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 50.27 million cases and 1.25 million deaths as of 8:45am EST on November 9. The WHO surpassed 50 million cumulative cases today, and the following timeline will provide some context for the trajectory of the COVID-19 pandemic:
1 case to 1 million cases- 90 days
1 million to 5 million- 48 days
5 million to 10 million- 38 days
10 million to 20 million- 44 days
20 million to 30 million- 37 days
30 million to 40 million- 31 days
40 million to 50 million- 21 days

The pandemic continues to accelerate globally, now increasing by 10 million cases every 3 weeks. The WHO has already reported more than 677,000 new cases today, which would easily be a new record high for single-day incidence. The WHO reported a new record high for weekly incidence, with more than 3.5 million new cases (a 4% increase over the previous week), as well as a new record high for COVID-19 mortality, with 52,718 deaths (a 16% increase over the previous week). This exceeds the first peak mortality in mid-April, and COVID-19 mortality has accelerated steadily for 3 consecutive weeks.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. USA: 109,184 new cases per day (+27,585)
2. France: 53,344 (+14,000; ↑ 1)
3. India: 46,335 (+712; ↓ 1)
4. Italy: 32,253 (+6,031)
5. Poland: 23,789 (+5,758; ↑ 3) 
6. United Kingdom: 22,443 (-574; ↓ 1) 
7. Spain: 20,451* (+111)
8. Russia: 19,650 (+2,093; ↑ 1)
9. Germany: 18,120 (+2,811; ↑ 1)
10. Czech Republic: 10,455 (-1,480; new)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Andorra: 1,032 daily cases per million population (-423)
2. Czech Republic: 976 (-138; ↑ 1)
3. Switzerland: 948 (+116; ↑ 3)
4. Montenegro: 931 (+494; new)
5. Liechtenstein**: 888 (+191; ↑ 4)
6. Luxembourg: 844 (-201; ↓ 2)
7. France: 817 (+214; ↑ 3)
8. Belgium: 704* (-521; ↓ 6)
9. Armenia: 676 (-30; ↓ 1)
10. Austria: 657 (+203; new)

*Spain’s and Belgium’s average daily incidence are 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.

Brazil fell out of the top 10 in terms of total daily incidence. The US is the first country to average more than 100,000 new cases per day, and its daily incidence increased by 33% compared to the previous week. After an increase of more than 35% over the previous week, France surpassed India as #2 globally in terms of total daily incidence. The entire top 10 in terms of per capita daily incidence is in Europe. Austria and Montenegro entered the top 10, and Slovenia fell out of the top 10***. Montenegro’s daily incidence more than doubled compared to the previous week, and it jumped all the way to #3 globally on a per capita basis.
***We previously included French Polynesia among the top 10 in terms of per capita daily incidence, but it is not a country under the WHO or UN.

The US CDC reported 9.81 million total cases and 236,547 deaths. The US reported a new record high daily incidence over the weekend, with 132,830 new cases reported on Saturday (corresponding to data through Friday), which is more than 75% higher than any single day during the previous 2 peaks. Additionally, the average daily incidence is nearly 100,000 new cases per day, almost triple the low reported in mid-September, and we expect the US to surpass 10 million cases in the next 2-3. Daily mortality also continues to increase, now up to 968 deaths per day. If it continues on this trajectory, the US could once again exceed 1,000 daily deaths in the next several days.

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 Johns Hopkins CSSE dashboard reported 10.02 million US cases and 237,742 deaths as of 1:30pm EST on November 9.

US ELECTION The result of the 2020 US presidential election was announced this weekend. After several days of continual updates from “battleground” states as they counted ballots, it became apparent that the former Vice President Joe Biden and Senator Kamala Harris defeated President Donald Trump and Vice President Mike Pence. The outcome will not become official until states certify their results and the Electoral College votes on December 14—and President Trump’s campaign and other Republican officials have already filed a number of lawsuits contesting the election outcome in closely contested states—but President-Elect Biden is already working on the transition, including his COVID-19 response plan. Most notably, President-Elect Biden announced the members of his COVID-19 taskforce, a team of 13 former government officials and other experts representing various aspects of medicine and public health. The taskforce will be led by Dr. Marcella Nunez-Smith, Yale physician and researcher; Dr. Vivek Murthy, former US Surgeon General; and Dr. David Kessler, former FDA Commissioner, and these experts will help President-Elect Biden’s transition team prepare to take immediate action after taking office in January 2021. In addition to the COVID-19 response, many experts are anticipating that President-Elect Biden will quickly make a number of changes to existing US policies enacted by President Trump’s administration once he assumes the office of President, including a reversal of President Trump’s decision to withdraw from the WHO.

One of the most pressing questions in terms of the election outcome is how President Trump, the US Congress, and other aspects of the US COVID-19 response will function during the “lame duck” period between now and Inauguration Day in January. In particular, the Congress and the White House had been negotiating a COVID-19 economic stimulus package in the weeks leading up to the election, but they were not able to finalize a deal. Some experts have highlighted the critical need for such a package—to support individuals and families, small businesses, schools, healthcare and public health systems, and state and local governments—but there does not appear to be much optimism that the federal government will be able to agree to a funding package before 2021. Senate Majority Leader Mitch McConnell has stated that a COVID-19 stimulus package is among his top priorities; however, he also stated that recent economic data indicate that a smaller package is warranted, likely in conflict plans supported by Democrats.

Beyond the presidential election results, several other interesting COVID-19-related stories emerged from the US election. Analysis conducted by NPR found that support for President Trump increased in counties that were more severely affected by COVID-19, compared to the 2016 election. In particular, the voting margin in favor of President Trump in 2020 increased for counties with higher per capita COVID-19 mortality. Notably, among counties in the top 25% of per capita mortality, two-thirds reported increased support for President Trump in the 2020 election. The drivers of individuals’ voting decisions are extremely complex.

In North Dakota, a Republican candidate that died from COVID-19 during the campaign was elected to the state’s House of Representatives. David Andahl reportedly had underlying health conditions, and he died of the disease on October 5. The election results have not yet been certified, but there appears to be conflict between North Dakota’s Governor and Attorney General regarding how to fill the vacant seat.

President Donald Trump’s Chief of Staff, Mark Meadows, reportedly tested positive for SARS-CoV-2. A report by the Associated Press indicates that Mr. Meadows attended an election night gathering at the White House in the days before his positive test, although the exact timing of the test is unclear. Like a number of previous examples at the White House, the attendees reportedly did not wear face masks or practice recommended physical distancing at the event. Mr. Meadows is one of at least 5 White House staff members to test positive over the past week or so, approximately 1 month after a previous outbreak at the White House.

US TESTING KITS The US CDC conducted an internal investigation of reliability issues with early SARS-CoV-2 diagnostic tests in the US, in particular that the test kits developed by the CDC’s Respiratory Viruses Diagnostic Laboratory. According to a report by NPR, the investigation determined that the final quality control test for the CDC-developed test kits suggested that the test would fail 33% of the time, but “laboratory officials” decided to release them anyway. Additionally, the CDC investigation identified “a lack of appropriate recognized laboratory quality standards, and organizational problems” at the laboratory. According to the NPR report, the director of the Respiratory Viruses Diagnostic Laboratory is no longer working in that laboratory, and “the CDC has effectively removed all the leadership from the division of viral diseases that oversaw the lab.” The lack of adequate testing capability and capacity early in the US epidemic was a major challenge in terms of identifying the scope of transmission early in the epidemic, and the delays associated with the CDC diagnostic test kit was a major contributor to national testing shortages early in the epidemic.

PFIZER VACCINE Pfizer Pharmaceuticals and BioNTech announced interim efficacy results from the Phase 3 clinical trial of their candidate SARS-CoV-2 vaccine. According to press releases issued by both companies, preliminary analysis of trial data shows that the vaccine could be 90% efficacious. The study has enrolled 43,538 participants, including 38,955 who have received both doses of the vaccine (as of November 8). The preliminary analysis was conducted by an external and independent Data Monitoring Committee. At the time of the analysis, 94 COVID-19 cases had been reported among participants. The available data indicate that the vaccine demonstrates at least a 90% efficacy 7 days after the second dose—corresponding to 28 days after the first dose. No serious adverse events have been reported so far among trial participants.

While these preliminary results are encouraging, additional data is still needed to better characterize both the vaccine’s efficacy and safety before Pfizer can apply for an Emergency Use Authorization (EUA) from the US FDA. A senior official for Pfizer indicated that the trial could potentially complete the efficacy portion (ie, based on detecting 164 total cases) by December, but negotiations are ongoing with the FDA regarding the required duration of safety monitoring. Additionally, the preliminary results were only reported via a press release, and the full datasets have not been published publicly and have not been subjected to peer review. Pfizer also aims to determine the vaccine’s efficacy in preventing severe COVID-19 disease and as post-exposure prophylaxis (PEP). Pfizer has reported that 50 millions doses of the vaccine could be available by the end of the year and 1.3 billion doses in 2021.

WORLD HEALTH ASSEMBLY Starting today and lasting until November 14, WHO Member States are gathering virtually for the 73rd World Health Assembly (WHA). This will be the second virtual WHA meeting to take place, after the scaled-back meeting held May 18-19. Key topics for the current meeting include the Pandemic Influenza Preparedness (PIP) Framework, the Global Vaccine Action Plan for meningitis, draft Immunization Agenda for 2030, polio eradication, and reflections on the efforts of the WHO Health Emergencies Programme, likely including the COVID-19 response. A statement issued last week by the WHO also noted that the week-long session will discuss a 10-year plan for addressing neglected tropical diseases and the WHO Global Code of Practice for Recruitment of Health Personnel, which was first adopted in 2010. After the conclusion of the virtual WHA, the Executive Board will resume its 147th session.

Convening the 73rd WHA has not been without controversy, however. Taiwanese officials, with support from the US and officials from 25 European countries, have expressed “strong regret and dissatisfaction” that Taiwan has not been invited to participate in the meeting. Taiwan is not officially recognized as a country by the WHO, and while Taiwan has participated in previous WHA meetings, “China has objected to Taiwan's inclusion in the WHA since Taiwanese President Tsai Ing-wen was elected.” In response to calls for Taiwan’s inclusion, the Chinese government reportedly stated that Taiwan can only participate in the WHA if it acknowledges that it is part of China, the principal source of conflict between China and Taiwan. Notably, Taiwan has demonstrated tremendous success in terms of containing COVID-19. Taiwan continues to detect and report imported cases, but it has not reported a domestic COVID-19 case in more than 200 days. The Taiwanese government and Taiwan CDC likely have many lessons to share with other countries, based on their experience and success in containing their epidemic, but it remains uncertain whether they will be able to do so in a high-profile forum like the WHA.

MARDI GRAS The Mardi Gras Carnival festival in New Orleans, Louisiana (US)—much like Carnival/Carnivale festivals in many other countries—is not traditionally known for being conducive to social or physical distancing. The large crowds and dozens of parades, concerts, and other celebrations spread across more than a month that are typically associated with the festival, held annually in January and February, are necessitating major changes for 2021 in order to mitigate COVID-19 risks. In anticipation of continued COVID-19 activity during the 2021 Mardi Gras festivities, the city of New Orleans is working with festival organizers to develop appropriate restrictions and protective measures to enable Mardi Gras to take place in 2021, even if not in the traditional form. New Orleans Mayor LaToya Cantrell directed the city’s Mardi Gras Advisory Committee to submit recommendations for COVID-19 policies and procedures by December 5, approximately a month before the start of Carnival season. Prospective measures include mask use, symptom screening, and live television broadcasts of parades. Additionally, committee members are considering policies to limit alcohol consumption and discourage parade floats from throwing “high value” items to spectators in order to reduce crowding.