COVID-19
Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.

The Center for Health Security is analyzing and providing update s  on  the emerging novel cor on avirus. If you would like to receive these daily  update s, please  s ign up below and select COVID-19. Additi on al resources are also available  on  our  website .
May 19, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 18 reports 4.62 million confirmed cases (93,324 new) and 311,847 deaths (4,452 new).

Brazil continues its accelerating trend, reporting 13,140 new cases, its fourth highest daily incidence to date. Brazil is currently reporting the second most new cases daily, following only the United States, and it has reported its 5 highest daily totals over the past 6 days. Nearly a quarter of Brazil’s cases are in the state of São Paulo, more than double the total from any other state, but the state also represents 22% of Brazil’s total population. Brazil’s daily per capita incidence (56.5 new cases per million population) has almost reached that of the United States (65.7), and it is exhibiting an overall increasing trend, whereas the United States appears to be on the decline.

Russia reported 9,263 new cases, continuing its recent trend of elevated incidence , and it will surpass 300,000 cases in its next update. India reported 5,970 new cases, posting its 3 highest daily totals over the past 3 days. The state of Tamil Nadu, where a large outbreak has been linked to one of Asia’s largest markets, reported 536 new cases.

Singapore reported 451 new cases, including 450 (99.8%) 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 8.22% of the total population across all migrant worker dormitories, compared to only 0.03% of the general public population. Of the 28,794 total COVID-19 cases reported in Singapore, 26,541 (92.2%) are among residents of migrant worker dormitories.

UNITED STATES
The US CDC reported 1.48 million total cases (13,284 new) and 88,709 deaths (698 new). A day after reporting its highest daily incidence since April 25, the CDC reported the lowest daily total since March 24. Monday and Tuesday updates are typically low due to reporting delays over the weekend, but yesterday was the fourth consecutive Monday with decreasing incidence compared to the previous week. After such a low incidence reported yesterday, the United States may not reach 1.5 million cases until Wednesday’s update. In total, 9 states (no change) reported more than 40,000 cases, including New York with more than 325,000; New Jersey with more than 125,000; and California, Illinois, and Massachusetts with more than 75,000. The CDC removed information about the degree of transmission reported in each state from its COVID-19 data website.

The New York Times continues to track state-level COVID-19 incidence, with a focus on state policies regarding social distancing. This tracker has been updated to differentiate between states that have relaxed social distancing measures statewide and those that have done so on a regional basis. After holding relatively steady for several weeks—approximately April 7-26— Texas has reported increasing incidence over the past 3 weeks, including a record high daily incidence (1,801 new cases) on May 16. Texas’ “stay at home” order expired on April 30, and non-essential businesses, including restaurants, barber shops/salons, retail stores, gyms, and movie theaters were permitted to reopen. Texas’s COVID-19 incidence was beginning to increase when the statewide order expired, and it has continued that trend in the weeks since. Texas also reported its 2 highest daily death totals on May 14 and 15—58 and 56 new deaths, respectively. Notably, Texas’ testing capacity has increased as well, more than doubling since the “stay at home” order expired. The positivity ratio decreased over that time, from approximately 6% to 4.5%. 

The Johns Hopkins CSSE dashboard is reporting 1.52 million US cases and 90,994 deaths as of 1:30pm on May 19.

LOS ANGELES SEROLOGICAL STUDY A research letter published in The Journal of the American Medical Association ( JAMA ) describes a study that evaluated the seroprevalence of SARS-CoV-2-specific antibodies adults in April 2020. Based on tests performed on 865 individuals, the researchers estimate that approximately 4.65% of the Los Angeles population would have antibodies against SARS-CoV-2, which would total approximately 367,000 individuals. At the time of the study, Los Angeles had reported a total of 8,430 confirmed cases, which suggests that there could potentially be more than 40 unidentified infections in Los Angeles for every confirmed case.

PRESIDENT TRUMP TAKING HYDROXYCHLOROQUINE US President Donald Trump shared yesterday that he has been taking a daily dose of hydroxychloroquine for the past few weeks. President Trump’s physician issued a statement that suggests that he prescribed the treatment course, citing its “potential benefit,” but it does not explicitly state that the President has been prescribed or is taking the drug. especially in light of recent news about potential SARS-CoV-2 exposures within White House staff. The announcement prompted a response from health experts across the country warning that the drug has not yet demonstrated an effect in treating or preventing COVID-19 and emphasizing that its use is associated with potentially severe adverse effects.

A report published yesterday by STAT News describes how widespread use of hydroxychloroquine in Utah necessitated drastic changes in state policy following high rates of adverse events. After initially placing large a order in order to establish a stockpile of the drug, the state “abandoned its plans to make the drugs available without prescriptions and canceled its order.” Based on its own investigation, STAT News outlines the timeline for these decisions and conflict between health experts and elected officials regarding hydroxychloroquine and its potential use in COVID-19 patients.

US SOCIAL DISTANCING Many US states are beginning to relax social distancing measures in an attempt to return to modified forms of business. California Governor Gavin Newsom announced an update to California’s plan that could potentially allow counties to move more quickly in their efforts to relax social distancing. Perhaps the most substantial change lies in updated epidemiological criteria for moving into State 2. Previously, counties were required to report “no more than 1 COVID-19 case per 10,000” population over the previous 2 weeks and no COVID-19 deaths over that same period. The updated requirements shift away from COVID-19 incidence and focus more on the impacts to healthcare systems. The new criteria require counties to have “stable/decreasing” COVID-19 hospitalizations—ie, less than a 5% daily increase—or no more than 20 total hospitalized COVID-19 patients over the previous 2 weeks. Additionally, counties must report fewer than 25 new cases per 100,000 population over a 2-week period or testing positivity below 8% over 1 week.

In Texas, which has also moved into its second phase of relaxing social distancing, some parts of the state, including El Paso, will reportedly face a delayed timeline . Texas Governor Greg Abbott announced that the delay was in response to an elevated burden on local health systems that did not provide sufficient surge capacity in the event of increased SARS-CoV-2 transmission. Currently, these counties are scheduled to enter Phase 2 on May 29, a week behind the original timeline. The announcement was reportedly a result of a request by local officials to be temporarily exempted from the statewide changes.

While businesses in many parts of the country are reopening as social distancing measures are relaxed, some consumers may not be quite ready to return . Perceived risk of COVID-19 is still high in many communities, and consumers—and potentially workers as well—may not yet feel it is safe enough to resume normal activities, even with some social distancing measures remaining in place. The economic recovery may proceed more slowly rather than simply switching on as businesses reopen. 

SARS-CoV-2 VACCINE HESITANCY Looking ahead to the availability of a SARS-CoV-2 vaccine—hopefully, sooner than later—concerns about individuals’ willingness to be vaccinated could potentially limit the effect of national and global vaccination campaigns. Vaccine hesitancy and anti-vaccine sentiment have grown worldwide in recent years, and proactive effort between now and when the vaccine is available could mitigate their effects on vaccine acceptance. A commentary published in JAMA outlines potential barriers to vaccine acceptance and emphasizes the importance of initiating appropriate engagement efforts now. Vaccine hesitancy or anti-vaccine sentiment broadly stem from concerns about the need for or value of vaccines, vaccine safety, and freedom of choice. Leveraging demand for the vaccine once it becomes available, ensuring transparency regarding vaccine efficacy and safety, and engaging trusted community and cultural leaders can help shape the conversation to promote vaccine acceptance. Additionally, it will be critical to counter mis- and disinformation around the vaccine and vaccination campaigns and ensure fair and equitable access to the vaccine, particularly for high-risk populations.

NAVAJO NATION The Navajo Nation (US) has surpassed New York and New Jersey in terms of per capita COVID-19 incidence. With 4,278 reported cases , the Navajo have an incidence of nearly 2,500 cases per 100,000 population, compared to approximately 1,670 and 1,800 cases per 100,000 in New Jersey and New York, respectively. Native American tribes face a number of barriers that can put them at elevated risk for COVID-19 and other diseases. In this case, multiple generations of family members often live together, which can facilitate transmission in the home, and limited options for groceries and other supplies can increase the number of people at certain stores such as supermarkets. The Navajo Nation has implemented a robust testing program that has reached more than 10% of the population already, which could be contributing to the elevated COVID-19 incidence; however, the test positivity is approximately 16%, which indicates that increased testing may be needed to better capture ongoing community transmission. Racial and ethnic minority populations have been disproportionately affected by the US COVID-19 epidemic, and additional effort is needed to provide essential services and support, including access to testing and health care, to mitigate the increased risk in these populations.

PRESIDENT TRUMP & THE WHO US President Donald Trump published a letter addressed to WHO Director-General Tedros Adhanom Ghebreyesus in which he threatens to terminate the United States’ membership in the WHO . The letter outlines findings from a US government investigation into the WHO response to COVID-19 and asserts that the WHO is unable to remain independent from China’s influence. The letter highlights a series of “missteps” made by the WHO and notes that the WHO “repeatedly made claims about the coronavirus that were either grossly inaccurate or misleading.” A number of the “missteps” address the WHO’s praise for China’s response and transparency, contradicting evidence suggesting that Chinese officials attempted to conceal or misrepresent relevant information regarding the emerging pandemic, and delays in the WHO declaring a Public Health Emergency of International Concern (PHEIC) and pandemic. President Trump previously ordered a temporary hold on WHO funding, and he stated that he intends to make this permanent and consider withdrawing from the WHO if “substantive improvements” are not made within 30 days.

In the letter, President Trump cited content published in The Lancet in December 2019 or earlier as evidence that the extent of transmission in China was known to the WHO at that time. The Lancet published a response this morning to correct the “factually inaccurate” statement, noting that the journal did not publish anything on the initial outbreak prior to January 24, 2020. Additionally, the journal emphasized the risk that President Trump’s statements pose to critical international cooperation as well as the importance of conducting “factually accurate” reviews of the global response. 

INDIA & BANGLADESH EVACUATE MILLIONS In advance of an impending “super cyclone,” India and Bangladesh are evacuating millions of residents living in the storm’s projected path. Cyclone Amphan —currently the equivalent of a Category 4 hurricane (Atlantic) or “super typhoon” (Pacific)— is forecasted to reach land in the next several days, and Bangladesh officials reportedly indicated that it is expected to be the worst storm since 2007. Much like the recent typhoon response and recovery efforts in the Philippines , evacuations and housing are complicated by the COVID-19 pandemic. Additional shelters are being opened, and masks are being distributed to mitigate the risk of transmission in densely populated evacuation shelters; however, some emergency shelters are currently being utilized to support the COVID-19 response and are not available for evacuees.

Both India and Bangladesh are exhibiting increasing COVID-19 incidence , and a major natural disaster could further increase the risk of transmission in affected areas. Additionally, Bangladesh recently reported its first confirmed COVID-19 cases in and around Rohingya refugee camps , which raised concerns about a future humanitarian crisis if an outbreak is seeded in the camps. The storm is projected to make landfall on Bangladesh’s Eastern border, on the opposite side of the country from the camps in Cox’s Bazar, but the storm could cause heavy rain and dangerous seas hundreds of miles away.

COVID-19 CASES IN FRENCH SCHOOLS Many students in France have returned to school , and in the week since classes resumed, France has reported 70 cases associated with the schools —potentially including teachers and students. French Minister of Education Jean-Michel Blanquer reportedly commented that the timeline suggests that the cases were likely infected prior to resuming classes, but this illustrates the potential risk of exposure as schools reopen. Additional schools in France’s “green zones” began reopening yesterday . France reported its first death in a child that appeared to be a result of a “syndrome related to Kawasaki disease” in a 9-year-old child on May 15, which is thought to be potentially associated with COVID-19 in children. Some countries are resuming classes, and others, including many parts of the United States, are evaluating plans to reopen schools, including the protective measures needed to mitigate transmission risk. It is important to monitor data in areas where schools are reopening to better characterize the role of children in community transmission and, more specifically, the effect of opening schools on the epidemic’s trajectory.