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

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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.
REVERSING CURRENT TRENDS As the US looks ahead to the coming holiday season and winter months, the rapid escalation of the COVID-19 epidemic poses considerable health risk. On November 19 (12-12:30pm EST), the Johns Hopkins Bloomberg School of Public Health will host a webinar to discuss what individuals, health officials, and elected leadership can and should do to mitigate COVID-19 risk in the coming months. The panelists will include experts from across the school: Dr. Josh Sharfstein, Vice Dean for Public Health Practice and Community Engagement; Dr. Amber D’Souza and Dr. David Dowdy, professors in the Department of Epidemiology; and the Center for Health Security’s own Dr. Caitlin Rivers.

Advance registration is not required, but you can submit a question in advance via the event website, where you can watch the webcast live.
EPI UPDATE The WHO COVID-19 Dashboard reports 54.30 million cases and 1.31 million deaths as of 9am EST on November 16. The WHO reported a new record high for weekly COVID-19 incidence for the ninth consecutive week—3.98 million new cases, a 6.5% increase over the previous week. The WHO also reported a new record high for weekly mortality for the second consecutive week—59,860 deaths, an 11% increase over the previous week.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. USA: 152,201 new cases per day (+43,017)
2. India: 41,639 (-4,696; ↑ 1) 
3. Italy: 34,775 (+2,522; ↑ 1)
4. France: 27,786 (-25,558; ↓ 2)
5. Brazil: 26,406 (9,491; new)
6. United Kingdom: 25,329 (+2,887) 
7. Poland: 23,792 (+3; ↓ 2) 
8. Russia: 21,642 (+1,991)
9. Spain: 18,537* (-1,537; ↓ 2) 
10. Germany: 18,494 (+374; ↑ 1)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Montenegro: 994 daily cases per million population (+64; ↑ 3) 
2. Luxembourg: 927 (+83; ↑ 4)
3. Andorra: 904 (-128; ↓ 2) 
4. San Marino: 884 (+400; new)
5. Austria: 809 (+152; ↑ 4) 
6. Georgia: 793 (+145; new)
7. Switzerland: 743 (-205; ↓ 4)
8. Liechtenstein**: 738 (-150; ↓ 3)
9. Slovenia: 679 (+25; new)
10. Poland: 629 (no change; new)
*Spain’s average daily incidence is not reported for today; these values correspond to the most recent data available.
**Liechtenstein is a member of the UN, but not the WHO; Liechtenstein’s COVID-19 data is reported by Switzerland.

The Czech Republic fell out of the top 10 in terms of total daily incidence, and it was replaced by Brazil, which jumped all the way to #5. France’s daily incidence decreased by nearly 50% compared to the previous week. Conversely, the daily incidence increased by nearly 40% in the US and 56% in Brazil. The US is reporting more than 3.5 times the incidence as every other country. Armenia, Belgium, the Czech Republic, and France fell out of the top 10 in terms of per capita daily incidence, and they were replaced by Georgia, Poland, San Marino, and Slovenia. San Marino’s COVID-19 incidence increased by 83%, and it jumped all the way to #4.

The US CDC reported 10.85 million total cases and 244,810 deaths. The US is averaging 148,280 new cases per day, the highest since May 24. The US is averaging 1,180 deaths per day, and it could reach 250,000 cumulative deaths by the end of the week.

The US reported a new single-day record for daily incidence on Friday, with 194,610 new cases. This is 36% more cases than the previous record, which was reported on the previous day. The US has reported more than 100,000 new cases on 10 of the 11 days since becoming the first country to do so on November 4, including the past 3 days with more than 150,000 new cases. Since that time, the average daily incidence has increased by 65%, and it appears to still be increasing exponentially. Notably, the US reported more than 1 million cases over the past 7 days.

Two-thirds of all US states have reported more than 150,000 cumulative cases, and 20 have reported more than 200,000 cases:
>1 million: California, Texas
>800,000: Florida
>500,000: Illinois, New York
>400,000: Georgia

On a per capita basis, more than half of all US states are reporting higher cumulative incidence than New York City, the country’s biggest hotspot early in the epidemic, including North and South Dakota, which are reporting more than twice the per capita cumulative incidence as New York City. In terms of mortality, the parts of the country that were affected most severely in the US this spring—eg, New York City, New Jersey, Massachusetts, Connecticut, and Louisiana—continue to report the highest per capita cumulative mortality; however, over the last 7 days, only Hawai’i, Oregon, and Vermont have reported lower per capita mortality than New York City (0.1 deaths per 100,000 population). On the other end of the spectrum, 4 states have reported 1 or more deaths per 100,000 population—Wyoming (1), Georgia (1), South Dakota (1.6), and North Dakota (1.8)—at least 10 times the current rate in New York City.

The Johns Hopkins CSSE dashboard reported 11.05 million US cases and 246,255 deaths as of 11:30am EST on November 16.

MODERNA VACCINE Moderna Therapeutics issued a series of press releases over the past several days regarding the progress for the Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine. Last week, Moderna announced that it identified enough cases among study participants—ie, at least 53—to conduct the first interim analysis on the vaccine’s efficacy. The study completed enrollment of 30,000 participants in late October, and the primary metric is preventing symptomatic COVID-19 disease, with secondary aims of preventing severe disease and preventing infection. Last Friday, Moderna announced that Swiss regulatory officials began reviewing the trial’s safety and efficacy data to evaluate the possibility of authorizing its use in Switzerland. The review will occur on a rolling basis, as new data become available, as opposed to waiting until all data are collected, in hopes of accelerating the review process compared to traditional timelines.

The most noteworthy news, however, was today’s announcement that interim analysis of the data indicates that the candidate vaccine could be nearly 95% effective. Like Pfizer’s announcement last week, this update was provided in a press release, and the actual data still need to be published and reviewed; however, the news is promising that multiple highly efficacious vaccines could be available in 2021. The Moderna interim analysis involved 95 participants with confirmed COVID-19 (90 of which were in the placebo group). Notably, 11 severe COVID-19 cases were reported among trial participants, and all were among the placebo group. Among the 95 cases, 15 are aged 65 years or older and 20 are racial or ethnic minorities—12 Hispanic or LatinX, 4 Black or African American, 3 Asian, and 1 multiracial. Moderna estimates the vaccine to be 94.5% efficacious based on the preliminary data, which would be comparable to the Pfizer vaccine. The vaccine also appears to have an acceptable safety profile, with no serious adverse events reported thus far.

Moderna also announced that the vaccine has demonstrated longer shelf life and greater stability at refrigeration temperatures than initially anticipated. According to the press release, “remains stable at 2° to 8°C (36° to 46°F)...for 30 days” and “at -20° C (-4°F) for up to six months.” The Moderna vaccine could be stored temporarily in standard refrigerators or freezers. Additionally, the Moderna vaccine can remain at room temperature for up to 12 hours and does not require onsite dilution or additional handling at the vaccination site, which could reduce the logistical burden required for mass vaccination.

Both Pfizer and Moderna are expected to file for Emergency Use Authorization (EUA) with the US FDA, and regulatory authorities in other countries, including the European Medicines Agency, have also announced they will review the Moderna candidate. The news about both vaccine candidates has been received positively and with relief, especially as initial expectations about the efficacy of mRNA vaccines were somewhat low. Neither company has released the full interim analysis or the data analyzed in a journal, however, and the long-term safety and efficacy of these candidates remains to be assessed. 

HEALTHCARE WORKER BURNOUT US COVID-19 incidence is surging to unprecedented levels, nearly reaching 200,000 new cases on November 12. While this surge is commonly described as a “third wave,” the reality, especially for frontline healthcare workers, is that this is just the ever-growing peak of a single, continuous wave since March. The US never successfully contained its “first wave,” so many US healthcare workers never got a reprieve between the second and third surges. The Atlantic published a detailed report on the current state of the US healthcare workforce, as emergency rooms across the country are reaching capacity with COVID-19 patients and medical staff are being pushed to the limit, sometimes working 36-hour shifts. The strain is particularly difficult in rural areas in the Midwest and West regions, where hospitals and health systems are running out of bed space and healthcare personnel to care for new patients. The seemingly endless surge in cases across many states has led to concerns of impending and continuing burnout from doctors and nurses, especially as many personnel are required to remain in quarantine or isolation due to their continual contact with COVID-19 patients. In some locations, such as North Dakota, the lack of available doctors and nurses has policies allowing healthcare workers who test positive for SARS-CoV-2 to keep working, as long as they remain asymptomatic.

The previous 2 surges in the spring and summer provided valuable experience and insight regarding how to best treat COVID-19 patients, and the development and availability of new therapies have helped to an extent. But with holidays rapidly approaching in the US, many are concerned about an impending surge in cases as people may congregate. US healthcare workers, like those in many countries are physically, mentally, and emotionally exhausted, and the third surge is the biggest to date, with no sign of slowing. Increased incidence inevitably brings increased hospitalizations and mortality, but if hospitals and health systems are unable to cope with the surge, including if healthcare workers are too exhausted to operate effectively, the US could risk mortality more like that reported early in the epidemic, when New York City was overwhelmed, except on a national scale.

SLOVAKIA As COVID-19 transmission continues to surge in Europe and many countries move to strengthen social distancing restrictions to mitigate transmission risk, Slovakia took a slightly different approach that initially appears to be paying dividends. As we covered previously, Slovakia implemented a plan to test every adult in the country, in addition to enhanced social distancing policies. In the first week of testing, Slovakia tested more than 3.6 million people—approximately two-thirds of the country—and a week later, it retested more than 2 million individuals in high-risk areas. The tests used for this effort are rapid antigen tests, which are slightly less reliable than traditional PCR-based diagnostic tests, but they can provide results in as little as 15-30 minutes. Individuals who tested positive during the nationwide effort were placed in quarantine or isolation to mitigate the risk of further transmission, and contact tracers conducted investigations to identify other at-risk individuals.

In the weeks since testing began, Slovakia has reported a significant decrease in COVID-19 incidence. Slovakia’s daily COVID-19 incidence fell dramatically from a peak of 2,547 new cases per day on November 4 to 1,610 on November 16, a 33% decrease. Slovakian Prime Minister Igor Matovič attributed the decreased incidence to the testing program and associated quarantine requirements. While Slovakia had a number of other social distancing measures in place—including prohibitions on large gatherings, curfew, and many business closures—some of these measures were tied to testing results to encourage participation. For example, the curfew, in place from 11pm to 5am, required those with exceptions for work, health care, or other essential activities to carry documentation of a negative PCR or antigen test.

These restrictive social distancing measures have been in place since early October, so it is not easy to distinguish the impact of the testing program, but the downward trend in incidence following the mass testing is certainly promising. Prime Minister Matovič announced that the next round of testing will be conducted the weekend of November 21-22 and will be much more limited in scope than the nationwide effort, focusing cities where the previous round of testing identified SARS-CoV-2 prevalence greater than 1 percent. In the announcement, he noted that continued widespread testing could enable Slovakia to "indulge in a little freedom," as opposed to facing highly restrictive “lockdown” through the winter months. He suggested that if the testing data continue to provide evidence that the country’s COVID-19 epidemic is moving in the right direction, Slovakia could ease some existing social distancing measures. While Slovakia elected to extend its state of emergency for another 45 days, Prime Minister Matovič later announced that Slovakia’s Pandemic Commission approved measures to reopen “cinemas, theaters and churches” at 50% capacity as well as gyms and swimming pools with limited capacity, indicating that the government is confident that the testing program is meeting its aims. While the curfew will remain in place, individuals who are eligible for the noted exceptions will no longer be required to provide documentation of a recent test. As many other countries, particularly in Europe and North America, struggle to combat their respective COVID-19 surges, Slovakia’s experience provides some evidence that widespread testing, in combination with contract tracing and quarantine/isolation, can help contain transmission and enable the relaxation of some social distancing measures.

WHITE HOUSE TRANSMISSION Last week, multiple news media reports indicated that more than 130 secret service officers, assigned to protect US President Donald Trump and other senior White House officials, have been ordered to quarantine or isolate as a result of testing positive for SARS-CoV-2 or an exposure to a known case, representing approximately 10% of the Secret Service’s core team. Much of that total comes from just the past several weeks, as an outbreak has spread among White House and other administration officials, including President Trump, Chief of Staff Mark Meadows, and Secretary of Housing and Urban Development Ben Carson.

PUERTO RICO Like many other areas in the US, Puerto Rico is experiencing a surge in COVID-19 incidence that has necessitated the addition of new protective restrictions. The US territory is currently reporting more than 600 cases per day, with projections reaching 1,200 cases per day by mid-December. The Puerto Rican government is taking several approaches to curb the rise in cases. Gyms, churches, restaurants, casinos, and other businesses will be limited to 30% capacity. Beaches will also be closed, with the exception of those using them for exercise. Free rapid testing, likely rapid antigen testing, will be available at toll booth locations during the weekends, providing results back in as little as 15 minutes. Mask use will remain mandatory in public spaces. Finally, Governor Wanda Velazquez activated the National Guard to help with the enforcement of an island-wide curfew from 10pm to 5am. These restrictions came into force on November 16 and are currently scheduled to remain in place until December 11. Governor Velazquez cautioned Puerto Ricans to reduce holiday travel and, instead, participate in virtual family get-togethers where possible.