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DEPARTMENT OF DEFENSE
Armed Forces Health Surveillance Branch
Integrated Biosurveillance Section
Global COVID-19 Surveillance Summary #10
26 MAR 2020
BLUF:
• (U) As of 26 MAR, 69,197 confirmed COVID-19 cases (1,046 deaths) have been reported in all U.S. states, the District of Columbia, Puerto Rico,
Guam, and the U.S. Virgin Islands.
• (U) States with the highest burden of COVID-19 include: NY, NJ, CA, WA, and FL. Approximately 200 million people (>60% of the total U.S.
population) are under shelter-in-place or stay-at-home orders due to the COVID-19 pandemic.
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DEPARTMENT OF DEFENSE (AFHSB/IB)
Global COVID-19 Surveillance Summary #10
26 MAR 2020
(U) CASE REPORT: From mid-DEC 2019 to 26 MAR 2020, 480,446 (+257,804) confirmed cases of Coronavirus Disease 2019 (COVID-19) including 21,571 (+12,456) deaths have
been reported in 175 (+16) countries, regions, and territories worldwide. Mainland China had accounted for the majority of reported cases at the start of the outbreak; however, over
the past four weeks, countries/regions outside of China have accounted for the majority of new cases. The highest cumulative case counts outside of mainland China include Italy
(15% of cases, 35% of deaths), the United States (14% of cases, 4.8% of deaths), Spain (10% of cases, 17% of deaths), Germany (8.2% of cases, 1% of deaths), and Iran (6.1% of
cases, 10.4% of deaths). As of 26 MAR, at least 398,664 (+257,176) cases of COVID-19 have been reported outside of mainland China. Per WHO, local transmission has been
documented in 13 countries/regions/territories in CENTCOM, 14 in AFRICOM, four (+2) in NORTHCOM, 53 in EUCOM, 23 (+1) in INDOPACOM, and 22 in SOUTHCOM.
(U) On 24 MAR, CDC reported 669 cases of COVID-19 had occurred in U.S. healthcare workers, including 38 cases that were travel-related, 141 in close contacts of known cases,
and 490 cases still under investigation. As of 25 MAR, CDC is tracking approximately 25 cruise ships disembarking domestically and internationally with American citizens on board.
CDC is also collaborating with other federal agencies to ensure proper disembarkation and repatriation of passengers.
(U) Confirmed COVID-19 cases are rapidly accelerating in the U.S., an increase expected due to amplified testing capacity and ongoing community spread. As of 25 MAR, CDC is
reporting community transmission of COVID-19 in 41 U.S. states and Guam; of these, transmission in 13 states has been characterized as “widespread.” On 24 MAR, WHO officials
warned that the U.S. had the potential of becoming the new epicenter of the pandemic given its recent acceleration in cases. As of 26 MAR, 69,197 (+59,782) confirmed COVID-19
cases (1,048 (+898) deaths) have been reported in 50 U.S. states, the District of Columbia, Puerto Rico, Guam , and the U.S. Virgin Islands (see map). States with the highest burden of
COVID-19 include: NY (33,066), NJ (4,402), CA (3,183), WA (2,585) , and FL (1,965). During a 24 MAR press conference, NY Governor Andrew Cuomo reported that new cases are
doubling every three days in the state. As of 26 MAR, officials in 21 states, 47 counties, and 14 cities in the United States (approximately 200 million people, over 60% of the total
population) are under shelter-in-place or stay-at-home orders due to the COVID-19 pandemic. As of 26 MAR, President Trump has approved major disaster declarations for NY, WA,
LA, IA, CA, FL, and TX.
(U) BACKGROUND: On 7 JAN, Chinese health officials reported the isolation of a novel coronavirus (subsequently labelled “severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2”) from a sample collected from one of 27 hospitalized cases of viral pneumonia of unknown etiology in Wuhan, China. Chinese health authorities subsequently made the full
genetic sequence available through publicly accessible databases/platforms including GenBank and GISAID, enabling multiple countries to develop PCR assays for the detection of
COVID-19. Preliminary analysis of SARS-CoV-2 found it to be 73% similar to severe acute respiratory syndrome coronavirus (SARS-CoV).
(U) GLOBAL SPREAD & CLUSTERS: On 23 MAR, the WHO Director-General warned that the virus is accelerating, noting that “it took 67 days from the first reported case to reach the
first 100,000 cases, 11 days for the second 100,000, and just four days for the third 100,000.” As of 26 MAR, the Secretary of Defense has issued a 60-day stop movement order for all
SMs, DoD civilians, and families overseas. On 16 MAR, U.S. CDC recommended that all public gatherings of 10 or more people be cancelled or postponed, and closing schools in
some areas.
(U) In Italy, 74,386 (+38,685) cases and 7,503 (+4,525) deaths have been reported to date. As of 24 MAR, Italy, Spain, France, Austria, Belgium, Denmark, Germany, Greece, the
Republic of Ireland, Portugal, Switzerland, and the United Kingdom (UK) have imposed lockdowns to restrict movement of their citizens. Most European Union (EU) member states
have shut down all non-essential shops and banned all gatherings. On 23 MAR, NATO reported that the Armed Forces of Spain and Ukraine had requested international assistance in
their responses to the COVID-19 pandemic. On 16 MAR, the EU voted to close its borders to outside travelers for at least 30 days. As of 13 MAR, the European Centre for Disease
Prevention and Control (ECDC) assesses the risk of COVID-19 in the EU/EEA and UK to be “moderate to high.”
(U) For all CDC travel health notices and U.S. Department of State (DoS) travel advisories for the COVID-19 pandemic, see table.
Text updated from the previous report will be printed in blue; items in (+xx) represent the change in number from 19 MAR 2020.
For information or assistance requests, contact AFHSB/IB at dha.ncr.health-surv.list.ib-alert-response@mail.mil
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DEPARTMENT OF DEFENSE (AFHSB/IB)
Global COVID-19 Surveillance Summary #10
26 MAR 2020
(U) MEDICAL COUNTERMEASURES & DIAGNOSTICS: On 4 FEB, the U.S. FDA issued an Emergency Use Authorization (EUA) for patients who meet the CDC criteria for COVID-
19 testing, enabling emergency use of the test kit in the U.S. On 5 FEB, CDC began shipping diagnostic test kits to 115 qualified state/local public health and DoD laboratories. As of
15 MAR, CDC confirmatory testing of presumptive positive samples is no longer required of laboratories using the CDC’s EUA assay.
(U) As of 21 MAR, the FDA approved the first SARS-CoV-2 point-of-care (POC) test (results in 15 minutes) for measurement of IgM/IgG antibodies in acutely infected
(symptomatic or asymptomatic at-risk) patients; this test has been widely used in China and shown to detect IgM and IgG in acute phase of infection.
(U) On 20 MAR, the WHO Director-General announced a global “solidarity trial” aimed to compare COVID-19 treatments across the world to evaluate which therapeutics are most
effective. The Director-General also noted that multiple small trials with differing methodologies may not provide clear, strong evidence needed to know which treatments save lives.
Ten countries have committed to the trial: Argentina, Bahrain, Canada, France, Iran, Norway, South Africa, Spain, Switzerland, and Thailand. On 24 MAR, FDA permitted COVID-19
convalescent serum use in clinical trials or for critically ill patients; the NY Department of Health was approved to start a convalescent plasma trial. On 24 MAR, NY Governor Andrew
Cuomo announced that the state would begin FDA-approved drug trials on chloroquine, hydroxychloroquine, and Zithromax (azithromycin).
(U) TRANSMISSION: As of 4 MAR, CDC reports that droplet spread (exposure within six feet of someone with respiratory symptoms) and contaminated surfaces (touching a droplet-
contaminated surface and then touching the eyes and mouth) continue to be the major routes of transmission. A 17 MAR Science article reported that substantial undocumented cases
(due to mild or asymptomatic infections) in China may have facilitated the rapid spread of COVID-19 prior to the institution of 23 JAN travel restrictions. A 17 MAR NEJM article about
research funded by NIH found that SARS-CoV-2 can survive for up to three days on plastic and stainless steel surfaces. A 23 MAR MMWR article on COVID-19 outbreaks on cruise
ships from FEB to MAR 2020 found that up to 47% of the Diamond Princess passengers and crew had asymptomatic infections, facilitating rapid transmission of the virus. Also,
COVID-19 viral RNA was identified on surfaces in cabins of both symptomatic and asymptomatic passengers for up to 17 days after cabins had been vacated (but before disinfection
procedures were conducted). In the case of the outbreak on the U.S. West Coast based Grand Princess, viral transmission from crew members to passengers occurred across multiple
consecutive voyages.
(U) On 25 MAR, the American Academy of Ophthalmology issued an alert to its members that several reports suggested that COVID-19 could cause a mild follicular conjunctivitis
indistinguishable from other viral causes, and possibly be transmitted through aerosol contact with the conjunctiva. The Academy recommends that members use PPE when
examining patients, and cease providing any treatments other than urgent or emergency care. A 24 MAR media article states that scientists that have studied thousands of COVID-19
samples believe that it has not mutated significantly as it passes through the human population, and that there is no evidence that some strains are deadlier than others.
(U) The source of SARS-CoV-2 is still unknown, but is most likely an animal reservoir. The World Organization for Animal Health (OIE) notes that genetic sequence data reveals that
SARS-CoV-2 is a close relative of another coronavirus found circulating in Rhinolophus (Horseshoe Bat) populations, however, it is possible that transmission to humans involved an
intermediate host. China has initiated research on the origins and transmission pathways of SARS-CoV-2, jointly initiated by the Chinese CDC, the Chinese Academy of Sciences, and
the Chinese Academy of Medical Sciences. The Chinese CDC Virology Institute tested 585 environmental and animal samples from the Huanan Seafood Market and many fresh
markets in Wuhan, the epicenter of the COVID-19 outbreak; 33 samples were positive for SARS-CoV-2, including 31 samples from the Western District of Huanan, where wild animals
are sold. According to China CDC, this concentrated data suggests that the outbreak may be related to wildlife trading. OIE is also closely liaising with its network of experts involved in
current investigations of the potential role of animals in the outbreak and the detection of SARS-CoV-2 in animals.
Text updated from the previous report will be printed in blue; items in (+xx) represent the change in number from 19 MAR 2020.
For information or assistance requests, contact AFHSB/IB at dha.ncr.health-surv.list.ib-alert-response@mail.mil
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DEPARTMENT OF DEFENSE (AFHSB/IB)
Global COVID-19 Surveillance Summary #10
26 MAR 2020
(U) TRANSMISSION (cont.): The Veterinary Services of the Hong Kong Agriculture, Fisheries, and Conservation Department reported to OIE in early and mid-MAR two instances of
dogs infected with COVID-19 after close exposure to their ill owners. In both cases, the dogs were quarantined and tested. Although PCR testing showed the presence of viral genetic
material, neither dog showed clinical signs of disease. OIE recommends reporting any cases of COVID-19 in animals the OIE, as the virus fits the criteria for an emerging disease. If a
decision is made to test a companion animal having close contact with a COVID-19 infected person/owner, OIE recommends using real time- PCR to test oral, nasal, and fecal/rectal
samples. While there is no evidence that COVID-19 spreads between animals, OIE recommends keeping COVID-19 positive animals away from unexposed animals.
(U) As of 23 MAR, the OIE states that there are no reports of animals presenting with clinical signs due to COVID-19 nor is there evidence to suggest that companion animals play a
role in transmitting COVID-19 to humans. However, visitors to live animal markets or wet markets are urged to observe good hygiene practices (wash hands with soap and water, avoid
touching eyes, mouth, or face), and avoid contact with live animals or their body fluids. OIE does not currently recommend trade restrictions on either animals or animal products due
to COVID-19. Similarly, precautions for food packaging materials are unnecessary over and above observing basic hygiene, such as ensuring they are clean and free of visible
contamination. DoD Veterinary Services has created a COVID-19 Resource website that addresses animal health, food protection, and Force Health Protection-specific guidance.
CDC Travel Health Notices and U.S. Department of State (DoS) Travel Advisories for COVID-19 Outbreak as of 26 MAR 2020
CDC DoS
Level Country Latest update Level Country Latest update
Russia 25 MAR COVID-19 UPDATE Information for Travelers 22 MAR
Ecuador 24 MAR Global Health Advisory 19 MAR
India 24 MAR Mongolia 18 MAR
Level 4: Do Not Travel
Indonesia 24 MAR China 2 FEB
Kingdom of Saudi Arabia 24 MAR Iran 26 FEB
Philippines 24 MAR Tajikistan 18 MAR
Qatar 24 MAR Israel, The West Bank, and Gaza 13 MAR
Romania 24 MAR Azerbaijan 6 MAR
Level 3: Reconsider Travel
Singapore 24 MAR Turkmenistan 6 MAR
South Africa 24 MAR ROK 29 FEB
Chile 23 MAR Italy 29 FEB
Pakistan 23 MAR Macao 11 FEB
Level 2: Exercise
Warning: Level 3, Avoid Thailand 23 MAR Hong Kong 20 FEB
Increased Caution
Nonessential Travel Turkey 23 MAR Japan 22 FEB
Australia 21 MAR
Brazil 21 MAR
Canada 21 MAR
Israel 21 MAR
Japan 21 MAR
Malaysia 18 MAR
Cruise Ship Travel 17 MAR
Europe 17 MAR
United Kingdom and Ireland 17 MAR
China 17 MAR
Iran 17 MAR
Republic of Korea (ROK) 17 MAR
Alert: Level 2, Practice Global COVID-19 Outbreak
16 MAR
Enhanced Precautions Notice
Text updated from the previous report will be printed in blue; items in (+xx) represent the change in number from 19 MAR 2020.
For information or assistance requests, contact AFHSB/IB at dha.ncr.health-surv.list.ib-alert-response@mail.mil
APPROVED FOR PUBLIC RELEASE
3
DEPARTMENT OF DEFENSE (AFHSB/IB)
Global COVID-19 Surveillance Summary #10
26 MAR 2020
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