Well, that escalated quickly.
New York Gov. Kathy Hochul reported Saturday that another 21,908 people had tested positive for COVID-19 — breaking the state’s record for cases over a 24-hour period for the second consecutive day. The mark bookends a fast-paced week — one that started with the introduction of a new statewide mask-or-vaccinate mandate and concluded with New York City Mayor Bill De Blasio pledging to hand out 1 million masks and 500,000 at-home tests.
But these milestones don't mean the state has reached its worst peak. For one, a cleaner readout is the seven-day average, which is also increasing fast but accounts for data reporting issues. Some places take time to report in all their numbers, so a single-day total may not reflect everyone who recently tested positive. New York City, for example, backfills its case data by up to a week, and it doesn't report stats over the weekends.
The single-day testing record also fails to convey severity. A COVID hospitalization lags behind an initial infection by weeks, and New York state's latest surge has been ongoing since late October. Despite this autumn wave starting around the same date as the one last year, the current hospitalization rate isn't rising as fast and is 30% lower than a year ago. COVID-19 deaths in New York state, too, have remained mercifully low and are nowhere near previous summits.
The news media and some regular consumers of COVID-19 stats are undoubtedly aware of these caveats, but pandemic anxiety is shown to overwhelm our memories and better judgments. A desire for normalcy as cases dropped this summer and fall has also caused leaders and the public to take more risks, according to Dr. Eric Topol, one of the nation’s leading COVID experts.
Ipsos national polling this week shows 52% of employees are required to wear masks in their workplace, down from 61% in early October. The same survey shows self-reported social distancing shrank from 64% in April to 45% now, and meanwhile, vaccine requirements doubled from mid-August to this week, from 16% to 33%. Likewise, Morning Consult polling shows people grew much more comfortable with going to the movies and eating out — while wearing masks less often.
“The greater danger is the false sense of security and complacency among the public after living with the pandemic for nearly two years,” Topol opined this week in the Los Angeles Times. “Many people, after reading early reports suggesting Omicron might be a milder form of the virus, are asking, “Why should I worry?””
The fear and complacency are creating amnesia about what has long been known about how this pandemic works and how to fight it. Indoor masking, vaccines, social distancing, ventilation and strategic testing can work in tandem to prevent surges that tax hospitals and hamper the economy. But these protective measures are still not universally required nor universally available during this surge. Instead, new provisions, including the one imposed in New York this week, seem to pit vaccines against masks — a tradeoff that’s been promised nationwide since well before this summer’s reopening.
Many infectious disease experts have long called for the opposite — layering on measures when cases are expected to rise in order to keep surges from causing too much severe disease.
“Our response has been so reactive. Something happens, and then we'll chase after it,” said Dr. Bruce Y. Lee, a public health policy expert at CUNY and executive director of Public Health Informatics, Computational, and Operations Research (PHICOR). “Rather than setting up all these systems and being organized or strategic about things, we seem to continue to be behind the wave.”
The Biden administration is now reportedly poised to recommend such measures to avoid lockdowns and get people comfortable with the concept of living safely with COVID-19, in perpetuity. In this scenario, known as an endemic, the coronavirus would continue to thrive, but vaccinated people would be largely spared the worst outcomes.
A COVID endemic would mean continuing to ride this rollercoaster of infection waves every few months or perhaps just every winter, but it could be brutal.
Influenza is endemic, and the worst recent flu season caused an estimated 52,000 deaths, 710,000 hospitalizations and 41 million symptomatic cases in the U.S. Yet, society has essentially become accustomed to the flu, if not somewhat indifferent to its disease burden. After pharmacies put out those “it’s time to get your flu shot” signs every autumn, only about 40-50% of American adults respond by getting one.
The coronavirus has averaged 400,000 deaths over two consecutive years in our country, an unsustainable toll. Is the U.S. prepared to settle for 50,000 COVID fatalities per year if it means keeping businesses and schools open? What about 100,000?
Omicron: A New Forest Fire
Several labs and public health agencies had predicted a resurgence of the delta coronavirus variant this winter as people moved indoors, similar to what happened a year ago. This time around, society has mostly reopened, meaning the coronavirus has much broader opportunities to spread.
Omicron is now thriving in New York, and so far, it’s thought to spread twice as fast as delta. This new variant also appears to more easily infect recovered patients and two-dosed vaccinated people because it is better at evading our immune system’s antibodies relative to delta. Early on, the vaccines reduced the chances of infection by 80 to 90%. Against omicron, the shots might only lower the odds by 30%, according to a large study from South Africa released this week.
“The prevalence of breakthrough infections in my private practice of family medicine in lower Manhattan has absolutely exploded,” said Dr. Mark Horowitz, a physician based in the Financial District. On Saturday, he said he had dealt with 21 breakthrough cases over the past three days, ranging in age from their mid-20s to the mid-60s.
“I would say in 72 hours, we matched the numbers of the previous four weeks,” Horowitz added.
In a positive sign, omicron may not thwart the body’s mainline defenses against severe disease, T cells, after just two doses of COVID-19 vaccine — based on data presented this week at the World Health Organization. That recent study from South Africa also showed that full vaccination still lowers the chances of severe disease by 70%. Boosters are expected to restore protection against initial infection, according to a series of preliminary results shared at the WHO meeting.
All of Horowitz's recent breakthrough patients have relatively mild to moderate symptoms, but he is keeping close watch over the older ones who might be more vulnerable. So far, they've all complained of having symptoms akin to a severe cold, he said.
“Unlike the pre-vaccine era, when we were seeing sicker people and the protocols involved [telling older patients to] get yourself a pulse oximeter, take some aspirin, use an inhaler and call me if your oxygen level drops below 94% — that's simply not happening [right now],” Horowitz said, adding that time would tell if that’s a universal experience.
If these early results and observations hold steady, the result would be an uptick in breakthrough infections among two-dose people, yet they would be much less likely to experience a hospitalization, akin to what has been the situation with delta.
But unvaccinated people would still face an abundant amount of peril, especially if they’ve never been infected previously by earlier variants because omicron spreads so fast.
Members of New Jersey’s largest health care system said they feel prepared to handle the ongoing surge without witnessing vast amounts of death. Last winter’s wave and this summer’s delta surge were far less lethal thanks to the vaccines and improvements in emergency medicine for COVID-19 that have been developed since March 2020. Dr. Craig Spencer, director of global health in emergency medicine at New York-Presbyterian/Columbia University Medical Center, agreed.
“I am not as concerned that we're going to see the same level of COVID death and destruction as we did in March and April of 2020,” Spencer told the BBC World Report on Saturday. "We have a community that has been largely hit by this virus and has immunity from having been vaccinated and still a lot of people that have gotten a third dose.”
Spencer is more worried about burnout among health care workers. Early findings in South Africa suggest protection against omicron remains for those with so-called "natural immunity," or people who solely rely on defenses built after past infections. But those trends may not save some U.S. areas from hospitalization surges because, as NPR reported this week, up to 66 million Americans have not been vaccinated nor infected. Another reason is that older immune systems tend to be less hearty. The U.S. median age is 10 years older than that in South Africa, which has been previously cited as a potential reason for differing COVID outcomes. And while natural immunity might provide some people with security, a study published in November found these folks were also five times more likely to experience a subsequent COVID hospitalization relative to vaccinated people.
Already closer to home, southern states — such as Georgia, Tennessee and South Carolina, where only about 50% are fully vaccinated — are starting to witness increases in newly hospitalized patients despite dealing with large waves in the past. Cases in Florida are rising just as sharply as in New York, which has a similar-sized population. The Orange State experienced a huge delta variant outbreak this summer. But it is only 62% fully vaccinated compared to the Empire State’s 70%.
Think of this situation as the coronavirus and its variants sparking multiple wildfire seasons, while our bodies are trees with bark for immunity. The earlier variants burnt through the U.S. Millions of trees survived because their bark was already sturdy and potentially became more robust, but at the expense of 800,000 deaths. Masks, social distancing and lockdowns allowed us to wall off hundreds of millions until they could reinforce their bark through full vaccination.
So far, omicron is expected to break through that reinforced bark, but those immune trees could likely remain upright. Only now, the entire forest is open. Scores of eligible people remain unvaccinated, including most children and a fair number of adults. About 29% of New York City is not fully vaccinated — 713,000 are ages 5-11 while 1.2 million are adults. Another half million city kids under 5 years old are also unvaccinated due to ineligibility.
Settling Into The Endemic
Elected leaders and businesses are reportedly starting to mull whether it makes sense to revert to lockdowns or just give communities the tools they need to emotionally and logistically adapt to a coronavirus endemic, a country perpetually threatened by COVID-19.
“Fewer people will die, fewer people will be hospitalized, and it'll become more of a seasonal respiratory virus,” said Lee from CUNY.
President Joe Biden is expected to lay out this plan in a speech Tuesday, according to CNN. Such a strategy would likely emphasize a mix of vaccination, masking and routine testing to help keep contagious people from spreading the disease. Along those lines, the NFL is changing its COVID protocols to allow players with breakthrough cases to leave isolation early if their symptoms abate and they subsequently test negative. The NBA has considered doing the same. Likewise, the Centers for Disease Control and Prevention have now endorsed Test-to-Stay practices, so unvaccinated kids who test negative after an exposure can exit quarantine.
“The concern, of course, is by allowing a virus to spread rapidly throughout the population, you're going to have people get hospitalized. You're going to have people die," Lee said. "You're going to have a not insignificant percentage of people who continue to have persistent symptoms.”
Some studies point to the vaccines protecting against those persistent symptoms, known informally as Long COVID, especially for younger patients. More study is needed to confirm the protective pattern.
An endemic is a risky bargain, and its pitfalls would be felt unevenly. Many regions, including parts of New York state, still lack the necessary vaccination rates and hospital staff to keep delta and omicron variants from overwhelming their medical centers. As multiple epidemiologists have said, omicron could appear or ultimately be milder than delta — and still cause a devastating amount of severe cases in some places.
That's the big concern of just allowing the virus to spread relatively unmitigated right now, Lee said: “People with heart problems, cancer or other types of problems — if the hospital is being overwhelmed, they may not get the proper care, and then they may suffer bad consequences.”
Both he and Horowitz said improving access to testing, especially at-home rapid tests, could also help keep omicron infections from publicly spreading through vaccinated and unvaccinated communities.
“Everybody should have a pile of reliable home tests on their kitchen table and, if they wake up with a sniffle or scratchy throat, should test themselves,” Horowitz said, referencing the recent long lines outside of New York City testing sites. “We're just burdening the system unnecessarily.”
