Pandemic Predictions

More than a year and a half into the pandemic, the transition back to normalcy has been tragically upended by a combination of the Delta variant, vaccine hesitancy, and lack of vaccine supplies in less-developed countries. 2020 models predicting more than half a million U.S. deaths by February 2021 were exceeded. Jefferson County’s COVID-19 infection rates have been rising, and public health officials are warning us it could get worse. I looked at some predictions for this fall and winter.

The good news: Dr. Thomas Locke, former Jefferson County Health Officer, said, “Vaccination rates are slowly increasing, but not near as fast as we would like.” As of October 4, 77.1% of Washingtonians 12 and older had received at least one dose of COVID-19 vaccine, and 70.7% of people 12 and older are fully vaccinated. Washington ranks in the top quartile, behind mostly northeastern states. In Jefferson County, 69.4% of the total population is fully vaccinated, with seniors aged 65+ approaching 90% and school-age children between 12 and 17 approaching 50%.

The bad news: COVID-19 is now the #1 cause of death in the state, and as of late September the data showed that its transmission is increasing, with hospitalizations peaking at a level 60% higher than in winter 2020. More women than men are getting sick, but more men are being hospitalized and are dying—54.57% of the deaths are men, versus 43.74% for women. More than 90% of deaths are unvaccinated. Testing shortages are also being reported across the state. In starker terms, one in 106 Washington residents are estimated to have an active COVID-19 infection (symptomatic and asymptomatic).

Studies of public perceptions have shown that one side of the political spectrum dismisses the severity and risks of COVID-19 whenever governmental regulations are quoted, and the other side withholds their support of vaccinations and the FDA’s Emergency Use Authorization because of mistrust of corporations and market solutions. This is polarization to where opposites on the left and right end up working together in digital echo chambers to justify their aversions to science-based solutions.

In Washington, House Bill 1638, which became law in 2019, removed personal belief exemptions from vaccine requirements for measles, mumps and rubella in public and private schools and daycare centers. Washington State Law permits a religious exemption that allows parents to exempt their children from vaccination if it compromises their sincere religious beliefs. It does not allow exemptions for philosophical, spiritual, or other personal beliefs.

Short-term prediction: From mid-September to January 1, 2022, an additional 2,000 to 3,200 deaths are predicted statewide—the exact number will depend on mask usage. As of October, the Delta variant is circulating in all states, the Beta variant is circulating in 2 states, and the Gamma variant is circulating in 14 states. All of these variants are circulating in Washington.

The hard facts: You can see the latest information in technical detail on the COVID-19 Data Dashboard at the Washington State Department of Health. It’s complex, goes county-by-county, and takes awhile to load and understand, but it’s comprehensive and is updated every 2-3 days. As of October 6, Jefferson County has seen 862 confirmed and 127 probable cases, 68 hospitalizations, and 15 deaths; COVID-19 has killed at least 705,000 people in the U.S. and infected about 44 million, according to data by Johns Hopkins University.

Projections from the Institute for Health Metrics and Evaluation (IHME), an independent global health research center at the University of Washington, are for nearly 780,000 total U.S. COVID-19 deaths by January 1, 2022. This is by no means a worst-case scenario. Given that there is a 17-21-day lag between infection and deaths, the IHME projects an infection rate of at least 319,000 new cases per day for this fall. That number, they say, could be reduced by 80%, to 64,000 new cases per day, if 95% of us wore masks. The number of deaths will depend on the level of vaccinations and the virulence of potential new strains of the virus. Without universal mask-wearing, U.S. fatality projections go much higher.

Hope floats: And yet, as I write this, some models and news reports are suggesting that cases could be way down by November. The virus always spreads via localized outbreaks that can either balloon into a nationwide surge, or be contained. It’s really up to us.

Even though the current vaccines were originally meant to prevent severe infections, the unexpectedly spectacular clinical trial results for Pfizer and Moderna gave reason to hope they might protect against all symptomatic infections, like the vaccines for polio and measles did. We know now that with the Delta variant that’s not possible, but an analysis by a global consulting firm suggests that “…the United States, Canada, and many European countries would likely have reached herd immunity by now if they had faced only the ancestral [original] SARS-CoV-2 virus, and if a high percentage of those eligible to receive the vaccine had chosen to take it.”

Healthcare crisis: The Delta variant is rapidly bringing several states to the brink of requiring crisis standards of care as their healthcare systems get overwhelmed. Crisis standards of care are what get invoked during mass disasters; it means a resource crunch, or rationing, that can include long waits, fewer doctors and nurses, delayed or cancelled elective and non-urgent surgeries, searches for hospital beds in other states, having to use hallways and tents for bed space, and possibly, prioritizing some patients over others to save the most lives. That would mean doing things like giving beds or ventilators only to those who are most likely to recover. Washington has so far not reached that point, but a doctor friend who spoke frankly and who I won’t identify said: “Whether or not Washington goes to crisis care standards, Jefferson County is functionally going to be there, because we’re expecting a hard winter with COVID.”

At a recent physical, I was handed a green POLST form (Physician Orders for Life-Sustaining Treatment.) I also received a booklet called Five Wishes, which is an advance directive about medical and other care for when you can’t make those decisions yourself. Frankly, I was surprised, because a, I’m healthy despite being older, and b, the last time I saw these forms was when my husband and I were caring for his brother in Hospice. These forms are about resuscitation and life support. I took them home to fill out.

I asked my doctor friend about them. “Well, if you don’t let us know what your wishes are,” they said, “then what you’re essentially saying is that you’re comfortable with a medical team making that decision for you at a time when they could be facing a lineup of three other patients in need. We are very clinical about how we make that decision.”

Scoring systems exist for mass disasters, to help with agonizing decisions on rationing healthcare. These scoring systems, as recently reported in the Washington Post, can have exclusion criteria that take into account the health of a patient’s internal organs, their chances of recovery and long-term survival including years left to live, and even whether or not they are a needed essential worker. If things get bad enough, there is also the possibility of universal do-not-resuscitate orders for hospitalized patients who go into cardiac arrest. Exclusion shouldn’t have to be a factor in medical care, but with enough desperately ill people, it could come to that right here at home.

Vaccination rates: They matter hugely, of course, but so do the ages of people who choose to remain unvaccinated. In communities where, for example, 10% of residents happen to be unvaccinated seniors, you can expect that five times as many people will need an ICU bed than in communities where only 2% of unvaccinated residents are seniors.

Long-term predictions agree on the likelihood of COVID-19 becoming endemic, meaning it’s here to stay, a constantly mutating virus that joins the other four coronaviruses that cause seasonal colds, but as a far more severe and virulent form. This doesn’t count seasonal flus, which aren’t from coronaviruses. For comparison, influenzas have caused between 12,000 and 61,000 U.S. deaths annually since 2010. Deaths from COVID-19 are thought to be at least 10 times higher.

Most health organizations agree that we are not even close to the end of this pandemic. Herd immunity was initially viewed as the epidemiological endpoint for COVID-19 in some countries, but the combination of vaccine hesitancy and the Delta variant have put that out of reach. This is shifting the endpoint to an ongoing burden of disease that must be managed as a constant threat (similar to severe flu) rather than a onetime society-wide occurrence.

It’s possible to get to high levels of disease control, but that means using the tools we have available that have been shown to stop transmission that causes disease and fills up our hospitals. We all know what those tools are, and how effective they can be in curbing this public health crisis. We also know there will be more pandemics.

Vaccines aren’t without possible side effects, but those who choose to get vaccinated accept that they’re risking that for the sake of their communities. So, it’s important that those who choose to not get vaccinated understand not only their personal risks but also the risks they present to the community. Thinking about the hospital bed you could be freeing up by getting vaccinated might not make you change your mind, but amid all the anxiety flying around, maybe it’ll give pause for sober reflection. As my doctor friend put it, “These times are unprecedented, and I’m tired. I’m tired of having to justify science.”

Top image by Gerd Altmann from Pixabay