Updates on the COVID-19 pandemic from the Johns Hopkins Center for Health Security.

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The Johns Hopkins Center for Health Security also produces US Travel Industry and Retail Supply Chain Updates that provide a summary of major issues and events impacting the US travel industry and retail supply chain. You can access them here.
EPI UPDATE The WHO COVID-19 Dashboard reports 31.43 million cases and 967,164 deaths as of 6:30am EDT on September 23. At 35-40,000 deaths per week, the global mortality could surpass 1 million deaths in the next week.

The US CDC reported 6.83 million total cases and 199,462 deaths. The US is averaging 41,141 new cases and 767 deaths per day. We expect the US to surpass 200,000 cumulative deaths in the CDC's afternoon update. In total, 22 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; Georgia with more than 300,000; and Arizona, Illinois, and New Jersey with more than 200,000.

The Midwest region of the US* is now reporting its highest average daily incidence to date. The increase began in mid-June, around the time incidence began to increase in the South, Southwest, and West; however, the Midwest incidence plateaued when other regions steadily declined. Over the past several weeks, the Midwest incidence has increased again. The timing of the recent surge coincides with the return to school, including in-person classes in some areas, and much of the increased incidence is among younger adults. The Midwest is now reporting its highest average incidence to date. According to data compiled by researchers at COVID Exit Strategy, Wisconsin’s daily incidence has more than doubled over the past 2 weeks, and the incidence in Nebraska and South Dakota has increased by 40% or more. Several Midwest states are also reporting concerning trends in terms of testing. Arkansas, Iowa, Kansas, Missouri, Nebraska, South Dakota, and Wisconsin are all reporting test positivity greater than 15% over the past 2 weeks, and Nebraska and Wisconsin have increased by more than 3 percentage points over that time.
*States included in the Midwest are defined differently by different groups.

The Johns Hopkins CSSE dashboard reported 6.91 million US cases and 201,204 deaths as of 12:30pm EDT on September 23.

US CDC DROPLET VS AIRBORNE/AEROSOL GUIDANCE When we covered the inadvertent changes to US CDC guidance on SARS-CoV-2 transmission on Monday, archived versions of the site captured Friday-Sunday had not yet been posted. You can now view archived versions via the Internet Archive and compare them to the current version. We will continue to monitor CDC guidance for any changes, particularly any associated with the draft version that was published on Friday and then removed.

WEDDING RECEPTION OUTBREAK An August wedding in Maine has been linked to more than 175 associated cases and 8 deaths, including many who did not attend the wedding. Notably, none of the associated deaths attended the wedding. Six of the 8 deaths were residents of a nearby long-term care facility, where an employee who lives with someone who attended the wedding is believed to have introduced the virus. Associated cases have been identified in multiple long-term care facilities and the county jail. The outbreak at the jail has been attributed to an employee who attended the wedding, and it has resulted in at least 84 cases, including nearly half of the incarcerated population and employees as well as 17 household contacts of employees.

The wedding reportedly had 62-65 attendees and an indoor ceremony and reception, which violated the state prohibition on gatherings of more than 50 people, and attendees reportedly did not adhere to recommendations regarding physical distancing or mask use. All attendees had their temperatures checked before entering; however, this failed to identify infectious individuals. The Maine CDC issued an “imminent health hazard” citation to the event facility where the reception was held for failing to maintain social distancing measures, allowing too many people to congregate, and neglecting to collect contact information from wedding guests. The facility reportedly suspended all operations due to the outbreak. This case study highlights the potential for transmission at individual events to spill over into the community as well as the limitations of temperature or symptom monitoring to identify infectious individuals.

K-12 SCHOOLS With no federal reporting guidelines, school COVID-19 reports continue to be fragmented. The New York Times has compiled information on the public availability of school-level COVID-19 data. Currently, 11 states have no public reporting for school-associated COVID-19 cases. Some states that do report COVID-19 cases do not do so clearly or explicitly, and data can be difficult to identify among other COVID-19 reporting. The level of reporting also varies by state, ranging from school- and district-level data to aggregated state-level data.

Lawsuits continue to be a mechanism for forcing school reopenings or closures. Several teachers in Palm Beach, Florida, filed a lawsuit against the local school board to keep classes online. Conversely, a local school board in Oregon filed a lawsuit against state health and education officials to allow them to resume in-person instruction, despite the county having one of the highest incidence rates in the state. In New Mexico, a lawsuit has been filed claiming that differences in state COVID-19 requirements for public and private schools is unconstitutional. A spokesperson for the governor’s office argued that the differences in requirements for public and private schools are a result of private schools having “more flexibility” to respond during the pandemic. Private schools in New Mexico are only permitted to return to 25% capacity, whereas public schools can operate at up to 50% capacity for in-person classes. Notably, however, private schools can resume in-person classes for all grades K-12, but public schools are currently limited to grades K-5. 

MIDWEST RESURGENCE COVID-19 incidence is once again on the rise in the Midwest region of the US*. Analysis conducted by researchers at Harvard University identified 6 Midwest states as being at a “tipping point”—Arkansas, Missouri, Oklahoma, North and South Dakota, and Wisconsin—signaling the potential for increased transmission over the coming weeks if not quickly brought under control. Notably, Wisconsin Governor Tony Evers issued a new public health emergency declaration for the state and extended the statewide mask mandate as a result of the recent surge in COVID-19 incidence. As we covered previously, the Big Ten Conference, which largely consists of schools from Midwest states, announced that it will resume athletic competition, including football. Of note, the counties where 9 of the 14 schools** are located are reporting increasing COVID-19 incidence, including 2 that doubled compared to the previous week. As a whole, counties with Big Ten schools are reporting per capita incidence that is more than double the national average, including 4 that are approximately 3 times the national average or higher.
*States included in the Midwest are defined differently by different groups.
**There are 14 schools in the Big Ten Conference.

HALLOWEEN & DÍA DE LOS MUERTOS As the weather cools, many are looking ahead to fall holidays. Halloween, widely celebrated throughout the US, and Día de los Muertos, an important Mexican cultural holiday, typically involve both family gatherings and community events. To mitigate the SARS-CoV-2 transmission risk linked to these holidays, the CDC published guidance on ways to safely participate in these celebrations. The guidance breaks down certain holiday-related activities for both Halloween and Día de los Muertos into low-, moderate-, and high-risk categories. Traditional trick-or-treating, in which children go house-to-house and adults give them candy, is considered a high-risk activity since it involves direct contact between numerous children and adults as well as the widespread movement of children around the community. Instead, the CDC suggests that families prepare individually packaged candy and place it outside the home in a way that children can take it with no contact necessary. For Día de los Muertos, the CDC suggests that families perform traditional activities only with members of their own households or meet with extended family members in outdoor settings with appropriate physical distancing to mitigate transmission risk. 

OCCUPATIONAL SAFETY Since the beginning of the pandemic, worker safety has been a primary concern, especially as many workers were quickly designated as “essential” and unable to work from home. While employers are required by law to minimize workplace hazards, the Occupational Safety and Health Administration (OSHA) is tasked with enforcing the implementation of worker safety laws. A commentary published in JAMA asserts that the federal government has not taken full advantage of OSHA’s authority to improve worker safety in the midst of COVID-19. While many businesses have taken steps to protect their employees, specific practices and the degree of implementation vary considerably across businesses and localities. The authors assert that a stronger federal presence and more stringent oversight of OSHA compliance would compel employers to take stronger actions to protect their employees against workplace COVID-19 hazards. They call on OSHA to implement an Emergency Temporary Standard (ETS) that would require all employers to create and implement an infection prevention and control plan during the pandemic. Some states have issued state-level ETSs, and a federal ETS mandate is currently being proposed to the US Senate.

AIR TRAVEL TRANSMISSION As social distancing policies are relaxed and air travel is increasing around the world, airlines are implementing measures to reduce transmission risk, particularly onboard aircraft. Two recently published case studies address the risk of SARS-CoV-2 transmission related to air travel. Both studies were published in the US CDC’s Emerging Infectious Diseases journal, and both document suspected transmission between passengers and crew onboard commercial aircraft. Both case studies evaluate transmission dynamics onboard long-haul flights. In the first study, researchers used genomic analysis of clinical specimens to link 4 cases onboard a flight arriving in Hong Kong. The researchers hypothesize that 1 or 2 passengers (traveling together) infected 2 flight attendants during the flight. The other study investigated a cluster of 16 cases on the same flight arriving in Vietnam. The index patient is believed to have flown in business class, and 12 other business class passengers were infected—as well as 2 passengers and 1 flight attendant in economy class. The attack rate in business class was 62%, and it was 92% among passengers seated within 2 seats (approximately 2 meters) of the index patient. The prolonged exposure and close proximity of the passengers in business class suggests that the infections occurred during travel, whether during the flight or before the flight (eg, in business class lounge areas or standing in line during boarding). Researchers are still trying to understand the exact mechanisms and risk of in-flight transmission (eg, droplet/airborne versus fomite transmission).

The US CDC has reportedly identified approximately 1,600 confirmed COVID-19 cases who flew while infectious and more than 11,000 contacts who may have been exposed during travel. Despite collaborating with airlines, health officials face a variety of barriers to conducting contact tracing for airline passengers, including testing insufficiencies and inaccurate or outdated contact information (particularly for international flights). Additionally, CDC guidance defines a close contact as anyone seated within 6 feet of a known case or anyone on a flight without assigned seating, which can overlook at-risk passengers seated farther away or those who may have had other forms of contact (e.g., using the onboard lavatories). Current CDC guidance to mitigate transmission risk during air travel suggests physical distancing, mask use, and frequent handwashing, but it also notes that avoiding travel is the best way to minimize risk. CDC officials stated that they have not yet confirmed SARS-CoV-2 transmission onboard a domestic flight; however, they emphasize that this does not mean that it has not happened or is not occurring.

Many countries around the world continue to restrict American travelers, due in part to the current state of the US epidemic. Notably, restrictions on US travelers entering Canada and Mexico have been extended through at least October 21.

VACCINE CLINICAL TRIALS Johnson & Johnson (J&J) announced that it commenced Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine. Similar to other vaccines in Phase 3 trials, the J&J vaccine is built on an adenovirus vector to deliver the vaccine—the same platform used for its Ebola vaccine that was recently licensed in Europe. The J&J vaccine, developed by Janssen Pharmaceuticals, does offer several advantages over other vaccines in Phase 3 trials that could be particularly useful in terms of implementing vaccination campaigns. Unlike some other leading candidates, the vaccine is designed to require only 1 dose, and while it must remain refrigerated, it does not need to be frozen. The clinical trials will include 60,000 participants in Argentina, Brazil, Chile, Colombia, Mexico, Peru, South Africa, the United Kingdom, and the United States. In a press release from J&J, the company committed to publishing Phase 1/2 trial data in the near future.

As concern persists regarding the potential for a vaccine to be authorized for use before Phase 3 trials are complete, the US FDA is expected to announce standards for issuing an Emergency Use Authorization (EUA) for a candidate vaccine. Amid ongoing political statements regarding the timeline for vaccine availability, the FDA guidance could increase transparency regarding how the candidate vaccines will be evaluated, including the metrics that must be met during clinical trials to receive the preliminary authorization. The standards are expected to be more stringent than those used for convalescent plasma and hydroxychloroquine, and reportedly, FDA officials have indicated that the standards for an EUA will be close to those required for a full authorization. By outlining the standards for an EUA, the FDA aims to build confidence that scientific evidence will drive the evaluation of candidate vaccines, rather than political influence.

PEER REVIEW OF SARS-CoV-2 SYNTHETIC ORIGIN PREPRINT Perhaps more so than any event in history, preprint manuscripts and other publications outside of the traditional peer review process (e.g., press release) have been particularly impactful over the course of the COVID-19 pandemic. Considering the pace of discovery and the potential for analysis to inform pandemic response operations and policies, preprint manuscripts can disseminate information much more quickly than the peer review process would allow. However, peer review provides an independent check on publications and research, and bypassing this process can allow research that does not meet acceptable standards to be widely circulated.

A recent preprint manuscript presents genomic analysis of the SARS-CoV-2 virus and concludes that the viral genome suggests that it is synthetic in origin, as opposed to a naturally occurring virus. The sensational claims and conclusions in the manuscript have the potential to garner significant public and media attention, and the nature of the conclusions could potentially impact global geopolitics and international COVID-19 response. The study and conclusions, however, have not been subjected to independent expert scrutiny. Several experts at the Johns Hopkins Center for Health Security endeavored to provide an analogue to the peer review process for this article and put the analysis in context for elected and appointed government officials, the media, and the public. The Center’s experts identified a number of flaws throughout the manuscript that call into question the validity of the analysis and findings.

GARBAGE As Americans, and presumably citizens in countries around the world, stay home as part of social distancing efforts, they are generating more garbage. According to a report by NPR, garbage volume “spiked as much as 25%” in the spring, when most Americans were under some form of “stay at home” order or other social distancing policy. In addition to increased volume, the distribution of garbage is shifting from businesses to homes, and the trucks designed to empty large dumpsters are not necessarily able to be repurposed to collect residential garbage that may require navigating narrower streets or alleys. In some countries, such as Japan, existing garbage collection practices are being updated to reduce the risk of exposure for sanitation workers.

Additionally, some cities are facing shortages of sanitation workers, which further challenges trash collection efforts. Sanitation workers are certainly essential, but it can be difficult to provide them with the same level of protection that other essential workers have. The CDC has published guidance for waste collectors and recyclers that includes recommendations for COVID-19 risk mitigation measures. In addition to general recommendations that are applicable to most businesses (eg, mask use, physical separation), the CDC recommends that sanitation workers practice enhanced hygiene, and it emphasizes the importance of personal protective equipment, including eye protection, gloves, and coveralls or uniforms. In particular, the CDC recommends avoiding contact with bodily fluids or items/surfaces contaminated with them; however, garbage often contains these items. In many cases, sanitation workers may not be able to avoid contact with garbage, which could potentially pose a transmission risk.