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

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May 4, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 3 reports 3.35 million confirmed cases (82,763 new from the previous day; approximately 260,000 new since Friday’s briefing) and 238,628 deaths (8,657 new from the previous day; 20,859 new since Friday’s briefing). The WHO updated its Situation Report format in order to make the reports more accessible for those with visual impairment.

The UK COVID-19 epidemic appears to be on pace to continue its decline in daily incidence. Because the data is displayed by specimen date (as opposed to report date), it will take a few more days before we can fully assess the data from April 26-30. Russia reported a total of 145,268 confirmed cases, moving up to 7th globally. Over the weekend, Russia reported 30,837 new cases, averaging more than 10,000 new cases per day, which exceeds its previous highest daily incidence . Russia’s COVID-19 epidemic appears to continue its acceleration.

India reported 7,793 new cases over the weekend, averaging nearly 2,600 new cases per day. These appear to be India’s three highest daily totals , illustrating that the epidemic continues to accelerate, despite national “lockdown” measures. Pakistan has reported its 6 highest daily incidence totals over the past 6 days. The highest total (1,297 new cases) was reported on May 1, and Pakistan reported 3,369 total new cases over the weekend. While Pakistan’s daily incidence continues to increase, its doubling time remains relatively consistent at approximately 11 days.

Singapore reported 573 new COVID-19 cases, including 560 (97.7%) among residents of migrant worker dormitories. Of the 1,677 total cases reported over the weekend , Singapore reported 1,617 (96.4%) among dormitory residents (plus an additional 36 migrant workers living elsewhere), compared to only 24 community cases. Indonesia’s daily COVID-19 incidence appears to have plateaued over the past 2-3 weeks, largely remaining between 250 and 450 new cases per day since the middle of April. Bangladesh reported 1,905 new cases over the weekend, including its 2 highest daily totals—665 and 668 new cases on May 3 and 4, respectively. Bangladesh's epidemic appears to be doubling approximately every 9 days.

New Zealand reported no new cases for the first time since March, illustrating the successful implementation of its COVID-19 response strategy.

New York state held relatively steady in terms of daily incidence over the past week, reporting between 3,100 and 4,700 new cases each day. Similarly, New York City reported between 1,800 and 2,700 new cases each day. We are continuing to monitor COVID-19 incidence trends in states that have started easing social distancing measures; however, it could be several weeks following any changes to social distancing before any effects begin to emerge in reported data.

The US CDC reported 1.12 million total cases (29,671 new from the previous day; approximately 90,000 new cases since the Friday briefing) and 65,735 deaths (1,452 new from the previous day; 5,678 new since the Friday briefing). The CDC reported elevated daily incidence in the updates on Friday, Saturday, and Sunday, all of which were more than 25% greater than the recent low reported on April 27. In total, 12 states reported more than 25,000 cases (no change), including New York with more than 300,000; New Jersey more than 100,000; and Illinois, California, and Massachusetts more than 50,000. Additionally, 34 states (decrease of 2 since Friday’s briefing), plus Guam, are reporting widespread community transmission.

The Johns Hopkins CSSE dashboard is reporting 1.17 million US cases and 68,046 deaths as of 1:30pm on May 4.

ESSENTIAL WORKERS As front-line essential workers continue to provide much-needed services across the country, it raises questions regarding how best to protect those individuals. An article in Politico addresses how some of these considerations are playing out in New York City. In New York City, 245 city employees have died from COVID-19 since the onset of the city’s outbreak, and none of the deaths have yet been labeled as occurring “in the line of duty.” In New York City, this designation would provide their families with lasting benefits, including access to continued health benefits and pension income. It is unclear, and potentially impossible to definitively determine one way or the other, if these individuals were exposed while performing their duties. Efforts by employee unions and lawmakers are underway to develop and implement solutions to protect these critical workers and their families, but they could be in for a long fight, particularly as the prospect of a protracted COVID-19 response and looming economic concerns may place financial limitations on city, state, and federal spending.

At the national level, there are calls to include “hazard pay” for front-line healthcare workers and other essential workers in federal COVID-19 spending packages. Proponents note that “health-care companies and firms with more than 500 employees” were exempted from requirements to provide paid sick leave under the Families First Coronavirus Response Act, leaving 13 million health workers without emergency sick pay. A variety of local , state , and federal elected officials are developing plans to provide “hazard” pay and other protections for essential workers. These plans take a variety of approaches to increasing the compensation for essential workers, including increased pay. The umbrella of “essential worker” also covers a variety of jobs, ranging from healthcare worker to child care to grocery stores to “gig” workers (eg, ride sharing or delivery drivers). These plans may also include other provisions that could help improve social distancing, provide protection against eviction, and address elevated risk among vulnerable populations like individuals experiencing homelessness.

TRAVEL BUBBLES Australia and New Zealand leaders are reportedly considering a “ travel bubble ” that would allow individuals to travel between the two countries without requiring a quarantine upon arrival. New Zealand reported no new cases for the first time since March, continuing its progress toward elimination , and Australia has reported steadily declining daily incidence since the end of March. The idea behind a “travel bubble” is that countries (or states, households, or other units) within that bubble would maintain low transmission risk, which would allow individuals to travel within that area without significantly increasing their individual risk of transmission or the higher-level risk of a larger outbreak. Other locations are beginning to consider if they could also successfully create "travel bubbles." In the United States, some states have collaborated to form regional coalitions to coordinate decisions regarding efforts to relax social distancing measures, but to our knowledge, none have indicated that this would result in a regional “travel bubble.” The Florida Keys (US) have established a de facto “travel bubble,” which permits travel between islands while restricting entry to local residents only. Similarly, Hawai’i (US) requires 14-day quarantine for all arriving travelers, but it does not restrict travel between islands. As described below, Austria permits entry only for travelers arriving from other European countries with a 14-day quarantine, but it will waive the quarantine for individuals with recent documentation of a negative diagnostic test, essentially permitting unrestricted movement across the border for individuals it determines to be low risk.

WHO NEWS & DEVELOPMENTS On April 30, WHO Director-General Dr. Tedros Adhanom Ghebreyesus convened the third meeting of the Emergency Committee under the International Health Regulations to re-evaluate the ongoing COVID-19 pandemic. On the committee’s recommendation, the Director-General declared that COVID-19 continues to constitute a Public Health Emergency of International Concern (PHEIC). The Emergency Committee will reconvene in 3 months, or earlier at the discretion of the Director-General. The most recent previous Emergency Committee meeting occurred on January 30 , when the pandemic had only reported 7,794 confirmed cases in 84 countries worldwide.

The WHO also announced an enhanced partnership with the European Investment Bank (EIB) that aims to address numerous COVID-19 response priorities, including the need to “strengthen public health, supply of essential equipment, training and hygiene investment in countries most vulnerable to the COVID-19 pandemic,” principally in low- and middle-income countries. The EIB committed to providing €1.4 billion (US$1.53 billion) to address the COVID-19 impact in Africa and an additional €5.2 billion (US$5.67 billion) to support the global response outside of the European Union. The EIB is also assessing more than 20 projects related to vaccine, diagnostic, and treatment development for COVID-19, with the potential for total investments in the range of €700 million (US$763 million). In addition to COVID-19, the EIB will also provide financial support for antimicrobial resistance and malaria treatment efforts.

COVID-19 VACCINE FUNDING The European Commission hosted a Coronavirus Global Response pledging event. According to event details, “governments and business leaders will announce their pledges for the development and universal deployment of diagnostics, treatments and vaccines against the coronavirus.” A funding tracker for the event indicates that the event raised at least €7.4 billion of the stated goal of €7.5 billion.

GAVI, the Vaccine Alliance, released a proposal for an Advance Market Commitment for COVID-19 vaccines to ensure global availability of vaccines when they become available. This commitment would provide funding and commitment to purchase vaccines, which is intended to incentivize manufacturers through guaranteed demand and provide funding support during development so that manufacturers can invest in production capacity, secure necessary raw materials, and support technology transfer to global manufacturing partners. The advance funding could stabilize prices for the vaccine and promote availability for all countries, as opposed to only those that could afford them upon initial availability.

SEROLOGICAL TESTS Over the weekend, the US FDA issued new Emergency Use Authorizations (EUAs) for 2 serological tests , bringing the total to 12 . One of the tests in particular, developed by Swiss biotechnology company Roche , reportedly has high specificity and sensitivity. According to a press release by the company, the test has a sensitivity of 100% sensitivity in specimens collected 14 days or longer after a positive PCR test (ie, detects 100% of individuals with antibodies present) and greater than 99.8% specificity (ie, fewer than 0.2% of tests will yield a false positive). Additionally, the test exhibits “no cross-reactivity to the four human coronaviruses causing common cold.” Roche intends to provide tens of millions of tests worldwide by the end of May, and the company is working to expand production capacity. The Roche test requires a blood draw instead of a finger prick. The test takes approximately 18 minutes to run and is fully automated, and the testing system can perform as many as 300 tests per hour.

FALSE POSITIVE “RE-INFECTION” TEST RESULTS In an interview on BBC News, the WHO Technical Lead for the COVID-19 response, Dr. Maria Van Kerkhove , discussed the potential for re-infection with SARS-CoV-2, in light of recent data regarding false positive diagnostic tests. She noted that the positive diagnostic tests in recently recovered COVID-19 patients are actually false positives rather than evidence of re-infection, supporting statements made by experts last week. Viral RNA fragments in dead lung cells are responsible for the positive PCR test results, and the virus detected by these tests is not viable (ie, cannot infect someone). She emphasized that clearing these dead cells and RNA fragments is a natural part of the body’s healing process and not a sign of re-infection or reactivation of a prior infection. She also commented on the WHO’s current understanding of human’s ability to be re-infected with SARS-CoV-2. At this time, studies are ongoing to determine whether the antibodies produced in response to SARS-CoV-2 infection confer immunity to those individuals and, if so, how long that immunity could persist. There is not currently sufficient evidence to determine whether individuals will maintain any lasting immunity against the virus.

REMDESIVIR Following the release of preliminary results from several clinical trials of the antiviral drug remdesivir, the US FDA issued an EUA to treat COVID-19 patients. Under the EUA, Gilead Sciences will provide the drug directly to the US government or designated “authorized distributors,” and the federal government will be responsible for coordinating distribution “in collaboration with state and local government authorities.” The drug can be prescribed for severe COVID-19 patients, as defined by oxygen saturation below 94% “on room air” or the need for mechanical ventilation or extracorporeal membrane oxygenation (ECMO). In an interview on Face the Nation, Gilead CEO Daniel O’Day committed to donating the existing supply of remdesivir to the US government, a total of 1.5 million doses, which could provide as many as 200,000 treatment courses. Additionally, Gilead is in the process of collaborating with other companies to scale up manufacturing capacity to meet global demand. The clinical trial conducted by the US National Institute of Allergy and Infectious Diseases (NIAID) determined that remdesivir can shorten the time to recovery for COVID-19 patients; however, it has not yet demonstrated statistically significant benefit in terms of reducing the risk of severe disease or death.

DOWNSTREAM EFFECTS As we have covered in recent briefings, the COVID-19 pandemic is having major downstream effects on health systems and health security, beyond the direct impacts of COVID-19 patients. Similar to the negative impact on other routine preventive and clinical services, including immunizations, routine cancer screenings have also decreased over the past several weeks. According to a report by the Epic Health Research Network , routine screenings for breast, cervical, and colon cancer decreased by 86-94% compared to previous years, based on data collected from electronic health records covering 2.7 million patients across 23 states. If this trend continues, delayed screening and diagnosis could result in later diagnosis of these cancers and, subsequently, elevated morbidity and mortality.

An article published by STAT News takes a closer look at potential long-term impacts on scientific research and the careers of researchers for whom the COVID-19 pandemic and associated social distancing restrictions have interrupted their research. Beyond interrupting the research and experiments themselves, some of which have been in progress for months or possibly years, training and other preparation required to maintain laboratory operations have been paused, which could impart further delays on resuming research activities once scientists can return to work. Additionally, the shutdown of laboratories or other research settings could preclude students and other researchers from collecting data, performing analyses, or publishing findings required for them to complete degrees or other career milestones, which could potentially jeopardize further career progression. Protracted interruptions to scientific research delay the completion of studies and publication of findings, which could have far-reaching and long-term effects on careers and scientific progress well after the pandemic subsides.

ARRIVING TRAVELER TESTING The Vienna Airport (Austria) is now offering SARS-CoV-2 diagnostic tests for arriving and departing travelers. Austria currently only permits entry for travelers arriving from the Schengen area, which largely covers European countries. Travelers arriving in Austria are required to either provide a certificate confirming a recent negative SARS-CoV-2 diagnostic test (issued within 4 days of arrival) or undergo a mandatory 14-day quarantine. The test performed at the airport can be used to provide the documentation that the individual is not currently infected, so s/he can forgo the mandated quarantine. The test costs approximately US$200, and results are available within 3 hours. Travelers are required to make an appointment in advance to ensure that the testing site is able to maintain appropriate social distancing for travelers and staff. Positive tests results will be reported both to the individual and Austrian health authorities.

ETHIOPIA’S PRIME MINISTER CALLS ATTENTION TO AFRICA Ethiopian Prime Minister Abiy Ahmed published an article via the World Economic Forum that calls on higher-income countries to assist African nations in responding to COVID-19. Prime Minister Ahmed acknowledged support in obtaining supplies for the African Union—including test kits, ventilators, and personal protective equipment (PPE)—but he noted that a more comprehensive strategy is necessary to overcome the health and economic crisis. Immediate funding support is needed to bolster health systems and “social safety nets.” Commitments to extend debt relief via the International Development Association and raise funding ceilings for grants and loans issued by the International Monetary Fund, the World Bank, and other multilateral development banks would provide much-needed funding for African nations to invest in necessary infrastructure and response needs. Prime Minister Ahmed also called on governments to increase funding for GAVI and the Coalition for Epidemic Preparedness Innovations (CEPI) to ensure that COVID-19 vaccines are accessible for all countries, regardless of their ability to pay, as well as a global coordinated effort to equitably distribute equipment and supplies, including diagnostic tests, mechanical ventilators, and PPE.