America has begun the gradual process of accepting that COVID-19 is going to be endemic—meaning it will always be present in the population to some degree—due to inherent properties of the virus (animal reservoirs, high transmissibility, long period of infectiousness, symptoms similar to other pathogens), and will remain so for the foreseeable future. But the United States is equipped with a vast array of tools to cope with this fact. The eligibility for vaccination is increasing and all adults are eligible to receive boosters. Are two effective antiviral oral drugs which prevent death and hospitalizations in COVID-19-infected people about to get approved? For people with weak immune systems, monoclonal antibody treatment is available. This important shift was made by the CDC, which acknowledged that it is impossible to achieve herd immunity. Policy must change with this important admission from the public health agency.
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The pandemic has reached an impasse where policies should not be built around the notion that normal life cannot continue until the number of cases is below a certain (arbitrary) threshold. One reason for this is because these levels were established before vaccination. They haven’t been modified accordingly. Another reason is that a significant number of cases are milder now, partly due to breakthrough cases. These metrics are also set in a context where policymakers were trying to establish thresholds for opening and closing social institutions without having access to reliable data. It is no longer sensible to set thresholds for activities based on cases. However, U.S. counties continue reporting daily fluctuations and case numbers as if policies should be centered around these figures.
In a recent article about Oregon’s COVID-19 restrictions, currently the strictest in the country, the state epidemiologist said that in order to ease restrictions, “We need to see cases going down and no resurgence of disease.” But hospitalizations have fallen 57 percent in Oregon since their peak in late August-early September 2021 and have been flat for the past three weeks. Oregon’s daily rate for new hospitalizations is about 3 per 100,000, down from 5 per 100,000 in August 2021. This means that the majority of cases do not lead to serious consequences. It no longer makes sense to assume “cases” equate to “disease” in areas of high vaccination coverage and this misguided equivalency can have negative consequences.
These negative consequences of mitigations is why Marin County, California, did not re-impose masks recently even though their cases had crept back up into the CDC’s recommended masking zone. The county had also zero Covid-19 hospitalizations. Marin County’s public health officer recently noted that hospitalizations were at a four-month low, and explained that going forward mask mandates would depend largely on hospitalization and vaccination metrics (instead of case counts) because in areas of high vaccination rates, hospitalizations became largely uncoupled from cases during the U.S. delta variant surge.
Aware of emerging therapeutics and the characteristics of the virus, as well the potential dangers of vaccines, it is important that the CDC stop basing its guidelines on unmasking on case count. In November, Montgomery County, Maryland, dropped indoor mask mandates based on the CDC’s case count guidance for metrics of transmission, then re-instated themA week later. Whipsawing lowers public trust, causes confusion and doesn’t do much to prevent COVID-19 transmission.
We will be trapped forever if we rely on cases numbers to determine whether COVID-19 mitigations should be taken. This includes long term mask mandates where high vaccination rates make them unnecessary; quarantining children who are healthy; disrupting school to keep tiny COVID-19 outbreaks from spreading; and sending college student to remote learning. Middlebury College also announced that they would be closing their dining halls and sending 50 students to online education after they received positive COVID-19 test results. Cornell University, despite the mild cases in students, banned any student-to-student social events for the rest of the semester. Meaningless mitigations such as these do not substantially slow the spread of COVID-19, may deter people from vaccination if they signal that vaccination does not mean a return to normal life, and take a toll on students’ mental and emotional health. It is absurd to think that vaccinating students in low-risk groups of severe COVID-19 cases will remove them from their social networks.
Focusing on case counts also creates the misperception that vaccination is not effective, because the proportion of breakthrough “cases” is going to grow as the number of vaccinated people increases. However, most breakthrough cases are not related to hospitalizations. Oregon’s most recent breakThrough data from December 9th indicate that, to date, “4.4% of all vaccine breakthrough cases have been hospitalized and 1.2% have died. The average age of vaccinated people who died was 81.” Oregon data also show that, for younger adults, unvaccinated people are hospitalized with COVID-19 at 15-20 times the rate of vaccinated people. For people over 80 years old, vaccines are four times more protective.
Another reason it’s important to rely less and less on the metric of cases is that measurement of case positivity is becoming increasingly inaccurate. Health departments will no longer have access to more information about cases (both negative and positive) from the at-home COVID-19 test, as indicated by the Biden Administration. The result is that the reported cases numbers will be more dissimilar to actual ones. Additionally, as mitigations drag on, the extreme consequence of reporting a positive test result, both for the person tested and for close contacts– which can include exclusion from school, sports, and social events for lengthy periods of time—are becoming a large disincentive to test at all. What good is it to use case numbers to decide if elective surgery should be cancelled or if masks need to be removed?
Florida reports half of the daily new cases reported in California, compared with 13 for 100,000 in California. Is this lower case count real and due to higher natural immunity (the two states’ overall vaccination rates are very similar), or are lower cases an artifact of less testing, lower test reporting, less breakthroughs due to later vaccination, or other unmeasured factors? We don’t know. It is difficult to know. It is possible to inflate hospitalizations with COVID by as much as 25% to 40%. Also, the relationship between hospitalizations and death has changed. Patients hospitalized with COVID-19 have less chance to succumb to it now than before the outbreak.
How can we make this happen?
It is time for the U.S. to start treating COVID-19 in the same way as other endemic virus infections like the flu.
The first step is to have COVID-19 monitored by health department CasesThe way that they handle cases of influenza. Flu monitoring happens at two levels; by the CDC’s influenza surveillanceNetzwerkThe CDC keeps track of how many people have tested positive for influenza. Additionally, county health officials will ensure that antiviral treatment such as oseltamivir is available at clinics when flu is suspected to be present in certain areas.
State and counties do not report daily cases of influenza to the public. They don’t even pivot when there are more. Because flu can switch, one of the most important elements of influenza monitoring is the tracking of variants. Starting at endemic You can find more information here pandemic. With COVID-19, we are going the opposite direction—from pandemic to endemic—and we need to get to where influenza monitoring starts, which is very different from what we are doing with COVID-19 cases, where every uptick is seen as a cause for panic.
Although the Omicron strain will increase the number of cases, there is preliminary evidence that it might cause milder symptoms than the delta variant. It isn’t causing any higher hospitalizations rates at this time, but it isn’t the predominant strain in the U.S.
It’s time for the U.S. to stop worrying so much about cases and redirect our energies to reaching the most high-risk unvaccinated people, a number we conservatively estimate at 10 million people, but which could be as high as 20 million. The most at-risk people include unvaccinated retired people, those 55-70 who are employed in small, exempted companies, as well as people with disabilities, many of whom are often disabled and have multiple chronic diseases. Additionally, they do not target our key metric of hospitalizations. These restrictions also come with a high price. The most recent Surgeon General’s report on the mental health crisis among young people tells a warning tale of the price of ongoing restrictions in their lives.
Given the changing landscape COVID-19 treatments and vaccines have created, it is important to shift COVID-19 mitigation metrics from hospitalizations to cases. This will not only be good public policy but also good for public health.
