Updates on the COVID-19 pandemic from the Johns Hopkins Center for Health Security.

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EPI UPDATE The WHO COVID-19 Dashboard reports 62.66 million cases and 1.46 million deaths as of 5:15am EST on December 1. The WHO surpassed 60 million cumulative cases on November 26. From the first COVID-19 case, it took 90 days for the global total to reach 1 million cases. From there:
1 million to 10 million- 86 days
10 to 20 million- 44 days
20 to 30 million- 37 days
30 to 40 million- 31 days
40 to 50 million- 21 days
50 to 60 million- 17 days

The US CDC reported 13.30 million total cases and 266,051 deaths. The US surpassed 13 million cumulative cases on November 28. From the first case reported in the US on January 22, it took 96 days to reach 1 million cases. From there:
1 to 2 million- 44 days
2 to 3 million- 27 days 
3 to 4 million- 15 days
4 to 5 million- 17 days
5 to 6 million- 22 days
6 to 7 million- 25 days
7 to 8 million- 21 days
8 to 9 million- 14 days
9 to 10 million- 10 days
10 to 11 million- 7 days
11 to 12 million- 5 days
12 to 13 million- 7 days

The US reported 12,999,624 cases on November 27, and it is likely that the US would have surpassed 13 million cases a day earlier, if not for delayed reporting over the Thanksgiving holiday.

The US COVID-19 average daily incidence and mortality both reached a peak over the Thanksgiving holiday weekend. On November 25, the US reported 173,518 new cases per day, a new record, and 1,658 deaths per day, the highest average since May 11. Both the daily incidence and mortality fell sharply since then, which is likely an artifact of reporting delays over the holiday weekend. Some of the direct effects of the Thanksgiving holiday are readily evident in the CDC’s COVID-19 incidence reporting. As expected during a normal week, the daily incidence increased for data collected November 23-25, corresponding to Monday through Wednesday (the final workday before Thanksgiving, which falls on a Thursday). The reported incidence fell sharply on Thursday, November 26 (Thanksgiving Day); jumped back up on Friday, November 27; and then fell again for the weekend reports on November 28-29.

It appears as though the national daily incidence may have passed an inflection point in mid-November. Prior to Thanksgiving, the daily incidence in a number of states—including Illinois, Iowa, North and South Dakota, and Wisconsin, all of which exhibited very high incidence during the current surge—began to taper off. However, with the interruptions to COVID-19 reporting and the varying trends at the state level, it could be a little more difficult to anticipate daily incidence trends over the next week or so. Regardless of what the daily incidence trend looks like in the wake of Thanksgiving, COVID-19 mortality in the US will likely continue to increase due to consistent and sharp increases in daily incidence over the past several weeks.

It will be critical to monitor these trends over the coming weeks to determine the impact of Thanksgiving travel and gatherings. Any spikes in cases this week are likely attributable to disruptions in reporting over the holiday. It will likely take 2-3 weeks before we begin to see any actual effects from Thanksgiving in cases and hospitalizations and several weeks after that before we could observe early signs in terms of mortality. We have observed this timing following several other US holidays or major events in 2020, including Memorial Day (May 23-25) and Labor Day (September 5-7)/the return of students to college and university campuses (early September). If the US epidemic follows a similar timeline after Thanksgiving, we could potentially start to see increasing daily incidence in the US the week of Christmas and surging mortality early in 2021. With that in mind, however, reporting over the weeks of Christmas and New Year’s are also expected to be inconsistent, so the effect of the holiday season on the US epidemic may not be apparent until well into January.

The Johns Hopkins CSSE dashboard reported 13.58 million US cases and 268,880 deaths as of 12:30pm EST on December 1.

US ISOLATION & QUARANTINE DURATION Last week, White House Coronavirus Task Force member ADM Brett Giroir commented that senior health officials are reevaluating the recommended time that individuals should quarantine after a known exposure to SARS-CoV-2 with an eye toward shortening the quarantine period. A recent study published in The Lancet found that the length of time that individuals can shed viable SARS-CoV-2 is shorter than previously believed. The US CDC currently recommends that exposed individuals quarantine for 2 weeks after their last close contact with a COVID-19 case and that infected individuals should isolate for at least 10 days after the onset of symptoms and at least 24 hours after the fever resolves. Updated CDC guidance could potentially include a provision to shorten quarantine or isolation if accompanied by negative results for a diagnostic test administered after a certain amount of time. This story was initially covered by news media outlets this time last week; however, no formal announcement has been made regarding changes to the official CDC guidance.

Reducing the quarantine or isolation period could potentially increase compliance by individuals who are not willing or able to isolate or quarantine for the full period currently recommended by the CDC. It could also reduce the impacts on employers and the US economy that result from workers being unavailable to perform in-person duties. There are concerns, however, that removing individuals from quarantine or isolation earlier could result in transmission by individuals who become or remain infectious after that point.

US LONG-TERM CARE FACILITIES As we have covered previously, residents of nursing homes and other long-term care facilities remain at high risk for severe COVID-19 disease and death. A report published on November 25 by the Kaiser Family Foundation finds that more than 100,000 COVID-19 deaths have been reported in the US among long-term care facility residents and staff. Notably, the cumulative total jumped from 84,136 in October to 100,033 in November, the highest 1-month increase since May. The report notes that these figures are likely an underestimate of COVID-19 deaths at these facilities, including due to delays in reporting—and no reporting at all by Alaska. Long-term care facilities account for 40% of all US COVID-19 deaths.

The ongoing COVID-19 surge in the Midwest region, and across most of the US, is fueling outbreaks in nursing homes and other long-term care facilities. In South Dakota, for example, the number of cases reported at these facilities tripled over the past month. Additionally, the total number of facilities reporting COVID-19 cases is approximately 30% higher than previous peaks, with more than 1,300 facilities nationwide reporting cases in the first week of November alone. In one long-term care facility for military veterans in Illinois, 4 cases identified in early November grew to nearly 200 cases within 3 weeks, resulting in at least 28 deaths. Health officials and experts as well as representatives for long-term care facilities across the country continue to call on the federal government to provide additional funding and support to help these facilities prepare for, prevent, and respond to COVID-19 outbreaks.

US VACCINE ALLOCATION As vaccine candidates get closer to receiving Emergency Use Authorizations (EUAs) under the US FDA, officials and health experts are working diligently to determine how the first doses should be allocated. Officials from the White House’s Operation Warp Speed announced that the initial doses purchased by the US government will be allocated to states based on population. From there, the current plan is for states to determine how best to allocate their allotted vaccines to individuals.

Prioritizing the initial limited supply of vaccine doses is a major challenge, with a number of competing factors with respect to determining which individuals are the highest priority. Last week, the CDC’s Advisory Committee on Immunization Practices (ACIP), which issues recommendations for a variety of vaccines used in the US, presented its preliminary guidelines regarding “phased allocation” of SARS-CoV-2 vaccines. The preliminary guidance indicates that the highest priority (Phase 1a) should include frontline healthcare workers and residents in long-term care facilities. Phase 1b would expand access to other essential workers, including in the education, food and agriculture, public utility, law enforcement and corrections, emergency response (e.g., firefighters), and transportation sectors. And Phase 1c would include those at elevated risk for severe COVID-19 disease, including those with underlying health conditions and those aged 65 and older. The Phase 1 plan received general agreement from the ACIP members, but additional data and discussion were needed.

The CDC announced an emergency meeting of ACIP, held today from 2-5pm EST, with the aim of finalizing the initial allocation guidance. Considering that the US FDA’s Vaccines and Related Biological Products Advisory Committee is scheduled to meet on December 10 to discuss the EUA application for Pfizer’s candidate SARS-CoV-2 vaccine and that US states are supposed to submit vaccination plans this week, the CDC wants to finalize the allocation plans in order to mitigate any delays in initiating mass vaccination efforts. ACIP is expected to formally approve Phase 1a, but further analysis and discussion may be needed before developing and approving the guidance beyond that. The meeting is scheduled for 2-5pm EST today, and the proceedings will be streamed live.

EUROPE As a whole, Europe has passed the peak of its current COVID-19 wave, and while a number of European countries have not yet turned the corner, some are beginning to announce plans to relax social distancing restrictions. The UK recently unveiled its COVID-19 Winter Plan, which outlines steps to return England to a “regional, tiered approach” to COVID-19 restrictions as opposed to a nationwide “stay at home” order. Retail stores, gyms and fitness centers, and other businesses will be permitted to reopen, and highly restrictive limits on attendance at religious services, weddings and funerals, and outdoor gatherings will be relaxed. The regional restrictions are scheduled to resume on December 2.

The UK government also announced COVID-19 policies specifically for the upcoming Christmas holiday, which will apply to all 4 countries in the UK—England, Northern Ireland, Scotland, and Wales. The Christmas plan “will allow some increased social contact for everyone,” including through the use of a “Christmas bubble.” The Christmas bubble can consist of individuals from up to 3 different households, and individuals in the bubble can gather in private homes, places or worship, and other locations without being limited by regional tiered restrictions. The Christmas bubble announcement comes at the end of a year in which holidays, ceremonies, and festivals across all religions have been muted by COVID-19 restrictions. The relaxation of COVID-19 gathering and travel restrictions specifically tied to Christmas, in the UK and other European countries, has generated frustration among some members of non-Christian religions, particularly those who faced restrictions earlier in the year during their own religious holidays. There is also concern that the temporary relaxation of COVID-19 restrictions that would permit increased travel and larger gatherings could result in another surge early in 2021. European governments are attempting to balance COVID-19 health risks against religious practices, social gatherings, and broad economic impact associated with Christmas.

France is also scaling back its COVID-19 restrictions. On November 24, French President Emmanuel Macron announced a timeline and epidemiological metrics for easing some social distancing restrictions over the coming weeks. Beginning on November 28, France eased travel restrictions and permitted outdoor activities to resume and some retail businesses and home services to reopen. If France is able to reduce daily incidence to fewer than 5,000 new cases per day and intensive care hospitalizations to fewer than 3,000 patients, it could enter the next phase, which will further reduce travel restrictions; allow theaters, cinemas, and museums to reopen; and permit indoor recreational activities. And if the epidemiological conditions are satisfactory on January 20 (not specified explicitly), restaurants and indoor sports facilities can reopen and high school students can resume in-person classes.

While some European countries are beginning to remove restrictions, others are extending current COVID-19 measures. For example, Greece is reportedly extending its current “lockdown” period by a week, through December 7, following a record high 121 deaths on November 28. Greece’s daily COVID-19 incidence peaked in mid-November, but the government has been fairly aggressive in terms of implementing COVID-19 restrictions. One of Greece’s principal concerns is that long-term economic struggles have negatively impacted national health system capacity, and implementing restrictions earlier and longer than other European countries could curb transmission before hospitals are overwhelmed. The current lockdown began in early November, with highly restrictive measures, including a requirement for individuals to notify the government via text/SMS message before leaving their homes. Reportedly, Greece recently issued more than €500,000 in fines and ordered a 15-day closure of multiple businesses in a single day following violations of national COVID-19 restrictions.

ASTRAZENECA VACCINE TRIAL DATA Following the release of interim Phase 3 clinical trial data for its candidate SARS-CoV-2 vaccine, AstraZeneca and the University of Oxford (UK) are facing criticism regarding the circumstances surrounding findings that indicated 90% efficacy in participants who received a half-dose in the first of their 2 injections, which was considerably higher than in participants who received 2 full doses. Beyond the unexpected results—i.e., higher efficacy among participants receiving smaller doses—the fact that the researchers inadvertently administered the wrong dose to a portion of the study group raised serious concerns, particularly because this was omitted from the press release announcing the interim results.

A number of factors could be influencing the higher efficacy reported among the subset of participants who received the initial half-dose, and further investigation is needed. Perhaps most notably, the participants who received the half-dose were reportedly all aged 55 years and younger, who would be at lower risk for severe disease and death than older individuals (e.g., age 65 years and older). Experts from around the world, including at the University of Oxford and the WHO, have called on AstraZeneca to publish more detailed trial data. Reportedly, AstraZeneca aims to publish the full data and analysis in a peer-reviewed journal “within the next week or so.” A senior executive for AstraZeneca dismissed concerns about the accidental half-dose and emphasized that the overall 70% efficacy still exceeds the minimum threshold of 50% set by multiple national-level regulatory agencies. While 70% would be sufficient for a novel SARS-CoV-2 vaccine, it is still below the 90-95% reported by Pfizer and Moderna.

MODERNA VACCINE EUA APPLICATION Moderna Therapeutics announced that the Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine reached the primary efficacy endpoints. In total, the trials detected 196 cases of COVID-19 among 30,000 total participants, including 185 cases among the placebo group. This corresponds to an overall efficacy of 94.1%, nearly identical to the 94.5% efficacy based on preliminary Phase 3 trial data announced on November 16. The most recent press release also indicates that the vaccine demonstrated similar efficacy across all “age, race and ethnicity, and gender demographics.” Additionally, Moderna reported that all 30 severe cases of COVID-19, including 1 death, were among participants in the placebo group, demonstrating that the vaccine is capable of substantially mitigating risk of severe COVID-19 disease.

Yesterday, Moderna submitted requests for Emergency Use Authorization to the US FDA and Conditional Marketing Authorization to the European Medicines Agency. Moderna expects the US CDC’s Vaccines and Related Biological Products Advisory Committee to meet to review its vaccine clinical trial data on December 17, one week after the committee meets to review the Pfizer vaccine. If the vaccine receives an EUA, Moderna’s CEO, Stéphane Bancel, indicated that vaccinations could begin as early as December 21. Evaluation of the vaccine is already underway in multiple other countries, including Canada, Israel, Singapore, Switzerland, and the UK. While limited data are presented in the press release, Moderna committed to publish more detailed data and analysis in a peer-reviewed publication.

In addition to the clinical trial data, Moderna announced that it finalized an agreement to provide an additional 2 million doses of the vaccine to the UK government, bringing the UK’s purchase from Moderna to 7 million total doses.

UK VACCINE AUTHORIZATION The UK is on track to be the first country to authorize the Pfizer COVID-19 vaccine for use among its citizens. The UK’s Medicines and Healthcare Products Regulatory Agency is currently conducting an expedited review of Pfizer’s vaccine candidate, under a special government rule to bypass certain EU regulatory processes. Sources indicate that the authorization could be announced as early as December 7, with distribution beginning that same day. It has been reported that British hospitals were told on Sunday to prepare for vaccine rollout within the next 10 days. The UK has ordered 40 million doses of the Pfizer vaccine, which corresponds to 20 million individuals at 2 doses per person. According to a report from the UK’s Joint Committee on Vaccination and Immunisation, long-term care facility and nursing home residents and associated healthcare workers are the first priority group for vaccination, with adults aged 80 years and older and NHS healthcare workers following in the next tier.

While the Pfizer vaccine would be the first to be distributed in the UK, it is unlikely to be the only candidate that will eventually be used in the country. The UK has invested in 7 different vaccine candidates from various companies, with the majority of the UK’s investment going to vaccine developed by UK-based AstraZeneca and the University of Oxford. Out of a total of 350 million doses purchased across all seven candidates, 100 million of those doses are expected to come from AstraZeneca. The UK government directed MHRA last week to begin evaluating the AstraZeneca data for safety, quality, and efficacy. If authorized for use, this vaccine could be rolled-out not long after the Pfizer product.

NORTH KOREA While North Korea has yet to officially report a single case of COVID-19, intelligence sources suggest that government officials are taking extreme measures against the pandemic. It is difficult to understand exactly what the North Korean approach is to COVID-19, but recent intelligence updates can provide some insight. While North Korea typically maintains highly restrictive limitations on international travel, travel to and from the country has stopped almost completely. Additionally, North Korea is believed to have drastically decreased trade with China, its only major trading partner, likely in an effort to prevent COVID-19 from entering the country. China accounts for at least 90% of all trade with North Korea, so the reduction in imports and exports will have significant impacts on the North Korean economy and the North Korean people. In addition to stricter border controls, sources believe that large-scale lockdowns have also been put into place. 

TRAVEL The travel sector, particularly the airline industry, has been among the hardest hit during the COVID-19 pandemic, largely due to a combination of travel restrictions and traveler concerns about exposures in other countries or during travel. Air travel has steadily started to increase compared to earlier in 2020, and many airlines have made major changes to their normal operations and requirements for passengers, including enhanced cleaning and hygiene practices, increased physical distancing, and mask mandates. Now, more airlines are considering testing requirements and, with potential vaccines on the horizon, vaccination requirements for passengers. Delta Airlines recently announced a “COVID-free” route from Atlanta to Rome that would require passengers to take 3 separate tests: 2 leading up to departure and 1 upon arrival. The first test would be a PCR-based test taken no later than 72 hours before departure. The second test would be a rapid antigen test at the gate before boarding. A third test, also a rapid antigen test, would be administered upon landing in Rome and before clearing through customs. Travelers will also be required to undergo another rapid antigen test prior to boarding their return flight to the US. Epidemiological models, developed in conjunction with experts at the Mayo Clinic (Minnesota, US), estimate that the new protocols will significantly decrease transmission risk on Delta’s flights, potentially as low as “one in a million.” 

With the prospect of a SARS-CoV-2 vaccine in the near future, some airlines are considering mandating vaccination for travelers. The CEO of Australia-based airline Qantas stated that customers will be required to provide proof of vaccination before taking international flights. He also indicated medical issues “should be the only basis” for exemptions to the vaccination policy, which suggests that personal belief or religious exemptions may not be accepted by the airline. The International Air Transport Association (IATA) is preparing for these types of mandates by developing its IATA Travel Pass smartphone application, which will allow travelers to input and present their vaccination and testing information to relevant travel authorities. The application will be free for travelers and will include information on their destination’s travel restrictions and requirements and will provide digital security for personal medical information related to COVID-19.