Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.

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May 11, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 10 reports 3.92 million confirmed cases (61,578 new; 245,128 since Friday’s briefing) and 274,361 deaths (8,499 new; 20,316 since Friday’s briefing). The global total could potentially reach 4 million cases by the middle of next week and 300,000 deaths by later this week.

Russia has not updated its COVID-19 data since Friday’s briefing; however, the Johns Hopkins CSSE dashboard reports 221,344 cases, which corresponds to an average incidence of more than 10,500 new cases per day over the weekend. Russia continues its recent trend of elevated incidence . This total would put Russia at #4 globally, behind the United States, Spain, and the United Kingdom. 

India reported 10,810 new cases over the weekend, averaging more than 3,600 new cases per day and continuing its recent trend of elevated daily incidence . Tamil Nadu state, where a large outbreak has been linked to one of Asia’s largest markets, reported 1,795 new cases over the weekend—nearly 600 new cases per day. Several media reports indicate that the market has been linked to approximately 2,000 cases, but we have been unable to identify an official government report describing the outbreak. Singapore reported 2,115 new COVID-19 cases since Friday’s briefing, including 2,080 (98.3%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s growing COVID-19 epidemic. Singapore estimates that 6.63% of the total population across all migrant worker dormitories are confirmed cases, compared to only 0.03% of the general public population.

Canada appears as though it may have reached a plateau and potentially passed its peak nationally. Daily incidence last week is slightly lower than the previous 2 weeks, and the number of active cases appears to have leveled off as well. Additionally, Quebec , Canada’s hardest-hit province, reported steady hospitalizations over the past 6 days. Daily incidence in Quebec has remained relatively consistent over the past several weeks, with approximately 750-900 new confirmed cases per day.

The US CDC reported 1.30 million total cases (26,660 new; 81,630 since Friday’s briefing) and 78,771 deaths (1,737 new; 5,474 since Friday’s briefing). The United States could potentially reach 1.5 million cases by early next week. In total, 8 states (1 new) reported more than 40,000 cases, including New York with more than 300,000; New Jersey with more than 125,000; and Illinois and Massachusetts with more than 75,000 each. Additionally, 35 states (no change), plus Guam, are reporting widespread community transmission.

The Indian Health Service (IHS) reported 5,255 total COVID-19 cases, including 3,239 cases (61.6%) among the Navajo Nation. The percent of tests with positive results in the Navajo Nation is high at 23.0%, compared to 4.8% across all other IHS areas. The elevated percent positive tests potentially indicates that transmission among the Navajo Nation could be even more widespread than the case counts suggest.

New York state and New York City both reported decreasing incidence each day over the weekend. The state reported its lowest incidence since March 18, and New York City reported its lowest incidence since March 17. The percent positive tests continues to decline.

The New York Times continues to track state-level COVID-19 incidence, with a focus on state policies regarding social distancing. Several states began relaxing social distancing measures more than a week ago, we report here on trends in states that recently implemented changes, those that may implement changes in the near future, and those that remain under statewide social distancing policies (e.g., “stay at home” or “safer at home” orders). The activities permitted after restrictions are eased vary from state to state, and are not necessarily directly comparable.

Alabama has reported an increase in incidence since early May, up from fewer than 200 new cases per day to more than 300 in less than 2 weeks, its highest incidence to date. The start of Alabama’s increasing trend coincided with the expiration of the statewide “safer at home” order on April 30. Texas reported relatively consistent incidence from April 5 through April 25, but the incidence has been elevated the past 2 weeks. Texas has also reported a steady increase in the number of hospitalized COVID-19 patients since at least early April. Texas’s “stay at home” order expired on April 30, but the increasing trends began prior to that point and have continued since. Tennessee began to reopen businesses in late April, and the state has reported elevated incidence over approximately the past week and a half. Georgia appears to have passed a peak in daily incidence. The peak in Georgia’s 7-day moving average (April 20) now falls outside the 14-day window during which new cases may not yet be reported. Georgia was one of the first states to begin relaxing social distancing measures, and there has not been a noticeable change in the daily incidence since that time. After several weeks of relatively consistent case counts,

Maine’s daily incidence has increased since late April, up to from approximately 600 new cases per day to more than 800. Maine’s “stay at home” order expires at the end of May; however, the state permitted some businesses to reopen starting May 1. Vermont has been on a steady decline since early April, and the statewide “stay at home” order is scheduled to expire later this week.

Iowa’s epidemic appears to be tapering off, down from a peak in late April. Notably, testing has increased substantially, and the percent positive tests is down from approximately 33% near the peak to 11%. Iowa relaxed social distancing measures for 77 of 99 counties starting May 1, but they remain in effect for more severely affected areas. Minnesota has reported elevated and increasing incidence since approximately April 22. Nebraska continues to report elevated incidence, consistently more than triple the daily totals reported in early April. Kansas’ daily incidence (by diagnosis date) is increasing rapidly, 2-3 times the daily totals from early April. All four states have all reported outbreaks at meat packing facilities, which may account for some of the increased incidence. Nebraska and Kansas have relaxed social distancing restrictions to allow some businesses, including restaurants and barber shops/salons, to reopen, but Minnesota has not.

Several states have had decreasing trends in incidence but have not yet implemented plans to relax social distancing measures. Notably, Michigan has had a decline in the number of new cases since early April. Manufacturing work is resuming Michigan, but most stores remain restricted to pick-up or delivery operations.

The Johns Hopkins CSSE dashboard is reporting 1.33 million US cases and 79,825 deaths as of 1:30pm on May 11.

COVID-19 IN THE WHITE HOUSE Two White House officials and other staff recently tested positive for SARS-CoV-2. Katie Miller, a top spokesperson for US Vice President Mike Pence tested positive last week. Miller is married to Stephen Miller, a senior advisor to US President Donald Trump. One of President Trump’s personal valets also tested positive. Testing, contact tracing, quarantine and isolation are underway as well as mitigation measures such as increased mask usage and remote work. Three top public health leaders in the US COVID-19 response are also self-quarantining due to potential exposure: Dr. Robert Redfield, Director of the Centers for Disease Control and Prevention; Dr. Stephen Hahn, Commissioner of the Food and Drug Administration; and Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases.

ARMED PROTESTS CONTINUE Support for social distancing measures, including “stay at home” orders, has waned slightly, according to a recent poll , but a majority of respondents (71%) still support these measures. Additionally, a majority of respondents (55%) disapprove of recent protests against these restrictions. Last Monday, officers in western Texas were alerted to a bar opening against the state’s order. Responding officers arrested the bar owner along with six men in body armor with rifles who were standing outside the establishment in protest of the state’s order. Armed protests were also recently held in Wisconsin and in Arizona, where protests occurred outside the state’s capitol.

RESTAURANTS & COVID-19 The restaurant and food industry has been significantly impacted by the direct and indirect effects of COVID-19, leading to protests, economic stress, and business closures. A survey by the National Restaurant Association found that the US restaurant industry lost an estimated $25 billion in sales and more than 3 million jobs from March 1-22. Additionally, “3% of restaurant operators have already permanently closed their restaurants.” As states begin to reopen, owners now face a difficult dilemma —to open their doors again or remain closed and wait until reopening is safer. The decision is complex, with questions about safety and liability for staff and patrons, logistics and cost of adopting mitigation measures , and uncertainty regarding whether or not patrons will return. Employees also face the question of whether or not to continue working at restaurants that may not be doing enough to mitigate risk of transmission. In Fargo, North Dakota, this reportedly led several employees to walk out at one restaurant.

NATIVE AMERICANS Native Americans are being disproportionately affected by the COVID-19 pandemic. The Navajo Nation has reported the third-highest per capita COVID-19 infection rate, after only New York and New Jersey, with 3,239 cases reported as of Saturday. The Navajo outbreak demonstrates how challenges of healthcare and public health infrastructure as well as poor access to basic needs can intensify the effects of the pandemic. Other Native American tribes across the country have taken measures to mitigate transmission in their communities, including the use of checkpoints or temporary roadblocks on state and federal highways to limit travel and mitigate transmission risk. South Dakota Governor Kristi Noem stated that her office intends to file a lawsuit against the Oglala and Cheyenne River Sioux tribes if they continue to operate checkpoints on state and federal highways. Harold Frazier, chairman of the Cheyenne River Sioux Tribe, responded by saying, “We will not apologize for being an island of safety in a sea of uncertainty and death.” The Indian Health Service has reported a total of 5,225 COVID-19 cases across Native American tribes. 

POTENTIAL SUPERSPREADING EVENT IN GHANA Sunday night, Ghanaian President Nana Akufo-Addo stated that 533 cases in the city of Tema of the country’s 4,700 total cases were linked to a single fish processing facility. According to President Akufo-Addo, all 533 individuals were infected by a single case, but it is unclear how health officials determined that the same individual was the source for all 533 secondary cases. Ghana has conducted more than 160,000 tests; however, Ghana cleared a substantial backlog of tests on May 7, which resulted in an additional 921 cases from tests as far back as April 26. These newly identified cases increased Ghana's national total by more than 35% in one day.

NEW LOCKDOWN IN IRAN Iran had reported steadily decreasing COVID-19 incidence since its peak in early April, down from more than 3,000 new cases per day to fewer than 1,000 in early May. Over the past several days, however, Iran has again reported increasing COVID-19 incidence—approximately 50% more cases than the low earlier this month—as a result of increased transmission in the Khuzestan province . Reportedly, the increased transmission is a result of residents relaxing social distancing efforts. COVID-19 incidence in the affected area tripled, and hospitalizations increased by 60%. Iran was in the midst of slowly relaxing national social distancing policies, but the increased transmission led Iran to re-impose more restrictive measures in affected areas of Khuzestan province, including local travel restrictions. In its most recent update , Iran reported 109,286 total cases, including 1,683 new cases from the previous day.

CONTACT TRACER TRAINING The Johns Hopkins University Bloomberg School of Public Health and Bloomberg Philanthropies, in partnership with New York state launched an online course to train contact tracers. University faculty teach the basics of interviewing COVID-19 cases, identifying their close contacts, and providing them advice and support for quarantine. The course aims to provide the tools needed for future contact tracers to support COVID-19 response efforts that are critical to the country’s ability to safely relax social distancing measures. New York’s professional contact tracers will be required to complete the course, but anyone may take it for free. The course is available via the Coursera platform starting today.

DOWNSTREAM EFFECTS A study published in the US CDC’s Morbidity and Mortality Weekly Report looked at the effects of the COVID-19 pandemic on routine childhood immunizations in the United States. Based on data from the federal Vaccines for Children Program and the CDC’s Vaccine Tracking System and Vaccine Safety Datalink, the authors found a significant decrease in the number of childhood immunizations administered compared to previous years, potentially driven by concerns that children could be exposed to SARS-CoV-2 during their doctor visits. The authors note, “[t]he decline began the week after the national emergency declaration.” Among children aged 2-18 years, the number of measles-containing vaccinations (e.g., MMR) fell from more than 2,000 per week to only several hundred over a 2-week period and has remained at that level from mid-March through at least mid-April. The decrease was less dramatic for children under 2 years old, and the number of vaccines for this age group has steadily rebounded, up to nearly 1,500 vaccinations by mid-April. The study evaluates only national-level data, and analysis of state and local variations in coverage will be needed to better characterize the local impact. The authors warn that interruptions and delays to childhood immunizations could “indicate that U.S. children and their communities face increased risks for outbreaks of vaccine-preventable diseases,” particularly as social distancing measures are relaxed and children resume social interaction. 

SENATE HEARING ON RELAXING SOCIAL DISTANCING Tomorrow (May 12), the US Senate Committee on Health, Education, Labor, and Pensions will hold a hearing to discuss appropriate measures to relax social distancing measures. The hearing—titled COVID-19: Safely Getting Back to Work and Back to School —will provide Senators the opportunity to question several high-profile members of the US COVID-19 response. The witnesses will beDr. Anthony Fauci, Director, National Institute of Allergy and Infectious Disease; Dr. Robert Redfield, Director, US CDC; Admiral Brett Giroir, MD, Assistant Secretary for Health; Dr. Stephen Hahn, Commissioner of the US FDA.

ANTIGEN DIAGNOSTIC TEST EUA The US FDA issued the first Emergency Use Authorization (EUA) for an antigen-based diagnostic test for SARS-CoV-2. Previously, the diagnostic tests used for SARS-CoV-2 were all PCR-based, which detects the presence of viral RNA. The new tests detect “fragments of proteins known as antigens found on or within the virus” and are capable of providing results more rapidly . They do have a higher probability of returning false negative results, so negative antigen tests “may need to be confirmed with a PCR test.” The positive results for the antigen tests are highly accurate, however, and the tests cost less to manufacture.