COVID has become almost invisible by standing still. Since last winter’s peak in COVID deaths faded in March, COVID has continued to kill people, but at a very steady rate, with no newsworthy ups and downs. The average COVID death toll in the US has been just under 3,000/week for over nine months now, with just one week barely over 4,000 (last week!) and one week barely under 2,000 (early November), after an average of more than 12,500/week for the first quarter of 2022.
Death by COVID is no longer a big story, and people are largely relieved to not think about it. There is an apparent equilibrium between many moving parts: the successive waves of incrementally more transmissible subvariants, the low bivalent booster uptake rate, the new infection rate, the rates at which immunity rises and falls, the sustained effectiveness of Paxlovid, the lost effectiveness of monoclonal antibodies, the reduced use of masks, more home testing, the reduced availability of case rate information, better ventilation in some places, the deaths of over a million people most vulnerable to COVID, and who knows what else.
This ensemble of variables seems to enforce both an upper and lower limit on the COVID death rate. Most of the deaths these days are concentrated among people who are immunocompromised, have co-morbidities, or are simply old. The debate over “dying of COVID vs. dying with COVID” has been blurred, with COVID sometimes the last straw for the overburdened bodies of people whose health is already in trouble.
Meanwhile, Long COVID sufferers—mostly in their 30s, 40s, and 50s who have had mild COVID cases—are piling up in the shadows by the millions, like veterans of a war we’re eager to forget. Here’s a sheaf of dispatches from that war.
XBB.1.5 is the new champion Omicron subvariant in the United States. It is the most transmissible yet and is rapidly displacing other subvariants here. It is more able to infect people despite their immunity than its predecessors, but the bivalent vaccine booster is doing a good job against XBB.1.5, preventing hospitalizations and deaths and apparently lowering infection and transmission rates.
Paxlovid continues to be a useful treatment tool against the latest variants, but none of the monoclonal antibodies that were important defenses against earlier variants is effective against XBB.1.5. It seems to have combined, to a unique extent, two tricks: a greater ability to glom onto cells and an ability to partially dodge immune response. There’s no evidence yet that it causes more severe disease, and it’s too soon to tell how it compares to earlier variants as a cause of Long COVID.
Because it is so transmissible, it helped push COVID hospitalizations up to a modest national peak in early January, from which a decline appears to have begun. Deaths are rising but should follow hospitalizations back down soon.
We have not had a whole new variant emerge since Omicron in late 2021, fortunately. Whether or not there are more in our future is unpredictable. Omicron is incrementally raising the bar that a new variant would have to clear to take over globally. As each new Omicron sub-variant bests its siblings in the transmissibility sweepstakes, it means that a new variant from a different lineage would have to make an even bigger jump from its starting point to out-do it.
The longer Omicron lingers and evolves, the bigger the jump will be. However, there is a countervailing force as well: as our immune systems get more and more tuned to Omicron, the odds increase that a new variant might arrive that is invisible to all that Omicron-oriented immunity and would thus have a large advantage over Omicron in a kind of fresh start surge which could be quite dangerous. Nobody knows what the tiny scriptwriters in the COVID Cinematic Universe have up their nano-sleeves.
China, in the midst of an enormous wave of cases, has begun to administer nasal spray vaccines. Early reports suggest they are effective, though China will not be able to scale up production very much to deal with its current crisis. Nasal spray vaccines are also being tested in Europe and the US. Nasally administered vaccines may be more effective in preventing infection and transmission, since they activate immune response in the mucus linings of the respiratory tract, where the SARS CoV-2 virus first infects new victims. Nasal vaccines may also appeal to people who avoid needles.
The other new category of vaccines currently being tested are pan-Coronavirus vaccines, which deliver a protein nanoparticle studded with a wide array of antigens. Such vaccines could provide more complete and long-lasting immunity to all the variants of COVID, as well as immunity to future coronaviruses and to the original SARS and MERS viruses, which were much less contagious than SARS CoV-2, but much more lethal.
There’s nothing like Operation Warp Speed behind the development of this new category of vaccines, so it could take years for them to become widely available. It’s worth remembering that good but imperfect vaccines are typically a better business than perfect ones, so the pharmaceutical companies currently shipping a lot of today’s imperfect vaccines and recurring boosters have an incentive to wring as much profit out of that model as they can before killing the golden goose with a vaccine that might provide permanent, or at least very long-term, protection against the whole coronavirus family.
Faced with massive public disinclination to take the bivalent boosters it has already purchased, the US Government has mostly lost interest in warp-speeding better vaccines.
Meanwhile, masking and distancing remain effective, but more infectious sub-variants require greater vigilance in their use, and usage has instead been reduced. We seem to be divided into two camps now, people in the habit of masking when they are indoors in close quarters with strangers, and people who simply never do. At this point, a major campaign to try to push COVID infection rates lower by urging people to mask and selectively distance would be a political failure. The result is that those who remain vulnerable to COVID are leading difficult lives.
The hardest nut to crack is protection against Long COVID. Researchers are looking for treatments which would reduce the risk, but the uncertainty about what Long COVID is and why it develops in some people and not in others makes it hard to figure out how to block it. There are one or two somewhat promising drugs, but no proven treatments yet. One drug being tested is—wait for it—Ivermectin.
The CDC believes that the vast majority of all Americans has acquired some degree of immunity to COVID by various combinations of vaccines and infections. Immunity to infection seems to wane quickly as SARS has proven to be a rapid mutator, but defense against serious disease and death is longer-lasting. We don’t know at this point whether we’ll go through a quiet period for a few years and then experience another major surge of COVID serious illness and death, or whether a steady rate of infections and deaths is the new normal and might slowly decline. A lot will depend on whether entire new variants emerge, and on new vaccine development and subsequent vaccine acceptance.
Long COVID remains a poorly understood threat. Researchers are slowly pinning down plausible mechanisms, and it appears likely that vaccination lowers the risk, but millions—and possibly tens of millions—of Americans are impaired at work and in daily life by heart, lung, brain and other impairments. Although those hospitalized for COVID have greater odds of developing Long COVID, the vast majority—about 90% worldwide—of Long COVID cases develop among people who had relatively mild initial disease.
There is some evidence that Omicron may produce lower rates of Long COVID than earlier variants, but confirming data is still to come. Overall, women are at higher risk than men, and adults at higher risk than children. The large majority of Long COVID cases are among people under 60.
It’s not known what the Long COVID risks are for people who are infected multiple times. About one COVID patient in ten will later have symptoms characterized as Long COVID, and About 1 in 7 Long COVID cases last a year or more. For some of those long-haulers, there’s a so-far-unquantified risk of Forever COVID, which is likely to lead to premature death.
There’s also concern among some scientists that COVID may cast a long shadow in premature deaths among people who were never diagnosed with Long COVID. There are reasons to worry that COVID’s damage to the lungs, the cardiovascular system, the brain and various other organs may lead to later-life problems that occur sooner and are more serious, making earlier death more likely. It will take years to measure the extent to which this might be true.
Globally, healthcare systems have been damaged by COVID, which killed practitioners, burned out many more, and inflicted a lot of financial harm on hospitals. The headline on this story in the Economist recently captures the situation pretty well: Why healthcare services are in chaos everywhere. Public health has also been hit hard: waves of anger often crashed against public health departments and their workers, up to and including threats of violence from people angry at lockdowns and mandates. Individual public health workers were often heroic, but public health institutions have had a mixed track record for effectiveness.
Extended school closures also had serious negative consequences to weigh against the good they did. Schools have reopened to find that some students are struggling to regain academic momentum, that serious behavioral issues have increased, that millions of students have left public school systems for private schools, that academic inequality has increased, and that there are teacher shortages in many places.
The anti-vaccine response to COVID has become entrenched in its own world of pseudoscience and seems unlikely to melt away quickly. It has served to increase the number of people who are opposed to all vaccines, meaning that the risk of new outbreaks of measles and other infectious diseases of childhood has increased in many places.
There are two things to prevent: continuing consequences of the COVID pandemic, and the emergence of an entirely new pandemic. As mentioned above, federal funding for COVID research has been sharply reduced; it was politically cuttable as the big spending bills of the last Congress came down to the finish line, and Washington’s attention is now focused on inflation, not infection.
Globally, advocates for a stronger international system for detection and rapid response to new pandemic threats are struggling to persuade governments to commit. Right now, response to emerging threats is up to the country where the threat emerges plus the World Health Organization.
Other nations may join the battle (The US often does), but there are no intermediate regional alliances pre-committed to reacting quickly against newly identified pathogens, with pre-positioned resources in place. There is a world-sized hole in our readiness to avoid doing all of this over again.
And in Conclusion…
The United States has muddled through COVID in a very American way: dazzling technology, destructive polarization, a flood of cash, and a short memory. We (and therefore the world) are more vulnerable to continuing COVID damage and future pandemics than we should be, but the scientific and technical leaps which were accelerated by COVID provide a better starting point for dealing with the next pathogenic attack. We are who we are.