EPI UPDATE The WHO COVID-19 Dashboard reports 592 million cumulative cases and 6.45 million deaths worldwide as of August 18. According to the WHO weekly epidemiological update for August 17, the number of new weekly cases decreased by 24% during the week of August 8-14, compared to the previous week. The number of new weekly deaths decreased by 6%, compared to the previous week. 

At the regional level, the number of new weekly cases decreased across all six regions: African (-38%), European (-38%), Eastern Mediterranean (-30%), Western Pacific (-18%), Americas (-17%), and South-East Asia (-11%). The number of new weekly deaths increased in the Western Pacific (+31%) and South-East Asia (+12%) regions and decreased or remained stable in the African (-33%), European (-25%), Eastern Mediterranean (-7%), and Americas (-4%) regions.

UNITED STATES

The US CDC is reporting 93 million cumulative cases of COVID-19 and 1,033,332 deaths. The current 7-day moving average of new daily cases is down over last week, dropping to 98,940 on August 16 from 107,899 on August 9. The average daily mortality remains relatively stable, at 398 on August 16. Daily mortality has remained above or around 400 since July 12.** New national ensemble forecasts of new and total deaths predict that the number of newly reported COVID-19 deaths will remain stable or have an uncertain trend over the next 4 weeks, with 1,800 to 5,000 new deaths likely reported in the week ending September 10, 2022, and a total of 1,046,000 to 1,055,000 COVID-19 deaths predicted to be reported by this date.

Both new hospital admissions (-3.5% over the past week) and current hospitalizations (-5.3%) decreased over the previous week, potentially reflecting a downward trend to the latest surge driven by the Omicron BA.5 subvariant. New national ensemble forecasts predict that the number of new daily confirmed COVID-19 hospital admissions will remain stable or have an uncertain trend, with 2,600 to 9,700 new confirmed COVID-19 hospital admissions likely reported on September 9, 2022.

BA.5 is now projected to account for 88.8% of sequenced specimens in the US. The BA.4 sublineage accounts for about 5.3% of cases, while the BA.4.6 sublineage accounts for 5.1% of cases. Together, BA.2.12.1 accounts for only about 0.8% of cases. According to the estimate, Omicron variants represent all new cases in the US.

**Changes in state-level reporting may affect the accuracy of recently reported data, particularly over weekends. In an effort to reflect the longer-term trends, the numbers reported here may not correspond to the most recent dates.

US RESPONSE The US appears to have entered somewhat of a COVID-19 plateau. While there are signs that the latest surge caused by the Omicron BA.5 subvariant might be slowing—the average number of daily infections and hospitalizations are falling—an average of about 400 people have died of the disease every day for the past month. US officials have indicated that Omicron-adapted vaccine boosters could be available for everyone aged 12 and older within the next month, but the US FDA and CDC must act first to authorize and recommend a new vaccine booster. Experts have mixed opinions regarding an FDA plan to base its authorization decision on studies involving mice instead of humans. The UK this week approved a new bivalent booster from Moderna that targets both the original SARS-CoV-2 strain as well as the original Omicron variant, BA.1. The FDA rejected BA.1 bivalent booster versions earlier this year, instead calling on vaccine manufacturers to develop bivalent boosters targeting the Omicron BA.4 and/or BA.5 subvariants. 

The federal government has already secured millions of doses of these not-yet-authorized bivalent vaccine boosters from Moderna and Pfizer-BioNTech, but the White House recently announced it is making plans to no longer buy vaccines, treatments, or diagnostic tests, as early as this fall. Without additional funding from the US Congress to purchase those products, availability will shift to the commercial market, raising questions about equitable access. However, the Biden administration is expected to extend the COVID-19 public health emergency for another 90 days in mid-October, which likely would ensure expanded Medicaid coverage, telehealth services, increased payments to hospitals, and other pandemic measures remain in place into early 2023. Meanwhile, the US CDC has loosened its COVID-19 guidance and public health agencies are adapting lessons learned during the pandemic to address other—possibly more pressing—public health and equity challenges, signaling what many see is an attempt to enter a “new normal.”

US CDC REORGANIZATION US CDC Director Dr. Rochelle Walensky on August 17 announced a large-scale reorganization and pivot for the agency, after receiving the results of an external review of the institution that she initiated in April. The review was led by James Macrae, a long-time senior official with the US Department of Health and Human Services, the parent agency of CDC, and was based on 120 interviews with key informants inside and outside the institution. Findings from the review are not yet public. Dr. Walensky announced that, according to the review, the future success of the CDC depends on pivoting from a slower, more academic institution to a swift emergency response agency, providing actionable information to the public and other health authorities in an appropriate and understandable fashion. Initial agency changes to institute this vision include revamping the website, creating a new equity office, creating a new executive council to oversee the overall new vision, hastening time to publication for data needed for response decisions, prioritizing budget allocation for the agency, and promoting staff according to public health impact. Additionally, officials responding to public health crises would now be required to stay in their positions for at least 6 months, and more staff would be trained for those roles as well. Dr. Walensky also is seeking greater authority for the CDC to collect data from states, more quickly finance external partners during health crises, and develop more competitive benefits for prospective staff recruitment. Outside experts have praised the proposed changes to the agency’s vision but some remain skeptical as to whether the proposed shifts are possible or will be enough to address the missteps of the agency during the COVID-19 pandemic.

IMMUNITY AGAINST OMICRON Various studies have indicated that prior SARS-CoV-2 infection may provide some protection against or reduce severity of future infection. However, new studies suggest that prior infection with an Omicron variant may provide increased protection against BA.4 or BA.5 compared to prior infection with Alpha, Beta or Delta variants—although outside experts note the comparison may not be fair because immunity wanes over time. A new preprint study posted August 17 to medRxiv supports this criticism, as it documented rapid waning of protection from an earlier Omicron variant infection against BA.5, particularly 3-5 months post-infection. Furthermore, another study published in Nature Communications suggests that protection post-Omicron infection (BA.1) declines more quickly among unvaccinated individuals compared to their vaccinated counterparts. Altogether, this growing body of literature emphasizes the continued importance of COVID-19 vaccination and the widespread variations in protection based on disease history, and the findings should be taken into consideration for future response planning.

LONG COVID RESEARCH RESULTS People with post-COVID conditions, or long COVID, and their advocates continue to push for more research and clinical treatments for the mix of—and far from uniform—lasting symptoms that make up the condition. Recent developments include a preprint study, posted to medRxiv this month, evaluating the distinguishing symptoms of long COVID. Notably, the researchers found that those with the condition had lower levels of the stress hormone cortisol, in addition to the often-present cognitive deficits—sometimes known as “brain fog”—and fatigue. Similar results have been reported in previous studies, including one published in Cell, which also documented “exhausted T-cells” that result in chronic inflammation indicative of several long COVID symptoms. Impaired memory, fatigue, shortness of breath, and trouble concentrating were among key complaints of participants of a study published August 12 in Clinical Infectious Diseases that followed patients for 12-18 months after infection. Overall, 43% of participants experienced persistent symptoms after mild COVID-19. Researchers also noted that shortness of breath and the number of experienced symptoms at the 12 month mark were significantly linked to specific SARS-CoV-2 spike protein-specific immune responses. 

In a 2-year study published August 17 in The Lancet Psychiatry, Oxford researchers retrospectively assessed the risks of 14 neurological and psychiatric diagnoses after SARS-CoV-2 infection among 1.25 million patient records, including children. The researchers matched the COVID-19 patients with patients who had different respiratory infections and found that while common mood disorders typically returned to baseline after 1-2 months in both groups, adults with COVID-19 had an increased risk of psychotic disorder, brain fog, dementia, and epilepsy or seizures by the end of the second year of the follow-up, compared with adults with other respiratory diseases. Children also were at an increased risk for brain fog, in addition to insomnia, intracranial hemorrhage, ischemic stroke, psychotic disorders, and seizures. Children, however, experienced a finite horizon of 75 days for brain fog, nor were they at an increased risk for mood or anxiety disorders in the 6 months following SARS-CoV-2 infection. The study also accounts for the rise of 3 viral variants. The emergence of the Delta variant increased risks of ischemic stroke, seizures, cognitive deficit, insomnia, and anxiety disorders, as well as an increased death rate. The death rate following Omicron emergence was lower than just before, but the risks of neurological and psychiatric symptoms remained similar. Risk profiles remained similar just before and after the emergence of the Alpha variant. The studies all point to the need for more attention to be given to the post-infection risks of SARS-CoV-2, as well as other viruses.

WASTEWATER SURVEILLANCE The COVID-19 pandemic helped bolster an existing surveillance system for infectious diseases: wastewater testing. The method is now being used to track not only older diseases such as norovirus, but also new and emerging viruses including SARS-CoV-2, monkeypox, and polio. Several US states and jurisdictions have taken steps to launch or expand wastewater surveillance programs to provide a better understanding of circulating SARS-CoV-2 levels and variants. The New York Times this week published an interactive exploration into how these systems work and the steps involved in extracting results.

MASKING & INFECTIOUS AEROSOLS Healthcare workers are at an increased risk of SARS-CoV-2 infection, with many required or choosing to wear personal protective equipment such as masks. Those who always wore respirator masks rather than surgical masks had a 40% lower likelihood of infection, irrespective of cumulative exposure, according to a study published August 15 in JAMA Network Open. Among 2,919 healthcare workers included in the study, 749 (26%) tested positive for SARS-CoV-2 between September 2020 and September 2021. Among those with patient exposure, test positivity was 21% among workers wearing respirators compared with 35% among those who used surgical masks or a mix of masks (OR, 0.49; 95% CI, 0.39-0.61). The study was conducted in Switzerland prior to the predominance of the Omicron variant, so the results might not be applicable to newer, more transmissible variants. 

A July 29 preprint study posted to medRxiv shows that viral shedding (measured as RNA copies) in exhaled breath aerosol was significantly greater during infections with the more highly transmissible SARS-CoV-2 Alpha, Delta, and Omicron variants than with the ancestral strain and variants not associated with increased transmissibility, even among people who are up to date on vaccinations. The researchers documented the highest viral shedding from a person with Omicron infection. They said the findings provide additional evidence that inhalation of infectious aerosols is the dominant mode of SARS-CoV-2 transmission and support the importance of continued mitigation efforts such as improving indoor air hygiene through ventilation, filtration, and air disinfection, and wearing masks or respirators.

PANDEMIC-RELATED FRAUD The US government has appropriated US$5 trillion in relief programs aimed at helping businesses and individuals during shutdowns due to the COVID-19 pandemic. However, that funding came with minimal oversight leading to an unprecedented amount of fraud, with billions of dollars stolen by thousands of people, through unemployment payouts or business assistance. Now, federal investigators and prosecutors are trying to identify and charge people who committed such crimes, with 500 people working on pandemic-fraud cases across at least 21 government agencies, as well as the FBI, Secret Service, Postal Inspection Service, and the Internal Revenue Service. But with tens of thousands of ongoing investigations, officials are concerned some crimes may never be prosecuted. New laws extend the statute of limitations for some pandemic-era fraud from 5 years to 10 years, and officials hope the extensions will help them find and prosecute more offenders. The costs of loose rules and lax oversight should provide lessons for future pandemic preparedness responses to include planning and prevention efforts for fraud. 

UNIVERSAL HEALTHCARE Countries with or close to achieving universal health coverage (UHC)—a system under which all individuals and communities receive needed health services without suffering financial hardship—saw smaller declines in routine childhood vaccinations during the COVID-19 pandemic, according to a study published August 16 in PLOS Medicine. Countries included in a “high UHC index” group had a 2.7% smaller reduction in childhood immunization coverage during 2020 when compared to countries with lower UHC Service Coverage Index rankings. Additionally, a study published August 17 in The Lancet Regional Health found that primary health care coverage in Brazil mitigated socioeconomic disparities in accessing SARS-CoV-2 vaccination. Taken together, these studies provide evidence that UHC guarantees more equitable access to vaccinations and suggest that policymakers should continue to advocate for working toward the goal of achieving access to safe, effective, quality, and affordable healthcare services for all.