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

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EPI UPDATE The WHO COVID-19 Dashboard reports 32.03 million cases and 979,212 deaths as of 6:34am EDT on September 25. At 35-40,000 deaths per week, the global mortality could surpass 1 million deaths in the next week.

As the US surpasses 200,000 cumulative deaths and the global total approaches 1 million, we want to take a closer look at cumulative deaths at the national level. In terms of total cumulative deaths, the US maintains a sizable lead over all other countries. Brazil is #2 with nearly 140,000 deaths. India appears to be on a trajectory that could eventually surpass the US; however, it is currently reporting fewer than half of the US total, so the situation could change.

On a per capita basis, the top 20 countries are largely divided between 2 groups: European countries affected severely early in the pandemic and Central and South American countries that peaked more recently. These groups are fairly easy to distinguish by the shapes of their curves in the figure, with European countries increasing sharply in April before leveling off and Central/South American countries increasing more slowly starting in May and June and just now beginning to taper off. The US is a notable exception, with peaks in the spring and summer. With more than 1,200 cumulative deaths per million population, San Marino is #1 globally; however, that corresponds to fewer than 50 total deaths nationwide. Peru is reporting more than 950 deaths per million population and steadily increasing, and it is on a trajectory to overtake San Marino in the coming weeks. With the exception of San Marino and Andorra, most of the countries in the top 20 have reasonably large populations. There is considerable overlap between the total and per capita top 20 lists, owing to the very large mortality totals in these countries, particularly in Europe and Central and South America.

The US CDC reported 6.92 million total cases and 201,411 deaths as of 12 PM ET on September 24. The US is averaging 43,245 new cases and 732 deaths per day. The cumulative US COVID-19 mortality surpassed 200,000 deaths, representing more than 20% of the global total. After reaching a minimum of 34,371 new cases per day on September 12, following the Labor Day holiday weekend, the US has reported increasing incidence for nearly 2 weeks, surpassing its previous plateau and up to its highest average daily incidence since August 22. In total, 22 states (no change) are reporting more than 100,000 cases, including California and Texas with more than 700,000 cases; Florida 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 Johns Hopkins CSSE dashboard reported 6.98 million US cases and 202,827 deaths as of 9:45am EDT on September 23.

UNITED KINGDOM While the UK’s COVID-19 epidemic has not yet returned to the height of its first peak, it is nearly there and still accelerating rapidly. UK health officials forecast that the country could potentially reach 50,000 new cases per day by mid-October, nearly 10 times the current current daily incidence. The average number of daily deaths has also increased in the UK; however, the daily mortality is still considerably lower than it was at the height of the “first wave”—fewer than 40 deaths per day, compared to more than 800. COVID-19 hospitalizations are beginning to increase as well. Based on the current COVID-19 trends, the Chief Medical Officers for England, Scotland, Wales, and Northern Ireland all recommended moving their respective countries to COVID-19 Alert Level 4.

UK Prime Minister Boris Johnson announced a number of policies to strengthen existing social distancing restrictions. The measures expand mandatory mask use, including for retail and hospitality businesses; prohibit in-person food and alcohol service after 10pm; and limit the size of gatherings, generally a maximum of 6 people with some exceptions. Businesses will also be required to display a QR code to support contact tracing efforts via a smartphone application, and businesses that repeatedly violate the restrictions will face fines of up to £10,000 (~US$12,700). Additionally, Prime Minister Johnson continued to encourage individuals to work from home to the extent possible. He also indicated that the restrictions could be in place for 6 months, which would potentially last through the majority of the 2020-21 influenza season. The new restrictions also resulted in a suspension of plans to allow spectators to begin returning to sporting events.

BRAZIL SEROPREVALENCE A team of researchers published a pre-print examining the seroprevalence of COVID-19 in two Brazilian cities. From February to August, researchers conducted a cross-sectional monthly estimate of seroprevalence among blood donors samples from Manaus and Sao Paulo, Brazil. After adjusting for the sensitivity and specificity of their diagnostic tests and weighting their values to account for differences in sex and age, the researchers saw a peak in their Manaus collection with 51.8% of samples containing SARS-CoV-2 antibodies this past June. The researchers did note that Manaus’ community immunity waned in the following months falling to 40% and 30.1% in July and August respectively. While significantly lower than the Manaus sample, researchers saw a similar trend in the samples from Sao Paulo. The authors note that they are unsure what contributed to such high rates of seroprevalence among blood donors in Manaus, and share that other studies from the region present differing results despite covering a similar time period. They describe a number of possibilities for this difference, including test sensitivity and sampling methods. The authors present an argument for the possibility of community immunity in regions with high COVID-19 transmission, like Manaus, and cite challenges of potential waning immunity.

CHINA TRAVEL RESTRICTIONS China’s early response to the COVID-19 pandemic included domestic travel restrictions. As the pandemic spread to other parts of the world, China also limited foreign travel into the country. China continues to keep a relatively low daily incidence rate of COVID-19 cases, and recently announced a roll-back of several external travel policies. Now foreign individuals with Chinese visas or residence permits can return to the country for economic or personal matters. They also have announced a reopening of their visa office. 

VACCINES ALLOCATION & DISTRIBUTION Earlier this week the WHO announced that 64 higher-income, “self-financing” countries are now part of the COVAX Facility to provide funding support for lower-income countries to purchase a future SARS-CoV-2 vaccine, and an additional 38 economies are expected to join soon. Of these, 29 are from Europe, participating as part of an agreement with the European Commission. A total of 156 countries are participating in the COVAX Facility, representing approximately 64% of the global population. Notably, the US and China are not participating. The allocation plan for the program expected to provide enough vaccine to cover approximately 20% of the population in receiving countries.

REFUGEES & DISPLACED POPULATIONS The Norwegian Refugee Council published a report this week discussing the impact of COVID-19 on refugees and displaced populations. The report describes results of a survey of 1,400 people across 8 countries who have been impacted by conflict within their countries and/or have been displaced from their homes as well as more targeted surveys and needs assessments across a total of 14 countries. The survey found that 77% of respondents have lost their jobs or income since March, and 62% who normally receive financial support from family abroad are receiving less money now than they were before the pandemic. Financial insecurity is also impacting families’ ability to send children to school and pay for medical expenses, and the risk of eviction or other housing insecurity increased as well. Food insecurity has increased as well, with 70% reporting that their household has reduced the number of meals since the start of the pandemic. The report recommends that G20 countries scale up bilateral financial assistance and implement plans for debt relief for countries experiencing large numbers of internally displaced or refugee populations. Additionally, the report calls for national governments to explicitly include refugee and displaced populations in economic stimulus efforts and expand the reach of social support programs.

The Internal Displacement Monitoring Centre published a report outlining the displacement among vulnerable populations amid the COVID-19 pandemic. The organization’s mid-year update reported more than 14 million new internal displacements across 127 countries in the first 6 months of 2020 alone. Of these, 4.8 million displacements were caused by violence, and 9.8 million were caused by disasters. Notably, the numbers displaced by violence was a sharp increase for several countries compared to previous years. Notably, the totals for the first half of 2020 were higher than the full-year 2019 total in Cameroon, Mozambique, Niger, and Somalia. Populations were displaced by disasters in countries representing all income categories, and many affected populations face prolonged displacement, particularly if their homes were destroyed.

The pandemic is driving a myriad of downstream effects on displaced population. The report indicates that populations living in camps may not have access to appropriate testing or clinical care for COVID-19. Like the NRC report, financial, housing, and food insecurity have been exacerbated by COVID-19. The report also indicates that stress stemming from the pandemic and its downstream effects could be driving an increase in violence among displaced populations, particularly toward women and children. Finally, the pandemic is also impacting humanitarian aid operations, including aid workers being evicted by local communities over fear that they will bring COVID-19.

PEDIATRIC VACCINE The world awaits a SARS-CoV-2 vaccine, but regardless of the timeline, it is clear that it will not be available for everyone initially. Beyond the initial limited supply, there are other barriers for some populations. Even if sufficient supply is available, a vaccine may not necessarily be authorized for use in children, due in part to their exclusion from ongoing clinical trials. The decision to omit children is supported by various leading experts, and it is a function of multiple factors both specifically in the context of COVID-19 and based on historical practice. One of the primary concerns is that children are not a high-risk group for severe COVID-19 disease, which places them as a lower priority from that perspective. Additionally, clinical trials in children traditionally only begin once safety and efficacy are established in healthy adults in order to reduce the possibility of harm in children. Some argue, however, that Phase 2 trials in children should begin soon, because children can still suffer from severe COVID-19 disease and because time is needed to assess possible long-term effects of vaccine candidates in children. As the age distribution of COVID-19 cases shifts toward younger individuals, it is clear that children and adolescents can transmit the infection, including to older or other high-risk individuals. Furthermore, ensuring that a safe and efficacious vaccine for children is available by the start of the 2021 school year could be an important tool for resuming normal social and economic activities, particularly for parents and guardians who are currently unable to return to work while their children are not in school.

VACCINE CHALLENGE TRIAL The UK government is reportedly considering challenge trials for candidate SARS-CoV-2 vaccines. In contrast to traditional, placebo-controlled clinical trials, participants in challenge trials all receive the vaccine and are then deliberately exposed to the virus in order to determine the efficacy of the vaccine. According to the reports, the trial could begin in January 2021, and the effort is supported by 1Day Sooner, an organization that “advocates on behalf of COVID-19 challenge trial volunteers.” While challenges trials could potentially provide more rapid assessment of vaccine efficacy, it poses a number of ethical challenges, particularly in the absence of a more effective treatment or a well-characterized understanding of the required exposure dose. Some experts, including at the US National Institutes of Health argue that the additional protective measures and monitoring for challenge trials could actually prevent them from providing results more quickly than traditional clinical trials.

PHUKET COVID-19 RESPONSE A new paper in EClinicalMedicine, details the potential impact of non-pharmaceutical interventions in limiting the spread of COVID-19. The paper examines the COVID-19 response in Thailand’s Phuket Island, one of Thailand’s most popular tourist destinations. The region maintained a relatively low number of COVID-19 cases despite a surge in activity earlier this spring. The paper provides a detailed outlook of state-run contact tracing efforts, and their process for quarantine. The findings suggest that 80% of new COVID-19 cases occurred in individuals they had identified as “high-risk” contacts. The authors suggest that this finding emphasizes the importance of contact tracing in an effort to identify such individuals and for proper quarantine as a necessary tool in stopping the chain of transmission. 

COVID-SNIFFING DOGS SARS-CoV-2 testing would likely be less scary or uncomfortable if it was conducted by puppies. Perhaps that is part of the motivation behind Finland’s new plan to deploy “coronavirus-sniffing dogs” at the Helsinki Airport. The airport is conducting a pilot project that uses specially-trained dogs to detect SARS-CoV-2 infection in passengers based on their scent. Dogs have been used in a similar manner to detect other infections or diseases that cause a distinct odor in patients, including cancer and Clostridium difficile, sometimes before the onset of symptoms. Samples are taken by swabbing passengers’ necks and then delivered to the dogs in a separate room. One researcher from the University of Helsinki indicated that the dogs can approach 100% sensitivity and can detect infection up to 5 days before the onset of symptoms. A similar program was also recently implemented in the Dubai International Airport. The use of dogs to detect SARS-CoV-2 has not been sufficiently assessed in scientific studies, so passengers identified by the dogs will be administered a more traditional test to confirm infection. Further research is needed to demonstrate the accuracy of this surveillance method, but it could provide rapid assessment capability, particularly for high-traffic areas like airports.

**While the following topic is largely a US issue, it is an emerging storyline that we feel is important to cover today, instead of waiting until next week.**
US FDA VACCINE REVIEW & AUTHORIZATION As we covered earlier this week, the US FDA signaled its intent to publish additional details regarding the process and standards for evaluating candidate SARS-CoV-2 vaccines undergoing Phase 3 clinical trials. According to multiple media reports, the proposed standards are currently under review at the White House, and some experts argue that the influence of officials outside of the FDA adds to concerns about the extent to which vaccine authorization decisions will be driven by political demands. US President Donald Trump suggested that the FDA announcement was politically motivated and that the forthcoming standards would need to be approved by White House officials. President Trump’s comments exacerbate a contentious debate regarding the independence and objectivity of US regulatory authorities and public health agencies and the role of appointed officials in reporting data and developing guidance.