The United States is finally “out of the pandemic phase,” the country’s top infectious disease expert said, as cases and hospitalizations are notably down and mask mandates are all but extinct.
While there are still new infections spreading throughout the country – an average of 50,000 per day as of Tuesday – the country is far from the heights of the pandemic, when daily case counts surpassed 1 million. Restrictions, too, are easing as many Americans appear to be putting the pandemic behind them. Masking requirements have been lifted across most of the country, and officials stopped enforcing a federal mask mandate in transportation settings after a judge struck down the requirement.
“We are certainly right now in this country out of the pandemic phase,” Anthony Fauci, President Joe Biden’s chief medical adviser, said Tuesday evening on PBS’s “NewsHour.”
Fauci said the United States was no longer seeing “tens and tens and tens of thousands of hospitalizations and thousands of deaths. We are at a low level right now.”
During the pandemic’s darkest moments, many wondered when the country would officially declare itself past the nationwide disaster, which has killed nearly 1 million Americans.
Fauci’s comments are likely to fuel debate about whether this is truly the moment: New cases are on the rise in the United States, and deaths are down, though they often lag spikes in cases. The Centers for Disease Control and Prevention said Tuesday that as of the end of February, nearly 60 percent of Americans – including three out of every four children – have been infected with the coronavirus. But officials cautioned that the data did not indicate that Americans have widespread immunity against the virus because of their prior infections.
While previous infections are believed to offer some protection against serious disease for most people, health experts say the best protection against infection and serious disease or death from the coronavirus is vaccination.
The coronavirus will not be eradicated, Fauci said, but can be handled if its level of spread is kept “very low” and people are “intermittently” vaccinated, though he said he did not know how frequently. And Fauci echoed warnings from the World Health Organization and the United Nations this month that worldwide, the pandemic is far from over as vaccinations lag, particularly in developing nations.
The Biden administration, meanwhile, is appealing a ruling by a Trump-appointed federal judge that struck down the federal mask mandate on transit, including on planes, though it is unclear whether they will be successful, and likely face an American public that could be unwilling to comply again.
And in a less-than-subtle reminder that the coronavirus is still hanging around, the White House on Tuesday announced arguably the nation’s highest-profile coronavirus infection since former president Donald Trump, saying that Vice President Kamala Harris had tested positive and was asymptomatic. She was not considered in close contact to Biden, the White House said.
But officials caution that people should not presume they have protection against the virus going forward.
Before omicron, one-third of Americans had been infected with the coronavirus, but by the end of February, that rate had climbed to nearly 60 percent — including about 75 percent of kids and 60 percent of people age 18 to 49, according to federal health data released Tuesday.
The data from blood tests offers the first evidence that over half the U.S. population, or 189 million people have been infected at least once since the pandemic began — double the number reflected in official case counts. Officials cautioned, however, that the data, in a report from the Centers for Disease Control and Prevention, does not indicate people have protection against the virus going forward, especially against increasingly transmissible variants.
“We continue to recommend that everyone be up to date on their vaccinations, get your primary series and booster, when eligible,” CDC Director Rochelle Walensky said during a media briefing.
Kristie Clarke, the CDC official who authored the report, said by February, “evidence of previous COVID-19 infections substantially increased among every age group, likely reflecting the increase in cases we noted as omicron surged in this country.”
Clarke said the greatest increases took place in those with the lowest levels of vaccination, noting that older adults were more likely to be fully vaccinated.
The largest increases were in children and teenagers through age 17 — about 75 percent of them had been infected by February, based on blood samples that look at antibodies developed in response to a coronavirus infection but not in response to vaccination. That’s about 58 million children.
The blood test data suggests 189 million Americans had covid-19 by end of February, well over double the 80 million cases shown by The Washington Post case tracker, which is based on state data of confirmed infections. Clarke said that’s because the blood tests captures asymptomatic cases and others that were never confirmed on coronavirus tests.
With the omicron surge, officials had expected there would be more infections. “But I didn’t expect the increase to be quite this much,” Clarke added.
Separately, CDC is about to publish another study that estimates three infections for every reported case, she said.
A subvariant of omicron known as BA.2 is now the dominant strain in the United States, according to new data from the Centers for Disease Control and Prevention (CDC).
The variant has been steadily rising in proportion because of its increased transmissibility compared to the original omicron strain, and it represented 54.9 percent of new cases for the week ending March 26, according to CDC data. That is up from about 27 percent two weeks earlier.
The BA.2 subvariant is thought to be about 30 percent more transmissible than the original BA.1 omicron strain, which itself was already more contagious than earlier versions of the virus.
Importantly, though, experts say there is no evidence that BA.2 causes more severe disease than the original omicron strain or that it evades the protection from vaccines to a greater degree.
The subvariant may cause some increase in cases after weeks of steady declines that have led to a relative lull in the virus. But it is unclear how sharp the increase will be, and people who are vaccinated and boosted are still well-protected against severe disease.
The Food and Drug Administration on Tuesday authorized a fourth COVID-19 vaccine shot for people 50 and older, which could further help protect the most vulnerable from the subvariant.
“CDC says the BA.2 subvariant of Omicron is now dominant in the US,” tweeted Leana Wen, a public health professor at George Washington University. “Reminder that while this appears to be even more contagious than the original Omicron, it is not more virulent than previous strains, and existing vaccines still protect well against severe disease.”
CDC Director Rochelle Walensky said last week that her agency was monitoring the subvariant, particularly in the Northeast, where it has been concentrated so far.
“Over the past week, we have seen a small increase in reported COVID-19 cases in New York state and New York City, and some increases in people in the hospital with COVID-19 in New England, specifically where the BA.2 variant has been reaching levels above 50 percent,” she said.
“This small increase in cases in the Northeast is something that we are closely watching as we look for any indication of an increase in severe disease from COVID-19 and track whether it represents any strain on our hospitals. We have not yet seen this so far.”
Atul Gawande leads global health and is co-chair of the Covid-19 Task Force at the U.S. Agency for International Development.
Nearly a year ago, President Biden announced that the United States would be the “arsenal of vaccines for the world,” just as America served as an arsenal for democracies during World War II. With the president’s leadership and the consistent bipartisan support of Congress, the United States has delivered more than half a billion coronavirus vaccines to 114 lower-income countries free of charge, a historic accomplishment. This example spurred contributions from other wealthy nations and contributed to vaccination of almost 60 percent of the world.
But the global battle against covid-19 is not done. Instead, the challenge has changed. The lowest-income countries, where vaccinations have reached less than 15 percent of people, are now declining free vaccine supply because they don’t have the capacity to get shots in arms fast enough.
We must therefore not just provide an arsenal; to protect our allies against future variants, we must also provide the support they need to ramp up their vaccination campaigns. That effort requires money, and despite generously funding our covid-19 response up to this point, Congress is now failing to provide the resources we need.
I am writing to say: This bodes serious trouble for the world.
Despite a period of relative calm here at home, we’re again seeing cases and hospitalizations spike in Europe and Asia, even in places with higher levels of vaccination than the United States. These surges are due to the more-transmissible BA.2 subvariant of the already highly infectious omicron strain. Without additional funding, we risk not having the tools we need — vaccines, treatments, tests, masks and more — to manage future surges at home. And no less troubling, if we don’t close the vaccine gap between richer and poorer countries, we will give the virus more chances to mutate into a new variant.
Since the virus first emerged, the package of tools we’ve developed to fight it has proved resilient against all coronavirus variants. But there’s no guarantee that will remain true. A new variant that evades our defenses might once again fuel new surges of severe illness and batter the global economy. Helping all countries protect their populations by supercharging vaccination campaigns is our best hope to prevent future strains from emerging and ending this pandemic once and for all.
Turning vaccines into actual vaccinations has been difficult even in wealthy countries, where capable health systems, state-of-the-art cold chains and public awareness campaigns mean that anyone who wants a vaccine can get one. In countries without strong health infrastructure — without enough freezers and refrigerated trucks to keep vaccines from spoiling or enough health-care workers to reach rural populations living miles from the nearest health facility — it’s much tougher. We’ve also seen the same vaccine myths and disinformation that swirl through our media ecosystem spread just as rapidly through social media and hurt public trust abroad.
But we’ve also learned how to successfully tackle these challenges. In December, the Biden administration launched an initiative called Global VAX to help low-income countries train health workers, strengthen health infrastructure and raise vaccine access and awareness. While vaccine coverage in those countries remains far below the global average, the rapid progress we’ve supported in places such as Ivory Coast, Uganda and Zambia show what is possible when governments that are committed to fighting covid-19 have the global support they need.
Without more funding, we would have to halt our plans to expand the Global VAX initiative. The United States would have to turn its back on countries that need urgent help to boost their vaccination rates. And many countries that finally have the vaccines they need to protect their populations would risk seeing them spoil on the tarmac.
We can’t let this happen. It not only endangers people abroad but also risks the health and prosperity of all Americans. The virus is not waiting on Congress to negotiate; it is infecting people and mutating as we speak.
Over the past two years, both parties in Congress have repeatedly stepped up to fight covid-19 in an inspiring show of bipartisan unity. Now, we need our leaders to come together once more. With an effective strategy in place and the tools to transform covid-19 from a killer pandemic to a manageable respiratory disease, the United States has the expertise and capabilities the world needs to win the fight against this virus. We need Congress to let us take the fight to the front lines.
The expected green light for a second coronavirus booster shot poses a challenge to the Biden administration, which will need to work overtime to convince a public that has largely decided to move on from the COVID-19 pandemic.
Both Pfizer and Moderna have filed for emergency use authorization with the Food and Drug Administration for a fourth dose of their respective vaccines, citing evidence that protection from the third shot has decreased enough to warrant a fourth dose.
Yet the nation’s vaccination and booster rates have dropped to record lows, just as experts and officials are bracing for the possibility of another wave of infections from the BA.2 subvariant of omicron.
The BA.2 version of omicron is much more transmissible than the original variant. Combined with relaxed precautions like indoor masking and waning immunity among those who have not received a vaccine booster, cases have risen sharply in Europe in the past few weeks, and the U.S. could follow shortly.
The omicron subvariant is responsible for about 35 percent of all cases in the country. In some regions though, like the northeast, it is responsible for the majority of infections.
Federal health officials are reportedly poised to authorize a fourth dose of coronavirus vaccine for adults age 50 and older as soon as this week. A fourth shot is already authorized for the immunocompromised.
But the issues that plagued the administration during the first booster campaign loom large, and officials are likely eager to avoid the same pitfalls.
Chaotic and at times disparate messages from administration health officials culminated in a complicated set of recommendations about who should be getting booster shots, and why, which experts said helped depress enthusiasm.
“I think that some of the low uptake of boosters, especially amongst people who would benefit, the high risk population, is because that message has been diluted,” said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.
But the underlying disagreement about the goal of booster shots has not changed. While there’s widespread agreement that older Americans are much more at risk for severe outcomes, it’s still not clear if younger people will benefit from an additional dose.
Much of the debate has centered on whether the goal is to prevent people from being hospitalized with COVID-19 or whether the goal is to prevent them from getting sick at all, even if it is milder.
Anthony Fauci, White House chief medical advisor and the nation’s top infectious disease doctor, said regulators are trying to determine how low protection against hospitalization needs to drop before a booster is warranted.
“So the real open question that we don’t know definitively the answer to, is how long is the durability of protection against severe disease going to last even when the protection against infection diminishes substantially,” Fauci said during a Washington Post event last week.
“For example, we know that when you get down to a rather low level 30, 40 or so percent of protection against infection, you still have, when you look at hospitalization, a high degree [of protection],” Fauci said.
President Biden last summer promised widespread boosters for all Americans by the end of September, well before the FDA and the Centers for Disease Control and Prevention (CDC) had examined the evidence.
While officials were careful to say the booster program was contingent on the FDA and CDC giving the green light, scientists inside and outside the government argued there wasn’t enough evidence showing protection against severe illness and hospitalization dropped to levels that warranted a booster.
The CDC initially decided against recommending broad authorization, and instead recommended a booster shot for people over the age of 65, as well as anyone who was at “high risk” of exposure to the virus in the workplace.
The agency eventually decided to make everyone eligible, but by then much of the damage had been done. Vaccinated Americans have largely shown they are not interested in getting a booster.
According to current CDC data, less than 45 percent of all adults have received a booster shot, but the number rises to about 67 percent of adults age 65 and older.
Adalja said it makes sense to be proactive and have a plan to get additional booster shots to the older group. But he said the decisions should be left to the scientists, and the health agencies should make decisions independent of the White House.
“Keep the politicians out of it,” Adalja said. “The miscommunications occurred because they made boosters a political issue, not a scientific issue.”
But even if there is a targeted recommendation, a stalled funding request in Congress further complicates matters. The U.S government does not have enough doses on hand to vaccinate everyone who would be eligible for another booster.
The White House says it needs tens of billions of dollars in COVID response funding, which is tied up due to political disagreements. Administration officials say they don’t have enough doses on hand to cover anyone other than the immunocompromised and people aged 65 and older.
But an independent analysis from the Kaiser Family Foundation found the government only has enough vaccine supplies to cover 70 percent of the 65 and older group.
As parents await an approved vaccine for children under 5, Moderna said on Wednesday a study had found its two-dose pediatric vaccine to be safe for young children, toddlers and babies. Its effectiveness, however, was complicated by the spread of the coronavirus’s omicron variant. While the pediatric vaccine generated an immune response equivalent to that of young adults before the highly transmissible variant emerged, those immune defenses were less strong in the face of omicron. In children, the pediatric vaccine was about 40 percent effective, Moderna said. The company plans to submit the data to the Food and Drug Administration for consideration in the coming weeks.
The FDA also faces requests to authorize a second booster vaccine dose for adults. But even if they are authorized, Biden administration officials said they lack the funds to purchase those shots. They said they’ve bought enough doses for Americans age 65 and older, as well as the potential initial regimen for children under 5, but can’t buy more doses for people in other age groups unless Congress passes a delayed $15 billion funding package. It’s not yet clear whether additional doses for adults will be necessary, but officials said placing orders for doses ahead of time has been an important lesson of the pandemic. White House officials have expressed worry that vaccine manufacturers will prioritize orders placed by other countries.
That concern comes as omicron’s BA.2 subvariant of the coronavirus now amounts to as much as 70 percent of new infections in much of the United States, according to the genomic surveillance company Helix. That version of the virus has prompted a surge of cases in Europe and fear that the United States will experience its own wave, similarly to how it has mirrored Europe in the past. A broad increase in cases has so far not happened in the United States, and disease experts don’t know for sure whether it will. If it does, it’s unclear whether the pandemic policies of the Biden administration and private institutions would substantially change.
A program to ensure global vaccine equity was doomed from the beginning to fall short, a Washington Post analysis found. The initiative, called Covax, was meant to convince wealthy and poor countries to combine their money to order vaccine doses in advance and then share them in a way that would protect the most vulnerable people first. But the program’s supporters underestimated the desperation of the wealthier countries, which snatched up doses from manufacturers for their own residents. Covax was also slow to adapt as nations declined to participate. Now, more than one-third of the world has not received a vaccine dose — a result that not only is inequitable, but also makes it easier for new variants to emerge.
In a study published Monday, people who had covid-19 had a 46 percent higher risk of developing Type 2 diabetes or being prescribed medication to control their blood sugar within a year than those who had not had the coronavirus. Greater severity of covid symptoms was associated with a higher chance of developing diabetes, but even people with less severe or asymptomatic infection had an increased risk, according to the study of more than 181,000 Department of Veterans Affairs patients. The study did not prove cause and effect but did show a strong association between covid-19 and diabetes.
Other important news
Omicron’s BA.2 subvariant has become the world’s dominant form of the coronavirus. The Post created a map and several charts to help you visualize how it’s spreading around the world.
White House press secretary Jen Psaki said Tuesday that she had tested positive for the coronavirus a second time. She had been scheduled to travel to Europe with President Biden and other administration officials, but canceled her trip.
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.”
HENRY KOTULA 