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 Situation Report for August 4 reports 18.1 million cases (219,862 new) and 691,013 deaths (4,278 new). The WHO data indicates that the global daily incidence could potentially be approaching a peak or plateau.

Brazil reported only 16,641 new cases on August 3, its lowest daily incidence since June 8, but yesterday, it reported more than 51,000 new cases. This is nowhere near its record high (69,074 new cases), but it is much more consistent with its recent trend. Brazil remains #3 globally in terms of daily incidence and continues to fall further behind India. Broadly, the Central and South American region remains a major COVID-19 hotspot. Colombia reported 7,129 new cases, its lowest daily incidence since July 22. Columbia remains #4 globally in terms of daily incidence. Mexico is reporting an average daily incidence of 6,752 new cases per day, and it remains #6 globally in terms of daily incidence. Including Brazil, Colombia, and Mexico, the Central and South American region represents 5 of the top 10 countries globally in terms of daily incidence, along with Peru (#7) and Argentina (#8), and multiple other countries in the region are reporting more than 1,000 new cases per day. Additionally, the region includes 6 of the top 10 countries in terms of per capita daily incidence—Panama (#2), Brazil (#3), Peru (#4), Colombia (#5), the US (#7), and Bolivia (#10)—and numerous other countries are reporting more than 100 new daily cases per million population.

India continues to report daily incidence in excess of 50,000 new cases per day, but the daily totals have remained relatively consistent over the past week. India remains #2 globally in terms of daily incidence. With the US daily incidence continuing to decrease and India’s leveling off, India could potentially surpass the US for #1 globally in the next week or so. Following several days of low daily incidence, Bangladesh reported 2,654 new cases, consistent with its expected trend. Bangladesh’s test positivity fell from a spike of 32% on August 2 to 24% today. The Philippines’ daily incidence continues to surge rapidly, climbing to more than 4,000 new cases per day—more than doubling since July 30. The Philippines remains #10 in terms of daily incidence, but it is on a trajectory to climb higher in the coming days.

South Africa reported 4,456 new cases and remains among the top countries globally in terms of both per capita (#9) and total daily incidence (#5). Additionally, South Africa remains #5 globally in terms of cumulative incidence.

Bahrain (#6) is the only country in the Eastern Mediterranean region remaining in the global top 10 in terms of per capita daily incidence, and Kuwait is the only other country in the region reporting more than 100 new daily cases per million population. Nearby Israel (#8), in the WHO’s European region, remains among the top countries globally as well.

The Maldives climbed to #1 globally in terms of per capita daily incidence, with nearly 250 new cases per day per million population. Montenegro fell out of the #10 in terms of per capita daily incidence.

The US CDC reported 4.70 million total cases (49,715 new) and 155,204 deaths (733 new). This is the second consecutive day that the CDC reported fewer than 1,000 deaths, but this is due, in part, to delays in weekend reporting. We expect the daily mortality to increase as the week progresses. According to the CDC data, 13 states are reporting more than 100,000 cases, including California with more than 500,000; Florida with more than 475,000; and New York and Texas with more than 400,000. The Florida Department of Health is currently reporting more than 500,000 cumulative cases, so we expect this to be reflected in the CDC data in the next day or two. The US remains #7 in terms of per capita daily incidence and #1 in terms of total daily incidence.

While the US COVID-19 incidence continues to slowly decrease at the national level, mortality remains elevated. The US is now averaging 1,078 deaths per day, a slight increase from the previous day. Notably, Texas (194 deaths per day), Florida (184), California (133), Georgia (59), Mississippi (30), North Carolina (29), Ohio (27), Nevada (15), Arkansas (9), and Oklahoma (8) are reporting increasing daily COVID-19 mortality. Arizona’s COVID-19 mortality (62 deaths per day) may have reached a peak, but further data is needed to characterize the longer-term trend.

The Johns Hopkins CSSE dashboard reported 4.79 million US cases and 157,186 deaths as of 12:30pm on August 5.

LONG-TERM HEALTH EFFECTS Clinicians and researchers continue to investigate potential lingering health effects after COVID-19 patients recover from the acute stage of the disease. Science published an overview of several recent studies and anecdotes from COVID-19 survivors that address long-term health effects associated with COVID-19. Much of the early research on COVID-19 focused on addressing treatment for acute COVID-19 symptoms, particularly severe and life-threatening disease, but as the pandemic continues and more patients recover, longitudinal studies are tracking patients after their recovery to identify conditions and symptoms that could last for months or longer.

COVID-19 patients often experience respiratory symptoms, so it is not surprising that some of these longer-term conditions are linked to respiratory function; however, SARS-CoV-2 appears to be capable of infecting a broad range of tissues. Some of the documented conditions include “brain fog,” which impairs individuals’ cognitive function; respiratory symptoms, including shortness of breath; and cardiological symptoms, such as heart arrhythmia and hypertension. Long-term symptoms vary both in terms of severity and the tissues or systems affected. The symptoms are mild or non-existent in some patients, but they can be severe in others, making it difficult or impossible for them to return to normal activity. Long-term health effects have been documented for many diseases, including those associated with viral infections, but it will take time to better characterize the full scope of effects from SARS-CoV-2.

In some studies, more than 70 or 80% of patients—including the full spectrum of acute disease severity, from mild to severe cases—experience lingering health effects after their initial recovery. At this time, there does not appear to be a direct correlation between the severity of the acute and chronic symptoms. Beyond the direct health impact for individuals, long-term conditions could hinder the ability of some COVID-19 patients to resume normal levels of activity, which could have long-term effects on societal and economic recovery as well.

ITALY SEROPREVALENCE SURVEY Italy published preliminary results from a national seroprevalence survey. The survey initially aimed to include more than 1 million participants, but the preliminary report includes 64,600 individuals whose results were available by July 27. The serological tests used for this study were CLIA or ELISA kits designed to detect IgG neutralizing antibodies for SARS-CoV-2 (sensitivity of 90% and specificity of 95%). This study estimates that Italy’s overall COVID-19 seroprevalence is 2.5%, with the highest seroprevalence in the Lombardy region at 7.5%. The Lombardy region represents more than 50% of Italy’s COVID-19 incidence. Additionally, the study estimates seroprevalence stratified by age group. The lowest estimated seroprevalence was among individuals aged 18-34 years (2.1%), and the highest was among those aged 50-59 years (3.1%). The analysis identified high levels of transmission among family units. Among seropositive individuals, 41.7% lived with someone else who was also infected. Notably, 27.3% of individuals with detectable antibodies reported never experiencing any symptoms, which indicates a relatively high level of asymptomatic infection.

US TESTING US SARS-CoV-2 testing capacity has increased dramatically since the early months of the pandemic, up to more than 800,000 tests per day, but numerous problems and barriers remain to achieving a robust and reliable testing system. Last month, the US government unveiled a plan to provide nursing homes and long-term care facilities across the country with machines capable of performing rapid, on-site SARS-CoV-2 tests. As we have covered previously, these types of facilities are among the highest risk settings for rapid transmission, severe disease, and death, largely due to prolonged close contact between patients and staff, older populations, and high prevalence of underlying health conditions. Rapid testing would provide the ability to quickly identify and isolate patients to mitigate transmission risk and to monitor staff to ensure infectious individuals do not have contact with high-risk patients. Reportedly, SARS-CoV-2 “Testing Czar” ADM Brett Giror noted that the program would only provide a limited supply of testing kits to go along with the machines and that individual facilities will be required to acquire their own test kits. The facilities will be expected to use funds from emergency funding previously provided by the federal government, but the US government has reportedly made arrangements with manufacturers to ensure easy and affordable access to the test kits as well as technical support.

Another major barrier is disparities in the availability of testing in underserved communities, particularly for communities of color. One study, conducted by ABC News and FiveThirtyEight, found that testing availability and wait times can vary widely. In particular, the researchers found that “people of color, especially Blacks and Latinos, are more likely to experience longer wait times and understaffed testing centers.” The study analyzed the expected testing demand and number of sites in communities nationwide and found that testing sites in and near Black and Hispanic communities were likely to face higher demand than sites located in White neighborhoods. Similarly, the sites located in lower-income neighborhoods were expected to serve more patients than those in higher-income neighborhoods. Higher patient demand can lead to longer wait times, which may be more difficult for lower-income individuals who may have more difficulty taking time away from work and family. These types of disparities contribute to the disproportionate effect of COVID-19 on racial and ethnic minority communities across the US. The study did not account for other factors, such as the testing capacity or throughput of individual testing sites, which could affect wait times.

TESTING IN SCHOOLS A commentary published in Science argues that a major shift in testing strategy is necessary to resume in-person classes in US schools. The current US testing protocol largely relies on diagnostic testing individuals who may be sick, but it may be necessary to implement programs to test students regularly in order to increase the chance of identifying infectious individuals and limit the number of exposed individuals. This kind of testing program would test everyone, possibly every few days, regardless of whether they are believed to be infected or even exposed. This would necessitate substantially increased testing capacity, but several pre-print studies evaluate options to utilize tests that return faster results, even if they are not quite as accurate as existing diagnostic tests.

A modeling study published in JAMA: Network Open evaluated various testing strategies in the context of a simulated college student population. The simulated scenario involved 10 initial asymptomatic infections out of a total population of 5,000 students and evaluated various testing protocols, including a range of testing frequencies and test characteristics. The researchers found that testing all students every 2 days using a test with low sensitivity (70%) but high specificity (98%), in conjunction with isolating individuals with positive tests, could be a viable option to mitigating transmission risk at schools with in-person classes. The model illustrated that testing frequency may be a more important factor than test sensitivity, in terms of limiting cumulative incidence for COVID-19 outbreaks.

ISRAELI SCHOOLS As schools in the US and elsewhere plan and implement protocols for reopening schools, Israel’s experience could provide insight into some of the operational challenges and risks associated with in-person classes in the midst of a COVID-19 epidemic. Israel was one of the first countries to reopen schools on a large scale for in-person classes. As Israel began to bring its COVID-19 epidemic under control the government permitted schools to resume in-person classes in May. At that time, Israel was reporting fewer than 50 new cases per day. Almost immediately, SARS-CoV-2 transmission was reported in schools, including one of the largest outbreaks at a single school anywhere in the world. The virus quickly spread in the community as well, sparking a “second wave” of transmission that was 3 times as bad as its first. With the exception of the first weeks of students resuming in-person classes, it does not appear that Israel implemented any consistent physical distancing or other risk mitigation protocols as students nationwide returned to school, which provided ideal conditions for rapid transmission. Furthermore, a heat wave drove some schools to exempt students from wearing masks and close classroom windows in order to use air conditioning. Ultimately, Israel’s Ministry of Education “closed more than 240 schools and quarantined more than 22,520 teachers and students.”

PHILIPPINES The Philippines has reported one of the world’s most severe COVID-19 surges over the past week. The national average daily incidence increased from 1,888 new cases per day on July 30 to 4,131 today, including a daily record of 6,263 new cases reported yesterday. Reportedly, some hospitals have been forced to turn away patients due to a lack of available capacity, and “80 medical associations...called on President Rodrigo Duterte to toughen restrictions” in order to contain the surge in transmission. The organization represents more than 1 million healthcare workers nationwide. The Philippines has reported more than 115,000 cases and 2,100 deaths nationwide, and there are currently more than 47,000 active cases.

As a result of ongoing surge, President Duterte re-instituted “modified enhanced community quarantine” (MECQ; the Philippines’ version of “lockdown”) in severely affected parts of the country, including the National Capital Region. The MECQ began yesterday and is scheduled to continue through August 18. In conjunction with the MECQ, the Philippines government is also implementing enhanced contact tracing and testing, including a pilot program for pooled testing (ie, combining multiple specimens and testing the pooled sample with a single test), as well as expanding hospital and isolation capacity, with the aim of increasing the number of hospital beds by 40-50%.

Some critics of President Duterte have drawn parallels between his militaristic response to the drug trade and the pandemic response. As part of the national government’s response to the current surge, President Duterte announced that he will mobilize “military reservists” and the Philippines National Police to combat the COVID-19 epidemic. While the use of military and law enforcement resources is aimed at supporting response activities, including clinical patient care, analysis published by The Washington Post identified approximately 76,000 arrests associated with lockdown violations between March and July. Additionally, the report indicates that government officials forcefully removed suspected COVID-19 cases from their homes and placed them in government-operated quarantine facilities, sometimes based on tips provided by neighbors. Some of these tactics echo those utilized in President Duterte’s “drug war.”

The Philippines government is also coordinating with the UN and international non-governmental organizations (NGOs) to implement humanitarian response operations. The effort will involve approximately 50 UN and NGO partners, which will work to implement a variety of response activities, including ensuring access to healthcare services, food and water, and proper sanitation. The program is projected to cost US$122 million and scheduled to continue throughout 2020, the “largest response” since the Typhoon Haiyan/Yolanda in the Philippines in 2013.

US TESTING COMPACT In a bipartisan agreement, 7 US states are collaborating to invest in 3.5 million diagnostic tests in an attempt to increase testing capacity and decrease delays in obtaining test results. The governors of Louisiana, Maryland, Massachusetts, Michigan, North Carolina, Ohio, and Virginia agreed to pool financial resources to encourage manufacturers of rapid diagnostic tests to increase their production and sales capacity. The governors maintain that these rapid tests will alleviate some of the strain on states’ traditional testing infrastructure and private laboratories. Crucially, these states determined their collaboration was necessary to ensure sufficient access to diagnostic test capacity in the absence of a coordinated national plan.

In collaboration with the Rockefeller Foundation, which has agreed to provide supplemental funding, the states participating in the compact will each receive 500,000 tests. Maryland Governor Larry Hogan worked with the Rockefeller Foundation to establish the deal through his position as the co-chair of the National Governors Association. The Rockefeller Foundation stated that speed of testing should be prioritized over sensitivity at this stage in the pandemic, particularly considering that numerous reports that diagnostic test results can still take several days. 

The participating governors are currently in talks with 2 manufacturers of rapid diagnostic tests, Becton Dickinson (BD) and Quidel. The BD test uses a proprietary handheld device and can return results within 15 minutes. The BD system is already used in healthcare and pharmacy settings across the US, further decreasing access issues. Similarly, Quidel system point-of-care devices that can return results within 15 minutes. Quidel reported that more than 43,000 of their systems are already in use in healthcare facilities around the world. In addition to the multi-state testing compact, BD and Quidel are supplying rapid diagnostic tests to support the HHS strategy to increase testing in nursing homes in hotspot areas.