COVID-19 Situation Report
Editor: Alyson Browett, MPH

Contributors: Clint Haines, MS; Noelle Huhn, MSPH; Natasha Kaushal, 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 future, potentially more severe, globally catastrophic infectious disease pandemic. The deadline is October 3, 2022. For more information:
MONKEYPOX OUTBREAKS UPDATE Read our latest update from June 15 on the monkeypox outbreaks and visit our monkeypox resource page. We will continue to analyze the situation and provide updates, as needed. If you would like to receive these updates, please sign up here.
EPI UPDATE The WHO COVID-19 Dashboard reports 538 million cumulative cases and 6.32 million deaths worldwide as of June 22.* The global weekly incidence remained relatively stable (-0.68%) from the previous week, when incidence was up nearly 8% after 3 weeks of decline. Global weekly mortality decreased as well, down 11% from the previous week. At the regional level, Europe (+17%), Southeast Asia (+46%), and the Eastern Mediterranean (+52%) experienced increases, while the other 3 regions had decreasing trends.
*The WHO COVID-19 dashboard indicates that there is a delay in reporting for the African Region, so the current totals may not be complete.

The US CDC is reporting 86.4 million cumulative cases of COVID-19 and 1,009,444 deaths. The average daily incidence has plateaued over the past several weeks, holding relatively steady at approximately 100-110,000 new cases per day. The current 7-day average is 99,365 new cases per day. Likewise, the average daily mortality has held relatively steady at approximately 250-300 deaths per day since late May.* Notably, the current 7-day average is 248, the lowest level since July 13, 2021.
*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.

Both new hospital admissions (+1.5% over the past week) and current hospitalizations (+1.1%) continue to increase, although they appear to have stabilized over the past week. Considering the plateau in daily incidence, it is possible that hospitalizations could also remain elevated, rather than peaking and then declining.

Community transmission in the US continues to be driven by the BA.2.12.1 sublineage of Omicron (56%), but BA.5 (23.5%) and BA.4 (11.4%) are now outpacing BA.2 (9.1%). The prevalence of BA.4 and BA.5 now appears to be increasing more rapidly than BA.2.12.1. These 4 sublineages of the Omicron variant represent all new SARS-CoV-2 infections in the US.

PEDIATRIC VACCINES Taking the recommendation of its advisory committee, the US FDA on June 17 authorized pediatric formulations of both the Moderna and Pfizer-BioNTech SARS-CoV-2 vaccines for children as young as 6 months old. The following day, US CDC Director Dr. Rochelle Walensky endorsed the agency’s Advisory Committee on Immunization Protection (ACIP)’s recommendation that all children younger than age 5 get vaccinated against COVID-19. US President Joe Biden visited a vaccine clinic in Washington, DC, on June 21 to mark the rollout of the last major phase of vaccinations in the nation, with virtually all individuals now eligible to receive at least 1 of 3 authorized or approved SARS-CoV-2 vaccines. In his remarks, President Biden said the availability of vaccines for the youngest children marks a “monumental step forward” and provides “some peace of mind” for parents who have been waiting 18 months since the first vaccines were authorized for adults. There are about 19 million children aged 6 months to 5 years in the US. 

The Biden administration has said 10 million doses are available for distribution to states and healthcare providers, but only 2.5 million doses of the Pfizer-BioNTech vaccine and 1.3 million doses of the Moderna vaccine have been ordered to date. While some parents have expressed excitement and relief at the vaccines’ availability, it remains unclear how many will vaccinate their young kids. Only 29% of 5-11 year-olds are fully vaccinated, while 59% of those aged 12-17 years are fully vaccinated. Some parents already are facing challenges securing an appointment to get their children vaccinated, despite a federal operational plan released and implemented earlier this month. While neighborhood pharmacies and pharmaceutical chains are included in this phase of the vaccination campaign, many are expecting families to go to primary care physicians and pediatricians because of trust, familiarity, and relationships that may not exist at the pharmacy. Additionally, some parents are weighing the differences between the 2-dose Moderna and 3-dose Pfizer-BioNTech vaccines for children.

The FDA also authorized Moderna’s vaccine for children and adolescents ages 6-17 last week. The CDC’s ACIP is meeting today to discuss clinical considerations and recommendations for the vaccine in that age group. The Pfizer-BioNTech vaccine is already available for adolescents and older children.

ANTIBODY ESCAPE A correspondence letter in the New England Journal of Medicine published June 22 by authors from the Beth Israel Deaconess Medical Center in Boston provides new evidence that Omicron subvariants, including BA.4 and BA.5, are showing substantial escape from neutralizing antibodies provided by vaccination or infection. The authors evaluated neutralizing antibody titers against against the original wildtype SARS-CoV-2 and Omicron subvariants BA.1, BA.2, BA.2.12.1, and BA.4 or BA.5 among 27 participants vaccinated with the Pfizer-BioNTech vaccine who had no indications of prior infection and 27 participants with recent infection with the BA.1 or BA.2 subvariants a median of 29 days earlier (range: 2-113 days), a majority of whom were vaccinated. Among vaccinated but never infected participants, neutralizing antibody titers compared to wild-type SARS-CoV-2 were lower by “a factor of 6.4 against BA.1, by a factor of 7.0 against BA.2, by a factor of 14.1 against BA.2.12.1, and by a factor of 21.0 against BA.4 or BA.5.” Participants with a prior history of infection with BA.1 or BA.2 showed similar trends with neutralizing antibody titers compared to wild-type SARS-CoV-2 lowered by “a factor of 6.4 against BA.1, by a factor of 5.8 against BA.2, by a factor of 9.6 against BA.2.12.1, and by a factor of 18.7 against BA.4 or BA.5.” The authors asserted that these findings indicate that the Omicron variants continue to feature further neutralization escape, which may lead to increased infection among populations with prior immunity against the virus. Findings in a recent Lancet Infectious Diseases correspondence provided similar evidence of substantial escape from neutralizing antibodies against Omicron variants among individuals vaccinated with the Sinopharm vaccine, with only partial recovery after a booster shot of the same vaccine.

SARS-COV-2 REINFECTION The newest Omicron subvariants of BA.4 and BA.5 are driving increases in new SARS-CoV-2 infections in several regions, with many people experiencing reinfections despite immunity from prior infection or vaccination (1+ shots). These subvariants appear to be able to evade antibodies more easily than their predecessors, possibly due to new and different spike proteins. Though global COVID-19-associated mortality appears to be decreasing, a new preprint study posted on Research Square cautions that reinfections pose an increased risk of hospitalization (HR 2.98), all-cause mortality (HR 2.14), and sequelae in pulmonary and other organ systems. The risk of these adverse outcomes—including those impacting the heart, blood, kidneys, lungs, and brain—were most pronounced in the acute phase of infection but persisted throughout the 6-month follow up. Additionally, for every reinfection (1, 2, 3+) there was a stepwise increase in risk for all sequelae evaluated, including hospitalization. Although not yet peer-reviewed, the study serves as a signal that the COVID-19 pandemic remains a threat to the health of the world’s population, and individuals must continue to take precautions to prevent infection.

MODERNA BIVALENT BOOSTER Moderna announced June 22 that it plans to seek regulatory approval for an updated booster vaccine, mRNA-1273.214, after new clinical data on the bivalent candidate showed success against newer Omicron variants. The announcement comes in anticipation of fall booster shots, with the company saying it could ship doses as early as August. Moderna found that mRNA-1273.214 increased neutralizing titers against BA.4 and BA.5 Omicron subvariants among all participants (95% CI: 5.0, 5.9). Neutralizing titers increased by 6.3-fold (95% CI: 5.7, 6.9) among specifically seronegative patients. However, the boost to neutralizing titers for BA.4 and BA.5 was not quite as high as the boost in neutralizing titers against the original Omicron variant, BA.1, or the Delta variant. Moderna noted that a peer-reviewed manuscript describing clinical trial data should be available soon. 

Scientists are hopeful that this new booster, as well as others under investigation, will aid in improving protection against a potential surge in the fall. However, both Moderna and BioNTech leadership expressed concern that regulatory processes needed to update boosters could cause delays, hoping that future updates to the most recent strains can be done without clinical trials. In a separate announcement, Moderna said it will establish a new research and manufacturing center in the UK, allowing that country to gain access to mRNA platform-based vaccines

COVID-19 REBOUND Following a US CDC health advisory issued last month warning about the potential for recurrence of COVID-19 or “COVID-19 rebound” following treatment with the antiviral Paxlovid, several new studies suggest potential causes of the occurrence and support initial studies’ findings that rebound happens in only a small proportion of patients. A study published June 20 in Clinical Infectious Diseases examined the experience of one patient with rebound following Paxlovid treatment. The researchers, from the University of California San Diego School of Medicine, isolated the SARS-CoV-2 BA.2 variant from the patient with symptom relapse and sampled their plasma to test for viral immunity. They found the isolate had not developed drug resistance, nor did the patient have impaired immunity, leading them to hypothesize the rebound likely was the result of insufficient exposure to the drug

Another study (preprint), posted to medRxiv and conducted by US NIH researchers, examined clinical, virologic, and immune measurements of 7 patients with COVID-19 rebound, 6 who had taken Paxlovid and 1 without previous treatment. Again, the researchers found no evidence of drug resistance, viral mutation, or impaired immune response. Instead, they found the rebounds were associated with elevated SARS-CoV-2-specific antibody and cellular immune responses, possibly due to the body trying to clear residual viral antigens possibly shed from dying infected cells. Both studies were very small and may not be generalizable to all COVID-19 rebound cases; additional larger studies are needed to confirm their findings. On June 21, the US CDC’s Morbidity and Mortality Weekly Report (MMWR) published a study examining 5,287 Paxlovid-treated patients aged 12 years and older, finding less than 1% experienced COVID-19-related hospitalization or emergency room visits 5-15 days after treatment was dispensed. 

PANDEMIC INEQUALITY The COVID-19 pandemic has drastically impacted people’s health, income, and various social risk factors, worsening existing inequalities and exposing others. Nature uses 6 graphs to explore the pandemic’s effects. The graphs express various data sets examining specific issues globally, in low- and middle-income countries, and in the US, UK, and Brazil. Notably, by the end of this year, 75 million more people will be pushed into poverty—living on less than US$1.90 per day—than was expected before the pandemic, derailing gains made prior to 2020 and highlighting the need for increased efforts to get the world back on track toward the UN Sustainable Development Goals.

US NATIONAL PUBLIC HEALTH SYSTEM A bipartisan commission of health leaders this week released a set of recommendations to overhaul public health in the US, with the aim of creating a “national public health system” to protect and improve health, advance health equity, and effectively respond to emergencies. The authors call for changes that could address current health challenges—including rising maternal mortality, overdoses, and diabetes—and avoid a repeat of what it called a “splintered” response to COVID-19 that led to widely disparate outcomes nationwide. The Commonwealth Fund Commission on a National Public Health System proposal outlines actions for the US Congress; the administration of US President Joe Biden; and state, local, tribal, and territorial governments to create a coordinated and collaborative national public health system.