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.
Starting next week, we will publish briefings on Tuesdays and Fridays, with both US and international content in each. Additionally, we will be scaling back the epidemiological analyses. Daily US state- and national-level COVID-19 data can be found from a variety of sources, so we will instead focus on our analysis of emerging trends. We will publish a list of some sources that we find useful on the Center’s COVID-19 resource page in the near future, which we hope will help streamline your efforts to find specific types of epidemiological data or analysis.

The new COVID-19 briefing schedule will start on Tuesday, November 24. There will be no briefing on Friday, November 27, due to the US Thanksgiving holiday weekend. We will resume the briefings on Tuesday, December 1 with the new schedule.
EPI UPDATE The WHO COVID-19 Dashboard reports 55.06 million cases and 1.33 million deaths as of 5am EST on November 18.

The US CDC reported 11.14 million total cases and 246,232 deaths. From the first case reported in the US on January 22, it took 96 days to reach 1 million cases. From there:
1 to 2 million- 44 days
2 to 3 million- 27 days 
3 to 4 million- 15 days
4 to 5 million- 17 days
5 to 6 million- 22 days
6 to 7 million- 25 days
7 to 8 million- 21 days
8 to 9 million- 14 days
9 to 10 million- 10 days
10 to 11 million- 7 days

The United States’ average daily incidence surpassed 150,000 new cases per day, just 11 days after first reporting more than 100,000 new cases in a single day. The US has reported more than 100,000 cases for 9 consecutive days and 12 of the last 13. Additionally, the US is reporting 1,214 deaths per day, the highest average since May 22. The US daily mortality has increased nearly 75% over the past month, and the US could surpass 250,000 cumulative deaths in the next 3 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

In order to capture the rapidly increasing daily incidence across the US, the COVID Exit Strategy website added yet another category to classify per capita daily incidence. The new category (light purple) designates states reporting more than 1,000 new cases per million population, which corresponds to 1 new case for every 1,000 residents every day. This category currently applies to 8 states in the north central portion of the country, ranging from the western part of the Midwest region, across the Plains, and into the Mountain region: Iowa (1,082 daily cases per million population), Minnesota (1,197), Montana (1,102), Nebraska (1,185), North Dakota (1,804), South Dakota (1,607), Wisconsin (1,186), and Wyoming (1,286). To put these states in context, all 8 are reporting higher per capita daily incidence than any country or territory on Earth. Notably, North Dakota’s daily incidence is 87% higher than the global leader, Montenegro (964).

In terms of COVID-19 mortality—which is trending upward as well, lagging several weeks behind the surge in incidence—a number of US states are reporting extremely concerning numbers. In total, 15 states are reporting more than 6 daily deaths per million population*. Both North and South Dakota—18 and 17 daily deaths per million population, respectively—are reporting daily per capita mortality on par with the global leaders. Bosnia and Herzegovina, #1 in the world, is reporting 18.0 daily deaths per million, and #2 Czech Republic is currently reporting 16.47. The remaining 13 states would fall somewhere in the top 25 globally. Additionally, North Dakota has reported 12% of its cumulative COVID-19 deaths over just the past 7 days, and South Dakota has reported 17% of its deaths over the same period.
*Reported by the US CDC as deaths per 100,000 population.

The COVID Exit Strategy also created a new category to account for the elevated test positivity in some of these states. The new category (also light purple) represents states with test positivity greater than 50%, more than 10 times the WHO’s 5% benchmark. Iowa (51.0%), South Dakota (56.3%), and Wyoming (74.3%) all fall into this category. Additionally, Idaho (40.1%) and Kansas (40.9%) fall into the next highest category (purple; 30-50%). Again, to put these states in context, all 5 would fall in the top 3 globally, if they were countries. Wyoming is reporting test positivity greater than the global leader, Mexico (66.5%). Iowa and South Dakota would fall between #1 and #2, ahead of Poland (47.0%), and the remaining states are reporting test positivity greater than #3 Bulgaria (38.2%)*.
*Oman is listed as #3 globally (38.9%), but the most recent data available are from July 30.

The Johns Hopkins CSSE dashboard reported 11.38 million US cases and 248,995 deaths as of 11:30am EST on November 18.

PFIZER VACCINE Pfizer Pharmaceuticals issued a new press release regarding the “final efficacy analysis” in the Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine, developed in partnership with BioNTech. Pfizer reported that the vaccine is even more efficacious than previously estimated, at 95% overall and 94% among individuals over the age of 65. Of the 170 total COVID-19 cases detected among the participants, 162 were in the placebo group. The press release also indicates that Pfizer and BioNTech intend to submit an Emergency Use Authorization application to the US FDA in the coming days and that they intend to submit safety and efficacy data for peer review “once analysis of the data is completed.” The trials will continue to monitor participants over 2 years for adverse events and to analyze longer-term immunity. The press release notes that Pfizer aims to produce 50 million doses of the vaccine by the end of 2020 (enough for a 2-dose regimen for 25 million people) and as many as 1.3 billion total doses by the end of next year.

US THANKSGIVING Ahead of the US Thanksgiving holiday, schools and students are preparing for travel and instruction plans. Some universities, such as the University of South Carolina, Emory University, and Syracuse University are planning to end in-person instruction prior to the break so that students do not have to return to campus between Thanksgiving and the traditional end of the term, which typically falls later in December. In a different approach, Boston University is asking students to refrain from traveling and remain on campus during the Thanksgiving holiday break. The State University of New York (SUNY) announced a new policy as part of its testing program that requires all on-campus students to have a negative SARS-CoV-2 test within 10 days of leaving campus, which will require the 64 SUNY colleges and universities to test approximately 140,000 students.

Canada celebrates Thanksgiving the second Monday in October. A surge in COVID-19 incidence following Canadian Thanksgiving is a cautionary reminder for the coming US Thanksgiving and other winter holidays. Canadians were advised to limit celebrations to household contacts only or host remote/virtual events, but the extent to which Canadians adhered to that guidance is not fully known. A month after the holiday, COVID-19 incidence continues to rise in Canada, but the largest increase was observed 2 weeks following the holiday, which is consistent with the epidemiology.

US Thanksgiving and other winter holidays typically involve travel across the country as individuals and families gather with family and friends. Historically, the Wednesday before and Sunday after Thanksgiving are among the busiest travel days of the year in the US. With COVID-19’s severe impact on travel, and associated travel restrictions in many US states, air travel in the US has been “subdued” throughout 2020; however, airlines and airports are expecting to see higher travel volumes over the upcoming Thanksgiving weekend. Notably, airlines have added hundreds of flights to account for the increased volume, and airports are adding surge staffing for airport security to mitigate lines. The US CDC published guidance regarding Thanksgiving and other holiday activities, including hosting and attending gatherings and holiday travel. The principal travel guidance includes mask use, maintaining appropriate physical distancing (ie, 6-foot separation), and enhanced hand hygiene.

US STATE RESPONSES In recent days, a number of states have implemented new restrictions in an effort to slow transmission as the US enters the holiday season. California Governor Gavin Newsom announced that the state is “pulling the emergency brake” on reopening plans and reinstating a number of restrictions in severely affected parts of the state. In the most recent update, 40 counties moved to higher risk levels, including 28 that moved to the state’s highest tier (more than 7 new cases per day per 100,000 population or test positivity greater than 8%), which reportedly covers 94% of the state’s population. The highest tier requires that many non-essential businesses close, including bars and nightclubs, concert venues and convention centers, and theaters and cinemas. Businesses and facilities that are permitted to remain open must implement specific COVID-19 risk mitigation measures.

In Michigan, Governor Gretchen Whitmer announced similar changes, such as suspending in-person dining at restaurants, limiting gatherings to 2 households only, shifting to remote learning for schools, and cancelling non-professional sporting events. Michigan is emphasizing “social pods” as a way to mitigate transmission risk over the holidays, and the new measures are scheduled to last for 3 weeks.

Ohio Governor Mike DeWine instituted a 3-week statewide curfew from 10pm to 6am with the aim of reducing risky interactions. The curfew includes exemptions for individuals transiting to or from work, food delivery or pickup, and other essential services.

New Mexico Governor Michelle Lujan Grisham took these efforts one step further and “reset” the state’s COVID-19 measures, essentially reinstituting the same restrictions as earlier in the epidemic. The state will “clos[e] in-person services for all non-essential activities” through the end of November, and essential businesses will be limited to 25% capacity. Additionally, residents “are instructed to stay at home” except for essential services, such as grocery shopping and health care. New Mexico will evaluate the restrictions on a county-by-county basis starting in December.

Even states that previously resisted large-scale COVID-19 restrictions are implementing statewide policies. In Iowa, Governor Kim Reynolds announced a statewide mask mandate, Iowa’s first to date. Notably, the mandate applies only indoors when individuals are within 6 feet of each other for at least 15 minutes, and it includes a number of notable exceptions, such as school classrooms and workspaces where 6-foot distancing can be maintained, presentations and musical or theatrical performances, and religious gatherings. North Dakota Governor Doug Burgum announced his state’s first mask mandate as well as several other measures. North Dakota’s mask mandate also includes an exception for religious services, but it applies indoors as well as outdoor public spaces where physical distancing cannot be maintained.

TEXAS Texas is nearing its record high in terms of daily incidence, and daily COVID-19 mortality has been increasing steadily since early October. In the city of El Paso, one of Texas’ major COVID-19 hotspots, COVID-19 deaths are overwhelming the county medical examiner’s office. Over the past week, several inmates incarcerated at a local detention facility have been supporting the medical examiner’s office, which has been forced to use refrigerated “mobile morgues” to hold the bodies of COVID-19 victims because there is not enough room at existing facilities. El Paso County currently has at least 8 mobile units and has requested more to handle the volume of COVID-19 deaths. Media reports have not specified how the inmates are assisting the medical examiner, but photos show them transporting bodies to and from the mobile morgue units. The inmates are reportedly working 8-hour shifts for $2 per hour and are being quarantined from the rest of the incarcerated population. Reportedly, El Paso has requested resources from the Texas National Guard to provide support as well.

The North Texas Food Bank (NTFB) has experienced growing demand for food assistance since the onset of the US COVID-19 epidemic, illustrating the downstream economic impact of the pandemic. Last weekend, NTFB distributed approximately 7,000 turkeys and 600,000 pounds of food in Fair Park, a suburb of Dallas, which is enough to feed approximately 25,000 people in need. This is the fifth distribution in the Fair Park neighborhood since the onset of the pandemic, and it was the largest event in NTFB’s history. Images from the event show lines of cars stretching for what appears to be miles. A NTFB spokesperson said that 40% of those who received food were doing so for the first time, further illustrating the economic impact of COVID-19, including on individuals and families who are normally financially stable. The NTFB has also been a part of other COVID-19 initiatives, including a mobile food pantry and a “Food 4 Kids” program, in partnership with the Red Cross, the Salvation Army, Volunteer Now, and the Texas National Guard. 

CHEROKEE NATION A report by STAT News describes how Cherokee Nation, one of 3 federally recognized Cherokee tribes, took an aggressive posture early in the US epidemic by implementing control measures, including mandatory mask use, and expanded testing. In contrast, the state of Oklahoma, where Cherokee Nation land is located, still has not implemented a mask mandate, despite reporting record incidence and mortality in recent days. Tribal leadership also prioritized acquiring PPE, even to the point of being able to donate excess supply to other Cherokee tribes and local non-Native health departments and health systems. Cherokee Nation is using federal COVID-19 funding (under the CARES Act) to develop its own PPE production capacity, including N95 respirators, to ensure that it is not reliant on external distributors during future emergencies.

Even before the onset of COVID-19, Cherokee Nation prioritized establishing and maintaining healthcare capacity, and tribal public health officials emphasized that tribal leadership, including Principal Chief Chuck Hoskin Jr., have followed evidence-backed recommendations from the beginning in order to implement effective prevention and response measures. As we have covered previously, tribal nations across the US are among the many racial and ethnic minorities facing disproportionate effects of the COVID-19 epidemic, but the Cherokee Nation has undertaken many important steps to slow transmission.

HOME TEST KIT EUA The US FDA granted Emergency Use Authorization to the first fully at-home SARS-CoV-2 diagnostic test kit. The Lucira COVID-19 All-In-One Test Kit must be prescribed by a healthcare provider, but it can be performed by individuals at home. The manufacturer recommends that children under 14 years old should have the test performed by a healthcare provider in order to maximize the chances of obtaining a valid result. The kit comes with a nasal swab, a test tube with detection reagents, and a small test machine. Once the used nasal swab is swirled around the test tube for the requisite amount of time, the user inserts the tube into the machine, which will automatically process the sample and provide visual indication of the results. The test kit will light up as positive, negative, or inconclusive results in around 30 minutes. 

MILITARY OUTBREAKS Two studies recently published in The New England Journal of Medicine evaluated case studies of US Marine Corps recruits and active duty US Navy personnel, respectively. The first study describes the public health program implemented by the US Marine Corps to enhance COVID-19 security among new recruits. Recruits first underwent a 14-day home quarantine, followed by a second 14-day quarantine on a nearby college campus after reporting for duty, where additional measures were strictly enforced. Among new recruits, 2% were diagnosed with COVID-19 during the on-site quarantine. These positive cases led to small case clusters but were generally contained to individuals platoons rather than spread widely among recruits.

The second study describes an outbreak on the aircraft carrier USS Theodore Roosevelt. The outbreak onboard the USS Roosevelt resulted in 1,271 infections out of a crew of 4,779 and forced the ship to remain in port in Guam for more than 2 months. Personnel working in confined spaces, such as the engine room, were at higher risk of contracting the virus than personnel who predominantly worked outdoors, such as the flight deck. Researchers also reported a number of comorbid conditions among hospitalized patients, including “asthma, lung disease…, hypertension, and liver disease-related conditions.” Following this outbreak, the US Navy implemented new COVID-19 protocols to mitigate the risk of future outbreaks onboard ships. Prior to getting underway, Sailors will be placed in “restriction of movement” (i.e., quarantine) for 14 days and then undergo PCR-based diagnostic testing. Additionally, the Navy is limiting activities during port visits to reduce the risk of introducing SARS-CoV-2 to ships while on deployment.