COVID-19 Global Health Portal
Last updated: 6 April 2020 9:56am EST Sources:
Confirmed Cases & Tests Globally
(1) Worldometer: Based on data from the WHO, CDC, ECDC, NHC, and direct reporting from local, provincial, and national health authorities.
(2) Foundation for Innovative New Diagnostics: Adoption of proactive and widespread testing strategies have been linked with lower Case Fatality Rates over time, particularly with increasing reports of asymptomatic transmission.
(3) Oxford (CEBM): CFR can be correlated with transmission dynamics, population demographics, and control & testing strategies. High initial CFR for COVID-19 is expected to trend downward as countries adopt widespread testing strategies (i.e. recording those dying with as opposed to from the virus).
(4) Liu et al: The basic reproduction number can vary by population and transmission dynamics, by also method of estimation. This paper reviewed twelve studies that used stochastic, mathematical, and statistical modelling methods.
(5) Lauer et al Incubation period and serial interval are important in understanding transmission dynamics of infectious diseases, particularly in cases where pre- and asymptomatic transmission occurs.
Last updated: 6 April 2020 9:56am EST
Update on the State of the Pandemic
Prepared by Dr. James Orbinski (Director, Dahdaleh Institute for Global Health Research) and Aria Ilyad Ahmad (Global Health Foresighting Research Fellow, Dahdaleh Institute for Global Health Research).
Monday, 6 April 2020
The total number of confirmed cases and deaths have increased to 1,287,742 and 70,559, respectively, as of 6 April 2020 (9:30am EST). The four worst affected countries – the U.S., Spain, Italy and Germany – represent more than half of all reported cases globally, with more than 100,000 cases each. The rapid increase of local clusters across low- and middle-income countries has emerged as a critical global issue, with 18 countries reporting more than 1,000 cases, and all 55 countries in Africa now with confirmed cases. The UN Secretary General described the COVID-19 pandemic as the "greatest global crisis since World War II," estimating that $2.5 trillion will be required to support pandemic response.
* Amid the surging pandemic, the WHO and partners have been forced to suspend mass immunization programs for at least 4-6 months to avoid placing communities and frontline workers at unnecessary risk. Many countries are also increasingly adopting restrictive control measures to "flatten the curve," which include lockdowns, quarantines and shutting down of non-essential services. 93% of the world's population are now in countries that have imposed some form of travel restrictions, posing particular and heightened risks of outbreaks in humanitarian response locations, which can include internally displaced persons settings, refugee camps and informal urban settlements.
* The UN Office for the Coordination for Humanitarian Affairs (UNOCHA) has issued a $2 billion appeal for a Coordinated Global Humanitarian Response Plan to support rapid mobilization of essential medical equipment, public information campaigns, water and sanitation stations, and airbridges and logistics hubs to assist with the movement of supplies and humanitarian workers.
* Countries are also increasingly taking up the WHO's advice to "test, test, test," with total number of tests performed globally increasing over the past week. The issue remains more acute in low- and middle-income countries, however, as limited availability of diagnostic kits and labs is almost certainly masking more widespread transmission.
* The true Case Fatality Rate will likely continue to fall – following patterns in prior pandemics as countries adopt more widespread and accurate testing strategies. Based on confirmed deaths / cases, the following are the estimated CFR rates (in order of highest number of deaths): Italy (12%), Spain (9.3%), U.S. (2.6%), France (9.1%), U.K. (9.5%), Iran (6.2%) and China (4.1%).
Humanitarian Response Locations
Over 4,422 cases and 166 deaths have been reported across 21 humanitarian sites, according to UNOCHA. This does not include countries such as Iran, where UN humanitarian agencies do not operate. In Iran, the number of reported COVID positive cases is 60,500 and the number of reported COVID deaths is 3,739.
* The World Food Programme has warned of major food shortages, as India and other countries across Asia and Africa have reported hunger and acute food shortages. In order to protect vulnerable communities, the WFP estimates that operations will need to be scaled up to reach as many as 100-120 million people in over 80 countries.
* Increased travel restrictions at points of entry, as reported by the International Organization for Migration, has limited mobility and the delivery of essential goods.
* Humanitarian agencies, like the International Committee of the Red Cross and Médecins Sans Frontières are urging countries to protect vulnerable groups, including internally displaced persons and asylum seekers, and remove disruptions in the delivery of essential goods, including medical equipment and food supplies.
* The UN Secretary General has called for a Global Ceasefire, as the UN Peacekeeping Office postponed troop rotations in peacekeeping operations while establishing a Field Support Group to strengthen COVID-19 response capacity,
The pandemic is increasing rapidly in Africa, with reported cases growing by 185% over the past week. All 55 countries of Africa now have confirmed cases, reporting a total of 9,435 cases and 445 deaths across the continent. While South Africa continues to lead the number of cases (1,655), three countries in Northern Africa surpassed 1,000 cases, including Algeria (1,320), Egypt (1,173), and Morocco (1,113). Alongside sporadic imported cases, many more countries are now reporting local transmission, which remains a critical risk as 17 countries have now reported more than 100 cases. The UN and regional authorities have expressed concern over sub-Saharan Africa, as limited diagnostic testing kits and public health surveillance capacity may be masking and further exacerbate local outbreaks. Healthcare workers are also acutely at risk, with at least 187 confirmed cases. National governments have warned of limited stress tolerance of health systems to the anticipated surge in cases over the next two weeks, requesting urgent support from regional partners and the international community.
China is reporting dozens of new asymptomatic cases amid growing concern about cases arriving from neighbouring countries. The surge comes as Wuhan prepares to allow residents to leave the city on April 8, while Hubei Province ended its lockdown last week. The number of reported cases and deaths in Iran, meanwhile, have surpasses 60,000, with 3,739 confirmed deaths. There are no official lockdowns in its major cities, despite internal government estimates that mortality rates in Iran could be limited to 7,700 instead of the projected "tens of thousands" of deaths by adopting 'maximum' interventions (e.g. banning movement inside cities, quarantines). Elsewhere in the Middle East, there are alarming rates of increase, with conflict-affected countries such as Iraq (1,031), Afghanistan (367), and Palestine (252) doubling in less than a week. The WHO also warns of a pending 'explosion' of cases in Yemen, as the UNDP has urged for a nation-wide ceasefire. The daily newly confirmed case count in South Korea has been at or below 100 for two weeks, as contact-tracing criteria will extend to two days before illness onset. An outbreak in Tokyo led to the biggest daily increase in cases in Japan (with no clear links in 92 of 143 reported cases yesterday), with the government expected to declare a state of emergency this week. Cases are also climbing across Southeast Asia, with Singapore reporting its highest daily jump in cases (n=120), leading to countrywide closure of non-essential business and schools until May 4. An increasing number of reports have also emerged, questioning the official case and mortality reports from particular countries, including China and Iran. While modelling estimates and proxy indicators (e.g. total mortality, demand for funeral services, local and social media accounts, etc.) suggest real figures may be significantly higher. There is likewise concern that the true outbreak size in India may be significantly higher than the 4,314 confirmed cases, which has doubled in just two days. In addition to wide-spread reports of food shortages, the nationwide 21-day lockdown has led to a mass exodus of hundreds of thousands of people from major urban areas, increasing the risk of local transmission in rural parts of the country.
The U.S. accounts for more than a quarter of all cases worldwide, surpassing 300,000 cases over the weekend and approaching 10,000 deaths. The CDC now recommends wearing face coverings in public where other social distancing steps are hard to maintain, especially in areas experiencing significant community transmission like New York City (NYC) where confirmed cases surpassed 120,000. In Canada, the number of confirmed cases has also increased to 15,512, including 280 reported deaths. With the outbreak expected to spread more widely across the continent over the next two weeks, there are increasing concerns over health care system capacities. Auxiliary health facilities such as the U.S. Navy Hospital Ship Comfort deployed to the port of NYC, and field hospitals have been set up in major urban centres, including NYC's Central Park and Toronto. The number of cases in South and Central American countries continue to grow, as PAHO launched an appeal for $95 million to support Latin American and Caribbean countries with priority public health measures. There is also uncertainty of the extent of the outbreak in Brazil, with worries that infections will soon surge far beyond the official count of 11,298 cases. For a population of 210 million - including 14 million living in crowded favelas - only 54,000 tests have also been distributed. The Brazilian government has also stopped publishing official number of suspected cases, while one researcher warns of a "mountain of deaths" beyond the 409 officially reported. Other countries in South America have also reported notable spike in cases, including Chile (4,815), Ecuador (3,646) and Peru (2,281).
Europe continues to lead the world with over 45% of confirmed cases, while Italy and Spain alone account for over 40% of global reported deaths (15,887 and 13,055, respectively). At least 11 countries are reporting more than 10,000 cases, while seven European countries have reported over 1,000 deaths. Spain surpassed Italy with the second highest number of cases globally (135,032), although deaths have declined for a third consecutive day. The U.K. reported its biggest one day jump in deaths, while Prime Minister Boris Johnson was admitted to the hospital over the weekend for persistent symptoms after testing positive ten days ago. The acceleration of case reports in Turkey remains a major concern, with a one-day increase of 11.5% to 27,069 total cases and 574 deaths. Many European countries are also reporting higher Case Fatality Rates (i.e. over 8%), including Italy (12%), U.K. (9.5%), Spain (9.3%), France (9.1%). This has been partly attributed to selective testing strategies in these countries, while widespread testing may likely contribute to relatively low CFR rate in countries like Germany (1.3%). The European CDC has nonetheless warned that given current testing capacity and if countries do not enact mitigation strategies, Europe could see a scenario similar to China by the middle of April.
Notable developments and research articles this week:
1. Estimating the impact of public health interventions
Estimating the number of infections and the impact of non- pharmaceutical interventions on COVID-19 in 11 European countries (Flaxman et al, Imperial College London)
Findings: This study attempts to infer the impact of different interventions across 11 European countries using a semi-mechanistic Bayesian hierarchical model. The authors estimate that through the end of March, interventions taken by countries likely averted 59,000 deaths while reducing reproduction numbers. During this period, the authors also estimate that 7-43 million people may have been infected across the 11 countries (or approx. 2-11% of total population). Spain and Italy are estimated to have the highest attack rate, with Germany and Norway on the lower end (possibly reflecting the relative stages of the epidemics). Interpretation: While the two to three-week delay between transmission changes and observed impact on mortality make it difficult to evaluate the effectiveness of recent interventions, the authors urge that preliminary evidence suggests that current interventions remain in place and that trends in cases and deaths be closely monitored to provide reassurance that transmission is slowing.
Canada Needs to Rapidly Escalate Public Health Interventions for Its COVID-19 Mitigation Strategies (Wu et al, SSRN)
Findings: The initial growth rate in Italy (0.22) has reduced to 0.1 two weeks after the lockdown (8 Mar 2020). This corresponds to an extension of the doubling time from about 3.15 to almost 7 days. In comparison, the growth rate in Canada has increased from 0.13 from 1 March to 13 March up to 0.25 between 13 March to 22 March. This current growth rate corresponds to a doubling time of 2.7 days, and unless public health interventions escalate in Canada, we project 15,000 cases by March 31st. The case number can be reduced to 4,000 if escalated public health interventions can be implemented instantly to reduce the growth rate to 0.1, the same level achieved in Italy. Interpretation: Intervention measures implemented by different countries have had various effects in reducing the growth rate and extending the doubling time, but their impacts come with a substantial delay (up to two weeks). Prompt and farsighted interventions are critical to counteract the very rapid initial growth of the COVID-19 epidemic. Mitigation plans must take into account the delayed effect of interventions by up to two weeks and the short doubling time of 3 to 4 days.
2. 'Stealth transmission’ and the need for early and proactive surveillance
Identifying Locations with Possible Undetected Imported Severe Acute Respiratory Syndrome Coronavirus 2 Cases by Using Importation Predictions (De Salazar et al, CDC Early Release)
Findings: The aim was to identify locations with likely undetected or under-detected imported cases of COVID-19. The results suggest that locations above the 95% PI of imported-and-reported cases could have higher case-detection capacity. Locations below the 95% PI might have undetected cases because of expected imported-and-reported case counts under high surveillance. Under-detection of cases could increase the international spread of the outbreak because the transmission chain could be lost, reducing opportunities to deploy case-based control strategies. Interpretation: They recommend rapid strengthening of outbreak surveillance and control efforts in locations below the 95% PI lower bound to curb potential local transmission. Early detection of cases and implantation of appropriate control measures can reduce the risk for self-sustained transmission in all locations
Substantial undocumented infection facilitates the rapid dissemination of COVID-19 (Li et al, Science)
Findings: Using a model-inference framework, the authors estimates the contagiousness and proportion of undocumented infections of COVID-19 in 375 cities in China before (Jan 10-23) and after (Jan 24-Feb 8) implementation of control measures in Wuhan (including: travel restrictions self-quarantine and contact precautions, access to rapid testing and PPE). The effective reproduction number (Re), i.e. number of secondary infections per index infection, was 2.4. The authors estimate that before control measures, 86% of all infections were undocumented, estimated to be about half (55%) as contagious as reported infections. After Control Measures, the proportion of undocumented infections fell to 31-35%, while the Re decreased to 0.99-1.4. Interpretation: although inference results should be interpreted with caution, the study suggests that control measures in Wuhan as of Jan 23 altered the epidemiological characteristics of the outbreak..
3. Increasing diagnostic testing
a. Many countries are experiencing shortages in diagnostic testing kits, as the development, production and distribution remain critical challenges that impede early detection and access to care. There are also reports of significant backlogs, in some cases taking over a week to provide results. Further efforts are needed in the development and scaling up of rapid (real-time) diagnostic tests. The Foundation for Innovative New Diagnostics (FIND), a WHO Collaborating Centre for Laboratory Strengthening and Diagnostic Technology Evaluation, has curated a list of the current Diagnostic Pipeline, while the U.S. FDA has now issued Emergency Use Authorizations to at least three COVID-19 rapid diagnostic tests over the last week, including:
* Cepheid Xpert Xpress SARS-Cov-2 Test (45min)
* Mesa Biotech Accula SARS-Cov-2 Test (30min)
* Abbott ID NOW COVID-19 Rapid Test (5-15min)
b. The Government of Canada has also accelerated approval for the Cepheid and Abbott diagnostic tests, following the issuance of an Interim Order by the Minister of Health on March 18 to expedite access to COVID-19-related medical devices. The COVID-19 Emergency Response Act (Bill C-13) also received royal assent on March 25. Among the sweeping number and scope of measures, the COVID-19 Emergency Response Actamends the Patent Act in order to allow the Government of Canada to issue compulsory licenses to respond to a “public health emergency that is a matter of national concern,” which could apply to diagnostic kits but also personal protective equipment, medical devices and therapeutic products.
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