COVID-19 Situation Report
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.
The COVID-19 Situation Report will not publish next week in recognition of the Thanksgiving holiday. We will resume publication on November 30.
GLOBAL HEALTH SECURITY INDEX On December 8 (9am EST), the Johns Hopkins Center for Health Security and the Nuclear Threat Initiative (NTI) are launching the 2021 Global Health Security Index. The GHS Index is a comprehensive assessment that provides a benchmark for capacities to prevent, detect, and respond to epidemics and pandemics across 195 countries. COVID-19 continues to disrupt lives and livelihoods, stress health systems, and exhaust social protections and government budgets around the world, and it will not be the last global health emergency the world will face. The need for durable national health capacities and political and social environments that foster effective prevention and response measures has never been clearer. Attendees are requested to register in advance, and an agenda will be sent to registrants. The launch event will be conducted in English with translation available in French, Spanish, Arabic, Mandarin, and Russian.
EPI UPDATE The WHO COVID-19 Dashboard reports 254.3 million cumulative cases and 5.1 million deaths worldwide as of November 17. Global weekly incidence increased for the fourth consecutive week, while global weekly mortality rose slightly over the previous week. Weekly incidence increased by 7.84% compared to the previous week, and mortality increased by 1.45%. During the week ending November 14, 3.3 million cases were reported, with Europe accounting for 2.15 million of those, according to the WHO COVID-19 Weekly Epidemiological Update.

Global Vaccination
The WHO reported 7.3 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of November 15. A total of 4.05 billion individuals have received at least 1 dose, and 3.06 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations has decreased over the past week, down to 29.6 million doses per day on November 17 from a recent high of 33.48 million doses per day on November 14.* 

Our World in Data estimates that there are 4.13 billion vaccinated individuals worldwide (1+ dose; 52.41% of the global population) and 3.25 billion who are fully vaccinated (41.23% of the global population). 
*The average daily doses administered may exhibit a sharp decrease for the most recent data, particularly over the weekend, which indicates effects of reporting delays. In an effort to reflect the longer-term trends, the numbers reported here may not correspond to the most recent data.

The US CDC reports 47.2 million cumulative COVID-19 cases and 762,994 deaths. The current daily incidence average is approximately 85,944 new cases per day and appears to be increasing. Daily mortality appears to be holding relatively steady, with the US currently averaging 1,028 deaths per day.*
*Changes in state-level reporting may affect the accuracy of recently reported data, particularly over weekends. In an effort to reflect the longer-term trends, the numbers reported here may not correspond to the most recent dates.

US Vaccination
The US has administered 434.5 million cumulative doses of SARS-CoV-2 vaccines. The daily vaccination trend reached a recent peak at 1.2 million doses on October 29 but has declined slightly to 1.17 million doses as of November 5.* Since CDC Director Dr. Rochelle Walensky endorsed the recommendation by the CDC’s Advisory Committee on Immunization Practices (ACIP) to authorize use of the Pfizer-BioNTech vaccine in children aged 5 to 11 years, an estimated 1 million elementary-age kids have received their first dose, according to a White House official.

There are 228.2 million individuals who have received at least 1 vaccine dose, equivalent to 68.7% of the entire US population. Among adults, 81.7% have received at least 1 dose, as well as 15.3 million children under the age of 18. A total of 195.6 million individuals are fully vaccinated, which corresponds to 58.9% of the total population. Approximately 70.7% of adults are fully vaccinated, as well as 12.9 million children under the age of 18. Since August 13, 31.5 million fully vaccinated individuals have received an additional or booster dose, including 37.3% of fully vaccinated adults aged 65 years or older.
*Due to delays in reporting, estimates for the average daily doses administered are less accurate for the most recent 5 days. The most current average provided here corresponds to 5 days ago.

BOOSTER DOSES The US FDA is expected to expand eligibility for booster shots of mRNA-based SARS-CoV-2 vaccines to all adults who received their second dose at least 6 months prior, as early as today. Both vaccines from Pfizer-BioNTech and Moderna already are authorized as booster doses* for adults aged 65 years and older, adults at risk of severe disease due to underlying health conditions, and adults at risk of disease due to their occupation. According to some estimates, between 30-40% of adults are not eligible for booster doses under current authorizations. The FDA is expected to decide on Pfizer-BioNTech’s and Moderna’s requests to expand their vaccines’ emergency use authorizations (EUAs) without convening the Vaccines and Related Biological Products Advisory Committee (VRBPAC) for discussion. VRBPAC previously rejected initial requests for booster doses for all adults for both vaccines in favor of scaled back authorizations focusing on at-risk populations. There are some concerns that not convening the expert panel could undercut its influence and skip important public discussions about the use of limited global vaccine resources and breakthrough cases. A meeting of the US CDC Advisory Committee on Immunization Practices (ACIP) is scheduled to discuss booster dose efficacy on November 19. Some US states—amid rising COVID-19 cases and frustration with what they see as a delay in federal approval for widespread booster shots—have moved forward to expand eligibility among their populations.

Meanwhile, the UK Joint Committee on Vaccination and Immunization (JCVI) expanded SARS-CoV-2 mRNA vaccine booster eligibility in England from all adults aged 50 and older to all adults aged 40 years and over in an effort to stem new infections, as mainland Europe experiences a large surge. The panel also recommended a second dose of the Pfizer-BioNTech vaccine for adolescents ages 16-17 years, a minimum of 12 weeks after their initial dose. Many in Europe are expecting a difficult winter with high SARS-CoV-2 transmission. But as wealthier nations continue to expand booster dose eligibility to larger swaths of their populations, WHO Director-General Dr. Tedros Adhanom Ghebreyesus last week called SARS-CoV-2 vaccine disparities between high-income and low- and middle-income countries a “scandal.” There are currently 100 countries at risk of falling short of the WHO’s previous goal of fully vaccinating 40% of the global population by year’s end. The WHO claims that this goal could still be achieved if COVAX immediately received 500 million additional doses of vaccine. Experts warn that ongoing global vaccine disparity could lead to the rise of additional SARS-CoV-2 variants with the potential to escape current immunity and vaccine design. 
*The Pfizer-BioNTech dose is the full dose of the prime-boost series (30μg) while the Moderna booster is administered as a half dose of the original 2 shots (50μg vs 100μg).

VACCINE SUPPLY The administration of US President Joe Biden this week announced plans to invest billions of dollars to expand domestic manufacturing capabilities to increase the supply of SARS-CoV-2 mRNA vaccines to low- and middle-income countries (LMICs) by 1 billion doses annually. According to the White House, the funds will go to companies that make mRNA vaccines—including Pfizer, BioNTech, Moderna, and other subcontractors—to expand vaccine infrastructure and capacity, such as facility space, equipment, and staff. Funding will come from the American Rescue Plan that President Biden signed into law in March. So far, the US has pledged to donate at least 1.1 billion doses to LMICs and is requesting that other wealthier countries make similar commitments to address global inequities in vaccine access and distribution. The Biden administration is under increasing pressure to do more to close vaccine access gaps and reach global vaccination goals, and while this latest announcement is welcomed, no agreement has been reached with the pharmaceutical companies and any results in increased manufacturing are not expected until the latter half of 2022. In a US House of Representatives Appropriations subcommittee hearing this week, some lawmakers focused their criticism on Moderna, saying the company has not contributed enough to global vaccine supplies and criticizing it for its reluctance to give credit and share vaccine technology patent rights with government scientists. For its part, the US government has asked Moderna to take steps to help increase vaccine supplies, particularly in Africa—where less than 7% of the population is vaccinated— and with COVAX. It is unclear whether these latest steps by the Biden administration will help quell the growing anger among some activists.

US HEALTHCARE WORKER EXODUS Due to the protracted nature of the COVID-19 pandemic, many US healthcare workers are facing extreme burnout and leaving their posts in droves. About 18% of healthcare workers in the US have quit since the beginning of the pandemic and another 12% have been laid off. The stressors of the current emergency have nearly doubled the risk of burnout among physicians, with up to 75% reporting symptoms of exhaustion, depression, sleep disorders, or post-traumatic stress disorder (PTSD). Healthcare workers also are reporting higher rates of “moral injury,” prolonged moral trauma caused by factors including staffing shortages, a lack of equipment necessary to treat patients, decreasing wages, or feelings of helplessness. The exodus is increasing strain on already pressured healthcare systems as they struggle to fill vacancies and ensure patients' needs are met. Some experts—worried about how to restore and reinvigorate an essential, yet exhausted, workforce—are calling on the federal government for help to address healthcare worker shortages and urging healthcare systems to implement better preventive measures, such as creating chief wellness officer positions to oversee employees’ needs. With so many healthcare workers leaving their jobs, steps must be taken to ensure continuity in patient care and to prevent an implosion of the nation’s healthcare system.

PFIZER ORAL ANTIVIRAL Pfizer submitted a request for emergency use authorization (EUA) of its candidate oral antiviral COVID-19 treatment PAXLOVID—a combination of a new antiviral, PF-07321332, and ritonavir—with the US FDA on November 16. The submission is based on an interim analysis from a Phase 2/3 clinical trial showing 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. If authorized, the medication could help people with COVID-19 recover at home instead of seeking treatment at a hospital, and therefore reduce the strain on the healthcare system. Another similar COVID-19 treatment could be authorized soon, with an FDA advisory committee set to consider an EUA application from Merck and Ridgeback Biotherapeutics for their candidate antiviral drug molnupiravir on November 30. The US government plans to purchase 10 million courses of Pfizer’s treatment at a cost of $5 billion, although the deal is not yet finalized. Both Pfizer and Merck have announced voluntary license agreements with the Medicines Patent Pool to allow sub-licensed generic medicine manufacturers to produce the antivirals for 95 countries, including all low- and lower-middle income countries. However, availability will remain a challenge, as Merck expects to supply around 3 million courses of its treatment before February 2022 and Pfizer expects to supply only about 300,000 courses prior to February. For context, an average of more than 500,000 cases are confirmed daily worldwide. 

ANTIMICROBIAL RESISTANCE An increasing number of countries are pledging to address antimicrobial resistance (AMR), but the COVID-19 pandemic has stalled progress and potentially drove an increase in the prevalence of AMR infections, according to a survey supported by the WHO, Food and Agriculture Organization (FAO), and the World Organization for Animal Health (OIE). Funding reductions, coordination challenges, lack of political commitment, and delays in surveillance are some of the factors impacting the development and implementation of national AMR plans, according to the 163 countries that responded to the Tripartite AMR survey. Part of the problem is a lack of regulatory enforcement in many countries, with only 33% of nations saying they have guidelines and practices in place to improve the use of antimicrobials in healthcare settings.

The Pan American Health Organization (PAHO) this week warned that the overuse of antimicrobial medicines has risen to unprecedented levels during the pandemic and some nations are reporting surges of drug-resistant infections. A large majority of hospitalized COVID-19 patients in the region are given antimicrobials for treatment—90% to 100%—but only 7% have a secondary infection that warranted the use of those drugs. The UK Health Security Agency (UKHSA) also released new data this week showing antibiotic-resistant bloodstream infections fell in 2020 for the first time since 2016. However, the agency cautioned the world could move from one pandemic into another “hidden pandemic” of AMR and warned the number of resistant infections could increase in the coming years if efforts to reduce them are not sufficient. For years, experts have been calling for more investment into ways to address AMR and prepare for potential outbreaks of drug-resistant diseases. World Antimicrobial Awareness Week (WAAW) is recognized November 18-24.

US OVERDOSE DEATHS An estimated 100,000 people died of drug overdoses in a yearlong period ending in April, a record high number spurred by the COVID-19 pandemic and a more deadly drug supply, according to new data from the US CDC. Social isolation and a lack of access to treatment during the beginning of the pandemic likely drove the increase, leading to what US President Joe Biden called “a tragic milestone.” The number of overdose deaths rose 28.5% from the same period a year earlier and has nearly doubled over the past 5 years. Experts warn that even if the COVID-19 pandemic ended today, the increasing use of the synthetic drug fentanyl will continue and urgent steps must be taken to improve access to treatment.