COVID-19 Situation Report
The Center also produces US Travel Industry and Retail Supply Chain Updates. You can access them here.
The Johns Hopkins Center for Health Security will be closed on July 5 in observance of the US Independence Day holiday. We will not be publishing a COVID-19 Situation Report on Tuesday, July 6. We will resume publication on Friday, July 9.
EPI UPDATE The WHO COVID-19 Dashboard reports 182 million cumulative cases and 3.95 million deaths worldwide as of 5:00am EDT on July 2.

Global Vaccination
The WHO reported 2.95 billion doses of SARS-CoV-2 vaccines administered globally as of July 1, and 1.17 billion individuals have received at least 1 dose. Analysis from Our World in Data shows that the global daily doses administered has decreased steadily from the record high of 43.1 million doses per day on June 27, now down to 40.1 million. The trend continues to be largely driven by vaccination efforts in Asia, which is, in turn, driven by China. Our World in Data estimates that there are 1.84 billion vaccinated individuals (1+ dose) worldwide (23.7% of the global population). There are an estimated 860 million who are fully vaccinated (11.0% of the global population), although reporting is less complete than for other data.

The US CDC reported 33.5 million cumulative COVID-19 cases and 602,401 deaths. Daily incidence has increased over the past week or so, up from a low of 11,281 new cases per day on June 20 to 12,514 on June 30, an increase of 11% over that period. Daily mortality continues to decline, down to 206 deaths per day, the lowest average since March 26, 2020.

With vaccination progress slowing and increasing prevalence of multiple variants of concern (VOCs), including Delta, there is growing concern that the US could face localized COVID-19 surges in the coming months. While the national daily incidence is increasing only slightly, some parts of the country are exhibiting steeper trends.

Daily incidence is increasing noticeably in 5 of the 10 HHS regions: Region 8 (Mountain) has increased 6% since June 21, Region 4 (Southeast) has increased 17% since June 19, Region 6 (South Central) has increased 26% since June 17*, Region 9 (West Coast) has increased 29% since June 13, and Region 7 (Central) has increased 82% since June 2. Regions 7, 8, and 9 have the highest estimated prevalence of the Delta variant (B.1.617.2) in the country—57.5%, 52.0%, and 38.2%, respectively—in the CDC’s projection for June 6-19. Additionally, these 5 regions account for most of the lowest-ranked states in terms of vaccination coverage. These 5 regions represent 20 of the bottom 25 states in terms of both 1+ dose coverage and full coverage. The combination of increasing Delta variant prevalence and low vaccination coverage is likely a contributing factor to the increases in daily incidence across these states. 
*The lowest recent daily incidence in Region 6 was 1,393 new cases on June 16, but that appears to be a result of a reporting anomaly in Texas. We used June 17 as our baseline.

Numerous states in these regions are exhibiting substantial increases in daily incidence from lows reported within the past month**. While there are other states with increasing trends—eg, Connecticut (+87%), Virginia (+48%)—most are limited to these 5 regions:
Region 4 (4 of 8 states): Alabama (+150%), Florida (+26%), Mississippi (+83%), and South Carolina (+33%)
Region 6 (4 of 5 states): Arkansas (+202%), Louisiana (+51%), Oklahoma (+160%), and Texas (+23%)
Region 7 (3 of 4 states): Kansas (+61%), Missouri (+126%), and Nebraska (+60%)
Region 8 (2 of 6 states):Wyoming (+38%) and Utah (+85%)
Region 9 (2 of 3 states): Arizona (+44%), and Nevada (+170%)
**Dates of individual lows vary.

US Vaccination
The US has administered 328 million cumulative doses of SARS-CoV-2 vaccines, and it is administering approximately 575,000 doses per day. A total of 181 million individuals in the US have received at least 1 dose of SARS-CoV-2 vaccine, equivalent to 54.6% of the entire US population. Among adults, 66.7% have received at least 1 dose as well as 9.0 million adolescents aged 12-17. A total of 156 million individuals are fully vaccinated, which corresponds to 47.0% of the total population. Among adults, 57.7% are fully vaccinated, and 6.8 million adolescents aged 12-17 years are fully vaccinated.

VARIANTS OF CONCERN Although vaccinations in the US continue to rise and appear to be largely protective against variants of concern (VOCs), unvaccinated populations in the US and abroad remain at high, even elevated, risk of severe COVID-19 disease due to VOC infection. In particular, the Delta variant’s increased transmissibility has contributed to significantly increased spread in unvaccinated communities, causing 26% of SARS-CoV-2 infections in the US. In the United Kingdom, COVID-19 cases increased sixfold and hospitalizations doubled in the wake of Delta’s introduction into the population. The WHO recently reiterated its position that all people, regardless of vaccination status, should continue to wear masks indoors and in crowded areas. The US CDC, however, has not reversed its recommendation that fully vaccinated people may be unmasked in all situations.

Last week, the US Assistant Secretary for Preparedness and Response (ASPR) and the US FDA announced they will halt distribution of bamlanivimab/etesevimab, two monoclonal antibody treatments for COVID-19, given their lowered efficacy profiles against the Gamma and Beta variants of concern. Both agencies have pledged to continue closely monitoring the efficacy of other authorized monoclonal antibody treatments in conjunction with the CDC and NIH.  

UK VACCINE BOOSTERS The UK’s Joint Committee on Vaccination and Immunisation (JCVI) published interim advice on a potential SARS-CoV-2 vaccine booster program for winter of 2021-22. JCVI advises that any potential booster program begin in September 2021 to maximize protection of those populations most vulnerable to COVID-19 and reduce the occurrence of severe disease. Additionally, JCVI recommends annual influenza vaccines also be administered in the fall, ideally utilizing a synergistic approach that would support delivery and maximize uptake of both vaccines. The potential booster program should be offered in two stages: Stage 1 will offer a third dose of SARS-CoV-2 vaccine and the annual influenza vaccine in September to immunosuppressed persons aged 16 and older, adults aged 16 and older who are considered clinically extremely vulnerable, those living in residential care facilities for older adults, frontline health and social care workers, and all adults aged 70 and older. Stage 2 will be implemented as soon as practicable after Stage 1 to offer a third SARS-CoV-2 vaccine dose and annual influenza vaccine to all adults over 50 years old, adults 16-49 years old who are in an influenza or COVID-19 at-risk group as noted in the Green Book, and adult household contacts of immunosuppressed persons. Additional scientific data will be considered as it becomes available prior to JCVI sharing final advice. 

mRNA VACCINE EFFECTIVENESS Researchers from the US CDC COVID-19 Response Team, in collaboration with several US academic institutions, published final analysis from a prospective cohort study evaluating the real-world effectiveness of the Pfizer-BioNTech and Moderna SARS-CoV-2 vaccines. The study, published in NEJM, included nearly 4,000 participants from the HEROES-RECOVER network—which includes a variety of healthcare workers, first responders, and other essential frontline personnel—across 6 states, who provided weekly nasal swabs, regardless of the presence of COVID-19 symptoms, as well as additional swabs if they became symptomatic. Among the participants, 80% were vaccinated (1+ dose of mRNA vaccine)—with 84% of those participants receiving both doses—and 20% were unvaccinated.

SARS-CoV-2 infection was confirmed by RT-PCR diagnostic tests in 204 participants (5%). Among these infections, 5 were in fully vaccinated participants, 11 were in partially vaccinated participants, and 156 were in unvaccinated participants*. The researchers estimated the vaccines’ combined adjusted vaccine effectiveness against SARS-CoV-2 infection to be 91% for full vaccination and 81% for partial vaccination. Notably, among infected participants, the mean viral RNA load was 40% lower in participants with at least partial vaccination compared to unvaccinated participants. Additionally, the risk of febrile symptoms was 58% lower among participants with at least 1 dose of the vaccine, and the duration of illness was 6.4 days shorter.
*An additional 32 infections were in participants with uncertain vaccination status.

Genomic sequencing was performed on specimens from 93 of the identified infections. Among these, 12 were in participants with unknown vaccination status and omitted from the analysis. Of the remaining 81 specimens, 10 were variants of concern (VOCs)—9 were the Epsilon variant (B.1.427/429) and 1 was the Alpha variant (B.1.1.7). Three (3) infections with the Epsilon variant were among vaccinated participants, and the rest of the VOCs were among unvaccinated participants.

NOVAVAX VACCINE PHASE 3 TRIAL RESULTS Researchers from the 2019cCov-302 Study Group published final data and analysis in NEJM from a Phase 3 clinical trial of the Novavax SARS-CoV-2 vaccine candidate, NVX-CoV2373. Preliminary data from the trial, conducted at 33 sites across the UK and including 15,187 participants ages 18 to 84, was first published in May to the preprint server medRxiv. Participants were randomized in a 1:1 ratio to receive 2 doses of the vaccine or a placebo administered 21 days apart. NVX-CoV2373 utilizes a different technology than existing vaccines—synthetic SARS-CoV-2 spike protein nanoparticles plus an adjuvant—to stimulate an immune response. 

Analysis shows the vaccine demonstrated 89.7% overall efficacy against symptomatic COVID-19 disease, with 10 cases in the vaccine group and 96 in the placebo group. Five (5) severe cases were identified among the placebo group, but none in the vaccine group, and no deaths were reported among participants who received both doses of the vaccine or placebo. The vaccine demonstrated similar efficacy among participants aged 18-64 years (89.8%) and those aged 65 years and older (88.9%). Efficacy was notably higher among White participants (90.7%) than non-White participants (75.7%), but the study population was nearly 95% White, making it difficult to draw any conclusions regarding race or ethnicity. Post-hoc analysis estimates the efficacy to be 86.3% against the Alpha variant (B.1.1.7) and 96.4% against non-Alpha variants (Gamma [P.1] and Beta [B.1.351]). Notably, the trial was conducted prior to the spread of the Delta variant. In mid-June, Novavax announced preliminary results for another Phase 3 clinical trial conducted in Mexico and the US, which demonstrated overall efficacy of 90.4% and 100% against moderate and severe COVID-19.

US EVICTION MORATORIUM In September 2020, the US CDC issued a “Temporary Halt in Residential Evictions” in response to the severe financial impacts of the COVID-19 pandemic. After a series of extensions, the order was scheduled to end on June 30, 2021; however, the CDC issued one final extension, which is scheduled to expire on July 31. The moratorium aimed to keep individuals and families—millions of whom lost their jobs during the pandemic—in their homes, in part, due to the increased risk of SARS-CoV-2 transmission in congregate settings such as homeless shelters. The CDC’s eviction moratorium has been criticized by some as overreach, exceeding the CDC’s authority. In fact, in May, a federal judge ruled that the CDC did not have the authority to issue the moratorium under the Public Health Service Act, but an appeals court issued a stay that kept the moratorium in place. This week, the US Supreme Court ruled to uphold that stay and keep the moratorium in place through the end of July. The Supreme Court conceded that the CDC exceeded its authority, but with the moratorium scheduled to end next month, the remaining few weeks would allow for a smoother transition and a “more orderly distribution of the congressionally appropriated rental assistance funds.”

Even with the moratorium in place and financial assistance through state and federal economic relief packages, many individuals and landlords struggled to navigate the assistance systems or come to agreements regarding past and future rent payments. In some cases, individuals who were able to catch up on their missed rent payments may still face eviction once the moratorium ends because late payments could violate the terms of their lease, regardless of the moratorium. In addition to the moratorium, many courts were closed during the pandemic and are now attempting to process a long backlog of cases, including many for eviction. With an estimated 10 million individuals still behind on rent payments, the US could face a parallel epidemic of evictions starting in only a few short weeks.

NORTH KOREA At a Politburo meeting last month, North Korea Supreme Leader Kim Jong-un chastised Workers’ Party of Korea executives for failing to implement long-term “organizational, institutional, material, scientific, and technological measures” to prevent the COVID-19 pandemic from reaching the country, possibly suggesting the virus has breached the nation’s borders. The historically reclusive North Korea has been even more closed off since the start of the pandemic, taking drastic containment measures, including shuttering its border with China, its largest trading partner. The country’s lockdown has further strained its economy and likely deepened existing food shortages. North Korea claims it has no COVID-19 cases, a position questioned by experts. According to the North’s official Korean Central News Agency (KCNA), the senior officials’ diversions from policy “thus caused a crucial case of creating a great crisis in ensuring the security of the state and safety of the people and entailed grave consequences.” The news agency did not elaborate on those consequences. 

Some experts speculate that the whole-of-government approach and continued large-scale, in-person meetings suggest any major outbreak may have been avoided. Other experts wonder whether Kim’s public airing of the enforcement problems was meant to send a signal to China for additional aid or to the US to loosen sanctions to allow more assistance to enter the country through international partners, such as the United Nations World Food Programme. Kim’s own dramatic and unexplained weight loss raised questions about a potential undisclosed health problem or a self-imposed belt-tightening to show fellowship with North Korean citizens facing food insecurity. On June 30, China offered to help North Korea if asked, and a South Korean official said the nation has continuously proposed to help its northern neighbor. North Korea was set to receive up to 1.9 million doses of AstraZeneca-Oxford vaccine by the end of May through COVAX, but the shipments have been delayed. North Korea likely has no vaccine doses; however, China has not revealed whether it has sent vaccines.  

AFRICA The African continent is in the midst of an “extremely aggressive” third wave of infections, driven by the Delta variant of concern (B.1.617.2; VOC) and low vaccination rates. During an Africa CDC briefing on July 1, Africa CDC Director Dr. John Nkengasong noted the continent had 5.5 million confirmed COVID-19 cases and experienced a 23% increase in COVID-19-related deaths over the past week. According to estimates, the continent has received only 65 million vaccine doses for its 1.2 billion population. Many African nations put faith in COVAX to deliver 700 million vaccine doses to the continent by year-end, but so far COVAX has delivered fewer than 50 million doses. With the lowest vaccination rate in the world—around 1% fully vaccinated—African officials and WHO leadership are voicing frustration over the drastic global divide in vaccine access. At the briefing, Strive Masiyiwa, a Zimbabwean-born businessman who serves as African Union (AU) Special Envoy and coordinator of the Africa Vaccine Acquisition Task Team (AVATT) initiative, condemned European countries for failing so far to ship any vaccine doses to Africa and accused COVAX of withholding information about donor pledge shortfalls. Dr. Nkengasong said Africa does not want to be seen as “the continent of COVID,” expressing resentment over stadiums full of sports fans in Europe. Previously, Dr. Mike Ryan, Executive Director of the WHO Health Emergencies Programme, accused Western nations of racism, paternalism, and neo-colonialism for delaying vaccine deliveries to Africa. Dr. Tedros Ghebreyesus, an Ethiopian who is WHO Director General, said, “Just give us the vaccines.”

Also at the July 1 briefing, Masiyiwa announced the US next week will begin shipping donated vaccine doses, mostly from Pfizer-BioNTech and a few from J&J-Janssen. The shipments are expected to be distributed to about 50 AU member states. NPR reports on new solar refrigeration technology that could help overcome the Pfizer-BioNTech vaccine’s cold-storage requirements. Additionally, the US International Development Finance Corporation (DFC) will lend about US$118 million to support South African pharmaceutical company Aspen Pharmacare in manufacturing the J&J-Janssen single-shot SARS-CoV-2 vaccine. The loan—part of a larger US$710 million long-term financing package—will help Aspen make up to 500 million doses of the vaccine through the end of 2022, with the goal of vaccinating much of the African population. US officials say this US-supported effort offers an alternative to China’s vaccine diplomacy on the continent. Meanwhile, South Africa this week reinstated strict lockdowns amid a strong surge in COVID-19 cases. South Africa President Cyril Ramaphosa, who is heavily involved in talks to bring more vaccine doses to the continent, said the surge in his country appears to be driven by the Delta variant.   

BANGLADESH After bringing its largest COVID-19 wave under control in May, COVID-19 cases in Bangladesh are surging again and expected to surpass the previous peak. Bangladesh’s daily incidence has increased by a factor of 8 since mid-May, now up to nearly 7,000 new cases per day. In an effort to bring transmission under control, the country is implementing a 7-day, highly restrictive national lockdown enforced by the military, prohibiting nearly all non-essential public activity. Unlike some other countries, Bangladesh did not have a reprieve following its previous surge, and the public and health system did not have time to recover before the current surge. Medical oxygen remains in short supply, which could exacerbate the already dire situation in overburdened hospitals. Bangladesh has relatively limited genomic sequencing data available; however, it appears that the Delta variant of concern (B.1.617.2; VOC) may be rapidly becoming the dominant variant, overtaking the Beta variant (B.1.351) that dominated its previous surge.

Like many countries, Bangladesh is making slow progress in terms of vaccination, although that progress essentially halted in late April, as India, Bangladesh’s principal vaccine supplier, suspended vaccine exports during its largest surge. Earlier this week, the US announced that it is shipping 2.5 million doses of the Moderna vaccine to Bangladesh to support vaccination efforts. Without sufficient vaccination coverage, though, surges like this inevitably will continue, and large-scale community transmission can provide opportunities for the virus to mutate into new and more dangerous VOCs.

IN-PERSON SCHOOLING A new report by the ABC Science Collaborative demonstrates that in-person schooling with proper masking protocols can safely be pursued at all educational levels in the US. The report analyzed 864,515 students and 160,549 staff members across 100 school districts and 14 charter schools in North Carolina. Under the state’s “Plan A” protocol, masks were required for all students and staff in all educational areas, including bus rides to and from school. Over the 4-month study period, 1 in 127 students and 1 in 138 staff were diagnosed with COVID-19, although researchers stated that around 95% of those infections occurred within the community and not in school. The report ultimately recommended that full capacity, in-person learning can be safely achieved at all grade levels with strong adherence to mask mandates. With adherence to masking protocols, students could be less physically distanced and even reach full capacity on school busses. The report provides strong data-driven evidence for in-person learning, as school district administrators nationwide create their plans for the upcoming school year. Still, vaccinations among eligible students and staff will be key to relaxing masking measures in the future.

SUMMER CAMP OUTBREAK The Illinois Department of Public Health (IDPH) reported an outbreak at a summer youth camp in mid-June. The outbreak resulted in at least 85 cases among teenagers and adults, including 1 unvaccinated camper who was hospitalized. According to the IDPH, the camp did not check vaccination status for campers nor staff, although reportedly all of the campers are old enough to be eligible for vaccination. Additionally, the camp did not require mask use indoors. The majority of the cases were among teenagers, illustrating the ongoing risk of COVID-19 among younger individuals. IDPH Director Dr. Ngozi Ezike emphasized that even mild cases of COVID-19 in children pose a risk of transmission and uncertain long-term health effects. Multiple individuals at the camp “also attended a nearby conference, which resulted in 11 additional cases,” 70% of whom were unvaccinated. The facility has postponed an upcoming camp until August as a result of the outbreak.