COVID-19 Situation Report
Weekly updates on COVID-19 epidemiology, science, policy, and other news you can use.

PUBLISHING NOTICE The COVID-19 Situation Report will be taking a break next week and will not publish on April 27. We will resume publishing on May 4.
In this issue

> COVID-19 pandemic still volatile, WHO says; disease remains a leading cause of death in US

> US health agencies authorize additional bivalent vaccine booster for certain populations, simplify recommendations; Biden administration launching effort to maintain equitable access to COVID-19 vaccinations

> US Congress continues investigations into COVID-19 pandemic origin with Republican-led Senate report, House hearing

> Experts debate universal masking recommendations for healthcare settings; about half of healthcare workers go to work sick with COVID-19, study shows

> People with long COVID, advocates frustrated with lack of attention to, actionable research on condition

> Wastewater surveillance gains traction as advantageous disease monitoring system in US, South Korea, globally

> What we're reading

> Epi update
COVID-19 pandemic still volatile, WHO says; disease remains a leading cause of death in US

The WHO this week said the COVID-19 pandemic remains volatile, warning that the virus could bring further trouble before settling into a predictable pattern. The agency noted that in the past 28 days, 23,000 people have died of COVID-19 and 3 million new cases have been reported, even with much lower levels of testing. In the US, COVID-19 remains a leading cause of death, with an average of about 245 deaths per day over the past 4 weeks, primarily among older adults or those who are immunocompromised. The WHO Emergency Committee on COVID-19 is set to meet in the beginning of May to once again reconsider whether the pandemic constitutes a public health emergency of international concern (PHEIC), which it has reaffirmed at its previous meetings since first making the declaration in January 2020.

Additionally, SARS-CoV-2 continues to mutate, with the Omicron subvariant XBB.1.16—first detected in India earlier this year—now accounting for more than 7% of US cases. Another Omicron subvariant, XBC.1.6, a combination of the Delta and Omicron variants of concern first detected in Southern Australia where it caused a wave of cases and hospitalizations, could provide competition to XBB.1.16. Even if many feel the pandemic is over, the virus remains a threat, particularly to vulnerable populations. 
US health agencies authorize additional bivalent vaccine booster for certain populations, simplify recommendations; Biden administration launching effort to maintain equitable access to COVID-19 vaccinations

Following US FDA regulatory action earlier this week, the US CDC on April 19 took steps to simplify COVID-19 vaccine recommendations and allow more flexibility for individuals at higher risk of severe disease who would like an additional vaccine dose. Adults aged 65 years and older and people who are immunocompromised may now receive a second dose of updated bivalent mRNA booster targeting both the original viral strain and Omicron BA.4 and BA.5 subvariants at least 4 months or 2 months after their last dose, respectively. Additionally, people who are immunocompromised will now be able to receive more doses if their healthcare provider feels the shots are necessary. About 250 people die each day of COVID-19-related causes in the US, the majority of whom are age 70 or older or have weakened immune systems.

Most US residents who have had one dose of the bivalent vaccine are not currently eligible for an additional jab, although authorization for another shot is expected for the autumn. However, the CDC recommends everyone aged 6 and older receive a bivalent vaccine, regardless of whether they have previously completed their primary series with the original monovalent vaccine. In fact, the monovalent mRNA vaccines are no longer authorized for use in the US. People who are unvaccinated will now require only a single dose of bivalent mRNA vaccine to be considered vaccinated. The guidelines for children remain complicated, with recommendations varying by age, vaccine, and which shots they previously received. The CDC is expected to post a detailed chart with recommendations for children under age 6.

In related news, the Biden administration plans to spend more than US$1 billion on a new public-private partnership to maintain broad access to COVID-19 vaccines, treatments, and tests for millions of uninsured Americans when the medical countermeasures move to the commercial market later this year. The US Department of Health and Human Services (HHS) Bridge Access Program For COVID-19 Vaccines and Treatments Program would allow officials to purchase COVID-19 vaccines for uninsured individuals after the current federal supply is exhausted and when vaccine manufacturers plan to charge as much as $130 per dose. People with private insurance or who are covered under Medicare or Medicaid will also not be expected to pay out-of-pocket expenses for vaccines once the public health emergency ends in May.

Additionally, HHS officials told state governors last week that it will maintain its authority allowing pharmacists, pharmacy technicians, and pharmacy interns to administer COVID-19 and flu vaccines after the COVID-19 public health emergency declaration ends. The extension, set to last through December 2024, is based on the Public Readiness and Emergency Preparedness (PREP) Act, which offers extra protections to companies and providers making, distributing, and administering medicines and vaccines in times of emergency. The White House “Test to Treat” initiative, which allows pharmacists to test people for COVID-19 and prescribe the antiviral Paxlovid, will also continue.
US Congress continues investigations into COVID-19 pandemic origin with Republican-led Senate report, House hearing

Republicans in both houses of the US Congress continued their efforts to investigate the origin of SARS-CoV-2. The investigations, shaped by tensions between scientific knowledge and political discourse, have broad political implications and some say are detracting from the need to take steps to prevent another disease emergency. On April 18, the US House Select Subcommittee on the Coronavirus Pandemic held a second hearing on the origins of COVID-19, with testimony from former intelligence officials discussing the intelligence community’s understanding of COVID-19 origins and the Chinese government’s lack of transparency in providing data and evidence. The hearing raised the ire of the Chinese Embassy, after Li Xiang, the embassy’s liaison to Congress, emailed a staff member of the subcommittee’s chair, Rep. Brad Wenstrup, on April 14 asking “the US side to respect science and facts,” “refrain from targeting China,” “put a stop to the intelligence-led, politics-driven origins-tracing,” and “help promote international solidarity against the pandemic.”

Earlier this week, US Senate Republicans who hold minority leadership on the health subcommittee released a 300-page report that concludes the pandemic most likely began from at least one unintentional lab-related incident—possibly resulting from failures of biosafety containment during vaccine-related research—rather than naturally, via an animal infecting a human; however, the document concedes both theories are plausible but lack key supporting evidence. The report is the result of former Sen. Richard Burr's investigation into the pandemic’s origin, began when he served as the minority leader of the Health, Education, Labor and Pensions Committee, although staffers noted Sen. Burr did not review the full report nor did it go through the vetting process that was afforded an executive summary publicly released last year. 

Speaking at a London summit on pandemic preparedness last week, former China CDC Director Dr. George Gao said there is no evidence yet to show an animal host or reservoir for SARS-CoV-2. The WHO has repeatedly called on China to immediately share all available data on the virus, with Chinese officials and scientists rejecting the agency’s accusations that they are hiding information. The WHO says all origin hypotheses remain plausible, while many international scientists say evidence points to a natural origin for the pandemic.
Experts debate universal masking recommendations for healthcare settings; about half of healthcare workers go to work sick with COVID-19, study shows

Most COVID-19-related mask mandates have ended—including those for the subway system in Beijing, China—but debate over whether to mask in healthcare settings is ongoing. While most US states have phased out mask mandates for healthcare settings, many healthcare facilities maintain mask requirements for all staff and patients, but they are increasingly dropping those rules. In a recent commentary published in the Annals of Internal Medicine, a group of infectious disease experts and epidemiologists notes that while “universal masking” was critically important during the pandemic—particularly when there was no population immunity, limited testing capacity, and no medical countermeasures (eg, vaccines, therapeutics)—they argue against masking becoming a required component of Standard Precautions, as COVID-19 transitions from a pandemic to an “endemic phase.” The authors conclude that mandatory masking remains an important infection prevention and control (IPC) strategy that could be employed in the future as “part of a dynamic approach to infection prevention policy that adapts to changing circumstances.” 

However, some healthcare workers and other infectious disease epidemiologists have voiced opposition to dropping universal masking, noting that other disease transmission precautions are not scrapped simply because a disease is endemic. In a commentary published in February in the journal Infection Control & Hospital Epidemiology, a separate group of infectious disease experts propose an update to Standard Precautions in healthcare settings, including permanently implementing universal masking in routine patient-care interactions. They say masking prioritizes safety for patients, healthcare providers, and visitors. Other experts fall somewhere in the middle, saying masks remain important in all patient-facing interactions or recommending them to patients who have underlying conditions that put them at higher risk of severe COVID-19.

Notably, a study published last week in the journal Infection Control & Hospital Epidemiology showed that about half of healthcare workers (HCWs) with COVID-19 worked for at least some time during a day when diagnosed but returned to work for additional days with symptoms. The study found that presenteeism rates did not vary for HCWs working directly with patients, suggesting that the potential for disease transmission to patients did not influence HCWs’ choices about whether to go to work. The researchers note that new strategies are needed to help HCWs with COVID-19 reconcile their duties to do no harm and to provide or support care. Additionally, a study presented this week at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in Copenhagen, Denmark, suggests requirements to wear surgical masks in a large London hospital during the first 10 months of Omicron activity (December 2021 to September 2022) made no discernible difference to reducing hospital-acquired SARS-CoV-2 infections. Another study published today in Scientific Reports uses a COVID-19 model showing that a combination of mask wearing and vaccination may be more effective and reasonable in preventing and controlling SARS-CoV-2 infection and suggests infection control departments strongly recommend the use of both strategies to protect unvaccinated individuals from becoming infected.
People with long COVID, advocates frustrated with lack of attention to, actionable research on condition

Americans suffering from post-COVID condition, commonly known as long COVID, are beginning to get frustrated—and for good reason. There is still no clear medical definition, diagnostic framework, or treatment for the condition. The US NIH has received more than US$1 billion to study the condition but it has yet to recruit patients to test potential therapeutics and has released minimal findings from observational studies conducted over the last 2 years, all with allegedly insufficient accountability or oversight. Patients are frustrated that the observational studies conducted so far seem redundant to already completed research and that there are no ongoing efforts to support private sector companies or researchers trying to study long COVID through the NIH. Additionally, one treatment option under consideration—exercise—has the real potential to worsen patients’ condition, causing advocates to raise alarm. Still, other researchers are currently exploring more promising candidates for the treatment or prevention of long COVID, such as metformin, Paxlovid, and low-dose naltrexone. In the meantime, patients continue to feel dismissed by peers, healthcare providers, and institutions, as their lives are disrupted by the condition, sometimes leading to unemployment and homelessness.
Wastewater surveillance gains traction as advantageous disease monitoring system in US, South Korea, globally

The COVID-19 pandemic has provided ample case studies on the value of conducting wastewater surveillance for infectious diseases. The process has certain advantages over hospital-based surveillance in that it can detect viral markers from people with mild cases who did not seek out healthcare or who may have been asymptomatic. Wastewater surveillance has also been instrumental in detecting new viral variants, even as fewer and fewer daily PCR tests are being performed that could provide sequencing material. The US National Wastewater Surveillance System currently has more than 1,000 sites across the country that feed into their data analysis to track SARS-CoV-2 incidence and new variant profiles. 

In South Korea, the Korea Disease Control and Prevention Agency (KDCA) is looking to pursue this strategy by implementing a wastewater surveillance system in most major cities and towns. In their current system, hospitals must report all positive tests, which the KDCA director described as an expensive and laborious process. The switch to wastewater surveillance is anticipated to be more cost effective and will provide a broader perspective of the country’s COVID-19 situation. There are also proposals to create a global wastewater surveillance system using airport wastewater. While this endeavor would be useful for disease monitoring, possible disincentives to participation include fear of the imposition of travel restrictions should a disease be detected.
What we’re reading

INFLUENZA PANDEMIC PREPAREDNESS Countries and international bodies must immediately revise existing pandemic influenza preparedness and response plans to incorporate lessons learned from and the impacts of COVID-19, experts from the Johns Hopkins Center for Health Security and colleagues write in Nature Medicine. The authors note these steps are “particularly urgent given both the emergence of a number of influenza spillover threats and exhausted and depleted public health systems globally.” They make recommendations about how revisions could be achieved, concluding, “The world is in a precarious public health position that warrants weighing potential pandemic risks more seriously. The next pandemic may not be influenza, but the risk calculus for such a pandemic must be prepared now.”

VACCINE MANDATE RULING A panel of the San Francisco-based 9th US Circuit Court of Appeals ruled on April 19 that President Joe Biden had the authority under the federal Procurement Act—which enables the president to adopt rules that promote economy and efficiency in federal contracting—to mandate COVID-19 vaccination for millions of federal contractor employees in 2021. The decision reverses a previous ruling by an Arizona court that blocked the mandate last year and creates a split with 3 other appeals courts that have said President Biden likely exceeded his authority. In October 2022, the White House told agencies not to enforce the contractor mandate in light of ongoing and pending legal challenges.

US PRISON POPULATION The United States is known for having the highest incarceration rate on the planet, with significant bias by class and race. COVID-19 reduced the country’s prison population by 17%, but a new study in Nature shows that racial disparities worsened with this decrease, as the proportion of incarcerated Black and Latino people sharply increased. The authors cited changes in typical distribution of those admitted into prisons, disruptions in court proceedings, disruptions in transfers from county jails, as well as ongoing racial disparities in sentence length, pre-trial case dismissals, and pre-trial plea deals as contributors to these trends. They also noted potential structural and racial inequalities in decarceration policies. Unfortunately, these trends reverse some of the progress made in the last decade to reduce prison populations and racial disparities within them.

TYPE 2 DIABETES In a study published this week in JAMA Network Open, Canadian researchers found that people who have had COVID-19 were significantly more likely to be diagnosed with Type 2 diabetes within a year of their infection, compared with those who had not been exposed to SARS-CoV-2. Notably, men were more likely than women to develop diabetes, and people who were hospitalized or in intensive care with COVID-19 were 2 and 3 times as likely to develop the condition, respectively, when compared with individuals who were not infected. The researchers concluded that 3–5% of new diabetes diagnoses could be related to COVID-19. At least 11 other studies have shown an increased risk of developing diabetes after SARS-CoV-2 infection, with one meta-analysis showing a 66% increased risk of diabetes following COVID-19. Some evidence exists suggesting that vaccination might have a protective effect but also that multiple reinfections could raise the risk of Type 2 diabetes. Healthcare organizations and medical professionals should be mindful of the potential long-term outcomes of COVID-19, including monitoring patients for diabetes

CHILDHOOD VACCINATIONS The COVID-19 pandemic, conflict, and a loss of confidence in vaccines due to misleading information led to 67 million children missing out on at least one routine vaccination between 2019 and 2021, according to UNICEF’s State of the World’s Children 2023 report. A trend of declining confidence in childhood vaccines of up to 44 percentage points in several countries is a “worrying warning signal” of rising vaccine hesitancy, decreasing trust in governments, and increasing politicization, UNICEF Executive Director Catherine Russell said. The report stressed that vaccine confidence can shift and the findings may not indicate a long-term trend.

GLOBAL VACCINATION KNOWLEDGE The Global Compendium of Country Knowledge on COVID-19 Vaccination is now available online from TechNet-21, the WHO announced. The Compendium, which stores more than 140 documents, provides country experiences, case studies, and country evaluations on COVID-19 vaccination and is a resource for national authorities managing or making key decisions on the deployment, implementation, and monitoring of COVID-19 vaccinations, as well as for partners who can provide technical support based on the best practices.
Epi update
As of April 19, the WHO COVID-19 Dashboard reports: 
  • 763.7 million cumulative COVID-19 cases 
  • 6.9 million deaths
  • 536,422 million cases reported week of April 10 
  • 24% decrease in global weekly incidence
  • 2,289 deaths reported week of April 10 
  • 48% decrease in global weekly mortality 

Over the previous week, incidence declined or remained relatively stable in the Africa (+4%), Europe (-11%), Eastern Mediterranean (-26%), Western Pacific (-30%), and Americas (-55%) regions but increased in South-East Asia (+79%). 

The US CDC is reporting*: 
  • 104.3 million cumulative cases
  • 1.13 million deaths
  • 101,437 cases week of April 12 (down from previous week)
  • 1,327 deaths week of April 12 (down from previous week)
  • 6.1% weekly decrease in new hospital admissions 
  • 11.4% weekly decrease in current hospitalizations 

The Omicron sublineages XBB.1.5 (78%), XBB.1.16 (7.2%), XBB.1.9.1 (6.5%), XBB.1.9.2 (2.5%), XBB.1.5.1 (2.4%), and FD.2 (1.7%) currently account for a majority of all new sequenced specimens, with various other Omicron subvariants accounting for the remainder of cases. 
*According to the CDC, as of April 1, 2023, the state of Iowa no longer reports aggregate COVID-19 case data to CDC. As a result, case counts from Iowa will no longer be reported at the national, regional, state, or county-levels on COVID Data Tracker or
Editor: Alyson Browett, MPH

Contributors: Erin Fink, MS; Clint Haines, MS; Amanda Kobokovich, MPH; Aishwarya Nagar, MPH; Christina Potter, MSPH; Matthew Shearer, MPH; and Rachel A. Vahey, MHS