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 36.36 million cases and 1.06 million deaths as of 9:30am EDT on October 9. Yesterday, the WHO reported 336,500 new cases, setting a new record for global daily incidence.

The COVID-19 resurgence in Europe continues to exhibit concerning trends, leading a number of countries to re-institute social distancing and other restrictions to contain their respective epidemics. Europe recently surpassed North America in terms of per capita daily incidence, and it is on pace to surpass South America in the coming days. In terms of total daily incidence, Europe is on pace to surpass Asia in the very near future. Europe’s epidemic is now more than more than twice as large as during its first peak in early April.

Most countries in Europe* are exhibiting exponential growth, and have for several weeks or months. While the top countries in terms of per capita daily incidence are dominated by smaller countries (eg, Andorra, Montenegro), several countries with sizeable populations (eg, France, Spain, the Netherlands, the UK) are high on the list as well, illustrating the scale of transmission in Europe. The epidemics in most European countries continue to accelerate. The biweekly change in both incidence and mortality is positive for nearly every country in Europe, including a number of countries that are currently reporting increases of more than 100%, in one or both categories, over the past 2 weeks. A number of European countries have reported concerning increasing trends in test positivity as well—greater than 10% and still increasing in several countries—indicating that testing capacity may not be sufficient to accurately capture the full scale of increased transmission.
*We believe this is a fairly comprehensive listing of European countries; however, we had to select them manually. If we missed any countries or if data is unavailable for certain countries, we apologize. Any omissions were not intentional.

The US CDC reported 7.53 million total cases and 211,132 deaths. The US daily COVID-19 incidence continues to climb, now up to 44,984 new cases per day, the highest since August 20. Yesterday, the CDC reported 53,051 new cases, the highest daily total since August 15. The US COVID-19 mortality continues to decline slowly, now down to 675 deaths per day, the lowest daily average since July 10. We have observed previously, however, that mortality trends tend to lag 2-3 weeks behind incidence, so it will be important to monitor mortality over the coming weeks.

Half of all US states 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.

The Johns Hopkins Coronavirus Resource Center reported 7.62 million US cases and 213,016 deaths as of 12:30pm EDT on October 9.

NEW ZEALAND Following a COVID-19 outbreak in Auckland, New Zealand once again stepped down social distancing measures to Alert Level 1 nationwide. During the outbreak, the majority of the country remained at a lower Alert Level while more restrictive measures were implemented in Auckland. In June, New Zealand interrupted all domestic SARS-CoV-2 transmission and moved the entire country to Alert Level 1. New Zealand reported the Auckland outbreak on August 11, shortly after passing 100 days with no new domestic cases. New Zealand moved the affected area to Alert Level 3 and the rest of the country to Alert Level 2. New Zealand methodically stepped down restrictions in Auckland and the rest of the country as it steadily brought the outbreak under control. As of October 7, Auckland rejoined the rest of the country at Alert Level 1.

New Zealand has reported 2 cases over the past 24 hours, both of which were among individuals currently in the Managed Isolation and Quarantine program (eg, travelers arriving from other countries). No new cases associated with known clusters have been reported in the past 24 hours, but the Auckland outbreak will remain “Open” until 28 days—2 incubation periods—after the last case completes isolation. The Auckland cluster has been linked to 179 cases, the country’s largest outbreak to date.

LATIN AMERICA Countries throughout Latin America are still struggling to control outbreaks of COVID-19. Peru has faced challenges maintaining national testing capacity, so it is reportedly shifting its focus to serological tests to supplement traditional diagnostic testing capacity. The laboratory equipment and supplies required to conduct traditional PCR diagnostic testing for SARS-CoV-2 are often expensive, and the country does not have sufficient access to facilities that can conduct these types of tests. Serological tests detect antibodies produced in response to SARS-CoV-2 infection rather than the presence of the virus itself, and they are not traditionally used for diagnostic purposes. In an effort to overcome this limitation, the Peruvian government purchased approximately 1.6 million antibody tests from a number of foreign sources. Notably, the accuracy of many of these tests has been called into question, including multiple tests that have failed to receive any kind of authorization from the US FDA. Accuracy issues and inherent limitations of serological tests have resulted in many false negative results, which can delay diagnosis and treatment and increase the risk of severe disease and death. The use of antibody tests in place of more sensitive tests, like PCR-based diagnostics, has hindered the effectiveness of Peru’s COVID-19 response; however, expanded serological testing appears to have resulted in increased detection of cases. Peru has reported more than 190,000 cases and 33,000 deaths nationwide.

In Guatemala, the government reportedly denied entry to nearly 3,500 refugees who attempted to cross the border from neighboring Honduras due to concerns about COVID-19. It is unclear whether any of the individuals attempting to enter Guatemala were infected, but Guatemalan President Alejandro Giammattei argued that they were stopped because these types of caravans are capable of spreading the virus. The refugees were reportedly attempting to pass through Guatemala en route to Mexico and ultimately the US. Guatemala has reported more than 96,000 cases and 3,000 deaths. 

EUROPE Countries across Europe have been experiencing a growing surge of COVID-19 cases and hospitalizations, prompting states of emergency and shortages of medical supplies for some countries.

Earlier this week, the Czech Republic instituted a new state of emergency in response to the country’s growing COVID-19 epidemic. The order will last at least 30 days, and it will include highly restrictive social distancing measures, including closing secondary schools, prohibiting spectators at events, suspending indoor sporting events, restricting restaurant in-person service and operating hours, and limiting the size of events like weddings and funerals to 30 people. The Czech Republic reported new records for daily incidence for 3 consecutive days, and the epidemic is more than 10 times larger than during its first peak.

France is now averaging nearly 13,500 new cases per day, nearly 3 times the average at its first peak in early April. Additionally, approximately 40% of ICU beds among hospitals in Paris are currently occupied, illustrating the burden on the country’s health system. The rise in incidence has led Parisian authorities to shut down bars and cafes for 2 weeks, although restaurants can remain open. Additionally, residents have been strongly urged to work from home as much as possible. Paris hospitals have also been directed to implement emergency provisions in an effort to ensure surge capacity is available, including adding beds, postponing non-essential procedures, and suspending vacations for staff.

Last month, the European Parliament announced that a monthly parliamentary meeting that usually occurs in Strasbourg, France, would now be held in Brussels, Belgium, the home of the European Parliament. The decision was made due to concerns about hundreds of Members of Parliament and staff converging on France at a time when France and other European countries are battling a resurgence of COVID-19. French leaders opposed the decision, as the monthly meeting had been held in France since the European Union was first established. The monthly Strasbourg meetings were reportedly a point of contention even before the pandemic due to cost and logistical constraints, but the pandemic has exacerbated these tensions. 

The surge in cases across Europe has led to supply constraints for remdesivir. The UK has reportedly begun rationing remdesivir and prioritizing its administration only to those patients who need it the most. Reportedly, the UK Ministry of Health intends to maintain the rationing plan for several weeks, as supply is expected to increase later this month. That being said, availability will depend on future trends in SARS-CoV-2 transmission. Notably, hospitals in the northern part of the UK are facing major patient surges, and the director of public health in Liverpool indicated that some of the city’s hospitals could reach their maximum capacity in the next week. European countries have arranged to purchase 500,000 courses of remdesivir directly from the manufacturer, Gilead Sciences, to distribute as appropriate to countries in need. Currently, most of the global supply has been secured by the US, prompting concerns and criticism as other countries experience surges in infections.

COVID-19 SYMPTOMS & INFECTION Researchers at the University College London published findings from their analysis of whether COVID-19 symptoms are markers of SARS-CoV-2 infection. The study, published in Clinical Epidemiology, used data from the Office for National Statistics COVID-19 Infection Survey, which is a survey of households in England, the researchers estimated the sensitivity, specificity, and proportion of asymptomatic cases in order to determine the ability to use COVID-19 symptoms to predict SARS-CoV-2 infection. The study assessed data from more than 36,000 individuals tested between April and June. Among those tested, 625 (1.7%) reported symptoms at time of testing and 115 people tested positive (0.32%). Of the 115 people who tested positive, 76.5% were asymptomatic on the day they were tested. The researchers then assessed a subset of the study population that exhibited at least one of the following symptoms: cough, fever, or loss of taste/smell. Of the 115 individuals who tested positive, 99 (86%) did not exhibit those particular symptoms at the time of testing. The researchers concluded that the presence or absence of COVID-19 symptoms was a poor predictor of SARS-CoV-2 infection. This study provides further evidence of the high prevalence of asymptomatic infection or mild disease (ie, that may not necessarily be recognized as being symptomatic) during the COVID-19 pandemic.

DEBT RELIEF The President of the World Bank, David Malpass, called this week for debt forgiveness for low-income countries, which have been severely affected by the COVID-19 pandemic. The economic impact in many countries, coupled with the resources required to combat the pandemic, may make it impossible for some countries to repay their debts. He previously noted that the economic consequences on individuals could drive as many as 100 million people into extreme poverty, exacerbating the need for economic forgiveness in the coming months and years. In his recent comment, he called on private banks to play a more active and direct role in the debt recovery process, warning of the potential for an economic depression following extended restrictions to routine economic activity. 

POOLED TESTING STRATEGY A mathematician at Cardiff University (UK) published an algorithm that aims to improve the efficiency of pooled testing. Pooled testing is a technique that performs a single test on specimens from multiple individuals in order to reduce both the overall number of tests needed and the time required to obtain results. A positive test indicates that at least 1 person in the “pool” is positive (and additional testing may be required to determine who), but a negative test can rule out the entire pool. The new algorithm, published in Health Systems, utilizes multiple tests per pool, and each specimen is assigned to a unique subset of those tests. In an example provided in the overview published by SciTechDaily, 200 specimens may utilize 10 tests, and each specimen would be included in 5 different tests. If a single specimen is positive, the 5 tests that return positive results will correspond to only 1 specimen, eliminating the need for subsequent testing. If there are more than 5 positive test results, it indicates that multiple specimens are positive. If that is the case, mathematical analysis performed based on the quantity of virus present in each specimen can determine which specimens are positive without the need for further testing.

This is at least the second effort to develop algorithms to increase the efficiency of pooled testing. As we covered previously, a mathematical epidemiologist in Rwanda developed a similar process, utilizing a hypercube model (preprint) to create overlapping pools that can provide highly accurate results with 2 rounds of testing. Pooled testing can significantly increase the available testing capacity without the need for additional tests or equipment, which can enable large-scale, rapid screening and/or substantially expand testing capacity in resource-limited settings. Efforts to increase the efficiency of these programs can further expand available capacity.

MONOCLONAL ANTIBODY EUA Regeneron Pharmaceuticals applied for an Emergency Use Authorization (EUA) from the US FDA for its monoclonal antibody cocktail. Regeneron announced preliminary results from a Phase 1 clinical trial, which indicated that the drug showed promise in reducing viral loads and mitigating symptoms in non-hospitalized COVID-19 patients. The Phase 1 trial included 275 participants, and the Phase 2/3 portion of the trial aims to include 1,300 participants. If the EUA is issued, the drug will be made available to the public free of charge, and Regeneron stated that it has enough currently available to treat 50,000 patients. The company also expects to have enough for 300,000 patients “within the next few months.”

The antibody cocktail is one of the investigational drugs used to treat US President Donald Trump, but it has not yet been demonstrated to be safe and effective in clinical trials. President Trump reportedly received access to multiple drugs outside of a clinical trial and EUA via a process known as “compassionate use.” STAT News provided an excellent overview of various implications and factors in the decision to make investigational products like the Regeneron monoclonal antibody cocktail available to President Trump.

NEWS FROM THE CENTER: NEW PhD & SCHOLARSHIP OPPORTUNITY The Johns Hopkins Center for Health Security announced a new Health Security PhD track in the Johns Hopkins Bloomberg School of Public Health Department of Environmental Health and Engineering. The track will begin accepting students for the 2021-22 school year, and applicants can indicate interest in their SOPHAS doctoral program application, which is due December 1, 2020. Full funding, supported by the Open Philanthropy Project, is available for up to 2 students. Dr. Tara Kirk Sell and Dr. Gigi Gronvall, both Senior Scholars at the Center for Health Security, will direct the track. A webinar will be held on October 21, 2020, at 2pm EDT to provide additional details about the program. Advance registration is required.
The Center for Health Security also announced a new Health Security Scholarship for Johns Hopkins Bloomberg School of Public Health students pursuing a master of public health (MPH) degree. This scholarship is supported by the Open Philanthropy Project and is intended for MPH students with an interest in the field of health security, particularly those with interest in pandemics and global catastrophic biological risks. The scholarships will cover full tuition for the Johns Hopkins Bloomberg School of Public Health MPH degree, and up to 2 scholarships will be awarded per academic year. The inaugural scholarships will be awarded for the 2021–22 program year.

**While the following topic is largely a US issue, it is an emerging storyline that we feel is important to cover today.**

US PRESIDENTIAL DEBATE The US vice presidential debate was held earlier this week, and the Commission on Presidential Debates implemented additional precautions to mitigate transmission risk, including plexiglass barriers between the candidates and mandatory mask use. After the VP debate, the Commission announced that the upcoming presidential debate scheduled for October 15 would be held virtually, following positive SARS-CoV-2 tests among White House staff, including President Trump. President Trump opposed the decision and announced that he will not participate in the debate if it is not held in person. President Trump’s campaign has issued several statements about the second debate, including a proposal for delaying the event in order to allow it to be held in person and a call for it to be held in person as originally scheduled. President Biden announced that he intends to participate in a town hall event if the second debate does not take place as scheduled. At this time, it remains unclear if or how the second debate would take place or if any changes could subsequently affect the third and final debate scheduled for October 22.