COVID-19 Situation Report
Editor: Alyson Browett, MPH

Contributors: Clint Haines, MS; Natasha Kaushal, MSPH; Amanda Kobokovich, MPH; Christina Potter, MSPH; Matthew Shearer, MPH; Marc Trotochaud, MSPH; and, Rachel A. Vahey, MHS.
EPI UPDATE The WHO COVID-19 Dashboard reports 448.3 million cumulative cases and 6.01 million deaths worldwide as of March 9. The global weekly incidence continues to decline but more slowly, down 3.5% from the previous week. Increased weekly incidence (+46.36%) in the Western Pacific region is driving the slowing decline. All other regions reported decreasing weekly incidence last week. Global weekly mortality fell 9.0% from the previous week. As expected, the cumulative number of deaths passed 6 million on March 8, serving as a reminder that the pandemic is far from over

Global Vaccination
The WHO reported 10.7 billion cumulative doses administered globally as of March 6. A total of 4.96 billion individuals have received at least 1 dose, and 4.37 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations appears to be declining again. As of March 9, 18.05 million doses per day were recorded, down from the 25.9 million doses per day on February 14.* The trend continues to closely follow that in Asia.** Our World in Data estimates that there are 4.99 billion vaccinated individuals worldwide (1+ dose; 63.43% of the global population) and 4.45 billion who are fully vaccinated (56.5% of the global population). A total of 1.44 billion booster doses have been administered globally.
*The average daily doses administered may exhibit a sharp decrease for the most recent data, particularly over the weekend, which indicates effects of reporting delays. In an effort to reflect the longer-term trends, the numbers reported here may not correspond to the most recent data.
**Data for China are reported at irregular intervals.

The US CDC is currently reporting 79.2 million cumulative cases of COVID-19 and 959,533 deaths. Daily incidence continues its sharp decline, down from a record high of 809,345 new cases per day on January 15 to 37,879 on March 8, a more than 95% decrease. Daily mortality appears to have peaked during this surge on February 2 at 2,642 deaths per day, down to 1,161 on March 8.* 
*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.

US Vaccination
The US has administered 556 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations continue to decline, down from the most recent peak of 1.79 million doses per day on December 6 to 246,106 on March 3.* The number of daily vaccinations is at its lowest level since late December 2020, right after the vaccines were authorized. A total of 254.3 million individuals have received at least 1 vaccine dose, which corresponds to 76.6% of the entire US population. Among adults, 88.1% have received at least 1 dose, as well as 26.9 million children under the age of 18. A total of 216.4 million individuals are fully vaccinated**, which corresponds to 65.2% of the total population. Approximately 75.1% of adults are fully vaccinated, as well as 22.3 million children under the age of 18. Since August 2021, 95.5 million individuals have received an additional or booster dose. This corresponds to 44.1% of fully vaccinated individuals, including 66.6% of fully vaccinated adults aged 65 years or older.
*Due to delays in reporting, estimates for the average daily doses administered are less accurate for the most recent several days. 
**Full original course of the vaccine, not including additional or booster doses.

SIGNIFICANCE OF MASS MORTALITY As the world passed 6 million official COVID-19 deaths this week, and the US moves closer to 1 million official deaths, journalist Ed Yong poses an important question in The Atlantic: “How did this many deaths become normal?” Yong notes that when the death toll in the US hit 100,000 in May 2020, The New York Times described the loss as “incalculable.” But as the nation nears another milestone 2 years later, many are left wondering how this happened and why the death rate in the US has far surpassed that of any other large, wealthy nation. As life in the US heads back toward something resembling a pre-pandemic normal, those who lost loved ones to COVID-19 know life will never be the same. Some are working to ensure the nation does not forget the pandemic and remembers those who died. A group called Marked By COVID is lobbying to establish a national COVID memorial day as well as physical memorials in cities nationwide. Following the 1918 influenza pandemic, no effort was made to commemorate those who died or suffered substantial losses. This time must be different, advocates say, to help future generations understand the significance of public health crises.

US COVID-19 RESPONSE FUNDING In a surprising last-minute revision to a US$1.5 trillion fiscal year 2022 omnibus spending package, Democratic leaders of the US House of Representatives stripped US$15.6 billion in emergency funding for the COVID-19 pandemic response from the legislation in order to salvage the measure, which includes aid for Ukraine and money to keep the federal government running through September. The House approved the measure on March 9, and the US Senate is expected to pass the bill over the weekend. Although government funding is set to expire on March 11, the House also passed a stopgap measure to keep the government running through March 15. In a letter to colleagues, House Speaker Representative Nancy Pelosi blamed Republicans for the move, but it was also discord among Democrats that led to the cut. A proposal to offset the US$15.6 billion in additional COVID-19 spending by using unspent money sent to at least 30 states as part of last year’s US$1.9 trillion American Rescue Plan riled Democrats from affected states. Facing pressure from both sides, Speaker Pelosi cut the COVID funding from the omnibus measure. The administration of US President Joe Biden originally suggested it would ask for US$30 billion but formally requested US$22.5 billion in funding for testing, vaccines, therapeutics, and efforts to address future variants. 

Administration officials have said they are quickly running out of money for COVID-19 response, and the cut leaves the future of the Biden administration’s National COVID-19 Preparedness Plan uncertain. The situation also highlighted the deep political divides over the pandemic and underlined that the pandemic is no longer a national political priority. US House Democrats later introduced a stand-alone bill that would provide US$15.6 billion in COVID-19 funding, but the measure is not expected to pass the Senate. Notably, the Biden administration estimates that monoclonal antibody treatment supplies will last through May, preventive treatments for immunocompromised individuals are expected to run out by July, and antiviral stocks will be depleted by September. Additionally, if additional spending is not authorized, the administration does not have funding to purchase more vaccines if another round of booster shots are deemed necessary, and ongoing research and pandemic preparedness efforts face funding shortfalls.

WHO ON BOOSTERS The WHO’s Technical Advisory Group on COVID-19 Vaccine Composition (TAG-CO-VAC) this week said it “strongly supports urgent and broad access” to primary series and booster doses of SARS-CoV-2 vaccines, particularly for groups at high risk of severe disease. The interim statement represents a policy shift for the agency after Director-General Dr. Tedros Adhanom Ghebreyesus last year urged wealthy nations to forgo booster doses through the end of the year and instead donate the shots to countries in need of additional supplies. The TAG-CO-VAC in January said evidence increasingly supported the use of booster doses, especially for vulnerable populations, but the group did not support “broad access” then as it did this week. Numerous studies have shown that booster doses of authorized vaccines help revive waning immune responses and help protect against severe disease, hospitalization, and death from COVID-19. The TAG-CO-VAC noted that although global vaccine supplies have increased, vaccine equity remains a challenge and efforts to rectify inequities are “strongly encouraged.” The statement also notes the potential need to update vaccines to address SARS-CoV-2 variants, as the currently authorized vaccines are based on the original form of the virus.

LONG COVID Long COVID, or post-acute sequelae of COVID-19 (PASC), is an emerging disease state that is poorly understood. Long COVID is characterized by several symptoms that last from 1 month to years after an acute SARS-CoV-2 infection clears. Symptoms of long COVID can include, but are not limited to, anxiety, depression, "brain fog," chronic fatigue, fever, myalgia, shortness of breath, and sleep problems. Long COVID already has led to an increase in the number of individuals suffering from long-term illness, and this trend may worsen as the pandemic continues. The UK-based disability charity Scope recently claimed that the number of people with mental health problems and chronic chest or breathing problems has risen by 800,000 individuals and 570,000 individuals, respectively, from 2018-19 to 2020-21. Worries are growing that an increase in the number of individuals suffering from long-term disabilities in the UK could also mean an increase in the number of people suffering from poverty and a lack of resources. In the US, Democratic Senator Tim Kaine introduced a bill to improve and expand research into long COVID. Senator Kaine suffers from long COVID and has become a champion for the issue as a result. The White House also has released a plan that includes support for Americans with long COVID. 

A series of studies released over the last week have begun to shine a light on the impact of SARS-CoV-2 infection on brain function and cognitive health. The first study, published in Nature on March 7, compared brain scans from 401 individuals before and after SARS-CoV-2 infection. The initial brain scans were part of the UK Biobank that was collecting data before the pandemic began. Individuals were invited back for a second scan approximately 5 months after a SARS-CoV-2 infection. The study also had 384 SARS-CoV-2-negative controls. According to the study, individuals who had a SARS-CoV-2 infection lost between 0.2-2% more gray matter—mostly in areas associated with the sense of smell—than the control group. Additionally, individuals who had been infected had lower scores on cognitive function tests. The findings are significant, but it is still possible that the changes are reversible. A second study, published March 8 in JAMA Neurology, examined cognitive health in a cohort of 1,438 COVID-19 patients who were 60 years and older and who were discharged from hospitals in Wuhan, China, during the first few months of the pandemic. The study found a 12.45% increase in cognitive impairment 12 months after discharge when compared to controls. The authors noted that 21% of individuals who experienced severe cases of COVID-19 experienced cognitive decline within 12 months. A third study, posted March 7 in Open Forum Infectious Diseases, examined new-onset dementia in patients who experienced COVID pneumonia. According to the study, 3% of individuals who experienced COVID pneumonia developed new-onset dementia within 182 days compared with 2.5% of individuals who experienced pneumonia from other causes. Risk factors for new-onset dementia included ages 55 years and older, alcohol use or abuse, Hispanic race, history of depression, and stroke during COVID-19 hospitalization. 

Additional complications related to long COVID include cardiovascular issues and nerve damage. A study published February 7 in Nature Medicine compared US Department of Veterans Affairs (VA) electronic health records from 150,000 patients who were infected with SARS-CoV-2 to millions of VA patients who did not have recorded infections. The study found a 4% increase in cardiovascular health issues in the SARS-CoV-2-positive individuals. Individuals who were hospitalized for COVID-19 were twice as likely to experience a significant cardiac event within 12 months of infection when compared to individuals who had milder cases of COVID-19. Another study, published in Neurology Neuroimmunology & Neuroinflammation on March 1, examined data from patients diagnosed with long COVID who did not have a prior history of nerve dysfunction. The study found that long COVID may lead to long-lasting nerve damage and pain. The growing body of research on long COVID indicates that the world may experience a surge in chronic illness once the emergency phase of the pandemic winds down. More research and support will be needed in the coming years to develop appropriate long COVID treatments and ensure that those suffering from long-term consequences of the pandemic are not forgotten. 

EVUSHELD Evusheld—a monoclonal antibody treatment that is authorized by the US FDA for pre-exposure prophylaxis of COVID-19 among certain immunocompromised individuals—is going unused. US President Joe Biden has promised to protect the more than 7 million people in the US with weakened immune systems and those who cannot be vaccinated for medical reasons, and Evusheld, which was developed by AstraZeneca with support from the federal government, is a large part of that strategy. The Biden administration has ordered 1.7 million doses, enough to treat 850,000 people. Nearly 200,000 doses will be distributed this week, bringing the total shipped to states and territories close to 850,000. However, confusion about the drug among healthcare providers and a lack of awareness about its availability has left about 80% of those doses unused, sitting in warehouses and on pharmacy shelves. 

The FDA recently revised Evusheld’s Emergency Use Authorization, updating the dosing regimen to a higher dose so the treatment might be more likely to protect against infection with certain Omicron subvariants. Additionally, Evusheld is expected to have greater neutralizing activity against the BA.2 sublineage of Omicron. However, the recommendation for doubling the dose will make the treatment even more scarce and could further confuse prescribers and patients. The Biden administration has accelerated its distribution schedule, but without further communication about the therapy’s availability and more equitable distribution, it appears access to the drug will remain complicated

US MASK MANDATES After Hawai’i lifts its mask mandate on March 25, there will be no state-wide mask mandates in effect in the US. Under new US CDC masking guidance, more than 90% of the nation’s population can choose not to wear masks. However, the agency and other experts maintain that people who want to keep wearing masks can do so and in some cases should, particularly individuals who are immunocompromised or otherwise at high risk of infection or severe disease. However, some who are continuing to mask are reporting harassment and bullying from peers, strangers, and even political leaders. Individuals and communities faced with these new changes to masking guidance may feel liberation, confusion, or anxiety based on their own masking preferences. Experts have had equally mixed reactions. Some praised the move by CDC to adapt to fatigue for COVID-19 precautions, while others criticized the guidance for echoing past mistakes of relaxing measures only to end up facing another surge in cases, and simultaneously placing undue burden on those who are immunocompromised or too young to be vaccinated.

The US Transportation Security Administration (TSA) announced today that it will extend the mask mandate for people using public transportation through April 18. The requirement was set to expire on March 18 and has been extended twice previously. TSA said it will continue to assess the duration of the requirement in consultation with the CDC.

MASKING IN US SCHOOLS As new US CDC masking guidance encourages many communities to drop mask mandates and unmask in public places, a new study published in the CDC’s Morbidity and Mortality Weekly Report (MMWR) has left some school officials in a confused position about whether to continue requiring masking among students and staff. The study compared COVID-19 incidence across 233 school districts in Arkansas that had different masking policies—from universal and partial requirements to no rules—and made additional adjustments for vaccination rates, incidence in the surrounding communities, and socioeconomic status. The researchers found that between August and October 2021, districts with universal masking requirements had a 23% lower incidence of COVID-19 among students and staff compared to districts without masking requirements (incidence rate ratio = 0.77 [95% CI = 0.66–0.88]). While data collection occurred during Delta variant predominance rather than Omicron predominance and adjustments for differences in ventilation were not done, outside experts judge that the evidence is strong that masking requirements had a powerful effect on lowering COVID-19 incidence in schools and remain an important part of multifaceted prevention strategies. 

NURSE ADVOCACY Nurses in the US have been celebrated since the start of the COVID-19 pandemic, hailed as heroes in an unprecedented time. Now, the nation’s 4 million nurses and their advocates are using that spotlight to bring attention to healthcare worker shortages and unsatisfactory working conditions. The advocacy push includes plans for a Washington, DC, National Nurses March on May 12 and lobbying efforts with federal and state lawmakers. The primary issue is increased scrutiny of travel nurses, whose wages have risen, sometimes doubling, during the pandemic. Some lawmakers argue that fees for such temporary health workers are too high and are calling for wage caps, while nurses are left wondering why no caps are placed on the pay of doctors or CEOs. Other issues under discussion include caps on patient-to-nurse ratios; antidiscrimination protections and stricter penalties for people who assault healthcare workers; loan repayment and better wages; and additional help to prevent health worker burnout, including more reasonable work hours and sufficient supplies of personal protective equipment (PPE).