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

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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.
Tomorrow - 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.
EPI UPDATE The WHO COVID-19 Dashboard reports 38.00 million cases and 1.08 million deaths as of 10:00am EDT on October 14. 

The US CDC reported 7.87 million total cases and 214,446 deaths. The US daily COVID-19 incidence continues to climb, now up to 50,181 new cases per day, the first time above 50,000 daily cases since August 17. At this pace, the US should surpass 8 million cumulative cases in the next 4-5 days. The US COVID-19 mortality continues to hold steady at approximately 675-700 deaths per day. It has been approximately 4 weeks since the US COVID-19 incidence began its current surge. COVID-19 mortality has not yet shown indication of an increase at the national level, but as discussed below, some states are reporting expected increases in COVID-19 mortality, following several weeks of increasing incidence.

More than 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. We expect Texas to surpass 800,000 cumulative cases in the next several days.

While the national average daily mortality has not yet started to increase, state-level mortality in some parts of the country are beginning to exhibit expected surges, following several weeks of increased incidence. Many state COVID-19 websites or dashboards do not display incidence and mortality data in a way that facilitates this analysis; however, some independent efforts do, such as the STAT News COVID-19 Tracker. While a number of states are beginning to exhibit increasing COVID-19 mortality, several notable examples stand out.

Wisconsin’s summer resurgence began in mid-June, and its current surge started in early September. The corresponding increases in mortality started around mid-July and late September, respectively—both lagging the incidence trend by approximately 3 weeks. Wisconsin’s COVID-19 mortality has doubled since the end of September. In Utah, the current surge began in mid-September, with incidence tripling since that time. Approximately 2 weeks later, the mortality began to surge as well, increasing by 400% since then. Missouri’s COVID-19 incidence began increasing in mid-June, peaked in mid-August followed by a slight decrease, and then surged again starting in early September. Missouri’s mortality has followed a similar trend, doubling from mid-July to early September and then doubling again from mid-September to now. North and South Dakota are both exhibiting substantial spikes in mortality. North Dakota’s current surge in incidence began around mid-August, which was followed by a surge in mortality starting in early September. North Dakota’s COVID-19 incidence has tripled since the start of the surge, and its mortality has increased by more than 400%. South Dakota’s surge began in mid-August as well, and the increase in mortality followed approximately 3-4 weeks later. South Dakota’s COVID-19 incidence and mortality have both increased nearly 500% over that time.

Notably, North and South Dakota and Utah have relatively small populations, so the total number of daily deaths remains low (ie, fewer than 15 per day). On a per capita basis, however, South Dakota’s daily mortality (0.65 daily deaths per 100k population) is more than double the national average (0.25 deaths/100k), and North Dakota’s (1.44 deaths/100k) is nearly 6 times the national average. The mortality in both states is still increasing rapidly. Utah went from 0.03 daily deaths per 100k population—12% of the current national average—to 0.15 deaths per 100k—up to 60% of the current national average—in less than 3 weeks.

A number of other states have exhibited similar trends with respect to incidence and mortality, but not necessarily to the same degree as these examples. 

The Johns Hopkins CSSE dashboard reported 7.88 million US cases and 216,278 deaths as of 1:30pm EDT on October 14.

ARIZONA SOCIAL DISTANCING & MASK ORDERS A study conducted by state health officials in Arizona (US) and the US CDC COVID-19 Response Team evaluated the effects of social distancing measures implemented in Arizona. The study, published in the CDC’s MMWR, found that COVID-19 incidence began to stabilize and then decrease approximately 2 weeks after the implementation of a series of social distancing measures that aimed to mitigate community transmission risk. The researchers evaluated trends in the 7-day average of Arizona’s daily COVID-19 incidence from January 22-August 7, compared against the dates that various social distancing measures were implemented at the state and local levels.

From June 1 to June 15, approximately 2-4 weeks after the state’s “stay at home” order ended, Arizona’s average daily incidence increased by more than 150%, which prompted state and local governments to take action. On June 17 the state government permitted local jurisdictions to mandate mask use, and a number of county, city, and tribal governments did so over the following week, covering approximately 85% of the state’s population. Additionally, state officials strengthened social distancing restrictions, including limiting the size of large gatherings, closing or limiting operations at “businesses where mask use and social distancing were difficult to maintain” (eg, restaurants, bars, and gyms/fitness centers), and encouraging mask use in areas where local mandates were not in place. In late June/early July, approximately 2 weeks after local mask mandates began to take effect, Arizona’s COVID-19 peaked and then began to decline. Arizona’s daily incidence decreased 75% from its peak, following the sustained use of local and statewide COVID-19 community mitigation measures. While this study is not able to determine a causal relationship between the measures and decreased transmission, the relative timing of the implementation and the decrease in incidence provide further evidence that social and physical distancing and mask use could be key tools in mitigating SARS-CoV-2 transmission risk.

NEW YORK CITY In an effort to contain emerging COVID-19 hotspots, New York City implemented neighborhood-specific control measures. The restrictions are implemented based on hotspot zones, designated as Red, Orange, or Yellow based on the incidence rate (as well as areas not currently designated as hotspots), and the restrictions include limitations on the operation of schools; businesses, including restaurants and bars; places of worship; and large gatherings. During the first weekend of the newly imposed social distancing and mask requirements, New York City issued 62 summons and more than $150,000 in fines to individuals and organizations for violations of the new policies.

Notably, the affected areas predominantly affect Orthodox Jewish communities, which have been singled out by state and local officials, including New York Governor Andrew Cuomo and New York City Mayor Bill DeBlasio, for not adhering to social distancing policies, including large gatherings for Jewish holidays. Notably, 5 of the summons issued over the weekend were to places of worship. Some in the community and neighborhoods have protested the new restrictions, arguing that they are facing discrimination while the rest of the city continues to operate under much looser social distancing policies. The protests led to the arrest of one local activist on charges of inciting a riot as well as unlawful imprisonment of a journalist, following an alleged assault of journalist reporting on the protests. Local Catholic leaders have also opposed the new restrictions, which limit the capacity at all places of worship in the affected areas. While the effort aims to avoid blanket, city-wide restrictions by targeting higher-risk areas, it is unclear if the highly localized restrictions could be effective in reducing transmission and preventing spillover of the virus into other parts of the city.

HOSPITAL PREPAREDNESS A study published in Infection Control and Hospital Epidemiology examined the preparedness of US community hospitals, as opposed to large academic medical centers, during the US COVID-19 epidemic. The researchers surveyed 50 community hospitals across 6 states in the Southeast region in April and May to determine the availability of critical personal protective equipment (PPE), including face masks and shields, N95 respirators, and powered-air purifying respirators (PAPRs). The survey also asked about other COVID-19 practices, including patient and staff screening, universal mask use, and suspension of non-essential procedures.

Among the respondents, 48% of community hospitals reported an insufficient supply (ie, “almost out or none” or “few days supply”) of PAPRs, 30% with insufficient supply of N95 respirators, 26% with insufficient surgical masks, and 16% with insufficient face shields. Additionally, approximately 80% of these hospitals implemented strategies to extend their supply of PPE, including extending use of various PPE items—including face masks, respirators, and face shields—or disinfecting and reusing them. The survey provides further data that community hospitals have struggled to maintain adequate PPE supply during their response to COVID-19.

More than 75% of the hospitals reported implementing universal masking for staff, patients, and visitors, while only 8% mandated mask use for only healthcare providers. The vast majority (90%) implemented some form of daily screening for hospital staff. By the time the survey was conducted, some facilities had begun to resume some non-essential procedures, including elective surgeries, although the degree to which this occurred varied by facility. Finally, approximately 30% of hospitals utilized on-site laboratories for SARS-CoV-2 testing, and nearly 12% utilized local health department laboratories. The report indicates that at least 30% utilized major private laboratory networks (Quest and LabCorp), but it does not specify how the remaining hospitals managed testing demand.

EARLY TRANSMISSION DYNAMICS A study by the US CDC COVID-19 Response Team, published in the US CDC’s MMWR, examined SARS-CoV-2 transmission dynamics among different age groups in US hotspots during the US summer resurgence. This study builds on previous analysis of US hotspot areas. The study included 767 US counties that were identified as COVID-19 hotspots in June and July—defined as reporting more than 100 COVID-19 cases over a 7-day period and increasing incidence over the previous 3-7 days—which represented approximately 24% of all US counties and 63% of the entire US population.

The researchers found that test positivity among individuals aged 0-17 and 18-24 years began to increase approximately 1 month before the county qualified as a hotspot. Test positivity increased progressively in older age groups, following a surge among the younger population. On average, test positivity at the time a county was identified as a hotspot was highest among the 18-24 age group (14%), followed by the 0-17 age group (11%). The test positivity decreased with age among older age groups: 25-44 years (10%), 45-64 years (8%), and 65 years and older (6%). The South and the West regions reported higher test positivity across all age groups during this period, which corresponds to the regions that were most severely affected during the summer.

The findings support the idea that transmission among younger portions of the population precedes increased risk among older individuals. It is important to reduce transmission of SARS-CoV-2 in younger population groups in order to protect older, more vulnerable portions of the population. 

HANDWASHING A study by the US CDC COVID-19 Response Team, published in the US CDC’s MMWR, aimed to understand how handwashing behavior in the US has changed since the start of the COVID-19 pandemic. The researchers compared survey data from October 2019, prior to the emergence of SARS-CoV-2, to a survey administered in June 2020 to evaluate how public perceptions and behaviors had changed with respect to handwashing. The survey data was collected from Porter Novelli Public Services’ fall and summer ConsumerStyles surveys. The fall survey included 3,624 respondents, and the summer survey included 4,053 respondents. Both surveys asked participants to select from 6 options (as many as applicable) in which they “would be likely to remember to wash their hands”: (1) after using the bathroom at home; (2) after using the bathroom in public; (3) after coughing, sneezing, or blowing one’s nose; (4) before eating at home; (5) before eating at a restaurant; or (6) before preparing food at home.

The researchers identified a statistically significant increase in the odds of participating in 4 of the 6 situations, all of them except before preparing food and after using the bathroom in public. Both of these scenarios had high participation in the fall 2019 survey, so there was not much room for improvement for those 2 options. It is important to note that the survey did not ask participants whether their individual behavior had changed—only the scenarios in which they would wash their hands—nor did it ask about COVID-19 in the context of handwashing behavior. These findings do, however, provide evidence that handwashing behaviors have changed since the start of the COVID-19 pandemic.

VACCINE CLINICAL TRIALS Johnson & Johnson (J&J) announced that it has paused the Phase 3 clinical trial for its candidate SARS-CoV-2 vaccine due to an unexplained illness in one of the participants. In a press release this week, J&J did not share detailed information about the adverse event. The company emphasized that the “study pause” is not uncommon in vaccine trials and that it differs from a “regulatory hold,” which would be mandated by a regulatory authority (eg, US FDA). It is still uncertain if the participant who experienced these events was part of the vaccinated group or the placebo group, and more information is expected to be released in the coming weeks.

This is the second leading SARS-CoV-2 vaccine candidate to pause a clinical trial in the US. AstraZeneca’s Phase 3 clinical trial has not yet restarted in the US after pausing in September, although trials have resumed in other countries. Additionally, Eli Lilly also suspended an ongoing trial for its monoclonal antibody cocktail this week due to safety concerns. The pauses in these trials reinforce the critical need to conduct large-scale clinical trials to evaluate efficacy and identify adverse events that may occur too infrequently to be captured in smaller study groups. The pauses and relative transparency from these pharmaceutical companies provides some measure of confidence that the trials are being conducted in an ethical manner and that safety remains a high priority. 

HERD IMMUNITY Three professors published an open letter calling for an approach to containing the COVID-19 pandemic that they call “Focused Protection.” The document, titled The Great Barrington Declaration argues that existing social distancing and other community mitigation policies risk long-term public health impact, and the proposal aims to achieve herd immunity in the absence of vaccination. The authors call for those “at minimal risk of death to live their lives normally [while] protecting those who are at highest risk.” In support of this plan, they call for lower-risk individuals to return to normal social activity—including in-person school and extracurricular activities and normal operations at restaurants, bars, and other businesses—and essentially isolating higher-risk individuals.
A number of health experts have highlighted the problematic nature of this proposal. Notably, UN Secretary-General Dr. Tedros Adhanom Ghebreyesus described a herd immunity approach in the absence of a vaccine “unethical.” Beyond the expected increase in COVID-19 hospitalizations and deaths that would accompany increased incidence among lower-risk populations, public health experts have highlighted a number of problems with the plan. Evidence continues to emerge about longer-term health effects from COVID-19, including among previously healthy individuals and those who do not experience severe acute illness. Increased incidence, even among lower-risk populations, could also risk patient surge that could threaten health systems, particularly as the Northern Hemisphere approaches influenza season. While documented cases of reinfection have been limited so far in the pandemic, it remains unclear how long immunity conferred by natural infection can last. Additionally, it is clear that transmission among certain populations (eg, correctional facilities, schools) can quickly spread to households and the community, so increasing transmission among lower-risk individuals is likely to increase transmission risk for higher-risk individuals. 

SCHOOL SCREENING & TESTING The Johns Hopkins Center for Health Security collaborated with the Duke University Margolis Center for Health Policy, with support from The Rockefeller Foundation, to develop guidance for implementing SARS-CoV-2 testing protocols at schools. The report outlines a framework for screening and testing at schools to mitigate school-based transmission risk. The framework enables schools to tailor their testing protocols based on local risk assessments in order to ensure that testing strategies meet local needs. The framework addresses multiple types of tests, including diagnostic and antigen tests; multiple testing strategies, including individual and pooled testing; the likelihood and impact of false positive and negative test results; and other mitigation strategies that can affect transmission risk. In further support of this effort, The Rockefeller Foundation is collaborating with the US Department of Health and Human Services to distribute at least 12,000 rapid antigen tests to 5 pilot cities to evaluate the framework.