US RESPONSE As the COVID-19 pandemic enters its third fall in the US, the White House has signaled it plans to slowly restructure its response efforts, including the phaseout of the White House COVID-19 Response Team mid-2023. With dwindling federal funds, responsibility for vaccinations and therapeutics is shifting to private industry and consumers within the next 6 months. Any remaining funds are largely being used for vaccination campaigns promoting this fall’s updated boosters and the purchase of at-home, rapid tests for the Strategic National Stockpile and Test-to-Treat locations. Officials are tentatively hopeful that the national public health emergency declaration for the pandemic may be allowed to expire in early 2023. While part of this transition can be attributed to fewer COVID-19 cases, deaths, and related hospitalizations, as well as the widespread availability of vaccinations and therapeutics, most response activities need to wind down due to a lack of new funding from the US Congress. Experts and officials emphasize that the pandemic is far from over, with COVID-19 on track to remain the third leading cause of death in the nation. 

At the state level, New York Governor Kathy Hochul allowed the COVID-19 state disaster emergency declaration to expire last night, leaving only 10 states with emergency orders in place—California, Connecticut, Delaware, Illinois, Kansas, New Mexico, Rhode Island, Texas, West Virginia, and Washington. The 10 states with the lowest vaccination rates in the country (Wyoming, Alabama, Mississippi, Louisiana, Idaho, Tennessee, Arkansas, Georgia, North Dakota, Indiana) have yet to vaccinate 60% of their populations with the 2-dose primary series, far below the nationwide total of 67.6% and evidence that an updated booster may have a limited impact in the face of continued unwillingness to get vaccinated.

US WORKFORCE According to a recent Gallup poll, one-third of adults are concerned about COVID-19 exposure in the workplace, a proportion that is relatively unchanged since November 2021. The percentage of people “not concerned at all” has increased from 23% in 2020 to a record high of 39%. The recent survey also shows significant gaps in results by gender—41% of working women are concerned about on-the-job exposure compared with 26% of working men—and political party affiliation—51% of Democrats expressed at least moderate concern compared with 14% of Republicans. Two-thirds of workers said they expect new COVID-19 cases to increase during the colder months, although the poll was conducted prior to the approval of updated booster doses. 

Additionally, recent research conducted by economists from Stanford University and Massachusetts Institute of Technology estimates that the labor force shrunk by about 500,000 people due to COVID-19 illness. Millions of people left the workforce for various reasons, including lack of childcare, fear of COVID, and retirement. But this research examines the direct impact of COVID-19 illness, estimating that workers with week-long COVID-19-related work absences are 7 percentage points less likely to be in the labor force one year later compared to otherwise-similar workers who do not miss a week of work for health reasons. In August, the total size of the labor force reached 164.7 million people, exceeding prepandemic levels for the first time. However, workforce recovery is experiencing slow-growth compared to prepandemic numbers, and economic recovery will depend on an expanded workforce in the long term.

BRAIN FOG When the COVID-19 pandemic first began, brain fog was not included in the list of possible symptoms. However, many COVID-19 patients report experiencing the condition, both during acute infection and lasting 3 or more months after recovery. Brain fog symptoms appear to be independent of initial disease severity. According to one review of multiple studies, about 22% of individuals report cognitive impairment 12 or more weeks following their initial diagnosis. Brain fog is often described as a disorder of executive function, the set of abilities that includes holding attention, remembering and recalling information, and blocking out distractions. Cognitive tasks that once seemed simple become excruciatingly difficult, and in some cases, impossible. Some people have had to leave their jobs due to an inability to perform their tasks, and many have faced frustration in obtaining medical care, often being dismissed as having anxiety or depression. Complicating the matter is that few clinicians are aware that many viral infections, not only COVID-19, can lead to brain fog and there are few reliable diagnostic tools. 

Other neurological complications have been reported following COVID-19 infection, including stroke, delirium, and encephalitis. A recent study published in the journal Brain showed that patients hospitalized with COVID-19 had elevated levels of sera markers of brain injury, neurofilament light (NfL) and glial fibrillary acidic protein (GFAP). However, no specific pathogenic mechanism was determined responsible. Researchers continue to investigate what leads to brain fog—with possible causes including neuro-inflammation, autoimmune responses, or microclots that inhibit blood flow, and therefore oxygen supply—and are hopeful treatments can be developed.

GENETIC MUTATIONS For years, scientists have known that specific genetic mutations can make certain people less susceptible to infection with HIV, norovirus, or the parasite that causes malaria. Now, scientists worldwide are searching for similar mutations or immune system variations that might explain why some people with known exposures to COVID-19 either never become infected or never show symptoms of SARS-CoV-2 infection. The hope is that if researchers can identify a genetic or immune response explanation for resistance, they can use that knowledge to manufacture treatments or vaccines, which possibly could provide cross-protection from other coronaviruses in the future. 

EUROPEAN BOOSTER AUTHORIZATIONS Following recommendations made earlier this month by the European Medicines Agency (EMA), the European Commission (EC) on September 12 approved the expanded conditional marketing authorization (CMA) of the Novavax COVID-19 vaccine, marketed as Nuvaxovid, in the EU as a homologous and heterologous booster for adults aged 18 and older. The protein-based vaccine is now available as a primary series or booster in EU Member States, Japan, Australia, and New Zealand, and is under review in other markets, including as a booster in the US. Only 4,872 people in the US have received the first 2 doses of the Novavax vaccine, which some officials hoped would entice unvaccinated individuals to get vaccinated because of its more traditional protein-based platform.

Also on September 12, the EMA recommended authorizing Pfizer-BioNTech’s adapted bivalent vaccine targeting the wild-type spike protein of SARS-CoV-2 and spike proteins of the Omicron BA.4 and BA.5 subvariants. The EC accepted the recommendation the same day, making the booster doses available for immediate shipment to EU Member States. Earlier this month, the EU authorized both Pfizer-BioNTech’s and Moderna’s bivalent vaccine boosters targeting Omicron BA.1.

CHINA As Chinese President Xi Jinping prepares to leave his country for the first time since the COVID-19 pandemic began in early 2020 to meet with Russian President Vladimir Putin, tens of millions of people in China remain under weeks-long lockdowns as part of the nation’s continued “dynamic zero COVID” strategy. President Xi is expected to seek an unprecedented third term as the nation’s leader, and observers say the lockdowns likely will continue at least through the 20th National Chinese Communist Party Congress set to begin October 16. Experts say President Xi likely does not want any uncontrollable rise in COVID-19 cases until after his next term is secured. However, residents in several cities are warning they are running out of food, have limited to no access to medicines and health supplies, and are suffering from psychological and economic impacts. Experts say the government’s insistence on its zero COVID policy exposes the politics behind the measures, with President Xi taking credit for its apparent success in preventing potentially millions of COVID-19 cases. But growing discontent among the nation’s population, as well as economic harms, raise questions about how long the policies can remain in place.

WESTERN PACIFIC REGION New Zealand dropped many of its COVID-19-related requirements on September 12, bringing an end to some of the most restrictive pandemic mandates in the world. People will no longer be required to wear masks in public places, except healthcare and long-term care facilities; all government-imposed vaccine mandates will end on September 26; and only people with COVID-19, and not their household contacts, will be required to isolate for 7 days. Additionally, the government will no longer require vaccinations for incoming travelers and air crew. New Zealand experienced its worst COVID-19 surge this year when Omicron killed more residents than any other pandemic surge. A total of 1,950 people have died of COVID-19 in New Zealand since March 2020. But the average number of new cases and hospitalizations are down significantly since the beginning of August, when influenza cases also surged. Prime Minister Jacinda Ardern said it is time for Kiwis to “take back control” of the future and thanked the population for its cooperation and endurance throughout the pandemic.

In neighboring Australia, federal health officials accepted a recommendation from the Australian Technical Advisory Group on Immunisation (ATAGI) to approve a bivalent vaccine booster from Moderna targeting the original SARS-CoV-2 strain and the Omicron BA.1 subvariant. The booster, which will be available for people aged 18 years and older, is the first bivalent shot cleared for use in Australia. Additionally, state and territorial health ministers moved this week to begin reporting weekly, instead of daily, COVID-19 metrics, including case numbers, new and total deaths, vaccination rates, and breakdowns of hospitalized ICU and ventilated patients.

In Japan, the government signaled its plans to further ease border restrictions aimed at curbing the spread of COVID-19 by waiving tourist visa requirements from some countries and possibly ditching a daily cap on foreign arrivals by next month. 

In the Philippines, President Ferdinand Marcos Jr. this week extended the national state of calamity first declared by former President Rodrigo Duterte in March 2020, primarily to allow continued emergency purchases and provide hazard allowances for healthcare workers. While indoor masking requirements will stay in effect, masking rules for outdoor spaces were immediately lifted, except for crowded places where physical distancing is difficult. The nation reopened schools 3 weeks ago, ending one of the world’s longest pandemic-related school system shutdown. 

In other Western Pacific nations, public health officials are warning of the possibility of “twindemics,” a rise of another infectious disease during the COVID-19 pandemic. In South Korea, experts are concerned over simultaneous outbreaks of COVID-19 and influenza during the colder fall and winter months, calling for the development of better diagnostic tests, including one that could detect flu and COVID-19 at the same time, and for healthcare services to offer individuals both vaccines during the same visit. In Vietnam, a severe outbreak of dengue fever is overwhelming healthcare facilities that also must treat COVID-19 patients. Experts say that 2 years of pandemic-related lockdowns caused a reduction in routine mosquito vector surveillance and slowed dengue control. The Philippines, Malaysia, and Singapore have also reported year-on-year increase in the number of reported dengue cases.