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.
EPI UPDATE The WHO COVID-19 Dashboard reports 247.5 million cumulative cases and 5.01 million deaths worldwide as of November 3. Global weekly incidence and mortality both increased for the second consecutive week. Weekly incidence increased by 4.1% compared to the previous week, and mortality increased by 7.9%. At the current rate, we expect the global cumulative incidence to surpass 250 million cases within the next week.

The global cumulative mortality surpassed 5 million deaths on November 2:
1 death to 1 million- 246 days
1 to 2 million- 116 days
2 to 3 million- 90 days
3 to 4 million- 90 days
4 to 5 million- 115 days

Global Vaccination
The WHO reported 7.0 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of November 5.* A total of 3.9 billion individuals have received at least 1 dose, and 3.0 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations has increased over the past week, up from 25.4 million doses per day on October 27 to 29.0 million on November 1.** The global trend continues to closely follow Asia. Since mid-October, daily vaccinations have increased in Europe and Asia and declined in Oceania. Africa is holding relatively steady near its highest rate, but it is still well below the other continents on a per capita basis. The overall trend in South America is unclear due to large fluctuations over the past several weeks. North America exhibited a spike in daily vaccinations on October 30, as a result of reporting from Mexico.

Our World in Data estimates that there are 3.93 billion vaccinated individuals worldwide (1+ dose; 49.9% of the global population) and 3.08 billion who are fully vaccinated (39.1% of the global population).
*This date might be an error but appears as such on the WHO page.
**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 46.1 million cumulative COVID-19 cases and 746,705 deaths. The current daily incidence average is approximately 68,151 new cases per day and appears to be increasing. The decline in daily incidence has tapered off, and the average has held relatively steady at approximately 71,000 new cases per day since October 26. While this is considerably lower than the January 2021 and September 2021 peaks, it is still higher than the peaks from all other surges. The decline in daily mortality appears to have passed an inflection point and is beginning to taper off as well. The US is currently averaging 1,190 deaths per day, more than the summer 2020 peak, despite the widespread availability of SARS-CoV-2 vaccines.*
*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.

If the US continues at this rate, we expect it to surpass 750,000 cumulative deaths within the next 2-3 days. If the US surpasses this benchmark on November 5:
1 death to 250k- 258 days
250k to 500k- 95 days
500k to 750k- 264 days

US Vaccination
The US has administered 425 million cumulative doses of SARS-CoV-2 vaccines. The daily vaccination trend has increased sharply since October 21, up from 684,000 doses per day to 1.2 million on October 29, the first time above 1 million doses per day since June 13.* Notably, this corresponds to the date on which CDC Director Dr. Rochelle Walensky endorsed the recommendation by the CDC’s Advisory Committee on Immunization Practices (ACIP) to expand eligibility for booster doses. We expect to see some associated increase in daily vaccinations as a result of the recent decision to authorize use of the Pfizer-BioNTech vaccine in children aged 5-11 years.

There are 222 million individuals who have received at least 1 vaccine dose, equivalent to 66.9% of the entire US population. Among adults, 80.2% have received at least 1 dose, as well as 15.2 million children under the age of 18. A total of 193 million individuals are fully vaccinated, which corresponds to 58.1% of the total population. Approximately 69.8% of adults are fully vaccinated, as well as 12.8 million children under the age of 18. Since August 13, 20.6 million fully vaccinated individuals have received an additional or booster dose, including 26.6% 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.

MOLNUPIRAVIR The UK Medicines and Healthcare products Regulatory Agency (MHRA) today authorized the use of the oral antiviral molnupiravir for the treatment of mild-to-moderate COVID-19 in adults with diagnostic-confirmed SARS-CoV-2 infection and who have at least one risk factor for developing severe illness, making it the first country to authorize a COVID-19 treatment that can be administered at home. Molnupiravir, which is branded as Lagevrio in the UK, was developed by Merck and Ridgeback Biotherapeutics. An interim analysis of a Phase 3 clinical trial released last month showed the antiviral reduced the risk of hospitalization or death among COVID-19 patients recovering at home by approximately 50% when given early in their infection. A US FDA advisory committee is scheduled to meet later this month to discuss Merck and Ridgeback’s request for emergency use authorization (EUA) for the drug. In a statement, UK Health and Social Care Secretary Sajid Javid called molnupiravir a “gamechanger for the most vulnerable and the immunosuppressed.” Merck is making efforts to accelerate access to the drug, including entering into advance purchase agreements with individual nations, implementing tiered pricing, and granting voluntary licenses to generic manufacturers and the Medicines Patent Pool. The company expects to produce 10 million treatment courses by the end of this year.

COVAXIN The WHO on November 3 issued an emergency use listing (EUL) for Covaxin, a SARS-CoV-2 vaccine developed by Indian drugmaker Bharat Biotech. The EUL adds an eighth vaccine to a growing list of shots validated by WHO for the prevention of COVID-19 and facilitates Covaxin’s use in many countries that depend on WHO guidance for their regulatory decisions. A WHO-convened Technical Advisory Group (TAG) determined Covaxin meets quality, safety, efficacy, and production standards, and that the benefits of the vaccine far outweigh the risks. Notably, the WHO said current data are insufficient to assess vaccine safety or efficacy in pregnancy. The panel’s decision had been delayed after it sought additional information from Bharat Biotech to assess the vaccine’s risks and benefits for global use. The WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) in early October recommended Covaxin be administered in a 2-dose regimen, 4 weeks apart, for adults aged 18 years and older. The vaccine—which has 78% efficacy after 2 doses—is easily stored, making it very suitable for use in low- and middle-income countries (LMICs) that might lack adequate cold chain storage and distribution capabilities. The listing also paves the way for COVAX to acquire and distribute the vaccine. Covaxin is the first vaccine fully developed and manufactured in India to receive an EUL, and the decision will help millions of Indians who have received the vaccine travel outside the country.

US AUTHORIZES PEDIATRIC VACCINE As expected, US CDC Director Dr. Rochelle Walensky on November 2 endorsed a unanimous recommendation from the CDC’s Advisory Committee on Immunization Practices (ACIP) that children aged 5 to 11 years receive a pediatric formulation of the Pfizer-BioNTech SARS-CoV-2 vaccine. The vaccine is the first to be authorized for that age group in the US, making about 28 million children immediately eligible to be vaccinated. The pediatric vaccine—a 2-dose regimen of 10μg administered 21 days apart, one-third of the dose recommended for individuals aged 12 and older—represents “a turning point” in the nation’s efforts against COVID-19, US President Joe Biden said. According to the CDC, every 1 million doses given to children aged 5 to 11 should prevent about 58,000 COVID-19 cases and 226 hospitalizations in that age group, and could prevent about 600,000 new cases in all age groups through March 2022. Widespread use of the vaccine among children will help slow the spread of the virus, make returning to in-person schooling safer, lower the risk of transmission during upcoming family holiday gatherings, possibly spur recovery in the travel industry, and generally “bring us closer to returning to a sense of normalcy,” acting US FDA Commissioner Dr. Janet Woodcock said in a statement

Concerns remain over whether children in this age group will be at risk of myocarditis and pericarditis—inflammation of the heart muscle or tissue surrounding the heart, respectively—rare but potentially serious adverse events associated with the Pfizer-BioNTech and Moderna mRNA vaccines. The risk is highest among adolescent and young adult males aged 12 to 29 years, and experts agree the risk in younger children likely will be lower. They also concur that the benefits of vaccination in preventing COVID-19 outweigh any risks in young kids, as COVID-19 itself can lead to heart damage and other complications, including multisystem inflammatory syndrome in children, or MIS-C, and long COVID. Already, about 15 million pediatric doses are in place and ready to be administered nationwide. Those parents who are eager to get their children vaccinated—about 27%, according to the KFF COVID-19 Vaccine Monitor—can contact their pediatrician, local pharmacy, or health department to make an appointment. The children’s vaccination program is expected to be fully operational next week, and will soon be updated with available locations. 

US VACCINE MANDATES The administration of US President Joe Biden today announced the details of 2 policies covering more than 100 million workers in an effort to get more people in the US vaccinated against COVID-19. The first rule, issued by the US Department of Labor’s Occupational Safety and Health Administration (OSHA), applies to employers with 100 or more employees and requires them to ensure their workers are either fully vaccinated or undergo weekly testing for SARS-CoV-2, for which employers are not required to pay. The rule also requires employers to provide paid-time off for employees to get vaccinated and compel unvaccinated workers to wear a face mask while at work. Employers who willfully do not comply with the mandate could face fines of up to $14,000 per violation, with the possibility of multiple citations per business. The second rule, issued by the Centers for Medicare & Medicaid Services (CMS) at the US Department of Health and Human Services (HHS), requires all healthcare workers employed at facilities that participate in Medicaid and Medicare—approximately 76,000 facilities nationwide—be fully vaccinated, with no option for testing but allowances for medical and religious exemptions. 

Notably, under the new guidelines, all employees who fall under the OSHA, CMS, or previously announced federal contractor rules are now required to be fully vaccinated by January 4, 2022. The new deadline satisfies requests from businesses to wait until after the holiday season to implement vaccine mandates, expressing concerns over workforce shortages and soaring demand for services. Additionally, OSHA and CMS clarified that the agencies’ new rules preempt any inconsistent state or local laws, such as those banning or limiting employers’ authority to require vaccination, testing, or masking. In rolling out the new policies, the Biden administration clarified its legal authority in implementing the rules, citing OSHA’s responsibility in keeping workers safe and in healthy environments. Nonetheless, legal challenges to the rules are expected in the coming days. 

Last week, 10 US states with Republican leaders filed a joint lawsuit challenging the vaccine mandate for federal contractors, saying the rule is unconstitutional. According to new vaccination mandate protocols published earlier this week, federal contractors will have more flexibility in how they enforce vaccination and testing mandates for workers who remain unvaccinated and who do not seek or receive a valid exemption. Federal contractors who do not comply with the new policies could face losing contracts. Some large federal contractors, including airlines Southwest and American and aerospace engineering company Boeing, have said their employees must abide by the original December 8 deadline to be fully vaccinated or apply for an exemption, although that deadline could be pushed back under the new guidance. According to results from the KFF COVID-19 Vaccine Monitor released last week, 5% of unvaccinated workers say they have left a job because of a vaccine requirement.

J&J-JANSSEN VACCINE A retrospective comparative-effectiveness study published in JAMA Open Network shows a single dose of the J&J-Janssen SARS-CoV-2 vaccine is 74% effective in preventing SARS-CoV-2 infection. The study—conducted by researchers from nference, a US-based software company affiliated with Janssen—examined the electronic health records (EHRs) of Mayo Clinic patients in several US states from February 27 to July 22, 2021, including 8,889 vaccinated and 88,898 matched unvaccinated adults. Both the Alpha and Delta variants were circulating at the time, although the Delta variant emerged toward the end of the study period. Overall, 0.7% of those vaccinated with the J&J-Janssen vaccine contracted SARS-CoV-2 compared with 2.5% of unvaccinated patients, corresponding to an overall vaccine effectiveness of 73.6% and 74.2% beginning 14 days post-vaccination. Vaccine recipients also had a lower risk of hospitalization and ICU admissions, although the groups had no difference in mortality due to a low number of deaths. 

In a research letter published in JAMA Internal Medicine, researchers from the Mayo Clinic compared the age- and sex-specific rates of cerebral venous sinus thrombosis (CVST), a type of blood clot, after vaccination with the J&J-Janssen vaccine with pre-pandemic CVST rates in the general population in Olmsted County, Minnesota (US). CVST remained a rare occurrence following vaccination, with the overall age- and sex-adjusted incidence at 2.34 per 100k person-years between 2001 and 2015, compared with a peak incidence of 8.65 per 100k person-years 15 days post-vaccination, calculated using data from the US CDC’s Vaccine Adverse Event Reporting System (VAERS) collected between February 28 and May 7, 2021. The post-vaccination CVST rate among women was 5.1 times higher compared with the pre-pandemic rate, and the risk was highest among women aged 40 to 49 years, followed by women aged 30 to 39 years. The researchers note that the absolute CVST risk remained low for women in these age groups and the reasons for the higher incidence is unclear.

IMPACT ON LIFE EXPECTANCY & PREMATURE MORTALITY A study conducted by an international collaboration of researchers estimated that the COVID-19 pandemic has contributed to an excess loss of life of more than 28 million years in 2020. The study, published in The BMJ, collected all-cause mortality data for 37 upper-middle- and high-income countries and regions and compared data from 2020 to data from 2005-19. The researchers estimated the decrease in life expectancy and excess years lost—which is similar to “excess deaths,” but accounts for the age at death compared to the life expectancy.

Only Denmark, Iceland, New Zealand, Norway, South Korea, and Taiwan reported lower mortality than expected in 2020, and only New Zealand, Norway, and Taiwan reported an increase in life expectancy. The remaining countries accounted for more than 28 million years of life lost above the expected value, based on the WHO’s standard life table. Notably, the decrease in life expectancy was significantly greater among men than women, with an estimated 17.3 million years lost globally for men and 10.8 million for women. On a per capita basis, the largest excess years lost were observed in Bulgaria (7,260 years/100k population in men; 3,730 in women), Russia (7,020; 4,760), and Lithuania (5,430; 2,640). The researchers estimate 4,350 years lost per 100k population for men and 2,430 for women in the US. The largest decreases in life expectancy were observed in Russia (-2.33 years in men; -2.14 years in women), the US (-2.27; -1.61), and Bulgaria (-1.96; -1.37). This study includes only a small fraction of the global population and omits the vast majority of Asia and South America—including China and India and the entire continent of Africa—so it is highly likely that the actual excess loss of life is much greater than this estimate. Additionally, more deaths have been reported in 2021 than in the first year of the pandemic, so the total impact of the pandemic is likely far greater than 28 million excess years lost.

INDIGENOUS COMMUNITIES The Navajo Nation—the largest indigenous US tribe, with nearly 400,000 members—is experiencing an increase in COVID-19 cases despite a relatively high vaccination rate of about 70%, according to tribal data. Other tribes with high vaccination rates also are seeing a surge in cases, leaving experts and tribal leaders to wonder what is driving the increases. There remain pockets of unvaccinated tribal members, with most in the 17- to 45-year-old range, leading some to conclude that those of working age, many of whom travel off of reservations for employment, could be driving the increase in cases on reservations, where many live in multigenerational housing that can facilitate virus transmission among age groups.

View the impact of COVID-19 on Tribal Nations (New on JHU Coronavirus Resource Center).

Around the globe, indigenous leaders in Australia and New Zealand are concerned that as those countries reopen their borders, COVID-19 incidence will rise in their communities, many of which are remote and have limited access to medical services. And in one isolated area of Peru’s Amazon rainforest, members of the Urarina indigenous community only learned of the pandemic last month, when healthcare workers arrived to vaccinate residents. The trip to vaccinate members of the community took 3 days by boat, highlighting the challenges of vaccinating villagers in remote areas where access to healthcare is sorely lacking.