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EPI UPDATE The WHO COVID-19 Dashboard reports 131.3 million cases and 2.9 million deaths as of 6:00am EDT on April 6. Global weekly incidence and mortality continue to increase. The weekly total of 4.0 million new cases is the highest incidence since mid-January 2021, and 71,387 deaths is the highest weekly mortality since early February 2021. 

India surpassed both Brazil and the US to become #1 globally in terms of total daily incidence. India is reporting 84,313 new cases per day, more than 7.5 times its most recent low on February 11 (11,145). For comparison, India’s current surge started 53 days ago, while a similar increase took 83 days during its previous surge. India’s daily incidence is only 9.5% below its record peak in September 2020 (93,199) and shows little sign of slowing. On this trajectory, India will surpass its previous peak in the next several days. The US surpassed Brazil as #2, but the two countries are reporting essentially equal daily incidence—64,662 in the US and 62,855 in Brazil. Brazil’s daily incidence has decreased sharply since its peak on March 27, down from 77,129 new cases per day—an 18.5% decrease. Combined, India, Brazil, and the US represent more than 35% of the global daily incidence.

In terms of total daily mortality, Brazil reported a new national record high of 3,117 deaths per day on April 1, nearly triple its average on February 22 (1,053) and 9% fewer deaths than the United States’ peak in January (3,428). Brazil’s daily mortality fell sharply to 2,698 over the past several days, but the rapid turnaround makes it difficult to determine the longer-term trajectory. India’s daily mortality also is accelerating, up from fewer than 100 deaths per day on March 8 to 490.

Global Vaccination
The WHO reported 604.0 million vaccine doses administered globally as of April 6, including 315.0 million individuals with at least 1 dose. The dashboard does not yet include data for daily or weekly vaccinations or fully vaccinated individuals.

Our World in Data reports 677.8 million doses administered globally. The global cumulative total continues to increase at a rate of approximately 20% per week. The daily average appears to have leveled off at approximately 16 million doses per day. At least 161 countries and territories are reporting vaccination data.

The US CDC reported 30.5 million cumulative cases and 554,064 deaths. 

The US surpassed 30 million cumulative cases on March 27:
1 case to 5 million cases- 200 days
5 million to 10 million- 92 days
10 million to 15 million- 29 days
15 million to 20 million- 24 days
20 million to 25 million- 24 days
25 million to 30 million- 62 days

The US surpassed 550,000 cumulative deaths on April 1:
1 death to 50k- 55 days
50k to 100k- 33 days
100k to 150k- 63 days
150k to 200k- 55 days
200k to 250k- 58 days
250k to 300k- 25 days
300k to 350k- 20 days
350k to 400k- 16 days
400k to 450k- 16 days
450k to 500k- 19 days
500k to 550k- 37 days

National-level data continue to indicate the start of a fourth COVID-19 surge, and more states are beginning to show the early signs as well. According to analysis published by Data USA, 29 states (and Puerto Rico) are reporting increasing daily COVID-19 incidence over the past 2 weeks (>+5%). Among these states, 16 are reporting increases of more than 20% over that period, including 5 with more than 30%: Michigan (+61.5%), Nebraska (+59.3%), Alaska (+45.0%), Maine (+31.4%), and Washington (+31.1%). Puerto Rico is reporting an increase of 61.1% over the past 2 weeks. There are concentrations of these states across the country, including all of New England, most of the Midwest and West Coast regions, and several states in the Southeast and Mid-Atlantic regions as well as Alaska and Hawai’i.

Michigan continues to exhibit among the most concerning trends, currently reporting daily incidence nearly 6.5 times its most recent low in late February. On a per capita basis, Michigan is reporting 67.3 daily cases per 100k population, the highest in the country and 40% higher than #2, New Jersey (47.9). Michigan is quickly approaching its record high daily incidence (8,344 new cases per day), set in early December 2020. Michigan’s current surge started in late February/early March, and its daily mortality appears to be starting to increase as well, up from 11 deaths per day on March 29 to 15 on April 4. It is too early to determine if this is the start of a longer-term trend, but the timing is consistent with a lag of 4 weeks behind the daily incidence trend. According to CDC data, Michigan is the only state reporting test positivity greater than 10%, and the Johns Hopkins Coronavirus Resource Center is reporting Michigan’s test positivity at 16.4% over the past week and increasing.

US Vaccination
The US surpassed 200 million SARS-CoV-2 vaccine doses distributed, and the US has administered 167.2 million doses. The US is currently administering 2.77 million doses per day*, including 1.24 million people fully vaccinated.

More than 100 million individuals have received at least 1 dose of the vaccine, equivalent to nearly one-third of the entire US population and more than 40% of all adults. Of those, 62.4 million (18.8% of the total population; 23.2% of adults) are fully vaccinated. More than 75% of adults aged 65 years and older have received at least 1 dose, and more than half are fully vaccinated.

In terms of full vaccination, 31.1 million individuals have received the Pfizer-BioNTech vaccine, 27.1 million have received the Moderna vaccine, and 4.2 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 30.8 million cumulative cases and 555,638 deaths as of 10:15am EDT on April 6.

SARS-COV-2 ORIGIN On March 30, the WHO published a report on its investigation into the origin of SARS-CoV-2. While it is nearly impossible to definitively identify the exact source of the COVID-19 pandemic, the report describes information collected during the WHO team’s visit to China in January and February 2021. The investigators considered a broad scope of evidence, including epidemiological data, genomic analysis of SARS-CoV-2 specimens, environmental sampling from animal markets and laboratories, and interviews with health officials and laboratory researchers.

The report outlines the evidence for 4 potential scenarios: (1) zoonotic transmission direct from an animal reservoir to humans, (2) zoonotic transmission via an intermediate host, (3) transmission to humans via cold/food chain products, and (4) laboratory accident. The investigators indicated that spillover from animals to humans via an intermediate host was the most likely scenario, and a laboratory accident was determined to be “extremely unlikely.” Based on a review of potential cases of COVID-19 from October and November 2019 (identified retrospectively), before the first cases were reported in Wuhan, the researchers determined that it is unlikely the virus was spreading in the community prior to December 2019.

Because the report does not provide clear-cut answers regarding the pandemic’s origin, experts around the world continue to espouse a range of theories and speculation, including that the virus escaped containment in a laboratory in Wuhan. WHO Director-General Dr. Tedros Adhanom Ghebreyesus commented that the investigation was not “extensive enough” and that further research is necessary to more fully characterize the circumstances surrounding the emergence of SARS-CoV-2. Notably, the report outlines future areas for study, focusing largely on zoonotic transmission rather than the laboratory-escape scenario; however, Dr. Tedros emphasized that “all hypotheses are open.”

The report has been described as a “compromise” between the international and Chinese members of the WHO-sponsored team, a fact seized upon by some in their critiques of the team’s findings. The terms of the agreement between China and the WHO outlined a collaborative effort, as opposed to an independent, external investigation. In particular, some experts are calling attention to a lack of transparency by Chinese officials and researchers, and the close professional relationship between some of the WHO team members and the Wuhan Institute of Virology.

J&J TO SUPPLY AFRICAN UNION On March 29, J&J-Janssen announced a new purchase agreement with the African Vaccine Acquisition Trust (AVAT) to provide up to 400 million doses of its single-shot SARS-CoV-2 vaccine to the African Union’s 55 member states. Up to 220 million doses will be available with delivery beginning in the third quarter of 2021, and potential for the AVAT to order an additional 180 million doses through 2022. Within member states, availability of the vaccine will be subject to authorization or approval by national regulatory agencies. This agreement is in addition to an agreement with Gavi, the Vaccine Alliance to support the COVAX vaccine facility. J&J-Janssen and Gavi expect to finalize an advance purchase agreement that would provide up to 500 million vaccine doses to COVAX in 2022. Many African nations are participating in COVAX.

VACCINE EFFECTIVENESS On April 2, a team of researchers led by the US CDC COVID-19 Response Team published interim estimates of a prospective cohort study describing the effectiveness of the two-dose Pfizer-BioNTech and Moderna SARS-CoV-2 mRNA vaccines among healthcare and other frontline workers. The report, published in the CDC’s Morbidity and Mortality Weekly Report (MMWR), describes data collected from December 14, 2020 to March 13, 2021, through the HEROES-RECOVER network of 8 US sites. Overall, 3,950 frontline workers (i.e., those who routinely are within 3 feet of other individuals as part of their occupation) with no prior laboratory documentation of SARS-CoV-2 infection were included in the analysis. Participants were actively monitored for COVID-19 symptoms and self-collected weekly nasal swabs which were tested for SARS-CoV-2 infection. 

Among the 3,950 participants, 2,479 (62.8%) received both recommended vaccine doses and 477 (12.1%) received only one dose of vaccine during the 13-week study period. For the duration of observation, there were 78,902 person-days followed for fully vaccinated individuals (two weeks or more post-second dose), 41,856 person-days of observation for partially vaccinated individuals (two weeks or more after first dose through receipt of second dose) and 116,657 person-days of observation for unvaccinated individuals (no doses received). 161 infections were identified among the unvaccinated group (1.38 infections per 1,000 person-days), 8 infections were identified among the partially vaccinated group (≥14 days after first dose and before second dose; 0.19 infections per 1,000 person-days), and 3 infections were identified among the fully vaccinated group (≥14 days after second dose; 0.04 infections per 1,000 person-days). The researchers note that the 13 days following participants’ first or second dose when immune status was indeterminate (67,483 person-days) were not included in analysis, but 33 infections were identified during that period of observation. 

The unadjusted vaccine effectiveness for the partially immunized group was 82% (95% CI: 62-91) and 91% for the fully immunized group (95% CI: 73-97). The adjusted vaccine effectiveness for the partially immunized group was 80% (95% CI: 59-90) and 90% for the fully immunized group (95% CI: 68-97). Notably, a majority of infections were symptomatic with common COVID-19-associated symptoms (87.3%), but only two hospitalizations occurred and no deaths occurred. In light of these findings, the CDC encourages vaccinated individuals to continue taking public health precautions to prevent infection and transmission.

ASTRAZENECA-OXFORD VACCINE AGE RESTRICTIONS As countries continue to evaluate the risk of blood clots associated with the AstraZeneca-Oxford SARS-CoV-2 vaccine, some are implementing age restrictions for that product. Canada’s National Advisory Committee on Immunization (NACI) issued updated guidance recommending the vaccine not be used in individuals under the age of 55 while it conducts further investigation into the risk of vaccine-induced prothrombotic immune thrombocytopenia (VIPT). NACI notes that VIPT cases reported thus far “have been primarily in women under the age of 55 years” who received the AstraZeneca-Oxford vaccine, but the exact frequency has not yet been confirmed. Canada is receiving sufficient supply of other vaccines, so the decision to restrict the use of the AstraZeneca-Oxford vaccine to older adults should not adversely impact vaccination progress.

Similarly, Germany suspended the use of the vaccine in individuals under the age of 60. Germany’s Standing Committee on Vaccination (STIKO) also indicated it will finalize its guidance for younger adults who already received the first dose of the AstraZeneca-Oxford vaccine by the end of April. Notably, Germany is administering the second dose of the vaccine at 12 weeks, so the first round of second doses are not scheduled to be administered until May since first doses began to be administered at the beginning of February.

SARS-COV-2 VACCINE PEDIATRIC TRIALS On March 31, Pfizer-BioNTech announced findings from a Phase 3 clinical trial of its SARS-CoV-2 vaccine among adolescents ages 12-15 with or without evidence of previous infection. No symptomatic COVID-19 cases were identified in the vaccinated group (n=1,131), and 18 symptomatic COVID-19 cases were identified in the placebo group (n=1,129), translating to 100% vaccine efficacy among vaccinated participants. Vaccinated participants demonstrated strong immunogenicity one month after their second dose, and the vaccine was well-tolerated. Both immunogenicity and side effects were consistent with results seen in previous trials among participants 16 to 25 years of age. 

Pfizer-BioNTech plans to submit amendments to the US FDA and the European Medicines Agency for use of the vaccine among individuals 12 and older under the current US Emergency Use Authorization and EU Conditional Marketing Authorization, respectively. Currently, the Pfizer-BioNTech COVID-19 vaccine is authorized for individuals ages 16 years and older. Depending on regulatory authorization, adolescents could begin to receive vaccinations soon, possibly before the beginning of next academic year. The companies also plan to submit the data for peer-reviewed publication. 

Pfizer-BioNTech also provided an update on the ongoing SARS-CoV-2 vaccine Phase 1/2/3 study among children ages 6 months to 11 years. Children in the trial are grouped by age: 5 to 11 years, 2 to 5 years and 6 months to 2 years. Dosing has begun in the oldest cohort, with the 2- to 5-year-old cohort to commence next. 

J&J-Janssen on April 2 announced it began vaccinating participants ages 12 to 17 in an ongoing Phase 2a trial that has been testing safety, reactogenicity and immunogenicity of one- and two-dose schedules with participants ages 18-55 years and 65 years and older since September 2020. Adolescents will be included in a step-wise approach, with participants ages 16-17 years included first before expanding to younger adolescents. Moderna is conducting clinical trials for its vaccine among adolescents 12 up to 18 years old and among children 6 months to 12 years old.

US CDC TRAVEL GUIDANCE On April 2, the US CDC released new domestic and international travel recommendations for individuals who are fully vaccinated. Fully vaccinated individuals are defined as people who have received all recommended doses of SARS-CoV-2 vaccine (i.e., two doses of Pfizer-BioNTech or Moderna vaccines or one dose of J&J-Janssen vaccine) and two weeks have passed since their final dose.

CDC guidance now states that fully vaccinated people “can travel safely within the United States” and “are less likely to get and spread COVID-19” while traveling internationally. Regarding domestic travel, fully vaccinated individuals are encouraged to continue following public health guidance such as masking, physical distancing, and increased handwashing or hand sanitizer use. Under the guidance, fully vaccinated domestic travelers do not have to self-quarantine or get tested pre- or post-travel unless their destination requires it.

Compared with domestic travel, CDC guidance notes that international travel is inherently riskier due to the possibility of becoming infected with and spreading new SARS-CoV-2 variants. Accordingly, all air passengers traveling to the US are required to show proof of a negative SARS-CoV-2 test within three days of travel or documentation of COVID-19 disease and recovery in the past three months prior to boarding their flight to a US destination. Additionally, fully vaccinated international travelers are encouraged to get tested 3-5 days after arriving in the US, follow advice for domestic travel, and adhere to local and state guidance. These new changes in travel guidance, based on studies showing the real world effectiveness of vaccination, are expected to bring some relief to individuals who have missed travel as well as a struggling travel industry. However, CDC Director Dr. Rochelle Walensky urged caution, advocating that individuals avoid travel due to rising case numbers in the US. 

US COVID-19 MORTALITY Researchers from the US National Center for Health Statistics on March 31 published a report in the US CDC’s Morbidity and Mortality Weekly Report describing the leading causes of US deaths in 2020. The authors analyzed provisional mortality data from the CDC’s National Vital Statistics System, ranking causes of mortality and contextualizing COVID-19 mortality trends with available demographic and medical data. Based on the provisional data, the estimated age-adjusted death rate in the US increased from 715.2 deaths per 100,000 in 2019 to 828.7 deaths per 100,000 in 2020 (+15.9%). COVID-19 was an underlying or contributing cause of death for 11.3% (377,883) of deaths in 2020; approximately 9% of COVID-19-associated deaths had an underlying cause of death that was not COVID-19. The top 3 leading underlying causes of death in 2020 were heart disease (690,882), cancer (598,932), and COVID-19 (345,323), with the next 7 leading underlying causes of mortality being unintentional injury, stroke, chronic lower respiratory disease, Alzheimer disease, diabetes, influenza and pneumonia, and kidney disease. Previously, suicide was the 10th leading underlying cause of death in the United States but was displaced from the list in 2020 due to mortality from the COVID-19 pandemic. 

FDA AUTHORIZES SERIAL SCREENING TESTS On March 31, the US FDA authorized several SARS-CoV-2 tests under a recently developed streamlined pathway for test developers to gain emergency use authorization for testing tools. The FDA authorized 3 over-the-counter, at-home SARS-CoV-2 tests for serial screening of individuals who are asymptomatic and have not had a known or suspected recent exposure to COVID-19; a point-of-care (POC) test for use without a prescription; and another POC test for use with a prescription. The FDA previously had authorized these tests for symptomatic individuals. Regulators and experts hope the availability of these tests will increase access to testing, aiding pandemic responses particularly in schools, workplaces, communities, and others that plan to establish screening programs. 

J&J-JANSSEN VACCINE DOSES RUINED A mistake at a vaccine manufacturing facility in Maryland (US) resulted in the loss of millions of doses of J&J-Janssen’s SARS-CoV-2 vaccine. A facility operated by Emergent Biosolutions was producing both the J&J-Janssen and AstraZeneca-Oxford vaccines and “accidentally conflated the ingredients,” resulting in the loss of an entire lot of 15 million doses of the J&J-Janssen vaccine. The error was identified through routine quality control processes before the doses were shipped. The facility had not yet received authorization to begin shipping any vaccine doses, and the incident does not affect any vaccine that was already distributed. Following the incident, the US government reportedly facilitated J&J to take over operations at the facility, and production of the AstraZeneca-Oxford vaccine has been moved to another facility. While the wasted doses were scheduled to be allocated to the US, the federal government does not anticipate major delays to national vaccination efforts.

FEMA COVID-19 FUNERAL COSTS The US Federal Emergency Management Agency (FEMA) announced it will provide financial support to offset the cost of funeral services for COVID-19 victims. The financial support is available for individuals who died in the US from COVID-19 (documented on the death certificate) after January 20, 2020, and while applicants must be US citizens or residents, there is no citizenship or residency requirement for the deceased individuals. FEMA is offering up to US$9,000 per funeral, and applicants can submit requests for multiple COVID-19 victims, up to US$35,500 per application. Among its many roles, FEMA supports disaster relief, and this effort will help mitigate the financial burden on the families of COVID-19 victims. Some of the funding for this program was allocated in the December 2020 federal COVID-19 relief package, which provided US$2 billion to FEMA to cover funeral costs for COVID-19 victims in 2020.