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 41.57 million cases and 1.13 million deaths as of 9:30am EDT on October 23.

The US surpassed India in terms of daily incidence, resuming the #1 position globally with approximately 60,000 new cases per day. This means that the US is again increasing its lead over #2 India in terms of cumulative COVID-19 incidence.

The current COVID-19 resurgence in Europe and the US have been well covered globally, as well as India’s epidemic and the high-profile success of countries like New Zealand. Today, we briefly discuss global trends in COVID-19 incidence, with a specific focus on parts of the world that are receiving less attention recently.
Notably, Central and South America, which were major global hotspots several months ago, are largely reporting decreasing COVID-19 incidence, as is the nearby Caribbean region. While there are some exceptions, many countries in Sub-Saharan Africa are reporting decreasing incidence as well. Additionally, daily incidence is decreasing in most of the Eastern Mediterranean region, which includes numerous countries that previously reported among the highest per capita incidence in the world. This trend continues across much of South and Southeast Asia as well, including India, which has reported a decrease of 40% over the past 5 weeks.

These trends can also be observed on a continental level, with incidence decreasing in South America and Asia (driven principally by India), increasing moderately in North America, and increasing more sharply in Europe (nearly doubling over the past 2 weeks). Incidence in Oceania is increasing sharply as well, but Oceania has generally reported very low incidence over the course of the pandemic, so even minor absolute increases result in large relative changes. Similarly, incidence in Africa appears to be increasing at approximately the same rate as North America, but this is a result of a much smaller absolute change due to Africa’s generally low incidence, particularly on a per capita basis.

The US CDC reported 8.31 million total cases and 221,438 deaths. The daily COVID-19 incidence continues to increase, now up to 59,699 new cases per day, the highest since August 3. Following the previous peak (66,960 new cases per day on July 24), the US daily incidence fell by 48% to its most recent low (34,371 new cases per day on September 12). Since that time, however, the US has climbed more than 75% of the way back to its highest peak, and still increasing steadily.

The US COVID-19 mortality increased for the third consecutive day, up from approximately 700 deaths per day to 773—a 10% increase and the highest average since September 19. It is still too early to determine if this is the beginning of a longer-term trend.

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

Wisconsin is averaging more than 3,500 new cases per day over the past week, so we expect it to surpass 200,000 cumulative cases in the next several days. 

The Johns Hopkins CSSE dashboard reported 8.43 million US cases and 223,289 deaths as of 12:30pm EDT on October 21.

LOMBARDY, ITALY Early in the COVID-19 pandemic, Italy’s Lombardy region was one of the most severely affected parts of the world. According to Italy’s Ministry of Health, the region has reported more than 143,000 total cases, including more than 17,000 deaths. The initial patient surge overwhelmed Lombardy’s health system, and approximately 12,000 healthcare workers were infected. In order to better understand the impacts and drivers of the epidemic, the Regional Council of Lombardy created a “COVID-19 investigative commission.” The commission will “analyse the sequence of events and the specific choices that led to so many infections and deaths” with the aim of learning and sharing lessons and providing “accountability [for] the Italian people.” The commission will assess a variety of data and include input from technical experts in order to characterize the COVID-19 epidemiology, response, and effects on the region. A member of the commission indicated that this effort is the first of its kind in Europe, and possibly globally.

IRELAND Ireland is implementing one of the most restrictive sets of social distancing measures in Europe in response to its “second wave” of COVID-19. This week, Ireland entered Phase 5 “lockdown,” the highest level in Ireland, which includes restrictions on social gatherings (indoors and outdoors), including weddings and funerals; religious services; retail businesses, restaurants, cafes, and pubs; essential services; sporting events and outdoor activities; and travel, hotels, and public transportation. Notably, schools and childcare services will remain open in Phase 5. Households are permitted to form a “support bubble” with one other household, under specific circumstances. The Irish government is also increasing financial assistance for unemployed individuals under Phase 5. The Phase 5 restrictions are currently scheduled to last at least 6 weeks. In early October, when Ireland was at Phase 2, senior medical experts in Ireland reportedly called on the government to move immediately to Phase 5, arguing that this was the only option to contain transmission while keeping schools open; however, Ireland moved one step to Phase 3, which still permitted many aspects of social and economic activity to continue. Ireland has reported nearly 55,000 cases and more than 1,800 deaths, and its daily incidence has increased by a factor of 11 since early September, setting new records there.

KENYA Following efforts by the Kenyan government to ease social and economic restrictions, Kenya is reporting a second surge in COVID-19 incidence. The policy changes included shifting the start of a nationwide curfew to a later hour in order to support bars and restaurants and a partial reopening of public schools. Kenyan President Uhuru Kenyatta announced the changes during a national address in late September, in which he discussed the challenges Kenya endured over the early stage of the pandemic and called for continued vigilance by Kenyans to contain the virus. The restrictions implemented in response to Kenya’s “first wave” of transmission enabled the country to largely bring its epidemic under control; however, Kenya has seen a steady increase in COVID-19 activity since mid-to-late September. Since its low of 118 new cases per day on September 21, Kenya’s daily incidence has increased by a factor of 5. It has nearly returned to the height of its first peak and is still increasing rapidly.

KYRGYZSTAN The government’s response to COVID-19 has added fuel to protests in Kyrgyzstan that started in opposition to disputed results of the country’s parliamentary election. In addition to concerns about the validity of the election results, protestors expressed frustration with the lack of government support during the national “lockdown.” According to a report by Reuters, some protestors indicated that citizens were largely left to “fend for themselves,” which has contributed to growing anger and opposition toward government leadership. Kyrgyzstan relies on external travel with China and Russia to support the national economy, and many have argued that the government did not do enough to support their citizens financially following the border closure and travel restrictions. COVID-19 daily incidence has been increasing in Kyrgyzstan since its low in mid-September, increasing from approximately 57 new cases per day to more than 500 over that time. 

WHO REFORM The German government and the EU reportedly drafted a document calling for reforms that aim to increase transparency by the WHO. The WHO has received criticism over the course of the COVID-19 pandemic, including for a perceived shortage of information shared publicly in the pandemic’s early stages. US President Donald Trump has repeatedly cited a lack of transparency, with a particular focus on China, as one of the primary reasons for his decision to withdraw the US from the WHO. According to a report by Reuters, the document is part of an ongoing EU effort to improve WHO’s capabilities. The report also indicates that the EU proposal aims to reduce the impact of “political influence” on WHO activities and reporting as well as increase funding and address the WHO’s lack of legal authority to take and compel action around health issues. The proposal is still in draft form and, to our knowledge, has not yet been published publicly. 

GERMANY Following a recent surge to more than 10,000 new cases per day, Germany issued travel warnings for nearby European countries, including popular tourist destinations such as Austria, Italy, and Switzerland. Returning travelers from these countries must self-quarantine for 10 days; however, if the individual tests negative after the fifth day, they can end their quarantine period early. The new travel policies take effect on October 24, and they are an expansion of previously issued warnings corresponding for more than 10 European countries, based on the Robert Koch Institute's list of high-risk areas. Countries across Europe are facing a severe resurgence of COVID-19, worse than the “first wave” in many countries. While the new measures may impact tourism to affected regions or countries, other tourist regions such as Spain’s Canary Islands have recently been removed from the Robert Koch Institute’s list of high-risk areas. 

Additionally, German Health Minister Jens Spahn recently tested positive for SARS-CoV-2. While Minister Spahn is in isolation and reportedly exhibiting “cold-like symptoms,” no other members of Chancellor Angela Merkel’s cabinet will be subjected to quarantine, despite having contact with Minister Spahn earlier in the week. The extent of the contact between Minister Spahn and other cabinet members is unclear; however, government officials indicated that quarantine is not warranted, based on Germany’s public health guidelines.

US CDC UPDATES “CLOSE CONTACT” DEFINITION The US CDC published updated guidance regarding the definition of “close contact” for COVID-19. The new iteration of the guidance indicates that even brief contact with infectious individuals could result in transmission. Both the previous version and the newest iteration define close contact as being within 6 feet of an infectious individual for 15 minutes, but the new version notes that the time is cumulative over a 24-hour period. This could include being within 6 feet of an infectious individual for 3 separate periods of 5 minutes each, whereas the previous version was generally understood as referring to a single, prolonged exposure period. The CDC guidance continues to emphasize that it is difficult to concretely define what qualifies as close contact and that the guidance is an “operational definition for contact investigation.”

The change was reported motivated by a case study recently published in the US CDC’s MMWR. The study documents suspected SARS-CoV-2 transmission over the course of multiple short exposure periods. The event occurred at a correctional facility in Vermont (US), and a correctional officer was infected after “multiple brief encounters with six incarcerated...persons” who were awaiting the results of SARS-CoV-2 tests after their arrival at the facility. All 6 individuals ultimately received positive test results. Review of video surveillance showed that the correctional officer was not within 6 feet of any of the individuals for a 15-minute period, and therefore, he was not identified as a close contact. The officer was not included in contact tracing efforts, and he was permitted to continue working. He later developed COVID-19 symptoms and tested positive for SARS-CoV-2. Further evaluation of the surveillance video found that the correctional officer was within 6 feet of the infected incarcerated individuals at least 22 times, totaling approximately 17 minutes over the course of an 8-hour shift. This example illustrates that SARS-CoV-2 transmission can occur over much shorter periods of contact than suggested by previous CDC guidance.

REMDESIVIR APPROVED The US FDA announced that it approved remdesivir as treatment for COVID-19, the first drug to obtain full regulatory approval (as opposed to an Emergency Use Authorization [EUA]). According to the official announcement, the approval applies to hospitalized COVID-19 patients aged 12 or older and weighing at least 88 pounds (40 kg). Remdesivir’s EUA remains in effect for hospitalized pediatric patients under the age of 12 and weighing at least 7.7 pounds (3.5 kg) and for hospitalized patients aged 12 and older and weighing 7.7-88 pounds (3.5-40kg). The FDA’s decision was based on the findings from 3 randomized controlled trials that demonstrated a statistically significant effect in terms of speeding recovery among hospitalized COVID-19 patients. However, the trials did not identify an improvement in the odds of recovery/reduction in mortality.

VACCINE CLINICAL TRIALS Moderna Therapeutics completed enrollment of the Phase 3 clinical trial for its candidate SARS-CoV-2 vaccine. The trial enrolled 30,000 participants, including more than 12,000 Americans who are over the age of 65 or have high-risk health conditions. Approximately 42% of the total trial population is at elevated risk for severe COVID-19 disease and death, including those with a myriad of underlying health conditions: diabetes (36%), severe obesity (25%), severe cardiac disease (19%), and chronic lung disease (18%). Additionally, 37% of enrollees are racial or ethnic minorities. Notably, 10% of all enrollees are Black, 20% are Hispanic or Latinx, and 4% are Asian. Black enrollment in the study is slightly lower than the proportion of Black individuals in the overall US population, but the diversity of the participants has been viewed positively, particularly considering that Moderna faced challenges enrolling participants from certain racial and ethnic minority groups.

It was widely reported this week that a participant enrolled in the Phase 3 clinical trial for the AstraZeneca/Oxford candidate vaccine trial died, raising concerns about the safety of the vaccine and the clinical trial timeline. The participant was a 28-year-old physician in Brazil who treated COVID-19 patients. However, according to multiple reports, the patient was a member of the control group, and did not receive the candidate SARS-CoV-2 vaccine. Rather, the participant received an approved meningitis vaccine. Because the death was not attributable to an adverse event associated with the candidate vaccine, the trial can continue. Focus has remained centered on developments in the AstraZeneca clinical trials around the world, particularly after the trials in the UK and other countries were paused after a participant was diagnosed with transverse myelitis. The trial has since resumed in the UK and other countries, but not in the US.