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

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June 12, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 11 reports 7.27 million confirmed cases (128,419 new) and 413,372 deaths (5,347 new).

Following a week of reporting slightly fewer than 10,000 new cases per day, India’s daily incidence jumped today to 10,956 new cases. India remains #3 globally in terms of daily incidence . Pakistan has exhibited increasing daily incidence over the past several weeks, reporting its highest daily total yesterday (6,397 new cases). Pakistan’s daily incidence has more than doubled since late May, and it is now #5 globally in terms of daily incidence. Bangladesh also reported its highest daily total yesterday, with 3,471 new cases. Bangladesh remains #10 globally in terms of daily incidence.

Iran reported 2,369 new cases. While the national incidence is down from more than 3,500 new daily cases last week, this represents an increase from earlier in the week. Iran is #12 globally in terms of daily incidence . Russia is now reporting more than 500,000 cumulative cases, with nearly half (49.0%) in Moscow and the Moscow Region. Russia remains #3 globally in terms of cumulative incidence and #4 in daily incidence.

Brazil reported more than 30,000 new cases for the third consecutive day—and the sixth time in the past 2 weeks. Brazil remains #1 globally in terms of daily incidence . Broadly, the Central and South American regions are still 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 Peru (#6), Chile (#7), and Mexico (#8)—and per capita daily incidence —Chile (#3), Peru (#5), Brazil (#8), and Panama (#9).

The Eastern Mediterranean Region also remains an emerging hotspot, particularly in terms of per capita incidence . The region represents 5 of the top 11 countries in terms of per capita incidence: Qatar (#1), Bahrain (#2), Oman (#4), Kuwait (#7), and Saudi Arabia (#11). Additionally, nearby Armenia is #6. Several Eastern Mediterranean countries are also exhibiting high total daily incidence . Saudi Arabia ranks #11 globally, and Qatar is #13, despite ranking #139 by total population . Bahrain and Saudi Arabia both reported their highest daily incidence, and Saudi Arabia’s daily incidence has doubled since early June.

The US CDC reported 1.99 million total cases (20,486 new) and 112,967 deaths (834 new). The United States will likely surpass 2 million cases in today’s update. 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 New York Times , ProPublica , Johns Hopkins University , and others continue to track state- and local-level COVID-19 incidence in a variety of forms. 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. Increased social interaction as well as mass gatherings associated with the Memorial Day holiday weekend and ongoing large-scale protests against racial injustice could potentially contribute to community transmission. We will continue monitoring these trends over the coming weeks.

As we have noted recently, a number of US states are exhibiting increasing COVID-19 incidence and hospitalizations , several weeks after initiating efforts to relax social distancing restrictions. We have covered several of these states already this week, including Arizona , California , and Texas ( hospitalizations and testing ). Other states of note include Alabama , Alaska , Florida , North Carolina , South Carolina , and Vermont . A number of these states reported their highest daily incidence and/or highest current COVID-19 hospitalizations over the past several days. While Alaska still has relatively few cumulative reported cases, its daily incidence has returned to a similar level as its “first wave” of cases, and modeling indicates that its epidemic is currently exhibiting exponential growth. In addition to increasing incidence, several of these states are also reporting increasing COVID-19 hospitalizations or increasing or elevated test positivity, which suggests that increased testing may not wholly account for the increased incidence. Increased incidence is not necessarily distributed evenly across these states. Multiple outbreaks in different locations—including congregate settings such as nursing homes, meat packing facilities, and prisons or jails—are contributing substantially to these totals in numerous states. Many of these states were not hit particularly hard early in the US COVID-19 epidemic, but they are now exhibiting increasing incidence that corresponds temporally with decisions several weeks ago to relax social distancing and permit increased social interaction. It is still a little early to identify any increased transmission related to Memorial Day holiday gatherings or protests against racial and social injustice in the United States or other countries.

The Johns Hopkins CSSE dashboard reported 2.03 million US cases and 113,924 deaths as of 12:30pm on June 12.

LUNG TRANSPLANT FOR COVID-19 PATIENT A COVID-19 survivor in the United States is the recipient of the first reported lung transplant on a former COVID-19 patient. The patient, a young and otherwise relatively healthy woman , had severe lung damage as a result of COVID-19, which caused other complications such as secondary bacterial infections and the onset of other organ failure due to lack of oxygen. The surgery was especially challenging, as the inflammation and lung damage nearly fused the lung tissue to the patient’s chest wall , according to surgeon Dr. Ankit Bharat. Her physicians expect her long-term prognosis to be good. The United States is experiencing a shortage of available organs for transplant and a growing waiting list of patients, even prior to the emergence of SARS-CoV-2. As we have covered previously, this situation is being exacerbated by the ongoing COVID-19 epidemic , due to a variety of factors. 

SARS-CoV-2 IMMUNITY Scientists and vaccine developers are working to understand how the human immune system responds to SARS-CoV-2 and the lasting immunological profile of infection. While evidence is emerging that recovering from COVID-19 does confer some protective immunity, the degree and duration of protection remain uncertain. There are a wide variety of cells and proteins that contribute to the immune response, including antibodies, T cells, and innate immune cells. Considerable attention is currently focused on the neutralizing antibody response, but more research is beginning to address the role of T cells in fighting SARS-CoV-2. Understanding these correlates of immunity is important vaccine development, as these products must elicit an appropriate and protective immune response. There is also great variability in the magnitude of the immune response from person to person, and vaccine developers must take these variations into account when developing a widely protective vaccine.

MASK USE Following the recent statement and clarification by the WHO regarding recommendations regarding the use of face masks and coverings to mitigate SARS-CoV-2 transmission risk, a study was published that suggests that widespread mask use by the general public can provide significant benefit in terms of curbing transmission. The study, a modeling effort by researchers in the United Kingdom, found that universal mask use by the public could be sufficient to contain a COVID-19 epidemic, in some cases, even without associated “lockdown” restrictions. The researchers modeled a variety of scenarios, utilizing both individual- and population-level transmission dynamics, to characterize the conditions, including mask filtering efficiency, under which mask use could be beneficial. In addition to modeling reduced transmission due to mask use, the researchers also factored in potential increased transmission risk resulting from improper mask use or self-contamination due to individuals touching their face and mask.

The study found that mask use, with or without “lockdown” restrictions could effectively reduce transmission risk. Under some conditions, mask use by the public could be sufficient to contain transmission by itself, and in others, it substantially reduced transmission. The largest effect was achieved for scenarios in which mask use was universal, including for asymptomatic individuals. The lead author, Dr. Richard Stutt, stated that the “analyses support the immediate and universal adoption of face masks by the public,” including both symptomatic and asymptomatic individuals. As with any modeling study, there are inevitable limitations and assumptions that will impact the results. Even if the magnitude of the effect is lower than this model indicates, however, it provides additional support for widespread mask use, including by those not currently exhibiting symptoms.

The UN High Commission for Refugees (UNHCR) is supporting efforts to produce and distribute face masks in Turkey. The effort is led by 12 Afghan refugees currently living in Turkey, who are coordinating with local volunteers to provide 1,000 masks per day, as well as soap and other supplies. The project ultimately aims to produce 30,000 masks over the course of a month. The group said that they wanted to find a way to thank Turkey for welcoming them and other Afghan refugees and to actively contribute to the COVID-19 response rather than “just rely[ing] on assistance.”

AFRICA COVID-19 PREPARATIONS Initially, many public health experts were concerned about the potential for COVID-19 to devastate the African continent, where many struggle with inadequate public health and healthcare infrastructure. Additionally, many African countries face a high prevalence of underlying health conditions—including HIV/AIDS, malaria, and tuberculosis—which place individuals at elevated risk for severe disease and death. To date, however, most countries in Africa have reported an unexpectedly slow rise of cases and relatively low mortality.

While some countries, like Nigeria, are beginning to experience an exponential increase in cases, some public health experts remain cautiously optimistic that strict control measures implemented early in the pandemic may have made a meaningful difference in many countries. When reports of imported cases first appeared in Egypt and Nigeria, many sub-Saharan African countries quickly moved to impose strict "lockdowns” and other restrictive physical distancing measures, although a number of countries are beginning to relax these policies. Another possible explanation for Africa’s relative success against COVID-19 is the overall “ younger demographic age structure ” in many countries. For example, 23% of Italy’s population is over the age of 65, compared to only 3% of the sub-Saharan African population, which could account for some of the reduced mortality observed so far in Africa. Climate could also potentially play a role, but further investigation is needed to better characterize any seasonality or impact from temperature or humidity. While Africa’s COVID-19 reporting appears to indicate relative success compared to other parts of the world, some experts remain concerned that the low incidence may be a function of limited testing capacity rather than an indication that countries are effectively containing their national epidemics. Experts recommend continued vigilance, support, and surveillance in the coming weeks and months in order to stay abreast of the COVID-19 pandemic’s effect on African nations.

SOUTH KOREA South Korea has been praised for the successful containment of its COVID-19 epidemic, but a recent increase in incidence, particularly in and around Seoul, is raising concern that South Korea could be on the precipice of a second “wave” of cases. Following substantial transmission among the members of a large religious group that fueled early SARS-CoV-2 transmission in South Korea, the country was largely able to bring COVID-19 under control. In fact, South Korea reported 10 or fewer cases on most days between mid-April and early May. As a result of successfully reducing transmission, South Korea relaxed a number of social distancing measures nationwide and permitted resumed operations at many businesses. Despite ongoing encouragement by government officials to continue practicing social distancing and refraining from unnecessary activity and gatherings, credit card and cell phone location data indicate that public activity has essentially returned to pre-pandemic levels.

South Korea has reported increased COVID-19 incidence since early May. While the total number of daily cases, now approximately 40-60 new cases per day, is nowhere near the incidence observed in many other countries, the fact that transmission has been linked to numerous exposures in and around South Korea’s most populous city gives cause for concern. As transmission has increased, South Korean health officials have reportedly struggled to keep up through contact tracing. The combination of social distancing and contact tracing has been touted as the key to South Korea’s early success, but if this capacity is unable to stay ahead of the epidemic and identify COVID-19 cases before they can infect others, an outbreak in Seoul could pose major challenges for the COVID-19 response. The Korean CDC emphasized that transmission is occurring at a variety of settings in Seoul, particularly those that involve prolonged close contact, such as nightclubs and bars, entertainment venues, and places of worship. Additionally, South Korea has reported dozens of cases associated with a logistics company warehouse. South Korea has not re-instituted nationwide or large-scale social distancing restrictions, but some cities are reacting to the increased transmission by implementing their own policies. Seoul, for example, reportedly closed nightclubs, bars, and entertainment venues to mitigate transmission risk.

US ECONOMY & EMPLOYEE SAFETY The US Department of Labor published its weekly report on unemployment claims, which yielded mixed results . On the positive side, the number of new unemployment claims fell last week, down more than 350,000 compared to the previous week. Additionally, the total number of active unemployment claims decreased by 339,000 compared to the previous week, and the national unemployment rate decreased from 14.4% to 14.2%. These figures indicate that some Americans are beginning to return to work. That being said, Americans still filed more than 1.5 million new unemployment claims last week, and 20.9 million unemployment claims remained active nationwide, indicating that many Americans continue to struggle with employment, even as states relax social distancing and economic activity increases. Additionally, the US Federal Reserve announced that it intends to keep interest rates low, potentially through 2021, in order to promote economic recovery, and it forecast a 6.5% decline in the national gross domestic product by the end of 2020.

As US states continue to relax social distancing and resume business, government, transportation, and other activities, workers are returning to a myriad of new policies and protective measures. Despite changes designed to ensure workers’ health and safety, many remain concerned that the protections are not sufficient to effectively mitigate the COVID-19 risk. One of the major challenges lies in the guidance issued by federal agencies, including the US CDC, much of which is voluntary, as opposed to mandatory and enforceable. While some industries have been more severely affected than others, such as meat processing, many aspects of the economy—including restaurants, barbershops and salons, and retail stores—are resuming activity across the country. Many businesses (or individual employees) are developing and implementing their own plans without the aid of government-mandated requirements, which could result in inconsistencies, within and between communities, in how federal guidance is operationalized.

The combination of the unemployment report, economic forecasts, and reports of increasing COVID-19 incidence and hospitalizations in numerous states appears to have made a major impact on the stock market . US stocks fell yesterday by their largest daily total since March, including a 6.9% drop in the Dow Jones Industrial Average. Responding to these economic and epidemic trends, US Secretary of the Treasury Steven Mnuchin commented that the United States could not afford to shut down the economy again in response to increased COVID-19 transmission, citing both economic impact and downstream effects, including on health.

BRAZILIAN FAVELAS RESPOND TO COVID-19 As Brazil’s COVID-19 incidence continues to increase dramatically, some of the country’s most vulnerable populations have been provided limited support or resources by the government to protect themselves or maintain financial security. Those living in Brazil’s favelas , densely populated and low-income areas, are at elevated risk from COVID-19. Like many countries, lower-income and racial and ethnic minorities are at higher risk of infection as well as severe disease and death. In São Paulo, Brazil, individuals living in lower-income parts of the city are reportedly up to 10 times as likely to die from COVID-19 than those living in wealthier areas, and Black residents are 62% more likely to die from COVID-19 than White residents.

Without adequate government support, favelas have been forced to become more self-reliant, particularly as gang violence, systemic racism, and other factors have limited access to vital resources. In response, local communities formed their own systems for services like mail, sanitation, and even internet access. Similarly, these communities are now mounting their own COVID-19 response. Local community organizations and leaders, including “street presidents” who represent smaller groups of neighbors among the favela communities, are coordinating efforts to deliver supplies like masks and hand sanitizer, distribute food, conduct disease surveillance, and dispel misinformation. Additionally, community organizations have hired ambulances for use in their neighborhoods and created funding support for those who are unemployed and in need of financial assistance.

STAFFING SHORTAGES AT NURSING HOMES Nursing homes and long-term care facilities are among the highest-risk settings in the US COVID-19 epidemic. Prolonged close contact among residents and staff and the presence of high-risk older residents with underlying health conditions have resulted in numerous outbreaks across the country, accounting for a disproportionate fraction of US COVID-19 cases and deaths. The Kaiser Family Foundation estimates that approximately 15% of COVID-19 cases and 45% of deaths (across 41 states with available data) are among residents of long-term care facilities.

In addition to the elevated risk, chronic staffing shortages and management problems at these facilities are reportedly being exacerbated by the COVID-19 epidemic, which poses additional challenges in caring for patients and controlling SARS-CoV-2 transmission. These facilities have experienced long-standing staffing and management limitations, but the COVID-19 epidemic has highlighted the magnitude of these challenges and the associated dangers. Staffing standards vary by state, and according to analysis conducted by Reuters , approximately 40% of nursing home facilities nationwide would fail to meet the strictest staffing standards, which are implemented in California. The federal government has been criticized by advocacy groups during the COVID-19 response for not providing sufficient coordination and guidance to nursing home facilities in order to protect the most vulnerable populations. For example, the US government recommends that states test all residents and staff at long-term care facilities, but it is not mandatory and compliance with this guidance reportedly varies by state and local jurisdiction. US Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma stated that CMS would cover the cost of testing for residents if there is a suspected outbreak; however, individual facilities or states are responsible for the cost of testing staff.