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EPI UPDATE The WHO COVID-19 Dashboard reports 617 million cumulative cases and 6.53 million deaths worldwide as of October 6. Global weekly incidence remained relatively steady at slightly more than 3 million cases for the fourth consecutive week, decreasing 2% compared to the previous week. Weekly incidence in Europe increased for the third consecutive week, up 18% over the previous week. All other regions reported decreasing trends. Global weekly mortality continued to decrease, for the seventh consecutive week, down 11% from the previous week. Last week’s total—8,491 deaths—was the lowest since the week of March 16, 2020.*
*The WHO dashboard notes that data from the Africa Region are incomplete.
UNITED STATES
The US CDC is reporting 96.3 million cumulative cases of COVID-19 and 1.06 million deaths. Daily incidence continues to decline, down to 44,414 new cases per day, the lowest average since April. Average daily mortality now appears to be decreasing steadily, down from a recent high of 505 deaths per day on August 12 to 330 on October 4.**
**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 6.9% and 8.1%, 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 as the dominant strain in the US, accounting for 81.3% of sequenced specimens; however, its estimated prevalence has decreased for 4 consecutive weeks. Several other Omicron sublineages are exhibiting increasing trends over the past several months. Notably, the BA.4.6 sublineage is up to 12.8%, BF.7 is up to 3.4%, and BA.2.75 is up to 1.4%. Relative to the BA.5 sublineage, these estimates are low, but the increasing trends suggest that these subvariants may have some advantage over BA.5.
EMERGING SUBVARIANTS The SARS-CoV-2 virus continues to evolve, with multiple emerging sublineages of the Omicron variant of concern (VOC) poised to play a dominant role in the next surge. As noted above, several sublineages are increasing in prevalence in the US as the current dominant strain, BA.5, begins to wane. At this point, it is unclear if the next principal variant would be capable of evading immunity conferred by vaccination, including Omicron-specific booster doses, or prior infection with other variants, but researchers are already working to identify key mutations and project their impact. In contrast to previous surges, the forecasted fall/winter surge may not be driven by a single variant, as was the case with the Delta and Omicron surges in 2021 and earlier in 2022. In fact, WHO officials recently indicated that they are currently monitoring more than 300 Omicron sublineages.
Several of these sublineages are particularly concerning, including BQ.1 and BQ.1.1 that evolved from BA.5 and BA.2.275 and XBB that evolved from BA.2. The BQ.1 and BQ.1.1 sublineages are currently circulating in Europe, which could forecast a fall/winter surge in other Northern Hemisphere countries. All 4 of these sublineages exhibit resistance to existing treatments and vaccines, and the XBB sublineage, in particular, threatens to render existing vaccines ineffective. In addition to the risk of global spread of a vaccine-resistant vaccine, the decline in testing volume worldwide and barriers to including at-home test results in SARS-CoV-2 reporting systems could make surveillance problematic. And the general absence of COVID-19 protective measures (eg, physical distancing, mask use) could facilitate community transmission. Additionally, governments seem to be unwilling to commit additional funding to COVID-19 responses, including research on future vaccines and therapeutics, as evidenced in the US government’s struggle to secure funding for Project COVID Shield, the follow-on to Operation Warp Speed to develop advanced SARS-CoV-2 vaccines. The world is simply in a much different place than it was in 2020 and 2021, which elevates the threat from these emerging sublineages.
As opposed to more radical antigenic “shifts”—like those observed with the emergence of the Delta variant or the original Omicron variant—the new sublineages of the Omicron variant are exhibiting more subtle antigenic “drift.” This is similar to the evolution observed in annual seasonal influenza epidemics, although on a much shorter timeline. New sublineages appear to be acquiring many of the same mutations, in various combinations, which signals that they may be converging on a common set of traits. Despite the recent pattern, however, it is still possible that the virus could take a more substantial shift, which could result in the emergence of a new major variant with much different characteristics.
FALL/WINTER SURGE POTENTIAL Experts are keeping an eye on whether the United States will experience a surge in SARS-CoV-2 cases, hospitalizations, and deaths during the fall and winter seasons, a potential that looks increasingly likely. Several factors point to a forthcoming wave: the number of new cases is rising in Europe, and the US historically has followed that region’s trend; several emerging SARS-CoV-2 Omicron sublineages appear to be more capable of evading immune system protection and therapies, as discussed above; individual immunity—from vaccination or prior infection—continues to wane, primary vaccinations have stalled, and booster uptake is slow; and policy and behavioral changes have limited the positive impact of previously implemented mitigation measures, such as mask use and physical distancing.
Fifteen countries in Europe are reporting increasing cases. France is experiencing its eighth wave of COVID-19 and hospitals in the UK report resource constraints amid a new wave. New subvariants of SARS-CoV-2 that are evolutionary descendants of BA.2, BA.4, and BA.5 have emerged and are being tracked by scientists. It is still unknown whether one or more of these new strains will outcompete others and drive a fall or winter surge, but scientists are worried that these new sublineages may be able to evade current monoclonal antibody treatments and natural or vaccine-induced immunity.
Many experts stress that waning immunity could be one of the strongest predictors of a fall/winter surge in COVID-19 cases, especially if there is low uptake of new bivalent booster doses authorized in early September. In July, people aged 50 and older who had a primary series of vaccination and only one booster dose had 2 times the risk of dying from COVID-19 compared with individuals in the same age group who had a primary vaccination series and two booster doses targeting the original wild-type virus, showing the impact of continuous boosters. The new bivalent boosters targeting the original virus and the Omicron BA.4/BA.5 sublineages are expected to hold up similarly well and could help protect individuals from experiencing the most severe impacts of SARS-CoV-2 infection. Notably, however, only 7.6 million people have received an updated booster, according to the US CDC, and polling data from the Kaiser Family Foundation support increased efforts to improve messaging surrounding the new vaccines, including better communication about who is eligible to receive the shots.
Policy and behavioral shifts indicate that the US is eager to reach a post-pandemic state of normalcy even though 400-500 people are dying of COVID-19 daily. Most emergency protections established at the onset of the pandemic have been lifted, and government funds for vaccines, treatments, and tests are quickly dwindling. Many experts have cautioned against dropping COVID-19 mitigation efforts too soon.
Additionally, experts are nervous about the impact of any surge in cases on already stressed healthcare and hospital systems. Increases in demand for care—from COVID-19, influenza, or other illnesses—will challenge hospitals that are overloaded and currently experiencing a limited availability of healthcare workers, many of whom are burnt out, having been driven to the point of exhaustion. Public health preparedness and response strategies will need to reckon with these barriers sooner rather than later, as there is evidence COVID-19 cases are set to rise in the US. Data from the Massachusetts Water Resources Authority show that the amount of SARS-CoV-2 in the state’s wastewater is increasing, as are numbers of new COVID-19 cases in several states.
BIVALENT BOOSTER UPTAKE If 80% of eligible individuals aged 5 and older in the US receive an updated bivalent booster dose by the end of 2022, an estimated 90,000 COVID-19 deaths could be prevented and billions of dollars in health care costs could be saved, according to an updated analysis from the Commonwealth Fund. However, if booster vaccinations continue at their current pace, the nation could experience more than 1,000 deaths per day due to COVID-19 this winter, according to the report, which models several scenarios. Currently, between 400-500 people die each day due to the disease. Undoubtedly, vaccination has helped mitigate the burden of COVID-19, likely preventing millions of deaths and hospitalizations since vaccines became available in late 2020. However, vaccine uptake has stalled in the US, with 68% (225 million) of the total population having received a primary series and 49% (110 million) of those receiving a first booster dose. Around 37% (24 million) of eligible people aged 50 years and older have received a second booster dose, and only 7.6 million people have received an updated booster.
The White House and many public health officials are encouraging eligible individuals to receive SARS-CoV-2 vaccines and boosters, as well as influenza vaccinations, early this fall. After a relatively mild flu season last year, health officials are warning that a severe flu season in Australia could portend a similarly severe season in the US. According to a survey from the National Foundation for Infectious Diseases (NFID), only about half of US adult respondents plan to get a flu vaccine this season, and only one-third said they feel safe getting vaccinations against flu and COVID-19 simultaneously.
Notably, messaging around the COVID-19 vaccination campaign appears to be lacking, with guideline complexity possibly playing a role in confusion regarding eligibility. A recent poll from the Kaiser Family Foundation (KFF) found awareness of the new boosters is relatively modest, with only about half of adult respondents saying they had heard “a lot” (17%) or “some” (33%) about the new boosters, and 40% of fully vaccinated respondents said they were not sure whether the updated booster is recommended for them. Only about one-third of adults say they have already gotten a new booster or intend to do so “as soon as possible,” while two-thirds said they plan to “wait and see,” would get a booster only if required, would “definitely not” get a booster, or are not eligible. In a separate analysis, KFF notes that elevated COVID-19 death rates among older adults compared to younger adults through the summer was due in part to relatively lower booster uptake, compared with primary vaccination, and waning immunity. Another poll, the Forbes Health-Ipsos Monthly Health Tracker, shows 63% of adult respondents familiar with the new booster vaccine are “somewhat likely” or “very likely” to get the shot, with only 28% saying they do not plan to get boosted. As the nation heads into the colder months, vaccinations and boosters remain the best method for mitigating a potential COVID-19 surge this winter.
DISRUPTIONS FOR PEOPLE WITH DISABILITIES For many people in the US who have a disability, the COVID-19 pandemic exacerbated the inequities and disparities they already faced in accessing healthcare. According to a recently published study in Health Affairs, adult Americans with disabilities experienced significant disparities in delayed and unmet need for medical care during the first year of the pandemic. The study shows that adults with a disability were much more likely than those without disabilities to report delaying medical care, not getting the medical care they needed for non-COVID-19-related issues, and not getting needed medical care at home from a nurse or other health professional because of the pandemic. These disruptions, as well as elevated rates of comorbidities that people with disabilities may experience, could have increased their risk for severe illness or death from COVID-19.
Several factors contributed to adults with disabilities delaying care during the beginning of the pandemic, including lack of access to technology and internet, financial insecurity, reduced availability of public transportation, or inaccessible COVID-19 risk communication formats. For many adults with disabilities who depend on home- and community-based services, pandemic-related disruptions to and lack of COVID-19 relief support for these programs was a significant barrier. The pandemic has exposed health inequities and disparities that people with disabilities—especially those who experience multiple and intersecting forms of marginalization and discrimination—have faced for a long time.
Despite these notable barriers, several inclusive practices and technologies emerged as the US population tried to adapt to pandemic-related disruptions. When schools initially shifted to virtual learning modalities, some teachers implemented creative solutions to support students with disabilities. At a high school in Indiana, teachers provided supportive technologies for students with visual impairments and leveraged the intuitive accessibility of iPads and digital books. Several broad measures implemented during the onset of the pandemic, such as pivoting to remote or virtual work and learning, providing hazard pay for frontline workers, less punitive action against people who needed to cancel tickets or miss work to stay at home due to an illness, holding online events with closed captions and American Sign Language interpretation, and intentional shopping hours for immunocompromised people, allowed people with disabilities and others to adapt to pandemic-related disruptions.
As many in the US move on from the pandemic, people with disabilities are anxious about being excluded and left behind. This is especially concerning because COVID-19 has increased the number of people with disabilities in the US, as discussed below, thereby necessitating broad policy changes that center disability and help ameliorate individuals’ lived experiences.
LONG COVID/PASC Most US adults experiencing post-acute sequelae of SARS-CoV-2 (PASC), more commonly known as long COVID, have symptoms that interfere with day-to-day activities, according to new data from the US CDC’s National Center for Health Statistics. As of September 26, 14.2% of the more than 50,000 survey respondents said they had experienced long COVID—which is characterized by a host of symptoms including shortness of breath, fatigue, and cognitive difficulties—at some point during the pandemic. Of those with long COVID, 81% said they had some limitations in their daily activities compared to their activities prior to infection. Notably, 1 in 4 adults with long COVID reported significant limitations, with the proportion jumping to nearly 40% of Black or Hispanic/Latino respondents, as well as those already living with disability. The data are limited to adults and do not provide information on whether respondents are vaccinated or the severity of their SARS-CoV-2 infection. Nearly 24 million adults in the US are estimated to currently have long COVID, and researchers are working to define the condition, describe underlying causes, and search for effective treatments. Long COVID is, and likely will remain, a significant cause of disability in the US.
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