Dr. Tom Frieden Blog: Covid Epidemiology
by Dr. Tom Frieden
January 30, 2022
We have better tools, more information, more experience, and the best chance to save make the world a safer place than ever in our lifetimes.
Yes, there could be a deadly, transmissible, immune-escape Covid variant. But even in that worst-case scenario, we'd be far better prepared to handle it. And, it's likely that our immunity will continue to protect us, at least somewhat and likely to a signficant degree, from severe illness.
- 1.Immunity from vaccines and prior infection. Many highly effective vaccines, with billions of doses given. Not so effective against infection, but the most important goal is to prevent severe illness. We need to know more about how to prevent and treat long Covid, but we already know that if you don't get Covid, you don't get long Covid, and if you get Covid and are vaccinated, you're far less likely to get long Covid.
- 2.Treatments. Although they won't save nearly as many lives as vaccines, new treatments can prevent severe Covid, prevent hospitalizations, and prevent death. We're taming this virus.
- 3.Masks. Better masks are better, and there are now more of them. Back in 2009, I suggested that the U.S. learn from East Asia and mask up if we have to go out and are
- Feeling sick;
- Medically vulnerable;
- Just concerned (or want to keep our noses warm in the winter or not sunburned in the summer :-) ... cycling around NYC I use a mask for those reasons)
Masking in this way would prevent many hospitalizations from influenza and other viruses, as would washing or sanitizing our hands more often. - 4.Tests. Which we can use if feeling sick or before gathering when Covid is spreading.
- 5.Ventilation and filtration. Used correctly, ventilation and filtration can provide an important added layer of protection.
- 6.Better genomic surveillance. We're more likely to have an early warning if a nightmare scenario from this or another virus emerges. We're less vulnerable to a microbial sneak attack.
We have the opportunity to make the world much safer from health threats, including through commitment to find, report, and stop outbreaks promptly:
7-1-7: A Global Goal for Early Detection & Response - Prevent Epidemics
Prevent Epidemics
The 7-1-7 goal can improve Global Health Protection as 90-90-90 is improving HIV care, treatment and control
And we have growing commitment to strengthen WHO as a core anchor of our global health architecture and provide substantial resources to the Global Fund to support country improvements in preparedness:
Opinion: Why the Global Fund must take on pandemic preparedness
Devex
The Global Fund, as part of the global health architecture, could be a game changer improving preparedness
Far, far too many lives have been lost to Covid, and it's not over yet. But we can learn the lessons from the past two years and work together to create a safer world where, instead of adding to fear of contagion, the connections among us strengthen our health, our economy, and our common community.
ovid has changed the world as we know it, and virulent variants such as Delta have upended early hopes of a clearer-cut “back to normal.” Unfortunately, achieving herd immunity may now be an impossible dream, but we can limit death and disruption as we get to a new normal.
Although the Delta-fueled wave in the United States is receding, Covid continues to spread globally and in many unvaccinated parts of the U.S. The reality is that many places around the world will continue to struggle with clusters and outbreaks until vaccine production is ramped up substantially. Until we can vaccinate the world, it’s up to us to deploy simple protection measures to control spread. I recently wrote in the Wall Street Journal about how we need to maximize control of Covid while minimizing its harm to our societies and economies.
The good news, at least in the U.S., is that just over 186 million — 76% of those eligible — are now fully vaccinated against SARS-CoV-2. This means that most of us have more freedom to do things that we used to do. But the truth is that the “new normal” will be different. This includes the way that we socialize and travel, the precautions we take, and how we move in public settings.
I’ve tried to address some of the most common questions about what the next few months and years may look like. One caveat: no one knows with certainty what will happen with Covid, and with our response to it. It’s conceivable that the virus could become less deadly and the pandemic could fizzle globally. It’s also conceivable that vaccine-escape variants could emerge and spread, setting the global fight back a year or more. Some questions can be answered, at least as of what we know in mid-October 2021, so here goes.
Should I get a booster shot?
Boosters are likely to benefit those for whom they’re recommended, including those at higher risk for severe disease such as the immunocompromised and elderly. We still don’t know if the Delta variant causes more severe disease, or whether immunity wanes significantly enough over time to warrant a third dose. Only time will tell if a third dose will be part of the full vaccine regimen for the entire population.
But it’s important to note — the reason we continue to see so many hospitalizations and deaths is that there are still nearly 70 million people in the U.S. who haven’t yet started their vaccination series.
The issue of booster doses also raises questions of vaccine equity. In many countries including the U.S., people will get their third doses long before healthcare workers and at-risk populations in Africa and elsewhere are able to receive their first. It’s another reason we need to ramp up production and distribution globally, and fast.
Do I still need to wear a mask, and for how much longer?
I previously wrote a Medium piece on masking. In short, there are three factors to consider about masking: who you are, where you are, and what you’re doing. Much as we may dislike it, continued masking is important for certain people and in certain situations. Those who are at higher risk for severe disease or live with those who are at higher risk, live in an area with high spread, or are taking part in a risky activity should consider masking up to protect themselves and those around them.
Consider upgrading to an N95 or KN95 mask, especially if you’re at high risk of severe Covid disease, are around someone who is, or around a lot of unvaccinated people. Not all masks are created equal, nor do they protect against Covid equally.
It’s likely that masking will be with us for the long run for certain situations. This doesn’t have to be a bad thing. Masking helps control the spread of other infectious diseases, including the seasonal flu which kills tens of thousands each year. Wearing a mask doesn’t just have to be a pandemic practice — it could become a social norm, as it is now in parts of Asia, that helps control the spread of various diseases and keeps us all healthier.
When will it be safe to resume normal activities such as taking public transit, or going to restaurants and the gym?
The truth is that every action we take has risks associated with it. Even something as basic as drinking a glass of water can present a risk. Some activities are riskier than others.
If you’re fully vaccinated, there’s a lot you can do safely now, with a few exceptions. Ultimately, it comes down to the levels of spread in your community and the risk to yourself and those you live with.
If you are vaccinated and need to take the subway to get to work, there’s a risk — we don’t know how high a risk — of infection. You’ll be safer and can minimize the risk by wearing a higher-grade mask such as an N95/KN95. But if you live in an area where there is a high incidence of Covid, you could well get infected if you go into a crowded gym or restaurant.
The best way to feel confident about resuming normal activities is to get vaccinated. Even with breakthrough infections, those who are vaccinated have much less severe illness. To minimize risks and be on the safer side, consider employing additional layers of protection, such as ventilation, masking, and distancing.
Is gathering for family events and holidays like Thanksgiving going to be safe?
Risks associated with gatherings such as Thanksgiving have to do with how likely participants are to have been infected, how vulnerable people are, and what they are doing. The CDC has provided recommendations on what we can all do to make Thanksgiving safer. Just as with any activity, the best way to minimize risk is to make sure that you and those around you are vaccinated, then take extra precautions to reduce further possibility of infection.
Wearing masks when not eating (including N95/KN95 masks for anyone older, vulnerable, or simply worried), opening windows to increase ventilation, and limiting exposures in the days before any gathering can reduce the risk that Covid is an uninvited guest to your Thanksgiving get-together.
The Biden Administration recently announced it would spend $1 billion to increase the supply of at-home rapid tests. Encouraging anyone who’s had a lot of potential exposure (such as college kids, those who work in high-risk settings, or people who have recently travelled) to test beforehand will act as another tool in our arsenal to minimize risk.
It’s really about risks and benefits — and we have the tools to decrease the risks.
What’s next? How long will the pandemic continue?
The honest answer to this question is: no one knows.
One likely scenario is that we continue to see flare-ups and outbreaks, especially in places with high-risk populations such as nursing homes, prisons, homeless shelters, and camps. But with vaccines and, to a much lesser degree, therapeutic treatments, the virus will be tamed and won’t cause nearly the death and destruction it causes now.
A better scenario would be much lower transmission; worse would be a new variant that evades immunity. In any case, there are important layered protection measures on top of vaccination — including masking, testing, ventilation, and distancing — that we can take. People with compromised immune systems may want to be even more rigorous about taking these precautions.
Unfortunately, Covid is likely here to stay. What doesn’t need to be here to stay are the restrictions and the fear we’ve been living with. By adapting our individual and societal behaviors, we can protect ourselves and our communities and advance into a vaccinated, safer new normal.
Even as the United States moves closer to resuming life as usual, the end of the pandemic is far away for the rest of the world. Vaccines won’t crush the global curve in the short term, but protective measures work, as I discuss in a new op-ed for CNN. Globally, effective action can save more than a million lives in the coming year.
India’s explosive outbreak of Covid is a reminder that most of the world still faces ongoing and increasing risks of the pandemic, driven by variants that are more contagious and likely also deadlier. While some Americans are getting ready to go to the movies, body bags are stacking up in other parts of the world where vaccines aren’t available.
Vaccines won’t do much to stop uncontrolled spread in the short term. We don’t have enough of them, our vaccine infrastructure can’t be relied on to produce enough vaccines for the world, vaccines take months to roll out, and vaccine-induced immunity takes weeks to months to develop. So, in the short term, places such as India and Brazil can save the most lives by improving masking and distancing, and reducing travel.
mRNA vaccines are our insurance policy against variants, the possible need for boosters, and production delays with other vaccines, but current capacity is nowhere close to where we need it to be. Immunity from vaccines is at best months or years away.
We need to transfer vaccine technology and ramp up manufacturing now.
Right now, these are six key steps we must take to deal with outbreaks:
1. Protect health care and health care workers
2. Mask up
3. Maintain distancing to avoid superspreading
4. Continue essential services, including school
5. Vaccinate, especially health care workers and older people
6. Learn and adapt
The situation in India shows the urgent need to keep variants at bay through swift and strategic action. Global cooperation is essential if we are to win our war against Covid. It’s possible to beat this virus.
Look at it this way – this week, we learned that our vaccine safety monitoring system works. Reports that a small number of people developed a rare form of blood clot after receiving the Johnson & Johnson vaccine led to quick investigation, quick action, and transparency about what is known, not known, and what our next steps should be. Vaccines remain our way out of the pandemic.
Global collaboration has been critical throughout the pandemic. Public health and medical experts around the world are collaborating to determine whether events associated with AstraZeneca vaccine are the same as those which may be associated with the J&J vaccine.
The pandemic is the world’s most important problem, making technology transfer for vaccines increasingly crucial. Right now, mRNA vaccine technology is our best solution. We need to create high-quality manufacturing platforms around the world to improve vaccine access. mRNA technology is an insurance policy against the pandemic.
mRNA vaccines are easier to tweak for vaccine-escape variants, less subject to production delays, and easier and quicker to bring to scale. They may be more effective against infection, and may be safer also. ALL licensed vaccines are safe and effective, but mRNA is the most promising technology.
We also need more efforts like Moderna’s to study vaccine thermostability at non-freezing temperatures and other efforts that may help get mRNA vaccines to places and communities that are harder to reach.
Vaccines are one of the most important public health interventions ever, having saved at least a billion lives. As with any medical intervention, there may be a small risk. The story of vaccines against rotavirus, which causes deadly diarrheal disease in young children, is instructive.
In 1999, the RotaShield vaccine was withdrawn from the US market because of a rare, serious complication. Other countries followed suit. This decision led to literally millions of preventable child deaths around the world until a new vaccine was developed 7 years later.
There’s still a low risk of serious complications associated with the newer rotavirus vaccines, but benefits of vaccination FAR outweigh the risks. Thus the US and around the world continue vaccinating children against rotavirus, looking carefully for possible complications, and saving millions of lives.
Even as rare but serious events possibly associated with the J&J vaccine continue to be investigated, the pandemic is continuing – and accelerating in much of the world. About 1 in 200 people with Covid die from it. There have so far been 6 reports of blood clots developing in the brain among almost 7 million people who received the J&J vaccine. There are no known reports of such events associated so far with the Pfizer or Moderna vaccines.
Analysis of risks and benefits guides recommendations for vaccines, including against Covid. This can be uncomfortable. We weigh “sins of commission” more heavily than “sins of omission.” But if every vaccine helps many thousands more people than it may harm, isn’t this the way to go?
Globally, until there is much more widespread availability of mRNA vaccines, benefits of use of the vectored vaccines will far outweigh risks in all communities in which Covid is spreading and for all populations at high risk of complications of Covid.
The more people who are vaccinated with available vaccines, the lower the case rates, the more lives saved, and the sooner we will get to the new normal. I still think we’re likely to crush the curve of infections by summer and be in the new normal in the fall in the US.
We must balance the immense risks posed by Covid with extremely low risks of getting vaccinated. Fundamentally, the case for scaling up mRNA vaccine platforms globally just got even stronger than when we advocated for this 6 weeks ago.
Scaling up production of mRNA vaccines won’t be simple. Life rarely is. Technological transfer of the most promising vaccine technology against Covid isn’t just the right thing to do altruistically, it’s essential to the health and safety of every person, everywhere in the world.
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The US vaccination campaign is facing a fundamental challenge: getting the vaccine where it’s needed most. Millions of Americans are still unprotected, many of them at high risk of severe illness. Our 4th surge is beginning. Lives are at stake.
As reported by @CDCgov in its Covid Data Tracker, 1 in 3 people in the US have received at least one dose of vaccine—but that means 2 in 3 haven’t. Millions of people age 50-64 and 65+ who haven’t yet been vaccinated can still get Covid and are at much higher risk of severe illness or death, especially with rapidly increasing spread of new variants.
There are still 12 million people age 65 and older who remain unvaccinated. Nearly half of those between 50 and 64 have been vaccinated, but that leaves 34 million in that group who haven’t been. Those not yet vaccinated are disproportionately Black and Latinx. We must do better.
The most prevalent strain of Covid in the US now is B117. This variant is more contagious and likely more deadly. How bad the 4th surge gets depends more on us than on the virus. New variant, but the same response is needed: vaccinate, mask, distance. Patience, discipline, solidarity.
In the coming weeks, we need to shift our strategy. It’s not enough for everyone to be eligible for vaccination, we have to make sure that people actually get vaccinated. That means reaching people at the highest risk of severe illness and death, and in the places with the most spread.
If we optimize vaccine distribution we can save the most lives. I explained last week how a single well-targeted vaccination could save 10 times more lives, and prevent 100 times more cases, than vaccinating a low-risk person in a low-risk community.
The number needed to vaccinate (NNV) to save one life shows impact of vaccines in high- vs. low-risk groups. Vaccinating anyone helps, but for the next 1-2 months, focusing on the highest-risk populations can save many more lives. We need to aim our shots better.
There have now been about 560,000 Covid deaths in the US: that’s 1 of 586 Americans. To prevent one death we need to vaccinate 586 people a year. Vaccinating 100 million people will save more than 170,000 lives from Covid this year (many more when secondary cases prevented are included in the calculation).
This is even more dramatic when we look at nursing homes. Roughly 220,000 nursing home residents have died from Covid. To prevent one death, we need to vaccinate around 7 nursing home residents, so vaccinating 1 million in this population alone will save 140,000 lives. Pretty amazing!
But focusing on age alone isn’t enough—we also have to improve vaccine equity by race and ethnicity. @KFF data shows a consistent pattern: Black and Hispanic people are less likely to be vaccinated even though they’re more likely to get Covid and die from it.
A preprint study showed we can save many more lives if we prioritize high-risk areas rather than focusing solely on age.
Right now, Michigan is being hit hard. Other states may follow. As hotspots emerge, we should flood the zone with vaccines. We also need to continue to mask up and take other measures, such as closing bars and limiting indoor dining at restaurants until vaccine coverage increases or cases decrease.
There’s a lot more we can do to improve equity and overcome vaccine hesitancy. Make it easy to get vaccinated. Convenience overcomes reluctance. Instead of requiring appointments, let people walk in—especially those at high risk of severe illness and who demonstrated that they live in places with extensive spread. Offer extended hours, allow time off from work, and provide transportation to vaccination sites. Make vaccines widely available at doctors’ offices. Provide translation and call centers.
Reach people where they are. That means getting creative with mobile and non-traditional vaccination sites such as churches, schools, corner stores, bars, and pop-ups at community events. Use the right messages and the right messengers. Partner with community organizations and leaders.
Ask your friends, family, and neighbors if they've been vaccinated. If they haven’t been, ask if you can help them sign up, drive them to a vaccine clinic, or otherwise support them to get vaccinated. Listen to them and acknowledge their concerns, address these concerns with facts, and tell real stories of real people who have been harmed by Covid and those who are now protected by the vaccine.
We must do better with focused, rapid vaccination in the US. And we must recognize that global vaccine equity is an urgent crisis. Increasing manufacturing is the only way forward. As long as the virus is still among us, it’s a threat to all of us.
There’s lots of good news to report on vaccines, but the virus and variants are gaining ground. Variants are spreading rapidly in the US, driving (along with premature opening) the fourth surge that’s now underway. Here, I’ll explain why equity is not just about fairness, but essential for pandemic control.
I had planned to stop these weekly analyses, but couldn’t help sharing thoughts on this week’s developments – there have been so many.
The feared fourth surge is building. CDC reports in its Covid Data Tracker Weekly that cases are up more than 8% nationally over the past week, and test positivity rates have risen slightly, to 5.1%. The situation in Michigan, which now has the highest rate of new cases of any state over the past seven days, is getting worse – and other states are at high risk of following this trend.
The news on vaccines just keeps getting better. A CDC study of mRNA vaccines published in this week’s MMWR found that both the Pfizer and Moderna vaccines blocked 90% of infections. Vaccinated people won’t spread much disease. This has HUGE implications for developing guidance for fully vaccinated people and altering the trajectory of the pandemic.
Pfizer released new data from clinical trials showing that their vaccine protects for at least 6 months. Protection will likely be longer – so far we only have 6 months of data – and only time will tell how long. Studies have also found that these vaccines work well against at least some variants, and are highly effective against the B.1.351 variant first identified in South Africa.
Now we have to get vaccines into arms around the world. Transfer of mRNA technology is key, because this technology can be tweaked for variants and is less susceptible to production problems. A biological vaccine process made into a chemical, more predictable one.
There’s no question that the vaccines are working. Look at the striking impact protecting the elderly in Michigan. Vaccines rock… but, we’re failing to get them to where they are most needed.
Israel is crushing the curve with vaccines. But more places need more vaccine – and quickly – especially Brazil and other places that are being hit hard.
Despite glitches (see: J&J/Emergent’s 15 million botched doses), supply keeps increasing. The US is vaccinating more than 2.5 million people a day now. BUT: the quality of vaccination – getting vaccines to those at highest risk – is important, and probably more important right now than quantity. See why below.
Vaccine reluctance keeps decreasing. And more availability and more convenience will overcome much of the remaining reluctance. A new survey from Kaiser Family Foundation shows that the “wait and sees” are deciding to get vaccinated – but that the proportion of “reluctants” is holding steady.
The news on variants is mixed, but mostly bad. On a positive note, Israel’s success shows that these vaccines beat these variants. But many new variants are spreading rapidly in the US.
Deaths aren’t falling nationally as rapidly as I had anticipated they would – likely because the variants are not only more transmissible but also more lethal. @EricTopol summarized the data on variant lethality well.
Some think SARS-CoV-2 may be running out of genetic tricks and won’t be able to evade vaccine-induced immunity, and I hope they’re right, but hope is not a plan. We have to anticipate the possibility of vaccine escape mutants and reduce uncontrolled spread wherever it occurs.
Now the most important point of this article and the reason I wrote it this week after planning not to write one. Equity, equity, equity. This is not just about what’s right ethically, but what’s essential for pandemic control in both the near- and long-term. Uncontrolled spread anywhere is a risk everywhere in the long-term because of the possibility that even more dangerous variants will emerge. But that’s not the only problem with the current unequal distribution of vaccine.
If we just chase the number vaccinated, we miss the point. Equitable vaccine distribution will lead to maximum impact from vaccines – for fairness, to reduce deaths, to reduce cases, and to reduce risk of emergence of even more dangerous variants.
100 million people in the US have received at least one dose of vaccine. But about 50 million people over age 50 (~37M age 50-64 and ~13M age 60+) haven't been vaccinated at all. Vaccinating these people, who are disproportionately Black and Latinx, will prevent many more deaths than vaccinating young people.
Think of it this way. Targeting vaccinations to people at highest medical risk – who are 10 to 100 times more likely to die if they get infected – is 10 to 100 times more likely to save a life. We'd have to vaccinate 10 million people at low medical risk to save as many lives as vaccinating 100,000 to 1 million people at high medical risk.
And targeting vaccinations to the communities at highest risk for spread is MUCH more likely to prevent cases than targeting vaccinations where there is low risk of spread. In some low-risk communities, 0.6% of the population may be infected each month, while in high-risk communities, it may be 6%. With a vaccine that offers 90% protection, if we vaccinate 1M people in low-risk communities, 5,400 cases would be prevented. In contrast, If we vaccinate 1M in high-risk communities, this would prevent 54,000 cases – 10 times as many. This difference will compound in future generations of spread, so the actual impact could be 40 times to even 100 times larger.
In other words, a single well-targeted vaccination could save 10 times more lives, and prevent 100 times more cases, than vaccinating a low-risk person in a low-risk community. This is the essential fact we must act on. Equity isn’t only good ethics. It’s essential for epidemic control.
“The availability of good medical care tends to vary inversely with the need for it in the population served.”
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As predicted, a 4th surge of Covid appears to be beginning in the US, fueled by spread of variants and by premature reopening. As CDC reports in its Covid Data Tracker, cases are up 7% nationally, and the test positivity rate is also inching up, now at 4.7%. Because the pace of vaccination has been accelerating, my prediction is that despite a 4th surge, deaths won't increase substantially. But we must solve systemic issues of vaccine inequity, both in the United States and globally.
One particularly concerning trend is in Michigan. Hospitalizations in Michigan are increasing rapidly, especially among 40-49 year olds. There is a 30% increase in cases at middle and high schools associated with new outbreaks, in tandem with increased community transmission. Fewer people are staying home, a rate that is now similar to pre-pandemic levels. Is this a harbinger of spring surges elsewhere?
Vaccinations are continuing at a high rate: 2-2.5 million per day. That’s about 1% of eligible Americans every day – the challenge isn’t to increase much more but to keep up that pace to meet the new goal of 200 million doses of vaccine administered by the beginning of May. And, even more importantly, to improve targeting. Expanding eligibility helps. Increasing availability of the J&J vaccine helps. And communication about expanded eligibility, how to schedule appointments, and where to get vaccinated helps.
It’s essential that we fix the horrific inequities in vaccine administration. Scarcity is the enemy of equity. North Carolina and Chicago have succeeded in providing vaccination that is roughly equivalent to the population breakdown, but nearly everywhere else – at least where I’ve seen the data – is only reaching Black and Latinx people at about half the rate of White people (Asian and Native American/American Indian access is variable, depending on the population – see re Navajo Nation below as one example).
This is even worse than it sounds, because Black and Latinx people are much more likely to get Covid and to die from it. In effect, other than the long-term care program (see below), we are aiming our shots in a way that doesn’t do nearly as much good as it could..
It’s not enough to be concerned about equity, and it’s not enough to have programs that attempt to address it. We must succeed. Vaccinating specifically in hard-hit communities, with J&J vaccine in addition to Moderna and Pfizer, is one important approach that needs to be scaled up, and fast.
Vaccines are saving lives already, and will save even more in the coming months. As I estimated last week, at least 40,000 more people would have died in US nursing homes and elsewhere since the beginning of 2021 without vaccines. Credit where credit due: the Long-Term Care vaccine program is a big success!
And as reported in NEJM, there was a marked decline in SARS-CoV-2 infections among health care workers at a medical center in Jerusalem after a vaccination program was initiated there. Another example of vaccinations working!
1. Equity. Black and Latinx people are still about twice as likely to be killed by Covid but only half as likely to be vaccinated. We mocked up a data visualization (DATA NOTE REAL!) to show how metrics could be reported. Every place should publish something like this to track their progress as they implement programs to fix inequities.
2. Doctors. Covid vaccination should be available in just about every doctor’s office, in addition to pharmacies and community vaccination sites. Many people who are reluctant to get vaccinated elsewhere will get vaccinated by their doctor. We need all hands on deck to end the pandemic.
3. Convenience. Polls show that many people who want to be vaccinated haven’t been able to get vaccinated. Variability among states – and even within states – is big. Particularly as the J&J vaccine becomes more available, 1-shot vaccination at malls and other sites will be important. Convenience trumps reluctance.
First: How strong and long-lasting is vaccine-induced immunity? It looks very strong, but duration will take time to determine. And there will undoubtedly be some vaccine failures – people who get sick after being fully vaccinated. Such failures have been amazingly rare so far, and, when they have occurred, illness has been mild.
Second: Will variants evade vaccine protection?
We need to continue reducing uncontrolled spread wherever it occurs, for ethical as well as epidemiologic reasons. The risk of dangerous variants is proportional to the amount of uncontrolled spread.
We also need to look closely at the data about the AstraZeneca vaccine and possible increased risk of blood clots. No vaccine is 100% effective or 100% safe, and some people will experience adverse events after vaccination. The challenge will be to determine if those events are caused by the vaccine, or are just coincidence.
As reported in BMJ, after 20 million doses of the AZ vaccine have been administered, less than 40 blood clot cases have been reported. Is there a link? Maybe, but even if so, it is not strong – and the benefits of vaccination still far outweigh risks. We need to resist drawing causal links where none may exist.
We’ll find out about vaccine failure when there are breakthrough cases, and about very rare adverse effects, if there are any, when many millions of people are vaccinated. So far, the vaccines are astonishingly safe and effective.
One great success story about the effectiveness of vaccines and a public health approach: the Navajo Nation has crushed the curve. Their impressive vaccination campaign has resulted in 57% receiving at least 1 dose (compared to 26% of the US population). They also maintained a mask mandate and continue to provide free masks and hand sanitizer and discourage travel. The result: cases and deaths have gone down to zero.
Global vaccine inequity is horrific. There is simply no ethical justification for healthy young people in any country getting the vaccine before seniors or health workers in any place where the virus is spreading. We must rapidly increase vaccine production and distribution to all countries, regardless of income level.
Although the vectored vaccines are less expensive, easier to store, and are single-dose, mRNA technology has a lower risk of missing production targets, is more adaptable to variants, and faster to scale. Basically, mRNA technology is as close as an insurance policy as we can have against production delays and variant vaccine escape. But we must scale up production of vaccines that are proven, with publicly available data, to be safe and effective.
Vaccine nationalism is ethically inexcusable but politically inevitable. Inevitable unless, of course, you’re Norway. Again showing moral and financial global leadership. Norway played a critical role in the development of many global health initiatives, and may well help create a better global system of solidarity and safety.
Cases are increasing again in many countries. Brazil, Kenya, Ethiopia, Poland, and the Philippines are just some of the countries struggling to control transmission and treat patients. We need control measures and vaccines quickly, for everyone. Until all are safe, we are all at risk.
The MMWR reports important new data on the mental health harms of the pandemic in the US, with at least 12 million more Americans struggling. There have been large increases reported in depression and anxiety, especially among young people and those with lower levels of education. Availability of treatment hasn’t kept up.
It’s very unlikely that SARS-CoV-2 was created in a lab. The genetic information strongly suggests that the virus evolved naturally. Is unintentional lab release a possibility? Yes, as the review commission has noted. In many ways, what happened doesn’t change what we need to do going forward. Whatever happened, we need better global lab safety and security.
The last smallpox case in the world was from a lab error in the UK. A flu strain accidentally released in the former Soviet Union in the 1970s may have spread around the world. Let’s work together globally to make laboratories safer and reduce the risk of future health threats.
First, what will humans do. Will we lose motivation to continue our fight against the virus as vaccines roll out? Will we fail to maintain patience, discipline, and solidarity?
Second, what will the virus do. Will variants evade the vaccine?
The future isn’t certain, but it’s certain our actions can make it safer.
After 14 months writing weekly on developments in Covid epidemiology every Friday night, I’m stopping. I may launch a weekly analysis including Covid to other public health issues. Remember, the right answer to epidemiologic questions is often: It depends. Life is complex, wonderful, and evolving. Thank you for reading!
It’s been said the only thing certain in life is death and taxes. To that, we must add the threat of future pandemics.
Covid is far from over, and the next pandemic could start any time. We must be better prepared, healthier, and more coordinated globally. Our public health and primary care systems need long-term investment.
Microbes outnumber us. If we work together, we can outsmart them.
“Encountering apathy, ignorance, and avarice is the lot of all conscientious health officers. As preventive measures in the health area are more successful, the public is less inclined to support the programs which ensure this success.”
Vaccinations have already saved 40,000+ lives in the US, and the pace keeps increasing. But explosive spread of variants in Brazil and lower interest in vaccination are ominous portents.
A 4th surge is likely in the US, but most likely a less deadly one than before.
First, the epidemiology. Cases are trending down, but have stopped decreasing in many places, and are increasing in some areas. New cases are plateauing nationally at about 50,000 per day, as reported by the CDC Covid Data Tracker (shown below), as are test positivity rates, with a concerning trend of PCR test positivity increasing slightly to 4.3% last week. Vaccinations are preventing deaths
The faster decline in deaths is striking and undoubtedly due to vaccination. Look how steep the decline in the red line is in the graph below. Because vaccination rates in people over 65 are so high, especially those in nursing homes, the lethality of the virus is decreasing – and that’s a result of vaccination.
We estimate that vaccines have likely saved at least 40,000 lives in the U.S. Here’s a simple way to calculate that. Previously, about 40% of reported Covid deaths were among nursing home residents vs. about 19% of the roughly 200,000 deaths in 2021 so far. If nursing home residents still accounted for 40% of Covid deaths, 40,000 more people would have died since January. That may be a slight overestimate for nursing homes, but when you other vaccinated people whose lives the vaccine has saved, the number would be much larger.
Will we have a 4th surge? I think so, but it won’t be as huge and not nearly as deadly as past surges, because so many of the most vulnerable people have now been vaccinated. The more we mask up and distance, the less we travel, and the faster we vaccinate, the fewer cases, hospitalizations, and deaths there will be.
Although winding down, the Covid Tracking Project is still providing important information. The trends in Michigan are concerning – with cases and hospitalizations increasing.
Cases are increasing in parts of Europe, often despite masks and distancing, following vacation travel. Travel is an accelerator of viral transmission. Traveling over spring break – while the virus isn’t taking a break – is not a good idea.
As reported in @CDCMMWR, there has been surprisingly high second-dose vaccine completion – largely among the long-term care population and health care workers. We should expect this proportion to decrease as more groups get vaccinated. The single-dose J&J vaccine will be a big help in many settings (shopping center vaccination, anyone?).
You shouldn’t have to live in the right place or know the right people to access vaccines. @NYTimes highlights inequities in vaccine distribution; 43 countries, nearly all of them high-income, are on track to vaccinate all or most of their populations in 2021, but 148 are not. Ramping up mRNA production is a promising approach to getting more shots on arms.
In the US, it will be increasingly difficult to keep up the pace of vaccination. Many of the most eager got vaccinated right away. Next will be the willing, then the reluctant, and finally the late converts. For each area and demographic, the key will be to listen and address concerns with right messages – and the right messengers. Last week I participated in a fascinating focus group on this. Guess what Trump voters wanted to hear most? Being respected and listened to and having their factual questions answered honestly and forthrightly. Exactly what every group deserves and needs.
Brazil presents a cautionary tale. Uncontrolled spread and slow vaccination rollout led to a huge wave, even though there had already been a devastating earlier wave. It seems likely that the P1 variant can reinfect people, although evidence for this is still emerging.
The B117 variant is spreading throughout the US, and may be associated with higher risk of death. Growing evidence suggests that available vaccines protect against this variant, according to a preprint article by Oxford University researchers, but the bigger problem is the possibility of newer variants. Immunity after infection isn’t perfect, and immunity after vaccination may be able to be overwhelmed by variants that haven’t yet emerged.
Those who have had COVID-19 should still be vaccinated! An interesting study from Denmark published online by @TheLancet suggests that previous infection provides 80% protection against reinfection, but that protection among those age 65 and older was only 47%.
More people getting vaccinated means that selective pressure on the virus will increase, and if strains emerge that can evade this immunity, these strains can spread. We don’t know if this will happen, but we know it’s a risk, and we know that we can reduce that risk by reducing uncontrolled spread wherever it occurs and increasing the pace of vaccination.
The virus is a wily enemy, and @HelenBranswell highlights an investigation published in @CDC_EIDjournal that demonstrates just how contagious it can be. If we let our guard down too early, Covid will take advantage.
With protections in place, especially masks, we can begin to do more as vaccination makes the virus less lethal – and adjusting our response if cases start to rise. The virus has had a major impact on many facets of our lives, from schools to jobs, and recovery will take a while.
In some places, the pandemic's impact hahttps://app.gitbook.com/@simpledotorg/s/tf-articles/~/drafts/-MWKrBmuVOAxArHGUg7b/tom-frieden-blog#variants-are-the-wild-cards been as harmful as Covid itself. Data from 19 @_AfricanUnion Member States, reported by the Partnership for Evidence-Based Response to COVID-19 (PERC), shows the extent that the pandemic has driven food insecurity and disruptions to health services. We must increase equitable access to vaccines.
A new report from @StopTB shows that Covid set us back years in TB control. As many as a million patients may have been missed as a result of the lack of access to health facilities. Each one can potentially infect other people. This is a truly devastating setback.
As reported in @Nature, this timeline of progress from the past year is remarkable. Scientists across the globe made rapid progress against the most disruptive health threat of the past century – but there is so much more we need to learn!
“We ignore public understanding of science at our peril.”
— Eugenie Clark
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The U.S. has now hit two milestones in the Covid pandemic: 100 million total Covid infections in the US (most of them undiagnosed), and as reported by the CDC, 100 million vaccine doses administered.
In the race of vaccination vs. variants, we're gaining on the virus. It’s slow progress that we hope to accelerate as more people get vaccinated. But nobody should declare victory in the third quarter. Safer doesn't mean safe.
@CDCgov reports encouraging progress in its weekly Covid summary and website, both of which continue to get better:
- 11% decrease in cases this week;
- Test positivity rate is down by 11%, to an encouragingly low 4.1%;
- Vaccinations up to 2.2 million per day, an 8% increase over the prior week;
- 65 million people have received at least one vaccine dose and 35 million are fully vaccinated;
- Deaths are down 19% – this decrease is faster than the case decrease, and represents thousands of lives saved by vaccination.
But better doesn’t mean good. Rates are lower, but they’re still still very high:
- More than 50,000 new cases a day;
- Nearly 5,000 hospitalizations last week;
- More than 1,400 deaths a day.
Right now we’re in a race between vaccination and variants. Which of them wins will determine whether there’s a 4th surge. Variants are spreading, and may now be responsible for more than half of NYC Covid cases and a growing proportion elsewhere.
Think of the most concerning variants as the “B1 bombers”: the B.1.1.7 variant, first identified in the UK, which is more infectious and likely more deadly, and which is doubling in the US every 10 days; the B.1.351 variant, which emerged in South Africa and reduces the effectiveness of some vaccines; and the B.1.526 variant, which is spreading rapidly in NYC. All of these variants increase the risk that the virus will overcome immunity from natural infection.
Fortunately, per @NEJM: The Pfizer-BioNTech vaccine appears to overcome the P.1 variant first identified in Brazil, another of the more concerning variants. But that’s no guarantee new variants won’t escape vaccine-induced immunity. The more the virus spreads, the greater the risk.
Will there be a 4th surge in the US? Those who answered this (admittedly unscientific) poll are optimistic there won’t be.
How well variants do depends partly on the virus, but mostly depends on us. That’s why it’s critical that we continue to wear masks, maintain distancing, and vaccinate quickly. It’s a mistake to lift mask mandates while the virus is still spreading at dangerous levels throughout most of the country.
And, as reported in BMJ this week, the variants may well be more deadly. Now that we can see that there may be an end in sight, we don’t want to let down our guard too soon. The pandemic isn’t over. Not in the US, and certainly not globally.
People who have been vaccinated aren't out of the woods. We can’t assume that the vaccine has kicked in to provide sufficient protection until 2 weeks after full vaccination.
The CDC has issued guidance on what people who have been fully vaccinated can safely do – and what they should not. This guidance, with the science brief that supports it, is a good example of evidence-based recommendations. As noted in this week’s JAMA, we need to have a clear discussion of what this guidance means for people day-to-day. As more data become available and more people get vaccinated, these recommendations will evolve. That’s how science works.
No vaccine is 100% effective. And every vaccine has some rate of adverse reactions – but the risks from vaccines are much less than the risks from infection.
Scaling up vaccination requires using multiple platforms: mass vaccination sites, networks of doctors’ offices and pharmacies, pop-up locations – even mobile vaccination clinics to go door-to-door in hard-hit and hard-to-reach communities.
Soon we will go from having too few vaccines to having too few arms to put vaccines into.
We should open schools and businesses safely. However, restaurants, bars, and large indoor events are much riskier, especially in places without mask mandates. A new MMWR study shows that masks work, and that places allowing on-premises restaurant dining had higher case and death rates. No worker should be avoidably exposed to Covid, or have to plead with a customer to mask up. OSHA should act.
Approximately 1 of every 200 infections in the US results in death, and therefore, with more than 500,000 deaths, there have been more than 100 million people infected already. (The 100 million estimate is also consistent with serological studies and epidemiologic models suggesting that 25-30% of Americans have been infected.) Globally, with a younger population, there may be one death per 300 or more infections – but we also know that Covid deaths are under-reported. There may have already been a billion Covid infections globally.
Second: Think about the next generation and how they will be affected by the pandemic in the long term. This cohort was to have been dubbed Gen Alpha, but now maybe they'll be Gen C (for Covid), skipping A and B after Generations X, Y, and Z.
Third: We need to recognize the failures at local, state, national, and global levels. No institution got it right. U.S. public health systems had pre-existing conditions that increased our vulnerability. We need long-term solutions.
The Trust for America’s Health just released a good report: Ready or Not? Sadly, the verdict right now is NOT. We can change that. We need to improve emergency response, public health, and primary care. In an article in AJPH, I’ve outlined what’s needed broadly and on cardiovascular health. Even BEFORE Covid, US life expectancy was lagging behind other countries’ – more disability, more illness, earlier death.
Fourth: We must build health resilience against Covid and other health threats, including the leading preventable killers. The Biden-Harris Administration can build on success stopping Covid. Start with preventing heart attacks and strokes, which will kill nearly a million Americans this year. As we explain in an article just published in JAMA, most of those deaths can be prevented.
And fifth: Stay safe. Keep masking up. Remember the mantra: patience, discipline, solidarity. The sooner we get to the new normal, the better we will all do.
“It ain’t over ‘till it’s over.”
— Yogi Berra, Great American Philosopher (and Catcher)
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Are we finally nearing the new normal? By May we'll be much safer – but we're not there yet. Vaccine rollout continues to gain momentum, saving lives. Cases are still trending down, although the declines are slowing. But transmission is still high in most of the country, and variants could quickly derail the progress we’ve made. Hang in there!
A HUGE thank you to all who worked on the Covid Tracking Project, which wound down this week. Their final weekly metrics are reported in the graphs below – this comprehensive level of data collection and analysis has not quite been replicated by @CDCGov, but the CDC’s weekly Covid Data Tracker is getting there. The blip in case decrease last week seems to have been mostly weather-related, with cases still trending down, but we’re not out of the woods.
Bookmark this for future reference (I did): Where to find and how to use Covid data. As impressive and helpful as this effort was, I hope we never again need something like this – that the Federal government never again abdicates its responsibilities.
Look at the orange line in the graph below of new cases. I’ve drawn in a heavier black line to highlight the dip, which is most likely due to both the effects of bad winter weather throughout much of the country (less testing leads to less diagnosis) and an actual slowing in the rate of the decline. The rate of decline is slowing (note that the slope of the black line is less acute than that of the orange line). This may be because there are more exposures and increased spread of variants.
Now some REALLY good news. As I’ve predicted for the past few months, we’re seeing a rapidly decreasing case fatality ratio with an even more remarkable decrease in nursing home deaths. This is the direct impact of vaccination: It saves lives. Within a month or less, the number of deaths should decline to less than 1000 a day. This is still horribly high, but much lower than it’s been for many months.
For some perspective: Nationally, there are more than 50,000 cases diagnosed per day, or about 15 new diagnosed cases daily per 100,000 population. This translates to about 1 in 6500 people in the US diagnosed every day. (Remember, too, that only a fraction of cases are ever diagnosed, and that infected but undiagnosed people can still spread the virus.)
People are infectious for roughly 7 days (possibly 10 with some of the variants). So let’s assume that about 1 in every 1000 people is infectious at any given time. If only one in 2-3 infections is diagnosed, it’s more like 1 in 400 people. In a month, if you have contact with 100 people (and some people in frontline positions have many more than that), there’s a 1 in 4 chance of being exposed. That’s not small.
It’s still raining Covid pretty hard out there. There’s now twice as much testing than there was in September, with similar case counts, so there’s been real progress. But, as an example, there are still more than 3,000 new diagnosed cases a day in New York City, at least 10 times more than outbreak investigation and control can realistically manage. And with the increased danger posed by more infectious variants, we’ll need all the tools at our disposal to prevent yet another wave of widespread disease transmission.
By next week, we’ll hit the milestone of 100 million total infections in the United States and, possibly, as many as 1 billion globally. Stay tuned – I’ll discuss these estimates and the basis for them in my blog next week.
The more contagious P.1 variant, first identified in Brazil, is concerning. So is the increased spread in children (but with no increase in severe illness), although this doesn’t change what should be a policy priority: To open schools and keep them open with proper mitigation strategies. More infectious variants will become much more prevalent in the US, but if we’re careful, they won’t drive a 4th surge.
On vaccines, the theme of the week is MORE. More good news. More people getting vaccinated. More vaccine options. And soon, much more vaccine access. Once you’re vaccinated, there are a lot of things that you can do with relative safety. Get a haircut, see the dentist, ride the subway, hug your grandkids, take that long-delayed vacation.
But don’t assume that vaccines provide perfect protection, and continue to mask up. If you’re older, remain cautious about gatherings with people outside your immediate household. If you develop any Covid symptoms, get tested as soon as possible.
Interestingly, CDC data suggests that the vast majority of people who got the first dose of vaccine are returning to get the second dose. This is encouraging and a pleasant surprise.
Vaccines are astonishingly effective, safe, and increasingly available – at least in the US and some other wealthy countries. But persistent national and global vaccine inequities are unethical and dangerous, and the US is in a unique position to fix this problem.
There are many routes to vaccine efficacy. Some interesting data shows that vectored vaccines (J&J, AZ/Oxford, Sputnik) may provide stronger immunity after 1-2 months. How long immunity lasts from single-dose vaccines has yet to be determined. And although we have highly effective vaccines from which to choose, there is still much, much more we need to learn about them.
There’s some great new CDC data on how facemasks reduce Covid cases and deaths. Simply put: Science saves lives. Great to see CDC back in the game.
Cool it just a little bit, public health. Reopening – while still managing to avoid superspreader events – as cases fall and vaccines make Covid much less deadly may be wrong, but may be defensible. However, relaxing mask mandates is NOT defensible. The only freedom masks inhibit is freedom of the virus to spread and kill people.
After Florida repealed its motorcycle helmet law back in 2000, helmet use dropped from nearly 100% to about half. This reduction in helmet compliance was at least partially responsible for a sharp increase in motorcycle fatalities. Costs of emergency medical care for motorcyclists hospitalized with head, brain, skull injuries more than doubled, from $21 to $50 million. Mandates work. Reversing mandates reverses progress.
Covid may never go away completely, but we can minimize its dangers. What will change as we tame Covid? Less travel. Fewer meetings and conferences. More (but less than now) Zoom. We may never see birthday candles in the same way. The virus adapts. Unless we adapt, it will continue to control us. The more we adapt, the more we can control it. Masks help, and will also help control seasonal influenza. I don’t know of anyone who wants to get the flu.
“Throwing out preclearance [mask mandates] when it has worked and is continuing to work to stop discriminatory changes [infections and death] is like throwing away your umbrella in a rainstorm because you are not getting wet.”
— The Notorious RBG
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There is now steady good news about Covid in the United States. Cases, hospitalizations, and deaths continue to decrease, and the pace of vaccination is accelerating. Serious risks remain from variants, vaccine inequity, and failure to learn the lessons of Covid.
First the good news. As reported by the CDC, US cases have decreased 75% from their peak in early January, with hospitalizations and deaths following. Vaccination (after a weather-related disruption) is increasing, and much more supply is on the way — the Johnson & Johnson vaccine will add millions of doses ready to the supply. If things continue to go as planned, by June anyone in the US over age 16 who wants a vaccine should be able to get one.
As reported by The New York Times, there has already been tremendous progress driving down Covid deaths in nursing homes, which has happened more rapidly than in the US as a whole. As I’ve been predicting for the past two months, we can expect even larger reductions in deaths in March as vaccine-induced immunity kicks in. The risk of death from Covid among all those infected will fall by at least two thirds.
Will vaccination make Covid no deadlier than seasonal influenza? There are at least two major problems with that question: First, with high infectivity and moderate case fatality, Covid would at best still be like a moderately severe flu. And, flu is the Rodney Dangerfield of infectious diseases — it doesn’t get the respect it deserves.
Every year in the US, flu causes tens of thousands of deaths, hundreds of thousands of hospitalizations, and billions of dollars in health care and economic costs — much of which could be prevented. Flu vaccination works, but not very well, and not as well as Covid vaccines appear to. Masks and distancing crush the flu curve, although it’s not something we’ve regularly done in the US as in other countries. Maybe we should start.
Now, the bad news. The worst news of the past month is that data from the Novavax trial in South Africa suggests that prior infection might not prevent reinfection with the B1351 variant. But the validity of the antibody tests used in that trial is uncertain — so the jury is still out.
There’s been unnecessary controversy on variants. Attacks from all sides aren’t helping. The bottom line: Variants are DEFINITELY a risk and we also DEFINITELY don’t know how big a risk.
It’s better to be safe than sorry, but we in public health should also recognize that people (including politicians) may choose to take risks. But we hope they’re informed risks based on careful consideration of the data, community prevalence, and other factors grounded in science. Also, that we distinguish between risks we take where the risk is to ourselves and risks we take with others’ lives.
Think of it this way. It’s one thing to risk your life climbing a cliff. It’s quite another to do that when you might start an avalanche that kills people in the town below.
Why do variants spread? Sometimes they’re more fit and better able to reproduce. But sometimes it’s “stochastic” — a fancy word for happenstance. A superspreader event could be the starting point. Or it could be the founder effect. Or it might just be plain bad luck (or good luck, if you look at it from the virus’ standpoint). More common doesn’t necessarily mean more infectious or more dangerous.
First: Why are US cases dropping SO fast?
See the arrows I’ve drawn in the second graph below from the Covid Tracking Project: US cases are dropping much faster in the most recent Surge 3 than they did in Surges 1 and 2. Was this because we started from a peak that was higher, which was driven by travel and holidays that are now over, increased masking up, and rapid roll-out of rational national policy? Maybe.
Imagine you’re a virus attacking 330 million people. 100 million have natural defenses from a prior attack. 10 million more are being vaccinated each week. The places where it’s still possible to land are shrinking. The concept of ‘herd immunity’ is another false dichotomy; the steeper slope of the current decline in cases is likely, at least in part, from increasing immunity.
(For those wondering about the 100 million number: That’s a reasonable estimate of the number of people infected in the US so far. There are various ways to estimate that. It’s simplest to estimate from the number of deaths to the number of infections at an approximate ratio of 1 to 200. So 500,000 deaths translates to about 100 million infections. Not all infections will result in immunity, and we still don’t know how long immunity will last.)
But the biggest driver of the decrease is us: masking, distancing, reducing travel. The odds of our experiencing a large fourth surge are falling steadily. But please, keep up your masks, your distance, and your perspective: 2,000 deaths a day is horrifying. A 75% reduction from a huge number is still a huge number. In a few more months, if all of us keep it up, we’ll be in much better shape.
Second: Why are cases in New York City not dropping nearly as fast?
I remain puzzled about NYC, which was hit hard and fast early in the pandemic. The decline there is real, but it’s much slower than the national decline. The baseline infection rate in NYC is higher, so it can’t be because of less immunity — there’s more. Test positivity rates are trending down, but only slowly as shown in the graph below, from NYC’s excellent site (which also shows 10-fold differences in risk in different neighborhoods of the city.) Variants are one theory (and a new variant has just been identified in NYC) but at this point it’s just that — a theory. Time will tell, for better or for worse, what is happening in NYC.
After variants, the second big risk is the lack of vaccine equity, both in the US and globally. Anywhere the virus spreads, more dangerous variants have a chance to emerge and threaten health everywhere. We need to scale up control measures, including vaccination, everywhere.
The third big risk is that we fail to learn the lessons Covid has to teach us. We need new funds to improve preparedness ($5–10 billion or more a year, for at least a decade) and for strengthened primary care. WHO and other global institutions need to be stronger. There needs to be more technical collaboration, better management, and better immunization of public health from politics. In short, we need substantial changes in how we approach pandemic prevention and response.
And so much is still unknown about long-haul Covid. It takes many people a long time to improve, even from a relatively mild case of Covid. Some people have continued to suffer for many months with no end in sight. It’s important that NIH lead systematic studies so we can learn more and, more importantly, do more to help those who are struggling with persistent symptoms.
When will it be safe to go out again? This summer, the US will be much safer. Will we learn to cluster bust, stopping spread promptly even though Covid won’t be as lethal since the most vulnerable people will have been vaccinated? Will variants evade our defenses? And will we help the world stop Covid?
Answers to these three questions will determine how much normality we get back and how soon. Often in public health, the right answer to a hard question is: “It depends.” In this case, it depends on us. Can we strengthen test/trace/isolate strategies to box in the virus as its potential landing places continue to shrink? Can we scale up vaccine manufacturing and distribution for the entire world?
Last week, the US reported 2,000 deaths per day. PER DAY! For the past 3 months, as shown in the graph below, Covid has killed more people in rich countries than the leading cause of death: cardiovascular disease. At Resolve to Save Lives, CVD is a primary focus. (Link in sentence above is from an excellent website visualizing the pandemic and its inequalities.)
This past week marked exactly a year since it became clear that a pandemic was inevitable. I summarized some of our work this past year in CVD and other areas in a message to our partners. To see more about what Resolve works on and where, here’s a link.
Covid isn’t over. Right now we have no idea what the upticks below (as reported by Our World in Data) mean and whether they will persist. Again, time will tell. We need to keep our perspective. A lot better still doesn’t mean good. Covid remains rampant. Global control is essential.
“Not everything that is faced can be changed; but nothing can be changed until it is faced.”
— James Baldwin
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2-20-21
Covid cases continue to plummet, although a small part the recent decrease may be due to weather-related testing site closures. And while vaccination roll-out is going more smoothly, we must address equity much more effectively. Deaths are decreasing. Global collaboration is rising. Spring, not Covid, is increasingly in the air.
Covid decreases are steep, sustained, and nation-wide. Cases decrease first, then hospitalizations, then deaths. There are four major reasons for the decrease: less travel, less mixing of people indoors, more consistent mask wearing, and growing immunity from infections (about 30% of the US population) and vaccination (12% have received at least one dose). Herd immunity isn’t an on-off switch; increased population immunity – primarily from infection, not vaccination – is likely accelerating the decreases. The virus has less and less room to maneuver.
But herd immunity also isn’t uniform across society, and most people are still susceptible.
Better does not mean good, and safer does not mean safe. More than half of the American people are still susceptible to becoming infected, and infection rates remain quite high in many places. We’re still higher on all three metrics – cases, hospitalizations, and deaths – than we were in September and October when the current, now subsiding wave started to pick up steam. So, although the situation is much improved over the past month, we’re still not where we were at the end of summer.
Ongoing surveys by Carnegie Mellon University using the Facebook platform show that we’ve sustained our behavioral change surrounding Covid. Changes in mobility and mixing were the major drivers of both the recent increase and the current decline.
The bumps over the winter holidays boosted and accelerated viral spread, and the tide is now steadily ebbing. But continued declines are not inevitable. We have to keep up our guard, or the virus, armed with new variant tools, could come roaring back in a deadly 4th wave.
Variants continue to be THE wild card in controlling the pandemic. If mutations mean the virus is better able to evade natural or vaccine defenses, the risk of explosive spread is high. CDC’s excellent weekly Covid summary notes that we can “stop variants by stopping the spread.” The overall national test positivity rate is down to 5.9% (although it’s double that or more in some parts of the country), but last week there were, in shocking numbers that we have become too accustomed to, 7,000 new hospitalizations and 2,700 deaths every day.
Another great thread by @youyanggu points out that a doubling every 10 days of the B.1.1.7 variant as a proportion of all Covid cases doesn’t mean a doubling in total B.1.1.7 numbers. More detailed projections about the impact of this variant have been published in the MMWR. The graph below from a preprint article may explain at least some of the increased infectivity of the B.1.1.7 variant, which may be due to a longer period of infectiousness.
The B.1.1.7 variant appears to result in a longer period of infectiousness
Although vaccination has not yet had a major effect on Covid cases overall, it IS driving down nursing home deaths: the share of deaths associated with long-term care facilities has been cut in HALF since early January, from more than 30% as a proportion of all deaths from Covid to less than 20%.
With most nursing home residents and many other people over age 65 having been vaccinated, I will make a prediction: the infection fatality ratio will likely drop from the current 1 in 200 infections resulting in death to less than 1 in 600 by some time in March.
There’s a good article in @NEJM about effective communication strategies that can be used to encourage the “moveable middle” of vaccine-hesitant people to accept vaccination. But convenience overcomes reluctance – and the continued difficulty that many BIPOC individuals experience in accessing vaccines perpetuates the unjust, racist power dynamics of the US.
Let’s talk about death – uncomfortable as it is, we need to do that more. We also need to highlight the harsh inequities of Covid. There were 344,854 reported Covid deaths in the US in 2020, of which 37% occurred in the first half of the year. CDC just published a new Vital Statistics Rapid Release with data showing the projected life expectancy decreases driven by these deaths.
Americans as a whole lost a full year of expected life due to Covid, but this jumps to 1.9 years lost for Hispanic people and 2.7 years for Black people. These decreases erased many years of health progress in just a few months.
Before we do a deep dive into the numbers, let’s try to never forget that each one is an individual whose life was tragically lost earlier than it otherwise should have. A deeply moving effort by @washingtonpostattempts to provide some sense of the enormity of our losses. Please read it.
Since more than 60% of US Covid deaths took place in the second half of 2020, we can expect the actual decrease in life expectancy to be well over 2 years. The Black/White disparity may decrease slightly, but not because prevention and care improved for Black people in the US: As Covid accelerated its spread, the proportion of cases among Whites doubled.
There’s far too much missing data but the data is still stark – there are far higher rates of death among Black and Latinx people. Vaccination programs have to prioritize the hardest hit groups. Vaccine hesitancy is real, but lack of access is the driving reason for lower rates of vaccination among minority populations.
There’s new and troubling data from Zambia. Of 362 people in one study who died from any cause, 70 tested positive for Covid, but only 6 of those – less than 10% – were diagnosed before they died. How many Covid cases and deaths have we missed globally? Sometimes the dog not barking in the night is really no one listening. Improved reporting on causes of death is crucial to improve global health.
Vaccine inequity in the US is just a small microcosm of the vaccine inequity globally. The UN reports that 130 countries have yet to receive a single Covid vaccine dose.
Can we have a healthy arms race – to see which country can help other countries get the most vaccines into arms? Increased manufacturing will be essential if we are to meet our moral imperative to rapidly expand global vaccination availability.
Bill Foege notes that public health is at its best when we see, and help others see, the lives and the faces behind the numbers.
“We are only as blind as we want to be.”
— Maya Angelou
The third US COVID-19 surge is fading fast, but variants – some of which deeply ominous – are spreading fast. Vaccination is picking up steam, but we’re failing to address equity. And already high levels of pandemic fatigue are increasing. We must hang on for a few more months until most of us are vaccinated.
Rapid decline in reported cases in U.S. after massive holiday surge
The fundamental question is whether we’ll have a 4th surge. If we do, it will cost lives, and also increase the risk that more dangerous variants will spread widely.
But first, some good news: there’s been a dramatically fast decline in cases and test positivity rates – a much steeper decline than in either prior surge. You can see it in both case counts, and test positivity – and test positivity is an even more revealing measurement, so the graph below, from Johns Hopkins, is the most encouraging graph I’ve seen in months.
Rapid decline in PCR test positivity for SARS-CoV-2
The thing about wearing masks, not traveling, and minimizing time spent sharing indoor air with people who are not in our household?
They work. It’s how we can win the war against the virus. Any time we let down our defenses, it attacks. When we let down our guard (and masks), we are complicit with our viral enemy.
The spike in cases which happened in other countries when variants took hold is scary. The proportion of cases from the B.1.1.7 variant (the “UK variant”) is now doubling in a bit over a week in the US, and may soon predominate here. The first known case caused by a COVID variant has also recently been found in a prison, where transmission rates are high.
This is no time for complacency – masks and distancing stop even the more transmissible strains.
As CDC put it in their weekly summary, which debuted today: “Better, but not good enough.” (It’s great to see the CDC able to share more of the important work and analysis they’ve been doing for the past year!)
Sign up for CDC’s weekly COVID Data Tracker newsletter. Hope that CDC adds the key metric of test positivity to their data next week.
Have a look at the @NYTimes graphic below, which our team at Resolve helped to design. It details county-by-county COVID risk. We’re doing way better than we were in December – but still way worse than in September.
Better than December, much worse than September
And there are warning signs, including in NYC, where test positivity is not decreasing (as seen in the graphic below, from @NYChealthy). In the battle against Covid, a stalemate favors the virus. The next few weeks will be crucial: If we don’t maintain discipline, viral variants can cause explosive spread.
But even more ominous is preliminary data from the Novavax trial in South Africa, with data, that, if confirmed would indicate that previous infection does not protect against reinfection with the variant strain. This would be the worst news about variants yet, because, if such variants spread, this would mean that prior infection would not count toward achieving herd immunity – a big setback.
Rates of infection, which was mostly with the 501Y.V2 variant (the variant first identified in South Africa) among the placebo group (those who did not receive the vaccine) 7 days after receiving the first placebo dose were 3.9% among those who tested seronegative, but exactly the same, 3.9% for those who were seropositive. If the serology was accurate, this suggests that prior infection didn’t protect people at all. This is quite different from other trials, in which seropositive participants who received placebo had protection rates of 80% or more, and studies in health care workers in the UK suggesting strong protection. Similar to breakthrough infections after vaccination, we don’t yet know if those infected despite immunity will have less severe disease, although we hope they will.
People born with severe immune deficiencies can harbor (and spread) the polio virus for years, and there has been work to identify, treat, and cure these people of their polio infection. Viral evolution and genetic recombination in immunosuppressed people is one theory for why we are seeing rapid genetic changes resulting in these SARS-CoV-2 variants. We need to learn, and do more to limit viral evolution and spread. One approach is to develop pan-corona vaccinations; good article on this by Dennis Burton and @EricTopol.
We are picking up the pace of COVID vaccination, and now averaging 1.6 million doses given a day. Both Pfizer and Moderna have promised to roughly double deliveries of their vaccines in next few weeks to meet President Biden’s goal of being able to vaccinate 300 million Americans by the end of summer. I hope the companies are able to keep that promise.
We must do MUCH better on equity. Black and Latinx Americans have 2-3x risk of hospitalization and death but only half the likelihood of being vaccinated. These continuing disparities are not acceptable and we need a concerted effort a national level and in every state, city, and community to empower and enlist communities and community leaders. Disproportionate burden means there must be disproportionately increased resources, including to find the right messages and messengers, and to make vaccination so easy that it becomes the default value. Convenience can overcome a lot of resistance.
The current math, unfortunately, is harsh. So far 70 million vaccine doses have been sent to states to be administered. We need 364 million doses for priority groups 1a (residents of nursing homes and other long-term care facilities, as well as health care personnel) and 1b (people age 75 and older as well as frontline essential workers), and those age 65-74 along with those who have underlying high-risk medical conditions (part of group 1c). And this would leave out people age 50-64 who are high risk, including those not aware of their underlying conditions. We’re looking at 1-2 more months of vaccine scarcity, at least.
Vaccination of nursing home residents and staff are likely to drive deaths in these facilities down by mid-March; this will also reduce the overall case fatality ratio significantly, since nursing homes account for nearly 40% of all deaths. Israel’s data is encouraging. A new preprint article published earlier this week shows the comparison between the population age 0-59 years old (orange line) and age 60+ (blue line) in new cases. Vaccination saves lives, and this is real-world proof of it, confirming the remarkable efficacy data from clinical trials.
There’s good new CDC guidance on schools. Schools, especially grades K-8, should open with safety measures that emphasize consistent and correct mask wearing and maintaining proper distancing. Additional layers of COVID-19 prevention include testing whenever possible and vaccination as soon as possible. Teachers are – and should be – prioritized for being vaccinated. While we wish there was sufficient vaccine for everyone right now, including all teachers, unfortunately we don’t.
On Friday I published an article in the @WSJ (open access) on how to prevent the next pandemic. @ResolveTSLhas worked with partners on developing this strategy for the past 4 years. It’s now or never – a teachable moment like no other we’ve experienced in our lifetimes.
I suggest a global target: “7-1-7”. Every country and every community should be able to find an outbreak in 7 days, investigate and report in 1, and respond effectively in 7. Success will take money, technical skill, collaboration, and persistence. Our children’s safety depend on it.
Six steps to meet the 7-1-7 target are:
- 1.Agree on goals and how to measure them.
- 2.Build country preparation and response capacity, particularly with collaboration among lower-income countries.
- 3.Improve global institutions, with the World Health Organization as the anchor and a key role for The Global Fund.
- 4.Get money – at least an additional $5-10 billion a year to build country capacity to find, stop, and prevent health threats.
- 5.Collaborate to global response to address dangerous, life-threatening gaps in preparedness, including laboratory safety and reducing the risk of spread from animals to humans.
- 6.Act now – the urgency of this work has never been so clear, and there is no time to lose.
We need to hang in there. The pandemic won’t go on forever. We'll be in a much better situation by the fall. For now, mask up and limit time indoors with people not in your household. Vaccines are coming, and we learn more every day about Covid and how to prevent and treat it.
“No winter lasts forever; no spring skips its turn.”
Hal Borland, American author, journalist and naturalist
When day comes we step out of the shade,
aflame and unafraid,
the new dawn blooms as we free it.
For there is always light,
if only we're brave enough to see it.
If only we're brave enough to be it.
Covid variants are here, and more are coming – but so are vaccines. There’s encouraging news: cases, hospitalizations, and percent test positivity are plummeting in all ages and in all parts of the country, and deaths have begun to decline.
Now the bad news: infections are still VERY high, and higher than at the peak of prior surges. The most likely explanation for the rapid rise and even more rapid fall: travel accelerates viral spread exponentially. We’re recovering from the huge amount of ill-advised travel and indoor contact over the holidays. When people travel, the virus travels.
This is a fight against the virus, but also a fight against becoming numb to the horrifying toll. Far too many who get sick are not recovering. The 7-day average is still 3,000 deaths per day, the number of people killed on 9/11. More than 20,000 died last week. Every life is precious. Every death robs us all.
As more people receive vaccines over the next several months, we can’t afford to ease up on the brakes now! Let’s double down on protection protocols (masks, distancing, limit travel), scale up equitable vaccine delivery, and spur innovation in vaccination and control measures. We can avoid another, steeper curve.
The sooner we vaccinate and the better we tamp down spread, the lower the risk from variants. We’ve had steady – though rocky and uneven – progress with vaccination. This week, @ResolveTSL and partners the American Public Health Association, Trust for America's Health, Association of Schools and Programs of Public Health, and Center for Health Security at The Hopkins Bloomberg School of Public Health released recommendations for vaccine indicators every state should collect and publicly share to inform decision-making and provide accountability and transparency in vaccine rollout.
There are two glaring gaps in the information the federal and state governments publish: data on vaccination by race/ethnicity over time, and vaccination coverage of staff and residents in nursing homes. Not coincidentally, there are problems not just with data availability but also with the reality in both areas. These are life and death problems.
First, race/ethnicity. We need to see vaccinations by race/ethnicity over time. Unless this is made available and updated weekly, there ’s no way for us to know if we're getting better at addressing inequality or not. North Dakota is tracking vaccine coverage over time by age. We need the same data collected and reported over time on race/ethnicity, not just cumulatively.
Reports from the Kaiser Family Foundation show that data on vaccination by race/ethnicity is alarming. Ohio has a good Covid vaccination dashboard (see figures below)and, as appears to be case nationally, Black and Latinx people are getting vaccinated at about half the rate of White people, despite having 2-3x the death rate. We MUST do better.
There’s been great progress vaccinating nursing home residents, with about 80% receiving their first dose. However, the proportion of staff who have been vaccinated is under half. Because turnover of residents is high, including people moving between facilities, vaccination of people when they are admitted to nursing homes is essential and needs to be routine.
This will require implementing a model that’s different from the standard pharmacy program for Covid vaccination. Unless there’s focused attention to vaccinating new residents, this will be missed. And in the context of low staff vaccination rates, that would be a deadly mistake.
We MUST do better at reaching staff of nursing homes. Staff vaccination needs focused outreach, education, and engagement. Positive and negative incentives for staff can increase vaccine coverage. But at some point, there’s an ethical question.
A staff member who isn’t vaccinated may introduce infection that spreads throughout a facility and results in the deaths of many residents. This has been an issue with influenza vaccination for years; although there has been progress, still, only about two thirds of health care workers in nursing homes and other long-term care facilities get flu shots.
Thanks to @drgregpoland for raising the issue of health care staff vaccination for years. First must come making vaccination free, convenient, and sensitive, and addressing staff concerns. But at some point, staff choices may have lethal implications.
There’s been a tsunami of information on vaccines in the past week. The Johnson & Johnson vaccine is promising: single dose, easy to handle, 85% protection against severe illness. Every new way to fight Covid helps. We can expect approval in February and increasingly widespread availability of this vaccine starting in April.
Interesting preliminary, pre-print data suggests that a single dose of the Pfizer and Moderna mRNA vaccines may be sufficient to provide protection in previously infected people. Practically, it would be difficult to get serology data in the contact of a mass vaccination program and so only give one dose to previously infected people, but this may be relevant for individuals. Again, it’s preliminary information and we don’t know how long the protection will last.
A single dose of the AstraZeneca vaccine has been reported to result in stable immunity for at least 3 months, but the data are messy and have not yet been peer-reviewed. The UK’s decision to delay the second dose of this vaccine is reasonable in the context of explosive spread of the predominant variant in that country, but we need much more data.
An approach from Russia using two different vectors also appears to be effective. Remember that old saying: Just because you’re paranoid doesn’t mean they’re not out to get you? Well, just because the data are dodgy, doesn’t mean that the vaccine doesn’t work.
Many different vaccine approaches are still being developed. China has a wide range of vaccines under development, ranging from inactivated, to vector (like the vaccines of AstraZeneca and Johnson & Johnson), to subunit (like the Novavax vaccine). Shouldn’t mRNA be considered a global public good for the benefit of all and widely available?
Thanks to Dr. Tony Fauci for the clear summary below of the different approaches being used for vaccine development in the United States. It’s amazing scientific progress – and also luck: Immunity is robust (unlike TB, malaria, HIV), and mRNA and adenovirus vector technologies were available just-in-time.
There’s also encouraging data from Israel. Vaccination of people over age 60 leads to big reductions (dark blue line in middle and right graphs) of severe illness. Vaccine programs must cover Palestinians in Israel and in the Occupied Territories, who face elevated risks. Disparities and inequalities must be fought everywhere they exist.
So if we’re ramping up vaccination, and the proportion of people with immunity from infection (which, as another and very interesting study shows, is likely protective) is increasing steadily, what could possibly go wrong?
Variants, that’s what.
In Manaus, Brazil, the P1 variant has caused at least one reinfection. There’s not yet enough data to know if the rapid increase in cases in that city is due to reinfection among people previously infected with other strains (due to waning immunity or immune escape), increased transmissibility of this new variant, or some combination.
One line in a Novavax press release on the company’s South Africa trial reports reinfections with new variant, but provides no data. Tony Fauci provides another good summary of what we know about variants. One thing is clear: we need to pay less attention to individual variants and more to what the variants as a group are telling us.
The virus outnumbers us; we need to outsmart it. It’s in our self-interest to make sure the virus is controlled in the US and globally. With uncontrolled spread, more variants will emerge. And with increasing immunity from vaccine and natural infection, variants that evade these defenses, if they emerge, will spread. This could result in reinfections and also the spread of vaccine-escape mutant strains. Vaccines protect us. We must reduce spread to protect vaccines.
As Dr. Martin Luther King, Jr, said:
“Injustice anywhere is a threat to justice everywhere.”
Uncontrolled viral spread anywhere is a threat to viral control everywhere.
And ill health anywhere is a threat to health everywhere.
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There’s been promising news this past week. Cases in many parts of the country are decreasing, meaning there’s less spread. Hospitalizations are trending down. The Biden-Harris Administration has issued executive orders to speed action in our fight against Covid.
But there’s a long way before we can get control of the virus. In terms of vaccination, we must focus on 3 key things:
- 1.Get doses out of freezers and into arms ASAP. Vaccine does no good if it’s not given out. We need a strategy to make sure doses can be administered quickly as they become available.
- 2.Denominators: What percentage of nursing home residents and staff have been vaccinated? This is the highest risk group; vaccinating these people will sharply reduce spread in long-term care facilities and greatly reduce deaths, even if the overall number of cases in the entire population isn’t substantially reduced.
- 3.Improve equity. We need to do better at reaching Black, Latinx, Native American, and all underserved groups now. Racial and ethnic minorities experience disproportionately higher rates of hospitalizations and deaths. They also make up a disproportionately large segment of our front-line workforce – health care workers as well as store employees, delivery drivers, teachers, and everyone else who risks their health by keeping our economy and society functional.
Some encouraging data from Israel. The more quickly we vaccinate, the more quickly we reduce deaths. How fast can vaccination against COVID-19 make a difference? Two weeks after 40% of those over 60 who had been vaccinated, the number of critically ill in the age 60+ group grew by 7% compared with the previous week’s growth of over 30%. There was less of a decrease in the growth of critically ill among the 40-55 age group – who were not as widely vaccinated as those over 60. If this trend continues, hospitalizations and deaths may already be dropping.
First, let’s get clear about the epidemiology and continued trajectory of the pandemic. Better does NOT mean good!!! In this case, it just means less terrible. The peak of hospitalizations in the prior two Covid surges in the US this past spring and summer was 60,000. Now we’re at 100,000. So our lower number is nearly double what it was at any prior peak.
Thanks to @NYTimes for working with @ResolveTSL to provide better and more actionable information on Covid risk in every community. Wide swaths of the country remain at extremely high risk, with only isolated pockets of low or even medium risk. http://nyti.ms/2MglGKu
I’m horrified to see so many communities opening up right now because they see that things are getting a little “better” when risk is still very, very high – as is the risk of new, more infectious, and potentially more deadly viral variants.
That sickening feeling. Imagine a punch-drunk boxer who has been knocked down twice, staggering up again to face an opponent winding up to deliver a knockout blow. That’s us, now, planning to open again because things are “better.” If communities open now, it’s not going to end well for far too many people.
There have been a lot of scientific developments on vaccine, not all of of which are encouraging.
The Johnson & Johnson vaccine looks promising and likely to be submitted for approval to the FDA and approved soon. The J&J vaccine, a non-replicating viral vector vaccine that uses a common cold adenovirus and is designed to be given as a single dose, is about as good as a single dose of an mRNA-based vaccine.
In an @NEJM article from earlier studies, the immune response continued to build for 57 days after vaccination. Today’s results from the latest trial only show the effects 28 days after vaccination. The jury is still out on whether a second dose would be even more effective. https://bit.ly/3pJSquh
The J&J vaccine can be kept at regular refrigerator temperatures (no need for deep freeze) and is easier to make, store, ship, and give – at half the price. The company plans to manufacture a billion doses this year.
The Novavax vaccine, also soon to be rolled out, uses an engineered protein and an adjuvant, and is nearly as good as the mRNA vaccines. It’s nearly 90% effective at preventing Covid and, importantly, is effective at preventing severe cases. However, as is the case with other vaccines, it appears to be less effective (but not ineffective) against some of the newer and more transmissible strains, in particular the B.1.351 variant first identified in South Africa.
There’s a tantalizing line in the company’s press release that suggests that placebo recipients in South Africa who were seropositive at trial enrollment became infected with the new strain during the trial. SHOW US THE DATA! This is important and the world needs to know.
Data on study design, data, and effectiveness of the Astra-Zeneca vaccine are still murkier than they should be, and there are now production problems.
It’s possible that we’ll wind up with vaccines that may be relatively more and less effective. But the key is how well do they prevent people from developing illness severe enough to require hospitalization – and so far all of the vaccines seem to do that.
SARS-Cov-2 is evolving to adapt to the human context. As we develop vaccines and as more people become infected, the virus will mutate to evade our defenses. We may eventually need multivalent vaccines to fight these multiple strains. This wouldn’t be new. Vaccine protects against 3 different strains of polio, up to 9 of HPV, and up to 23 different pneumococcal strains. This could be where we’re headed with Covid vaccines, but it’s far too soon to know this for sure.
But the vaccines we have now work against strains that are circulating today. Things have gotten off to a bumpy start – this is the most complicated vaccination program in US history – but we have to get vaccines out of freezers and into people’s arms.
And we have to make sure that those who have been neglected so far – Blacks, Latinx, Native Americans, the poor, and, surprisingly, primary care doctors – are also prioritized to receive vaccines. First-come, first-served is a recipe to further exacerbate persistent inequalities.
Revealing description of the smoother roll-out in the UK, where they relied on their National Health Service and primary care doctors. Hope we’ll get the hint and strengthen primary care and make it central to our response.
We can use four platforms to get as many people vaccinated as quickly as vaccines are ready:
- 1.All health care systems
- 2.Mass vaccination clinics (there’s a great article describing how LA’s Dodger Stadium has been transformed into a high throughput vaccination center) – but it’s important not to reduce post-vaccination observation time to less than 15 minutes in case of very rare but potentially serious allergic reactions
- 3.Pharmacies (chains as well as independent pharmacies)
- 4.Pop-up, community-outreach sites set up anywhere they are needed that could be run by any of the first three.