July 29: Johns Hopkins Update

COVID-19

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 Situation Report for July 28 reports 16.34 million cases (226,783 new) and 650,805 deaths (4,153 new). The WHO reported 5 of the 6 highest daily incidence over the past 6 days.

NOTE: The July 27 Situation Report includes an erratum that indicates the US reported 74,235 new cases on July 26, which were included in the global cumulative totals.

In total, 10 countries are reporting test positivity greater than 25%, well over the WHO’s benchmark of 5% to facilitate easing social distancing measures, and most are continuing to increase steadily. Notably, 7 of these countries are in the Americas; Bolivia, Brazil, and Mexico are currently reporting test positivity greater than 60%. By contrast, all countries in Europe are reporting test positivity of less than 10%, and most are less than 3%. Additionally, more than 25 countries are reporting more than 100% more cases than they did 2 weeks ago. Many of these countries are reporting relatively low daily incidence, so smaller changes in absolute numbers can result in large relative changes. But 11 countries are reporting more than 100 new cases per day, including several that were more severely affected early in the pandemic and are now experiencing a resurgence of transmission: Australia, Belgium, China, Japan, the Netherlands, and Spain. On a more positive note, there are currently no countries reporting more than 250 new daily cases per million population.

Brazil reported 40,816 new cases. This is approximately equal to the corresponding day the previous week and fairly consistent with the several weeks before that; however, last week, Brazil reported significantly higher daily incidence later in the week. Brazil fell to #3 globally in terms of daily incidence, but its daily incidence is essentially equal to #2 India.

Broadly, the Central and South American region remains a major COVID-19 hotspot. Colombia reported 10,284 new cases, setting a new record high and exceeding 10,000 daily cases for the first time. After a week of reporting 6,500-8,000 new cases per day—Columbia’s daily incidence jumped by more than 2,000 cases. Colombia remains #5 globally with respect to daily incidence. Mexico’s daily incidence continues to vary widely, often jumping up or down by 1,500 cases or more from day to day. Looking at the 7-day average, Mexico’s increase in daily incidence may be starting to slow. Over the past 6 days, Mexico has consistently reported 6,500-6,700 new cases per day. Mexico remains #6 globally in terms of daily incidence. Including Brazil, Colombia, and Mexico, the Central and South American region represents 5 of the top 10 countries globally in terms of daily incidence, along with Argentina (#8) and Peru (#9). Multiple other countries in the region are reporting more than 1,000 new cases per day. Additionally, the region includes 4 of the top 10 countries in terms of per capita daily incidence—Panama (#1), Brazil (#5), the US (#7), and Colombia (#9)—and a number of other countries in the region are reporting more than 100 new daily cases per million population.

India continues to report relatively consistent daily incidence—approximately, 48-50,000 new cases per day. This trend has now persisted for 6 days, following several weeks of exponential growth. India’s testing continues to increase, but its test positivity increased sharply over the course of the past week. India surpassed Brazil to regain the #2 position globally in terms of daily incidence, but its daily incidence is essentially equal to Brazil’s. Bangladesh continues to report slowly decreasing daily incidence. Its daily testing appears to have leveled off after 2 weeks of steady decline; however, its test positivity appears to have increased slightly, up from 20-23% from late May through early July to 23-25% since then. Bangladesh remains #10 globally in terms of daily incidence.

South Africa reported 7,232 new cases yesterday and 7,096 new cases on Monday, the country’s 2 lowest daily incidence since July 1. South Africa remains among the top countries globally in terms of both per capita (#8) and total daily incidence (#4). South Africa’s daily incidence appears to have reached a peak or plateau, and it has reported slightly decreasing average daily incidence over the past week or so.

The Eastern Mediterranean region remains a global COVID-19 hotspot, particularly with respect to per capita daily incidence. The region represents 3 of the top 10 countries globally—Oman (#3), Bahrain (#4), and Kuwait (#10). Nearby Israel (#6), in the WHO’s European region, is among the top countries globally as well. While no countries in the region are in the top 10 in terms of total daily incidence, many are reporting more than 1,000 new cases per day.

As a result of several recent days of reporting more than 300 new cases, Montenegro has climbed rapidly into the global top 10 in terms of per capita daily incidence (#2).

The US CDC reported 4.28 million total cases (54,448 new) and 147,672 deaths (1,126 new). The US once again reported more than 1,000 new deaths, the fifth time in the past 7 days, and the country could potentially reach 150,000 cumulative deaths in tomorrow’s update. California is reporting more than 450,000 cases; Florida and New York are reporting more than 400,000 cases; Texas is reporting more than 375,000 cases; and 8 additional states are reporting more than 100,000 cases. The US fell to #7 globally in terms of per capita daily incidence, but it remains #1 in terms of total daily incidence.

The Johns Hopkins CSSE dashboard reported 4.38 million US cases and 149,783 deaths as of 12:45pm on July 29.

US COVID-19 STIMULUS BILL Republican leadership in the US Senate unveiled their version of a “Phase 5” COVID-19 economic stimulus package Monday afternoon. The draft bill, titled the HEALS Act, includes approximately US$1 trillion in funding to address a variety of financial and economic needs for both individuals and businesses. There appear to be major differences between the HEALS Act and the HEROES Act that was drafted by Democrat leadership and passed by the House of Representatives several weeks ago. One major area of agreement between the two bills appears to be a second direct stimulus payment to individuals. Both bills include a US$1,200 payment to individuals making up to $75,000 per year (or US$2,400 for married couples making US$150,000 or less). Beyond that measure, however, the rest of the bill will require substantial negotiations to compromise on funding for the Paycheck Protection Program, unemployment insurance, state and local governments, schools and healthcare systems, student loans, and other priorities.

According to multiple reports, including by The Washington Post, the draft Republican bill includes funding for several major Department of Defense (DOD) programs and a new FBI building. The DOD funding includes ships, aircraft, and other weapons systems—including the Expeditionary Fast Transport amphibious cargo ship and F-35 fighter aircraft—as well as reimbursements for military contractors that kept workers employed while work was suspended due to COVID-19. Reportedly, the weapons systems and programs funded under the bill include some that were defunded when US President Donald Trump repurposed DOD funding to construct portions of a wall along the US-Mexico border. Some Democrats and others have already expressed opposition to including military funding in the COVID-19 bill, particularly to supplement funds used to construct the border wall.

As we have discussed previously, the provisions included in both the HEROES Act and HEALS Act will inevitably change as negotiations proceed, and the final form and scope of a Phase 5 COVID-19 emergency funding bill remains uncertain.

CALL FOR US CDC TO REGAIN CONTROL OVER COVID-19 REPORTING Yesterday, the Attorneys General from 22 states issued a letter to Secretary of Health and Human Services Alex Azar calling on him to rescind a recent directive that shifts the responsibility for COVID-19 reporting from the CDC to the Department of Health and Human Services (HHS). The letter urges Secretary Azar to “restore the CDC to its rightful role as the primary repository for and source of information about the nation’s public health data” and notes that the decision to “bypass the CDC” erodes trust in COVID-19 data, hinders state and local response efforts, and risks millions of lives. The authors argue that any need to improve data reporting and analysis should be addressed by adapting existing CDC systems, including through the use of US$500 million designated by the CARES Act to update CDC data collection and reporting systems. They contend that the new mechanism “circumvent[s] our nation’s top public health experts.” According to the letter, the new data reporting system is operated by private contractors rather than health experts employed by federal health agencies, and it separates data reported by hospitals from other sources, including nursing homes and other long-term care facilities.

MALNUTRITION, COVID-19 & HUMANITARIAN AID The Lancet recently published a call to action co-authored by the directors of UNICEF, the Food and Agriculture Organization, the World Food Programme, and the WHO. The statement addresses the growing threat of childhood malnutrition due to downstream effects of the COVID-19 pandemic and associated response policies and operations, particularly in low- and middle-income countries. The statement listed 5 “urgent actions” to support children's right to adequate nutrition during the pandemic. Specifically, the authors call on national governments and private donors to support efforts to ensure access to nutritious, safe, and affordable diets; maternal and child health; early detection and treatment for child wasting; nutritious school meals for vulnerable children; and safe access to food and essential services. These priorities must be integrated more completely into the COVID-19 response.

MULTILATERALISM IN AFRICA The Washington Post published an article outlining multilateral efforts to combat COVID-19 in Africa. African countries have promoted collaborative, multilateral efforts to share physical, educational, and public health resources in an effort to curb the spread of COVID-19 across the continent, in contrast to many other countries around the world that have increased restrictions on travel, immigration, and border control policies. Leaders in Africa quickly recognized that existing public health and healthcare infrastructure and supply limitations in Africa placed many countries at elevated risk for severe COVID-19 epidemics.

The focus on multilateral approaches “reflects the rise of political ownership and accountability” among national and regional leaders, and the engagement of stakeholders across multiple countries stemmed from the need to quickly identify and mobilize critical resources, particularly at a time when international humanitarian aid and other international assistance dwindled. Additionally, leadership by intergovernmental organizations like the Africa CDC has been critical to organizing coordinating response activities across the continent, including allocating and distributing resources such as medical and testing supplies.

NAVAJO NATION As we have covered previously, the Navajo Nation, which spans 4 states in the western US, was severely affected early in the US COVID-19 epidemic. The Navajo Nation is currently reporting 10,364 cumulative cases, which represents a third of all COVID-19 cases reported by the Indian Health Service. With 3,500 cumulative cases per 100,000 population, the Navajo Nation has been more severely affected than any US state, and its cumulative per capita incidence is 50% higher than the leading state (Louisiana with 2,389 cases per 100,000 population). The Navajo Nation was able to flatten the curve, and its epidemic peaked in mid-May.

The Navajo face a variety of risk factors for severe COVID-19 disease and death, including high rates of underlying health conditions, such as diabetes and heart disease, and limited access to health care and other services. These factors have contributed to elevated mortality among Navajo populations. For example, the Navajo Nation in New Mexico accounts for 57% of the state’s total COVID-19 deaths, despite only representing 9% of the population.

In response to the early surge in transmission, the Navajo Nation implemented a “lockdown” and mandated mask use on tribal and issued “travel advisories against leaving the Navajo Nation.” Tribal leadership have also encouraged Navajo living outside of reservations to return, particularly in states that have not yet implemented protective measures like mandatory mask use, such as Arizona. These measures have enabled Navajo Nation to bring its COVID-19 epidemic under control, decreasing daily incidence from approximately 220 new cases per day in mid-May to fewer than 45 today. Vox published an interview with Navajo Nation President Jonathan Nez that addresses the Navajo COVID-19 response and ongoing risks and challenges.

MADAGASCAR Hospitals in Madagascar are reportedly exceeding capacity due to a recent surge in COVID-19, and some hospitals are only admitting severe patients in order to make the most efficient use of limited beds and supplies. According to several media reports, Madagascar’s Minister of Health recently published an open letter requesting supplies and equipment to support overwhelmed health systems, but the Madagascar government “disavowed” the request. Madagascar’s President Andry Rajoelina, reinstituted a lockdown in central Madagascar in early July in response to increased transmission, but the country’s epidemic continues to accelerate. Madagascar has reported more than 10,000 total COVID-19 cases and nearly 100 deaths, and its daily incidence has doubled since July 8.

NICARAGUA Last week, Science published a letter criticizing the COVID-19 response within Nicaragua. The authors, including one from Nicaragua, described Nicaragua’s response as “disastrous,” following several decisions to forgo recommended policies adopted by other South American countries, including prohibitions on mass gatherings, closing schools and businesses, and robust screening and disease surveillance at border crossings and other points of entry. The authors indicate that neighboring countries have asked PAHO to pressure Nicaragua’s government leadership to more substantively address the disease risk.

Earlier this week, The Wall Street Journal reported that doctors in the country who have organized to disseminate COVID-19 information to the public have lost their jobs, exacerbating the risk of COVID-19 and damaging the health care system. Nicaraguan President Daniel Ortega has reportedly stated that the COVID-19 epidemic is not as severe as reported and that it has not affected health systems or other sectors. Nicaragua often reports to the WHO weekly instead daily, but it has reported a total of 3,004 total cases and 108 deaths. While these numbers are relatively low, they are among the highest in Central America on a per capita basis. The authors of the Science letter state Nicaragua’s COVID-19 mortality as nearly 350 deaths per million population; however, other sources indicate that it is much lower (17.51 deaths per million population). We were unable to identify an official government report from a Nicaraguan health agency, so it is difficult to determine the actual scale of the country’s epidemic.

CRISIS STANDARDS OF CARE STAFFING GUIDANCE The US National Academies of Sciences, Engineering, and Medicine (NASEM) published a report outlining updated considerations for staffing needs while implementing crisis standards of care during the COVID-19 response. As the US battles a surge in COVID-19, particularly in areas of the country that were not severely affected early in the US epidemic, reports continue of hospitals and health systems struggling to meet COVID-19 patient demand. One option for managing major patient surge is to alter the existing standards of care to allow clinicians to treat more patients with fewer resources.

This NASEM report specifically addresses staffing issues in order to implement crisis standards of care in a safe and appropriate manner. The report includes recommendations regarding the transfer of staff between facilities and affected geographic areas, adjusting staff-to-patient ratios, utilizing external temporary or contracted personnel to supplement facility staffing, and changing personnel’s duties and responsibilities. Additionally, updated staffing models should address hazard pay or compensation; ensure appropriate leave or other time off for a variety of issues, including healthcare and family needs; and child care services to support increased personnel availability. In particular, the report highlights the demand for personnel with specialized training or skills during the COVID-19 response, including with respect to mechanical ventilation, and the importance of providing guidance and support regarding potential SARS-CoV-2 exposures and infections among healthcare workers and other personnel. This report builds on analysis and recommendations that the committee published in March. 

RESETTING THE US RESPONSE As the US rapidly approaches 5 million COVID-19 cases and 150,000 deaths, it is clear that changes to the national response plan are needed. Researchers at the Johns Hopkins Center for Health Security published areport outlining key steps to “reset” the US response and put the country on a better path toward effectively combating COVID-19. Operational recommendations include encouraging or, “when appropriate,” mandating nonpharmaceutical interventions, including mask use; reinstituting social distancing restrictions in hard-hit areas where health systems are stressed, including “stay at home” orders and prohibitions on large gatherings and other high-risk activities; and conducting and publishing epidemiological analysis, including for case investigations and contact tracing. Additionally, the report outlines recommendations to provide necessary infrastructure and support ongoing research and operational efforts, including scaling up supply chains for personal protective equipment and testing, improving distribution and allocation systems, conducting rapid research to address emerging information needs, and identifying and disseminating best practices for response operations and policies. Finally, the authors highlight the importance of preparing for the production, distribution, and administration of a future vaccine, including effective community engagement efforts.