COVID-19 Situation Report
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EPI UPDATE The WHO COVID-19 Dashboard reports 194.1 million cumulative cases and 4.16 million deaths worldwide as of 12:28 EDT on July 26. Global weekly incidence increased for the fifth consecutive week, a 7.89% increase over the previous week. Global weekly mortality increased for the third consecutive week, a 20.77% increase compared to the previous week.

Global Vaccination
The WHO reported 3.7 billion doses of SARS-CoV-2 vaccines administered globally as of July 26. The WHO reports a total of 1.44 billion individuals have received at least 1 dose, and 672 million are fully vaccinated. Analysis from Our World in Data shows that the global daily doses administered is up, now at 33 million doses per day, driven by increases in Asia. Our World in Data estimates that there are 2.14 billion vaccinated individuals worldwide (1+ dose; 27.5% of the global population) and 1.08 billion who are fully vaccinated (13.9% of the global population).

The US CDC reported 34.4 million cumulative COVID-19 cases and 608,528 deaths. Daily incidence continues to increase, now up to 42,226 new cases per day, which is nearly 3.7 times the most recent low on June 19 (11,467) and is still increasing steadily. Daily mortality also continues to increase, up to 239 deaths per day, which is more than 45% higher than the most recent low on July 10 (164).

US Vaccination
The US has administered 342.2 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations are increasing slowly, now up to 471,948 doses per day*. A total of 188.7 million individuals in the US have received at least 1 dose, equivalent to 56.8% of the entire US population. Among adults, 69% have received at least 1 dose, as well as 10.5 million adolescents aged 12-17 years. A total of 163.2 million individuals are fully vaccinated, which corresponds to 49.1% of the total population. Approximately 60% of adults are fully vaccinated, as well as 8.1 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.

US HOSPITALIZATIONS The number of COVID-19-related hospitalizations is beginning to rise in most US states, following increasing numbers of COVID-19 cases driven by the spread of the more transmissible Delta variant. Nationally, hospitalization rates remain low overall, nowhere near the previous pandemic peaks. But the increases in hospitalizations are high and rising in parts of the country that have low vaccination rates, including Florida, Nevada, Arkansas, and Missouri. Some Florida hospitals are seeing the highest number of COVID-19 patients since the beginning of the pandemic, and the pace of this surge is accelerating rapidly. One hospital in Missouri said its increase in patients occurred nearly 5 times as fast as last fall’s surge. An estimated 97% of hospitalized patients are unvaccinated. Patients also are skewing younger, with 69% under the age of 65, according to CDC data as of July 17. Some hospitals are scrambling to find space for intensive care patients, trying to address personnel shortages, and attempting to maintain adequate supplies of medical equipment such as ventilators. 

According to new projections released last week by the COVID-19 Scenario Modeling Hub—a consortium of researchers working with the US CDC to track the pandemic—the current US surge will continue throughout the summer and into the fall. In the most likely of 4 scenarios, there would be around 60,000 new cases and about 850 deaths per day, with 70% of eligible Americans vaccinated. Currently, the US is averaging around 42,000 new cases per day and about 250 deaths per day. Nationwide, 57.5% of eligible people are fully vaccinated. The researchers encouraged state and local leaders to take note of the projections, urging them to reimplement mask mandates and physical distancing requirements that could help lessen the surge’s impact.

US GOVERNMENT RESPONSE As the number of new COVID-19 cases continues to rise in the US, the US government is examining further tactics to contain the pandemic. Last week, the White House purchased an additional 200 million doses of the Pfizer-BioNTech vaccine. The purchase is in anticipation that additional doses will be recommended for certain populations and that the vaccine could “soon” be authorized for use in children ages 5-11. The US government also hinted at reinstated mask recommendations.

Overall, the US government is focused on improving national vaccination rates, particularly in communities with low coverage where most new COVID-19 cases are in unvaccinated individuals. On July 22, the government announced US$100 million for rural health clinics to develop vaccine confidence and outreach efforts. Additionally, the US Department of Health and Human Services will invest US$1.6 billion from the American Rescue Plan to support COVID-19 testing and mitigation activities in vulnerable communities. These funds will address the rise in cases among unvaccinated people by detecting, diagnosing, tracing, and mitigating the spread of SARS-CoV-2 in homeless shelters, correctional facilities, and other hard-hit and high-risk areas. In recognizing the 31st anniversary of the Americans with Disabilities Act, the government announced a package of guidance and resources to support individuals experiencing “long COVID,” also known as post-acute sequelae of COVID-19. According to the guidance, long COVID can be considered a disability under certain federal civil rights laws, thereby allowing federal protections and resources for adults and children impacted by long-lasting symptoms of COVID-19.

As the US government focuses on challenges to the nation’s domestic recovery from the pandemic, including rising consumer prices and turbulent financial markets, officials from the US Agency for International Development who are responsible for making the US an “arsenal of vaccines” are struggling to help other countries acquire resources and distribute SARS-CoV-2 vaccines, COVID-19 therapeutics, and personal protective equipment. At issue is more than US$1 billion the White House diverted from the agency in June to pay for the purchase of 500 million additional doses of the Pfizer-BioNTech vaccine, meant to supplement the 80 million vaccine doses the government has already allocated for donations abroad, according to unnamed officials. But the unexpected shift in funding, and the wait time for those doses to be delivered, has put pressure on the US government to maintain its status as a leading donor of COVID-19 assistance. USAID officials tasked with vaccine distribution abroad continue to advocate for increased resources from the White House and US Congress in order to assist countries in need. 

VACCINATION MANDATES As the Delta SARS-CoV-2 variant sweeps across the US, more jurisdictions and companies are considering strengthening public health measures to mitigate the virus’s impact. This includes vaccination mandates for employees. On July 26, California, the country’s most populous state, became the first in the nation to announce that all state employees and on-site public and private workers in health care and high-risk congregate settings will be required to show proof of vaccination or submit to mandatory once-or-twice weekly testing. State employees are required to submit vaccination documentation by August 2, and health care and congregate-setting facilities must be in full compliance by August 23. Unvaccinated workers also will be required to wear appropriate PPE. A few hours earlier, New York City, the nation’s largest city, announced that all 340,000 municipal employees of the city, including police officers and teachers, will be required to be vaccinated or start weekly testing by September 13. As of August 2, any employee who is unvaccinated must wear a mask indoors at all times or risk termination. In their announcements, both California Governor Gavin Newsom and New York City Mayor Bill De Blasio encouraged other local governments and private sector employers to implement vaccination mandates.

The Department of Veterans Affairs on July 26 became the first federal agency to implement a vaccination mandate, requiring 115,000 of its frontline healthcare workers to show proof of full vaccination within the next 8 weeks. In its announcement, the VA referenced several organizations that support vaccine mandates. Many of those groups—including the American Medical Association, the American Nurses Association and 55 other groups representing millions of doctors, nurses, pharmacists, and other healthcare workers—issued a joint statement early on July 26 calling for all healthcare and long-term care employers to require their employees to be vaccinated for SARS-CoV-2. The statement cites highly contagious variants, including the Delta variant, and “significant numbers” of unvaccinated people as drivers for rising numbers of COVID-19 cases, hospitalizations, and deaths in the US. The groups also called on other employers across the country to implement policies to encourage vaccination. As we have previously reported, vaccination mandates for employees of a hospital system (Bridges et al v. Houston Methodist Hospital et al) and students of a university (Ryan Klaasen et al v. The Trustees of Indiana University) so far have been upheld in US federal district courts. An appeal from one of those cases is expected, and additional legal challenges likely will result from these, and future, vaccination mandates.

MODERNA VACCINE FOR ADOLESCENTS The European Medicines Agency’s Committee for Medicinal Products for Human Use on July 23 approved the Moderna SARS-CoV-2 vaccine (known as Spikevax in Europe) for use in children aged 12 to 17 years. The vaccine already is authorized for adults aged 18 and older, but it is the first time this vaccine has been authorized for people under age 18. According to the EMA, data from more than 3,700 children ages 12 to 17 showed the vaccine produced an antibody response comparable to the one seen in young adults aged 18 to 25 years. The younger group also experienced similar mild-to-moderate side effects. The agency noted that the trial was unable to detect new, uncommon side effects or evaluate the risk of known ones, including the inflammation of heart muscle and tissue, because of the relatively small number of study participants, but added that the “benefits of Spikevax in children aged 12 to 17 outweigh the risks.” Until now, the Pfizer-BioNTech was the only option for children aged 12 and older in Europe. The US FDA currently is considering whether to authorize the Moderna vaccine for the same age group. 

VACCINE TRIALS FOR CHILDREN The US FDA reportedly has urged 2 SARS-CoV-2 vaccine makers, Pfizer-BioNTech and Moderna, to expand the size of their clinical trials among children aged 5 to 11 years in order to assess whether the rare side effects of myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the lining around the heart) that have been seen in young adults shortly following vaccination also appear in this younger age group. Federal regulators requested the companies include at least 3,000 children in their studies, reportedly about double the original number of participants. Moderna confirmed its plans to expand the size of its pediatric clinical trial and expects to have data on its vaccine’s use among children ready to submit to the FDA in winter 2021 or early 2022. Pfizer-BioNTech indicated it does not plan to alter its original timeline of submitting a request for the FDA to expand authorization to 5-to-11-year-old children by the end of September, and presenting data for younger children, aged 6 months to 2 years, in October or November. The FDA last month added warnings about the potential for myocarditis and pericarditis to patient and provider fact sheets for both the Moderna and Pfizer-BioNTech vaccines.

LONG COVID/PASC IN CHILDREN Children’s National Hospital (US), in collaboration with the US NIH’s National Institute of Allergy and Infectious Diseases, announced on July 25 they are launching a large, multi-year study to examine the long-term effects of COVID-19 and multisystem inflammatory syndrome in children (MIS-C) following recovery from acute SARS-CoV-2 infection. The study will enroll up to 1,000 children and young adults under age 21 who have recovered from confirmed infection with SARS-CoV-2, with or without symptoms, or MIS-C, as well as up to 1,000 household contacts who will serve as a control group, and 1 parent or guardian per participant to complete questionnaires. Surveys will gather information about quality of life, social impact, and any long-term physical impacts of the virus, and researchers also plan to detail the role of genetics; duration and quality of immune responses following infection; so-called “long COVID,” also called post-acute sequelae of COVID-19 (PASC); and MIS-C. 

In the US, more than 4.1 million children have tested positive for SARS-CoV-2, and nearly 500 have died. In the week ending July 22, children accounted for 16.8% of reported weekly COVID-19 cases nationwide. Black, Hispanic/Latino, and Native American children have been hardest hit, accounting for 3 out of 4 deaths among patients under age 21. According to researchers, between 2% and 10% of recovered children have long-term symptoms, and about 2 out of 3 children who develop MIS-C are Black or Hispanic/Latino. The US$40 million study is one of many NIH is supporting to understand the range of SARS-CoV-2 effects on children. Little is known about why some children experience long-term symptoms following COVID-19 recovery, just as long COVID-19 is not well understood in adults. It is hoped that these controlled clinical trials will provide more answers about how these conditions can be more effectively treated and, possibly, prevented.

GLOBAL VACCINE ACCESS The World Bank and the COVAX facility on July 26 announced a new financing mechanism to help improve access to SARS-CoV-2 vaccines for low- and middle-income countries (LMICs), where vaccination rates are lagging. Countries that are seeking to purchase vaccines through the COVAX advance market commitment cost-sharing system via Gavi, the Vaccine Alliance, are facing hurdles in guaranteeing their own payments. Now, COVAX will be able to negotiate advance purchase agreements with vaccine makers based on aggregated demand across several of the 92 LMICs that participate in the advance market commitment, using financial backing from the World Bank and other multilateral development banks. The mechanism should enable more countries to receive bulk vaccine purchases at a lower cost, instead of relying solely on donations through COVAX, and countries would be able to select specific vaccines that align with their preferences. Additionally, it will allow for more transparency regarding vaccine availability, pricing, and delivery schedules, World Bank President David Malpass noted in a statement. Under the AMC cost-sharing arrangement, COVAX plans to provide up to 430 million additional vaccine doses for delivery between late 2021 and mid-2022. COVAX has already delivered nearly 153 million doses to 137 countries, but that number is far below its 2021 goal of 2 billion doses. The new financing mechanism comes amid growing concern over the widening gap in global vaccine access, with experts hoping the arrangement will facilitate vaccine deliveries to countries in need.

VIETNAM LOCKDOWN On July 23, Vietnam’s capital city of Hanoi began a 15-day lockdown amid a spike in new COVID-19 cases. The country’s health ministry reported 7,968 new cases on July 24, a record daily increase and up from the previous day’s count of 7,307. With the addition of Hanoi’s 8 million people, about one-third of Vietnam’s 100 million people are now on lockdown. Residents in larger cities, like Ho Chi Minh City and Hanoi, are no longer allowed to congregate in groups of more than 2 people and are only allowed to leave their homes for food, medication, or in the case of an emergency. According to Our World in Data, Vietnam has fully vaccinated only 0.4% of its population and is taking steps to procure more vaccine doses. On July 25, the country announced it received 3 million doses of the Moderna vaccine from the US through COVAX. Vietnamese officials are in talks with US officials about the domestic production of mRNA vaccines, which could begin late this year or in early 2022, with the goal of producing 100 to 200 million doses a year. The government also indicated it is considering authorizing the domestically produced Nanocovax vaccine. A phase 3 clinical trial testing the vaccine is ongoing, but results are not yet available.

FRANCE HEALTH PASS The French Parliament on July 26 approved a law mandating special health passes for entry to all restaurants, trains, planes, and some other public venues and requiring vaccinations for all healthcare workers and other essential workers such as firefighters beginning September 15. In order to obtain a health pass, people must show digital or paper proof of full vaccination, results of a recent negative SARS-CoV-2 test, or documentation of recent recovery from acute COVID-19. More than 160,000 people demonstrated around France over the weekend to protest the legislation requiring health passes. France President Emmanuel Macron welcomed peaceful demonstrations but added they will not make the pandemic disappear. “My message is simple: to get vaccinated,” he said. Nearly 60% of the French population has received at least 1 dose of vaccine, but the number of new daily COVID-19 cases has risen sharply since the beginning of the month. The Constitutional Council is expected to review the law next week to determine whether it complies with the country’s Constitution.

NFL COVID-19 RULES The US National Football League (NFL) sent a strong message to its 32 teams last week, encouraging clubs to convince players to get vaccinated for SARS-CoV-2 and alerting them that games having to be cancelled due to a COVID-19 outbreak among unvaccinated players would be forfeited and counted as a loss. According to a memo, the league intends to play its entire 272-game schedule over 18 weeks and would not add a “19th week” to accommodate games that cannot be rescheduled during the 18-week regular season. If a game is cancelled due to an outbreak and cannot be rescheduled, neither team’s players would receive their weekly salary and the responsible team would cover all financial losses. Additionally, vaccinated players or staff who test positive but are asymptomatic can return to the field after 2 negative tests 24 hours apart; however, unvaccinated individuals who test positive would be required to complete a 10-day isolation period. Unvaccinated players are required to undergo daily testing, physically distance, wear a mask indoors, and be prohibited from gathering with the team for media events or outside of official team activities, such as at nightclubs, bars, or house parties. If unvaccinated players violate the gathering rules, the NFL and clubs are permitted to issue fines of up to US$50,000 for a first offense, and more for further violations. For violating other COVID-19 protocols, such as not wearing a mask when required, players could be fined US$14,650 every time a transgression occurs. According to the memo, more than 75% of players are in the process of being vaccinated and more than half of the teams have vaccination rates of more than 80% of players. With the NFL placing the burden on teams and players to get vaccinated or else face significant economic consequences, it will be interesting to see if teams can reach near-100% vaccination rates.