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

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EPI UPDATE The WHO COVID-19 Dashboard reports 22.49 million cases (236,093 new) and 788,503 deaths (6,047 new) as of 4:30am EDT on August 21.

Globally, there are 7 countries currently reporting test positivity of 20% or greater. As we have discussed previously, high test positivity can indicate that testing capacity or volume may not be sufficient to fully capture the scale of community transmission. The WHO previously set 5% test positivity as one of the key benchmarks for determining if countries have their COVID-19 epidemic under control. Five (5) of the 7 countries in the top tier are in the Central and South America region: Argentina (57.9%), Bolivia (44.6%), Colombia (32.4%), Mexico (63.7%), and Panama (34.8%). The remaining 2 countries are in Asia (including the Eastern Mediterranean region): Bangladesh (20.5%) and Oman (38.9%)*. A number of other countries, spread across all continents, are reporting test positivity greater than 10%. Many countries—including some current hotspots (eg, Brazil, Peru, Suriname), China, and most countries in Africa—do not regularly report test positivity, so there are likely others that are facing similar challenges.
*Most recently reported July 30.

At the continent level, Asia now represents the most daily incidence, surpassing North America in early July and South America in early August. Both Asia and South America are continuing to report increasing incidence, whereas North America has been on the decline since late July. Notably, Asia’s ascendance is driven primarily by the epidemic in India, and North America’s decline is due in large part to decreasing incidence in the US. Africa’s daily incidence previously exceeded that of Europe; however, Africa’s epidemic has been on the decline since early August, while Europe’s daily incidence is rebounding. Africa’s recent trend is largely driven by South Africa’s epidemic, and numerous countries in Europe are reporting increasing daily incidence. On a per capita basis, South America’s daily incidence (172 daily cases per million population) is considerably higher than all other continents, including more than 70% higher than #2 North America (99). And North America is reporting at least 3-4 times the per capita daily incidence as the remaining continents. Europe is #3 (31), and is Asia #4 (20), followed by Oceania and Africa, which are both reporting fewer than 10 new daily cases per million population.

The US CDC reported 5.51 million total cases (46,500 new) and 172,416 deaths (1,404 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 with more than 500,000; New York with more than 400,000; and Georgia and Illinois with more than 200,000. For nearly 3 weeks, the US continues to average more than 1,000 deaths per day.

Several US territories are exhibiting high per capita daily incidence. The US Virgin Islands is reporting 226 new daily cases per million population, which would be #3 globally, between the Maldives and Colombia. Puerto Rico is reporting 185 new daily cases per million population, which would put it at #7 globally in terms of per capita daily incidence, falling between Brazil and Israel. Guam is also reporting 192 new daily cases per million population, which would be #4 globally; however, this appears to be driven largely by a spike of 105 new cases reported today, more than double its previous record daily incidence.

The Johns Hopkins CSSE dashboard reported 5.60 million US cases and 174,647 deaths as of 1:30pm EDT on August 21.

SOUTH KOREA South Korea’s COVID-19 epidemic continues to grow, with the Korean CDC reporting 315 new domestic cases today. Additionally, 2,241 individuals are currently under quarantine, and South Korea’s Vice Health Minister, Kim Gang-lip, described the situation as “grave.” More than 50 of the new cases are associated with the Sarang Jeil Church in Seoul, a place of worship that has recently participated in large protests against South Korean President Moon Jae-in. The emergence of large churches as drivers of transmission in South Korea, both early in the epidemic and the current resurgence, has driven division in South Korean society. In response to epidemic response measures, including investigations and orders to suspend gatherings, as well as public criticism and stigmatization, some congregations have accused the government of manipulating COVID-19 data to reflect poorly on the churches. News media have reported that misinformation, including conspiracy theories, are exacerbating divisions as the COVID-19 response becomes increasingly politicized.

In addition to these churches, South Korea has reported COVID-19 clusters and outbreaks in a number of other settings. One outbreak, in particular, has been linked to a Starbucks cafe near Seoul, which has prompted the government to strengthen restrictions on cafes and restaurants. As of August 20, 58 cases have been linked to the cafe. Case investigations have identified 4 index patients who infected at least 25 other patrons, and 29 secondary cases have been identified as well. The investigation is ongoing, but health officials reportedly indicated that the index cases were not wearing masks and that the cafe did not have sufficient ventilation. Other outbreak or cluster settings include a variety of businesses, such as life insurance call centers, as well as hospitals and nursing homes.

FRANCE MANDATES MASKS The French Ministry of Labor, Employment, and Integration recently announced a new mandate requiring that individuals wear masks while at work. The move makes France one of the only countries in the world to require universal mask usage in all workplaces. SARS-CoV-2 transmission in the workplace is a major concern as countries weigh decisions regarding the ability to resume in-person work. Many countries around the world have established some sort of mask mandate or recommendation, with wide variance.

Earlier this week, JAMA published a commentary that addresses the effectiveness of employees wearing face shields in mitigating transmission risk among community health workers. The researchers describe a small study of COVID-19 incidence among a group of community health workers before and after implementing face shield use. The study involved 62 community health workers in Chennai, India, who provided counseling for individuals and households in the community. Prior to implementing face shield use, the workers wore surgical masks and adhered to other risk mitigation procedures. Over a period of 9 days, 12 health workers were infected. Following these infections, the health workers wore face shields in addition to their masks and existing risk mitigation protocols. Over a 41-day period after instituting this protocol, zero of the remaining 50 health workers tested positive for SARS-CoV-2. Considering the risk of transmission for community health workers, who have close contact with numerous individuals and households on a daily basis, these results offer support for potential effectiveness of face shields in combination with masks in preventing the spread of COVID-19.

VENEZUELA The Venezuelan government has received criticism for extreme measures taken to enforce COVID-19 interventions. Multiple reports have identified a variety of inhumane punishments—including physical abuse, forced exercise, and prolonged detainment—for those caught violating social distancing restrictions or those suspected of being infected. The country’s government has reportedly referred to individuals who come into contact with COVID-19 as “bioterrorists” and used security forces to enforce strict measures. Additionally, the government has imposed strict measures for returning migrants, forcing individuals to remain in isolation, potentially for weeks, as they attempt to cross the border back into Venezuela. Despite these hard-line efforts, opposition leader Juan Guaidó announced earlier this week that Venezuela’s daily incidence could soon exceed the national testing capacity. This could result in a perceived “flattening” of the epi curve; however, it would be due to insufficient testing capacity rather than decreased transmission, which could provide a false sense of confidence that could lead to further increases in transmission. The US government announced that it will unfreeze some funds for Mr. Guaidó—previously frozen under sanctions imposed on Venezuela—to establish a system to financially support medical professionals in the country. The human rights advocacy group, Amnesty International, recently released a report outlining the failure of Venezuelan authorities to protect their health care professionals, including reprisals against whistleblowers or those who have spoken out against the government’s response. 

INDIA SEROPREVALENCE Indian health officials recently published the results of several seroprevalence studies, which found widespread transmission compared to studies previously conducted in other countries. In New Delhi, a new seroprevalence survey suggests that more than 29% of the city’s population may have been exposed to SARS-CoV-2. A previous study conducted in July by India’s National CDC estimated that 23.5% of the New Delhi population was seropositive. The state of Delhi is the fifth most severely affected state in India. In the city of Pune, researchers from the Indian Institute of Science Education and Research conducted a seroprevalence study involving more than 1,600 participants. The researchers estimate that more than 50% of the entire city population is seropositive, including more than 65% in one part of the city. Pune is in Maharashtra, the most severely affected state in India, with more than 450,000 reported cases. If these results are accurate, it could mean millions of additional cases in India. India is currently reporting the highest daily incidence of any country, and it is #3 globally in terms of cumulative incidence, behind only the US and Brazil. Serological studies in other countries have reported much lower rates of seropositivity, typically less than 15% and often less than 10%. Some experts have suggested that herd immunity could be reached at 50-70% seropositivity; however, there is considerable uncertainty around that number, and it could vary from population to population, depending on a number of complex factors.

VACCINE TRIAL IN SOUTH AFRICA US-based pharmaceutical company Novavax announced that it will conduct a Phase 2b clinical trial for its candidate vaccine in South Africa. The Bill and Melinda Gates Foundation provided funding for the trial, which will include 2 cohorts, a larger group of healthy adults and a smaller group of HIV-positive adults, that will total more than 2,600 participants. Pending successful results from this and other clinical trials, Novavax had previously signed a partnership with The Serum Institute of India to produce the vaccine for countries in Africa. African countries have reported more than 1 million cumulative cases, but recent data suggest that the spread of COVID-19 has slowed. South Africa has reported the highest cumulative incidence in Africa (and #5 globally) at just under 600,000 cases; however, South Africa has reported a steady decrease in daily incidence over the past several weeks.

AUSTRALIA VACCINE PURCHASE Australian Prime Minister Scott Morrison and the Ministers of Health and Industry, Science, and Technology jointly announced that the Australian government finalized an agreement with pharmaceutical manufacturer AstraZeneca to procure enough early doses of its SARS-COV-2 vaccine for every Australian. If AstraZeneca’s vaccine candidate (in collaboration with Oxford University [UK]) successfully demonstrates efficacy in Phase 3 clinical trials, the Australian Government will have priority access to enough vaccine for 25 million Australians, which will be administered free of charge to the public. In addition to the new purchase agreement, the Australian government has invested AU$333 million (~US$238 million) to support medical countermeasures (MCMs) development for COVID-19. Australia also unveiled its new national vaccination and treatment strategy, which emphasizes MCM research and development, MCM purchasing and manufacturing, international partnerships to improve access to MCMs, regulation and safety through clinical trials and oversight, and vaccine administration and monitoring programs. In addition to the agreement with Australia, AstraZeneca has finalized similar deals with other countries, including the US and the whole of the EU. In light of these massive contracts, some on the order of hundreds of millions of doses, have driven WHO Director-General Tedros Adhanom Ghebreyesus to call on national governments to avoid “vaccine nationalism” in order to ensure equitable access for affected populations around the world, including countries that cannot compete financially with larger, high-income countries in order to procure their own doses from among the earliest supply.

UK DISMANTLES PUBLIC HEALTH ENGLAND The UK government recently announced that its leading public health agency, Public Health England (PHE), is being dismantled and replaced with a National Institute for Health Protection that is reportedly to be modeled after the Robert Koch Institute in Germany. This new institute will merge PHE response efforts with the National Health Service Test and Trace program and the Joint Biosecurity Centre, and it is expected to formally start operations in early 2021. The decision was made after news that Health Secretary Matt Hancock and other members of UK Prime Minister Boris Johnson’s administration were displeased with how PHE handled SARS-CoV-2 testing and contact tracing efforts. The decision has been met with widespread criticism among news media and public health stakeholders that see it as an attempt by the British government to shift blame for challenges with the country’s COVID-19 response. While the National Institute for Health Protection will reportedly focus principally on addressing the needs of the UK COVID-19 epidemic and future health emergencies, it is unclear how PHE’s work on other public health issues, such as obesity and smoking, will be handled after the transition. 

CLINICAL TRIALS IN CHILDREN & PREGNANT WOMEN As vaccine developers rapidly conduct clinical trials for candidate SARS-CoV-2 vaccines, researchers are paying increased attention to priority high-risk populations. Clinical trials have generally focused on testing vaccine safety and efficacy in healthy adults, and have largely excluded children and pregnant women, among other populations. To date, AstraZeneca is the only manufacturer contracted to provide vaccines to the American public that is conducting clinical trials in children, according to a report by STAT News. While children may not be among the highest-priority populations early in a mass vaccination campaign because of their relatively lower risk of severe disease and death, they may be a priority in terms of resuming in-person schooling. To our knowledge, no clinical trials have included pregnant women or those who are breastfeeding. The inclusion of pregnant women, and other high-risk or vulnerable populations, in vaccine clinical trials, particularly early stage trials, has been a longstanding debate, due to concerns about the potential for adverse events. There has been a push in recent years from researchers, bioethicists, and medical professionals to open clinical trials to pregnant women and support their involvement, as it can be crucial for pregnant women to be immunized to protect themselves and the fetus, particularly for emerging pathogens like Zika virus and Ebolavirus that could disproportionately affect pregnant women or the fetus.

WHO UPDATES QUARANTINE GUIDANCE The WHO published an update to its COVID-19 quarantine guidance, specifically for arriving travelers and individuals with known exposure to SARS-CoV-2. The previous iteration of the guidance was published on March 19, and the update includes additional information on maintaining sufficient ventilation in quarantine areas, including standards for minimum ventilation rate and airflow pattern and direction, and providing care for children under quarantine—as well as other updates based on information and analysis since the previous version was published. Notably, the guidance recommends quarantining children at home when possible, and with a parent or caretaker who is at lower risk for severe COVID-19 disease and death. Risk assessment for children under quarantine should be conducted in a holistic manner, accounting for a variety of factors beyond just COVID-19 risk, such as mental wellbeing.

LONG-TERM EFFECTS Ed Yong, writing for The Atlantic, continued his in-depth investigation of the long-term health effects of COVID-19. He previously covered COVID-19 “long-haulers”—recovered COVID-19 patients who experience symptoms long after their recovery from the acute stage of the disease—in June. He notes that many of the “long-haulers” are not those typically associated with elevated risk of severe COVID-19 disease or death. Many of those with longer-term health effects are younger, with an average age in the 40s, and “most were formerly fit and healthy.” Additionally, these long-term symptoms are more often observed in women. Notably, a substantial portion of “long-haulers” did not necessarily experience severe disease during the acute infection. As the primary driver of transmission, both in the US and globally, shifts toward younger individuals, the risk of prolonged health effects is concerning. Compared to acute COVID-19 disease, the longer-term health effects have not been as well studied or characterized, and further research will be required as more people are affected, in particular to provide a more accurate picture of the total burden of COVID-19. Long-term health effects could have a major impact on societies’ ability to recover from the pandemic, even after transmission is brought under control.