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

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June 19, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 18 reports 8.24 million confirmed cases (181,232 new) and 445,535 deaths (5,245 new). This is the WHO’s 150 th COVID-19 Situation Report. The WHO reported 8 million global cases on June 17 . Overall, the global daily incidence continues to increase , and the pandemic appears as though it continues to accelerate.

This daily incidence is the highest reported by the WHO to date, surpassing the previous high by nearly 39,000 cases. A significant driver of the increased incidence is Chile, which reported a large one-day spike of 36,179 new cases. Archived versions of the Chilean COVID-19 website are not available for June 16, but between June 15 and June 17 , Chile’s cumulative confirmed COVID-19 incidence jumped from 179,436 cases to 220,628. The Chilean Ministry of Health stated that it identified nearly 30,000 COVID-19 cases that were not previously included in the national surveillance data and reported them on June 16. Several news media reports cite the total as 31,412 cases. Other than June 16, Chile is reporting approximately 5-7,000 new cases per day and steadily increasing. Chile is currently reporting 225,103 cumulative cases (4,475 new).

India reported 13,586 new cases, setting a new high for daily incidence for the second consecutive day. India’s COVID-19 epidemic has accelerated rapidly over the past several weeks, with the daily incidence doubling since May 28. India is currently #4 in terms of daily incidence . We are tracking a 3-day average, which is still affected by Chile’s recent spike in incidence, and we expect India to resume the #3 position. Pakistan reported 4,944 new cases. This is Pakistan’s tenth highest daily total to date, substantially fewer cases than its recent peak of 6,825 new cases on June 13. Pakistan remains #6 globally in terms of daily incidence. Since reporting 4,008 new cases on June 16, Bangladesh has reported 2 consecutive days of decreasing daily incidence, down to 3,243 new cases yesterday—still Bangladesh’s fifth highest daily total. Bangladesh is currently #9 globally in terms of daily incidence.

Russia reported fewer than 8,000 new cases for the first time since early May. Russia is currently #5 in terms of daily incidence, but we expect it to return to #4 when Chile’s 3-day average returns to normal.

Brazil reported 22,765 new cases. Brazil’s incidence reporting pattern typically includes 4-5 days of higher incidence interspersed with 1-2 days of lower incidence; however, Brazil only reported 2 days of elevated incidence this week before decreasing in its most recent update. That being said, the decreased value is still greater than in previous weeks, so it remains to be seen whether this is indicative of any longer-term trend. Brazil remains #1 globally in terms of daily incidence . Broadly, the Central and South American regions are still a major COVID-19 hotspot, representing 5 of the top 13 countries globally in terms of daily incidence—including Chile (currently #3, but likely to return to #5), Mexico (#7), Peru (#10), and Colombia (#13)—and 4 of the top 11 in terms of per capita daily incidence —Chile (currently #1, but likely to return to #2-3), Panama (#6), Brazil (#7), and Peru (#11).

Iran reported 2,615 new cases, bringing its national total to 200,262 cumulative cases. While still lower than both the peak last week and its first peak in late March, Iran’s current daily incidence remains elevated. Iran is currently #12 globally in terms of daily incidence . Overall, the Eastern Mediterranean Region remains an emerging hotspot, representing 5 of the top 11 countries in terms of per capita incidence Qatar (currently #2, but likely to return to #1), Bahrain (#3), Oman (#5), Saudi Arabia (#8), and Kuwait (#9). Additionally, nearby Armenia is #4. In addition to Iran, Saudi Arabia is currently #8 globally in terms of total daily incidence, and Qatar is #19, despite ranking only #139 by population .

The US CDC reported 2.16 million total cases (22,834 new) and 117,632 deaths (754 new). In total, 18 states (increase of 2) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; California, New Jersey, and New York state with more than 150,000; and Illinois with more than 125,000. Following an overall decrease in daily incidence from mid-April through the end of May, the United States’ national COVID-19 incidence appears to be increasing since early June, several weeks after states began to relax social distancing measures.

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.

Numerous US states continue to report concerning COVID-19 trends. The New York Times analysis indicates that 20 states are reporting significant increases in COVID-19 incidence, based on a 7-day average. Among these states, 12 appear to be reporting record daily incidence over the past several days. Texas reported its highest daily incidence and COVID-19 hospitalizations yesterday as well as its second highest test positivity since April. Multiple hospitals in Florida are currently reporting that all of their intensive care unit (ICU) beds are occupied . According to data published by the Florida Agency for Health Care Administration (AHCA), 9 hospitals with a capacity of at least 25 ICU beds report no availability. Additionally, numerous smaller hospitals are also reporting zero available ICU beds, including 2 in Palm Beach, one of Florida’s current COVID-19 hotspots. Arkansas and North Carolina continue to report increasing COVID-19 hospitalizations. Notably, Arkansas is reporting nearly 4 times the number of hospitalized COVID-19 patients as it was in mid-May and more than 7 times the number of active community cases.

The Johns Hopkins CSSE dashboard reported 2.20 million US cases and 118,695 deaths as of 12:30pm on June 19.

RNA VACCINE DEVELOPMENT The United Kingdom announced that a Phase 1 clinical trial is scheduled to begin for a vaccine developed by Imperial College London. The vaccine utilizes self-amplifying RNA technology, and it will be administered to 300 health participants (2 doses). The vaccine received £41 million (US$51 million) in funding from the UK government and another £5 million (US$6 million) from various philanthropies and the public. The researchers believe the vaccine will be easier and less expensive to produce than traditional vaccines, and efforts are ongoing to establish a funding mechanism to make the vaccine widely available at a low cost. Imperial College is partnering with Morningside Ventures, a Hong Kong-based investment firm, to form a company to coordinate global manufacturing capacity and distribution.

Multiple SARS-CoV-2 vaccine candidates are utilizing self-amplifying RNA; however, there are no existing approved vaccines that use this technology. This type of platform has also be used in candidate vaccines against Ebolavirus and cancer therapy. Self-amplifying RNA vaccines have been demonstrated to produce immunogenic responses in animal models that are comparable to mRNA vaccines, with the benefit of requiring smaller doses. In one recent study ( preprint ), researchers at Imperial College found that their vaccine candidate produced a robust immune response in mice following 2 doses of the vaccine, which will hopefully translate to promising results in future in human trials. While self-amplifying RNA vaccines may offer a range of benefits, a number of barriers remain, including challenges with vaccine stability and delivery methods to ensure successful uptake. 

REMDESIVIR CLINICAL TRIAL Gilead Sciences announced that it will soon begin enrollment of an open-label, single-arm Phase 2/3 clinical trial to investigate the use of remdesivir as a treatment for pediatric COVID-19 patients. The trial is designed to involve approximately 50 pediatric patients with moderate-to-severe COVID-19, including newborns, across 30 sites in the United States and Europe, and it is scheduled to be completed by December 2020. Remdesivir was previously available to pediatric patients via compassionate use and Emergency Use Authorization (EUA), but a clinical trial will provide valuable data to evaluate its efficacy and safety in pediatric patients.

VACCINE DEVELOPMENT & ALLOCATION The European Commission is reportedly negotiating with pharmaceutical company Johnson & Johnson to reserve doses of its SARS-CoV-2 vaccine candidate . This development follows the announcement of a mandate from 27 EU governments to use €2 billion (US$2.3 billion) to arrange access to vaccine supply from multiple vaccine developers. Germany, Italy, and the Netherlands recently secured approximately 400 million doses of the AstraZeneca candidate vaccine, which could be allocated across EU member states. The United States made a similar arrangement with the company.

Arrangements between pharmaceutical companies and governments of high-income countries have raised concerns that low-income countries may not be able to access sufficient doses of vaccines as they become available. While international organizations and stakeholders—including the WHO, Médecins Sans Frontières (MSF), and Gavi—have advocated for and promoted equitable allocation of the SARS-CoV-2 vaccine, there is a lack of legally enforceable mechanisms and frameworks to enforce it, particularly for situations in which vaccine development efforts have received funding from national governments. An editorial published in Nature called for pooling relevant data and proprietary information necessary to advance vaccine development and production, similar to open-source software, in order to enable more companies and countries to contribute to these efforts. This concept has been met with opposition from vaccine manufacturers, who are concerned about the maintaining the value of their intellectual property, and high-income country governments that have invested in vaccine research and development.

CONVALESCENT SERUM ANTIBODIES A recent study published in Nature evaluated the neutralizing capacity of convalescent serum collected from recovered COVID-19 patients. The study generally found low levels of neutralizing activity present in the specimens. The researchers did find that all of the specimens possessed at least a small volume of potent antibodies specific to the receptor binding domain (RBD) of SARS-CoV-2. The ability of these potent neutralizing antibodies to target the RBD portion of the virus has implications for vaccine development. If a vaccine could be designed to elicit an immune response that produces many of these RBD-specific antibodies, then such a vaccine could induce sufficient protection against infection. Additional research is required to better characterize the immune response to SARS-CoV-2 infection and the potential role of convalescent serum as a potential treatment or prophylaxis.

While the benefits of convalescent serum are still being studied, the Mayo Clinic (Minnesota, US) recently published (pre-proof) a study that found serum transfusion to be a safe procedure for patients with minimal side effects. This study evaluated serious adverse events reported among 20,000 patients who received convalescent serum transfusion between April 3 and June 2, 2020. Fewer than 1% of all transfusions resulted in serious adverse events.

WHO ENDS HYDROXYCHLOROQUINE TRIAL Following the US FDA decision to revoke the EUA for hydroxychloroquine, the WHO announced that it is terminating the hydroxychloroquine arm of its Solidarity trial . The WHO based its decision on data from several clinical trials, including the Solidarity trial and trials conducted in the United Kingdom and France, as well as a review of other available evidence. Overall, the data did not demonstrate reduced mortality among COVID-19 patients treated with hydroxychloroquine compared to the existing standard of care. The WHO update does not reference an increased risk of serious adverse effects that has been documented in other studies.

PRONING In a small cohort study, conducted at Columbia University (New York, US) and published in The Journal of the American Medical Association: Internal Medicine ( JAMA Internal Medicine ), researchers found that placing non-intubated COVID-19 patients with severe respiratory failure in the prone position (ie, lying o n their stomach) was associated with improved saturated oxygen levels. The study included 25 COVID-19 patients in the intermediate care unit, who were asked to place themselves in the prone position for as long as tolerable, up to 24 hours per day. Participants were able to move themselves into other positions; in fact, the ability to move in and out of the prone position without assistance was part of the inclusion criteria. After 1 hour in the prone position, saturated oxygen levels increased between 1% and 34% over their baseline assessment across all 25 participants, with a median improvement of 7%. This study is limited by the small sample size and lack of a control group; however, these preliminary findings are a positive indicator of the potential clinical benefits of proning non-intubated COVID-19 patients. 

ARIZONA SOCIAL DISTANCING Following a recent surge in reported COVID-19 incidence in Arizona —along with increases in COVID-19 hospitalizations, test positivity, and other indicators— Governor Doug Ducey issued an executive order to enhance the state’s response and strengthen social distancing measures. Arizona aims to strengthen testing and contact tracing capacity, including mobilizing the Arizona National Guard. Arizona also published specific requirements for restaurants and other businesses to implement additional protective measures, including ensuring appropriate physical distancing (eg, 6-foot separation), mandating symptom monitoring and mask use for employees, and limiting groups or gatherings to no more than 10 people. The new guidance for restaurants and other businesses provides more detailed instruction than previous versions , including some new requirements. With respect to mask use, restaurant employees who interact with customers are now required to wear masks, and other businesses are directed to require employees to wear masks “when possible.” Previously, guidance for some businesses, such as retail stores , did not mention mask use at all.  

Governor Ducey’s previous executive order included a provision that prohibited local governments from implementing any measures that conflicted with or were more restrictive than those mandated by the state. Notably, the new executive order permits local governments to implement their own policies or requirements regarding mask use based on their local situation. Numerous mayors across Arizona coordinated to call on Governor Ducey to allow more flexibility and authority at the local level to address COVID-19 risk, and several local governments have reportedly already indicated that they intend to mandate mask use to mitigate transmission risk in their communities. Arizona is one of a number of states reporting increased COVID-19 incidence over the past several weeks, and it is among the first to implement additional restrictions in response to increased community transmission.

Yesterday, California updated its COVID-19 policies to mandate mask use statewide for environments in which it may not be possible to maintain proper physical distancing (eg, 6-foot separation). The new guidance states that masks must be worn in places such as indoor public spaces (or waiting in line to enter), healthcare settings, public transportation or ride-sharing vehicles (drivers and passengers), workplaces where there is interaction with the public, food preparation areas, and other public spaces where it is not feasible to maintain physical distancing. California includes exceptions for children aged 2 years and younger, those with medical conditions that preclude them from safely wearing a mask, communicating with someone who reads lips, eating and drinking, and outdoor recreation where proper physical distancing can be maintained.

UK RISK LEVEL 3 The UK Joint Biosecurity Centre recommended that the UK COVID-19 alert level be lowered from Level 4 to Level 3 , and the Chief Medical Officers for England, Northern Ireland, Scotland, and Wales concurred. This signals that the UK epidemic is no longer exhibiting high transmission or exponential growth. It is unclear at this point how the lower alert level will translate to changes in the UK COVID-19 response. When the system was unveiled on May 11 , Alert Level 4 corresponded to maintaining the existing social distancing restrictions; however, the United Kingdom eased some restrictions earlier in June , while still at Alert Level 4 . The United Kingdom reported 1,346 new cases, bringing its total to 301,815 cumulative confirmed cases, and it has reported steadily decreasing daily incidence since early May and decreasing daily deaths since mid-April. The United Kingdom is currently #18 globally in terms of daily incidence .

NATIONAL SEROLOGICAL TESTING STRATEGY Building on a previous effort to address serological testing in the context of the COVID-19 pandemic, experts from the Johns Hopkins Center for Health Security and the Johns Hopkins University School of Nursing and Bloomberg School of Public Health published guidance regarding a national strategy to implement serological testing. This most recent effort outlines several recommendations for developing a cohesive approach to collecting and utilizing serological data to support the COVID-19 response in the United States. The authors recommend establishing a centralized repository for ongoing and completed serological study data, similar to Employers, academic institutions, and others should register studies in this repository and report their data and findings. Additionally, they call on the US CDC to develop a standardized approach for conducting serological surveys, which would enable government agencies and other organizations to conduct studies and report data in a consistent manner. They also note the current absence of validation for serological tests, which is critical to analyzing and interpreting study data. They call on the US National Institutes of Health (NIH) and other government agencies to publish validation data for those tests that have been registered with the federal government.

The guidance also outlines priorities for conducting serological studies. Cross-sectional studies can be conducted with relatively limited resources. These can be useful early in a response, but they can provide “only a snapshot of a population.” As testing capacity increases, local and state jurisdictions can implement cross-sectional studies on a serial basis to “monitor populations over time.” Coordinating studies across jurisdictions—eg, to implement them over similar time periods, using similar parameters—could provide a more comprehensive perspective on the epidemic’s progression while still operating under relatively constrained resources. Ultimately, longitudinal cohort studies can provide more detailed information on community transmission over time; however, these studies require more resources to complete and may not be feasible at this time.