Public Health Weekly

The End Is Near for the U.S., but Not the World

The latest Covid insights from former CDC Director Tom Frieden

There is now steady good news about Covid-19 in the United States. Cases, hospitalizations, and deaths continue to decrease, and the pace of vaccination is accelerating. Serious risks remain from variants, vaccine inequity, and failure to learn the lessons of Covid-19.

First, the good news. As reported by the CDC, cases in the United States have decreased 75% from their peak in early January, with hospitalizations and deaths following. Vaccinations (after a weather-related disruption) are increasing, and much more supply is on the way — the Johnson & Johnson vaccine will add millions of doses to the supply. If things continue to go as planned, by June anyone in the United States over the age of 16 who wants a vaccine should be able to get one.

Vaccinations are saving lives

As reported by the New York Times, there has already been tremendous progress in driving down Covid-19 deaths in nursing homes, which has happened more rapidly as compared to deaths in the United States as a whole. As I’ve been predicting for the past two months, we can expect even larger reductions in deaths in March as vaccine-induced immunity kicks in. The risk of death from Covid-19 among all those infected will fall by at least two-thirds.

Covid-19 tamed?

Will vaccination make Covid-19 no deadlier than seasonal influenza? There are at least two major problems with that question: First, with high infectivity and moderate case fatality, Covid-19 would still at best be like a moderately severe flu. And flu is the Rodney Dangerfield of infectious diseases — it doesn’t get the respect it deserves.

Every year in the United States, flu causes tens of thousands of deaths, hundreds of thousands of hospitalizations, and billions of dollars in health care and economic costs — much of which could be prevented. Flu vaccination works, but not very well, and not as well as Covid-19 vaccines appear to work. Masks and distancing crush the flu curve, although neither are something we’ve regularly done during flu season in the United States, as in other countries. Maybe we should start.

Variants are the wild card

Now, the bad news. The worst news of the past month is that data from the Novavax trial in South Africa suggests that prior infection might not prevent reinfection with the B.1.351 variant. But the validity of the antibody tests used in that trial is uncertain — so the jury is still out.

There’s been unnecessary controversy on variants. Attacks from all sides aren’t helping. The bottom line: Variants are definitely a risk, and we also definitely don’t know how big a risk.

It’s better to be safe than sorry, but we in public health should also recognize that people (including politicians) may choose to take risks. But we hope they are informed risks based on careful consideration of the data, community prevalence, and other factors grounded in science. Also, hopefully we all distinguish between risks we take where the risk is to ourselves and risks we take with others’ lives.

Think of it this way: It’s one thing to risk your life climbing a cliff. It’s quite another to do that when you might start an avalanche that kills people in the town below.

Why do variants spread? Sometimes they’re more fit and better able to reproduce. But sometimes it’s “stochastic” — a fancy word for happenstance. A superspreader event could be the starting point. Or it could be the founder effect. Or it might just be plain bad luck (or good luck, if you look at it from the standpoint of the virus). More common doesn’t necessarily mean more infectious or more dangerous.

Two puzzlers for the week

Why are U.S. cases dropping so fast?

See the arrows I’ve drawn in the second graph below from the Covid Tracking Project: U.S. cases are dropping much faster in surge three, the most recent surge, than they did in surges one and two. Was this because we started from a higher peak (driven by travel and holidays that are now over), increased masking, and rapid rollout of rational national policy? Maybe.

Imagine you’re a virus attacking 330 million people; 100 million have natural defenses from a prior attack, and 10 million more are being vaccinated each week. The places where it’s still possible for you to land are thus shrinking. The concept of herd immunity is another false dichotomy; the steeper slope of the current decline in cases is likely, at least in part, from increasing immunity.

For those wondering about the 100 million number: That’s a reasonable estimate of the number of people infected in the United States so far. There are various ways to estimate that. It’s simplest to estimate from the number of deaths to the number of infections at an approximate ratio of 1:200. So, 500,000 deaths translates to about 100 million infections. Not all infections will result in immunity, and we still don’t know how long immunity will last.

But the biggest driver of the decrease is us: masking, distancing, reducing travel. The odds of the United States experiencing a large fourth surge are falling steadily. But please, keep up your masks, your distance, and your perspective: 2,000 deaths a day is horrifying. A 75% reduction from a huge number is still a huge number. In a few more months, if all of us keep it up, we’ll be in much better shape.

Why are cases in New York City not dropping nearly as fast?

I remain puzzled about New York City, which was hit hard and fast early in the pandemic. The decline there is real, but it’s much slower than the national decline. The baseline infection rate in New York City is higher, so it can’t be because of less immunity — there’s more. Test positivity rates are trending down, but only slowly, as shown in the graph below from the city’s excellent site (which also shows tenfold differences in risk in different neighborhoods of the city). Variants are one theory (and a new variant has just been identified in New York City) but at this point, it’s just that — a theory. Time will tell, for better or for worse, what is happening there.

Vaccine equity

After variants, the second big risk is the lack of vaccine equity, both in the United States and globally. Anywhere the virus spreads, more dangerous variants have a chance to emerge and threaten health everywhere. We need to scale up control measures, including vaccination, everywhere.

A safer future

The third big risk is that we fail to learn the lessons Covid-19 has to teach us. We need new funds to improve preparedness ($5 billion to $10 billion or more per year, for at least a decade) and for strengthened primary care. The World Health Organization and other global institutions need to be stronger. There needs to be more technical collaboration, better management, and better immunization of public health from politics. In short, we need substantial changes in how we approach pandemic prevention and response.

And so much is still unknown about long-haul Covid-19. It takes many people a long time to improve, even from a relatively mild case. Some people have continued to suffer for many months, with no end in sight. It’s important that the National Institutes of Health lead systematic studies so we can learn more and, more importantly, do more to help those who are struggling with persistent symptoms.

We’re near the end — but will we get there?

When will it be safe to go out again? This summer, the United States will be much safer. Will we learn to cluster-bust, stopping spread promptly, even though Covid-19 won’t be as lethal since the most vulnerable people will have been vaccinated? Will variants evade our defenses? And will we help the world stop Covid-19?

Answers to these three questions will determine how much normality we get back and how soon. Often in public health, the right answer to a hard question is “it depends.” In this case, it depends on us. Can we strengthen test/trace/isolate strategies to box in the virus as its potential landing places continue to shrink? Can we scale up vaccine manufacturing and distribution for the entire world?

Last week, the United States reported 2,000 deaths per day. PER DAY! For the past three months, as shown in the graph below, Covid-19 has killed more people in rich countries than the leading cause of death: cardiovascular disease. At Resolve to Save Lives, Covid-19 is a primary focus. (Pandem-ic.com, also linked above, is an excellent website visualizing the pandemic and its inequalities.)

This past week marked exactly one year since it became clear that a pandemic was inevitable. I summarized some of our work during this past year in Covid-19 and other areas in a message to our partners. Here is more about what we do at Resolve to Save Lives.

Covid-19 isn’t over. Right now we have no idea what the upticks below, as reported by Our World in Data, mean and whether they will persist. Again, time will tell. We need to keep our perspective clear. A lot better still doesn’t mean good. Covid-19 remains rampant. Global control is essential.

Not everything that is faced can be changed, but nothing can be changed until it is faced.—James Baldwin