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

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May 22, 2020

In light of the Memorial Day holiday (US) on Monday, the next COVID-19 update will be sent on Tuesday, May 26.

EPI UPDATE The WHO COVID-19 Situation Report for May 21 reports 4.89 million confirmed cases (103,981 new) and 323,256 deaths (4,467 new). The global total incidence could potentially reach 5 million cases by today’s update.

Brazil reported 18,508 new cases, its second highest daily incidence to date. Brazil’s daily incidence is second to only the United States, and if the current trajectories continue, it could become #1 globally in the coming days. Brazil’s daily per capita incidence is now more than 25% greater than the United States’. The per capita incidence in Peru and Chile is even higher, however, with Peru reporting nearly 140 new cases per million population each day and Chile reporting more than 200, approximately double and triple the per capita incidence in the United States, respectively. South America is emerging as a major global hotspot for COVID-19. These South American countries now represent 3 of the top 6 countries in terms of daily incidence .

Russia reported 8,894 new cases, its third consecutive day with fewer than 9,000 new cases. Moscow and the Moscow Region continue to represent the majority (58.2%) of Russia’s COVID-19 cases. India reported 6,088 new cases, its highest daily incidence to date. The state of Tamil Nadu, where a large outbreak has been linked to one of Asia’s largest markets, reported 743 new cases. Russia and India are #3 and #4 in the world, respectively, in terms of daily incidence .

South Africa ’s COVID-19 epidemic continues to accelerate. South Africa reported 1,134 new cases, which is its second highest daily total and the second time in the past 5 days that the daily incidence exceeded 1,000. South Africa is currently reporting the highest cumulative COVID-19 incidence (19,137 cases) and highest daily incidence in Africa. After appearing to approach a plateau in the first half of May, Djibouti is once again reporting increasing daily incidence. Between April 23 and May 16, Djibouti reported fewer than 10 new cases 8 times and more than 25 new cases only 3 times. Since then, Djibouti has not reported fewer than 70 new cases per day.

Singapore reported 614 new cases, including 610 (99.3%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s COVID-19 epidemic. Singapore estimates that the cases confirmed so far represent 8.72% 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, 92.5% are among residents of migrant worker dormitories.

The US CDC reported 1.55 million total cases (22,860 new) and 93,061 deaths (1,397 new). Daily COVID-19 deaths in the United States are generally on the decline , but the total could potentially reach 100,000 deaths in the next 6-7 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 150,000; and Illinois with more than 100,000.

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 reported 1.59 million US cases and 95,276 deaths as of 12:30pm on May 22.

US STATE-LEVEL COVID-19 TRACKING Researchers from Imperial College London—including its WHO Collaborating Centre for Infectious Disease Modelling—MRC Centre for Global Infectious Disease Analytics, and the University of Oxford published a detailed report on their modelling efforts regarding the effects of statewide social distancing measures on population mobility and the time-varying reproductive number (Rt) in the United States. Results are presented on both a state and regional basis. The researchers found that statewide emergency declarations and social distancing orders had varying effects on different types of population movement, including public transit use and residential mobility. Additionally, the researchers identified trends in Rt associated with population density and the timing of the onset of state COVID-19 outbreaks. High population density and earlier community transmission were associated with higher Rt values early in the epidemic. The report also outlines projections for future transmission based on varying population mobility models as states relax social distancing measures. As expected, increases in public mobility are projected to result in increased transmission, potentially including subsequent epidemic waves that far exceed the incidence reported thus far.

FOMITE TRANSMISSION The US CDC updated its website on SARS-CoV-2 transmission , adjusting the language regarding the relative role of various routes of transmission. Multiple news media outlets reported on the change yesterday; however, it appears that the changes began sometime early last week . Notably, the CDC website currently indicates that it was last reviewed on April 13, despite changes being made more recently.

The most substantial change is the language used to describe the role of transmission via fomites—ie, contaminated objects or surfaces. Both the current and previous iteration of the CDC information state, “It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it.” Additionally, both versions of the guidance note that fomites are “not thought to be the main way the virus spreads.” The updated guidance takes this a step further, however, explicitly stating that “the virus does not spread easily” via fomites. It does not appear that the CDC made an official announcement regarding the update, but a recent statement by a CDC spokesperson indicates that the changes do not reflect meaningful change in the CDC’s position or understanding regarding SARS-CoV-2 transmission. Practically speaking, the changes should have little effect on current recommended protective measures, such as improved hygiene (eg, hand washing) and disinfection practices.

TRAVEL BUBBLES As countries bring their national COVID-19 epidemics under control and and begin to ease social distancing measures, there is increasing discussion about the use of “travel bubbles” in order to permit some travel among countries with low rates of transmission while still restricting travel from countries with higher burden. Australia and New Zealand, both of which have largely been able to control COVID-19 transmission, have proposed resuming travel between the 2 countries in the coming months, possibly in August. Lithuania, Latvia, and Estonia created a similar travel bubble, becoming the first set of countries to do so in Europe. The United Kingdom and France also appear to be considering a travel bubble, and UK Prime Minister Boris Johnson’s office reportedly announced an agreement with French President Emmanuel Macron that would eliminate the required quarantine for travelers arriving to the United Kingdom from France.

Essentially, travel bubbles would allow individuals to travel freely between and within partnering countries (or potentially states or cities), while travelers arriving from other locations would be subject to certain restrictions, potentially including quarantine. Increased travel presents the possibility of economic activity and growth for the participating countries, particularly for economies that rely heavily on tourism. Without a vaccine, however, any increase in travel and social interaction could also pose the risk of increased SARS-CoV-2 transmission, which is why these bubbles would likely be limited to countries with similar levels of transmission and those that have demonstrated the ability to control the disease.

FLORIDA THEME PARKS Multiple theme parks in Florida (US) announced plans to reopen soon . The Orange County Economic Recovery Task Force approved Universal Studios’ plans to reopen its theme parks on June 5, pending approval by Florida Governor Ron DeSantis. Legoland is planning to reopen on June 1. Several other large theme park venues, including those owned by Disney, have yet to announce reopening plans. Those parks that intend to resume operations will implement a variety of safety measures to mitigate transmission risk, including mandatory or recommended mask use, temperature checks, park occupancy and parking restrictions, and enhanced cleaning and disinfection. Additionally, the parks will promote appropriate physical distancing for visitors and staff.

KAWASAKI-LIKE SYNDROME From the onset of the COVID-19 pandemic, data indicated that older adults were at elevated risk for severe disease and death compared to younger adults and children. Emerging evidence indicates, however, that children and young adults may face increased risk of a condition resulting from an overstimulation of the body’s immune system , triggered by SARS-CoV-2 infection, that can result in severe complications or death. The condition—dubbed by the US CDC as multisystem inflammatory syndrome in children (MIS-C) —is similar to Kawasaki disease, and researchers and clinicians are racing to better understand and characterize the condition as more cases are documented around the world. Notably, the condition has been reported less in Asia than in Europe and North America, which some believe may be driven by genetic factors in affected individuals or the circulating virus strain. It may also be the case that MIS-C is rare enough that it only reaches an observable level in major outbreaks, which have been more prominent in US and European cities over the past couple months.

INDONESIA As COVID-19 incidence increases in Indonesia, public health officials are experiencing challenges promoting distancing measures , particularly during the Eid-al Fitr holiday. News media reports indicate that markets, public spaces, and even the airport are crowded, with many people disregarding physical and social distancing guidance. Government officials are requiring that plantation workers , many of whom would normally return home for the holiday, remain on the plantation due to the risk of SARS-CoV-2 transmission. Indonesian President Joko Widodo has kept some large-scale restrictions in place but loosened others, including the resumption of public transportation and airline flights, and there are reportedly plans to lift more restrictions in the near future with the aim of returning to normal activity by the end of July.

Further complicating social distancing implementation in Indonesia, a tornado struck the island of Sumatra yesterday, damaging hundreds of homes and requiring the evacuation of local residents. Much like recent experiences in the Philippines, India, and Bangladesh, evacuation centers and other response activities could potentially increase the risk of SARS-CoV-2 transmission in affected communities. 

CYCLONE AMPHAN Several thousand people are homeless as a result of the Cyclone Amphan , and at least 96 people were killed, with casualties expected to increase. Response efforts to help affected populations recover and seek shelter are further complicated by both the pandemic and impending monsoon rains that are expected to hit affected areas over the coming weeks. Government efforts aimed to promote s ocial distancing in shelters housing evacuees, but some accounts indicate that this was not possible, at least in some cases. Additionally, a lack of testing capacity could reduce the ability to identify and isolate those who are infected before they can infect others.

The cyclone also affected one of the world’s largest refugee settlements in Cox’s Bazar, Bangladesh, which houses nearly 1 million Rohingya refugees. The first COVID-19 cases near the camps were recently detected, and the living conditions could facilitate the rapid spread of COVID-19 through the camps. The Bangladeshi government reportedly placed 28 Rohingya refugees in quarantine on the nearby island of Bhasan Char , which is known to be vulnerable to cyclones and flooding. The refugees recently arrived at Cox’s Bazar after weeks at sea and were quarantined over concern that they could potentially be infected.

YEMEN HEALTH SYSTEM Reports from humanitarian and international organizations indicate that Yemen remains highly vulnerable to COVID-19 and that current official disease incidence and death reports are underestimating the actual COVID-19 disease burden in the country. A spokesperson for the UN Office for the Coordination of Humanitarian Affairs (UNOCHA) reportedly warned that the Yemeni health system has “in effect collapsed.” Health workers have reported that they are forced to turn away people who need care due to a lack of supplies.

Yemen has suffered from years of civil war, which has devastated the country’s health system and economy and led to widespread famine and infectious disease epidemics. The UNOCHA Global Humanitarian Response Plan lists Yemen among the top 10 countries at highest risk of suffering health and humanitarian impacts from COVID-19. The document highlights that social distancing measures, including COVID-19 curfews, have affected the operation of markets that are important for providing fresh food to a population already suffering high levels of malnutrition. In late March, UNOCHA announced it is seeking US$2 billion in funds to support countries, such as Yemen, that are experiencing humanitarian crises in the midst of the COVID-19 pandemic. 

COVID-19 RACIAL & ETHNIC DISPARITIES In the United States, and elsewhere, the COVID-19 epidemic has disproportionately affected racial and ethnic minorities. Racial and ethnic minorities represent a high proportion of essential jobs, including healthcare workers, and a number of underlying health conditions associated with severe COVID-19 disease and death have higher prevalence in minority populations. Additionally, racial and ethnic minority communities “may be more likely to live in densely populated areas in cities” which have been hit hardest early in the US COVID-19 epidemic. A number of efforts are ongoing to help characterize the effects of COVID-19 on minority individuals and communities , and some researchers and elected officials are beginning to call for dedicated government programs to address these disparities. One study conducted by the APM Research Lab found that COVID-19 mortality for African Americans is more than double the mortality for white, Asian, and Latinx Americans. The study report presents a myriad of data corresponding to racial and ethnic disparities in the context of COVID-19, including on a national and state basis. The Washington Post also published analysis, based on data from PolicyMap, to evaluate links between a variety of health and socio-economic characteristics in the context of the US epidemic.

HYDROXYCHLOROQUINE A study published in The Lancet aimed to evaluate the treatment benefit of chloroquine and hydroxychloroquine for COVID-19 patients . The retrospective study utilized medical records from a total of 96,032 patients across 671 hospitals on 6 continents. Among these patients, 14,888 were included in one of the 4 treatment groups—chloroquine or hydroxychloroquine, alone or in combination with macrolide antibiotics (eg, azithromycin)—and 81,144 patients were included in the control group. This appears to be the largest study of the drugs conducted to date. Patients who received remdesivir or who were already on mechanical ventilation when the treatment was started were excluded from this study.

After adjusting for a range of demographic and risk factors—including age, pre-existing health conditions, and baseline COVID-19 severity—the researchers found no evidence that chloroquine or hydroxychloroquine provided benefit to the patients. Rather, the patients in all 4 treatment groups exhibited statistically significant increases in mortality as well as increased risk of ventricular arrhythmia. The authors comment, “In the absence of reported randomised trials, there is an urgent need to evaluate real-world evidence related to outcomes with the use of hydroxychloroquine or chloroquine” in COVID-19 patients. While not a randomized control trial (RCT), this study leverages data from nearly 100,000 patients across a broad range of hospitals and countries. The absence of a detectable positive benefit with respect to COVID-19 mortality—and in fact, finding significantly increased risk of death—provides further evidence that hydroxychloroquine is not effective as a treatment for COVID-19 and may, in fact, be harmful to patients.