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

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May 20, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 19 reports 4.73 million confirmed cases (112,637 new) and 316,169 deaths (4,322 new). This is the second time in the past 3 days that the WHO has reported more than 100,000 new cases, and the global total incidence could reach 5 million cases by Friday’s Situation Report.

Brazil reported 17,408 new cases, its highest daily incidence to date. Brazil is now #3 globally in terms of total incidence—behind only the United States and Russia—and its daily per capita incidence is now nearly identical to the United States—60.35 new cases per million population in Brazil, compared to 61.11 for the United States. While the daily incidence in the United States has been decreasing for several weeks, Brazil’s is rapidly increasing.

Russia reported 8,764 new cases, slightly fewer than its recent trend of elevated incidence . India reported 5,611 new cases, continuing its recent trend of elevated and increasing daily incidence. The state of Tamil Nadu, where a large outbreak has been linked to one of Asia’s largest markets, reported 688 new cases.

Singapore reported 570 new cases, including 562 (98.6%) 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 8.39% of the total population across all migrant worker dormitories, compared to only 0.03% of the general public population. Of the total confirmed cases reported in Singapore, 92.3% are among residents of migrant worker dormitories.

The US CDC reported 1.50 million total cases (24,481 new) and 90,340 deaths (933 new). Daily COVID-19 deaths in the United States are on the decline , but the total could potentially reach 100,000 deaths in the next 7-10 days. In total, 10 states (1 new) 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 New York Times continues to track state-level COVID-19 incidence, with a focus on state social distancing policies. This tracker now differentiates between states that have relaxed social distancing measures statewide and those that have done so on a regional basis.

New York state and New York City have reported steadily increasing tests since late March and steadily decreasing incidence since mid-to-late April, an encouraging sign from the hardest-hit area of the country.

Alabama continues to exhibit increasing daily incidence after beginning to relax social distancing measures on May 1. Following a brief period of relatively level or decreasing incidence in mid-to-late April (approximately April 9-28), Alabama’s reported incidence has increased substantially over the past several weeks. The 14-day average increased from fewer than 200 new cases per day on April 29 to more than 300 yesterday, and the states 399 new cases yesterday, its highest daily incidence to date. Alabama’s COVID-19 hospitalizations are also increasing, up from 515 patients on April 6 to a high of 706 on May 18. Notably, Alabama’s test positivity increased from 6.6% for the week of March 28 to 9.8-9.9% through most of April before falling to 7.0% for the week of May 9. According to the Johns Hopkins COVID-19 Testing Insights Initiative , which utilizes data compiled by the COVID Tracking Project , Alabama appears to have increased testing since March, which would likely contribute to increasing reported incidence. Alabama ranks #27 among states with respect to per capita testing—3,215 tests performed per 100,000 population.

The Johns Hopkins CSSE dashboard is reporting 1.53 million US cases and 92,149 deaths as of 12:30pm on May 20.

RE-POSITIVE TESTS The Korean Centers for Disease Control and Prevention (Korean CDC) reported findings from a study of recovered COVID-19 patients who tested positive for SARS-CoV-2 after their recovery. The study aimed to determine whether the positive test results after recovery—as long as 37 days after discharge from isolation—were artifacts of testing or due to reinfection or reactivation of the virus. The study concluded that the re-positive test results were not due to reinfection or reactivation , but rather, were a result of the PCR diagnostic tests detecting non-viable viral particles as the infection is slowly cleared from the body. These results indicate that individuals who have recovered from acute illness can no longer infect others. As such, the Korean CDC updated its guidance regarding the management of “re-positive cases,” including the removal of a mandatory 14-day self isolation period after being discharged from isolation and the requirement for subsequent PCR testing if symptoms present after a patient is discharged from isolation. 

LIVE SARS-CoV-2 IN FECES A Research Letter published in Emerging Infectious Diseases reported results from a study that documented the presence of infectious SARS-CoV-2 virus in fecal matter. The researchers were able to isolate SARS-CoV-2 from fecal specimens from COVID-19 patients in Guangdong, China, and successfully infect non-human primate cells in vitro using the viral isolates. While the study does not necessarily demonstrate that SARS-CoV-2 transmission in humans is possible via the fecal-oral or fecal-respiratory routes or that fecal transmission is a significant driver of the ongoing COVID-19 pandemic, it does provide evidence that viable SARS-CoV-2 virus can be excreted in COVID-19 patients’ feces. Further research is necessary to determine the extent to which fecal-oral or fecal-respiratory transmission of SARS-CoV-2 occurs in humans, but these findings suggest that infection control and prevention measures may be necessary to mitigate exposure to SARS-CoV-2 via COVID-19 patients’ feces.

CHILE PROTESTS In Santiago, Chile, protesters gathered to call attention to a lack of food and government aid during the recently implemented COVID-19 "lockdown" in Chile’s capital city. Following the protest, Chilean President Sebastián Piñera reportedly committed to increasing aid to the affected population, with a focus on supporting the most vulnerable among them. Chilean citizens have protested the national government in recent years, demanding political and social reforms to policies and legislation enacted under former dictator Augusto Pinochet. A referendum on constitutional changes was originally scheduled for the end of April, but it has been delayed until at least October due the country's COVID-19 epidemic. 

BRAZIL HEALTH MINISTER RESIGNS Brazil’s Minister of Health, Nelson Teich, resigned from his position after only several weeks in office. Dr. Teich and his predecessor were reportedly pressured by Brazilian President Jair Bolsonaro to promote the use of hydroxychloroquine and to work with the state governors to lift social distancing restrictions, which may have contributed to their respective decisions to resign. President Bolsonaro reportedly instructed Dr. Teich to issue federal guidance that would increase the early use of hydroxychloroquine, despite concerns regarding the drug’s efficacy and risk of severe adverse effects. President Bolsonaro has also clashed with state governors, some of whom are resisting orders to relax social distancing measures. Brazil has been reporting increasing COVID-19 incidence and deaths, including reporting its record high daily COVID-19 incidence and deaths yesterday, and the health system in São Paulo is reportedly on the brink of collapse .

IN-PERSON COLLEGE CLASSES Some US colleges and universities are making plans to reopen their institutions for in-person classes this fall. While universities face difficult choices regarding when and how to resume classes, they are also developing creative options in an attempt to support the health and safety of their students, faculty, and staff while still providing a valuable education experience. The University of Notre Dame, for example, plans on beginning classes August 10 and intends to end the semester before Thanksgiving , which would avoid students dispersing across the country for the holiday and then returning for the final weeks of classes and exams between Thanksgiving and Christmas. New York University (NYU) is offering a “Go Local” option , which will allow students to attend the NYU campus closest to where they live. This could allow some students in other countries to resume classes without needing return to New York, one of the hardest-hit areas in the United States. The University of Kentucky is considering several options to resume classes, including one that will allow only freshmen and sophomores to return to campus , while juniors and seniors will take classes online in order to reduce the number of students on campus.

DOWNSTREAM EFFECTS As we have covered previously, the ongoing US COVID-19 epidemic is impacting hospital and health system operations far beyond COVID-19 patient surge. “Stay at home” orders and recommendations to avoid emergency departments unless absolutely necessary have resulted in substantial decreases in non-COVID patient volumes at many hospitals across the country. While a substantial portion of the decrease can be attributed to fewer trauma patients—eg, due to fewer automobile accidents—patients with other emergent conditions, including heart attacks and strokes, have decreased as well. Patients may avoid or delay seeking care for truly emergent health conditions due to concern about exposure to SARS-CoV-2 in the hospital, which can result in death if treatment is not received in time. Some estimates indicate that normal emergency department patient volume decreased by 50%, or possibly more, compared to last year. Additionally, “elective procedures” (eg, scheduled surgeries) have been prohibited in many states, which can include surgeries and other treatments for cancer . Some conditions may not pose an immediate risk of death, but lengthy delays to treatment can allow these conditions to worsen, which can ultimately increase the risk of death. The effect of the COVID-19 epidemic is similar to what has been observed in areas affected by hurricanes or other major disasters; however, the COVID-19 impact is persisting for a prolonged period of time.

JILIN PROVINCE, CHINA Health officials in Jilin Province, China, have implemented “lockdown” measures, reminiscent of those implemented in Wuhan, following a recent cluster of COVID-19 cases that began on May 7. We have not been able to definitively determine the exact incidence in Jilin prior to the current outbreak, but it appears as though approximately 100 cases had been reported prior to May 7. At least 34 new cases have been reported in Jilin City and Shulan since that date [Note: Shulan appears to be under the jurisdiction of Jilin City]. Shulan was designated as a high-risk area on May 10, “the only such area in China” at that time, and several other districts in Jilin City have been designated as medium- or high-risk areas since then. On May 13, the Jilin City rail station was closed , allowing trains to pass through but not permitting them to stop for passengers. Lockdowns have been initiated in Shulan and Jilin City, potentially affecting approximately 1.5 million local residents . Additionally, medical response teams have been deployed from other cities in Jilin Province to support the response, and several hospitals have been designated to treat COVID-19 patients . Jilin Province had nearly 4.5 million visitors for its May Day celebration from May 1-5, just 2 days before the onset of the current outbreak, which could potentially pose risk of broader spread to other parts of China. Multiple media outlets are reporting that more than 100 million people across Jilin Province are under lockdown, but we have not identified any official sources to confirm that lockdowns are in place in Jilin Province outside Jilin City.

Also of note, China’s National Health Commission recently announced that face masks are no longer mandatory across China. Masks are no longer required in outdoor spaces in areas of low infection risk, where social distancing can be properly maintained. Individuals should still wear masks indoors or in crowded areas.

HOW TO GET REOPENING RIGHT The Johns Hopkins University Bloomberg School of Public Health is hosting a webcast to discuss various metrics and criteria, challenges, and recommendations as states continue to relax social distancing measures, including protective measures individuals can take to mitigate their infection risk. The event, How to Get Reopening Right , will take place tomorrow—Thursday, May 21—from 2:30-3:15pm EDT. The panelists will be Dr. Tom Inglesby and Dr. Crystal Watson from the Johns Hopkins Center for Health Security and Beth Blauer from the Johns Hopkins University Centers for Civic Impact, and it will be moderated by Stephanie Desmon, co-host of the Johns Hopkins Bloomberg School of Public Health’s Public Health on Call podcast.

MASKS MANDATORY IN SPAIN Spain’s Ministry of Health issued an order requiring all persons aged 6 years and older to wear a mask in public spaces where it is not possible to maintain social distancing. The order extends to both indoor and outdoor settings, and it includes exceptions for individuals who have health conditions (eg, difficulty breathing) that would not allow them to wear a mask. The order also recommends mask use for children between the ages of 3-5 years, but is not mandatory. Spain was subject to one of the worst national COVID-19 epidemics, which necessitated implementing some of the most restrictive social distancing measures in Europe, including not allowing children outside for more than 6 weeks. In addition to the new mask order, Spanish Prime Minister Pedro Sanchez requested that the national parliament extend emergency authorities for an additional 2 weeks, which would allow Spain to slow its process of relaxing social distancing measures. Protests are ongoing in some parts of the country, calling for “lockdown” measures to be removed. 

CDC SOCIAL DISTANCING GUIDANCE The US CDC published new guidance to support states’ efforts to relax social distancing measures implemented in response to COVID-19. The guidance— CDC Activities and Initiatives Supporting the COVID-19 Response and the President’s Plan for Opening America Up Again —includes both “gating criteria” and recommendations for each of 3 phases. The gating criteria address daily COVID-19 incidence; health system capacity, including emergency department (ED) and outpatient volume for COVID- and influenza-like illnesses as well as inpatient and intensive care unit (ICU) capacity; and SARS-CoV-2 testing, including capacity and test positivity. The CDC also includes a variety of metrics, tools, and guidance to support states’ efforts to properly collect and analyze data needed to evaluate trends and thresholds related to these criteria. Additionally, the document provides “setting specific guidance” for schools and child care, high-risk individuals in the workplace, restaurants and bars, and public transit, which appears to provide more detailed information to supplement similar guidance published last week.

This most recent guidance is dated May 2020, but it is unclear exactly when the CDC published it. Multiple media outlets began reporting on its release late yesterday evening , but the CDC does not appear to have made a formal announcement coinciding with its release. We have not identified any archived versions of the document before today. The new guidance comes at a time when all 50 states have already started to relax social distancing measures, a number of which do not appear to have met the recommended gating criteria outlined in the document.

LINGERING QUESTIONS FOR CANDIDATE VACCINE In a recent press release , Moderna, Inc., revealed preliminary information from the Phase 1 trial for its mRNA vaccine candidate against SARS-CoV-2. The press release claimed that several of the Phase 1 study participants developed antibodies against SARS-CoV-2 consistent with the levels found in COVID-19 patients. While this information seems promising, scientists quickly called for a more cautious evaluation of the results. Experts pointed out that Moderna has not released enough data for efficacy to be properly evaluated, including the levels of antibodies present in the specimens or the values against which they were compared. The actual biological and statistical data from the trial has yet to be released, which is critical to understanding the vaccine’s effects on the body’s immune response. Additionally, the claim in Moderna’s press release is based on a very small sample size, only 8 of 45 total study participants, and it is unclear whether the remaining participants had comparable levels of neutralizing antibodies. The information presented in the press release is encouraging, but considerable data and analysis are needed to better understand the vaccine candidate’s effects.