EPI UPDATE The WHO COVID-19 Dashboard reports 607 million cumulative cases and 6.50 million deaths worldwide as of September 14. Global weekly incidence continues to decline, for the fifth consecutive week—down 25% from the previous week. Global weekly mortality decreased as well, for the fourth consecutive week—down 19% from the previous week.

Weekly incidence continues to decline in all WHO regions, ranging from -5% in Europe to -36% in the Western Pacific region. Notably, the pace of the decreasing trend in Europe appears to be slowing, and the region may be approaching a local minimum or plateau.

UNITED STATES

The US CDC is reporting 95.2 million cumulative cases of COVID-19 and 1,046,195 deaths. Daily incidence continues to decline, down to 60,558 new cases per day. This is the lowest average since May 1 and a 54% decrease from the most recent peak on July 16. Daily mortality continues to decline as well, down to 350 deaths per day. This is the lowest average since July 9 and a decrease of 30% from the most recent high on August 12. The CDC reported a slight increase in both daily incidence and mortality on September 12, but this is likely due to delayed reporting over the US Labor Day holiday weekend.*

*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 6.5% and 5.4%, respectively, over the past week. Both trends peaked around the last week of July, similar to trends in daily incidence, and both are approximately 80% lower than the record peak in mid-January 2022.

The BA.5 sublineage continues as the dominant strain in the US, accounting for 87.5% of sequenced specimens; however, growing evidence indicates that BA.4.6 might be capable of outcompeting it. The prevalence of BA.4.6 has steadily increased since at least mid-summer 2022, but the BA.5 prevalence increased more rapidly over much of that period. This is the first week that the CDC’s Nowcast projection shows a noticeable decrease in BA.5 prevalence**, while BA.4.6 continues to account for a larger share of US cases. Since last week, the BA.4.6 prevalence increased from 8.3% to 9.2%, while the prevalence of BA.5 fell slightly from 87.9% to 87.5%. The prevalence of all other reported lineages continues to decline, and together, the Omicron sublineages account for essentially all new US cases.

**From the week of August 27 to the week of September 3, the BA.5 prevalence decreased from 88.0% to 87.9%, but we interpret this as essentially remaining constant over that period.

PANDEMIC RESPONSE EVALUATIONS As daily COVID-19 incidence and mortality continue to decline globally, attention is shifting to pandemic recovery efforts, including lessons for future pandemic preparedness and response. In a long-awaited report published September 14, The Lancet COVID-19 Commission described the tremendous pandemic death toll as “both a profound tragedy and a massive global failure at multiple levels,” underlined by an absence of international cooperation, dismissal of risks by national leaders, influence of misinformation, paucity of governmental and organizational transparency, and disregard for basic public health precautions. As a result, COVID-19 impacted countries in “highly unequal” ways, with particularly severe outcomes for the most vulnerable populations, including children, immigrants and refugees, and those in low- and middle-income countries (LMICs). Additionally, a substantial portion of COVID-19 survivors continue to experience prolonged health effects stemming from SARS-CoV-2 infection, and many people are dealing with the impact of COVID-19-related deaths among family and friends. The report cites the rapid development of vaccines as a positive example of international cooperation, but it also acknowledges substantial disparities in vaccination coverage at the national level, particularly between LMICs and higher-income countries. The report also calls attention to downstream and longer-term effects of the pandemic, including setbacks in progress toward achieving Sustainable Development Goals (SDGs) in many countries.

The report—produced by a panel of 28 experts who consulted more than 170 contributors through 12 task forces—makes several recommendations falling under 5 pillars: prevention, containment, health services, equity, and global innovation. The recommendations include improving multilateral cooperation; implementing a “vaccination-plus” strategy that combines vaccination with other medical countermeasures (MCMs) and nonpharmaceutical interventions (NPIs); improving surveillance and prevention for natural and accidental spillover events; expanding international research and development and manufacturing capacity for vaccines and other products; establishing sustainable financial support for LMICs; and strengthening the WHO and national health systems. The report also calls for intensifying efforts to identify the origins of SARS-CoV-2, noting that the task force examining the pandemic’s origins was ended because “the divisive public discussion about the source of SARS-CoV-2 damaged the trust needed for the task force to complete its work.”

The report has already met pushback from some experts and organizations, including the WHO. The WHO issued a statement in response to criticisms that it acted too cautiously and sluggishly, both to declare a public health emergency of international concern (PHEIC) and warn of the potential for airborne/aerosol transmission. The WHO emphasized that it welcomes the report’s overarching recommendations but argued that there are “several key omissions and misinterpretations,” particularly related to the speed with which the WHO responded to the initial outbreak. Additionally, several experts criticized the report for reviving debate about the virus’ origins and for omitting recent relevant evidence that the novel coronavirus likely emerged through a zoonotic event in a market in Wuhan, China. Notably, the commission’s Chair, Dr. Jeffrey Sachs, has publicly supported the “lab leak” theory as the origin of the virus, and some contest that his personal beliefs unduly influenced the commission’s findings.

Earlier on September 14, WHO Director-General Dr. Tedros Adhanom Ghebreyesus told journalists during his weekly briefing that the world has “never been in a better position to end the pandemic” but is “not there yet.” He called on the international community to “seize this opportunity” and announced the release of 6 WHO policy briefs that outline essential actions for national and subnational policymakers to help reach the goal of ending the pandemic. The briefs include guidance for testing, vaccination, clinical disease management, healthcare facility infection control, combating misinformation, and community engagement. Following those comments, Africa CDC Acting Director Dr. Ahmed Ogwell Ouma emphasized that low vaccination coverage and ongoing transmission across the continent illustrate that COVID-19 remains a major threat.

In related news, an investigation published today by POLITICO and the German newspaper WELT examines the influence of several entities in the COVID-19 pandemic response, including the Bill & Melinda Gates Foundation; the Wellcome Trust; Gavi, the Vaccine Alliance; and the Coalition for Epidemic Preparedness Innovations (CEPI). The investigation concludes that the organizations were better prepared than governments for an infectious disease outbreak; the groups’ leaders were able to routinely meet with high-level government and multilateral organization leaders; they pledged billions of dollars to help close equity gaps for vaccines and treatments but hoarding by high-income nations got in the way; and their initial lack of support for intellectual property waivers might have impeded access to vaccines and therapeutics in LMICs. Several experts have criticized the report for being shortsighted and naïve, including by undervaluing public-private partnerships in pandemic responses and misrepresenting CEPI and Gavi—both financial intermediary funds (FIFs) under the World Bank—as nongovernmental organizations.

US GLOBAL RESPONSE & RECOVERY The Biden administration today released an updated version of its US COVID-19 Global Response & Recovery Framework, meant to help guide the US commitment to a globally equitable end to the emergency phase of the pandemic by working with international partners to use available tools and expertise, integrating COVID-19 response elements into existing health structures, and improving global pandemic preparedness. The plan outlines 3 primary objectives to achieve those goals: vaccinating those who are at highest risk and the hardest-to-reach by ensuring access to vaccines and integrating vaccinations into existing health structures; integrating and scaling testing and treatment efforts into existing health structures without disrupting other health services; and preparing for future variants and pandemic threats by strengthening health security infrastructure to detect and rapidly respond to emerging threats. The updated global framework comes at a time when the US is facing domestic pandemic fatigue, dwindling amounts of federal funding, and hundreds of daily deaths due to COVID-19. 

US ECONOMIC IMPACTS Recent data from the US Census Bureau is helping to illuminate impacts of the COVID-19 pandemic and response. The bureau released 1-year estimates from its American Community Survey today, showing various social and economic changes. For example, fewer people moved to a new home, more people gained internet access through expanded coverage and computer ownership, more unmarried couples moved in together, more people spent over 30% of their income on rent, preschool enrollment dropped, and public transportation use dropped by half. Another report, the 2022 Current Population Survey Annual Social and Economic Supplement (CPS ASEC), included some rare good news. Childhood poverty is at a historic low, falling from 9.7% to 5.2% between 2020-2021. Experts attribute much of this improvement to the boosted child tax credit included in the American Rescue Plan that provided families additional money to pay for food, clothes, education, and extracurricular activities. Notably, the overall poverty rate also fell to 7.8% in 2021 from 9.2% in 2020. Additionally, the report shows that insurance coverage expanded in 2021, most likely due to pandemic-related measures that mandated a continuous enrollment provision Medicaid. Many of these measures have already ended or are set to expire, and it is now up to the US Congress to decide whether these measures should be renewed or stay in place.

LONG COVID IN EUROPE An estimated 17 million people across the WHO’s Europe region experienced post-acute sequelae or long-term symptoms of COVID-19, also known as long COVID, during the pandemic’s first 2 years, according to a modeling study conducted by the Institute for Health Metrics and Evaluation (IHME) for WHO/Europe. The region comprises 53 Member States across Europe and Central Asia that are home to nearly 900 million people. The report highlights the ongoing public health challenges posed by the condition, which is characterized by cognitive and mental health problems, fatigue, shortness of breath, and other symptoms experienced 12 weeks or more following a COVID-19 diagnosis. 

The report, published September 13, found the number of new long COVID cases identified between 2020 and 2021 rose threefold, driven by the rapid increase in confirmed COVID-19 cases from late 2020 through 2021; women are twice as likely than men to suffer from the condition; and the risk of long COVID increases dramatically among people with severe infections who need hospitalization. WHO officials and the report authors said that although most people fully recover from COVID-19, the findings underline the need for additional analysis and investment to determine the long-term effects of the disease, including implications for the workforce and the need for rehabilitative and support services.

SARS-COV-2 VACCINE BOOSTER DURABILITY Recently published data on SARS-CoV-2 vaccine booster durability indicate that protection wanes by approximately 10-20% each month. Researchers at Ohio State University conducted a longitudinal study of healthcare workers to assess the durability of antibody titers stimulated by booster doses and published their preliminary analysis as a commentary in the New England Journal of Medicine. The study included 46 fully vaccinated participants who received their first booster—24 with the Moderna vaccine and 22 with the Pfizer-BioNTech vaccine*—and serum specimens were collected every 3 months after the booster dose to assess neutralizing antibody titers against the multiple variants, including the Omicron variant of concern (VOC). 

*Neither the commentary nor supplementary appendix explicitly indicates whether the booster doses were the monovalent or bivalent formulation, but based on the study timing and duration, we understand them to be monovalent.

Among the participants, 14 had breakthrough infections during the study period, including 9 during the US Omicron variant surges. Notably, the duration of antibody titers was more robust in individuals with prior SARS-CoV-2 infection. Overall, neutralizing antibody titers decayed at a mean rate of 17.53% per month against lineages containing the D614G mutation (ie, Omicon sublineages). More specifically, titers decayed by 19.50% against the B.1 sublineage, 18.44% against BA.2.12.1, and 19.55% against BA.4/5 each month. Among participants with previous SARS-CoV-2 infection, antibody titers decayed 17.07% against lineages containing the D614G mutation, 14.22% against BA.1, 9.97% against BA.2.12.1, and 12.12% against BA.4/5. Additionally, the decay in antibody titers following the first booster dose was slower than after receiving the second dose of the primary series of the vaccines.

Experts note that waning protection is not unexpected for vaccines, emphasizing that this should not dissuade anyone from recommended booster doses. Some experts, however, have called attention to the contrast between this analysis and federal officials’ recent comments about plans for annual boosters, much like seasonal influenza. They argue that if antibody titers wane over a period of several months, annual boosters may not be often enough to provide sufficient protection. Available evidence demonstrates that booster doses do maintain protection against severe disease; however, rapid waning of that protection may necessitate regular booster doses—potentially as frequently as 4 months—especially for those at elevated risk of severe disease and death. Others posed questions regarding barriers to accessing booster doses, particularly in the context of the generally low coverage for annual seasonal influenza vaccinations.

Another issue is the absence of clearly defined and regular seasonal trends for COVID-19. While seasonal influenza tends to peak annually in the winter months, the COVID-19 pandemic has not exhibited traditional seasonality, peaking multiple times each year, across all seasons. Additionally, the emergence of new variants of concern or associated sublineages has occurred more frequently than once per year so far in the pandemic, which White House officials acknowledged could necessitate additional booster doses. Many questions remain regarding future COVID-19 trends and how those will factor into vaccination planning and guidance.