COVID-19 Situation Report

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EPI UPDATE The WHO COVID-19 Dashboard reports 150.1 million cases and 3.2 million deaths worldwide as of 8:45am EDT on April 30. From the first reported COVID-19 case, it took 90 days to reach 1 million cases and 177 days to reach 10 million cases:
1 case to 25 million- 240 days
25 to 50 million- 69 days
50 to 75 million- 41 days
75 to 100 million- 40 days
100 to 125 million- 57 days
125 to 150 million- 35 days

India surpassed 200,000 cumulative COVID-19 deaths on April 28, and Brazil surpassed 400,000 deaths on April 29. Brazil remains #2 globally, with 401,186 deaths, and India is #4 with 208,330. The US is #1 (575,194), and Mexico is #3 (216,447). At its current pace, however, India could surpass Mexico in the next several days. Additionally, India surpassed 350,000 new cases per day on April 29, the only country to surpass this milestone. With 357,040 new cases per day, India currently accounts for more than 40% of the global daily incidence and nearly 6 times the daily incidence in any other country. It does appear as though India may have passed an inflection point, as the increase in daily incidence has tapered off to some degree over the past several days.

In addition to India, several other countries in and near the WHO’s South-East Asia Region (SEARO) are exhibiting concerning COVID-19 incidence trends. Including India, 7 of the 11 SEARO countries are exhibiting biweekly increases greater than 100%. These countries’ respective epidemics are considerably smaller than India’s, which is allowing them to be overlooked; however, the proportionate increases are concerning indications that they could be facing severe impacts in the very near future. In addition to the SEARO region, nearby Afghanistan, Cambodia, and Laos also are battling substantial surges. The surges in these countries—most of which either border India or are located within approximately 1,000 miles (1,600 km)—started around the same time or shortly after India’s. If these countries continue on this trajectory, they could face similar impacts on their health systems as we have observed in India as well as associated increases in COVID-19 mortality. These countries should be monitored closely.

Nepal’s COVID-19 biweekly incidence increased by more than 600% compared to 2 weeks ago. After peaking at more than 3,800 new cases per day in October 2020, Nepal brought its COVID-19 epidemic under control, down to 71 new cases per day in mid-March 2021. Nepal’s epidemic began a sharp surge in early April, and it is already back up to more than 3,600 new cases per day and still increasing rapidly. The current surges in Thailand and Bhutan began in late March/early April as well, but their increases have not been quite as sharp as Nepal’s. Thailand is currently reporting more than 2,200 new cases per day, more than double its previous peak, and still increasing rapidly. Bhutan is only reporting 10-12 new cases per day, but this is at least a 20-fold increase since late March.

The surges in Sri Lanka and Maldives started several weeks later, in mid-to-late April. In Sri Lanka, the daily incidence increased from a recent low of 215 new cases per day on April 17 to more than 1,100. Sri Lanka is currently reporting nearly 25% more daily cases than its previous highest peak, and its epidemic continues to accelerate rapidly. Maldives is also setting new national records. Its current daily incidence climbed from 84 new cases per day to 327, 75% higher than its previous highest peak and still increasing rapidly.

Timor-Leste is the most remote SEARO country relative to India, and its surge started in early March, around the same time as India’s. Timor’s daily incidence increased from fewer than 0.5 new cases per day to nearly 90. The daily incidence fell sharply from 88 to 76 new cases per day on April 29, but it is too early to determine if this is the start of a longer-term trend.

Outside the SEARO region, nearby Afghanistan, Cambodia, and Laos also are facing surges that raise concern. Cambodia and Laos are in the WHO’s Western Pacific Region, but they border Thailand and are located approximately 1,000 miles (1,600 km) or less from India. Laos is the #1 country globally in terms of the relative increase in biweekly incidence, up more than 15,000% compared to 2 weeks ago. From the onset of the pandemic through April 20, Laos reported more than 5 cases in a single day only once and only 60 cumulative cases; however, it has reported more than 600 new cases since then. Laos currently is averaging more than 80 new cases per day and increasing rapidly. In the context of larger countries and epidemics, Laos’ epidemic is small, but its rapid acceleration is particularly concerning. Cambodia reported fewer than 1 new case per day as recently as mid-February, before a smaller surge. Since early April, however, its daily incidence has surged sharply, up from 53 new cases per day to more than 650—a 12-fold increase in less than a month. Afghanistan is in the WHO’s Eastern Mediterranean Region, but it is located approximately 125-250 miles (200-400 km) from India. Afghanistan’s current surge began in mid-to-late March, and its daily incidence has increased from fewer than 20 new cases per day to 181, and still increasing. The current daily incidence is approaching Afghanistan’s previous peak (217 on November 24, 2020), but it is still well below its highest peak (759 on June 5, 2020). Afghanistan’s epidemic is accelerating at a much slower rate than many of the other countries discussed here.

Global Vaccination
The WHO reported 1.0 billion vaccine doses administered globally, including 546 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 reported 1.1 billion cumulative doses administered globally. The global total continues to increase at 13% per week. After a brief decline, the daily doses administered rebounded to the previous record high of 18.7 million doses per day. Our World in Data estimates that there are 262 million people worldwide who are fully vaccinated, although reporting is less complete than for other data.

The US CDC reported 32.0 million cumulative cases and 571,297 deaths. Both daily incidence and mortality continue to decrease. Daily incidence is down to 52,528 new cases per day, the lowest average since October 12, 2020. The CDC reported an average of 626 and 628 deaths per day, respectively, over the past 2 days, which are the lowest daily mortality averages since June 27, 2020*. Notably, national test positivity is decreasing as well, down from 5.43% on April 12 to 4.47% on April 27**, which is an encouraging sign.
*Excepting the reports immediately following the 2020 Independence Day holiday.
**Test positivity data not published for April 28.

US Vaccination
The US has distributed more than 300 million doses of SARS-CoV-2 vaccine and administered 237 million doses. Daily doses administered* continues to decrease, down from a high of 3.2 million (April 11) to 2.5 million. Approximately 1.4 million people are achieving fully vaccinated status per day.

A total of 144 million individuals have received at least 1 dose of the vaccine, equivalent to 43% of the entire US population and 55% of all adults. Of those, nearly 100 million (99.7 million) are fully vaccinated, which corresponds to 30% of the total population and 38% of adults. 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, 50 million individuals have received the Pfizer-BioNTech vaccine, 41 million have received the Moderna vaccine, and 8.1 million have received the J&J-Janssen vaccine.

The Johns Hopkins Coronavirus Resource Center is reporting 32.3 million cumulative cases and 575,213 deaths in the U.S. as of 10:15am EDT on April 30.

UPDATED US CDC GUIDANCE On April 27, the US CDC issued updated guidance on COVID-19 protective measures, with the changes focusing largely on vaccinated individuals and outdoor activities. The new guidance accounts for a variety of factors, including increasing vaccination coverage, declining community transmission, and evolving evidence regarding transmission risk factors. The CDC’s overhauled webpage on “Choosing Safer Activities” provides a consolidated overview of the changes, including differences between vaccinated and unvaccinated individuals across a broad scope of activities. Notably, the new guidance indicates that fully vaccinated individuals can participate in a number of outdoor activities without wearing a mask, including exercise, small gatherings with vaccinated and unvaccinated individuals, and dining at restaurants. Mask use is still recommended for vaccinated individuals, however, for large outdoor gatherings (eg, concerts, sporting events) and indoor settings, including restaurants and bars, movie theaters, gyms and fitness centers, and places of worship.

Recognizing the relatively low risk of transmission in most outdoor settings, the CDC no longer recommends mask use for unvaccinated individuals in general outdoor settings (eg, walking or exercising) or for small gatherings with vaccinated individuals. Unvaccinated individuals are encouraged to wear masks in small gatherings with other unvaccinated individuals and in higher-risk settings, including indoor and outdoor dining at restaurants and bars, large indoor and outdoor gatherings, and other indoor settings. The CDC guidance emphasizes that many of these higher-risk settings are “less safe” or “least safe” for unvaccinated individuals, even with mask use.

The CDC also issued updated guidance this week for international travelers, including removing the requirements for a negative SARS-CoV-2 test before departing the US* and mandatory quarantine upon arrival in the US for fully vaccinated individuals**. Testing remains mandatory for all air travelers before departing on a flight to the US. Last week, the CDC issued new COVID-19 guidance for youth and summer camps, including updates regarding vaccination, physical distancing, screening and testing, and ventilation.
*Unless required by the destination country.
**Notably, the guidance explicitly specifies vaccines authorized for use by the US FDA or WHO.

EUROPEAN TRAVEL After restrictions on nonessential travel over the past year, fully vaccinated Americans will be allowed to travel to the EU this summer. European Commission President Ursula von der Leyen said in an interview Sunday with the New York Times that as long as visitors have been vaccinated with a product authorized by the European Medicines Agency (EMA), they will be permitted to enter all 27 member countries. The 3 vaccines authorized by the US FDA also are authorized by the EMA: Moderna, Pfizer-BioNTech, and J&J-Janssen. A specific date has not been announced to lift restrictions, but President von der Leyen noted that policies are in flux based on vaccination rates, the “epidemiological situation,” and vaccination certificates. Individual EU countries will be allowed to enact stricter regulations than the EU as a whole when travel resumes to the region.   

INDIA VACCINE SUPPLIES India’s record-breaking COVID-19 surge is impacting the country’s ability to supply SARS-CoV-2 vaccine doses domestically and abroad. India is the world’s leading producer of vaccines, but it is struggling to produce and distribute enough vaccines for its population of 1.4 billion. As a result, India Prime Minister Narendra Modi recently suspended exports of nearly all 2.4 million doses of the AstraZeneca-Oxford vaccine produced daily by the Serum Institute of India, in effect stopping supply of the vaccine to the COVAX facility. This has raised alarms in Africa, which relies on COVAX for its vaccine doses. Africa CDC officials called the anticipated delay in supplies “devastating” and urged other nations to step in to fill the gaps. In an unexpected move, the Democratic Republic of Congo is returning 1.3 million vaccine doses to COVAX, saying it will be unable to administer them before they expire due to difficulties in distribution and vaccine refusal. The vaccines will now go to nations who can use them more quickly. 

Additionally, many global health experts and others worldwide are insisting the US and other nations support a proposal at the World Trade Organization (WTO) by India and South Africa to temporarily waive some trade and intellectual property rules to help low- and middle-income countries (LMICs) fill the gaps. Even if the temporary waiver goes through at the WTO, which is set to hold its next General Council meeting on May 5, production and distribution challenges will remain. But experts contend these constraints could be overcome with more global cooperation and funding. In an April 28 address to the US Congress, US President Joe Biden focused his comments on the COVID-19 pandemic’s impacts on the US population and economy and did not mention global cooperation on vaccines. However, US government officials insist several proposals are being considered to pressure companies to share information on vaccines or boost US vaccine production for export. The White House also on April 28 published a fact sheet outlining its plans to help India with emergency assistance. 

US-MADE VACCINE SHIPPED TO MEXICO This week Pfizer shipped US-made doses of its SARS-CoV-2 vaccine produced with BioNTech to Mexico, marking the first time the pharmaceutical company has delivered abroad from US facilities following the expiration of US government restrictions on vaccine exports. Pfizer is Mexico’s largest supplier of SARS-CoV-2 vaccines, having shipped more than 10 million doses so far. Pfizer expects to be making up to 25 million vaccine doses each week in the US by mid-year, more than it needs to meet US commitments. With agreements to supply more than 1 billion doses to countries worldwide, the company plans to continue shipping extra US-made vaccine doses abroad, as well as from production facilities in Belgium. 

VACCINE EFFECTIVENESS An early release article published April 28 in the US CDC’s Morbidity and Mortality Weekly Report details the effectiveness of the Pfizer-BioNTech and Moderna vaccines in preventing COVID-19-related hospitalizations among a population at higher risk of the disease. Data from 24 hospitals in 14 states were collected from January to March 2021 for adults ages 65 years and older who were hospitalized for COVID-19-like illnesses to gauge the effectiveness of the two vaccines via partial or full vaccination. The adjusted vaccine effectiveness for full vaccination against COVID-19-associated hospitalization was estimated to be 94% (95% CI: 49-99%), and 64% (95% CI: 28-82%) for partial vaccination. The real-world findings confirm those from clinical trials, highlighting the importance of vaccinating older populations to reduce the risk of COVID-19-associated hospitalizations and potentially leading to reductions in post-COVID conditions and deaths. 

SECOND DOSES The US government has directed pharmacies to expand access for second-dose vaccinations to include those who may have received their first dose elsewhere. The move follows reports that millions are skipping their second dose, sometimes due to supply challenges or access issues. The directive is aimed largely at college students, many of whom received their first dose on or near their campuses but will be returning home before becoming eligible for their second dose. Pharmacies participating in the federal vaccine distribution program will waive any residency requirements to allow people easier access to receive a second dose. 

VACCINATION & RACIAL/ETHNIC DISPARITIES Preventing disparities in vaccine uptake among racial and ethnic groups in the US will be critical to mitigating disproportionate impacts of COVID-19 among people of color. According to US CDC data as of April 29, race/ethnicity data were available for 55% of people with at least one dose of vaccine and 58% of those fully vaccinated, with 64% and 67% of those, respectively, identifying as white. The Kaiser Family Foundation (KFF) also monitors this data, comparing it to localized health outcomes of race/ethnicity groups during the pandemic. According to KFF, Black and Hispanic populations have received smaller shares of vaccine doses compared to their shares of COVID-19 burden (cases and deaths) and their shares of total population in most states. According to experts, a complex set of reasons has led to these disparities in vaccine coverage, but access remains a leading issue. Across the US, vaccination sites’ locations, registration processes, time requirements to register and receive a vaccine, and transportation play predominant roles in vaccination coverage. Public health officials are encouraging the establishment of vaccination sites in communities with the lowest vaccination rates and with easier appointment scheduling, including walk-in clinics. 

VACCINATION INCENTIVES With the number of daily SARS-CoV-2 vaccines administered in the US declining, public health entities and companies are getting creative, implementing various incentives to encourage more people to be vaccinated. Examples include offers of free donuts, beer, and even marijuana in states where it is legal; chances to win vehicles, airline tickets, or other large items; time off from work; or cash for people who give others rides to vaccination sites. Officials say the incentives are necessary to reach people who have yet to be vaccinated due to hesitancy, difficulties making appointments, or obstacles to accessing sites. According to one survey, more than two-thirds of respondents would get vaccinated in exchange for a financial incentive. However, some critics say the incentives could perpetuate individual unhealthy behaviors while promoting public health efforts. And some experts are calling for more strict interventions, urging some employers—including health systems and academic institutions—to make vaccination mandatory for employees.

TURKEY Earlier this week, Turkish President Tayyip Erdoğan announced a nearly 3-week lockdown in response to a sharp rise in COVID-19 cases and deaths across the country. The measure, which is being described as a “full lockdown,” went into effect on the evening of April 29 and will remain active until the early morning of May 17. The lockdown order requires residents to stay at home, with exceptions for essential functions such as grocery shopping, and mandates individuals receive permission before conducting inter-city travel. Notably, some businesses and industries are exempt from the shutdown, and lawmakers, healthcare workers, law enforcement officers, and tourists also are exempt from the stay-at-home order. The lockdown will encompass the final weeks of Ramadan, including Eid al-Fitr, a holiday traditionally marked by social gatherings across the country. Some families departed city centers for coastal vacation homes before the lockdown’s initiation, causing crowding in bus terminals and airports and along the nation’s highways.

ROUTINE TESTING STRATEGIES Researchers from the UK developed a model to evaluate the ability of routine asymptomatic PCR-based testing to detect SARS-CoV-2 infection. The study, published in BMC Medicine, utilized data from a study of repeated, self-administered testing of healthcare workers to estimate probability that twice-weekly testing would identify infected, asymptomatic individuals. Notably, individuals who were infected within several days of testing may not have sufficient virus present to result in a positive test. The researchers evaluated both the probability that a symptomatic case would be detected before the onset of symptoms and the probability that an asymptomatic infection would be detected within 7 days of infection, including test turnaround time, for various testing frequencies.

Assuming a 1-day test turnaround time, the researchers estimate that testing every 4 days would have a 76% probability of detecting an asymptomatic infection within 7 days, but increasing the frequency to every 2 days would increase that probability to 95%. Not surprisingly, increased test turnaround time decreased the probability of timely detection for both symptomatic and asymptomatic infections. The researchers note that as the frequency of testing increases, burden on laboratories increases, which can slow the turnaround time. It may be necessary to balance increased testing frequency against the associated increase in testing volume and slower turnaround times. As organizations—including health systems, businesses, and schools—consider routine testing programs, this study can provide insight into the appropriate frequency to mitigate transmission risk.