Friday, May 07, 2021

UK PHE: `Indian' Variant B.1.617.2 Reclassified As a Variant of Concern (VOC)



Earlier this week the CDC added 4 new VOIs (Variants of Interest), all belonging to the `Indian' B.1.617.x lineage, and all being closely watched for signs they may pose a greater threat than other `wild type' COVID strains. 

For now, most of what we know about these variants - and their contribution to COVID crisis in India - is anecdotal.  But the CDC's initial assessment (see chart below) suggests potential reduction in neutralization by some EUA monoclonal antibody treatments and Slightly reduced neutralization by post-vaccination sera.


The UK's PHE added two variants of the B.1.617 lineage to their watchlist (see UK PHE COVID Variant Update - Adds 12th & 13th Variant To Watchlist) a week ago, as VUI's (Variants Under Investigation). 

Today, only hours after the British media reported on `leaked' documents, the PHE has published the following update reclassifying B1.617.2 as a VOC.

VUI-21APR-02 reclassified as a Variant of Concern (VOC)
Following a rise in cases in the UK and evidence of community transmission, PHE has reclassified VUI-21APR-02 (B.1.617.2, classified as a Variant Under Investigation (VUI) on 28 April) as a Variant of Concern (VOC), now known as VOC-21APR-02.

This is based on evidence which suggests this variant, first detected in India, is at least as transmissible as B.1.1.7 (the Kent variant). The other characteristics of this variant are still being investigated.

There is currently insufficient evidence to indicate that any of the variants recently detected in India cause more severe disease or render the vaccines currently deployed any less effective. PHE is carrying out laboratory testing, in collaboration with academic and international partners to better understand the impact of the mutations on the behaviour of the virus.

Cases of VOC-21APR-02 have increased to 520 from 202 over the last week and almost half the cases are related to travel or contact with a traveller. The cases are spread across the country, however, the majority of the cases are in 2 areas – the North West (predominantly Bolton) and London – and this is where we are seeing the greatest transmission.

PHE health protection teams are working with local authorities, Directors of Public Health (DsPH) and NHS Test and Trace to detect cases and limit onward spread.

Surge and community testing is an effective way of finding and isolating new cases of variants and will be deployed where there is evidence of community transmission. This is in addition to the comprehensive work that is already underway to trace and test all contacts of cases.

Everyone in the affected areas will be asked to get a test, even if they don’t have symptoms. If someone tests positive, they must isolate to stop the spread.

In partnership with local DsPH, additional measures are being implemented across the country where there are clusters, to contain the spread. These include:
  • enhanced contact tracing for those testing positive with a VOC to define locations they may have acquired or transmitted infection to focus further testing
  • enhanced community and surge testing in areas defined by the local authorities and regional teams
  • working closely with communities and community leaders to ensure that individuals have the right support to test and isolate
  • increased community engagement, including ensuring that messages are accessible in languages that are used by communities and provided by trusted community representatives
Where clusters of other VOCs are detected, PHE will continue to take all appropriate public heath action to break the chains of transmission.

Understanding how this virus behaves in the community is key to assessing its transmissibility, severity and whether it responds to the vaccines currently in use, all of which help to determine the risk to the public from this variant. While overall rates of COVID-19 remain low, there are actions that everyone can take to reduce spread.

PHE is encouraging the public to continue to:
  • work from home where you can
  • follow the current guidance on mixing with others
  • take up the universal, free offer of twice weekly LFDs tests
  • if positive, order a confirmatory PCR test kit and stay at home
  • get vaccinated when you are called to do so
Dr Susan Hopkins, COVID-19 Strategic Response Director at PHE, said:

The way to limit the spread of all variants is the same and although we are all enjoying slightly more freedom, the virus is still with us. Keep your distance, wash your hands regularly and thoroughly, cover your nose and mouth when inside and keep buildings well ventilated and meet people from other households outside. If you are told to get a test, if you have any symptoms at all or have been in contact with someone who has tested positive, please make sure you get tested too.

We are monitoring all of these variants extremely closely and have taken the decision to classify this as a Variant of Concern because the indications are that this VOC-21APR-02 is a more transmissible variant.

The current evidence suggests that the other variants detected in India, VUI-21APR-01 and VUI-21APR-03 are not VOCs, but this will be kept under constant review and investigations are ongoing into the reasons behind the different behaviours of these variants.

The UK has pulled itself back from the brink over the past couple of months going from a 7-day average of nearly 60,000 cases in early January to just over 2,000 a day during this first week of May.  

The sudden detection, and rapid spread, of a new variant that is judged by the PHE to be ". . .  at least as transmissible as B.1.1.7 (the Kent variant)", is obviously of considerable concern.

As far as any other traits that might be of concern, we'll need to wait for additional data. 

Hong Kong Hospital Authority Ramps Up Procedures For New COVID Variants

 Hong Kong CHP COVID Dashboard


Hong Kong, with a population of roughly 7 million, has managed to keep their daily COVID numbers in the double digits for months, and has one of the lowest death rates (28 per million) in the world.  By contrast, the death rate per capita in Hungary (2936 per million) is more than 100 times higher. 

Part of this is due to their early, and coordinated response to the COVID pandemic (see A Tale of Two Outbreaks: Hong Kong & Italy), a culture that already embraced mask wearing (see HK CDW: Surgical Masks For Respiratory Protection), and the dominance of the original, milder, `asian' lineage of COVID for much of 2020. 

As an international city - even with a strict 14-day quarantine policy for arriving visitors - there remains the potential for the introduction and spread of newer, possibly more dangerous, variants which could undermine Hong Kong's success to date. 

On Tuesday, May 4th, the CHP announced the detection of a local COVID case with the 501Y mutation, raising concerns of community spread. 

Among the newly reported cases announced, three are imported cases and one is a possibly local case with unknown sources.

The possibly local case with unknown sources is a 48-year-old woman (case number: 11791) involving N501Y mutant strain. As N501Y mutant strain is with high transmissibility, the CHP decided to carry out prudent measures on infection control and prevention to stop the potential risk of spread of N501Y mutant strain.
The CHP will, in accordance with the Prevention and Control of Disease Regulation (Cap. 599A), transfer asymptomatic residents of all units on all floors of the building (involving over 220 units) where the patient resided (Block R, Allway Gardens, Tsuen Wan) to quarantine centres ; symptomatic residents will be sent to the hospital for treatment. They will undergo compulsory quarantine for 21 days.

The normal quarantine period of 14 days has been extended by 50% to 21 days out of an abundance of caution. Today Hong Kong's Health Authority has announced enhanced measures to deal with this new threat. 

Hospital Authority heightens vigilance towards mutant strains

The following is issued on behalf of the Hospital Authority:

In light of the latest global epidemic situation and the emergence of local cases with mutant strains, the Hospital Authority (HA) today (May 7) reminded hospital clusters to prepare for deploying adequate single isolation facilities to dovetail with the stepped-up patient isolation arrangement, while the regular staff testing arrangement will be further extended to reduce the risk of nosocomial transmission of COVID-19 to safeguard patients and staff.

"Single isolation will be arranged for all patients confirmed with COVID-19 infection upon their admission, with gene sequencing tests arranged immediately. Patients of imported cases will be kept in single isolation until they are discharged upon recovery, while patients of local cases will also be kept in single isolation until discharge, unless they test negative for mutant strains through gene sequencing tests," the HA spokesperson said.

In addition, the HA will arrange regular COVID-19 testing for around 65 000 front-line staff who have direct patient contact, starting from next week.

"Upon consultation with infection control experts and making reference to the regular testing arrangements of overseas and local healthcare institutions and other professions, the HA decided to extend the staff testing arrangement next week," the HA spokesperson said.

"The staff concerned will be provided with rapid antigen test kits for conducting self-testing regularly every week. Upon completion of a test, staff members can report their test results through a mobile app designated for HA staff, or save a photo record by themselves. Staff who have received two doses of a COVID-19 vaccine for more than 14 days can indicate their preference for participation in the regular testing exercise."

Since January 2021, the HA has introduced pilot COVID-19 regular testing for about 5 000 staff members caring for vulnerable patients and patients with end-stage illness. Rapid antigen testing was later introduced in mid-March. The testing and the reporting workflow have been smooth so far, while feedback from participating staff has been positive. No confirmed case has been identified during the period.

The HA spokesperson reiterated that regular testing and vaccination are types of stepped-up measures. Front-line staff still need to comply with infection control measures and wear appropriate personal protective equipment as stipulated in the guidelines when taking care of patients.

The HA thanks staff members for their co-operation in the testing arrangement and urges members of the public and staff to get vaccinated early so as to reduce their own risk of COVID-19 infection and to prevent the resurgence of a large-scale community outbreak.

Ends/Friday, May 7, 2021
Issued at HKT 17:00

While no one factor can be credited with the success (when graded on the curve) that many Asian nations have had in curbing community transmission of COVID-19, not having to deal often with more transmissible variants like B.1.1.7, B.1.351, and P.1  has been certainly helped. 

Mainland China has been very vocal about the need to prevent entry of the `foreign' variants, and last December their CDC published a paper (see CCDC Weekly: Models Suggest D614G Spike Protein Mutation Accelerates Transmission of COVID-19) with the following map showing the relative lack of the `European' variant in Asia.

The ability to keep the rising tide of COVID variants at bay - even with strict travel policies and quarantines - becomes increasingly difficult over time, and today's announcement from Hong Kong reflects that reality. 

Thursday, May 06, 2021

Saudi Arabia Reports A Fatal MERS-CoV Case

 Reported MERS-CoV Cases By KSA In 2021


In the first 4 months of 2020, before COVID had really begun to pummel the Middle East, Saudi Arabia had reported roughly 50 MERS-CoV cases.  Once the pandemic virus firmly arrived, however, reporting on MERS-CoV abruptly stopped. 

Between June 1st and early November of 2020, Saudi Arabia reported no MERS cases, nor did any other Middle Eastern nation. 

Four cases were reported late in the year, but the WHO EMRO monthly report on MERS went without an update for more than a year (see WHO EMRO Updates A Year's Worth Of MERS-COV Reports From Saudi Arabia).

In the first 4 months of 2021, KSA had only reported 7 MERS-CoV cases - a reduction of roughly 85% over 2020. But even in the best of times (pre-COVID), estimates were that only a fraction of symptomatic MERS cases were identified (see EID Journal: Estimation of Severe MERS Cases in the Middle East, 2012–2016).

A 2018 study, written by former Deputy Health Minister Ziad A. Memish et al. (see Evaluation of a Visual Triage for the Screening of MERS-CoV Patients), concluded that Saudi Arabia's screening process for MERS testing was `. . .  not predictive of  MERS  infection.'

Add in the repeated `lapses' in MERS reporting over the years - sometimes lasting months - by KSA (see The Saudi MOH Breaks Their Silence On MERS-CoV), and the reduction in MERS cases being reported over the past year may be a little less reassuring. 

Although it doesn't (yet) appear on their Epi Week 18 MERS Surveillance page, digging a little deeper reveals KSA's 8th reported case of 2021, involving a 36 y.o. male in Hafr al-Batin with reported camel exposure, who is deceased at the time of this report. 

Hafr al-Batin has been the site of a number MERS cases and clusters over the years (see herehere, and here)  and a 2014 epidemiological study suggested the camel festival held there – Mazayin al-Ibl aka “The Best of the Herds” – might have been a source of at least some of those infections.

Today's report is notable in that the victim is relatively young (36), and was deceased at the time of reporting. 

These initial Saudi reports don't give us crucial information like onset dates, hospitalization dates, or when a positive test was first received. So it is impossible to know how long this individual may have been hospitalized before being isolated. 

In the past, we've seen posthumously identified MERS-CoV cases linked to hospital outbreaks, in some cases involving scores of cases.  Large hospital outbreaks have been on the decline in Saudi Arabia for the past few years, so hopefully this will not the case this time. 

In any event, we'll be watching the region for additional reports in the days ahead.  

Wednesday, May 05, 2021

CDC Update On SARS-CoV-2 Variant Classifications and Definitions - Adds 5 VOIs To List


Just as we've seen in the UK (see last week's UK PHE COVID Variant Update - Adds 12th & 13th Variant To Watchlist), the CDC continues to monitor scores of major and minor COVID variants in the United States and to add emerging variants to their VOC (Variant of Concern) and VOI (Variant of Interest) watchlist. 

For the past couple of months, the CDC has selected 8 variants for closer monitoring:
  • The B.1.1.7, B.1.351, P.1, B.1.427, and B.1.429 variants circulating in the United States are classified as VOCs.
  • The B.1.526, B.1.527, and P.2 variants circulating in the United States are classified as VOIs. 
Today the CDC has updated their list, adding five more variants to their VOI list (B.1.526.1, B.1.617, B.1.617.1, B.1.617.2, B.1.617.3).  Notably, 4 of the 5 new variants are all related to the Indian Variant (B.1.617) that has caused so much concern over the past few weeks. 

As of their last biweekly update (see CDC U.S. Variant Update: B.1.1.7 Continues To Gain Ground In The United States), published a little over a week ago,  B.1.617.x variants weren't even on their list of top 20 variants in the United States (see chart below).

Excerpts from the CDC update, including a portion of the table on the Indian variant - published this morning - follow:
SARS-CoV-2 Variant Classifications and Definitions

Updated May 5, 2021

Key Points:
  • Genetic variants of SARS-CoV-2 have been emerging and circulating around the world throughout the COVID-19 pandemic.
  • Viral mutations and variants in the United States are routinely monitored through sequence-based surveillance, laboratory studies, and epidemiological investigations.
  • A US government interagency group developed a Variant Classification scheme that defines three classes of SARS-CoV-2 variants:
  • The B.1.526, B.1.526.1, B.1.525, B.1.617, B.1.617.1, B.1.617.2, B.1.617.3, and P.2 variants circulating in the United States are classified as variants of interest.
  • The B.1.1.7, B.1.351, P.1, B.1.427, and B.1.429 variants circulating in the United States are classified as variants of concern.
  • To date, no variants of high consequence have been identified in the United States.
  • In laboratory studies, specific monoclonal antibody treatments may be less effective for treating cases of COVID-19 caused by variants with the L452R or E484K substitution in the spike protein.
    • L452R is present in B.1.526.1, B.1.427, and B.1.429.
    • E484K is present in B.1.525, P.2, P.1, and B.1.351, but only some strains of B.1.526 and B.1.1.7.
Viruses constantly change through mutation. A variant has one or more mutations that differentiate it from other variants in circulation. As expected, multiple variants of SARS-CoV-2 have been documented in the United States and globally throughout this pandemic. To inform local outbreak investigations and understand national trends, scientists compare genetic differences between viruses to identify variants and how they are related to each other.

Despite the dire reports from India in recent weeks, it isn't clear how much of their crisis is due to any enhanced traits of the B.1.617 variant, and so - for now, at least - the UK and the United States have not listed them as VOCs. 

We should be getting new bi-weekly surveillance numbers from the CDC in the next week or so, and we may begin to see some or all of these new variants included in that report as well. 

Stay tuned. 

Naegleria Fowleri Season & A Potential Summer Chlorine Shortage



At the start to each summer we look at a rare, mostly fatal brain infection caused by free living amebas (Naegleria fowleri) that inhabit warm, fresh water (see A Reminder About Naegleria Season - 2019).

Dubbed the `brain eating amoeba' by the press - this infection is called PAM (Primary amebic meningoencephalitis) - and occurs when the amoeba enters the brain through the nasal passages, usually due to the forceful aspiration of contaminated water into the nose.

We generally only hear about 3 or 4 cases in the United States each summer, but in 2017 a research letter written by epidemiologists at the CDC (see EID Journal: Estimation of Undiagnosed Naegleria fowleri (PAM), United States) estimated the yearly number PAM cases in the United States probably averages closer to 16 (8 males, 8 females).

Meaning that right now - although almost universally fatal if untreated - 70%-80% likely go unrecognized.

Until a few years ago, nearly all of the Naegleria infections reported in the United States were linked to swimming in warm, stagnant freshwater ponds and lakes (see Naegleria: Rare, 99% Fatal & Preventable), making this pretty much a summer time threat.

In 2011, however,  we saw two cases reported in Neti pot users from Louisiana, prompting the Louisiana Health Department to recommend that people `use distilled, sterile or previously boiled water to make up the irrigation solution’ (see Neti Pots & Naegleria Fowleri).

 Photo Credit – Wikipedia Commons
While rare in the United States, every year Pakistan reports a dozen or more infections from this `killer amoeba’, as chlorination of their water supplies is often inadequate, and for many, nasal ablutions are part of their daily ritual.

In 2013, in Louisiana: St. Bernard Parish Water Supply Tests Positive For Naegleria Fowleri, we saw the tragic story of a 4-year-old Mississippi child visiting a St. Bernard Parish home, who (according to this NOLA.COM report) appears to have contracted the amoeba while playing with a water hose and a slip-and-slide. 

Five years ago we looked at an MMWR: Epidemiological Investigation Into A Case Of Primary Amebic Meningoencephalitis in California which suggested a poorly chlorinated spring-fed swimming pool was the likely source of infection and death of a 21 year old woman. 

While most PAM infections are linked to warm, stagnant freshwater ponds and lakes, this isn't the only report of finding Naegleria in an improperly maintained swimming pool (PubMed returns 68 hits), although most incidents have occurred outside the United States. 

As a thermophilic (heat-loving), free-living amoeba, it is hardly surprising to see that Florida and Texas lead the nation in cases over the past three decades, although infections have occurred as far north as Minnesota. 

Credit Florida DOH
The State of Florida's Primary Amebic Meningoencephalitis (PAM) website recommends:
The only known way to prevent Naegleria fowleri infections is to refrain from water-related activities. However, some common-sense measures that might reduce risk by limiting the chance of contaminated water going up the nose include:
  • Avoiding water-related activities in bodies of warm freshwater, hot springs, and thermally-polluted water such as water around power plants.
  • Avoiding water-related activities in warm freshwater during periods of high water temperature and low water levels.
  • Holding the nose shut or using nose clips when taking part in water-related activities in bodies of warm freshwater such as lakes, rivers, or hot springs. 
  • Avoiding digging or stirring up sediment while taking part in water-related activities in shallow, warm freshwater areas. 
Recreational water users should assume that there is always a low-level of risk associated with entering all warm fresh water in southern tier states. Because the location and number of ameba in the water can vary a lot over time, posting signs is unlikely to be an effective way to prevent infections. In addition, posting signs on only some fresh water bodies might create a misconception that bodies of water that are not posted are Naegleria-free.
Information about the risks associated with Naegleria fowleri infection should be included in public health messages discussing general issues of recreational water safety and risk.
When preparing solutions of tap water for sinus irrigation, the user should use tap water previously boiled for 1 minute (at elevations above 6,500 feet, boil for 3 minutes) and left to cool, use water filtered with an absolute filter pore size of 1 micron or smaller, or use clearly marked distilled or sterile water in the irrigation device. Rinse the irrigation device after each use with water that has been previously boiled, filtered, distilled, or sterilized and leave the device open to air dry completely.

Up until a recently, infection with Naegleria fowleri was universally fatal, but in 2013 an investigational drug called miltefosine was used successfully for the first time to treat the infection.  Early diagnosis, and administration of this drug, are crucial however.

Even with this new drug, prevention is the key to saving lives, and leading the charge in educating the public is, a USF Philip T. Gompf Memorial Fund project, which was set up by a pair of Florida doctors who tragically lost their 10 year-old son to this parasite in 2009.

Potentially complicating matters this summer, however, is what is reported to be a national shortage of chlorine tablets for swimming pools.  Over the past few days numerous media outlets have carried stories on the rising costs, and lowered availability, of chlorine (see below)

Chlorine shortage becoming major issue for pool owners, suppliers

Chlorine Shortage Could Ruin Pool Fun

Chlorine tablets aren't the only way to safely treat swimming pool water, but they are the safest, easiest, and most popular method.  The concern is that some pool owners - unused to alternate methods - might not treat the water safely, or properly.

While Naegleria is probably the least likely threat in a swimming pool, other more common recreational water illnesses sicken thousands of people every year.  The CDC maintains a Recreational Water Illness webpage (excerpts below). 

Recreational water illnesses are diseases that people can get from the water they swim and play in—like pools, hot tubs, water playgrounds, oceans, lakes, and rivers—if the water is contaminated with germs. The most common symptoms are diarrhea, skin rashes, ear pain, cough or congestion, and eye pain. Swallowing just a mouthful of water that contains diarrhea-causing germs can make you sick. You can also get sick from other contact with water contaminated with germs, such as breathing its mist.
Key Facts
  • The most common recreational water illness is diarrhea. Swallowing water contaminated with poop that contains germs can cause diarrheal illness.
  • Diarrheal illnesses can be caused by germs such as Cryptosporidium, Giardia, Shigella, norovirus, and E. coli.
  • People typically have about 0.14 grams of poop on their bodies at any given time. This poop can wash off swimmers’ bodies and can contaminate the water with germs.
  • Recreational water illnesses can also be caused by chemicals in the water or chemicals that evaporate from the water or turn into gas in the air.
If you own, or help to maintain a swimming pool, and haven't already secured enough chemicals to get you through the swimming season, you might want to start tracking them down now.  

And if you are forced to use an unfamiliar method, take the time to get some expert advice from your local pool chemical supply house.  

Tuesday, May 04, 2021

Denmark: SSI 4th National COVID Prevalence Study & Reopening Risk Assessment


Denmark peaked with their COVID Pandemic in mid-December with just over 3,200 cases a day being reported.  Since then, their numbers have declined, with their most recent 7-day average being 764 cases, a bit off their lows in early February, but fairly constant. 

Like many countries, Denmark is anxious to reopen their society, and they have announced plans to  allow concert venues, theatres and cinemas to open on May 6th. Additional phased relaxations will occur during the month of May. 

While lower daily COVID case totals are an important indicator, there are other metrics that help researchers evaluate the risk of reopening society. Prime of among them, the presumed level of community immunity to the virus. 
While prior infection or vaccination don't guarantee immunity, they are viewed as reasonably good indicators, at least in the near term.  How long immunity lasts from either is currently unknown (see Denmark SSI: Assessment of Protection Against Reinfection with SARS-CoV-2).
Our first stop is the prevalence study, which finds that nearly 20% of the population (over the age of 12) has either been vaccinated, or has detectable COVID antibodies.  This is far from what is assumed to be needed for `herd immunity' (i.e. 70%-80%), but is a significant increase over their last survey.
The number of covid-19 infections has increased significantly, according to the fourth national prevalence survey

The fourth national prevalence study shows a marked increase in Danes who have been infected with covid-19 and formed antibodies. This indicates that 7.0% of the Danish population has now been infected with covid-19. The latest prevalence survey in early December showed that 3.9% of Danes had been infected with covid-19

Last edited 4 May 2021

In order to be able to follow the spread of the covid-19 epidemic in the population, a study is periodically made of how many Danes have antibodies against new coronavirus.

This provides a measure of what proportion of the Danish population has already been infected with covid-19. It is the Folketing that has decided that the survey must be made. It is performed by the Statens Serum Institut (SSI) within the framework of TestCenter Danmark.

Now the results of the fourth round of this study are ready. They cover the months of March and April of 2021.

What does the study show?

The study indicates that 7.0% of the Danish population over the age of 12 had been infected with covid-19 at the beginning of March 2021. This would correspond to 325,000-375,000 people over the age of 12 having been infected since the beginning of the epidemic. This is a significant jump upwards from the previous study, which showed that 3.9% of the population had antibodies.

"The part of the population that has antibodies against the covid-19 virus has, as expected, increased significantly since the last survey from the end of November. It reflects that there was a lot of infection in the community over the winter. ” says Steen Ethelberg, who is a senior researcher at SSI and has been involved in conducting the study.

If we add the vaccinated proportion of the population to the proportion of the population that has been infected with covid-19, the study shows that 19% of the Danish population had antibodies against covid-19 in March 2021.

The study also suggests that in the first months of the year, for every time there were two people positive in a covid-19 test, there was only one undetected infection. It is significantly lower than previously estimated.

“The Danish test activity is very high, and it actually looks as if we have found most of the infected people in Denmark with the testing. Every time three people have been infected, the two of them have actually been tested positive. This means that there are fewer undetected infections than before. This is very positive, as chains of infection can thus be broken, ”Steen Ethelberg continues.
Want to know more about the survey?

You can read more about the fourth prevalence survey and the new results here .

See the note: The results from the 4th round of antibody testing with 50,000 extracted citizens, week 9-12, 2021

The fifth prevalence survey will be launched on 14 May.

The links to the SSI's risk assessments follow, after which I'll have some excerpt from their risk assessment:
SSI's risk assessments in connection with the reopening of Denmark
In connection with the new plan for the reopening of Denmark, the Statens Serum Institut has provided advice and a number of qualitative risk assessments to support the political considerations and decisions. Below are links to the three risk assessments
Last edited 4 May 2021

The Statens Serum Institut (SSI) views the agreement on further reopening of the country positively.
We are pleased that a broad-based reopening has now been agreed, and we are pleased that the corona passport and the strategy for local efforts with closures are part of the agreement. With this extended reopening, we step on the accelerator, but do it knowing that the brakes are working, and it is crucial that we do not put the disease control out of control, "says Henrik Ullum, director of the Statens Serum Institut.

Risk of infection when lifting additional restrictions Read the risk assessment here:
Health professional assessment of phasing out restrictions in connection with the reopening plan for 6 May (pdf)
18 reliefs and consequences for the spread of infection
Read the risk assessment here:
Health professional assessment of individual reliefs in connection with the reopening plan for 6 May (pdf)
Additional reopening scenarios
Read the risk assessment here:
Health professional assessment of further reopening scenarios in connection with the reopening plan for 6 May (pdf)

Below you'll find the (translated) summary from Health professional assessment of phasing out restrictions in connection with the reopening plan for 6 May (pdf).

It isn't exactly a ringing endorsement of a rapid reopening strategy, and warns (repeatedly) of the myriad things that can go awry, and the need to be able to `adjust' the reopening strategy and timetable going forward. 

While Denmark is arguably in a better position to reopen than most other countries, success - depending, of course, on how you measure that - is far from guaranteed.   You can read the caveat-heavy assessment (bolding mine) below.

Overall assessment 

The Statens Serum Institut (SSI) has been asked for a professional contribution with a view to assessing risk of infection by lifting further restrictions as part of the further reopening The covid-19 epidemic has been stable over a long period of time with largely stable infection rates as well a stabilization of new admissions and inpatients, which means that the observed development continues stays below the level of the latest forecasts. 
This may be due to the massive testing effort and implementation of a model for automatic shutdown. There has been an increase in recent days in number of detected cases and an increase in the number of contacts, but it is too early to assess whether there are talk of random variation or a consequence of the recent reopening.
While the infection situation in Denmark is still stable, epidemic control is being challenged internationally the emergence of new, more contagious varieties. Several countries around Denmark experienced, especially in the weeks around Easter, worrying increases in infection that gave rise to the introduction of further restrictions, and more countries are experiencing health care pressures and excess mortality.
The situation looks very serious in several third countries outside Europe, including in particular India and Pakistan, which is currently experiencing an explosion in infection and a derived pressure on the healthcare system that is close on collapse. There are already many uncertainties associated with qualitatively assessing the potential risk of an increase in infection due to further easing.
But it is particularly difficult at present time when the effects of the openings on 21 April 2021, which SSI assessed would entail high risk for the spread of infection, can not yet be read with certainty in the number of infected or in admission numbers. SSI's professional assessment up to the negotiations on the previous reopening was made against the background of a stable development in the epidemic over several weeks and a period without major nationwide relief.
The recently implemented reductions include both school and the education area, outdoor and indoor sports for children, outdoor and indoor dining as well assembly ban. Some of the relaxations include areas that the professional reference group has assessed to be associated with a high risk of infection (bars and pubs, relaxation of assembly bans).
In a new assessment of further relief, in the same way as in the most recent assessment, continue to make reservations that increased activity in different sectors will interact with each other, and that it is not possible to fairly quantify these indirectly derived effects both in relation to other new reductions as well as in relation to the reductions already introduced. For example, relaxation of the assembly ban contributes to people to a greater extent meeting across social networks in extension of other activities, such as education, sports, physical attendance at work, or cultural activities.
Thus, greater interaction across networks and sectors, such as it is not possible to incorporate in an overall assessment of the risk of infection increase. It is also noted that further easing of restrictions will signal diminished concern in the authorities, which may give rise to changing behavioral patterns of the population in step with a diminished threat picture. This can lead to further spread of infection through increased socialization across networks as well as reduced compliance with recommendations for infection prevention efforts, which must be expected to challenge existing epidemic control.
Mobility data from DTU and data from HOPE is already showing signs of behavioral changes in the population in relation to an increased number of contacts across networks and increased traffic activity over recent weeks. Overall, the speed of the reopening process challenges the possibility of truthfully quantitatively that assess derivative contagion effects of increasing activity in the community in a situation where the effects of it recent major reopening cannot yet be assessed.
SSI therefore continues to consider that the reopening should take place carefully and step by step so that changes in infection can be responded to quickly, especially in light of the easing happens at such short intervals. In particular, reliefs that are expected to carry the least risk should be avoided increase in infection is a priority, which includes activities with limited volume as well as limited risk for interaction across facilitation.
Overall, it is estimated that a reopening with large, and for quickly implemented easing, increases the risk of the need for major local shutdowns to maintain control of the epidemic. In parallel with the step-by-step reopening, a lot should take place detailed monitoring of both key epidemiological indicators and close monitoring of behavioral indicators and activity data so that behavioral changes can be addressed with intensive communication. In addition, a model for local shutdowns should be maintained as a mechanism to control epidemic development.

          (Continue . . . )

The good news in all of this is that Denmark's testing and surveillance programs are top notch, and they should be able to pick up any signs of significant backsliding relatively quickly.