CM – Most chaotic phase of the pandemic to date

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Alexis C. Madrigal, The Atlantic

The numbers are remarkable. More than 100 million people in the US are likely to have contracted SARS-CoV-2 and 167 million people are fully vaccinated. Despite this huge population with at least some level of immunity, the delta variant has increased the number of cases and hospital admissions. Florida is on the way to getting twice as many people hospitalized as any other wave before, when virtually no one was vaccinated.

One way to think about it, as epidemiologist Ellie Murray has pointed out, is that, if Delta is as transmissible as the CDC thinks, we need a much higher percentage of our population who are just vaccinated against vaccines and natural infections to dry up the virus. Even if the vast majority of people in a given location got the coronavirus or an injection, outbreaks can still occur, as Brown University health expert Ashish Jha fears after the Sturgis Motorcycle Rally in South Dakota.

These realities have already undone more optimistic late spring predictions, including my own. After watching these numbers for months with the COVID tracking project at The Atlantic, I never thought that we would see hospital admissions higher in any state than during the winter peak. But here we are.

It is time for a data-driven reset of the basic known and unknown of this pandemic, a task that must be approached with great humility. The virus is constantly changing, as is our understanding of the social and biological components of the pandemic. But if we examine both the known and the unknown, we can see how complex the pandemic has become – and that we are still missing important data due to the failings of the state and federal governments.

Let’s start with the best, good one News. Based on the available data, all vaccines administered in the United States appear to confer solid immunity to serious outcomes such as hospitalization and death. Over a three-month period this summer, the CDC recorded 35,937 deaths from COVID-19 – but only 1,191 of those who died were fully vaccinated. In other words, 96.7 percent of deaths that summer were unvaccinated. Hospitalization dates look similar, with few fully vaccinated people requiring hospitalization.

The CDC’s data reflect what other institutions have found. The New York Times was able to compile data from most states on the percentage of people with breakthrough cases who were hospitalized. Although the percentage of breakthrough patients ranged from just 0.2 percent of all hospital admissions in Texas to 4.7 percent in Arkansas, more than 95 percent of hospital patients in each state were unvaccinated. This also agrees with data from the UK, which has better data than the US because of its National Health Service. Many other, smaller studies in different states show very similar results.

In Israel, data showed that fully vaccinated patients who were hospitalized were much more likely to have comorbidities such as high blood pressure, diabetes and heart failure.

That So is known: At this point in the pandemic, less than 5 percent of people who are hospitalized and die are fully vaccinated.

Although the randomized controlled trials of vaccine efficacy showed that vaccines provide significant protection against Symptomatic infections – with about 95 percent effectiveness for the mRNA vaccines – their real performance is almost certainly inferior, although it is not exactly clear to what extent. (More on that in a moment.) At the same time, increasing evidence suggests that some people with breakthrough infections can transmit the virus. Combine these two facts with Delta’s extremely high portability, and we find ourselves in a world where even well-vaccinated communities can grow rapidly in cases. In the days leading up to the pandemic, 70 percent vaccination was considered a gross goal to achieve herd immunity, the point at which virus growth could no longer be sustained in a community. Yet San Francisco, where 70% of the population is vaccinated, has seen a similar increase in cases as in Maricopa County, home of Phoenix, Arizona, where only 43% of the population are vaccinated.

Although counties and states are using If higher vaccination rates statistically show lower case numbers and hospital stays, they have nonetheless become areas of high prevalence in the community.

There are probably different transmission dynamics within these cities. Young, unvaccinated people are likely responsible for much of the transmission. There are still 50 million children under 12 who are not eligible for the vaccines. However, it is also likely that older, vaccinated people are responsible for some spread as the amount of virus increases in the community.

In some places this has not resulted in a large increase in hospital admissions, but that is not generally true. Perhaps the most surprising example is The Villages in Florida. Almost 90% of people over 65 are vaccinated in this metropolitan area, but the number of cases and hospitalizations has increased.

Although again, statistically, places where more people are vaccinated do better than places where fewer people are vaccinated, there are enormous fluctuations in the numbers. Some of this can be explained by political decisions and political loyalties. But some things are just lucky.

In the spring, when the variant we were most concerned about was called Alpha, Michigan, and almost only Michigan, was completely set on fire, which peaked in winter hospital stays. This did not happen anywhere else, although some epidemiologists expected it to be based on the experience of European countries. Alpha just walked away, and it seemed like the US cleared up.

Enter Delta. In this surge, a piece of Missouri began to take off before the rest of the country. Would it be like Michigan? As we all know, the answer was no. The southeastern United States is currently experiencing huge outbreaks as many states approach or exceed their pandemic peaks in cases and hospital admissions.

The healthcare system in northern Florida is under pressure few places have experienced during the entire pandemic. Why there? Why not elsewhere with similar vaccination rates and political opposition to viral countermeasures? Nobody knows for sure, and we probably never will find out.

One of the rare blessings of the pandemic has been that children have proven to be uniquely able to deal with the SARS-CoV-2 attacks. Your risk of getting serious illness has always been very, very low. And the evidence available suggests that hasn’t changed. COVID-NET, a CDC sample of hospitals, shows that the rate of hospital admissions for children during the pandemic varied from about 0.3 hospital admissions per 100,000 to 1.5 hospital admissions per 100,000. That rate is now rising rapidly, but remains within the historical framework of the pandemic in the United States – around one hospitalization per 100,000 children. Similar trends apply to age subgroups such as 0-4, 5-11, and anyone under 18 years of age. And hospitalization rates for children under 18 remain significantly lower than the highest hospitalization rates for adults between 18 and 49 years of age (10 in 100,000), 50-64 (28 in 100,000), and 65 and older (72 in 100,000).

The CDC’s COVID-NET data doesn’t cover the entire country, however – it pulls data from 99 counties in 14 states, representing roughly 10 percent of the US population. And there is no data from hospitals in the worst-hit state of Florida.

If we look at the pediatric hospital admissions collected by the Department of Health and Human Services, we can see that they are now hitting record highs, the worst day of the winter spike excel and still go straight to the top. Although the totals are still low – the seven-day average of hospital admissions is less than 300 per day – children in the southeast are almost twice as likely to be hospitalized as at any other time in the pandemic. Some states admit two or even three times as many children as they have at any point in the pandemic.

It is important to note that there can be several reasons why we are seeing this surge in pediatric hospital admissions. Taken alone, the increases do not mean that the average infection of the Delta variant in children is more severe than that of previous SARS-CoV-2 strains. In an early Scottish study, the data were worrying, but the bigger problem is that almost all of the data available to school decision-makers is pre-delta wave. The nation’s kids will be back in the classroom before we definitely know if Delta hits kids harder than previous variations.

Still, the kids’ numbers pretty much match those of the adults – and it’s not entirely clear whether this is a meaningful shift from earlier stages of the pandemic.

All the data taken together seems to indicate that an absolutely monster wave of coronavirus is circulating in the south and that our current case numbers do not come close to the true numbers of infections in this region of the country record.

There would always be groundbreaking infections for vaccinated people. No vaccine offers perfect immunity, and the immune system is strange and somewhat unpredictable.

But the hope that these infections might not pass the virus on had some logic. Since the vast majority of those vaccinated have mild symptoms, it was thought that they might have a lower viral load and therefore less likely to spread the virus.

How good the vaccines are at protecting against infection (not just symptomatic infections, hospital admissions, or death) a hotly contested topic. A plethora of data suggests that vaccinations help prevent infection with the virus from turning into infection, and that this obviously helps slow the spread of an outbreak.

But it has also become clear that vaccinated people who become infected can spread the virus. The latest evidence came when American scientists were able to cultivate viruses from samples taken from vaccinated individuals who had become infected. The same people showed similar viral loads as unvaccinated people. And yes, even those with asymptomatic infections.

While this is bad news, there is also good news: breakthrough infections seem to be significantly shorter than infections in the unvaccinated. That would shorten the time in which people with breakthrough infections could spread the virus.

There will undoubtedly be many more studies in this direction, and the papers cited above are preprints, which means they have not yet been peer-reviewed . But the data, including unpublished studies cited by public health officials, point in the same direction: there are breakthrough infections. And if they do, these people can spread the virus.

We already know that we underestimated the true number of infections over the course of the pandemic. Sure, we have a list of cases, but that number consists almost entirely of cases confirmed by a positive test result. And as the conditions of the pandemic have changed, the relationship between that number of cases and the actual number of infections has changed. It’s such a fundamental question that it seems absurd to ask, yet we just don’t know how many Americans have had COVID-19.

This is not a purely academic question. Natural infection should confer some level of immunity, although it is unclear whether natural immunity is as protective as vaccines. Regardless, it is important to know how many naive immune systems there are in order for the virus to arrive. We know the number of people fully vaccinated with some accuracy – let’s call it just under 170 million people. But how can you best estimate how many people have become infected? The CDC has performed some tests for antibody levels in the US population, but the data are incomplete and inaccurate. You couldn’t just multiply the percentage of people with antibodies by the number of people in the country and get an exact number.

From hospital stays and death dates, we know the approximate shape of the waves of infection. In the spring of 2020 there was a great New York-centric wave; a smaller, south-facing summer wave; then last winter’s massive nationwide wave. In 2021 there was a small spring wave in the upper Midwest, and now there is the current massive summer wave in the southeast.

You can add up all the cases from these waves and find approximately 36 million confirmed cases. But for each era of the pandemic, there were different availability and uses of tests – not to mention a large pool of asymptomatic infections. Over time, this has led to very different and still unknown case detection rates. Public health officials know they were severely undercounted at the start of the pandemic, an issue that improved over the year. But in 2021, the availability of home testing and COVID-19 denial – especially in the less-vaccinated right-wing areas where the virus thrives – may have reduced the number of cases we have confirmed, among other things. Vaccinated people with mild cases may also have less incentive to get tested, knowing that major complications are unlikely to occur. The CDC itself did not initially recommend having fully vaccinated people post-exposure tested before that policy was amended in late July. Some institutions also discontinued testing systems for vaccinated people, and some testing centers reduced their services. All of this is to say: Both interest and access may be lower than it was earlier in the pandemic.

The CDC estimates the total number of infections. That number was 120 million before the delta wave, ranging from 103 million to 140 million. How many people have been infected since June 1st? The CDC has counted around 3 million cases, but who knows how this number relates to the true number of infections.

Then there is one final unknown regarding immunity: How do the infected and the vaccinated? The US doesn’t have this data, but it’s a pretty important part of our current situation. If there was no overlap between the 170 million vaccinated and 150 million infections, we would be looking at 320 million people with some immunity, almost the whole country.

However, it is likely that there is a lot of overlap. And the more overlap, the dry tinder there is to keep this pandemic going. If everyone in the United States is vaccinated or infected, it doesn’t mean the pandemic is over, but our collective immune systems will have become a more dangerous adversary for the many strains of SARS-CoV-2.

As mentioned earlier , all available data show that the vaccines continue to be remarkably effective in reducing the risk of hospitalization and death from COVID-19. But after this very important result, the data is much more opaque.

So the effectiveness of the vaccines is a matter of perspective. What people can call vaccine effectiveness can mean different things, and therefore the nature of their data and calculations may vary. If we want to talk specifically about the effectiveness of vaccines, we need to specify effectiveness against an endpoint (infection, symptomatic illness, hospitalization, death). We also have to define the temporal parameters: over how long of a period? When were the vaccines given? We have to break open the different vaccines. We need to have a rough understanding of the variants in circulation when a particular study was conducted. Finally, we need to indicate which population group is being discussed – young, old, immunocompromised, health workers, etc.

Sure, all of these factors can and had to be combined into a single number during the vaccine approval process to determine the effectiveness of the vaccine. That number was 95% in the original studies for the mRNA vaccines.

Effectiveness is what is empirical evidence. Following the publication of these results, what we typically heard from the CDC on vaccine effectiveness page: “mRNA COVID-19 vaccines provide similar protection in real-life conditions as clinical trials and reduce the risk of COVID-19, including more severe ones Illnesses in people who are 90 percent or more fully vaccinated.

But here’s the thing. Change one of the crucial variables and the picture changes. This has led to the publication of several conflicting studies. A study by the New England Journal of Medicine found Pfizer’s effectiveness against symptomatic Delta variant diseases is 88%. That’s great!

However, a preprint paper that worked with data from the Mayo Clinic found much lower effectiveness against infection, especially for the Pfizer vaccine, which the authors claim has an effectiveness of only 42 % had against infection after Delta became widespread in the populations studied. These results are both surprising and worrying.

There are also big differences in international studies. We can see the same hard-to-explain results on slides made by the CDC for the panel of experts, making recommendations about vaccines. Pfizer looks good in the Anglo-Scottish and Canadian data, even on infection and symptomatic disease, but Israeli and Qatari data do not perform the same.

It may be that these data can be reconciled in some way. For example, the NEJM study looked at symptomatic illnesses, while the Mayo Clinic study may have identified more asymptomatic illnesses. But even that wouldn’t be all that reassuring at the population level because, as mentioned earlier, it now seems likely that vaccinated people with asymptomatic infections can at least sometimes spread the virus. And at least the Israelis didn’t seem to show much of a difference between the effectiveness of the vaccine in preventing infection and symptomatic infection.

There are many other possible explanations. Could vaccines be less effective than hoped, making those with less current vaccinations more likely to become infected? Could there be a problem with the distribution of some of the Pfizer doses that require the most intense cold storage of all immunizations? Perhaps the way the studies selected their subject populations or the data work shifted the results one way or the other. And none of that affects the effectiveness of the Johnson & Johnson vaccine, which has been shown to be less effective in studies. Infections and / or symptomatic illnesses.

After a glorious June when cases in the US fell to their lowest level since the pandemic began, more viruses began to circulate across the country. The UK had just seen an increase, but it did not lead to an increase in hospital admissions or deaths. That seemed to mean good things for the United States.

On June 1, when the Delta Wave took off in the UK, about 40 percent of the population were fully vaccinated. The wave came up – it hit 80 percent the height of fall from the winter – but hospital admissions only hit 15 percent of the winter peak before the wave receded. That was fantastic news from a British perspective.

Fast forward a month and cross the Atlantic. When the delta wave took off in the US in early July, around 47 percent of the US population was fully vaccinated. But in the American context, hospital admissions have not only soared to 50 percent of their pre-pandemic peak, but are still on the rise. Several southern states are peaking in hospital admissions despite three previous waves of infection and millions of residents vaccinated.

Florida vaccinated a larger proportion of its population at the start of the American Delta Wave than Britain when it saw the variant grow exponentially. But in Florida, the state now has almost twice as many COVID-19 patients in hospitals as never before during the pandemic.

It will take a long time to work out the different factors between the US and the UK. Obviously, for example, the United States is a much larger country with diverse urban structures.

But there are several other immediate ways to think about why things are going so differently in the United States. The UK’s vaccination strategy was very different from that of America, despite the general similarity in vaccination rates. It could also be that American unvaccinated people were more unevenly distributed across the country than unvaccinated people in the British context, with different epidemiological implications.

However, if you look at Florida, one thing stands out. For reasons few epidemiologists could understand, the state wasn’t hit as hard as neighboring towns with similar populations and politics. Look at just about every metric before the delta wave, and Florida did pretty well compared to New York, California, or Illinois. It was only with the current delta wave that Florida experienced a surge comparable to that in other large states.

In contrast, the UK has been hit by two massive waves of COVID-19 that almost doubled the death rate was as high as in the US. The virus may no longer have bodies to attack.

Perhaps, in Florida, the happiness of the state in previous waves – along with political opposition to societal countermeasures – could be one of the factors driving this gigantic surge in COVID-19 drive.

Positivity rates – as my colleagues on the COVID tracking project repeatedly argued – are a difficult metric, especially when used as a threshold for making important decisions. However, as a rough measure of whether tests are appropriate, they help tell the story of the case numbers coming in from the American South.

Note that the goal for the positivity rate was below 3 percent in most states. In the Florida Panhandle and adjacent counties in Alabama and Georgia, the positivity rate is greater than 25% in many counties. This is akin to many jurisdictions in the days of severely restricted test supplies during the first wave of the pandemic. It is not for nothing that these areas are also seeing massive increases in hospital admissions, and since serious illnesses predominantly occur in unvaccinated people, we will also see an increase in deaths.

At first glance, increased positivity rates in the past have meant monitoring the public health a greater proportion of infections were absent in a community. But there is more evidence that this is happening. Compared to the previous waves, the ratio of cases to hospital admissions is lower. Last winter, we confirmed 12 million cases in December and January. In this wave, we have confirmed fewer than 3 million cases since July 1. Last winter we reached a record high in the hospital with more than 120,000 COVID-19 patients at the same time. At the moment we’re already over 64,000. So we show 25 percent of cases and 50 percent of hospital admissions.

Additionally, home tests like the Abbott BinaxNOW and other types of tests in institutional settings like schools may not be reported to authorities. It’s all really a mess.

There are more accurate ways to look at this data in specific hospital systems and areas, but the result is that either Delta makes people sicker – which, as mentioned above, is a real possibility – or our case detection rate has decreased. Or, just to muddy things, maybe both.

For people in countries with access to vaccines, the good news is that it seems almost certain that fewer people will die in this COVID-19 wave than in the winter wave. Less, both in absolute terms and in terms of percentage of COVID-19 infections, as the vaccines make them much less susceptible to serious illnesses. This is an unlimited good (and a moral imperative for the rest of the world).

But millions of unvaccinated people are still getting infected. And the old math of COVID-19 will apply to them. Older people who get sick are more likely to die. The more comorbidities an infected person has, the more likely it is that they will die.

Here, too, there is good news at the national level. The most vulnerable group – people over 75 – are infected at about 10 percent of the rate at the winter peak. That’s a big drop.

But in certain areas, again in Florida, this trend is not sustaining. There, the rate of hospital admissions is increasing in every age group, from young people to over 80 years of age. And people between the ages of 50 and 79 are being hospitalized more often than ever before in the pandemic. Some of these people will die, and the number will not be small.

There is also hope that better therapeutics and improved care practices will lower the death rate. But there is also pressure in the other direction. With hospitals in badly affected areas under tremendous strain, they are less likely to be able to provide the highest standard of care.

Florida already reports a seven-day average of more than 150 deaths per day, a number which will likely increase as the statistics work their way through the system. Florida’s winter peak was around 180 deaths a day.

So the big question in all of this is: Does Florida indicate what is likely to happen in the rest of the country? That is not yet clear and we hope not.

This section is more of a list of questions than answers. There is so much we don’t know about the risks of long-term COVID. For example, how susceptible are adults with mild infections to long-term COVID? How about kids How about breakthrough infections? And asymptomatic infections?

Postviral syndromes haven’t been explored enough for a long time. Long COVID is a bundle of unexplained aftermath of a virus that we have never encountered before. This is especially difficult to study. However, at the urging of patient advocates, scientists are trying to get a grip on the depths of the problem.

According to a meta-analysis of research, at least some symptoms persist in 80% of COVID-19 patients for more than two weeks. A UK poll found that more than 10 percent of people with COVID-19 said the effects of the disease still had a « significant impact on my daily life » 12 weeks after being infected. Another found that only 2% of people showed symptoms 12 weeks after being infected. And another found 38% of people after COVID-19 with at least one symptom after 12 weeks. Many research studies and anecdotal stories speak of the prevalence of these problems. But the details are really difficult to determine, as are the risk factors.

What about post-vaccination infection? Will the vaccinations also prove effective in reducing long-term COVID? In a small study of healthcare workers, widespread symptoms were found in some people with breakthrough infections. If the Delta variant really catches on across the country, there will be lots of breakthrough infections.

If you are relatively young and healthy, you can always bet that you probably got through a COVID-19 infection well, neither hospitalized still dead. This applies twice to the vaccinated. But for a long time COVID has been the big, rotating question mark in all the risk calculations that people continue to have to do.

NEXT STORY:

Department of Justice outlines protocols for vaccine certification and testing

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