Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.

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June 1, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 31 reports 5.93 million confirmed cases (117,551 new) and 367,166 deaths (4,461 new).

After reporting its highest daily incidence to date (33,274 new cases) on May 31, Brazil reported 16,409 new cases today, less than half of the previous day’s incidence but consistent with Brazil’s COVID-19 reporting in the past. Brazil is currently #2 in the world in terms of daily incidence ; however, Brazil’s epidemic appears to be continuing its acceleration and shows no obvious sign of slowing. Peru and Chile continue to exhibit concerning trends as well, both currently reporting more than 3 times the per capita incidence as the United States. Additionally, Peru is now #4 globally in terms of total daily incidence, surpassing India, and it could potentially surpass Russia for #2 in the coming days. South and Central America—specifically, Brazil, Chile, Mexico, and Peru—continue to represent 4 of the top 7 countries globally in terms of daily incidence —and Colombia is #16. 

Russia has reported 4 consecutive days of increasing daily incidence , climbing above 9,000 new cases for the first time since May 24. India continues to report increasing daily incidence as well, closing the gap with Russia. If the recent trends continue, India could surpass Russia as #4 in terms of daily incidence in the coming days.

Singapore reported 408 new cases, all of which were among residents of migrant worker dormitories. Singapore estimates that the cases confirmed so far represent 10.23% of the total population across all migrant worker dormitories, compared to only 0.03% of the general public population. Of the total confirmed cases reported in Singapore, 93.6% are among residents of migrant worker dormitories, including 99.0% over the past 2 weeks. The epidemic largely remains centered in migrant worker dormitories, and Singapore continues to report hundreds of cases a day among residents of these facilities.

South Korea has reported steadily increasing incidence since early May. After bringing daily incidence down to single-digit counts in the first week of May, the daily incidence has increased over the past several weeks. South Korea has identified multiple COVID-19 clusters, particularly in and around Seoul, following decisions to relax some social distancing measures in early May. The Korean CDC has identified 270 cases linked to nightclubs (including 96 cases believed to have been exposed at the clubs) and 112 cases associated with a logistics warehouse (including 74 workers) as well as multiple clusters associated with churches and other faith-based activities.

South Africa reported the 5 highest daily incidence totals over the past 5 days, continuing its acceleration. South Africa ’s daily incidence has more than doubled since May 21, and it is currently reporting the highest cumulative COVID-19 incidence and highest daily incidence in Africa.

Following 2 major one-day spikes in daily incidence —3,325 and 1,828 new cases on May 29 and 31, respectively— France ’s reported daily incidence fell back in line with its previous trend, with 257 new cases today.

The US CDC reported 1.76 million total cases (23,553 new) and 103,700 deaths (915 new). Daily COVID-19 deaths in the United States continue to decline overall, but the total reached 100,000 deaths recently. The CDC separated New York City from New York state in its table of jurisdiction-level COVID-19 incidence and deaths. In total, 13 states (no change) and New York City reported more than 40,000 cases, including New York City with nearly 200,000; New Jersey and New York with more than 150,000; and Illinois and California with more than 100,000.

The New York Times continues to track state-level COVID-19 incidence, with a focus on state policies regarding social distancing. A number of states began to relax social distancing measures—including resuming operations at restaurants, retail stores, and barbershops/salons—at the end of April/early May. Mass gatherings associated with the Memorial Day holiday weekend (US) and ongoing large-scale protests against racial injustice could potentially contribute to community transmission. We will continue monitoring state-level trends over the coming weeks.

The Johns Hopkins CSSE dashboard reported 1.79 million US cases and 104,484 deaths as of 11:30am on June 1.

TRUMP WITHDRAWS FROM WHO On Friday, US President Donald Trump announced that he intends to direct the United States’ withdrawal from the WHO over concerns regarding the WHO’s handling of the COVID-19 pandemic and its relationship with China. President Trump previously called for the WHO to implement systemic reforms and suspended US government funding for the WHO, aimed in part to curtail China’s influence. The process for withdrawing from the WHO is unclear , as is the President’s authority to direct such an action. President Trump indicated that the United States will redirect the funding intended for the WHO to other global health initiatives, but the US government may be obligated to pay its outstanding dues first.

Numerous health and elected officials and health experts condemned the announcement, emphasizing that it could hinder global response efforts to the COVID-19 pandemic, potentially including ongoing clinical trials for vaccines and therapeutics against SARS-CoV-2, as well as other major health threats. While a thorough and transparent review of the WHO’s COVID-19 response is widely supported, terminating the US relationship with the WHO in the midst of a pandemic could be dangerous.

DOWNSTREAM IMPACT The WHO released findings from a May survey that assessed how delivery of health services for noncommunicable diseases (NCDs) are being impacted by the COVID-19 pandemic in 155 countries. These survey findings are particularly important considering that those with underlying conditions are at elevated risk of severe disease or death due to COVID-19. In total, 120 countries reported that health services for preventing or treating NCDs had been partially or completely disrupted due to the pandemic, with disruption of services increasing with increased community transmission. While lower-income countries reported the greatest impact, these challenges are global. The leading reported cause of disruption was a decrease in inpatient volume stemming from cancellation of elective procedures and services. Other major barriers included suspension of population-level screening initiatives, decreased access to care due to “lockdown” measures, and shifting personnel from NCD programs to the COVID-19 response. Countries increased use of telemedicine and triaging patients to identify and care for those in the greatest as mechanisms to mitigate the impact of these disruptions.

COVID-19 SPREADING IN THE US IN JANUARY The US CDC COVID-19 Response Team, in collaboration with researchers and health officials from California, Illinois, New York, and Washington, published findings from a study on early SARS-CoV-2 transmission in the United States. The study, published in the US CDC’s Morbidity and Mortality Weekly Report , indicates that limited community transmission of SARS-CoV-2 in the United States may have begun as early as January, based on a variety of disease surveillance data as well as genetic analysis and retrospective case investigations. This would place community transmission in the United States weeks earlier than the first identified domestic transmission, reported in late February in California. Diagnostic testing on postmortem specimens identified 2 unrelated cases in California, one who developed symptoms on January 31 and another who “died at home between February 13 and 17.” Genomic sequence data suggest that early community transmission could be linked to travelers who arrived from Wuhan, China, or passengers or crew members from a cruise ship that departed from San Francisco, and subsequent introductions arrived via Europe.

Dr. Jay Butler, US CDC Deputy Director for Infectious Diseases, further noted in a media briefing that there was no evidence for widespread transmission earlier than late January, dispelling speculation that the virus could have been circulating in the US in December of last year. CDC Director Dr. Robert Redfield stated that the findings indicate that the delayed rollout of SARS-CoV-2 testing did not negatively impact the speed of the US response, because even expanded testing would have been unlikely to have detected such limited transmission; however, some experts have disagreed. 

US PROTESTS Historic protests against racial injustice and police brutality continued over the weekend, drawing crowds in cities across the United States that numbered in the thousands. Although not the primary focus of the protests, data indicate that racial and ethnic minorities are disproportionately affected by COVID-19 in the United States; multiple health experts have emphasized the health emergency posed by pervasive racial, ethnic, and social disparities. The underlying racial and ethnic inequalities that contribute to the disproportionate COVID-19 impact on these communities are an inherent part of the current protests.

The large-scale events have raised concern regarding the associated risk of increased community transmission . Mass gatherings, including these protests and recent Memorial Day weekend celebrations, can create conditions that can facilitate SARS-CoV-2 transmission, and health officials will need to closely monitor COVID-19 surveillance and other indicators over the coming weeks in order to quickly identify any indication of increasing community transmission.  Several media outlets published tips and guidance for mitigating transmission risk during the protests, and there are multiple reports of masks, hand sanitizer, and other materials being distributed to protesters .

COVID-19 TREATMENT PHASE 1 TRIAL Pharmaceutical manufacturer Eli Lilly commenced early stage human trials of a monoclonal antibody therapeutic for COVID-19, marking the first trial of a treatment developed specifically for COVID-19. The Phase 1 clinical trial of LY-CoV555 , an antibody treatment created from a blood sample of early US COVID-19 survivors, will test the drug’s safety in 32 patients who are currently hospitalized for COVID-19. Results of the trial are expected to be available later this month in order to determine if the treatment can continue to a larger trial testing efficacy and safety in non-hospitalized patients. Eli Lilly is already working to scale up production, with the aim of making the drug available as early as this fall, if it is demonstrated to be safe and effective. In addition to these trials, Eli Lilly plans to test other antibody therapies, and combinations of antibodies, as both treatment and prevention against SARS-CoV-2 infection.

UNDERSTANDING SARS-COV-2 SPILLOVER New research published in Science Advances may provide further insight into when and how SARS-CoV-2 adapted to infect and spread in humans. Through the use of genetic sequence data, recombination and selection analysis, and structure modeling of receptor binding, the study found evidence that the human SARS-CoV-2 coronavirus may have emerged from a bat coronavirus that recombined with a pangolin coronavirus to acquire a gene fragment that allows SARS-CoV-2 to bind to human ACE2 receptors. The pangolin strain of coronavirus has been previously studied as a potential link to the ongoing COVID-19 pandemic, but it may not be similar enough to the human strain to play a direct role in the spillover event. This study illustrates that pangolins could potentially have played a key intermediate role in supplying the binding receptor necessary for infecting humans, but additional research is needed to more fully characterize the evolutionary process that facilitated zoonotic transmission.

SARS-COV-2 INFECTION & SURGERY A study of COVID-19 patients undergoing a variety of surgical procedures during the COVID-19 pandemic found elevated mortality and rates of pulmonary complications. The study, published in The Lancet , included clinical data from 1,128 COVID-19 patients across 24 countries, including those who underwent emergency surgery (74.0%) and elective surgery (24.8%). Among these patients, SARS-CoV-2 infection was diagnosed preoperatively in 26.1% and postoperatively in 71.5%. The 30-day postoperative mortality was 23.8% (268 deaths), and 51.2% of patients (577) experienced postoperative pulmonary complications, illustrating potential elevated risk associated with COVID-19. The study does not include a control group against which to compare these values directly; however, an associated commentary indicates that these rates “exceeded those seen in most types of major surgery.” Additionally, one of the study authors commented that typical postoperative mortality for these procedures would be expected to be under 1%. The commentary also notes that these findings suggest that the potential for increased risk of death or pulmonary complications following surgery needs to be carefully weighed against the risk of postponing elective surgery procedures and that the “clear perioperative guidelines for emergency and elective surgery during the pandemic” are needed.

HYDROXYCHLOROQUINE STUDY A study published on May 22 in The Lancet presented analysis of clinical data for nearly 100,000 COVID-19 patients that aimed to characterize the effects of treatment using hydroxychloroquine. The study was conducted retrospectively—as opposed to the gold standard, a placebo-controlled, randomized clinical trial (RCT)—but including data from nearly 100,000 patients lended the study credibility. The study found no evidence that hydroxychloroquine provided treatment benefit, and rather, the researchers observed significantly elevated mortality in patients treated with the drug. Following the study’s release and subsequent media attention, a number of scientists have raised concerns about the study’s design, analysis, and conclusions, including the role of various potential confounding factors. The authors indicate that they are unable to publicly share the data, so it is difficult to determine the underlying drivers of some of the findings.

The authors published an erratum to the original journal article to correct a data classification error; however, the change did not alter any of their findings. Subsequent to the erratum, a group of scientists published an open letter to the study authors and The Lancet that highlights their concerns and requests details regarding the data provenance as well as an independent review of the data and analysis. The company controlling the data published a response , but it does not appear to address or commit to address any of the identified concerns. Rather, it highlights the importance of RCTs to evaluate drug safety and efficacy, reiterates the limitations noted in the original article, and emphasizes the study’s value in the context of the available data. The questions raised by other researchers do not necessarily negate any of the study’s findings—particularly considering that multiple other studies have also failed to identify evidence of a treatment benefit—but it does illustrate some of the barriers and challenges to rapidly disseminating data and research in the midst of a major health emergency. This should serve as a reminder that all studies should be considered in the appropriate context, and no individual study should be regarded as the singular, definitive source, particularly on an emerging field of study, such as for COVID-19.