COVID-19 Situation Report
Editor: Alyson Browett, MPH

Contributors: Clint Haines, MS; Natasha Kaushal, MSPH; Amanda Kobokovich, MPH; Christina Potter, MSPH; Matthew Shearer, MPH; Marc Trotochaud, MSPH; and, Rachel A. Vahey, MHS.
GLOBAL HEALTH SECURITY INDEX COVID-19 continues to disrupt lives and livelihoods, stress health systems, and exhaust social protections and government budgets—and it will not be the last global health emergency the world will face. On December 8 at 9 am ET, join the Johns Hopkins Center for Health Security and the Nuclear Threat Initiative for the launch of the 2021 Global Health Security Index, a comprehensive assessment that provides a benchmark for capacities to prevent, detect, and respond to epidemics and pandemics across 195 countries. The need for durable national health capacities and political and social environments that foster effective prevention and response measures has never been clearer. Register in advance.
EPI UPDATE The WHO COVID-19 Dashboard reports 262.2 million cumulative cases and 5.2 million deaths worldwide as of December 1. Global weekly incidence increased for the sixth consecutive week, while global weekly mortality declined from the previous week. Weekly incidence increased by 5.61% compared to the previous week, and mortality decreased by 9.4%. During the week ending November 30, nearly 3.8 million new cases were reported, with the African, Western Pacific, and European regions reporting increases, according to the WHO COVID-19 Weekly Epidemiological Update. While the overall number of deaths decreased, 2 regions—South-East Asia and Africa—reported increases of 26% and 7%, respectively. Notably, the European region reported the highest weekly incidence in deaths of 3.1 per 100,000 population, while <1 new death per 100,000 was reported in all other regions.

The newly designated variant of concern (VOC), Omicron, appears to be in at least 23 countries and continues to be detected in new areas, according to the WHO. GISAID reports 25 countries and territories have confirmed Omicron cases, while BNO News reports cases of the VOC have been confirmed in 31 countries and territories, totaling 379. In South Africa, where Omicron was first identified, health authorities are reporting a dramatic surge in the number of new COVID-19 cases. Since November 24, when health officials notified the WHO about the new variant, the 7-day average of daily cases has increased nearly 6-fold. The number of newly confirmed cases doubled on December 1 over the previous day’s count, rising from 4,373 to 8,561, and experts are bracing for even greater increases. The US has confirmed 2 cases of Omicron, while 15 nations in the European Union and European Economic Area (EU/EEA) have reported a total of 79 Omicron cases as of today, with 20 of those cases being confirmed since yesterday. Notably, the majority of the cases have a history of travel to African countries, but several cases of apparent community transmission have been documented, including in the US.

It appears Omicron is outpacing the Delta VOC in South Africa, but it remains unclear whether the new VOC will overtake Delta in other regions, such as Europe, where Delta remains the dominant circulating variant. Notably, prior to Omicron, South Africa did not have much circulating Delta. While Omicron certainly seems to be more transmissible than Delta—and appears to be capable of causing breakthrough cases among vaccinated individuals—we continue to await lab and real-world data about how Omicron’s mutations impact transmissibility, vaccine-induced and natural immunity effectiveness, and disease severity. 

Global Vaccination
The WHO reported 7.9 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of December 1. A total of 4.2 billion individuals have received at least 1 dose, and 3.28 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations has increased over the past week, up to 32.78 million doses per day on December 1 from a recent low of 30.74 million doses per day on November 27.* 

Our World in Data estimates that there are 4.3 billion vaccinated individuals worldwide (1+ dose; 54.62% of the global population) and 3.45 billion who are fully vaccinated (43.61% of the global population). 
*The average daily 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.

The US CDC reports 48.5 million cumulative COVID-19 cases and 780,131 deaths. The current daily incidence average is approximately 80,230 new cases per day and appears to be holding relatively steady since mid-November, although there may be reporting delays due to the Thanksgiving holiday. Daily mortality appears to have dropped over the holiday—likely due to lags in reporting—but appears to be rising again, with the US currently averaging 816 deaths per day.*
*Changes in state-level reporting may affect the accuracy of recently reported data, particularly over weekends. 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 462.3 million cumulative doses of SARS-CoV-2 vaccines. The daily vaccination trend reached a recent peak at 1.44 million doses on November 23 but has declined sharply to 1.03 million doses as of November 26.* 

There are 233.6 million individuals who have received at least 1 vaccine dose, equivalent to 70.4% of the entire US population. Among adults, 82.8% have received at least 1 dose, as well as 19.8 million children under the age of 18. A total of 197.4 million individuals are fully vaccinated, which corresponds to 59.4% of the total population. Approximately 71.2% of adults are fully vaccinated, as well as 13.5 million children under the age of 18. Since August 13, 41.9 million fully vaccinated individuals have received an additional or booster dose, including 44.7% of fully vaccinated adults aged 65 years or older.
*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.

FIRST OMICRON CASES IN US The US has confirmed 2 cases of SARS-CoV-2 caused by the Omicron variant of concern (VOC). The first case was confirmed by California state health and US CDC officials on the afternoon of December 1. That patient is a fully vaccinated (not boosted) teacher from San Francisco, who returned from a trip to South Africa on November 22 and tested positive on November 29. The patient’s symptoms were mild, and they are recovering at home. The second case was confirmed today in a fully vaccinated man who traveled to New York City to attend the Anime NYC 2021 convention at the Javits Center from November 19-21. That patient has since recovered. In both cases, officials are conducting contact tracing but have not yet identified linked cases. More Omicron cases likely will be confirmed in the US over the coming days, especially considering the second case—who did not travel outside of the US—indicates Omicron is spreading within the nation. Additionally, domestic viral sequencing has increased significantly since the start of the pandemic, increasing the likelihood that other cases will be identified. 

In response to the emergence of Omicron, US President Joe Biden is scheduled to deliver a speech at 1 pm ET today outlining a domestic plan for COVID-19 in the winter months. He is expected to announce an extension to mask mandates on public transit into March 2022. The mandate was set to end on January 18, 2022, and this new extension will extend until March 18, 2022. Reportedly, President Biden also will announce tighter restrictions for all individuals entering the US via air travel, including providing proof of a negative COVID-19 test taken within 24 hours of entering the country. Other pieces of the Biden administration’s 9-pronged plan likely will include efforts to increase SARS-CoV-2 vaccine and booster dose uptake and access to at-home COVID-19 tests. 

As of now, many unknowns remain about how the Omicron VOC will impact the US and other nations, with uncertainties regarding economic recovery looming. On one hand, there is hope that people with vaccine-induced or natural immunity will be somewhat protected against severe disease, although the CEO of Moderna recently predicted that the current cadre of SARS-CoV-2 vaccines likely will be less effective against Omicron. All of the vaccine manufacturers are working on strategies to combat the new VOC, with new vaccines or booster doses expected to be ready within 3 months. 

US VACCINE REQUIREMENTS A federal judge in Louisiana on November 30 temporarily halted enforcement of the Biden administration’s SARS-CoV-2 vaccine requirements for healthcare workers employed at institutions receiving Medicare or Medicaid funding, 1 of 3 court decisions this week that call for a freeze on vaccination rules as they make their way through the courts. One of the emergency regulations in question, issued by the Centers for Medicare and Medicaid Services (CMS), requires healthcare workers be fully vaccinated against COVID-19 by January 4, 2022, or risk their facilities losing Medicare and Medicaid funding. The day before, a federal judge in St. Louis, Missouri issued a preliminary injunction on the CMS requirement that blocked its enforcement in 10 states. The ruling from US District Judge Terry Doughty of the Fifth Judicial District Court in Louisiana applies nationwide, except in the 10 states covered under the prior order. In his opinion, Judge Doughty cited protection of the separation of powers under the US Constitution, saying the Biden administration does not have the authority to bypass the US Congress during “indefinite states of emergency.” The US Department of Justice did not comment on the order, but the department already has asked the 8th US Circuit Court of Appeals to revive the mandate blocked on November 30 by the Missouri district court, and it is expected to do so in the Louisiana case.

In a separate case, US District Judge Gregory Frederick Van Tatenhove of the US District Court for the Eastern District of Kentucky granted a preliminary injunction of the Biden administration’s vaccine requirements for employees of government contractors, which prevents the rule’s enforcement in Kentucky, Ohio, and Tennessee while it makes its way through the courts. The White House defended the regulation and said the Justice Department will defend it in court. Another temporary standard issued through the US Department of Labor’s Occupational Safety and Health Administration (OSHA) requiring employers with 100 or more employees to compel their employees to be vaccinated or undergo weekly testing is on hold due to a separate court order. In the latest KFF COVID-19 Vaccine Monitor, released today, more than half of employees who work for such companies either say their employer already requires vaccination (36%) or say they want their employer to require it (17%). Four (4) in 10 employees (41%) say they do not want their employer to require SARS-CoV-2 vaccination. 

PANDEMIC TREATY At the conclusion of a special session of the World Health Assembly (WHA) on December 1—only the second to ever be held since the WHO’s founding in 1948—WHO member states agreed to begin negotiations on an international agreement, or “pandemic treaty,” meant to strengthen pandemic prevention, preparedness, and response. Looking ahead, a newly formed intergovernmental negotiating body will meet at least once by March 1, 2022, and a second time by August 1, 2022; deliver a progress report to the 76th World Health Assembly in 2023; and submit a final document for consideration by the 77th World Health Assembly in 2024. WHO Director-General Dr. Tedros Adhanom Ghebreyesus said the consensus decision—which came less than a week after the designation of Omicron as a new SARS-CoV-2 variant of concern—said the action “is cause for celebration, and cause for hope.” Notably, the adopted resolution stops short of calling for a legally binding instrument, which has seen support from the WHO Director-General, the EU, and Britain. The US said it supports the development of “a new WHO convention, agreement or other international instrument and making agreements to improve the effectiveness and agility of international health regulations.” Other nations, including China and Russia, have shown hesitation toward approving a legally binding agreement. The process resulting from the WHA’s decision will be long and likely fraught with politicization and setbacks.

POST-SEVERE COVID-19 MORTALITY RISK Researchers are learning more about the post-acute sequelae of COVID-19 (PASC), including the symptoms of so-called long COVID, and a recent report published in Frontiers in Medicine raises concerns for people who are recovered from severe COVID-19 requiring hospitalization. The analysis of more than 13,500 patients conducted by researchers in Florida (US) found that severe COVID-19 patients were significantly more likely to die in the year following recovery than patients who had mild disease or never contracted the illness. For patients with severe COVID-19, the adjusted all-cause mortality risk was significantly higher compared with both COVID-19-negative patients (HR 2.50; 95% CI 2.02, 3.09) and patients who had mild COVID-19 (HR 1.87; 95% CI 1.28, 2.74). A majority of the deaths (79.5%) were due to causes other than respiratory or cardiovascular reasons, and the risk of death within 1 year was 3 times as high for patients younger than 65 years compared with COVID-19-negative patients under age 65 (HR 3.33; 95% CI 2.35, 4.73). The study’s findings suggest that patients with severe COVID-19 experienced an overall decline in their health after recovery, leaving them vulnerable to other health conditions, and underline the importance of vaccination, which is highly effective at preventing severe COVID-19.

LUNG TRANSPLANTS Prior to the COVID-19 pandemic, about 2,000 lung transplants occurred each year in the US, primarily for patients with lung diseases such as emphysema, cystic fibrosis, and pulmonary fibrosis. But the number of lung transplants for COVID-19 patients is rising quickly, increasing tenfold in the first 2 years of the pandemic, while the overall number of lung transplants is down compared with previous years, according to data from the United Network for Organ Sharing (UNOS). Currently, almost 1 in 10 lung transplants are performed in COVID-19 patients, and nearly 240 people nationwide have received lung transplants due to COVID-19 since August 2020. The rising demand for COVID-related lung transplants is forcing medical professionals to confront the complicated ethical issue of who should get the few available transplants. The American Society of Transplant Surgeons says in a position statement that “‘good medicine’ is to mitigate against known risks, and vaccination is an effective tool that decreases the risk for the transplant candidate and recipient.” In line with this recommendation, some transplant centers have stated outright that patients on waiting lists will lose their spot if they are not vaccinated against COVID-19. Part of this reasoning is because transplant recipients, who need to take immune-suppressing drugs for life, are more vulnerable to acquiring infections, including COVID-19, that could threaten their lives.