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EPI UPDATE The WHO COVID-19 Dashboard reports 133.1 million cases and 2.9 million deaths as of 6:00am EDT on April 9.

The global attention on vaccination progress has largely focused on China, Israel, the US, and Europe. Among the first to initiate large-scale mass vaccination efforts, these countries have made more progress than most; however, vaccination has commenced in most countries around the world, and today, we will take a closer look at the progress made elsewhere*. 

In terms of the continent-level breakdown, Asian countries account for more than half of the daily total doses administered globally, followed by North America, Europe, South America, Africa, and Oceania. On a per capita basis, the global average is currently 0.21 daily doses administered per 100 people. North America (0.62), Europe (0.29), and South America (0.27) are higher than the global average, and Asia (0.20), Oceania (0.09), and Africa (0.02) are reporting less than the average.

Excepting the US, Brazil (25.0 million) is reporting the most cumulative doses administered in the Americas, and Chile (11.4 million) and Mexico (10.6 million) are the only other countries reporting more than 10 million doses. Most countries are reporting fewer than 1 million doses. On a per capita basis, Chile is #1 in the Americas, with 60 doses per 100 population, followed by the US (52), Uruguay (28), Antigua and Barbuda (27), and Dominica (25). Most countries are reporting fewer than 10 doses per 100 population. After the US, Brazil is leading the Americas in terms of total daily doses administered, with more than 700,000 doses per day. Mexico (342,160), Canada (193,674), and Argentina (106,885) are the only other countries reporting more than 100,000 doses per day. Approximately half of the countries in the Americas are reporting fewer than 10,000 doses per day. Uruguay (0.98 daily doses per 100 population) is reporting more daily doses per capita than the US (0.91), followed by Chile with 0.68. Canada is the only other country reporting more than 0.5.

Compared with other continents, limited data are available for Africa**, as many countries have not yet commenced vaccination efforts or reported vaccination data. In terms of cumulative doses administered, Morocco is leading the continent with 8.5 million doses, more than 8 times #2 Nigeria (nearly 1 million). Ghana (599,128), Rwanda (348,926), Kenya (340,121), Senegal (326,910), and South Africa (283,629) have also reported more than 200,000 cumulative doses. Notably, Nigeria commenced vaccination operations more recently than a number of African countries, but its progress accelerated quickly compared to others. On a per capita basis, Seychelles is #1 in Africa with more than 1 dose administered per person (106 per 100 population), followed by Morocco (23 per 100). No other African countries are reporting more than 5 doses per 100. Most countries that have reported data are at fewer than 1, with many reporting fewer than 0.5 doses per 100. Morocco (58,968 doses per day), Nigeria (44,891), and Kenya (25,479) are reporting the highest total daily doses administered. Zimbabwe is the only other country reporting more than 10,000 doses per day, and most countries are reporting fewer than 5,000 doses per day.

Asia and Oceania span multiple WHO regions, so we will provide a brief look at the Eastern Mediterranean, Southeast Asia, and Western Pacific regions individually. In the Eastern Mediterranean region**, the UAE is #1 in terms of cumulative total doses administered, with 8.9 million, followed by Saudi Arabia (5.8 million). All other countries are reporting 1 million or fewer doses. On a per capita basis, only the UAE (90), Bahrain (53), and Qatar (35) are reporting more than 20 doses per 100 population. In terms of daily progress, Saudi Arabia (168,367) and the UAE (71,181) are the only 2 countries reporting more than 30,000 doses per day, and most are reporting fewer than 15,000.

In Southeast Asia, India is #1 and rapidly approaching 100 million cumulative doses, more than 7 times the doses administered in #2 Indonesia (14.1 million). South Korea is the only other country to report more than 1 million doses administered. On a per capita basis, Bhutan (61 doses per 100 population) and Maldives (52) are #1 and #2, respectively, with India in a distant #3 (7). India is also #1 in terms of daily doses administered. With more than 3.5 million, it is reporting nearly 14 times the daily doses in #2 Indonesia (263,637). All other countries are reporting fewer than 50,000 doses per day. And finally, in the Western Pacific***, China is far and away #1 in terms of cumulative total doses administered, with more than 150 million, although it commenced vaccination efforts well before other countries. Singapore is #2 with 1.7 million. On a per capita basis, Singapore (29), Mongolia (18), and China (11) are the only 3 countries reporting more than 10 doses per 100 population. China is also #1 in terms of daily doses administered, with more than 4 million doses per day. Japan (62,499) and Cambodia (57,059) are #2 and #3, respectively, and several countries are reporting 25-40,000 doses per day.
*For the purpose of this analysis, we will limit our scope to WHO Member States. The WHO COVID-19 Dashboard does not break down vaccinations in terms of individual countries or by vaccination status (i.e., partial or full), so we will rely on data published by Our World in Data, which principally draws from national-level reporting.
**We included Djibouti, Egypt, Libya, Morocco, Somalia, Sudan, and Tunisia, in Africa, even though they are in the WHO’s Eastern Mediterranean Region.
***Our World in Data is missing data available for some WPRO countries, particularly small island nations.

Global Vaccination
The WHO reported 669.2 million vaccine doses administered globally as of April 9, including 361.1 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 733.6 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 171 countries and territories are reporting vaccination data.

The US CDC reported 30.7 million cumulative cases and 556,106 deaths. The recent increase in daily incidence appears to have leveled off to some degree, at approximately 63-64,000 new cases per day, although this could be a function of delayed reporting over the Easter holiday weekend. Daily mortality continues to decrease, now down to 710 deaths per day, the lowest average since October 2020. Daily mortality is approaching the low between the first and second surges (671 on October 6, 2020).

On April 7, Oklahoma reported approximately 1,300 previously unreported cases and 1,800 deaths. The previously unreported cases were a result of a technical error with the state’s electronic laboratory reporting system, and they occurred between December 2020 and March 2021. The deaths were a result of a discrepancy in the state’s reporting to the CDC. Oklahoma state officials are working to resolve the reporting issue, but there may be additional previously unreported deaths over the coming weeks. 

US Vaccination
The US has distributed nearly 230 million doses of SARS-CoV-2 vaccine and administered nearly 175 million doses. The US is currently administering 2.8 million doses per day*, including 1.3 million people fully vaccinated.

A total of 112 million individuals have received at least 1 dose of the vaccine, equivalent to approximately one-third of the entire US population and 43% of all adults. Of those, 66.2 million (20% of the total population; 26% of adults) are fully vaccinated. Among adults aged 65 years and older, 77% have received at least 1 dose, and 58% are fully vaccinated.

In terms of full vaccination, 32.8 million individuals have received the Pfizer-BioNTech vaccine, 28.5 million have received the Moderna vaccine, and 4.9 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.

The Johns Hopkins Coronavirus Resource Center is reporting 31.0 million cumulative cases and 560,152 deaths as of 10:15am EDT on April 6.

ASTRAZENECA-OXFORD VACCINE & BLOOD CLOTS Now several weeks after the initial reports of blood clots in a handful of individuals who were recently vaccinated with the AstraZeneca-Oxford vaccine in Europe, countries are still struggling to determine the best approach to using the vaccine. On April 7, the European Medicines Agency (EMA) released preliminary findings from its analysis of blood clotting events associated with the vaccine. The EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) analyzed data from 86 total cases of thrombosis following vaccination, including 18 deaths, and determined that blood clotting should be listed as a “very rare” adverse event for the AstraZeneca-Oxford vaccine—approximately 1 case per 100,000 people. Notably, the 86 cases occurred out of approximately 25 million people who have received one or more doses of the vaccine. The clotting events occur more frequently in women under the age of 60 and typically occur within 2 weeks of vaccination, but additional risk factors have not yet been characterized. The EMA explicitly noted that the “overall benefits of the vaccine in preventing COVID-19 outweigh the risks of side effects.” The PRAC called for further investigation of blood clotting following vaccination in order to more fully characterize risk factors and overall risk. AstraZeneca is working with British and European regulators to list thromboembolic events as an extremely rare but potential adverse event.

Evaluations by multiple other national regulatory authorities are ongoing, and in addition to Canada and Germany, several other countries restricted the use of the AstraZeneca-Oxford vaccine in younger adults. Australia’s Technical Advisory Group on Immunisation reported the blood clotting risk as 4-6 cases per million people, and it recommended largely restricting use of the vaccine to adults aged 50 years and older. Adults under the age of 50 who have already received the first dose and have not exhibited serious adverse events can receive the second dose.

The UK’s Joint Committee on Vaccination and Immunisation recommended a much younger age, setting its cutoff at 30 years. The UK’s Medicines and Healthcare Products Regulatory Agency found a slightly lower risk than the EMA at 1 case per 250,000 vaccinations. The UK guidance notes that there are no reports of blood clotting following the second dose, so anyone who has already received the first dose of the vaccine should continue with their second dose, regardless of age. For younger adults, Australia and the UK both recommend alternate vaccines that are already authorized for use. The Philippines and South Korea also suspended the vaccine’s use among people under age 60, and France, Italy, and the Netherlands all set minimum ages for the vaccine this week, following the release of the EMA’s findings. 

Additionally, the African Union suspended plans to purchase the AstraZeneca-Oxford vaccine, citing concerns over shortages of supply from India. Dr. John Nkengasong, Director of the Africa CDC, said AU member states will receive the AstraZeneca-Oxford vaccine through the COVAX facility, while the AU focuses on purchasing J&J-Janssen’s single-shot vaccine. Dr. Nkengasong stressed the decision had “nothing to do” with the blood-clot concerns and noted the Africa CDC continues to recommend the AstraZeneca-Oxford vaccine.

VACCINATION CERTIFICATES Some experts and government officials have proposed vaccine certificates or passports as a means to resume “normal” pre-pandemic activities, but there have been mixed responses over the idea. Israel has implemented a “Green Pass” to those who have received two vaccine doses more than a week prior or have recovered from COVID-19 with presumed immunity to allow them access to gyms, hotels, and theaters. Applicants’ status is proven either with a hardcopy of their vaccination certificate or digitally through a health ministry app that is linked to the person’s medical file. China and the European Union also have expressed support for vaccine passports, with both planning to move forward with implementation. Although originally opposed to the idea, EU leaders are working toward approving and implementing a “digital green pass” program, which is expected to take three months to establish. 

Despite growing support among some nations, not all are onboard. The American Civil Liberties Union previously expressed concern that vaccine passports would exacerbate racial and economic disparities. Some US Republicans have shown disapproval of vaccine passports, including Florida Governor Ron DeSantis, who promised an executive order barring the state from participating in any vaccination credentialing efforts. Texas Governor Greg Abbott, also opposed to requirements to show proof of vaccination, issued an executive order on April 5 saying government agencies, private businesses, and institutions that receive state funding cannot require people to show proof that they have been vaccinated on the grounds that vaccination status is private health information.

White House Coronavirus Response Coordinator Jeff Zients has said there will not be a federally mandated vaccination credentialing system and has promised more information in the coming weeks. US officials say they are struggling with several challenges in devising recommendations, including data privacy and health-care equity. Several international and US efforts are underway to provide guidance, including those by the WHO Smart Vaccination Certificate Working Group, the Vaccination Credential Initiative, and the US Federal Health IT Coordinating Council

PANDEMIC TREATY On March 30, leaders from more than 2 dozen countries, the EU, and the WHO published a call for an international treaty for pandemic preparedness that they argue would “build a more robust international health architecture that will protect future generations.” Citing COVID-19 as the biggest global challenge since World War II, the leaders acknowledged the “pandemic has been a stark and painful reminder that nobody is safe until everyone is safe.” The main goals of the treaty would be to foster international cooperation on information sharing and research and to strengthen national, regional, and global resilience for future pandemics, including the production and distribution of public health tools, such s diagnostics, vaccines, medicines, and personal protective equipment. European Council President Charles Michel first proposed the idea of a pandemic treaty at the UN General Assembly in December.

According to WHO Director-General Dr. Tedros Adhanom Ghebreyesus, the treaty would fill gaps exposed by the COVID-19 pandemic by strengthening the implementation of the agency’s International Health Regulations (IHR) and providing a framework for pandemic preparedness cooperation. However, some experts warn that without more authority to independently verify official state reports, the WHO would continue to struggle in its efforts to alert the world of potential threats in a timely and transparent manner. The IHR, in its current form, has been in place since 2005; however, many countries have not fully implemented “core health system capacities” required under the IHR and technical and financial assistance from wealthier to lower-income countries remains lacking in many areas, so it is unclear if or how a new treaty could fill those gaps. Formal negotiations of the proposed treaty have not begun, but Dr. Tedros said discussions could begin in May at the World Health Assembly. He added that all Member States should be involved in drafting the treaty, which would be grounded in the WHO constitution and include “the principles of health for all and no discrimination.” 

EMERGING VARIANTS During the April 7 White House COVID-19 Response Team briefing, US CDC Director Dr. Rochelle Walensky said that 52 jurisdictions were reporting SARS-CoV-2 variants of concern and that the B.1.1.7 variant is now the most common lineage circulating in the US. A study published on March 30 in the journal Cell suggests the B.1.1.7 strain is 40-50% more transmissible than other known variants. The researchers note the strain is more transmissible among younger populations and can lead to more severe disease, although there is no evidence the strain can evade currently available SARS-CoV-2 vaccines. Dr. Walensky urged the public to continue mitigation strategies, including mask use, physical distancing, and avoiding large gatherings, especially among younger individuals. Michigan has seen the sharpest rise in new cases among US states over the past week, and surveillance data indicate that approximately 70% of the state’s new cases are due to the B.1.1.7 strain.

Researchers from Stanford University (US) identified at least 5 cases of a “double mutant” SARS-CoV-2 strain in the San Francisco area that was originally detected in Maharashtra, India. The variant contains 2 key mutations, E484Q and L452R, that have been found separately in other variants. US regional variants, including the B.1.526 strain that first appeared in New York City in November 2020, are believed to be driving an increase in community transmission in several Northeastern states.

US VACCINE ELIGIBILITY & DISTRIBUTION On April 6, US President Biden announced that all US adults will be eligible to receive a SARS-CoV-2 vaccine on April 19, two weeks earlier than his previous deadline for states. Biden noted the US government is on track to meet its new goal of administering 200 million doses in its first 100 days, and approximately 80% of K-12 teachers in the US have received at least one vaccine dose. Many states have accelerated their eligibility timelines, with some already ahead of Biden’s new April 19 goal.

Michigan is experiencing a surge of new daily cases near its all time peak in December, with state officials and scientists urging the federal government to send additional vaccine doses. However, federal officials said they plan to maintain vaccine-allocation strategies based on population, not new COVID-19 cases. Michigan Governor Gretchen Whitmer first requested additional doses and a shift away from population-based allocation to instead target hard-hit areas of the country on March 30, but White House Coronavirus Response Coordinator Jeff Zients rebuffed the request, saying the administration is not inclined to change its system at this time. 

MANDATORY VACCINATION Discourse continues over the potential implementation of SARS-CoV-2 vaccination mandates for various institutions and workplaces before their return to normal operating procedures. Several universities have implemented policies requiring students to be fully vaccinated if they wish to attend in-person classes this fall. The rationale behind these decisions comes from data suggesting college campuses might be a significant contributor to local SARS-CoV-2 transmission due to factors such as congregant living and travel from various geographic regions. Of the at least 8 universities who have announced this plan, all will allow for religious and medical exemptions. The CDC has offered guidance for SARS-CoV-2 vaccination policies in the workplace, but there are no discussions of a national vaccine mandate.

“BRIDGING” TRIALS India, one of the world’s largest vaccine manufacturers, is facing a new challenge after the Drug Controller General of India (DCGI) implemented requirements for foreign companies and domestic companies working with foreign partners to perform “bridging trials” before the agency will consider authorizing any vaccines first tested abroad. In other words, DCGI is requiring any vaccine that completed Phase 3 trials outside of the country to undergo bridging trials, or local clinical trials, before being considered for authorization. The rationale behind the bridging trials is to see whether vaccine candidates are able to provide similar results when applied to specific in-country factors. 

COVID-19 & NEUROLOGICAL CONDITIONS A study published in The Lancet Psychiatry estimates that more than one-third of COVID-19 survivors experienced neurological symptoms within 6 months of their infection. Researchers at the University of Oxford (UK) evaluated medical record data for nearly 250,000 COVID-19 patients and found that 33.62% were diagnosed with a neurological or psychiatric condition in the 6 months following their infection, including 12.84% for whom this was their first such diagnosis. The proportion increased among those who were admitted to an intensive care/treatment unit (ICU/ITU), up to 46.42% and 25.79%, respectively. The most common conditions included anxiety disorders (17.39%), mood disorders (13.66%), substance use disorder (6.58%), insomnia (5.42%), nerve disorders (2.85%), and ischemic stroke (2.10%). The study breaks down each condition by disease severity.

The researchers also compared the cohort against patients who were diagnosed with influenza and other respiratory diseases and found that COVID-19 patients were at significantly higher risk of neurological and psychiatric conditions following infection. Many neurological and mental health conditions are underdiagnosed in the broader population, so it difficult to definitively link these conditions to COVID-19, but the evidence indicating the elevated incidence compared to patients with other respiratory diseases provides further indication that SARS-CoV-2 can have lasting effects long after the acute stage of infection or disease.

SCHOOL TESTING WEBINAR The Johns Hopkins Center for Health Security is hosting a webinar on April 13 (2pm EDT) to discuss lessons from K-12 testing programs in Delaware (US). A panel of experts will discuss school-based testing strategies and best practices as well as the importance of testing to ensure schools can effectively mitigate COVID-19 risk and resume in-person learning. The panelists will also provide insights into Becton Dickinson's SARS-CoV-2 testing capabilities, including training and education efforts.

The panelists include Dr. Adam Zerda, Director of Strategy and Public Affairs at Becton Dickinson; Dr. Richard Pescatore, Delaware’s Chief Physician and Associate State Medical Director; and Andrew Lux, Director of Application Management and Implementations for Healthcare IT Leaders, and the panel will be moderated by the Center for Health Security’s Dr. Gigi Gronvall. This webinar is part of a series hosted by the Center’s COVID-19 Testing Toolkit program, which provides essential information for organizations seeking to engage in SARS-CoV-2 testing. You can register for the webinar here.