Making sense of the COVID pandemic's omicron phase
COVID cases are surging. You might remember that day the U.S. tallied a million infections in one day. However, in those numbers, some doctors see the beginning of the pandemic’s end.
“COVID will always be here, and I will see the end of the pandemic being when CNN stops having this growing number of cases at the bottom,” Dr. Paul Checchia, cardiac section chief at Texas Children’s Hospital, says. “When that stops, then the pandemic stops.”
Today, On Point—If not cases, then what? We learn how to make sense of the pandemic, now.
Dr. Richard Lessells, senior infectious diseases specialist at the University of KwaZulu-Natal. (@rjlessells)
Dr. Nahid Bhadelia, founding director of BU Center for Emerging Infectious Diseases Policy and Research. Associate director of the National Emerging Infectious Diseases Laboratories (NEIDL). (@BhadeliaMD)
Dr. Celine Gounder, infectious disease specialist and epidemiologist at NYU and Bellevue Hospital. Host of the podcasts “American Diagnosis” and “Epidemic,” which focus on the coronavirus pandemic. (@celinegounder)
Web Extra: Extended Highlights From Our Conversation With Dr. Celine Gounder
On recommendations for the Biden administration’s national COVID strategy
Dr. Celine Gounder: “What we outline in this series of three articles in JAMA is really a reset for the national strategy to control COVID. And that starts with, what are the goals? And I think for much of the pandemic, everyone has wanted to jump in a time machine, to get back to November 2019 before this all started. I think for some people, that means pretending COVID doesn’t exist and just going about life, as they did back in November of 2019. For some people, that means let’s eliminate or eradicate COVID, and get back to that old life. And neither is realistic. We cannot eliminate or eradicate COVID. It’s not that kind of infectious disease. It’s not amenable to that.
“At the same time, we don’t want to continue seeing this level of hospitalizations and deaths. The health system is currently buckling under that load, and it’s impacting our ability to care for any number of medical conditions. And so how do we accept that we are going to have to co-exist with COVID? How do we evolve and adapt to live with COVID? And I think the operative word there is live. And so that first starts with saying, OK, we want to agree upon this goal. That goal is in our mind, how do we minimize hospitalizations and deaths? How do we get that level of hospitalization and death down to a level comparable to what we see in a bad flu year or RSV year?
“Those are the two main viral infections, pre-pandemic, that caused a lot of hospitalization and death. And to give you some sort of context for that, we’re at about 10 times the number of deaths currently just from COVID alone, as we had from those two major other viral respiratory illnesses, pre-pandemic. So we have a lot of work to do.
“What we also outline in those three pieces is how do we suppress cases, hospitalizations and deaths? Understanding that vaccines are highly effective, they’re a very important tool. But unfortunately, vaccines are not going to prevent all infections. And many people are not yet vaccinated, may not get vaccinated for a while. Yet, we still have about a third or more of the country not vaccinated. And so in that context, if we want to suppress hospitalizations and deaths, we really do need to be making use of other interventions.
“So what are those other interventions? That includes masking. We really need to up our game on masking. We need to be wearing masks like N95 masks and KN95 masks. Ideally, the federal government would be providing those to people for free. We also need to be improving our indoor ventilation and air filtration. There are tens, hundreds, really of billions of dollars available for improving indoor ventilation and air filtration in K-12 schools through the CARES Act, the American Rescue Plan, the Infrastructure Bill and more. And yet schools are not accessing that money and spending it on those HVAC improvements in the way that had been planned for.
“And so that’s a major area that needs to be emphasized. And then tests. How can we use tests? How can we make tests more widely available, make them available for free so that people know when they’re contagious, when they’re a danger to others? And then also when they’re infected, and they’re sick and want to get treatment. We have new treatments becoming available in the next several months. In particular, Pfizer’s pill PAXLOVID.
“It will be in relatively short supply in the first couple of months. But then after that, it’s going to be essential that we have a strong, widely available, accessible, free, rapid testing system. So that as soon as somebody feels sick or thinks they might have been highly exposed that they can go, get a test and get medication to treat them, to keep them out of the hospital.”
On other tools the Biden administration can add to a national strategy
Dr. Celine Gounder: “The emphasis of the administration has really been on vaccination. And that is really important, don’t get me wrong. It is so important to get people vaccinated, because that is our best tool in the toolbox. That’s what’s keeping a lot of people out of the hospital right now, through this omicron wave. But vaccines alone are not going to get us to the goals that we’ve outlined. And that’s partly because the vaccines will not prevent all transmission and infection.
“Particularly with omicron now, the incubation period is so short with vaccinations, you’re going to have to keep re-boosting people so that their antibody levels stay persistently high. If you let those antibody levels wane, people are then still protected by their memory immune responses. But it does take four to five days for those memory immune responses to kick in. They will protect you from severe disease, hospitalization and death, but they’re not going to protect you from breakthrough infections.
“And so the other thing I think we have to recognize is there is a significant proportion of the country that is still not yet vaccinated — about a third of the country — that may not get vaccinated for quite a long time, if ever. And so in that context, we really do need to be layering other interventions. And I think while the administration had been really hopeful that first, through trusted messengers, and then later through incentives, and then after that different kinds of mandates, that they would be able to get us to a really high vaccination rate across the country. That has unfortunately not been the case.
“Two of the mandates, one for health care workers and other staff working at health facilities that accept Medicare and Medicaid funding, that is before the Supreme Court right now. It looks pretty promising that that requirement will be upheld. But the other requirement, an OSHA rule for workplaces with 100 or more employees that they either require vaccination or weekly testing, it looks like the Supreme Court may not uphold that rule, may strike down that rule.
“And that was perhaps one of the strongest tools that the Biden administration had to get our vaccination rates up further. And so we really do need to look at other tools. And so those other tools, again masking, indoor ventilation and air filtration, testing, treatment, all of those other tools need to be re-emphasized and better incorporated into the national strategy.”
On whether the pandemic has reached its ‘endemic stage’
Dr. Celine Gounder: “I think a lot of people are confused about what endemic means, a bit the way they misuse terms like herd immunity early in the pandemic. Endemic is really a description of the shape of the case curve. You can think of it as epidemic or pandemic is these big tsunami tidal waves.
“So you see these huge spikes up and down in cases. Endemic is more like ripples in a pond where the ups and downs are not so steep. You have this constant level of transmission in the community. Endemic can be at a high level or at a low level, but it’s not these big up and downs and we’re not anywhere near that yet.”
On whether we’ve reached ‘the new normal’
Dr. Celine Gounder: “We have not yet reached the new normal. I hope we get there eventually. And the new normal that we’re outlining is let’s get hospitalizations and deaths down to a level that’s at least closer to what we saw pre-pandemic. But to get to that new normal, we need to not just vaccinate, we need to do some of these other things. I think the health care system right now is really struggling to function in many parts of the country.
“COVID is really taking over. I’ve been on service at Bellevue, and we are sending our congestive heart failure patients to the cardiothoracic surgeon to manage. Not for surgery, but for the medical treatment we would be normally providing. We have medical ICU patients, patients with COVID, going to the surgical ICU because we have no place else to send them. And that means that all these other surgeries are not happening. So there is a real cost to the entire health care system.
“And it’s not just an impact on people who have COVID, it’s really an impact on anybody who needs to go to the hospital for medical care. That we may not be able to provide them the services that they need … as quickly as we would like. So early in the pandemic, we spoke a lot about flattening the curve, and I think frankly, that remains the goal, this idea that hospitals are not overwhelmed, that they’re able to cope with the volume of patients coming to see them with services. And we still have not achieved that goal.”
On a long-term goal of flattening the curve
Dr. Celine Gounder: “We need to have this reality check. Again, we cannot jump in a time machine, get back to November of 2019. We cannot get rid of COVID. At the same time, I do not think it’s sustainable for the health care system to keep functioning in this way. It is truly crushing the health system, and it’s really costing us. And it’s having a real impact on our workforce. You have health care workers that are quitting, which is leaving more work for those left behind.
“And it’s having a real impact on the quality and timeliness of health care services for all of our patients, not just patients with COVID. But even just to get to flattening the curve, we’re going to have to accept that to get there, we need to do these other things. Not just vaccination, but also masking, improving our indoor ventilation and air filtration, scaling up testing and making treatments more widely available. That’s how we get there. And the sooner we accept that reality, the sooner we can start making progress.”
On a multi-pronged approach to living with COVID
Dr. Celine Gounder: “It’s a multi-pronged approach. I think we have been in denial for far too long that we would need to do more than just vaccinate. I think we’ve been in denial that we could get back to pre-pandemic life. That is not the future, unless we are willing to bear the levels of hospitalizations and deaths that we are seeing right now. If that is the future we want, that we are willing to accept, it’s going to mean opening up a lot more hospitals, hiring a lot more doctors and nurses.
“Taxpayers paying a lot more money for Medicare and Medicaid funded services, and finally higher insurance premiums for people on private insurance. That is the reality. And so we can either pay for it on the front end by investing in ways to mitigate the impacts of COVID, or we can pay for it on the back end with the cost of hospitalization and death.”
On the best way to measure the current phase of the pandemic
Dr. Celine Gounder: “I don’t think cases are the right number to be looking at in determining should we be tightening up or loosening our mitigation measures. Whether that’s in-person schooling, or should you go indoor dining? I think what we really want to focus on are hospitalizations and deaths. We know people will have breakthrough infections, even if they’re vaccinated. Most of those are relatively mild, and they’re not causing people to land in the hospital.
“People are not requiring supplemental oxygen, which is to us, as health care providers, a key barometer of whether a case is mild or not. You might feel bad, but if you can stay home and get better without going to the hospital, that’s still a pretty mild case. And so what we are really advocating is that you decide, do you dial up or dial down various different mitigation measures on the basis of hospitalizations, hospital capacity and in particular, when hospitals are overrun? You know, you really need to do something to slow things down.”
On a takeaway message for the current COVID surge
Dr. Celine Gounder: “People should be upping their mask game, so that means that we would strongly suggest people wear either a KN95 or an N95. Those are no longer in short supply as they were early in the pandemic. They are readily available. We have been advocating to the Biden administration that they make those available for free to people. And just as they will be launching a federal website where people can order rapid antigen tests online and have them delivered for free to their homes. We have suggested that they include KN95 and N95 as part of that website.
“What else can people do for themselves? As rapid antigen tests become more and more available and as they become available for free through the federal website, this is an important tool for people to be incorporating into their routines. So for example, before you go out to dinner with friends, before you visit grandmother at the nursing home, you should be using those rapid antigen tests to assess, Are you contagious, are you a threat to others?
“I think that as those get cheaper, more widely available, those will become a tool that is used increasingly to mitigate risk. And I think another tool, if you can afford it, would be to purchase HEPA air filtration units and put those in rooms in the house or in the workplace. I would say in the home, to put them in places like the kitchen and living room dining room where people are hanging out together, that can also help reduce the risk.”
On a ‘collective action’ COVID strategy
Dr. Celine Gounder: “Very often the … media covers these issues in terms of what can I do as an individual? And that is not how public health works. Public health is about collective action, and collectively solving. And it would be like saying, How can I as an individual flight fight climate change? You’re never going to be able to solve climate change on your own. So I would just urge you guys to think about what are larger-scale interventions that people can be advocating for, that they may not be able to do for themselves. … That’s where things are really going to change, is through collective action.”
This article was originally published on WBUR.org.
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