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

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EPI UPDATE The WHO COVID-19 Dashboard reports 46.17 million cases and 1.19 million deaths as of 08:40 am EST on October 26. The WHO reported a new record high for global weekly incidence for the sixth consecutive week. The global weekly total reached 3.33 million cases—an increase of more than 17% over the previous week, continuing a trend of rapid increase. The WHO reported 223,280 new cases on Monday.

Total Daily Incidence (change in average incidence; change in rank, if applicable)

USA: 81,599 new cases per day (+12,804)
India: 45,622 (-5,761)
France: 39,344 (+4,848)
Italy: 26,222 (+10,287; ↑3)
United Kingdom: 23,016 (+1,389) 
Brazil: 21,654 (-1,030; ↓2)
Spain: 19,935 (+2,239; ↑1)
Poland: 18,030 (+6,898; new)
Russia: 17,558 (+1,194; ↓3)
Germany: 15,309 (+5,085; new)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)

Andorra: 1,455 (+233)
Belgium: 1,271 (-25;↑ 1)
Czech Republic: 1,115 (-9;↓ 1)
Luxembourg: 1,045 (+233; ↑ 1)
Slovenia: 873 (+199; ↑ 2)
Switzerland: 832 (+355; new)
French Polynesia: 745 (-272; ↓ 3)
Armenia: 706 (+25; ↓ 2 )
Liechtenstein: 697*** (+169)
 France: 603 (+74; ↓ 2)

*Spain’s average daily incidence is not reported for today; these values correspond to the previous day’s averages.
**Belgium’s average daily incidence is not reported for today; these values correspond to the daily average two days ago.
***Liechtenstein is a member of the UN, but not the WHO. Liechtenstein’s COVID-19 data is reported by Switzerland.

This week, the US continued to remain the country with the highest cumulative incidence and is reporting the highest number of global daily cases. The US, India, and Brazil continue to lead in cumulative incidence, with few signs of leveling off. The United Kingdom is experiencing a resurgence and is among the top 10 countries with highest cumulative incidence this week, with an 18% increase in incidence compared to last week. Germany has also reported an increase of over 5,000 new cases on average per day compared to last week, currently positioned at number 10 among the top 10 countries for daily incidence. Italy’s daily incidence has also shot up 3 spots to number 4 among the top 10 countries for daily incidence, whereas incidence in Brazil and Russia have both decreased. 

Belgium now has the second highest per capita daily incidence this week, replacing the Czech Republic which is now in third place. Italy’s daily incidence grew the most this week, moving up to position 7 from position 9 last week. While still not among the top 3 countries with highest per capita incidence, Luxembourg has experienced a 29% increase compared to last week. Additionally, Switzerland has now entered the top 10 countries, with a 74% increase in per capita incidence compared to last week. 

The US CDC reported 9.1 million total cases and 229,932 deaths. The average daily COVID-19 incidence is currently at 80,932 new cases, which is a slight decrease from 83,851 new cases per day reported last week. Last week, the US set a new record peak for new daily incidence with 101,273 cases on October 31, which is about 20,000 cases higher than the record from last week. Following the expected dip in reporting over the weekend, we will continue to track whether a new record peak will be set later this week.

The US COVID-19 mortality decreased slightly from 900 to currently around 823 new deaths per day; however, data over the weekend generally provides an underestimate of actual death counts. Currently mortality at the national level appears to be stagnating at this level, but it is unclear whether this will remain a longer term trend. 

More than half of all US states have reported more than 100,000 cases, including 11 with more than 200,000 cases:
>900,000: California, Texas
>700,000: Florida
>400,000: New York, Illinois
>300,000: Georgia

The Johns Hopkins CSSE dashboard reported 9.2 million US cases and 231,011 deaths as of 11:20 AM November 2. 

HOUSEHOLD TRANSMISSION A new publication from the Morbidity and Mortality Weekly Report examines the risk of SARS-CoV-2 transmission among household members. The authors described findings from a prospective study involving 191 initially asymptomatic household contacts of 101 index patients in Tennessee and Wisconsin. Among 102 of the household contacts who tested negative upon enrollment in the study, 53% later tested positive for SARS-CoV-2. Secondary infection rate was notably lower for index patients aged 12-17 (38%) but not for index patients under the age of 12 (53%) - although only 14 of the index patients enrolled were under the age of 18. Notably, 75% of household infections were identified within the first five days of index patients becoming symptomatic. These secondary infection rates may be an underestimate as household contacts were enrolled 2-4 days after illness onset of index patients, so earlier household transmission may not have been included in the identification of secondary infection rates. Authors recommend that symptomatic individuals promptly isolate from household members as soon as possible after illness onset, even while waiting for testing results and that household members adopt mask usage and distancing when housed with a confirmed infection. 

US TESTING DATA Journalists from The New York Times have recently pointed out inconsistencies in types of testing data reported across states. 37 states combine antigen testing with diagnostic testing to report COVID-19 case statistics, six states report antigen testing separately and seven states and D.C. do not report antigen testing results. These inconsistencies can lead to undercounting of COVID-19 cases or an unclear picture of whether public health mitigation measures are sufficiently succeeding in quelling outbreaks. Notably, antigen testing is less sensitive and specific than testing via PCR, but the CDC recommends that states report COVID-19 case statistics using both PCR and antigen testing data.

Other issues with testing data interpretation can also arise due to testing refusals. The New York Times recently alleged that community members in Kiryas Joel, a village in Orange County, New York, may have actively discouraged individuals from seeking or accepting COVID-19 testing in order to artificially lower the village’s COVID-19 test positivity rate. The village reportedly reduced testing positivity from 34% to 2% in only two weeks.

RISK TO HEALTH CARE PERSONNEL Three recent publications have drawn attention to the COVID-19 risked faced by health workers and their households. One study in the Morbidity and Mortality Weekly Report (MMWR) discussed exposure factors and infections among 21,406 Minnesota health worker exposure events. 5,374 of the exposure events included close and prolonged contact with an infected case while not wearing suitable personal protective equipment (i.e. within six feet for at least 15 minutes). While two thirds of high-risk exposure events happened in the patient care setting, one third of exposures involved infected coworkers, household contacts or social contacts. The authors highlighted the need for health workers to remain vigilant regarding COVID-19 prevention measures when not in the patient care setting. Health care personnel working in long-term care or congregate living were also found to be more likely to continue working while symptomatic or after receiving positive test results than those working in acute care settings, emphasizing the need for flexible sick leave policies, access to testing and access to personal protective equipment. 

The other two publications discussed hospitalization of health workers and their households due to COVID-19. The study in BMJ identified risk factors for hospital admission across 158,445 health workers and 229,905 household members of health workers in the United Kingdom. 17.2% of COVID-19 hospital admissions in the UK among individuals aged 18-65 were hospital workers or their household members. Risk factors for hospital admission largely mirrored risk factors previously identified for the general population (e.g. age, certain underlying medical conditions) but also included in-person care of patients or being a household member of a health worker who provided in-person care of patients. Health workers in “front door” roles such as paramedics or those working in emergency rooms had a higher risk of hospital admission due to COVID-19 than other in-person patient care workers. The absolute risk of hospital admission due to COVID-19 for healthcare workers and their households was calculated to be 0.5%, similar to the general population. 

Meanwhile, an additional MMWR study discussed US hospitalization data for 6,760 adult hospitalized COVID-19 patients of whom 438 were health care personnel. Notably, 36% of hospitalized health care personnel were in an nursing-related profession, 71.9% were female, 52% were non-Hispanic Black and 89.8% had an underlying condition, largely represented by individuals reported as obese (73%). The median age of hospitalization for health care personnel (49) was notably lower than for those hospitalized among the general population (62). One in four health workers in the data set were also admitted to an intensive care unit, which is in line with the proportion admitted to intensive care units among general population COVID-19 hospitalizations for adults aged 18 to 64. 

WHO DIRECTOR-GENERAL Director-General of the World Health Organization, Tedros Adhanom Ghebreyesus, is now working from home while self-quarantining following exposure to a COVID-19 case, according to a tweet posted on Sunday. The Director-General has not reported any symptoms of COVID-19 thus far.

UNITED KINGDOM On Saturday night, Prime Minister Boris Johnson announced a swath of new restrictions aimed at reducing the spread of COVID-19 within the United Kingdom. New policies included closure of bars, in-person dining at restaurants and other non-essential businesses. Educational institutions and childcare facilities will remain open. A stay-at-home order will also be in place with individuals only allowed to leave their residences for work if remote work is not possible, education, exercise, caregiving or essential shopping. Amateur sports are recommended to cease activities. The measure to pay 80% of wages for furloughed workers has also been extended. New restrictions are slated to be in place through December 2. Parliament will be voting on the new measures this Wednesday. The United Kingdom notably has the highest official death toll for the COVID-19 pandemic in Europe. 

ELI LILLY A recent study published in the New England Journal of Medicine last week reported that convalescent plasma derived monoclonal antibody treatment (LY-CoV555), developed by Eli Lilly, showed clinical benefit in patients. The study found that patients experienced decreased viral loads and severity, and had no serious adverse effects in outpatients. The phase II trial involved outpatients that had mild to moderate COVID-19. A total of 452 patients participated, receiving either low, medium or high concentration of the antibody, or placebo. Researchers measured the change in viral load after 11 days of treatment, and the study has reported on interim findings. Patients receiving the medium dose (2800 mg) had about a 3 fold reduction in viral load. Differences among placebo and treatment groups were non-significant and smaller for both the low and the high dosage categories. However, patients receiving any antibody dose had lower symptom severity as well as lower hospitalization rates than placebo. Additionally, the percentage of adverse events was similar across treatment and placebo groups. 

The report came after an announcement from the NIH that it was going to halt a trial investigating the antibody after the trial’s Data Safety Monitoring Board reviewed the data on October 26th and recommended that no further participants enroll, as it concluded there was a “low likelihood that the intervention would be of clinical value” for hospitalized patients. Scientists currently believe that while there may be possible benefit among outpatients, as observed in the NEJM study, the longer course of infection and severity among hospitalized patients reduces likelihood of benefit for the treatment. An additional hurdle is that there are highly limited doses of antibody treatments available for both the Eli Lilly and Regeron cocktails. Eli Lilly reportedly anticipates it can ship 100,000 doses of its monoclonal antibody once allowed, and that it can produce as much as a million doses by the end of the year; however, that is at the lowest dosage concentration, which was currently not found to yield significant benefit in the NEJM study.  

BEHAVIORAL DIFFERENCES BY AGE A recent CDC study published in the MMWR assessed self-reporting of recommended behaviors to mitigate SARS-CoV-2 transmission, including mask-wearing, hand washing, social distancing, and staying home when sick. The Data Foundation COVID Impact Survey collected national data on reported mitigation behaviors from April to June among adults. The study found that mask use increased from 78% in April to 89% in June. Other crucial mitigation measures, including hand washing, social distancing, and avoiding crowded areas, stagnated or declined. The prevalence of reported behaviors was lowest among those aged 18-29 years old and highest among those over 60 years. Across all age groups, however, mask wearing increased. Handwashing decreased across all groups from April to June, with the greatest decrease occurring among those aged 30-44 years old (from about 92% to 87%) and those over 60 years old (96.5% to 93%). The proportion of respondents who cancelled social activities and avoided crowded places generally stagnated or decreased from April to June, particularly for those aged 18-29 and 30-44 years old. The study concluded that understanding the factors leading to uptake of each mitigation behavior is important, particularly among the younger age groups. While news media, particularly earlier in the year, generally emphasized and criticized the lack of social distancing among young people at parties and other social events, other factors such as job type could also play a large role in disproportionately preventing younger people from distancing. 

SYSTEMIC RACISM & COVID-19 The Johns Hopkins Center for Health Security’s journal, Health Security, issued a call for papers for an upcoming Special Feature on systemic racism in the context of the COVID-19 pandemic (scheduled for May/June 2021). Additional information is available here.