Editor: Alyson Browett, MPH

Contributors: Clint Haines, MS; Natasha Kaushal, MSPH; Amanda Kobokovich, MPH; Christina Potter, MSPH; Matthew Shearer, MPH; Marc Trotochaud, MSPH; and, Rachel A. Vahey, MHS.

HEALTH SECURITY MPH & PhD APPLICATIONS The Johns Hopkins Center for Health Security provides scholarships for 2 Masters of Public Health (MPH) students and funds 2 doctoral candidates for the Health Security PhD track at the Johns Hopkins Bloomberg School of Public Health. These funding opportunities are intended for students with an interest in the field of health security, particularly in the context of pandemics and global catastrophic biological risks. We are currently accepting applications for the 2022-23 academic year, which can be submitted via the SOPHAS application system. Applications are due by December 1, 2021. Please click here for more information.

US VACCINE MANDATE The United States’ “vaccine mandate”* was put on hold following a ruling by a 3-judge panel of the 5th US Circuit Court of Appeals. The panel concluded that the mandate, an Emergency Temporary Standard (ETS) issued by the Occupational Safety and Health Administration (OSHA) that generally applies to companies and organizations with 100 or more employees, is “staggeringly overbroad” and does not sufficiently account for variations in working conditions and environments. The panel concluded that the policy should be suspended until the case can be argued in court. Lawyers from the Biden Administration appealed the initial panel ruling, arguing that a delay in implementing the mandate could result in many unnecessary deaths, but the judges upheld the initial decision. In its ruling, the panel described the policy as “fatally flawed” and indicated that lawsuits aiming to overturn it “are likely to succeed on their merits,” which suggests that the White House could face an uphill battle to institute the mandate in January.

The original deadline was scheduled for January 4, 2022, at which time employers would be required to implement weekly testing requirements for unvaccinated employees. Lawsuits have been filed across multiple jurisdictions in opposition to the policy, including by several state governments as well as private companies and religious organizations. Reportedly, these lawsuits may be consolidated into a single jurisdiction, but it is unclear which court could try the case.

AUSTRIA LOCKDOWN On November 15, Austria implemented increased COVID-19 restrictions on unvaccinated individuals that resemble "lockdown" measures implemented early in the pandemic. Last week, Austria announced that negative tests would no longer be permitted as a substitute for vaccination or proof of prior infection required for individuals to enter many public spaces, including restaurants and Christmas markets, or for gatherings of more than 25 people. But the new measures take the protective measures a step further by restricting unvaccinated individuals to their homes except for essential activities such as grocery shopping and going to work. Reportedly, police can perform “spot checks” to verify individuals’ documentation of vaccination or prior infection, and individuals who violate the restrictions could be fined up to €1,450 (US$1,660). The new policies essentially implement restrictions similar to the “lockdowns” previously implemented across Europe, but they will apply only to individuals aged 12 years and older who are not fully vaccinated or recovered from SARS-CoV-2 infection. The affected population constitutes approximately 2 million individuals nationwide.

Austria’s full vaccination coverage is approximately 65%. This is currently lower than many central and western European countries but higher than both the European average and the US. Like multiple other European countries, Austria is in the midst of its largest surge to date. At more than 11,000 new cases per day, the daily incidence is already 50% higher than Austria's previous record and increasing rapidly. The daily incidence has increased by a factor of 6 since mid-October and a factor of 170 since early July. On a per capita basis, Austria’s daily incidence ranks #3 globally. Austria’s daily mortality is also accelerating on a concerning trajectory. Austria is currently averaging 33 deaths per day, which is essentially equal to its second highest peak (April 2021).

In addition to Austria, several other countries in Europe are strengthening COVID-19 restrictions in response to the current surge. Multiple European countries, particularly across the central portion of the continent, are facing their most severe surges to date. Like Austria, several German states are eliminating negative tests as an option to eat indoors at restaurants or bars, which limits those spaces to individuals who are fully vaccinated or recovered from prior infection. The Netherlands is reportedly reinstating a nationwide “partial lockdown” for 3 weeks, which will mandate that nonessential businesses close at 6pm and essential businesses (eg, supermarkets) and restaurants close at 8pm. Additionally, the restrictions limit large indoor gatherings, such as at sporting events and museums. The Netherlands also reinstated a mask mandate on November 6 for public spaces where individuals are not required to show their COVID-19 entry pass, including public transit, retail shops, and colleges and universities.

AFRICA: DIABETES & COVID-19 Since early in the pandemic, evidence has shown that certain underlying health conditions can elevate the risk of severe COVID-19 disease and death. A team of WHO researchers analyzed COVID-19 data from 13 African countries and identified a four-fold increase in the case fatality ratio among COVID-19 patients with diabetes—10.2% compared to 2.5% in other COVID-19 patients. Additionally, the case fatality ratio for individuals with diabetes was twice as high as for individuals with other underlying health conditions (eg, hypertension, heart disease), although individuals with diabetes frequently suffer from multiple comorbidities. Preliminary findings from the study were presented to coincide with World Diabetes Day on November 14.

Diabetes can result in inflammation and decreased blood circulation, which increases the risk of complications from COVID-19 disease. The elevated risk of severe disease and death appears to affect individuals with both type 1 and type 2 diabetes, but the prevalence of type 2 across Africa is increasing rapidly. There are currently an estimated 24 million people across Africa who have diabetes—approximately 1.7% of the total population—but this number is expected to more than double by 2045—to 55 million; 4.0% of the population. The WHO estimates that 70% of affected individuals do not know they have the disease and, therefore, are not aware that they are at higher risk for severe COVID-19. The WHO’s Regional Director for Africa, Dr. Matshidiso Moeti, commented that “fighting the diabetes epidemic in Africa is, in many ways, as critical as the battle against the current pandemic.” African countries continue to struggle to access SARS-CoV-2 vaccines, with only 6.6% of the continent fully vaccinated, compared to the global average of 40%.

PFIZER ORAL ANTIVIRAL Pfizer announced today that it signed a voluntary license agreement with the Medicines Patent Pool, which is supported by the UN, to allow sub-licensed generic pharmaceutical manufacturers to produce its candidate oral antiviral COVID-19 treatment—a combination of ritonavir and a new antiviral, PF-07321332—pending regulatory authorization or approval. Interim analysis from Phase 2/3 clinical trials found that the treatment demonstrated an 89% risk reduction in COVID-19-related hospitalization or death among high-risk adults when administered within 3 days of symptom onset. Under the terms of the agreement qualified manufacturers would be allowed to supply the treatment to 95 countries, including all low- and lower-middle income countries. Pfizer will not collect royalties on sales to low-income nations or other countries covered under the agreement while COVID-19 is classified as a Public Health Emergency of International Concern (PHEIC) by the WHO.

HEART INFLAMMATION France and Germany joined Finland, Norway, and Sweden in recommending that the Moderna SARS-CoV-2 vaccine not be used for individuals under the age of 30 due to increased risk of myocarditis in that age group. Denmark has similarly recommended against offering the vaccine to individuals under the age of 18. French authorities recently emphasized, however, that vaccine effectiveness was slightly higher for the Moderna vaccine than for the Pfizer-BioNTech vaccine, and the Moderna product should be preferentially utilized for individuals aged 30 years or older. The European Medicines Agency (EMA) has authorized the Moderna vaccine for use in individuals aged 12 years and older.

PLANNING FOR ENDEMICITY As we approach the 2-year anniversary of the onset of the COVID-19 pandemic, many around the world are starting to plan for a future in which COVID-19 is an endemic threat. Early on, many public health experts discussed the potential for reaching herd immunity at some point in the pandemic, which could effectively contain community transmission in the absence of other protective measures. At the time, estimates suggested that at least 85% of the population would need to have immunity, whether through natural infection or vaccination. Some scientists are now calling for a shift away from herd immunity as the “end goal” and toward preparing for COVID-10 to become endemic.

The rationale behind this paradigm shift is multi-factored. First, the emergence of more transmissible variants, including the Alpha and Delta variants of concern, has increased the immunity threshold needed to achieve herd immunity. Pairing this reality with low vaccination coverage and stalled vaccination progress in many countries, including the US, shifts the goal of herd immunity even further away. Many scientists calling for this shift recognize that it would be difficult for governments to backtrack on the promise of herd immunity, which could further damage confidence in public health agencies and potentially harm ongoing vaccination efforts. But this process is already in motion in some countries. Last month, for example, White House Chief Medical Advisor Dr. Anthony Fauci acknowledged that elimination of the virus may not be achievable.

Over the past several months, many news media outlets have featured articles with input from public health experts regarding the potential outcomes for the US COVID-19 epidemic. Many of these experts projected that the virus will be a permanent fixture for the foreseeable future. While many unknowns remain that could impact how SARS-CoV-2 spreads in the future, including the potential for new variants and the duration of vaccine effectiveness, now is the time to prepare for the distinct possibility that COVID-19 will transition from a pandemic to an endemic global threat that will require continual investment and response activities in countries around the world.