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.