As we’ve discussed for the past few weeks, we’re in a high-COVID-plateau right now. The official case count and hospitalizations and deaths are up and down, and we’re all bracing and hoping that we’ve gone far enough down to counteract any potential winter surge on the horizon. One of the major things we’re trying to avoid is overwhelmed hospitals and healthcare systems. It’s not a 1 + 1 + 1 additive effect when hospitals are overwhelmed. Instead, overwhelmed hospitals reach a tipping point where providers are working harder than seems possible and it’s not enough to cover patient needs, and care has to be rationed. That means all patients – not just COVID-19 patients – are at risk of lower quality care and a severe outcome that wouldn’t happen if care wasn't being rationed. To be clear, this is not a healthcare provider issue, this is a system issue. I think the symbolism of the system bending during periods of high use vs. breaking when overwhelmed can be a helpful way to think about it.
Last week I was able to report that our local transmission dropped from “high” to “substantial,” but this week we’re right back in the “high” category of transmission in Hampshire County. We were also noting a decrease in the number of counties in New England in the yellow “medium” risk category, based on infection rate and hospitalizations, but that trend has reversed this week. All of MA, except for Hampshire and Hampden counties, are in the medium risk category because of an increase in hospitalizations.
In general, we seem to have landed in this “living with COVID” time of the pandemic. To be sure, experts still classify COVID-19 as a pandemic, but there’s no easy way to identify when we reach an endemic stage (if we reach it – more on that below). Here’s what public health experts really want you to remember – we might be living with the virus and disease for now, but we should not settle for the current scenario to be endemic. Average daily deaths have remained at about 400 deaths per day for the past four months, which ranks as our fourth(ish) leading cause of death. This is too many deaths per day to be the baseline we accept. This is far worse than our worst flu seasons. It’s caused US life expectancy to drop for two years in a row. In 2019, average US life expectancy was 78.9 years. It dropped to 77.0 years in 2020, and dropped again to 76.6 years in 2021. This is the sharpest decline in life expectancy in the US in about 100 years – ironically (or maybe not?), the last large decline in life expectancy occurred during the 1918 flu pandemic. Many countries experienced an initial decline in life expectancy in 2020, but most saw that reverse in 2021. The US has both excellent healthcare and quite fragmented healthcare. Even without the recent decline, the US ranks about 30th in average life expectancy compared to other countries tracked by the Organisation for Economic Co-operation and Development (OECD), which includes about 50 countries. All to say – not great. And certainly not an endemic level that we can settle for as our "living with COVID" level. A severe outcome is most likely to occur among the high-risk, including older adults, those with comorbidities, the immunocompromised, and the unvaccinated. Getting up-to-date on your COVID-19 vaccine is the easiest “modifiable” thing you can do to move yourself into a lower risk category.
Speaking of which, the Pfizer and Moderna versions of the bivalent omicron specific COVID-19 boosters are approved for EUA use starting this week! Everyone over age 12 is eligible and should get the booster. It will result in a significant reduction in risk of infection (at least for a little while) and a lasting significant reduction in the risk of severe disease and death. I’m hopeful it will get approved for children ages 6-11 sooner rather than later. The official recommendation is to get the fall booster 2-3 months after your last vaccine dose or infection (respectively). Dr. Jetelina (“Your Local Epidemiologist (YLE)”) has written an excellent overview of the recommended waiting interval before getting the bivalent omicron-specific booster. With thanks to YLE, I’ll repeat that information below. Check out yourlocalepidemiologist.substack.com/considerations-for-your-fall-booster
for more information.
If it has been...
- less than 3 months since infection or vaccine dose: Wait.
- 3-4 months since infection / vaccine dose: In general, wait, but you may want to get the booster in this time-frame if you are high-risk.
- 4-6 months since infection / vaccine dose: Anytime in here is a great time to get the booster.
- 6+ months since infection / vaccine dose: Get the booster ASAP.
We focus a lot on severe disease and death, but it’s worth remembering that infection can also cause other negative outcome, including minor disruption and illness, but each infection is also associated with a risk of developing long COVID. We don’t know a lot about long COVID, but we know it’s more common than we see with other viral infections (like influenza or RSV), and we know that members of our community are suffering with debilitating symptoms. If you are among this group, I hope you will keep reaching out to providers until you find one you trust and who understands that you’re experiencing something real. If you’re able to and feeling up to it, you can also consider enrolling in a research study so we can learn more about long COVID (check out https://recovercovid.org/
for more information). I hope research on long COVID catches up with the situation on the ground soon.
Finally, the European Centre for Disease Prevention and Control just released a report outlining several possible scenarios for how the COVID-19 pandemic might play out over the next decade. The report does not predict any one scenario over another scenario and makes clear that the scenario that comes to pass will depend on virus characteristics (such as how quickly the virus mutates), immune characteristics (such as how quickly immunity wanes), and human behavior (such as vaccine uptake and use of mitigation measures). Of course, we’re all hoping that the best-case scenario is the one that comes to pass – that COVID-19 becomes and remains a diminished threat. This is essentially saying that COVID-19 is endemic and without significant peaks and valleys in cases. It is possible, however, that some degree of reinfection and severe disease and death is possible, depending on what happens next. The worst-case scenario is that a variant with immunity or treatment escape comes along that causes a surge of disease severe enough to put us back in the early days of the pandemic.
There’s a bit of good news on that front, actually. The virus continues to mutate (as viruses do!), but we’ve now spent about nine months in the land of the omicron variant. This is our longest stretch in a particular set of mutations, and since the BA.4 and BA.5 variants became dominant, there’s not a seriously worrying mutation that we’re watching closely. We can’t really ever be sure until the variant is circulating, but scientists do typically identify problematic mutations early and are on high alert for variant spread – think back to last November, when we first identified the omicron variant and we knew we were just waiting for it to arrive and cause a surge. We don’t have a variant of that magnitude in the pipeline right now. As a result, I’m going to put one hopeful tally mark in the “diminishing threat” category.
There’s both a lot to process right now related to COVID-19 and also, somehow, not that many changes. I hope there’s some information in here that’s helpful in figuring out your next move! Please reach out to your healthcare provider and/or your local Board of Health with questions about your specific situation.
Megan W. Harvey, PhD (she/her)