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 35.11 million cases and 1.04 million deaths as of 10:00am EDT on October 5. The global weekly incidence remained slightly above 2 million for the third consecutive week. These are the 3 highest weekly totals since the onset of the pandemic. The weekly mortality increased by nearly 7% from the previous week to more than 39,000 deaths.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. India: 78,445 new cases per day (-5,430)
2. USA: 43,257 (-1,062)
3. Brazil: 26,140 (-671)
4. Argentina: 12,452 (-178)
5. France: 11,514 (-601) 
6. Spain: 10,493* (-478)
7. United Kingdom: 9,716 (+3,900; new)  
8. Russia: 9,084 (+2,218; ↓ 1) 
9. Colombia: 5,999 (-855; ↓ 1) 
10. Israel: 5,307 (-779; ↓ 1)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Israel: 613 daily cases per million population (-90)
2. Andorra: 507 (+4)  
3. Montenegro: 413 (+26) 
4. Bahrain: 326 (-33)
5. Argentina: 276 (-4)
6. Czech Republic: 238 (+33; ↑ 2)
7. Bahamas: 225 (+72; new) 
8. Spain: 224* (-10)
9. Netherlands: 202 (+53; new)
10. Moldova: 202 (+50; new)
*Spain’s average daily incidence is not reported for today; these values correspond to the previous day’s averages.

India’s daily incidence continues to decline from its peak in mid-September (93,198 new cases per day), now reporting fewer than 80,000 new cases per day for the first time since September 5. Indonesia fell out of the top 10 in terms of total daily incidence, and it was replaced by the United Kingdom, which jumped to #7. After reporting a slow, steady decline in daily incidence for several months, Russia’s COVID-19 incidence appears to be increasing quickly. If it continues on this trajectory, Russia could surpass its first peak in the next several days. Israel’s daily incidence decreased sharply from its record peak; however, it remains above 600 daily cases per million population. Costa Rica, France (entered the top 10 the previous week), and Peru fell out of the top 10 in terms of per capita daily incidence, and they were replaced by the Bahamas (fell out of the top 10 the previous week), the Netherlands, and Moldova.

The US CDC reported 7.36 million total cases and 208,821 deaths. The US is averaging 42,980 new cases and 684 deaths per day. This is the first time that US mortality is fewer than 700 deaths per day since July 11. In total, 24 states (increase of 2) are reporting 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, and North Carolina with more than 200,000. The Tennessee COVID-19 dashboard is currently reporting more than 200,000 cases, and we expect that to be reflected in the CDC data soon. We also expect Oklahoma to surpass 100,000 cases in the next week or so.

The Johns Hopkins CSSE dashboard reported 7.42 million US cases and 209,857 deaths as of 11:30pm EDT on October 5.

US PRESIDENT Last week, US President Donald Trump tested positive for SARS-CoV-2, and on Friday, he was admitted to Walter Reed National Military Medical Center for treatment and monitoring. The exact timing of his SARS-CoV-2 tests and the onset of symptoms remain unclear, and limited information has been provided regarding the severity of his symptoms and his exact course of treatment. Based on official statements from the White House, including the President’s physician and other physicians who treated the President at Walter Reed, and multiple media reports, President Trump received supplemental oxygen, remdesivir, monoclonal antibodies, convalescent plasma, dexamethasone, and vitamin D, some of which were provided under Emergency Use Authorization or compassionate use protocols. President Trump remains in the hospital, but White House officials anticipate that he could be discharged as early as today. Over the weekend, the President posted several videos to his Twitter account and took a short ride in the Presidential motorcade to see supporters gathered near the hospital.

In addition to President Trump, a number of close advisers and Republican officials have tested positive for SARS-CoV-2 over the past several days. As far as we know, health officials have not definitively identified the index patient/s for this outbreak nor the site/s of exposure. Many of the cases associated with this outbreak attended the ceremony at which President Trump announced Amy Coney Barrett as his nomination to the US Supreme Court, fueling speculation that it could have served as a superspreader event. Notably, images and video of the event show that most attendees were not adhering to social or physical distancing recommendations, including mask use. There is concern that some of the people recently identified as infected participated in large-scale events, including fundraisers and rallies, while infectious. In addition to high-profile elected and appointed officials, exposures at the White House could include a number of support staff—such as custodial workers, valets and cooks, administrative staff and aides, the media, and the Secret Service (including those that escorted President Trump in the motorcade).

YOUNG ADULTS Last week, US CDC’s MMWR published a study that describes trends in SARS-CoV-2 transmission among young adults, including college and university students. COVID-19 cases among young adults increased by 55% during August and early September, with the greatest increases occurring in the Northeast and Midwest regions, where cases more than doubled. The researchers determined that the increased incidence was “not solely attributable to increased testing.” Notably, incidence among non-Hispanic White young adults increased by nearly 150% from August 2 to September (and even higher in the Midwest and Northeast), while incidence among racial and ethnic minorities remained steady or decreased over that time. Considering the timing of the increase among this age group, the researchers speculate that it could have been related to students returning to school; however, there are likely a myriad of factors that require further investigation.

US universities continue to face increased scrutiny regarding their campus-related outbreaks, such as at Appalachian State University, where more than 700 confirmed cases have been reported since early June. Additional epidemiological investigations and studies are needed to further understand and address risk factors for outbreaks at US colleges. One study, published in the US CDC’s MMWR, aimed to fill in some outstanding gaps. The authors documented the reopening process and subsequent COVID-19 outbreak for an unnamed university in North Carolina. The school implemented various preventive measures, including reduced capacity in classrooms and dining halls, reduced occupancy in residence halls, increased take-out options at dining halls, daily symptom monitoring, mandatory mask use in indoor spaces, physical distancing, and prohibitions on gatherings or more than 10 people indoors and 25 people outdoors. Adherence data was not available for any of these measures. Despite the social and physical distancing measures implemented at the university, the school reported 18 clusters of 5 or more linked cases, which accounted for 201 of 670 total confirmed cases from August 3-25. Of these clusters, 8 were in residence halls, 5 were linked to fraternities or sororities, 4 were among athletic teams, and 1 was in an off-campus apartment. After reporting 334 cases, the school transitioned all classes to remote, and it implemented measures to further limit residency in on-campus student housing. Student gatherings and congregate living were identified as contributing factors to the campus outbreak.

MULTISYSTEM INFLAMMATORY SYNDROME Multisystem inflammatory syndrome in children (MIS-C), is a rare, severe complication of SARS-CoV-2 infection in pediatric patients that can lead to hospital admission or death. A similar condition has not been well documented in adults, but researchers from the CDC COVID-19 Response Team published a study in the CDC’s MMWR provides analysis of 27 adult patients determined to have a related condition, MIS-A. The patients exhibited cardiovascular, gastrointestinal, dermatologic and neurological symptoms without severe respiratory presentation, similar to what has been observed in children experiencing MIS-C. The researchers used a case definition requiring 5 criteria: (1) severe illness requiring hospitalization in a patient aged 21 years or older; (2) current or recent SARS-CoV-2 infection; (3) severe impairment of one or more non-respiratory organ system; (4) evidence of severe inflammation, indicated by various laboratory analyses; and (5) absence of moderate or severe respiratory illness. The authors recommended that clinicians consider a MIS-A diagnosis for relevant clinical manifestations and use serological testing, if needed, to confirm current or recent SARS-CoV-2 infection. Notably, 8 of the 27% patients included in this study did not have any documented positive SARS-CoV-2 diagnostic test, although all had positive serological tests. Further study is needed to better characterize MIS-A, including whether it is associated with acute COVID-19 disease or if it is “an entirely post-acute phenomenon.” 

CARDIAC ARREST & CPR Researcher from a number of US medical institutions published findings from a study on the use of cardiopulmonary resuscitation (CPR) in COVID-19 patients who experience cardiac arrest. The researchers note that “anecdotal reports of poor outcomes in critically ill patients with COVID-19 who have had in-hospital cardiac arrest have prompted discussions on the futility of [CPR] in this patient population.” The study, published in BMJ, included more than 5,000 COVID-19 patients who were admitted to intensive care units at 68 hospitals across the US. Among these patients, 701 participants (14%) experienced cardiac arrest while hospitalized, and 400 (57.1%) of those individuals received CPR. Among the 400 patients who received CPR, 48 (12%) survived to discharge, and 28 (7%) exhibited normal neurological function or only mild neurological impairment. These percentages are relatively consistent with studies of CPR among non-COVID-19 patients, which indicates that CPR does provide benefit to COVID-19 patients. Additionally, the study illustrates the high rate of cardiac arrest among COVID-19 patients, and hospitals and health systems should be prepared for the increased demand among severe COVID-19 patients.

NEW YORK CITY Yesterday, New York City Mayor Bill de Blasio announced the upcoming implementation of new restrictions for 20 neighborhoods in the New York City boroughs of Brooklyn and Queens in response to the increase in COVID-19 incidence and test positivity since late September. Nine (9) of the neighborhoods will face closure of public and private schools as well as all non-essential businesses, including the suspension of indoor and outdoor dining. The other 11 neighborhoods will be subject to more limited restrictions, such as the suspension of indoor dining and the closure of gyms and pools. The newly-announced policies are expected to be in place for 2-4 weeks, depending on the impact on local COVID-19 transmission. New York Governor Andrew Cuomo will reportedly need to approve the new measures before they are allowed to take effect. Increased transmission has been identified in some Orthodox or Hasidic Jewish communities. A variety of city government agencies are engaging with these communities to promote social and physical distancing measures and increase testing to contain the outbreaks. Some affected neighborhoods are reporting test positivity as high as 7-8%, which is higher than the city average but still much lower than some parts of the country. 

MENTAL HEALTH Today, the WHO released the results of a survey describing the impact of COVID-19 on “mental, neurological, and substance use services” in 130 countries. Notably, 93% of countries surveyed faced disruption or suspension of critical mental health services due to the pandemic, with outpatient services in hospitals and community-based services being the most affected. One-third of countries responding noted disruption in at least 75% of these services. Among responding countries, 35% of reported disruption in emergency or life-saving services, and 30% experienced disruption in supply of medicines for conditions related to mental, neurological, or substance use disorders. Disruptions in provision of services were mainly attributed to decreases in patients seeking outpatient care, travel restrictions, and decreases in inpatient volume due to suspension of elective procedures. These findings come in advance of the WHO’s Big Event for Mental Health, a virtual event on World Mental Health Day that aims to increase awareness and advocacy for mental health during the pandemic. 

REMDESIVIR On Friday, the European Medicines Agency announced a safety review regarding reports of acute kidney injury in COVID-19 patients treated with remdesivir. Remdesivir is currently being used in the US under an Emergency Use Authorization issued by the US FDA and a conditional marketing authorisation in the EU. Enhanced safety monitoring has been in place for the therapeutic due to animal studies that previously documented renal toxicity, but a causal relationship between use of remdesivir and kidney injury has not yet been established. For now, recommendations regarding use of the therapeutic have not changed.

BLEACH-BASED CLEANING SUPPLIES More than 9 months into the COVID-19 pandemic, some supplies are still difficult to come by. In addition to surgical masks, N95 respirators, and other supplies and equipment for healthcare workers, some cleaning products are still hard for shoppers to find. Toilet paper and paper towels have generally returned to store shelves, as have hand sanitizer and hand soap; however, bleach-based disinfecting wipes and sprays are still a relatively rare commodity. Cleaning products capable of killing coronaviruses became increasingly popular as the attention to enhanced hygiene and disinfection grew. Companies like Clorox and Lysol have been unable to scale up production to meet the demand, which reportedly “surged 500 percent in the last few months.” Manufacturers and retail stores went through several months’ worth of inventory in 1 or 2 weeks. These supplies have been critical to industries such as air travel, as companies are relying on them as convenient and effective ways to disinfect high-touch surfaces. 

NFL GAMES POSTPONED This weekend, the NFL postponed multiple Week 4 games due to positive SARS-CoV-2 tests. The first postponement followed multiple positive tests among players and staff for the Tennessee Titans. At least 18 individuals associated with the team tested positive, starting on Tuesday, September 29. Today was the first day since then that the team has reported no new positive tests, which is the first step in reopening team facilities and resuming team activities. The Titans’ game against the Pittsburgh Steelers will now be played in Week 7, and the NFL also moved the Steelers’ game against the Baltimore Ravens to Week 8 and the Ravens’ bye week to Week 7 to accommodate the schedule change. Later in the week, New England Patriots quarterback Cam Newton tested positive shortly before the team departed for its game against the Kansas City Chiefs. The Patriots vs Chiefs game will still be played this week, but it was rescheduled for tonight, although the Patriots will be without their starting quarterback. 

VACCINES & SCIENTIFIC INTEGRITY Johns Hopkins University and the University of Washington are hosting a virtual symposium to discuss the critical importance of ensuring scientific integrity throughout the process of evaluating and authorizing SARS-CoV-2 vaccines. Transparency, “scientific and ethical rigor,” and communication are vital to ensuring that vaccine clinical trials are not affected by political interference. Particularly in light of increased vaccine hesitancy and anti-vaccine rhetoric over recent years, it will be important to establish and maintain the public’s trust for future SARS-CoV-2 vaccines. The two universities have gathered an impressive list of confirmed speakers, including Dr. Anthony Fauci (National Institute of Allergy and Infectious Diseases), Dr. Francis Collins (National Institutes of Health), Dr. Peter Marks (Center for Biologics Evaluation and Research, US FDA), and Dr. Moncef Slaoui (Operation Warp Speed) as well as Dr. Tom Inglesby, Director of the Johns Hopkins Center for Health Security. The event will be held on Tuesday, October 6 (1:30-4:45 EDT).