Light at the End of the Tunnel
By Nayyer Ali MD
Almost a year after America began to shut down in the face of the COVID pandemic, we can see light at the end of the tunnel. Not a moment too soon, at that. After a horrific winter surge, with daily deaths peaking over 4,000, cases and deaths are falling rapidly. More important, widespread vaccination is ramping up even faster than expected. Combined, we could see life return to a semblance of normal within a few months.
For the US there were three waves to this pandemic. Last March and April, an initial surge occurred in the Northeast, particularly New York City, where over 2,000 people were dying every day and the hospitals were overwhelmed. With lockdowns and social distancing this wave came under control, but a second wave occurred in July and August as states reopened and allowed indoor dining and other activities. That wave subsided and by October daily cases and deaths in the US were higher than in Europe, but manageable. Schools reopened in the fall in many states, and both the NBA and MLB were able to complete their shortened seasons and complete their playoffs, just without fans in the stands.
But then Americans grew tired of the restrictions and social distancing and let their guard down. Holidays followed rapidly with Thanksgiving, Christmas, and New Year’s combining to spread the disease widely. Cases grew quickly in November, followed by a surge in hospital admits and deaths in December and even worse in early January. By now, over half a million Americans have died from COVID. But after peaking around 250,000 new cases daily the new case counts have dropped to under 80,000 by mid-February. The number in hospital has dropped from over 130,000 to under 70,000. This is still above the prior peaks which reached 60,000, but the trend is sharply downward. Deaths have also dropped from 3,300 per day to 2,300.
These declines are gratifying, and even more so because they are not due to vaccinations. Less than 15 million had been vaccinated by end of January, and so those numbers are not large enough to have an impact. But vaccinations are finally starting to ramp up. By mid-February, 40 million Americans have had at least one vaccine dose, which is enough to reduce severe cases by 90%. Last fall, Biden stated his goal was to get 100 million doses of vaccine given in the first 100 days. We are now giving 1.6 million doses a day and that will continue to climb as more vaccine becomes available and distribution channels become more efficient. By early March we should giving over 2 million doses per day. Johnson & Johnson is also awaiting FDA action to give emergency use authorization for their vaccine, which works well too, and importantly, only requires a single dose and can be stored in a standard refrigerator. Pfizer and Moderna, who have the two currently approved vaccines, are ramping up their production faster than expected, and combined with JNJ, vaccine availability will be plentiful by April. Dr Anthony Fauci has stated that by April the vaccine will be available for anyone who wants it.
As we vaccinate, the question then arises when do we get to be normal again? When can we take off our masks? When can we eat in restaurants and go to a concert or sporting event without limitations? When can we attend a convention, or hold a banquet again? The answer to that depends on what level of risk Americans as a whole are willing to live with. If the goal is that there is no risk of getting COVID, then we are still many months away. We would really need to vaccinate most of the population, probably about 250 million people or more. But if we are willing to live with some illness, perhaps less than 50 deaths a day around the country, then we could be there by May or June. If COVID is a rare condition, then hospitals can provide excellent care to patients and have even better results than when ICUs are full and doctors overwhelmed.
Most deaths occur in patients over age 50 or who have diabetes and other serious conditions. Nursing home residents are particularly vulnerable to COVID. These groups could all be vaccinated by end of March. At that point, we could see hospital numbers and daily deaths plummet to very low levels. Americans will then want life to return to normal. Fifty deaths a day is less than 20 thousand per year, which is about how many die in a flu season and is less than the number of people who die in traffic accidents per year. COVID would then become just another risk of life but not one that can overwhelm society.
For the world to return to normal though, vaccines have to reach the entire planet. One of the big mysteries of COVID is how much illness and death have varied from country to country. Africa and South Asia have had much less death than Europe and North America. COVID initially killed many in Wuhan, China, but has been basically very limited in its impact in East Asia. These huge differences in illness and death are still hard to understand, and government policies and health system capacities do not explain these results.
It does lead to the obvious question: how much of the world needs the vaccine? Do all adults everywhere need it, or only those over age 50? If the latter, the number needed to vaccinate globally goes way down. Fortunately, the number of effective vaccines is rising rapidly. Both Russia and China have shown their vaccines work well, as did Astra Zeneca in Europe. There will be enough vaccine to meet global demand this year, but the rich nations need to step up and provide funding needed to get vaccine to the poorest.
Is there any fly in the ointment? Can things go bad again? The one issue that causes concern is the development of viral mutations that might render the vaccines less effective. Several mutant strains of COVID have been identified around the world. So far, the vaccines appear to still be effective against these mutants. SARS CoV-2, the official name of the virus that causes COVID, does not mutate rapidly, unlike the flu virus, for example. It is however less stable than the polio or measles virus, where vaccines made decades ago are still perfectly effective. Flu vaccines are only good for one season, and then need to be redesigned. COVID appears to be in-between. It may be that vaccine makers will have to tweak their vaccines or update them, and in a worst case scenario, we may need to give a booster vaccine dose once a year to high risk individuals. But for now those are theoretical worries, the current mutants can be controlled with our current vaccines. Continued vigilance and surveillance are important.
President Biden has brought competence and efficiency back to the US government. His policies are hitting all the right notes, and if all goes well, America will surge back in the next few months. The economy will recover rapidly and this year-long nightmare of infection will be behind us
