Virus World

Though COVID has held at very low levels late spring and into summer, some early indicators show signs of rising activity, according to the latest data from the Centers for Disease Control and Prevention (CDC). In other developments, the CDC and the Department of Health and Human Services (HHS) fleshed out more details about when the updated COVID-19 vaccine will roll out and how federal health officials will ensure that uninsured and underinsured people can receive their doses.

Upticks in 3 early indicators

The two main metrics that the CDC uses to track COVID-19 activity—hospital admission rates and percentage of deaths from the virus—both declined over the past week. Hospitalizations for COVID dropped 0.8%, and deaths from COVID were down 20% compared to the previous week. When looking at hospitalizations by region, a few counties in central Montana reported high admission levels, as did a few in southern Texas. A few states, including Texas, Kansas, and North Dakota, have a small number of counties at medium admission levels for COVID. Two measures that the CDC tracks as early indictors, however hint at rising activity. Emergency department visits for COVID at the national level were up 10.7% compared to the previous week, with Alaska, Florida, and Hawaii reporting percentages that were higher than other states. Also, test positivity at the national level was up slightly, by 0.7%, rising to 5.5% compared to the previous week. Positivity was 7% or higher in Arizona, Arkansas, Idaho, Louisiana, Oklahoma, Oregon, Texas, and Washington. Epidemiologists are also closely watching wastewater COVID levels as an early indicator. On her Substack "Force of Infection" blog yesterday, Caitlin Rivers, PhD, with the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, said the Biobot COVID-19 wastewater platform shows an increase in the Southern, Northeastern and Western regions. She said mid-summer often marks the beginning of a new COVID-19 wave, which often starts in the South.

Vaccine plans from CDC, HHS

In other COVID developments, HHS, in a letter to COVID vaccine manufacturers yesterday, outlined its expectations for the rollout of updated COVID vaccines as the market transitions to the traditional method of distribution and payment. HHS said it hopes vaccine makers can plan their vaccine supply and regulatory submissions to the Food and Drug Administration (FDA) so that the CDC can make a recommendation by the end of September. Pfizer and BioNTech on June 23 announced that they have submitted their applications to the FDA for their monovalent (single-strain) Omicron XBB.1.5 vaccine, noting that they have manufactured them and are ready to ship them pending regulatory review and approval. Moderna made a similar announcement on June 22 and noted that it is prepared to deliver the updated COVID vaccines in time for the fall vaccination season. In response to the HHS letter, Novavax said yesterday that it is making its protein-based monovalent Omicron XBB.1.5 vaccine to scale with the goal of meeting the September timeline and pending FDA approval and a CDC recommendation. Also yesterday the CDC spelled out more details about its plan to ensure that uninsured and underinsured people have access to COVID vaccine, as the vaccine program transitions from federal to private-market hands in early August.

"Protecting people from COVID-19 remains a top priority for CDC," said CDC Director Mandy Cohen, MD, MPH.  "CDC is partnering with state and local public health agencies, health centers, and pharmacies to ensure that all adults nationwide maintain access to lifesaving COVID-19 vaccines. "Ultimately, we know that vaccines save money and lives. Vaccination is especially important as we head into fall and winter, a time when COVID-19 and other respiratory diseases are likely to circulate." As part of the temporary Bridge Access for COVID-19 vaccines, the CDC said it is working with pharmacy chains to enable uninsured adults to be vaccinated at participating retail pharmacies and with vaccine companies to ensure there is enough vaccine for the program.

The Biden administration is moving to make the shot available for older people and those with impaired immune systems. While federal authorities are poised to authorize a second dose of the omicron-targeting coronavirus booster for vulnerable groups, not all experts believe it is necessary. (Kristopher Radder/Brattleboro Reformer/AP) Federal regulators have decided to authorize a second omicron-specific coronavirus vaccine booster shot for people who are at least 65 or have weak immune systems — an effort to provide additional protection to high-risk individuals, according to several officials familiar with the plan. The Food and Drug Administration is expected to announce the step in the next few weeks, and the Centers for Disease Control and Prevention is expected to move quickly to endorse it, said the officials, who spoke on the condition of anonymity because they were not authorized to publicly discuss internal discussions. Eligible individuals will be able to receive the dose as long as it has been at least four months since their first shot of what’s known as the bivalent booster, which targets omicron subvariants BA.4 and BA.5 as well as the original novel coronavirus. The expectation is that consumers will consult with their health-care providers about whether to get the extra booster, the officials said. The FDA’s policy change will be “permissive” — people may get the shot but will not be told they should get it, the officials said. It’s not clear whether the CDC’s vaccine advisory committee would meet to discuss the change before CDC Director Rochelle Walensky makes a final recommendation.

Nearly 6 million Americans have taken Paxlovid for free, courtesy of the federal government. But the government plans to stop footing the bill within months, and millions of people who are at the highest risk of severe illness and are least able to afford the drug may have to pay the full price. And that means fewer people will get the potentially lifesaving treatments, experts said. “I think the numbers will go way down,” said Jill Rosenthal, director of public health policy at the Center for American Progress, a left-leaning think tank. A bill for several hundred dollars or more would lead many people to decide the medication isn’t worth the price, she said. In response to the unprecedented public health crisis caused by COVID, the federal government spent billions of dollars on developing new vaccines and treatments, to swift success: Less than a year after the pandemic was declared, medical workers got their first vaccines. But as many people have refused the shots and stopped wearing masks, the virus still rages and mutates. In 2022 alone, 250,000 Americans have died from COVID, more than from strokes or diabetes. But soon the Department of Health and Human Services will stop supplying COVID treatments, and pharmacies will purchase and bill for them the same way they do for antibiotic pills or asthma inhalers. Paxlovid is expected to hit the private market in mid-2023, according to HHS plans shared in an October meeting with state health officials and clinicians. Merck’s Lagevrio, a less-effective COVID treatment pill, and AstraZeneca’s Evusheld, a preventive therapy for the immunocompromised, are on track to be commercialized sooner, sometime in the winter.

The U.S. government has so far purchased 20 million courses of Paxlovid, priced at about $530 each, a discount for buying in bulk that Pfizer CEO Albert Bourla called “really very attractive” to the federal government in a July earnings call. The drug will cost far more on the private market, although in a statement to KHN, Pfizer declined to share the planned price. The government will also stop paying for the company’s COVID vaccine next year — those shots will quadruple in price, from the discount rate the government pays of $30 to about $120. Bourla told investors in November that he expects the move will make Paxlovid and its COVID vaccine “a multibillion-dollars franchise.” Nearly 9 in 10 people dying from the virus now are 65 or older. Yet federal law restricts Medicare Part D — the prescription drug program that covers nearly 50 million seniors — from covering the COVID treatment pills. The medications are meant for those most at risk of serious illness, including seniors. Paxlovid and the other treatments are currently available under an emergency use authorization from the FDA, a fast-track review used in extraordinary situations. Although Pfizer applied for full approval in June, the process can take anywhere from several months to years. And Medicare Part D can’t cover any medications without that full stamp of approval. Paying out-of-pocket would be “a substantial barrier” for seniors on Medicare — the very people who would benefit most from the drug, wrote federal health experts. “From a public health perspective, and even from a health care capacity and cost perspective, it would just defy reason to not continue to make these drugs readily available,” said Dr. Larry Madoff, medical director of Massachusetts’ Bureau of Infectious Disease and Laboratory Sciences. He’s hopeful that the federal health agency will find a way to set aside unused doses for seniors and people without insurance.

In mid-November, the White House requested that Congress approve an additional $2.5 billion for COVID therapeutics and vaccines to make sure people can afford the medications when they’re no longer free. But there’s little hope it will be approved — the Senate voted that same day to end the public health emergency and denied similar requests in recent months. Many Americans have already faced hurdles just getting a prescription for COVID treatment. Although the federal government doesn’t track who’s gotten the drug, a Centers for Disease Control and Prevention study using data from 30 medical centers found that Black and Hispanic patients with COVID were much less likely to receive Paxlovid than white patients. (Hispanic people can be of any race or combination of races.) And when the government is no longer picking up the tab, experts predict that these gaps by race, income, and geography will widen. People in Northeastern states used the drug far more often than those in the rest of the country, according to a KHN analysis of Paxlovid use in September and October. But it wasn’t because people in the region were getting sick from COVID at much higher rates — instead, many of those states offered better access to health care to begin with and created special programs to get Paxlovid to their residents. About 10 mostly Democratic states and several large counties in the Northeast and elsewhere created free “test-to-treat” programs that allow their residents to get an immediate doctor visit and prescription for treatment after testing positive for COVID. In Massachusetts, more than 20,000 residents have used the state’s video and phone hotline, which is available seven days a week in 13 languages. Massachusetts, which has the highest insurance rate in the country and relatively low travel times to pharmacies, had the second-highest Paxlovid usage rate among states this fall.

States with higher COVID death rates, like Florida and Kentucky, where residents must travel farther for health care and are more likely to be uninsured, used the drug less often. Without no-cost test-to-treat options, residents have struggled to get prescriptions even though the drug itself is still free. “If you look at access to medications for people who are uninsured, I think that there’s no question that will widen those disparities,” Rosenthal said. People who get insurance through their jobs could face high copays at the register, too, just as they do for insulin and other expensive or brand-name drugs. Most private insurance companies will end up covering COVID therapeutics to some extent, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. After all, the pills are cheaper than a hospital stay. But for most people who get insurance through their jobs, there are “really no rules at all,” she said. Some insurers could take months to add the drugs to their plans or decide not to pay for them. And the additional cost means many people will go without the medication. “We know from lots of research that when people face cost sharing for these drugs that they need to take, they will often forgo or cut back,” Corlette said. One group doesn’t need to worry about sticker shock. Medicaid, the public insurance program for low-income adults and children, will cover the treatments in full until at least early 2024. HHS officials could set aside any leftover taxpayer-funded medication for people who can’t afford to pay the full cost, but they haven’t shared any concrete plans to do so. The government purchased 20 million courses of Paxlovid and 3 million of Lagevrio. Fewer than a third have been used, and usage has fallen in recent months, according to KHN’s analysis of the data from HHS. Sixty percent of the government’s supply of Evusheld is also still available, although the COVID prevention therapy is less effective against new strains of the virus. The health department in one state, New Mexico, has recommended against using it. HHS did not make officials available for an interview or answer written questions about the commercialization plans. The government created a potential workaround when they moved bebtelovimab, another COVID treatment, to the private market this summer. It now retails for $2,100 per patient. The agency set aside the remaining 60,000 government-purchased doses that hospitals could use to treat uninsured patients in a convoluted dose-replacement process. But it’s hard to tell how well that setup would work for Paxlovid: Bebtelovimab was already much less popular, and the FDA halted its use on Nov. 30 because it’s less effective against current strains of the virus. Federal officials and insurance companies would have good reason to make sure patients can continue to afford COVID drugs: They’re far cheaper than if patients land in the emergency room. “The medications are so worthwhile,” said Madoff, the Massachusetts health official. “They’re not expensive in the grand scheme of health care costs.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

WASHINGTON, Dec 15 (Reuters) - U.S. households can order four free at-home COVID-19 tests from the government website COVIDTests.gov beginning on Thursday as part of the Biden administration's efforts to tackle coronavirus infections over the winter. The White House said it would use existing funding to pay for the tests since it has been unsuccessful so far in getting Congress to pass a bill to put more money toward the U.S. COVID-19 response. The free tests program was paused because officials wanted to make sure there were enough tests available for a likely spike in COVID cases in the winter, White House COVID-19 response coordinator Ashish Jha said. "We knew there will be a moment later in the year when COVID cases would rise again. So we preserved the tests so we could have them on hand for exactly this moment," White House COVID-19 response coordinator Ashish Jha said on Thursday. "And if we don't get more funding, we won't be able to send more tests out to the American people."

White House Press Release (Dec. 15, 2022):

https://www.whitehouse.gov/briefing-room/statements-releases/2022/12/15/fact-sheet-biden-administration-announces-covid-19-winter-preparedness-plan/ 

Flu-related hospitalizations nationwide have risen dramatically in recent weeks, reaching levels historically not seen until much later in flu season, according to data released Friday by the Centers for Disease Control and Prevention. "We haven't seen this level of activity this early before," said Lynnette Brammer, team lead of the domestic influenza surveillance team at the CDC. Typical flu seasons usually don't pick up steam until December. Flu hospitalizations are rising across all age groups, especially children. The increase comes as other respiratory viruses, including RSV, or respiratory syncytial virus, are also spiking in kids. According to the Department of Health and Human Services, 76% of pediatric hospital beds nationwide are full. "We realize the potential implications of the co-circulating viruses all at once," Brammer said. "We're taking it very seriously."  Doctors are not required to report each positive flu test to public health officials, so the CDC and others monitor likely flu activity by looking at "influenza-like illnesses": a fever of at least 100 degrees Fahrenheit and a cough and/or sore throat without any other known cause.

Also Friday, the CDC reported the first flu-related death in a child so far this season. The CDC did not provide any details about the child, however KVEO, the NBC affiliate in Brownsville, Texas, recently reported that a 3-year-old girl had died after testing positive for the flu. While the flu and similar viral illnesses are rising nationwide, they're notably high across the Southeast and Eastern Seaboard — from Texas to Georgia, and South Carolina up to Virginia and New Jersey, according to the new report. Doctors also warn that other infections can follow severe cases of the flu, including bacterial infections like pneumococcal pneumonia. Dr. Greg Poland, director of the Mayo Clinic's Vaccine Research Group in Rochester, Minnesota, worries that this season could be bad for these post-viral infections.  Dr. Shannon Martinello, a pediatrician in private practice in New Haven, Connecticut, is already seeing an uptick in post-viral bacterial illness. "The more mucus they have, and the more congested they are, it increases their risk of ear infections," she said. "I always tell parents when their kids have flu, it's going to be a rough week, and they're going to get better," Martinello said. But if a child who has recovered from the flu starts to feel sick again a week or 10 days later, she advises parents to take the child back to the doctor. "I want to re-listen to his lungs and re-check his ears and make sure that something else hasn't happened as a secondary issue." 

There are early signs that this year's flu shot appears to work well at keeping people out of the hospital. A report on Chile's flu season, released Thursday by the CDC, found the vaccine was 49% protective against flu-related hospitalizations. That might seem low, but from 2015 to 2020, flu shot effectiveness in the U.S. ranged from 29% to 48%.  It's unclear whether this year's flu shots in the U.S. will be as effective as was found during Chile's flu season. But the shots used in both countries have one of the same targets: the H3N2 flu strain, which accounts for a majority of flu cases currently detected in the U.S. H3N2 is an influenza A virus and is often associated with increased hospitalizations. Kids under age 5 may be at particular risk. The CDC recommends that everyone 6 months and older get an annual flu shot. Children up through 8 years old may need two shots this year, the agency said, especially if they've never had the flu vaccine. The American Academy of Pediatrics has the same recommendation, adding that kids should get their flu shots by the end of October. But the early start to the flu season has left many Americans vulnerable. Only about half of the population gets an annual flu shot, typically. Many who do often wait until October to get it. "I cannot stress enough how important it is to go ahead and get that vaccine now," Brammer said.

Monkeypox is a viral disease that occurs mostly in central and western Africa. It is called monkeypox because it was first identified in laboratory monkeys. However, it is much more common among animals such as rats, mice, rabbits, and the African Squirrel.

To date, multiple people have died of the virus in several other countries that have not previously experienced monkeypox outbreaks, including Spain, Brazil and India.

KEY FACTS

In the past couple of weeks, UK, Germany, France and others are experiencing a new wave. The US should get ready.  When it comes to Covid, the United States specializes in denialism. Deny the human-to-human transmission of the virus when China’s first cases were publicized in late 2019. Deny that the virus is airborne. Deny the need for boosters across all adult age groups. There are many more examples, but now one stands out – learning from other countries. In early 2020, with the major outbreak in the Lombardy region of Italy that rapidly and profoundly outstripped hospital resources and medical staffing, Americans expressed confidence that it won’t happen here. That it couldn’t happen here. And then it did. Fast forward two years of the pandemic: the United Kingdom and Europe have provided five unmistakable warnings to America that a new surge was occurring. Within weeks, each time, the United States experienced a new wave, some not as severe (such as with the Alpha variant), some worse (Delta and Omicron variants). From this Covid track record over two years, it is palpable: what happens in the UK and Europe doesn’t stay in the UK and Europe.  In the past couple of weeks, the UK and several countries in Europe, including Germany, France and Switzerland, are experiencing a new wave. At least 12 countries, geographically extending from Finland to Greece, are experiencing new increases in cases, some quite marked, such as Austria exceeding its pandemic peak, and Finland with an 85% increase from the prior week. Many of these countries are also showing a rise in hospital admissions. This is the sixth warning from the UK and Europe to the United States.

Indications within the United States support the idea that new wave is already getting started. Wastewater surveillance is relatively sparse in the United States, but 15% of the 410 sites where it was conducted between 24 February to 10 March 2022 showed a greater than 1000% increase compared with the prior 15-day period. Also, the BA.2 variant is gaining steam in the United States and is now accounting for more than 30% of new cases. The root cause for the new wave is hard to pin down. Certainly, the BA.2 variant is known to have increased transmission, at least about 30% more than its sister lineage, Omicron BA.1. With the concomitant reduction of mitigation restrictions and waning immunity protection of vaccines, that transmission advantage will increase. This “BA.2 triad” of factors is thus hard to dissect, as they are clearly interdependent. Rather than focusing on what precisely is driving the new wave, the imperative is to drive some preventive action. As with the first five warnings from the UK and Europe, the United States did not take heed. Instead of proactively gearing up with non-pharmaceutical interventions (masks, quality of masks, distancing, air filtration, ventilation, aggressive testing, etc.), it just reacted to the surges when they were manifest. Now we are at a point with very low vaccination and booster rates, only 64% of the populations has had two shots, and 29% three shots. That puts the United States at 65th and 70th in the world ranking of countries, respectively.

Indeed, the people who need protection the most, besides those who are immunocompromised, are the 65-plus group. The US has a booster rate of 65% in this age group, whereas the UK and many European and Asian countries exceed a 90% booster rate for people 65 and over. This is a critical issue, because there is a substantial dropdown of protection, from 90-95% with a third shot to 75-80% without a booster, versus Omicron hospitalization and death. The problem of lack of adequate vaccination in the United States is compounded by not having any plan for a fourth dose. The Israeli study of over 1 million people age 60 and over showed a 4.3 fold enhanced protection versus severe illness from Omicron compared with those receiving three shots. Not only is there a gaping hole in our immunity wall, but the $58bn budget of the American Pandemic Prepared Plan (AP3) advanced by the White House to comprehensively address the deficiencies was gutted by the Senate, reduced to $2bn, now threatening to cancel the order of more than 9.2m Paxlovid pills, the Test-to Treat program announced at the State of the Union address, along with better data, wastewater surveillance, efforts to develop a pan-coronavirus vaccine, research on long Covid, and many other critical public health measures. We haven’t even seen a new, major variant yet, but there are too many reasons to believe that is likely in the months ahead, owing to extensive animal reservoirs and documented cases of spillover to humans, a large number of immunocompromised people in whom the virus can undergo accelerated evolution, rare but increasingly seen co-infections, and lack of containment of the virus globally. That, in itself, requires preparedness. Unfortunately, we have a mindset that the pandemic is over, which couldn’t be further than the truth, as I wrote about in the epidemic of Covid complacency. Add to all this is what is happening in China, which has fully relied on a zero-Covid policy, resulting in very little natural immunity, and vaccines that have weak efficacy against Omicron. Now this country is facing major outbreaks in two of its most populous cities, Shanghai and Shenzhen, and undoubtedly the whole country will be affected. We learned in 2019 that what happens in China doesn’t stay in China.

During the first wave of the COVID-19 pandemic, fewer than 10% of the US adult population formed antibodies against SARS-CoV-2, and fewer than 10% of those with antibodie swere diagnosed. Public health efforts to limit SARS-CoV-2 spread need to especially
target racial and ethnic minority and densely populated communities. Many patients receiving dialysis in the USA share the socioeconomic characteristics of underserved communities, and undergo routine monthly laboratory testing, facilitating a practical, unbiased, and repeatable assessment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence.

We perform a statistical analysis for understanding the effect of the environmental temperature on the exponential growth rate of the cases infected by COVID-19 for US and Italian regions.

In particular, we analyze the datasets of regional infected cases, derive the growth rates for regions characterized by readable exponential growth phase in their evolution spread curve and plot them against the environmental temperatures averaged within the same regions, derive the relationship between temperature and growth rate, and evaluate its statistical confidence. The results clearly support the first reported statistically significant relationship of negative correlation between the average environmental temperature and exponential growth rates of the infected cases.

The critical temperature, which eliminates the exponential growth, and thus the COVID-19 spread in US regions, is estimated to be Tc = 86.1 ± 4.3 °F. (30.1°C). It is straightforward to ask when the environmental temperature will climb above this critical value. As an example, Figure 10 plots the daily average temperatures in San Antonio, Texas, shown that will be clearly above the estimated TC threshold in the second half of May. The plot suggests a possible date for loosening the strict measures in San Antonio, that is, May 24. The resulted high statistical confidence of the negative correlation of the environmental temperature on the exponential growth rate of the cases infected by COVID-19 is certainly encouraging for loosening super-strict social-distancing measures, at least, during the summery high temperatures. However, we are, by no-means, recommending a return-to-work date based only on this study. But we do think that this should be part of the decision, as well as an inspiration for repeating the same analysis in other heavily infected regions. 

Most people are still not eligible for a second booster, but the FDA will revisit the topic after an expert panel meets in June. The Food and Drug Administration on Tuesday approved a second omicron booster from Moderna and Pfizer for people over the age of 65 and immunocompromised individuals.

Why it matters: An additional dose of the bivalent vaccine can help high-risk individuals with waning immunity to COVID, the FDA said.

• Most people who have received a single shot of the bivalent vaccine aren't eligible for a second dose, but the FDA could revise criteria after an expert panel meets to discuss the topic in June.

Details: Tuesday's decision means those over 65 can get a second booster no sooner than four months after the first.

• Immunocompromised people may receive the second shot at least two months after receiving the first dose "and additional doses may be administered at the discretion of, and at intervals determined by, their health care provider," the FDA said.
• The agency made additional changes, saying that unvaccinated people may receive a single dose of the bivalent vaccine as their first shot, rather than multiple doses of the original monovalent vaccine.
• Children between six months and five years old who have received up to three doses of the monovalent vaccine may receive a bivalent vaccine shot, but the number of doses they receive "will depend on the vaccine and their vaccination history," per the FDA.
• The monovalent shots from Moderna and Pfizer are no longer authorized for use in the U.S.

What they're saying: "At this stage of the pandemic, data support simplifying the use of the authorized mRNA bivalent COVID-19 vaccines and the agency believes that this approach will help encourage future vaccination," said Peter Marks, director of FDA's Center for Biologics and Research.

• "Evidence is now available that most of the U.S. population 5 years of age and older has antibodies to SARS-CoV-2 ... either from vaccination or infection that can serve as a foundation for the protection provided by the bivalent vaccines," Marks added.

Catch up fast: An FDA advisory committee in January unanimously recommended that the U.S. replace initial doses of the original COVID monovalent shots with bivalent ones to target omicron subvariants, directing Pfizer, Moderna and Novavax to focus on bivalent vaccines.

A decade after a landmark report on Americans' shorter lives, the problem has only gotten worse. Unlike other wealthy nations, U.S. life expectancy has not bounced back from the pandemic. Just before Christmas, federal health officials confirmed life expectancy in America had dropped for a nearly unprecedented second year in a row – down to 76 years. While countries all over the world saw life expectancy rebound during the second year of the pandemic after the arrival of vaccines, the U.S. did not. Then, last week, more bad news: Maternal mortality in the U.S. reached a high in 2021. Also, a paper in the Journal of the American Medical Association found rising mortality rates among U.S. children and adolescents. "This is the first time in my career that I've ever seen [an increase in pediatric mortality] – it's always been declining in the United States for as long as I can remember," says the JAMA paper's lead author Steven Woolf, director emeritus of the Center on Society and Health at Virginia Commonwealth University. "Now, it's increasing at a magnitude that has not occurred at least for half a century." Across the lifespan, and across every demographic group, Americans die at younger ages than their counterparts in other wealthy nations. How could this happen? In a country that prides itself on scientific excellence and innovation, and spends an incredible amount of money on health care, the population keeps dying at younger and younger ages.

An unheard alarm

One group of people are not surprised at all: Woolf and the other researchers involved in a landmark, 400-page study ten years ago with a name that says it all: "Shorter Lives, Poorer Health." The research by a panel convened by the National Academy of Sciences and funded by the National Institutes of Health compared U.S. health and death with other developed countries. The results showed – convincingly – that the U.S. was stalling on health advances in the population while other countries raced ahead. The authors tried to sound an alarm, but found few in the public or government or private sectors were willing to listen. In the years since, the trends have worsened. American life expectancy is lower than that of Cuba, Lebanon, and Czechia.

Ten years later, here's a look back at what that eye-popping study found, and why the researchers involved believe it's not too late to turn the trends around.

Beyond bad habits

Americans are used to hearing about how their poor diets and sedentary lifestyles make their health bad. It can seem easy to brush that off as another scold about eating more vegetables and getting more exercise. But the picture painted in the "Shorter Lives" report could shock even those who feel like they know the story. "American children are less likely to live to age 5 than children in other high-income countries," the authors write on the second page. It goes on: "Even Americans with healthy behaviors, for example, those who are not obese or do not smoke, appear to have higher disease rates than their peers in other countries." The researchers catalog what they call the "U.S. health disadvantage" – the fact that living in America is worse for your health and makes you more likely to die younger than if you lived in another rich country like the U.K., Switzerland or Japan. "We went into this with an open mind as to why it is that the U.S. had a shorter life expectancy than people in other countries," says Woolf, who chaired the committee that produced the report. After looking across different age and racial and economic and geographic groups, he says, "what we found was that this problem existed in almost every category we looked at." That's why, says Eileen Crimmins, professor of gerontology at the University of Southern California who was also on the panel that produced the report, they made a deliberate choice to focus on the health of the U.S. population as a whole. "That was a decision – not to emphasize the differences in our population, because there is data that actually shows that even the top proportion of the U.S. population does worse than the top proportion of other populations," she explains. "We were trying to just say – look, this is an American problem."

Digging into the 'why'

The researchers were charged with documenting how Americans have more diseases and die younger and to explore the reasons why. "We were very systematic and thorough about how we thought about this," says Woolf. The panel looked at American life and death in terms of the public health and medical care system, individual behaviors like diet and tobacco use, social factors like poverty and inequality, the physical environment, and public policies and values. "In every one of those five buckets, we found problems that distinguish the United States from other countries." Yes, Americans eat more calories and lack universal access to health care. But there's also higher child poverty, racial segregation, social isolation, and more. Even the way cities are designed makes access to good food more difficult. "Everybody has a pet thing they worry about and say, 'it's oral health' or 'it's suicides' – everyone has something that they're legitimately interested in and want to see more attention to," says John Haaga, who was the director of the Division of Behavioral and Social Research at the National Institute on Aging at NIH, before he retired. "The great value of an exercise like this one was to step back and say, 'OK, all of these things are going on, but which of them best account for these long-term population level trends that we're seeing?' " The answer is varied. A big part of the difference between life and death in the U.S. and its peer countries is people dying or being killed before age 50. The "Shorter Lives" report specifically points to factors like teen pregnancy, drug overdoses, HIV, fatal car crashes, injuries, and violence.

"Two years difference in life expectancy probably comes from the fact that firearms are so available in the United States," Crimmins says. "There's the opioid epidemic, which is clearly ours – that was our drug companies and other countries didn't have that because those drugs were more controlled. Some of the difference comes from the fact that we are more likely to drive more miles. We have more cars," and ultimately, more fatal crashes. "When we were doing it, we were joking we should call it 'Live free and die,' based on the New Hampshire slogan, ['Live free or die']," Crimmins says. "The National Academy of Sciences said, 'That's outrageous, that's too provocative.' " There are some things Americans get right, according to the "Shorter Lives" report: "The United States has higher survival after age 75 than do peer countries, and it has higher rates of cancer screening and survival, better control of blood pressure and cholesterol levels, lower stroke mortality, lower rates of current smoking, and higher average household income." But those achievements, it's clear, aren't enough to offset the other problems that befall many Americans at younger ages. All of this costs the country tremendously. Not only do families lose loved ones too soon, but having a sicker population costs the country as much as $100 billion every year in extra health care costs. "Behind the statistics detailed in this report are the faces of young people – infants, children, and adolescents – who are unwell and dying early because conditions in this country are not as favorable as those in other countries," the paper's authors wrote....

More than 1,000 incarcerated people died from hepatitis C-related complications between 2014 and 2019, even though a simple cure is available, according to a new STAT investigation.

He knew he had hepatitis C. And he knew, too, about the simple, once-daily pills that could fully cure him of the potentially deadly viral infection in about 12 weeks. But Ritchie was serving a 20-year sentence for armed robbery, and the Missouri Department of Corrections refused to treat him. Ritchie begged repeatedly for the medicine. He went through all the formal steps to request medical care. The prison system knew he was getting sicker and sicker — it documented his deteriorating condition in his health records. The prison’s doctors wrote frequently he would benefit from hepatitis C treatment. But officials still denied him, in the same way a STAT investigation documented prisons around the country are still denying thousands of others the cure. So the virus infecting Ritchie’s blood continued to replicate, scarring his liver until it was so damaged that it could hardly function. Eventually he was diagnosed with liver cancer, a common complication of untreated hepatitis C. Now, the prison argued, he was too sick for the drugs to work. They refused him again. “I don’t have the energy to do nothing anymore,” Ritchie told a court in 2019. “I try to talk too long, I can’t breathe … I get out and get a little fresh air, but I can’t do a lot of walking, and I can’t get in the sun.” He died in June 2021 at the age of 64, nearly five years after his first request for medication.

STAT’s investigation found that 1,013 people died of hepatitis C-related complications in states’ custody in the six years after the first cure, a Gilead antiviral drug called Sovaldi, hit the market in late 2013. This tally, based on an analysis of 27,674 highly restricted death records, has never before been reported. Many of those 1,013 people were not serving life sentences; they would likely have had the chance to return home, reapply for jobs, and reconnect with parents, spouses, and children — or, in Ritchie’s case, his one grandchild, Gabe. Many should not have died. In fact, the treatment for hepatitis C is a modern medical marvel. The scientists who paved the way for its discovery won a Nobel Prize. Public health experts say it’s possible to cut hepatitis C deaths to virtually zero, and effectively eliminate the virus as we’ve done with smallpox or polio. Francis Collins, the White House science adviser and former longtime director of the National Institutes of Health, called STAT’s findings “unacceptable.” “You have to wonder if this individual [Ritchie] had received [treatment] at the first opportunity, would he still be alive today?” Collins said. Told of STAT’s findings, Chelsea Clinton, a global health advocate and vice chair of the Clinton Foundation, said the rationing of hepatitis C care by prisons and people dying as a result is “incredibly infuriating.” “It certainly is a gross injustice that we are continuing to punish people who are already incarcerated as a punishment,” she said. “That sometimes there’s a death sentence attached if there’s untreated hepatitis C — that to me is morally indefensible.....

The cumulative hospitalization rate for flu in the U.S. is higher than it has been at this point for more than a decade. There are increasing signs that flu season is off to a very early start in parts of the United States, with the cumulative hospitalization rate higher than it has been at this point in the fall for more than a decade, the Centers for Disease Control and Prevention reported Friday.  In its weekly FluView report, the CDC estimated that there have already been 880,000 influenza illnesses, 6,900 flu hospitalizations, and 360 deaths caused by flu this season, which started at the beginning of October. It is unusual for the CDC to have enough data to issue estimates on the burden of flu this early in the season.  These figures are estimates, based on data from a flu hospitalization surveillance network of acute care hospitals in 14 states. Flu activity is currently highest in south-central and southeast parts of the country, and New York. It is also picking up along the Eastern Seaboard. The CDC also reported the death of a child, the first pediatric flu death of the new flu season. It occurred in the week ending Oct. 8. 

In the first two winters of the Covid-19 pandemic, the new coronavirus and the measures people took to protect themselves from it suppressed transmission of a number of respiratory pathogens that normally make the rounds. That hiatus has ended and those viruses are returning, though often at times when they didn’t normally circulate in the past. Hospitals around the country are seeing record numbers of cases of respiratory syncytial virus, or RSV, right now. In pre-Covid times, RSV didn’t typically emerge until the winter. Some people are interpreting the early start of flu activity as evidence we are in for a harsh flu season. But Lynnette Brammer, team lead for domestic surveillance in the CDC’s influenza division, said it’s impossible at this point to know how bad the season will be.  “What a lot of people are implying is because it’s early and levels are high for this time of year that it’s going to be a severe season. We don’t know that,” Brammer told STAT.  “Right now all we can say is we’re off to an early start.”  She noted that people who have been waiting to get a flu shot to try to time it to the start of flu circulation should not hold off any longer. “You need to get vaccinated now, if you haven’t already done that.” Ed Belongia, director of the Center for Clinical Epidemiology and Population Health at Wisconsin’s Marshfield Clinic Research Institute, said there is good reason to be worried that this could be a severe flu season. Most immune systems haven’t seen flu viruses for a couple of years, which means the pool of people susceptible to infection is large. And the measures society took to try to slow spread of Covid — mask-wearing, social distancing, school closures — have mostly been abandoned.  But Belongia has been studying flu for too long to guess how a flu season will unfold. The virus is maddeningly unpredictable. “Whether or not the whole season is going to be longer and more severe, we really just don’t know at this point. It’s too early to say,” he said.

Evidence from the Southern Hemisphere’s flu season — which sometimes provides hints of what’s in store for us — showed oddly timed and active flu seasons, but not necessarily bad ones. Australia had a lot of flu activity, mainly in children. But a report on its 2022 winter season issued earlier this month stated that the clinical severity of the season, based on the numbers of intensive care admissions and deaths, was actually low. It rated the overall impact of the flu season as low to moderate. Other hopeful news from the Southern Hemisphere was that the flu vaccine seems well-matched to the viruses that are circulating. A report this week from Chile in the CDC’s online journal Morbidity and Mortality Weekly Report estimated flu vaccine efficacy at 49% against H3N2 viruses, the subtype that caused most of the disease there. It is also the virus currently causing most disease in the U.S. Belongia said he was pleasantly surprised, adding  “49% is about as good as you can expect to see for H3N2. So I thought that was encouraging. While it’s impossible to guess how bad the flu season will be, there is one thing that does look reasonable to assume. If the current levels of circulation of influenza and RSV virus continue or increase, there could be a lot of respiratory illness around Thanksgiving. Much of the current illness is in young children, who typically get sick first in the cold and flu season and spread their bugs to siblings, parents, grandparents, and other adults with whom they are in contact.

There's been a surge of about 900,000 people with disabilities in the U.S. workforce since 2020, likely because of the increase in Americans with long COVID, according to new research published by the Federal Reserve Bank of New York.

Why it matters: It's an encouraging sign, in one sense. Disabled Americans face enormous obstacles in the job market; if folks with long COVID can keep working, that means some employers are accommodating their needs.

• But as the economy cools, employers could become less willing on that front — and it's an open question as to whether these folks stay employed.
• "I hope that isn't true, but it's something I would certainly keep an eye on," says Katie Bach, a nonresident senior fellow at Brookings who has been studying long COVID's impact on the workforce, and recently found the condition is keeping as many as 4 million people out of work.

State of play: The pandemic led to an increase in the number of Americans who say they're disabled. (See the chart below.)

• There were 1.05 million more disabled working-age Americans in August 2022 compared to January 2020, according to data compiled by Richard Deitz, an economist at the NY Fed.
• "The majority [of the newly disabled] deal with fatigue and brain fog, the hallmarks of long COVID," he writes.

The intrigue: Economists are still nailing down why so many more disabled people, who traditionally have very low labor force participation, are working now.

• Deitz's paper is among the first to pinpoint long COVID as a possible factor; others attribute the surge to the tight labor market and the rise of remote work — which can make it easier for disabled workers to remain employed or get a job.
• There's likely an interplay between the two. Some disabled people can now more easily work remotely and may have entered the job market; and the ability to work from home is also helping many of those with long COVID — a cohort that didn't exist before 2020 — keep their jobs.

What they're saying: "I would bet that the majority of the [increase in disabled workers] is people with long COVID who are still working," Bach says. She's currently researching the newly disabled population to better understand these numbers.

As cases rise in the U.S. and other parts of the world, Omicron subvariants are a continued culprit. Experts are watching closely to see if further mutations of the virus may become even more contagious, or may gain the ability to evade immunity from prior infections and vaccinations.

BA.4 and BA.5 in South Africa

When South African scientists sounded the alarm about Omicron in November, they identified three versions of the variant, called BA.1, BA.2, and BA.3. BA.1 first spread rapidly through South Africa and the rest of the world in December and January; BA.2 then outcompeted BA.1 to become the dominant strain globally. Now, South African scientists are sounding the alarm again: this time about new Omicron lineages, dubbed BA.4 and BA.5. These two lineages have driven another new surge in the country, with both cases and hospital admissions rising sharply in recent weeks. The surge might be starting to slow, as of late this week, but it’s unclear if this trend will continue.  South Africa saw a huge BA.1 surge in November and December, then didn’t see much of a BA.2 bump—likely because so many people infected with BA.1 had immunity to this variant. But BA.4 and BA.5 may be a different story, according to a preprint from Alex Sigal and colleagues at the Africa Health Research Institute. Sigal and his collaborators tested neutralizing antibodies—a commonly-studied aspect of immune system protection—from BA.1 against BA.4 and BA.5. They found that a BA.1 infection offered relatively limited protection against BA.4 and BA.5, especially if the person who had BA.1 was unvaccinated. “BA.4 and BA.5 have potential to result in a new infection wave,” the authors wrote. This study is a preprint, not yet peer-reviewed. But it’s still a major warning sign for the U.S. and other countries: watch out for BA.4 and BA.5.

BA.2 subvariants in the U.S.

Meanwhile, here in the U.S., BA.2 continues to mutate and spread rapidly. The BA.2.12.1 subvariant, first identified by the New York State health department in mid-April as a sublineage that spreads even faster than BA.2, is now causing more than one-third of new COVID-19 cases in the country, according to CDC estimates. In New York and New Jersey, BA.2.12.1 is causing over 60% of new cases; it’s no coincidence that these states are also reporting some of the highest case and hospitalization rates in the country right now. New England, mid-Atlantic, South, and Midwest states are also seeing high proportions of BA.2.12.1. The CDC’s variant proportions estimates don’t yet include BA.4 and BA.5, but other reports suggest that these subvariants are already in the U.S. and starting to compete with our homegrown BA.2 lineages. Marc Johnson, a leading wastewater expert in Missouri, posted on Twitter yesterday that he’s seeing “a circus of Omicron sublineages” in his state, including BA.4 and BA.5. Also worth noting: a new U.S. study (shared as a preprint last week) found that, actually, Omicron is not inherently less severe than other variants. In comparing hospitalization and mortality risks after accounting for vaccination and medical risk factors, the researchers behind this study found little difference between the Omicron wave and prior periods. While this study also has yet to be peer-reviewed, it doesn’t bode well for future Omicron-driven surges.

The head of Operation Warp Speed says that by spreading out doses of the Moderna vaccine, more people would be able to get some level of protection sooner, a strategy opposed by other experts. Update (January 5): On Monday evening, the FDA stated that dosing in the US will occur as planned, based on available data regarding efficacy, saying: “We know that some of these discussions about changing the dosing schedule or dose are based on a belief that changing the dose or dosing schedule can help get more vaccine to the public faster. However, making such changes that are not supported by adequate scientific evidence may ultimately be counterproductive to public health.” 

0fficials involved with the United States’s Operation Warp Speed—the program tasked with expediting the creation of a vaccine for COVID-19—are discussing the merits of rationing the Moderna vaccine for adults aged 18–55, as is being discussed in the United Kingdom. This would be accomplished either by giving half doses of the first shot or delaying the immunization’s second shot, Moncef Slaoui, the head of OWS, tells CBS News’s “Face the Nation.” Ultimately, the Food and Drug Administration will determine if the vaccines can be given on a different schedule, and a decision has not yet been made.  Originally, OWS anticipated that 20 million vaccine doses would have been distributed by the end of 2020. As of January 2, the Centers for Disease Control and Prevention reports that 13 million doses have gone out, and 4.23 million people in the US have received at least one dose, primarily frontline healthcare workers and nursing home residents so far. Going off-schedule for lower-risk adults would allow twice as many people to receive their first shot, Slaoui says. The vaccine’s urgency has become more pronounced as a more contagious strain of SARS-CoV-2 that originated in the UK has now been found in the US. If reducing the volume of the first dose is approved by the FDA, the rationing would only affect the vaccine made by Moderna, Slaoui explains, which he claims would still provide the same protection as a full dose. Officials from Moderna have not yet verified if that is the case. Germany is also deliberating holding off on the second shot to spread around more initial doses, while Denmark has already approved the measure, Reuters reports.

Officials from Pfizer and BioNTech released a joint statement last week in response to the UK’s desire to hold off on the second dose from the initial plan of 21 days to as long as 12 weeks after the first. “The safety and efficacy of the vaccine has not been evaluated on different dosing schedules as the majority of trial participants received the second dose within the window specified in the study design,” the statement reads, according to Reuters. Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, along with other medical experts around the globe, say they disagree that rationing would be effective, The New York Times reports. Fauci says that the US will not be following the UK’s lead to delay the second dose, should the British government decide to do that. Still, it will be down to the FDA to decide if altered dosing will be permitted. Speaking on CNN, Leana Wen, the former health commissioner of Baltimore, agrees with Fauci’s take. “I understand the desire to stretch out the doses that we have and to say, ‘Hey, if one dose can offer some partial protection, why not give it to as many people as we can?’ The problem, though, is that is not how the studies were conducted.”

Covid-19 update: The U.S. has now reached 200,000 coronavirus deaths, just four months after the death toll hit 100,000. In the predawn hours of March 30, Dr. Deborah Birx stepped in front of the camera on the White House lawn and made an alarming prediction about the coronavirus, which had, by then, killed fewer than 3,000 people in the United States. "If we do things together, well, almost perfectly, we can get in the range of 100,000 to 200,000 fatalities," Birx, coordinator of the White House coronavirus task force, told Savannah Guthrie of NBC News' "Today" show. "We don't even want to see that," she added, before Guthrie cut her off. "I know, but you kind of take my breath away with that," Guthrie said. "Because what I hear you saying is that's sort of the best-case scenario." "The best-case scenario," Birx replied, "would be 100 percent of Americans doing precisely what is required." On Saturday, Birx's prediction came true, as the number of lives lost to Covid-19 in the U.S. topped 200,000. Experts like Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention, said it didn't have to be this way. "Tens of thousands of people would not have died if the U.S. response had been more effective," said Frieden, now president of Resolve to Save Lives, a global public health initiative.

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said Birx's prediction in late March was "very sobering." That was the time, he said, to develop and implement a plan to stop or at least slow the spread of the virus. That didn't happen then, and it hasn't happened since. "Where is our national plan?" Osterholm asked. "How are we this far along and we don't have one?" "We have a long way to go," he added. Indeed, the country still faces many challenges in overcoming the pandemic, including agreeing on even the most basic facts. Americans are still fighting over whether to wear masks, whether the virus is serious and to what extent it's safe to reopen certain businesses and to resume certain activities. In short, 100 percent of Americans — government officials included — still aren't doing precisely what is required.

Now, many experts are making another ominous prediction: A surge in the number of new infections in the fall and winter, combined with growing fatigue over social distancing and other public health measures, could result in more than 415,000 deaths in the U.S. by January, according to the Institute for Health Metrics and Evaluation, or IHME, at the University of Washington. The prediction comes even as doctors are growing more adept at treating patients and clinical trials are finding that treatments like remdesivir and dexamethasone can help. And as the pandemic has spread, it has moved into younger, healthier populations, who are less likely to die from Covid-19. The IHME's projections are by no means set in stone. Changes in human behavior, such as increased adherence to wearing masks, can bring the number down considerably, said the director of the IHME, Dr. Christopher Murray, a professor of health metrics sciences at the University of Washington. But the experiences of other countries have shown that, as the pandemic wears on, public complacency is a real concern. "We're seeing it in a very big way in parts of Europe, for example, where lack of vigilance is leading already to a big uptick," Murray said. The IHME model is one of several that the CDC uses to track the evolution of the pandemic, but it has faced its share of skepticism. The model often includes high degrees of uncertainty, and it was criticized early on for underestimating the number of deaths nationwide. In April, for example, the IHME model projected that the death toll in the U.S. through August could be 60,415, although the prediction included a wide range to account for uncertainties early in the pandemic...