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 32.97 million cases and 995,836 deaths as of 10:00am EDT on September 28. The global weekly incidence remained greater than 2 million new cases last week, but it decreased slightly (1.45%) compared to the previous week. At approximately 36,000 deaths per week (~5,142 deaths per day), the global cumulative COVID-19 mortality could reach 1 million by tomorrow.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. India: 83,875 new cases per day (-7,719)
2. USA: 44,319 (+3,628)
3. Brazil: 26,811 (-3,785)
4. Argentina: 12,627 (+1,705)
5. France: 12,115 (+1,734; ↑ 1) 
6. Spain: 10,920* (-185; ↓ 1)
7. Russia: 6,863 (+1,064; ↑ 1) 
8. Colombia: 6,854 (-111; ↓ 1)
9. Israel: 6,086 (+1,538; ↑ 1)
10. Indonesia: 5,846 (+2,090; new)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Israel: 703 daily cases per million population (+178)
2. Andorra: 503 (+96; ↑ 2)  
3. Montenegro: 387 (-45; ↓ 1) 
4. Bahrain: 359 (-53; ↓ 1)
5. Argentina: 279 (+38)
6. Costa Rica: 234 (+2)
7. Spain: 234* (-4)
8. Czech Republic: 205 (+31)
9. France: 186 (+27; new) 
10. Peru: 158 (-12; ↓ 1)
*Spain’s average daily incidence is not reported for today; these values correspond to the previous day’s averages.

India’s daily incidence continues to decline from its peak in mid-September, down 10% over the past 2 weeks. Peru fell out of the top 10 in terms of total daily incidence, and it was replaced by Indonesia. Israel set a new record for per capita incidence over the weekend, with 718 daily cases per million population. The Bahamas fell out of the top 10 in terms of per capita daily incidence, and it was replaced by France.

The US CDC reported 7.06 million total cases and 204,033 deaths. From the first case reported in the US on January 22, it took 96 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: 15 days
4 million to 5 million: 17 days
5 million to 6 million: 22 days
6 million to 7 million: 25 days

The US is averaging 44,307 new cases and 755 deaths per day. This is the highest average daily incidence since August 21 and nearly 30% greater than the low reported on September 12. We are now 3 weeks past the Labor Day holiday—which is also typically the latest that US schools begin the school year—and the US is exhibiting another increase in incidence at the national level.

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, New Jersey, and North Carolina with more than 200,000. California’s state COVID-19 website is currently reporting more than 800,000 cases, and Florida’s COVID-19 website is reporting more than 700,000 cases. We expect both of those to be reflected in the CDC data in the coming days.

The Johns Hopkins CSSE dashboard reported 7.12 million US cases and 204,790 deaths as of 11:30pm EDT on September 28.

FLORIDA On Friday, Florida Governor Ron DeSantis announced that the state would enter Phase 3 of Florida’s COVID-19 recovery plan, which would essentially lift all COVID-19-related restrictions on businesses, including measures that restricted capacity for bars and restaurants. Local governments are permitted to institute their own COVID-19 restrictions on restaurants; however, they must “quantify the economic impact of each limitation” and justify “why each necessary for public health.” Governor DeSantis’ executive order also suspends fines or other penalties for individuals who do not comply with COVID-19 restrictions. Businesses are still free to set and enforce their own policies for employees and patrons. The announcement comes as Florida surpasses 700,000 cumulative cases, and COVID-19 incidence is increasing in many parts of the country.

VACCINE CLINICAL TRIAL Johnson & Johnson (J&J) published (preprint) preliminary findings from the Phase 1/2a clinical trials for its candidate SARS-CoV-2 vaccine (Ad26.COV.S). The studies included nearly 800 participants, who were split into 3 cohorts for the randomized, double-blinded, placebo-controlled study. The first 2 cohorts were made up of 402 healthy adults aged 18-55 years, and the third cohort included 394 healthy adults over the age of 65. The vaccine was given as a single dose or 2 doses administered 56 days apart. The vaccine was generally well tolerated, and the researchers reported 2 serious adverse events. One of the serious adverse events was determined to be unrelated to the vaccine, and the other was a fever that resolved within 12 hours.

Neutralizing antibody activity was observed in 98% of participants aged 18-55 years, and 99% of participants in those cohorts also demonstrated seroconversion following the vaccination. The younger adult cohorts also had strong T cell, antibody, and a Th1 cytokine response. Only 15 participants from the older cohort had immunogenicity data available, although the researchers reported that initial data are promising. Last week, J&J announced that it will commence Phase 3 clinical trials involving 60,000 participants across approximately 215 sites to test the single-dose vaccine formulation. The J&J candidate vaccine is the only vaccine in Phase 3 trials utilizing only 1 dose, which may expedite results of the trial. 

SUSCEPTIBILITY IN CHILDREN & ADOLESCENTS A systematic review and meta-analysis published in JAMA: Pediatrics describes findings from 32 contact tracing studies and population screening studies to compare susceptibility to SARS-CoV-2 infection among children and adolescents to susceptibility among adults. The researchers—from Australia, the Netherlands, and the UK—evaluated studies representing 41,640 children and 268,945 adults. They determined that individuals under 20 years old had 44% lower odds of infection compared to older adults, a statistically significant difference. Notably, they determined that this association appeared to be largely attributable to younger childrenunder the age of 10-14 years—and that adolescents appeared to have similar infection risk as adults.

The younger children also exhibited lower seroprevalence compared to adults, but adolescents and adults exhibited similar seroprevalence. Many of the included studies were conducted at a time when highly restrictive social distancing measures were in place, including school closings, which could have affected children’s exposure both inside and outside the home. Additionally, contact tracing efforts and community-level seroprevalence studies had lower participation for children compared to adults. The researchers were unable to determine the risk of community transmission by children, and further research is necessary to better characterize the role of pediatric cases in the COVID-19 pandemic. This study does provide evidence that older children and adolescents may be similarly susceptible to SARS-CoV-2 as adults.

DRIED BLOOD SPOT TESTING A study published in the US CDC’s Emerging Infectious Diseases journal demonstrates that dried blood spot (DBS) samples could be used to detect SARS-CoV-2 antibodies. Compared to blood serum, which must be obtained by venipuncture, DBS specimens are much easier to collect, including at home by the general public; ship/transport; and process. A study of 80 participants in the UK tested 87 DBS specimens against matched blood serum specimens from the same participant. The DBS test exhibited 98% sensitivity and 100% specificity compared to the serum samples. DBS testing is used to test for antibodies for a variety of other pathogens, and this capability could reduce the cost, difficulty, and logistical burden of expanding community-level seroprevalence efforts, particularly in lower- and middle-income countries. Additional study is needed to fully characterize the capabilities of DBS testing for SARS-CoV-2, but this initial data provides promising indication that DBS could be a useful tool during the COVID-19 pandemic.

FACE COVERINGS The use and availability of face coverings, including for the general public and for healthcare workers, has been one of the major ongoing storylines over the course of the pandemic. Researchers continue to evaluate the role of masks and other face coverings in mitigating SARS-CoV-2 transmission, and hospitals and health systems in the US (and likely elsewhere) continue to struggle to maintain sufficient supply of respirators and surgical masks that are critical for protecting healthcare workers and patients.

Researchers from the University of California Davis and the Icahn School of Medicine at Mount Sinai (New York) published findings from a study to evaluate the ability of various mask types in reducing exhaled respiratory droplets. The study, published in Scientific Reports (a Nature journal), evaluated several different mask types, including N95 and KN95 respirators (vented and unvented; not fit-tested), surgical masks, and homemade cloth masks (single and double-layer). Measurements for respiratory droplets were taken while participants breathed, spoke, coughed, and chewed, and additional measurements were taken before and after washing cloth masks. The respirators and surgical masks exhibited a statistically significant decrease in respiratory droplets, whereas the homemade t-shirt masks did not. Notably, the cloth masks resulted in an increase in droplets in some instances, similar to results from a previous study that found increased droplets for neck gaiters. The researchers determined that cloth masks have the potential to shed cloth particles as the material breaks down, which could contribute to the volume of airborne particles. The current study only evaluated paper towel and t-shirt material for the homemade masks, and further research is needed to better characterize the effects of different types of cloth and mask construction. The researchers also note that the sampling methodology did not account for droplets that escape around the edges of the masks.

An investigation conducted by ECRI—”an independent, nonprofit organization improving the safety, quality, and cost-effectiveness of care across all healthcare settings”—found that KN95 respirators originating in China may not provide sufficient protection for healthcare workers. During the pandemic, KN95 respirators have been used to supplement limited supply of NIOSH-certified N95 respirators, including in healthcare settings. In theory, KN95 respirators should provide similar filtration capabilities as the certified N95 respirators; however, ECRI found that some KN95 respirators do not meet the same filtering standards. The researchers tested 200 respirators across 15 different models, and 60-70% of the KN95 masks imported from China did not filter 95% of airborne particles like they should. Notably, it may be difficult to distinguish between KN95 and N95 respirators visually; however, many of the tested KN95 respirators utilize ear loops, as opposed to elastic straps that go around the head and neck, which do not provide an adequate seal between the respirator and the wearer’s face. ECRI recommended that hospitals and health systems purchasing KN95 respirators conduct tests to ensure the products are providing appropriate protection. In April, the US FDA issued an Emergency Use Authorization (EUA) for non-NIOSH-certified respirators, and it has issued several updates since then to address quality control issues with imported products, including a list of products no longer authorized under the EUA due to inadequate performance.

DISEASE SEVERITY INDICATORS Last week, two studies published in Science provide evidence that type 1 interferon may play an important role in fighting SARS-CoV-2 infection. The first article, researchers conducted whole-genome or exome sequencing for for 659 patients with life-threatening pneumonia due to COVID-19 and compared the results against sequencing from 534 participants with asymptomatic infection or mild disease. The researchers evaluated the genomes for 13 rare mutations associated with decreased interferon production. Among the patients with severe COVID-19 infection, 3.5% had loss of function in one of these genes, representing 8 of the 13 mutations evaluated. Notably, no members of the control group (asymptomatic/mild) had any of these mutations.

The second study found the body’s immune response could also inhibit interferon activity in patients who are able to produce their own in sufficient quantities. Among 987 patients with severe COVID-19 pneumonia, the researchers identified “rogue antibodies” (auto-Abs) that attacked interferon in 101 patients. These antibodies were not observed in 663 individuals with asymptomatic infection or mild disease, and only 4 of 1,227 healthy individuals had the rogue antibodies. Interestingly, 94% of the patients with the rogue antibodies were male.

These studies may help identify individual risk factors for developing severe COVID-19 disease. The authors indicate that these 2 conditions could account for 14% of severe COVID-19 cases. They suggest that convalescent plasma donors be screened for rogue antibodies prior to donation to reduce the chance that they could attack interferon in patients receiving the treatment and that synthetic interferons could be a potential area of investigation in terms of developing additional treatment options. 

RELIGIOUS PRACTICES As Israel’s COVID-19 epidemic continues to surge, setting new records in terms of per capita daily incidence, Jewish rabbis, particularly those serving ultra-Orthodox communities, are addressing a myriad of questions to help their followers safely worship during the High Holiday season. Social distancing restrictions have had significant impacts on religious services around the world, in particular on the role of large gatherings for many religious holidays and celebrations. The questions posed to ultra-Orthodox rabbis range from how to best lead prayers and services remotely (eg, via Zoom) to the role of blessing food for those who lost their senses of taste and smell due to COVID-19. There has been some opposition to social distancing measures in some ultra-Orthodox communities, including keeping schools open during national “lockdowns,” but the Israeli government is working to engage with local religious leaders and promote lower-risk alternatives or adaptations for religious services and celebrations, particularly for the High Holiday season.

JOHNS HOPKINS COVID-19 DASHBOARD Since the early days of the COVID-19 pandemic, the Johns Hopkins Coronavirus Resource Center, including the global and US dashboards developed by the Center for Systems Science and Engineering (CSSE), has served as a principal source of updated COVID-19 information for experts and the public around the world. COVID-19 data published via these resources are cited by elected officials, experts, and the media, often over officially reported data. On Wednesday, September 30 (4-5pm EDT), the Science and Entertainment Exchange (US National Academy of Sciences) will host a webinar featuring several experts from across the Johns Hopkins University and Medicine system—including the Center for Health Security’s own Dr. Jennifer Nuzzo—to discuss the dashboard and the role of data in the COVID-19 response, including efforts to compile, analyze, and present data collected from a variety of disparate sources and ways that these data can and should be leveraged to support response operations at all levels of government.