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 35.66 million cases and 1.04 million deaths as of 10:30am EDT on October 7.

The US CDC reported 7.45 million total cases and 209,560 deaths. The US is averaging 43,852 new cases and 708 deaths per day. The daily mortality increased for the second consecutive day, after falling below 700 for the first time since mid-July. In total, 24 states (no change) are reporting more than 100,000 cases, including California with more than 800,000 cases; Texas and Florida with more than 700,000; New York with more than 400,000; Georgia and Illinois with more than 300,000; and Arizona, New Jersey, North Carolina, and Tennessee with more than 200,000. We expect Oklahoma to surpass 100,000 cases in the coming days. The CDC is reporting 98,244 total cases and 87,444 confirmed cases for Oklahoma, but the Oklahoma State Department of Health is reporting 93,346 cases. The reason for the discrepancy between the CDC and state health department data is unclear.

COVID-19 daily incidence continues to increase in most of the US. In addition to the Midwest, which we have addressed previously, a number of other states are also reporting concerning trends. The COVID Exit Strategy website categorizes all but 9 states and Washington, DC, as either Trending Poorly or Uncontrolled Spread. Among these 41 states, 13 are reporting test positivity greater than 10%, including 3—Idaho, South Dakota, and Wyoming—at 20% or greater. Notably, several of these states are reporting per capita incidence on par with or greater than the spring and summer peaks in other parts of the country—and still increasing (changes in testing availability make this an imperfect comparison). In fact, North Dakota is currently reporting more than 555 daily cases per million population, breaking the record set by Florida in mid-July.

The Johns Hopkins CSSE dashboard reported 7.52 million US cases and 211,343 deaths as of 1:30pm EDT on October 7.

AIRBORNE TRANSMISSION The CDC published new guidance on the potential for airborne transmission of SARS-CoV-2 earlier this week. The updated guidance distinguishes between droplet and airborne transmission (as well as contact transmission); however, it emphasizes that respiratory droplets exist in a spectrum of sizes, ranging from large droplets “that fall out of the air rapidly” to smaller droplets or particles “that can remain suspended for many minutes to hours and travel far from the source.” The guidance also describes aerosols—referring both to smaller droplets and particles and the “clouds of these respiratory droplets in the air”—and clarifies the public health definition of “airborne transmission”—specifically, transmission via “infectious, pathogen-containing, small droplets and particles suspended in the air over long distances and that persist in the air for long times.”

The guidance goes on to state that most SARS-CoV-2 infections are principally spread through “close contact,” primarily through respiratory droplet transmission within a short range of 6 feet or less, rather than airborne transmission. The guidance highlights certain conditions that can facilitate airborne transmission—including enclosed spaces, inadequate ventilation, and prolonged exposure (e.g., greater than 30 minutes)—due to the accumulation of suspended respiratory droplets that could increase exposure. The CDC emphasizes that certain protective measures can mitigate airborne transmission risk in enclosed spaces, such as increased ventilation, avoiding crowded indoor spaces, mask use, and enhanced hand hygiene and disinfection practices.

US ECONOMY The US has managed to recover only about half of the jobs lost due to COVID-19, and recent data, including the latest employment date published by the Bureau of Labor Statistics, indicate that the pace of this recovery has slowed. While there are still millions of Americans out of work, hiring has slowed over the past month. According to the most recent BLS jobs report, employers added 661,000 new jobs in September, compared to 1.5 million added in August. Federal Reserve Chairman Jerome Powell recently argued that the federal government should focus on providing more economic stimulus funding in order to support the struggling economy. Negotiations on proposed stimulus packages stalled recently when President Donald Trump announced his intention to suspend efforts to finalize a new stimulus package until after the election.

CDC DEPLOYMENTS The CDC COVID-19 Emergency Response Team and Division of Emergency Operations published an article in the CDC’s MMWR describing the deployment of CDC field teams to support state, tribal, local, and territorial health officials. As of July 25, the CDC deployed 208 teams involving more than 700 staff across 55 jurisdictions nationwide. Among these deployments, 26% were to long-term care facilities, 12% were to food processing facilities, 6% were to correctional facilities, and 5% were to homeless shelters. For those teams that completed their deployment by July 25, the mean deployment length was 20 days, with durations ranging up to 89 days. A total of 85% of the total deployments were to state health departments, and the remaining were distributed relatively equally between tribal, local, and territorial health departments. A total of 69% of deployments provided epidemiologic support, 37% provided infection prevention and control support in healthcare settings, 18% provided health communications support, 17% supported community mitigation efforts, and 15% supported occupational safety and health. The deployments were cited as informative for the development of epidemiologic publications describing key outbreaks in the US, characteristics of outbreaks and epidemics, and guidance on testing in long-term care facilities, homeless shelters, and food processing and meat packing facilities, and other settings.

WHITE HOUSE OUTBREAK Following the announcement that President Trump and other White House and elected officials tested positive for SARS-CoV-2, New Jersey state health officials are working to contact at least 206 individuals who attended a fundraiser event over concerns that they could have been exposed to confirmed COVID-19 cases, including President Trump. Similar events, including the presidential debate, were held in multiple other states and at the White House during the period in which President Trump and other known cases may have been infectious.

Without explicit detailed information on the results of contact tracing efforts for the White House outbreak, multiple efforts outside the White House are attempting to identify and track new cases and possible exposures, based on data available through official White House statements, media reports, personal accounts, and other publicly available sources. Among these efforts are The New York Times, Axios, and Tableau Public. To date, confirmed cases have been reported among a wide variety of individuals, including several who may be secondary cases with no direct exposure at the White House or other recent events (e.g., presidential debate).

Washington, DC, has faced a surge in demand for testing following news of the White House outbreak. Tests performed on Monday of this week represented an 81% increase from the previous week.

PRESIDENTIAL & VP DEBATES As the US moves closer to the general election on November 3, the candidates for president and vice-president have 3 more scheduled debates. The vice-presidential debate will be held tonight, and the final 2 presidential debates are scheduled for each of the next 2 weeks. In response to emerging information regarding the ongoing White House COVID-19 outbreak, particularly concern regarding Vice President Pence’s exposure to known cases, additional precautions are being implemented for tonight’s vice-presidential debate. Notably, plexiglass barriers will be erected between the candidates in an effort to better protect against droplet transmission. The candidates will maintain a 12-foot separation, and Vice President Pence has reported negative SARS-CoV-2 tests to date. Additionally, all attendees at the debate, with the exception of the moderator and candidates, will be required to wear a mask throughout the event.

VACCINE CLINICAL EUA STANDARDS The FDA published a guidance document to vaccine manufacturers regarding the process and standards to receive an Emergency Use Authorization (EUA) for SARS-CoV-2 vaccines. The document, which contains nonbinding recommendations, specifies at a high level some of the key information that manufacturers need to provide to the FDA in seeking an EUA for their vaccine candidates. Notably, the data from Phase 3 clinical trials should include a “median follow-up duration of at least [2] months” to assess both safety and efficacy. The document specifies that the “FDA does not intend to make a favorable determination” unless “well over 3,000 vaccine recipients” are monitored for serious adverse events or adverse events of special interest for at least 1 month after vaccination. Additionally, a total of 5 or more severe COVID-19 cases in the placebo group would “generally be sufficient” to evaluate the vaccine’s efficacy. 

The guidance was welcomed by public health authorities and other stakeholders, but it was met with some opposition. According to a report published by The Washington Post, senior White House officials delayed approval of the document. Of particular concern was the duration of follow-up, which would likely prevent a vaccine from receiving an EUA prior to the November election. Releasing the guidance publicly provides transparency into the metrics by which the FDA will review candidate vaccines and the standards required to move forward with an EUA. This transparency will be critical to establishing public support for future vaccines.

ANTIGEN TESTING A pilot program involving the US Department of Health and Human Services and The Rockefeller Foundation aims to assess approaches for using rapid point-of-care antigen testing to screen for SARS-CoV-2 infection. The program will involve multiple study sites across the US and will use at least 120,000 Abbott BinaxNOW SARS-CoV-2 antigen tests. On-site antigen testing could provide support for screening at schools, businesses, and other settings. As we covered previously, the US government recently purchased 150 million of these tests, which will be distributed to states for use in schools, long-term care facilities, and other priority settings. The BinaxNOW test is currently the only rapid point-of-care antigen test with an EUA issued by the FDA. The pilot study will support efforts to operationalize these screening programs, including at “laboratories, retail pharmacies, and other community entities.”

MONOCLONAL ANTIBODY TREATMENT EUA Pharmaceutical manufacturer Eli Lilly submitted an EUA request to the FDA for its monoclonal antibody cocktail as a COVID-19 treatment after clinical trials for the drugs met the target clinical endpoints. Results from a Phase 2 clinical trial indicate that a combination of two of Eli Lilly’s monoclonal antibodies reduced viral load in COVID-19 patients mitigated symptoms and resulted in fewer hospitalizations and emergency department visits. The study included 268 total participants with mild-to-moderate COVID-19 symptoms, 112 of whom received the treatment and 156 who received a placebo. Additionally, a press release issued by the company indicates that no serious adverse events were reported. The company stated that it aims to make 100,000 doses of a single antibody available by the end of October and 1 million by the end of 2020. For the combination therapy, the company hopes to produce 50,000 doses by the end of 2020, and it is collaborating with various external partners to ensure availability for lower-income countries.

LONG-TERM HEALTH EFFECTS Nine months into the COVID-19 pandemic, clinicians are observing more well-defined patterns of long-term health consequences for COVID-19 patients. A commentary published in JAMA describes some of the frequently reported manifestations in recovered patients. Although long-term health effects are more likely to be exhibited by patients with more severe disease (e.g., admitted to an intensive care unit), these effects are also being observed in persons with milder illnesses. General fatigue and dyspnea were the most commonly reported long-term sequelae, in addition to general joint and chest pain.

The authors also describe organ-specific manifestations in 3 specific organ systems: cardiovascular, pulmonary, and neurological. In the cardiovascular system, myocarditis and myocardial injury are being reported in patients with a range of disease severity, including individuals who were younger and healthier prior to infection. The presence of myocardial injury in previously healthy student athletes, for example, suggests that damage to the heart is a potentially serious complication of SARS-CoV-2 infection. In the lungs, one study found more than 60% of patients had persistent symptoms or other indication of pulmonary dysfunction 3 months after discharge from the hospital. Another study found decreased pulmonary muscle strength in nearly 50% of patients 30 days after discharge. Neurological sequelae such as anosmia and ageusia have been commonly reported, but encephalitis, seizures, mood swings, and “brain fog” have been identified in recovered COVID-19 patients as well, although less frequently. While larger studies on these long-term sequelae are still forthcoming, preliminary reports of serious health effects in major organ systems are sufficiently concerning to encourage adherence to prevention measures.