COVID-19 Situation Report
EPI UPDATE The WHO COVID-19 Dashboard reports 235 million cumulative cases and 4.80 million deaths worldwide as of October 4. Global weekly incidence and mortality continue to decline, for the fourth consecutive week. Weekly incidence decreased by 9% from the previous week, and mortality fell by 4%. All WHO regions are exhibiting steady declines over the past 3-11 weeks, with the exception of Europe, which has held relatively steady at approximately 1.1 million new cases per week since mid-July.
The WHO dashboard indicates that October 4 reporting is delayed for a number of countries in the Region of the Americas.

Global Vaccination
The WHO reported 6.19 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of October 3. A total of 3.53 billion individuals have received at least 1 dose, and 2.58 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations continues to decline steadily, down from the most recent high of 42 million doses per day on August 30 to 27 million on October 3—decreasing by more than one-third over that period*. The global trend continues to closely follow the trend in Asia. Our World in Data estimates that there are 3.61 billion vaccinated individuals worldwide (1+ dose; 45.8% of the global population) and 2.69 billion who are fully vaccinated (34.2% of the global population). Oceania’s full vaccination coverage (34.20%) surpassed the global average (34.19%), which leaves 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 US CDC reports 43.6 million cumulative COVID-19 cases and 700,176 deaths. Daily incidence continues to decline, down to approximately 103,000 new cases per day, which is the lowest average since early August. Daily mortality appears to have passed a peak and started to decline; however, the trend has not been consistent. The average daily mortality declined from a peak of 1,744 deaths per day on September 15 to 1,460 on September 28 before jumping back up to nearly 1,500 on September 29. The US reported 2,025 deaths on September 29, the third-highest single-day total since mid-to-late February*.

The US surpassed 700,00 cumulative deaths on October 3:
1 death to 100,000: 110 days**
100k to 200k: 109 days
200k to 300k: 89 days
300k to 400k: 33 days
400k to 500k: 33 days
500k to 600k: 122 days
600k to 700k: 112 days

With 87 days still remaining in 2021, the US could surpass 750,000 cumulative deaths by the end of the year. The US reported 371,911 total deaths in 2020, which would make 2021 even more deadly than the first year of the pandemic, despite the availability of multiple highly effective vaccines.
*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.
**The CDC reports 247 cumulative deaths on February 3, 2020, the first date with available mortality data.

US Vaccination
The US has administered 397 million cumulative doses of SARS-CoV-2 vaccines. The daily vaccination trend increased over the past several days, up from fewer than 600,000 doses per day on September 23 to more than 750,000 on September 29—a 25% increase over that period. Even with expected delays in reporting, it appears that the average is poised to continue increasing. The averages for September 30 and October 1 are already more than 784,000 and 777,000, respectively, despite being within the 5-day window during which we expect reporting delays*. The timing of this increase corresponds to the FDA authorization and CDC recommendations regarding third doses of the Pfizer-BioNTech vaccine for many adults.

There are 215.5 million individuals in the US who have received at least 1 dose of SARS-CoV-2 vaccine, equivalent to 64.9% of the entire US population. Among adults, 77.7% have received at least 1 dose, as well as 14.7 million adolescents aged 12-17 years. A total of 185.8 million individuals are fully vaccinated, which corresponds to 56.0% of the total population. Approximately 67.3% of adults are fully vaccinated, as well as 12.0 million adolescents aged 12-17 years. A total of 5.7 million “booster” doses (ie, third doses of the Pfizer-BioNTech or Moderna vaccine) have been administered nationwide**. Adults aged 50 years and older have received 4.8 million “booster” doses, including 3.7 million among adults 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.
**The second dose of the Pfizer-BioNTech, Moderna, AstraZeneca-Oxford, and other 2-dose vaccines is technically a booster dose as well (ie, part of a prime-boost regimen), but here, we are specifically addressing additional “booster” doses administered beyond the original full vaccination regimen.

J&J-JANSSEN BOOSTER DOSE Johnson & Johnson (J&J) today announced it has submitted data to the US FDA for an Emergency Use Authorization (EUA) amendment to allow for a booster dose for its SARS-CoV-2 vaccine, developed in collaboration with Janssen Pharmaceuticals. In a press release, J&J reported that Phase 3 clinical trial data indicate that a booster dose administered 56 days after the first dose provided 94% protection against moderate-to-severe COVID-19 and 100% protection against severe disease. The booster dose request follows a previous report that hundreds of thousands of J&J-Janssen vaccine doses in the US will soon expire. The federal government shipped 22 million doses to states in need, but only 15 million were administered. Several independent experts expressed concern at a meeting of the CDC’s Advisory Committee on Immunization Practices (ACIP) in September that J&J-Janssen vaccine recipients were being left behind in discussions over booster doses, as the focus has been on the Pfizer-BioNTech and Moderna mRNA vaccines. J&J-Janssen now joins Pfizer-BioNTech and Moderna as the third vaccine provider to request an EUA for a booster dose. The FDA’s Vaccine and Related Biological Products Advisory Committee (VRBPAC) is scheduled to discuss the possible EUA amendments, as well as vaccines for younger children, on October 15. 

EU BOOSTER/ADDITIONAL DOSES The European Medicines Agency (EMA) on October 4 issued recommendations for third doses of the SARS-CoV-2 vaccines from Pfizer-BioNTech (Comirnaty) and Moderna (Spikevax). The EMA’s Committee for Medicinal Products for Human Use (CHMP) differentiated between additional doses—which they recommended for people with severely compromised immune systems who had received either vaccine, given at least 28 days from the second dose—and booster doses—which can now be considered for people aged 18 years and older who received the Pfizer-BioNTech vaccine at least 6 months after their second dose. The committee said it will continue to evaluate data on booster doses of Moderna’s vaccine. Specific recommendations on booster doses will be left up to national-level public health bodies, the CHMP noted. Some EU countries—including France and Germany—already are administering additional doses to people with immunocompromising conditions, whereas few EU countries—such as Hungary—are offering booster doses to all adults. The regulator also warned of the risk of inflammatory heart conditions and other “very rare” side effects following a third dose of vaccine, noting they will continue to collect and examine safety and effectiveness data. 

On the same day, the WHO updated its interim statement on booster doses, outlining the differences between booster and additional doses, as well as factors to be considered in the administration of booster doses. The statement underscores WHO’s position that the introduction of booster doses “should be rigorously evidence driven” and limited to populations in greatest need. The WHO continues to discourage broad-based booster dose administration, as it risks worsening global inequities in vaccine access. 

US VACCINE MANDATES Vaccine mandates continue to take effect across the US for numerous populations, and could be part of the reason for an increase in daily vaccinations over the past several days. New York City’s requirement that public school employees be vaccinated began October 4, with Mayor Bill de Blasio announcing 95% of full-time Department of Education employees are at least partially vaccinated. US Supreme Court Justice Sonia Sotomayor on October 1 denied a request for an emergency injunction of the policy made by 4 teachers and teaching assistants who claim the city's policy violates their constitutional rights. The decision by Justice Sotomayor, who offered no explanation, echoes one made by Supreme Court Justice Amy Coney Barrett in August when she turned down a request to block Indiana University’s vaccine mandate for students. With about 1,000 colleges and universities nationwide requiring vaccinations for students and staff, some students have decided to withdraw from school rather than get vaccinated, even as other cases are pending. 

On October 1, California became the first US state to require SARS-CoV-2 vaccination for all eligible public and private schoolchildren, similar to inoculations for other diseases. Governor Gavin Newsom announced the mandate will take effect during the first school term following the US FDA’s full approval of a vaccine for children aged 12 and older—possibly as soon as January 2022—with vaccinations for younger children to be phased in after approval for their age group. Notably, because the requirement is being implemented through a regulatory process, the rule allows for exemptions due to personal, medical, and religious beliefs; however, the state legislature and governor could later approve a law to eliminate the personal-belief exemption, and individual school districts are able to implement their own vaccine mandates sooner than statewide requirements.

The White House is pushing more US airlines to require vaccination for their employees. Many large US airlines hold federal contracts and therefore are required to vaccinate their employees under rules implemented last month under executive order. American Airlines, JetBlue Airways, and Alaska Airlines all announced last week that they would implement vaccine mandates as early as December 8, the deadline for federal contractors to be vaccinated. United Airlines, one of the first large US companies to announce strict vaccine requirements for its employees, said only about 300 of the airline’s 67,000 US-based staff have not yet complied with the rule and about 2,000 have applied for exemptions. Workers in other industries—including healthcare workers, firefighters, and other first responders—are being fired or suspended for missing vaccine mandate deadlines or are seeking exemptions. Meanwhile, the chronically understaffed US Occupational and Safety Administration (OSHA) is preparing to enforce federal mandates for about 8 million worksites nationwide with only 1,850 federal and state inspectors. Nevertheless, it appears vaccine mandates are convincing more people to get the shots.

COVAX The COVAX facility—with its goal of equitable global vaccine acquisition, allocation, and distribution—this month will for the first time send SARS-CoV-2 vaccines only to countries with the least amount of coverage. The policy represents a shift in dose allocation, as COVAX previously distributed doses proportionally to countries based on population size, not need. According to Our World in Data, only 2.3% of people in low-income countries have received at least one dose of SARS-CoV-2 vaccine, placing the global goal of 40% vaccination coverage far out of reach. Under the new plan, about 75 million doses of the Pfizer-BioNTech, AstraZeneca-Oxford, Moderna, J&J-Janssen, and Sinopharm vaccines will be distributed to 49 countries most in need this month.

While many experts welcomed the policy shift, some argued that the strategy should have been adopted at COVAX’s launch. Despite the WHO’s call for a moratorium on booster shots to ensure equitable global vaccine access, the US and several other countries have begun administering additional doses. Vaccine manufacturers maintain that there are enough shots for everyone, with about 1.5 billion doses being produced each month. The concern now, they say, is that many doses in wealthy nations are sitting unused rather than being redistributed to countries in need.                             

TRAVEL REQUIREMENTS COVID-19-related travel restrictions and requirements are becoming increasingly confusing worldwide, with each nation implementing various rules pertaining to whether travelers need to be vaccinated, are required to quarantine, or can even enter a country. England’s new guidance came into force on October 4, replacing its previous “traffic light” system with a single “red list” of countries, from which only British or Irish nationals or those with UK residency will be permitted to enter. While the most recent iteration of the rules eliminates pre-travel testing for vaccinated individuals arriving from non-red list countries, a maze of requirements—including pre-departure and post-arrival testing, mandatory quarantining, and completing a locator form—remains, largely determined by a traveler’s vaccination status. Reportedly, the red list of countries is expected to be trimmed from 54 to 9 later this week. The travel guidance continues to not recognize the Indian version of the AstraZeneca/Oxford SARS-CoV-2 vaccine, known as Covishield, and India on October 1 implemented reciprocal restrictions on all British travelers, including pre-departure and post-arrival testing and quarantines.

Beginning November 1, New Zealand will allow only fully vaccinated individuals aged 17 years and older to enter the country from abroad, although travelers will still be required to show a negative pre-departure test result and quarantine for 14 days upon arrival. Beginning in February 2022, Air New Zealand, the nation’s flagship airline, will require all passengers on international flights to be vaccinated, with few exceptions. Australian Prime Minister Scott Morrison announced last week that Australia will allow international travel for fully vaccinated citizens and permanent residents beginning in November, with a required 7 day quarantine upon entry. The Australian government continues to work on plans to allow foreign nationals to visit. The borders of both New Zealand and Australia have been closed since March 2020, and both nations recently have experienced an increase in COVID-19 cases. Japan and Argentina also recently announced changes to their travel rules. 

US HEALTHCARE SYSTEM STRAIN Healthcare workers in the US have been battling COVID-19 for over 18 months and continue to experience the crippling impacts of chronic stress, fatigue, and burnout, which in some cases is impacting patient care. A recent influx of COVID-19 patients in several regions has strained healthcare facilities and forced some to implement crisis standards of care. At the beginning of October, 20 out of 31 healthcare facilities in Alaska activated emergency crisis protocols that allow them to ration care in order to cope with the burden of COVID-19 cases. Several factors—including a lack of supplies, resources, bed space, and a shortage of healthcare workers—led the state to implement the protocols, leaving decisions about prioritizing treatment up to doctors. The situation led Alaska Governor Mike Dunleavy to request additional healthcare worker support from the US government at the end of September.

Similarly, intensive care units (ICUs) in New England are filling amid a shortage in healthcare workers and an increase in COVID-19 cases due to the Delta variant, largely among unvaccinated populations. Despite having some of the highest vaccination coverage rates in the US, public health officials continue to plead with the thousands of people who remain unvaccinated and vulnerable to SARS-CoV-2 infection. Notably, some hospital systems in the region are seeing almost 20 times the number of COVID-19 patients than during June 2020 and have no open ICU beds.

MULTICOMPONENT PREVENTIVE STRATEGIES Youth camps in the US that use multicomponent COVID-19 preventive strategies—including high vaccination rates among staff and campers, pre-arrival and frequent onsite testing, podding, masking, physical distancing, focusing on hand hygiene, and wastewater surveillance—provide a safer environment for attendees and counselors, according to 2 studies published last week in the US CDC’s Mortality and Morbidity Weekly Report (MMWR). One study reported on 9 US overnight camps across the country that occurred during June through August 2021 and implemented multiple prevention strategies, including having a vaccination rate over 93% among eligible persons aged 12 years or older. Among 7,173 staff members and campers from 50 states, 13 countries, and US military overseas bases who took tens of thousands of rapid antigen and RT-PCR tests over the 2021 season, 9 COVID-19 cases were detected at 4 camps, and no secondary transmission was detected.

Another study examined COVID-19 outbreaks at 14 overnight and 14 day camps in Louisiana during June and July 2021, as the Delta variant became predominant. During the study period, 321 camp-associated cases were identified, an increase over the number of cases observed in Louisiana camps the previous year. The researchers note the study period also coincided with an “apparent underutilization” of preventive measures such as vaccination, masking, and physical distancing. Together, the studies provide support for the CDC’s guidance that eligible children be vaccinated and highlight the importance of simultaneously using multicomponent strategies to reduce the risk of and prevent SARS-CoV-2 transmission at camps and other youth-focused settings such as schools.

NEW ZEALAND New Zealand announced an end to its zero tolerance approach to COVID-19 and acknowledged that it will need to start a phased reopening through lessening restrictions and increasing vaccination rates. The restrictions in Auckland, which have been in effect for 7 weeks, will gradually ease in 3 stages. The first stage, alert level 3, will allow people to gather outdoors with members from no more than 2 households and 10 individuals. Early childhood education centers will reopen and people will be able to take part in certain outdoor recreational activities. The second stage, alert level 2, will allow the reopening of retail stores, pools, and zoos—with certain preventive measures—and the number of individuals who can meet outdoors will increase to 25. The third and final stage, alert level 1, will allow for the opening of restaurants and hairdressers with some public health interventions and limits on seating, and the number of individuals who can meet outdoors will increase to 50. 

The zero tolerance approach to COVID-19 worked well for New Zealand until recently, when the Delta variant proved impossible to eliminate despite intensive lockdowns. New Zealanders were able to live restriction-free for the majority of the pandemic and the government’s strategy was viewed in a highlighly favorable light. But recently, public opinion began to shift when thousands of people protested the restrictive public health measures. Prime Minister Jacinda Ardern stated that strict lockdown measures will be eased once the nation reaches full vaccination for 90% of the eligible population. According to the Ministry of Health, 79% of the eligible population has received at least one dose, but efforts to fully vaccinate the population could take months due to difficulties convincing the remaining 20% to get the shots. 

PORTUGAL More than 85% of Portugal’s total population is fully vaccinated against SARS-CoV-2, among the world’s leaders in vaccinations. In fact, about 98% of those eligible for vaccines—those aged 12 and older—are fully vaccinated, and the country has experienced a sharp decline in the number of new COVID-19 cases since the end of August. The number of COVID-19-related deaths are down too, although there has been a slight increase in the 7-day average since the beginning of October.* The government this week lifted most COVID-19 restrictions. However, some health officials are concerned a winter surge in cases is possible, including more hospitalizations, as many people—and especially the elderly—received their vaccinations more than 6 months ago. Several studies, including one conducted in Portugal, provide evidence that a drop in vaccine effectiveness is possible over time, particularly in older populations. The country may soon begin administering third vaccine doses to older people and those with compromised immune systems, with a goal of reaching 100% of them by the end of the year.

Many credit the country’s success to the leadership of Vice Admiral Henrique Gouveia e Melo, a former submarine squadron commander who led a nationwide vaccination campaign that faced many of the same misinformation and hesitancy challenges as other countries. Admiral Gouveia e Melo credited the campaign’s success to consistent and trustworthy communication from elite military personnel, who were distanced from politics, and the use of military-style language that rallied the nation onto a war footing. As the country returns to a sense of normalcy, the remainder of the world will be eagerly watching.
*Due to delays in reporting, estimates for the average daily deaths likely are less accurate for the most recent 5 days.

NEXT-GENERATION MASKS Masks and respirators have played an essential role in the global COVID-19 response; however, the ubiquitous disposable medical/surgical masks and N95 respirators used by healthcare workers have not appreciably improved since the mid-1990s, and the non-medical masks in wide public use during the pandemic are not governed by associated quality or design standards. The Johns Hopkins Center for Health Security published a report outlining recommendations for the US government regarding improvements to mask quality and supply and developing a sustainable market for these products. The approach outlined in the report touches on the development, manufacturing, and stockpiling of masks and respirators for healthcare workers, the non-healthcare workforce, and the broader US public. The report, Masks and Respirators for the 21st Century: Policy Changes Needed to Save Lives and Prevent Societal Disruption, describes a confluence of factors that are hindering the mask market, including industrial inertia, lack of competition, complacent consumers, regulatory barriers, supply chain limitations, an uncertain market, and the absence of US government policy.

The report calls for efforts to improve the design and quality of masks and respirators, including their degree of protection, fit and wearability, and durability and reusability. The report also focuses on the importance of developing a robust supply chain that could mitigate the need for and limitations of stockpiling and provide reliable supply capacity during emergencies. The authors also list specific actions for the US government, including expanding the use of reusable products (eg, elastomer-based respirators), updating federal procurement and stockpiling systems, funding the development of improved products and manufacturing capacity (eg, through BARDA), and encouraging the routine use of masks for other respiratory diseases (eg, seasonal influenza).