Covid-19 Cases Are Dropping. What Comes Next?

The next phase of the pandemic hinges on vaccines, variants, and doubling down on protective measures

Image: cromaconceptovisual/Pixabay

I’ve treated hundreds of Covid patients in my emergency room. I saw many say goodbye to their family over grainy FaceTime videos. I’m as eager as anyone to see the end of this pandemic. Thankfully, that may be in sight.

Covid cases and hospitalizations are dropping. Vaccines are getting into arms. So, what happens next?

Some experts are warning of a fierce fourth wave driven by viral variants. Others believe the worst is behind us and Covid will fade in the coming months.

The truth is: The next phase depends on a balance of vaccines, variants, and continued adherence to protective public health measures.

Vaccines

The Covid-19 vaccines are miracles of modern science. We’re already seeing their dramatic impact on this pandemic.

The United Kingdom and Israel — two countries that have vaccinated a larger proportion of their population than the U.S. — have seen a drastic decline in hospitalizations after their vaccine rollouts.

Vaccination in the U.S. started much slower. When I got my first dose in December 2020, every day brought more new cases of Covid than people vaccinated against it. Two months later, that has changed dramatically.

We now administer 1.5 million doses per day, vaccinating more Americans in eight hours than will be diagnosed with Covid in a week.

Despite our slow rollout we already see the benefit of targeting the most vulnerable populations at the outset. Nursing home residents were prioritized for vaccination since they account for 35% of Covid deaths in the U.S. Since vaccinations began in late December deaths in nursing homes have dropped precipitously, suggesting the vaccine is saving lives.

Source: KFF (Kaiser Family Foundation)

As the rollout picks up steam in the U.S., it’s increasingly obvious that vaccines are one of the most critical tools for slowing the pandemic. Every dose delivered gets us closer to putting Covid behind us.

Variants

The optimism around vaccines has been tempered by reports of variants circulating around the world and across the U.S. These variants — B.117 (first identified in the U.K.), B.1.351 (South Africa), P.1 (Brazil), and B.1.427/B.1.429 (California) — concern virologists and public health experts because they possess characteristics that could complicate control measures and prolong the pandemic.

For example, B.1.117 is 30–50% more transmissible (and likely more deadly) than the strain causing most infections in the U.S. It has been identified in over 90 countries and 33 U.S. states, and the CDC recently issued a precautionary message warning that B.1.117 would be the predominant variant in the U.S. by the end of March.

The B.1.351 variant fueled a massive Covid resurgence in South Africa where it was first identified. Since its emergence in December it has been found in 46 countries and 13 states. There is concern it may be better able to reinfect those who’ve already had Covid. But what causes the most alarm is its impact on vaccine efficacy.

Numerous vaccines were less effective at preventing infection in places where B.1.351 was the primary variant. The Johnson & Johnson/Janssen vaccine saw a drop in efficacy from 72% in the United States to 57% in South Africa. Similarly, the Novovax vaccine showed 90% efficacy in the United Kingdom, but only 49% in South Africa. And most recently, a small trial of the Oxford/AstraZeneca vaccine in South Africa showed it did not protect against mild or moderate Covid, halting the planned rollout of the vaccine there.

The emergence of multiple variants gives us reason to worry about the protective effects of the shots. But, the most important finding from the vaccine trials is usually overlooked in the scary headlines: all vaccines prevented hospitalizations and death — even with their decreased efficacy against those variants.

Similarly, even the worry that these variants may lead to an explosion of cases and a feared fourth wave is not guaranteed.

In the U.K., the B.1.117 variant fueled a surge of cases in December, raising worries that a similar spike was imminent in the U.S. However, much like the U.S., cases have plummeted in the U.K., dropping ~40% in the last two weeks alone. South Africa experienced a similar rise in December followed by a precipitous decline in cases despite the B.1.351 variant composing nearly all the cases there.

Source: Financial Times (ft.com/covid19)

The takeaway is that the variants are certainly worth watching. But there is no guarantee they will outsmart our vaccines or drive a spike in cases in the U.S.

Continued adherence to protective public health measures

Even if vaccination is helping control the pandemic, it was strict adherence to proven public health measures — masking, social distancing, and hand hygiene — that drove the easing of the pandemic seen in the past few weeks.

This rapid decline in Covid cases has unfortunately been countered by a rapid loosening of restrictions in many places across the country, creating the conditions for a resurgence.

Despite their growing use, their proven value in reducing spread, and President Biden’s plea to mask up for 100 days, only 35 states (plus D.C. and Puerto Rico) currently mandate face coverings in public.

Even as the new CDC Director, Dr. Rochelle Walensky, warns against lifting mask mandates amid the uncertainty around variants, politicians are citing the drop in cases to ease restrictions in small towns and multiple states. North Dakota, Iowa, and Montana have rolled back mask mandates in the past month. Others will undoubtedly follow.

It’s not just masks. And it’s not only “red states” easing restrictions. In New York City indoor dining was shuttered last December after a rise in Covid cases. Indoor dining is now reopening (albeit at limited capacity) even though Covid prevalence is higher now than when the restrictions were put in place. And movie theaters are slated to open in March — at 25% capacity and with masks required — even though New York City is classified as “extremely high risk” for contracting Covid.

So, What’s Next?

There is finally reason for optimism a year into the pandemic. As cases drop, the vaccine rollout is hastening and targeting the most vulnerable groups, making a surge in deaths from Covid unlikely. There is growing hope the variants won’t trigger a painful resurgence in the coming months, different from our fears just weeks ago.

But that optimism must be tempered with a hefty dose of reality. Covid cases and hospitalizations are still at the same levels as last summer’s peak. More than two thousand Americans die every day from Covid. Even with the recent improvement, we are not out of the woods. And lifting the proven public health measures that helped control the spread could quickly backfire.

What does all this mean for what comes next? It’s not entirely clear. Anyone who speaks with absolute certainty is only speculating.

The only thing we know for sure is that as case counts slope dramatically downward, people get vaccinated at a greater pace, and politicians roll back restrictions, the end of this pandemic is most contingent on us taking the proven steps to protect ourselves, our families, and our communities.

The reality is that we don’t know for certain whether there will be a fourth wave. But we do know how to prevent it.

NYC ER doctor | Ebola Survivor | Director of Global Health in Emergency Medicine at Columbia University | Public Health Professor | Doctors Without Borders BoD