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 25.12 million cases (264,107 new) and 844,312 deaths (5,385 new) as of 8:15am EDT on August 31.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. India: 65,526 new cases per day (+8,031)
2. USA: 42,079 (-684)
3. Brazil: 36,647 (-1,294)
4. Colombia: 9,542 (-860)
5. Argentina: 9,205 (+2,390; ↑ 1)
6. Spain: 7,605* (+1,428; ↑ 1)
7. Peru: 7,549 (-791; ↓ 2)
8. Mexico: 5,097 (-554)
9. France: 5,006 (+1,526; new)
10. Russia: 4,797 (-45; ↓ 1)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Maldives: 235 new daily cases per million population (-28)
2. Peru: 229 (-24)
3. Bahrain: 213 (-6)
4. Argentina: 204 (+53; ↑ 5)
5. Colombia: 188 (-16; ↓ 1)
6. Israel: 179 (+6)
7. Brazil: 172 (-7; ↓ 2)
8. Panama: 171 (+7; ↓ 1)
9. Costa Rica: 165 (+15; ↑ 1)
10. Spain: 163 (+21; new)

*Spain’s average daily incidence is not reported for today; these values correspond to the previous day’s averages. Spain’s average daily incidence has not changed since August 27.

India has surpassed the US for the global record for average daily incidence. At 73,557 new cases per day, India is already nearly 10% higher than the previous record, and case counts are still accelerating. The Philippines fell out of the top 10 in terms of total daily incidence, and it was replaced by France. The Bahamas fell out of the top 10 in terms of per capita daily incidence, and it was replaced by Spain. No countries are currently reporting more than 250 daily cases per million population.

The US CDC reported 5.93 million total cases (44,292 new) and 182,149 deaths (1,006 new). In total, 19 states (no change) are reporting more than 100,000 cases, including California, Florida, and Texas with more than 600,000 cases; New York with more than 400,000; and Arizona, Georgia, and Illinois with more than 200,000. We expect California to surpass 700,000 cases in its next update. The US continues to average fewer than 1,000 deaths per day; however, the daily total is decreasing very slowly. The US is currently averaging 928 deaths per day, still nearly double the national low of 484 deaths per day on July 6.

Several US territories continue to report extremely high per capita daily incidence. Guam is reporting 446 daily cases per million population, which would be #1 globally—nearly 90% greater than the Maldives, the actual #1. Guam’s daily incidence has held relatively steady since August 27. The US Virgin Islands is reporting 205 daily cases per million population, which would be #4, falling between Bahrain and Argentina. Puerto Rico would have fallen out of the top 10, but it is still reporting 147 daily cases per million population—more than 15% greater than the rest of the US.

The Johns Hopkins CSSE dashboard reported 6.01 million US cases and 183,258 deaths as of 1:30pm EDT on August 31.

PREVALENCE & TRANSMISSION IN CHILDREN New research published in JAMA Pediatrics describes the prevalence of asymptomatic SARS-CoV-2 infection in children. The study included pediatric patients who sought care at 25 US children’s hospitals who were tested for SARS-CoV-2 prior to receiving care for other conditions (e.g., surgery). Out of 33,041 children tested in April and May, 250 asymptomatic infections were detected. The prevalence at individuals facilities ranged from 0%-2.2%, and the overall prevalence was estimated to be 0.65%. Increases in asymptomatic pediatric infections within the hospitals was significantly associated with increases in incidence among the surrounding general population.

Two case studies published in the US CDC’s Morbidity and Mortality Weekly Report (MMWR) address SARS-CoV-2 transmission among children in non-school congregate settings. One article describes the reopening of 4 overnight summer camps in Maine (US). The camps had a total of 1,022 attendees from 41 states, and they were successful in preventing secondary transmission of SARS-CoV-2 in the camp setting. The camps implemented multiple preventative measures, including quarantine, symptom screening, testing, and enhanced hygiene measures. All campers and staff were instructed to quarantine for 10-14 days with their family prior to arriving at the camp, and the camp provided additional guidance for campers during travel to the site. All attendees either tested negative within 5-7 days prior to arriving at the camp or had documented SARS-CoV-2 infection in the previous 2 months. Four asymptomatic individuals tested positive during the pre-arrival testing, and they were required to complete isolation before joining the group. The attendees were placed in a “bubble” with a designated cohort of attendees, and cohorts remained separate from each other for 14 days after arrival. Testing was repeated 4-9 days after arrival, and 3 additional asymptomatic cases were identified and isolated. Symptom screenings were conducted for all campers and staff daily. No secondary transmission by symptomatic individuals was detected at any of the 4 camps, but the possibility of additional asymptomatic cases cannot be ruled out.

The second MMWR article describes the reopening of 666 childcare programs—approximately 18,945 children—in Rhode Island (US) in June and July. The Rhode Island Department of Human Services initially limited capacity at childcare centers to 12 total individuals initially and then later expanded to 20. The programs were also required to implement universal mask use for staff, daily symptom screenings for staff and children, and enhanced hygiene and cleaning practices. Compliance with regulations was enforced through unannounced visits by state officials. If anyone developed symptoms, the centers were required to close for 14 days, or until a negative test ruled out SARS-CoV-2 infection. Throughout the study period, 101 individuals were identified as a possible SARS-CoV-2 infections, of which 33 tested positive and 19 were symptomatic but not tested—30 children, 20 teachers, and 2 parents. In total, 29 childcare programs, and health officials were able to rule out secondary transmission in all but 4 programs. 

IMMUNOLOGY Two recent studies provide further analysis of the immune response to SARS-CoV-2 infection. The first study, published in the US CDC’s Emerging Infectious Diseases, included 28 participants with severe COVID-19 disease and 15 participants who recently recovered from mild COVID-19. Participants with mild COVID-19 exhibited a delayed increase in IgG and neutralizing antibodies compared to patients with severe COVID-19; however, the IgM response reactive toward S1 and E proteins increased early for both groups. The researchers suggest that mild cases of COVID-19 may “not necessarily represent an intermediate stage between severe and asymptomatic COVID-19,” but further research is required to better characterize the human immune response and any associations with disease severity.

The second study, published in Nature, explored differences in viral load, antibody titers, and plasma cytokines in female and male COVID-19 patients. The study included 98 total participants treated at Yale-New Haven hospital in Connecticut (US). The researchers found that female patients exhibited a more robust T cell activation than male patients, whereas male patients had higher levels of innate immune response, including IL-8 and IL-18 cytokines. They also found that poor T cell response was “associated with worse disease outcomes in male patients, but not female patients” and that elevated innate cytokine response was associated with more severe disease in females but not males. These differences could potentially inform variations in treatment courses for female and male COVID-19 patients.

REINFECTION After researchers in Hong Kong published details of a COVID-19 patient who appears to have been infected twice, with different strains of the virus, a team of US researchers report evidence that a COVID-19 patient in Nevada was also reinfected. The patient, a 25-year-old male, tested positive for SARS-CoV-2 in late April and was discharged following 2 negative diagnostic tests. He then tested positive again approximately 1 month later. The researchers indicate (preprint) that, like the patient in Hong Kong, genetic analysis of the specimens from the Nevada patient indicated that he was infected with 2 different strains of SARS-CoV-2. This is the first documented instance of SARS-CoV-2 reinfection in the US. One notable difference between the Hong Kong patient and Nevada patient is the severity of their second infection. The Hong Kong patient was asymptomatic when he was identified via screening upon arrival in Hong Kong, whereas the Nevada patient experienced much more severe disease during his second infection. While it still appears that reinfection is relatively rare, researchers will inevitably identify more cases. With tens of millions of cases, many of whom recovered from their initial infection months ago, we will certainly hear about more reinfections in the coming months. As more examples of reinfection are identified, researchers will aim to answer critical questions, some of which could provide critical insight into the efficacy of future vaccines. 

INFLUENZA VACCINE MANDATE Health experts continue to warn about the risks associated with simultaneous epidemics of COVID-19 and seasonal influenza, and governments are scaling up efforts to increase access and participation in seasonal influenza vaccination. While the US government has purchased an increased volume of seasonal influenza vaccine this year, state governments, many of which are already overburdened with the COVID-19 response, will be responsible for coordinating the distribution and administration of the vaccine to the public. Some states are also purchasing their own vaccine and initiating campaigns to educate the public and promote seasonal influenza vaccination. While many Southern Hemisphere countries reported much lower seasonal influenza incidence compared to previous years, many of those countries have had greater success in limiting SARS-CoV-2 transmission than the US, including through social distancing and mask use. It remains unclear whether COVID-19 measures will have any meaningful impact on the Northern Hemisphere influenza season or if simultaneous epidemics in some countries could compound the burden on health systems.

In Massachusetts (US), the Department of Public Health is requiring seasonal influenza vaccination for all children age 6 months and older in order to attend child care, preschool, K-12, and colleges and universities. Exemptions will be available for medical and religious reasons. Vaccination will not be required for college and university students participating in all-remote classes; however, K-12 students in school districts that are conducting classes remotely will not be exempt. The addition of the seasonal influenza vaccine to the Massachusetts vaccination schedule appears to be a permanent change, extending beyond the COVID-19 pandemic, but the health department’s Medical Director, Dr. Larry Madoff, emphasized that seasonal influenza vaccination is even more important during the COVID-19 response. In response to the announcement, hundreds of protesters gathered at the Massachusetts State House. The protesters included both anti-vaccine advocates and parents concerned about the state eliminating their ability to make choices for their children’s health.

RAPID TEST IN ASYMPTOMATIC INFECTIONS Following the announcement of an Emergency Use Authorization (EUA) for its new SARS-CoV-2 rapid antigen test, the CEO of Abbott Laboratories, Robert Ford, announced that the company is currently conducting a clinical trial to collect data on the test’s accuracy for asymptomatic infection. The EUA limits the test’s use to individuals within 7 days of developing COVID-19 symptoms, but it is generally understood that transmission by asymptomatic or presymptomatic individuals plays a major role in driving the pandemic. The ability to rapidly screen asymptomatic individuals for infection would further increase the test’s utility during the pandemic. The test does not require specialized or proprietary equipment or supplies beyond the test kit itself. The test is capable of providing results in approximately 15 minutes, much faster than traditional PCR-based diagnostic tests. The widespread availability of a rapid point-of-care diagnostic test that works on asymptomatic individuals could improve the ability to identify and isolate infectious individuals or screen larger groups of people for possible infection, which could facilitate efforts to resume some social and economic activities.

BURIAL RITUALS In addition to the threat of COVID-19 itself, many communities are working to adapt funerary and burial practices for COVID-19 victims. Traditional practices, including large gatherings and washing the deceased’s body, are common in many cultures, but these activities could pose transmission risk. Many countries and state/regional governments have implemented restrictions on funerals, including prohibitions on washing the body and limitations on the number of attendees, and domestic and international travel restrictions can make it difficult or impossible for family and friends who live elsewhere to attend the service. As we have seen in previous epidemics, such as the 2014-16 West Africa Ebola epidemic, communities are adapting to new burial processes, which likely do not conform to long-standing traditions. These changes can put additional stress on affected families and communities, compounding challenges in dealing with social distancing, economic damage, and other disruptions associated with the pandemic. Communities are working to balance the importance of providing a dignified burial for COVID-19 victims with the need to protect the health of families and communities, as well as the the religious leaders, morticians, and others who participate in funerary services.