EPI UPDATE The WHO COVID-19 Dashboard reports 43.5 confirmed COVID-19 cases and 1.16 million COVID-19 deaths as of 8:30am EDT on October 28.
The US CDC reported 8.68 million total cases, 225,084 total deaths, and 492,026 new cases in the past 7 days. The daily COVID-19 incidence continues to increase, now up to 63,589 new cases per day, compared to 59,699 new cases reported last Wednesday and almost as high as the peak incidence in late July. 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 about 94% of the way back to this previous peak. The 7 day moving average of mortality was 797 deaths for October 26, compared to increasing numbers of daily deaths in recent weeks, with most recently 815 deaths on October 25th.
Most US states now have at least 100,000 cumulative cases, including 12 states with more than 200,000 cases:
Per capita, states in the West and Midwest - including but not limited to Montana, North and South Dakota, Wisconsin, Wyoming and Idaho - have reported at least 50 new cases per 100,000 population per day within the past 7 days. North and South Dakota have reported 102.7 and 95.6 cases per 100,000 population.
US HOSPITAL CAPACITY Healthcare systems across the United States are feeling the burden of increased COVID-19 incidence. Hospitals in communities across the country are nearing full capacity as the number of currently hospitalized patients exceends 41,000. According to The Atlantic’s COVID Tracking Project, there is an estimated 46% increase in domestic hospitalizations, a continuation of a disconcerting trend. Despite this surge in new infections, the mortality rate for COVID-19 has remained relatively stable. T his is good news considering the rise in new infections, but the quality of care could be at risk if availability of care becomes more limited. Individual states have taken new actions to accommodate the rise in COVID-19 hospitalizations. Wisconsin has opened a field hospital at their state fair grounds, and other states have begun discussions about rationing care if infections continue to rise. In Utah, Governor Gary Herbet spoke with the president of the Utah Hospital Association about a potential need to decide which patients receive treatment in intensive care units. The state has not had to put these measures into place, but the discussion underscores the severity of the current epidemiological situation.
AIR TRAVEL The United States Transportation Command released results of a study looking at SARS-CoV-2 exposure on a contracted airline. The test used a Boeing 767-300 and 7770200 aircraft to map particle concentration for passengers in different zones of the aircraft in real time. Over the course of 8 days, the research team conducted over 300 aerosol releases in different situations to get a better picture of the risk of transmission during all aspects of a commercial flight. In total, the researchers found little evidence of aerosol exposure during the tests they performed. They attribute this to the high air exchange rates, and found that aerosol particles remained detectable within the cabin less than 6 minutes on average. The researchers noted that their test conditions only took into account the presence of a single infected passenger.
This research adds to the growing body of literature examining the safest ways for individuals to conduct air travel during the COVID-19 pandemic. Southwest Airlines cited the study above, as well as studies from IATA and the Harvard T.H. Chan School of Public Health, while announcing the reversal of a policy that blocked individuals from filling the middle seat in their plane’s three-seat passenger rows. The discussion to open the middle seat back to travelers is at odds with an earlier study from MIT that cited a protective value from flying with these seats empty. And a new study from Eurosurveillance describes a COVID-19 outbreak linked to a flight from Ireland this past summer.
VACCINE TRIALS Vaccine manufacturers Sanofi and GlaxoSmithKline have agreed to provide 200 million doses of their joint SARS-CoV-2 vaccine candidate to the COVAX Facility to foster equitable distribution of the vaccine. The candidate is a recombinant protein-based antigen with an adjuvant developed by GSK. The candidate is currently at the stage of phase I/II trials, with initial results expected by December. Sanofi has also been engaged with Translate Bio to develop a separate mRNA vaccine candidate, but that has not yet reached clinical trials. In other news, Pfizer recently announced that they have not yet been able to conduct an analysis of efficacy of their mRNA candidate vaccine. The announcement indicates that the trial is progressing more slowly than initially anticipated, with earlier estimates of the timeline suggesting that an analysis could be conducted as early as September. The news also follows discussions last week from the Vaccines and Related Biological Products Advisory Committee that expressed some hesitancy in prematurely issuing an emergency use authorization (EUA) without longer term assessment of the safety and efficacy of the vaccine, particularly because issuing an EUA would likely impact the ability for the longer trials and more robust analyses to occur.
VACCINE ROLLOUT Members of the US Advisory Committee on Immunization Practices (ACIP), an independent federal advisory board advising on the use of SARS-CoV-2 vaccines, published guiding principles last week on how vaccines should be allocated within the US population. The JAMA viewpoint focuses on ethical principles and allocation when supplies are limited, noting that more detailed recommendations will be issued once safety data is available following licensure or authorization under EUA. Recommendations from ACIP will be sent to the CDC director, and if approved, will become official CDC recommendations for immunizations in the US. Around the same time, stakeholders involved in Operation Warp Speed efforts discussed the preliminary distribution plans and potential challenges that would need to be addressed. Some of the key logistical challenges associated with vaccine distribution include the need for certain vaccine candidates to require -70 degree C freezers, which not all clinics have on hand. This week, the federal government is reportedly announcing a plan to cover out-of-pocket expenditures for SARS-CoV-2 vaccination to people enrolled in Medicare or Medicaid plans. The ruling, which to our knowledge has not yet been officially announced, is expected to determine that Medicare and Medicaid will cover out of pocket costs for vaccines that have an emergency use authorization.
SPORTS New publications in CDC’s Morbidity and Mortality Weekly Report are shedding light on the effectiveness of mitigation measures for preventing the spread of COVID-19 among amateur, collegiate and professional sports teams. One article described an outbreak among recreational hockey players in Florida. After the indoor game, nine players of one team and five players of the opposing team, as well as a rink staff member, reported symptoms of COVID-19. Eleven of the 15 individuals reporting symptoms tested positive for SARS-CoV-2 by RT-PCR and two others reported positive antigen tests. The other two symptomatic players and asymptomatic players were not tested. Mask usage and distancing were not adhered to during the game, which may have contributed to spread amongst the players.
The second article described an outbreak among men’s and women’s collegiate soccer teams. Seventeen of 45 players across both teams tested positive for SARS-CoV-2 with whole genome sequencing, indicating that all cases were linked to the same cluster. While team members were mandated to wear masks during practice, social gatherings without masks or distancing in place and shared accommodations between players were found to be the most likely circumstances where spread occurred.
The third article described SARS-CoV-2 transmission among 20 players and associated staff on a Major League Baseball team that resulted in no secondary transmission to other teams. Mitigation measures in place included regular diagnostic testing, isolation and quarantine as needed, mask usage, and social distancing. The authors concluded that transmission most likely occurred off-field during interactions that lacked physical distancing and proper mask usage, particularly social interactions occurring indoors. Major League Baseball concluded its 2020 season last night.
COLLEGES & UNIVERSITIES Colleges and universities across the country have experienced substantial financial and logistical challenges as a result of the pandemic, with some schools eliminating programs, furloughing faculty, and implementing austerity measures. The financial strain preceded the pandemic, but has been exacerbated by reduced enrollment and revenue, paired with substantial expenditures to support expansive testing, contact tracing, and quarantining of students. The American Council on Education published a letter last week stating that the pandemic would cost higher education institutions $120 billion. As part of response efforts, some universities are implementing studies to test wastewater and sewage for COVID-19. Testing wastewater is much cheaper than testing individual students, and implementation is more feasible in a dorm environment. The testing approach cannot identify which individuals are infected with SARS-CoV-2, nor how many infections there are. However, the data can indicate potential trends or the occurrence of an outbreak in a setting.
POLL WORKERS As the US approaches the general election on November 3rd, the CDC has published a study in the Morbidity and Mortality Weekly Report on Delaware’s efforts to protect poll workers and voters during their September 15, 2020 primary election. This study was performed as part of a collaboration between the CDC, the Delaware Department of Health and Social Services, and the Delaware State Election Commission. 522 poll workers were invited to participate in a self-administered survey about their experiences and observations during the 2020 Delaware primary election. The survey included questions on training, availability of personal protective equipment, polling location set-up, and mitigation measure compliance. Poll workers reported that personal protective measures, such as mask wearing and physical distancing, were generally well followed by fellow poll workers and voters. Despite personal measures and adjustments to distancing of polling booths, 72% of poll workers reported that they had been in close contact (<6 feet and >15 minutes) with more than 100 people on election through the course of performing their duties. Nearly half (45%) of surveyed poll workers were older than 65 years old, which may put them at higher risk of severe illness.
The results of this study reinforce the need for strict adherence to mask wearing, handwashing, and physical distancing while voting in-person. The CDC also proposed that recruiting younger poll workers could decrease the overall risk of severe disease within the voluntary workforce. Other recommendations to reduce crowding at polling locations include extending polling hours, reconfiguring polling booths and waiting lines to promote physical distancing, and encouraging greater adoption of voting options that are not in person.
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