COVID-19 Situation Report
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EPI UPDATE The WHO COVID-19 Dashboard reports 165 million cumulative cases and 3.4 million deaths worldwide as of 4:45am EDT on May 21.

Following a brief decrease, India’s daily mortality is once again increasing, setting new global records. On May 18, India reported 4,529 deaths, surpassing the previous record for single-day mortality (US: 4,475 deaths on January 12, 2021). With 4,150 deaths per day on May 18, India also holds the global record for average daily mortality. India is the only country to report an average of more than 4,000 deaths per day, and it has hovered around 4,100 deaths per day for the past several days.

On Tuesday, we looked at state-level test positivity in the US, and in light of numerous ongoing surges in countries around the world, we will take a similar look at some national trends in test positivity. Of the top 20 countries* globally, 10 are in Central and South America (including 5 of the top 7), plus Trinidad and Tobago and the Dominican Republic in the Caribbean; 4 are in Africa; and 3 are in Asia. Ukraine is the only country in Europe. Notably, 13 of these countries are reporting test positivity of more than 20%, including 5 with more than 30%: Nepal (44.2%), Paraguay (36.9%), Maldives (31.3%), Argentina (30.6%), and Ecuador (30.6%).
*Oman would be in the top 20, based on its most recent report, but it has not updated its test positivity data since July 2020.

Fortunately, fewer than half of these countries are reporting increasing trends in daily incidence. In terms of the relative biweekly change, 9 are reporting positive values, 7 of which are greater than +10% and 4 of which are greater than +50%. Maldives is reporting the largest biweekly increase, with +177%, followed by Trinidad and Tobago (+94%), the Dominican Republic (+89%), and Nepal (+57%). The high test positivity in these countries could result in substantial underreporting of COVID-19 incidence, which is particularly concerning in light of their increasing trends. Maldives may be the most concerning country on this list. In addition to having the largest biweekly increase, it is also reporting the world’s highest per capita daily incidence. At more than 2,500 daily cases per million population, Maldives is reporting more than 2.5 times the per capita incidence of the next closest country in this group (Uruguay; 906). Notably, while Nepal’s overall biweekly trend is positive, it does appear to have passed a peak and is now declining.

While their relative biweekly increases do not necessarily reflect it, several other countries also are reporting concerning increases in daily incidence. Following approximately 2 weeks of decreasing trends, both Uruguay and Argentina are reporting increasing daily incidence. In fact, Argentina has already surpassed its previous peak, and Uruguay could soon do so as well, if it continues on its current trajectory. Additionally, Bolivia’s daily incidence has increased steadily since late March, briefly surpassing its previous record on May 17. Paraguay’s epidemic has exhibited a protracted but slow increase since early February, and it is currently reporting near its record high, set on April 23.

Notably, most of the countries with high test positivity are reporting decreasing daily incidence, including 4 that have decreased by more than one-third over the past 2 weeks: Madagascar (-49%), Tunisia (-36%), the Democratic Republic of Congo (-35%), and Ecuador (-33%).

Several countries with biweekly increases in daily incidence also are reporting increasing test positivity, which signals that testing capacity is falling further behind as the surges worsen. The Dominican Republic reported a steady decline in test positivity in early 2021; however, it recently reported a considerable increase, from 11.4% on May 10 to 15.3% on May 15 (its most recent report), an increase of more than one-third over only a few days. After a prolonged decline from late January to April, Bolivia’s test positivity has increased from a low of 9.5% on April 17 to nearly 25% on May 17 before falling slightly to 22.3%. Trinidad and Tobago’s test positivity accelerated consistently from 1% in late February to a high of 38.2% on May 10 before falling sharply to 20.2% on May 11 (its most recent report). Maldives also reported a concerning accelerating trend, up from 3.2% on April 16 to 30.9% on May 19, slightly more than a month later. While Nepal’s test positivity increased from less than 2% in early March to a peak of more than 45% on May 13, it has declined steadily in the few days since then. In contrast to other countries discussed here, this is an encouraging indication that its testing capacity is beginning to move in the right direction during its ongoing surge, even though test positivity remains elevated.

Global Vaccination
The WHO reported 1.42 billion doses of SARS-CoV-2 vaccines administered globally as of May 20, including 666 million individuals with at least 1 dose. Our World in Data reported 1.59 billion cumulative doses administered globally. The global cumulative total continues to increase at approximately 13% per week. Daily doses administered continue to increase, up to a new record of 26.0 million doses per day. Our World in Data estimates there are 376 million people worldwide who are fully vaccinated, corresponding to approximately 4.8% of the global population, although reporting is less complete than for other data.

The US CDC reported 32.9 million cumulative cases and 584,975 deaths. The current average daily incidence—27,788 new cases per day—is the lowest since June 18, 2020. The average daily COVID-19 mortality fell below 500 deaths per day for the first time since March 31, 2020.

US Vaccination
The US has distributed 352 million doses of SARS-CoV-2 vaccines and administered 279 million. After more than a month of decline, the daily doses administered* increased slightly on May 15 to 1.6 million doses per day. Approximately 1.0 million people are achieving fully vaccinated status per day, down from a high of 1.8 million per day on April 12.

A total of 160 million individuals in the US have received at least 1 dose of SARS-CoV-2 vaccine, equivalent to 48% of the entire US population. Among adults, 61% have received at least 1 dose, and 4.1 million adolescents aged 12-17 years have received at least 1 dose. A total of 127 million people are fully vaccinated, which corresponds to 38% of the total population. Among adults, 48% are fully vaccinated, and 1.8 million adolescents aged 12-17 years are fully vaccinated. Progress has largely stalled among adults aged 65 years and older: 85% with at least 1 dose and 73% fully vaccinated. In terms of full vaccination, 65 million individuals have received the Pfizer-BioNTech vaccine, 51 million have received the Moderna vaccine, and 9.8 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 33.1 million cumulative cases and 588,559 deaths in the US as of 10:15am EDT on May 21.

BRAZIL PEDIATRIC MORTALITY Since early in the pandemic, it was clear that older adults were at elevated risk for severe COVID-19 disease and death. In contrast, Brazil’s epidemic is exhibiting elevated mortality among children and infants. A report by The New York Times describes some of the factors that could be contributing to increased pediatric mortality. Since the onset of the pandemic, Brazil has reported at least 832 deaths among children aged 5 years and younger, which likely is a “substantial undercount.” In fact, researchers at the University of São Paulo estimate that the actual total is closer to 2,200, including more than 1,600 infants younger than 1 year. For comparison, the US has reported only 139 deaths among children aged 4 years and younger. While the age range is slightly smaller than in Brazil’s tally, the US has a population approximately 50% larger than Brazil’s.

Myriad factors could be contributing to Brazil’s high pediatric mortality. The P.1 variant that is circulating widely in Brazil has been linked to increased disease severity and mortality among pregnant women as well as elevated risks of stillbirth or premature delivery. A lack of testing leads to untimely or inadequate access to health care for children with COVID-19, and poor and overwhelmed health systems also could result in increased mortality among this population. Underlying health conditions—some related to poverty and food insecurity—can exacerbate the risk of severe disease in children, but Brazil’s pediatric COVID-19 mortality also is elevated in otherwise healthy children. Further study is needed to better characterize the factors influencing elevated mortality among children and infants in Brazil.

COVAX MANUFACTURING TASK FORCE The COVAX facility is struggling to reach its goal of providing 2 billion doses of SARS-CoV-2 vaccines to low- and middle-income countries (LMICs) by the end of this year. So far, COVAX has delivered just over 68 million doses, or 3.4% of its goal. Experts maintain the 3 primary obstacles preventing COVAX from reaching its goal include a lack of funding, vaccine supply constraints, and a lack of willingness from some countries to share vaccine doses. But they also argue all of these problems are solvable. WHO Regional Director for Africa Dr. Matshidiso Moeti on Thursday appealed to rich nations to share their surplus vaccine doses, commending France for shipping jabs to Mauritania and the US for pledging to donate 80 million of its excess doses. Yet more needs to be done, as the world continues to stumble in ramping up manufacturing of vaccines that were developed with record speed.

In an effort to address bottlenecks in the supply of vaccine raw materials and trade barriers impacting the supply chain, the co-leads of COVAX—the Coalition for Epidemic Preparedness Innovations (CEPI), WHO, Gavi, and UNICEF, working in partnership with the Bill & Melinda Gates Foundation, International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), Developing Countries Vaccine Manufacturers Network (DCVMN), and Biotechnology Innovation Organization (BIO)—announced the launch of the “COVAX Manufacturing Task Force.” The Task Force plans to engage additional partners within the clinical development, manufacturing, and regulatory sectors, as well as governments, regional entities, and other institutions, to address short-, medium-, and long-term objectives that aim to alleviate shortages of raw and single-use materials, speed delivery of such materials, and encourage cooperation among manufacturers. 

EMERGENT VACCINE PRODUCTION FACILITY On May 19, the US House of Representatives Select Subcommittee on the Coronavirus Crisis held a hearing as part of an investigation into Emergent BioSolutions’ failures to address manufacturing problems at its Baltimore, MD, (US) plant that led to the contamination and subsequent destruction of 15 million doses of the J&J-Janssen SARS-CoV-2 vaccine made at the facility. The hearing comes 1 month after the US government put J&J in charge of the plant following revelations that Emergent, under federal contract to make key materials for J&J-Janssen and AstraZeneca-Oxford vaccines, cross-contaminated ingredients for the different jabs.

At the hearing, Emergent executives testified for more than 3 hours about manufacturing deficiencies and disclosed for the first time that more than 100 million doses of the J&J-Janssen vaccine are on hold and under review by the US FDA, 30 million more than previously recognized. Emergent CEO Robert G. Kramer acknowledged that it was J&J, not Emergent, that first discovered the contaminated doses. The subcommittee also released a preliminary report outlining details about unaddressed issues at the Emergent plant, including unsanitary conditions, mold, poor employee training, and insufficient attention paid to operating protocols. In 2020, the federal government awarded Emergent a $628 million contract to produce SARS-CoV-2 vaccines, and so far has paid $271 million. However, the FDA has yet to clear for use a single dose of vaccine produced at the plant. The FDA published a report in April stating the Baltimore facility was unsuitable to produce vaccine doses, and Emergent agreed to pause production of materials until issues identified in the report are resolved.

EU TRAVEL The European Council on May 20 adopted updated recommendations for non-essential travel into the region, a move that could increase the number of foreign travelers able to enter the EU. The bloc has had many restrictions on the movement of travelers during the COVID-19 pandemic, with this new policy marking a turning point for pandemic policies. The plan would grant anyone vaccinated with an EU-approved COVID-19 vaccine permission to travel, greatly increasing the potential for tourism. This rule could open up travel to an increasing number of foreign individuals but would restrict those who received Russian- or Chinese-made vaccines, none of which are authorized in the EU. Bloc leadership has shared that countries may still implement more restrictive guidance if they choose, but they are urging member states to move toward more open borders as larger percentages of adults receive SARS-CoV-2 vaccines. The recommendations allow for an “emergency brake mechanism,” under which member countries can adopt urgent, temporary travel restrictions if a variant of concern or interest is detected.

MODERNA VACCINE PRODUCTION In an effort to further scale up SARS-CoV-2 vaccine production capacity, the Swiss government is supporting efforts to hire temporary personnel to staff a facility operated by the Lonza Group. The Lonza facility in Visp, Switzerland, manufactures ingredients that are needed to produce Moderna’s SARS-CoV-2 vaccines, and Lonza recently added 3 new production lines to meet the ongoing demand. Reportedly, Lonza was struggling to find qualified personnel to operate the production lines, but the Swiss government was able to identify 75 personnel with the required expertise from within government agencies as well as academic institutions. Lonza anticipates further efforts to increase production capacity, up to 600 million doses per year. Lonza will require additional personnel in the future, as the current temporary employees are not a long-term solution.

INDIA VACCINATIONS At the beginning of May, India expanded eligibility for SARS-CoV-2 vaccinations to its entire adult population. The country has faced an incredibly challenging surge in new COVID-19 cases, increasing the urgency to vaccinate its population. However, access to vaccines is being hindered by the current outbreak, lockdowns, cost, and production backlogs. The government recently estimated it would be able to produce 1.46 billion doses of the authorized AstraZeneca-Oxford, Sputnik V, and Covaxin vaccines between the months of August and December, but lower-than-expected production estimates reported to Reuters fall short of the government’s goal. In a further setback, the Indian government and Pfizer have reached an impasse over the company’s demand for indemnity against any claims related to its vaccine. In addition to questions over vaccine supply, the influence of mis- and disinformation surrounding COVID-19 and vaccines is hampering willingness among some to be vaccinated, particularly those in rural areas. It is reasonable to expect that the severity of the ongoing outbreak, and other events like Cyclone Tauktae, have negatively impacted the country’s vaccination efforts, but it will be troublesome if a high prevalence of vaccine hesitancy impedes vaccination rates as more doses become available. 

CHINA VACCINE DONATIONS China on May 20 said it has donated or sold at “favorable prices” its homegrown vaccines to nearly 40 African countries, describing its actions as purely altruistic. The announcement is the latest example of how geopolitics is intensifying global moves on what is being called vaccine diplomacy. A day before, the 15-member UN Security Council unanimously approved a presidential statement calling for the accelerated availability of SARS-CoV-2 vaccines for Africa and expressing concern that the continent has received only about 2% of all doses administered worldwide. Also at the Security Council meeting, organized by China, which holds the body’s rotating presidency for May, member states heard from Africa Union Commission Chair Moussa Faki Mahamat, who said vaccine access is the biggest challenge Africa faces, amid increasing numbers of COVID-19 cases and related deaths. The same day, the US government said it will prioritize sending excess vaccine doses to Latin America over concerns that China is using vaccine donations to the region to influence nations there to drop diplomatic recognition of Taiwan. Both Paraguay and Honduras have signaled they might switch ties from the US to China, which claims Taiwan as its territory, in order to gain access to Chinese vaccine supplies. Chinese and Taiwanese officials have accused one another of politicizing pandemic responses, accusations both sides deny.

AFRICA R&D FUNDING Global health experts affiliated with academic, medical, and nonprofit institutions in Africa, the UK, and the US published an open letter to African political and research leaders, calling on them to expand funding and support for research and development capacity on the continent. In 2006, African Union member countries pledged to allocate at least 1% of their GDP to research and development; however, by 2019, the average across the continent remained below 0.5% of GDP—compared with 1.7% globally. The authors emphasized that the COVID-19 pandemic should serve as a wake-up call and inspire investments to avert future health emergencies. They argue that a “glaring lack of leadership” at the national level is driving “the chronic lack of government investment—and regard—for science,” both for COVID-19 and the broader scope of infectious diseases. The absence of political priority has driven an “overreliance on international funding” across Africa, and as COVID-19 forced countries to focus inward, international funding support dwindled. The group previously penned a letter published in Nature Medicine that called on international funders of science and development in Africa to recognize power imbalances, include more Africa-based programs in their investments, and more equitably distribute funding.  

PFIZER-BIONTECH VACCINE STORAGE The US FDA extended the storage period at refrigeration temperatures for the Pfizer-BioNTech SARS-CoV-2 vaccine. The FDA now permits the vaccine to be stored at refrigerator temperatures—2-8°C (35-46°F)—for as long as 1 month. The change applies only to thawed but undiluted vials. Previously, FDA guidance limited refrigerator storage to only 5 days. Earlier this week, the European Medicines Agency (EMA) announced a similar change. Increasing the time that the vaccine can be stored outside of ultra-cold temperatures will ease logistical and operational burdens for this vaccine and can increase the radius of vaccination efforts from centralized ultra-cold freezers.

IMMUNE RESPONSE The human immune system’s production of antibodies is important to fend off infection with SARS-CoV-2, but more evidence is emerging that the production of autoantibodies—which can target a person’s tissues and organs and interfere with other immune system proteins meant to fight infections—can cause more severe or longer-lasting disease in some COVID-19 patients. In a study published in Nature, Yale University researchers detail how these so-called rogue autoantibodies interact with nearly 3,000 human proteins using a novel technology called Rapid Extracellular Antigen Profiling (REAP). The researchers underscored the importance of SARS-CoV-2 vaccination to lower the risk of infection, as autoantibody production was seen in even mild COVID-19 cases, having the potential to cause long-term health consequences. The team’s findings could lead to treatment or prevention strategies for SARS-CoV-2, and the new REAP technology already is being used to identify specific antibody responses for other conditions, including autoimmune diseases, cancer, and neurological illnesses.

VACCINE LOTTERIES In an effort to promote vaccinations, some US states are turning to lotteries to increase interest. In contrast to lotteries to allocate scarce vaccines—such as those proposed and opposed during the pandemic response—these vaccine lotteries are offering the chance for cash payments and other prizes, and eligibility is limited to vaccinated individuals. Under Ohio’s Vax-A-Million lottery, the state government is awarding US$1 million to 1 lucky adult vaccinee each week for 5 weeks. Additionally, the state will award a full 4-year scholarship to 5 vaccinated adolescents aged 12-17 years. Notably, Ohio reported increasing vaccination rates following the program’s announcement—a weekly increase of more than 50%—a potential indication that the program is increasing interest in vaccination. In a similar program, New York state will distribute “scratch-off” lottery tickets to individuals who get vaccinated at some state-run clinics. New York’s “Vax and Scratch” tickets offer a 1-in-9 chance of a prize, ranging from US$20 to US$5 million. Maryland also announced its own vaccine lottery, VaxCash, which will award a total of US$2 million through 40 daily drawings for US$40,000 each and a final grand prize drawing on July 4 worth US$400,000.

OLYMPICS As the 2020 Summer Olympic and Paralympic Games in Tokyo, Japan, rapidly approach, many questions remain regarding the status of the games. According to multiple news media reports, there is growing opposition to the Tokyo Olympics—including among the public, Japan’s health system, and other experts—in light of ongoing struggles to contain the country’s COVID-19 epidemic. Earlier this month, an online petition to cancel the Tokyo Olympics reportedly received approximately 50,000 signatures within the first 24 hours. Recent polling data estimate that 60-80% of the Japanese public oppose hosting the Olympics this summer. The Tokyo Medical Practitioners’ Association recently called on senior Tokyo and Japanese elected officials—including Prime Minister Yoshihide Suga, Tokyo Governor Yuriko Koike, and Olympic Minister Tamayo Marukawa—to cancel the games. Some high-profile athletes also are questioning the safety of holding the Olympics this year.

On May 19, the International Olympic Committee (IOC) provided an update on the situation, emphasizing that it intends to move forward as planned. The IOC statement indicated that the 2020 Summer Olympics have now moved into the final “operational delivery” phase of preparations and that the IOC and Japanese government will “move forward at full speed” to ensure that the Olympics can be hosted in a safe manner, both for the athletes and the Tokyo community. Additionally, the IOC committed to providing additional support for the medical community, including at the Olympic Village and event venues, but it is unclear exactly what that will entail.