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 39.94 million cases and 1.11 million deaths as of 8:00am EDT on October 19. The WHO reported a new record high for global weekly incidence for the fifth consecutive week. The global total reached 2.44 million cases—an increase of more than 5% over the previous week. Additionally, the WHO reported 394,510 new cases on Saturday, a new daily record.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. India: 61,391 new cases per day (-9,570)
2. USA: 56,007 (+6,765)
3. France: 23,151 (+6,608; ↑ 1)
4. Brazil: 20,052 (-5,619; ↓ 1)
5. United Kingdom: 16,956 (+2,565)
6. Russia: 14,374 (+2,414; ↑ 1)
7. Argentina: 13,639 (-35; ↓ 1)
8. Spain: 10,778* (-15)
9. Italy: 8,470 (+4,239; new)
10. Czech Republic: 8,111 (+3,159; new)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Andorra: 1,259 daily cases per million population (+176)
2. Czech Republic: 757 (+295)
3. Belgium: 620 (+90; ↑ 2)
4. Netherlands: 448 (+126; ↑ 2)
5. Armenia: 397 (+207; new)
6. Montenegro: 397 (+1; ↓ 3)
7. France: 355 (+101; ↑ 1)
8. Slovenia: 345 (+196; new)
9. Liechtenstein**: 322 (+277; new)
10. Argentina: 302 (-1; ↓ 3)
*Spain’s average daily incidence is not reported for today; these values correspond to the previous day’s averages.
**Liechtenstein is a member of the UN, but not the WHO. Liechtenstein’s COVID-19 data is reported by Switzerland.

Considering the current COVID-19 resurgence in the US, India is unlikely to surpass the US as #1 for cumulative incidence in the near future. India is still reporting more new daily cases than the US; however, India continues its decline, while US daily incidence is increasing again.

Colombia and Mexico fell out of the top 10 in terms of total daily incidence, and they were replaced by the Czech Republic and Italy. Notably, Italy’s daily incidence doubled over the past week, and the daily incidence increased by more than 60% in the Czech Republic. France’s daily incidence has doubled over the past 2 weeks. The Bahamas, Iceland, and Israel fell out of the top 10 in terms of per capita daily incidence, and they were replaced by Armenia, Liechtenstein, and Slovenia. Belgium, which was not in the top 10 per capita daily incidence two weeks ago, has jumped to #3 globally. Armenia’s daily incidence increased by 108% compared to the previous week, Slovenia’s increased by 132%, and Liechtenstein’s increased by 617%.

The US CDC reported 8.08 million total cases and 218,511 deaths. The daily COVID-19 incidence continues to increase, now up to 55,323 new cases per day, the highest since August 5. On Saturday (data corresponding to October 16), the CDC reported 70,078 new cases, the highest daily incidence since July 24 and the sixth highest daily total to date. The US COVID-19 mortality continues to hold steady at approximately 700 deaths per day.

The US surpassed 8 million cumulative cases. From the first case reported in the US on January 22, it took 96 days to reach 1 million cases. From there:
1 million to 2 million: 44 days
2 million to 3 million: 27 days 
3 million to 4 million: 15 days
4 million to 5 million: 17 days
5 million to 6 million: 22 days
6 million to 7 million: 25 days
7 million to 8 million: 21 days

More than half of all US states have reported more than 100,000 cases, including 10 with more than 200,000 cases:
>800,000: California, Texas
>700,000: Florida
>400,000: New York
>300,000: Georgia, Illinois

The Johns Hopkins CSSE dashboard reported 8.17 million US cases and 219,811 deaths as of 12:30pm EDT on October 19.

US HOSPITAL SURGE As much of the US continues to face another resurgence of COVID-19, rural hospitals are struggling to manage the patient demand. The US COVID-19 epidemic, which was largely concentrated in higher-density urban populations early on (eg, New York City, Boston, Detroit), has shifted toward rural populations across the country. In fact, the per capita COVID-19 mortality in small towns and rural areas is now more than double the mortality in large cities. Unlike urban areas, which may have many nearby hospitals to provide care for their large populations, and to distribute increased patient load, hospitals and other healthcare facilities in rural areas are spread further apart, covering much larger geographic areas. In some cases, the nearest hospital may be hundreds of miles away. Additionally, these hospitals tend to be smaller than their urban counterparts, and the associated limitations on resources, including hospital and intensive care unit (ICU) beds, increase the burden of COVID-19 patient surges. As we covered early in the pandemic, a growing number of rural hospitals in the US have closed their doors over the past several years, and restrictions on elective procedures during the height of social distancing measures in the US placed additional economic stress on hospitals and health systems, causing more to close.

In an effort to decompress patients from overburdened health systems (ie, transfer them to other facilities), Wisconsin established a temporary field hospital at its state fairgrounds. The facility opened last week, and it will initially be able to accommodate up to 50 patients. It is designed to provide care for patients who are recovering from COVID-19 but who are not yet ready to be discharged. More severe patients will remain at traditional hospitals to receive more advanced clinical care. Ultimately, the field hospital could be expanded to handle more than 500 patients, if necessary. Wisconsin currently has more than 1,000 hospitalized COVID-19 patients statewide, its highest total to date.

SWEDEN SOCIAL DISTANCING Since early in the COVID-19 pandemic, Sweden has largely resisted highly restrictive social distancing and other mitigation measures to limit SARS-CoV-2 transmission. Unlike most other European countries, Sweden placed few restrictions on retail stores, restaurants and bars, or schools. The reluctance to implement widespread social distancing policies has resulted in numerous accusations from the international community that Sweden is pursuing a herd immunity strategy through natural infection—Swedish officials have denied that herd immunity is the goal. In light of increased incidence during Europe’s “second wave,” Swedish officials are reportedly evaluating plans to implement local social distancing restrictions in severely affected areas.

Dr. Anders Tegnell—Sweden’s leading epidemiologist, who received the brunt of opposition to Sweden’s perceived herd immunity strategy—recently commented that the seroprevalence in the population was not as high as previously believed, which likely factors into Sweden’s evolving mindset. It appears as though the new policies will still largely be recommendations, as opposed to mandates, and they will be implemented locally not at the national level. While these measures are not nationwide mandates, it appears that Sweden’s overall strategy toward containing COVID-19 is moving closer to the model implemented across the rest of Europe. On October 13, Sweden reported 970 new cases, its highest daily total since late June.

VATICAN/HOLY SEE When reporting the per capita daily incidence top 10, we typically omit small countries that normally report zero daily cases but occasionally report a minor, temporary spike in incidence in favor of countries that exhibit a trend of elevated incidence. This week, the Vatican/Holy See reported 7 new cases twice, which would put it at #1 globally in terms of per capita incidence, at nearly 2,500 daily cases per million population.

At least 11 of the 14 new COVID-19 cases are among the Swiss Guard, who provide security for the Pope. Additionally, a man who lives “in the same Vatican residence as Pope Francis” tested positive for SARS-CoV-2. Pope Francis is 83 years old, and he reportedly “had part of one lung removed during an illness when he was a young man,” which could further increase his risk for severe COVID-19 disease. The Pope undergoes regular testing, and there is no indication that he has been directly exposed to any infectious individuals. These are the first cases reported by the Vatican/Holy See since mid-March—and more than doubled the country’s cumulative total—but considering that both reports included multiple cases and that most of the cases were among a small group of individuals, it is worth monitoring for early signs of sustained transmission.

LITHUANIA ELECTION Lithuania updated its policies regarding COVID-19 isolation and quarantine to provide an exemption that would allow quarantined citizens to vote during the upcoming elections. Under the new policy, individuals who have exposure to known COVID-19 cases but who have not tested positive are permitted to leave quarantine to participate in a limited window of early voting, October 19-22 from 7-8pm only. Voters must be transported to the polling station in their own car, wear a face covering while voting, and then return directly home. Reportedly, 4 polling stations have set up drive-through ballot drop-off. Individuals with active COVID-19 disease are not permitted to participate in early voting, but they can “vote from home,” presumably by mail. According to a report by the Associated Press, Lithuania did not offer an option for quarantined individuals to vote in person during the previous round of the national election.

WHO SOLIDARITY TRIAL Last week, the WHO published preliminary results from the Solidarity Therapeutics Trial, the world’s largest randomized controlled trial evaluating candidate COVID-19 treatment drugs. Despite high hopes, the findings indicated that remdesivir, hydroxychloroquine, lopinavir/ritonavir, and interferon—all of which are repurposed drugs—had “little or no effect on…mortality or the in-hospital course of COVID-19 among hospitalized patients.”

Physicians and researchers have expressed mixed reviews of the trial, however, including criticism of the study design and inconsistency between the Solidarity Trial’s results and other major clinical trials, particularly for remdesivir.

Notably, Gilead Sciences, the company that produces remdesivir, issued a press release that leveled criticism against the WHO’s findings. In particular, Gilead argued that while the international, multi-center nature of the Solidarity Trial increased availability of the drugs, it also introduced heterogeneity that could call into question the validity of the results. Additionally, Gilead noted that the data had not yet been peer reviewed. Solidarity Trial researchers submitted a manuscript discussing the Solidarity Trial data for peer review, but a preprint version is available here.

VACCINE ROLLOUT Despite Pfizer’s recent announcement that it would not seek an Emergency Use Authorization (EUA) from the US FDA before late November, US government planning continues for the future rollout of a COVID-19 vaccine. Last Friday marked the deadline for US states to submit preliminary plans to the US CDC regarding future vaccine distribution programs. The CDC released its own guidance for state planning in mid-September. The US Department of Health and Human Services and the Department of Defense also recently announced an agreement with the CVS and Walgreens pharmacy chains to vaccinate residents and staff of nursing homes and long-term care facilities, once a vaccine is available, at zero out-of-pocket cost for recipients. CVS and Walgreens will also manage storage of the vaccine and related supplies as well as reporting vaccination data to local, state, and federal officials. Long-term care facilities will not be mandated to participate in the mass vaccination program, but they can opt in via the CDC’s National Healthcare Safety Network.

This planning comes at a time when polls show Americans are increasingly hesitant to receive a SARS-CoV-2 vaccine. In fact, a recent poll conducted by STAT News and The Harris Poll found that only 58% of Americans indicated that they would receive a vaccination as soon as it was available. This is down from 69% in August. Among Black Americans, only 43% of individuals stated they would receive a vaccination as soon as it was available—down from 65% in August—further illustrating challenges in encouraging vaccination among racial and ethnic minority communities. Rob Jekielek, Managing Director of The Harris Poll, indicated that Black individuals are more likely to live more than 1 hour away from a primary care physician and more likely to use a hospital emergency department as their point of entry into the healthcare system. T As we have covered previously, racial and ethnic minorities have been demonstrated to be at elevated risk for severe COVID-19 disease and death, so it is critical to engage these communities prior to the availability of a SARS-CoV-2 vaccine in order to increase vaccination coverage among vulnerable individuals.

Outside of the US, similar preparation work is also being done. UNICEF, Gavi, and the WHO recently partnered to stockpile supplies and equipment needed for future vaccine distribution, such as syringes, safe syringe disposal boxes, and cold chain equipment. Notably, UNICEF announced that it is working to stockpile more than half a billion syringes by the end of 2020.

DIABETES Emerging reports indicate that COVID-19 patients may develop new-onset diabetes or experience complications to pre-existing diabetes as a result of SARS-CoV-2 infection. Diabetes has already been documented as one of the underlying health conditions that can increase the risk of severe COVID-19 disease and death, but it appears as though the association could work the opposite way as well—with COVID-19 actually causing patients to develop diabetes. Current hypotheses indicate that the complication may be related to SARS-CoV-2 binding to ACE2 receptors, which also play a part in regulating glucose metabolism.

The onset of type 1 diabetes has been linked in the past to other viral infections, which may cause stress that raises blood sugar levels; however, new-onset diabetes in those circumstances typically only occurs in patients who are already predisposed to developing diabetes. Conversely, new-onset diabetes in COVID-19 patients has been observed in patients that do not have risk factors for diabetes. Further, some hospitals have reported unusually high rates of pediatric diabetes and patients presenting with diabetic ketoacidosis—a complication of diabetes—during the pandemic.

In order to further research this phenomenon, doctors and researchers from King’s College London and Monash University (Australia) are establishing an international registry of COVID-19-related diabetes cases. More than 300 physicians have already agreed to participate by sharing clinical case data. The US National Institutes of Health is also funding research exploring the link between COVID-19 and new-onset diabetes or high blood glucose. 

GENETICS Previous studies have evaluated genetic risk factors for severe COVID-19, including a potential link between severe outcomes and blood type, but a new study published in the The New England Journal of Medicine may provide further evidence of genetic risk factors for COVID-19. The genomewide association study (GWAS), conducted by the Severe COVID-19 GWAS Group, involved 1,980 severe COVID-19 patients from 7 hospitals in Italy and Spain.

The researchers found that the ABO blood group locus at 9q34.2 and the multigene locus at 3p21.31 were associated with severe COVID-19 outcomes. Consistent with other research, the findings suggest that patients with blood type A had a higher risk of severe outcomes and that patients with blood type O had a lower risk of severe outcomes. An insertion-deletion GA or G variation at locus 3p21.31 was specifically linked to patients requiring mechanical ventilation. Due to limitations in the methodology, the researchers were not able to test and adjust for some potential sources of bias known to be associated with COVID-19, and further study is needed to better characterize the identified relationships. Regardless, the study identified potential areas of focus for future genomic research, and the researchers call for future efforts to further investigate the immunologic synapse between T-cells and antigen-presenting cells.