by Michael D. Cohen MD

Course of the Pandemic

Some of the worst surges of the pandemic are occurring in Brazil, India, and Uruguay. The surges seem to be driven in part by bad policies, like relaxing restrictions too soon. The surges also appear to be driven by variants of the virus that are more infectious and possibly cause more severe disease.

In Latin America, the pandemic is intense. Latin America has 35% of the world deaths, but only 8% of the world’s population. In Brazil, the P-1 variant is predominant. P-1 is more contagious and causes more severe disease, especially in younger adults. Hospitals are overwhelmed. Uruguay, also struck by the P-1 variant, has one of the highest infection rates recorded in the world (83/100,000 population; compared to US at 9.3/100,000) and recently had the highest death rate in the world too.

In India the most severe surge yet is occurring. At the peak earlier this month there were over 360,000 cases and over 4,000 deaths per day. The B.1.1.7 variant (first found in the UK) and a new variant B.1.617, first found in India, may be driving the surge in some regions. Younger people and some people who were already vaccinated are getting sick.

In the U.S., nationwide cases continue to decline after the winter surge, but local outbreaks occurred recently in Michigan and Oregon. Rapid spread among middle and high school students was reported from Colorado. A new surge is starting in Arizona. We don’t really understand why these concentrated local outbreaks occur, but they have become a characteristic of the pandemic. Some experts are predicting that the pandemic may become largely a disease of children and youth if vaccines are not approved for children soon. One news source reported that 22% of new infections in the US are in children now.

A recent opinion article in the New England Journal of Medicine discussed the pandemic in US prisons and jails. In addition to pointing out the need for standard preventive measures to be made available to incarcerated people, their main point was the need to reduce the populations. They believe the only way to stop the pandemic in prisons and jails is to reduce the populations substantially. Methods of decarceration may include: reduce or eliminate cash bail so fewer people are admitted to jails; early release of selected groups due to age, chronic illness or other risk factors for more severe COVID disease; clemency or pardon or earlier access to parole; and stopping re-imprisoning people for minor parole violations.

Prevention

The Centers for Disease Control (CDC) issued new mask recommendations for people who have been fully vaccinated. For fully vaccinated people, masks may not be necessary any more for most outdoor and indoor activities. However, unvaccinated people should continue to wear masks in many public places. Even vaccinated people should still wear masks and keep physically distant in some circumstances such as: visiting doctors’ offices, hospitals, or long-term care facilities like nursing homes; traveling by bus, plane, train, or other modes of public transportation; going to transportation hubs like airports and bus stations; visiting prisons, jails, or homeless shelters.

Many people are still hesitant to stop wearing masks in public despite the relaxed recommendations. Caseloads are still high in some regions, so risk of exposure is greater. Risk is surely greater when there are large numbers of people gathered together in bars, restaurants, malls, and public events. Also, a recent outbreak on the NY Yankees baseball team has been difficult to understand. Because the team is tested frequently, it was found that 8 people were infected despite being fully vaccinated and at least one of them had the COVID disease before. None had any symptoms, but they could still be infectious to others.

Another reason for concern about stopping wearing masks is the issue of trust. People who are not fully vaccinated are expected to continue to wear masks. As reported in the New York Times, quoting a reader, “The first day of The Great Unmasking at work went exactly as you’d expect: people who have previously bragged about not being vaccinated walking around without masks on,” she wrote. “Assuming people would act unselfishly to protect others goes against everything we’ve seen so far this pandemic.”

Nevertheless, states are proceeding to cancel indoor mask mandates and reopen indoor entertainment as if the pandemic were over.

Another recent development has been recommendations to improve the quality of indoor air to prevent disease outbreaks in the future. Research has shown that coronavirus can remain floating in the air for a long time and can circulate beyond six feet. To minimize the risk of airborne infections, engineers will have to improve indoor air in public buildings. This can be done with filters in ventilation systems, portable air cleaners, ultraviolet lights that kill germs, and opening windows to improve air circulation.

Vaccines

The current vaccines are highly effective against the viruses currently in circulation. For example, the Cleveland Clinic reported this month that from January 1 until April 13, 99% of the patients hospitalized for COVID at their hospital were not vaccinated.

In May vaccines were approved for adolescents down to age 12, and it is expected that children ages 2-11 years will be allowed vaccination as early as September.

At present, less than 50% of the US population is fully vaccinated. While New Hampshire has vaccinated 59% of their people, Mississippi and Alabama are at 30%. Southern states in general lag behind the rest of the nation. Demand for vaccines has started to drop and states are starting to reduce their vaccine allotments as there are fewer people willing to be vaccinated.

To encourage vaccination, many states, cities, and cooperating businesses have developed incentives to encourage vaccination: paid time off to get the vaccine and recover from any symptoms that may occur from it; vaccination and free public transit passes in subway stations in NYC; five million dollar lotteries for vaccinated people in Ohio; $100 savings bonds in West Virginia; bonuses for people who bring others to be vaccinated in Detroit; free Uber and Lyft rides to and from vaccine sites; and vaccine information printed on coffee cups at McDonald’s.

The reasons for the decline in vaccine demand are being actively investigated, as well as the best ways to encourage people to step up and get the vaccine for themselves and their children. Some people can be persuaded by facts. Others have strong feelings that cannot be addressed simply with more information about safety, efficacy, or risk.

Long Term Effects of COVID Infection

Perhaps one incentive for people to get vaccinated is the growing evidence that the long-term effects of COVID infection may not be as benign as people think. A study at the Veterans Administration (VA) health programs assessed the risk of death and onset of new chronic medical conditions after mild COVID disease. Medical records of 73,000 people from throughout the U.S. who had COVID but did not require hospitalization were reviewed six months after their infection. Over the six months after they had COVID they had a 60% greater risk of death and a 20% greater likelihood of needing outpatient medical care than people who had not had COVID.

Conclusion:

Overall, the pandemic is declining in the U.S., but hot spots continue to emerge. People living in institutions like jails and prisons should continue to do everything they can to protect themselves with masks, keeping apart, staying outside, avoiding close contacts with others, improving ventilation of indoor air wherever possible, and good personal hygiene to prevent exposure.

One person in the free world reported he had followed a “Two out of Three” rule for his personal safety (unless he was face-to-face talking with someone or in a crowded space). He felt safe if he had two of the three of the following measures in place: he was outside, distanced, or masked. But face-to-face and in crowded places three out of three was best. 

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