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

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June 24, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 23 reports 8.99 million cases (133,326 new) and 469,587 deaths (3,847 new). The global daily incidence continues to exhibit an overall increasing trend. The global cumulative incidence surpassed 8 million cases on June 17 , so it has only taken 6 days to reach 9 million cases. The following timeline illustrates the COVID-19 pandemic’s trajectory to date:
-Zero cases to 1 million cases : ~100 days
-1 million to 2 million cases : 12 days
-2 million to 3 million cases : 13 days
-3 million to 4 million cases : 12 days
-4 million to 5 million cases : 11 days
-5 million to 6 million cases : 10 days
-6 million to 7 million cases : 8 days
-7 million to 8 million cases : 8 days
-8 million to 9 million cases : 6 days

India has reported a new record high daily incidence , nearly 16,000 new cases. India’s daily incidence has increased by 60% since June 11, and its epidemic continues to accelerate. India is currently #3 in terms of daily incidence . After a recent peak in daily incidence on June 13 (6,825 new cases), Pakistan has reported decreased daily incidence, with the exception of a spike on June 19. Pakistan’s daily incidence is down to 3,892 new cases, a 43% decrease from the peak and its lowest daily total since June 3. It appears that Pakistan may have passed its initial peak. Pakistan fell to #8 globally in terms of daily incidence. Since its recent peak on June 16 (4,008 new cases), Bangladesh’s daily incidence has held relatively consistent at 3,500 new cases per day. Notably, Bangladesh’s test positivity continues to hold steady at approximately 20%, which is considerably higher than the WHO’s 5% benchmark for relaxing social distancing measures. Bangladesh climbed to #9 globally in terms of daily incidence.

Brazil reported its second highest daily incidence to date, 39,436 new cases. This is second only to June 19, which was elevated due to reporting delays from the previous day. It appears that Brazil’s epidemic may be continuing to accelerate. Brazil is currently #2 globally, behind the United States, in terms of daily incidence . Broadly, the Central and South American regions are still major COVID-19 hotspots. Including Brazil, the region represents 5 of the top 12 countries globally in terms of daily incidence—including Mexico (#5), Chile (#6), Peru (#11), and Colombia (#12)—and 5 of the top 13 in terms of per capita daily incidence —Chile (#4), Panama (#6), Brazil (#9), Peru (#10), and Bolivia (#13).

Iran reported 2,531 new cases, holding relatively consistent with other recent reports. Since a second peak on June 5, Iran has reported approximately 2,300-2,500 new cases per day. Iran remains #13 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 (#1), Bahrain (#2), Oman (#3), Kuwait (#8), and Saudi Arabia (#11). Additionally, nearby Armenia is #5. The region also includes several notable countries in terms of total daily incidence. In addition to Iran and Pakistan, Saudi Arabia is #10 and Iraq is #14, and several other countries in the region are reporting more than 1,000 new cases per day.

STAT News updated its COVID-19 Tracker to enable the display of national, regional, state, and local COVID-19 data for many countries over a variety of time windows, ranging from daily to 1-month averages. The dashboard includes daily and cumulative incidence and deaths and daily recovered cases (total and per capita) as well as daily testing totals. Additionally, the dashboard shows relative changes for the selected time window—eg, relative increase or decrease in the weekly average incidence compared to the previous week.

The US CDC reported 2.30 million total cases (26,643 new) and 120,333 deaths (410 new). 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; California and New York state with more than 175,000; 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 incidence is clearly increasing. Typically, early week reporting by the CDC is lower due to reporting delays over the weekend; however, even those troughs this week are elevated compared to the peak day from the week of June 7-13. 

According to the New York Times analysis, more than half of US states are reporting increased COVID-19 incidence over the past 2 weeks. Some of these states—including Florida, Idaho, Hawai’i, Kansas, Missouri, Montana, Nevada, and Washington—reported several weeks of decreasing incidence but are now heading toward a second peak. Other states—such as Alabama, Arizona, California, North Carolina, South Carolina, Tennessee, and Texas—never really appeared to bring their respective epidemics under control, reporting generally increasing incidence from the beginning. ProPublica also provides analysis of SARS-CoV-2 testing, and several states continue to exhibit worrisome trends. Florida, South Carolina, Texas, and Utah are reporting test positivity greater than 10% and increasing, and Arizona is at 21% and increasing. Additionally, Alabama and Georgia are at 9% and increasing. Based on the STAT News COVID-19 Tracker dashboard, the national 1-week average daily incidence is nearly as high as it was at the initial peak on April 10 (31,363 new cases). After falling as low as 20,338 new cases on June 9, the national weekly average is currently 29,681 new cases per day and still increasing exponentially.

The Johns Hopkins CSSE dashboard reported 2.35 million US cases and 121,279 deaths as of 12:30pm on June 24.

US COVID-19 AGE SHIFT The US COVID-19 incidence continues to increase , since early June, coinciding with states’ efforts to relax social distancing and resume normal activities, but US COVID-19 deaths have steadily decreased since mid-April. One potential explanation for these differing trends is a shift in age distribution of COVID-19 patients toward younger age groups. Several states that are currently reporting surges in COVID-19 incidence—including Arizona , California , Florida , Texas , and Washington —have exhibited an increasing proportion of cases among younger adults (eg, in their 20s and 30s). A number of factors are likely contributing to this trend. One possible driver is increased social interaction following the relaxation of social distancing restrictions, which has been observed among younger individuals who are at lower risk of severe disease and death. Despite the lower risk, Dr. Anthony Fauci noted yesterday in his testimony to the US House of Representatives Energy and Commerce Committee that some younger individuals do get severe COVID-19 disease and die. Additionally, as testing and contact tracing capacity has increased nationwide, it has facilitated the detection of milder cases and asymptomatic infections, which appear to be more common among younger individuals. Early in the US epidemic, limited testing capacity was largely focused on hospitalized patients, which skewed to toward older patients.

While many of the newly identified COVID-19 cases may be among younger individuals who are at lower risk for severe disease and death, any increase in cases in the community increases transmission risk, including to higher-risk individuals. Some health experts view the shift toward younger cases as an “ominous” signal that could forecast future increases in severe disease and death as transmission spreads beyond younger demographic groups. Notably, several of these states are also exhibiting increased COVID-19 hospitalizations , which indicates that the increasing incidence is not limited to mild cases and asymptomatic infections. In fact 7 states— Arizona , Arkansas , California , North Carolina , South Carolina , Tennessee , and Texas —are reporting record numbers of hospitalized COVID-19 patients.

US VISA RESTRICTIONS US President Donald Trump issued an executive order that extends restrictions on several classes of visas through the end of 2020. The order will reportedly not affect individuals who have already received visas or seasonal farm workers, and there are exceptions for certain professions, including coronavirus researchers. It is not clear, however, if the renewal process will be impacted. The order to restrict visas will apply to the following categories: (1) H1-B visas, which allow workers with advanced degrees to be hired into positions with specialist skill sets; (2) H2-B visas, which apply primarily to seasonal workers in industries such as agriculture, food processing, hospitality, and healthcare; (3) J-1 visas, which are used by many university students to complete their education at US universities; and (4) L visas for individuals in managerial positions often employed by multinational companies. The administration justified the decision as a mechanism to improve job opportunities for Americans and mitigate the severe economic impacts from the COVID-19 pandemic. The announcement garnered criticism by those who accuse the administration of exploiting the pandemic to advance an agenda of restricting immigration and by companies that rely on these visas to bring specialized workers to the United States. 

ROBOT COVID-19 CARE UNIT Healthcare systems are facing pressure, with increasing numbers of patients needing care for COVID-19. The use of robotic technology to improve healthcare delivery offers the opportunity to enhance capacity without necessarily needing to increase the human capital behind healthcare operations. During the early stages of the pandemic in China, robots supplemented a shortage of appropriately skilled healthcare workers to care for COVID-19 patients. As we have covered previously, robots have been employed during the pandemic to mitigate transmission risk for healthcare workers and to monitor social distancing in public spaces. The market for robotic technology is fairly nascent in many areas, but the integration of robotic technology into industries such as hospitality is gaining in reach. At the Wuhan Hongshan Sports Centre , a temporary clinical ward caring for approximately 200 people infected with COVID-19, robot healthcare workers carry out tasks such as monitoring patients’ vital signs, delivering food and medication, and cleaning and disinfecting, with oversight and control by human healthcare workers. 

DIGITAL DISPARITIES COVID-19 has brought to light social inequities around the world. One emerging challenge, particularly as many countries implement remote education programs and begin to evaluate how to resume classes for children and university students, is disparities in access to digital services and internet access. School closures and social distancing orders at home have created a stronger reliance on technology as a means to access social support systems and connect to routine aspects of daily life. In Chile , for example, disparities in internet access has impacted students' ability to learn in the COVID-19 environment. For 47% of students in Chile, access to a computer with an internet connection to support online learning is not available. For these students, “internet cafes” are essential to submit assignments and remain on schedule with their coursework; however, a city-wide “lockdown” in Santiago, Chile’s capital city, forced internet cafes to shut down, effectively preventing many students from accessing their school materials. The pandemic continues to exacerbate existing social, racial/ethnic, and economic disparities, and technical solutions to challenges posed by the pandemic and associated social distancing restrictions could potentially compound these inequities.

DEXAMETHASONE CLINICAL TRIAL Researchers from the United Kingdom published ( preprint ) preliminary results from the dexamethasone arm of the UK RECOVERY clinical trials. Highlights from the findings were published via a press release last week, but this manuscript provides further details. The study yielded promising results, including a 34% decrease in mortality among patients receiving mechanical ventilation and a 20% decrease among patients receiving oxygen therapy. However, the researchers highlighted relative risk reduction among the most serious cases, but the original trial design did not specify analyzing these subgroups. Additionally, more than a quarter of the patients were still under treatment at the time of data collection, so their outcomes are unknown. The data does provide evidence that dexamethasone provides treatment benefit, but further study is needed to determine longer-term effects, including for mild or moderate disease. WHO Director-General Dr. Tedros Adhanom Ghebreyesus highlighted the value of the preliminary data and noted that the next challenge is scaling up production. The drug is relatively inexpensive, and there are already multiple manufacturers distributed around the world, which will factor positively into efforts to expand global availability. 

DECONTAMINATE PPE AT HOME The US Department of Homeland Security developed a process for people to “decontaminate” personal protective equipment (PPE), including N95 respirators and masks, at home using only a fairly common kitchen appliance, a programmable multicooker or pressure cooker. Multicookers, such as the Instant Pot, have gained popularity in the United States and elsewhere in recent years. In light of the limited supply of various types of PPE, scientists at DHS developed a process that would enable people to clean their PPE at home so it can be reused safely. Multicookers enable users to generate moist heat, which has been identified by the US CDC as an effective method for killing the SARS-CoV-2 virus. The instructions —and accompanying video—direct users to place water in the multicooker and insert a wire rack (to prevent the respirator from sitting in the water). The respirator (up to 3 at a time) should be placed inside a paper bag and set on the rack, and the unit should be set at 149°F (65°C) for 30 minutes. Once the cycle is complete, users should remove the bag and open it for 1 hour to allow the respirators to cool and dry.

SARS-CoV-2 VACCINE CANDIDATES Global efforts continue to develop and evaluate vaccine candidates against SARS-CoV-2. Researcher from the United Kingdom published ( preprint ) findings from an animal study evaluating the immune response following 1 and 2 doses of the SARS-CoV-2 vaccine developed at the University of Oxford Jenner Institute. Following a study in non-human primates that demonstrated that the vaccine generated an immune response against SARS-CoV-2, this study aimed to understand the effect of a “prime-boost” vaccination schedule on the associated immune response. The study compared a single dose of the vaccine against 2 doses administered 28 days apart in both mice and pigs. The mouse model did not demonstrate a major difference between the single dose and prime-boost vaccinations. The researchers note, however, that the immune response was at the upper end of the spectrum for both study groups, which could limit the ability to discern any differences. In the pig model, the researchers identified a significant increase in various aspects of the immune response among those pigs that received the prime-boost vaccination compared to those that received a single dose. While animal models are not always representative of human immune responses, these data could indicate that multiple doses of the vaccine could be required to confer sufficient immunity against SARS-CoV-2 in humans. Further research is necessary to better characterize the effect of prime-boost vaccination on the degree and duration of immunity, particularly in humans. Phase I clinical trials using a single dose of the vaccine have been completed, and Phase 2 and 3 trials are already underway.

Sanofi Pasteur is collaborating with partners to develop and test multiple vaccine candidates, although the clinical trial schedule is several months behind some other products, such as the Oxford University vaccine. Recently, senior officials at Sanofi indicated that they believe their candidate vaccines could potentially make up time against other companies’ candidates and even reach the market first. Sanofi’s collaboration with GlaxoSmithKline, is a recombinant vaccine, which uses a vaccine delivery platform that could enable them to more rapidly scale up production capacity. At this time, Sanofi believes that it has 2 products that could receive regulatory approval in 2021. Sanofi is already scaling up production of its recombinant vaccine in anticipation of favorable results from Phase 1/2 trials this fall, with the aim of producing 100 million doses available by the end of 2020 and another 1 billion doses by the end of 2021. Additionally, Sanofi is partnering with Translate Bio, a smaller biotechnology company, to develop mRNA-based vaccine candidates, which are expected to have a slightly longer timeline.

During his testimony yesterday before the US House of Representatives Energy and Commerce Committee , Dr. Anthony Fauci commented that he is “cautiously optimistic” that a vaccine could begin to be made available by the end of 2020. Numerous researchers and manufacturers have candidate vaccines at various stages of development, and multiple manufacturers are already scaling up production to facilitate larger clinical trials and early distribution, including under Emergency Use Authorization. There is still considerable uncertainty regarding the timeline to the availability of a safe and effective SARS-CoV-2 vaccine, but accelerated trials and production could potentially make Dr. Fauci’s timeline feasible. If that is the case, this would likely be the shortest time from development to availability for any vaccine in history.