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 30.06 million cases and 943,433 deaths as of 10:00am EDT on September 18. This week appears to be on pace to set a new record for weekly incidence—currently at 315,919 cases. As the cumulative global incidence surpasses 30 million, the following timeline will provide some context for the trajectory of the COVID-19 pandemic:
1 case to 1 million cases: 90 days
1 million to 5 million: 48 days
5 million to 10 million: 38 days
10 million to 20 million: 44 days
20 million to 30 million: 37 days

The global daily incidence is once again increasing, driven largely by increasing incidence in India and multiple countries in Europe. After leveling off at approximately 260,000 new cases per day, the global daily average is now up to 285,000. As expected, the daily incidence in Asia and Europe are increasing, while North and South America appear to have plateaued or started to decline. Africa’s daily incidence peaked in mid-to-late June, and it has steadily decreased since then, now reporting fewer than 7,500 new cases per day for the entire continent. Proportionately, Asia’s and Europe’s contribution to the global daily incidence are increasing, while North and South America’s and Africa’s are decreasing. In fact, Asia currently accounts for more than 40% of the total daily incidence. On a per capita basis, South America still leads all continents at 140 daily cases per million population, followed by North America (84 per million) and Europe (58 per million). The global average is 37 daily cases per million population.

With respect to deaths, Asia and North and South America are all reporting similar daily mortality (1,350-1,800 deaths per day), and Africa, Europe, and Oceania are all reporting fewer than 500 deaths per day. On a per capita basis, South America (3.4 daily deaths per million population) and North America (2.2 per million) are both reporting higher than the global average (0.7 per million). Europe (0.6 per million) is near the global average, and Africa, Asia, and Oceania are all reporting fewer than 0.4 daily deaths per million population.

The US CDC reported 6.61 million total cases and 196,277 deaths. The US is averaging 38,538 new cases and 859 deaths per day. The average daily incidence has increased by 11% over the last 3 days, and daily mortality has increased by 17% over the last 4 days. It is possible that these increases represent a reversion to the expected average after lower reporting over the Labor Day holiday weekend, but we will continue to monitor the situation to determine if it is the beginning of longer-term trends. If the US continues at its current pace, it could reach 200,000 cumulative COVID-19 deaths by Tuesday’s update.

In total, 21 states (no change) 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. The Georgia Department of Health is reporting 300,903 cumulative cases, so we expect this to be reflected in the next CDC update.

The Johns Hopkins CSSE dashboard reported 6.69 million US cases and 198,055 deaths as of 1:30pm EDT on September 18.

EUROPE The WHO offered a stark warning for Europe as COVID-19 incidence continues to increase. Last week, incidence in Europe exceeded the continent’s first peak in March, and the epidemic continues to grow. While the resurgence of the virus is spread across the continent, rather than located in a few countries or regions with high transmission, the recent trend is concerning. The rise in European COVID-19 incidence has been driven, in part, by individuals aged 25-49. One potential change that could be affecting this increase is a shift in countries’ approach to containing their respective epidemics. A number of European countries have modified their approach from combatting the virus to coexistence. For example, French President Emmanuel Macron and Italian Minister of Health Roberto Speranza that emphasize that the public needs to learn how to “live with the virus.”

UNITED KINGDOM The UK continues to struggle with SARS-CoV-2 testing capacity. The national laboratory network was not prepared to handle the surge in testing demand that coincided with children returning to school, and the UK testing program was forced to send tests to France and Germany in order to increase capacity. Following reports of a national backlog of 185,000 tests that is delaying results and hindering the public health response, UK Prime Minister Boris Johnson unveiled a plan dubbed Operation Moonshot, which aims to scale up national testing capacity to 10 million people a day by early 2021. This capacity could effectively allow everyone in the UK to be tested weekly. In light of a series of failures or missteps in the UK testing program—a situation in which the UK is not alone—experts question the feasibility of scaling up testing to this volume. Notably, the kind of rapid tests needed to realize this vision are still not widely available, nor are they approved for use in the UK.

Like most countries, the UK has felt serious economic consequences from the COVID-19 pandemic and its corresponding impact on routine social and economic activity. The country’s unemployment rate is now the highest it has been in the past 2 years, and the 16-24 age group is facing the most severe decrease in employment. Like many schools in the US and elsewhere, colleges and universities in the UK have resumed fall classes. And like we have reported in the US, some schools are implementing harsh punishments for students who violate COVID-19 policies. For example, Trinity College Cambridge came under some scrutiny after announcing that it would evict students from university housing if they are involved in a COVID-19 outbreak. In addition to the effects on students who may not have alternate housing, this approach disincentivizes reporting by students, which could allow outbreaks to go undetected. If students are afraid to report symptoms or suspected cases, it could facilitate transmission both on campus and in the local community.

INDIA India reported nearly 100,000 new COVID-19 cases, continuing to set new records for daily incidence, and it is currently reporting more than 1 million active cases nationwide. At this pace, India will soon surpass the US as #1 globally in terms of cumulative COVID-19 incidence. In addition to the national incidence, incidence is also increasing in major cities, including Mumbai and New Delhi, after a temporary plateau. India is testing more than 1 million samples a day. While this is a large number, it is unfortunately low on a per capita and per case basis. There are concerns over whether the country will be able to meaningfully slow the transmission of SARS-CoV-2, and questions about how much of the population may have already had the disease. The Times of India reported that serological studies have identified some communities with high seropositivity, including some greater than 50%. One study estimates that as many as 25% of the population nationwide have been infected. While some health and government officials have estimated that herd immunity could be observed at 60-70% seropositivity, it is unclear how accurate this estimate is. Additionally, there are considerable differences in seropositivity between communities, and the presence of antibodies does not necessarily mean that an individual is immune from infection. Regardless, India’s national trends suggest that its epidemic continues to accelerate.

INDONESIA Indonesia’s COVID-19 epidemic has surged over the past several weeks, with daily incidence increasing more than 80% since August 25. In order to address the growing epidemic, some Indonesian officials are using unique approaches to increase adherence to policies, including mask use. In the Cerme district in East Java, the local government reportedly forced 8 individuals to dig graves for COVID-19 victims as punishment for violating the local mask mandate. The district is experiencing a shortage of grave diggers, and the district’s leadership believed that the punishment could both fill that role temporarily and serve as a deterrent to others. Notably, the individuals did not participate in any burial services and did not have contact with the bodies of any COVID-19 victim. And in Jakarta, the local government reportedly ”paraded” coffins containing dummies wearing masks through the city and displayed them in various public locations to serve as a stark reminder to wear a mask. The effort was met with considerable criticism and opposition by the public, some of whom cited the government’s failure to effectively implement social distancing and quarantine policies and delays in distributing economic and social assistance to the public.

VACCINE ESPIONAGE As governments and countries press ahead with efforts to develop their own SARS-CoV-2 vaccine—as opposed to large, collaborative, multilateral efforts—”vaccine nationalism” not only creates challenges for the equitable global availability of a future vaccine, it also provides incentive for increased foreign intrusion and “espionage targeting vaccine research and development.” According to analysis published by the Council on Foreign Relations, espionage (including cyber espionage) is not technically prohibited under international law; however, it would violate international law if it were to result in “significant adverse or harmful consequences.” The analysis highlights the “ubiquity of cyber espionage” on SAR-CoV-2 vaccine efforts and the difficulty in “defending against or deterring” it.

A previous report by The New York Times indicates that Chinese intelligence operatives conducted cyber espionage on academic research institutions working on SARS-CoV-2 vaccines, rather than pharmaceutical companies, and leveraged information from the WHO to direct their activities. Additionally, Russian and Iranian intelligence organizations “targeted vaccine research networks” in multiple countries, including in Canada, the UK, and the US. In July, the US Department of Justice charged 2 Chinese nationals with spying on multiple US entities conducting SARS-CoV-2 vaccine research—including Moderna Therapeutics, which is currently conducting late-stage clinical trials for its vaccine candidate—and entities in multiple other countries.

DOWNSTREAM IMPACTS: GLOBAL HEALTH The Bill and Melinda Gates Foundation released a report that assesses the progress made and outstanding gaps in terms of achieving the Sustainable Development Goals (SDGs). The SDGs were established in 2015 as a follow-on to the Millennium Development Goals, with the goal of ending poverty, reducing inequality, and stopping climate change by 2030. The Gates Foundation report notes that, while progress has been made each year since the establishment of the SDGs, that progress largely stopped in 2020, primarily as a direct result of the COVID-19 pandemic. Additionally, the report notes that efforts to establish strong vaccine coverage have been severely affected, commenting that vaccination has been “set back about 25 years in about 25 weeks.” The severe global recession has driven much of the regression in 2020, particularly in lower-income countries that are largely reliant on informal economies. Women are especially affected. Additionally, the pandemic response has reduced the amount of funding available from governments, both for domestic populations and international aid, which further limits aid available to the public. The report indicates that 68 million people in lower-middle-income countries have been forced into poverty as a result of the pandemic and that an additional 37 million people have been forced into extreme poverty worldwide. 

VIRTUAL UN GENERAL ASSEMBLY In July, the UN announced that the 75th UN General Assembly would largely be held virtually, with Member States and others participating remotely via videoconference and pre-recorded video statements. UN Secretary-General Antonia Guterres acknowledged that the virtual solution is far from ideal, and he expects a “huge loss in the efficiency of diplomacy” resulting from the virtual format. As with many international and diplomatic fora, much of the important and interesting work at the General Assembly occurs outside of formal meetings, which is considerably more difficult if relevant parties are unable to have face-to-face conversations. Notably, the option to deliver statements via video has resulted in increased participation by heads of state, particularly by those who do not typically attend the General Assembly in New York. The annual meeting commenced earlier this week, and is scheduled to continue through October 2. In addition to a virtual General Debate, other high-profile events—including on Sustainable Development Goals, biodiversity, women’s rights, and the commemoration of the UN’s 75th anniversary—will also be held virtually.

PREGNANT WOMEN MORBIDITY & MORTALITY Researchers from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) published findings from a study on COVID-19 in pregnant women. The study, published in the US CDC’s MMWR, involved 598 hospitalized pregnant women with confirmed SARS-CoV-2 infection. The patients included women in all 3 trimesters of pregnancy, but 87.4% were hospitalized during the third trimester. Notably, 81.9% of those admitted during the third trimester were hospitalized for “obstetric indications” (eg, labor and delivery).

Among 458 women who had completed pregnancy at the time of their discharge, 97.8% resulted in a live birth. Pregnancy losses occurred in both symptomatic and asymptomatic patients. Among live births, 12.6% were pre-term, including 23.1% of live births among symptomatic patients and 8.0% among asymptomatic patients. The overall prevalence of pre-term births in 2010 was 10%, which suggests that pregnant COVID-19 patients could potentially be at elevated risk for pre-term birth. Additionally, 2 live births died shortly after delivery, and both were born to symptomatic patients who required mechanical ventilation. From March-August, an estimated 25% of hospitalized women aged 15-49 with confirmed SARS-CoV-2 infection were pregnant, compared to an estimated 5% in the general population. The study was not designed to determine the significance of these findings, but the results indicate that pregnant women could be at elevated risk for SARS-CoV-2-related complications and that additional research should be conducted to better characterize the effects of SARS-CoV-2 infection in pregnant women.

**While the following topics are largely US issues and guidance, they are emerging storylines that we feel are important to cover as they unfold instead of waiting until next week.**

US CDC SCHOOL & CHILDCARE GUIDANCE The US CDC published a set of indicators to assist school officials and state and local governments in making dynamic decisions regarding how to operate schools in the midst of the US COVID-19 epidemic. The indicators include specific thresholds for estimating the risk of SARS-CoV-2 transmission in schools. The Core Indicators include per capita COVID-19 incidence and test positivity in the community over the past 2 weeks as well as the school’s ability to implement 5 recommended risk mitigation strategies: mask use, social distancing, enhanced hygiene and respiratory etiquette, enhanced cleaning and disinfection, and contact tracing. An additional list of Secondary Indicators address relative change in incidence, hospital bed and ICU capacity, and the existence of local COVID-19 outbreaks. Each indicator is divided into 5 risk categories to aid school and government officials in their risk assessments.

The guidance suggests that schools with higher assessed risk “could consider alternative learning models,” such as virtual or hybrid classes, to mitigate the risk. The guidance does not instruct school and government officials how exactly to factor these indicators into their risk assessment, but these metrics and key recommended strategies do provide additional information to inform school decision-making. 

The timing of the guidance has raised criticism of the CDC for not distributing it sooner, in time to inform school planning and preparedness efforts. Notably, many schools have been in session for weeks already, and this kind of guidance would have been more helpful as schools were developing their plans, particularly those that aimed to resume in-person classes. Analysis by Dr. Ashish Jha, Director of the Harvard Global Health Institute, found that 56% of US counties fall into the “highest” risk category and 31% in the “higher” risk category (the two highest categories), based on local COVID-19 incidence and test positivity, which accounts for nearly 90% of the US population.

CDC Director Dr. Robert Redfield also indicated that the CDC is developing guidance regarding asymptomatic or presymptomatic testing to screen for SARS-CoV-2 infections, including at schools, businesses, and other locations. As effective rapid tests become available, screening could provide important information to help school and health officials more quickly identify and respond to emerging outbreaks. That guidance is expected to be published in the near future.

US VACCINE DISTRIBUTION PLAN On September 16, the US CDC released guidance for jurisdictions to prepare operationally for SARS-CoV-2 mass vaccination. The document states that pandemic influenza planning activities and routine immunization preparedness efforts can serve as a foundation for SARS-CoV-2 vaccination planning; however, additional planning is necessary to undertake vaccination on scale necessary to combat the pandemic. Jurisdictions are required to submit their plans by October 16 in order to receive federal funding support. The document advises jurisdictions to test their plans and establish timelines for their preparedness efforts.

The document describes 3 main phases to support SARS-CoV-2 mass vaccination planning efforts. Phase 1 is expected to involve an initial limited supply of vaccine, which will focus primarily on critical high-priority populations. Vaccination during Phase 1 will occur predominantly in closed points of dispensing (PODs; ie, limited to specific eligible groups). Phase 1A will prioritize healthcare workers, and Phase 1B will expand to other essential workers and individuals at high risk for severe disease and death. In Phase 2, it is expected that the available supply will be sufficient to start vaccinating the general population. The venues for vaccination would need to expand to include clinical settings, pharmacies, and public health mass vaccination clinics (eg, open PODS) and other settings. Phase 3 consists of continued vaccination and a shift to routine immunization strategies for SARS-CoV-2.

The guidance notes that a surge in vaccine demand may be possible by Phase 2, and a broad vaccine administration network could be needed to support surge capacity. The guidance document notes several key challenges, including ensuring equitable allocation and distribution of the vaccines. Additionally, the guidance also highlights the potential that the vaccine could require an ultra-cold chain (-60 to -80°C). Ancillary kits containing some of the key supplies needed to conduct vaccination, including syringes and alcohol pads, will be sent to jurisdictions. The vaccine itself may be distributed centrally by the federal government or potentially directly from the manufacturer—such as early in the vaccination effort for vaccines requiring ultra-cold chain. 

Considerable uncertainty remains regarding the timeline for vaccine availability, so the document does not include specific timelines for each mass vaccination phase. CDC Director Dr. Robert Redfield recently stated in testimony to the US Senate that a vaccine would likely not be available for large-scale general public rollout until spring or summer of 2021. President Donald Trump directly contradicted Dr. Redfield at a press conference later that day, stating that distribution would be “rapid,” possibly starting in October, and that the military would be involved in mass vaccination efforts. The role of the military in distributing the vaccine is unclear, and some experts have raised concerns that the inclusion of military assets in vaccination could exacerbate mistrust in the federal government among certain populations, particularly communities of color. An additional concern is the lack of funding that state and local jurisdictions have to support large-scale mass vaccination, particularly considering the chronic underfunding of public health infrastructure. Dr. Redfield stated that it could take up to US$6 billion to distribute the vaccine; however, the CDC currently has approximately US$600 million to support COVID-19 relief efforts. The funding needed to support vaccine distribution efforts have reportedly been stalled as Congress has been unable to finalize another COVID-19 relief package

US CDC TESTING GUIDANCE Following up on an emerging storyline regarding the potential influence of political appointees in CDC reporting and guidance, The New York Times reports that controversial SARS-CoV-2 testing guidance published on the US CDC website was not drafted by CDC experts. The guidance in question stated that individuals with known exposure to COVID-19 cases but who are not exhibiting symptoms “do not necessarily need” to be tested. Following the update, multiple media outlets reported that the changes were influenced by pressure from White House officials, including reports that Dr. Anthony Fauci did not sign off on the changes before they were published. The new New York Times report indicates that the update was drafted by officials at the Department of Health and Human Services and the White House Coronavirus Task Force and posted to the CDC website without going through the CDC’s traditional scientific review process. According to the report, additional changes to the testing guidance are expected to be posted today; however, these changes may also be circumventing the CDC review process.