Globally, the Covid-19 pandemic is a threat because of scarcity of vaccines, with the highly transmissible Delta variant threatening millions around the world who can’t get vaccinated.
In the United States, the threat is dysfunction, with unwanted vaccines ready to expire on the shelves as desperate people around the world die for lack of them.
“This is becoming a pandemic of the unvaccinated,” Dr. Rochelle Walensky, the director of the Centers for Disease Control and Prevention, recently said, as the data shows that almost everyone who died from Covid-19 recently was unvaccinated.
Certainly the severe consequences will fall mostly on the unvaccinated. But the dysfunction affects all Americans.
To start with, not everyone is unvaccinated by choice. Children under 12 are not eligible to get the shots — that’s about 50 million young people. Plus, the immunocompromised may not respond as well to vaccines, which is at least about five million more people.
Then there’s the risk that, especially over time, the elderly, whose immune systems are not as robust, may lose some of their vaccine protection — as occurs with other illnesses, and as we’ve seen with Covid, to some extent, in Britain and Israel.
Finally, initial data from Britain suggests that Delta may lead to more-severe cases than previous variants. That question remains unsettled, but the possibility greatly increases the urgency for a powerful public health response.
In addition, Delta seems to be able to evade some immunity, so, compared to earlier variants, vaccinated or previously infected people are more likely to have infections break through their immunity, even ones leading to mild or moderate symptoms, which means they may be more likely to transmit onward, too. Thus even the vaccinated may pose a danger to unvaccinated children or vulnerable co-workers.
Our vulnerability isn’t small, even among those eligible for vaccines. About 34 percent of Americans over the age of 12 and about 44 percent of the entire U.S. population haven’t been vaccinated at all. Some of those may have had Covid, so they have some level of protection, but that is not as good as being fully vaccinated, especially against Delta.
Even an optimistic projection leaves tens of millions of unvaccinated people exposed to higher risks of hospitalization and death from Covid.
Already, we are seeing rises in hospitalizations and deaths, almost entirely among the unvaccinated, and the Delta surge has just begun. Based on what we’ve seen elsewhere, we can expect it to rapidly accelerate and wash over the country fairly quickly.
The most important thing we can do now is to increase vaccination coverage.
One important step would be to implement and broaden vaccine mandates. There’s plenty of precedent for mandating vaccines in health care, the military and schools, so it wouldn’t be some novel step to do so for one of the safest vaccines we’ve ever had.
Some large employers already mandate flu vaccines. Kentucky legally requires everyone working at a long-term care facility to be vaccinated against the flu and pneumococcal disease, unless they have a medical or religious exemption. Mandates for Covid vaccines, too, should be issued, especially for people who work with high risk or vulnerable populations — children, the elderly, the incarcerated and those in medical settings — and possibly for employees in workplaces where large numbers of people congregate indoors. Exemptions, too, should be re-examined so that they aren’t overly broad.
A staggering 40 percent of workers at nursing homes and other long-term care facilities remain unvaccinated. This is terrible, considering that the elderly, even if vaccinated, would be expected to have more breakthrough infections.
People may have a right to take their chances with an infection but not to risk transmitting the virus to vulnerable others.
An obstacle to extending mandates is that the Food and Drug Administration has approved the vaccines only for emergency use and has yet to fully approve them. Typically a company can apply for and receive full approval after six months of compiling safety data. Pfizer submitted its application in early May, and the F.D.A. just accepted it, so two months have passed. Moderna applied in early June and is still waiting for acceptance of its application.
The F.D.A. has until January to decide whether to formally approve Pfizer’s vaccine. The acting F.D.A. commissioner, Janet Woodcock, said she hopes it will get done more quickly. Let’s hope so. It would be a grave mistake for the agency to take another six months.
The lack of formal approval has allowed some anti-vaxxers to claim the vaccines are experimental. Polls show that a lack of trust in the vaccine is a rationale for some of the vaccine hesitancy. And without full approval, it might be easier to fight vaccine mandates, both legally and politically.
Lack of full approval also helps feed a misunderstanding. Adverse reactions to some drugs can indeed occur long after we start taking them, especially after long-term use. However, vaccination is a one-time event (or two, if you count the booster). Immediate side effects, like allergic reactions, would occur fairly soon after inoculation. That’s why people are asked to spend 15 minutes in a waiting room postvaccination or 30 minutes if they’ve had a history of allergic reactions. There are also questions about immune system reactions that can take longer to appear. However, as the immunologist Andrew Croxford explained, medical experts have learned to expect such problems within the first few weeks and months after vaccination. Regulators require six months of safety data, not more. They have that now.
The F.D.A. said it needs to complete “a high-quality review and evaluation,” and it does. But it has the data to do that quickly. The safety data on these vaccines is comparable to that of many fully approved vaccines. This is not to mention the evidence from hundreds of million doses administered in the United States alone.
Given the severe threat the Delta variant poses to the unvaccinated, the risk-benefit calculation is especially stark, and the need for full approval is even more urgent.
Some might feel less concern for the unvaccinated, viewing them as hard-core anti-vaxxers or eager consumers of extremist propaganda on social media or Fox News. It’s true that attitudes toward vaccination have become affected by our political polarization. At a major conservative event recently, a mention of low vaccination rates was met with cheers. As horrifying as this was, we still have to try to reach this population.
In general, it is easier to convince people if the message comes from a trusted intermediary, and the current polarization makes this even more important. For conservatives, one good place to look might be Republican governors who face more direct accountability to the affected people.
The effort isn’t necessarily hopeless. Almost 90 percent of Americans 65 or older have received a vaccine. Since many of them are Republicans and heavy consumers of misinformation, this demonstrates that the harsh reality of the risk calculation can, under the right circumstances, cut through the misinformation. Delta’s terrible effects may provide that tragic tipping point for more.
And the vaccination gap runs through ideological, racial and social divisions. Black and Hispanic people are still less likely to be vaccinated, despite having suffered disproportionately throughout the pandemic. This is probably due to lack of access, especially early on, when getting an appointment could be complicated; a fear of side effects, especially if working without paid sick leave; and historic distrust of the medical system, in which, studies show, they continue to face discrimination.
Reaching underrepresented and historically mistrustful communities requires resources and, crucially, local action: a public health system in which trusted local leaders can work with the medical system to take both the vaccine and the persuasion to the people. In New York City, about 20,000 people who were offered a free weekly MetroCard or train ticket got vaccinated at pop-up clinics in subway and train stations. We can try versions of this in neighborhoods, shopping malls, supermarkets and workplaces as much as possible. It’s fine to offer incentives, but it might help just to have health care workers present to answer questions.
The federal government should deploy epidemiologists, pollsters and ethnographers to figure out what arguments, incentives and approaches work best now and even carry out local experiments.
Meanwhile, schools will open in the coming weeks, and yet so much remains unclear and confusing about protecting younger children until they can get vaccinated. Even if they seem to be largely spared from severe outcomes of Covid-19, they are not invulnerable. Plus, they can bring the infection home.
C.D.C. guidelines make clear that good ventilation is essential for lowering the risk of airborne transmission. The federal government allocated more than $120 billion for K-12 schools in the latest relief package for improving ventilation and other mitigations, but rules for using these funds are flexible, and local implementation remains haphazard.
Parents need concrete information. Can windows in classrooms be opened, and will they be? Are HEPA filters, which cost a few hundred dollars each, being used in classrooms? Has the air-conditioning, if used, been adjusted to bring in outside air, and have its filters been upgraded to better catch pathogens? Have classroom ventilation rates been evaluated, for example by using carbon dioxide monitors?
Teachers and other staff members who work with kids younger than 12 should be subject to vaccine mandates, just like those who work with the elderly. We should also increase the use of rapid tests in schools, to try to catch outbreaks early.
Masking policies in schools remain confusing and muddled as well. The American Academy of Pediatrics is recommending that all children, even if vaccinated, wear masks in schools, which contradicts C.D.C. guidelines saying only the unvaccinated should wear them. Meanwhile, places like Texas and Iowa have barred schools from requiring masks.
How are parents supposed to negotiate a situation like this, especially if their children are under 12?
The problem with selective masking indoors, as the C.D.C. recommends now, is that it’s impossible to enforce. This could get especially tricky in schools, where peer pressure can play a large role.
A sensible school policy would be to mandate masks for all elementary school children, at least until a vaccine becomes available to them, and tie it to local infection and vaccination rates for those 12 and over. Parents who can vaccinate their kids are less at the mercy of everyone else’s choices, making mandates less crucial.
In the meantime, rules on indoor masking and crowding limits should be kept in place or restored until local vaccination rates rise to a set benchmark — say, at least 70 percent of those eligible — and case numbers remain low and steady. Too many people remain vulnerable, and in many places with low vaccination rates, hospitalizations are soaring. Even if we can’t expect people to keep masking indoors forever while others refuse vaccination, too many remain vulnerable now to throw up our hands. One lesson in this pandemic has been that waiting too long to respond or relaxing rules too early can create serious problems.
There is also a question about how likely the vaccinated are to transmit to others if they are infected with Delta. In May the C.D.C. stopped tracking breakthrough cases unless people became hospitalized. That was a mistake. Its explanation was that such cases were rare, and they may well have been when the decision was made. Delta is a reminder that the reason for surveillance is to be able to quickly notice changes in an outbreak.
Since Delta came onto the scene, I’ve acquired a pile of anecdotes from social media and a few examples from countries, like Singapore, that are doing a better job of tracing such cases that indicate vaccinated people are sometimes transmitting the virus. In comparison, I had hardly heard of any such examples from the Alpha variant, and studies did not indicate it could evade immunity in a substantive way. We also know that Delta has a higher viral load and infected people start shedding viral particles much earlier, so it makes sense why all this is happening.
Shouldn’t we have better evidence, though, so we can have better guidance, especially for those who live with unvaccinated children or have immunocompromised family members?
Given the ongoing nature of the threat and many remaining unknowns, the Occupational Safety and Health Administration should provide rules for rapid testing in workplaces, paid sick leave and, as appropriate, high-filtration masks and even ventilation standards.
As both vaccinations and infections increase, we get closer to the point that this virus joins the other four endemic coronaviruses that commonly circulate among humans. Though it is too early to predict what exactly will happen with this one, those mostly cause nuisance colds.
But the acute phase of this pandemic is far from over. Our moral obligation is to make vaccines available for as many people as possible and as fast as possible and to do everything we can to save the lives and health of people who don’t yet have that protection.
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