Daily updates on the emerging novel coronavirus pandemic from the Johns Hopkins Center for Health Security.

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July 1, 2020

Our office will be closed Friday, July 3, in recognition of the Independence Day holiday (US) this weekend. The next COVID-19 update will be sent on Monday, July 6.

EPI UPDATE The WHO COVID-19 Situation Report for June 30 reports 10.19 million cases (163,865 new) and 503,862 deaths (3,946 new). The global cumulative incidence surpassed 10 million cases in Monday’s Situation Report , and global deaths surpassed 500,000 yesterday (499,913 as of Monday). The pandemic has been ongoing for 6 months, and it continues its recent trend of exponential growth . In terms of daily incidence , Asia, North America, and South America are reporting approximately the same number of cases, and Africa is now reporting essentially the same number of cases as Europe.

India reported 18,653 new cases. While fewer new cases than in recent days, this is consistent with India’s reporting pattern, and we expect it to set new records for daily incidence as the week continues. India is currently #3 globally in terms of daily incidence . Pakistan reported 4,133 new cases. Following its peak on June 13 (6,825 new cases), Pakistan has consistently reported lower daily incidence, approximately 3-4,000 new cases per day over the past week. Pakistan is now #10 globally in terms of daily incidence. Bangladesh reported 3,775 new cases. Bangladesh’s epidemic appears to be continuing along its increasing trajectory; however, it may be tapering off slightly over the past week. Additional data is needed to better understand longer-term trends. Bangladesh remains at #9 globally in terms of daily incidence.

Brazil reported 33,846 new cases. While its reported incidence for Sunday and Monday were elevated compared to previous weeks, yesterday’s update is lower than the past 2 Tuesdays. Brazil is currently #2 globally in terms of daily incidence , but it is reporting large fluctuations from day to day. Mexico reported 4,429 new cases. While Mexico’s early week incidence is lower than the previous week, it is still elevated compared to weeks prior to that. Based on recent trends, we expect Mexico to report increasing daily incidence over the coming days; however, it is possible that Mexico could be approaching a peak. Mexico remains #6 globally in terms of daily incidence. Broadly, the Central and South American regions are still a major COVID-19 hotspot. Including Brazil and Mexico, the region represents 5 of the top 12 countries globally in terms of daily incidence—including Chile (#8), Colombia (#11), and Peru (#12). Additionally, Argentina is reporting more than 1,000 new cases per day . Central and South America also represent 3 of the top 7 countries in terms of per capita daily incidence Panama (#3), Chile (#5), and Brazil (#7).

Overall, the Eastern Mediterranean Region remains a global hotspot as well, representing 5 of the top 9 countries in terms of per capita incidence : Bahrain (#1), Qatar (#2), Oman (#4), Kuwait (#6), and Saudi Arabia (#9). Additionally, nearby Armenia is #12. The region also includes several notable countries in terms of total daily incidence . In addition to Pakistan, Saudi Arabia is #7, and several other countries in the region are reporting more than 1,000 new cases per day .

South Africa is among the top countries globally in terms of both per capita (#11) and total daily incidence (#5). South Africa reported 6,945 new cases , its second highest daily total to date, and its epidemic continues to accelerate.

The US CDC reported 2.58 million total cases (35,664 new) and 126,739 deaths (370 new). In total, 19 states (no change) and New York City reported more than 40,000 total cases, including California and New York City with more than 200,000 cases; New Jersey, New York state, and Texas with more than 150,000; and Florida and Illinois with more than 140,000. Following an overall decrease in daily incidence from mid-April through the end of May, the United States is now consistently reporting higher daily incidence than at its first peak in mid-April. The United States’ daily incidence has more than doubled since June 9, up from 20,338 new cases per day to 40,948 yesterday ( 7-day average ). The United States’ epidemic is currently following a similar trajectory to what was observed leading up to its first peak.

US disease surveillance reporting is notorious for being low early in the week, especially Mondays and Tuesdays, due to delays in reporting over the weekend. This is particularly true at the national level, as the CDC must compile reports from the states. With that in mind, the CDC reported 41,390 new cases on Monday and 35,664 new cases on Tuesday. These represent the United States’ fourth and eighth highest daily incidence to date, respectively. We expect the reported incidence to increase over the rest of the week, which will likely set new records for national daily incidence. The current daily incidence is more than 30% higher than the country’s first peak on April 10 ( 7-day average ), and there is currently no indication of it slowing. The New York Times analysis indicates that 35 states are reporting increasing incidence over the past 2 weeks, and at least half appear to have set records for daily incidence over that period.

The Johns Hopkins CSSE dashboard reported 2.64 million US cases and 127,485 deaths as of 11:30pm on July 1.

EU TRAVEL RESTRICTIONS As European countries continue to control their respective COVID-19 epidemics, the European Union released updated travel provisions which will allow the bloc to begin opening borders to outside countries . The European Commission approved recommendations to begin allowing travelers from countries outside the continent, based on the current epidemic situation in those countries. In particular, eligible countries will be determined based on epidemiology, containment measures in place, and “economic and social considerations.” The initial announcement includes a list of 15 countries that meet the current standards, representing all other continents. Notably, but not surprisingly, travelers from the United States , where the COVID-19 epidemic is growing exponentially, are still restricted from traveling to European countries. The plan takes effect today, following the expiration of previous travel restrictions yesterday. 

VIRAL MUTATION As the COVID-19 pandemic accelerates, researchers continue to look to the SARS-CoV-2’s genome to identify critical factors that drive transmissibility and disease severity. One mutation in particular, to the gene responsible for the virus’ spike protein , is garnering increased attention. The prevalence of the mutation appears to be increasing in COVID-19 patients, which could potentially indicate that it has some evolutionary advantage over other variants of the virus. The spike protein enables SARS-CoV-2 to infect human cells by attaching to the cells’ ACE2 receptor. There are several theories about how and why this particular mutation is spreading. Some speculate that the mutation changes the spike protein in a way that makes it easier to infect human cells, which could make the virus more transmissible. Additionally, the mutation could enable the virus to replicate more efficiently once it infects someone, which could increase viral load and make those individuals better able to transmit the infection to others. At this time, the mutation does not appear to have an effect on disease severity.

The mutation appears to have spread to the United States via Europe , as opposed to directly from China, so its prevalence could also be a result of widespread transmission among high-risk populations in Europe earlier in the pandemic (eg, older individuals in Italy) rather than a direct result of any associated evolutionary advantage. Several studies (all preprint or not yet published) attempt to provide some insight into this phenomenon; however, additional research is required to better characterize the effect of this mutation and any potential role in facilitating transmission.

REMDESIVIR PRICE Gilead Pharmaceuticals announced the price for its antiviral drug, remdesivir . The announcement comes after a number of studies demonstrated that the drug has some efficacy in treating COVID-19 patients. According to multiple reports, Gilead will charge at least US$2,340 for a 5-day treatment course (for the US Indian Health Services and the Department of Veterans Affairs) in the United States. Private insurance companies as well as Medicare and Medicaid will be charged US$3,120 for the same amount. Gilead indicated that it will charge other developed countries the same price as the United States. Some experts have criticized the price as too high, arguing that cost should not be prohibitive for any patient, particularly in the midst of a pandemic. Gilead’s CEO, Daniel O’Day , published an open letter discussing the company’s cost evaluation, and he argues that the cost saved by shortening the treatment time and hospitalization stay far outweighs the cost of the drug.

Low-and-middle-income countries may be able to acquire a generic formulation of the drug at a discounted price, but this could vary from country to country. The US FDA issued an Emergency Use Authorization (EUA) for remdesivir in early May. Following the price announcement, the US Department of Health and Human Services (HHS) announced that it has secured 500,000 treatment courses of the drug, and it will coordinate national distribution.

US RESPONSE As the daily COVID-19 incidence continues to increase in the United States, senior health experts warn that this could be only the beginning of a much larger epidemic. US CDC Principal Deputy Director Dr. Anne Schuchat commented this week that SARS-CoV-2 is “spreading too rapidly and too broadly for the U.S. to bring it under control.” The current rate of transmission is exceeding contact tracing and isolation capacity, which is facilitating further community transmission. During his testimony to the US Senate Health and Education Committee, Dr. Anthony Fauci projected that the United States could soon face more than 100,000 new cases per day. He also noted that some states have progressed through their recovery plans too quickly, disregarding key metrics and federal guidance in an effort to quickly resume social and economic activity, and that these efforts are contributing to increased transmission.

Texas continues to report concerning COVID-19 trends, posting record highs for daily incidence , test positivity , and hospitalized COVID-19 patients over the past several days. Texas is reportedly facing limited testing capacity relative to its current level of transmission. Public testing sites in Dallas and Houston have been forced to close early, by noon or early afternoon, after reaching their daily testing capacity. Travis County home of Austin, Texas' capital city recently limited public testing sites to symptomatic individuals only in order to prioritize the use of limited testing capacity. While testing capacity has increased, it is being outpaced by increased community transmission. Without adequate testing capacity, health officials cannot accurately understand the scale of community transmission, which was a major problem early in the US epidemic.

The decision last week by Governor Greg Abbott to close bars statewide in an effort to mitigate transmission risk prompted protests by some bar owners and patrons , several of whom threatened to reopen despite the governor’s order. Officials from the Texas Alcoholic Beverage Commission reportedly visited nearly 1,500 businesses statewide over the weekend to verify compliance with the order, and they were forced to suspend the liquor license for several bars that refused to comply.

In light of increasing hospitalizations and test positivity statewide, Ohio Governor Mike DeWine extended several existing statewide health orders through this week, while officials update the state’s recovery plans. The updated plan is scheduled to be published tomorrow. The existing orders apply to a variety of economic sectors, including retail businesses, restaurants, gyms, entertainment, and other services as well as schools, camps, and child care. At the local level, cities continue to implement their own mask mandates. Franklin County —home to Columbus, the state’s capital city—announced that it will support city efforts to mandate mask use, although it will not institute a countywide policy. The county’s decision aims to publicly establish a position by the county health department that can lend support to decisions by city officials.

Kansas Governor Laura Kelly announced that she will issue an executive order mandating mask use statewide. The order will apply to individuals in public spaces where it is not feasible to maintain appropriate physical distancing (eg, 6-foot separation), including stores and restaurants. The order is scheduled to take effect on Friday, July 3, but it has not yet been published. Governor Kelly also issued executive orders to extend some provisions enacted as a result of the COVID-19 epidemic, including temporary extensions for government licensing (including driver’s licenses), tax deadlines, vehicle registration, and other government functions as well as suspension of certain requirements regarding unemployment benefits .

Jacksonville, Florida , also recently implemented mandatory mask usage in public spaces. Like many aspects of the US COVID-19 response, the use of face masks has been heavily politicized by elected officials at all levels of government. Notably, Jacksonville is scheduled to host the 2020 Republican National Convention in August, a major event leading up to the 2020 election in November. It is unclear if or how the mask mandate will impact the convention. The Republican Party previously moved the convention from North Carolina to Jacksonville, reportedly over disagreements with North Carolina state officials regarding social distancing policies and restrictions, including on mass gatherings.

VACCINE ALLOCATION Currently, more than a dozen vaccine candidates have entered clinical trials , with some already entering Phase 3 trials or even receiving limited authorization for use in certain populations . Discussions are already underway to determine how a SARS-CoV-2 vaccine could be allocated if and when one is determined to be safe and effective. While certain populations, such as healthcare workers, may be clear priority groups vaccination, others, such as pregnant women, may have more complex considerations. The WHO released a high-level framework outlining possible global vaccine allocation strategies, which generally prioritize healthcare workers and high-risk populations, including adults over the age of 65 and those with certain underlying health conditions.

The US CDC Advisory Committee on Immunization Practices (ACIP) also met last week to discuss SARS-CoV-2 vaccine allocation for the US population. Currently, allocation schemes are roughly based on previously published plans for distribution of pandemic influenza vaccines ; however, there are notable differences between COVID-19 and influenza epidemiology that could potentially affect how groups are prioritized. In light of increasing discussions, in the United States and elsewhere, regarding systemic racism, racial and social inequities, and increased vulnerability to COVID-19 among racial and ethnic minorities, determining whether and how to factor race and ethnicity into prioritization decisions is a critical issue as these discussions move forward. 

REOPENING SCHOOLS As US states continue to implement COVID-19 recovery plans, the issue of resuming schools in the fall is increasingly important. The American Academy of Pediatrics published guidance on how to safely reopen schools, which strongly supports the goal of having children physically present in classrooms. In particular, these experts highlighted evidence indicating that children are not drivers of SARS-CoV-2 community transmission and emphasized the negative aspects of virtual education, including substantial barriers to learning and social isolation among children at a critical point in their social development. Additionally, many vulnerable and low-income children who rely on school services and meal programs lost access to those vital resources when schools closed, and resuming in-person schooling could enable them to access these services once again. Furthermore, reopening schools is a crucial component of resuming economic activity and reopening businesses , as parents will need to be able to return to work in the coming months, which could be difficult with children at home all day rather than in school. The guidance outlines higher- and lower-priority strategies for in-person education during the pandemic across all grade levels, from pre-kindergarten to secondary schools, as well as special education programs.

It is important that reopening decisions also consider the benefits and risks for teachers , as approximately one-third of teachers are over the age of 50, which puts them at elevated risk of severe COVID-19 disease and death. Some have argued that effective infection prevention and public health measures—such as increased physical distancing, greater emphasis on hygiene, and formation of social bubbles that limit student interactions—can mitigate possible risks of reopening schools, but implementing these efforts on this scale, among a pediatric population, and over a prolonged period of time could make this difficult.

BRAZIL TRAVEL RESTRICTIONS Brazil will reportedly suspend travel from nearly every country for 30 days as a result of COVID-19. Reuters reported that Brazil officially announced that most travelers originating from another country will not be permitted to enter Brazil, but we have not yet been able to locate an official source. Exceptions will include Brazilian citizens and permanent residents and travelers transiting through Brazil (as long as they do not leave the airport). Additionally, Venezuelan citizens will be permitted to cross the land border between the two countries.

ASYMPTOMATIC AND PRE-SYMPTOMATIC INFECTIONS Several recently published studies provide insight into asymptomatic SARS-CoV-2 infection. The first, published ( preprint ) by researchers in Italy, utilized the results of diagnostic and serological tests for 5,484 individuals to determine the prevalence of asymptomatic infection. Symptomatic cases were defined by the presentation of respiratory symptoms or a fever, and participants were tracked over time to identify any that developed symptoms after testing. These individuals represent 3,420 COVID-19 clusters in Lombardy, Italy, for which all identified contacts had been tested. Of these contacts, 2,824 (51.5%) were determined to be infected. Among the infected individuals, 876 (31.0%) ultimately developed symptoms. Notably, the proportion of symptomatic cases increased with age—ranging from 18.1% for individuals younger than 20 to 64.6% for individuals 60 years and older.

Another study conducted on an incarcerated population in Louisiana aimed to characterize asymptomatic infection and presymptomatic cases. The study, published in the US CDC’s Morbidity and Mortality Weekly Report ( MMWR ), utilized data from diagnostic tests conducted serially on incarcerated and detained individuals at a single facility. Following the onset of a COVID-19 outbreak at the facility, diagnostic tests were administered 3 times over a period of 2 weeks, along with symptom screening. The study found that symptom screening alone would have missed a significant number of pre-symptomatic cases and asymptomatic infections. Of 98 individuals tested on Day 1, 53 were positive. Those with negative tests were tested again on Day 4, and another 16 were positive. Of the 29 individuals who tested negative the first 2 times, 2 more were positive on Day 14. In total, 71 total individuals tested positive. Of these individuals, 3 (4%) were presymptomatic at the time of their positive test (ie, asymptomatic at the time of the test and later developed symptoms), and another 29 (41%) were completely asymptomatic.

Studies of asymptomatic infection and serological prevalence have reported a broad range of results. These studies illustrate that a significant proportion of infected individuals either never develop symptoms or could test positive for SARS-CoV-2 infection prior to the onset of symptoms.

MULTISYSTEM INFLAMMATORY SYNDROME T he New England Journal of Medicine ( NEJM ) recently published 2 articles that aim to quantify the occurrence and characteristics of multisystem inflammatory syndrome in children (MIS-C). MIS-C has been found to be associated with SARS-CoV-2 infection in children and young adults. It presents with symptoms similar to Kawasaki’s disease, and both conditions have been linked to hyperinflammatory responses as a result of infection. O n e study reported on 186 pediatric MIS-C patients across 26 US states from mid-March to mid-May. Among the participants, 73% were previously healthy, and 70% tested positive for SARS-CoV-2 infection. Additionally, 88% were hospitalized after April 16. Kawasaki’s Disease-like symptoms were identified in 74 (40%) of the patients.

The second study reported on 99 confirmed and suspected MIS-C patients in New York from March 1 to May 10. Of note, the New York study found that Black (40%) and Hispanic (36%) children were over-represented among the MIS-C cases in the study population compared to the demographics of the local community. Existing data indicates that communities of color are more vulnerable to COVID-19 exposure; however, additional study is needed to better characterize any association. Among the 94 confirmed cases of MIS-C who were tested for SARS-CoV-2, 19 (20%) tested positive using a diagnostic test and 77 (81% tested positive using a serological test—31 (33%) tested positive for both tests. Symptoms of Kawasaki’s Disease were more common among younger children than in adolescents.