COVID-19 Situation Report
Editor: Alyson Browett, MPH

Contributors: Clint Haines, MS; Noelle Huhn, MSPH; Amanda Kobokovich, MPH; Christina Potter, MSPH; Matthew Shearer, MPH; Marc Trotochaud, MSPH; and, Rachel A. Vahey, MHS
CALL FOR PAPERS There is an opportunity to integrate Global Catastrophic Biological Risks (GCBRs) into pandemic preparedness policy and practice. In 2023, Health Security will devote a supplement to GCBRs. We encourage submissions of original research articles, case studies, and commentaries that discuss lessons learned from the COVID-19 pandemic response and/or key policy and technology advances that could prevent or better prepare for a more severe, globally catastrophic infectious disease pandemic. Deadline for submissions is October 3, 2022. More information is available here:
EPI UPDATE The WHO COVID-19 Dashboard reports 570 million cumulative cases and 6.38 million deaths worldwide as of July 27.* The global weekly incidence remained relatively stable from the previous week, falling 1.2%. Global weekly mortality also remained stable, rising 1.8% over the previous week. However, global weekly mortality has steadily increased since mid-June. 

At the regional level, the Western Pacific (+52%), Eastern Mediterranean (+45%), and South-East Asia (+13%) experienced increases in new weekly cases, while Africa (-44%), Europe (-24%), and the Americas (-12%) had decreasing trends. The number of new weekly deaths increased in the Eastern Mediterranean (+88%), Western Pacific (+19%), and South-East Asia (+8%) regions, decreased in the Africa (-47%) and Europe (-6%) regions, and remained stable in the Americas region.
*The WHO notes the case and death data for the Africa region are incomplete and will be updated as soon as more information becomes available.

The US CDC is reporting 90.6 million cumulative cases of COVID-19 and 1,023,382 deaths. The 7-day moving average of new daily cases rose slightly over last week, up to 127,786 on July 26. The average daily mortality has risen slightly over the past 2 weeks, up to 366 on July 26, after holding relatively steady at approximately 275-350 deaths per day between late April and July 11.**

Both new hospital admissions (+6.1% over the past week) and current hospitalizations (+5.1%) continue to increase, possibly reflecting the slight increase in daily incidence. 

Community transmission in the US is primarily driven by the Omicron BA.5 sublineage. BA.5 is now projected to account for 82% of sequenced specimens, up from 78% for the week of July 16. The BA.4 sublineage continues to account for about 13% of cases, whereas BA.2.12.1 now accounts for only about 5% of cases. Together, Omicron variants represent essentially 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.

WESTERN PACIFIC For the past several weeks, several countries in the Western Pacific region have reached record high numbers of new daily COVID-19 cases and have led global cases per 100,000 million population compared to countries in other regions. In particular, previous bastions of relative safety from COVID-19, Australia and New Zealand, have undergone their worst surges to date. In the last 7 days, on average, Australia has reported around 45,000 daily new cases while New Zealand has reported around 8,100 daily new cases. Experts predict that some areas of Australia will peak in cases around mid-August, while New Zealand appears to have turned away from its worst-case prediction scenario as case numbers are falling. This rapid rise in cases is likely attributable to the various Omicron subvariants that recently have established predominance worldwide. Australia and New Zealand had strong initial public health responses that helped prevent COVID-19 from gaining a foothold in their populations and have since made great strides to vaccinate their populations. In Australia, around 86% of the eligible population has received at least one dose of vaccine. In New Zealand, that figure is around 84%. However, as has been seen in other countries, high vaccination rates and natural infection-acquired immunity do not appear to be as protective against the BA.5 subvariant, currently the main driver of cases in the Western Pacific region. According to serology samples, Australia predicts that around 47% of its population has been infected with SARS-CoV-2 between January and June of this year, compared to only 17% of the population at the beginning of 2022.

In addition to Australia and New Zealand, other island nations have been going through some of their first experiences with COVID-19 outbreaks. Micronesia is likely the last nation in the world with a population over 100,000 to experience COVID-19, with its number of cases rising to more than 1,000 in one week. In response, the Micronesian government has mandated masks in all public places, even outdoors, or risk a fine of up to US$1,000. Additionally, the government had previously instituted a broad vaccine mandate for all eligible citizens. At last count, around 75% of the island-nation’s eligible population had been vaccinated, with more coming forward to get their shots in light of this most recent outbreak. 

Japan also is struggling with its largest surge to date, far eclipsing any previous waves. The nation reported 233,100 new cases today, hitting a new record for the second day in a row. Osaka and Tokyo prefectures are reporting their highest numbers of cases and hospitalizations and have raised COVID-19 alert levels to discourage non-essential travel. However, the Japanese government has not been keen to renew stricter COVID-19 measures, such as lockdowns and travel restrictions, amid high compliance with mask wearing. On the other hand, the government is looking to shorten the isolation period from 5 days to 3 days for those who have tested positive. Officials say the decision is based on data that would indicate it is safe for people who are feeling well to leave isolation earlier, but it is perhaps ill-timed with the current exponential rise in cases. Still, the government also is preparing to distribute rapid antigen tests and possibly to expand eligibility for a fourth booster shot

FUTURE VACCINE & BOOSTERS At a July 26 White House vaccine summit, US government officials, scientists, and pharmaceutical industry representatives discussed their ideals for future COVID-19 vaccines, including wishes for vaccines that could prevent infection, not only prevent hospitalizations and deaths; be administered easily, possibly through nasal sprays or skin patches; or provide broader and more durable protection against a range of coronaviruses, including potential future variants of SARS-CoV-2. Officials and scientists also discussed ways to speed research and streamline regulatory hurdles. Notably, officials from the US FDA and US CDC did not appear on panels during the summit, and no US lawmakers attended the meeting. Many attendees stressed the need for government support to develop next-generation vaccines, although funding was not a broad topic of discussion. The US Congress has not yet agreed to new emergency funds for COVID-19 after a deal crumbled in March. US Senate Democrats are expected to propose US$21 billion in new emergency funds for the COVID-19 response and other pandemic preparedness.

Additionally, top White House officials this week laid out an ambitious timeline for updating current vaccines to be more protective against the Omicron variant of concern and its sublineages. The FDA is hoping vaccine makers Moderna and Pfizer-BioNTech can ready "bivalent" boosters that target both the original virus strain and Omicron subvariants by September, earlier than the previously discussed October or November timeline. Pfizer-BioNTech announced this week they have begun a phase 2 randomized clinical trial testing their bivalent vaccine candidate, while Moderna last month announced preliminary data from an ongoing phase 2/3 study of its bivalent candidate. A new analysis from the Commonwealth Fund estimates that an aggressive fall COVID-19 booster vaccination campaign could save up to 160,000 lives and avert US$109 billion in medical costs, noting that policymakers must take quick action to implement such a nationwide campaign.

RACIAL/ETHNIC DISPARITIES Across the US, racial/ethnic gaps in COVID-19 mortality rates decreased between the first and second year of the pandemic. These inequities decreased due to several factors, including narrowing gaps in vaccination rates among Black and Hispanic residents and reductions in mortality for these populations alongside increases in non-Hispanic white mortality. However, substantial racial/ethnic inequities in COVID-19 mortality persist, particularly in rural areas. A preprint study posted to medRxiv showed that during the second year of the pandemic, through February 2022, Black and Hispanic people died at higher rates than their non-Hispanic white counterparts in non-urban areas, and those rates increased for some racial/ethnic groups. The researchers highlighted the need for improved access to healthcare, especially to COVID-19 therapeutics and vaccination, and increased public health messaging surrounding vaccination, mitigation strategies, and how to access care. The study underscores that residency in urban or rural areas has as much to do with individuals’ COVID-19 experiences as their region of residence and highlights the need to refocus efforts to prioritize health equity—among racial and ethnic groups but also between rural and urban areas—and address systemic racism that continues to contribute to racial/ethnic health inequities. 

ANTIVIRALS Researchers from McMaster University in Canada recently conducted a systematic review and frequentist network meta-analysis, finding that use of molnupiravir (made by Merck and marketed as Lagevrio) and nirmatrelvir-ritonavir (made by Pfizer and marketed as Paxlovid) reduced the risk of hospitalization and death among COVID-19 patients with mild or moderate disease when compared to placebo or standard of care. The findings also indicated that Paxlovid may be superior to molnupiravir for treatment of mild and moderate COVID-19. For example, across 32 trials, 10,837 patients, and 291 deaths, researchers found that molnupiravir and Paxlovid each reduced the risk of death with moderate certainty although Paxlovid more so (10.9 fewer deaths per 1,000; 95% CI 12.6 to 4.5 fewer for molnupiravir; and 11.7 fewer deaths per 1,000; 95% CI 13.1 fewer to 2.6 more for Paxlovid) when compared to standard of care or placebo. Across 10 trials with 5,575 patients and 252 events, Paxlovid further reduced the risk of hospital admission (46.2 fewer admissions per 1,000; 95% CI 50.1 to 38.9 fewer; high certainty) while molnupiravir probably reduced risk of admission but less so (16.3 fewer admissions per 1,000; 95% CI 27.2 to 0 fewer; moderate certainty) compared to standard of care or placebo. The researchers also included trials related to 38 other antivirals, notably finding that remdesivir likely had no effect on risk of death but may have lowered hospitalizations, albeit with low certainty (39.1 fewer admissions per 1,000; 95% CI 48.7 to 13.7 fewer). 

Findings from this study hopefully will help increase uptake of the high performing antivirals, particularly Paxlovid, as both drugs have suffered from high supply and lower-than-expected demand due to low testing and need for a physician’s prescription in some settings outside the US. While Paxlovid has been seen as a game changer by many, uptake has further suffered from concerns regarding COVID-19 symptoms rebounding post-treatment, which occurs in an estimated 5% of patients.

LONG COVID Long COVID continues to pose a threat to a portion of patients who have recovered from SARS-CoV-2 infection. Diagnosis proves difficult due to lack of quality research on the subject, and treatment options are limited, with a focus on symptom management. Symptoms of the disease range widely and are still being discovered, such as new research indicating that some people may experience lower sex drive or hair loss. Prevalence, mechanism of disease, and risk factors are still under investigation, although some studies suggest that up to one-fifth of COVID-19 patients may experience lasting symptoms. Additionally, individuals with severe COVID-19 symptoms and those with comorbidities are most likely to experience long COVID. One recent BMJ study found that 5% of COVID-19 patients could experience permanent dysfunction in taste or smell. Another recent study published in Nature Medicine noted that sneezing and ejaculation difficulty were significantly associated with long COVID, with ethnic minority, socioeconomic deprivation, smoking, and female sex also being risk factors of note. It is now more imperative than ever that the evidence base for the condition expands, as increasingly desperate patients turn to unproven or dangerous treatments such as ivermectin or “blood washing.” 

ISOLATION PERIOD An article in Nature has renewed the debate among some experts over how long individuals should isolate after testing positive for SARS-CoV-2. The US CDC currently recommends that people with COVID-19 isolate for 5 full days after testing positive and can end isolation if they are fever-free for 24 hours (without the use of fever-reducing medication) and their symptoms are improving. The agency recommends all people with COVID-19 take precautions, such as wearing a mask, for 10 full days after a positive test. However, some experts say there is not sufficient evidence to support a 5-day isolation period and maintain that many people remain infectious beyond that timeframe. One preprint study, posted to medRxiv, suggests 25% of people with COVID-19 could be infectious after 8 days. Another preprint study, also posted on medRxiv, suggests that a significant number of vaccinated adults who had mild COVID-19 symptoms may have ongoing transmission risk of Omicron subvariants beyond current isolation periods, specifically days 7-10. Additionally, a small number of people could remain infectious beyond 10 days, experts warn. Notably, a small proportion of people who take the antiviral Paxlovid experience a rebound of symptoms or test positive again after completing the treatment and could be infectious. Most experts agree that individuals should continue to isolate and take precautions until they test negative on a rapid antigen test.

US SCHOOLS As many US students prepare to return to classrooms this fall amid a surge in COVID-19 cases, school districts nationwide are making decisions about whether to require masks. Jefferson County Public Schools, Kentucky’s largest school district, will require masks for everyone, regardless of vaccination status in buildings and on buses, and Gwinnett County Public Schools outside Atlanta, Georgia, recently reinstated a mask mandate for all employees and could extend the requirement when the school year begins on August 3. But while some districts are reinstating mask mandates, others are dropping them. Prince George's County in Maryland, which had the longest-running school mask mandate in the state, recently announced optional masking for the upcoming school year. Notably, a recent ruling from the 5th US Circuit Court of Appeals upheld Texas Governor Greg Abbott’s executive order forbidding the state's school districts from imposing mask mandates to help curb COVID-19. Experts agree that schools should fluctuate their masking policies based on COVID-19 data within their communities. 

Millions of school-age children remain unvaccinated as they prepare to return to classrooms. Everyone older than 6 months is eligible for vaccination, and those ages 5 and older are eligible for a booster. About 23.9 million children aged 5-17 years in the US are fully vaccinated against COVID-19, about 45% of that age group, according to US CDC data. A recent study published in Science Translational Medicine found that mRNA vaccination among children aged 6-11 years can elicit strong immune system responses against SARS-CoV-2, often stronger than those observed in children diagnosed with COVID-19. The study highlights the importance of vaccination in this age group. However, vaccine uptake among children ages 5-17 appears to have slowed, according to a recent poll from KFF, which also found that 43% of parents of the youngest children aged 6 months to 4 years say they will “definitely not” get their child vaccinated against COVID-19 and 13% said they will do so “only if required.” 

SARS-COV-2 ORIGIN In June, a WHO-backed team working to better understand the origins of SARS-CoV-2, the virus behind the COVID-19 pandemic, issued a report calling for additional investigations into all possible origins, including that the virus could have escaped from a laboratory. But 2 studies published this week in Science both support the theory that the Huanan Seafood Market in Wuhan, China, likely was the epicenter for the COVID-19 pandemic. Both studies were posted online as preprints in February but now have been peer-reviewed. One study examined what evidence there was for the virus in the market and found there appeared to be a correlation between where the virus was first detected and the area where wildlife was being sold. The other study analyzed the genomes of viruses isolated from early cases and concluded there were at least 2 different spillover events from an unknown animal host to people, likely around mid-November 2019. The virus began spreading from human to human more frequently in December 2019. 

Many scientists agree that the preponderance of evidence, included in these studies and others, supports a zoonotic origin story of SARS-CoV-2 instead of an accidental laboratory leak. None of the studies provide definitive evidence disproving the lab leak theory, but many experts feel these studies help make that scenario less plausible. The WHO-supported group, known as the Scientific Advisory Group for the Origins of Novel Pathogens, continues its work to collect information about viral outbreaks in Wuhan in late 2019, although its work is progressing slowly. In related news, officials in Wuhan shut down the city’s Jiangxia district this week, saying it would enforce “temporary control measures” for the area’s more than 970,000 residents after detecting 4 asymptomatic COVID-19 cases.

CORRECTION In a story on US hospitals in our July 26 issue, we incorrectly stated the results of a forecast as predicting "1,800-5,600 new deaths per day by August 13." The metric should be "1,800-5,600 new deaths per week by August 13." We apologize for any confusion.