COVID-19 Situation Report
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Capitol Hill Steering Committee on Pandemic Preparedness & Health Security – June 16

Join us on Wednesday, June 16, at 1:00pm ET for the webinar Global Vaccine Access: Challenges and Opportunities. Speakers will evaluate where things stand in terms of global access to COVID-19 vaccines and the urgent need to expedite global vaccine distribution to save lives and reduce the risk that variants pose. Global vaccination approaches will be considered, including bilateral or multilateral agreements, additional donations of vaccines or money to COVAX, investments in globally distributed manufacturing sites, and other useful solutions. To register, click here.
EPI UPDATE The WHO COVID-19 Dashboard reports 173.2 million cumulative cases and 3.7 million deaths worldwide as of 6:00am EDT on June 8. Global weekly incidence and mortality continue to decline. The weekly incidence as of May 31 decreased 15.43% from the previous week, and weekly mortality decreased by 8.33%. Data are showing potentially steep declines for the week ending June 7, although data remain incomplete.

Global Vaccination
The WHO reported 1.9 billion doses of SARS-CoV-2 vaccines administered globally as of June 5, and 800 million individuals have received at least 1 dose. Our World in Data reported 2.18 billion cumulative doses administered globally, and the global cumulative total continues to increase at 12% per week. Daily doses administered have begun to decrease, to 34.5 million doses per day, down from a record of 35.9 million doses per day on June 5. Our World in Data estimates there are 467 million people worldwide who are fully vaccinated, corresponding to approximately 6% of the global population, although reporting is less complete than for other data.

The US CDC reported 33.2 million cumulative cases and 594,802 deaths. Daily incidence and mortality continue to decline, to the lowest levels since early in the pandemic. The current average daily incidence—13,276 new cases per day—is the lowest since March 27, 2020, early in the United States’ initial surge. On May 31, the US reported fewer than 10,000 new cases in a single day for the first time since March 21, 2020. With 378 deaths per day, the United States’ daily mortality is the lowest since March 29, 2020. Additionally, the US continues to report new record values for test positivity, now down to 2.11%.

As the US reaches daily incidence levels not reported since the earliest days of its COVID-19 epidemic, we will take a brief look at trends in daily incidence at the state and regional levels. At the regional level, current trends are relatively similar across the country. All regions are currently reporting decreasing trends in daily incidence. On a per capita basis, Regions 7 (central), 8 (mountain west), and 9 (west coast) faced the most severe winter 2020 surges, but Regions 7 and 9 reported minimal surges in spring 2021. Regions 4 (southeast) and 6 (south central) also reported relatively small spring 2021 surges. On a per capita basis, the largest spring 2021 surges were in Regions 1 (northeast), 2 (New York/New Jersey), and 5 (midwest).

While there was considerable variation in terms of the timing and magnitude of the regional peaks in winter 2020 and spring 2021, all regions are currently reporting similar per capita daily incidence and decreasing trends. Regions 8 (8.1 daily cases per 100,000 population) and 10 (northwest; 7.1) are currently reporting the highest per capita daily incidence, and Regions 1 (2.3) and 9 (2.4) are reporting the lowest. Most of the remaining regions fall between approximately 3.0-4.5 daily cases per 100,000 population. For context, most regions were reporting between 60 and 100 daily cases per 100,000 population during their autumn/winter 2020 peak.

Notably, multiple sources indicate that most US states are reporting decreasing or steady trends in daily incidence. The Johns Hopkins Coronavirus Resource Center identifies only 6 states (plus Washington, DC) with notable increasing trends over the past 2 weeks: Alabama, Idaho, Louisiana, Montana, Nevada, and Wyoming. The Reuters COVID-19 Tracker reports that 40 states are reporting decreasing trends over the past 2 weeks, and the other 10 (plus Washington, DC) are reporting steady trends over that period. Analysis by The New York Times shows state-level biweekly trends in daily incidence range from -5% to -81%, with no states reporting increasing trends over that period.

According to US CDC data, the state-level per capita daily incidence ranges from Vermont with 1.0 daily case per 100,000 population to Colorado with 9.9. Wyoming (9.3) and Florida (9.1) are the only other states reporting more than 9 daily cases per 100,000. South Dakota (1.3), California (1.6), Nebraska (1.6), New Hampshire (1.6), Connecticut (1.75), Michigan (1.8), and Maryland (1.8) are other states reporting fewer than 2.0 daily cases per 100,000. Most states fall between approximately 3.1 and 6.2. As a whole, the US is reporting 4.0 daily cases per 100,000. But even with this wide variation between states, all are currently reporting a small fraction of their highest peak.

US Vaccination
The US has distributed 371.5 million doses of SARS-CoV-2 vaccines and administered 302.8 million. After a brief increase, the daily doses administered* is once again decreasing, down to 828,634 doses per day as of June 2, the lowest average since January 11. Approximately 469,294 people are achieving fully vaccinated status per day, down from a high of 1.8 million per day on April 12.

A total of 171 million individuals in the US have received at least 1 dose of SARS-CoV-2 vaccine, equivalent to 51.6% of the entire US population. Among adults, 63.7% have received at least 1 dose, and 6.8 million adolescents aged 12-17 years have received at least 1 dose. A total of 139.7 million people are fully vaccinated, which corresponds to 42.1% of the total population. Among adults, 53% are fully vaccinated, and 3 million adolescents aged 12-17 years are fully vaccinated. Progress has largely stalled among adults aged 65 years and older: 86.4% with at least 1 dose and 75.6% fully vaccinated. In terms of full vaccination, 72 million individuals have received the Pfizer-BioNTech vaccine, 56.6 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.

WHO VARIANT NAMING CONVENTION For months, experts have recognized the challenge of effectively communicating about variants of concern (VOCs) and called for a simplified naming convention. On May 31, the WHO unveiled a new system that will assign Greek letters to VOCs and variants of interest (VOIs) as a more convenient label. While many VOCs have been colloquially labeled using their place of origin (e.g., Brazil, India, South Africa, UK), the use of locations is inconsistent with existing WHO guidelines for naming diseases and pathogens. The use of locations, events, peoples, or other characteristics contributes to stigmatization of affected individuals, locations, and cultures. The use of Greek letters for SARS-CoV-2 variants shortens the nomenclature into a convenient shorthand without risking associated stigma. 

The WHO has updated its list of VOCs, with Greek letters assigned to the first 4 VOCs—Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), Delta (B.1.617.2)—as well as 6 VOIs. The existing scientific VOC/VOI labels will continue to be used in some settings, as they “convey important scientific information,” but the Greek letters will be used broadly in public communications. While the new method aims to simplify communications, it is not without limitations. Perhaps most notably, it is not immediately clear what will happen if more than 24 VOCs/VOIs are identified. Additionally, the new naming convention does not appear to apply to variants that are not designated as VOCs/VOIs, and it is unclear whether variants will retain their Greek letter if they are ultimately removed from these lists.

US GLOBAL VACCINE DONATION As part of the US pledge to donate 80 million doses of SARS-CoV-2 vaccines by the end of June, US President Joe Biden on June 3 announced an immediate donation of 25 million doses to low- and middle-income countries. About 75%, or 19 million doses, will go to the COVAX initiative, through which approximately 5 million doses will go to Africa, 7 million to South and Southeast Asia, and 6 million to Latin America and the Caribbean. The vaccine donation to COVAX represents nearly one-third of the total vaccine doses the initiative has supplied to date. The other 6 million doses will be donated bilaterally to countries in need, those experiencing surges, immediate neighbors, and other countries that have requested US assistance, including India, the West Bank and Gaza, Canada, Mexico, Egypt, Iraq, and the Republic of Korea. The total 80 million doses are expected to come from 4 manufacturers: Pfizer-BioNTech, Moderna, J&J-Janssen, and AstraZeneca-Oxford, the last of which has not yet received emergency authorization in the US. 

According to White House COVID-19 Response Coordinator Jeffrey Zients, the US also lifted the Defense Production Act’s “priority rating” for 3 vaccine manufacturers—AstraZeneca, Novavax, and Sanofi—that do not have vaccines authorized in the US. This means US producers of vaccine materials and ingredients do not have to prioritize orders from those companies, potentially clearing the way for more materials to be shipped to overseas vaccine manufacturers. Zients acknowledged that the US pledge to provide 80 million doses by the end of June will not be sufficient to end the pandemic but represents a significant step toward that goal. He promised the US government will continue to work among its own agencies and with other countries, including the G7, to end the pandemic.  

GLOBAL VACCINE ACCESS Amid alarming global disparities in SARS-CoV-2 vaccine access, more than 230 former government leaders and prominent figures are calling upon leaders of G7 countries to pay the majority of the US$66 billion required to vaccinate people in low-income countries. The letter, released ahead of a 3-day G7 summit hosted by the UK that begins June 11, argues that such an investment is affordable, vital to stopping the spread of new SARS-CoV-2 variants, and “the best insurance policy in the world.” The letter—signed by former Prime Ministers Gordon Brown and Tony Blair, former UN Secretary-General Ban Ki-moon, and 15 former African leaders—calls on G7 countries to lead the way on sharing vaccine doses, voluntary licensing agreements, and temporary patent waivers to enable vaccine manufacturing to begin on every continent. The signatories expressed dismay over the failure of global cooperation in 2020, but conveyed hope that 2021 could usher in a new age. In another open letter published on June 7, global health experts laid out an action plan for the G7 to quickly and fairly distribute vaccine doses. 

UK Prime Minister Boris Johnson on June 5 called for leaders of the G7 to commit to vaccinating the world by the end of 2022 amid mounting pressure for the UK to take the lead in sharing vaccine doses. Leaders of the International Monetary Fund, WHO, World Bank, and World Trade Organization are calling on the G7 to prevent a “two-track pandemic,” with richer countries having access to vaccines and poorer ones being left behind. The leaders endorsed an IMF proposal published in May that supports the ongoing work of WHO, its partners in the Access to COVID-19 Tools Accelerator initiative, and its global vaccine access programme COVAX, and includes a goal to vaccinate at least 40 percent of the population in all countries by the end of 2021 and at least 60 percent by the first half of 2022. On June 2, the COVAX initiative received nearly US$2.4 billion in pledges during a virtual summit hosted by Japan, which pledged US$800 million. The initiative has raised a total of US$9.6 billion, with a goal of providing 1.8 billion vaccine doses to lower-income countries and economies in 2021 and early 2022. So far, COVAX has shipped more than 81 million COVID-19 vaccines to 129 participants. 

WHO VALIDATES SINOVAC VACCINE On June 1, the WHO validated the Sinovac-CoronaVac SARS-CoV-2 vaccine for emergency use. The vaccine, produced by the Beijing-based pharmaceutical company Sinovac, is an inactivated vaccine that has storage requirements that make it suitable for low-resource settings. As such, the WHO recommends the vaccine for use in adults aged 18 and older, as a 2-dose regimen spaced 2-4 weeks apart. WHO noted that vaccine efficacy data show the vaccine prevented symptomatic disease in 51% of those vaccinated and prevented severe disease and hospitalization among 100% of those studied.

On June 4, China granted emergency authorization for the Sinovac-CoronaVac vaccine’s use for children and adolescents ages 3 to 17. Sinovac also announced results (unpublished) from a Phase 2 study showing a third booster shot of the vaccine resulted in up to a 20-fold increase in antibody production after 2 weeks. However, the company cautioned that more research needs to be completed to determine the timing and dose of a third shot. 
VACCINE MIX & MATCH Canada’s National Advisory Committee on Immunization is allowing patients to choose a different shot for their second dose following an initial AstraZeneca-Oxford dose. Some studies suggest this mixing of doses may provide additional protection against emerging variants by triggering a stronger immune response. In one small study published by medRxiv (preprint), German researchers examined reactogenicity, antibody response, and T-cell reactivity among 26 people ages 25-46 who received the AstraZeneca-Oxford vaccine followed by the Pfizer-BioNTech vaccine 8 weeks later. The researchers concluded the heterologous vaccination regimen was at least as protective as a 2-dose regimen of the same vaccine, but they cautioned more research is needed. Another clinical trial involving 673 people in Spain showed similar results. If data continue to support safe and effective mixing of vaccines, the strategy could provide countries with solutions to some supply challenges.

VARIANTS OF CONCERN In the UK, evidence is growing that the delta variant of SARS-CoV-2 (B.1.617.2, VOC21APR-02) first identified in India is more transmissible and more capable of immune escape when compared with the previously dominant Alpha variant (B.1.1.7), even in vaccinated individuals. The delta variant is now dominant in the UK, with the number of new cases recorded daily rising slowly. According to a report from Public Health England, there is some suspicion that the delta variant may be associated with an increased risk of hospitalization. UK health officials are evaluating data on the delta variant to determine whether the country will lift lockdown restrictions by June 21 as planned. 

Last week, researchers reported in The Lancet that the Pfizer-BioNTech SARS-CoV-2 vaccine elicited a weaker antibody response to the delta variant than to the original wildtype virus, especially among older populations. The data raise the likelihood of a booster shot being needed for some people, although the scientists cautioned that more data are needed to know whether the vaccine would be any less effective at preventing severe disease, hospitalization, or death.

US CONTACT TRACING A recent study published in JAMA details the contact tracing efforts of 14 local health departments between June 2020 and October 2020. Contact tracers had difficulty reaching individuals with laboratory-confirmed COVID-19, and many that were reached by phone did not report any contacts. Researchers estimate that approximately 66% of recent contacts were not identified through contact tracing efforts. With this many contacts unidentified, researchers conclude that contact tracing efforts at these locations were minimally helpful in controlling community transmission of SARS-CoV-2. However, contacts that were named by individuals with confirmed disease were able to be reached at much higher rates; approximately 71% of named contacts were successfully reached by health departments. High levels of transmission, antiquated contact tracing systems, low numbers of available contact tracers, and public unfamiliarity or lack of trust in the contact tracing process all contributed to low success rates of contact identification. Uptake of digital contact tracing tools allowed public health staff to focus their efforts on targeted outreach and alleviated some of the burden. 

ADOLESCENT HOSPITALIZATIONS US CDC Director Dr. Rochelle Walensky on June 4 urged parents to vaccinate their eligible children against SARS-CoV-2 and follow prevention measures for the disease, citing new data from a CDC study showing increased hospitalization rates in spring 2021 for adolescents with COVID-19. Researchers used data from the Coronavirus Disease 2019-Associated Hospitalization Surveillance Network to examine demographic and clinical characteristics and hospitalization rates of adolescents aged 12-17 years who were admitted to hospitals between March 1, 2020 and April 24, 2021. Among 204 adolescents who were likely hospitalized primarily for COVID-19 during January 1-March 31, 2021, 31.4% were admitted to an intensive care unit, and 4.9% required invasive mechanical ventilation. There were no COVID-19-associated deaths. Of the 204 adolescents, 52% were female, 31% were Latino, and 36% were Black. About 70% of the 204 adolescents had at least one underlying medical condition, with the most common being obesity. But nearly 30% had no underlying condition, reinforcing that even healthy adolescents are at risk of severe COVID-19-related disease.

Between March 1, 2020 and April 24, 2021, weekly adolescent hospitalization rates peaked at 2.1 per 100,000 in early January 2021, declined to 0.6 in mid-March 2021, and then rose to 1.3 in April 2021. The cumulative COVID-19 hospitalization rates for the adolescents from October 1, 2020, through April 24, 2021, were 2.5 to 3 times higher than recent seasonal influenza-associated hospitalization rates. Notably, some experts raised concern over the researchers’ use of data only through April 24, despite the availability of data through the end of May, which show another decrease in the 3-week average, down to 0.9 per 100,000.

The FDA’s Center for Biologics Evaluation and Research on June 10 will convene a virtual meeting of the Vaccines and Related Biological Products Advisory Committee to discuss the data needed to support an Emergency Use Authorization and Biologics License Application for SARS-CoV-2 vaccines intended for use in children younger than 12 years old. The committee will not discuss individual products during this meeting.

GLOBAL SUPPLY CHAIN Before COVID-19, global businesses had evolved to run efficiently with minimal stockpiling of necessary materials, instead leveraging their smaller overhead to produce a wider array of products. Relying on Just In Time manufacturing, parts and materials are delivered to manufacturers as they are needed rather than being stored in large quantities. While this practice has boosted global industry, the practice could not be adapted rapidly enough to handle the demands put on the supply chain by the COVID-19 pandemic. Everything from obtaining raw materials to delivering products to the end user came under acute stress as manufacturers struggled to keep up with changing pressures. 

A recent policy paper from the Center for Global Development analyzes global supply trends in 2020 and highlights key lessons. Among these is the interplay between political and market powers to influence global supply and movement of goods. While market forces have a large influence on product movement, political powers played a significant role during the pandemic to procure medicines and other medical supplies. Policy recommendations from the paper include increasing redundancy in the global supply chain and localizing production of critical materials for medicines. Although the worst of supply shortages appears to have mostly resolved, the cascading supply chain effects could have a lasting impact. Certainly, the world has witnessed supply chain fragility in the face of a global crisis, and realized more work must be done to better secure its resources.