A new omicron subvariant of the virus that causes COVID-19, BA.2, is quickly becoming the predominant source of infections amid rising cases around the world. Immunologists Prakash Nagarkatti and Mitzi Nagarkatti of the University of South Carolina explain what makes it different from previous variants, whether there will be another surge in the U.S. and how best to protect yourself.
What is BA.2, and how is it related to omicron?
BA.2 is the latest subvariant of omicron, the dominant strain of the SARS-CoV-2 virus that causes COVID-19. While the origin of BA.2 is still unclear, it has quickly become the dominant strain in many countries, including India, Denmark and South Africa. It is continuing to spread in Europe, Asia and many parts of the world.
The first omicron subvariant, BA.1, is unique in the number of alterations it has compared to the original version of the virus – it has over 30 mutations in the spike protein that helps it enter cells. Spike protein mutations are of high concern to scientists and public health officials because they affect how infectious a particular variant is and whether it is able to escape the protective antibodies that the body produces after vaccination or a prior COVID-19 infection.
BA.2 has eight unique mutations not found in BA.1, and lacks 13 mutations that BA.1 does have. BA.2 does, however, share around 30 mutations with BA.1. Because of its relative genetic similarity, it is considered a subvariant of omicron as opposed to a completely new variant.
While standard PCR tests are still able to detect the BA.2 variant, they might not be able to tell it apart from the delta variant.
Is it more infectious and lethal than other variants?
BA.2 is considered to be more transmissible but not more virulant than BA.1. This means that while BA.2 can spread faster than BA.1, it might not make people sicker.
Does previous infection with BA.1 provide protection against BA.2?
Yes! A recent study suggested that people previously infected with the original BA.1 subvariant have robust protection against BA.2.
Because BA.1 caused widespread infections across the world, it is likely that a significant percentage of the population has protective immunity against BA.2. This is why some scientists predict that BA.2 will be less likely to cause another major wave
However, while the natural immunity gained after COVID-19 infection may provide strong protection against reinfection from earlier variants, it weakens against omicron.
How effective are vaccines against BA.2?
A recent preliminary study that has not yet been peer reviewed of over 1 million individuals in Qatar suggests that two doses of either the Pfizer–BioNTech or Moderna COVID-19 vaccines protect against symptomatic infection from BA.1 and BA.2 for several months before waning to around 10%. A booster shot, however, was able to elevate protection again close to original levels.
Importantly, both vaccines were 70% to 80% effective at preventing hospitalization or death, and this effectiveness increased to over 90% after a booster dose.
How worried does the US need to be about BA.2?
The rise in BA.2 in certain parts of the world is most likely due to a combination of its higher transmissibility, people’s waning immunity and relaxation of COVID-19 restrictions.
CDC data suggests that BA.2 cases are rising steadily, making up 23% of all cases in the U.S. as of early March. Scientists are still debating whether BA.2 will cause another surge in the U.S.
Though there may be an uptick of BA.2 infections in the coming months, protective immunity from vaccination or previous infection provides defense against severe disease. This may make it less likely that BA.2 will cause a significant increase in hospitalization and deaths. The U.S., however, lags behind other countries when it comes to vaccination, and falls even further behind on boosters.
Whether there will be another devastating surge depends on how many people are vaccinated or have been previously infected with BA.1. It’s safer to generate immunity from a vaccine, however, than from getting an infection. Getting vaccinated and boosted and taking precautions like wearing an N95 mask and social distancing are the best ways to protect yourself from BA.2 and other variants.
Over the next few weeks, the U.S. should expect an increase in cases from the BA.2 variant, Dr. Anthony Fauci told ABC News, but it may not lead to as severe a surge in hospitalizations or deaths.
“I would not be surprised if in the next few weeks we see somewhat of either a flattening of our diminution or maybe even an increase,” Fauci told ABC News’ Brad Mielke on the podcast “Start Here.”
His prediction is based on conversations with colleagues in the U.K., which is currently seeing a “blip” in cases, Fauci said. The pandemic trajectory in the U.S. has often followed the U.K. by about three weeks.
However, he added, “Their intensive care bed usage is not going up, which means they’re not seeing a blip up of severe disease.”
The BA.2 variant, a more transmissible strain of omicron, now represents around 23% of all cases in the U.S., according to the latest data from the Centers for Disease Control and Prevention.
And while Fauci predicted that the BA.2 variant will eventually overtake omicron as the most dominant variant, it’s not yet clear how much of a problem that will be.
“Whether or not that is going to lead to another surge, a mini surge or maybe even a moderate surge, is very unclear because there are a lot of other things that are going on right now,” Fauci said.
Similar to the U.K., much of the U.S. has recently relaxed mitigation efforts like mask mandates and requirements for proof of vaccination. At the same time, people who were vaccinated over six months ago and still haven’t gotten a booster shot, which is about half of vaccinated Americans, according to the CDC, are facing continuously waning immunity.
It’s also not yet clear how long immunity from prior infection will last, Fauci said.
Taken together, it’s why Fauci and other experts, including CDC Director Rochelle Walensky, have increasingly predicted that elderly people will need a second booster shot soon. The Food and Drug Administration began reviewing data from Pfizer on the safety and efficacy this week, and its advisory panel will debate if and when the additional booster shot is necessary in the coming weeks.
At the same time, Fauci urged Americans who haven’t yet gotten their first booster, which would be their third shot in a Pfizer or Moderna series, to do so.
A resurgence of cases could also mean Americans are asked to wear masks again, which Fauci predicted would be an uphill battle.
“From what I know about human nature, which I think is pretty much a lot, people are kind of done with COVID,” Fauci said.
Still, he defended the CDC decision to loosen its mask recommendations earlier this month by shifting to a strategy that focused more on severe outcomes, like hospitalizations and deaths, rather than on daily case spread.
“You can go ahead and continue to tiptoe towards normality, which is what we’re doing, but at the same time, be aware that you may have to reverse,” Fauci said.
And if the U.S. does continue to make its way back toward normal times, Fauci himself has a personal choice to consider. At 81 years old, the director of the National Institute of Allergy and Infectious Diseases is “certainly” thinking about retirement.
“I have said that I would stay in what I’m doing until we get out of the pandemic phase and I think we might be there already, if we can stay in this,” Fauci said, referring to the falling cases and hospitalizations in the U.S.
“I can’t stay at this job forever. Unless my staff is gonna find me slumped over my desk one day. I’d rather not do that,” he said, laughing.
While he doesn’t currently have retirement plans, the recent hire of Dr. Ashish Jha, dean of the Brown University School of Public Health, to be White House coronavirus coordinator, could alleviate some of his pandemic response duties and give him a window.
But Fauci, who has dedicated his career to public health, primarily studying HIV and AIDS, and worked under seven U.S. presidents, said he doesn’t have any particular hobbies waiting for him in retirement.
“I, unfortunately, am somewhat of a unidimensional physician, scientist, public health person. When I do decide I’m going to step down, whenever that is, I’m going to have to figure out what it is I’m going to do,” he said.
“I’d love to spend more time with my wife and family. That would really be good.”
A surge in coronavirus infections in Western Europe has experts and health authorities on alert for another wave of the pandemic in the United States, even as most of the country has done away with restrictions after a sharp decline in cases.
Infectious-disease experts are closely watching the subvariant of omicron known as BA.2, which appears to be more transmissible than the original strain, BA.1, and is fueling the outbreak overseas.
In all, about a dozen nations are seeing spikes in coronavirus infections caused by BA.2, a cousin of the BA.1 form of the virus that tore through the United States over the past three months.
In the past two years, a widespread outbreak like the one now being seen in Europe has been followed by a similar surge in the United States some weeks later. Many, but not all, experts interviewed for this story predicted that is likely to happen. China and Hong Kong, on the other hand, are experiencing rapid and severe outbreaks, but the strict “zero covid” policies they have enforced make them less similar to the United States than Western Europe.
A number of variables — including relaxed precautions against viral transmission, vaccination rates, the availability of antiviral medications and natural immunity acquired by previous infection — may affect the course of any surge in the United States, experts said.
Most importantly, it is unclear at this point how many people will become severely ill, stressing hospitals and the health-care system as BA.1 did.
Another surge also may test the public’s appetite for returning to widespread mask-wearing, mandates and other measures that many have eagerly abandoned as the latest surge fades and spring approaches, experts said.
“It’s picking up steam. It’s across at least 12 countries … from Finland to Greece,” said Eric Topol, director of the Scripps Research Translational Institute in San Diego, who recently posted charts of the outbreak on Twitter. “There’s no question there’s a significant wave there.”
Topol noted that hospitalizations for covid-19, the disease caused by the virus, are rising in some places as well, despite the superior vaccination rates of many Western European countries.
At a briefing Monday, White House press secretary Jen Psaki said about 35,000 cases of BA.2 have been reported in the United States to date. But she offered confidence that “the tools we have — including mRNA vaccines, therapeutics and tests — are all effective tools against the virus. And we know because it’s been in the country.”
Kristen Nordlund, a spokeswoman for the Centers for Disease Control and Prevention, said in an email Tuesday that “although the BA.2 variant has increased in the United States over the past several weeks, it is not the dominant variant, and we are not seeing an increase in the severity of disease.”
The seven-day average of cases in the United States fell 17.9 percent in the past week, according to data tracked by The Washington Post, while the number of deaths dropped 17.2 percent and hospitalizations declined 23.2 percent.
Predicting the future course of the virus has proved difficult throughout the pandemic, and the current circumstances in Europe elicited a range of opinions from people who have closely tracked the pathogen and the disease it causes.
In the United States, just 65.3 percent of the population, 216.8 million people, are fully vaccinated, and only 96.1 million have received a booster shot, according to data tracked by The Post. In Germany, nearly 76 percent are fully vaccinated, according to the Johns Hopkins data, and the United Kingdom has fully vaccinated 73.6 percent.
That lower vaccination rate is very likely to matter as BA.2 spreads further in the United States, especially in regions where it is significantly lower than the national rate, several experts said. And even for people who are fully vaccinated and have received a booster shot, research data is showing that immunity to the virus fades over time. Vaccine-makers Pfizer and BioNTech asked the Food and Drug Administration on Tuesday for emergency authorization to offer a fourth shot to people 65 and older.
“Any place you have relatively lower vaccination rates, especially among the elderly, is where you’re going to see a bump in hospitalizations and deaths from this,” said Céline Gounder, an infectious-diseases physician and editor at large for public health at Kaiser Health News.
Similarly, as the public sheds masks — every state has dropped its mask mandate or announced plans to do so — another layer of protection is disappearing, several people tracking the situation said.
“Why wouldn’t it come here? Are we vaccinated enough? I don’t know,” said Kimberly Prather, a professor of atmospheric chemistry and an expert on aerosol transmission at the University of California at San Diego.
“So I’m wearing my mask still. … I am the only person indoors, and people look at me funny, and I don’t care.”
Yet BA.2 appears to be spreading more slowly in the United States than it has overseas, for reasons that aren’t entirely clear, Debbie Dowell, chief medical officer for the CDC’s covid-19 response, said in a briefing Saturday for clinicians sponsored by the Infectious Diseases Society of America.
“The speculation I’ve seen is that it may extend the curve going down, case rates from omicron, but is unlikely to cause another surge that we saw initially with omicron,” Dowell said.
One reason for that may be the immunity that millions of people acquired recently when they were infected with the BA.1 variant, which generally caused less-severe illness than previous variants. Yet no one really knows whether infection with BA.1 offers protection from BA.2.
“That’s the question,” said Jeffrey Shaman, an epidemiologist at the Columbia University Mailman School of Public Health. “Better yet, how long does it provide protection?”
Topol said the United States needs to improve its vaccination and booster rates immediately to protect more of the population against any coming surge.
“We have got to get the United States protected better. We have an abundance of these shots. We have to get them into people,” he said.
Biden administration officials said that whatever the further spread of BA.2 brings to the United States, the next critical step is to provide the $15.6 billion in emergency funding that Congress stripped from a deal to fund the government last week. That money was slated to pay for coronavirus tests, more vaccines and antiviral medications.
“That means that some programs, if we don’t get funding, could abruptly end or need to be pared back, Psaki said at Monday’s briefing. “And that could impact how we are able to respond to any variant.”
In May 2020, a 33-year-old mother of three in North Carolina started experiencing symptoms of COVID-19. Four days later, a different set of symptoms set in. She stopped sleeping well and started having paranoid delusions that people were tracking her through her cell phone—culminating in a frantic scene at a fast-food restaurant, in which she tried to pass her children through the drive-through window, where they’d be safe from the phones and other dangers.
A restaurant employee called 911, and emergency medical services workers arrived, gathered up the family, and hurried to the nearby emergency department of the Duke University Medical Center in Durham, where the mother was quickly attended to by physicians. “She was physically in the room, but she wasn’t making consistent eye contact,” says Dr. Colin Smith, who is now chief resident of the hospital’s internal medicine psychiatry program but was a second-year resident when he took care of the patient. “She was not really engaging all that much. Her thought processes were disorganized.”
Despite that, the patient acknowledged two things to Smith and the other doctors: She knew her behavior was out of character, and the changes all happened quickly after she was diagnosed with COVID-19.
There’s growing evidence that COVID-19 and new psychotic episodes are connected. The North Carolina case, reported in the British Medical Journal in August 2020, joins a slew of case reports published in medical journals during the pandemic that detail psychotic episodes following a COVID-19 diagnosis. In the July 2020 issue of BJPsyh Open, researchers reported that a 55-year old woman in the U.K., with no history of mental illness, arrived at a hospital days after recovering from a severe case of COVID-19 with delusions and hallucinations, convinced that the nurses were devils in disguise and that monkeys were jumping out of the doctors’ medical bags. In April 2021, other researchers wrote in BMJ Case Reports of a middle-aged British man, also with no prior mental health disorders, who had appeared at a London hospital experiencing auditory and visual hallucinations and banging his head against walls until he bruised his skin. (Weeks before, he had recovered from a bout with COVID-19 that had landed him in the intensive care unit.) In yet another case, published in the Journal of Psychiatric Practice in March 2021, a 57-year-old-man turned up at Columbia University’s New York Presbyterian Hospital insisting that his wife was poisoning him, that cameras had been planted throughout his apartment, and that the patients in the hospital’s emergency department were being secretly murdered.
“The situation was strikingly similar to one we’d expect from someone who had a schizophrenia spectrum illness,” says Dr. Aaron Slan, now a fourth-year psychiatry resident at Columbia University, who cared for the patient and co-authored the report. But this patient too had no history of mental health disorders and was too old for a first-onset case of schizophrenia, which typically occurs between ages 20 and 30 for men, Slan notes. What the patient did have, as a test in the hospital revealed, was COVID-19.
COVID-19-related psychotic breaks are rare—though researchers say that it’s too early to say exactly how rare—and plenty of experts believe that the connection between the two conditions, if any, is not causal. In a review published in 2021 in Neurological Letters, a group of researchers in the U.K. casts doubt on the emerging body of work on the COVID-19-psychosis link as “beset by both small sample size, and inadequate attention to potential confounding factors,” such as heightened stress, substance abuse, and socioeconomic hardship.
Still, researchers are investigating the link. One U.K. study published in the Lancet in October 2020 found that of 153 people who were diagnosed with COVID-19 early in the pandemic, 10 suffered new-onset psychotic episodes following their COVID-19 diagnosis, and seven exhibited the onset of psychiatric disorders, including catatonia and mania.
A study published last August in General Hospital Psychiatry took a broad view of the phenomenon, analyzing 40 scientific articles, which included 48 adults from 17 different countries who suffered psychotic episodes associated with COVID-19 infection, and tried to find commonalities among them. As with the Neurological Letters paper, the authors of this study found plenty of other variables that might muddy the link between COVID-19 and psychosis—like stress, substance use, and medications—but the relationship still held.
“We see post-infectious neuroinflammatory disorders associated with a variety of different viral illnesses,” says Dr. Samuel Pleasure, a neurology professor at the University of California, San Francisco (UCSF). “Normally we see it in very small numbers, but here we have [COVID-19] infecting tens of millions of people at the same time.” Even rare cases of psychiatric conditions will start to show themselves when the sample group of infected people is so large.
There are more questions than answers at this point. It’s still unclear whether the severity of COVID-19 symptoms plays any role in the likelihood of a psychotic break. “There seem to be clearly cases of neuropsychiatric consequences of COVID that are linked to cases that are not severe,” Pleasure says. “I believe that the quality of the studies at this point are so preliminary, and the ability to really capture these patients to study is really at early stages, so it’s hard to be definitive.” Similarly, Pleasure says, it’s impossible to say whether people suffering from Long COVID—symptoms that last for months after the infection is over—are more susceptible to psychotic symptoms.
There are multiple possible mechanisms at work, any one of which—or a combination—could be contributing to the neuropsychiatric symptoms associated with COVID-19. The most straightforward would be direct infection of brain tissue itself, according to Pleasure. If that’s so, the number of COVID-19 patients who suffer loss of the sense of taste and smell would suggest that the brain’s olfactory bulb may be struck by the virus first.
“There are documented cases where people have done MRIs early in the [COVID-19 disease] process and have seen some local inflammation in the olfactory bulb,” Pleasure says. “That has contributed further to the idea that maybe that’s the portal of entry.” Once that portal has been breached, the brain at large could be exposed.
Just how the COVID-19 infection reaches the brain is unclear, but Pleasure and his colleague Dr. Michael Wilson, associate professor of neurology at UCSF, conducted lumbar punctures of three teens with COVID-19 who had developed neuropsychiatric symptoms to examine their cerebrospinal fluid. In two cases, they found antibodies in the fluid that target neural antigens. That presented an apparent puzzle: the patients had SARS-CoV-2; if anything, they should be exhibiting antibodies to the virus, not to their own neural tissue. But Pleasure cites one study he conducted with a group from Yale University showing that antibodies specific to the coronavirus spike protein could also cross-react with nerve cells, attacking them as well.
“There was molecular mimicry between the spike protein and a neural antigen,” he says. “One of the main hypotheses is that if there’s an antibody that targets the virus, then, out of bad luck, you also see damage to the host.” In other words, he says, you start with an immune response adaptive to fighting the virus, and that turns into an autoimmune response.
That’s just one theory. There are still other routes by which COVID-19 can affect the brain. Upper respiratory infections can, on occasion, cause the immune system to go awry and develop antibodies against parts of the brain known as NMDA (N-methyl-D-aspartate) receptors, which are the main excitatory receptors that react to neurotransmitters. A broad attack on receptors spread throughout the brain can lead to quick and severe symptoms, says Dr. Mudasir Firdosi, a Consultant Psychiatrist at the Kent and Medway NHS and Social Care Partnership Trust and a co-author of the 2021 BMJ paper.
“[NMDA involvement] presents a very, very florid way to be psychotic,” Firdosi says. Slan agrees: “When someone has an abrupt onset of psychosis following a viral illness, NMDA antibodies are frequently invoked,” he says.
Yet another suspect in the development of neuropsychiatric symptoms is the so-called cytokine storm that often follows infection with SARS-CoV-2. Cytokines are proteins critical for cell signaling that are produced by the immune system and give rise to inflammation that in turn can fight infection. But if cytokine production spins out of control, extreme body-wide inflammation can follow, and brain tissue would not be spared the impact.
“The neurons themselves are not being invaded,” says Slan, “but what happens is that the systemic inflammatory response causes both stress and changes in signaling throughout the body. That includes the brain, and can precipitate these types of [psychotic] symptoms.”
One other bit of evidence that COVID-19 is linked to psychotic breaks comes not from the current scientific literature, but from history. Following the influenza pandemic of 1918 and 1919, there was a spike in what was called encephalitis lethargica, which was essentially a form of early-onset Parkinson’s disease that often didn’t appear for a number of years after the infection—but left patients in what was effectively a state of catatonia.
“That flu virus caused a post-infection inflammation that killed brain cells that in turn led to the Parkinson’s,” says Pleasure. The book and movie Awakenings, about patients who temporarily recovered consciousness and lucidity after treatment with l-dopa—a precursor of the neurotransmitter dopamine—was based on cases of people suffering from that form of Parkinson’s.
The good news is that unlike more chronic forms of psychosis, most cases seemingly related to COVID-19 do not appear to last. The symptoms can respond to antipsychotic medications like Risperdal (risperidone) and Zyprexa (olanzapine), say Smith and Slan. Intravenous immunoglobulin infusions—which reduce the overall load of abnormal cells and inflammatory agents—and steroids, which also reduce inflammation, can be effective as well.
By no means is the case for virus-triggered psychosis closed. Even Slan, who has first-hand experience treating a patient suffering from a seemingly virus-linked psychotic break believes that there is more work to be done—and acknowledges the doubts of the researchers who believe other psychological factors might be at play.
“Given the stress of COVID,” he says, “given the concerns about mortality, seclusion, all of these things represent huge psychosocial stressors, and they have the potential to precipitate oftentimes short-lived psychotic symptoms.”
Of course, even a transitory psychosis is still a psychosis—something no one wants to experience even fleetingly. That puts a premium on avoiding infection in the first place. “The best way to treat COVID-19 and the risk of psychosis is to prevent it,” says Smith. “Even if neurological complications are rare, getting vaccinated remains the smartest choice.”
The February 14th deadline for healthcare workers to receive their first dose of the COVID vaccine does not appear to have significantly worsened the hospital staffing crisis, even in rural hospitals. But the mandate hasn’t necessarily meant that all healthcare workers are now vaccinated, as some hospitals reported approving a flurry of medical and religious exemptions to avoid staff departures.
The Gist: Just as when states and early-adopter health systems enforced healthcare worker vaccine mandates last year, COVID vaccine uptake jumped just ahead of the federal deadline.
After months of challenges, we may finally be moving beyond debates over healthcare worker vaccine requirements. And as hospitalizations from the Omicron wave continue to decline, most states and health systems are not planning to implement booster requirements.
The website for the group Physicians for Informed Consent (PIC) reads like an apolitical, educational resource that provides information on vaccines and why they shouldn’t be government-mandated. Its mission is “that doctors and the public are able to evaluate the data on infectious diseases and vaccines objectively, and voluntarily engage in informed decision-making about vaccination.”
The group’s accompanying social media accounts, however, tell a different story. On PIC’s Facebook, Twitter, Instagram, and LinkedIn feeds, you’ll find post after post about reasons to be scared of vaccines – especially for children – often highlighting selective portions of scientific research that contain vaccination risks.
Who’s Behind PIC?
The group was founded in 2015 after California passed a law that prohibited the use of personal belief exemptions from vaccinations required for children to attend any public or private school in the state.
Three years later, the number of waivers issued by doctors to parents seeking medical exemptions for their children tripled. As a result, another law was passed in 2019, cracking down on the inappropriate use of medical exemptions.
The group’s founder, Shira Miller, MD, is a concierge integrative medicine doctor based in Los Angeles, specializing in menopausal care. On her own Twitter profile, she describes herself as “Facebook’s Most Popular Menopause Doctor.”
Miller earned her medical degree in 2002 from Technion-Israel Institute of Technology in Haifa, Israel, and has reportedly been working as a concierge physician since 2010.
PIC’s leadership team also includes 20 physicians from a wide range of specialties, most of whom, like Miller, don’t specialize in infectious diseases.
Among its leaders is Paul Thomas, MD, an Oregon-based pediatrician. Thomas, who is listed as one of PIC’s founding directors, was issued an emergency suspension order of his medical license in 2021 by the state medical board, in which they cited at least eight cases of alleged patient harm. In line with PIC’s philosophy, Thomas maintains that he isn’t “anti-vax” – he’s pro-informed-consent.
Also on the team is Jane Orient, MD, internist and executive director of the Association of American Physicians and Surgeons (AAPS), a group that also opposes vaccine mandates. Orient received her medical degree from Columbia University and currently practices in Arizona. In 2020, the AAPS sued the federal government for withholding its stockpile of hydroxychloroquine from COVID patients, despite research showing that the drug is ineffective. The complaint was dismissed in September 2021.
Doug Mackenzie, MD, a plastic surgeon who graduated from Johns Hopkins University of Medicine, is PIC’s treasurer. He has previously identified himself as an “ex-vaxxer” rather than an anti-vaxxer when speaking on a panel in 2019.
The only RN on the team is Tawny Buettner. After California mandated vaccinations for healthcare workers, Buettner organized a protest outside of her place of work, Rady Children’s Hospital in San Diego; she later sued the hospital after she was dismissed from her job. According to the complaint, Buettner and the 36 other plaintiffs alleged that their requests for religious exemptions from the COVID-19 vaccine were all denied.
Kenneth Stoller, MD, also listed on the leadership team, graduated from the American University of the Caribbean School of Medicine and completed pediatric residency training at the University of California Los Angeles. Stoller was disciplined in 2019 for doling out medical exemptions to children without adequate evidence. According to state records, his license in California has since been revoked; he currently holds a medical license in New Mexico.
What’s PIC?
The most notable physician groups accused of spreading COVID-19 misinformation since the vaccine rollout have been affiliated with right-wing media, if not overtly proclaiming conservative, anti-vaccination beliefs.
For example,America’s Frontline Doctors, a group notorious for its support of hydroxychloroquine as a treatment for COVID-19, has made its values well-known. The group’s founder, Simone Gold, MD, JD, was arrested for participating in the Jan. 6 capitol riot and has openly opposed mask-wearing. Similarly, physician leaders of theFront Line COVID-19 Critical Care Alliance, known for promoting the use of ivermectin to treat COVID-19, tout their appearances on the ultra-conservative Newsmax on the website’s homepage.
PIC wants to be different. The group’s focus, according to its general counsel Greg Glaser, JD, of Copperopolis, California, is on the “authoritative citations that show, or calculate, the risks [of vaccines] to the public,” he told MedPage Today.
“We are pro-informed consent, pro-ethics, pro-health. PIC is not anti-vaccine, and PIC is not pro-vaccine – PIC is neutral,” Glaser said on behalf of the group.
In August 2021, Glaser submitted an amicus brief to the Supreme Court PIC’s behalf, arguing against the implementation of vaccine mandates. The document claims that “government statements confirm there is no evidence that COVID-19 vaccines prevent the spread of SARS-CoV-2 or COVID-19,” ignoring the breadth of existing literature that says otherwise.
As COVID-19 cases fall and hospitals tiptoe out from yet another surge, the nation is left collectively asking one major question: What comes next?
By now, health experts have made it clear COVID-19 will always be around in some capacity but have stressed uncertainty about the potential scope and severity of future surges.
While difficult to predict what the pandemic’s next act could look like, several potential scenarios have emerged in recent months.
Below are four possible paths the pandemic could take in the future, as outlined by physicians, epidemiologists and global health officials:
1. Delta rebound. Delta has seemingly fallen out of the collective pandemic lingo amid omicron’s dominance in recent months, though there is still a chance delta — thought to be the deadliest strain thus far — makes a comeback.
In a Jan. 24 op-ed for The Washington Post, Ashish Jha, MD, dean of Brown University’s School of Public Health in Providence, R.I., said “It is possible, though unlikely, that the delta variant returns and co-circulates with omicron in different populations, contributing to ongoing infections and hospitalizations.”
It’s important to note that delta is still dominant in some parts of the world, health experts toldThe Atlantic, adding that while unlikely, there is a chance it could morph into something that catches up with omicron, allowing the two to tag-team — a dangerous combination given delta’s brutality and omicron’s transmissibility.
2. COVID-19 may become a seasonal virus. Dr. Jha said this scenario is likely, whether delta makes a comeback or not.
“That means we are likely to see surges in Southern states this summer (as people there spend more time indoors) and in Northern states next fall and winter as the weather turns cold again,” he wrote in a Jan. 24 op-ed for The Washington Post.
Emerging evidence suggests COVID-19 may be a seasonal disease, though the research is still preliminary. A July 2021 study from the University of Pittsburgh projected a seasonal COVID-19 pattern in North America with three repeating waves: one starting in New England in the spring, the second starting in the South in the summer, and the third kicking off in the Dakotas in the fall. Based on these findings, researchers predicted the U.S. would see a summer 2021 wave in the South and a fall 2021 wave in North-Central states, which is similar to what happened with the delta and omicron surges. As of November 2021, the study had not been peer reviewed.
3. A new variant emerges. If there’s one thing on this list that’s near certain, it’s that there will be new variants in the future. Global health officials have said they expect future variants to be even more transmissible than omicron.
“Omicron will not be the last variant that you will hear us talking about,” Maria Van Kerkhove, PhD, the World Health Organization’s technical lead on COVID-19, said Jan. 25. “The next variant of concern will be more fit, and what we mean by that is it will be more transmissible, because it will have to overtake what is currently circulating.”
Health officials aren’t so much concerned about the emergence of new variants themselves but whether they will cause more or less disease severity. WHO officials have warned against assuming the virus will become milder as it continues to mutate.
“There is no guarantee of that,” Dr. Van Kerkhove said. “We hope that is the case, but there is no guarantee of that and we can’t bank on it,” she added, emphasizing the importance of interventions such as ramping up global vaccination coverage to prevent the emergence of new variants.
Health experts are also concerned white-tailed deer may become a reservoir for the virus to mutate and spread to other animals or back to humans in the form of a new variant.
“This is a top concern right now for the United States,” said Casey Barton Behravesh, who directs the CDC’s One Health Office, which focuses on connections among human, animal and environmental health. “If deer were to become established as a North American wildlife reservoir — and we do think they’re at risk of that — there are real concerns for the health of other wildlife species, livestock, pets and even people,” she told The New York Times.
Preliminary findings recently found white-tailed deer on New York’s Staten Island infected with omicron, the first time the strain has been detected in wild animals in the U.S. Scientists are still exploring a number of questions regarding the virus’s spread among deer, such as how they contract the virus, how the pathogen might mutate inside the host, and whether deer could pass the virus back to humans.
4. The omicron subvariant may spread globally, prolonging the current COVID-19 surge in some parts of the world.
Research shows BA.2 is more transmissible than BA.1, the original omicron strain, though there is no evidence to suggest the subvariant causes more severe illness. The WHO said it expects cases of the omicron subvariant to increase globally due to its growth advantage over BA.1.
“We expect to see BA.2 increasing in detection around the world,” Dr. Kerkhove said during a Feb. 8 media briefing.
In late January, Nathan Grubaugh, PhD, an epidemiologist at the Yale University School of Public Health in New Haven, Conn., toldThe New York Times he was “fairly certain” the subvariant will become dominant in the U.S. but is unclear on “what that would mean for the pandemic.”
The BA.2 variant could spur a new surge, but it’s more likely that U.S. cases will continue to decrease, according to Dr. Grubaugh. If anything, the variant may simply slow the decline.
Overall, most experts told the Times that BA.2’s presence would not significantly alter the course of the pandemic, and so far, data backs this up. COVID-19 cases have been falling nationwide since peaking in mid-January, and modeling from Rochester, Minn.-based Mayo Clinic predicts this trend will continue over the next 14 days.
The weekly number of BA.2 sequences identified in the U.S. has also fallen since mid-January, according to a Feb. 11 U.K. Health Security Agency’s report. The U.S. confirmed 191 BA.2 sequences in the week of Jan. 17, which fell to 116 in the week of Jan. 24. In the week of Jan. 31, just four sequences were confirmed, according to supplemental data from the report.
Data from federal, state, and local health agencies show COVID-19 case, hospitalization, and death rates are much lower for vaccinated Americans than they are for the unvaccinated.
The first week of December 2021, when Omicron was first detected in the US, unvaccinated adults were nearly 25 times more likely to be hospitalized than vaccinated adults. While Omicron caused a big spike in COVID-19 cases, vaccinated people continued to be less likely to be hospitalized than the unvaccinated.
In King County, Wash., which includes Seattle, unvaccinated people were 13 times more likely to be hospitalized for coronavirus since December than people who were fully vaccinated.
New York City was one of the first areas in the US to get hit with Omicron. During the week ending January 15, 0.6% of all unvaccinated people were hospitalized with COVID-19 , compared with 0.02% of all vaccinated people.
These two areas have some of the most up-to-date data that illustrates the differences in susceptibility and severity of coronavirus based on vaccination status. But other state and local health agencies as well as the Centers for Disease Control and Prevention (CDC) also provide data that shows vaccine effectiveness.
As of January 26, 210 million Americans, or 64% of the population, were considered fully vaccinated after completing the initial series of COVID-19 shots. Twenty-six percent of Americans had received a booster dose.
National data isn’t as recent but shows lower hospitalization risks among the boosted.
CDC data compiled from hospitals in 12 states shows that, in the week before Christmas, unvaccinated people ages 50 to 64 were 32 times more likely to be hospitalized with COVID-19 than people in the age range who got a booster shot. They were eight times more likely to be hospitalized with COVID-19 than fully vaccinated people without a booster.
Unvaccinated people 65 and older were about 50 times more likely to be hospitalized than those who were fully vaccinated and received a booster.
More recent data from across the country suggests vaccinated people continue to experience lower hospitalization rates.
Georgia and North Dakota are two states publishing recent data on hospitalizations for people who have received a booster shot.
These comparisons do not account for age, so they don’t directly show the effectiveness of boosters. But the available data suggests vaccinated people are hospitalized at lower rates than unvaccinated people, just like before the Omicron wave.
In the first week of December, the combination of Georgia’s unvaccinated population and those receiving only one dose of the vaccine were 10 times more likely to be in a hospital with COVID-19 than the boosted population.
Georgia counts anyone in a hospital who tests positive for COVID-19 as a COVID-19 hospitalization.
Hospitalization rates in the state increased for everyone regardless of vaccination status during the Omicron wave. But the gap between the boosted population and the unvaccinated or partially vaccinated remained.
As of mid-January, the weekly hospitalization rate for Georgia’s booster group was a third of the rate for the combined unvaccinated and not fully vaccinated population. As of January 31, 48% of Georgians were not fully vaccinated, while 17% had received a booster.
During the same period in North Dakota, unvaccinated and partially vaccinated people were about twice as likely to be hospitalized with COVID-19 compared with the vaccinated. The hospitalization gap was three times greater for those with boosters.
Several other states published data on hospitalizations through mid-January. They all show vaccinated Americans at much lower risk.
Covid-19 death rates in the United States are “eye-wateringly” high compared with other wealthy nations—a problem that several health experts say underscores the shortfalls of the country’s pandemic response.
U.S. Covid-19 death rates exceed those of other wealthy nations
According to CDC data, over 880,000 Americans have died from Covid-19 since the beginning of the pandemic—a death toll greater than that of any other country. And during the current omicron wave, Covid-19 deaths are now greater than the peak number seen during the delta wave and more than two-thirds as high as record numbers seen last winter before vaccines were available, the New York Times reports.
Moreover, since Dec. 1, when omicron was first detected in the United States, the proportion of Americans who have died from Covid-19 has been at least 63% higher than other large, wealthy countries, including Britain, Canada, France, and Germany, according to a Times analysis of mortality figures.
Currently, the daily Covid-19 death rate in the United States is nearly double that of Britain and four times that of Germany. The only large European countries to surpass the United States’ Covid-19 death rates have been the Czech Republic, Greece, Poland, Russian, and Ukraine—all of which are less wealthy nations where the most effective treatments may be limited.
“Death rates are so high in the States—eye-wateringly high,” said Devi Sridhar, head of the global public health program at the University of Edinburgh. “The United States is lagging.”
Similarly, Joseph Dieleman, an associate professor at the University of Washington, said the United States “stands out” with its high Covid-19 death rate. “There’s been more loss than anyone wanted or anticipated,” he said.
Vaccination shortfalls plague the U.S.
Lagging Covid-19 vaccination rates among Americans likely contributed to the country’s outsized death toll compared with other nations, several health experts said.
Currently, around 64% of the U.S. population has been fully vaccinated. However, several peer countries, including Australia (80%), Canada (80%), and France (77%), have achieved higher vaccination rates.
Unvaccinated people make up the majority of hospitalized Covid-19 patients, according to the Times, but lagging vaccination and booster rates among vulnerable groups, such as older Americans, has also led to increased hospitalizations.
Around 12% of Americans ages 65 and older are not fully vaccinated, and among those who are fully vaccinated, 43% still have not received a booster shot, leaving them with waning immunity against the omicron variant. In comparison, only 4% of Britons ages 65 and older are not fully vaccinated, and only 9% have not had a booster shot.
“It’s not just vaccination—it’s the recency of vaccines, it’s whether or not people have been boosted, and also whether or not people have been infected in the past,” said Lauren Ancel Meyers, director of the University of Texas at Austin’s Covid-19 modeling consortium.
Similarly, former FDA Commissioner Scott Gottlieb said that the United States‘ lagging vaccination rates compared to the U.K.’s, particularly for boosters, may be due to “protracted wrangling” that “may have sowed confusion, sapping consumer interest.”
How the U.S. could fare in future Covid-19 waves
According to some scientists, the gap between the United States and other wealthy nations may soon begin to narrow. Although U.S. vaccination rates have been slow, the delta and omicron waves have infected so many people that overall immunity against the coronavirus has increased—which could potentially help blunt the effect of future waves.
“We’ve finally started getting to a stage where most of the population has been exposed either to a vaccine or the virus multiple times by now,” said David Dowdy, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health. “I think we’re now likely to start seeing [American and European Covid-19 death rates] be more synchronized going forward.”
However, other experts noted that the United States has other disadvantages that could make future Covid-19 waves difficult. For example, many Americans have chronic health problems, such as diabetes and obesity, that increase the risk of severe Covid-19 outcomes.
Overall, health experts said the impact of future Covid-19 waves will depend on what new variants emerge, as well as what level of death people decide is tolerable.
“We’ve normalized a very high death toll in the U.S.,” said Anne Sosin, who studies health equity at Dartmouth University. “If we want to declare the end of the pandemic right now, what we’re doing is normalizing a very high rate of death.”
The Food and Drug Administration fully approved Moderna’s mRNA COVID-19 vaccine on Monday, saying it meets its safety and manufacturing requirements.
Why it matters: Moderna’s vaccine, which will now be marketed as Spikevax, is the second coronavirus vaccine to receive full approval after the FDA approved Pfizer-BioNTech’s vaccine in August.
Hundreds of millions of doses of Moderna’s vaccine have already been administered in the U.S. under the FDA’s emergency use authorization.
What they’re saying: “The public can be assured that Spikevax meets the FDA’s high standards for safety, effectiveness and manufacturing quality required of any vaccine approved for use in the United States,” acting FDA Commissioner Janet Woodcock said in a statement.
“The totality of real-world data and the full [Biologics License Application] for Spikevax in the United States reaffirms the importance of vaccination against this virus,” Moderna CEO Stéphane Bancel said.
The big picture: The rise of the Omicron variant forced vaccine makers to reevaluate the effectiveness of their vaccines, which were developed based on eaarlier forms of the virus.
Studies show that Moderna and Pfizer-BioNTech’s vaccines still overwhelmingly prevent severe disease and hospitalizations, especially when the first two doses are reinforced with a booster shot.
HENRY KOTULA 