America Has Lost the Plot on COVID

Post Reply New Topic

We know how this ends: The coronavirus becomes endemic, and we live with it forever. But what we don’t know—and what the U.S. seems to have no coherent plan for—is how we are supposed to get there. We’ve avoided the hard questions whose answers will determine what life looks like in the next weeks, months, and years: How do we manage the transition to endemicity? When are restrictions lifted? And what long-term measures do we keep, if any, when we reach endemicity?

The answers were simpler when we thought we could vaccinate our way to herd immunity. But vaccinations in the U.S. have plateaued. The Delta variant and waning immunity against transmission mean herd immunity may well be impossible even if every single American gets a shot. So when COVID-related restrictions came back with the Delta wave, we no longer had an obvious off-ramp to return to normal—are we still trying to get a certain percentage of people vaccinated? Or are we waiting until all kids are eligible? Or for hospitalizations to fall and stay steady? The path ahead is not just unclear; it’s nonexistent. We are meandering around the woods because we don’t know where to go.

What is clear, however, is that case numbers, the metric that has guided much of our pandemic thinking and still underlies CDC’s indoor-masking recommendation for vaccinated people, are becoming less and less useful. Even when we reach endemicity—when nearly everyone has baseline immunity from either infection or vaccination—the U.S. could be facing tens of millions of infections from the coronavirus every year, thanks to waning immunity and viral evolution.

The more highly vaccinated a community is, the less tethered case numbers are to the reality of the virus’s impact.

So if not cases, then what? “We need to come to some sort of agreement as to what it is we're trying to prevent,” says Céline Gounder, an infectious-disease expert at New York University. “Are we trying to prevent hospitalization? Are we trying to prevent death? Are we trying to prevent transmission?” Different goals would require prioritizing different strategies. The booster-shot rollout has been roiled with confusion for this precise reason: The goal kept shifting.

On the ground, the U.S. is now running an uncontrolled experiment with every strategy all at once. COVID-19 policies differ wildly by state, county, university, workplace, and school district. And because of polarization, they have also settled into the most illogical pattern possible: The least vaccinated communities have some of the laxest restrictions, while highly vaccinated communities—which is to say those most protected from COVID-19—tend to have some of the most aggressive measures aimed at driving down cases. “We’re sleepwalking into policy because we’re not setting goals,” says Joseph Allen, a Harvard professor of public health. We will never get the risk of COVID-19 down to absolute zero, and we need to define a level of risk we can live with.

Scientific experts have been reluctant to make that call themselves. For one, there is real scientific uncertainty ahead. We don’t know how much immunity may continue to wane, how long the effects of a booster last, the exact incidence of long COVID in the vaccinated, or if a new variant will upend even the best-laid plans.

But the level of COVID-19 risk we can live with is also not an entirely scientific question. It is a social and political one that involves balancing both the costs and benefits of restrictions and grappling with genuine pandemic fatigue among the public.

One plausible goal is to focus on minimizing COVID-19’s impact on hospitals. A collapsed health-care system means more people will die, not just of COVID-19 but from other treatable diseases and injuries. Elsewhere in the world, like in the U.K. and Germany, leaders have explicitly tied their policies to containing hospitalizations rather than all cases. But in addition to hospitalizations, Gounder suggests we should also consider the risk of long COVID. “I think for people that is the big question. We just don’t know enough,” she says. Preliminary data suggest vaccines do reduce the risk of long COVID, but exactly how much is unclear given the uncertainties in diagnosing it.

Once we’ve defined what we are trying to prevent, we can define thresholds for lifting and, if necessary, reinstating COVID-19 measures. This can actually be quite tricky if the goal is minimizing hospitalizations, a lagging indicator that gives you a picture of the past rather than the present.

In the absence of a coherent strategy, our attention has focused on a policy change we know is coming: vaccines for kids under 12. COVID shots for kids 5 to 11 were authorized last week, and data for those ages 2 to 4 are expected before the end of the year.

To prevent hospitals from being overwhelmed, the key group we need to vaccinate is really the elderly.

The U.S. still has too many unvaccinated elderly people—or rather, parts of the U.S. do. States such as Vermont and Hawaii have done well, given almost 100 percent of people over 65 immunized at least one dose. But in Idaho, Arkansas, and Mississippi, the percentage is languishing in the 80s. Even small differences in this percentage can have an outsize impact on hospitalization outcomes. For example, two communities with 90 versus 99 percent of the elderly vaccinated actually have a tenfold difference in the number of people at risk for hospitalization.

One country that has excelled at vaccinating its elderly population is Denmark. Ninety-five percent of those over 50 have taken a COVID-19 vaccine, on top of a 90 percent overall vaccination rate in those eligible. (Children under 12 are still not eligible.) On September 10, Denmark lifted all restrictions. No face masks. No restrictions on bars or nightclubs.

Even when the coronavirus is endemic, it will still make people sick and it will still cause deaths and hospitalizations. That means our fight against COVID-19 is not over, and we might consider strategies sustainable over the long term.

Hard questions lie ahead, and the answers require political will. But first, we have to stop avoiding them. We need a goal.

Yep....I see annual booster shots in our future.