COVID-19 Daily Update (2/29)
A daily update on the emerging coronavirus ("COVID-19") from a US perspective.
Global situation by the numbers
[Infections (Daily Increase) (%) ] [Fatalities (Daily increase) (%) ] [CFR %]
East Asia
🇨🇳Mainland China — 78,824 (+427) (0.5%) — 2,788 (+47) (1.7%) — 3.5% [CDC Level 3]
🇰🇷South Korea — 3,150 (+813) (34.7%) — 16 (+3) (23%) — 0.54% [CDC Level 3]
🇯🇵Japan — 933 (+2) (0.2%) — 8 — 0.85% [CDC Level 2]
🇭🇰Hong Kong— 94 — 2 — 2.1% [CDC Level 1]
🇸🇬Singapore — 96 (+3) (3.2%) — 0 — 0%
🇹🇼Taiwan — 34 — 1 — 2.9%
🇲🇴Macau — 10 — 0 — 0%
Southeast Asia / Australasia
🇹🇭Thailand — 41 — 0 — 0%
🇲🇾Malaysia — 25 (+2) (8.6%) — 0 — 0%
🇦🇺Australia — 25 (+2) (8.6%) — 0 — 0%
🇻🇳Vietnam — 16 — 0 — 0%
🇵🇭Philippines — 3 — 1 — 0%
🇰🇭Cambodia — 1 — 0 — 0%
🇳🇿New Zealand —1 — 0 — 0%
South Asia
🇮🇳India — 3 — 0 — 0%
🇳🇵Nepal — 1 — 0 — 0%
🇱🇰Sri Lanka — 1 — 0 — 0%
Middle East
🇮🇷Iran — 593 (+205) (52.8%) — 43 (+9) (26.4%) — 7.2% [CDC Level 3]
🇰🇼Kuwait — 45— 0 — 0%
🇧🇭Bahrain — 38 (+2) (5.5%) — 0 — 0%
🇦🇪United Arab Emirates — 19 — 0 — 0%
🇮🇶Iraq — 8 (+1) — 0 — 0%
🇮🇱Israel — 7 (+3) — 0 — 0%
🇴🇲Oman — 6 (+2) — 0 — 0%
🇱🇧Lebanon — 4 (+2) — 0 — 0%
🇵🇰Pakistan — 2 — 0 — 0%
🇦🇫Afghanistan — 1 — 0 — 0%
🇦🇿Azerbaijan — 1 — 0 — 0%
Europe
🇮🇹Italy — 889 (+1) (0.1%) — 21 — 2.3% [CDC Level 3]
🇫🇷France — 73 (+16) (28%) — 2 — 3.5%
🇩🇪Germany — 48 — 0 — 0%
🇪🇸Spain — 51 (+19) (59.3%) — 0 — 0%
🇬🇧UK — 20 — 0 — 0%
🇸🇪Sweden — 11 — 0 — 0%
🇨🇭Switzerland — 8 — 0 — 0%
🇳🇴Norway — 6 — 0 — 0%
🇭🇷Croatia — 5 — 0 — 0%
🇬🇷Greece — 4 — 0 — 0%
🇦🇹Austria — 3 — 0 — 0%
🇷🇴Romania — 3 — 0 — 0%
🇫🇮Finland — 2 — 0 — 0%
🇷🇺Russia — 2 — 0 — 0%
🇧🇪Belgium — 1 — 0 — 0%
🇬🇪Georgia — 1 — 0 — 0%
🇲🇰North Macedonia — 1 — 0 — 0%
🇩🇰Denmark — 1 — 0 — 0%
🇪🇪Estonia — 1 — 0 — 0%
🇳🇱Netherlands — 1 — 0 — 0%
🇧🇾Belarus — 1 — 0 — 0%
🇱🇹Lithuania — 1 — 0 — 0%
🇸🇲San Marino — 1 — 0 — 0%
🇮🇸Iceland — 1 — 0 — 0%
Africa
🇪🇬Egypt — 1 — 0 — 0%
🇩🇿Algeria — 1 — 0 — 0%
🇳🇬Nigeria — 1 — 0 — 0%
North America
🇨🇦Canada — 16 (+1) — 0 — 0%
🇲🇽Mexico — 2 — 0 — 0%
South America
🇧🇷Brazil — 1 — 0 — 0%
US situation by the numbers
🇺🇸United States — 65 (+5) (8.3%) — 1 — 1.5%
State-by-state breakdown:
California - 28 (+1)
Nebraska - 13
Texas - 11 (+1)
Washington - 7 (+2**)
Illinois - 2
Wisconsin - 1
Massachusetts - 1
Arizona - 1
Oregon - 1 (+1)
**Presumptive positive - pending confirmation by CDC lab test.
Latest developments in US
Two new cases of person-to-person (P2P) transmission reported in Washington state. The individuals reside in both King and Snohomish Counties. In King County, a woman in her 50s with confirmed travel to Daegu, South Korea is a presumptive positive. In Snohomish County, a person under the age of 18 with no travel history is also a presumptive positive. Washington DOH “We don’t know how or where the new Snohomish County case was infected”. Both cases are “presumptive positives” pending CDC test confirmation.
First case of P2P transmission in Oregon (Hillsboro - suburb outside of Portland). Oregon health officials on Friday reported a coronavirus case of unknown origin. The patient (age and gender undisclosed) is from Washington County and reportedly was symptomatic for ~9 days before being tested. The case was not a person under monitoring or a person under investigation. The individual had neither a history of travel to a country where the virus was circulating, nor is believed to have had a close contact with another confirmed case. The individual is employed at a school in Clackamas County and may have exposed students and staff there. This case is “presumptive positive” and subject to confirmation by CDC test.
Second case of P2P transmission in California. Health officials in Santa Clara County (south of San Francisco) reported a 65-year old resident tested (+). The individual had no known exposure to the virus through travel or close contact with a known infected individual, making it the second possible instance of COVID-19 community transmission in California. Previously known instances of person-to-person transmission in the United States include one instance in Chicago, Illinois, and one in San Benito County, California (~90 miles away from most recent case). The second case (along with the Oregon case) would further support the theory that COVID-19 is already circulating in the continental United States, passing from person-to-person in local communities.
ICYMI: Whistle-blower complaint: US health workers lacked proper training and protective gear during intake of repatriated Americans. The team was “improperly deployed” to two military bases in California to assist the processing of Americans who had been evacuated from coronavirus hot zones in China and elsewhere. Staff members from the Department of Health and Human Services’ Administration for Children and Families were sent to Travis Air Force Base and March Air Reserve Base in late January and early February and were ordered to enter quarantined areas, including a hangar where coronavirus evacuees were being received, the complaint said. They were not provided safety-protocol training until five days into their assignment.
Returned passengers from Diamond Princess cruise ship. The federal government informed California officials that it has determined it does not need to use the Fairview Development Center (Orange County) site for the isolation of passengers from the cruise ship given the imminent end of the isolation for those passengers and the small number of persons who ended up testing positive for COVID-19. Approximately 30-50 patients have been quarantined at Travis Air Force Base; the federal government had considered relocating them to the site before running into local opposition.
Nurses union says hospitals are unprepared for COVID-19. Eight days before a patient with suspected COVID-19 was admitted to hospital, nurses approached hospital management and asked them to institute infection control measures (plans which already existed and had been in place since 2014 Ebola outbreak). Selected quotes from National Nurses United published statement provided below:
The recent UC Davis Medical Center COVID-19 case highlights the vulnerability of the nation’s hospitals to this virus and the insufficiency of current Centers for Disease Control guidelines. The single COVID-19 patient admitted to the facility on Feb. 19 has now led to the self-quarantine at home of at least 36 RNs and 88 other health care workers.
Additionally, the National Nurses United conducted a survey of registered nurses on hospital preparedness in the state of California (~1000 nurses surveyed):
Only 27 percent report that there is a plan in place to isolate a patient with a possible novel coronavirus infection. 47 percent report they don’t know if there is a plan.
Trump admin response
Trump administration weighs using 1950 law to step up production of medical supplies. President Trump could use a Korean War-era law to require manufacturers to speed up production of emergency supplies needed to fight the new coronavirus, Alex M. Azar II, the health and human services secretary said on Friday. The Defense Production Act, enacted in 1950, allows the president to exert control over parts of the civilian economy when it is necessary for national defense — forcing industries to step up production, reallocating basic resources and imposing price controls. The law could be used to help stockpile n-95 face masks (which are experiencing a nationwide shortage) and other supplies.
White House Chief of Staff Mick Mulvaney critical of media coverage. Mick Mulvaney, the acting White House chief of staff, on Friday blamed the media for exaggerating the seriousness of coronavirus because “they think this will bring down the president, that’s what this is all about.” Mr. Mulvaney said the administration took “extraordinary steps four or five weeks ago,” to prevent the spread of the virus. President Trump had this to say:
“They’re doing everything they can to instill fear in people, and I think it’s ridiculous. And some of the Democrats are doing it the way it should be done, but some of them are trying to gain political favor by saying a lot of untruths. We haven’t lost anybody yet, and hopefully we can keep that intact. There’ve been no deaths in the United States at all. A lot of that’s attributable to the fact that we closed the border very early. Otherwise it could be a very different story.
Mulvaney also suggested that COVID-19 is not as deadly as the seasonal flu:
“The flu kills people. This is not Ebola. It’s not SARS, it’s not MERS. It’s not a death sentence, it’s not the same as the Ebola crisis.”
NIH official was sidelined once VP Pence took over US coronavirus efforts. Rep. John Garamendi (D-Calif.) on Friday said the director of the National Institute of Allergy and Infectious Diseases was told to "stand down" and not appear on five Sunday morning talk shows to discuss the coronavirus. Garamendi told MSNBC's Hallie Jackson that NIH’s Anthony Fauci was scheduled to do all five major Sunday talk shows, but says Fauci canceled the appearances after Vice President Pence took over the administration's response to the disease.
FDA won’t say which drug is now in short supply due to supply chain problems in China. The FDA refused to disclose the name of the drug and its manufacturer — as well as where the product or its ingredients were made — saying that it could not reveal “confidential commercial information.” The FDA has said it is closely monitoring about 20 products where the manufacturers rely solely on China for their finished products or active pharmaceutical ingredients.
At South Carolina rally, President Trump calls coronavirus the Democrats’ “new hoax”. Trump blamed the press for acting hysterically about the virus, which has now spread and downplayed its dangers, saying against expert opinion it was on par with the flu. "The Democrats are politicizing the coronavirus. They're politicizing it," Trump said.
Testing capability in US
The FDA announced they will begin allowing high-complexity US labs to develop in-house testing for COVID-19. The move (coupled with increased testing capacity of public health labs - see below) would enable an additional ~10,000 tests/day over next two weeks:
US expanding testing capability, but still a laggard globally. Health and Human Services (HHS) Secretary Alex Azar told Congress Thursday that testing capacity is expanding, with 40 labs qualified to screen for coronavirus. Another 93 labs will have an easier test by the weekend, and about 70 manufacturers are working on bedside diagnostic tests. HHS keeps a “strategic stockpile” of critical medical supplies, including protective equipment, which is available to hospitals when they can’t replenish inventory from the market or state and local reserves. To date, HHS hasn’t received requests or deployed protective equipment in response to the coronavirus epidemic.
New York. State health officials have already begun distributing critical medical supplies from public stockpiles. Gov. Andrew Cuomo said Wednesday the state will be seeking approval from the New York state Legislature for $40 million in emergency funds to combat coronavirus in the state and pay for needed equipment, including protective gear for health-care workers. Hospital and public health emergency plans include contingencies for a surge in patients, which include possible makeshift wards outside hospitals
California. The California Department of Public Health announced that new CDC test kits used to detect COVID-19 can be used to do diagnostic testing in the community. California will immediately receive an additional shipment of kits to test up to 1,200 people. There will be eight public health labs capable of testing for COVID-19 in the counties of Richmond, Alameda, Santa Clara, Tulare, Ventura, Los Angeles, Orange, and San Diego.
What public health professionals are saying
World Health Organization (W.H.O.) raised its risk assessment of the coronavirus to “very high” citing risk of spread and impact. “This is a reality check for every government on the planet,” said Dr. Michael J. Ryan, deputy director of W.H.O.’s health emergency program. “Wake up. Get ready. This virus may be on its way.” The W.H.O. does not officially use the word “pandemic,” often defined as the worldwide spread of a new disease, but many health experts say the coronavirus epidemic is one, or soon will be.
In a new report, W.H.O. praised China’s aggressive tactics for containing COVID-19 outbreak. “China’s bold approach to contain the rapid spread of this new respiratory pathogen has changed the course of a rapidly escalating and deadly epidemic,” the report said. China’s strategy “has averted or at least delayed hundreds of thousands” of cases, and “played a significant role in protecting the global community.” Key findings of that report:
Among 55,924 laboratory confirmed cases reported as of 20 February 2020, the median age is 51 years with the majority of cases (77.8%) aged between 30–69 years. Among reported cases, 51.1% are male.
COVID-19 is transmitted via droplets and fomites during close unprotected contact between an infector and infectee. Airborne spread has not been reported for COVID-19 and it is not believed to be a major driver of transmission based on available evidence. Fecal shedding has been demonstrated from some patients.
In China, human-to-human transmission of the COVID-19 virus is largely occurring in families.
Early cases identified in Wuhan are believed to be have acquired infection from a zoonotic (of animal origin) source.
The cordon sanitaire around Wuhan and neighboring municipalities imposed since 23 January 2020 has effectively prevented further exportation of infected individuals to the rest of the country.
Data on individuals aged 18 years old and under suggest that there is a relatively low attack rate in this age group (2.4% of all reported cases).
People with COVID-19 generally develop signs and symptoms, including mild respiratory symptoms and fever, on an average of 5-6 days after infection (mean incubation period 5-6 days, range 1-14 days).
Selected quotes from W.H.O.-China Joint Mission on COVID-19 report:
“China has rolled out perhaps the most ambitious, agile and aggressive disease containment effort in history.”
“Achieving China’s exceptional coverage with and adherence to these containment measures has only been possible due to the deep commitment of the Chinese people to collective action in the face of this common threat. Despite ongoing outbreaks in their own areas, Governors and Mayors have continued to send thousands of health care workers and tons of vital PPE supplies into Hubei province and Wuhan city.”
“China’s bold approach to contain the rapid spread of this new respiratory pathogen has changed the course of a rapidly escalating and deadly epidemic. Based on a comparison of crude attack rates across provinces, the Joint Mission estimates that this truly all-of-Government and all-of-society approach that has been taken in China has averted or at least delayed hundreds of thousands of COVID-19 cases in the country.”
“Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China. These are the only measures that are currently proven to interrupt or minimize transmission chains in humans. Fundamental to these measures is extremely
proactive surveillance to immediately detect cases, very rapid diagnosis and immediate case isolation, rigorous tracking and quarantine of close contacts, and an exceptionally high degree of population understanding and acceptance of these measures.”
What doctors / scientists are saying
How to Save Lives in a COVID-19 Pandemic. As the pandemic progresses, more accurate categorization will be possible. The most recent comparable influenza pandemics may be H2N2 in 1957 and H3N2 in 1968, which resulted in some 1.1 million and 1 million deaths worldwide, respectively, but in a much different global context. Vaccines and medications can be developed more rapidly than half century ago. Intensive care is more effective now, but today diseases can have greater impact due to increased travel and urbanization, larger populations of older people and those with comorbidities, and wide disparities between the most and least prepared countries in the world. Although there is now more timely access to information, there is also faster spread of misinformation. Select quotes below:
To better understand transmissibility, detailed epidemiologic investigations should be undertaken in countries when the virus is first identified, including studies of its "attack rate" in households, schools, health care facilities, and community at large.
Our current understanding of how severe COVID-19 is may be overestimated, since it's easier to detect people who are suffering severely than mild or asymptomatic cases. Some of the available measures we can apply to assess its severity include case-fatality ratios, deaths-to-hospitalization ratios, and the proportion of intensive care unit (ICU) admissions.
To accurately ascertain disease severity, we should establish longitudinal studies that monitor the outcomes of infected patients, stratifying by variables such as age, sex, and medical comorbidities.
A worst-case scenario with a more transmissible and severe coronavirus would affect 10 percent of the global population with a case fatality ratio of 1 percent, causing millions of deaths.
What do these non-pharmaceutical interventions look like? They include things like covering your mouth when you cough or sneeze, hand hygiene, and voluntary home isolation when a person is sick. It also includes routine cleaning of frequently touched surfaces at home, work, schools, and in health care settings. A big part of implementing these interventions is education—communicating frequently and effectively to the public and training workers on how to reduce the spread of infection.
Funding to support COVID-19 operations at WHO has been inadequate, and a U.S. $2.5 billion proposal by the Trump Administration for COVID-19 pales in comparison to prior U.S. appropriations for the much less severe health threats of H1N1 influenza ($7.6 billion) and Ebola ($5.4 billion).
What other governments are doing
Singapore. It was the first country after North Korea and Russia to shut its borders to China and has enforced a strict 14-day leave of absence for Chinese nationals returning from the mainland who are permanent residents or have work permits. It has a zero tolerance approach to any breaches of the measures it has put in - and this is of comfort to many Singaporeans. Employees caught breaking isolation rules saw their work permits revoked and were barred from working in Singapore permanently.
Chinese government’s response to outbreak in that country appears difficult to replicate elsewhere:
Economic impact in the US
Outbreak in the US would severely test hospitals’ already strained capacity. A large-scale U.S. coronavirus outbreak would strain a health-care system already facing a global disruption in medical supplies, with an anticipated shortage in rooms that could safely isolate patients, infectious disease experts said:
“You can’t just invent medical equipment and more beds overnight,” said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy. “This could escalate here in a matter of weeks.”
A domestic outbreak would also land more critically ill patients in hospitals, which are already seeing a seasonal surge from flu patients, experts say.
California - Video game developers conference postponed in San Francisco. Following withdrawals from high-profile exhibitors, including Microsoft, Epic Games, Sony and Kojima Productions, organizers for the Game Developers Conference announced Friday that the event would be postponed. The annual conference draws tens of thousands of game developers and industry stakeholders from around the world.
Global economic impact
US pulls out of summit with Asian leaders. A summit of the U.S.-Association of Southeast Asian Nations Business Council that was set for March 14 in Las Vegas has been postponed by the Trump administration over the coronavirus outbreak, a senior administration official said on Friday.
Outbreak starts to look more like a global economic crisis. A measure of business sentiment in Germany fell sharply last week, suggesting that some companies could postpone investment and expansion plans. China is a huge export market for German manufacturers. In the U.S., online retail giant Amazon said Friday that it has asked all of its 800,000 employees to postpone any non-essential travel, both domestic and internationally. Economists have forecast global growth will slip to 2.4% this year, the slowest since the Great Recession in 2009:
“This is a case where in economic terms the cure is almost worse than the disease,″ said Jacob Kirkegaard, senior fellow at the Peterson Institute for International Economics. “When you quarantine cities ... you lose economic activity that you’re not going to get back.”
Run on face masks worldwide. Fear of the spreading COVID-19 has led to a global run on sales of face masks despite evidence that most people who aren’t sick don’t need to wear them. The shortages are being attributed not just to high demand, but to disruptions in supply: An outsize share of the world’s surgical masks are made in China — 50%, by its own estimate. But even factories there that have ramped up production say they are hard pressed to meet local demand. The government has taken over manufacturers, and exports have plunged. US officials have estimated that the country would need ~300 million face masks in the event of a major outbreak; right now, strategic stockpile amounts to 1/10 of that.
China purchasing index drops to record lows as workers are still hard to find. The official manufacturing purchasing managers index tumbled to 35.7 in February from 50 in January, indicating a deep contraction. February’s reading from the National Bureau of Statistics on Saturday was the first official data for a full month of economic activity in China since the coronavirus began affecting the economy in late January. One of the biggest obstacles to restarting production is finding enough workers to return to factories. The employment component of the index, which measures the staffing situation, decreased to 31.8 in February from 47.5 during the previous month.
Worthy of your time
The US badly bungled coronavirus testing. China had five commercial tests on the market 1 month ago and can now do up to 1.6 million tests a week; South Korea has tested 65,000 people so far. The CDC, in contrast, has done only 459 tests since the epidemic began. When the United States declared the outbreak a public health emergency on 31 January, a bureaucratic process kicked in that requires FDA’s “emergency use approval” for any tests. “The declaration of a public health emergency did exactly what it shouldn’t have. It limited the diagnostic capacity of this country,” [epidemiologist Michael] Mina says. “It’s insane.”
How coronavirus cases exploded in South Korean churches and hospitals. South Korea managed to avoid a major outbreak with only 30 people contracting the virus, despite many interactions between those later confirmed as being sick and hundreds more people being identified as contacts of the sick patients. This changed with the emergence of “Patient 31.”