the ability to telework is greatly dependent on the type of work involved.

ECONOMIC IMPACTS OF COVID-19 CONTINUE Stocks have continued to fall in response to fears about the impact of COVID-19. In the US, news of a substantial drop in the 10-year Treasury yield such that bonds are paying less than 1% interest, further contributed to a large sell-off. As stock markets continue to tumble globally, NPR has reported increased fears of a global recession. South China Morning Post has reported that in China, the epidemic has led to a $108B loss in exports, $72B loss in travel and $10B in transport services, totaling to approximately $190B in losses, though recent reports indicating the country’s economy is starting to recover. A CNBC article has reported that the Chinese government has issued “force majeure” certificates, enabling companies to exempt themselves from contractual obligations and mitigating the risk of financial penalties for companies, covering contracts valued at more than US$50 billion. These measures, however, may not be effective for arrangements with companies based outside of China. 

USE OF IMMUNOGLOBULIN BEING INVESTIGATED AS TREATMENT A STAT News article reported that Takeda Pharmaceuticals has been working on developing a new treatment against COVID-19 by using intravenous immunoglobulin from the blood serum of individuals who have survived infection with the causative virus, SARS-CoV-2. The therapy, if determined to be effective, would be intended for use among patients with severe disease, as it is possible that antibodies from multiple people will be needed to provide enough supply for treating one person. Other pharmaceutical companies, such as Regeneron and Vir Biotechnology, have also been investigating similar technologies.

COVID-19 MORTALITY STUDY A pre-print manuscript published by the Centre for Mathematical Modeling of Infectious Diseases provides insight into the infection fatality ratio (CFR) and case fatality ratio (CFR) for COVID-19 based on data from the Diamond Princess cruise ship that was quarantined in Japan. The study adjusted for several biases that can skew early estimates of severity. The authors estimate that the CFR on the Diamond Princess is 2.3% (0.75%–5.3%) and the infection fatality ratio (accounting for asymptomatic infections) is 1.2% (0.38–2.7%). In China, the authors estimated IFR and CFR to be 0.5% (95% CI: 0.2–1.2%) and 1.1% (95% CI: 0.3–2.4%) respectively.

Note: Our next briefing will be published on Monday, March 9.