Two pieces of hopeful news on the COVID front this week.
First, pharmaceutical manufacturer Merck announced this morning that molnupiravir, the oral antiviral drug it developed along with Ridgeback Biotherapeutics, reduced hospitalizations among newly diagnosed COVID patients by 50 percent. A five-day course of the drug was so successful in Merck’s clinical study that an independent monitoring group recommended halting the study and submitting the pill to the Food and Drug Administration (FDA) for emergency use authorization. Molnupiravir is activated by metabolism, and upon entering human cells, is converted into RNA-like building blocks, causing mutations in the COVID virus’s RNA genome and interfering with its replication. For that reason, the drug is unlikely to be prescribed during pregnancy, but otherwise the therapy seems to hold great promise in adding to the limited armamentarium available to fight the pandemic. One possible concern: the drug’s price tag. The federal government has agreed to purchase 1.7M courses of the drug at $700 per course, and with most insurance companies having returned to normal cost-sharing for COVID treatments, the drug may be out of reach for some patients. Still, a major clinical development to be celebrated, and more to come as Merck’s drug is vetted by the FDA.
At $20 to $40 per dose, with costs fully absorbed by the federal government, and remarkable effectiveness at preventing severe disease, hospitalizations, and deaths, vaccines remain far and away our best frontline weapon for fighting the COVID pandemic. Promising, then, that the much-debated vaccine mandates have begun to demonstrate success in increasing vaccination rates, even among those who have thus far resisted getting the shot.
Despite concerns about massive staffing shortages among hospitals resulting from the implementation of its mandate, the state of New York found that 92 percent of healthcare workers had been vaccinated by Monday, when the mandate went into effect. That was a 10-percentage-point increase from a week earlier, holding promise that the Biden administration’s planned federal mandate for healthcare workers could have the desired effect.
California’s mandate for healthcare workers went into effect yesterday, and was credited with boosting vaccination rates to 90 percent at many of the state’s health systems. Among private employers considering mandates, the experience of United Airlines may also be instructive: its employee mandate led to the vaccination of more than 99 percent of its workers, resulting in the termination of only 700 of its 67,000 employees. Of course, everyone prefers carrots to sticks, but sweepstakes and bonuses have only gotten so far in encouraging people to get vaccinated—now it appears mandates have a useful role to play as well.
With 56 percent of the population fully vaccinated, the US now ranks 43rd among nations, just ahead of Saudi Arabia and far behind most of Europe. In the next few days we’ll reach the grim milestone of 700,000 COVID deaths in this country—anything that helps stop that number from growing further should be welcome news.
Widely circulating coronavirus variants and persistent hesitancy about vaccines will keep the goal out of reach. The virus is here to stay, but vaccinating the most vulnerable may be enough to restore normalcy.
Early in the pandemic, when vaccines for the coronavirus were still just a glimmer on the horizon, the term “herd immunity” came to signify the endgame: the point when enough Americans would be protected from the virus so we could be rid of the pathogen and reclaim our lives.
Now, more than half of adults in the United States have been inoculated with at least one dose of a vaccine.But daily vaccination rates are slipping, and there is widespread consensus among scientists and public health experts that the herd immunity threshold is not attainable — at least not in the foreseeable future, and perhaps not ever.
Instead, they are coming to the conclusion that rather than making a long-promised exit, the virus will most likely become a manageable threat that will continue to circulate in the United States for years to come, still causing hospitalizations and deaths but in much smaller numbers.
How much smaller is uncertain and depends in part on how much of the nation, and the world, becomes vaccinated and how the coronavirus evolves. It is already clear, however, that the virus is changing too quickly, new variants are spreading too easily and vaccination is proceeding too slowly for herd immunity to be within reach anytime soon.
Continued immunizations, especially for people at highest risk because of age, exposure or health status, will be crucial to limiting the severity of outbreaks, if not their frequency, experts believe.
“The virus is unlikely to go away,” said Rustom Antia, an evolutionary biologist at Emory University in Atlanta. “But we want to do all we can to check that it’s likely to become a mild infection.”
The shift in outlook presents a new challenge for public health authorities. The drive for herd immunity — by the summer, some experts once thought possible — captured the imagination of large segments of the public. To say the goal will not be attained adds another “why bother” to the list of reasons that vaccine skeptics use to avoid being inoculated.
Yet vaccinations remain the key to transforming the virus into a controllable threat, experts said.
Dr. Anthony S. Fauci, the Biden administration’s top adviser on Covid-19, acknowledged the shift in experts’ thinking.
“People were getting confused and thinking you’re never going to get the infections down until you reach this mystical level of herd immunity, whatever that number is,” he said.
“That’s why we stopped using herd immunity in the classic sense,” he added. “I’m saying: Forget that for a second. You vaccinate enough people, the infections are going to go down.”
Why reaching the threshold is tough
Once the novel coronavirus began to spread across the globe in early 2020, it became increasingly clear that the only way out of the pandemic would be for so many people to gain immunity — whether through natural infection or vaccination — that the virus would run out of people to infect. The concept of reaching herd immunity became the implicit goal in many countries, including the United States.
Early on, the target herd immunity threshold was estimated to be about 60 to 70 percent of the population. Most experts, including Dr. Fauci, expected that the United States would be able to reach it once vaccines were available.
But as vaccines were developed and distribution ramped up through the winter and into the spring, estimates of the threshold began to rise. That is because the initial calculations were based on the contagiousness of the original version of the virus.The predominant variant now circulating in the United States, called B.1.1.7 and first identified in Britain, is about 60 percent more transmissible.
As a result, experts now calculate the herd immunity threshold to be at least 80 percent. If even more contagious variants develop, or if scientists find that immunized people can still transmit the virus, the calculation will have to be revised upward again.
Polls show that about 30 percent of the U.S. population is still reluctant to be vaccinated. That number is expected to improve but probably not enough. “It is theoretically possible that we could get to about 90 percent vaccination coverage, but not super likely, I would say,” said Marc Lipsitch, an epidemiologist at the Harvard T.H. Chan School of Public Health.
Though resistance to the vaccines is a main reason the United States is unlikely to reach herd immunity, it is not the only one.
Herd immunity is often described as a national target. But that is a hazy concept in a country this large.
“Disease transmission is local,” Dr. Lipsitch noted.
“If the coverage is 95 percent in the United States as a whole, but 70 percent in some small town, the virus doesn’t care,” he explained. “It will make its way around the small town.”
Uneven Willingness to Get Vaccinated Could Affect Herd Immunity
In some parts of the United States, inoculation rates may not reach the threshold needed to prevent the coronavirus from spreading easily.
How insulated a particular region is from the coronavirus depends on a dizzying array of factors.
Herd immunity can fluctuate with “population crowding, human behavior, sanitation and all sorts of other things,” said Dr. David M. Morens, a virologist and senior adviser to Dr. Fauci. “The herd immunity for a wealthy neighborhood might be X, then you go into a crowded neighborhood one block away and it’s 10X.”
Given the degree of movement among regions, a small virus wave in a region with a low vaccination level can easily spill over into an area where a majority of the population is protected.
At the same time, the connectivity between countries, particularly as travel restrictions ease, emphasizes the urgency of protecting not just Americans but everyone in the world, said Natalie E. Dean, a biostatistician at the University of Florida in Gainesville. Any variants that arise in the world will eventually reach the United States, she noted.
Many parts of the world lag far behind the United States on vaccinations. Less than 2 percent of the people in India have been fully vaccinated, for example, and less than 1 percent in South Africa, according to data compiled by The New York Times.
“We will not achieve herd immunity as a country or a state or even as a city until we have enough immunity in the population as a whole,” said Lauren Ancel Meyers, the director of the Covid-19 Modeling Consortium at the University of Texas at Austin.
What the future may hold
If the herd immunity threshold is not attainable, what matters most is the rate of hospitalizations and deaths after pandemic restrictions are relaxed, experts believe.
By focusing on vaccinating the most vulnerable, the United States has already brought those numbers down sharply. If the vaccination levels of that group continue to rise, the expectation is that over time the coronavirus may become seasonal, like the flu, and affect mostly the young and healthy.
“What we want to do at the very least is get to a point where we have just really sporadic little flare-ups,” said Carl Bergstrom, an evolutionary biologist at the University of Washington in Seattle. “That would be a very sensible target in this country where we have an excellent vaccine and the ability to deliver it.”
Over the long term — a generation or two — the goal is to transition the new coronavirus to become more like its cousins that cause common colds. That would mean the first infection is early in childhood, and subsequent infections are mild because of partial protection, even if immunity wanes.
Some unknown proportion of people with mild cases may go on to experience debilitating symptoms for weeks or months — a syndrome called “long Covid” — but they are unlikely to overwhelm the health care system.
“The vast majority of the mortality and of the stress on the health care system comes from people with a few particular conditions, and especially people who are over 60,” Dr. Lipsitch said. “If we can protect those people against severe illness and death, then we will have turned Covid from a society disrupter to a regular infectious disease.”
If communities maintain vigilant testing and tracking, it may be possible to bring the number of new cases so low that health officials can identify any new introduction of the virus and immediately stifle a potential outbreak, said Bary Pradelski, an economist at the National Center for Scientific Research in Grenoble, France. He and his colleagues described this strategy in a paper published on Thursday in the scientific journal The Lancet.
“Eradication is, I think, impossible at this stage,” Dr. Pradelski said. “But you want local elimination.”
Vaccination is still the key
The endpoint has changed, but the most pressing challenge remains the same: persuading as many people as possible to get the shot.
Reaching a high level of immunity in the population “is not like winning a race,” Dr. Lipsitch said. “You have to then feed it. You have to keep vaccinating to stay above that threshold.”
Skepticism about the vaccines among many Americans and lack of access in some groups — homeless populations, migrant workers or some communities of color — make it a challenge to achieve that goal. Vaccine mandates would only make that stance worse, some experts believe.
A better approach would be for a trusted figure to address the root cause of the hesitancy — fear, mistrust, misconceptions, ease of access or a desire for more information, said Mary Politi, an expert in health decision making and health communication at Washington University in St. Louis.
People often need to see others in their social circle embracing something before they are willing to try it, Dr. Politi said. Emphasizing the benefits of vaccination to their lives, like seeing a family member or sending their children to school, might be more motivating than the nebulous idea of herd immunity.
“That would resonate with people more than this somewhat elusive concept that experts are still trying to figure out,” she added.
Though children spread the virus less efficiently than adults do, the experts all agreed that vaccinating children would also be important for keeping the number of Covid cases low. In the long term, the public health system will also need to account for babies, and for children and adults who age into a group with higher risk.
Unnerving scenarios remain on the path to this long-term vision.
Over time, if not enough people are protected, highly contagious variants may develop that can break through vaccine protection, land people in the hospital and put them at risk of death.
“That’s the nightmare scenario,” said Jeffrey Shaman, an epidemiologist at Columbia University.
How frequent and how severe those breakthrough infections are have the potential to determine whether the United States can keep hospitalizations and deaths low or if the country will find itself in a “mad scramble” every couple of years, he said.
“I think we’re going to be looking over our shoulders — or at least public health officials and infectious disease epidemiologists are going to be looking over their shoulders going: ‘All right, the variants out there — what are they doing? What are they capable of?” he said. “Maybe the general public can go back to not worrying about it so much, but we will have to.”
The Biden administration is working to stamp out misinformation that might dissuade people from getting coronavirus shots, a crucial task as the nation shifts into the next, more difficult phase of its vaccination campaign.
The White House announced Friday that 100 million Americans are now fully vaccinated against COVID-19, but the nationwide rollout is plateauing as fewer people sign up for shots.
Administration officials and health experts know the difficulty ahead in getting vaccines into as many people as possible, and are trying to eliminate the barriers to doing so.
Authorities need to dispel the legitimate concerns that make people hesitant, while also stopping waves of misinformation.
This past week, top infectious diseases expert Anthony Fauci corrected Joe Rogan, a popular podcast host who himself later acknowledged his lack of medical knowledge, after Rogan said young healthy people don’t need to be vaccinated.
“You’re talking about yourself in a vacuum,” Fauci said of the podcast host. “You’re worried about yourself getting infected and the likelihood that you’re not going to get any symptoms. But you can get infected, and will get infected, if you put yourself at risk.”
White House communications director Kate Bedingfield also joined in the criticism.
“Did Joe Rogan become a medical doctor while we weren’t looking? I’m not sure that taking scientific and medical advice from Joe Rogan is perhaps the most productive way for people to get their information,” she told CNN.
Rogan’s comments were trending on Twitter for two days before he attempted to walk them back.
“I’m not a doctor, I’m a f—ing moron, and I’m a cage fighting commentator … I’m not a respected source of information, even for me,” he said.
Public health experts said Rogan’s comments were irresponsible, and potentially dangerous because they could perpetuate hesitancy.
“You have a responsibility as an adult, you have a responsibility as a community leader, your responsibility as a communicator to get it right,” said Georges Benjamin, executive director of the American Public Health Association.
While Rogan is not a political figure, he has one of the most popular podcasts in the world, and an enormous platform.
Rogan hosts the most popular podcast on Spotify. Rogan said in 2019 that his podcast was being downloaded 190 million times per month.
People are not getting all their information from Rogan, but when his comments clash with what public health experts say, that is problematic.
“It’s not so much that Joe Rogan’s a comedian, he’s very popular with people sort of leaning on the conservative side, especially young people. And that’s the group that we have to reach, especially young men,” said Peter Hotez, a leading coronavirus vaccinologist and dean of Baylor University’s National School of Tropical Medicine.
Hotez, who has appeared on Rogan’s show in the past, said he thinks the host was just misinformed. Hotez said he has reached out, and wants to help Rogan have a more productive discussion about why it’s so important for everyone to be vaccinated against the coronavirus.
Polls show vaccine hesitancy is declining, but the holdouts are not monolithic, and experts believe trusted messengers will be needed.
“I just think they have to speak the facts. You speak the facts, and anytime you discover the facts that are incorrect, you try to correct them,” said Benjamin. “And … I don’t think you demonize the individual, nor do I think you try to pin motive to it, because you don’t know what the motive is.”
Some people are most worried about side effects, some are concerned about the safety of the vaccines and some people don’t think COVID-19 is a problem at all. There are also likely some people who will never be convinced, and try to sow confusion and distrust.
Biden administration officials are aware of the harmful impact of misinformation, but know they are walking a fine line between people who legitimately want more information and those who just want chaos.
“We know that people have questions for multiple reasons. Sometimes because there’s misinformation that they’ve encountered, sometimes because they’ve had a bad experience with the healthcare system and they’re wondering who to trust, and some people have just heard lots of different news as we continue to get updates on the vaccine, and they want to hear from someone they trust,” Surgeon General Vivek Murthy said during a White House briefing.
For the White House, using medical experts like Fauci to correct obvious misinformation is part of the strategy to boost vaccine confidence.
“Our approach is to provide, and flood the zone with accurate information,” White House press secretary Jen Psaki said Friday. “Obviously that includes combating misinformation when it comes across.”
The administration has also invested $3 billion to support local health department programs and community-based organizations intended to increase vaccine access, acceptance and uptake.
Still, experts said different messengers are needed, especially when trying to reach conservatives who may now view Fauci as a polarizing political figure.
“There needs to be a better organized effort by the administration to really understand how to reach groups that are identified in polls as saying they won’t get vaccinated,” Hotez said. “We need to figure out how to do the right kind of outreach with the conservative groups, and we’ve got to do something about” the damage caused by members of the conservative media.
In a recent CBS-YouGov poll, 30 percent of Republicans said they would not get the vaccine and another 19 percent said they only “maybe” would do so.
The underlying mistrust comes after a year in which Trump and his allies played down the severity of a virus that has killed more than half a million Americans already.
A national poll and focus group conducted by GOP pollster Frank Luntz showed Republicans who voted for President Trump will be far more influenced by their doctors and family members than any politician.
To that end, a group of Republican lawmakers who are also physicians released a video urging people to get the COVID-19 vaccine.
The video, led by Sen. Roger Marshall (R-Kan.), features some of the lawmakers wearing white coats with stethoscopes around their necks speaking into the camera.
The American public’s attitude toward COVID-19 vaccination has evolved rapidly since the end of last year. The share of adults who report they have either already been vaccinated or intend to get the vaccine as soon as possible continues to rise (currently about 62 percent), while the share who say they will “wait and see” continues to shrink (now 17 percent). Importantly, however, the share who say they will either “definitely not” get vaccinated or only do so “if required” (currently 20 percent) has remained stubbornly consistent since December.
As the US reaches a vaccine tipping point, with more COVID vaccines available than people willing to be vaccinated, it will be important to understand this vaccine-hesitant population more clearly. A recent consumer segmentation analysis found that this group falls into four major behavioral profiles, shown on the right side of the graphic above.
The next phase of vaccine rollout must specifically address the key concerns of individuals in each of these different segments. For example, the “watchful” group, the easiest to persuade, will likely respond to a more transparent vaccination process and the amplification of positive vaccination testimonials. On the other hand, “system distrusters,” generally comprised of younger, lower-income minorities, would benefit most from hearing community leaders discuss vaccine safety. Unfortunately, the largest segment of vaccine-hesitant Americans, the “misinformation believers”, will also be the most difficult to turn. These individuals are more likely to hold rigid, politically driven beliefs.
While countering misinformation by leveraging trusted influencers may help convince some, this group may be the hardest to persuade—although their participation will be crucial to hitting any goal of “herd immunity” by this fall.