Updates on the emerging novel coronavirus pandemic from the Johns Hopkins Center for Health Security.

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Over the next week, we will be updating the format of the COVID-19 updates. Mondays will include country-specific data in the Epi Update section, including on the top 10 countries in terms of total and per capita daily incidence. The Epi Update section on Wednesdays and Fridays will focus more on epi trend analysis. We will also largely be shifting to 7-day averages when reporting national daily incidence for all countries, rather than daily incidence totals, to provide a higher-level perspective on national trends. Many countries do not directly report weekly averages, so we will rely on other sources. The principal exceptions will likely be data published by the WHO and US CDC.

For the rest of the content, Mondays will focus on a variety of events and topics reported over the weekend. On Wednesdays and Fridays, we will dedicate one day to US-specific topics and one day to international issues. It may be longer between updates on specific topics, but it will allow us to include more diverse content, particularly in light of the considerable volume of US-specific content on any given day. Thank you for continuing to read these updates.

EPI UPDATE The WHO COVID-19 Situation Report for August 9 reports 19.46 million cases (273,552 new) and 722,285 deaths (6,207 new). The global cumulative incidence could potentially reach 20 million cases by tomorrow or Wednesday’s Situation Report, and the global mortality could reach 750,000 deaths by the end of this week.

Central and South America continues to be the major global COVID-19 hot spot, with 5 of the top 10 countries in terms of both total and per capita daily incidence. Brazil surpassed 3 million cumulative COVID-19 cases, and it is currently reporting 43,106 new cases per day. Brazil remains #3 globally in terms of daily incidence. Colombia is reporting 9,976 new cases per day, and its daily incidence appears to be leveling off. Columbia remains #4 globally in terms of daily incidence, but it is well behind the top 3 countries. Peru has reported steadily increasing daily incidence since late June. It is now reporting 7,025 new cases per day, surpassing its first peak in early June. Peru climbed to #5 globally in daily incidence. Argentina’s COVID-19 epidemic continues to accelerate steadily, up to 6,467 new cases per day. Argentina is currently #7 globally in terms of daily incidence. Mexico has reported decreased daily incidence over the past week or so, down from a high of 7,022 on August 2 to 5,890 today. Mexico fell to #8 globally in terms of daily incidence. Multiple other countries in the region are also reporting more than 1,000 new cases per day. In terms of per capita daily incidence, Panama is #1, Peru is #3, Brazil is #5, Colombia is #6, and Argentina is #9. Bolivia fell out of the top 10, but it and several other countries are reporting more than 100 new daily cases per million population.

India has reported more than 2 million cumulative COVID-19 cases. India is now #1 globally with respect to daily incidence, surpassing the US, with 58,768 new cases per day and still increasing. The global record for average daily incidence is 67,374, set by the US on July 23, and India could soon surpass this mark if it continues along its current trajectory. The Philippines’s daily incidence fell to 3,818 new cases per day, down from a high of 4,356 on August 6. The Philippines remains #10 in terms of daily incidence, but it could soon fall out of the top 10.

South Africa has reported steadily decreasing daily incidence since its peak on July 20 (12,584 new cases per day), and it is down to 6,910 new cases per day. South Africa fell to #6 in terms of daily incidence, and it fell out of the top 10 for per capita daily incidence.

After consistent decreases in daily incidence since late June, Bahrain reported increasing daily totals over the past several days. At #4 it remains the only country in the Eastern Mediterranean region in the global top 10 in terms of per capita daily incidence. Kuwait is the only other country in the region reporting more than 100 new daily cases per million population. Nearby Israel (#7), in the WHO’s European region, remains among the top countries globally as well.

The Maldives remains #2 globally in terms of per capita daily incidence.

The US CDC reported 4.97 million total cases (54,590 new) and 161,284 deaths (1,064 new). We expect the US to surpass 5 million cases in this afternoon’s update. In total, 15 states (increase of 2) are reporting more than 100,000 cases, and Ohio and South Carolina should surpass this benchmark in the coming days. California and Florida are reporting more than 500,000 cases; Texas more than 450,000; New York* more than 400,000; and Georgia more than 200,000.
*The CDC removed New York City from its list of jurisdictions, but it did not combine the total state incidence for New York on this list. The CDC reports New York as having 192,761 cases, but the New York State Department of Health reports 420,860 cases. It does not appear that this impacts the cumulative national incidence reported by the CDC.

The US fell to #2 in terms of total daily incidence, behind India, and also fell to #8 in terms of per capita daily incidence

The Johns Hopkins CSSE dashboard reported 5.06 million US cases and 163,156 deaths as of 1:30pm on August 10.

US COVID-19 STIMULUS PACKAGE On Saturday, US President Donald Trump signed an executive order and 3 memoranda that aim to provide economic relief from the effects of the US COVID-19 epidemic. The decision to take executive action followed continued struggles in negotiations in the Congress to finalize a “Phase 5” spending package. The executive order addresses the risk of an “abnormally large wave of evictions” after protections under the CARES Act expired, directing the Secretaries of Health and Human Services (and the CDC Director), Treasury, and Housing and Urban Development (HUD) to evaluate the need to provide protection for individuals at risk for eviction and associated options for doing so. The individual memoranda direct the deferral of payroll taxes, suspension of student loan repayment and interest accrual, and extension of expanded unemployment benefits through the end of 2020.

Opponents of President Trump’s efforts have highlighted several notable issues with the executive actions that could limit their effect. With respect to eviction protections, the executive order does not appear to actually extend the federal moratorium on evictions that expired several weeks ago, but rather, it directs senior government leadership to evaluate further options. The memorandum on payroll taxes postpones the payments until 2021, which temporarily increases paychecks but could force taxpayers to pay back the difference later, unless the Congress authorizes an associated tax cut. Payroll taxes fund federal programs such as social security and Medicare/Medicaid, so a future payroll tax cut could ultimately impact national programs that support millions of Americans. The expanded unemployment benefits total US$400 per week, which is down from US$600 under the CARES Act. Additionally, they require the Federal Emergency Management Agency (FEMA) to redirect funding from the Disaster Relief Fund (DRF) to state governments to cover US$300 per week, and it requires states to supply another US$100 per week using funds previously allocated to support COVID-19 response operations. Notably, the DRF is used to provide federal support for disasters like hurricanes, and the US is just entering the 2020 hurricane season. Additionally, some elected officials, Democrat and Republican, and experts have highlighted specific concerns about policies in the orders that may be unconstitutional, including allocating federal funding. Others have noted that executive action is not sufficient to fix these problems and that Congressional action is needed to address them, particularly with respect to identifying long-term solutions.

US CHILDREN & SCHOOLS The beginning of the 2020-21 school year continues to be tumultuous with some schools conducting classes in-person, some only teaching remotely, and others utilizing hybrid approaches. Plans also continue to change rapidly in many school districts, particularly in those that have been forced to implement quarantine, to varying degrees, or even suspend in-person classes entirely following positive SARS-CoV-2 tests among students or staff. Schools in multiple states—including Georgia, Indiana, Mississippi, North Carolina, and Tennessee—have had to adapt existing plans in response to COVID-19 cases.

A study published jointly by the American Academy of Pediatrics and the Children’s Hospital Association found that 97,078 new confirmed infections among children were reported in the last 2 weeks of July, representing a 40% increase in overall reported infections among children. By the end of July, there were 338,982 total infections by children in the US, equivalent to 447 cases per 100,000 children and making up 8.8% of total US cases. Notably, the study found that 0.6%-8.9% of all cases among children—across 20 states and New York City—were hospitalized. Additionally, states reported COVID-19 mortality in children as high as 0.3%, although 20 of 44 states reported zero pediatric COVID-19 deaths. Two studies published in the US CDC’s Morbidity and Mortality Weekly Report (MMWR) address COVID-19 disease and associated conditions in pediatric cases. The first study describes clinical manifestations and characteristics of multisystem inflammatory syndrome in children (MIS-C), a rare but serious condition among pediatric COVID-19 patients that has thus far affected at least 570 children across 40 states and Washington, DC. The second study describes characteristics of hospitalized pediatric COVID-19 patients in the US from March to July. The researchers noted that hospitalization rates were higher among racial and ethnic minorities, consistent with data reported among adult COVID-19 cases. The hospitalization rate was 4-8 times higher among Black and Hispanic and Latino children than among non-Hispanic White children. Notably, one-third of all hospitalized children were ultimately admitted to an intensive care unit (ICU), clearly illustrating that, while children are at lower risk for severe disease than adults, pediatric patients can experience severe COVID-19 disease. Among hospitalized children, 42% had an underlying medical condition, with obesity being the most common. In the US, 1 in 5 children are obese, which further highlights the risk of severe COVID-19 disease among pediatric patients. 

ANTIGEN TESTS Since the onset of the US epidemic, the response has been hampered by testing delays, with tests often taking more than 48 hours—or in some cases, more than a week—to process. These lengthy delays make successful contact tracing difficult or impossible in many cases, which allows community transmission to continue. Rapid, point-of-care tests could potentially provide a solution to testing delays. These antigen tests detect the presence of virus in the sample by looking specifically for molecular structures on the outside of viral particles, as opposed to the presence of viral RNA. These same antigens are what the immune system uses to detect viral particles and initiate an immune response.

While these tests can be conducted more quickly, potentially on the order of 15-30 minutes, they may not be as accurate as the standard PCR diagnostic tests currently in use for SARS-CoV-2.

With the aim of supplementing existing SARS-CoV-2 testing capacity and reducing delays, 7 governors are arranging to purchase 3.5 million rapid tests, including antigen tests. The governors acknowledged that antigen tests are more likely to produce inaccurate results, but these tests could provide the capacity needed to implement community-wide screening programs. Additionally, the US government is working to procure antigen tests to supplement national testing capacity. The federal government reportedly hopes to obtain 20 million tests per month by September, but some experts believe that the US may need more than 4 times that many tests to implement an effective testing/screening program. As with existing tests, including diagnostic and serological, antigen tests are not a universal solution; however, they can provide valuable information, particularly if utilized in conjunction with other testing products and strategies.

INDIA MORTALITY India’s COVID-19 case fatality ratio has been declining steadily since mid-June, and it is poised to cross below 2%. But as India becomes the third country to surpass 2 million COVID-19 cases, there is concern that its COVID-19 mortality could be artificially low. With only 44,386 cumulative deaths nationwide and case fatality ratio at 2%, India appears to be in much better shape than most other countries, particularly those that have reported high incidence. As we discussed previously, case fatality is notoriously difficult to estimate in the midst of an epidemic, and there are a number of factors that could be contributing to India’s low reported mortality. One report from 2019 found that only 22% of deaths nationwide are “medically certified”—and much lower in some parts of the country—including rural areas where local populations do not have easy access to medical care. It is possible that COVID-19 victims without an official cause of death may not be accounted for or may be under reported in the national totals. It is unclear if or how this may have changed as a result of the COVID-19 pandemic. Additionally, the average age of India’s population is lower than some other countries that have been severely affected, which could be contributing to lower mortality. From this perspective, India’s case fatality aligns relatively closely with countries with similar population age. In contrast, countries like France, Italy, Spain, and the UK have much older populations (mean age of 40 years and older, compared to 26.7 years in India) and much higher case fatality (9% and higher).

NEW ZEALAND On Sunday, New Zealand marked 100 days since its last domestic SARS-CoV-2 transmission. New Zealand implemented a robust screening, testing, and contact tracing response, complemented by national social distancing policies, that ultimately led to eliminating the virus in early June. While domestic transmission has been successfully interrupted, there is still concern that imported cases could ignite new transmission chains within the island nation. The WHO has not established formal criteria for COVID-19 elimination, but New Zealand is currently demonstrating its ability to maintain zero domestic transmission, including through effective border screening and quarantine policies. In total, New Zealand has reported 1,219 confirmed cases of COVID-19 and 22 deaths since the beginning of the pandemic.

MASK EFFICACY Researchers from Duke University (US) evaluated various types of face masks to compare their ability to filter respiratory droplets. Mask use has become popular in many countries, and mandatory in some countries or regions, since the onset of the pandemic, and many types of mask construction are available, ranging from medical-grade respirators and surgical masks to homemade cloth masks and bandanas. With many options available, this study provides insight into how effective various types can be in terms of reducing exposure to respiratory droplets. The study, published in Science: Advances, evaluated 14 types of mask construction, including a fit-tested (non-valved) N95 respirator, a valved N95 respirator, a surgical mask, a bandana, a neck gaiter, and various examples of cloth masks using different designs and materials. Individuals wore the masks and spoke aloud into the test chamber. The experimental setup was designed to be low cost, utilizing a cell phone camera to record laser light reflected and refracted by the respiratory droplets, and an automated algorithm calculated the droplet count based on the recorded video. The results for each mask were compared against a control using no mask.

The majority of the masks tested reduced the number of expelled droplets by more than 60%, and 10 of the masks reduced droplets by approximately 80% or more. Not surprisingly, the most effective options were the fitted N95 respirator and surgical mask, which contained nearly all of the droplets. Also not surprisingly, the fitted, non-valved N95 respirator was “far superior” to the valved respirator, as the valve allows exhaled air to pass through unfiltered. The mask constructed of knit material (ie, as opposed to woven) was only 65% effective, and the bandana was only 35-40% effective. Notably, the neck gaiter actually increased the number of expelled droplets. The researchers believe this resulted from the material separating larger droplets into numerous smaller droplets. Considering that smaller droplets remain aloft longer than larger droplets, this could indicate that this type of mask may be less effective in reducing transmission, or even “counterproductive.”

Using a low-tech option (ie, cell phone camera) for data collection could limit the size and quantity of droplets counted in the study compared to more sensitive cameras and sensors designed for this purpose; however, the study does provide a high-level overview of the relative performance of certain types of masks. Additionally, the study specified that the bandanna material was folded over to provide a second layer, but it does not address whether the neck gaiter was folded as well. Some mask policies recommend or require at least 2 layers of material for a mask, so this could potentially provide improved efficiency over a single layer. The study does not make any assessment of the role of masks in protecting the wearer from exposure.