COVID-19 Situation Report

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EPI UPDATE The WHO COVID-19 Dashboard reports 153 million cases and 3.2 million deaths worldwide as of 5:00am EDT on May 4. The global weekly incidence remained relatively consistent from the previous week at 5.7 million new cases, a decrease of 0.6%. Global weekly mortality increased for the seventh consecutive week, up to 93,253 deaths. This is the highest weekly total since late January 2021 and the fourth highest weekly total to date.

The COVID-19 epidemic in India continues to worsen, setting new global records for total daily incidence. India is currently reporting an average of 378,092 new cases per day. On April 30, India became the first country to report more than 400,000 new cases in a single day, but this was followed by 3 consecutive days of decreasing reports. India has reported more than 300,000 cases for 13 consecutive days, and it is currently reporting nearly 6.5 times the daily incidence in any other country and 47% of the global daily incidence.

Global Vaccination
The WHO reported 1.05 billion doses of SARS-CoV-2 vaccines administered globally, including 564 million individuals with at least 1 dose. The WHO dashboard does not yet include data for daily or weekly vaccinations or fully vaccinated individuals.

Our World in Data reported 1.2 billion cumulative doses administered globally, and the global total continues to increase at 13% per week. The daily doses administered decreased over the past 2 days, down from a high of 20.6 million doses per day on May 1 to 18.7 million. Our World in Data estimates that there are 280 million people worldwide who are fully vaccinated, although reporting is less complete than for other data.

The US CDC reported 32.2 million cumulative cases and 574,220 deaths. Both daily incidence and mortality continue to decrease. Daily incidence is down to 48,164 new cases per day, the lowest average since October 8, 2020. Daily mortality leveled off over the past several days, at approximately 625-650 deaths per day.

US Vaccination
The US has distributed 313 million doses of SARS-CoV-2 vaccine and administered 247 million doses. Daily doses administered* continues to decrease, down from a high of 3.3 million (April 11) to 2.3 million. Approximately 1.3 million people are achieving fully vaccinated status per day.

A total of 148 million individuals have received at least 1 dose of SARS-CoV-2 vaccine, equivalent to 44% of the entire US population and 56% of all adults. Of those, 106 million are fully vaccinated, which corresponds to 32% of the total population and 41% of adults. Among adults aged 65 years and older, progress has largely stalled at 83% with at least 1 dose and 70% fully vaccinated. In terms of full vaccination, 54 million individuals have received the Pfizer-BioNTech vaccine, 44 million have received the Moderna vaccine, and 8.3 million have received the J&J-Janssen vaccine.

As daily vaccinations continue to decline in the US, the impact is not distributed equally between first and second doses**. At the national level, the total doses administered has decreased from a high of 3.26 million doses per day on April 11 to 2.30 million on April 28, a 29% decline over that period. In terms of full vaccination**, the average fell 24% from the peak on April 12—1.77 million doses per day to 1.35 million. In contrast, the average for first doses decreased by half from its peak on April 11—from 1.93 million doses per day down to 965,421. The steep decline in first doses is being masked in the overall national data due to the continued progress by those obtaining their second dose. As we reach 3-4 weeks past the peak in first doses—when those individuals will receive their second doses—we can expect a sharper decline in the number of fully vaccinated individuals each day.

Vaccinations in long-term care facilities (LTCFs) illustrate the time lag between trends in first and full vaccination, but the magnitude of the changes align more closely than we are currently seeing in the overall national data. The overall national LTCF average decreased from a peak of 164,790 doses per day on February 6 to 34,095 on March 6—corresponding to an 80% decrease, or 2.9% per day over that period. In terms of first doses, the daily average began to peak in mid-January. The peak in fully vaccinated individuals started around February 7, nearly 4 weeks later, although the peak lasted only a few days. Following the peak, daily first doses declined 87% between January 31 and March 4, corresponding to 2.7% per day. In terms of full vaccination, the average decreased 84% from February 12 to March 15, also 2.7% per day.
*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 CDC only reports vaccination data for first doses and fully vaccinated individuals. It does not distinguish between fully vaccinated individuals who received 2 doses of the Pfizer-BioNTech or Moderna vaccines and those who received a single dose of the J&J-Janssen vaccine.

US VACCINE HESITANCY A complex combination of challenges faces ongoing vaccination efforts, including barriers to accessing vaccination, vaccine hesitancy, and denialism. Notably, a recent survey conducted by the Kaiser Family Foundation observed declining vaccine hesitancy from December 2020 through March 2021. Overall vaccine hesitancy and opposition—those who would “wait and see,” get vaccinated “only if required,” or “definitely not” get vaccinated—decreased from 64% to 37%. Notably, “wait and see” responses fell from 39% to 17% over that period, indicating increased confidence among those who were uncertain. These data were collected prior to the temporary suspension of the J&J-Janssen vaccine. With vaccine supply now exceeding demand, it is critical to identify and implement effective mechanisms to engage individuals and populations that have not yet been vaccinated. Some people in higher risk professions—including law enforcement, long-term care facility personnel, and healthcare workers in rural areas—as well as in certain rural communities, have lower vaccination coverage. It is also important to continue public education efforts regarding the benefits and timing of second doses to ensure vaccinated individuals develop full protection.

PEDIATRIC VACCINES The US FDA is expected to authorize the Pfizer-BioNTech SARS-CoV-2 vaccine for adolescents ages 12 to 15 late this week or early next week, according to an anonymous federal official. An amendment to the vaccine’s existing Emergency Use Authorization would open the US vaccination campaign to millions more people, reaching a younger population key to raising levels of immunity. If authorization is granted, the US CDC’s Advisory Committee on Immunization Practices (ACIP) would meet soon after to review data and make recommendations for the vaccine’s use among adolescents. According to data from Pfizer released at the end of March, a clinical trial involving 2,260 participants aged 12 to 15 showed the vaccine was well-tolerated and 100% efficacious. The Pfizer-BioNTech vaccine is currently authorized for people ages 16 and older. The companies are conducting clinical trials using the vaccine in people as young as 6 months old. BioNTech Chief Executive Ugur Sahin last week told German magazine Spiegel that the company expects first results in July for the group ages 5 to 12 and in September for the youngest age group. He also said the company will soon submit an application to European regulators to expand the vaccine’s use to adolescents there.

US VACCINE WASTAGE US CDC data suggest two national pharmacy chains are responsible for the majority of wasted SARS-CoV-2 vaccine doses, according to a KHN analysis. Overall, waste has been minimal, with the agency recording 182,874 wasted doses as of late March, out of approximately 189.5 million doses delivered and 147.6 million doses administered at that time. Of those wasted doses, CVS was responsible for about 50% and Walgreens for 21%, a greater total percentage than waste reported by US states, territories, and federal agencies combined*. The Pfizer-BioNTech vaccine accounted for nearly 60% of the wasted doses, possibly because it was the first to be rolled out in December 2020 and initially required storage at ultracold temperatures. CVS said “nearly all” of its reported vaccine waste happened in 2020 during early efforts to administer the vaccines to residents and employees of long-term care facilities. Walgreens did not specify what percentage of doses were wasted during those early efforts. KHN noted that while understanding vaccine waste is important to identify bottlenecks in distribution efforts, reporting has been inconsistent among US states and territories, and the CDC continues to have limited knowledge about how many doses are wasted, where the waste is occurring, and who is responsible. Public health experts warn that vaccine waste could increase in the coming weeks as efforts shift to administer doses among harder-to-reach populations, as perhaps the biggest reason for waste is people not showing up for their shot once a vial is opened.
*CDC data include reporting from 35 states, 17 pharmacies, and three other federal agencies through March 29, likely resulting in underreported waste.

VACCINE INTELLECTUAL PROPERTY U.S. Trade Representative Katherine Tai is expected this week to begin talks at the World Trade Organization (WTO) about efforts to more widely distribute, license, and share SARS-CoV-2 vaccines among countries in need. The White House has been under pressure from lawmakers and others to join an effort to temporarily waive intellectual property (IP) rights on vaccines to facilitate the manufacture of generic versions in low- and middle-income countries. On Sunday during an appearance on NBC News' "Meet the Press," US Senator Bernie Sanders said the US has a “moral responsibility” to help other nations and called efforts to slow the pandemic in “our own self interest.” He called on pharmaceutical companies and the WTO to waive intellectual property rights on vaccines and for the US to donate excess vaccine doses. Surges of COVID-19 cases in India and several other nations are driving what appears to be an increased willingness by the US to consider the issue of IP waivers. 

Experts estimate around 11 billion doses are required to immunize 70% of the world’s population with 2-dose vaccines. To date, around 8.6 billion doses have been ordered, but 6 billion of those are earmarked for high- and upper-income countries. Pharmaceutical companies continue to oppose IP waivers, maintaining they can produce 10 billion vaccine doses this year under the existing IP system. However, some say that number is unattainable. Other critics say IP waivers alone will not help boost vaccine supplies because other drugmakers might not have the personnel, technology, and manufacturing techniques necessary to produce the newer mRNA vaccines. Instead, they encourage pharmaceutical companies to expand their own output, partnering with and licensing their technologies to other companies to support manufacturing expansions.

Another option could be laws passed at the national level. For example, Brazil’s Senate last week passed a bill that would suspend patent protections for SARS-CoV-2 vaccines, diagnostics, and medications during the pandemic. It remains unclear if the country’s lower house of Congress will support the bill. Brazil President Jair Bolsonaro, while facing mounting pressure from public health officials to increase vaccinations, does not support patent waivers. 

INDIA The world continues to watch the grave situation in India, which last week became the first country to report more than 400,000 new COVID-19 cases in one day and continues to record more than 3,000 deaths per day. Experts warn these numbers are underestimates of the true impact of the pandemic in the country.

Prime Minister Narendra Modi has reached out to other nations for assistance, with the US and UK pledging to send supplies. Last week, the US sent a cargo plane full of oxygen cylinders, rapid diagnostic tests, and 100,000 N95 masks to assist India’s efforts, and the UK is planning to send an additional 1,000 ventilators to the country as well as offering technical assistance in the form of an expert advisory group. Over the weekend, US White House Chief of Staff Ron Klain said the US government is looking into ways to distribute more SARS-CoV-2 vaccines to India. Late last month, Prime Minister Modi discussed with US President Joe Biden lifting intellectual property rights for the vaccines, an issue expected to be discussed this week at a World Trade Organization meeting. Domestic and international health experts are urging Prime Minister Modi to implement a nationwide lockdown to ameliorate the impacts of the current surge. After reviewing India’s situation, the US government on April 30 imposed a travel ban for individuals coming from India, with exceptions for U.S. citizens. The Australian government has implemented similar policies, asking even their citizens to remain in India. 

Critics point out the current surge is in stark contrast to the February comments by Prime Minister Modi’s party, the BJP, which declared defeat of COVID-19. They also admonish the government for exporting vaccines to bolster international standing at the expense of its own vaccination rates—less than 2% of the nation’s 940 million adults have been fully vaccinated—and continuing to allow mass religious gatherings and political rallies. Some health experts are decrying the lack of coordinated response, overcrowded cremation grounds, and neglected health system that has left many impoverished and without care for years. 

MODERNA VACCINE & COVAX On May 3, Gavi, the Vaccine Alliance announced that it finalized an advance purchase agreement with Moderna for 500 million doses of its SARS-CoV-2 vaccine to be distributed through the COVAX facility. The agreement will start with 34 million doses in the fourth quarter of 2021, with the remaining doses delivered in 2022. The WHO issued an Emergency Use Listing (EUL) for the Moderna vaccine on April 30, the fourth SARS-CoV-2 vaccine to receive an EUL*. The EUL will facilitate many countries’ efforts to “expedite their own regulatory approval” for the vaccine, and it enables the vaccine to be distributed by COVAX. Additionally, Moderna announced that it is scaling up its production capacity at its Massachusetts (US) facility, with the goal of increasing output by 50% by early 2022, and it revised its 2021 production forecast from 800 million to 1 billion doses. Moderna also is increasing production capacity across its partner facilities, which could increase global production capacity to 3 billion doses per year in 2022.
*The WHO has issued 5 EULs, but 2 of them apply to the AstraZeneca-Oxford vaccine.

COVID-19: VASCULAR DISEASE The spike protein of SARS-CoV-2 helps the virus latch onto and invade healthy cells. It also plays a key role in damaging vascular endothelial cells, according to a study published in Circulation Research. The findings show COVID-19 is a vascular disease and provide a clear link to disease processes that lead to blood clots and stroke, researchers from the Salk Institute and colleagues said. Notably, this is the first research to show the spike protein causes damage on its own, without viral replication. The researchers hope the findings can lead to more effective therapies to interrupt the spike protein’s mechanisms for damaging cells.

INCARCERATED POPULATIONS & VACCINATION As we have covered previously, incarcerated populations are at elevated risk for both SARS-CoV-2 infection and severe COVID-19 disease and death. But as vaccination efforts expand in the US, it is unclear when or how people who are incarcerated will be vaccinated, particularly considering that many states did not include these populations as a priority for vaccination. A commentary published in the New England Journal of Medicine calls for increased attention and priority for vaccinating these populations as well as decarceration to mitigate COVID-19 risk. The authors assert that while vaccination is critical to protecting incarcerated individuals, it may not necessarily be enough. Incarcerated populations are at increased risk for transmission—approximately 5.5 times the risk of infection compared to the general public—and even a high-efficacy vaccine, such as those available for SARS-CoV-2, may not provide sufficient protection to contain outbreaks. In order to effectively contain COVID-19 in incarcerated populations, the authors call for increased decarceration efforts in combination with vaccination. Decarceration could include releasing individuals who do not pose public safety risks, increasing the use of home confinement, reducing the use of pretrial detention, and increasing the use of noncarceral alternatives for individuals whose alleged offenses do not represent “ongoing threats to public safety.”

OLYMPICS The 2020 Summer Olympic Games in Tokyo, Japan, have been surrounded with controversy, but also with innovation, as their start date rapidly approaches in July. With the prospect of tens of thousands of Olympic athletes and team members entering the country, the Japanese public has expressed concerns over holding the Games. A recent public opinion poll showed that 80% of the Japanese public wanted the Games to be either postponed or canceled, as the country undergoes a renewed surge in COVID-19 cases and an increase in COVID-19-related deaths. On April 23, the Japanese government declared its third state of emergency for the Tokyo region. Hospitals and ICU beds are at some of their highest occupancy levels in months. With this backdrop, many are skeptical about the ability of the International Olympic Committee (IOC) to ensure the safety of athletes and the surrounding community.

While some experts argue that it is possible to hold mass gathering events during COVID-19 by following strict precautions, it is unclear whether the Games will be able to meet these requirements. Underlining the public’s reluctance to host the Games, a call from Tokyo Olympic organizers for the Japanese Nursing Association to recruit 500 nurses to volunteer at the event was met with harsh rebukes by Japanese nurses who say they already are desperately needed in their own hospitals and healthcare facilities. Apart from volunteer medical personnel, the corps of 78,000 Olympic volunteers is concerned that they will not be able to enforce safety measures to the levels needed or that they themselves could transmit SARS-CoV-2 to the athletes within the Olympic bubble. While athletes and other Olympic staff will be ordered to remain within the Olympic bubble and undergo daily testing, volunteers must pass in and out of the bubble daily and might not be subject to tests. The IOC remains undecided about whether to allow Japanese spectators into the Games, but a decision is expected to be made in June.