#return to normal

From the report by Sarah Zhang, posted 1 Nov 2021:

The answers were simpler when we thought we could vaccinate our way to herd immunity. But vaccinations in the U.S. have plateaued. The Delta variant and waning immunity against transmission mean herd immunity may well be impossible even if every single American gets a shot. So when COVID-related restrictions came back with the Delta wave, we no longer had an obvious off-ramp to return to normal—are we still trying to get a certain percentage of people vaccinated? Or are we waiting until all kids are eligible? Or for hospitalizations to fall and stay steady? The path ahead is not just unclear; it’s nonexistent.

We are meandering around the woods because we don’t know where to go.

What is clear, however, is that case numbers, the metric that has guided much of our pandemic thinking and still underlies CDC’s indoor-masking recommendation for vaccinated people, are becoming less and less useful.

Even when we reach endemicity—when nearly everyone has baseline immunity from either infection or vaccination—the U.S. could be facing tens of millions of infections from the coronavirus every year, thanks to waning immunity and viral evolution.

(For context, the flu, which is also endemic, sickens roughly 10 to 40 million Americans a year.)

But with vaccines available, not every case of COVID-19 is created equal.

Breakthrough cases are largely mild; 10,000 of them will cause only a fraction of the hospitalizations and deaths of 10,000 COVID cases in the unvaccinated. The more highly vaccinated a community is, the less tethered case numbers are to the reality of the virus’s impact.

So if not cases, then what? “We need to come to some sort of agreement as to what it is we're trying to prevent,” says Céline Gounder, an infectious-disease expert at New York University. “Are we trying to prevent hospitalization? Are we trying to prevent death? Are we trying to prevent transmission?” Different goals would require prioritizing different strategies.

The booster-shot rollout has been roiled with confusion for this precise reason: The goal kept shifting. First, the Biden administration floated boosters for everyone to combat breakthroughs, then a CDC advisory panel restricted them to the elderly and immunocompromised most at risk for hospitalizations, then the CDC director overruled the panel to include people with jobs that put them at risk of infection.

On the ground, the U.S. is now running an uncontrolled experiment with every strategy all at once. COVID-19 policies differ wildly by state, county, university, workplace, and school district. And because of polarization, they have also settled into the most illogical pattern possible: The least vaccinated communities have some of the laxest restrictions, while highly vaccinated communities—which is to say those most protected from COVID-19—tend to have some of the most aggressive measures aimed at driving down cases.

“We’re sleepwalking into policy because we’re not setting goals,” says Joseph Allen, a Harvard professor of public health. We will never get the risk of COVID-19 down to absolute zero, and we need to define a level of risk we can live with. 

Scientific experts have been reluctant to make that call themselves. For one, there is real scientific uncertainty ahead. We don’t know how much immunity may continue to wane, how long the effects of a booster last, the exact incidence of long COVID in the vaccinated, or if a new variant will upend even the best-laid plans.  But the level of COVID-19 risk we can live with is also not an entirely scientific question. It is a social and political one that involves balancing both the costs and benefits of restrictions and grappling with genuine pandemic fatigue among the public...

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One plausible goal is to focus on minimizing COVID-19’s impact on hospitals. A collapsed health-care system means more people will die, not just of COVID-19 but from other treatable diseases and injuries. Elsewhere in the world, like in the U.K. and Germany, leaders have explicitly tied their policies to containing hospitalizations rather than all cases. But in addition to hospitalizations, Gounder suggests we should also consider the risk of long COVID. “I think for people that is the big question. We just don’t know enough,” she says. Preliminary data suggest vaccines do reduce the risk of long COVID, but exactly how much is unclear given the uncertainties in diagnosing it.

Once we’ve defined what we are trying to prevent, we can define thresholds for lifting and, if necessary, reinstating COVID-19 measures. This can actually be quite tricky if the goal is minimizing hospitalizations, a lagging indicator that gives you a picture of the past rather than the present. By the time hospitalizations start to rise, a bigger increase may already be baked in with people already infected but not yet sick enough to see a doctor.

What to track instead?  Here are some answers I got from scientific experts: hospitalizations and deaths, but stratified by age and vaccination status; a combination of vaccination rate and local transmission; a combination of vaccination rate and hospitalizations; a combination of long-COVID cases, hospitalizations, and deaths; a combination of case growth rate, testing uptake, vaccination rate, and hospitalizations.

If this seems confusing, why not consider a real-life example? San Francisco and seven other Bay Area counties recently set three-pronged criteria for lifting indoor mask mandates: (1) Community transmission is moderate, as defined by the CDC, for at least three weeks, (2) hospitalization numbers are low and stable, and (3) 80 percent of the total population is fully vaccinated or eight weeks have passed since COVID-19 vaccines have been available for kids age 5 to 11.

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Even when the coronavirus is endemic, it will still make people sick and it will still cause deaths and hospitalizations. That means our fight against COVID-19 is not over, and we might consider strategies sustainable over the long term. Better ventilation, for example, can make indoor spaces safer against all respiratory viruses, not just COVID-19. And even without mask mandates, people who feel at risk can still voluntarily mask up. In the longer term, Çevik says, we also need less focus on policies that work by “reducing small risks among many” and more on policies targeted at the people most affected by COVID-19. During the pandemic, the virus has disproportionately sickened people who are poor, who are less likely to be able to work from home, and who are less likely to have space to isolate from their family at home. When COVID-19 becomes endemic, it will likely, as many diseases are, continue to be correlated with poverty. “Pay much more attention to who and why people are at risk,” says Stefan Baral, an epidemiologist at Johns Hopkins University. Baral says public health needs to go back to its traditional roots, where tackling disease also means reforming the living and working conditions that make people more susceptible. For example, universal paid sick leave and free voluntary isolation spaces can help minimize the impact of COVID-19, as well as many other diseases.

Hard questions lie ahead, and the answers require political will. But first, we have to stop avoiding them. We need a goal.

Hello, Anon:

Any sign of a return to some semblance of normalcy is always a good sign, for any and all of us in these troubling and uncertain times, but especially so for Armie Hammer, given what he’s been through in the last year.

He’s long overdue for true happiness in his life, and I hope he finds it.

Thanks for your question. 😊❤️🧿

The demon lands itself in the middle of the Flower Meadow. The night is dark with a new moon. “It is time for me to leave this body. My time is up. The curse has ended.” A pause. “Yes, you will remember. You will remember it all. A gift from me to you.” A pause and grim smile. “No, why would I let you waste such valuable knowledge by erasing it. It’s not like they will forget what you ave done.” Another pause. “But they will still blame you. All the death, destruction, mayhem. It was all you. What fun I had while here.” Another pause. “Oh don’t worry. I won’t be far away. We’re connected now. If you ever need power just give me a call. I’ll pop in from time to time to have a chat.” A pause. “I’ll make sure you never forget. Never forget the name, Beelzitrix. I will always linger.”

With that runes appeared once more beneath Laural. The darkness closed in again and fled. Leaving Laural alone and normal. The demon was gone, but he could still feel him linger.