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From the February 17, 2022 Newsletter; Editor: Alyson Browett, MPH

EPI UPDATE The WHO COVID-19 Dashboard reports 414.5 million cumulative cases and 5.83 million deaths worldwide as of February 16. The global cumulative incidence passed 400 million cases on February 9, only 33 days after reaching 300 million. The global weekly incidence continues to decline, down 18.2% from the previous week. Notably, all WHO regions with the exception of the Western Pacific region (+18.7%) reported decreasing weekly incidence last week. 

Global weekly mortality remained relatively steady, up 0.5% from the previous week. The weekly total of 73,145 deaths is the highest since the week of August 23, 2021—the peak of the previous wave. 

Global Vaccination

The WHO reported 10.2 billion cumulative doses administered globally as of February 14. A total of 4.84 billion individuals have received at least 1 dose, and 4.21 billion are fully vaccinated. Analysis from Our World in Data indicates that the overall trend in global daily vaccinations began to increase last week, closely following the trend in Asia. The trend is up from the most recent low of 18.32 million doses per day on February 7 to 22.1 million per day on February 15.* The global weekly average jumped to 29.5 million doses per day on February 16, corresponding to a large increase reported in Asia and may be a reporting error.** Our World in Data estimates that there are 4.88 billion vaccinated individuals worldwide (1+ dose; 62% of the global population) and 4.28 billion who are fully vaccinated (54.4% of the global population). A total of 1.23 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 OWID data show 16.3 million doses reported in Asia on February 15 and 24.1 million on February 16 (+7.8 million), but it is not immediately clear what country or countries accounted for that increase. 

UNITED STATES

The US CDC is currently reporting 77.95 million cumulative cases of COVID-19 and 923,067 deaths. Daily incidence continues its sharp decline, down from a record high of 807,120 new cases per day on January 15 to 134,468 on February 15, an 83% decrease over 4 weeks. Average daily incidence is now below the peak of the previous wave. Daily mortality appears to have peaked on February 1 at 2,516 deaths per day, down to 2,100 on February 15.* *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 677.8 million cumulative doses of SARS-CoV-2 vaccines. Daily vaccinations continue to decline, down from the most recent peak of 1.78 million doses per day on December 6 to 429,530 on February 11.* A total of 252.4 million individuals have received at least 1 vaccine dose, which corresponds to 76% of the entire US population. Among adults, 87.6% have received at least 1 dose, as well as 26.3 million children under the age of 18. A total of 214 million individuals are fully vaccinated**, which corresponds to 64.5% of the total population. Approximately 74.6% of adults are fully vaccinated, as well as 21.5 million children under the age of 18. Since August 2021, 92.2 million individuals have received an additional or booster dose. This corresponds to 46.3% of fully vaccinated individuals, including 65.7% 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 5 days. The most current average provided here corresponds to 5 days ago.**Full original course of the vaccine, not including additional or booster doses.


US RESPONSE 

Daily COVID-19 incidence has dropped sharply over the past month in the US, and many states are rolling back mitigation measures, including masking requirements for public spaces and schools. Additionally, some Republicans in the US Congress are urging US President Biden to end the designation of COVID-19 as a public health emergency. Based on comments from the White House COVID-19 Response Team on February 16, it appears the Biden administration is working on a plan for the next phase of the pandemic. White House Coronavirus Response Coordinator Jeff Zients said the country has made “tremendous progress” and the Biden administration is actively planning for a future “when COVID isn’t a crisis.” US CDC Director Dr. Rochelle Walensky said the agency wants to “give people a break” from mask wearing and expects to update its indoor masking guidelines as early as next week. The CDC reportedly is shifting its focus to COVID-19 hospitalizations as a key benchmark for determining when mitigation measures can be lifted or tightened. The Biden administration this week requested US$30 billion in additional funding for the domestic pandemic response. According to an anonymous source, the majority of the money would go toward vaccines and therapeutics (US$17.9 billion), with the remainder split among testing, care for uninsured individuals, and future variants. There is bipartisan skepticism surrounding the need for additional pandemic funding, with several members of Congress saying the American Rescue Plan provided plenty of support.

Notably, the funding request does not contain additional money for global vaccination efforts in low- and middle-income countries (LMICs), efforts that are running low on funds. A group of Democratic lawmakers is pushing for an additional US$17 billion for the global COVID-19 response, and USAID has said it needs an additional US$19 billion in 2022 to complete its COVID-related work. According to reporting from Politico, the White House’s proposed global COVID-19 supplemental funding request is US$10.95 billion, although it is unclear whether the Biden administration will officially request that money. In a virtual meeting with other countries earlier this week, US Secretary of State Antony Blinken acknowledged the world is not on pace to reach the goal of vaccinating 70% of the world’s population by later this year. Secretary Blinken announced a “Global Action Plan,” with a focus on overcoming last-mile challenges to deliver and administer vaccines in LMICs. President Biden is expected to hold another international vaccine summit next month, although details on the meeting are not yet available.


US EXCESS DEATHS 

The US CDC’s National Center for Health Statistics (NCHS) has been tracking excess deaths associated with the COVID-19 pandemic in the United States, crossing the threshold of 1 million excess deaths last week. Excess deaths are defined as the number of unexpected observed deaths to occur during a specific time period. This statistic can aid in further elucidating the burden of COVID-19, documenting both mortality directly caused by the virus as well as deaths indirectly caused by the pandemic’s impact. The NCHS’s excess death dashboard associated with COVID-19 breaks down deaths by direct cause, time, age and race/ethnicity. Dr. Robert Anderson, Chief of Mortality Statistics at NCHS, noted to The Washington Post that 91% of the excess deaths associated with COVID-19 were directly attributed to the disease, while the other 9% of excess deaths had COVID-19 listed as a contributing factor. These non-COVID-19 deaths were attributed to 13 other conditions, with Alzheimer’s disease and dementia, hypertensive diseases, and diabetes showing the greatest increases. Excess deaths not directly attributable to COVID-19 could be due to undiagnosed COVID-19 or conditions exacerbated by the pandemic’s impacts on society, including poorer healthcare due to health system strain or patients reluctant to seek care for other conditions while trying to avoid COVID-19. Timing of excess deaths appears to coincide with surges in SARS-CoV-2 transmission during the pandemic beginning in late March 2020.


US CDC TRAVEL GUIDANCE

The US CDC is warning travelers to avoid at least 135 destinations, this week moving several countries—including South Korea, Azerbaijan, and Belarus—to its level 4 COVID-19 risk category due to “very high” transmission levels. The agency warned that people who must travel to these areas be fully vaccinated before going. Several nations moved into the “high” level 3 category, with Eswatini and Mauritius dropping a level and El Salvador and Indonesia moving up from lower levels. Notably, the CDC lowered the cruise travel warning from “very high” to “high,” recommending that travelers be “up to date” on vaccinations—meaning completing a primary series and a booster dose—before vacationing on a cruise ship. The agency recommended prospective cruise ship passengers get tested prior to departures, check to see if the ship has reported COVID-19 cases, and see if the majority of crew and passengers will be vaccinated. CDC’s Conditional Sailing Order, which outlined mandatory rules cruise companies had to follow to operate in US waters, expired on January 15, allowing operators to implement voluntary mitigation measures and choose whether to participate in the agency’s COVID-19 Program for Cruise Ships. According to the agency, 14,803 COVID-19 cases were reported on cruise ships between December 30, 2021, and January 12, 95 times the number reported during the first 2 weeks of December 2021.


VACCINATION DURING PREGNANCY 

As reported here previously, evidence shows people who receive SARS-CoV-2 vaccinations during pregnancy pass along more durable antibodies to their newborns than do unvaccinated individuals who had COVID-19 during pregnancy. Now, a study published in the US CDC’s Morbidity and Mortality Weekly Report (MMWR) suggests that completion of a 2-dose primary mRNA vaccination series during pregnancy is associated with a reduced risk for COVID-19 hospitalization among infants aged <6 months. For women who completed the series at any time during pregnancy, vaccine effectiveness against COVID-19-associated hospitalization in infants aged <6 months was 61% (95% CI: 31% to 78%). Vaccine effectiveness against infant hospitalization was 32% (95% CI: –43% to 68%) for women who completed vaccination during the first 20 weeks of pregnancy and 80% (95% CI: 55% to 91%) for women who completed vaccination late in pregnancy, at 21 weeks’ gestation through 14 days before delivery. The case-control study recruited participants from 20 pediatric hospitals in 17 states from July 2021 to January 2022, with 176 hospitalized infants with COVID-19 and 203 hospitalized infants without COVID-19. This news could bring some comfort to prospective parents concerned by the recent increase in hospitalization among children under the age of 5 who are not yet eligible for vaccination against COVID-19. Further research results on the effects of COVID-19 variants and vaccination among pregnant women and newborns is expected in May 2022 with the University of Oxford launching a global study this week involving 40 medical institutions and 4,500 pregnant women.


ESTROGEN LEVELS 

Higher estrogen levels may be associated with a decreased risk of dying from COVID-19 among older women who take supplements of the hormone, according to a study published in the February issue of BMJ Open. All of the 14,685 postmenopausal Swedish women, aged 50 to 80 years, included in the study had COVID-19 between February 1 and September 14, 2020. They were grouped based on estrogen levels, with women receiving endocrine therapy because of breast cancer representing lower estrogen levels, women on hormone replacement therapy representing higher levels, and a control group of women who had received neither therapy. The adjusted odds ratio (OR) for death following COVID-19 remained statistically significant for only the higher estrogen group with OR 0.47 (0.34 to 0.63), a risk reduction of more than half. Absolute risk of death was 4.6% for the control group versus 10.1% and 2.1%, for the decreased and increased estrogen groups, respectively. The researchers noted that the risk of death from COVID-19 was significantly associated with age, annual income, and education, and they recommended further clinical trials testing the use of estrogen supplementation as a COVID-19 therapy among postmenopausal women.


LONG COVID/PASC 

Researchers continue to examine potential causes for post-acute sequelae of SARS-CoV-2 infection (PASC), otherwise known as post-COVID condition or long COVID, with recent findings pointing to vagus nerve dysfunction (VND)microclots, or inflammation as possible underlying factors or opportunities for treatment. The range of symptoms that people with long COVID experience—including fatigue, shortness of breath, joint and muscle pain, cognitive problems, depression, headache, and rapid heartbeat—call for a multidisciplinary approach to treatment, according to researchers who are developing a consensus statement (preprint) on core outcomes of long COVID in adults. 
Studies differ on how many people experience long COVID symptoms, with one US CDC study estimating 1 in 10 will develop symptoms more than a month after acute infection and another from Oxford University estimating 1 in 3 individuals. While some see their symptoms resolve within weeks or months, others are experiencing nagging symptoms that have lasted a year or more. Additionally, evidence is emerging that people who have had COVID-19—including those with mild cases and who do not have typical long COVID symptoms—have an increased risk of cardiovascular disease and mental health conditions when compared with individuals who have never had the disease. Therefore, millions of people worldwide could experience long COVID or future health implications, with lasting societal and economic impacts. In a survey of 804 organizations representing more than 4.3 million employees in the UK, the Chartered Institute of Personnel and Development (CIPD) found that 46% of the organizations had employees who experienced long COVID and 26% of those employers now include long COVID as a primary cause of long-term sickness absence. In the UK, 1.3 million people—2% of the population—reported experiencing long COVID symptoms for more than 4 weeks after their initial infection.

This week the UK Health Security Agency released a rapid review examining available evidence from 15 studies conducted around the world prior to January 12, 2022, to determine the effectiveness of SARS-CoV-2 vaccination against long COVID. The analysis suggests that individuals who are fully vaccinated against COVID-19 have a significantly reduced risk of developing long COVID symptoms compared to partially vaccinated or unvaccinated individuals, and those currently suffering long COVID who are unvaccinated may experience some improvement if they get the shots. The review underscores the importance of vaccination in lowering the risk of infection in the first place and the potential to lower the risk of long-term symptoms if a breakthrough infection occurs.


IMMUNOCOMPROMISED INDIVIDUALS 

US states’ rollbacks of certain COVID-19 restrictions and mask mandates signal a bit more freedom is on the horizon for some. But for immunocompromised people, who are at high risk of infections including SARS-CoV-2, the relaxation of public health measures places them in a sort of limbo, unsure about their safety in a world where the coronavirus continues to circulate and people are returning to pre-pandemic activities. At least 7 million people in the US take immunosuppressive drugs, and millions more have conditions that inhibit immune responses, including HIV and genetic disorders. They are less likely to mount a significant immune response to SARS-CoV-2 vaccinations, even after 3, sometimes 4, doses. Many immunocompromised people feel vulnerable, left behind by a nation that is increasingly loosening precautions such as masking and working from home without any consideration of how to keep them safe. Vaccinating more of the US population, improving ventilation systems, and taking other steps to limit the amount of circulating virus would help. Additionally, making prophylactic antibody treatments such as Evusheld more widely available to immunocompromised people—as Israel did this week—and improving access to other COVID-19 treatments for the highest-risk patients could help some return to more of a sense of normalcy. The US government has announced it plans to convene a working group of advocates for people with vulnerabilities, but in the meantime, immunocompromised people continue to feel abandoned, isolated, frustrated, and fearful.

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