COVID-19 Situation Report
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EPI UPDATE The WHO COVID-19 Dashboard reports 163 million cumulative cases and 3.4 million deaths worldwide as of 5:45am EDT on May 18. As India’s current COVID-19 surge peaked and began to decline, global weekly incidence decreased for the second consecutive week, down more than 12% compared to the previous week. Global weekly mortality also declined for the second consecutive week, down nearly 5% from the previous week. Notably, the global trend in mortality is not lagging incidence by 3-4 weeks, as we have observed previously during the pandemic. It is not immediately apparent why this is the case, and it warrants monitoring over the coming weeks.
India’s daily incidence continues to decrease sharply from its peak on May 8 (391,282 new cases per day). Notably, the rate of decrease since the peak appears to be even sharper than the steep increase prior to the peak. The current daily incidence is 319,497 new cases per day, representing a 18% decrease over the past 9 days. India’s test positivity is also decreasing sharply, down from a peak of 22.7% on May 8 to 18.9% on May 15*, a 17% decrease over that period. While India’s test positivity remains elevated, which suggests that the official reports continue to undercount the true daily incidence, the decreasing trend provides an indication that testing volume is beginning to catch up to the scale of community transmission.
*The most recent data available for India.
Global Vaccination
The WHO reported 1.26 billion doses of SARS-CoV-2 vaccines administered globally, including 637 million individuals with at least 1 dose, but these data have not been updated since May 12. Our World in Data reported 1.50 billion cumulative doses administered globally, an increase of 13% over the previous week. Daily doses administered continues to increase, up to a new record of 24.7 million doses per day. Our World in Data estimates there are 360 million people worldwide who are fully vaccinated, corresponding to approximately 4.6% of the global population, although reporting is less complete than for other data.
UNITED STATES
The US CDC reported 32.8 million cumulative cases and 583,074 deaths. On May 16, the US reported 17,724 new cases, the first day with fewer than 20,000 new cases since June 15, 2020, and the lowest single-day total since June 7, 2020. On May 14, the United States’ per capita daily incidence fell below 10 daily cases per 100,000 population for the first time since early in the country’s second surge. The current daily incidence (30,211 new cases per day) is the lowest since June 23, 2020. Between the first and second surges, the lowest average daily incidence was 19,817 new cases per day (June 1, 2020), the only day below 20,000 since March 2020. If the US continues on its current trajectory, it could fall below that number in the next week or so. At 545 deaths per day, the current daily mortality is at its lowest point since April 1, 2020, which was less than 1 month after the first COVID-19 death was reported in the US.
Daily incidence and mortality continue a prolonged decline, first from the largest peak in January 2021 and again following the minor surge that peaked in mid-April. Testing volume similarly decreased over that time. At the national level, test positivity peaked at nearly 15% in early January 2021, the highest point since the initial surge in early 2020, when testing capacity was extremely limited and eligibility was focused on symptomatic patients. From there, both testing volume and positivity decreased substantially through mid-March 2021, as the US recovered from its winter surge. Testing volume increased only slightly during the March-April surge, but test positivity increased over that period, from 4% to nearly 5.5%. Test positivity decreased steadily after that peak, and on May 16, the CDC reported the lowest average since it started tracking it on March 1, 2020 (3.32%).
In total, 10 states are reporting test positivity* of more than 5%. Of these states, only Montana is reporting an increasing trend, up from 3.52% on March 28 to 5.17% on May 15. Most of these states—including Florida (5.58%), Michigan (6.36%), Nebraska (5.89%), Oregon (5.02%), South Dakota (6.94%), Tennessee (5.18%), and West Virginia (5.97%)—have reported declines in test positivity since mid-to-late April, and if they continue on their respective current trajectories, they could fall below 5% in the near future. Indiana’s test positivity (5.18%) increased after its most recent surge and has hovered around 4.5-5.5% since then. Alabama (5.44%) has largely hovered around 5.25-6% since mid-March.
The majority of states are reporting steady declines in test positivity over the past several weeks, particularly since the peak of the most recent surge in mid-April. Massachusetts is reporting the lowest test positivity, at 1.03% and still decreasing. New Mexico and Utah have reported steadily increasing test positivity since late March/early April. New Mexico’s average is up from a low of 1.93% to 2.66% in its more recent report on May 5, and Utah’s average has increased from 3.73% on April 4 to 4.6%. Louisiana (3.61%) is reporting a slight increase over the past several weeks, up from 2.62% on May 1. Arizona is exhibiting a similar trend, but on a longer timeline. Arizona’s test positivity has increased slowly from a low of 3.58% on March 24 to 4.95% on May 12, before falling slightly to 4.69%. The overall decreasing trends, including a number of states that are setting or approaching new record lows, is an encouraging indication that testing volume is reaching and sustaining at a level that can accurately capture the scale of community transmission.
*Data not available for May 16; the values reported here correspond to the most recent data available for each state, most of which are from May 15.
US Vaccination
The US has distributed 345 million doses of SARS-CoV-2 vaccine and administered 274 million. Daily doses administered* continues to decrease steadily, down from a high of 3.3 million on April 11 to 1.6 million. Approximately 1.1 million people are achieving fully vaccinated status per day, down from a high of 1.8 million per day on April 12.
A total of 158 million individuals in the US have received at least 1 dose of SARS-CoV-2 vaccine, equivalent to 48% of the entire US population and 60% of all adults. Of those, 124 million are fully vaccinated, which corresponds to 37% of the total population and 47% of adults. Among adults aged 65 years and older, progress has largely stalled at 85% with at least 1 dose and 73% fully vaccinated. Among individuals aged 12-17 years—including individuals aged 16 and 17 who were previously eligible—3.3 million have received at least 1 dose, and 1.6 million are fully vaccinated. In terms of full vaccination, 64 million individuals have received the Pfizer-BioNTech vaccine, 50 million have received the Moderna vaccine, and 9.6 million have received the J&J-Janssen vaccine.
*The US CDC does not provide a 7-day average for the most recent 5 days due to anticipated reporting delays for vaccine administration. This estimate is the most current value provided.
US CDC MASK GUIDANCE Following the US CDC’s announcement of updated mask guidance on May 14, federal health officials have spent the past several days “defending” the updated guidance. Numerous accounts describe the new guidance that eliminated recommendations for mask use and physical distancing for fully vaccinated individuals in most situations as “surprising” or “startling.” Reportedly, the CDC did not brief state and local health officials on the changes prior to the announcement, which resulted in many being caught off guard by the new guidance. Numerous states and businesses removed or relaxed mask mandates in response to the change, some with little or no advance notice. The sudden change has caused confusion among the public, state and local health and elected officials, and schools and businesses, particularly regarding whether (and how) to maintain mandates for unvaccinated individuals while allowing vaccinated individuals to go maskless.
Some experts applauded the change, but others expressed concern about both the policy’s content and its rollout. While many felt guidance has evolved too slowly, the CDC is now being criticized for overcorrecting and moving too quickly. Some are concerned that the change—and subsequent end of mandates—will encourage individuals to forego COVID-19 protective measures, such as mask use, even if they are not yet vaccinated, which could increase the risk for individuals who are not yet fully protected. Some argue that the guidance is based, at least in part, on the assumption that anyone who wants to get vaccinated is already fully protected. Notably, some states only expanded eligibility to everyone aged 16 years and older in late April, adolescents aged 12-15 have only been eligible since May 12, children under the age of 12 are still not eligible at all, and millions of individuals with compromised immune systems either cannot be vaccinated or may only obtain partial protection. National Nurses United, the country’s largest nurses union, issued a statement opposing the new guidance, emphasizing concern about ongoing elevated daily incidence, increasing prevalence of variants of concern, risk to healthcare workers and patients, and the disproportionate impact on historically underserved Black, Hispanic/Latino, and Indigenous populations.
CDC Director Dr. Rochelle Walensky emphasized that the risk of infection and transmission for vaccinated individuals is very low and that the changes stem from evolving data. She also encouraged “individual assessment of...risk” and stressed unvaccinated individuals should continue practicing physical distancing and mask use. White House Chief Medical Advisor Dr. Anthony Fauci acknowledged that additional clarification on the new guidance likely would be published in the coming weeks.
US VACCINE ACCESS As vaccination progress in the US slows, health officials are increasing efforts to understand and mitigate the remaining barriers, particularly in undervaccinated populations. Much attention has been given to vaccine hesitancy, particularly in the context of historical examples of unethical medical practices in communities of color, the lasting effects of systemic racism, and political divisions. However, vaccine hesitancy may be less of an issue among some communities than barriers to accessing the vaccine.
The declining trend in daily doses administered, particularly in the context of increasing supply, could signal waning demand, but evidence shows that interest remains high. In fact, recent data from the US Census Bureau indicates that more than 40% of adult Americans who have not yet been vaccinated are interested in doing so, which is more than those who do not intend to get vaccinated (37.8%; 21.6% remain unsure). Many individuals are finding it difficult to make time to get vaccinated, particularly lower-income individuals who do not have the benefit of paid time off to get vaccinated and who may be working multiple jobs to provide for their families.
Looking ahead, there appears to be a shift away from large-scale, centralized mass vaccination sites and toward smaller efforts that disperse vaccination sites throughout communities. Vaccination availability at national and regional chain pharmacies and drug stores has increased access in many communities, but including primary care offices and mobile programs to reach people at home or other convenient locations can further increase accessibility. In addition to making vaccination more convenient, community-based efforts also can make vaccination more comfortable by involving vaccinators or advocates who have established relationships in the community.
US VACCINE DONATIONS On May 17, US President Joe Biden announced the US government will send an additional 20 million SARS-CoV-2 vaccine doses abroad. Previously, the US government announced a donation of 60 million doses of the AstraZeneca-Oxford vaccine as soon as they are reviewed by the US FDA, and Monday’s announcement adds at least 20 million doses of vaccines already authorized in the US. The government also previously committed to providing about 4 million doses of vaccine to Canada and Mexico, although in the form of a loan. According to a White House fact sheet, the government will continue to donate vaccines from its excess supply as it receives delivery of that supply. US government officials are expected to announce in the coming days how they are deciding where to send vaccines.
The US has come under increasing pressure to play a larger role in global vaccination efforts, as countries in South Asia and South America struggle with outbreaks. Additionally, US diplomats and other experts are pressing the US to move more quickly in helping to distribute vaccines to counter efforts by China and Russia, over concerns that those countries are using their homegrown vaccines as political collateral. The US government explicitly states it “will not use its vaccines to secure favors from other countries.” US diplomats in South Asia, the Middle East, and Africa say they received urgent requests from officials in their host countries for COVID-19 assistance. On Monday, President Biden committed to working with the international community, including the COVAX facility and G7 leaders, to play a significant role in helping to slow the pandemic’s global toll.
TRACKING VARIANTS GLOBALLY Researchers and health officials are tracking the emergence of several variants of concern (VOCs), including B.1.1.7, B.1.351, P.1, and the B.1.617 variant that appears to be driving the surge in India. Because emerging variants may behave differently, which can affect the effectiveness of protective measures (e.g., physical and social distancing, vaccines), it is critical to quickly identify and characterize new variants and to identify their origin.
One of the principal challenges in identifying and tracing VOCs back to their origin is genomic sequencing capacity at the global and national levels. Countries vary widely in terms of the proportion of COVID-19 cases that they can sequence, and even higher-income countries like the US have struggled to scale up this capacity in the midst of the pandemic. Health officials also are monitoring the geographic spread of VOCs, such as possible expansion of the B.1.617 from India to neighboring countries, including Sri Lanka and Nepal. The national sequencing capacity in many countries would be limited under ideal circumstances, but restricted travel during the pandemic is further stressing available resources by delaying the delivery of supplies, such as the reagents necessary for genomic sequencing. A number of organizations are supporting efforts to expand laboratory capacity to monitor emerging variants, including the Coalition for Epidemic Preparedness Innovations, which is expanding its laboratory network to provide better global surveillance coverage for emerging variants—from 8 laboratories to 10—with a focus on assessing vaccine efficacy against VOCs, part of a US$17.5 million effort.
VACCINATION TIMING When rolling out its vaccination program at the end of 2020, the UK made a bold and controversial decision to recommend a longer interval between SARS-CoV-2 vaccine doses to extend its limited supply and maximize the number of people who would at least be partially protected from hospitalization and death. Now a study (preprint) published May 17 by medRxiv shows delaying the second dose of the Pfizer-BioNTech SARS-CoV-2 vaccine to 12 weeks instead of 3 weeks produced a much stronger antibody response among older adults. Researchers from the University of Birmingham and Public Health England found that delaying the second shot of the mRNA vaccine produced peak antibody responses 3.5-fold higher among people aged 80-99 years who had no evidence of previous infection when compared with those who received the vaccine after the recommended 3-week interval. Cellular immune responses were 3.6-fold lower among those in the 12-week group but that did not impact antibody level decline over 9 weeks post-final vaccination. The researchers noted the extended interval has the potential to enhance and extend humoral immunity among older individuals, although further research is needed to assess long-term immunity and clinical protection. This data—as well as data from a predictive modeling study from US researchers published in The BMJ showing delaying mRNA vaccine second doses could reduce deaths, hospitalizations, and infections among people aged 65 and older if certain conditions are met—could inform other countries’ vaccination efforts and recommendations.
PFIZER-BIONTECH VACCINE STORAGE The European Medicines Agency Committee for Medicinal Products for Human Use (CHMP) updated its recommendation regarding the storage of the Pfizer-BioNTech SARS-CoV-2 vaccine. The new guidance extends the duration that thawed but unopened/undiluted vials of the vaccine can be stored at normal refrigerator temperatures (2-8°C; ~36-46°F) from 5 days to 31 days. This change will facilitate vaccination efforts, particularly those conducted outside of healthcare facilities, by reducing the dependence on ultra-cold freezers. The CHMP approved the change based on an assessment of “additional stability study data” submitted by BioNTech. The US FDA previously extended the storage period for frozen vials at regular freezer temperature to 2 weeks, but it has not extended storage for thawed vials. The US FDA guidance continues to limit the storage of thawed vials at refrigerator temperatures to 5 days.
INDIA India’s cumulative COVID-19 caseload passed 25 million today, as Cyclone Tauktae hit the western states of Gujarat and Maharashtra, complicating pandemic response efforts in those already hard-hit states. Although India recently reported adecline in new COVID-19 cases, the number of daily deaths remains above 4,000, and health experts estimate the true burden of COVID-19 in the country to be much higher due to poor testing availability, fear and stigma of getting tested, and limited health service capacity especially in rural areas. In Mumbai, the number of new cases has dropped precipitously, and New Delhi is beginning to see shrinking caseloads, with some experts attributing the declines to strict and tightly enforced lockdowns. Others lament the lack of adequate preparedness and government-facilitated response, especially given India’s size, population density, and social structure.
In a comment published online May 14 by The Lancet, a group of clinicians, public health professionals, and scientists working in India or with collaborators in the country endorsed the national action plan put forth by The Lancet COVID-19 Commission India Task Force and outlined 8 steps for the international community to help ameliorate the crisis in India, including expanding healthcare capacity, scaling up mass vaccination and testing, and stepping in to ensure the global supply chains of medications produced in India is not interrupted.
SINGAPORE With the number of new COVID-19 cases rising inSingapore, health officials are expressing concern over unknown chains of community transmission, and the government has tightened measures meant to control the virus’s spread. Increased restrictions on travel and in-person activities—such as restaurant dining and limitations on social gatherings—began on May 16 and will run through June 13. The number of new cases without a link to an identified case has more than doubled over the previous week. Overall, 71 new cases have been identified in the last week, up from 48 the previous week, with a cluster linked to Changi Airport. Singapore’s increase in cases and move to tighten restrictions is hindering its ability to meet criteria to open an “air travel bubble” with Hong Kong, which was expected to open on May 26. Officials plan to reevaluate the launch of the travel bubble no earlier than June 13.
UK EASING RESTRICTIONS The United Kingdom moved this week into their third of 4 phases to lift COVID-19 restrictions. In this phase, pubs and restaurants are allowed to serve customers indoors, museums and movie theaters can open, and more people from separate households can gather. Additionally, travel restrictions have been somewhat eased, with destination countries classified as “red,” “amber,” or “green” depending on each country’s situation. The different color classifications also outline various requirements for quarantine following travel. Supporting the easing of restrictions is the UK’s strong vaccination program, which has delivered a first dose to nearly 70% of its population. However, the proportion of the population fully vaccinated remains closer to 36%.
While the vaccines appear to be contributing to decreasing COVID-19 cases overall, the UK government is concerned with the spread of the B.1.617.2 variant that was first identified in India. Current evidence suggests that the B.1.617.2 variant may be even more transmissible than the B.1.1.7 variant but current evidence suggests it does not cause more severe disease. Still, the UK has pledged to speed up its vaccinations in order to remain abreast of the variant’s spread. It is hoped that the B.1.617.2 variant will not disrupt further relaxations of COVID-19 restrictions or, in a worse case, cause the country to reinstate stricter measures.
GLOBAL EXCESS MORTALITY On May 14, The Economist published statistical modeling that estimates 7-13 million people have died worldwide as a result of the COVID-19 pandemic, approximately 2-4 times the deaths reported in the official WHO data. The model is based on 121 indicators and modeled excess mortality in more than 200 countries. They used a machine learning approach to identify relationships between the various indicators and excess mortality in countries that report it and then used those relationships to project excess mortality at the national level for all of the included countries.
The model estimates 10 million excess deaths (95% CI: 7.1-12.7 million) globally. Notably, excess deaths include those directly attributable to COVID-19 as well as those due to downstream effects of the pandemic. The Economist researchers assert that the most severe impact of excess mortality is in low- and middle-income countries, where SARS-CoV-2 testing is less widespread, which could result in the underreporting of COVID-19 cases and deaths. In India, the researchers estimate that 20,000 people are dying each day, 5 times the 4,000 deaths per day reported in India’s official COVID-19 data. Some countries—including Australia, New Zealand, and Norway—actually have negative excess mortality (ie, fewer deaths than expected based on historical data). These countries have faced relatively mild COVID-19 epidemics, and the decreased mortality could be a result of COVID-19 measures (eg, physical distancing, mask use) on other causes of deaths, such as seasonal influenza.
Notably, the researchers estimate that on a per capita basis, the impact of COVID-19 has been worse in higher-income countries. They posit that this could be driven by differences in population age. Because older individuals are at elevated risk for severe COVID-19 disease and death, countries with older populations—which tend to be higher-income countries—may have elevated COVID-19 mortality, while lower-income countries with younger populations may have higher incidence but lower mortality.
COVID-19 “LONG HAULER” REGISTRIES Long-term symptoms following recovery from acute SARS-CoV-2 infection continue to be described for a nontrivial portion of the population. Commonly described symptoms of so-called “long COVID-19,” also known as Post-Acute Sequelae SARS-CoV-2 infection (PASC), include brain fog, trouble breathing, and fatigue. To gain insight into lasting COVID-19 symptoms, some US state and federal lawmakers are pushing to create COVID-19 registries to track such cases. These registries could be modeled on the registry created to track chronic illnesses among those exposed to toxins during the September 11, 2000, World Trade Center attacks. New York state lawmakers have drafted legislation for a registry based on this model. Through these voluntary registries, researchers will be able to analyze possible patterns within the data to target potential treatments. Already, some studies are underway to evaluate the effect of vaccination on improving “long COVID-19” symptoms. One survey indicated improvement of lasting symptoms in just over half of 812 people surveyed following their first vaccine dose. The data also showed mRNA vaccines appear to have a greater effect on symptom improvement compared to other types of vaccines.
“COVID HEART” According to a case-control study published in JACC: Cardiovascular Imaging, SARS-CoV-2 infection does not impact the heart more than other viral illnesses. The issue of “COVID-19 Heart” was first introduced into mainstream media early in the pandemic, when some researchers expressed concern over the potential impact of SARS-CoV-2 infection on cardiovascular health. Results from this recent study, which examined 74 seropositive healthcare workers 6 months post-infection and 75 seronegative matched control subjects, showed no differences between cardiac structure, function, tissue or biomarkers. Some experts say data from this study, along with information from several others, should be sufficient evidence to show COVID-19 does not cause cardiac problems. Though COVID-19 can result in some cardiac issues, like other viral diseases, science communication in the future must do a better job of explaining the scientific review process, methodology, and study implications, experts maintain.
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