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

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July 10, 2020

EPI UPDATE The WHO COVID-19 Situation Report for July 9 reports 11.87 million cases (204,967 new) and 545,481 deaths (5,575 new). The WHO has reported more than 200,000 new cases for 4 of the last 6 days. The pandemic has been ongoing for more than 6 months and continues to accelerate .

India reported its highest daily incidence to date, with 26,506 new cases. India remains #3 globally in terms of daily incidence . Pakistan continues to report decreasing incidence since its peak in mid-June, and its total active cases continues to decline, dropping below 90,000 for the first time since June 15. Pakistan fell to #12 globally in terms of daily incidence. Bangladesh continues to report decreased daily incidence as well, reporting 2,949 new cases. This is only the second time since June 12 that Bangladesh reported fewer than 3,000 new cases. Notably, Bangladesh’s test positivity remains slightly greater than 20%, and the number of daily tests performed has decreased steadily since early July. This could indicate that Bangladesh's decreased incidence could be driven more by reduced testing than slowing transmission. Bangladesh is now #10 globally in terms of daily incidence.

Brazil reported 42,619 new cases, its fifth highest daily incidence to date. Brazil has not yet set a new high daily incidence this week, which could potentially indicate that its epidemic is approaching a peak or plateau. Brazil remains #2 globally in terms of daily incidence , following only the US. Mexico reported 7,280 new cases, its highest daily incidence to date and its first day with more than 7,000 new cases. Mexico surpassed Russia to become #5 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 6 of the top 13 countries globally in terms of daily incidence, including Colombia (#7), Argentina (#8), Peru (#9), and Chile (#13). Additionally, Bolivia is reporting more than 1,000 new cases per day . Central and South America also represent 5 of the top 13 countries in terms of per capita daily incidence Panama (#3), Brazil (#4), Chile (#11), Peru (#12), and Bolivia (#13).

Israel reported its highest and third highest daily incidence to date over the past 2 days—1,335 and 1,268 new cases, respectively. Israel’s epidemic continues to exhibit a concerning acceleration, after the country appeared to bring it under control for several weeks. Israel is now #10 globally in terms of per capita daily incidence . Overall, the Eastern Mediterranean Region remains a global hotspot, representing 5 of the top 10 countries in terms of per capita incidence: Bahrain (#1), Oman (#2), Qatar (#5), Kuwait (#8), and Israel. Additionally, nearby Armenia is #9. Saudi Arabia fell below 100 new cases per million, dropping it out of the top tier of countries. The region also includes several notable countries in terms of total daily incidence . In addition to Pakistan, Saudi Arabia is #11, and several other countries in the region are reporting more than 1,000 new cases per day .

Kosovo has recently reported rapidly increasing daily COVID-19 incidence , up to 214 new cases in its most recent update. While not necessarily a large number in and of itself, this now puts Kosovo at #14 globally on a per capita basis . Kosovo’s cumulative incidence is 4,100 cases, including 86 deaths.

South Africa remains among the top countries globally in terms of both per capita (#6) and total daily incidence (#4). South Africa reported 13,674 new cases , its highest daily incidence to date and more than 25% above the previous record.

After several weeks of maintaining low levels of transmission, several countries around the world are beginning to report increasing COVID-19 incidence once again. Australia, Israel, and Japan have reported increasing COVID-19 incidence since early-to-mid June as well as multiple European countries—including Austria, Luxembourg, Iceland, and Serbia. In contrast to the US, which failed to bring its epidemic under control before its resurgence, these countries appear to be facing legitimate “second waves” of COVID-19, illustrating the challenge of maintaining containment while relaxing social distancing measures. In the absence of a vaccine, it is likely that any increased social interaction (eg, from easing social distancing measures) will result in increased transmission, and we will continue to observe this pattern as countries try to balance economic activity against COVID-19 risk.

The US CDC reported 3.05 million total cases (64,771 new) and 132,056 deaths (991 new). This is the United States’ highest daily total to date, and the US has reported more than 50,000 new cases for 6 of the last 8 days. This is also the second consecutive day that the US reported more than 900 new deaths. In total, 22 states (increase of 1) and New York City reported more than 40,000 total cases, including California with more than 275,000 cases; Florida, New York City, and Texas with more than 200,000 cases; and 6 additional states with more than 100,000. The current daily incidence in the US is more than 50% higher than the first peak in mid-April, and it has increased by 165% since June 9, up from 20,338 new cases per day to 53,795 yesterday ( 7-day average ).

Regional analysis of state-level COVID-19 data illustrates several concerning trends in the US epidemic. While nationally, US COVID-19 deaths have decreased steadily over the past several weeks—before rebounding substantially in the days since the Independence Days holiday weekend—this trend is not consistent across all regions. New England, the Mid-Atlantic region, and the Midwest are all exhibiting marked declines in COVID-19 mortality, but both the South and Southwest regions are reporting increased daily deaths since early-to-mid June. Additionally, test positivity is increasing nearly nationwide, indicating that increased transmission may be outpacing the growing testing capacity. New England and the Mid-Atlantic are reporting relatively steady or slight increases in test positivity, but test positivity is increasing significantly in the Midwest, South, Southwest, and West regions, where many states are currently facing COVID-19 surges.

The Johns Hopkins CSSE dashboard reported 3.14 million US cases and 133,542 deaths as of 1:00pm on July 10.
NOTE: In Wednesday’s briefing, we mistakenly reported the number of US deaths listed on the Johns Hopkins CSSE Dashboard as 313,666. The correct number was 131,666 deaths.

DISNEY REOPENING Disney is planning to begin its phased reopening of Walt Disney World in Orlando, Florida, tomorrow. Not all areas of Disney World will reopen at the same time. Tomorrow, Disney will reopen the main Magic Kingdom park and Animal Kingdom, followed by Epcot and Hollywood Studios on July 15. Some Disney hotels and campgrounds have already begun their reopening procedures in advance of the parks.

Disney will limit the number of guests allowed in the parks per day and implement enhanced screening and hygiene measures. Temperature checks will be performed on visitors upon entry. Individuals with fevers of 100.4°F or higher will not be permitted to enter the parks. Face masks will also be required for guests over 2 years old, as well as park staff, at all times except for eating, drinking, and swimming. Notably, Disney provides specific guidance for allowable face masks, requiring a minimum of 2 layers, and neck gaiters or bandanas will not qualify as face masks at the Disney parks. Despite these and other precautions, there are many that feel Disney should not move forward with reopening the parks, particularly in light of surging COVID-19 incidence in Florida and other areas of the country. Previously, some employees signed a petition asking Disney to delay its reopening procedures.

INCARCERATED POPULATION OUTBREAK Experts have been concerned over the potential for rapid SARS-CoV-2 transmission in congregate settings such as correctional facilities. Crowded conditions, poor ventilation, poor healthcare infrastructure, and large populations with underlying conditions put incarcerated populations at elevated risk for COVID-19. San Quentin State Prison in California (US) is now experiencing exactly this situation. More than one-third of the prison population, including inmates and staff, has tested positive in the past 5 weeks. Health experts have called for correctional facilities to release inmates who pose little risk to public safety or those who have nearly completed their sentences and to implement regular testing for all inmates and staff. Notably, local researchers offered free SARS-CoV-2 testing to the facility for several months, but the prison reportedly declined.

The outbreak appears to have originated with several high-risk individuals who were transferred from another facility that was experiencing its own outbreak. The individuals were not tested within a week of their transfer, and several developed symptoms after arriving at the San Quentin facility. At least 62 inmates from the facility have been hospitalized, and 6 have died. The facility has established tents to house inmates who need to be treated or isolated. The outbreak finally garnered the attention of state legislators, who are now working to identify measures to mitigate the risk of this scenario repeating in other California correctional facilities.

SERBIA PROTESTS Thousands of Serbs protested in Belgrade, Serbia following an announcement that the national government intended to re-institute COVID-19 “lockdown” measures. Serbian President Aleksandar Vucic previously lifted many social distancing restrictions after COVID-19 incidence initially declined, which permitted activities such as sporting events to resume and business to reopen, more rapidly than many other European countries. COVID-19 incidence in Serbia has more than tripled since June 24, however, nearly returning Serbia to where it was at its first peak. Reportedly, the protesters indicated that they were more upset by the policy decisions that facilitated the resurgence of COVID-19 than they were about reinstituting the restrictions. In response to the protests , President Vucic announced that the government would not implement highly restrictive “lockdown” measures; however, the government prohibited gatherings of more than 10 people and implemented other social distancing restrictions in an effort to once again contain the epidemic.

US SCHOOLS Following a White House event addressing plans for schools to reopen this fall, in which US President Donald Trump indicated that he would pressure states to resume in-person classes, President Trump criticized the existing US CDC COVID-19 guidance for schools . He described the CDC guidance as “very tough & expensive” and called for updated guidance that would be easier for schools to follow. Subsequently, Vice President Mike Pence stated that the CDC would issue revised guidance in the coming days. Numerous experts argue that softening the CDC guidance based on factors other than the available scientific evidence will inherently increase transmission risk in school settings. In contrast to the statements by the President and Vice President, US CDC Director Dr. Robert Redfield stated yesterday that the CDC will not issue updated guidance for schools. He emphasized that the guidance is a set of recommendations, not requirements, and that states and schools are responsible for making decisions regarding whether and how to implement protective measures. He also noted that the CDC will issue additional guidance documents, but they will include supplemental information as opposed to revised guidance.

While US schools have yet to resume after most closed in March, some summer camps are operating in various parts of the country . Several camps—which, much like schools, involve prolonged close contact between children and instructors—have already reported COVID-19 outbreaks, with dozens of students and camp staff testing positive, either while at the camp or shortly after returning home. Several of these camps have closed operations as a result of the outbreaks. Camps may not necessarily adhere to the same physical distancing, hygiene and sanitation, and other COVID-19 recommendations as schools will; however, these outbreaks provide some indication that COVID-19 can spread rapidly among children and staff and potentially result in further spread in the community.

Similarly, some sports programs, including college and professional, have resumed practices, and some have been forced to alter plans due to transmission of SARS-CoV-2 among players and coaches. Multiple universities, including the University of North Carolina and Ohio State University , reportedly suspended voluntary workouts following positive SARS-CoV-2 tests among players, coaches, and staff. The Ivy League conference announced the cancellation of all fall collegiate sports for 2020, which could potentially have far-reaching impact on other conferences and universities across the country. Following that announcement, the Big Ten Conference announced that it is removing all non-conference competitions from the schedule for all fall sports. It is unclear if or how this could affect post-season tournaments, championships, and football bowl games. Additionally, Stanford University announced that it is discontinuing 11 sports programs due to financial challenges exacerbated by the COVID-19 pandemic.

US COVID-19 RESURGENCE Many parts of the US continue to battle surging SARS-CoV-2 transmission. Numerous states are reporting increasing—and in some instances, record-breaking—COVID-19 incidence, hospitalizations, test positivity, and now deaths. This recent trend has driven some to re-institute various forms of social distancing that were previously lifted or implement new policies, such as mandatory mask use. While many states have paused their recovery plans or reversed course to some degree, it may not be sufficient to contain the current level of community transmission in the most severely affected areas. Dr. Anthony Fauci recently commented that “any state that is having a serious problem...should seriously look at shutting down,” although he acknowledged that a “complete shutdown” would be an “extreme” option. So far governors have resisted re-issuing “stay at home” orders that were implemented widely earlier in the epidemic. As we move toward the scheduled start of school in the fall, state officials will likely need to make difficult decisions regarding social distancing orders, particularly considering the interdependence between children returning to school, parents returning to work, and risks of community transmission.

Reports continue to emerge of hospitals and health systems in severely affected areas struggling to cope with COVID-19 patient surge , particularly in intensive care units. States are taking a variety of approaches to mitigate stress on health systems, including ordering hospitals to implement surge capacity plans, prohibiting elective procedures, and deploying supplemental personnel to affected hospitals.

The US continues to scale up testing, but test positivity in many states continues to increase as well, indicating that existing capacity is not sufficient compared to the current level of transmission. One analysis—published in The New York Times , using data from the COVID Tracking Project—indicates that the US is only conducting 39% of the testing needed for the current scale of transmission. Notably, 22 states are conducting fewer than 50% of the necessary tests, including Arizona at 10% and 3 other states below 20%. Yesterday, Democrats on the US Senate Committee on Health, Education, Labor, and Pensions published a report on their investigation into US government efforts to scale up SARS-CoV-2 testing capacity. The senators argue that challenges with testing capacity, now and early in the US epidemic , stem from a failure of leadership and coordination at the most senior levels of government. 

UK EXPECTED TO OPT OUT OF EU VACCINE EFFORT The UK government is expected to announce that it will not participate in the EU’s vaccine development effort. Reportedly, the UK government has determined that joining the effort would result in minimal gains for the UK while potentially introducing delays in distribution due to allocation issues. Some Members of Parliament have criticized the decision, especially in the wake of the UK’s departure from the EU; however, the UK has its own vaccine development strategy already underway. In an agreement with Oxford and AstraZeneca , the UK would be among the first recipients of any vaccine that emerges from those efforts. The US has similar agreements with various pharmaceutical companies, leading some world leaders to criticize the two countries for lack of collaboration and practicing “ vaccine sovereignty .”

WHO COVID-19 RESPONSE REVIEW The WHO is establishing an independent panel to review its handling of the COVID-19 pandemic response. The effort will reportedly be led by former New Zealand Prime Minister Helen Clark and former Liberian President Ellen Johnson Sirleaf. The review is in response to an unanimous resolution passed by WHO Member States at the 2020 World Health Assembly calling for an evaluation of the global pandemic response. The resolution calls for an “impartial, independent, and comprehensive evaluation” of the WHO-coordinated international response to the pandemic. Representatives of EU countries and others, including Australia and the UK, indicate that the purpose of the review is not to assign blame, but rather, to address key epidemiological questions relevant to the response. The WHO also announced that it is sending a team of experts to China to collaborate with Chinese officials in the development of a program to identify the zoonotic origin of SARS-CoV-2 . The program will ultimately be implemented by a “WHO-led international mission.”

PPE SHORTAGES The US is once again experiencing increasing shortages of crucial personal protective equipment (PPE)—including masks, gowns, and face shields—as COVID-19 incidence and hospitalizations incidence continue to rise in many parts of the country. Several media outlets have reported that unions and associations representing nurses and doctors across the country have raised concerns about the lack of PPE and its implications for operations in a variety of healthcare settings, including hospitals and doctors’ offices. Democratic lawmakers have called on President Trump to develop a national strategy for acquiring and distributing PPE, particularly in anticipation of further increases in transmission. The President of the National Nurses United union states that calls for action from March regarding PPE supply chain limitations have still not been addressed. She also criticized President Trump for the decision to make state and local governments principally responsible for addressing PPE shortages rather than implementing a centralized and coordinated federal program. Despite statements from numerous US government officials that PPE supply is not an issue, Vice President Pence stated that guidance will be issued soon that encourages healthcare workers to reuse PPE. 

AIRBORNE TRANSMISSION Following the publication of a letter signed by more than 200 researchers and experts calling for the WHO to acknowledge the role of airborne or aerosol transmission during the COVID-19 pandemic, the WHO published updated briefing information that outlines its current understanding of SARS-CoV-2 transmission routes. The new document updates WHO guidance from late March and includes detail regarding various types of transmission, including via respiratory droplets, aerosols (also referred to as “droplet nuclei”), and fomites. The WHO continues to emphasize that respiratory droplets are the primary route of transmission Additionally, airborne/aerosol transmission is a risk during aerosol-generating medical procedures (e.g., intubation), and fomites are a potential route of transmission as well.

With respect to airborne/aerosol transmission, the WHO describes some of the available evidence supporting the role of airborne transmission; however, there is not sufficient evidence to support to suggest that it is a primary transmission route outside of aerosol-generating procedures. It remains possible that some exhaled respiratory droplets can form infectious droplet nuclei/aerosols via evaporation; however, the extent to which these contribute to transmission is unclear. While research has been conducted for other pathogens, additional investigation is needed for SARS-CoV-2 in order to more fully characterize the potential for airborne transmission. The report also includes an overview of the available evidence for other types of transmission—including from animals, vertically from mother to fetus, and via other bodily fluids such as urine or feces—and the timing of the infectious period relative to infection and symptom onset.

MASK UP AT STARBUCKS The United States’ most ubiquitous coffee chain, Starbucks, is now requiring customers to wear masks at all of its US locations, starting July 15. Mask use mandates in the US continue to vary by state; however, the new Starbucks policy will be applied consistently, regardless of the state’s policy. Customers who do not wish to wear masks may be able to purchase coffee and other products via drive-through windows, curbside pickup, or delivery. Several other national business chains have implemented similar mask mandates at all locations, including Costco , and other national chains have called on governors to mandate mask use statewide, following high-profile conflicts and incidents at stores across the country. 

PUBLIC’S ROLE IN VACCINATION While many technical and logistical challenges remain in order to develop, distribute, and administer SARS-CoV-2 vaccinations on a global scale, these are far from the only outstanding barriers. Human factors—”including understandings of disease, perceptions of risk, and social factors affecting access”—will likely affect the public’s willingness and ability to adhere to vaccine recommendations. Experts and researchers around the world are already studying factors associated with individuals’ willingness to be vaccinated , even though a vaccine is still months away at the very earliest. The Johns Hopkins Center for Health Security , in collaboration with experts from Texas State University, published a report outlining analysis and recommendations from the Working Group on Readying Populations for COVID-19 Vaccine.

The recommendations focus on establishing trust with the public and providing reliable and factual information—including on “vaccine risks, benefits, and supply”—so that they can make informed decisions regarding protective actions like vaccination. Equitable allocation and distribution and transparency about associated decisions also builds trust, and officials must implement efforts to ensure that the vaccine is available at times and in locations that are reasonably convenient for everyone to mitigate barriers to accessing the vaccine. Like existing vaccination programs, misinformation will remain a major challenge for experts, officials, and communicators. Effective oversight and transparent review of vaccination data, including for adverse events, will be critical to maintaining trust and demonstrating positive benefit for individuals and communities in the face of misinformation and opposition.