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 11 reports 19.72 million cases (253,409 new) and 728,013 deaths (5,719 new). We expect the global cumulative incidence to surpass 20 million cases in today’s or tomorrow’s update. The global mortality remains on track to surpass 750,000 deaths by this weekend. The following timeline of select milestones will provide some context for the trajectory of the COVID-19 pandemic.
Zero to 1 million cases: 100 days
1 million to 5 million: 48 days
5 million to 10 million: 38 days
10 million to 20 million: 45 days (based on August 13)

In the August 10 Situation Report, the WHO announced that it will shift from daily Situation Reports to weekly epi updates starting on Monday, August 17; however, it will continue to publish data daily in its global COVID-19 dashboard as well as other regular updates on operational and policy issues.

Central and South America remains as the major global COVID-19 hotspot, with 5 of the top 10 countries in terms of both total and per capita daily incidence. Brazil’s daily incidence is holding relatively steady at approximately 43-46,000 new cases per day, and it remains #3 globally in terms of daily incidence. After a week of holding steady, Colombia’s daily incidence increased slightly to 10,782 new cases per day, its highest average to date. Colombia 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. With 7,113 new cases per day, Peru remains #5 globally with respect to daily incidence. Argentina’s COVID-19 epidemic continues to accelerate steadily as well, up to 6,732 new cases per day, its highest average to date. Argentina climbed to #6 globally in terms of daily incidence. Mexico has reported slightly decreased daily incidence compared to its high of 7,022 new cases per day on August 2, down to 6,080 today (a slight increase from the previous 2 days). Mexico remains #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, Colombia is #4, Brazil is #5, and Argentina is #9. Additionally, Suriname is reporting more than 140 daily cases per million population, which puts it just outside the top 10. Several other countries are reporting more than 100 new daily cases per million population as well.

India is reporting more than 60,000 new cases per day, surpassing that milestone for the first time, and it remains #1 globally with respect to daily incidence. 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 appears to have leveled off, holding relatively steady between approximately 3,800 and 4,300 new cases per day since August 5. The Philippines remains #10 in terms of daily incidence.

South Africa has reported steadily decreasing daily incidence since its peak on July 20 (12,584 new cases per day). South Africa is currently reporting 6,399 new cases per day, its lowest average since June 30, and it fell to #7 in terms of daily incidence.

After consistent decreases in daily incidence since late June, Bahrain reported increasing daily totals over the past several days, climbing to #2 globally in terms of per capita daily incidence. Kuwait re-entered the top 10 (currently #10), following nearly a week of increasing daily incidence. Qatar is also again 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.

After its daily incidence decreased nearly 25% from its high on August 6, the Maldives fell to #6 globally in terms of per capita daily incidence.

The US CDC reported 5.06 million total cases (40,522 new) and 162,407 deaths (565 new). From the first case reported in the US on January 22, it took 98 days to reach 1 million cases. From there:
1 million to 2 million: 44 days
2 million to 3 million: 27 days 
3 million to 4 million: 14 days
4 million to 5 million: 18 days

In total, 17 states (increase of 2) are reporting more than 100,000 cases to date, including California and Florida with more than 500,000 cases; New York* and Texas with more than 400,000; and Georgia with more than 200,000. Additionally, Puerto Rico is currently reporting more than 200 daily cases per million population. It is a US territory, but its current per capita daily incidence would be #7 globally, falling between the Maldives and Israel.
*The CDC removed New York City from its list of jurisdictions and now reports only the cumulative totals for all of New York state.

The US remains #2 globally in terms of total daily incidence and #8 in terms of per capita daily incidence

The Johns Hopkins CSSE dashboard reported 5.16 million US cases and 164,994 deaths as of 12:30pm on August 12.

RUSSIAN VACCINE Russian President Vladimir Putin announced that Russia has developed and authorized a SARS-CoV-2 vaccine for public use, with the aim of initiating mass vaccination in October. The announcement did not appear to include accompanying data to support Russia’s decision, and some experts have raised concerns about the evaluation process and the vaccine’s safety and efficacy profile. Notably, the Russian vaccine is not among those listed by the WHO as having commenced Phase 3 clinical trials, and it does not appear that Phase 3 clinical trials have been initiated. The WHO is reportedly negotiating with the Russian government to conduct a review of the vaccine trial data. The Health Ministry of the Russian Federation registered a Phase 1/2 clinical trial with the US National Institutes of Health, which involves fewer than 40 participants. The studies were estimated to last 2 months, although follow-up phone calls were scheduled for 3 and 6 months after vaccination. Reportedly, Russia is in the process of negotiating with several national governments and pharmaceutical companies to provide access to early doses and increase global production capacity. 

The principal concern is that the vaccine does not appear to have been subjected to larger, Phase 3 clinical trials, but rather, regulatory approval was based on a very small number of participants monitored over a very limited time frame. Additionally, Russia does not appear to have published data from early-stage clinical trials, so they cannot be evaluated independently. With limited safety and efficacy evaluation, Russia would essentially be conducting larger trials on the general public, and safety and efficacy issues that arise as the mass vaccination campaign continues could pose significant challenges for both the immediate COVID-19 response and for future vaccines. The vaccine utilizes a human adenovirus base and is administered in a prime-boost formulation. Several other candidate vaccines utilize a human adenovirus platform, but concerns have been raised that previous exposure to human adenovirus strains could result in existing antibodies that could neutralize the vaccine before immunity can be conferred to SARS-CoV-2.

NEW ZEALAND DOMESTIC TRANSMISSION Following more than 100 days with no domestic SARS-CoV-2 transmission, New Zealand reported 4 new cases in South Auckland with no known source. All 4 cases are members of the same family, and none reported any recent overseas travel. In response to the newly identified cases, New Zealand implemented contact tracing efforts as well as enhanced social distancing protocols. The Auckland region will move to Alert Level 3 for three days, while health officials gather further information, and the rest of the country will move to Alert Level 2. At Alert Level 3, individuals are encouraged to work from home, bars and restaurants are limited to delivery or takeaway/take-out service, and physical distancing and mask use are encouraged in public. Additionally, gatherings of more than 10 people are prohibited, and gatherings of up to 10 are permitted only for weddings, funerals, and tangihanga—a traditional Māori funeral rite. For Alert Level 2, businesses can open for in-person service, gatherings of up to 100 persons are permitted, and mask use is recommended when appropriate physical distancing cannot be maintained.

New Zealand previously transitioned to Alert Level 1 on June 9 after successfully interrupting all domestic transmission. At Alert Level 1, New Zealand removed the majority of social distancing restrictions, including all prohibitions on large gatherings, but many international travel restrictions remained, including border screening and mandatory quarantine for arriving travelers.

NAVAJO NATION The Navajo Nation, located in northeastern Arizona, as well as parts of New Mexico and Utah, faces numerous challenges to implementing effective controls against COVID-19, and it has been severely affected early in the US COVID-19 epidemic. High prevalence of chronic health conditions—including diabetes, heart disease, and obesity—coupled with challenges accessing healthy food, running water, and electricity placed many Navajo at elevated risk for COVID-19, including severe disease and death. Following a peak in mid-May, when the Navajo Nation averaged more than 165 new cases per day, the daily incidence is down to fewer than 30. Navajo leaders implemented aggressive social distancing restrictions, including mandatory curfew and mask use as well as restrictions on entering tribal land. The restrictions have had numerous downstream effects, including making it difficult for some to shop for groceries; however, the controls have driven community transmission down to a manageable level.

While the public health measures have helped bring the epidemic under control, Navajo leaders remain concerned about the potential for a “second wave” of transmission. In order improve resilience to COVID-19 and future health emergencies, Navajo leaders want to utilize more than $700 million in funding supplied by federal COVID-19 emergency funding, including the CARES Act, to bolster public health and other infrastructure. They are facing numerous barriers, however, which could risk them having to repay a large portion of the money in the event they cannot utilize it by the end of 2020. Some of that funding supported immediate response efforts, including purchasing PPE; however, much of it could be used to improve and expand existing infrastructure, including broadband internet access, that could improve future response efforts and other public health and healthcare services on tribal land. One concern, in particular, is a dearth of intensive clinical care capacity. Navajo Nation healthcare facilities only have approximately 40 intensive care unit (ICU) beds, which quickly filled earlier in the epidemic. While the Navajo were largely able to bring their COVID-19 epidemic under control, longer-term investments in critical infrastructure and public health and healthcare capacity could build resilience to subsequent waves of transmission or other health emergencies.

SEROPREVALENCE IN HEALTHCARE WORKERS The largest health system in New York state implemented a study to characterize SARS-CoV-2 seroprevalence in healthcare workers (HCWs). The study, published in JAMA, offered free serological tests to all HCWs in the health system, which were administered at more than 50 sites in the New York City area between April and June. Of more than 70,000 total personnel, 46,117 (65%) were tested, and 5,523 were seropositive (13.7% of tested HCWs). Among the HCWs that previously tested positive using a PCR diagnostic test, 93.5% were seropositive, compared to 10.3% among those who previously underwent diagnostic testing but never tested positive. Of more than 34,000 who had never received a PCR diagnostic test, 9.0% were seropositive. The overall seroprevalence among these healthcare workers was similar to previous seroprevalence studies conducted in New York City, which have found seroprevalence of approximately 14% among the general public.

NEW YORK NURSING HOMES New York state has recently drawn attention due to how it classifies and reports COVID-19 deaths in nursing homes and other long-term care facilities. According to a report by the Associated Press, supported by other media reports, the number of nursing home COVID-19 deaths reported by New York includes only COVID-19 victims that die in a nursing home and excludes nursing home residents who were transferred to another healthcare facility (eg, hospital) and died there. Analysis of data reported directly by nursing home facilities suggests that the state reports could be significantly underestimating the effect of COVID-19 on nursing home populations. State lawmakers questioned senior state health department officials on the topic at a hearing held last week, noting that this classification could be misleading by not reporting all deaths among nursing home residents. Notably, not all states report nursing home COVID-19 deaths at all. Nationally, nursing home residents account for approximately 44% of all COVID-19 deaths, more than double the percentage reported by New York.

MEXICO Despite high daily incidence of COVID-19, Mexicans are increasingly less willing to seek treatment at hospitals, choosing instead to remain at home. Many cite aging and overwhelmed hospital infrastructure as a primary factor in their reluctance to seek medical care. A recent national survey found that 68% of respondents would feel unsafe admitting a family member to a hospital, including 40% that would feel very unsafe. The cycle of avoiding hospitals until the disease is too severe to adequately treat has contributed to a nearly 40% mortality rate in hospitalized COVID-19 patients in Mexico City. Health professionals are deeply concerned about this trend in hospital avoidance, emphasizing that treatment at home likely leads to more transmission, particularly in multi-generational households. Furthermore, COVID-19 victims who die at home may never receive a SARS-CoV-2 test and, thus, not be counted as a COVID-19 case or death.

Misinformation is a major contributor to the reluctance to seek medical care. For example, Mexican President Andrés Manuel López Obrador has reportedly encouraged people to remain at home for treatment and highlighted his use of “religious amulets and a clear conscience” to protect himself against COVID-19. Many hospitals have initiated community outreach and education activities in order to establish or regain trust among the community; however, it will take considerable resources to counter the current volume of this dangerous messaging.

US MOTORCYCLE RALLY Tens of thousands of motorcycles, recreational vehicles (RVs), and campers arrived in Sturgis, South Dakota (US), for the city’s annual motorcycle rally, which began on August 7. The 10-day event is expected to host 250,000 visitors, likely making it the largest public gathering since the start of the COVID-19 pandemic. This year’s attendance is expected to only be half of what would be expected in a normal year, but many still fear that the rally will become a “superspreader event.” A survey of local residents found that more than 60% supported postponing the event, but local officials were not able to cancel or suspend the rally, due in part to a large portion of the event taking place on state-licensed campgrounds. Several Native American nations in South Dakota have established checkpoints to prevent visitors from crossing tribal land in accordance with their existing COVID-19 restrictions. The South Dakota Department of Tourism and rally organizers published guidance for attendees on allowable and alternate travel routes.

Local health officials and rally organizers, as well as those for associated concerts and other events, issued COVID-19 guidance for vendors and staff and recommendations for attendees, but there do not appear to be many mandatory precautions. Attendees are encouraged to wear masks, maintain appropriate physical distancing, and avoid large gatherings, and vendors and event staff are implementing enhanced hygiene and sanitization measures, including ensuring hand sanitizer is available. Some media reports indicate that mask use among attendees is very low, with one Associated Press reporter counting fewer than 10 masks out of several thousand people over the course of several hours. Despite US CDC recommendations to wear a mask to prevent viral spread, particularly in spaces where appropriate physical distancing is not feasible, South Dakota is one of 18 states that still does not mandate mask use. South Dakota is also one of the few states that never issued a “stay at home” order. The South Dakota Department of Health tested local first responders prior to the event and will test them again after the event concludes, and testing capacity has been increased at local healthcare facilities. Additionally, the Sturgis city government will offer free testing for local residents.

Much like large gatherings earlier in the year, including for holidays like Memorial Day and Independence Day, it will likely be several weeks before any associated increase in transmission starts to become evident. Additionally, because event attendees come from across the country, it may be more difficult to link any transmission back to the event.

ANTIBODIES & NANOBODIES While numerous efforts are ongoing to develop, evaluate, and produce SARS-CoV-2 vaccines, effective treatments or other prophylactics could provide a critical tool to mitigate COVID-19 risk until a vaccine becomes available. Numerous pharmaceutical companies have monoclonal antibody products in various stages of development, including animal or human trials. Results from some late-stage clinical trials could be available by this fall. Despite the considerable effort and investment, however, there are concerns that antibody treatments may not have a major effect on the COVID-19 pandemic. Depending on the timing of Phase 3 vaccine clinical trial results and production capacity, it may not be possible to manufacture sufficient doses of monoclonal antibodies before a vaccine is available. Even with a vaccine available, monoclonal antibodies and other products will be necessary to treat those who do get sick, including those who may not be able to get vaccinated (eg, due to an allergic reaction or other health condition); however, monoclonal antibodies may not necessarily be as critical as they would have been if they were available sooner in the pandemic.

Other researchers are taking a less traditional approach, utilizing “nanobodies” derived from llamas to develop a COVID-19 treatment. “Llamas, alpacas, and other camelids” produce a specialized kind of antibody that are much smaller than traditional antibodies (hence the name), which makes them more able “nestle into the nooks and crannies of proteins” to prevent viruses from attaching to cells. These nanobodies may be “among the most potent anti-coronavirus compounds” identified to date. Researchers at the University of California San Francisco (UCSF; US) created a synthetic version of these nanobodies that can be formulated as an aerosol to facilitate easier administration (ie, compared to intravenous treatments). The researchers published (preprint) results from in vitro laboratory tests, which demonstrate the nanobodies’ ability to inhibit SARS-CoV-2 spike proteins’ from binding to cell ACE2 receptors. The researchers are currently in search of collaborators to support further testing and development.

US COLLEGE SPORTS Yesterday, the Big Ten Conference and Pac-12 Conference (US collegiate athletics) announced that they are postponing all fall sports, including cross country, field hockey, football, soccer, and volleyball. With no disrespect intended to the other affected sports and athletes, the decision to postpone the upcoming college football season is perhaps the biggest news coming out of these announcements. The Big Ten was not the first to cancel the 2020 football season, but it was the first of the Power Five conferences to do so, followed shortly by the Pac-12. Previously, individual schools (eg, University of Connecticut) as well as the Mid-American Conference (MAC) and Mountain West Conference suspended their upcoming seasons. Additionally, a number of athletes previously announced that they were opting out of the upcoming season due to concerns about COVID-19. At many schools, football is as much as part of the college experience as going to class, but the conferences determined that the risk posed by COVID-19 was too great.

The decisions have been hotly debated and criticized—by sports commentators, athletes and coaches, elected officials, and others—largely mirroring the rhetoric around schools resuming in-person classes. Reportedly, both the Big Ten and Pac-12 are considering playing the affected sports in the spring, if conditions permit. Other conferences are currently evaluating their own options, and some individual schools may attempt to arrange their own competitions; however, it is unclear to what extent the Big Ten’s and Pac-12’s decisions could impact the remaining NCAA schools.