EPI UPDATE The WHO COVID-19 Situation Report for April 21 reports 2.4 million confirmed cases (83,007 new) and 162,956 deaths (5,109 new).
Spain and Italy both reported slight increases in daily incidence. However, Italy reported its second consecutive day of decreasing active cases, down from 108,257 on April 19 to 107,709 today. Additional data over the coming days will help determine whether Italy has truly reached a peak, but this is an encouraging trend.
Belarus has exhibited a significant acceleration in COVID-19 incidence since early April. Belarus’ epidemic grew from fewer than 200 cases on April 1 to 7,281 today. Austria’s reported COVID-19 incidence appears to be remaining at a low level, following initial steps to relax some social distancing measures. Germany has experienced several consecutive weeks of overall declining daily incidence as well. It may take time for potential increases in community transmission to become evident in European countries that are beginning to relax social distancing measures, but it is at least a promising start.
India reported fewer new cases (999) compared to yesterday, but the daily total is still considerably higher than it was in early April. Pakistan’s COVID-19 epidemic continues to accelerate. Today’s reported incidence was considerably lower than yesterday (533 new cases compared to 796), but it is still in line with an overall increasing trend over the past several weeks.
Singapore reported 1,016 new COVID-19 cases, including 967 among dormitory residents, as were 1,050 of the 1,111 cases reported yesterday. Through April 22, 80% of all COVID-19 cases (8,092 out of 10,141) reported in Singapore are dormitory residents. Additionally, Singapore’s epidemic doubled over the past 5 days, and 95.5% of the new cases were among dormitory residents. In contrast, Singapore reported only 122 instances of community transmission in that time. Indonesia reported 283 new cases yesterday. There has been a lot of fluctuation over the past several days, but Indonesia’s increasing daily incidence may be beginning to taper off slightly. Data over the coming days will help clarify if this is the start of a longer-term trend. Bangladesh’s COVID-19 epidemic has been steadily growing since early April, reaching 492 new cases on April 20 before falling off slightly over the past 2 days (390 new cases reported today).
New York state again reported its lowest daily incidence (4,178 new cases) since March 20. This is the state’s sixth consecutive day of declining incidence, but the number of tests performed also continues to decline—April 21 had the fewest tests performed of any day in April—which could be a trend to monitor. Notably, however, the percent of tests that are positive yesterday is considerably lower than the overall statewide total (27.0% compared to 38.8% over the entire epidemic), which could be promising. New York City reported slightly elevated incidence compared to the previous day—2,519 new cases compared to 2,370 yesterday—but it is still the city’s second lowest daily total since March 20.
The US CDC reported 776,093 total cases (29,468 new; 3,396 probable) and 41,758 deaths (2,675 new; 5,352 probable*) on April 21. Excluding the day New York City first reported probable COVID-19 deaths (April 14), this appears to be the highest daily total deaths for the United States. Yesterday’s daily incidence was also considerably higher than the previous day, but this could be a result of delayed reporting from the weekend. In total, 17 states reported more than 10,000 cases (1 new), and 27 states (no change) are reporting widespread community transmission. Based on recent daily incidence trends, the United States could reach 1 million cases by the end of April and 50,000 deaths by April 25.
*Based on the provided guidance regarding the reporting of probable COVID-19 cases, it is unclear how there could be more probable deaths than there are probable cases.
The Johns Hopkins CSSE dashboard** is reporting 826,248 US cases and 45,153 deaths as of 11:30am on April 22. Notably, the dashboard shows the highest daily incidence for the United States—39,500 new cases—since the beginning of the pandemic. Considering the dashboard tends to be a day or so ahead of the official CDC reporting, this will warrant close monitoring over the next several days.
**The Johns Hopkins CSSE also publishes US-specific data, at the county level, on a dedicated dashboard.
US RESPONSE The US Senate passed an amendment to the Paycheck Protection Program and Health Care Enhancement Act which will provide further support for small businesses and the US healthcare system. The bill will be sent to the House of Representatives, which is expected to vote on it later this week. The new amendment will provide an additional US$484 billion—including $380 billion for small businesses, $75 billion for hospitals, and $25 billion to expand testing capacity—to support the US COVID-19 response. Progress on the bill follows a surge in recent reporting on challenges with the initial round of small business loans, including large national companies receiving financial support over smaller local businesses, delays in processing applications, and demand far exceeding the allocated funding.
US President Donald Trump formally announced that he will direct additional restrictions on immigration in response to the economic impact of the US COVID-19 epidemic. The new measures will suspend immigration for those seeking permanent residency—commonly referred to as a Green Card—for a period of at least 60 days in order to ensure that American workers are not “replaced with new immigrant labor flown in from abroad” as states relax social distancing measures and businesses resume operation. The restrictions will not apply to those seeking temporary visas. President Trump also noted that the measure will also aim to mitigate the impact of COVID-19 on the US healthcare system. The restrictions are expected to take the form of an Executive Order, but it has not been issued as of this writing. Immigration advocates opposed the new measures, noting the major role that immigrants are playing right now in essential jobs that are keeping the country and economy operating under existing social distancing measures. Exemptions are expected to be included for seasonal workers, who are critical to the agriculture industry and food supply chain, and healthcare workers or other essential workers.
WISCONSIN LINKS COVID-19 CASES TO ELECTION Health officials in Wisconsin (US) reportedly linked at least 7 COVID-19 cases to the statewide election held on April 7. The state’s Supreme Court ruled to overturn Wisconsin Governor Tony Evers’ last-minute executive order to postpone the election, and the election proceeded as scheduled. Many in-person polling locations were closed, which raised concerns about potential transmission associated with long lines and congestion at those locations that remained open. State and local health officials initiated an investigation to monitor transmission potentially linked to in-person voting. Yesterday, Milwaukee Health Commissioner Jeanette Kowalik confirmed that the local health department identified 7 cases of COVID-19—6 voters and 1 poll worker—that could be traced back to the polls. Local health officials indicated that they have only 30% of the data and that additional cases could be identified as more information becomes available. More than 1.1 million absentee ballots were submitted for Wisconsin’s 2020 primary—37% more than in the 2016 presidential election. We have not identified an official statement, but the media reports cited here quote local health officials.
SARS-CoV-2 VACCINE HUMAN CHALLENGE TRIALS On April 20, US Representative Bill Foster and more than 30 members of Congress wrote a letter to Secretary of Health and Human Services Alex Azar and FDA Commissioner Stephen Hahn calling for an expedited research, development, and approval process for COVID-19 vaccines. The letter notes that “every week of delay in the deployment of a vaccine to the seven billion humans on Earth will cost thousands of lives.” Notably, the letter expresses support for human challenge trials (HCTs), in which trial participants would volunteer to be intentionally infected with SARS-CoV-2 in order to directly assess the efficacy of candidate vaccines. HCTs have been used during past vaccine development efforts, but their use for SARS-CoV-2 vaccine trials is controversial, particularly in the absence of an effective treatment that could be used for those for which the vaccine is not effective.
AFRICA EXPEDITES COVID-19 CLINICAL TRIALS National regulatory agencies and ethics review boards in Africa are collaborating to speed up the review process for proposed clinical trials for COVID-19 pharmaceuticals and tests. The agreement was formalized in early April under the African Vaccines Regulatory Forum, which was established by the WHO in 2006 to improve regulatory capabilities and oversight for clinical trials conducted in Africa. Under the agreement, proposed clinical trials can be reviewed by multiple countries and agencies simultaneously via an online portal, and study sponsors and researchers can respond to countries’ questions or concerns in real time via the same platform. Similar approaches have been used in the past for other diseases, including meningitis, malaria, and Ebola. The collaborative effort aims to accelerate the study review and approval process while maintaining the ability for national regulatory agencies to provide the necessary oversight and protection for their individual populations.
COVID-19 RACIAL & ETHNIC DISPARITIES Michigan’s Chief Medical Executive, Dr. Joneigh S. Khaldun, published a letter to clinicians statewide to call attention to racial and ethnic disparities associated with COVID-19. The letter highlights elevated COVID-19 incidence and severity observed in minority populations in Michigan, including African Americans, who represent 30% of cases and 40% of deaths statewide despite comprising only 14% of the state’s population. Dr. Khaldun cites a broad scope of challenges facing racial and ethnic minorities that could be contributing to these disparities, including working lower wage jobs, crowded living conditions, and use of public transit. These factors can place individuals at elevated risk of exposure to SARS-CoV-2 and hinder efforts to implement CDC-recommended social distancing and enhanced hygiene efforts in public and at home. The letter also includes several recommendations for clinicians to address these disparities, including proactive recognition and awareness of the disparities themselves, to mitigate the risk of biasing decisions regarding testing and treatment, as well as the difficulties these individuals and families may face in implementing recommended protective actions (including quarantine and isolation).
US NATIONAL VENTILATOR SHARING PROGRAM On April 14, the White House announced a new public-private partnership intended to reallocate ventilators from hospitals experiencing relatively lower levels of demand to those experiencing high demand due to the US COVID-19 epidemic. The Dynamic Ventilator Reserve is a voluntary program that includes at least 20 large healthcare systems. Yesterday, the White House’s Council of Economic Advisors published its analysis of the program and its effect on hospitals’ ability to cope with the surge of COVID-19 patients. According to the Council’s projections, the national supply of ventilators is sufficient to handle peak demand, and the Reserve program will “provide enough ventilators for the hospitals participating in the network” by moving surplus ventilators to areas of high demand.
US COVID-19 DEATHS IN JANUARY The Santa Clara County (California, US) Medical Examiner identified COVID-19 deaths from early February, which suggests that SARS-CoV-2 was circulating in the community in January, weeks before previously thought. Two individuals who died in their homes in Santa Clara County on February 6 and 17, respectively were tested for SARS-CoV-2 infection by the US CDC, which confirmed that the specimens tested positive for SARS-CoV-2 infection. Another victim who died on March 6 also tested positive. Previously, the earliest reported COVID-19 death in the county was on March 9, and the earliest reported death in the United States was on February 29 in Kirkland, Washington. At the time of their deaths, testing was largely limited to individuals with known travel history to affected areas or exposure to confirmed COVID-19 cases. This discovery suggests that the virus was transmitting in the broader community, potentially for weeks, before community transmission was identified.
USS ROOSEVELT OUTBREAK The US Navy continues to report COVID-19 cases among the Sailors and Marines onboard the USS Roosevelt aircraft carrier. A joint investigation between the Navy and the US CDC is ongoing to better understand the transmission of SARS-CoV-2 among the ship’s crew. The study will reportedly include broad diagnostic and serological testing of crew members. The outbreak was detected approximately 2 weeks after the ship was in Da Nang, Vietnam; however, it is unclear exactly how the virus was introduced to the ship. The US Air Force constructed a temporary medical facility to provide treatment and isolation capacity for COVID-19 patients. So far, more than 700 cases have been reported from among the ship’s crew, which remains in quarantine in Guam. The ship’s Commanding Officer, Captain Brett Crozier, was relieved of duty after sending a letter to senior US Navy leadership calling for additional support and response early in the ship’s outbreak. Secretary of the Navy Thomas Modly resigned shortly after the incident, and an investigation is ongoing.
In a similar outbreak in the French Navy, more than 1,000 crew members from France’s Charles de Gaulle aircraft carrier group have tested positive for SARS-CoV-2. Cases have been identified on multiple ships, but the majority are stationed aboard the aircraft carrier.