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

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June 22, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 21 reports 8.71 million confirmed cases (183,020 new) and 461,715 deaths (4,743 new). This exceeds the record daily incidence set on June 18 (which included more than 30,000 cases not previously reported by Chile). It appears that Brazil may be the key driver of this elevated incidence, reporting more than 54,000 new cases. However, Brazil reported an unexpectedly low incidence the previous day, so this may be the result of a reporting anomaly. Nonetheless, the global daily incidence continues to increase, and the pandemic continues to accelerate. Not considering the 2 recent spikes, the WHO is reporting approximately 1 million cases new per week .

India has reported its 5 highest daily incidence over the past 5 days, including more than 15,000 new cases yesterday. India’s COVID-19 epidemic continues to accelerate, doubling since May 29. India is currently #3 in terms of daily incidence . Pakistan reported its second highest daily incidence to date (6,604 new cases), but all other days since June 14 have been fewer than 6,000 new cases. It appears that Pakistan may be reaching a peak or plateau, but additional data is required to understand the longer-term trend. Pakistan remains #6 globally in terms of daily incidence. Bangladesh reported its fourth and fifth highest daily incidence over the past 2 days (3,531 and 3,480 new cases, respectively). Notably, Bangladesh’s test positivity is holding steady at approximately 20%, which is considerably higher than the WHO’s 5% benchmark for relaxing social distancing measures. Bangladesh is currently #11 globally in terms of daily incidence.

Brazil reported its highest and third highest daily incidence over the weekend, including 54,771 new cases on June 19, a 57% increase above the previous high. However, Brazil reported an uncharacteristically low incidence on June 18, so the elevated incidence on June 19 could be a result of reporting issues, covering cases that would have normally been reported the previous day. Brazil remains #1 globally in terms of daily incidence . Broadly, the Central and South American regions are still a major COVID-19 hotspot. The region represents 6 of the top 14 countries globally in terms of daily incidence—including Chile (#5), Mexico (#7), Peru (#10), Colombia (#12), and Argentina (#14)—and 5 of the top 13 in terms of per capita daily incidence —Chile (#2), Panama (#5), Brazil (#7), Peru (#10), and Bolivia (#13).

Iran reported 2,573 new cases. While still lower than the peaks in late March and early June, Iran’s current daily incidence remains elevated compared to most of April and May. Iran is currently #13 globally in terms of daily incidence . Overall, the Eastern Mediterranean Region remains an emerging hotspot, representing 5 of the top 9 countries in terms of per capita incidence : Qatar (#1), Bahrain (#3), Oman (#6), Kuwait (#8), and Saudi Arabia (#9). Additionally, nearby Armenia is #4. In addition to Iran and Pakistan, Saudi Arabia is #9, Iraq is #15, and Turkey is #18. Nearby Egypt is #16.

The US CDC reported 2.25 million total cases (32,411 new) and 119,615 deaths (560 new). Additionally, the CDC reported 32,218 new cases the previous day. These represent the 2 highest daily totals for the United States since April 25 and the sixth and seventh highest daily incidence to date. In total, 18 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New York state with more than 175,000; California and New Jersey 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 burden has increased since early June, approximately several weeks after states began to relax social distancing measures.

The Johns Hopkins CSSE dashboard reported 2.29 million US cases and 120,044 deaths as of 12:30pm on June 22.

CONTAMINATION OF EARLY US TEST KITS The US Department of Health and Human Services completed an internal investigation regarding delays in scaling up US SARS-CoV-2 testing capacity . The final report, obtained by multiple media outlets , was published on Friday. The investigation concluded that initial batches of critical reagents were “likely” contaminated at some point during the manufacturing process. CNN reported that representatives from the US FDA indicated that the tests were not manufactured in the traditional fashion. Specifically, the testing material was produced in a CDC laboratory rather than a manufacturing facility. A variety of factors, including “time pressure” to make the test kits available quickly, could have impacted the implementation of production protocols and resulted in inadvertent contamination of test kit materials or disrupted quality control checks that could have identified the contamination prior to shipping the test kits. The HHS report indicates that the tests are extremely sensitive and that even seemingly minor breaches of protocol could have resulted in the contamination. It notes that “a single person walking through an area with positive control material and then later entering an area where tests reagents were being manipulated" could have contaminated the reagents.

US MANDATORY MASK ORDERS As numerous states report continued increases in COVID-19 incidence, some state and local officials are moving to require citizens to wear masks. Washington Governor Jay Inslee announced over the weekend that he intends to issue a proclamation mandating mask use in public in Yakima County, which is experiencing increased community transmission, making the current local order enforceable. According to The Seattle Times , more than 20% of Washington’s cases and 22% of its COVID-19-related hospitalizations can be attributed to Yakima County, despite it only accounting for only 4% of the state’s total population. Similar situations are occurring in other states as well. Oregon Governor Kate Brown announced last Wednesday mandatory mask use would be implemented in 7 counties that make up the majority of Oregon’s COVID-19 burden. Additionally, other counties could opt in to the mandate. In North Carolina, multiple local jurisdictions have implemented mandatory mask use, and Governor Roy Cooper announced that a prospective proposal this week could mandate mask use statewide.

Not all states, however, are enforcing mask use. Notably, Florida Governor Ron DeSantis —despite acknowledging that increased community transmission, and not increased testing, is driving the state’s increased COVID-19 incidence—continues to refrain from mandating mask use. According to CNN , at least 15 states have put statewide mask requirements in places as of Friday evening. A report by CNN indicates that the CDC may issue updated mask guidance in the near future; however, it is unclear what the update would include or when it would be released.

SARS-COV-2 & WASTEWATER According to a press release, the Italian National Institute of Health det e cted SARS-CoV-2 in wastewater samples from Milan and Turin that were collected in December 2019, nearly 2 months prior to Italy’s first reported case of COVID-19. The investigation tested 40 sewage samples from northern Italy that were collected between October 2019 and February 2020. The researchers note that discovery of virus in wastewater samples does not necessarily indicate that Italy’s epidemic originated with these early cases. A publication with the full data set is expected this week. This new evidence, along with the detection of SARS-CoV-2 in wastewater in other European countries and Australia, suggests that SARS-CoV-2 may have been circulating outside of China in late 2019, prior to when initial COVID-19 cases were reported. 

In the United States, Clemson University and the city of Clemson, South Carolina, reported elevated SARS-CoV-2 levels in wastewater, which coincides with increased COVID-19 incidence statewide. Similarly, Cape Canaveral , Florida, detected SARS-CoV-2 in wastewater specimens from the week of May 26. Local officials believe that the concentration of the virus in the specimens could be equivalent to approximately 85 cases of COVID-19. Those involved in the testing note that the results may not match the city’s low official COVID-19 incidence at the time, as a number of travelers visited Cape Canaveral for Memorial Day as well as a SpaceX launch around the same time.

Systematic wastewater testing could have the potential to provide advance warning of circulating pathogens prior to initial detection and reporting of early cases. Reports of SARS-CoV-2 detected in wastewater, particularly prior to detected COVID-19 suggests that this kind of system could be developed, but additional research is required in order to establish this capability.

BEIJING OUTBREAK Beijing’s COVID-19 outbreak continues, now reporting more than 200 associated cases since June 11, including 9 new cases today . One major component of China’s response includes large-scale SARS-CoV-2 testing. As part of this effort, China’s National Health Commission reported that Beijing more than doubled its testing capacity, up to 230,000 tests, although the report does not specify over what period. Another report by the Beijing government indicates that the city has the capacity to perform 500,000 tests per day, rapidly scaled up from 8,000 prior to the outbreak. In order to increase testing capacity, China constructed temporary testing sites at local facilities, including sports arenas. Additionally, the NHC reported that it has shared data from the identified COVID-19 cases linked to the Beijing outbreak with the WHO and international partners. An investigation continues to determine the source of the outbreak. While the initial cases have been linked to the Xinfadi Market, it remains unclear how and when the virus was introduced.

Several cases of COIVID-19 were reported among construction workers at 2 construction sites in Beijing . Health officials conducted screening and testing at 435 ongoing construction projects across the city, including more than 1,600 tests for individuals who had recent contact with someone who visited the market.

INHALED REMDESIVIR Gilead Sciences announced today that it received authorization from the US FDA to commence a Phase 1 clinical trial to evaluate an inhaled formulation of remdesivir, an antiviral that has demonstrated efficacy in treating COVID-19 in clinical trials. The new version could be administered using a nebulizer, and it could potentially enable administration outside of hospitals, including at earlier stages of the disease. Gilead will also pursue other investigations with remdesivir to expand its use, including testing intravenous infusions for outpatient cases as well as the combination of remdesivir with other therapeutics, particularly anti-inflammatory drugs such as dexamethasone. Studies to test the use of remdesivir in vulnerable populations such as children and pregnant women are also underway or being planned. Currently, remdesivir is currently allowed to be used for certain hospitalized patients under the US FDA Emergency Use Authorization that was issued at the beginning of May. 

UK SOCIAL DISTANCING The United kingdom announced today that its national policies regarding “shielding” highly vulnerable individuals will begin to relax on July 6. Previously, shielded individuals , based on pre-existing health conditions that put them at particularly elevated risk for severe COVID-19 disease and death, were instructed to fully isolate themselves. These conditions included organ transplant recipients, individuals undergoing chemotherapy, pregnant women with health conditions, and those with severe respiratory diseases. Because these individuals faced more restrictive social and physical isolation than others, the UK government instituted broad support for affected individuals—including volunteer assistance with delivering food and medications, transportation to medical appointments, and regular social contact via phone or other form of communication—which will continue through the end of July. Starting on July 6, shielded individuals will be permitted to create a “support bubble” with one other household, and beginning August 1, shielding guidance will be relaxed completely. The announcement emphasizes that individuals at elevated risk of severe disease and death should continue to practice “strict social distancing” as they resume some of their routine activities, including shopping and returning to work. The Shielded Patient List includes approximately 2.2 million people across the United Kingdom.