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

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May 27, 2020

Schedule change: Starting this week, we will send out the COVID-19 Situation Report on Monday, Wednesday, and Friday. For the epidemiological data we include, we will continue to report daily changes when possible, but we will not necessarily report the total change since the previous briefing.

Thank you to all our subscribers for reading our daily updates. 

EPI UPDATE The WHO COVID-19 Situation Report for May 26 reports 5.40 million confirmed cases (99,780 new) and 343,514 deaths (1,486 new). In terms of relative contribution to the global COVID-19 incidence , South America has surpassed all other continents, currently representing nearly 30% of the global daily incidence. North America represents 26% of the daily incidence (and steadily decreasing), and Asia represents 22%. Europe has dropped to approximately 18%, and Africa’s relative contribution continues to grow steadily, now more than 4%.

Brazil reported 16,324 new cases, consistent with the daily incidence reported last week. Brazil’s daily incidence is 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 140 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 continues to emerge as a major global hot spot for COVID-19. These South American countries represent 3 of the top 7 countries globally in terms of daily incidence .

Potentially overlooked due to the total volume of cases in the United States and the growing incidence in Brazil, Chile, and Peru, Mexico ’s COVID-19 epidemic is also exhibiting a concerning acceleration. Mexico is currently #5 in the Americas in terms of daily incidence and #8 globally . Mexico has reported a total of 74,560 cases, including 3,455 new cases, its highest daily total to date.

Russia reported 8,338 new cases, relatively consistent with its recent trend. India reported 6,387 new cases, and it has reported its 5 highest daily totals over the past 5 days. The state of Tamil Nadu, where a large outbreak has been linked to one of Asia’s largest markets, reported 646 new cases. Russia and India are #3 and #4 in terms of daily incidence , respectively.

After several weeks of generally increasing daily incidence, including 5 consecutive days near or greater than 1,000 new cases, South Africa reported its lowest daily incidence (649 new cases) since May 12.  South Africa is currently reporting the highest cumulative COVID-19 incidence (23,615 cases) and second highest daily incidence in Africa.

Singapore reported 533 new cases, including 529 (99.2%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s COVID-19 epidemic, but these cases appear to be decreasing slowly over the past several weeks. Singapore estimates that the cases confirmed so far represent 9.48% 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, 93.1% are among residents of migrant worker dormitories, including 99.0% over the past 2 weeks. Singapore’s per capita daily incidence has declined substantially over the past several weeks, down from a peak of more than 200 new cases per million population on April 23 to fewer than 75 now, its lowest value since April 16.

The US CDC reported 1.66 million total cases (24,958 new) and 98,261 deaths (592 new). Daily COVID-19 deaths in the United States are generally on the decline , but the total could potentially reach 100,000 deaths by tomorrow’s update. In total, 12 states (no change) 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, and mass gatherings associated with the Memorial Day holiday weekend (US) could have provided the conditions to drive increased community transmission. We will continue monitoring state-level trends over the coming weeks.

The Johns Hopkins CSSE dashboard reported 1.68 million US cases and 99,123 deaths as of 11:30am on May 27.

COVID-19 MORTALITY IN YOUNGER POPULATIONS As COVID-19 continues to spread beyond China, Europe, and the United States including to Brazil, Chile, Peru, and Mexico in the Americas—the risk profile appears to be shifting . While severe cases and deaths in many countries impacted early in the pandemic tended to be reported in older patients, developing countries are increasingly reporting severe cases and deaths among younger individuals. As illustrated by this figure , most countries in Africa, South America, and Asia are reporting lower median age for COVID-19 patients, which could be contributing to the elevated incidence of severe disease in younger patients. Notably, 15 percent of COVID-19 deaths in Brazil have been in patients younger than 50 years old, and nearly quarter of deaths in Mexico have been between the ages of 25 and 49 years. These proportions are orders of magnitude higher than what has been reported in other severely affected countries like Spain and Italy. A myriad of factors—including high population density, pervasive poverty, high prevalence of comorbidities (eg, diabetes, obesity), and poor access to healthcare—could be contributing to a shift toward more severe disease in younger individuals. As COVID-19 incidence shifts toward developing nations, it will be critical to address all relevant risk factors, including those beyond patient health and demographics, in order to effectively mitigate the COVID-19 risk.

US VACCINE POLL As the world looks ahead to the availability of a SARS-CoV-2 vaccine, it is important to understand existing expectations and perceptions in order to begin messaging and education efforts. A recent poll, conducted by the Associated Press and NORC , aimed to understand public opinions regarding the future of a SARS-CoV-2 vaccine. Among the respondents, 61% expected that a vaccine will be publicly available sometime in 2021, compared to 20% who think it will be available in 2020 and 17% who believe it will be sometime after 2021. Notably, only 49% of respondents indicated that they intend to get vaccinated, while 20% said they would not get vaccinated (31% not sure). For comparison, a similar study in 2019 found that 52% of people intended to get vaccinated against seasonal influenza.

Among the reasons cited for not getting vaccinated were: concerns about side effects (70%), concerns that the vaccine could result in SARS-CoV-2 infection (42%), the belief that the individual would not experience severe COVID-19 illness (31%), and the belief that vaccines more broadly are not effective (30%). Notably, the accelerated process for developing, testing, and producing a SARS-CoV-2 vaccine could increase concerns regarding vaccine safety , including that manufacturers and regulators may be willing to sacrifice safety in order to shorten the time to vaccine availability. Considering that many of these issues are similar to those facing other vaccination efforts, including routine childhood immunizations and seasonal influenza, it is critical to begin messaging now, before a vaccine is available, in order to increase support for and participation in vaccination programs and appropriately frame the potential benefits and risks.

COVID-19 MISINFORMATION Mis- and disinformation are presenting substantial challenges to the global COVID-19 response, as rumors and conspiracy theories may be linked to increased transmission and unnecessary disease. Claims related to disease severity, government response, and vaccine or treatment efficacy are circulating widely, and it is extremely difficult to provide fact-checking or verification in real time, particularly across the myriad of traditional and social media platforms available worldwide. COVID-19 has presented optimal circumstances for the spread of rumors, including increased stress and anxiety around the virus that can make individuals more susceptible to mis- and disinformation. An investigation by the BBC identified a number of events—including mass poisonings and threats or incidents involving physical violence—linked to misinformation regarding COVID-19.

To combat the spread of misinformation and disinformation, social media sites are increasingly attempting to identify potentially false information through fact checking in order to alert users; however, mis- and disinformation campaigns persist. The nature of COVID-19 response activities, particularly those that disrupt daily life, can breed skepticism, which can potentially further susceptibility to associated misinformation, particularly information that confirms existing views or perceptions. Additionally, as people are spending more time at home, they have a greater opportunity to browse online content, which can further increase exposure to mis- and disinformation. 

SARS-CoV-2 TESTING IN AFRICA As the COVID-19 pandemic spreads beyond China, Europe, and the United States, concern is growing regarding the potential impact on African countries, particularly those with lower resources and underdeveloped healthcare systems. While the relative proportion of COVID-19 cases in Africa is slowly growing, the continent still only represents a small fraction ( fewer than 5% ) of reported cases worldwide. Lack of available testing is repeatedly cited as a barrier to the public health response in Africa. As has been illustrated in numerous other countries, including the United States, insufficient testing capacity can allow community transmission to go undetected, which creates major challenges for containing spread. Notably, the testing capacity varies considerably between countries in Africa, ranging from approximately 10 tests per 1,000 population in South Africa and 61 tests per 1,000 population in Mauritius to countries like Chad and Mali that have conducted only 1 or 2 tests per 10,000 population.

An article published in Nature discusses how scientists in some African countries are leveraging international professional networks to improve the availability of critical supplies to bolster SARS-CoV-2 testing capacity. Partnerships with colleagues in academic and other institutions in the United States, Europe, and elsewhere have been able to supply materiel needed to perform tests, and laboratories and networks that traditionally work on tuberculosis, HIV, and malaria have transitioned to provide SARS-CoV-2 laboratory capacity. Professional connections have made these critical supplies more widely available in Africa, supplementing the limited support provided by other national governments. The nature of COVID-19 as a global pandemic means that nations around the world are experiencing stressed healthcare systems and resource limitations. Under different circumstances , nations with great resource availability would be providing additional aid to countries in need; however, resource limitations in even the wealthiest countries means that external support may be lacking. Unique solutions may be necessary to ensure that countries have access to the supplies and equipment necessary to combat the pandemic. 

US SOCIAL DISTANCING Reuters published analysis of state-level COVID-19 incidence data —from The COVID Tracking Project —to evaluate epidemic trends. The analysis found that 20 states reported increased weekly incidence (for May 18-24) over the previous week, compared to 13 states identified last week. Notably, Alabama (28% increase), Missouri (27%), and North Carolina (26%) reported the highest weekly increases. After several weeks of declining incidence, Georgia reported a 21% increase as well. The US CDC and White House recommend that states exhibit declining incidence for at least 14 days before initiating or furthering efforts to relax social distancing measures. According to the Reuters analysis, 17 states have not met that criteria at any point since the onset of the US epidemic, even though every state has begun relaxing social distancing to some degree. Additionally, the analysis found that US COVID-19 incidence is actually holding relatively steady or potentially increasing slightly, if New York and New Jersey are omitted, illustrating that the decline in national incidence over recent weeks has been driven largely by these 2 states, which represent more than 10% of the national total . Numerous individual states are experiencing increasing incidence, which can be masked by the overall national-level trend.

SARS-CoV-2 MONITORING IN SEWAGE Researchers from Yale University (Connecticut, US) published ( preprint ) findings from a study that evaluated the presence of SARS-CoV-2 virus in a local sewage system. The study aimed to determine the potential for monitoring SARS-CoV-2 presence and concentration in sewage systems to provide insight into the level of local community transmission. Utilizing daily samples taken from a local sewage processing facility (March 19-May 1), the researchers performed quantitative viral RNA testing (qRT-PCR) for SARS-CoV-2 and compared the concentration to local COVID-19 reporting. They found a strong correlation between the amount of SARS-CoV-2 present in the sewage and the number of confirmed COVID-19 cases and hospitalizations several days later. The trend in hospitalizations lagged 3 days behind the peak viral concentration, and the reported cases lagged the viral concentration by 7 days. Because viral shedding often occurs before SARS-CoV-2 infections can be diagnosed, this study illustrates that conducting surveillance on the concentration of SARS-CoV-2 in wastewater systems could potentially provide several days advance warning of increased COVID-19 incidence in the community.

ANTIBODY PRODUCTION IN COVID-19 SURVIVORS Researchers at The Rockefeller University published ( preprint ) data from a study of 149 COVID-19 patients to eval uate the presence of antibodies in blood serum after their recovery. Their analysis identified a broad scope of immune response among the participants, including the production of various types of antibodies. The researchers found that the majority of the COVID-19 patients did not produce the appropriate type or quantity of antibodies necessary to result in the “neutralizing activity” necessary to prevent SARS-CoV-2 infection, including 33% whose neutralizing activity was below the minimum detectable level. They did identify “remarkably high” neutralizing activity in 2 of the participants. The researchers were further able to identify and clone key neutralizing antibodies from these “‘elite’ responders,” and they are working to translate them into a potential COVID-19 treatment.

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