COVID-19
Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.

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June 15, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 14 reports 7.69 million confirmed cases (137,526 new) and 427,630 deaths (4,281 new). The WHO reported 142,672 new cases on June 13, the highest global daily incidence to date. Overall, the global daily incidence continues to increase , and the pandemic appears as though it may be accelerating. The global cumulative incidence could reach 8 million cases by Wednesday’s Situation Report.

Broken down by continent , Europe continues to represent a decreasing proportion of new COVID-19 incidence, down to approximately 12% of the global total. North America has accounted for approximately 20-25% of new daily cases since late May, and it is holding relatively steady. The relative contributions of Asia and South America continue to increase. Asia now represents approximately 30% of the global daily incidence, up from 15% in early May. South America accounts for 25-35% of the global incidence, which fluctuates considerably from day to day. Africa’s contribution continues to increase steadily as well, although to a lesser extent. Africa is now representing more than 7% of the global daily incidence, its highest to date. Looking at the relative change in growth rate over the past 2 weeks , the majority of countries with increases of 25% or greater are in Asia, Africa, and South America. Notably, there are at least 10 countries in Africa that have relative increases of 100% or greater over the past 2 weeks.

Following a week of reporting slightly fewer than 10,000 new cases per day, India’s daily incidence jumped to more than 11,500 new cases over 2 days and remained there over the weekend. India has reported its 4 highest daily totals over the past 4 days, including its record high of 11,929 new cases on June 14. India remains #3 globally in terms of daily incidence . India is now reporting more than 300,000 cumulative cases, surpassing the United Kingdom over the weekend to become #4 globally in terms of cumulative incidence . After reporting a new high daily incidence for 5 consecutive days, including its current record of 6,825 new cases on June 13, Pakistan reported 5,248 new cases yesterday. While this is a decrease of more than 1,500 cases from the previous day, it is still Pakistan’s sixth highest daily total. With this decrease, Pakistan is currently #6 globally in terms of daily incidence. Bangladesh also reported a slight decrease from its daily record, down from 3,471 new cases on June 11 to 3,099 new cases yesterday—this is also Bangladesh’s sixth highest daily total. Bangladesh is currently #11 globally in terms of daily incidence.

Iran reported 2,449 new cases. While lower than both the peak last week and its first peak in late March, Iran’s current daily incidence increased over the weekend, compared to the end of last week. Iran is #13 globally in terms of daily incidence . Russia has remained relatively steady at approximately 8,500-9,000 new cases per day for the past several weeks, currently #4 in terms of daily incidence.

Brazil reported 17,110 new cases, but this low value, relative to other recent reports, is likely the result of delayed weekend reporting. Last week, Brazil reported its highest weekly incidence; however, it was only a slight increase over the previous week—177,668 new cases compared to 174,406 the previous week. This was the smallest weekly increase in 11 weeks (when Brazil reported only 2,784 total cases), which suggests that Brazil could be approaching a peak or plateau. Brazil is currently #2 globally in terms of daily incidence , behind the United States, but Brazil will likely regain the #1 spot this week. Broadly, the Central and South American regions are still a major COVID-19 hot spot. In total, the region represents 5 of the top 12 countries globally in terms of daily incidence—including Chile (#5), Peru (#7), Mexico (#8), and Colombia (#12)—and 4 of the top 11 in terms of per capita daily incidence —Chile (#2), Panama (#6), Peru (#7), and Brazil (#11).

The Eastern Mediterranean Region also remains an emerging hotspot, representing 5 of the top 11 countries in terms of per capita incidence: Qatar (#1), Oman (#3), Bahrain (#5), Kuwait (#8), and Saudi Arabia (#9). Additionally, nearby Armenia is #4. Additionally, Saudi Arabia ranks #9 globally in terms of total daily incidence .

UNITED STATES
The US CDC reported 2.06 million total cases (24,468 new) and 115,271 deaths (646 new). The United States surpassed 2 million cases in Friday’s, and the overall trend in daily incidence appears to have plateaued over the past several weeks. In total, 16 states (increase of 2) 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 at the end of April/early May. Increased social interaction as well as mass gatherings associated with the Memorial Day holiday weekend and large-scale protests against racial and social injustice could potentially contribute to increased community transmission. We will continue monitoring these trends over the coming weeks.

The Johns Hopkins CSSE dashboard reported 2.10 million US cases and 115,827 deaths as of 12:30pm on June 15.

PUBLIC ATTITUDES & SOCIAL DISTANCING On Friday, the US CDC hosted its first COVID-19 briefing in several months . US CDC Director Dr. Robert Redfield and COVID-19 Incident Manager Dr. Jay Butler discussed the US COVID-19 response as well as a recent publication on the public’s perception of social distancing orders. They cautioned that the US COVID-19 epidemic is not over and that continued vigilance and adherence to recommended preventive measures are necessary to mitigate the risk of increased transmission as social distancing measures are relaxed. The study, published in the CDC’s Morbidity and Mortality Weekly Report , surveyed US households—with a particular focus on New York and Los Angeles—to better understand perceptions of “stay at home” orders and other social distancing restrictions as well as the public’s adherence to those orders. The researchers found that the public generally agreed with the restrictions and believed they struck an appropriate balance between permitting necessary activities and reducing transmission risk. The survey respondents also reported high levels of compliance with the orders.

On Friday, the CDC also published updated guidance to help the general public mitigate transmission risk as they begin to resume social activities . One document aids in making informed decisions regarding going out or engaging in social activities, and the other assists with planning events and other gatherings .

From a local standpoint, government leaders are concerned that complacency in maintaining mask usage and social distancing measures could lead to decreased compliance and increased transmission. For example, New York Governor Andrew Cuomo expressed unease following reports of New York City residents failing to maintain recommended physical distancing or wear masks while in crowded public areas. After bars and restaurants in several other US cities were forced to close following COVID-19 cases among bartenders and other employees, Governor Cuomo emphasized that increased transmission could result in closing businesses in New York as well.

US CDC CONSOLIDATED TESTING GUIDANCE On Friday, the US CDC updated its SARS-CoV-2 testing guidance, publishing a consolidated testing strategy that includes high-risk populations and critical infrastructure sectors. The new guidance brings together numerous existing and updated guidance documents related to SARS-CoV-2 testing and provides a common location from which to access testing recommendations. Notably, the document addresses both diagnostic tests and serological tests, and the document provides links to specific guidance for a variety of purposes and in a variety of populations and individuals. These include diagnostic and clinical purposes for individuals exhibiting symptoms, asymptomatic individuals with and without known exposures, and decisions regarding patient discharge or ending isolation as well as public health surveillance. Special instructions are provided for high-risk settings, such as long-term care facilities and correctional facilities, and critical infrastructure workplace settings following the identification of a confirmed or suspected case.

CLINICAL TRIALS CoronaVac, a SARS-CoV-2 vaccine created by Sinovac Biotech based in Beijing, has shown preliminary success in a Phase 2 clinical trial. The company enrolled 743 healthy participants in the randomized, double-blinded, placebo-controlled Phase 1 and 2 trials. In a press release, Sinovac announced that the Phase 2 trial data indicate that the vaccine induced neutralizing antibodies in 90% of the participants 2 weeks after the second dose of the vaccine. No serious adverse events were reported in either trial. The company anticipates publishing the clinical trial data in an academic journal in the near future, but results of animal challenge studies were published in Science in April. Sinovac also announced a plan to conduct a Phase 3 clinical trial in Brazil. The company is constructing a manufacturing facility that is designed to produce up to 100 million doses of the vaccine per year in anticipation of further success in the clinical trials. 

Regeneron Pharmaceuticals announced that it will commence clinical trials at multiple sites to test its dual antibody cocktail, REGN-COV2, as both a prophylactic and treatment. Hospitalized and non-hospitalized COVID-19 patients will be involved in testing REGN-COV2 as a treatment, and prophylactic effects will be tested in uninfected individuals at high risk of exposure, such as healthcare workers, and those with close contact with a COVID-19 case. Regeneron also noted that 2 manuscripts have been accepted for publication by Science , which are scheduled to be available online today. The manuscripts describe preclinical studies regarding the creation of the cocktail and how the dual antibody approach is more likely to provide protection than a single antibody approach.

As we have covered previously, the prospect of effective vaccines, treatments, and other drugs against COVID-19 has raised concerns about drug pricing and availability. An article published by STAT News discusses the process of determining a drug’s value, using remdesivir as a hypothetical case study. The article discusses ongoing efforts to determine the drug’s value and associated pricing models and limitations of these methods as well as the importance of accounting for the value of public investment in these products and continued investments to develop improved products in the future. 

BEIJING COVID-19 OUTBREAK China has reported increased SARS-CoV-2 transmission in Beijing over the past several days and re-instituted some social distancing measures in order to contain an emerging outbreak. Beijing health authorities first identified the outbreak on June 11 , linked the Xinfadi market, the largest in Beijing. The market is temporarily closed as health officials conduct their epidemiological investigation , including extensive environmental testing. China deployed 100,000 responders in Beijing to support the response activities. Officials aim to test 90,000 people in the Beijing area, and by Sunday afternoon, health officials had already tested more than 29,000 individuals who recently visited the market and more than 76,000 total across the affected communities. Additionally, affected areas in Beijing were placed under restrictive social distancing measures, including prohibiting the entry of visitors and vehicular traffic, closing non-essential businesses and public spaces, and prohibiting mass gatherings. Communities in Beijing that do not currently have COVID-19 cases are implementing screening measures as well, including temperature checks and symptoms monitoring. While the Xinfadi market remains closed, other markets and chain stores are increasing the supply of vegetables and other food products to ensure availability in Beijing. As a result of a “failure” to prevent or immediately contain the outbreak, several local officials were removed from office . In terms of population, Beijing is considerably larger than Wuhan , and it is a major global transit hub. A significant COVID-19 epidemic in Beijing could be a major global problem, and Chinese officials appear to be implementing rapid and aggressive containment and investigation measures in an effort to contain the transmission before it can gain a foothold in the broader public.

PAKISTAN Pakistan continues to exhibit an overall increase in COVID-19 incidence, following national steps to relax social distancing measures. Pakistan largely lifted social distancing restrictions on May 9 in order to resume economic activity. According to a New York Times report, some hospitals are already turning away patients, because they do not have capacity available to treat them. Other reports indicate that some severe COVID-19 patients are unable to be transferred to intensive care units , because there are no available beds, meaning that they may not get the level of care needed.

Pakistan is currently reporting 144,478 confirmed cases, including 5,248 in the past 24 hours. One report indicates that Pakistani health officials anticipate as many as 1.2 million cases by the end of July . Increasing transmission could overwhelm what is already an overburdened health system, and incidence on the order of a million cases over the next several months could be devastating. Notably, more than 18% of tests performed yesterday in Pakistan were positive, which suggests that testing is not sufficient to fully capture the volume of ongoing transmission. Additionally, Pakistan has reported its 6 highest daily incidence totals over the past 6 days. While the most recent report was lower than the previous 5 days, it is still twice the daily incidence at the end of May.

MAYO CLINIC NEUTRALIZING ANTIBODY TEST The Mayo Clinic announced that it will begin using a novel SARS-CoV-2 neutralizing antibody test as part of ongoing efforts to develop convalescent plasma and other COVID-19 treatments. The test was developed and validated through a collaboration between the Mayo Clinic; Vyriad, Inc.; Regeneron; and Imanis Life Sciences. Many existing serological tests detect antibodies that indicate ongoing or prior infection, but the new test provides a “semi-quantitative” assessment specifically for the presence of neutralizing antibodies against SARS-CoV-2. Potential uses include identifying ideal convalescent plasma donors (i.e., those with high levels of neutralizing antibodies) and testing the efficacy of investigational vaccines.

VACCINE DELIVERY As the world looks ahead in hopeful anticipation of a SARS-CoV-2 vaccine, one major outstanding challenge is how to best make that vaccine available around the world. While major hurdles still remain in terms of testing and producing even the most advanced vaccine candidates—as well as developing and testing others—efforts need to begin now to address challenges associated with allocating limited initial inventory, communicate about vaccine efficacy and safety, and coordinate international distribution logistics. Having these plans in place, coordinated on the global level, will help mitigate delays and barriers to global vaccine access once approved products become available. On Wednesday, June 17, at 1pm EDT, experts from the Johns Hopkins University International Vaccine Access Center will host a webinar to discuss challenges and associated communication and policy considerations in order to support global efforts to establish effective plans and programs in advance of vaccine availability and ensure equitable global access.