It was supposed to be over by now.
Remember a year ago at this time, when President Trump announced that he wanted the economy open by Easter? Or the numerous pronouncements that COVID-19 would simply melt away in the summer heat? Indeed, things seemed to be on the wane last June, only to spike back up higher than ever in July and August. A fall lull gave us all false hope, with vaccine makers dangling tantalizing preliminary results from their clinical trials—but then came Thanksgiving, with its attendant crescendo in cases, followed by another steep national rise in cases during January, after the winter holidays.
At long last, the vaccines became available, starting in December and January. There were fits and starts, and supply was initially limited, but as Pfizer, Moderna and Johnson and Johnson all received Emergency Use Authorization by the FDA, cases began dropping and hospitals began emptying. In addition to the clinical trial data that the vaccines are ~95% effective in preventing disease acquisition and nearly 100% effective in preventing serious illness requiring hospitalization, there are good data that the available vaccines are quite effective in “real world” use, preventing disease acquisition and transmission to others (https://www.telegraph.co.uk/global-health/science-and-disease/pfizer-modernas-mrna-vaccines-90-per-cent-effective-real-world/ )(https://www.nytimes.com/2021/03/29/world/pfizer-moderna-covid-vaccines-infection.html ). Moreover, the vaccines are quite safe, with serious side effects only seen in ~ 2 persons out of every million who are vaccinated (https://www.cnn.com/2021/04/09/health/covid-vaccines-adverse-reaction-rare-trnd/index.html ). Vaccine availability is ramping up; in fact, most states will make every citizen over the age of 16 eligible for immediate vaccination this month, if they have not already (Georgia allowed all persons to be eligible as of this past week). The U.S. has been setting new vaccination records daily, averaging over 3 million vaccinations per day last week, with a record 4.1 million vaccines given on Saturday, April 3. The total number of Americans who have received at least one dose of a COVID-19 vaccine has now reached 142 million, or 43.2% of the U.S. population, and 24% of Americans have been fully vaccinated. It seems like the end of the COVID-19 pandemic, with wide availability of safe and effective vaccines for most of the population, should finally be readily at hand, right?
But as ESPN’s Lee Corso is fond of saying, “Not so fast, my friend.”
Despite these efforts, our country has seen a steady increase in cases in recent weeks. On March 8, there was a daily average of around 46,000 new COVID-19 infections nationally, representing the low point of new cases after the January case spike. The rolling 7-day average is currently ~65,000 cases per day. Michigan, Florida, Connecticut and New Jersey are all having sharp increases in case numbers. Deaths, always a lagging metric, continue to fall nationally—but that may not last for long.
So what is happening? There are two explanations, both of which are likely contributors: The rise of the variant strains, which are more transmissible, sometimes more deadly and may be more resistant to our current vaccines, and the relaxation of pandemic mitigation strategies such as mask-wearing and social distancing (https://www.nytimes.com/interactive/2021/04/06/us/variants-cases-spread.html?referringSource=articleShare ).
Variant Strains
Much has been made of the new variant strains of COVID-19 which have been emerging in this country. The same thing is happening just to our north, in Canada, where a variant-fueled outbreak has led to additional economic shutdowns. The Canadian outbreak, centered primarily in the provinces of Ontario, Quebec and British Columbia, has been particularly troublesome among young people. Nearly half of the patients in Ontario’s ICUs are people under 60. Low COVID-19 vaccination rates in Canada have further accentuated the effects of this outbreak, as less than 2% of all Canadians have been fully vaccinated (https://www.businessinsider.com/canada-3rd-covid-19-wave-young-people-new-variants-2021-4) .
The CDC currently lists five “variants of concern:”
The B.1.1.7 variant, responsible for the recent surge in cases in England, has been steadily increasing in the U.S. It accounted for 32% of all new U.S. cases as of March 13, and the CDC recently announced that B.1.1.7 is the most common single COVID-19 variant being isolated in the U.S. This variant is about 50% more transmissible than earlier variants and appears to be more deadly. As a result, it is much more likely to be spread among young people (i.e. among school-age children), and to cause serious illness in those populations. The good news is that it appears to be prevented by the currently available vaccines (https://www.nationalgeographic.com/science/article/how-this-more-contagious-virus-variant-became-dominant-in-the-us ). The B.1.351 variant, originally isolated in South Africa, is also about 50% more transmissible, and appears to be moderately resistant to the current vaccines. There is no information currently about the relationship between this variant and disease severity. The P.1 variant, originally isolated in Brazil, is the strain responsible for the current deadly outbreak in that country. Brazil is currently averaging over 4000 deaths per day and has now become the global epicenter of the pandemic. Its total number of deaths may ultimately exceed that of the U.S., despite having only 2/3 of the U.S. population. The P.1 variant was isolated from patients in a COVID 19 outbreak at Whistler Blackcomb ski resort in British Columbia. Strikingly, 83% of the COVID-19 patients in the Whistler outbreak were persons aged 20-39. The B.1.427 variant, first detected in California, is about 20% more transmissible, and is moderately resistant to current vaccines. This is similar to the B.1.429 variant, also isolated in California, which is about 20% more contagious, and is moderately resistant to current vaccines. It is not clear if the California variants cause more severe disease (https://www.beckershospitalreview.com/public-health/state-of-covid-19-what-you-should-know-about-the-cdc-s-5-variants-of-concern.html ).
Cases of all of these variant strains have been reported in Georgia. Although Georgia’s prevalence of the B.1.1.7 variant was most recently estimated at just over 20%, that variant’s share of cases has been doubling every 10 days or so. A rise in B.1.17 transmission, coupled with a relatively low vaccination rate, have been cited as factors in the recent spike in COVID-19 case counts in Michigan, which has seen a 50% rise in cases over the past month.
Relaxation of Pandemic Mitigation Strategies
The rise of the variant strains has been accompanied by a relaxation of social distancing measures in a number of states. A recent Gallup poll showed that only 38% of American households are mostly isolating themselves from outside contacts, which ties with November 2020 for the all-time low value during the pandemic. Similarly, record low numbers of Americans are avoiding public places like restaurants (48%), large crowds (62%) and travel (57%), all of which are down about 30% from the all-time high numbers recorded in April 2020 (https://news.gallup.com/poll/343022/social-distancing-behaviors-drop-vaccinations-rise.aspx ). Many states have relaxed masking and business restriction guidelines, including Florida, which is in the midst of its own case spike. Miami/Dade County has been averaging over 1200 COVID-19 cases per day over the week ending on April 3, and the majority of those cases have been among young people (https://www.nytimes.com/interactive/2021/us/florida-covid-cases.html?referringSource=articleShare ). In Orange County, Florida, for example, the average age of persons diagnosed with COVID-19 has recently dropped to 30. The relaxation of pandemic mitigation measures (mask-wearing mandates, business restrictions, etc.) has been touted by Florida Governor Ron DeSantis as one reason people are flocking to Florida for vacation—but those same relaxed standards have certainly been additional drivers for the recent spike in infection rates in that state (https://www.cbsnews.com/news/gottlieb-covid-infections-hot-spots-face-the-nation/ ). Travel is also increasing, with AAA reporting that more Americans are willing to travel now, as compared to a year ago (https://www.ajc.com/news/business/aaa-more-georgia-residents-willing-to-travel-as-vaccinations-expand/GOIXLR6PJNHT7PEOH6ZCADKHSE/ ).
What Does the Future Hold?
At current vaccination rates, it is estimated that 90% of the U.S. population may be vaccinated by July 24 (https://www.nytimes.com/interactive/2020/us/covid-19-vaccine doses.html?referringSource=articleShare ). This includes children, even though no vaccine has yet been approved for vaccination of children under the age of 16. Clinical trials of the Pfizer vaccine among 12 to 16-year-olds have been encouraging, however, and will likely lead to Emergency Use Authorization (EUA) for that vaccine among middle school and high school-age children soon (https://www.cbsnews.com/news/pfizer-covid-vaccine-safe-effective-adolescent-12-15-year-olds/). Pfizer has recently asked the FDA to allow EUA for its vaccine for 12-15 year-olds (https://www.medscape.com/viewarticle/949071 ). As younger people are currently the most prevalent persons being diagnosed with COVID-19, and as the B.1.1.7 variant seems to have a higher virulence among young people than earlier COVID-19 strains, it is of paramount importance that vaccines be available to persons in that age group before the start of the next school year.
One issue that is emerging as an impediment to the drive to get Americans vaccinated has been so called vaccination reluctance. Unfounded social media rumors about the COVID-19 vaccines have undermined efforts to broaden the base of vaccinated persons in this country, leaving many states with a surplus of available vaccine doses and unfilled vaccination spots (https://www.nytimes.com/2021/04/09/health/vaccine-mississippi-demand.html?referringSource=articleShare ). Reluctance has been particularly robust among young conservatives, who have an amorphous distrust of big government or who simply do not trust the COVID-19 vaccines themselves, citing unfounded concerns about safety, efficacy and long-term side effects while simultaneously downplaying the potential deleterious effects of COVID-19 infection itself. A recent poll showed that 57% of self-identified Republican voters under the age of 49 said that they would not take a COVID-19 vaccine if it were available to them. That same poll revealed that vaccine reluctance among African-Americans, widespread earlier in the pandemic, appears to be waning (https://civiqs.com/results/coronavirus_vaccine?annotations=true&uncertainty=true&zoomIn=true&party=Republican ).
There has been a great deal of attention paid to the concept of “herd immunity.” That’s the level of immunity required to successfully prevent ongoing community transmission. There are many variables which play a role in reaching that goal, including vaccination rates, relaxation of viral mitigation strategies and the emergence of resistant variant strains. Looking at all of those variables, the public health research group PHICOR has estimated that we will likely reach herd immunity in the U.S. sometime in July, 2021 (https://www.nytimes.com/interactive/2021/02/20/us/us-herd-immunity-covid.html ). However, in the interim, thousands of Americans may still become infected—and many more will still die.
Georgia has lagged behind other states in terms of vaccination rates (https://www.nytimes.com/interactive/2020/us/covid-19-vaccine-doses.html?referringSource=articleShare ). As of April 9, 2021, a total of 29% of the adult population in Georgia has received at least one dose of a COVID-19 vaccine, and 15% are fully vaccinated. Unfortunately, Georgia ranks 46th out of 50 states in the efficiency of vaccine utilization, as the state has only administered 66% of the COVID-19 vaccine doses which have been delivered to the state so far. In addition, according to the CDC, Georgia ranks dead last among the 50 U.S. states among the percentage of its citizens who are fully vaccinated. New Mexico, at 28%, has the highest full-vaccination percentage.
Chatham County has had 24% of its population receive at least one dose, with 19% having reached full vaccination status. Interestingly, over 75% of Chatham County residents over the age of 65 have been vaccinated, as compared to less than 25% of persons under the age of 55 (https://experience.arcgis.com/experience/3d8eea39f5c1443db1743a4cb8948a9c ).
The Way Out
From a U.S. public health standpoint, this has been the most brutal year any of our lifetimes. Not since the 1918 influenza A pandemic has there been such a catastrophic failure of public health measures in this country. When we compare the U.S. deaths due to COVID-19 to those of countries with more effective pandemic public health strategies, the scope of our public health failure is astonishing. Excess deaths of Americans relative to prior years spiked upward 23% during the pandemic (https://www.medscape.com/viewarticle/948641 ). A study in JAMA published in October 2020 compared excess U.S. mortality during the pandemic to other nations whose pandemic response was more effective. For example, Australia had 3.3 COVID-19 deaths per 100,000 by that point, relative to 60.3/100,000 in the U.S. If the U.S. COVID-19 strategy had been as effective as Australia’s, there would have been about 188,000 fewer deaths from COVID-19 by that time—and that was seven months ago. The disparity at this point would be even more staggering (https://jamanetwork.com/journals/jama/fullarticle/2771841?utm_source=silverchair&utm_campaign=jama_network&utm_content=covid_weekly_highlights&utm_medium=email )!
Measurement of the overall impact of the pandemic simply by virtue of the number of COVID-19 deaths alone grossly oversimplifies the situation. It has been estimated that only 66% of all of the excess deaths in this country during the pandemic can be directly attributed to COVID-19. Diversion of health care resources away from other acute illnesses, such as strokes, heart attacks and things like appendicitis, etc. has caused numerous deaths from all of those other disease processes. Due to fears over contracting COVID-19, many people have not sought medical attention for conditions which they might otherwise have addressed. Social distancing measures have led to increases in alcoholism, drug abuse, domestic violence and suicide, not to mention indirect impacts related to loss of income among millions. Violent crime has increased during the pandemic, as well. All of this has led to a staggering increase in all-cause excess mortality during the past year ( https://ourworldindata.org/excess-mortality-covid ) and a sharp drop in life expectancy in this country of well over one year, with disproportionately high drops in life expectancy among underserved African American and Hispanic populations(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523145/ ). These figures do not even take into account the long-term effects of people not addressing appropriate preventative measures such as mammograms, colonoscopies and measures to control high blood pressure and blood sugar. The impact of those variables will likely not be fully appreciated for years.
We have been dealing with this pandemic for well over a year now. To date, over 31 million U.S. citizens have been formally diagnosed with COVID-19, and over 560,000 have died (https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html ), although both of these figures undercount the true numbers. Georgia’s official counts are over a million COVID-19 cases and nearly 19,000 deaths. In Chatham County, we have seen 22,000 cases and 418 deaths. What is abundantly clear is this: The effective use of viral mitigation strategies such as social distancing and mask-wearing, coupled with ongoing mass vaccination, are our best weapons for defeating COVID-19 once and for all.
The politicization of our nation’s pandemic response has led to conflicts over mask-wearing, social distancing efforts and vaccine acceptance. Those conflicts, in turn, have led to a fragmented, patchwork pandemic response and, ultimately, to mass confusion about what constitutes the most appropriate pandemic strategy. Partisan politics have left us largely rudderless throughout the past year, our country’s health strategy drifting aimlessly on the random currents of public opinion. It is 100% certain that the lack of a unified and cohesive national strategy for dealing with COVID-19 has been directly responsible for the deaths of hundreds of thousands of Americans. As a physician, I find this not only unacceptable, but morally bankrupt. Anyone who has seen the effects of COVID-19 firsthand, as I have, would understand.
I have said this before in this blog, and I will say it again: COVID-19 is not the flu. It is far more transmissible and far more deadly. The case fatality rate (CFR) of COVID-19 worldwide ranges from 0.2% to 10%; in the U.S., it is currently around 1.8%., although it is far higher in the elderly and in those with pre-existing conditions such as COPD and heart disease. By comparison, the CFR of influenza A in this country is around 0.1-0.2% (https://ourworldindata.org/mortality-risk-covid?country=~USA#what-do-we-know-about-the-risk-of-dying-from-covid-19 ). The pandemic’s morbidity and mortality data are not overblown, nor are those data being manipulated by health care providers to “get more money,” as has been suggested by some on social media. Health care providers, most of whom wear masks for up to 12 hours per day, are more ready for this to be over than just about anyone. To imply that there is some sort of conspiracy to inflate the impact of this pandemic in order to line the pockets of those individuals who put their health and, indeed, their very lives at stake every day in the face of this disease does not show them the respect that they should have earned by virtue of their efforts over the past year. More than 3600 U.S. healthcare workers have died of COVID-19 during the pandemic (https://www.medscape.com/viewarticle/947304 ). These were not individuals who were elderly and ill. Instead, these were productive members of society who had dedicated their lives to the care of others. Those 3600 souls paid the ultimate price as a result of their career choice.
The COVID-19 pandemic has been a trying time for people worldwide. The death toll, which has been substantial, only tells a part of the story. Numerous survivors of the disease have had long-term side effects, often lasting for months. Job losses, business failures and changes in the social fabric of our society have altered the entire landscape of our day-to-day life experiences. At long last, we can now see the finish line, but we aren’t there yet. It is imperative that we continue to protect the most vulnerable among us, expand vaccine availability, educate people about the importance of mitigation strategies and persevere through these next few months as we work our way back towards normalcy—and we WILL get there. Barring the emergence of another more resistant variant strain, I anticipate that things will seem relatively normal by the fall of 2021. Restaurants will be fully open again, stadiums will fill up, and live music will once again be a part of all of our lives. We should all be able to see family members and loved ones without fear of spreading infection to others. By Thanksgiving, I anticipate that we all should have a lot more to be thankful for.
That would be truly welcome outcome for all of us.