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| People queue for a COVID-19 test as the Omicron coronavirus variant continues to spread in Manhattan, New York [Andrew Kelly/Reuters] by Aljazeera.com |
The United States has been hit hard by a winter wave of COVID-19, which was fueled by the highly transmissible Omicron variant. Today's daily death toll is higher than it was during the peak of last fall's Delta wave, and has plateaued at about 2,500 per day. Numerous hospitals remain overburdened and are deferring elective surgeries to make room for patients with COVID-19. Daily cases have been higher than they were during the Delta surge, despite numerous enthusiastic predictions that we had reached herd immunity and the pandemic was over.
Nonetheless, there are encouraging signs that we are approaching a turning point. Daily new cases are rapidly declining—they are down more than 75% from their peak during the Omicron wave. Additionally, hospitalizations are decreasing. While we are not yet immune, particularly in under-vaccinated regions of the United States, the sharp decline in cases is cause for optimism.
The decline in cases also provides an opportunity for fundamental preparation, given the likelihood of another wave. To avoid being overwhelmed again, we should take proactive measures now to establish a preparedness system.
Rather than that, some commentators are calling for an end to pandemic control measures such as indoor masking and testing of people who exhibit no symptoms. Additionally, several states have repealed mask mandates, despite the fact that indoor mask mandates remain popular in public opinion polls (the Biden Administration is being more cautious about easing masking). We completely understand the annoyance and impatience that accompany these calls. Pandemic fatigue is a real phenomenon. However, this yearning for 'normalcy' obscures the fact that our society prior to COVID-19 was far from normal. If it had been, we might not have faced such a devastating pandemic. Rather than that, it was precisely those conditions that allowed for heinous inequities and disproportionate impacts on America's poor, which persist to this day.
We are concerned that the Biden Administration does not place a high enough premium on preparedness. The Administration's decision to make 400 million N95 masks available for free at pharmacies and community health centers was a positive step, and we are delighted that Americans can now order four free rapid tests per household online. However, four rapid tests and a mask will be insufficient to halt the pandemic. These measures are not proportionate to the magnitude of the problem, and they must be implemented in conjunction with actual public health strategies to ensure their effectiveness and sustainability.
Perhaps the most serious issue is that viral transmission continues at a high rate, with approximately 175,000 new cases per day. Fewer than two-thirds of Americans are fully vaccinated—defined as two doses of Pfizer or Moderna or one dose of Johnson & Johnson—which provides less protection than it did prior to the introduction of Omicron. Only about a quarter of Americans have received a booster dose, which offers the best protection against infection, hospitalization, and death. Vaccination continues to be inequitable, including racial disparities, with Black and Hispanic populations receiving vaccination at a lower rate than white populations. Only 24% of children aged 5-11 and 57% of children aged 12-17 are completely vaccinated. Hospitalizations among children under the age of five reached record levels during the Omicron outbreak, but vaccines for this age group are not yet licensed.
Additionally, there is a "pandemic of the forgotten," as the New York Times describes it. Around 7 million Americans have weakened immune systems as a result of transplantation, cancer treatment, rheumatoid arthritis medications, or other medical conditions, and they may become very ill if exposed to COVID-19. Nonetheless, this push toward normalcy appears to dismiss them casually. Additionally, there is an increasing number of people suffering from long-term morbidity as a result of infection—a condition now referred to as Long Covid—that we are only beginning to understand.
When it comes to pandemics, one recurring issue is that we have short term memory. Our fingers are crossed in the hope that this is the final wave. Many of us were taken aback when Vice President Kamala Harris stated that the Biden Administration "did not see Delta coming" and "did not see Omicron coming." This is illogical. It was entirely predictable that viral mutations would occur. There is a significant risk of additional variants emerging, particularly in areas of the world with inequitable and low vaccination coverage due to supply hoarding. Distributing a few rapid tests and masks in the hope that this wave will pass and the pandemic in the United States will be over is not a prudent course of action.
Even with the current variants in circulation, we may see additional waves, as was the case in the South during previous summers, particularly in under-vaccinated states, and as people seek refuge indoors from the heat and humidity. Similarly to what has occurred in the northeast, future winter waves may occur. With Omicron cases on the decline, the time has come to establish a resilient infrastructure capable of withstanding future surges. Rather than declaring "mission accomplished," we must commit a significant amount of effort to true preparedness.
Along with increasing vaccination coverage, how would true preparedness manifest itself?
Rather than distributing N95 masks on a one-time basis, the government should replenish the stockpile sufficiently to deploy them in the event of future outbreaks. These should be widely available and come in a variety of shapes and sizes, and should be stationed outside any high-risk venues, such as public transportation or densely populated indoor gathering places (grocery stores, malls, retail, movie theaters, gyms, and offices), during surges.
Serial rapid tests are required, and they must be made available to individuals who cannot order them online. A single test provides a snapshot in time; therefore, following a known exposure, having enough tests for daily testing prior to leaving the house is all that is required for 5 to 7 days. Rapid tests identify contagious individuals prior to the onset of symptoms, enabling individuals to avoid spreading the infection and thus disrupting transmission cycles. In the past, one of us made analogous arguments for Ebola and Zika. These rapid tests for SARS-CoV-2 can help keep schools and workplaces open and protect vulnerable individuals in nursing homes, jails, prisons, and other high-risk congregate settings. Protecting frontline workers requires the use of high-quality masks and rapid testing.
With the introduction of new antiviral medications, such as Paxlovid, and evidence that early antiviral treatment with Remdesivir is more effective, universal access to free tests has become even more critical. These medications can significantly reduce your risk of hospitalization or death if taken promptly after symptoms begin, but this requires access to testing for an early diagnosis. Increased access to testing must be accompanied by equitable access to these medications—particularly for historically underserved communities.
Paid sick leave would also be part of a comprehensive preparedness plan. During the 2009 swine flu pandemic, an estimated three in ten people in the United States with symptoms went to work, infecting up to seven million others. The United States is the only high-income country that does not require mandatory federal sick leave, and this will continue to be a significant impediment to COVID-19 control.
Another method of reducing SARS-CoV-2 transmission is to enhance ventilation and air filtration in all buildings, including schools. Congress has authorized up to $170 billion in funding for school infrastructure improvements, including air quality improvements. Regrettably, a sizable portion of this money has been squandered. As Joseph Allen and Celine Gounder note, some schools are already facing "attacks from parents opposed to other pandemic-related public health measures, such as masking." Other school districts lack the expertise necessary to upgrade their facilities—they require improved guidance and standards. Some schools report that even with federal assistance, they are unable to afford upgraded ventilation systems.
Rather than being caught off guard by the next wave or variant, we require more comprehensive data and surveillance systems, including wastewater sampling and genomic surveillance to detect and track new variants. We can use improved data to determine when to increase and decrease public health protections. As Megan Ranney, professor of emergency medicine and academic dean of public health at Brown University, puts it, we need "immediate investments in better data systems to signal when a surge is approaching and to provide clear metrics for when to increase protective measures (such as masks)—and clear lines for when these protections can be relaxed."
With so many people remaining unvaccinated globally and many Americans lacking boosters, we should brace for future pandemic ebbs and flows. To avert a pandemic, the US should significantly increase global vaccine access by donating severalfold more doses, rapidly sharing vaccine technology, and funding massive global production. Domestically, a critical guiding principle is that our policies should be driven by data rather than dates; for example, we believe it is preferable to base the end of mask mandates on metrics such as vaccination coverage, hospitalization rates, and ICU capacity rather than an arbitrary end date. Unlike at the start of the pandemic, we now have a remarkable array of science-based tools that can transform COVID-19 into something akin to the common cold or flu, but we'll need higher vaccination rates, improved data and surveillance systems, data-driven policies on masks and rapid tests, improved ventilation in shared public spaces, and a more resilient preparedness system to get there.