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

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May 21, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 20 reports 4.79 million confirmed cases (57,804 new) and 318,789 deaths (2,621 new). After several days of reported incidence of nearly or more than 100,000 new cases, today’s update is much lower. The global total incidence could reach 5 million cases by Friday or Saturday.

At the global level, the relative proportion of COVID-19 cases continues to shift away from Europe and North America and toward Africa, South America, and Asia. After at one point peaking at more than 75% of the global COVID-19 daily incidence, new case in Europe now represent less than 15% of the daily total. Similarly, North America, driven largely by the United States, represented nearly 45% of the global total in early April, and now constitutes slightly more than 25%. For reference, Europe and North America represent approximately 9.6% and 4.7% of the global population , respectively. Asia and South America have steadily increased their relative contribution to the global incidence, up to nearly 25% for Asia and more than 30% for South America. Africa is slowly but steadily increasing as well, now up to approximately 4% of the global total.

Brazil reported 19,951 new cases, its highest daily incidence to date and an increase of more than 2,500 (14.6%) compared to the previous high reported yesterday. Brazil is now #3 globally in terms of total incidence, and it could potentially surpass Russia to become #2 by early next week. Brazil’s daily per capita incidence is now more than 20% greater than the United States’. The per capita incidence in Peru and Chile is even higher, however, with Peru reporting nearly 120 new cases per million population each day and Chile reporting 172, more than double Brazil’s current per capita daily incidence. Like Brazil, the daily incidence in Peru and Chile are also increasing rapidly.

Russia reported 8,849 new cases, its second consecutive day with fewer than 9,000 new cases. After peaking at more than 11,000 new cases in mid-May, Russia’s daily incidence has decreased over the past week. India reported 5,609 new cases, continuing its recent trend of elevated and increasing daily incidence. On a per capita basis , India’s daily incidence is still well below the global average; however, the increasing trend is concerning. The state of Tamil Nadu, where a large outbreak has been linked to one of Asia’s largest markets, reported 743 new cases.

Singapore reported 448 new cases, including 434 (96.8%) 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 8.53% 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, 92.4% are among residents of migrant worker dormitories.

The US CDC reported 1.53 million total cases (23,405 new) and 91,664 deaths (1,324 new). Daily COVID-19 deaths in the United States are declining , but the total could potentially reach 100,000 deaths in the next 6-8 days. In total, 10 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.

The New York Times continues to track state-level COVID-19 incidence, with a focus on state policies regarding social distancing. This tracker now differentiates between states that have relaxed social distancing measures statewide and those that have done so on a regional basis.

The Johns Hopkins CSSE dashboard is reporting 1.56 million US cases and 93,606 deaths as of 11:30am on May 21.

US MEDICAL SUPPLY CHAIN The US government awarded a 4-year, US$354 million contract to a startup pharmaceutical company to establish and operate domestic production capacity for various generic drugs and active pharmaceutical ingredients (APIs). The contract, awarded through the Biomedical Advanced Research and Development Authority to Phlow Corp., aims to shift production of critical pharmaceuticals back to the United States in order to reduce reliance on foreign production and build a domestic inventory of APIs and surge production capacity for future emergencies. Many generic drugs and APIs used in the United States are currently produced overseas, particularly in China and India, and the COVID-19 pandemic has highlighted the vulnerability of these supply chains to major global health emergencies. The contract could be extended for up to a total of 10 years and $812 million.

In another effort to streamline the domestic medical supply chain, the US Department of Health and Human Services is considering a program to implement a centralized public-private management infrastructure for the Strategic National Stockpile (SNS) . The Office of the Assistant Secretary for Preparedness and Response posted a request for information to solicit public input regarding the program’s “strategy and structure” and the role of public-private partnerships in managing the SNS. The program, referred to as NextGen SNS, looks to streamline procurement, inventory management, and distribution of critical stockpiles supplies and equipment during health emergencies, which have been identified as barriers to the US COVID-19 response .

NEW YORK COVID-19 EPIDEMIOLOGY A study published in The Lancet evaluated the clinical records from 1150 hospitalized patients at 2 Manhattan (New York, US) hospitals. Of the 1,150 patients included in the study, 257 (22%) were critically ill. Out of those critically ill patients, 212 (82%) had at least 1 chronic condition, most commonly hypertension, obesity, and diabetes. The study also found that people of color came to the hospital later in the course of their disease compared to white patients.

COVID-19 ALERT LEVELS Resolve to Save Lives released a color-coded COVID-19 alert system to signify the risk of transmission in communities and recommend appropriate levels of individual precautions. Dr. Tom Frieden, former director of the US CDC, likened this system to wildfire risk level signs on hiking trails or ocean hazard flags on beaches; it is up to individuals reading these signs to understand the risk level around them and act accordingly. This system includes four levels ranging from “new normal” to “high alert,” with corresponding measures that communities and individuals can take at each level to mitigate transmission risk. COVID Exit Strategy , a collaborative COVID-19 data visualization website, has incorporated live data into the Resolve to Save Lives system to make a state-by-state alert system, including metrics for 3 key areas: disease situation, healthcare systems, and disease control. Notably, every US state is evaluated as High Alert as of today, even as all states begin to ease social distancing measures.

DOWNSTREAM EFFECTS We continue to describe a variety of second- and third-order effects of the COVID-19 pandemic, with a focus on impacts on health beyond COVID-19 cases and deaths. We have noted previously that emergency department (ED) volume has decreased since the onset of the US epidemic and implementation of community mitigation measures. A substantial portion of this decrease is due to fewer trauma patients, which is believed to be, in part, a result of fewer cars on the roads and fewer automobile collisions . The sharp decline in trauma patients has led to an associated decline in available organs for transplants. We also noted previously that EDs are reporting decreases in the number of stroke and heart attack patients as well, another major source of organ donations. Additionally, donor patients are often kept on ventilators and other life support to keep the organs viable until a recipient can be identified and the transplant surgery scheduled, but there is concern in some areas that these ventilators could be needed for COVID-19 patients. Overall, transplant surgeries in the United States reportedly decreased by more than 50% compared to this time last year.

SWEDEN SEROLOGICAL STUDY Sweden’s Public Health Authority announced preliminary results from a serological study , based on more than 1,100 specimens collected across 9 regions. The study is ongoing and aims to collect 1,200 specimens per week over an 8-week period. The preliminary results described in the press release correspond to Week 18 (April 27-May 3). During that period, 7.3% of participants in Stockholm had SARS-CoV-2 antibodies, the highest of the regions tested. The press release included results from two other regions—4.2% in Skåne and 3.7% in Västra Götaland. Among the specimens tested, participants aged 20-64 years had the highest seroprevalence (6.7%), followed by 0-19 years (4.7%) and 65-70 years (2.7%). Sweden has previously reported results of studies conducted using molecular tests (e.g., PCR). Molecular tests only detect active infection, whereas serological testing can identify individuals who were previously infected. Sweden has been criticized for not implementing more restrictive mandatory community mitigation measures. Sweden continues to report elevated per capita incidence compared to most of Europe, and its daily per capita deaths is currently the highest in Europe.

PITFALLS OF IMMUNITY PASSPORTS The concept of “immunity passports” based on COVID-19 antibody testing has been the subject of much discussion. The authors of a recent Nature commentary argue against the use of such passports for both practical and ethical reasons. On the practical side, little is known about the durability of immunity in individuals who recover from SARS-CoV-2 infection, and the scale at which serological testing would need to be conducted for such a program would be enormous. Rather than focus resources and efforts on a system of immunity passports, the authors recommend that governments should instead redouble efforts on testing, contact tracing, and vaccine development. Although the WHO has recommended against the use of immunity passports, some countries are still reportedly considering them as an option to bolster efforts to relax community mitigation measures. For example, Estonia has reportedly started testing digital immunity passports , which would enable individuals to temporarily share their “immune status” with a third party through a smartphone app, although it is unclear how this status would be determined. Chile is reportedly planning to offer “virus-free” certificates to certify that an individual has recovered from COVID-19. One health official maintained this would certify that the individual was fully recovered and has completed the associated isolation period; the certificates will not serve the same purpose as an immunity passport.

HOST FACTORS A recent study published in Nature found that host factors were better determinants of severe disease than variations in viral genetics. The study included analysis of molecular and immunologic data from 326 COVID-19 patients from Shanghai, China. Phylogenetic analysis was performed with 221 samples from the GISAID database. With 2 major lineages of SARS-CoV-2 currently circulating, some experts have expressed concern that genetic differences between these lineages could have implications for transmissibility or pathogenicity. This study found no significant differences in transmissibility or in clinical manifestations between patients infected with the 2 different lineages. Instead, the levels of cytokines IL-6 and IL-8 and T lymphocytes were associated with clinical disease severity.

OXFAM SCALES BACK OPERATIONS Oxfam International , a major international humanitarian aid organization, announced that it will restructure its global operations, in part, as a result of financial challenges associated with the COVID-19 pandemic. The new strategic framework aims to improve efficiency by shifting operations and reallocating resources to where they can provide the most benefit. Oxfam will scale back its global footprint from 66 countries to 48, and “it will phase out 18 of its country offices.” The global financial crisis stemming from the pandemic has hindered fundraising opportunities, which have had a major effect on many non-profit and non-governmental organizations like Oxfam.

VENEZUELAN MIGRANT WORKERS As cases in South American countries continue to rise, strict “lockdowns” and associated job losses have disproportionately affected migrant workers from Venezuela. Due to the unstable political, social, and economic situation in Venezuela, thousands of Venezuelans migrate to neighboring countries in search of work. The growing COVID-19 pandemic has led many Venezuelans to attempt to return home . Approximately 40,000 Venezuelans have already returned, and a program implemented by the Venezuelan government, called “Return to the Homeland,” is currently prioritizing the repatriation of homeless migrant workers from Chile, Educador, and Peru—3 of the hardest-hit countries in South America. Wait lists for repatriation are extensive, however, and workers in non-prioritized countries are reportedly attempting to cross into priority counties in an effort to improve their chance of swift repatriation.

TIMING OF COMMUNITY MITIGATION MEASURES A modeling study by researchers at Columbia University (New York, US) evaluated the role that the timing of community-level social distancing measures in the United States played on COVID-19 incidence and mortality. The study ( preprint ) found that implementing widespread social distancing measures (e.g., “stay at home” orders) 1 week before that point could have reduced the cumulative COVID-19 incidence and mortality through May 3 by more than 60% and 50%, respectively, saving nearly 36,000 lives. According to the authors, initiating social distancing measures an additional week earlier, at the beginning of March, could have prevented nearly 100,000 cases and 54,000 deaths, reducing the total mortality by 83%. The study also models the effects of relaxing community-level social distancing on transmission and mortality. They forecast that decreases in reported incidence resulting from existing measures could continue for several weeks after they are relaxed, due to the time delay in detecting and reporting increased community transmission. Even if social distancing measures are re-implemented at the first sign of increased incidence, the increased community transmission could feed a resurgence of COVID-19 that could persist for several weeks.