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 25.60 million cases (245,984 new) and 852,758 deaths (4,355 new) as of 10:00am EDT on September 2.
UNITED STATES
The US CDC reported 6.00 million total cases (32,087 new) and 183,050 deaths (428 new). From the first case reported in the US on January 22, it took 98 days to reach 1 million cases. From there:
1 million to 2 million: 44 days
2 million to 3 million: 27 days
3 million to 4 million: 14 days
4 million to 5 million: 18 days
5 million to 6 million: 21 days
COVID-19 case fatality in the US has been declining since its peak (approximately 6%) in mid-May, but it is beginning to level off. Case fatality at the national level appears to be settling in at approximately 3%, but the ratio varies considerably from state to state. According to data compiled on the COVID Exit Strategy website, the states affected early in the US epidemic are reporting* elevated case fatality ratios, including Connecticut (8.4%), New Jersey (8.3%), Massachusetts (7.0%), Michigan (6.0%), New Hampshire (5.9%), New York (5.8%), and Pennsylvania (5.7%). This is largely driven by the early patient surge and associated impact on local health systems, under-reporting of cases due to an absence or dearth of testing early in the epidemic, and improved clinical care for COVID-19 patients over the past several months. While these states have largely brought their epidemics under control (at least relative to the early peak), their respective case fatality ratios are weighted heavily by those initial patients.
States that were severely affected during the summer resurgence—including Arizona (2.5%), California (1.8%), Florida (1.8%), and Texas (2.1%)—have fared much better in terms of case fatality; however, they had the advantage of advanced warning that provided additional time to improve preparedness and acquire necessary resources (eg, PPE, ventilators) as well as increased testing capacity, which identified many more cases than early in the pandemic. Additionally, the summer resurgence was spread across a larger geographic area, which mitigated to some extent the patient surge on individual health systems. A number of states remain at or below 1% case fatality, including Alaska, Hawai’i, North Dakota, and Utah.
*Unlike many of the trends we monitor, case fatality is typically analyzed cumulatively (ie, based on all the cases and deaths to date) rather than on a daily basis or moving average, so it represents the overall trajectory of the epidemic more so than current conditions.
Several US territories continue to report high per capita daily incidence. Guam is reporting 392 daily cases per million population, which would be #1 globally. Guam’s per capita daily incidence decreased from its high of 446 (August 31), but it remains elevated. The US Virgin Islands and Puerto Rico are both reporting decreasing daily incidence over the past week or so. Both would have fallen out of the global top 10, but they remain elevated compared to the US national average.
VACCINE DISTRIBUTION PLANS The US government is partnering with 4 states—California, Florida, Minnesota, and North Dakota—and Philadelphia to draft plans to distribute and administer COVID-19 vaccines. State and local governments already have plans to distribute and dispense or administer MCMs, including vaccines, for other scenarios like pandemic influenza and deliberate biological attacks; however, a mass vaccination effort on a nationwide scale would likely exceed the volume possible under existing plans. The new plans include provisions to establish mass vaccination sites (eg, points of dispensing [PODs]) due to the potential that an approved vaccine may need to remain frozen, which would require large vaccine freezers that could preclude some local healthcare providers from storing and administering the vaccine. In addition to distribution and dispensing plans, the 4 states and Philadelphia must also determine their approach to identifying and vaccinating high-risk and other priority populations (eg, healthcare workers, other essential workers) early in the campaign, when supply will be limited.
DRAFT COVID-19 VACCINE ALLOCATION FRAMEWORK Researchers at the National Academies of Sciences, Engineering, and Medicine (NASEM) published a draft framework to support efforts to equitably allocate limited supply of COVID-19 vaccine once it becomes available. It is expected that the initial production capacity of any COVID-19 vaccine will be insufficient to provide it broadly to the public all at once. Production will scale up over time, but the initial doses will need to be prioritized to specific populations until enough is available to expand access to everyone. The committee considered a variety of challenges and factors in its analysis, including health disparities, characteristics of prospective vaccines, and geographic distribution of the US epidemic. The framework outlines considerations for identifying the initial, first tier priority populations as well as the process for expanding access to subsequent tiers as production capacity increases. The committee also included analysis of historical mass vaccination campaigns, various ethical principles and frameworks—including those proposed by other organizations, such as the Johns Hopkins Center for Health Security—and practical and political limitations in their effort to develop the framework.
The framework includes 4 phases, with priority access for “high risk workers in health care facilities” and first responders in Phase 1a and individuals at the highest risk for infection and severe disease or death—eg, older individuals living in congregate settings and those with serious underlying health conditions—in Phase 1b. Phase 2 would expand access to other higher-risk essential workers, all older adults, those with less severe comorbidities, and individuals living in other congregate settings (eg, incarcerated populations, homeless shelters). Phase 3 would open access to the remaining essential workers, young adults, and children. Finally, Phase 4 would provide access broadly to remaining portions of the public.
TESTING As the US approaches influenza season, rapid and reliable SARS-CoV-2 testing remains vital for the next phase of the pandemic response. Despite the existence of several authorized PCR-based diagnostic tests, there are still significant delays in testing in some parts of the country, and increased routine testing capacity is needed to ensure adequate coverage of the US population. The Rockefeller Foundation COVID-19 Testing Solutions Group recommended that the US be capable of conducting 30 million diagnostic tests per week by October—a combination of 5 million PCR-based tests and 25 million rapid antigen tests. Last week, the US conducted approximately 4.7 million tests, falling well short of this recommendation.
While continued investment in rapid tests aims to supplement existing diagnostic testing capacity, private testing companies are still struggling to keep pace with demand. Florida Governor Ron DeSantis ordered state agencies to “sever their...testing relationships with Quest [Diagnostics] effective immediately," following the release of delayed results from nearly 75,000 SARS-CoV-2 tests, some of which dated back to April. Among these results were more than 7,500 positive tests. Quest apologized for the delay, citing a technical error, and stated that it provided timely results to patients and healthcare providers, just not to the Florida Department of Health. Florida will now have to identify alternative testing solutions, as Quest was responsible for approximately 30% of the state’s total SARS-CoV-2 testing volume.
INDIGENOUS POPULATIONS A study published in the CDC’s Morbidity and Mortality Weekly Report (MMWR) found that American Indians and Alaskan Natives (AI/AN) are disproportionately affected by COVID-19 compared to White Americans. Previously published data indicate that racial and ethnic minorities are at elevated risk for both infection and severe COVID-19 disease and death. Based on race/ethnicity data and laboratory-confirmed COVID-19 incidence from 23 states, the study found that COVID-19 incidence was 3.5 times higher in AI/AN populations than in non-Hispanic White populations. On a per capita basis, the COVID-19 incidence in AI/AN populations was 594 per 100,000 population, compared to only 169 in White populations. Additionally, AI/AN COVID-19 cases tended to be younger than White COVID-19 cases.
Long-standing racial and ethnic disparities, elevated prevalence of underlying health conditions, and inadequate access to infrastructure (eg, electricity, running water) and health services contribute to the disproportionate effect of COVID-19 on AI/AN populations. The researchers argue that public health agencies and programs must adapt data collection on race and ethnicity, including the use of culturally appropriate interview questions and data collection methods, in order to better account for AI/AN populations in COVID-19 data. Misclassification of individuals into other racial/ethnic groups is common among AI/AN populations, which complicates efforts to implement targeted interventions. The researchers also state that the US government should do more to provide culturally appropriate access to healthcare and public health services for high-risk and vulnerable racial and ethnic communities.
US SCHOOLS
K-12
Schools are continuing to adapt to changing plans to start their school year. New York City schools delayed the start of in-person classes from September 10 to September 21, citing the need to increase time for teachers to prepare. Teachers will return on August 8, as previously planned, but the delayed start will provide additional time to prepare for blended/hybrid classes—involving both remote and in-person learning. In New Jersey, some local school districts are rapidly developing and implementing plans to conduct classes remotely, following an announcement in mid-August that schools statewide would be permitted to conduct online-only instruction, a major shift in the statewide plan that previously required all schools to offer in-person instruction. Once some school districts made the decision to start the school year with online instruction, many others followed, creating a “cascade” of pressure on schools to institute remote learning options on short notice.
One of the principal concerns about resuming in-person school is the increased risk to adults—including teachers, parents, and the broader community—not necessarily the students themselves. An article published in the Annals of Internal Medicine discusses the COVID-19 risk among teachers and adults living with school-aged children stemming from students returning to school. Based on data collected through the National Health Interview Survey, the researchers estimate that 40 million US adults who live or work with children have “definite or possible risk factors” for COVID-19. The researchers also estimate that an additional 4.4 million non-teachers who work at schools and 1.6 million daycare employees would also be at elevated risk for severe COVID-19 disease or death.
COLLEGES & UNIVERSITIES
As US colleges and universities resume classes, many students are returning to campus, whether they are participating in in-person classes or not. Schools are implementing a variety of protective measures, including testing programs, in order to identify and respond to cases of COVID-19 among students and staff. Several large schools have reported high COVID-19 incidence in the early weeks of class, and there have been a number of high-profile examples of students gathering on or near campus. School officials continue to point the finger at students for not adhering to recommended or required social distancing measures, but some students are pushing back, arguing that schools are not doing enough to protect them. As more COVID-19 cases are reported on campus, many schools have updated or adapted their plans to increase the use of remote learning or restrict in-person activities, including classes and other campus events. Following previous decisions to suspend in-person classes, some schools have announced that they intend to resume in-person learning, following efforts to contain transmission identified early in the school year.
The University of Alabama’s main campus in Tuscaloosa has reported more than 1,000 cases among students (and an additional 82 among staff) since August 18—which does not include 310 cases identified during the “student entry testing.” The University of Iowa has reported 922 cases among students and 13 among staff since the start of the semester. The New York Times college and university dashboard shows more than 26,000 COVID-19 cases associated with schools nationwide. This total includes all cases since the onset of the pandemic; however, colleges and universities have reported more than 20,000 cases since the end of July. The New York Times also publishes a list of the cities currently reporting the highest per capita incidence (over the past 2 weeks), and notably, many of the top 20 cities are home to major colleges and universities, including Ames and Iowa City, Iowa (Iowa State and University of Iowa, respectively); Auburn-Opelika and Tuscaloosa, Alabama (Auburn University and University of Alabama, respectively); Pullman, Washington (Washington State University); Oxford, Mississippi (University of Mississippi [Ole Miss]); and Columbia, Missouri (University of Missouri). Many of these schools only resumed classes in the past several weeks, so many of the detected cases were likely infected prior to arriving on campus. It will be critical to monitor incidence over the coming weeks in order to better characterize the scale of transmission on campus.
The University of Arizona reportedly identified an emerging COVID-19 outbreak in one of its dormitories by monitoring the sewage system. The university implemented the wastewater monitoring program in an effort to provide early warning of COVID-19 cases on campus. Last week, the system yielded positive tests from one of the campus dormitories, and the university followed up with diagnostic testing for students living there, which identified 2 COVID-19 cases. Both students were placed in isolation, and health officials are conducting contact tracing efforts. Students in the dormitory are also undergoing “periodic” testing. The sewage monitoring system supplements the university’s “Test, Trace, Treat” plan, and it aims to enable university officials to implement containment measures, such as isolation and quarantine, before the first cases even become symptomatic. The University of Arizona has implemented a myriad of other protective measures, including mandatory mask use on campus, and it is implementing a phased system for relaxing COVID-19 restrictions. The university also offers a smartphone application (voluntary participation) that can provide notifications for students and staff who may have been exposed to an infectious individual. Other colleges and universities across the country are implementing similar efforts to test wastewater and offer smartphone applications to support campus outbreak response.
NURSE SURVEY The American Nurses Association (ANA) published the results from a recent nationwide survey of nurses. The study surveyed more than 21,000 nurses—between July 24 and August 14—about PPE use, supply shortages, and decontamination practices in the context of the ongoing COVID-19 response. The survey was distributed to nurses working in various healthcare settings across the US, including hospitals and long-term care facilities. Approximately one-third of nurses reported that they are “out” or “short” of N95 respirators, and 58% stated that they are required to reuse their N95 respirators for more than 5 days. Additionally, 62% of respondents reported feeling unsafe reusing the respirators, and 55% felt unsafe using decontaminated respirators. ANA President Dr. Ernest Grant emphasized that the “re-use and decontamination of single-use PPE as the ‘new normal’ is unacceptable.” The ANA renewed its calls for immediate federal action, including increased use of the Defense Production Act and passing new legislation, to better protect nurses against workplace transmission of SARS-CoV-2.
The posts refer to provisional COVID-19 mortality data published by the CDC’s National Center for Health Statistics, which states in its August 26 update that 6% of the “deaths involving...COVID-19” have COVID-19 listed as the only cause of death. These data come from death certificates, which may list multiple conditions as causing or contributing to death. These conditions could include those resulting directly from COVID-19 (eg, respiratory failure) or underlying health conditions that compound the effects of COVID-19 (eg, heart disease).
Assigning a cause of death is complicated, because death is often not attributable to a single, definitive cause. Doctors and medical examiners must judge, based on their expertise, the degree to which various conditions contributed to a patient’s death. It is well understood that numerous underlying health conditions—including heart disease, diabetes, and respiratory conditions—increase the risk of severe COVID-19 disease and death, so it is likely that these conditions would be included on death certificates along with COVID-19. A patient who tests positive for SARS-CoV-2 but dies of a completely unrelated cause (eg, trauma) should not be listed as a COVID-19 death, but a patient that dies due to complications of COVID-19, whether pre-existing comorbidities or conditions caused by COVID-19 itself, will likely have other conditions listed on the death certificate in addition to COVID-19. COVID-19 deaths are not limited to only those caused (or reported as being caused) solely by COVID-19.
RACE & CLINICAL TRIALS A commentary published in The New England Journal of Medicine highlights the importance of increasing the inclusion of racial and ethnic minority participants in clinical trials for COVID-19 drugs. The authors note that data from completed or ongoing trials indicate that racial and ethnic minorities are underrepresented in the study population, particularly considering the disproportionate incidence and disease severity among these populations. Notably, the studies they cite either have not yet published “outcome data according to sex or gender, race, and ethnicity” or did not include sufficient racial and ethnic minority participants to yield statistically significant results among these groups. As more candidate drugs, both treatments and vaccines, enter advanced phase clinical trials, it is critical to ensure appropriate diversity among trial participants, both to promote equitable access and to obtain the data necessary to fully characterize the drugs’ effects across all races and ethnicities, particularly those at the highest risk for infection and severe disease or death.
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