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.
Our team is taking a short break for the holidays. We will resume publishing the COVID-19 Situation Report on January 6, 2022.

We would like to thank you, our supporters and colleagues, for helping make our work possible and stronger by utilizing our resources, attending our events, reading our COVID-19 situation reports, and learning alongside us.

We are encouraged by the strength and resilience of our community, and hopeful that a brighter future is ahead. (Read a summary of our 2020 COVID-19 response work and about our work in 2021.)
EPI UPDATE The WHO COVID-19 Dashboard reports 275 million cumulative cases and 5.36 million deaths worldwide as of December 22. Global weekly incidence increased for the ninth consecutive week, up 4.7% from the previous week. Europe’s surge, which is believed to be largely driven by the Omicron variant, appears to be peaking, and the trend in Africa continues to accelerate sharply, setting a new weekly record (90,450 new cases; +55% from the previous week). The overall trends in the Americas and the Western Pacific are increasing as well. Global weekly mortality decreased for the second consecutive week, down 5.2% from the previous week. With 46,554 new deaths, last week's total fell slightly below the average since mid-October, but it is unclear whether this is the beginning of a longer-term trend, particularly in the context of increasing trends in weekly incidence.

Global Vaccination
The WHO reported 8.4 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of December 20. A total of 4.38 billion individuals have received at least 1 dose, and nearly 3.5 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations increased from mid-October (21.3 million doses per day) through mid-December (39.9 million). Daily vaccinations have decreased since December 15, down to 34.5 million, but it is unclear whether this is a result of short-term fluctuations or the start of a longer-term trend.* Our World in Data estimates that there are 4.49 billion vaccinated individuals worldwide (1+ dose; 57.1% of the global population) and 3.77 billion who are fully vaccinated (47.9% 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.

On December 16, the US officially surpassed 800,000 cumulative COVID-19 deaths. The US CDC is currently reporting 51.3 million cumulative cases and 807,397 deaths. The US reported 288,381 new cases on December 20 and 204,913 on December 21, surpassing 200,000 new cases in a single day for the first time since January 18. The December 20 total is the second-highest single-day total since the onset of the pandemic. These 2 reports caused the average daily incidence to jump from 135,911 new cases per day to 161,261, a 19% increase in only 2 days. The current average is the highest since September 5 and only 1.8% below the United States’ second-highest peak in September 2021 (164,241). Daily incidence has increased by a factor of 2.5 since the most recent low on October 24 (64,162), and the trend appears to be accelerating. The sharp increase at the national level is a result of similar trends across states in multiple regions of the country. Analysis by The New York Times indicates that the daily incidence has more than doubled in 7 states—plus Puerto Rico (+1,302%) and Washington, DC (+541%)—over the past 2 weeks, including Florida (+509%) and Hawai’i (+670%) that have increased by a factor of 5 or greater.*

Daily mortality continues to increase steadily, up to 1,223 deaths per day, an increase of more than 20% since before the US Thanksgiving holiday weekend.*

Following a cybersecurity incident, Maryland suspended reporting for COVID-19 data. As of December 20, approximately 2 weeks after the incident, the state reported that 90% of its COVID-19 data have been restored. Maryland’s COVID-19 dashboard is once again available, and it has resumed reporting to the CDC.
*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.

Genomic sequencing data from the CDC show a rapid increase in the prevalence of the Omicron variant across the US. At the national level, the estimated prevalence increased from 0.1% the week of November 27 to 0.7% the week of December 4. In the 2 weeks since then, the prevalence surged to an estimated 73.2% nationwide, replacing Delta as the dominant variant.** Additionally, 8 of the 10 HHS regions are reporting Omicron prevalence greater than 50%, including 5 with greater than 90%: Regions 2 (New York/New Jersey), 4 (Southeast), 5 (Midwest), 6 (South), and 10 (Pacific Northwest).
**US CDC Nowcast projection.

US Vaccination
The US has administered 499 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations peaked on December 6, with 1.71 million doses administered per day. The trend has declined steadily since then, down to 1.36 million doses on December 17—a 20% decrease over that period.* A total of 241 million individuals have received at least 1 vaccine dose, equivalent to 72.8% of the entire US population. Among adults, 85.0% have received at least 1 dose, as well as 22.2 million children under the age of 18. A total of 204.8 million individuals are fully vaccinated**, which corresponds to 61.7% of the total population. Approximately 72.7% of adults are fully vaccinated, as well as 17.2 million children under the age of 18. Since August 13, 63.2 million fully vaccinated individuals have received an additional or booster dose, including 55.8% 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.
**Full original course of the vaccine, not including additional or booster doses.

US OMICRON PREDICTIONS & PLAN Analysis from the University of Washington predicts that a new surge in COVID-19 incidence driven by the Omicron variant could produce nearly 3 million new cases per day in the US during the peak. Similarly, retired US NIH Director Dr. Francis Collins warned that the US could see as many as 1 million new cases per day as Omicron spreads. Some evidence suggests that daily incidence could peak quickly, possibly within the next 4-5 weeks, and that Omicron infections are associated with a lower risk of hospitalization and severe disease when compared to Delta. However, experts warn it is impossible to predict how individual countries’ populations and healthcare systems will be impacted by surges in Omicron cases. Individuals who are unvaccinated and have never been exposed to SARS-CoV-2 may still be at risk of severe disease. A large increase in COVID-19 cases also still runs the risk of overwhelming healthcare systems in the US and abroad. 

On December 21, US President Joe Biden gave a speech on his administration’s plans to respond to Omicron. The plan includes procuring 500 million rapid tests for free shipment to US residents, beginning in January. This represents a pivot for the administration, which recently said people would have to seek reimbursement from their healthcare insurance plans for tests purchased on their own. Experts said the new policy is a step in the right direction but noted that countries such as the UK and Germany have been distributing billions of test kits and recommending citizens check their status twice a week. The US would need to ship 2.3 billion tests monthly to hit this same benchmark. Biden also announced plans to deploy more federal aid to hospitals and testing sites, including military personnel, ventilators from the national stockpile, and more ambulances and teams of paramedics to aid in transporting patients. President Biden called on unvaccinated individuals to fulfill their “patriotic duty” and seek out the shots, encouraged fully vaccinated individuals who are eligible to get a booster, and said those who are vaccinated should go ahead with holiday celebrations with friends and family. Meanwhile, WHO Director-General Dr. Tedros Adhanom Ghebreyesus encouraged people worldwide to cancel their holiday plans, saying, “An event canceled is better than a life canceled.”

US AUTHORIZES ORAL ANTIVIRALS The US FDA this week authorized the use of 2 oral, at-home antiviral therapies for COVID-19, a significant step in treatment of the disease that comes as the number of new cases begins to surge in the US, driven primarily by the Omicron variant of concern (VOC). The agency today authorized the use of the oral antiviral molnupiravir, developed by Merck and Ridgeback Biotherapeutics, for COVID-19 patients aged 18 years and older who have a positive SARS-CoV-2 viral test result, are within 5 days of symptom onset, are at high risk of severe disease or hospitalization, and who cannot access or do not qualify for alternative authorized COVID-19 treatments. Molnupiravir reduced the risk of hospitalization among high-risk patients by 30%, according to clinical trail data, but some experts are concerned over the potential for side effects and the development of drug resistance. The drug is not recommended for use during pregnancy, and men and women of childbearing age are recommended to use birth control, with men suggested to continue using it for 3 months post-administration. Molnupiravir—administered as capsules taken twice a day for 5 days—works by causing errors in the virus’s genetic code, disabling its reproduction capacity but also raising concerns that it could cause mutations in people who take it or lead to new variants. 

On December 22, the FDA authorized the first oral antiviral to treat COVID-19 patients. The emergency use authorization (EUA) is for Pfizer’s Paxlovid—a new antiviral called nirmatrelvir co-packaged with the older antiviral ritonavir—that is taken as tablets twice a day for 5 days. Paxlovid is indicated to treat mild-to-moderate COVID-19 in individuals ages 12 and older weighing at least 40 kg (about 88 pounds) who have a positive SARS-CoV-2 test result and are at high risk of progression to severe disease. Administration of the pills, which are available by prescription only, should be started within 5 days of symptom onset and could be available to patients as early as this weekend, although initial supplies will be limited due to manufacturing constraints. Pfizer’s clinical trial results (not yet peer-reviewed) showed Paxlovid reduced the overall risk of hospitalization by 88% if started within 5 days of symptom onset, and the company’s laboratory studies show the pills should be effective against Omicron. 

The authorizations come as healthcare providers face the realization that 2 of the 3 authorized monoclonal antibody treatments—previously shown to be highly effective at keeping high-risk patients out of the hospital—are not working against Omicron. The European Medicines Agency (EMA) has made recommendations for both Paxlovid and molnupiravir (known as Lagevrio outside of the US) for use in certain COVID-19 patients, paving the way for authorization in Europe. 

CONVALESCENT PLASMA The results of a clinical trial evaluating antibody-rich plasma as an outpatient treatment for people with symptomatic COVID-19 was posted as a preprint to medRxiv on December 21, reopening debate over the use of convalescent plasma therapy. The study, conducted in the US and led by researchers from Johns Hopkins Medicine and the Johns Hopkins Bloomberg School of Public Health, showed outpatient treatment with convalescent plasma, when given within 8 days of symptom onset, reduced the risk of hospitalization by 54% compared with the placebo-control group. The trial primarily used plasma collected before vaccines were widely available and ended prior to the arrival of the Omicron SARS-CoV-2 variant in the US. However, the authors of the study believe that antibody-rich plasma could be an effective treatment against Omicron and other variants if taken from patients who are fully vaccinated and recovered from a breakthrough case of COVID-19. Individuals who fall into this category are believed to have higher levels of neutralizing antibodies than either individuals who are only vaccinated or only recovered from previous infection. 

The study’s data come only a few weeks after the WHO recommended against the use of convalescent plasma to treat COVID-19. The WHO recommendation was made using information from 16 clinical trials with more than 16,000 participants that indicated convalescent plasma does not improve chances of survival or reduce the risk of needing mechanical ventilation. In the US, convalescent plasma is available under a US FDA emergency use authorization (EUA) to treat hospitalized COVID-19 patients early in the course of disease. The authors of the current study hope their results will prompt the WHO and FDA to revisit their guidance, especially because most of the currently authorized monoclonal antibody treatments might prove useless against Omicron and convalescent plasma is relatively easy to produce in low- and middle-income countries. 

VACCINE INEQUITY In 2022, the international community must focus on global vaccine equity in order to end the COVID-19 pandemic. This past year saw vaccination goals fall far short, particularly in low- and middle-income countries (LMICs), in what has been called a “year of vaccine inequity” and a “failure for humanity.” Public health experts warn that the rapid spread of the Omicron variant could cause further setbacks in efforts to end vaccine inequity, leaving large populations unvaccinated and providing circumstances in which SARS-CoV-2 could continue to mutate. Additionally, the effects of these inequities will be felt for decades: 8 out of 10 people pushed into poverty during the pandemic are estimated to live in the poorest nations, and socioeconomic inequalities—such as access to schools and healthcare—will worsen for women and girls. Access to vaccine supplies, capacity to deliver the shots, and vaccine hesitancy all must be addressed in order to improve global vaccination rates. The world has the tools necessary to end the pandemic in 2022, but unless those tools are implemented effectively, including vaccinating the world’s population, the next year will not see the end of the current pandemic and we will remain unprepared for the next pandemic.  

WHO Director-General Dr. Tedros Adhanom Ghebreyesus this week warned that widespread vaccine booster programs could prolong the pandemic, increase inequity, and provide a false sense of security in the face of Omicron. The WHO issued an update to its interim guidance on boosters, saying nations considering booster vaccination policies should consider their strategic and programmatic priorities; data on the performance of booster doses; how targeted booster dose administration could prevent healthcare system strain; and importantly, how booster programs impact globally limited vaccine supplies. Notably, Israel this week became the first country to begin rolling out a fourth dose of SARS-CoV-2 vaccine to certain populations, including adults ages 60 and older, medical workers, and people with compromised immune systems. Other nations might be considering similar policies on boosters. In the US, a group of more than 80 Democratic lawmakers has requested at least US$17 billion be included in the fiscal year 2022 appropriations omnibus to support global vaccination, testing, and treatment of COVID-19. In a US House of Representatives select subcommittee hearing on December 14, experts warned that continued inequity in vaccine access will continue to threaten the global population, including in the US, and prolong social and economic recovery.  

US LIFE EXPECTANCY Life expectancy for the US population in 2020 dropped 1.8 years over 2019—down to 77 years in 2020 from 78.8 years in 2019—the largest single-year reduction in more than 75 years, according to new data from the US CDC’s National Center for Health Statistics (NCHS). The top 10 causes of death in 2020 were heart disease, cancer, COVID-19, unintentional injuries (including drug overdose), stroke, chronic lower respiratory diseases, Alzheimer’s disease, diabetes, influenza and pneumonia, and kidney disease. The drop in life expectancy was driven by increases in mortality due to COVID-19, unintentional injuries, heart disease, homicide, and diabetes. Of the 10 leading causes of death in 2020—which accounted for 74.1% of all deaths in the US in 2020—9 remained the same as in 2019, although 5 causes switched rank. Heart disease and cancer remained the top 2 leading causes. COVID-19 debuted in the ranking list in 2020, becoming the third leading cause of death and pushing suicide off the list. This is the first time a novel disease has entered the top 10 causes of death so quickly, and many feel much of the elevated death rate in 2020 is attributable directly or indirectly to COVID-19, as people might have had underlying conditions worsened by COVID-19, had limited access to health care, or feared accessing emergency or maintenance care.

In total, more than half a million more US resident deaths were recorded in 2020 than in 2019, and COVID-19 was the underlying cause of death for 350,831 people, representing 10.4% of the total number of deaths in 2020. The decrease in life expectancy was larger for men—2.1 years, from 76.3 years in 2019 to 74.2 years in 2020—than for women—1.5 years, from 81.4 in 2019 to 79.9 in 2020. Notably, age-adjusted death rate increases from 2019 to 2020 were highest among racial and ethnic minorities, reflecting an increased risk of death from COVID-19. The greatest increases in death rate were seen among Hispanic males (42.7%), Hispanic females (32.4%), non-Hispanic Black males (28.0%), and non-Hispanic Black females (24.9%), compared with non-Hispanic White males (13.4%) and non-Hispanic White females (12.1%). Death rates for non-Hispanic Black males were highest in 2020—1,399 deaths per 100,000 people—and lowest among Hispanic females—570 per 100,000. On a positive note, the infant mortality rate (IMR) decreased 2.9% from 558.3 infant deaths per 100,000 live births in 2019 to reach a record low of 541.9 in 2020.

US SPORTS As daily COVID-19 incidence and the prevalence of the Omicron variant surge in the US, professional and collegiate sports have been forced to rapidly adapt their COVID-19 protocols and mitigation plans.  

National Hockey League: The NHL postponed a number of games already this season due to COVID-19 outbreaks on affected teams. But this week, the league suspended all games and team activities through Saturday, December 25, starting the scheduled Christmas break 2 days early. Including the games during this period, the NHL has postponed 50 games since the season began on October 12. Notably, more than 15% of all NHL players are currently under the league’s COVID-19 protocols. The NHL and the NHL Players Association also announced that NHL players will not be participating in the 2022 Winter Olympic Games in Beijing, China, due to the disruptions to the NHL schedule. The NHL is expected to reschedule postponed games during that period.

National Football League: At the start of the season, the NFL (American football) announced that it would not reschedule games due to COVID-19, but last week, it reversed its position due to more than 150 players and coaching staff testing positive across multiple teams. The league rescheduled 3 games last week, moving an extra game to Monday and 2 games to Tuesday. In response to increasing positive tests, the NFL updated its COVID-19 protocols in an effort to allow players to return sooner after a positive test. Following a number of asymptomatic or mild cases among NFL players, including those infected with the Omicron variant, the NFL shifted from weekly testing for vaccinated players to “a random cadence” or if a player develops symptoms. Less frequent testing will allow more players to be available, but it will likely miss some asymptomatic infections, including individuals who could be infectious. Additionally, vaccinated, asymptomatic players may be able to return to practice and games sooner under the new protocol.

National Basketball Association: While the NHL and NFL are updating their COVID-19 protocols and adjusting the league schedule, the NBA reportedly intends to continue with its season. While some NBA games have been postponed, NBA Commissioner Adam Silver indicated that there are no plans to suspend the season. Additionally, the NBA currently does not have any plans to update its COVID-19 protocols to allow players to return sooner after a positive test. The NBA suspended 7 games over the past week alone, and more than 90 players are under the league’s COVID-19 protocols. Commissioner Silver commented that approximately 90% of new cases are a result of the Omicron variant.

College Football: As the NCAA looks ahead to the College Football Playoff (CFP), it announced that the National Championship could be decided by forfeit if teams are unable to compete due to COVID-19. If teams are unable to play in the CFP semifinals, there is no opportunity to reschedule the game. That team would be forced to forfeit, and their opponent would move on to the championship game, and if neither team is able to play, the winner of the other semifinal game would automatically be declared the National Champion. If teams in the championship game are unable to play, that game could be moved from January 10 to as late as January 14. If the game cannot be held by then, a team that cannot play would forfeit and its opponent would be declared the National Champion. If neither team can play, then the National Championship will be vacated for this season. In preparation for the CFP, several of the competing teams have implemented additional protective measures to reduce the risk of COVID-19 impacting the coaches and players. The University of Alabama has reportedly reinstated its original COVID-19 protocols, including mask use and physical distancing at team facilities. Similarly, the University of Michigan restored masking and physical distancing as well as grab-and-go meals, and the players reportedly received booster doses of the SARS-CoV-2 vaccine as a team on December 22.