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 26 reports 15.75 million cases (200,625 new) and 640,016 deaths (7,097 new). The global daily incidence does not include data for the US—the second time in the past week or so—and we expect the actual global daily incidence to be approximately 275,000 new cases, which would be the third highest to date. The WHO reported the 2 highest global daily incidence totals on July 24 and July 25 —284,196 and 284,083 new cases, respectively.

Brazil has reported 4 of its 5 highest daily totals over the past 5 days, including its record of 67,860 new cases on July 22. Over the past several weeks, Brazil’s daily incidence appeared to be plateauing; however, the data reported over the past several days is considerably higher than the previous few weeks. In fact, Brazil set a weekly incidence record with 319,653 new cases reported for Week 30 (July 19-25). Brazil surpassed India for #2 globally in terms of daily incidence , but they are essentially equal.

Broadly, the Central and South American region remains a major COVID-19 hotspot. Colombia reported 8,181 new cases , its third highest daily incidence to date. It appears as though Colombia’s incidence may be starting to level off, but more data is needed to evaluate longer-term trends. Colombia remains #5 globally with respect to daily incidence. Mexico ’s daily incidence reporting varies widely from day to day, but the overall trend is clearly increasing. Looking at its 7-day average , it is clear that Mexico’s COVID-19 epidemic continues to accelerate, but the increase in daily incidence may be starting to slow to a small degree. Mexico 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 Argentina (#8) and Peru (#9). Multiple other countries in the region are reporting more than 1,000 new cases per day. Additionally, the region includes 4 of the top 10 countries in terms of per capita daily incidence —Panama (#3), Brazil (#4), the US (#5), and Colombia (#10)—and a number of other countries in the region are reporting more than 100 new daily cases per million population.

India has reported 48-50,000 new cases for each of the past 4 days. India’s weekly trend over the past several weeks has been to report dramatically increasing incidence for several days, peaking Saturday or Sunday before decreasing slightly and beginning the pattern again. Last week, however, India’s daily incidence only increased for 2 days before several days of relatively consistent reports. India fell to #3 globally in terms of daily incidence , but its average daily incidence is essentially equal to Brazil’s. Bangladesh continues to report slowly decreasing daily incidence. Its daily testing appears to have leveled off after 2 weeks of steady decline; however, its test positivity appears to have increased slightly, up from 20-23% from late May through early July to 23-25% since then. Bangladesh remains #10 globally in terms of daily incidence.

South Africa reported 11,233 new cases , and it remains among the top countries globally in terms of both per capita (#6) and total daily incidence (#4). South Africa’s daily incidence appears to have reached a peak or plateau, and it has reported slightly decreasing daily incidence over the past week, currently in the range of 11,000 new cases per day.

The Eastern Mediterranean region remains a global COVID-19 hotspot, particularly with respect to per capita daily incidence . Oman is currently the only country averaging more than 250 new cases daily per million population. The region represents 3 of the top 10 countries globally—Oman (#1), Bahrain (#2), and Kuwait (#9). Nearby Israel (#7), in the WHO’s European region, is among the top countries globally as well. While no countries in the region are in the top 10 in terms of total daily incidence, many are reporting more than 1,000 new cases per day.

Russia continues to report steadily declining daily incidence , but it remains #7 globally . Luxembourg is #8 globally in terms of per capita daily incidence .

The US CDC reported 4.16 million total cases (64,582 new) and 145,982 deaths (969 new). The US surpassed 4 million cases in its July 24 update. The US also reported more than 1,000 new deaths for 4 consecutive days, July 22-25, and nearly reached that benchmark again in the July 26 update. The US reported 2 of its 3 highest daily incidence totals over the weekend, including the record high of 74,818 new cases on July 25 (corresponding to July 24 data on the epi curve). Notably, the national 7-day average daily incidence appears to have reached a plateau at 66-67,000 new cases per day. While this is a promising sign, it is still more than twice the average daily incidence at the country’s first peak in mid-April. California, Florida, and New York are reporting more than 400,000 cases; Texas is reporting more than 375,000; and 8 additional cases are reporting more than 100,000. The US remains #5 globally in terms of per capita daily incidence and #1 in terms of total daily incidence .

California is reporting 453,659 cases, and Florida surpassed New York (411,736 cases) to become #2, with a total of 423,855 cases. With an average daily incidence of nearly 9,000 new cases per day, Texas (381,656 cases) could surpass New York by the late this week. With nearly 10,000 new cases per day, California could surpass 500,000 cumulative cases by late this week as well. Florida continues to report nearly 11,000 new cases per day . Additionally, California, Florida, and Texas continue to report increasing daily COVID-19 deaths. Texas is averaging more than 150 deaths per day, Florida is reporting more than 125, and California is reporting more than 100. On a per capita basis, Arizona is reporting more than 1 death per 100,000 population per day, compared to approximately 0.5 for Florida and Texas and 0.25 for California.

The Johns Hopkins CSSE dashboard reported 4.26 million US cases and 147,103 deaths as of 1:00 pm on July 27.

LONG-TERM ILLNESS The US CDC COVID-19 Response Team, in collaboration with researchers from across the US, published analysis on the long-term health effects of COVID-19 in patients who did not require hospitalization. The study, published in the CDC’s Morbidity and Mortality Weekly Report , investigated recovering COVID-19 patients’ return to normal health status . Based on interviews with 270 COVID-19 patients who were not admitted to the hospital for treatment, 35% reported that they had not yet returned to their normal level of health at the time of the interview, conducted 14-21 days after their positive SARS-CoV-2 test. The proportion of patients who had not yet fully recovered increased with age, ranging from 26% for patients aged 18-34 years to 47% for patients aged 50 years and older, and with the number of underlying health conditions, ranging from 28% for individuals with zero or one pre-existing health condition to 57% for individuals with 3 or more underlying health conditions. The most common persistent health conditions following SARS-CoV-2 infection were cough (43% of those who reported experiencing the symptom at the time of their test), fatigue (35%), and shortness of breath (29%). Among those whose symptoms resolved, the median time for individual symptoms to resolve was 4-8 days after the test date. Interestingly, among participants that reported returning to their normal health status, 34% still reported experiencing at least 1 of 17 symptoms associated with COVID-19 at the time of their interview.

Most studies on the long-term health effects of COVID-19 focus on hospitalized or severe cases, but this study provides evidence that even COVID-19 patients who are not ill enough to warrant hospitalization can experience longer-term health effects. Depending on the severity and duration of these chronic conditions, they could potentially impact individuals’ ability to resume normal activities after recovery from the acute stage of the disease.

WUHAN INSTITUTE OF VIROLOGY A senior researcher at the Wuhan Institute of Virology (WIV) in China participated in an interview with Science to address concerns and accusations that the SARS-CoV-2 virus may have originated in laboratories at the facility. Dr. Shi Zhengli, who researches bat coronaviruses, stated that, while her lab has detected and studied more than 2,000 coronaviruses (mostly genetic sequences extracted from bat fecal specimens), her lab has only grown 3 coronavirus strains in culture, all related to the original SARS-CoV virus that emerged in 2003. She pushed back against claims that researchers at WIV developed the virus and released it, deliberately or accidentally. Following the emergence of SARS-CoV-2 in Wuhan, China, the US National Institutes of Health terminated a funding grant that, in part, supported coronavirus research efforts at WIV, reportedly due to concerns about biosafety practices at the facility.

NONPROFIT ORGANIZATIONS In 2017, nonprofit organizations became the third largest employer industry in the US; however, like all major industries, they have faced significant impacts from the COVID-19 pandemic. Projections indicate that nonprofit organizations lost more than 1.6 million workers between March and May, according to a report by the Johns Hopkins Center for Civil Society Studies . The study also found that many nonprofit organizations struggled to access federal funding support under the Paycheck Protection Program, despite meeting the criteria. A separate analysis— conducted by Candid , a philanthropic research group—projects that tens of thousands of US nonprofit organizations could ultimately be forced to close as a result of the pandemic. Many of these operations provide safety net services for high-risk and vulnerable populations, including health clinics, food pantries, and other charities. Efforts are underway to save these establishments by scaling up federal aid and establishing mutual aid partnerships at the grassroots level to multiply the impact of limited resources across multiple service organizations. 

US ECONOMIC RELIEF Lawmakers continue negotiations today as federal protections against evictions and temporary unemployment benefits are scheduled to expire this week. These unemployment benefits have provided unemployed individuals with an additional $600 per week, but extending these benefits is one of many potential stumbling blocks in ongoing efforts to develop a “Phase 5” federal COVID-19 economic relief package. Due to the broad range of potentially contentious issues associated with a new emergency funding bill, White House Chief of Staff Mark Meadows and Treasury Secretary Steven Mnuchin have suggested that in order to avoid the unemployment stumbling block, negotiations may need to occur on an issue-by-issue basis rather than as a single, comprehensive package. Senate leadership are expected to unveil a legislative proposal this afternoon. Regardless, pressure is mounting for legislators to find solutions to mitigate the economic impact of the US COVID-19 epidemic. Even if new funding is agreed to quickly, implementing the plan at the federal and state level could potentially delay distribution by weeks or months , depending on the complexity of the plan. The Congressional Budget Office forecasts that long-term economic effects could persist for years, particularly with respect to unemployment.

NORTH KOREA North Korea announced the country’s first suspected case of COVID-19. According to North Korean state media , the case was identified in an individual who had previously defected to South Korea and recently crossed the border back into North Korea. The individual reportedly exhibited symptoms associated with COVID-19, but there are currently no reports that the individual has tested positive for SARS-CoV-2 infection. The city of Kaesong, near the border with South Korea, is reportedly under “lockdown” following the identification of the suspected case, but it is difficult to accurately determine the current state of the response and degree of restrictions in place in North Korea. This appears to be the first time that the North Korean government has acknowledged a COVID-19 case in the country. The case is not included in the most recent WHO COVID-19 Situation Report .

US COVID-19 MORTALITY A number of US states continue to report increasing COVID-19 mortality, even as some states appear to be reaching a peak or plateau in daily incidence and the national daily incidence is leveling off. As discussed above, the US reported more than 1,000 deaths per day for 4 consecutive days last week, and multiple states are still reporting record numbers of daily deaths. This recent surge is accelerating COVID-19’s rise through the top causes of death in the US . With 145,982 deaths , COVID-19 would currently be the #6 cause of death in the US—ahead of Alzheimer’s disease, diabetes, and influenza and pneumonia—based on official 2018 data from the US CDC. Projections based on the CDC’s ensemble COVID-19 model indicate that COVID-19 could surpass stroke, chronic lower respiratory disease, and unintentional injury (ie, accidental death) to become #3 by the middle of August. Based on current trends, it is unlikely that deaths from COVID-19 could surpass cancer (599,274 deaths) and heart disease (655,381 deaths) this year.

Reports continue to emerge about hospitals and health systems in severely affected parts of the country struggling to handle COVID-19 patient surge. Many of these reports address challenges in densely populated urban areas—such as Miami, Florida , and Houston, Texas —but rural areas are struggling as well, particularly those with fewer hospitals available to serve the population. In one example, a hospital in Starr County, Texas , has been forced to establish ethics and triage committees to prioritize COVID-19 patients to receive care, because the hospital cannot accommodate the demand. The hospital quickly filled its 8 existing intensive care unit (ICU) beds and expanded to 29 beds, but it is still transferring patients to other counties. If beds, mechanical ventilators, or other limited resources are not available, the committees will determine which patients are most likely to survive and admit them for care. Those who are not likely to survive may be sent home to be cared for by family members. Texas Governor Greg Abbott announced that the US Department of Defense is deploying medical resources, including US Navy SEAL doctors to support the COVID-19 response in southern Texas, where Starr County is located. If hospitals and health systems are unable to handle COVID-19 cases, particularly serious and severe COVID-19 patients, it could drive continued increases in COVID-19 mortality.

VACCINES & THERAPEUTICS A 2-dose candidate SARS-CoV-2 vaccine developed by Moderna, Inc. and the US National Institute of Allergy and Infectious Diseases (NIAID), mRNA-1273, will begin Phase 3 clinical trials today. Trial participants will include approximately 30,000 healthy, adult volunteers at 89 clinical research sites in the US. Sites chosen include those that are predicted to be emerging COVID-19 hotspots as well as areas that already have sustained community transmission. Doses will be given via intramuscular injections 28 days apart, but the researchers are hopeful that there will be evidence of immunity following the first dose. The trial will be double-blind, randomized, and placebo-controlled. If fewer than 150 participants develop COVID-19 of the 30,000 enrolled, the trial will be considered a success by trial organizers. The US Biomedical Advanced Research and Development Authority (BARDA) has contributed $472 million to support further development efforts for the vaccine in addition to the $483 million that the federal agency contributed in April. There are currently 3 other candidate vaccines undergoing Phase 3 clinical trials, including 2 in China and one in the UK. 

A commentary published last week in JAMA proposed pooling the results of clinical trials that were not initially designed to function as a network in order to establish a more robust dataset for evaluating candidate drugs. As we covered previously, many research sites enroll only a small number of participants in COVID-19 trial, which does not provide sufficient data to evaluate efficacy. By pooling results across multiple trials, it could be possible to generate enough data to characterize the drugs’ effects. Statistical stumbling blocks would need to be overcome, including merging data from studies with different designs, as well as details regarding data sharing and safety monitoring agreements. Despite these challenges, pooling data from multiple trials could warrant further investigation as a mechanism to make use of disparate datasets to contribute to evaluating candidate COVID-19 drugs. 

As investigational vaccines progress through clinical trials, scientists, response leaders and governments are beginning to theorize what rollout of an approved vaccine would like and how to counter potential obstacles. One such obstacle may be concern regarding negative associated side effects . Often, reactions associated with vaccines are mild, such as the muscle soreness at the injection site, but a few participants in earlier clinical trials for candidate SARS-CoV-2 vaccines, particularly those receiving higher doses, have experienced more severe reactions, including high fevers that require medical attention. There is concern that the fear of side effects may prevent individuals from getting vaccinated, so public messaging is already being crafted to educate the public on the benefits and risks and counter anticipated misinformation in order to increase the likelihood that the vaccine will be broadly accepted.

VIETNAM On Saturday, Vietnam reported its first locally acquired COVID-19 case in 100 days, a 57-year old man in Danang with no history of international travel. Vietnam has mobilized response operations to execute contact tracing and widespread testing in the area. Health officials continue to emphasize the importance of mask use, physical distancing, and handwashing among the public to mitigate transmission risk and prevent an outbreak. Vietnam has been lauded as a success due to its low incidence (fewer than 500 cases) and zero reported deaths thus far during the pandemic. Since the initial reporting Saturday, 3 additional residents of the city have tested positive for SARS-CoV-2, and now 80,000 people, predominantly domestic tourists, are reportedly being evacuated from the city by government officials. Dispersing potentially exposed travelers across the country could risk geographic spread of the disease, not all travelers will be required to quarantine after returning home. Beginning Tuesday, mass gatherings and non-essential services with potential for prolonged close contact (eg, beauty salons, bars) will be closed in Da Nang. Schools, tourist sites, restaurants, and other businesses will be permitted to remain open with precautions in place, such as reduced occupancy, use of personal protective equipment, and temperature screening.