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 23.31 million cases (253,963 new) and 806,410 deaths (5,501 new) as of 8:30am EDT on August 24.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. India: 65,526 new cases per day (+3,728)
2. USA: 42,763 (-8,438)
3. Brazil: 37,941 (-5,598)
4. Colombia: 10,402 (-1,148)
5. Peru: 8,340 (+65)
6. Argentina: 6,815 (+59)
7. Spain: 6,177* (+2,113; ↑ 3)
8. Mexico: 5,429 (-554; ↓ 1)
9. Russia: 4,842 (-203; ↓ 1)
10. Philippines: 4,050 (-427; ↓ 1)
*Spain’s average daily incidence is not reported for today; this value corresponds to the previous day’s average. Spain’s average daily incidence has not changed since August 21.

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Maldives: 263 new daily cases per million population (+66; ↑ 5)
2. Peru: 253 (+2; ↓ 1)
3. Bahrain: 219 (+16; ↑ 2)
4. Colombia: 204 (-23; ↓ 1)
5. Brazil: 179 (-26; ↓ 1)
6. Israel: 173 (+13; ↑ 1)
7. Panama: 164 (-83; ↓ 5)
8. Bahamas: 163 (+12; ↑ 2)
9. Argentina: 151 (+2; new)
10. Costa Rica: 150 (+5; new)

India reported its highest average daily incidence to date—65,526 new cases—and it remains on track to surpass the global record for global average incidence, which is currently held by the US (67,374 on July 23). The US and Suriname fell out of the top 10 in terms of per capita daily incidence and were replaced by Argentina and Costa Rica. The Maldives and Peru are the only 2 countries currently averaging more than 250 daily cases per million population.

The US CDC reported 5.64 million total cases (45,265 new) and 175,651 deaths (1,006 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. The US is averaging fewer than 1,000 deaths per day for the first time since July 27.

Several US territories are exhibiting extremely high per capita daily incidence. The US Virgin Islands is reporting 332 new daily cases per million population, which would be #1 globally. Puerto Rico is reporting 194 new daily cases per million population, which would put it at #5 globally, falling between Colombia and Brazil. Guam is also reporting 222 new daily cases per million population, which would be #3 globally; however, this appears to be driven largely by a spike of 105 new cases reported on August 21 that resulted in Guam’s daily incidence increasing by a factor of 4 in just one week. Guam’s daily incidence does appear to be increasing, but potentially not quite at this rate over the longer term.

The Johns Hopkins CSSE dashboard reported 5.72 million US cases and 176,978 deaths as of 1:30pm EDT on August 24.

CONVALESCENT PLASMA The US FDA issued an Emergency Use Authorization (EUA) for convalescent plasma as a COVID-19 treatment. Plasma is a component of blood that contains antibodies, and the plasma from individuals who recover from SARS-CoV-2 could be administered to COVID-19 patients in order to boost immune response. Prior to the EUA, some patients were able access convalescent plasma through compassionate use programs and randomized clinical trials, but the EUA will make the treatment more broadly available to COVID-19 patients. 

The FDA previously postponed issuing the EUA to allow for further analysis of recently published clinical trial data, and several senior health experts at the NIH, including Dr. Anthony Fauci and Dr. Francis Collins, indicated that more robust clinical data was needed in order to better understand the potential benefits. As we covered previously, the study in question was conducted by the Mayo Clinic. While the study included 35,000 participants and provided promising results, it did not involve a placebo control group, which complicates efforts to interpret the findings and draw conclusions about the treatment’s efficacy. Previous studies have demonstrated the treatment’s safety in COVID-19 patients.

Numerous health experts have expressed concern about the data underlying the EUA as well as statements made in the EUA announcement and by senior US government officials, including Secretary of Health and Human Services Dr. Alex Azar. Both the EUA press release and Secretary Azar indicate that convalescent plasma reduces mortality by 35%; however, it is unclear exactly what these statements are based on. Several experts have asserted that these statements overestimate or misrepresent the drug’s effect. Rather than a groundbreaking treatment, it may be more likely that convalescent plasma provides incremental benefit to COVID-19 patients. Additionally, some experts have expressed concern that the decision could have been politically motivated, particularly in light of recent comments by President Donald Trump, who suggested that the FDA was delaying trials and approval for candidate treatments and vaccines until after the upcoming presidential election. To some, the circumstances surrounding the convalescent plasma EUA are reminiscent of the EUA that the FDA issued for hydroxychloroquine, which was widely promoted by President Trump. Ultimately, the FDA rescinded the EUA after additional data indicated that it was not effective as a COVID-19 treatment.

VACCINE USE China reportedly announced that it has been administering its novel SARS-CoV-2 vaccine to certain high-risk populations since late July, raising concerns about the use of a vaccine in the general public prior to the completion of robust clinical trials. If true, this would make China the first country to use a SARS-CoV-2 vaccine in the public, beating Russia’s effort to deploy its Sputnik V vaccine by at least several weeks. China previously announced that it would administer the vaccine to its military, and it is unclear why China waited several weeks before publicly announcing the vaccination program. Both Russia and China are moving ahead with public vaccination programs for vaccines that do not appear to have progressed through the full, traditional evaluation and authorization process. This highlights concerns that the various health, economic, and political pressures associated with the COVID-19 pandemic could lead to accelerated review processes being insufficient to effectively characterize the safety and efficacy for candidate vaccines and other drugs in order to make them available more rapidly.

The controversial announcement by China follows a recent report that Papua New Guinea forced a flight containing Chinese mine workers to turn around due to concern that the workers had received a SARS-CoV-2 vaccine as part of a previously unannounced trial. Earlier in August, a group of Chinese workers received a SARS-CoV-2 vaccine shortly before departing China as part of a clinical trial, and government officials in Papua New Guinea detained the travelers when they landed because no trial was registered or approved in Papua New Guinea. The company that owns the mine sent a letter to officials in Papua New Guinea stating that the workers had been vaccinated and that the vaccine could potentially result in false positive results for SARS-CoV-2 tests. It is unclear what vaccine the workers who arrived previously received or if the workers onboard the diverted flight were vaccinated.

SARS-CoV-2 REINFECTION Researchers from the Hong Kong University LKS Faculty of Medicine published the first information on a patient with confirmed SARS-CoV-2 reinfection. The case study, published in Clinical Infectious Diseases, indicates that genomic analysis of specimens collected from the patient confirms that he was infected twice. The patient is a 33-year-old male who was originally hospitalized for COVID-19 in March, with a positive PCR diagnostic test, and then discharged in April after 2 negative PCR tests. The man returned to Hong Kong from Spain in August and tested positive (PCR diagnostic test) during arrival screening at the airport. He was asymptomatic, but he was hospitalized for further evaluation. Whole genome sequencing analysis was conducted on specimens collected in March and August, and the analysis found the virus in the samples belonged to 2 distinct lineages/clades. Further analysis of the genomic data indicates that the specimen from March “is most closely related to strains from the USA or England collected in March and April 2020,” whereas the specimen from August “is most closely related to strains from Switzerland and England 186 collected in July and August 2020.” These results confirm that the patient was infected at two different points in time, several months apart. Research is ongoing to characterize the degree to which SARS-CoV-2 infection confers lasting immunity, which has major implications for a variety of response measures, including vaccination. This case study illustrates that reinfection is possible, but the risk of reinfection still remains highly uncertain.

REMDESIVIR TRIAL Results from another clinical trial of remdesivir provide additional evidence that the drug can provide treatment benefit, but it not necessarily provide additional clarity on the drug’s benefit for COVID-19 patients. The study, published in JAMA, included 584 patients across more than 100 hospitals in the US, Europe, and Asia. The patients were randomly assigned to receive a 5-day or 10-day treatment course of remdesivir or the current standard of care, and the researchers evaluated the patients’ health using a 7-point ordinal scale—1 corresponding to death and 7 corresponding to patient recovery and discharge. The study had a control group, but it was not a placebo-controlled trial, which poses challenges to interpreting the results. The study identified an improvement in clinical condition for patients who received the 5-day course of treatment but not for the 10-day course, compared to the control group. The researchers explicitly note that, while the difference was statistically significant, “the difference was of uncertain clinical importance.”

An accompanying commentary highlights this study’s findings in the context of previous studies, several of which have also yielded statistically significant but clinically ambiguous results. The authors describe the implications of certain study design choices—such as clinical metrics or endpoints, patient population, and placebo-controlled versus open label—can have on the results. While this most recent study does provide valuable information on the treatment benefit of remdesivir, it remains clear that further study is needed in order to better characterize its effects and determine how best to use it in the COVID-19 pandemic.

US CDC SCHOOL GUIDANCE The US CDC published updated guidance regarding school openings. The updated guidance provides additional recommendations for a myriad of topics, including ventilation, food service, and mask use as schools continue to prepare and implement their plans to start the 2020-21 school year. The guidance also expands on previous iterations regarding students with “special healthcare needs and disabilities” with a new section dedicated to these challenges. Schools may need to develop individualized plans for some students and staff, including those with limited mobility, those with visual or hearing impairments, those with underlying health conditions, or those who may have difficulties understanding or adapting to new routines. The information notes that some individuals may struggle with social distancing or isolation or mask use, or they may need additional visual or verbal reminders or assistance implementing the school’s social distancing protocols. The information also links to guidance regarding protections related to service animals.

Another notable addition is guidance regarding how schools should address infected students or staff. The document advises schools to coordinate with local health officials to address the issue of suspending in-person classes and events. The CDC notes that short-term building closures may be necessary to allow health officials time to assess the situation, and local health officials can help determine whether longer-term interruptions to in-person classes and activities may be necessary. If schools are cohorting students, particularly if they are cohorted in specific areas, it may be possible to limit interruptions to just those groups or spaces, rather than the entire school.

AUCKLAND EXTENDS LOCKDOWN Earlier today, New Zealand Prime Minister Jacinda Ardern announced that the current level of social distancing restrictions in Auckland will be extended beyond the previously scheduled termination date. The decision aims to “provide a greater degree of certainty” that community transmission in Auckland remained at a low level before moving forward with efforts to relax existing restrictions in order to better ensure that it can remain at the lower Alert Level following the transition. The Auckland area is now scheduled to move from Alert Level 3 to Alert Level 2 on August 31, which will permit schools to reopen and restaurants and bars to begin reopening, among other changes. As Auckland transitions to Alert Level 2, there will be additional restrictions beyond the normal Alert Level 2 standards, including on the size of some gatherings and continued mandatory mask use.

Auckland’s outbreak began 2 weeks ago, after more than 100 days without documented domestic transmission in New Zealand. Since then, health officials have identified at least 101 associated cases, including 8 in the past 24 hours. Notably, Māori and Pacific Peoples comprise 87% of identified cases in the current outbreak, compared to only 19% for New Zealand’s entire national epidemic. The majority of cases early in New Zealand’s epidemic, before successfully interrupting domestic transmission, were of European descent, but the current outbreak is disproportionately impacting lower-income racial and ethnic minority communities. These disparities mirror those observed in many other countries, including systemic racism, high prevalence of underlying health conditions, high-density or crowded living conditions, and barriers to accessing health care. Health officials and other experts have placed increased importance in communicating and educating the affected populations and promoting recommendations, including testing and social distancing.