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 27.49 million cases and 844,312 deaths as of 9:30am EDT on September 9. Last week’s incidence was the highest to date (1.91 million cases) and an increase of 5.7% from the previous week. Weekly global deaths has decreased for 3 consecutive weeks, down to 37,553 last week.

Total Daily Incidence (change in average incidence; change in rank, if applicable)
1. India: 85,801 new cases per day (+20,275)
2. USA: 36,020 (-6,059)
3. Brazil: 30,163 (-6,484)
4. Argentina: 10,039 (+834; ↑ 1)
5. Spain: 9,077* (+1,472; ↑ 1)
6. Colombia: 7,921 (-1,621; ↓ 2)
7. France: 7,074 (+2,068; ↑ 2) 
8. Peru: 5,580 (-1,969; ↓ 1)
9. Mexico: 5,261 (+164; ↓ 1)
10. Russia: 5,106 (+309)

Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
1. Bahrain: 345 daily cases per million population (+132; ↑ 2)
2. Israel: 321 (+142; ↑ 4)
3. Argentina: 222 (+18; ↑ 1)
4. Montenegro: 218 (+116; new)
5. Costa Rica: 216 (+51; ↑ 4)
6. Maldives: 195 (-40; ↓ 5)
7. Spain: 194 (+31; ↑ 3)
8. Kuwait: 182 (+45; new)
9. Peru: 169 (-60; ↓ 7)
10. Panama: 161 (-10; ↓ 2)
*Spain’s average daily incidence is not reported for today; these values correspond to the previous day’s averages.

India’s epidemic continues to accelerate and set new records for daily incidence. India surpassed Brazil as #2 globally in terms of cumulative COVID-19 incidence. The “second waves” in France and Spain are now bigger than the first waves. After more than 3 months of consistent decline, Russia’s daily incidence has increased steadily since late August. Israel and Bahrain are the only 2 countries reporting more than 250 daily cases per million population. Brazil and Colombia fell out of the top 10 in terms of per capita daily incidence, and they were replaced by Kuwait and Montenegro. Several countries in the top 10 per capita daily incidence have exhibited major surges over the past week or so. Notably, Bahrain’s daily incidence increased by more than 60% since August 31, Israel’s increased by nearly 80%, and Montenegro’s more than doubled. While not in the top 10, the UK is also exhibiting a concerning increase in daily incidence, more than doubling since August 22—now up to 2,032 new cases per day

The US CDC reported 6.29 million total cases and 188,688 deaths, and the US is averaging 40,417 new cases and 805 deaths per day. In total, 19 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.

Guam continues to report elevated per capita daily incidence, but its average has decreased substantially over the past week. The current per capita daily incidence of Guam is 225 daily cases per million population.

COVID-19 incidence data was unavailable from the Johns Hopkins CSSE dashboard. The dashboard reported 189,972 US deaths as of 11:30am EDT on September 9.

VACCINE TRIAL SAFETY PAUSE The Phase 3 clinical trial for AstraZeneca’s candidate SARS-CoV-2 vaccine (developed in collaboration with Oxford University) has been paused following the identification of a serious adverse event in one of the participants. Neither AstraZeneca nor Oxford University have yet disclosed details of the adverse event, which reportedly occurred in the UK; however, The New York Times reports that the patient developed transverse myelitis. It has not yet been determined whether the condition was associated with the vaccine. An earlier clinical trial for the AstraZeneca vaccine was also paused following the diagnosis of transverse myelitis in a participant, but the trial resumed after a safety review determined that the condition was not related to the vaccine.

These types of holds on Phase 3 trials are not uncommon. In a statement, AstraZeneca explained this hold was a routine action after identifying an unexplained illness during the course of the trial. AstraZeneca announced that independent experts will examine the vaccine’s safety data before determining the next steps. Phase 3 trials are designed to identify less common adverse events by recruiting tens of thousands of participants. Because these rarer side effects occur infrequently, they may not have been detected in smaller Phase 1/2 trials.

UNITED KINGDOM COVID-19 incidence has been on the rise in the UK, but the response has been hampered by issues with testing accessibility. The UK’s National Health Service (NHS) test and trace program has experienced difficulties processing the volume of requested tests and delays in reporting results. Some individuals have reported that the NHS website directed them to travel hundreds of miles to be tested, even though testing centers exist nearby. UK officials stated that a glitch in the online system was responsible for directing people to distant testing centers, but testing centers near London are reportedly at maximum capacity and not accepting new appointments. Matt Hancock, UK Secretary of State for Health and Social Care, attributed the backlog in testing to an increase in testing demand from asymptomatic individuals. Others in the UK government oppose this view and maintain that the NHS system simply does not have adequate capacity to meet expectations. Regardless of the cause, the inability to rapidly test and trace individuals is troublesome for the UK, particularly at a time of increasing transmission.

In response to the recent increase in daily incidence, the UK government decreased the allowable social gathering size from 30 to 6 individuals. This rule will not apply to households or bubbles of more than 6 persons. Additionally, pubs, restaurants, and other hospitality-based businesses will be required to collect customers’ contact information in order to aid in contact tracing efforts following suspected exposures. Collecting customer information was previously voluntary. The UK is not alone in redoubling social distancing measures in response to increased cases. Spain, France, and other European countries are currently experiencing spikes in cases following efforts to relax social distancing measures. For example, France has implemented free testing nationwide and mandated mask use in public, but government officials are wary of reimposing restrictive “lockdowns.” 

RUSSIA VACCINE OPPOSITION Some frontline healthcare workers and other essential workers (e.g., teachers) in Russia are reportedly expressing opposition to the use of Russia’s candidate SARS-CoV-2 vaccine before the completion of Phase 3 clinical trials. Russia announced initial approval for the vaccine following limited Phase 1 and 2 clinical trials, and it reportedly intends to begin administering the vaccine to essential workers in advance of larger Phase 3 clinical trials. The vaccine is currently available on a voluntary basis; however, some teachers and other essential workers have raised concerns that it could become mandatory before Phase 3 trials are complete, whether mandated by the government, schools, or other employers. Russia’s “Uchitel” teacher’s union circulated a “petition against compulsory vaccination for teachers” in anticipation that this could become a problem in the future. Those opposing the vaccine emphasize that there is tremendous pressure on teachers and healthcare workers, in particular, to get vaccinated, but there is also considerable concern about the safety and efficacy of the vaccine.

CHINA VACCINE EFFICACY Chinese pharmaceutical company SinoVac reportedly announced preliminary results from Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine, CoronaVac. Reuters reports that SinoVac officials described early safety and efficacy data from the Phase 3 trials, but the full data have not been published publicly. According to the company officials, the vaccine continues to exhibit an acceptable safety profile and generate an immune response in recipients. More than 90% of the study participants so far developed antibodies following vaccination following 2 doses of “low, medium, or high-dose” vaccine. Notably, the vaccine appears to generate an immune response in older individuals, but it is not as strong as in younger recipients. The Phase 3 trials are ongoing in Brazil and Indonesia. We have not yet been able to confirm this information in official statements, press releases, or data published by SinoVac.

Multiple media outlets are also reporting that approximately 90% of SinoVac employees and their families have been vaccinated with the candidate vaccine. China previously issued emergency authorization for the vaccine based on Phase 1 and 2 clinical trial results. The emergency authorization aimed to provide the vaccine for essential workers. SinoVac “offered the candidate vaccine to approximately 2,000 to 3,000 employees and their families on a voluntary basis.”

US TESTING CAPACITY Researchers at The Rockefeller Foundation and Duke University published a report today that includes projections for the testing capacity needed to safely resume social activities, including reopening schools for in-person classes and supporting other high-risk populations (eg, nursing homes). The report indicates that the US could need 193 million tests per month to mitigate SARS-CoV-2 transmission risk to the point that the public could resume priority activities (e.g. in-person schooling) in a reasonably safe manner. The researchers also note that, while testing capacity is expected to increase over the coming months, it could be January before national capacity reaches 200 million tests per month, unless additional tests become available or production capacity is increased more rapidly than current projections. The COVID Tracking Project estimates that national testing capacity is currently 21 million tests.

The aim of the effort was to outline a testing framework to support efforts to increase capacity to a level that would permit a return to “some form of normalcy.” The researchers call on the US government to develop a national strategy and direct a “short- and long-term plan to procure and distribute tests to states, localities, and businesses,” as opposed to leaving these entities to navigate this process on their own. One of the principal recommendations is the expanded availability and use of rapid tests for screening purposes. While these tests may be less accurate, widespread availability could allow them to be used more often in order to support existing surveillance efforts. This report closely follows the recent shift in testing recommendations by the US CDC, which now indicates that testing may not be necessary for asymptomatic individuals with known exposure to COVID-19 cases.

US COLLEGES & UNIVERSITIES As college students across the US return to campus, colleges and universities continue to report elevated and increasing COVID-19 incidence. As we covered last week, a number of the top cities in terms of both daily per capita incidence and increase in per capita incidence are home to major colleges and universities. Additionally, counties where college students represent at least 10% of the local population are reporting a sharp increase in COVID-19 incidence—nearly doubling since mid-August—whereas incidence in counties without sizable student populations continues to decline.

These outbreaks, mitigation measures, and responses vary by school, and one of the biggest areas of divergence is with respect to SARS-CoV-2 testing. Some schools that have resumed in-person classes or otherwise returned students to campus have implemented SARS-CoV-2 testing programs—including arrival testing and regular testing—but not all schools took this approach. Notably, the US CDC guidance for colleges and universities emphasizes that widespread testing of asymptomatic students without known exposure (e.g., entry/arrival testing) is not recommended. The University of Iowa reportedly elected not to implement widespread testing as students returned to campus. As tens of thousands of students converged from around the country, and even around the world, university officials had no way of identifying and isolating potentially infectious students until they sought care for their symptoms. Since classes resumed in mid-August, the University of Iowa has reported more than 1,500 COVID-19 cases. The University of Iowa notes that these are only self-reported cases, which means that there are likely many more infectious individuals (e.g., mildly symptomatic or asymptomatic) on campus.

Students and employees at several colleges and universities—including the University of Iowa, University of Kansas, and University of Michigan—have taken action to protest university COVID-19 policies, including strikes and “sickouts.” Additionally, schools continue to penalize students for gathering (eg, for parties), including suspending them from class. New York University, Northeastern University, and West Virginia University have all suspended students, including from participating in remote classes, and in some cases kept their tuition.

At the University of Alabama, students and professors have raised concerns about the University’s COVID-19 plan and risk mitigation measures. An investigation by Alabama News identified some potentially concerning practices as part of the University’s plan to isolate and quarantine infectious and exposed students on campus. The outlet interviewed multiple students who were under isolation in one of the campus dormitories, and some discussed a lack of communication and support from the university after receiving notification that they tested positive and needed to isolate. Some students reported no problems, but others indicated that health officials did not provide support in transporting themselves and their belongings to the isolation dormitory and that they had not been contacted at all to conduct contact tracing.

US K-12 SCHOOLS Two more Florida schools have closed due to COVID-19 outbreaks, bringing the total to 3 schools in the central Florida area since the school year began. Both schools will transition completely to online/remote classes. In addition to the school closings, other schools are extending remote classes and further delaying in-person activities. In Polk County, Florida, schools are now in their third week of classes, and more than a quarter have reported COVID-19 cases. There are 74 confirmed cases across the district's 41 campuses. Several Florida school districts have created coronavirus dashboards to report school-based COVID-19 data. Some school officials have cited privacy concerns for students as a barrier to reporting COVID-19, but Manatee County officials say the dashboards can convey important outbreak information while maintaining confidentiality and privacy.

In Alabama, schools are using a variety of formats—including remote learning, full-week in-person classes, and hybrid options—with varying levels of success. Several schools in Alabama suspended in-person classes following COVID-19 cases. In addition to classes, schools are also struggling with sporting events. Issues of social distancing at football games in several districts have surfaced, despite social media campaigns and signage advising attendees to maintain appropriate physical distancing (eg, 6-foot separation). Photos fans at a high school volleyball game also show little physical distancing and inconsistent mask use among the spectators. In response to these events, and others like them, the Alabama High School Athletic Association (AHSAA) reportedly “put [all schools statewide] on notice” that failure to adhere to COVID-19 policies could result in suspension or cancellation of high school sports. The AHSAA directs schools to ensure appropriate physical distancing and mask use among spectators at high school sporting events and encourages physical distancing, to the extent possible, among athletes and coaching staff.

As we covered previously, a teacher in Kansas began tracking COVID-19 cases in US schools in early August to support her own awareness. Her efforts gained national recognition, and now the National Education Association (NEA) has taken over the project, publishing data starting last week. The new database provides the ability for educators to report school-based COVID-19 cases and outbreaks, which are then verified by the NEA. The data is compiled and displayed on a nationwide dashboard, which includes school-associated COVID-19 incidence broken down by state as well as school district and school (for those with reports), for cases among students and school staff. The vast majority of reports are accompanied by links to media or other sources to corroborate the information. As of today, the NEA dashboard reports 7,199 cases and 38 deaths across more than 2,000 schools.

The American Academy of Pediatrics and the Children’s Hospital Association report that more than 513,000 children have now been diagnosed with COVID-19 (9.8% of all reported US COVID-19 cases). This represents an increase of 16% (70,630 cases) over the past 2 weeks, which largely corresponds to the start of the school year in many areas. Much of this is due to increased testing at schools, but it will be critical to monitor epidemiological trends over the coming weeks to better understand the role of schools in community transmission.

SEROPREVALENCE AMONG HEALTHCARE WORKERS Researchers from the Influenza Vaccine Effectiveness in the Critically Ill Network published findings from a serological survey of frontline healthcare workers. The study, published in the US CDC’s Morbidity and Mortality Weekly Report (MMWR), included more than 3,200 healthcare personnel across 13 US medical centers who had “direct patient contact in hospital-based units caring for adult COVID-19 patients”—conducted from April to June. All participants took part in both a survey to assess demographic information and exposure risk factors, including PPE use and availability, as well as a serological test.

Among the participants, 40% principally worked in an intensive care unit and 35% worked in an emergency department. In total, 6% of the participants had positive serological tests, indicating prior SARS-CoV-2 infection. The seroprevalence in individual facilities ranged from 0.8% to 31.2%, which “generally correlated with community cumulative incidence.” Consistent with previous studies, seroprevalence was higher among men and among racial and ethnic minorities. Notably, only 31% of seropositive individuals reported having a previous positive SARS-CoV-2 diagnostic test. Additionally, 29% of seropositive individuals reported experiencing no relevant symptoms since February, and 44% did not believe that they had been previously infected with SARS-CoV-2. Seroprevalence was lower among participants who reported using “a face covering during all clinical encounters in the [preceding] week” compared to those who did not, and it was also lower among participants who did not report experiencing any PPE shortages since the onset of the US epidemic.

The authors emphasize that the correlation between PPE availability and use and seroprevalence “highlight[s] the importance of maintaining PPE supplies at hospitals caring for COVID-19 patients and...adhering to policies that encourage the use of masks for all interactions [with] patients.” This study was not able to distinguish between infections that occurred in healthcare settings and those that occurred in the community, but it provides additional data regarding transmission risk for healthcare workers.