COVID-19 Situation Report
EDUCATIONAL OPPORTUNITIES The Johns Hopkins Center for Health Security provides education and academic training focused on Health Security for students at the Johns Hopkins Bloomberg School of Public Health. For academic year 2022-23, the Center will provide 2 Masters of Public Health scholarships and fund 2 PhD candidates for the Health Security PhD track at the Johns Hopkins Bloomberg School of Public Health. These opportunities are now accepting applications. Find more information and application details here.
EPI UPDATE The WHO COVID-19 Dashboard reports 233.5 million cumulative cases and 4.77 million deaths worldwide as of October 1.

After plateauing since late July and recording slightly fewer than 800 deaths per day, Russia set a new national record this week for daily mortality (816.4), surpassing 800 daily deaths for the first time since the onset of the pandemic. Russia also reported a new single-day record (852 deaths) on September 28. Russia’s daily incidence has been increasing steadily since mid-September, up from approximately 18,000 new cases per day to nearly 22,000 (+22%) over that period. Russia’s highest average daily incidence was 28,500 new cases per day in late December 2020. Russia has fully vaccinated nearly 30% of its population, but daily vaccinations have steadily declined to less than 25% of its record high in mid-July.

Global Vaccination
The WHO reported 6.14 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of September 29. A total of 3.51 billion individuals have received at least 1 dose, and 2.55 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations continues to decline, remaining at or below 30 million doses per day since September 22*. The global trend continues to closely follow the trend in Asia. Our World in Data estimates that there are 3.57 billion vaccinated individuals worldwide (1+ dose; 45.3% of the global population) and 2.65 billion who are fully vaccinated (33.7% of the global population). As we observed previously with 1+ dose coverage, Oceania’s full vaccination coverage (32.3%) is quickly approaching the global average (33.7%). Oceania could surpass this benchmark in the next several days, which would leave Africa (4.4%) as the only continent below the global average. Oceania and Africa were reporting similar full vaccination coverage as recently as late May, but vaccination efforts in Oceania have progressed rapidly over the past several months.
*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 WHO’s Regional Office for Africa (AFRO) announced that only 15 African countries surpassed 10% full vaccination coverage by the target date of September 30. The goal was set by the World Health Assembly in May 2021. Despite accounting for 17% of the global population, only 2% of SARS-CoV-2 vaccine doses administered globally have been in Africa, illustrating the magnitude of ongoing disparities in vaccine access. These countries represent nearly one-third of African nations—compared to nearly 90% of high-income countries—but only about 11% of the African population (1.3 billion). Most of the countries that surpassed the 10% benchmark have small populations, and more than half of all African countries are reporting full vaccination coverage of 2% or less. Seychelles and Mauritius remain at the top of African countries in terms of full vaccination coverage, with 72% and 63%, respectively. Morocco surpassed 50% coverage, Tunisia is reporting 32%, and Cape Verde* is reporting nearly 25%. Vaccination progress is accelerating, however, with monthly distributions increasing 10-fold from June to September. The target by the end of 2021 is 40% coverage, but it is unlikely that more than a small handful of African countries will reach that benchmark.
*Or Cabo Verde.

The US CDC reports 43.3 million cumulative COVID-19 cases and 694,701 deaths. Daily incidence continues to decline at the national level, down to approximately 106,000 new cases per day, which is the lowest average since early August. Daily mortality appears to have passed a peak and started to decline. While the average decreased over the second half of September—down to 1,476 per day—the single-day total for September 29 was more than 2,000 deaths, the third-highest since February. At the current pace, the US could surpass 700,000 cumulative deaths in the next 4 days*. 
*Changes in state-level reporting may affect the accuracy of recently reported data, particularly over the weekend or for states that are reporting mortality by date of death. 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 393 million cumulative doses of SARS-CoV-2 vaccines. The daily vaccination trend continues to decline from the most recent peak on August 29*, from approximately 850,000 doses per day to slightly more than 600,000. There are 214.3 million individuals who have received at least 1 dose, equivalent to 64.6% of the entire US population. Among adults, 77.3% have received at least 1 dose, as well as 14.6 million adolescents aged 12-17 years. A total of 184.6 million individuals are fully vaccinated, which corresponds to 55.6% of the total population. Approximately 66.9% of adults are fully vaccinated, as well as 11.9 million adolescents aged 12-17 years. The CDC recently updated its vaccination tracking dashboard to include booster doses. To date, 4.03 million individuals have received booster doses, the majority of whom are aged 50 years and older (3.35 million), including 2.50 million aged 65 years and 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.

VACCINE MANDATES Evidence from several states and private companies that have implemented SARS-CoV-2 vaccine mandates shows the requirements are working to boost vaccination rates among healthcare workers and other employees. In California, major health systems reported a statewide mandate helped increase vaccination rates among their employees to 90% or more, and in New York, 92% of hospital and long-term care facility employees have received at least 1 dose of vaccine after a mandate took effect on September 27, an increase of about 10 percentage points over 1 week ago. However, hospitals in New York continue to fear staff shortages. New York Governor Kathy Hochul signed an executive order earlier this week aimed at providing short-term relief to healthcare systems impacted by staff shortages, but no facilities have closed since the mandate went into effect. 

Private employer vaccine mandates are becoming more common, but opposition remains. United Airlines announced this week the company would terminate nearly 600 of its 67,000 employees if they continue to refuse to comply with its vaccination requirement. The company, one of the first large US corporations to impose a mandate, said 99% of its workforce is vaccinated and it is working with employees who decide to get vaccinated after the initiation of their termination proceedings. Tyson Foods, which announced a vaccine mandate for employees in August, said this week that 91% of the company’s 120,000 workers are now vaccinated. Tyson’s frontline workers now have until November 1 to get vaccinated or request an exemption, whereas its 6,000 office workers’ deadline is today. Earlier this month, US President Biden announced a federal vaccine mandate for companies with 100 or more employees, to be enforced by the Occupational Safety and Health Administration (OSHA). The US Armed Forces also are requiring vaccinations for active duty personnel. On September 30, a group of 10 plaintiffs, including US Air Force officers and a Secret Service agent, filed a lawsuit seeking an injunction halting federal vaccination requirements, claiming the mandates violate the First Amendment. 

SCHOOL MASK POLICIES Children across the US have had a tumultuous start to the new school year, with more than 900,000 students in 44 states having been affected by COVID-19-related closures between August 1 and mid-September. In 2 new analyses published in the US CDC’s Morbidity and Mortality Report (MMWR), the agency adds to the growing evidence that school mask mandates can help prevent COVID-19 outbreaks in classrooms. Using information from 520 US counties, representing 16.5% of the nation’s total counties, researchers found that pediatric COVID-19 case rates rose more sharply in counties without school mask requirements between July 1-September 4, 2021, when compared with counties that had school mask mandates. The daily case rates remained lower in schools requiring masks even after controlling for covariates. Another analysis examined the association between mask policies and school-associated COVID-19 outbreaks in 2 large Arizona counties that returned to in-person, K-12 schooling in late July/early August 2021. The researchers found that schools without mask mandates were 3.5 times more likely to have a school-related COVID-19 outbreak than those that instituted early mask mandates.

Regardless, legal disputes over mask requirements in schools continue in several states. The US government on September 30 filed a formal statement with the federal district court in Austin, Texas, saying the state’s ban on school mask mandates violates the rights of students with disabilities if it prevents them from safely attending public school in-person. In Iowa, the American Academy of Pediatrics (AAP) and its state chapter filed an amicus brief on behalf of a group of parents and disability rights advocates who filed a federal lawsuit against Governor Kim Reynolds seeking to reverse a law prohibiting school boards from imposing mask mandates. The AAP warned that pediatric COVID-19 cases have risen sharply since the beginning of the school year. Legal proceedings over a law in Arizona banning schools from implementing mask requirements are ongoing, with the state Supreme Court on September 29 setting a briefing schedule to hear arguments. And in Michigan, several local health departments are working to understand language that appears to ban school mask mandates contained within the state’s budget signed this week by Governor Gretchen Whitmer. Although she issued a statement saying a provision that strips state funding from local health departments with school mask mandates is unconstitutional, some districts are rescinding mask requirements over fear of lawsuits. 

VACCINE EFFICACY & EFFECTIVENESS REVIEW Researchers from Johns Hopkins University (US) led a systematic review of the efficacy and effectiveness of existing SARS-CoV-2 vaccines. The study (preprint) evaluated clinical trial and observational data for all vaccines that submitted applications for Emergency Use Listing (EUL) from the WHO by August 15, 2021, including data published in peer-reviewed journals and via preprint servers, government public health and regulatory websites and databases, news media, and manufacturers’ websites. The researchers accounted for differences in study population, case definition, follow-up duration, presence of variants of interest or concern (VOIs/VOCs), epidemiological situation (eg, degree of community transmission), and study design.

The study included 24 vaccine products, including multiple vaccine platform technologies, of which 13 had published Phase 3 clinical trial results or data and 6 had received an EUL from the WHO. The researchers provide an overview of the available data and highlight outstanding gaps, including specific types of analysis (eg, effectiveness in previously infected individuals, efficacy/effectiveness against the Gamma variant) and individual products (eg, Sputnik V. Sinopharm-Beijing). Of the 24 products, Phase 3 clinical trial data were available for 15, but only 9 had been subjected to peer review. The researchers also include a set of figures that illustrate the timing of Phase 3 clinical trials in the context of the daily COVID-19 incidence in various countries, which can affect the quality of study data and the duration of clinical trials. Overall, the vaccines currently in use have demonstrated high efficacy/effectiveness against symptomatic COVID-19 disease, severe disease, and death, and analysis exists that also shows some degree of protection against infection. The results vary between products, but among those with available estimates, the efficacy/effectiveness against symptomatic disease was greater than 65% for all of them (and none of the confidence intervals fell below 50%).

ADDITIONAL VACCINE DOSE SAFETY People who received a third dose of an mRNA SARS-CoV-2 vaccine experienced similar adverse events compared with the second dose, according to a report published September 28 in the US CDC’s Morbidity and Mortality Weekly Report (MMWR). Individuals with moderate-to-severe immune-compromising conditions became eligible for an additional dose on August 12, when the US FDA amended the Emergency Use Authorizations (EUAs) for both the Pfizer-BioNTech and Moderna vaccines. The report’s data come from voluntary V-SAFE registrants who completed check-ins for all 3 doses. According to data from 12,591 vaccinees who recorded information for a third dose from August 12-September 19, 2021, 79.4% reported local reactions compared to 77.6% of individuals after a second vaccine dose. Systemic reactions were reported by 74.1% of people after a third dose compared with 76.5% after the second dose. The most frequently reported symptoms included injection site pain, headache, and fatigue, and most commonly occurred the day after vaccination. Overall, no unexpected patterns of side effects were reported among more than 22,000 individuals who received a third vaccine dose and reported to V-SAFE between August 12 and September 19, and their recorded symptoms were categorized as mild or moderate.  

PREGNANCY & VACCINATION The US CDC issued a Health Alert Network (HAN) advisory recommending urgent action aimed at vaccinating pregnant individuals against SARS-CoV-2. The advisory encourages those who are pregnant, recently pregnant (including lactating individuals), who are trying to become pregnant, or who may become pregnant in the future to get vaccinated. The advisory comes after the highest reported number of COVID-19-related deaths in pregnant people (n=22) occurred in August 2021, the agency noted, with more than 125,000 laboratory-confirmed cases and 22,000 hospitalizations among pregnant people since January 2020. A similar directive was issued last month, but this is one of the agency’s strongest recommendations yet for pregnant individuals. Vaccination coverage among pregnant individuals remains low, at 32%, but varies by race/ethnicity. The lowest rate for fully vaccinated pregnant persons is among non-Hispanic Black individuals at 17%, followed by Hispanic or Latino individuals at 27%. Asian pregnant individuals have the highest rate of vaccination at 47%. Non-Hispanic White individuals and those in the ‘other’ category fall in at 35% and 32%, respectively. 

LONG COVID Ongoing studies are helping to better characterize and determine the prevalence of so-called long COVID, also known as post-acute sequelae of SARS CoV-2 infection (PASC). In a study published in PLOS Medicine, researchers led by scientists with the University of Oxford conducted a retrospective cohort study based on linked electronic health records (EHRs) data from 81 million patients including 273,618 COVID-19 survivors, primarily in the US, and included 114,449 patients with influenza as a control. The researchers found that nearly 37% of COVID-19 patients studied reported having at least 1 or more features of long COVID between 3 and 6 months after their initial diagnosis, a higher percentage than the 10%-30% reported in previous studies and significantly higher than after influenza. The most commonly reported symptoms included abnormal breathing; fatigue; chest, throat, or other pain; headache; abdominal symptoms; and anxiety or depression. While lingering symptoms occurred more frequently among people who had more severe acute COVID-19, including those who were hospitalized, and older individuals, the researchers stressed that people who had mild disease and children and young adult survivors also experienced long COVID

In a study published September 29 in JAMA Network Open, researchers interviewed 2,433 COVID-19 patients who were discharged from 2 hospitals in Wuhan, China, between February 12 and April 10, 2020. Notably, 45% of patients reported at least 1 symptom at 1-year follow-up, with the most common symptoms being fatigue, sweating, chest tightness, anxiety, and muscle pain. Patients who experienced more severe COVID-19 cases and who were older were more likely to have at least 3 lingering symptoms. In yet another study, posted to the preprint server medRxiv, researchers found that SARS-CoV-2 infection, even mild cases, could reduce gray matter thickness in the brain, possibly contributing to long-term neurological damage. Taken together, the studies highlight the fact that the health impacts from COVID-19 extend far beyond the acute phase, and contribute more knowledge about the risk of long COVID, for both unvaccinated and vaccinated individuals, that could help identify those at greatest risk, plan necessary ongoing health services support, and help develop treatments for the condition.

COVAX 2022 STRATEGY The governing body for Gavi, The Vaccine Alliance, met this week to discuss its primary objective of expanding routine immunization but also welcomed participation of the Co-Chairs of the AMC Engagement Group and the COVAX Shareholders’ Council to assess the vaccine initiative’s “critical challenges” and make progress toward developing the 2022 COVAX strategy. The Co-Chairs and Board members expressed support for COVAX’s urgent call to lift all SARS-CoV-2 vaccine export restrictions; manufacturers to deliver on their commitments to COVAX with transparency on schedules and supply chains; countries with high vaccination coverage rates to relinquish their place in line to allow more vaccine supply to go to COVAX and low- and middle-income countries (LMICs) in need; and global donations to be expanded, fast-tracked, and standardized. With more than 311 million doses shipped, the Board highlighted the importance of quickly scaling up vaccine deliveries, as supply is significantly increasing. Echoing the results of the meeting, Gavi Board Chair José Manuel Barroso, a former president of the European Commission, writing in an opinion piece published in POLITICO Europe on September 30, called on wealthy countries’ governments and manufacturers to do more to “close today’s unacceptable gap in vaccine equity.”

US PANDEMIC PREPAREDNESS More than 20 stakeholder organizations this week sent a letter to the US Congress urging them to provide at least US$16 billion in pandemic preparedness funding included in a version of the Build Back Better Act passed by the US House Committee on the Budget. The funding would go toward efforts to improve the country’s pandemic defenses, including the ability to produce diagnostics, vaccines, and treatments for known and future biological threats; track and monitor potential outbreaks; provide sufficient medical supplies; improve indoor air quality; and build a stronger public health infrastructure. But as journalist Ed Yong highlights in a piece in The Atlantic, much more will have to be accomplished in order to protect the nation from the next pandemic, or natural disaster, or climate change impact. Most importantly, those efforts must include improving equity—in education, labor wages, food security, healthcare access, and other social factors—in order to buffer against the next crisis.

SOCIAL MEDIA & VACCINE MISINFORMATION YouTube on September 29 announced the video platform is expanding its medical misinformation policies, including new guidelines for any vaccine that is approved and confirmed to be safe and effective by local and global health authorities. Since last year, the Google-owned company has removed more than 130,000 videos for violating its COVID-19 vaccine policies, but the new guidelines extend beyond the current pandemic and apply to videos claiming proven vaccines are not effective; including misinformation about vaccines’ ingredients; or claiming that vaccines cause autism, cancer, or infertility, or that they contain tracking devices. YouTube also announced it is removing several channels associated with high-profile anti-vaccine proponents, including Joseph Mercola, Sherri Tenpenny, and Robert F. Kennedy Jr. There are exceptions to the rules, as YouTube will continue to allow content providing scientific discussions on vaccine policies, clinical trials, or historic vaccine successes and failures, as well as testimony about personal experiences with vaccines, as long as it doesn’t spill over into advocating against vaccines. The expanded guidelines mark a turning point for YouTube, which has shown some hesitancy against broadening its policing of content, and brings its policies more in line with other social media platforms, including Facebook and Twitter. While many of the so-called Disinformation Dozen continue to have active accounts across social media platforms, misinformation researchers hope YouTube’s policies will help staunch the flow of false vaccine information, as videos from the channel often lead to viral posts on Facebook and Twitter. Some researchers warn that anti-vaccine activists will simply move to other, newer platforms that have fewer restrictions, including Telegram or Gab.

ANTIVIRAL TREATMENT & PREVENTIVE TRIALS Pharmaceutical companies are pushing to develop more effective, easily administered therapeutics for COVID-19, some of which are being studied for the prevention of SARS-CoV-2 infection. This morning, Merck announced that its investigational oral antiviral molnupiravir, which is being developed with Ridgeback Biotherapeutics, significantly reduced the risk of hospitalization or death among non-hospitalized adult COVID-19 patients with mild-to-moderate symptoms who were considered high risk due to other health conditions such as obesity, diabetes, or heart disease. Among patients who took a 5-day course of the drug, 7.3% (28/385) were hospitalized or died compared with 14.1% (53/377) of patients who took a placebo, according to the interim analysis of the Phase 3 MOVe-OUT trial. Merck said it will file an application for Emergency Use Authorization (EUA) with the US FDA as soon as possible, as well as filing applications for marketing with regulatory agencies globally. Over the summer, the US government announced plans to purchase 1.7 million courses of molnupiravir from Merck for about US$1.2 billion, pending US FDA authorization or approval. If authorized, the drug would become the first oral medication available to treat COVID-19.

Pfizer announced on September 27 that it has begun a large Phase 2/3 clinical trial—named EPIC-PEP (Evaluation of Protease Inhibition for COVID-19 in Post-Exposure Prophylaxis)—to evaluate its investigational oral antiviral drug candidate PF-07321332, administered with a low-dose of the antiviral ritonavir, for the prevention of SARS-CoV-2 infection. The global trial is a randomized, double-blind, placebo-controlled study that intends to enroll up to 2,660 healthy adult participants who live in the same household as someone with confirmed, symptomatic COVID-19 disease. In a different study, Pfizer is testing the experimental antiviral among non-hospitalized, symptomatic adult COVID-19 patients. 

Swiss pharmaceutical company Roche also is reportedly developing similar treatments for COVID-19. So far, the FDA has approved only Gilead’s antiviral Veklury (remdesivir) for the treatment of COVID-19 in hospitalized patients. However, the drug’s intravenous or injection administration presents challenges to widespread use, so the authorization or approval of an effective orally administered COVID-19 treatment or preventive could help to lower the burden of patients on hospitals.

WINTER OLYMPICS Less than 2 months from the end of the 2020 Summer Olympic Games—which took place a year late due to the COVID-19 pandemic—organizers are formulating pandemic countermeasures for the upcoming 2022 Olympic and Paralympic Winter Games, set to take place in February and March in Beijing. This week, the International Olympic Committee announced some spectators will be allowed to attend events, but only if they are from mainland China. Athletes and team members will not be required to be fully vaccinated to attend, but those who are not will be subject to a 21-day quarantine upon arrival in Beijing. Additionally, an Olympics bubble, or “closed-loop management system,” including required daily testing, will be established like it was in Tokyo in order to help improve safety. During this summer’s Games in Tokyo, at least 430 people tested positive for SARS-CoV-2, including athletes, officials, journalists, employees, contractors, and volunteers.