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 30 reports 16.81 million cases (253,801 new) and 662,095 deaths (5,999 new). The daily incidence is slightly higher than the corresponding day from the previous week.

Brazil reported 2 of its 4 highest daily incidence over the past 2 days, including a record high of 69,074 new cases on July 29. Following several weeks in which Brazil’s COVID-19 epidemic appeared to be plateauing, Brazil is reporting significantly elevated daily incidence for the second consecutive week. Brazil remains #3 globally in terms of daily incidence but fell slightly further behind India. Broadly, the Central and South American region remains a major COVID-19 hotspot. Colombia reported 3 of its 4 highest daily incidence over the past 3 days, and its epidemic continues to accelerate. Columbia remains #5 globally in terms of daily incidence. Mexico ’s average daily incidence remains relatively steady at approximately 6,600 new cases per day, and it 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 (#1), Brazil (#3), the US (#5), and Colombia (#9)—and numerous other countries in the region are reporting more than 100 new daily cases per million population.

After approximately a week of relatively consistent reporting, India ’s daily incidence has increased each of the past 3 days, including a new record high of 55,078 new cases today. India remains #2 globally in terms of daily incidence . Bangladesh continues to report slowly decreasing daily incidence, and its test positivity appears to be decreasing slightly over the past week. Bangladesh fell out of the top 10 in terms of daily incidence.

South Africa reported 11,046 new cases yesterday. South Africa remains among the top countries globally in terms of both per capita (#8) and total daily incidence (#4). South Africa has reported decreasing daily incidence over the past week or so.

The Eastern Mediterranean region remains a global COVID-19 hotspot, particularly with respect to per capita daily incidence , but countries from several other regions are displacing the Eastern Mediterranean in the top 10. The region still includes 2 of the top 10 countries globally—Bahrain (#2) and Oman (#7)—and several other countries are still reporting more than 100 new daily cases per million population. Nearby Israel (#4), in the WHO’s European region, is among the top countries globally as well. Iraq surpassed Bangladesh in terms of total daily incidence to become #10 globally. Numerous other countries in the region are reporting more than 1,000 new cases per day.

Montenegro remains in the the global top 10 in terms of per capita daily incidence at #6, and the Maldives climbed to #10, with more than 160 new cases per day per million population.

The US CDC reported 4.41 million total cases (65,935 new) and 150,283 deaths (1,417 new). The US once again reported more than 1,000 new deaths—now 7 of the past 9 days—and surpassed 150,000 cumulative deaths. The 1,417 deaths is the highest daily total since May 28 . California is reporting more than 475,000 cases; Florida, New York, and Texas are reporting more than 400,000; and 10 additional states (increase of 2) are reporting more than 100,000. Additionally, California has surpassed Massachusetts as #3 nationally in terms of COVID-19 deaths; Florida and Texas are #8 and #9, respectively. The US climbed to #5 globally in terms of per capita daily incidence , but it remains #1 in terms of total daily incidence .

With more than 150,000 cumulative COVID-19 deaths , the US leads the world. The US has reported more than 3 times as many deaths as every country except Brazil. The US represents 22.5% of the global COVID-19 deaths —and 26% of the global cases —despite accounting for only 4.3% of the global populat ion . The US is #9 globally in terms of per capita cumulative deaths —but will likely surpass France as #8 in the coming days.

National COVID-19 incidence and hospitalizations appear to have peaked over the past week, but deaths continue to increase. The US is reporting an average of approximately 65,000 new cases per day , more than double the first peak in mid-April. National COVID-19 hospitalizations are at essentially the level reported during the United States’ first peak in mid-April. Analysis by the COVID Tracking Project indicates that more than 56,000 COVID-19 patients are currently hospitalized across the country, based on data reported by individual states. This is a slight decrease from the most recent peak of nearly 60,000 on July 23. The US is averaging more than 1,000 deaths per day for the first time since June 3. Multiple states continue to report record high daily deaths , including Arizona , Arkansas , California , Florida , Oregon , and Texas . Notably, Texas is averaging nearly 250 deaths per day , and Florida is reporting more than 150. Arizona is averaging more than 1 death per 100,000 population per day.

The Johns Hopkins CSSE dashboard reported 4.50 million US cases and 152,074 deaths as of 10:30am on July 31.

US SCHOOLS, COLLEGES & UNIVERSITIES Schools across the country are preparing for the start of the upcoming school year, whether they intend to hold in-person classes, remote classes only, or a hybrid option. A study conducted by The New York Times found that at least 6,600 COVID-19 cases have been linked to colleges and universities across the US, despite most schools suspending in-person in the spring. In total, 12 schools reported at least 100 cases, including among students and staff. The data was collected as part of a nationwide survey and was then combined with other sources to conduct further analysis, including with respect to schools’ plans to resume classes this fall. Participating schools represent a spectrum of plans for fall classes, ranging from wholly or principally in-person classes to entirely online or remote classes. Notably, each of these categories included schools with low reported incidence and schools with high incidence. A number of schools declined to participate in the study for a variety of reasons, including concerns over student privacy with respect to sharing health information and simply not tracking or reporting COVID-19 cases at all. The article also notes that student athletes, particularly (American) football players, are among the first students to return to campus as they begin preparations for seasons scheduled to begin in a few weeks. A separate study of NCAA Division I college football teams identified at least 630 COVID-19 cases among players, coaches, and other personnel at 68 different schools.

Researchers from Cincinnati, Ohio (US), published their findings regarding the impact of school closures on COVID-19 incidence and mortality in the US. The study, published in JAMA , found that the timing of US school closures was associated with magnitude of declines in COVID-19 incidence and mortality. Schools in all US states were closed in March, and the researchers evaluated the timing of these decisions, relative to the per capita COVID-19 incidence in the state at the time schools were closed, to the reported incidence and mortality during the following several weeks. The researchers found that states that closed schools earlier (ie, when COVID-19 incidence was lower) experienced greater decline in COVID-19 incidence and mortality than those that closed schools later in their epidemic (ie, when COVID-19 was higher). In light of the timing of school closures with respect to other social distancing policies and the complex interaction between these policies, the researchers attempted to adjust for the effects of other policies, testing capacity, nursing home population, and a variety of other factors in order to better isolate the effects of school closures. They estimate that school closures could have prevented 1.37 million cases over a period of 26 days and 40,600 deaths over a period of 16 days.

Due to the inherent risk associated with holding in-person classes, many schools are evaluating remote/online classes to enable students to continue their education. Some educators are working to improve the quality of remote learning. Many teachers in the US and elsewhere were forced to shift their classes online in the spring, largely without plans in place to do so effectively. Teachers across the US are working to develop best practices and new online platforms to support students in anticipation of the need for remote classes this fall. For example, live instruction may be engaging for students, but it may not be ideal for all students, especially if they are sharing computers or other devices with siblings. Remote classes may not be ideal for many students, particularly those without reliable access to the internet or computers and those whose parents need to remain home rather than return to work, but incorporating lessons and best practices can help mitigate some disadvantages of suspending in-person classes.

SARS-CoV-2 VIRAL LOAD Researchers have been attempting to understand the dynamics between viral load and transmissibility since the beginning of the pandemic. Conflicting data, however, have made it difficult to discern key characteristics such as the duration and levels that SARS-CoV-2 can persist in the body and their relationship to the infectious period. In a preprint meta-analysis study , authors from several medical schools and hospitals in the UK and Italy reviewed 79 studies on coronaviruses—specifically, SARS-CoV-2, SARS-CoV-2, and MERS-CoV—that address viral load kinetics in humans. The studies indicate that, while viral RNA can persist in and be shed from the body for long periods of time (more than 80 days in some cases), SARS-CoV-2 only remains viable and infectious for approximately one week after the onset of symptoms. Viral load was at its highest approximately 3-5 days after the onset of symptoms, and there was a positive correlation between prolonged viral shedding and disease severity. Older patients also experienced prolonged viral shedding compared to younger patients, even when accounting for disease severity. While there are fewer studies on the kinetics of viral load for asymptomatic infections, viral shedding appeared to be of a shorter duration, and overall viral load appeared to be lower compared to symptomatic cases. The authors conclude that PCR testing is likely not a good tool for evaluating patient recovery, because viral RNA is detectable long after the end of the infectious period. The authors also emphasize that early case detection and isolation should be prioritized in order to maximize control efforts during the time when patients are the most infectious. 

BRAZIL At #2 globally in terms of cumulative COVID-19 incidence, cumulative deaths, and daily deaths and #3 in terms of daily incidence, Brazil continues to struggle to control its COVID-19 epidemic amid conflicting strategies from President Jair Bolsonaro, regional governors, and public health authorities. President Bolsonaro recently recovered from COVID-19, but he has now reported a lung infection that he describes as “ mold in [the] lungs ” that he claims he caught while in isolation. His wife, First Lady Michelle Bolsonaro, was also recently diagnosed with COVID-19 and is currently being treated.

President Bolsonaro credits his recovery to hydroxychloroquine, despite continued evidence that the drug is not an effective treatment, and his continued praise of hydroxychloroquine as a treatment for COVID-19 has been credited for widespread use of the drug in Brazil. For example, a recent survey found that 50% of doctors in the state of São Paulo reportedly felt pressured to prescribe the drug to patients. Additionally, mask wearing remains highly variable among the Brazilian populace, especially in the hard-to-reach interior of the country, which is likely contributing to continued transmission. While deaths and incidence are beginning to slow in highly populated areas, deaths in interior states are starting to increase. These states have relatively little public health or healthcare infrastructure, including few intensive care hospital beds and poor access to oxygen supplies to treat COVID-19 patients.

Notably, Brazil will participate in two Phase 3 vaccine trials , one involving the Oxford/AstraZeneca vaccine (UK) and one for the Sinovac vaccine (China). Experts say that Brazil’s unique mix of high community transmission and strong scientific institutions make Brazil an ideal study population for candidate COVID-19 drugs. As part of its participation in these trials, Brazil expects to be able to manufacture any vaccines that prove to be effective, which would provide a major benefit in terms of securing access, particularly when initial supplies are limited.

GLOBAL VACCINE ALLOCATION As we look ahead to a future SARS-CoV-2 vaccine—whether later this year, sometime in 2021, or beyond—governments and experts are developing models and principles for equitably and effectively distributing the vaccine to populations around the world. Many experts argue that the most effective use of a vaccine, particularly in the early stages of production when supply is limited, is to prioritize those in the greatest need. Priority populations would include healthcare workers, individuals at elevated risk for severe disease and death, and areas with high levels of community transmission in order to have the largest impact on slowing the spread of the pandemic and reducing mortality. The WHO and other international groups, such as CEPI and GAVI, have established the COVID-19 Vaccines Global Access (COVAX) Facility to encourage and coordinate donations from high-income countries in order to support the distribution of vaccine doses to lower-income countries. Low- and middle-income countries (LMICs) may not be able to purchase sufficient vaccine on their own or compete against wealthier countries to secure access to early doses without external support. Several countries—including the US, UK, and EU—have already contracted directly with pharmaceutical companies to guarantee priority access to early doses. If early vaccine access is limited to high-income countries, it could enable the pandemic to continue devastating LMICs, many of which do not have sufficient public health and healthcare infrastructure to combat health emergencies like COVID-19. International coordination and commitment are needed to ensure that a future vaccine is allocated in a manner that enables it to make the greatest impact.

ECONOMIC IMPACT The US GDP fell by 9.5% in the second quarter, the worst economic quarter in US history, including the Great Depression . Extrapolated out, this would correspond to a 32.9% decrease in GDP over a full year. While this is severe, it is actually slightly better than 34.7% projection . C onsumer spending sharply decreased and supply chains were severely stressed d ue to COVID-19 and associated social distancing restrictions, including including the closure of many non-essential businesses.

Last week, 1.43 million Americans filed new unemployment claims, the second consecutive week of increasing new claims following several weeks of consistent decreases. Federal Reserve Chair Jerome Powell stated that emergency funding federal, including under COVID-19 stimulus packages, has successfully kept people in their homes and businesses operating; however, both federal eviction protections and expanded unemployment payments from the previous stimulus package expire this weekend, and Congress has not finalized negotiations for a Phase 5 funding package. Some parts of the US economy are showing signs of a slow recovery, but recent surges in COVID-19 incidence and mortality in some parts of the country have resulted in some states re-instituting various social distancing restrictions, which could hinder economic recovery in the third quarter and beyond.

US COVID-19 REPORTING A private company, TeleTracking , has been responsible for collecting data for the US Department of Health and Human Services (HHS) since April. The agreement has come under increased scrutiny after a directive issued earlier this month that compels hospitals to report important COVID-19 data to HHS through TeleTracking rather than through the longstanding CDC reporting system, the National Health Safety Network . Proponents of the new system have noted that the CDC system was optimized for other diseases, such as pneumonia and other hospital acquired infections, but the new HHS system is specifically designed for COVID-19 in hospitals, which could better serve the data needs for the ongoing response. Critics, however, have voiced concerns that reporting critical data, such as personal protective equipment (PPE) and hospital bed use and availability, to HHS rather than CDC could reduce transparency and access to data. Additionally, hospitals had only a few days to make the transition, which could introduce reporting delays that could impact response operations. Some have also noted that the new requirements for reporting are potentially even more labor intensive and cumbersome for hospitals, despite being designed to streamline the reporting process.

US SPORTS Sporting events have already resumed in a number of countries around the world, but the scale of the US epidemic could pose extra challenges as professional sports leagues in the US resume play. The National Women’s Soccer League (NWSL) completed its Challenge Cup tournament with zero reported COVID-19 cases. The league implemented a “bubble” for players, coaches, and other personnel before and during the competition and conducted regular testing (more than 2,000 total tests over the course of the tournament). All games were played at a single site outside Salt Lake City, Utah, over a month-long period. Notably, the Orlando Pride withdrew from the tournament before it started due to at least 10 positive SARS-CoV-2 tests among players and coaching staff.

The National Hockey League (NHL) is taking a similar approach to salvage its suspended 2019-20 season. The league decided to forgo the remainder of the regular season after it was suspended in March and, instead, resume play with a modified Stanley Cup Playoffs . Teams are playing in 2 “bubble cities” in Canada, one each for the Eastern and Western Conference. Warmup games took place earlier this week, and the opening round of the playoffs begins tomorrow. The NBA also established a bubble at the Disney/ESPN sports complex in Orlando, Florida, to hold a modified playoff tournament, which began yesterday.

Major League Baseball (MLB) began a shortened season last week, attempting to resume a more traditional schedule, with most games to be played in teams’ home cities. Notable exceptions include the Toronto Blue Jays , who will play all of their games in the US due to travel restrictions between the US and Canada. Less than 2 weeks into the season, an outbreak of at least 17 cases associated with the Miami Marlins has resulted in games for several teams being suspended. Following the outbreak, MLB leadership implemented new COVID-19 policies , including compliance officers for each team to ensure players and staff adhere to the league’s COVID-19 protocols. 

Several other professional sports leagues have also been competing this summer, including NASCAR (auto racing) and the PGA Tour (golf); however, as individual sports, they offer better opportunity to maintain physical and social distancing during play than most team sports. Unlike most other sports, NASCAR has begun to permit fans to attend races , although not at full capacity. The US Golf Association (USGA) announced that the upcoming US Open tournament , one of golf’s 4 major tournaments (and one of only 3 to be played this year), will be held without spectators. Athletes and other personnel associated with both leagues have tested positive for SARS-CoV-2 .

A number of NFL (American football) players have “opted out” of playing in the upcoming season due to COVID-19 concerns. The NFL COVID-19 policy allows players to sit out this season but still receive some pay, even without playing any games. Players determined to be at high risk for severe COVID-19 disease (eg, due to underlying health conditions) can receive US$350,000 for the season, and other players can receive US$150,000.