COVID-19 Situation Report
Editor: Alyson Browett, MPH

Contributors: Clint Haines, MS; Noelle Huhn, MSPH; Amanda Kobokovich, MPH; Aishwarya Nagar, MPH; Christina Potter, MSPH; Matthew Shearer, MPH; Marc Trotochaud, MSPH; and, Rachel A. Vahey, MHS
COVID-19 REBOUND US President Joe Biden once again tested positive for SARS-CoV-2 infection this week, following several days of negative tests last week. His symptoms are reportedly mild, and he returned to isolation after the positive tests. The phenomenon is commonly referred to as “Paxlovid rebound” or “COVID-19 rebound,” and it occurs in COVID-19 patients who take the drug, test negative for SARS-CoV-2 infection, and then test positive again. The phenomenon was not seen as an issue during clinical trials of the drug but appears to be more frequently reported since Paxlovid became widely available, although it remains unclear what proportion of people experience rebound. Typically, the recurrence of COVID-19 symptoms tends to be relatively mild.

President Biden’s rebound case has called attention to the US CDC’s guidance regarding isolation after COVID-19 diagnosis or a positive SARS-CoV-2 test. The CDC currently recommends isolation for a minimum of 5 days after the onset of symptoms or positive test. To end isolation, those who were symptomatic should wait until their fever has subsided for at least 24 hours and other symptoms are improving—and those leaving isolation should wear a mask in public through Day 10. Notably, the CDC indicates that individuals can test before they end their isolation, but the guidance emphasizes that testing is optional (ie, as opposed to recommended) for anyone who “wants to.” Those who elect to test and obtain a positive result should remain in isolation. The isolation and testing protocol implemented for President Biden went “above and beyond” the CDC recommendations, and CDC Director Dr. Rochelle Walensky indicated that the CDC must issue guidance that is feasible for most people to follow. Recent studies have demonstrated that many individuals continue to test positive for 6 days or longer, and most can shed the virus for 8 days or longer, which could enable them to infect others if they end isolation after 5 days. In light of this evidence, some experts have called on the CDC to revisit its guidance to slow transmission, particularly in light of the current Omicron surge.

PUBLIC HEALTH OFFICIAL HARASSMENT Over the course of the COVID-19 pandemic, an increasing number of public health officials in the US have received personal threats and harassment. A study, published July 29 in JAMA Network Open and led by researchers from the Johns Hopkins Bloomberg School of Public Health, set out to examine the share of US adults who thought it was acceptable to threaten or harass public health officials because of business closures and the basis for those beliefs. Overall, the study suggests that 1 in 5 survey respondents feel that threatening or harassing public health authorities is acceptable. From November 2020 to July and August 2021, the share of surveyed US adults who believed that harassing or threatening public health officials over pandemic-related closures rose from 20% to 25% and 15% to 21%, respectively, according to the study. The most significant increases were among respondents who identified as male, Hispanic, and Republican. Increases also were observed among those with higher incomes. The study identified a concerning uptick in support of these attacks among economically advantaged groups, as well as individuals who are historically more trusting of science. Researchers emphasized that restoring trust in public health officials and the entire public health workforce will require tailored approaches to reach diverse groups. 

Such harassment and threats can have devastating consequences. In Austria this week, national leaders appealed for solidarity and medical representatives urged greater protections for healthcare providers after a physician who received death threats and harassment from people opposed to COVID-19 vaccination committed suicide.

IMPACTS ON US HEALTH Beyond the immediate health risks of SARS-CoV-2 infection, we are beginning to gain more clarity about the long-term impacts of COVID-19 on US residents’ health. Notably, more than 1 million people in the country have died of COVID-19, and an additional 350 people are dying of the disease each day. But other health indicators have worsened during the pandemic, as people missed routine appointments, changed their habits, felt isolated or stressed, or experienced loss. Overall, deaths and death rates from heart disease and stroke increased in the US over the past 2 years, with some studies suggesting COVID-19 can increase the risk for both, even after recovery. Drug overdose deaths, excessive alcohol consumption, serious mental illness, gun-homicide rates, and hospital-associated antimicrobial resistant infections all increased in 2020. 

Additionally, millions of people in the US have post-COVID-19 conditions, also known as long COVID. The US CDC estimates that nearly 1 in 5 individuals who have had COVID-19 continue to report long-term symptoms lasting 3 months or longer. Many of them have left their jobs because they have symptoms, such as fatigue or brain fog, that hinder their ability to perform daily or work tasks. Under federal guidance, people with long COVID can qualify for disability, meaning employers must offer accommodations to their workers. But many people with long COVID say negotiating accommodations or finding support from social assistance programs remains difficult. Some experts advocate for a better definition of the condition to facilitate diagnosis, more robust educational campaigns to warn people of the risk for long COVID, and more support for people with the condition. More than 100,000 US residents are diagnosed with COVID-19 everyday, some for a second or third time, and evidence suggests people who are infected more than once are at greater risk of long-term health consequences. It will be years before we fully understand the disease’s impacts on the public health, employment, and health coverage landscapes.

RACIAL/ETHNIC DISPARITIES IN VACCINATIONS The COVID-19 pandemic has disproportionately affected racial and ethnic populations in the US, with substantial racial and ethnic inequities in COVID-19 mortality persisting, particularly in rural areas. Several recent studies examine racial and ethnic disparities in US COVID-19 vaccine distribution and uptake. According to a study published in the August issue of Health Affairs, researchers used CDC data to illustrate that uptake rates for the first COVID-19 vaccine dose were higher among Hispanic and Asian populations than among White and Black populations, while booster uptake was higher among Asian and White populations than among Black and Hispanic populations.

Many factors could influence this disparate uptake of COVID-19 vaccines and boosters, including systemic and structural inequalities in vaccine rollout and distribution. A study published July 28 in PLOS Medicine found that healthcare facilities were less likely to serve as vaccine administration locations if they were in urban counties with large populations of Black residents or rural counties with large populations of Hispanic residents. Additionally, racial and ethnic populations may be skeptical about getting vaccinated due to a long history of discriminatory and predatory medical research and practices in the US. According to another recent study published in Social Science & Medicine, vaccine hesitancy was higher among Black adults than among White adults and US-born Hispanic adults, largely due to lack of trust in the government’s communication about risk, concerns that vaccines were developed too quickly, beliefs that vaccines would give people COVID-19, and fears that vaccines may cause infertility. The study also suggests that foreign-born Hispanic adults were not more hesitant to get vaccinated than US-born White and Hispanic adults, which counters perceptions that immigrants may be less likely to opt for vaccination out of fear of being deported. These recent findings suggest that a concerted effort is needed to combat structural inequities in vaccine rollouts, for COVID-19 and other diseases, as well as to address the misinformation and mistrust that underlines vaccine hesitancy among racially and ethnically diverse communities in the US.

AFFORDABLE HOUSING In order to help prevent the further spread of SARS-CoV-2 in overcrowded housing conditions caused by evictions, the US CDC imposed a nationwide temporary federal moratorium on residential evictions for nonpayment of rent in September 2020. The moratorium ended in August 2021 after the US Supreme Court ruled to end a temporary stay on a lower court ruling seeking to overturn the rule, ending protections that had kept millions of people in their homes during the pandemic. Despite the moratorium, at least 4 corporate landlords attempted to aggressively push nearly 15,000 renters out of their homes between March 2020 and July 2021, according to a US House subcommittee investigation report. During the period covered by the report, the Eviction Lab at Princeton University documented 495,216 eviction actions. 

As the pandemic progressed, many renters left urban areas to move to midsize cities—what became known as “Zoom towns”—leaving landlords with no choice but to slash rents to attract tenants. Some renters moved into those lower-priced, but often not rent-controlled, homes, only to have their rents increase immensely over the past year, often by 30-65%. Now, with a shortfall of 1.5 million homes and skyrocketing rents and home prices in communities nationwide, the US Treasury this week announced state, local, and tribal governments will have more flexibility to use COVID-19 funds from the American Rescue Plan to fill financing gaps for affordable housing projects, which could help increase the housing supply for families hit hard with high rent and inflation. The new rules allow the use of rescue funds to finance long-term affordable housing loans that extend at least 20 years and offer affordable units to households earning 65% or less of the area’s median income over the same period; to be directed to 6 additional federal housing programs; and to finance the development, repair, or operation of existing affordable rental housing units. 

JAPAN Japan’s current COVID-19 surge, and largest to date, surpassed 200,000 new cases per day, ranking #1 globally in terms of total daily incidence and #6 on a per capita basis. The surge is driven largely by the BA.5 sublineage of the Omicron variant of concern (VOC), and reportedly, individuals younger than 20 years old represent approximately 30% of new cases in July, and those less than 30 years old accounted for approximately half. For comparison, these 2 age ranges comprise approximately 16% and 26% of Japan’s total population, respectively. While Japan reports relatively high vaccination coverage (including boosters) in older adults, it is much lower among younger adults and children. Only one-third of those aged 12-19 years have received their first booster, and only 17% of children aged 5-11 years have received the original 2-dose course of the vaccine. Despite facing the country’s largest surge, Japanese Prime Minister Fumio Kishida indicated that there are no plans to implement national restrictions, and Daishiro Yamagiwa, the government’s COVID-19 response lead, emphasized the importance of balancing COVID-19 protections against economic and social activity. Rather, prefecture governments can issue requests for local populations and businesses to take recommended protective measures, such as voluntary movement restrictions or increased remote work.

Reportedly, the Japanese government is considering changes to its COVID-19 reporting requirements, in an effort to reduce the burden on hospitals and laboratories. Currently, Japan requires all COVID-19 cases to be reported, but potential changes could reclassify COVID-19 under the same category as seasonal influenza. While this shift could ease reporting requirements, it would also limit the ability to identify and quarantine close contacts, which could facilitate further transmission. Additionally, it could eliminate measures for the national government to cover the costs of testing.

Since the onset of the pandemic, Japan’s travel and tourism sector has faced severe impacts. Amid reports of a travel resurgence in many regions, particularly in Europe, Japan has not benefited from a similar windfall. In June, Japan announced decisions to resume international travel, albeit with specific COVID-19 restrictions in place, just in time for the summer travel season. While international travelers would once again be able to enter Japan, restrictions mandate that their activities be part of organized group itineraries, and visitors must remain with designated chaperones throughout their trip. Additionally, travelers also face quarantine measures upon arrival. These measures have reportedly factored into travelers’ decisions, and many have opted for other destinations, including South Korea. Both global and regional travel have been impacted in Japan, and one report indicates that approximately 10% of hotels and travel agencies have shut down over the course of the pandemic. Historically, Japan’s largest tourism market is China, but prolonged national-level quarantine and travel restrictions have resulted in substantial decreases in Chinese tourists.

NEW ZEALAND New Zealand fully reopened its borders on July 31 after more than 2 years of strict pandemic restrictions. The final stage of the country’s phased reopening began in April, when tourists from countries on a visa-waiver list could enter. Now, visitors from all over the world are allowed into New Zealand, including those on student visas and from non-visa waiver countries. Per New Zealand’s Ministry of Health, electronic or paper proof of vaccination is required to enter, as well as a rapid antigen test conducted upon arrival and on the fifth or sixth day post-arrival. Masks are required indoors, including museums, grocery stores, and pharmacies. In a speech on August 1, Prime Minister Jacinda Ardern emphasized the reopening was part of a carefully staged plan to keep people safe. As the nation reopened, the Ministry of Health reported 5,312 new COVID-19 cases. Daily new COVID-19 deaths began to increase in February 2022 and remain elevated at an average of 3 deaths per day.