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

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June 3, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 2 reports 6.19 million confirmed cases (113,198 new) and 376,320 deaths (4,242 new). The global totals could reach 7 million cases by the middle or end of next week and 400,000 deaths by the middle of next week.

India ’s cumulative COVID-19 incidence surpassed 100,000 cases, and its daily incidence continues to increase. India reported 8,909 new cases, its highest daily total to date . If the recent trends continue, India could surpass Russia as #3 globally in daily incidence in the coming days.

Spain reported no new deaths for 2 consecutive days, an encouraging sign from one of the countries hit hardest early in the pandemic. Spain’s COVID-19 mortality held steady at 27,127 deaths from May 31 to June 2 , and Spain reported only 1 new death today .

Iran appears to be in the middle of a second “wave” of COVID-19. Following a decline in daily incidence from the end of March through early May, Iran has reported increasing daily incidence over the past month, more than tripling in that time and now on par with its previous peak. Today, Iran reported 3,134 new cases, bringing the national total to 160,696 cases. Iran has relaxed some social distancing measures in many parts of the country, but it reportedly reinstated “lockdown” in Khuzestan, which is reporting elevated COVID-19 incidence.

Brazil reported 28,936 new cases, its second highest daily total to date. Brazil is #1 in the world in terms of daily incidence , and it appears to still be increasing. Peru and Chile continue to exhibit concerning trends as well, both currently reporting more than 3 times the per capita daily incidence as the United States. Additionally, Peru is #5 globally in terms of total daily incidence . Panama is also exhibiting elevated incidence over the past week or so. After remaining relatively consistent throughout April and most of May, reporting approximately 150-225 new cases per day, Panama’s daily incidence jumped to more than 400 new cases since May 23. Panama’s per capita incidence is now on par with Brazil.

The US CDC reported 1.80 million total cases (14,790 new) and 105,157 deaths (761 new). The United States could potentially surpass 2 million cases in the next 10-14 days. The CDC updated its jurisdiction-level reporting table, which now includes total, confirmed, and probable values for both cases and deaths; however, not all states have data available for confirmed and probable values. In total, 14 states (increase of 1) 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, Illinois, and Massachusetts with more than 100,000.

The New York Times continues to track state- and local-level COVID-19 incidence in a variety of forms. A number of states began to relax social distancing measures—including resuming operations at restaurants, retail stores, and barbershops/salons—at the end of April/early May. Mass gatherings associated with the Memorial Day holiday weekend and ongoing large-scale protests against racial injustice could potentially contribute to community transmission. We will continue to monitor these trends over the coming weeks.

Several states continue to exhibit concerning trends following efforts to relax social distancing measures. Alabama is reporting several notable trends in addition to increasing daily incidence since late April, which more than doubled over that period. Some of this increase is likely associated with increased testing; however, Alabama has also reported increasing test positivity over the past 2 weeks, even as testing capacity increases. After declining from a high of 12.8% in mid-April to 9.0% in early May, test positivity was back up to 12.2% for the week of May 17-23. This potentially indicates a relative increase in community transmission and that the testing capacity may not be sufficient. Alabama is reporting a slight increase in hospitalized COVID-19 cases since mid-to-late April.

After a period of declining daily incidence, Georgia is exhibiting an increase. The Georgia Department of Public Health appears to report COVID-19 data by testing date, so data within the past 14 days are likely incomplete. Looking at data prior to that 14-day window, however, Georgia’s daily incidence fell from a high of 766.4 new cases per day (7-day moving average) on April 22 to 520.5 new cases on May 9. Georgia’s incidence climbed again to 704.0 new cases on May 19, which is the most recent day outside the 14-day window. Analysis by The New York Times displays Georgia’s incidence by report date, and it shows an overall decline in cases from mid-April through mid-May, but it is difficult to determine a longer-term trend for data after that point. Additionally, numerous counties in Georgia that previously reported flat or declining incidence are now reporting increases.

Texas is also exhibiting a steady increase in COVID-19 incidence, reporting 3 of its 4 highest daily totals over the past 6 days as well as its highest 7-day average . California is in the process of relaxing social distancing measures on a local/regional basis, but as a whole, the state continues to report increasing COVID-19 incidence, posting its 3 highest daily totals over the past 6 days. California is also reporting its highest 7-day average daily incidence .

The Johns Hopkins CSSE dashboard reported 1.84 million US cases and 106,312 deaths as of 11:30am on June 3.

US NURSING HOMES The US Centers for Medicare and Medicaid Services (CMS) and CDC published a report outlining the toll of COVID-19 on nursing homes in the United States. According to the report, more than 25,000 nursing home residents and 400 staff have died so far as a result of the US COVID-19 epidemic. In total, nursing homes and other long-term care facilities reported more than 60,000 infections in residents and 34,000 infections in staff. The report shows the immense impact that COVID-19 has had on these facilities, with 20% of them reporting at least 1 COVID-19 death. Findings from the report have been widely covered in the US media , but the report itself is not expected to be publicly available until tomorrow, June 4.

WHO & CHINA The relationship between the WHO and China during the COVID-19 pandemic response has received considerable global attention. An investigation by the Associated Press uncovered some of the frustration experienced by the WHO, resulting from delays in receiving important information from China needed to support the global response. Recordings of internal WHO meetings reportedly indicate that the Chinese government withheld important information—including surveillance data and the viral genetic sequence—potentially for weeks, delayed early containment activities and the development of diagnostic tests. Despite these delays, the WHO has repeatedly praised the Chinese response in public statements. The WHO is in a difficult position, responsible for protecting the health and well-being of people around the world without the authority or ability to enforce cooperation by autonomous national governments. According to the report, there was much debate at the WHO regarding how best to approach the situation, wanting both to promote transparency from China and push for the information needed for the COVID-19 response.

UK COVID-19 DISPARITIES Public Health England (PHE) published findings from its analysis of various disparities related to COVID-19 morbidity and mortality in the United Kingdom. The study analyzed COVID-19 data related to age and sex, geographic location, race and ethnicity, occupation, underlying health conditions, and a myriad of other factors. Consistent with our current understanding, the analysis found that older individuals are at elevated risk of severe COVID-19 disease and death, which was the largest disparity identified by the researchers. The data indicated increased risk of infection for Black ethnic groups and elevated risk of death among Black and Asian ethnic groups. Broken down further, individuals of Bangladeshi ethnicity had twice the risk of death compared to those of White British ethnicity, and individuals of “Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British.” Much like the United States, PHE identified elevated COVID-19 risk among nursing homes, which represented 27% of COVID-19 deaths. The study found more than double the all-cause mortality in nursing homes compared to previous years, more than 20,000 excess deaths.

US PROTESTS Protests against racial and social injustice , including police brutality directed at Black Americans, continue across the United States, and US protesters have been joined by thousands of others around the world. Many photos show protesters wearing face masks and taking efforts to protect themselves; however, no mass gathering is without risk of increased SARS-CoV-2 transmission. US Surgeon General Dr. Jerome Adams expressed concern about the risk of increased transmission following the protests, due to how the disease spreads. In Atlanta, state health officials are working to establish pop-up testing sites for protesters to show that individuals should not have to choose between fighting for justice and protecting their health. 

A number of health experts around the country have weighed in on the importance of these protests and the need to address underlying and pervasive disparities that drive a myriad of social and health inequities among racial and ethnic minority groups, including increased risk from COVID-19 . Dr. Lauren Powell , published her perspective in STAT News . She notes that these protests are necessary, but their synchronicity with the pandemic is her “deepest public health nightmare.” She encourages protesters to take appropriate precautions to protect themselves against COVID-19, including wearing masks and gloves, using hand sanitizer, and maintaining physical distancing, “even while marching.”

Dr. Powell also calls on state and local officials to “reconsider the use of pepper spray” due to subsequent coughing, which can increase the risk of transmission. Others have also questioned the use of chemical irritants like pepper spray and tear gas for crowd control due to their potential role in amplifying respiratory transmission. It is understood that individuals with underlying health conditions, including asthma and other respiratory diseases, are at elevated risk for severe COVID-19 disease and death; however, there is no data available to determine any effects from respiratory irritation from these chemicals.

CONTACT TRACING The University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP) published Part 4 of its COVID-19 Viewpoints series, addressing contact tracing. The report discusses contact tracing principles and considerations and emphasizes that a “one-size-fits-all” system across all state and local jurisdictions is likely not an ideal approach. While the overall purpose and concept remain the same, each jurisdiction will need to develop and implement a plan that makes the most efficient use of its available resources and considers its current COVID-19 situation and surveillance needs. The authors pose a variety of questions to help the United States work through challenges associated with contact tracing, including the relative costs and benefits of various types of contact tracing (eg, widespread vs targeted), the role of quarantine and isolation, the use of technological solutions (eg, smartphone apps), and potential adverse effects.

The Johns Hopkins University—led by Dr. Jeffrey P. Kahn of the Berman Institute of Bioethics, in collaboration with the Center for Health Security and the Project on Ethics and Governance of Digital Contact Tracing Technologies—recently published a book that addresses digital contact tracing solutions and their associated challenges and benefits. The book, Digital Contact Tracing for Pandemic Response: Ethics and Governance Guidance , draws on a broad scope of expertise—“bioethics, health security, public health, technology development, engineering, public policy, and law”— to provide guidance and recommendations for “technology companies, policymakers, institutions, employers, and the public” regarding the development and implementation of technological solutions to supplement traditional contract tracing capabilities and capacity in the context of a pandemic response.

SARS-CoV-2 VACCINE The development, production, and distribution of SARS-CoV-2 remains a global priority in combating the COVID-19 pandemic. Multiple vaccines are currently in various stages of development, and there is “cautious optimism” that some will be determined to be safe and effective. Notably, Dr. Anthony Fauci commented that the manufacturers of promising candidates are already preparing for subsequent clinical trial phases based on preliminary results. This will enable Phase 2 and 3 trials to commence sooner, which could potentially accelerate vaccine availability. The vaccine candidate developed by Moderna is completing Phase 1 clinical trials, and Phase 3 is scheduled to begin in July. Several other candidates, including from AstraZeneca and Johnson & Johnson, may have advanced stage clinical trials this summer as well. These trials could potentially yield results by this fall. Dr. Fauci noted, however, that a vaccine may not confer long-term immunity , if SARS-CoV-2 behaves like other coronaviruses. This could translate into needing multiple doses of the vaccine or periodic boosters to ensure lasting immunity.

PRESYMPTOMATIC TRANSMISSION Characterizing presymptomatic transmission of SARS-CoV-2 has been a priority to improve guidelines, testing recommendations, and control measures. A study published in Emerging Infectious Diseases evaluated the secondary attack rate following contact with presymptomatic COVID-19 cases, based on contact tracing surveillance data collected in Guangzhou, China. The study found that secondary transmission occurs most often among individuals sharing a living space, including family members, or those with frequent close contact. The study demonstrated that transmission of SARS-CoV-2 prior to the onset of symptoms is, indeed, possible; however, it appears to be less effective than by individuals exhibiting symptoms. 

SWEDEN Throughout the COVID-19 pandemic, Sweden has stood out as a case study of an alternative approach responding to the virus. In contrast to many other nations, Sweden did not implement strict mandatory social distancing measures. Rather, Sweden encouraged social distancing but largely limited mandatory restrictions to a prohibition of gatherings of greater than 50 people. Sweden has reported COVID-19 mortality among the highest per capita in the world, including compared to other Nordic countries, which have reported significantly fewer deaths. In an interview with Swedish radio , Dr. Anders Tegnell of the Swedish Public Health Agency noted that the Swedish COVID-19 response has room for improvement, particularly with respect to Sweden’s COVID-19 mortality. In a subsequent interview , Dr. Tegnell emphasized that Sweden’s approach was implemented based on available information, and it is unclear at this time how Sweden should have reacted differently. In particularly, Swedish officials officials have acknowledged that the COVID-19 response did not provide adequate protection for high-risk individuals, such as older adults residing in nursing homes. While Sweden’s COVID-19 response permitted stores, restaurants, and other businesses to continue operating, the continued economic activity does not appear to have prevented a financial crisis. Unfortunately, due to the heavy reliance on exports, Sweden’s Minister of Finance Magdelena Andersson notes that Sweden may face its worst recession since World War 2 . The Swedish government has committed to establishing a commission to evaluate the nation's strategy for responding to COVID-19.