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

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May 6, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 5 reports 3.52 million confirmed cases (81,454 new) and 243,401 deaths (3,797 new).

The UK COVID-19 epidemic appears to be on pace to continue its decline in daily incidence. It looks like last week will be the third consecutive week of decreasing incidence. Russia again 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, and it could potentially surpass Germany and France tomorrow in terms of total cases, which would put it at #5 globally. More than 60% of all cases reported nationwide (102,563 cases of 165,929 total) are in Moscow or the Moscow Region.

India reported nearly 3,000 new cases, likely its second highest daily total . India’s epidemic continues to accelerate, despite national “lockdown” measures; however, expanded testing capacity could account for some of the recent increase. Pakistan reported 1,049 new cases, nearly 300 fewer than the previous day but still its fourth-highest daily total.

Singapore reported 788 new COVID-19 cases, including 759 (97.5%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s growing COVID-19 epidemic. Singapore announced plans to begin relaxing some of the national “circuit breaker” measures , including resuming operation at some retail stores and restaurants, beginning May 12, so it will be important to monitor for potential increases in community transmission. Indonesia reported 367 new cases, consistent with its trend over the past several weeks of slowing its rise in daily incidence. Bangladesh recorded a new high daily incidence (790 new cases) for the fourth consecutive day, although it is a minor increase over the previous day. Bangladesh's epidemic continues to double approximately every 9 days.

New York state and New York City both reported decreasing daily incidence for the third consecutive day, the lowest daily value for each since March 18. The percentage of tests performed with positive results continues to decline, an encouraging trend. We are continuing to monitor COVID-19 incidence trends in states that have started easing social distancing measures; however, we may not yet be able to observe new cases associated with the changes.

The US CDC reported 1.17 million total cases (19,138 new) and 68,279 deaths (1,719 new). The daily totals are much lower than in previous days, but this is likely due to reporting delays over the weekend. In total, 13 states reported more than 25,000 cases (no change), including New York with more than 300,000; New Jersey more than 125,000; and 4 additional states with more than 50,000. Additionally, 35 states (increase of 1), plus Guam, are reporting widespread community transmission.

The Johns Hopkins CSSE dashboard is reporting 1.21 million US cases and 71,220 deaths as of 12:30pm on May 6.

SEROLOGICAL TEST VARIATION The number of serological tests available for SARS-CoV-2 is rapidly increasing. One organization tracking tests, available or in development, estimates more than 200 different products exist . Most of these tests are manufactured in China, with additional companies based in Germany, South Korea, the United Kingdom, and the United States. In the United States, 12 serological tests have received an Emergency Use Authorization (EUA) from the US FDA. Companies were previously permitted to introduce and distribute tests without an EUA before the FDA revised the policy earlier this month . Variability in the quality of serological tests has led research groups to conduct independent evaluations of the tests to enable more informed selection of tests to use. One such effort, conducted under the COVID-19 Testing Project, published ( preprint ) results from the evaluation of 12 different serological tests, including both lateral flow assays and ELISA tests, utilizing 130 specimens collected from 80 COVID-19 patients (and 108 control specimens).

MONOCLONAL ANTIBODIES Monoclonal antibodies are proteins designed to function like the antibodies produced by the human immune system, and a number of efforts are ongoing to develop products to combat COVID-19. A research team from Utrecht University (Netherlands) published the results of such a study in Nature Communications . The researchers identified a monoclonal antibody, named 47D11, that offers the potential to treat individuals already infected with SARS-CoV-2 or possibly prevent infection. The monoclonal antibody also exhibited cross-neutralizing activity against the original SARS-CoV virus, the pathogen responsible for the 2003 SARS epidemic. Additionally, the researchers indicate that this monoclonal antibody could also be used in developing serological tests. The antibody binds to trimeric spike glycoproteins on the surface of the virus, which blocks interaction between the spike protein and the ACE2 receptor, which normally facilitates virus entry into human cells. The study was performed in cell cultures, and further study is required to determine the monoclonal antibodies’ effects in animal models or human trials.

WHISTLEBLOWER COMPLAINT Former Director of the Biomedical Advanced Research and Development Authority (BARDA), Dr. Rick Bright , filed a whistleblower complaint with the US Office of Special Counsel. The 89-page complaint alleges that he was removed from his position at BARDA —a US government agency responsible, in part, for developing medical countermeasures for infectious diseases, including COVID-19—as retaliation for his opposition to US government policies and actions during the COVID-19 response. In particular, the complaint cites conflict over his resistance to the widespread use of hydroxychloroquine for COVID-19 patients, due to insufficient data supporting its efficacy and the risk of adverse side effects, as a main driver of his removal. Additionally, Dr. Bright alleges that he attempted to raise awareness of the growing COVID-19 threat to senior leadership at the US Department of Health and Human Services (HHS) early in the pandemic—including the need to increase the availability of personal protective equipment (eg, N95 respirators), obtain specimens from China, and fund programs to develop medical countermeasures (MCMs)—but “HHS leadership criticized him for his efforts and removed him from meetings.” The complaint references dozens of exhibits, including e-mail communications with senior HHS officials, to document his claims. A spokesperson for HHS reportedly indicated that Dr. Bright was transitioned to a position at the National Institutes of Health (NIH) that would focus on COVID-19 diagnostics, and unnamed HHS officials reportedly indicated that discussions about removing Dr. Bright from his position at BARDA had been ongoing for months.

US SOCIAL DISTANCING On May 4, less than a week after extending a statewide “stay at home” order (scheduled to expire May 15), Arizona Governor Doug Ducey issued an executive order relaxing some of the statewide restrictions . The newest order permits barber shops and salons to resume operations and restaurants to resume dine-in service. These businesses must implement prescribed social distancing and other safety measures , but they can reopen starting May 8 for barbershops and salons and May 11 for restaurants. The previous order extending the “stay at home” measures allowed retail businesses to resume some in-person operations starting May 8 as well. Arizona’s efforts to relax social distancing come in the midst of what could be a concerning trend. Last week, Arizona reported its highest weekly COVID-19 incidence (based on specimen collection date), 2,116 new cases. This is an increase of 21.3% over the previous week, and this total could further increase over the next several days as cases who provided specimens late last week are reported to the state. Arizona has substantially increased testing statewide—jumping from 12,687 weekly tests to 20,087 over the past two weeks—and the percent of those tests with positive results decreased from 11% three weeks ago to 8% last week. Notably, however, data reported by the COVID Tracking Project , which obtains data from state health department websites, indicates that the percent of positive tests conducted last week was 13%. The cause for the discrepancy between these data is unclear. While Arizona has increased testing, it has not exhibited a decrease or plateau in COVID-19 incidence in recent weeks. Additionally, a team at Arizona State University that was providing epidemic modeling in support of Arizona’s COVID-19 response was reportedly directed to stop their work and return the data to the state, following shortly after the Governor’s Monday announcement. The notification reportedly indicated that the state would be relying on a model developed by the Federal Emergency Management Agency (FEMA). As states begin to relax social distancing measures, it will be critical to monitor trends in COVID-19 incidence in order to quickly identify indications of increased community transmission. Considering that the incubation period can last as long as 14 days, it could be days or weeks before any changes in transmission become evident, which could mean that community transmission has already increased by the time associated cases are detected.

In Utah County, Utah, local health officials identified COVID-19 outbreaks associated with 2 local businesses that refused to adhere to recommended social distancing practices . The outbreaks resulted in 68 total cases, including 48% of employees at one of the businesses. During contact tracing efforts, health officials discovered that the “businesses instructed employees to not follow quarantine guidelines after exposure to a confirmed case at work and required employees with a confirmed COVID-19 diagnosis to still report to work.” Local officials subsequently closed one of the businesses. The announcement about these outbreaks follows a recent decision by Utah Governor Gary Hebert to begin relaxing statewide social distancing restrictions after the state transitioned from “high risk” to “moderate risk.”

INDIA MARKET OUTBREAK As India begins to relax nationwide “lockdown” measures in some parts of the country, in the midst of recent increases in reported COVID-19 incidence, health officials identified an outbreak associated with one of the “largest fruit and vegetable markets” in Asia . The Koyambedu market is located in Chennai (Tamil Nadu state), and the outbreak has been linked to more than 500 cases in Tamil Nadu and Kerala states. Notably, the number of active cases reported in Tamil Nadu has more than tripled over the past 8 days, increasing from 812 cases on April 28 to 2,540 on May 6.

The market reportedly continued to operate during India’s nationwide “lockdown,” as it is a critical component of the regional food supply; however, the use of face masks, PPE, and hand sanitizer was reportedly not widely implemented at the market. According to a report published by ABC News, thousands of local residents “rushed to the market” in late April to stockpile food after the Tamil Nadu government announced a “four-day ‘intensified’ lockdown,” which could have resulted in mass exposure to the virus. The first case associated with the market was not detected until 3 days later. Individuals exposed that day could still be in their incubation period or potentially already infectious and transmitting the infection to others.

The market is currently closed, but public health responders are struggling to trace contacts and identify associated cases, in particular because affected individuals may be reluctant to come forward due to concerns about “stigma or quarantines.” An inability to identify and isolate/quarantine new cases and exposed individuals could lead to further transmission. This outbreak illustrates that community transmission was occurring in some parts of India prior to cases being detected, even during the “lockdown.” As India begins to relax social distancing, it is critical to expand testing and surveillance capacity, including outside of “hotspot” areas . Otherwise, large-scale community transmission can go unnoticed, which can risk sparking a larger epidemic and necessitate further restrictions. 

EARLY COMMUNITY TRANSMISSION The Cook County Medical Examiner’s Office (Illinois, US) will begin reviewing deaths from as early as November 2019 to determine if any were caused by COVID-19. Deaths in Cook County, where Chicago is located, that were originally determined to be a result of heart attacks or pneumonia will be included in the review. Cook County’s first reported COVID-19 case was in March 2020, and officials do not anticipate finding cases from November; however, they want to conduct a comprehensive investigation. If any cases are identified from November, then the effort could be expanded to include earlier deaths. In light of other recent reports of COVID-19 cases and deaths identified retrospectively, a review of these deaths could provide insight into the timeline and extent of community transmission in the Chicago area prior to the earliest reported cases, particularly considering that the testing availability and strategy early in the pandemic likely resulted in community transmission going undetected in many areas prior to the first reported case.

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