Confronting the Delta Variant
Earlier this summer, epidemiologists began warning that the Delta variant would soon become the dominant strain of the coronavirus throughout the world and that the U.S. should expect a new surge in COVID cases by the fall when the nation’s children returned to their classrooms and the weather turned colder. Now that prediction is well on its way to being fulfilled as over 93% of the new confirmed cases in this country are the product of the Delta variant. The only remaining questions are just how large this new surge will be and how many American lives will be lost.
In early July I addressed the dangers posed by the Delta variant in my article entitled “Fish in a Barrel” wherein I pointed out that those Americans who had not become vaccinated would become easy prey for this highly virulent new variant. Since then, we have learned a lot more about it and it’s far more frightening than originally portrayed. This has prompted the CDC to do a rapid about-face in the guidance it has provided to minimize the new surge which is already well underway. Now, the CDC is recommending that both vaccinated, as well as unvaccinated, individuals wear masks in indoor public spaces. While the CDC still has not recommended measures that would reduce commercial activity, that may happen in the coming weeks.
From its rapid spread through India, Israel and the U.K. it was immediately apparent that the Delta variant is far more transmissible than its predecessors. An analysis of the variant’s physical characteristics reveal that it has more spikes on its outer surface enabling it to more easily attach to human cells and multiply within the bodies of its victims. Early assessments were that it is 50% to 60% more transmissible than the Alpha variant that triggered the surge in infections this past spring. By way of comparison the CDC has published a chart revealing that among all communicable diseases that have have invaded America, only the measles is more transmissible.
Over the course of the past month epidemiologists have ascertained why this variant is so much more transmissible and why its victims require hospitalization at roughly twice the rate of earlier strains of the virus. Many on these revelations came from an analysis of the victims of what turned out to be a super-spreader event attended by an estimated 60,000 people. This event took place over the July 4th weekend in Provincetown on Cape Cod and gave rise to over 900 COVID infections. What epidemiologists discovered was that 74% of the 469 infected persons they studied had been previously vaccinated. While that seems like as astoundingly high percentage, it must be remembered that this event took place in Massachusetts where roughly two-thirds of adults have been vaccinated. These previously vaccinated victims, however, were largely asymptomatic and even those who became ill had much less serious infections than the unvaccinated victims. This finding reinforced previous studies showing that the current vaccines are highly effective against the Delta variant in preventing serious illness even though they are only about 84% effective against preventing infections by the Delta variant.
One startling discovery emerging from the Provincetown event was that the viral loads found in the nasal passages of the infected persons were roughly ten times greater than those found in the nasal passages of individuals infected with the earlier strains of the virus. This in large measure explains why the Delta variant is so much more transmissible than its predecessors. It’s simple arithmetic that infected persons who emit ten times the number of pathogens are not only more likely to impart a critical mass of pathogens to persons in their close proximity, but also will to be able to do so in a briefer encounter. Equally important, they will be able to infect a larger number of persons in their immediate vicinity. Similarly, because the volume of pathogens being expelled by persons infected by the Delta variant is so much greater there is also a greater likelihood that they will reach persons located further away from the infected person.
The ability of the Delta variant to rapidly attach to human cells and replicate itself also explains why those infected by the variant tend to experience more serious symptoms and are more likely to require hospitalization and have a greater chance of dying. It could also explain why their infections could become contagious sooner (after only one or two days) than those of persons infected with a slower replicating variant. For the same reason, it might even allow those infected by the Delta variant to have a longer period of transmissibility (perhaps ten days, rather than seven days) although this is yet to be established.
An even more startling discovery from the Provincetown event was that the viral loads found in the nasal passages of vaccinated victims were essentially the same as those found in the nasal passages of the unvaccinated victims. This means that vaccinated individuals could be just as efficient vectors of the virus as non-vaccinated individuals. Equally scary is the fact that those individuals are more likely to be asymptomatic and, therefore, more stealthy vectors of the virus. In fact, because of their presumed immunity they are unlikely to even realize that they are spreading the virus. It was this discovery that prompted the CDC to change its guidance to recommend that vaccinated individuals, as well as unvaccinated individuals, wear face a mask in public indoor facilities.
Another factor affecting the seriousness of the coming surge is that the number of Americans without immunity is now believed to be in excess of 100 million, rather than the 30 to 80 million that I had previously hypothesized. This past week Dr. Fauci stated that there are 100 million Americans “eligible to become vaccinated “ who have not already done so. This would not include the nation’s roughly 48 million children under the age of 12. In addition, there are also those who have already been vaccinated but are not fully immune to the Delta variant who will add to the potential number of COVID victims and vectors. Dr. Fauci’s estimate seems overly high (163 million fully vaccinated Americans, 35 million confirmed COVID cases and 48 million children under 12 only leaves only 84 million of the nation’s total population of 330 million) and wholly discounts the possibility of unrecorded infections. It does, however, underscore the fact that there remains an enormous pool of people vulnerable to attack by the Delta variant.
The coming surge has already surpassed those which the U.S. experienced last summer and this spring and could rival, if not exceed, last winter’s surge which produced 300,000 new confirmed cases in a single day (January 8, 2021). That surge also produced an aggregate of nearly 15 million confirmed cases and claimed the lives of over 225,000 Americans in the three-month period ended February 28, 2021. At least one epidemiologist has predicted that the current surge could produce as many as 500,000 confirmed cases in a single day. Considering the large number of potential victims, an average daily infection rate that has already exceeded 100,000 and the 113% increase in the weekly average number of newly infected Americans over the previous two weeks, this projection not only appears reasonable but possibly conservative.
There is also a debate among epidemiologists as to when the new surge will peak. Dr. Scott Gottlieb, a former FDA Commissioner, estimated that the new surge could peak during the next two to three weeks. Others have estimated that the surge will peak in October. To be sure, the reopening of schools and the cooler fall air will help propel infection rates to higher levels. The questions remain whether the nation’s additional efforts to thwart the spread of the virus discussed below will be as effective as those employed this past spring and whether the current rapid spread of the Delta variant will slow as the number of potential victims is diminished. My sad conclusion is that neither of these factors will bring about a decline in the daily number of infections any time soon as the number of potential victims seems far too large to be materially affected by the virus’ current rate of spread. In addition, the efforts now being undertaken to slow the spread of the virus do not seem sufficiently robust to have a significant impact.
As expected, these new developments have caused the Biden administration to reassess and revise its efforts to contain the virus. The focal point of the administration’s strategy will continue to be its efforts to convince, cajole or even coerce those unvaccinated Americans to become vaccinated. Since their introduction last December, the vaccines produced by Pfizer, Moderna and Johnson & Johnson have proven that they are both safe and highly effective in preventing the spread of the virus. Although the Delta variant has been successful in infecting roughly 16% of those who have been vaccinated, the vaccines sufficiently fortify their immune systems to prevent serious illness and hospitalization. In fact, in recent weeks over 95% of those COVID patients requiring hospitalization and over 99% of those dying have not been vaccinated.
This has prompted the Biden administration to not only widened its distribution of vaccines to supermarkets and drug stores, but also to set up vaccination stations around the country in neighborhoods that have few commercial establishments. In addition, the administration has employed mobile vaccination facilities in order to reach individuals in remote locations. On top of that, the federal government has helped the states produce radio and television advertisements encouraging their citizens to get vaccinated. In an effort to take this message to hard-to-reach elements of the population the Biden administration has organized door-to-door campaigns staffed by local volunteers to explain the benefits of getting vaccinated and offering guidance as to where vaccinations are being administered. The federal government is also retaining on-line “influencers” to encourage their followers to become vaccinated.
To further encourage those reluctant to become vaccinated the federal government and many state governments are now offering incentives, including free food, free beer and participation in lotteries with valuable prizes. This past week, President Biden in his news conference offered $100 to each unvaccinated person who becomes vaccinated. While the President apologized to those who had voluntarily become vaccinated, he justified this incentive as being far more cost effective than having to treat those individuals at local hospitals, many of which are already currently in danger of becoming overwhelmed with COVID patients.
Finding messages of encouragement and incentives insufficient, the President has turned to coercion to increase the current rate of vaccinations. He announced that all federal employees would either have to become vaccinated or submit to weekly testing for the virus. He also imposed a similar requirement upon employees of federal government contractors and has instructed the Department of Defense to develop a vaccination program for U.S. military personnel. For those affected employees working in healthcare facilities the alternative of weekly testing will not be available. Even so, unless covered employers also impose mask requirements their employees will remain vulnerable for at least thirty days after their employees’ vaccinations have been administered.
To encourage private companies to require their employees to become vaccinated, the Department of Justice published an opinion stating that it is not illegal for private businesses to adopt mandatory vaccination policies. This has prompted a number of large corporations, like Google, Morgan Stanley, Amazon, Tyson Foods, Microsoft, United Airlines, Walmart, Netflix, Disney World and The Washington Post, to impose similar requirements on their employees. It’s still not clear whether a significant number of private employers will adopt mandatory vaccination policies as many of them are now facing difficulty simply finding and retaining employees. Another discouraging factor is that more than a dozen states have enacted statutes prohibiting private employers from imposing vaccine mandates and these are generally the states with the lowest percentages of vaccinated residents.
Most state governments have been reluctant to impose vaccination mandates on their employees and contractors. Those states that have imposed them currently only include the New York, Louisiana, Illinois, North Carolina, New Jersey and California. While virtually all states with Democratic administrations have encouraged their citizens to become vaccinated, less than one-third of the twenty-eight states with Republican administrations have even been willing to do that; and fifteen states with Republican governors have gone in the other direction issuing or contemplating orders prohibiting county and local governmental officials from imposing vaccination mandates.
While all of these efforts have clearly had a positive effect on increasing the number of people seeking vaccinations, their impact to date has nevertheless been small. Over the past two weeks the daily number of vaccinations administered in this country has risen from 550,000 to 850,000 which is a remarkable increase, but still a small fraction of the over 4 million vaccinations in a single day recorded in mid-April of this year. Moreover, the 850,000 figure only represents a single day’s efforts and the average daily number of vaccinations this past week was still only 652,000. Even if the U.S. were to vaccinate 850,000 Americans on a daily basis, that would only represent the delivery of 26.35 million doses over the course of the next month. Since each individual requires two doses, the resulting increase in the number of vaccinated Americans would only be roughly 13 million or a relatively small fraction of the potential number of virus victims. Adding to the problem is that it takes a month for the vaccines to become fully effective with the result that even those now becoming vaccinated will remain vulnerable through the first week in September. Thus, it will take at least two months before an even robust vaccination program will have a significant impact in reducing the spread of the virus.
As noted above, there are roughly 48 million children under the age of 12 who currently are not even eligible to receive the approved vaccines. Although the FDA has encouraged Pfizer and Moderna to accelerate the clinical trials of their respective vaccines for children between the ages of 5 to 11, FDA approval (even on an emergency basis) for pediatric use is still at least a couple of months away. In addition, roughly 60% of the remaining unvaccinated Americans (roughly two-third of whom are registered Republican) are adamantly against getting vaccinated. Not only have many of the Republican governors not encouraged their constituents to become vaccinated, but a majority of the Republican members of the House of Representatives have not been vaccinated. It would thus appear that not getting vaccinated has become a “badge of honor” within Republican circles.
This leaves only about 20 to 30 million adult Americans who, while reluctant to become vaccinated, could nevertheless be persuaded to do so. There have been a number of surveys seeking to ascertain what it would take to convince them to become vaccinated. One of the problems is that the answers given in these surveys are not particularly candid. It does, however, seem unlikely that persons who have reservations about becoming vaccinated would be persuaded by a free beer, a free lottery ticket or even a $100 inducement. Also unlikely to be effective are messages regarding the safety and efficacy of the vaccines delivered by celebrities or even medical officials. Perhaps the most effective message would be to have the FDA issue a final approval of the currently available vaccines as many unvaccinated individuals cite the lack of a final approval as the reason for their hesitancy. While that action is expected by early September, even those who immediately respond to it would still not obtain immunity to the virus until the beginning of October.
Because no vaccine comes with an iron-clad guarantee there are a number of politicians and their allies in the media who seize upon infrequent infections of vaccinated individuals to cast doubts about the efficacy of the current vaccines. This means that even a final approval of the current vaccines may only have a modest impact on convincing the vaccine-hesitant to take steps to protect their health as well as that of their friends and family members.
This has led at least one public health expert (Joseph Allen of Harvard University’s Chan School of Public Health) to conclude that only a federal mandate requiring vaccinations is likely to prove effective. Such a mandate requiring smallpox vaccinations was upheld by the U.S. Supreme Court’s 1908 decision in Jacobson v. Massachusetts. Still such mandates are very unpopular (particularly among libertarians) and it’s not clear that the current Supreme Court Justices would follow their Court’s prior decision. In any event, there is a strong likelihood that the pandemic may run its course long before the issue could be resolved by our courts.
There is, however, one measure that might have a significant impact in convincing the unvaccinated to reconsider their position. This was suggested in a New York Times Op-Ed article written by two public health experts, Elizabeth Rosenthal and Glenn Kramon. While a government mandate may be politically (and possibly judicially) unfeasible, a stick is far more likely than a carrot to be effective in changing the minds of unvaccinated individuals. Such an approach could include requiring unvaccinated persons to pay a substantial co-pay or deductible of their hospitalization costs (which could be in the tens of thousands of dollars). Imposing higher costs for health insurance is already recognized for those who engage in activities that pose health risks (such as smoking or drug or alcohol addiction) or a high risk of injury (such as rock-climbing or sky-diving). While there are legal obstacles which might prevent federal health programs from requiring unvaccinated individuals to pay a substantial portion of their hospital costs, there is no reason why private health insurers could not immediately require unvaccinated individuals to pay a significant portion of their own hospital expenses. Indeed, the vast majority of unvaccinated individuals are under the age of 65 which means that their hospital costs are only likely to be covered by private insurance.
While vaccinations are clearly the best way to defeat the Delta variant, protecting oneself and one’s fellow citizens will also require a re-imposition of mask and social distancing mandates. This is a necessary step to “buy time” until a much greater percentage of Americans become vaccinated. While a few Republican governors have been willing to encourage their constituents to become vaccinated, most still object to any form of governmental mask or social-distancing mandate and some have issued orders preventing local governments from doing so. This is true of Governor DeSantis of Florida who issued an executive order prohibiting such mandates, an order which the County executives in both Dade (Miami) and Orange (Orlando) counties have defied. In fact, over fifteen Republican-controlled states have either enacted or are considering laws prohibiting local mandates to control the spread of the virus. While the State of Missouri has not sought to preclude such local mandates, the St. Louis City Council has overruled a mask requirement issued by their city’s mayor. Similarly, a Tennessee health official was terminated for trying to impose a mask requirement for the public schools in her district. Thus, in the states where the vulnerability to the Delta variant is high, political resistance to remedial efforts seems to be equally high.
In addition, to political push-back against mask and social distancing mandates, there is the added problem that mandates are difficult to enforce. Even those who have already been vaccinated may choose not to comply as they only have a minimal incentive to wear a mask or to practice social distancing as any break-through infection which they may incur is unlikely to require them to become hospitalized. In short, it appears that the Delta variant has caught our nation off-guard at a time when too many Americans are suffering from an acute case of political gamesmanship or pandemic fatigue to do what is necessary to prevent a reprise of last winter’s health crisis. This time it will be the nation’s rural communities that will suffer the most.