COVID-19 Situation Report
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EPI UPDATE The WHO COVID-19 Dashboard reports 191 million cumulative cases and 4.10 million deaths worldwide as of 6:00am EDT on July 20. Global weekly incidence increased for the fourth consecutive week, up 11.6% from the previous week and the highest weekly total since the week of May 24. Weekly global mortality increased for the second consecutive week, but the weekly increase was only 1.1% compared to the previous week.

Weekly incidence decreased in Africa for the first time since mid-May. Overall, the Americas are holding relatively steady over the past several weeks; however, reported cases in South America are declining, while reported cases in North America are increasing—both starting in late June. Case counts in other WHO regions are increasing as of late June.

Global Vaccination
The WHO reported 3.44 billion doses of SARS-CoV-2 vaccines administered globally as of July 19. The WHO reports a total of 1.35 billion individuals have received at least 1 dose, and 637 million are fully vaccinated. Analysis from Our World in Data shows that the global daily doses administered leveled off over the past week, now hovering at slightly more than 30 million doses per day. Vaccinations leveled off in Asia as well. Europe’s daily vaccinations are beginning to decline, down 11% over the past 2 weeks, and North America continues to decline steadily. Vaccination trends in Africa are increasing slightly, with daily vaccinations up 25% since the beginning of July. Trends in South America continue to increase steadily, and daily vaccinations leveled off in Oceania (with a slight decline) over the past week or so. Our World in Data estimates that there are 2.06 billion vaccinated individuals worldwide (1+ dose; 26.5% of the global population) and 1.02 billion who are fully vaccinated (13.1% of the global population).

The US CDC reported 33.9 million cumulative COVID-19 cases and 606,618 deaths. The US reported 29,578 new cases on July 16—more than 2.5 times higher than the low on June 18 (11,457)—before falling slightly on July 18 (26,011). Daily mortality also peaked on July 16, increasing from a low of 159 deaths per day on July 11 to 234 (+47%) before falling slightly to 218.

We have observed a similar trend over the past several weeks, with data reported early in the week indicating a slight decrease in the average daily incidence and mortality from Friday to Sunday. The trend disappears, however, after several days, which indicates that it is likely an artifact of reporting, potentially due to states shifting from daily to weekly reports to the CDC. This shift in reporting could complicate efforts to maintain an accurate understanding of the US COVID-19 epidemic in real time, particularly at a time when the country is facing the early stages of another surge. The most recent several days’ worth of COVID-19 data may no longer be a reliable representation of the current state of the US epidemic.

US Vaccination
The US has administered 338 million cumulative doses of SARS-CoV-2 vaccines. After reaching a low of approximately 425,000 doses per day on July 9 (the lowest average since January 2), daily vaccinations increased slightly over the next several days, up to 447,583*. A total of 186 million individuals in the US have received at least 1 dose, equivalent to 56.1% of the entire US population. Among adults, 68.3% have received at least 1 dose as well as 10.0 million adolescents aged 12-17 years. A total of 161 million individuals are fully vaccinated, which corresponds to 48.6% of the total population. Approximately 59.5% of adults are fully vaccinated, as well as 7.8 million adolescents aged 12-17 years.
*Due to delays in reporting, estimates for the average daily doses administered are less accurate for the most recent 5 days. The most current value provided here corresponds to 5 days ago.

CHILDHOOD IMMUNIZATIONS DISRUPTED The COVID-19 pandemic has disrupted routine immunizations for millions of children worldwide. According to data from WHO and UNICEF published July 15, 23 million children missed out on routine immunizations in 2020 due to the pandemic, with up to 17 million children not receiving a single vaccine in 2020. This lapse in routine vaccinations, the greatest since 2009, risks resulting in outbreaks of measles, polio, meningitis, or other vaccine-preventable diseases. Not only are these outbreaks dangerous to children and their communities, but they could burden health systems and reverse decades of progress in closing the global gap in vaccinations. Countries with the greatest increase in the number of children not receiving their first dose of diphtheria-tetanus-pertussis combined vaccine (DTP-1) include India, Pakistan, and Indonesia, all of which have come under strain during the pandemic. A recent study published in The Lancet examined the impact of the pandemic on childhood vaccine coverage and highlighted the need to strengthen health systems, surveillance systems, and targeted outreach programs in order to reach children who have missed routine immunizations. As countries begin to loosen COVID-19 restrictions, experts highlight the very real possibility of seeing increased transmission and outbreaks of vaccine-preventable pathogens.   

PRIORITY REVIEW OF PFIZER-BIONTECH VACCINE Pfizer-BioNTech on July 16 announced the US FDA granted priority review status for the Biologics License Application for their 2-dose SARS-CoV-2 mRNA vaccine. An FDA official reportedly said a decision on whether to grant full approval for the vaccine’s use in people ages 16 and older will come soon, possibly within the next 2 months. The FDA must make its decision by January under the priority review. Pfizer-BioNTech completed their application in May and expects to apply for full approval for people ages 12 to 15 when data are available. Moderna has begun its application to the FDA for full approval of its 2-dose SARS-CoV-2 vaccine, and J&J-Janssen also is expected to seek full approval of its 1-dose vaccine. Full approval of a vaccine could impact US vaccination coverage by prompting vaccine mandates for some schools, businesses, or the US military, and by swaying some who are reluctant because of safety concerns to undergo vaccination.

VACCINE DISINFORMATION On July 15, US Surgeon General Dr. Vivek Murthy warned of the threat of health misinformation. As we covered previously, misinformation on a wide variety of topics has had a substantial negative effect on COVID-19 response and risk mitigation activities, including vaccination. Dr. Murthy emphasized that “health misinformation is an urgent threat to public health” and that it puts “American risk.” Notably, the announcement explicitly highlighted the role of social media platforms in spreading misinformation, and Dr. Murthy called on social media companies to take action in countering this ongoing threat. In a report published in March, the Center for Countering Digital Hate found that approximately two-thirds of all anti-vaccine misinformation found on social media platforms originates with one of 12 individuals. While some accounts operated by these individuals have been removed from social media platforms, many remain active. Dr. Murthy also called on the American public to refrain from sharing questionable information via their social media networks. Combating the far-reaching network that supports the spread of misinformation will require a “whole-of-society effort.” The health advisory outlines key principles for promoting accurate information, including identifying trusted voices in the community and longer-term investments in “media, science, digital, data, and health literacy.”

UK “FREEDOM DAY” England marked “Freedom Day” on July 19, with the government lifting all but a few COVID-19 restrictions amid a 41% surge in new cases over the past week. Prime Minister Boris Johnson defended his decision to open from his country residence, where he is isolating after coming into contact with UK Health Secretary Sajid Javid, who on Saturday said he tested positive for COVID-19 and is showing mild symptoms. The move into phase 4 of the country’s reopening plan removes limits on social gatherings and events, the need for physical distancing, and mask requirements except on public transportation.

Many experts see England's move to reopen as a major gamble, with more than 1,200 scientists signing a letter published in The Lancet calling the plan “dangerous and premature,” highlighting the likely negative impacts on children’s health and education, and warning the strategy “provides fertile ground for the emergence of vaccine-resistant variants.” Others say the reopening risks a massive wave of infections and will test the resilience of the nation’s health care system and the effectiveness of vaccines. Nearly 70% of the adult population is fully vaccinated, with 87.9% having received at least one dose.

On July 19, the country’s Joint Committee on Vaccination and Immunisation advised against the mass vaccination of all children and teenagers, instead opting to offer doses only to children between 12 and 15 who are at increased risk of serious COVID-19 disease—including those with "severe neurodisabilities, Down’s syndrome, immunosuppression, and multiple or severe learning disabilities"—and children and young people aged 12 to 17 who live with an immunocompromised person.

Also on July 19, the US CDC raised its UK Risk Assessment Level for COVID-19 to “Level 4: COVID-19 Very High,” prompting the US Department of State to raise its travel advisory level for the UK from “Level 3: Reconsider Travel” to “Level 4: Do Not Travel.” Notably, though the travel advisory is for the whole of the UK, the lifting of restrictions only impacts England, as Scotland, Wales, and Northern Ireland continue to make their own policies on COVID-19 restrictions.

FRANCE VACCINATIONS In an effort to control the surging Delta variant (B.1.617.2), French President Emmanuel Macron announced that proof of SARS-CoV-2 vaccination or a recent negative COVID-19 test must soon be provided to enter certain public venues or transportation. Beginning in August, a “green pass” will be required for anyone over the age of 12 to enter a cinema, theater, museum, theme park, or cultural center, and anyone entering venues like cafés, restaurants, shopping centers, or public transit must show the pass. Additionally, vaccination will be mandatory for anyone working in healthcare facilities and retirement homes, or assisting with elderly or other vulnerable people. Those employers and employees who do not comply could face sanctions or fines. The digital vaccine green pass will serve as a certification of vaccination and regulate entry to venues via a QR code specific to each person. 

France has fully vaccinated 40% of its population, and the new restrictions on the unvaccinated are spurring people to get vaccinated. Immediately following Macron’s announcement, online French medical platform Doctolib received a record of more than 900,000 visits as people rushed to book their first vaccine dose. However, opponents of the requirement have taken to the streets in protest, citing government overreach. Several vaccination sites were vandalized over the weekend. Although polls suggest two-thirds of the population support the new measures, some claim the pass is too ambitious, may not clear institutional hurdles, and will infringe on personal freedoms. Health officials continue to fine tune the details of the health pass, and parliament is set to vote on the legislation.

OLYMPIC ATHLETES COVID-19 CASES With only days to go before the start of the 2020 Summer Olympic Games in Tokyo, Japan, reports of COVID-19 cases among Olympic athletes and other residents of the Olympic Village are clouding the already delayed event. Olympic organizers said at least 71 people have tested positive, including athletes, team officials, volunteers, contractors, and a “games-concerned personnel.” Two athletes and a video analyst with the South African soccer team tested positive in the Olympic Village despite receiving 2 negative tests within 4 days of traveling to Tokyo. Eight members of the UK delegation are in isolation after exposure to SARS-CoV-2 from an infected individual on their flight to Japan. At least 2 members of the US delegation are in isolation after an alternate for the US Women’s Gymnastics Team tested positive. Additionally, US tennis star Cori “Coco” Gauff on July 18 announced she will not compete in the Olympics after testing positive. Despite unprecedented measures to control COVID-19 during the Olympics, including daily testing and required masking when not training, competing, eating, or sleeping, the growing number of cases is raising questions over how well outbreaks can be controlled. At a press conference today, the head of the 2020 Tokyo Olympics organizing committee did not rule out a last-minute cancellation of the event.

HAJJ Historically, the annual Muslim pilgrimage to Mecca draws millions of visitors from around the world. Last year, Saudi Arabia limited visitors to only 1,000 pilgrims, but for the ongoing Hajj (July 17-22), the government is permitting a total of 60,000 visitors, limited to Saudi residents who are fully vaccinated, aged 18-65 years, and have no chronic health conditions. While this is considerably more people than were permitted in 2020, it is still far fewer than the more than 2 million who typically attend Hajj.

In order to reduce risk, the Saudi Ministry of Hajj and Umrah implemented additional restrictions and protective measures. Upon arrival, pilgrims are assigned to groups of 20, with no mixing between groups. Individuals are assigned specific dates and times to visit the Grand Mosque, where 6,000 individuals are permitted to enter every 3 hours. Facilities at the Grand Mosque undergo sterilization between each session. Despite the additional protective measures, including the vaccination requirement, the US CDC still has a Level 3 Travel Warning in place (Avoid Nonessential Travel) for the Hajj, due in part to the risk of SARS-CoV-2 transmission associated with mass gatherings.

VACCINE EQUITY The global inequities in access to SARS-CoV-2 vaccines are worsening, with wealthy nations continuing to stockpile instead of share unused doses and lacking a viable, well-funded global plan to reach poorer nations. For some nations dependent upon vaccine imports, the shipments have only recently begun, more than 1.5 years into the pandemic. COVAX has delivered only 135.5 million doses to 136 countries, and with little funding to purchase additional doses, the facility is left to depend upon donations from countries. Last week, COVAX launched an international marketplace to help address supply chain challenges hampering global vaccination efforts. The platform hopes to match vaccine producers with suppliers of vital components—such as bioreactor bags, biologic ingredients, or vials—who might have unused products needing to be reallocated. 

Additionally, leaders of countries in the Asia-Pacific Economic Cooperation (APEC) trade group on July 16 pledged to expand their global sharing and manufacturing of SARS-CoV-2 vaccines, including encouraging voluntary transfer of technologies. However, they offered no specific details about how this expansion would be accomplished. Following the virtual meeting, New Zealand Prime Minister Jacinda Ardern, whose country serves as the current APEC host, said, “Our discussions moved us beyond vaccine nationalism. Now we are focusing on all aspects of contributing to the global vaccination effort—making vaccines, sharing vaccines, and using vaccines.”

HIV INFECTION HIV infection is a significant comorbidity for both severe or critical COVID-19 at hospital admission and in-hospital mortality, according to a WHO report released last week. The report described clinical surveillance data from 37 countries in Asia, Europe, Africa, and South America, and found that the risk of developing severe or fatal COVID-19 was 30% greater for people living with HIV compared with people without HIV, and 23.1% of all people living with HIV who were hospitalized with COVID-19 died. Other underlying conditions such as diabetes and hypertension increased the risk further, especially among men living with HIV over the age of 65 years.

In sub-Saharan Africa, home to two-thirds of people living with HIV, less than 3% of the population had received one dose of vaccine by July 2021, according to the UNAIDS Global AIDS Update 2021, also released last week. COVID-19 lockdowns and restrictions have disrupted HIV testing, referrals to care, and HIV treatment initiation and continuation. In some places, these disruptions bred ingenuity, with the emergence of new models of differentiated service delivery starting in communities worldwide, often guided by patients and advocates themselves. Health officials and organizations are detailing these efforts during the International AIDS Society Conference on HIV Science, which began July 18 in Berlin, Germany, and calling for continued flexibility to meet people’s lifestyles beyond the COVID-19 pandemic.

LONG COVID/PASC Researchers continue efforts to understand and treat post-acute sequelae of SARS-CoV-2 infection (PASC), commonly referred to as “long COVID.” PASC is a constellation of long-lasting symptoms following an initial infection with SARS-CoV-2 that can affect individuals regardless of the presence or severity of the acute COVID-19 symptoms. The UK announced it will provide £20 million (US$27.17 million) to support 15 clinical trials examining the diagnosis, treatments, and care of the condition. The studies will test existing drugs as therapies, look at the use of MRI scans for diagnosing organ damage, assess the possible role of overactive or impaired immune systems, and evaluate the impact of obesity among people with long COVID-19, among other objectives. The UK government previously allocated £100 million (US$36 million) for support services for people with long COVID-19, establishing 80 such services so far.

At least 4 new studies examining long COVID-19 recently were published. The first study, published in The Lancet’s journal EClinicalMedicine and the largest-ever international study on long COVID-19, identified more than 200 symptoms of the condition and prompted researchers—all of whom have had or are still living with long COVID—to call for the creation of a national screening program in the UK for anyone who suspects they have the condition. The second study, published in the Journal of the Royal Society of Medicine, found that people who experience 5 or more COVID-19 symptoms in the first week of infection are significantly more likely than people with fewer symptoms to develop long COVID-19. A third study, published in JAMA, found a low prevalence of long-term COVID-19 symptoms among a randomly selected cohort of children who were assessed at least 6 months after being tested for SARS-CoV-2. A fourth study, published in PLOS ONE, found that 26% of adult COVID-19 patients did not fully recover within 6-8 months after diagnosis, with 55% experiencing fatigue, 25% breathlessness, and 26% symptoms of depression. The researchers highlighted the need for accessible care for individuals experiencing long COVID-19 symptoms.

SUPER ANTIBODY In a study published July 14 in Nature, researchers describe a newly discovered “super antibody” capable of protecting against SARS-CoV-2 and a group of related coronaviruses, called sarbecoviruses. The antibody, named S2H97, is believed to work by attaching to a section of the ACE2 receptor binding motif on the virus spike protein that is only exposed when a sarbecovirus is attempting to enter a cell. S2H97 was able to prevent the spread of multiple sarbecoviruses between cells in a lab, and the antibody also protected hamsters from infection with SARS-CoV-2 isolated from the initial Wuhan, China, outbreak. Researchers further described the antibody as a pan-sarbecovirus due to its broad efficacy across the sarbecovirus subgenus. The description of a usually hidden antibody binding region in the ACE2 RBM is important because it could be used as a target for future vaccines and therapeutics. Additionally, a pan-sarbecovirus vaccine could be used to prevent outbreaks from as-of-yet-undiscovered members of the Coronaviridae family of viruses.