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

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May 26, 2020

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EPI UPDATE The WHO COVID-19 Situation Report for May 25 reports 5.30 million confirmed cases (100,264 new) and 342,029 deaths (4,342 new). The global total incidence could potentially reach 5 million cases by today’s update.

Brazil reported 11,687 new cases. This is considerably fewer than other recent days; however, Brazil tends to report lower daily incidence coming out of the weekend. Notably, these values are following an increasing trend from week to week, and this week is Brazil’s highest to date—nearly 50% greater than the previous week. Brazil surpassed Russia and is now #2 globally in terms of cumulative confirmed cases. Brazil’s daily incidence is also second to only the United States, and if the current trends continue, it could become #1 globally in the coming days. The per capita incidence in Peru and Chile continue to exhibit concerning trends as well, with Peru reporting more than 120 new cases per million population each day and Chile reporting more than 200, more than double and triple the per capita incidence in the United States, respectively. South America is emerging as a major global hotspot for COVID-19. These South American countries represent 3 of the top 6 countries globally in terms of daily incidence .

Following a peak in daily incidence of more than 11,000 new cases in mid-May, Russia has held relatively steady at approximately 9,000 new cases per day for the past week. Moscow and the Moscow Region continue to represent the majority (56.4%) of Russia’s COVID-19 cases. India continued its increasing daily incidence, reporting its 4 highest daily totals over the weekend—a high of nearly 7,000 new cases on May 25. The state of Tamil Nadu, where a large outbreak has been linked to one of Asia’s largest markets, averaged more than 775 new cases per day over the weekend, slightly more than its daily totals from last week. Russia and India are #3 and #4 in terms of daily incidence , respectively.

South Africa reported its 2 highest daily incidence totals over the weekend, and the daily incidence has exceeded 1,000 for 4 of the last 5 days. South Africa is currently reporting the highest cumulative COVID-19 incidence (23,615 cases) and highest daily incidence in Africa. Testing in South Africa increased steadily through mid-May; however, it appears to have leveled off for the week of May 18-24.

Singapore reported 383 new cases, including 381 (99.5%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s COVID-19 epidemic. Singapore estimates that the cases confirmed so far represent 9.32% of the total population across all migrant worker dormitories, compared to only 0.03% of the general public population. Of the total confirmed cases reported in Singapore, 93.0% are among residents of migrant worker dormitories, including 99.0% over the past 2 weeks.

Ontario, Canada , has exhibited elevated daily incidence since approximately May 13. From its peak of nearly 750 new cases reported per day on April 17, Ontario reported a steady decrease to a low of 256 new cases on May 12. Ontario has reported approximately 350-400 new cases each day over the past 2 weeks. Additionally, the number of active COVID-19 cases in Ontario has steadily increased from a recent low of 3,412 on May 17 to 4,104 cases on May 25.

The US CDC reported 1.63 million total cases (15,342 new) and 97,669 deaths (620 new). Daily COVID-19 deaths in the United States are generally on the decline , but the total could potentially reach 100,000 deaths in the coming days. In total, 12 states (increase of 2) reported more than 40,000 cases, including New York with more than 350,000; New Jersey with more than 150,000; and Illinois with more than 100,000.

The New York Times continues to track state-level COVID-19 incidence, with a focus on state policies regarding social distancing. 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. After several weeks of increased activity, several of them appear to be experiencing a continued increase in daily incidence. These states include: Alabama , Arizona , Arkansas , Florida , North Carolina , North Dakota , and Texas . Increased testing capacity across the United States will contribute to increased reported incidence in these and other states; however, these increasing trends warrant close attention as potential signals of increasing community transmission. Following numerous reports of large gatherings at beaches and other locations over the Memorial Day holiday weekend (the unofficial start of summer in the United States), with many people appearing to relax social distancing steps, we will continue to monitor state-level incidence trends for signals of increased community transmission.

The Johns Hopkins CSSE dashboard reported 1.67 million US cases and 98,426 deaths as of 12:30pm on May 26.

SARS-CoV-2 VACCINE TRIAL Researchers published data from a non-randomized Phase 1 clinical trial for a SARS-CoV-2 vaccine conducted in Wuhan, China. The study, published in The Lancet , describes adverse event outcomes for 108 susceptible participants, each of whom received one of 3 different doses of a candidate vaccine. The vaccine utilizes a modified adenovirus as a vector to deliver the vaccine’s genetic material. The vaccine candidate was generally well tolerated among the participants, with most adverse events being mild or moderate in severity and relatively short in duration. In total, 10 (9%) participants reported severe adverse events—2 (6%) each among the low and middle dose groups and 6 (17%) among the high dose group. In addition to safety data, the researchers published preliminary data regarding the participants’ immune response. Participants in all 3 dose groups had rapid binding antibody and neutralizing antibody responses following vaccination, with the higher doses eliciting increased immune response. Notably, the researchers observed that pre-existing antibody titers to the strain of adenovirus used in the vaccine correlated with reduced immune response. Phase 1 studies are designed to evaluate the vaccine’s safety, not efficacy. A randomized Phase 2 trial is ongoing in Wuhan, China.

As vaccine trials continue and we move closer to the availability of a vaccine to combat the COVID-19 pandemic, the extent to which these vaccines will be effective remains uncertain. Vaccines are not 100% effective at preventing infection or disease, and some vaccines—for example, the annual seasonal influenza vaccine—confer only partial immunity. A vaccine that confers partial immunity may not necessarily be able to prevent infection in everyone, but it could potentially reduce the risk of severe disease. Additionally, the vaccine may not confer lasting immunity. Researchers are still evaluating the duration of immunity conferred by natural SARS-CoV-2 infection, and additional research will be needed to evaluate the durability of vaccine-acquired immunity.

SARS-CoV-2 TRANSMISSION, ADULTS VS CHILDREN Older adults are at elevated risk for severe COVID-19 disease and death compared to younger adults and children. The extent to which children contribute to transmission of the virus, however, remains uncertain. A study ( preprint ) published by researchers in the United Kingdom, the Netherlands, and Australia uses 18 previously published contact tracing and screening studies to evaluate the relative contribution of children and adults to SARS-CoV-2 transmission. The article reviews each of the included studies and an assessment of its relative contribution to the understanding of children’s role in SARS-CoV-2 transmission.

Based on the included contact tracing studies, the researchers estimate that children (approximately age 18-20 years and younger) have a 56% lower odds of infection compared to adults. The population screening studies, however, “were more heterogenous and were not suitable for meta-analysis.” Depending on the study, the results showed lower prevalence among children or prevalence similar to adults. The studies evaluated did not provide sufficient information to fully evaluate the role of children in infecting others, making it difficult to characterize their role in driving community transmission. This study provides “preliminary evidence” that children have lower susceptibility to SARS-CoV-2; however, further data and research are needed to better characterize the role of children in the COVID-19 pandemic.

WHO SUSPENDS HYDROXYCHLOROQUINE TRIAL As we covered on Friday, a recent study published in The Lancet raised potential safety concerns regarding hydroxychloroquine as a treatment for COVID-19. Following this study’s publication, the WHO announced that it would temporarily suspend the use of hydroxychloroquine in the multinational Solidarity Trial. WHO Director-General Dr. Tedros Adhanom Ghebreyesus stated that an independent executive group will further investigate hydroxychloroquine’s safety in COVID-19 patients, including data already collected from the Solidarity Trial, before making a final determination regarding whether or not to completely remove it from the study. Other arms of the Solidarity Trial are continuing as planned.

US IMPOSES TRAVEL RESTRICTIONS FOR BRAZIL In response to the recent acceleration of Brazil’s COVID-19 epidemic, US President Donald Trump imposed travel restrictions on Brazil . The order restricts entry for arriving travelers with travel to Brazil in the past 14 days. Brazil is emerging as a COVID-19 hot spot , and it is now #2 in the world, behind the United States, in terms of cumulative and daily COVID-19 incidence . Brazilian President Jair Bolsonaro has repeatedly downplayed the severity of the country’s epidemic, despite the accelerating incidence . President Bolsonaro continues to promote increased economic activity and clash with local governors regarding social distancing measures while health systems struggle to meet COVID-19 demand. Brazil’s last two Ministers of Health have either been terminated or resigned, in the span of several weeks, which may have resulted from conflicts with President Bolsonaro regarding the national COVID-19 response.

REMDESIVIR TRIAL DATA Researchers from the US National Institutes of Health published data from a clinical trial that corresponds to earlier reports describing the effectiveness of remdesivir as a treatment for COVID-19. The article, published in The New England Journal of Medicine , details a randomized, double-blind, placebo-controlled clinical trial involving a total of 1,063 patients. The researchers conclude that remdesivir shortened the recovery time in adults with COVID-19 compared the placebo. Preliminary data were described at a high level previously in a press release, but this is the first time that detailed results have been released publicly. The research also notes a clear benefit when treatment was initiated early in the course of illness compared to later.

There were several limitations . There appeared to be little benefit to patients who were on mechanical ventilation, suggesting that we may still lack treatment for the most severe COVID-19 cases. Additionally, the mortality for participants treated with remdesivir was nearly 5% lower than in the control group, but the improvement was not statistically significant, due in part to insufficient sample size to achieve the study power necessary to achieve a significant result. Additional data are needed to better characterize this relationship. Experts have stated that remdesivir alone will not be enough to control this pandemic; however, this research is a promising early step in developing an evidence-based treatment course for COVID-19 patients. 

RELAXING SOCIAL DISTANCING New Zealand , which has mounted one of the world’s most successful COVID-19 containment efforts, announced that it will relax restrictions on the size of gatherings later this week. Starting on May 29, New Zealand will permit gatherings of up to 100 people, including both private and public events as well as at businesses. Previously, gatherings were limited to no more than 10 people. Additionally, the national government is collaborating with Sport New Zealand, a national government organization that promotes sports and physical activity in New Zealand, to develop new guidance that will enable the resumption of sports nationwide. New Zealand will begin reviewing the Alert Level 2 restrictions on June 8 with the aim of evaluating the transition to Alert Level 1 by June 22.

On May 25, Japan lifted the state of emergency on its remaining 5 prefectures, including the Tokyo area, which means that the emergency has been lifted for the entire country. The emergency was initially declared nationwide on April 7, and was lifted for most of the country in mid-May. In his announcement, Japanese Prime Minister Shinzō Abe emphasized that lifting these restrictions did not mean that the COVID-19 risk was zero, but rather, that Japan would implement a phased approach to relaxing social distancing measures and resuming social and economic activity in order to mitigate this risk. Japan will re-evaluate existing restrictions on a regional basis every several weeks to determine whether additional restrictions can be relaxed. Japan will reportedly implement contact tracing and individual exposure notification via a smartphone app in the coming weeks.

US SARS-CoV-2 TESTING STRATEGY The US Department of Health and Human Services delivered an 81-page testing strategy to the US Congress. The report, COVID-19 Strategic Testing Plan , outlines the national-level strategy for SARS-CoV-2 testing and testing goals for each state, including a recommendation to test at least 2% of their population by the end of June. This document outlines a state-by-state approach to COVID-19 testing, rather than a centralized national effort. The report cites the availability of a supply of accurate COVID-19 tests that is large enough to contain the national epidemic, although some Democratic leaders and public health and healthcare experts have questioned if the existing capacity is sufficient.

The testing strategy has drawn some criticism for placing the responsibility for testing on state governments rather than providing centralized federal coordination, which could result in states competing against each other for limited resources. Other public health experts have applauded the positive steps taken under this strategy, including a decision to allow storage of test kits by the Strategic National Stockpile and federal efforts to distribute critical testing supplies (e.g., swabs and viral transport media), which has helped increase national testing capacity. Testing will be critical as states continue efforts to relax social distancing restrictions and resume business operations and social events. 

CONVALESCENT SERUM A recent study ( preprint ) evaluates the use of convalescent plasma as a treatment for severe COVID-19 cases. The matched control study, conducted by the Icahn School of Medicine at Mount Sinai (New York, US), included 39 severe COVID-19 patients who were treated using convalescent plasma from recovered COVID-19 patients. The study group was retrospectively matched to controls based, in part, on their supplemental oxygen requirement at the start of the study. The researchers found a statistically significant improvement in supplemental oxygen requirements following the treatment as well as reduced mortality among non-intubated patients. While the positive results are encouraging, further analysis, including via randomized, placebo-controlled trials, are necessary to better characterize the effects of convalescent plasma as a COVID-19 treatment and associated risks.

NHL PLAYOFFS The National Hockey League (NHL; US) is moving forward with tentative plans to resume the 2019-20 season. League and player representatives collaborated to develop a modified format that would enable the season to resume. Player representatives from each team recently voted in favor of a plan that would resume the season with the playoffs—expanding from 16 to 24 teams—with seeding based on the standings when the season was suspended in March. The exact format may change, and the timeline has not yet been determined. Notably, this agreement does not constitute a commitment to resume play; however, it provides a framework under which the NHL season could resume, if the league determines that it is safe to do so.