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.
Upcoming Center Event: COVID-19 and the US Criminal Justice System- Evidence for Public Health Measures to Reduce Risk
Join the Johns Hopkins Center for Health Security and the Center for Public Health and Human Rights at the Bloomberg School of Public Health as they release a new report detailing COVID-19’s impact on the United States’ criminal justice system. You are invited to join us on Thursday, October 15 (2-3 PM EDT), for the release of the report and a discussion on the findings and recommendations.

COVID-19 outbreaks are growing fast in carceral facilities (eg, jail, prisons, detention centers). As of June 6, the COVID-19 incidence rate in prisons was 5.5 times higher than that of the overall US population, and the age-adjusted mortality rate was 3 times higher. Register for the webinar.
CORRECTION: In Friday’s COVID-19 Update, we mistakenly referred to former Vice President Joe Biden as “President Biden.” This was a typographical error.

EPI UPDATE The WHO COVID-19 Dashboard reports 37.42 million cases and 1.07 million deaths as of 9:30am EDT on October 12. The WHO reported a new record high for global weekly incidence for the fourth consecutive week. The global total reached more than 2.25 million cases—an increase of nearly 10% over the previous week. Additionally, the WHO reported 378,044 new cases on Saturday, a new daily record.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. India: 70,960 new cases per day (-7,484)
2. USA: 49,243 (+5,986)
3. Brazil: 25,670 (-470)
4. France: 16,543 (+5,029; ↑ 1) 
5. United Kingdom: 14,391 (+4,676; ↑ 2)
6. Argentina: 13,674 (+1,223; ↓ 2) 
7. Russia: 11,960 (+2,879; ↑ 1)
8. Spain: 10,169* (+862; ↓ 2)
9. Colombia: 8,038 (+2,038; ↓ 1) 
10. Mexico: 7,523 (+3,045; new)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Andorra: 1,083 daily cases per million population (+577; ↑ 1)
2. Czech Republic: 462 (+224; ↑ 4)
3. Montenegro: 396 (-16) 
4. Israel: 390 (-223; ↓ 3)
5. Belgium: 332 (+103; new)
6. Netherlands: 323 (+121; ↑ 3)
7. Argentina: 303 (+27; ↓ 2)
8. France: 253 (+77; new)
9. Iceland: 253 (+129; new)
10. Bahamas: 242 (+18; new)
*Spain’s average daily incidence is not reported for today; these values correspond to the previous day’s averages.

Israel fell out of the top 10 in terms of total daily incidence, and it was replaced by Mexico. Israel’s daily incidence has decreased by nearly 50% since its peak in early October. Andorra surpassed Israel for #1 globally in terms of per capita daily incidence. Andorra is reporting more than 1,000 daily cases per million population—the first country to do so— which is more than double its daily incidence from the previous week. Andorra has a population of approximately 77,000 people, so this translates to only 80-85 total cases per day; however, the extremely high per capita rate is very concerning. A number of European countries are climbing the list in terms of per capita daily incidence. Notably, Belgium, France, and Iceland all entered the top 10, and the Netherlands and Czech Republic jumped multiple places from last week. Spain fell out of the top 10, but its incidence increased compared to the previous week. Moldova and Bahrain also fell out of the top 10.

India’s daily incidence continues the decline from its peak in mid-September, but the country surpassed 7 million cumulative cases. If India continues on this trajectory, it will likely surpass the US for #1 globally in terms of cumulative cases in the coming days or weeks. Additionally, Brazil’s epidemic continues its decline since late July, but it surpassed 5 million cumulative cases.

The US CDC reported 7.70 million total cases and 213,614 deaths. The US daily COVID-19 incidence continues to climb, now up to 47,844 new cases per day, the highest since August 18. On Saturday, October 10 (corresponding to October 9 data), the CDC reported 58,302 new cases, the highest daily total since August 7. The US COVID-19 mortality appears to have leveled off at approximately 675-700 deaths per day over the past week or so. Considering that mortality tends to lag 2-3 weeks behind changes in COVID-19 incidence, we will monitor these trends closely for early signs of increasing mortality stemming from the current resurgence.

Half of all US states have reported more than 100,000 cases, including California with more than 800,000 cases; Texas and Florida with more than 700,000; New York with more than 400,000; Georgia and Illinois with more than 300,000; and Arizona, New Jersey, North Carolina, and Tennessee with more than 200,000.

The Johns Hopkins CSSE dashboard reported 7.78 million US cases and 214,917 deaths as of 1:30pm EDT on October 12.

PEER PRESSURE The age distribution for COVID-19 cases has shifted toward younger adults over the past several months, in the US and elsewhere. Researchers from the US CDC COVID-19 Response Team, in collaboration with state health officials in Wisconsin (US), sought to better characterize potential drivers of this phenomenon by evaluating characteristics of COVID-19 patients between the ages of 18 and 23 in Winnebago County, Wisconsin. The study, published in the US CDC’s MMWR, utilized information from Wisconsin’s Electronic Disease Surveillance System and interviews with young adults, community leaders, and owners of businesses frequented by young adults. The researchers identified exposure to misinformation, conflicting or inconsistent public health messaging, and low perceived severity of disease as factors that may contribute to riskier behavior among young adults.

The researchers also identified numerous barriers to consistent and effective mask use among this age group, including the absence of a local or national mask mandate, social or peer pressure to not wear a mask, and mixed perceptions regarding the effectiveness of mask use. The researchers identified work and social gatherings as principal sites for potential exposure among this age group. Notably, the study was conducted in March-July, prior to the start of the ongoing COVID-19 surge in Wisconsin and the start of classes for the 2020-21 school year, which could affect the volume and type of communication aimed at this age group, the types of exposure they face, and their perceptions of COVID-19 risk. The researchers recommended that future public health messaging be tailored to the young adult population, with a focus on empathy, personal and community responsibility, and peer or social pressure to not wear masks.

US PRESIDENT US President Donald Trump’s physician, Dr. Sean Conley, issued a statement on Saturday that indicates that President Trump is no longer considered to be infectious. Dr. Conley stated that President Trump is now more than 10 days since the onset of his symptoms and that he has been fever-free for at least 24 hours, which meets the standards outlined by the US CDC for ending the isolation period. Additionally, the statement reports that “advanced diagnostic tests” detected no “evidence of actively replicating virus.” Notably, traditional PRC-based diagnostic tests can detect viral RNA, including fragments of destroyed virus, in a recovered COVID-19 patient, even if s/he is not infectious. This is why the US CDC isolation guidance is based on the time since symptom onset rather than on obtaining negative diagnostic tests. The evidence that the virus is no longer replicating provides evidence that President Trump is recovering and is no longer a transmission risk. Having completed the isolation period, President Trump aims to resume his campaign schedule, including in-person rallies. And while the second presidential debate, originally scheduled for October 15, was cancelled, the final presidential debate currently remains on the schedule for October 22.

UNITED KINGDOM In response to an ongoing resurgence of COVID-19, the UK government unveiled a 3-tier “lockdown” system to help contain the epidemic in severely affected areas. UK Prime Minister Boris Johnson addressed Parliament earlier today to discuss the new system. The decision to implement a new set of social distancing measures comes at a time when UK health officials are facing a “tipping point” in the UK’s epidemic and as the country looks ahead to influenza season. According to media reports, the system will include Medium, High, and Very High risk categories, each with its own set of corresponding restrictions. In areas at very high risk—which will reportedly include Liverpool—any mixing between households or “bubbles” will be prohibited, and all pubs and bars will be closed. The government will also issue travel advisories for these areas in an effort to reduce travel into or out of severely affected areas. In high-risk areas, household mixing will be permitted outdoors but not indoors. Medium-risk areas will currently cover most of the UK, and the current restrictions will remain in place. Schools will reportedly remain open for all 3 tiers. Parliament is expected to vote on the new measures tomorrow, and they could be implemented starting Wednesday. Details are still emerging about the new system, and we will provide updates in Friday’s briefing.

Several industry groups representing UK hospitality businesses, including pubs and bars, are reportedly planning to challenge the new restrictions in court. The groups argue that the ongoing resurgence is largely driven by household outbreaks rather than transmission at hospitality-related businesses. Notably, previous research has identified the significant role of household transmission during the pandemic; however, the index patients for household outbreaks would likely need to be exposed in the community in order to bring the disease home. The UK government has reportedly committed to subsidizing wages for affected individuals; however, the financial support may not be enough for individuals or businesses.

OBESITY The US CDC updated its guidance regarding individuals at elevated risk of severe COVID-19 disease and death due to underlying medical conditions, including more detailed information regarding the risk associated with obesity. The previous iteration of the guidance noted that individuals with a body mass index (BMI) of 30 or higher were at elevated risk of severe COVID-19 disease. The most recent update includes multiple categories: obesity (BMI of greater than 30 but less than 40) and severe obesity (BMI of 40 or greater). Additionally, the guidance notes that individuals “having overweight” (BMI of greater than 25 but less than 30) may also be at elevated risk of severe disease. The expanded risk group could potentially mean that 72% of all Americans are at elevated risk of severe disease based solely on their weight. Notably, BMI does not accurately characterize body fat percentage or overweight/obesity in all individuals, but it provides a simplified metric to help categorize risk associated with these conditions.

Multiple recent studies provide data that help to better characterize COVID-19 risk stemming from overweight and obesity. A study published in the International Journal of Obesity found that individuals with overweight and obesity were at elevated risk of death and intubation (eg, for mechanical ventilation) compared to those with normal weight, even after adjusting for age, gender, and commonly associated conditions such as diabetes, asthma, and hypertension. Another study, published in Brain, Behavior and Immunity evaluated COVID-19 risk associated with various lifestyle factors, including “smoking, physical inactivity, obesity, and excessive alcohol intake” based on data from more than 380,000 individuals in the UK. The researchers found strong associations between COVID-19 hospitalization and smoking, physical inactivity, and obesity, but not excessive alcohol intake. Utilizing a combined “lifestyle score”—on a scale from 0 to 8, with 0 being optimal—that includes a variety of these factors, individuals with “less favourable” scores (5 or greater) were more than 4 times likely to be hospitalized compared to individuals with “optimal” scores.  

REMDESIVIR Researchers conducting the ACTT-1 clinical trial for remdesivir published the final report on their findings in The New England Journal of Medicine (NEJM). Preliminary findings from the study were announced in April, via a press release issued by Gilead Pharmaceuticals, the drug’s manufacturer, and a statement by the US National Institute for Allergy and Infectious Diseases. Preliminary analysis was also published in NEJM in September—the URL is the same for both articles, so you need to use an archived version to compare them. The preliminary analysis indicated that remdesivir decreased the time to recovery for COVID-19 patients who were hospitalized.

The final report arrives at a similar conclusion and provides additional data on the study population and outcomes. Based on data from 1,062 patients—541 who received remdesivir treatment and 521 placebo-controlled controls—treatment with the drug resulted in a statistically significant decrease in recovery time. The median recovery time for patients treated with remdesivir was 10 days, compared to 15 days for the control group—a decrease of 33%—and the treatment group was more likely to show clinical improvement by Day 15. Patients in the treatment group also exhibited improved mortality at Day 15 and Day 29; however, these results were not statistically significant. Additionally, the data suggest that the drug also helped mitigate the risk of progressing to more severe disease, based on a reduction in “serious adverse events” and lower incidence of “new oxygen use” in the treatment group, compared to the placebo group.

YOUNG CHILDREN Researchers from the Medical University of Warsaw (Poland) published findings from their analysis of an outbreak at a nursery. The study, published in the US CDC journal Emerging Infectious Diseases, found that very young children (ie, under the age of 3) who are asymptomatic may effectively transmit SARS-CoV-2 to adults and other children. Following notification that a staff member was exposed, the facility was closed and PCR-based diagnostic testing was conducted among children, staff, and family members of children and staff. Despite measures to mitigate transmission risk, including mask use and multiple independent cohorts of children and staff, the outbreak resulted in 29 confirmed infections. The infections represented 27% of the individuals tested, including 8 children at the nursery and 12 family members with no direct exposure at the nursery. This study illustrates both that transmission can occur among children and staff in school-type settings and at home and that transmission associated with school-based outbreaks can extend into the community.

CRISPR-BASED DIAGNOSTICS A new CRISPR-based diagnostic test could provide the ability to detect SARS-CoV-2 in as little as 5 minutes. Other CRISPR-based SARS-CoV-2 diagnostic tests have been developed previously, but this newest test does not require RNA amplification, saving time and resources and allowing the test to be conducted at the point of care. The new test was developed by a team led by Dr. Jennifer Doudna, who was recently awarded the Nobel Prize for her work in pioneering the use of CRISPR. The test is not as sensitive as conventional PCR-based tests; however, the researchers demonstrated (preprint) that it is capable of both detecting the presence of SARS-CoV-2 virus and quantifying the amount present in a specimen, another advantage over traditional diagnostic tests. If the CRISPR-based diagnostic test is successfully validated, the rapid, on-site results and the ability to quantify viral load could allow clinicians to better tailor treatments.

A detailed protocol for another CRISPR-based diagnostic was also recently published in The New England Journal of Medicine. This test, developed by researchers at the Massachusetts Institute of Technology’s (MIT’s) Broad Institute, demonstrated results in 15 to 45 minutes with 93% sensitivity and 98% specificity, when compared against the US CDC’s standard RT-qPCR diagnostic test. The researchers noted that the streamlined test was suitable for use in “low-complexity clinical laboratories” using “minimal equipment.” Expanded testing capacity, particularly for tests that do not require advanced laboratory capabilities, could be a critical tool for containing outbreaks, operating in low-resource settings, and screening larger populations.

SURVIVAL ON SURFACES While respiratory transmission is generally understood to be the primary driver of the COVID-19 pandemic, a study published in the journal Virology has raised new concerns for fomite transmission. Researchers from the Commonwealth Scientific and Industrial Research Organisation at the Australian Centre for Disease Preparedness analyzed the survival of SARS-CoV-2 virus on various surfaces under controlled laboratory conditions. They found wide variations in survival time based on surface type and temperature. Most notably, infectious virus survived on glass, stainless steel, and paper and polymer bank notes (ie, paper currency) for at least 28 days at 20°C (68°F). In contrast, viable virus was detected on cotton cloth after only 14 days. As temperature increased, the survival time of infectious virus decreased. At 40°C (104°F), infectious virus lasted less than 24 hours on cotton and less than 48 hours on all other surfaces.

The researchers inoculated the surfaces using a viral load and fluid matrix designed to mimic a typical COVID-19 patient. Humidity remained relatively standard at 40-50% during the tests, and the experiment was conducted in darkness to negate the effect of UV light, which can kill the virus. While the study illustrated that SARS-CoV-2 could potentially survive on surfaces for longer than previously thought, it is important to note that these standardized conditions do not necessarily represent real-world conditions. Additionally, the virus titer did reduce by 50% on all surfaces within 3 days and by 90% on all surfaces within 10 days, which illustrates that fomite transmission risk decreases over time, even without effective disinfection practices.