POST 252. May 22, 2022. CORONAVIRUS. “The stakes, two years into the pandemic, should be clear. Fewer vaccines, fewer treatments, and fewer tests will mean more infections, more serious illnesses, and more deaths. That is the scenario the country is staring down: one million people already dead and more to come because politicians became complacent.”

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“New York City raised its COVID alert level to high on Tuesday, less than 24 hours after warning of the possibility, as a fifth pandemic wave fueled by the most contagious COVID subvariants yet tighten their grip on the metro area and the nation.

The five boroughs had been in a “medium” COVID alert state since May 2 after passing a critical infection rate threshold — 200 new daily cases per 100,000 residents over a rolling seven-day period. The upgrade to “high” alert status means the COVID hospitalization rate also hit a key benchmark — 10 new admissions per 100,000 residents on a rolling basis. Both are based on current CDC community guidelines.

At the time health officials announced the change to medium alert, the rolling hospitalization rate was 6.8 per 100,000 residents, while the rolling new case rate was 218.22. Both rates have steadily been increasing since — to 10.2 and 308.51…

“Now is the time to double down on protecting ourselves and each other by making choices that can keep our friends, neighbors, relatives and coworkers from getting sick,” NYC Health Commissioner Dr. Ashwin Vasan said in announcing the transition.

“As a city, we have the tools to blunt the impact of this wave, including distributing tests, masks and promoting treatments,” he added. “Getting back to Low Risk depends on everyone doing their part and if we follow guidance, our forecasts anticipate this wave’s peak will not last long. What we do now can make all the difference…

The switch doesn’t automatically trigger any new COVID mandates. Those would be considered only if the alert level reached “very high,” which is the highest of the four tiers, health officials say.

That said, the health department issued a new mask advisory Monday, even before the official switch to a high COVID alert level, urging all New Yorkers to mask up indoors regardless of vaccination status for the time being.” (A)

“As the number of new Covid-19 cases reported each day in New York City topped 4,000 this week, the message the mayor seemed to be sending was: As you were. We got this.

He issued no public warnings. He did not reinstate a mask mandate for public indoor settings, even though a new alert system he approved in March recommends doing so at the risk level the city has now hit.

Even as city schools requested — but did not require — that older students resume wearing masks, Mr. Adams let stand his recent decision to let students go unvaccinated to senior proms.

Students can “celebrate all of their hard work with a prom and graduation, regardless of vaccination status,” he said in a news release, adding, “I encourage anyone who hasn’t yet gotten vaccinated to do so.”

Three main considerations are behind Mr. Adams’s approach, my colleague Emma G. Fitzsimmons reports: Hospitalizations and deaths have risen more slowly than in previous waves. New restrictions could cost him politically with a weary public. And he worries that mandates could hurt restaurants, tourism and the city’s economic comeback.

“If every variant that comes, we move into shutdown thoughts, we move into panicking, we’re not going to function as a city,” Mr. Adams said Wednesday.

Former city officials and many health experts disagree.

Health experts have argued that taking action when hospitals and health workers are overwhelmed or about to be — as Mr. Adams says he would — would be too late. Since most home tests are not counted in the city statistics, it is likely that there are already far more new daily cases than the official tally. As of Tuesday, more than 770 city residents were hospitalized with Covid.

Dr. Dave Chokshi, the health commissioner under Mayor Bill de Blasio and during Mr. Adams’s early months as mayor, said recently that the city was acting on “collective amnesia.”

“People would say, ‘Well, it’s only cases increasing, let’s see what happens to hospitalizations,’” he said. “It’s hard not to have your head explode when you feel the public, and in many cases, the political conversation, go in those circles. And you’re like, ‘Wow, when are we going to learn.’” (B)

COVID cases and hospitalizations are continuing to rise in New Jersey, with nearly every county now seeing high levels of transmission.

But severe outcomes — intensive care admissions, ventilator use and deaths — are still relatively low in a state that has one of the nation’s highest vaccination rates, at 76%…

It’s becoming hard to determine if it’s up or down at this point in the pandemic, more than two months after Gov. Phil Murphy ended the statewide public health emergency and called for a “more normal way of life.”

From the start of the pandemic, COVID has shifted its trajectory becoming almost impossible to forecast as it continues to mutate into new variants. Scientists are wary about the effect multiple reinfections can have now that several subvariants of omicron have spread across the globe, including the BA.2 strain, which quickly became the dominant line in New Jersey. The worry is that a subvariant could evade immunity from vaccines or from a prior infection and sicken people.

“We’re just at the beginning of this surge, and the metrics are trending in the wrong direction,” said Stephanie Silvera, an infectious disease specialist at Montclair State University. “While we may not be seeing a rise in severe outcomes, we still need to be mindful of reinfections, of long COVID — things that may well have a lasting effect.” ..

So just how bad is COVID-19 in New Jersey these days?

A Health Department report released Thursday shows that almost every corner of the state jumped from a “moderate” to a “high” level of transmission during the first week of May

The sharp decline from the omicron surge coupled with the end of mandates and warmer weather has changed behavior.

Indoor mask-wearing has dropped significantly in recent months even in such places as Hudson County, which is often among the first places in New Jersey to get hit with a COVID surge due to its dense population and close proximity to New York City. On Tuesday morning, shoppers and staff without masks at the ShopRite in Hoboken far outnumbered those wearing them, whereas it was the opposite just a few months ago, when the weather was colder and COVID was waning.

“When you take mask mandates away, it’s almost impossible to put them back on,” Silvera said. “Politically to mandate it again is extremely challenging, especially when, and I know this sounds cynical, we have an important election coming up.”..

Murphy has been reluctant to reinstate any mandates, saying the state is “shifting to an endemic reality” in which the disease has to be managed as normal daily life continues.

“Not a single community has been spared from this tragedy,” Murphy said last week . “It is a loss that will impact our state and our country for years to come.” (C)

“Last week, White House COVID-19 coordinator Dr. Ashish Jha warned in an interview with The Associated Press the U.S. will be increasingly vulnerable to the coronavirus this fall and winter if Congress doesn’t swiftly approve new funding for more vaccines and treatments.

Jha warned that without additional funding from Congress for the virus would cause “unnecessary loss of life” in the fall and winter, when the U.S. runs out of treatments.

He added the U.S. was already falling behind other nations in securing supplies of the next generation of COVID-19 vaccines and said that the domestic manufacturing base of at-home tests is already drying up as demand drops off…

Jha said domestic test manufactures have started shuttering lines and laying off workers, and in the coming weeks will begin to sell off equipment and prepare to exit the business of producing tests entirely unless the U.S. government has money to purchase more tests, like the hundreds of millions it has sent out for free to requesting households this year.

That would leave the U.S. reliant on other countries for testing supplies, risking shortages during a surge, Jha warned. About 8.5 million households placed orders for the latest tranche of 8 free tests since ordering opened on Monday, Jha added.

The pandemic is now 2 1/2 years old. And the U.S. has seen — depending how you count them — five waves of COVID-19 during that time, with the later surges driven by mutated versions of the coronavirus. A fifth wave occurred mainly in December and January, caused by the omicron variant.

The omicron variant spread much more easily than earlier versions.

Some experts are worried the country now is seeing signs of a sixth wave, driven by an omicron subvariant. On Wednesday, Walensky noted a steady increase in COVID-19 cases in the past five weeks, including a 26% increase nationally in the last week.

Hospitalizations also are rising, up 19% in the past week, though they remain much lower than during the omicron wave, she said…

Officials said they are concerned that waning immunity and relaxed mitigation measures across the country may contribute to a continued rise in infections and illnesses across the country. They encouraged people — particularly older adults — to get boosters.

Some health experts say the government should be taking clearer and bolder steps.

The CDC community level guidelines are confusing to the public, and don’t give a clear picture of how much virus transmission is occurring in a community, said Dr. Lakshmi Ganapathi, an infectious diseases specialist at Harvard University.

When the government officials make recommendations but do not set rules, “it ultimately rests on every single individual picking and choosing the public health that works for them. But that’s not what is effective. If you’re talking about stemming hospitalizations and even deaths, all of these interventions work better when people do it collectively,” she said.” (D)

“Supplies of key Covid-19 therapies are in danger of running out as soon as this summer, a senior health official said, as the Biden administration seeks more funds to fight the pandemic.

Stocks of Eli Lilly & Co.’s monoclonal Covid antibody, bebtelovimab, are expected to be exhausted by July, the official said on a call, and newer omicron variants have already rendered other monoclonal treatments ineffective. Supplies of AstraZeneca Plc’s Evusheld antibody treatment could run dry by the fall, according to the official, who requested not to be identified as a condition of participation in the briefing.

The US government is preparing to extend the public health emergency that allows the authorization and use of vaccines and drugs like Pfizer Inc.’s antiviral Paxlovid during the pandemic. The administration has been wrangling with Congress to approve funds to obtain additional medical supplies and support programs to fight the coronavirus.

Stockpiles of Paxlovid will last through fall, but the government will need to purchase additional courses to continue providing the drug beyond that, the official said. Though supply of the antiviral has increased in recent months, demand has also risen as newer omicron variants drive Covid in the US. The number of Paxlovid courses administered increased 315% between April 10 and May 14, the Office of the Assistant Secretary for Preparedness and Response said Tuesday in a statement.” (E)

“After the Omicron variant caused massive numbers of infections this past winter, lots of people looked on the bright side, hoping it would be “a free shot for the country,” says Eli Rosenberg, deputy director for science at the New York State Department of Health’s Office of Public Health. Even though lots of people got infected with the highly contagious variant, at least they would then have immunity against the virus, protecting them from getting sick in the future. In theory.

But that hasn’t turned out to be true. Many people—even those who are vaccinated, boosted, and previously infected—are again testing positive as Omicron relatives like BA.2 and BA.2.12.1 circulate throughout the country.

Not all states track reinfections, but many of those that do are seeing upticks. In Indiana, about 14% of cases reported in the week ending May 12 were reinfections, up from about 10% the week before. North Carolina and New York are seeing similar, albeit slightly lower, percentages. The actual numbers may be higher, since official case counts are increasingly missing diagnoses due to widespread home testing and other factors.

“This is going to keep cycling through the population,” Rosenberg says. “Every few months you could keep getting it.”..

Rosenberg says there’s always a spike in reinfections when a new variant starts to surge, since antibodies from one strain may not hold up well against the next. Experts often say reinfection is unlikely for at least 90 days following a COVID-19 illness, and maybe longer. But that’s only true if a new variant doesn’t pop up, Rosenberg says, and the virus “keeps switching on us every few months—faster than 90 days.”

Research suggests the newer variants are also better at evading immune defenses than their predecessors. Omicron caused huge numbers of breakthrough infections and reinfections thanks to mutations that made it extra contagious and able to get around natural immune blockades, research shows

It’s too early to say exactly how BA.2.12.1 will compare. But two studies published in May as preprints—meaning they were not peer-reviewed prior to publication—suggest that newer Omicron subvariants, including BA.2.12.1, could be even better at evading prior immunity than the original Omicron strains.

It’s early, but preliminary findings suggest “it’s both very highly transmissible and it has escape mutations…that make it somewhat resistant to previous infection or to vaccination,” says Dr. Peter Hotez, co-director of the Center for Vaccine Development at Texas Children’s Hospital and dean of the National School of Tropical Medicine at Baylor College of Medicine…

The good news is that vaccines and prior infections still seem to be effective at preventing serious disease. People with immunity from vaccination and past bouts with the virus are better protected than those who have been infected alone, Hotez says, so everyone should stay up-to-date on their shots. Combined with “situational awareness”—like wearing a protective mask or skipping large, mask-free gatherings if COVID-19 is rampant in your area—Hotez says that’s our best defense, at least right now. (Other tools, such as nasal vaccines that could theoretically stop transmission, boosters that could protect against multiple variants, or protein-based shots that could provide more durable protection, are in the works, but they’re not here yet.)..

No one knows for sure whether SARS-CoV-2 will ever cause illnesses as mild as the common cold. The virus is continually evolving, and it’s impossible to predict what the next variant will bring—but it’s safe to assume reinfections are no longer the rarities they were once thought to be.” (F)

“The coronavirus isn’t getting complacent. The latest iterations of the omicron variant are more contagious than anything that came before. But at the same time, America is letting its guard down. People are getting back to their lives, while Congress dithers on another round of support for the country’s pandemic response.

One-third of Americans still haven’t gotten two doses of the Covid-19 vaccines. Booster rates are lagging, with only 63 percent of people over 64 — those most likely to benefit — having received an additional dose. Kids under 5 still can’t get a shot. With the virus getting better at evading prior immunity, there are widespread vulnerabilities that require a national response…

The Biden administration has played a significant role in pushing the country out of an emergency footing. It has loosened masking and isolation guidance, sometimes earlier than some experts thought was appropriate. It has adopted a message that Americans are going to have to learn to live with the virus.

But that transition to a new normal was always contingent on the easy availability of vaccines, tests, and treatments, something the White House is still fighting to secure.

The stakes, two years into the pandemic, should be clear. Fewer vaccines, fewer treatments, and fewer tests will mean more infections, more serious illnesses, and more deaths. That is the scenario the country is staring down: one million people already dead and more to come because politicians became complacent.

“I think it’d be terrible,” Jha said. “I think we would see a lot of unnecessary loss of life if that were to happen.”

The question now is whether his warnings will be heeded — or whether they will fall on the deaf ears of a country, and a Congress, that has been moving on.” (G)

“Just weeks after the Centers for Disease Control and Prevention began a comprehensive internal review with an eye toward restructuring, the agency’s director announced on Friday that the team that coordinated the national response to the Covid-19 pandemic would return some of its functions to other departments.

But the so-called Incident Management Structure, initially brought together to respond to the public health emergency, is not being dissolved and will continue to meet “the demands of this evolving pandemic,” according to a letter sent to employees on Friday by the agency’s director, Dr. Rochelle Walensky.

The move signals the beginning of efforts to put in place comprehensive changes at the agency, whose public standing and reputation have suffered in recent years. Some 60 percent of Americans, for example, say they are confused by changes in official pandemic recommendations, according to a recent Pew Research Center survey.

But Dr. Walensky’s letter was short on details regarding the changes. A statement in response to questions from The New York Times said only that the review’s “initial data collection phase is complete, and now the director will synthesize the information, identify themes, and prioritize next steps to formalize approaches and find new ways to adapt the agency to the changing environment.”…

The C.D.C. has long been admired for its scientific approach to improving public health. Many scientists from around the world were trained by its experts and have emulated the agency’s standards and methods.

But the C.D.C.’s infrastructure was neglected for decades, along with the public health system generally. Agency scientists stumbled early in the pandemic with the flawed design of a diagnostic test, and went on to make some recommendations about masking, isolation and quarantine that critics charged were based on insufficient evidence.” (H)

“Federal health officials this week warned Americans that coronavirus cases are at a high level, but with a caveat: Estimates are sure to be a significant undercount of the true infections.

“Depending on which tracker you use, we’re at about 100,000 infections a day,” White House COVID-19 response coordinator Ashish Jha said at a press briefing on Wednesday. “And we know that the number of infections is actually substantially higher than that – hard to know exactly how many, but we know that a lot of people are getting diagnosed using home tests.”

Rapid tests, which offer fast results and can be taken anywhere, grant people a convenient way to determine if they have the coronavirus. The Biden administration this week started offering a third round of free rapid tests, and Jha said it has seen “really impressive demand” for the tests.

But the rise in at-home testing comes with a downside – possibly hundreds of thousands of cases are going unreported to health departments. Some experts say cases could be five to 10 times higher than the official numbers, making the current surge much more wide-reaching than it seems on the surface.

“I’ve been a huge fan of home tests for the last two years,” Jha said. “But what that means is we’re clearly undercounting infections.”

Experts agree that general trends presented in coronavirus metrics are more important than individual data points, but missing coronavirus cases still present some issues.

One of the biggest problems could be lacking data on exactly who is getting the virus. Such data is vital for deciding where to direct resources and how to make policy.

“If we are at a point where our telescope is pointed to a completely different part of the sky, we have less of an understanding of what our case numbers mean and what we are missing,” says Jennifer Nuzzo, an epidemiologist at Brown University.

And certain populations are more likely than others to be left out of the picture. Federal funds that covered tests for the uninsured dried up last month. Meanwhile, a two-pack of rapid tests costs $24 at major retailers. These factors cause an income barrier for who is getting tested, according to Nuzzo.

“The fact that we are doing less testing now in people with lower incomes worries me that we are missing surveillance in possibly one of our highest risk populations,” Nuzzo says.

Perry Halkitis, the dean of the Rutgers School of Public Health, concurs that the added expenses mean that only those who can afford testing are getting it. He notes that such costs place the burden on poorer Americans, much like other health crises.

“At the beginning, it affects everybody. But diseases over time as they evolve tend to lodge themselves in the most vulnerable,” Halkitis says.

Additionally, missing coronavirus cases means experts could have difficulties spotting a new variant when it pops up.

“If people are diagnosing themselves at home, or they’re just not getting tested at all, we are missing the opportunity to sequence and see if there is a new variant causing those infections,” Nuzzo says.

It’s important to start studying a new variant as soon as possible because the mutations in the virus could lead to changes in the disease. For example, knowing that a new variant renders vaccines ineffective or targets certain populations would lead to modifications in mitigation strategies…”

Once testing infrastructure erodes, Nuzzo says, “it’s really hard to build back when you need it.” (I)

“Back at the start of February 2022, at what in retrospect was the peak of the Omicron surge, with over 2,500 deaths per day in the United States from the infection, Ashish Jha, then the dean of the Brown University School of Public Health and now the White House Covid czar, told The New York Times’ David Leonhardt, “I don’t actually care about infections. I care about hospitalizations and deaths and long-term complications.”

The mind-numbing logical inconsistency at the heart of the new consensus that Covid-19 case numbers don’t matter is one thing—the road to hospitalizations, deaths, long-term complications starts with infections. Even if Omicron, in David Leonhardt’s words, was milder than previous variants—which, frankly, is starting to look like a dubious proposition—its sheer transmissibility was always going to be a problem. Because it’s the infection fatality ratio and the reproductive number together that matter in the end. A wildly transmissible variant—even of putatively less clinical severity—is going to cause more carnage than one that cannot manage to infect very many people at all. That was the winter of 2021–22.

But the main hypothesis here is based on a notion that we can, no, rather we have, delinked case numbers from all those nasty downstream effects; given the infectiousness of SARS-CoV-2’s recent variants, we’re all going to get it, and we might as well just give in. It won’t be that bad. As physician and talking head Leana Wen has said:

I really believe that all of us, unless we take really extraordinary steps, are going to get Covid and therefore be at risk for long Covid. I accept that risk for myself. I accept that risk for my children the same way that I accept that when my 2-year-old climbs onto a play gym and her brother is there, he may very well push her off of the play gym. Now, I wish that that won’t happen. I will do my best to make sure that doesn’t happen, but that is a risk that I have to be able to tolerate. And I think of Covid in that same sense.

We’re all just falling off the jungle gym. Nothing that a Band-Aid and a parent’s kiss can’t soothe…

But here we are in the midst of another surge. I’ve known more people infected over the past few weeks than I have in many, many months. Almost all have been in bed for just a few days; all were vaccinated and boosted; some have gotten access to Paxlovid; none were hospitalized. And all have recovered, though a few have lingering symptoms—a cough, shortness of breath—though these are rare among my friends and colleagues. But we are more than lucky. We are privileged. We may not be the 1 percent, but we are doctors, public health experts, university professors; we work for big nonprofits, and have access to most anything we need should we get sick…

Jonathan Reiner, a physician in DC, has let the CDC have it: “The fact that CDC continues to propagate this green bullshit tells me that they’ve made a decision to hide this massive Covid surge from you. You deserve to know your risk when you go out (and maybe even wear a mask?). This map is camouflage.” But if cases don’t matter and getting infected doesn’t matter, then the CDC’s decision—the White House’s decision that there is little need to alert the public—makes complete sense. We’re good. Don’t worry. Here’s a Band-Aid and a kiss…

So, the very least of what I’d expect from our leaders now—the politicians, the agency officials, the talking heads and experts—is to sound the alarm. Warn people that the risk to them and their families is high, as too many are unvaccinated and unboosted. Some have suggested that we wait for rises in national deaths to start to break through, but that is akin to not calling the fire department until you’re sure you’ve got a good burn going. Besides, deaths are already starting to sneak up…

But we won’t even get an acknowledgment that we are in a new wave. And of course, if you can’t admit the basics, all the rest is far less likely. Still, we keep pushing because as my old Yale College classmate—now infectious disease physician and researcher—Abraar Karan has said:

Cases matter. Surge of cases matter. Re-infections matter. Testing matters. Sequencing for new variants matters. Morbidity & Long Covid matter. Cases in unboosted individuals matter. Cases in high-risk patients matter. Cases among those without ‘the tools’ matter.

Plenty of people know this, and are trying to do their best to fight. You’re not alone if you share these concerns. In the end, you need to know where you stand. When this is all over, I hope there is a reckoning, in this life or the next, for the ways in which people who have committed their lives to public service, to the care of others, were so willing to cut loose the ties that bind us to each other, to sacrifice so many others for the good of those just like themselves.” (J)

• A.‘Wear a Mask Indoors:’ NYC Enters High COVID Alert Level as Hospitalization Rate Hits Key Mark, By Jennifer Millman, https://www.nbcnewyork.com/news/coronavirus/nyc-enters-high-covid-alert-level-as-hospitalization-rate-tops-key-benchmark/3692127/
• B.Eric Adams Resists ‘Shutdown Thoughts’ Despite Covid Rise, By Anne Barnard, https://www.nytimes.com/2022/05/20/nyregion/eric-adams-shutdown-covid.html?
• C.Another COVID surge in New Jersey? Transmission level is now high in much of the state, by Scott Fallon, https://www.northjersey.com/story/news/coronavirus/2022/05/18/nj-covid-transmission-rate-coronavirus-cases-rising/9776621002/
• D.A third of U.S. should be considering indoor masking, officials say, by Zeke Miller and Mike Stobbe, https://whyy.org/articles/covid-face-mask-recommendations-united-states/
• E.Some US Covid Drugs Are In Danger of Running Out This Summer, Official Warns, By Madison Muller, https://www.bloomberg.com/news/articles/2022-05-17/some-us-covid-drug-supplies-to-wane-in-summer-official-warns
• F.As the Virus Evolves, COVID-19 Reinfections Are Going to Keep Happening, BY JAMIE DUCHARME, https://time.com/6177192/covid-19-reinfection-how-often/
• G.“A lot of unnecessary loss of life”: The White House’s dire warning on Covid-19 funding, By Dylan Scott, https://www.vox.com/coronavirus-covid19/23123609/us-covid-cases-on-the-rise-vaccines-paxlovid
• H.C.D.C.’s Pandemic Team Will Surrender Some Responsibilities, by Roni Caryn Rabin, https://www.nytimes.com/2022/05/20/health/covid-cdc-reorganization.html?referringSource=articleShare
• I.Latest COVID-19 Surge in U.S. is Drastically Undercounted, By Cecelia Smith-Schoenwalder, https://www.usnews.com/news/health-news/articles/2022-05-20/latest-covid-19-surge-in-u-s-is-drastically-undercounted
• J.“Case Numbers Don’t Matter”—and Other Fatal Covid Fallacies, By Gregg Gonsalves, https://www.thenation.com/article/society/case-numbers-covid/
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