Updates on the COVID-19 pandemic from the Johns Hopkins Center for Health Security.
Additional resources are available on our website.
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The Johns Hopkins Center for Health Security also produces US Travel Industry and Retail Supply Chain Updates that provide a summary of major issues and events impacting the US travel industry and retail supply chain. You can access them here.
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The Johns Hopkins Center for Health Security is now producing a weekly roundup of updates on SARS-CoV-2 vaccine development, policy, and public perception in the US. This is a resource from CommuniVax, a research coalition convened by the Johns Hopkins Center for Health Security and the Texas State University Department of Anthropology, with support from the Chan Zuckerberg Initiative. Read the weekly summary here.
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EPI UPDATE The WHO COVID-19 Dashboard reports 91.49 million cases and 1.98 million deaths as of 7am EST on January 15.
Despite initial concerns about public health and healthcare infrastructure in many countries, the continent of Africa continues to represent a small fraction of the global daily COVID-19 incidence. But while many African countries have demonstrated prolonged success in terms of containing COVID-19, daily incidence and mortality in Africa have been increasing sharply since early December. Daily incidence has increased by nearly 150% and daily mortality has more than tripled since December 1.
As a whole, Africa’s daily incidence has increased 36% over the past 2 weeks, but this trend is not consistent across all countries. Much of the recent surge has been focused geographically in the southern part of the continent as well as the coastal portion of West Africa. In total, 23 countries have reported increases in daily incidence of more than 50% over the past 2 weeks. Excluding the island nations, all but 4 of these—Burundi, Chad, Sudan, and Tanzania—are located in the South or West regions of Africa. The countries reporting steady or declining daily incidence over the past 2 weeks are more evenly distributed geographically, with 12 of the 16 located in the East, Central, and North regions; 2 in the South region; and 2 in West Africa.
At the highest end of the scale, 11 countries in Africa have reported increases in daily incidence of more than 300% over the past 2 weeks, including São Tomé and Principe at 3,400% and Liberia at 1,533%. São Tomé and Principe is currently reporting only 12 new cases per day, and Liberia is reporting 14; however, the drastic proportionate increase over the past several weeks is certainly cause for increased attention. While it is actually near the middle of African countries in terms of the relative change in daily incidence, South Africa (46% biweekly increase) continues to represent the majority of the daily incidence in Africa. South Africa is currently reporting 18,031 new cases per day, approximately 56% of the continent’s daily total. In terms of total daily incidence, Tunisia is #2 (2,663; 37% biweekly increase) and Nigeria is #3 (1,363; 57% increase). On a per capita basis, Seychelles is #1 in Africa with 369 daily cases per million population (587% increase), followed by South Africa (304) and Tunisia (225). In total, 24 African countries are reporting fewer than 5 new daily cases per million population, including 10 with fewer than 2.
UNITED STATES
The US CDC reported 22.97 million total cases and 338,351 deaths. Since January 8, the average US daily incidence has hovered between 240-250,000 new cases per day, and it appears as though the daily incidence could be leveling off to some degree. Looking at the monthly average, which smooths out some of the effects of delayed holiday reporting, the US could be approaching a peak or plateau. That being said, it has been less than 3 full weeks since the Christmas holiday weekend and less than 2 weeks since the New Year’s holiday weekend, so we are likely not yet seeing the full effects of holiday travel and gatherings on the national scale.
On January 12 and 13, the US reported 4,131 and 4,096 deaths, respectively. These are the second and third highest daily totals to date*, and this is the first time since the onset of the pandemic that the US reported more than 4,000 deaths on consecutive days. The current average daily mortality (3,357 deaths per day) is 17.5% higher than the peak of the initial US surge in April, and the average mortality has remained higher than the initial peak for 6 consecutive days. The US reported 23,502 new COVID-19 deaths in the past week, which exceeds the estimated 22,000 seasonal influenza deaths for the entire US 2019-20 influenza season. If the US is, in fact, approaching a peak or plateau in terms of daily incidence, we can expect mortality to continue increasing for at least the next 2-3 weeks.
The US CDC reported 30.63 million vaccine doses distributed and 11.15 million doses administered (36.4%), including 1.23 million administered in long-term care facilities (LTCFs). The CDC vaccine tracker now includes data on the total number of people who have received at least 1 dose (9.69 million) and those who have received 2 doses of the vaccine (1.34 million people). These data are also available at the state level. The CDC also added a breakdown of the administered doses by manufacturer, with 6.53 million doses of the Pfizer/BioNTech vaccine and 4.62 million doses of the Moderna vaccine.
VACCINE TRIALS & AUTHORIZATION On January 12, the European Medicines Agency (EMA) received the conditional marketing application for AstraZeneca/Oxford University’s SARS-CoV-2 vaccine. A press release from the EMA indicated that the application “will proceed under an accelerated timeline,” with the EMA issuing its recommendation as early as January 29. The short timeline is possible as a result of the EMA’s rolling review process, which enabled EMA officials to evaluate interim Phase 3 clinical trial data as they became available.
Additional reports of clinical trial results for the vaccine candidate developed by Sinovac (China) continue to emerge. Researchers conducting Phase 3 clinical trials conducted in multiple countries have reported varying levels of efficacy over the past several weeks. Previously, researchers in Turkey reported 91%, Brazil reported 78% efficacy, and Indonesia reported 65%. Multiple news media reports indicate that, earlier this week, researchers from Brazil’s Butantan Institute released new efficacy analysis that is considerably lower than previous estimates. The newest results estimate the Sinovac to be 50.4% efficacious at preventing COVID-19 disease. While this is still above the generally accepted threshold for a successful vaccine, it is much lower than the estimates for other vaccines currently in use, and the inconsistency in the Sinovac trial results, coupled with relatively low value in the most recent results, has raised concerns. Notably, the individual clinical trials utilized their own study designs, so the efficacy estimates may not be directly comparable between trials. To our knowledge, neither the full datasets nor peer-reviewed analysis have been published for any of the Phase 3 trials of the Sinovac vaccine. Following the announcement, officials in Malaysia and Singapore reportedly indicated that more data would be required before finalizing existing purchase agreements.
Researchers conducting clinical trials for the Johnson & Johnson (J&J)/Janssen candidate SARS-CoV-2 vaccine published interim Phase 1/2a trial data in The New England Journal of Medicine (NEJM). The early-stage trials demonstrated that the J&J/Janssen vaccine generated neutralizing antibody response in 90% of participants after 29 days and in 100% after 57 days, and the vaccine exhibited an acceptable safety profile. This is encouraging news, but Phase 3 trial data will be important in terms of assessing the vaccine’s efficacy. The Phase 1/2a trials consisted of only 805 participants, but officials from J&J indicated that the results from much larger Phase 3 trials could be released by the end of January. In contrast to the vaccines already in use, the J&J/Janssen vaccine requires only a single dose, which could be an important tool in speeding vaccination efforts. A report published in The New York Times indicated that existing production capacity for the J&J/Janssen vaccine has not met the expected timeline, potentially 2 months behind schedule, which could slow its initial release once authorized for use.
INTERNATIONAL VACCINATION
EUROPE
Earlier this week, UK Prime Minister Boris Johnson announced that vaccination operations will be conducted around the clock. He also indicated that vaccine production and supply are the biggest barriers currently, as opposed to vaccine administration. Public Health England reported that more than a third of adults aged 80 years and older in England have received at least 1 dose of the SARS-CoV-2 vaccine.
In Spain, record snowfall across the central region of the country reportedly delayed vaccination distribution and operations. Approximately, 350,000 doses of the Pfizer/BioNTech vaccine arrived this week at airports across the country, but the inclement weather resulted in the doses destined for Madrid to be diverted to the northern city of Vitoria. A senior government health expert indicated that he expected the overall impact to be limited in terms of the total doses administered, but future plans will need to be adapted to increase efforts in the affected areas. According to the Ministry of Health, Spain has administered approximately 60% of its 1.13 million doses.
To aid vaccine rollout in Germany, mass vaccination sites are being established in sports venues and concert halls, with the aim of establishing national capacity to administer 300,000 doses per day. Many of these facilities remain empty, however, as long-term care facilities remain the priority. Like many other countries, Germany’s vaccination effort has experienced delays. In the first 2 weeks of the vaccination campaign, only 533,000 doses were administered, approximately 40% of the 1.3 million doses it received. Germany is expected to receive 5.3 million doses of the Pfizer/BioNTech vaccine by mid-February as well as another 2 million doses of the Moderna vaccine by the end of March. Additionally, Germany is in the process of establishing new production facilities and converting existing facilities to manufacture various SARS-CoV-2 vaccines, some of which could be operational in the coming weeks.
AFRICA
The African Vaccine Acquisition Task Team announced that it has provisionally secured access to 270 million doses for African countries, including 50 million that are expected to be available by June. The allotment will include doses from multiple manufacturers, including AstraZeneca (via the Serum Institute in India), Pfizer, and Johnson & Johnson. These efforts are intended to supplement the doses provided through COVAX, which may only be enough to cover frontline healthcare workers. Acquiring enough doses is a financial concern for many African countries, and the Africa CDC director has encouraged countries with surplus supply to donate to countries in need to supplement the efforts of COVAX and Gavi to support 92 low- and middle-income countries, more than half of which are in Africa.
South Africa reportedly expects to receive 1 million doses of the AstraZeneca/Oxford University vaccine in January, with another 500,000 doses in February, manufactured by India’s Serum Institute. This total is expected to cover approximately half of South Africa’s Phase 1 priority group, frontline healthcare workers (1.25 million). Phase 2 will expand eligibility to other essential workers, individuals living in congregate settings, adults aged 60 and older, and those with underlying health conditions. The AstraZeneca/Oxford vaccine is not currently authorized for use in South Africa, but regulatory officials will reportedly leverage the authorizations in other countries (e.g., UK, India) to permit the emergency use of an unregistered product. According to a report published in The Wall Street Journal, no vaccine manufacturers have yet filed applications for any kind of authorization; but this may not necessarily delay the vaccines’ availability for use in South Africa.
ASIA
Indonesia reportedly initiated its SARS-CoV-2 vaccination campaign after receiving shipments of China’s Sinovac vaccine. Indonesia will prioritize its frontline healthcare workforce (approximately 1.5 million people), largely due to high COVID-19 mortality among this group. Like other countries, Indonesia is facing challenges regarding vaccine hesitancy and opposition, including among healthcare workers, particularly in light of the recent Phase 3 clinical trial results from Brazil. Indonesian President Joko Widodo publicly received his vaccination this week in an effort to bolster community support. We have not identified a definitive list of priority groups for Indonesia, but new media outlets have reported multiple different strategies, including healthcare workers, older individuals, and younger individuals. Several news media reports indicate that social media “influencers” are among the highest priority groups. While many of these individuals are younger and at lower risk for severe COVID-19 disease and death, Indonesia hopes this approach can help build support for vaccination among the public and mitigate the effects of vaccine hesitancy and opposition.
China is also establishing large mass vaccination sites in an effort to scale up vaccine administration capacity. A recent surge in transmission—which has prompted regional “lockdowns,” including in Beijing—is a driver of the increased vaccination efforts. Concerns regarding the efficacy of Chinese-developed vaccines, as well as the lockdowns themselves, could be posing barriers to vaccination; however, analysis by Reuters indicates that China’s vaccination program is scaling up rapidly, surging from 1.5 million doses administered from July-November 2020 to 10 million doses as of January 13.
OCEANIA
Australia and New Zealand have both demonstrated the ability to effectively contain their respective COVID-19 epidemics. Considering their success in limiting transmission, both countries are reportedly delaying their vaccination campaigns until mid-to-late February. This extra time will allow health and regulatory officials to gather more information on the efficacy and safety of the various SARS-CoV-2 vaccines and vaccine candidates. Additionally, the delay will provide both countries an opportunity to better prepare their distribution plans.
In Australia, the government has announced that they plan to administer the Pfizer vaccine candidate to their highest priority groups and largely use the AstraZeneca/Oxford vaccine for the broader population. The rationale for this decision seems to be based on the anticipation that Australia will receive the Pfizer vaccine first, but that the AstraZeneca/Oxford vaccine will be manufactured domestically. The Australian first priority group includes, quarantine and border workers, frontline health care workers, and long-term care facility residents and workers, which could include approximately 700,000 people. The Australian government aims to vaccinate 80,000 people per week initially, with the goal of covering the entire country’s population by the end of 2021, using community partners like drug stores. In New Zealand, Prime Minister Jacinda Ardern announced plans to vaccinate the country’s entire population (5 million), largely in the second half of 2021. New Zealand could begin with border control personnel and first responders in the spring, and it will prioritize areas with ongoing COVID-19 outbreaks, including healthcare workers, household contacts, and the general public in affected areas. New Zealand has actually developed phased vaccination priority groups for 3 different scenarios, based on the level of community transmission.
US VACCINE PRIORITIZATION Last week, the incoming Biden Administration announced that it intends to make nearly all of the existing US SARS-CoV-2 vaccine inventory available to states, rather than the current plan of reserving vaccine to ensure availability for second doses. Following the release of the Biden Administration plan, US Secretary of Health and Human Services Alex Azar announced that the federal government will begin distributing the remaining reserve inventory to states even before President-Elect Biden takes office. Secretary Azar also recommended that states expand eligibility to all adults aged 65 and older as well as adults under the age of 65 with underlying health conditions that could put them at risk for severe COVID-19 disease or death. As part of this recommendation, the federal government will allocate doses to states based on their respective populations aged 65 and older. Secretary Azar argued that some states’ strict adherence to limited initial priority groups has slowed vaccinations and that the new policy would speed progress.
The sudden policy shift, with little warning and little financial or operational support for state and local officials responsible for implementing mass vaccination campaigns, has raised concerns among some experts. States are already conducting vaccination operations using their own priority groups—with substantial variation from state to state—some of which have caused confusion among the public regarding who is eligible or how to get vaccinated. Notably, this bulk expansion could include approximately 150 million adults nationwide, nearly half of the entire US population, all at once. Current production estimates project that the US could have 200 million doses available by the end of March; however, this is only enough to provide 2 doses for 100 million people, well short of the eligible population.
The new policy also deviates from the most recent guidance from the CDC’s Advisory Committee on Immunization Practices, which recommends expanding to adults aged 75 and older and essential workers in Phase 1b—approximately 49 million people. Under the ACIP plan, adults aged 65 and older and adults with underlying health conditions would be included in Phase 1c. The absence of essential workers (e.g., those who cannot work remotely) from the new HHS guidance could delay vaccination for those who are most likely to be exposed, many of whom are racial and ethnic minorities who have been disproportionately affected during the pandemic. The change to expand eligibility more broadly does align with comments from some experts, who argue that the complex eligibility requirements from ACIP were too difficult to implement and could slow vaccination progress, but this is not necessarily the only consideration in terms of establishing priority groups. At this point, it is unclear how states will respond to the new recommendations.
US CDC TRAVEL & TESTING REQUIREMENTS The US has implemented COVID-19-related travel advisories and restrictions for most countries around the world (including the US itself) for many months, but it recently updated screening and testing requirements for inbound travelers. The new policy, which takes effect on January 26, requires all airline passengers arriving from another country to have a negative SARS-CoV-2 test or documentation of prior infection before they are permitted to enter the US. The negative test must be administered within 3 days of the flight’s departure, and in order to document prior infection, travelers must provide both the test results and a written letter from a licensed healthcare provider that attests to the traveler’s recovery. The new order supersedes a similar order issued in December that applied only to travelers arriving from the UK. The order explicitly addresses the emerging B.1.1.7 variant, although not by the lineage nomenclature, which provides indication that the new travel restrictions aim to limit the introduction of new, more transmissible variants to the US.
The B.1.1.7 variant has already been detected in numerous US states, including in individuals with no recent international travel. In particular, the variant was recently identified in a patient in New York state, which prompted New York City Mayor Bill de Blasio to call for a complete ban on travel from the UK. Notably, prohibiting travel from other countries will not prevent the introduction to the US, particularly because it is already circulating to some degree among the general public. With the advance warning from the UK and other countries, it is critical to use any time gained by the new testing requirements to expand surveillance capacity capable of detecting the emerging variants (e.g., genomic sequencing) before the variant is widespread. Additionally, recommended public health measures—including enhanced hygiene, physical distancing, and mask use—will be important tools to mitigating community transmission and limiting the impact of emerging variants on the public’s health as vaccination efforts continue to scale up.
EMA CYBERATTACK In December, the European Medicines Agency (EMA) was the victim of a cyberattack that targeted communications and data related to its SARS-CoV-2 vaccine evaluation and authorization process. The EMA immediately initiated an investigation to determine the extent of the breach and to identify the perpetrators. On January 12, the EMA issued an update indicating that some of the documents accessed during the attack had been published publicly on the internet. In an update issued today, the EMA reported that some of the leaked documents were altered prior to their publication. Notably, the update states that some of these correspondence were “manipulated by the perpetrators...in a way which could undermine trust in vaccines.” These deliberate efforts to spread disinformation are highly concerning, particularly in light of concerns about the existing level of hesitancy and opposition to the new SARS-CoV-2 vaccines. The statement makes it clear that the EMA and EU countries have not compromised in any way regarding the safety and efficacy of the vaccines available in Europe. The EMA is coordinating with law enforcement officials, and the investigation is ongoing.
VACCINATION INCENTIVES As vaccine eligibility in the US expands beyond Phase 1a to include members of the broader public, some employers are evaluating options that aim to encourage employees to get vaccinated once they become eligible. As we have covered previously, there are growing concerns regarding the level of hesitancy and opposition to SARS-CoV-2 vaccination, in the US and around the world. In an effort to combat vaccine hesitancy and opposition, some businesses are offering incentives for those who get vaccinated. For example, a hospital system in Houston, Texas, is reportedly offering employees a US$500 bonus if they get vaccinated. Similarly, Dollar General, which operates a national chain of retail stores, is offering its employees 4 hours’ pay to enable them to get vaccinated. As opposed to a bonus-style payment, this effort aims to allow employees who earn hourly wages the ability to take time off of work in order to get vaccinated without negatively impacting their income. Some experts and elected officials have proposed similar programs that would pay all individuals who get vaccinated, but none have yet come to fruition, at least not in the US.
Some experts have raised concerns about these kinds of payments, noting that they could be viewed as efforts to coerce individuals because the vaccines are risky or dangerous, which can feed existing anxiety and concern in others. The use of financial incentives could “unfairly tak[e] advantage of those...who have lost jobs, experienced food and housing insecurity, or slipped into poverty during the pandemic” and who may then view vaccination as a necessity “in order to...purchase food or pay rent.” The prospect of financial payment or other incentives could also potentially lead some individuals to deliberately delay vaccination in hopes of future compensation.
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