Public Health Weekly
Best of Times, Worst of Times
The latest Covid insights from former CDC Director Tom Frieden
The third U.S. Covid-19 surge is fading fast, but variants — some of which are deeply ominous — are spreading fast. Vaccination is picking up steam, but we’re failing to address equity. And already high levels of pandemic fatigue are increasing. We must hang on for a few more months until most of us are vaccinated.
The fundamental question is whether we’ll have a fourth surge. If we do, it will cost lives, and also increase the risk that more dangerous variants will spread widely.
But first, some good news: there’s been a dramatically fast decline in cases and test positivity rates — a much steeper decline than in either prior surge. You can see it in both case counts, and test positivity — and test positivity is an even more revealing measurement, so the graph below, from Johns Hopkins, is the most encouraging graph I’ve seen in months.
The thing about wearing masks, not traveling, and minimizing time spent sharing indoor air with people who are not in our household? They work. It’s how we can win the war against the virus. Any time we let down our defenses, it attacks. When we let down our guard (and masks), we are complicit with our viral enemy.
The calm before the variant storm?
The spike in cases which happened in other countries when variants took hold is scary. The proportion of cases from the B.1.1.7 variant (the “UK variant”) is now doubling in a bit over a week in the U.S., and may soon predominate here. The first known case caused by a Covid variant has also recently been found in a prison, where transmission rates are high.
This is no time for complacency — masks and distancing stop even the more transmissible strains.
As CDC put it in their weekly summary, which debuted today: “Better, but not good enough.” (It’s great to see the CDC able to share more of the important work and analysis they’ve been doing for the past year!) Sign up for CDC’s weekly COVID Data Tracker newsletter. And let’s hope that CDC adds the key metric of test positivity to their data next week.
Have a look at the New York Times graphic below, which our team at Resolve to Save Lives helped to design. It details county-by-county Covid risk. We’re doing way better than we were in December — but still way worse than in September.
And there are warning signs, including in NYC, where test positivity is not decreasing (as seen in the graphic below, from the NYC Department of Health). In the battle against Covid, a stalemate favors the virus. The next few weeks will be crucial. If we don’t maintain discipline, viral variants can cause explosive spread.
Variants very worrisome
But even more ominous is preliminary data from the Novavax trial in South Africa, with data, that, if confirmed would indicate that previous infection does not protect against reinfection with the variant strain. This would be the worst news about variants yet, because, if such variants spread, this would mean that prior infection would not count toward achieving herd immunity — a big setback.
Rates of infection, which was mostly with the 501Y.V2 variant (the variant first identified in South Africa) among the placebo group (those who did not receive the vaccine) 7 days after receiving the first placebo dose were 3.9% among those who tested seronegative, but exactly the same, 3.9% for those who were seropositive. If the serology was accurate, this suggests that prior infection didn’t protect people at all. This is quite different from other trials, in which seropositive participants who received placebo had protection rates of 80% or more, and studies in health care workers in the UK suggesting strong protection. Similar to breakthrough infections after vaccination, we don’t yet know if those infected despite immunity will have less severe disease, although we hope they will.
People born with severe immune deficiencies can harbor (and spread) the polio virus for years, and there has been work to identify, treat, and cure these people of their polio infection. Viral evolution and genetic recombination in immunosuppressed people is one theory for why we are seeing rapid genetic changes resulting in these SARS-CoV-2 variants. We need to learn, and do more to limit viral evolution and spread. One approach is to develop pan-corona vaccinations (here is good article on this by Dennis Burton and Eric Topol).
Vaccines remain in short supply
We are picking up the pace of Covid vaccination, and now averaging 1.6 million doses given a day. Both Pfizer and Moderna have promised to roughly double deliveries of their vaccines in next few weeks to meet President Biden’s goal of being able to vaccinate 300 million Americans by the end of summer. I hope the companies are able to keep that promise.
We must do MUCH better on equity. Black and Latinx Americans have 2–3x risk of hospitalization and death but only half the likelihood of being vaccinated. These continuing disparities are not acceptable and we need a concerted effort at a national level and in every state, city, and community to empower and enlist communities and community leaders. Disproportionate burden means there must be disproportionately increased resources, including the right messages and messengers to make vaccination so easy that it becomes the default value. Convenience can overcome a lot of resistance.
The current math, unfortunately, is harsh. So far, 70 million vaccine doses have been sent to states to be administered. We need 364 million doses for priority groups 1a (residents of nursing homes and other long-term care facilities, as well as health care personnel) and 1b (people age 75 and older as well as frontline essential workers), and those age 65–74 along with those who have underlying high-risk medical conditions (part of group 1c). And this would leave out people age 50–64 who are high risk, including those not aware of their underlying conditions. We’re looking at 1–2 more months of vaccine scarcity, at least.
Vaccination of nursing home residents and staff are likely to drive deaths in these facilities down by mid-March; this will also reduce the overall case fatality ratio significantly, since nursing homes account for nearly 40% of all deaths. Israel’s data is encouraging. A new preprint article published earlier this week shows the comparison between the population age 0–59 years old (orange line) and age 60+ (blue line) in new cases. Vaccination saves lives, and this is real-world proof of it, confirming the remarkable efficacy data from clinical trials.
Progress is possible
There’s good new CDC guidance on schools. Schools, especially grades K-8, should open with safety measures that emphasize consistent and correct mask wearing and maintaining proper distancing. Additional layers of Covid-19 prevention include testing whenever possible and vaccination as soon as possible. Teachers are — and should be — prioritized for being vaccinated. While we wish there was sufficient vaccine for everyone right now, including all teachers, unfortunately there is not.
On Friday I published an article in the Wall Street Journal (open access) on how to prevent the next pandemic. Resolve to Save Lives has worked with partners on developing this strategy for the past 4 years. It’s now or never — a teachable moment like no other we’ve experienced in our lifetimes.
I suggest a global target: “7–1–7”. Every country and every community should be able to find an outbreak in 7 days, investigate and report in 1, and respond effectively in 7. Success will take money, technical skill, collaboration, and persistence. Our children’s safety depend on it.
Six steps to meet the 7–1–7 target are:
- Agree on goals and how to measure them.
- Build country preparation and response capacity, particularly with collaboration among lower-income countries.
- Improve global institutions, with the World Health Organization as the anchor and a key role for The Global Fund.
- Get money — at least an additional $5–10 billion a year to build country capacity to find, stop, and prevent health threats.
- Collaborate to global response to address dangerous, life-threatening gaps in preparedness, including laboratory safety and reducing the risk of spread from animals to humans.
- Act now — the urgency of this work has never been so clear, and there is no time to lose.
We need to hang in there. The pandemic won’t go on forever. We’ll be in a much better situation by the fall. For now, mask up and limit time indoors with people not in your household. Vaccines are coming, and we learn more every day about Covid and how to prevent and treat it.
“No winter lasts forever; no spring skips its turn.”
Hal Borland, American author, journalist and naturalist
When day comes we step out of the shade,
aflame and unafraid,
the new dawn blooms as we free it.
For there is always light,
if only we’re brave enough to see it.
If only we’re brave enough to be it.
Amanda Gorman, U.S. National Youth Poet Laureate
from her Inaugural Poem, Jan 20, 2021
