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 July 21 reports 14.56 million cases (213,637 new) and 607,781 deaths (4,083 new). The pandemic has been ongoing for more than 6 months and continues to accelerate .
NOTE: The July 20 WHO Situation Report included an erratum stating that the US daily incidence for July 19 was 74,354 cases (not included in the July 19 Situation Report ), and the epi curve displayed the updated global incidence for that date, approximately 240,000 cases.

At least 9 countries are reporting test positivity greater than 20%, considerably higher than the WHO recommendation of 5% to support easing social distancing measures. Of these countries, 6 are located in the Americas: Argentina, Bolivia, Colombia, Costa Rica, Mexico, and Panama. The top tier also includes Bangladesh, Oman, and South Africa. Notably, all of these countries are reporting increasing test positivity as well, which indicates that transmission is outpacing national testing capacity. Other notable countries include India  at 10.3% (more than tripled since May 3) and the US at 8.5% (up nearly 90% since June 16). Test positivity data are unavailable for many countries, so it is likely that additional countries around the world are facing similar challenges. While these figures are concerning, a number of countries are reporting low test positivity, including Australia, Malaysia, New Zealand, South Korea, and most countries in Europe.

Brazil reported 41,008 new cases and remains #3 globally in terms of daily incidence *. The daily incidence is slightly lower than the same day during the previous several weeks, providing further evidence that Brazil has passed a peak or reached a plateau. Colombia reported 7,033 new cases , its fourth highest daily incidence to date, and its epidemic continues to accelerate. Colombia is currently #5 globally with respect to daily incidence, and Mexico (6,859 new cases ) is #6. Broadly, the Central and South American regions are still major COVID-19 hotspots. Including Brazil, Colombia, and Mexico, the region represents 5 of the top 10 countries globally in terms of daily incidence, along with Peru (#8) and Argentina (#9). Additionally, the region includes 7 of the top 16 countries in terms of per capita daily incidence : the US (#4), Brazil (#7), Colombia (#10), Bolivia (#13), Peru (#14), Chile (#15), and the Dominican Republic (#16).

India reported 37,724 new cases and remains #2 globally in terms of daily incidence *. India’s daily incidence has more than doubled since the beginning of July and appears to be increasing rapidly. Bangladesh continues to report slowly decreasing daily incidence; however, it is also reporting decreased testing while its test positivity remains slightly above 20%. This could indicate that Bangladesh's decreased incidence could be driven more by reduced testing than slowing transmission. Bangladesh is #10 globally in terms of daily incidence.
*India’s COVID-19 website does not report daily incidence, so we typically rely on other sources. Our usual source reported fewer than 10,000 new cases in India, so we calculated it manually based on the cumulative cases reported today and yesterday . The 7-day average daily incidence figure factors in this lower value, but we believe India should be closer to 36,000 new cases per day and that it remains #2 globally over Brazil in terms of daily incidence.

South Africa reported 13,449 new cases , and it remains among the top countries globally in terms of both per capita (#5) and total daily incidence (#4).

The Eastern Mediterranean Region remains a global COVID-19 hotspot, particularly with respect to per capita daily incidence . The region represents 4 of the top 12 countries globally—Oman (#1), Bahrain (#2), Qatar (#11), and Kuwait (#12). . Nearby Israel (#6) and Armenia (#8), both in the WHO’s European region, are among the top countries globally as well. The Eastern Mediterranean also includes several of the top countries in terms of total daily incidence —including Saudi Arabia (#11), Iran (#12), Iraq (#13), and Pakistan (#15)—as well as nearby Israel (#16).

NOTE: The website Our World in Data updated its Data Explorer to provide additional analysis and display options. We will now be using 7-day averages for daily per capita and total incidence instead of 3-day averages when ranking countries to reduce the effects of day-to-day variation.

The US CDC reported 3.82 million total cases (57,777 new) and 140,630 deaths (473 new). In total, more than half of US states and New York City reported more than 40,000 total cases, including California with more than 375,000 cases; Florida with more than 350,000; Texas with more than 325,000; New York City with more than 200,000; and 8 additional states with more than 100,000. The US is #4 globally in terms of per capita daily incidence .

Daily COVID-19 incidence at the national level in the US may be approaching a peak or plateau. The 7-day average daily incidence appears to have passed an inflection point, and the increasing trend is beginning to taper off. The record high daily total of 74,710 reported last week was a substantial increase over the previous week’s high (66,281 new cases reported on July 11), so the late-week reporting this week will provide important insight into the future trajectory of the US epidemic. COVID-19 mortality in the US continues to increase slowly as well. The average mortality is currently 800 deaths per day, up from 581 deaths per day on July 8.

At the state level , several hard-hit states appear to be peaking or plateauing as well. Arizona, California, Florida, and Texas are all exhibiting relatively steady or decreasing daily incidence over the past week or so; however, Arizona, Florida, and Texas continue to report record mortality (and continuing to increase). Florida and Texas are both now averaging more than 100 deaths per day, and Arizona is reporting more than 80 deaths per day. Notably, Arizona is reporting more than 1.1 daily deaths per 100,000 population, which is more than double the current rate in Florida and Texas. Additionally, Florida is still reporting more new cases per capita than New York did at its first peak in April. Arizona’s peak value exceeded New York’s as well, but it has since fallen back below that level. A number of other states continue to exhibit increasing incidence, including Alabama, Georgia, Louisiana, Maryland, Tennessee, Virginia, and Washington.

Our team feels that any increased transmission resulting from Independence Day celebrations should be just starting to become evident in disease surveillance and reporting. In addition, a number of states have strengthened or re-imposed certain social distancing restrictions over the past several weeks. There are a number of complex factors impacting SARS-CoV-2 transmission across the US.

The Johns Hopkins CSSE dashboard reported 3.92 million US cases and 142,350 deaths as of 12:30 pm on July 22.

MANDATORY MASK USE Mask mandates are becoming increasingly common across the US. Available evidence continues to support mask use as an effective mechanism for reducing transmission risk, and many elected officials continue to recommend mask use, even if they are not mandating it. Masks use is now mandatory in more than half of US states ; however, the exact details vary by state. Generally, mask orders require individuals to wear masks in public spaces where it is not feasible to maintain social distancing, particularly indoors, but they may not require mask use at all times when in public. Governors in several other states, including Georgia and Florida, have resisted state-level mandates, instead electing to encourage the public to participate. Notably, Georgia Governor Brian Kemp filed a lawsuit against Atlanta’s Mayor and City Council over the city’s local mask mandate, arguing that the governor’s executive order prohibits local governments from taking actions more restrictive than the state’s requirements. Some health experts , elected officials , and labor union leadership have called for a national mask order, but US President Donald Trump and Surgeon General Jerome Adams have opposed this approach—although, Surgeon General Adams did plead with viewers to wear masks during a recent interview. President Trump did, however, recently encourage the use of face masks as “patriotic,” in contrast to his past opposition to and/or mixed messaging regarding mask use as a means of controlling the COVID-19 epidemic.

In the absence of a national mandate—and in some cases, statewide mandate—a number of retail and other businesses are implementing their own mask requirements. A number of the country’s largest retail chains —including Walmart, Target, CVS, Walgreens, and Kroger—will require mask use in all of their stores nationwide, regardless of whether the state or city has a policy in place or not. Additionally, several major hotel chains are requiring masks to be worn in public spaces within their hotels, such as the lobby. A week after reopening its Florida theme parks, Disney issued an update to its mask mandate that prohibits visitors from eating and drinking while walking around the park in order to improve compliance with the requirement. But not all businesses are taking this approach. Family Dollar and Dollar Tree , for example, have reportedly lifted their mandatory mask policies in favor of requesting mask use in states and cities without mask mandates. Analysis by Goldman Sachs estimates that a national mandate could increase mask use by 15% and reduce the need for more restrictive social distancing measures, potentially mitigating US$1 trillion in economic losses associated with those restrictions.

Internationally, France and England both recently implemented nationwide mask mandates, largely similar to many state and local mandates in the US. France requires mask use on public transit and in public when appropriate physical distancing cannot be maintained. Violations in France could reportedly be met with a €135 fine. In the UK , masks requirements vary, to some degree, by country. In England, masks will be required in shops, but the mandate will reportedly only apply to patrons, not employees. Violations could result in fines of up to £100. Scotland maintains a similar policy regarding mask use in shops, but fines are limited to £60. Masks are also required while using public transit.

EU ECONOMIC STIMULUS PACKAGE The EU reached an agreement on a new stimulus package to address economic shortcomings driven by the COVID-19 pandemic. European leaders held a 5-day summit in Brussels to discuss pathways forward to bolster the bloc’s economy and mitigate the financial impact of COVID-19. The stimulus package includes €390 billion for grants, focusing largely on countries hit the hardest by COVID-19, most notably Italy and Spain, as well as €360 billion in low-interest loans available to all EU countries. Certain technical aspects of the deal are still being worked out, and the European parliament must still approve the final plan. 

US SCHOOLS States and school systems in the US continue to develop and debate plans to send students back to school for in-person learning for the start of the 2020-21 school year, which typically begins in late August or early September in most states. The Florida Education Association, a labor union representing Florida educators, filed a lawsuit against Florida Governor Ron DeSantis following his push for a return to in-person schooling starting at the end of August. The lawsuit claims that the current COVID-19 epidemiological situation in Florida makes it unsafe for teachers and students to return to schools and calls for substantive action to provide PPE for schools and resources to develop online curricula. Similarly, “a group of students, parents, teachers, and a bus driver” in Detroit, Michigan, filed a lawsuit with the aim of closing summer school programs as COVID-19 incidence increases. In Harris County, Texas, one of the largest counties in the US, the County Judge and health department announced that the start of in-person classes and other school-related activities, including sports and clubs, for kindergarten through 12th grade will be delayed until at least October due to “severe and uncontrolled disease transmission in [the] community,” with more than 35,000 active cases in the county. 

REPORTING COVID-19 DEATHS IN ITALY Due to a variety of limitations, including testing capacity and strategy, reported COVID-19 deaths may underestimate the pandemic’s true mortality. Researchers in Italy conducted a study to compare the number of reported deaths to the total number of excess deaths as a way to better characterize the true impact of COVID-19. In Italy, reported COVID-19 deaths account for deaths in individuals with positive SARS-CoV-2 tests, either in hospitals or a limited number of nursing homes, but individuals who died from presumed COVID-19 in their homes or in nursing homes without testing capacity are not counted in the national total. The researchers compared the number of deaths from all causes in January-March 2020—across 1,869 cities, representing 21.4% of the total population—to the average number of deaths over the same 3-month period in 2015-19 to determine the total increased mortality during Italy’s COVID-19 epidemic.

The researchers identified a 104.5% increase in the number of deaths reported March 1-April 4, 2020, compared to 2015-2019, which corresponds to more than 21,000 deaths above the historical average during that period. Nearly half of all of the deaths reported March 1-April 4, 2020, (19,824) were in the Lombardy region, the area in Northern Italy hit hardest by COVID-19, corresponding to an increase of 173.5% compared to 2019. For comparison, Italy reported 27,682 total COVID-19 deaths nationwide through the end of April, not much more than the excess deaths identified in this limited population over only a 1-month period. This study does not directly compare the excess deaths to the reported COVID-19 deaths over the period of study, and it included only municipalities that reported a 20% increase in deaths between March 1 and April 4. While it is not possible to attribute the cause of all of these excess deaths to COVID-19, this study provides further evidence that reported COVID-19 deaths are likely underestimating the burden of the pandemic, whether due to the disease itself or downstream effects on health systems and society.

US GOVERNMENT VACCINE DEAL WITH PFIZER The US government has finalized an agreement with Pfizer and BioNTech to acquire 100 million doses of their candidate SARS-CoV-2 vaccines, worth US$1.95 billion . Additionally, the US government could purchase an additional 500 million doses under the agreement. Pfizer and BioNTech currently have several candidate vaccines in the development pipeline, including various stages of clinical trials. According to a press release issued by Pfizer, the companies aim to begin Phase 2b/3 clinical trials later this month with the goal of securing US FDA authorization for at least one vaccine by October and delivering the vaccine doses by the end of 2020. The companies also hope to expand production to a total of 1.3 billion doses by the end of 2021. The agreement was signed as part of Operation Warp Speed , which has resulted in similar agreements—to support research and development, scale up manufacturing capacity, and purchase vaccine doses—with other pharmaceutical companies pursuing their own candidate vaccines.

AIRBORNE TRANSMISSION While we continue to learn more about the SARS-CoV-2 virus, many uncertainties remain, particularly with respect to modes of transmission. As we previously covered, emerging evidence supports the possibility of airborne/aerosol transmission of the virus, and a number of health experts recently called on the WHO to update its transmission and infection control guidance to place greater emphasis on airborne transmission risk. The WHO did issue updated guidance on SARS-CoV-2 transmission, which noted the possibility of airborne transmission. However, the document continues to emphasize that droplet transmission is believed to be the principal driver of the pandemic.

A recent study published ( preprint ) by researchers at several US health and academic institutions provides additional evidence supporting the possibility of airborne transmission. The researchers collected aerosol samples from 6 COVID-19 patient treatment areas to determine the presence of SARS-CoV-2 in the airborne environment. The specimens were analyzed to identify the presence of infectious virus in various particle sizes—greater than 4.1 µm, 1-4 µm, and less than 1 µm—via “real-time reverse-transcriptase polymerase chain reaction (rRT-PCR), cell culture, western blot, and transmission electron microscopy (TEM).” The study identified viral RNA in all 6 patient rooms and in all 3 particle sizes. Additionally, the researchers were able to culture viable virus from multiple aerosol samples in the “less than 1 µm” category. While this study demonstrates that viable virus can be present in aerosol form, additional research is necessary to determine the role it plays in transmission. In particular, questions remain regarding the infectious dose for SARS-CoV-2, especially with respect to the amount of virus present in aerosols, and how long the virus can remain viable in aerosol form.