The US CDC reported 5.51 million total cases (46,500 new) and 172,416 deaths (1,404 new). In total, 19 states (no change) are reporting more than 100,000 cases, including California with more than 600,000 cases; Florida and Texas with more than 500,000; New York with more than 400,000; and Georgia and Illinois with more than 200,000. For nearly 3 weeks, the US continues to average more than 1,000 deaths per day. Several US territories are exhibiting high per capita daily incidence. The US Virgin Islands is reporting 226 new daily cases per million population, which would be #3 globally, between the Maldives and Colombia. Puerto Rico is reporting 185 new daily cases per million population, which would put it at #7 globally in terms of per capita daily incidence, falling between Brazil and Israel. Guam is also reporting 192 new daily cases per million population, which would be #4 globally; however, this appears to be driven largely by a spike of 105 new cases reported today, more than double its previous record daily incidence.

The US epidemic passed its second peak around July 24, and since then, the national COVID-19 incidence has decreased steadily. While many states are exhibiting similar trends, case counts in some states continue to climb. Hawai’i, which largely maintained low COVID-19 incidence for the first several months of the pandemic, has reported increasing incidence since mid-July, now up to more than 200 new cases per day. Illinois has reported steadily increasing daily incidence for the past 2 months, up to nearly 75% of its first peak. While it is only reporting approximately 100 new cases per day, South Dakota’s daily incidence has been slowly increasing since mid-to-late July, and it does not appear to be exhibiting any indication of slowing. Kansas appeared to reach a second peak in late July; however, incidence rebounded after approximately a week, and it set a new high daily incidence yesterday of nearly 500 new cases per day. Missouri and Wyoming exhibited a similar trend, peaking in late July before rebounding. The increase in daily incidence in Kentucky and North Dakota has tapered off to some degree, but it is still increasing in both states, potentially approaching a peak or plateau. A number of other states have largely plateaued over the past 2 weeks and continued to report elevated daily incidence. With the peak in national daily incidence occurring approximately 3 weeks ago, we expect to see an associated decrease in daily mortality in the near future. Mortality tends to lag several weeks behind incidence, as it takes time for COVID-19 patients to progress through the course of disease. Nationally, the US continues to average more than 1,000 new deaths per day. Multiple states are reporting overall increases in daily mortality, including several states that were severely affected during the summer resurgence. Notably, Georgia reported its record high mortality (133 deaths) on August 11, and it continues to report more than 60 deaths per day. The Tennessee Department of Health does not report or display average daily mortality, but the weekly average reported by STAT News shows the state remaining at its record high of 22 deaths per day. California’s COVID-19 mortality has plateaued over the past week or so, remaining relatively steady at approximately 130 deaths per day. Florida’s average mortality has fluctuated over the past 2 weeks, but it remains elevated at approximately 170 deaths per day. Texas reported a peak in mortality in early August (largely driven by a spike of more than 1,000 deaths reported on August 6), and mortality decreased substantially since then; however, Texas continues to report 170-200 deaths per day.

The US CDC reported 5.34 million total cases (54,686 new) and 168,696 deaths (1,150 new). In total, 19 states (increase of 4) are reporting more than 100,000 cases. California is reporting more than 600,000 cases; Florida and Texas more than 500,000 cases; New York more than 400,000; and Georgia and Illinois more than 200,000. Puerto Rico is a US territory, but at 194 new daily cases per million population, it would be #7 globally in terms of per capita daily incidence, falling between the Maldives and Israel. For nearly 3 weeks, the US has averaged more than 1,000 deaths per day.

The US FDA issued an Emergency Use Authorization for a saliva-based diagnostic test developed by researchers at the Yale School of Public Health. When compared with other FDA-authorized diagnostic tests, the SalivaDirect protocol demonstrated an 83%-100% agreement. A saliva-based test offers a number of potential benefits over existing diagnostic tests. Collecting a saliva sample is more comfortable than nasopharyngeal swabs, and the SalivaDirect tests can use any sterile container, as opposed to requiring expensive tubes as is the case for some other saliva-based tests. Additionally, the testing protocol is reportedly more streamlined than other diagnostic tests, which eliminates the need for certain reagents and decreases testing time, and the tests require no proprietary supplies to process. Yale researchers are also making the protocol “open source,” so any laboratory can order supplies and follow the instructions rather than purchase tests from a single manufacturer. Test materials are also relatively inexpensive, less than US$5 per test. Researchers are currently working with the National Basketball Association on the Surveillance with Improved Screening and Health (SWISH) study to determine the test’s ability to detect asymptomatic infections, but the ultimate goal is to expand availability more broadly to supplement existing testing capacity. Additional studies to modify the original protocol to increase testing capacity via automation, pooled testing, and rapid detection are also underway. Additional information about the test, including instructions for use and obtaining authorization to use the protocol, can be found here.

The US CDC reported 5.18 million total cases (56,307 new) and 165,148 deaths (1,497 new). Following steady declines since July 24, the average daily incidence in the US increased slightly over the past 2 days, up from 52,193 new cases per day to 53,361. Additionally, the US continues to average more than 1,000 new deaths per day, a trend that has persisted for more than 2 weeks. Numerous states that were severely affected during the summer COVID-19 resurgence—including Arizona, California, Florida, and Texas—appear to be at or past their peak in terms of daily COVID-19 mortality, but others are still reporting increasing mortality or still approaching a peak. Considering that the national daily incidence peaked 3 weeks ago, we expect to start seeing an associated decline in national COVID-19 deaths in the near future. In total, 17 states are reporting more than 100,000 cases, including California, Florida, and Texas with more than 500,000 cases; New York with more than 400,000; and Georgia with more than 200,000. We expect Illinois to surpass 200,000 cases in the next update. Additionally, Puerto Rico is currently reporting more than 225 daily cases per million population and increasing steadily. It is a US territory, but its current per capita daily incidence would be #4 globally, falling between Peru and the Maldives—up 2 spots since our last briefing.

The US CDC reported 5.06 million total cases (40,522 new) and 162,407 deaths (565 new). From the first case reported in the US on January 22, it took 98 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: 14 days; 4 million to 5 million: 18 days. In total, 17 states (increase of 2) are reporting more than 100,000 cases to date, including California and Florida with more than 500,000 cases; New York* and Texas with more than 400,000; and Georgia with more than 200,000. Additionally, Puerto Rico is currently reporting more than 200 daily cases per million population. It is a US territory, but its current per capita daily incidence would be #7 globally, falling between the Maldives and Israel.

The Navajo Nation, located in northeastern Arizona, as well as parts of New Mexico and Utah, faces numerous challenges to implementing effective controls against COVID-19, and it has been severely affected early in the US COVID-19 epidemic. High prevalence of chronic health conditions—including diabetes, heart disease, and obesity—coupled with challenges accessing healthy food, running water, and electricity placed many Navajo at elevated risk for COVID-19, including severe disease and death. Following a peak in mid-May, when the Navajo Nation averaged more than 165 new cases per day, the daily incidence is down to fewer than 30. Navajo leaders implemented aggressive social distancing restrictions, including mandatory curfew and mask use as well as restrictions on entering tribal land. The restrictions have had numerous downstream effects, including making it difficult for some to shop for groceries; however, the controls have driven community transmission down to a manageable level. While the public health measures have helped bring the epidemic under control, Navajo leaders remain concerned about the potential for a “second wave” of transmission. In order improve resilience to COVID-19 and future health emergencies, Navajo leaders want to utilize more than $700 million in funding supplied by federal COVID-19 emergency funding, including the CARES Act, to bolster public health and other infrastructure. They are facing numerous barriers, however, which could risk them having to repay a large portion of the money in the event they cannot utilize it by the end of 2020. Some of that funding supported immediate response efforts, including purchasing PPE; however, much of it could be used to improve and expand existing infrastructure, including broadband internet access, that could improve future response efforts and other public health and healthcare services on tribal land. One concern, in particular, is a dearth of intensive clinical care capacity. Navajo Nation healthcare facilities only have approximately 40 intensive care unit (ICU) beds, which quickly filled earlier in the epidemic. While the Navajo were largely able to bring their COVID-19 epidemic under control, longer-term investments in critical infrastructure and public health and healthcare capacity could build resilience to subsequent waves of transmission or other health emergencies.

The US CDC reported 4.97 million total cases (54,590 new) and 161,284 deaths (1,064 new). We expect the US to surpass 5 million cases in this afternoon’s update. In total, 15 states (increase of 2) are reporting more than 100,000 cases, and Ohio and South Carolina should surpass this benchmark in the coming days. California and Florida are reporting more than 500,000 cases; Texas more than 450,000; New York* more than 400,000; and Georgia more than 200,000. The US fell to #2 in terms of total daily incidence, behind India, and also fell to #8 in terms of per capita daily incidence.

On Saturday, US President Donald Trump signed an executive order and 3 memoranda that aim to provide economic relief from the effects of the US COVID-19 epidemic. The decision to take executive action followed continued struggles in negotiations in the Congress to finalize a “Phase 5” spending package. The executive order addresses the risk of an “abnormally large wave of evictions” after protections under the CARES Act expired, directing the Secretaries of Health and Human Services (and the CDC Director), Treasury, and Housing and Urban Development (HUD) to evaluate the need to provide protection for individuals at risk for eviction and associated options for doing so. The individual memoranda direct the deferral of payroll taxes, suspension of student loan repayment and interest accrual, and extension of expanded unemployment benefits through the end of 2020. Opponents of President Trump’s efforts have highlighted several notable issues with the executive actions that could limit their effect. With respect to eviction protections, the executive order does not appear to actually extend the federal moratorium on evictions that expired several weeks ago, but rather, it directs senior government leadership to evaluate further options. The memorandum on payroll taxes postpones the payments until 2021, which temporarily increases paychecks but could force taxpayers to pay back the difference later, unless the Congress authorizes an associated tax cut. Payroll taxes fund federal programs such as social security and Medicare/Medicaid, so a future payroll tax cut could ultimately impact national programs that support millions of Americans. The expanded unemployment benefits total US$400 per week, which is down from US$600 under the CARES Act. Additionally, they require the Federal Emergency Management Agency (FEMA) to redirect funding from the Disaster Relief Fund (DRF) to state governments to cover US$300 per week, and it requires states to supply another US$100 per week using funds previously allocated to support COVID-19 response operations. Notably, the DRF is used to provide federal support for disasters like hurricanes, and the US is just entering the 2020 hurricane season. Additionally, some elected officials, Democrat and Republican, and experts have highlighted specific concerns about policies in the orders that may be unconstitutional, including allocating federal funding. Others have noted that executive action is not sufficient to fix these problems and that Congressional action is needed to address them, particularly with respect to identifying long-term solutions.

The US CDC reported 4.80 million total cases (53,685 new) and 157,631 deaths (1,320 new). This is the second consecutive day that the CDC reported more than 1,000 deaths. The US will likely reach 5 million cases by the end of this weekend or Monday. In total, 13 states are reporting more than 100,000 cases, including California with more than 500,000; Florida with nearly 500,000; and Texas with more than 450,000. The US remains #7 in terms of per capita daily incidence, and it is still #1 in terms of total daily incidence, but India is reporting essentially the same daily average. We expect the US to fall to #2 in the next update. The US may be approaching a peak in terms of daily mortality, and reporting over the next several days will provide insight on the longer-term trend. The peak daily incidence was on July 25, so the timing is appropriate to begin observing an associated peak in mortality.

Schools in numerous US states have started reopening for in-person classes. As classes resume, health officials and other experts are monitoring them closely for signs of increased transmission within schools and in the community. Tennessee has reported at least 14 COVID-19 cases in 2 school districts that are connected to schools that recently reopened, driving both to close or alter their schedules. Mississippi, Indiana, and North Carolina have also reported cases among students following schools reopening. Families that are uncomfortable sending their children back for in-person classes have faced tough choices, with some schools allegedly threatening suspension or expulsion for students who do not return. Teachers have faced similar threats, with some reportedly being told to resign if they had concerns of being infected at schools. Despite guidance from the US CDC and other experts regarding appropriate risk mitigation strategies for COVID-19, there is evidence that some schools are not implementing some of these recommended measures. In Georgia, for example, photos of a high school show students packed closely together in a hallway, with few wearing masks and nobody maintaining appropriate physical distancing. The school district superintendent commented that the schools are learning from their experiences and updating policies to promote a safe learning environment, although mask use will not be mandated. The specific risk mitigation protocols used will inevitably vary between schools and communities, but experts generally agree that physical and social distancing practices, including mask use and proper ventilation, and enhanced hygiene and sanitization standards can mitigate transmission risk to some degree. The current CDC guidance notes that the level of community transmission should be a principal consideration when making decisions regarding when and how to reopen schools.

The US CDC reported 4.70 million total cases (49,715 new) and 155,204 deaths (733 new). This is the second consecutive day that the CDC reported fewer than 1,000 deaths, but this is due, in part, to delays in weekend reporting. We expect the daily mortality to increase as the week progresses. According to the CDC data, 13 states are reporting more than 100,000 cases, including California with more than 500,000; Florida with more than 475,000; and New York and Texas with more than 400,000. The Florida Department of Health is currently reporting more than 500,000 cumulative cases, so we expect this to be reflected in the CDC data in the next day or two. The US remains #7 in terms of per capita daily incidence and #1 in terms of total daily incidence. While the US COVID-19 incidence continues to slowly decrease at the national level, mortality remains elevated. The US is now averaging 1,078 deaths per day, a slight increase from the previous day. Notably, Texas (194 deaths per day), Florida (184), California (133), Georgia (59), Mississippi (30), North Carolina (29), Ohio (27), Nevada (15), Arkansas (9), and Oklahoma (8) are reporting increasing daily COVID-19 mortality. Arizona’s COVID-19 mortality (62 deaths per day) may have reached a peak, but further data is needed to characterize the longer-term trend.

In a bipartisan agreement, 7 US states are collaborating to invest in 3.5 million diagnostic tests in an attempt to increase testing capacity and decrease delays in obtaining test results. The governors of Louisiana, Maryland, Massachusetts, Michigan, North Carolina, Ohio, and Virginia agreed to pool financial resources to encourage manufacturers of rapid diagnostic tests to increase their production and sales capacity. The governors maintain that these rapid tests will alleviate some of the strain on states’ traditional testing infrastructure and private laboratories. Crucially, these states determined their collaboration was necessary to ensure sufficient access to diagnostic test capacity in the absence of a coordinated national plan. In collaboration with the Rockefeller Foundation, which has agreed to provide supplemental funding, the states participating in the compact will each receive 500,000 tests. Maryland Governor Larry Hogan worked with the Rockefeller Foundation to establish the deal through his position as the co-chair of the National Governors Association. The Rockefeller Foundation stated that speed of testing should be prioritized over sensitivity at this stage in the pandemic, particularly considering that numerous reports that diagnostic test results can still take several days. The participating governors are currently in talks with 2 manufacturers of rapid diagnostic tests, Becton Dickinson (BD) and Quidel. The BD test uses a proprietary handheld device and can return results within 15 minutes. The BD system is already used in healthcare and pharmacy settings across the US, further decreasing access issues. Similarly, Quidel system point-of-care devices that can return results within 15 minutes. Quidel reported that more than 43,000 of their systems are already in use in healthcare facilities around the world. In addition to the multi-state testing compact, BD and Quidel are supplying rapid diagnostic tests to support the HHS strategy to increase testing in nursing homes in hotspot areas.

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 US CDC reported 4.41 million total cases (65,935 new) and 150,283 deaths (1,417 new). The US once again reported more than 1,000 new deaths—now 7 of the past 9 days—and surpassed 150,000 cumulative deaths. The 1,417 deaths is the highest daily total since May 28. California is reporting more than 475,000 cases; Florida, New York, and Texas are reporting more than 400,000; and 10 additional states (increase of 2) are reporting more than 100,000. Additionally, California has surpassed Massachusetts as #3 nationally in terms of COVID-19 deaths; Florida and Texas are #8 and #9, respectively. The US climbed to #5 globally in terms of per capita daily incidence, but it remains #1 in terms of total daily incidence. With more than 150,000 cumulative COVID-19 deaths, the US leads the world. The US has reported more than 3 times as many deaths as every country except Brazil. The US represents 22.5% of the global COVID-19 deaths—and 26% of the global cases—despite accounting for only 4.3% of the global population. The US is #9 globally in terms of per capita cumulative deaths—but will likely surpass France as #8 in the coming days. National COVID-19 incidence and hospitalizations appear to have peaked over the past week, but deaths continue to increase. The US is reporting an average of approximately 65,000 new cases per day, more than double the first peak in mid-April. National COVID-19 hospitalizations are at essentially the level reported during the United States’ first peak in mid-April. Analysis by the COVID Tracking Project indicates that more than 56,000 COVID-19 patients are currently hospitalized across the country, based on data reported by individual states. This is a slight decrease from the most recent peak of nearly 60,000 on July 23. The US is averaging more than 1,000 deaths per day for the first time since June 3. Multiple states continue to report record high daily deaths, including Arizona, Arkansas, California, Florida, Oregon, and Texas. Notably, Texas is averaging nearly 250 deaths per day, and Florida is reporting more than 150. Arizona is averaging more than 1 death per 100,000 population per day. The Johns Hopkins CSSE dashboard reported 4.50 million US cases and 152,074 deaths as of 10:30am on July 31.

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.

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.

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.

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.

The US CDC reported 4.16 million total cases (64,582 new) and 145,982 deaths (969 new). The US surpassed 4 million cases in its July 24 update. The US also reported more than 1,000 new deaths for 4 consecutive days, July 22-25, and nearly reached that benchmark again in the July 26 update. The US reported 2 of its 3 highest daily incidence totals over the weekend, including the record high of 74,818 new cases on July 25 (corresponding to July 24 data on the epi curve). Notably, the national 7-day average daily incidence appears to have reached a plateau at 66-67,000 new cases per day. While this is a promising sign, it is still more than twice the average daily incidence at the country’s first peak in mid-April. California, Florida, and New York are reporting more than 400,000 cases; Texas is reporting more than 375,000; and 8 additional cases are reporting more than 100,000. The US remains #5 globally in terms of per capita daily incidence and #1 in terms of total daily incidence. California is reporting 453,659 cases, and Florida surpassed New York (411,736 cases) to become #2, with a total of 423,855 cases. With an average daily incidence of nearly 9,000 new cases per day, Texas (381,656 cases) could surpass New York by the late this week. With nearly 10,000 new cases per day, California could surpass 500,000 cumulative cases by late this week as well. Florida continues to report nearly 11,000 new cases per day. Additionally, California, Florida, and Texas continue to report increasing daily COVID-19 deaths. Texas is averaging more than 150 deaths per day, Florida is reporting more than 125, and California is reporting more than 100. On a per capita basis, Arizona is reporting more than 1 death per 100,000 population per day, compared to approximately 0.5 for Florida and Texas and 0.25 for California.

A number of US states continue to report increasing COVID-19 mortality, even as some states appear to be reaching a peak or plateau in daily incidence and the national daily incidence is leveling off. As discussed above, the US reported more than 1,000 deaths per day for 4 consecutive days last week, and multiple states are still reporting record numbers of daily deaths. This recent surge is accelerating COVID-19’s rise through the top causes of death in the US. With 145,982 deaths, COVID-19 would currently be the #6 cause of death in the US—ahead of Alzheimer’s disease, diabetes, and influenza and pneumonia—based on official 2018 data from the US CDC. Projections based on the CDC’s ensemble COVID-19 model indicate that COVID-19 could surpass stroke, chronic lower respiratory disease, and unintentional injury (ie, accidental death) to become #3 by the middle of August. Based on current trends, it is unlikely that deaths from COVID-19 could surpass cancer (599,274 deaths) and heart disease (655,381 deaths) this year. Reports continue to emerge about hospitals and health systems in severely affected parts of the country struggling to handle COVID-19 patient surge. Many of these reports address challenges in densely populated urban areas—such as Miami, Florida, and Houston, Texas—but rural areas are struggling as well, particularly those with fewer hospitals available to serve the population. In one example, a hospital in Starr County, Texas, has been forced to establish ethics and triage committees to prioritize COVID-19 patients to receive care, because the hospital cannot accommodate the demand. The hospital quickly filled its 8 existing intensive care unit (ICU) beds and expanded to 29 beds, but it is still transferring patients to other counties. If beds, mechanical ventilators, or other limited resources are not available, the committees will determine which patients are most likely to survive and admit them for care. Those who are not likely to survive may be sent home to be cared for by family members. Texas Governor Greg Abbott announced that the US Department of Defense is deploying medical resources, including US Navy SEAL doctors to support the COVID-19 response in southern Texas, where Starr County is located. If hospitals and health systems are unable to handle COVID-19 cases, particularly serious and severe COVID-19 patients, it could drive continued increases in COVID-19 mortality.

A 2-dose candidate SARS-CoV-2 vaccine developed by Moderna, Inc. and the US National Institute of Allergy and Infectious Diseases (NIAID), mRNA-1273, will begin Phase 3 clinical trials today. Trial participants will include approximately 30,000 healthy, adult volunteers at 89 clinical research sites in the US. Sites chosen include those that are predicted to be emerging COVID-19 hotspots as well as areas that already have sustained community transmission. Doses will be given via intramuscular injections 28 days apart, but the researchers are hopeful that there will be evidence of immunity following the first dose. The trial will be double-blind, randomized, and placebo-controlled. If fewer than 150 participants develop COVID-19 of the 30,000 enrolled, the trial will be considered a success by trial organizers. The US Biomedical Advanced Research and Development Authority (BARDA) has contributed $472 million to support further development efforts for the vaccine in addition to the $483 million that the federal agency contributed in April. There are currently 3 other candidate vaccines undergoing Phase 3 clinical trials, including 2 in China and one in the UK. A commentary published last week in JAMA proposed pooling the results of clinical trials that were not initially designed to function as a network in order to establish a more robust dataset for evaluating candidate drugs. As we covered previously, many research sites enroll only a small number of participants in COVID-19 trial, which does not provide sufficient data to evaluate efficacy. By pooling results across multiple trials, it could be possible to generate enough data to characterize the drugs’ effects. Statistical stumbling blocks would need to be overcome, including merging data from studies with different designs, as well as details regarding data sharing and safety monitoring agreements. Despite these challenges, pooling data from multiple trials could warrant further investigation as a mechanism to make use of disparate datasets to contribute to evaluating candidate COVID-19 drugs. As investigational vaccines progress through clinical trials, scientists, response leaders and governments are beginning to theorize what rollout of an approved vaccine would like and how to counter potential obstacles. One such obstacle may be concern regarding negative associated side effects. Often, reactions associated with vaccines are mild, such as the muscle soreness at the injection site, but a few participants in earlier clinical trials for candidate SARS-CoV-2 vaccines, particularly those receiving higher doses, have experienced more severe reactions, including high fevers that require medical attention. There is concern that the fear of side effects may prevent individuals from getting vaccinated, so public messaging is already being crafted to educate the public on the benefits and risks and counter anticipated misinformation in order to increase the likelihood that the vaccine will be broadly accepted.

The US CDC reported 3.95 million total cases (70,106 new) and 142,755 deaths (1,078 new). On July 22, the CDC reported more than 1,000 deaths for the first time since early June, and it has now exceeded that threshold for the second consecutive day. The US could potentially surpass 150,000 deaths by the end of next week. Additionally, both of the last 2 updates exceeded the daily incidence for the corresponding day from the previous week by more than 2,000 cases. The 7-day average daily incidence is 66,920 cases, the country’s highest to date, indicating that daily incidence continues to increase, even if it is potentially beginning to level off. More than half of US states have reported more than 40,000 total cases, including California and New York with more than 400,000 cases; Florida and Texas with more than 350,000; and 8 additional states with more than 100,000. The US fell to #5 globally in terms of per capita daily incidence, but it remains #1 in terms of total daily incidence. We expect the US to surpass 4 million cumulative cases in this afternoon’s update. From the first case reported in the US on January 22, it took 81 days to reach 500,000 cases and 98 total days to reach 1 million cases. From there: 1 million to 2 million cases: 44 days 2 million to 3 million cases: 27 days 3 million to 4 million cases: 14 days California (425,616 cases) surpassed New York (410,450 cases) to become #1 in the US in terms of cumulative COVID-19 incidence. With an average daily incidence of more than 11,000 cases, we expect Florida (402,312 cases) to surpass New York today, and with approximately 10,000 new cases per day, Texas (361,125 cases) could surpass New York by the middle-to-end of next week. California (nearly 10,000 new cases per day) could surpass 500,000 cumulative cases by the end of next week. The Johns Hopkins CSSE dashboard reported 4.06 million US cases and 144,552 deaths as of 12:30 pm on July 24.

The US continues to battle a resurgence of COVID-19, driven largely by states that were not severely affected early in the US epidemic. As noted above, the US reported 1 million cases over the past 2 weeks alone, and numerous states are exhibiting concerning trends. Current data indicate stark regional differences in the severity of the current COVID-19 resurgence. States in the Northeast, including New England and the Mid-Atlantic region—particularly the northern portion, including Connecticut, New Jersey, and New York—appear to be faring considerably better than the South, Southwest, West, and Midwest. These differences are evident across all major indicators, including incidence, mortality, test positivity, and hospitalizations. Increasing COVID-19 hospitalizations, in particular, have garnered considerable attention, following reports that hospitals and health systems are struggling to meet the COVID-19 patient surge. Newly published data from HHS shows multiple states in these severely affected regions reporting more than 25% of inpatient hospital beds currently occupied by COVID-19 patients, including Arizona, California, Georgia, New Mexico, and Texas. Several other states in the South, Southwest, and West—including Alabama, Arkansas, Louisiana, Mississippi, Nevada, and South Carolina—are reporting that more than 15% of inpatient beds are occupied by COVID-19 patients. Additionally, analysis from the COVID Tracking Project indicates that national COVID-19 hospitalizations are now equal to the country’s first peak in mid-April. In the first peak, COVID-19 cases were largely concentrated in a few major metropolitan areas—including Boston, Detroit, and New York—and overwhelmed local health systems, which accounts, to some degree, for the higher per capita incidence in these areas. Now, the cases are spread out across a much larger geographic area and population, and more hospitals and health systems, and the overall mortality is lower than it was early in the US epidemic (although beginning to increase again). If continued uncontrolled transmission continues, however, it could necessitate spreading limited health resources (eg, mechanical ventilators, investigational treatment drugs) more thinly across the country, which could exacerbate recent increases in mortality. Statistically speaking, some portion of hospitalized patients are expected to die from COVID-19, so as hospitalizations increase, so will COVID-19 mortality, particularly if available resources are exhausted. These state- and regional-level disparities have driven a number of states to implement domestic travel advisories or restrictions. Some states require arriving travelers to be tested for SARS-CoV-2 and/or provide documentation of a recent negative test, and some require or recommend self-quarantine, typically for 14 days. Some of these requirements pertain to specific states, and others are broadly applied to all out-of-state travelers. Connecticut, New Jersey, and New York previously implemented a joint policy that requires travelers arriving from severely affected states to quarantine themselves for 14 days upon arrival. The initial list was relatively limited, with only 9 affected states; however, it has ballooned to more than 30 states, covering approximately two-thirds of the entire US population. Additionally, the Ohio Department of Health issued a similar travel advisory for any state reporting test positivity of 15% or greater. The new Ohio policy currently covers 9 states. The Ohio Department of Health recommends 14-day self-quarantine and temperature/symptom monitoring for individuals with recent travel to the affected states, but it does not appear to be mandatory. Interestingly, it appears that Florida’s mandatory quarantine for travelers arriving from the New York tri-state area, implemented earlier in the US epidemic, remains in effect, despite the fact that Florida is currently reporting more than 11 times the combined daily incidence of New York, New Jersey, and Connecticut. In response to surging COVID-19 incidence in Florida, US President Donald Trump announced that activities for the Republican National Convention scheduled in Jacksonville will be cancelled. Some convention activities were originally moved from Charlotte, North Carolina, after disagreements regarding the state’s restrictions on large gatherings; however, Republican delegates will reportedly still meet in Charlotte to announce President Trump as the Republican nominee for the 2020 presidential election.

The US NIH is initiating several clinical trials as part of the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) public-private partnership. Initiated on April 17, the goal of this effort is to develop a coordinated research strategy to speed up the development of COVID-19 candidate pharmaceuticals. ACTIV has 4 fast-track areas of focus, including pre-clinical treatments, accelerating clinical testing for vaccines and treatments, improving clinical trial capacity, and accelerating evaluation of vaccine candidates. The new trials include antiviral monoclonal antibodies, for both hospitalized and at-home patients; drugs to reduce dangerous inflammatory responses to COVID-19; and drugs to treat blood clotting. A principal goal of the program is to ensure coordinated and standardized protocols and study designs across multiple testing sites in order to promote robust analyses. More than 1,200 clinical trials have been registered with the US government for COVID-19 drugs, and nearly 40% of them involved fewer than 100 patients. This disorganized approach likely will not yield robust data to support effective analysis of many candidate drugs, and ACTIV aims to improve consistency and coordination nationwide. NIH Director Dr. Francis Collins and several NIH colleagues published a special report in The New England Journal of Medicine that outlined the Rapid Acceleration of Diagnostics program (RADx), led by NIH in partnership with other US government entities, including the Biomedical Advanced Research and Development Authority (BARDA) and the Department of Defense. RADx was conceived to support rapid development and production of novel diagnostics, including the use of “innovative diagnostic technologies.” Perhaps most notably, it is “expressly focused on health disparities,” rather than purely technical challenges. The program includes 4 principal components, each with a specific focus. Three of the components focus on technical aspects of product research, development, and production, and the fourth is dedicated to improving equity among underserved populations. Racial and ethnic minorities are disproportionately affected by COVID-19, and this component, RADx-UP, aims to characterize the factors driving this elevated burden and improve access to testing among high-risk populations, including through community engagement activities.

The US government continues to evaluate options for a possible “Phase 5” COVID-19 funding bill, but considerable uncertainty remains regarding the content and timeline. Senate Majority Leader Mitch McConnell was expected to release a draft bill this week as a starting point for debate in the Senate, but it appears that it may be delayed until at least next week as details are finalized. The funding bill could potentially provide support for hospitals and health systems and state and local governments as well as individuals. Individual stimulus payments and expanded federal unemployment benefits are among a long list of high-profile priorities. A report by The Hill indicates that the Senate bill is expected to include similar stimulus payments as the previous phase of funding, possibly US$1,200 per person for everyone with an annual income of $75,000 or less. Senator McConnell previously suggested that the income cap could be lowered for this round to US$40,000, but there are indications that this may have changed. Considering that the current expanded federal unemployment insurance, an extra US$600 per week, is scheduled to expire next week, it is possible that individuals receiving those benefits could lose that additional funding for a period of weeks while a bill is finalized and implemented. It is unclear if any temporary measures are being evaluated to prevent these payments from lapsing. The Senate bill will reportedly not include a payroll tax cut for businesses, previously a priority for President Trump, following opposition from Republican Senators. Again, these negotiations are ongoing, and the Senate draft has yet to be finalized and released. The House of Representatives passed its own funding bill several weeks ago, but there will likely be substantial differences between the House and Senate proposals. There appears to be pressure to reach an agreement soon in order to provide economic support as states continue to maintain, and in some cases strengthen, social distancing policies, but the exact path forward is not clear at this time.

As the US moves toward the scheduled start of the 2020-21 school year, the US CDC published several updated guidance documents to support schools in preparing for classes in the midst of the COVID-19 pandemic. A number of prominent US government officials, including President Trump, have publicly called for schools to resume in-person classes, but many state governments, school officials and teachers, and health experts warn that might not be feasible or safe in some circumstances. The updated guidance includes information for schools regarding the current understanding of COVID-19 risk to children and their role in driving transmission in the community and at home as well as recommendations for implementing appropriate social and physical distancing (including mask use), enhanced hygiene and sanitation, and disease surveillance and monitoring systems. The guidance also includes considerations based on the current level of community transmission, including the possible need to close schools due to uncontrolled community spread. In addition to schools, the CDC offers tools and information aimed at parents to help evaluate risk. The updated CDC guidance includes a statement that explicitly emphasizes the importance of in-person school for children. Some media reports have characterized this as a push by the CDC to resume in-person classes during the pandemic, as it focuses primarily on the benefits of in-person learning rather than public health considerations related to COVID-19. The statement highlights the disproportionate impact of remote classes on lower-income students, racial and ethnic minorities, and students with disabilities or special needs as well as the importance of services schools provide beyond education that support these and other students. Notably, the CDC emphasizes repeatedly that the risk to students—including direct health risks to children and risks of spreading the disease at home—are relatively low in communities with low levels of SARS-CoV-2 transmission. The statement largely focuses on the impact for students and does not fully address the risks to teachers, staff, and family members.

The US CDC reported 3.82 million total cases (57,777 new) and 140,630 deaths (473 new). In total, more than half of US states and New York City reported more than 40,000 total cases, including California with more than 375,000 cases; Florida with more than 350,000; Texas with more than 325,000; New York City with more than 200,000; and 8 additional states with more than 100,000. The US is #4 globally in terms of per capita daily incidence. Daily COVID-19 incidence at the national level in the US may be approaching a peak or plateau. The 7-day average daily incidence appears to have passed an inflection point, and the increasing trend is beginning to taper off. The record high daily total of 74,710 reported last week was a substantial increase over the previous week’s high (66,281 new cases reported on July 11), so the late-week reporting this week will provide important insight into the future trajectory of the US epidemic. COVID-19 mortality in the US continues to increase slowly as well. The average mortality is currently 800 deaths per day, up from 581 deaths per day on July 8. At the state level, several hard-hit states appear to be peaking or plateauing as well. Arizona, California, Florida, and Texas are all exhibiting relatively steady or decreasing daily incidence over the past week or so; however, Arizona, Florida, and Texas continue to report record mortality (and continuing to increase). Florida and Texas are both now averaging more than 100 deaths per day, and Arizona is reporting more than 80 deaths per day. Notably, Arizona is reporting more than 1.1 daily deaths per 100,000 population, which is more than double the current rate in Florida and Texas. Additionally, Florida is still reporting more new cases per capita than New York did at its first peak in April. Arizona’s peak value exceeded New York’s as well, but it has since fallen back below that level. A number of other states continue to exhibit increasing incidence, including Alabama, Georgia, Louisiana, Maryland, Tennessee, Virginia, and Washington.

Mask mandates are becoming increasingly common across the US. Available evidence continues to support mask use as an effective mechanism for reducing transmission risk, and many elected officials continue to recommend mask use, even if they are not mandating it. Masks use is now mandatory in more than half of US states; however, the exact details vary by state. Generally, mask orders require individuals to wear masks in public spaces where it is not feasible to maintain social distancing, particularly indoors, but they may not require mask use at all times when in public. Governors in several other states, including Georgia and Florida, have resisted state-level mandates, instead electing to encourage the public to participate. Notably, Georgia Governor Brian Kemp filed a lawsuit against Atlanta’s Mayor and City Council over the city’s local mask mandate, arguing that the governor’s executive order prohibits local governments from taking actions more restrictive than the state’s requirements. Some health experts, elected officials, and labor union leadership have called for a national mask order, but US President Donald Trump and Surgeon General Jerome Adams have opposed this approach—although, Surgeon General Adams did plead with viewers to wear masks during a recent interview. President Trump did, however, recently encourage the use of face masks as “patriotic,” in contrast to his past opposition to and/or mixed messaging regarding mask use as a means of controlling the COVID-19 epidemic.

States and school systems in the US continue to develop and debate plans to send students back to school for in-person learning for the start of the 2020-21 school year, which typically begins in late August or early September in most states. The Florida Education Association, a labor union representing Florida educators, filed a lawsuit against Florida Governor Ron DeSantis following his push for a return to in-person schooling starting at the end of August. The lawsuit claims that the current COVID-19 epidemiological situation in Florida makes it unsafe for teachers and students to return to schools and calls for substantive action to provide PPE for schools and resources to develop online curricula. Similarly, “a group of students, parents, teachers, and a bus driver” in Detroit, Michigan, filed a lawsuit with the aim of closing summer school programs as COVID-19 incidence increases. In Harris County, Texas, one of the largest counties in the US, the County Judge and health department announced that the start of in-person classes and other school-related activities, including sports and clubs, for kindergarten through 12th grade will be delayed until at least October due to “severe and uncontrolled disease transmission in [the] community,” with more than 35,000 active cases in the county.

The US government has finalized an agreement with Pfizer and BioNTech to acquire 100 million doses of their candidate SARS-CoV-2 vaccines, worth US$1.95 billion. Additionally, the US government could purchase an additional 500 million doses under the agreement. Pfizer and BioNTech currently have several candidate vaccines in the development pipeline, including various stages of clinical trials. According to a press release issued by Pfizer, the companies aim to begin Phase 2b/3 clinical trials later this month with the goal of securing US FDA authorization for at least one vaccine by October and delivering the vaccine doses by the end of 2020. The companies also hope to expand production to a total of 1.3 billion doses by the end of 2021. The agreement was signed as part of Operation Warp Speed, which has resulted in similar agreements—to support research and development, scale up manufacturing capacity, and purchase vaccine doses—with other pharmaceutical companies pursuing their own candidate vaccines.

The US CDC reported 3.70 million total cases (67,574 new) and 139,659 deaths (877 new). In total, 25 states and New York City have reported more than 40,000 total cases, including California with more than 375,000 cases; Florida and Texas with more than 300,000; New York City with more than 200,000; and 7 additional states with more than 100,000. The US is currently averaging more than 750 deaths per day, and it could reach 150,000 cumulative deaths in the next 2 weeks. New York, including New York City, has reported the most COVID-19 cases of any US state, with 406,807 total cases; however, California, Florida, and Texas continue on pace to surpass this total in the coming days. California is reporting an average daily incidence of 8,323 new cases per day; Florida is reporting 11,461 new cases per day; and Texas is reporting 9,886 new cases per day. New York is reporting fewer than 750 new cases per day, so we can expect California to surpass New York by the middle of this week, Florida by the end of this week, and Texas by the middle of next week. The Johns Hopkins CSSE dashboard reported 3.79 million US cases and 140,716 deaths as of 1:00 pm on July 20.

Some portions of US COVID-19 relief funding are expiring soon, and efforts are ongoing to evaluate the possibility of another round of stimulus funding. In particular, previous COVID-19 funding bills provided for increased unemployment insurance—an extra US$600 per week—which will expire next week. Additionally, a federal moratorium on some evictions will also expire, which would put many individuals and families at risk of losing their homes, particularly those who remain unemployed. The expiration of state-level eviction moratoria are already resulting in substantial volumes of eviction proceedings in some states. Many individuals have used the extra unemployment funding to pay bills, including rent, and they may not be able to continue making their required payments without an extension or other federal funding support. With many Americans still unable to return to work—due to a variety of factors, including temporary or permanent closure of their business, remaining social distancing restrictions, children still home from school, or a lack of available jobs—federal lawmakers are discussing potential options for another stimulus package. There is some evidence that the expanded unemployment funding is allowing some individuals to make more money than if they were working, which could complicate decisions regarding when and how to return to work. Concerns about rising federal debt and potential misuse of federal funding are factoring into these plans. While the negotiations involve many complex issues and decisions, there are several primary proposals and areas of contention with respect to how future funding would be distributed. Democrats in the House of Representatives previously passed a US$3 trillion funding package that included a broad range of support for individuals, businesses, state and local governments, and hospitals; however, the bill never received a vote in the Senate. Senate Majority Leader Mitch McConnell has indicated that Senate Republicans are drafting their own legislation, potentially more limited in scope and funding, could be unveiled this week. One of Senator McConnell’s stated priorities is liability protection for businesses, including hospitals, to protect them against lawsuits following COVID-19 infections among employees or patrons. Speaker of the House Nancy Pelosi emphasized the need for direct payments and extended unemployment insurance for individuals to ensure they have funds available for rent, food, and other necessities, but there are differing opinions regarding how best to accomplish it and who could be eligible. Additionally, US President Donald Trump has called for a payroll tax cut for businesses; however, there appears to be some opposition to this mechanism from both Republicans and Democrats. While a payroll tax cut could reduce financial burden on businesses, it could also reduce federal funding for programs such as Social Security.

As the US school year rapidly approaches, federal, state, and local government officials are working to develop and implement plans to resume classes. Proposals range from full-time, in-person classes to online/remote classes only, including a myriad of hybrid options in between. Much of the uncertainty and debate revolves around the direct risk to children and the role they play in community transmission. It is generally understood that children are at lower risk for severe COVID-19 disease and death than adults—although, certainly not zero risk—but it is much less clear how easily children transmit the infection to others, including adults or other high-risk individuals at home or in the community. A recent study by researchers in South Korea, published in the US CDC’s Emerging Infectious Diseases journal, found that SARS-CoV-2 transmission was far more common in household settings compared to public settings. Based on analysis of more than 59,000 contacts of more than 5,700 COVID-19 “index patients,” the researchers found that household contacts were more than 6 times more likely to become infected than non-household contacts. The study identified cases in 11.8% of household contacts, compared to only 1.9% of non-household contacts. Notably, households with an “index patient” aged 10-19 years were at even higher risk for transmission—cases identified in 18.6% of household contacts, compared to 11.8% in households with “index patients” of other ages. The lowest transmission risk among household contacts was for “index patients” aged 0-9 years. In these households, cases were identified in only 5.3% of household contacts; however, this was still greater than the overall risk for non-household contacts. This indicates that children who are infected at school could transmit the infection at home more easily than in other settings, particularly for older children, which would put other family members at increased risk. The study only evaluated symptomatic cases, so further evaluation is required to better characterize the role of asymptomatic or pre-symptomatic transmission by children. It appears that there may be significant risk of transmission by children as they return to in-person classes, and many schools are evaluating options for remote/online classes this fall. Other options include home schooling, which some parents are investigating after positive experiences with remote classes this spring after most schools closed. While these options may appear similar on the surface, remote classes and home schooling are very different. Home school options vary widely, including utilizing existing curricula or developing personalized course work, and the standards and requirements vary from state to state. While online classes and home school may be effective, they may not be viable options for everyone. These options may require computers, tablets, or smartphones and reliable high-speed internet service to fully participate, particularly for live-streamed classes or video sessions. Availability for both computers and internet services may not be feasible for lower-income families or those living in remote areas, and many parents may not be able to continue to work remotely or remain at home in order to supervise their children during the day.

The US CDC reported 3.48 million total cases (67,404 new) and 136,938 deaths (947 new). Thirty nine states are reporting increasing incidence of confirmed cases, with the largest outbreaks occurring in Texas and Florida. Both of those states reported a record number of new deaths with 110 and 156 new deaths respectively. Cases in the US have increased by 206% since June 9, up from 20,338 new cases per day to 62,324 yesterday (7-day average).

Virginia has reportedly become the first state in the country to mandate coronavirus-related workplace safety measures. The measure, called an “emergency temporary standard” will compel companies to comply with safety measures or face up to $130,000 in fines. The measures include mandates focused on protective gear, disinfection and sanitation, and physical distancing, among other features. The move also protects employees who voice safety concerns to their employers. The measure is expected to last at least 6 months and comes amid measures by a growing number of US states to mandate face coverings in public.

The US CDC reported 3.35 million total cases (58,858 new) and 135,235 deaths (351 new). The 7-day average for daily incidence has risen steadily since it’s plateau in early June, and now sits at 58,619, its highest total since the pandemic began. In total, 24 states (increase of 2) and New York City have reported more than 40,000 total cases, including California with almost 330,000 cases; Florida and Texas with more than 250,000 cases; and 6 additional states and New York City with more than 100,000. The Johns Hopkins CSSE dashboard reported 3.45 million US cases and 136,807 deaths as of 1:00pm on July 15.

Yesterday, California Governor outlined that California will be asking businesses to alter their operations once again and announced that both Los Angeles and San Diego school districts will start this fall online.

News broke yesterday that the current Presidential Administration has ordered hospitals to bypass the CDC when sharing COVID-19 data with the US government. The new process would have data sent to a central database within HHS. Officials from the president’s administration have suggested that this move was used to improve information access for the White House coronavirus task force, allowing the group to make decisions around the allocation of supplies including PPE and medical countermeasures. Many experts worry that this transition may limit data access and harm public transparency. The Presidential Administration has also asked governors to consider sending the National Guard to assist in hospital data collection efforts.

The US CDC reported a total of 3.29 million total cases (60,469 new) and 134,884 total deaths (312 new today, 906 yesterday). While the number of new cases reported today is currently lower than that reported on Friday, July 10 (64,771 new), it continues the trend of reporting over 50,000 new cases per day. A total of 22 states and New York City have reported more than 40,000 total cases, unchanged from Friday. States with some of the highest case counts include California with over 300,000 cases, Florida and Texas each with over 250,000, and New Jersey, New York City, New York State, and Illinois with at least 150,000 cases. Over the weekend, Florida broke a US state record of daily new cases, with over 15,200 new cases in a day, making it the single-largest increase in daily case counts reported by any state. In addition, 3 additional states have at least 100,000 cases. There has been a 68% increase in number of new daily cases reported compared to 2 weeks ago, up from 32,220 to 54,100 cases yesterday (Two Week Tracker). Regional analysis of state-level COVID-19 data continues to show the epidemic accelerating across most regions in the US. The South, Southwest, West, and Midwest regions all have demonstrated marked increases in daily new cases, with the rate of increases also accelerating particularly in the South. The midwest, after having successfully slowing its epidemic by mid-June, is now approaching the similar weekly incidence rates it experienced during its first peak in early May. While the Midwest has reported about 5% test positivity that has been steadily increasing since June 18th, the South and Southwest have about 13% and 18% test positivity, respectively, compared to about 2% in mid-Atlantic and New England.

Testing challenges and limitations that have hampered the US response efforts from the first days of the pandemic have increased as COVID-19 incidence continues to resurge. According to the CDC, the US has conducted 40,787,857 tests across the country, of which approximately 9% have come back positive nationwide. As supply chain limitations and infrastructure challenges became evident in March, the Trump Administration assigned ADM Brett Giroir to address testing efforts and ensure national scale up, with a goal of having the capacity to conduct at least 500,000 tests per day. Much of the response efforts to expand testing, however, fell substantially onto state and local officials to manage, and although testing capacity increased across the US as a whole, wide disparities remain across states remain. As case counts rise, many states are now reporting substantial delays in receiving test results, sometimes taking up to 14 days. In addition to supply constraints and lab capacity limitations, logistical challenges such as transporting large numbers of samples, and communicating results to public health responders in a timely manner have caused delays. Separately, about 1,000 current employees at the United States Centers for Disease Control and Prevention (CDC) - equivalent to at least 9% of the organization’s total workforce - have signed a letter addressed to CDC Director Dr. Robert Redfield regarding racial discrimination in the workplace and racism as a greater public health crisis. The letter comes at a particularly fraught time for CDC as the organization.

The US CDC reported 3.05 million total cases (64,771 new) and 132,056 deaths (991 new). This is the United States’ highest daily total to date, and the US has reported more than 50,000 new cases for 6 of the last 8 days. This is also the second consecutive day that the US reported more than 900 new deaths. In total, 22 states (increase of 1) and New York City reported more than 40,000 total cases, including California with more than 275,000 cases; Florida, New York City, and Texas with more than 200,000 cases; and 6 additional states with more than 100,000. The current daily incidence in the US is more than 50% higher than the first peak in mid-April, and it has increased by 165% since June 9, up from 20,338 new cases per day to 53,795 yesterday (7-day average). Regional analysis of state-level COVID-19 data illustrates several concerning trends in the US epidemic. While nationally, US COVID-19 deaths have decreased steadily over the past several weeks—before rebounding substantially in the days since the Independence Days holiday weekend—this trend is not consistent across all regions. New England, the Mid-Atlantic region, and the Midwest are all exhibiting marked declines in COVID-19 mortality, but both the South and Southwest regions are reporting increased daily deaths since early-to-mid June. Additionally, test positivity is increasing nearly nationwide, indicating that increased transmission may be outpacing the growing testing capacity. New England and the Mid-Atlantic are reporting relatively steady or slight increases in test positivity, but test positivity is increasing significantly in the Midwest, South, Southwest, and West regions, where many states are currently facing COVID-19 surges.

Many parts of the US continue to battle surging SARS-CoV-2 transmission. Numerous states are reporting increasing—and in some instances, record-breaking—COVID-19 incidence, hospitalizations, test positivity, and now deaths. This recent trend has driven some to re-institute various forms of social distancing that were previously lifted or implement new policies, such as mandatory mask use. While many states have paused their recovery plans or reversed course to some degree, it may not be sufficient to contain the current level of community transmission in the most severely affected areas. Dr. Anthony Fauci recently commented that “any state that is having a serious problem...should seriously look at shutting down,” although he acknowledged that a “complete shutdown” would be an “extreme” option. So far governors have resisted re-issuing “stay at home” orders that were implemented widely earlier in the epidemic. As we move toward the scheduled start of school in the fall, state officials will likely need to make difficult decisions regarding social distancing orders, particularly considering the interdependence between children returning to school, parents returning to work, and risks of community transmission. Reports continue to emerge of hospitals and health systems in severely affected areas struggling to cope with COVID-19 patient surge, particularly in intensive care units. States are taking a variety of approaches to mitigate stress on health systems, including ordering hospitals to implement surge capacity plans, prohibiting elective procedures, and deploying supplemental personnel to affected hospitals. The US continues to scale up testing, but test positivity in many states continues to increase as well, indicating that existing capacity is not sufficient compared to the current level of transmission. One analysis—published in The New York Times, using data from the COVID Tracking Project—indicates that the US is only conducting 39% of the testing needed for the current scale of transmission. Notably, 22 states are conducting fewer than 50% of the necessary tests, including Arizona at 10% and 3 other states below 20%. Yesterday, Democrats on the US Senate Committee on Health, Education, Labor, and Pensions published a report on their investigation into US government efforts to scale up SARS-CoV-2 testing capacity. The senators argue that challenges with testing capacity, now and early in the US epidemic, stem from a failure of leadership and coordination at the most senior levels of government.

Following a White House event addressing plans for schools to reopen this fall, in which US President Donald Trump indicated that he would pressure states to resume in-person classes, President Trump criticized the existing US CDC COVID-19 guidance for schools. He described the CDC guidance as “very tough & expensive” and called for updated guidance that would be easier for schools to follow. Subsequently, Vice President Mike Pence stated that the CDC would issue revised guidance in the coming days. Numerous experts argue that softening the CDC guidance based on factors other than the available scientific evidence will inherently increase transmission risk in school settings. In contrast to the statements by the President and Vice President, US CDC Director Dr. Robert Redfield stated yesterday that the CDC will not issue updated guidance for schools. He emphasized that the guidance is a set of recommendations, not requirements, and that states and schools are responsible for making decisions regarding whether and how to implement protective measures. He also noted that the CDC will issue additional guidance documents, but they will include supplemental information as opposed to revised guidance. While US schools have yet to resume after most closed in March, some summer camps are operating in various parts of the country. Several camps—which, much like schools, involve prolonged close contact between children and instructors—have already reported COVID-19 outbreaks, with dozens of students and camp staff testing positive, either while at the camp or shortly after returning home. Several of these camps have closed operations as a result of the outbreaks. Camps may not necessarily adhere to the same physical distancing, hygiene and sanitation, and other COVID-19 recommendations as schools will; however, these outbreaks provide some indication that COVID-19 can spread rapidly among children and staff and potentially result in further spread in the community. Similarly, some sports programs, including college and professional, have resumed practices, and some have been forced to alter plans due to transmission of SARS-CoV-2 among players and coaches. Multiple universities, including the University of North Carolina and Ohio State University, reportedly suspended voluntary workouts following positive SARS-CoV-2 tests among players, coaches, and staff. The Ivy League conference announced the cancellation of all fall collegiate sports for 2020, which could potentially have far-reaching impact on other conferences and universities across the country. Following that announcement, the Big Ten Conference announced that it is removing all non-conference competitions from the schedule for all fall sports. It is unclear if or how this could affect post-season tournaments, championships, and football bowl games. Additionally, Stanford University announced that it is discontinuing 11 sports programs due to financial challenges exacerbated by the COVID-19 pandemic.

The US CDC reported 2.93 million total cases (46,329 new) and 130,133 deaths (322 new). Following 4 consecutive days of more than 50,000 new cases, the US reported a slight decrease in daily incidence early this week. Low reported incidence early in the week is not unexpected due to delays in weekend reporting, particularly over a long holiday weekend; however, even these lower reports are greater than any day prior to June 27. In total, 21 states (no change) and New York City reported more than 40,000 total cases, including California with more than 250,000 cases; Florida, New York City, and Texas with more than 200,000 cases; and 5 additional states with more than 100,000. The current daily incidence in the US is more than 50% higher than the first peak in mid-April, and it has increased by more than 150% since June 9, up from 20,338 new cases per day to 51,711 yesterday (7-day average). A number of US states are exhibiting per capita incidence on par with or greater than the peaks in states hit hardest by COVID-19 early in the US epidemic. At its peak on April 10, New York state’s per capita daily incidence was 50.9 cases per 100,000 population (7-day average). Other notable states early in the epidemic include: New Jersey with 41.4 new cases per 100,000 population; Massachusetts with 38.1; Louisiana with 33.9; and Connecticut with 30.9. On July 6, Arizona reported 52.8 new cases per 100,000 population, higher than any state so far in the US epidemic. Similarly, Florida reported 40.8 new cases per 100,000 population on July 7, and South Carolina reported 32.6 on July 6. Louisiana’s per capita daily incidence decreased to 5.77 new cases per 100,000 population on May 29 before rebounding to 31.2 on July 7. California and Texas, the country’s two largest states by population, are reporting 20.0 and 25.9 new cases per 100,000 population, respectively, and a number of other states are reporting more than 25.

Florida’s COVID-19 epidemic continues to accelerate. According to several reports, hospitals and health systems in multiple parts of the state are struggling to meet patient surge as COVID-19 transmission increases. Unlike most states, Florida does not report current COVID-19 hospitalizations (only cumulative), so other sources must be used to track this trend. Based on data from the state’s Agency for Health Care Administration, dozens of hospitals have reached their ICU capacity. While many of these are smaller hospitals with relatively few ICU beds, a substantial number are larger facilities with a capacity of 25 or more ICU beds. One local effort to track hospitalizations indicates that the state reported multiple record highs for daily COVID-19 hospitalizations over the past week. Additionally, the recent surge in COVID-19 incidence in Florida is complicating contact tracing efforts, as the volume of contacts exceeds available capacity. Potential exposures in public locations such as parties and nightclubs could result in dozens of contacts, many of which may not be identified. Despite the continued concerning COVID-19 trends, Florida announced that schools will open for in-person instruction this fall. The emergency order, issued by the state’s Commissioner of Education, directs school boards to “open brick and mortar schools at least five days per week,” unless prohibited under future health department or executive orders. The order permits the use of alternative options for instruction, including remote classes, but schools must be open to offer in-person instruction for those who desire it. Some educators and organizations, including teachers unions, have opposed the order, emphasizing that decisions regarding in-person instruction should be directed by scientific evidence rather than economic priorities.

In addition to Florida, Arizona and Texas also remain major COVID-19 hotspots in the US. Both states are reporting concerning trends in terms of incidence, testing, hospitalizations, and even deaths. In Arizona, state officials directed hospitals to implement crisis standards of care for COVID-19 patients, if necessary, and there are reports that major health systems in some parts of Texas are quickly filling with COVID-19 patients. In fact, more than 20 states have reported increased COVID-19 hospitalizations over the past 2 weeks. There are concerns that existing supply of critical personal protective equipment (PPE)—including surgical masks, gowns, and gloves—could once again be in short supply as COVID-19 hospitalizations continue to increase. Following initial shortages, particularly in the cities hit the hardest early in the US epidemic, PPE supplies have largely recovered, but a prolonged surge across multiple states could be a major challenge for national distribution systems.

The White House hosted an event yesterday to discuss plans for schools to reopen in the midst of the COVID-19 pandemic. At the event, and on social media, US President Donald Trump indicated that he would put pressure on states to reopen schools this fall for in-person instruction, including K-12 as well as colleges and universities. In fact, multiple senior US government officials and advisors, including President Trump, emphasized that schools should strive to hold full-time, in-person classes this fall. US CDC Director Dr. Robert Redfield emphasized that the CDC never recommended school closures, and he noted that he hoped the agency’s guidance was not viewed by schools as a reason to remain closed. Many, including health experts and officials, argue that attending school in person is important for childhood development, both from an educational and social perspective, and allowing children to return to school is critical for many families to return to work. Despite these benefits, many questions remain regarding how to safely resume in-person classes and mitigate transmission risk for students, teachers, and the community. Existing guidance emphasizes the importance of physical distancing, improved hygiene and sanitation, and utilizing outdoor spaces when possible, but these may be challenging for many schools. Maintaining 6-foot separation between students in classrooms could be particularly challenging for many schools, especially with full in-person attendance. Additionally, the risk of severe disease and death may be lower among children, but many teachers and other school staff are at high risk for COVID-19.

The US government, including US Immigration and Customs Enforcement (ICE), issued modifications to the federal Student and Exchange Visitor Program (SEVP) that would prevent immigrants on common types of student visas (F-1 and M-1) from remaining in the US if they take all of their courses online. Students attending universities that are fully transitioning to online coursework must either depart the US or transfer to a school that is holding in-person classes in order to fulfill their visa requirements. Earlier in the COVID-19 pandemic, SEVP granted exceptions for F-1 and M-1 visa holders in order to accommodate students as universities transitioned to remote coursework. The updated policy will pose numerous challenges for colleges and universities, as well as their students, as fall classes rapidly approach. Some schools plan to hold in-person classes, while others intend to hold all classes online. In the wake of the changes to SEVP, more schools may move toward hybrid models, which would involve a mixture of in-person and online courses. The impact of losing international students reaches far beyond academic institutions. International students generated more than $41 billion in revenue for the US economy during the 2018-19 academic year. Universities are now looking for stronger guidance regarding how to safely proceed with in-person courses in order to support their international students and protect students, faculty, and staff against COVID-19.

The US is pushing ahead with “Operation Warp Speed” in an attempt to rapidly develop and deploy a SARS-CoV-2 vaccine. A commentary published in JAMA earlier this week outlined the 5 “core” vaccine candidates at the center of the federally organized effort. The US government has already invested considerable funding for vaccine research, including US$1.6 billion for the Novavax vaccine. The authors acknowledge that these 5 vaccine candidates are being developed using 3 unique technological platforms, exemplifying the diversity and innovation in SARS-CoV-2 vaccine development. Despite the current progress and the existence of multiple candidates, a number of questions still need to be answered regarding the efficacy of each vaccine candidate, and considerable work remains in terms of testing and production for all of the products. For example, US government officials have reportedly “squabbled” with Moderna over clinical trial design and implementation for its candidate vaccine, which has resulted in delays in initiating advanced clinical trials. The authors argue that the vaccine development landscape will be permanently altered by the COVID-19 pandemic.

The US has reportedly withdrawn from the WHO in the midst of the worst pandemic in a century. US President Donald Trump previously threatened to withdraw the US from the world’s leading international health organization, following calls for the WHO to implement reforms, including some related to its relationship with China. We have not yet identified an official US government source or announcement; however, the United Nations reportedly confirmed that it received written notification that the US intends to withdraw from the WHO, effective July 6, 2021. The US is currently #1 globally in terms of daily and cumulative COVID-19 incidence and total deaths, and its epidemic has been accelerating since early June. Notably, it is unclear whether the US President has the authority to unilaterally withdraw from the WHO, as opposed to needing Congressional approval; however, the Joint Resolution passed by the US Congress in 1948 to join the WHO includes a provision mandating that the US pay its dues before fully withdrawing. This would require the US to pay in full its financial obligations—currently US$198 million—which President Trump previously put on hold. Numerous experts and organizations have criticized the decision, including the American Medical Association. Withdrawing from the WHO would effectively omit the US from important health-related decisions made and coordinated by the WHO, including the formulation of seasonal influenza vaccines and potentially the global allocation of a SARS-CoV-2 vaccine.

The US CDC reported 2.84 million total cases (52,228 new) and 129,576 deaths (271 new). The US has reported more than 50,000 new cases for 4 consecutive days, including a record high of 57,718 on July 4. In total, 21 states (increase of 2) and New York City reported more than 40,000 total cases, including California with more than 250,000 cases; New York City with more than 200,000 cases; and Florida, New York state, and Texas with more than 175,000. The current daily incidence in the US is more than 50% higher than its first peak in mid-April. The daily incidence has more than doubled since June 9, up from 20,338 new cases per day to 47,389 yesterday (7-day average).

A number of US states have reversed course on their efforts to relax social distancing measures, in response to recent concerning COVID-19 trends. One analysis published by The New York Times found that 19 states are pausing their recovery plans or reinstituting or strengthening existing social distancing restrictions. Multiple states recently announced the closure of businesses that pose elevated exposure risk, including bars, movie theaters, and gyms/fitness centers that were previously permitted to reopen. Some of these efforts have met significant opposition from business owners and patrons, and some states have had to threaten regulatory or legal action to prompt compliance with the new restrictions. Several states have also implemented mandatory mask use in many or all public spaces, including stores and restaurants. In fact, nearly half of all US states now have some form of mask mandate, including 7 that implemented new policies since the second half of June. Notably, analysis published by Forbes shows that 10 states are reporting level or decreasing COVID-19 incidence over the past 2 weeks, and 7 of these states had mandatory mask policies in place since at least the middle of May. In response to increasing COVID-19 transmission in Arizona, the Mexican state of Sonora implemented border restrictions in advance of the Independence Day holiday weekend. The policy limited border crossings from Arizona into Mexico to essential purposes only. Sonora’s beach towns are a common vacation destination for Arizonans. A number of beaches throughout Florida were also closed for the Independence Day weekend. Many of these beaches were previously open as Florida progressed through its recovery plan. As we have discussed previously, the effects of changes to social distancing policies and practice will likely not be immediately evident. The current ongoing surge in COVID-19 incidence followed several weeks after many states began to ease social distancing policies in late May and early June. People who were infected immediately prior to these most recent changes, or are infected as adherence increases, will likely not be detected for several days or possibly weeks.

US government employees under numerous government departments are beginning to return to the office. Each department is addressing the return of personnel differently. While many federal government offices and services can continue to function remotely, others (e.g., passport processing) may require in-person work. While some offices, particularly senior department leadership, are centralized in Washington, DC, others (e.g., Veterans Affairs) are distributed widely across the country, which makes it difficult to resume operations uniformly across their various facilities. Additionally, Washington, DC, is surrounded by Maryland and Virginia, both of which are implementing their own response and recovery plans, and many federal employees make their daily commute from their homes in these states.

The US CDC reported 2.58 million total cases (35,664 new) and 126,739 deaths (370 new). In total, 19 states (no change) and New York City reported more than 40,000 total cases, including California and New York City with more than 200,000 cases; New Jersey, New York state, and Texas with more than 150,000; and Florida and Illinois with more than 140,000. Following an overall decrease in daily incidence from mid-April through the end of May, the United States is now consistently reporting higher daily incidence than at its first peak in mid-April. The United States’ daily incidence has more than doubled since June 9, up from 20,338 new cases per day to 40,948 yesterday (7-day average). The United States’ epidemic is currently following a similar trajectory to what was observed leading up to its first peak. US disease surveillance reporting is notorious for being low early in the week, especially Mondays and Tuesdays, due to delays in reporting over the weekend. This is particularly true at the national level, as the CDC must compile reports from the states. With that in mind, the CDC reported 41,390 new cases on Monday and 35,664 new cases on Tuesday. These represent the United States’ fourth and eighth highest daily incidence to date, respectively. We expect the reported incidence to increase over the rest of the week, which will likely set new records for national daily incidence. The current daily incidence is more than 30% higher than the country’s first peak on April 10 (7-day average), and there is currently no indication of it slowing. The New York Times analysis indicates that 35 states are reporting increasing incidence over the past 2 weeks, and at least half appear to have set records for daily incidence over that period.

Texas continues to report concerning COVID-19 trends, posting record highs for daily incidence, test positivity, and hospitalized COVID-19 patients over the past several days. Texas is reportedly facing limited testing capacity relative to its current level of transmission. Public testing sites in Dallas and Houston have been forced to close early, by noon or early afternoon, after reaching their daily testing capacity. Travis County—home of Austin, Texas' capital city—recently limited public testing sites to symptomatic individuals only in order to prioritize the use of limited testing capacity. While testing capacity has increased, it is being outpaced by increased community transmission. Without adequate testing capacity, health officials cannot accurately understand the scale of community transmission, which was a major problem early in the US epidemic. The decision last week by Governor Greg Abbott to close bars statewide in an effort to mitigate transmission risk prompted protests by some bar owners and patrons, several of whom threatened to reopen despite the governor’s order. Officials from the Texas Alcoholic Beverage Commission reportedly visited nearly 1,500 businesses statewide over the weekend to verify compliance with the order, and they were forced to suspend the liquor license for several bars that refused to comply.

In light of increasing hospitalizations and test positivity statewide, Ohio Governor Mike DeWine extended several existing statewide health orders through this week, while officials update the state’s recovery plans. The updated plan is scheduled to be published tomorrow. The existing orders apply to a variety of economic sectors, including retail businesses, restaurants, gyms, entertainment, and other services as well as schools, camps, and child care. At the local level, cities continue to implement their own mask mandates. Franklin County—home to Columbus, the state’s capital city—announced that it will support city efforts to mandate mask use, although it will not institute a countywide policy. The county’s decision aims to publicly establish a position by the county health department that can lend support to decisions by city officials.

Kansas Governor Laura Kelly announced that she will issue an executive order mandating mask use statewide. The order will apply to individuals in public spaces where it is not feasible to maintain appropriate physical distancing (eg, 6-foot separation), including stores and restaurants. The order is scheduled to take effect on Friday, July 3, but it has not yet been published. Governor Kelly also issued executive orders to extend some provisions enacted as a result of the COVID-19 epidemic, including temporary extensions for government licensing (including driver’s licenses), tax deadlines, vehicle registration, and other government functions as well as suspension of certain requirements regarding unemployment benefits.

Jacksonville, Florida, also recently implemented mandatory mask usage in public spaces. Like many aspects of the US COVID-19 response, the use of face masks has been heavily politicized by elected officials at all levels of government. Notably, Jacksonville is scheduled to host the 2020 Republican National Convention in August, a major event leading up to the 2020 election in November. It is unclear if or how the mask mandate will impact the convention. The Republican Party previously moved the convention from North Carolina to Jacksonville, reportedly over disagreements with North Carolina state officials regarding social distancing policies and restrictions, including on mass gatherings.

The US CDC reported 2.50 million total cases (44,703 new) and 125,484 deaths (508 new). The CDC reported the United States’ 2 highest daily totals over the past 2 days, and 4 of the top 5 over the past 4 days. In total, 19 states (increase of 1) and New York City reported more than 40,000 total cases, including California and New York City with more than 200,000; New Jersey and New York state with more than 170,000; and Florida, Illinois, and Texas with more than 130,000. Following an overall decrease in daily incidence from mid-April through the end of May, the United States’ national COVID-19 incidence is clearly increasing. The United States’ daily incidence has nearly doubled since June 9, up from 20,338 new cases per day to 38,006 (7-day average).

Following weeks of increasing COVID-19 incidence, hospitalizations, and test positivity, Florida Governor Ron DeSantis issued an executive order reversing some recent efforts to ease social distancing restrictions. Notably, the order, issued on Friday, prohibits on-site consumption of alcohol at bars statewide, which some state officials have blamed for statewide increases in transmission. Florida has reported its 6 highest daily case counts over the past 6 days, including its record of 9,557 on June 26. The Florida Department of Health only reports current COVID-19 hospitalizations (as opposed to providing a longer-term display); however, the Florida Agency for Health Care Administration indicates that 23.2% of the state’s adult intensive care unit (ICU) beds are available as of today, which would rank it #48, ahead of only Rhode Island and Arizona—according to analysis by COVID Exit Strategy. In terms of testing, Florida’s positivity increased from 2% for the week of May 17 to 11.7% last week, and it is currently 15.5%, according to the Johns Hopkins SARS-CoV-2 testing dashboard. Like Texas last week, reinstituting social distancing restrictions represents a major shift for Florida, which implemented restrictions later than many states and began lifting them earlier and more aggressively than many states. While Florida reported promising COVID-19 trends for several weeks, health officials and experts warned that increased social interaction could facilitate increased community transmission. Florida continued to ease social distancing, even in the midst of increasing transmission. Florida’s daily incidence (7-day average) climbed from 584 new cases per day on May 11 to 876 on June 3 (50% increase), when Florida entered Phase 2 of its recovery plan. Notably, testing inherently lags behind infection, on the order of several weeks for COVID-19. From there, Florida’s daily incidence doubled by June 15 and again by June 24—and it is on pace to double again in the next day or so. It could potentially take several weeks before we begin to observe any effects of the newest order on Florida’s COVID-19 epidemic.

Texas and California also closed bars either statewide or in high-risk areas. Some believe that bars can be epicenters of community transmission, particularly among younger individuals.

The US CDC reported 2.37 million total cases (37,667 new) and 121,809 deaths (692 new). This is the United States’ second highest daily incidence to date. The US record was reported on April 7 (43,438 new cases), which may have been elevated as a result of reporting delays over the Easter holiday weekend. The CDC has reported more than 25,000 new cases for 7 consecutive days, and 8 out of the last 9 days. Prior to that, the national daily incidence exceeded 25,000 cases only 3 times between June 1 and June 15. In total, 18 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; California and New York state with more than 175,000; New Jersey with more than 150,000; and Illinois and Texas more than 125,000. Following an overall decrease in daily incidence from mid-April through the end of May, the United States’ national COVID-19 incidence is clearly increasing.

Notably, Arizona is currently reporting higher per capita incidence than Brazil or any European country at the height of its epidemic. Additionally, Maricopa County, home to Phoenix, is reporting higher incidence than New York City boroughs, “even on their worst days.” In addition to COVID-19 incidence, Arizona reported a record high on June 24 for both hospitalized COVID-19 patients (2,453) and COVID-19 patients on mechanical ventilators (415). Arizona is also currently reporting test positivity of 20%, which has steadily increased from 5% for the week of May 10.

As we noted in the Epi Update section above, and in previous COVID-19 briefings, a number of US states are exhibiting concerning trends in terms of COVID-19 incidence, hospitalizations, and testing. In light of increased transmission, some state and local governments are strengthening social distancing policies and slowing plans to relax existing measures. In Palm Beach County, Florida, local elected officials voted unanimously to implement mandatory mask use, but a number of local residents expressed opposition to the policy. Notably, the decision follows several weeks of concerning increases in COVID-19 incidence, with daily incidence nearly tripling since the end of May and the cumulative incidence doubling over that same period. A number of local governments in South Carolina have also implemented mandatory mask policies. This week, South Carolina’s Attorney General weighed in on these orders, confirming that they are valid under the state’s constitution. North Carolina Governor Roy Cooper issued an executive order pausing the state’s recovery plan in Phase 2 for at least 3 more weeks. The order also institutes statewide mandatory mask use in public where appropriate physical distancing (eg, 6-foot separation) is not possible. The order applies for customers and employees of some businesses as well, including retail stores, restaurants, child care facilities, some government agencies, public transportation, healthcare settings, and agricultural and meat processing facilities. Nevada Governor Steve Sisolak also issued an executive order to mandate mask use, following 4 weeks of increasing COVID-19 incidence. The order applies to adults and adolescents aged 9 years and older while in any public space. Notably, the order does not appear to be limited to situations in which it is difficult to maintain physical distancing, with the exception of outdoor activities such as swimming and exercising. Texas Governor Gregg Abbott issued an executive order directing hospitals in several counties to postpone elective services and procedures in order to ensure available hospital capacity for COVID-19 patients. Texas is currently exhibiting significant increases in COVID-19 incidence, as well as increasing numbers of hospitalized COVID-19 patients and increasing test positivity, following efforts to relax social distancing measures across the state. The number of hospitalized COVID-19 patients has more than doubled since June 15. The previous executive order issued by Governor Abbott (June 3) moved Texas into Phase 3 of its recovery plan, including increasing the permissible capacity at many restaurants and other businesses from 25% to 50%. Governor Abbott announced yesterday that Texas will suspend further efforts to relax social distancing and remain in Phase 3 while it attempts to contain the current level of community transmission. Furthermore, Governor Abbott issued another executive order earlier today that re-imposed some social distancing restrictions that were recently relaxed. In particular, the order prohibits dine-in service at bars and requires that any outdoor gatherings of 100 or more people receive approval by local governments. This represents a major shift in Texas' approach to COVID-19, particularly considering that it was one of the earliest and most aggressive states in easing statewide social distancing measures.

The governors of Connecticut, New Jersey, and New York announced a joint travel advisory that will require travelers from states with high SARS-CoV-2 transmission to quarantine upon their arrival. The policy will mandate a 14-day quarantine for anyone arriving in the tri-state area who has recently been in any state with a test positivity greater than 10% or with COVID-19 incidence greater than 10 new cases per 100,000 population—both based on a rolling 7-day average. At the time of the announcement, the policy would apply to 8 states—Alabama, Arkansas, Arizona, Florida, North Carolina, South Carolina, Utah, and Texas. The 14-day period will be measured from the last date the individual was in any of the affected states. These 3 states were among those hit the hardest early in the US COVID-19 epidemic, but they were able to bring their respective epidemics under control and maintain relatively low levels of transmission. They are concerned that travel from areas of high transmission could ignite local outbreaks. Previously, several states imposed restrictions on travelers from the tri-state area, including Florida and neighboring Rhode Island.

The US CDC published updated guidance regarding the risk factors for severe COVID-19 disease and death, which expands the risk groups compared to previous iterations of the guidance. Individuals older than 65 are still among those at the highest risk for severe COVID-19, but recent data indicate that pregnant women may be at increased risk of severe COVID-19 disease, hospitalization, admission to the intensive care unit (ICU), and mechanical ventilation. Among pregnant women, Black and Hispanic women appear to have disproportionately worse health outcomes compared to White women. The CDC’s updated guidance separates risk factors into 3 categories: strong evidence, mixed evidence, and limited evidence. The first category includes risk factors that have strong, consistent evidence of association with severe disease. The second and third categories include risk factors for which there is emerging or incomplete, but compelling, evidence of association with severe disease. The strong evidence category includes serious heart conditions, chronic kidney disease, obesity, and Type 2 diabetes. The mixed category includes asthma, hypertension, pregnancy, and history of smoking. Finally, the limited evidence category includes HIV/AIDS, other immunodeficiencies, liver disease, and Type 1 diabetes.

The US CDC reported 2.30 million total cases (26,643 new) and 120,333 deaths (410 new). In total, 18 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; California and New York state with more than 175,000; New Jersey with more than 150,000; and Illinois with more than 125,000. Following an overall decrease in daily incidence from mid-April through the end of May, the United States’ national COVID-19 incidence is clearly increasing. Typically, early week reporting by the CDC is lower due to reporting delays over the weekend; however, even those troughs this week are elevated compared to the peak day from the week of June 7-13.

US President Donald Trump issued an executive order that extends restrictions on several classes of visas through the end of 2020. The order will reportedly not affect individuals who have already received visas or seasonal farm workers, and there are exceptions for certain professions, including coronavirus researchers. It is not clear, however, if the renewal process will be impacted. The order to restrict visas will apply to the following categories: (1) H1-B visas, which allow workers with advanced degrees to be hired into positions with specialist skill sets; (2) H2-B visas, which apply primarily to seasonal workers in industries such as agriculture, food processing, hospitality, and healthcare; (3) J-1 visas, which are used by many university students to complete their education at US universities; and (4) L visas for individuals in managerial positions often employed by multinational companies. The administration justified the decision as a mechanism to improve job opportunities for Americans and mitigate the severe economic impacts from the COVID-19 pandemic. The announcement garnered criticism by those who accuse the administration of exploiting the pandemic to advance an agenda of restricting immigration and by companies that rely on these visas to bring specialized workers to the United States.

The US Department of Homeland Security developed a process for people to “decontaminate” personal protective equipment (PPE), including N95 respirators and masks, at home using only a fairly common kitchen appliance, a programmable multicooker or pressure cooker. Multicookers, such as the Instant Pot, have gained popularity in the United States and elsewhere in recent years. In light of the limited supply of various types of PPE, scientists at DHS developed a process that would enable people to clean their PPE at home so it can be reused safely. Multicookers enable users to generate moist heat, which has been identified by the US CDC as an effective method for killing the SARS-CoV-2 virus. The instructions—and accompanying video—direct users to place water in the multicooker and insert a wire rack (to prevent the respirator from sitting in the water). The respirator (up to 3 at a time) should be placed inside a paper bag and set on the rack, and the unit should be set at 149°F (65°C) for 30 minutes. Once the cycle is complete, users should remove the bag and open it for 1 hour to allow the respirators to cool and dry.

The US CDC reported 2.25 million total cases (32,411 new) and 119,615 deaths (560 new). Additionally, the CDC reported 32,218 new cases the previous day. These represent the 2 highest daily totals for the United States since April 25 and the sixth and seventh highest daily incidence to date. In total, 18 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New York state with more than 175,000; California and New Jersey with more than 150,000; and Illinois with more than 125,000. Following an overall decrease in daily incidence from mid-April through the end of May, the United States’ national COVID-19 burden has increased since early June, approximately several weeks after states began to relax social distancing measures.

As numerous states report continued increases in COVID-19 incidence, some state and local officials are moving to require citizens to wear masks. Washington Governor Jay Inslee announced over the weekend that he intends to issue a proclamation mandating mask use in public in Yakima County, which is experiencing increased community transmission, making the current local order enforceable. According to The Seattle Times, more than 20% of Washington’s cases and 22% of its COVID-19-related hospitalizations can be attributed to Yakima County, despite it only accounting for only 4% of the state’s total population. Similar situations are occurring in other states as well. Oregon Governor Kate Brown announced last Wednesday mandatory mask use would be implemented in 7 counties that make up the majority of Oregon’s COVID-19 burden. Additionally, other counties could opt in to the mandate. In North Carolina, multiple local jurisdictions have implemented mandatory mask use, and Governor Roy Cooper announced that a prospective proposal this week could mandate mask use statewide. Not all states, however, are enforcing mask use. Notably, Florida Governor Ron DeSantis—despite acknowledging that increased community transmission, and not increased testing, is driving the state’s increased COVID-19 incidence—continues to refrain from mandating mask use. According to CNN, at least 15 states have put statewide mask requirements in places as of Friday evening. A report by CNN indicates that the CDC may issue updated mask guidance in the near future; however, it is unclear what the update would include or when it would be released.

The US CDC reported 2.16 million total cases (22,834 new) and 117,632 deaths (754 new). In total, 18 states (increase of 2) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; California, New Jersey, and New York state with more than 150,000; and Illinois with more than 125,000. Following an overall decrease in daily incidence from mid-April through the end of May, the United States’ national COVID-19 incidence appears to be increasing since early June, several weeks after states began to relax social distancing measures.

Following a recent surge in reported COVID-19 incidence in Arizona—along with increases in COVID-19 hospitalizations, test positivity, and other indicators—Governor Doug Ducey issued an executive order to enhance the state’s response and strengthen social distancing measures. Arizona aims to strengthen testing and contact tracing capacity, including mobilizing the Arizona National Guard. Arizona also published specific requirements for restaurants and other businesses to implement additional protective measures, including ensuring appropriate physical distancing (eg, 6-foot separation), mandating symptom monitoring and mask use for employees, and limiting groups or gatherings to no more than 10 people. The new guidance for restaurants and other businesses provides more detailed instruction than previous versions, including some new requirements. With respect to mask use, restaurant employees who interact with customers are now required to wear masks, and other businesses are directed to require employees to wear masks “when possible.” Previously, guidance for some businesses, such as retail stores, did not mention mask use at all. Governor Ducey’s previous executive order included a provision that prohibited local governments from implementing any measures that conflicted with or were more restrictive than those mandated by the state. Notably, the new executive order permits local governments to implement their own policies or requirements regarding mask use based on their local situation. Numerous mayors across Arizona coordinated to call on Governor Ducey to allow more flexibility and authority at the local level to address COVID-19 risk, and several local governments have reportedly already indicated that they intend to mandate mask use to mitigate transmission risk in their communities. Arizona is one of a number of states reporting increased COVID-19 incidence over the past several weeks, and it is among the first to implement additional restrictions in response to increased community transmission.

Yesterday, California updated its COVID-19 policies to mandate mask use statewide for environments in which it may not be possible to maintain proper physical distancing (eg, 6-foot separation). The new guidance states that masks must be worn in places such as indoor public spaces (or waiting in line to enter), healthcare settings, public transportation or ride-sharing vehicles (drivers and passengers), workplaces where there is interaction with the public, food preparation areas, and other public spaces where it is not feasible to maintain physical distancing. California includes exceptions for children aged 2 years and younger, those with medical conditions that preclude them from safely wearing a mask, communicating with someone who reads lips, eating and drinking, and outdoor recreation where proper physical distancing can be maintained.

The US CDC reported 2.10 million total cases (18,577 new) and 116,140 deaths (496 new). In total, 16 states (increase of 2) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New Jersey and New York state with more than 150,000; and California and Illinois with more than 125,000. Recent COVID-19 incidence reports by the CDC appear to be slightly higher than in previous weeks. Considering the variation from day to day, it is difficult to determine if this is the beginning of a national-level trend or if it is simply an anomaly. A recent publication by the CDC’s COVID-19 Emergency Response team, in its Morbidity and Mortality Weekly Report, presents analysis of the COVID-19 incidence through May 30. The analysis indicates that the 7-day average incidence decreased from the first peak in early April through the end of May. It appears that the 7-day average has increased since that date, but it is difficult to determine if it will continue to increase further. A number of US states are reporting increased daily COVID-19 incidence, but most are also reporting increased testing, which could potentially be responsible for a proportion of the increase in reported cases. As part of its analysis, ProPublica compiles state-level test positivity rates and indicates whether each is currently increasing, decreasing, or holding steady. In total, at least 15 states are reporting increasing test positivity (out of 47 states with available data). Among these states, 2 states, Alabama and Arizona, are reporting positive results in more than 10% of all tests, and an additional 5 states—Arkansas, Florida, Mississippi, South Dakota, and Texas—are reporting test positivity greater than 5% (the benchmark recommended by the WHO). Three (3) states—Louisiana, North Carolina, and Utah—are reporting steady test positivity greater than 5%. Another expert analysis shows 20 states with increasing test positivity (out of 50), including 3 states greater than 10%—Alabama, Arizona, and South Carolina—and another 7 greater than 5%.

Some states and cities are taking notice of recent increases in COVID-19 incidence and have begun slowing efforts to ease social distancing restrictions. Other states, however, continue on their intended course, despite increased incidence, hospitalizations, or test positivity. At the state level, the governors of Utah and Oregon recently announced that increased transmission would slow progress statewide in terms of easing social distancing restrictions. Health officials and experts nationwide continue to emphasize that the pandemic is not over or under control in the United States, and they highlight the risk of complacency among the general public. Several governors have acknowledged the increasing COVID-19 incidence and associated risk, but note that this will not affect existing plans or timelines to relax statewide social distancing policies. Arkansas Governor Asa Hutchinson stated, “Regardless of what we see in the next week, we made the right decision to...lift some of these restrictions so we don’t cause more damage to people’s lives and their livelihood.” Arkansas’ COVID-19 incidence, hospitalizations, and active cases have all doubled (or more) since Memorial Day Weekend (May 25), and the statewide test positivity increased since that time as well. Similarly, Florida Governor Ron DeSantis stated that the state would not be “rolling back” recent efforts to relax social distancing as a result of recent increases in COVID-19 incidence, citing the need to maintain a functioning society. Rather, Florida continues forward with its recovery plan, including permitting major amusement parks such as Universal Studios and Disney to reopen, while reporting record daily COVID-19 incidence. Florida’s daily incidence has increased from fewer than 1,000 new cases per day on June 1 to 2,800 on June 15.

The US FDA revoked an Emergency Use Authorization for hydroxychloroquine and chloroquine. The EUA for both drugs was issued last month, but recent studies have not provided sufficient evidence that the drugs provide treatment benefit. Additionally, several studies have found that the drugs are associated with increased risk of cardiac arrest and other serious adverse events. The WHO recently suspended clinical trials of the drugs in order to evaluate the available data, but they soon resumed these studies. The decision has larger implications for the United States’ continued COVID-19 response. Following early pressure from US political leaders, a number of states invested significant resources in building stockpiles of hydroxychloroquine.

The US CDC reported 2.06 million total cases (24,468 new) and 115,271 deaths (646 new). The United States surpassed 2 million cases in Friday’s, and the overall trend in daily incidence appears to have plateaued over the past several weeks. In total, 16 states (increase of 2) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New Jersey and New York state with more than 150,000; and California and Illinois with more than 125,000.

On Friday, the US CDC hosted its first COVID-19 briefing in several months. US CDC Director Dr. Robert Redfield and COVID-19 Incident Manager Dr. Jay Butler discussed the US COVID-19 response as well as a recent publication on the public’s perception of social distancing orders. They cautioned that the US COVID-19 epidemic is not over and that continued vigilance and adherence to recommended preventive measures are necessary to mitigate the risk of increased transmission as social distancing measures are relaxed. The study, published in the CDC’s Morbidity and Mortality Weekly Report, surveyed US households—with a particular focus on New York and Los Angeles—to better understand perceptions of “stay at home” orders and other social distancing restrictions as well as the public’s adherence to those orders. The researchers found that the public generally agreed with the restrictions and believed they struck an appropriate balance between permitting necessary activities and reducing transmission risk. The survey respondents also reported high levels of compliance with the orders. On Friday, the CDC also published updated guidance to help the general public mitigate transmission risk as they begin to resume social activities. One document aids in making informed decisions regarding going out or engaging in social activities, and the other assists with planning events and other gatherings.

On Friday, the US CDC updated its SARS-CoV-2 testing guidance, publishing a consolidated testing strategy that includes high-risk populations and critical infrastructure sectors. The new guidance brings together numerous existing and updated guidance documents related to SARS-CoV-2 testing and provides a common location from which to access testing recommendations. Notably, the document addresses both diagnostic tests and serological tests, and the document provides links to specific guidance for a variety of purposes and in a variety of populations and individuals. These include diagnostic and clinical purposes for individuals exhibiting symptoms, asymptomatic individuals with and without known exposures, and decisions regarding patient discharge or ending isolation as well as public health surveillance. Special instructions are provided for high-risk settings, such as long-term care facilities and correctional facilities, and critical infrastructure workplace settings following the identification of a confirmed or suspected case.

The US CDC reported 1.99 million total cases (20,486 new) and 112,967 deaths (834 new). The United States will likely surpass 2 million cases in today’s update. In total, 14 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New Jersey and New York state with more than 150,000; and California and Illinois with more than 125,000.

As we have noted recently, a number of US states are exhibiting increasing COVID-19 incidence and hospitalizations, several weeks after initiating efforts to relax social distancing restrictions. We have covered several of these states already this week, including Arizona, California, and Texas (hospitalizations and testing). Other states of note include Alabama, Alaska, Florida, North Carolina, South Carolina, and Vermont. A number of these states reported their highest daily incidence and/or highest current COVID-19 hospitalizations over the past several days. While Alaska still has relatively few cumulative reported cases, its daily incidence has returned to a similar level as its “first wave” of cases, and modeling indicates that its epidemic is currently exhibiting exponential growth. In addition to increasing incidence, several of these states are also reporting increasing COVID-19 hospitalizations or increasing or elevated test positivity, which suggests that increased testing may not wholly account for the increased incidence. Increased incidence is not necessarily distributed evenly across these states. Multiple outbreaks in different locations—including congregate settings such as nursing homes, meat packing facilities, and prisons or jails—are contributing substantially to these totals in numerous states. Many of these states were not hit particularly hard early in the US COVID-19 epidemic, but they are now exhibiting increasing incidence that corresponds temporally with decisions several weeks ago to relax social distancing and permit increased social interaction. It is still a little early to identify any increased transmission related to Memorial Day holiday gatherings or protests against racial and social injustice in the United States or other countries.

The US Department of Labor published its weekly report on unemployment claims, which yielded mixed results. On the positive side, the number of new unemployment claims fell last week, down more than 350,000 compared to the previous week. Additionally, the total number of active unemployment claims decreased by 339,000 compared to the previous week, and the national unemployment rate decreased from 14.4% to 14.2%. These figures indicate that some Americans are beginning to return to work. That being said, Americans still filed more than 1.5 million new unemployment claims last week, and 20.9 million unemployment claims remained active nationwide, indicating that many Americans continue to struggle with employment, even as states relax social distancing and economic activity increases. Additionally, the US Federal Reserve announced that it intends to keep interest rates low, potentially through 2021, in order to promote economic recovery, and it forecast a 6.5% decline in the national gross domestic product by the end of 2020.

The US CDC reported 1.96 million total cases (17,598 new) and 110,925 deaths (550 new). The United States could potentially surpass 2 million cases in the next 2-3 days. In total, 14 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New Jersey and New York state with more than 150,000; and California and Illinois with more than 125,000.

Arizona has reported significant increases in daily incidence over the past 2 weeks, and now state health officials are directing health systems to anticipate a surge in COVID-19 patients. On June 6, the Director of Arizona’s Department of Health Services, Dr. Cara Christ, reportedly distributed a letter to hospitals across the state that urged them to “fully activate” their emergency response plans. This would likely include activating hospital incident command systems, preparing to implement crisis standards of care, suspending elective medical procedures, and expanding intensive care unit (ICU) bed capacity. The number of hospital, emergency department (ED), and ICU beds in use statewide has increased steadily since mid-April, and the number of mechanical ventilators in use has increased since at least late March. Dr. Christ emphasized that “COVID-19 is widespread and still circulating” in Arizona, even though the state is relaxing social distancing and resuming normal activities.

Texas reported record numbers for COVID-19 hospitalizations this week, as efforts continue to relax social distancing. In addition to elevated daily incidence, Texas reported 5 of its 6 highest daily totals for COVID-19 hospitalizations over the past 5 days, including its first day with more than 2,000 hospitalized COVID-19 patients. Texas’ test positivity is also increasing, up from a low of 4.27% on May 26 to 7.55% on June 6 (currently 6.66%). On June 3, Texas Governor Greg Abbott announced that the state would move into Phase 3 of its recovery plan, which allows businesses to increase to 50% of their normal capacity. In the announcement, Governor Abbott stated that the increased transmission was a “result of isolated hot spots in nursing homes, jails, and meat packing plants” rather than broader increases in community transmission. Governor Abbott also stated that 1,457 COVID-19 patients were hospitalized at that time, but this comment is inconsistent with data reported by the Texas Department of State Health Services, which indicates nearly 1,800 hospitalizations on that date.

The US CDC reported 1.92 million total cases (29,214 new) and 109,901 deaths (709 new). Over the weekend, the United States reported its 2 highest daily totals since May 16, and the United States could potentially surpass 2 million cases in the next 3-5 days. In total, 14 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New Jersey and New York state with more than 150,000; and California and Illinois with more than 125,000.

New York continues to exhibit encouraging progress in containing COVID-19. In its most recent update, the statewide test positivity was 1.3%. In New York City it was 1.8%. New York reported 781 new cases statewide, its lowest daily total since March 17, and New York City reported 56 new cases, it lowest since March 14. Florida continues to report elevated and increasing daily incidence. In fact, its 7-day average is approximately equal to its peak in early April and is still increasing. Georgia appears to have passed a second peak in mid-May; however, its recent incidence data, which may not yet be complete, already indicate another increase in the 7-day average. California’s daily incidence continues to increase, with 3 of its 5 highest daily totals reported in the last 3 days. While the number of tests conducted in Utah is holding steady or possibly decreasing slightly, the COVID-19 incidence has increased dramatically over the past 2 weeks, up from 150-200 new cases per day to 447 and 547 new cases on June 4 and 5, respectively. Arizona continues to report increasing COVID-19 incidence as well. Arizona reports its cases by specimen collection date (which means that data from the past 7 days may be incomplete) and it reported its 2 highest daily totals on June 1 and 2, both more than 1,000 new cases per day. Arizona’s daily incidence has more than doubled since early May.

The US government is coordinating with Gilead Sciences to facilitate increased production and distribution of remdesivir, the only drug that has been demonstrated to provide treatment benefit for COVID-19 patients in a randomized clinical trial. Gilead previously donated its available remdesivir inventory to the US government; however, this supply is expected to be exhausted by the end of June. Gilead is working to increase production capacity, with material support from the US government; however, the next delivery may not be available until July or August. The US Department of Health and Human Services Assistant Secretary for Preparedness and Response, Dr. Robert Kadlec, expressed confidence that additional remdesivir will be available this summer and that production will increase substantially into the fall and beyond. It is unclear at this point how much Gilead will charge for subsequent shipments, and the incredibly high demand—as the only available treatment with demonstrated efficacy—has raised concerns about the potential that the drug could be expensive.

The US CDC reported 1.84 million total cases (14,676 new) and 107,029 deaths (827 new). The United States could potentially surpass 2 million cases in the next 7-10 days. In total, 14 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New Jersey and New York state with more than 150,000; and California, Illinois, and Massachusetts with more than 100,000.

As Florida looks ahead to further easing social distancing measures, with most of the state entering Phase 2 of Florida’s recovery plan today, the state reported its highest daily incidence to date. The Florida Department of Health reported 1,419* new cases, surpassing the previous high of 1,413 on April 17. Additionally, Florida reported 1,317 new cases the previous day, which appears to be the state’s fourth-highest daily total. Florida reported decreasing daily incidence from early April through early-to-mid May, but incidence has been increasing over the past several weeks.

As a result of the disproportionate impact of the COVID-19 epidemic on racial and ethnic minorities in the United States, the US Department of Health and Human Services issued new COVID-19 laboratory reporting requirements that include direction for key demographic data such as race, ethnicity, age, and sex. These enhanced reporting requirements aim to better capture COVID-19 risk disparities among racial and ethnic communities. This move comes amid increased focus on disparities in justice and health in the US, which motivated widespread protests currently underway.

The US CDC reported 1.80 million total cases (14,790 new) and 105,157 deaths (761 new). The United States could potentially surpass 2 million cases in the next 10-14 days. The CDC updated its jurisdiction-level reporting table, which now includes total, confirmed, and probable values for both cases and deaths; however, not all states have data available for confirmed and probable values. In total, 14 states (increase of 1) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New Jersey and New York state with more than 150,000; and California, Illinois, and Massachusetts with more than 100,000.

Alabama is reporting several notable trends in addition to increasing daily incidence since late April, which more than doubled over that period. Some of this increase is likely associated with increased testing; however, Alabama has also reported increasing test positivity over the past 2 weeks, even as testing capacity increases. After declining from a high of 12.8% in mid-April to 9.0% in early May, test positivity was back up to 12.2% for the week of May 17-23. This potentially indicates a relative increase in community transmission and that the testing capacity may not be sufficient. Alabama is reporting a slight increase in hospitalized COVID-19 cases since mid-to-late April.

After a period of declining daily incidence, Georgia is exhibiting an increase. The Georgia Department of Public Health appears to report COVID-19 data by testing date, so data within the past 14 days are likely incomplete. Looking at data prior to that 14-day window, however, Georgia’s daily incidence fell from a high of 766.4 new cases per day (7-day moving average) on April 22 to 520.5 new cases on May 9. Georgia’s incidence climbed again to 704.0 new cases on May 19, which is the most recent day outside the 14-day window. Analysis by The New York Times displays Georgia’s incidence by report date, and it shows an overall decline in cases from mid-April through mid-May, but it is difficult to determine a longer-term trend for data after that point. Additionally, numerous counties in Georgia that previously reported flat or declining incidence are now reporting increases.

The US Centers for Medicare and Medicaid Services (CMS) and CDC published a report outlining the toll of COVID-19 on nursing homes in the United States. According to the report, more than 25,000 nursing home residents and 400 staff have died so far as a result of the US COVID-19 epidemic. In total, nursing homes and other long-term care facilities reported more than 60,000 infections in residents and 34,000 infections in staff. The report shows the immense impact that COVID-19 has had on these facilities, with 20% of them reporting at least 1 COVID-19 death. Findings from the report have been widely covered in the US media, but the report itself is not expected to be publicly available until tomorrow, June 4.

The US CDC reported 1.76 million total cases (23,553 new) and 103,700 deaths (915 new). Daily COVID-19 deaths in the United States continue to decline overall, but the total reached 100,000 deaths recently. The CDC separated New York City from New York state in its table of jurisdiction-level COVID-19 incidence and deaths. In total, 13 states (no change) and New York City reported more than 40,000 cases, including New York City with nearly 200,000; New Jersey and New York with more than 150,000; and Illinois and California with more than 100,000.

On Friday, US President Donald Trump announced that he intends to direct the United States’ withdrawal from the WHO over concerns regarding the WHO’s handling of the COVID-19 pandemic and its relationship with China. President Trump previously called for the WHO to implement systemic reforms and suspended US government funding for the WHO, aimed in part to curtail China’s influence. The process for withdrawing from the WHO is unclear, as is the President’s authority to direct such an action. President Trump indicated that the United States will redirect the funding intended for the WHO to other global health initiatives, but the US government may be obligated to pay its outstanding dues first. Numerous health and elected officials and health experts condemned the announcement, emphasizing that it could hinder global response efforts to the COVID-19 pandemic, potentially including ongoing clinical trials for vaccines and therapeutics against SARS-CoV-2, as well as other major health threats. While a thorough and transparent review of the WHO’s COVID-19 response is widely supported, terminating the US relationship with the WHO in the midst of a pandemic could be dangerous.

The US CDC COVID-19 Response Team, in collaboration with researchers and health officials from California, Illinois, New York, and Washington, published findings from a study on early SARS-CoV-2 transmission in the United States. The study, published in the US CDC’s Morbidity and Mortality Weekly Report, indicates that limited community transmission of SARS-CoV-2 in the United States may have begun as early as January, based on a variety of disease surveillance data as well as genetic analysis and retrospective case investigations. This would place community transmission in the United States weeks earlier than the first identified domestic transmission, reported in late February in California. Diagnostic testing on postmortem specimens identified 2 unrelated cases in California, one who developed symptoms on January 31 and another who “died at home between February 13 and 17.” Genomic sequence data suggest that early community transmission could be linked to travelers who arrived from Wuhan, China, or passengers or crew members from a cruise ship that departed from San Francisco, and subsequent introductions arrived via Europe. Dr. Jay Butler, US CDC Deputy Director for Infectious Diseases, further noted in a media briefing that there was no evidence for widespread transmission earlier than late January, dispelling speculation that the virus could have been circulating in the US in December of last year. CDC Director Dr. Robert Redfield stated that the findings indicate that the delayed rollout of SARS-CoV-2 testing did not negatively impact the speed of the US response, because even expanded testing would have been unlikely to have detected such limited transmission; however, some experts have disagreed.

The US CDC reported 1.70 million total cases (19,680 new) and 100,446 deaths (1,415 new). Daily COVID-19 deaths in the United States continue to decline overall, but the total reached 100,000 deaths in yesterday’s update. The CDC separated New York City from New York state in its table of jurisdiction-level COVID-19 incidence and deaths. In total, 13 states (1 new) and New York City reported more than 40,000 cases, including New York City with more than 200,000; New Jersey and New York with more than 150,000; and Illinois with more than 100,000.

New York Governor Andrew Cuomo issued an executive order stating that businesses have the right to refuse entry to anyone not wearing a mask. A previous executive order mandated mask use in public by all individuals aged 2 years and older for situations in which it is not possible to maintain appropriate physical distancing (ie, 6-foot radius), with exceptions for those with medical conditions that would prevent safe mask use. The new order follows New York City’s slow decline in COVID-19 incidence after weeks of social distancing and mask use. Enforcement of mask use has become a flashpoint for some, but there is evidence to suggest that masks can mitigate the risk of secondary transmission. For example, one study of 124 households in Beijing reported that mask use by COVID-19 cases and other household contacts was highly effective at preventing secondary transmission, particularly when worn prior to the onset of symptoms. Enhanced cleaning and hygiene practices were also observed to decrease secondary transmission among household contacts. While this study has been met with criticism, including for its study methodology and interpretation of the results, a reduction in household clusters would have a meaningful impact on the pandemic writ large. If more evidence emerges that mask use in the home setting reduces these clusters, new changes in behavior within the home may be warranted.

The US Department of Labor published its weekly report on unemployment claims, and more than 25% of the US workforce has filed for unemployment over the past 10 weeks, more than 40 million people in total. New unemployment claims continue to decrease from the weekly high of nearly 7 million in mid-March, down to 2.1 million in the most recent report. The current national unemployment rate is estimated to be 14.5%, representing more than 21 million people nationwide. The unemployment rate varies by state, but 6 states exceeded 20%—California, Florida, Hawai’i, Michigan, Nevada, and Washington. A survey conducted by the US Federal Reserve found that employment continues to decrease nationwide, most notably in the retail, leisure, and hospitality sectors, which have hit particularly hard by social distancing and travel restrictions. Concerns about worker safety and child care availability, along with expanded unemployment benefits implemented in response to the COVID-19 epidemic, are hindering efforts to bring workers back. The COVID-19 pandemic continues to exert historical pressure on the US and global economies. At this point, all US states have started relaxing social distancing restrictions, including those on restaurants, retail stores, and other businesses, but the degree to which Americans will resume normal activities, including work, remains to be seen.

The US CDC reported 1.66 million total cases (24,958 new) and 98,261 deaths (592 new). Daily COVID-19 deaths in the United States are generally on the decline, but the total could potentially reach 100,000 deaths by tomorrow’s update. In total, 12 states (no change) reported more than 40,000 cases, including New York with more than 350,000; New Jersey with more than 150,000; and Illinois with more than 100,000.

The US CDC reported 1.63 million total cases (15,342 new) and 97,669 deaths (620 new). Daily COVID-19 deaths in the United States are generally on the decline, but the total could potentially reach 100,000 deaths in the coming days. In total, 12 states (increase of 2) reported more than 40,000 cases, including New York with more than 350,000; New Jersey with more than 150,000; and Illinois with more than 100,000.

In response to the recent acceleration of Brazil’s COVID-19 epidemic, US President Donald Trump imposed travel restrictions on Brazil. The order restricts entry for arriving travelers with travel to Brazil in the past 14 days. Brazil is emerging as a COVID-19 hot spot, and it is now #2 in the world, behind the United States, in terms of cumulative and daily COVID-19 incidence. Brazilian President Jair Bolsonaro has repeatedly downplayed the severity of the country’s epidemic, despite the accelerating incidence. President Bolsonaro continues to promote increased economic activity and clash with local governors regarding social distancing measures while health systems struggle to meet COVID-19 demand. Brazil’s last two Ministers of Health have either been terminated or resigned, in the span of several weeks, which may have resulted from conflicts with President Bolsonaro regarding the national COVID-19 response.

The US Department of Health and Human Services delivered an 81-page testing strategy to the US Congress. The report, COVID-19 Strategic Testing Plan, outlines the national-level strategy for SARS-CoV-2 testing and testing goals for each state, including a recommendation to test at least 2% of their population by the end of June. This document outlines a state-by-state approach to COVID-19 testing, rather than a centralized national effort. The report cites the availability of a supply of accurate COVID-19 tests that is large enough to contain the national epidemic, although some Democratic leaders and public health and healthcare experts have questioned if the existing capacity is sufficient. The testing strategy has drawn some criticism for placing the responsibility for testing on state governments rather than providing centralized federal coordination, which could result in states competing against each other for limited resources. Other public health experts have applauded the positive steps taken under this strategy, including a decision to allow storage of test kits by the Strategic National Stockpile and federal efforts to distribute critical testing supplies (e.g., swabs and viral transport media), which has helped increase national testing capacity. Testing will be critical as states continue efforts to relax social distancing restrictions and resume business operations and social events.

The US CDC reported 1.55 million total cases (22,860 new) and 93,061 deaths (1,397 new). Daily COVID-19 deaths in the United States are generally on the decline, but the total could potentially reach 100,000 deaths in the next 6-7 days. In total, 10 states (no change) reported more than 40,000 cases, including New York with more than 350,000; New Jersey with more than 150,000; and Illinois with more than 100,000.

The US CDC updated its website on SARS-CoV-2 transmission, adjusting the language regarding the relative role of various routes of transmission. Multiple news media outlets reported on the change yesterday; however, it appears that the changes began sometime early last week. Notably, the CDC website currently indicates that it was last reviewed on April 13, despite changes being made more recently. The most substantial change is the language used to describe the role of transmission via fomites—ie, contaminated objects or surfaces. Both the current and previous iteration of the CDC information state, “It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it.” Additionally, both versions of the guidance note that fomites are “not thought to be the main way the virus spreads.” The updated guidance takes this a step further, however, explicitly stating that “the virus does not spread easily” via fomites. It does not appear that the CDC made an official announcement regarding the update, but a recent statement by a CDC spokesperson indicates that the changes do not reflect meaningful change in the CDC’s position or understanding regarding SARS-CoV-2 transmission. Practically speaking, the changes should have little effect on current recommended protective measures, such as improved hygiene (eg, hand washing) and disinfection practices.

The US CDC reported 1.53 million total cases (23,405 new) and 91,664 deaths (1,324 new). Daily COVID-19 deaths in the United States are declining, but the total could potentially reach 100,000 deaths in the next 6-8 days. In total, 10 states (no change) reported more than 40,000 cases, including New York with more than 350,000; New Jersey with more than 125,000; and California, Illinois, and Massachusetts with more than 75,000.

The US government awarded a 4-year, US$354 million contract to a startup pharmaceutical company to establish and operate domestic production capacity for various generic drugs and active pharmaceutical ingredients (APIs). The contract, awarded through the Biomedical Advanced Research and Development Authority to Phlow Corp., aims to shift production of critical pharmaceuticals back to the United States in order to reduce reliance on foreign production and build a domestic inventory of APIs and surge production capacity for future emergencies. Many generic drugs and APIs used in the United States are currently produced overseas, particularly in China and India, and the COVID-19 pandemic has highlighted the vulnerability of these supply chains to major global health emergencies. The contract could be extended for up to a total of 10 years and $812 million. In another effort to streamline the domestic medical supply chain, the US Department of Health and Human Services is considering a program to implement a centralized public-private management infrastructure for the Strategic National Stockpile (SNS). The Office of the Assistant Secretary for Preparedness and Response posted a request for information to solicit public input regarding the program’s “strategy and structure” and the role of public-private partnerships in managing the SNS. The program, referred to as NextGen SNS, looks to streamline procurement, inventory management, and distribution of critical stockpiles supplies and equipment during health emergencies, which have been identified as barriers to the US COVID-19 response.

The US CDC reported 1.50 million total cases (24,481 new) and 90,340 deaths (933 new). Daily COVID-19 deaths in the United States are on the decline, but the total could potentially reach 100,000 deaths in the next 7-10 days. In total, 10 states (1 new) reported more than 40,000 cases, including New York with more than 325,000; New Jersey with more than 125,000; and California, Illinois, and Massachusetts with more than 75,000.

Alabama continues to exhibit increasing daily incidence after beginning to relax social distancing measures on May 1. Following a brief period of relatively level or decreasing incidence in mid-to-late April (approximately April 9-28), Alabama’s reported incidence has increased substantially over the past several weeks. The 14-day average increased from fewer than 200 new cases per day on April 29 to more than 300 yesterday, and the states 399 new cases yesterday, its highest daily incidence to date. Alabama’s COVID-19 hospitalizations are also increasing, up from 515 patients on April 6 to a high of 706 on May 18. Notably, Alabama’s test positivity increased from 6.6% for the week of March 28 to 9.8-9.9% through most of April before falling to 7.0% for the week of May 9. According to the Johns Hopkins COVID-19 Testing Insights Initiative, which utilizes data compiled by the COVID Tracking Project, Alabama appears to have increased testing since March, which would likely contribute to increasing reported incidence. Alabama ranks #27 among states with respect to per capita testing—3,215 tests performed per 100,000 population.

The US CDC published new guidance to support states’ efforts to relax social distancing measures implemented in response to COVID-19. The guidance—CDC Activities and Initiatives Supporting the COVID-19 Response and the President’s Plan for Opening America Up Again—includes both “gating criteria” and recommendations for each of 3 phases. The gating criteria address daily COVID-19 incidence; health system capacity, including emergency department (ED) and outpatient volume for COVID- and influenza-like illnesses as well as inpatient and intensive care unit (ICU) capacity; and SARS-CoV-2 testing, including capacity and test positivity. The CDC also includes a variety of metrics, tools, and guidance to support states’ efforts to properly collect and analyze data needed to evaluate trends and thresholds related to these criteria. Additionally, the document provides “setting specific guidance” for schools and child care, high-risk individuals in the workplace, restaurants and bars, and public transit, which appears to provide more detailed information to supplement similar guidance published last week. This most recent guidance is dated May 2020, but it is unclear exactly when the CDC published it. Multiple media outlets began reporting on its release late yesterday evening, but the CDC does not appear to have made a formal announcement coinciding with its release. We have not identified any archived versions of the document before today. The new guidance comes at a time when all 50 states have already started to relax social distancing measures, a number of which do not appear to have met the recommended gating criteria outlined in the document.

The US CDC reported 1.48 million total cases (13,284 new) and 88,709 deaths (698 new). A day after reporting its highest daily incidence since April 25, the CDC reported the lowest daily total since March 24. Monday and Tuesday updates are typically low due to reporting delays over the weekend, but yesterday was the fourth consecutive Monday with decreasing incidence compared to the previous week. After such a low incidence reported yesterday, the United States may not reach 1.5 million cases until Wednesday’s update. In total, 9 states (no change) reported more than 40,000 cases, including New York with more than 325,000; New Jersey with more than 125,000; and California, Illinois, and Massachusetts with more than 75,000. The CDC removed information about the degree of transmission reported in each state from its COVID-19 data website.

The Navajo Nation (US) has surpassed New York and New Jersey in terms of per capita COVID-19 incidence. With 4,278 reported cases, the Navajo have an incidence of nearly 2,500 cases per 100,000 population, compared to approximately 1,670 and 1,800 cases per 100,000 in New Jersey and New York, respectively. Native American tribes face a number of barriers that can put them at elevated risk for COVID-19 and other diseases. In this case, multiple generations of family members often live together, which can facilitate transmission in the home, and limited options for groceries and other supplies can increase the number of people at certain stores such as supermarkets. The Navajo Nation has implemented a robust testing program that has reached more than 10% of the population already, which could be contributing to the elevated COVID-19 incidence; however, the test positivity is approximately 16%, which indicates that increased testing may be needed to better capture ongoing community transmission. Racial and ethnic minority populations have been disproportionately affected by the US COVID-19 epidemic, and additional effort is needed to provide essential services and support, including access to testing and health care, to mitigate the increased risk in these populations.

California Governor Gavin Newsom announced an update to California’s plan that could potentially allow counties to move more quickly in their efforts to relax social distancing. Perhaps the most substantial change lies in updated epidemiological criteria for moving into State 2. Previously, counties were required to report “no more than 1 COVID-19 case per 10,000” population over the previous 2 weeks and no COVID-19 deaths over that same period. The updated requirements shift away from COVID-19 incidence and focus more on the impacts to healthcare systems. The new criteria require counties to have “stable/decreasing” COVID-19 hospitalizations—ie, less than a 5% daily increase—or no more than 20 total hospitalized COVID-19 patients over the previous 2 weeks. Additionally, counties must report fewer than 25 new cases per 100,000 population over a 2-week period or testing positivity below 8% over 1 week.

In Texas, which has also moved into its second phase of relaxing social distancing, some parts of the state, including El Paso, will reportedly face a delayed timeline. Texas Governor Greg Abbott announced that the delay was in response to an elevated burden on local health systems that did not provide sufficient surge capacity in the event of increased SARS-CoV-2 transmission. Currently, these counties are scheduled to enter Phase 2 on May 29, a week behind the original timeline. The announcement was reportedly a result of a request by local officials to be temporarily exempted from the statewide changes.

US President Donald Trump published a letter addressed to WHO Director-General Tedros Adhanom Ghebreyesus in which he threatens to terminate the United States’ membership in the WHO. The letter outlines findings from a US government investigation into the WHO response to COVID-19 and asserts that the WHO is unable to remain independent from China’s influence. The letter highlights a series of “missteps” made by the WHO and notes that the WHO “repeatedly made claims about the coronavirus that were either grossly inaccurate or misleading.” A number of the “missteps” address the WHO’s praise for China’s response and transparency, contradicting evidence suggesting that Chinese officials attempted to conceal or misrepresent relevant information regarding the emerging pandemic, and delays in the WHO declaring a Public Health Emergency of International Concern (PHEIC) and pandemic. President Trump previously ordered a temporary hold on WHO funding, and he stated that he intends to make this permanent and consider withdrawing from the WHO if “substantive improvements” are not made within 30 days. In the letter, President Trump cited content published in The Lancet in December 2019 or earlier as evidence that the extent of transmission in China was known to the WHO at that time. The Lancet published a response this morning to correct the “factually inaccurate” statement, noting that the journal did not publish anything on the initial outbreak prior to January 24, 2020. Additionally, the journal emphasized the risk that President Trump’s statements pose to critical international cooperation as well as the importance of conducting “factually accurate” reviews of the global response.

The US CDC reported 1.47 million total cases (31,967 new; 82,135 since Friday’s briefing) and 88,709 deaths (1,394 new; 4,762 since Friday’s briefing). The United States will likely reach 1.5 million cases by tomorrow’s update. The 31,967 new cases is the United States’ highest daily total since April 25. In total, 9 states (no change) reported more than 40,000 cases, including New York with more than 350,000; New Jersey with more than 125,000; and California, Illinois, and Massachusetts with more than 75,000. Additionally, 36 states (no change), plus Guam, are reporting widespread community transmission.

Last week, US President Donald Trump provided additional details on Operation Warp Speed, the US plan to rapidly develop, test, and manufacture a SARS-CoV-2 vaccine. The program will involve senior experts and leadership from both the US Department of Health and Human Services and the Department of Defense, and it aims to develop, test, and scale up production for a SARS-CoV-2 vaccine in order to make millions of doses available by early 2021. This would be a monumental effort and would considerably accelerate the process for any previous vaccine by months or years. One of the project leaders, Dr. Moncef Slaoui, commented that he had recently seen encouraging preliminary data from early clinical trials of a vaccine candidate. This morning, Moderna, Inc., issued a press release describing encouraging preliminary results from its Phase 1 vaccine trial. While Phase 1 trials are designed to evaluate safety of the vaccine in humans, Moderna noted that early data (based on only 8 participants) are promising that the vaccine could induce the development of protective antibodies. More data is required to better characterize the body’s immune response, particularly with respect to the effect on conferring immunity to SARS-CoV-2. President Trump committed to collaborating with other countries to ensure wide availability of any successful vaccine, regardless of where it is developed, including distributing production around the world. The WHO is reportedly considering the development of a voluntary global repository for relevant data, patent rights, intellectual property, and other technical and regulatory information to support the worldwide availability of the vaccine as soon as possible. The United States has previously declined to participate in the WHO-led international consortium to support SARS-CoV-2 vaccine development, and it is unclear whether it would participate in the voluntary repository.

Massachusetts Governor Charlie Baker is expected to announce the initial steps to relax statewide social distancing measures. Massachusetts is among the hardest-hit states after an early outbreak linked to a biotechnology conference. Massachusetts will use a 4-phase plan, which will incrementally relax social distancing until the point at which the availability of a vaccine or treatment will permit “the resumption of a ‘new normal.’”

Kentucky is scheduled to lift its “travel ban” and reopen most state parks this week ahead of Memorial Day weekend. Several state parks are being used to house “low acuity patients,” so those will remain closed to the public. Minnesota is also set to begin resuming operations at non-essential businesses and state parks this week. As businesses, parks, and other facilities reopen, they will be required to implement various social distancing, hygiene, and other protective measures.

The US CDC reported 1.38 million total cases (20,869 new) and 83,947 deaths (1,701 new). The United States could potentially reach 1.5 million cases by Tuesday next week. If the current trend continues, the United States could record its second consecutive week of decreasing incidence. In total, 9 states reported more than 40,000 cases, including New York with more than 300,000; New Jersey with more than 125,000; and Illinois and Massachusetts with more than 75,000. Additionally, 36 states (increase of 1), plus Guam, are reporting widespread community transmission.

The US CDC published a series of “decision trees” to provide guidance to state and local governments, schools and child care services, restaurants and other businesses, and others regarding when and how to safely relax social distancing measures for various aspects of society. The guidance documents address public transit, workplaces, restaurants and bars, schools, child care, and camps and other youth programs. Each document provides guidance regarding criteria and metrics to consider with determining whether or not it is appropriate to resume operations as well as recommended “safeguards” for both health and safety and disease monitoring. Most of the guidance is consistent across all sectors—including hygiene, disinfection, and social/physical distancing measures—but guidance for each sector also includes tailored recommendations. For example, the guidance for child care addresses the need to limit the sharing of toys and other objects between children. While not nearly as comprehensive as the unreleased draft guidance that has circulated among news media outlets over the past week or so, this appears to be among the most concrete guidance issued by the CDC with respect to efforts to safely relax social distancing measures.

US states are continuing to advance plans to relax social distancing measures implemented in response to COVID-19. New York Governor Andrew Cuomo announced that several regions in the state will be able to start relaxing social distancing measures beginning today. In total, 5 regions have met the state’s criteria to move into Phase 1 of the recovery plan, which would allow them to begin reopening non-essential businesses and easing other restrictions. The “NYS on PAUSE” order expires today, but the remaining 5 regions, including New York City, will stay under more restrictive social distancing measures until they meet the criteria necessary to move into Phase 1. Notably, the New York Stock Exchange is scheduled to reopen its trading floor on May 26, albeit with a fraction of the usual personnel and with additional social distancing measures.

Ohio and Rhode Island both announced new efforts to ease social distancing measures. In Ohio, child care; gyms, pools, and non-contact/limited contact sports; campgrounds; Bureau of Motor Vehicles offices; and horse racing (without spectators) will be permitted to resume operations by the end of May. Outdoor dining at restaurants as well as barber shops, hair and nail salons, spas, and tanning facilities are permitted to resume operations starting today. Indoor dining at restaurants will resume on May 21. In Rhode Island, summer camps and other youth programs are scheduled to resume starting June 29, and libraries are beginning to expand operations, including in-person browsing and computer access.

The US CDC reported 1.36 million total cases (21,467 new) and 82,246 deaths (1,426 new). The United States could potentially reach 1.5 million cases by Tuesday next week. In total, 9 states (increase of 2) reported more than 40,000 cases, including New York with more than 300,000; New Jersey with more than 125,000; and Illinois and Massachusetts with more than 75,000. Additionally, 35 states (no change), plus Guam, are reporting widespread community transmission.

New York state and New York City both reported increases in daily incidence from the previous day; however, they both reported a substantial increase in the number of tests performed as well. New York City reported a 54% increase in the number of tests from the previous day (compared to a 47% increase in new cases), and the state reported a 65% increase in tests (compared to a 52% increase in new cases).

The Wisconsin Supreme Court (US) ruled yesterday that the state’s “safer at home” order, issued by Secretary of the Department of Health Services Andrea Palm, was issued outside the scope of her authority. The decision largely nullified the order with immediate effect, which permitted businesses to reopen and removed prohibitions on large gatherings. The court allowed existing restrictions that closed schools to remain as well as language permitting local governments to implement their own restrictions. Following the decision, some restaurants and bars reopened, some of which did not appear to impose any social distancing or other protective measures. Some local governments are reportedly developing and implementing their own restrictions, but they will likely result in inconsistencies across the state. Any future efforts by the governor or appointed state officials to implement COVID-19 policies will be required to utilize the normal process, which involves the state legislature and could take weeks or longer to pass.

The US CDC reported 1.34 million total cases (18,106 new) and 80,820 deaths (1,064 new). The daily incidence is the lowest since March 27. Based on the pattern from previous weeks, we expect the incidence to be higher over the next several days due to reporting delays over the weekend. Nonetheless, today’s report is still lower than previous Tuesday updates—19,138 new cases reported last Tuesday and 23,371 new cases the week before. The United States could potentially reach 1.5 million cases by Tuesday next week. In total, 7 states (increase of 1) reported more than 40,000 cases, including New York with more than 300,000; New Jersey with more than 125,000; and Illinois and Massachusetts with more than 75,000. Additionally, 35 states (no change), plus Guam, are reporting widespread community transmission.

mRNA VACCINE DEVELOPMENT Biotechnology company Moderna received US FDA “Fast Track” designation for the development of its mRNA vaccine against SARS-CoV-2. The Fast Track program is designed to facilitate expedited review of therapeutics for life-threatening conditions. Messenger RNA (mRNA) technology uses natural cellular processes to produce proteins designed to increase immune defenses against the pathogen for which the proteins are designed. Moderna’s mRNA-1273 vaccine candidate is designed to mimic the SARS-CoV-2 spike protein that will hopefully produce a rapid and targeted immune response against future infection. The vaccine has already undergone a Phase 1 clinical trial led by the National Institute for Allergy and Infectious Diseases, and results are expected soon. Moderna is currently preparing protocols for Phase 2 and 3 clinical trials, tentatively scheduled to begin this summer.

As Washington state continues its process of relaxing social distancing measures, Governor Jay Inslee released guidance for various sectors under the state’s “Safe Start” plan. Under Phase 2 of the state’s plan, retail stores must remain below 30% occupancy and identify and reduce choke points where customers could become clustered in order to maintain the recommended physical distancing. Restaurants must maintain below 50% occupancy for both indoor and outdoor seating and must close off any bar seating. Additional cleaning and disinfection guidelines are provided as well. This guidance also outlines provisions for employee safety and facility hygiene as businesses, including retail stores and restaurants, begin to resume in-person operations.

The US CDC reported 1.32 million total cases (23,792 new) and 79,756 deaths (985 new). The daily totals for both cases and deaths are lower than the recent trend; however, reporting delays over the weekend typically manifest in the CDC’s Monday and Tuesday updates. The United States could potentially reach 1.5 million cases by Tuesday next week. In total, 7 states. Notably, this is one fewer than yesterday. Additionally, 35 states (no change), plus Guam, are reporting widespread community transmission.

As US states begin to relax social distancing policies, businesses and governments both are struggling to maintain and enforce appropriate protective measures. In Pennsylvania, where social distancing is being relaxed on a county-by-county basis, Governor Tom Wolfe addressed reports of counties and businesses moving forward without authorization from the state government. Pennsylvania has implemented a system to categorize COVID-19 risk at the country level, based on available epidemiological data, and counties will progress through these categories as conditions improve. Governor Wolf emphasized that progressing too rapidly would risk increased transmission. He stated that local governments that prematurely relax social distancing measures could risk losing federal COVID-19 funding distributed by the state and that businesses that reopen ahead of schedule could lose their insurance or liquor license. In Colorado, a city government forced a local restaurant to close after a video surfaced that showed patrons crowding into the dining area on Mother’s Day in defiance of statewide restrictions on in-person dining. The restaurant reportedly opened for in-person dining after receiving instruction from the local health department not to do so. In South Dakota, casinos were permitted to reopen, which reportedly drew large crowds. According to one report, some casinos were operating at 85-90% of their designed occupancy. The casinos required dealers to wear face shields or masks, gaming tables were limited to 2 players, and some slot machines were shut down to promote social distancing. Patrons are supposed to maintain 6-foot social distancing; however, the included image shows some individuals in close proximity without wearing face masks.

In the United States, New York Governor Andrew Cuomo announced the state’s plan to begin relaxing social distancing measures, following continued declines in COVID-19 incidence and increases in testing capacity. The New York plan will operate on a regional level, enabling some parts of the state to resume activities before others, if they meet the designated criteria. Specific metrics for determining the ability to progress to the next phase address COVID-19 incidence and mortality, health system capacity, and contact tracing and testing capacity. The plan also includes guidance for businesses, schools, and individuals regarding the protective measures they can and should take as social distancing restrictions are eased.

Some US states are progressing through the early phases of their recovery. In Illinois, for example, Governor J.B. Pritzker announced that 3 of the state’s 4 “medical regions” have met the established criteria for moving to the third phase of recovery. The remaining region is home to Chicago, and it has not yet met the threshold of 20% test positivity (currently 22.3%), which it is required to remain below for 14 days in order to move from Phase 2 (Flattening) to Phase 3 (Recovery). Phase 3 will not begin for any region prior to May 29, so the remaining region could still meet the requirement and progress to the next phase along with the other regions. Phase 3 in Illinois will permit “manufacturing, offices, retail, barbershops and salons” to resume limited operations. Phase 4 permits restaurants and bars to reopen for in-person service, and schools and travel can resume. Phase 5 includes larger events such as festivals and conferences.

The US CDC reported 1.30 million total cases (26,660 new; 81,630 since Friday’s briefing) and 78,771 deaths (1,737 new; 5,474 since Friday’s briefing). The United States could potentially reach 1.5 million cases by early next week. In total, 8 states (1 new) reported more than 40,000 cases, including New York with more than 300,000; New Jersey with more than 125,000; and Illinois and Massachusetts with more than 75,000 each. Additionally, 35 states (no change), plus Guam, are reporting widespread community transmission.

Native Americans are being disproportionately affected by the COVID-19 pandemic. The Navajo Nation has reported the third-highest per capita COVID-19 infection rate, after only New York and New Jersey, with 3,239 cases reported as of Saturday. The Navajo outbreak demonstrates how challenges of healthcare and public health infrastructure as well as poor access to basic needs can intensify the effects of the pandemic. Other Native American tribes across the country have taken measures to mitigate transmission in their communities, including the use of checkpoints or temporary roadblocks on state and federal highways to limit travel and mitigate transmission risk. South Dakota Governor Kristi Noem stated that her office intends to file a lawsuit against the Oglala and Cheyenne River Sioux tribes if they continue to operate checkpoints on state and federal highways. Harold Frazier, chairman of the Cheyenne River Sioux Tribe, responded by saying, “We will not apologize for being an island of safety in a sea of uncertainty and death.” The Indian Health Service has reported a total of 5,225 COVID-19 cases across Native American tribes.

A study published in the US CDC’s Morbidity and Mortality Weekly Report looked at the effects of the COVID-19 pandemic on routine childhood immunizations in the United States. Based on data from the federal Vaccines for Children Program and the CDC’s Vaccine Tracking System and Vaccine Safety Datalink, the authors found a significant decrease in the number of childhood immunizations administered compared to previous years, potentially driven by concerns that children could be exposed to SARS-CoV-2 during their doctor visits. The authors note, “[t]he decline began the week after the national emergency declaration.” Among children aged 2-18 years, the number of measles-containing vaccinations (e.g., MMR) fell from more than 2,000 per week to only several hundred over a 2-week period and has remained at that level from mid-March through at least mid-April. The decrease was less dramatic for children under 2 years old, and the number of vaccines for this age group has steadily rebounded, up to nearly 1,500 vaccinations by mid-April. The study evaluates only national-level data, and analysis of state and local variations in coverage will be needed to better characterize the local impact. The authors warn that interruptions and delays to childhood immunizations could “indicate that U.S. children and their communities face increased risks for outbreaks of vaccine-preventable diseases,” particularly as social distancing measures are relaxed and children resume social interaction.

The US FDA issued the first Emergency Use Authorization (EUA) for an antigen-based diagnostic test for SARS-CoV-2. Previously, the diagnostic tests used for SARS-CoV-2 were all PCR-based, which detects the presence of viral RNA. The new tests detect “fragments of proteins known as antigens found on or within the virus” and are capable of providing results more rapidly. They do have a higher probability of returning false negative results, so negative antigen tests “may need to be confirmed with a PCR test.” The positive results for the antigen tests are highly accurate, however, and the tests cost less to manufacture.

The US CDC reported 1.22 million total cases (25,253 new) and 73,297 deaths (2,495 new). The CDC updated its state map display again, increasing the top category to more than 40,000 cases. In total, 7 states reported more than 40,000 cases, including New York with more than 300,000 and New Jersey with more than 125,000. Additionally, 35 states (no change), plus Guam, are reporting widespread community transmission.

New York state and New York City both reported slight increases in daily incidence, but both remained below most days reported last week (April 26-May2). The percentage of tests performed with positive results continues to decline. Last week, a total of 17.4% of tests in New York City were positive, compared to 11.9% so far this week. Statewide, the percent positive tests dropped from 15.7% last week to 10.6% this week. We are continuing to monitor COVID-19 incidence trends in states that have started easing social distancing measures. We may begin to see indications of changes in transmission over the next several days.

The COVID-19 epidemic in the United States continues to wreak havoc on the economy. The US Bureau of Labor Statistics published its April Employment Situation Summary this morning, revealing further indication of severe economic effects. The national unemployment rate increased from 4.4% in March to 14.7%, the largest monthly increase in history and a level of unemployment not seen since the Great Depression. The number of jobs fell by 20.5 million nationwide, which builds on a loss of 870,000 jobs in March. The COVID-19 pandemic has essentially negated all of the jobs gained in the 10 years since the Great Recession in a period of 2 months.

The US FDA granted an EUA for the first CRISPR-based diagnostic test for SARS-CoV-2. CRISPR technologies have been developed for a wide variety of uses, including gene editing and gene drives. The Sherlock CRISPR SARS-CoV-2 test kit works by programming a CRISPR molecule to detect specific parts of the SARS-CoV-2 virus. Once the CRISPR system binds to its target site, a signal is released that can then be detected by researchers running the test. Sherlock stands for “Specific High-sensitivity Enzymatic Reporter unLOCKing.” With the appropriate, corresponding instrumentation, this test kit could be used at the point of care, and results can be reported within minutes. The FDA also authorized the use of a saliva-based diagnostic developed by Rutgers University. The test costs approximately US$100 each and enables individuals to collect specimens in their own home. The test kits must be sent back to Rutgers for processing, which can provide results in 48 hours (completing 20,000 tests per day). The test is aimed at individuals who are currently experiencing symptoms of COVID-19.

The US CDC reported 1.19 million total cases (21,303 new) and 70,802 deaths (2,523 new). In total, 13 states reported more than 25,000 cases (no change), including New York with more than 300,000; New Jersey more than 125,000; and 4 additional states with more than 50,000. Additionally, 35 states (no change), plus Guam, are reporting widespread community transmission. The overall incidence may appear to have reached a plateau, but this does not necessarily capture variations in transmission dynamics across the country. For example, the New York metropolitan area—including New York, New Jersey, and Connecticut—has been the epicenter of the US COVID-19 epidemic. When you separate data for these states from the rest of the country, a much different trend emerges. The New York City metropolitan area exhibits a considerable and consistent decline in COVID-19 incidence that spans several weeks; however, the rest of the country has a concerning upward trend over a similar period. Similar trends are emerging at the state level as well, with key differences between cities affected early in the US epidemic and other areas. Some of this may be attributable to increased diagnostic testing, but likely not all of it.

In Texas, 2 restaurants are directing their employees not to wear face masks as they resume dine-in operations. Reportedly, multiple employees indicated that the restaurants stated that they would not be permitted to work if they wear masks. The restaurant group’s website notes that face masks are not required to be worn by guests or staff and encourages those who are uncomfortable with policy to “join [them] at a later date.” Dallas County Judge Clay Jenkins recently amended his local “safer at home” order to mandate mask use; however, Texas Governor Greg Abbott’s order encourages the use of face coverings but prohibits local governments from “impos[ing] civil or criminal penalty for failure to wear a face covering.” The US CDC recommends the use of face masks for situations in which appropriate social distancing (eg, 6-foot separation) cannot be maintained, which could certainly apply in restaurants when taking orders or delivering food.

The Ohio Legislature passed a bill that would place restrictions on the duration of orders issued by the state’s Director of Health. The bill would require the Director of Health to apply to the legislature in order to extend an order, such as the “stay at home order” issued in response to the COVID-19 epidemic, beyond 14 days. Ohio Governor Mike DeWine has reportedly confirmed that he intends to veto the bill. This effort comes as some state legislatures across the country are increasing their opposition to executive orders and other policies enacted by governors or senior appointed officials that implement statewide social distancing measures.

The US CDC reported 1.17 million total cases (19,138 new) and 68,279 deaths (1,719 new). The daily totals are much lower than in previous days, but this is likely due to reporting delays over the weekend. In total, 13 states reported more than 25,000 cases (no change), including New York with more than 300,000; New Jersey more than 125,000; and 4 additional states with more than 50,000. Additionally, 35 states (increase of 1), plus Guam, are reporting widespread community transmission.

New York state and New York City both reported decreasing daily incidence for the third consecutive day, the lowest daily value for each since March 18. The percentage of tests performed with positive results continues to decline, an encouraging trend. We are continuing to monitor COVID-19 incidence trends in states that have started easing social distancing measures; however, we may not yet be able to observe new cases associated with the changes.

On May 4, less than a week after extending a statewide “stay at home” order (scheduled to expire May 15), Arizona Governor Doug Ducey issued an executive order relaxing some of the statewide restrictions. The newest order permits barber shops and salons to resume operations and restaurants to resume dine-in service. These businesses must implement prescribed social distancing and other safety measures, but they can reopen starting May 8 for barbershops and salons and May 11 for restaurants. The previous order extending the “stay at home” measures allowed retail businesses to resume some in-person operations starting May 8 as well. Arizona’s efforts to relax social distancing come in the midst of what could be a concerning trend. Last week, Arizona reported its highest weekly COVID-19 incidence (based on specimen collection date), 2,116 new cases. This is an increase of 21.3% over the previous week, and this total could further increase over the next several days as cases who provided specimens late last week are reported to the state. Arizona has substantially increased testing statewide—jumping from 12,687 weekly tests to 20,087 over the past two weeks—and the percent of those tests with positive results decreased from 11% three weeks ago to 8% last week. Notably, however, data reported by the COVID Tracking Project, which obtains data from state health department websites, indicates that the percent of positive tests conducted last week was 13%. The cause for the discrepancy between these data is unclear. While Arizona has increased testing, it has not exhibited a decrease or plateau in COVID-19 incidence in recent weeks. Additionally, a team at Arizona State University that was providing epidemic modeling in support of Arizona’s COVID-19 response was reportedly directed to stop their work and return the data to the state, following shortly after the Governor’s Monday announcement. The notification reportedly indicated that the state would be relying on a model developed by the Federal Emergency Management Agency (FEMA). As states begin to relax social distancing measures, it will be critical to monitor trends in COVID-19 incidence in order to quickly identify indications of increased community transmission. Considering that the incubation period can last as long as 14 days, it could be days or weeks before any changes in transmission become evident, which could mean that community transmission has already increased by the time associated cases are detected.

The Cook County Medical Examiner’s Office (Illinois, US) will begin reviewing deaths from as early as November 2019 to determine if any were caused by COVID-19. Deaths in Cook County, where Chicago is located, that were originally determined to be a result of heart attacks or pneumonia will be included in the review. Cook County’s first reported COVID-19 case was in March 2020, and officials do not anticipate finding cases from November; however, they want to conduct a comprehensive investigation. If any cases are identified from November, then the effort could be expanded to include earlier deaths. In light of other recent reports of COVID-19 cases and deaths identified retrospectively, a review of these deaths could provide insight into the timeline and extent of community transmission in the Chicago area prior to the earliest reported cases, particularly considering that the testing availability and strategy early in the pandemic likely resulted in community transmission going undetected in many areas prior to the first reported case.

The US CDC reported 1.15 million total cases (28,763 new) and 67,456 deaths (1,719 new). In total, 13 states reported more than 25,000 cases (1 new), including New York with more than 300,000; New Jersey more than 100,000; and Illinois, California, and Massachusetts more than 50,000. Additionally, 34 states (decrease of 2 since Friday’s briefing), plus Guam, are reporting widespread community transmission.

New York state reported 2,538 new cases, its lowest daily incidence since March 18—and the state performed 21,399 tests (11.8% positive), compared to only 7,698 (23.0% positive) on March 18. New York City also reported its lowest daily total since March 18 (1,320 new cases)—performing 9,183 tests (14.4% positive), compared to 3,344 (33.8% positive) on March 18. Several states across the Midwest and Plains regions have exhibited elevated incidence over the past 2 weeks or so—including Indiana, Iowa, Kansas, Minnesota, and Nebraska—all of which have reported COVID-19 outbreaks at meat processing facilities.

The US FDA revised its policy regarding the use of serological tests for SARS-CoV-2. In light of the increased number and availability of serological tests in the United States, the FDA announced that companies developing serological tests are now required to seek Emergency Use Authorization (EUA) for the tests, which will include submitting relevant validation data. The FDA also published minimum performance standards for serological tests, both sensitivity and specificity, to ensure appropriate levels of accuracy. The FDA also published EUA submission templates for both commercially developed serological tests and those developed at CLIA-certified laboratories. The goal of the policy change is to increase oversight and, therefore, the quality of available serological tests.

A number of states in the US are beginning to relax social distancing measures implemented under “stay at home” or “safer at home” orders. Florida began that process yesterday, allowing most of the state’s counties to start reopening non-essential businesses, with some restrictions. For example, restaurants, retail stores, and some other businesses can resume operation with a maximum of 25% of their normal capacity. Restrictions on elective medical procedures were lifted as well, as long as sufficient capacity exists to handle COVID-19 patients. Some beaches and parks opened to the public, but large groups will still be prohibited from gathering. Barbershops, gyms, and other businesses that involve close contact will remain closed in Florida for the time being. Miami-Dade, Broward, and Palm Beach counties will remain under “stay at home” restrictions, as they continue to have elevated risk of SARS-CoV-2 transmission, although some restrictions have relaxed in those counties, including opening state parks and beaches for some activities. Florida has reported decreasing COVID-19 incidence over the past several weeks, which aligns with the White House guidance on relaxing social distancing.

The US CDC reported 1.12 million total cases (29,671 new from the previous day; approximately 90,000 new cases since the Friday briefing) and 65,735 deaths (1,452 new from the previous day; 5,678 new since the Friday briefing). The CDC reported elevated daily incidence in the updates on Friday, Saturday, and Sunday, all of which were more than 25% greater than the recent low reported on April 27. In total, 12 states reported more than 25,000 cases (no change), including New York with more than 300,000; New Jersey more than 100,000; and Illinois, California, and Massachusetts more than 50,000. Additionally, 34 states (decrease of 2 since Friday’s briefing), plus Guam, are reporting widespread community transmission.

New York state held relatively steady in terms of daily incidence over the past week, reporting between 3,100 and 4,700 new cases each day. Similarly, New York City reported between 1,800 and 2,700 new cases each day. We are continuing to monitor COVID-19 incidence trends in states that have started easing social distancing measures; however, it could be several weeks following any changes to social distancing before any effects begin to emerge in reported data.

Over the weekend, the US FDA issued new Emergency Use Authorizations (EUAs) for 2 serological tests, bringing the total to 12. One of the tests in particular, developed by Swiss biotechnology company Roche, reportedly has high specificity and sensitivity. According to a press release by the company, the test has a sensitivity of 100% sensitivity in specimens collected 14 days or longer after a positive PCR test (ie, detects 100% of individuals with antibodies present) and greater than 99.8% specificity (ie, fewer than 0.2% of tests will yield a false positive). Additionally, the test exhibits “no cross-reactivity to the four human coronaviruses causing common cold.” Roche intends to provide tens of millions of tests worldwide by the end of May, and the company is working to expand production capacity. The Roche test requires a blood draw instead of a finger prick. The test takes approximately 18 minutes to run and is fully automated, and the testing system can perform as many as 300 tests per hour.

The US CDC reported 1.03 million total cases (26,512 new) and 60,057 deaths (2,552 new). This is the second consecutive day of increasing incidence, but the daily total is still less than most days over the past several weeks. In total, 12 states reported more than 25,000 cases (1 new), including New York with more than 200,000; New Jersey more than 100,000; and Illinois and Massachusetts more than 50,000. Additionally, 36 states (increase of 1), plus Guam, are reporting widespread community transmission.

A number of US states had emergency declarations and “stay at home” orders that were scheduled to expire at the end of April or beginning of May. Some governors elected to allow them to expire in an effort to resume economic activity in their states, but others extended those orders. States that extended the orders took a variety of approaches, including relaxing some restrictions while maintaining others and varying the duration of the extensions. These states include Arizona, Illinois, Louisiana, Michigan, Minnesota, Nevada, and Ohio. Several other states, including Washington, are expected to issue extensions in the coming days. The governors and health officials in these states determined that COVID-19 data does not yet indicate that the epidemic is sufficiently under control to allow further relaxation of social distancing measures. Notably, the decision by Michigan Governor Gretchen Whitmer prompted a protest, during which protesters, some armed with assault-stye rifles and other firearms, entered the state house. Both chambers of the Michigan Legislature passed bills attempting to overturn Governor Whitmer’s executive orders and authorizing their leadership to file associated lawsuits against the governor. Additionally, California Governor Gavin Newsom announced the closure of a number of state parks and beaches in an effort to mitigate large crowds that have been reported in some locations in recent days. The decision to close beaches has angered some local communities, some of which have reportedly threatened to file lawsuits to oppose the restrictions.

The US CDC announced a new program to collect and analyze genomic data during the COVID-19 pandemic. The effort—labeled SARS-CoV-2 Sequencing for Public Health Emergency Response, Epidemiology and Surveillance (SPHERES)—will leverage “clinical and public health laboratories, academic institutions, and the private sector” across the country to characterize the genetic evolution of the SARS-CoV-2 virus over the course of the pandemic, support disease surveillance and contact tracing, and inform diagnostic, therapeutic, and vaccine development. Other countries, including Canada and the United Kingdom, are initiating similar programs. Coordinating national genetic sequencing efforts through a centralized mechanism, under the CDC’s Advanced Molecular Detection (AMD) program, can establish common standards for data collection and reporting, which can help researchers make better use of the data.

Yesterday, Maryland Governor Larry Hogan announced expansions to the state’s COVID-19 response, including enhancing response efforts at nursing homes statewide. These actions included appointing the state’s Surgeon General as the Emergency Safety and Compliance Officer for nursing homes, conducting universal testing for nursing home staff and residents, and implementing daily evaluation for nursing home residents for COVID-19 symptoms. The plan also notes that the state will provide supplemental healthcare professionals to bolster understaffed nursing homes. Nursing home residents account for 19% of Maryland’s total COVID-19 cases and 46% of the state’s total deaths.

The US CDC reported 1,005,147 total cases (23,901 new) and 57,505 deaths (2,247 new). Overall, daily incidence in the US has remained relatively steady since early April, but recent fluctuations make it difficult to forecast any longer-term trend. The past 2 days represent the 2 lowest daily incidence since the end of March (excluding reporting issues on April 3-5); however, daily incidence for the 4 days before that were elevated. In total, 11 states reported more than 25,000 cases (no change), including New York with more than 200,000; New Jersey more than 100,000; and Massachusetts more than 50,000. Additionally, 35 states (increase of 1), plus Guam, are reporting widespread community transmission.

New York state reported a nearly 50% increase in cases from the previous day (4,585 new cases compared to 3,110), and New York City reported a 35% increase over the previous day (2,503 new cases compared to 1,849). This ended a streak of 3 consecutive days with decreasing daily incidence for both the city and state Notably, the percent of tests that are positive has decreased substantially compared to earlier in the epidemic. At the peak of New York City’s daily incidence (7,837 new cases on April 14), 48% of tests were positive, whereas only 18% were positive in the most recent data. Similarly, New York state reported 43% of tests positive at its peak on April 14 and only 17% positive according to the most recent data.

The US government is reportedly initiating an effort called “Operation Warp Speed” to speed the development and production of medical countermeasures against COVID-19, including vaccines. According to media reports, the program will provide liability protection and funding for vaccine developers to facilitate expanded research and development operations. It is unclear how much money will be allocated for this program, and it is unclear whether this program will be a consolidation of existing efforts—e.g., under the Biomedical Advanced Research and Development Authority —or an entirely new program. The goal of the program is reportedly to manufacture hundreds of millions of doses by the end of 2020, which would dramatically shorten the timeline normally associated with novel vaccine development. Operation Warp Speed has not been officially announced by the US government.

This week, the United States Department of Labor announced that an additional 3.8 million new unemployment insurance claims were filed last week. The new data lowers the 4-week average; however, the national unemployment total and rate both set historical records for the previous week—17,992,000 individuals and 12.4%, respectively. In total, Americans have filed more than 30 million new unemployment claims over the past 6 weeks. In a recent poll conducted by NPR, PBS, and Marist, half of the respondents reported that someone in their household lost their job or had hours decreased, more than double the percentage from the poll conducted in March. Additionally, The New York Times reported that a number of changes and restrictions on unemployment benefits implemented by states over the past several years are posing challenges for individuals seeking support during the COVID-19 pandemic. Some of these efforts include requirements to apply in person and document efforts to find employment, which may not be feasible or realistic under the current social distancing restrictions. While these efforts potentially eased some of the financial strain on state unemployment programs, putting them in a better position now to provide unemployment funding, the restrictions may be barriers for the people now navigating the unemployment system.

The US CDC updated its COVID-19 data website. Major changes include increasing the highest category to “25,001 cases or more” for state reporting, adding change in total cases and deaths from the previous day, removing data for probable cases and deaths, adding state- and county-level COVID-19 cases and deaths, and adding a figure that tracks daily incidence. The CDC reported 981,246 total cases (23,371 new) and 55,258 deaths (1,336 new) as of April 27. Overall, the United States’ daily incidence has remained relatively steady since early April; however, April 23-26 were elevated compared to the previous 10 days. In total, 11 states reported more than 25,000 cases, including New York with more than 200,000; New Jersey more than 100,000; and Massachusetts more than 50,000. In total, 34 states (decrease of 2), plus Guam, are reporting widespread community transmission. Based on recent daily incidence trends, the United States will likely reach 1 million cases in the update later this afternoon.

New York state and New York City both reported their third consecutive day of decreasing daily incidence and their lowest daily totals since March 19 and 20, respectively. The daily incidence for both New York City and state continue to largely follow trends in the number of tests performed. We are continuing to monitor COVID-19 incidence trends in states that have started to ease social distancing measures; however, it could be several weeks before any effects become evident in reported data.

As part of the White House’s roadmap to relax social distancing measures, the US President Donald Trump unveiled a “Testing Blueprint” to further scale up testing nationwide, with the stated goal of performing 2 million tests per week by the end of May. According to the plan, state, tribal, and local governments are largely responsible for procuring tests and “overcom[ing] barriers to efficient testing”; however, the federal government will “act as a supplier of last resort” and coordinate with private sector suppliers to increase production and testing capacity. A number of private sector companies announced plans to increase testing capacity to support these efforts.

In Detroit, Michigan (US), free testing sites are now being opened to the general public. Detroit is among the US cities hit hardest by COVID-19, reporting more than 8,800 cases and nearly 1,000 deaths. Previously, Detroit testing sites had offered free services for first responders and healthcare workers, but eligibility has now expanded to the broader public, including those without a doctor’s order. Some sites offer diagnostic and serological testing, which provides the opportunity to detect both current and prior infections. Some test sites are available for those who are not exhibiting symptoms, but others remain limited to symptomatic individuals only.

The US Department of Commerce published “advance estimates” for the US economy in the first quarter of 2020. The preliminary data indicate that the US gross domestic product (GDP) fell by 4.8% over the first 3 months of 2020, ending the longest period of economic expansion in US history. This quarter’s decrease was also the largest since 2008, at the height of the Great Recession. A significant decrease in consumer spending during the early months of the COVID-19 pandemic contributed to the economic contraction. The US Federal Reserve is expected to make a statement this afternoon following its first meeting since before states began implementing social distancing plans. Even as US states begin to plan for and implement efforts to ease social distancing, the future of the US economy remains uncertain.

In response to recent outbreaks at major meat processing facilities, some of which prompted those facilities to suspend operations, President Trump invoked the Defense Production Act to enable the US Department of Agriculture to ensure the continued operation of these facilities nationwide. The facilities will need to meet guidelines issued by the US CDC and Occupational Safety and Health Administration (OSHA). In response to the order, the United Food and Commercial Workers International Union, which represents workers at these facilities, called on the federal government to implement effective safety standards, including increased testing and PPE availability, to ensure the safety of workers as they continue to work during the pandemic. COVID-19 outbreaks have already resulted in the closure of major beef, pork, and poultry processing facilities in multiple states, resulting in major decreases to processing capacity.

The US CDC reported 957,875 total cases (29,256 new; 4,999 probable) and 53,922 deaths (3,483 new; 6,142 probable) as of April 26. This appears to be a new record high for daily reported deaths (excluding the day New York City first reported probable COVID-19 deaths [April 14]), exceeding the previous high by more than 650 (23.6%). Notably, the United States represents a third of the global cases and more than a quarter of the global deaths. In total, 18 states reported more than 10,000 cases (no change), including New York with more than 200,000; New Jersey more than 100,000; and Massachusetts more than 50,000. In total, 36 states (increase of 1), plus Guam (added again), are reporting widespread community transmission. Based on recent daily incidence trends, the United States could reach 1 million cases in 2 days.

New York state and New York City both reported their second consecutive day of decreasing daily incidence and their lowest daily totals since March 20. The daily incidence for both New York City and state continue to largely follow trends in the number of tests performed. In New York City, 21.2% of tests performed yesterday were positive, and 16.9% were positive outside of New York City (19.0% positive statewide).

US President Donald Trump revealed the Blueprint For Testing Plans And Rapid Response Programs, which outlines plans to increase testing capacity to 2 million tests per week across the country. The Blueprint delineates roles and responsibilities of the federal government, state/local/tribal governments, and the private sector in order to reach this goal. While the Blueprint does not call specific actors or companies to action, pharmacy chain CVS said in response that it will partner with the federal government to provide drive-through testing at its facilities, among other potential activities. Scaling up testing capacity is a major factor in many plans to safely reopen parts of the economy in the coming weeks and months. The Blueprint highlights several areas in which capacity could be scaled, including expanding the number of testing platforms, enhancing sample collection, and maximizing laboratory capacity.

The US government continues to evaluate options to provide financial support for US businesses and individuals to offset the economic impact of the COVID-19 pandemic and associated social distancing measures. Today, US Secretary of the Treasury Steven Mnuchin announced that the US government will audit companies that received loans of more than $2 million from the Paycheck Protection Program. The economic stimulus effort was designed to provide financial support for small businesses during the COVID-19 response; however, reports have emerged since the initiation of the program of larger companies—including nationwide restaurant and hotel chains and the Los Angeles Lakers basketball team (which returned the loan)—receiving sizable loans while some small businesses have been unable to access the emergency funding. The Small Business Association has made changes designed to limit the loans to small businesses, but these audits would provide additional oversight for the program.

Several states, including Ohio and Texas, announced detailed plans to initiate efforts to relax statewide social distancing measures. The guidance for both states include a number of restrictions that will remain in place as nonessential businesses reopen, including limiting the maximum occupancy, physical distancing, face mask use, enhanced hygiene, and temperature/symptom monitoring. Certain aspects of businesses, such as buffets and salad bars at restaurants, will be prohibited, even for businesses that reopen. Additionally, some elective healthcare services will be permitted to resume, but capacity must be reserved for COVID-19 response.

On Friday, April 24, the US CDC reported 37,144 new cases, the country’s highest daily total since the onset of the pandemic. On April 26, the CDC reported 928,619 total cases (32,853 new from the previous day; 2,663 probable) and 50,439 deaths (2,020 new from the previous day; 5,402 probable). In total, 18 states reported more than 10,000 cases (no change), including New York with more than 200,000; New Jersey more than 100,000; and Massachusetts more than 50,000. In total, 35 states (decrease of 2) are reporting widespread community transmission. Based on recent daily incidence trends, the United States could reach 1 million cases in 2-3 days.

The US CDC reported 828,441 total cases (25,858 new; 4,211 probable) and 46,379 deaths (1,804 new; 5,922 probable*) on April 23. After 2 consecutive days of elevated daily death totals, yesterday’s update was approximately 1,000 fewer than each of the previous 2 days. In total, 18 states reported more than 10,000 cases (1 new), and 37 states (10 new) are reporting widespread community transmission. Based on recent trends, the United States could reach 1 million cases by the end of April, and it could exceed 50,000 deaths later today.

The US CDC reported 828,441 total cases (25,858 new; 4,211 probable) and 46,379 deaths (1,804 new; 5,922 probable*) on April 23. After 2 consecutive days of elevated daily death totals, yesterday’s update was approximately 1,000 fewer than each of the previous 2 days. In total, 18 states reported more than 10,000 cases (1 new), and 37 states (10 new) are reporting widespread community transmission. Based on recent trends, the United States could reach 1 million cases by the end of April, and it could exceed 50,000 deaths later today.

New York Governor Andrew Cuomo reported preliminary results from a serological study conducted in New York state. The study tested 3,000 individuals across 19 counties statewide. A fact sheet about the test linked in the press briefing describes it as having a specificity of 93-100%; however, additional details about the test are not provided. The preliminary study results found that nearly 14% of New York residents may have been previously infected with SARS-CoV-2. These results are weighted heavily by the New York City area, with much lower estimates for the rest of the state. Like many other serological studies currently being implemented, additional information on the test is necessary to fully analyze the serological test data and characterize the scope of transmission in a given community.

The US CDC reported 802,583 total cases (26,490 new; 3,981 probable) and 44,575 deaths (2,817 new; 5,862 probable*) on April 22. This is the second consecutive day that the CDC reported a record high for new deaths—excluding the day New York City first reported probable COVID-19 deaths (April 14). In total, 17 states reported more than 10,000 cases (no change), and 27 states (no change) are reporting widespread community transmission. Based on recent daily incidence trends, the United States could reach 1 million cases by the end of April and 50,000 deaths by April 24.

Earlier today, the US Department of Labor released new information relating to the impact of COVID-19 on the US workforce. This report indicated that more than 4.4 million individuals filed initial claims for unemployment, owing largely to prolonged public health measures impacting companies’ ability to operate. While this number is a decrease from the previous week, it brings the national total to approximately 26 million new claims over the last 5 weeks, roughly 7.8% of the entire US population (not just those of working age).

As elected officials and health officials in the United States look ahead to relaxing social distancing measures, some initial decisions have been met with opposition, particularly because current epidemic conditions and response capacities (eg, diagnostic testing and contact tracing) have not met proposed thresholds for relaxing those measures. Earlier this week, Georgia Governor Bill Kemp issued an executive order that would ease existing statewide restrictions, including permitting some non-essential businesses to reopen as early as later this week. Yesterday, US President Donald Trump—in contrast to previous calls for states to “reopen”—stated that he disagreed with Governor Kemp’s decision. He emphasized that Georgia had not yet demonstrated the key criteria to enter “phase 1” and that businesses such as tattoo parlors and barber shops that pose elevated risk of transmission would be more appropriate to open in “phase 2.” Dr. Anthony Fauci also warned of the potential for SARS-CoV-2 transmission to “rebound” if social distancing measures are not eased in the appropriate manner.

New York Governor Andrew Cuomo and former New York City Mayor Mike Bloomberg announced the start of an ambitious COVID-19 contact tracing effort. The scale of the contact tracing effort is set to exceed that of any in New York’s history, with financial contributions and plans for recruitment already in progress. The program is set to launch immediately, but there is an expectation that it will take time before contact tracing operations can formally commence. Governor Cuomo has repeatedly emphasized the importance of contact tracing to New York State’s prolonged COVID-19 response, including efforts to relax social distancing, with the goal being to develop a system that can effectively “identify, contact, isolate” patients in a way that will limit spread of the disease.

The US CDC reported 776,093 total cases (29,468 new; 3,396 probable) and 41,758 deaths (2,675 new; 5,352 probable*) on April 21. Excluding the day New York City first reported probable COVID-19 deaths (April 14), this appears to be the highest daily total deaths for the United States. Yesterday’s daily incidence was also considerably higher than the previous day, but this could be a result of delayed reporting from the weekend. In total, 17 states reported more than 10,000 cases (1 new), and 27 states (no change) are reporting widespread community transmission. Based on recent daily incidence trends, the United States could reach 1 million cases by the end of April and 50,000 deaths by April 25.

New York state again reported its lowest daily incidence (4,178 new cases) since March 20. This is the state’s sixth consecutive day of declining incidence, but the number of tests performed also continues to decline—April 21 had the fewest tests performed of any day in April—which could be a trend to monitor. Notably, however, the percent of tests that are positive yesterday is considerably lower than the overall statewide total (27.0% compared to 38.8% over the entire epidemic), which could be promising. New York City reported slightly elevated incidence compared to the previous day—2,519 new cases compared to 2,370 yesterday—but it is still the city's second lowest daily total since March 20.

The US Senate passed an amendment to the Paycheck Protection Program and Health Care Enhancement Act which will provide further support for small businesses and the US healthcare system. The bill will be sent to the House of Representatives, which is expected to vote on it later this week. The new amendment will provide an additional US$484 billion—including $380 billion for small businesses, $75 billion for hospitals, and $25 billion to expand testing capacity—to support the US COVID-19 response. Progress on the bill follows a surge in recent reporting on challenges with the initial round of small business loans, including large national companies receiving financial support over smaller local businesses, delays in processing applications, and demand far exceeding the allocated funding.

US President Donald Trump formally announced that he will direct additional restrictions on immigration in response to the economic impact of the US COVID-19 epidemic. The new measures will suspend immigration for those seeking permanent residency—commonly referred to as a Green Card—for a period of at least 60 days in order to ensure that American workers are not “replaced with new immigrant labor flown in from abroad” as states relax social distancing measures and businesses resume operation. The restrictions will not apply to those seeking temporary visas. President Trump also noted that the measure will also aim to mitigate the impact of COVID-19 on the US healthcare system. The restrictions are expected to take the form of an Executive Order, but it has not been issued as of this writing. Immigration advocates opposed the new measures, noting the major role that immigrants are playing right now in essential jobs that are keeping the country and economy operating under existing social distancing measures. Exemptions are expected to be included for seasonal workers, who are critical to the agriculture industry and food supply chain, and healthcare workers or other essential workers.

On April 20, US Representative Bill Foster and more than 30 members of Congress wrote a letter to Secretary of Health and Human Services Alex Azar and FDA Commissioner Stephen Hahn calling for an expedited research, development, and approval process for COVID-19 vaccines. The letter notes that “every week of delay in the deployment of a vaccine to the seven billion humans on Earth will cost thousands of lives.” Notably, the letter expresses support for human challenge trials (HCTs), in which trial participants would volunteer to be intentionally infected with SARS-CoV-2 in order to directly assess the efficacy of candidate vaccines. HCTs have been used during past vaccine development efforts, but their use for SARS-CoV-2 vaccine trials is controversial, particularly in the absence of an effective treatment that could be used for those for which the vaccine is not effective.

Health officials in Wisconsin (US) reportedly linked at least 7 COVID-19 cases to the statewide election held on April 7. The state’s Supreme Court ruled to overturn Wisconsin Governor Tony Evers’ last-minute executive order to postpone the election, and the election proceeded as scheduled. Many in-person polling locations were closed, which raised concerns about potential transmission associated with long lines and congestion at those locations that remained open. State and local health officials initiated an investigation to monitor transmission potentially linked to in-person voting. Yesterday, Milwaukee Health Commissioner Jeanette Kowalik confirmed that the local health department identified 7 cases of COVID-19—6 voters and 1 poll worker—that could be traced back to the polls. Local health officials indicated that they have only 30% of the data and that additional cases could be identified as more information becomes available. More than 1.1 million absentee ballots were submitted for Wisconsin's 2020 primary—37% more than in the 2016 presidential election. We have not identified an official statement, but the media reports cited here quote local health officials.

Michigan’s Chief Medical Executive, Dr. Joneigh S. Khaldun, published a letter to clinicians statewide to call attention to racial and ethnic disparities associated with COVID-19. The letter highlights elevated COVID-19 incidence and severity observed in minority populations in Michigan, including African Americans, who represent 30% of cases and 40% of deaths statewide despite comprising only 14% of the state’s population. Dr. Khaldun cites a broad scope of challenges facing racial and ethnic minorities that could be contributing to these disparities, including working lower wage jobs, crowded living conditions, and use of public transit. These factors can place individuals at elevated risk of exposure to SARS-CoV-2 and hinder efforts to implement CDC-recommended social distancing and enhanced hygiene efforts in public and at home. The letter also includes several recommendations for clinicians to address these disparities, including proactive recognition and awareness of the disparities themselves, to mitigate the risk of biasing decisions regarding testing and treatment, as well as the difficulties these individuals and families may face in implementing recommended protective actions (including quarantine and isolation).

On April 14, the White House announced a new public-private partnership intended to reallocate ventilators from hospitals experiencing relatively lower levels of demand to those experiencing high demand due to the US COVID-19 epidemic. The Dynamic Ventilator Reserve is a voluntary program that includes at least 20 large healthcare systems. Yesterday, the White House’s Council of Economic Advisors published its analysis of the program and its effect on hospitals’ ability to cope with the surge of COVID-19 patients. According to the Council’s projections, the national supply of ventilators is sufficient to handle peak demand, and the Reserve program will “provide enough ventilators for the hospitals participating in the network” by moving surplus ventilators to areas of high demand.

The Santa Clara County (California, US) Medical Examiner identified COVID-19 deaths from early February, which suggests that SARS-CoV-2 was circulating in the community in January, weeks before previously thought. Two individuals who died in their homes in Santa Clara County on February 6 and 17, respectively were tested for SARS-CoV-2 infection by the US CDC, which confirmed that the specimens tested positive for SARS-CoV-2 infection. Another victim who died on March 6 also tested positive. Previously, the earliest reported COVID-19 death in the county was on March 9, and the earliest reported death in the United States was on February 29 in Kirkland, Washington. At the time of their deaths, testing was largely limited to individuals with known travel history to affected areas or exposure to confirmed COVID-19 cases. This discovery suggests that the virus was transmitting in the broader community, potentially for weeks, before community transmission was identified.

The US Navy continues to report COVID-19 cases among the Sailors and Marines onboard the USS Roosevelt aircraft carrier. A joint investigation between the Navy and the US CDC is ongoing to better understand the transmission of SARS-CoV-2 among the ship’s crew. The study will reportedly include broad diagnostic and serological testing of crew members. The outbreak was detected approximately 2 weeks after the ship was in Da Nang, Vietnam; however, it is unclear exactly how the virus was introduced to the ship. The US Air Force constructed a temporary medical facility to provide treatment and isolation capacity for COVID-19 patients. So far, more than 700 cases have been reported from among the ship’s crew, which remains in quarantine in Guam. The ship’s Commanding Officer, Captain Brett Crozier, was relieved of duty after sending a letter to senior US Navy leadership calling for additional support and response early in the ship's outbreak. Secretary of the Navy Thomas Modly resigned shortly after the incident, and an investigation is ongoing.

The US CDC reported 746,625 total cases (25,995 new; 1,696 probable) and 39,083 deaths (4,752 probable*) on April 20. In total, 16 states reported more than 10,000 cases (zero new), and 27 states (1 new state; Guam removed) are reporting widespread community transmission. The United States appears to be exhibiting a slight overall decline in daily incidence. The values fluctuate daily, but they appear to be closer to 25-26,000 per day recently, compared to 27-28,000 per day in previous weeks. This is likely driven by recent declines in larger outbreaks rather than a nationwide trend, but it is a welcome sign nonetheless.

Yesterday, New York state reported its lowest daily incidence (4,726 new cases) since March 20. This is the state’s fifth consecutive day of declining case counts, but the number of tests performed is also declining—April 20 had the fewest tests performed of any day in April. Notably, New York City represents more than half of the new cases reported statewide (2,370 new cases), but the city has also reported 5 consecutive days of declining incidence.

Following the announcement by US President Donald Trump regarding guidance for US states to begin easing physical distancing measures, several states have already initiated or announced the removal or relaxation of some of their statewide efforts. The governors of Georgia, South Carolina, Tennessee, and Texas all announced immediate or forthcoming changes to existing physical distancing measures. Each state is taking a different approach to identifying activities that are appropriate to resume, but all note that the efforts are designed to provide relief to economic burdens in the state while continuing to mitigate COVID-19 risk. Notably, available COVID-19 data do not necessarily indicate that these states have exhibited the recommended 14-day downward trends in COVID-19 activity as outlined in the White House guidance. Additionally, the extent to which these states have the testing and capacity in place to support the necessary contact tracing efforts necessary to monitor SARS-CoV-2 activity in the community is not immediately clear—although expanded testing programs have been reported. Some of the changes outlined by these governors apply statewide, and others are limited to areas with lower rates of community transmission, but each state includes specific requirements for businesses regarding risk mitigation measures that must be implemented in order to resume operations. As states look ahead to relaxing social distancing measures, it will be critical to closely monitor the associated effects on COVID-19 incidence.

The US CDC reported 720.6k total cases (1.3k probable) and 37.2k deaths (4.2k probable) on April 19. This represents 29.9k new cases since the previous day and 88k cases and 6.1k new deaths since our Friday briefing. In total, 16 states reported more than 10,000 cases (2 new since Friday’s briefing), and 26 states, plus Guam, are reporting widespread community transmission. Notably, 8 fewer states reported widespread transmission than did so in Friday’s briefing. The Johns Hopkins CSSE dashboard is reporting 762k US cases and 40.7k deaths as of 11:30am on April 20.

New York state reported 222k cases and 14k deaths—6k new cases from the previous day and 20.5k new cases and 1.7k new deaths since Friday’s briefing. New York state has reported declining daily incidence for 4 consecutive days, down from its high of 11.6k new cases on April 14. New York City reported 117.6k cases and 10k deaths—12.2k new cases and 1.1k new deaths since Friday’s briefing.

The Indian Health Service reported 1,212 total cases (384 new since Friday’s briefing), with 75% reported among the Navajo Nation (908 cases).

As US states begin planning to relax physical distancing measures, testing capacity could once again be a limiting factor in the US COVID-19 response. One of the key components in the White House’s guidance to states is to establish sufficient testing capacity to implement effective surveillance and contact tracing efforts as physical distancing measures are lifted. Since the announcement, a number of governors have called for additional support from the federal government to increase testing capacity to a level that would support efforts to resume public activity. President Trump intends to invoke the Defense Production Act to increase production of swabs to support testing efforts nationwide, and Vice President Mike Pence announced that the federal government will provide additional information and support for state governments to ensure the availability of testing supplies and capacity to scale up SARS-CoV-2 appropriately to support relaxing physical distancing around the country.

In addition to diagnostic tests, serological testing is a growing priority, both for assessing population-level prevalence of SARS-CoV-2 infection and determining individual-level exposure and risk. At this time, the US FDA has only issued Emergency Use Authorization for a small handful of serological tests; however, others have been developed and are available without FDA authorization. Some of these tests have been purchased for use by health departments, health systems, and others for use in determining individual exposure or to conduct community serological surveys, but there remains uncertainty regarding their reliability. Officials at the Association for Public Health Laboratories and other experts have expressed concern about the availability of SARS-CoV-2 serological tests without sufficient data to demonstrate their reliability.

The US CDC updated its COVID-19 reporting website this week. On April 15, the CDC added demographic data for reported COVID-19 cases, and yesterday it included data on both confirmed and probable cases and deaths. Additionally, the CDC updated its map display to re-categorize states by total incidence (now separating states with 5,001-10,000 cases and 10,001 cases or more). The CDC reported 632,548 total cases (27,158 new; 632,220 confirmed; 348 probable) and 31,071 total deaths (6,489 new; 26,930 confirmed; 4,141 probable) on April 16. In total, 14 states reported more than 10,000 (zero new), and 34 states (1 new), plus Guam, are reporting widespread community transmission.The Johns Hopkins CSSE dashboard* is reporting 672,303 US cases and 33,898 deaths as of 12:45pm on April 17.

The United States continues to report high rates of COVID-19 incidence and deaths nationally. Yesterday, US President Donald Trump announced new guidance regarding future efforts to relax existing social distancing measures. Earlier this week, there appeared to be disagreement regarding the relative authority of the federal and state governments with respect to implementing and relaxing these measures. The plan outlined yesterday seems to direct governors to make decisions based on transmission, risk, and resources on a state-by-state basis. In particular, the plan outlines 3 phases, in which social distancing measures can be relaxed incrementally, as well as guidance on considerations and conditions that should be in place before transitioning to each phase. The principal “gating criteria” before moving into the first phase include a “downward trajectory” for influenza-like illnesses, syndromic COVID-19 surveillance reports, confirmed COVID-19 cases, and percent of SARS-CoV-2 tests that are positive over a 14-day period. Additionally states should have sufficient healthcare capacity to treat all COVID-19 patients and a “robust testing program” for healthcare workers and “emerging antibody testing.”

Several groups of US States have made plans to coordinate regional roll backs of social distancing measures, including existing coalitions on the east and west coasts. Yesterday, a group of 7 Midwestern states—Illinois, Michigan, Ohio, Wisconsin, Minnesota, Indiana, and Kentucky—announced that they are similarly coordinating a regional plan to relax social distancing measures and “reopen the regional economy.” Governors in some of these states have dealt with public opposition to statewide “stay at home” orders—mostly, in the form of small organized protests rather than broad disregard for the policies—which may be contributing to pressure for the region to develop a course of action. The group plans to focus on 4 factors in their decision to relax social distancing across the region: epidemic control, testing capacity, healthcare capacity, and social distancing best practices in businesses and workplaces. The group did not announce a set date for a planned roll out of these procedures, but Ohio Governor Mike DeWine announced yesterday Ohio will begin this process on May 1.

The US CDC implemented the COVID-19–Associated Hospitalization Surveillance Network (COVID-NET) surveillance system in March to provide insight into hospitalized COVID-19 patients in the United States. The system, built on existing framework utilized by the Influenza Hospitalization Surveillance Network (FluSurv-NET) (4) and the Respiratory Syncytial Virus Hospitalization Surveillance Network (RSV-NET), collates epidemiological and clinical data on hospitalized COVID-19 patients across the country. A study of hospitalized cases reported in March provides preliminary insight into the clinical features among hospitalized patients early in the US epidemic. Among 1,482 hospitalized COVID-19 patients, nearly 75% were aged 50 years or older, and hospitalization rates increased with age. These are both consistent with previously presented data from many countries. Only 178 patients had available data on underlying health conditions, but among these patients, “the most common were hypertension (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%), and cardiovascular disease (27.8%).”

Two articles published in the US CDC’s Morbidity and Mortality Weekly Report provide analysis of healthcare worker infections in the United States. The first provides an overview of COVID-19 cases healthcare workers (HCWs) in the US. During the period February 12-April 9, the US reported 315,531 COVID-19 cases. Of that total, 49,370 had associated employment data, and 9,282 (19%) of those were reported as a HCW. Among the HCW COVID-19 cases, the median age was 42 years and 73% were female, which the authors believe to likely reflect the distributions in the broader HCW workforce. The racial/ethnic distribution among HCW COVID-19 patients is also believed to reasonably reflect the distribution within the HCW population. Of those with data on potential exposure to SARS-CoV-2, 55% of HCWs reported exposure to COVID-19 patients only in healthcare settings. Approximately 8-10% of HCW COVID-19 patients were hospitalized, and increased age was associated with increase risk of severe disease and death—although both were reported in all age groups. The second article documents HCW exposure to a patient with undiagnosed COVID-19 and provides insight into the risk of SARS-CoV-2 transmission in the healthcare setting. A patient hospitalized in Solano County, California, in February did not report relevant travel or contact with symptomatic individuals and was not initially suspected of being infected with SARS-CoV-2. The patient was hospitalized for 4 days at one hospital before being transferred to a second hospital, where he/she was confirmed to be infected with SARS-CoV-2. During the patient’s hospitalization at the first facility, the HCWs utilized standard infection control precautions, but the patient underwent several aerosol-generating procedures before being transferred. Ultimately, 43 of the 121 HCWs exposed to the patient (35.5%) developed COVID-19 symptoms within 14 days of treating the patient, and 3 (2.5%) tested positive for SARS-CoV-2 infection. Based on interviews with 37 of the HCWs, including the 3 who tested positive, “performing physical examinations and exposure to the patient during nebulizer treatments were more common” among those who tested positive than in those who did not. Additionally, the HCWs who tested positive “also had exposures of longer duration to the patient.”

The US CDC reported 605,390 cases (26,385 new) and 24,582 deaths (2,330 new) on April 15. In total, 20 states have reported more than 5,000 cases (1 new), including 14 states with more than 10,000 (1 new). New York state reported 213,779 cases (11,571 new), including 11,586 deaths (752 new). New York City reported 111,424 cases (4,161 new), including 7,905 deaths (not updated since yesterday). Additionally, there are currently 33 states (3 new), plus Guam, reporting widespread community transmission. The Indian Health Service (IHS) has not published updated COVID-19 data since April 13—1,124 total cases, with more than half reported among the Navajo Nation (636 cases). The Johns Hopkins CSSE dashboard* is reporting 640,291 US cases and 31,015 deaths as of 11:45am on April 16.

The FEMA Federal Healthcare Resilience Task Force published the “COVID-19 Hospital Resource Package,” which is intended to provide publicly accessible guidance and tools to better enable the healthcare response to COVID-19. The document provides guidance on surge planning for the emergency department, critical care, and mortuary services; crisis standards of care; staffing surge and resilience; workforce protection; regulatory concerns; PPE and healthcare supply chains; and telemedicine to support US health systems’ efforts to combat the growing epidemic.

Even with the recent emergency federal COVID-19 funding under the CARES Act, many local governments are struggling economically as a result of the pandemic and associated social distancing measures. The funding allocated to state and local governments may not adequately address the scope of the economic impact. States and larger local governments received funding directly from the federal government; however, smaller local governments received associated funding via their respective state governments, which are experiencing their own financial challenges. Additionally, the funding is reportedly restricted to COVID-19 response activities, but local governments are also experiencing financial losses due to decreased tax revenue, including lost sales tax. The National Association of Counties, representing more than 3,000 county governments, published a letter to US President Donald Trump calling on the federal government to provide additional financial support for local governments to help mitigate these losses, particularly as it is increasingly likely that economic impacts could persist for many months.

The US CDC reported 579,005 cases (24,156 new) and 22,252 deaths (310 new) on April 14. In total, 19 states have reported more than 5,000 cases, including 13 states with more than 10,000. New York state reported 202,208 cases (7,177 new), including 10,834 deaths, and New York City reported 107,263 cases, including 7,905 deaths. Additionally, there are currently 30 states (1 new), plus Guam, reporting widespread community transmission. In addition to states and territories, the Indian Health Service (IHS) is publishing COVID-19 data reported by tribal partners. The IHS reported 1,124 total cases (87 new), with more than half reported among the Navajo Nation (636 cases). The Johns Hopkins CSSE dashboard is reporting 610,774 US cases and 26,119 deaths as of 12:00pm on April 15.

US President Donald Trump announced that he has directed his administration to suspend US government funding for the WHO in the midst of the COVID-19 pandemic. President Trump has been critical of the WHO’s role in the pandemic response and suggested that the WHO participated in a cover-up regarding the spread of COVID-19 early in the pandemic. In particular, President Trump expressed displeasure with the WHO’s opposition to travel restrictions early in the pandemic, including those imposed by the US government on travelers from China. The White House presented a video at the April 13 Coronavirus Task Force briefing that addressed US government actions in response to COVID-19; however, the video raised questions regarding what measures the US government took during the period immediately after the travel restrictions on China were implemented. Following President Trump’s announcement, UN Secretary General emphasized that now is “not the time to reduce the resources” for the WHO, but he did not explicitly refer to the United States or President Trump. The announcement also garnered opposition from health experts in the United States and elsewhere, including the American Medical Association. WHO Director-General Tedros Adhanom Ghebreyesus commented that President Trump’s decision was regrettable, but he emphasized that the United States has been a longstanding partner of the WHO and that the WHO endeavours to “improve the health of many of the world’s poorest and most vulnerable people” with the “support from the people and government of the United States.” Some supporters of President Trump have agreed with the decision, and efforts are reportedly underway in the US Congress to investigate some of the associated claims regarding the WHO’s handling of the global response. It is unclear at this point how much of US government funding to the WHO will be suspended or how the suspension would be implemented.

The US Department of Health and Human Services announced that it finalized contracts with several companies to produce mechanical ventilators for the national COVID-19 response. Contracts with 5 companies were issued under the Defense Production Act (DPA), and 2 additional contracts were issued outside the scope of the DPA. Combined with previous federal ventilator contracts, US companies have committed to producing 6,190 ventilators by May 8; 29,510 by June 1; and 137,431 by the end of 2020. These units will be allocated to the Strategic National Stockpile which will then distribute them to support state-level responses. The 7 new contracts total more than US$1.4 billion.

The US CDC reported 554,849 cases (29,145 new) and 21,942 deaths (1,456 new) on April 12. In total, 19 states have reported more than 5,000 cases, and there are currently 29 states, plus Guam, reporting widespread community transmission. In addition to states and territories, the Indian Health Service (IHS) is publishing COVID-19 data reported by tribal partners. The IHS reported 1,037 total cases (52 new), with more than half reported among the Navajo Nation (579 cases). The Johns Hopkins US COVID-19 dashboard* is reporting 572,689 US cases and 23,134 deaths as of 11:45am on April 14.

Governors from several states on the east and west coasts have begun coordinating plans to relax social distancing measures. The states include New York, New Jersey, Connecticut, Pennsylvania, Rhode Island, Delaware, and Massachusetts on the east coast and California, Oregon, and Washington on the west coast. These efforts will aim to rely on available data and expert input in order to determine the best approach to relaxing social distancing measures. States in the eastern coalition announced they would have a council that will involve public health and economic experts from each state, in addition to the governors. At the federal level, US President Donald Trump is expected to announce a council that will advise him on planning for resuming normal business and community activity, which could include members representing a variety of perspectives, potentially including some state governors.

A study published by the US CDC’s COVID-19 Response Team—in collaboration with the Georgia Tech Research Institute and local health departments in New York, Louisiana, Washington state, and California—evaluated the timing and implementation of large-scale social distancing efforts in several areas of high SARS-CoV-2 transmission. The study found that social distancing efforts progressed incrementally in New Orleans, New York City, San Francisco, and Seattle, increasing from emergency declarations to stay-at-home orders—and in the case of parts of New Orleans, up to mandatory curfew orders. The community mobility in these cities decreased as the number of restrictions increased. Emergency declarations did not appear to drive sustained changes in the public’s activity level; however, limits on the size of gatherings, school closures, and stay-at-home orders (as well as the White House’s 15-day plan) coincided with incremental decreases in community mobility. The study also provides preliminary evidence that these policies, and associated decreases in community mobility, may correspond to decreased transmission; however, additional study is needed to better characterize this relationship.

The US CDC reported 525,704 cases and 20,486 deaths on April 12. Currently there are 49 states or territories that have reported community transmission. The Johns Hopkins CSSE dashboard is reporting 557,590 US cases and 22,109 deaths as of 9:00 AM US EDT on April 13. In addition to states and territories, the Indian Health Service (IHS) is publishing COVID-19 data reported by tribal partners. The IHS reported 985 total cases, among 11,818 individuals tested. The largest number of cases were found in the Navajo Nation (536 cases).

The US CDC published a report that found that 33% of 580 individuals hospitalized with COVID-19 were black and 8% were Hispanic, suggesting that black populations could be disproportionately affected by COVID-19. Maryland has published COVID-19 case counts and data by zipcode, and areas with high prevalence of minorities were found to be particularly affected.

The US CDC reported 427,460 cases (32,449 new) and 14,696 deaths (1,942 new) on April 9. As of yesterday, 17 states reported more than 5,000 cases (1 new), and the number of states reporting widespread community transmission remained at 31 states, plus Guam. The Johns Hopkins CSSE dashboard is reporting 467,184 US cases and 16,736 deaths as of 10:30am on April 10.

The US CDC published new guidance intended to enable critical infrastructure workers to remain on the job following a known or suspected exposure to SARS-CoV-2. The guidance requires that that they remain healthy and that additional precautions are implemented. The guidance, which applies to personnel in 16 sectors of the workforce deemed to be critical, calls for temperature screening and symptom checks for all workers as well as self-monitoring by employees, mask usage, social distancing measures, and enhanced cleaning and disinfection protocols to mitigate the risk of transmission at the workplace.

The US CDC reported 395,011 cases (20,682 new) and 12,754 deaths (690 new) on April 8. As of yesterday, 16 states reported more than 5,000 cases (2 new), and 31 states, plus Guam, reported widespread community transmission (1 new, plus Guam). The Johns Hopkins CSSE dashboard is reporting 432,579 US cases and 14,830 deaths as of 10:45am on April 9.

The San Francisco Department of Public Health is implementing a contact tracing task force to suppor COVID-19 surveillance and response in the city. The task force includes approximately 40 people, including members drawn from non-traditional fields, including library science and university students, and it could potentially grow to as many as 150 people, if needed. As of yesterday afternoon, San Francisco reported 676 positive COVID-19 cases and 10 total deaths.

On Tuesday, the US Department of Health and Human Services announced that it would relax enforcement of legislation prohibiting healthcare institutions from sharing patients’ protected medical information as long as it is used for “public health and health oversight activities” related to COVID-19.

The US CDC reported 374,329 cases (43,438 new) and 12,064 deaths (3,154 new) on April 7. These are both a substantial increase over the previous day; however, it is potentially the result of delays in reporting over the weekend. As of yesterday, 14 states have reported more than 5,000 cases (1 new), and 30 states have reported widespread community transmission (1 new). The Johns Hopkins CSSE dashboard is reporting 401,166 US cases and 12,936 deaths as of 10:30am on April 8.

Mayor of Los Angeles Eric Garcetti issued an emergency order requiring employees working at business or organizations that are designated as “essential services”—as well as their customers—to wear face coverings to reduce SARS-CoV-2 transmission. Business owners are responsible for supplying masks for their employees. The order emphasizes this order does not refer to non-medical masks or respirators (which should be reserved for healthcare workers); rather, the coverings include cloth masks, scarves, or bandannas. Multiple other cities in California and elsewhere in the United States are also mandating mask use in the community. The US CDC guidance recommends mask use by the public, particularly when maintaining proper social distancing is not possible, but the CDC guidance emphasizes that the measure is voluntary.

The US Department of Health and Human Services announced this morning that the government finalized a $500 million contract with GM to produce 30,000 ventilators to support the US response.

The US CDC reported 330,891 cases (26,065 new) and 8,910 deaths (1,294 new) on April 6. As of yesterday, 13 states reported more than 5,000 cases (2 new), and 29 states reported widespread community transmission (2 new). The Johns Hopkins CSSE dashboard is reporting 378,289 US cases and 11,830 deaths as of 12:00pm on April 7.

In response to a shortage of hydroxychloroquine, President Trump called on India to relax export restrictions to allow hydroxychloroquine to be shipped to the United States, and at yesterday’s White House Coronavirus Task Force briefing, he referenced potential “retaliation” if India did not comply with the request. India reportedly acquiesced to the request and will allow hydroxychloroquine to be exported to the United States. This request follows a US government announcement that it would restrict shipments of personal protective equipment to other countries under the Defense Production Act.

A recent decision by the Wisconsin state Supreme Court overturned an executive order by Wisconsin Governor Tony Evers that would have suspended in-person voting during the state’s primary election today. Yesterday, Governor Evers issued a last-minute executive order suspending in-person voting in the state through June 9 due to concerns about SARS-CoV-2 transmission at voting sites. Later that day, however, the state Supreme Court overturned the order, and the state’s primary election takes place today as scheduled. Reports indicate that many voters are hesitant about voting in person, particularly in light of the state’s “safer at home” order. Additionally, many voting locations were not open, which would result in longer lines and wait times for those who do vote. Furthermore, the US Supreme Court ruled to overturn a lower court’s decision that would have extended absentee voting in Wisconsin until April 13, allowing ballots submitted after the election date to be counted.

The US CDC reported 304,826 cases (27,043 new since the previous day; 65,007 new since Friday’s briefing) and 7,616 deaths (1,023 new since the previous day; 3,103 new since Friday’s briefing) on April 6. Of these cases, fewer than 2.5% have an identified exposure—travel-related or close contact of a known case. As of yesterday, 11 states have reported more than 5,000 cases (2 new since Friday’s briefing), and 27 states have reported widespread community transmission (1 new since Friday’s briefing). The Johns Hopkins CSSE dashboard is reporting 338,995 US cases and 9,683 deaths as of 11:45am on April 6.

On Friday, the US CDC updated guidance regarding the use of masks among the general public. Based on data collected over the course of the pandemic, the CDC now “recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission.” The new guidance is based on the current understanding that individuals with no symptoms or mild symptoms can transmit SARS-CoV-2 to others, so wearing a mask could reduce that risk. The mask use aims to trap droplets expelled by the mask wearer in order to reduce the amount of virus potentially released into the environment. The CDC emphasizes that respirators and surgical masks should be reserved for healthcare personnel and that wearing a mask does not replace existing social distancing guidance. The CDC also provides instructions for constructing homemade masks for this purpose—as well as donning, doffing, and washing instructions.

Washington Governor Jay Inslee announced that the state will return 400 ventilators obtained from the SNS in order to support the COVID-19 response in New York and other states. In light of the recent decline in COVID-19 incidence in Washington, state officials, including representatives from the Washington State Hospital Association, determined that they did not need the additional ventilators to support their response operations at this time. Additionally, Washington state purchased 750 ventilators of their own, which are anticipated to arrive in the coming weeks.

The US CDC reported 213,144 cases (27,043 new) and 4,513 deaths (910 new) on April 2, continuing its accelerating trajectory. Of these cases, fewer than 2% have an identified exposure—travel-related or close contact of a known case. As of yesterday, 10 states have reported more than 5,000 cases (2 new), and 26 states have reported widespread community transmission (1 new). The Johns Hopkins CSSE dashboard is reporting 245,658 US cases and 6,058 deaths as of 10:45am on April 3.

Yesterday, US President Donald Trump invoked the Defense Production Act (DPA) twice, in order to secure production respirators and mechanical ventilators to support the COVID-19 response. President Trump invoked the DPA to increase the production of mechanical ventilators from 6 companies and again to ensure the supply of N95 respirators from 3M.

Reports continue about the construction of temporary hospital facilities across the country, including retrofitting existing buildings, such as the Javits Convention Center in New York, or field hospitals, such as the one established in Central Park. On the West Coast, the US Army is establishing a 250-bed field hospital in Seattle, at the CenturyLink Event Center. Like many similar facilities in the United States, this hospital is not intended to treat COVID-19 patients. Rather, it will provide care for other conditions in an effort to make additional capacity available in the local health system for COVID-19 patients. This was the initial plan for the Javits Convention Center facility, but this recently changed to permit the admission of COVID-19 patients. Similar provisions may be implemented at similar facilities in Louisiana and Texas.

The CDC updated its information regarding SARS-CoV-2 transmission. In the previous iteration of this information, the CDC noted that individuals not currently experiencing symptoms could potentially transmit the infection to others, citing anecdotal reports, but this was not thought to be a main driver of disease spread. The current guidance reflects growing evidence that transmission by asymptomatic individuals—including during the incubation period before symptoms present and by infected individuals that never develop symptoms—is possible, based on “recent studies” demonstrating this capability. Additionally, the updated information removes a previous reference to “affected geographic areas” and acknowledges widespread community transmission in the United States and states that SARS-CoV-2 is transmitting more readily than influenza.

The US CDC reported 186,101 cases (22,562 new) and 3,603 deaths (743 new) on April 1. Of these cases, fewer than 2.5% have an identified exposure—travel-related or close contact of a known case. As of yesterday, 8 states have reported more than 5,000 cases (1 new), and 25 states have reported widespread community transmission (5 new). The Johns Hopkins CSSE dashboard is reporting 217,263 US cases and 5,151 deaths as of 11:00am on April 2.

Over the weekend, the US Army Corps of Engineers completed its conversion of the Jacob K. Javits Convention Center in New York City into a temporary 2,000-bed hospital, and patients were admitted starting on March 30. Similar to the hospital ships, this facility will not treat COVID-19 patients, but rather, it will provide care for other patients in order to free up additional capacity at nearby hospitals.

The CDC reported 163,539 cases (22,635 new) and 2,860 deaths (455 new) on March 31. As of yesterday, 7 states have reported more than 5,000 cases, and 20 states have reported widespread community transmission. The Johns Hopkins CSSE dashboard is reporting 190,740 US cases and 4,127 deaths as of 12:00pm on April 1. Notably, New York state reported 9,298 new cases yesterday, bringing the statewide total to 75,795—a daily increase of 14%. New York City has reported 43,139 of these cases, including 5,686 of the newly reported cases—a daily increase of 15.2%.

The US Coronavirus Task Force presented updated projections for US COVID-19 epidemic. The discussion included rationale behind recent orders to extend social distancing . Based on available modeling, notably by the Institute for Health Metrics and Evaluation , the US government projects at least 100,000 deaths nationwide, under continued and effective implementation of social distancing measures.

The US CDC reported 140,904 cases (18,251 new) and 2,405 deaths (293 new) on March 30. The Johns Hopkins CSSE dashboard is reporting 164,610 US cases and 3,170 deaths as of 7:45am on March 31. According to the dashboard data, New York City is approaching 1,000 deaths (currently 914), and the state of New York is currently at 1,192 deaths, more than a third of the national total.

The US FDA issued an Emergency Use Authorization for the Battelle Critical Care Decontamination System, which is designed to decontaminate N95 respirators in order to allow healthcare workers to safely reuse them (as many as 20 times) and extend existing inventory in health systems across the country. The system utilizes hydrogen peroxide vapor to “destroy bacteria, viruses and other contaminants, including...SARS-CoV-2,” and it can process up to 80,000 masks per day. The FDA initially limited the throughput to 10,000 masks per day, but the system is now permitted to operate at full capacity. The system is currently in use in Ohio, and Battelle intends to deploy units to New York, Washington state, and Washington, DC.

Today, the CDC reported 140,904 cases (18,251 new) and 2,405 deaths (293 new). Of these cases, 97.7% do not have an identified exposure—travel-related or close contact of a known case—and are still under investigation. The United States now has the most reported COVID-19 cases of any country, followed by Spain (85,195 cases) and Italy (75,528 cases). The United States has reported approximately 50% more cases than China, but only 64% of the deaths (81,470 cases and 3,304 deaths in China). The Johns Hopkins CSSE dashboard is reporting 144,672 US cases and 2,575 deaths as of 12:00pm on March 30.

On Friday, March 27, US President Donald Trump signed the CARES Act , the “phase 3” COVID-19 response and funding package containing economic stimulus measures. The package includes $1,200 “tax rebates” for individuals (with additional $500 rebates for dependents), suspension of payments for federal student loans, tax relief for businesses, additional funding for the healthcare system, and regulatory changes to promote testing and authorization of investigative pharmaceuticals.

Yesterday, President Trump announced that the national guidelines regarding social distancing measures would remain in effect until the end of April. What was announced initially as the White House’s “15-Day Plan” was set to expire today, but after evaluating the US epidemic, the White House determined that the measures needed to remain in place in order to slow transmission across the country. A number of states and cities have implemented more restrictive and mandatory social distancing programs, but the national guidelines provide a minimum standard for individuals, families, and businesses nationwide.

The US government invoked the Defense Production Act (DPA) for the first time, reportedly after negotiations with General Motors to produce ventilators stalled last week. Reportedly, General Motors was already in the process of transitioning production lines to manufacture the ventilators, so it is unclear whether invoking the DPA will speed the delivery of ventilators. Additionally, President Trump delegated additional authorities under the DPA to the Secretaries of Homeland Security and Health and Human Services, including the ability to provide loans necessary to increase production of necessary resources and authority to coordinate the nationwide production and distribution of medical resources, including materials and services available “in the civilian market.” States have reported barriers to obtaining necessary supplies , including bidding against each other and losing contracts to the federal government, so centralized control of nationwide distribution could potentially provide more efficient use of limited resources.

President Trump also issued an executive order to activate some members of the US military reserve to support COVID-19 response efforts. Additionally, FEMA will provide funding to Florida, Louisiana, Maryland, Massachusetts, New Jersey, Guam, and Puerto Rico to cover 100% of COVID-19 response activities conducted by National Guard units as well as additional operational support for those activities.

The US CDC has not historically issued travel advisories for travel within the United States ; however, it issued a travel advisory over the weekend for New York, New Jersey, and Connecticut. Most travel guidance issued by the US CDC includes recommendations for US travelers who may be traveling to an affected area (eg, considerations for deciding whether or not to travel, precautions to take while traveling), but the coronavirus-related guidance for these 3 states take a different approach. This travel advisory “urges residents of New York, New Jersey, and Connecticut to refrain from non-essential domestic travel for 14 days,” essentially asking residents of this affected area to avoid traveling elsewhere. The CDC guidance followed a series of statements by President Trump regarding the possibility of instituting a federal quarantine on New York tri-state area, which prompted opposition from New York Governor Andrew Cuomo and others.

Florida Governor Ron DeSantis issued several executive orders requiring all travelers arriving from New York, New Jersey, Connecticut , and Louisiana to isolate or quarantine themselves for 14 days after entering Florida. Florida will not bear any costs associated with the quarantine or isolation of these individuals. The executive order pertaining to Louisiana also includes provisions for establishing “checkpoints on the roadways for those persons and vehicles entering the State of Florida,” at which Florida officials will require written documentation of travelers’ purpose and destination in Florida.

In Rhode Island, Governor Gina Raimondo issued executive orders requiring 14-day quarantine for all travelers arriving from outside the state, including establishing checkpoints along the state’s southern border with Connecticut, which will divert all vehicles with out-of-state license plates for screening and instruction.

Texas Governor Greg Abbott expanded previously issued travel restrictions (originally for the New York tri-state area) to include mandatory quarantine for all travelers from New Orleans, Louisiana, and all travelers arriving by air from California; Louisiana; Washington; Atlanta, Georgia; Chicago, Illinois; Detroit, Michigan; and Miami, Florida. Other states are also recommending against travel to areas with higher reported transmission or considering their own travel restrictions. Kentucky Governor Andy Beshear, for example, called on Kentuckians to avoid unnecessary travel across the border to Tennessee, particularly for the purpose of participating in activities that are prohibited in Kentucky but not Tennessee.

The United States currently has 85,996 confirmed cases according to the Johns Hopkins CSSE dashboard, surpassing the total for China (81,894 cases). Of these, 39,140 cases are from New York and 6,876 are from New Jersey. In its most recent situation report published March 26th, US CDC reported 68,440 total cases and 994 total deaths.

The US House of Representatives is expected to vote today on the largest economic stimulus package in US history to provide support to affected families, businesses and health systems. Due to several members of Congress testing positive for the virus and various quarantine policies being implemented across states, voice voting will be conducted and a smaller number of representatives will be present in the Capitol. A single lawmaker could potentially delay the ability for the House to vote if they ask for a roll call or quorum, which would require 216 lawmakers to be present in the building. Multiple House members from both political parties have threatened to ask for a quorum to delay the vote. The bill comes at a time of substantial health system strain and shortages of critical testing kits and PPE.

The US CDC reported 54,453 total (confirmed and presumptive) COVID-19 cases (10,270 new) and 737 deaths (193 new) nationwide on March 25. The Johns Hopkins CSSE dashboard is reporting 69,246 US cases and 1,046 deaths as of noon EDT on March 26. The dashboard reports that New York City accounts for 20,011 of these cases and 280 of the deaths.

The US Senate unanimously approved a $2 trillion relief package. While still awaiting approval from the US House of Representatives, if approved and enacted this package would become the largest in US history. According to NPR and the Washington Post , the package includes payments to qualifying Americans earning less than $75,000 and an expansion of unemployment insurance that allows for four months of full pay and raises the maximum unemployment insurance benefit by $600 per week. Additionally, the package would provide $150 billion in funding to the health system, including funding to increase supply of ventilators and other materials.

The US CDC reported 44,183 total (confirmed and presumptive) COVID-19 cases on March 24 and 54,453 cases today (10,270 new). There were 544 deaths nationwide on March 24 and 737 deaths reported today (193 new). Of these cases, 97.1% do not have an identified exposure—travel-related or close contact of a known case—and are still under investigation. The Johns Hopkins CSSE dashboard is reporting 55,568 US cases and 809 deaths as of 12:00pm on March 24.

In remarks yesterday at the White Coronavirus Task Force briefing , US President Donald Trump expressed his desire to ease nationwide social distancing guidelines, outlined under the White House's ongoing "15-Day Plan," by Easter, which falls on April 12. Dr. Anthony Fauci, Director of the National Institutes of Allergy and Infectious Diseases, commented that the situation will continue to be evaluated daily, and a decision will be made regarding the future of national social distancing policies based on the available evidence and trends. Recommended measures may also differ at the state level.

The US Senate reportedly reached an agreement on a US$2 trillion economic stimulus package in response to the ongoing COVID-19 pandemic. The plan will include $1,200 checks directly to individuals to supplement lost income and other financial difficulties; $367 million in small business loans; a $500 billion loan fund for "industries, cities and states"; $130 billion for hospitals; and $150 billion for "state and local stimulus funds." The bill also expands unemployment funding and increases associated benefits, includes transparency mechanisms regarding how funding is utilized, and prohibits stimulus funds from going to companies or programs owned by the President, White House staff, or member of Congress. The Senate is scheduled to vote on the bill today, but it is still unclear how it will proceed in the House of Representatives. The House is not in session, but there are mechanisms—such as "unanimous consent"—which could allow the bill to pass and be sent to the President without the Representatives voting in person.

The US CDC reported 33,404 total (confirmed and presumptive) COVID-19 cases and 400 deaths nationwide on March 23, more than double the number of cases reported on Friday and just shy of twice the reported deaths. Of these cases, 97.0% do not have an identified exposure—travel-related or close contact of a known case—and are still under investigation. The Johns Hopkins CSSE dashboard is reporting 46,485 US cases and 591 deaths as of 8:45am on March 24.

Yesterday, the White House announced the COVID-19 High Performance Computing Consortium, a new public-private partnership that aims to "significantly advance the pace of scientific discovery in the fight to stop the virus." The consortium brings together high-power computing resources from across the private sector, academic institutions, and federal agencies and resource organizations—"all volunteering free compute time and resources"—to tackle highly technical and complex challenges associated with COVID-19. Researchers requiring advanced computing resources, such as to identify prospective compounds or formulations for vaccines and treatment products, are encouraged to submit proposals via an online system.

The US Senate is reportedly making progress toward an economic stimulus package , now estimated at US$2 trillion, which could potentially pass the Senate as early as today. The "phase 3" funding aims to provide financial security for workers and businesses as well as boost funding for hospitals and health systems as they prepare for and respond to an increase in COVID-19 cases. There appears to be optimism that an agreement can be reached soon . A proposal presented recently by Speaker of the House Nancy Pelosi outlines a number of additional measures supported by Democrats. The House proposal—the Take Responsibility for Workers and Families Act —outlines US$2.5 trillion in economic support, but it is unclear the extent to which the Senate version of the bill will include any of these provisions.

On Friday, March 20, the US Army Corps of Engineers announced plans to convert hotels, university dormitories, and similar spaces into hospitals to increase clinical bed space to support the COVID-19 response. States will identify suitable spaces—principally, those currently out of service and empty—and lease them to the Army Corps of Engineers, which will rapidly convert the available rooms for clinical care, with capabilities similar to intensive care units (ICUs), using standardized construction plans. FEMA and the Department of Health and Human Services will provide supplies for these units. The program is already being implemented in New York, and the Department of Defense plans to extend it to at least 18 states in the coming weeks. States will also be permitted to implement the program on their own, without needing to wait for the Corps of Engineers, using the same conversion plans and operational model. The plan is also adaptable to other settings like gymnasiums, arenas, or convention center, but those sites may focus on a lower level of clinical care due to the inability to separate patients into individual rooms.

Building on an existing pilot study to conduct seasonal influenza surveillance, the Seattle Coronavirus Assessment Network (SCAN) aims to better characterize community transmission of SARS-CoV-2. SCAN will perform SARS-CoV-2 testing for a representative sample of the Seattle population, including for individuals not experiencing COVID-19 symptoms, in order to more accurately evaluate the scope of the local epidemic. The extent to which SARS-CoV-2 infection results in mild or no disease and the role of asymptomatic infections and mild cases in driving community transmission remains uncertain, particularly as testing in the United States largely remains limited to more severe cases—especially, those requiring hospitalization. SCAN aims to conduct 300 tests per day, with an additional 100 tests from local clinical specimens, and the program will notify participants if their test is positive so that they can reduce the risk of further transmission.

The US CDC reported 15,219 total (confirmed and presumptive) COVID-19 cases and 201 deaths nationwide. This represents a 45.7% increase in reported cases and a 34% increase in deaths from Thursday to Friday*. Of these cases, 95.6% do not have an identified exposure—travel-related or close contact of a known case—and are still under investigation. The Johns Hopkins CSSE dashboard is reporting 35,345 US cases and 473 deaths as of 10:30am on March 23. This would put the United States at #3 worldwide in terms of national COVID-19 incidence, behind only China (81,496 cases) and Italy (59,138).

Yesterday, the White House issued a memorandum to governors announcing the federal government's intention to provide 100% cost sharing—via FEMA—for National Guard units activated by states in response to the COVID-19 pandemic. The National Guard units will still support state governments (i.e., will not be federalized), but this measure is intended to make it more financially feasible for states to activate them to support local response activities.

Efforts to finalize an economic stimulus package to mitigate COVID-19's financial impact on US businesses and individuals stalled yesterday, as the Senate failed to pass the bill in its current form. There are conflicting reports regarding how close Republicans and Democrats in the Senate are to negotiating a solution. Reportedly, differences remain with respect to how funding is allocated for businesses. Additionally, bipartisan efforts in both the House of Representatives and Senate to implement policies that would allow Representatives and Senators to vote remotely have failed to make progress. This issue is increasingly gaining attention as members of of Congress have tested positive for SARS-CoV-2 and several others have self-quarantined due to potential exposures, all of whom are unable to vote in person.

US President Donald Trump delegated as much as $50 billion from the Exchange Stabilization Fund to Treasury Secretary Steven Mnuchin to inject much-needed stability for various aspects of economic markets and industries in the United States. Among the top priorities is the airline industry , which has taken a historic financial hit as travelers across the country cancel flights over concerns about COVID-19.

Following closely on the heels of California, New York Governor Andrew Cuomo issued an executive order on Friday, directing that "100% of the workforce must stay home, excluding essential services" such as "shipping, media, warehousing, grocery and food production, pharmacies, healthcare providers, utilities, banks and related financial institutions." The New York COVID-19 website describes it as: " New York State on PAUSE ." Previously—on March 18 and March 19 —Governor Cuomo issued executive orders to direct businesses statewide that provide non-essential services to reduce the non-essential workforce by 50% and 75%, respectively. Additionally, "non-essential gatherings," including parties or other social events, are cancelled or postponed, regardless of size. When people do go into public, they "must practice social distancing of at least six feet from others," and they should limit their use of public transportation to the extent possible. The current executive order extends the restrictions to April 19. New York published detailed guidance on what qualifies as essential businesses and services , which includes bars, restaurants, liquor stores, breweries, distilleries , and other establishments that produce or sell alcohol. Despite efforts to keep restaurants viable during the COVID-19 crisis, there are reports that some (or possibly many) have already determined that maintaining limited operations for takeout of delivery is not feasible and closed their doors and laid off their entire staff.

Illinois, Connecticut, New Jersey, Ohio, Delaware, Louisiana, and Massachusetts each also issued statewide "stay at home" orders, as did a number of cities, including Philadelphia. All of the orders generally include similar provisions. Individuals are directed to stay at home to the extent possible, but they are permitted to leave their homes to shop for groceries and other supplies; seek medical, dental, or veterinary care; provide care for others; exercise or engage in other outdoor activities; work at essential businesses; and utilize other essential services (e.g., post office, laundry). When people do need to go into public, the orders direct them to maintain social distancing, including staying 6 feet away from others and reducing public transit use, if possible. Some states require written documentation for essential workers to be carried while they are in public. Additionally, the orders direct restaurants, bars, and other eating establishments to operate only for drive-thru, takeout, or delivery, and the orders may place restrictions on other types of public spaces, like playgrounds, beaches, and parks.

The US CDC reported 10,442 total (confirmed and presumptive) COVID-19 cases and 150 deaths nationwide. This represents a 48.3% increase in reported cases and a 54.6% increase in deaths from the previous day. Of these cases, 94.3% do not yet have an identified exposure. The Johns Hopkins CSSE dashboard is reporting 14,250 US cases and 150 deaths as of 11:15am on March 20.

Yesterday afternoon, US President Donald Trump and members of the White House Coronavirus Task Force announced that the Federal Emergency Management Agency (FEMA) would be taking over as leader for the national COVID-19 response . FEMA is currently activated at Level 1 for the COVID-19 response, its highest level for a national emergency. Following the press briefing, President Trump and Vice President Pence held a teleconference at FEMA headquarters with governors from across the United States. During that call, the President re-emphasized FEMA's new leadership role for the federal coronavirus response and urged governors to coordinate directly with their respective FEMA Regional Offices. The shift in response leadership away from the HHS has raised questions about the future of the US government's response operations. Some have noted that high-profile and senior CDC officials have not been visible or available recently and that there have been contradictions between CDC and White House COVID-19 recommendations, including the maximum size of gatherings. Some experts argue that the CDC is the lead government agency for infectious disease response and that CDC officials need to provide information and guidance directly to the public. It is unclear at this point if or how the roles of the CDC, FEMA, and other government agencies will change in the coming weeks as FEMA takes the lead.

Yesterday, the US Senate unveiled an initial draft of a US$1 trillion economic stimulus package that aims to mitigate the financial impact of the COVID-19 pandemic on individuals, companies, and industries in the United States. This "phase 3" package includes US$300 million in loans to support small businesses, US$200 million for the most-affected industries (e.g., airlines), and direct payments to individuals. The direct payments could be on the order of $1,200 per person for adults, with additional smaller payments for children, and they aim to supplement lost income due to the pandemic. The current draft also proposes moving the income tax filing deadline from April to July. The proposal also reportedly includes provisions for additional healthcare resources and addressing student loans and business taxes. Negotiations between Republicans and Democrats are just getting underway, but there appears to be initial opposition to some of the bill's provisions. The previous 2 legislative efforts to address the COVID-19 response have involved a good deal of bipartisan cooperation and support, so hopefully, that trend continues now and in the future.

Yesterday, California Governor Gavin Newsom issued a statewide "stay at home" order in response to the COVID-19 pandemic. The order, similar to the "shelter in place" order recently implemented in the San Francisco Bay area, directs all California residents to "stay home or at their place of residence," except for essential tasks. The Governor's priorities for issuing the order include ensuring the continuity of operations for essential infrastructure sectors , as outlined by the federal government, and protecting the health of high-risk individuals. California's COVID-19 website provides additional clarification, noting that individuals will be permitted to leave their homes for things such as purchasing gasoline, shopping for food and other supplies (including farmers markets, food banks, and restaurant takeout/delivery), banking, or doing laundry. Additionally, essential state and local government functions will continue, including law enforcement.

The US CDC reported 7,038 total (confirmed and presumptive) COVID-19 cases and 97 deaths across all 50 states as well as Washington, DC; Puerto Rico; Guam; and the US Virgin Islands. This represents a 66.5% increase in reported cases and a 29.3% increase in deaths from the previous day. Of these cases, only 545 have an identified source (travel-related or close contact of another identified case) and 6,493 cases (92.2%) are still under investigation. The Johns Hopkins CSSE dashboard is reporting a total of 9,415 COVID-19 cases and 150 deaths in the United States as of 7:30am on March 19.

At a press conference yesterday, US President Donald Trump and senior officials from US government agencies announced a series of measures aimed to bolster the domestic COVID-19 response. Perhaps the biggest announcement was that President Trump is invoking the Defense Production Act in order to increase production of critical supplies and equipment to support the US COVID-19 response. The Defense Production Act enables the federal government to compel private companies to manufacture materials, supplies, and equipment during crises. In this instance, the Act will be used to increase the supply of personal protective equipment, such as masks, respirators, and gloves, and ventilators needed to treat COVID-19 patients. President Trump authorized Secretary of Health and Human Services Alex Azar to coordinate nationwide production and distribution of critical supplies, equipment, and services.

The White House also announced that the US Department of Defense would increase support for the domestic COVID-19 response. The increased support will include the deployment of hospital ships USNS Mercy and Comfort to provide additional hospital capacity for New York and California as well as field hospitals. The military will also distribute 2,000 ventilators and various personal protective equipment (including 5 million N95 masks) to hospitals nationwide. Also, the US Department of Defense will soon certify its 16th laboratory to perform SARS-CoV-2 testing, which will provide additional testing capacity to support the domestic response.

President Trump signed the " Families First Coronavirus Response Act ," which will provide additional support for the domestic COVID-19 response. The bill includes provisions for establishing a federal emergency paid leave program for individuals unable to work as a result of the COVID-19, expanding state unemployment benefits, requiring employers to provide paid sick leave, providing SARS-CoV-2 diagnostic testing free of charge to consumers, and providing liability protection for "respiratory protective devices" used as part of the COVID-19 response. The bill is reportedly "phase 2" of US legislative efforts to bolster the response, and "phase 3", which is currently estimated to total $1 trillion , will address an economic stimulus package proposed by the US Department of the Treasury.

The US CDC reported 4,226 total (confirmed and presumptive) COVID-19 cases and 75 deaths across 53 states and Washington, DC; Puerto Rico, Guam, and the US Virgin Islands. Of these cases, 474 have an identified source (either travel-related or close contact of another identified case) and 3,752 cases (88.8%) are still under investigation. The Johns Hopkins CSSE dashboard is reporting a total of 6,519 COVID-19 cases and 115 deaths in the United States as of 11am on March 18.

Yesterday, New York Mayor Bill DeBlasio issued an executive order banning "pooled" or "shared rides" for 5 days. Pooled or shared rides refer to high-volume taxi or ride-sharing services that allow riders that are not otherwise part of the same group to ride together in the same vehicle, such as Uber Pool. Mayor DeBlasio also discussed the possibility of implementing a "shelter in place" order in New York in the coming days, similar to what is currently in place in San Francisco. Several reports note that New York Governor Andrew Cuomo opposed the idea and commented that the state government must approve any such measure. At a press conference, Mayor DeBlasio said a decision would be made in the next 48 hours, but it remains to be seen to what extent a citywide order would or could be implemented in New York.

The US CDC reported 4,226 total (confirmed and presumptive) COVID-19 cases and 75 deaths across 49 states and Washington, DC; Puerto Rico, Guam, and the US Virgin Islands. This is more than double the 1,629 cases reported on Friday, March 13. Of these cases, only 474 have an identified source (travel-related or close contact of another identified case) and 3,752 cases (88.8%) are still under investigation. The Johns Hopkins CSSE dashboard is reporting a total of 5,204 COVID-19 cases and 92 deaths in the United States as of 12:15pm on March 17.

Yesterday, US President Trump announced a series of guidelines as part of a 15-day plan to slow the growing COVID-19 epidemic in the United States. In addition to existing guidance regarding improved hygiene, self-isolation for those that feel ill, and generally reducing public interaction, particularly for older and other high-risk individuals, the plan promotes more aggressive social distancing actions. The President recommended remote work and school "whenever possible"; using drive-thrus, takeout, or delivery instead of eating in restaurants and bars; avoiding "discretionary travel"; and not visiting nursing homes or other long-term care facilities where there are older, high-risk individuals. Perhaps the biggest policy change was the President's recommendation to avoid social gatherings of more than 10 people. Many states have restrictions or recommendations in place for much larger gatherings (eg, 100 or 250 people), and this is significantly more restrictive than the existing CDC guidance, which lists 50 or 250 people (in various locations on the CDC website). The President's guidance also recommends schools should be closed in and around areas with evidence of community transmission and that "bars, restaurants, food courts, gyms, and other indoor and outdoor venues where groups of people congregate" should be closed in states with evidence of community transmission.

The San Francisco Bay area in California instituted a "shelter in place" starting at 12:01am this morning in order to enforce enhanced social distancing measures. The shelter in place order was jointly issued by Health Officers in San Francisco, Marin, San Mateo, Santa Clara, Contra Costa, and Alameda Counties as well as the City of Berkeley, and it is currently scheduled to end on April 7 (3 weeks) unless otherwise extended or terminated early. The order directs residents of the San Francisco Bay area to remain in their homes, except for designated "essential activities," and it aims to build on more traditional social distancing measures. The associated FAQ page emphasizes that provisions of the shelter in place order are mandatory, as opposed to previous voluntary social distancing measures, and that violations will be treated as misdemeanor criminal offenses. The order aims to "minimize social interactions," but residents will be permitted to go out in public to buy groceries or other supplies, for medical or veterinary appointments, or even just to get some fresh air (as long as they remain 6 feet apart from each other). Those who perform designated essential functions in the community (e.g., healthcare workers and first responders, government agencies and postal service, grocery stores, gas stations) are permitted to continue working, and food delivery services will remain in operation. As of 10am on March 16, San Francisco had reported 40 cases of COVID-19 and zero deaths .

The Johns Hopkins CSSE map reports 3,813 COVID-19 cases and 69 deaths in the United States across 49 US states. The largest outbreaks are reported in New York, Washington, and California, in addition to several other states topping 100 cumulative cases. Earlier today, Governor Andrew Cuomo announced 221 new cases in New York State, bringing the total there to 950. The Washington State Department of Health reports 769 COVID-19 cases and 42 deaths. Over half of the cases (55%) and deaths (88%) are tied to patients from King County. California's Department of Health's most recent report listed 335 COVID-19 cases and 6 deaths.

Several US states and territories have implemented curfews and other restrictions. Certain cities in New Jersey , such as Hoboken, have instituted a curfew that prevents people from leaving their homes from 10 PM to 5 AM. Puerto Rico has also issued an executive order requiring a two-week closure for most businesses as well as an overnight curfew starting at 9 PM through March 30.

The US Senate is expected to vote on the House-passed Families First Coronavirus Response Act to support businesses and families affected by response measures. The bill allows for paid sick leave for companies of 500 employees or fewer. Businesses with fewer than 50 employees, however, could apply for exemption from this rule if offering the benefit is detrimental to the business. The exemptions could apply to over 30 million Americans who are employed by small businesses. The bill also includes funding for expanding food support programs and for free COVID-19 testing.

The US CDC reported a total of 1,215 cases and 36 deaths across 42 states and Washington, DC. Of those cases, 125 are travel-related, 102 are close contacts of known cases, and 988 are still under investigation.

The US Senate will cancel the recess scheduled to begin today in order to remain in session to draft and debate legislation related to the US COVID-19 response. Senate Majority Leader Mitch McConnell was under pressure, including from fellow Republican Senators, to keep the Senate in session in order to finalize coronavirus legislation. The US House of Representatives and the White House are still negotiating a legislative package that aims to address economic and other effects of the COVID-19 epidemic in the United States. Reportedly, the bill is close to being finalized, with hopes that the House of Representatives could vote on it today. Key issues include free coronavirus testing, paid sick leave for COVID-19 patients, and increased support for states to address funding for unemployment and food assistance programs.

Ohio Governor Mike Dewine announced that all K-12 schools will be closed through April 3, and the state banned all mass gatherings of more than 100 people. Michigan Governor Gretchen Whitmer also announced that all K-12 schools will be closed through April 5. Notably, Governor Whitmer also expanded access to telemedicine statewide, and she called for President Trump to initiate a special enrollment period for the ACA to ensure access to healthcare during the COVID-19 pandemic. Maryland Governor Larry Hogan announced closure of all schools through March 27 as well as a series of other response measures, including a ban on gatherings larger than 250 people, the closure of cruise ship terminal in Baltimore, and the activation of the Maryland National Guard to support the response. The announcement comes on the heels of Maryland detecting its first reported instance of community SARS-CoV-2 transmission . Washington, DC, public schools will be closed from March 16 - March 31. Spring Break for these schools has been rescheduled for March 17-23 (formerly scheduled for April), and students will participate in distance learning from March 24-31. Meals will be made available for all students during that period at designated schools throughout the District.

In addition to Ohio, Michigan, Maryland, and Washington, DC, several other states have closed schools in certain higher-risk areas. Washington Governor Jay Inslee ordered K-12 schools closed in King, Pierce, and Snohomish counties through April 24, affecting 600,000 students in high-risk areas. Schools in San Francisco and part of nearby Contra Costa County in California are also closed, but the state has not mandated closures statewide. Pennsylvania Governor Tom Wolfe announced that schools in Montgomery County (13 reported cases) will be closed for 2 weeks. Pennsylvania is also mandating remote work for state employees, and the state is implementing a 10-day paid leave policy for individuals who cannot work remotely. The governors in Georgia and Kentucky both recommended that schools consider closing, but they did not mandate closures.

The US CDC reported 938 confirmed cases and 29 deaths across 38 states and Washington, DC. Other estimates for US cases, including The New York Times and the Johns Hopkins CSSE dashboard , report more than 1,300 cases nationwide and at least 38 deaths.

US President Donald Trump delivered an address from the White House Oval Office yesterday evening to provide updates on the COVID-19 epidemic and associated response activities and policies. The new policy initiatives included restrictions on travel from European countries —excluding the United Kingdom and Ireland—in an effort to reduce imported COVID-19 cases. Foreign nationals who have been in any European country in the past 14 days will be prevented from entering the United States, and US citizens and permanent residents (as well as several other excepted groups) will be required to undergo screening upon their arrival. The address also announced an economic stimulus package to mitigate the impact to the US economy, including increased small businesses loans, deferral of tax payments for affected individuals and businesses, and financial support for quarantined or ill individuals affected by COVID-19. The President also called on the US Congress to approve payroll tax relief. The travel restrictions have already appeared to have negative economic impact for the airline industry , and some warn that they may not be effective at meaningfully slowing domestic transmission. European Council President Charles Michel and European Commission President Ursula von der Leyen issued a joint statement condemning the travel restrictions , noting that the pandemic is a "global crisis" and that "the U.S. decision...was taken unilaterally and without consultation."

Notably, the US CDC issued a blanket Level 3 travel warning ("avoid nonessential travel") for 29 European countries and a global Level 2 travel alert ("practice enhanced precautions") for all international travel.

In other news, the House and Senate sergeants at arms said in a statement released Thursday morning that the Capitol will be closed to the public until April 1. Only members, staff, journalists and visitors on official business will be permitted entry. The AP quoted their statement as saying, "[w]e are taking this temporary action out of concern for the health and safety of congressional employees as well as the public, … We appreciate the understanding of those with planned visits interrupted by this necessary but prudent decision."

The CDC reports a total of 938 COVID-19 cases and 29 deaths nationally across 39 states.

The US Centers for Disease Control reported 647 cases in 37 states and Washington DC.

Santa Clara County, which has reported 43 confirmed cases, has ordered the cancelation of all mass gatherings. Sacramento County is no longer requiring automatic quarantine for people with a known exposure, indicating a shift from containment to mitigation measures.

New York announced the enactment of a containment area for a one-mile radius around the area with the highest numbers of cases in Westchester County. There will not be movement restrictions, but there will be widespread cancellation of events. The National Guard will be supporting cleaning efforts and ensuring food is delivered to individuals in quarantine.

Updated reports share that there are more than 500 cases and 22 deaths tied to the COVID-19 outbreak in the United States.

The US Department of State published a travel warning for cruise ships . The warning specifically recommends that US citizens—"particularly travelers with underlying health conditions—avoid travel on cruise ships due to the ongoing COVID-19 epidemic. The US CDC has acknowledged the increased risk for infection in cruise ship environments. The State Department notice emphasizes that travelers should not rely on the federal government for repatriation flights in the event of an outbreak onboard a cruise ship, noting that recent examples may not be standard operating procedure moving forward.

In its March 5 update the US CDC confirmed 99 cases and 10 deaths across 13 states (data current through 4pm on March 4).

CNBC reported that President Trump signed a sweeping $8.3 billion spending bill to fund US response to COVID-19. The spending bill received wide bipartisan support with only three Congressmen opposing it. Other legislative issues, such as determining how US workers could receive paid time off, are still to be finalized.

The government in King County, Washington (USA)—home to Seattle— purchased a local motel for the purposes of housing quarantined or isolated COVID-19 patients and persons under investigation (PUIs).

The US CDC is officially reporting 129 total confirmed cases—80 domestic cases and 49 repatriated cases from China and the Diamond Princess cruise ship—including 9 deaths (data through 4pm on March 3). The WHO Situation Report lists 108 US cases and 6 deaths.

As of this morning, 15 US states have reported a total of over 100 cases, including 6 deaths in Washington. Texas, Washington state, California, and Nebraska are all reporting over 10 cases each, including those evacuated from Wuhan or the Diamond Princess cruise ship.

On February 29, the US State Department and CDC updated their travel advisories. The State Department has increased its advisory to level 3 for Italy , suggesting to reconsider travel. CDC recommends that travelers should avoid all nonessential travel to the country due to widespread community transmission. Similarly, the State Department issued a level 3 travel warning to South Korea advising to reconsider travel, and the CDC has recommended avoiding all nonessential travel. A Level 4 State Department travel advisory (Do Not Travel) remains in place for China . The existing Level 4 travel advisory for Iran , originally implemented over security concerns, was updated to include an additional warning about the country's COVID-19 outbreak and associated protective measures.

Last night, President Trump gave a national address on the coronavirus outbreak and the status of the US response. In it, he announced that Vice President Pence would be taking charge of the federal response. Subsequently, acting chief of staff Mick Mulvaney directed other administration officials to route all media requests regarding COVID-19 through the Vice President's office. This morning, the Vice President appointed Amb. Debbie Birx to serve as the White House Coronavirus Response Coordinator.

The CDC has issued a Level-3 travel advisory to South Korea recommending avoiding all non-essential travel, stating that there is "limited access to adequate medical care in affected areas". This follows announcements of Level-2 travel advisories for Italy and Iran , which call for enhanced precautions and recommendations to postpone nonessential travel for older adults and those with chronic medical conditions.

The US State Department and CDC raised travel alert warnings to Level 2 for Japan and South Korea. In its Traveler's Health Alert for both Japan and South Korea , the CDC said that sustained community transmission was occurring in the countries and that older adults or those with chronic medical conditions should consider postponing nonessential travel. Echoing the CDC's language, the State Department warnings for Japan and South Korea also stated that those suspected of having COVID-19 in these countries could face "travel delays, quarantine" and expensive medical costs.

The US CDC announced that some states reported issues with the SARS-CoV-2 test kits they received. The issues were identified during normal quality assurance procedures at the state laboratories, and the CDC is working to identify which states can continue using the test kits and which states need replacement supplies. The issue appears to be with the reagents used during the test, which resulted in inconclusive results in the affected states.

The US CDC announced that shipping has commenced to distribute 2019-nCoV diagnostic test kits nationwide. The kits are real-time reverse transcriptase PCR (RT-PCR) tests that use a testing instrument commonly used for seasonal influenza. The tests are designed to be used on both upper and lower respiratory specimens, and they can provide results in 4 hours from initial specimen processing. The initial shipments will distribute approximately 200 test kits to domestic laboratories, and additional kits will be shipped to "select international laboratories" as well. Each test kit can process 700-800 specimens. The test kits are not FDA-approved, so they will be utilized under an Emergency Use Authorization.

The United States Department of State has expanded their level four travel advisory, "Do Not Travel", to include all of China. China was previously at a level three advisory, while Hubei Province was at a level four.

President Trump is convening a task force on the US government's response to nCoV. " The Task Force is led by Secretary of Health and Human Services Alex Azar, and is coordinated through the National Security Council. It is composed of subject matter experts from the White House and several United States Government agencies, and it includes some of the Nation's foremost experts on infectious diseases.

The US CDC and State Department have both issued Level 3 travel warnings for China, recommending that travelers "reconsider travel" (State Department) or "avoid non-essential travel" (CDC). Included in the State Department's Level 3 travel warning is a short note that there is an additional Level 4 travel warning (ie, "do not travel") specifically for Hubei Province. Interestingly, the main State Department list of travel advisories shows China as having a Level 3 advisory, but it does not mention that a Level 4 warning exists for Hubei Province. The US Embassy & Consulates in China website has a dedicated page for the Hubei-specific Level 4 travel warning . Previously, the US CDC had separate travel alerts for China and Wuhan/Hubei, but these appear to have merged into a single Level 3 warning for the entire country.

The first case of 2019-nCoV in the United States is confirmed in a 35-year-old man who had returned from Wuhan, China.

Chinese state media reports the discovery of a new strain of coronavirus that has sickened dozens in central China.