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

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July 8, 2020

EPI UPDATE The WHO COVID-19 Situation Report for July 7 reports 11.50 million cases (172,512 new) and 535,759 deaths (3,419 new). Prior to yesterday, the WHO reported more than 200,000 new cases for 3 consecutive days—July 4-6. The pandemic has been ongoing for more than 6 months and continues to accelerate . We have previously discussed the relative distribution of each continent to the total global daily incidence , but the data published by the WHO clearly illustrate similar trends across the WHO regions. Europe’s relative contribution has decreased steadily since early April, while other regions’ contributions are increasing. Most notably, the Americas continues to represent the most substantial proportion of global incidence, driven by multiple large and growing national epidemics, including in Argentina, Brazil, Bolivia, Chile, Colombia, Mexico, Panama, Peru, and the United States. Africa’s relative contribution continues to increase as well, owing largely to South Africa’s epidemic. The Eastern Mediterranean and Southeast Asia regions, which do not align directly with continents, are also representing a sizable fraction of the global daily incidence.

India continues its overall trend in daily incidence , and we expect it to report increasing incidence as the week goes on, potentially with a new record high. India remains #3 globally in terms of daily incidence , and it surpassed Russia on July 6 as #3 globally in terms of cumulative incidence . Pakistan continues to report decreasing incidence since its peak in mid-June. Additionally, its total active cases continues to decline following a peak on July 1, dropping to 91,602 active cases (the lowest total since June 15). Pakistan remains #11 globally in terms of daily incidence. Bangladesh continues to report decreased daily incidence as well, with fewer than 3,500 new cases for 6 consecutive days. Bangladesh remains #12 globally in terms of daily incidence.
Brazil reported 45,305 new cases, its fifth highest daily incidence to date. Brazil remains #2 globally in terms of daily incidence , following only the US. Looking at bi-weekly incidence , it appears as though Brazil may have passed an inflection point on its way toward a peak. Mexico reported 6,258 new cases, its fifth highest daily incidence to date. If Mexico continues its reporting trend, we expect to see increased daily incidence as the week progresses, potentially including a new record high. 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 6 of the top 14 countries globally in terms of daily incidence—including Colombia (#8), Chile (#9), Peru (#10), and Argentina (#14). Additionally, Panama and Bolivia are reporting more than 1,000 new cases per day . Central and South America also represent 4 of the top 12 countries in terms of per capita daily incidence Panama (#2), Chile (#5), Brazil (#10), and Peru (#12).

Israel has reported 7 of its 8 highest daily totals over the past 8 days, including its record high daily incidence on July 3 (1,285 new cases). Much like the US, Israel’s COVID-19 epidemic peaked in early April, followed by decreasing daily incidence through late May before increasing again to a new, higher peak. In fact, Israel reported fewer than 10 new cases on several days between May 16 and May 24, including zero new cases twice. Since then, the daily incidence has increased to a new record level.

Overall, the Eastern Mediterranean Region remains a global hotspot, representing 5 of the top 11 countries in terms of per capita incidence : Bahrain (#1), Oman (#3), Qatar (#4), Kuwait (#9), and Saudi Arabia (#11). Additionally, nearby Armenia is #8. 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 remains among the top countries globally in terms of both per capita (#7) and total daily incidence (#4). South Africa reported 10,134 new cases, its second highest daily total to date. South Africa's daily incidence has more than doubled since June 24, and its epidemic continues to accelerate.

The US CDC reported 2.93 million total cases (46,329 new) and 130,133 deaths (322 new). Following 4 consecutive days of more than 50,000 new cases, the US reported a slight decrease in daily incidence early this week. Low reported incidence early in the week is not unexpected due to delays in weekend reporting, particularly over a long holiday weekend; however, even these lower reports are greater than any day prior to June 27. In total, 21 states (no change) and New York City reported more than 40,000 total cases, including California with more than 250,000 cases; Florida, New York City, and Texas with more than 200,000 cases; and 5 additional states with more than 100,000. The current daily incidence in the US is more than 50% higher than the first peak in mid-April, and it has increased by more than 150% since June 9, up from 20,338 new cases per day to 51,711 yesterday ( 7-day average ).

A number of US states are exhibiting per capita incidence on par with or greater than the peaks in states hit hardest by COVID-19 early in the US epidemic. At its peak on April 10, New York state’s per capita daily incidence was 50.9 cases per 100,000 population ( 7-day average ). Other notable states early in the epidemic include: New Jersey with 41.4 new cases per 100,000 population; Massachusetts with 38.1; Louisiana with 33.9; and Connecticut with 30.9. On July 6, Arizona reported 52.8 new cases per 100,000 population, higher than any state so far in the US epidemic. Similarly, Florida reported 40.8 new cases per 100,000 population on July 7, and South Carolina reported 32.6 on July 6. Louisiana’s per capita daily incidence decreased to 5.77 new cases per 100,000 population on May 29 before rebounding to 31.2 on July 7. California and Texas, the country’s two largest states by population, are reporting 20.0 and 25.9 new cases per 100,000 population, respectively, and a number of other states are reporting more than 25.

The Johns Hopkins CSSE dashboard reported 3.02 million US cases and 313,666 deaths as of 12:30pm on July 8.
US COVID-19 RESURGENCE A number of countries affected early in the COVID-19 pandemic have gained control over their respective epidemics, and many others are combating their first wave of transmission. The US, on the other hand, began to turn the corner in its first wave before surging again several weeks later , following efforts to relax social distancing in many states. While the early stage of this first wave largely centered on the New York City area, including neighboring New Jersey and Connecticut, the current surge in transmission is spread across many states , particularly those that were not severely affected early in the epidemic. In addition to rapidly increasing COVID-19 incidence, states are also experiencing increasing hospitalizations and, in some cases, deaths. Additionally, test positivity is increasing in many states, which indicates that existing capacity is not sufficient to meet the growing demand and suggests that reported incidence may be underestimating the scale of community transmission.

Florida’s COVID-19 epidemic continues to accelerate. According to several reports , hospitals and health systems in multiple parts of the state are struggling to meet patient surge as COVID-19 transmission increases. Unlike most states, Florida does not report current COVID-19 hospitalizations (only cumulative), so other sources must be used to track this trend. Based on data from the state’s Agency for Health Care Administration , dozens of hospitals have reached their ICU capacity . While many of these are smaller hospitals with relatively few ICU beds, a substantial number are larger facilities with a capacity of 25 or more ICU beds. One local effort to track hospitalizations indicates that the state reported multiple record highs for daily COVID-19 hospitalizations over the past week. Additionally, the recent surge in COVID-19 incidence in Florida is complicating contact tracing efforts, as the volume of contacts exceeds available capacity. Potential exposures in public locations such as parties and nightclubs could result in dozens of contacts, many of which may not be identified. Despite the continued concerning COVID-19 trends, Florida announced that schools will open for in-person instruction this fall. The emergency order , issued by the state’s Commissioner of Education, directs school boards to “open brick and mortar schools at least five days per week,” unless prohibited under future health department or executive orders. The order permits the use of alternative options for instruction, including remote classes, but schools must be open to offer in-person instruction for those who desire it. Some educators and organizations, including teachers unions, have opposed the order, emphasizing that decisions regarding in-person instruction should be directed by scientific evidence rather than economic priorities.

In addition to Florida, Arizona and Texas also remain major COVID-19 hotspots in the US. Both states are reporting concerning trends in terms of incidence, testing, hospitalizations, and even deaths. In Arizona, state officials directed hospitals to implement crisis standards of care for COVID-19 patients, if necessary, and there are reports that major health systems in some parts of Texas are quickly filling with COVID-19 patients. In fact, more than 20 states have reported increased COVID-19 hospitalizations over the past 2 weeks. There are concerns that existing supply of critical personal protective equipment (PPE) —including surgical masks, gowns, and gloves—could once again be in short supply as COVID-19 hospitalizations continue to increase. Following initial shortages, particularly in the cities hit the hardest early in the US epidemic, PPE supplies have largely recovered, but a prolonged surge across multiple states could be a major challenge for national distribution systems.

The bi-weekly COVID-19 incidence in the US is more than double that of every country except Brazil, and it does not show much of an indication that it is starting to slow. Notably, the current trend is a similar trajectory as the approach to the first US peak; however, it is spread across numerous states rather than largely concentrated on a single metropolitan area (New York City). Spreading these cases across more hospitals and health systems could factor into the continuing decrease in reported COVID-19 deaths ; however, if hospitals and health systems begin to reach or exceed capacity, it could exacerbate the disease severity and result in additional deaths. Additionally, decreasing mortality in some states could be masking increases in others when observed at the national level. With that in mind, several states that are exhibiting concerning COVID-19 incidence trends are already reporting increasing COVID-19 deaths . Arizona’s daily COVID-19 death total never really exhibited a significant decline; however, it has increased from 12.4 deaths per day on May 27 to 40.3 on July 7 (225% increase; 7-day average). Several other states did report decreasing COVID-19 mortality earlier in the epidemic, but are now increasing again. Texas’ COVID-19 deaths are up from 18.6 deaths per day on June 12 to 43.3 on July 7 (133% increase), Florida increased from 30.4 deaths per day on June 18 to 47.9 (58% increase), and South Carolina increased from 4.71 deaths per day on June 18 to 15.3 (225% increase).

US SCHOOLS The White House hosted an event yesterday to discuss plans for schools to reopen in the midst of the COVID-19 pandemic. At the event, and on social media, US President Donald Trump indicated that he would put pressure on states to reopen schools this fall for in-person instruction, including K-12 as well as colleges and universities. In fact, m ultiple senior US government officials and advisors, including President Trump, emphasized that schools should strive to hold full-time, in-person classes this fall. US CDC Director Dr. Robert Redfield emphasized that the CDC never recommended school closures, and he noted that he hoped the agency’s guidance was not viewed by schools as a reason to remain closed.

Many, including health experts and officials, argue that attending school in person is important for childhood development , both from an educational and social perspective, and allowing children to return to school is critical for many families to return to work. Despite these benefits, many questions remain regarding how to safely resume in-person classes and mitigate transmission risk for students, teachers, and the community. Existing guidance emphasizes the importance of physical distancing, improved hygiene and sanitation, and utilizing outdoor spaces when possible, but these may be challenging for many schools. Maintaining 6-foot separation between students in classrooms could be particularly challenging for many schools, especially with full in-person attendance. Additionally, the risk of severe disease and death may be lower among children, but many teachers and other school staff are at high risk for COVID-19.

COLLEGE & UNIVERSITY TOOLKIT The Johns Hopkins Center for Health Security collaborated with Tuscany Strategy Consulting and the Council for Higher Education Accreditation to produce practical planning resources to help higher education institutions prepare for operations during the COVID-19 pandemic. The team developed a comprehensive toolkit, OpenSmartEDU , that includes an operational guide and accompanying self-assessment calculator to help colleges and universities gauge how effectively they are addressing a range of COVID-19 scenarios. The toolkit now includes a new planning template—the “Higher Education Return-to-Campus Planning Tool”—to aid schools in planning and monitoring the progress around essential health and safety factors as they work to bring students and instructors back to campus for in-person courses and other activities. Using Smartsheet—a free, customizable work management platform—school leadership can convert the COVID-19 Planning Guide into an actionable plan, including through assigning workstreams, developing implementation timelines, and visualizing critical data via convenient dashboards.

US HIGHER EDUCATION VISAS The US government, including US Immigration and Customs Enforcement (ICE), issued modifications to the federal Student and Exchange Visitor Program (SEVP) that would prevent immigrants on common types of student visas (F-1 and M-1) from remaining in the US if they take all of their courses online. Students attending universities that are fully transitioning to online coursework must either depart the US or transfer to a school that is holding in-person classes in order to fulfill their visa requirements. Earlier in the COVID-19 pandemic, SEVP granted exceptions for F-1 and M-1 visa holders in order to accommodate students as universities transitioned to remote coursework.

The updated policy will pose numerous challenges for colleges and universities, as well as their students, as fall classes rapidly approach. Some schools plan to hold in-person classes, while others intend to hold all classes online. In the wake of the changes to SEVP, more schools may move toward hybrid models , which would involve a mixture of in-person and online courses. The impact of losing international students reaches far beyond academic institutions. International students generated more than $41 billion in revenue for the US economy during the 2018-19 academic year. Universities are now looking for stronger guidance regarding how to safely proceed with in-person courses in order to support their international students and protect students, faculty, and staff against COVID-19.

SARS-CoV-2 CANDIDATE VACCINES The US is pushing ahead with “Operation Warp Speed” in an attempt to rapidly develop and deploy a SARS-CoV-2 vaccine. A commentary published in JAMA earlier this week outlined the 5 “core” vaccine candidates at the center of the federally organized effort. The US government has already invested considerable funding for vaccine research, including US$1.6 billion for the Novavax vaccine. The authors acknowledge that these 5 vaccine candidates are being developed using 3 unique technological platforms, exemplifying the diversity and innovation in SARS-CoV-2 vaccine development. Despite the current progress and the existence of multiple candidates, a number of questions still need to be answered regarding the efficacy of each vaccine candidate, and considerable work remains in terms of testing and production for all of the products. For example, US government officials have reportedly “squabbled” with Moderna over clinical trial design and implementation for its candidate vaccine, which has resulted in delays in initiating advanced clinical trials. The authors argue that the vaccine development landscape will be permanently altered by the COVID-19 pandemic. 

NURSING HOME DATA A report published by the Associated Press described incomplete COVID-19 data for nursing homes available from the US Centers for Medicare and Medicaid Services (CMS). CMS publishes weekly reports on the impact of COVID-19 in domestic nursing homes in order to provide additional transparency for residents, families, and the public during the country’s COVID-19 response. According to the AP report, nursing homes are only required to share data dating back to May 8, several months after the start of the US epidemic. Notably, the data for multiple facilities with known COVID-19 cases and deaths indicate none in the CMS reports, including from the first documented outbreak at a long-term care facility in Washington state. According to AP , the decision to provide data prior to May 8 is at the discretion of individual facilities. The incomplete data can be misleading, and there may be incentive for these facilities to limit reporting in order to present the appearance of fewer, or in some instances, no cases.  

BRAZILIAN PRESIDENT POSITIVE FOR SARS-CoV-2 Numerous media outlets are reporting that Brazilian President Jair Bolsonaro tested positive for SARS-CoV-2 on Monday . President Bolsonaro reportedly developed symptoms, including a fever, on Sunday and was subsequently tested. He addressed his diagnosis in a TV interview yesterday and commented that he was feeling “very well.” President Bolsonaro is reportedly receiving hydroxychloroquine and azithromycin as a treatment. The Brazilian President has faced criticism over his response to the country’s COVID-19 epidemic, including pressuring local governments to relax social distancing restrictions and downplaying the severity of the disease, even as Brazil's epidemic accelerates. Brazil’s national epidemic is second only to the US in terms of daily and cumulative incidence and total deaths . Some experts have expressed concern that insufficient testing capacity in Brazil may significantly underestimate the size of the epidemic, potentially by a factor of 10 or more. We have not yet identified an official report from the Brazilian government regarding the President’s diagnosis.

US WITHDRAWS FROM WHO The US has reportedly withdrawn from the WHO in the midst of the worst pandemic in a century. US President Donald Trump previously threatened to withdraw the US from the world’s leading international health organization, following calls for the WHO to implement reforms, including some related to its relationship with China. We have not yet identified an official US government source or announcement; however, the United Nations reportedly confirmed that it received written notification that the US intends to withdraw from the WHO, effective July 6, 2021. The US is currently #1 globally in terms of daily and cumulative COVID-19 incidence and total deaths , and its epidemic has been accelerating since early June.

Notably, it is unclear whether the US President has the authority to unilaterally withdraw from the WHO, as opposed to needing Congressional approval; however, the Joint Resolution passed by the US Congress in 1948 to join the WHO includes a provision mandating that the US pay its dues before fully withdrawing . This would require the US to pay in full its financial obligations—currently US$198 million—which President Trump previously put on hold. Numerous experts and organizations have criticized the decision , including the American Medical Association . Withdrawing from the WHO would effectively omit the US from important health-related decisions made and coordinated by the WHO, including the formulation of seasonal influenza vaccines and potentially the global allocation of a SARS-CoV-2 vaccine.

ISRAEL Israel’s top public health official, Dr. Siegal Sadetzki, has reportedly resigned in response to Israeli government efforts to contain its COVID-19 epidemic. Dr. Sadetzki cited the government’s failure to heed her professional advice with respect to relaxing national social distancing measures as a factor in her decision. In a Facebook post addressing her resignation , she noted that Israel’s early success in containing its first wave of transmission has been undone by efforts to rapidly lift social distancing measures in order to resume economic activity. The Israeli government removed many of the restrictions in May, including reopening schools and allowing larger gatherings such as weddings, permitting up to 250 attendees. As COVID-19 surges again in Israel, the government has re-instituted a number of social distancing restrictions , including closing bars, nightclubs, and gyms and restricting large gatherings.