Public Health Weekly

Safer Doesn’t Mean Safe (Yet)

The latest Covid-19 insights from former CDC Director Tom Frieden

Better, But Not Yet Good

Covid decreases are steep, sustained, and nationwide. Cases decrease first, then hospitalizations, then deaths. There are four major reasons for the decrease: less travel, less mixing of people indoors, more consistent mask wearing, and growing immunity from infections (about 30% of the U.S. population) and vaccination (12% have received at least one dose).

Herd immunity isn’t an on-off switch — increased population immunity (primarily from infection, not vaccination) is likely accelerating the decreases. The virus has less and less room to maneuver. But herd immunity also isn’t uniform across society, and most people are still susceptible.‌

Better does not mean good, and safer does not mean safe. More than half of the American people are still susceptible to becoming infected, and infection rates remain quite high in many places. We’re still higher on all three metrics — cases, hospitalizations, and deaths — than we were in September and October when the current, now subsiding wave started to pick up steam. So, although the situation is much improved this month, we’re still not where we were at the end of summer.

‌Ongoing surveys by Carnegie Mellon University using the Facebook platform show that we’ve sustained our behavioral change surrounding Covid. Changes in mobility and mixing were the major drivers of both the recent increase and the current decline.‌

The bumps over the winter holidays boosted and accelerated viral spread, and the tide is now steadily ebbing. But continued declines are not inevitable. We have to keep up our guard, or the virus — armed with new variant tools — could come roaring back in a deadly 4th wave.

Variants Are the Wild Card

Variants continue to be THE wild card in controlling the pandemic. If mutations mean the virus is better able to evade natural or vaccine defenses, the risk of explosive spread is high. CDC’s excellent weekly Covid summary notes that we can “stop variants by stopping the spread.” Though the overall national test positivity rate is down to 5.9% (although it’s double that or more in some parts of the country), last week there were (in shocking numbers that we have become too accustomed to) 7,000 new hospitalizations and 2,700 deaths every day.‌

Another great thread by Youyang Gu points out that a doubling every 10 days of the B.1.1.7 variant as a proportion of all Covid cases doesn’t mean a doubling in total B.1.1.7 numbers. More detailed projections about the impact of this variant have been published in the MMWR. The graph below from a preprint article may explain at least some of the increased infectivity of the B.1.1.7 variant, which may be due to a longer period of infectiousness.

Death and Vaxes

‌Although vaccination has not yet had a major effect on Covid cases overall, it IS driving down nursing home deaths: the share of deaths associated with long-term care facilities has been cut in HALF since early January, from more than 30% as a proportion of all deaths from Covid to less than 20%.‌

With most nursing home residents and many other people over age 65 having been vaccinated, I will make a prediction: The infection fatality ratio will likely drop from the current 1 in 200 infections resulting in death to less than 1 in 600 by some time in March.

‌There’s a good article in NEJM about effective communication strategies that can be used to encourage the “moveable middle” of vaccine-hesitant people to accept vaccination. But convenience overcomes reluctance — and the continued difficulty that many BIPOC individuals experience in accessing vaccines perpetuates the unjust, racist power dynamics of the U.S.

Let’s talk about death — uncomfortable as it is, we need to do that more. We also need to highlight the harsh inequities of Covid. There were 344,854 reported Covid deaths in the U.S. in 2020, of which 37% occurred in the first half of the year. CDC just published a new Vital Statistics Rapid Release with data showing the projected life expectancy decreases driven by these deaths.

Americans as a whole lost a full year of expected life due to Covid, but this number jumps to 1.9 years lost for Hispanic people and 2.7 years for Black people. These decreases erased many years of health progress in just a few months.‌

Before we do a deep dive into the numbers, let’s try to never forget that each one is an individual whose life was tragically lost earlier than it otherwise should have. A deeply moving effort by the Washington Post attempts to provide some sense of the enormity of our losses. Please read it.

Since more than 60% of Covid deaths in the U.S. took place in the second half of 2020, we can expect the actual decrease in life expectancy to be well over two years. The Black/White disparity may decrease slightly, but not because prevention and care improved for Black people in the U.S. Instead, as Covid accelerated its spread, the proportion of cases among Whites doubled.‌

There’s far too much missing data but the data is still stark — there are far higher rates of death among Black and Latinx people. Vaccination programs have to prioritize the hardest hit groups. Vaccine hesitancy is real, but lack of access is the driving reason for lower rates of vaccination among minority populations.

‌There’s new and troubling data from Zambia. Of 362 people in one study who died from any cause, 70 tested positive for Covid, but only six of those — less than 10% — were diagnosed before they died. How many Covid cases and deaths have we missed globally? Sometimes the dog not barking in the night is really no one listening. Improved reporting on causes of death is crucial to improve global health.

Vaccine inequity in the U.S. is just a small microcosm of the vaccine inequity globally. The UN reports that 130 countries have yet to receive a single Covid vaccine dose.

Can we have a healthy arms race — to see which country can help other countries get the most vaccines into arms? Increased manufacturing will be essential if we are to meet our moral imperative to rapidly expand global vaccination availability.

Bill Foege notes that public health is at its best when we see, and help others see, the lives and the faces behind the numbers.‌

“We are only as blind as we want to be.”

— Maya Angelou

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President and CEO, Resolve to Save Lives | Former CDC Director and NYC Health Commissioner | Focused on saving lives. twitter.com/drtomfrieden

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