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

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June 17, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 16 reports 7.94 million confirmed cases (118,502 new) and 434,796 deaths (3,255 new). The global cumulative incidence could reach 8 million cases in today’s Situation Report. Overall, the global daily incidence continues to increase .

India’s daily incidence remains above 10,000 new cases for the sixth consecutive day. India remains #3 globally in terms of daily incidence . Following 2 days of decreased COVID-19 incidence reporting, Pakistan reported 5,839 new cases, its fourth highest daily total to date. With this decrease, Pakistan is currently #6 globally in terms of daily incidence. Bangladesh reported its 2 highest daily totals over the past 2 days—3,862 new cases on June 15 and 4,008 on June 16. Bangladesh’s COVID-19 epidemic continues to accelerate, and Bangladesh is currently #11 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.

Iran reported 2,612 new cases, bringing the national total to 195,511 cumulative cases. Iran could reach 200,000 cases by Friday. While lower than both the peak last week and its first peak in late March, Iran’s current daily incidence continues to increase. Iran is #12 globally in terms of daily incidence .

Brazil reported 34,918 new cases, its highest daily total to date. Brazil resumed the #1 position in terms of daily incidence , once again surpassing the United States. 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), Mexico (#8), Peru (#9), and Colombia (#13)—and 4 of the top 10 in terms of per capita daily incidence —Chile (#2), Panama (#6), Peru (#7), and Brazil (#10).

The Eastern Mediterranean Region also remains an emerging hotspot, representing 5 of the top 11 countries in terms of per capita incidence : Qatar (#1), Bahrain (#3), Oman (#4), Saudi Arabia (#7), and Kuwait (#9). Additionally, nearby Armenia is #5. Notably, Qatar remains #1, but its per capita daily incidence has decreased substantially since late May, down from 730 cases per million on May 31 to 424 cases per million today (42.5% decrease). Saudi Arabia climbed to #7 globally in terms of total daily incidence .

The US CDC reported 2.10 million total cases (18,577 new) and 116,140 deaths (496 new). 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.

Recent COVID-19 incidence reports by the CDC appear to be slightly higher than in previous weeks. Considering the variation from day to day, it is difficult to determine if this is the beginning of a national-level trend or if it is simply an anomaly. A recent publication by the CDC’s COVID-19 Emergency Response team, in its Morbidity and Mortality Weekly Report , presents analysis of the COVID-19 incidence through May 30. The analysis indicates that the 7-day average incidence decreased from the first peak in early April through the end of May. It appears that the 7-day average has increased since that date , but it is difficult to determine if it will continue to increase further.

A number of US states are reporting increased daily COVID-19 incidence, but most are also reporting increased testing, which could potentially be responsible for a proportion of the increase in reported cases. As part of its analysis, ProPublica compiles state-level test positivity rates and indicates whether each is currently increasing, decreasing, or holding steady. In total, at least 15 states are reporting increasing test positivity (out of 47 states with available data). Among these states, 2 states, Alabama and Arizona, are reporting positive results in more than 10% of all tests, and an additional 5 states—Arkansas, Florida, Mississippi, South Dakota, and Texas—are reporting test positivity greater than 5% (the benchmark recommended by the WHO ). Three (3) states—Louisiana, North Carolina, and Utah—are reporting steady test positivity greater than 5%. Another expert analysis shows 20 states with increasing test positivity (out of 50), including 3 states greater than 10%—Alabama, Arizona, and South Carolina—and another 7 greater than 5%.

The Johns Hopkins CSSE dashboard reported 2.15 million US cases and 117,129 deaths as of 12:30pm on June 17.

DEXAMETHASONE Earlier this week, researchers described findings from study that suggest the steroid dexamethasone could be effective at reducing COVID-19 mortality . The drug is part of the RECOVERY clinical trials conducted in the United Kingdom, one of the largest clinical trials testing potential COVID-19 therapeutics. The preliminary results have not undergone peer review. The study tested a small daily dose of the drug in 2,104 hospitalized COVID-19 patients. When compared to a non-placebo-controlled control group who received the normal standard of care, dexamethasone was associated with a 34% decrease in mortality for patients on mechanical ventilation and 20% decrease for those receiving oxygen therapy.

These results show promise, and the UK government reportedly already announced plans to distribute doses of the drug currently available in its national stockpile, potentially as many as 200,000 doses. Some health experts have criticized the researchers for publishing the preliminary results in a press release rather than making the data publicly available or awaiting peer review, particularly in light of recent retractions for other COVID-19 analyses.

COVID-19 RISK FACTORS Efforts are ongoing around the world—by government health agencies, academic institutions, and others—to better characterize and understand risk factors for SARS-CoV-2 infection as well as severe disease and death. While it is generally understood that older individuals and those with underlying health conditions are at elevated risk of severe disease and death, a myriad of other factors influence infection and disease risk. Beyond physical and health characteristics, numerous studies are evaluating the role of race and other social factors in COVID-19 risk. Several studies found that Black Americans are at elevated risk of death from COVID-19, after adjusting for income, health insurance coverage, comorbidities, and other factors. Issues such as disparities in the quality of health care and access to testing as well as broader challenges associated with systemic inequalities likely factor into this increased risk. Another study conducted by researchers at the Harvard Center for Population and Development Studies found similar results in terms of mortality risk among racial and ethnic minorities. The researchers found that racial and ethnic minorities (age 24-56 years) experienced 5-9 times the mortality risk as non-Hispanic White individuals, depending on age within that range.

A study published in The Lancet: Global Health , evaluated the prevalence of known risk factors for severe disease around the world. The researchers estimate that 1.7 billion people globally (approximately 22% of the global population) have existing health conditions that increase risk for severe COVID-19 disease, including nearly 350 million (4% of the global population) with conditions that would put them at “high risk” of severe disease. The study also stratifies the results by countries and continents/regions and provides distributions of relevant health conditions by age. Another study, published in Nature Medicine , found that children are half as likely to get infected with SARS-CoV-2 as adults. The researchers fit an age-structured model to COVID-19 data from China, Italy, Japan, Singapore, Canada, and South Korea in order to better characterize age-based COVID-19 risk. In addition to the age-based infection risk, the model also projects the proportion of SARS-CoV-2 infections that become symptomatic, stratified by age. The researchers found that among children aged 10-19 years, 21% of SARS-CoV-2 infections develop symptoms, which increases with age, up to 69% for adults 70 years and older.

US SOCIAL DISTANCING Multiple US states continue to report elevated or increasing COVID-19 incidence. Elected officials, including President Donald Trump and Vice President Mike Pence , have identified increased testing as the driver of increased COVID-19 reporting; however, other indicators suggest that this may not be the whole story. At the national level, the United States has reported relatively steady incidence over the past several weeks; however, there are notable regional and state-level differences. One analysis combined state-level data to track regional trends, and found that the South, Southwest, and West Coast regions are exhibiting increased incidence, while New England, the Mid-Atlantic, and the Midwest are declining. Additionally, the test positivity rate in the South and Southwest is increasing, which indicates that the increased incidence in these regions may not be wholly attributable to increased testing. Furthermore, COVID-19 incidence is decreasing in states that were affected earlier in the US epidemic—Massachusetts, Michigan, New York, New Jersey, and Pennsylvania—but it is increasing steadily across the rest of the country.

Some states and cities are taking notice of recent increases in COVID-19 incidence and have begun slowing efforts to ease social distancing restrictions. Other states, however, continue on their intended course , despite increased incidence, hospitalizations, or test positivity. At the state level, the governors of Utah and Oregon recently announced that increased transmission would slow progress statewide in terms of easing social distancing restrictions. Health officials and experts nationwide continue to emphasize that the pandemic is not over or under control in the United States, and they highlight the risk of complacency among the general public.

Several governors have acknowledged the increasing COVID-19 incidence and associated risk, but note that this will not affect existing plans or timelines to relax statewide social distancing policies. Arkansas Governor Asa Hutchinson stated, “Regardless of what we see in the next week, we made the right decision to...lift some of these restrictions so we don’t cause more damage to people’s lives and their livelihood.” Arkansas ’ COVID-19 incidence, hospitalizations, and active cases have all doubled (or more) since Memorial Day Weekend (May 25), and the statewide test positivity increased since that time as well. Similarly, Florida Governor Ron DeSantis stated that the state would not be “rolling back” recent efforts to relax social distancing as a result of recent increases in COVID-19 incidence, citing the need to maintain a functioning society. Rather, Florida continues forward with its recovery plan, including permitting major amusement parks such as Universal Studios and Disney to reopen, while reporting record daily COVID-19 incidence. Florida’s daily incidence has increased from fewer than 1,000 new cases per day on June 1 to 2,800 on June 15.

HYDROXYCHLOROQUINE The US FDA revoked an Emergency Use Authorization for hydroxychloroquine and chloroquine. The EUA for both drugs was issued last month, but recent studies have not provided sufficient evidence that the drugs provide treatment benefit. Additionally, several studies have found that the drugs are associated with increased risk of cardiac arrest and other serious adverse events. The WHO recently suspended clinical trials of the drugs in order to evaluate the available data, but they soon resumed these studies . The decision has larger implications for the United States’ continued COVID-19 response. Following early pressure from US political leaders, a number of states invested significant resources in building stockpiles of hydroxychloroquine.

MONOCLONAL ANTIBODIES In the search for tools in the fight against COVID-19, many discussions have focused on vaccines, antiviral agents, and convalescent plasma; however, these are not the only options. As discussed in a viewpoint published in The Journal of the American Medical Association ( JAMA ), monoclonal antibodies may offer an alternative strategy for treating those already infected with SARS-CoV-2 and could potentially offer prophylactic protection for those at increased risk for infection. While neutralizing antibodies could be isolated from the blood serum of recovered COVID-19 patients, they can also be isolated from other sources, including infected animals, or even developed synthetically .

For SARS-CoV-2, neutralizing antibodies could interfere with the interaction between the virus’ spike protein and the ACE-2 receptor on host cells, which could prevent the virus from infecting host cells. This mechanism could potentially offer treatment for patients (e.g., to reduce symptom severity) or offer temporary prophylaxis against the infection. Current monoclonal antibody drug formulations are administered via infusion into the bloodstream, and clinical trials for some products are anticipated to begin this summer.

NEW ZEALAND Eight days after New Zealand Prime Minister Jacinda Ardern announced that the country had reached zero active COVID-19 patients, New Zealand reported 2 imported cases. Yesterday, New Zealand Minister of Health Dr. Ashley Bloomfield announced that 2 women who recently arrived from the United Kingdom tested positive for SARS-CoV-2 in New Zealand . Following the discharge of New Zealand’s last COVID-19 patient on June 8, New Zealand lifted many of its social distancing measures; however, arriving travelers were still required to undergo a mandatory 14-day quarantine upon arrival. The 2 women arrived in New Zealand on June 7 to visit an ill relative, and they were permitted to leave their mandatory 14-day quarantine period early, on June 13, under a “compassionate exemption.” They traveled from Auckland to Wellington (approximately 400 miles/645 km) by car. They reportedly had no contact with anyone while en route or after their arrival, except the family member they visited in Wellington.

As part of a plan agreed to by the New Zealand Ministry of Health, the 2 women were tested in Wellington, and both received positive results. One of the women reported experiencing mild symptoms, and the other was reportedly completely asymptomatic. Contact tracing efforts are ongoing to identify, quarantine, and test potentially exposed individuals, including passengers on their flights and customs or border security personnel at the airport in Auckland. While no subsequent transmission has yet been identified in New Zealand, this highlights the importance of continued vigilance and rapid response in order to quickly identify and contain possible chains of transmission, via arriving travelers or other sources. Of note, Dr. Bloomfield stated that anyone released quarantine early under “compassionate exemption” in the future will be required to be tested prior to being released.

BEIJING OUTBREAK The COVID-19 outbreak in Beijing continues, and China is implementing increasingly restrictive measures , including lockdown-style policies in affected parts of the city, in an effort to contain transmission. China’s National Health Commission reported 137 cases in Beijing between June 11 and June 16 , including 31 new cases reported yesterday. In response to the outbreak, China deployed significant resources to identify and contain chains of transmission, including teams with experience responding to the COVID-19 epidemic in Wuhan . Chinese health officials have already conducted interviews with approximately 200,000 individuals who visited the Xinfadi market since late May and implemented movement restrictions, fever and symptom screening, and other measures in at least 21 communities in Beijing. In addition to closing the Xinfadi market to allow for environmental testing and disinfection, Chinese officials also closed 11 other “underground and semi-underground markets” across Beijing.

Cases linked to the market have also been identified in other cities , some of which have increased their own social distancing and travel restrictions, including mandatory 14-day quarantine for individuals with recent travel to Beijing. China appears to be implementing a robust response to the Beijing outbreak, in an effort to prevent broader community transmission in the country’s second most populous city .

HEALTH SYSTEM CAPACITY & PATIENT SURGE Over the course of the COVID-19 pandemic, healthcare systems have braced for the possibility that patient surge could exceed available capacity. In New York , which emerged as the major US hotspot early in the US epidemic, the state required hospitals and health systems to submit plans to effectively double patient capacity in anticipation of a major local epidemic. Strategies included converting spaces otherwise used for suspended activities (e.g., elective procedures) into intensive care units and using conference rooms and other non-clinical spaces for patient triage and care. To supplement capacity at hospitals, New York also established field hospitals at multiple locations around New York City. In addition to bed space for patients, hospitals also needed to account for additional staff and associated personal protective equipment and other supplies. Ultimately, New York did not exceed its total capacity, and efforts are ongoing to understand why the models used to estimate the clinical capacity needs did not necessarily align with the actual experience.

Even as cases are beginning to recede in certain localities, many healthcare workers and health experts emphasize that continued vigilance and adherence to social distancing and other recommended protective measures are critical to mitigating the risk of a surge in transmission as states resume economic and social activity. Health systems need to learn from these early lessons and plan for the potential of future patient surge, particularly in areas that were not severely affected early in the epidemic. Changes to hospital procedures and policies can have a major effect on nosocomial transmission risk, and critical changes should be implemented in advance of a patient surge, or be available for rapid implementation, in order to have the greatest effect.

COVID-19 & FOOD INSECURITY COVID-19 continues to impact human health well beyond direct morbidity and mortality. There is growing concern that a food crisis in Latin America and the Caribbean could be imminent, as food insecurity and hunger are on the rise. The Food and Agriculture Organization and the UN’s Economic Commission for Latin America and the Caribbean report that COVID-19 could result in more than 83 million people in Latin America and the Caribbean living in extreme poverty. Pandemic-related economic disruptions have influenced the aability to access and pay for food has been reduced for many households, and economic growth in many countries has stagnated. The organizations proposed 10 measures that could provide financial stability to the region and bolster food security during and after the pandemic. One proposal, “anti-hunger grants,” would provide cash subsidies, food vouchers, and access to baskets of food for individuals and families in need. Additionally, the organizations called on national governments to expand social and financial support programs, including to migrant workers and those working outside traditional employment (i.e., “informal workers”).