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

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May 15, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 14 reports 4.25 million confirmed cases (77,965 new) and 292,046 deaths (4,647 new). The global total could potentially reach 300,000 deaths by Saturday’s Situation Report.

While most European countries—including those that were hit particularly hard early in the pandemic, such as Spain, Italy, and Germany—have a decreasing trend in daily incidence , several are not . Armenia, Belarus, and Moldova have reported steadily increasing incidence for more than a month. Poland, Romania, Sweden, and Ukraine appear to have reached a plateau—although the reports have fluctuated from day to day, making it somewhat difficult to identify longer-term trends. Additionally, Armenia, Belarus, Moldova, and Sweden are exhibiting elevated per capita daily incidence . Moldova is reporting approximately 4 times the global per capita daily incidence, Armenia approximately 5 times the global average, Sweden 6 times the global average, and Belarus nearly 10 times the global average. For reference, the United States is currently reporting approximately 6-7 times the global average.

Russia reported 10,598 new cases, continuing its recent trend of elevated incidence . The United Kingdom continues to report steadily decreasing daily incidence and deaths, which would be the fourth consecutive week. India reported nearly 4,000 new cases, continuing its recent trend of elevated and increasing daily incidence . India could surpass China's total case counts tomorrow. Tamil Nadu state, where a large outbreak has been linked to one of Asia’s largest markets, reported 447 new cases.

Singapore reported 793 new cases, including 791 (99.7%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s growing COVID-19 epidemic. Singapore estimates that the cases confirmed so far represent 7.60% of the total population across all migrant worker dormitories, compared to only 0.03% of the general public population. Of the 26,891 total COVID-19 cases reported in Singapore, 24,549 (91.3%) are among residents of migrant worker dormitories. Over the past 2 weeks, Singapore has reported 9,703 COVID-19 cases among migrant workers (including 58 not living in dormitories), compared to only 86 community cases.

The US CDC reported 1.38 million total cases (20,869 new) and 83,947 deaths (1,701 new). The United States could potentially reach 1.5 million cases by Tuesday next week. If the current trend continues, the United States could record its second consecutive week of decreasing incidence. In total, 9 states 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, 36 states (increase of 1), plus Guam, are reporting widespread community transmission.

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 1.42 million US cases and 85,974 deaths as of 10:30am on May 15.

SLOVENIA DECLARES END TO COVID-19 EPIDEMIC Slovenia declared an end to its COVID-19 epidemic and will lift a number of social distancing and other protective measures . Yesterday, Prime Minister Janez Janša addressed the National Assembly and stated that the epidemic could be declared over by the end of the month. In his remarks, he emphasized that Slovenia is “transitioning into a phase where there is a danger of individual outbreaks occurring in the second wave” and cited recent outbreaks in South Korea as evidence of the risk. Today, the Slovenian government officially declared the end of the epidemic . As part of the declaration , Slovenia removed the mandatory 7-day quarantine for travelers arriving from Europe that had been in place since mid-April . Additionally, many children will return to school starting May 18, and additional classes will resume on May 25.

COVID-19 IN AFRICA According to a modeling study accepted for publication in BMJ Global Health there could be as many as 250 million COVID-19 cases and 190,000 deaths across Africa in the first year of the pandemic. As of April 29, 45 of the 47 countries in the WHO Africa Region have reported cases of COVID-19. Additionally Djibouti, Egypt, Libya, Morocco, Somalia, Sudan, and Tunisia have reported cases but are not members of the WHO Africa Region. The researchers estimated that 4.6-5.5 million could require hospitalization, which would quickly overwhelm healthcare resources and potentially impact other health campaigns, including for HIV, tuberculosis, and malaria control. The study estimates that younger, seemingly healthy individuals in Africa could be at elevated risk due to undiagnosed health conditions. The researchers estimate that geographic and socio-ecological effects could result in slower spread across the continent, but the epidemic could persist for a longer period of time than in other parts of the world.

LOCKDOWN IN CHILE Chile’s capital city, Santiago , has been placed under complete lockdown with mandatory quarantine imposed for the entire province. The decision was made to implement the lockdown after a 60% increase in COVID-19 incidence, including 2,660 new cases reported in a 24-hour period. Of the approximately 34,000 reported cases of COVID-19 in Chile, 80% are reported in the city of Santiago. During the lockdown, residents will only be permitted to leave their homes for essential supplies like food and medication. Previously, Chile implemented containment measures, including quarantine, based on the COVID-19 risk in specific areas. In addition to the Santiago lockdown, Chile will enforce mandatory quarantine measures nationwide for individuals over the age of 75. Chile has conducted 313,750 tests to date, one of the highest totals in Latin America.

COVID-19 IN ROHINGYA CAMPS COVID-19 cases have reportedly been detected in individuals living in or near refugee camps in Cox’s Bazar , Bangladesh. These camps are home to nearly 1 million Rohingya refugees, and one expert estimates that the population density could be 8 times that of Wuhan, China. The refugee camps have very few public health or healthcare resources. Sanitation infrastructure is largely non-existent, making it would be extremely difficult to contain a COVID-19 outbreak in these communities. According to one report, at least 2 cases have been identified in or near the camps, and both cases were placed in isolation. The camps have been “under a complete lockdown” since early April, and health experts fear a major humanitarian disaster if the virus is able to take root in the camps. At the national level, Bangladesh’s epidemic is accelerating , and the country reported more than 1,200 new cases today, its highest daily total.

ABBOTT POINT-OF-CARE TEST The US FDA released an alert after data suggested that results from the Abbott Laboratories ID NOW point-of-care test for SRS-CoV-2 can return a high proportion of false negatives. To promote transparency, the FDA is releasing an alert while actively communicating with Abbott to further investigate the issue, and Abbott will also be conducting their own studies. The FDA has received 15 adverse event reports suggesting inaccurate negative results for patients. Users of the Abbott point-of-care test will receive a notification to alert them that patients may need additional confirmatory testing, if a negative test result does not align with the patients’ clinical presentation. The alert is not meant to state that the Abbott rapid test should not be used; but to remind users that clinical management decisions should be made with consideration of both patient presentation and test results, including additional confirmatory testing if necessary. The Abbott test has reportedly been used to screen White House staff . US Secretary of Health and Human Services Alex Azar commented today that the false negative results may be a result of “user error” and that the White House still has confidence in the test’s accuracy.

COVID-19 STIGMA Stigma against persons and places associated with cases of COVID-19 has created additional challenges for adequately controlling transmission in the community. In Haiti , the Director General of the Ministry of Public Health and Population identified the fight against stigma as the greatest battle in the management of the epidemic. COVID-19 patients have experienced harassment, which has resulted in a reticence to come forward to receive treatment and disclose potential contacts who may be infected. Medical centers have opted not to open COVID-19 treatment units after opposition from local communities sparked fear of violence. Healthcare workers have received threats of attack, and there is a need for additional security at healthcare facilities to ensure the safety of staff and patients. Stigma is also preventing safe and dignified burials of COVID-19 victims.

CDC SOCIAL DISTANCING DECISION TOOLS The US CDC published a series of “decision trees” to provide guidance to state and local governments, schools and child care services, restaurants and other businesses, and others regarding when and how to safely relax social distancing measures for various aspects of society. The guidance documents address public transit , workplaces , restaurants and bars , schools , child care , and camps and other youth programs . Each document provides guidance regarding criteria and metrics to consider with determining whether or not it is appropriate to resume operations as well as recommended “safeguards” for both health and safety and disease monitoring. Most of the guidance is consistent across all sectors—including hygiene, disinfection, and social/physical distancing measures—but guidance for each sector also includes tailored recommendations. For example, the guidance for child care addresses the need to limit the sharing of toys and other objects between children. While not nearly as comprehensive as the unreleased draft guidance that has circulated among news media outlets over the past week or so, this appears to be among the most concrete guidance issued by the CDC with respect to efforts to safely relax social distancing measures.

STATES RELAXING SOCIAL DISTANCING US states are continuing to advance plans to relax social distancing measures implemented in response to COVID-19. New York Governor Andrew Cuomo announced that several regions in the state will be able to start relaxing social distancing measures beginning today. In total, 5 regions have met the state’s criteria to move into Phase 1 of the recovery plan , which would allow them to begin reopening non-essential businesses and easing other restrictions. The “NYS on PAUSE” order expires today, but the remaining 5 regions, including New York City, will stay under more restrictive social distancing measures until they meet the criteria necessary to move into Phase 1. Notably, the New York Stock Exchange is scheduled to reopen its trading floor on May 26, albeit with a fraction of the usual personnel and with additional social distancing measures.

Ohio and Rhode Island both announced new efforts to ease social distancing measures. In Ohio , child care; gyms, pools, and non-contact/limited contact sports; campgrounds; Bureau of Motor Vehicles offices; and horse racing (without spectators) will be permitted to resume operations by the end of May. Outdoor dining at restaurants as well as barber shops, hair and nail salons, spas, and tanning facilities are permitted to resume operations starting today . Indoor dining at restaurants will resume on May 21. In Rhode Island , summer camps and other youth programs are scheduled to resume starting June 29, and libraries are beginning to expand operations, including in-person browsing and computer access.

In Michigan, armed protesters once again gathered at the state house to oppose the ongoing statewide “stay at home” order. The gathering was reportedly smaller than previous protests. Michigan’s stay at home order is scheduled to expire on May 28. The state has exhibited several weeks of declining daily incidence , but it still remains elevated compared to many other states. Analysis published in Health Affairs found that social distancing measures had significant effects in reducing SARS-CoV-2 transmission. Based on analysis conducted at the county level in the United States, the researchers concluded that “shelter in place” orders (eg, “stay at home” or “safer at home” orders) that restricted community activity to essential services and the closure of restaurants, bars, gyms, and entertainment businesses were both associated with statistically significant reductions in community transmission after they were implemented.