Updates on the emerging novel coronavirus pandemic from the Johns Hopkins Center for Health Security.

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EPI UPDATE The WHO COVID-19 Dashboard reports 27.97 million cases and 905,426 deaths as of 4:30am EDT on September 11. The global average daily incidence has largely leveled off at approximately 265,000 new cases per day, and the global average mortality is currently 5,814 deaths per day.

Since August 1, 11 countries have reported relative increases in daily incidence of 500% or greater, including 6 greater than 1,000%. Myanmar tops the list at more than 16,000%. It was reporting only 1 new case per day on August 1, and its daily incidence has increased to 160 cases. In fact, with the exception of France, these 11 countries are all reporting relatively few new cases (fewer than 750 per day), but several are exhibiting exponential growth since early August. While these are still relatively small totals—in some cases, even on a per capita basis—the consistent exponential increase could signal the early stages of an epidemic if not contained quickly. Among all of these countries, 4 are reporting more than 50 daily cases per million population—France (118; 627% increase), Libya (107; 548% increase), Monaco (80; 633% increase), and Trinidad and Tobago (73; 2,544% increase). Additionally, Hungary is reporting a nearly 4,000% increase, up to 48 daily cases per million population.

The US CDC reported 6.34 million total cases and 190,262 deaths, and the US is averaging 36,594 new cases and 738 deaths per day. Reporting delays due to the 3-day Labor Day holiday weekend are likely affecting the volume of cases in the most recent update. The average daily incidence had been holding relatively steady at approximately 42,000 new cases per day, until the past several days when reported incidence fell sharply. We expect the reported incidence to increase over the coming weekend as state reporting catches up from the holiday, which would bring the average back up closer to its previous value.

In total, 20 states (increase of 1) are reporting more than 100,000 cases, including California with more than 700,000 cases; Florida and Texas with more than 600,000; New York with more than 400,000; and Arizona, Georgia, and Illinois with more than 200,000.

Guam’s average per capita daily incidence remains elevated, but it is considerably less than its peak in late August (447 daily cases per million population). At 242 daily cases per million population, a slight increase over the past several days.

The Johns Hopkins CSSE dashboard. The dashboard reported 6.40 million US COVID-19 cases and 191,811 deaths as of 10:30am EDT on September 11.

RESPONSE COST IN LMICs Experts from the WHO, in collaboration with other colleagues, published a modeling study to project the costs associated with future COVID-19 response efforts in low- and middle-income countries (LMICs). The study, published in The Lancet: Global Health, forecasted the number of COVID-19 cases across 73 LMICs for 3 different scenarios—current level of transmission, 50% reduction in transmission, and 50% increase in transmission—over both 4-week and 12-week timeframes. Based on the modeled incidence, the researchers estimated the total healthcare cost associated with implementing the WHO’s Strategic Preparedness and Response Plan. They specifically focused on the costs associated with implementing the SPRP’s 9 pillars, and they limited the scope of their analysis to “costs expected to be borne by the health sector” and excluded costs to implement “social mitigation interventions.”

For the status quo scenario, the estimated cost at 4 weeks is more than US$52 billion, approximately US$8.60 per person. For the 50% reduction in transmission, the researchers estimated the cost to be US$33 billion, and it would be more than US$61 billion for the 50% increased transmission scenario. When assessing the 12-week time period, the researchers estimated that the costs would triple for both the status quo and increased transmission scenarios—US$154 billion and US$197 billion, respectively; however, they projected only a moderate increase for the decreased transmission scenario—US$52 billion.

The researchers projected that the costs to implement several pillars—including country-level coordination, risk communication/community engagement, points of entry control, and logistics/supply management—remained relatively consistent across the 3 scenarios, but there were major differences among other pillars. The biggest projected difference, between the reduced and increased transmission scenarios, were for investigation, surveillance, and rapid response; case management (e.g., clinical care); and maintaining essential services.

PERU Despite receiving initial praise for implementing early lockdown measures and other public health response efforts, Peru is now reporting one of the highest per capita fatality rates in the world. Prior to COVID-19, Peru was a growing economic leader in South America, but now, like many countries, it is experiencing substantial economic impacts stemming from the pandemic. Peru’s economy took a particularly sharp decline, 30% reduction in the second quarter of 2020, and it is expected to contract by a total of 12% for the full year. The economic strain experienced by Peru has resulted in opposition Peruvian lawmakers filing a motion to remove the government’s Minister of Finance. Critics argue that the economic relief measures passed in Peru were inadequate to address the magnitude of COVID-19’s impact, particularly for small businesses.

Peru’s experience, like many others, highlights the link between health and economics, particularly low- and middle-income countries (LMICs). Many LMICs have long-standing vulnerabilities in their healthcare and public health systems, exacerbated by higher proportions of informal or unofficial labor, elevated rates of underlying and chronic health conditions, and the direct and indirect effects of COVID-19 social distancing and other risk mitigation measures. A survey conducted earlier in the year found that approximately half of Peruvians who were informally working stopped receiving income entirely during the country’s “lockdown,” making a long-term shutdown financially unfeasible for their families and resulting in a large-scale food crisis, which likely further compounded the health effects of COVID-19.

SPAIN Spain’s COVID-19 epidemic continues its resurgence, surpassing 500,000 cumulative cases and exceeding the daily incidence exhibited in its first peak. As incidence increased over the summer and into the fall, following efforts to lift highly restrictive “lockdown” measures implemented in the spring, Spain was forced to re-institute a number of social distancing and other risk mitigation measures in an effort to contain its “second wave.” While mask use was recommended nationwide, mandates varied by region, some of which prompted protests. In mid-August, Spain closed discos, dance halls, and cocktail bars; mandated physical distancing and restricted operating hours and capacity at restaurants; and implemented a nationwide prohibition on smoking in outside areas where physical distancing could not be maintained in order to reinforce mask use in crowded spaces. Additional tourism restrictions aimed to limit the influx of COVID-19 from areas with high community transmission. Despite these increasingly restrictive measures, Spain’s COVID-19 epidemic surged, driven in part by younger portions of the population and the reopening of restaurants, bars, nightclubs, beaches, and other areas where people can gather socially.

Now, in the midst of its second wave, Spain is attempting to send children back to school. Like many countries, including the US, there is considerable debate regarding the safety and risk associated with resuming in-person classes, including for the students and the community. Schools across the country have implemented a variety of policies and solutions to mitigate the risk, but not all schools can afford these investments. Well-resourced schools have been better able to implement creative solutions, such as constructing new spaces or facilities, but schools with fewer resources have struggled to implement effective measures that would enable them to reduce class sizes, increase physical distancing, improve ventilation, and other steps to mitigate transmission risk. Some teachers and parents have raised concerns that planning efforts to reopen schools began too late, and school officials are rushing to develop and implement plans. In Spain, many households include multiple generations. As children return to school, it could put older individuals in these homes at increased risk of exposure, which could have significant effects on mortality and the burden on local health systems.

TEMPORARY HOSPITALS In February 2020, at the peak of the COVID-19 epidemic in Wuhan, China constructed 2 hospitals (Huoshenshan and Leishenshan) within the affected area specifically to isolate and treat the surge of COVID-19 patients. Additionally, China added more than a dozen other hospitals or treatment centers converted from convention centers and gymnasiums to treat milder cases. In total, 16 hospitals or treatment facilities were built over the course of 16 days, according to Chinese state media. The sites ranged from several hundred beds to approximately 1,500. On March 10, Chinese media reported that the last 2 remaining temporary facilities in Wuhan closed, after treating over 1,500 patients. After rapidly scaling up clinical capacity in Wuhan through the construction and conversion of these facilities, all of them were closed within several weeks of opening.

The facilities currently remain empty, and it is unclear if or how they will be used in the future. The situation recalls a similar scenario following the SARS epidemic in 2003, during which the Xiaotangshan Hospital in Beijing was constructed as a temporary field hospital and then eventually abandoned after the epidemic ended. Over time, components of the hospital were demolished, and some were reportedly repurposed to treat COVID-19 patients. China’s experience with SARS in 2003 and COVID-19 highlights challenges regarding how to best scale up clinical surge capacity for an emergency (such as a pandemic) and how to scale down the temporary capacity after the initial demand subsides, in order to make the most efficient use of finite resources.

The challenge of building, using, and maintaining field hospitals amid patient surge during a pandemic is not limited to China. During the initial peak in the US, the US Army Corps of Engineers and private contractors built field hospitals across the country, ranging from 40 beds to 2,000 beds. In total, the efforts cost US$660 million; however, many of these facilities never treated any patients. Only the Javits Center facility in New York treated more than 50 patients (1,095). While the fact that most of these facilities were ultimately not needed could be considered a credit to an effective public health response and a sufficiently robust health system, some experts note that the need to construct them in the first place (and unnecessarily utilize limited financial resources) stems from inadequate planning and preparedness for large-scale health emergencies. Regardless of the reasons, the situation in both countries highlights the challenges of establishing and maintaining flexible surge capacity to meet unpredictable demand during health crises, such as a major pandemic.

SARS-CoV-2 EXPOSURE RISK As governments around the world continue to struggle to balance social and economic activity against SARS-CoV-2 transmission risk, a new study provides insight into community and close contact exposure risk among COVID-19 patients. The study, published in the US CDC’s Morbidity and Mortality Weekly Report (MMWR), was a case-control investigation involving adults in the US who received SARS-CoV-2 tests in outpatient healthcare settings or at one of the Influenza Vaccine Effectiveness in the Critically Ill (IVY) Network testing sites who were symptomatic at the time of their test. Of the 314 total participants, 154 tested positive (cases), and 160 were negative (controls). Among the case participants, 42% reported known contact with confirmed COVID-19 patients, compared to only 14% among the control participants, a statistically significant difference. The majority of these contacts (51%) were family members.

The researchers surveyed the participants to identify potential exposures in a variety of settings in the 2 weeks prior to their test. Overall, there was no significant difference between cases and controls for most settings, including shopping, large gatherings at home, public transportation, bars or coffee shops, religious services, salons, and gyms. Notably, however, cases were twice as likely to report dining at a restaurant than controls, a statistically significant difference. When limiting the analysis to those with no known contact with COVID-19 cases, cases were 2.8 times more likely to have dined at a restaurant and 3.9 times more likely to have visited a bar or coffee shop. Additionally, among those participants who reported dining at a restaurant or visiting a bar or coffee shop, controls were statistically more likely to report that most other patrons were adhering to recommendations, including mask use and social distancing.

The researchers acknowledge several limiting factors, including not distinguishing between indoor and outdoor dining, which could potentially play a role in the transmission risk for patrons. Additionally, the analysis did not account for state- and local-level variations in social distancing restrictions, including for restaurant and bar operations. While it is not possible to definitively determine the circumstances of transmission for any of these patients, the data indicate that settings such as restaurants, cafes, and bars could pose higher risk of exposure and transmission, particularly those where patrons do not observe recommended social distancing practices.

VACCINE CLINICAL TRIALS Earlier this week, vaccine manufacturer AstraZeneca announced a pause in the Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine after researchers identified a serious adverse event in one of the study participants. The company’s CEO reportedly stated on a private call with investors that the participant is suffering from transverse myelitis, an inflammation of the spinal cord. He also reportedly noted that the patient’s condition is improving and that she could be discharged from the hospital soon. Another report indicates that the CEO remained confident that Phase 3 clinical trials could be completed by the end of the year. The company has made limited official, public announcements about the pause.

A group of 26 experts published an open letter to the Editor of The Lancet, raising concerns about some of the data reported from Phase 1/2 clinical trials for Russia’s candidate SARS-CoV-2 vaccine—published last week in The Lancet. The authors identified some unlikely patterns in the reported data, and they highlighted potential issues regarding the data visualization and experimental design. Notably, the critique is based solely on the results summarized in the Lancet article and not the underlying trial data, which has not been publicly released. Researchers from Russia’s Gamaleya Institute, who conducted the trials, “rejected the critique,” and Dr. Naor Bar-Zeev, one of the peer reviewers for the article, defended the underlying data and noted that he saw no reason to question the legitimacy of the data or findings. Editors for The Lancet have reportedly offered the study’s authors an opportunity to respond to the concerns raised in the open letter.

AVOIDING VACCINE ACCESS BARRIERS The Johns Hopkins International Vaccine Access Center (IVAC) will host a webinar on Wednesday, September 16 (8am EDT), to discuss past experiences with introducing novel vaccines, including lessons that can be applied for prospective SARS-CoV-2 vaccines in the future. Dr. Jerome Kim, Director General of the International Vaccine Institute (IVI), and Dr. Naor Bar-Zeev, Deputy Director of IVAC, will discuss the barriers to vaccine access that must be overcome and the role that the international community must play in promoting equity in delivering a SARS-CoV-2 vaccine worldwide. Even before the COVID-19 pandemic, countries have faced a myriad of challenges when introducing new safe and effective vaccines for other diseases. Understanding factors such as disease burden, cost effectiveness, necessary infrastructure (eg, to maintain cold chain), cultural norms, and underlying or systemic biases is critical to deploying vaccines to prevent disease spread and save lives. Learning from past experiences with vaccine introductions, including failures, will be crucial for ensuring equitable access to a SARS-CoV-2 vaccine when one becomes available. Advance registration is required.