According to Nigeria's Ministry of Health, more than 20 cases of yellow fever per week, a significant increase over average incidence, are being reported in Bauchi, Delta, and Enugu states. More than 220 cases (including 19 laboratory-confirmed cases and > 75 deaths) have been reported since June 2020. Confirmation in an international reference laboratory is pending. Shoreland continues to recommend vaccination for all travelers aged ≥ 9 months going to this country.
Saudi Arabia: 2020 Umra Temporarily Suspended; Hajj Limited to Local Pilgrims
The following Saudi Arabian Ministry of Health requirements and recommendations will be in effect for pilgrims participating in Hajj 1441H (July 28-August 2, 2020) and/or the 2020-21 Umra season.
Travel restrictions: Entry into the country is temporarily suspended for the purpose of Umra and/or visiting the Prophet's Mosque in Medina and is banned for international pilgrims for the purpose of Hajj over concerns about COVID-19 importation. Hajj attendance is limited to approximately 1,000 pilgrims already residing in Saudi Arabia (regardless of nationality) who are aged < 65 years and have no chronic medical conditions; pilgrims will be tested for COVID-19 before arriving in Mecca and will be required to self-quarantine at home after performing Hajj. U.S. citizens already in Saudi Arabia are advised not to attend.
Meningococcal meningitis: Proof of meningococcal vaccination (with either quadrivalent meningococcal polysaccharide vaccine or quadrivalent meningococcal conjugate vaccine) is required for all travelers aged > 2 years arriving for the purpose of Umra or Hajj pilgrimage or seasonal work in Hajj/Umra zones, not less than 10 days and not more than 3 years (polysaccharide vaccine) or 5 years (conjugate vaccine; certificate must clearly state conjugate for 5-year validity to apply) before planned arrival in Saudi Arabia. Proof of vaccination with conjugate vaccine is required for domestic pilgrims, residents of Mecca and Medina, and any persons who might have direct contact with pilgrims in Saudi Arabia (e.g., health care workers [HCWs] or other authorities). Additionally, antibiotic chemoprophylaxis may be administered to certain travelers upon arrival if deemed necessary by port-of-entry officials.
Polio: Proof of polio vaccination is required for all travelers arriving from countries with circulating wild poliovirus or circulating vaccine-derived poliovirus types 1, 2, or 3 and for those arriving from countries at risk of polio reintroduction.
Proof of vaccination (at least 1 dose of inactivated poliovirus vaccine [IPV] or bivalent oral poliovirus vaccine [OPV]) given between 4 weeks and 1 year prior to arrival is required for travelers (regardless of age or previous vaccination status) arriving from Afghanistan, Burma (Myanmar), Nigeria, Pakistan, Papua New Guinea, Somalia, or Yemen.
Proof of vaccination (at least 1 dose of IPV) given between 4 weeks and 1 year prior to arrival is required for travelers (regardless of age or previous vaccination status) arriving from the Democratic Republic of the Congo, Mozambique, Niger, or the Philippines.
Regardless of vaccination status, travelers from Afghanistan, Burma (Myanmar), Nigeria, Pakistan, Papua New Guinea, Somalia, or Yemen will also be given 1 dose of OPV upon arrival.
Yellow fever: Proof of yellow fever (YF) vaccination (valid for life) is required in accordance with international health regulations for all travelers aged > 9 months arriving from countries at risk of YF transmission or having transited an airport for longer than 12 hours in these countries. Vaccine must be administered at least 10 days prior to arrival at the border. Both new and existing certificates of vaccination are valid for the life of the person vaccinated.
Influenza: Saudi Arabia recommends seasonal influenza vaccination with the most currently available vaccine at least 10 days prior to arrival in Hajj/Umra areas for all visiting pilgrims, particularly those at increased risk for severe complications, such as pregnant women, children aged < 5 years, adults aged > 65 years, or those with chronic or immunocompromised medical conditions.
Southern Hemisphere vaccine is recommended for all pilgrims from the Southern Hemisphere or from countries that routinely use this vaccine.
Vaccination with the most currently available vaccine is required for all domestic pilgrims and HCWs at least 10 days prior to arrival in Hajj/Umra areas.
Public health: Pilgrims are encouraged to observe good respiratory hygiene (cough and sneeze etiquette) and hand hygiene (frequent, thorough handwashing); to wear face masks, especially in crowded locations; to avoid contact or sharing personal belongings with ill-appearing persons; to avoid close contact with animals, especially camels; and to avoid consumption of raw camel milk, camel urine, or improperly cooked meat.
Middle East Respiratory Syndrome Coronavirus (MERS-CoV): Efforts to prevent MERS-CoV infection during Hajj/Umra have been implemented; no known MERS cases have ever been reported in Hajj pilgrims.
Zika, chikungunya, and dengue: The Aedes aegypti mosquito that transmits these diseases has not been detected in Hajj or Umra areas for years, although it is present in surrounding cities. Travelers should observe daytime insect precautions.
Outbreak Break Report
What's New
Cumulative case numbers for COVID-19, caused by SARS-CoV-2, are as follows:
Cases worldwide: more than 3.78 million cases in more than 210 countries
Cases in Europe: more than 1.52 million cases
Cases in the U.S.: more than 1.24 million cases
Cases reported from China since March 3: more than 2,600 out of 82,800 cumulative cases
Deaths worldwide: more than 261,000 (Europe: more than 146,000; U.S.: more than 73,000; China: more than 4,600)
Transmission aboard large ships: more than 2,600 cases aboard at least 50 ships
Globally, the outbreak appears to have peaked on April 24 with more than 100,000 cases per day, and daily new cases have plateaued for the past 30 days at approximately 80,000 on average. Daily new deaths peaked on April 29 at more than 10,000 deaths per day and have plateaued, with some peaks and valleys over the past 12 days, at approximately 6,000. Of the 570,000 new cases reported from April 26 through May 3, sixty percent of cases were reported from the following 5 countries (total new cases; weekly cases per million): the U.S. (> 200,900 cases; 614 cases/million), Russia (> 53,700 cases; 371 cases/million), Brazil (> 38,200 cases; 182 cases/million), the U.K. (> 33,700 cases; 507 cases/million), and Peru (> 18,400 cases; 575 cases/million). Approximately 40% of cases reported outside the U.S. from April 26 through May 3 were reported in Russia, Brazil, Peru, India, Saudi Arabia, and Mexico; significant numbers of daily new cases continue to be reported in these countries. Globally, 58 countries have daily case counts that are increasing (although some may be past peak), 63 are declining, and 27 have plateaued. In the E.U./E.E.A. and the U.K., 28 of the 31 countries have daily case counts that are decreasing, with rates at least 10% lower than their most recent peak; 8 countries have reported no new deaths in the past 1 to 29 days, but deaths are increasing in the rest of the countries. In the U.S., daily cases have decreased for the past 5 days and deaths have plateaued over the past 2 days. No new locally acquired cases have been reported in Taiwan, Vietnam, or Hong Kong since April 12, 16, and 19, respectively; however, sporadic imported cases continue to be reported. In the past 24 hours, Australia has reported only 26 cases, South Korea and New Zealand have reported only 2 cases each, and Thailand has reported only 1 case. More than 90,000 cases have occurred in HCWs (likely an underestimation) in 30 countries since the outbreak began.
In a new, well-documented study, 642 PCR-confirmed COVID-19 patients with mild disease in NYC and with sequential IgG and PCR testing (Mount Sinai IgG ELISA peer-reviewed assay with FDA EUA and Roche cobas PCR) were examined. The maximum duration of positive nasopharyngeal PCR testing was 43 days from symptom onset and 28 days from symptom resolution; 19% of patients were PCR positive 2 weeks after symptom resolution. The U.S. CDC test-based criteria for return to work or release from isolation (2 negative PCR tests on consecutive days) should be avoided as a definition of SARS-CoV-2 clearance if testing begins 3 days after symptom resolution; current symptom-based criteria seem reliable. All but 3 of 642 confirmed COVID-19 patients seroconverted to the SARS-CoV-2 spike protein. IgG antibodies developed over 7 to 50 days from symptom onset and 5 to 49 days from symptom resolution; the medians to higher antibody titers were 24 days from symptom onset and 15 days from symptom resolution. Conclusions are that the optimal timeframe for widespread antibody testing is at least 3 to 4 weeks after symptom onset and at least 2 weeks after symptom resolution.
More than 88,000 additional cases have been reported since May 5, 2020 (through May 6 at 2 p.m. EDT) in the U.S. (> 21,200 cases; > 1,900 deaths), Russia (> 10,500 cases; > 85 deaths), Brazil (> 7,600 cases; > 590 deaths), the U.K. (> 6,200 cases; > 640 deaths), India (> 5,800 cases; > 190 deaths), and in 148 other countries. In examining trends, daily new case numbers appear to have peaked in Australia, Brazil, Canada, China, France, Germany, Hong Kong, Iran, Italy, Japan, the Netherlands, Russia, Singapore, South Korea, Spain, Switzerland, Taiwan, the U.K., and the U.S., although the daily new case numbers remain high in most of the aforementioned countries. In the U.S., daily new cases have overall plateaued at 28,000 per day over the past 30 days; a peak of more than 36,000 cases was reported on April 24, and cases have decreased to approximately 25,000 per day over the past 5 days. Since April 28, thirty-seven percent of states had the highest daily case numbers since the outbreak began, and 3 states had their highest daily cases in the past 3 days. Only 6 states have had consistent downward trends for the past 2 weeks. As of May 5, twenty-two states have reported more than 10,000 cases. In New York, daily new case numbers, which peaked at more than 11,000, have decreased to approximately 4,200 per day from April 29 through May 5. In NYC, daily new case numbers increased to approximately 4,400 on April 29 and decreased to approximately 2,000 per day from April 30 through May 5. Nationally, daily new deaths in the U.S. have had multiple peaks over the course of the outbreak; a peak of approximately 2,800 deaths was reported on April 22, and following a 5-day consecutive decrease, deaths have increased and plateaued at approximately 2,000 per day over the past 2 days. Among the top 10 most affected states, daily new cases have peaked in Connecticut, Florida, Massachusetts, Michigan, New Jersey, New York, Pennsylvania, and Texas.
In Africa, more than 46,000 cases and more than 1,800 deaths have been reported in 56 countries from February 25 through May 4, mainly in South Africa (> 7,200 cases; > 130 deaths), Egypt (> 6,800 cases; > 430 deaths), and Morocco (> 5,000 cases; > 170 deaths); since April 22, total cases have increased by more than 50% and deaths by more than 25%. Eritrea, Namibia, and the Seychelles have not reported any new cases since April 22. Only Lesotho has not reported any cases, but locally acquired cases are likely occurring undetected. In Latin America, more than 262,700 cases and more than 13,800 deaths have been reported in all 27 countries from February 26 through May 4, mainly in Brazil (> 102,700 cases; > 7,100 deaths), Peru (> 45,900 cases; > 1,200 deaths), and Ecuador (> 31,800 cases; > 1,500 deaths); total cases increased by more than 50% and deaths by more than 65% from April 27 through May 4.
In the U.S., approximately 40% of the 21,000 cases reported since May 5 have been reported in the top 5 states: California (> 2,400 cases; > 80 deaths), Illinois (> 2,100 cases; > 170 deaths), New Jersey (> 1,400 cases; > 280 deaths), Massachusetts (> 1,100 cases; 120 deaths), and Texas (> 1,100 cases; > 50 deaths). Cumulatively, since January 21, more than 1.24 million cases and more than 73,100 deaths have been reported in all 50 states and Washington, D.C., mainly in New York (> 330,100 cases; > 25,400 deaths), New Jersey (> 133,000 cases; > 8,500 deaths), Massachusetts (> 70,200 cases; > 4,200 deaths), Illinois (> 65,900 cases; > 2,800 deaths), and California (> 58,700 cases; >2,300 deaths). More than 20,600 of these cases (2.3% of the total) have been among children younger than 18 years (through May 5). Disease is exceptionally mild in children and no more severe in immunocompromised children. More than 182,200 total cases have been reported in NYC.
Coronavirus Disease: What's New
What's New
According to Chinese health authorities, more than 1,400 additional, confirmed cases (including 192 deaths) of COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported since February 21, 2020, throughout China, mainly in Hubei (> 1,400) Province. Most recent deaths have occurred in Hubei Province, with 4 deaths in the city of Shanghai and in Guangdong, Hebei, and Xinjiang provinces; 4,200 more patients have recovered and been discharged. More than 76,900 confirmed cases (including > 2,400 deaths)—reported through February 23 at 3:00 p.m. EST—have been officially reported since December 8, 2019. The confirmed case total in China and elsewhere for February 13-18 refers to laboratory-confirmed cases only, except for Hubei Province, where clinically confirmed cases are included in the confirmed case total. As of February 19, confirmed case numbers for Hubei Province no longer include clinically confirmed cases.
Three additional, imported confirmed cases from China have been reported since February 21 in Japan, Singapore, and the U.S.; just 6 cases have been reported in the past 7 days, and only 1 additional country has officially reported imported cases from China since February 2. More than 210 cases imported from China have been reported at international ports of entry since January 6 in 26 countries.
In contrast, more than 510 additional cases have been reported since February 21 in South Korea (> 390 cases, including 4 deaths), Italy (73 cases, including 2 deaths), Japan (> 35 cases), Iran (23 cases, including 3 deaths), Singapore, and United Arab Emirates. Since January 14, approximately 55 cases of severe disease and 23 deaths (at least 3 of these cases reported travel history to China) have been reported in cases exported from China or cases acquired outside of China. More than 320 of the 602 total cases reported in South Korea are from Daegu (and surrounding areas), and a majority of these cases are associated with a single case in a super-spreading event linked to the Shincheonji Church of Jesus and the Cheongdo Daenam Hospital. Visitors and residents of Daegu have been urged to stay indoors, and all nonessential travel to Daegu is prohibited for active U.S. service members. Eighteen cases were reported among South Korean tourists who traveled to Israel from February 8-15; contact tracing is underway in Israel. Cases in Iran continue to increase, and 4 exported cases from Iran have been reported in Canada, Lebanon, and the United Arab Emirates since February 21. More than 670 cases with transmission occurring outside of China (including locally acquired cases) have been reported since January 14 in 20 countries: Canada, Egypt, France, Germany, Hong Kong, Iran, Italy, Japan, Lebanon, Macau, Malaysia, Singapore, Spain (Canary Islands and Mallorca Island), South Korea, Taiwan, Thailand, United Arab Emirates, U.K., U.S., and Vietnam. Despite excellent public health infrastructure, Hong Kong, Japan, and Singapore have reported multiple known case clusters of COVID-19 with no established link to known transmission chains, which is worrisome for sustained transmission in those areas. In South Korea, Singapore, and Hong Kong, despite intensive efforts, locally acquired cases now outnumber imported cases 357 to 13 (South Korea), 60 to 13 (Hong Kong), and 56 to 24 (Singapore).
More than 60 additional cases have been reported since February 21 among passengers who were aboard the Diamond Princess cruise ship; 6 of these cases were among repatriated citizens in Australia (5 cases) and Hong Kong (1 case). More than 700 total cases (including 3 deaths and 36 in serious condition) have been reported; more than 330 cases were asymptomatic at the time of diagnosis. The mandatory 14-day quarantine aboard the ship officially expired on February 19, and the disembarkation of approximately 1,800 passengers has begun for those who are asymptomatic and negative for SARS-CoV-2. Approximately 970 passengers have disembarked since February 19; Canada, Israel, and Taiwan repatriated some of their citizens beginning on February 20. Indonesia, Italy, the Philippines, and the U.K. plan to repatriate citizens aboard the ship beginning on February 21. Citizens will be required to be symptom free when boarding their respective flights and will uniformly be subject to quarantine upon arrival in country. Approximately 1,000 crew members will remain aboard to complete an additional 14-day quarantine, which is now expected to expire on March 6. Approximately 300 passengers remain aboard the ship; 100 of these passengers have been identified as close contacts and will be removed and placed in a government-provided quarantine facility.
The U.S. CDC is now advising older adults and those with chronic medical conditions to consider postponing nonessential travel to Japan and South Korea. No precise definition for "older adults" has been provided. Israel now advises avoidance of nonessential travel to Hong Kong, Japan, Macau, Singapore, South Korea, Taiwan, and Thailand in addition to China. Israel has banned all nonresidents or noncitizens who visited Japan or South Korea in the last 14 days before arriving. In addition all citizens and residents arriving from Japan or South Korea (in addition to arrivals from China, Hong Kong, Macau, Singapore, or Thailand) will be subject to mandatory home quarantine in Israel.
Consensus guidelines on an interval for a safe return to work or the community for a confirmed case of COVID-19 require further data on viral shedding. At present, case-by-case decisions are needed. At present, where PCR testing is accessible in a timely manner, patients should have samples obtained from the nose and throat twice, spaced by 24 hours. No return to work should be allowed until all 4 such specimens are negative. The best estimate of when to start testing is 14 days after symptom onset but delayed until the patient has been well for at least a week. In a small study of serial swabs for PCR, most were negative within 14 days of symptom onset (including those who were very sick), but several minimally symptomatic persons were still minimally PCR-positive at 15 days and 1 at 21 days.
In addition to U.S. CDC, only 3 U.S. states (California, Illinois, and Nebraska) can currently test for SARS-CoV-2; some of the testing kits previously sent to other states and at least 30 countries were flawed and produced inconclusive results. U.S. CDC has increased its testing capacity until the testing kits are replaced.
Philippines: One Imported 2019-nCoV Case
According to international health authorities, 1 imported, laboratory-confirmed case of 2019 novel coronavirus (2019-nCoV) infection has been reported; the case arrived on January 21, 2020, and developed symptoms on January 25.
Germany: One Locally Acquired 2019-nCoV Case in Bavaria State
According to Germany's Ministry of Health and press sources, 1 locally acquired, laboratory-confirmed case of pneumonia caused by 2019 novel coronavirus (2019-nCoV) was reported on January 27, 2020, in Bavaria State. The case reported contact on January 21 with an asymptomatic Chinese resident who had traveled to Germany while asymptomatic. Fever and respiratory symptoms would likely manifest in contacts within the 14-day incubation period usual for coronaviruses.
Bolivia: Widespread Violent Protests
Widespread, violent protests and civil unrest in response to the political situation have been reported since October 20, 2019, throughout the country, especially in La Paz and other cities. Further unrest is likely. Extensive road closures and transportation delays (especially flights via El Alto International Airport) should be expected. Extreme vigilance is recommended; bystanders are at risk of harm from violence or from the response by authorities. Travelers should avoid demonstrations, carry a fully charged communication device, follow the advice of local authorities, and monitor the situation through local media and embassy communications.
Hurricane Dorian
From September 1-3, 2019, Hurricane Dorian struck mainly northwestern areas of the Bahamas. Catastrophic flooding and infrastructure damage, especially on Grand Bahama and Abaco islands, have been reported. Disruptions to transportation, mobile and internet services, and basic services (including power outages and limited access to potable water) should be expected for the for seeable future. Grand Bahama International Airport is closed. Nassau International airport has reopened. Travelers should avoid travel to this country and monitor the situation through local media and embassy communications.
Hong Kong: Widespread Protests
Widespread, increasingly violent protests and civil unrest in response to the political situation have been reported since early June 2019 at several locations throughout Hong Kong, including Hong Kong International Airport, Mass Transit Rail (MTR) stations, police headquarters, Central Government Complex, Admiralty, and Tamar Park. Further unrest of increasing magnitude is likely. Road closures and transportation delays (including trains to and flights from Hong Kong International Airport) should be expected during protests and may result in the temporary suspension of services. Passengers are advised to check with their airlines and to proceed to the airport only when their flight has been confirmed. Bystanders are at risk of harm from violence or from the response by authorities. Travelers should avoid demonstrations, follow the advice of local authorities, and monitor the situation through local media and embassy communications.
India: Advisory Due to High Terrorist Threat in Jammu and Kashmir State
According to regional government authorities, a heightened threat of terrorist attacks, civil unrest, and ongoing security concerns exist in Jammu and Kashmir State, especially in Srinagar, in response to the revocation by India of constitutional guarantees of Kashmiri autonomy. The presence of tens of thousands of heavily armed security forces should be expected and a state of emergency is in effect, with restrictions on movement and assembly imposed until further notice. Internet services have been shut down. Extreme vigilance is recommended. Travelers are advised to reconsider travel (or avoid nonessential travel) to Jammu and Kashmir State. Travelers should maintain a high level of security awareness, follow the advice of local authorities, and monitor the situation through local media and embassy communications.
