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EPI UPDATE The WHO COVID-19 Dashboard reports 141.5 million cases and 3.0 million deaths as of 4:30am EDT on April 20. Global weekly incidence and mortality continue to increase. Last week, the WHO reported a new record high for weekly incidence, with 5.23 million new cases, a 14% increase over the previous week. Weekly incidence has increased for 8 consecutive weeks, and it appears to be accelerating. Global weekly mortality has increased for 5 consecutive weeks, up to 83,021 deaths, a 7.6% increase over the previous week and the highest weekly total since early February.

The global surge is largely driven by the epidemic in India, which continues to set new national records. On April 17, India became the second country to exceed 200,000 new cases per day, after the US. India is currently reporting 233,074 new cases per day, and its epidemic continues to accelerate. If it continues on this trajectory, India could surpass 250,000 new cases per day and set a new global record in the next 1-2 days. India set its national single-day incidence record on April 18, with 273,802 new cases before falling slightly to 259,167. India is #2 globally in terms of total daily mortality, with 1,353 deaths per day, and still accelerating rapidly. India is reporting fewer than half the daily mortality of #1 Brazil (2,866), but on this trajectory, it could close that gap quickly.

Turkey continues to exhibit a concerning surge as well. At 60,003 new cases per day, Turkey is now within 11% of the US (#2; 67,122) in terms of total daily incidence. Turkey’s COVID-19 surge appears as though it could be starting to level off, but it could potentially approach Brazil or the US in the near future.

Global Vaccination
The WHO reported 843 million vaccine doses administered globally as of April 20, including 450 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 920 million doses administered globally. The global cumulative total continues to increase at a rate of approximately 18% per week. The daily average has declined for 5 consecutive days, down from 18.6 million doses per day on April 14 to 15.6 million on April 19. At least 185 countries and territories* are reporting vaccination data.
*Out of 191 reporting COVID-19 incidence data.

The US CDC reported 31.5 million cumulative cases and 564,292 deaths. Daily incidence has decreased slightly over the past several days—down from 69,953 new cases per day on April 13 to 66,747 on April 18. The daily incidence is still elevated compared to several weeks ago. Daily mortality is slightly elevated compared to last week, but it has held relatively steady at approximately 700 deaths per day since April 12, approximately equal to the low reported immediately prior to the autumn/winter 2020 surge.

Michigan appears to have passed a peak in terms of daily incidence, but some inconsistencies in its recent reporting make it difficult to determine if this is the beginning of a longer-term trend. Michigan does not typically report COVID-19 data to the CDC on Sundays (or holidays), but last week—on Sunday, April 11—it reported 4,837 new cases.

US Vaccination
The US has distributed 265 million doses of SARS-CoV-2 vaccine and administered 211 million doses. Daily doses administered* remains steady at approximately 3 million, including 1.6 million people fully vaccinated.

More than half of all adults have received at least one dose of SARS-CoV-2 vaccine, and one-third are fully vaccinated. A total of 132 million individuals have received at least 1 dose of the vaccine, equivalent to 40% of the entire US population and 51% of all adults. Of those, 85 million (26% of the total population; 33% of adults) are fully vaccinated. Among adults aged 65 years and older, 80% have received at least 1 dose, and 65% are fully vaccinated. In terms of full vaccination, 42 million individuals have received the Pfizer-BioNTech vaccine, 35 million have received the Moderna vaccine, and 7.9 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.

In light of the US surpassing 50% coverage in terms of adults with at least 1 dose of SARS-CoV-2 vaccine, we will look at the partial coverage (i.e., 1 or more doses) at the state level**. New Hampshire stands out among all states, leading in terms of partial coverage among both all adults and adults aged 65 and older. In fact, New Hampshire is reporting at least 1 dose for 99.9% of its older adults. And its 71.2% partial coverage among all adults is nearly 10 percentage points higher than #2 New Mexico (61.5%). New Hampshire’s success is likely a factor in the state’s decision to open vaccination to non-residents starting April 19, the same day that the few remaining US states expanded eligibility to everyone aged 16 years and older.

Four other states are reporting partial coverage greater than 60% among all adults: New Mexico (61.2%), Connecticut (61.2%), Maine (60.3%), and Massachusetts (60.2%). The median is slightly higher than 50%, and most states fall between approximately 46% and 54%. Alabama (38.7%) and Mississippi (38.2%) are the only states reporting less than 40% partial coverage among all adults. Impressively, the median coverage among adults aged 65 years and older is nearly 80%, with most states falling between 75-85%. In addition to New Hampshire, Vermont (93.6%) is reporting partial coverage greater than 90% among older adults. Hawai’i (69.3%) and West Virginia (69.5%) are the only 2 states reporting less than 70% coverage among older adults.

Most of the states that fall in the top and bottom 10 in both partial and full coverage. In fact, 7 states appear in the top 10 of both lists, and 8 appear in the bottom 10 of both lists. However, Hawai’i ranks #25 for partial coverage among all adults (50.1%), but it falls all the way to #50 among adults aged 65 years and older (69.3%). Kansas falls from #9 in terms of partial coverage among older adults (86.5%) to #21 among all adults (52.5%). Both New Mexico and New Jersey rank in the top 10 for all adults but fall 12 places for older adults. New Mexico ranks #2 in terms coverage among all adults (61.5%) and #14 (84.3%) among older adults, and New Jersey falls from #6 among all adults (58.8%) to #18 for older adults (82.3%).
**By state of residence, even if individuals received the vaccination in another state.

ROUTES OF TRANSMISSION Scientific evidence increasingly supports the theory that the primary mode of SARS-CoV-2 transmission is through airborne infectious aerosols passed from person-to-person, according to some researchers. In three separate pieces published last week, experts outlined reasoning and evidence supporting SARS-CoV-2 transmission from both near-field and far-field aerosols. In a commentary published April 15 in The Lancet, researchers from the UK, US, and Canada present 10 reasons backing airborne transmission. In another piece published online in JAMA on April 16, experts from Harvard University and the University of Michigan describe the rationale for improving air circulation and filtration in indoor spaces to reduce far-field transmission of SARS-CoV-2 and other respiratory infectious diseases. While noting that airborne viral particles are a significant route of SARS-CoV-2 transmission and calling for improved air ventilation in indoor spaces, experts from the UK, US, and China in an editorial published April 14 in The BMJ also underline the significance of mask quality and fit. 

These pieces appeal to the public health community to take action to help improve indoor air quality, ventilation, and filtration, through policy and structural changes, particularly in healthcare, work, and educational settings. Such efforts could help reduce the number of COVID-19 cases as well as other airborne infectious diseases. The commentaries could be viewed as rebuttal to a systematic review funded by the WHO and published last month that says there is inconclusive evidence for airborne transmission. On April 19, a US CDC official said during a telephone briefing that the CDC has determined the risk of SARS-CoV-2 transmission via surfaces is low and secondary to transmission through direct contact with droplets and aerosolized particles. In light of the evidence, the CDC has updated its guidance for cleaning and disinfecting surfaces in community settings.

EMERGING VARIANT RESPONSE FUNDING The US government on April 16 announced it will invest US$1.7 billion from the American Rescue Plan to help states and local jurisdictions detect, monitor, and mitigate emerging variants of SARS-CoV-2. A White House fact sheet says that an essential component of these efforts is increasing genomic sequencing, especially in states experiencing surges of cases. According to the US CDC, the B.1.1.7 variant is now the dominant strain in the US, and several states have seen recent increases in cases due to the variant. The US government is committing US$1 billion of the total allocation to the CDC, states, and localities to bolster surveillance. Of the remaining funds, US$400 million will help create 6 new Centers of Excellence in Genomic Sequencing across the nation. These centers will work in partnership with state health departments and academic institutions to develop new concepts, methods, and technologies for genomic surveillance tools. Additionally, US$300 million will go toward developing and supporting a National Bioinformatics Infrastructure to help scientists track the spread of diseases and allow for improved decision-making. The fact sheet outlines funding distribution by state, noting the first tranche will be distributed in May with a second tranche expected to be invested over the next several years.
INDIA & BANGLADESH The city of Delhi, India initiated a weeklong lockdown on April 19 in an effort to stem a severe surge in cases. On Sunday, the city reported a record single-day case count, with 24,642 cases. As a result of the increasing number of cases, city hospitals have reported near-full ICU capacity and critical shortages of oxygen and drugs. Crematoriums also report being overburdened. During the lockdown, casual gatherings will be prohibited and non-essential businesses will be ordered to close, although essential services will be allowed to remain open. Weddings and funerals will be allowed to continue, albeit with capacity restrictions. Sporting events without spectators will be permitted to continue. Public transport will be reduced to 50% seating capacity. The city lockdown is scheduled to lift the morning of April 26. Various factors may be fueling this rise in cases in India, including recent mass gatherings, as well as a new variant of interest, B.1.617. In addition to the restrictions in Delhi, new mitigation measures have been implemented in localities in the states of Uttar Pradesh and Maharashtra. 

Bangladesh enacted a similar but more restrictive lockdown on April 5, with the closure of shops and offices and the cessation of domestic transportation and international flights. Citizens have been asked not to leave their residences from 6pm-6am. Restrictions were expected to lift on April 22, but they have been extended an additional week. Several senior government officials indicated that the extended lockdown will be enforced more strictly, which could further exacerbate financial impacts on lower-income individuals. Reportedly, the government is considering easing some of the restrictions before the Eid holiday.

BREAKTHROUGH INFECTIONS With vaccination rates continuing to climb in the United States, many who are vaccinated are beginning to engage in more activities that could increase their exposure to SARS-CoV-2 infection. While the vaccines available under US FDA Emergency Use Authorizations are effective, there is still a chance that vaccinated persons can become infected with SARS-CoV-2. These “breakthrough” infections are considered rare events, with the CDC on April 19 reporting fewer than 6,000 cases out of 84 million vaccinated persons. The agency continues to monitor reports of breakthrough cases and launched a website with information for public health departments and laboratories to investigate and report such cases. The agency is monitoring the age, sex, type of vaccine, and underlying conditions from breakthrough cases, but no pattern among cases has been identified. When possible, monitoring also includes genomic sequencing to identify which virus lineage caused the infection.

US VACCINE ELIGIBILITY As of April 19, all US states have expanded COVID-19 vaccine eligibility to include all individuals aged 16 years and older, meeting the goal set by the US government to expand vaccine eligibility to all adults by April 19. Hawai’i, Massachusetts, New Jersey, Oregon, Rhode Island, and Vermont were the last states to meet the deadline yesterday.

AT-HOME TEST KITS On April 19, Abbott announced that its BinaxNOW rapid antigen at-home test kit is available for purchase in the US. The test is available without a prescription and provides results in approximately 15 minutes. Initially, the test kits will be available through national chain pharmacies, including CVS, Walgreens, and Walmart. At less than US$25 per kit—which includes 2 tests—they are likely still too expensive for routine daily testing. Over-the-counter (i.e., non-prescription) test kits provide a widely accessible at-home test that can be kept on hand or potentially obtained quickly for a variety of purposes, such as after an exposure to a known COVID-19 case or prior to travel. Abbott’s announcement indicates that it aims to produce “tens of millions” of tests per month, with the potential to increase capacity beyond that point, if necessary. The test kit received an Emergency Use Authorization from the US FDA in March 2021 for use in both symptomatic and asymptomatic individuals as young as 2 years old.

VACCINE DISINFORMATION Researchers are launching projects to catalogue and counteract misinformation and disinformation about SARS-CoV-2 vaccines on social media, as well as collect data on how that information spreads and influences vaccination uptake. One research consortium, called the Virality Project and started by experts from multiple US academic institutions, is using strategies learned during the 2020 US presidential election to help social media platforms counter vaccine mis- and disinformation. Earlier this year, Facebook and Twitter announced new policies aimed at stemming the spread of misinformation. The companies will remove offending posts and shut down accounts that perpetually post false information about vaccines. However, social media platforms increasingly are running up against “gray area misinformation,” or posts that do not contain explicitly false information but present only select facts that drive commentary meant to further misleading narratives. A researcher from the nonprofit First Draft News alleged that many of the same people who pushed misleading information via social media during the 2020 election also are peddling misinformation about vaccines and the COVID-19 pandemic.

US EXCESS DEATHS Researchers at the US CDC’s National Center for Health Statistics published a brief overview of excess deaths in the US since the start of the US COVID-19 epidemic. The study, published in the US CDC’s MMWR, analyzed mortality data from the National Vital Statistics System (NVSS), corresponding to deaths from 2013 through February 2021. Between January 26, 2020—the date of the first reported COVID-19 death in the US—through February 27, 2021, the researchers estimate 545,600-660,200 excess deaths above what would be expected during that period based on historical data. During that time, approximately 75-88% of the excess deaths were directly attributable to COVID-19, leaving 63,700-162,400 additional excess deaths. These additional deaths could potentially be directly attributable to COVID-19 (i.e., undiagnosed victims), or they could result from the downstream effects of the pandemic beyond the disease itself, including “disruptions in health care access or utilization.”

US FDA REVOKES BAMLANIVIMAB EUA On April 16, the US FDA terminated the Emergency Use Authorization for Eli Lilly’s investigational monoclonal antibody bamlanivimab as a treatment for COVID-19. Specifically, the agency terminated the EUA that authorized bamlanivimab as a treatment “when administered alone”*. Analysis of available clinical data found a “sustained increase of SARS-CoV-2 viral variants that are resistant” to the drug and “increased risk for treatment failure.” Bamlanivimab remains authorized for use in combination with etesevimab, another of Eli Lilly’s monoclonal antibodies. Notably, the FDA’s decision came at the request of Eli Lilly, but a press release from the company indicates that it does not currently intend to request the withdrawal of emergency authorization for bamlanivimab as a standalone treatment in any other country.
*Emphasis in original source.

TRIAL EXAMINING REPURPOSED DRUGS The US NIH on April 19 announced it is launching a large randomized, placebo-controlled clinical trial to test whether several existing prescription and over-the-counter medications can help resolve mild-to-moderate symptoms among people with COVID-19. The Phase 3 trial, part of the Accelerating COVID‑19 Therapeutic Interventions and Vaccines (ACTIV) public-private partnership, will explore up to 7 drugs approved by the US FDA for other conditions, a strategy called drug repurposing. According to the Washington Post, which quotes anonymous sources, several of the drugs under consideration for the trial include the antiparasitic ivermectin, the antidepressant fluvoxamine, and the acid-controller famotidine, the generic name for Pepcid. At least one study published in the March 4 JAMA showed that early administration of ivermectin did not significantly shorten the time to symptom resolution among nearly 400 adults with mild COVID-19 randomized to take ivermectin or placebo. As for fluvoxamine, 2 small studies, one published in JAMA and the other in Open Forum Infectious Diseases, showed the serotonin reuptake inhibitor helped reduce disease progression among those who took the drug compared with people who took a placebo or refused the drug. At least 3 other clinical trials are currently recruiting to test fluvoxamine, according to, and a recent episode of 60 Minutes highlighted the drug’s potential as a COVID-19 treatment.

SUBUNIT VACCINE On April 19, Nature published an early-version manuscript describing research into a subunit SARS-CoV-2 vaccine that researchers hope will provide protective immunity against the virus. Subunit vaccines are widely used and highly effective against several infectious diseases. Researchers from various US-based institutions and the pharmaceutical company GSK showed positive results that a SARS-CoV-2 spike receptor binding domain on a protein nanoparticle (RBD-NP) can offer protection against the virus in non-human primates. The researchers evaluated 5 different adjuvants, showing variation in efficacy against SARS-Cov-2 variants and wild-type virus. With these promising results of an adjuvanted RBD-NP vaccine candidate among primates, the authors report the vaccine will move to Phase 1/2 human trials. A successful adjuvanted subunit vaccine potentially could help fill vaccination gaps in younger and older populations, as other such vaccines historically have good safety profiles in these groups.