Updates on the COVID-19 pandemic from the Johns Hopkins Center for Health Security.

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EPI UPDATE The WHO COVID-19 Dashboard reports 118.1 million cases and 2.6 million deaths as of 5:00am EST on March 12.

March 10 marked the 1-year anniversary of the WHO designating COVID-19 as a pandemic.

Global Vaccination
The WHO reported 300.0 million vaccine doses administered globally, including 180.7 million individuals with at least 1 dose. The dashboard does not yet include daily vaccinations.

Our World in Data reports that 335.4 million vaccine doses have been administered globally, a 17% increase compared to this time last week. While the daily average is still depressed compared to the previous week, down from 8.1 million to 7.1 million doses per day (-12%), the overall trend continues to increase. At least 129 countries and territories are reporting national vaccination data.

Israel continues to lead the world in most metrics related to SARS-CoV-2 vaccination, but other countries are reporting increasing vaccination volume and coverage. Cumulatively, Israel has administered 106 doses per 100 population. Israel is followed by Seychelles (89) and the UAE (65) as the only 3 countries reporting more than 50 doses per 100 population. In total, 9 countries are reporting more than 25 cumulative doses per 100 population. On a daily basis, Chile is now #1 globally with 1.4 daily doses administered per 100 population, followed by Maldives (1.3), San Marino (1.2), and Israel (1.0) as the only countries reporting 1 or more daily doses per 100 population. A total of 12 countries are administering more than 0.5 doses per 100 population per day.

As vaccination efforts expand, the data on vaccination coverage is increasing as well. Seychelles is currently #1 globally in terms of the proportion of the population that has received at least 1 dose of the SARS-CoV-2 vaccine, with 61.5%. Israel is #2, with 59.0% of its population, followed by the UAE (35.2%)* and the UK (34.0%). In total, 14 countries have reported 1-dose coverage of 10% or greater. In terms of full vaccination coverage, Israel leads all other countries by nearly double. Israel is reporting 47.0% of its population receiving 2 doses of the SARS-CoV-2 vaccine**, followed by Seychelles (27.0%) and the UAE (22.1%). Only 8 countries are reporting full vaccination coverage greater than 5%.
*The UAE has only reported data on January 10 and February 23.
**Israel is using the Pfizer-BioNTech and Moderna vaccines, both of which require 2 doses.

As COVAX continues its first allocation of SARS-CoV-2 vaccines to eligible low- and middle-income countries (LMICs) around the world, more and more countries are initiating SARS-CoV-2 vaccination efforts. With the exception of India, COVAX commenced its global vaccine distribution effort on February 24, with the first shipment arriving in Ghana. At that time, 106 countries and territories were reporting vaccinations administered. Currently, 129 countries and territories are reporting ongoing vaccination efforts. Of the 21 new countries since February 24, 19 are included in the initial COVAX allocation. A number of other countries eligible under COVAX had initiated small vaccination efforts prior to that date as well, and many of those countries have scaled up their vaccination efforts since receiving their first COVAX deliveries.

With the exception of a 1-day spike in doses on February 9, the global average for daily vaccinations remained between approximately 4.6 million and 4.9 million doses per day from January 31 to February 24. The current global average is 7.1 million doses per day, an increase of nearly 50% over a period of 2 weeks. Countries that initiated vaccination efforts prior February 24, including some COVAX countries, continue to increase their daily capacity; however, there is a noticeable change in the global trend around the time that COVAX began to distribute doses.

The US CDC reported 29.1 million cumulative cases and 527,726 deaths. Daily incidence and mortality continue to decrease, but at a slower rate than over the past several weeks. Daily mortality is down to 1,484 deaths per day, falling below 1,500 for the first time since November 30, 2020. While the current daily mortality is less than half of the peak on January 13, 2021 (3,378), it is still nearly 30% higher than the summer 2020 peak (1,147).

US Vaccination
The US CDC has distributed 131.1 million doses of SARS-CoV-2 vaccines and administered 98.2 million doses nationwide. In total, 64.1 million people (19.3% of the entire US population; 25.1% of the adult population) have received at least 1 dose of the vaccine, and 33.9 million (10.2%; 13.3%) are fully vaccinated. Among adults aged 65 years and older, 62.4% have received at least 1 dose and 32.2% are fully vaccinated.

The US surpassed 2 million doses administered per day but fell slightly below that benchmark in the most current average (1.99 million)*, including 733,733 individuals receiving their second dose. The breakdown of doses by manufacturer remains relatively steady, with slightly more Pfizer-BioNTech doses (49.7 million) than Moderna (47.7 million) administered nationwide, followed by J&J-Janssen (638,469)**.
*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.
**As a 1-dose vaccine, all individuals receiving the J&J-Janssen vaccine are fully vaccinated.

A total of 7.5 million doses have been administered at long-term care facilities (LTCFs)***, including residents and staff. This covers 4.8 million individuals with at least 1 dose and 2.7 million with 2 doses.
***The dashboard only includes data for doses administered through the Federal Pharmacy Partnership for Long-Term Care (LTC) Program. It does not report data from West Virginia, which opted out of the program.

The Johns Hopkins CSSE dashboard reported 29.3 million US cases and 531,276 deaths as of 12:30pm EST on March 12.

EU AUTHORIZES J&J-JANSSEN VACCINE On March 11, the European Commission issued a conditional marketing authorization for the J&J-Janssen SARS-CoV-2, based on the recommendation of the European Medicines Agency (EMA). This is the fourth vaccine available in the EU, but the first 1-dose vaccine authorized in Europe. The EMA indicated that the full risk management plan and clinical data will be available in the coming days. J&J is expected to deliver 200 million doses to the EU by the end of June 2021. That contract also allows EU member states to purchase an additional 200 million doses.

COMPARING VACCINES As more data become available from Phase 3 clinical vaccine trials, it is natural to compare vaccines’ performance characteristics against each other. For example, the Mayor of Detroit, Michigan, reportedly declined a shipment of the J&J-Janssen vaccine in favor of prioritizing the Pfizer-BioNTech and Moderna vaccines. But unlike many products that have well-established standards and metrics, the clinical trials for each vaccine were designed and implemented independently, which makes direct comparison difficult. The focus on specific efficacy numbers between trials may not provide the whole picture. The relatively small numbers of severe cases and deaths in the clinical trials for all of the vaccines so far make it more difficult to evaluate their efficacy in preventing more severe forms of COVID-19, as a single case could result in major changes to the efficacy estimates.

Health officials and experts continue to emphasize the importance of vaccination, regardless of which vaccine is available: “The best vaccine is the one that’s in your arm.” This does not mean that the vaccines are identical in terms of their performance, but regardless of whether one specific vaccine is slightly more efficacious than another, any of them will provide more protection—and a high degree of protection—than no vaccine at all. And beyond the direct effect to the vaccinated individual, evidence continues to emerge that vaccination reduces the risk of infection, which could contribute to broader community protection in the form of herd immunity.

GLOBAL VACCINE ACCESS Approximately 190 countries, including 64 high-income countries, have joined the COVAX effort, which aims to distribute SARS-CoV-2 vaccines equitably to low- and middle-income countries. Many higher-income countries have made their own arrangements directly with vaccine manufacturers, including some that have secured access to considerably more doses than needed to fully vaccinate their population. In fact, 11 countries have secured enough supply to vaccinate 2.9 billion people beyond their own populations, including the US and Canada. Even as vaccine production continues to scale up, access remains largely limited to higher-income countries, posing significant questions regarding global equity and potential barriers to bringing the pandemic under control.

Several countries, such as France and Norway, already have committed to sharing their vaccine supply with other countries in the midst of their own vaccination efforts. The US has indicated it will share excess supply, but not until all Americans are vaccinated. Reportedly, Mexico requested the US share some of its current vaccine inventory, and after the request was denied, it negotiated an agreement with multiple Chinese manufacturers—including Sinovac, CanSino Biologics, and Sinopharm—to supplement its supply. But while some higher-income countries appear to be reserving much of the available supply, some LMICs are supporting their neighbors. For example, Chile donated 40,000 doses of its Sinovac vaccine supply to Ecuador and Paraguay, even though it qualifies to receive doses under COVAX.

While the US has indicated it does not intend to share its existing supply of authorized vaccines right away, the federal government reportedly has tens of millions of doses of the AstraZeneca-Oxford vaccine that it is currently unable to use. The AstraZeneca-Oxford vaccine is not yet authorized for use in the US, but it is in a number of other countries. According to multiple news media reports, there are ongoing discussions in the US government, including with AstraZeneca, regarding whether these doses can and should be donated to other countries. Officials from AstraZeneca reportedly requested the US government “loan” doses for distribution in Europe, where the company is behind schedule in fulfilling purchase agreements. Because the vaccine was developed with support from funding issued under the Defense Production Act, the doses manufactured in the US require presidential authorization before being exported.

ASTRAZENECA-OXFORD VACCINE & BLOOD CLOTTING Several countries across Europe have partially or fully suspended the use of the AstraZeneca-Oxford SARS-CoV-2 vaccine following reports of blood clotting (thromboembolic) in some vaccinated adults, including multiple deaths. The European Medicines Agency (EMA) is investigating the reports. Austria, Bulgaria, Estonia, Lithuania, Luxembourg, Latvia, and Italy have suspended the use of at least some batches of the AstraZeneca-Oxford vaccine. Additionally, Denmark, as well as non-EU members Iceland and Norway, completely suspended use of the vaccine for at least 2 weeks as EMA and national regulatory agencies conduct their investigations.

On March 11, the EMA issued a statement indicating that the available evidence does not suggest a link between vaccination and the thrombolytic conditions, noting that they are not listed as a side effect of the vaccine. As of March 10, 30 cases of thromboembolic events had been reported among nearly 5 million people vaccinated with the AstraZeneca-Oxford vaccine. The EMA’s safety committee urged countries to continue AstraZeneca-Oxford vaccination campaigns, as “the vaccine’s benefits continue to outweigh its risks.” A spokesperson for AstraZeneca emphasized that patient safety was the company’s highest priority and that peer-reviewed clinical trial data demonstrate that the vaccine is generally well tolerated.

US VACCINE EQUITY As access to SARS-CoV-2 vaccines continues to grow in the US, states are struggling with equitable distribution. Nationwide, there is a consistent pattern of disparities in vaccine coverage of racial and ethnic minority communities, particularly relative to their disproportionate burden of COVID-19 incidence and mortality. In Alabama, NPR reports that some local officials have accused the state of not distributing vaccines to Black-majority communities because of an unsubstantiated fear that the doses will go unused because of a lack of interest in getting vaccinated. In Michigan, state officials are engaged in a partisan battle over the use of the US CDC's Social Vulnerability Index—used to distribute aid following natural disasters based on economic and demographic factors—to help guide its vaccine distribution. Elected officials in some White-majority parts of the state have expressed concern that distribution based on the index has prevented older residents in their communities from accessing the vaccine, leaving them at elevated risk for severe disease and death.
But some states, like Colorado, are moving their focus to equitable distribution, with the intent to reach racial and ethnic minorities and rural residents who typically have less access to health care. Colorado plans to send 40% of its doses to local public health agencies and safety net clinics and 15% to “equity clinics,” which are located in underserved areas; provide services in multiple languages; and provide additional information on other services, such as food banks and rental assistance. California made a similar
shift this week, announcing that 40% of its vaccine allocation would be directed to 446 communities that fall in the bottom quartile of the state’s Healthy Places Index. These communities represent approximately 40% of the state’s COVID-19 cases and deaths.

BRAZIL Brazil is experiencing a deadly surge of COVID-19 incidence, with hospital ICUs nearing or exceeding capacity and daily mortality reaching record highs. While many nations are experiencing decreasing incidence and mortality, Brazil is facing its worst surge, averaging nearly 70,000 cases per day. Brazil reported a record number of COVID-19 deaths on March 10 (2,286) and surpassed the US as #1 globally in terms of daily mortality.
According to a study by the Oswaldo Cruz Foundation (Fiocruz), more transmissible and lethal SARS-CoV-2 variants of concern are now dominant in at least 6 Brazilian states, including Amazonas, where the P.1 variant first emerged. Because the virus continues to spread rapidly within the country, researchers are warning Brazil is now home to potentially hundreds of new variants, increasing the possibility of an even more dangerous variant emerging and spreading globally. President Bolsonaro continues to adamantly oppose COVID-19 risk mitigation measures, leaving state and local governments to implement their own restrictions. Some experts have also blamed President Bolsonaro for not securing more vaccine doses. With less than 2% of the population fully vaccinated, Brazil must implement more rigorous risk mitigation measures in order to bring its epidemic under control.

LONG-TERM CARE FACILITY GUIDANCE On March 10, the Centers for Medicare & Medicaid Services announced updated visitation guidance for long-term care facilities (LTCFs), developed in collaboration with the US CDC. The guidance allows for increased indoor visitation for all residents, regardless of the vaccination status of the visitor or the resident. The guidance lists 3 conditions that would limit visitation for: (1) unvaccinated residents, if the local test positivity exceeds 10% and less than 70% of facility residents are fully vaccinated; (2) residents with confirmed SARS-CoV-2 infection, regardless of vaccination status; and (3) residents who are in quarantine following a known exposure, regardless of vaccination status. While indoor visits are allowed, outdoor visits are preferred. These changes come among a continued decrease in daily COVID-19 incidence across much of the country and an increase in vaccination coverage at LTCFs.
VACCINE DISTRUST & HESITANCY In Pakistan, the legacy of fake vaccination programs conducted by the US Central Intelligence Agency (CIA)—such as the program used to locate Osama bin Laden in 2011—is reportedly contributing to vaccine distrust during the pandemic. Mistrust of vaccinators in Pakistan, stemming in part from these operations, has impacted polio eradication efforts, and it threatens to hinder SARS-CoV-2 vaccination efforts. In addition to the potential effect on vaccination coverage, vaccinators and other health workers could face risks of violence due to concerns they support intelligence services. According to an investigation by Vice, there may be more willingness among Pakistanis to accept Chinese or Russian vaccines than those developed in Europe or the US.
In Ukraine, vaccine hesitancy is reportedly stemming from concerns that government corruption and incompetence led to the distribution of ineffective or dangerous vaccines. Additionally, misinformation spread by politicians is negatively affecting perceptions of SARS-CoV-2 vaccine safety and efficacy. A nationwide survey conducted by the Kyiv International Institute of Sociology estimated that 60% of the population is unwilling to get vaccinated. Ukraine received 500,000 doses of the AstraZeneca-Oxford vaccine in late February, but it has administered fewer than 40,000 doses nationwide.

In the US, a poll conducted by Monmouth University found that 24% of respondents do not intend to get vaccinated, and another 21% indicated that they will wait for others to get vaccinated before making a decision. A majority of respondents either already received the vaccine (16%) or intend to get vaccinated when they become eligible (38%). Vaccine hesitancy among people of color declined from 22% in January 2021 to 14% in the most recent poll. There remains a stark divide along political divisions, with 36% of Republican respondents indicating that they do not intend to get vaccinated, compared to 6% among Democrat respondents.
US VACCINE SUPPLY & COVID-19 RELIEF BILL On March 11, US President Joe Biden addressed the nation and outlined the next phase of the US COVID-19 response. He expressed hope that the US can return to some semblance of normalcy by July 4th (Independence Day). Notably, President Biden indicated that he is directing all states, territories, and tribes to expand eligibility for SARS-CoV-2 vaccines to all adults by May 1. Earlier in the day, he signed the American Rescue Plan, a US$1.9 trillion bill that provides funding for vaccine distribution, stimulus checks, expanded unemployment benefits and child tax credits, SARS-CoV-2 testing, schools, and state and local governments. Additionally, the federal government plans to purchase another 100 million doses of the J&J-Janssen vaccine, which would bring the US total to 800 million doses ordered from 3 manufacturers, more than enough to fully vaccinate the entire US population. The federal distribution of the Pfizer-BioNTech and Moderna vaccines to state governments and pharmacies will increase to more than 20 million doses per week.
VACCINE EFFICACY Pfizer issued a press release that discusses effectiveness data from Israel’s vaccination program. Based on data collected from January 17-March 6, 2021, the Pfizer-BioNTech vaccine was at least 97% effective in preventing symptomatic COVID-19 cases, hospitalizations, and deaths. Furthermore, the vaccine demonstrated 94% effective in preventing asymptomatic SARS-CoV-2 infections. Notably, the data were collected at a time when the B.1.1.7 variant was the dominant circulating strain in Israel, providing further evidence that the Pfizer-BioNTech vaccine remains effective against this variant.
Novavax reported the final efficacy analysis from Phase 3 clinical trials in the UK for its vaccine candidate. The Phase 3 trials included more than 15,000 participants, including 27% over the age of 65. The vaccine demonstrated 96.4% efficacy against any COVID-19 disease caused by the original SARS-CoV-2 strain and 86.3% efficacy against the B.1.1.7 variant. Additionally, the vaccine completed Phase 2b clinical trials in South Africa, demonstrating 55.4% efficacy among HIV-negative participants in an area where the B.1.351 variant is dominant. While efficacy against the B.1.351 variant was lower, the Novavax candidate was 100% efficacious in preventing severe COVID-19 disease, including hospitalization and death, across both the Phase 3 and 2b trials. To our knowledge, the full clinical trial data has not been published publicly or subjected to peer review.