US be concerned about India’s COVID 19 crisis

India's COVID tsunami is the worst in the world. Why that should concern Americans.

Andrew Romano

·West Coast Correspondent

Thu, April 22, 2021, 9:02 AM

In America, it’s easy to believe — and likely correct, given the country’s rapid pace of vaccination and high level of prior infection — that the worst of the COVID-19 pandemic is over.

But in India right now, every day is worse than the last.

“In the last 24 hours alone, [India has] had 300,000 cases, and that’s most certainly an undercount,” said Dr. Kavita Patel, a Yahoo News medical contributor. “In some parts of India, like Mumbai and New Delhi, as high as 1 in 3 or 1 in 4 people are testing positive, [and that’s] actually, again, an underestimate. As a result, India’s hospitals are completely full. There is now rationing of everything, including doctors, nurses, oxygen, beds, supplies.”

More than one year into the pandemic, the deepening disparities between two of the world’s largest countries should remind optimistic Americans that the light at the end of their own tunnel remains a long way off for most of the planet’s population — and that it’s probably time for the U.S. to start thinking about how it can help end the pandemic elsewhere too.

A woman in Ahmedabad, India, is consoled Tuesday after her husband died from COVID-19. (Amit Dave/Reuters)

At its peak this winter, the U.S. was recording an average of 260,000 new COVID-19 cases each day. Yet after skyrocketing 122 percent over the last 14 days, India’s daily case counts have already crossed that threshold twice this week. The curve is so steep, it’s almost vertical.

If the virus continues to spread at the same clip, according to Bhramar Mukherjee, a biostatistician at the University of Michigan, India could be averaging half a million new daily cases within the next month — a figure that no other country has ever come close to. Deaths are likely to follow: Over the past two weeks alone, they have soared 128 percent.

At this point, India accounts for about 1 in every 3 new cases globally. Its rate of spread is the fastest in the world. And the tsunami shows no sign of subsiding anytime soon.

But the bigger problem is that these terrible numbers tell only part of the story. For one thing, India is currently testing at a much lower rate (about 1 test per 1,000 residents per day) than the recent high-water marks in Western countries such as the U.S. (5.5), France (8) or the U.K. (21). Meanwhile, in Delhi, one of India’s hardest-hit areas, test positivity reached 30 percent this week, prompting a six-day lockdown. The combination of inadequate testing and high positivity suggests that hundreds of thousands of infections are going undetected each day.

A health worker tests a girl for COVID-19 in Srinagar, Indian-controlled Kashmir, on Wednesday. (Dar Yasin/AP)

Many — perhaps most — COVID-19 deaths are being missed as well. India is currently averaging more than 1,100 daily deaths, the second-highest level in the world after Brazil. But as Ramanan Laxminarayan, an economist and epidemiologist who is the founder and director of the Center for Disease Dynamics, Economics & Policy, explained in a recent interview with the New Yorker, “We don’t know the cause of death for four out of five people in normal times” in India because “only one in five deaths is medically recorded” — and “that has continued during COVID.”

At the same time, Laxminarayan continued, “the levels of testing are so low that the people who didn’t get tested and then died of a stroke or a heart attack that was likely COVID-related would not be reported as a COVID death.”

The undercount, in other words, is probably huge.

Reports from the frontlines of India’s spiraling surge support this theory. According to a Reuters investigation published Monday, “Several major [Indian] cities are reporting far larger numbers of cremations and burials under coronavirus protocols than official COVID-19 death tolls, according to crematorium and cemetery workers, media and a review of government data.”

Relatives wearing personal protective equipment at the funeral of a man who died from COVID-19, at a New Delhi crematorium on Wednesday. (Adnan Abidi/Reuters)

In Surat, for instance, Reuters reported that over the last week, two facilities have cremated more than 100 bodies a day under COVID protocols — far in excess of the city’s official daily COVID death toll of around 25. At one of them, gas and firewood furnaces have been running so long without a break that “metal parts have begun to melt.”

In Lucknow, data from the largest COVID-only crematorium shows that the number of bodies that arrived on six different days in April was twice as high as the official number of deaths recorded across the entire city. Elsewhere, India Today reported that two Bhopal facilities alone cremated 187 bodies on days when the city’s official death toll stood at five, and in Ahmedabad last week, 63 bodies left a single COVID-only hospital for cremation on a day when the entire city recorded just 20 coronavirus deaths.

Hospitals, likewise, are on the brink of collapse. “There are two patients per bed in the big hospitals in New Delhi, and that’s if you can get into the hospital in the first place. There are literally lines of ambulances that are fifty or a hundred long,” Laxminarayan said. The result is a vicious cycle: the more patients have to compete for limited beds, oxygen and medicine, the more care suffers — and the more people die who could have been saved.

Ambulances carrying COVID patients at a dedicated COVID-19 government hospital in Ahmedabad, India, last week. (Ajit Solanki/AP)

“The huge pressure on hospitals and the health system right now will mean that a good number who would have recovered had they been able to access hospital services may die,” Gautam Menon, a professor at Ashoka University, told Reuters.

The point is not just that the situation is bad in India, and likely to deteriorate even further. The point is that India is not all that unique. Like many poorer countries across the developing world, it seemed to dodge a bullet during earlier stages of the pandemic, leaving most of its population untouched — and lacking any immunity.

Like many of those same countries, India was lulled into a false sense of security after a seemingly successful lockdown and a recent ebb in infections; less than two months ago, the country’s health minister announced that it had entered “the endgame” of the pandemic, and mass gatherings — cricket matches, large weddings, election rallies — promptly resumed. And as in nearly all other developing countries, barely anyone in India — just 8 percent of its vast population — has received at least one vaccine dose.

Hindu holy men, not following COVID-19 precautions, in the Ganges River earlier this month in a ritual called Shahi Snan, or royal bath. (Danish Siddiqui/Reuters)

To put that in perspective, 40 percent of Americans, 50 percent of Britons and 60 percent of Israelis have received at least one vaccine dose.

Yet globally, the U.S., the U.K. and Israel are outliers. So far, just 33 countries have administered one vaccine dose to at least 20 percent of their residents. The other 160 or so haven’t — and more than 100 of them are lagging even further behind than India.

Epidemiologists tend to tell Americans they should care about these inequities because they pose a direct risk to America’s progress against the pandemic in the form of variants, or mutant versions of the virus that can potentially dodge immunity, evade vaccines and/or transmit more efficiently from person to person. Why? Because dangerous variants are most likely to evolve in places where spread is high and lots of people are sick for long periods of time.

And it’s true, for what it’s worth, that India is now battling a concerning variant of its own. Called B.1.617, it is a “double mutant,” with a pair of protein-spike changes that may increase its transmissibility and help it partly resist immunity. Scientists are still trying to figure out what role, if any, B.1.617 is playing in India’s surge. To be safe, the U.K. on Monday banned travel from India, and Prime Minister Boris Johnson canceled his own trip there.

The bottom line, however, is that India — with its relative lack of prior immunity, its slow rate of vaccination, its mass gatherings and its close quarters — was vulnerable to a massive COVID-19 surge even without a new variant making matters worse. And so are most other countries around the world.

A notice about a COVID-19 vaccine shortage in Mumbai on April 8. (Francis Mascarenhas/Reuters)

By the same token, a country like the U.S. — home to just 4.3 percent of the world’s population but a full 23.9 percent of its vaccinations — is increasingly invulnerable. Even the risk of variants is likely overhyped in America: The existing vaccines still protect against them, and extra-effective booster shots are already in development.

So as U.S. supply starts to exceed demand — and as even the nation with the world’s largest vaccine maker struggles to vaccinate its own people — the question then becomes: What is America, with a population of 328 million, ultimately going to do with the rest of the 1.2 billion vaccine doses it has already secured?

“Now that we have experienced our own supply and it is sufficient for our entire population, [the United States] should shift gears to thinking about allocating any excess vaccines, as well as our own domestic manufacturing ability, to help other countries,” said Patel.

“That is something that we’re going to have to contend with as we are getting closer and closer to our own herd immunity … but other countries are significantly behind.”

Above is from:  https://www.yahoo.com/news/indias-covid-tsunami-is-the-worst-in-the-world-why-that-should-worry-americans-140203352.html

April 21: 2765 New COVID 19 Cases in Illinois

April 20: 2587 New COVID 19 Cases in Illinois

April 20: Johns Hopkins COVID 19 Report

COVID-19

The Center also produces US Travel Industry and Retail Supply Chain Updates. You can access them here.

EPI UPDATE The WHO COVID-19 Dashboard reports 141.5 million cases and 3.0 million deaths as of 4:30am EDT on April 20. Global weekly incidence and mortality continue to increase. Last week, the WHO reported a new record high for weekly incidence, with 5.23 million new cases, a 14% increase over the previous week. Weekly incidence has increased for 8 consecutive weeks, and it appears to be accelerating. Global weekly mortality has increased for 5 consecutive weeks, up to 83,021 deaths, a 7.6% increase over the previous week and the highest weekly total since early February.

The global surge is largely driven by the epidemic in India, which continues to set new national records. On April 17, India became the second country to exceed 200,000 new cases per day, after the US. India is currently reporting 233,074 new cases per day, and its epidemic continues to accelerate. If it continues on this trajectory, India could surpass 250,000 new cases per day and set a new global record in the next 1-2 days. India set its national single-day incidence record on April 18, with 273,802 new cases before falling slightly to 259,167. India is #2 globally in terms of total daily mortality, with 1,353 deaths per day, and still accelerating rapidly. India is reporting fewer than half the daily mortality of #1 Brazil (2,866), but on this trajectory, it could close that gap quickly.

Turkey continues to exhibit a concerning surge as well. At 60,003 new cases per day, Turkey is now within 11% of the US (#2; 67,122) in terms of total daily incidence. Turkey’s COVID-19 surge appears as though it could be starting to level off, but it could potentially approach Brazil or the US in the near future.

Global Vaccination

The WHO reported 843 million vaccine doses administered globally as of April 20, including 450 million individuals with at least 1 dose. The WHO dashboard does not yet include data for daily or weekly vaccinations or fully vaccinated individuals.

Our World in Data reports 920 million doses administered globally. The global cumulative total continues to increase at a rate of approximately 18% per week. The daily average has declined for 5 consecutive days, down from 18.6 million doses per day on April 14 to 15.6 million on April 19. At least 185 countries and territories* are reporting vaccination data.

*Out of 191 reporting COVID-19 incidence data.

UNITED STATES

The US CDC reported 31.5 million cumulative cases and 564,292 deaths. Daily incidence has decreased slightly over the past several days—down from 69,953 new cases per day on April 13 to 66,747 on April 18. The daily incidence is still elevated compared to several weeks ago. Daily mortality is slightly elevated compared to last week, but it has held relatively steady at approximately 700 deaths per day since April 12, approximately equal to the low reported immediately prior to the autumn/winter 2020 surge.

Michigan appears to have passed a peak in terms of daily incidence, but some inconsistencies in its recent reporting make it difficult to determine if this is the beginning of a longer-term trend. Michigan does not typically report COVID-19 data to the CDC on Sundays (or holidays), but last week—on Sunday, April 11—it reported 4,837 new cases.

US Vaccination

The US has distributed 265 million doses of SARS-CoV-2 vaccine and administered 211 million doses. Daily doses administered* remains steady at approximately 3 million, including 1.6 million people fully vaccinated.

More than half of all adults have received at least one dose of SARS-CoV-2 vaccine, and one-third are fully vaccinated. A total of 132 million individuals have received at least 1 dose of the vaccine, equivalent to 40% of the entire US population and 51% of all adults. Of those, 85 million (26% of the total population; 33% of adults) are fully vaccinated. Among adults aged 65 years and older, 80% have received at least 1 dose, and 65% are fully vaccinated. In terms of full vaccination, 42 million individuals have received the Pfizer-BioNTech vaccine, 35 million have received the Moderna vaccine, and 7.9 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.

In light of the US surpassing 50% coverage in terms of adults with at least 1 dose of SARS-CoV-2 vaccine, we will look at the partial coverage (i.e., 1 or more doses) at the state level**. New Hampshire stands out among all states, leading in terms of partial coverage among both all adults and adults aged 65 and older. In fact, New Hampshire is reporting at least 1 dose for 99.9% of its older adults. And its 71.2% partial coverage among all adults is nearly 10 percentage points higher than #2 New Mexico (61.5%). New Hampshire’s success is likely a factor in the state’s decision to open vaccination to non-residents starting April 19, the same day that the few remaining US states expanded eligibility to everyone aged 16 years and older.

Four other states are reporting partial coverage greater than 60% among all adults: New Mexico (61.2%), Connecticut (61.2%), Maine (60.3%), and Massachusetts (60.2%). The median is slightly higher than 50%, and most states fall between approximately 46% and 54%. Alabama (38.7%) and Mississippi (38.2%) are the only states reporting less than 40% partial coverage among all adults. Impressively, the median coverage among adults aged 65 years and older is nearly 80%, with most states falling between 75-85%. In addition to New Hampshire, Vermont (93.6%) is reporting partial coverage greater than 90% among older adults. Hawai’i (69.3%) and West Virginia (69.5%) are the only 2 states reporting less than 70% coverage among older adults.

Most of the states that fall in the top and bottom 10 in both partial and full coverage. In fact, 7 states appear in the top 10 of both lists, and 8 appear in the bottom 10 of both lists. However, Hawai’i ranks #25 for partial coverage among all adults (50.1%), but it falls all the way to #50 among adults aged 65 years and older (69.3%). Kansas falls from #9 in terms of partial coverage among older adults (86.5%) to #21 among all adults (52.5%). Both New Mexico and New Jersey rank in the top 10 for all adults but fall 12 places for older adults. New Mexico ranks #2 in terms coverage among all adults (61.5%) and #14 (84.3%) among older adults, and New Jersey falls from #6 among all adults (58.8%) to #18 for older adults (82.3%).

**By state of residence, even if individuals received the vaccination in another state.

ROUTES OF TRANSMISSION Scientific evidence increasingly supports the theory that the primary mode of SARS-CoV-2 transmission is through airborne infectious aerosols passed from person-to-person, according to some researchers. In three separate pieces published last week, experts outlined reasoning and evidence supporting SARS-CoV-2 transmission from both near-field and far-field aerosols. In a commentary published April 15 in The Lancet, researchers from the UK, US, and Canada present 10 reasons backing airborne transmission. In another piece published online in JAMA on April 16, experts from Harvard University and the University of Michigan describe the rationale for improving air circulation and filtration in indoor spaces to reduce far-field transmission of SARS-CoV-2 and other respiratory infectious diseases. While noting that airborne viral particles are a significant route of SARS-CoV-2 transmission and calling for improved air ventilation in indoor spaces, experts from the UK, US, and China in an editorial published April 14 in The BMJ also underline the significance of mask quality and fit.

These pieces appeal to the public health community to take action to help improve indoor air quality, ventilation, and filtration, through policy and structural changes, particularly in healthcare, work, and educational settings. Such efforts could help reduce the number of COVID-19 cases as well as other airborne infectious diseases. The commentaries could be viewed as rebuttal to a systematic review funded by the WHO and published last month that says there is inconclusive evidence for airborne transmission. On April 19, a US CDC official said during a telephone briefing that the CDC has determined the risk of SARS-CoV-2 transmission via surfaces is low and secondary to transmission through direct contact with droplets and aerosolized particles. In light of the evidence, the CDC has updated its guidance for cleaning and disinfecting surfaces in community settings.

EMERGING VARIANT RESPONSE FUNDING The US government on April 16 announced it will invest US$1.7 billion from the American Rescue Plan to help states and local jurisdictions detect, monitor, and mitigate emerging variants of SARS-CoV-2. A White House fact sheet says that an essential component of these efforts is increasing genomic sequencing, especially in states experiencing surges of cases. According to the US CDC, the B.1.1.7 variant is now the dominant strain in the US, and several states have seen recent increases in cases due to the variant. The US government is committing US$1 billion of the total allocation to the CDC, states, and localities to bolster surveillance.Of the remaining funds, US$400 million will help create 6 new Centers of Excellence in Genomic Sequencing across the nation. These centers will work in partnership with state health departments and academic institutions to develop new concepts, methods, and technologies for genomic surveillance tools. Additionally, US$300 million will go toward developing and supporting a National Bioinformatics Infrastructure to help scientists track the spread of diseases and allow for improved decision-making. The fact sheet outlines funding distribution by state, noting the first tranche will be distributed in May with a second tranche expected to be invested over the next several years.

INDIA & BANGLADESH The city of Delhi, India initiated a weeklong lockdown on April 19 in an effort to stem a severe surge in cases. On Sunday, the city reported a record single-day case count, with 24,642 cases. As a result of the increasing number of cases, city hospitals have reported near-full ICU capacity and critical shortages of oxygen and drugs. Crematoriums also report being overburdened. During the lockdown, casual gatherings will be prohibited and non-essential businesses will be ordered to close, although essential services will be allowed to remain open. Weddings and funerals will be allowed to continue, albeit with capacity restrictions. Sporting events without spectators will be permitted to continue. Public transport will be reduced to 50% seating capacity. The city lockdown is scheduled to lift the morning of April 26. Various factors may be fueling this rise in cases in India, including recent mass gatherings, as well as a new variant of interest, B.1.617. In addition to the restrictions in Delhi, new mitigation measures have been implemented in localities in the states of Uttar Pradesh and Maharashtra.

Bangladesh enacted a similar but more restrictive lockdown on April 5, with the closure of shops and offices and the cessation of domestic transportation and international flights. Citizens have been asked not to leave their residences from 6pm-6am. Restrictions were expected to lift on April 22, but they have been extended an additional week. Several senior government officials indicated that the extended lockdown will be enforced more strictly, which could further exacerbate financial impacts on lower-income individuals. Reportedly, the government is considering easing some of the restrictions before the Eid holiday.

BREAKTHROUGH INFECTIONS With vaccination rates continuing to climb in the United States, many who are vaccinated are beginning to engage in more activities that could increase their exposure to SARS-CoV-2 infection. While the vaccines available under US FDA Emergency Use Authorizations are effective, there is still a chance that vaccinated persons can become infected with SARS-CoV-2. These “breakthrough” infections are considered rare events, with the CDC on April 19 reporting fewer than 6,000 cases out of 84 million vaccinated persons. The agency continues to monitor reports of breakthrough cases and launched a website with information for public health departments and laboratories to investigate and report such cases. The agency is monitoring the age, sex, type of vaccine, and underlying conditions from breakthrough cases, but no pattern among cases has been identified. When possible, monitoring also includes genomic sequencing to identify which virus lineage caused the infection.

US VACCINE ELIGIBILITY As of April 19, all US states have expanded COVID-19 vaccine eligibility to include all individuals aged 16 years and older, meeting the goal set by the US government to expand vaccine eligibility to all adults by April 19. Hawai’i, Massachusetts, New Jersey, Oregon, Rhode Island, and Vermont were the last states to meet the deadline yesterday.

AT-HOME TEST KITS On April 19, Abbott announced that its BinaxNOW rapid antigen at-home test kit is available for purchase in the US. The test is available without a prescription and provides results in approximately 15 minutes. Initially, the test kits will be available through national chain pharmacies, including CVS, Walgreens, and Walmart. At less than US$25 per kit—which includes 2 tests—they are likely still too expensive for routine daily testing. Over-the-counter (i.e., non-prescription) test kits provide a widely accessible at-home test that can be kept on hand or potentially obtained quickly for a variety of purposes, such as after an exposure to a known COVID-19 case or prior to travel. Abbott’s announcement indicates that it aims to produce “tens of millions” of tests per month, with the potential to increase capacity beyond that point, if necessary. The test kit received an Emergency Use Authorization from the US FDA in March 2021 for use in both symptomatic and asymptomatic individuals as young as 2 years old.

VACCINE DISINFORMATION Researchers are launching projects to catalogue and counteract misinformation and disinformation about SARS-CoV-2 vaccines on social media, as well as collect data on how that information spreads and influences vaccination uptake. One research consortium, called the Virality Project and started by experts from multiple US academic institutions, is using strategies learned during the 2020 US presidential election to help social media platforms counter vaccine mis- and disinformation. Earlier this year, Facebook and Twitter announced new policies aimed at stemming the spread of misinformation. The companies will remove offending posts and shut down accounts that perpetually post false information about vaccines. However, social media platforms increasingly are running up against “gray area misinformation,” or posts that do not contain explicitly false information but present only select facts that drive commentary meant to further misleading narratives. A researcher from the nonprofit First Draft News alleged that many of the same people who pushed misleading information via social media during the 2020 election also are peddling misinformation about vaccines and the COVID-19 pandemic.

US EXCESS DEATHS Researchers at the US CDC’s National Center for Health Statistics published a brief overview of excess deaths in the US since the start of the US COVID-19 epidemic. The study, published in the US CDC’s MMWR, analyzed mortality data from the National Vital Statistics System (NVSS), corresponding to deaths from 2013 through February 2021. Between January 26, 2020—the date of the first reported COVID-19 death in the US—through February 27, 2021, the researchers estimate 545,600-660,200 excess deaths above what would be expected during that period based on historical data. During that time, approximately 75-88% of the excess deaths were directly attributable to COVID-19, leaving 63,700-162,400 additional excess deaths. These additional deaths could potentially be directly attributable to COVID-19 (i.e., undiagnosed victims), or they could result from the downstream effects of the pandemic beyond the disease itself, including “disruptions in health care access or utilization.”

US FDA REVOKES BAMLANIVIMAB EUA On April 16, the US FDA terminated the Emergency Use Authorization for Eli Lilly’s investigational monoclonal antibody bamlanivimab as a treatment for COVID-19. Specifically, the agency terminated the EUA that authorized bamlanivimab as a treatment “when administered alone”*. Analysis of available clinical data found a “sustained increase of SARS-CoV-2 viral variants that are resistant” to the drug and “increased risk for treatment failure.” Bamlanivimab remains authorized for use in combination with etesevimab, another of Eli Lilly’s monoclonal antibodies. Notably, the FDA’s decision came at the request of Eli Lilly, but a press release from the company indicates that it does not currently intend to request the withdrawal of emergency authorization for bamlanivimab as a standalone treatment in any other country.

*Emphasis in original source.

TRIAL EXAMINING REPURPOSED DRUGS The US NIH on April 19 announced it is launching a large randomized, placebo-controlled clinical trial to test whether several existing prescription and over-the-counter medications can help resolve mild-to-moderate symptoms among people with COVID-19. The Phase 3 trial, part of the Accelerating COVID‑19 Therapeutic Interventions and Vaccines (ACTIV) public-private partnership, will explore up to 7 drugs approved by the US FDA for other conditions, a strategy called drug repurposing. According to the Washington Post, which quotes anonymous sources, several of the drugs under consideration for the trial include the antiparasitic ivermectin, the antidepressant fluvoxamine, and the acid-controller famotidine, the generic name for Pepcid. At least one study published in the March 4 JAMA showed that early administration of ivermectin did not significantly shorten the time to symptom resolution among nearly 400 adults with mild COVID-19 randomized to take ivermectin or placebo. As for fluvoxamine, 2 small studies, one published in JAMA and the other in Open Forum Infectious Diseases, showed the serotonin reuptake inhibitor helped reduce disease progression among those who took the drug compared with people who took a placebo or refused the drug. At least 3 other clinical trials are currently recruiting to test fluvoxamine, according to ClinicalTrials.gov, and a recent episode of 60 Minutes highlighted the drug’s potential as a COVID-19 treatment.

SUBUNIT VACCINE On April 19,Nature published an early-version manuscript describing research into a subunit SARS-CoV-2 vaccine that researchers hope will provide protective immunity against the virus. Subunit vaccines are widely used and highly effective against several infectious diseases. Researchers from various US-based institutions and the pharmaceutical company GSK showed positive results that a SARS-CoV-2 spike receptor binding domain on a protein nanoparticle (RBD-NP) can offer protection against the virus in non-human primates. The researchers evaluated 5 different adjuvants, showing variation in efficacy against SARS-Cov-2 variants and wild-type virus. With these promising results of an adjuvanted RBD-NP vaccine candidate among primates, the authors report the vaccine will move to Phase 1/2 human trials. A successful adjuvanted subunit vaccine potentially could help fill vaccination gaps in younger and older populations, as other such vaccines historically have good safety profiles in these group

April 19: 1959 New COVID 19 Cases in Illinois

April 16: Johns Hopkins COVID 19 Report

COVID-19

The Center also produces US Travel Industry and Retail Supply Chain Updates. You can access them here.

CommuniVax Webinar

As the COVID-19 vaccination campaign continues, it is critical that vaccines are delivered fairly and equitably—so that everyone has access.

Join us for a webinar, Community-Centric Public Health Practice: COVID-19 Vaccination and Beyond, hosted by CommuniVax, a Coalition to Strengthen the Community’s Involvement in an Equitable Vaccination Rollout, and the Johns Hopkins Center for Health Security. The session will examine the roles health departments can take in achieving health equity. Speakers will discuss real-world examples, best practices, ways forward for health departments pursuing health equity and how to build recovered, resilient communities.

Please register here.

EPI UPDATE The WHO COVID-19 Dashboard reports 138.4 million cases and 3.0 million deaths as of 5:15am EDT on April 16.

On April 13, India surpassed 150,000 new cases per day, and on April 14, it reported more than 200,000 new cases in a single day for the first time. India’s COVID-19 epidemic appears to still be accelerating. In fact, its average daily incidence is increasing at approximately 10,000 more new cases each day. If it continues on this trajectory, India could surpass 200,000 new cases per day in the next 2-3 days. India is only the second country to surpass 150,000 new cases per day, after the US; however, due to the size of its population, India remains well below the United States’ peak on a per capita basis. Turkey’s current COVID-19 surge is twice as high as its previous peak (December 2020), and it continues to move toward the US (#2) and Brazil (#3) in terms of total daily incidence.

As countries increase vaccination coverage, governments and experts are beginning to look for evidence of the vaccines’ effect on national COVID-19 epidemics. It remains unclear exactly what degree of coverage is necessary to make a noticeable impact on community transmission—or how that might depend on the current level of community transmission—so there is no clear target in place. It is likely that the vaccines will begin to slow community transmission before countries achieve the coverage necessary for herd immunity—ie, the level of immunity that will contain most outbreaks in the absence of other interventions (eg, mask use, physical distancing)—particularly in areas where COVID-19 restrictions remain in place. This week, we will look at COVID-19 incidence trends in countries with the highest vaccination coverage*.

Israel and Seychelles remain the top 2 countries in terms of SARS-CoV-2 vaccination coverage. Israel is #1 globally in terms of full vaccination coverage, with 57.3% of its population, and Seychelles is #2 with 46.7%. The ranks are reversed for partial vaccination (ie, at least 1 dose), with Seychelles at #1 (67.4%) and Israel at #2 (61.7%). Israel and Seychelles have made considerably more progress than the rest of the top 20 countries. In terms of full vaccination, the remaining countries range from Chile with 26.8% to Czechia with 7.7%. For partial vaccination, the UK is #3 with 47.8%, and Morocco is #20 with 12.3%.

Among these 20 countries, 9 are reporting increasing incidence over the past 2 weeks. Turkey is reporting the largest biweekly change, with daily incidence up 78.9% compared to 2 weeks ago. Bahrain (34.1%), Singapore (28.6%), and Morocco (24.3%) are all reporting increases of more than 20% over that period. Notably, Bahrain and Turkey are facing ongoing surges, while Singapore and Morocco are reporting consistently low daily incidence. While Turkey’s full vaccination coverage is still relatively low (9.2%), Bahrain’s coverage ranks #4 globally, with more than one-quarter of its population fully vaccinated. But even this level of coverage does not appear to be sufficient to contain Bahrain’s epidemic, although it appears to be leveling off to some degree over the past several days. Other countries among this group that are exhibiting clear increases in daily incidence include Chile, Denmark, Switzerland, and the US.

Each country’s epidemiologic situation is different, so it may not be possible to draw any direct conclusions solely based on vaccination coverage and incidence for each individual country, but perhaps grouping countries by coverage could allow us to identify relevant trends. Among the top 20 countries, 7 are reporting full vaccination coverage of less than 10%. Three (3) of these countries—Czechia, Iceland, and Romania—are reporting decreasing daily incidence, while the other 4—Denmark, Singapore, Switzerland, and Turkey—are reporting increasing trends. Five (5) countries are reporting 10-20% coverage. Among these countries, only Morocco is reporting increasing daily incidence, while Hungary, Malta, Serbia, and the UK are all decreasing. In fact, the UK’s epidemic has been declining from its highest peak since early January 2020, when its vaccination coverage was less than 1%. Another 6 countries are reporting 20-30% full vaccination coverage. This group is split evenly, with 3 countries reporting decreasing daily incidence—Monaco, San Marino, and the UAE—and 3 reporting increasing trends—Bahrain, Chile, and the US. The top tier includes just 2 countries: Israel and Seychelles, both with coverage greater than 40%. Israel’s epidemic has been declining since mid-January, when its vaccination coverage was less than 4%. Seychelles’ epidemic trends are more difficult to discern, but its monthly average does appear to show an overall decline from its largest peak.

Looking at just the top countries in terms of partial coverage, there is not much additional evidence of vaccination related trends. In terms of daily incidence, Chile’s epidemic has been steadily growing since late 2020, despite 40% of the population with at least 1 dose. Maldives and Malta are reporting decreases from their highest peak, which both occurred within the past month. The UAE is reporting a relatively steady decline from its highest peak, and the United States’ daily incidence has increased steadily over the past several weeks, despite increasing vaccination coverage. Bhutan has reported essentially zero daily incidence since late January, so it is difficult to identify any meaningful trend.

Clearly, we are not yet to the point at which we can draw definitive conclusions regarding the effect of national vaccination efforts on containing COVID-19. The clinical trials have demonstrated high efficacy at the individual level for many of the vaccines currently in use**, but it is more difficult to observe their effects on the population level. While countries like Israel and the UK are reporting consistent and long-term declines in daily incidence, the trends began well before vaccination coverage was at a meaningful level. It could be possible, however, that the current coverage is high enough to help keep low-level transmission suppressed. A number of other countries near the top in terms of vaccination coverage are reporting ongoing COVID-19 surges, including some that are setting new national records. Some of these countries are quite large, and regional differences in vaccination coverage and SARS-CoV-2 community transmission could be masked in national-level data. It is likely that the countries demonstrating success in terms of containing their respective COVID-19 epidemics are utilizing a combination of COVID-19 restrictions (eg, physical distancing, mask use) and vaccination. Without sufficient vaccination coverage to contain community transmission by itself, COVID-19 risk mitigation measures are still needed in the near term to drive down transmission until vaccination coverage is high enough.

*Not all countries that are reporting COVID-19 incidence data are reporting the number of partially (ie, at least 1 dose) or fully vaccinated individuals. We limited our analysis to the top 20 countries with available data for fully vaccinated individuals.

**Several vaccines do not yet have publicly available Phase 3 clinical trial data.

Global Vaccination

The WHO reported 751 million vaccine doses administered globally as of April 16, including 422 million individuals with at least 1 dose. The WHO dashboard does not yet include data for daily or weekly vaccinations or fully vaccinated individuals.

Our World in Data reports 860 million doses administered globally. The global cumulative total continues to increase at a rate of approximately 18% per week. The daily average surpassed 18 million doses per day briefly before falling slightly to 17.5 million doses per day. At least 176 countries and territories* are reporting vaccination data.

*Out of 191 reporting COVID-19 incidence data.

UNITED STATES

The US CDC reported 31.2 million cumulative cases and 561,356 deaths. Daily incidence continues to increase, up more than 30% from the recent low on March 19. Daily mortality also has increased over the past several days, up from 642 deaths per day on April 7 to 712 on April 14, an 11% increase over that period. The timing of the most recent low in daily mortality coincides with the Easter holiday weekend, so that could be due, in part, to delayed holiday reporting.

US Vaccination

The US has distributed 255 million doses of SARS-CoV-2 vaccine and administered 198 million doses. Daily doses administered* has leveled off at approximately 3 million, including 1.6 million people fully vaccinated.

A total of 126 million individuals have received at least 1 dose of the vaccine, equivalent to 38% of the entire US population and 48% of all adults. Of those, 78 million (24% of the total population; 30% of adults) are fully vaccinated. Among adults aged 65 years and older, 80% have received at least 1 dose, and 64% are fully vaccinated. In terms of full vaccination, 38 million individuals have received the Pfizer-BioNTech vaccine, 32 million have received the Moderna vaccine, and 7.7 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.

The Johns Hopkins Coronavirus Resource Center is reporting 31.5 million cumulative cases and 565,318 deaths as of 10:15am EDT on April 16.

J&J-JANSSEN VACCINE & BLOOD CLOTTING On April 14, the US CDC’s Advisory Committee on Immunization Practices (ACIP) met to discuss data on blood clotting events—specifically, cerebral venous sinus thrombosis (CVST) with thrombocytopenia—in individuals who recently received the J&J-Janssen SARS-CoV-2 vaccine. ACIP was expected to vote on any updated recommendations in the meeting; however, committee members determined that additional data are needed before deciding on next steps. Reportedly, ACIP aims to hold a follow-up meeting in the next 7-10 days to avoid unnecessary delays in resuming the vaccine’s use. Some of the ACIP members acknowledged that continuing or extending the pause could have negative downstream effects on vaccination efforts, both in the US and around the world.

The US CDC’s recommendation to pause the vaccine’s use remains in place, and the CDC published updated information regarding the blood-clotting events, including symptoms and treatment recommendations. In addition to providing time to assess whether an increased risk of thrombosis is associated with the J&J-Janssen vaccine, it also enables the CDC to disseminate treatment guidance for clinicians, including via the Health Alert Network to public health and healthcare systems nationwide, as these blood clots must be treated differently than many others. Some health experts criticized ACIP for postponing their recommendations, but the CDC, including ACIP, and US FDA are grappling to balance transparency and oversight to ensure vaccine safety with the risk of COVID-19 and the potential effects on vaccine confidence in the J&J-Janssen vaccine specifically, other vaccines utilizing similar vaccine platforms, and SARS-CoV-2 vaccines as a whole.

“BREAKTHROUGH” INFECTIONS During an April 15 hearing of the US House Select Subcommittee on the Coronavirus Crisis, US CDC Director Dr. Rochelle Walensky discussed the agency’s investigation into “breakthrough” infections—ie, infections in individuals who are fully vaccinated against SARS-CoV-2. According to Dr. Walensky, the CDC has identified approximately 5,800 such infections, out of 77 million fully vaccinated individuals*. Among these infections, 396 required hospitalization and 74 died. As has been the case from the beginning of the pandemic, it is more difficult to detect asymptomatic infections. The CDC noted that 29% of the infections detected were asymptomatic, but it is likely that there are more undetected infections. Dr. Walensky did not identify any patterns related to vaccinees’ demographic characteristics or specific vaccines. More than 40% of the infections were among adults aged 60 years and older, but this is not unexpected, considering that adults aged 65 years and older represent 44% of fully vaccinated individuals. The low number of hospitalizations and deaths is encouraging. No vaccine is 100% effective, and this is the first data reported by the CDC on breakthrough infections. The CDC is continuing to monitor vaccine effectiveness, including genomic sequencing to evaluate the effects of emerging variants, and it expects to begin publishing official data starting next week.

*At the time of the report.

VACCINE THIRD DOSE Pfizer CEO Albert Bourla recently said people likely will need to get a third dose of the company’s SARS-CoV-2 vaccine within 12 months of completing their vaccinations. He speculated that annual vaccinations might be required but more research needs to be completed to confirm his predictions. Bourla’s comments were made on April 1 at a CVS Health event but were released April 15. That same day at a US House Select Subcommittee on the Coronavirus Crisis hearing, Chief Science Officer of the White House COVID-19 Response Team Dr. David Kessler noted the emergence of variants of concern will challenge available vaccines’ effectiveness, probably requiring booster shots. However, Dr. Kessler also stated additional research is needed to understand timing and necessity.

RACIAL & ETHNIC DISPARITIES Researchers from the CDC COVID-19 Response Team and colleagues on April 12 posted 2 early release studies in the CDC’s Morbidity and Mortality Weekly Report that further investigate and validate previous findings on racial and ethnic disparities in COVID-19 hospitalizations and emergency room visits. The studies, published in today’s MMWR, provide more data on longstanding systemic inequities in the US health system, which researchers hope will be used to prioritize care for disportionately affected communities moving forward. Additionally, the CDC has launched a Racism and Health page on its Minority Health and Health Equity site, accompanied by a commentary by CDC Director Dr. Rochelle Walensky, to promote education and discussion around racism and health.

In one study, researchers evaluated disparities in COVID-19 hospitalizations by US region from March-December 2020. Age-adjusted COVID-19 proportionate hospitalization ratios (aPHRs) were calculated from administrative discharge data and found that the cumulative aPHR was highest (range 2.7-3.9) among Hispanic and Latino patients across the four US census regions. Disparities were largest from May to July in 2020, and while they became less pronounced through the end of the year, they remained in all regions by December 2020. The other study used National Syndromic Surveillance Program data to evaluate emergency department visits in 13 states from October-December 2020. According to the data, when compared with White persons, Hispanic and American Indian or Alaska Native persons experienced 1.7 times the rate of emergency department visits during the study period and Black persons experienced 1.4 times the rate.

VACCINE ACCESS FOR IMMIGRANTS According to the US government, every person in the country can receive a SARS-CoV-2 vaccination regardless of immigration status. However, the registration process varies among states and clinics, with some requesting proof of residency, official identification, or insurance card. Because of these policies, often expressed in English, immigrants have been discouraged or turned away from pharmacies and other places offering vaccines, exacerbating racial and ethnic divides in vaccination access. A recent analysis by the Kaiser Family Foundation showed only about one-quarter of state websites explicitly note that undocumented immigrants are eligible for vaccinations and that getting a vaccine will not negatively impact immigration status. Advocates insist reaching immigrant populations requires holding vaccine clinics in places they trust, including churches, cultural centers, and advocacy organizations. Some experts have called on the US CDC to issue clear guidance noting that lack of documentation should not be a reason to deny a person vaccination.

US AND GAVI HOST COVAX EVENT The US government and Gavi, the Vaccine Alliance, on April 15 hosted the “One World Protected” event to take stock of global progress toward equitable access to SARS-CoV-2 vaccines and launch a campaign seeking to raise an additional US$2 billion for such efforts through the COVAX facility. The funding will be allocated to the facility’s Advance Market Commitment (AMC), which expects to use the additional funding to reach 30%, instead of 20%, of target populations in 92 lower-income countries this year. At the event, a variety of countries, private sector partners, and foundations announced new pledges totaling nearly US$400 million. In addition to new funding pledges, the first commitments to vaccine dose sharing were announced. New Zealand said it will donate more than 1.6 million doses of SARS-CoV-2 vaccines to COVAX, with a focus on the Pacific region. At the virtual event, US Secretary of State Antony Blinken called on nations to support vaccine manufacturing but did not propose specific policies nor address the issue of surplus vaccine supply in the US.

A paper from Duke University published on April 15 estimates the US will have at least 300 million excess vaccine doses by the end of July and argues US leadership is “imperative” to achieve equitable global access. The paper proposes a 3-part US-led effort to increase and leverage funding through COVAX to improve vaccine access; undertake bilateral and multilateral actions to provide excess doses to countries in need; and increase manufacturing and distribution capacities. Another proposal from the Center for Strategic & International Studies’ (CSIS) Global Health Policy Center lays out a 4-part US diplomatic strategy for shrinking the global vaccine access gap. The CSIS plan focuses on the US helping to bring greater predictability, transparency, and investment partnerships to the vaccine marketplace; expand global supply through various funding, sharing, and manufacturing efforts; build local capacity for vaccine manufacturing, distribution, and administration; and boost demand for and confidence in SARS-CoV-2 vaccines worldwide. On April 14, the People’s Vaccine Alliance released an open letter signed by more than 100 former heads of state and Nobel laureates calling on the US government to support a waiver of intellectual property rights for SARS-CoV-2 vaccines to help expand global vaccine manufacturing.

MERCK ANTIVIRAL TRIALS Merck announced April 15 that it will end a clinical trial of its antiviral molnupiravir in hospitalized COVID-19 patients but will continue testing the treatment among outpatients with the disease. Additionally, Merck said it is discontinuing development of MK-7110 for the treatment of hospitalized COVID-19 patients. In a statement, the company said it plans to focus its pandemic efforts on advancing molnupiravir and manufacturing J&J-Janssen’s SARS-CoV-2 vaccine.

B.1.1.7 CLINICAL DATA In an article published April 12 in The Lancet Infectious Diseases, researchers from University College London and colleagues outline new clinical data of patients who contracted the B.1.1.7 SARS-CoV-2 variant. The study used a cohort design to assess if individuals hospitalized with B.1.1.7 infection experienced with worse disease outcomes. Researchers sequenced and analyzed samples positive for SARS-CoV-2 from patients admitted to two British hospitals between November 9, 2020 and December 20, 2020, and used the WHO’s ordinal scale for severe disease as their outcome measure. The final set of study participants included 198 patients who contracted the B.1.1.7 SARS-CoV-2 variant and 143 who contracted a non-B.1.1.7 variant. The research team found no evidence for a higher risk of severe disease among those who had contracted the variant in both adjusted and unadjusted models. The researchers did see that patients with the B.1.1.7 variants presented with higher viral load levels than their non-B.1.1.7 counterparts, implying that those with the B.1.1.7 variant could be more infectious. While this research presents valuable findings, additional research will continue to be compiled to further analyze the relationship between emerging SARS-CoV-2 variants and disease outcomes.

DISEASE SEVERITY IN CHILDREN Researchers from the US CDC and US Public Health Service published a cohort study in JAMA Network Open estimating adjusted associations between demographic and clinical characteristics and severe COVID-19 among hospitalized pediatric patients using data from more than 20,000 patients ages 18 or younger. Of the 20,714 patients included in the study, 10,950 were female (52.9%), 11,153 were aged 12-18 years (53.8%), 8,148 were Hispanic (39.3%), and 5,054 were non-Hispanic Black individuals (24.4%). Additionally, 6,047 had one or more chronic conditions (29.2%). Among the cohort of 2,430 patients who were hospitalized for COVID-19 (11.7%), nearly one-third of those (756, 31.1%) experienced severe COVID-19. An increased association of severe COVID-19 was seen in patients with one or more chronic conditions versus those with none (AOR 3.27) and in male versus female patients (AOR 1.52). An increased association with severe COVID-19 was also seen in the 2-5 year and 5-11 year age groups when compared to the 12-18 year group (AOR 1.53 for both).

BRAZIL Brazil continues to struggle with increased COVID-19 activity across the country. Earlier this week, the health secretary of Sao Paulo warned that a diminishing supply of critical therapeutics needed to treat COVID-19 patients has put the state’s medical system on the verge of collapse. On April 14, Science published a paper from a group of researchers taking a closer look at the spread of SARS-CoV-2 through the country’s different geographic regions. The group concludes that there is no singular explanation for the virus’s spread across the country, rather a set of reinforcing factors have led to devastating health outcomes. These factors include the country’s expansive size, large gaps in equity of resources, the density of urban populations, the political response to the pandemic, and a lack of early detection. The researchers warn that without improved risk mitigation strategies, the current surge in cases and deaths and the circulation of variants of concern will further increase the country’s COVID-19 burden. 

AUSTRALIA TRAVEL RESTRICTIONS Under Australia’s COVID-19 travel restrictions, Australian citizens do not necessarily have the right to return home, ostensibly “stranding” tens of thousands of Australians overseas. The UN Human Rights Commission (UNHRC) is scheduled to hear a case filed by 2 such individuals, who argue that Australia is violating the International Covenant on Civil and Political Rights by not allowing them to return. Both individuals reportedly already have been vaccinated and are willing to undergo the mandatory quarantine period. Australia currently has a quota for returning Australians, due in part to limitations on space available for mandatory quarantine. While the UNHRC has agreed to hear the case, Australia has 8 months to respond, indicating there may not be resolution anytime soon.

Reportedly, Australia is considering steps to ease its international travel restrictions, including allowing vaccinated individuals to travel overseas, although they may still be required to undergo quarantine upon their return. On April 19, Australia and New Zealand are scheduled to officially implement a “travel bubble,” which will allow travelers to move relatively freely between the 2 countries. Travelers will still be required to wear masks during their flights; however, if they show proof of a negative SARS-CoV-2 test or vaccination, they will not be required to undergo quarantine upon their arrival.

MASK-WEARING POLICIES In a paper published April 14 in PLOS ONE, researchers from the Boston University School of Public Health examine mask-wearing policies and adherence in association with COVID-19 case rates across the United States. The research team collected data on mask wearing and physical distance policies, mask adherence, COVID-19 cases, and demographics from publicly available resources. According to the data, none of the 8 states with at least 75% reported mask adherence experienced a high COVID-19 rate. However, states with the lowest levels of reported mask adherence were most likely to have high COVID-19 rates in the subsequent month, independent of mask policy or demographic factors. The researchers conclude that their findings reinforce the importance of mask-wearing policies, and adherence to such policies, in association with reduced COVID-19 incidence.