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EPI UPDATE The WHO COVID-19 Dashboard reports 619.8 million cumulative cases and 6.54 million deaths worldwide as of October 12. Global weekly incidence remained relatively steady at slightly more than 3 million cases for the fifth consecutive week, decreasing 6% compared to the previous week. Weekly incidence in Europe increased for the fourth consecutive week, up 5% over the previous week. All other regions reported decreasing trends. Global weekly mortality continued to decrease for the eighth consecutive week, although it appears to be leveling off, down 5% from the previous week.*
*The WHO dashboard notes that data from the Africa Region are incomplete.
UNITED STATES
The US CDC is reporting 96.6 million cumulative cases of COVID-19 and 1.06 million deaths. Daily incidence continues to decline, down to 39,893 new cases per day, the lowest average since mid-April. Average daily mortality is down from a recent high of 505 deaths per day on August 12 to 338 on October 11, but the steadily decreasing trend appears to be leveling off.**
**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 and current hospitalizations continue to exhibit downward trends, with decreases of 2.8% and 5.2%, respectively, over the past week. Both trends peaked around the end of July, approximately 1 week after the peak in daily incidence.
The BA.5 sublineage continues to be the dominant strain in the US, accounting for 79.2% of sequenced specimens; however, its estimated prevalence has decreased for 7 consecutive weeks. Several other Omicron sublineages continue to exhibit increasing trends. Notably, the BA.4.6 sublineage is up to 13.6%, BF.7 is up to 4.6%, and BA.2.75 is up to 1.8%. The increasing trends suggest that these subvariants may have some growth advantage over BA.5.
UPDATED BOOSTERS FOR CHILDREN US health regulators on October 12 authorized the updated SARS-CoV-2 bivalent vaccine boosters for children as young as 5 years old. Specifically, the booster from Pfizer-BioNTech is now available for children aged 5-11 and the shot from Moderna is authorized for children and adolescents aged 6-17. The booster shots—which target the original virus and the currently predominant Omicron BA.5 and BA.4 sublineages—are available to anyone age 5 or older who completed their 2-dose primary series at least 2 months prior. US CDC Director Dr. Rochelle Walensky signed off on the updated bivalent COVID boosters for children shortly after the US FDA issued its authorization. The new formulations will help bolster antibodies that have waned since prior vaccination or infection while targeting newer variants that are more transmissible and immune evasive, particularly important as children are back to in-person schooling and as the US heads into a busy holiday season.
Experts hope the new booster formulation will renew interest in getting children vaccinated before an expected fall and winter surge in cases. As of September 28, only 15.2% of children aged 5-12 years had received a first booster dose, according to CDC data. According to US regulators, there are no safety concerns for the bivalent vaccines, and they stress that vaccination is one of the best ways to keep children healthy and in school. Currently, no bivalent vaccines are approved for children under 5; however, Moderna and Pfizer-BioNTech are expected to have data available later this year. Vaccination continues to be the best way to protect against severe disease and hospitalization, and all eligible individuals are recommended to receive a bivalent booster dose as soon as possible.
LONG & 'MEDIUM' COVID Increasing evidence shows that a significant proportion of people infected with SARS-CoV-2 do not fully recover from acute infection even months later, experiencing a host of post-acute sequelae of SARS-CoV-2 (PASC), more commonly known as long COVID. Research to better understand the condition will help inform the development of care, treatment, and social support systems for people experiencing the condition. A new modeling study, published online this week in JAMA and based on information from a database of more than 1.2 million COVID-19 patients in 22 countries, estimates that 6.2% of people had long COVID symptoms 3 months after symptomatic SARS-CoV-2 infection. The model estimates the proportion of those who had at least 1 of 3 self-reported long COVID symptom clusters: persistent fatigue with bodily pain or mood swings (3.2%), cognitive problems (2.2%), or ongoing respiratory problems (3.7%). Estimated symptom duration for hospitalized COVID-19 patients was 9 months, and 4 months for those who were not hospitalized. Even after one year, 15.1% of those with long COVID continued to experience symptoms.
Another study, published in Nature Communications and performed in Scotland, utilized a matched pair design to evaluate long COVID outcomes in people with and without a previous COVID-19 diagnosis. The cohort of more than 33,000 laboratory-confirmed SARS-CoV-2 infections and nearly 63,000 individuals who had not been infected were evaluated at several time points during the study, including 6, 12, and 18 months. Among those who had symptomatic infection, 6% reported they had not recovered at all, and 42% said they had only partially recovered. No recovery was associated with hospitalization, age, female sex, deprivation, respiratory disease, depression, and multimorbidity. While asymptomatic infection was not associated with adverse outcomes, previous symptomatic infection was associated with poorer quality of life and persistent symptoms—including breathlessness, palpitations, chest pain, and confusion—that impact daily life. Vaccination was associated with a reduced risk of 7 of the 26 symptoms listed in the questionnaire. Further research is ongoing through the COVID in Scotland Study.
Many studies are focusing on the implications of long COVID, but concerns are being raised over “medium COVID”: the middle phase of recovery that stretches to about 12 weeks after infection. Lumping lasting symptoms into the long COVID category and varying definitions of post-COVID conditions have led to little clarity on what classifies as medium COVID. Notably, a few studies indicate that the most severe post-COVID complications may arise in this middle phase of recovery, rather than many months after infection or in the midst of active, symptomatic infection. While time-limited, medium COVID can still cause months of distress and life-altering symptoms. A Swedish study suggests that the risk of developing pulmonary embolism was 32 times higher in the first month after testing positive, twice as likely at 60 days, and indistinguishable from baseline by 3-4 months after infection. Similar risks and trends were found for heart attack and stroke. The findings are supported by similar data from a UK study published over the summer, in which researchers found that new-onset cardiovascular disease was increased early after COVID-19—primarily due to pulmonary embolism, atrial arrhythmias, and venous thrombosis—and new-onset diabetes mellitus incidence remained elevated for at least 12 weeks following COVID-19 before declining. All of these studies have incredible public health implications and show that even if the emergency phase of the pandemic is winding down in many regions, its long-lasting impacts are only beginning to be understood.
THERAPEUTICS Scientists expect numerous countries will experience sizable COVID-19 surges from this month through January, driven by various SARS-CoV-2 Omicron sublineages that will likely be the most transmissible and immune evasive yet. Several nations in Europe—including Germany, France, and Italy—are in the early stages of another wave, and the US typically follows this trend by about 4-6 weeks. Additionally, the new, highly immune-evasive variant XBB—a combination of two different Omicron subvariants—is driving a surge of cases in Singapore. Researchers are concerned over the new strains’ abilities to dodge vaccine-induced or natural immunity, as well as other authorized treatments.
There is evidence that Evusheld, a monoclonal antibody treatment used to bolster protection among immunocompromised individuals, may not be effective against the BA.4.6 Omicron sublineage, which now accounts for about 14% of cases in the US. If BA.4.6 can evade Evusheld, bebtelovimab could be the only monoclonal antibody treatment available to treat circulating strains of the virus. Additionally, Merck and Ridgeback Biotherapeutics released preliminary data last week showing their antiviral molnupiravir (Lagevrio) failed to reduce hospitalizations or deaths compared to placebo among multiply-vaccinated adults mostly under age 65 who were at higher risk of severe disease. The therapy did reduce the time to recovery by 6 days, and use of the drug was associated with earlier recovery across a variety of other symptom measures.
Another antiviral, Paxlovid, is being underused among patients at highest risk of severe disease in the US, experts warn. Some physicians might be reluctant to prescribe the drug due to its known interactions with several types of medications, including some used for cardiovascular disease. Notably, however, several studies show the therapy can reduce hospitalization, death, and time to recovery among older adults and those with at least one high-risk comorbidity, even those who are vaccinated. The US NIH released results from a small study last week showing that a return of COVID-19 symptoms and/or a positive test after completing an initial 5-day course of Paxlovid—commonly called COVID-19 rebound—is likely not caused by impaired immune responses. Instead, the rebound in symptoms could be partially driven by robust cellular immune responses to residual viral RNA in the respiratory tract. Infectious virus was detected in only 1 of 8 rebound participants. The study authors note that larger studies are needed to more fully understand the clinical significance and epidemiological consequences of COVID-19 rebound, but added that the findings do not support the hypothesis that a 5-day course of Paxlovid is too short for the body to mount a robust immune response. Nevertheless, Pfizer, which makes the treatment, plans to study a repeat 5-day course of Paxlovid among people who experience rebound. The US FDA requested such a clinical trial in August, ordering Pfizer to complete such a test by September 30, 2023.
US PUBLIC HEALTH MEASURES The US government, states, and localities implemented various types of public health measures—including mask use requirements, physical distancing recommendations, vaccination mandates, and quarantine rules—during the COVID-19 pandemic to help mitigate transmission of SARS-CoV-2 and protect communities. The results of a new survey, published October 10 in JAMA Network Open, show that nearly 42% of the 1,733 adult respondents reported misrepresenting and/or nonadherence to at least 1 of 9 public health measures. The survey—conducted by researchers from Middlesex Community College in Connecticut and the University of Utah between December 8-23, 2021—showed that 24.3% of respondents told someone they were with or about to be with that they were taking more COVID-19 precautions than they were; 22.5% disobeyed quarantine rules; 21.5% avoided testing when they thought they might be infected; and 20.4% did not divulge that they had a suspected or confirmed infection when entering a doctor's office.
The most common reasons for the diversions were wanting life to feel normal or desiring to exercise personal freedoms, although some people said they felt the pandemic was a hoax or not serious, were following the advice of a celebrity or other public figure, or did not want to miss work. Certain public health measures can be burdensome and highly disruptive, but they are effective, the researchers noted, and nonadherence or dishonesty can have significant consequences, including prolonging the pandemic by leading to more infections, hospitalizations, or deaths. Notably, misrepresentation and nonadherence was more common among those with a greater distrust for science, although the researchers found no association between misrepresentation/nonadherence and political belief, political party affiliation, or religion. Understanding the public’s concerns regarding public health measures could help improve willingness to follow them in the future.
WORSENING INEQUALITY Oxfam and Development Finance International (DFI) published a research report on October 11 that ranks countries on their commitment to reducing inequality between 2020-2022. The report, titled “The Commitment to Reducing Inequality Index 2022,” reviews the spending, tax, and labor policies of 161 governments and finds that both high-income countries (HICs) and low- and middle-income countries (LMICs) pursued policies that worsen inequality since the start of the COVID-19 pandemic. According to the report, 70% of LMICs made cuts to their education budgets, 50% of LMICs cut their health budgets, and nearly 50% of LMICs reduced social protection program spending. In 2021, lower-income countries reportedly spent 27.5% of their budgets to repay debts, about four times the amount those countries spent on health. Additionally, nearly 90% of assessed countries froze tax rates for the rich while poverty levels increased, and many countries failed to raise minimum wages.
The report highlights Norway and Germany as top performers in actions taken to reduce inequality. Other well-performing nations include Australia, Belgium, and Canada. However, the report claims that HICs played a role in exacerbating inequality in LMICs by overseeing lender repayment demands despite the economic hardships imposed by the COVID-19 pandemic. Oxfam accused the International Monetary Fund (IMF) of worsening inequality by demanding new austerity measures to reduce budget deficits. One of the important lessons learned during the COVID-19 pandemic is that health inequality leaves the door open for new and more dangerous viral variants to develop and has the potential to mask the emergence of novel pathogens with pandemic potential. The world must address rapidly deteriorating equality levels to help prepare for and prevent the next pandemic.
SARS-COV-2 ORIGIN A panel of experts examining the origins of SARS-CoV-2—many of whom were originally convened as part of a task force for The Lancet COVID-19 Commission—this week reported their findings in the Proceedings of the National Academy of Sciences (PNAS). Like the Commission’s report, the PNAS analysis stresses the need to apply a One Health lens to help decrease the risk of disease spillover events and to make improvements in the safety of laboratory and field research. While the Commission’s report gave equal weight to theories supporting the virus naturally spilling over to humans and accidentally being leaked from a lab, the PNAS report concludes that increasing scientific evidence is most consistent with the theory that the COVID-19 pandemic began due to zoonosis from wildlife to humans via the wildlife trade or farming. To reach that conclusion, the researchers conducted a literature review, interviewed other experts, and examined major RNA virus outbreaks since 1967 to identify common features as well as opportunities to prevent novel disease emergence. Though the origin of SARS-CoV-2 has not yet been conclusively determined—and may never be—the authors of the PNAS paper say it is time to look beyond trying to answer that question and use lessons learned from the COVID-19 pandemic to improve upon future prevention and preparedness.
BIOSAFETY The COVID-19 pandemic has spurred plans to build more than 40 high-level biosafety laboratories in several nations, prompting concerns from researchers about how these new facilities—which many agree are needed—will obtain sustainable funding to handle dangerous pathogens safely and securely. India, Kazakhstan, Singapore, Philippines, Russia, and the United States plan to establish high-containment facilities. While some researchers question the need for so many new labs and their high operating costs, others maintain that new biosafety centers could lead to improved safety practices, allowing scientists to work more safely than they could without them.
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