COVID-19 Situation Report
EPI UPDATE The WHO COVID-19 Dashboard reports 216.9 million cumulative cases and 4.5 million deaths worldwide as of August 31. Global weekly incidence decreased for the first time since mid-June, down 3.12% from the previous week. Weekly mortality also decreased, for the first time since late June*, falling 2.41% compared to the previous week.
*With the exception of the week of July 19, when Ecuador reported 8,786 deaths.

The global cumulative mortality surpassed 4.5 million deaths in today’s update:
1 death to 500k: 165 days
500k to 1 million: 86 days
1 to 1.5 million: 70 days
1.5 to 2 million: 44 days
2 to 2.5 million: 37 days
2.5 to 3 million: 52 days
3 to 3.5 million: 38 days
3.5 to 4 million: 51 days
4 to 4.5 million: 54 days

Global Vaccination
The WHO reported 5.02 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of August 30. A total of 1.93 billion individuals have received at least 1 dose, and 1.16 billion are fully vaccinated. Analysis from Our World in Data indicates that global daily vaccinations increased sharply over the past several days, up to 41 million doses per day, which would be the third highest peak to date*. The global trend continues to closely follow the trend in Asia. Our World in Data estimates that there are 3.11 billion vaccinated individuals worldwide (1+ dose; 39.45% of the global population) and 2.12 billion who are fully vaccinated (26.9% of the global population)**.
*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.
**China reported 448 million new vaccinated individuals (1+ dose) and 112 million fully vaccinated individuals on August 26, its first report since June 10.

The US CDC reported 38.9 million cumulative COVID-19 cases and 636,015 deaths. Daily incidence continues to increase, but the trend is tapering off toward a peak or plateau. The current average of 149,334 new cases per day is the highest since January 29. Daily mortality also continues to increase, and the mortality trend may be starting to taper off as well. The current average of 970 deaths per day is the highest since March 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 numbers reported here may not correspond to the most recent dates.

Data from HHS indicate that more than 100,000 COVID-19 patients are currently hospitalized nationwide. This represents the second highest peak to date, and is still increasing. The CDC reports more than 84,000 COVID-19 patients currently hospitalized, 32% below the highest peak.

US Vaccination
The US has administered 369.6 million cumulative doses of SARS-CoV-2 vaccines, and daily vaccinations appear to have peaked over the past several days. The average briefly exceeded 798,000 doses per day on August 23 before falling to 787,000 on August 25*. Notably, we have not observed a marked increase in daily vaccinations since the US FDA issued full approval for the Pfizer-BioNTech vaccine. There are 204.5 million individuals who have received at least 1 dose, equivalent to 61.7% of the entire US population. Among adults, 74.1% have received at least 1 dose, as well as 13.4 million adolescents aged 12-17 years. A total of 173.8 million individuals are fully vaccinated, which corresponds to 52.4% of the total population. Approximately 63.4% of adults are fully vaccinated, as well as 10.2 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.

US CDC ACIP MEETING At a meeting on August 30, the US CDC's Advisory Committee on Immunization Practices (ACIP) expressed initial support for third doses of SARS-CoV-2 mRNA vaccines for vulnerable populations, such as long-term care facility residents, and healthcare workers but said there is not enough data yet to recommend so-called booster shots for the general population. In a presentation to the committee, Dr. Sara Oliver, Co-Lead for the COVID-19 Vaccines ACIP Work Group, said data through July show the vaccines appear to provide strong protection against severe disease and hospitalization. Vaccine effectiveness (VE) against hospitalization remains high, between 75% to 95%, while VE against infection spans a much broader range, between 39% to 84%, since the predominance of the Delta variant. Dr. Oliver noted the reasons for lower VE “likely include both waning over time and the Delta variant.” Instead of focusing on booster doses, ACIP members emphasized that improving overall vaccination coverage is a “top priority,” as a high percentage of hospitalizations are occurring among unvaccinated individuals. They also said any booster dose recommendation should take into account equitable access to vaccines, both domestically and globally. The committee did not vote on booster doses, noting it intends to do so after the US FDA authorizes their use. The committee expects to meet in a few weeks to discuss data covering August, although a date was not announced. While the administration of US President Joe Biden has endorsed booster shots, saying they will be available by September 20, the FDA and CDC must first make recommendations based on scientific evidence.

At the meeting, the ACIP backed the US FDA’s full approval of the Pfizer-BioNTech SARS-CoV-2 mRNA vaccine, voting 14-0 to recommend the vaccine for individuals aged 16 and older. CDC Director Dr. Rochelle Walensky endorsed the recommendation, 9 months after the committee made an interim recommendation supporting the vaccine’s use. The committee reiterated that though there are rare reports of heart inflammation after mRNA vaccination, especially among males under age 30, the benefits of the vaccine outweigh the risks because the condition can occur at higher rates in COVID-19 patients than among those who received an mRNA vaccination.

DELTA HOSPITALIZATION RISK A study published August 27 in The Lancet Infectious Diseases adds evidence to what many experts already suspected: people infected with the highly contagious SARS-CoV-2 Delta variant are twice as likely to be hospitalized as those infected with the Alpha variant. To compare hospitalization rates, researchers from Public Health England (PHE) and Cambridge University examined data on 43,338 sequencing-confirmed COVID-19 cases between March 29 and May 23, 2021, during which time the Delta variant was becoming the predominant variant in the UK. The majority of the cases were among unvaccinated individuals (74%), while 2% were fully vaccinated and 24% had received one dose. Of 34,656 Alpha cases, 764 (2.2%) were admitted to the hospital within 14 days of a positive SARS-CoV-2 test, while 196 of 8,682 (2.3%) Delta cases were hospitalized. Although the percentages of hospitalized cases were similar between both variants, the risk of being hospitalized more than doubled (adjusted hazard ratio [HR] 2.26, 95% confidence interval [CI] 1.32-3.89) for Delta cases compared with Alpha cases when the researchers adjusted the data to account for certain factors, including age and sex. Delta cases also were more likely to seek emergency medical care or be hospitalized within 14 days versus Alpha cases (adjusted HR 1.45, 95% CI 1.08-1.95). 

Although the researchers examined differences between vaccinated and unvaccinated groups for hospitalizations and emergency care or hospitalization, the results were non-significant due to low numbers of cases who were fully vaccinated. Therefore, the results only apply to people who are unvaccinated. In a statement, Dr. Anne Presanis, Senior Statistician at the University of Cambridge and a lead author of the study, emphasized the importance of getting fully vaccinated to reduce the risk of symptomatic infection with Delta, as well as reduce the risk of severe disease and hospitalization. The researchers noted that a previous study conducted in Scotland and published in The Lancet in June showed a similar increase in hospitalization risk among people infected with the Delta variant. While the UK study is the largest to date examining hospitalization risk for the Delta versus Alpha variants based on whole-genome sequenced cases, the researchers called for further assessments into how hospitalization risks differ for vaccinated individuals after infection with either variant. 

SCHOOL TRANSMISSION A case study published August 27 in the US CDC’s Morbidity and Mortality Weekly Report (MMWR) shows how quickly the highly contagious SARS-CoV-2 Delta variant can spread within a classroom of children too young to be vaccinated. The outbreak involved an unvaccinated Marin County, California (US), elementary school teacher who began showing COVID-19 symptoms on May 19, but who came to work the next 2 days, attributing the symptoms to allergies. During that time, the teacher read aloud to the class without wearing a mask, even though masks were required for staff and students while indoors. The teacher received a positive SARS-CoV-2 test on May 21 and informed the school on May 23. Several students became symptomatic on May 22, and the Marin County Department of Public Health (MCPH) initiated an investigation on May 26 to characterize the outbreak. Overall, 27 COVID-19 cases were identified, including the teacher. Among the teacher’s 24 students—all of whom were too young to be eligible for vaccination—12 of 22 who were tested received positive results between May 23-26. Notably, 8 out of 10 students who sat in the 2 front rows closest to the teacher became infected, representing an extremely high attack rate of 80%. 

In another classroom, located across an outdoor courtyard from the source classroom, 6 of 18 students in a different grade—also too young for vaccine eligibility—tested positive between May 24 and June 1. Additionally, 8 other cases were identified among parents and siblings of the students in the 2 classes, 3 of whom were fully vaccinated. An additional infected adult was unvaccinated. Of the 18 cases sequenced, all were identified as the Delta variant. The report’s authors underlined the importance of vaccination and other preventive measures, “including masking, routine testing, facility ventilation, and staying home when symptomatic” to ensure safe in-person learning in schools. Notably, all of the children were seated 6 feet apart and the classrooms had portable high-efficiency particulate air filters with open doors and windows, raising a question about whether consistent masking could have helped contain transmission in this outbreak.

A separate MMWR report published the same day concluded that in Los Angeles County, California, schools with transmission mitigation and containment protocols in place, “case rates in children and adolescents were 3.4 times lower during the winter peak compared with rates in the community,” showing multi-pronged prevention strategies are critical in helping to prevent new cases as children return to classrooms. However, the authors cautioned the data were collected prior to the predominance of the Delta variant (September 1, 2020-March 31, 2021). 

SARS-CoV-2 ORIGIN: US REPORT As expected, the US Office of the Director of National Intelligence on August 27 released an unclassified summary of a report stating that the US Intelligence Community “remains divided on the most likely origin of COVID-19. All agencies assess that two hypotheses are plausible: natural exposure to an infected animal and a laboratory-associated incident." Just over 3 months ago, US President Joe Biden ordered the Intelligence Community to undertake a systematic, detailed review of any evidence that could elucidate the origins of the COVID-19 pandemic. The only strong conclusion expressed in the summary is that SARS-CoV-2 was not developed as a biological weapon. Most agencies also agreed, with low confidence, that the virus probably was not genetically engineered, although 2 agencies believed there was insufficient evidence to make an assessment either way. In a statement following the summary’s release, President Biden said the US will continue to search for answers, adding, “I will not rest until we get them.” In order to do so, however, investigators will need cooperation from China, which continues to deflect blame and resist sharing information, according to the summary.

HURRICANE IDA Southern Louisiana (US) hospitals, already inundated with COVID-19 patients, are now dealing with damage from Hurricane Ida. The Category 4 storm made landfall in Lafourche Parish on August 29, battering the area for 16 hours with heavy rainfall and strong winds that caused widespread power outages, levee failures, flooding, collapsed buildings, and the need for rescues. At least 2 hospitals in Lafourche Parish reported significant damage, including extensive roof damage and partial generator failure. Residents of the parish were ordered to evacuate, but evacuating hospital patients was not an option because no other hospitals had the capacity to take additional patients due to an overwhelming number of COVID-19 patients and staff shortages. 

Louisiana Governor John Bel Edwards said that with more than 2,400 COVID-19 patients hospitalized in the state, many in serious or critical condition, the focus is on ensuring there is enough generator power and clean water at hospitals to meet patients’ needs, including providing oxygen and ventilator support, both of which require electricity. Nearly 1 million people within the New Orleans power grid were without power due to the storm’s “catastrophic intensity,” with the Entergy Corporation working to get lines back in operation. Hurricane Ida hit on the 16th anniversary of Hurricane Katrina and, with sustained winds of 150 mph, tied a record for the most intense hurricane on record to hit Louisiana. Notably, lessons learned after Katrina, including the relocation of hospital generators to higher floors, likely helped save lives during this storm.

COURT-ORDERED VACCINATION As the rate of SARS-CoV-2 vaccination slowly creeps up in the US, a significant portion of the population continues to resist getting the shots. In what appears to be efforts to persuade the reluctant, several judges have ordered defendants to be vaccinated as part of their orders. In New York, a Bronx County criminal court judge ordered a man pleading guilty to drug possession and shoplifting to get a SARS-CoV-2 vaccine as part of his plea deal, an action that the judge said would be viewed as rehabilitative. In another case in New York, a federal judge in Manhattan granted bail for a defendant charged with conspiracy to distribute fentanyl on the condition that she be vaccinated so she posed less of a danger to the community. Neither defendant appeared to object. 

In a similar case, a Cook County, Illinois, judge on August 10 revoked a woman’s right to visit her 11-year-old son until she is vaccinated for SARS-CoV-2. The 39-year-old woman shares custody of the boy with her divorced husband, who did not seek such an order. The woman’s lawyer said she believes the judge exceeded his authority and hopes an appellate court, which is expected to hear the case this week, reverses the decision. While some legal experts say these judges might have overstepped their authority, others argue that the orders fall within their jurisdiction, highlighting the legal and ethical questions surrounding the interpretation of the line between civil responsibility and civil liberty. 

EU TRAVEL RESTRICTIONS The EU on August 30 recommended that member states halt all non-essential travel from the US due to the rising number of COVID-19 cases throughout the country. The EU also recommended the removal of Israel, Kosovo, Lebanon, Montenegro, and North Macedonia from the bloc’s “white list” of places whose tourists could be permitted entry without certain restrictions. In order to be included on the white list, countries have to have no more than 75 new daily COVID-19 cases per 100,000 residents over the last 14 days, and these 6 countries no longer meet that criterion. The decision is non-binding, as each EU member state is able to set its own tourism policies and restrictions. Possible restrictions include testing requirements, quarantine upon arrival, a ban on non-vaccinated travelers, and a ban on all non-essential travelers from the stated countries. The white list now includes 18 countries.

Removal of the US from the white list follows a previous decision in June that recommended lifting restrictions on non-essential travelers from the US and 14 other nations. A majority of countries in the EU lifted non-essential travel restrictions after the decision in hopes of retaining income from the summer tourism season. New travel restrictions are anticipated to cost billions in lost tourism income. 

AUSTRALIA Australian Prime Minister Scott Morrison announced that the country is moving past its “COVID zero” goal, arguing that the current level of restrictions “is not a sustainable way to live,” particularly in light of the emergence of the Delta variant. Throughout the pandemic, Australia has responded to local outbreaks with highly restrictive “lockdown” measures, while facing relatively few restrictions in the periods between outbreaks. This plan aimed to interrupt chains of transmission and prevent localized outbreaks from spreading to a regional- or national-level epidemic in order to reach and maintain essentially zero domestic transmission. The policy change appears to be tied to vaccination coverage, and the government could begin easing restrictions once national coverage reaches 70% among eligible individuals. Australia is currently reporting full vaccination coverage of 35% for individuals ages 16 and older, and officials reportedly believe Australia can double this rate by the end of 2021. Notably, Prime Minister Morrison also announced children aged 12-17 years are now be eligible for vaccination.

MEDIGEN VACCINE Taiwan on August 23 launched an island-wide rollout of its domestically produced Medigen SARS-CoV-2 vaccine, produced by Taipei-based Medigen Vaccine Biologics Corporation, with Taiwan President Tsai Ing-wen publicly receiving the first shot. But the rollout quickly hit speed bumps, with experts criticizing the launch of the vaccine without the completion of Phase 3 clinical trial and no efficacy data. Then, over the next 3 days, 4 people died after receiving the vaccine, raising questions about its safety among some experts. Taiwan’s Central Epidemic Command Center (CECC) said it does not plan to halt the campaign, as there is no indication that the deaths are associated with the vaccine. The CECC will continue to investigate whether there is a causal relationship, indicating the news has not affected vaccine uptake among the Taiwanese population. Throughout the pandemic, Taiwan has been successful at curbing dramatic surges in COVID-19 cases and reports fewer than 16,000 total confirmed cases to date. 

SPUTNIK V Russia’s Sputnik V SARS-CoV-2 vaccine, officially known as Gam-COVID-Vac, appears to reduce the risk of hospitalization and prevent severe lung damage among COVID-19 patients, according to a preprint paper posted to medRxiv. The analysis, which has not yet been peer-reviewed, includes data from 13,894 patients, 9.3% of whom were fully vaccinated, having completed their second shot at least 2 weeks prior. Among those fully vaccinated, the adjusted vaccine effectiveness (VE) against hospital referral was 81% (95% confidence interval [CI], 68-88). The VE against hospital referral was slightly better among women (84%, 95% CI, 66-92) compared with men (76%, 95% CI, 51-88). The data also show that Sputnik V was 76% effective at protecting against severe lung injury, defined as more than 50% lung involvement. Although the data do not include genetic sequencing for viral variants, Russian health officials say 95% of new infections in July and August, when the study was conducted, were attributable to the Delta variant. The Sputnik V vaccine is authorized for use in 69 countries, but the European Medicines Agency (EMA) and the WHO continue to review the vaccine for authorization.

C.1.2 VARIANT A preprint article posted on medRxiv from a group of South African researchers describes a potential SARS-CoV-2 variant of interest assigned to the PANGO lineage C.1.2. According to the paper, which is not yet peer-reviewed, the variant was first identified in May 2021 and likely originated from the C.1 viral lineage, one of the lineages that dominated the first wave of SARS-CoV-2 infections in South Africa. The C.1.2 variant is believed to have between 44-59 mutations in regions such as the spike protein, receptor binding motif, and furin cleavage site, representing more mutations than previous variants of interest and variants of concern. The mutations described in the article are associated with increased neutralizing antibody evasion, increased transmissibility, and potentially increased viral reproduction. 

By August 13, 2021, the variant had been detected in a majority of South African provinces, as well as in the Democratic Republic of the Congo, Mauritius, New Zealand, Portugal, and Switzerland. Despite the wide geographic spread, prevalence of C.1.2 in tested samples remains low. However, monthly increases in prevalence are similar to those seen in the early stages of the Beta and Delta variants. Researchers are currently assessing the effectiveness of vaccines against this lineage and more information is expected soon. Notably, though the researchers say they are “concerned” about C.1.2, it has not yet been named a variant of interest or concern, as more data are necessary to make that determination. 

COMPARING mRNA VACCINE IMMUNE RESPONSE A research letter published in the Journal of the American Medical Association (JAMA) describes results from a prospective study comparing antibody responses to the Pfizer-BioNTech and Moderna SARS-CoV-2 vaccines among a cohort of Belgian healthcare workers. For the study, antibodies against the SARS-CoV-2 nucleocapsid protein were measured after vaccination. Among the 1,647 healthcare workers included in the evaluation, 2 doses of Moderna produced higher antibody titers than 2 doses of Pfizer-BioNTech; participants who were previously infected with SARS-CoV-2 had higher antibody titers than participants who were never infected; and higher antibody titers were correlated with younger age groups. The limitations of the study include a lack of information on cellular immunity and neutralizing antibody titers. Neutralizing antibodies can stop a virus from entering a cell and initiating infection while binding antibodies alert white blood cells to the presence of a pathogen and mark them for destruction. Neutralizing antibodies serve a different purpose from binding antibodies and they can result in long-term immunity to certain infections. 

BLOOD CLOTTING RISKS The risk of blood clotting events after infection with SARS-CoV-2 is much higher than the risk posed by vaccination with either the Pfizer-BioNTech or AstraZeneca-Oxford vaccines, according to a large UK study published August 27 in the British Medical Journal (BMJ). A team led by researchers from the University of Oxford examined the health records of more than 29 million people who received a first dose of either vaccine between December 2020 and April 2021, as well as nearly 1.8 million who were infected with the virus, looking for complications up to 28 days post-vaccination or infection.

The researchers found that people who received the Pfizer-BioNTech vaccine had an increased risk of ischemic stroke and blood clots in arteries, while those who received the AstraZeneca-Oxford vaccine had an increased risk of low platelets (thrombocytopenia) and blood clots in veins. While the researchers said that people should be aware of the increased risk, they stressed that the risks of the same complications among people infected with SARS-CoV-2 are much higher. For example, the risk of thrombocytopenia is almost 9 times higher with infection than vaccination with the AstraZeneca-Oxford vaccine, and the risk of stroke is nearly 12 times higher after COVID-19 than with the Pfizer-BioNTech vaccine. The risk of blood clotting events also remained elevated for a longer period of time after infection compared with vaccination. Experts continue to stress that the short- and long-term complications of COVID-19 are much more severe than the risks associated with vaccination, and they urge those eligible to get vaccinated.