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

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June 10, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 9 reports 7.04 million confirmed cases (108,918 new) and 404,396 deaths (3,539 new). The global totals surpassed 7 million cases in yesterday’s Situation Report and 400,000 deaths on June 8 .

India continues to report elevated daily incidence , holding steady at slightly fewer than 10,000 new cases per day for the past several days. Pakistan has exhibited increasing daily incidence over the past several weeks, reporting its highest daily total yesterday (5,385 new cases). Pakistan’s daily incidence has doubled since late May, and it is now #5 globally in terms of daily incidence . Bangladesh’s COVID-19 epidemic is also accelerating. Bangladesh reported 3,190 new cases, its highest daily incidence to date, and it is now #10 globally in terms of daily incidence.

Iran reported 2,111 new cases , down from more than 3,500 new daily cases last week. Iran remains #11 globally in terms of daily incidence .

Following 2 days with fewer than 20,000 new cases, Brazil reported 32,091 new cases, its second highest daily incidence to date. Brazil updated its COVID-19 dashboard again, restoring cumulative values for cases and deaths as well as figures displaying various epidemiological trends and maps. These trends indicate that Brazil’s COVID-19 epidemic continues to accelerate; however, the growth in reported deaths appears to be slowing and could potentially reach a peak or plateau in the next several weeks. Brazil is once again #1 globally in terms of daily incidence . Broadly, Central and South America remain a major COVID-19 hot spot. In total, the region represents 4 of the top 10 countries globally both in terms of daily incidence—including Mexico (#6), Peru (#7), and Chile (#8)—and per capita daily incidence —Chile (#3), Peru (#7), Brazil (#8), and Panama (#9).

The US CDC reported 1.96 million total cases (17,598 new) and 110,925 deaths (550 new). The United States could potentially surpass 2 million cases in the next 2-3 days. In total, 14 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New Jersey and New York state with more than 150,000; and California and Illinois with more than 125,000.

The Johns Hopkins CSSE dashboard reported 1.88 million US cases and 108,334 deaths as of 11:30am on June 5.

WHO CLARIFIES COMMENTS ON ASYMPTOMATIC TRANSMISSION At the June 8 COVID-19 media briefing, Dr. Maria Van Kerkhove , Technical Lead for the WHO COVID-19 response, commented in response to a journalist's question that current evidence suggests that asymptomatic transmission is possible but “very rare,” based on data from available studies. The comment garnered significant attention , including uncertainty about how to interpret the statement in the context of the ongoing pandemic response, which prompted the WHO to clarify the statement to provide additional detail and put the statement in the proper context. 

In a live-streamed question and answer session on June 9, Dr. Van Kerkhove clarified her initial statement. In her explanation, Dr. Van Kerkhove noted that she was addressing a limited subset of studies that followed truly asymptomatic individuals to identify transmission to others, which found limited transmission by these individuals. However, there is a key difference between truly asymptomatic infections (i.e., that never develop any symptoms) and presymptomatic cases (i.e., that are not currently exhibiting symptoms but will develop them in the future). Dr. Van Kerkhove emphasized that when the WHO uses the term “asymptomatic,” they are exclusively referring to those individuals who never develop symptoms. The difference in transmission risk for asymptomatic and presymptomatic individuals is unclear at this time. Data indicate that viral load peaks in COVID-19 patients shortly before symptoms present, but this does not necessarily correlate with viral shedding or transmissibility.

At the session, Dr. Mike Ryan, Executive Director of the WHO Health Emergencies Programme, emphasized that transmission by individuals not exhibiting symptoms is occurring, but the extent remains unknown. Strategies implemented to date, including large-scale social distancing and “lockdown,” have been effective at limiting contact and exposures in the community, which has impacted both symptomatic and asymptomatic transmission. As social distancing measures are relaxed and public health focuses on identifying and isolating symptomatic cases (e.g., via contact tracing), further efforts are needed to characterize the role of asymptomatic transmission and implement mechanisms that will enable health officials to better identify and isolate asymptomatic and presymptomatic infections in order to mitigate their risk of transmitting the virus to others.

Dr. Anthony Fauci commented that the existing evidence indicates that the severity of COVID-19 can range from truly asymptomatic infections to very mild symptoms to severe and deadly disease, and that patients across the spectrum of disease pose transmission risk.

INTERNATIONAL COVID-19 INCIDENCE While many of the countries that were severely affected early in the pandemic are now reporting decreasing COVID-19 incidence and subsequently relaxing some of their social distancing measures, incidence is climbing in other parts of the world. Countries like China, South Korea, the United States, and numerous European countries are reporting declining or lower levels of transmission as their epidemics come under control. Countries in Africa, Asia (excluding China), and South America are representing increasing proportions of the global COVID-19 incidence; WHO Director-General Dr. Tedros Adhanom Ghebreyesus noted that the pandemic is shifting geographically. The WHO reported more than 136,000 new cases on June 7, the highest daily global total to date, and the majority of cases were reported by countries in the Americas and South Asia. Multiple WHO officials emphasized the importance of maintaining vigilance and continuing to implement effective social distancing and epidemic control measures.

Following efforts to lift “lockdown” measures in May, Pakistan is stepping up enforcement of existing social distancing policies in response to recent increases in COVID-19 incidence. One report indicates that the WHO is urging Pakistan to re-institute more restrictive social distancing in order to slow transmission, noting that Pakistan does not currently meet the recommended gating metrics to begin relaxing social distancing. Pakistan has increased testing; however, the test positivity has increased—up from 10-15% in early May to more than 20% now—which suggests that the increase in reported incidence is not entirely due to increased testing.

Despite increasing incidence, some countries are moving ahead with efforts to relax social distancing. South Africa , for example, reopened schools this week. The plan to reopen was reportedly delayed by a week in order to provide additional training for teachers and staff. South Africa continues to report the highest daily incidence on the continent (#2 in terms of per capita daily incidence ). South Africa has reported decreased daily incidence in the past several days, but overall, the daily incidence has exhibited a substantial increase over the past several weeks, more than doubling between May 29 and June 7.

US COVID-19 INCIDENCE Several weeks after US states began to relax social distancing measures and “stay at home” orders as well as celebrations over the Memorial Day holiday weekend, a number of states are reporting increasing COVID-19 incidence. Analysis published by NPR identifies 23 US states and Puerto Rico with increasing COVID-19 incidence over the past 2 weeks, including 5 states with more than double the daily incidence compared to 2 weeks ago. Additionally, analysis published by The Washington Post found that 13 states and Puerto Rico recently reported their highest 14-day average incidence. Reported incidence does not necessarily represent the full impact, and other analysis indicates that the number of COVID-19 hospitalizations is increasing as well. Increased hospitalizations suggest that growing case counts in many states is not entirely a result of more testing. Much like trends on the international scale, areas hit the hardest early in the US epidemic are largely exhibiting decreasing COVID-19 incidence, whereas areas not previously affected are experiencing increasing community transmission.

Arizona has reported significant increases in daily incidence over the past 2 weeks, and now state health officials are directing health systems to anticipate a surge in COVID-19 patients . On June 6, the Director of Arizona’s Department of Health Services, Dr. Cara Christ, reportedly distributed a letter to hospitals across the state that urged them to “fully activate” their emergency response plans. This would likely include activating hospital incident command systems, preparing to implement crisis standards of care, suspending elective medical procedures, and expanding intensive care unit (ICU) bed capacity. The number of hospital, emergency department (ED), and ICU beds in use statewide has increased steadily since mid-April, and the number of mechanical ventilators in use has increased since at least late March. Dr. Christ emphasized that “COVID-19 is widespread and still circulating” in Arizona, even though the state is relaxing social distancing and resuming normal activities.

Texas reported record numbers for COVID-19 hospitalizations this week, as efforts continue to relax social distancing. In addition to elevated daily incidence , Texas reported 5 of its 6 highest daily totals for COVID-19 hospitalizations over the past 5 days, including its first day with more than 2,000 hospitalized COVID-19 patients. Texas’ test positivity is also increasing, up from a low of 4.27% on May 26 to 7.55% on June 6 (currently 6.66%). On June 3, Texas Governor Greg Abbott announced that the state would move into Phase 3 of its recovery plan, which allows businesses to increase to 50% of their normal capacity. In the announcement, Governor Abbott stated that the increased transmission was a “result of isolated hot spots in nursing homes, jails, and meat packing plants” rather than broader increases in community transmission. Governor Abbott also stated that 1,457 COVID-19 patients were hospitalized at that time, but this comment is inconsistent with data reported by the Texas Department of State Health Services, which indicates nearly 1,800 hospitalizations on that date.

AMERICAN COVID-19 POLL A poll released today indicates that Americans are still divided on their perceptions of returning to normal activity and the US government’s response. The poll , conducted by SSRS on behalf of CNN, included responses from 1,259 people across the country compiled June 2-5. Overall, 49% of respondents indicated that they were comfortable resuming normal activities, up from 41% in the previous poll (May 7-10). Those who identified as Republicans reported increased comfort (73%) compared to Democrats (23%), although both parties (and Independents) showed increases from the previous poll. Notably, those who indicated that they are uncomfortable with resuming normal activity, 17% believe they will resume their normal routine by the end of the year, compared to 32% who think it will be after the start of 2021. Even as states continue to relax social distancing and permit businesses to resume operations, 36% of the respondents believe the economy is continuing to worsen, compared to 23% that believe that it is beginning to recover. Perceptions on the economy are also divided by political party, with Republicans more likely to believe the economy is recovering (40%) than Democrats (12%). Notably, 47% of respondents believe that the worst of the pandemic is still ahead, compared to 46% who believe that it is already behind us. Participants who identified as Democrat (64%), Black (68%), and Latino (55%) were more likely to believe the worst is yet to come, compared to those who identified as Republican (22%) and White (40%).

EVALUATING COVID-19 THERAPEUTICS IN CHILDREN COVID-19 incidence data indicate that children represent both a smaller proportion of infections and deaths . In the United States, for example, children aged 0-17 years represent only 0.4% of reported COVID-19 cases nationwide according to the CDC. Despite the overall trend, there are reports of severe COVID-19 disease and other potentially associated conditions such as Multisystem Inflammatory Syndrome in Children (MIS-C). Clinical trials are being rapidly implemented globally to evaluate therapeutic candidates for COVID-19, but unfortunately, the majority of these trials exclude children. A Viewpoint published in The Journal of the American Medical Association: Pediatrics ( JAMA Pediatrics ) discusses the implications of excluding children from these trials. The authors, from the Harvard Medical School and Boston Children’s Hospital, argue that excluding children will hinder our ability to understand the drugs’ efficacy in children, which still represent a large number of cases, and would require off-label prescription by clinicians or emergency authorization by regulatory authorities. Without adequate data from pediatric patients, future patients could be subject to treatment with an ineffective or potentially dangerous product. Legislation and regulatory policies exist that direct the conduct of pediatric clinical trials, including the Best Pharmaceuticals for Children Act in the United States, which could be leveraged to expand clinical trial access for pediatric patients.

In response to the gap in research evaluating therapeutics in children, the US National Institutes of Health is funding the Pharmacokinetics of Understudied Drugs Administered in Children Per Standard of Care , a 40-site study conducted through the Pediatric Trials Network. Rather than evaluating new or candidate drugs in pediatric patients, this study aims to evaluate how children’s bodies and immune system process drugs they are already receiving, including antiviral and antiinflammatory drugs. Additionally, the study “also aims to analyze drug dosage and safety for special populations, including premature infants, critically ill children, children with Down syndrome and obese children.”