EPI UPDATE NOTE: The Situation Report’s esteemed epidemiologist is on vacation this week, so we will be back next week with a deeper-dive look at trends. Here are the latest numbers:
The WHO COVID-19 Dashboard reports 196.6 million cumulative cases and 4.2 million deaths worldwide as of 12:30 EDT on July 30.
Global Vaccination
UNITED STATES
The US CDC reported 34.7 million cumulative COVID-19 cases and 609,853 deaths. Daily incidence continues to increase, now up to 66,606 new cases per day, which is nearly 6 times the most recent low on June 19 (11,469) and is still increasing steadily. Daily mortality also continues to increase, up to 296 deaths per day, which is 78% higher than the most recent low on July 10 (166)*.
*In an effort to provide a more accurate analysis of the current epidemiology, we are largely focusing on longer-term trends, as the most recent data are more likely to be affected by changes in the frequency of state-level reporting, particularly over the weekend.
US Vaccination
The US has administered 344 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations are increasing slowly, now up to 513,685 doses per day*. A total of 189.9 million individuals in the US have received at least 1 dose, equivalent to 57.2% of the entire US population. Among adults, 69.4% have received at least 1 dose, as well as 10.5 million adolescents aged 12-17 years. A total of 163.9 million individuals are fully vaccinated, which corresponds to 49.4% of the total population. Approximately 60.3% 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 CDC MASK GUIDANCE Amid a national surge in COVID-19 cases, hospitalizations, and deaths attributed to the highly transmissible Delta variant, the US CDC this week issued updated guidance recommending indoor mask use in areas with high or substantial transmission rates, regardless of individual vaccination status. The agency also called for universal mask use by teachers, staff, and students returning to K-12 schools this fall, regardless of their vaccination status. According to CDC Director Dr. Rochelle Walensky, the agency reinstated its indoor mask use recommendations based on new research showing that vaccinated people infected with the Delta variant carry viral loads similar to those of people who are unvaccinated. The data comes from a new CDC report released today. Dr. Walensky reiterated that the vaccines remain highly effective at preventing severe disease, that breakthrough infections among vaccinated individuals remain uncommon, and that most of the new COVID-19 cases are among unvaccinated people. US health officials continue to urge those who are not yet vaccinated or partially vaccinated to undergo the shots to help slow the spread.
US FEDERAL WORKER VACCINE RULES US President Joe Biden on July 29 announced sweeping new COVID-19-related requirements for more than 4 million federal employees and hundreds of thousands of contractors who work at federal facilities worldwide, with the goal of increasing vaccination rates among the nation’s workforce and influencing other employers. Though not considered a vaccine mandate, all federal workers will be required to sign forms attesting they are fully vaccinated for SARS-CoV-2 or face inconveniences in their daily work lives. Unvaccinated workers “will be required to wear a mask on the job no matter their geographic location, physically distance from all other employees and visitors, comply with a weekly or twice weekly screening testing requirement, and be subject to restrictions on official travel," according to information released by the White House. In his speech, President Biden also called on states and local governments to use federal funding they have received, including from the American Rescue Plan, to give US$100 to anyone who gets fully vaccinated, and he said the federal government would reimburse small- and medium-sized businesses for providing paid leave so their employees and their families could get vaccinated. He also urged the US Department of Defense to quickly implement a mask mandate for members of the military, many of whom are reluctant to undergo vaccination. The plan received mixed reactions from labor unions and other groups, some of which said giving employees options was a tactic aimed at preventing harsh resistance from some people. Questions about the plan remain, and it will be interesting to see how quickly federal agencies implement the requirements.
ADDITIONAL DOSES/”BOOSTERS” Executives from Pfizer-BioNTech, Moderna, and J&J-Janssen, which manufacture the 3 SARS-CoV-2 vaccines authorized for use in the US, have all said fully vaccinated individuals can expect to eventually need additional doses of the vaccines, or “boosters.” However, there is not enough evidence-based data yet to provide a recommendation, according to a WHO official and the CDC’s Advisory Council on Immunization Practices (ACIP), which met last week to discuss the possibility of additional doses among immunocompromised individuals. Several US government health officials, including National Institute of Allergy and Infectious Diseases (NIAID) Director Dr. Anthony Fauci, have signaled that some Americans who are older or have weakened immune systems might need an additional vaccine dose.
Pharmaceutical companies, officials, and healthcare workers cannot technically recommended additional doses for any of the vaccines in the US, which are being administered under US FDA emergency use authorizations (EUAs) that set specific standards for each regimen: 2 doses given 3 or 4 weeks apart for the Pfizer-BioNTech and Moderna vaccines, respectively, and 1 dose for the J&J-Janssen vaccine. In order to provide additional doses, the FDA would need to change a vaccine’s EUA or fully license the vaccine, which would provide greater leeway for providers to recommend additional doses. But last week, Dr. Amanda Cohn, Chief Medical Officer for the CDC’s National Center for Immunization and Respiratory Diseases (NCIRD), indicated the US government is actively looking into ways to provide access to additional doses prior to regulatory decisions, such as a compassionate use program. Some people are taking it upon themselves to seek out third doses, sometimes traveling to other states or even other countries to obtain shots.
PFIZER-BIONTECH EFFICACY/THIRD DOSE On July 28, medRxiv published preprint data from Pfizer-BioNTech showing the efficacy of its vaccine to prevent COVID-19 declined about 6% every 2 months over a period of 6 months. The data were collected from more than 40,000 clinical trial participants in Europe and the Americas. From 7 days to <2 months post-dose 2, vaccine efficacy was 96.2% (95% confidence interval [CI] 93.3-98.1); from 2 months to <4 months, efficacy was 90.1% (95% CI 86.6-92.9); and from 4 months to 6 months, efficacy was 83.7% (95% CI 74.7-89.9). Overall, vaccine efficacy was 91.1% (95% CI 88.8-93.0) for preventing symptomatic COVID-19, and 96.7% (95% CI 80.3-99.9) against severe disease. The companies said the data show the vaccine to be safe and highly efficacious in preventing COVID-19 through 6 months post-second dose in diverse populations but further data are needed to know whether efficacy continues to wane or whether “booster” doses will be necessary, and, if so, the timing of such doses.
Many experts said the not-yet-peer-reviewed data are reassuring, showing that people who are fully vaccinated likely are adequately protected. However, if the observed decline in efficacy steadily continues over time, it would fall below the internationally accepted threshold of 50% within 18 months of vaccination. This would bolster Pfizer-BioNTech’s claim that an additional shot of its vaccine will be needed to maintain long-term protection. The data also do not address the vaccine’s efficacy against the now widespread Delta variant. On July 28, Pfizer officials presented unpublished data in a quarterly earnings report to investors showing a third dose of the Pfizer-BioNTech vaccine could boost neutralizing antibody titers against the Delta variant in a small sample of individuals. The data show a more than 5-fold increase in post-second dose titers among vaccinees aged 18 to 55 and a more than 11-fold increase among those ages 65 to 85. The officials said they plan to seek authorization with the US FDA for a third dose by mid-August and indicated clinical studies of an experimental Delta variant vaccine are awaiting regulatory approval but also are expected to begin in August.
BREAKTHROUGH CASES A study published in the New England Journal of Medicine on July 28 examines breakthrough COVID-19 cases among healthcare workers who received 2 doses of the Pfizer-BioNTech vaccine. From January 20 to April 28, 2021, researchers identified breakthrough cases at Sheba Medical Center in Israel by monitoring healthcare workers for COVID-19 symptoms and testing those with known COVID-19 exposures. Following the identification of a breakthrough case, the research team matched the individual with 4 or 5 uninfected controls using generalized estimating equations. Of 39 breakthrough cases among 1,497 fully vaccinated healthcare workers, the researchers found the infected individuals had lower levels of neutralizing antibody titers than their uninfected controls. Additionally, most of the breakthrough cases were asymptomatic or mildly symptomatic, although 19% of the individuals reported symptoms that lasted longer than 6 weeks. The majority of the breakthrough cases (85%) were caused by the Alpha variant (B.1.1.7), and the research team observed no secondary cases stemming from breakthrough cases.
IMF GLOBAL FORECAST In an updated “World Economic Outlook,” the International Monetary Fund (IMF) on July 27 warned that the gap in economic recovery is widening between higher- and lower-income nations due to the COVID-19 pandemic and uneven access to SARS-CoV-2 vaccines. Overall, the global economy is expected to grow 6% in 2021 and 4.9% in 2022. The IMF upgraded its 2022 estimate, with a 0.5 percentage point increase over its projection made earlier this year, driven by growth in the US and UK markets. However, for emerging and developing markets, the IMF downgraded projections for 2021 by 0.4 percentage points from its previous projection, to 6.3%, noting the biggest risks include low vaccination rates and growing numbers of COVID-19 cases. The IMF called on wealthier nations to take urgent action to share vaccine doses with low- and middle-income countries (LMICs), warning that a worsening pandemic could severely hit those markets as well as impact growth projections for richer nations.
The IMF also cautioned that if inequality worsens, nations risk experiencing political instability and discontent, which is happening already in some countries. The pandemic is sowing a “summer of anger,” with political protests documented in Tunisia, Iraq, South Africa, Thailand, Colombia, Brazil, and Haiti, to name a few. Even some wealthier nations—including France and Australia—recently have witnessed large protests against vaccination mandates and lockdown tactics centered on slowing the number of new COVID-19 cases. Experts from the Council on Foreign Relations (CFR) and Columbia University write that “COVID-19 has acted like lighter fluid for countries where embers of discontent were already smoldering.” In a closed briefing this week, Ramesh Rajasingham, UN Acting Assistant Secretary-General for Humanitarian Affairs and Deputy Emergency Relief Coordinator, warned UN Security Council members that three-quarters of the countries needing humanitarian aid have already recorded more COVID-19 cases and related deaths than in all of 2020. Calling the response so far “inadequate,” Rajasingham urged the international community to not only increase vaccine shipments to fragile and conflict-affected countries but also bolster delivery systems by providing logistical and security support. The need for effective and efficient vaccine delivery to LMICs is an issue that cannot be ignored by the developed nations and the private sector.
US POVERTY REDUCTION The number of poor Americans is expected to decline nearly 45% this year from 2018 levels—a record drop in record time—but pieces of the enormous temporary safety net created amid the COVID-19 pandemic that helped to achieve this reduction have ended or are scheduled to soon revert to their pre-pandemic size. In a report released on July 28, the Urban Institute estimated the American Rescue Plan Act, enacted in March 2021, will reduce the 2021 annual poverty rate to 7.7%, well below the 13.9% rate estimated for 2018. The projected poverty rate is expected to be lowest among children (5.6%), but rise for adults ages 18 to 64 (8.1%) and again for older Americans (9.2%). The rates are higher for Hispanic people (11.8%), Asian American and Pacific Islanders (AAPI; 10.8%), and Black people (9.2%) than for white people (5.8%). The federal stimulus checks have had a larger impact on poverty reduction than any other program, according to the report.
One of these programs, the US CDC’s extended federal eviction moratorium, which has prevented eviction for an estimated 10 million people over the past year, is set to expire on July 31. Some advocates, researchers, and US lawmakers are calling for another extension of the program, citing an analysis showing many of these evictions would occur in communities with low vaccination rates and increasing numbers of COVID-19 cases attributed to the Delta variant. A study published this week in the American Journal of Epidemiology supports calls for extending the moratorium, showing that between March and September 2020, eviction moratorium expirations were associated with increased COVID-19 incidence and deaths and backing up the notion that eviction prevention constitutes an important public health measure to mitigate the pandemic’s impacts.
“MEDICAL FREEDOM” LAW New Hampshire (US) Governor Chris Sununu last week signed into law a so-called “medical freedom” bill that prohibits “any public facility, any public benefit, or any public service” from requiring state residents be vaccinated against SARS-CoV-2 to receive or access such services or facilities. The law states that “every person has the natural, essential, and inherent right to bodily integrity, free from any threat or compulsion by government to accept an immunization.” Notably, the law sets out several exceptions, including vaccination requirements for schools, childcare, county nursing homes, and the state’s mental health system. Additionally, the New Hampshire Department of Corrections may mandate certain medical treatments or immunizations “when a direct threat exists.” The law does not address private businesses. Governor Sununu continues to voice support for SARS-CoV-2 vaccines. According to state data, nearly 54% of the state’s residents are fully vaccinated, above the national average.
TANZANIA Tanzania President Samia Suluhu Hassan on July 28 kicked off the country’s SARS-CoV-2 vaccination campaign, publicly receiving the J&J-Janssen vaccine in an effort to bolster confidence in the shots and quell fear stemming from disinformation spread under her predecessor’s administration. Former President John Magufuli, who died in March of heart complications, downplayed the COVID-19 pandemic, endorsed home remedies and prayer as treatments, and called vaccinations “dangerous.” After Magufuli’s death, President Hassan established a COVID-19 expert committee to evaluate the safety and effectiveness of vaccines, as well as make public health recommendations including physical distancing and mask wearing. Tanzania joined COVAX in June, despite having been eligible since the facility’s establishment. The country received more than 1 million doses of the J&J-Janssen vaccine over the weekend from a US donation delivered through COVAX, and President Hassan on July 27 placed an order with the African Union's African Vaccine Acquisition Task Team (AVATT) for an undisclosed number of additional vaccines. The Tanzania government faces challenges to reversing skepticism about vaccines, but President Hassan assured residents the country will obtain enough supplies to reach its goal of vaccinating 60% of the population. Only 2 other African nations—Burundi and Eritrea—have yet to begin national vaccination campaigns.
TOKYO OLYMPICS The Olympics have entered the start of their second week as the COVID-19 situation in Tokyo and Japan continues to worsen. Both the city and the nation on July 29 reported record numbers of new COVID-19 cases, with the nation averaging 6,518 daily new cases. Tokyo, which remains under a state of emergency, recorded 3,865 new cases on July 29, after only the day before passing 3,000 new cases for the first time. The city’s health officials have asked for hospitals to prepare extra beds as the spread of the SARS-CoV-2 Delta variant continues, with more than 75% of new cases caused by the variant. So far, COVID-19 precautions appear to have minimized the spread of SARS-CoV-2 outside of the Olympic “bubble,” although the number of new daily cases reported among Olympic accreditation holders appears to have risen on July 29 and July 30.
COGNITIVE IMPACTS Scientists have long known that areas of the brain involved with smell and taste also are involved in memory, thinking, planning, and mood, and public health officials are increasingly concerned about the long-term impacts of COVID-19 on brain function, memory, and cognition, a phenomenon known as “brain fog.” Scientific evidence is emerging that the virus’s neurological impacts are multi-pronged and not necessarily related to “long COVID,” or post-acute sequelae of COVID-19 (PASC). In a study published in The Lancet journal EClinicalMedicine, researchers from Imperial College London and colleagues examined data from 81,337 people who took exams as part of the Great British Intelligence Test and completed questionnaires regarding self-reports of suspected or confirmed COVID-19. The team found that the 12,689 individuals who had recovered from COVID-19 exhibited significantly more cognitive deficits than their matched counterparts, even among people who said they were no longer experiencing symptoms. Cognitive deficits were found to be especially substantial among those who were hospitalized, those who were hospitalized and on a ventilator, and those who had more severe symptoms but recovered at home.
Researchers with the University of Texas Health Science Center at San Antonio, who recently presented data at the Alzheimer's Association International Conference, found that neurological changes seen after COVID-19 mirror those found in people with Alzheimer’s disease. Genetic studies are showing that the genes responsible for increasing the risk of more severe COVID-19 also increase the risk of Alzheimer’s. Additionally, anecdotal reports suggest Alzheimer’s diagnoses appear to be more common among people in their 60s and 70s who have had severe COVID-19. Further research is ongoing to determine COVID-19’s longer-term impacts on neurological function, including cognition, intelligence, and risk of Alzheimer’s disease.
MUCORMYCOSIS Following India’s most severe COVID-19 surge in the spring, the country has seen an increase in cases of mucormycosis, also called “black fungus,” and related deaths. Since late March, the nation has recorded more than 45,000 cases of the disease, a serious but rare fungal infection caused by the mucormycetes group of molds, and more than 4,300 people have died, with most having contracted COVID-19 prior to their fungal infection. Clinicians have noted that symptoms usually manifest 12-18 days after COVID-19 recovery. In a letter published July 29 in Drug Development Research, researchers warn that because uncontrolled diabetes and other immunosuppressive diseases, as well as corticosteroid treatment, are seen as risk factors for the fungal infection, they suggest avoiding steroids to treat COVID-19, as they might be a contributing factor to the disease. As the number of mucormycosis cases continue to rise, there are questions about unreliable supplies of the drug used to treat the infection, adding an additional challenge to India’s already complicated COVID-19 recovery.
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