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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).
UNITED STATES
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
).
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.
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.
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.
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