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 24.30 million cases (281,581 new) and 827,730 deaths (6,261 new) as of 10:30am EDT on August 26. The average global mortality has decreased from a peak of more than 6,300 new deaths per day on August 14 to 5,425 deaths per day now. If the global average remains greater than 5,000 deaths per day, the cumulative global mortality could reach 1 million deaths by the end of September.

Overall, the global daily COVID-19 mortality appears to be starting to decline, following a peak around mid-August. Asia is currently exhibiting the most notable increase in COVID-19 mortality, and South America appears to have reached a plateau. Since coming down from its first peak early in the pandemic, Europe has exhibited a very slow increase in mortality, up to 325 deaths per day from a low of 270 in late July. Mortality in Africa and North America peaked in mid-August and has declined steadily since then. Over the past 2 weeks, it appears that most countries are reporting decreasing COVID-19 mortality, an encouraging sign; however, numerous countries reported increases greater than 100% over that period. They are largely distributed around the world, but there is a noticeable concentration in Europe.

In total, there are 10 countries averaging more than 100 daily deaths. Brazil, India, and the US are all reporting essentially equal daily mortality, approximately 900-950 daily deaths. Mexico is reporting slightly more than half of that total, at 498 daily deaths, and Colombia is reporting 326 daily deaths. The remaining 5 countries are reporting fewer than 250 daily deaths. The Central and South America region represents 5 of the top 10 countries in terms of total daily mortality. In terms of per capita daily mortality, 10 countries are averaging 3 or more daily deaths per million population. Of these countries, 8 are from Central or South America. Also in the Americas, the Bahamas is #1 after jumping from just 1 daily death per million population to 10 in only 11 days, and the US falls just outside the top 10 (#12).

The US CDC removed its previous COVID-19 reporting page and transitioned to its COVID Data Tracker dashboard. The dashboard provides links to a variety of data, including incidence and mortality, laboratory testing, community impact (eg, mobility), and high-risk populations (eg, healthcare workers, incarcerated populations). Some of the data is available at the state and county level directly through the dashboard. The dashboard added a 7-day moving average for daily deaths, and it once again reports COVID-19 data from New York City and New York state separately.

The CDC reported 5.80 million total cases (46,393 new) and 178,998 deaths (1,239 new). In total, 19 states (no change) are reporting more than 100,000 cases, including California and Florida with more than 600,000 cases; Texas with more than 500,000; New York with more than 400,000; and Georgia and Illinois with more than 200,000. We expect Arizona to surpass 200,000 total cases in the coming days. Notably, the US fell out of the global top 10 in terms of per capita daily incidence.

Several US territories continue to report extremely high per capita daily incidence. Guam is reporting 446 new daily cases per million population, which would be #1 globally—more than 75% greater than the Maldives, the actual #1. It previously appeared as though much of Guam’s increased incidence was due to a large spike of 105 new cases reported on August 21; however, Guam has reported more than 50 new cases on 6 of the 7 days since then, including a new record high of 136 new cases on August 27. The US Virgin Islands is reporting 282 new daily cases per million population, which would also be #1 globally. Puerto Rico’s daily incidence has decreased over the past week or two, but it is still reporting 162 new daily cases per million population. This would put it at #10 globally, falling between Costa Rica and Spain.

The Johns Hopkins CSSE dashboard reported 5.88 million US cases and 181,092 deaths as of 12:30pm EDT on August 28.

SOUTH KOREA South Korea continues to report a resurgence of COVID-19, and it has experienced a range of disruptions and operational changes as a result of the increased transmission or response activities. The surge in incidence drove the Ministry of Health and Welfare to increase social distancing restrictions nationwide to Step 2 for a period of 2 weeks. On Thursday, proceedings of South Korea’s National Assembly were suspended in order to disinfect the building after a journalist tested positive for SARS-CoV-2. Additionally, the South Korean government ordered most schools in and around Seoul to close and transition classes online earlier this week. All students in the affected cities and provinces, with the exception of high school seniors, will participate in online classes through at least September 11. After delays and disruptions earlier in the year, South Korean schools reopened in late May and early June.

Earlier this week, physicians across the country, including in Seoul, engaged in a 3-day strike organized by the Korean Medical Association. The walkout of thousands of doctors, primarily interns and resident doctors at hospitals, stems from their disapproval of recent government decisions to increase the number of medical students admitted to medical schools in the future and to open a new public medical school for the purpose of expanding access to healthcare services nationally. The government also aims to expand insurance coverage to more traditional medicines and practices and increase the availability of telemedicine. The doctors reportedly disapprove of these plans because they believe they would unfairly increase competition in an already-crowded job market. They argue that the funding for these efforts would be better spent to increase salaries for trainees, which could enable them to move to rural areas that are experiencing a shortage of doctors. The strike has led to disruptions in hospital operations, leading facilities to reduce operating hours, cancel appointments, and delay procedures. South Korean Minister of Health Dr. Park Neung-hoo ordered protesting doctors to return to work, threatening those who do not comply with the possibility of suspending or revoking their licenses, fines of up to US$25,000, or up to 3 years in prison. To date, the government does not appear to have taken punitive action against striking doctors.

EUROPEAN SCHOOLS Like most of the rest of the world, European countries have been debating whether to reopen schools and how to best protect students and teachers. Public Health England conducted enhanced surveillance among schools that reopened between June 1-July 31 in order to provide better information regarding SARS-CoV-2 transmission risk in school settings. While approximately 80% of schools remained open in some capacity during the UK lockdown to support certain priority groups (eg, children of healthcare workers), the vast majority of children did not attend in-person classes. In June, the number of students attending schools increased from 475,000 to more than 1.6 million. The researchers identified 198 total COVID-19 cases over the study period, including 121 linked to 30 different outbreaks and 67 individual cases (ie, not linked to transmission in schools). An additional 10 cases were reported as "co-primary" cases, which were detected at the same time and had a common epidemiological link (eg, to a parent). Of these cases, 70 were students, and 128 were staff members. The study found a strong correlation between COVID-19 incidence in the region and the number of outbreaks in schools. The authors concluded that schools were associated with relatively few COVID-19 outbreaks after the easing of the lockdown, and the outbreaks that did occur were more likely to involve staff members. As a result of the correlation between school-based outbreaks and community transmission, the researchers emphasized the importance of community-based risk mitigation measures (eg, mask use, physical and social distancing). While the study provides evidence that schools do not drive transmission, Dr. Shamez Ladhani, one of the study’s authors, noted that the results reflect only data that were gathered right after the lockdown ended. Class sizes were very small at the time, and school-based transmission principally affected adult staff.

While it is possible that schools are not major drivers of transmission, Dr. Hans Kluge, the WHO Regional Director for Europe, stated that there is increasing evidence of children infecting others at social gatherings and that incidence among young people is increasing. The WHO recently advised that children 12 years and older should wear a mask under the same conditions as adults in order to mitigate transmission risk. As winter approaches in the Northern Hemisphere, there are concerns that increased close contact between children and more vulnerable older adults could lead to a rise in incidence and deaths.

In Germany, schools are beginning to reopen, with the majority of students returning for in-person classes. To mitigate transmission risk, German schools are reportedly focusing on improved ventilation and cohorting students (ie, keeping classes separate). The decision to bring all students back at once hinged partly on the number of available teachers, which did not support efforts to split students into smaller groups. Interestingly, masks are required on most school grounds in Germany, but not necessarily in classrooms in order to help students concentrate. 

KENYA On Wednesday, Kenyan President Uhuru Kenyatta announced that Kenya is extending its current social distancing restrictions for 30 days. Kenya’s COVID-19 epidemic peaked in early August, at approximately 675 new cases per day, and it is now less than half of that (286 new cases per day) and still decreasing. In early July, despite several months of steadily increasing daily incidence, Kenya relaxed a number of social distancing measures in order to enable its economy to recover. Three (3) weeks later, however, President Kenyatta was forced to re-institute more restrictive measures to combat Kenya’s rapidly growing epidemic. He urged Kenyans to be vigilant in complying with the recommended actions, noting that they must all hold themselves and others accountable. The effort was successful in turning the tide against the COVID-19 epidemic, and in his most recent address, President Kenyatta applauded Kenyans’ efforts. He also continued to emphasize their personal responsibility and duty to protect others, “a happy debt to pay [their] fellow citizens.” While Kenya made considerable progress since the measures were implemented a month ago, he noted that much uncertainty remains about the future trajectory of the epidemic, encouraging Kenyans not to be complacent.

While some restrictions will remain intact, such as the nationwide 9pm-4am curfew, others will be relaxed to some degree. Bars and nightclubs will remain closed, but hotels will be permitted to serve alcohol. Additionally, the Ministry of Health will coordinate with bar owners to develop “self-regulating mechanisms” over the next 30 days with the aim of allowing them to resume operations. Restaurant hours of operation will still be restricted, but they will be permitted to extend closing by 1 hour, from 7pm to 8pm. Additionally, the limit on the attendance at weddings and funerals will increase to 100 people, and the Ministries of Health and Sports, Culture, and Heritage are expected to issue guidance for resuming sporting events.

WILD POLIO ELIMINATION IN AFRICA Earlier this week, the WHO announced that wild-type polio viruses have been eliminated from the continent of Africa, a major step toward eradication. Polio eradication programs, including vaccination campaigns, were suspended early in the COVID-19 pandemic due to concerns that the programs would not be able to continue in-person, door-to-door efforts safely in the midst of the pandemic, particularly that these efforts could inadvertently spread COVID-19 in vulnerable communities. Experts warned that scaling back eradication activities would inevitably result in polio outbreaks that could have lasting negative effects on eradication efforts. Polio vaccination programs began to resume in July, initially limited to outbreak response before expanding to include preventive campaigns.

In addition to contributing toward eradication, lessons and capacities from polio have been critical to the COVID-19 response in Africa. Over its history, polio eradication efforts have incorporated a myriad of other healthcare and public health benefits—including mosquito nets, vitamin A, and other vaccinations—and this approach is now being applied to the COVID-19 response. Additionally, it is critical to establish trusted relationships with local leaders, which helps establish inroads with affected communities, implement culturally appropriate interventions, and build public confidence in the response efforts, including contact tracing and vaccination. The laboratory network and infrastructure established for polio is also being utilized for COVID-19. The network includes 16 laboratories across 15 countries in Africa, and 50% of its capacity has been transitioned to support SARS-CoV-2 testing. Leveraging existing capacity and expertise, such as through polio eradication efforts, is critical to making efficient use of available resources.

CHINA SCHOOLS REOPENING China is expected to fully reopen schools next week. China has already opened schools for 75% of students, and this move will ultimately enable all students to resume in-person classes. China’s school systems include nearly 300 million teachers and students nationwide. According to China’s Ministry of Education, no cases of COVID-19 have been detected at schools during the initial phases of resuming in-person classes, through the point of reaching 75% capacity. The Ministry of Education emphasized that conditions at schools across the country may vary and that schools cannot take a “one size fits all” approach to implementing appropriate COVID-19 protective measures. It also emphasizes the importance of local control of COVID-19 transmission, much like the US CDC emphasizes the need to account for risks associated with local community transmission as students resume in-person classes. Colleges and universities have been directed to strictly control access to campus, including checking identification for students and teachers and limiting visitors, in order to mitigate the risk of introducing SARS-CoV-2. While all schools will reportedly be open, it may still take time for all students to resume in-person classes. According to information published by the Ministry of Education, schools will phase in their students, and provincial plans could take as long as 37 days to reach 100% capacity. Including colleges and universities, the phase-in period is scheduled to continue into mid-October.

RAPID ANTIGEN TEST EUA The US FDA issued an Emergency Use Authorization (EUA) for a rapid antigen test developed by Abbott Laboratories that can return results in approximately 15 minutes. The test uses widely available testing equipment, as opposed to proprietary reagents or machines, and it can be performed on site at the point of care. A press release from Abbott indicates that the test has demonstrated reasonably high sensitivity (97.1%) and specificity (98.5%). Antigen tests detect the presence of viral particles, including specific proteins, whereas traditional PCR tests detect the presence of viral RNA. Antigen tests can be performed more quickly than PCR tests, but they tend to be less accurate. The test is projected to cost US$5 each, which could help make it more widely available, and it will have an accompanying smartphone application that will enable individuals to present documentation of recent negative tests. The US government finalized an agreement to purchase 150 million tests, at a cost of US$750 million. Widespread distribution of these tests would substantially increase national testing capacity, and rapid, on-site testing capability would dramatically decrease the delays in processing tests and return results that continue to plague PCR-based diagnostic tests.

The test has been described by some, including US Assistant Secretary for Health Admiral Brett Giroir, as a “game changer”; however, there are some notable limitations that should be considered as well. The ability to use widely available testing equipment expands the number of laboratories that could perform the test, but the test still requires a laboratory and trained personnel to conduct it, as well as a nasopharyngeal swab to obtain the specimen. It is not a test that individuals can take at home. Additionally, the US$5 cost pertains only to the test, and the cost of personnel time and laboratory testing supplies and equipment will likely increase the overall cost. The test is also limited to symptomatic individuals, and as we have covered previously, asymptomatic or presymptomatic transmission is a major driver of the COVID-19 pandemic. A number of other relatively inexpensive, rapid antigen tests are currently in development, including some that are designed for home use. 

**While this is largely a US issue, we are continuing to cover emerging information regarding recent US CDC changes to SARS-CoV-2 testing guidance.**
US CDC TESTING GUIDANCE Multiple reports indicate that the changes to the US CDC’s SARS-CoV-2 testing guidance—in particular, that asymptomatic individuals “do not necessarily need a test,” even if they have known exposure to a COVID-19 case—were directed by senior US government leadership outside the CDC. The changes were reportedly made under pressure by senior officials at the Department of Health and Human Services and the White House coronavirus task force. Notably, several reports also indicate that Dr. Anthony Fauci was undergoing surgery at the time of these discussions and did not sign off on the changes. This conflicts directly with statements made by Admiral Brett Giroir, the Assistant Secretary for Health and the “coronavirus testing czar,” who stated that “all the doc[tors] signed off” on the new guidance and that the updates represent an “absolute consensus” by the US government’s top experts.

Multiple experts have commented that these reports raise serious concerns that the changes may have been made on the basis of political pressure rather than available scientific evidence. President Donald Trump has repeatedly stated that he would like to see reduced testing in order to decrease the reported COVID-19 incidence, which would likely have serious negative effects on the US response. Late Wednesday evening, CDC Director Dr. Robert Redfield issued a statement in support of the new guidance. In his statement, Dr. Redfield noted that “testing is meant to drive actions and achieve specific public health objectives”; however, it is unclear how health officials could effectively conduct actions such as contact tracing and notifying individuals who were exposed to asymptomatic infections if no testing is conducted.