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 28.92 million cases and 922,252 deaths as of 9:30am EDT on September 14. The global weekly incidence continues to hold relatively steady at approximately 1.8-1.9 million cases. After 3 consecutive weeks of decreasing global mortality, the weekly total last week increased by 8.4% compared to the previous week, up to 40,720 deaths.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. India: 91,688 new cases per day (+5,887)
2. USA: 34,794 (-1,226)
3. Brazil: 27,562 (-2,601)
4. Argentina: 10,668 (+629)
5. Spain: 9,620* (+502)
6. France: 8,045 (+971; ↑ 1)
7. Colombia: 7,114 (-807; ↓ 1)
8. Peru: 5,663 (+83)
9. Russia: 5,329 (+224; ↑ 1)
10. Mexico: 4,908 (-352; ↓ 1)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Israel: 428 daily cases per million population (+107; ↑ 1)
2. Bahrain: 404 (+60; ↓ 1)
3. Montenegro: 264 (+46; ↑ 1)
4. Costa Rica: 239 (+23; ↑ 1)
5. Andorra: 239 (+96; new)
6. Argentina: 236 (+14; ↓ 3)
7. Spain: 206* (+11)
8. Kuwait: 173 (-8)
9. Peru: 172 (+3)
10. Panama: 156 (-5)
*Spain’s average daily incidence is not reported for today; these values correspond to the previous day’s averages.

India’s epidemic continues to accelerate and set new records for total daily incidence, now exceeding the previous record of 67,374 new cases per day in the US by more than 25%. India is also reporting more than double the current daily incidence in the US, more than 3 times Brazil's incidence, and more than 8 times that of any other country. Brazil’s daily incidence has decreased by a third since September 5. Bahrain, Israel, and Montenegro continue to report rapidly increasing COVID-19 incidence. Bahrain’s incidence has increased by more than 150% since September 2, Israel’s has increased by nearly 140% since August 31, and Montenegro’s has quadrupled since August 25. The Maldives fell out of the top 10 in terms of per capita daily incidence, and it was replaced by Andorra, which jumped all the way to #5.

The US CDC reported 6.47 million total cases and 193,195 deaths, and the US is averaging 34,371 new cases and 734 deaths per day. If the US continues at its current pace, it could reach 200,000 cumulative COVID-19 deaths in the next 10 days. In total, 21 states (increase of 2) 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 per capita daily incidence remains elevated. It has held relatively steady at approximately 225 daily cases per million population since September 6, which would be #7 globally, if Guam were a country.

The Johns Hopkins CSSE dashboard reported 6.53 million US cases and 194,238 deaths as of 1:30pm EDT on September 14.

GLOBAL ECONOMIC IMPACT The Organisation for Economic Co-operation and Development (OECD) published data on national economies for G20 countries in Quarter 2 of 2020. As a whole, the G20 economy contracted by 6.9% from Quarter 1. This contraction is an all-time record and more than 4 times what was observed during the peak of the 2009 global financial crisis. Of the G20 countries, China was the only one to report economic growth (+11.5%), likely in part due to its success in containing its epidemic. Excluding China, the combined economy of the rest of the G20 contracted by 11.8%. Notably, India’s economy contracted by more than 25%, and the UK’s contacted by more than 20%. Across all OECD countries, the combined economy contracted by 10.6%. For many of the listed countries, the contraction compared to Quarter 2 in 2020 was even more severe, since the pandemic had already hindered economic growth in Quarter 1 of this year. Many countries have relaxed social distancing measures in an effort to increase economic activity; however, a number of them have re-instituted or strengthened these restrictions following a resurgence, in some cases worse than their “first wave.” It remains unclear how long the economic effects of COVID-19 will persist and the extent to which subsequent waves of transmission or a future vaccine will affect recovery efforts.

VACCINE CLINICAL TRIALS Less than a week after suspending Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine due to a serious adverse event, AstraZeneca announced that the trials have resumed in the UK. According to a press release issued by AstraZeneca, the trials resumed after the UK government’s Medicines Health Regulatory Authority (MHRA) evaluated the evidence and determined that it was safe to continue testing the vaccine. The press release states that AstraZeneca and the University of Oxford are not permitted to “disclose further medical information” regarding the adverse event, presumably including the associated safety data reviewed by MHRA or the results of their analysis. It appears that the Phase 3 trials in other countries remain on hold.

The CEO of Pfizer, Inc., announced that the company could be ready to begin distributing its candidate SARS-CoV-2 vaccine to the American public by the end of 2020. In support of this effort, Pfizer received approval to expand its Phase 3 clinical trial from 30,000 participants to 44,000 in order to more quickly collect necessary safety and efficacy data. A press release published by Pfizer indicates that expanding the study would “further increase trial population diversity” and allow for the inclusion of children aged 16 years and older and those with various pre-existing health conditions. Pfizer (and collaborator BioNTech) expects to have preliminary findings by the end of October.

Experts have criticized both AstraZeneca and Pfizer for their lack of transparency with respect to their candidate vaccines and associated clinical trials. These experts argue that the companies should publish more information, both in terms of trial study design and data analysis in order to build confidence among the public in advance of future availability. This could be particularly important in light of the recent pause in AstraZeneca's trials and speculation regarding the nature of the participant’s serious adverse event.

REMDESIVIR Remdesivir is one of the few treatments available for COVID-19 with an Emergency Use Authorization (EUA) from the US FDA. Reports during the summer warned of shortages of remdesivir for hospitals in need, but officials from the US Department of Health and Human Services have recently noted that purchases of the antiviral have slowed. State and territory public health systems accepted only 72% of their allocation, and hospitals purchased only two-thirds of that supply. It appears that overall demand for the drug in hospitals has decreased since the US summer resurgence. Additionally, while the FDA expanded the authorization to include any hospitalized patient, some facilities are limiting its use to more severely ill patients. Despite the decreased demand, some hospitals continue to stockpile remdesivir in anticipation of a surge during the fall and winter months. 

MORTALITY RISK It is well understood that increased age and underlying medical conditions elevate the risk of severe disease or death in COVID-19 patients, but health officials continue to struggle with communicating the relative mortality risk posed by COVID-19. One commentary, published in The BMJ, discusses a method of translating COVID-19 risk into an effective analogy by comparing increased mortality risks due to COVID-19 to the normal mortality risks that individuals face at different ages. Based on data published by Imperial College London, the authors determined that the risk of death posed by COVID-19 alone is approximately equal to the normal risk of death for individuals over the age of 20 years. The authors note that this equates to nearly double the normal risk of death for younger individuals (who have a lower baseline risk of death), and the proportional increase tapers off as age (and normal risk of death) increases. Providing a framework to help individuals comprehend the relative risk of COVID-19 to their health and life can help them appreciate the risk and encourage the use of recommended protective measures.

COVID-19 vs SEASONAL FLU IN PEDIATRIC PATIENTS A study published in JAMA: Network Open compared disease severity among pediatric seasonal influenza and COVID-19 patients. The study analyzed clinical data from 315 pediatric COVID-19 patients and 1,402 pediatric seasonal influenza patients during the Northern Hemisphere 2019-20 influenza season. The researchers found that the two groups did not differ significantly in terms of hospitalization rates, admission to intensive care units, or mechanical ventilator use. In terms of clinical presentation, COVID-19 patients were more likely to report fever, diarrhea or vomiting, headache, body aches, and chest pain than seasonal influenza patients. As the pandemic continues into the Northern Hemisphere 2020-21 influenza season, it will be critical to rapidly distinguish COVID-19 patients from seasonal influenza patients.

If COVID-19 severity among pediatric patients is similar to seasonal influenza, it can provide additional insight into mortality risk. The US CDC estimates that 7-26,000 children were hospitalized in a given influenza season (since 2010), and as many as 600 may have died in 2017-18. It is well understood that older individuals are at elevated risk for severe disease and death; however, there is certainly still risk of severe disease and death in children.

MORTALITY RISK RAPID ASSESSMENT A study published in The BMJ describes the development and validation of a rapid risk assessment tool for hospitalized COVID-19 patients. The tool was developed by the International Severe Acute Respiratory and emerging Infections Consortium Coronavirus Clinical Characterisation Consortium (ISARIC-4C). The researchers analyzed clinical data for more than 35,000 hospitalized COVID-19 patients in the UK in order to identify a set of indicators, including both clinical presentation and underlying risk factors, that could be rapidly assessed during hospital admission with the aim of identifying patients who may be at higher risk of death. The researchers identified 8 predictive indicators and developed a tool that yielded a score (4C Mortality Score) that correlates with the patient’s risk of death: age, sex, number of relevant comorbidities, respiratory rate, peripheral oxygen saturation, level of consciousness, urea level, and C reactive protein level. Each patient is scored on a scale of 0-21, with higher scores corresponding to increased risk. Patients with scores of 15 or greater exhibited 62% mortality, compared to only 1% mortality for those with scores of 3 or less. While the tool needs further validation, it could provide rapid assessment capability to enable clinicians to “stratify [COVID-19] patients admitted to [the] hospital...into different management groups,” which could streamline clinical response operations and enable clinicians to more proactively initiate specific treatment protocols for higher-risk patients.

GLOBAL PREPAREDNESS MONITORING BOARD The Global Preparedness Monitoring Board (GPMB) is an independent body convened by the WHO and the World Ban that focuses on global preparedness for health emergencies. GPMB published its second annual report today, titled “A World in Disorder.” The report delivers a fairly scathing review of the world’s response thus far to the COVID-19 pandemic. In particular, the report notes that the crisis “has revealed a collective failure to take pandemic prevention, preparedness and response seriously and prioritize it accordingly.” The GPMB also notes that the recommendations outlined in its first report were minimally implemented, with insufficient financial and political investment. The report emphasizes the importance of political leadership that prioritizes public health and science, establishing and maintaining community support for preventive measures, and proper response execution in order to mitigate both health effects as well as downstream social and economic impacts.

The authors outline a series of recommendations to address various aspects of pandemic preparedness and response. Specifically, the report addresses the role of national and global leadership, the broader global public, national and global systems and programs for addressing global health security, investments in preparedness and prevention for large-scale health emergencies like a pandemic, and global governance and coordination for preparedness efforts. The report includes a discussion of both the current COVID-19 pandemic response and a look ahead to future emergencies.

ISRAEL Israeli Prime Minister Benjamin Netanyahu announced on Sunday that Israel will undergo its second nationwide “lockdown” as COVID-19 incidence continues to surge. The lockdown is scheduled to last at least 3 weeks, starting this Friday. Israel’s epidemic has surged since late August, and Israel is now reporting the highest daily per capita incidence globally. Additionally, Israel is heading into a month of religious festivals and holidays, which could provide opportunity for large gatherings and increased transmission risk. The restrictive measures include closing schools and non-essential businesses (e.g., retail stores, gymnasiums, swimming pools), prohibiting in-person dining at restaurants, restricting individuals’ movement outside their homes to 500m (except for essential activities), and limiting gatherings to 10 people indoors and 20 people outdoors. The Israeli government will evaluate the epidemiologic situation at the end of the lockdown period and determine whether the country can move into the first stage of recovery.

WINE WINDOWS In the Tuscany region of Italy, residents are reviving a centuries-old architectural feature to support economic activity and social distancing. In the mid-1500s, the Grand Duke of Tuscany permitted noble families in the region to sell wine directly from their palaces. In order to facilitate the sales, “wine windows” were incorporated into city walls to allow the wine to be passed through to patrons. These windows, unique to the region, were particularly useful during the Black Plague in the 1600s, as they allowed the sale of wine, food, and other goods without contact between retailers and customers. The wine windows are once again providing this capability, allowing businesses of all sorts, particularly restaurants, to serve customers via the medieval equivalent of curbside pickup. Even now that “lockdown” restrictions have relaxed, some businesses continue to operate their wine windows to serve customers.