COVID-19 Situation Report
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EPI UPDATE The WHO COVID-19 Dashboard reports 188 million cumulative cases and 4.06 million deaths worldwide as of 4:30am EDT on July 16.

Global Vaccination
The WHO reported 3.40 billion doses of SARS-CoV-2 vaccines administered globally as of July 15, including 1.31 billion individuals who have received at least 1 dose and 620 million who are fully vaccinated. Analysis from Our World in Data shows that the global daily doses administered continues to decline rapidly from the record high of 43.3 million doses per day on June 27, now down to 29.0 million. Daily vaccinations are decreasing steadily in Asia and North America, leveling off in Europe and Africa, and increasing in Oceania and South America. Our World in Data estimates that there are 2.02 billion vaccinated individuals worldwide (1+ dose; 25.9% of the global population). There are an estimated 988 million who are fully vaccinated (12.7% of the global population), although reporting is less complete than for other data.

The US CDC is reporting 33.8 million cumulative COVID-19 cases and 605,905 deaths. The US is averaging 26,306 new cases per day, more than double the low of 11,472 on June 20. Superficially, the epi curve over the past several weeks closely resembles the early stages of previous US surges. Daily mortality has increased over the past several days as well, up to 211 deaths per day from a low of 154 on July 11—a 37% increase over the past 4 days. If this is the beginning of a longer term increasing trend in daily mortality, it would correspond to a lag of 3 weeks behind the trend in daily incidence, which is consistent with trends we have observed over the course of the pandemic. Analysis from the New York Times indicates that all 50 states are exhibiting increasing daily COVID-19 incidence over the past 2 weeks, including 22 (plus Washington, DC and Puerto Rico) that have doubled or more over that period.

As the US continues to exhibit early signs of a COVID-19 surge, increasing daily incidence in some states is calling attention to disparities in vaccination coverage. This week, we will take a closer look at recent trends in incidence and vaccination coverage at the state level.

Among the 10 states with the lowest per capita weekly incidence, 7 are in the top 10 in terms of 1+ dose vaccination, and 7 are in the top 10 in terms of full vaccination. While the majority of states with lower weekly incidence also are reporting higher vaccination coverage, there are some notable exceptions. Michigan is currently reporting the lowest per capita weekly incidence (9.2 weekly cases per 100,000 population), but it ranks #24 in terms of 1+ dose coverage (52.2%) and #23 for full coverage (48.1%). Similarly, South Dakota is reporting the third lowest incidence, but it is #28 (51.3%) and #26 (46.2%) for partial and full vaccination coverage, respectively.

Among the 10 states with the highest per capita weekly incidence, 4 are reporting among the bottom 10 in terms of both partial and full vaccination coverage—Mississippi, Wyoming, Louisiana, and Arkansas—and Oklahoma ranks just outside the bottom 10 for partial coverage (#39) but ranks #41 for full coverage. Like with the states reporting lower incidence, there are exceptions here as well. Notably, Florida is #21 (55.2%) and #25 (47.3%) in terms of partial and full vaccination coverage, respectively, but it is reporting the third-highest per capita weekly incidence (183.2).

Analysis from the New York Times—which draws from official CDC and state data—provides the relative change in daily incidence over the past 2 weeks. Among those states in the top 10 largest changes, 4 are among the bottom 10 states in terms of vaccination coverage—Tennessee (+373%), Alabama (+194%), Louisiana (+185%), and Oklahoma (+155%). Notably, however, this list also includes Vermont (+211%) and Massachusetts (+208%), which are #1 and #2, respectively, in terms of full vaccination coverage. The low daily incidence in these 2 states results in large relative changes for even small increases in total daily incidence.

There appears to be an association between recent COVID-19 incidence trends and vaccination coverage at the state level, although on the surface, it is not quite as clear as might be expected. Additionally, the increased effect from full vaccination coverage is not quite as strong as we anticipated, and more detailed analysis is needed to better characterize the differences between partial and full vaccination. It is important to remember, however, that vaccination coverage and SARS-CoV-2 transmission are not distributed evenly across states, and community-level vaccination coverage is likely a better measure of protection. Pockets of lower vaccination coverage can provide ideal conditions for transmission, particularly in the absence of other protective measures, which have been largely lifted across the country.

US Vaccination
The US has administered 336 million cumulative doses of SARS-CoV-2 vaccines, and it is administering approximately 421,000 doses per day, holding relatively steady over the past several days. A total of 185 million individuals in the US have received at least 1 dose, equivalent to 55.8% of the entire US population. Among adults, 67.9% have received at least 1 dose as well as 9.7 million adolescents aged 12-17 years. A total of 160 million individuals are fully vaccinated, which corresponds to 48.3% of the total population. Approximately 59.2% of adults are fully vaccinated as well as 7.6 million adolescents aged 12-17 years.

INDONESIA The more transmissible Delta variant of SARS-CoV-2 is driving a steep increase in COVID-19 cases in Indonesia, the world’s fourth most populous country. Indonesian officials reported a record 56,757 new cases on July 15, with a 7-day average of 44,145, putting the nation ahead of India and Brazil and making it the pandemic epicenter in Asia. The test positivity rate is 29.3%, suggesting the number of infected people likely is much higher. Results from a survey published July 10 indicate that nearly half (44.5%) of Jakarta’s approximately 10.6 million residents may have acquired SARS-CoV-2 by the end of March. Nevertheless, the daily number of new cases recorded in the archipelago country has risen 10-fold since then. Hospitals across the country are at or nearing capacity, family members are buying up scarce oxygen supplies for home use, and gravediggers are working day and night. On July 3, the islands of Bali and Java entered an Emergency Community Activity Restriction (PPKM) in an effort to stem new infections, with President Joko Widodo urging residents to “remain calm and alert.” The government is working to increase the number of available hospital beds; provide treatments for 210,000 COVID-19 asymptomatic patients or those with loss of smell, fever, or cough; import additional oxygen supplies; and distribute rice and other food to fulfill a presidential order stating “that no one should go hungry.” 

The government also is increasing vaccination efforts, implementing programs for junior high and high school students and door-to-door vaccinations. Indonesia has relied primarily on the Chinese-produced Sinovac SARS-CoV-2 vaccine for its national vaccination rollout, but some experts have raised concerns over that vaccine’s effectiveness against the Delta variant. In total, Indonesia has received nearly 138 million doses of the Sinovac, AstraZeneca-Oxford, and Moderna vaccines, enough to fully vaccinate 69 million people but far short of its goal of reaching 181 million by March 2022. On July 15, the Indonesian FDA (BPOM) authorized the Pfizer-BioNTech vaccine, and the country is set to receive 50 million doses. Only about 15% of the country’s population has received at least one dose of vaccine, with approximately 6% fully vaccinated. Coordinating Minister for Maritime Affairs and Investment Luhut Binsar Pandjaitan expressed hope that the government’s efforts would quickly begin to realize results, but it remains to be seen how the country will fare over the coming weeks. 

SARS-COV-2 ORIGIN WHO Director-General Dr. Tedros Adhanom Ghebreyesus on July 15 said there had been a “premature push” to rule out the theory that SARS-CoV-2 escaped a Chinese laboratory and asked China to be more transparent and cooperative with investigators trying to determine the origins of the COVID-19 pandemic. Dr. Tedros’s remarks stray from the agency’s own report that concluded a laboratory leak was “extremely unlikely.” As we previously reported, most experts agree that SARS-CoV-2 was not man made nor genetically modified, and there is no empirical evidence suggesting the virus accidentally or intentionally escaped a laboratory setting. Nevertheless, the issue has become entangled in politics, with China arguing that attempts to link the pandemic’s origins to a lab are politically motivated and encouraging future attempts to search for the virus’s origin continue in other countries. In remarks to the media, Dr. Tedros renewed calls for China to share information about a government lab in Wuhan, the city where SARS-CoV-2 was first identified, saying, “If we get full information, we can exclude (the lab theory).” 

US SURGE Following months of decline, the number of new daily COVID-19 cases is rising again in the US, more than doubling over the past 3 weeks. The increase in cases likely is being driven by the highly transmissible SARS-CoV-2 Delta variant, low vaccination rates in some regions, a loosening of prevention measures, and gatherings over the Independence Day holiday. Nationwide, 55.8% of the population has received one dose of vaccine and 48.3% is fully vaccinated. However, the 5 states with the largest 2-week rise in cases per capita all had vaccination initiation rates lower than the national rate: Missouri (45.7%); Arkansas (43.4%); Nevada (51.4%); Louisiana (39.5%); and Utah (50.5%). 

US NIH Director Dr. Francis Collins expressed concern about the increase in cases in Missouri, where the Delta variant is spreading rapidly. The state is reporting a 7-day average of nearly 1,800 new cases each day, compared with about 400 at the beginning of June. In Los Angeles County, California, the Delta variant also is driving an increased number of cases. In response, the county is reinstating its indoor mask mandate for all residents regardless of vaccination status beginning July 17. Almost all of the county’s COVID-19 cases and related hospitalizations and deaths are among unvaccinated individuals. In contrast, Florida Gov. Ron DeSantis’s reelection campaign team this week unveiled new merchandise reading “Don’t Fauci My Florida,” at the same time the state is experiencing some of the greatest increases in new infections, COVID-19-related deaths, and hospitalizations per capita in the country.

BREAKTHROUGH INFECTIONS In order to understand the effectiveness of vaccination efforts, health officials are monitoring for signs of “breakthrough” infections—ie, infections in fully vaccinated individuals—which provide insight regarding both the degree of protection provided by the vaccines as well as risk factors that could affect that protection. But in order to effectively utilize these data, health officials must determine (1) what qualifies as a breakthrough infection and (2) whether they should treat all breakthrough infections equally. As we covered previously, clinical trials for SARS-CoV-2 vaccines utilized different metrics to estimate efficacy, and depending on whether you look at SARS-CoV-2 infection, symptomatic COVID-19 disease, or severe disease or death, vaccine efficacy can vary widely. An article published in The Atlantic takes a similar look at breakthrough infections.

From a strict epidemiological perspective, taken by the US CDC, any SARS-CoV-2 infection in a fully vaccinated individual is technically a breakthrough infection; however, breakthrough infections are not “synonymous with vaccine failure.” Breakthrough infections encompass a broad scope of disease severity, ranging from asymptomatic infections to severe disease and, in some instances, death. But the fraction of breakthrough infections that result in severe disease is extremely small, which is exactly what the clinical trial data illustrate. While the authorized vaccines’ efficacy against symptomatic COVID-19 disease is 90% or higher, the efficacy against severe disease is nearly 100%. Symptomatic breakthrough infections are not unexpected—nor are severe cases—but the vaccines have demonstrated their ability to drive that risk to nearly zero. In fact, the CDC has reported only 3,554 hospitalized breakthrough cases and 733 deaths out of more than 157 million fully vaccinated individuals*. Ultimately, the goal of vaccination is to prevent severe disease and death, and any additional benefit in terms of mitigating infection or transmission is a bonus. Based on the available data, it is clear that the SARS-CoV-2 vaccines are excelling, and they will remain a critical tool in preventing serious disease and death around the world as vaccination efforts continue.
*Through July 6; excluding asymptomatic individuals and those whose hospitalization or death was a result of other conditions.

J&J-JANSSEN VACCINE IMMUNITY DURATION Researchers from Janssen Vaccines and Prevention and Beth Israel Deaconess Medical Center conducted an 8-month Phase 1/2a clinical trial to assess the duration of immunity following vaccination with the J&J-Janssen SARS-CoV-2 vaccine (Ad26.COV2.S) and published interim results in the New England Journal of Medicine. The study consisted of 20 participants who received 1 or 2 doses of the vaccine and 5 who received a placebo. The researchers evaluated antibody and T-cell responses 8 months after the first dose—which corresponds to 6 months after the second dose for those who received 2 doses.

Antibody responses remained relatively stable over the study period and were detectable in all 20 vaccinated participants. The median neutralizing antibody titer decreased by a factor of 1.8 between the peak response on Day 71 and the end of the study, a relatively minimal difference over that period. In addition to the wild-type strain of the virus, the researchers also tested for antibodies against several variants of concern/interest (VOCs/VOIs), including Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), and Delta (B.1.617.2). The immune response to the VOCs/VOIs tended to be substantially lower early after vaccination (Day 29), but while the overall antibody response decreased slightly, the neutralizing antibody titers against the variants increased over time. By the end of the study period, the antibody response against the VOCs/VOIs reached levels comparable to those against the wild type strain, regardless of whether participants received 1 or 2 doses. This demonstrates both that the J&J-Janssen vaccine maintains sufficient protection over a prolonged period of time and stimulates increasing protection against emerging variants, even without a booster dose.

DELTA VARIANT TRANSMISSION In a report posted on the Virological discussion forum, researchers compared data from quarantined patients in a 2021 outbreak of the SARS-CoV-2 Delta variant (B.1.617.2) in mainland China to those of a 2020 outbreak caused by the 19A/19B genetic strains. Between May 21, 2021 and June 18, 2021, 167 cases of Delta were reported, all of which could be epidemiologically or genetically traced back to the index case. The time interval from exposure to first PCR positive test in the 2020 outbreak was 6 days, compared with 4 days in the 2021 outbreak. On the day of first detection, the relative viral loads of the Delta variant infections were 1,260 times higher than the 19A/19B strains infections, suggesting a higher within-host growth rate of Delta and a higher degree of infectiousness in the early days of infection. The researchers also note that this higher degree of viral replication for Delta likely results in an increased risk of viral mutation during outbreaks, underlining the need to quickly identify and quarantine people who have been exposed in outbreaks. 

PEDIATRIC VACCINE CLINICAL TRIALS A recent study published in the New England Journal of Medicine reports that the Pfizer-BioNTech vaccine (BNT162b2) produced a greater immune response in 12-to-15-year-old participants than in young adults aged 16 to 25 and was highly effective against COVID-19 with a favorable safety profile. The ongoing multinational, placebo-controlled, observer-blinded trial randomly assigned 2,260 participants in a 1:1 ratio to receive two injections, 21 days apart, of 30 μg of vaccine (1,131 participants) or placebo (1,129 participants). There were no serious vaccine-related adverse events but some mild-to-moderate primary complaints, including injection site pain (79-86% of participants), fatigue (60-66%), and headache (55-65%). Among participants with no evidence of previous SARS-CoV-2 infection, no cases of COVID-19 with onset of 7 days or more after the second dose occurred in the vaccine group, while 16 cases were reported in the placebo group, resulting in an observed efficacy level of 100% (95% confidence interval [CI], 75.3 to 100). After dose 1 and before dose 2, there were 3 cases of COVID-19 in the vaccine group, and 12 cases in the placebo group (vaccine efficacy, 75%; 95% CI, 7.6 to 95.5). The Pfizer-BioNTech vaccine currently is the only SARS-CoV-2 vaccine authorized for younger individuals aged 12 and older. 

SUMMER CAMPS & SCHOOLS In what some experts fear could be a forecast for the upcoming school year, recent COVID-19 outbreaks at summer camps have occurred in several US states. Camps in Illinois, Texas, Kansas, Florida, Utah, and Missouri have reported outbreaks among children and staff, with some leading to transmission in the wider community. Many of the camps did not require masking or physical distancing, and, from what we can ascertain, a majority of the cases were among unvaccinated campers and staff. Other camps—including 225 overnight and thousands of day camps run by local YMCAs—have been operating at slightly reduced capacity, requiring masks indoors, and taking other precautions, and have recorded only a few COVID-19 cases. Experts agree that vaccination is the best way to reduce the risk of COVID-19, but no SARS-CoV-2 vaccine is authorized for children under age 12. Until a vaccine is authorized for that population, the US CDC in updated guidance highlighted masking, physical distancing, improved ventilation, screening and testing, and other layered prevention measures for students and staff as schools resume in-person learning this fall.

TENNESSEE VACCINATIONS This week, the Tennessee (US) Department of Health suspended all adolescent vaccine outreach, including for SARS-CoV-2, stating the conversation surrounding the issue is “polarized” and highlighting the cessation as an opportunity to evaluate its messaging. In Tennessee, minors as young as 14 years are able to be vaccinated without parental consent under the state’s “Mature Minor Doctrine.”  Notably, Tennessee lags behind most other states in SARS-CoV-2 vaccination coverage, ranking #43 with only 38% of its total population fully vaccinated.

Tennessee’s Health Commissioner, Dr. Lisa Piercey, reportedly directed health officials to stop sending second-dose reminders to teenagers and end all SARS-CoV-2 vaccine events on school property. But the effort expands beyond SARS-CoV-2 vaccines, including terminating outreach regarding routine vaccinations, including the HPV vaccine, as well as “pre-planning” for influenza vaccination events at schools. Additionally, health officials were directed not to acknowledge August as National Immunization Awareness Month. The decision is believed to be in response to a mid-June legislative hearing, during which several state lawmakers accused the health department of attempting to circumvent parents’ vaccine decisions and pressuring minors to get vaccinated. Reportedly, the hearing also included discussions about dissolving the health department entirely. Health department leaders are scheduled to appear again before the same group of lawmakers on July 21 for additional questioning.

On July 12, the Tennessee Department of Health reportedly fired Dr. Michelle Fiscus, the state’s Medical Director of Vaccine-Preventable and Infectious Diseases, without explanation. Dr. Fiscus published a 1,200-word letter in response to her dismissal, noting that she and other health officials have felt pressure as COVID-19 vaccinations have increasingly become politicized. The American Academy of Pediatrics issued a statement in support of Dr. Fiscus. Also on July 12, several experts published a commentary in JAMA Pediatrics arguing that teenagers should be allowed to decide for themselves whether to get vaccinated. US CDC Director Dr. Rochelle Walensky called Tennessee’s decision to halt vaccine outreach to teens “incredibly disturbing,” and the CDC has warned that pandemic-related disruptions to routine childhood vaccinations continue, which could lead to outbreaks of certain illnesses. These events help illustrate the risks of resource diversions and political divisions stemming from the COVID-19 pandemic spilling into broader public health efforts.

NATIVE AMERICAN VACCINATION Thanks to targeted efforts and historic levels of investment, US indigenous peoples have the highest vaccination rates in the country. Currently, the CDC COVID Data Tracker estimates that approximately 46.3% of American Indians/Alaska Natives (AI/AN) have received at least one dose of a SARS-CoV-2 vaccine, compared with 34.1% of the non-Hispanic white population and 26.5% of the Black population. According to the US Indian Health Service (IHS), AI/AN persons have infection rates up to 3.5 times higher than white persons and are 4 times more likely to be hospitalized. Given these grim statistics, the IHS, along with many non-affiliated indigenous health organizations, undertook massive campaigns to educate, vaccinate, and bring necessary supplies to US indigenous populations. A common rallying point to encourage people to get vaccinated is the sense of responsibility to one’s community and tribe, and the importance of preserving culture in the face of the pandemic. A report by the Urban Indian Health Institute recommends that vaccination campaigns center their efforts on tribal cultural values in order to encourage even more AI/AN persons to receive their doses.

DRUG OVERDOSE DEATHS According to provisional data released by the US CDC this week, more than 93,000 people died of a drug overdose in 2020, a nearly 30% increase over the number of overdose deaths in 2019. This estimate is the highest number of overdose deaths ever recorded and the largest percent increase since 1999. Public health agencies continue to fight the opioid epidemic, declared a public health emergency by the US government in 2017, but health departments were overwhelmed by the demands put on them during the COVID-19 pandemic. As a result, non-COVID-19 programs suffered. In addition, pandemic control measures such as lockdowns and stoppages of in-person treatment groups facilitated an environment that exacerbated conditions for those with substance use disorders. The combination of isolation and increasing barriers to treatment appear to have resulted in the staggering increase in overdose numbers for 2020. Preliminary estimates for 2021 do not show much improvement, although Congress did allocate an additional $1.5 billion this year to address the opioid epidemic in the context of COVID-19. Other useful federal measures include allowing patients enrolled in methadone clinics to take doses home with them and the use of federal funds to buy supplies for needle exchange programs, including rapid test strips that can detect fentanyl in drugs. The federal government also eased regulations to facilitate access to care through telemedicine services for people in treatment. 

COMMUNIVAX REPORT As the US SARS-CoV-2 vaccination campaign continues, it is critical that vaccines are delivered fairly and equitably—to ensure everyone has access. CommuniVax, a coalition to strengthen the community’s involvement in an equitable vaccination rollout, this week released a new report, “Carrying Equity in COVID-19 Vaccination Forward: Guidance Informed by Communities of Color.” The report provides specific guidance on adapting SARS-CoV-2 vaccination efforts to achieve greater vaccine coverage in underserved populations, and through this, to develop sustainable, locally appropriate mechanisms to advance equity in health. The report provides 5 overarching policy and practice recommendations, across 2 focus areas: urgently providing vaccines for Black and Latino/Hispanic communities and putting in place essential changes to provide a more robust public health system moving forward.