COVID-19 Situation Report
Applications Now Open for Johns Hopkins Center for Health Security Educational Opportunities for 2022-2023 Academic Year
In a world of rapid innovation in the biological sciences, the emergence of new diseases, and changing environmental pressures, health security risks to the global community are a rising concern. The field of health security has a growing need for trained expertise that can provide science-based solutions and inform global policies to shape preparedness and response efforts. The Johns Hopkins Center for Health Security is pleased to announce it is now accepting applications for its educational opportunities for the 2022-2023 academic year. The Johns Hopkins Center for Health Security provides 2 Masters of Public Health scholarships and funds 2 PhD candidates for the Health Security PhD track at the Johns Hopkins Bloomberg School of Public Health.
These funding opportunities are supported by Open Philanthropy and are targeted toward students with an interest in the field of health security, particularly in pandemics and global catastrophic biological risks.
EPI UPDATE The WHO COVID-19 Dashboard reports 214.5 million cumulative cases and 4.47 million deaths worldwide as of August 27. If global mortality continues on this trajectory, we expect to surpass 4.5 million cumulative deaths in the next 3-4 days.

Global Vaccination
The WHO reported 4.95 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of August 25. A total of 1.90 billion individuals have received at least 1 dose, and 1.13 billion are fully vaccinated. Analysis from Our World in Data indicates that the global daily doses administered has held relatively steady over the past 2 weeks at approximately 36 million doses per day*. The global trend continues to closely follow the trend in Asia. Our World in Data estimates that there are 2.59 billion vaccinated individuals worldwide (1+ dose; 33.0% of the global population) and 1.96 billion who are fully vaccinated (24.9% of the global population). We expect to surpass one-third of the global population with 1+ dose and one-quarter with full vaccination by early next week.
*The average doses administered may exhibit a sharp decrease for the most recent data particularly over the weekend, 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.

As global vaccination efforts continue, enormous disparities remain in terms of access and coverage. African countries, in particular, are still struggling to secure sufficient vaccine supply, which is severely hindering vaccination efforts across the continent. In fact, just 10 countries account for nearly 75% of the 5 billion cumulative doses administered globally, including 6 that have each administered more doses than the entire continent of Africa. Africa represents approximately 17.5% of the global population but only 1.9% of the cumulative doses administered.

Daily vaccinations are increasing in Africa, but overall vaccination coverage remains low, with many African countries among the lowest globally. Notably, of the 52 countries reporting partial vaccination coverage (1+ dose) less than 10%, 40 are in Africa**. Additionally, the average across the continent is only 4.6%, the lowest among all continents by a factor of more than 7. Only Seychelles (75%) and Mauritius (62%) are reporting partial coverage greater than 50%, and only 3 others—Morocco (47%), Cabo Verde (38%), and Tunisia (30%)—are reporting more than 20%.
**Data are unavailable for Burundi and Eritrea.

Similarly, among 73 countries reporting fewer than 0.2 daily doses administered per 100 population, 41 are in Africa. The average for Africa as a whole is 0.11 doses per day per 100 population, the lowest among all continents by nearly a factor of 3. In terms of total daily vaccinations, Africa is beginning to approach North America—1.52 million doses per day, compared to 1.89 million. Africa’s current average daily vaccinations is more than 3.5 times its average on July 1 and more than double its average on August 1. The trend continues to increase exponentially, which is a positive sign.

A number of African countries are exhibiting substantial increases in their daily vaccinations. In total, 10 African countries reported increases in daily vaccinations of more than 500% since July 1, including 5 that increased more than 1,000%. Gambia’s average increased 2,539%; Rwanda’s increased 2,637%, and Malawi’s increased 2,882% over that period. While most African countries reported extremely low daily vaccinations as of July 1—on the order of 1,000 doses per day or fewer—this is not necessarily the case for all African countries. For example, Morocco averaged more than 100,000 doses per day on July 1, and its average increased to more than 350,000 doses per day (+243%) since then. And Egypt’s average increased from nearly 28,000 to nearly 170,000 (+510%).

The increasing trends in daily vaccinations across Africa are encouraging; however, supply volume remains a major constraint. This is particularly concerning in light of recent decisions by a number of higher-income countries, including the US, to begin administering additional booster doses to some or all fully vaccinated individuals. Existing global production capacity has still not caught up with demand, and any doses allocated as extra boosters inherently take away from doses that could be allocated to low- and middle-income countries (LMICs).

The US CDC reported 38.3 million cumulative COVID-19 cases and 631,440 deaths. Daily incidence continues to increase, up to 142,006 new cases per day, the highest average since January 30. Daily incidence continues to taper off, however, and if the trend continues on this trajectory, we expect the surge to peak in the next several weeks. Daily mortality continues to increase as well, up to 864 deaths per day, the highest average since March 16*.
*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 numbers reported here may not correspond to the most recent dates.

US Vaccination
The US has administered 365.8 million cumulative doses of SARS-CoV-2 vaccines, and daily vaccinations continue to increase slowly, up to 783,239 doses per day*. There are 203.0 million individuals who have received at least 1 dose, equivalent to 61.1% of the entire US population. Among adults, 73.5% have received at least 1 dose, as well as 13.1 million adolescents aged 12-17 years. A total of 172.2 million individuals are fully vaccinated, which corresponds to 51.9% of the total population. Approximately 62.8% of adults are fully vaccinated, as well as 9.9 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.

J&J-JANSSEN SECOND DOSE On August 25, J&J-Janssen announced it has interim data showing a second shot of its SARS-CoV-2 vaccine administered 6 to 8 months after the initial dose generates “a rapid and robust increase in spike-binding antibodies,” up to 9-fold higher after 28 days than a single shot. The data—which have not been published in a scientific journal nor peer reviewed—come from 2 Phase 1/2a studies conducted in the US and Europe. The company plans to submit the data to the US FDA in the hopes of receiving authorization for a booster dose and indicated it is in talks with the FDA, US CDC, European Medicines Agency (EMA), and other health authorities regarding the need for second doses of its vaccine. The company also is testing a 2-dose regimen delivered 2 months apart, with data from that clinical trial expected in the next few weeks.

As we covered previously, US health officials have announced plans to begin providing third doses of the mRNA vaccines made by Moderna and Pfizer-BioNTech as soon as mid-September and have indicated boosters likely will be necessary for recipients of the J&J-Janssen vaccine. Initially, officials said the extra doses would be available for people who finished their regimen 8 months prior but now are looking at a 6-month gap instead, perhaps in part because of the J&J-Janssen data. Currently, only people with compromised immune systems are eligible for booster doses in the US.

Pfizer-BioNTech announced on August 25 that it plans to complete an application to the FDA for a third dose of its vaccine by the end of this week. The company received full approval of its vaccine, called Comirnaty, earlier this week. The CDC’s Advisory Committee on Immunization Practices is expected to meet next week and will discuss a framework for SARS-CoV-2 booster doses. While several studies show a higher level of antibody production in extra-dose recipients, it remains unclear whether this will translate to improved protection against SARS-CoV-2 infection or severe COVID-19 disease.

MODERNA FDA APPLICATION Moderna on August 25 completed its submission of a Biologics License Application to the US FDA for full approval of its SARS-CoV-2 vaccine to prevent COVID-19 in people aged 18 or older. The company requested priority review designation, meaning the FDA would have until the end of February to make a decision if it grants the designation. If approved, the vaccine would be the second for the prevention of COVID-19 after the FDA granted full approval to Pfizer-BioNTech on August 23. The agency’s review process for the Pfizer-BioNTech vaccine took 97 days, 40% of the normal time for such a submission, and it is expected regulators will take at least 3 months to review Moderna’s application. Moderna also has filed for emergency use authorization for its vaccine to be used in adolescents aged 12 and older.

VACCINE EFFECTIVENESS Researchers are collecting more proof that protection provided by SARS-CoV-2 vaccines is waning over time. In a study published this week in the US CDC’s Morbidity and Mortality Weekly Report (MMWR), researchers with the HEROES-RECOVER initiative—a US network of longitudinal cohorts including more than 4,000 healthcare workers, first responders, and other frontline workers—report that vaccine effectiveness (VE) fell from 91% in mid-December 2020, before the SARS-CoV-2 Delta variant was predominant, to 66% by mid-August following Delta’s spread. Among participants, 83% were vaccinated, with 65% having received the Pfizer-BioNTech vaccine, 33% Moderna, and 2% J&J-Janssen. The researchers cautioned that while Delta might be more capable of causing breakthrough infections, a reduction in VE could be due to detecting few infections among the cohorts, increasing time since vaccination, an easing of other preventive measures, or a combination of factors. Still, a “sustained two-thirds reduction in infection risk underscores the continued importance and benefits of COVID-19 vaccination,” they write.

In another analysis released on August 25 but not yet published, researchers from the UK’s ZOE COVID Study found a reduction in VE for both the Pfizer-BioNTech and AstraZeneca-Oxford vaccines. The data include more than 1 million self-reported test results among people who received full regimens of either vaccine, as well as test results from more than 75,000 people not yet vaccinated. Protection against infection 1 month after the second dose was 88% for Pfizer-BioNTech and 77% for AstraZeneca-Oxford, prior to the Delta variant’s predominance, but fell to 74% and 67%, respectively, after 4-5 months and after Delta spread throughout the UK. The researchers noted that more data on younger people are needed, as those who were vaccinated in the winter and spring were primarily older individuals.

In yet another study published this week in the MMWR, the CDC presented data from Los Angeles County, California (US), showing unvaccinated individuals were 5 times more likely to get COVID-19 than their vaccinated counterparts, and 29 times more likely to be hospitalized with the disease. These analyses add evidence that VE does appear to be waning over time and in the face of the highly transmissible Delta variant, but they also underscore the importance of vaccination in preventing infection, hospitalization, and serious disease. Still, more effort is needed to collect data on breakthrough infections among vaccinated people, with several officials familiar with the situation alleging the CDC is using “outdated and unreliable data,” Politico reports.

HEART INFLAMMATION The Pfizer-BioNTech SARS-CoV-2 vaccine is associated with an increased risk of myocarditis (inflammation of the heart muscle), but infection with the virus is associated with a much greater risk of the condition, according to a real-world case-control study published on August 25 in the New England Journal of Medicine. Researchers analyzed the health records of more than 2 million people who are members of the Clalit Health Services (CHS), the largest healthcare organization in Israel. Vaccination was associated with a 3-fold increase in the risk of myocarditis (risk ratio [RR], 3.24, 95% confidence interval [CI], 1.55-12.44), as well as several other conditions including swollen lymph nodes (RR, 2.43; 95% CI, 2.05 to 2.78), appendicitis (RR, 1.40; 95% CI, 1.02 to 2.01), and herpes zoster infection (RR, 1.43; 95% CI, 1.20 to 1.73). In a separate cohort, the researchers found SARS-CoV-2 infection is associated with an 18-fold increased risk of myocarditis (RR, 18.28; 95% CI, 3.95 to 25.12), as well as an increased risk of several other serious adverse events such as pericarditis (inflammation of tissue surrounding the heart), irregular heartbeat, blood clots, heart attack, bleeding in the brain, and kidney damage. Pfizer-BioNTech and the US CDC are conducting studies to examine the risks of myocarditis and pericarditis among people who receive the vaccine.  

SARS-COV-2 ORIGINS The US Intelligence Community on August 24 delivered a classified report to US President Joe Biden that made no conclusions about the origins of the novel coronavirus, including whether the virus was transmitted to humans naturally through an animal vector or if human transmission was the result of a laboratory mishap. The report, some of which is expected to be declassified in the coming days, is the result of an order from President Biden given in late May for the Intelligence Community to provide another, more thorough assessment of the origins of SARS-CoV-2 within 90 days. The report’s lack of conclusions prompted calls from global health experts, scientists, and politicians for a more urgent international effort to find the source of the pandemic in order to inform future pandemic preparedness. According to The Wall Street Journal, 2 senior US officials said a lack of cooperation from China, where the virus is assumed to have originated, hampered the US investigation. 

A lack of Chinese cooperation also challenged a WHO-convened joint WHO-China delegation’s investigation in early 2021, culminating in a March report that concluded a lab leak was “extremely unlikely.” However, WHO Director-General Dr. Tedros Adhanom Ghebreyesus later undercut the team's statement, saying there is not enough evidence to support any conclusion. WHO officials reiterated that stance this week, saying all of the origin hypotheses “are still on the table.” Then, on August 25, the independent international members of the WHO-China team published a detailed piece in the journal Nature, outlining their review process and calling for an expedited second phase of investigation, noting the search is “at a critical juncture.” 

On the same day, Chinese officials urged any future investigations to be broadened, possibly to other countries; refused to take blame for stalled efforts; and said the country will continue to participate in “science-based origin tracing efforts.” Chinese officials also accused the US of politicizing the investigation and attempted to shift blame, once again suggesting without evidence that the virus possibly escaped an US Army research facility. The Chinese embassy in Washington, DC, and China’s envoy to the United Nations this week publicly called for investigations into US labs. While understanding the origins of the COVID-19 pandemic is a global priority, the likelihood of quickly finding evidence grounded in science is slim, especially without full and transparent cooperation from Chinese authorities.

GLOBAL VACCINE ACCESS The WHO this week again called for wealthier nations with higher SARS-CoV-2 vaccination rates to delay the deployment of booster doses for 2 months and instead donate those doses to countries with much lower coverage. WHO Director-General Dr. Tedros Adhanom Ghebreyesus expressed disappointment at the scope of vaccine donations worldwide, saying “vaccine injustice and vaccine nationalism” raise the likelihood of new, possibly more deadly SARS-CoV-2 variants emerging as the virus continues to circulate. Dr. Tedros noted that 75% of the 5 billion vaccine doses distributed globally have gone to only 10 countries. Overall, donations from wealthier nations have not reached the level required to provide the 11 billion doses needed to vaccinate 70% of the world’s population. 

And now, several countries—including the US, Israel, France, Hungary, and others—have or are planning to implement booster dose programs. For its part, UK scientists are looking into using smaller, fractional doses for boosters, which, in theory, could help increase supplies for other parts of the world if the “extra” amounts were distributed internationally. But countries are running into another issue: a surplus of expiring doses. The 6-month shelf life provided to most SARS-CoV-2 vaccines under emergency authorizations is rapidly approaching and threatens to undermine donations of unused doses, as vaccines close to expiration raise suspicion in many countries, potentially increasing vaccine hesitancy. Some nations are publicly destroying expired vaccines to “stay accountable,” even though most experts agree the doses, if stored properly, could be viable for up to 2 years. While some countries have extended the shelf lives for authorized vaccines based on stability studies, others remain skeptical.

The US so far has donated more than 120 million doses to 80 countries and provided US$4 billion in funding and other resources to the COVAX facility, he noted. While the US has pledged to donate another approximately 500 million doses, as well as made efforts to expand manufacturing domestically and overseas, global health advocates and some members of the US Congress are calling on the US President Joe Biden to do more. An analysis from PrEP4All, an AIDS advocacy organization, criticizes the Biden administration for spending less than 1% of US$16 billion included in the American Rescue Plan meant for procuring and manufacturing COVID-19 treatments, vaccines, diagnostics, and other tools for distribution in other countries. The group, along with others, called on the US government to immediately scale up vaccine production to improve global supply. 

In Africa, only 2.5% of the population is fully vaccinated. In an interview on CNBC this week, African Development Bank (ADB) President Akinwumi Adesina said the continent had been “shortchanged” in regard to vaccine access and that “Africa should not depend on the rest of the world for supplying it with critical vaccines and also therapeutics.” In an effort to improve self-sufficiency, Adesina said the ADB plans to invest at least US$3 billion in health care infrastructure and the pharmaceutical sector across the continent. 

EVICTION MORATORIUM On August 26, the US Supreme Court granted a request to lift a US CDC moratorium on evictions, ending the measure meant to keep millions of people who owe back rent housed during the latest surge of the COVID-19 pandemic. In an unsigned, 8-page majority opinion, the court said the CDC exceeded its authority, relying “on a decades-old statute that authorizes it to implement measures like fumigation and pest extermination.” If a federal eviction moratorium is to continue, the US Congress must authorize it, the court said. However, Congress failed to do so when the last moratorium expired on July 31. Justices Stephen Breyer, Sonia Sotomayor, and Elena Kagan dissented from the majority opinion, saying the moratorium should remain in place in the midst of a public health crisis and calling on the court to hold a full briefing and arguments. In a statement, White House Spokesperson Jen Psaki said US President Joe Biden “is once again calling on all entities that can prevent evictions—from cities and states to local courts, landlords, Cabinet Agencies—to urgently act to prevent evictions.”

US MASK MANDATE BANS States across the country have begun the transition into a new, in-person school year. In last week’s COVID-19 briefing, we covered a number of states that were requiring masks and vaccinations for eligible students in an effort to minimize the spread and impact of COVID-19. This week, Illinois joined several states, ordering a mask mandate for students and vaccinations for students aged 16 and older. While many states have adopted this approach for the new school year, several states have gone in opposite directions, banning schools’ abilities to mandate mask wearing. In Florida, 10 school districts have fought back against a mask mandate ban from Florida Governor Ron DeSantis, facing potential backlash, including funding freezes, for violating the state-sanctioned ban. In South Carolina, the American Civil Liberties Union (ACLU) filed a new lawsuit challenging South Carolina’s ban on mask mandates in schools. The lawsuit was driven by a number of parents who have school-aged children with risk factors that could lead to more severe COVID-19 cases. The case for masks in schools has federal support, as many policymakers worry about the health and safety of children and the potential for school-based cases to drive up disease incidence. Although only 19 states have gone back to school these past few weeks, 90,000 children already have entered quarantine or isolation following contact with a COVID-19 case. It will be critical to monitor school-based COVID-19 outbreaks as more parts of the country return to the classroom. 

INSURANCE SURCHARGE Following the US FDA’s approval of the Pfizer-BioNTech SARS-CoV-2 vaccine, many employers implemented vaccination mandates, but one large US company is taking a different tack. Beginning November 1, Delta Air Lines will charge employees an additional $200 per month to remain enrolled in the company’s health plan if they refuse to be fully vaccinated for SARS-CoV-2. Additionally, unvaccinated employees are required to wear masks in all indoor company settings, will no longer qualify for pay protection if they are diagnosed with COVID-19, and will be required to take weekly tests beginning September 12. In a memo to staff, Delta CEO Ed Bastian noted that 75% of the company’s employees are fully vaccinated but expressed a desire to get “as close to 100% as possible.” Delta said the surcharge is necessary to cover the financial risk unvaccinated employees pose to the company, citing the average cost of a COVID-19-related hospital stay is $50,000. The airline is self-insured and sets its own premiums for its health plans, which are administered by UnitedHealthcare. Delta also requires new employees to be vaccinated.

United Airlines is the only major airline so far to require all of its employees to get vaccinated or risk termination, with religious or medical exemptions reviewed on a case-by-case basis.

STURGIS MOTORCYCLE RALLY Last summer, the Sturgis Motorcycle Rally—held annually in Sturgis, South Dakota (US)—was subsequently linked to more than 300 cases of COVID-19 across more than 20 states, including an outbreak in Minnesota that resulted in at least 77 cases linked directly to the event. Despite the ongoing pandemic, the rally was held again this year—August 6-15—largely without any COVID-19 restrictions or protective measures. Reportedly, the 2021 rally was one of the largest in the event’s history, drawing approximately 700,000 visitors. Even though the event ended only 11 days ago, there are already early indications of a major COVID-19 surge in the area. The experience following the 2020 event and the ongoing nationwide surge, driven largely by the highly transmissible Delta variant, should have been sufficient to inspire event and government officials to implement effective COVID-19 protections this year, but unfortunately, that did not happen.

Meade County, SD—where Sturgis is located—averaged fewer than 1 new case per day from late May through late July, before beginning to increase slightly. At the start of the 2021 rally, Meade County averaged 3 new cases per day, but daily incidence surged to 38 as of August 24, nearly a 13-fold increase and a new record for the county. The 86 cases reported in Meade County on August 23-24 accounted for 10% of the state’s total, despite the county only representing 3% of the state’s population. Analysis by The New York Times indicates that COVID-19 hospitalizations have more than tripled over the past 2 weeks. Test positivity surged past 40% (currently 34%), which indicates that testing may not be fully capturing the true scale of community transmission in the area. Considering that 700,000 visitors have returned to their homes across the US, the Sturgis Motorcycle Rally certainly has the potential to be another national-level superspreader event. While we are observing the early signs of a surge in and around Sturgis, it might be months before we could expect to have a clear idea of the extent to which this single event impacts state- and national-level epidemics.

CRUISE LINES Cruise lines are implementing more strict COVID-19 preventive measures, requiring passengers to be vaccinated, wear masks while in public areas aboard the ship, and show proof of a negative test within a few days of boarding, amid a current surge in cases and reports of breakthrough infections among vaccinated staff and passengers. Last week, Carnival Cruise Lines announced 27 COVID-19 cases aboard the Carnival Vista sailing out of Galveston, Texas (US). Most of the cases were among crew, but the one passenger casea 77-year-old woman from Oklahomareceived medical care on the ship, was hospitalized in Belize, evacuated to her home state, and later died. In a statement, Carnival expressed condolences to the woman’s family and added that she “almost certainly” did not contract the virus onboard the ship.

On August 20, the US CDC updated its guidance for cruise ship travelers, recommending people who are at a higher risk for severe COVID-19 avoid cruises and asking passengers to have both a recent negative SARS-CoV-2 test and proof of vaccination. Additionally, some popular destinations, including the Bahamas, are requiring all cruise ship passengers aged 12 and older be vaccinated in order for ships to dock. This prompted Disney Cruise Line, Royal Caribbean, and Carnival to adopt vaccination requirements for their passengers. Norwegian Cruise Line already requires all eligible passengers to be vaccinated, after the company successfully challenged a Florida law banning companies from demanding proof of vaccination.

IVERMECTIN POISONINGS On August 26, the US CDC issued a Health Alert Network (HAN) advisory in response to a recent surge in poisonings in individuals who attempted to prevent or treat COVID-19 using ivermectin. As we covered previously, ivermectin is approved by the US FDA to treat parasitic infections in humans, but it is primarily used to treat animals, including livestock. The drug is not authorized for use to treat COVID-19, and currently available data do not indicate a treatment benefit for COVID-19. A study of prescriptions filled at retail pharmacies in the US found that the volume of ivermectin prescriptions in January 2021 was more than 10 times greater than the pre-pandemic baseline, and the volume in mid-August 2021 was more than 24 times greater than before the pandemic and still increasing. The CDC also reported that the volume of “veterinary formulations available over the counter but not intended for human use” increased as well.

The American Association of Poison Control Centers confirmed that poison control centers nationwide are fielding an elevated call volume related to the “misuse and overdose” of ivermectin, including veterinary formulations. The volume of poison control center calls related to ivermectin was 3 times higher than the pre-pandemic baseline in January 2021 and 5 times higher in July 2021. Available data also indicate an increase in associated visits to emergency departments and hospitals.

JAPAN The Japanese government recently halted a rollout of 1.6 million doses of the Moderna SARS-CoV-2 vaccine due to worries over contamination. The cause of the contamination has yet to be disclosed, but there were reports of 40 doses with unspecified contaminants found at 8 different vaccination sites across the country. These 40 doses led to the decision to pull the entire lot in addition to 2 other lots made at the same location in Spain. The Takeda Pharmaceutical Company, which is leading the sales and distribution of the vaccine in Japan, said the decision was made as safety precaution and has requested Moderna conduct an emergency investigation. Japan had a slow start to its vaccination campaign, but now 44% of the population is fully vaccinated