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 August 2 reports 17.7 million cases (262,929 new) and 662,095 deaths (5,999 new). The WHO reported the 2 highest daily incidence to date on July 31 and August 1—292,527 and 289,321 new cases, respectively. If the current trend continues, the global daily incidence could potentially exceed 300,000 new cases for the first time later this week. The average global daily incidence is nearly 260,000 new cases per day, putting the pandemic on pace for approximately 1.8 million cases per week. Asia is now reporting the most new cases, but North and South America remain close at #2 and #3, respectively. Africa and Europe have reported similar daily incidence since late June. The global COVID-19 mortality is holding relatively steady at approximately 5,700 new deaths per day, which corresponds to more than 170,000 deaths per month.
Following a long period of declining daily incidence from approximately early April through mid-June, Europe is exhibiting what could be the early signs of a resurgence of COVID-19 transmission. A number of European countries—including Spain, France, and Germany, which were severely affected early in the pandemic—are reporting increasing COVID-19 incidence. Overall, Europe’s daily incidence is at a similar level as where it was in late May, but not nearly as high as it was at the first peak in early April. The increased incidence comes several weeks after the EU began to ease social distancing measures and travel restrictions and the beginning of Europe’s summer holiday and tourism season. No European countries are in the top 10 globally in terms of daily incidence, but several are reporting more than 1,000 new cases per day.
Brazil reported approximately 6,000 fewer cases last week than the previous week, but it was the second consecutive week that it reported more than 300,000 new weekly cases. Brazil remains #3 globally in terms of daily incidence but fell slightly further behind India. Broadly, the Central and South American region remains a major COVID-19 hotspot. Colombia surpassed 300,000 cumulative cases and 10,000 deaths. Colombia reported 11,470 new cases, a record high daily incidence for the second consecutive day. Colombia climbed to #4 globally in terms of daily incidence. Mexico’s average daily incidence exceeded 7,000 new cases per day for the first time on August 2 before falling slightly below that mark today. 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 Peru (#7) and Argentina (#9), and 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 (#3), Colombia (#5), and the US (#7)—and numerous other countries are reporting more than 100 new daily cases per million population.
India reported its 5 highest daily case counts over the past 5 days, including a record high of 57,118 new cases on August 1. India remains #2 globally in terms of daily incidence and appears to be on a trajectory to potentially surpass the US. Bangladesh reported extremely low incidence on August 1-2—886 and 1,356 new cases, respectively. Notably, this dramatic decrease corresponded to elevated test positivity (32% on August 2), which could indicate that it is more likely a result of decreased testing than decreased incidence. The Philippines climbed to #10 in terms of daily incidence, with an average of more than 3,200 new cases per day.
South Africa surpassed 500,000 cumulative COVID-19 cases over the weekend and reported 8,195 new cases yesterday. South Africa remains among the top countries globally in terms of both per capita (#9) and total daily incidence (#5). Additionally, South Africa is #5 globally in terms of cumulative incidence.
The per capita daily incidence in the Eastern Mediterranean region appears to be waning to some degree, and countries from several other regions are displacing the Eastern Mediterranean in the top 10. Bahrain (#4) is the only country remaining in the global top 10, and Kuwait is the only other country in the region reporting more than 100 new daily cases per million population. Nearby Israel (#8), in the WHO’s European region, remains among the top countries globally as well. Iraq fell out of the top 10 in terms of total daily incidence, but numerous countries in the region are reporting more than 1,000 new cases per day.
The Maldives climbed to #2 globally in terms of per capita daily incidence, with more than 225 new cases per day per million population. Montenegro fell to #10 in terms of per capita daily incidence.
The US CDC reported 4.60 million total cases (58,947 new) and 154,002 deaths (1,132 new). The US has reported more than 1,000 new deaths for 10 of the past 12 days, and it is currently averaging more than 1,100 new deaths per day, the highest average since May 25. California surpassed 500,000 cases; Florida is reporting nearly 475,000; New York and Texas are reporting more than 400,000; and 9 additional states are reporting more than 100,000.
The Johns Hopkins CSSE dashboard reported 4.68 million US cases and 154,992 deaths as of 12:45pm on August 3.
US SCHOOLS The US school year is rapidly approaching in many parts of the country and has even started in some jurisdictions. With some evidence now available from experiences in summer camps, childcare settings, and the early days of in-person classes, the focus is shifting from what could happen if schools reopen toward what has happened—and the news is not encouraging. A case study published in the US CDC’s Morbidity and Mortality Weekly Report describes an outbreak at an overnight summer camp in Georgia that resulted in at least 260 confirmed infections out of 597 total campers and staff, between when staff reported to the camp and 14 days after the camp was closed due to the outbreak. This corresponds to an overall attack rate of approximately 44%. Notably, test results were only available for 344 individuals, so this may be an underestimate. Among the individuals with positive tests, 136 had accompanying data on the presence or absence of symptoms, and 100 of those individuals were symptomatic (73.5%). Campers and staff were required to provide proof of a negative test conducted within 12 days of arriving at camp, and the camp implemented a number of recommended preventive measures. Notably, however, masks were only required for staff, not campers, and the camp did not open windows to improve indoor ventilation. This case study does not address any subsequent transmission by campers or staff to others at home or in the community after departing the camp. Regardless, this outbreak does illustrate that SARS-CoV-2 can “spread efficiently in a youth-centric overnight setting, resulting in high attack rates among persons in all age groups” and that “children of all ages...might play an important role in transmission.”
Two junior and senior high schools in Madison County and Hancock County, Indiana, were reportedly forced to close this week, shortly after resuming in-person classes, due to positive SARS-CoV-2 tests among students and staff. In Georgia, approximately 260 employees in the state’s largest school district tested positive for SARS-CoV-2 or are under quarantine due to possible exposure as the school district began in-person meetings in preparation for resuming classes in the coming weeks. The New York Times reported that only 6 of the 25 largest school districts in the country plan on reopening for in-person classes when the school year starts. The New York Times also published analysis on the number of positive cases that could be expected to show up at a school, based on the level of community transmission and school size. It is unclear if or how the reports of cases at other schools or projections of cases in schools will influence the debate around school reopening. A number of health experts and officials—including CDC Director, Dr. Robert Redfield; White House Coronavirus Task Force Response Coordinator, Dr. Deborah Birx; and former US FDA Commissioner, Dr. Scott Gottlieb—have expressed concern about the viability of resuming in-person classes, particularly in areas with high community transmission. Notably, Dr. Redfield commented last week that, while in-person classes are important for children, schools in areas with test positivity above 5% may need to utilize remote learning instead, at least initially, to mitigate transmission risk among children.
SPAIN Spain was among the most severely affected countries early in the COVID-19 pandemic, reaching its first peak of nearly 8,000 new cases per day in early April. Following highly restrictive “lockdown” measures, implemented in conjunction with other EU countries, Spain brought its epidemic under control. By mid-June, Spain’s daily incidence had fallen to fewer than 350 new cases per day. As the EU began to ease social distancing and travel restrictions, COVID-19 began to rebound, prompting fears of a “second wave” across the continent. After several weeks of steadily increasing daily incidence, Spain now leads Europe* with 2,300 new cases per day.
*Not including Russia.
Much like the US, Spain’s COVID-19 resurgence includes an increasing proportion of cases among younger individuals. Notably, the average of COVID-19 cases in Spain “has fallen from 63 [years old] in the spring to 45 now,” which has fortunately placed less stress on the health system. Some of the increased incidence can be attributed to improved testing capacity, but the trend remains concerning. Spain’s test positivity is down from more than 20% in April to less than 5% now, but it has been increasing slowly since early June, an indication that the increased testing is not fully accounting for the increased incidence. Some parts of Spain—including Catalonia, where Barcelona is located—have reinstituted some social distancing measures, such as closing nightclubs and mandating mask use in public, in order to slow transmission. Additionally, the recent increase in COVID-19 incidence drove the UK government to implement a mandatory 14-day quarantine for travelers arriving from Spain.
COLOMBIA Over the weekend, Colombia passed the milestones of 300,000 cases and 10,000 deaths, and its epidemic continues to accelerate. Colombia remains one of the major hotspots in Central and South America, and health systems and other sectors are struggling to combat the epidemic. Reportedly, hospitals in Bogotá, Colombia’s capital city, are on the verge of being overwhelmed by COVID-19 patients, and the government has provided refrigeration units for cemeteries that are unable to keep up with cremation demand for COVID-19 victims. Colombia’s Ministry of Health provided support to local hospitals to expand intensive care unit (ICU) capacity and stave off collapse, and the Mayor of Bogotá implemented quarantine and curfew for severely affected parts of the city, currently scheduled from July 31 through August 14. Armed groups in some parts of the country, including paramilitary groups associated with drug cartels, have reportedly begun using gunfire and other violent means to enforce curfews. It appears that the groups are leveraging the COVID-19 epidemic to consolidate control over local populations rather than support recommended health actions. One report by Human Rights Watch identified these types of “lockdowns” in 11 of 32 states across Colombia.
VACCINE CANDIDATES Several candidate SARS-CoV-2 vaccines have initiated Phase 3 clinical trials, which are much larger and will provide a wealth of detailed safety and efficacy data over the course of the next several months. While these candidate vaccines have demonstrated promise in previous trials, numerous barriers remain to implementing a successful global mass vaccination campaign. Dr. Tom Frieden, former US CDC Director, authored an editorial in The Wall Street Journal to discuss some of these challenges.
Vaccines in Phase 3 trials have already demonstrated acceptable safety profiles and exhibited promising efficacy in smaller Phase 1 and 2 trials, but Phase 3 trials will involve tens of thousands of people, as opposed to dozens or hundreds, which will allow researchers to better characterize the vaccines’ effects on the immune system and identify a broader range of potential adverse events. One outstanding question, in particular, regarding the vaccine’s efficacy is the degree and duration of the conferred immunity. In an ideal scenario, the vaccine would confer long-term immunity, on the order of years, 100% of the time. However, it is possible that like the seasonal influenza vaccine, a SARS-CoV-2 vaccine could be only partially effective at preventing infection or COVID-19 disease, which could potentially limit its effect in the public. Additionally, it is possible that the vaccine could only remain effective for a short period of time, potentially on the order of months, which would necessitate regular vaccination or booster shots to ensure individuals maintain immunity to SARS-CoV-2. The Phase 3 trials will allow researchers to analyze longer-term trends in immune response, including both the degree and duration of the associated immune response. Phase 3 trials could also identify rarer adverse events that were not evident in the smaller Phase 1/2 trials. Even if the vaccines continue to demonstrate acceptable safety profiles in the larger Phase 3 trials, continued surveillance will be needed as vaccination programs scale up to millions and then billions of people to identify any additional adverse events that may arise in larger populations. Based on historical trends, it is inevitable that some candidate vaccines, potentially including those already entering Phase 3 trials, will fail to reach the public due to safety or efficacy issues during clinical trials. Regardless of which vaccine, or vaccines, successfully obtains regulatory approval, scaling up production, distributing the vaccine worldwide, and dispensing it to every individual will be a monumental task.
TROPICAL STORM ISAIAS Tropical Storm Isaias continues to threaten the East Coast of the US, with a hurricane warning in effect for North Carolina and South Carolina, but the storm is expected to impact communities beyond wind, rain, and flooding. The storm was originally forecasted to impact Florida directly, which drove the state to preemptively close all state-run COVID-19 testing centers from Friday through this Tuesday—although some reopened early when the storm veered north. The Coastal Health District in Georgia also closed COVID-19 testing sites in advance of the storm.
North Carolina declared a state of emergency and ordered evacuations for some parts of the state. Additionally, the state advised residents to include specific items in emergency kits to protect against COVID-19, such as masks, hand sanitizer, and cleaning products. North Carolina Governor Roy Cooper recommended that evacuees stay with friends or family or in a hotel, if possible, in order to reduce the population at emergency shelters, which could be higher risk for SARS-CoV-2 transmission. Shelters will implement COVID-19 preventive measures, including symptom screening, reduced capacity to promote physical distancing, mandatory mask use, and serving meals in sealed containers. Georgia and South Carolina have not declared states of emergency, but both states issued similar recommendations regarding the use of shelters as a last resort. Emergency shelters in both Georgia and South Carolina will also implement similar enhanced safety precautions for COVID-19. Emergency management officials in Georgia noted that physical distancing and reduced shelter capacity, in particular, pose challenges for evacuation plans, as officials must find more buses and shelters in unaffected areas and coordinate additional logistics for those resources.
WORLD HEALTH ORGANIZATION On July 30, the WHO published updated guidance for international travel. Many countries have implemented some form of travel restrictions, ranging from prohibitions on travelers from certain countries or areas to screening or self-quarantine upon arrival. The new WHO guidance emphasizes that decisions regarding when and how to lift existing travel restrictions should be made based on careful risk assessments, and they should prioritize essential travel activities, such as emergency response, humanitarian assistance, and repatriation of citizens or residents. Similarly, cargo and shipping companies should prioritize the transport of essential supplies, including as medicine and food. Prospective passengers who are feeling ill and individuals at an elevated risk of severe COVID-19 disease or death should postpone travel, particularly to areas with sustained community transmission. The guidance document also includes recommended actions for travelers, such as testing prior to travel and enhanced hygiene, physical distancing, and mask use while traveling.
On July 31, WHO Director-General Dr. Tedros Adhanom Ghebreyesus convened the fourth meeting of the IHR (2005) Emergency Committee regarding the COVID-19 pandemic. Following the meeting, the Director-General declared that COVID-19 continued to constitute a Public Health Emergency of International Concern. Additionally, the Emergency Committee issued guidance to the WHO Secretariat regarding priorities for coordinating the international response—including on mobilizing resources, combating misinformation, and issuing travel guidance—and to national governments, specifically with respect to supporting multilateral response efforts, enhancing public health response capacity, and information sharing.
ANOTHER CRUISE SHIP OUTBREAK Following a number of high-profile COVID-19 outbreaks onboard cruise ships around the world early in the pandemic, many cruise lines suspended operations over concerns about COVID-19 risk to passengers and crew. Hurtigruten cruise line, operating out of Norway, is one of the first companies to resume operations, but it was forced to suspend all of its cruises after an outbreak of at least 40 passengers and crew. Initially, 4 crew members onboard the MS Roald Amundsen tested positive for SARS-CoV-2, and an additional 32 crew and 4 passengers tested positive during subsequent testing. After identifying the outbreak, passengers and crew on the ship were placed in quarantine, and the cruise line suspended operations. Notably, the ship visited multiple ports in Norway in the days leading up to the first positive tests, including shore excursions and passengers embarking and disembarking at various ports along the way. These visits could have resulted in exposures in “dozens of towns and villages along Norway’s western coast” by passengers or crew who were asymptomatic or presymptomatic at the time. The cruise line emphasizes that it operates in compliance with all guidance from the Norwegian Institute of Public Health, but the outbreak highlights the risk of rapid transmission in congregate settings like cruise ships, even with enhanced social distancing and sanitization standards in place.
