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.
SYSTEMIC RACISM & COVID-19 The Johns Hopkins Center for Health Security’s journal, Health Security, issued a call for papers for an upcoming Special Feature on systemic racism in the context of the COVID-19 pandemic (scheduled for May/June 2021). The COVID-19 pandemic’s impacts on health, economies, and social structures have disproportionately impacted racially marginalized populations. Racial and ethnic minority communities are experiencing elevated COVID-19 morbidity and mortality, stemming in part from ineffective response efforts and longstanding barriers to accessing healthcare and public health programs and services. Evidence-based and peer-reviewed research is urgently needed to examine the root causes and impacts of systemic and pervasive racial and ethnic inequities in the context of COVID-19 as well as how systemic racism manifests in the practice of health security, including in preparedness for, response to, and recovery from COVID-19. The journal is actively encouraging submissions from women, underrepresented minority scholars in health security, and scholars with disabilities. Additional information is available here.
EPI UPDATE The WHO COVID-19 Dashboard reports 40.67 million cases and 1.12 million deaths as of 12:00pm EDT on October 21. As the cumulative global incidence surpasses 40 million, the following timeline will provide some context for the trajectory of the COVID-19 pandemic:
1 case to 1 million cases: 90 days
1 million to 5 million: 48 days
5 million to 10 million: 38 days
10 million to 20 million: 44 days
20 million to 30 million: 37 days
30 million to 40 million: 31 days

The US CDC reported 8.19 million total cases and 219,499 deaths. The daily COVID-19 incidence continues to increase, now up to 57,291 new cases per day, the highest since August 5. The US COVID-19 mortality increased from approximately 700 deaths per day to 721, but additional data is needed in order to determine if this is the start of any longer-term trend or if it is just a temporary spike.

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

As the current US COVID-19 surge continues, patient demand is beginning to threaten hospitals and health systems in some parts of the country. Nationally, 37 states are reporting increasing COVID-19 hospitalizations, including 21 states that have recently reported new records or are near their previous record and still increasing. Current COVID-19 hospitalizations are increasing nationally, but the trend is more pronounced throughout the Midwest region. There are also increases in hospitalizations in states that were more severely affected earlier in the US epidemic, although to a lesser degree, including those affected in the early stages of the US epidemic (e.g., New York, New Jersey, Massachusetts) as well as the summer resurgence (e.g., Alabama, Arizona, Texas). The majority of states in each region—West (9/13), South (13/16), Midwest (12/12), and Northeast (6/9)—are reporting increasing hospitalizations over the past several weeks. Additionally, 12 states are reporting more than 1,000 currently hospitalized COVID-19 patients, representing 3 of the 4 regions—although New York and Pennsylvania in the Northeast region are both reporting more than 900 hospitalized cases.

The Johns Hopkins CSSE dashboard reported 8.29 million US cases and 221,460 deaths as of 1:30pm EDT on October 21.

RACIAL & ETHNIC DISPARITIES A recent study, published in the US CDC’s MMWR, was conducted by researchers at the US CDC and the New York City Health+Hospitals health system. The study included data from all COVID-19 deaths reported in the National Vital Statistics System over that period, totaling more than 114,000 deaths. The researchers found that the relative proportion of deaths among White persons and Black persons decreased from May through August and increased among Hispanic persons, from 16.3% of COVID-19 deaths to 26.4%. One possible explanation for this outcome could be the geographic shift in COVID-19 from the Northeast to the South and West regions of the country in the summer months. Notably, the relative proportion of COVID-19 deaths in the South increased from 23.4% of national COVID-19 deaths to 62.7% over that period, and the relative proportion in the West increased from 10.6% to 21.4%.

Racial and ethnic minorities also represent a disproportionate proportion of pediatric COVID-19 deaths. Another study published in the MMWR found that 104 of 121 (86%) COVID-19 deaths reported among individuals under the age of 21 (through July 21) were non-White, including 35 Black children and 54 Hispanic children. Although White children make up approximately 50% of all children in the US, the emerging data indicates that they are less likely to die from COVID-19 than their peers. The impacts of systemic racism and racial disparities must be proactively addressed by all communities in order to mitigate these disproportionate outcomes.

US TESTING A monthly survey by Northeastern, Harvard, Rutgers, and Northwestern Universities found that SARS-CoV-2 test results are being returned sooner than they were earlier in the US epidemic, but still not fast enough to support effective disease control efforts. The nationwide study included more than 50,000 individuals, and data were weighted to match US national demographics, including age, race/ethnicity, and education level. Among those surveyed, more than 12,000 reported being tested for SARS-CoV-2, including nearly 9,000 who were tested using a nasopharyngeal swab. From April to September, the average time to return test results fell from 4.0 to 2.7 days, and the percentage of tests returned within 24 hours increased from 23% to 27%.

Notably, only 56% of those who tested positive reported being contacted as part of contact tracing efforts. Black and Hispanic Americans reported longer wait times, with an average of 4.4 days and 4.1 days respectively, compared to an average wait for 3.5 days for White individuals and 3.6 days for Asian Americans. In addition to delays in receiving test results, Americans continue to face delays in obtaining tests. Over one third (35%) of respondents indicated that they "had to wait at least 3 days between the decision to get a test and receiving the test," which further increases the time that they could be infectious before receiving test results.

ECONOMIC STIMULUS PACKAGE The US Congress is continuing to negotiate another large stimulus package to relieve some of the economic strain from COVID-19. While progress has reportedly been made toward a compromise between Speaker of the House Nancy Pelosi and Secretary of the Treasury Steven Mnuchin, it remains unclear whether a final deal could be reached in time to pass the legislation before the upcoming election on November 3. Speaker Pelosi’s core demands for the package include tax cuts for the lower-income individuals, a national SARS-CoV-2 testing program, and aid to state and local governments to support COVID-19 response activities. Secretary Mnuchin, representing the White House in the negotiations, reportedly opposes the proposed tax credits and the overall size of the package, which could be on the order of US$2 trillion. Reports suggest they agree on the need for additional direct stimulus payments to individuals, a testing and vaccination strategy, and relief for businesses.

US EXCESS DEATHS Researchers from the US CDC National Center for Health Statistics evaluated all-cause mortality data to determine the number of excess deaths during the US COVID-19 epidemic. The term “excess deaths” refers to the number of deaths above what would be expected based on historical data, and it captures a more complete picture of the deaths associated with COVID-19. Excess deaths include those due to COVID-19 that went undiagnosed as well as non-COVID-19 deaths that occurred due to downstream impacts of the epidemic (e.g., delayed screenings or medical procedures). The study, published in the US CDC’s MMWR, evaluated provisional data from the CDC’s National Vital Statistics System from January 26 to October 3. The researchers found that nearly 300,000 more people died than would be expected during that period, including nearly 200,000 attributed directly to COVID-19. The COVID-19 mortality is consistent with US CDC reporting, which means that an additional 100,000 excess deaths occurred during that period that were not directly attributed to COVID-19. The distribution of excess deaths varied by age group and race/ethnicity. The excess deaths ranged from 841 for individuals less than 25 years old to 94,646 for adults aged 75-84 years. The relative increase above the expected deaths, however, peaked among adults aged 25-44 years (26.5% increase). As has been observed throughout the US epidemic, racial and ethnic minorities have been disproportionately affected. Compared to White individuals (11.9% increase above expected deaths), disproportionately higher mortality was observed among Hispanic (53.6% increase), Asian (36.6% increase), Black (32.9% increase), and American Indian/Alaska Native (28.9% increase) individuals.

US ELECTION The US general election will be held November 3, but early voting, including mail-in and in-person voting, is already underway in many states. Owing in part to concerns about COVID-19 and transmission risk at crowded polling sites, early voting in 2020 is setting records. The Associated Press reported that more than 22 million votes have been cast already, which equates to 16% of the total number of votes during the entire 2016 general election.

The COVID-19 epidemic is having a major influence on how and when people cast their votes. In the US, even federal elections are managed by individual states, so voting options and requirements vary from state to state. According to a report by ABC News, at least 33 states (plus Washington, DC) have implemented some form of mask mandate or recommendation for voters. Some states are also implementing options to accommodate individuals who cannot or will not wear a mask, including drive-through ballot drop-off and sequestered areas in which poll workers wearing extra personal protective equipment can provide assistance. For example, in Texas, the statewide mandate for mask use in public explicitly includes an exception for voters or poll workers, although mask use at polling sites “is strongly encouraged.”

COLLEGE FOOTBALL On August 11, the Big Ten collegiate athletic conference indefinitely postponed all fall sports due to COVID-19. A week later, in an open letter to the Big Ten community, the conference emphasized that the decision to postpone fall sports was “overwhelming” among university leadership and that the decision would “not be revisited.” On September 16, slightly more than a month after the initial decision—with input from athletes and their families, state and federal lawmakers, and US President Donald Trump—the conference announced a plan to resume athletic activity. The plan included widespread antigen testing for athletes and coaching and training staff members, and the opening week of college football was scheduled for October 23-24

With the first Big Ten football games scheduled for this weekend, we will look briefly at the current state of the COVID-19 epidemic in these states, compared to where they were on August 11, when the decision to postpone sports was made. In mid-August, most of the states that are home to Big Ten Schools—largely in the Midwest region—were beginning to come down from the peak of their respective summer COVID-19 surges. Since that time, however, nearly every one of these states has reported increased COVID-19 incidence. Notably, all except Maryland, New Jersey, and Pennsylvania have reported new record high daily incidence since the first announcement in August. Additionally, Wisconsin and Nebraska are currently reporting higher per capita daily incidence than New Jersey did at its first peak in April. COVID-19 hospitalizations, intensive care unit hospitalizations, and mortality are also increasing in most of these states. Wisconsin and Nebraska are currently reporting record daily mortality. In addition to incidence and mortality, most of the Big Ten states are also reporting increased test positivity since August, which indicates that existing testing volume is not sufficiently capturing the full scale of transmission. While some of the increases are slight or moderate, several states are reporting test positivity greater than 10%, which is concerning: Iowa (25.5%), Nebraska (18.2%), Wisconsin (12.6%).

Health officials in Washtenaw County, Michigan—home to Ann Arbor and the University of Michigan—issued a “stay in place” yesterday for University of Michigan students, as a result of increasing incidence among students and the university community. The order explicitly indicates that it does not apply to student athletes for practices and competitions—including Michigan’s first football game this weekend—as long as medical staff are present and monitoring activities. Washtenaw County recently reported record high COVID-19 incidence, and of the 4,200 cases reported across the county, 61% have been linked to the university, including more than 1,000 among students since they returned to campus in late August.

VACCINE CHALLENGE TRIAL A partnership between Imperial College London; hVIVO, an organization with experience conducting human challenge trials for respiratory pathogens; and the Royal Free London NHS Foundation Trust will move forward with human challenge studies in the evaluation of a candidate SARS-CoV-2 vaccine. In contrast to traditional, placebo-controlled vaccine clinical trials, challenge trials involve administering candidate vaccines to participants and then deliberately exposing them to the virus to evaluate the vaccine's efficacy. While challenge trials offer the potential to speed the evaluation process, they pose operational and ethical challenges.

The UK government is providing £33.6 million (US$44 million) to back the trial, including a contract with hVIVO worth £10 million (US$13 million); however, several barriers remain before the trial can commence, including reviews by ethics boards and regulatory agencies. The trial, dubbed UK COVID Challenge, will include 30-50 participants aged 18-30 years, and it will aim to identify a suitable vaccine dose to generate a protective immune response. More than 2,500 people have volunteered for the trial, according to 1Day Sooner, a nonprofit organization that advocates for human challenge trials as a way to speed the evaluation of candidate vaccines. The group has drawn the interest of more than 38,500 prospective participants for human challenge trials across the globe. The UK trial is expected to begin in January 2021, with results anticipated by May. 

The NIH Vaccine Working Group published a commentary in The New England Journal of Medicine in July, which outlines several major risks and concerns about challenge trials for a SARS-CoV-2 vaccine as well as some of the practical considerations for implementing them. The most notable limitation is that there are currently no "reliable treatment" options for COVID-19, which places participants at risk with limited options available to provide clinical care if they get sick.