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CommuniVax Webinar

As the COVID-19 vaccination campaign continues, it is critical that vaccines are delivered fairly and equitably—so that everyone has access. 

Join us for a webinar, Community-Centric Public Health Practice: COVID-19 Vaccination and Beyond, hosted by CommuniVax, a Coalition to Strengthen the Community’s Involvement in an Equitable Vaccination Rollout, and the Johns Hopkins Center for Health Security. The session will examine the roles health departments can take in achieving health equity. Speakers will discuss real-world examples, best practices, ways forward for health departments pursuing health equity and how to build recovered, resilient communities.
Please register here.
EPI UPDATE The WHO COVID-19 Dashboard reports 138.4 million cases and 3.0 million deaths as of 5:15am EDT on April 16.

On April 13, India surpassed 150,000 new cases per day, and on April 14, it reported more than 200,000 new cases in a single day for the first time. India’s COVID-19 epidemic appears to still be accelerating. In fact, its average daily incidence is increasing at approximately 10,000 more new cases each day. If it continues on this trajectory, India could surpass 200,000 new cases per day in the next 2-3 days. India is only the second country to surpass 150,000 new cases per day, after the US; however, due to the size of its population, India remains well below the United States’ peak on a per capita basis. Turkey’s current COVID-19 surge is twice as high as its previous peak (December 2020), and it continues to move toward the US (#2) and Brazil (#3) in terms of total daily incidence.

As countries increase vaccination coverage, governments and experts are beginning to look for evidence of the vaccines’ effect on national COVID-19 epidemics. It remains unclear exactly what degree of coverage is necessary to make a noticeable impact on community transmission—or how that might depend on the current level of community transmission—so there is no clear target in place. It is likely that the vaccines will begin to slow community transmission before countries achieve the coverage necessary for herd immunity—ie, the level of immunity that will contain most outbreaks in the absence of other interventions (eg, mask use, physical distancing)—particularly in areas where COVID-19 restrictions remain in place. This week, we will look at COVID-19 incidence trends in countries with the highest vaccination coverage*.

Israel and Seychelles remain the top 2 countries in terms of SARS-CoV-2 vaccination coverage. Israel is #1 globally in terms of full vaccination coverage, with 57.3% of its population, and Seychelles is #2 with 46.7%. The ranks are reversed for partial vaccination (ie, at least 1 dose), with Seychelles at #1 (67.4%) and Israel at #2 (61.7%). Israel and Seychelles have made considerably more progress than the rest of the top 20 countries. In terms of full vaccination, the remaining countries range from Chile with 26.8% to Czechia with 7.7%. For partial vaccination, the UK is #3 with 47.8%, and Morocco is #20 with 12.3%.

Among these 20 countries, 9 are reporting increasing incidence over the past 2 weeks. Turkey is reporting the largest biweekly change, with daily incidence up 78.9% compared to 2 weeks ago. Bahrain (34.1%), Singapore (28.6%), and Morocco (24.3%) are all reporting increases of more than 20% over that period. Notably, Bahrain and Turkey are facing ongoing surges, while Singapore and Morocco are reporting consistently low daily incidence. While Turkey’s full vaccination coverage is still relatively low (9.2%), Bahrain’s coverage ranks #4 globally, with more than one-quarter of its population fully vaccinated. But even this level of coverage does not appear to be sufficient to contain Bahrain’s epidemic, although it appears to be leveling off to some degree over the past several days. Other countries among this group that are exhibiting clear increases in daily incidence include Chile, Denmark, Switzerland, and the US.

Each country’s epidemiologic situation is different, so it may not be possible to draw any direct conclusions solely based on vaccination coverage and incidence for each individual country, but perhaps grouping countries by coverage could allow us to identify relevant trends. Among the top 20 countries, 7 are reporting full vaccination coverage of less than 10%. Three (3) of these countries—Czechia, Iceland, and Romania—are reporting decreasing daily incidence, while the other 4—Denmark, Singapore, Switzerland, and Turkey—are reporting increasing trends. Five (5) countries are reporting 10-20% coverage. Among these countries, only Morocco is reporting increasing daily incidence, while Hungary, Malta, Serbia, and the UK are all decreasing. In fact, the UK’s epidemic has been declining from its highest peak since early January 2020, when its vaccination coverage was less than 1%. Another 6 countries are reporting 20-30% full vaccination coverage. This group is split evenly, with 3 countries reporting decreasing daily incidence—Monaco, San Marino, and the UAE—and 3 reporting increasing trends—Bahrain, Chile, and the US. The top tier includes just 2 countries: Israel and Seychelles, both with coverage greater than 40%. Israel’s epidemic has been declining since mid-January, when its vaccination coverage was less than 4%. Seychelles’ epidemic trends are more difficult to discern, but its monthly average does appear to show an overall decline from its largest peak.

Looking at just the top countries in terms of partial coverage, there is not much additional evidence of vaccination related trends. In terms of daily incidence, Chile’s epidemic has been steadily growing since late 2020, despite 40% of the population with at least 1 dose. Maldives and Malta are reporting decreases from their highest peak, which both occurred within the past month. The UAE is reporting a relatively steady decline from its highest peak, and the United States’ daily incidence has increased steadily over the past several weeks, despite increasing vaccination coverage. Bhutan has reported essentially zero daily incidence since late January, so it is difficult to identify any meaningful trend.

Clearly, we are not yet to the point at which we can draw definitive conclusions regarding the effect of national vaccination efforts on containing COVID-19. The clinical trials have demonstrated high efficacy at the individual level for many of the vaccines currently in use**, but it is more difficult to observe their effects on the population level. While countries like Israel and the UK are reporting consistent and long-term declines in daily incidence, the trends began well before vaccination coverage was at a meaningful level. It could be possible, however, that the current coverage is high enough to help keep low-level transmission suppressed. A number of other countries near the top in terms of vaccination coverage are reporting ongoing COVID-19 surges, including some that are setting new national records. Some of these countries are quite large, and regional differences in vaccination coverage and SARS-CoV-2 community transmission could be masked in national-level data. It is likely that the countries demonstrating success in terms of containing their respective COVID-19 epidemics are utilizing a combination of COVID-19 restrictions (eg, physical distancing, mask use) and vaccination. Without sufficient vaccination coverage to contain community transmission by itself, COVID-19 risk mitigation measures are still needed in the near term to drive down transmission until vaccination coverage is high enough.
*Not all countries that are reporting COVID-19 incidence data are reporting the number of partially (ie, at least 1 dose) or fully vaccinated individuals. We limited our analysis to the top 20 countries with available data for fully vaccinated individuals.
**Several vaccines do not yet have publicly available Phase 3 clinical trial data.

Global Vaccination
The WHO reported 751 million vaccine doses administered globally as of April 16, including 422 million individuals with at least 1 dose. The WHO dashboard does not yet include data for daily or weekly vaccinations or fully vaccinated individuals.

Our World in Data reports 860 million doses administered globally. The global cumulative total continues to increase at a rate of approximately 18% per week. The daily average surpassed 18 million doses per day briefly before falling slightly to 17.5 million doses per day. At least 176 countries and territories* are reporting vaccination data.
*Out of 191 reporting COVID-19 incidence data.

The US CDC reported 31.2 million cumulative cases and 561,356 deaths. Daily incidence continues to increase, up more than 30% from the recent low on March 19. Daily mortality also has increased over the past several days, up from 642 deaths per day on April 7 to 712 on April 14, an 11% increase over that period. The timing of the most recent low in daily mortality coincides with the Easter holiday weekend, so that could be due, in part, to delayed holiday reporting.

US Vaccination
The US has distributed 255 million doses of SARS-CoV-2 vaccine and administered 198 million doses. Daily doses administered* has leveled off at approximately 3 million, including 1.6 million people fully vaccinated.

A total of 126 million individuals have received at least 1 dose of the vaccine, equivalent to 38% of the entire US population and 48% of all adults. Of those, 78 million (24% of the total population; 30% of adults) are fully vaccinated. Among adults aged 65 years and older, 80% have received at least 1 dose, and 64% are fully vaccinated. In terms of full vaccination, 38 million individuals have received the Pfizer-BioNTech vaccine, 32 million have received the Moderna vaccine, and 7.7 million have received the J&J-Janssen vaccine.
*The US CDC does not provide a 7-day average for the most recent 5 days due to anticipated reporting delays for vaccine administration. This estimate is the most current value provided.

The Johns Hopkins Coronavirus Resource Center is reporting 31.5 million cumulative cases and 565,318 deaths as of 10:15am EDT on April 16.

J&J-JANSSEN VACCINE & BLOOD CLOTTING On April 14, the US CDC’s Advisory Committee on Immunization Practices (ACIP) met to discuss data on blood clotting events—specifically, cerebral venous sinus thrombosis (CVST) with thrombocytopenia—in individuals who recently received the J&J-Janssen SARS-CoV-2 vaccine. ACIP was expected to vote on any updated recommendations in the meeting; however, committee members determined that additional data are needed before deciding on next steps. Reportedly, ACIP aims to hold a follow-up meeting in the next 7-10 days to avoid unnecessary delays in resuming the vaccine’s use. Some of the ACIP members acknowledged that continuing or extending the pause could have negative downstream effects on vaccination efforts, both in the US and around the world.

The US CDC’s recommendation to pause the vaccine’s use remains in place, and the CDC published updated information regarding the blood-clotting events, including symptoms and treatment recommendations. In addition to providing time to assess whether an increased risk of thrombosis is associated with the J&J-Janssen vaccine, it also enables the CDC to disseminate treatment guidance for clinicians, including via the Health Alert Network to public health and healthcare systems nationwide, as these blood clots must be treated differently than many others. Some health experts criticized ACIP for postponing their recommendations, but the CDC, including ACIP, and US FDA are grappling to balance transparency and oversight to ensure vaccine safety with the risk of COVID-19 and the potential effects on vaccine confidence in the J&J-Janssen vaccine specifically, other vaccines utilizing similar vaccine platforms, and SARS-CoV-2 vaccines as a whole.

“BREAKTHROUGH” INFECTIONS During an April 15 hearing of the US House Select Subcommittee on the Coronavirus Crisis, US CDC Director Dr. Rochelle Walensky discussed the agency’s investigation into “breakthrough” infections—ie, infections in individuals who are fully vaccinated against SARS-CoV-2. According to Dr. Walensky, the CDC has identified approximately 5,800 such infections, out of 77 million fully vaccinated individuals*. Among these infections, 396 required hospitalization and 74 died. As has been the case from the beginning of the pandemic, it is more difficult to detect asymptomatic infections. The CDC noted that 29% of the infections detected were asymptomatic, but it is likely that there are more undetected infections. Dr. Walensky did not identify any patterns related to vaccinees’ demographic characteristics or specific vaccines. More than 40% of the infections were among adults aged 60 years and older, but this is not unexpected, considering that adults aged 65 years and older represent 44% of fully vaccinated individuals. The low number of hospitalizations and deaths is encouraging. No vaccine is 100% effective, and this is the first data reported by the CDC on breakthrough infections. The CDC is continuing to monitor vaccine effectiveness, including genomic sequencing to evaluate the effects of emerging variants, and it expects to begin publishing official data starting next week.
*At the time of the report.

VACCINE THIRD DOSE Pfizer CEO Albert Bourla recently said people likely will need to get a third dose of the company’s SARS-CoV-2 vaccine within 12 months of completing their vaccinations. He speculated that annual vaccinations might be required but more research needs to be completed to confirm his predictions. Bourla’s comments were made on April 1 at a CVS Health event but were released April 15. That same day at a US House Select Subcommittee on the Coronavirus Crisis hearing, Chief Science Officer of the White House COVID-19 Response Team Dr. David Kessler noted the emergence of variants of concern will challenge available vaccines’ effectiveness, probably requiring booster shots. However, Dr. Kessler also stated additional research is needed to understand timing and necessity.

RACIAL & ETHNIC DISPARITIES Researchers from the CDC COVID-19 Response Team and colleagues on April 12 posted 2 early release studies in the CDC’s Morbidity and Mortality Weekly Report that further investigate and validate previous findings on racial and ethnic disparities in COVID-19 hospitalizations and emergency room visits. The studies, published in today’s MMWR, provide more data on longstanding systemic inequities in the US health system, which researchers hope will be used to prioritize care for disportionately affected communities moving forward. Additionally, the CDC has launched a Racism and Health page on its Minority Health and Health Equity site, accompanied by a commentary by CDC Director Dr. Rochelle Walensky, to promote education and discussion around racism and health. 

In one study, researchers evaluated disparities in COVID-19 hospitalizations by US region from March-December 2020. Age-adjusted COVID-19 proportionate hospitalization ratios (aPHRs) were calculated from administrative discharge data and found that the cumulative aPHR was highest (range 2.7-3.9) among Hispanic and Latino patients across the four US census regions. Disparities were largest from May to July in 2020, and while they became less pronounced through the end of the year, they remained in all regions by December 2020. The other study used National Syndromic Surveillance Program data to evaluate emergency department visits in 13 states from October-December 2020. According to the data, when compared with White persons, Hispanic and American Indian or Alaska Native persons experienced 1.7 times the rate of emergency department visits during the study period and Black persons experienced 1.4 times the rate. 

VACCINE ACCESS FOR IMMIGRANTS According to the US government, every person in the country can receive a SARS-CoV-2 vaccination regardless of immigration status. However, the registration process varies among states and clinics, with some requesting proof of residency, official identification, or insurance card. Because of these policies, often expressed in English, immigrants have been discouraged or turned away from pharmacies and other places offering vaccines, exacerbating racial and ethnic divides in vaccination access. A recent analysis by the Kaiser Family Foundation showed only about one-quarter of state websites explicitly note that undocumented immigrants are eligible for vaccinations and that getting a vaccine will not negatively impact immigration status. Advocates insist reaching immigrant populations requires holding vaccine clinics in places they trust, including churches, cultural centers, and advocacy organizations. Some experts have called on the US CDC to issue clear guidance noting that lack of documentation should not be a reason to deny a person vaccination.

US AND GAVI HOST COVAX EVENT The US government and Gavi, the Vaccine Alliance, on April 15 hosted the “One World Protected” event to take stock of global progress toward equitable access to SARS-CoV-2 vaccines and launch a campaign seeking to raise an additional US$2 billion for such efforts through the COVAX facility. The funding will be allocated to the facility’s Advance Market Commitment (AMC), which expects to use the additional funding to reach 30%, instead of 20%, of target populations in 92 lower-income countries this year. At the event, a variety of countries, private sector partners, and foundations announced new pledges totaling nearly US$400 million. In addition to new funding pledges, the first commitments to vaccine dose sharing were announced. New Zealand said it will donate more than 1.6 million doses of SARS-CoV-2 vaccines to COVAX, with a focus on the Pacific region. At the virtual event, US Secretary of State Antony Blinken called on nations to support vaccine manufacturing but did not propose specific policies nor address the issue of surplus vaccine supply in the US

A paper from Duke University published on April 15 estimates the US will have at least 300 million excess vaccine doses by the end of July and argues US leadership is “imperative” to achieve equitable global access. The paper proposes a 3-part US-led effort to increase and leverage funding through COVAX to improve vaccine access; undertake bilateral and multilateral actions to provide excess doses to countries in need; and increase manufacturing and distribution capacities. Another proposal from the Center for Strategic & International Studies’ (CSIS) Global Health Policy Center lays out a 4-part US diplomatic strategy for shrinking the global vaccine access gap. The CSIS plan focuses on the US helping to bring greater predictability, transparency, and investment partnerships to the vaccine marketplace; expand global supply through various funding, sharing, and manufacturing efforts; build local capacity for vaccine manufacturing, distribution, and administration; and boost demand for and confidence in SARS-CoV-2 vaccines worldwide. On April 14, the People’s Vaccine Alliance released an open letter signed by more than 100 former heads of state and Nobel laureates calling on the US government to support a waiver of intellectual property rights for SARS-CoV-2 vaccines to help expand global vaccine manufacturing.

MERCK ANTIVIRAL TRIALS Merck announced April 15 that it will end a clinical trial of its antiviral molnupiravir in hospitalized COVID-19 patients but will continue testing the treatment among outpatients with the disease. Additionally, Merck said it is discontinuing development of MK-7110 for the treatment of hospitalized COVID-19 patients. In a statement, the company said it plans to focus its pandemic efforts on advancing molnupiravir and manufacturing J&J-Janssen’s SARS-CoV-2 vaccine. 

B.1.1.7 CLINICAL DATA In an article published April 12 in The Lancet Infectious Diseases, researchers from University College London and colleagues outline new clinical data of patients who contracted the B.1.1.7 SARS-CoV-2 variant. The study used a cohort design to assess if individuals hospitalized with B.1.1.7 infection experienced with worse disease outcomes. Researchers sequenced and analyzed samples positive for SARS-CoV-2 from patients admitted to two British hospitals between November 9, 2020 and December 20, 2020, and used the WHO’s ordinal scale for severe disease as their outcome measure. The final set of study participants included 198 patients who contracted the B.1.1.7 SARS-CoV-2 variant and 143 who contracted a non-B.1.1.7 variant. The research team found no evidence for a higher risk of severe disease among those who had contracted the variant in both adjusted and unadjusted models. The researchers did see that patients with the B.1.1.7 variants presented with higher viral load levels than their non-B.1.1.7 counterparts, implying that those with the B.1.1.7 variant could be more infectious. While this research presents valuable findings, additional research will continue to be compiled to further analyze the relationship between emerging SARS-CoV-2 variants and disease outcomes. 

DISEASE SEVERITY IN CHILDREN Researchers from the US CDC and US Public Health Service published a cohort study in JAMA Network Open estimating adjusted associations between demographic and clinical characteristics and severe COVID-19 among hospitalized pediatric patients using data from more than 20,000 patients ages 18 or younger. Of the 20,714 patients included in the study, 10,950 were female (52.9%), 11,153 were aged 12-18 years (53.8%), 8,148 were Hispanic (39.3%), and 5,054 were non-Hispanic Black individuals (24.4%). Additionally, 6,047 had one or more chronic conditions (29.2%). Among the cohort of 2,430 patients who were hospitalized for COVID-19 (11.7%), nearly one-third of those (756, 31.1%) experienced severe COVID-19. An increased association of severe COVID-19 was seen in patients with one or more chronic conditions versus those with none (AOR 3.27) and in male versus female patients (AOR 1.52). An increased association with severe COVID-19 was also seen in the 2-5 year and 5-11 year age groups when compared to the 12-18 year group (AOR 1.53 for both).

BRAZIL Brazil continues to struggle with increased COVID-19 activity across the country. Earlier this week, the health secretary of Sao Paulo warned that a diminishing supply of critical therapeutics needed to treat COVID-19 patients has put the state’s medical system on the verge of collapse. On April 14, Science published a paper from a group of researchers taking a closer look at the spread of SARS-CoV-2 through the country’s different geographic regions. The group concludes that there is no singular explanation for the virus’s spread across the country, rather a set of reinforcing factors have led to devastating health outcomes. These factors include the country’s expansive size, large gaps in equity of resources, the density of urban populations, the political response to the pandemic, and a lack of early detection. The researchers warn that without improved risk mitigation strategies, the current surge in cases and deaths and the circulation of variants of concern will further increase the country’s COVID-19 burden.  

AUSTRALIA TRAVEL RESTRICTIONS Under Australia’s COVID-19 travel restrictions, Australian citizens do not necessarily have the right to return home, ostensibly “stranding” tens of thousands of Australians overseas. The UN Human Rights Commission (UNHRC) is scheduled to hear a case filed by 2 such individuals, who argue that Australia is violating the International Covenant on Civil and Political Rights by not allowing them to return. Both individuals reportedly already have been vaccinated and are willing to undergo the mandatory quarantine period. Australia currently has a quota for returning Australians, due in part to limitations on space available for mandatory quarantine. While the UNHRC has agreed to hear the case, Australia has 8 months to respond, indicating there may not be resolution anytime soon.

Reportedly, Australia is considering steps to ease its international travel restrictions, including allowing vaccinated individuals to travel overseas, although they may still be required to undergo quarantine upon their return. On April 19, Australia and New Zealand are scheduled to officially implement a “travel bubble,” which will allow travelers to move relatively freely between the 2 countries. Travelers will still be required to wear masks during their flights; however, if they show proof of a negative SARS-CoV-2 test or vaccination, they will not be required to undergo quarantine upon their arrival.

MASK-WEARING POLICIES In a paper published April 14 in PLOS ONE, researchers from the Boston University School of Public Health examine mask-wearing policies and adherence in association with COVID-19 case rates across the United States. The research team collected data on mask wearing and physical distance policies, mask adherence, COVID-19 cases, and demographics from publicly available resources. According to the data, none of the 8 states with at least 75% reported mask adherence experienced a high COVID-19 rate. However, states with the lowest levels of reported mask adherence were most likely to have high COVID-19 rates in the subsequent month, independent of mask policy or demographic factors. The researchers conclude that their findings reinforce the importance of mask-wearing policies, and adherence to such policies, in association with reduced COVID-19 incidence.