COVID-19 Situation Report
The Center also produces US Travel Industry and Retail Supply Chain Updates. You can access them here.
COVID-19 Testing Toolkit Webinar Series – June 21

Join us for a webinar on June 21 at 10:00am ET, Lessons from Lufthansa, COVID-19 Testing for the Airline Industry. Our speaker, Martin Knuchel, Senior Director, Head of Crisis, Emergency & Business Continuity Management Lufthansa Group Airlines, will discuss how Lufthansa has handled the challenges of the last year and how the experiences will be used for travel going forward. This webinar is part of a series hosted by the Center’s COVID-19 Testing Toolkit which provides essential information on COVID-19 testing for organizations. Please register here.
EPI UPDATE The WHO COVID-19 Dashboard reports 174.4 million cumulative cases and 3.8 million deaths worldwide as of 7:30am EDT on June 11.

Global Vaccination
The WHO reported 2.2 billion doses of SARS-CoV-2 vaccines administered globally as of June 11, and 874 million individuals have received at least 1 dose. Our World in Data reported 2.30 billion cumulative doses administered globally, an increase of 12% compared to this time last week. After a week-long decline, global daily doses administered rebounded slightly to 34.4 million doses per day, down from a record of 36.0 million doses per day on June 5. Our World in Data estimates there are 488 million people worldwide who are fully vaccinated, corresponding to approximately 6.3% of the global population, although reporting is less complete than for other data.

The recent decline in global average daily doses administered is driven largely by a sharp decline in Asia and, to a lesser degree, a steady decline in North America over the past several weeks. Asia’s recent decline is largely a result of the trend in China, where the average daily doses administered fell by more than 15% from June 5 to June 9 before rebounding slightly. After a steady 6-week decline from its April peak, India’s daily average began increasing again in late May. It appears that India could potentially surpass its previous peak if it continues on its current trajectory, but there is still a considerable gap to its current record. Similarly, the trend in North America is driven largely by the steady decline in the US, down by two-thirds compared to its peak on April 13. Longer-term increases in Canada, the Dominican Republic, Mexico, and other countries in the region are making up for some of the decline in the US.

With the exception of North America, all continents are reporting steadily increasing or accelerating trends in daily vaccinations. While Asia’s daily average decreased over the past week, it is still more than 5.5 times higher than it was in mid-March and double where it was in mid-May. Notably, Oceania is now reporting an average daily per capita vaccination rate that is nearly on par with North America and slightly below the global average. Daily vaccinations continue to increase slowly in Africa as well. As a whole, Africa remains well behind the other continents on a per capita basis, but it appears that its collective daily vaccination trend may be starting to accelerate. On a per capita basis, Europe is reporting the highest daily average, and its peak on June 7 was only 11% less than North America’s record high in mid-April.

At the national level, China is easily #1 globally in terms of total daily doses administered. Despite its decline over the past week, China’s 17.4 million doses per day is more than 5.5 times the average in #2 India (3.13 million). At #3, the US (1.14 million) is the only other country reporting more than 1 million doses per day. Among the top 10 countries, 4 countries are in Asia, 4 are in Europe, and 2 are in the Americas.

On a per capita basis, the Dominican Republic is #1 globally with 1.6 daily doses per 100 population, and Fiji is #2 with 1.4. Notably, China (1.2) is #3 globally, despite having the world’s largest population. In fact, China accounts for approximately 18.5% of the global population but more than half of the daily global vaccinations. South Korea also is in the top 10 for both total and per capita daily doses administered, and its daily average has increased by a factor of 7.5 since mid-May. Among the top 10 countries in terms of per capita daily doses administered, 5 are in Europe, 2 are in Asia, 2 are in the Americas, and Fiji represents Oceania. All countries in the top 10 are reporting more than 1 daily dose per 100 population, more than double the global average (0.44).

Among African countries, Morocco (189,216 doses per day) is reporting the highest total average, and Mauritius is reporting the highest per capita average (0.54 daily doses per 100 population). In Oceania, Australia is reporting the highest total daily doses administered, with 120,710 doses per day.

The US CDC reported 33.2 million cumulative cases and 596,059 deaths. After steady declines since mid-April, the United States’ daily incidence increased slightly on June 7-8. Notably, however, states have reported nearly 12,500 previously unreported cases over the past week—including more than 1,000 on June 3; more than 2,500 on June 8; and more than 7,500 on June 9—which is contributing to an artificially elevated average. Additionally, delayed reporting over the Memorial Day holiday weekend is likely contributing to elevated reports as states caught up. A similar effect can be observed in daily mortality. Daily mortality quickly climbed from a low of 321 deaths per day on June 4 to 366 on June 7—the first day that the Memorial Day holiday weekend moved outside the 7-day window—an increase of 14% over that period. We expect both daily incidence and mortality to continue decreasing once reporting fully returns to normal, but we will monitor these trends closely.

US Vaccination
The US has distributed 372.8 million doses of SARS-CoV-2 vaccines and administered 305.7 million. Similar to daily incidence and mortality, the average daily vaccine doses administered* increased slightly over the past several days, likely stemming from delayed reporting over the Memorial Day holiday weekend. The US is averaging 867,109 doses per day, and 535,221 people are achieving fully vaccinated status per day, down from a high of 1.8 million per day on April 12.

A total of 172 million individuals in the US have received at least 1 dose of SARS-CoV-2 vaccine, equivalent to 51.9% of the entire US population. Among adults, 64.0% have received at least 1 dose, and 7.3 million adolescents aged 12-17 years have received at least 1 dose. A total of 141.6 million people are fully vaccinated, which corresponds to 42.6% of the total population. Among adults, 53.4% are fully vaccinated, and 3.6 million adolescents aged 12-17 years are fully vaccinated. Progress has largely stalled among adults aged 65 years and older: 86.5% with at least 1 dose and 75.8% fully vaccinated. In terms of full vaccination, 73 million individuals have received the Pfizer-BioNTech vaccine, 57 million have received the Moderna vaccine, and 11 million have received the J&J-Janssen vaccine.
*The US CDC does not provide a 7-day average for the most recent 5 days due to anticipated reporting delays for vaccine administration. This estimate is the most current value provided.

The Johns Hopkins Coronavirus Resource Center is reporting 33.4 million cumulative cases and 598,756 deaths in the US as of 10:30am EDT on June 11.

mRNA VACCINES & RISK REDUCTION US CDC researchers last week published a study in medRxiv (preprint) showing 2-dose mRNA vaccines, specifically those from Pfizer-BioNTech and Moderna, are highly effective among working-age adults in preventing SARS-CoV-2 infections when administered in real-world conditions. Additionally, the vaccines lessened viral load, febrile symptoms, and illness duration among those vaccinated participants who became ill with COVID-19. Initial findings from the study, called HEROES-RECOVER, were released in March, with the latest findings based on 3,975 healthcare personnel, first responders, and other essential and frontline workers who self-collected nasal swabs for 17 consecutive weeks from December 13, 2020 to April 10, 2021. 

Once fully vaccinated, participants’ risk of SARS-CoV-2 infection was reduced by 91%, and the risk among those with partial vaccination was reduced by 81%. Only 16 of the 204 people who became infected had been vaccinated. Participants who were fully or partially vaccinated were more likely to have milder and shorter illness when compared with those who were unvaccinated, with some having asymptomatic infection. Those participants who were fully or partially vaccinated and experienced infections also had 40% less detectable viral load, were 66% less likely to test positive for the virus for more than 1 week, and experienced 6 fewer days of viral shedding when compared with those who were unvaccinated. The study adds to the growing body of real-world evidence that US FDA-authorized mRNA vaccines are effective at preventing SARS-CoV-2 infection, according to the CDC.

VARIANTS OF CONCERN & VACCINATION The emergence of the SARS-CoV-2 Delta variant (B.1.617.2) has prompted health officials worldwide to encourage people to become fully vaccinated to help lower the risk of infection and severe disease. The Delta variant appears to be more transmissible than the wild type virus and other SARS-CoV-2 variants, shows some ability to escape immune detection in individuals after vaccination or initial infection, and could cause more severe disease, although more research is needed to confirm the latter. In the UK, the Delta variant is associated with more than 60% of infections and is causing surges of COVID-19 in some parts of England. In the US, the variant is responsible for more than 6% of infections sequenced by researchers. At a White House briefing on June 8, White House Chief Medical Advisor Dr. Anthony Fauci noted the variant has been detected in 60 countries and, in the UK, is impacting younger populations aged 12- to 20-years-old. Dr. Fauci also discussed vaccine effectiveness against the Delta variant, saying 2 doses of the Pfizer-BioNTech and AstraZeneca-Oxford vaccines appear to be significantly more effective than 1 dose in preventing infection or severe disease caused by the variant, and urged everyone to be vaccinated.

In a study published in Nature on June 9 as an accelerated article preview, researchers reported the J&J-Janssen vaccine offers “strong protection against symptomatic” cases of COVID-19 caused by the wild type SARS-CoV-2 virus, as well as the Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), and Epsilon (B.1.427 and B.1.429) variants. The small study, which examined the immune responses of 20 volunteers between the ages of 18 and 55, found fewer neutralizing antibodies against the Beta and Gamma variants when compared to the original wild type virus. However, the non-neutralizing antibody and T-cell immune responses remained largely preserved in these individuals, making up for a lack of neutralizing antibodies when challenged by variants. These findings reiterate the importance of full vaccination in protecting against all known SARS-CoV-2 variants.

VACCINE PASSPORTS The use of vaccination “passports” continues to expand in Europe. This week, Germany unveiled CovPass, a digital vaccination card that individuals can save on their mobile phones. CovPass is compatible with the EU’s Digital COVID Certificate, which will document vaccination status, negative test results, or prior SARS-CoV-2 infection for individuals across the European bloc starting July 1, 2021. Jens Spahn, Germany’s Federal Minister of Health, indicated that CovPass is expected to be fully implemented by the end of June, which would support international travel during Europe’s summer tourism season. In addition to travel, the digital vaccination documentation can be used at businesses, museums, and other venues that require vaccination. Individuals can upload their vaccination status into the CovPass smartphone application by scanning a QR code provided after vaccination, and the app can then display the QR code wherever it is required. Vaccinated individuals will still be able to use the printed vaccination certificate, if they elect or are unable to use the digital version.

As vaccination coverage increases, many countries are allowing travelers to provide documentation of full vaccination status instead of negative SARS-CoV-2 test results upon arrival. The International Air Transport Association (IATA) already has documented instances of counterfeit vaccination documents in multiple countries, but it appears that the responsibility for verifying these documents is largely falling on airlines. Reportedly, airlines are calling for increased use of digital documentation, which is more difficult to counterfeit than paper copies, and it reduces the burden on airline personnel, who do not necessarily have the expertise necessary to identify fraudulent documentation.

US TRAVEL ADVISORIES On June 8, the US updated its COVID-19 travel advisories for several dozen countries. Notably, the Department of State lowered 58 countries from Level 4 (Do Not Travel) to Level 3 (Reconsider Travel) and lowered another 27 countries to either Level 1 (Exercise Normal Precautions) or Level 2 (Exercise Increased Caution). Additionally, the CDC issued updates for more than 120 countries and territories. The CDC’s Level 4 category (Very High COVID-19 Activity) fell from 140 countries and territories to 61, and the number of countries in the Level 1 category (Low COVID-19 Activity) jumped from 30 to 56. The changes reflect both a continuing decrease in COVID-19 burden in many countries around the world and growing evidence of the protection conferred by SARS-CoV-2 vaccines, in the US and elsewhere. The changes also aim to differentiate countries “with severe outbreak situations from countries with sustained, but controlled” transmission.

The CDC continues to recommend that individuals are fully vaccinated before traveling to other countries. Additionally, all unvaccinated individuals should avoid travel to Level 3 (High COVID-19 Activity) countries, and unvaccinated individuals who are at elevated risk for severe COVID-19 disease should avoid nonessential travel to Level 2 (Moderate COVID-19 Activity) countries.

VACCINE DONATIONS TO TAIWAN Last week, Taiwan received a donation of 1.24 million doses of the AstraZeneca vaccine from Japan to aid in its vaccination campaign. Taiwan is facing challenges in acquiring vaccines, with Taiwan President Tsai Ing-wen repeatedly turning down offers from China after expressing concerns about the Chinese vaccines’ safety. Taiwan also has accused China of trying to block its vaccine purchases internationally. China regards Taiwan as part of its territory. On June 6, 3 US Senators stopped in Taiwan for a 3-hour visit, expressing bipartisan US support for the island and pledging the US government will donate 750,000 vaccine doses to reduce its severe vaccine shortage. Notably, the Senators’ visit could have implications of its own on US-China relations, as the delegation arrived in a US Air Force C-17 Globemaster III freighter, a primary strategic lift aircraft for the military. Some speculated that the optics of a military aircraft capable of transporting troops and tactical cargo on a Taiwanese runway could rouse a response from Chinese officials. 

Approximately 3.25% of Taiwan’s 23.5 million people have received at least one dose of vaccine. Through COVAX, Taiwan has signed contracts for 4.76 million doses as well as 10 million doses of the AstraZeneca vaccine, and 5.05 million of the Moderna vaccine. Delivery delays are expected for the AstraZeneca vaccine produced in Thailand over distribution concerns in Southeast Asia. Taiwan also is pursuing development of its own vaccines; Medigen Vaccine Biologics said it will apply for Emergency Use Authorization locally following the release of phase 2 vaccine trial results and plans to apply to the European Medicines Agency (EMA) and other international health authorities to start large-scale phase 3 trials. Taiwan also is engaged in early stage discussions to produce vaccines for US companies. Additionally, Germany reportedly is assisting Taiwan in talks with Pfizer-BioNTech to supply the island with the company’s vaccine. 

CHINA LOCKDOWN Officials in Guangzhou, the capital of the southern province of Guangdong, China, this week instituted strict lockdowns impacting more than 180,000 residents after a new SARS-CoV-2 outbreak, blamed on the Delta variant, was detected among people who ate at several restaurants in the city’s Liwan district. Officials said each infected person has passed the virus along to more people than in any other previous outbreak in the country. As of June 11, officials reported 2 imported COVID-19 cases and 9 indigenous cases in Guangdong, with nearly the city’s entire population of 18.7 million people undergoing testing earlier this week. China continues to rely on several core principles of prevention strategies, including tight lockdowns, widespread testing, limits on movement, and 2-week or longer government-supervised quarantines for people arriving from other countries. The strict travel restrictions are expected by many to remain in place through at least February, when Beijing will host the Winter Olympics. 

Chinese leaders are urging people to get vaccinated, with an average of nearly 20 million people getting vaccinated daily. As of June 8, the nation has administered more than 794 million doses to its population of 1.4 billion, according to the government. The majority of the vaccinations are using 2 Chinese-produced vaccines, Sinovac’s Coronavac and the Sinopharm vaccine, both of which have received Emergency Use Listings (EUL) from the WHO. In clinical trials, the Sinovac vaccine showed it prevented symptomatic disease in 51% of those vaccinated and prevented severe COVID-19 and hospitalization in 100% of the studied population. The Sinopharm vaccine’s efficacy for preventing symptomatic and hospitalized disease was estimated to be 79% for all age groups combined. However, with the spread of the Delta variant in Guangzhou, some are raising questions about the effectiveness of China’s vaccines, as that variant has proven capable of vaccine escape in other countries. 

VACCINES IN AFRICA WHO Director-General Dr. Tedros Adhanom Ghebreyesus said on June 7 he hopes that some SARS-CoV-2 vaccine manufacturing sites in Africa will be close to commencing production by the end of 2021. Senegal reportedly is among the potential sites, under an agreement with Belgian biotech group Univercells. Last month, the EU announced an investment of €1 billion (US$1.2 billion) for manufacturing and access to vaccines, medicines, and health technologies in Africa. The leading candidates for regional manufacturing hubs are Senegal, South Africa, Rwanda, Morocco, and Egypt. In South Africa, Aspen Pharmacare is already producing the J&J-Janssen vaccine locally, and the Biovac Institute is working with the French and German governments and pharmaceutical companies to establish production capacity of 30 million doses annually.

A report by The Wall Street Journal indicates that government officials in South Africa seized 2,400 doses of counterfeit SARS-CoV-2 vaccines. The problem of counterfeit vaccines is certainly not limited to African nations, but the limited supply available to most countries could drive increased demand, fueling a market for fraudulent products. Previously, fraudulent doses have been confiscated in Mexico, Poland, China, and other countries. Networks and markets for counterfeit medications already exist in many low- and middle-income countries (LMICs), which could facilitate the distribution of fake SARS-CoV-2 vaccines. In fact, the WHO estimates that 10% of all medical products in LMICs are “either substandard or falsified.” In response to an increased risk of counterfeit vaccines, Kenyan officials suspended the importation of SARS-CoV-2 vaccines by private companies in order to provide more control and oversight. To date, there are no known instances of fraudulent vaccines being administered at any government vaccination sites, and national governments are collaborating with Interpol to continue combating the threat.

INDIA VACCINATION POLICIES India’s federal government announced this week it would begin to play a larger role in the administration of SARS-CoV-2 vaccinations across the country. The change comes amid public backlash at the low rates of domestic vaccine administration, especially amid the country’s worst COVID-19 surge. As of June 10, more than 46 million people in India, or 3.4% of the population, are fully vaccinated. India has set an ambitious goal to vaccinate 900 million adults by the end of 2021 and provide cost structures that enable people from all economic backgrounds to receive a vaccine. The Indian government also reversed its original plan to have states and the private sector lead the charge to vaccinate those between the ages of 18 and 44, announcing the federal government will provide free vaccines to any adult starting later this month. Under the new directive, the federal government will send 75% of vaccines procured directly from manufacturers to states at no cost. The remaining 25% of vaccines will be available for sale to the private sector, which can resell the vaccines through private clinics or hospitals. This is a change from previous allocations, which sent 50% of vaccines to the federal government and the other 50% to states and the private sector. The hope is that the new policy, which will go into effect on June 21, will increase vaccine coverage across the country, aiding in the government’s response to the ongoing COVID-19 surge. 

PEDIATRIC VACCINE CLINICAL TRIALS Pfizer announced this week it will expand its SARS-CoV-2 vaccine clinical trials to include children aged 5 to 11 years, with testing among younger age groups to begin in the coming weeks. The vaccine being used is the same as that authorized for use among adolescents and adults ages 12 and older, but it will be administered as lower doses based on age group. The phase 2/3 trial is expected to enroll as many as 4,500 participants across the US, Finland, Poland, and Spain. The company said it expects to have safety and immune response data for children aged 5-11 years in September, with data for children as young as 2 expected shortly after. Data for children aged 6 months to 2 years is expected to be available in October or November, according to company officials. 

PEDIATRIC LONG COVID/PASC The risk factors, clinical presentation, and recovery timeline for post-acute sequelae of COVID-19 (PASC), colloquially referred to as “long COVID,” largely remain a mystery, even 1.5 years into the COVID-19 pandemic. Most of the attention remains on adult PASC patients, and relatively little data are available for children who experience longer-term effects of SARS-CoV-2 infection. Estimates for the prevalence of PASC among adults who recover from acute SARS-CoV-2 infection range from 1-in-10 to 1-in-3 patients, but a dearth of data on pediatric PASC patients makes it more difficult to estimate the burden in that population. Several small studies suggest that approximately 7-20% of pediatric SARS-CoV-2 infections could result in longer-term physical and mental health effects.

There remains considerable uncertainty regarding the risk factors for PASC in both adults and children, and the focus on adults—in terms of both testing and clinical care—and relatively milder COVID-19 disease among children during the pandemic could make it difficult to identify children who are at risk of PASC. Additionally, pediatric PASC patients tend to have more normal test results, including blood tests, EKGs, and imagery (eg, CT scan), despite experiencing PASC symptoms. It may also be more difficult for children to explain symptoms such as “brain fog” to parents, guardians, or clinicians, and the longer-term impacts of PASC on physical and mental development may not be fully evident for years later. Similar long-term effects have been documented in children who recover from other diseases, such as Lyme disease or mononucleosis, but it likely will take dedicated research efforts over many years to fully characterize PASC in pediatric patients.

ROUTINE CHILDHOOD IMMUNIZATIONS A study published today in the US CDC’s Morbidity and Mortality Weekly Report (MMWR) examines the impact of the COVID-19 pandemic on the administration of certain routine childhood and adolescent vaccines. Researchers examined data from 10 US jurisdictions with robust vaccination reporting systems, comparing the number of vaccine doses administered between March-September 2020 with the same time period in both 2019 and 2018. The research team split the time frame into two distinct periods of March-May and June-September to account for areas implementing and then lifting stay-at-home orders. The researchers found that administration of routine pediatric and adolescent vaccines lagged significantly in the first time period (March-May) when compared to past years. Though the researchers noted a rebound in the second time period (June-September), it was not significant enough to make up for the lack of vaccine administration during the first period. The CDC expressed concern that this gap in vaccine coverage could lead to an increased risk of disease outbreaks in schools when many children return to in-person learning this fall, and the agency encouraged health care providers to consider providing missed vaccines at the same time as administering SARS-CoV-2 vaccines in an effort to catch up. The CDC previously advised a 2-week break between administering a SARS-CoV-2 vaccine and other vaccines but reversed that guidance late last month.

BAMLANIVIMAB Results from a phase 3 clinical trial published in JAMA found that the preventive administration of the monoclonal antibody (mAb) treatment bamlanivimab as a monotherapy reduced the incidence of SARS-CoV-2 infection among residents and staff at skilled nursing home facilities with at least 1 confirmed index case. The randomized, double-blind, single-dose trial enrolled residents and staff at 74 skilled nursing and assisted living facilities across 11 states with at least one confirmed COVID-19 case, for a total of 1,175 participants for the duration of the trial between August and November 2020. Within 7 days of a confirmed SARS-CoV-2 case at a facility, participants were screened for enrollment, tested for SARS-CoV-2 infection, and randomly assigned and dosed with 4,200 mg of intravenous bamlanivimab or placebo (saline) if eligible. Bamlanivimab significantly reduced the incidence of COVID-19 in the prevention population compared with placebo (8.5% vs 15.2%; odds ratio, 0.43 [95% CI, 0.28-0.68]; P < .001). Five (5) deaths attributed to COVID-19 occurred during the trial period, all of whom were in the placebo group. Notably, the US FDA in April 2021 rescinded its Emergency Use Authorization (EUA) for bamlanivimab as a monotherapy because of resistance of SARS-CoV-2 variants to the drug. However, the mAb treatment is still permitted to be used as a treatment in combination with another monoclonal antibody, etesevimab.