Virus World

We report highly pathogenic avian influenza A(H5N1) virus in dairy cattle and cats in Kansas and Texas, United States, which reflects the continued spread of clade 2.3.4.4b viruses that entered the country in late 2021. Infected cattle experienced nonspecific illness, reduced feed intake and rumination, and an abrupt drop in milk production, but fatal systemic influenza infection developed in domestic cats fed raw (unpasteurized) colostrum and milk from affected cows. Cow-to-cow transmission appears to have occurred because infections were observed in cattle on Michigan, Idaho, and Ohio farms where avian influenza virus–infected cows were transported. Although the US Food and Drug Administration has indicated the commercial milk supply remains safe, the detection of influenza virus in unpasteurized bovine milk is a concern because of potential cross-species transmission. Continued surveillance of highly pathogenic avian influenza viruses in domestic production animals is needed to prevent cross-species and mammal-to-mammal transmission.

Published in Emerging Infectious Diseases (April 20, 2024)

https://doi.org/10.3201/eid3007.240508 

Explore the Walgreens COVID-19 Index, taking data from our stores to visualize trends and patterns in COVID-19 across the United States.

This is a continuously updated repository of federal and private funding opportunities that are intended for postdoctoral investigators. The opportunities are pre-sorted chronologically and alphabetically, and can be searched by funding amount and subject matter.

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....

The offshoot accounts for 40% of Covid cases in the US, raising fears of fresh waves of illness as it spreads to other countries. Scientists have raised concerns about a new Covid variant that is spreading fast in the US and threatening to cause further waves of infection. Here’s what we know so far.

What is the new variant called?

It’s known as XBB.1.5. It’s one of the latest descendants of Omicron, the highly transmissible version of Covid that caused cases to surge in the UK last winter. Offshoots of Omicron have dominated global Covid infections ever since. XBB.1.5 evolved from the XBB variant of Omicron, itself a fusion of two different BA.2 variants.

How fast is it spreading?

The variant seems to have arisen in or around New York state in late October. At the end of December, the number of cases in the US more than doubled in a week. It now accounts for about 40% of all Covid infections in the US. Hospitalisations are rising in New York, raising fears that XBB.1.5 is about to cause further waves of illness as it spreads to other countries. Some US estimates suggest that XBB.1.5 is spreading more than twice as fast as the BQ.1.1 variant, which is one of the most common variants found in the UK.

Why is it spreading so rapidly?

The variant has an unusual mutation known as F486P that is helping it spread. The mutation changes part of the Covid virus that many antibodies from vaccination or previous infection target. The change makes the antibodies less effective at neutralising the virus. The parent variant, XBB, has a different mutation at the same position. This makes XBB good at evading immune defences too, but the mutation comes with a cost: the virus cannot latch on to human cells as effectively, so the virus is actually less infectious. The XBB.1.5 offshoot suffers no such handicap: the F486P mutation allows it to evade antibodies without compromising how well it attaches to human cells. In fact, it binds to them even more strongly than XBB, driving up its infectivity. “The mutation can give that immune evasion without the cost to infectivity and that’s why it’s become so successful,” says Ravi Gupta, professor of clinical microbiology at the University of Cambridge.

Has the virus reached the UK?

Scientists in the UK analyse the genetics of only a fraction of Covid samples now, so there’s some uncertainty around XBB.1.5. But the variant has been detected here, and surveillance suggests it makes up at least 4% of Covid viruses being sequenced.

Does it cause more severe disease?

There is no evidence that XBB.1.5 causes more severe disease than other Omicron variants. But the fact that it is spreading fast is worrisome, as the virus is more likely to reach vulnerable people who could be hospitalised or die from the infection, especially if they have not received their latest booster.

Will it spark another wave?

That is the concern. In the US, scientists suspect XBB.1.5 is at least partly responsible for the rise in hospital admissions in New York, though cold weather and indoor gathering will also contribute. It is unclear whether the variant will drive a big surge in the UK, but some rise is anticipated. “It might drive an increase in cases, but I’m not convinced this will necessarily cause an explosive wave of infections in the UK,” says Gupta. “I don’t think there’s any cause to panic. The main thing we worry about is the severity of the disease, and there is no evidence that it’s more severe. People should, however, make sure they are up to date with their vaccines.” Paradoxically, the winter wave of influenza and other nasty respiratory viruses that are doing the rounds might blunt any spike in Covid. If you catch a virus it should activate the innate immune system, the body’s frontline defences against pathogens, offering at least some protection against viruses that follow soon after. So if you caught flu or another respiratory virus over Christmas, your immune defences might resist a brief encounter with Covid.

What do scientists advise?

Vaccines are still the best way to protect against severe Covid, but Sam Wilson, a professor of virology at the University of Glasgow, says taking familiar Covid precautions will also help. “Regardless of the impact of a new variant, the NHS is already under tremendous pressure from a cocktail of different viruses this winter,” he says. “Where it is possible, taking voluntary steps to reduce transmission – reducing contacts, wearing high-quality masks in crowded indoor spaces, and isolating if you have symptoms – will help reduce the pressure on the NHS.”

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.....

First infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with increased risk of acute and postacute death and sequelae in various organ systems. Whether reinfection adds to risks incurred after first infection is unclear. Here we used the US Department of Veterans Affairs’ national healthcare database to build a cohort of individuals with one SARS-CoV-2 infection (n = 443,588), reinfection (two or more infections, n = 40,947) and a noninfected control (n = 5,334,729). We used inverse probability-weighted survival models to estimate risks and 6-month burdens of death, hospitalization and incident sequelae. Compared to no reinfection, reinfection contributed additional risks of death (hazard ratio (HR) = 2.17, 95% confidence intervals (CI) 1.93–2.45), hospitalization (HR = 3.32, 95% CI 3.13–3.51) and sequelae including pulmonary, cardiovascular, hematological, diabetes, gastrointestinal, kidney, mental health, musculoskeletal and neurological disorders. The risks were evident regardless of vaccination status.

The risks were most pronounced in the acute phase but persisted in the postacute phase at 6 months. Compared to noninfected controls, cumulative risks and burdens of repeat infection increased according to the number of infections. Limitations included a cohort of mostly white males. The evidence shows that reinfection further increases risks of death, hospitalization and sequelae in multiple organ systems in the acute and postacute phase. Reducing overall burden of death and disease due to SARS-CoV-2 will require strategies for reinfection prevention. A new analysis using US Department of Veterans Affairs databases showed that reinfection is associated with increased risk of all-cause mortality, hospitalization and a wide range of long COVID complications in individuals who have had SARS-CoV-2 compared to those with no reinfection.

Published Nov. 10, 2022 in NAt. Medicine:

 https://doi.org/10.1038/s41591-022-02051-3 

NEW YORK (AP) — Some U.S. health officials are conceding that monkeypox is probably not going away anytime soon. The disease’s spread is slowing but the virus is so widespread that elimination is unlikely, the Centers for Disease Control and Prevention said.  That conclusion was in a recent CDC report, and echoed Friday by Marc Lipsitch, director of science in the agency’s disease-forecasting center. Lipsitch hesitated to say monkeypox is permanently here to stay, but he said it stands to be a continuing threat for the next few years. “It’s in many geographic locations within the country” as well as in other countries, Lipsitch told The Associated Press. “There’s no clear path in our mind to complete elimination domestically.” The virus has mainly spread among gay and bisexual men, though health officials continue to stress that anyone can be infected. It’s important that people at risk take steps to prevent spread and that vaccination efforts continue, Lipsitch said. The CDC report contained some good news: The U.S. outbreak seems to have peaked in early August. The average number of daily cases being reported — fewer than 150 — is about a third what it was reported in the middle of the summer, and officials expect the decline will continue for at least the next several weeks.  Lipsitch attributed the good news to increasing vaccinations, cautious behavior by people at risk and infection-derived immunity in the highest risk populations. Dr. Tom Inglesby, director of the Johns Hopkins Center for Health Security, agreed that it’s unlikely that spread of monkeypox will stop in the U.S. anytime soon, but he said it’s still possible in the long term.

If domestic transmission were stopped, infections may still continue if people catch the virus while traveling internationally, he said. But the declining cases makes it seem like “we’ve turned a real corner.” “The efforts underway are succeeding, and should be continued, if not intensified,” he said. With case numbers going down, this is a good time for local health departments to take a new stab at doing intensive contact tracing to try to stop chains of transmission, he said. Monkeypox is endemic in parts of Africa, where people have been infected through bites from rodents or small animals, but it wasn’t considered a disease that spreads easily among people until May, when infections emerged in Europe and the U.S.  There have been more than 67,000 cases reported in countries that have not historically seen monkeypox. The U.S. has the most infections of any country — more than 25,600. One U.S. death has been attributed to monkeypox. More than 97% of U.S. cases are men. The vast majority have been men who reported recent sexual contact with other men. Though cases have been declining, the proportion of new cases that have information about recent sexual contact is also down, officials said. That’s causing a growing blind spot about how the virus may be spreading, Lipsitch noted.

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The Associated Press Health & Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

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CDC Report (Sept. 23, revised Sept. 29, 2022) available at:

https://www.cdc.gov/poxvirus/monkeypox/cases-data/technical-report/report-3.html 

The Biden administration has proposed using a less common injection method that would allow a single dose of the monkeypox vaccine to be split into five. As the monkeypox virus continues to spread in the United States, the Biden administration has adopted a strategy of vaccine-splitting to stretch the nation’s limited supply. A method known as intradermal vaccination allows a single-use vial to be split into five injections. Bavarian Nordic makes Jynneos, the only monkeypox-specific vaccine approved in the United States. It was initially approved by the Food and Drug Administration for a single 0.5 milliliter subcutaneous injection, followed by a second 0.5 milliliter dose four weeks later....

Lyme disease diagnoses have increased dramatically in the U.S. during the past 15 years, rising 357% in rural areas and 65% in urban areas, according to new data released by FAIR Health. 

The trends show that tick-borne illnesses are becoming a more common concern nationally, not just in the areas where Lyme disease has been found historically. “Lyme disease remains a growing public health concern,” Robin Gelburd, president of FAIR Health, said in a statement. FAIR Health is a national, independent nonprofit group that highlights health care information by looking at data from its collection of more than 36 billion private insurance claims records. “FAIR Health will continue to use its repository of claims data to provide actionable and relevant insights to healthcare stakeholders seeking to better understand the ongoing rise of Lyme disease cases,” Gelburd said. The 15-year analysis included private insurance claims from 2007 to 2021, which showed a 357% increase in Lyme disease diagnoses in rural areas and a 65% increase in urban areas. In the past 5 years, from 2016 to 2021, diagnoses rose 60% in rural areas and 19% in urban areas.  The cases peaked in the summer months, when people spend more time outside in grassy areas, wooded areas, parks, and fields where ticks live. In June and July, Lyme disease diagnoses were more common in rural areas, but from November to April, diagnoses occurred more often in urban areas.

The latest omicron offshoot, BA.5, has quickly become dominant in the United States, driving a wave of reinfections across the country.  America has decided the pandemic is over. The coronavirus has other ideas. The latest omicron offshoot, BA.5, has quickly become dominant in the United States, and thanks to its elusiveness when encountering the human immune system, is driving a wave of cases across the country. The size of that wave is unclear because most people are testing at home or not testing at all. The Centers for Disease Control and Prevention in the past week has reported a little more than 100,000 new cases a day on average. But infectious-disease experts know that wildly underestimates the true number, which may be as many as a million, said Eric Topol, a professor at Scripps Research who closely tracks pandemic trends. Antibodies from vaccines and previous covid infections offer limited protection against BA.5, leading Topol to call it “the worst version of the virus that we’ve seen.”  Other experts point out that, despite being hit by multiple rounds of ever-more-contagious omicron subvariants, the country has not yet seen a dramatic spike in hospitalizations.

About 38,000 people were hospitalized nationally with covid as of Friday, according to data compiled by The Washington Post. That figure has been steadily rising since early March, but remains far below the record 162,000 patients hospitalized with covid in mid-January. The average daily death toll on Friday stood at 329 and has not changed significantly over the past two months. There is widespread agreement among infectious-disease experts that this remains a dangerous virus that causes illnesses of unpredictable severity — and they say the country is not doing enough to limit transmission. Restrictions and mandates are long gone. Air travel is nearly back to pre-pandemic levels. Political leaders aren’t talking about the virus — it’s virtually a nonissue on the campaign trail. Most people are done with masking, social distancing, and the pandemic generally. They’re taking their chances with the virus. “It’s the wild west out there,” said Ziyad Al-Aly, an epidemiologist at Washington University in St. Louis. “There are no public health measures at all. We’re in a very peculiar spot, where the risk is vivid and it’s out there, but we’ve let our guard down and we’ve chosen, deliberately, to expose ourselves and make ourselves more vulnerable.” Angela Rasmussen, a virologist at the University of Saskatchewan, would like to see more money for testing and vaccine development, as well as stronger messaging from the Biden administration and top health officials. She was dismayed recently on a trip to southern California, where she saw few people wearing masks in the airport. “This is what happens when you don’t have politicians and leaders taking a strong stand on this,” she said. The CDC said it has urged people to monitor community transmission, “stay up to date on vaccines, and take appropriate precautions to protect themselves and others....”

In early March, veterinarian Barb Petersen noticed the dairy cows she cared for on a Texas farm looked sick and produced less milk, and that it was off-color and thick. Birds and cats on the farm were dying, too. Petersen contacted Kay Russo at Novonesis, a company that helps farms keep their animals healthy and productive. “I said, you know, I may sound like a crazy, tinfoil hat–wearing person,” Russo, also a veterinarian, recalled at a 5 April public talk sponsored by her company. “But this sounds a bit like influenza to me.” She was right, as Petersen and Russo soon learned. On 19 March, birds on the Texas farm tested positive for H5N1, the highly pathogenic avian flu that has been devastating poultry and wild birds around the world for more than 2 years. Two days later, tests of cow milk and cats came back positive for the same virus, designated 2.3.4.4b. “I was at Target with my kids, and a series of expletives came out of my mouth,” Russo said. Now, 3 weeks into the first ever outbreak of a bird flu virus in dairy cattle, Russo and others are still dismayed—this time by the many questions that remain about the infections and the threat they may pose to livestock and people, and by the federal response. Eight U.S. states have reported infected cows, but government scientists have released few details about how the virus is spreading.

In the face of mounting criticism about sharing little genetic data—which could indicate how the virus is changing and its potential for further spread—the U.S. Department of Agriculture (USDA) did an unusual Sunday evening dump on 21 April of 202 sequences from cattle into a public database. (Some may be different samples from the same animal.) And despite public reassurances about the safety of the country’s milk supply, officials have yet to provide supporting data.  The cow infections, first confirmed by USDA on 25 March, were “a bit of an inconvenient truth,” Russo says. Taking and testing samples, sequencing viruses, and running experiments can take days, if not weeks, she acknowledges. But she thinks that although officials are trying to protect the public, they are also hesitant to cause undue harm to the dairy and beef industries. “There is a fine line of respecting the market, but also allowing for the work to be done from a scientific perspective,” Russo says.

Only one human case linked to cattle has been confirmed to date, and symptoms were limited to conjunctivitis, also known as pink eye. But Russo and many other vets have heard anecdotes about workers who have pink eye and other symptoms—including fever, cough, and lethargy—and do not want to be tested or seen by doctors. James Lowe, a researcher who specializes in pig influenza viruses, says policies for monitoring exposed people vary greatly between states. “I believe there are probably lots of human cases,” he says, noting that most likely are asymptomatic. Russo says she is heartened that the Centers for Disease Control and Prevention has “really started to mobilize and do the right thing,” including linking with state and local health departments, as well as vets, to monitor the health of workers on affected farms.

As farms in more states began to report infected dairy cows last month, one theory held migratory birds were carrying the virus across the country and introducing it repeatedly to different dairy herds. But Lowe dismisses the idea as “some fanciful thinking by some cow veterinarians and some cow producers” who hoped to “protect the industry.”

Richard Webby, an avian influenza researcher at St. Jude Children’s Research Hospital, notes that available data on the virus’ genetic sequence show “no smoking guns”—mutations that could enable it to jump readily from birds to cows. At a 4 April meeting organized by a group known as the Global Framework for the Progressive Control of Transboundary Animal Diseases, Suelee Robbe Austerman of USDA’s National Veterinary Services Laboratory said “a single spillover event or a couple of very closely related spillover events” from birds is more likely. The cow virus—which USDA has designated 3.13—could then have moved between farms as southern herds were moved northward for the spring, perhaps spreading from animal to animal on milking equipment. Lowe notes that researchers at Iowa State necropsied infected cows and found no virus in their respiratory tracts, which could enable spread through the air.

USDA considers H5N1 in poultry a “program disease,” which means it is foreign to the country and subject to regulations to control it. But the agency has made no such determination for the cow disease, which means the federal government has no power to restrict movement of cattle or to require testing and reporting of infected herds or of the humans who work with them. As a result, confusion is rife. A knowledgeable source who asked not to be identified says cattle that were healthy when they left a Texas farm appear to have brought the virus to a North Carolina farm. That raises the possibility that many cattle are infected but asymptomatic, which would make the virus harder to contain. Evidence suggests it has spread from cattle back to poultry, USDA says. Another source told Sciencenone that birds tested positive for the 3.13 strain and were culled at a Minnesota turkey farm right next to a dairy farm that refused to test its cattle. The industry and veterinarians bear some responsibility for the confusion, Lowe says. “We didn’t even try to get ahead of this thing,” he says. “That’s a black mark on the industry and on the profession.” Webby also faults USDA for not releasing data more quickly. The agency made six sequences from cattle—plus six related ones from birds and one from a skunk—available on the GISAID database on 29 March, 1 week after learning that cows were infected. It released one more sequence on 5 April, but then shared nothing else until the data dump 16 days later. Webby suspects the agency has moved cautiously because of the potential impact on the dairy industry. “There are a lot of people who are vested in this, and their livelihoods, at least on paper, can be impacted by whatever is found.”

Thijs Kuiken, an avian influenza researcher at Erasmus Medical Center, says the “very sparse” information released by the U.S. government has international implications, too. State and federal animal health authorities have “abundant information … that [has] not been made public, but would be informative for health professionals and scientists” in the United States and abroad, he says, “to be able to better assess the outbreak and take measures, both for animal health and for human health.” He notes that even the new sequences released by USDA do not include locations of the samples or the date they were taken. USDA said in a statement to Sciencenone that it will continue “to provide timely and accurate updates” and that its staff “are working around the clock” on a thorough epidemiological investigation to determine routes of transmission and help control spread. With its Sunday evening release, USDA made the unusual move to bypass GISAID—which requires a login and restricts how data can be used—and instead posted on a database run by the National Institutes of Health that everyone can access and do with as they please. USDA explained it did this “in the interest of public transparency and ensuring the scientific community has access to this information as quickly as possible to encourage disease research.”  The dairy industry is particularly worried that sales could suffer because of unwarranted fears that milk might infect people with the virus. The Food and Drug Administration (FDA) has said it has “no concern” that pasteurized milk presents risks because the process “has continually proven to inactivate bacteria and viruses, like influenza, in milk.”

But Lowe says for this specific virus, there are no data to back that claim. That’s “shocking,” he says. “It should not be that hard to get that data. I do not know why the foot dragging is occurring there.”

In a statement to Sciencenone, FDA said the agency is working to “reinforce our current assessment that the commercial milk supply is safe” and will share data as soon as possible. “U.S. government partners are working with all deliberate speed on a wide range of studies looking at milk along all stages of production, including on the farm, during processing and on shelves,” the statement said.

Daniel Perez, an influenza researcher at the University of Georgia, is doing his own test tube study of pasteurization of milk spiked with a different avian influenza virus. The fragile lipid envelope surrounding influenza viruses should make them vulnerable, he says. Still, he wonders whether the commonly used “high temperature, short time” pasteurization, which heats milk to about 72°C for 15 or 20 seconds, is enough to inactivate all the virus in a sample. Lowe predicts that with increased safety precautions at farms, including more rigorous cleaning of milking equipment, and the end to the seasonal movement of cattle, this outbreak likely will die out—as often happens when bird influenza viruses infect mammals that do not make particularly good hosts. But he and other researchers say to truly assess the continuing threat of H5N1 in cattle, they need to understand how this virus succeeded at infecting dairy cows in the first place. “Which cells is the virus replicating in? How is it getting around the body? What receptor is it using to get into cells?” Lowe wonders. “Those are the really interesting questions.”

Correction, 23 April 2024, 7:35 a.m.: A previous version of this story said James Lowe necropsied infected cows. He didn't but noted that researchers at Iowa State University did.

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.

This report describes the effectiveness of hybrid immunity among people aged 16 years and older from a blood donor cohort. 

What is already known about this topic?

SARS-CoV-2 hybrid immunity (immunity derived from both previous infection and vaccination) has been reported to provide better protection than that from infection or vaccination alone.

What is added by this report?

By the third quarter of 2022, an estimated 96.4% of persons aged ≥16 years in a longitudinal blood donor cohort had SARS-CoV-2 antibodies from previous infection or vaccination, including 22.6% from infection alone and 26.1% from vaccination alone; 47.7% had hybrid immunity. Hybrid immunity prevalence was lowest among adults aged ≥65 years.

What are the implications for public health practice?

Low prevalence of infection-induced and hybrid immunity among older adults, who are at increased risk for severe disease if infected, reflects the success of public health infection prevention efforts while also highlighting the importance of this group staying up to date with recommended COVID-19 vaccination, including at least 1 bivalent dose.

Published in MMWR (June 2, 2023):

 http://dx.doi.org/10.15585/mmwr.mm7222a3 

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/ 

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.

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

A top F.D.A. regulator cited compelling data for redesigned coronavirus vaccines from Pfizer-BioNTech and Moderna.

WASHINGTON — The Biden administration plans to offer the next generation of coronavirus booster shots to Americans 12 and older soon after Labor Day, a campaign that federal officials hope will reduce deaths from Covid-19 and protect against an expected winter surge. Dr. Peter Marks, the top vaccine regulator for the Food and Drug Administration, said in an interview on Tuesday that while he could not discuss timing, his team was close to authorizing updated doses that would target the versions of the virus now circulating. Even though those formulations have not been tested in humans, he said, the agency has “extremely good” data showing that the shots are safe and will be effective. “How confident am I?” he said. “I’m extremely confident.” This week, both Moderna and Pfizer-BioNTech finalized their submissions to the F.D.A. asking for emergency authorization of booster shots aimed at BA.5 and another subvariant of Omicron that together account for most coronavirus cases in the United States. Federal health officials say they are eager to offer the updated boosters as quickly as possible, pointing to a death toll that now averages about 450 Americans per day and could rise in the coming months as people spend more time indoors.

Cases of the viral disease monkeypox in the United States have been identified for the first time in children - a toddler in California and an infant who is not a U.S. resident, health authorities said on Friday.  The two cases are unrelated and are likely the result of household transmission, the Centers for Disease Control and Prevention (CDC) said in a statement. The agency said the children are in good health and are being treated. Monkeypox, which causes flu-like symptoms and skin lesions, has been spreading largely in men who have sex with men in the recent outbreak, outside the west and central Africa countries where it is endemic. The disease spreads chiefly through close contact.  So far this year, there have been more than 14,000 cases of monkeypox in more than 60 countries, and five deaths in Africa. Speaking on a conference call, Dr. Jennifer McQuiston, deputy director of the CDC's division of high consequence pathogens and pathology, said it is not a surprise that pediatric cases of monkeypox have emerged, but "there is no evidence to date that we are seeing this virus spread outside of" the communities of gay, bisexual and other men who have sex with men.  She said 99% of the 2,891 monkeypox cases confirmed in the United States involve men who have sex with men, but there have been a handful of women and transgender men who have become infected.

White House COVID-19 response coordinator Dr. Ashish Jha, speaking on the same call, said the government has delivered 300,000 doses of a monkeypox vaccine and is working to expedite the shipment from Denmark of 786,000 more doses. He said there is already enough vaccine on hand to provide a first vaccine dose to more than half of the eligible population in New York City and over 70% of the eligible population in Washington D.C. The fatality rate in previous outbreaks in Africa of the current strain has been around 1%, but so far this outbreak seems to be less lethal in the non-endemic countries. However, a number of patients have reported being hospitalized for severe pain. Jha said the U.S. is still evaluating whether the monkeypox outbreak should be declared a public health emergency. "We're looking at that, looking at what are the ways in which the response could be enhanced, if any, by declaring a public health emergency."