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.
NOTICE The COVID-19 Situation Report will not publish on Tuesday, May 31, 2022. The next Report will be published on Thursday, June 2, 2022.
UPCOMING WEBINAR With summer approaching, engaging in sporting events can seem daunting for athletes and spectators alike, especially as the world continues to respond to the pandemic. This webinar will focus on COVID-19 testing strategies and best practices for large sporting events. The panelists, Dr. Brian McCloskey and Ms. Lucia Mullen, served on WHO’s COVID-19 Mass Gatherings Expert Group. They advised Olympic organizers on COVID-19 countermeasures for the Tokyo 2020 Summer and the Beijing 2022 Winter Games. They will discuss developing and implementing masking, testing, and vaccination strategies for the world’s largest international sporting celebrations. Please join us on June 1 at 10:00am ET. Registration is available here.
MONKEYPOX OUTBREAKS UPDATE Read our latest update from May 25 on the monkeypox outbreaks. A new fact sheet also is available. 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 524.3 million cumulative cases and 6.28 million deaths worldwide as of May 25. The global weekly incidence decreased slightly (-0.8%) over the previous week. The weekly trends are increasing in the Americas (+13.2%) and Western Pacific (+5.7%) regions, while decreasing trends were observed in the remaining 4 regions. The trend in reported global weekly mortality decreased for a seventh consecutive week, down 6% from the previous week. The number of new weekly deaths increased in the Eastern Mediterranean region (+30%) after the region reported major increases in daily incidence over the past couple weeks. The number of new weekly deaths remained stable in the Western Pacific and the Americas regions (both <1%), and decreased in the other 3 regions.

UNITED STATES
The US CDC is reporting 83.4 million cumulative cases of COVID-19 and 1,000,254 deaths. As expected, the cumulative number of COVID-19 deaths surpassed 1 million on May 24. The current average daily incidence continues to increase, up to 104,399 on May 24 from 99,215 new cases per day on May 17. The daily mortality is fairly steady at an average of 288 deaths per day*, and we have not yet observed an increase corresponding to the surge in daily incidence. New COVID-19 hospital admissions continue to trend upwards, with an increase of 14% over the past week. New cases are now being driven by the the BA.2.12.1 sublineage of Omicron (58%), which this week became the predominant variant over the BA.2 subvariant (39%).
*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.

OMICRON SUBVARIANTS The US recently began averaging more than 100,000 new daily COVID-19 cases for the first time since February. As of the end of last week, 58% of new US cases are caused by the Omicron subvariant known as BA.2.12.1. There is no indication the variant causes more severe disease than previous Omicron variants, but new hospitalizations also are increasing. However, BA.2.12.1—as well as the other Omicron sublineages BA.4 and BA.5, which the European Centre for Disease Control and Prevention (ECDC) have deemed variants of concern and are currently circulating at low levels in the US—are even more transmissible than the BA.1 version of Omicron that caused high caseloads in early 2022. The 3 sublineages also likely are capable of escaping some of the immunity produced by infection with BA.1 and BA.2. The consistent resurgence of viral variants creates challenges to maintaining long-lasting defense against COVID-19, but the best defense against severe disease and death remains staying up-to-date on vaccinations. 

US CDC PAXLOVID ADVISORY ​The US CDC on May 24 issued a Health Alert Network (HAN) Health Advisory to inform healthcare providers and the public about the possible recurrence of COVID-19 following Paxlovid treatment, commonly referred to as “COVID-19 rebound” or “Paxlovid rebound.” Paxlovid, an oral antiviral drug for early-stage treatment of mild-to-moderate COVID-19, was authorized for emergency use in December 2021 for persons aged 12 years and older who are at high risk for progression to severe illness. The drug has shown to reduce the risk of hospitalization and death due to COVID-19. In the advisory, the CDC emphasized that brief recurrence of COVID-19 symptoms could be part of the natural history of infection, regardless of treatment and vaccination status. However, individuals with recurrent symptoms or a new positive viral test are advised to follow current CDC recommendations for isolation by re-isolating for at least 5 days and when fever has resolved for 24 hours.  

Today, the administration of US President Joe Biden announced plans to make Paxlovid even more accessible as the nation experiences another surge in new COVID-19 cases. The nation’s first federally supported test-to-treat site opened today in Rhode Island to provide Paxlovid to individuals who test positive. Other test-to-treat sites are expected to open soon in Massachusetts and New York City, and established testing sites across the country will soon be equipped to transition to test-to-treat locations, according to the administration.

LONG COVID/PASC In the third year of the COVID-19 pandemic, researchers are beginning to learn more about post-acute sequelae of SARS-CoV-2 (PASC), commonly known as long COVID. The condition—characterized by a broad range of symptoms lasting anywhere from 4 weeks to 2 years or longer—could prove one of the biggest hurdles to pandemic recovery. Estimates of the proportion of people who have had COVID-19 and continue to experience symptoms range from 5% to 80%, although the WHO puts the range at 10% to 20%. Results from a large study published this week in the US CDC’s Morbidity and Mortality Weekly Report (MMWR) estimates that 1 in 5 COVID-19 survivors aged 18-64 and 1 in 4 survivors aged 65 or older experienced at least 1 of 26 conditions often attributable to long COVID at 30 days and up to 1 year following diagnosis. Both age groups had twice the risk of uninfected people of developing respiratory symptoms or other lung problems, including pulmonary embolism. The older cohort was at greater risk than the younger group to develop kidney failure, neurological conditions, and mental health conditions. The authors of the study, members of the CDC COVID-19 Emergency Response Team, encouraged people who survive COVID-19 to undergo routine assessment for post-COVID conditions.

Another study, published in Nature Medicine on May 23, found that 1 in 8 adults who were hospitalized with COVID-19 developed myocarditis 28 to 60 days post-discharge, and many COVID-19 survivors experienced reduced exercise capacity, lower quality of life, and persistent abnormalities in heart, lung, and kidney exams. The researchers said study participants’ post-COVID conditions were more closely correlated with the severity of their COVID-19 infection, not their underlying health condition prior to infection, and they cautioned these persistent health problems could place a substantial demand on healthcare services in the future, as more people survive COVID-19. 

US NIH researchers conducting an ongoing study comparing 189 COVID-19 patients to 120 similar patients who did not have COVID-19 found no indications of underlying cause for the COVID-19 group to have more persistent symptoms. The study, published in the Annals of Internal Medicine, showed no evidence of persistent viral infection, autoimmunity, or abnormal immune activation among long COVID patients. They did note that women and those with a history of anxiety disorder were at increased risk of PASC/long COVID, but they also stressed the findings do not mean the condition is psychological. A third study, published in the Annals of Clinical and Translational Neurology, found that neurological symptoms—including brain fog, numbness/tingling, headache, dizziness, blurred vision, tinnitus, and fatigue—among many of the 52 non-hospitalized COVID-19 patients in the study persisted for nearly 15 months after initial diagnosis. Some symptoms, including variations in heart rate and blood pressure and gastrointestinal problems, increased over time, but loss of taste and smell generally improved. Among the participants, 77% were vaccinated against COVID-19, but vaccination did not have a positive or negative impact on cognitive function or fatigue.

Notably, a large study conducted by the US Department of Veterans Affairs (VA) and published in Nature Medicine showed that SARS-CoV-2 vaccination appears to reduce the risk of lung and blood clot disorders among COVID-19 survivors, but vaccination does little to protect against long-term symptoms among those who had breakthrough infections, about 1% of the study participants. Overall, vaccinated people who had breakthrough infections had lower risks of death (HR=0.66, 95% CI: 0.58, 0.74) and long-term symptoms (HR=0.85, 95% CI: 0.82, 0.89). The data confirm that vaccination strongly protects against serious disease and death but suggest that vaccination prior to infection confers only partial protection against PASC and should not be relied upon as a sole mitigation strategy, the researchers noted. The VA study was conducted prior to the emergence of the Omicron variant, and a preprint study conducted in Japan and posted this week to medRxiv suggests the prevalence of long-term symptoms following infection with Omicron might be less than with other variants. 

PFIZER PRICING DEAL During the World Economic Forum annual meeting in Davos, Switzerland, this week, Pfizer pledged to provide 23 of its patented medicines and vaccines to treat infectious diseases, certain cancers, and rare and inflammatory diseases—including those for COVID-19—at not-for-profit pricing to 45 lower-income countries. The company’s “An Accord for a Healthier World” also includes future products and is expected to benefit 1.2 billion people. Rwanda, Ghana, Malawi, Senegal, and Uganda are the first nations included in the deal. Haiti, Bangladesh, and Tajikistan also are on the list. Pfizer CEO Albert Bourla said the plan also includes strategies aimed at improving access to diagnostics, technical assistance, and training of healthcare workers. Some advocates welcomed the announcement, while others criticized the effort as being too little, too late.

Also at the meeting, the Serum Institute of India (SII), the world's largest vaccine manufacturer, announced it is looking into establishing a manufacturing plant in Africa. SII CEO Adar Poonawalla said he is working to distribute a draft global treaty to help ensure more equitable access to vaccines and other healthcare during this pandemic and future outbreak emergencies. 

PANDEMIC PREPAREDNESS The World Health Assembly (WHA) is meeting this week in Geneva, the first time the WHO decision-making body has met in person since the beginning of the COVID-19 pandemic. On May 24, the WHA approved a report from the Working Group on Preparedness and Response to Health Emergencies that includes a roadmap for the creation of a new instrument for pandemic preparedness and response. The report proposes actions to address critical gaps in prevention, preparedness and response to health emergencies, including pandemics; categorizes 131 recommendations by priority, feasibility, and implementation pathway; and highlights which steps are currently underway. High priority recommendations include recommitment to the binding obligations of the International Health Regulations (IHR). Other priorities include building capacity for local manufacturing with the support of technology transfer and research hubs, international coordination to quickly identify and sound alerts to emerging zoonotic diseases, and expanding regional capacities for genomic sequencing. In June, the Intergovernmental Negotiating Body will meet to discuss the roadmap and recommendations.

​​The WHA has faced online conspiracy theories regarding the discussion of a pandemic treaty, with misinformation accusing the WHO of attempting to impede national sovereignty. While Member States agreed that a new agreement is needed, negotiations for such an agreement will take years to produce a final draft. The false ideas of the treaty being used to take power from national governments have been popularized by various internet figures and boosted by mainstream politicians. Despite these statements, the WHA remains focused on navigating the end of the COVID-19 pandemic and preparing for the next health emergency.

CHILDHOOD LEARNING LOSS The COVID-19 pandemic caused the greatest disruption to education in history, causing students worldwide to miss an average of 4.5 months of schooling or up to 22 weeks of learning. Many students fell behind in standards of learning, and some developed behavioral or psychological problems. Those students in the poorest countries have been hit hardest, as have disadvantaged and vulnerable children in wealthier nations, exacerbating existing inequities. As school systems and teachers try to get students back on track, some nations are looking to decades of research to inform their COVID-19 responses, with a focus on tutoring, voluntary summer school, and other evidence-based education recovery strategies. Proponents of evidence-informed education encourage more quality research be conducted and urge educators and policymakers to seriously consider the results and implement reforms specific to their settings in order to strengthen education systems. Additionally, they encourage the coupling of education research and continuing education for teachers, making teachers researchers and vice versa. But advocates warn that national, state, and local leaders must act quickly to fill the educational gaps created by school closures during the pandemic.

CHINA Full economic recovery from the COVID-19 pandemic is expected to be a gradual process for China. But the country is taking the matter seriously, with China’s cabinet holding an emergency meeting of more than 100,000 provincial, city, and council leaders to discuss new measures to stabilize the economy. Shanghai, the nation’s financial hub, looks to be making steps toward normalization after dealing with months of severe pandemic prevention restrictions. China continues to pursue a “zero COVID” policy, but increasingly strict control measures are causing tension in some metropolitan areas. The government has used extreme measures, including locking residents in their buildings, relocating thousands of residents to other cities for quarantine, and invading private residences to spray disinfectants. Now, some cities and provinces are instituting regular mass SARS-CoV-2 testing to try to keep the virus at bay. The 99 million residents of Henan Province will be required to take PCR tests every other day as of June, and people in Beijing must test in order to ride the subway or enter any public space. The intense restrictions on personal life and freedom have been a major cause of discontent among younger populations, and many are now seeking to leave China or are protesting the restrictions by refusing to have children. The discontented populations claim they do not want to have children because they feel they could never protect them from an authoritarian regime that has little regard for personal liberties. 

RESEARCH ROUNDUP The research roundup provides quick synopses of COVID-19-related research.

From JAMA Network Open, a small cohort study of 50 healthy young and middle-aged individuals examining factors associated with blood levels of anti-SARS-CoV-2 antibodies at 6 months following vaccination. The study found that anti-SARS-CoV-2-specific antibody levels were inversely correlated with bodyweight, body mass index, body fat amount, and body weight to height ratio, sustained up to 6 months post-vaccination. The researchers concluded that young and middle-aged healthy persons with low body weight could wait at least 6 months after finishing a primary 2-dose vaccination series to receive a booster dose.

From The Lancet Respiratory Medicine, a randomized, open-label, controlled clinical trial evaluating the safety and immune response of a heterologous high- or low-dose booster of an adenovirus vector-based SARS-CoV-2 vaccine (CanSino Biologic’s Convidecia) administered via oral aerosolization or a homologous intramuscular vaccination with CoronaVac among Chinese adults who previously received 2 doses of CoronaVac. The researchers found that participants in both the high- and low-dose heterologous booster groups had fewer side effects and higher neutralizing antibody responses compared with the CoronaVac group. The interim analysis serves as a proof of concept for an inhaled aerosolized vaccination, and an additional trial to evaluate the vaccine as a booster is planned.

From eClinicalMedicine, a systematic review of 156 studies published through March 13, 2022, analyzing social media use and attitudes toward and behaviors related to SARS-CoV-2 vaccination. The researchers—from Italy, Serbia, and the US—conclude that public health interventions could effectively use social media platforms to promote vaccine uptake.

From JAMA, a research letter describing a prospective study examining the outcomes of children with multisystem inflammatory syndrome (MIS-C) as a complication of SARS-CoV-2 infection who were evaluated at 12 Israeli hospitals over 16-week periods in each of the Alpha, Delta, and Omicron variant waves. The researchers found that cardiac outcomes were more favorable, fewer children were admitted to intensive care units (ICUs), and median hospital length of stay was shorter during the Omicron wave compared with the Alpha and Delta waves. None of the patients needed mechanical ventilation during the Omicron wave, compared with 8.5% during Alpha and 8.9% during Delta. The results suggest that MIS-C was less severe during the Omicron wave compared with other COVID-19 pandemic waves, a finding that is consistent with other studies. 

From BMJ, a retrospective, test-negative, case-control study examining the relative vaccine effectiveness (VE) of a fourth dose of the Pfizer-BioNTech mRNA SARS-CoV-2 vaccine compared with 3 doses over a 10-week span. The study included nearly 97,500 individuals aged 60 and older in Israel. The researchers concluded that a fourth vaccine dose appears to provide additional protection from COVID-19-related severe disease and death but the relative VE of the fourth dose against infection wanes sooner than that of a third dose, peaking at 65% 3 weeks following the booster and falling to 22% at the end of week 10. However, relative VE against severe disease remained high (72%) through the 10-week follow-up, although severe disease was rare among participants who had received 3 or 4 doses.

From The Lancet Oncology, a population-based, test-negative, case-control study examining overall SARS-CoV-2 vaccine effectiveness (VE) against breakthrough infections at 3-6 months after the second dose among people with cancer and a control population in the UK. The researchers found that although SARS-CoV-2 vaccination is effective in most individuals with active or recent cancer, vaccination provides lower levels of protection against infection, hospitalization, and death than in the general population. Additionally, VE wanes more quickly among cancer patients than the general population and is lowest and wanes most quickly in those with lymphoma and leukemia. The researchers encouraged those with active or recent cancer, and especially those with blood cancers, to stay up-to-date on their vaccine doses, in some cases meaning 5 doses.

From Scientific Reports, a longitudinal study evaluating COVID-19 containment strategies across 50 different countries and territories, differentiating between pre-vaccine and vaccinating phases. The ranking shows that countries in Oceania and Asia outperformed countries in other regions on pandemic containment during the pre-vaccine phase, with success related to nonpharmaceutical interventions (NPIs), early action, and policy adjustment when necessary. In the vaccinating phase, the researchers found that maintaining NPIs was the best way to protect populations, providing insight into the effectiveness of various infectious disease containment policies in different regions.