Updates on the COVID-19 pandemic from the Johns Hopkins Center for Health Security.

Additional resources are available on our website.
The Johns Hopkins Center for Health Security also produces US Travel Industry and Retail Supply Chain Updates that provide a summary of major issues and events impacting the US travel industry and retail supply chain. You can access them here.
EPI UPDATE The WHO COVID-19 Dashboard reports 51.25 million cases and 1.27 million deaths as of 12:00pm EST on November 11.

The US CDC reported 10.04 million total cases and 237,731 deaths. A cumulative incidence of 10 million cases corresponds to approximately 3% of the entire US population. From the first case reported in the US on January 22, it took 96 days to reach 1 million cases. From there:
1 million to 2 million- 44 days
2 million to 3 million- 27 days 
3 million to 4 million- 15 days
4 million to 5 million- 17 days
5 million to 6 million- 22 days
6 million to 7 million- 25 days
7 million to 8 million- 21 days
8 million to 9 million- 14 days
9 million to 10 million- 10 days

The daily incidence in the US is nearly 110,000 new cases per day and still increasing exponentially. The US is also reporting 976 deaths per day, an increase of nearly 40 percent since October 18. We expect that the average daily mortality will once again exceed 1,000 deaths per day in the coming days. If the US continues on this trajectory, it could surpass 250,000 cumulative deaths in the next 2 weeks.

More than half of all US states have reported more than 100,000 cumulative cases, and more than one-third have reported more than 200,000 cases:
>900,000: California, Texas
>800,000: Florida
>500,000: New York
>400,000: Illinois
>300,000: Georgia

The Illinois Department of Health is currently reporting more than 500,000 cases, so we expect that to be reflected in the CDC data in the coming days. We also expect North Carolina to surpass 300,000 cases and Virginia to surpass 200,000 cases in the near future.

By essentially every metric, the US COVID-19 epidemic is accelerating at a concerning rate. The average daily incidence more than doubled in less than a month—from approximately 50,000 new cases per day on October 12 to 110,000 daily cases on November 9—with no sign of slowing. Analysis published on the COVID Exit Strategy website classifies all but 3 states—Hawai’i, Maine, and Vermont—as having “Uncontrolled Spread." Additionally, 19 states are reporting more than 500 daily cases per million population. Most of these states are in the central portion of the country, with the exception of Alaska and Rhode Island. Notably, only 2 states, Alabama and Georgia, are reporting flat or decreasing COVID-19 incidence over the past 2 weeks. In fact, 11 states are reporting increases of more than 100% over that time, including Maine at 215%. More than half of all US states have reported their single day record incidence over the past 2 weeks.

As we have covered previously, COVID-19 incidence does not tell the full story. In addition to incidence, testing, hospitalizations, and mortality provide important insight into the current state of the US epidemic. The national testing capacity has largely increased on a linear trajectory since early in the US epidemic, but recent exponential increases in COVID-19 incidence and hospitalizations illustrate that the current testing volume may not be sufficient to fully capture the scope of community transmission. In fact, the US test positivity has doubled, from 4.2% to 8.3%, since early-to-mid October, once again putting the US above the WHO's recommended 5% threshold. COVID-19 hospitalizations are increasing nationwide, with the Midwest exhibiting the most substantial surge over the past several weeks. Looking at mortality, it is clear that COVID-19 deaths continue to follow trends in incidence, with a lag of approximately 3-4 weeks. The national surge in incidence began in mid-September, followed by a corresponding increase in mortality starting in mid-October. Since that time, daily COVID-19 mortality has increased by more than one-third.

To put the current US surge in the global context, the US is #29 globally in terms of per capita daily incidence. Additionally, the US (354 new cases per million population) has nearly caught up to the average across Europe (377), the current major global hotspot. Compared to the 8 European countries with populations greater than 20 million, the US is reporting per capita daily incidence greater than 4 of them, and the per capita daily incidence in the US is currently reporting 8 times the global average (71). The US is faring slightly better in terms per capita daily mortality, ranking #35 globally. At 3 daily deaths per million population, the US is currently reporting 60% of the European average (5 deaths per million), and the US ranks behind 6 of the 8 most populous countries in Europe. The US daily mortality is increasing, although not nearly to the same degree as some European countries.

The Johns Hopkins CSSE dashboard reported 10.31 million US cases and 240,265 deaths as of 1:30pm EST on November 11.

NURSING HOMES Despite efforts to keep COVID-19 out of nursing homes, incidence among residents and staff is increasing after a period of relative stability. From May through October, incidence among both residents and staff of these facilities nearly quadrupled, and mortality among residents doubled over that time. The federal government previously allocated US$5 billion to provide nursing homes with access to rapid testing capacity and personal protective equipment (PPE), but despite this investment, nursing home staff inevitably are exposed to community transmission, which can then introduce SARS-CoV-2 to high-risk residents in these facilities.

This pattern is especially true for nursing homes in areas where community spread is the highest. Nursing home incidence has been elevated in more severely affected areas, regardless of heightened protective measures. A study conducted by researchers at the University of Chicago, on behalf of The Associated Press, found that nursing home quality was not a meaningful predictor of success against COVID-19, after accounting for the level of community transmission. Furthermore, nursing homes have been struggling to manage increasing incidence, staffing shortages, and new health mandates. For example, the study found that for the week of October 25, 1 in 6 nursing homes had not tested staff in the previous week, despite a national mandate for such weekly testing. Additionally, nearly 25% of facilities reported some sort of staffing shortage, and 20% reported a shortage of PPE. Many experts argue that nursing home residents cannot be protected unless community transmission is effectively contained, regardless of the extra protective measures implemented.

US CDC MASK GUIDANCE Yesterday, the US CDC published updated analysis regarding the role of mask use in protecting the wearer. The official CDC guidance continues to emphasize the value of masks in terms of “source control”—ie, that masks limit the volume of droplets expelled into the environment—rather than as protection for the wearer; however, the updated analysis indicates that masks can provide protection for the wearer as well, including the ability to filter “fine droplets and particles less than 10 microns.” Recent studies found that the filtration effect varied between masks and mask types, with multi-layer masks constructed with more densely woven material performing better than single-layer masks made from lower thread count fabric. The guidance also references studies that evaluated various mask materials, including both synthetic (eg, polypropylene) and natural materials (eg, silk). The CDC does not appear to have issued a corresponding update to its guidance on mask use (ie, to highlight the benefit to the wearer), but we will monitor the CDC website for any forthcoming changes. Hopefully, this new information will encourage increased mask use among the public.

TESTING REFUSAL While mask reluctance and refusal has been a common phenomenon throughout the US COVID-19 epidemic, there are also increasing reports of reluctance toward testing. Testing volume and capacity vary widely across the country, with some states having greatly increased their capacity and others still largely limited to symptomatic individuals; however, even in areas with sufficient testing capacity, some individuals may resist getting tested. Factors driving this reluctance could include the desire to keep schools or businesses open (eg, by not contributing to reported incidence or triggering contact investigations at local businesses), personal concerns about isolation or quarantine, and political viewpoints. Personal autonomy is a major driver of testing hesitancy, much like for anti-vaccine sentiment or vaccine hesitancy, with some individuals viewing their ability to decide whether or not to be tested as their personal right. Notably, the Equal Employment Opportunity Commission determined that employers can mandate diagnostic testing for employees who work on site, illustrating the competing interests between personal autonomy and public benefit, particularly under “exceptional circumstances” like a pandemic. The extent of testing reluctance remains unknown, but it is evident that more work is necessary in order to both educate the public on the importance of testing and better characterize the degree to which individuals and communities experience testing reluctance.

UTAH Utah joins 34 other states in establishing a statewide mask mandate, as part of recent efforts to strengthen social distancing measures. Governor Gary Herbert declared a new state of emergency and unveiled new statewide public health measures to combat the state’s ongoing COVID-19 surge. The state of emergency and public health order follow Utah’s most devastating week to date in terms of COVID-19 incidence and mortality. In addition to the mask mandate, the new measures expand testing operations, including mandatory weekly testing for college and university students, and place restrictions on restaurants and bars, including a prohibition on on-site alcohol sales after 10pm. Utah will also limit social gatherings to single households only and suspend many athletic or other extracurricular activities (with exceptions for high school, collegiate, and professional sports). The new measures are scheduled to remain in effect through November 23, and additional recommendations for the Thanksgiving holiday weekend are expected to be announced in the coming days. Governor Herbert warned that those who violate the new measures could be subjected to fines of up to US$10,000 per violation. 

HOPI TRIBE Two articles published last week in the US CDC’s MMWR detailed the Hopi Tribe’s COVID-19 response efforts. The Hopi Tribe is a Native American tribe and sovereign nation with a population of approximately 7,500 spread across 12 rural villages in northeastern Arizona. The first article details the investigation of a COVID-19 outbreak in May and June. The Hopi Health Care Center (HHCC) led the overall response efforts, in coordination with the tribal leadership and the Hopi Emergency Response Team. Following the identification of 2 related COVID-19 patients (siblings), contact tracing efforts identified 58 primary and secondary contacts of the co-index patients. Among the contacts, 27 (47%) tested positive for SARS-CoV-2, and 22 of the 29 total infections (76%; including the co-index patients) were symptomatic. Health officials identified 2 gatherings of extended family members and workplace exposures as likely loci of transmission beyond household contacts. Additionally, both of the co-index patients were symptomatic for at least 1 week prior to their positive test, during which time they continued to socialize in the community. The investigation identified a “limited understanding of how and when to wear masks, adhere to physical distancing...and practice hand hygiene” among the community, highlighting the need for “enhanced community education,” particularly regarding mask use and the signs and symptoms of COVID-19. Following the investigation, HHCC and tribal leadership “increased community messaging,” in both English and Hopi.

The second article describes efforts by the HHCC and the Hopi Tribe Department of Health and Human Services (DHHS), in collaboration with the US CDC, to conduct community-wide screening, surveillance, and education in 2 Hopi villages. Early contact tracing efforts found inconsistent mask use and limited knowledge of SARS-CoV-2 testing, isolation, and quarantine procedures, and the Hopi DHHS and the CDC developed a community-focused program to enhance surveillance and health communication. A pilot test of the screening, surveillance, and education program was conducted in 2 villages, interviewing 141 individuals across 101 households in fewer than 10 hours. The effort achieved 95% participation and obtained information on more than 259 individuals. The health officials utilized a standardized form to screen for COVID-19 symptoms and exposures and provide education on everyday prevention measures and testing using “culturally adapted materials.” The surveillance teams reported that residents of the 2 villages were receptive to and appreciative of the screening and education efforts, and they attributed the success, in part, to the involvement of trusted community health representatives. As a result of the successful pilot, the Hopi Tribe expanded the screening to cover all villages between July and October, and tribal leadership are seeking additional resources to expand the program, including increased frequency and additional services such as distributing masks.

MONOCLONAL ANTIBODY EUA The US FDA issued an Emergency Use Authorization (EUA) for the use of bamlanivimab, a monoclonal antibody, as a COVID-19 treatment in some patients. The EUA pertains specifically to patients who meet several key criteria: (1) aged 12 years and older and weighing 40kg (88 pounds) or more; (2) test positive for SARS-CoV-2; (3) currently experiencing mild or moderate COVID-19 disease, but not currently hospitalized; AND (4) at high risk for severe COVID-19 disease. Notably, the EUA emphasizes that bamlanivimab should not be administered to individuals who are receiving supplemental oxygen therapy (ie, high-flow oxygen or mechanical ventilation), as this could increase the risk of “worse clinical outcomes.” This is the first EUA issued for a monoclonal antibody treatment for COVID-19. Bamlanivimab will continue to be evaluated as a COVID-19 treatment, but the data currently available indicate that the drug can “reduce COVID-19-related hospitalization or emergency room visits in patients at high risk” for severe COVID-19.

Last week, the US government announced that it finalized the purchase of 300,000 doses of bamlanivimab in anticipation of the FDA’s decision. The Biomedical Advanced Research and Development Authority (BARDA) purchased the doses directly from the manufacturer, Eli Lilly, as part of Operation Warp Speed. The current contract is valued at US$375 million, with the option of 650,000 more doses through the end of 2021 at an additional cost of US$812.5 million.

VACCINE DISTRIBUTION Even before the announcement by Pfizer Pharmaceuticals this week regarding interim efficacy analysis of its candidate SARS-CoV-2 vaccine, hospitals, health systems, and public health departments have been working to purchase and set up “ultra-cold freezers” in anticipation that they may be needed to store SARS-CoV-2 vaccines. The Pfizer vaccine, developed in partnership with BioNTech, must be stored at -70°C (-94°F) in order to remain viable, which is below the temperatures typically capable in pharmaceutical freezers. Not all vaccines require this level of freezing, but if the Pfizer vaccine is the first available, maintaining the cold chain during the vaccine distribution and administration process could be a major barrier, particularly for rural areas.

According to a report by STAT News, the US CDC has advised against the purchase of these freezers, but many organizations are moving forward anyway. While hospitals, health systems, and public health departments in large urban areas may be able to afford the cost of these freezers, those in rural parts of the country may not have funding available to cover the purchase, putting them at a disadvantage. According to the National Rural Health Association, “nearly half of U.S. rural hospitals were operating at a loss in April of this year,” and the situation has been exacerbated by the COVID-19 epidemic. Pfizer is working with state and local health departments to coordinate national distribution plans. The plans include boxes that can provide temporary storage capacity using dry ice, but the system has major limitations, including that the boxes “can be opened only for a minute at a time no more than twice a day.” As the US and countries around the world look ahead to the availability of a SARS-CoV-2 vaccine, logistical challenges, including cold chain management, need to be addressed well in advance in order to mitigate their impact on mass vaccination operations.

COLLEGE FOOTBALL On Saturday, the University of Notre Dame football team (ranked #4 nationally) defeated Clemson University (ranked #1) in double-overtime, in what ESPN labeled an “epic win.” While that description is debatable—considering that Clemson’s starting quarterback, Heisman Trophy contender Trevor Lawrence, did not play following a positive SARS-CoV-2 test—Notre Dame’s students reacted predictably after the victory, charging the field en masse. Notre Dame is among the approximately 50% of schools that allow fans to attend football games, and while it does limit the number of spectators, approximately 11,000 students were present for the game against Clemson. Fortunately, images show that the vast majority of students were wearing masks; however, physical distancing was not maintained while the students were on the field. Some media commentary suggests that university leadership should have anticipated this kind of incident and questions whether it is appropriate for schools to permit spectators in the stadium, or even to continue the season, in light of the ongoing surge in transmission and mortality across the country.

Following the incident, Notre Dame’s President, Reverend John Jenkins, issued a statement admonishing the students for their actions, both after the game and at other gatherings in recent days. Rev. Jenkins’ letter is reminiscent of those issued by a number of universities to their respective student bodies earlier this year as schools resumed in-person classes and students gathered in dormitories, houses, bars, and other locations on and near campus. In addition to chastising students for acting like students, Rev. Jenkins announced “zero tolerance” policies for student gatherings—under threat of “severe sanctions”—as well as mandatory testing for students, including exit testing before students are permitted to leave at the end of the semester. Those who do not get tested will not be able to register for future classes or obtain an official transcript from the university.

With the letter, Rev. Jenkins’ letter also called attention to his own recent actions with respect to COVID-19, including attending a White House ceremony during which he did not wear a mask. The event—US President Donald Trump’s announcement of now-Justice Amy Coney Barrett as his nomination for the US Supreme Court—was subsequently identified as the locus of transmission for a number of COVID-19 cases among White House staff and other attendees, potentially including Rev. Jenkins himself. Notably, Notre Dame’s Faculty Senate met last week “to consider a vote of no confidence because of [Reverend] Jenkins' appearance at the Rose Garden without a mask,” but the group ultimately decided to forgo the vote and, instead, passed a motion which "expresses its disappointment...(and) also accepts his apology."

In the week leading up to the game against Clemson, Notre Dame’s average daily COVID-19 incidence climbed from 18.9 cases per day to 30.7, a 62% increase; however, increasing incidence on campus did not dissuade the university from allowing students to attend the game in person. This kind of incident should serve as a cautionary tale for other universities and sports teams, particularly as national incidence and mortality continues to increase and students prepare to return home for Thanksgiving, Christmas, and the end of the term.

RUSSIAN VACCINES Following Pfizer’s announcement regarding the preliminary efficacy analysis for its candidate SARS-CoV-2 vaccine, Russia made a similar announcement for its first vaccine*. On Monday, the Russian Ministry of Health announced that early observations from the public use of its vaccine indicated that it was more than 90% efficacious. According to multiple media reports, the initial announcement also indicated that Russia intends to publish interim results from its ongoing Phase 3 clinical trial for the vaccine in the near future.

In a subsequent announcement today, Russia reported that interim clinical trial data shows the vaccine efficacy to be 92%, based on data from approximately 16,000 participants who have received both doses. The preliminary results were based on data obtained after 20 cases of COVID-19 among study participants, compared to 94 cases in the Pfizer trial. Much like the announcement from Pfizer, there are no publicly available data to analyze, so many questions remain about the Russian vaccine, including the duration of immunity. Russia in continuing Phase 3 clinical trials on the vaccine, and it is already conducting a separate study on a second vaccine. Russia also anticipates that a third candidate vaccine will be available in the near future.