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 42.75 million cases and 1.15 million deaths as of 5:15am EDT on October 26. The WHO reported a new record high for global weekly incidence for the sixth consecutive week. The global total reached 2.85 million cases—an increase of more than 14% over the previous week. Additionally, the WHO reported 223,026 new cases on Monday.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. USA: 68,795 new cases per day (+12,788; ↑ 1)
2. India: 51,383 (-10,007; ↓ 1)
3. France: 34,496 (+11,344)
4. Brazil: 22,683 (+2,631)
5. United Kingdom: 21,627 (+4,671)
6. Russia: 16,363 (+1,989)
7. Italy: 15,934 (+7,464; ↑ 2)
8. Spain: 15,653* (+3,441; ↑ 1)
9. Argentina: 14,415 (+776; ↓ 2)
10. Belgium: 12,199** (+2,017; new)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Andorra: 1,222 daily cases per million population (-36)
2. Czech Republic: 1,123 (+366)
3. Belgium: 1,052 (+174; ↑ 2)
4. French Polynesia: 1,017 (+455 ; new)
5. Luxembourg: 811*** (+518 ; new)
6. Armenia: 680 (+283; ↓ 2)
7. Slovenia: 673 ( +366; ↑ 1)
8. France: 528 (+173; ↓ 1)
9. Liechtenstein: 528 (+206)
10. Netherlands: 522 (+74 ;↓ 6)

*Spain’s average daily incidence is not reported for today; these values correspond to the previous day’s averages.
**Belgium’s average daily incidence is not reported for today; these values correspond to the daily average two days ago.
***Liechtenstein is a member of the UN, but not the WHO. Liechtenstein’s COVID-19 data is reported by Switzerland.

This week, the US retook the number one global position for cumulative incidence and is reporting the highest number of global daily cases. The US, India, and Brazil remain significantly higher than any other country in terms of cumulative incidence with little signs of leveling off. While India’s daily cumulative incidence remains high, their daily incidence decreased by 16% compared to last week.

Belgium has moved into the top 10 countries for daily incidence this week, replacing the Czech Republic. Italy’s daily incidence grew the most this week, moving up to position 7 from position 9 last week. This growth represents an 88% increase over last week. In keeping with the past 3 weeks, France’s daily incidence has approximately doubled again at a 49% increase from last week. Argentina and Montenegro fell out of the top 10 in terms of per capita daily incidence, and they were replaced by French Polynesia and Luxembourg. Not only did these two countries enter the top 10 per capita daily incidence group, but they also jumped to #4 and #5 globally, respectively. French Polynesias’s daily incidence increased by 81% compared to the previous week, Luxembourg’s increased by 177%, and Slovenia’s increased by 119%. However, #1 position Andorra’s daily per capita incidence decreased by 3% this week compared to last week.

The US CDC reported 8.55 million total cases and 224,221 deaths. The daily COVID-19 incidence continues to increase, now up to 83,851 new cases per day, the highest since August 3. Last week, the US set a new record peak for new daily incidence with 85,329 cases on October 24. Following the expected dip in reporting over this past weekend, we will continue to track whether a new record peak will be set later this week.

The US COVID-19 mortality continues to hover around 900 deaths per day. Last week on October 22, daily new deaths reached 1,135, making it the worst day since September 24 when 1,104 deaths were recorded. It is still too early to determine if this is the beginning of a longer-term trend, but it is concerning that the mortality deviated to such a degree from a trend that persisted for nearly 3 weeks. 

More than half of all US states have reported more than 100,000 cases, including 11 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 8.64 million US cases and 225,247 deaths as of 10:24am EDT on October 26.

WHITE HOUSE INFECTIONS Marc Short, the US Vice President’s Chief of Staff, tested positive on Saturday. Four other aides have also tested positive, including political adviser Marty Obst and personal aide Zach Bauer. While Vice President Mike Pence and his wife have thus far tested negative on Saturday and Sunday. Devin O’Malley, a spokesperson for the Vice President, recently announced that the Vice President does not plan to quarantine and will continue campaigning as he is considered “essential personnel” - a reasoning typically only applicable to critical infrastructure workers who cannot work remotely, such as firefighters and police officers. These essential personnel may defer quarantine after exposure as long as they remain asymptomatic and additional precautions are put in place such as mask usage and social distancing. Health experts have condemned the Vice President’s decision to skip quarantine and continue attending in-person events - including his presence at a Sunday evening rally in North Carolina and his expected attendance at the Senate vote to confirm Judge Amy Coney Barrett to the Supreme Court today. Concerns have specifically been based on the Vice President’s past behavior of inconsistent mask wearing and from recorded increases in COVID-19 cases associated with campaign rallies

US COUNTY HOTSPOTS A recent publication from CDC’s Morbidity and Mortality Weekly Report explored the potential association between social vulnerability and COVID-19. Authors compared COVID-19 incidence for counties to their score with the CDC’s 2018 Social Vulnerability Index - an index that scores counties on fifteen social factors, such as the prevalence of poverty or crowded housing, in order to identify vulnerable counties that may require additional assistance to respond to disasters or outbreaks. Findings noted that counties with crowded housing and a high proportion of racial and ethnic minority residents were significantly more likely to be identified as a COVID-19 hotspot; although, other social vulnerability factors also showed positive associations with likelihood to be identified as a COVID-19 hotspot. Authors recommended that leaders at the local, state and federal level take additional measures to address social vulnerability factors in the context of COVID-19 such as culturally sensitive risk communication messaging, provision of temporary housing, and other supportive measures for COVID-19 patients residing in crowded housing units.

EFFECTIVENESS OF CONTROL MEASURES A recently published article in Lancet Infectious Diseases has taken a look at potential associations between country-level reproduction numbers (R) and non-pharmaceutical interventions introduced and lifted throughout the course of the pandemic. For context, R is an epidemiological metric that calculates the average number of people infected by one infected individual; an R value of 1 or higher indicates sustained transmission leading to a growing outbreak while an R value under 1 indicates a shrinking outbreak. Findings from the modeling study noted decreases in R associated with school closures, business or office closures, public event bans, stay-at-home orders and other movement restrictions. However, public event bans were the only measure significantly associated with a reduction of R to a value of 1 or less. 

Increases in R were associated with relaxing of the following measures: school closures, public event bans, bans on gatherings greater than ten people, stay-at-home orders and other movement restrictions. However, the only significant associations for increases in R above 1 were school reopening and lifting bans on gatherings over 10 people. Authors noted that the full effect of introducing or lifting non-pharmaceutical interventions took 1-3 weeks on average from the date of implementation. Authors made further recommendations regarding the use of non-pharmaceutical interventions by national governments, noting that other factors, such as population compliance, also influence the success of non-pharmaceutical interventions and may not be fully captured in the study. 

SPAIN As of last night, Prime Minister Pedro Sánchez has announced that Spain has declared a national state of emergency and implemented an evening curfew in response to a new rise in COVID-19 cases in the country. The evening curfew will be in place from 11pm to 6am nightly. Businesses and other establishments open to the public will need to close by 9pm each night to meet curfew requirements. Other new measures to control the spread of COVID-19 include a ban on travel between regions and a limit on gatherings to six people. These new measures will remain in place for at least the next 15 days, but may be extended to six months if parliament allows. Local officials will have some flexibility on implementation of measures, but thus far reactions to the new measures have been positive with some localities seeking greater restrictions. Madrid has imposed a ban on mixing households for overnight stays. The Canary Islands, a tourist destination, have been excluded from the newly implemented measures. 

CONVALESCENT PLASMA A study published last week in BMJ discussed the results of an open-label, Phase 2 PLACID trial of convalescent plasma in adults in India. In this multi-center, randomized control trial, 464 adult patients with moderate COVID-19 were separated into intervention and control groups and followed for 28 days post-enrollment. Despite general public hope for the use of convalescent plasma in treating COVID-19, this study found no evidence that convalescent plasma was associated with a reduction in disease severity or a reduction in all-cause mortality for their study population. This study is one of the first full RCTs for convalescent plasma rather than an observational study. While convalescent plasma transfusion appears to be a safe procedure, the actual benefits for COVID-19 patient recipients remains questionable. However, convalescent plasma transfusion is not without risks of its own; blood clotting is a potential risk of the procedure, and is particularly concerning among COVID-19 patients since blood clots are already a clinical manifestation of COVID-19. The authors of the study have called for more randomized control trials of convalescent plasma to further evaluate its efficacy in COVID-19 patients, even as its use has been authorized in many countries. 

VACCINE TRIAL RESTART Two major vaccine trials, those of AstraZeneca and Johnson & Johnson, are positioned to restart after being paused over potential safety concerns. The AstraZeneca trial was paused on September 6th, but after independent monitoring of the adverse event several trial sites in other countries resumed later in September. The US FDA held off on restarting AstraZeneca trial sites in the US through October in order to further investigate the event with their own team. The Johnson & Johnson vaccine trial was paused on October 11 after a participant suffered a stroke. This adverse event was also independently reviewed and a final report was sent to the US FDA that recommends the vaccine trial continue. The Johnson & Johnson trial can start re-enrolling participants as early as next week. This vaccine is of particular interest to many since it is a one-dose vaccine which would greatly simplify the process of quickly inoculating millions of people. The AstraZeneca vaccine has already shown promising preliminary results and seems to produce an immunogenic response in elderly participants as well as in younger ones. It is important that any eventual vaccine can produce immunogenic responses in the eldery, in children, and in those with underlying conditions. The Pfizer vaccine has begun to enroll a cohort of children between the ages of 12-18 to test its efficacy in this age group. 16- and 17-year-old volunteers are the first to be enrolled in this study, with researchers soon looking to enroll their younger peers.

TOCILIZUMAB A recently published study in the New England Journal of Medicine assessed the efficacy of the drug tocilizumab, an interleukin-6 receptor blockade, in patients hospitalized with COVID-19 in a randomized, double-blind placebo-controlled trial. It was hypothesized that administration of this drug could potentially disrupt the cytokine storm associated with COVID-19. The study involved 243 patients, 45% of whom were Hispanic or Latino, and about half of participants had a BMI above 30 and hypertension. Additionally about 31% of the participants had known diabetes mellitus. Patients were randomized 2:1 to receive standard care and a simple dose of tocilizumab or placebo, and key outcomes assessed included receiving time to intubation or death. A total of 11.2% of patients were intubated within 28 days or had died prior to intubation. The proportion of patients who experienced these outcomes in the tocilizumab group was about 2% lower than in the control group, though these results were not statistically significant. The authors concluded that the study data do not provide sufficient evidence supporting early administration of tocilizumab as an effective treatment for moderately ill patients hospitalized with COVID-19. Given the wide confidence intervals, the authors stated they could not draw any conclusions about whether the drug exhibits benefits or harms for COVID-19 treatment, and acknowledged that their study yielded different results than open label trials and non-randomized case series that had shown more positive results for using the treatment.  

POOLED TESTING A pre-print publication has recently reported on findings from a large-scale trial aimed at assessing the efficiency of using a pooled-testing strategy within an Israeli population from April to September 2020. The study analyzed 133,816 samples using 17,945 pools to determine how many tests could be spared compared to traditional testing approaches (efficiency), the diagnostic sensitivity, and the operational feasibility of implementing this approach. Despite fluctuating prevalence in the study population, the authors concluded that they spared 76% of potential PCR reactions compared to individual testing; however, the authors noted that there was an “acceptable” reduction in sensitivity. As the prevalence rate increased from 1% to 6% in the population, they switched from 8 sample pooling to 5 sample pooling, with about 9% of the 8 sample pools and 22% of the 5 sample pools testing positive. The sensitivity decreased by 3 cycle threshold levels (Cts), which the authors believed was a clinically acceptable and expected reduction as a result of pooling. The study, though not peer-reviewed, indicates the possibility for using pooled-testing strategies to use limited testing resources with greater efficiency without sacrificing on sensitivity of testing.

DOWN SYNDROME A new paper from the Annals of Internal Medicine aimed to assess the mortality risk of COVID-19 in individuals with Down syndrome. The study examined over 8 million individuals from the UK using a population-level primary care database, 4,053 of whom had Down syndrome. After adjusting for key demographic variables, the researchers estimated that individuals with Down Syndrome had a 4-fold increase of COVID-19 hospitalization and a 10-fold increase of death. The researchers emphasize that this estimated association between Down syndrome and COVID-19 is not a claim of a causal relationship, but argue that they warrant further investigation. Down syndrome is not currently listed as a COVID-19 risk factor within the United Kingdom or United States.