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COVID-19 Report: Week of September 20, 2021

Sam Shames, Emergency Management, Health, and Hazards (EMH2) Team

Week of Monday, September 20th, 2021

Partnership between the US and Ghana[1]

Worldwide Cases: 231,850,000[2] Worldwide Deaths: 4,750,000[3]

*Updated as of September 27, 2021*


Notable Outbreaks


  • After a sustained period of growth, COVID-19 cases in the United States are beginning to decline. The states experiencing the largest daily average increases in cases per 100 people are Tennessee, West Virginia, Alaska, South Carolina, Kentucky, Wyoming, Montana, North Carolina, Idaho, and Alabama. Kentucky, Georgia, West Virginia, Alabama, Tennessee, South Carolina, Florida, Texas, Mississippi, and Idaho are experiencing the largest daily average increases in hospitalizations per 100 people. Finally, Florida, Alaska, Mississippi, Idaho, West Virginia, South Carolina, Louisiana, Georgia, Texas, and Wyoming are experiencing the largest daily increases in deaths per 100 people. Cross referencing the bulleted data below with vaccination rates in these states reveals that states experiencing the highest death, hospitalizations, and case rates oftentimes have lower vaccination rates. The only state with >60% vaccination rate that is experiencing daily average hospitalization and case rates similar to that of states with vaccination rates lower than 60% is NY. Even so, the death rate in NY per 100 and without adjustments for population is significantly lower than that of the top 10 states with the highest rates.[4] Overall, the data suggests that higher vaccination rates correlate with lower case, hospitalization, and death rates across the US. As states begin to roll out booster shots for approved groups, it is likely that the number of hospitalizations and deaths among the 65+ age group and those with high risk of severe illness will decline. However, it is possible that the number of cases among these groups will continue to decrease at previous rates.


  • Over the past month, cases have declined significantly in South America.[5] Experts are attributing this decline to rapid vaccine rollout despite inconsistent and oftentimes lax COVID-19 prevention measures.[6] However, the Mu Variant is increasingly prevalent in Colombia and Ecuador. Lack of enforcing COVID-19 prevention measures will likely cause cases and hospitalizations to increase if the Mu Variant continues to spread. Since early data suggest that the Mu Variant may be more vaccine resistant, high vaccination rates will not offer as much protection against these mutations compared to other SARS-CoV-2 variants.[7] As a result, it is slightly likely that the Mu Variant will spread rapidly across all groups, including those who are fully vaccinated.


  • Trends in cases vary across Europe, with many regions in Western Europe experiencing declines and several countries in Eastern Europe seeing increases in cases. Some of the countries with high vaccination rates are experiencing decreases in cases, such as Italy (64% vaccinated), France (65%), and Spain (78%), whereas Bulgaria (20%), Romania (28%), and the Ukraine (13%) have lower vaccination rates and increases in cases.[8],[9] Vaccine mandates are increasingly prevalent across Europe, with France and Italy having some of the broadest mandates. While protests have erupted in response to these requirements, it is likely that these countries will benefit from mandates, resulting in declines in cases, hospitalizations, and deaths.


  • Many countries in the PACOM region are still experiencing high case rates, including Australia, New Zealand, India, Malaysia,​ The Philippines, Vietnam, Thailand, and Myanmar. Australia and New Zealand have managed to keep death rates low, and Australia has initiated a two-tier reopening plan that first allows vaccinated individuals to slowly emerge from lockdown.[10] The country aims to end lockdown completely at the end of October when around 70% of the population is estimated to be vaccinated.[11] While only about 40% of the population is currently fully vaccinated, if Australia continues on its drastic upward trajectory for administering vaccines, they will likely reach that 70% goal in the coming weeks. New Zealand’s vaccination rates are just below Australia’s, and efforts to ramp up vaccine administration are expected to increase.

  • India is slightly more prepared for its current surge with the addition of hospital beds and medical supplies.[12] Hospitals are continuing to prepare for another Delta-like outbreak as other countries detect first cases of vaccine resistant variants, such as the Mu Variant. The emergence of this type of mutation in such a densely populated country like India would be devastating to the population and healthcare system.


  • The main concern in Africa is vaccine equity as the continent has the highest proportion of countries with the lowest vaccination rates, including many with less than1% of the population vaccinated.[13] The United Nations (UN) and other agencies have repeatedly stated that rich countries are hoarding vaccines, making it difficult for Africans to get vaccinated.[14] As a result, many international health organizations are not recommending booster shots to ensure additional doses are available for African countries.

Notable News:

  • UNICEF urges countries to reopen schools to address education inequality[15]

  • COVID-19 transmission, hospitalization, and death rates are high in children[16],[17]

  • Moderna chief executive says there will be enough vaccine doses available to vaccinate the world’s population by mid-2022[18]

COVID-19 Reports

  • Prioritization of COVID-19 response has hindered treatment of Tuberculosis, HIV, and Malaria, especially in poor nations[19]

  • Series of studies shows evidence of “hybrid immunity” in some individuals, giving them the ability to fight off current and possibly future variants of COVID-19[20]

  • US Centers for Disease Control and Prevention (CDC) director says research supports masking in schools to decrease transmission of COVID-19[21]

  • One study by the Indian Council of Medical Research suggests that COVID-19 may infect a higher proportion of pregnant women[22]

  • US CDC reports that the efficacy of the Pfizer shot drops from 91% in the first four months to 77% thereafter, while the Moderna vaccine is 92% effective after four months[23]

  • Pfizer seeks vaccine approval for ages 5-11 after phase II and III clinical trials show robust immune response and appropriate safety profile[24]

  • Johnson & Johnson says a second shot after two months boosts protection from 70% to 94% against moderate-severe COVID-19[25]

Global Vaccination Progress

  • Indonesia and South Africa being considered by WHO for global mRNA vaccine hubs to improve distribution and build capacity[33]

  • Singapore considering non-mRNA booster shots[34]

  • COVAX is on course to fall nearly 30% short of its previous goal of 2 billion shots this year[35]

Trend: Vaccine approval for younger age groups

  • Britain's Chief Medical Officers recommend vaccines for ages 12-15, citing reduced disruptions to education[36]

  • Cuba is the first country to vaccine children as young as two years old with their homegrown Abdala and Soberana vaccines, which are not yet recognized by WHO[37]

  • Pfizer is seeking vaccine approval for ages 5-11[38]

  • As an increasing number of adults become inoculated and the evidence base for the safety and efficacy of COVID-19 vaccines on children grows, many countries have approved vaccines for younger age groups. With the school year beginning in many countries, leaders are eager to get children vaccinated to avoid disruptions to education. It is highly likely that vaccines will be approved for children in many countries by the end of 2021. As a result, countries will see vaccination rates increase drastically, which will bring them closer to reaching herd immunity.

Booster shots

  • A US Food and Drug Administration (FDA) panel recommends booster shots for those over 65 and individuals at high risk for severe illness but not for others, pending a more robust evidence base on the long-term safety and efficacy of current vaccines, especially in young people[39]

  • US Centers for Disease Control and Prevention (CDC) panel does not recommend booster shots for individuals “who live or work in institutions with high risk of contracting COVID-19,” but does support boosters for 65+ and some high risk individuals[40]

  • On September 1, Moderna submitted an application to the FDA for approval of booster shots after one study found the efficacy of its vaccine declines over time*[41],[42]

  • On September 22, the FDA approved Pfizer single-dose booster shots for the following groups: 65+ and high risk individuals between 18-64[43]

  • Johnson & Johnson Phase III trial reveals “strong and long-lasting protection against COVID-19-related hospitalizations...and death,” and increased efficacy with a booster shot[44],[45]

  • The World Health Organization (WHO) chief says wealthy countries should halt booster shots so additional doses are available for poorer countries[46]

  • The European Center for Disease Prevention and Control (ECDC) says booster shots for the fully vaccinated are not necessary[47]

  • With the increasing availability of vaccines and the emergence of evidence on the waning efficacy of some vaccines after a few months, many countries are considering offering booster shots to their populations. While many health organizations such as the WHO and ECDC stress that booster shots are unnecessary and vaccine efforts should be targeted at countries with low vaccination rates, various countries have proceeded with booster shot rollout. The US has approved some high risk groups in an attempt to keep cases, or at least hospitalizations and deaths minimal, but has been hesitant to approve booster shots for the general population. As the evidence base for booster shots grows, it is highly likely that some countries will continue implementing programs in the race to reach herd immunity and return to normal life.

Vaccine mandates

  • US announces widespread vaccine mandates

  • US President Joe Biden declares an executive order that requires the COVID-19 vaccination of all federal employees.[48] The administration aims to have vaccinations completed by November, 2021.

  • Italy is the first European country to require all workers have green passes, which show vaccination status and test results, or risk a 5-day suspension without pay[49]

  • France mandates vaccines for healthcare workers, resulting in thousands of suspensions[50]

  • After nearly one year of vaccine distribution, many countries are instituting vaccine mandates in response to their struggles in reaching herd immunity. While Italy and France have faced backlash for their mandates for some groups of workers, it is highly likely that other countries in Europe will follow suit with vaccine mandates for broad groups of workers. As a result, vaccination rates will increase and case rates will decline. The emergence of the Mu Variant, however, could increase deaths despite high vaccination rates. In the US, Biden announced a new plan to tackle rising COVID-19 cases, including vaccine mandates for many groups of workers. With these new mandates and the approval of vaccines for younger age groups, the number of vaccinated individuals will increase in the coming months.

New Vaccines/in development

  • Moderna is working on a single-dose booster shot offering protection against COVID-19 and flu[51]

  • Pfizer, Merck & Co, and Roche are working on gathering data for oral COVID-19 drugs[52]

  • South Korea approves Celltrion's antibody COVID-19 treatment for high-risk infected adults with severe illness[53]

International Vaccination Developments

Percent Vaccinated by Country

World Vaccination Progress


[2] What is the cumulative number of confirmed cases?, Our World in Data, September 2021,

[3] What is the cumulative number of confirmed deaths?, Our World in Data, September 2021,

[4] Coronavirus in the U.S.: Latest Map and Case Count, New York Times, September 2021,

[5] COVID cases surge in North America, decline in South America, says health agency, Reuters, September 2021,

[6] Covid Ravaged South America. Then Came a Sharp Drop in Infections., New York Times, September 2021,

[7] Beyond Delta, scientists are watching new COVID-19 variants, Channel News Asia, September 2021,

[8] Coronavirus (COVID-19) Vaccinations, Our World in Data, September 2021,

[9] Coronavirus (COVID-19) Cases, Our World in Data, September 2021,

[10] Sydney's COVID-19 lockdown to end sooner for the vaccinated, Reuters, September 2021,

[11] Australia reports 1,607 COVID-19 cases as states learn to live with virus, Reuters, September 2021,

[12] India 'prepares for the worst' ahead of possible COVID-19 third wave, Channel News Asia, September 2021,

[13] Less than 3.5 % of Africans vaccinated against COVID - Africa CDC, Reuters, September 2021,

[14] Africa faces 470 million COVID-19 vaccine shortfall in 2021, World Health Organization, September 2021,

[15] UNICEF calls for schools to reopen in COVID-19 pandemic-hit nations, Channel News Asia, September 2021,

[16] Unvaccinated children suffering COVID-19 impact, Pan American health agency warns, Channel News Asia, September 2021,

[17] England's top medic says COVID-19 transmission highest in children, Channel News Asia, September 2021,

[18] Moderna chief executive sees end of COVID-19 pandemic in one year: Report, Channel News Asia, September 2021,

[20] New Studies Find Evidence Of 'Superhuman' Immunity To COVID-19 In Some Individuals, NPR, September 2021,

[21] Research “absolutely” shows masking lowers Covid-19 outbreaks in schools, CDC director says, CNN, September 2021,

[23] Big gap between Pfizer, Moderna vaccines seen for preventing COVID hospitalizations, Yahoo News, September 2021,

[24] BioNTech say data shows COVID-19 vaccine safe for children aged 5 to 11, Channel News Asia, September 2021,

[25] Johnson & Johnson says second shot boosts protection against moderate-severe COVID-19 to 94%, Channel News Asia, September 2021,

[26] More Vaccine-resistant, Highly Transmissible: FAQs on Epsilon Covid Variant Detected in Pakistan, News 18, August 2021,

[27] “SARS-CoV-2 Lambda variant exhibits higher infectivity and immune resistance,” BioRxiv, 2021,

[28] “SARS-CoV-2 Lambda Variant Remains Susceptible to Neutralization by mRNA Vaccine-elicited Antibodies and Convalescent Serum,” BioRxiv, 2021,

[29] “SARS-CoV-2 Lambda variant exhibits higher infectivity and immune resistance,” BioRxiv, 2021,

[30] COVID-19: New Mu variant could be more vaccine-resistant, UN, September 2021,

[31] Beyond Delta, scientists are watching new COVID-19 variants, Channel News Asia, September 2021,

[32] WHO warns new Mu variant of Covid-19 could be more vaccine-resistant, Business Standard, September 2021,

[33] Indonesia in talks with WHO to become global vaccine hub: Health minister, Channel News Asia, September 2021,

[34] Singapore studying possibility of non-mRNA vaccines for COVID-19 booster shots: Janil Puthucheary, Channel News Asia, September 2021,

[35] COVAX vaccine 2021 delivery target cut by almost 30%, Channel News Asia, September 2021,

[36] Britain's top medics recommend 12 to 15-year-olds get COVID-19 vaccine, Channel News Asia, September 2021,

[37] In world first, Cuba starts COVID-19 vaccine jabs for toddlers, Channel News Asia, September 2021,

[38] BioNTech to seek global approval to use its COVID-19 vaccine in 5-11 year olds: report, CBC, September 2021,

[39] FDA panel votes against broad rollout of Pfizer booster shot, endorses narrower use, Politico, September 2021,

[40] US CDC advisers back COVID-19 booster shots for those 65 and older, not for high-risk workers, Channel News Asia, September 2021,

[41] *This study by Moderna has not yet been peer reviewed

[42] Moderna says COVID-19 vaccine protection wanes, makes case for booster, Channel News Asia, September 2021,

[43] FDA Authorizes Booster Dose of Pfizer-BioNTech COVID-19 Vaccine for Certain Populations, FDA, September 2021,

[44] Johnson & Johnson Announces Real-World Evidence and Phase 3 Data Confirming Strong and Long-Lasting Protection of Single-Shot COVID-19 Vaccine in the U.S., Johnson & Johnson, September 2021,

[45] “Effectiveness of the Single-Dose Ad26.COV2.S COVID Vaccine,” medRxiv, 2021,

[47] EU health body says no urgent need for COVID-19 vaccine boosters, Channel News Asia, September 2021,

[48] Executive Order on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, The White House, September 2021,

[49] Italy Is Making COVID-19 Health Passes Mandatory For All Workers, NPR, September 2021,

[50] France suspends 3,000 health workers for failing to get a COVID vaccine, Euronews, September 2021,

[51] Moderna working on combination COVID-19 vaccine booster and flu shot, Reuters, September 2021,

[52] Pfizer, Merck launch new trials of oral COVID-19 drugs, Channel News Asia, September 2021,

[53] South Korea approves Celltrion's COVID-19 treatment for use, Channel News Asia, September 2021,



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