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

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May 13, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 12 reports 4.09 million confirmed cases (82,591 new) and 283,153 deaths (4,261 new). The global total could potentially reach 300,000 deaths by later this week.

The majority of countries are currently exhibiting doubling times of more than 10 days. Compared to the end of March —when most countries’ epidemics were doubling faster than 8 days—this is an encouraging sign. A number of countries in Africa , however, are doubling faster. Burundi, the Central African Republic, Gabon, Guinea-Bissau, South Sudan, Sudan, Togo, and Zambia are all currently doubling faster than 10 days. The combination of low testing and surveillance capacity (and variation between countries), inconsistent reporting, and relatively low reported incidence in many countries results in highly dynamic doubling times. At the continent level, Africa’s COVID-19 epidemic is doubling approximately every 10-15 days.

Several countries have recently reported concerning per capita COVID-19 incidence . Bahrain, Belarus, Chile, Kuwait, Russia, the United Arab Emirates are all reporting more than 75 new cases per million population each day . For reference, the United States has consistently reported 60-100 new cases per million since late March, and the global average is approximately 10 new cases per million population. Additionally, all but Singapore have increased over the past several weeks. Other notable countries in terms of daily per capita incidence include Peru (71.2), the United States (60.9), Saudi Arabia (55.4), and the United Kingdom (55.0). Of these countries, Peru and Saudi Arabia have been increasing since late March.

Russia reported more than 10,000 new cases, continuing its recent trend of elevated incidence . Russia’s daily incidence is approximately twice what it was in late April. Russia will likely reach 250,000 cases tomorrow. India reported 3,525 new cases, 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 716 new cases. The number of active cases in Tamil Nadu doubled over the previous 6 days, and Tamil Nadu now reports the second highest number of active cases among all Indian states. Singapore reported 675 new cases, including 671 (99.4%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s growing COVID-19 epidemic. Singapore estimates that 7.12% of the total population across all migrant worker dormitories are confirmed cases, compared to only 0.03% of the general public population. Of the 25,346 total COVID-19 cases reported in Singapore, 23,008 (90.8%) are among residents of migrant worker dormitories.

The US CDC reported 1.34 million total cases (18,106 new) and 80,820 deaths (1,064 new). The daily incidence is the lowest since March 27. Based on the pattern from previous weeks, we expect the incidence to be higher over the next several days due to reporting delays over the weekend. Nonetheless, today’s report is still lower than previous Tuesday updates—19,138 new cases reported last Tuesday and 23,371 new cases the week before. The United States could potentially reach 1.5 million cases by Tuesday next week. In total, 7 states (increase of 1) 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. Additionally, 35 states (no change), plus Guam, are reporting widespread community transmission.

New York state and New York City both reported their fifth consecutive day of decreasing daily incidence and their lowest daily incidence since March 17. While New York City continues to represent the majority of cases in the state, incidence outside of New York City is declining as well.

The New York Times continues to track state-level COVID-19 incidence, with a focus on state policies regarding social distancing. The Johns Hopkins CSSE dashboard is reporting 1.38 million US cases and 82,806 deaths as of 12:30pm on May 13.

SINGAPORE OUTBREAK Singapore has reported an average of 700 new cases per day across all dormitories housing migrant workers—compared to 8 new cases per day among the broader public. In response to these numbers, Singapore’s Ministry of Health has implemented a mass testing strategy at these dormitories, using a combination of PCR and serological tests. Singapore is currently testing more than 3,000 migrant workers per day. With the aggressive testing strategy, health authorities expect reported incidence to remain high for some time as new cases are found, and will then decrease as the outbreaks are brought under control through case identification and isolation.

In addition to addressing transmission among migrant workers, health authorities are beginning to develop creative ways to encourage physical distancing. A pilot project will utilize the Boston Dynamics robot dog “Spot” to patrol public parks and broadcast pre-recorded messages reminding residents to adhere to physical distancing guidance. Spot will also reportedly be capable of estimating the number of individuals in the park, but it will not use facial recognition or other systems to identify or track individual people. If the pilot goes well, authorities will consider expanding the program to busier park hours and to more locations. Spot is also being used to deliver medication to patients in designated isolation facilities. 

mRNA VACCINE DEVELOPMENT Biotechnology company Moderna received US FDA “Fast Track” designation for the development of its mRNA vaccine against SARS-CoV-2. The Fast Track program is designed to facilitate expedited review of therapeutics for life-threatening conditions. Messenger RNA (mRNA) technology uses natural cellular processes to produce proteins designed to increase immune defenses against the pathogen for which the proteins are designed. Moderna’s mRNA-1273 vaccine candidate is designed to mimic the SARS-CoV-2 spike protein that will hopefully produce a rapid and targeted immune response against future infection. The vaccine has already undergone a Phase 1 clinical trial led by the National Institute for Allergy and Infectious Diseases, and results are expected soon. Moderna is currently preparing protocols for Phase 2 and 3 clinical trials, tentatively scheduled to begin this summer.

PROTECTIVE IMMUNITY Serological tests are a key component of testing strategies to provide information on prior infections with SARS-CoV-2. Rapid diagnostic tests (RDTs) and ELISA tests can detect antibodies specific to SARS-CoV-2 in a matter of minutes or hours, respectively. A major drawback of these tests is that they cannot determine whether the detected antibodies provide protection against future infection. In order to answer this question, results from RDTs and ELISA tests must be correlated against neutralization assays, the gold standard for determining protective immunity. To fill this gap, Vyriad, in partnership with Regeneron, developed a neutralizing antibody test that can be performed at a lower biosafety level in CLIA-certified laboratories. Neutralization assays usually must be performed at high biosafety levels due to the need to work with live pathogens. The results for these tests typically take 1 week, so a safer and more rapid approach is needed to determine protective immunity for recovered COVID-19 patients. Vyriad is currently applying for FDA Emergency Use Authorization for this test.  

REOPENING WASHINGTON STATE BUSINESSES As Washington state continues its process of relaxing social distancing measures, Governor Jay Inslee released guidance for various sectors under the state’s “Safe Start” plan. Under Phase 2 of the state’s plan, retail stores must remain below 30% occupancy and identify and reduce choke points where customers could become clustered in order to maintain the recommended physical distancing. Restaurants must maintain below 50% occupancy for both indoor and outdoor seating and must close off any bar seating. Additional cleaning and disinfection guidelines are provided as well. This guidance also outlines provisions for employee safety and facility hygiene as businesses, including retail stores and restaurants, begin to resume in-person operations. 

BROADWAY THEATERS REMAIN CLOSED Broadway theaters in New York City will remain closed for the foreseeable future, with no reopening date yet set. The Broadway League announced that refunds and exchanges will be offered for any tickets for performances through September 6. New York and New Jersey remain hot spots for COVID-19 cases, and many businesses are shuttered, but the New York City economy will likely be negatively impacted from Broadway theater closures. According to the Broadway League, Broadway business contributed approximately $14.7 billion to the city’s economy in 2018-19 and accounts for more than 100,000 jobs, including show cast, crew, and theater operators.

SOCIAL DISTANCING & VIOLENCE Reports of violence associated with physical distancing policies continue, in the United States and elsewhere, as countries develop and implement plans to ease these restrictions while mitigating the risk of a resurgence in transmission. In addition to high-profile protests over state social distancing requirements in the US, there have also been a number of incidents involving law enforcement or members of the public violating or trying to enforce social distancing measures. One major point of contention as state and local governments adjust social distancing measures is the use of face masks or coverings . Face coverings are mandatory in some parts of the country but not others, and some governments have maintained requirements for mask use in public as they ease other restrictions. In some states where mask use is not mandatory, individual businesses are permitted to set their own requirements, which can result in variations within the same community. Confrontations between employees and patrons over mask requirements have resulted in multiple physical altercations and at least one shooting in the United States. Other incidents involving violence related to enforcing physical distancing have been reported in other countries as well, including the United Kingdom and Germany .

UK ECONOMIC IMPACT The UK Office for National Statistics published economic data for the first quarter of 2020, including a 2% decrease in the gross domestic product . The first quarter only included 1 week of “lockdown,” and the second quarter is expected to be worse due to the prolonged implementation of national physical distancing measures. Like the United States and many other countries, the United Kingdom is forecasting a severe recession as a result of the COVID-19 pandemic. The Bank of England reportedly projected that the UK economy could shrink by 30% for the first half of 2020, followed by a recovery in the second half of the year—potentially resulting in a 14% decrease over the course of the year. The UK’s COVID-19 epidemic has also had major negative effects on unemployment. The United Kingdom is beginning to ease some national physical distancing policies this week, but it remains to be seen how much and how quickly these changes will impact the UK economy.

COVID-19 MORTALITY MODELS Several high-profile models of expected COVID-19 deaths used by government officials appear to be converging on similar mortality projections for the next several months. Researchers at the University of Massachusetts Amherst evaluated these models and merged them into a single “ensemble” model based on a technique typically used for annual seasonal influenza models—which has demonstrated the utility of ensemble models. As more data become available, the various models appear to be coming into closer agreement. Notably, the difference between the highest and lowest COVID-19 mortality projections decreased from 36,000 deaths to 17,000 deaths over the past 2 weeks. The ensemble model projects approximately 110,000 cumulative COVID-19 deaths in the United States by June 6, but this total “will unquestionably rise much higher” after that point.

US SENATE COVID-19 HEARING Yesterday, the US Senate Committee on Health, Education, Labor, and Pensions held a hearing with several senior officials from the US government’s COVID-19 response . Dr. Anthony Fauci (NIAID), Dr. Robert Redfield (CDC), Admiral Brett Giroir (HHS), and Dr. Stephen Hahn (FDA) offered testimony on the US COVID-19 response and the epidemic’s trajectory, with a particular focus on states’ efforts to begin easing physical distancing restrictions. The experts addressed a broad scope of topics , including the potential for increased transmission as states relax stay at home measures, the timeline for vaccine availability, the distribution of remdesivir, and the US COVID-19 death toll.

DOWNSTREAM IMPACT As we have covered previously, the effects of the COVID-19 pandemic reach far beyond the immediate illness and death associated with the disease. The WHO and UNAIDS jointly warned about the impacts of disruptions to the supply chain and health services on excess deaths from HIV/AIDS , particularly in the sub-Saharan African region. A modeling group convened by WHO and UNAIDS estimated that a 6-month disruption in antiretroviral therapy could result in 500,000 excess deaths from AIDS-related illnesses in sub-Saharan Africa in the coming year. Disrupted services could reverse hard-fought gains in the region, where 25.7 million people are living with HIV/AIDS. In response to this study, Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, called on countries to maintain critical health services and support for vulnerable countries and populations in the midst of the COVID-19 pandemic. 

TANZANIA Since late April, COVID-19 reporting from Tanzania has been uneven . Tanzania reported 180 new cases on April 30 , corresponding to a 60% increase in the national total, and another 29 new cases on May 8 , but nothing else to date . Today, the US Embassy in Dar es Salaam issued a Health Alert that highlighted the COVID-19 risk in Tanzania. The alert notes that Tanzania has not consistently reported COVID-19 data and that “all evidence points to exponential growth of the epidemic in...Tanzania.” The alert also states that “many hospitals in Dar es Salaam have been overwhelmed in recent weeks” and that “the risk of contracting COVID-19 in Dar es Salaam is extremely high.”

Tanzanian President John Magufuli has denied reports of increased incidence. According to several reports , President Magufuli recently accused public health laboratories of reporting falsified positive test results in an attempt to make the situation appear worse. He claimed that he secretly submitted specimens from a goat, sheep, bird, and papaya to Tanzania’s National Laboratory and that the tests were positive, providing evidence that the laboratory results cannot be trusted. Additionally, President Magufli suspended the National Laboratory director in order to conduct an investigation. Several reports also claim that Tanzania is withholding reports of COVID-19 deaths . Tanzania has officially reported only 21 total deaths, but there is concern that the actual total could be much higher.

NEW US HOUSE COVID-19 BILL Democrats in the US House of Representatives introduced a new economic stimulus bill to support essential workers , including frontline healthcare professionals and first responders. The bill—called the Health and Economic Recovery Omnibus Emergency Solutions Act ( HEROES Act )—would provide an estimated US$3 trillion in funding to individuals and state, local, and tribal governments. In addition to funding for stimulus checks, supplemental unemployment benefits, student loan forgiveness, small businesses, and healthcare, the new bill includes a number of other provisions . Notably, the HEROES Act would provide supplemental pay for “essential frontline workers”—$25,000 each through the end of 2020—and a $15,000 recruitment incentive to facilitate expanding the healthcare workforce. The House of Representatives is expected to vote on the bill by Friday, but Senate Majority Leader Mitch McConnell reportedly indicated that the bill is unlikely to pass the Senate.