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

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CORRECTION: We previously misstated that Auckland is the capital of New Zealand. Auckland is New Zealand’s most populous city, but Wellington is the capital.

EPI UPDATE The WHO COVID-19 Dashboard reports 21.99 million cases (213,391 new) and 775,893 deaths (4,644 new) as of 10:00am EDT on August 19.

The US CDC reported 5.42 million total cases (40,117 new) and 169,870 deaths (520 new). In total, 19 states (no change) are reporting more than 100,000 cases, including California with more than 600,000 cases; Florida and Texas more than 500,000 cases; New York more than 400,000; and Georgia and Illinois more than 200,000. For nearly 3 weeks, the US has averaged more than 1,000 deaths per day.

The US epidemic passed its second peak around July 24, and since then, the national COVID-19 incidence has decreased steadily. While many states are exhibiting similar trends, case counts in some states continue to climb. Hawai’i, which largely maintained low COVID-19 incidence for the first several months of the pandemic, has reported increasing incidence since mid-July, now up to more than 200 new cases per day. Illinois has reported steadily increasing daily incidence for the past 2 months, up to nearly 75% of its first peak. While it is only reporting approximately 100 new cases per day, South Dakota’s daily incidence has been slowly increasing since mid-to-late July, and it does not appear to be exhibiting any indication of slowing. Kansas appeared to reach a second peak in late July; however, incidence rebounded after approximately a week, and it set a new high daily incidence yesterday of nearly 500 new cases per day. Missouri and Wyoming exhibited a similar trend, peaking in late July before rebounding. The increase in daily incidence in Kentucky and North Dakota has tapered off to some degree, but it is still increasing in both states, potentially approaching a peak or plateau. A number of other states have largely plateaued over the past 2 weeks and continued to report elevated daily incidence.

The COVID Exit Strategy website still classifies 18 states as having “Uncontrolled Spread,” although the US as a whole recently improved from “Uncontrolled Spread” to “Trending Poorly.” Additionally, the site reports 16 states with increasing test positivity, including 2 with test positivity greater than 10%.* An additional 7 states are reporting test positivity greater than 10% percent and exhibiting a flat or decreasing trend.
*In addition to the 2 states reporting both increasing test positivity and test positivity greater than 10%, the data for Washington indicates 100% test positivity, which may not accurately reflect the current state of testing.

With the peak in national daily incidence occurring approximately 3 weeks ago, we expect to see an associated decrease in daily mortality in the near future. Mortality tends to lag several weeks behind incidence, as it takes time for COVID-19 patients to progress through the course of disease. Nationally, the US continues to average more than 1,000 new deaths per day. Multiple states are reporting overall increases in daily mortality, including several states that were severely affected during the summer resurgence. Notably, Georgia reported its record high mortality (133 deaths) on August 11, and it continues to report more than 60 deaths per day. The Tennessee Department of Health does not report or display average daily mortality, but the weekly average reported by STAT News shows the state remaining at its record high of 22 deaths per day. California’s COVID-19 mortality has plateaued over the past week or so, remaining relatively steady at approximately 130 deaths per day. Florida’s average mortality has fluctuated over the past 2 weeks, but it remains elevated at approximately 170 deaths per day. Texas reported a peak in mortality in early August (largely driven by a spike of more than 1,000 deaths reported on August 6), and mortality decreased substantially since then; however, Texas continues to report 170-200 deaths per day.

The Johns Hopkins CSSE dashboard reported 5.50 million US cases and 172,109 deaths as of 1:30pm EDT on August 19.

The challenge of resuming classes continues across the US, at all levels of education. As more schools resume classes, particularly those using in-person or hybrid models, school districts and states are reporting more COVID-19 cases linked to schools. One teacher in Kansas started compiling reports of COVID-19 cases in K-12 schools as a local resource for her school, but when the document circulated more widely, she received hundreds of reports from across the country. Today, 35 people are supporting the effort to document reports of COVID-19 among US students, teachers, and other school staff, and the Google Sheet includes data from all 50 states, plus Washington, DC, and Guam.

A school district outside Phoenix, Arizona, was forced to cancel plans to resume in-person classes this week due to a “sickout” organized by teachers and staff. The school district’s Governing Board recently voted to start the school year with in-person classes, which prompted “a high volume of staff absences for Monday citing health and safety concerns.” Facing the prospect of “insufficient staffing levels” when classes were scheduled to resume this week, the school district elected to postpone in-person classes. Notably, no school districts in Arizona have met the benchmarks established by the Arizona Department of Health Services in order to resume in-person or hybrid classes (as of August 13).

The Los Angeles Unified School District (California), the country’s second-largest school district, announced its own SARS-CoV-2 testing program to support in-person classes this fall. The program reportedly aims to administer nearly 800,000 tests to students and staff over a period of weeks or months, in advance of schools resuming in-person instruction. The school district will implement its own testing program in order to ensure sufficient testing capacity, which might not be available under existing local public health testing efforts. The program is expected to cost US$150 million, the equivalent of $300 per student across the entire school district. The school system views widespread and routine testing as a key to eventually being able to resume in-person classes.

By this point, K-12 school systems nationwide have largely determined how they intend to resume instruction in the fall, and we are starting to see the early impact of those decisions. Tomorrow—Thursday, August 20—at 12:15pm EDT, the Johns Hopkins University Bloomberg Schools of Public Health will host a webcast to address the various scenarios that community and elected leaders, teachers, parents, and students may face in the coming months, depending on the US epidemic’s trajectory. The webcast will include experts from both the Bloomberg School of Public Health—including Center for Health Security Senior Scholar Dr. Jennifer Nuzzo—and the Johns Hopkins School of Education. The discussion will include a broad scope of topics, such as how to react to cases in schools offering in-person classes, manage stress and concern among students amid uncertainty during the coming school year, and plan ahead for potential changes.

Numerous colleges and universities are also facing challenges as students return to campus. In the short time since many schools started their school year, numerous colleges and universities have reported cases, clusters, and larger outbreaks of COVID-19. At the University of North Carolina (UNC), the Chapel Hill campus was forced to abruptly cancel in-person classes after identifying at least 135 cases since the start of fall classes, including multiple clusters, and an associated increase in test positivity from 2.8% to 13.6%. While classes transitioned to online only, some space at on-campus residential facilities will remain open to support students, including international students, who may not have other options available to them. The University of Notre Dame (Indiana) also suspended in-person classes, following 147 cases detected since August 3.

In order to support resuming in-person classes, colleges and universities have implemented a variety of risk mitigation measures, including testing programs; however, most schools do not have the ability to enforce school policies off campus. For example, videos and photos of off-campus parties and local bars—including at schools in Alabama, Georgia, and Oklahoma—show dozens or hundreds of students present, the majority of whom do not appear to be practicing appropriate physical distancing or wearing masks. Elected and university officials have been quick to admonish students for not adhering to public health recommendations; however, none appeared to take any responsibility for the decision to resume in-person classes in the first place, as noted by the Editorial Board of UNC student newspaper, The Daily Tar Heel.

In addition to traditional colleges and universities, the US services academies—the US Military (West Point), Naval, Air Force, Coast Guard, and Merchant Marine Academies—resumed activity in time for fall classes, including the traditional summer orientation period for new Cadets and Midshipmen. The service academies implemented a variety of strict measures, including mandatory mask use and physical distancing, routine testing, and staggered arrival times for students (complete with quarantine periods). These student populations and environments are much different than a traditional campus setting (e.g., students are used to wearing prescribed uniforms and following orders); however, there may be lessons that other schools can draw for their own students.

US ELECTION & VOTING SAFETY As the US approaches the 2020 election, in the midst of the COVID-19 pandemic, traditional voting practices are raising concerns about increased transmission risk, particularly for in-person voting. A report published by the RAND Corporation assessed state voting processes in preparation for the upcoming election. The researchers identified flexible voter registration policies, remote voting, and early voting among the key tools in mitigating exposure risk for voters and election workers. In particular, the researchers highlighted options for remote or automatic registration and no-excuse mail-in voting as particularly important in terms of reducing in-person contact that can facilitate SARS-CoV-2 transmission. Twelve (12) states and Washington, DC, have implemented automatic registration, early voting, and no-excuse mail-in voting for this year’s election, while 9 states have implemented none of these options. In a companion report, RAND outlines key factors that policymakers and election officials must balance in order to promote voter safety and election integrity, including protecting the health of election workers and ensuring equitable access for all eligible voters. In particular, the report highlights the increased risk that in-person voting can pose for higher-risk individuals (eg, older individuals and those with underlying health conditions), but also that increased absentee or mail-in voting can pose logistical challenges compared to previous elections.

Similarly, the Brennan Center and the Infectious Diseases Society of America issued guidance for mitigating COVID-19 risk for voters for in-person voting. Physical distancing and associated signage, selection of well-ventilated polling locations, mask use, and limiting unnecessary persons in the facility can help reduce contact at polling locations that can facilitate transmission. Compared to previous elections, these efforts may require additional resources in order to implement, so advance planning is recommended.

US TESTING VOLUME & DELAYS Even as the US moves further away from its second peak in daily COVID-19 incidence, the country struggles to conduct SARS-CoV-2 testing. The peak in daily testing occurred in late July, around the same time as the peak daily incidence, and both have decreased, in relative tandem, since then. Some health officials have expressed concern about the decrease in testing volume, particularly in states with increasing test positivity. Notably, national test positivity remains elevated (ie, greater than 5%), but it has been decreasing since late July as well. This indicates that testing volume is beginning to catch up with community transmission, at least at the national level. The situation varies considerably at the state level, however, and multiple states are reporting increasing test positivity, including 13 that already exceed 5%. Notably, Mississippi is currently reporting test positivity greater than 20% and increasing. While the test positivity trend appears encouraging at the national level, testing volume needs to increase in multiple states in order to better capture the scale of community transmission.

In addition to testing volume, there are growing concerns about delays in obtaining test results. A survey conducted by CNBC and Dynata, conducted July 30-August 10, found that nearly 40% of COVID-19 tests took more than 3 days to process. By the time these test results are returned, affected individuals may be past their infectious period, which largely negates the value of the test in terms of limiting transmission risk. The turnaround time varies widely by state, ranging from 2 to 5.5 days on average, but there are reports of some individuals waiting a week or longer. The situation has improved dramatically since mid-July, when the national average was greater than 7 days; however, rapid results (or at least timely results) are critical to containing the epidemic. Additionally, individuals who get tested are recommended to keep themselves isolated until they receive their test results in order to mitigate transmission risk for those who are positive, and longer wait times may make it difficult for individuals to comply with this guidance or less likely that they will choose to do so.

Beyond scaling up testing capacity, which has been an ongoing struggle since the onset of the US epidemic, there are other options to increase testing volume. Some states, health systems, and laboratory networks have attempted to implement pooled testing strategies as a way to increase testing capacity, but these efforts have largely been ineffective due, in part, to increasing prevalence of SARS-CoV-2 infection in the community. As the proportion of infected specimens increases, pooled strategies are less effective at decreasing the number of tests required. New York is a notable exception, as it has maintained low levels of transmission since it contained the “first wave” of COVID-19. Additionally, a group of professional organizations, headlined by the American Medical Association, called for prioritizing some specimens for testing, including patients exhibiting symptoms and those with known exposure to a COVID-19 case. While this could decrease turnaround time for the priority specimens, it could potentially increase wait times for others. The groups argue that increased testing demand has been driven by asymptomatic individuals with no known exposure and that existing capacity should be directed toward “those with a medically-indicated need.” Additionally, as we covered previously, the US FDA recently issued an Emergency Use Authorization for a saliva-based test that could be a useful tool for screening purposes, which could potentially be directed at individuals without “medically-indicated need,” including those who are returning to work or school, and free up more traditional diagnostic test capacity.

DEMOCRATIC NATIONAL CONVENTION The Democratic National Convention, which traditionally nominates the Democratic Party's candidate for the US presidential election, is taking place remotely/virtually this year. The Democratic and Republican National Conventions typically take place in person and draw tens of thousands of attendees to the host city for several days; however, both conventions are largely forgoing in-person events for the first time in modern history. In addition to a series of video or live-streamed speeches, the Democratic National Convention utilized remote voting by delegates, who nominated Joe Biden as the presidential candidate. The Republican National Convention is expected to use a similar virtual format for speakers, or possibly multiple smaller satellite events, when it convenes next week, but it intends to host delegates in Charlotte, North Carolina, in order to vote in person for the Republican presidential candidate, presumably President Donald Trump.

VACCINE ALLOCATION In support of planning efforts for future vaccination campaigns, the Johns Hopkins Center for Health Security published a framework for vaccine allocation and distribution in the US. The report, published today, focuses on challenges early in the vaccination campaign that stem from limited availability as production capacity increases. There will inevitably be initial vaccine shortages, so it will be critical to identify who will be eligible for the first available doses in advance of the start of a vaccination campaign. The researchers included a variety of relevant factors in the development of this framework, including “medical risk, public health, ethics and equity, economic impact, and logistics” with the dual aim of mitigating harm and maintaining societal function. This is a complex challenge with no single correct answer, and other organizations may reach different conclusions, even with the same considerations.

The report outlines numerous “candidate groups that should be given serious consideration” for priority access, with the highest priority groups divided between 2 tiers. In Tier 1, the highest priority, the researchers included 3 groups of individuals: (1) those who are “most essential” to implementing the COVID-19 response, including frontline healthcare workers caring for COVID-19 patients and “vaccine manufacturing and supply chain personnel”; (2) “those at the greatest risk of severe disease and death,” such as individuals aged 65 and older and those with certain underlying health conditions; and (3) those “most essential to maintaining core societal functions,” including public transportation and food supply personnel and teachers. Tier 2 includes other individuals who support the provision of health care and maintenance of core societal functions, those who may have difficulty accessing healthcare in the event they are infected, and others who may be at elevated risk of infection (eg, due to living or working conditions). The report also addresses historical efforts to develop and implement priority groups for vaccination programs as well as important considerations with respect to obtaining input and support from the public, developing culturally competent prioritization protocols, and communicating the plan to the community.

CONVALESCENT PLASMA The use of convalescent plasma to treat COVID-19 patients has been discussed and evaluated since the onset of the pandemic, but it has been difficult to fully assess evidence of its efficacy. Antibodies found in convalescent plasma obtained from COVID-19 survivors could provide a meaningful boost to the immune systems of hospitalized patients, but the extent to which this occurs remains uncertain. To examine this possibility, the Mayo Clinic enrolled more than 35,000 COVID-19 patients in an observational study, the results of which are beginning to be published. The study (preprint) found that patients who received convalescent plasma transfusions within 3 days of diagnosis exhibited improved mortality after 7 days over those who received the treatment 4 days or more after diagnosis—8.7% compared to 11.9%. The results were statistically significant, but there was no control group against which to compare the results. The researchers also observed that patients who received plasma with higher antibody concentrations exhibited a statistically significant improvement in 7-day mortality over patients receiving plasma with lower antibody concentrations—8.9% for high antibody levels, compared to 11.6% for medium and 13.7% for low levels.

While these results are promising, the lack of a control group significantly limits the strength of conclusions that can be drawn from this study. Unlike in a randomized control trial, which is designed to evaluate the direct impact of a certain treatment on patient outcomes, this observational study had several uncontrolled factors, including differences in clinical care and disease severity. The use of convalescent plasma under “expanded access” protocols has made the treatment more widely available and provided increased data; however, it has made the development and enrollment for randomized control trials more difficult. While there are some randomized control trials ongoing for COVID-19 convalescent plasma, some researchers maintain that it is too soon for the US FDA to determine whether to grant an EUA to the treatment based on the Mayo Clinic’s study data alone. According to a report by The New York Times, the FDA was “preparing to issue and emergency use authorization” for convalescent plasma, but the decision was postponed while regulatory officials evaluate data from the Mayo Clinic study.