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

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June 8, 2020

EPI UPDATE The WHO COVID-19 Situation Report for June 7 reports 6.80 million confirmed cases (136,409 new) and 397,388 deaths (4,586 new). This appears to be the highest global daily incidence * to date. The global totals could reach 7 million cases by tomorrow’s WHO Situation Report and 400,000 deaths by today’s update.
*This analysis uses data from the European CDC, not the WHO.

We continue to observe shifts in the geographic distribution of COVID-19 incidence . Since the end of May, Europe has reported fewer than 15% of the new COVID-19 cases each day, and North America has reported approximately 20-25% of new cases over the past week. Asia’s contribution to the global incidence continues to increase, now reporting more than 25% of new cases each day since the beginning of June. With the exception of June 6, South America’s proportion of COVID-19 cases continues to grow as well, now up to approximately 30-35% of the global total. The relative contribution by Africa continues to increase as well, but more slowly. Africa is now reporting approximately 5% of the global daily incidence.

India’s COVID-19 epidemic continues to accelerate, setting a new high for daily incidence today , 9,983 new cases. India has now reported more than 250,000 total cases nationwide. India’s COVID-19 incidence has leveled off over the past few days, just shy of 10,000 new cases per day, but it is still increasing slightly from day to day.

Iran reported 2,389 new cases , down from more than 3,500 new daily cases last week. Iran is now #11 globally in terms of daily incidence .

Brazil updated its COVID-19 dashboard, removing cumulative incidence and deaths as well as figures displaying various epidemiological trends. Brazil reported 18,912 new cases, which would be its lowest daily total since late May. Other sources , however, indicate that the daily incidence is considerably higher, in the range of 27,000 new cases. The source of this discrepancy is not clear. Depending on which daily incidence value is used, Brazil could be #11-13 globally in terms of per capita daily incidence , but it is still #1 or #2 in terms of total daily incidence . Brazil is also currently #3 globally in terms of cumulative COVID-19 deaths , but recent trends put it on track to surpass the United Kingdom in the coming days. Chile’s epidemic continues to exhibit a concerning acceleration, and it remains #3 in the world in terms of per capita daily incidence and #5 for total daily incidence.

The US CDC reported 1.92 million total cases (29,214 new) and 109,901 deaths (709 new). Over the weekend, the United States reported its 2 highest daily totals since May 16, and the United States could potentially surpass 2 million cases in the next 3-5 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 and Illinois with more than 125,000.

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. Increased social interaction as well as mass gatherings associated with the Memorial Day holiday weekend and ongoing large-scale protests against racial injustice could potentially contribute to transmission. We will continue monitoring these trends over the coming weeks.

New York continues to exhibit encouraging progress in containing COVID-19. In its most recent update, the statewide test positivity was 1.3%. In New York City it was 1.8%. New York reported 781 new cases statewide, its lowest daily total since March 17, and New York City reported 56 new cases, it lowest since March 14.

Florida continues to report elevated and increasing daily incidence. In fact, its 7-day average is approximately equal to its peak in early April and is still increasing. Georgia appears to have passed a second peak in mid-May; however, its recent incidence data, which may not yet be complete, already indicate another increase in the 7-day average. California ’s daily incidence continues to increase, with 3 of its 5 highest daily totals reported in the last 3 days. While the number of tests conducted in Utah is holding steady or possibly decreasing slightly, the COVID-19 incidence has increased dramatically over the past 2 weeks, up from 150-200 new cases per day to 447 and 547 new cases on June 4 and 5, respectively. Arizona continues to report increasing COVID-19 incidence as well. Arizona reports its cases by specimen collection date (which means that data from the past 7 days may be incomplete) and it reported its 2 highest daily totals on June 1 and 2, both more than 1,000 new cases per day. Arizona’s daily incidence has more than doubled since early May.

The Johns Hopkins CSSE dashboard reported 1.95 million US cases and 110,734 deaths as of 1:30pm on June 8.

WHO UPDATES MASK GUIDANCE The WHO released updated guidance on mask usage last Friday, including information on who should use a mask and when masks should be worn, as well as the materials or type of mask that should be used. The new recommendations deviate from previous guidance in a few key areas, particularly for areas experiencing widespread SARS-CoV-2 transmission. The WHO now recommends that masks be worn by all health personnel seeing patients in areas of widespread transmission, not just clinicians treating COVID-19 patients. In areas experiencing community transmission (a step below widespread transmission), individuals at elevated risk of severe COVID-19 disease or death, including those over the age of 60 or those with underlying health conditions, should wear medical masks whenever physical distancing from other people is not possible. The general public should wear masks in crowded areas when physical distancing from other people is not possible in areas experiencing widespread transmission.

In terms of materials, the WHO now recommends that cloth masks be made out of at least 3 layers of different materials , ideally an inner layer of absorbent material (e.g., cotton), a middle layer of non-woven material (e.g., polypropylene), and an outer layer of non-absorbent material (e.g., polyester). WHO Director-General Dr. Tedros Adhanom Ghebreyesus emphasized that mask use alone does not protect against SARS-CoV-2 infection and that masks should be used as part of a “comprehensive strategy” of protective measures.

HYDROXYCHLOROQUINE TRIAL TERMINATED The United Kingdom terminated the hydroxychloroquine arm of its RECOVERY clinical trial after finding no evidence of treatment benefit for COVID-19 patients. The UK’s Randomised Evaluation of COVID-19 Therapy ( RECOVERY ) trial, a national clinical trial to test the efficacy of potential COVID-19 treatments, has stopped enrolling new patients in a trial arm testing hydroxychloroquine. In a statement released Friday, the study’s chief investigators stated that preliminary findings from 1,542 patients demonstrated that there was no clinical benefit from the use of hydroxychloroquine. The trial participants in the hydroxychloroquine treatment arm showed no significant improvements in mortality or hospital stay length compared to other participants receiving usual medical care. The statement committed to publishing the full results in the near future.

PEDIATRIC MULTISYSTEM INFLAMMATORY SYNDROME Two recently published studies provide new analysis of pediatric multisystem inflammatory syndrome (PIMS) associated with COVID-19 in children. The first study, published in Eurosurveillance , describes the results of a nationwide surveillance effort in France conducted March 1-May 7. The researchers identified 156 potential cases of PIMS over that period, including 79 confirmed, 16 probable, and 13 possible cases (48 were ruled out based on the study’s case definition). The PIMS incidence in France peaked several weeks after the national COVID-19 peak, which suggests that PIMS ma y be a “post-infectious manifestation” of COVID-19 , and the geographic distribution of PIMS cases largely correlated with COVID-19 incidence. Based on a maximum estimated COVID-19 incidence in French children (defined as those under the age of 15) of 5%, the researchers estimate the risk of PIMS to be fewer than 2 cases per 10,000 children.

The second study, published in The BMJ , looked at the clinical presentation of PIMS in Paris, France. The prospective study identified 21 PIMS patients in Paris between April 27 and May 11. Of these children, 12 presented with Kawasaki disease, and 16 presented with myocarditis. Among these patients, 9 reported previously experiencing “viral-like symptoms” (e.g., fever, headache), and the mean duration between these symptoms and the onset of Kawasaki disease was 45 days. In total, 8 (38%) of the PIMS patients tested positive for SARS-CoV-2 infection during the study, and only 1 had symptoms consistent with COVID-19 during the study. In contrast, 19 of the 21 (90%) patients tested positive for IgG antibodies, indicating prior infection. The delay following viral symptoms and the prevalence of IgG antibodies relative to active infection further support the idea that PIMS is a post-infectious manifestation of COVID-19. The researchers also observed disease severity in these patients, with 17 (81%) of them requiring intensive care and 11 (52%) requiring mechanical ventilation. Notably, 57% of the patients were of African ancestry, but further data and analysis are needed to characterize any potential association.

COVID-19 ELIMINATED IN NEW ZEALAND New Zealand Prime Minister Jacinda Ardern announced that New Zealand has eliminated COVID-19 , following 17 days with no new reported cases and the discharge of the country’s last remaining active COVID-19 patient. New Zealand subsequently transitioned to Alert Level 1 and lifted nearly all remaining COVID-19 restrictions. The notable exception is continued strict border controls, including mandatory 14-day quarantine for arriving travelers, to mitigate the risk of imported cases and travel-associated outbreaks. Additionally, New Zealand shifted its COVID-19 mindset from “Unite Against COVID-19” to “ Unite for Recovery ,” which will focus on economic recovery while maintaining vigilance and enhanced hygiene to mitigate the risk of COVID-19. Prime Minister Arden emphasized that the dedication and commitment to the successful response has placed New Zealand at an advantage in terms of economic recovery, particularly as many countries remain under restrictive social distancing measures. In total, New Zealand reported only 1,154 confirmed infections and 22 deaths.

SOCIAL DISTANCING IMPACT Two new articles were published in Nature today that describe the effects of social distancing and other interventions on the COVID-19 pandemic. One article used data from 1,717 different interventions at the local, regional and national level in the United States, France, Iran, Italy, South Korea, and China. Based on econometric modeling techniques, which are typically used to evaluate economic impact of events and policies, the researchers evaluated the impact of various non-pharmaceutical interventions (NPIs), including large-scale social distancing policies, on the epidemic growth. They concluded that interventions in these countries may have prevented 62 million confirmed COVID-19 cases worldwide, which corresponds to an estimated 530 million total SARS-CoV-2 infections. These include 4.8 million confirmed cases (60 million infections) in the United States alone.

The other article focused on interventions in Europe through May 4, 2020, when some countries began to relax national social distancing measures. Considering available data from serological studies, the researchers estimated the true number of infections in order to evaluate the effects of social distancing policies on transmission and mortality. This study found that nonpharmaceutical interventions, including national “lockdowns,” could have averted approximately 3.1 million COVID-19 deaths across 11 European countries. 

State and local governments across the United States continue to relax social distancing measures. Notably, New York City and Las Vegas are expanding business and social activities. The changes in Las Vegas, in particular, have raised concern about increased transmission risk as videos and photos have circulated showing individuals crowding into casinos with questionable social distancing and many people not wearing face masks. 

GENETIC VARIATIONS & COVID-19 A recent study ( preprint , not yet peer reviewed ) indicates that individuals with certain blood types and other genetic variations may be at elevated risk of respiratory failure due to COVID-19. The genome-wide association study (GWAS), included 1,980 participants experiencing respiratory failure due to COVID-19 in Italy and Spain were included in the genome-wide association analysis. One key finding suggested that individuals with Type A blood were at 50% higher risk of requiring oxygen therapy or mechanical ventilation. Notably, genetic variations related to the ACE2 receptor, which is how the SARS-CoV-2 virus attaches to human cells, did not show any significant impact on infection. Results of this study could help clinicians to identify patients at higher risk of respiratory failure that may need aggressive, proactive measures. Considering the broad range of disease severity for COVID-19, from asymptomatic infection to severe disease and death, information regarding risk factors is important to characterizing the disease and pandemic and potentially identify targets for treatment or vaccine development.

IRAN SECOND WAVE Iran has reported decreased daily COVID-19 incidence over the past several days, following increasing incidence since early May, a second “wave” that drove incidence higher than the peak of Iran’s first wave in late March. It is too early to tell, however, whether this indicates that Iran has passed its second peak. As a result of the second wave, Iran once again scaled up response activities and implemented additional restrictions in an effort to contain the epidemic. In order to increase national screening for SARS-CoV-2 infection, Iran deployed 23,000 teams of health experts across the country and implemented both online and phone-based screening programs. In total, Iran has screened more than 50 million individuals nationwide. Iran also increased domestic production of critical supplies , including personal protective equipment. Notably, Iran scaled up production capacity for N95 respirators from 5-10,000 to 85,000 per day and increased production of surgical masks by a factor of 8. Iran also scaled up diagnostic testing capacity, setting a new national record with 25,000 tests performed in a single day .

Schools are beginning to reopen in Iran, with additional protective measures in place to mitigate COVID-19 risk. Previously, Iran suspended schools and universities , although some medical schools remained in operation in order to allow students to graduate and immediately support the COVID-19 response. Iran’s Ministry of Health and Medical Education cancelled in-person interviews for international students hoping to study “medical sciences” at Iranian universities and announced that the application process will proceed via an online system in order to comply with COVID-19 social distancing measures. Schools across the country will reopen at the direction of local governments, and capacity will be limited, particularly in dormitory settings. Additionally, students taking in-person classes will undergo health screening, and diagnostic testing will be available on campus, with a focus on symptomatic students.

US REMDESIVIR SUPPLY The US government is coordinating with Gilead Sciences to facilitate increased production and distribution of remdesivir, the only drug that has been demonstrated to provide treatment benefit for COVID-19 patients in a randomized clinical trial. Gilead previously donated its available remdesivir inventory to the US government; however, this supply is expected to be exhausted by the end of June. Gilead is working to increase production capacity, with material support from the US government; however, the next delivery may not be available until July or August. The US Department of Health and Human Services Assistant Secretary for Preparedness and Response, Dr. Robert Kadlec, expressed confidence that additional remdesivir will be available this summer and that production will increase substantially into the fall and beyond. It is unclear at this point how much Gilead will charge for subsequent shipments, and the incredibly high demand—as the only available treatment with demonstrated efficacy—has raised concerns about the potential that the drug could be expensive.