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EPI UPDATE The WHO COVID-19 Dashboard reports 147.5 million cases and 3.1 million deaths worldwide as of 10:00am EDT on April 27. The WHO reported a new record high last week in terms of weekly incidence, with nearly 5.7 million new cases. Weekly incidence increased for the ninth consecutive week. Global weekly mortality increased for the sixth consecutive week, up to 87,733 deaths—the highest weekly total since the first week of February.

India continues to set new global records in terms of daily incidence. On April 24, India became the first country to surpass 300,000 new cases per day, and its daily incidence continues to increase rapidly. India is currently reporting more than 330,000 new cases per day, and if it continues on this trajectory, it could surpass 350,000 new cases per day in the next 2-3 days. The rate of increase appears to have slowed slightly over the past several days, but it is not yet clear whether this is an early sign of a longer-term trend. India also became the first country to report more than 350,000 new cases in a single day on April 25.

Turkey’s daily incidence peaked on April 20, with 60,266 new cases per day. Turkey approached Brazil (#3) and the US (#2)—both of which continue to report decreasing daily incidence—but it did not surpass either country before declining for 6 consecutive days. The epidemics in Argentina, Colombia, Germany, and Iran also appeared to level off over the past several days. France’s and Italy’s epidemics are declining as well.

Global Vaccination
The WHO reported 961 million vaccine doses administered globally, including more than 500 million individuals with at least 1 dose. The WHO dashboard does not yet include data for daily or weekly vaccinations or fully vaccinated individuals.

According to Our World in Data, the global cumulative total doses administered surpassed 1 billion doses. This is 13% more than this time last week, slightly lower than the previous growth rate of approximately 18% per week. After 6 days of declining averages, the daily doses administered rebounded slightly over the past 6 days, back up to 16.6 million.

The US CDC reported 31.9 million cumulative cases and 569,272 deaths. Both daily incidence and mortality are decreasing in the US. Daily incidence is down to 54,405 new cases per day, a 22% decrease from the most recent peak on April 13 (69,878). Daily mortality fell to 661 deaths per day, which is still essentially equal to the low that preceded the autumn/winter 2020 surge (662).

US Vaccination
The US has distributed 291 million doses of SARS-CoV-2 vaccine and administered 231 million doses. Daily doses administered* continue to decrease, down from a high of 3.2 million (April 11) to 2.6 million. Approximately 1.4 million people are achieving fully vaccinated status per day.

A total of 141 million individuals have received at least 1 dose of the vaccine, equivalent to 43% of the entire US population and 54% of all adults. Of those, 96 million (29% of the total population; 37% of adults) are fully vaccinated. Among adults aged 65 years and older, progress has largely stalled at 82% with at least 1 dose and 68% fully vaccinated. In terms of full vaccination, 48 million individuals have received the Pfizer-BioNTech vaccine, 40 million have received the Moderna vaccine, and 8.0 million have received the J&J-Janssen vaccine.

As of April 19, all US states expanded vaccination eligibility to all individuals aged 16 years and older, but the pace of vaccinations is beginning to taper off. Since the national high of 3.2 million doses per day on April 11, the daily average has steadily decreased by more than 20%, down to 2.4 million*. Even with everyone aged 16 years and older now eligible and with sufficient supply, progress toward herd immunity will slow considerably over the coming weeks for a variety of reasons. Some reasons include vaccine opposition and hesitancy, barriers to accessing the vaccine, and dwindling unvaccinated population. In light of the slowing pace, we will look at state-level trends in daily vaccine administration.
*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 majority of states reported their peak doses administered around the time they expanded eligibility to everyone aged 16 years and older or shortly thereafter. More than half of US states (27) reported peaks between 3 days before and 11 days after they expanded to full eligibility. Three states—New Mexico (44 days before), Oklahoma (32 before), and South Dakota (39 before)—reported peaks more than 4 weeks before they expanded eligibility to all individuals aged 16 years and older. If you remove short, temporary reporting spikes for these states, however, their peaks would be in early April, near or shortly after they expanded eligibility. Three (3) states reported peaks at least 3 weeks after they expanded eligibility: Alaska (+35 days), Florida (+25), and Utah (+26). All 3 states reported peaks in early-to-mid April, similar to many other states, but they expanded eligibility much earlier than most states. Alaska was the first state to expand eligibility to everyone aged 16 years and older (March 9), and Florida (March 25) and Utah (March 24) were among the first 6 states to do so.

In total, 9 states reported their peak daily doses administered by the end of March; however, none of these states appear to have exhibited a definitive early peak. Notably, reporting aberrations could account for nearly half of these states. As noted above, the peaks in New Mexico (February 25), Oklahoma (February 25), and South Dakota (February 25) appear to be due to reporting fluctuations, and Louisiana (March 13) exhibited a similar brief spike. The true peaks for these states were actually in early April. Additionally, Arizona’s peak was on March 31, just before April, and Idaho’s average held relatively steady between March 24 and April 13. Iowa (March 13), Mississippi (March 4), and North Carolina (March 18) all reported early peaks, followed by a slight decrease and then a second peak in April that was nearly as high, before finally beginning to decline steadily.

Only 3 states reported their record high in the past week: California (April 20), Hawai’i (April 26), and Maryland (April 24). California and Hawai’i were among the last states to expand to full eligibility (April 15 and 19, respectively). The peak in Hawai’i could be a function of a spike in reported doses on April 20, but the trend does appear to still be increasing overall. More than half of all states (28) reported their peak daily doses administered within the past 2 weeks.

A total of 6 states are currently reporting increasing daily doses administered over the past week**. Pennsylvania reported its highest peak on April 16, but its overall trend appears to still be increasing. As noted above, Hawai’i reported a sharp spike in doses administered on April 20, which puts its weekly average far above the previous week; however, it still appears to be exhibiting an increasing trend since that jump. While Idaho and Wyoming are reporting increases compared to last week, they both appear to be exhibiting an overall decline in daily doses administered—although it is a little difficult to be certain due to fluctuations in the weekly average. Rhode Island and Minnesota appear to be near their respective peaks, but they have not begun to exhibit a clear decline. Massachusetts also could still be approaching its peak, but it is difficult to determine the longer-term trend. The remaining states generally appear to be past their peak and either holding relatively steady or declining. Nine (9) states are holding steady (including Massachusetts), and 35 are reporting decreasing trends**.
**Increasing means at least a 5% increase compared to this time last week, holding steady is less than a 5% increase or decrease, and decreasing means 5% or greater decrease.

The Johns Hopkins Coronavirus Resource Center is reporting 32.1 million cumulative cases and 572,794 deaths as of 11:15am EDT on April 27.

INDIA India is experiencing the world’s largest COVID-19 surge, with more than 350,000 new cases per day. Experts fear the true number of cases could be substantially higher, with cases underreported for reasons including a variety in case-reporting infrastructures and lack of testing. Under the already strained health care system, hospitals are unable to take new patients and many grieving families have been forced to forgo regular funeral ceremonies for mass cremations, painting a devastating picture of the reality on the ground. India’s government has left decisions about non-pharmaceutical interventions such as physical distancing or mask wearing up to individual states, with many citizens lamenting a lack of proper government direction and dearth of resources, including diagnostics, hospital bed space, and oxygen. While some volunteers, dubbed “COVID Warriors,” are developing databases to connect people to resources, hospitals, and supplies, others are turning to the black market in a last-ditch effort to save their loved ones. In response to international pressure and rising calls for action, the US government on April 25 announced intentions to provide supplies and support to India, and lifted previous bans on the export of raw materials, diagnostic kits, and equipment. Additionally, USAID and the US CDC are deploying a “strike team” of staffers to India to work with local governments and organizations to address the surge in cases. 

US DONATING ASTRAZENECA-OXFORD VACCINE The US government announced on April 26 it intends to share up to 60 million doses of the AstraZeneca-Oxford SARS-CoV-2 vaccine with other nations, greatly expanding its previous announcement to share about 4 million doses of the vaccine with Mexico and Canada. The US FDA has not yet authorized the AstraZeneca-Oxford for emergency use, although it is widely available in other countries. White House Coronavirus Response Coordinator Jeffrey Zients said about 10 million doses of the vaccine are undergoing a safety and quality review, which is expected to be complete in the next several weeks. An additional 50 million doses are in various production stages and could be available to ship in May and June after FDA review. White House officials said they are in the planning phase and do not yet know which countries will receive the donated doses. The announcement followed a conversation between US President Joe Biden and India Prime Minister Narendra Modi, whose country currently is facing the world’s largest surge in COVID-19 cases. The US government has come under increasing pressure to do more to address the pandemic abroad, and the announcement marks a shift in the government’s willingness to commit to vaccine donations.

VACCINE INTELLECTUAL PROPERTY US Trade Representative Katherine Tai on April 26 met virtually with executives of Pfizer and AstraZeneca to discuss increasing access to and production of SARS-CoV-2 vaccines during the COVID-19 pandemic. The meetings follow delivery to the White House of a petition signed by more than 2 million people urging the US government to support a proposal at the World Trade Organization to temporarily waive the intellectual property (IP) rights of pharmaceutical companies to allow low- and middle-income countries (LMICs) to more easily produce SARS-CoV-2 vaccines. India and South Africa, with support from more than 100 LMICs, repeatedly have proposed the waiver to the WTO’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), but their efforts have failed amid pushback from the pharmaceutical industry and several wealthy nations, including the US. Industry lobbyists have increased their efforts to oppose a waiver, with some warning a loosening of patents could expose new technologies to exploitation by China and Russia. However, US trade officials have acknowledged steps need to be taken to increase global vaccine production, as gaps in access could undermine US progress toward ending the COVID-19 pandemic. Tai’s meetings with the pharmaceutical executives reflect the USTR’s engagement in efforts to increase access to vaccines and support her statements at a recent WTO meeting that the divide in access is “completely unacceptable.”

J&J-JANSSEN VACCINE & BLOOD CLOTS The US CDC and US FDA on April 23 recommended resuming use of the J&J-Janssen SARS-CoV-2 vaccine following a temporary pause. The agencies issued a pause on April 13 due to reports of rare but potentially serious blood-clotting events among 6 vaccine recipients, out of nearly 7 million recipients at the time. The FDA has amended the vaccine’s Emergency Use Authorization to mention the potential for clotting issues and will add warnings on fact sheets for providers and vaccinees specifically mentioning blood clots occurring with low platelets. The CDC’s Advisory Committee on Immunization Practices (ACIP) also recommended the continued use of the vaccine after a meeting on Friday, saying their review of data shows that the J&J-Janssen vaccine’s “known and potential benefits outweigh its known and potential risks.” The committee emphasized that nearly all reported cases of the adverse event occurred among women younger than age 50, that those women should be aware of the rare but increased risk, and that there are other SARS-CoV-2 vaccine options. Some experts are warning the pause might have caused more harm than good, with more than 10 million doses of the single-shot vaccine now waiting to be administered. According to a Washington Post-ABC poll, only 22% of respondents who are not yet vaccinated said they are willing to receive the J&J-Janssen vaccine. This unwillingness of the public to use the vaccine could negatively impact US vaccination efforts, especially in rural areas, prisons, and among homebound or transient populations, where the single-dose shot provided convenience. 

On April 20, the European Medicines Agency (EMA) Pharmacovigilance Risk Assessment Committee (PRAC) issued a statement recommending a warning about unusual blood clots with low blood platelets be added to the label of the J&J-Janssen vaccine but maintained these events should be listed as very rare. Like the US agencies, the European regulator emphasized that the vaccine’s benefits in preventing COVID-19 outweigh the risks of adverse events. On April 23, the EMA Committee for Medicinal Products for Human Use (CHMP) addressed concerns over blood-clotting events associated with the AstraZeneca-Oxford SARS-CoV-2 vaccine, saying people who have received a first dose should move forward to receive a second dose between 4 and 12 weeks after their initial shot. As we previously reported, the same rare type of blood clots with low platelet counts have been identified among some people who received that vaccine, which uses a viral vector platform similar to the J&J-Janssen vaccine. 

US CDC RECOMMENDS VACCINATION FOR PREGNANT WOMEN Following the publication of preliminary findings detailing the effectiveness of SARS-CoV-2 mRNA vaccines in pregnant persons in the April 21 New England Journal of Medicine, US CDC Director Dr. Rochelle Walensky said during a briefing on April 23 that the agency recommends all pregnant persons receive a vaccine. Dr. Walensky noted that no safety concerns arose for pregnant persons vaccinated during their third trimester nor for their infants, although the study did not include the J&J-Janssen vaccine. Experts have taken special interest in the effect of vaccinations in pregnant persons, and a study published on April 22 in JAMA Pediatrics shows they are at a higher risk for complications due to COVID-19. The research, which described the experiences of 2,130 pregnant persons in 18 countries, concluded that the risks of COVID-19-related morbidity and mortality among pregnant people and their infants are greater than previously thought, underscoring the importance of vaccination for pregnant people.  

BRAZIL REJECTS RUSSIAN VACCINE Brazil’s national health surveillance agency Anvisa has rejected importation of Russia’s Sputnik V vaccine, citing a lack of consistency in the vaccine’s efficacy and safety data. The decision was made following a unanimous vote from Anvisa’s 5 board directors, each of whom expressed doubts about the vaccine candidate’s benefits and concerns over the potential risk of harmful adverse events. Ana Carolina Moreira Marino Araújo, advisor for the Directorate of Authorization and Registration at Anvisa, stated the agency’s inspectors were denied access to key manufacturing facilities in Russia and found faults in areas they were able to inspect. Russian officials pushed back against the decision, alleging it was politically rather than scientifically motivated. The Gamaleya National Research Center of Epidemiology and Microbiology, which developed the Sputnik V vaccine, maintains the vaccine’s efficacy to be 97.6% in preventing symptomatic COVID-19 disease. Several of Brazil’s state governments have contracts to receive millions of Sputnik V doses once it is cleared for importation. Despite pushback, Anvisa has stood behind its decision, even amid circulation of the P.1 SARS-COV-2 variant, saying other SARS-CoV-2 vaccines are approved for use in Brazil.

SECOND DOSES According to new US CDC data reported by multiple news media outlets, nearly 8% of people who received their first dose of the Pfizer-BioNTech or Moderna SARS-CoV-2 vaccines have not received their second dose. That is more than double the rate seen in the early part of vaccination campaigns, from December 2020 to February 2021. The CDC’s new data cover missed doses through April 9, including those who received a first Moderna dose by March 7 or a first Pfizer-BioNTech dose by March 14. Reasons for the lapses in dosing vary, ranging from a lack of supply, fears of side effects, or feelings among vaccine recipients that one dose provides sufficient protection, especially as vaccine administration becomes more widespread. But the increasing number of people missing or foregoing a second dose is fueling concern among state public health officials, some of whom are implementing reminder services and allocating doses to be used specifically for people who are overdue for their second shot. Data from clinical trials and real-world follow-up studies show that a single dose triggers a weaker immune response than two doses, potentially leaving those one-dose recipients more susceptible to infection. 

Brazil is facing similar concerns, with 1.5 million people missing appointments for their second dose, according to the Ministry of Health. In a technical note issued April 26, the agency urged people to receive their second dose even if the recommended timing target had passed. Some experts cited concerns over real-world data from Chile, showing the Sinovac SARS-CoV-2 vaccine, which accounts for about 80% of Brazil's vaccination program, is only 16% effective after one shot. The Ministry of Health said it is planning a national media campaign to improve communication surrounding the importance of getting the second dose.

EU LAWSUIT AGAINST ASTRAZENECA The European Commission (EC), the EU’s executive branch, announced a lawsuit against AstraZeneca alleging the company has failed to meet its contractual agreements for vaccine delivery. The lawsuit claims AstraZeneca has failed to deliver hundreds of millions of vaccine doses in a timely manner, according to an advanced purchase agreement. AstraZeneca previously stated it would only be able to provide about 100 million out of 300 million promised vaccine doses by the end of June. EC representatives also allege AstraZeneca has not developed an adequate strategy to combat delivery delays. In response to the lawsuit, AstraZeneca said in a statement that it is on course to fulfill its commitments to the EU for the end of this month and noted that its vaccine made up 97% of the vaccine doses provided through the COVAX facility. The lawsuit follows a dispute resolution mechanism launched by the EC in March that was intended to internally settle existing disputes between the two entities. Regardless of the outcome, the fact remains that the EU has fewer than anticipated doses of SARS-CoV-2 vaccines to distribute among its Member States. To fill in some of these gaps, EC President Ursula von der Leyen announced a new contract with Pfizer-BioNTech last week for 1.8 billion doses of its vaccine over the 2021-2023 period. 

LONG-TERM EFFECTS Research continues to better characterize the long-term health effects of SARS-CoV-2 infection, formally referred to as post-acute sequelae of SARS-CoV-2 infection (PASC) and commonly referred to as “long COVID.” Researchers from St. Louis, Missouri (US), published an analysis of morbidity and mortality risk in the 6 months following infection. The study, published in Nature, included data from more than 73,000 COVID-19 patients treated in the US Department of Veterans Affairs health system and compared them with nearly 5 million non-COVID-19 patients within the system. The researchers found that mortality risk among COVID-19 patients beyond the first 30 days of illness was nearly 60% higher, corresponding to 8.39 excess deaths per 1,000 individuals at the 6-month point. The excess deaths among hospitalized COVID-19 patients was even higher (28.79).

The researchers also observed a statistically significant increase in outpatient care and use of certain treatment drugs, including opioid and non-opioid pain medications, among COVID-19 patients. The use of beta blockers and opioid analgesics was nearly 10 times higher among COVID-19 patients when compared with non-COVID-19 patients. The study presents detailed results for more than 75 conditions and medications associated with COVID-19. Notably, many of the statistically significant results remained when compared against seasonal influenza patients. This appears to be the largest study of its kind to evaluate the long-term health effects of SARS-CoV-2 infection.

HOMELESSNESS & VACCINATION As the US moves toward increased SARS-CoV-2 vaccine coverage among a majority of adults, current vaccination efforts aim to address at-risk and vulnerable populations, such as persons experiencing homelessness. Public health officials are facing vaccine refusal and hesitancy among the entire US population, but they face additional policy and logistical challenges—such as the added complexity of a multi-dose regimen—when creating outreach plans for persons experiencing homelessness. Reaching adequate coverage among this population will require joint task forces, community-level outreach, information and education campaigns geared at addressing vaccine willingness, and establishing mobile vaccination teams to meet residents where they are. For example, the City of San Francisco implemented mobile teams to serve homebound adults and people living in congregate facilities. Community members and non-profit organizations are collaborating to provide food and other incentives at vaccination events to increase accessibility and awareness of the SARS-CoV-2 vaccine.