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

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Starting Monday, August 17, we will be updating the format of our 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, rather than daily incidence totals, when reporting national daily incidence for all countries in order 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 rather than more frequent but incremental updates, 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 13 reports 20.44 million cases (276,398 new) and 744,385 deaths (6,933 new). We expect the global mortality to surpass 750,000 deaths in this afternoon’s or tomorrow’s Situation Report.
NOTE: With the WHO shifting to weekly epi updates, we will transition to reporting data from the WHO’s COVID-19 global dashboard starting Monday, August 17.

The Central and South America region remains the primary global COVID-19 hotspot, with 5 of the top 10 countries in terms of total daily incidence and 6 of the top 10 for per capita daily incidence. Brazil’s daily incidence continues to hold relatively steady at 43-46,000 new cases per day, and it remains #3 globally in terms of daily incidence. Following a slight increase earlier this week, Colombia’s daily incidence remains elevated at 10,870 new cases per day, down slightly from its record high yesterday (10,972). Colombia remains #4 globally in terms of daily incidence. Peru has reported steadily increasing daily incidence since late June. With 7,513 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 6,841 new cases per day, its highest average to date. Argentina remains #6 globally in terms of daily incidence. Mexico is reporting 6,152 new cases per day, climbing to #7 globally. Multiple other countries in the region are also reporting more than 1,000 new cases per day. Suriname climbed into the global top 10 in terms of per capita daily incidence, jumping to #7. Additionally, Panama fell to #2, Peru remained #3, Colombia fell to #5, Brazil fell to #6, and Argentina fell to #10. Several other countries in the region are reporting more than 100 new daily cases per million population as well.

India is reporting more than 62,000 new cases per day and still increasing, and it remains #1 globally with respect to daily incidence. The global record for average daily incidence is 67,374 new cases per day, 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 steady at approximately 4,000 new cases per day since August 5. The Philippines remains #10 in terms of daily incidence. After decreasing 25% from its peak, the Maldives’ daily incidence increased again, and it climbed to #4 globally in terms of per capita 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 4,954 new cases per day, its lowest average since June 26, and it fell to #9 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 again to #1 globally in terms of per capita daily incidence. Kuwait fell out of the top 10 again, but only just. Qatar also continues to report more than 100 new daily cases per million population. Nearby Israel, in the WHO’s European region, fell to #8 in terms of per capita daily incidence.

While Europe does not have any countries in the top 10 in terms of total or per capita daily incidence (with the exception of Israel), a number of countries are reporting more than 1,000 new cases per day. Additionally, Spain is reporting more than 3,900 new cases per day, which puts it just outside the top 10 for total daily incidence.

The US CDC reported 5.18 million total cases (56,307 new) and 165,148 deaths (1,497 new). Following steady declines since July 24, the average daily incidence in the US increased slightly over the past 2 days, up from 52,193 new cases per day to 53,361. Additionally, the US continues to average more than 1,000 new deaths per day, a trend that has persisted for more than 2 weeks. Numerous states that were severely affected during the summer COVID-19 resurgence—including Arizona, California, Florida, and Texas—appear to be at or past their peak in terms of daily COVID-19 mortality, but others are still reporting increasing mortality or still approaching a peak. Considering that the national daily incidence peaked 3 weeks ago, we expect to start seeing an associated decline in national COVID-19 deaths in the near future.

In total, 17 states are reporting more than 100,000 cases, including California, Florida, and Texas with more than 500,000 cases; New York with more than 400,000; and Georgia with more than 200,000. We expect Illinois to surpass 200,000 cases in the next update. Additionally, Puerto Rico is currently reporting more than 225 daily cases per million population and increasing steadily. It is a US territory, but its current per capita daily incidence would be #4 globally, falling between Peru and the Maldives—up 2 spots since our last briefing.

The US remains #2 globally in terms of total daily incidence, and it fell to #9 in terms of per capita daily incidence

The Johns Hopkins CSSE dashboard reported 5.27 million US cases and 167,528 deaths as of 1:30pm on August 14.

UN SCHOOLS REPORTS More than 1 billion children worldwide have been affected by school closures due to the COVID-19 pandemic. The UN has provided educational resources, including for virtual or remote learning options, for children around the world, but educational disruption remains a major challenge in many parts of the world. The UN published a policy brief on schooling in the context of the COVID-19 pandemic, which discusses the substantial ways in which the pandemic has disrupted education, particularly in low-income settings where remote learning is not feasible on a wide scale. In many settings, school closures were occurring even before the pandemic began, due to political or social instability. The pandemic has exacerbated these disruptions, leading UN Secretary-General António Guterres to warn of a “generational catastrophe” that could “undermine decades of progress...and exacerbate entrenched inequalities.”

The UN report highlights that these disruptions in education widen social disparities for vulnerable populations and reduce access to valuable resources typically provided by schools. Additionally, disruptions in education have downstream effects on national economies, as parents, particularly women, may not be able to return to work. The report provides high-level recommendations, including calling on stakeholders to plan extensively for how schooling can resume in ways that mitigate transmission risk, ensure sustainable financial support for educational systems, and re-imagine education to foster resilience and innovation.

The UN Educational, Scientific, and Cultural Organisation (UNESCO) published guidance that addresses strategies for catch-up learning to support students for whom educational disruptions have put their learning behind schedule. The recommendations include teaching only what must be learned at a certain grade level and utilizing “microschools” or “microlearning” in smaller groups. Appropriate strategies will likely be context- and setting-specific.

UNICEF and the WHO Joint Monitoring Programme published a report on the availability of drinking water, sanitation, and hygiene (WASH) resources in schools around the world. Substantial gaps remain in the availability of WASH resources, with only 57% of the world’s schools having basic hygiene services (including soap for handwashing) in 2019. As the world considers ways to reopen schools safely, careful consideration will need to be provided to ensure that students have the WASH resources they need to return safely, especially in light of enhanced hygiene and sanitization mechanisms needed to mitigate SARS-CoV-2 transmission risk. 

RWANDA POOL TESTING Rwanda has implemented a novel “pooled” testing strategy in order to make more efficient use of limited testing supplies and capacity. Like many countries, including the US, Rwanda is facing challenges to scaling up testing capacity. Pooled testing combines specimens from multiple people into a single sample for testing. If the pooled sample tests positive, then all individuals in that sample are tested individually. A single infected individual among the pool should result in a positive test, so a negative test means that nobody in that pool is positive. By testing multiple people with a single test and only testing individual specimens when necessary, pooled testing can increase testing capacity, as long as the expected prevalence of active infection is sufficiently low.

Rwanda is reportedly taking the pooled testing concept a step further by implementing an adaptive algorithm to further increase testing efficiency, developed by Dr. Wilfred Ndifon, “a mathematical epidemiologist and director of research at the African Institute for Mathematical Sciences Global Network” in Rwanda. Following a positive test in a pooled sample, the algorithm determines the most efficient way to conduct tests on smaller, overlapping pooled samples from among the affected individuals, rather than testing each specimen individually. This novel approach further reduces the number of tests required (and money needed to purchase the tests) as well as the time necessary to return accurate results without sacrificing accuracy. In a recent publication (preprint), Dr. Ndifon and his colleagues describe the algorithm and the potential impact on tests, time, and financial costs. Other African countries, including South Africa, have expressed interest in utilizing the algorithm.

UK SEROPREVALENCE Researchers at Imperial College London reported findings from a large seroprevalence study involving more than 100,000 participants in the UK, using a self-administered lateral flow immunoassay (LFIA) to detect SARS-CoV-2 antibodies. The LFIA selected for this study previously demonstrated sensitivity of 84.4% and specificity of 98.6% using finger-prick blood specimens. Analysis of multiple LFIAs, recently published in BMJ: Thorax, determined that these performance characteristics make this assay “suitable for seroprevalence studies.” The seroprevalence study, conducted under the UK’s REal-time Assessment of Community Transmission-2 (REACT-2) program, was implemented after the UK’s epidemic peak. It estimates the overall UK seroprevalence to be 6.0%, which translates to approximately 3.36 million adult infections through June 20. For comparison, the UK has reported 313,798 cumulative cases to date, which corresponds to approximately 0.6% of the total UK adult population.

Seroprevalence was found to be the highest among individuals aged 18-24 years (7.9%), compared to other age groups. The study identified racial and ethnic disparities as well, with seroprevalence of 17.3% and 11.9% among those of “Black or Asian (mainly South Asian) ethnicity,” respectively, compared to only 5.0% among Whites. Seroprevalence also varied geographically, with the highest rate reported in London (13.0%). Nearly one-third of those with detectable antibodies reported experiencing no symptoms. The study also reports seroprevalence among various professions, including essential workers and healthcare personnel.

These results align relatively closely with previous seroprevalence studies in the UK. A study conducted by the UK Biobank, published July 30, involved 20,000 participants. This study found that 7.1% of participants had detectable antibodies. Seropositivity was higher among individuals under 30 years old (10.8%), racial and ethnic minorities (11.3% among Black participants and 9.0% among South Asian participants), and individuals living in London (10.4%).

SPAIN RESURGENCE Spain faced one of the most severe COVID-19 epidemics early in the pandemic. After extended “lockdowns” brought community transmission under control, Spain is reporting increasing incidence that could potentially signal the beginning of a “second wave” of transmission. In May and June, Spain reported only 1 day for which daily incidence exceeded 1,000 new cases. Over the last 2 weeks, however, Spain reported 3 days with more than 5,000 new cases. Last week, The Lancet published a commentary that called for an independent investigation into Spain’s handling of the COVID-19 epidemic, including at both the national and regional levels, in order to identify lessons with respect to governmental decision-making, healthcare and public health operations, and the public’s response that could inform efforts to prepare for subsequent waves of transmission. The authors stressed that this investigation should not be an effort to assign blame, but rather, an opportunity to identify and strengthen weaknesses in the system. 

“CONTAMINATED” FOOD PRODUCTS Chinese officials issued a warning that frozen chicken wings originating in Brazil and frozen shrimp originating in Ecuador tested positive for SARS-CoV-2. Following the positive tests, Chinese officials conducted contact tracing to identify individuals who may have come into contact with the frozen food products, and no one has yet tested positive. Additionally, authorities disinfected the area where the products were stored. The positive tests were reportedly from “the surface of frozen chicken wings” and “the packaging of frozen shrimp,” but it is unclear when or where these items were originally contaminated. Additionally, it is unclear if the virus detected on the products was viable (ie, capable of infecting a human) or if the test detected dead virus or portions of dead virus.

While scientists and health officials—including at the US CDC, US FDA, and WHO—believe that the risk of foodborne transmission is low, the announcement prompted concerns that food packaging could potentially play a role in virus transmission. Fomite transmission is possible, particularly if people touch their face without washing their hands thoroughly, but it is not expected to be the primary mode of transmission. Handling food packaging that may contain virus particles is currently not expected to be a substantial contributor to SARS-CoV-2 transmission; however, it remains important to wash hands thoroughly and regularly, including before eating or handling food. The US FDA has issued guidance on safe food handling in the context of COVID-19. In response to these reports, senior WHO officials—including Dr. Mike Ryan, Executive Director of the WHO Health Emergencies Programme—emphasized that “people should not fear food or food packaging or the processing or delivery of food.”

US COVID-19 REPORTING Last month, the US government announced the creation of a new COVID-19 reporting system for hospitals, which would require direct reporting to the US Department of Health and Human Services (HHS), rather than via state health departments and the US CDC. The effort was initiated to expedite the provision of relevant COVID-19 data to the federal task force; however, numerous health officials and experts called attention to the risk of bypassing the CDC and added burden on hospitals. Multiple reports indicate that data reporting from the federal level has lagged significantly since transitioning to the new system, which is hindering state and local officials from implementing effective response activities and policies. In fact, some key data are lagging by more than a week, which impairs the ability to understand the current state of SARS-CoV-2 transmission and the epidemic’s impact on health systems. HHS officials argue that the delays are an inevitable part of quality control checks to ensure the system is working properly and that the data reported provides more detail and includes more facilities than the previous method, providing improved awareness of the current COVID-19 situation. A myriad of experts and government officials have emphasized the potential damage caused by an interruption in the availability of critical data, particularly as the country attempts to gain control of a major resurgence in transmission.

The New York Times published an open letter from more than 30 current and former members of the federal Healthcare Infection Control Practices Advisory Committee (HICPAC), which cites the dangers of the new HHS COVID-19 reporting system. The authors argue that the transition endangers the integrity of national COVID-19 data and that new reporting requirements put increased stress on the national healthcare system. They also note that the CDC maintains robust and established disease reporting systems, including the National Healthcare Safety Network (NHSN) that was previously used to report COVID-19 data, and that the new system is unnecessary. The letter was reportedly written as an unpublished document following the announcement of the new reporting system last month, but it was only made public earlier this week. 

US SCHOOLS Many school systems in the US have begun their transition to the 2020-21 school year, with some moving forward with in-person classes and others adopting virtual/remote or hybrid models. The results have been mixed, with some in-person attempts leading to sizable exposures. Reportedly, more than 2,000 individuals—including students, teachers, and other staff—across multiple states have been quarantined following exposures at schools, and at least 230 positive cases have been identified. In numerous instances, schools that resumed in-person classes have been forced to shift to virtual/remote models following the detection of COVID-19 cases. In one example, Cherokee County School District—outside of Atlanta, Georgia—has reportedly quarantined at least 1,193 individuals after starting the school year with in-person classes, and multiple schools in the district suspended in-person classes after opening for less than a week. In other examples, schools have provided parents and the students the option of attending in-person or remote classes, and COVID-19 cases detected in the schools have reportedly driven some students to shift from in-person to remote classes. Most schools are just starting to resume classes, so any effect on incidence, within schools or in the community, may not be evident for several more weeks.

As these types of reports continue to raise questions about the feasibility of having safe, in-person schooling during the COVID-19 pandemic, some school districts are beginning to invest in what seems like an inevitable continuation of distance learning that most schools utilized in the spring. In Harris County, Texas—which hosts one of the largest school districts in the country—the local government announced that it is investing US$32 million to increase access to computers and wifi for students in order to improve their ability to take part in virtual/remote learning options. The county will utilize emergency COVID-19 funding provided under the CARES Act to implement the program. The effort will reportedly provide more than 200,000 computers and 80,000 wifi hotspots.

US MASK MANDATE Yesterday, US Presidential candidate Joe Biden called on state governors to implement mask mandates nationwide to mitigate COVID-19 transmission risk. He framed mask use as an issue of individual responsibility instead of individual rights, noting that wearing a mask to protect others is the patriotic thing to do. Similarly, experts from Georgetown, Harvard, and Emory Universities published a commentary in JAMA calling for universal mask use in the US. They highlight the need for state governments to implement mask mandates, as a uniform approach is critical to combating a health emergency like COVID-19 that can “spill over to adjoining states [or] even the entire country.” Researchers have conducted a number of studies to model the impact of mask use, and several indicate that universal masking could potentially save tens of thousands of lives in the US over the course of several months. As of August 4, 35 states have implemented some form of mask mandate, although the details vary from state to state. Mandates have also been implemented by local governments where statewide mandates do not exist; however, some states, like Georgia, have prohibited local officials from instituting their own mask policies. Mask use is not wholly sufficient for containing the US epidemic, but it is a “minimally invasive” tool that nearly everyone can utilize to reduce transmission risk in the community.

NEW ZEALAND DOMESTIC TRANSMISSION New Zealand extended its Alert Level 3 “lockdown” of Auckland, the country’s most populous city, through August 26 as a result of an ongoing COVID-19 outbreak. Since the first case tested positive on Tuesday, New Zealand has identified 29 cases linked to the Auckland cluster, including 13 in the past 24 hours. One additional case is suspected to be linked to the cluster, and 38 individuals are currently under quarantine. An ongoing epidemiological investigation has identified cases with symptom onset as early as July 31, but it is not yet clear if this corresponds to the index case for this outbreak.

In addition to enhanced social distancing measures in Auckland, Alert Level 3 restricts travel into and out of the affected area, and checkpoints have been established around the city. The checkpoints are principally aimed at education and awareness efforts regarding the new restrictions; however, law enforcement officers are also screening travelers. While New Zealand had largely lifted all COVID-19-related social distancing measures in June, following the interruption of domestic transmission, it maintained travel restrictions and border screening for arriving travelers. Genomic analysis indicates that the current outbreak is not directly linked to the strain that previously circulated in New Zealand, suggesting that it could be the result of a recent importation, as opposed to ongoing undetected circulation; however, the investigation has not yet identified a link to international travel.

BRUSSELS MASK MANDATE Earlier this week, the city council of Brussels, Belgium’s capital city, mandated mask use in public spaces. The order was issued in the hopes of curbing a surge of COVID-19 cases over the past several weeks. The daily incidence in Brussels is approximately 50 cases per 100,000 population, which is more than double the highest national per capita daily incidence globally (Bahrain; 23.8 daily cases per 100,000 population). The city has approximately 1.2 million residents, and masks were previously only required in indoor or crowded public spaces.