July 26, 2022: Johns Hopkins COVID 19 Situation Report

COVID-19 Situation Report

Editor: Alyson Browett, MPH

Contributors: Clint Haines, MS; Noelle Huhn, MSPH; Amanda Kobokovich, MPH; Christina Potter, MSPH; Matthew Shearer, MPH; Marc Trotochaud, MSPH; and, Rachel A. Vahey, MHS.

VACCINATION STRATEGIES The WHO last week published an updated COVID-19 vaccination strategy prioritizing vaccination of certain populations, including healthcare workers, older people, individuals with underlying conditions, and other vulnerable groups. The focus is on reaching 100% of those populations while continuing efforts to achieve the goal of vaccinating 70% of the global population. The latter target was missed this month, as only 58 countries had vaccinated 70% of their population by mid-year. The new goal remains a challenge; only 28% of older adults and 37% of healthcare workers in low-income countries have received a primary vaccination series and most have not had booster doses. The WHO also called for greater equity in locating vaccine manufacturing facilities across all regions; said it will continue to collaborate with the COVAX initiative and other partners to support vaccine rollouts; and urged innovation to develop new vaccines that can substantially reduce SARS-CoV-2 transmission, are easier to administer, and provide longer-lasting and broader protection against current and emerging variants. Efforts are underway globally to create a Coronavirus Vaccines Research and Development (R&D) Roadmap focused on preventing a broad range of coronavirus infections.

In the US, the administration of US President Joe Biden is hosting a meeting today of federal officials, leading scientists, and pharmaceutical representatives to discuss next-generation COVID-19 vaccines, including new technologies and a timeline for development. Current vaccines are highly effective at preventing severe COVID-19-related illness and death, but researchers hope new vaccines will be capable of preventing infection and transmission of current and possibly future SARS-CoV-2 variants, as well as be more easily administered, such as through nasal sprays or skin patches. While some companies are developing Omicron-specific booster shots to be delivered this fall, that strategy—of trying to keep up with variants—is unsustainable over the long term. In related news, the Biden administration has slowed its push to quickly authorize second booster doses for adults under age 50 in the hopes that vaccine makers can have updated Omicron-inclusive shots as early as mid-September.

POST-COVID CONDITIONS IN CHILDREN An international study published July 22 in JAMA Network Open examined the prevalence of post-COVID-19 conditions (PCCs) in children infected with SARS-CoV-2 90 days after they were treated in emergency rooms. Overall, the study enrolled a total of 8,642 children who visited 36 emergency departments (EDs) in Argentina, Canada, Costa Rica, Italy, Paraguay, Singapore, Spain, and the United States between March 2020 and late January 2021. A total of 1,884 of the enrolled children tested positive for SARS-CoV-2 and completed a 90-day followup appointment. The study found that, overall, 5.8% of the children with COVID-19 who attended a followup appointment reported PCCs, including symptoms such as fatigue or weakness, cough, shortness of breath, and other respiratory issues that are in line with what most call “long COVID.” The rate was higher among children who were hospitalized (9.8%), regardless of symptom severity, compared with those who were discharged from the ED (4.6%). Most children (59.1%) reporting PCCs at 90 days had 1 persistent, new, or recurring health problem, most commonly including respiratory and systemic issues such as fatigue. Additionally, PCCs at 90-day followup were more common among children who were hospitalized for 48 hours or longer compared with those who were not hospitalized; children who had 4+ reported symptoms during their ED visit compared to those with 1-3 symptoms; and children who were aged 14 years or older compared to those younger than 1 year.

The researchers noted that the rates of PCCs among children with COVID-19 were only slightly higher than the rates among uninfected controls but called for appropriate guidance for follow up and treatment of children with COVID-19, as well as appropriate mitigation strategies. Overall, the study showed that children had a lower prevalence of PCCs than has been shown in most studies looking at long COVID in adults, but it is still possible that COVID-19 could lead to additional, future health problems among children. The best way to prevent the possibility of these impacts is to prevent infection. Notably, the study comes at a time when vaccinations for children between the ages of 6 months and 5 years appear to be slowing down in the US, with only 2.8% of the population having received their first dose. This rate of vaccine uptake is much slower than it was for kids between the ages of 5 and 11 years. Parents should be further encouraged to seek vaccinations for their children.

“COVID VIRGINS” An estimated 82% of US residents have been infected with SARS-CoV-2 at least once, according to the Institute of Health Metrics and Evaluation. Some of those individuals may think they have never had COVID-19 because they had an asymptomatic infection, but that leaves about 18% of the US population who have managed to avoid infection, even in times when the risk is high, such as during the winter Omicron surge or now, with the more transmissible BA.5 subvariant circulating widely. But that club of “super-dodgers” or “COVID virgins” becomes more exclusive each day. For example, in the UK, 55% of new COVID-19 cases are occurring among the approximately 15% of people who have never been infected.

The reasons why some people have yet to be infected likely vary, including engaging in preventive behaviors such as mask wearing or having vaccine-induced immunity. Beyond these factors, scientists are examining several others—including individuals’ genetics, immune system function, and the effects of inflammatory conditions such as allergies—that could influence their risk of SARS-CoV-2 infection. A specific genetic mutation in some individuals prevents most HIV strains from entering human cells, effectively rendering them immune to the virus. Something similar could be happening among certain people who have never had a SARS-CoV-2 infection, although some experts say the theory is a long shot. If scientists can identify such a mutation, they could use that knowledge to better understand who is most susceptible to infection and potentially develop new COVID-19 therapeutics.

US HOSPITALS Hospital systems in the US are struggling with funding shortfalls, staffing shortages, and pandemic fatigue as the SARS-CoV-2 Omicron BA.5 subvariant spreads across the nation. Once again, hospitals are reporting staffing problems due to burnout, high staff turnover, and absences due to COVID-19. Officials are worried that burnout could create additional challenges to providing treatment during a new surge of patients. Additional stress is being felt because federal funding for the COVID-19 response is running out. A deal in the US Congress on a $22.5 billion pandemic funding bill fell apart in March due to partisan infighting, leaving hospitals with no additional funds and significantly less flexibility to hire new staff or ramp up COVID-19 response efforts, even if BA.5 or a future variant leads to higher numbers of hospitalizations.

Meanwhile, CDC predictions for how hospitalizations and deaths will change due to BA.5 are uncertain. A forecast of new hospitalizations from 16 modeling groups predicted that the increase could range from 3,100-13,800 new COVID-19 hospitalizations per day by August 12. A similar forecast on new COVID-19 deaths from 17 modeling groups predicted that the increase could range from 1,800-5,600 new deaths per day by August 13. Additionally, a study published July 22 in the CDC’s Morbidity and Mortality Weekly Report (MMWR) showed that 40% of state and local governmental public health agency workers plan to leave their jobs within the next 5 years. More than half (51%) of the survey respondents reported the need for additional staff to adequately respond to COVID-19. The study only highlights public health and healthcare workforce staffing issues that existed prior to the pandemic and continue today. Sustained investments and large-scale healthcare reform is needed to adequately respond to COVID-19 and to prepare for future health emergencies such as a “Disease X” pandemic.

TREATMENT ACCESS IN US PRISONS The Federal Bureau of Prisons (BOP) is under scrutiny for its minimal use of COVID-19 therapeutics. The latest critique comes in a letter from 14 US Senators demanding an explanation for the limited use of therapeutics. Data show that federal prisons issued only 363 prescriptions for COVID-19-authorized antivirals from March 31, 2020, to March 24, 2022. Of those, only 3 prescriptions were for one of the preferred therapeutics, Paxlovid. Officials with the US Department of Health and Human Services said the BOP also has declined distribution of additional therapeutics despite the agency offering assistance.  STAT News previously reported on BOP’s poor usage of allotted therapeutics, citing it as the latest example of BOP’s failure to effectively respond to outbreaks, leading to a disproportionately negative impact on inmates who already receive limited healthcare. The BOP reports 55,351 positive SARS-CoV-2 tests of the 128,703 tests completed by inmates in current BOP custody, noting that not all tests are reported to BOP. Currently, 71 of the 97 BOP facilities are listed as Level 3 facilities, operating at the highest level of modifications based on COVID-19 medical isolation rate, combined percentage of staff and inmate completed vaccinations series, and respective community transmission rates.

CHINA In an attempt to alleviate public concerns over SARS-CoV-2 vaccine safety, Chinese health officials this week disclosed that state and ruling Communist Party leaders had received domestically developed and manufactured shots. About 90% of the population is vaccinated against COVID-19 and 56% have received a booster dose. However, only 61% of people above age 80 have finished their primary series, prompting officials to make the unusual disclosure regarding the nation’s leaders. The announcement comes about 2 years after the nation launched its vaccination drive, primarily using vaccines made by Sinovac and Sinopharm. As of July 23, nearly one-fifth of China’s population was under COVID-19-related full or partial lockdown, and the country is experiencing another increase in cases, reporting 976 cases on July 25, versus 800 cases the day prior. China continues to enforce its “zero COVID” strategy, despite the policy’s unpopularity and damage to the national economy.

Monkeypox in Chicago

Can Chicago slow the spread of monkeypox?

Fatigue from the COVID-19 pandemic and a shortage of monkeypox vaccines are raising questions over whether the spread of the virus can be contained.

By Courtney Kueppers

Wednesday, July 20, 11:40 a.m. CT

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This 2003 electron microscope image made available by the Centers for Disease Control and Prevention shows mature, oval-shaped monkeypox virions, left, and spherical immature virions, right. Cynthia S. Goldsmith, Russell Regner / CDC via Associated Press

The amount of people waiting for a monkeypox vaccine outside Test Positive Aware Network in Edgewater on Monday quickly outnumbered the 100 doses the nonprofit had available.

Standing in the heat, people who learned they wouldn’t get a shot tried to help one another out by passing around phones to share social media posts and texts about where else they may be able to find a vaccine, said a local writer and artist who goes by the name Kal Jazeera, who called Howard Brown Health Center from the line to see if he could get an appointment.

TPAN CEO Kara Eastman said the nonprofit was prepared for high demand, but the level of turnout was “overwhelming.”

The frustrating scavenger hunt for a vaccine comes as monkeypox cases near 200 in Chicago. The rare disease that can lead to a rash is spread primarily through skin-to-skin contact or prolonged intimate contact like kissing, cuddling and sex. The virus began spreading internationally this year and has now been reported in most major U.S. cities. In Chicago, like elsewhere, “most, but not all” of the cases have been reported in gay and bisexual men, or other men who have sex with men, Dr. Allison Arwady said, but stressed that anyone can get monkeypox.

While the overall cases remain low compared to the COVID-19 outbreak, Dr. Anthony Fauci, the country’s top medical official, warned over the weekend that “we have to act like it will have the capability of spreading much more widely than it’s spreading right now.” In Chicago, vaccines have been made available to those most at risk of being exposed to the virus, but demand has far outpaced supply.

• RELATED STORY

Chicago announced its first probable case of monkeypox — here’s what to know about the disease

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“The severity and the concern and urgency to get vaccinated has really come up very quickly, because it got close to home really fast,” Kal Jazeera said by phone Tuesday afternoon. “I currently know one person with monkeypox and I know about eight to 10 people who have been exposed.”

As of Tuesday, Chicago has received and distributed about 5,000 doses of the monkeypox vaccine, Jynneos, with approximately 15,000 more doses expected to start arriving as early as this week.

But Arwady, the city’s top doctor, acknowledged in a weekly Facebook Live event on Tuesday that even 15,000 doses isn’t enough.

“Many many more people would like to get this vaccine than we have available for,” she said. “As vaccine supply increases, I expect this will evolve and we will likely recommend it to more individuals.”

Here’s how the city is prioritizing who is able to get the two-dose vaccine at this time. It is not recommended for the general public, including men who have sex with men but don’t have other listed risk factors:

• If you have had close physical contact or were intimate with someone who has been diagnosed with monkeypox.

• If you are gay, bisexual or a man who has sex with men and have had sexual contact with other men in a social venue or otherwise have had multiple anonymous partners and therefore may not be able to adequately contact trace.

Arwady said the low number of vaccines available is, in part, because of the infrequency of monkeypox outbreaks in the United States.

“Because MPV is really rare, it’s not like there’s lots and lots of this vaccine just sitting on the shelf, your doctor does not just have it in their office, your pharmacist does not have it on the shelf,” she said, adding that the vaccines available have come from the Strategic National Stockpile maintained by the federal government in case of disease outbreaks.

Dr. Anu Hazra of Howard Brown Health Center said the nonprofit LGBTQ health care provider has been “inundated with calls” — hearing from as many as 200 people a day looking for testing or a vaccine.

“What concerns me is how can we tamp down transmission?” Hazra said. “A lot of us talked about how ‘COVID zero’ is sort of an impossible goal, but monkeypox zero should be very much possible. We have the tools to stop it.”

In addition to testing and vaccines, Hazra is recommending that people consider tightening their sexual networks. As a sexual health doctor, he said he will never tell people to stop having sex, but he said it’s important to think carefully about sexual interactions right now and to not have sex if you’re experiencing symptoms.

People diagnosed with monkeypox tend to experience flu-like symptoms, followed by a rash that can look like pimples or blisters. While there are no known deaths from the illness, for some the lesions can be quite painful, officials said.

“I worry about symptom and pain control with monkeypox,” Hazra said. “Just because it doesn’t have the same case fatality rate or whatnot as COVID-19 doesn’t make it any less important.”

While officials have learned a lot in the last two years about responding to public health crises, COVID has also put a strain on health care systems and has highlighted the ways bureaucracy can slow down response. As the monkeypox outbreak emerges amid the still-ongoing pandemic, it’s met by a system that has been highly tested.

“I feel like everyone is tired. I mean, the general public is tired. Health care workers are tired, public health officials are tired,” Hazra said. “So I think all of that also is in the background here.”

Chicago is not the only city where demand has outpaced supply. In New York, where there are more than 500 cases of monkeypox as of Tuesday, soaring demand for the vaccine caused the appointment system to crash.

The frustrations came as the federal government announced additional steps to respond to the outbreak, including providing more monkeypox vaccines and a goal to expand testing.

Anyone who thinks they may have been exposed to monkeypox or who is experiencing an unusual rash is urged to reach out to their health care provider. For those without a primary care doctor, Arwady said publicly people can call the Department of Public Health at 312-746-4835 to be connected to care. However, WBEZ called the number on two different occasions and both times, operators were unsure about directing questions about monkeypox.

TPAN will offer vaccines again next Monday afternoon. For those who plan to come out, Eastman, the CEO, said “be prepared to be patient, but we will make it as smooth as possible.”

The Associated Press contributed to this report.

Courtney Kueppers is a digital producer/reporter at WBEZ. Follow her @cmkueppers.

July 20, 2022: Outbreak Alert Monkeypox

Outbreak Alerts

Monkeypox

Editor: Alyson Browett, MPH

Contributors: Christina Potter, MSPH, Eric Toner, MD, Rachel Vahey, MHS, and Lane Warmbrod, MS, MPH

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Additional Monkeypox Resources

Recent Outbreaks Update as of July 19, 2022 at 3pm EDT

As of 5pm EDT on July 19, there were 14,511 cumulative confirmed cases of monkeypox in 70 countries, territories, and areas, according to the US CDC.* We expect the global cumulative incidence to surpass 15,000 in the next 1-2 days, 11 weeks after the first case in the current outbreak was reported.

A majority of the confirmed cases continue to be reported in European countries, with Spain (3,125), the UK (2,137), and Germany (2,033) making up the 1st, 2nd, and 4th spots, respectively. This week, the US moved into 3rd position, reporting 2,107 confirmed cases, 2.27 times the number reported this time last week. No deaths have been reported in countries not historically reporting monkeypox, while 5 deaths have been reported in African countries.

Based on data from Global.health,** Our World In Data shows a 7-day average of 473 daily confirmed cases as of July 19. The 7-day rolling average of daily confirmed cases appears to have peaked at 537 on July 13 but appears to be leveling out.

*The total number includes 14,268 cases in 64 countries not historically reporting monkeypox cases and 243 cases in 6 countries historically reporting monkeypox cases. The CDC map only includes cases confirmed as monkeypox virus or orthopoxvirus through laboratory testing and are year-to-date totals.

**Global.health data only include countries that have not historically reported monkeypox cases.

WHO EMERGENCY COMMITTEE With many experts expressing concern that the confirmed number of cases likely is an undercount and that the window is closing to contain the global monkeypox outbreak, the WHO Emergency Committee is set to meet again July 21 to decide whether the outbreak now constitutes a Public Health Emergency of International Concern (PHEIC). The committee first met at the end of June but decided at that time the outbreak did not qualify as a PHEIC, WHO’s highest level of alert for events that show extraordinary public health risk to other countries through international spread and require coordinated international responses.

SEXUAL HEALTH CLINICS Sexual health clinics that are on the frontlines of diagnosing many of the cases—the majority of which are occurring in men who have sex with men (MSM)—say they are preparing for the possibility that monkeypox will become endemic. The clinics are best suited to identify, test, and treat monkeypox cases, but they already are under-resourced after years of financial neglect, according to sexual health experts in the US and UK.

Although monkeypox is not historically considered to be a sexually transmitted infection (STI)—experts believe the virus is typically transmitted through skin-to-skin or close face-to-face contact—public health authorities are struggling with messaging surrounding prevention, trying to strike a balance between encouraging people to have fewer sexual partners while not stigmatizing specific communities. A study published in Eurosurveillance last week found a large proportion of semen, saliva, urine, and feces samples taken from 12 monkeypox patients in Barcelona, Spain, contained DNA of the poxvirus. Though the study suggests monkeypox transmission might be viable through sexual fluids or saliva, the presence of viral DNA does not mean infectious virus is present.

US TESTING & TREATMENT US CDC Director Dr. Rochelle Walensky this week remained optimistic that the monkeypox outbreak can be contained and defended CDC’s response, saying “dramatic progress” has been made to educate the public and healthcare providers and increase testing and vaccine access.

The CDC is working to ramp up the nation’s testing capacity, which is up to 70,000 samples per week versus 6,000 samples at the beginning of the outbreak. Aegis Science and Sonic Healthcare USA (Sonic) this week became the fourth and fifth commercial laboratories to announce monkeypox testing availability. Still, anecdotal evidence shows people continue to face major challenges to obtaining testing and treatment for monkeypox. Additionally, physicians face challenges in obtaining the smallpox treatment tecovirimat (TPOXX) for their patients due to cumbersome paperwork because the drug is not approved for monkeypox but available under expanded access Investigational New Drug (EA-IND) protocol. The US Department of Health and Human Services (HHS) and US FDA have said they are working to make the drug more easily accessible.

VACCINE SUPPLY & ACCESS As of July 15, the US government said more than 300,000 doses of the Jynneos smallpox vaccine are available to states and jurisdictions. About 156,000 of those doses had been shipped, with about 100,000 of those delivered last week. The government expects to add about 780,000 additional doses from a Bavarian Nordic facility in Denmark that recently passed US FDA inspection to the available supply by the end of July. In total, the US government has ordered nearly 7 million vaccine doses, but most of those will not be ready until late this year or next year.

Vaccine supply has been unable to keep up with demand, especially in New York City, San Francisco, and other areas. Notably, New York City announced it will only offer first doses of the 2-dose primary series until supplies increase. The move is not in line with FDA and CDC recommendations, which call for the vaccine doses to be administered 28 days apart. Both the UK and Canada are taking a similar approach to administering first doses to as many people as possible before offering second doses.

In Europe, health authorities have delivered about 25,000 vaccine doses to 6 EU member states. The European Commission announced July 18 it has ordered an additional 54,000 doses of Jynneos from Bavarian Nordic, after placing an initial order of 110,000 doses in June. Both Spain and France last week updated their vaccination strategies to include pre-exposure vaccination for high-risk populations. Portugal announced the vaccine will be offered as post-exposure prophylaxis, preferably within 4 but up to 14 days after exposure, with people who were previously vaccinated against smallpox receiving only 1 dose of Jynneos.

The world has known of the potential threat of resurgent monkeypox for decades. Now, as the number of new cases continues to rise, the international community must come up with a plan to make vaccination for monkeypox—with either the Jynneos monkeypox or ACAM2000 smallpox vaccines—widely available and avoid the inequity experienced during the COVID-19 pandemic. Additionally, increased access to diagnostic testing, treatment, and targeted education campaigns that minimize stigma are quickly needed. A determination from the WHO Emergency Committee on whether the monkeypox outbreak constitutes a PHEIC and any recommendations on how to better manage the global public health response are expected later this week.

July 19, 2022: Johns Hopkins COVID 19 Situation Report

COVID-19 Situation Report

Editor: Alyson Browett, MPH

Contributors: Clint Haines, MS; Noelle Huhn, MSPH; Amanda Kobokovich, MPH; Christina Potter, MSPH; Matthew Shearer, MPH; Marc Trotochaud, MSPH; and, Rachel A. Vahey, MHS.

UPCOMING WEBINAR The country’s response to the COVID-19 pandemic led to new public-private partnerships (PPPs) that drove the development of new medical countermeasures and bolstered domestic manufacturing capacity for medical products. It is critical to sustain PPPs and build a domestic bioindustrial base beyond the current pandemic. Join us for a webinar, Strengthening Private Public Partnerships in Pandemic Preparedness for National Security and Economic Competitiveness, on Wednesday, July 20, at 12pm ET. Register here: https://jh.zoom.us/webinar/register/WN_fiapVqnbToKHkgwPcaDtIA

CONCERN OVER BA.5 SUBVARIANT As the Omicron subvariant BA.5 drives increases in COVID-19 cases and hospitalizations in several regions and countries worldwide, health officials are, for the most part, holding back on sounding alarms. In the US, where the average number of cases and hospitalizations are at their highest levels since February, many state and local health authorities are characterizing the increase in cases as concerning but not disturbing, with many saying repeated warnings about COVID-19 surges are falling on pandemic-fatigued ears. However, US health officials are speaking out. White House COVID-19 Coordinator Dr. Ashish Jha has warned the BA.5 subvariant is the most immune evasive variant yet, urging US residents to stay up to date on their vaccines and expressing support for the reinstatement of mask mandates. Chief Medical Advisor to the US President Dr. Anthony Fauci called on eligible people to get vaccine boosters and said a decision about boosters for those under age 50 likely will soon be announced. In Europe, the WHO announced today that COVID-19 case numbers have tripled and hospitalizations have doubled across Europe over the past 6 weeks. WHO Europe Director Dr. Hans Kluge warned that people should not underestimate BA.5, calling on nations to bolster vaccine uptake and require mask wearing.

A dearth of data is complicating the true picture of how big BA.5-driven surges are, or will get, as publicly reported data has become less common due to the closing of testing sites and an increase in at-home test use. Some experts estimate that for every 1 reported case, there are 7-10 unreported cases. Additionally, BA.5 has several spike protein mutations that make it better at infecting human cells and evading immunity from vaccination or previous SARS-CoV-2 infection. These capabilities allowed the subvariant to gain predominance in the US in just over 2 months, and it is now causing 3 of every 4 new COVID-19 cases in the nation. BA.5 is so adept at skirting immune defenses that many people who were recently infected with a different Omicron variant are becoming reinfected. Some studies suggest that reinfections could cause lasting symptoms. And as the virus continues to circulate, there is a real risk of further mutations, meaning we likely will be living with some form of the virus for the foreseeable future.

VACCINE BOOSTERS The administration of US President Joe Biden is pressing the need for US residents aged 50 years and older and immunocompromised individuals to get their second COVID-19 vaccine booster as soon as possible due to the immune-evasive nature of the Omicron subvariant BA.5, as well as said a decision is expected soon about additional booster doses for all adults. According to US CDC estimates, BA.5 is now responsible for 78% of all new COVID-19 cases. Officials have stressed that booster doses provide additional protection against earlier Omicron subvariants and potentially later subvariants as well. However, current boosters have not yet been updated to more specifically target Omicron and its subvariants, leaving a dilemma for eligible individuals about whether to get a booster now or wait for updated versions. Additionally, some experts wonder and worry whether BA.5 will even be the predominant variant in the fall, potentially making new boosters less effective than expected.

Only 34% of the US population aged 5 years or older has received their first booster dose, COVID-19 pandemic response funding is dwindling, and public appetite for continued vaccinations is diminishing. All of these uncertainties create a perfect storm for risk communication difficulties for experts and officials alike, uncertain of the best course to recommend and how to inform the public about their choices. Some experts hope that next-generation vaccines, such as nasal vaccines—which may have a higher chance of preventing not just severe disease outcomes but also infection—or pan-coronavirus vaccines—which may work better against future variants as well as current variants—may help to boost vaccination rates. Additionally, the CDC is expected to make an announcement about its recommendations for the newly authorized Novavax vaccine later today. Some hope the protein-based vaccine also will help boost vaccination rates among unvaccinated individuals.

In related news, the British government on July 15 announced that individuals aged 50 or older, certain individuals in high-risk professions, and individuals over age 5 who are more likely to be at risk of severe disease outcomes will be eligible for a second booster dose in the fall. The announcement broadens eligibility beyond those who are aged 65 years and older.

YOUNG CHILD VACCINATIONS US medical experts and public health officials are expressing concern over low demand for COVID-19 vaccinations for the youngest children under age 5 and those ages 5-11. States were charged with ordering doses commensurate to expected demand, but some states’ orders only cover a small fraction of their child residents. For example, Mississippi has ordered enough vaccine doses to cover only 16% of its under-5 population with 1 dose. Florida did not preorder any doses for its under-5 population. Many parents there are struggling to find medical practitioners and health systems, which were able to independently order doses, that can provide the shots. The impacts are highest among families in underserved areas and those who rely on government-run health services. However, other experts caution that some states’ initial orders may not reflect future demands and childhood COVID-19 vaccination coverage. They say several factors may change over time, such as available vaccine storage, rampant misinformation, limited initial appointment slots, pushback from parents, reimbursement and logistical challenges, and some practitioners preferring to wait for full FDA approval prior to delivering vaccinations to younger populations.

Relatedly, Europe also may soon be administering vaccines to young children, as the European Medicines Agency (EMA) on July 18 began reviewing Pfizer-BioNTech’s vaccine for use in children aged 6 months to 4 years. Notably, increasing vaccination rates among young children at this point in the global response is paramount and could provide high impact. A recent study in JAMA Network Open found that antibody levels in previously infected individuals waned quickly over the first 200 days post-infection, with levels dropping most quickly in children under age 6.

WESTERN PACIFIC REGION A new wave of COVID-19 cases has hit the Western Pacific region, largely driven by the BA.4 and BA.5 Omicron subvariants. In Japan, cases are rising in every prefecture. The 7-day rolling average of new daily cases has surpassed February’s Omicron peak, and transmission does not seem to be slowing. The situation was further complicated by a 3-day weekend that saw high levels of activity at beaches and other tourist hotspots. The Japanese government is now trying to balance keeping the nation running with few restrictions while preventing hospitals from becoming overwhelmed. Cases also are rising in South Korea, where experts are predicting 200,000 daily cases by late-August, which would amount to half of the nation’s previous Omicron wave in March.

Hospitals in several Australian states are reaching capacity under the nation’s latest surge. Experts warn that while many emergency rooms are overwhelmed, most areas of the nation remain weeks away from their expected peak hospitalization rates. The situation is further complicated by a worse than average influenza season. According to data from the New York Times, New Zealand—a nation famous for early successes against COVID-19—now has the third highest daily confirmed rate of cases per 100,000 people of all nations, after Brunei and San Marino. Experts are concerned that the strain of new cases could lead to a collapse of the nation’s healthcare workforce. As a result, New Zealand officials are urging a renewed sense of urgency around COVID-19 precautions, including masking and testing.

In China, approximately 264 million people across 41 cities are under full or partial lockdown as part of the nation’s zero-COVID policy. Health experts are worried that the zero-COVID policy could become difficult to maintain given the increased transmissibility of the Omicron BA.4 and BA.5 subvariants. Some larger Chinese cities are rolling out new measures, such as mass testing and intense lockdowns, to try to curb the spread of the virus. There are growing concerns that increased COVID-19 prevention measures could further destabilize a struggling global economy.

ECONOMIC IMPACTS Fears of a global economic recession are on the rise. The global economic web was unsettled earlier this year when Russia invaded Ukraine, lowering the availability of energy, fertilizer, and food supplies. However, the largest disruptor of economic growth is the ongoing COVID-19 pandemic. The early phases of the pandemic disrupted the production of goods and the availability of services when governments implemented lockdowns to prevent transmission of the SARS-CoV-2 virus. However, the lockdowns prompted those stuck at home to begin ordering enormous volumes of goods over the internet. The combination of laborers stuck at home plus sky-high demand resulted in a global supply chain crisis. The supply chain crisis pushed prices for goods and services higher, and some industries have taken advantage of the global instability and their market dominance to secure record-breaking profits. Additional factors impacting inflation in the United States include an aggressive stimulus initiative and hesitancy by the Federal Reserve to increase interest rates.

The COVID-19 pandemic also is responsible for economic downturns in other nations with a large impact on the global market, including China. China has adopted an aggressive and highly controversial zero-COVID policy that has led to forced lockdowns in many of the country's large cities. The lockdowns have prevented normal industrial operations that supply a large portion of the world’s manufactured goods. The disruption in production and shipping of goods has significantly slowed growth for the Chinese economy, which shrank by 2.6% during the latest quarter. This slowdown, which denotes a growth of only 0.4% from the end of June last year, represents the lowest growth rate since early 2020, when the nation completely shut down to fight the pandemic. The latest economic reports have cast doubt on whether China can reach its 5.5% growth target for the year set by the ruling Communist party.

However, a couple of recent studies hint that aggressive COVID-19 responses might limit economic damage in the long-term. One study, an assessment of business closure policies in New York City published by the International Monetary Fund, set out to determine the impact of closures in specific industries on the spread of COVID-19. According to the results, reopening businesses early allowed New York City to recover functionality as an economic hub but at the cost of a large wave of infections in 2020. The study also found that an alternative policy that extended lockdowns made future travel safer and was ultimately more cost-effective. Another study, examining the impact of long COVID on the workforce of the UK, estimated that 80,000 people have left the UK workforce due to long COVID as of March 2022. According to the authors, continued pandemic waves will lead to more people missing work, losing jobs, or permanently leaving the workforce due to long COVID. While many experts agree that a zero-COVID policy is unrealistic, it is becoming rapidly apparent that pretending like the pandemic is over may also lead to long-term and impactful health and economic consequences.

GLOBAL VACCINE ACCESS Last month, the 12th World Trade Organization (WTO) Ministerial Conference agreed to a version of a proposal for a global intellectual property waiver to allow countries to more easily use patented technologies to develop COVID-19 vaccines. Originally proposed only a few months into the pandemic by India and South Africa, and endorsed by more than 100 other nations, the approved deal on a Trade-Related Aspects of Intellectual Property (TRIPS) waiver is much narrower in scope than the original proposal and likely comes too late to make a significant impact on vaccine access. The deal does not include intellectual property waivers for diagnostics, treatments, or other COVID-19-related medical tools, and it excludes countries with “existing” production capacity. The power imbalances in both the COVID-19 pandemic and the WTO negotiations are apparent, from vaccine nationalism to sluggish negotiations. But over the past 2 years, low- and middle-income countries (LMICs) from South America to Africa have worked to solidify plans to cooperate on mRNA technologies in order to develop and produce their own versions of vaccines for SARS-CoV-2 and other diseases. This effort to collaboratively develop an mRNA vaccine technology transfer hub, which is supported by the WHO and the US NIH, must overcome significant challenges but provides hope for a new model to enable more LMICs to overcome future disease outbreaks more effectively, without having to rely on high-income countries or corporations.

MENSTRUAL CYCLES When COVID-19 vaccines became widely available in 2021, recipients were made aware of the potential for adverse events—including fever, fatigue, headache, and pain at the injection site—because the side effects were documented in clinical trials. But those clinical trials did not track effects on the menstrual cycle. After hearing hundreds of anecdotes from people who experienced temporary irregularities in menstruation after receiving a vaccination, such as heavier bleeding or breakthrough or unexpected bleeding, researchers from the University of Illinois at Urbana-Champaign and Washington University School of Medicine in St. Louis surveyed more than 39,000 menstruating or previously menstruating people ages 18 to 80 years old who were fully vaccinated and had no history of COVID-19.

The survey results, published July 15 in Science Advances, show that 42% of people with regular menstrual cycles bled more heavily than usual after receiving a vaccine dose, 44% reported no change, and about 14% reported lighter bleeding. Among people who were not menstruating at the time of vaccination, including those who are post-menopause or who use long-term contraceptives or hormones, many experienced breakthrough bleeding. The authors note the study has several limitations, such as not having a control group, but they say more attention to people’s experiences can help to gain a better understanding of the issue, provide evidence for further research, and build trust in medicine by offering vaccine recipients warning that they may experience menstrual irregularities.

CRUISE SHIPS The US CDC announced on July 18 that its COVID-19 Program for Cruise Ships is no longer in effect. Although the agency will continue to publish guidance to help cruise ships provide safer and healthier environments for crews and passengers, the color-coded chart and spreadsheet that detailed the level of spread on ships is no longer available. According to a statement in the webpage’s FAQ section, the CDC is ending the program because it depended on each cruise line having the same testing and screening guidelines, which now all differ among companies. However, cruise ships will continue to report COVID-19 cases to the CDC, and passengers have the option of directly contacting their cruise line for information on outbreaks aboard their ship.