EPI UPDATE The WHO COVID-19 Dashboard reports 116.9 million cases and 2.6 million deaths as of 11:00am EST on March 9. The weekly global incidence remained steady from the previous week, with 2.70 million new cases. The weekly global mortality declined for the fifth consecutive week, down to 59,786 deaths—a 6.9% decrease from the previous week.
On March 7, Brazil surpassed the US as #1 globally in terms of total daily incidence. The US had held the #1 position since October 21, 2020, and it is still the only country to average more than 100,000; 150,000; and 200,000 new cases per day—it also fell just short of 250,000 at its highest peak (249,360 on January 11). Brazil is now reporting 66,381 new cases per day, and except for the weeks of Christmas and New Year’s, its daily incidence has increased steadily since early November 2020. Notably, Brazil’s daily incidence has increased 41% over the past 2 weeks, up from 46,921 new cases per day on February 22.
The WHO added cumulative vaccination data to its COVID-19 dashboard. In total, 268.2 million vaccine doses have been administered globally, including 156.3 million individuals with at least 1 dose. The dashboard does not yet include daily vaccinations.
Global Vaccination
Our World in Data reports that 312.2 million vaccine doses have been administered globally, an 18% increase compared to this time last week. The daily average fell slightly over the past week, from 7.2 million to 7.0 million doses (-4%). Vaccination efforts have been reported in at least 125 countries and territories.
UNITED STATES
The US CDC reported 28.81 million cumulative cases and 523,850 deaths. Daily incidence and mortality continue to decrease, but at a much slower rate than over the past several weeks. The US is averaging fewer than 60,000 new cases per day for the first time since October 20, 2020. The average mortality appears to have leveled off at slightly more than 1,700 deaths per day. As of March 4, the 806 previously unreported deaths in Los Angeles County, California, moved out of the 7-day window, which caused the average to decrease by nearly 200 deaths per day.
In addition to the overall national epidemiological trends, long-term care facilities (LTCFs) have also seen steady declines in COVID-19 incidence and mortality over the past several months, for both residents and staff. Due to the high risk of infection and severe disease, LTCFs were among the earliest priorities for SARS-CoV-2 vaccination. Through March 4, 2021, more than one-third of all US COVID-19 deaths* were among LTCF residents.
*Not including Arizona, which does not report LTCF COVID-19 deaths.
Since the start of the US vaccination effort in mid-December, weekly COVID-19 incidence and mortality has decreased substantially. At the peak (the week of December 20, 2020), the CDC reported 34,251 new cases among LTCF residents, and the weekly total has declined since then. During the week of February 28, 2021, the US reported only 1,474 new cases, a decrease of more than 95% from the peak. Similarly, the US reported 7,049 deaths among LTCF residents during the week of December 20, 2020, which fell to 1,350 the week of February 28, 2021—a decrease of more than 80%.
Beyond the residents, similar trends are evident in the LTCF staff population. At the peak (week of December 13, 2020), the US reported 29,181 new cases among LTCF staff. During the week of February 28, 2021, there were only 2,157 cases among LTCF staff, a decrease of 92% from the peak. The mortality data for LTCF staff is a little more difficult to analyze due to relatively low numbers and delayed holiday reporting, However, from the most recent peak of 63 deaths during the week of January 10, 2021, mortality fell to 26 deaths the week of February 28, 2021—a decrease of 58%.
For comparison, the national daily incidence and mortality have decreased by 77% and 49% since their peaks in mid-January 2021. The decline in weekly incidence and mortality among LTCF residents began in late December 2020, several weeks before the national epidemic peaked, and the weekly incidence peaked among LTCF staff at approximately the same time. The magnitude and timing of the COVID-19 decline in LTCF residents and staff provide evidence that the vaccination campaign is making a direct impact on this vulnerable population.
US Vaccination
The US CDC has distributed 116.4 million doses of SARS-CoV-2 vaccines and administered 92.1 million doses nationwide. In total, 60.0 million people (18.1% of the entire US population; 23.5% of the adult population) have received at least 1 dose of the vaccine, and 31.5 million (9.5%; 12.3%) have received both doses. The US continues to set new records for daily doses administered, up to 1.98 million doses per day*, including 815,748 individuals receiving their second dose. The breakdown of doses by manufacturer remains relatively steady, with slightly more Pfizer-BioNTech doses (46.8 million) than Moderna (44.9 million) administered nationwide. The CDC reported the first data for the J&J-Janssen vaccine, with 208,590 doses administered**.
*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.
The Indian Health Service (IHS) has administered 665,997 million doses, including 439,930 individuals with at least 1 dose (21.1% of the total population covered by IHS) and 219,925 individuals who have been fully vaccinated (10.6%). If IHS were a state, it would rank #9 nationally in terms of 1+ doses per capita and #13 for full vaccination per capita.
VACCINE DISINFORMATION A spokesperson for the US Department of State’s Global Engagement Center discussed efforts by Russia to perpetuate disinformation about SARS-CoV-2 vaccines manufactured in the US. According to a report by The Wall Street Journal, the GEC identified 4 online media outlets that it believes serve as fronts for Russian intelligence agencies. These outlets have cooperated to share reports that emphasize the Pfizer-BioNTech and Moderna vaccines’ side effects, question their efficacy, and raise doubts about the accelerated development timeline. While the individual publications’ readership is small, social media platforms enable them to widely disseminate the disinformation. State Department officials did not elaborate on how the publications were controlled by Russian intelligence agencies, and the Russian government denies the allegations. An August 2020 GEC special report examined 7 disinformation proxy sites and organizations linked to the Russian government and their activities in amplifying information critical of the US and favorable to Russia, particularly related to COVID-19.
In public settings, vaccinated individuals are recommended to follow existing COVID-19 risk mitigation measures, including physical distancing (e.g., 6-foot separation) and mask use, because much of the public remains unvaccinated and still at risk for COVID-19. In private settings, fully vaccinated individuals can meet with other fully vaccinated individuals or with unvaccinated individuals from one other household without wearing masks or physically distancing, as long as all unvaccinated individuals are at low risk for severe disease. Gatherings of more than 2 households or gatherings with unvaccinated high-risk individuals should still employ COVID-19 prevention measures, such as mask use, physical distancing, enhanced hygiene, and meeting in a well-ventilated space. The CDC has not yet issued travel-related guidance for vaccinated individuals, and health officials continue to recommend against non-essential travel for everyone, regardless of vaccination status.
Vaccinated individuals do not need to quarantine or get tested if exposed to a known COVID-19 case, as long as they remain asymptomatic, with the exception of those living in congregate settings (e.g., long-term care facilities [LTCFs], correctional facilities). If a vaccinated individual does test positive or exhibit COVID-19 symptoms, s/he should self-isolate for 10 days.
In addition to the guidance itself, the CDC published information regarding the underlying evidence, including from animal studies, human clinical trials, and real-world data collected since the initiation of mass vaccination operations. The CDC emphasized that the guidance will continue to be updated as vaccination coverage increases, the epidemiological situation evolves, and researchers more fully characterize vaccine’s effectiveness, particularly with respect to the vaccines’ impact on transmission.
US COVID-19 STIMULUS On Saturday, the US Senate approved an updated version of the American Rescue Plan, the US$1.9 trillion COVID-19 economic relief package. The vote passed 50-49 (1 Senator absent), with all Democratic Senators voting in favor and no Republican support. The US House of Representatives is expected to vote on the new version of the bill tomorrow, and US President Joe Biden could potentially sign it this week. The Internal Revenue Service could begin distributing stimulus checks to qualified individuals as early as next week, based on the timeline for the previous round of stimulus checks.
The American Rescue Plan has gone through multiple iterations, and the current version includes US$1,400 stimulus checks for individuals earning US$75,000 or less and US$2,800 for married couples earning US$150,000 or less as well as their dependents. One notable change from previous stimulus packages is that individuals and married couples earning US$80,000 or US$160,000 or more, respectively, will not be eligible for the direct payments. The package also extends expanded federal unemployment benefits of US$300 per week through September 2021. Additionally, the federal child tax credit will temporarily increase by 50% or more per child, from US$2,000 to US$3,000 or US$3,600, depending on age. Additional funding will be allocated to support SARS-CoV-2 testing and sequencing capacity, state and local COVID-19 response activities, and small businesses.
COVID-19 THERAPEUTICS On March 2, the WHO published updated guidance for COVID-19 therapeutics. The guidance was published in The BMJ as part of an ongoing compendium of official WHO COVID-19 guidance. The WHO issued a strong recommendation against using hydroxychloroquine as COVID-19 prophylaxis. The guidance draws on results from 6 clinical trials with more than 6,000 participants, leading the WHO to conclude with “high evidence quality” that hydroxychloroquine has little or no effect in reducing the risk of COVID-19 incidence or SARS-CoV-2 infection compared, including “small or no effect” on death or hospitalization. Additionally, hydroxychloroquine has been associated with increased risk of adverse events severe enough to discontinue use of the drug.
A clinical trial conducted by researchers at the Centro de Estudios en Infectologia Pediatrica in Cali, Colombia, demonstrated that the antiparasitic drug ivermectin did not significantly shorten duration of COVID-19 symptoms among adults with mild disease. The study, published in JAMA, included nearly 400 total patients—200 randomly assigned to receive a 5-day course of ivermectin and 198 patients in the placebo group. Among the treatment group, the median time to symptom resolution was 10 days, compared to 12 days in the placebo group. Additionally, by Day 21, 82% of the treatment group had fully recovered, compared to 79% of the placebo group. Neither of these results were statistically significant, and the researchers concluded the findings do not support the use of ivermectin for the treatment of mild COVID-19 disease.
COVID-19 MORTALITY Researchers from the University of California, Irvine Medical Center (US) published findings in JAMA: Network Open from a study on outcomes of hospitalized COVID-19 patients early in the US epidemic. The study included data for nearly 200,000 COVID-19 patients from 555 hospitals across the US who were hospitalized from March 1-August 31, 2020. In-hospital mortality was strongly associated with age, with the case fatality ratio ranging from 1.4% for adults aged 18-29 years to 26.6% for adults aged 80 years and older. The researchers also analyzed the cost of care for these patients and found a median of US$10,520 for non-ICU patients and US$39,825 for those admitted to the ICU.
The overall in-hospital mortality was 13.6%, but the monthly average decreased significantly over time. In March 2020, the case fatality ratio was 22.1%, and it fell steadily to only 6.5% in August 2020. The elevated mortality early in the US epidemic illustrates the effect from both the intense patient surge on hospitals and limited initial understanding of clinical care best practices. Early in the US epidemic, the vast majority of cases were concentrated in a few major urban areas—including Boston, Detroit, New Orleans, and New York City—so while the overall national peak during the initial surge is similar to the summer 2020 peak and much lower than the fall/winter 2020 peak, the burden was concentrated in relatively few health systems, which threatened to overwhelm available resources. Additionally, many health systems faced shortages of critical equipment and supplies early in the US epidemic, including mechanical ventilators, which negatively affected patient care. As the epidemic spread across the country, the supply of critical equipment and supplies increased, and clinicians’ understanding of how to treat COVID-19 improved, the case fatality ratio decreased dramatically in hospitalized patients.
VACCINE DIPLOMACY Countries around the world continue to craft new partnerships with allies in an effort to secure adequate supply of SARS-CoV-2 vaccines for their domestic populations. Late last week, Israel, Austria, and Denmark established a joint fund for research and development and potential production of SARS-CoV-2 vaccines. The coalition aims to provide long-term stability for booster shots, in the event that emerging SARS-CoV-2 variants that reduce vaccine effectiveness become more widespread. Delays in distributing SARS-CoV-2 vaccines to EU member states may have played a role in Denmark and Austria seeking the partnership with Israel, particularly in light of the success of Israel’s national vaccination effort. Global health organizations have raised concerns over equitable global vaccine distribution during the COVID-19 pandemic, and multilateral efforts such as COVAX may not be sufficient to ensure sufficient access for lower-income countries.
Vaccine supplies and donations have been used as political tools in the past, and early vaccine distribution efforts during the COVID-19 pandemic appear to follow historical patterns and alliances. China and Russia have long been active players in the global vaccination space, fostering relationships with both neighboring and distant countries in an effort to distribute their domestically-produced vaccines. Some experts and news outlets have expressed concern that China and Russia may be overselling their vaccination resources, both in terms of efficacy and production capacity, in an effort to gain political support.
RUSSIAN VACCINE PRODUCTION Russia reportedly finalized an agreement to manufacture its Sputnik V SARS-CoV-2 vaccine in Italy. This would be the first time that the Russian vaccine would be manufactured in an EU country. The contract aims to produce 10 million doses of the vaccine in Italy by the end of 2021, leveraging the production capacity of an Italian subsidiary of Adienne, a Swiss pharmaceutical company. Italian Minister of Health Roberto Speranza indicated that he is open to introducing the Russian vaccine in Italy, but only after it receives approval from the European Medicines Agency (EMA). The EMA began a rolling review of the Sputnik V vaccine last week. Russia also announced that it is currently working on 20 additional production collaborations in Europe.
COVID-19 RISK MITIGATION The US CDC COVID-19 Response Team published findings from a study on the impact of state-level mask mandates and in-person dining restrictions on COVID-19 incidence and mortality. The study, published in the US CDC’s MMWR, evaluated county-level COVID-19 data from March 1-December 31, 2020, and compared counties in states that implemented mask mandates and restricted in-person dining to those in states without state-issued restrictions. To account for changes in state-level policies over the study period, the researchers evaluated COVID-19 incidence and mortality at multiple intervals following statewide changes—ranging from 1-20 days to 81-100 days after they took effect.
State-issued mask mandates were associated with significant decreases in both COVID-19 daily incidence and mortality. The daily incidence growth rate decreased 0.5% for Days 1-20, with the magnitude of the effect increasing over subsequent intervals, up to a 1.8% decrease for Days 81-100. The daily mortality growth rate decreased 0.7% for Days 1-20 and as high as 1.9% for Days 81-100. Similarly, lifting state-issued prohibitions on in-person dining was significantly associated with increased COVID-19 incidence and mortality, although not immediately after the policy change. The daily incidence growth rate increased by 0.9% for Days 41-60 and up to 1.1% for Days 81-100 after lifting the restrictions, and the daily mortality growth rate increased by 2.2% for Days 61-80 and 3.0% for Days 81-100. The researchers suggest that not all restaurants resumed in-person service immediately after state-level restrictions were lifted. Additionally, the public’s comfort with in-person dining may have been initially low and then increased over time following changes to state-level policy, which could potentially explain the limited effect on COVID-19 incidence and mortality soon after the changes.
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