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.
UPCOMING WEBINAR The COVID-19 pandemic has caused trillions of dollars in US economic losses and made clear that the country must bolster its public health emergency preparedness posture. In fact, the President’s FY23 budget request includes US$88.2 billion in mandatory funding for emerging biological catastrophes. Hosted by the Johns Hopkins Center for Health Security, this webinar will explore the outlook for this budget request and the options for future pandemic preparedness and health security funding. Please join us on Wednesday, May 25 at 12:00pm ET. Registration is available here.
EPI UPDATE The WHO COVID-19 Dashboard reports 516 million cumulative cases and 6.3 million deaths worldwide as of May 11. The global weekly incidence decreased for the seventh consecutive week, although at a slower pace, down 9% last week compared to a 16% decrease over the previous week. Europe, South-East Asia, and the Eastern Mediterranean regions continued to report decreasing trends in weekly incidence, while the Americas, Western Pacific, and Africa regions reported increasing trends. The increasing trends are being driven by Omicron subvariants. The trend in reported global weekly mortality decreased for a sixth consecutive week, down 23.5% from the previous week. 

Global Vaccination
As of May 4, WHO reported 11.65 billion cumulative vaccine doses administered globally, with 5.2 billion individuals receiving at least 1 dose, and 4.7 billion fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations increased slightly over the past few days—up to 8.6 million per day on May 11 from a recent low of 8 million on May 8*. However, the number of daily doses is at its lowest level since the beginning of March 2021. The trend continues to closely follow that in Asia. Our World in Data estimates that there are 5.16 billion vaccinated individuals worldwide (1+ dose; 65.5% of the global population) and 4.69 billion who are fully vaccinated (59.5% of the global population). A total of 1.9 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.

The US CDC is reporting 81.9 million cumulative cases of COVID-19 and 995,747 deaths. The average daily incidence has more than tripled over the past 2 weeks, up from 25,292 new cases per day on March 28 to 78,236 on May 10. The daily mortality is remaining fairly stable, at an average of 326 deaths per day on May 10*. If daily mortality continues at this pace, the cumulative mortality will reach 1 million deaths within the next 12-13 days. Notably, new COVID-19 hospital admissions continue to trend upwards, with an increase of 20% over the past week. New cases are being driven by the BA.2 subvariant of Omicron, with an increasing proportion of cases due to the BA.2.12.1 sublineage.
*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 580 million cumulative doses of SARS-CoV-2 vaccines. After a slight increase starting in late March, following US FDA authorization of a second booster dose, daily vaccinations are once again declining. A total of 258 million individuals have received at least 1 vaccine dose, which corresponds to 77.8% of the entire US population. Among adults, 89.2% have received at least 1 dose, as well as 27.8 million children under the age of 18. A total of 220.3 million individuals are fully vaccinated**, which corresponds to 66.3% of the total population. Approximately 76.3% of adults are fully vaccinated, as well as 23.3 million children under the age of 18. A total of 101.5 million individuals have received an additional or booster dose. This corresponds to 46.1% of fully vaccinated individuals, including 68.9% of fully vaccinated adults aged 65 years or older. Only 49.4% of individuals eligible for a first booster dose have received one.
*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.

SECOND GLOBAL COVID-19 SUMMIT This morning, US President Joe Biden marked 1 million US deaths from COVID-19, saying the nation “must not grow numb to such sorrow.” US flags will be flown at half-staff to remember those lost in the pandemic. Later today at the second Global COVID-19 Summit, President Biden is expected to forcefully call on Congress to take urgent action to pass additional COVID-19 funding, according to unnamed administration officials. A US$10 billion proposal for more funding is stalled in Congress over disagreements regarding pandemic-related immigration policies. Notably, that package only includes money for the domestic response after lawmakers stripped the proposal of global COVID-19 aid in March. The summit—co-hosted by the US, Belize, Germany, Indonesia, and Senegal—is aimed at securing new investments for pandemic responses in low- and middle-income countries (LMICs), even as momentum for vaccinating the world dwindles. Only 16% of people in low-income countries have received at least 1 dose of vaccine, whereas 65.5% of the total world population has received at least 1 dose.

The global COVID-19 response needs approximately US$17 billion this year, according to the WHO, but only about US$2 billion has been secured. With no new funding from Congress for international efforts, President Biden is not expected to make significant pledges at the summit. Other nations—including France, Germany, Canada, and the UK—could pledge additional funds. The US is expected to increase its pledge to the new Global Pandemic Preparedness and Health Security fund hosted by the World Bank to US$450 million, up from an initial promise of US$250 million. The US also is expected to offer US$20 million for pilot projects testing the implementation of “test-and-treat” initiatives in LMICs. Additionally, the US will announce that the US NIH will license its stabilized spike protein technology that is critical to manufacturing some types of SARS-CoV-2 vaccines and treatments to companies through the WHO-backed Medicines Patent Pool. On May 11, the White House released a fact sheet on its work to strengthen the global health workforce through a new US$1 billion initiative. While the funding is contained in the President’s Fiscal Year 2023 Budget, Congress must first approve the funds. 

NORTH KOREA Throughout the pandemic, North Korea has claimed it has never experienced a single case of COVID-19. That assertion has long been widely doubted by international experts who have dubbed the country’s public health measures, including sealing its borders, unsustainable. However, until now, experts have conceded that there has not been any signs of a large-scale outbreak in the country. Today, North Korea announced for the first time that it is in the midst of a COVID-19 outbreak with cases in Pyongyang attributed to a lapse in public health measures that allowed the BA.2 Omicron subvariant to sneak in. The outbreak has led to sweeping new public health measures, including health system mobilization, masking among officials, and increased movement limitations among the public. Experts have voiced concern over the newly acknowledged outbreak because of North Korea’s fragile healthcare system and refusal to initiate SARS-CoV-2 vaccinations thus far. Foreign nations have offered or are considering offers of aid to North Korea, including China and South Korea, but it is uncertain if North Korea will accept such offers of assistance at this time.

CHINA’S ZERO-COVID POLICY China’s strict “zero-COVID” approach has been controversial among international public health experts due to its adverse effects on human rights and the Chinese economy, but censure increased when WHO Director-General Dr. Tedros Adhanom Ghebreyesus on May 10 criticized the strategy as unsustainable due to the transmissibility of Omicron. Chinese officials have called the WHO Director-General’s remarks “irresponsible” and, for now, plan to continue the current approach of strict lockdowns, including limiting movement of residents. Censorship efforts on Weibo and WeChat, Chinese social media platforms, have now been deployed to suppress access to Dr. Tedros’s comments. Adding to the debate, a new modeling study published in Nature Medicine asserts that a relaxation of measures in China leading to a wave of Omicron cases could overwhelm the existing healthcare system and currently insufficient population immunity, leading to more than 1.5 million deaths nationwide. 

BREAKTHROUGH CASES Cases of COVID-19 are beginning to rise again in the United States, and hospitalizations also are on the rise, especially in areas such as New England and Puerto Rico. Previous surges have been characterized by much higher rates of hospitalization and death among unvaccinated populations when compared to the vaccinated. However, the gap between these 2 groups is narrowing. Breakthrough infections among the vaccinated have become increasingly common, and elderly populations seem to be bearing the brunt of this trend. Many US residents aged 65 and older received their first 2 primary series vaccine doses approximately 1 year ago in the summer of 2021, and nearly one-third have yet to receive their first booster dose. As a result, the Delta surge in 2021 was characterized by younger populations being at higher risk of hospitalization and death, while this year’s Omicron surge was marked by a shift back toward elderly populations once again being at a higher risk. 

However, elderly populations will not be the only group at risk for breakthrough infections if a new surge occurs later this year. Vaccine uptake has slowed in the US, and less than half of all eligible US residents have received their first booster dose. Waning immunity, slow vaccine and booster uptake, increasingly transmissible SARS-CoV-2 variants, and a lack of pandemic funding in the US could put nearly 100 million individuals at risk of COVID-19 later this year. 

US HOSPITAL STRAIN COVID-19 caseloads in the United States are rising again and are projected to continue rising over the next several weeks. Approximately 15,000 COVID-19 positive patients are currently receiving care in US hospitals, and about 2,600 new patients are being admitted daily. This rate of new hospitalizations represents a nearly 20% increase over last week. Additionally, about 5,000 new deaths are anticipated over the next 2 weeks, as the nation rapidly approaches the harrowing number of 1 million dead from the pandemic. These increasing numbers are especially troubling because more than half of US adults have at least one underlying health condition that puts them at an increased risk of hospitalization or death. 

The increase in COVID-19 caseloads is further complicated by a lack of federal funding to treat uninsured COVID-19 positive patients. A US$20 billion program that covered testing, treatment, and vaccination for uninsured individuals has run out of money, and Medicaid coverage for certain individuals promised under a 2020 coronavirus relief bill could soon end. According to a new analysis from the Kaiser Family Foundation, between 5.3 million and 14.2 million people could lose Medicaid coverage when the nation’s public health emergency ends. Once that declaration ends, states will begin removing people no longer eligible for Medicaid from the program, a move that was prohibited under the 2020 bill. Even the new test-to-treat initiative, which provides treatment using federally funded doses of Paxlovid, could become inaccessible for many due to the costs associated with necessary medical consultations. Though the nation came close to universal health coverage for COVID-19 during the height of the pandemic, it appears those safety nets are drying up, putting many US residents at risk of forgoing necessary healthcare and experiencing significant financial hardships due to rising costs. 

MASK MANDATES Despite the recent rise in COVID-19 cases across the country, localities and federal authorities have generally not reinstated mask mandates, instead recommending the measure in appropriate circumstances, such as crowded events or public indoor spaces. Several school districts across the country—including some in North Carolina, Massachusetts, Maine, New Jersey, and Pennsylvania—are the exceptions, reinstating mask mandates for staff and students. Some authorities attribute the move away from mandates to a lack of desire among the public to return to masking, which could result in a lack of compliance with the public health tactic. Experts also have noted that while cases are rising, protection from severe disease due to vaccination has remained strong and health systems are not currently overwhelmed; however, if metrics related to those outcomes were to change, perhaps a return to mask mandates would be more appropriate. 

Additionally, recent legal challenges to public health measures, such as the overturned federal mask mandate for transit systems, also serve as a deterrent to reinstating mitigation requirements. Some experts worry that the shift away from mask mandates came too soon and contributes to inequity in the COVID-19 response with those who are immunocompromised, children too young to be vaccinated, low-income workers, and communities of color bearing the brunt of the consequences of lifted mandates. Others have also voiced concerns that the decisions to drop pandemic requirements could be politically motivated as midterm elections approach.

VACCINE QUALITY CONTROL INVESTIGATION Emergent BioSolutions, which was contracted by the US government to produce hundreds of millions of SARS-CoV-2 vaccine doses, last year concealed quality control problems from US FDA inspectors weeks prior to announcements that the company destroyed millions of doses due to a contamination incident, according to a joint report from the US House Committee on Oversight and Reform and the US House Select Subcommittee on the Coronavirus Crisis. The yearlong investigation uncovered evidence showing that 400 million doses of SARS-CoV-2 vaccines—significantly more than the 75 million previously revealed—were destroyed because of quality control failures. Emergent disputes allegations it intentionally misled FDA investigators and the claim that 400 million vaccine doses were rendered unusable. Despite regulatory concerns over the company’s SARS-CoV-2 vaccine production, Emergent maintains a federal contract to develop anthrax vaccines.

US FIREARM DEATHS Firearm deaths are a continuing and growing public health problem in the United States. During the first year of the COVID-19 pandemic, the firearm homicide rate in the US reached its highest level since 1994, according to analysis published in the CDC’s Vital Signs. In 2020, 79% of all homicides and 53% of all suicides in the US involved guns, with the firearm homicide rate increasing about 35% from 2019 to 2020 and the firearm suicide rate remaining relatively stable but high. Notably, firearm-related deaths increased disparities along racial, ethnic, and income divides, but no group was affected more than Black people. Black boys and young men ages 10 to 24 had firearm homicide rates 21 times that of White males of the same ages. Counties with the highest poverty level in 2020 had firearm homicide rates 4.5 times as high and firearm suicide rates 1.3 times as high as counties with the lowest poverty level. The study did not examine reasons for the dramatic increase in firearm homicide rate but recognized the reasons likely are complex. The CDC acknowledged stressors associated with the COVID-19 pandemic—including disruptions and changes to services and education, mental stress, social isolation, and economic stressors—could have contributed to the increase. 

Another study—published May 9 as a research letter in JAMA Internal Medicine—also blames the COVID-19 pandemic for racial and ethnic disparities in estimated excess deaths from external causes between March and December 2020. The researchers, led by University of California scientists, suggest that structural racism is the fundamental cause of these disparities, but also propose the opioid epidemic contributed to higher rates of murder, suicide, vehicle crashes, and drug overdoses among American Indian/Alaska Native and Black individuals than among White and Asian/Pacific Islander individuals. Both of the studies underscore the urgency of addressing structural determinants of violence, mental health, substance abuse, and transportation safety, particularly among racial and ethnic minority groups.
If you or someone you know is considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (Español: 1-888-628-9454; deaf and hard of hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.

BARICITINIB The US FDA on May 10 granted full approval to Lilly and Incyte's Olumiant (baricitinib) for the treatment of COVID-19 in hospitalized adults requiring supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). The FDA first authorized the drug for certain COVID-19 patients in November 2020, and it will continue to be available under Emergency Use Authorization (EUA) for hospitalized pediatric patients aged 2 to less than 18 years who require various forms of oxygen support. Baricitinib, which is already approved to treat moderate-to-severe rheumatoid arthritis, is a Janus kinase (JAK) inhibitor, a class of drug that can modulate immune cell function and the production of blood cell components. According to Lilly, nearly 1 million COVID-19 patients in about 15 countries have been treated with baricitinib.

RESEARCH ROUNDUP The research roundup provides quick synopses of COVID-19-related research. 

From The Lancet Respiratory Medicine, a study of nearly 1,200 individuals hospitalized with COVID-19 in Wuhan, China, followed up at 6 months, 12 months, and 2 years post-discharge to determine the persistent health effects of COVID-19. While physical and mental health improved over time, 68% of participants reported experiencing at least 1 original COVID-1 symptom at 6 months, and 55% reported at least 1 original symptom 2 years later. Around half of participants had symptoms of long COVID such as fatigue and sleep difficulties at 2 years, and those participants reported poorer quality of life, reduced ability to exercise, more mental health problems, and increased use of healthcare services than those without long COVID symptoms. Additionally, recovered patients tended to be in poorer health 2 years after discharge compared with the general population.

From JAMA Psychiatry, a cohort study of data from more than 8 million adults in England quantifying the risks of new-onset neuropsychiatric conditions and new neuropsychiatric medication prescriptions after discharge from hospitalization due to COVID-19 or other severe acute respiratory infections (SARI) during the pandemic. Relative to the general population, the COVID-19 and SARI survivors were at a higher risk of subsequent diagnosis of neuropsychiatric conditions, but the absolute risks were low. There were no significant differences in rates of newly diagnosed disorders or new prescriptions when the SARI and COVID-19 survivor groups were compared. The researchers posit that disease severity, not the causative agent, could be more strongly associated with elevated risks of neuropsychiatric disorders following recovery from severe respiratory disease.

From the New England Journal of Medicine, a study examining the effectiveness of the 2-dose primary series of the Pfizer-BioNTech vaccine and 2 doses of the J&J-Janssen vaccine against the SARS-CoV-2 Omicron variant. This study used a test-negative design to measure vaccine effectiveness among individuals in South Africa. The researchers note that after 2 doses, both vaccines were equally effective against severe disease from the Omicron variant, underlining the importance of continued vaccination campaigns.

From the New England Journal of Medicine, a study examining the safety and efficacy of a plant-based adjuvanted SARS-CoV-2 vaccine. The Phase 3 randomized, placebo-controlled trial included 24,141 participants and showed that the tested vaccine, CoVLP+ASO3, was effective against multiple SARS-CoV-2 variants. The study reported 69.5% efficacy in preventing symptomatic infection and 78.8% efficacy in protecting against moderate-to-severe disease. 

From the New England Journal of Medicine, a study examining the efficacy and confirming the safety of the experimental ZF2001 vaccine. The randomized, placebo-controlled trial included 28,873 adult participants in Uzbekistan, Indonesia, Pakistan, Ecuador, and China. The safety analysis of the 3-dose regimen concluded it is safe. Additionally, the researchers found that the vaccine efficacy of the full regimen at 6 months was 75.7% against symptomatic COVID-19, 87.6% against severe-to-critical disease, and 86.5% against death. 

From The Lancet Regional Health, a study examining the clinical characteristics of maternal COVID-19 deaths that occured in Latin America between March 1, 2020, and November 29, 2021. The observational study looked at maternal deaths across 8 Latin American countries, for a total of 447 deaths. The study provides an important clinical picture of maternal health in the region during the COVID-19 pandemic and emphasizes challenges including access to intensive care. 

From Open Forum Infectious Diseases, a study examining the impact of SARS-CoV-2 vaccination on post-acute sequelae of COVID-19 (PASC). This retrospective study used data from 1,578,719 patients to match a pool of 25,225 patients who completed a primary series vaccination with a similar pool of patients who had not received complete vaccination. The study found that complete vaccination was protective against several prolonged COVID-19 symptoms tied to PASC.