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 48.53 million cases and 1.23 million deaths as of 10:00am EST on November 4. The WHO reported 529,256 new cases yesterday, the third highest daily total to date. The data posted on Saturdays is typically the highest daily total of the week, so we expect this to continue increasing today and tomorrow. Yesterday’s daily incidence was 4% greater than the same day from the previous week, so it is possible that we could see a new global record in the coming days. On the current trajectory, the global total could surpass 50 million cases by the end of the weekend.

As COVID-19 incidence continues to surge across Europe, COVID-19 mortality is increasing as well. In fact, on a per capita basis, Europe accounts for 18* of the top 20 countries globally in terms of daily mortality. Of these countries, 13 reported record high daily mortality in the past week, and most are increasing exponentially. In terms of total daily mortality, 13 of the top 20 countries are in Europe as well. The US (861 deaths per day) and India (541) continue to lead the world in daily mortality, but France (413) is #3. Notably, 5 European countries are reporting more daily COVID-19 deaths than the whole of Africa (256). COVID-19 mortality has more than doubled over the past 2 weeks in nearly every European country, and as a whole, the European continent’s COVID-19 mortality increased 120% over that time. Outside of Europe (including the WHO European Region), the only countries in this category are Cote d’Ivoire, Mali, Sri Lanka, and Tunisia, and all but Tunisia (46.3) are currently averaging fewer than 1.5 deaths per day.
*We omitted Liechtenstein from this list due to having a population of less than 100,000. Liechtenstein would technically be in the top 20—giving Europe 19 of the top 20—but its per capita mortality can fluctuate considerably for even individual deaths. Liechtenstein has reported a cumulative mortality of only 3 deaths (including 1 in the past week), and it is currently averaging fewer than 0.5 deaths per day.

The US CDC reported 9.46 million total cases and 233,129 deaths. The US reported 106,537 new cases yesterday, the first country to surpass 100,000 cases in a single day. The daily COVID-19 incidence continues to increase and set new records, now up to an average of 89,912 new cases per day. The reported incidence is expected to increase even further in the updates posted today. Additionally, the US reported more than 1,000 deaths for the second consecutive day and the fifth time in the last 8 days. The US COVID-19 mortality has climbed steadily since October 18, up from approximately 700 deaths per day to 869. This represents an increase of nearly 25% and the highest average since September 2.

More than half of all US states have reported more than 100,000 cumulative cases, including 14 with more than 200,000 cases:
>900,000: California, Texas
>800,000: Florida
>500,000: New York
>400,000: Illinois
>300,000: Georgia

Alabama’s COVID-19 dashboard is reporting more than 200,000 cases, so we expect that to be reflected in the CDC report in the coming days. We expect Indiana and Missouri to surpass 200,000 cases in the near future as well. With the addition of these 3 states, more than a third of all US states will have exceeded 200,000 cumulative cases.

The Johns Hopkins CSSE dashboard reported 9.64 million US cases and 235,199 deaths as of 12:30pm EST on November 6.

MILLIONS OF MINK Danish Prime Minister Mette Frederiksen announced this week that Denmark will cull all mink at farms across the country, including those used for breeding, in order to mitigate the risk of zoonotic transmission of SARS-CoV-2. Mink have been identified as animals capable of transmitting SARS-CoV-2 to humans, and there have been multiple examples of outbreaks among mink populations in Denmark and elsewhere. Mink are bred in Denmark and other countries for their pelts.

Researchers at Denmark’s Statens Serum Institut identified a mutation of the SARS-CoV-2 virus that is spreading through mink populations and is capable of infecting humans. Reportedly, hundreds of human cases in northern Denmark have been linked to mink, but information published by the Danish government indicates that there is no evidence that this particular variant of the virus is more dangerous to humans. As of November 5, Denmark’s most recent update to OIE, more than 200 farms nationwide have reported SARS-CoV-2 infections in mink. The culling effort in Denmark began in October, with an order to cull animals within 7.8km of an infected farm, which resulted in culling at least 1.4 million mink. The new nationwide policy could impact 12 million remaining animals.

In a similar effort, the Netherlands announced in August that it ordered the closure of more than 100 mink farms nationwide, following reports of outbreaks at “dozens of locations.” The Netherlands reportedly intended to end the practice of mink breeding by 2024, but it is accelerating that timeline due to SARS-CoV-2. Additionally, more than 3,000 mink at a farm in Wisconsin (US) reportedly died from COVID-19 over the past month. Officials from Wisconsin’s Department of Agriculture, Trade, and Consumer Protection reported that there is “little evidence that infected mink have transmitted the coronavirus to humans” stemming from the Wisconsin outbreak.

PHEIC Last week, the WHO Emergency Committee on COVID-19 convened to review the current pandemic and reiterated unanimously that the pandemic remains a Public Health Emergency of International Concern. While the continued declaration of a PHEIC is no surprise given the ongoing severity of the pandemic, the committee also issued several recommendations to both the WHO and national governments regarding leadership, response, surveillance, research efforts, risk communication, and other activities. Key recommendations to the WHO included providing a mechanism to enable countries to report on national progress in implementing recommended activities and policies; accelerating support to countries in preparing to distribute and administer a future SARS-CoV-2 vaccine, including a focus on cold chain logistics and monitoring capacity; and continuing to update and review guidance on international travel consistent with the International Health Regulations. Recommendations to countries included urging national leaders to “avoid politicization or complacency” in shaping response strategies that could possibly negatively impact public health and ensuring that decision-making is grounded in scientific evidence. Furthermore, the committee recommended that each country establish a national multidisciplinary task force to develop and report on readiness for future mass vaccination operations. 

EUROPE HEALTH SYSTEMS Under substantial strain due to ongoing COVID-19 resurgence, the health systems in numerous high-resourced European countries—including Germany, Belgium, and France—are nearing their maximum capacity. Some Belgian doctors who have tested positive for SARS-CoV-2 but who remain asymptomatic and have a low viral load have reportedly been directed to continue treating COVID-19 patients in order to maintain sufficient clinical capacity. Some hospitals in Belgium are reportedly trying to reduce the COVID-19 burden by transferring patients to neighboring Germany, but this may not be a viable option in the longer term.

As the COVID-19 resurgence in Europe began over the summer months, many cases were reported among younger individuals, who are at lower risk for severe disease; however, as the resurgence continued, the epidemic once again spread to older and more vulnerable individuals, contributing to the current pressure on hospitals and health systems. While medical mask shortages are less of a concern compared to the first European wave and the doubling time for hospital admissions is still slower than in April, the workforce shortages have not been resolved, despite months of time to prepare.

AUSTRIA Like the rest of Europe, Austria is facing a substantial resurgence of COVID-19, which is threatening to exceed hospital and health system capacity nationwide. In an effort to mitigate community transmission, Austrian Chancellor Sebastian Kurz announced that the country will enter a second “lockdown” period, which involves a national curfew, mask mandate in public spaces, reduced capacity at retail stores and hotels, and restrictions on most in-person dining at restaurants. Additionally, “upper grades” of secondary school—which we understand to mean high school/senior high school (grades 9-12)—as well as colleges and universities will transition to remote learning, but kindergarten, primary school (ie, grades 1-4), and “lower grades” of secondary school (ie, middle/junior high school; grades 5-8) will continue in-person classes. Most gatherings and events are prohibited, with limited exceptions, such as funerals (limited to 50 people) and public demonstrations (with mandatory physical distancing and mask use). The new restrictions took effect earlier this week, and they are currently scheduled to last through the end of November. Austria reported record high daily incidence (6,694 new cases), hospitalizations, intensive care unit patients, and deaths within the past several days, and all metrics appear to be increasing exponentially.

GREECE Greece’s COVID-19 Committee of Experts issued recommendations earlier this week to implement a month-long nationwide “lockdown” to slow SARS-CoV-2 transmission. Greek Minister of Health Vasilis Kikilia also called for recruiting additional doctors to support the increasing number of hospitalized COVID-19 patients, particularly in ICUs. The northern regions of Greece are severely affected, with Attica, home to the capital city of Athens, reporting 72% of all “ICU-COVID” beds occupied and the city of Thessaloniki forced to expand ICU capacity to manage the influx of severe patients. In response to the resurgence, Greek Prime Minister Kyriakos Mitsotakis announced increasingly restrictive social distancing policies in the northern regions of the country, including closing restaurants, cafes, movie theaters, museums, and gyms for a month. Additionally, a curfew that previously applied to the most severely affected regions will be expanded nationwide. While not the nationwide lockdown recommended by the Committee of Experts, these efforts certainly expand the geographic scope and intensity of COVID-19 restrictions in Greece. Greece’s daily COVID-19 incidence has increased more than five-fold since mid-October, and daily mortality has doubled over that time.

SLOVAKIA Slovakian Prime Minister Igor Matovič announced that the government tested more than 3.6 million individuals last weekend, approximately two-thirds of the country’s total population. The surge in testing is part of an effort to test the entire adult population. Country officials made the testing process voluntary, but required individuals who did not get tested to stay quarantined for a 10-day period. Violating the quarantine order would result in a fine of €1,650 (US$1,960). The bold initiative used antigen tests. These tests are easier and faster to conduct than traditional PCR-based diagnostic tests, but are somewhat less accurate. Tests were conducted at 5,000 testing sites across the country. The tests found just over 38,000 positive cases, corresponding to a test positivity of 1.06%.

Data from large-scale testing efforts can be used to inform immediate public health response activities and policies. While labor- and resource-intensive, other countries in Europe are reportedly considering similar mass testing measures in order to develop a more robust understanding of their current COVID-19 epidemiological situation. For example, the UK government is asking that every resident of Liverpool get tested, which will rely on the military to carry out the logistics. If the effort in Liverpool is successful, the UK could expand mass testing to other parts of the country. The WHO continues to recommend individual testing over mass testing, but this strategy has largely “broken down in most of Europe,” due in large part to the sheer scale of ongoing transmission.

INDONESIA ECONOMY For the first time in 22 years, Indonesia has fallen into an economic recession. Indonesia has Southeast Asia’s largest economy, but it contracted by approximately 3.5% in the third quarter this year, following a contraction by 5.3% in the second quarter. The Indonesian government reportedly forecasts that 3.5 million people could lose their jobs as a result of the pandemic. A major driver of Indonesia’s economic decline is the country’s heavy reliance on tourism, which has been among the most severely affected sectors worldwide, particularly in light of international travel restrictions.

The Indonesian government aimed to mitigate the economic contraction by reducing taxes and spending more on social support services. The government passed an economic relief package in June worth nearly US$50 billion, on top of a similar package in April worth US$45 billion. Despite the recession, some experts and senior government officials have expressed longer-term optimism, and Indonesia’s Minister of Finance indicated that further government spending is forthcoming to promote economic growth.

AFRICA’S SUCCESS As COVID-19 surges across the US and Europe, African countries have generally successfully contained their respective COVID-19 epidemics. At the onset of the pandemic in early 2020, many public health experts expressed concern that weak public health and healthcare systems in many African countries would facilitate rapid transmission across the continent and result in significant mortality. Despite these concerns, Africa appears to be in much better shape than many other parts of the world. A commentary authored by 2 researchers at Yale University (Connecticut, US) highlights a number of potential factors driving Africa’s success, including aggressive social distancing policies, public cooperation with and adherence to those policies, reliance on scientific data and expertise, effective public communication and education efforts, and regional coordination and leadership from national governments. The pandemic continues to grow globally, setting new records for daily incidence, so African countries must remain vigilant; however, their experiences can offer lessons for other countries around the world.

AUSTRALIA For the first time since June, Australia reported zero locally-acquired COVID-19 cases nationwide. The country declared a state of disaster after increasing incidence in early August. The state of Victoria, Australia’s second largest, recently ended a 111-day lockdown, which included highly restrictive social distancing policies in order to curb community transmission. Australia officially reported 10 total COVID-19 cases on October 31 (and no recent days report zero total cases), but the official data do not distinguish between community transmission and cases identified among travelers or in settings other than the general public.

CAMBODIAN PM QUARANTINED Cambodia’s Prime Minister and 4 cabinet members have been quarantined following a meeting with Hungary’s Foreign Minister. Hungarian Foreign Minister Peter Szijjarto met with Cambodian Prime Minister Hun Sen on November 3 and then flew to Thailand, where he tested positive for SARS-CoV-2 as part of entry screening. Cambodia’s Ministry of Health has already tested all 628 individuals who participated in the visit, and all have tested negative so far. This incident adds to a growing list of heads of state and other senior government officials who have been directly impacted by COVID-19, illustrating both that the disease can affect everyone as well as the ongoing impact of the pandemic on international relations.

VACCINE ALLOCATION As the world looks ahead to a future SARS-CoV-2 vaccine, the prospect that higher-income countries will monopolize early vaccine production continues to raise concerns, as lower-income countries will struggle to compete financially in order to purchase doses from the initial limited supply. A study (not peer reviewed) led by researchers at Northeastern University (Massachusetts, US) and funded by the Bill and Melinda Gates Foundation modeled the effect of vaccine allocation strategies on COVID-19 mortality. The researchers modeled 2 scenarios for the allocation of the first 2 billion doses of 2 different hypothetical SARS-CoV-2 vaccines. In one scenario, all of the initial doses are claimed by 50 high-income countries, and in the other, the initial doses are allocated proportionately to all countries based on population. The vaccines represented in the study require a single dose and have efficacies of 65% and 80%, respectively.

The researchers found that equitable distribution of the vaccines (i.e., by population) would prevent nearly twice the number of deaths globally than if higher-income countries monopolized the initial supply. In fact, the model estimated that the equitable allocation plan would prevent 61% of global COVID-19 deaths for the 80% efficacious vaccine and 57% for the 65% efficacious vaccine, compared to preventing 33% and 30% of global deaths, respectively, if the initial doses were allocated to high-income countries only. Additionally, the model illustrates that the excess mortality in lower-income countries if high-income countries monopolize the initial supply would far outweigh the modest direct benefits to the high-income countries in that scenario. For the 80% efficacious vaccine, countries in Western Europe would avert 74% of their deaths if the initial supply were allocated to high-income countries, compared to 55% under the equitable allocation scenario, and North America would avert 67% of deaths, compared to 53% for the equitable distribution. In contrast, utilizing the equitable strategy would increase the prevented deaths from 5% to 62% in Southeast Asia and from 13% to 93% in West Africa.