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

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May 5, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 4 reports 3.44 million confirmed cases (86,108 new) and 239,604 deaths (976 new). The daily change in deaths is negative, possibly because of a reporting error.

The UK COVID-19 epidemic appears to be on pace to continue its decline in daily incidence. The UK is on track to record the third consecutive week of decreasing incidence.

Russia reported more than 10,000 new cases, continuing its recent trend of elevated daily incidence . Russia’s COVID-19 epidemic appears to continue its acceleration.

India reported 3,597 new cases, its highest daily total . India’s epidemic continues to accelerate, despite national “lockdown” measures; however, increased testing capacity could account for some of the recent increase. Pakistan has now reported its 7 highest daily incidence totals over the past 7 days, setting a new high of 1,315 new cases. While Pakistan’s daily incidence continues to increase, its doubling time remains relatively consistent at approximately 11-12 days.

Singapore reported 632 new COVID-19 cases, including 605 (95.7%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s growing COVID-19 epidemic. Following several weeks of tapering off, Indonesia reported a new high for daily COVID-19 incidence, 484 new cases. Bangladesh recorded a new high daily incidence for the third consecutive day, 786 new cases. Bangladesh's epidemic appears to be doubling approximately every 9 days.

One day after reporting zero new cases, New Zealand actually reported a decrease in total cases, as one probable case was ruled out (-1 case from the previous day).

New York state reported 2,538 new cases, its lowest daily incidence since March 18—and the state performed 21,399 tests (11.8% positive), compared to only 7,698 (23.0% positive) on March 18. New York City also reported its lowest daily total since March 18 (1,320 new cases)—performing 9,183 tests (14.4% positive), compared to 3,344 (33.8% positive) on March 18. Several states across the Midwest and Plains regions have exhibited elevated incidence over the past 2 weeks or so—including Indiana , Iowa , Kansas , Minnesota , and Nebraska —all of which have reported COVID-19 outbreaks at meat processing facilities.

The US CDC reported 1.15 million total cases (28,763 new) and 67,456 deaths (1,719 new). In total, 13 states reported more than 25,000 cases (1 new), 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 1.18 million US cases and 69,079 deaths as of 12:30pm on May 5.

EARLY SARS-CoV-2 CIRCULATION IN FRANCE A commentary published in the International Journal of Antimicrobial Agents suggests that SARS-CoV-2 was circulating in France in December 2019, a month before the country’s first reported case. The study analyzed retained samples from patients with influenza-like illness from early December 2019 to mid-January 2020 with negative PCR tests for other respiratory infections, including influenza. The researchers conducted RT-PCR tests for SARS-CoV-2 on specimens from 14 patients that matched their criteria, and 1 specimen returned a positive SARS-CoV-2 test result. The patient’s clinical presentation and radiological patterns were consistent with those reported in early COVID-19 patients in China and Italy. Notably, the patient’s medical history included no travel or other direct links to China, which suggests that community transmission may have occurred earlier than previously thought.

SEROLOGICAL TESTING & IMMUNITY CERTIFICATES The US FDA revised its policy regarding the use of serological tests for SARS-CoV-2. In light of the increased number and availability of serological tests in the United States, the FDA announced that companies developing serological tests are now required to seek Emergency Use Authorization (EUA) for the tests, which will include submitting relevant validation data. The FDA also published minimum performance standards for serological tests, both sensitivity and specificity, to ensure appropriate levels of accuracy. The FDA also published EUA submission templates for both commercially developed serological tests and those developed at CLIA-certified laboratories. The goal of the policy change is to increase oversight and, therefore, the quality of available serological tests. 

As the interest in the widespread use of serological tests increases, conversations around the use of official documentation of immunity status as a basis for resuming social activity continue. These so-called “immunity passports/certificates” pose a variety of technical, social, ethical, and legal issues. A commentary published in The Lancet addresses some of these challenges. The author, Dr. Alexandra Phelan highlights technical barriers, including uncertainty regarding the degree and duration of immunity conferred by SARS-CoV-2 infection and the impact of false positive and negative test results. Additionally, a variety of social and economic factors could introduce incentive for individuals to deliberately infect themselves or introduce opportunity for corruption and increased socioeconomic inequities. Legal barriers, including ensuring appropriate protections of individuals, regardless of immune status or the presence of risk factors such as age or underlying health conditions, and “immunity passports would risk enshrining such discrimination in law.” Beyond the national scale, the use of immunity to determine eligibility for international travel could pose challenge both in terms of the health benefit (considering the technical challenges of administering and interpreting the tests) and discriminatory impact. Dr. Phelan argues that there is a fundamental difference between “immunity passports” based on infection, as would currently be the case for SARS-CoV-2, and those based on vaccination, such as for yellow fever. In the absence of a SARS-CoV-2 vaccine, an “immunity passport” would only incentivize infection.

US SOCIAL DISTANCING A number of states in the US are beginning to relax social distancing measures implemented under “stay at home” or “safer at home” orders. Florida began that process yesterday , allowing most of the state’s counties to start reopening non-essential businesses, with some restrictions. For example, restaurants, retail stores, and some other businesses can resume operation with a maximum of 25% of their normal capacity. Restrictions on elective medical procedures were lifted as well, as long as sufficient capacity exists to handle COVID-19 patients. Some beaches and parks opened to the public, but large groups will still be prohibited from gathering. Barbershops, gyms, and other businesses that involve close contact will remain closed in Florida for the time being. Miami-Dade, Broward, and Palm Beach counties will remain under “stay at home” restrictions, as they continue to have elevated risk of SARS-CoV-2 transmission, although some restrictions have relaxed in those counties, including opening state parks and beaches for some activities. Florida has reported decreasing COVID-19 incidence over the past several weeks, which aligns with the White House guidance on relaxing social distancing.

In Michigan, US Representative Paul Mitchell (Michigan’s 10th district) filed a lawsuit against Michigan Governor Gretchen Whitmer and the Director of the state’s Department of Health and Human Services, arguing that statewide social distancing orders are unconstitutional and violate the separation of powers. Representative Mitchell reportedly cited an inability to visit in-state family members or to obtain medical care for a knee injury in his lawsuit. Additionally, Michigan’s Republican-led state legislature is considering its own lawsuit , which could be filed next week. Governor Whitmer maintained statewide restrictions in place after the state legislature “declined to provide an extension” last week, prompting protests by armed protestors at the state house.

PEDIATRIC INFLAMMATORY CONDITION IN CHILDREN Reports from New York City and Europe describe new cases of a rare multisystem inflammatory syndrome in some pediatric COVID-19 patients. In New York City, 15 children, aged 2-15 years, have presented symptoms consistent with a rare pediatric condition called Kawasaki disease. Four of these patients tested positive for active SARS-CoV-2 infection, and 6 had positive serological tests, indicating previous infection. The Paediatric Intensive Care Society alerted its members of this condition in late April, and public health officials in New York and elsewhere are distributing notices to local health systems to inform pediatricians of the potential connection between the condition and SARS-CoV-2. 

SARS-CoV-2 VACCINE TRIAL IN THE US A candidate SARS-CoV-2 vaccine, jointly developed by Pfizer and BioNTech, is being studied in a vaccine clinical trial in the United States, at the New York University Grossman School of Medicine and the University of Maryland School of Medicine—with 2 additional locations enrolling participants in the near future. The study will be conducted alongside a trial cohort in Germany, which commenced last week. The combined Phase 1/2 trial aims to evaluate both safety and efficacy for 4 different mRNA vaccines as well as determine the dosage required to elicit the appropriate immune response. The study will initially involve 360 healthy subjects in two age cohorts. The study reportedly aims to expand to 8,000 individuals by the end of Phase 2. The two companies are also scaling up production capacity in order to ensure vaccine availability for future trials if the initial tests yield a successful candidate.

INDIA LOCKDOWN EXTENDED India has been under national “lockdown” restrictions since March 25, with extensions issued through May 3. On May 1, India again extended the national lockdown , following recent increases in reported COVID-19 cases. The new extension is scheduled to expire on May 18, but the new plan relaxes physical distancing measures for some parts of the country. Indian districts will be color-coded based on transmission risk: Green Zones for areas with no confirmed cases for the past 21 days, Red Zones for areas with high risk of transmission, and Orange Zones for all other areas. Containment Zones will be established in higher-risk parts of Red and Orange Zones to implement enhanced surveillance, including 100% mandatory participation using India’s COVID-19 surveillance app , Aarogya Setu . Perimeters will be established around the Containment Zones to prevent individuals from entering or leaving the area.

M any social distancing measures will continue nationwide under the extension, regardless of the Zone type, including prohibiting inter-state travel, including by air, rail, or bus; closing schools, restaurants, cinemas/movie theaters, retail stores, athletic facilities, and other non-essential businesses; and prohibiting large gatherings, including for religious services. Within the Containment Zones, outpatient medical services are prohibited as well as the operation of rickshaws and taxis, intra-district buses, and barbershops and salons. Some restrictions on buses, taxis, and inter-district travel remain for Orange and Green Zones as well, but they are relaxed to some extent. India has been working to scale up SARS-CoV-2 testing in recent weeks—one report indicated that India conducted 80,000 tests on May 4—which is potentially contributing to the recent increase in reported daily incidence. India reported a record high of 3,597 new cases today.

SARS-CoV-2 ANTIBODY TARGETS A recent study ( preprint ) evaluated patients' COVID-19 antibody response to various SARS-CoV-2 antigens. Using specimens collected from 15 COVID-19 patients from Hong Kong, the researchers were able to detect antibody responses to 11 of 15 SARS-CoV-2 antigens tested, including the identification of several novel immunogenic targets. Based on the results, a serological test based on a combination of 3 antigens—ORF3b, ORF8, and N—could have 100% sensitivity and 100% specificity as early as 4 days after the onset of symptoms, whereas a test targeting antibodies to the S protein would not.

ADAPTING THE US HEALTHCARE SYSTEM FOR COVID-19 So far in the US COVID-19 epidemic, health systems have been able to successfully expand patient capacity, but this has forced altered standards of care and reduced routine services in some locations and even the construction of temporary medical facilities in some major cities. The Johns Hopkins Center for Health Security published a guidance document that outlines concrete recommendations for systematic changes to establish and maintain resilience to pandemic events and mitigate existing health system vulnerabilities. This report addresses a broad scope of issues facing US health systems during the COVID-19 epidemic, including supply chain vulnerabilities, health system funding, workforce needs (including mental health services and sick leave), increased use of telemedicine capabilities, infectious disease screening and diagnostic capabilities, and the need to resume routine services and deferred procedures. This document outlines steps that can be taken now and in the future to establish necessary capabilities and capacity to combat COVID-19 and other future health emergencies.

DOWNSTREAM EFFECTS We continue to evaluate potential downstream effects of the COVID-19 pandemic, beyond the direct impact on morbidity and mortality. Mark Lowcock , the UN Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator, published an op-ed that describes the financial resources needed to address the global recession associated with the COVID-19 pandemic. Global lenders, including higher-income countries and international financial organizations, will need to “fundamentally shift their approach to aid and debt” in order to mitigate long-term and devastating economic effects that could “prove even more painful, and much more expensive...for everyone,” compared to the funding needed. Mr. Lowcock forecasts increased “conflict, hunger, and poverty” following the pandemic due to contracting national and global economies, and countries already facing challenges of weak health infrastructure could experience “and uptick in measles, malaria, cholera and other disease.” He also noted that the downstream effects of the pandemic on national economies and health systems could potentially double the number of people worldwide who face starvation . An estimated US$90 billion is needed to protect the most vulnerable 10% of the global population.