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PUBLISHING NOTICE The COVID-19 Situation Report will be taking a break next week and will not be published on May 11. We will resume publishing on May 18.
In this issue

> Surveillance efforts decline as US prepares to wind down public health emergency; WHO panel meets to discuss whether to continue PHEIC

> Experts begin to assess pandemic responses, glean lessons learned to prepare for next pandemic

> Journal articles review progress made, lessons learned on COVID-19 treatment; studies into new treatments, repurposed drugs continue

> Vaccine effectiveness studies support use of bivalent formulations, show monovalent vaccines highly effective against severe disease, death but effectiveness waned quickly against Omicron

> Decreasing US racial disparities in COVID-19 deaths possibly due to more deaths among Whites, study shows

> What we're reading

> Epi update
Surveillance efforts decline as US prepares to wind down public health emergency; WHO panel meets to discuss whether to continue PHEIC

As the COVID-19 pandemic enters its fourth year, surveillance of the disease has declined dramatically, both in the US and internationally. The US public health emergency is set to expire on May 11—bringing an end to most federal COVID-19 vaccine requirements—and the US CDC plans to stop reporting its color-coded COVID-19 Community Levels, switching to tracking hospitalizations in some areas. Hospitalizations, however, are a lagging indicator, as it takes about a week to 10 days for a person to be hospitalized with a serious infection. Additionally, most states have stopped public reporting of COVID-19 cases and related deaths, or stopped surveillance efforts altogether, leaving little information to enable scientists to determine how the virus is trending. While most feel the nation, and the world, has moved beyond the days of massive case surges and overwhelmed hospitals, the new normal remains unknown but likely will entail a series of smaller “wavelets.” The virus’s evolution remains unpredictable, however, and without better surveillance, experts are unable to say whether this period of the lowest levels of reported cases and deaths since the beginning of the pandemic is the beginning of a post-pandemic stability or a temporary reprieve

A panel of global health experts is meeting today to discuss whether COVID-19 still constitutes a public health emergency of international concern (PHEIC). Although there is no consensus on what course the panel may recommend, and whether WHO Director-General Dr. Tedros Adhanom Ghebreyesus follows that advice, several experts feel it is time to wind down the emergency declaration. Regardless of its decision, COVID-19 will remain a complex public health challenge into the future, requiring countries to transition their emergency response activities to longer-term sustained disease prevention, control, and management.
Experts begin to assess pandemic responses, glean lessons learned to prepare for next pandemic

As the COVID-19 public health emergency comes to an end in the US, health officials are working to assess the nation’s response to the COVID-19 pandemic and ensure we are prepared for future health emergencies. In one such effort, 34 experts who were gearing up for the establishment of a 9/11-style commission instead formed the COVID Crisis Group, led by Dr. Philip Zelikow. When the call to establish a National COVID Commission never came, the group pivoted to develop a nonpartisan, dispassionate review of the pandemic response, which was often marred by politicization and infighting. In a report titled, Lessons from the COVID War: An Investigative Reportpublished by PublicAffairs as a book—the authors outline what went right and wrong with the pandemic response, including why people made certain choices, the availability of information necessary for decision makers to make choices, and the tools that were available and those that necessitated development. 

The report includes information from interviews with nearly 300 people and often compares the pandemic response to a military conflict, saying the efforts in the US unraveled like fighting a war with no army or battle plan. According to the report, a lack of human coordination due to a fragmented US public health system, rather than scientific limitations, was one of the major points of failure in the response. Another major lesson centers around communication, with the report highlighting overall emergency communications as a point of failure, during both the Trump and Biden administrations. Poor communication likely exacerbated a loss of trust in US public health institutions, according to the authors. Notably, however, efforts that reached out to local community leaders were often more successful, and future responses will need practical toolkits to aid decision makers in implementing effective communications and mitigation efforts. 

The European Centre for Disease Prevention and Control (ECDC) this week published its own assessment of its pandemic response. The report, titled Lessons from the COVID-19 Pandemic, contains 4 main lesson areas: investment in the public health workforce, preparation for the next public health crisis, risk communication and community engagement, and collection and analysis of data and evidence. The collection of pandemic response lessons and recommendations is a crucial task, but political buy-in is needed to implement many of the changes recommended by these assessments that are necessary for preventing and responding to the next pandemic.
Journal articles review progress made, lessons learned on COVID-19 treatment; studies into new treatments, repurposed drugs continue

The journals Nature Reviews Drug Discovery and The BMJ recently published articles examining therapeutic strategies for COVID-19, including progress made, lessons learned, and global standard of care development. Authorized or approved therapies that reduce mortality, length of hospital stay, or time on a ventilator for patients with severe disease include systemic corticosteroids (such as dexamethasone), interleukin-6 receptor antagonists (such as tocilizumab), and Janus kinase inhibitors (such as baricitinib). Additionally, marketed antivirals, including molnupiravir (Lagevrio), nirmatrelvir/ritonavir (Paxlovid), and remdesivir (Veklury), are effective against non-severe COVID-19, particularly when given within 10 days of symptom onset. More than 400 randomized clinical trials have been conducted worldwide on treatments for COVID-19, and research into new therapies continues. 

  • A study published in the Annals of Internal Medicine evaluated the use of 2 repurposed drugs, the oral selective serotonin reuptake inhibitor (SSRI) fluvoxamine plus the inhaled corticosteroid budesonide, among nonhospitalized adults with early symptomatic COVID-19 and at least one risk factor for severe disease in Brazil. Though a lower proportion of patients in the treatment group than in the placebo group were seen in an emergency setting for COVID-19 for more than 6 hours or were hospitalized within 28 days, no differences were noted in secondary outcomes.  

  • Another study published in the Annals of Internal Medicine assessed the safety and efficacy of the monoclonal antibodies amubarvimab plus romlusevimab among patients at high risk for poor outcomes in the US, Brazil, South Africa, Mexico, Argentina, and the Philippines during the first half of 2021. Cumulative incidence of hospitalization or death was significantly lower in the treatment group than in the placebo group, regardless of treatment timing. A subgroup analysis of patients with variant data showed the combination was equally effective against Delta and pre-Delta strains, but the researchers speculated the therapy likely would have limited efficacy against the currently predominant Omicron variant. 
Vaccine effectiveness studies support use of bivalent formulations, show monovalent vaccines highly effective against severe disease, death but effectiveness waned quickly against Omicron

Advisors to the US FDA are scheduled to meet on June 15 to discuss and make recommendations on future vaccinations against COVID-19 for the general public, now that a second round of bivalent boosters is available for older adults and other people at high risk of severe disease. The FDA will make decisions after the panel meets, but officials previously indicated a desire to recommend annual shots that are possibly updated to match currently circulating variants, similar to flu vaccines. In a study published in Open Forum Infectious Diseases, researchers report that the effectiveness of both Omicron BA.1-containing and BA.4/BA.5-containing bivalent COVID-19 mRNA vaccines against symptomatic infection during the BA.5-dominant period in Japan was high compared to no vaccination (65% and 76%, respectively) and moderate compared to monovalent vaccines administered over half a year earlier (46% combined). Notably, however, the bivalent vaccines were not as effective against Omicron subvariants as the original, monovalent vaccines were against the ancestral strain (Alpha) and Delta variants. 

Though the monovalent mRNA vaccines are no longer authorized for use in the US, having been replaced by the bivalent versions, several recent studies show they provided substantial, durable protection against severe COVID-19 disease and death. A study published last week in Morbidity and Mortality Weekly Report found monovalent mRNA vaccination was 76% effective in preventing COVID-19-associated invasive mechanical ventilation (IMV) and death less than 6 months after the last dose and remained 56% effective at 1–2 years. Vaccine effectiveness was higher among older adults, supporting optional, additional bivalent boosters for individuals at highest risk of severe disease. A meta-analysis published in JAMA Network Open shows that vaccine effectiveness of the monovalent vaccines waned quickly and significantly against laboratory-confirmed Omicron infection and symptomatic disease, although the type of vaccine played some role. These studies support the use of updated, bivalent mRNA vaccines and boosters moving forward, and provide some evidence for reformulating the vaccines to match future dominant variants.
Decreasing US racial disparities in COVID-19 deaths possibly due to more deaths among Whites, study shows

A study published this week in JAMA Network Open examines the factors driving changes in mortality rate disparities among racial and ethnic groups over the course of the COVID-19 pandemic. Mortality rates for Hispanic and non-Hispanic Black US residents were much higher than mortality rates for non-Hispanic White residents during the initial wave of the pandemic in 2020. However, those mortality rate disparities decreased in 2021. According to the study, 60.3% of the decrease in mortality disparities are attributable to higher mortality among non-Hispanic White adults and a shift in higher mortality rates to nonmetropolitan areas, where more non-Hispanic White adults reside. The findings highlight a continued need to prioritize racial health equity despite recent reports of decreased mortality disparities, according to the authors, who also make several policy recommendations that could address health equity, including: paid medical leave for essential workers, extended unemployment benefits, and further moratoriums on eviction and foreclosure. 

The Kaiser Family Foundation recently released a brief examining the impact of the COVID-19 pandemic by race and ethnicity through the lens of premature mortality, using the measures of premature mortality rate and years of life lost among excess deaths that occurred during the pandemic. The analysis shows that for all groups of color, the pandemic was associated with a steeper increase in the premature death rate than for White people. Notably, the increase in the premature death rate for Hispanic people (33%) was more than twice that of White people (14%) from 2019 to 2022.
What we’re reading

HEALTH SYSTEM RECOVERY According to a new interim report from the WHO, health systems in many countries are beginning to show the first major signs of recovery after 3 years of the COVID-19 pandemic. By early 2023, most countries reported experiencing reduced disruptions in the delivery of routine health services but highlighted the need to apply lessons learned to build more prepared and resilient health systems for the future, according to the report. Despite signs of recovery, service disruptions persist across countries in all regions and income levels, and additional support is needed for recovery, resilience, and preparedness.

US CDC CONFERENCE OUTBREAK The US CDC is investigating several dozen COVID-19 cases linked to its own annual conference held near the agency’s headquarters in Atlanta, Georgia, last week. About 35 people have tested positive as of May 2, according to a CDC spokesperson. The 3-day 2023 Epidemic Intelligence Service conference was the first time in 4 years that EIS officers and alumni gathered in-person. Around 2,000 people attended the conference, and while attendees said many people at the conference did not wear masks or socially distance, most were likely fully vaccinated. The CDC is working with state health officials to determine transmission patterns. The outbreak serves as a reminder that while COVID-19 may not pose the serious risks it did at the beginning of the pandemic, the virus continues to circulate, maybe especially easily at large indoor gatherings.

IVERMECTIN The Wisconsin Supreme Court this week ruled that a hospital cannot be forced to administer ivermectin to a COVID-19 patient. The 6-1 ruling overturned a lower court's order that required Aurora Health Care to treat John Zingsheim, who was placed on a ventilator due to COVID-19 complications, with the anti-parasitic medication. Zingsheim's nephew, Allen Gahl, who was authorized to make medical decisions for Zingsheim, requested his uncle be treated with the drug, but Aurora determined that ivermectin did not meet the standard of care for treating Zingsheim's symptoms. Gahl then sued after doctors refused to administer a prescription for ivermectin that he received from a doctor outside Aurora. The court found that the lower court had no legal basis for its order, citing no law in either its written or oral ruling. The FDA has not approved ivermectin for the treatment of COVID-19, and its misuse can be harmful, even fatal. The lawsuit is one of dozens filed across the US seeking to force hospitals to administer ivermectin to treat COVID-19.

BRAZIL INVESTIGATION Brazil's federal police on May 3 raided the home of former President Jair Bolsonaro as part of an investigation into the alleged falsification of COVID-19 vaccine cards. Authorities seized his phone, searched more than a dozen homes in Rio de Janeiro and Brasília, and arrested 6 people, including some of Bolsonaro’s closest aides. In a statement, the police said the investigation is focused on whether officials in Bolsonaro's inner circle created false vaccination certificates so that unvaccinated travelers, including Bolsonaro, his family members, and assistants' relatives, could circumvent mandatory immunization requirements to enter the US. Bolsonaro confirmed to reporters that he is not vaccinated against COVID-19 but denied playing a role in any fraud.
Epi update
As of May 3, the WHO COVID-19 Dashboard reports: 
  • 765.2 million cumulative COVID-19 cases 
  • 6.9 million deaths
  • 630,979 million cases reported week of April 24 
  • 15% decrease in global weekly incidence
  • 3,568 deaths reported week of April 24 
  • 18% decrease in global weekly mortality 

Over the previous week, incidence declined or remained relatively stable in all regions except Africa (+17%). 

The US CDC is reporting: 
  • 104.5 million cumulative cases
  • 1.13 million deaths
  • 88,330 cases week of April 26 (down from previous week)
  • 1,052 deaths week of April 26 (down from previous week)
  • 13.7% weekly decrease in new hospital admissions 
  • 15.2% weekly decrease in current hospitalizations 

The Omicron sublineages XBB.1.5 (69%), XBB.1.16 (12%), XBB.1.9.1 (69%), XBB.1.9.2 (4%), XBB (2.4%), XBB.1.5.1 (2.2%), and FD.2 (1.3%) currently account for a majority of all new sequenced specimens, with various other Omicron subvariants accounting for the remainder of cases.
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