The U.S. has experienced a brutal winter wave of COVID-19, driven by the highly transmissible Omicron variant. Daily deaths are higher today than they were during the peak of last fall’s Delta wave, and have plateaued at about 2,500 per day. Many hospitals are still under huge strain and are postponing elective surgeries to free up beds for patients with COVID-19. Daily cases have been higher than during the Delta surge, despite multiple eager predictions in the past that we had reached herd immunity and that the pandemic was over.
Nevertheless, there are promising signs that we are turning a corner. New daily cases are falling rapidly—they are down by over 75% from the peak of the Omicron wave. Hospitalizations are also falling. While we are not out in the clear yet, especially in poorly vaccinated regions of the U.S., the sharp downturn in cases is cause for optimism.
The fall in cases is also an opportunity for fundamental preparation, given the high chance of a future wave. To prevent being overwhelmed again, we should be proactive now in putting a preparedness system in place.
Instead, in the face of these receding cases, some pundits are calling for an end to pandemic control measures, such as indoor masking and testing of people with no symptoms. And several states have rolled back mask mandates, even though indoor masks mandates remain popular in public polling (the Biden Administration is being more cautious about easing masking). We fully understand the frustration and impatience behind these calls. Pandemic fatigue is real. Yet this yearning for ‘normal’ ignores the reality that our society before COVID-19 was anything but normal. If it had been, we may not have suffered as devastating a pandemic as we have. Instead it was those very conditions that allowed for terrible inequities and outsized impacts on America’s poor, which still continue today.
We are concerned that the Biden Administration is not taking preparedness seriously enough. It was a welcome step to see the Administration making 400 million N95 masks available for free at pharmacies and community health centers, and we are delighted that Americans can now go online and order four free rapid tests per household. But four rapid tests and a mask will not be enough to end the pandemic. These measures are not commensurate with the size of the problem, and they must be coupled with actual public health strategies for effective roll-out and sustained uptake.
Perhaps the biggest problem is that there is still a huge amount of viral transmission, with around 175,000 new daily cases. Less than two thirds of Americans are fully vaccinated—defined as two doses of Pfizer or Moderna or one dose of Johnson & Johnson—which does not provide as much protection as it did before Omicron. Only a quarter of Americans have received a booster dose, which provides the highest level of protection against infection, hospitalization, and death. There are ongoing inequities in vaccination, including racial inequities, with Black and Hispanic populations being vaccinated at a lower rate compared to white populations. Only 24% of children aged 5-11 and 57% of those aged 12-17 are fully vaccinated. Hospitalizations among the under 5 hit record levels during the Omicron surge, yet vaccines are not yet licensed for this age group.
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There is also what the New York Times calls a “pandemic of the forgotten.” Around 7 million Americans have weakened immune systems from transplants, cancer treatment, rheumatoid arthritis medications, or other medical conditions, and they could get very ill if they get COVID-19. Yet this push toward returning to normal seems to matter-of-factly ignore them. And, there is the growing number of people who are suffering from long-term morbidity after surviving infection—the condition now known as Long Covid—which we are only just beginning to understand.
One recurring problem when it comes to pandemics is that we suffer from short term memory. We cross our fingers and hope that this wave is the last. Many of us were surprised when Vice President Kamala Harris said that the Biden Administration “didn’t see Delta coming….didn’t see Omicron coming.” That’s absurd. Viral mutations were entirely expected. There is a serious risk of further variants arising, especially with inequitable and low vaccination coverage in much of the world due to supply hoarding. Distributing a few rapid tests and masks and hoping that this wave disappears and will be the end of the U.S. pandemic is not a sound approach.
Even with the current variants in circulation, we could see further waves, such as was seen in the South in past summers, especially in poorly vaccinated states, and as people move indoors to escape the heat and humidity. We could similarly see future winter waves as we have witnessed in the northeast. With cases of Omicron receding, now is the time to put in place a proper infrastructure, resilient enough to handle further surges. Instead of declaring “mission accomplished,” we must declare a considerable effort toward true preparedness.
In addition to driving up vaccination coverage, what would true preparedness look like?
Instead of a one-off distribution of N95 masks, the government should replenish the stockpile enough to deploy them again in the face of future outbreaks. These should be ubiquitously available, and in different shapes and sizes, placed outside any high-risk venues including public transport or crowded indoor sites of congregation (grocery stores, malls, retail, movie theaters, gyms, offices) during surges.
Serial rapid tests are needed, and they need to reach those unable to order them online. A single test is a snapshot in time—so after a known exposure, having enough tests for daily testing prior to leaving the home is what would actually be needed for 5 to 7 days. Rapid tests identify contagious people before they get symptoms, allowing people to avoid spreading the infection, thus breaking the cycles of transmission. One of us presented similar arguments for both Ebola and Zika in the past. Such rapid tests for SARS-CoV-2 can help keep schools and workplaces open, and they can protect vulnerable people in nursing homes, jails, prisons, and other high-risk congregate settings. High quality masks and rapid tests are particularly critical for protecting front line workers.
With the arrival of new antiviral drugs, such as Paxlovid, and data showing early antiviral use with Remdesivir is more effective, universal access to free tests has become even more urgent. These medicines can reduce your chances of being hospitalized or dying if they are taken soon enough after symptoms begin, but this requires access to testing for early enough diagnosis. Greater access to testing needs to be combined with fair and equitable access to these medications—especially for communities that traditionally have low access to care.
A joined-up preparedness plan would also include paid sick leave. During the 2009 swine flu pandemic, an estimated 3 in 10 people with symptoms in the U.S. went to work, infecting up to 7 million others. The U.S. is the only high-income nation without mandatory federal sick pay, and this will continue to be a huge barrier to controlling COVID-19.
Another way to curb transmission of SARS-CoV-2 is to improve ventilation and air filtration in all buildings, including schools. Congress has allocated up to $170 billion for school infrastructure improvements, including improving air quality. Unfortunately, too much of this money has been left on the table. In some cases, as Joseph Allen and Celine Gounder note, some schools are “already under attack by parents who are opposed to other pandemic-related public health measures, like masking.” Other school districts lack the know-how to make the upgrades—they need better guidance and standards. Some schools say they struggle to pay for upgraded ventilation systems even with federal aid.
Instead of being caught flat-footed by the next wave or variant, we need more comprehensive data and surveillance systems, including wastewater sampling, as well genomic surveillance to identify and track new variants. With better data, we can know when to titrate public health protections up and down. As Megan Ranney, professor of emergency medicine and academic dean of public health at Brown University says, we need “investments in better data systems, now, to signal when a surge is on its way and to provide clear metrics of when to increase protections (like masks)—and clear lines about when these protections can be relaxed.”
With so many people worldwide still unvaccinated, and many Americans without boosters, we should prepare ourselves for future pandemic ebbs and flows. To end the pandemic, the U.S. should do much more to boost global vaccine access including donating several-fold more doses, sharing vaccine technology more urgently, and funding massive global production. Domestically, an important guiding principle is that our policies should be driven by data and not dates—for example, we believe it is better to base the end of mask mandates on metrics such as vaccination coverage, hospitalization rates, and ICU capacity rather than picking an arbitrary end date. Unlike the start of the pandemic, we now have a remarkable array of science-based tools that can turn COVID-19 into something akin to a cold or flu, but to get there we’ll need higher vaccination rates, better data and surveillance systems, data-driven policies on masks and rapid tests, improved ventilation in shared public spaces, and a more resilient preparedness system.
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