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.
EPI UPDATE The WHO COVID-19 Dashboard reports 332.6 million cumulative cases and 5.55 million deaths worldwide as of January 19. Global weekly incidence increased again last week, up 29.77% over the previous week. This is the 13th consecutive week of increasing weekly incidence, setting another new record with 20.32 million new cases. All WHO regions except Africa (-27.24%) reported increases last week. The Omicron variant drove the greatest percentage increases in South-East Asia (+144.58%), Eastern Mediterranean (+68.25%), and the Western Pacific (+38.49%), followed by the previous leaders of the Americas (+32.46%) and Europe (+17.01%). 

Global weekly mortality increased for the second week, up 10.88% from the previous week with 48,911 total deaths. Cumulative global mortality passed 5.5 million the week ending January 10, up from 5 million on November 1, 2021. The true global death toll of the pandemic is estimated to be much higher, with models from the Institute for Health Metrics and Evaluation and The Economist suggesting COVID-19-related deaths to be between 2 and 4 times higher. 

Global Vaccination
The WHO reported 9.57 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of January 11. A total of 4.7 billion individuals have received at least 1 dose, and 4.0 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations increased from mid-October (21.36 million doses per day) through late-December (38.87 million). However, daily vaccinations continue to decrease, down to 30.15 million on January 19.* Our World in Data estimates that there are 4.73 billion vaccinated individuals worldwide (1+ dose; 60.11% of the global population) and 4.05 billion who are fully vaccinated (51.59% of the global population).
*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 is currently reporting 67.9 million cumulative cases of COVID-19 and 853,230 deaths. The US is averaging 755,095 new cases and 1,669 deaths per day.* Some models estimate that the cumulative number of deaths could rise above 1 million by mid-March, when the Omicron wave is expected to subside.
*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.

COVID-19 hospitalizations in the US set another record high this week, with a 7-day average of 21,086 new hospitalizations per day. The CDC is also reporting a surge in the number of current hospitalizations, up from an average of 125,106 hospitalized COVID-19 patients on January 10 to 142,595 on January 17, an increase of 14% over that period. The current average is the highest since the beginning of the pandemic. 

US Vaccination
The US has administered 530.4 million cumulative doses of SARS-CoV-2 vaccines. The trend in daily vaccinations continues to decline, down from a recent high of 1.74 million doses per day on December 6 to 1.04 million on January 14.* 

A total of 249.7 million individuals have received at least 1 vaccine dose, equivalent to 75.2% of the entire US population. Among adults, 87.1% have received at least 1 dose, as well as 24.7 million children under the age of 18. A total of 209.5 million individuals are fully vaccinated**, which corresponds to 63.1% of the total population. Approximately 73.6% of adults are fully vaccinated, as well as 19.3 million children under the age of 18. Since August 13, 81.7 million fully vaccinated individuals have received an additional or booster dose. An estimated 39% of fully vaccinated individuals have received a booster, including 62.3% 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.

COVID-19 IMMUNE LANDSCAPE With cases of COVID-19 continuing to surge worldwide due to the Omicron variant of concern (VOC), scientists are looking to recent experiences with the Delta variant to shed insight into what the immune landscape might look like for individuals who are unvaccinated and have recovered from previous SARS-CoV-2 infection, those who are vaccinated, and those who are both recovered and vaccinated. The world will be in a significantly different place after Omicron subsides, with millions of people having at least short-term immune memory of its distinct S-gene mutations. More people than ever before will have some form of natural immunity against SARS-CoV-2, but it is unclear the extent to which recent infection might protect against future infection or hospitalization. In a new report published in the US CDC’s Morbidity and Mortality Weekly Report (MMWR), researchers examined case and hospitalization rates in New York and California during the surge of the Delta VOC. They describe a complex immune landscape through the beginning of Delta’s takeover to the time when it became the predominant global variant. 

Initially, in May 2021, vaccinated persons with no prior infection had the lowest rates of hospitalization, but as Delta began to infect more people and cause breakthrough cases, individuals with previous infection were less likely to be hospitalized compared to unvaccinated persons with no prior infection. From May 2021 to June 2021, vaccinated persons with no prior infection had the lowest hospitalization rates of any other group at 27.7-fold lower compared with unvaccinated persons with no prior infection. But from October 2021 to November 2021, hospitalization rates among vaccinated persons with prior infection were 57.5-fold lower and 55.3-fold lower among unvaccinated individuals with prior infection, compared with unvaccinated individuals with no prior infection. By comparison, hospitalization rates in vaccinated persons with no prior infection were 19.8-fold lower. These data suggest that natural immunity from prior infection can play an important role in preventing severe consequences of subsequent SARS-CoV-2 infections, even among those who have not been fully vaccinated. 

Some important context to these findings is that the shift in protection from vaccine-alone to vaccine-plus-prior infection occurred during a time of known waning immunity from initial rounds of vaccination. Additionally, people who were fully vaccinated with an additional booster dose were not evaluated as a separate group in this study. All of these data point to having high levels of antibodies—whether vaccine-induced, naturally acquired, or a combinationas vital in protecting against hospitalization and severe COVID-19 outcomes. It is still unclear whether these patterns will hold for the Omicron VOC, which has a greatly different viral profile compared with previous variants. Hospitals are still reporting that the unvaccinated have the highest risk of severe COVID-19, while the group with the lowest risk of severe COVID-19 are those who are fully vaccinated and boosted, underscoring the continuing need for vaccines and booster doses.  

A word of caution: Some might interpret these findings as a “green light” to ignore all COVID-19 precautions and take unnecessary risks for themselves and others. Even if natural immunity does confer protection for an extended time, the consequences of contracting and recovering from COVID-19 cannot be overstated; it is estimated that 15-80% of people recovering from illness will experience “long COVID,” or prolonged symptoms including brain fog, dizziness, loss of taste and smell, and other symptoms which can alter daily life for those affected. While those who might get COVID-19 twice do seem fortunate in that their bodies are better able to fight off the newest infection, it is still better never to become infected with SARS-CoV-2 because of the uncertainties of long-term sequelae. Vaccines, masks, and physical distancing are all still vital tools in bringing an end to the pandemic with as few deaths as possible.

US RESPONSE Beginning next week, the administration of US President Joe Biden will supply 400 million “high-quality” masks at no cost to the US population through community health centers and pharmacies. The N95 respirators, which will come from the Strategic National Stockpile, offer the highest level of protection from SARS-CoV-2, according to new guidance from the US CDC, filtering out 95% of all airborne particles. It is not clear yet how many masks will be available to each person at one time, and recipients will not be prioritized based on vulnerability, income, or other criteria. 
Late last week, the CDC updated its guidance on the types of masks and respirators recommended for use during the COVID-19 pandemic, removing concerns related to shortages of N95 or KN95 respirators and saying “people can choose” those respirators. The agency clarified that some types of masks and respirators provide more protection to the wearer than to others and that “surgical N95s”—respirators that provide additional protection against certain hazards present during medical procedures, such as blood splatter—should be reserved for healthcare professionals. Overall, the CDC continues to encourage people to “wear the most protective mask you can that fits well and that you will wear consistently.” Nearly 150 manufacturer applications to sell N95 masks are backlogged at the CDC, which is being criticized for taking months to review the applications. 

The US government on January 18 quietly launched its new website,, that allows 4 at-home SARS-CoV-2 tests to be shipped to “valid residential addresses” at no cost. According to the site, orders usually will ship within 7-12 days—meaning they are not appropriate for people who need to be tested immediately—and will be delivered by the US Postal Service. The website’s launch comes 1 month after US President Joe Biden announced the government will obtain an additional 500 million free tests and 1 week after he doubled that number to 1 billion tests. White House officials noted a telephone hotline to request tests is also being established, with more information available at the end of this week. Additionally, most US residents with private insurance are now eligible to purchase tests online or in stores and have them covered at the time of purchase or be reimbursed by submitting a claim to their insurer. Only tests bought on or after January 15 are eligible, and insurers are required to pay for up to 8 tests per covered individual per month. Tests available for purchase online or in stores remain difficult to find in many areas of the country, and the Biden administration’s efforts to distribute tests and masks to millions are being viewed by some as a push to regain the trust of the American public in the federal pandemic response.

US VACCINE REQUIREMENTS The US Supreme Court last week issued opinions in response to 2 sets of cases involving federal SARS-CoV-2 vaccine requirements. In one unsigned opinion, the court halted the Biden administration’s enforcement of the Occupational Safety and Health Administration’s (OSHA) Emergency Temporary Standard (ETS) that would have required all workers at firms with 100 or more employees to either get vaccinated or be tested weekly and wear a mask to work (National Federation of Independent Business v. Department of Labor, No. 21A244). In a 6 to 3 decision, the justices concluded that OSHA overstepped its authority in issuing the requirement covering 84 million workers and issued a stay pending a decision from the US Court of Appeals for the Sixth Circuit. The stay undercuts one of US President Joe Biden’s most significant efforts to encourage widespread vaccination and leaves states and companies responsible for making their own policies. For example, Starbucks—which employs 228,000 people in the US—will no longer require employees to be vaccinated following the Supreme Court’s ruling. President Biden expressed disappointment over the court’s decision, saying that the “common sense life-saving requirements” are “grounded squarely in both science and the law.” 

In a separate unsigned opinion, the Supreme Court allowed the Biden administration to continue enforcing a Centers for Medicare and Medicaid Services (CMS) regulation issued by the US Department of Health and Human Services (HHS) requiring vaccination for nearly all workers at hospitals, nursing homes, and other medical facilities that receive federal funds through Medicare and Medicaid (Biden v. Missouri, No. 21A240). The vote in that case was 5 to 4, with Chief Justice John G. Roberts Jr. and Associate Justice Brett M. Kavanaugh joining the liberal justices to form a majority. They concluded that the rule is necessary to protect the safety of patients and “is consistent with the fundamental principle of the medical profession: first, do no harm.” The court’s ruling overturns lower federal court injunctions in 2 dozen states, requiring that facilities participating in federally funded programs vaccinate their employees. Some concerns remain that the mandate will exacerbate existing staffing shortages, especially at some long-term care facilities and smaller rural hospitals. 

TREATMENT DISPARITIES New research published in the US CDC’s Morbidity and Mortality Weekly Report (MMWR) examines racial and ethnic disparities in the use of medications to treat COVID-19 cases within the US. The researchers looked at patient electronic health record data collected between March 2020 and August 2021 at 41 US healthcare systems. They focused on 3 main countermeasures used to treat patients with confirmed SARS-CoV-2 infection during that time period: monoclonal antibodies (mAb) delivered through intravenous infusion or subcutaneous injection, the steroid dexamethasone, and the antiviral remdesivir. Overall, mAb were rarely used to treat individuals with SARS-CoV-2 infection, but when administered, Hispanic patients received mAb 58% less often than did non-Hispanic patients, and Black, Asian, or Other race patients received mAb 22%, 48%, and 47% less often, respectively, than did White patients during November 2020-August 2021. The disparities were different and less pronounced for the other 2 treatments, with Black inpatients receiving remdesivir 9% more often than other racial groups and Hispanic patients receiving dexamethasone 6% more often than non-Hispanic groups. The researchers stressed the importance of better understanding this data and addressing gaps to build more equitable healthcare systems. 

In an attempt to bridge these gaps, some states—including New York, Utah, and Minnesota—updated guidance to include formulations offering race as a preferential factor for receiving mAb treatment. However, at least Minnesota has dropped the scoring system that took race into account after the threat of a lawsuit. A fact sheet from the FDA also lists race and ethnicity as potential risk factors that may put patients at high risk for progression to severe COVID-19. That language has drawn criticism from some conservative US lawmakers. 

BEIJING WINTER OLYMPICS China this week announced that tickets to the Beijing Winter Olympics will no longer be sold to the general public, with the announcement coming less than 2 days after health authorities detected the city’s first case of the SARS-CoV-2 Omicron variant of concern (VOC). Ticket sales already were limited to domestic spectators, and now will be further limited to certain approved groups that will need to undergo strict screening and quarantining measures. In a statement, the International Olympic Committee said the new rules were intended to “help create an absolutely safe environment for the athletes.” In recent weeks, China has switched from a “zero tolerance” approach to COVID-19 to a new “dynamic clearing” policy, which accepts that cases will happen and empowers local authorities to implement strategies to deal with them. However, the thinking behind the previous approach continues to prevail, with authorities taking aggressive steps to quell a series of outbreaks and more than 20 million people across the country in some stage of lockdown. 

The highly transmissible Omicron variant poses a significant test to the country’s policies, especially after several studies have shown that the Chinese-produced vaccines from Sinovac Biotech and Sinopharm produce significantly lower neutralizing antibodies against Omicron than other major vaccines. Additionally, some evidence suggests that prior natural immunity gained from previous infection plus vaccination provides the most robust immune response to protect from severe disease. With low levels of natural immunity among China’s population, as well as weak health systems in some areas, hospitals could become overwhelmed if Omicron were to spread. Pfizer-BioNTech has licensed its vaccine to Shanghai Fosun Pharmaceutical Group, allowing the company to domestically manufacture the shots and the government to roll out a booster program using them. In the meantime, companies worldwide are preparing for continuing supply chain disruptions as Chinese officials continue to impose community- and citywide lockdowns.

ENGLAND British Prime Minister Boris Johnson announced on January 19 that all COVID-19 mitigation measures implemented under the government’s “Plan B”—including mandatory mask-wearing on public transportation and in retail shops and the use of vaccine certificates—will be dropped in England late next week. The guidance to work from home and the need for students to wear masks at secondary schools both ended immediately. Prime Minister Johnson noted England is moving back to “Plan A” due to the successful rollout of booster doses and what appeared to be a peak in the Omicron surge. Notably, while the number of new COVID-19 cases is dropping, the level still remains well above the previous high peak in January 2021. Scotland and Wales have also announced similar easing of mitigation measures. While the news was welcomed by many businesses, some teaching and health unions and public health representatives raised concern over the loosening of restrictions. Teachers warned that COVID-19-related disruptions continue at schools; National Health Service (NHS) officials cautioned that nearly 20,000 COVID-19 patients remain in hospital and the system is stretched thin; and health groups said the abrupt switch could send the wrong message to the public as more of a political move than one grounded in science. Indeed, Prime Minister Johnson is facing political challenges over allegations that he held several large events at Downing Street that breached lockdown policies.

TONGA While more continues to be learned about the devastation in Tonga after a massive volcanic eruption on January 15, life is beginning to return to normal on the main island of Tongatapu after it was covered in a thick coating of ash and hit by a tsunami resulting from the blast. As many as 150 homes were damaged or destroyed and at least 3 people were killed as a result of the eruption and tsunami. UN humanitarian flights have been delayed as ash is cleared from the airport runway, and aid agencies are working to coordinate delivery of aid without direct contact with residents. Tonga is a COVID-free zone, logging only one COVID-19 case during the pandemic, and fears are high that outside assistance—without the nation's mandatory 21-day quarantine—could bring the virus to the country, complicating recovery efforts. UN officials have noted that they are taking action to follow necessary protocols for entry into the country.