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 34.16 million cases and 1.02 million deaths as of 11:00am EDT on October 2.

Early in the pandemic, there was concern that COVID-19 could have devastating effects on countries in Africa, due to a variety of factors, including importation risk, inadequate public health and healthcare infrastructure, ongoing armed conflict and outbreaks of other diseases, food security challenges, and political and economic instability. When severe COVID-19 epidemics did not emerge, there was concern that testing capacity and surveillance and reporting systems in Africa were not able to fully capture the scale of countries’ epidemics and that large-scale transmission was occurring undetected. However, over the past several months, most African countries have continued to report encouragingly low COVID-19 incidence. Notably, Africa as a whole is reporting daily per capita COVID-19 incidence similar to Oceania. To put that in the global context, the global per capita average is currently more than 6 times the incidence in Africa, and Europe, North America, and South America are reporting 14.5, 16.5, and 23 times the current rate in Africa, respectively.

For much of the pandemic, Africa’s COVID-19 incidence was largely driven by the epidemic in South Africa, which passed its first peak (more than 12,500 new cases per day) in mid-to-late June and steadily decreased since then. Currently, only 5 countries in Africa are reporting more than 500 new cases per day: Morocco, South Africa, Tunisia, Libya, and Ethiopia. These 5 countries represent more than 75% of Africa’s daily total. All other African countries are reporting fewer than 250 new cases per day. In terms of per capita incidence, Cape Verde/Cabo Verde** is reporting the highest daily total, with 157 daily cases per million population. This would rank #14 globally, and it is slightly higher than the US (#16; 129 per million population). No other African countries are reporting more than 100 daily cases per million population, and only 3 more are reporting more than 50: Libya, Tunisia, and Morocco. All remaining African countries are reporting per capita daily incidence below the global average (37.5 daily cases per million), and all but 8 are reporting fewer than 10 daily cases per million population. Other indicators not immediately available, including test positivity and excess mortality, may shed additional light on the pandemic's effects.
**The WHO refers to the country as Cape Verde, and the UN refers to it as Cabo Verde.

The US CDC reported 7.21 million total cases and 206,402 deaths. The US is averaging 42,446 new cases and 713 deaths per day. In total, 22 states (no change) are reporting more than 100,000 cases, including California with more than 800,000 cases; Texas with more than 700,000; Florida with more than 600,000; New York with more than 400,000; Georgia with more than 300,000; and Arizona, Illinois, New Jersey, and North Carolina with more than 200,000. Florida’s COVID-19 website has reported more than 700,000 total cases since at least the beginning of this week, but it is not yet reflected in the US CDC data. Notably, Florida’s COVID-19 dashboard reports both “total cases” and “positive residents.” The “positive residents” total just surpassed 700,000 cases, whereas the “total cases” is nearly 710,000—more than 10,000 more cases than are reported in the CDC data. It is unclear which data Florida is reporting to the CDC, but the CDC data appear to align more closely with Florida’s “positive residents” data. Minnesota’s COVID website is reporting more than 100,000 cases, and we expect that to be reflected soon in the CDC data. We also expect Illinois to surpass 300,000 cases; Tennessee to surpass 200,000 cases; and Mississippi to surpass 100,000 cases over the next several days.

The Johns Hopkins CSSE dashboard reported 7.29 million US cases and 208,068 deaths as of 12:30pm EDT on September 28.

PRESIDENT TRUMP TESTS POSITIVE Late last night, US President Donald Trump announced that he and First Lady Melania Trump tested positive for SARS-CoV-2. The announcement follows a report that Hope Hicks, one of President Trump’s closest advisers, tested positive earlier this week; however, the exact timing of the infections and potential sources of transmission remain uncertain. According to a timeline published by the Associated Press, Ms. Hicks felt unwell on Wednesday while onboard Air Force One, and she then she later tested positive. President Trump and his staff are tested regularly. In recent days, President Trump has traveled to participate in the first presidential debate, campaign rallies, and fundraiser events.

ISRAEL The Israeli Knesset, its national legislative body, passed several measures this week to combat the impacts of COVID-19. Israeli legislators passed the Special Powers for Dealing with the Novel Coronavirus Bill, which authorizes the government to declare a “special state of emergency” during a period of “national lockdown” that can be renewed weekly for up to 21 days. Under the state of emergency, the government can impose additional restrictions to mitigate SARS-CoV-2 transmission risk. In particular, the measures prohibit individuals from traveling more than 1 kilometer from their homes. Exceptions include seeking medical care. The government can also place additional restrictions on large gatherings, including religious services and demonstrations, but the events are not banned entirely. Some members of the Knesset have expressed concern that the additional restrictions are unconstitutional, arguing that the lockdown is political in nature. The Knesset also approved an economic aid package to support businesses impacted by social distancing and other restrictions and maintain unemployment benefits for affected individuals. The bill will allow businesses to apply for grants if they “sustained a 25% drop in volume compared to the corresponding period last year.”

UNITED KINGDOM In recent weeks, the UK has reported a sharp increase in daily COVID-19 incidence, and the UK government is implementing new restrictions to reduce inter-household interactions and reduce community transmission. The most recent restrictions will be implemented in the port city of Liverpool, as local case numbers continue to rise. The UK announced similar measures on September 28 for 7 areas in the northeastern part of the country. The announcement notes that 6 of the 7 areas are reporting more than 1,000 daily cases per million population. Schools and businesses designated as “COVID-safe” are not impacted by the new restrictions. The enhanced restrictions advise individuals to avoid contact with people outside of their household or “bubble” when indoors, including restaurants and pubs.

A recent large-scale study found that the trajectory of the UK’s COVID-19 epidemic is beginning to slow, providing evidence that the UK’s current approach is helping to reduce SARS-CoV-2 transmission. The study, conducted by researchers at Imperial College London, involved diagnostic testing for more than 84,000 individuals, and the researchers estimate that 0.55% of the entire population is actively infected with SARS-CoV-2, up from 0.13% in a previous study. Notably, however, the researchers estimate that transmission is slowing—with an estimated reproductive number of 1.1, compared to 1.7 in the previous study. The ongoing study aims to test 150,000 randomly selected individuals each month.
INDIA EPIDEMIOLOGY A study published in Science analyzed surveillance and contact tracing data from two South Indian states, Tamil Nadu and Andhra Pradesh, collected through August 1. This is one of the few studies that captures the epidemiology of COVID-19 in low- or middle-income countries on a large scale. Together, these states account for approximately 10% (127.8 million) of India’s national population, and they contain the most robust healthcare workforces and public health infrastructure in the country. The study provides a detailed look at the timeline and growth of the COVID-19 epidemics in these states, including incidence and mortality.

The researchers found that the majority of cases (71%) did not result in secondary transmission to any of their contacts identified through contact tracing efforts. Based on data collected from more than 600,000 cases and contacts, the researchers estimate that 8% of the detected COVID-19 cases accounted for 60% of the transmission, providing further evidence that super-spreading events play a major role in the COVID-19 pandemic. The researchers also identified that transmission among individuals of approximately the same age was highest among children under 15 years old and adults 65 years and older. While the researchers were not able to determine the degree of transmission from children to adults, the study results support that pediatric cases do play a role in the ongoing pandemic. Overall, the case fatality ratio was 2.06%, and generally increased with age; however, unlike the US, mortality tended to plateau rather than increase in individuals 75 years and older. The reasons for this trend are uncertain. Additionally, the median hospital admission time before death was 6 days.

IMPACTS ON CHILDREN The far-reaching economic and societal impacts of the COVID-19 pandemic have raised concerns in recent months about the rise of child labor in many countries. Due to a combination of interrupted schooling and household financial instability, children are going to work in grueling and dangerous jobs to support their families. While many schools have implemented some level of virtual learning, UNICEF has warned that approximately 463 million children cannot access remote learning due to a range of factors, lack of access to computers, reliable internet access, or other technology. Additionally, approximately 24 million children are projected to drop out of school entirely as a result of the pandemic. These challenges are affecting students in countries and communities at all income levels; however, low-income countries and communities living in poverty are the most severely impacted.

LONG COVID A commentary published in The BMJ: Opinion highlights the increasing importance of long-term effects of COVID-19. The article, authored by researchers across several UK universities, makes the case for using the term “Long COVID” to describe this condition, which can persist in some COVID-19 patients for weeks or months after recovery from the acute stage of the disease or infection. A number of terms have been used to address this condition—including “long haulers,” as we have covered previously. The authors argue that the term “Long COVID” is sufficiently non-specific to account for the many outstanding unknowns associated with the condition—including the timeline and duration, clinical presentation, severity, and cause—and it highlights morbidity as a major concern for COVID-19 patients, as opposed to just mortality. As the authors note, clinicians, researchers, and policymakers need to acknowledge “Long COVID” as a condition, and further study is necessary to better characterize the longer-term effects of COVID-19, which will enhance our understanding of the full impact of the ongoing pandemic.

GLOBAL RAPID TESTING The WHO announced a plan to increase testing capacity across low- and middle-income countries. The plan will distribute 120 million SARS-CoV-2 tests to 133 countries. The low-cost rapid tests, which can provide results in as little as 15-30 minutes and do not require advanced laboratory equipment to process, have garnered considerable attention in recent weeks as they are implemented in a variety of settings. These tests aim to provide critical testing capacity for low- and middle-income countries, particularly in areas without the necessary equipment or trained personnel to perform more traditional diagnostic tests. Initial funding for the program to support the scale-up of production capacity was provided by the Bill and Melinda Gates Foundation, and WHO Director-General Dr. Tedros Adhanom Ghebreyesus called on countries to provide the funding necessary to purchase the tests. The tests are scheduled to be provided over the next 6 months.

SOCIAL & PHYSICAL DISTANCING A study published in The Lancet explores lessons identified as countries began to ease social distancing measures implemented in response to COVID-19. The researchers evaluated efforts to scale back social distancing measures in 9 high-income countries—5 in the Asia Pacific region, and 4 in Europe. They documented and categorized the approaches used in each country’s recovery plan, including key metrics used in determining when to proceed to the next step. The authors conclude that effective transition from COVID-19 restrictions did not rush to return to pre-pandemic practices, but rather, worked to establish a “new normal.” Effective policies incorporated the principle of physical distancing into recovery phases and supported individuals and businesses in effectively modifying behaviors to reduce risk while resuming some level of normal activity. Additionally, countries must be able to recognize when it is necessary to increase restrictions in response to unacceptable levels of community transmission.

As countries continue to ease social distancing restrictions and increase social and economic activity, the age distribution of COVID-19 cases is shifting toward younger portions of the population. This shift has led a number of experts, elected officials, and pundits to blame associated resurgences in community transmission on younger individuals. Younger individuals are perceived to be responsible due to increased activity at restaurants and cafes, pubs and bars, parties, and other social gatherings as well as a perceived aversion to maintaining appropriate physical distancing. Recent survey data published by the Life with Corona network suggests that young adults are undertaking recommended protective actions to mitigate transmission risk. While the researchers identified an association between increased age and increased participation in protective measures, the actual difference in the degree of participation between age groups was small.