COVID-19 Situation Report
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EPI UPDATE The WHO COVID-19 Dashboard reports 198.8 million cumulative cases and 4.2 million deaths worldwide as of 11:30 EDT on August 3. Global weekly incidence increased for the sixth consecutive week, up 5.1% over the previous week, but weekly mortality decreased for the first time since June, down 8% compared to the previous week.

The US is #1 globally in terms of total daily incidence (85,459 new cases per day), accounting for 14% of the global total, and Indonesia is #1 in terms of total daily mortality (1,789 deaths per day), representing 19% of the global total.

Global Vaccination
The WHO reported 3.89 billion doses of SARS-CoV-2 vaccines administered globally as of August 3. The WHO reports a total of 1.51 billion individuals have received at least 1 dose, and 752 million are fully vaccinated. Analysis from Our World in Data shows that the global daily doses administered continued to increase through August 1, peaking at 41 million doses per day before falling to 39 million on August 2. The global trend continues to closely follow the trend in Asia. Our World in Data estimates that there are 2.23 billion vaccinated individuals worldwide (1+ dose; 28.6% of the global population) and 1.15 billion who are fully vaccinated (14.8% of the global population).

The US CDC reported 34.97 million cumulative COVID-19 cases and 611,051 deaths. Despite considerable vaccination coverage at the national level, daily incidence continues to accelerate, mirroring the early stages of previous surges. At 72,790 reported cases per day on July 30, the current surge is the United States’ second largest to date, surpassing both the spring 2020 and spring 2021 peaks. The average daily incidence is the highest since February 17*.

We expect the US to surpass 35 million cases in this afternoon’s update. If that is the case:
1 case** to 5 million cases- 196 days
5 million to 10 million- 93 days
10 million to 15 million- 29 days
15 million to 20 million- 25 days
20 million to 25 million- 22 days
25 million to 30 million- 61 days
30 million to 35 million- 132 days
**First reported cases on January 22, 2020.

Daily mortality also continues to increase, up to 302 deaths per day on July 30, which is 76% higher than the most recent low on July 10 (172)*. Daily mortality does not appear to be increasing exponentially like daily incidence; however, this could change over the coming weeks as daily incidence increases.

As the US epidemic continues to surge, several states are reporting daily incidence at or near their highest peak to date. According to CDC data, Louisiana (4,119 new cases per day) has already surpassed its previous record—10% higher than its January 2021 peak—and Hawai’i (298) surpassed its highest peak (August 2020). On July 30, Florida reached its second highest average daily incidence to date (15,817). Florida has not yet reported data from this weekend, and we expect that it will set a new record in its next report. Arkansas (1,869) and Mississippi (1,475) are at 61% and 63% of their respective highest peaks, both in January 2021. And Alabama (2,057) and Missouri (2,642) are both approaching 50% of their highest peaks from January 2021 and November 2020, respectively*.
*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 current date.

US Vaccination
The US has administered 347 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations are increasing slowly, now up to 552,647 doses per day*. A total of 191.8 million individuals in the US have received at least 1 dose, equivalent to 57.8% of the entire US population. Among adults, 70.0% have received at least 1 dose—finally reaching the White House’s target—as well as 11.1 million adolescents aged 12-17 years. A total of 164.9 million individuals are fully vaccinated, which corresponds to 49.7% of the total population. Approximately 60.6% of adults are fully vaccinated, as well as 8.4 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.

VACCINE-RESISTANT VARIANT RISK With the number of new COVID-19 cases rising in much of the world, scientists are warning that continued transmission provides an opportunity for the evolution of new, and potentially more harmful, SARS-CoV-2 variants. The current increase in cases is being fueled by the highly transmissible Delta variant as well as the loosening and inconsistent use of public health prevention measures, increased social mobility, and inequitable vaccine access, WHO Director-General Dr. Tedros Adhanom Gebreyesus said on July 30, warning that health systems in many countries are overwhelmed and that more variants will emerge as long as the virus continues to spread. US CDC Director Dr. Rochelle Walensky cautioned that a new variant could potentially evade vaccines but added the vaccines authorized in the US continue to protect people from severe disease and death. 

In a modeling study published in Nature Scientific Reports on July 30, researchers with the Austria Institute of Science and Technology examined the impact of the rate of vaccination and the strength of non-pharmaceutical interventions on the probability of the emergence and establishment of a vaccine-resistant SARS-CoV-2 strain. The researchers' model identified three factors that could lead to the establishment of a vaccine-resistant strain: the high probability of a resistant strain’s initial emergence, a high number of infected individuals, and a low rate of vaccination. The researchers’ analysis showed that the highest risk of vaccine-resistant strain establishment occurs when a large proportion of the population is vaccinated but viral transmission is high, underlining the importance of controlling transmission through public health interventions while continuing vaccination campaigns. Nevertheless, the researchers conclude “the emergence of a partially or fully vaccine-resistant strain and its eventual establishment appears inevitable.” The UK’s Scientific Advisory Group for Emergencies (SAGE) published an updated theoretical and non-peer-reviewed paper on July 30 essentially coming to the same conclusion, that a vaccine-resistant SARS-CoV-2 variant almost certainly will emerge and public health authorities must continue efforts to reduce transmission as much as possible.   

US CDC MASK GUIDANCE ​​The US CDC’s latest masking guidance—calling for all people, even those who are vaccinated, to wear masks in indoor public settings in areas where transmission is categorized as high or substantial—is in direct response to the increased transmissibility of the Delta variant. According to data released last week, data show that individuals fully vaccinated for SARS-CoV-2 who become infected—known as breakthrough cases—carry viral loads similar to those found in infected unvaccinated individuals, suggesting that vaccinated people can transmit the Delta variant of concern just as easily as those who are unvaccinated

The data are based on a COVID-19 outbreak that began in Provincetown, MA (US) in early July following multiple summer events and large public gatherings. Of the 496 cases reported in the outbreak at the time of data analysis, 346 (74%) cases were among fully vaccinated people and 90% of 133 cases sequenced were caused by the Delta variant. Almost 80% of the breakthrough cases were symptomatic, with common symptoms including cough, headache, sore throat, myalgia, and fever. Among 5 patients who were hospitalized, 3 had underlying medical conditions and 4 were vaccinated. No deaths were reported. The report, published as an early release in the CDC’s MMWR, said even jurisdictions without high or substantial transmission should consider expanding prevention measures, including masking for all individuals in indoor public spaces. Health officials emphasize that breakthrough cases remain rare and that vaccines provide protection against severe symptoms and hospitalization. Lending further credence to the protective power of the vaccines, data show that counties with low vaccination rates are experiencing rapid rises in COVID-19 cases and increases in deaths. 

SARS-COV-2 TRANSMISSIBILITY An internal report from the US CDC suggests that the SARS-CoV-2 Delta variant may be capable of causing more severe disease than previous variants and that it may be as transmissible as chickenpox. Studies from Canada, Scotland, and Singapore indicate that individuals infected with the Delta variant are at a higher risk of hospitalization and requiring oxygen supplementation. Evidence discussed in the report shows that the Delta variant may be capable of skirting the protection offered by the vaccines, and fully vaccinated individuals who become infected may carry high viral loads in their noses and throats, possibly making transmission from the vaccinated more common than previously understood. Despite the concerns raised in the report, vaccination remains the best way to protect against severe disease. The report states that vaccines are capable of preventing severe symptoms in at least 90% of cases, even though they might be less effective at preventing infection. Experts acknowledge that discussions around vaccination may need to shift from preventing transmission to personal protection in light of the new data. 

US EVICTION MORATORIUM The federal eviction moratorium, administered by the US CDC, expired on July 31, without extension, after the US Supreme Court on June 29 declared that the agency could no longer extend the program without “clear and specific congressional authorization (via new legislation).” A recent surge in COVID-19 daily incidence, driven by the highly transmissible Delta variant, is lending urgency to efforts to keep people in their homes and out of congregate or dangerous living situations, such as in shelters or on the street. More than 11 million adult renters are behind on payments, according to the Center on Budget and Policy Priorities. But it appears the CDC, US Congress, and the White House were caught off guard by the moratorium’s expiration, leaving officials scrambling for solutions. 

Over the weekend, White House officials asked the CDC to extend the moratorium, focusing specifically on areas with high or substantial COVID-19 transmission, but the CDC denied the request, saying it has no legal authority to do so under the Supreme Court’s ruling. Additionally, Congress failed to pass legislation that would have provided a last-minute extension of the federal moratorium until October 18. Afterward, Congressional leaders called on the White House to extend the moratorium, but officials said they also lack legal authority to do so. On August 2, US President Joe Biden called on state and local governments to extend or implement eviction moratoria for at least the next 2 months. Approximately one-third of states currently have eviction moratoria through August. Additionally, President Biden, at the request of Congressional leadership, is asking relevant federal agencies to examine why more of US$46.5 billion in Emergency Rental Assistance provided to state and local governments has not yet been distributed. The White House made other requests of federal, state, and local agencies and jurisdictions and committed to “doing everything in its power” to keep people housed.

US GLOBAL VACCINATION PROGRAM The US government announced today that the country has donated and shipped more than 110 million doses of SARS-CoV-2 vaccines to more than 60 countries, fulfilling a June pledge by President Joe Biden to donate at least 80 million doses. The majority of the vaccines were shipped through the COVAX facility, with other portions provided through regional partners such as the African Union and the Caribbean Community (CARICOM). Reportedly, an “initial tranche” of 25 million vaccines is going to African nations, and the US government is supporting vaccine manufacturing efforts in South Africa and Senegal. A White House fact sheet lists the countries and amount of vaccines the US has donated to date. 

According to the fact sheet, the US government has purchased 500 million doses of the Pfizer-BioNTech vaccine and expects to begin shipping them to 100 low-income countries at the end of August. The donated vaccine doses, worth $3.5 billion, will be delivered through COVAX, helping the facility get closer to its goal of delivering 2 billion doses in 2021. However, to offset the costs of purchasing the supply, the US reportedly is diverting hundreds of millions of dollars intended to support vaccination drives in low-income countries. COVAX continues to struggle, delivering only 177 million vaccines so far, some of which are going unused in recipient countries due to a lack of funding, shortage of sufficient transportation, a dearth of trained vaccine administrators, or the absence of public interest to receive the shots.

EMERGENT VACCINE PRODUCTION FACILITY After a more than 3-month shutdown of SARS-CoV-2 vaccine manufacturing at Baltimore, MD (US)-based Emergent BioSolutions, the US FDA last week granted permission for the plant to resume manufacturing based on the regulatory agency’s “observations of the implemented corrective actions.” As we previously reported, the FDA published a report in April stating the facility was unsuitable to produce vaccine doses, and Emergent agreed to pause production until issues identified in the report were resolved, which appears to have happened. At the time, Emergent was manufacturing both the J&J-Janssen and AstraZeneca-Oxford vaccines for the federal government; production for the latter has since moved to another company. J&J, which has been in control of the plant since April, confirmed the FDA is permitting manufacturing to resume and said it will continue to work with the agency to gain clearance to use up to 30 million doses of its vaccine made at the facility prior to its shutdown. 

In a call with investors on July 29, Emergent officials disclosed a US$41.5 million loss from having to discard vaccine doses deemed unusable by regulators as well as the expenditure of US$12.4 million to address problems at the facility. The following day, Emergent filed documents with the US Security and Exchange Commission disclosing for the first time it has received “preliminary inquiries and subpoenas to produce documents” stemming from shareholder lawsuits and investigations from the SEC, the US Department of Justice, the Financial Industry Regulatory Authority, the state attorney generals of Maryland and New York, and committees in both houses of the US Congress. Additionally, Reuters reports that AstraZeneca-Oxford vaccine doses sent from the plant to Canada and Mexico in late March were cleared without proper regulatory inspections. These reports underscore ongoing troubles for Emergent, which holds a US$628 million federal contract to be the primary domestic manufacturer of both the J&J-Janssen and AstraZeneca-Oxford vaccines, as well as other federal contracts for various products included in the National Strategic Stockpile, most notably the company’s anthrax vaccine. 

DELTA VARIANT IN CHINA Once recognized as implementing the world’s strictest COVID-19 prevention measures, China’s zero tolerance COVID-19 policy is facing challenges amid a recent increase in cases caused by the Delta variant. The policy attempts to keep the country’s number of cases to zero by limiting international travel, requiring regular testing, and enforcing stringent quarantine measures, among other regulations. But over a period of 2 weeks, the country’s average number of new daily COVID-19 cases has more than doubled and nearly half of China’s 32 provinces have reported cases caused by the Delta variant, indicating the variant is moving quickly. This current wave is thought to have originated at the international airport in the eastern city of Nanjing, after a case was first detected on July 20. All 9.3 million residents of Nanjing are undergoing testing, and the city of Wuhan, where the virus was first detected in late 2019, plans to test all 12 million residents. Wuhan recently recorded 3 cases of the Delta variant after having reported no cases since mid-May 2020. The variant’s rapid spread has raised concerns over the level of protection provided by Chinese vaccines. So far, China has administered 1.7 billion doses, enough to fully vaccinate about 60% of its population. Public health officials estimate 80% of the population will be fully vaccinated by the end of the year. 

INDONESIA Healthcare workers in Indonesia are overwhelmed, as daily COVID-19 incidence remains high, daily mortality continues to climb, patient capacity surges, and medical supplies dwindle. The country’s average number of new daily cases peaked on July 18, reaching a number 4 times higher than the previous peak in January 2020. Average daily incidence is down as of August 2 but still remains high. Average daily mortality continues to rise as of August 2 and is currently 6 times higher than the previous peak in January 2020. Approximately 1,200 healthcare workers in Indonesia have died during the pandemic; nearly half of those were doctors. Many more healthcare professionals have been infected and returned to work after recovering. Facing long hours, stressful working conditions, and greater exposure to infected patients, Health Minister Budi Gunadi Sadikin said the country is prioritizing providing additional vaccine doses to healthcare workers. Most who have been vaccinated received the Chinese Sinovac vaccine, but the additional doses will be the Moderna vaccine.

AUSTRALIA LOCKDOWNS Military personnel are being brought in to help local police enforce a lockdown in New South Wales, Australia. The lockdown comes in response to an outbreak of the highly transmissible SARS-CoV-2 Delta variant in the region. The lockdown was recently extended to August 28 after an outbreak of 170 cases was traced to an infected individual who failed to self-isolate. The 300 unarmed military personnel will aid in enforcing the lockdown by knocking on residents’ doors to ensure everyone is complying with stay-at-home orders. In parts of Sydney, the state’s largest city, residents will be required to wear masks when outdoors and stay within 5 kilometers (3 miles) of their residence. On August 2, Queensland state extended lockdown orders through August 8 in its largest city, Brisbane, after officials detected 13 new locally acquired cases. Australia is expected to continue cycles of stop-start lockdowns until at least 70% of the population is fully vaccinated. Prime Minister Scott Morrison said he expects to reach that goal by the end of the year; only 15.4% of the population is fully vaccinated as of August 2.

BLOOD CLOTS Two studies recently published by The Lancet provide additional insight into the risk of blood clots associated with the AstraZeneca-Oxford SARS-CoV-2 vaccine. A peer-reviewed study conducted by researchers at AstraZeneca included data from all reported cases of thrombosis with thrombocytopenia syndrome (TTS, a blood clotting disorder) within 14 days of vaccination with either dose of the AstraZeneca-Oxford vaccine reported to AstraZeneca’s global safety database through April 30. The researchers identified 399 cases of TTS among 49.2 million individuals who received the first dose of the vaccine, equating to an estimated risk of 8.1 cases per million doses. The risk decreased following the second dose, however, down to 2.3 per million doses—13 cases of TTS among 5.62 million individuals who received the second dose. The researchers estimated that the average over a 14-day period prior to the pandemic was as high as 7.16 cases of TTS per million people. So while the risk following the first dose of the vaccine was a slight increase over the expected risk, the risk following the second dose was “within preliminary estimates.”

A preprint study, conducted in Spain and funded by the European Medicines Agency, included 1.3 million vaccinated individuals as well as 225,000 COVID-19 patients and 4.5 million control participants. The vaccinated participants included 946,000 who received the first dose of the Pfizer-BioNTech vaccine (including 779,000 who received both doses) and 426,000 who received the first dose of the AstraZeneca-Oxford vaccine. The researchers evaluated the risk of blood clotting disorders—including venous thromboembolism (VTE), thrombocytopenia, and thrombocytopenia syndrome (TTS)—following vaccination. Participants who received the Pfizer-BioNTech vaccine had 29% higher occurrence of VTE following the first dose than expected, but there was no significant difference following the second dose. For the AstraZeneca-Oxford vaccine, the researchers did not observe a significant difference in the occurrence of VTE. Notably, the risk of VTE was 8 times higher than expected among COVID-19 patients. Similarly, there was an elevated risk of thrombocytopenia following both doses of the Pfizer-BioNTech vaccine, but not for the AstraZeneca-Oxford vaccine. Neither vaccine exhibited an elevated risk of TTS. The study also provides further analysis of the associated risks by sex and age group; however, the duration was not sufficient to include data regarding clotting risk after the second dose of the AstraZeneca-Oxford vaccine.

MONOCLONAL ANTIBODY The US FDA on July 30 expanded the emergency use authorization (EUA) for the monoclonal antibody REGEN-COV—a combination of casirivimab and imdevimab—to include post-exposure prophylaxis (PEP) among certain people exposed to or at high risk of exposure to an individual infected with SARS-CoV-2. The EUA now allows monoclonal antibody PEP among people at high risk for progression to severe COVID-19, who are not fully vaccinated, or who are not expected to mount an adequate response to vaccination and who have been exposed to a SARS-CoV-2-infected individual or who are at high risk of exposure to an infected individual in congregate or institutional settings such as nursing homes or prisons. Under the EUA, REGEN-COV now can be administered monthly as a subcutaneous injection or intravenous infusion to qualifying people aged 12 and older. The expanded EUA represents the first time an antibody treatment has been authorized for this purpose.

SARS-COV-2 EXPOSURE IN DEER A study conducted by the US Department of Agriculture (USDA) evaluated exposure to SARS-CoV-2 among white-tailed deer in several US states. The USDA’s Animal and Plant Health Inspection Service (APHIS) conducted serological testing on 481 serum specimens collected from white-tailed deer in Illinois, Michigan, New York, and Pennsylvania, from January 2020 through 2021. Antibodies against SARS-CoV-2 were detected in 33% of specimens, including 67% of specimens collected in Michigan. For comparison, only 1 out of 143 specimens collected prior to January 2020 tested positive for SARS-CoV-2 antibodies, and that specimen “was at the minimum threshold of detection,” which could potentially indicate a false-positive result. The researchers did not identify any animals that exhibited signs of illness.

Statements by APHIS note that the study was not sufficient to draw conclusions regarding population-level exposure among deer, but it does provide evidence that deer have been infected by the virus. It is unclear how the animals were exposed or the extent to which the infection is spreading among deer populations. It is also uncertain whether deer can transmit the infection to humans, but information from APHIS indicates there is no evidence that consuming meat from an infected animal could result in SARS-CoV-2 infection. While many questions remain unanswered, this study does provide additional information regarding potential animal reservoirs for SARS-CoV-2, which could potentially impact longer-term epidemic control efforts.