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 The Johns Hopkins Center for Health Security and the Nuclear Threat Initiative on December 8 released 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. ​​According to the report, all countries remain dangerously unprepared for future epidemic and pandemic threats, including threats potentially more devastating than COVID-19. Read the report’s findings and recommendations, explore the data, view the country rankings, and learn more about the GHS Index.
EPI UPDATE The WHO COVID-19 Dashboard reports 267 million cumulative cases and 5.3 million deaths worldwide as of December 8. Global weekly incidence increased for the seventh consecutive week, up 4.6% from the previous week. At 4.2 million new cases, last week was 74% of the highest weekly total (April 2021). Europe accounts for the vast majority of the increase, and it continues to set new weekly records. Last week, European countries reported 2.80 million new cases, which is more than double the previous record (November 2020). Weekly incidence in Africa has more than tripled over the past 2 weeks, up from 22,632 new cases the week of November 15 to 79,491 new cases last week. Global weekly mortality has held relatively steady at approximately 50,000 deaths per week since late October.

Global Vaccination
The WHO reported 7.95 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of December 6. A total of 4.28 billion individuals have received at least 1 dose, and 3.38 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations has increased steadily since mid-October, up from 21.3 million doses per week to 37.8 million on December 4.* Our World in Data estimates that there are 4.36 billion vaccinated individuals worldwide (1+ dose; 55.4% of the global population) and 3.55 billion who are fully vaccinated (45.1% of the global population).

Our World in Data now provides 6-month, 9-month, and 12-month rolling windows for doses administered, which provides a smoother long-term perspective on vaccination efforts. Looking at the 6-month trends, North America peaked in August, and Europe peaked in September. The global trend as well as Oceania and South America appear to be reaching their highest peaks. And Africa’s trend continues to increase steadily, although at a much slower rate than the other continents.
*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 49.3 million cumulative COVID-19 cases and 788,903 deaths. Daily incidence has increased steadily since the most recent low on October 24, up from 64,151 new cases per day to 117,488 on December 7—+83% over that period. Daily mortality is currently 1,097 deaths per day, which is higher than the average prior to the US Thanksgiving holiday weekend.*

At the current pace, the US could surpass 800,000 cumulative deaths in the next 11 days and 2.5 deaths per 1,000 population—or 1 death per 400 population—in the next month. The US is #19 globally in terms of per capita cumulative mortality. Daily incidence began to increase in the last week of October, so we expect to see an associated increase in daily mortality starting around the week of Thanksgiving—which could shorten those timelines. The CDC’s daily COVID-19 data appear to have largely recovered from reporting delays due to Thanksgiving, but it could still be another week or so before we have a clearer picture of the longer-term trends.
*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 476 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations have increased steadily since early July, up from 446,000 doses per day to 1.5 million on December 3, which is higher than the average prior to the Thanksgiving holiday weekend. There was a substantial decline in reported vaccinations over Thanksgiving, but it is unclear to what extent this was a result of an actual decrease in vaccinations (eg, due to clinic closures) compared to reporting delays. It will likely be another week or so before we have a clearer picture of the longer-term trends in daily vaccinations.*

There are 237 million individuals who have received at least 1 vaccine dose, equivalent to 71.4% of the entire US population. Among adults, 83.8% have received at least 1 dose, as well as 20.7 million children under the age of 18. A total of 200 million individuals are fully vaccinated**, which corresponds to 60.4% of the total population. Approximately 71.8% of adults are fully vaccinated, as well as 15.0 million children under the age of 18. Since August 13, 48.9 million fully vaccinated individuals have received an additional or booster dose, including 48.6% 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.

VACCINE EFFICACY AGAINST OMICRON Having only been on the global radar since late November, early analysis around the world regarding the Omicron variant of concern (VOC) is providing insight into its characteristics and risks. Some preliminary laboratory analyses suggest that the Omicron variant could exhibit some resistance to SARS-CoV-2 vaccines. One study conducted by researchers in Germany (preprint) found that blood serum collected from fully vaccinated individuals had reduced efficacy in neutralizing the Omicron variant. The researchers tested sera from a variety of vaccinated patients, including those who received the Moderna, Pfizer-BioNTech, and AstraZeneca-Oxford vaccines, including some with heterologous combinations and some who received booster doses. The researchers observed reductions in neutralizing capacity on the order of 10-30 times, compared to the Delta variant. Additionally, sera from participants who received a heterologous combination of the AstraZeneca-Oxford and Pfizer-BioNTech vaccines exhibited “no efficacy against Omicron.” Preliminary findings from studies conducted by researchers in South Africa and Sweden (both preprint) are similar.

Pfizer-BioNTech announced (via press release) preliminary findings from their study on efficacy against the Omicron variant. This study identified sufficient neutralizing antibody titers among individuals who received 3 doses of the Pfizer-BioNTech vaccine, but there was a 25-fold reduction in neutralizing capacity for individuals who received only 2 doses of the Pfizer-BioNTech vaccine. Notably, these findings are based on the volume of neutralizing antibodies against the Omicron variant present in the sera, and not a direct assessment of efficacy against the variant.

These studies provide initial insight into the efficacy of existing SARS-CoV-2 vaccines against the emerging Omicron variant, but we currently only have data from small, in vitro laboratory studies on which to base these analyses. The in vivo immune response varies widely, and it is unclear exactly how the current vaccines will function among the broader public or to what degree booster doses are necessary to provide sufficient protection. Current evidence suggests that existing vaccines may be less effective against the Omicron variant, but some experts indicate that fully vaccinated individuals would likely maintain some protection against severe disease. Larger studies among vaccinated individuals are necessary to gain the necessary insight.

In a likely effort to help control the Omicron variant, the US FDA today expanded its authorization for booster doses of the Pfizer-BioNTech vaccine to 16- and 17-year-olds, available 6 months after their initial 2-dose series. The CDC is expected to make formal recommendations soon, possibly today. Additionally, the WHO today recommended that only people who are immunocompromised or who received an inactivated SARS-CoV-2 vaccine receive a third vaccine dose after a primary 2-dose series. The WHO is not yet recommending third or booster doses for all vaccine recipients in order to promote equity in the global distribution of vaccines.

Dr. Mike Ryan, Director of the WHO’s Health Emergencies Programme, addressed speculation that the Omicron variant results in milder disease. He emphasized that while viruses tend to evolve to become more transmissible, the idea that a more transmissible virus results in milder symptoms is “an urban legend.” Even if the Omicron variant causes milder disease, increased transmission can put additional pressure on health systems. In addition to more patients with mild disease seeking care, milder disease that goes untreated can progress to more severe symptoms, and increased transmission can facilitate further mutations to the virus. 

“STEALTH” OMICRON Scientists have identified a version of the SARS-CoV-2 Omicron (B.1.1.529) variant of concern (VOC) that cannot be distinguished from other variants using certain PCR tests that many public health officials use to quickly identify probable cases. The so-called “stealth” variant has many of the same genetic mutations as the originally identified Omicron VOC, but it lacks a certain deletion on the spike protein making it undetectable as the original Omicron lineage. Researchers have expanded the breadth of the B.1.1.529 lineage, creating 2 sub-lineages: BA.1 for the original VOC and BA.2 for the new outlier lineage. All of the usual tests are still effective at identifying the new lineage as SARS-CoV-2, but the new form of Omicron will make it more difficult to track Omicron infections because they need to be sequenced in genomic testing that takes a longer time to process. The US FDA updated its information on which molecular tests could be impacted by various mutations in the Omicron VOC. The new sub-lineage could vary from the original in transmission or disease severity, although it is too soon to say whether or if it behaves differently.

ENGLAND ENTERS “PLAN B” On December 8, England enacted its COVID-19 “Plan B” contingency plan, with British Prime Minister Boris Johnson stressing that the new restrictions “do not amount to a lockdown” ahead of the busy Christmas season. Under the plan, people are required to work from home when possible, wear masks in public places, and show vaccine passports or proof of a negative lateral flow test in order to enter certain venues such as nightclubs and theaters. Additionally, people who have come in contact with an infected person will be allowed to take daily tests instead of isolating. Prime Minister Johnson said moving into Plan B—which was intended to be used only if new COVID-19 case numbers increased to an extent that could burden the health system—was necessary in response to the variant of concern (VOC) Omicron. Some scientists estimate the number of new Omicron cases is doubling every 2-3 days and predict the VOC will likely overtake the Delta variant in the next 2-4 weeks. Scotland also announced a return to working from home, and Scotland, Northern Ireland, and Wales all have similar vaccine passport requirements and mask mandates either in place or planned. The UK recorded a 7-day average of 47,827 new COVID-19 cases on December 7, surpassing its most recent high of 47,115 on October 22 as well as the previous peak reached in July. The UK has found 568 Omicron cases as of December 8, but the UK Health Security Agency estimates the number to be closer to 10,000.

US VACCINATION REQUIREMENTS A US judge on December 7 issued a nationwide preliminary injunction against the Biden administration’s SARS-CoV-2 vaccine mandate for employees of federal contractors. Judge R. Stan Baker of the US District Court for the Southern District of Georgia concluded that US President Joe Biden likely overstepped his authority under the Procurement Act in issuing the mandate and that the rule could “have vast economic and political significance.” The vaccine-or-test mandate already was on hold for contractors and subcontractors in Kentucky, Ohio, and Tennessee after a separate preliminary injunction was issued last week. Notably, it does not appear that the injunction applies to other aspects of the COVID-19 safety rules for contractors, including those related to masking and social distancing. The White House said the US Department of Justice plans to “vigorously defend” the vaccine requirement. With the issuance of this preliminary injunction, all 3 of the Biden administration’s vaccine requirements affecting the private sector—one for federal contractors, another for healthcare workers, and one for companies with more than 100 employees—are now on hold nationwide. It is likely that 1 or more of the various cases challenging federal vaccine rules will reach the US Supreme Court. To date, the vaccine mandate for federal employees has not been enjoined.

In a move that is largely seen as symbolic, the US Senate late on December 8 voted to overturn the proposed rule requiring large companies to mandate their employees be vaccinated, undergo weekly testing, or risk losing their jobs. The vote was 52-48, with 2 Democrats voting for the measure to overturn the regulation. The US House is not expected to pass the resolution, but if it did, President Biden has indicated he would veto

WHO ON CONVALESCENT PLASMA The WHO on December 6 issued a strong recommendation against using convalescent plasma to treat people with non-severe COVID-19 and a recommendation against its use in people with severe and critical illness, saying the therapy shows no improvement in survival nor a reduction in the need for mechanical ventilation. Additionally, the WHO said convalescent plasma therapy is expensive and time-consuming to administer. The agency did say the treatment could continue to be used in severe and critical patients who are participants of a randomized controlled trial (RCT). The recommendations are based on the outcomes of 16 clinical trials involving more than 16,000 COVID-19 patients and are part of the WHO’s living guideline on drugs for the disease. The WHO’s updated recommendations contradict a US FDA revision to the emergency use authorization (EUA) of convalescent plasma therapy issued earlier this year, which limits the authorization to the use of high-titer COVID-19 convalescent plasma for the treatment of hospitalized patients early in the disease course and hospitalized patients who have impaired antibody responses. 

EVUSHELD EUA The US FDA on December 8 issued an emergency use authorization (EUA) for AstraZeneca’s long-acting monoclonal antibodies tixagevimab and cilgavimab—which are co-packaged and administered together under the brand name Evusheld—for the prevention of COVID-19 in certain adults and youth aged 12 years and older weighing at least 88 pounds who have moderate to severe immune system compromise or for whom a SARS-CoV-2 vaccine is contraindicated. Individuals also must not have active SARS-CoV-2 infection or have had a recent exposure. The long-acting antibody therapy—the first authorized to prevent COVID-19 prior to an exposure—is administered as 2 separate but immediately consecutive intramuscular injections and may be effective as pre-exposure prophylaxis for up to 6 months. While the authorization provides an alternative prevention method for certain individuals, vaccination remains the best defense available to prevent SARS-CoV-2 infection, severe disease, hospitalization, or death.

LONG COVID Researchers worldwide continue to learn more about the constellation of long-lasting COVID-19-related symptoms known formally as post-acute sequelae of COVID-19 (PASC) and more commonly as long COVID. A retrospective, observational analysis of data collected from patients of the Mount Sinai Health System in New York (US) found the most common symptoms of long COVID among a group of 156 unvaccinated individuals to be fatigue, cognitive impairment or “brain fog,” headache, sleep disturbance, and dizziness, with many reporting continuing symptoms nearly 1 year after their initial diagnosis. Some people report a long-lasting loss or distortion of their sense of smell, anosmia or parosmia, respectively. One preprint study examined the experiences of some people with long COVID who have protracted internal vibration, pain, and tremors, which could have mental health implications if left untreated, the researchers warned. Many long COVID patients complain of shortness of breath, and a study published online November 29 in the Journal of the American College of Cardiology: Heart Failure suggests that cardiopulmonary exercise testing (CPET) could uncover respiratory and circulatory abnormalities that are undetectable on normal chest imaging and pulmonary function tests. The most serious circulatory impairment complications have led to some patients to undergo amputations of their extremities. Many questions regarding long COVID still remain, including how to properly diagnose the condition, how vaccines might impact long-term symptoms, and how to properly treat and rehab patients. The condition also has implications for the workforce, with the Mount Sinai analysis showing a significant proportion of patients did not return to full-time work after their COVID-19 diagnosis and a preprint analysis from South Africa cautioning that long COVID among frontline healthcare workers could impact health service delivery.