The Center also produces US Travel Industry and Retail Supply Chain Updates. You can access them here.
Editor’s Note: Our COVID-19 Situation Report team is taking a short break next week; we will not send updates on Tuesday, March 30 nor Friday, April 2. We’ll be back on Tuesday, April 6 with our curated analysis of the latest COVID-19 news and research.

Thanks to our wonderful team who pulls these together: Alyson Browett, Amanda Kobokovich, Margaret Miller, Christina Potter, Caitlin Rivers, Matthew Shearer, Marc Trotochaud, and Rachel Vahey.
EPI UPDATE The WHO COVID-19 Dashboard reports 124.9 million cases and 2.7 million deaths as of 12:00am EDT on March 26. 

As global-level epidemiological trends indicate another COVID-19 surge, the epidemics in Brazil and India are driving a major portion of the global increase in daily incidence and mortality. Brazil’s current surge began in mid-November 2020, and its incidence has increased relatively steadily since then. It experienced brief decreases in daily incidence in early January and early-to-mid February 2021, but not enough to affect the overall trajectory. Conversely, India’s current surge began in late February 2021, but it is accelerating more rapidly. Brazil is currently #1 globally in terms of daily incidence, with more than 77,000 new cases per day. With more than 47,000 new cases per day, India is currently #3 globally; however, it could surpass the US (~59,000) as #2 in the coming days if it continues on its current trajectory. The global daily incidence was at a relative low on February 20, with 358,550 new cases per day, and since that time, daily incidence has increased by nearly 50% to 528,854—a difference of 170,304 cases. Notably, Brazil and India account for 38% of the global increase over that time (65,081 combined cases).

Brazil has reported more than 500,000 new cases each of the past 2 weeks, its 2 highest weekly totals to date. Brazil reported its highest single-day total on March 25, surpassing 100,000 new cases for the first time since the onset of the pandemic. Brazil’s daily incidence has increased 11% over the past 2 weeks and 50% over the past 4 weeks. On March 9, Brazil surpassed the US as #1 globally in terms of daily mortality, and its trend continues to increase sharply. With more than 2,300 deaths per day, Brazil is currently reporting more than a quarter of the global daily COVID-19 mortality. Last week, Brazil reported 15,650 deaths, its highest weekly total to date and 22% more than its previous record the week before. On March 23, Brazil reported 3,251 deaths, its highest single-day total. Brazil’s daily COVID-19 mortality has increased 34% over the past 2 weeks and doubled over the past 4 weeks.

While India’s current surge started much more recently, it is exhibiting a much sharper increase in daily incidence. India’s daily incidence has increased 146% over the past 2 weeks, and it has more than tripled since the beginning of March. On this trajectory, it will surpass the US as #2 globally in the next several days. India’s national records in terms of daily incidence remain from its peak in mid-September 2020 (93,198 new cases per day), but its epidemic currently is accelerating proportionately faster than at any time since May 2020, when the daily incidence was still fewer than 4,000 new cases per day. From its low on February 11, India is already 44% of the way back to its previous peak. India’s daily mortality is beginning to increase as well. Notably, the increase in mortality started on March 9, approximately 3 weeks after the daily incidence began to increase (February 16), consistent with the pattern exhibited throughout the pandemic. Since March 9, India’s daily mortality has more than doubled, from 102 deaths per day to 225—and is still accelerating. In fact, the current relative increase in mortality is India’s highest since June 2020.

India and Brazil are both in the top 5 globally in terms of total vaccine doses administered per day. Brazil is currently administering more than 500,000 doses per day, #5 globally, and India is #2 with 2.3 million. Both countries also are in the top 5 in terms of total cumulative doses administered—India at #3 (55.5 million doses) and Brazil at #5 (16.6 million). Both countries have very large populations, however, and they rank much lower in terms of the per capita daily and cumulative doses administered. With such large populations, even the large number of doses administered does not necessarily translate to high vaccination coverage. Brazil reports that 6.0% of its population has received at least 1 dose and 1.8% is fully vaccinated. In India, 3.4% of the population has received at least 1 dose and 0.6% is fully vaccinated. Both countries are far behind some other countries in terms of vaccination coverage, including Israel, the US, and the UK. For reference, the global average is 3.7% with at least 1 dose and 1.4% fully vaccinated, and many countries have not yet started vaccination efforts or have only recently started.

Global Vaccination
The WHO reported 456.8 million vaccine doses administered globally as of March 24, including 256.1 million individuals with at least 1 dose. The dashboard does not yet include data for daily or weekly vaccinations or fully vaccinated individuals.

Our World in Data reports that more than half a billion doses have been administered globally (508.2 million), a 23% increase compared to this time last week. The global cumulative total continues to increase at a rate of approximately 20% per week. The daily average continues to increase, up to 13.7 million doses per day (+29% compared to the previous week). At least 145 countries and territories are reporting vaccination data.

The US CDC reported 29.8 million cumulative cases and 542,584 deaths. Daily incidence has increased slightly over the past 5 days, up from 53,501 new cases per day to 57,249 (+7%). It is too early to determine if this is the beginning of a longer-term trend, but this is the highest daily incidence since March 7. Daily mortality continues to level off, hovering at slightly more than 1,000 deaths per day for more than a week.

US Vaccination
The US CDC reported 173.5 million SARS-CoV-2 vaccine doses distributed and 133.3 million doses administered. With 87.3 million individuals receiving at least 1 dose of the vaccine, more than a quarter of the entire US population (26.3%) and a third of all adults (33.7%) have been at least partially vaccinated. Of those, 47.4 million (14.3% of the total population; 18.3% of adults) are fully vaccinated. Among adults aged 65 years and older, 71.0% have received at least 1 dose and 44.8% are fully vaccinated.

The average daily doses administered* decreased slightly to 2.2 million doses per day, including 823,570 individuals fully vaccinated (ie, second dose of a 2-dose vaccine or a single dose of a 1-dose vaccine). In terms of full vaccination, 23.6 million individuals have received the Pfizer-BioNTech vaccine, 21.1 million have received the Moderna vaccine, and 2.7 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.

The Johns Hopkins Coronavirus Resource Center is reporting 30.1 million cumulative cases and 546,915 deaths as of 12:15am EDT on March 26.

ASTRAZENECA-OXFORD VACCINE PHASE 3 RESULTS Following questions about reported Phase 3 clinical trial efficacy data, AstraZeneca issued a press release containing updated results for its SARS-CoV-2 vaccine, developed in collaboration with the University of Oxford. The updated analysis estimates an overall efficacy of 76% against any symptomatic COVID-19 disease, slightly less that the 79% announced in the original press release. The updated analysis included an additional 49 symptomatic cases, bringing the total to 190 out of more than 32,000 participants, and an additional 14 possible or probable cases were identified, though they have not yet been adjudicated. Additionally, AstraZeneca reported 85% efficacy in adults aged 65 years and older and 100% efficacy against hospitalization and death. Notably, the new press release indicates there were 8 cases of severe COVID-19 disease among the placebo group. AstraZeneca noted that these figures “will be the basis for a regulatory submission [to the US FDA] in the coming weeks.” The clinical trial data have not yet been published publicly nor subjected to peer review.

EU VACCINE EXPORTS The European Union continues to weigh options that will limit the export of regionally produced COVID-19 vaccinations. The governing body this week proposed emergency legislation that would curb the number of vaccine exports over the next six weeks. AstraZeneca is in line to be most heavily impacted by these new rules. The company has been in conflict with the EU since the manufacturer reduced the number of COVID-19 vaccines they planned to deliver earlier this year. The EU’s original contract with AstraZeneca aimed to deliver 300 million vaccine doses by the end of June, but the company has since cut this target by two-thirds. While some EU leaders acknowledge the negative implications that curbing vaccine distribution will have on global vaccination targets, others are steadfast in their opinion that vaccine production companies work to meet earlier agreements. The EU has stressed that this new legislation will not be a blanket ban on regional exports and that there will be measures put in place to allow for flexibility of vaccine exports internationally. 

PFIZER-BIONTECH VACCINE TRIALS IN CHILDREN Pfizer and BioNTech announced they are beginning a Phase 1/2/3 clinical trial evaluating their SARS-CoV-2 vaccine in children under the age of 12. Results from the trial are expected later this year, and depending on data, will support an application to the US FDA for emergency use authorization (EUA) this autumn, a company spokesperson noted. The companies finished enrolling a study of the vaccine among children ages 12-15 in January. The FDA already granted an EUA for use of the Pfizer-BioNTech vaccine among people ages 16 and older. The new trial intends to enroll 144 children in the first phase, which is aimed at identifying the preferred dosing level for 3 age groups—participants ≥5 to <12 years, ≥2 to <5 years, and ≥6 months to <2 years of age. Phase 2/3 will evaluate the safety, tolerability, and immunogenicity in each age group at the selected dose level from Phase 1, when compared with patients in a placebo arm. After 6 months, the trial will be unblinded and offer the vaccine to all participants. The trial is expected to enroll a total of 4,500 children in the US and UK.  

The news follows announcements last week from Moderna that it began enrolling for a Phase 2/3 trial testing its SARS-CoV-2 vaccine, which is authorized for adults ages 18 and older, among children ages 6 months to less than 12 years. AstraZeneca last month began testing its vaccine in children 6 months and older, and Johnson & Johnson-Janssen has plans to extend its trials of its vaccine among younger children. Though children appear to be at lower risk of contracting SARS-CoV-2 compared with adults, the American Academy of Pediatrics estimates they account for 13% of US COVID-19 cases. Children comprise 23% of the US population, so vaccinating the younger population is critical to achieving herd immunity, according to experts. Vaccinating children also will help lower their and teachers’ risk of disease as they return to school buildings. 

EMERGING VARIANTS & VACCINES In a letter published in the New England Journal of Medicine, infectious disease experts from South Africa provide an overview of emerging COVID-19 variants, including those that have become the dominant strain in several countries, and evaluate the implications for vaccine efficacy, transmissibility, and disease severity. The authors highlight the B.1.1.7 strain, first identified in the UK; B.1.351 (501Y.V2), first identified in South Africa; and P.1 (B., first reported in Brazil, and note the need for continued genomic surveillance to manage variants. 

A group led by researchers from the London School of Hygiene and Tropical Health report on case fatality risk of the B.1.1.7 variant in an Eurosurveillance article. Noting the strain is now dominant in the UK and increasing in prevalence across Europe, the authors evaluated the case fatality risk of the variant in England from November 2020-January 2021. Infection with the variant of concern (VOC) was consistently associated with an increased hazard of death, and once adjusted for comorbidities and demographics, the researchers found a two-thirds higher hazard ratio in the VOC group (1.67 HR, 95% CI: 1.34-2.09).
The B.1.351 (501Y.V2) variant, now the dominant strain in South Africa, elicits cross-reactive neutralizing antibodies that may provoke an immune response capable of fending off multiple variants. In a preprint study published in bioRxiv, South African researchers describe how sera from B.1.351-infected patients showed robust binding and neutralizing activity against variants from the first wave of infections in South Africa as well as against the P.1 variant. The cross-reactive responses of sera from B.1.351-infected patients suggests the broad specificity potential of a vaccine designed with the that variant’s sequence. Moderna is conducting a Phase I clinical trial of its mRNA-1273.351 vaccine, which encodes for a protein specific to the B.1.351 variant. Other developers are expected to follow suit. 

The B.1.1.7 variant has been identified for the first time in household pets. In a preprint study published in bioRxiv, veterinarians from a specialty veterinary clinic located in the southeast of England describe the first cases of B.1.1.7 infection among 8 cats and 3 dogs, all of which required veterinary visits due to new-onset symptoms, including lethargy, loss of appetite, rapid breathing, and severe cardiac abnormalities. All of the owners had tested positive for SARS-CoV-2 prior to their pets developing symptoms. In another report, researchers from Texas A&M University, as part of an ongoing research project funded by the US CDC, describe a cat and dog from the same household infected with the B.1.1.7 variant but showing no symptoms at the time of initial testing. Their owner was diagnosed with the B.1.1.7 variant only two days prior to the pets’ tests. The report notes both pets later developed symptoms, including sneezing, that resolved after one month. The researchers say these cases raise questions regarding the risk companion animals may play in the COVID-19 pandemic, particularly given the enhanced infectivity and transmissibility of the B.1.1.7 variant, and encourage additional research.  

GERMANY EASTER SHUTDOWN On March 22, Germany announced highly restrictive COVID-19 “emergency brake” measures that were scheduled to be in effect through April 18, including additional restrictions over the Easter holiday weekend. However, German Chancellor Angela Merkel reversed that decision on March 24. Chancellor Merkel noted that the plan was finalized too close to the start date and that too many questions remained regarding how to implement the restrictions. The original plan included “quiet days” on April 1 and April 3, the Thursday before and Saturday of Easter weekend, during which non-essential businesses would be closed and gatherings would be limited to individual households plus one additional individual, up to 5 total individuals. Additionally, the restrictions would have limited gatherings in churches and other religious services. Combined with the existing national holiday dates on Friday and Monday, the restrictions would have resulted in a 5-day national shutdown over Easter weekend. Germany’s daily incidence has more than doubled since its low on February 14, including a 69% increase over the past 2 weeks.

On March 25, Germany announced a reinstatement of vaccination efforts using the AstraZeneca-Oxford vaccine. Germany resumed use of the vaccine following safety analysis by the European Medicines Agency (EMA) and Germany’s Paul Ehrlich Institute (PEI). Vaccination with this vaccine was paused on March 15 over concerns regarding the possible associated risk of blood clots (thromboembolic events) following vaccination.

US EVICTION MORATORIUM The US government is weighing an extension of a federal policy prohibiting landlords from evicting tenants who have fallen behind on paying rent during the COVID-19 pandemic. The extension, which would impact an estimated 10 million families, could run through at least July. Without an extension, the ban is set to expire at the end of this month. The recently passed stimulus bill, known as the American Rescue Plan, included more than $40 billion to help homeowners and renters behind on their mortgage and rent payments. However, due to implementation delays, many people have not yet received the assistance, putting pressure on the government to extend the ban. According to a survey by the Census Bureau released last week, nearly 1 in 5 renters say they are behind on payments, with people of color bearing a majority of the hardship. According to the Washington Post, some officials at the US CDC, which implements the policy, have expressed concern over the agency overseeing the ban, saying it was implemented in a way no one thought possible. Biden administration officials largely have been silent on the extension and have not named another agency that could steward the policy.

COVID-19 WAVES IN AFRICA In a report published online in The Lancet, researchers led by the Africa CDC detail the first and second waves of SARS-CoV-2 infections across the African continent from February 2020 to December 2020. Using epidemiological, testing, and mitigation strategy data reported by African Union (AU) member states, the group conducted descriptive analyses for cumulative and weekly incidence rates, case fatality ratios (CFRs), tests per case ratios, growth rates, and public health and social measures in place. Their analysis showed the continent experienced a more aggressive second wave of infections compared to the first. In July 2020, at the peak of the first wave, the continent’s mean daily number of new cases was 18,273, with that number rising to a mean of 23,790 daily new cases by the end of December 2020, representing a 30% increase. Nine of 55 AU member states accounted for 82.6% of reported cases as of December 2020, and eighteen countries reported CFRs greater than the global CFR of 2.2%. By April 15, 2020, 96% of 50 AU countries had five or more stringent public health and social measures in place, but that number decreased to 36 (72%) countries as of December 31, 2020, despite an increasing number of cases.  

Dr. John Nkengasong, Director of the Africa CDC and one of the study’s authors, said the increase in cases likely was due to several factors, including lower adherence to public health mitigation strategies like mask wearing and physical distancing as well as a growing prevalence of more infectious SARS-CoV-2 variants. In a statement to CNN, he called on countries to improve testing capacity, strengthen their public health campaigns, and recognize the importance of balancing mitigation strategies with economic needs. Dr. Nkengasong also called for a scale-up of vaccine distribution throughout the continent, warning some countries are beginning to see the start of a third wave.

CUBAN VACCINES Cuba announced that one of its five SARS-CoV-2 vaccine candidates, Soberana 2, has had promising preliminary results and is entering a Phase 3 trial involving 44,000 people. This is the first SARS-CoV-2 vaccine developed in Latin America to enter the final phase of testing. A second Cuban vaccine candidate, named Abdala, has entered Phase 3 testing. Several Cuban experts shared that the country could produce enough vaccinations for its entire population by the end of the summer, assuming the vaccine candidate proves successful in the last phase of clinical trials. This is a major development for Cuba, which has not yet purchased foreign-produced vaccines nor attempted to acquire vaccines through the COVAX initiative. By May, Cuba plans to administer one of its experimental vaccines to 1.7 million people, nearly the entire population of the capital, Havana. The country already has begun vaccinating the city’s frontline workers. Havana is experiencing its worst outbreak since the beginning of the pandemic, according to local authorities. 

US GOVERNMENT PATENT A group of public health advocates and academics is urging the US NIH to negotiate with Moderna to create patent licensing terms that would help speed the production and reduce the price of its SARS-CoV-2 vaccine for use in low- and middle-income countries (LMICs). At issue is a key patent owned by the US government that applies to the spike protein molecule necessary for Moderna’s vaccine to elicit a human immune response against the virus. The group, led by PrEP4All, claims the patent is being used by 5 different vaccine manufacturers, although only one, BioNTech, has paid to obtain a license. Historically, the US government has been reluctant to exert its patent rights over private sector partners. However, the US government filed a lawsuit in 2019 against the pharmaceutical company Gilead over a patent used in the HIV treatment and prevention medications Truvada and Descovy. That lawsuit is pending. Some patent lawyers and public health experts say similar lawsuits over the SARS-CoV-2 patent are possible unless other companies negotiate licensing agreements with the government.

SINOPHARM VACCINE Reports are emerging from the United Arab Emirates (UAE) that some individuals vaccinated with the Sinopharm vaccine from China may require a third dose. Some individuals have not developed sufficient immune response following their second dose, and they may benefit from a third dose to stimulate the appropriate antibody response. The UAE reportedly has implemented a program to reach out to individuals with low antibody response and offer them an additional booster. It is unclear what proportion of vaccinees are affected or the degree to which they benefit from a third dose, but it is not necessarily rare for individuals to not respond to vaccines against other pathogens. China has distributed its vaccines, including the Sinopharm vaccine, to numerous other countries; however, Phase 3 clinical trial data for these vaccines have not yet been published publicly. Sinopharm has reported efficacy of 79%. The UAE issued an emergency authorization for the Sinopharm vaccine in September 2020, prior to the completion of a Phase 3 clinical trial conducted there.

COMBATING MISINFORMATION The COVID-19 pandemic has illustrated that health-related misinformation and disinformation can dangerously undermine responses to public health crises. To address this issue, the Johns Hopkins Center for Health Security published the National Priorities to Combat Misinformation and Disinformation for COVID-19 and Future Public Health Threats. The report provides an overview of mis- and disinformation challenges during the pandemic—including contradictory messaging and active subversion, increased mistrust in science, and the politicization of public health measures—and ongoing efforts to counter them. The report also presents a series of recommendations targeted at a broad range of stakeholders, including media companies, government officials, and the public. The report also calls for a national strategy, under the purview of the National Security Council (NSC), to coordinate government activities and policies to counter mis- and disinformation and to develop evidence-based guidelines and recommendations for nonpartisan oversight of these challenges.

PANDEMIC PREPAREDNESS On Tuesday, March 30 at 11am EDT, Anita Cicero, JD, Deputy Director of the Johns Hopkins Center for Health Security, will moderate a webinar for the Capitol Hill Steering Committee on Pandemic Preparedness and Health Security, titled “Strengthening the Supply Chain for US Pandemic Response: Strategies for Stockpiling, Surge Capacity, and Distribution.” The webinar will examine supply challenges in the ongoing COVID-19 pandemic, vulnerabilities exposed by the pandemic, and emerging lessons from both the private and public sectors that can inform new policies and practices that enhance US preparedness for future pandemics. The non-partisan Steering Committee is sponsored and managed by the Johns Hopkins Center for Health Security. Register for the webinar here.