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

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EPI UPDATE The WHO COVID-19 Dashboard reports 109.59 million cases and 2.42 million deaths as of 10:00am EST on February 19.

As countries continue to scale up vaccination efforts, many are beginning to report data for both partially and fully vaccinated individuals. As we have covered previously, Israel is leading the world in terms of SARS-CoV-2 vaccination, with 48.8% of its population receiving at least 1 dose of the vaccine. Seychelles is #2, with 42.6%, followed by the UK countries—Wales (26.1%), Scotland (24.8%), England (24.6%), and Northern Ireland (22.6%). Bahrain (15.5%), the US (12.3%), and Chile (12.1%) are the only other countries reporting higher than 10% coverage with at least 1 dose. In total, 50 total countries are reporting 1-dose coverage greater than 1%. Of those countries that have commenced vaccinations, 51 are reporting the number of individuals who have been fully vaccinated, mostly in Europe and North America. Israel (33.0%) and Seychelles (19.8%) lead all countries in terms of the proportion of their populations with full coverage, and no other countries are reporting higher than 5%. The US (4.8%), Malta (4.2%), and Denmark (3.0%) round out the top 5. In total, 35 countries have reported full vaccination in more than 1% of their total population.

There are major differences in how countries are allocating their available supply to first and second doses, evident in the differences between partial and full vaccination coverage. Some countries are aggressively pursuing second doses for individuals who have already received their first dose, while others are focusing on broader coverage using the first dose. For example, Costa Rica (78.5%), Croatia (78.2%), Russia (76.8%), and Spain (70.0%) are all reporting full vaccination for 70% or more of individuals who received their first dose. In contrast, fewer than 10% of those who have received the first dose are fully vaccinated in the UK—England (3.6%), Northern Ireland (7.0%), Scotland (1.8%), and Wales (2.3%); Singapore (2.3%); and Chile (2.4%). While the UK and Chile have among the highest 1-dose coverage, they are among the lowest in terms of full vaccination coverage.
*These data address “fully vaccinated” from the perspective of the number of doses administered and not with respect to the time required after the last dose to develop the full immune response.

Our World in Data reports that 194.44 million vaccine doses have been administered globally, a 21% increase compared to this time last week. Vaccination efforts have been reported in at least 92 countries and territories.

The US CDC reports 27.67 million total cases and 489,067 deaths. Daily incidence in the US continues its steady decline, now down to 77,385 new cases per day—the lowest daily average since October 28, 2020. The daily mortality is currently 2,708 deaths per day, the lowest average since January 6, 2021; however, reporting irregularities due to previously unreported deaths and holiday delays are making it difficult to project the longer-term trajectory. While the actual 7-day average daily mortality is uncertain, we expect the US to surpass 500,000 cumulative deaths in the next several days.

US Vaccination
The US CDC reported 73.38 million vaccine doses distributed and 57.74 million doses administered nationwide (78.7%).

In total, 41.02 million people (approximately 12.4% of the entire US population) have received at least 1 dose of the vaccine, and 16.16 million (4.9%) have received both doses. The average daily doses administered continues to increase, now up to a record high of 1.54 million doses per day*, including 679,199 second doses per day*. The CDC is still reporting slightly more Pfizer-BioNTech doses administered (29.59 million; 51%) than Moderna (28.04 million; 49%), but the gap is closing.
*The US CDC does not provide a 7-day average for the most recent 5 days due to anticipated reporting delays for vaccine administration. This estimate is the most current value provided.

A total of 6.18 million doses have been administered at long-term care facilities (LTCFs)**, including residents and staff. This covers 4.31 million individuals with at least 1 dose and 1.84 million with 2 doses. Approximately 59% of the doses have gone to residents, and 41% to staff.
**The dashboard only includes data for doses administered through the Federal Pharmacy Partnership for Long-term Care (LTC) Program. It does not report data from West Virginia, which opted out of the program.

The Johns Hopkins CSSE dashboard reported 27.91 million US cases and 493,670 deaths as of 12:30pm EST on February 19.

VACCINE CLINICAL TRIALS The UK has approved plans for the world’s first SARS-CoV-2 human challenge trial, backed by £33.6 million (US$47 million) in government funding. The UK COVID Challenge trial is expected to begin sometime in the next month, pending final ethics review. It will include up to 90 healthy volunteers, aged 18-30 years old, who will be deliberately exposed to SARS-CoV-2 and monitored under controlled conditions. The first stage of the trial will aim to characterize “the smallest amount of virus needed to cause infection,” and future efforts will include patients who are vaccinated prior to exposure to assess vaccine efficacy. The trial will be a partnership between the UK government’s Vaccine Task Force, Imperial College London, the Royal Free London NHS Trust Foundation, and hVIVO, a company with experience in human viral challenge trials. 

The University of Oxford announced that it will conduct a clinical trial for the AstraZeneca-Oxford vaccine in children. The Phase 2 clinical trial will take place across 3 study sites in England and include 300 participants aged 6-17 years. The placebo-controlled trial will administer the vaccine to as many as 240 participants, and the control group will receive a meningitis vaccine in order to stimulate a similar reaction (e.g., injection site soreness). Another team of researchers is also conducting a Phase 2/3 clinical trial for the Moderna vaccine. The Moderna trial aims to enroll 3,000 participants, and it will use a saline injection as its placebo. Now that several SARS-CoV-2 vaccines have demonstrated safety and efficacy in adults, children are an important population to evaluate in these next stages of clinical trials.

Researchers are also initiating clinical trials in other special populations, such as pregnant women. On February 18, Pfizer and BioNTech announced that the first participants were vaccinated in a “global Phase 2/3" clinical trial to evaluate the safety and efficacy of their SARS-CoV-2 vaccine in pregnant women. The study aims to include 4,000 participants (aged 18 years and older), and the vaccine will be administered between 24 and 34 weeks of gestation.

US VACCINE SUPPLY Following announcements from multiple US states that demand is outpacing federal supply of SARS-CoV-2 vaccine doses, the White House announced another increase in weekly distributions. The federal government will provide 13.5 million doses to state governments per week and 2 million weekly doses directly to pharmacies, compared to previous shipments of 10 million and 2 million doses per week, respectively. This brings the total national distribution to 15.5 million doses per week, which would enable 2.2 million doses to be administered per day nationwide. This corresponds to an increase of nearly 50% over the current average of 1.5 million doses administered per day.

HONG KONG AUTHORIZES SINOVAC VACCINE On February 18, the Hong Kong Secretary for Food and Health authorized the Sinovac SARS-CoV-2 vaccine for emergency use. The announcement followed recommendations from Hong Kong’s Advisory Panel on COVID-19 Vaccines. Reportedly, the efficacy data used in Hong Kong’s regulatory review showed 62% efficacy, which is higher than some other recent clinical results for the vaccine but lower than other vaccines authorized in other countries. The data have not been published, and some scientists have called on Sinovac to publicly release the clinical trial data. While Sinovac shared data with the advisory panel, critics argue that this does not meet the rigorous standard of a public peer review. Notably, a recent study conducted by Hong Kong University found that fewer than 30% of respondents would get vaccinated using the Sinovac vaccine due, in part, to concerns about its efficacy.

Hong Kong’s current agreement would supply 1 million doses of the vaccine to later this week, and vaccination is expected to start on February 26. Hong Kong established 5 priority groups for the earliest eligibility: (1) healthcare workers and “staff involved in anti-epidemic work,” (2) adults aged 60 years and older, (3) residents and staff at long-term care facilities, (4) essential workers, and (5) border control and workers at points of entry.

GLOBAL VACCINE ALLOCATION At least 92 countries and territories around the world have commenced SARS-CoV-2 vaccination campaigns. Several sizable gaps remain in vaccine access, most notably in Africa. In total, only 5 countries in Africa have reported vaccinations to date: Algeria, Egypt, Mauritius, Morocco, and Seychelles. In total African countries have reported 2.3 million cumulative vaccinations, the vast majority of which (97%) are in Morocco. Additionally, several African countries recently announced the delivery of their first vaccine doses or the start of vaccination campaigns. South Africa previously suspended its national vaccination program for the AstraZeneca-Oxford vaccine due to concerns regarding that vaccine’s efficacy against the B.1.351 variant, which was first identified in South Africa; however, it commenced vaccinations on February 17 using the Johnson & Johnson (J&J)-Janssen vaccine. Zimbabwe also commenced vaccinations this week, using Sinopharm vaccines from China. Sinopharm has also supplied doses to Egypt and Equatorial Guinea. Rwanda commenced its vaccination efforts as well, focusing initially on high-risk populations such as frontline healthcare workers. The Rwandan Ministry of Health announced the program on February 14.

In response to global disparities in SARS-CoV-2 vaccine access, particularly with respect to countries’ wealth, Mexican Minister of Foreign Affairs Marcelo Ebrard’s statement to the UN Security Council called for the “international community to guarantee fair, equitable and timely access” to the vaccine. Minister Ebrard’s statement noted that 10 countries have received 75% of the global vaccine supply and that more than 100 countries have not yet administered a single vaccination. Mexico has reportedly purchased 230 million doses of SARS-CoV-2 vaccines, across multiple manufacturers; however, its allotments have been limited relative to wealthier countries like China, the US, the UK, and many European countries. To date, Mexico has reported only 1.32 million doses administered, although more than 500,000 of those (43%) have been reported in the past 3 days. On a per capita basis, Mexico has administered only 1 dose per 100 people, compared to 17.4 in the US, 6.35 across Europe, and 2.8 in China.

As we reported previously, the COVAX facility published its anticipated vaccine allotments, which includes more than 88 million doses for 46 African countries and nearly 6.5 million doses for Mexico. The Emergency Use Listings recently issued by the WHO for the AstraZeneca-Oxford vaccine cover more than 99% of the 320 million doses in the first COVAX allotment and move COVAX one step closer to shipping the first doses.

EU VACCINE SUPPLY As supply continues to be a bottleneck in SARS-CoV-2 vaccination efforts, Pfizer and BioNTech are reportedly behind schedule in delivering vaccine to the EU, including approximately 10 million doses that were supposed to arrive in December. The missing Pfizer doses represent one-third of the anticipated supply, exacerbating the impact of delays in delivering the AstraZeneca-Oxford and Moderna vaccines. As a result of ongoing concerns regarding the availability of the AstraZeneca-Oxford vaccine, the European Commission reportedly finalized new contracts to purchase an additional 350 additional doses of the Pfizer-BioNTech and Moderna vaccines, scheduled to be delivered through the end of 2021. Recent agreements, including the February contract with Pfizer/BioNTech, include “anti-variant” clauses that would allow the bloc not to purchase vaccines that are not effective against emerging variants, and the EC reportedly hopes to add similar clauses to existing contracts. Additionally, the EU is funding almost US$300 million for efforts to combat variants, including at least €75 million (US$91 million) for expanded genomic sequencing capacity and the development of specialized tests for emerging variants and €150 million (US$182 million) for research and data sharing. 

EMERGING VARIANTS A study published (preprint) by Harvard University examines the nasopharyngeal viral concentration in individuals infected with the B.1.1.7 SARS-CoV-2 variant. The researchers performed a series of PCR-based diagnostic tests over a series of weeks to evaluate temporal dynamics of the viral concentration for this variant of concern. The study included 65 total participants, including 7 infected with the B.1.1.7 variant. The researchers found that infection with the B.1.1.7 variant lasted significantly longer than for other variants, with a mean duration of infection of 13.3 days for the B.1.1.7 variant, compared to 8.2 days for non-B.1.1.7 variants. While the duration of infection was longer for the B.1.1.7 variant, the peak viral concentration was similar between B.1.1.7 and non-B.1.1.7 variants.

Even though the peak nasopharyngeal viral concentration is similar between the B.1.1.7 and non-B.1.1.7 variants, the longer duration of infection could potentially be a factor in the variant’s increased transmissibility. If individuals infected with the B.1.1.7 variant take longer to clear the virus from their system, their infectious period could potentially be longer as well, which could result in additional exposures compared to non-B.1.1.7 variants. Further investigation is necessary to better characterize the drivers of the increased transmissibility, but this study provides insight into potential mechanisms that contribute to the variant’s ability to spread more rapidly in the community.

US MORTALITY The US CDC published findings from analysis of US mortality data from January-June 2020, which indicates that the average life expectancy in the US decreased by 1 year compared to estimates from 2019. The analysis was conducted by the CDC’s National Center for Health Statistics, and the researchers evaluated all reported deaths from the first half of 2020*. The researchers estimate the overall life expectancy in the US for the first half of 2020 to be 77.8 years, a decrease from 78.8 years in 2019 and the lowest estimate since 2006. This is the largest single-year decline since World War II. The decrease was slightly greater in males than females—1.2 years compared to 0.9 years. The analysis also evaluated changes in life expectancy by racial and ethnic groups, a major concern due to the disproportionate burden of COVID-19 on racial and ethnic minorities. Life expectancy decreased by 0.8 years for the non-Hispanic White population, 1.9 years for the Hispanic population, and 2.7 years for the non-Hispanic Black population, illustrating “a worsening of racial and ethnic mortality disparities.”

Notably, these reported deaths include the initial COVID-19 surge, but they do not cover the autumn/winter 2020-21 surge, which exhibited a higher and more sustained mortality rate—exceeding 2,000 deaths per day since early December 2020 and 3,000 deaths per day from mid-January through mid-February 2021. One of the researchers indicated that the “majority of the decline” stemmed from the pandemic.
*The report indicates that the analysis is based on preliminary data and that some reports could be delayed by months.

JAPAN VACCINATION On February 17, Japan commenced its SARS-CoV-2 vaccination campaign, focusing initially on healthcare workers and older adults. Japan faced its largest surge in December 2020 and January 2021, but it delayed the start of its vaccination campaign after requiring domestic clinical trials of the Pfizer-BioNTech vaccine. Pfizer and BioNTech applied for emergency approval in Japan in December, but reportedly, Japan waited for preliminary data from a clinical trial of 160 Japanese participants in order to better assess safety in the Japanese population. Critics argue that the small sample size likely delayed the start of vaccination efforts while providing limited benefit. Review of the application for the AstraZeneca-Oxford is ongoing, and Moderna has not yet submitted an application in Japan. Japanese officials continue to express optimism that the delayed 2020 Summer Olympic Games will be held in 2021, and the national vaccination effort is likely a key step in achieving that goal.

TAIWAN VACCINE SUPPLY Taiwan’s Minister of Health and Welfare, Chen Shih-chung, announced that an agreement to purchase 5 million doses of the Pfizer-BioNTech SARS-CoV-2 vaccine is on hold. Reportedly, Taiwan was negotiating with BioNTech to purchase the vaccine, but “the company suddenly backed out.” Minister Chen indicated that the negotiations fell through as a result of “outside forces intervening,” but he did not elaborate further. Some have speculated that influence from the Chinese government is responsible for the delay, but Chinese officials deny involvement in the decision. BioNTech has not offered an explanation regarding the underlying factors in their decision.

BioNTech was coordinating with the Shanghai Fosun Pharmaceutical Group to manufacture SARS-CoV-2 vaccines for mainland China, Hong Kong, Macau, and Taiwan; however, Taiwanese pharmaceutical company TTY Biopharm was reportedly involved in negotiations directly between the Taiwanese government and BioNTech. Representatives from BioNTech stressed that the deal with Taiwan is only delayed and not withdrawn entirely. The response to the COVID-19 pandemic has further exacerbated the tense political relationship between Taiwan and China. Taiwan announced in late December that it secured approximately 20 million doses of SARS-CoV-2 vaccine, including 10 million from AstraZeneca, nearly 5 million from COVAX, and another 5 million from an impending contract, which is believed to be the suspended agreement with BioNTech. 

VACCINE CEASEFIRE The UK government called for “local ceasefires across the globe” in order to enable governments and humanitarian aid organizations to implement SARS-CoV-2 vaccination efforts in conflict zones. UK Secretary of State for Foreign, Commonwealth, and Development Affairs Dominic Raab issued a statement at a meeting of the UN Security Council emphasizing the COVID-19 risk to more than 160 million people living in areas of ongoing armed conflict—“including in Yemen, South Sudan, Somalia and Ethiopia”—and highlighting the importance of conducting vaccination efforts in those areas. These “vaccine ceasefires” would not only provide direct benefit to vaccinated individuals, but it could also mitigate the risk of viral mutation and emerging variants. The UK also called for increased financial contributions to the COVAX facility, in order to increase the vaccine supply for low- and middle-income countries.