COVID-19 Situation Report
EPI UPDATE The WHO COVID-19 Dashboard reports 207.2 million cumulative cases and 4.36 million deaths worldwide as of 12:45pm EDT on August 16. Global weekly incidence continues to increase, but it appears to be approaching a peak or plateau, however this could be a function of reporting delays. Last week, the weekly total increased less than 2% compared to the previous week. Global weekly mortality held relatively steady last week, decreasing less than 0.5% compared to the previous week. The dashboard indicates that there are delayed reports from multiple countries in the African Region for August 15, which are likely impacting the global trends. Notably, the weekly incidence for the African Region was nearly 23% lower than the previous week—a difference of more than 40,000 new cases—and weekly mortality was nearly 18% lower—a difference of 834 deaths. The global trends could shift upward once reporting is complete for Africa for last week.

Global Vaccination
The WHO reported 4.46 billion doses of SARS-CoV-2 vaccines administered globally as of August 16. The WHO reports that a total of 1.70 billion individuals have received at least 1 dose, and 880 million are fully vaccinated. Analysis from Our World in Data shows that the global daily doses administered has leveled off after a week of decline, holding relatively steady at approximately 37 million doses per day*. The global trend continues to closely follow the trend in Asia. Our World in Data estimates that there are 2.47 billion vaccinated individuals worldwide (1+ dose; 31.7% of the global population) and 1.85 billion who are fully vaccinated (23.7% of the global population). Notably, the global total jumped from 1.25 million fully vaccinated individuals on August 11 to 1.81 million on August 12 due to newly reported data from China**.
*The average doses administered may exhibit a sharp decrease for the most recent several days, which indicates effects of reporting delays. In an effort to reflect the longer-term trends, the averages reported here may not correspond to the most recent data.
**The previous report from China’s National Health Commission was on June 10. China has not updated data regarding its partially vaccinated population (1+ dose) since June 10.

The US CDC reported 36.7 million cumulative COVID-19 cases and 619,564 deaths. The daily average is up to 121,873 new cases per day, the highest since February 4. Daily incidence continues to increase rapidly, but it appears as though the US may be passing an inflection point. It is difficult to determine, however, whether this is an artifact of reporting frequency—particularly over the weekend—or an early indication of a longer-term trend. Daily mortality continues to increase as well, although it is difficult to determine whether the current trend is a linear or exponential increase. The current average of 548 deaths per day is the highest since May 13*.
*Changes in the frequency of state-level reporting may affect the accuracy of recently reported data, particularly over the weekend. In an effort to reflect the longer-term trends, the averages reported here may not correspond to the most recent dates.

US Vaccination
The US has administered 357.3 million cumulative doses of SARS-CoV-2 vaccines. After approximately 5 weeks of steady increase, the daily vaccinations leveled off over the past several days, holding relatively steady at approximately 650-660,000 doses per day*. A total of 198.6 million individuals in the US have received at least 1 dose, equivalent to 59.8% of the entire US population. Among adults, 72.1% have received at least 1 dose, as well as 12.4 million adolescents aged 12-17 years. A total of 168.7 million individuals are fully vaccinated, which corresponds to 50.8% of the total population. Approximately 61.8% of adults are fully vaccinated, as well as 9.2 million adolescents aged 12-17 years.
*Due to delays in reporting, estimates for the average daily doses administered are less accurate for the most recent 5 days. The most current average provided here corresponds to 5 days ago.

THIRD DOSE FOR IMMUNOCOMPROMISED INDIVIDUALS The US CDC approved a recommendation to provide a third dose of mRNA-based SARS-CoV-2 vaccines to individuals with moderate-to-severe compromised immune systems on August 13. CDC Director Dr. Rochelle Walensky’s approval of the recommendation followed a unanimous vote by the agency’s Advisory Committee on Immunization Practices (ACIP) and an emergency use authorization by the US FDA. The Pfizer-BioNTech vaccine is authorized for use among individuals aged 12 and older, and the Moderna vaccine is authorized for individuals aged 18 and older. The FDA did not extend the authorization for a third dose to the J&J-Janssen vaccine due to a lack of efficacy data, but officials have stated they are working to develop a recommendation. 

A third dose of the mRNA-based SARS-CoV-2 vaccines is recommended for moderately to severely immunocompromised individuals, including those receiving cancer treatment, recent recipients of an organ or stem cell transplant, those with advanced or untreated HIV infection, individuals taking a high dose of corticosteroid, and people who are anticipating treatment that may weaken their immune system. However, a third dose of vaccine is not recommended for adults with chronic conditions that may cause mild immunosuppression, such as people with diabetes and heart disease or residents in long-term care facilities. According to the guidance, the third dose should be given at least 28 days after the second dose for the best results. The CDC urges eligible individuals to try to get the same vaccine for their third dose, but receiving a different vaccine for the third dose is acceptable if the original is unavailable. Notably, immunocompromised people will not need a prescription or doctor’s note to get a third dose but will need to attest to their eligibility, raising questions about the potential for people to lie about their immune status in order to receive a third vaccine dose.

PFIZER-BIONTECH THIRD DOSE Pfizer-BioNTech submitted early-stage clinical trial data to the US FDA on August 16 to seek emergency use authorization for a third SARS-CoV-2 vaccine dose for all people aged 16 years and older. The companies claim the trial data show a third dose administered 6 to 12 months after the second dose generates higher levels of neutralizing antibodies against the Alpha, Beta, and Delta variants of SARS-CoV-2. The companies state that late-stage trial data will be submitted to the FDA and additional worldwide regulatory authorities once available. 

The US government is not yet officially recommending third doses of mRNA-based vaccines for the general public despite the recent guidance for booster vaccinations for people with moderate-to-severely compromised immune systems. However, officials are reportedly developing plans to start offering third doses of vaccines to more of the general public as early as the fall. Initial doses given under the plan likely would be reserved for healthcare workers and long-term care facility residents who are at increased risk of severe disease. The FDA must first review the data submitted by Pfizer-BioNTech before an emergency use authorization can be approved and before the US CDC can make an official recommendation. 

US EVICTION MORATORIUM The new version of a US CDC eviction moratorium faced its first legal challenge last week, with US District Judge Dabney Friedrich in Washington, DC, allowing the order to stay in place because she is bound by a ruling from the US Court of Appeals for the District of Columbia (DC) Circuit that allowed the previous version of the moratorium to continue. In May, Judge Friedrich ruled the previous nationwide moratorium exceeded the CDC’s authority but she stayed the judgment pending appeal, which allowed the moratorium to remain in force. The plaintiffs then asked the US Court of Appeals to vacate the stay, but the court declined, again allowing the moratorium to continue. In doing so, the court said the moratorium falls within a 1944 public health emergencies law and that the US government “made a strong showing that it is likely to succeed on the merits.” At this point, the plaintiffs asked US Supreme Court Chief Justice John Roberts to vacate Judge Friedrich’s stay, but Chief Justice Roberts denied relief on June 29. Notably, 5 justices indicated they would grant the application to vacate the stay.

When a group of property managers and realtors asked Judge Friedrich to put a hold on the new eviction ban—which is set to expire October 3 and applies only to places in the country experiencing significant SARS-CoV-2 transmission, instead of the entire nation—she wrote that “the minor differences between the current and previous moratoria do not exempt the former from this Court’s order.” Judge Friedrich indicated she would vacate the stay but that she does not have the authority to act on a higher court’s decision. The plaintiffs are expected to ask the US Court of Appeals to reconsider its ruling and likely will go to the US Supreme Court if they don’t get their desired outcome. In a statement, White House Press Secretary Jen Psaki said the administration of US President Joe Biden “believes that CDC’s new moratorium is a proper use of its lawful authority to protect the public health. We are pleased that the district court left the moratorium in place, though we are aware that further proceedings in this case are likely.” She said President Biden is calling on all officials to urgently distribute US$46.5 billion in emergency rental assistance funds made available through Congressional action on COVID relief.

US SUPREME COURT VACCINE MANDATE CHALLENGE The US Supreme Court last week refused to block Indiana University’s requirement that all students, faculty, and staff have a SARS-CoV-2 vaccination, unless they qualify for one of several exemptions. The decision to turn down a group of students’ request for emergency relief was issued independently by Justice Amy Coney Barrett, who handles emergency requests from Indiana, without explanation, without dissents from other justices, and without asking the university for a response. All of these moves could signal the request does not stand on solid legal ground. Both a federal district judge and an unanimous panel of the US Court of Appeals for the 7th Circuit previously rejected requests for emergency relief while the issue moved through the courts. This was the first case involving mandatory SARS-CoV-2 vaccinations to reach the Supreme Court.

FUNDING FOR US RURAL HEALTHCARE The Administration of US President Joe Biden on August 13 announced the US Department of Health and Human Services (HHS) will provide US$8.5 billion in American Rescue Plan (ARP) spending to help aid healthcare providers who serve rural Medicare, Medicaid, and Children’s Health Insurance Plan (CHIP) patients for lost revenue and increased expenses associated with COVID-19. Additionally, the US Department of Agriculture (USDA) will use US$500 million in ARP funding to establish the Emergency Rural Health Care Grant Program to help rural healthcare facilities increase access to SARS-CoV-2 vaccines and testing, medical supplies, telehealth, and food assistance; support construction or renovation; compensate for lost revenue or staffing expenses due to the pandemic; and plan and implement models to improve long-term viability. The announcement also included funding to train new rural healthcare providers and expand telehealth services. In a fact sheet, the White House said the funding “builds on efforts the Administration has already taken to help rural communities tackle the COVID-19 crisis and improve access to health care,” including a previous announcement of US$100 in funding to assist rural health facilities conduct vaccine outreach.

VACCINE INCENTIVES Mercer, an employee benefit consultant company, recently stated that at least 20 companies have approached them to ask about implementing health insurance coverage surcharges of US$20-50 per month for employees who refuse to get a SARS-CoV-2 vaccine. Employers have offered benefits and incentives such as cash payments and paid time off to encourage vaccination among their ranks, but stalling vaccination rates have some companies reconsidering their approach. Health coverage surcharges already are a tool used when insured individuals act against common medical advice, such as continuing to smoke cigarettes. For example, the Affordable Care Act allows insurers to charge smokers up to 50% more than non-smokers for health coverage. The likelihood of health coverage surcharges for not receiving a SARS-CoV-2 vaccine remains unclear, but employers or insurers may decide to implement these measures if the cost of hospitalization for unvaccinated insurance recipients gets too high.

FLORIDA SCHOOL DISTRICT The Hillsborough County School District, which includes Tampa, Florida (US), is expected to hold an emergency school board meeting on August 18 to discuss COVID-19 protective measures only 1 week after resuming in-person classes for the fall semester. Since the start of classes, nearly 6,000 students and employees have been asked to isolate or quarantine due to SARS-CoV-2 infection or exposure. COVID-19 data from the school district indicate that nearly 1,300 new cases have been reported among students and staff since August 2, including 399 students and 88 staff reported on August 16 alone. The school district reported 8,771 cumulative cases from March 2020 to August 1, 2021. Notably, the cases are distributed relatively evenly across the county’s 250 schools, with only one school exceeding 50 cases. The district announced on August 7 that it was implementing a mask requirement through September 3, but parents would be able to opt their children out of the requirement. So far, the district—the 7th largest in the nation with 208,000 students—has received 27,915 opt-out submissions. Florida Governor Ron DeSantis’s office has said the state Board of Education could withhold the salaries of district superintendents or school board members who disregard the governor’s executive order that effectively prohibits school districts from implementing mask mandates. Statewide, Florida’s epidemic continues to surge to record levels.

GLOBAL VACCINE DISTRIBUTION Australia has purchased and received 500,000 doses of SARS-CoV-2 vaccine from the COVAX facility, raising questions about how many of the vaccine-sharing mechanism’s doses should go to low- and middle-income countries (LMICs). Australia received the doses in COVAX’s third round of vaccine distributions. Also in that round, the UK received nearly 540,000 doses and New Zealand received nearly 101,000 doses. Australia is domestically producing the AstraZeneca-Oxford vaccine and has plentiful supplies but has been trying to obtain more doses of the Pfizer-BioNTech vaccine due to medical advice that the vaccine is preferred for people under age 59 and hesitancy among some to receive the AstraZeneca-Oxford vaccine. According to a report in The New York Times, Pfizer-BioNTech expressed its desire for a COVAX shipment of its vaccine to go only to LMICs, but the facility allegedly insisted it first fulfill orders from higher-income nations that paid more for the doses. Concerns remain whether COVAX can move beyond pressures from wealthy countries and pharmaceutical companies, manufacturing delays, and bureaucratic infighting to help reach its goal of supplying 2 billion vaccine doses by the end of 2021. 

In the meantime, millions of J&J-Janssen vaccine doses being “filled and finished” by South African-based Aspen Pharmacare are being shipped to Europe for distribution because of “an unusual stipulation” in the contract between the country’s government and the vaccine company. Reportedly, the contract required South Africa to waive its right to impose export restrictions on vaccine doses finished in-country. A South African health ministry official said the government was not pleased with the contract’s stipulation but did not have the leverage to change it. J&J-Janssen has shipped 32 million doses to Europe in recent months, according to an investigation by The New York Times. The company had agreed to sell enough of its vaccine to African countries to eventually vaccinate about one-third of the continent’s residents. However, Africa continues to struggle to obtain enough supplies, and only about 2% of Africans are fully vaccinated. According to a J&J official, the Aspen plant will begin exclusively supplying doses to African countries later this year. In a Guardian opinion piece, former UK Prime Minister Gordon Brown criticized Europe for taking a “neocolonial approach” to global health, saying the shipments of J&J-Janssen vaccine from South Africa to Europe represent a “shocking symbol of the west’s failure to honor its promise of equitable vaccine distribution.”

GERMANY PEDIATRIC VACCINATION Germany’s vaccine advisory committee, known as STIKO, on August 16 updated its guidance to recommend that all individuals aged 12 to 17 years receive a SARS-CoV-2 vaccine. The recommendation expands on the committee’s previous guidance for that age group, which advised only those children and young adults who had an increased risk of severe COVID-19 disease, including those with compromised immune systems or those who might have professional exposure to the virus, be vaccinated. STIKO said its decision was based on surveillance data from the US showing the benefits of vaccination outweigh the risk of very rare side effects, including heart inflammation, and modeling data showing children and adolescents have a higher risk of infection from the Delta variant. Germany’s 16 state health ministers decided on August 2 that all children and teenagers ages 12 and older should be eligible for vaccination, but the STIKO held off on recommending the same until now. The European Medicines Agency (EMA) has authorized both the Pfizer-BioNTech and Moderna vaccines for that age group.

IRAN The spread of the highly transmissible SARS-CoV-2 Delta variant in Iran has led to record numbers of COVID-19 cases and deaths, forcing the country’s health system to the edge of collapse. On August 16, Iran’s Ministry of Health reported a daily record of 655 deaths, although some, including Iran’s state television, estimate the daily totals to be higher, between 720 and 1,000. A 6-day nationwide lockdown began August 16, including the closure of offices, banks, bazaars, and non-essential businesses such as theaters, gyms, and restaurants in all Iranian cities, and a separate 6-day ban on intra-city travel began on August 15. 

According to the Ministry of Health, nearly 15.5 million Iranians have received at least one dose of a SARS-CoV-2 vaccine, with 4.4 million having received 2 doses, less than 5% of the total population. Supreme Leader Ayatollah Ali Khamenei earlier this year banned vaccines made in the US and Britain, saying the shots were designed to “contaminate other nations.” Last week, Khamenei appeared to backpedal slightly, calling the pandemic the country’s top priority and saying “efforts must be redoubled so vaccines can be provided for the people through any means necessary.” Following his comments, a health official said vaccines developed by Western countries would be allowed if they are manufactured in other nations. So far, Iran has accepted more than 21 million doses of various vaccines from China, Russia, India, Cuba, Japan, and the COVAX initiative. The country also is using its domestically developed COVIran Barekat vaccine, which the government has said is 85% effective at preventing COVID-19 but has not released any clinical data. In the absence of sufficient vaccine and medication supplies, private dealers and black markets are filling the gaps, affordable only to more wealthy Iranians, with each vaccine dose costing up to US$1,200.

More Iranians are trying to raise awareness about the country’s plight, using the hashtag #SOSIran on social media and speaking anonymously to media outlets. Iranian security forces arrested 5 lawyers and a civil rights advocate over the weekend, allegedly for planning to take legal action against Iranian authorities for mismanagement of the pandemic and a slow vaccination campaign rollout. Critics blame both Khamenei and newly elected President Ebrahim Raisi for the current crisis, while some officials recently shifted blame to the previous government of President Hassan Rouhani.

AFGHANISTAN The WHO today expressed concern over the Taliban’s rapid advance and seizure of power in Afghanistan, as the security situation deteriorates and humanitarian needs increase. At a UN briefing, a WHO spokesperson said the agency is “extremely concerned over the unfolding safety and humanitarian needs in the country, including risk of disease outbreaks and rise in COVID-19 transmission." He indicated WHO mobile teams are on hold in the capital, but the agency remains committed to staying in the country. The Taliban reportedly has banned SARS-CoV-2 vaccines in Paktia province, one of the nation's 34 provinces located in the country’s eastern region. In recent weeks and since the withdrawal of US troops from Afghanistan, the Taliban have captured much of the northern, western, and southern regions of the country. 

NEW ZEALAND LOCKDOWN Following its first domestic case of COVID-19 in 6 months, New Zealand is entering a nationwide lockdown. Prime Minister Jacinda Ardern announced the Alert Level 4 restrictions earlier today, which will apply to the entire country for a period of 3 days. The restrictions are scheduled to last for 7 days in Auckland and the Coromandel Peninsula where the case was identified and traveled in the days prior to testing positive. The individual was unvaccinated but was in the process of scheduling an appointment when he tested positive. His wife, who is vaccinated, has tested negative. Prime Minister Ardern noted that it is not yet known if the case was a result of the Delta variant, but she emphasized that all recent infections identified among quarantined travelers have been a result of the Delta variant.

AIR POLLUTION & COVID Wildfires continue to rage across several western US states, and exposure to smoke and soot from the blazes could be associated with an increased risk of COVID-19 disease, including severe disease and death. Like smoking tobacco, exposure to smoke from wildfires can impair lung function, especially due to tiny airborne particles that can penetrate deep into lung tissue. Smoke from wildfires can contain high concentrations of this fine particulate matter, known as PM 2.5 (ie, particulate matter with a diameter of 2.5 microns or less), and exposure to high concentrations of PM 2.5 can impede the exchange of oxygen in the lungs.

The study, published on August 13 in Science Advances, evaluated COVID-19 data and PM 2.5 concentration data from 92 counties in California, Oregon, and Washington from March-December 2020. The researchers from Harvard University estimated air pollution levels based on satellite imagery from the US National Oceanic and Atmospheric Administration (NOAA), and they defined “wildfire days” as heavy PM 2.5 concentration (21-32 μg/m3). Based on the smoke exposure data, the researchers developed a model to estimate the effect of higher-than-expected PM 2.5 concentration on COVID-19 incidence and mortality. The researchers observed increased daily COVID-19 incidence and mortality for up to 4 weeks following exposure to high concentrations of PM 2.5 particles, although they noted several differences across counties. They estimated that even relatively short-term exposure to smoke from wildfires (typically on the order of days or weeks) was associated with nearly 20,000 extra COVID-19 cases and 750 deaths. Numerous complex environmental, social, and epidemiological factors drive COVID-19 incidence and mortality, but the study provides evidence that short-term exposure to elevated concentrations of air pollution, including from wildfire smoke, potentially can increase the risk of COVID-19 disease and death.