COVID in Canada vs. US

U.S. Is Open as Canada Shuts Down. The Difference? Their Health Care Systems

• U.S. free-market system has more surge capacity than Canada’s

• Omicron exposes a trade-off of government-run health care

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Hospitals Jammed, But ICUs Less Crowded: Johns Hopkins

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Hospitals Jammed, But ICUs Less Crowded: Johns Hopkins

By

Brian Platt

and Kevin Orland

January 6, 2022, 10:30 AM ESTUpdated onJanuary 6, 2022, 12:21 PM EST

As omicron sweeps through North America, the U.S. and Canadian responses couldn’t be more different. U.S. states are largely open for business, while Canada’s biggest provinces are shutting down.

The difference partly comes down to arithmetic: The U.S. health care system, which prioritizes free markets, provides more hospital beds per capita than the government-dominated Canadian system does.

“I’m not advocating for that American market-driven system,” said Bob Bell, a physician who ran Ontario’s health bureaucracy from 2014 to 2018 and oversaw Toronto’s University Health Network before that. “But I am saying that in Canada, we have restricted hospital capacity excessively.”

The consequences of that are being felt throughout the economy. In Ontario, restaurants, concert halls and gyms are closed while Quebec has a 10 p.m. curfew and banned in-person church services. British Columbia has suspended indoor weddings and funeral receptions.

The limits on hospital capacity include intensive care units. The U.S. has one staffed ICU bed per 4,100 people, based on data from thousands of hospitals reporting to the U.S. Health and Human Services Department. Ontario has one ICU bed for about every 6,000 residents, based on provincial government figures and the latest population estimates.

Covid Crunch

Ontario has the most residents per hospital bed of Canada's provinces

Sources: Canadian Institute for Health Information, Statistics Canada.

Of course, hospital capacity is only one way to measure the success of a health system. Overall, Canadians have better access to health care, live longer than Americans and rarely go bankrupt because of medical bills. Canada’s mortality rate from Covid-19 is a third of the U.S. rate, a reflection of Canada’s more widespread use of health restrictions and its collectivist approach to health care.

Still, the pandemic has exposed one trade-off that Canada makes with its universal system: Its hospitals are less capable of handling a surge of patients.

The situation is especially stark in Ontario. Nationally, Canada has less hospital capacity than the U.S. has, as a proportion of the population. But even among Canadian provinces, Ontario fares the worst. It had one intensive-care or acute-care bed for every 800 residents as of April 2019, the latest period for which data is available, according to the Canadian Institute for Health Information. During the same period, the average ratio in the rest of Canada was about one bed for every 570 residents. (The state of New York has about one inpatient hospital bed per 420 residents.)

That leaves the province’s health care system in a precarious position whenever a new wave of Covid-19 arrives.

“The math isn’t on our side,” Ontario Premier Doug Ford said Monday as he announced new school and business closures this week to alleviate pressure on the province’s hospitals. The province has nearly 2,300 people hospitalized with Covid-19.

No Surge Capacity

On Wednesday, after Brampton Civic Hospital in the Toronto suburbs declared an emergency because of a shortage of beds and workers, Brampton’s mayor, Patrick Brown, tweeted: “We need a national conversation on inadequate health care capacity and staffing.”

Ontario Premier Doug Ford

Source: Bloomberg

The biggest bottleneck in the system is the staffing required by acute care, particularly in the emergency departments and intensive care units, Bell said. The personnel crunch becomes extreme during Covid waves when large numbers of staff are forced to isolate at home because of infection or exposure.

“We haven’t done an adequate job of developing capacity that will serve the needs of Ontarians,” Bell said. “There’s just no surge capacity available.”

Stephen Archer, head of the medicine department at Queen’s University in Kingston, Ontario, about three hours east of Toronto, spent two decades working in hospitals in Minneapolis and Chicago. He said he believes strongly that the Canadian system is better and provides more equitable care.

Still, he called it “embarrassing” to see Toronto’s hospitals having to transfer virus patients to smaller hospitals around the province, as happened last year. The Kingston Health Sciences Center, where he works, took in more than 100 Covid patients from Toronto earlier in the pandemic, which was no surprise, Archer said, because Ontario’s hospitals get overwhelmed even by a busy flu season.

“I think a very fair criticism of the Canadian system and the Ontario system is we try to run our hospitals too close to capacity,” he said. “We couldn’t handle mild seasonal diseases like influenza, and therefore we were poorly positioned to handle Covid-19.”

Diverging Outcomes

The U.S. death rate from Covid-19 is three times Canada's

Source: Johns Hopkins University

Beyond hospital capacity, Archer and Bell cited other reasons for the disparity in the way that the U.S. and Canada respond to new outbreaks. Canadians put more trust in their government to act for the larger collective good, and they won’t tolerate the level of death and severe disease that America has endured from Covid, they said.

David Naylor, a physician and former University of Toronto president who led a federal review into Canada’s response to the 2003 SARS epidemic, said hospital capacity probably plays a bigger role in Canadian decision-making than in the U.S. because Canada’s universal system means “the welfare of the entire population is affected if health care capacity is destabilized.”

But he also argued that focusing only on hospital capacity could be misleading. “Both Canada and the U.S. have lower capacity than many European countries,” he wrote by email.

The major difference between the two countries’ responses to Covid outbreaks is cultural, Naylor argues. In Canada, more than the U.S., policy is guided by a “collectivist ethos” that tolerates prolonged shutdowns and other public health restrictions to keep hospitals from collapsing.

“America’s outcomes are almost inexplicable given the scientific and medical firepower of the USA,” Naylor said. “With regret, I’d have to say that America’s radical under-performance in protecting its citizens from viral disease and death is a symptom of a deeper-seated political malaise in their federation.”

January 6, 2022 Johns Hopkins COVID Report

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 294 million cumulative cases and 5.45 million deaths worldwide as of January 5. Global weekly incidence increased substantially last week, up 72% over the previous week. This is the 11th consecutive week of increasing weekly incidence, setting a new record with 9.73 million new cases. The increase is largely due to surges in the Americas (+100%) and Europe (+66%), but all WHO regions reported increases last week. Notably, the WHO reported increases of 38.1% in the Western Pacific, 39.8% in the Eastern Mediterranean, and 77.6% in South-East Asia, but the magnitude of those surges are much smaller than those in the Americas and Europe. Global weekly mortality decreased for the fourth consecutive week, down 8.3% from the previous week. The weekly total of 41,990 deaths is the lowest since the week of October 19, 2020.

Several countries in Europe are setting new records in terms of per capita daily incidence. To our knowledge, the previous record per capita daily incidence was 3,385 daily cases per million population in Seychelles (May 2021). Over the past several days, Greece (3,418), Ireland (3,927), San Marino (4,364), Andorra (4,554), and Cyprus (4,855) all surpassed that record. A number of other countries in Europe, as well as the US, are exhibiting rapidly increasing trends and could surpass the previous record in the coming days or weeks.

Global Vaccination

The WHO reported 9.12 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of January 5. A total of 4.57 billion individuals have received at least 1 dose, and 3.86 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations increased from mid-October (21.3 million doses per day) through mid-December (39.9 million). Daily vaccinations have decreased since December 15, down from 40.6 million doses per day to 30.4 million. The trend has persisted since before the holiday season, but some of the decline could be due to vaccination clinics being closed during that time.* Our World in Data estimates that there are 4.63 billion vaccinated individuals worldwide (1+ dose; 58.8% of the global population) and 3.91 billion who are fully vaccinated (49.7% 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.

UNITED STATES

The US CDC is currently reporting 57.2 million cumulative cases of COVID-19 and 827,879 deaths. The US is averaging 554,328 new cases and 1,238 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.

Since December 27, 2021, the US has continually set new records for both single-day incidence and average daily incidence. Notably, the US exceeded 300k, 400k, 500k, 600k, 700k, 800k, and 900k new cases reported in a single day for the first time since the onset of the pandemic. The United States’ average daily incidence also exceeded 300k, 400k, and 500k new cases per day for the first time. We expect that part of these massive reports are a result of delays in reporting over the Christmas and New Year’s holiday weekends; however, even reports from the holidays themselves, both of which fell on weekends, were considerably higher than the weekends leading up to the holiday season. The US reported more than 100,000 new cases on Christmas Day and another 200,000 on Sunday, December 26, which is more than 75% higher than the previous weekend total. Similarly, the average from January 1 and January 2 exceeded the previous single-day record from January 2021. On January 3, 2022, the US reported 956,893 new cases. For context, only 45 other countries have reported more cumulative cases than the new US single-day record. The new US record is also a global single-day record, surpassing India’s May 2021 peak of 414,188 new cases by more than double, despite India having nearly 4 times as many people.

Since the US Thanksgiving holiday weekend, daily incidence in the US has increased by a factor of nearly 6, and it has quadrupled since just December 19. The current average of 554,328 new cases per day is more than double the previous record—250,435 on January 11, 2021. The US has reported more than 6 million new cases since December 20.

COVID-19 hospitalizations in the US are rapidly approaching a record high as well. The record is 16,497 new hospitalizations per day (January 8, 2021), and the CDC reported 14,776 on January 2, 2022. The average has nearly doubled since December 18, 2021. The CDC is also reporting a surge in the number of current hospitalizations, up from an average of 61,574 hospitalized COVID-19 patients on December 20 to 85,423 on January 2, an increase of nearly 40% over that period. The current average is 31% below the record high—124,031 on January 11, 2021—but the trend is increasing rapidly. Daily mortality appears to have increased slightly over the past several weeks, but reporting fluctuations over the holidays make it difficult to determine whether this is the start of a longer-term trend. A surge in hospitalizations could place severe stress on health systems nationwide, particularly in the context of staffing shortages in many parts of the country, which could contribute to increased mortality for COVID-19 patients as well as those seeking care for other conditions.

Genomic sequencing data from the US CDC show a continued increase in the prevalence of the Omicron variant across the US. When we last looked at the genomic data, the estimated prevalence at the national level was 73.2% for the week of December 18, 2021; however, the CDC revised its estimate that week down to 37.9%. While that estimate fell substantially, the increasing trend continues, up to an estimated 95.4% for the week of January 1, 2022.** Omicron is estimated to be the dominant variant in all 10 HHS regions, including 8 regions with more than 90%. The lowest estimates are 82.4% in Region 1 (New England) and 77.4% in Region 7 (Central).

**US CDC Nowcast projection.

US Vaccination

The US has administered 514 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations peaked on December 6, with 1.71 million doses administered per day. The trend in daily vaccinations continues to decline, down from a recent high of 1.74 million doses per day on December 6 to 971,000 on December 31, a 45% decrease over that period.* Some of this decline could be a result of vaccination clinics, pharmacies, and other vaccination sites being closed over the Christmas and New Year’s holiday weekends, but the trend was already decreasing prior to the holidays.

A total of 245 million individuals have received at least 1 vaccine dose, equivalent to 73.9% of the entire US population. Among adults, 85.9% have received at least 1 dose, as well as 23.3 million children under the age of 18. A total of 207 million individuals are fully vaccinated**, which corresponds to 62.3% of the total population. Approximately 73.0% of adults are fully vaccinated, as well as 18.2 million children under the age of 18. Since August 13, 72.3 million fully vaccinated individuals have received an additional or booster dose. An estimated 34.9% of fully vaccinated individuals have received a booster, including 59.4% 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.

**Full original course of the vaccine, not including additional or booster doses.

RAPID ANTIGEN TEST PERFORMANCE As the SARS-CoV-2 virus mutates over time, changes in its genetic makeup could impact the ability of certain tests to recognize and detect viral antigens. A preprint study posted to medRxiv this week raises questions about the reliability of at-home rapid antigen tests in the early days of infection with the highly mutated Omicron variant of concern (VOC). The small real-world study, which is not yet peer-reviewed, examined test results from 30 people who, because of their workplace rules, were undergoing both rapid antigen and polymerase chain reaction (PCR) tests on a daily basis. On days 0 and 1 following a positive PCR test, both of the at-home rapid antigen tests in use—Abbott BinaxNOW and Quidel QuickVue—produced false-negative results despite the presence of viral loads high enough for transmission. The researchers confirmed that 4 cases transmitted the virus between false-negative test results and noted there likely were more transmissions that were unconfirmed. On average, it took 3 days for people to test positive on a rapid antigen test after testing positive on a PCR test. The researchers shared their results with US CDC and US FDA officials and called for the real-world performance of rapid antigen tests to be reassessed for each new VOC.

The study’s results suggest that even if the supply and accessibility of at-home tests were sufficient, rapid antigen testing might not be reliable as an early warning, when people are most infectious and before symptoms begin. Although these findings warrant further study, scientists and public officials are urging the public to continue rapid testing but to use caution when interpreting the results. Some evidence suggests that Omicron might replicate more quickly and efficiently in the throat and mouth than in the nose. And while some individuals have reported swabbing their throats and noses in the hope of increasing the accuracy of test results, the FDA maintains the at-home tests should be used only as authorized. The agency recently updated its information on how SARS-CoV-2 variants could impact tests’ performance.

PFIZER-BIONTECH BOOSTER & ADDITIONAL DOSES This week, the US FDA and US CDC made several adjustments to the emergency use authorization (EUA) and recommendations for the Pfizer-BioNTech SARS-CoV-2 vaccine. On January 3, the FDA made 3 amendments to the EUA, including expanding the use of booster doses to include adolescents aged 12-15 years; shortening the time between primary series and booster to 5 months from 6 months for people who received the Pfizer-BioNTech vaccine; and allowing for a third primary series dose for certain immunocompromised children ages 5 to 11 years. The following day, the CDC updated its recommendation for booster dose timing to 5 months, noting the interval recommendations for other vaccines remains the same (2 months for J&J-Janssen; 6 months for Moderna). The agency also recommended that moderately or severely immunocompromised 5- to 11-year-olds receive an additional primary dose of vaccine 28 days after their second shot. The CDC’s Advisory Committee on Immunization Practices (ACIP) on January 5 voted 13-1 in favor of expanding eligibility of and strengthening the recommendation for Pfizer-BioNTech booster doses in adolescents aged 12-15 years, and the CDC later that day endorsed the recommendation. In a statement, CDC Director Dr. Rochelle Walensky said booster doses 5 months after a primary series “will provide optimized protection against COVID-19 and the Omicron variant” for adults and adolescents aged 12-17. Only the Pfizer-BioNTech vaccine is authorized for individuals under age 18.

During a White House press briefing, Dr. Walensky cited outcomes from several studies conducted in Israel that suggest booster doses decrease the risks of infection, severe disease, and death. Notably, the studies were conducted when the Delta variant of concern was predominant, but Dr. Walensky said “we expect to see a similar trend of increased protection” for the Omicron variant. Israel on January 2 became the first country to officially recommend a fourth dose of SARS-CoV-2 vaccine to people aged 60 and older and medical workers who had their last dose at least 4 months ago. Fourth doses already were available to people with weakened immune systems and residents and staff of nursing homes. The Israeli government said preliminary data show a fourth dose of the Pfizer-BioNTech vaccine spurred an average fivefold increase in antibodies 1 week post-shot. However, some experts question the move, saying too many booster rounds could further vaccine inequity and potentially dampen the immune response if too many doses of the same vaccine are administered. Israel is reporting a record number of new COVID-19 cases, with nearly 12,000 recorded on January 5. Little data on the safety and efficacy of additional doses is not stopping some in the US from seeking fourth, fifth, or even sixth shots, particularly those with compromised immune systems who fear infection. However, some researchers believe that certain immunocompromised people may never generate immune system responses to the vaccines, no matter how many doses they receive.

US CDC QUARANTINE & ISOLATION GUIDANCE In late December, the US CDC updated its guidance regarding isolation for individuals who test positive for SARS-CoV-2 infection. The CDC shortened the recommended isolation period to 5 days for individuals who are asymptomatic or whose symptoms have resolved. After that point, those individuals should wear masks in public to mitigate the risk of transmission to others. The shortened isolation period is based on data that indicate that “the majority of SARS-CoV-2 transmission occurs…in the 1-2 days prior to onset of symptoms and the 2-3 days after.”

Notably, the updated isolation guidance did not include a negative test as a condition to end the isolation period. In response to criticism regarding the absence of a testing requirement—particularly in the context of a shorter isolation period in the midst of the United States’ largest surge to date—the CDC issued a subsequent update on January 4. But rather than including a testing requirement, the CDC provides recommendations regarding how an individual should proceed if s/he “has access to a test and wants to test.” The American Medical Association on January 5 released a statement expressing concern over the guidelines’ exclusion of testing, saying the “recommendations put our patients at risk and could further overwhelm our healthcare system.”

The CDC also updated its guidance regarding quarantine following exposures to known COVID-19 cases. Individuals who are not fully vaccinated should quarantine for 5 days following the exposure, followed by strict mask use for an additional 5 days. If a 5-day quarantine is not practicable, then exposed individuals should wear a mask for 10 days. Individuals who are fully vaccinated do not need to quarantine following an exposure, as long as they remain asymptomatic; however, they should wear a mask in public for 10 days. In this context, the CDC defines fully vaccinated as having received a full original course of the vaccine—eg, 2 doses for the Moderna and Pfizer-BioNTech vaccines and 1 dose of the J&J-Janssen vaccine—as well as a booster dose as recommended—6 months after the second dose of the Moderna or Pfizer-BioNTech vaccines and 2 months after the J&J-Janssen vaccine for adults. Individuals who have tested positive for SARS-CoV-2 in the past 90 days are treated similarly to fully vaccinated individuals. The CDC also recommends testing for all exposed individuals at Day 5 or later after the exposure. As with the previous guidance, anyone who develops symptoms should self-isolate until they receive a negative test or an alternate diagnosis that explains the symptoms.

On December 23, the CDC updated guidance specifically for healthcare workers following exposures to SARS-CoV-2. The new recommendations include updates regarding the process and timeline for returning to work following an exposure as well as the definition of “higher-risk exposures.” The update includes specific testing requirements and timelines for healthcare workers to return to work following SARS-CoV-2 infection, depending on their vaccination status and the presence and severity of symptoms. Largely, fully vaccinated and boosted healthcare workers do not face any work restrictions following an exposure, as long as they remain asymptomatic and do not test positive for SARS-CoV-2 infection, even with a higher-risk exposure. Under the updated guidance, healthcare workers wearing a face mask are no longer considered to have a higher-risk exposure if the patient is also wearing a face mask. Previously, exposures were considered to be higher risk if the healthcare worker was not wearing a respirator. At least 4 nursing organizations have expressed concern over the guidance for healthcare workers, with the American Nurses Association saying the “guidance is premature given what is known about the Omicron variant and tips toward economic needs as opposed to the health needs of nurses and other healthcare workers.”

COVID-19 TREATMENTS As the number of new COVID-19 cases skyrockets in the US, hospitalizations too are beginning to rise. While some nations—including South Africa and the UK—have seen lower hospitalization rates due to the Omicron variant of concern (VOC) compared with previous variants, it remains unknown whether this will be the case in the US. Full vaccination with a booster dose remains the best way to prevent severe COVID-19, but keeping people with the disease from progressing to more severe disease requiring hospitalization is imperative, to both save lives and lessen the strain on the healthcare system. Two highly anticipated and recently authorized antivirals—Pfizer’s Paxlovid and Merck and Ridgeback Biotherapeutics’ molnupiravir—are administered to patients recovering at home to help prevent progression to more severe disease, but the medications are in limited supply, causing dismay among healthcare providers. US President Joe Biden on January 4 announced the government will double its order of Paxlovid to 20 million courses, but long manufacturing times means only 435,000 of those courses are expected to be delivered over the next 2 months. The US government also has purchased 3 million of molnupiravir, with about 300,000 courses already delivered to states based on population. With the limited supply, doctors must make choices about who might benefit the most from the antivirals, both of which are recommended to be administered within 5 days of symptom onset.

While both of the newly authorized antivirals are expected to work against Omicron, 2 of the 3 monoclonal antibody treatments available under FDA emergency use authorization (EUA) do not work against the VOC. After a short pause in distribution, the US government restarted shipments of both Eli Lilly’s bamlanivimab plus etesevimab and Regeneron’s casirivimab plus imdevimab (REGEN-COV) monoclonal antibody therapies, which should be used for patients in areas where the Delta VOC represents a significant portion of cases and other options are not available. The US Health and Human Services (HHS) in a statement warned that the treatments would be ineffective if given to patients with the Omicron VOC and noted other therapeutics—including oral and intravenous (IV) antivirals and GSK/Vir Biotechnology’s sotrovimab monoclonal antibody—are effective alternatives against Omicron. A study published December 22, 2021, in the New England Journal of Medicine (NEJM) examining the IV antiviral remdesivir (Veklury) in symptomatic, non-hospitalized patients with COVID-19 at high risk of disease progression showed a 3-day course of the drug was safe and resulted in an 87% lower risk of hospitalization or death than placebo. Notably, Gilead Sciences, the drug’s maker, funded the study and submitted the trial results to the US FDA to consider expanding the drug’s approval for use in earlier stages of COVID-19.

On December 28, the FDA both expanded and limited the EUA for convalescent plasma to treat COVID-19 by restricting the use of high-titer convalescent plasma to patients with immunosuppressive disease or receiving immunosuppressive treatment but allowing its use in either outpatient or inpatient settings. Previously, the therapy was allowed to be used among any hospitalized COVID-19 patients early in their disease course, but EUA revisions have narrowed the treatment’s use since it was first authorized in August 2020. Additionally, a group of physician-scientists led by Dr. David Boulware of the University of Minnesota filed an EUA application with the FDA for fluvoxamine—a generic selective serotonin reuptake inhibitor (SSRI) that is used to treat several mental health conditions such as depression—to treat COVID-19. Technically, physicians could prescribe the medication off-label for COVID-19 but some might be reluctant to or work in settings that prohibit the practice. The EUA application is based primarily on 2 randomized controlled clinical trials supporting fluvoxamine’s use to prevent disease progression, and Dr. Boulware noted several other studies are looking at whether the drug can help prevent hospitalizations or death among COVID-19 patients.

OMICRON SCHOOL DISRUPTIONS The Omicron variant of concern (VOC) is causing disruptions in nearly every country worldwide. While there is still uncertainty regarding the variant’s clinical presentation, evidence suggests it causes less serious disease, is more transmissible than its predecessors, and is able to at least partially evade preexisting immunity. But a rapid increase in the number of cases worldwide has led to interruptions and staffing shortages in the healthcare, travel, and other industries. Schools are no exception. Analysis from Burbio's School Tracker shows nearly 5,000 pandemic-related disruptions to K-12 US public schools in this week alone. In Chicago, Illinois, the third largest school district in the US closed schools again for a second day, sending more than 350,000 students home as the teachers union and city officials continue a standoff over COVID-19 safety protocols. School closures, delays in returning to in-person learning after the winter holidays, and returns to remote learning in other districts nationwide have parents scrambling for resources and clarity, with some desiring children return to schools and others relieved their children do not have to return to classrooms. According to US CDC data, a record high number of children are being hospitalized with confirmed COVID-19.

In Europe, countries are prioritizing the reopening of schools. France, Greece, and Ireland—which boasts 91% of ages 12 and older fully vaccinated—are returning to in-person schooling with strategies including increased testing and expanded inoculations to kids as young as 5 years old. In England, school leaders are witnessing high levels of staff absences at schools and daycare centers due to COVID-19. Some teachers and one union have expressed concern about government guidance that advises combining classes in the event of staff shortages, citing the possibility of increased transmission. Like the US, countries across the European region are loosening quarantine and isolation restrictions to ease staffing shortages and missed time in class.

PREGNANCY & BIRTH OUTCOMES Pregnant people with COVID-19 have an increased risk for severe illness and adverse birth outcomes. Still, many are reluctant to receive vaccination against COVID-19, with only about 40% of pregnant people in the US fully vaccinated as of mid-December. A retrospective cohort study involving more than 45,000 pregnant people published this week in the US CDC’s Morbidity and Mortality Weekly Report (MMWR) found that SARS-CoV-2 vaccination during pregnancy was not associated with increased risks of preterm delivery or underweight newborns. The data—drawn from 8 healthcare organizations in 6 US states—support the CDC’s recommendation of vaccination and booster doses for all people who are pregnant, recently pregnant, or who are trying to become pregnant. Notably, most of the people involved in the study became pregnant prior to the availability of vaccines and those who were vaccinated received the shots in the second or third trimester, so the study does not include information on first-trimester vaccinations. Experts continue to recommend vaccination for all pregnant people, as the risk of preterm birth is higher among those infected with SARS-CoV-2 and vaccination may help protect infants by passing along beneficial antibodies. A study published in Pediatrics this week suggests that vaccine-induced SARS-CoV-2 antibodies in human breast milk, including IgG and neutralizing activity, persist for up to 6 months.

Another study, published in JAMA Pediatrics, found that in utero exposure to maternal SARS-CoV-2 infection was not associated with differences in neurodevelopment at age 6 months. However, the researchers did find that birth during the pandemic, regardless of SARS-CoV-2 exposure, was associated with slightly lower scores on developmental screening tests of social and motor skills at 6 months compared to infants born right before the pandemic. The researchers said the results suggest that pandemic-related stresses among parents or caregivers, such as job loss or housing insecurity, could have contributed to the small differences between infants born before and during the pandemic. They noted the results of the small study do not necessarily mean infants born during the pandemic will have lasting neurodevelopmental impairment, and they plan to follow the 255 newborns involved in the study.

B.1.640.2 VARIANT Researchers late last year identified a new SARS-CoV-2 variant with 46 mutations and 37 deletions compared with the original novel coronavirus, but the WHO has said the variant is of little concern, for now. The B.1.640.2 variant was first recognized in October 2021 by researchers in France, who dubbed the variant “IHU” after the Méditerranée Infection University Hospital Institute (IHU) that helped to identify it. The isolate came from a vaccinated person who had recently traveled to Cameroon, where the variant is assumed to have originated. So far, fewer than 20 samples have been sequenced, and only 1 in December, compared to the more than 120,000 Omicron variant sequences that have been uploaded to the Gisaid database since its discovery in late November. Many SARS-CoV-2 variants have been identified since the beginning of the pandemic, but many of them never cause widespread infections. The B.1.640.2 variant is likely piquing interest due to the publication of a preprint article (not peer-reviewed) describing it posted on December 29, as well as the heightened anxiety surrounding the recently discovered, highly transmissible, and extensively disruptive Omicron variant of concern. Although experts are not worried about the B.1.640.2 variant at this time, new variants continue to be a threat until more of the world is vaccinated.

Doctors: “How do we treat current COVID cases”

Variant Diagnosis Has Doctors Struggling With Virus Treatment Decisions

Jainer Munoz, a Venezuelan doctor working as a nurse as he studies for his U.S. medical license, runs rapid PCR tests on nasal swabs at a testing center operated by Nomi Health inside Miami International Airport, Friday, Dec. 17, 2021, in Miami. Nomi nurses said that both demand for tests and positivity rates at their testing center have risen significantly since Thanksgiving. (AP Photo/Rebecca Blackwell)

Christina Jewett

Tue, January 4, 2022, 6:53 AM

Most U.S. doctors have no way to determine which variant of the coronavirus a patient is carrying, a distinction that could mean the difference between life and death.

High-risk patients carrying the delta variant could benefit greatly from two particular monoclonal antibody treatments shown to reduce hospitalization and death. But those medications would most likely do nothing for patients with omicron, who would only respond to a third antibody treatment that is in very short supply.

While U.S. officials have endorsed using a workaround test that can identify omicron’s genetic signature, experts say it’s not feasible for large health systems facing a crush of patients to employ in each case.

That makes treating patients challenging in places like Maryland, where cases are spiking and omicron accounts for roughly 58% of them. The delta variant is also holding strong in the Great Plains and swaths of the West, including California.

While there is no approved test to determine each individual’s variant, a national network of state and other labs use genome-sequencing tests to track variants broadly in communities. Health systems then use those regional estimates or their own data to decide which antibody treatments to use in their clinics and hospitals.

Many of them concluded that a community of largely delta patients would benefit most from the antibody drugs made by Regeneron and Eli Lilly, while communities where omicron patients are predominant would benefit from antibodies from GlaxoSmithKline and Vir Biotechnology.

Federal officials have dabbled with making the decision for the nation. On Dec. 23, they stopped shipments of antibody treatments by Eli Lilly and Regeneron after the Centers for Disease Control and Prevention said 73% of U.S. COVID cases were omicron.

An outcry followed from Republican political leaders, who argued that some people in their states were still infected with delta. And on Tuesday, the CDC slashed its estimate of national omicron cases to 59%. On Dec. 31, federal officials resumed national shipping all of the antibody treatments.

For the next few weeks, as the country grapples with this uneven mix of both variants, tailoring treatments to each patient will be “extraordinarily difficult,” said Dr. Alex Greninger, assistant director of the clinical virology laboratories at the University of Washington Medical Center.

Greninger is credited with developing one of the first tests to detect the coronavirus in the United States. But he is pessimistic that health systems can pivot quickly to sort out which patients have delta or omicron. And although a shortcut test can detect omicron, there’s no simple way to report the results in bulk, he said.

What’s more, the genome sequencing used by public health officials takes nearly a week — too long to target the early antibody treatments that have been found to reduce the need for hospitalizations. That makes patient care particularly difficult right now, said Dr. Mark Siedner, an infectious disease clinician and researcher at Massachusetts General Hospital.

In Massachusetts and nearby states, an estimated 44.5% of cases are omicron. Siedner said his health system has stopped using the Regeneron and Eli Lilly antibodies that are not effective against omicron and are “anxiously awaiting” more doses of the effective treatment by GlaxoSmithKline and Vir Biotechnology.

“We’re in a holding pattern and it’s a terrible time to be in that place,” he said.

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December 23: Johns Hopkins COVID 19 Report

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.

Our team is taking a short break for the holidays. We will resume publishing the COVID-19 Situation Report on January 6, 2022.

We would like to thank you, our supporters and colleagues, for helping make our work possible and stronger by utilizing our resources, attending our events, reading our COVID-19 situation reports, and learning alongside us.

We are encouraged by the strength and resilience of our community, and hopeful that a brighter future is ahead. (Read a summary of our 2020 COVID-19 response work and about our work in 2021.)

EPI UPDATE The WHO COVID-19 Dashboard reports 275 million cumulative cases and 5.36 million deaths worldwide as of December 22. Global weekly incidence increased for the ninth consecutive week, up 4.7% from the previous week. Europe’s surge, which is believed to be largely driven by the Omicron variant, appears to be peaking, and the trend in Africa continues to accelerate sharply, setting a new weekly record (90,450 new cases; +55% from the previous week). The overall trends in the Americas and the Western Pacific are increasing as well. Global weekly mortality decreased for the second consecutive week, down 5.2% from the previous week. With 46,554 new deaths, last week's total fell slightly below the average since mid-October, but it is unclear whether this is the beginning of a longer-term trend, particularly in the context of increasing trends in weekly incidence.

Global Vaccination

The WHO reported 8.4 billion cumulative doses of SARS-CoV-2 vaccines administered globally as of December 20. A total of 4.38 billion individuals have received at least 1 dose, and nearly 3.5 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations increased from mid-October (21.3 million doses per day) through mid-December (39.9 million). Daily vaccinations have decreased since December 15, down to 34.5 million, but it is unclear whether this is a result of short-term fluctuations or the start of a longer-term trend.* Our World in Data estimates that there are 4.49 billion vaccinated individuals worldwide (1+ dose; 57.1% of the global population) and 3.77 billion who are fully vaccinated (47.9% 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.

UNITED STATES

On December 16, the US officially surpassed 800,000 cumulative COVID-19 deaths. The US CDC is currently reporting 51.3 million cumulative cases and 807,397 deaths. The US reported 288,381 new cases on December 20 and 204,913 on December 21, surpassing 200,000 new cases in a single day for the first time since January 18. The December 20 total is the second-highest single-day total since the onset of the pandemic. These 2 reports caused the average daily incidence to jump from 135,911 new cases per day to 161,261, a 19% increase in only 2 days. The current average is the highest since September 5 and only 1.8% below the United States’ second-highest peak in September 2021 (164,241). Daily incidence has increased by a factor of 2.5 since the most recent low on October 24 (64,162), and the trend appears to be accelerating. The sharp increase at the national level is a result of similar trends across states in multiple regions of the country. Analysis by The New York Times indicates that the daily incidence has more than doubled in 7 states—plus Puerto Rico (+1,302%) and Washington, DC (+541%)—over the past 2 weeks, including Florida (+509%) and Hawai’i (+670%) that have increased by a factor of 5 or greater.*

Daily mortality continues to increase steadily, up to 1,223 deaths per day, an increase of more than 20% since before the US Thanksgiving holiday weekend.*

Following a cybersecurity incident, Maryland suspended reporting for COVID-19 data. As of December 20, approximately 2 weeks after the incident, the state reported that 90% of its COVID-19 data have been restored. Maryland’s COVID-19 dashboard is once again available, and it has resumed reporting to the CDC.

*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.

Genomic sequencing data from the CDC show a rapid increase in the prevalence of the Omicron variant across the US. At the national level, the estimated prevalence increased from 0.1% the week of November 27 to 0.7% the week of December 4. In the 2 weeks since then, the prevalence surged to an estimated 73.2% nationwide, replacing Delta as the dominant variant.** Additionally, 8 of the 10 HHS regions are reporting Omicron prevalence greater than 50%, including 5 with greater than 90%: Regions 2 (New York/New Jersey), 4 (Southeast), 5 (Midwest), 6 (South), and 10 (Pacific Northwest).

**US CDC Nowcast projection.

US Vaccination

The US has administered 499 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations peaked on December 6, with 1.71 million doses administered per day. The trend has declined steadily since then, down to 1.36 million doses on December 17—a 20% decrease over that period.* A total of 241 million individuals have received at least 1 vaccine dose, equivalent to 72.8% of the entire US population. Among adults, 85.0% have received at least 1 dose, as well as 22.2 million children under the age of 18. A total of 204.8 million individuals are fully vaccinated**, which corresponds to 61.7% of the total population. Approximately 72.7% of adults are fully vaccinated, as well as 17.2 million children under the age of 18. Since August 13, 63.2 million fully vaccinated individuals have received an additional or booster dose, including 55.8% 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.

**Full original course of the vaccine, not including additional or booster doses.

US OMICRON PREDICTIONS & PLAN Analysis from the University of Washington predicts that a new surge in COVID-19 incidence driven by the Omicron variant could produce nearly 3 million new cases per day in the US during the peak. Similarly, retired US NIH Director Dr. Francis Collins warned that the US could see as many as 1 million new cases per day as Omicron spreads. Some evidence suggests that daily incidence could peak quickly, possibly within the next 4-5 weeks, and that Omicron infections are associated with a lower risk of hospitalization and severe disease when compared to Delta. However, experts warn it is impossible to predict how individual countries’ populations and healthcare systems will be impacted by surges in Omicron cases. Individuals who are unvaccinated and have never been exposed to SARS-CoV-2 may still be at risk of severe disease. A large increase in COVID-19 cases also still runs the risk of overwhelming healthcare systems in the US and abroad.

On December 21, US President Joe Biden gave a speech on his administration’s plans to respond to Omicron. The plan includes procuring 500 million rapid tests for free shipment to US residents, beginning in January. This represents a pivot for the administration, which recently said people would have to seek reimbursement from their healthcare insurance plans for tests purchased on their own. Experts said the new policy is a step in the right direction but noted that countries such as the UK and Germany have been distributing billions of test kits and recommending citizens check their status twice a week. The US would need to ship 2.3 billion tests monthly to hit this same benchmark. Biden also announced plans to deploy more federal aid to hospitals and testing sites, including military personnel, ventilators from the national stockpile, and more ambulances and teams of paramedics to aid in transporting patients. President Biden called on unvaccinated individuals to fulfill their “patriotic duty” and seek out the shots, encouraged fully vaccinated individuals who are eligible to get a booster, and said those who are vaccinated should go ahead with holiday celebrations with friends and family. Meanwhile, WHO Director-General Dr. Tedros Adhanom Ghebreyesus encouraged people worldwide to cancel their holiday plans, saying, “An event canceled is better than a life canceled.”

US AUTHORIZES ORAL ANTIVIRALS The US FDA this week authorized the use of 2 oral, at-home antiviral therapies for COVID-19, a significant step in treatment of the disease that comes as the number of new cases begins to surge in the US, driven primarily by the Omicron variant of concern (VOC). The agency today authorized the use of the oral antiviral molnupiravir, developed by Merck and Ridgeback Biotherapeutics, for COVID-19 patients aged 18 years and older who have a positive SARS-CoV-2 viral test result, are within 5 days of symptom onset, are at high risk of severe disease or hospitalization, and who cannot access or do not qualify for alternative authorized COVID-19 treatments. Molnupiravir reduced the risk of hospitalization among high-risk patients by 30%, according to clinical trail data, but some experts are concerned over the potential for side effects and the development of drug resistance. The drug is not recommended for use during pregnancy, and men and women of childbearing age are recommended to use birth control, with men suggested to continue using it for 3 months post-administration. Molnupiravir—administered as capsules taken twice a day for 5 days—works by causing errors in the virus’s genetic code, disabling its reproduction capacity but also raising concerns that it could cause mutations in people who take it or lead to new variants.

On December 22, the FDA authorized the first oral antiviral to treat COVID-19 patients. The emergency use authorization (EUA) is for Pfizer’s Paxlovid—a new antiviral called nirmatrelvir co-packaged with the older antiviral ritonavir—that is taken as tablets twice a day for 5 days. Paxlovid is indicated to treat mild-to-moderate COVID-19 in individuals ages 12 and older weighing at least 40 kg (about 88 pounds) who have a positive SARS-CoV-2 test result and are at high risk of progression to severe disease. Administration of the pills, which are available by prescription only, should be started within 5 days of symptom onset and could be available to patients as early as this weekend, although initial supplies will be limited due to manufacturing constraints. Pfizer’s clinical trial results (not yet peer-reviewed) showed Paxlovid reduced the overall risk of hospitalization by 88% if started within 5 days of symptom onset, and the company’s laboratory studies show the pills should be effective against Omicron.

The authorizations come as healthcare providers face the realization that 2 of the 3 authorized monoclonal antibody treatments—previously shown to be highly effective at keeping high-risk patients out of the hospital—are not working against Omicron. The European Medicines Agency (EMA) has made recommendations for both Paxlovid and molnupiravir (known as Lagevrio outside of the US) for use in certain COVID-19 patients, paving the way for authorization in Europe.

CONVALESCENT PLASMA The results of a clinical trial evaluating antibody-rich plasma as an outpatient treatment for people with symptomatic COVID-19 was posted as a preprint to medRxiv on December 21, reopening debate over the use of convalescent plasma therapy. The study, conducted in the US and led by researchers from Johns Hopkins Medicine and the Johns Hopkins Bloomberg School of Public Health, showed outpatient treatment with convalescent plasma, when given within 8 days of symptom onset, reduced the risk of hospitalization by 54% compared with the placebo-control group. The trial primarily used plasma collected before vaccines were widely available and ended prior to the arrival of the Omicron SARS-CoV-2 variant in the US. However, the authors of the study believe that antibody-rich plasma could be an effective treatment against Omicron and other variants if taken from patients who are fully vaccinated and recovered from a breakthrough case of COVID-19. Individuals who fall into this category are believed to have higher levels of neutralizing antibodies than either individuals who are only vaccinated or only recovered from previous infection.

The study’s data come only a few weeks after the WHO recommended against the use of convalescent plasma to treat COVID-19. The WHO recommendation was made using information from 16 clinical trials with more than 16,000 participants that indicated convalescent plasma does not improve chances of survival or reduce the risk of needing mechanical ventilation. In the US, convalescent plasma is available under a US FDA emergency use authorization (EUA) to treat hospitalized COVID-19 patients early in the course of disease. The authors of the current study hope their results will prompt the WHO and FDA to revisit their guidance, especially because most of the currently authorized monoclonal antibody treatments might prove useless against Omicron and convalescent plasma is relatively easy to produce in low- and middle-income countries.

VACCINE INEQUITY In 2022, the international community must focus on global vaccine equity in order to end the COVID-19 pandemic. This past year saw vaccination goals fall far short, particularly in low- and middle-income countries (LMICs), in what has been called a “year of vaccine inequity” and a “failure for humanity.” Public health experts warn that the rapid spread of the Omicron variant could cause further setbacks in efforts to end vaccine inequity, leaving large populations unvaccinated and providing circumstances in which SARS-CoV-2 could continue to mutate. Additionally, the effects of these inequities will be felt for decades: 8 out of 10 people pushed into poverty during the pandemic are estimated to live in the poorest nations, and socioeconomic inequalities—such as access to schools and healthcare—will worsen for women and girls. Access to vaccine supplies, capacity to deliver the shots, and vaccine hesitancy all must be addressed in order to improve global vaccination rates. The world has the tools necessary to end the pandemic in 2022, but unless those tools are implemented effectively, including vaccinating the world’s population, the next year will not see the end of the current pandemic and we will remain unprepared for the next pandemic. 

WHO Director-General Dr. Tedros Adhanom Ghebreyesus this week warned that widespread vaccine booster programs could prolong the pandemic, increase inequity, and provide a false sense of security in the face of Omicron. The WHO issued an update to its interim guidance on boosters, saying nations considering booster vaccination policies should consider their strategic and programmatic priorities; data on the performance of booster doses; how targeted booster dose administration could prevent healthcare system strain; and importantly, how booster programs impact globally limited vaccine supplies. Notably, Israel this week became the first country to begin rolling out a fourth dose of SARS-CoV-2 vaccine to certain populations, including adults ages 60 and older, medical workers, and people with compromised immune systems. Other nations might be considering similar policies on boosters. In the US, a group of more than 80 Democratic lawmakers has requested at least US$17 billion be included in the fiscal year 2022 appropriations omnibus to support global vaccination, testing, and treatment of COVID-19. In a US House of Representatives select subcommittee hearing on December 14, experts warned that continued inequity in vaccine access will continue to threaten the global population, including in the US, and prolong social and economic recovery. 

US LIFE EXPECTANCY Life expectancy for the US population in 2020 dropped 1.8 years over 2019—down to 77 years in 2020 from 78.8 years in 2019—the largest single-year reduction in more than 75 years, according to new data from the US CDC’s National Center for Health Statistics (NCHS). The top 10 causes of death in 2020 were heart disease, cancer, COVID-19, unintentional injuries (including drug overdose), stroke, chronic lower respiratory diseases, Alzheimer’s disease, diabetes, influenza and pneumonia, and kidney disease. The drop in life expectancy was driven by increases in mortality due to COVID-19, unintentional injuries, heart disease, homicide, and diabetes. Of the 10 leading causes of death in 2020—which accounted for 74.1% of all deaths in the US in 2020—9 remained the same as in 2019, although 5 causes switched rank. Heart disease and cancer remained the top 2 leading causes. COVID-19 debuted in the ranking list in 2020, becoming the third leading cause of death and pushing suicide off the list. This is the first time a novel disease has entered the top 10 causes of death so quickly, and many feel much of the elevated death rate in 2020 is attributable directly or indirectly to COVID-19, as people might have had underlying conditions worsened by COVID-19, had limited access to health care, or feared accessing emergency or maintenance care.

In total, more than half a million more US resident deaths were recorded in 2020 than in 2019, and COVID-19 was the underlying cause of death for 350,831 people, representing 10.4% of the total number of deaths in 2020. The decrease in life expectancy was larger for men—2.1 years, from 76.3 years in 2019 to 74.2 years in 2020—than for women—1.5 years, from 81.4 in 2019 to 79.9 in 2020. Notably, age-adjusted death rate increases from 2019 to 2020 were highest among racial and ethnic minorities, reflecting an increased risk of death from COVID-19. The greatest increases in death rate were seen among Hispanic males (42.7%), Hispanic females (32.4%), non-Hispanic Black males (28.0%), and non-Hispanic Black females (24.9%), compared with non-Hispanic White males (13.4%) and non-Hispanic White females (12.1%). Death rates for non-Hispanic Black males were highest in 2020—1,399 deaths per 100,000 people—and lowest among Hispanic females—570 per 100,000. On a positive note, the infant mortality rate (IMR) decreased 2.9% from 558.3 infant deaths per 100,000 live births in 2019 to reach a record low of 541.9 in 2020.

US SPORTS As daily COVID-19 incidence and the prevalence of the Omicron variant surge in the US, professional and collegiate sports have been forced to rapidly adapt their COVID-19 protocols and mitigation plans. 

National Hockey League: The NHL postponed a number of games already this season due to COVID-19 outbreaks on affected teams. But this week, the league suspended all games and team activities through Saturday, December 25, starting the scheduled Christmas break 2 days early. Including the games during this period, the NHL has postponed 50 games since the season began on October 12. Notably, more than 15% of all NHL players are currently under the league’s COVID-19 protocols. The NHL and the NHL Players Association also announced that NHL players will not be participating in the 2022 Winter Olympic Games in Beijing, China, due to the disruptions to the NHL schedule. The NHL is expected to reschedule postponed games during that period.

National Football League: At the start of the season, the NFL (American football) announced that it would not reschedule games due to COVID-19, but last week, it reversed its position due to more than 150 players and coaching staff testing positive across multiple teams. The league rescheduled 3 games last week, moving an extra game to Monday and 2 games to Tuesday. In response to increasing positive tests, the NFL updated its COVID-19 protocols in an effort to allow players to return sooner after a positive test. Following a number of asymptomatic or mild cases among NFL players, including those infected with the Omicron variant, the NFL shifted from weekly testing for vaccinated players to “a random cadence” or if a player develops symptoms. Less frequent testing will allow more players to be available, but it will likely miss some asymptomatic infections, including individuals who could be infectious. Additionally, vaccinated, asymptomatic players may be able to return to practice and games sooner under the new protocol.

National Basketball Association: While the NHL and NFL are updating their COVID-19 protocols and adjusting the league schedule, the NBA reportedly intends to continue with its season. While some NBA games have been postponed, NBA Commissioner Adam Silver indicated that there are no plans to suspend the season. Additionally, the NBA currently does not have any plans to update its COVID-19 protocols to allow players to return sooner after a positive test. The NBA suspended 7 games over the past week alone, and more than 90 players are under the league’s COVID-19 protocols. Commissioner Silver commented that approximately 90% of new cases are a result of the Omicron variant.

College Football: As the NCAA looks ahead to the College Football Playoff (CFP), it announced that the National Championship could be decided by forfeit if teams are unable to compete due to COVID-19. If teams are unable to play in the CFP semifinals, there is no opportunity to reschedule the game. That team would be forced to forfeit, and their opponent would move on to the championship game, and if neither team is able to play, the winner of the other semifinal game would automatically be declared the National Champion. If teams in the championship game are unable to play, that game could be moved from January 10 to as late as January 14. If the game cannot be held by then, a team that cannot play would forfeit and its opponent would be declared the National Champion. If neither team can play, then the National Championship will be vacated for this season. In preparation for the CFP, several of the competing teams have implemented additional protective measures to reduce the risk of COVID-19 impacting the coaches and players. The University of Alabama has reportedly reinstated its original COVID-19 protocols, including mask use and physical distancing at team facilities. Similarly, the University of Michigan restored masking and physical distancing as well as grab-and-go meals, and the players reportedly received booster doses of the SARS-CoV-2 vaccine as a team on December 22.