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 29, 2020

Just a reminder that we are scaling back the COVID-19 Situation Report e-mails to Mondays, Wednesdays, and Fridays.

EPI UPDATE The WHO COVID-19 Situation Report for May 28 reports 5.59 million confirmed cases (104,505 new) and 353,334 deaths (4,221 new). While national-level daily incidence is decreasing for the United States, many countries across Europe, and others that were affected earlier in the pandemic, the overall global trend is increasing. The overall increase is driven largely by increasing incidence in Asia and South America, with more minor increases in Africa and Central America , particularly Mexico.

Brazil reported 26,417 new cases, its highest daily total to date and more than 25% greater than its previous high. Brazil’s daily incidence has more than doubled since March 14, and its national epidemic appears to be accelerating. Brazil has surpassed the United States as #1 in terms of daily incidence , now exceeding the US daily incidence by more than 20%. Peru and Chile continue to exhibit concerning trends as well. Both are currently reporting 3-4 times the per capita incidence as the United States and still increasing. Additionally, Peru and Chile are #5 and #6 in terms of total daily incidence, with 5,874 and 4,654 new cases, respectively. Mexico ’s COVID-19 epidemic also continues its acceleration, with 3,377 new cases. Mexico has reported its 3 highest daily totals over the past 3 days. Brazil, Chile, Mexico, and Peru represent 4 of the top 7 countries globally in terms of daily incidence —and Colombia is #17. 

Russia reported its 2 lowest daily totals since May 2 over the past 2 days. It appears that Russia is continuing its decline from a peak daily incidence on May 12. India reported 7,466 new cases, its highest daily incidence to date. It appears that India’s COVID-19 is continuing to accelerate—doubling its daily incidence since mid-May—and if the recent trends continue, India could surpass Russia as #3 in terms of daily incidence in the coming days.

Singapore reported 611 new cases, including 602 (98.5%) among residents of migrant worker dormitories. Singapore estimates that the cases confirmed so far represent 9.78% 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, 93.3% are among residents of migrant worker dormitories, including 98.8% over the past 2 weeks. While Singapore’s epidemic largely remains confined to migrant worker dormitories, Singapore continues to report hundreds of cases a day among residents of these facilities, and these outbreaks risk spillover into the broader community.

South Korea has reported elevated daily incidence over the past several days, including its 3 highest daily values —40 new cases on May 27 , 79 on May 28 , and 58 on May 29 —since April 8 . South Korea has identified multiple COVID-19 clusters, particularly in and around Seoul, following decisions to relax some social distancing measures in early May. The Korean CDC has identified 266 cases linked to night clubs and 102 cases associated with a logistics warehouse. The recent increase in COVID-19 incidence led South Korea to re-impose certain social distancing restrictions in affected areas, including enhanced social distancing measures and inspections for some businesses and recommendations for the public to refrain from non-essential activities. The measures are scheduled to remain in place through June 14.

Immediately following a large, one-day decrease in reported incidence, South Africa reported its 2 highest daily totals to date. The daily incidence over the past 2 days is more than double the value reported on May 27, and it exceeded 1,500 new cases for the first time. South Africa is currently reporting the highest cumulative COVID-19 incidence and highest daily incidence in Africa.

France reported a major spike in new cases today. After remaining below 1,000 new cases for several weeks, France reported more than 3,000 new cases in a single day. France has previously reported similar large, one-day spikes, approximately every 2-3 weeks, before returning to normal incidence. At this time, the reason for this dramatic increase is unclear.

UNITED STATES
The US CDC reported 1.70 million total cases (19,680 new) and 100,446 deaths (1,415 new). Daily COVID-19 deaths in the United States continue to decline overall, but the total reached 100,000 deaths in yesterday’s update. The CDC separated New York City from New York state in its table of jurisdiction-level COVID-19 incidence and deaths. In total, 13 states (1 new) and New York City reported more than 40,000 cases, including New York City with more than 200,000; New Jersey and New York 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. A number of states began to relax social distancing measures—including resuming operations at restaurants, retail stores, and barbershops/salons—at the end of April/early May, and mass gatherings associated with the Memorial Day holiday weekend (US) could have provided the conditions to drive increased community transmission. Ongoing large-scale protests in Minnesota and Tennessee could also potentially contribute to increased community transmission. We will continue monitoring state-level trends over the coming weeks.
The Johns Hopkins CSSE dashboard reported 1.72 million US cases and 101,706 deaths as of 10:30am on May 29.

SEROLOGICAL SALIVA TEST Researchers from Emory University and Johns Hopkins University conducted a study ( preprint ) to determine the feasibility of using saliva specimens for serological tests. The researchers developed a multiplex SARS-CoV-2 antibody immunoassay and tested 167 saliva and 324 blood serum specimens, including from patients that tested positive and negative for SARS-CoV-2 infection utilizing molecular diagnostic assays. They found that the antibody assay exhibited similar sensitivity and specificity for both the saliva specimens and serum specimens and performance consistent with other existing serological tests. They also demonstrated that the “temporal kinetics of IgG, IgA, and IgM in saliva were consistent with those observed in serum.” Further research is required to fully characterize the performance, accuracy, and reliability of saliva-based serological tests, but if available, they could potentially provide benefits to conducting large-scale serological testing. Participating individuals can easily collect their own specimens, as opposed to blood samples required for existing SARS-CoV-2 serological tests, and the saliva specimens can be transported and stored at ambient temperature. The US FDA has already issued an Emergency Use Authorization (EUA) for a saliva-based molecular/diagnostic test that utilizes specimens that individuals can collect on their own at home.

FLEEING QUARANTINE Hundreds of individuals reportedly fled from quarantine facilities in Malawi and Zimbabwe. At least 46 of more than 400 quarantined individuals that fled in Malawi tested positive for SARS-CoV-2, and more than 100 individuals fled quarantine in Zimbabwe. Notably, “nearly all of Zimbabwe’s 75 new cases this week” were identified in quarantined individuals. Many of the quarantined individuals recently arrived, “sometimes involuntarily,” from South Africa or Botswana. According to the report, enforcement of the quarantine and appropriate protective measures were lax at the quarantine sites, and quarantined individuals and their families were observed entering and exiting the quarantine area freely, including to buy food at local markets. Efforts are ongoing to track down the individuals. Both Zimbabwe and Malawi have reported relatively low COVID-19 incidence to date; however, a sudden influx of infectious individuals into the community could potentially result in significant increases in local transmission.

WHO FOUNDATION The WHO announced the development of the WHO Foundation, a non-profit entity designed to provide funding to the WHO and its partners. According to the WHO announcement, the WHO Foundation will be a legally separate entity from the WHO, and its purpose will be to facilitate the use of philanthropic contributions—including from individual and corporate donors as well as the general public—which will aim to “broaden [the] WHO’s donor base and work towards more sustainable and predictable funding.” The funds will be used to support WHO efforts to prevent and respond to health emergencies, extend universal health coverage, and promote health and wellbeing. The Foundation is also anticipated to boost funding to support ongoing COVID-19 response efforts. While the Foundation has reportedly been in development for years, the announcement follows recent efforts by US President Donald Trump to suspend US government funding for the WHO. 

ASYMPTOMATIC SARS-CoV-2 INFECTION A Research Letter published in JAMA Network Open describes the characteristics of asymptomatic SARS-CoV-2 infections identified in Wuhan, China. The study compiled clinical data from 78 patients, representing 26 COVID-19 clusters—identified between December 24, 2019, and February 24, 2020—with known epidemiological links to known cases or exposure at the Hunan Seafood Market in Wuhan. Among these patients, 33 (42.3%) were asymptomatic throughout their infection. The asymptomatic individuals tended to be younger than symptomatic individuals—median age of 37 years, compared to 57 years—and a higher proportion of asymptomatic infections were in females—66.7% of asymptomatic infections, compared to 31% of symptomatic cases. Additionally, asymptomatic individuals exhibited a shorter duration of viral shedding than symptomatic cases—median of 8 days in asymptomatic individuals, compared to 19 days in symptomatic cases.

Another study, published in Thorax , describes findings from the epidemiological investigation of a COVID-19 outbreak onboard a cruise to Antarctica. Among 217 total passengers and crew, 128 (59%) tested positive for SARS-CoV-2 infection, but only 24 (19%) were symptomatic—81% were asymptomatic. Interestingly, there were 10 instances of passengers sharing a cabin in which some passengers tested negative while others tested positive. Among the symptomatic individuals, 16 (66.7%) reported mild symptoms and 8 (33.3%) required medical evacuation due to severe disease—including 4 that required mechanical ventilation. While shipboard outbreaks, or other outbreaks in congregate settings, do not necessarily represent transmission dynamics in the general public, data regarding the proportion of infections with and without symptoms can provide valuable insight in terms of understanding the potential scope of asymptomatic infection in the community.

SHORTAGE OF TESTING MACHINES Following a series of challenges and delays in distributing a variety of supplies needed to scale up SARS-CoV-2 testing in the United States—including test kits, reagents, and nasal swabs—the next barrier may be a shortage of the machines needed to perform the tests . Multiple manufacturers of these machines—including Hologic, Inc; Roche; and Abbott Laboratories—have reportedly confirmed that they have not been able to manufacture enough of the testing machines to meet the existing demand. The machines are capable of processing hundreds of specimens at a time, and increased availability is critical to expanding testing capacity to the volume that health experts argue is necessary to conduct large-scale testing and surveillance and support efforts to relax social distancing. Both private labs and government laboratories, including those operated by the US Army, have reported challenges obtaining additional testing machines, and even some orders placed prior to the pandemic have not yet been filled. While the manufacturers have stated that they are doing everything they can to increase production, there are concerns that unpredictable future demand could hinder incentives to scale up production capacity. Increasing production requires substantial investment and funding, and the units themselves are expressive. The economic impact of the COVID-19 pandemic means that available funding for many governments, health systems, and other laboratories may be limited, which could make it challenging to justify a substantial investment in new equipment, especially if the future demand could be low.

DOWNSTREAM EFFECTS As we have covered repeatedly, the COVID-19 pandemic is having far-reaching downstream effects on other aspects of human health. While many of the examples we have included previously have been anecdotal (and many in the United States), a recent study published in The Lancet: Public Health describes these effects on out-of-hospital cardiac arrest (OHCA) in France. The researchers compared the number of reported OHCAs in the Paris area from March 16 to April 26, 2020, to data from a similar period in 2012-2019. Compared to previous years, the weekly incidence of OHCAs nearly doubled—26.64 per million population, compared to 13.42 per million—in Paris before returning to normal at the end of the pandemic period. More OHCAs were reported in homes, and there were fewer reports of cardiopulmonary resuscitation (CPR)—considered to be an aerosol-generating procedure that could increase transmission risk—performed by bystanders. OHCA victims also faced increased time to treatment during the pandemic period as well as significantly decreased odds of survival. The researchers estimated that approximately one-third of the effects could be attributed directly to COVID-19 (confirmed or suspected); however, social distancing restrictions, postponed or deferred routine or emergent care, and other factors associated with the pandemic likely contributed as well.

TRACKING COVID-19 WITH GENOMICS Since early in the COVID-19 pandemic, thousands of genomic sequences of SARS-CoV-2 have been analyzed and shared worldwide in an effort to further characterize the novel virus. As the pandemic has progressed, genomic approaches have allowed researchers to identify distinct lineages of SARS-CoV-2 that can be traced to different points of origin. Scientists can use genomics to understand the timing of transmission and establish likely transmission routes based on phylogenetic analysis of SARS-CoV-2 genetic sequences. As countries begin to relax social distancing measures, some are looking to genomics as a means to supplement contact tracing efforts . Comparing genomic data from newly identified cases to previous cases can help health officials identify chains of transmission and likely exposures in order to more efficiently target contact tracing and containment efforts. This strategy would likely be most effective when a country has relatively few cases, as opposed to widespread community transmission, and has a large quantity of sequence data available, ideally spanning the duration of the pandemic, to support analysis. As countries bring community transmission under control and relax travel restrictions, imported cases will continue to seed new outbreaks, and genomic data can also help health officials identify likely sources of emerging outbreaks.

New Zealand and Australia are two such countries that are currently liaising with scientific institutions to support contact tracing through genomic sequencing. To date, New Zealand has sequenced specimens from approximately 25% of all of its reported cases, with a goal of reaching 70%. Genomic approaches to contact tracing are resource intensive, potentially limiting their use to higher-income countries, and asymptomatic infection will likely continue to be missed by these surveillance efforts. Genomic sequencing is not sufficient, in and of itself, for COVID-19 surveillance purposes, but it can potentially provide supplementary data to enhance more traditional efforts.

NEW YORK MASK POLICY New York Governor Andrew Cuomo issued an executive order stating that businesses have the right to refuse entry to anyone not wearing a mask. A previous executive order mandated mask use in public by all individuals aged 2 years and older for situations in which it is not possible to maintain appropriate physical distancing (ie, 6-foot radius), with exceptions for those with medical conditions that would prevent safe mask use. The new order follows New York City’s slow decline in COVID-19 incidence after weeks of social distancing and mask use.

Enforcement of mask use has become a flashpoint for some, but there is evidence to suggest that masks can mitigate the risk of secondary transmission. For example, one study of 124 households in Beijing reported that mask use by COVID-19 cases and other household contacts was highly effective at preventing secondary transmission, particularly when worn prior to the onset of symptoms. Enhanced cleaning and hygiene practices were also observed to decrease secondary transmission among household contacts. While this study has been met with criticism , including for its study methodology and interpretation of the results, a reduction in household clusters would have a meaningful impact on the pandemic writ large. If more evidence emerges that mask use in the home setting reduces these clusters, new changes in behavior within the home may be warranted.

US UNEMPLOYMENT The US Department of Labor published its weekly report on unemployment claims, and more than 25% of the US workforce has filed for unemployment over the past 10 weeks, more than 40 million people in total. New unemployment claims continue to decrease from the weekly high of nearly 7 million in mid-March, down to 2.1 million in the most recent report. The current national unemployment rate is estimated to be 14.5%, representing more than 21 million people nationwide. The unemployment rate varies by state, but 6 states exceeded 20%—California, Florida, Hawai’i, Michigan, Nevada, and Washington.

A survey conducted by the US Federal Reserve found that employment continues to decrease nationwide, most notably in the retail, leisure, and hospitality sectors, which have hit particularly hard by social distancing and travel restrictions. Concerns about worker safety and child care availability, along with expanded unemployment benefits implemented in response to the COVID-19 epidemic, are hindering efforts to bring workers back. The COVID-19 pandemic continues to exert historical pressure on the US and global economies. At this point, all US states have started relaxing social distancing restrictions, including those on restaurants, retail stores, and other businesses, but the degree to which Americans will resume normal activities, including work, remains to be seen.