COVID-19 Situation Report
EPI UPDATE The WHO COVID-19 Dashboard reports 209.2 million cumulative cases and 4.39 million deaths worldwide as of August 20.

As we previously covered, COVID-19 data from August 15 was delayed for multiple countries in the African Region, which gave the appearance of decreasing trends in last week’s data. It appears that reporting for last week is now complete, which corrected the weekly trends. Weekly incidence increased for the eighth consecutive week—an increase of 3.2% over the previous week—although the trend is tapering off toward a peak or plateau. Weekly mortality increased for the sixth consecutive week*, 0.7% higher than the previous week.
*With the exception of the week of July 19, when Ecuador reported 8,786 deaths.

Global Vaccination
More than 1 billion individuals worldwide are fully vaccinated. The WHO reported 4.56 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of August 20. The WHO reports that a total of 1.78 billion individuals have received at least 1 dose, and 1.03 billion are fully vaccinated. Analysis from Our World in Data indicates that the global daily doses administered continues to hold relatively steady at approximately 35-40 million doses per day*. The global trend continues to closely follow the trend in Asia. Our World in Data estimates that there are 2.51 billion vaccinated individuals worldwide (1+ dose; 32.2% of the global population) and 1.88 billion who are fully vaccinated (24.2% of the global population). We expect the global total to surpass one-third of the population with 1+ dose and one-quarter with full vaccination in the coming days.
*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 numbers reported here may not correspond to the most recent data.

The US CDC reported 37.3 million cumulative COVID-19 cases and 623,244 deaths. Daily incidence is up to 133,055 new cases per day, the highest since February 2. Daily incidence continues to increase rapidly, but it appears that the US has passed an inflection point and is now tapering off. Based on the timeline from the previous peak, this could indicate that the current surge could peak in the next several weeks. While some severely affected states are beginning to peak—including Arkansas, Florida, and Louisiana—many others are still exhibiting increasing trends as the surge spreads to other parts of the country, with some states still early in their respective surges. 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 640 deaths per day is the highest since April 24. On August 18, the US reported more than 1,000 deaths in a single day for the first time since March 19*.
*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.

As the US continues to combat its ongoing surge hospitalizations are setting new records at the national and state level, particularly for individuals under the age of 50. At the national level, new daily hospitalizations are at record highs for all age groups aged 49 years and younger, and the 50-59 years age group is at 91% of its record high. Notably, the 0-17 years age group—most of whom are still not eligible for vaccination—is currently 40% higher than its previous peak and still increasing rapidly, just as schools are resuming classes across the country. In terms of the percent of emergency department (ED) visits for COVID-19, most age groups appear to be peaking at the national level. Similar to new hospitalizations, all age groups aged 49 years and younger are setting new records, ranging from 3.2% for 0-11 years to 8.1% for 40-49 years. The CDC’s COVID-19 dashboard does not provide data for current hospitalizations broken down by age group, but the current average across all age groups (76,077 hospitalized patients) is within 40% of the previous peak and still increasing.

Similar trends are evident across the whole of HHS Region 4 (Southeast), where the current surge is most severe. Current hospitalizations in the region set a new record high last week, and the current average is just shy of 30,000 patients and still increasing. We have paid considerable attention to Region 4, but Region 10 (Northwest) is also exhibiting concerning trends. While Region 10 is not setting records for new daily hospitalizations in the 0-11 years age group—suggesting lower transmission among children—all other age groups 59 years and younger are surpassing their previous records and still increasing sharply. Region 10 is also setting new records in terms of the percent of ED visits for COVID-19, both averaged across all ages and individually for all age groups 64 years and younger. Regions 4 and 10 also are both reporting record high current hospitalizations, and Region 6 (South) is 11% below its highest peak and still increasing steadily. While these 3 regions are exhibiting similar trends, the magnitude of the epidemics are quite different, with Region 10 reporting 2,000 hospitalizations compared to 30,000 and 17,000 in Regions 4 and 6, respectively. On a per capita basis**, COVID-19 hospitalizations in Regions 4 and 6 are 2.3 and 1.9 times higher than in Region 10, respectively.
**Based on 2020 census data.

At the state level, Arkansas, Florida, Hawai’i, Louisiana, Mississippi, Oregon, and Washington are all setting new records in terms of current hospitalizations. A total of 5 other states—3 from Region 4 and 2 others that border it—are within 20% of their records and still increasing. Among the states setting new records for current hospitalizations, all are setting new records in terms of new daily hospitalizations among most age groups 59 years and younger. Notably, all of these states, with the exception of Oregon and Washington, are setting new records for the 0-11 years age group. As with the regional trends, the magnitude of these epidemics varies widely at the state level. Hawai’i, Oregon, and Washington are reporting between 1.7 and 3.5 new daily hospitalizations per 100,000 population, whereas Arkansas, Florida, Louisiana, and Mississippi range from 6 to more than 10. In Florida, all age groups—with the exception of 0-11 years—have equaled or surpassed the record peak for percent of ED visits for COVID-19 set by the 65-74 years and 75+ years age groups in the previous surge—ie, higher than the highest peak for the most vulnerable age groups. Notably, the 40-49 years and 50-64 years age groups are more than 60% higher than that previous record. A similar trend is evident in Louisiana, with all age groups except 0-11 years and 75+ years equaling or surpassing the previous record.

US Vaccination
The US has administered 359.6 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 670,000 doses per day*. A total of 199.9 million individuals in the US have received at least 1 dose, equivalent to 60.2% of the entire US population. Among adults, 72.5% have received at least 1 dose, as well as 12.6 million adolescents aged 12-17 years. A total of 169.6 million individuals are fully vaccinated, which corresponds to 51.1% of the total population. Approximately 62.0% of adults are fully vaccinated, as well as 9.4 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.

US PLANS FOR THIRD DOSES US health officials on August 18 announced plans to make third doses of SARS-CoV-2 mRNA vaccines available to all US residents as soon as the week of September 20. The third dose is meant to bolster individuals’ immune responses at least 8 months from their second dose of either the Pfizer-BioNTech or Moderna vaccines. People who received the J&J-Janssen vaccine likely will need an additional dose, but officials are waiting on results from a clinical trial expected to be available later this month. US officials based their decision to offer booster doses on published and unpublished data showing vaccine effectiveness across age groups appears to wane over time and particularly amid the spread of the highly transmissible Delta variant. While they stressed the vaccines remain highly effective at preventing severe disease, hospitalizations, and death, they said the vaccines’ ability to prevent infection or symptomatic disease has declined since the spring. Some of the breakthrough infections seen among vaccinated individuals could be due to weakening immunity, lapses in protective measures such as mask wearing, or the now widespread Delta variant, or a combination of such factors, experts noted, contending that no vaccine was meant to be 100% effective in preventing infection.

At a White House COVID-19 Task Force briefing, US CDC Director Dr. Rochelle Walensky presented data from 3 early release Morbidity and Mortality Weekly Report (MMWR) studies, 1 not-yet-peer-reviewed study published on medRxiv, and unpublished CDC data. One of the MMWR studies included data from New York collected between May 3 and July 25, 2021, showing vaccine effectiveness (VE) against infection declined from 91.7% to 79.8%. A second MMWR study showed the mRNA vaccines’ protection against infection among nursing home residents declined from 75% between March 1 and May 9, 2021, before Delta became the dominant strain, to 53% between June 21 and August 1, when Delta accounted for at least half of new COVID-19 cases. In positive news, a third MMWR publication showed no significant decline in the vaccines’ effectiveness against COVID-19 hospitalization over a 24-week period, ranging from 85% 2-12 weeks post-vaccination and 84% at 13-24 weeks. However, data from a Mayo Clinic preprint in medRxiv showed Moderna VE fell from 86% in January 2021 to 76% in July, while Pfizer-BioNTech VE dropped from 76% to 42% during the same time. According to a joint statement from US Department of Health and Human Services (HHS) experts, data from these sources make the argument for booster doses “very clear” that protection against SARS-CoV-2 infection wanes over time. However, some experts argued the case for third doses remains unclear, saying officials presented no data regarding how much third doses boost immune responses or how long any benefits might last. US officials previously said the logistics of rolling out a booster dose program are too complex to wait for scientific certainty that the extra doses are actually necessary.

Third doses initially will be available for about 5 million people who were first to receive vaccines over the 2020-2021 winter, including healthcare workers, nursing home residents, and older adults. Last week, regulators authorized third doses for people with compromised immune systems, such as cancer patients and organ transplant recipients, who represent less than 3% of the US population. The plan to provide booster doses is contingent upon the US FDA authorizing a third dose of either mRNA vaccine and the CDC’s Advisory Committee on Immunization Practices (ACIP) making subsequent recommendations. Only earlier this week did Pfizer-BioNTech submit initial data to the FDA supporting the evaluation of a booster dose of its vaccine. Moderna has yet to submit data. Some experts speculate that a third dose given 8 months from the second dose could provide a more robust and long-lasting immune response, potentially requiring few or no future boosters, although US Surgeon General Vivek Murthy said “there’s nothing magical” about the 8-month timeframe. Some of the same experts, as well as others, expressed additional concerns over the plan for multiple reasons, including that all US residents might not immediately need boosters, that a timeframe for providing extra doses apparently has been decided prior to regulatory decisions, and that more focus should be placed on vaccinating more people in the US and globally

THIRD DOSE CONCERNS The announcement reignited criticism about global vaccine inequity, with some experts expressing fear, frustration, and even anger over wealthier nations’ continuing disregard for a WHO call for a moratorium on booster doses. WHO officials and other experts continue to argue that booster programs—also implemented in Israel, France, Germany, and other nations—will further deplete scarce vaccine resources and deprive low- and middle-income countries (LMICs) of needed doses. The WHO estimates 11 billion vaccine doses are needed to help control the pandemic. WHO Regional Director for Africa Dr. Matshidiso Moeti chastised wealthier nations, saying “they make a mockery of vaccine equity” by stockpiling vaccine doses while the situation in Africa remains “very fragile.” WHO chief scientist Dr. Soumya Swaminathan and other researchers warned that a focus on booster programs in wealthy nations could lead to the development of more viral variants and “an even more dire situation” globally, because the virus continues to spread unabated in unvaccinated—not vaccinated—populations. Other experts said there was still not enough conclusive evidence supporting third doses to recommend them to everyone. 

But US officials pushed back at the disapproval. White House Press Secretary Jen Psaki said the notion the US would not be able to provide boosters and simultaneously donate doses to countries in need represented a “false choice.” US CDC Director Dr. Rochelle Walensky agreed, saying, “We're going to do both and we have been doing both," noting the country plans to distribute 200 million doses worldwide and administer 100 million booster doses by the end of the year. Global health advocates continue to call on the US to be more of a leader in efforts to bolster global vaccine supplies, including by pressuring pharmaceutical companies to share technologies with LMICs and help scale up manufacturing in those countries.

US CDC DISEASE FORECASTING CENTER On August 18, the US CDC officially announced its new Center for Forecasting and Outbreak Analytics. The center will leverage advanced data and modeling capacities to provide health officials with projections and other analysis during outbreaks and epidemics, aiming to “accelerate access to and use of data for public health decision-makers.” The center also will provide forecasting capacity for emerging infectious disease threats, as the pandemic response highlighted the need to streamline and modernize data collection reporting at the state and local levels. Prior to establishing this center, the US government had relatively little internal capacity for infectious disease modeling, genomic surveillance, and other real-time analytics, requiring it to draw on external support from academic institutions, think tanks, and other organizations, which often volunteered their time and effort. The new center will continue to draw on these external resources, but it establishes a central point within the CDC to provide coordination and support. Initial funding for the program comes from the American Rescue Plan, part of a series of emergency funding packages approved during the COVID-19 pandemic. The center will be led by Dr. Marc Lipsitch, Dr. Dylan George, Dr. Rebecca Kahn, and the Johns Hopkins Center for Health Security’s own Dr. Caitlin Rivers.

US NURSING HOME FUNDING US President Joe Biden announced on August 18 that nursing home staff must be vaccinated against SARS-CoV-2 or their facilities risk losing federal funding that many facilities rely on to maintain operations. The vaccine requirement would affect more than 15,000 facilities and 1.3 million employees nationwide. According to the Centers for Medicare and Medicaid Services (CMS), nursing home residents have a higher rate of vaccination compared to staff, with nearly 83% of residents vaccinated per facility compared to 60% of staff per facility. But that represents the national average; vaccination rates vary by state since many nursing homes have not implemented vaccine requirements. Florida has the lowest percentage of staff with completed vaccinations per facility at 40%. At the other end of the spectrum, Hawai'i boasts the highest percentage, with nearly 87% of staff vaccinated per facility. The new mandate is expected to be formalized by CMS regulation. An official deadline for the requirement has not been set, although it could take effect as soon as next month.  

MASKS IN SCHOOLS US President Joe Biden this week ordered Secretary of Education Miguel Cardona to use all available tools to ensure that governors and other state officials are taking appropriate actions to safeguard students' return to in-person schooling, including possibly taking legal action against governors who ban universal masking in schools. Secretary Cardona said he will use the department’s civil rights enforcement capacity to investigate states that ban masking. The Biden administration plans to send letters to the governors of Arizona, Iowa, Oklahoma, South Carolina, Tennessee, and Utah—in addition to those Secretary Cardona already sent to Florida and Texas—reprimanding their efforts to block universal masking in schools and expressing support for local officials who defy mask bans. Secretary Cardona also noted that the department would pay the full salaries of educators if their “states move to withhold pay or levy financial penalties on their schools.” Earlier this year, the department’s Office of Civil Rights published a report outlining the impacts of the COVID-19 pandemic on US students, warning that existing educational gaps are widening during the pandemic, falling disproportionately on those students with the greatest educational needs and fewest opportunities, many from historically marginalized and underserved populations. 

In Miami-Dade County, the largest county in Florida, the school board on August 18 voted to require masks for students when in-person learning resumes next week, defying an order from Governor Ron DeSantis that effectively bans mask mandates. Miami-Dade joins Alachua, Broward, and Hillsborough as Florida counties requiring masks for students, employees, and visitors, with only medical exemptions accepted. The school districts cited updated CDC guidance and the rise in pediatric infections, including record high hospitalizations, as the basis for requiring face coverings.

In Texas, the State Supreme Court on August 19 denied Governor Greg Abbott’s request to block temporary restraining orders on his ban on mask mandates issued by Travis County Judge Jan Soifer. As a result, the lower court’s ruling stands, for now, allowing school districts to continue their requirements. The governor now must appeal to the Texas Court of Appeals. On the same day, the Texas Education Agency suspended enforcement of Governor Abbott’s ban in the state’s public school system. The State Supreme Court’s order comes only days after it sided with Governor Abbott, granting a temporary emergency stay of an appellate court ruling and allowing his ban on mask mandates, including those in public schools. Following that order, the Dallas and San Antonio school districts, 2 of the largest in the state, said they would continue to require masks until a final ruling is made. Since then, several other districts have implemented universal masking requirements. The legal battles over masking in schools undoubtedly will continue to work their way through the courts.

SCHOOL VACCINE MANDATES As states around the country return or prepare to return to school in the coming weeks, some state legislatures are taking final steps to increase the proportion of vaccinated public school employees. In Washington state, Governor Jay Inslee announced a vaccination requirement for all employees in K-12 schools at the private, public, and charter levels and those working in childcare settings and higher education institutions. Employees must show proof of full vaccination prior to October 18 or possibly face dismissal. The policy has limited medical and religious exemptions, and there is no test out option, possibly representing the most widespread and strict requirements implemented by a state yet. Governor Inslee also expanded a statewide mask mandate, applicable to all individuals regardless of vaccination status. Other states with vaccine requirements for school staff, such as California and Connecticut, have allowed employees the option of choosing between mandatory vaccination or routine testing for those who wish not to comply. Several major cities across the country, including Los Angeles and Chicago, also are requiring public school employees to get vaccinated. Other states likely will implement vaccine requirements for school staff as students return to in-person learning, with rumors that New Jersey could be next. 

MODERNA VACCINE FOR UK ADOLESCENTS The UK Medicines and Healthcare products Regulatory Agency (MHRA) granted Conditional Marketing Authorization (CMA) for the use of the Moderna SARS-CoV-2 vaccine in children aged 12-17 years. The CMA was granted through the European Commission (EC) Decision Reliance Route, which allows for new Marketing Authorizations based on previous authorizations through the centralized EC process, but it means that the CMA only applies to Great Britain. Northern Ireland issued a CMA for 12- to 17-year-olds via the same process on July 23. The approval in Great Britain comes a week after the England Department of Health announced 16- and 17-year-olds will be offered a first dose of SARS-CoV-2 vaccine by August 23, before schools resume classes in September. MHRA Chief Executive Dr. June Raine said “the vaccine is safe and effective in this age group” and that it will be up to the Joint Committee on Vaccination and Immunization (JCVI) to advise on whether adolescents aged 12 and older should receive the Moderna vaccine as part of the deployment program. The Moderna vaccine has not yet been authorized for use in individuals aged 12 to 17 years in the US, but the European Medicines Agency (EMA) recommended its use in this age group on July 23.

ISRAEL Throughout the COVID-19 pandemic, Israel has been one of the countries on the forefront of disease control. Following an early and successful SARS-CoV-2 vaccination campaign, Israel saw a drop in the incidence of new COVID-19 cases. Unfortunately, the region has now seen a drastic increase in cases, despite a large proportion of its adult population having received a SARS-CoV-2 vaccine. With worries that waning vaccine effectiveness contributed to the new surge, Israel announced a campaign of so-called booster doses for senior residents that started at the end of July. However, there is minimal evidence to support the application of booster doses, leading some experts to question the decision. So far, 37 individuals have tested positive for COVID-19 following their third dose. These recent developments have increased concerns over the longevity of vaccine efficacy, especially against more transmissible SARS-CoV-2 variants of concern. 

POPE ENCOURAGES VACCINATION In a new public service campaign made in coordination with the Ad Council and directed specifically at the Americas, Pope Francis encourages people to get vaccinated, saying it is “an act of love.” The video features Pope Francis speaking Spanish with English subtitles in the Ad Council’s first campaign outside of the United States. The Pope is joined by church officials from Brazil, Mexico, the United States, and other countries who describe getting vaccinated as a “moral responsibility.” Vaccine hesitancy among religious groups has been a barrier to vaccination during the pandemic, but a survey by the Public Religion Research Institute and Interfaith Youth Core nonprofit groups conducted in June suggests acceptance may be on the rise. Of more than 5,000 people surveyed in the US, acceptance rose from 56% in March to 80% in June among Hispanic Catholics, and from 68% to 79% among White Catholics. Vaccine-hesitant participants also told researchers that faith-based arguments may convince them to get vaccinated, underlining the importance of the Pope’s message. The ad will be run on Telemundo, Universo, and WarnerMedia platforms, and media outlets in various Spanish-speaking countries. 

FAKE VACCINATIONS/CARDS As more SARS-CoV-2 vaccine requirements are enacted for everything from employment, to travel, to restaurant dining, the black market for vaccine cards is growing. US Customs and Border Protection (CBP) agents in Memphis, Tennessee (US), recently announced they have seized more than 3,000 fake vaccination cards shipped from China and destined for various US cities since the end of June. Additionally, a Chicago pharmacist was charged with 12 counts of theft of government property after allegedly stealing and selling official US CDC vaccination cards on eBay. The FBI has warned that buying, selling, or using counterfeit vaccination cards is a crime, punishable by a fine and up to 5 years in prison. In France, fake vaccine passes are being sold through social media platforms such as Snapchat and Facebook for up to €400 (US$467). If caught, those who distribute counterfeit passes face up to 5 years in prison and fines up to €150,000 (US$175,000), and users could spend 3 years in prison. Officials in the US and France reminded the public that SARS-CoV-2 vaccines are available at no cost.

In more disturbing developments, the WHO identified counterfeit versions of Covishield—the Indian-made version of the AstraZeneca-Oxford SARS-CoV-2 vaccine—in India and Africa in recent months. The Indian government said it has launched an investigation into the allegations. Last month, around 4,000 people in India paid to receive a SARS-CoV-2 vaccine at a “vaccination camp” but instead got shots of saline solution. Authorities arrested 14 people in connection with the scheme. In Germany, a Red Cross nurse is believed to have injected more than 8,000 residents with shots of saline rather than a SARS-CoV-2 vaccine, authorities there say, although it is unclear whether any arrests have been made or charges filed. Officials continue their work to stop the counterfeiting of vaccine cards and shots worldwide.

NFL VACCINATION This week the Atlanta Falcons became the first and reportedly only US National Football League (NFL) team to achieve 100% SARS-CoV-2 vaccination of its roster. Now, all players are able to work out and eat together and are exempt from daily testing, mask use in team facilities, and quarantine following close contact with someone who tests positive, the team confirmed in a statement. As we previously reported, the NFL implemented strict consequences for teams with unvaccinated players, potentially including forfeiting games that are canceled because of outbreaks. Additionally, unvaccinated players could lose pay for games missed due to testing positive. On August 18, Tampa Bay Buccaneers Head Coach Bruce Arians said his team likely would reach 100% vaccination before the start of the regular season on September 9. The NFL Network on August 11 reported that 92% of NFL players have at least 1 dose of vaccine, well above the national average of 60%. NFL teams could provide insight into vaccine effectiveness in close-contact settings where every individual is vaccinated.