The Race To Mitigate the Fourth Surge
The United States is now engaged in another race against the coronavirus. This one is to head off what epidemiologists have warned will be a fourth surge in COVID-19 infections. The most recent surge was propelled by cold weather in which the virus thrives and by the popular gatherings around the holiday season. That surge, which is currently receding, caused over 300,000 new confirmed cases in a single day giving rise to a record number of COVID hospitalizations (131,000) and a record number of COVID deaths (over 4,000 in a single day). Now, three new variants of the virus have been identified in the United States and have the potential for even surpassing the third surge in what has already been characterized as “America’s Dark Winter.”
One of the new variants (denominated as the B.1.1.7 strain) originated in the U.K and has already caused a significant increase in virus cases in that country. While there are already a significant number of cases of the U.K strain in this country, those emerging from South Africa and Brazil have only been identified in a relatively small number of U.S. COVID victims. All three of these variants are believed to be significantly more transmissible than the original strain that originated in China or the one that traveled here from Europe last spring. Because of its head start over the other two, the U.K. variant will likely become the dominant strain of the virus in this country by the end of March.
In studying the physical properties of these variant strains epidemiologists have detected differences in the spikes that emanate from the virus’ spherical cores enabling them to attach to and more easily invade human cells. Individuals who have contracted these strains have displayed much higher levels of the virus in their nasal passages and respiratory tracts. This makes those individuals much more likely to disburse the virus into the atmosphere. Using statistical analyses, epidemiologists have also determined that these variants are likely to be transmitted roughly 50% more often than those strains that have been wreaking havoc here over the past 11 months. Because viruses spread exponentially this 50% increased rate of transmission doesn’t simply mean that the peak number of people who stand to be infected will exceed the previous peak number of infections by 50%. That increase could be many times that amount and, without concerted intervention, could potentially result in 25 times more deaths in a given day than we have previously experienced.
This sobering discovery has led Dr. Michael Osterholm, a respected epidemiologist who serves as the Director of the Center for Infectious Diseases at the University of Minnesota, to predict that we are about to experience a fourth surge of the virus, one which will far outstrip the recent surge that alone caused over 100,000 deaths in a little over one month. The greater the number of cases, the more people who will require hospitalization and if the nation’s hospitals become overwhelmed with patients, death rates will rise. The only seemingly bright news is that the U.K. variant appears to be somewhat less lethal than its predecessors.
An ancillary problem is that the more a virus spreads, the more likely it is to mutate. A recent case in a Boston hospital provided some insight as to how mutations might be fomented. The case involved a man with a compromised immune system. Although he was treated with the same monoclonal antibody treatment that enabled President Trump to quickly recover from his COVID infection, the man never fully recovered and the virus mutated many times while tit remained in his system. When the hospital’s findings were published, other medical professionals around the world were able to identify this same process in one or more of their patients. Epidemiologists have already detected 23 different variants of the original Wuhan virus (17 of which only recently appeared) and future variants could prove to be even more transmissible and more lethal and may not be subject to mitigation by current vaccines or therapeutics. While there is insufficient evidence from which to reach conclusions about the South African and Brazilian variants, there is concern among epidemiologists that they might not be inhibited by the current vaccines.
All of this means that the United States and other nations are now in a race to bring down the number of infections before these new strains of the virus becomes prevalent. The reason for this is simple. Over the course of the past week, the U.S. reported an aggregate of roughly 850,000 new confirmed cases of the virus. Since the virus remains contagious in an infected person for roughly seven days, that means that in the U.S. there are currently 850,000 individuals who are capable of transmitting the virus. If an infected person can infect more than one other person on average the pandemic will continue to grow and if it starts from a base of 850,000 infectious persons, rather than a base of 500,000, the resulting spread of the virus will be many times greater. This makes it imperative that the nation maximize its efforts to reduce the incidence of the virus using all of those weapons that are currently available.
Over the past year, the spread of the virus has grown faster during some periods and slower in others. This essentially means that transmission coefficient at times has hovered slightly above a 1 to 1 infection rate and at times slightly below a 1 to 1 infection rate. The effective transmission rate has been governed by the extent to which the nation has pursued measures to curtail the transmission of the virus. Last spring, the virus spread rapidly in certain northeast states causing the hospitals in New York City to become so overwhelmed that temporary hospitals had to be set up in Central Park and in the Javits Convention Center. In response, a business lockdown was imposed in most parts of the country and the spread of the virus was quickly curtailed. In May and June businesses were slowly reopened which gave rise to a second surge in cases which caused hospitals in Texas, Arizona and California to be pressed to their limits. In response to that surge, the nation reacted by closing bars in infected areas, limiting the size of public gatherings and encouraging the wearing of masks which by then had become more readily available. These efforts proved successful, again stemming the tide of new cases. The third surge of cases was largely the result of an increase in social activity occasioned by the Thanksgiving and year-end holidays. That surge far surpassed the two earlier surges because the virus had gained footholds in all states and was not limited to certain geographic areas.
While simple measures like wearing masks, limiting public gatherings and indoor dining seemed to work well while combatting a virus with a transmission rate of slightly over 1 to 1, much stronger measures are required when addressing a virus which under those same circumstances has a transmission rate of 1.5 to 1. What this calls for is that we do everything we have done in the past to contain the spread of the virus and both do it better and expand our arsenal of weapons if we are to have any hope containing the spread of the new variants of the virus.
The prospect of enhancing what we have been doing does not look particularly bright. There is still a great deal of resistance to taking common sense measures like wearing face masks, limiting social gatherings and social distancing. The pressure to reopen schools to in-class activity has grown as the nation’s children have fallen behind in their traditional learning trajectory. Similarly, many businesses that have been closed or have been operating at limited capacity for the past 11 months are now facing extinction unless they find some way of resuming more robust activity or are subsidized while they remain impaired. On top of that, the Trump administration politicized the whole effort to slow the spread of the virus leading many Americans to reject it as contrary to their political belief. In a recent 136-page report the Government Accountability Office sharply rebuked the Trump administration’s failure to pursue all but a handful of the nearly three dozen common sense recommendations that it had made. As a result, a sizable portion of the population has become resistant to adhering to those measures which over the past year have been proven to help stem the tide of the virus.
To counteract that lingering resistance, the Biden administration and many state and local governments are stepping up their efforts to achieve compliance with the common sense measures like wearing masks, hand hygiene, strategic testing of persons at increased risk of becoming infected, tracing and quarantining infected persons, limiting large and indoor gatherings and maintaining social distancing. The Biden administration is also planning to enhance OSHA regulations that assure worker safety in meatpacking facilities and other businesses where employees are required to work in close proximity to each other.
Unfortunately, these efforts are not universally welcomed. The Wisconsin legislature recently overturned a face mask requirement imposed by that state’s governor and the Governor of Iowa recently relaxed her state’s mask requirement and its state-wide limitations on gatherings. In addition, many Americans are individually resisting such efforts contending that it is an undue limitation on their personal freedom. Fortunately, some industries, such as the airline industry, have taken a firm position that if you want to fly, you must wear a mask or you won’t fly again until the pandemic has been defeated.
The only truly positive news is that the two vaccines currently being utilized (produced by Pfizer and Moderna) as well as the two expected to become available within the next month (produced by Johnson & Johnson and AstraZeneca) and another expected to be ready by the summer (produced by Novavax) seem be effective in preventing the transmission of the U.K. and Brazilian variants or at least in preventing them from causing major illnesses requiring hospitalization. There is some concern, however, whether they will be effective against the South African variant. Israel, which has moved far more quickly in vaccinating its population, has already proven that these vaccinations can quickly reduce the spread of the virus.
The bad news is that the U.S. has only administered the prescribed two doses of the Pfizer and Moderna vaccines to six million Americans and one dose to another 27 million Americans. Even combining those 33 million individuals with the roughly 27.5 million Americans who have been confirmed to have already contracted the virus the percentage of Americans who are likely to be immune to the virus is still no more than 17%. This means that even if the Biden administration reaches its goal of vaccinating 1.5 million Americans a day between now and the end of March, only about 130 million Americans (or just under 40%) will be protected from the virus by that time. This is far less than the roughly 70%-80% of the population that epidemiologist estimate is needed to achieve herd immunity. This explains why a fourth surge of the virus could be far worse than the recent third surge which itself left many of the nation’s hospitals overwhelmed.
There is a significant unknown which could impact the equation as to whether there will even be a fourth surge in coronavirus cases. That unknown is just how many Americans have already been infected by the virus. One thing that seems pretty clear is that the total number of confirmed cases does not fully encompass everyone who has been infected. Right now the number of confirmed cases in the U.S. total 27.5 million. The CDC has estimated that the actual number of infected persons might be as high as eight times that number. If that is the case, there would already be over 250 million Americans who are immune to the virus and herd immunity would already be beginning to come into play even if no more Americans were vaccinated. On the other hand, if the number of previously infected Americans were only five times the number of persons whose infections have been confirmed, the total number of Americans likely to be currently immune would be roughly 170 million and the additional 130 million who might be vaccinated between now and the end of March would put the nation close to herd immunity. In that case, there still might be a fourth surge in COVID infections, but the magnitude of that surge might not be greater than the last surge. If the actual number of infection were less than five time the number of confirmed infections. There would not only be a fourth surge in COVID infections, but it would be far more devastating that the one we recently experienced.
It’s difficult to explain how the number of infected persons could be many times the number of confirmed infections. Many of them might have been asymptomatic while other might have experienced only minor symptoms and not bothered to get tested for the virus. It has also been suggested that many infected persons received false-negative readings when they were tested. Still, it’s difficult to conceive that the number of non-confirmed infected persons could be more than one or two times the number of persons whose infections have been confirmed. Yet, there is some evidence that is consistent with the possibility that the number of infected persons could be several times the number of persons whose infections have been confirmed.
Over the past three and a half weeks there has been a precipitous drop in the daily number of new confirmed cases of the virus. According to the COVID Tracking Project, the 7-day average number of daily new confirmed cases dropped from a high of 244,551 during the 7-day period ended on January 13th to 120,446 during the seven-day period ended February 6th. This represents a decline of over 50% in less than one month. This drop appears to be the product of two factors: (1) a decrease in the number of social gatherings following the conclusion of the year-end holiday season (unquestionably a major factor) and (2) an increase in the number of COVID vaccinations (roughly 20 million). While the Israeli experience clearly demonstrates that a widespread vaccination program will cause a sharp drop in the number of COVID infections, 20 million vaccinations in a nation of 330 citizens (even when combined with a reduction in social gatherings) would not appear to be a likely cause of such a dramatic decrease in the number of new confirmed cases. This could be evidence that the ratio of actual infections to confirmed cases could be close to 8 to 1 and that we are starting to see the early effects of herd immunity.
Assuming that a fourth surge remains a distinct possibility, the Biden administration is stepping in to help state and local governments coordinate their vaccination programs. It has called upon FEMA to help establish vaccination centers in areas that can treat minorities who have been disproportionately infected by the virus. While utilizing drugstores and grocery stores to administer vaccinations will certainly help speed the vaccination process, those stores are generally not found in poor neighborhoods. These efforts, however, while commendable will not necessarily make the nation’s vaccination program successful. The Wall Street Journal reports that as many as 25% of Americans will not seek COVID vaccinations which is rather alarming considering the approaching fourth surge of the deadly virus.
This problem is compounded by the fact that the current supply of the available vaccines is limited and additional supplies may not become available until the early summer by which time the new strains of the virus may be causing great havoc. To help alleviate this problem Moderna is applying to increase the number of doses it can deliver in a single vial. At the same time, the Biden administration has committed to additional purchases of the Pfizer and Moderna vaccines and is taking measures to expedite production of those vaccines. The limited supplies of vaccines have also prompted Dr. Osterholm to recommend that the U.S. immediately use all available doses of approved vaccines to vaccinate as many people as possible as fast as possible and delay second doses for those who have already had a single dose of the Pfizer or Moderna vaccines. The CDC also seems to be coming to this position although its ultimate decision may depend upon its assessment of the number of Americans who have already been infected by the virus.
It’s still too early to predict whether the nation’s efforts to prevent or limit a fourth surge of the virus will be successful. All that can be said at this moment is that at least we now have an administration that is fully engaged in trying to address it.