The Center also produces US Travel Industry and Retail Supply Chain Updates. You can access them here.
EPI UPDATE The WHO COVID-19 Dashboard reports 144.1 million cases and 3.1 million deaths worldwide as of 5:45am EDT on April 23.

On April 21, India surpassed 250,000 new cases per day and set a new global record for total daily incidence. India is currently reporting 281,683 new cases per day and still increasing rapidly. On this trajectory, India could surpass 300,000 new cases per day in the next 1-2 days. On April 21, India became only the second country to report more than 300,000 new cases in a single day, after the US. India has reported more than 300,000 new cases on 2 consecutive days, including a record high 332,921 new cases on April 22.

The global daily incidence is already setting new records, and daily mortality is on track to surpass its previous high as well. While the global trends in daily incidence are largely driven by India’s ongoing surge, this is slightly less the case for mortality. Currently, South America accounts for nearly one-third of the global daily mortality, more than any other continent; however, it appears to have leveled off over the past week or so. Asia recently surpassed Europe as #2 globally, and both are reporting essentially equal daily mortality—each accounting for more than a quarter of the global total. Asia’s daily mortality is accelerating rapidly, up by more than 400% since mid-March—driven largely by India—and it could surpass South America as #1 in the coming days. Europe’s daily mortality remains slightly elevated from its most recent low in mid-March, but it has declined over the past several days. Daily mortality in Africa and North America steadily decreased from late January through mid-April; however, both are reporting increases over the past 2 weeks. Oceania averaged fewer than 1 death per day from October 2020 through mid-March 2021, and while its daily mortality is increasing, it is still fewer than 3 deaths per day.

In terms of total daily mortality, Brazil remains #1 globally, with 2,580 deaths per day, but it has decreased steadily since April 12. Brazil’s daily mortality has fluctuated around 2,700-3,000 deaths per day since late March, but this is the largest and longest decline during that period. India is #2 globally, with 1,802 deaths per day and increasing rapidly. On this trajectory, India could surpass Brazil as #1 in the coming days. Daily mortality in the US (#3; 698) and Mexico (#5; 409) have decreased steadily from their highs in mid-to-late January, but both appear to be leveling off. Poland (#4; 506), Colombia (#6; 397), Peru (#7; 399), and Iran (#8; 365) are all reporting steadily increasing trends over the past several weeks. Ukraine (#10; 379) also reported increases over the past several weeks, but it appears to be leveling off. Russia’s daily mortality (#9; 380) has held relatively steady since December 2020.

On a per capita basis, the top countries are all in Europe and South America. In fact, among the top 20 countries in terms of per capita daily mortality, 15 are in Europe, and 5 are in South America. Hungary is #1 globally, with 21.9 daily deaths per million population. Bosnia and Herzegovina (20.1) is the only other country reporting more than 20 daily deaths per million population. At #3, Uruguay (17.9) is the highest ranked South American country. All other countries in the top 10 are reporting more than 10 daily deaths per million, more than 6 times the global average (1.6). The European countries largely exhibit a similar trend. Their daily mortality peaked in December 2020, followed by a steady decline through January/February 2020 and then another steep increase. Most of these countries appear to be at or near another peak, and as noted above, the overall European daily mortality is beginning to decline. Similarly, the South American countries are reporting similar trends. With the exception of Uruguay, the South American countries reported surges with peaks between July and September 2020—Uruguay did not exhibit a major surge in 2020. Brazil and Uruguay reported increasing trends starting in late 2020, and in January 2021 for Peru. All 4 countries began exhibiting a sharp increase in daily mortality between early and late March, and all have far surpassed their previous peaks.

Global Vaccination
The WHO reported 900 million vaccine doses administered globally, including 491 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 973 million doses administered globally. This is 13% more than this time last week, slightly lower than the previous growth rate of approximately 18% per week. After 6 consecutive days of declining averages, the daily doses administered rebounded slightly over the past 2 days to 15.6 million. At least 189 countries and territories* are reporting vaccination data.
*Out of 191 reporting COVID-19 incidence data.

The US CDC reported 31.7 million cumulative cases and 566,494 deaths. Daily incidence has decreased slightly over the past several days—down from 69,878 new cases per day on April 13 to 62,595 on April 21. The daily incidence fell below the summer 2020 peak, but it is still elevated compared to several weeks ago. Daily mortality continues to hold relatively steady at approximately 700 deaths per day (since April 12), which is approximately equal to the low reported immediately prior to the autumn/winter 2020 surge.

US Vaccination
The US has distributed 282 million doses of SARS-CoV-2 vaccine and administered 219 million doses. Daily doses administered* has decreased over the past several days, down from a high of 3.2 million (April 11) to 2.8 million. The fully vaccinated population is increasing by 1.4 million people per day.

A total of 136 million individuals have received at least 1 dose of the vaccine, equivalent to 41% of the entire US population and 52% of all adults. Of those, 89 million (27% of the total population; 34% of adults) are fully vaccinated. Progress among older adults has slowed considerably. Among adults aged 65 years and older, 81% have received at least 1 dose, and 66% are fully vaccinated. In terms of full vaccination, 44 million individuals have received the Pfizer-BioNTech vaccine, 37 million have received the Moderna vaccine, and 8.0 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 31.9 million cumulative cases and 570,357 deaths as of 9:15am EDT on April 23.

INDIA COVID-19 OXYGEN SHORTAGE As India faces the world’s most severe COVID-19 epidemic, setting new records in terms of daily incidence and mortality, India’s health system is unable to manage the patient surge, and its health system may be nearing collapse. One critical problem is a severe nationwide shortage of oxygen. As we have covered previously, high-flow oxygen therapy has become a key component of COVID-19 patient care, and hospitals in areas with ongoing surges may be unable to produce or procure sufficient supply. Reportedly, hospitals are exhausting their supply or are down to minutes or hours of oxygen on hand, which is contributing to COVID-19 patient deaths, and hospitals are competing against each other to obtain limited resources.

This week, the High Court of Delhi held an emergency hearing to address a complaint filed by one Delhi hospital system alleging that India’s national government was not doing enough to ensure adequate oxygen supply. In response, a representative of the national government indicated that relevant agencies already had made plans to provide 480 metric tons of oxygen to Delhi. Regardless, the court ordered the national government to “ensure strict compliance” with that allocation plan and threatened “criminal action” in the event of non-compliance. Following the original hearing, several additional hospitals filed similar pleas. The court also chastised the government for not prioritizing hospitals over industrial uses to ensure adequate supply. Following the hearing, India’s national government reportedly put oxygen tankers on express trains to transport it to areas of need, and India’s Supreme Court directed the national government to submit its COVID-19 response plans, including for oxygen supply and vaccination.

US TRAVEL ADVISORIES The US Department of State updated its travel advisories, resulting in nearly 80% of countries falling under the “Do Not Travel” category. Previously, the State Department issued Level 4 (Do Not Travel) guidance for only 34 countries, but the recent additions bring the total to more than 150. Among the Level 4 category countries are Austria, Brazil, France, India, Italy, Mexico, Russia, and the UK. The department said the additions were made "to better reflect CDC's science-based Travel Health Notices" as well as to consider the logistics of testing availability and other travel restrictions for US travelers. The department also noted it is continuing to monitor COVID-19 data across the globe and will regularly update destination-specific advice as conditions evolve.

US PUBLIC HEALTH FUNDING US public health officials fear that once the COVID-19 pandemic ends so will state and federal public health emergency funding, pushing them back to patching together budgets from a variety of sources to provide basic, necessary services to their communities. According to the Trust for America’s Health, funding for the Public Health Emergency Preparedness cooperative agreement—which provides critical federal funding to state, local, and territorial public health departments—dropped by about half between fiscal years 2003 and 2021. Since 2010, spending for state public health departments dropped by 16% per capita and spending for local health departments has fallen by 18%, a KHN/Associated Press (AP) analysis published in July 2020 showed. These decreases led to the loss of at least 38,000 public health jobs at the state and local levels between 2008 and 2019. Compounding the problem, at least 248 state and local public health department leaders resigned, retired, or were fired during the COVID-19 pandemic, between April 1, 2020, and March 31, 2021. Experts warn this is the largest exodus of public health leaders in US history. 

Years of underfunding have not only impacted staffing as public health departments’ infrastructures are suffering too, with antiquated computer, data collection, and communication systems. Several US Senators have introduced the Public Health Infrastructure Saves Lives Act, which would eventually provide $4.5 billion annually in core public health funding. But in the meantime, some state legislatures have proposed measures to weaken or remove public health powers, according to a KHN/AP investigation from December 2020. If public health departments continue to operate under a boom-or-bust cycle, experts warn they will be forced to operate at a deficit during the current pandemic and be incapable of properly preparing for the next public health disaster.

GLOBAL VACCINE ACCESS On April 22, the New York Times published an opinion piece by WHO Director-General Dr. Tedros Adhanom Ghebreyesus, who called the inequity in global SARS-CoV-2 vaccine distribution “unacceptable.” According to Dr. Tedros, of more than 890 million vaccine doses administered globally, more than 81% have been given in high- and upper-middle-income countries, with low-income nations only receiving 0.3%. To address the problem, Dr. Tedros urged countries and companies that control the global supply of vaccines to share financial support, share extra vaccine doses with the COVAX Facility, and support the massive scale-up of vaccine production and distribution. In order to achieve the latter, he proposed companies use voluntary licensing with technology transfer; share licenses through the COVID-19 Technology Access Pool, started by the WHO last year; or waive intellectual property rights on COVID-19 products, an option that South Africa and India have proposed repeatedly at the World Trade Organization. Dr. Tedros’s commentary echoed calls to action he made last week during an UN Economic and Social Council (ECOSOC) special ministerial meeting titled “A Vaccine for All.” During his opening remarks at the meeting, Dr. Tedros said, “Vaccine equity is the challenge of our time. And we are failing.” Experts warn that the longer it takes to reach vaccine equity worldwide, the longer the pandemic will continue and the higher the risk of variants emerging to which the currently available vaccines provide diminished protection.

HEALTH WORKER STRESS According to a Washington Post-Kaiser Family Foundation poll, approximately 3 in 10 healthcare workers have considered leaving their profession during the COVID-19 pandemic, with those feelings fueled by burnout, trauma, and disillusionment. The poll of 1,327 US frontline healthcare workers, conducted between February 11 and March 7, showed more than half of respondents said they are burned out and about 6 in 10 said pandemic stress has negatively impacted their mental health. Respondents cited a lack of equipment to protect themselves or treat patients, guilt and trauma over patient deaths, or frustration with governments and some in the public for refusing to enforce or take basic risk mitigation precautions. Some noted the pandemic exposed and magnified how ill-equipped the nation’s health system is to deal with public health emergencies. Experts warn the US was facing a shortage of doctors and nurses prior to the pandemic and additional losses to staffing could further harm US health care by making it more expensive, less accessible, and lower in quality. 

Healthcare workers’ responses also highlight the importance of addressing mental health to prevent post-traumatic stress, anxiety, depression, substance use, or suicide. Because many healthcare workers suffer in silence, implementing accessible mental health programs becomes even more important. Still, 76% of respondents said they feel “hopeful,” and two-thirds said they remain “optimistic” about going to work. Nearly 6 in 10 said they anticipate the COVID-19 pandemic in the US will be controlled enough by early 2022 or later so people can resume normal life, while nearly half said they hope normal life can resume by mid-fall or sooner—including 5% who believed life can safely resume now.  

UK CHALLENGE TRIALS A research team at the University of Oxford (UK) have announced the start of a human challenge trial that will look at what type of immune response is necessary to prevent SARS-CoV-2 reinfection and how the immune system responds during reinfection. The study is designed to include two phases. During the first phase, researchers will determine the lowest dose of SARS-CoV-2 needed to cause active but asymptomatic or low-symptom infection in 50% of participants who have fully recovered from a previous natural infection. In the second phase, scheduled to begin this summer, researchers plan to inject all participants with the “optimal” dose determined in phase one. Notably, the study will use the original strain of the virus. In February, the UK became the first country to approve human challenge trials for SARS-CoV-2, in which volunteers are deliberately exposed to the virus. Some researchers cite the positive impact these controlled trials can have on scientific understanding, while critics question the ethical and practical nature of the method. 

NURSING HOME OUTBREAKS Health officials in Kentucky and experts at the US CDC published a case study of an outbreak at a long-term care facility (LTCF) initiated by an unvaccinated employee. At the facility, 90% of the residents and 53% of the staff received 2 doses of SARS-CoV-2 vaccine. Routine testing identified the outbreak, which began in an unvaccinated and symptomatic healthcare worker. Ultimately, the outbreak involved 46 total cases, including 26 residents and 20 facility personnel. Notably, 18 of the residents and 4 personnel received their second dose of the vaccine more than 14 days before the outbreak. Three (3) residents died, including 2 who were unvaccinated.

The risk of infection among unvaccinated residents was 3 times higher than among vaccinated residents. Similarly, the risk among unvaccinated personnel was 4 times higher than among vaccinated personnel. For this outbreak, the vaccine’s effectiveness against SARS-CoV-2 infection was estimated to be 66% among residents and 76% among employees, and the effectiveness against symptomatic COVID-19 disease was 86.5% among residents and 87% among employees. This is in line with the expected effectiveness based on clinical trial efficacy data. The authors conclude that low vaccination coverage among employees at LTCFs could facilitate introduction of SARS-CoV-2, which could result in outbreaks, even among resident populations with high vaccination coverage. While the authorized SARS-CoV-2 vaccines are highly effective*, COVID-19 risk remains, particularly among individuals at elevated risk for exposure and severe disease. Even as vaccination coverage increases, it is critical to maintain COVID-19 risk mitigation measures until sufficient community protection is in place to bring the pandemic under control. 
*For those vaccines with publicly available Phase 3 clinical trial data. 

VACCINATION & PREGNANCY The New England Journal of Medicine on April 21 published a study of preliminary findings of mRNA SARS-CoV-2 vaccine safety among pregnant people. Researchers from the CDC’s V-safe COVID-19 Pregnancy Registry Team used data from the agency’s V-safe surveillance system, the V-safe pregnancy registry, and the Vaccine Adverse Event Reporting System (VAERS). A total of 35,691 V-safe participants aged 16 to 54 years identified as pregnant. Among those people, injection site pain was reported more frequently than among the nonpregnant population, but headache, muscle aches, chills, and fever were reported less frequently. Of 221 pregnancy-related adverse events reported to the VAERS, the most frequently reported was spontaneous abortion (46 cases). The researchers note that although not directly comparable, the proportions of adverse pregnancy and neonatal outcomes (eg, fetal loss, preterm birth, small size for gestational age, congenital anomalies, and neonatal death) among vaccinated persons who had completed pregnancy were similar to incidences reported in studies of pregnant people conducted prior to the COVID-19 pandemic. The preliminary findings did not show obvious safety signals for pregnant persons receiving mRNA SARS-CoV-2 vaccines, but the researchers noted the need for continued monitoring. The American Society for Reproductive Medicine has encouraged everyone, including pregnant persons and those seeking to become pregnant, to receive a SARS-CoV-2 vaccination.

EMERGENCY DEPARTMENT VISITS The CDC’s Morbidity and Mortality Weekly Report (MMWR) on April 16 published updated data on changes to emergency department (ED) visits during the COVID-19 pandemic. Previously, researchers with the CDC COVID-19 Response Team and colleagues published data collected from the National Syndromic Surveillance Program (NSSP) showing ED visits declined 42% between March 29-April 25, 2020, following the national emergency declaration on March 13, 2020. Although the number of ED visits increased by July 2020, they remained below pre-pandemic levels. The updated data show ED visits were 25% lower during December 2020-January 2021 when compared with the same months from a year prior. The researchers note the reasons for ED visits have changed during the pandemic period when compared to those during the pre-pandemic period, with more people seeking care for mental and behavioral health-related concerns, especially pediatric patients. The researchers emphasize that, although smaller in total number, the increased proportion of visits due to mental and behavioral health complaints in both adult and pediatric groups is a sign of concern and call for public health measures to provide health messaging and resources for managing related symptoms. The impact of COVID-19 on mental health is well noted, and the CDC provides some resources on managing stress during the pandemic.

COUNTERFEIT VACCINES & VACCINATION CARDS Pfizer announced that counterfeit vaccines were seized in Mexico and Poland. Reportedly, approximately 80 people received the counterfeit vaccine in Mexico, at a cost of US$1,000 each—but so far, none of the recipients have reported any physical harm. In Poland, the doses were seized before they could be administered, and the vials are believed to contain an “anti-wrinkle treatment.” Laboratory analysis confirmed that the products contained in the vials were not the Pfizer-BioNTech vaccine. With high demand and limited supply for the SARS-CoV-2 vaccines, these incidents highlight the risk of criminals distributing counterfeit products for profit. Some of these products are being sold online, and Pfizer emphasized that no legitimate SARS-CoV-2 vaccines are sold online. Pharmaceutical companies and law enforcement agencies around the world are collaborating to quickly identify counterfeit vaccines and intervene.

As countries, businesses, schools, and other organizations evaluate options regarding mandatory vaccination, counterfeit vaccination cards also are a growing problem. Individuals who elect not to get vaccinated are seeking counterfeit vaccination cards to serve as documentation for a vaccination that they never received. There also are reports of individuals falsifying documentation of the first dose in order to jump ahead in the queue. Some of the counterfeit cards are truly counterfeit, and others are blank versions of the official vaccination cards, such as those reportedly sold online by a pharmacist in Chicago (US). The US FBI issued a warning about the counterfeit vaccination cards, emphasizing that making or purchasing the cards or filling in a blank card with false information are all illegal. The FBI encouraged the continued use of COVID-19 risk mitigation measures (eg, mask use, physical distancing) to mitigate the risk posed by counterfeit vaccination cards. The National Association of Attorneys General issued a statement calling on social media and e-commerce companies to take immediate action to prevent the sale of fraudulent vaccination cards. Some experts have criticized the use of paper forms to document vaccination status, as opposed to digital documentation, due to the ease of counterfeiting them. Reportedly, the US CDC originally intended to use digital certificates, but technical problems and delays prevented the implementation of a nationwide system in time to begin vaccination efforts.

TOKYO OLYMPICS With only 3 months until the start of the rescheduled Summer Olympics in Japan, Prime Minister Yoshihide Suga today implemented a third state of emergency order for Tokyo and 3 western prefectures—Osaka, Kyoto, and Hyogo. The order, set to last through May 11, is intended to prevent people from traveling and gathering in public spaces during Japan’s “Golden Week” holidays that run from late April through the first week in May. Prime Minister Suga expressed concern over the spread of a SARS-CoV-2 variant, saying more stringent measures are needed to curb the number of new cases. Under the state of emergency, bars, department stores, malls, theme parks, theaters, and museums in the 4 prefectures are ordered to close. Restaurants that do not serve alcohol and public transportation are being asked to close early, and universities should return to online classes, although grade schools will remain open. International Olympic Committee President Thomas Bach is scheduled to visit Japan on May 17-18 to greet the Olympic torch relay in Hiroshima. Bach said the new state of emergency is not related to his planned visit, and an official with the Japan Olympic organizing committee said there is no discussion of cancelling the event, scheduled to begin on July 23.

RECRUITING FOR VACCINATION STUDY The Johns Hopkins COVID-19 Vaccine Risk Uptake study is recruiting in-home healthcare providers to participate in focus groups to discuss motivation, hesitancy, and situational factors that impact awareness, acceptability, and access to vaccines. Interviews will be conducted in focus groups remotely (via Zoom) and will last approximately 90 minutes. If you are interested in participating, or know someone who may be, please contact Jennifer McKneely at (571) 228-1680 or Additional information is available here.