EPI UPDATE The WHO COVID-19 Dashboard reports 112.65 million cases and 2.50 million deaths as of 9:30am EST on February 26. The global cumulative mortality surpassed 2.5 million deaths today:
1 death to 500k- 171 days
500k to 1 million- 91 days
1 to 1.5 million- 66 days
1.5 to 2 million- 43 days
2 to 2.5 million- 41 days
With more than 110 million cases and 2.5 million deaths, case fatality ratios (CFRs) in most countries are reaching an equilibrium. The global average peaked at 7.2% in late April/early May 2020, and it is now settling around 2.2%. The CFRs at the continent level range from 1.7% in Asia to 2.9% in Oceania. The highest continental peak was in Europe in late April 2020, with 10% case fatality, and Asia (4.3% in late March 2020) and Oceania (3.1% in October/November 2020) have reported the lowest peaks. Notably, the CFRs in Africa, Europe, and North America have increased slightly since late 2020, although with a change of less than 0.5% over that period, and CFRs continue to decrease slowly in Asia, Oceania, and South America.
Case fatality ratios range widely between countries, from less than 1% to more than 25%. Of the 178 countries and territories with available CFR data, 38 are reporting 1% or less. Of these countries, most are reporting very few cumulative deaths; in fact, only 8 have reported more than 1,000 cumulative deaths—Israel (5,687), Serbia (4,398), Nepal (2,685), Belarus (1,948), Venezuela (1,334), UAE (1,182), Malaysia (1,100), and Kuwait (1,067). The median CFR is 1.8%, and most countries and territories are reporting between 1.1% and 2.6%. In total, 33 countries and territories are reporting CFRs of 3% or greater, including 6 countries with 5% or greater. Yemen is reporting the highest CFR, with 27.7%, but no other country or territory is greater than 10%. Among the 26 countries* with the highest CFR, most have reported fewer than 500,000 cumulative cases (the denominator when calculating CFR). Only Italy (2.87 million), Mexico (2.07 million), Iran (1.61 million), and Peru (1.30 million) have exceeded that total. For countries with lower cumulative incidence, any single death can have a larger effect on the CFR.
*3 countries are tied at #24 with 3.4%.
Most of the countries with elevated CFR are reporting relatively steady values over the past several months; however, some are reporting notable changes recently. Iran’s CFR remained relatively steady at approximately 5.7% from August to November 2020, but it has decreased since then, down to 3.7%. In Eswatini, the CFR was approximately 2% from August to late December 2020, and then it increased sharply in 2021 to 3.8%. Zimbabwe’s CFR declined slowly but steadily from 3.1% in September 2020 to 2.4% in January 2021 before increasing rapidly to more than 4%. Syria’s CFR has been increasing steadily since August 2020, up from 4% to 6.6%. Ecuador’s CFR has decreased steadily from a peak of 8.6% in May 2020; however, it reported more than 3,800 previously unreported deaths on September 7, which caused its CFR to jump from 5.7% to 9.6%. The CFR has continued its downward trend since then, down to 5.6%.
Our World in Data reports that 227.62 million vaccine doses have been administered globally, a 16% increase compared to this time last week. Vaccination efforts have been reported in at least 103 countries and territories. With vaccination efforts starting in Australia and New Zealand, vaccinations are now ongoing on all continents.
UNITED STATES
The US CDC reported 28.14 million total cases and 503,587 deaths. After steep declines since mid-January 2021, the average daily incidence increased for 2 consecutive days, up to 66,347 new cases per day. Daily mortality increased slightly as well, once again above 2,000 deaths per day. Some of these increases could be attributable to depressed or delayed reporting the previous week as a result of the President’s Day holiday and severe winter weather.
The US surpassed 500,000 cumulative deaths on February 23, less than 1 year from the first reported death on February 29, 2020. Despite reaching this tragic milestone, the daily mortality has decreased substantially over the past several weeks:
1 death to 50k- 55 days
50k to 100k- 33 days
100k to 150k- 63 days
150k to 200k- 55 days
200k to 250k- 58 days
250k to 300k- 25 days
300k to 350k- 20 days
350k to 400k- 16 days
400k to 450k- 16 days
450k to 500k- 19 days
US Vaccination
The US CDC reported 91.67 million vaccine doses distributed and 68.27 million doses administered nationwide (74.5%). This percentage is a notable decrease from the previous briefing (85.3%), and it appears to stem from a combination of increased supply and slowing vaccine administration, potentially a result of the ongoing effects of severe winter weather affecting much of the country.
In total, 46.07 million people (13.9% of the entire US population; 18.0% of the adult population) have received at least 1 dose of the vaccine, and 21.56 million (6.5%; 8.4%) have received both doses. The average daily doses administered continues to decrease, down from a peak of 1.64 million doses per day to 1.29 million, including 659,192 second doses per day*.
*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 6.82 million doses have been administered at long-term care facilities (LTCFs)**, including residents and staff. This covers 4.53 million individuals with at least 1 dose and 2.26 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.
J&J-JANSSEN VACCINE EUA The US FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) will meet today to evaluate safety and efficacy data for the Johnson & Johnson (J&J)-Janssen Biotech SARS-CoV-2 vaccine candidate, the first single-dose vaccine to apply for an Emergency Use Authorization (EUA). Like with the previous VRBPAC meetings for the Pfizer-BioNTech and Moderna vaccines, detailed clinical trial data was made available in advance of the meeting, including briefing documents (and addendum) from Janssen and the FDA. To our knowledge this is the first time that detailed clinical trial data have been made public for the J&J-Janssen candidate. VRBPAC will submit its recommendations to the FDA, which will make the final determination regarding an EUA for the vaccine.
The briefing document from the FDA indicates that the vaccine demonstrated acceptable safety and efficacy profiles in the Phase 3 clinical trials. Overall, the vaccine demonstrated 66.1% efficacy in preventing moderate-to-severe COVID-19 disease, with 66 cases in the vaccine group compared to 193 in the control group, and it was 85.4% efficacious in preventing severe and critical disease. Notably, there were no deaths among vaccinated participants (compared to 7 in the control group), and there were no hospitalizations identified in the vaccine group after 28 days post-vaccination. In addition to assessing efficacy in preventing COVID-19 disease, the data also provide insight on the vaccine’s ability to prevent infection. Among a small portion of the participants—2,650 out of approximately 40,000 total—the vaccine reduced the risk of infection by 65.5%, demonstrating an effect in limiting transmission. The FDA’s analysis indicates that the efficacy could potentially be lower among older adults (e.g., ages 60 or 75 years and older), although additional data are needed.
With respect to emerging variants, the vaccine demonstrated 81.7% efficacy in preventing severe or critical COVID-19 disease and 64.0% efficacy in preventing moderate disease in the South Africa portion of the trial—where the B.1.351 variant represented 94.5% of the sequenced cases. The vaccine’s efficacy was not markedly lower in Brazil, where the P.2 variant is prominent. No cases were identified for the B.1.1.7 or P.1 variants.
As we have covered previously, the J&J-Janssen vaccine requires a single dose, rather than 2 doses spread over a period of weeks (or months in some countries). Additionally, the vaccine only requires refrigeration temperatures for medium-term storage and transportation. These characteristics could reduce operational and logistical challenges for large-scale vaccination operations, which could have a substantial impact on the speed at which vaccination programs can proceed. Notably, however, the current supply is limited, and it could be another month or longer before high-volume distribution can begin.
OCCUPATION TRANSMISSION RISK The UK government published a report on the infection risk associated with various occupations, based on data on COVID-19 cases in England from September 2020-January 2021. The analysis compared the likelihood of testing positive for SARS-CoV-2 during the study period for 25 standardized occupation categories. The occupation-specific risk ranged from 2.1% to 4.8%, with an overall risk of 3.9%. None of the individual occupation groups had a statistically significant difference from the overall average; however, some of the occupations with the highest risk showed a significant increase over those with the lowest risk. Occupation groups at the upper end include professions such as teachers, law enforcement and prison staff, childcare and home care, and secretarial professions. Occupation categories with lower infection risk include professions such as farmers and gardeners; scientists, engineers, and researchers; legal, social work, and news media; and textiles and printing services.
VARIANT-SPECIFIC VACCINES Vaccine efficacy against emerging SARS-CoV-2 variants is a growing concern, and vaccine manufacturers are already working to address specific variants of concern (VOCs). Pfizer and BioNTech announced that they are initiating clinical trials for a second booster dose (i.e., a third dose) of their vaccine to evaluate efficacy against emerging variants. Three doses could potentially provide additional protection by producing higher antibody titers. Pfizer and BioNTech are also developing an adapted version of the vaccine specifically to target new variants. Moderna also announced that it is conducting clinical trials for an updated version of their vaccine which will target the B.1.351 variant, following a study that found evidence of decreased neutralizing antibody titers against that variant. Moderna has shipped the variant-specific vaccine to the US NIH to evaluate 3 approaches: a single-variant booster dose, a multivalent booster dose, and a second booster dose (i.e., third total dose) of the original vaccine.
In anticipation of vaccines adapted for emerging variants, the US FDA released guidance this week regarding how EUAs will be evaluated for SARS-CoV-2 vaccines that target emerging variants. Most notably, the FDA indicated that it could accept data from smaller clinical trials, similar to those conducted for seasonal influenza vaccines. This could accelerate the review process for modified versions of vaccines that have already demonstrated acceptable safety and efficacy profiles.
COVAX VACCINE DISTRIBUTION This week, Ghana became the first country outside India to receive SARS-CoV-2 vaccines via the COVAX facility. The shipment of 600,000 doses of the AstraZeneca-Oxford vaccine arrived Wednesday as part of the effort to deliver at least 2 billion doses to low- and middle-income countries by the end of 2021. Another 504,000 doses arrived today in Cote d’Ivoire, and shipments will continue to other countries eligible under COVAX.
UNICEF is shipping syringes to COVAX countries to support future vaccination efforts. Over the next several weeks, UNICEF will distribute 14.5 million auto-disable syringes to more than 30 countries. The first shipments include 100,000 syringes for the Maldives, which are expected to arrive next Tuesday. Côte d'Ivoire and São Tomé and Príncipe are also among the earliest scheduled recipients. In total, UNICEF is expected to supply up to 1 billion syringes by the end of the year. Supply will be drawn from the UNICEF stockpiles in Dubai and Copenhagen that were established in 2020.
EU VACCINATION EU leaders met this week to discuss plans to accelerate vaccination efforts in the bloc, including efforts to alleviate production bottlenecks and delivery delays stemming from international travel restrictions. Reportedly, the discussions also included the possibility of issuing vaccination certificates in order to facilitate international travel. Many countries in Europe rely heavily on tourism—including Greece and Spain—which has been severely hindered throughout the pandemic, and they are eager to resume international travel before the summer tourist season. Discussions are ongoing regarding the extent to which these certificates could increase travel and any restrictions that could apply to individuals without a certificate. Media reports indicate that there could be a desire to develop a vaccination certificate for the EU before large US-based technology companies (e.g., Apple, Google) develop their own, in part due to concerns about data security and privacy.
US VACCINE EQUITY The US continues to scale up vaccine distribution and administration nationwide, but many high-risk communities are still struggling to access the vaccine. The authority and responsibility for public health in the US exists at the state level, and states are taking a variety of approaches to rolling out vaccination programs. Even within the same region, or even in neighboring states, vaccine eligibility can vary widely. In some states, vaccines are still reserved for frontline healthcare workers and older adults, whereas others have expanded eligibility to other high-risk groups, including racial and ethnic minorities and those with underlying health conditions that put them at elevated risk for severe disease.
Younger individuals with underlying medical conditions are struggling in many states to access the vaccine. Some states are expanding eligibility to adults ages 64 and younger who have multiple high-risk comorbidities, while others require only one underlying health condition. Some states, including Connecticut and Nebraska, do not consider medical conditions at all and are relying solely on age to determine eligibility. And in some states, eligibility based on comorbidities can vary from county to county. Notably, the CDC's Advisory Committee on Immunization Practices (ACIP) includes individuals with high-risk comorbidities among its Phase 1c priority populations, alongside adults ages 65-74 years.
These inconsistencies are driving disparities in vaccination coverage and providing incentive for some individuals to cheat the system. California, for example, implemented a system to distribute access codes in racial and ethnic minority communities that enable individuals to schedule a vaccination appointment. The program aimed to facilitate access to the vaccine for those who might otherwise have difficulty obtaining an appointment. Some of the codes, however, have been circulated outside those communities and used by individuals in more affluent communities and some who are not yet eligible under California’s vaccination policy. California Governor Gavin Newsom indicated that the state is implementing changes to the access code program in an effort to ensure they are used by the intended communities, but critics have raised concerns that California’s vaccination program is inherently inequitable and called for larger-scale changes to promote equitable access for vulnerable communities.
US VACCINE SUPPLY Pfizer, Moderna, and Johnson & Johnson (J&J) committed to supply a total of 240 million doses to the US government by the end of March, with 220 million coming from Pfizer and Moderna and an additional 20 million from J&J (pending receipt of an EUA). Manufacturing these new vaccines at such a large scale is posing challenges, including in obtaining raw materials and optimizing manufacturing processes, but Pfizer and Moderna are working to increase supply.
As vaccine supply increases, the US CDC is increasing support for the general public to accelerate vaccine administration. This week, the CDC unveiled the VaccineFinder.org website, which provides US residents with updated information regarding local vaccine availability, including locations of local pharmacies, clinics, and health departments with available doses. For locations with vaccine in stock, individuals can also check appointment availability. The website is managed collaboratively by the CDC, Boston Children's Hospital, Harvard Medical School, and Castlight. Initially, the website included data on 29,000 locations nationwide, but it is expected to expand.
GLOBAL COVID-19 DATA PLATFORM An international team of epidemiologists launched a website to provide anonymized data on COVID-19 patients worldwide. The new site, Global.Health, was developed with support from Google and the Rockefeller Foundation. The website will include records for more than 5 million COVID-19 patients from 160 countries, with data ranging from patient demographics to travel history. Detailed data on COVID-19 patients has been difficult to obtain and compile since the onset of the pandemic. This data is critical to conducting the epidemiological analysis necessary to understand the effects of COVID-19. Previous efforts, including manual entry into a shared Google spreadsheet, quickly exceeded file size limitations, and the Global.Health effort aims to provide detailed open access to COVID-19 data on a much larger scale.
CRISIS STANDARDS OF CARE The Johns Hopkins Center for Health Security published its second report on COVID-19 crisis standards of care (CSC), in collaboration with New York City Health+Hospitals. This report focuses on lessons from New York City’s experience managing the early COVID-19 surge in April-June 2020. Based on discussions with frontline clinicians, hospital emergency management practitioners, and other experts from hospitals and public health agencies in New York City, the researchers identified a number of key themes and recommendations.
The study participants shared their experiences with developing and implementing CSC in the midst of an emergency; challenges with insufficient equipment, supplies, space, and personnel; the mental and physical toll of responding to multiple consecutive COVID-19 surges; and coordinating CSC and patient care between emergency medical services (EMS) and hospitals. The participants indicated that the effects on personnel were among the biggest challenges they faced, including the lasting mental health impact. The report also outlines a series of recommendations and issues for future consideration.
Established and consistent CSC, including a formal declaration from hospital or health system leadership, can help mitigate some of these burdens during a health emergency. This report is part of an ongoing effort to improve CSC during communicable disease emergencies.
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