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

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May 18, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 17 reports 4.53 million confirmed cases (100,012 new; 277,108 since Friday’s briefing) and 307,395 deaths (5,336 new; 15,349 since Friday’s briefing).

Brazil is now #4 in the world in terms of total incidence, with 241,080 confirmed cases. Brazil reported its 2 highest daily incidence totals on May 15 and 16—15,305 and 14,919 new cases, respectively—and it will likely surpass the United Kingdom (246,406 cases) with the next update. Additionally, Peru surpassed China over the weekend to reach #12 in the world in terms of total incidence, with 92,273 cases. Chile (46,059 cases) and Ecuador (33,182) are currently #18 and #22 in the world, respectively. 

Many of the countries with the highest per capita incidence have passed their peak already, including those in Western Europe. Among those with total incidence greater than 2,000 cases per million population, several appear to still be accelerating. Notably, the per capita incidence in Qatar (11,317 cases per million) is more than double every other country and still accelerating. Also in the Eastern Mediterranean region, Bahrain, Kuwait, and the United Arab Emirates are exhibiting concerning accelerating trends. In Central and South America, Chile, Panama, and Peru are all accelerating as well, as are Belarus and Maldives. The epidemics in Canada, Singapore, Sweden, and the United States appear to be slowing.

Russia reported 27,835 new cases since Friday’s briefing, continuing its recent trend of elevated incidence . India reported 14,199 new cases since Friday’s briefing, averaging more than 4,700 new cases per day over the weekend. India reported its 2 highest daily totals and exceeded 5,000 new cases per day for the first time. India surpassed China in terms of total incidence and is now #11 in the world, behind Iran. Tamil Nadu state, where a large outbreak has been linked to one of Asia’s largest markets, reported 1,550 new cases since Friday’s briefing, averaging more than 500 new cases per day. In response to the increased incidence, India extended its national “lockdown” policy through the end of May, although areas of lower risk have fewer restrictions.

Singapore reported 1,452 new cases since Friday’s briefing, including 1,433 (98.7%) 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 8.1% of the total population across all migrant worker dormitories, compared to only 0.03% of the general public population. Of the 28,343 total COVID-19 cases reported in Singapore, 26,090 (92.1%) are among residents of migrant worker dormitories.

The US CDC reported 1.47 million total cases (31,967 new; 82,135 since Friday’s briefing) and 88,709 deaths (1,394 new; 4,762 since Friday’s briefing). The United States will likely reach 1.5 million cases by tomorrow’s update. The 31,967 new cases is the United States’ highest daily total since April 25. In total, 9 states (no change) reported more than 40,000 cases, including New York with more than 350,000; New Jersey with more than 125,000; and California, Illinois, and Massachusetts with more than 75,000. Additionally, 36 states (no change), 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. This tracker is updated to differentiate between states that have relaxed social distancing measures statewide and those that have updated their policies on a regional basis.

The Johns Hopkins CSSE dashboard is reporting 1.49 million US cases and 89,874 deaths as of 12:30pm on May 18.

LANCET EDITORIAL As we have noted previously, a number of experts around the world—including from health care, public health, and other fields—have lamented that the US CDC appears to be “sidelined” during the US COVID-19 response . An unsigned editorial published in The Lancet continued this conversation, noting the scaled-back US CDC presence in China prior to the emergence of SARS-CoV-2, partisan conflict over CDC funding, and waning trust in CDC experts, particularly among senior US government officials. The piece describes the CDC’s current role as “an ineffective and nominal adviser," and calls for an expanded role for the CDC, commensurate with its considerable expertise and a return to political independence. Former CDC Director, Dr. Tom Frieden , commented that “it’s not clear that the CDC’s expertise is feeding into the decisions that are being made.”

VACCINE DEVELOPMENT Last week, US President Donald Trump provided additional details on Operation Warp Speed , the US plan to rapidly develop, test, and manufacture a SARS-CoV-2 vaccine. The program will involve senior experts and leadership from both the US Department of Health and Human Services and the Department of Defense, and it aims to develop, test, and scale up production for a SARS-CoV-2 vaccine in order to make millions of doses available by early 2021. This would be a monumental effort and would considerably accelerate the process for any previous vaccine by months or years. One of the project leaders, Dr. Moncef Slaoui, commented that he had recently seen encouraging preliminary data from early clinical trials of a vaccine candidate. This morning, Moderna, Inc., issued a press release describing encouraging preliminary results from its Phase 1 vaccine trial. While Phase 1 trials are designed to evaluate safety of the vaccine in humans, Moderna noted that early data (based on only 8 participants) are promising that the vaccine could induce the development of protective antibodies. More data is required to better characterize the body’s immune response, particularly with respect to the effect on conferring immunity to SARS-CoV-2.

President Trump committed to collaborating with other countries to ensure wide availability of any successful vaccine, regardless of where it is developed, including distributing production around the world. The WHO is reportedly considering the development of a voluntary global repository for relevant data, patent rights, intellectual property, and other technical and regulatory information to support the worldwide availability of the vaccine as soon as possible. The United States has previously declined to participate in the WHO-led international consortium to support SARS-CoV-2 vaccine development, and it is unclear whether it would participate in the voluntary repository.

Yesterday, Jerome Powell, Chairman of the US Federal Reserve , commented that the full recovery of the US economy may be contingent on the availability of a vaccine. Without a vaccine to mitigate transmission risk, experts are concerned that any increased social contact resulting from states loosening social distancing restrictions could result in increased transmission. Chairman Powell stated that he expects the economy to steadily recover over the coming months, but it will depend on individuals’ confidence in their health and safety. And full confidence may not be feasible without a vaccine.

US SOCIAL DISTANCING US states continue to announce and implement plans to ease social distancing measures. Last week, New York , New Jersey , Connecticut , and Delaware laid out plans to begin resuming some aspects of society. Notably, the 4 states will begin opening some beaches in time for the Memorial Day holiday weekend. The plan will apply to state beaches, which will be limited to 50% capacity. Some group activities, such as sports like volleyball, will be prohibited, and concession stands, picnic areas, and pavilions will be closed in an effort to promote social distancing. Local beaches may reopen as well, if they follow the state guidance, at a minimum.

Massachusetts Governor Charlie Baker is expected to announce the initial steps to relax statewide social distancing measures. Massachusetts is among the hardest-hit states after an early outbreak linked to a biotechnology conference . Massachusetts will use a 4-phase plan , which will incrementally relax social distancing until the point at which the availability of a vaccine or treatment will permit “the resumption of a ‘new normal.’”

Kentucky is scheduled to lift its “travel ban” and reopen most state parks this week ahead of Memorial Day weekend. Several state parks are being used to house “low acuity patients,” so those will remain closed to the public. Minnesota is also set to begin resuming operations at non-essential businesses and state parks this week. As businesses, parks, and other facilities reopen, they will be required to implement various social distancing, hygiene, and other protective measures.

WORLD HEALTH ASSEMBLY The 73rd World Health Assembly (WHA 73) commenced today, conducted virtually for the first time in history . While a number of health issues are on the agenda—including polio eradication, neglected tropical diseases, and International Health Regulations implementation—the discussion is expected to focus heavily on the COVID-19 pandemic and the mechanisms and capabilities necessary bring it under control. A group of 41 individual countries as well as the Africa Group Member States and the European Union submitted a proposal that calls, in part, for a systematic and independent review of the WHO’s COVID-19 pandemic response in order to inform best practices for future responses. Additionally, the proposal directs the WHO to continue collaboration with the World Organisation for Animal Health, including on determining the zoonotic origin of the pandemic.

In an opening address at WHA 73, Chinese President Xi Jinping announced that China will commit approximately US$2 billion in aid over the next 2 years to combat the COVID-19 pandemic, particularly in Africa. President Xi also indicated that China supports a review of the COVID-19 response. After recent increases by several countries, including the United States, in their support for Taiwan’s inclusion in WHA 73 , particularly in light of Taiwan’s successful COVID-19 response, Taiwan did not receive an invitation. Taiwan announced that it would not pursue further efforts to participate in the meeting.

COVID-19 ANIMAL MODEL The search for a suitable animal model for SARS-CoV-2 continues. Numerous scientists are currently researching animal species that can mimic COVID-19 in humans in order to develop animal models for research purposes; an animal model would more easily allow for challenge studies for investigational vaccines and therapeutics. The WHO instituted a working group to study prospective animal models in mid-April, and initial studies are beginning to publish results. Researchers have demonstrated that non-human primates, including the African green monkey and multiple species of macaques , and rodents, including Syrian hamsters , can be infected with SARS-CoV-2 and exhibit COVID-19-like clinical manifestation. Additional research is necessary to better characterize the limitations of these models; however, these are promising initial steps that could provide critical data necessary for future pharmaceutical research. 

NIGERIA Reports are emerging of a COVID-19 hotspot in Kano, Nigeria . Nigeria has reported 5,959 confirmed cases and 182 deaths, including 825 cases and 36 deaths in Kano, but reports indicate that COVID-19 incidence and deaths in Kano are being underreported and that the outbreak could be much worse than the data indicate. Nigeria began easing restrictions in select areas on May 4 , including the cities of Lagos and Abuja, but government officials are struggling to enforce the restrictions in areas that have not yet lifted them. In response to the increased incidence, Nigeria reportedly announced today that it will implement “precision” lockdown in 9 areas reporting high incidence, including Kano, and strengthen efforts to enforce those measures. Nigeria is expected to continue its national plan to relax social distancing measures in other areas, but the first phase will be prolonged by 2 weeks.

ITALY SCHEDULED TO LIFT TRAVEL RESTRICTIONS Italy is allowing most businesses to reopen, with social distancing measures in place, including higher-risk settings such as bars, hairdressers, and churches. Movement restrictions for travel within regions have been lifted, but inter-region travel is still largely restricted, except for work or health reasons, until June 2. Italy may permit international travel to resume as well starting June 3, although international travel may be limited to certain countries, depending on COVID-19 risk assessments. Italy has reported 66,553 confirmed cases, including 32,007 deaths, but the national incidence has been declining for several weeks.

COVID-19 IN RURAL AMERICA Over the past several weeks, the expansion of the US COVID-19 epidemic beyond major cities and into rural parts of the country has garnered considerable attention. The epidemic spread rapidly in urban areas where high population density and other factors facilitate transmission; however, rural areas face their own challenges. Low population density could slow the spread of the disease, but rural populations do not necessarily have access to the same health care capacity as urban or suburban populations. As we have covered previously, rural areas are struggling to maintain health care capacity , and a large number of hospitals and other medical facilities have been forced to close over the past several years, including some recently affected by decreased demand stemming from social distancing and concern about SARS-CoV-2 transmission. Rural populations are also disproportionately affected by underlying medical conditions, which could translate into more severe outcomes. Some outbreaks reported in rural communities center around particularly high-risk populations, including nursing homes, meat packing facilities, or correctional facilities, but these events may not remain limited to those institutions. As states continue to relax social distancing measures, it will be important to monitor COVID-19’s spread further into rural populations that were not affected early in the epidemic.