COVID-19 Situation Report
EPI UPDATE The WHO COVID-19 Dashboard reports 229.9 million cumulative cases and 4.71 million deaths worldwide as of September 23. Global weekly incidence decreased by 5.9% compared to the previous week, and mortality fell by 3.1%.

Global Vaccination
The WHO reported 5.87 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of September 23. A total of 3.36 billion individuals have received at least 1 dose, and 2.43 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations continues to decline, down to fewer than 28 million doses per day*. The global trend continues to closely follow Asia. Our World in Data estimates that there are 3.46 billion vaccinated individuals worldwide (1+ dose; 44.13% of the global population) and 2.54 billion who are fully vaccinated (32.24% 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 42.5 million cumulative COVID-19 cases and 680,688 deaths. The US has passed a peak in terms of daily incidence. The most recent high was 160,200 new cases per day on September 1, and the trend began to decline slightly before the Labor Day holiday weekend. The current average is approximately 121,532 new cases per day and appears to be decreasing. Daily mortality continues to increase slowly, now up to 1,556 deaths per day—the highest average since February 27. If the daily incidence peaked on September 1, mortality could peak in the next week or so*. 
*Changes in state-level reporting may affect the accuracy of recently reported data, particularly over the weekend. In an effort to reflect the longer-term trends, the numbers reported here may not correspond to the most recent dates.

The US surpassed 675,000 cumulative deaths on September 20, which makes the COVID-19 pandemic more deadly than the 1918 influenza pandemic in the US. Notably, the US population in 1918 was less than one-third of the current population (approximately 105 million), so the COVID-19 mortality is much lower on a per capita basis.

US Vaccination
The US has administered 388 million cumulative doses of SARS-CoV-2 vaccines. The daily vaccination trend continues to decline from the most recent peak on August 29*, worrying some officials as flu season approaches. There are 212.6 million individuals who have received at least 1 dose, equivalent to 64.0% of the entire US population. Among adults, 76.7% have received at least 1 dose, as well as 14.4 million adolescents aged 12-17 years. A total of 182.6 million individuals are fully vaccinated, which corresponds to 55% of the total population. Approximately 66.2% of adults are fully vaccinated, as well as 11.6 million adolescents aged 12-17 years.
*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.

US BOOSTER DOSES Third doses of the Pfizer-BioNTech SARS-CoV-2 vaccine are now recommended for certain US populations at least 6 months after their primary 2-dose series. Following the US FDA’s authorization of third doses of the Pfizer-BioNTech vaccine on September 22, the US CDC’s Advisory Committee for Immunization Practices (ACIP) on September 23 voted to recommend booster doses be offered to people aged 65 years and older, residents in long-term care facilities, people aged 50-64 years with underlying medical conditions, and individuals aged 18-49 who have underlying medical conditions. The ACIP rejected a proposal to offer the shots to people aged 18-64 who are at an increased risk of COVID-19 because they live or work in high-risk occupational and institutional settings, including healthcare workers and teachers. Later the same day, in an unusual move, CDC Director Dr. Rochelle Walensky aligned her recommendation with the FDA’s authorization instead of the CDC committee's recommendations, to include those who work in high-risk settings to be eligible for booster shots. Several ACIP members expressed surprise over Dr. Walensky’s decision, which highlights ongoing divisions and confusion among federal regulators, Biden administration officials, and outside advisers about efforts to bring the pandemic under control.

While the new CDC recommendations authorize millions of US residents to receive a third dose, the plan still falls short of US President Joe Biden’s original announcement that booster shots would be available to all US residents. Biden administration officials are expected to announce a plan for rolling out booster shots as soon as today. The current recommendations only apply to the Pfizer-BioNTech vaccine, but a decision on boosters for the Moderna and J&J-Janssen vaccines could come within weeks.

VIRTUAL COVID-19 SUMMIT One day after UN Secretary-General António Guterres scolded the world for its inequitable distribution of SARS-CoV-2 vaccines on September 21, US President Joe Biden hosted a virtual COVID-19 summit—bringing together world leaders, advocacy groups, nonprofit organizations, and business leaders—in an effort to end the COVID-19 pandemic in 2022 and bolster support for a list of targets that includes vaccinating 70% of the world’s population by September 2022 and alleviating a global oxygen shortage. Calling the COVID-19 pandemic an “all-hands-on-deck crisis,” President Biden confirmed the US will donate another 500 million Pfizer-BioNTech vaccine doses by mid-2022, announced a partnership with the European Union (EU) to improve access to vaccines and therapeutics, and called on other wealthy nations to increase their pledges to countries in need. To facilitate several nations’ purchasing of vaccines through Gavi, the Vaccine Alliance, and the COVAX facility, the US International Development Finance Corporation announced it will provide US$383 million in political risk insurance, one of the conditions for self-financing countries to obtain doses through the initiative.

Questions remain over whether the new vaccine-related commitments will help, as many rich countries’ donation pledges have yet to materialize and the Pfizer-BioNTech vaccine requires specialized infrastructure to store and ship the shots, unavailable in most low-income nations. Advocates said the virtual summit, which was held behind closed doors and involved many pre-recorded speeches, was a missed opportunity to end the piecemeal international approach, increase the urgency for actually delivering vaccines, and coalesce global leadership and coordination to end the pandemic. With growing pressure on US pharmaceutical companies to share vaccine technology, some experts regretted that the summit’s lack of interactive conversation did not permit discussion over the potential for international property rights waivers, which the US has said it supports but has not taken steps to finalize. Additionally, the US government continues to face criticism over its plan to soon begin administering vaccine booster doses for some adults, but officials continue to claim they can vaccinate both US residents and people around the world

Looking toward the future, US Vice President Kamala Harris announced the US will contribute US$250 million in startup funding for a new global health security fund, with the goal of raising US$10 billion to help confront future pandemics. The Biden administration has asked the US Congress to allocate an additional US$850 million for the new financial intermediary fund (FIF), according to Vice President Harris. Both she and President Biden, in his address to the UN General Assembly on September 21, called for the creation of a Global Health Threats Council that could elevate health threats to heads of state, as well as ensure nations’ transparency and accountability. 

ECONOMIC RECOVERY Global vaccine inequity will directly impact economic recovery from the COVID-19 pandemic, and many of those same countries struggling for vaccine access likely will face difficulties financing their healthcare systems as governments cut overall spending, several new reports warn. The global economy has managed to bounce back this year, and likely will be able to rebound close to its pre-crisis trend, driven by growth in wealthy nations that have vaccinated large portions of their populations, a new report from Organisation for Economic Cooperation and Development (OECD) shows. But the gap between rich countries and the developing world is expanding due to continuing unequal access to vaccines. In its report, the OECD urged wealthy nations to share excess vaccine doses with countries in need, invest in resources to facilitate administration of the shots, and not be too quick to withdraw the “extraordinary support” they provided to their own economies during the pandemic. The OECD warned that the outlook remains uncertain, as employment levels in many countries have been severely impacted and not yet recovered. 

In a separate report, the World Bank cautioned that at least 52 low- and middle-income countries (LMICs) that are experiencing declines in overall per capita government spending will be unable to adequately fund their healthcare systems, further threatening COVID-19 recovery and health security. Some nations will struggle to finance SARS-CoV-2 vaccine purchases and administration, or prepare for future disease outbreaks, the report noted, calling on wealthier nations to “recognize their interests” in a stable global recovery and commit the necessary resources. Another report, from Pathfinders for Peaceful, Just and Inclusive Societies, based at New York University’s Center on International Cooperation, warns that more than 100 countries are facing cuts to public spending on health, education, and social programs while simultaneously confronting problems paying down debt amid the pandemic, leading to growing inequality. The report cautions that cuts to government spending for vital services could lead to a reversal in development gains and unrest in some of these countries.

ENGLAND TRAVEL RULES England’s new “simplified” international travel rules—which come into effect on October 4—are igniting outrage and frustration across Africa, South Asia, and Latin America, with some calling the government’s decision to recognize only vaccinations in certain countries discriminatory and racist. Under the new rules, people who received the AstraZeneca-Oxford, Pfizer-BioNTech, Moderna, or J&J-Janssen vaccines in countries with approved health bodies—including the US, Australia, New Zealand, South Korea, an EU country, and several other nations—will be considered “fully vaccinated” and exempt from a 10-day quarantine upon arrival in England from an Amber list country, while people vaccinated with the same vaccines in African or Latin American countries or India will be considered “not fully vaccinated” and subject to quarantine when arriving from an Amber list country. The African Union’s lead health official said the policy is confusing and regrettable and asked why England would not recognize vaccination with shots it sent to the continent. England claims its policy is based on concerns over vaccine certification, but other European nations have found ways to alleviate concerns by allowing anyone vaccinated with a shot authorized by the European Medicines Agency to apply for a vaccine certificate before visiting. While the initial guidelines excluded India’s Covishield vaccine, which has been distributed in the UK, the vaccine was added to the travel list this week, even though it has not yet been formally authorized by UK regulators. A UK government spokesperson said additional changes to the policy would be considered during regular reviews every 3 weeks.

REMDESIVIR EFFECTIVENESS Gilead Sciences’ antiviral COVID-19 treatment Veklury, also known as remdesivir, appeared to reduce hospitalization among non-hospitalized patients at high risk of disease progression when given early in the disease, according to Phase 3 clinical trial results released in a September 22 press release. The results have not yet been published or peer-reviewed. The randomized, double-blind study evaluated the efficacy and safety of a 3-day regimen of remdesivir, which is delivered intravenously. Among the 562 patients assigned 1:1 to receive remdesivir or placebo, the remdesivir group experienced a statistically significant 87% reduction in risk of COVID-19-related hospitalization or all-cause death by Day 28 when compared with the placebo group. The treatment group also had an 81% reduction in risk for medical visits due to COVID-19 when compared with the placebo group. No deaths occurred in the study by Day 28. The safety profile between remdesivir and placebo were similar, with the most common adverse events in the remdesivir group being headache and nausea. Veklury was the first COVID-19 treatment to receive full FDA approval, for use among adult and pediatric patients requiring hospitalization. However, there remains controversy over its effectiveness, with clinical trials showing varying success of the drug. Although antivirals tend to work better early in the course of disease, the drug’s intravenous administration presents logistical challenges for its use in non-hospitalized COVID-19 patients. 

RONAPREVE/REGEN-COV The WHO today added the combination monoclonal antibody treatment known as Ronapreve, or REGEN-COV in the US, to its list of recommended COVID-19 therapeutics and called for producing companies and governments to address the high price and limited production of the drug, which contains casirivimab and imdevimab. The WHO urged US-based Regeneron Pharmaceuticals, which holds the patent on the combination drug, to share technology to allow for more widespread manufacturing, and said UN agencies are negotiating with Roche, which is currently manufacturing the drug for distribution at lower costs with a focus on low- and middle-income countries (LMICs). The WHO made conditional recommendations for the combination therapy—which is authorized for use in the US and the UK—to be used in patients with non-severe COVID-19 who are at high risk of hospitalization and individuals with severe cases but no existing antibodies.

US HOSPITAL CAPACITY Alaska is the latest US state to impose crisis standards of care this week, as hospitals nationwide are facing a continuing surge in severe cases. Alaska has set new single-day case records over the past several days due to the spread of the Delta variant, which is “crippling the health system,” according to Alaska Chief Medical Officer Dr. Anne Zink. In Idaho, which has seen a surge in COVID-19 cases and related deaths, health officials expanded to the entire state crisis standards of care already in place for health districts in the northern part of the state. Idaho currently has the lowest vaccination rate of any state, according to CDC data. Echoing the early days of the pandemic, elective surgeries again are being postponed across many states—including Idaho, Alaska, Montana, Nevada, and Oregon—in an effort to ration care in areas where hospital bed availability is limited. According to the US HHS Protect Public Health Data Hub, 78.6% inpatient beds across the nation are currently occupied. 

SOUTHERN US BLACK COMMUNITIES Rural communities in the US South are disproportionately impacted by the COVID-19 pandemic, most likely due to disparities in social determinants of health such as employment and access to healthcare. In the region's predominantly Black communities, the pandemic has exacerbated ongoing medical and financial inequities. In a photojournalism report, titled “Distanced: Pandemic stories of Black life in the rural South,” STAT News examines the challenges these communities face and how they have found strength in the midst of this unprecedented public health emergency. Although the racial gap in COVID-19-related deaths seems to have shrunk in recent months, data can obscure the nuances in disparities; for example, Black people are less likely to live into older age, when COVID-19 is most lethal. Even when controlling for individual factors such as economic status, housing, education levels, preexisting health conditions, and occupation, researchers warn that structural racism contributes to demographic disparities in COVID-19 deaths, and the recent wave of cases due to the Delta variant have worsened these imbalances.