this endless pandemic

Waiting for Omicron

The new variant comes to a country that still does not have the pandemic under control.

Photo: Jammy Yoon
Photo: Jammy Yoon

The news doesn’t seem great. Throughout the whole of the pandemic, the World Health Organization has only declared four “variants of concern”; Omicron is the fifth. It has been only a week since the variant was first identified, and the picture still remains murky on matters of transmissibility, virulence, and immune evasion — all the important questions. But while there are some possibly encouraging signs that the new variant may be less immune evasive than feared — that the vaccines may hold up pretty well against it, and that observed breakthrough infections remain, at least among the young, mostly mild — there is also some analysis suggesting escape potential could be “substantial” and enough alarming news to have rattled many epidemiologists and prompted new public-health interventions, including the possibility of quarantines for all those arriving now in the U.S. and insurance reimbursement for anyone buying (and taking) at-home antigen tests. It is helpful to remember that neither of the two previous variants exhibiting immune-evading features ultimately upended the course of the global pandemic. That was left to Delta, which dominated simply through its transmission advantage. Omicron may well demonstrate such an advantage, too, and over Delta, which could mean a quite bad course ahead, especially for the unvaccinated, for whom the new variant may be more severe, as well.

In the meantime, swimming in Omicron uncertainty, it is worth doing some level-setting, partly because for many Americans — particularly since the Delta peak passed, and perhaps especially among the well-vaccinated — the present state of the pandemic has drifted out of sharp focus. The level I would set is this: The new variant is not arriving in a country in which the pandemic is well under control but in a country where Delta is merely stalled, with at least half as many new cases being reported each day as were recorded during the peak of this wave; where because of waning immunity and low uptake of boosters, considerably more vulnerable seniors are losing vaccine protection daily than are gaining protection through new vaccinations; where among the population as a whole, vaccine protection is not just not rising fast enough to meet a new threat but actually falling from already disappointing levels; where the worst season for respiratory viruses like this one is also upon us (and although seasonality has not been precisely predictive in this pandemic, the worst period so far took off in December 2020 and ended in March of 2021); and where, over the last month, despite relatively widespread vaccination and quite high levels of immune protection from exposure to the disease itself, there are still enough vulnerable people out there for more than a thousand of them to be dying in a single day. That is a rate equivalent to 400,000 annual deaths, more than were recorded either in 2020 or so far in 2021.

The well-vaccinated are well-protected against severe disease, all things considered. But the U.S. as a whole is not, and does not appear to have much hope of becoming so through vaccination, before natural exposure runs its fuller course through the population. Which means that even barring bad news on Omicron, and positing hypothetically that it’s just a brief scare, the country could still be in for a dispiriting few months. The first day of December, the country registered more than 2,000 new deaths. Acknowledging all caveats, that is still an annual pace of more than 700,000.

The period ahead may well prove happier than forecast — again and again through this pandemic, the disease has surprised us, sometimes by retreating much more quickly than experts predicted. But at the moment, many signs are pointing in the wrong direction, should we care to look at them. Many of us aren’t, demonstrating a distressing pattern by which concerns for personal safety predominate in our picture of the pandemic, illness and death elsewhere matter much less, and those dying having declined to vaccinate themselves barely count as deaths.

Over the last several months, as vaccinated Americans — particularly the young and middle-aged — have come to terms with their own safety and started to feel their way back to “normalcy,” they have also been treated to a series of articles and essays and public statements suggesting that the pandemic was dissipating enough that it was now almost a matter of mind-set and could be changed, essentially, by force of will. “The pandemic is ending with a whimper,” Juliette Kayyem wrote in the Atlantic just last week. “The bottom line,” David Leonhardt wrote a week before, in the New York Times, “is that Covid now presents the sort of risk to most vaccinated people that we unthinkingly accept in other parts of life. And there is not going to be a day when we wake up to headlines proclaiming that Covid is defeated. In many ways, the future of the virus has arrived.”

I wrote a version of this story myself, suggesting that along with childhood vaccinations, the astonishing results of Pfizer’s therapeutic Paxlovid — a clinical trial was halted when the drug was shown to reduce the risk of hospitalization and death by 89 percent — allowed us to “see the outline of a new phase — or at least enough to declare one, as grim as it may be to begin to turn the page, socially and culturally and psychologically, when more than a thousand Americans are still dying each day.”

But while the well-vaccinated may see that new phase clearly, the “endemic” endgame is not yet upon us as a country. When Trevor Bedford, a MacArthur “genius,” modeled that endemic future recently, he suggested an annual death toll between 40,000 and 100,000 Americans — at the low end, roughly the annual death toll of the flu, and, at the high end, nearly three times as high. Normalizing that might prove both difficult and necessary, eventually. But at the moment we are on a pace roughly four times that high-end estimate and ten times the low-end one.

Will that trend, in fact, continue? It’s not easy to say, even putting aside the complicating matter of Omicron’s impact and the additional measures being put in place to slow its spread. Looking backward is much easier, and the picture there is very clear. September and October were among the deadliest months of the entire American pandemic — the very deadliest, if you put aside the first wave in spring 2020, which crashed against a mostly undefended population, and the winter surge, a year ago, which tore through the country just before the widespread availability of vaccines. More Americans have now died in the year Joe Biden took office than the one in which he defeated Donald Trump, which suggests, as we probably should have seen earlier, that pandemic control was probably never as simple as just hitting the “science” button.

And while vaccination does continue to offer dramatic protection against severe disease for individuals, and has surely blunted the impact of the disease this year, at the national level, the effect has been almost invisible in the Delta era. Last winter, the surge produced a month of between 150,000 and 250,000 cases a day, with about 115,000 ongoing hospitalizations and a rough daily average of between 2,800 and 3,400 deaths. The Delta surge produced a “worst month,” September, with between 110,000 and 160,000 new daily cases, 85,000 hospitalizations, and between 1,100 and 2,000 deaths. The latest surge was smaller, in terms of cases, but the ratio of hospitalizations to cases, or deaths to cases, was almost precisely the same. For hospitalizations, in fact, the ratio was worse.

At the national level, vaccination didn’t really push back the pandemic at all. Instead, the two forces — the new vaccines and the new variant — basically fought to a draw. The big-picture result: Many Americans have felt increasingly safe themselves, which they are, but in a country in which more other Americans were dying than they had, on average, over the last two years.

Perhaps this fact seems strange to you, as it does to me. More than half of Americans are officially, fully vaccinated, including at least 80 percent of seniors, who are, by far, the most vulnerable. In theory, given what we know about vaccine efficacy, this should mean that a large share of the country’s overall mortality risk has been eliminated, since most of the most vulnerable are now mostly protected. And because the age skew of the disease is so dramatic — with those in their 80s nearly 10,000 times more at risk than someone under the age of ten — mass vaccination of the elderly should be very visible at the national level. Protecting most seniors should mean effectively trading the age structure of the American population for a much younger and less vulnerable one, with much lower death rates than we saw last winter. And yet the U.S. isn’t really dying like a much younger country; it is dying like pretty much the exact same country.

There are a number of partial explanations. The country isn’t well-vaccinated by the standards of its peers, which have by and large demonstrated a much more predictable pattern of divergent cases and deaths (in which any small growth in severe disease is accompanied by much larger growth in cases). That means, especially with a population of 330 million, there are a lot of unvaccinated people out there, some of them quite old and vulnerable. “It really doesn’t take a lot of vulnerable to see large numbers of deaths,” says Emory’s Natalie Dean, offering a counterfactual statement to consider: “What would you view in the absence of the vaccine? You would have had an even larger wave, both of cases and deaths because Delta is so highly transmissible. But what we end up seeing is something that is on the same order of magnitude as before, because a lot of cases and deaths were averted.”

There is some vulnerability among the vaccinated, too, though we know from state-level data that the vaccinated account for only perhaps a quarter of recent deaths. The Delta variant is probably more virulent, too, though much of the early messaging focused on its transmissibility rather than its pathogenicity. There may be considerably less social distancing and considerably more cross-generational socializing than there was at this time last year, which would mean that, all else being equal, the same number of cases could lead to more severe illness and death (since the chances that a mild case in a young person would make its way to an old person would be much higher). In a long, question-raising analysis, the contrarian Philippe Lemoine suggests that population networks play a much larger role in shaping the course of the disease than has been widely acknowledged, meaning that it may make less sense to conceptualize the pandemic as spreading through the population as a whole than through a number of relatively discrete pockets. “This is like a heat-seeking missile,” says Eric Topol of Scripps. “It just finds all these people, finds the children and finds the elderly. It finds whoever. “

And there do appear to be quite significant problems with our vaccination data, which complicate any effort to theorize about any of this. I first saw these concerns floated about Florida, which has reported vaccination rates very close to the national average but experienced by far the country’s deadliest Delta surge, and whose data, it turned out, suggested in some places considerably more than 100 percent of local residents were vaccinated there, in some cases 200 percent of local residents — perhaps “snowbirds” living part-time in the state, perhaps international travelers, perhaps people from elsewhere in the country who visited Florida for vaccination purposes early last year.

More distressingly, the problem seems to afflict our national data, too, where “something is clearly wrong,” as Bedford has put it. At the moment, though between 8 and 14 percent of American seniors have told pollsters they will never be vaccinated, the CDC is reporting — with data repeated and republished by the Times, among other outlets — that 99.9 percent of Americans over the age of 65 have received at least one dose of the vaccine, with 86 percent “fully” vaccinated. “That is completely farcical,” says Topol. “We know that can’t be true.” Experts have been calling attention to these problems for weeks, and yet the numbers are still up there on the site, uncorrected. “And who knows what other errors there are in that data,” Topol says. “But my guess is, at best, it’s in the low 80s, for fully vaccinated.”

Topol calls the data problems a “profound deficiency” and one of the more exasperating features of the American mishandling of the pandemic. “You can’t navigate a pandemic without data,” he says. “We haven’t had it throughout, but especially in the new administration, the thought was we were going to get real here, that we were going to start having good data.” But, he says, “you’ve watched our White House and Biden. Have you ever heard them make an announcement that they’re going to get the data? Have you ever heard them say this is a priority?”

What this all means for Omicron isn’t entirely clear, though it is not encouraging that the country may be less well-vaccinated than we thought, when we thought the country was pretty poorly vaccinated to begin with. But what worries Topol even more than the data problems is waning immunity, especially among the old. “More than ten large reports have shown that the reduced protection from infections, including symptomatic infections, across all age groups, wanes from 90 to 95 percent at two months down to about 60 percent for Pfizer and 70 percent for Moderna after five to six months,” he wrote recently in the Washington Post, with Michael Osterholm of the University of Minnesota adding, “There is further substantial waning after six months.” And because 40 percent of the country was fully vaccinated by June 1, much more than half of our vaccine protection could be degrading quite rapidly right about now, with relatively slow uptake of boosters (only 40 million out of 200 million counted as “fully vaccinated” have gotten an additional shot, including those who were given weaker Johnson & Johnson vaccines). “Each day in the United States, the number of people with waning immunity greatly exceeds those who are getting newly vaccinated,” Topol and Osterholm wrote. “Accordingly, rather than building our wall of population immunity, the United States is suffering attrition.”

“When you add it all up, we’re more like pre-vaccination than post,” Topol tells me, which isn’t exactly where you want to be staring down the prospect of a new variant. “We’re not in a good position,” he says. “We still haven’t learned to handle any of this.”

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