COVID-19 Situation Report
Editor: Alyson Browett, MPH

Contributors: Clint Haines, MS; Natasha Kaushal, MSPH; Amanda Kobokovich, MPH; Christina Potter, MSPH; Matthew Shearer, MPH; Marc Trotochaud, MSPH; and, Rachel A. Vahey, MHS.
CALL FOR PAPERS: Special Feature on Climate Change and Health Security Health Security will devote a special feature to climate change and its impact on national and global health security. We encourage submissions of original research articles, case studies, and commentaries on topics including climate change-related public health emergencies, public health emergency management and climate change, displacement of populations and the health impact of climate change, and more. All manuscripts should be submitted for consideration by March 21, 2022. Learn more at:
EPI UPDATE The WHO COVID-19 Dashboard reports 460 million cumulative cases and 6.05 million deaths worldwide as of March 16. After 5 weeks of decline, the global weekly incidence increased 10% from the previous week. The increase appears to be driven principally by trends in Europe and the Western Pacific region. Notably, the Western Pacific continues to set new records for weekly incidence, with more than 5 million new cases last week (+29% over the previous week). All other regions reported decreasing weekly incidence last week, although the rate of decline is slowing. Global weekly mortality decreased for the fourth consecutive week, down 17% from the previous week. 

Global Vaccination
The WHO reported 10.7 billion cumulative doses administered globally as of March 13. A total of 4.97 billion individuals have received at least 1 dose, and 4.38 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations continues to decline, down from nearly 40 million doses per day in late December 2021 to 17.5 million on March 16, a decrease of 56% over that period.* The trend continues to closely follow that in Asia. Notably, Africa is now administering more daily vaccinations than any continent other than Asia, although it is ahead of only Europe (and virtually tied with North America) on a per capita basis. Our World in Data estimates that there are 5.03 billion vaccinated individuals worldwide (1+ dose; 63.8% of the global population) and 4.48 billion who are fully vaccinated (56.9% of the global population). A total of 1.47 billion booster doses have been administered globally.
*The average daily doses administered may exhibit a sharp decrease for the most recent data, particularly over the weekend, which indicates effects of reporting delays. In an effort to reflect the longer-term trends, the numbers reported here may not correspond to the most recent data.

The US CDC is currently reporting 79.4 million cumulative cases of COVID-19 and 964,831 deaths. The decline in daily incidence is tapering off, with the current average at slightly fewer than 31,000 new cases per day. Daily mortality continues to decline, down to 1,107 deaths per day on March 15.* While daily mortality continues in an encouraging direction, the US is still reporting more than 1,000 deaths per day. At this pace, the US would surpass 1 million cumulative deaths in the next month.
*Changes in state-level reporting may affect the accuracy of recently reported data, particularly over weekends. In an effort to reflect the longer-term trends, the numbers reported here may not correspond to the most recent dates.

US Vaccination
The US has administered 558 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations continue to decline, down from the most recent peak of 1.79 million doses per day on December 6 to approximately 190,000 on March 10*, the lowest average since the first week of available data in December 2020, when supply was still extremely limited. A total of 255 million individuals have received at least 1 vaccine dose, which corresponds to 76.7% of the entire US population. Among adults, 88.2% have received at least 1 dose, as well as 27.0 million children under the age of 18. A total of 217 million individuals are fully vaccinated**, which corresponds to 65.3% of the total population. Approximately 75.3% of adults are fully vaccinated, as well as 22.5 million children under the age of 18. Since August 2021, 96.2 million individuals have received an additional or booster dose. This corresponds to 44.4% of fully vaccinated individuals, including 66.8% of fully vaccinated adults aged 65 years or older.
*Due to delays in reporting, estimates for the average daily doses administered are less accurate for the most recent several days. 
**Full original course of the vaccine, not including additional or booster doses.

US COVID-19 FUNDING A measure to provide US$15 billion in additional COVID-19 pandemic response funding was stripped from the US$1.5 trillion omnibus spending bill on Wednesday. According to multiple news media reports, Republicans demanded that the new COVID-19 funding be offset, including by redirecting unused COVID-19 funding from previous spending packages. The COVID-19 funding was separated from the omnibus bill in order to ensure it could be passed quickly, as it included both funding for the federal government and US$13.6 billion in aid for Ukraine. A separate COVID-19 funding bill could be voted on next week, which would potentially include US$15.6 billion, including US$8.6 billion that would be offset from sources other than previous state and local COVID-19 relief funding. Some public health advocates have expressed concern that this new plan will make it easier for Republicans to reject the funding entirely. The new plan is expected to pass in the House of Representatives, but success in the Senate is much less likely. 

The White House released a fact sheet detailing the consequences if the Congress does not allocate additional COVID-19 funding, including an inability to acquire new variant-specific vaccines and booster doses, ending reimbursement for services provided to uninsured patients, scaling back distribution of monoclonal antibody treatments, suspending various treatment and vaccination efforts, reduced ability to combat future SARS-CoV-2 variants, and damage to global vaccination efforts that could lead to increased risk for a new variant to emerge. Concerns are mounting that a failure to secure additional funding could leave the US severely underprepared for a new variant that has the potential to cause economic devastation far greater than the US$15 billion needed for prevention. 

US CDC DATA COLLECTION During the COVID-19 pandemic, the US CDC has been given expansive access to public health data necessary for the federal agency to characterize SARS-CoV-2 transmission and COVID-19 disease and develop guidance, but this may soon be coming to an end. This expanded access is a function of the national-level public health emergency declaration, which mandates that states report certain data to the CDC; however, the emergency declaration is scheduled to come to an end in April, unless it is reauthorized. The initial emergency declaration was issued in 2020, and it must be renewed every 90 days. CDC Director Dr. Rochelle Walensky emphasized that the CDC typically only has the authority to compile data from states, but not to collect them, and if the emergency declaration lapses, the CDC may not have access to the state and local data it needs. Notably, the existing CDC guidance on COVID-19 protective measures relies on incidence and hospitalization data, including at the county level, and without access to routine reports, the CDC may not be able to provide updated recommendations as the US epidemic evolves.

The Biden Administration is reportedly considering options that would allow the public health emergency to lapse in April. Discussions are ongoing regarding the possibility of expanding federal monitoring systems for hospital data. The hospital-based reporting system would enable the CDC to collect data on various respiratory diseases, including influenza and COVID-19, for nearly 6,200 facilities nationwide. But while the hospital reporting system would provide the CDC with access to COVID-19 data, there are concerns that the loss of routine reporting of incidence and mortality data from state and local health departments could limit the agency’s ability to provide real-time monitoring and updates.

Several former CDC Directors—representing 27 years, from 1990-2017—published an editorial in The Hill calling on the Congress to include provisions in the PREVENT Pandemics Act to “standardize and coordinate public health data” from the local to the national level. They draw a parallel to the National Weather Service, which relies on data gathered from a national network of radar sites and other local sources, even in the absence of a major storm or other weather event. They argue that the CDC needs the same capabilities to monitor for, identify, and respond to emerging outbreaks and epidemics. Efforts to modernize and coordinate US public health reporting systems are necessary for COVID-19 as well as a broad scope of existing and future threats.

RACIAL & ETHNIC DISPARITIES IN CRISIS STANDARDS OF CARE During the COVID-19 pandemic, patient surges and supply chain disruptions forced health systems to plan for and implement crisis standards of care (CSOC) in order to make the best use of available resources. The Massachusetts (US) Department of Health (DOH) developed a scoring algorithm to identify priority patients in anticipation of the need to ration scarce resources. During a surge period in early 2020, Boston-area hospitals “preemptively scored patients to prepare for the imminent possibility of inadequate critical care resources,” such as mechanical ventilators. Fortunately, it was not necessary to actually implement these CSOC; however, a study of the scoring data at Beth Israel Deaconess Medical Center identified racial and ethnic disparities in patient priority groups.

The scoring system aimed to account for both disease severity and risk of progressing to severe disease and death. The Massachusetts DOH published its original guidance on April 7, 2020, but it soon issued a revision over “concerns that the higher prevalence of comorbidities in underrepresented minority groups and people with disabilities would result in an inequitable distribution of resources.” The revision replaced the presence and severity of comorbidities with a life expectancy estimate, and the change was implemented on April 28. Data were collected for nearly 500 COVID-19 patients admitted to the ICU from April 13-May 22, 2020, which spans both sets of guidelines.

Researchers from the hospital conducted a retrospective review of the data and published their findings in JAMA Network Open. They found that Black patients were nearly twice as likely to be placed in the lowest priority group (15.2% compared to 8.1% among other patients). The researchers also modeled prioritization for mechanical ventilators—which were allocated only to the highest priority group—and found that the scoring system would have resulted in 43.9% excess mortality among Black patients and 28.6% among all other patients*. The researchers also modeled a random lottery scenario and compared the results to the scoring system. The models projected that the scoring system would have resulted in fewer overall excess deaths, but it was not clear that it provided benefit for individual racial groups compared to random allocation. This analysis illustrates that existing prioritization systems can result in major racial and ethnic disparities in access to scarce medical resources, and additional work is necessary to establish more equitable CSOC frameworks that improve patient outcomes both within and across racial and ethnic groups.
*The baseline mortality was established using the actual deaths among the cohort of patients who were placed on a ventilator.

MENTAL HEALTH IMPACTS A study published in The Lancet Public Health studied the prevalence of adverse mental health symptoms among patients who recovered from acute COVID-19 disease. The study included 247,249 individuals from European countries, such as Denmark, Estonia, Iceland, Norway, Sweden, and the UK. From March 2020-August 2021, 9,979 of these individuals were diagnosed with COVID-19. Individuals who tested positive over the course of the study were more likely to experience acute symptoms of depression or poor sleep quality that would typically resolve within 2 months. Individuals who tested positive for COVID-19 and were bedridden for approximately 7 days or longer were significantly more likely to experience anxiety and depression up to 16 months post-diagnosis.

The study identified associations between COVID-19 and mental health conditions, but it did not determine a mechanistic link. Social isolation and symptoms of Long COVID—or Pose-Acute Sequelae of COVID-19 (PASC)—such as brain fog and fatigue may play some role, but the researchers were not able to determine if the physical symptoms fueled the mental health symptoms or vice versa—or if there were other interactions responsible. Physicians who specialize in Long COVID care have argued that it is important to not discount the condition as a simple physical manifestation of depression and anxiety. Mounting evidence regarding a link between COVID-19 and mental health symptoms hints at the possibility of a second pandemic that could emerge in the future. Appropriate resources to support mental health services are needed now to address the prolonged physical and mental health effects of the COVID-19 pandemic. 

PFIZER-BIONTECH VACCINE FOURTH DOSE On March 15, Pfizer and BioNTech submitted an application to the US FDA for an Emergency Use Authorization (EUA) for a second booster dose of its SARS-CoV-2. The application is specifically limited to fully vaccinated adults aged 65 years and older who have already received a booster dose of any approved or authorized SARS-CoV-2 vaccine, and not for the broader public. The request is based primarily on data from Israel, where a fourth dose of the Pfizer-BioNTech vaccine is available for a broader group of adults, including high-risk group such as individuals aged 60 years and older, individuals with compromised immune systems, healthcare workers, caregivers of high-risk individuals, and others who are at high risk of exposure because of their occupation. The Israeli data also include a non-randomized clinical trial of 154 adults aged 18 years and older who received a fourth dose, which showed an increased neutralizing antibody response (including against the Omicron variant), compared to individuals who received only 1 booster dose. Analysis of Israeli Ministry of Health records, which have not yet been peer-reviewed, was conducted while the Omicron variant was circulating widely, but additional data are needed to assess the duration of any increased protection. Additionally, it is unclear to what extent vaccine-induced protection against severe disease and hospitalization wanes over time.

Experts remain divided over the utility of administering additional doses of vaccine, with some advocating, instead, for a focus on developing vaccine candidates that could confer longer-duration protection or broader protection against future SARS-CoV-2 variants. To be sure, individual risk assessments remain an important factor in whether an additional booster dose is warranted, as some people, particularly those in the US who are immunocompromised, already are recommended to receive a fourth dose.

INTELLECTUAL PROPERTY RIGHTS WAIVER After 18 months of deadlocked negotiations, the US, EU, India, and South Africa have reached a compromise on a proposal to waive intellectual property rights on certain SARS-CoV-2 vaccines. Under the compromise intellectual property rights would be waived for World Trade Organization (WTO) member countries that exported less than 10% of the world’s vaccine doses in 2021, which would enable those countries to establish their own manufacturing capacity without explicit permission from the patents’ owners. Reportedly, some elements of the consensus still must be finalized, including the duration of the patent waivers, and the agreement could be extended in 6 months to cover diagnostics and treatments. EU Member States, as well as the WTO’s 164 member countries, will need to formally approve the deal for it to take effect. The proposal to waive intellectual property rights was originally proposed by India and South Africa in 2020, but the plan faced strong opposition from several WTO members, including the UK and the EU, as well as the pharmaceutical industry. Critics of the deal expressed frustration that it pertains only to vaccines, maintaining that treatments and diagnostics are equally important in low- and middle-income countries (LMICs).