The COVID-19 vaccine is having a stunning impact.
Take, for instance, nursing homes. Though they were the site of more than 26,000 COVID-19 deaths between thanksgiving and New Years, they’ve seen deaths decline by 66 percent since vaccinations began in December.
But amid all that success, and with the prospect of the vaccine becoming available to a growing number of people across the country within the next few months, it still remains unclear what life will look like in the U.S. as the vaccination campaign begins to dampen rates of severe illness and death from the virus. Questions linger about how quickly state and local governments will release businesses from social distancing mandates, and whether interventions like masking requirements will survive what may be the end of the pandemic’s deadliest phase.
The Centers for Disease Control has begun drafting guidance aimed specifically at what people who have been vaccinated against COVID-19 can do, an affirmative list that would counter criticism that the organization has been too pessimistic about the extent to which distancing mandates should remain in place for the vaccinated as the rest of the population awaits the shot.
That critique came after the agency suggested that the fully vaccinated should still practice social distancing, part of an announcement which also said that vaccinated people exposed to the virus don’t have to quarantine.
The lack of clarity, combined with the Trump administration’s failure to conduct a public messaging campaign around the vaccine, has left many confused.
“The population of people being fully vaccinated is increasing, so there needs to be much clearer guidance from the CDC and the federal government about what fully vaccinated people are able to do,” Leana Wen, a former Baltimore health commissioner and visiting professor at Georgetown University’s School of Public Health, told TPM. “Many people are eager to see their loved ones; we should be providing people with that kind of guidance.”
Central to questions around a return to normalcy is a key debate in the public health response to the virus: is the goal of vaccination to end severe disease and hospitalization? Or do broader concerns around transmission without severe disease, and the possibility of new variants, outweigh the benefits of encouraging the vaccinated to resume normal life? And what should be done after the most vulnerable are vaccinated and safe from severe illness, but the virus remains in circulation among the young and healthy?
“This threshold of where we’re going to be accepting — of how much exposure we’re going to allow — is unknown, and that’s where the challenge is,” Dr. Litjen Tan, an executive at the Immunization Action Coalition, told TPM.
What’s the goal here?
The debate over the guidance underlies questions about what level of immunity in the population needs to be targeted before easing can occur.
The answers will affect how quickly life returns to a modicum of normalcy, including such large indoor activities as concerts.
Those decisions are being made now, as the rollout overcomes problems inherited from the Trump administration: funding is making its way to the local level and a new degree of organization from the federal is speeding along the effort to get millions of doses into American arms. UPS projected on Thursday that its vaccine distribution would increase by 40 percent next week.
To Dr. Christina Ramirez, a professor of biostatistics at the UCLA Fielding School of Public Health, the only real question at play should be one of ending severe disease and death.
“Most people care if they’re going to be put in the hospital or if they or their loved ones get really sick and die,” Ramirez argued. “The whole purpose of the vaccine is to prevent hospitalizations.”
But other public health experts argue that the goal for vaccinations should be far broader: curbing transmission to a point where the virus is not just inert from a health standpoint, but unlikely to continue circulating.
“What we need to target is a point where transmission is such that it’s unlikely for people to come into contact with COVID-19, even if they’re not vaccinated,” Dr. Cindy Prins, an infectious disease epidemiologist at the University of Florida, told TPM.
The two goals may seem similar, but end up with drastically different conclusions: one projects a level of normalcy this summer, while the more expansive goal of curbing transmission across the country could push distancing recommendations into 2022.
“You’ll see baby steps, and then gradual opening,” Tan said. “And that’s going from the pandemic phase, now, and the transition phase, then, and into the endemic phase.”
Part of the debate involves lingering questions over whether the vaccinated can transmit the virus. Early data from Israel suggests that vaccines do limit recipients’ propensity for spreading, but whether those early findings will be borne out as vaccinations continue remains unclear.
Prins took it a step further, and pointed out that COVID-19 interventions have succeeded in accomplishing other long-held public health goals, like drastically curbing flu transmission this season
“We need to consider if we’re going to keep a lot of the measures that we’ve put in place,” she said. “I don’t propose that we keep all of that indefinitely, but there’s still some opportunity for mask wearing, of thinking about physical distancing the benefit of that, even in times when you don’t necessarily have active COVID but knowing that maybe a crowded restaurant is where transmission occurs.”
The one last risk
Much of the debate comes down to the risk of new variants. The risk there is twofold: in addition to more contagious mutations infecting more people before vaccines can eliminate the possibility of severe illness, higher rates of transmission can increase the chance that a virus will mutate beyond the capacity of current vaccines to protect.
The more people incubating the virus, the greater chance that the virus could mutate out of the reach of currently existing vaccines.
That, experts said, could present a problem in part because the group of people least likely to come down with serious disease has also played the largest role in transmitting the virus: young people.
A situation where severe disease is curbed for the elderly but the virus circulates among the young, creating the potential for new variants, has forced some to think of how to better target messaging around vaccinations and social distancing.
“If I’m vaccinated and I still have to quarantine, isolate, socially distance, then what’s in it for me to do it?” Tan said. “So policymakers right now are trying to figure out where the balance on that should be.”
The extremely contagious UK variant, in particular, threatens to cause a new surge before enough Americans can be vaccinated to significantly pull down the disease’s death rate, professor of molecular medicine at the Scripps Research Institute Dr. Eric Topol told TPM.
“Hopefully it won’t be a surge, but it could be, because we’re relaxing things instead of tightening right now,” Topol said, adding that the next month would likely determine whether the new variant causes cases to spike across the country. “We’re going to get through it one way or another, but if we don’t have that surge, it’s going to happen much faster.”
Dr. Syra Madad, senior director of the special pathogens program at NYC Health + Hospitals, told TPM that rates of severe disease would likely be low enough thanks to vaccinations to allow “some normalcy” over the summer.
She projected a situation in which the virus is mostly gone, apart from “sporadic outbreaks where we have to go in and extinguish the small pocket of fire that we’re going to see, and make sure that it’s not causing severe disease and illness.”
“We know this pandemic is not going to end in a bang, it’s going to end in a whimper, it’s going to be drawn out,” she added.