Updates on the COVID-19 pandemic from the Johns Hopkins Center for Health Security.

Additional resources are available on our website.
The Johns Hopkins Center for Health Security also produces US Travel Industry and Retail Supply Chain Updates that provide a summary of major issues and events impacting the US travel industry and retail supply chain. You can access them here.
In light of the upcoming holidays, we will be altering the schedule for our COVID-19 updates over the next several weeks:

Friday, December 25: No briefing
Tuesday, December 29: 12-month review
Friday, January 1: No briefing
Tuesday, January 5: Normal briefing

We hope you, your friends, and your family have a safe and healthy holiday season.
EPI UPDATE The WHO COVID-19 Dashboard reports 76.25 million cases and 1.70 million deaths as of 10:15am EST on December 22. The WHO again reported a new record for global weekly incidence with 4.59 million cases last week, an increase of more than 5% from the previous week. The global cumulative incidence surpassed 75 million cases on December 20, and it could reach 80 million in the next 5-6 days. The WHO also reported a new record for weekly mortality. Last week’s 78,611 deaths surpassed the previous week by more than 3.5%.

This week we get the opportunity to start monitoring vaccination progress. Our World in Data has started compiling reports of SARS-CoV-2 vaccination from countries that have initiated their vaccination campaigns. Currently, there is no official comprehensive or aggregated source for national-level vaccination data, so the data presented here are drawn from individual national reports and announcements. To date, this site includes quantitative data from Canada, China, Israel, Russia, the UK, and the US. It notes that other countries have initiated vaccination, and they will be added as soon as reports can be verified.

To date, the UK leads globally in terms of doses per capita, with 0.74 doses per 100 population. The remaining countries, in order, are the US (0.17), Russia (0.14), Israel (0.12), China (0.07), and Canada (0.05). In terms of total vaccination, China is #1, with 1 million doses administered, followed by the US (556,208), the UK (500,000), Russia (200,000), Canada (17,633), and Israel (10,000). Our World in Data also displays vaccination policies by country, mapping countries by what proportion of their population is eligible for vaccination: nobody/none, 1 or 2 vulnerable groups, all vulnerable groups, vulnerable groups and others, and universal. At this time, only 4 countries are included in this dataset: United Arab Emirates (vulnerable populations and some others), the UK (all vulnerable groups), Canada (2 vulnerable groups), and the US (1 vulnerable group).

The US CDC added a vaccination tab to its COVID-19 data tracker. Currently, the tab shows only national totals for doses distributed and administered, as opposed to state-level data. The CDC reports more than 4.6 million doses have been distributed nationwide and 614,117 doses have been administered. Additionally, the Johns Hopkins Coronavirus Resource Center has added a vaccine tracker, which will provide updates from US states as they report vaccination data. Currently, the tracker includes data from 23 states.

The US CDC reported 17.79 million total cases and 316,844 deaths. On December 18, the US reported 403,359 new cases, far exceeding the previous single-day record; however, this included 171,505 previously unreported probable cases in Texas. Without this addition of historical cases, the US would have reported 231,854 new cases on that day, which would have been the third highest single-day total to date. Texas jumped from 1.37 million cumulative cases on December 17 to 1.56 million on December 18.

The US is currently averaging 239,604 new cases per day, but this is inflated due to the data from December 18. We expect that the actual average is closer to 215,000. Following the US Thanksgiving holiday weekend, COVID-19 reporting recovered from holiday delays and resumed its previous trend. It appears as though the US is reaching a peak or plateau in terms of daily incidence. The US reported its highest daily incidence to date on December 17, with 216,159 new cases per day. Omitting the probable cases reported by Texas, the expected daily incidence fell slightly December 18 and 19 before increasing again yesterday to 215,104.

The US is averaging more than 2,600 deaths per day. While this is still the highest mortality since April 20-21*, it does appear that the US is approaching or has passed an inflection point in terms of COVID-19 mortality. Daily mortality was increasing exponentially leading up to Thanksgiving, and it appears to be increasing approximately linearly since then. This could be a sign that US mortality is starting to taper off; however, if incidence increases again as a result of holiday travel and gatherings, we would expect mortality to increase again as well. As we have observed throughout the pandemic, COVID-19 mortality tends to lag 3-4 weeks behind incidence, so it could be mid-late January before such a trend becomes evident. Even if there is no effect from Thanksgiving, it would likely be 3-4 more weeks before mortality peaks.
*Which closely followed the April 15 report by New York City, which included more than 3,700 previously unreported probable deaths from the onset of its epidemic.

It could be difficult to track national-level epidemiological trends in the US over the coming weeks. Between Texas’ probable cases reported over the weekend, expected reporting delays over the Christmas and New Year’s holidays, and potential effects of holiday travel and gatherings over the coming weeks, it could potentially be mid-January or later before we have a clear picture of US COVID-19 trends.

The Johns Hopkins CSSE dashboard reported 18.06 million US cases and 319,827 deaths as of 10:30am EST on December 22.

US FDA AUTHORIZES MODERNA VACCINE On Friday, the US FDA issued an Emergency Use Authorization (EUA) for Moderna’s SARS-CoV-2 vaccine, the second vaccine authorized for use in the US. This development follows positive findings from FDA’s analysis as well as unanimous recommendation from the Vaccines and Related Biological Products Advisory Committee (with one abstention). The vaccine is authorized for use for adults aged 18 years or older and will be administered in 2 doses spaced one month apart. The Moderna vaccine demonstrated nearly 95% efficacy in Phase 3 clinical trials, on par with the Pfizer/BionNTech vaccine that received an EUA the previous week. Moderna is currently prepared to deliver enough doses to vaccinate 10 million individuals by the end of December. While this additional supply is exciting in and of itself, officials arranging for vaccine distribution are also no doubt relieved that the Moderna vaccine does not require the same extremely cold storage conditions that are needed for the Pfizer vaccine. 

EU AUTHORIZES PFIZER VACCINE On Monday, the European Commission issued a conditional marketing authorization for the Pfizer/BioNTech SARS-CoV-2 vaccine, based in part on the recommendation of the European Medicines Agency. The vaccine is authorized for individuals aged 16 years and older. This authorization will allow for use of the vaccine within the 27 EU member states, and the first vaccines are expected to be administered on December 27. The EMA published information on its safety monitoring program, which will be implemented as vaccination efforts commence. In addition to EU countries, Switzerland’s Swissmedic also authorized the use of the Pfizer/BioNTech vaccine. The European Commission President assured the public that the vaccine will be available in all member states at once. The EU has already secured 200 million doses from Pfizer, which are scheduled to be delivered by September 2021, and it is working to purchase an additional 100 million doses.

UK SARS-CoV-2 VARIANT A new SARS-CoV-2 variant has come to prominence in the UK, and there are concerns that it has increased transmissibility compared to other variants. The new variant was originally labeled as VUI-202012/01—variant under investigation; the first VUI in December 2020— and subsequently updated to VOC-202012/01—variant of concern. Other analysis labels the variant B.1.1.7. The variant is characterized by at least 17 specific mutations, including 8 for the spike protein, which attaches to the ACE2 receptor and allows the virus to enter cells. Preliminary research indicates that the change could make the virus more transmissible. UK researchers identified the mutations in specimens from as far back as September based on analysis of genetic sequencing data, and the variant “circulated at very low levels...until mid-November.” UK health officials began investigating the new variant in November, after increasing social distancing restrictions were not having the intended effect in Kent County in southeast England. Health officials subsequently identified widespread community transmission of the variant in nearby London and Essex County.

UK officials, including Prime Minister Johnson and Secretary of State for Health and Social Care Matt Hancock as well as officials from Public Health England and researchers from Imperial College London, indicate that the new variant could be substantially more transmissible. Notably, Dr. Susan Hopkins from Public Health England indicated that the new variant could potentially be 70% more transmissible, and Prime Minister Johnson noted that it could increase the reproductive number (R) by as much as 0.4. At this time, there is an absence of evidence that the strain results in more severe disease. Preliminary assessments suggest that the Pfizer/BioNTech vaccine will still be effective against the variant, but additional research is ongoing. The UK has issued guidance to laboratories to enable them to update existing PCR-based diagnostic tests to ensure that tests can effectively detect infection with the new variant.

Researchers from the COVID-19 Genomics Consortium UK (CoG-UK) published (preprint) preliminary analysis of the variant’s genome. The researchers note that this variant exhibits a large number of mutations that appeared over a very short period of time. They theorize that the variant could have, in part, evolved in a chronically infected patient; however, it is not possible to determine the exact cause at this point. Additionally, the UK government published its own investigation of the variant, conducted by Public Health England (PHE). PHE analysis indicates, among other findings, that the variant has increased in prevalence since at least the week of October 12. Dr. Chris Witty, England’s Chief Medical Officer, estimated that the variant is responsible for 60% of recent infections in London.

This is not the first SARS-CoV-2 variant to gain widespread attention, particularly in the context of transmissibility. As we covered previously, the D614G spike protein mutation was found to have spread more efficiently in Europe and the US, and researchers determined that the mutation enabled the virus to spread more rapidly in nasal epithelial cells and the upper respiratory tract, which could make that variant more transmissible.

VARIANT, POLICY RESPONSE In response to increasing daily incidence, UK Prime Minister Boris Johnson announced that COVID-19 restrictions would increase to Tier 4 for much of Southeast England, including London and numerous surrounding cities and counties. The enhanced restrictions prohibit households from mixing over the Christmas holiday and prohibit individuals from traveling to or from Tier 4 areas. Individuals and families in parts of the country currently in Tiers 1-3 will still be permitted to form “Christmas bubbles,” but only for December 25, Christmas Day. Previous iterations of the Christmas bubble guidance permitted the bubbles from December 23-27. In addition to restrictions on gatherings, Tier 4 will require all non-essential businesses to close. The UK also issued guidance for “clinically extremely vulnerable” individuals in Tier 4 areas, including individuals with compromised immune systems or those with severe respiratory conditions, which recommends remaining at home except for exercise and attending medical appointments.

In addition to increased restrictions in England, numerous European countries have instituted travel restrictions for the UK, interrupting air, rail, automobile, and maritime travel between the UK and mainland Europe. In total, more than 40 countries—including many in Europe as well as Canada and India—have cancelled air travel from the UK. Reportedly, France prohibited all travel from the UK for a period of 48 hours, including freight, in order to provide time to develop appropriate measures to ensure safe transit of passengers and goods to and from the UK.

In the US, New York Governor Andrew Cuomo coordinated with 3 airlines that offer flights between the UK and New York City in order to implement mandatory testing for passengers before departing. Governor Cuomo called on the US government to strengthen restrictions for travelers arriving from the UK in response to the emerging variant. Dr. Anthony Fauci argued that travel restrictions are not necessary at this time, and Admiral Brett Giroir, the Trump administration's “testing czar,” indicated that the US government, including the CDC, is monitoring the situation closely and evaluating potential response options. Other experts suggest that the UK’s high volume of sequencing simply enabled it to identify the variant earlier than other countries and that the variant is likely already more widespread globally than currently evident. A similar set of mutations is reportedly emerging in South Africa, which has been identified in nearly 90% of sequenced specimens in South Africa since mid-November.

US VACCINATION PRIORITY GROUPS On Sunday, the US CDC’s Advisory Committee on Immunization Practices (ACIP) debated and voted on vaccine priority groups for Phases 1b and 1c, following the initiation of vaccination for healthcare workers and long-term care facility residents in Phase 1a. ACIP recommended that Phase 1b include adults aged 75 years and older as well as frontline essential workers. Frontline essential workers were defined as “first responders, teachers and other education workers including day care workers, food and agriculture workers, correctional facility staff, postal workers, public transit workers, and people who work in manufacturing and in grocery stores”who have direct contact with the public as part of their job. Some essential workers who are able to work remotely or do not interact with the public may not be eligible under this designation. ACIP recommended that Phase 1c include adults aged 65-74 as well as individuals aged 16-64 who have high-risk medical conditions.

The priority populations included in Phases 1b and 1c attempt to balance the committee’s goals of protecting both those who are most at risk of severe outcomes from COVID-19 disease and those who have the highest risk of exposure in their essential work environment. The decision to designate adults aged 65-74 as lower priority as adults aged 75 and older has drawn criticism, in light of analysis showing that the 65-74 age group has similar risk of severe disease and death as adults aged 75 and older. In total, 202 million Americans could be included in the 3 tiers of Phase 1: 24 million in Phase 1a, 49 million in Phase 1b, and 129 million in Phase 1c.

US CDC Director Dr. Robert Redfield must review and approve the ACIP recommendations before they will become official CDC guidance. State governments may draw on that guidance, but will be responsible for establishing protocols for their own vaccination efforts. Additionally, as vaccination campaigns move forward nationwide, it is likely that Phases and tiers will overlap chronologically, rather than one Phase reaching completion before beginning the next Phase, and it is possible that states will progress through the tiers at different speeds, which could pose operational, logistical, and communication challenges. 

CALIFORNIA HOSPITAL CAPACITY In California, hospitals are beginning to exceed their capacity, with no signs of slowing incidence or hospitalization rates. Reports show that ICU capacity is at 0% in the Southern California region. Analysis published by The Los Angeles Times found that intensive care unit (ICU) capacity across 11 counties in Southern California, including Los Angeles and San Diego, fell to 0% on December 17. California continues to set new records in terms of COVID-19 incidence, averaging approximately 45,000 new cases per day and reporting 62,661 new cases on Monday.

When faced with shortages of ICU capacity, hospitals are forced to implement surge plans to increase the number of available beds. This can involve converting other beds to support ICU patients, transferring patients to other facilities, or using ICU-trained personnel from other parts of the hospital. But when every hospital is facing the same challenge, it is difficult to expand capacity enough to meet demand. St. Mary Medical Center, a hospital in Apple Valley, is currently caring for patients at double its capacity, including placing patients in hallways and parking lot triage tents. Normally, the hospital would send overflow patients to another hospital with more capacity, but no nearby hospitals have excess capacity to handle transferred patients.

In order to combat the increasing hospitalizations and preserve hospital function, California Governor Gavin Newsom extended “stay at home” orders and ordered other enhanced social distancing measures. Approximately 98% of California’s population is currently under a 3-week “stay at home” order, which covers the entire state with the exception of the Northern California region. The California government has used ICU capacity below 15% as a metric to signal the need to impose “stay at home” orders. While many areas of California currently meet this definition, some areas of northern California are above 15% ICU capacity and therefore have been subject to more lenient policies.

CDC DATA REPORTING Last Friday, the Department of Health and Human Services (HHS) unveiled the COVID-19 Community Profile Report, which shows the history of various key indicators at the local, state, and regional level. The report format highlights week-by-week changes, visualizations of meaningful data trends, and additional contextual information specific to the geographic area of interest. One notable benefit is standardizing state-level reporting across the country. States report data in different ways, which can make it challenging to compare states directly, and the COVID-19 Community Profile Report presents data that have been harmonized across all states to facilitate analysis. The data are aggregated, as opposed to broken down by demographics. The report is generated and updated daily by the Data Strategy and Execution Workgroup under the supervision of the White House COVID-19 Task Force, and the data are managed by an interagency team with members from CDC, HHS, the Assistant Secretary for Preparedness and Response, and the Indian Health Service.

LONG-TERM HEALTH EFFECTS Since the early months of the pandemic, evidence has steadily emerged about long-term COVID-19 symptoms and syndromes following recovery from acute infection. According to the UK’s Office for National Statistics, 1 in 5 COVID-19 patients experience symptoms for longer than 5 weeks after the initial recovery, and 1 in 10 experience symptoms for longer than 12 weeks. Now commonly referred to as “long COVID,” long-term COVID-19 effects can manifest in a variety of ways, including organ inflammation or damage, new-onset diabetes or thyroid conditions, and cardiac conditions. Even young, previously healthy patients have experienced severe “long COVID” symptoms, such as heart failure and severe organ damage. Some doctors are recommending that athletes who had moderate-to-severe COVID-19 be screened for heart conditions before returning to exercise as a precaution. The existing medical literature and guidance for “long COVID” patients is expanding, but more work needs to be done to better educate COVID-19 survivors and physicians in order to more quickly and accurately recognize and respond to potentially severe “long COVID” manifestations. 

US ECONOMIC STIMULUS US legislators reached an agreement on a new round of COVID-19 economic stimulus funding. The bill, passed yesterday by both the House of Representatives and the Senate, totals nearly US$900 billion, including funding for expanded unemployment benefits (US$300 per week), US$600 direct payments to most individuals, US$284 billion in Paycheck Protection Program support for small businesses, US$25 billion for rental assistance and an extended moratorium on evictions, and US$82 billion to support schools and colleges. Several high-profile priorities for Democrats and Republicans were omitted from the COVID-19 funding package, including support for state and local governments, suspension of student loan payments, and liability protections for businesses. The COVID-19 economic stimulus funding is tied to a larger US government funding bill that US President Donald Trump is expected to sign in the coming days. 

ANTARCTICA COVID-19 cases have now been reported on every continent on Earth. Reportedly, 36 individuals tested positive for SARS-CoV-2 at a Chilean research facility in Antarctica, likely among the most remote and isolated places on the planet. The individuals have been evacuated to Punta Arenas, Chile, for treatment and isolation. An additional 3 cases have been reported among the crew of a support ship, all of whom tested negative prior to getting underway en route to Antarctica. According to a tweet by The Antarctica Report, personnel at the base recently conducted their annual rotation, which could have provided an opportunity to import the virus. Notably, there were no known cases in Antarctica during the 1918 influenza pandemic.