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

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July 6, 2020

EPI UPDATE The WHO COVID-19 Situation Report for July 5 reports 11.13 million cases (203,836 new) and 528,204 deaths (5,195 new). The WHO reported more than 200,000 new cases in a single day for the first time on July 4 , and it took only 6 days for the global cumulative incidence to go from 10 million to 11 million cases. The pandemic has been ongoing for more than 6 months, and it continues to accelerate . In terms of daily incidence , Asia, North America, and South America are reporting approximately the same number of cases, and Africa has surpassed Europe. Africa is now representing more than 8% of the global daily incidence , compared to less than 7% for Europe. Asia, North America, and South America all represent approximately 25-30%.

India continued its recent increase, reporting a record high for daily incidence on July 5 (24,850 new cases) and remaining #3 globally . Pakistan has reported nearly 2 weeks of decreased daily incidence, and its total active cases reached a peak on July 1 (108,642 active cases). Since then, Pakistan’s active cases dropped below 100,000 for the first time since June 17—currently 95,407 active cases. Pakistan fell to #11 globally in terms of daily incidence. After reporting a steady increase in daily incidence to its highest daily total on July 1 (4,019 new cases), Bangladesh has reported 4 consecutive days of lower daily incidence—approximately 2,750-3,250 new cases per day. The increase in Bangladesh’s daily incidence appeared to be tapering off slightly toward the end of last week; however, additional data is needed to determine if this is the beginning of a longer-term trend. Bangladesh fell to #12 globally in terms of daily incidence.

Brazil continues to report increasing daily incidence. Last week, Brazil reported 263,337 new cases, its highest weekly total to date. Brazil remains #2 globally, behind only the US, in terms of daily incidence . Mexico reported a record daily incidence on July 5 (6,914 new cases), and its epidemic continues to accelerate. 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 10 countries globally in terms of daily incidence—including Colombia (#8), Chile (#9), and Peru (#10). Additionally,several other countries are 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), Chile (#6), Brazil (#7), Peru (#12), and Bolivia (#13).

Overall, the Eastern Mediterranean Region remains a global hotspot as well, representing 5 of the top 11 countries in terms of per capita incidence : Bahrain (#1), Oman (#2), Qatar (#4), Kuwait (#8), and Saudi Arabia (#11). Additionally, nearby Armenia is #5. Notably, Qatar’s per capita incidence has fallen to #4 globally, decreasing by nearly 70% since its peak in late May. The region also includes several notable countries in terms of total daily incidence . In addition to Pakistan, Saudi Arabia is #7, Iran is #13, 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 (#9) and total daily incidence (#4). South Africa reported 6,945 new cases —its second highest daily total to date—and its epidemic continues to accelerate. Notably, most countries in Africa continue to report low per capita and total daily incidence . On a per capita basis, only 6 countries—Cape Verde, Djibouti, Mauritania, South Africa, Swaziland, and Western Sahara—are reporting more than 25 new daily cases per million population. With the exception of South Africa, these are relatively small countries. Over the past 2 weeks , only 4 African countries have reported more than 5,000 new cases—Egypt (20,020), Ghana (5,931), Nigeria (8,467), and South Africa (99,448).

The US CDC reported 2.84 million total cases (52,228 new) and 129,576 deaths (271 new). The US has reported more than 50,000 new cases for 4 consecutive days, including a record high of 57,718 on July 4. In total, 21 states (increase of 2) and New York City reported more than 40,000 total cases, including California with more than 250,000 cases; New York City with more than 200,000 cases; and Florida, New York state, and Texas with more than 175,000. The current daily incidence in the US is more than 50% higher than its first peak in mid-April. The daily incidence has more than doubled since June 9, up from 20,338 new cases per day to 47,389 yesterday ( 7-day average ).

The Johns Hopkins CSSE dashboard reported 2.90 million US cases and 130,007 deaths as of 11:30pm on July 6.

AIRBORNE TRANSMISSION The WHO , US CDC , and other experts have continually emphasized that respiratory droplets are the main driver SARS-CoV-2 transmission; however, 239 scientists from 32 countries are reportedly challenging that notion in an open letter to the WHO. The authors argue that airborne transmission may be playing a larger role in the pandemic than previously believed, which would significantly impact future prevention strategies and the resources needed to fulfill them. While droplet transmission risk can be mitigated via physical distancing and barriers like face shields and face masks, airborne transmission would mean that virus particles could linger in the air for prolonged periods of time or travel longer distances, including via ventilation systems, instead of quickly settling on surfaces. If this is the case, mask usage could be necessary in many more environments, particularly indoors, even if the recommended physical distancing (e.g., 6-foot separation) is maintained. Additionally, individuals at elevated exposure risk, such as healthcare workers, could need N95 respirators instead of surgical or medical masks.

The existing WHO guidance emphasizes that aerosol transmission is possible , including during aerosol-generating medical procedures, but it is not a primary driver of community transmission. The authors of the forthcoming letter criticize the WHO’s unwillingness to address emerging evidence supporting the role of aerosol/airborne transmission. Experts broadly acknowledge the difficult task the WHO faces in developing universal guidance for the world and navigating a complex political climate on a tight budget, but some believe that the WHO should reconsider the evidence. The letter will reportedly be published in the journal Clinical Infectious Diseases in the coming days.

SUPERSPREADER EVENTS A number of reports have emerged over the past several weeks about “superspreader” events , which are events or gatherings that have been identified as a possible or likely source of numerous subsequent infections, potentially from as few as a single infected individual. Coverage of these events have increased in recent weeks, as countries, states, and cities have relaxed social distancing measures and resumed many normal community activities. Examples include exposures at weddings and birthday parties , dinner parties , university parties and spring break , family gatherings, and restaurants and bars , some of which have been linked to dozens of new cases. With bars and nightclubs closed in some locations, large parties with club-like atmospheres are reportedly being held at private residences. In several instances, an individual that attended these events felt healthy at the time and then were later determined to be infectious.

The Independence Day holiday weekend in the US provided ample opportunity for these types of gatherings, and much like the Memorial Day holiday in late May, it could be several weeks before we begin to see any signs of increased transmission stemming from these events. The UK recently permitted bars to resume in-person operations , which reportedly resulted in crowding and disregard of physical distancing guidance that could provide similar elevated risk of transmission. Other upcoming opportunities for superspreading events include political rallies, debates, and conventions associated with the 2020 US elections. Notably, the Texas Republican party reportedly intends to host its election convention in person late next week, which could draw thousands of attendees as the state continues to report record daily totals for COVID-19 incidence , deaths, and hospitalizations as well as elevated test positivity.

REVERSING COURSE ON SOCIAL DISTANCING A number of US states have reversed course on their efforts to relax social distancing measures, in response to recent concerning COVID-19 trends. One analysis published by The New York Times found that 19 states are pausing their recovery plans or reinstituting or strengthening existing social distancing restrictions. Multiple states recently announced the closure of businesses that pose elevated exposure risk, including bars, movie theaters, and gyms/fitness centers that were previously permitted to reopen. Some of these efforts have met significant opposition from business owners and patrons, and some states have had to threaten regulatory or legal action to prompt compliance with the new restrictions. Several states have also implemented mandatory mask use in many or all public spaces, including stores and restaurants. In fact, nearly half of all US states now have some form of mask mandate, including 7 that implemented new policies since the second half of June. Notably, analysis published by Forbes shows that 10 states are reporting level or decreasing COVID-19 incidence over the past 2 weeks, and 7 of these states had mandatory mask policies in place since at least the middle of May.

In response to increasing COVID-19 transmission in Arizona, the Mexican state of Sonora implemented border restrictions in advance of the Independence Day holiday weekend. The policy limited border crossings from Arizona into Mexico to essential purposes only. Sonora’s beach towns are a common vacation destination for Arizonans. A number of beaches throughout Florida were also closed for the Independence Day weekend . Many of these beaches were previously open as Florida progressed through its recovery plan.

As we have discussed previously, the effects of changes to social distancing policies and practice will likely not be immediately evident. The current ongoing surge in COVID-19 incidence followed several weeks after many states began to ease social distancing policies in late May and early June. People who were infected immediately prior to these most recent changes, or are infected as adherence increases, will likely not be detected for several days or possibly weeks.

RACIAL INEQUITIES The New York Times published in-depth analysis of national and local racial and ethnic disparities, based on federal COVID-19 data on nearly 1.5 million COVID-19 cases. In the US, Black and Latino communities have been disproportionately affected by the epidemic compared to White communities. The study estimates that Black and Latino individuals are 3 times as likely to be infected by SARS-CoV-2 and twice as likely to die from COVID-19 as White individuals. Native Americans and Asians are disproportionately affected by COVID-19 as well.

Notably, many racial and ethnic minorities work in essential jobs, including in healthcare settings and service or production jobs, many of which cannot be performed remotely. Continued contact at work, particularly in environments that facilitate transmission (e.g., meat processing facilities, warehouses, long-term care facilities), increases transmission risk among these populations. Additionally, racial and ethnic minorities are also disproportionately affected by comorbidities associated with increased risk of severe COVID-19 disease and death, which further compounds these disparities. There are many complex and interdependent factors that drive the elevated COVID-19 risk for racial and ethnic minorities, and further research is necessary to better characterize these relationships and implement effective interventions to mitigate their effects, both for COVID-19 and for many other health risks.

SPAIN SARS-CoV-2 PREVALENCE Spain continues to study the national and sub-national prevalence of SARS-CoV-2 infection. Spain was among the hardest-hit countries early in the pandemic, and researchers have endeavored for several months to better characterize the scale of its epidemic. A new study published in The Lancet surveyed more than 35,000 households nationwide, using a randomized sampling methodology based on “province and municipality size.” In total, the study included more than 61,000 individual participants (75% response rate) who participated in both a questionnaire, including symptom history and COVID-19 risk factors, and a serological test. The study estimates the national seroprevalence to be 5.0%, with variations identified by age and location. Seroprevalence in children under the age of 10 was estimated at 3.1%, and seroprevalence was higher in Madrid (greater than 10%) and lower in coastal communities (less than 3%). The results also indicate that approximately one-fifth to one-third of SARS-CoV-2 infections could be asymptomatic or only mildly symptomatic, which could potentially correspond to 376,000 to 1.04 million infections nationwide.

AUSTRALIA CLOSES STATE BORDER An outbreak of COVID-19 in Melbourne, Australia, has driven the Australian government to restrict border crossings between Victoria—where Melbourne is located—and New South Wales, the country’s two most populous states. The border closure goes into effect on July 8 , and further details are expected in the coming days, including on exemptions and exclusions, particularly for those who live, work, and go to school on both sides of the border. The last time the border between Victoria and NSW was closed was in 1919, in response to the influenza pandemic.

FEDERAL WORKFORCE BACK IN THE OFFICE US government employees under numerous government departments are beginning to return to the office. Each department is addressing the return of personnel differently. While many federal government offices and services can continue to function remotely, others (e.g., passport processing) may require in-person work. While some offices, particularly senior department leadership, are centralized in Washington, DC, others (e.g., Veterans Affairs) are distributed widely across the country, which makes it difficult to resume operations uniformly across their various facilities. Additionally, Washington, DC, is surrounded by Maryland and Virginia, both of which are implementing their own response and recovery plans, and many federal employees make their daily commute from their homes in these states. 

HYDROXYCHLOROQUINE Despite multiple previous studies that have failed to demonstrate efficacy, hydroxychloroquine continues to be evaluated as a possible treatment option for COVID-19. Clinicians at the Henry Ford Health System in Michigan (US) published findings from a recent study that indicate that the drug could provide treatment benefit. The study, published in the International Journal of Infectious Diseases ( IJID ), involved a retrospective review of 2,541 COVID-19 patients from March 10 and May 2. The researchers found that 13.5% of those treated with hydroxychloroquine died, compared to 26.4% of patients that were not treated with the drug. Notably, the study was not a randomized controlled trial (RCT), and the patients were prescribed hydroxychloroquine under “specific protocol criteria.” Other researchers have raised concerns about the study’s design, in particular that selection of patients based on specific criteria could potentially bias the results . The WHO announced on Saturday that it is discontinuing the hydroxychloroquine arm of its SOLIDARITY Trial, as interim data have not demonstrated sufficient treatment benefit. The WHO is also discontinuing the lopinavir/ritonavir arms of the trial.

A study conducted by STAT News , in collaboration with Applied XL, evaluated the relative investments in studying various prospective COVID-19 treatment options. The researchers found that effort to study hydroxychloroquine far outweighs other possible therapeutics, including several that have already demonstrated efficacy against the disease; 1 out of every 6 studies has evaluated hydroxychloroquine. The STAT News study found that 237,000 total patients had been enrolled in hydroxychloroquine/chloroquine studies, which potentially hindered efforts to evaluate other drugs that might be more likely to demonstrate a positive effect by drawing patients away from those trials. Many of these smaller studies are conducted independently, as opposed to collaboratively (i.e., utilizing the same trial protocol across multiple facilities) in order to increase the sample size and statistical power. Larger studies, such as the UK’s RECOVERY Trial and the WHO’s SOLIDARITY Trial, have provided a common platform for conducting studies and compiling larger datasets across multiple testing sites. These studies have already yielded results, including demonstrating efficacy of dexamethasone as a COVID-19 treatment.