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 114.14 million cases and 2.54 million deaths as of 5:30am EST on March 2.

The global weekly incidence increased for the first time since the early January 2021. Last week, the global weekly incidence increased 6.6% compared to the previous week, up to 2.65 million new cases. Global weekly mortality continues to decline, down to 63,370 deaths, the lowest weekly total since the week of November 9, 2020.

Our World in Data reports that 249.26 million vaccine doses have been administered globally, a 17% increase compared to this time last week. The daily average increased to 5.18 million doses, 7% higher than this time last week. Vaccination efforts have been reported in at least 114 countries and territories.

The US CDC reported 28.41 million total cases and 511,839 deaths. The US reported 3,240 deaths on February 25, the highest single-day total in 2 weeks. This included 806 previously unreported deaths in Los Angeles County, California. Without these extra deaths, the mortality for February 25 would have been 2,434 deaths—on par with the previous day (2,407).

The daily incidence in the US has fallen considerably from its highest peak—249,303 new cases per day on January 11—but the current average (66,594) still remains equal to or greater than both of the previous 2 peaks (67,316 on July 23, 2020, and 31,936 on April 12, 2020).

The average daily mortality is currently 2,050 deaths per day, slightly less than the first peak in April 2020 (2,857*) but nearly double the peak in August 2020 (1,148). Mortality has also declined considerably over the past several weeks before leveling off in recent days. The decline in daily mortality is less marked than the decline in incidence; however, this difference could be due to lags in mortality data.
*This peak included April 15, when New York City reported more than 3,700 previously unreported probable deaths from the onset of its epidemic. Without these deaths, the peak average would have been closer to 2,300 deaths per day.

This week, we will look at the most severely affected states in terms of cumulative incidence and mortality and put them in the global context.

At the national level, the per capita cumulative incidence is 85,560 cases per million population, which ranks #8 globally*. In total, 31 US states are reporting higher per capita cumulative incidence than that. Notably, Utah (115,800) and Rhode Island (118,580) would each rank #3 globally, ahead of Czechia (115,795), and North Dakota (131,030) and South Dakota (127,080) would each rank #2 globally, ahead of Montenegro (121,458). Only Andorra (140,930) is reporting higher per capita cumulative incidence than all US states. Rhode Island was among the most severely affected states during the first US surge in spring 2020 and then experienced a much higher peak late during the autumn/winter 2020 surge. North and South Dakota were the most severely affected states during the early part of the autumn/winter surge, peaking at more than 1,600 daily cases per million population, higher than any of the top 10 countries in terms of per capita cumulative incidence.

The US ranks #10 globally* in terms of per capita cumulative mortality, with 1,540 deaths per million population. Five US states would each rank #1 globally, ahead of San Marino (2,180): New Jersey (2,610), Rhode Island (2,360), Massachusetts (2,320), Mississippi (2,240), and Arizona (2,190). Another 4 states would rank #2 globally: South Dakota (2,130), Connecticut (2,130), Louisiana (2,060), and Alabama (2,020). Additionally, New York City**—which reports data to the CDC separately from New York state—is reporting 3,500 cumulative deaths per million, 60% higher than San Marino. The high cumulative mortality in New York City, New Jersey, Rhode Island, and Massachusetts are driven largely by the severe impact of the initial surge, at a time when health systems were overwhelmed, especially in New York City, and little was known about effective clinical care for COVID-19 patients. Arizona was the most severely affected state during the summer surge, followed by a higher peak in the autumn/winter 2020 surge. Mississippi was also severely affected during the summer surge, but its daily mortality remained elevated through September and October before surging again in the autumn/winter.
*The Our World in Data website utilizes the Johns Hopkins CSSE COVID-19 dashboard as opposed to the official US CDC data, so the numbers do not match exactly.
**The COVID Tracking Project does not include separate data for New York City, so New York state is displayed.

US Vaccination
The US CDC reported 96.40 million vaccine doses distributed and 76.90 million doses administered nationwide (79.8%). In total, 50.73 million people (15.3% of the entire US population; 19.9% of the adult population) have received at least 1 dose of the vaccine, and 25.47 million (7.7%; 10.0%) have received both doses. The average daily doses administered is rebounding from its brief decrease, which was likely caused by severe winter weather and now stands at 1.42 million doses per day*. The breakdown of doses by manufacturer remains relatively steady, with slightly more Pfizer-BioNTech doses administered (39.26 million; 51%) than Moderna (37.52 million; 49%). No doses of the J&J-Janssen vaccine have been reported, but we expect the first of those doses to be reported this week.
*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.

A total of 7.15 million doses have been administered at long-term care facilities (LTCFs)**, including residents and staff. This covers 4.65 million individuals with at least 1 dose and 2.47 million with 2 doses. Approximately 59% of the doses have gone to residents, and 41% to staff.
**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 28.68 million US cases and 515,195 deaths as of 12:30pm EST on March 2.

J&J-JANSSEN VACCINE EUA On February 27, the US FDA issued an Emergency Use Authorization for the Johnson & Johnson (J&J)-Janssen Biotech SARS-CoV-2 vaccine. The EUA closely followed the review and recommendations by the FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC). Additionally, the US CDC’s Advisory Committee on Immunization Practices recommended the vaccine for use in all adults aged 18 years and older. The ACIP recommendations were approved by CDC Director Dr. Rochelle Walensky on February 28.

Reportedly, the US government could begin shipping available inventory of the J&J-Janssen vaccine across the country early this week, with some deliveries arriving as early as today. The federal government currently has 3.9 million doses available, and it expects to receive “another 16 million the end of March.” Because only one dose is required, there will be no need to schedule follow-up appointments for booster doses or maintain stockpiles at the state and local level to cover second doses. Vaccinators will be able to administer all of the available J&J-Janssen doses, without needing to reserve any for booster vaccinations, which could further accelerate vaccination efforts. Additionally, the vaccine is stable at normal refrigerator temperatures and does not require on-site dilution.

Janssen Biotech’s briefing materials submitted for the VRBPAC review indicated that plans for future clinical trials for the vaccine include children under the age of 18, pregnant women and infants, and immunocompromised individuals (pages 34 and 93).

VACCINATION & TRANSMISSION RISK While multiple vaccines have demonstrated efficacy in terms of preventing COVID-19 disease, including severe disease and death, evidence is continuing to emerge regarding their ability to mitigate infection or transmission risk.

Last week, researchers from the University of Cambridge and Public Health England published (preprint) findings from a study on the efficacy of the Pfizer-BioNTech vaccine in preventing asymptomatic SARS-CoV-2 infection. The researchers evaluated PCR-based diagnostic test results for vaccinated and unvaccinated healthcare workers (HCWs) several weeks after the initiation of vaccination efforts. The researchers identified 26 positive results out of 3,252 total tests in unvaccinated healthcare workers (0.80%), compared to 13 positive tests out of 3,535 tests (0.37%) among HCWs vaccinated less than 12 days after their first dose and 4 out of 1,989 tests (0.20%) among HCWs who received their first dose 12 days or more before the test. This corresponds to a statistically significant decrease in infection risk among vaccinated HCWs. Viral loads in vaccinated HCWs tended to be lower than in unvaccinated HCWs, although these results were not statistically significant. While not a placebo-controlled and randomized clinical trial, this study does provide real-world evidence that the Pfizer-BioNTech vaccine could provide protection against infection.

A nationwide study conducted in Israel also found evidence of lower infection risk in individuals vaccinated with the Pfizer-BioNTech vaccine. The study, published in The New England Journal of Medicine (NEJM), included nearly 1.2 million participants, pairing nearly 600,000 vaccinated individuals to unvaccinated individuals (1:1 ratio) based on “demographic and clinical characteristics.” The researchers evaluated SARS-CoV-2 infection and COVID-19 disease during 2 periods: 14-20 days after the first dose and 7 or more days after the second dose. Between 14 and 20 days after the first dose, the vaccine demonstrated 46% efficacy in preventing SARS-CoV-2 infection. At Day 7 or later after the second dose, the vaccine efficacy was 92% in terms of preventing infection. The vaccine also demonstrated high efficacy (>90%) in preventing COVID-19 disease, including severe disease, at Day 7 or longer after the second dose. Like with the UK study, this provides real-world evidence that the Pfizer-BioNTech vaccine can mitigate infection risk.

CONVALESCENT PLASMA In a systematic review and meta-analysis published in JAMA, researchers evaluated treatment with convalescent plasma compared to standard of care or use of a placebo in randomized clinical trials (RCTs)—published through January 29, 2021. The researchers identified 10 total RCTs—4 published peer-reviewed studies and 6 unpublished studies—including a total of 11,782 COVID-19 patients. Overall, convalescent plasma did not significantly differ from placebo or standard of care for any of the major outcomes of interest: all-cause mortality, length of hospital stay, mechanical ventilation use, clinical improvement, clinical deterioration, and serious adverse events. The researchers noted that there was limited data available regarding clinical improvement, clinical deterioration, and serious adverse events in these studies.

POST-ACUTE SEQUELAE OF COVID-19 Last week, the US NIH announced a new initiative focused on learning more about COVID-19 patients who experience persistent symptoms or develop new symptoms after recovery from acute SARS-CoV-2 infection. Formerly known as “long COVID,” the condition is now being referred to as post-acute sequelae of SARS-CoV-2 infection (PASC). PASC can include fatigue, shortness of breath, “brain fog,” sleep disorders, fevers, gastrointestinal symptoms, anxiety, and/or depression. The NIH study will use US$1.15 billion in funding over 4 years to address PASC from multiple perspectives, including the underlying biological cause of PASC, the prevalence of PASC among those who recover from SARS-CoV-2 infection, and the risk factors for PASC, including the interaction between SARS-CoV-2 infection and pre-existing health conditions (e.g., cardiac and neurological disorders).

During the February 24 White House COVID-19 Press Briefing, White House Chief Medical Advisor and NIAID Director Dr. Anthony Fauci said the magnitude of the problem is not yet clear. But he cited a research letter published in JAMA: Network Open by researchers at the University of Washington (US), who found that approximately 30% of COVID-19 patients experienced persistent symptoms for up to 9 months following illness. That could correlate to more than 8 million Americans to date. According to a report by NBC News more than 80 specialized “post-COVID” clinics have been established across the US to provide support to individuals suffering from PASC and gather information to better understand the condition.

OXYGEN SHORTAGE Access to affordable and sustainable oxygen supplies has been a challenge, particularly in low- and middle-income countries (LMICs). These challenges have been exacerbated by the shift from mechanical ventilation to high-flow oxygen therapy for patients with severe disease. To address the shortages, the WHO’s Access to COVID Tools Accelerator (ACT-A) launched the COVID-19 Oxygen Emergency Taskforce. The taskforce falls under ACT-A’s therapeutics pillar, co-led by Unitaid and the Wellcome Trust. The taskforce estimates that US$90 million in immediate funding is needed to address oxygen shortages across 20 LMICs, and an estimated US$1.6 billion will be needed over the next 12 months. Unitaid and Wellcome committed a total of US$20 million for the effort.

Experts note that oxygen shortages are leading to unnecessary deaths in LMICs, with 500,000 patients in need of 1.1 million oxygen cylinders daily. Dr. Peter Piot, Director of the London School of Hygiene and Tropical Medicine, highlighted disparities in the availability of medical oxygen as “one of the defining health equities...of our age.” Notably, oxygen production capacity “met less than half the need” in sub-Saharan Africa. A number of countries are constructing oxygen production facilities in order to scale up production capacity; however, this process is taking time. According to a report by the Associated Press, many countries view oxygen production from the perspective of industrial uses, rather than medical. India is leveraging its existing industrial production capacity and repurposing industrial oxygen storage tanks for use at healthcare facilities.

GLOBAL VACCINE ACCESS & DISTRIBUTION Today, Gavi published updated information regarding the first round of COVAX allocations. The first allocation includes 237 million doses of the AstraZeneca-Oxford vaccine to 142 countries, with projected deliveries through May 2021. Additionally, the publication accounts for an “exceptional distribution” of 1.2 million doses of the Pfizer-BioNTech vaccine to countries that requested it and demonstrated the ability to manage the additional logistical requirements (e.g., ultra-cold freezer capacity).

COVAX began shipping vaccines last week, including 600,000 doses to Ghana and 504,000 doses to Côte d'Ivoire, and both of those countries began vaccinations on Monday. Today, the COVAX delivered 624,000 doses to Angola and 3.94 million doses to Nigeria, and on Monday, Colombia became the first of 36 COVAX countries in the Americas to receive the vaccine, with 117,000 doses of the Pfizer-BioNTech vaccine.

Even with the acceleration in vaccine distribution through COVAX, questions remain over how the world will achieve global vaccine equity. A recent report by The Economist Intelligence Unit estimates that some parts of South America, Africa, and Asia will not achieve widespread vaccination coverage until 2023. And many experts remain cautious that COVAX will hit its goal of delivering 1.8 billion vaccine doses in 2021, as funding and supply shortages persist.

Some governments and experts, including at the WHO, are calling for vaccine manufacturers to share technology, intellectual property, and data in order to expand production capacity. Sharing access to the information and technology necessary to produce the vaccines could be achieved in several ways. One option, supported by the WHO, is a “patent pool,” similar to the platforms used for HIV, tuberculosis, and hepatitis treatments. To date, no companies have offered to participate. Another proposal involves suspending intellectual property rights during the pandemic. This plan is opposed by vaccine developers, and it was rejected in the World Trade Organization by the US and European countries, despite support from at least 119 countries and the African Union.

Pharmaceutical companies argue that wealthier nations should donate more vaccine doses, including through COVAX. Some countries are doing that, including bilateral agreements with China, Russia, and India to obtain those nations’ locally developed and approved vaccines. India has launched a 49-nation “friendship program,” and China is shipping vaccine supplies across Africa nations, Turkey, and Afghanistan. As many as 50 countries have finalized agreements with Russia for its Sputnik V vaccine. WHO Director-General Dr. Tedros Adhanom Ghebreyesus has repeatedly warned against a focus on bilateral or selective vaccine supply deals, arguing that they could result in further inequities among lower-income countries. Instead, he continues to call for more investment in the COVAX facility. Even with the recent donations, including US$2 billion from the US, COVAX remains US$800 million short of its 2021 goals.

US COVID-19 PROTECTIVE MEASURES & RELIEF Despite warnings from White House and US CDC that emerging SARS-CoV-2 variants pose a growing risk, governors across the US are lifting and relaxing restrictions on businesses, schools, and social activities following substantial decreases in daily incidence over the past several weeks. Governors in several states, both Democrat and Republican, have announced efforts to remove or relax capacity limits on restaurants, reopen bars and performance venues, and end mask mandates. At a White House briefing on Friday, CDC Director Dr. Rochelle Walensky warned that the recent decline in COVID-19 incidence does not mean that the US can relax. Daily incidence is still at the same level as the peak of the summer 2020 surge.

Even with its calls for states to continue their mitigation efforts, the federal government continues efforts to support economic recovery. On Saturday, the US House of Representatives narrowly passed a US$1.9 trillion COVID relief bill, called the American Rescue Plan, which includes funding for vaccination programs, direct stimulus payments, expanded unemployment benefits, state and local governments, and schools as well as additional funding for the global response. The Senate is expected to vote on a similar bill in the near future, possibly as early as this week. If approved, the plan would represent the sixth round of federal aid during the COVID-19 epidemic. Speaking from the White House on Saturday, US President Joe Biden called for quick action from the Senate, saying that decisive action can help reinvigorate the US economy.

J&J-MERCK PARTNERSHIP Industry competitors Johnson & Johnson (J&J) and Merck & Co. are expected to announce that they will work together to manufacture the J&J-Janssen SARS-CoV-2 vaccine. Currently, there are only approximately 4 million doses available for distribution. J&J was supposed to produce 12 million doses by the end of February, but it fell behind schedule.

In order to augment production, the US government worked with the 2 pharmaceutical companies to establish a joint partnership to manufacture the vaccine. Merck will convert 2 of its manufacturing facilities to produce the new vaccine. Merck developed its own vaccine candidate, but it abandoned the effort after the candidate did not produce a sufficient immune response in early clinical trials.

Officials from J&J have indicated that the company is on track to produce an additional 16 million total doses by the end of March and more than 100 million total doses by the end of 2021. It is unclear whether those projected numbers factor in production at the Merck facilities.

NEW ZEALAND New Zealand has received praise for its aggressive, science-led response to its COVID-19 epidemic, but a recent outbreak in Auckland continues into its third week. New Zealand officials are conducting extensive contact tracing and surveillance efforts, including genomic sequencing for all detected cases. In response to recent cases linked to the outbreak that was first reported on February 14, the Auckland region has been moved back to Alert Level 3, which is scheduled to end on March 4. The rest of the country is at Alert Level 2.

Individuals in the Auckland region are expected to remain in their household bubbles outside of work or school obligations, and mask use and physical distancing are mandatory in public spaces. Additionally, the government implemented travel restrictions for the Auckland region. Public venues are directed to close, and gatherings are heavily restricted. In accordance with these restrictions, the first weekend of the 36th America’s Cup has been postponed.