COVID-19
Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security.

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June 5, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 4 reports 6.42 million confirmed cases (129,281 new) and 382,867 deaths (4,842 new). The global totals could reach 7 million cases by the middle of next week and 400,000 deaths by early next week.

India’s COVID-19 epidemic continues to accelerate. India again reported its highest daily incidence today, 9,851 new cases. India’s daily incidence has doubled since May 19, and India surpassed Russia as #3 globally in terms of daily incidence.

Iran reported 3,574 new cases, continuing its second “wave.” This appears to be Iran’s highest daily incidence to date, surpassing the peak of its first wave (3,186 on March 31). Iran is now #8 globally in terms of daily incidence . After a period of relaxing nationwide social distancing measures, Iranian President Dr. Hassan Rouhani recently emphasized the importance of limiting non-essential travel. Additionally, Iran has deployed medical teams “from successful provinces” to areas where COVID-19 is re-emerging.

Central and South America continue to be heavily impacted by the COVID-19 pandemic. Brazil reported 30,925 new cases, its second highest daily total to date. Brazil has reported 3 of its 4 highest daily totals in the past 3 days and all 6 of its highest daily totals over the last 6 non-weekend reporting days. Brazil remains #1 in the world in terms of daily incidence —reporting nearly 50% more new cases than the United States—and #7 globally in terms of per capita daily incidence . Chile and Peru continue to exhibit concerning trends as well, currently #3 and #10 in the world, respectively, for per capita incidence. Additionally, Chile is #5 and Peru is #7 globally in terms of total daily incidence . Panama is #11 in per capita incidence, and Mexico is #6 in total daily incidence.

EASTERN MEDITERRANEAN
The Eastern Mediterranean region represents 4 of the top 10 countries in terms of per capita incidence —Qatar (#1), Bahrain (#2), Kuwait (#5), and Oman (#8)—as well as the United Arab Emirates at #15 and Saudi Arabia at #17. Many of these countries are relatively small in terms of population, and among these 6 countries, Saudi Arabia is the only one with a population greater than 10 million . In fact, the Eastern Mediterranean has the smallest total population of all WHO regions. The total COVID-19 incidence may not necessarily garner global attention when compared to larger countries like the United States, Brazil, and Russia; however, these COVID-19 epidemics are concerning relative to population size. Saudi Arabia’s and the United Arab Emirates’ daily per capita incidence are down from their highs on May 19 and May 23, respectively, but 4 countries in the top 10 have been increasing over the past several weeks. Notably, Qatar reported a high of 730 new cases per million population (3-day average) on May 31, which doubled from May 9. For reference, this is more than 10 times the per capita incidence in the United States. Bahrain is reporting more than 4 times the daily per capita incidence as the United States, Kuwait is reporting more than 3 times, and Oman is reporting more than double. Additionally, nearby Djibouti and Armenia are #4 and #7, respectively, in terms of per capita incidence.

Previously, a large majority of COVID-19 cases in some of these countries were identified in expatriate or migrant worker communities, but this trend is shifting to some degree. However, in Saudi Arabia, the proportion of cases among Saudi citizens has increased substantially since we last reported on its national epidemic. On May 10 , the Saudi Ministry of Health reported that only 25% of COVID-19 cases were among Saudi citizens, compared to 45% on June 3 . Through April 26 , Bahrain reported approximately 74% of its total COVID-19 cases among expatriate workers. On May 29 , however, the Bahraini Ministry of Health reported 300 new cases, including 183 expatriate workers (61%), potentially indicating an increasing proportion among Bahraini citizens. On May 13 , Kuwait reported 648 of 751 new cases (86%) among non-citizens, but yesterday, the Kuwaiti Ministry of Health reported only 385 of 562 new cases (69%) in non-citizens. The Qatari Ministry of Public Health does not explicitly distinguish cases among citizens and non-citizens; however, it continues to report that “the new cases are due to expatriate workers” while also noting that “cases...have also increased among citizens and residents.”

UNITED STATES
The US CDC reported 1.84 million total cases (14,676 new) and 107,029 deaths (827 new). The United States could potentially surpass 2 million cases in the next 7-10 days. In total, 14 states (no change) 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 and in early May.

As Florida looks ahead to further easing social distancing measures , with most of the state entering Phase 2 of Florida’s recovery plan today, the state reported its highest daily incidence to date . The Florida Department of Health reported 1,419* new cases, surpassing the previous high of 1,413 on April 17. Additionally, Florida reported 1,317 new cases the previous day, which appears to be the state’s fourth-highest daily total . Florida reported decreasing daily incidence from early April through early-to-mid May, but incidence has been increasing over the past several weeks.
*Note: The media is widely reporting 1,419 new cases as yesterday’s incidence; however, this does not match the value displayed on Florida’s COVID-19 dashboard (“1.3k” cases). The reported cumulative total of 60,183 cases is consistent with the dashboard.

The Johns Hopkins CSSE dashboard reported 1.88 million US cases and 108,334 deaths as of 11:30am on June 5.

CONVALESCENT PLASMA TRIAL Researchers in China published findings from a randomized, placebo-controlled clinical trial to evaluate the use of convalescent blood plasma as a treatment for COVID-19. The study, published in The Journal of the American Medical Association , included 103 COVID-19 patients in Wuhan, China, but it was terminated because there were not enough patients to enroll when the outbreak was brought under control. Of the 101 patients that completed the trial, the researchers observed clinical improvement in 51.9%, compared to 43.1% of the control group, although this difference was not statistically significant. Among patients with severe disease, the treatment group exhibited statistically significant improvement over the control group—clinical improvement in 91.3%, compared to 68.2%. Critically ill patients did not experience similar improvements, however. The treatment group also exhibited decreased time to achieving a negative diagnostic test result. Two patients in the treatment group experienced adverse events following the treatment, both of whom responded well to associated treatment.

This appears to be the first RCT for convalescent plasma treatment for COVID-19. In an associated editorial, several experts from Johns Hopkins University, the Mayo Clinic, and the Montefiore Medical Center, note that the results demonstrate that clinicians now have an additional tool for treating COVID-19 patients, despite the study’s limitations. These experts suggest that additional research is necessary to determine if convalescent plasma could potentially complement remdesivir, the other treatment with documented benefits in a RCT.

US CDC CRITIQUE The New York Times published a critique of the US CDC’s role in the US government response to COVID-19, highlighting a series of missteps that contributed to the United States leading the world in COVID-19 incidence and mortality. The lengthy article highlights the CDC’s origins, purpose, and culture, with a focus on actions and decisions during the COVID-19 response as well as the agency’s relationship to state-level health departments and officials and US President Donald Trump. The findings are based on “a review of thousands of emails and interviews with more than 100 state and federal officials, public health experts, C.D.C. employees and medical workers.” Much of the article focuses on months-long challenges in scaling up SARS-CoV-2 testing capacity, which CDC Director Dr. Robert Redfield recently refuted as a major barrier early in the response.

In an accompanying editorial, one of the article’s authors, Michael Shear , highlighted 5 specific areas that factor into these challenges and failures. He explicitly discusses the United States’ fractured and antiquated disease surveillance and reporting systems, perceptions of the CDC as an adversary among White House officials, the CDC’s risk-averse culture, the demand for Dr. Redfield to balance competing demands of the CDC and President Trump, and an absence of timely, reliable, and actionable CDC guidance for state and local health officials.

In a separate editorial published yesterday in The New York Times , former CDC Director Dr. Tom Frieden argues that the original critique mischaracterized how the US COVID-19 response unfolded and the CDC’s responsibility or authority with respect to the missteps. He emphasizes that chronic under-funding of public health programs at all levels of government underpin the lack of adequate national capacity to respond to events like the COVID-19 pandemic. Additionally, he asserts that efforts by the current Presidential administration hindered CDC response efforts, redirected critical capacity to non-essential tasks, and “stifled [the CDC’s] ability to speak directly to the public.” He argues that the resulting delays and the absence of a “coherent national strategy” are responsible for the poor US response rather than capabilities, expertise, and leadership at the CDC.

US HEALTH DISPARITIES As a result of the disproportionate impact of the COVID-19 epidemic on racial and ethnic minorities in the United States, the US Department of Health and Human Services issued new COVID-19 laboratory reporting requirements that include direction for key demographic data such as race, ethnicity, age, and sex. These enhanced reporting requirements aim to better capture COVID-19 risk disparities among racial and ethnic communities. This move comes amid increased focus on disparities in justice and health in the US, which motivated widespread protests currently underway.

GAVI VACCINE SUMMIT Gavi, the Vaccine Alliance, held its 2020 Global Vaccine Summit in London, hosted by UK Prime Minister Boris Johnson. The summit helped to raise US$8.8 billion from 32 donor governments and 12 foundations and organizations to support routine vaccination efforts for low-income countries and establish the infrastructure needed to implement mass vaccination for SARS-CoV-2. Gavi also announced its Advance Market Commitment for COVID-19 Vaccines , a financing mechanism that aims to raise US$2 billion to “incentivi[ze] vaccine manufacturers to produce sufficient quantities of eventual COVID-19 vaccines, and to ensure access for developing countries.” This advance market commitment is the first step in a broader effort to ensure global access to SARS-CoV-2 vaccines.

Concerns about equitable vaccine access and allocation are increasing as leaders from high-income countries, particularly the United States and the United Kingdom, begin to formalize arrangements that could prioritize access to candidate SARS-CoV-2 vaccines for their own populations. Notably, the US Department of Defense recently awarded a $60-million contract to Novavax to provide 10 million doses of its candidate vaccine, manufactured in the United States, by the end of 2020 for use in Phase 2 and 3 clinical trials or under an Emergency Use Authorization. The Novavax vaccine has previously received significant funding support from the Coalition for Epidemic Preparedness Innovations, up to $388 million, for advanced clinical development of the vaccine. Priority access for the wealthiest countries—which are better able to afford investments in vaccine development, establish vaccine production capacity, and purchase vaccine doses—could inhibit equitable global distribution of the vaccine, particularly for lower-income countries.   

SARS-CoV-2 NOT MUTATING TO BECOME MORE DANGEROUS During the WHO daily COVID-19 briefing on June 3, Dr. Maria Van Kerkhove , Technical Lead for the WHO COVID-19 response, indicated that the genomic analysis conducted thus far has not identified any genetic changes to the SARS-CoV-2 virus that would suggest an increase in transmissibility or disease severity. She emphasized that complacency or fatigue among the public resulting from prolonged social distancing restrictions could contribute to increased transmission, even if the virus itself is not undergoing significant mutations.

HYDROXYCHLOROQUINE STUDIES RETRACTED Two major health journals retracted recently published studies on the use of hydroxychloroquine in COVID-19 patients after questions were raised about the integrity of the underlying data. The recently published studies—one in The Lancet and the other in The New England Journal of Medicine ( NEJM )—concluded that hydroxychloroquine treatment for COVID-19 was associated with increased cardiovascular risks and possible increases in mortality, without finding sufficient evidence of treatment benefit. Both journals published a subsequent “expression of concern” regarding the quality of data, and then both The Lancet and NEJM retracted the articles.

Both studies relied on data from a company called Surgisphere, which stated that it collected the data from 671 hospitals across 6 continents. Scientists raised concerns that data contained errors and that the data itself was not made publicly available for independent analysis. Earlier this week, a large group of experts published an open letter to the study authors and the editor of NEJM that highlighted questions about the data’s quality and provenance and requested an independent validation of the study’s evidence. The studies’ authors are reportedly initiating an independent review of the original data for both studies. Surgisphere stated the data were valid and drawn from electronic health records from “real-time patient encounters.”

A separate study published June 3 in NEJM found that hydroxychloroquine did not appear to be associated with severe adverse events in a randomized, placebo-controlled trial, but it also failed to demonstrate a benefit as post-exposure prophylaxis to prevent COVID-19. The WHO previously suspended the hydroxychloroquine arm of its SOLIDARITY trial, following the original publications; however, it announced that this portion of the clinical trial will resume, based on the findings of an internal investigation.
 
WUHAN TESTING Health officials in Hubei Province, China , implemented a mass SARS-CoV-2 testing campaign in Wuhan that aimed to test the entire population of 11 million people. The campaign ultimately resulted in 9.9 million tests and identified 300 asymptomatic infections and zero symptomatic cases. Additionally, tests of nearly 1,200 contacts of the infected individuals yielded zero positive tests. Based on testing completed for 90% of the entire population, the study found no ongoing chains of SARS-CoV-2 transmission.

N95 RESPIRATOR REUSE & FIT FAILURE A study conducted by researchers at the University of California, San Francisco (US) evaluated the potential that repeated use of respirator masks could result in fit failures, which could risk exposure to viruses like SARS-CoV-2. The study, published in JAMA , evaluated the fit integrity of both dome-shaped and duckbill-shaped N95 respirators after repeated use by healthcare workers. The researchers found that the duckbill-shaped respirators had a higher failure rate (70.6%) than the dome-shaped respirators (27.5%) and that an increased failure rate was associated with the number of uses for the dome-shaped masks. No results were reported for any association between the number of uses and failure in duckbill-shaped respirators. The study included 68 participants—51 using dome-shaped respirators and 17 using duckbill-shaped respirators—and additional study is required to better characterize the risk and failure rate for various respirator products, including differences between specific models manufactured by different companies. Due to challenges facing medical supply chains, many healthcare facilities have needed to clean and reuse various types of personal protective equipment (PPE), including respirators. These items are not designed for reuse, so it is critical to understand the limitations on multiple uses, including any potential increased risk of exposure during subsequent uses.