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EPI UPDATE The WHO COVID-19 Dashboard reports 633.3 million cumulative cases and 6.59 million deaths worldwide as of November 17. Global weekly incidence increased significantly for the first time since August, rising 5% compared to a decrease of 10% the previous week. A total of 2.4 million cases were confirmed the week of November 7. Weekly incidence fell over the previous week in Europe (-15%) and the Eastern Mediterranean (-12%) and remained steady in Africa (0.42%). The Americas (+17%), South-East Asia (+15%), and Western Pacific (+18%) regions experienced increasing weekly incidence. Global weekly mortality declined from the previous week, down 26%, reaching the lowest level since the beginning of the pandemic.*
*The WHO dashboard notes that data from the Eastern Mediterranean and Africa regions are incomplete.
UNITED STATES
The US CDC is reporting 97.9 million cumulative cases of COVID-19 and 1.07 million deaths. Incidence for the week ending November 2 rose slightly over the previous week, rising to 288,989 from 273,021 for the week ending November 2. Weekly mortality remained relatively steady for the week ending November 9, down slightly to 2,344 reported deaths from 2,489 deaths the week ending November 2.**
**The US CDC updates weekly COVID-19 data on cases and deaths on Thursdays by 8pm ET.
Both new hospital admissions and current hospitalizations remained stable, falling slightly by 0.9% and 0.8%, respectively.
The BA.5 sublineage is expected to lose dominance in the US over the next week. BA.5 now accounts for 29.7% of sequenced specimens. The Omicron sublineages BQ.1.1 (24.1%) and BQ.1 (20.1%) are exhibiting growth advantages over other sublineages, including BF.7 (7.8%) and BA.4.6 (5.5%). The CDC is now tracking the Omicron sublineage BN.1, which is now responsible for 4.3% of cases. Other Omicron sublineages appear to be declining in prevalence, including BA.5.2.6 (2.9%), BA.2.75 (1.2%), and BA.2.75.2 (0.9%).
US RESPONSE The Biden administration is expected to keep in place the public health emergency status of the COVID-19 pandemic through spring 2023 to address a potential winter surge in cases and provide more time to transition vaccines and treatments to the private market, according to 2 unnamed officials. The declaration, most recently renewed in October, was set to expire in January. The US HHS has promised to provide states 60 days’ notice before winding down the emergency, and did not do so on November 11, which marked that date. This week, the White House requested the US Congress authorize an additional US$9.25 billion in pandemic funding for this year. According to officials, about US$8.25 billion would go toward purchasing treatments and vaccines ahead of a possible winter surge, efforts to accelerate research into next-generation vaccines and treatments, and long COVID research, with an additional US$1 billion going toward global vaccination and response efforts. The Biden administration has repeatedly tried to secure additional funding with no success; observers say the best chance might be during the current lame-duck session while Democrats retain control of both congressional chambers.
Though the need remains for additional spending for COVID-19 and general pandemic preparedness and response, public and congressional interest is waning. On November 15, the US Senate voted 62-36 to end the emergency declaration, with support from 12 Democrats. In response, the Office of Management and Budget said abruptly ending the emergency would be “a reckless and costly mistake” and noted US President Joe Biden would veto the measure if passed by Congress. It is unclear whether the US House will take up the resolution.
WINTER SURGE PREDICTIONS The WHO on November 16 announced that the worldwide number of new COVID-19 cases increased last week for the first time in 4 months, warning that the true number of infections is likely higher due to declines in testing. Additionally, upticks in influenza and respiratory syncytial virus (RSV) cases also are straining hospitals, particularly some countries in the Americas.
While many in the US work to find balance between COVID-19 precautions and returning to a sense of normalcy, there are signs the coronavirus has not gone away. The number of new weekly COVID-19 cases are beginning to increase, raising concerns over a potential winter surge amid waning immunity and the emergence of new subvariants. About 330 people die of COVID-10 each day in the US, and around 21,000 are hospitalized with COVID-19 on any given day. Despite low levels of uptake of the bivalent booster vaccine—only 10% of the population aged 5 and older have received the updated shot—some US health officials, including White House COVID-19 Response Coordinator Dr. Ashish Jha, say they are not expecting a large surge in cases during the winter holiday season. Dr. Jha is confident that broad vaccine coverage and widespread previous infections will help keep a large surge at bay. Other experts are not so assured, saying the possibility remains for a substantial surge, with several factors making the US underprepared. Declining support for community vaccination campaigns, a public that is tuning out renewed government vaccination messaging, few remaining treatments effective against emerging Omicron sublineages, waning use of nonpharmaceutical interventions (NPIs) such as mask use, and diminishing surveillance place the US in uncharted territory heading into what is traditionally the height of respiratory virus season.
MODERNA BIVALENT BOOSTER On November 14, Moderna announced data showing its updated Omicron BA.4/BA.5-adapted bivalent vaccine booster offers a strong immune response against BA.5 by increasing antibodies levels, when compared to the company’s original booster. The bivalent vaccine (mRNA-1273.222) demonstrated a 15-fold increase in neutralizing antibody titers compared to pre-booster levels. The data are not yet peer-reviewed or posted to a preprint server. An exploratory analysis of data from 40 participants suggested both of the company’s bivalent boosters—with the other targeting BA.1 (mRNA-1273.214)—showed robust levels of neutralizing antibodies against the emerging Omicron subvariant BQ.1.1, which has the potential to become dominant in the US by next week. Notably, however, the demonstrated antibody responses were lower than those against BA.4 and BA.5. Since Omicron-adapted booster shots began to rollout earlier this fall, acceptance and uptake has been dismal. Only 10% of the US population aged 5 and older have received an updated booster, spurring the Biden administration to launch a new campaign urging residents to get boosted ahead of Thanksgiving.
COVID-19 REBOUND Cases of COVID-19 rebound—the return of test positivity or symptoms after clearance or resolution—following treatment with the antiviral Paxlovid appear to be more common than previously believed, a preprint study posted November 15 to medRxiv suggests. The prospective observational study, which is not yet peer-reviewed, found that viral rebound among the 127 participants who took a 5-day course of Paxlovid was 14.2%, while 9.3% of the control group of 43 people experienced viral rebound. There were no significant differences in viral rebound by demographics, pre-existing conditions, or major symptoms experienced during the acute phase or at 1 month. Additionally, COVID-19 symptom rebound incidence was higher in the Paxlovid group (18.9%) compared with the control group (7.0%). Though the study was not able to determine whether the observed differences were due to chance or as a result of treatment, many researchers agree the results mirror their real-life experiences that rebound is more common in people who take Paxlovid.
Larger studies are being planned to better understand the issue, which hopefully will help alleviate one of the causes for underprescription of Paxlovid. High-profile cases of rebound likely are contributing to underuse of the treatment. In clinical trials, Paxlovid was nearly 90% at preventing hospitalizations and deaths of high-risk patients with COVID-19. Notably, another preprint study suggests treatment with Paxlovid is associated with a 26% reduction in the occurrence of post-acute symptoms, commonly known as long COVID.
PASC/LONG COVID Although many people with COVID-19 recover within weeks, some continue to experience a constellation of symptoms—or start experiencing new ones—that can last long after their acute infection. The US CDC has recognized that post-acute sequelae of SARS-CoV-2 infection (PASC), commonly called long COVID, includes new or ongoing symptoms such as fatigue, brain fog, shortness of breath, headaches, chest pain, loss of taste or smell, and more. Notably, however, there is no widely accepted definition of the condition, often leaving clinics wrestling with how to treat long COVID patients with varying conditions.
To understand the prevalence of post-COVID-19 symptoms, a recent cross-sectional cohort study published in JAMA Network Open compared the presence of post-COVID symptoms in 360 hospitalized and 308 nonhospitalized patients at 2 healthcare centers in Madrid, Spain, 2 years after their initial acute infection early in the pandemic. The study reported that 2 years after initial infection, 59.7% of those who were hospitalized and 67.5% of those who were not hospitalized still had at least one symptom of COVID-19, with the most prevalent symptoms being fatigue (44.7% vs. 47.7%, respectively), pain and headaches (35.8% and 29.9%, respectively), and memory loss (20% and 15.9%, respectively). Overall, the research team observed no significant differences in post–COVID symptoms between hospitalized and nonhospitalized patients, although hospitalized patients experienced slightly higher levels of anxiety.
Similarly, a recent study published in PLOS Medicine investigated post-COVID-associated morbidity in children, adolescents, and adults using comprehensive healthcare data on half of the German population. The study determined that children, adolescents, and adults have the same relative risk of experiencing post-COVID-19 symptoms 90 days after their initial acute infection. Children, adolescents, and adults experienced shared symptoms like cough, fever, headache, malaise/fatigue/exhaustion, and throat or chest pain. Adults were slightly more likely to experience disturbances of smell and taste, fever, and respiratory symptoms, while children and adolescents were slightly more likely to experience malaise, fatigue/exhaustion, cough, throat or chest pain, and adjustment disorder.
This growing evidence base around the characterization and prevalence of long COVID can help inform efforts to support people whose symptoms have a significant impact on their lives. Although the US HHS and US Department of Justice have jointly declared long COVID as a disability, some Americans with long COVID have faced barriers to accessing disability benefits. Long COVID-related disability assistance is frequently denied due a lack of specific guidance on how to evaluate the claims and lack of standard processes for diagnosing the condition. HHS in August released a report outlining federal services and support for people with long COVID, and advocates and researchers are working to raise awareness of these resources. A recent report from the Brookings Institution estimated that long COVID could be contributing to a national labor shortage, with as many as 4 million people out of work due to the condition.
VACCINE MANDATES Vaccine mandates—for COVID-19 and other diseases—are contentious issues in the US. On several occasions, the US Supreme Court has refused to hear arguments or let lower court rulings stand, allowing COVID-19 vaccine mandates to remain in force. Now, the Blackfeet Nation is challenging a Montana law that prohibits businesses and governments from discriminating against people who are not vaccinated against COVID-19 or other diseases, after a meeting on the Blackfeet Indian Reservation that checked attendees’ COVID-19 vaccination status came under scrutiny for potentially violating state law. The case raises the question of whether Montana can enforce its law on the Blackfeet Nation, superseding the tribe’s right to enforce its own ordinances as a sovereign nation within US borders to protect the health of its people. A 1855 treaty allows the Blackfeet tribe to regulate tribal and nontribal members alike on its land. The US CDC has lauded Blackfeet Nation for implementing effective COVID-19 risk mitigation and prevention measures. Relatedly, a separate lawsuit argues that Montana’s law is unconstitutional and prevents hospitals and physicians from protecting disabled patients and employees from exposure to COVID-19.
VACCINE APPROVAL PROCESS IN INDIA India’s national drugs regulator approved a domestically developed vaccine for COVID-19—Covaxin, produced by Bharat Biotech—despite discrepancies in the number of clinical trial participants, questionable changes to trial protocols, and efforts to speed trials along without complete data on safety and efficacy, according to a report from STAT. A lack of transparency surrounding the vaccine’s development efforts, questions over Bharat Biotech’s manufacturing facilities, as well as political and scientific pressure to move testing forward contribute to ongoing concerns over Indian government oversight of and commitment to producing quality medical products. A day after the STAT report’s publication, India’s Health Ministry said any allegations that the government made missteps or rushed Covaxin’s development and testing are “completely misleading, fallacious, and ill-informed,” and Bharat Biotech called the narrative misleading, clarifying that any pressure felt originated within the company. Bharat Biotech also reiterated that Covaxin is safe and effective, having been tested more than any other Indian vaccine and with several million doses administered worldwide.
India’s pharmaceutical industry is one of the world’s largest by volume, exporting medicines to more than 200 countries and contributing a large volume of generic drugs, especially in the US. Last month, the WHO linked an Indian-made cough syrup to the deaths of nearly 70 children in West Africa; India’s drugs regulator disputed the WHO’s findings.
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