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 38.79 million cases and 1.10 million deaths as of 10:00am EDT on October 16.

In Central America, most countries appear to be holding relatively steady or decreasing in terms of daily incidence. Notably, Mexico and Panama, both hotspots several months ago, have passed their respective first peaks. Mexico’s daily incidence is down 38% from its peak, and Panama’s is down 40%. Mexico remains #1 in the region in terms of total daily incidence, although this is not surprising, considering that Mexico represents more than 70% of the region’s total population. On October 9, Mexico reported a large number of cases identified on previous dates, but the average has since returned to its previous trend. On a per capita basis, Costa Rica is reporting 233 daily cases per million population, which leads the region. Costa Rica’s daily incidence increased sharply from mid-to-late June through mid-September, and it has held relatively steady since then. Belize reported a dramatic increase in daily incidence in early August, jumping from 1.3 new cases per day to 49, and its incidence has largely fluctuated between 30 and 50 new cases per day since then. COVID-19 mortality largely follows the incidence trends, with most Central American countries exhibiting decreasing or steady trends, except for Costa Rica and Belize.

A number of the South American countries that previously exhibited concerning COVID-19 trends have passed their peaks, including Brazil, Colombia, Peru, and Suriname. Brazil remains #1 in South America in terms of total daily incidence, but its average has decreased by 56% since its peak in late July. Colombia recently reported a surge in incidence, but it has declined steadily over the past several days. The major exception in South America is Argentina, which is reporting an increase in daily incidence—up to a record high of more than 13,000 new cases per day—and it is #1 in South America in terms of per capita daily incidence (293 daily cases per million population). Guyana is also exhibiting a steady increase in daily incidence, but it remains in the bottom half of South American countries in terms of per capita incidence. Like Central America, the mortality trends in South America are aligned closely with daily incidence.

The US CDC reported 7.89 million total cases and 216,025 deaths. The daily COVID-19 incidence continues to climb, now up to 52,350 new cases per day, the highest since August 13. Yesterday, the CDC reported 59,761 new cases, the highest daily total since August 7. At this pace, the US could surpass 8 million cumulative cases by tomorrow. The US COVID-19 mortality continues to hold steady at approximately 700 deaths per day.

More than half of all US states have reported more than 100,000 cases, including California and Texas with more than 800,000 cases; 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 8.01 million US cases and 218,097 deaths as of 1:30pm EDT on October 16.

WUHAN SEROPREVALENCE STUDY Following the world’s first major COVID-19 outbreak, local health officials in Wuhan, China, conducted a city-wide seroprevalence study to determine the extent of community transmission. A study recently published in Clinical Microbiology and Infection described the seropositivity data for more than 60,000 tests conducted in the Wuchang District of Wuhan.

Among those tested, 1,470 (2.39%) individuals were seropositive for IgM and/or IgG immunoglobulin, indicating prior SARS-CoV-2 infection. Despite the major outbreak in Wuhan— which resulted in a prolonged, highly restrictive “lockdown”— the overall seroprevalence among this population is very low, indicating that the vast majority of residents remain susceptible to the virus. The authors note that many “nonlocal workers” who left Wuhan prior to the lockdown had returned by the time the study was conducted, but many local college and university students had not yet returned, which could have contributed to a slightly lower seroprevalence found in this study. The seroprevalence could vary between communities in Wuhan as well; however, the results from this study are relatively consistent with those from previous studies in other districts.

ITALY Italy is one of many European countries currently facing a resurgence of COVID-19, following a period of relative control. Last week, Italian Minister of Health Roberto Speranza announced that the country was evaluating new social distancing measures in an attempt to curb the spread of disease. The newest restrictions, unveiled on Monday, target social gatherings by restricting gathering in private homes to no more than 6 people; restrict operating hours for restaurants and bars/pubs, including in-person service; limiting receptions following “civil or religious ceremonies” to 30 people; limiting spectators at sporting events, concerts, or other events to 1,000 people for outdoor events and 200 for indoor events; and suspending operations at dance halls and discos. Italy is also mandating mask use in public spaces, including indoors and outdoors and requiring travelers arriving from several European countries—Belgium, the Czech Republic, France, the Netherlands, the UK, and Spain—to provide documentation of a recent negative molecular or antigen test or undergo testing at the point of entry or local health authority within 48 hours of arrival (and self-isolate until the results are available).

UNITED KINGDOM As cases and deaths continue to increase in the UK, government officials are implementing increasingly restrictive measures to contain transmission. Following the announcement by UK Prime Minister Boris Johnson that England will implement a 3-tiered system of social distancing measures, some parts of the country are moving into highly restrictive “lockdowns.” The 3-tiered system—which categorizes localities into Medium, High, and Very High Alert Levels—outlines specific restrictions based on the current SARS-CoV-2 transmission risk. The most restrictive level, Very High, largely prohibits or severely restricts social interaction between households or “bubbles.” Restaurants and pubs are limited to delivery or pick-up/takeaway service only (i.e., no in-person dining), and households and bubbles are only permitted to interact with one another outdoors—and even in that case, they are limited to 6 total people. Violations can lead to fines, including up to £10,000 (US$13,000) for gatherings of 30 people or more. According to media reports, the UK government is under pressure to implement “circuit breaker” measures—a short-term, highly restrictive lockdown that aims to drive large-scale interruption of community transmission—in an effort to rapidly contain the current resurgence before the country enters influenza season. Other countries have implemented similar short-term “circuit breaker” plans, including Singapore in April and May.

The government in Northern Ireland is strengthening restrictions to curb transmission. In addition to existing restrictions, “bubbles” will be limited to 10 total people, in-person service at restaurants will be prohibited after 11pm, most gatherings will be limited to 15 people, and alcohol sales at supermarkets and some other businesses will be restricted after 8pm. Funerals and wedding ceremonies will be permitted to include 25 attendees, but wedding receptions will be prohibited. These restrictions are scheduled to remain in place for 4 weeks.

The Welsh government is also implementing enhanced restrictions in response to its COVID-19 surge. Much like England, Wales is implementing a series of ”local lockdown” restrictions. In addition to the local social distancing measures, Wales is also restricting travelers from other parts of the UK. Individuals “living in areas with a high-prevalence of coronavirus in England, Scotland and Northern Ireland” will be prohibited from traveling “to parts of Wales where there is a low prevalence.” Reportedly, the Welsh government is also considering a “circuit breaker” or “fire-break” approach, which could last several weeks, in order to bring the epidemic under control. The plan is still under evaluation, but it could potentially be announced as early as Monday.

YOUTUBE BANS COVID-19 VACCINE MISINFORMATION The social media platform YouTube is banning misinformation related to COVID-19 vaccines. YouTube has long been criticized for a culture that allows for the spread of misinformation, including on the COVID-19 pandemic, but the recent announcement indicates that the platform will take a tougher stance against content that contradicts evidence-based statements by the WHO or other legitimate health agencies. The announcement cited several examples of prominent COVID-19 vaccination rumors to illustrate the type of material that would be targeted under the platform’s COVID-19 Medical Misinformation Policy. A spokesperson for YouTube said that the platform would allow videos that shared “broad concerns” regarding potential future COVID-19 vaccines, but not information that contradicts evidence-based information from reliable health sources.

BLOOD TYPES Two recent studies—both published in Blood Advances, an open-access journal from the American Society of Hematology—provide evidence that an individual’s blood type (or blood group) could be a factor in their risk of SARS-CoV-2 infection or severe COVID-19 disease. The first study was conducted by researchers in Denmark, who found that SARS-CoV-2 infection prevalence was significantly lower among individuals with type O blood, compared to other blood groups. The study included data from all patients tested for SARS-CoV-2 in Denmark between February 27 and July 30—more than 450,000 individuals, including nearly 7,500 cases—as well as 2.2 million non-tested individuals (approximately 38% of the entire Danish population) to serve as a reference population. The researchers found that individuals with type O blood represented 41.69% of the reference population but only 38.41% of positive SARS-CoV-2 tests. Individuals with types A and AB represented a significantly higher proportion of positive cases than the reference population—44.41% vs 42.73% and 5.09% vs 4.46%, respectively. Previous research has demonstrated that anti-A antibodies present in type O blood are capable of glycosylating the SARS-CoV-1 virus, and the researchers theorize that this could be possible for the SARS-CoV-2 virus as well, which could potentially physiological basis for the disparities between the various blood types. The study did not find a significant association between blood type and severe COVID-19 disease or death.

The second study—conducted by researchers in Vancouver, Canada—found a significant association between blood groups and COVID-19 disease severity. In contrast to the study above, this study was much smaller. The researchers included data from 95 hospitalized COVID-19 patients, but the distribution of blood groups among the patients was relatively representative of the national and provincial populations. The researchers found that patients with type A and AB blood were more likely to require mechanical ventilation and continuous renal replacement therapy and had longer admission times in an intensive care unit, compared to patients with types B and O blood.

Previous studies on associations between COVID-19 and blood type have been published with mixed results. For example, one study conducted in Boston, Massachusetts (US), found no link between blood type and disease severity. The researchers did find a potential association with SARS-CoV-2 infection, but only among Rh positive individuals. Another study, conducted in New York City, found a decreased risk of infection among individuals with type O blood, compared to all other types. The researchers also found a decreased risk of intubation among individuals with type A blood and decreased risk among those with types AB/B blood, compared to type O.

LONG-TERM HEALTH EFFECTS The UK National Institute for Health Research published a review of scientific literature on long-term, “ongoing” COVID-19 disease, also referred to by some as “long Covid.” A unique feature of this report is that the researchers included both an expert steering group, composed of clinicians and other experts, and direct input from patients experiencing long-term effects following SARS-CoV-2 infection. The report notes that while much of the attention about COVID-19 has focused on acute illness and mortality, there is growing evidence of the long-term health effects of COVID-19. There is currently a lack of consensus on how to define and diagnose these long-term effects, which can vary widely in presentation and severity between patients, including fatigue, difficulty breathing, and chest pain. Additionally, the types of symptoms and severity can fluctuate over time and affect multiple organs, including the lungs, heart, kidneys, and brain. The researchers believe that ongoing COVID-19 may actually be a combination of 4 syndromes, rather than one underlying condition, and that symptoms in one organ system can subside and then emerge in other organ systems. The 4 syndromes identified include: (1) permanent damage to the lungs and heart, (2) post-intensive care syndrome, (3) post-viral fatigue syndrome, (4) and continuing COVID-19 symptoms. Patients experiencing these syndromes spanned the spectrum of acute disease severity, from mild to severe, as well as individuals who were not ill enough to be tested during their acute infection.

CRISPR DIAGNOSTIC TEST Research and development continues on a variety of rapid, point-of-care tests for SARS-CoV-2. Researchers at the Institute of Genomics and Integrative Biology in New Delhi, India, developed a CRISPR-based testing assay that exhibits comparable sensitivity and specificity to the gold standard PCR-based diagnostic tests—96% and 98%, respectively—while providing faster results and eliminating the need for associated specialized equipment. Key advantages of the test include that it can be conducted more rapidly than the gold standard qPCR diagnostic assays, in as little as 1 hour. The test, named FELUDA (after a fictional Indian detective), does require a nasopharyngeal swab and a RT-PCR process, but it does not require the expensive equipment or advanced training necessary to conduct traditional quantitative PCR-based diagnostic tests. Gold nanoparticles in the test strip cause it to change color for positive tests, providing easy-to-read visual indication for the user. The test could be usable in a variety of settings, including in low-resource settings or the point of care, and the company also indicated that it is working on developing a test kit for at-home use. This test is conceptually similar to the SHERLOCK test developed at MIT (Massachusetts, US)—also named after a fictional detective—which received an Emergency Use Authorization from the US FDA in May.

HERD IMMUNITY The Great Barrington Declaration, a document that argues for a deliberate effort to develop herd immunity to SARS-CoV-2 through natural infection by encouraging lower-risk individuals to resume normal activity, has faced substantial opposition from health experts. Several groups of experts have published opposition statements. Perhaps most notably, The John Snow Memorandum, originally published in The Lancet, outlines the current evidence-based understanding of SARS-CoV-2 transmission and effective protective measures. The memo emphasizes that “uncontrolled transmission in younger people risks significant morbidity and mortality across the whole population” and threatens to “overwhelm the ability of healthcare systems.” A separate but related effort by 14 highly respected public health and health security organizations, including the Johns Hopkins Center for Health Security, condemns the Barrington Declaration and the associated herd immunity strategy as dangerous. The organizations argue that the Barrington Declaration “ignores sound public health expertise” and that the “suggestions put forth...are NOT based in science” (emphasis in original). They also emphasize that “lockdowns” and “full reopening” are not binary choices. Protective measures exist along a spectrum, and multiple complementary policies can provide meaningful protection while enabling individuals to resume some semblance of normal activity. They also note that protecting health and economic security are not mutually exclusive. Rather, they are interdependent, and responsible and effective COVID-19 strategies support both.

COVID-19 & CRIMINAL JUSTICE The Johns Hopkins Center for Health Security, in collaboration with a number of other experts from the Johns Hopkins University Bloomberg School of Public Health, published a report on COVID-19 and the US criminal justice system. As we have covered previously, incarcerated populations have been identified as being at elevated risk of COVID-19 outbreaks as well as severe disease and death. These vulnerable populations live in prolonged close contact with others, have high rates of underlying health conditions, and often face systemic discrimination, including for race, physical disability, mental health issues, and financial insecurity. This report, supported by the National Commission on COVID-19 and the Criminal Justice System, provides an overview of the impacts of COVID-19 on incarcerated populations and provides recommendations for mitigating these risks. The findings focus heavily on reducing population and population density in carceral facilities and improving infection control practices. The recommendations range from improving testing capacity, quarantine and isolation strategies, and clinical care for incarcerated populations to rethinking how the criminal justice system addresses physical and mental health issues, including substance abuse, in order to reduce the overall number of incarcerations. The authors also call for including incarcerated populations and staff working at carceral facilities among priority populations for vaccination due to the increased COVID-19 risk.