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 111.42 million cases and 2.47 million deaths as of 9:00am EST on February 23. The global weekly incidence continues to decrease. The weekly total is fewer than 2.5 million cases for the first time since early October 2020 and less than half the weekly total of the peak in early January. Weekly mortality continues to decrease as well, down to 66,359 deaths last week. This is a decrease of nearly 20% compared to the previous week and an overall decrease of nearly one-third from the high in late January.

Our World in Data reports that 212.15 million vaccine doses have been administered globally, a 19% increase compared to this time last week. Vaccination efforts have been reported in at least 98 countries and territories.

The US CDC reported 27.94 million total cases and 497,415 deaths. Daily incidence continues to fall sharply in the US, now down to fewer than 65,000 new cases per day—the lowest average since October 23, 2020. This trend is evident across the country, with daily incidence decreasing rapidly in all 4 regions. Additionally, 40 states (plus Washington, DC) are reporting decreasing daily incidence over the past 2 weeks. Of the remaining states, 6 are holding relatively steady (-10% to +10% change), and only 4 are reporting increasing trends: Alaska (+108%), North Dakota (+46%), Rhode Island (+14%), and Wyoming (+117%).

As daily COVID-19 incidence and mortality continue to decrease in the US, so do hospitalizations. According to data compiled by the COVID Tracking Project, current hospitalizations nationwide are down to 55,403, a decrease of 58% from the peak on January 6. Notably, the current total is now below the previous peaks in April and July 2020. Similar to incidence and mortality, current COVID-19 hospitalizations are decreasing across all 4 regions of the country. The Midwest region peaked first, in late November/early December 2020, as it began to come down from its autumn/winter surge, and the Northeast, South, and West regions all peaked around January 6-12, 2021. Most US states are reporting fewer than 200 hospitalizations per million population, and no state is reporting more than 300. New York is reporting the most per capita hospitalizations, with 298 per million population, followed by Washington, DC, with 293. Compared to the previous week, 36 states are reporting decreasing hospitalizations, and 13 states (plus Washington, DC) are holding relatively steady (-10% to +10% change). Alaska (+11%) and Hawai’i (+35%) are the only 2 states reporting an increasing trend. Data compiled by the COVID Exit Strategy website show a different trend.

The official CDC data track the number of new hospitalizations per day (ie, as opposed to current hospitalizations). New hospitalizations peaked on January 6, with an average of 16,536 per day. Since then, new daily hospitalizations have declined steadily, down to 6,417—a decrease of more than 60% from the peak. The current average is more than 20% less than the previous week.

US Vaccination
The US CDC reported 75.21 million vaccine doses distributed and 64.18 million doses administered nationwide (85.3%).

In total, 44.14 million people (13.3% of the entire US population; 16.9% of the adult population) have received at least 1 dose of the vaccine, and 19.44 million (5.9%; 7.5%) have received both doses. The average daily doses administered decreased slightly to 1.46 million doses per day*, including 664,618 second doses per day*. These decreases could be a result of delays in vaccine distribution and administration stemming from severe winter weather affecting much of the country.
*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 6.58 million doses have been administered at long-term care facilities (LTCFs)**, including residents and staff. This covers 4.45 million individuals with at least 1 dose and 2.01 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 28.20 million US cases and 501,117 deaths as of 12:30pm EST on February 23.

VACCINATION EFFICACY More evidence is emerging that vaccination campaigns are significantly reducing the risk of both severe COVID-19 disease and SARS-CoV-2 transmission. A study by Public Health England found that the risk COVID-19 disease among healthcare workers (HCWs) decreased by 65-72% after the first dose of the Pfizer-BioNTech vaccine, and more than 85% after the second dose. Additionally, the risk of infection decreased by 70% in HCWs who received one dose and 85% in those who received both doses. Similarly, data from Public Health Scotland indicates that hospitalization risk decreased 94% for individuals vaccinated with the AstraZeneca-Oxford vaccine and 85% for the Pfizer-BioNTech vaccine. In Israel, data from the Ministry of Health reportedly indicate that the Pfizer-BioNTech vaccine decreases the risk of infection by 89% and the risk of disease by 94%. Israel has fully vaccinated approximately 27-32% of the population using the Pfizer-BioNTech vaccine, and nearly 50% of the population has received at least one dose. This is some of the earliest evidence that demonstrates SARS-CoV-2 vaccines’ effect on transmission.

NOVAVAX CLINICAL TRIALS Novavax announced that it completed enrollment in Mexico and the US for the Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine. Combined, the trials will include approximately 30,000 participants, many of whom are in “communities and demographic groups most impacted by the disease.” The researchers proactively sought a demographically diverse group of participants—including 20% Latinx, 13% African American, 6% Native American, 4% Asian American, and 13% aged 65 years and older—in order to test the vaccine in communities at elevated COVID-19 risk. Additionally, study sites were deliberately assigned to areas with elevated community transmission, with the aim of accelerating the timeline for obtaining the data needed to conduct the efficacy analysis.

Novavax is using a different vaccine technology than previously authorized SARS-CoV-2 vaccines. The Novavax vaccine is protein-based, and it contains recombinant nanoparticles constructed of synthetic SARS-CoV-2 spike proteins to generate the desired immune response. The vaccine also contains a proprietary adjuvant to boost the immune response. The Novavax vaccine requires 2 doses, administered 21 days apart.

COVAX DONATIONS In conjunction with the 2021 summit of the Group of Seven (G7) on February 19, the leaders of Canada, France, Germany, Italy, Japan, the UK, and the US issued a joint statement pledging improved international collaboration and support for the global COVID-19 response, including additional funding for the COVAX facility, which aims to provide SARS-CoV-2 vaccine for low- and middle-income countries (LMICs). Collectively, the G7 governments committed an additional US$4 billion to COVAX, bringing the total to US$7 billion from these 7 countries. The pledge includes US$2 billion from the US, with an additional US$2 billion in the future, contingent upon the other G7 countries fulfilling their commitments.

While the financial donations help to increase the doses COVAX can afford to purchase, it does not necessarily impact the current lack of accessibility for most countries eligible under COVAX. With countries like the US, the UK, and those in the European Union consuming the majority of available vaccine supply, most LMICs remain unable to access doses, even if they could afford to pay for them. WHO Director-General Dr. Tedros Adhanom Ghebreyesus called on high-income countries to make vaccine available to LMICs. He noted that “having the money doesn’t mean anything,” if there is no vaccine available to purchase. Unilateral arrangements directly with vaccine manufacturers to acquire additional doses are delaying access and reducing allocations for LMICs, including through programs like COVAX. Dr. Tedros called on high-income countries to consider the effect on COVAX before negotiating any new contracts to purchase additional doses. Notably, he emphasized that when high-income countries “undermine” the COVAX effort, they are not only increasing the risk for LMICs, they are also increasing their own risk, because areas that remain unvaccinated will allow continued transmission and mutation that could then spread internationally.

MENTAL HEALTH OF SURVIVORS Several recent articles have investigated mental health effects of the COVID-19 pandemic. One study conducted by researchers in Italy, published in JAMA: Psychiatry, evaluated post-traumatic stress disorder (PTSD) in survivors of severe COVID-19 disease. The study involved 381 patients who sought care through an emergency department. Trained psychiatrists diagnosed PTSD in these patients using a standardized Clinician-Administered PTSD Scale, based on the results of a psychiatric assessment. The researchers diagnosed PTSD in 115 (30%) of the participants as well as depressive episodes in 66 (17%) and generalized anxiety disorder in 27 (7%). The presence of persistent medical symptoms was among the factors significantly associated with PTSD diagnosis. While a relatively small sample size, this study provides evidence that severe COVID-19 disease could be associated with longer-term mental health issues in recovered patients. This illustrates the broad array of long-term health conditions that can stem from COVID-19. 

US VACCINE SAFETY MONITORING Researchers from the US CDC COVID-19 Response Team and the US FDA published analysis of early SARS-CoV-2 vaccine safety monitoring from the US vaccination campaign. The study, published in the US CDC’s MMWR, reviewed safety monitoring data for the Pfizer-BioNTech and Moderna vaccines administered in the US from December 14, 2020, to January 13, 2021—accounting for approximately the first month of vaccinations for both products. During this period, 13.8 million doses of vaccine were administered, and there were 6,994 post-vaccination adverse events reported in the Vaccine Adverse Event Reporting System (VAERS). The most common symptoms were headache (22.4%), fatigue (16.5%), and dizziness (16.5%). Anaphylactic reactions were reported in approximately 4.5 out of every million vaccinations, which is similar to the rate expected for inactivated seasonal influenza vaccines. Adverse events were more likely to be reported after an individual’s second dose than their first dose. 

Among the 6,994 total reports, 640 (9.2%) were considered to be serious adverse events, including 113 deaths (78 among residents of long-term care facilities). Notably, VAERS data include reports from “healthcare providers, vaccine manufacturers, and the public,” and further investigation is required in order to determine whether a reported adverse event was associated with the vaccine. Information collected from “death certificates, autopsy reports, medical records, and clinical descriptions from VAERS reports and health care providers” do not indicate that any of the deaths were caused by vaccination.

US ECONOMIC STIMULUS Yesterday, the White House announced changes to the federal Payment Protection Program (PPP), part of the United States’ COVID-19 economic relief efforts, that aim to better support small and minority-owned businesses. Starting this week, the PPP will institute a 2-week period dedicated to businesses that employ fewer than 20 employees, many of which have struggled to navigate the PPP application process, which will enable lenders to provide additional assistance to the smallest businesses. The PPP will also update how it determines financial support for independent contractors and self-employed individuals, many of whom received PPP loans as little as US$1 under previous iterations of the program. “Exclusionary restrictions” for businesses owned by individuals who committed non-fraud felonies or individuals who are delinquent in repaying federal student loans will be eliminated. Finally, the changes will correct inconsistencies to ensure eligibility for businesses owned by non-citizen legal US residents, including Green Card holders and individuals residing in the US under a visa. The PPP has distributed billions of dollars in support to small businesses, but critics have raised concerns that structural barriers have prevented funding from being allocated to those in the greatest need, including businesses owned by racial and ethnic minorities.

The US House of Representatives is expected to vote this week on the newest COVID-19 economic stimulus package. The bill—the American Rescue Plan, published on February 19—includes US$1.9 trillion in funding to support state and local COVID-19 response, including vaccination and schools; financial support for small businesses and extended unemployment benefits; and direct payments to individuals and families. Reportedly, efforts to negotiate a bipartisan funding package have largely stalled, and Democratic members of the Congress could use a budget reconciliation process to pass the bill without Republican support.

LONG COVID As more and more people recover from acute COVID-19 disease, clinicians and researchers are gathering additional information on the chronic effects of SARS-CoV-2, commonly referred to as “long COVID.” A study conducted in Israel, published in Clinical Microbiology and Infection, investigated chronic symptoms in recovered COVID-19 patients over a 6-month period. The study included 103 patients who recovered from mild COVID-19 illness, and investigators collected data on the onset and duration of a variety of symptoms. Fever was among the first symptoms to resolve, with a mean duration of 5.6 days, whereas fatigue (31.1 days), difficulty breathing (18.6), and changes to taste (18.6) and smell (23.5) tended to persist longer. Notably, nearly half of the participants reported chronic symptoms that persisted for 6 months, including 22% with ongoing fatigue, 15% with changes to taste and smell, and 8% with breathing difficulties. The onset of some of the chronic symptoms—such as fatigue, breathing difficulties, memory disorders, and hair loss—tended to be reported after the 6-week point, indicating that they were newly developed conditions in recovered patients rather than longer-term continuations of acute disease.

Increasing prevalence of long-term health effects from SARS-CoV-2 infection are raising concerns regarding how long-term care will be managed for patients with long COVID. Chronic health conditions such as fatigue, neurological disorders, and difficulty breathing can be debilitating for some patients, and advocates and elected officials have raised the possibility of classifying long COVID as a disability. Patients with severe chronic conditions following SARS-CoV-2 infection may be unable to return to work, or school or other activities, but they may not be eligible for Social Security Disability Insurance benefits. Some advocates have called on the US Social Security Administration to proactively issue guidance regarding how to handle COVID-19-related claims, in anticipation of increased need in the coming months and years for disability support for recovered patients, including financial support or accommodations or assistance in the workplace.

SCHOOL-BASED TRANSMISSION A study conducted by the University of Florida and the Florida Department of Health, published in JAMA, investigated the impact of student quarantine and testing protocols at K-12 schools in Alachua County, Florida. Data indicate that the COVID-19 incubation period in children is 6 to 7 days, shorter than the 4 to 5 days in adults. The county implemented 14-day self-quarantine for students exposed to known COVID-19 cases, and students were allowed to return to school early if they received a negative RT-PCR diagnostic test on Day 9 or later. The rationale for this program was that SARS-CoV-2 infection should be detectable by Day 9 and that students who tested negative could safely return to school the next day. Out of 799 students who received a negative test under this program, only 1 developed symptomatic disease after returning to school, and genomic data indicate that the student was actually infected through a different exposure than the one that prompted quarantine. The program to enable students to end their quarantine period early reduced the total number of missed school days by more than 30% without resulting in any additional transmission. This study provides evidence that schools can implement testing protocols to promote in-person learning while effectively mitigating transmission risk. 

A study conducted by the US CDC COVID-19 Response Team and school and public health officials in Georgia, published in the CDC’s MMWR, found that half of school-associated cases initiated from teacher-to-teacher transmission and then spread from teachers to students. The researchers evaluated data from 24 days of in-person learning at elementary schools in a single school district, which included approximately 2,600 students and 700 staff. In total 9 clusters of cases were identified, involving 13 teachers, 32 students, and 18 additional instances of household transmission. Of the 31 school-associated cases, 15 were students who are believed to have been infected following transmission between teachers. Notably, all 9 of the school clusters “involved less than ideal physical distancing, and five involved inadequate mask use by students.” The “central” role of teachers in school-based transmission provides support for vaccinating teachers in order to mitigate transmission risk during in-person classes. Current US CDC guidance indicates that teachers need not be vaccinated before schools can reopen, but many teachers unions are calling for changes to existing guidance and policies that would prioritize teachers as essential workers in order to provide protection before resuming in-person learning. 

TANZANIA On February 20, WHO Director-General Dr. Tedros Adhanom Ghebreyesus issued a statement urging the Tanzanian government to report COVID-19 data and implement COVID-19 control measures. He noted that numerous Tanzanians traveling to other countries have tested positive for SARS-CoV-2, which indicates that Tanzania's epidemic is not contained. Tanzanian President John Magufuli has repeatedly stated that Tanzania eliminated COVID-19 and opposed vaccination and other protective measures; however, recent reports of COVID-19 deaths, including several senior government officials, have called attention to the country’s ongoing epidemic. Tanzania has not reported COVID-19 data since May 2020, when it had 509 cumulative cases and 21 deaths. President Magufuli reportedly changed course to some degree, now encouraging Tanzanians to take appropriate precautions to protect against COVID-19, including mask use and proper hand hygiene.

INFODEMICS On February 19, the Johns Hopkins Center for Health Security, in collaboration with experts at the WHO, published a special feature on Infodemics and Health Security in the journal Health Security. As the COVID-19 pandemic unfolded, the quickly WHO recognized the critical need to combat mis- and disinformation. Following the first Global Infodemiology Conference in 2020, the WHO collaborated with partners across 5 disciplines to publish research and commentaries in 5 peer reviewed journals on topics related to misinformation and infodemic management during public health emergencies. The special feature in Health Security includes a series of articles that analyze infodemics in the midst of health emergencies and communication policies and practices to overcome a variety of misinformation challenges, particularly in the context of emerging and ongoing health emergencies. Additionally, the special feature includes commentaries that specifically address crisis and emergency risk communication during the COVID-19 pandemic.