States’ COVID strategies are taking a high stakes gamble

Recently, we argued that President Biden’s goal of small July 4 cookouts could be realized if six interim goals were achieved: increased vaccine uptake; continued use of face masks and other measures as directed by Centers for Disease Control and Prevention guidelines; pausing states’ widespread relaxation of other precautionary measures; improved access to diagnosis and treatment for symptomatic cases; reducing the daily number of COVID deaths to be similar to influenza; and reducing racial and ethnic disparities in all measures above. 

Our point was that jurisdictions can return to normal faster by using all tools at their disposal. A strategy that employs multiple levels of protection will reduce risk more than a strategy that relies on a single intervention (witness the multiple layers of safety features in contemporary automobiles). Further, public health history shows that slowing precautions in advance of infectious disease elimination often leads to a resurgence of disease.

Unfortunately, the U.S. has made mixed progress on these six interim goals. Rather than employ multiple tools to blunt the pandemic, what has emerged in many states is a drive to rely almost entirely on the use of vaccinations. While widespread vaccination use is the lynchpin to ending the COVID pandemic, relying on a single intervention is a public health gamble. True, current COVID vaccines prevent severe disease, death and even initial infection with outstanding effectiveness — generally over 90 percent. And authorized vaccines appear to be effective against currently known variants. However, vaccine demand is weakening and new viral variants may well continue to emerge. Failing to employ all reasonable efforts to end this pandemic now and taking our collective eyes off of the actual outcome measures of importance, such as the absolute number of deaths per day, is risky for several reasons. 

The first threat is that while the nation is reducing COVID cases and deaths they are still unacceptably high. There is still a COVID death just over every 2 minutes in the U.S., cases hover around roughly 45,000 per day, and racial and ethnic disparities in vaccine coverage persist.  Further, the national number of COVID tests being conducted is about one third lower than it was in mid-winter.  Given that the test positivity rate in the U.S. is still near 3.5 percent, this lessening of the number of tests may mean that some infections are going unidentified. This high level of cases and deaths is both dangerous and deadly especially given the possibility of multiple viral variants emerging in the U.S. and elsewhere.

The second threat is that demand for vaccines is quickly lessening in the U.S. Should it stall further, the number of susceptible persons will remain at a dangerous level. Outdoor activities in summer may lessen the probability of viral transmission, but summer doesn’t last forever and we are not yet at a sufficient vaccine coverage level to achieve herd immunity (no matter your definition of that term). To keep the uptake moving forward toward Biden’s just-announced goal of 70 percent of U.S. adults having at least one vaccination by July 4, we must greatly increase efforts to understand the reasons people have heretofore avoided vaccination, and rapidly implement empirically-tested strategies (based on past public health successes) to address their concerns. 

The third threat is growing confusion about the rationale of employing all reasonable efforts to interrupt viral transmission. For example, some statements in the national discourse have characterized vaccine use and mask use as antagonists. Some assert that fully vaccinated persons should not be encouraged to mask in any circumstances, for to do so is to, ipso facto, express a lack of confidence in vaccines. We argue that at this “tipping point” in the pandemic the use of a variety of prevention strategies together does not indict the benefits of any of them alone but, instead, allows one to enjoy their collective benefits. This is analogous to using the many safety features in automobiles. Clicking one’s seat belt does not mean that you should turn off the airbags, anti lock brakes, and lane departure detectors. Analogously, even though COVID vaccines are very highly effective, they are not perfect and can still benefit from a bit of complementary protection at the margin. A May 5 CDC Morbidity and Mortality Weekly Report analysis found synergistic benefits of combining vaccine uptake with continued societal use of non-pharmaceutical interventions such as mask use and social distancing when appropriate.

We believe that CDC’s recent interim prevention guidelines for fully vaccinated persons gets the message about right — namely, that vaccination makes nearly all life events much safer. So how can we best enjoy this tremendous benefit of vaccine protection? CDC recommends indoor mask use even for fully vaccinated persons in a number of settings so as to help disrupt any further transmission in the community (given the number of still susceptible persons), help reduce the very small number of detected breakthrough infections to even vanishingly lower levels, and help guard against new variants should they emerge. Outdoors, CDC opines that fully vaccinated people may choose to remove their mask especially when socially distant, in small groups of fully vaccinated persons, or around masked unvaccinated persons. CDC has signaled that as vaccination levels increase and case rates decline, further relaxation of precautionary measures may well follow…but first things first.   

Given that many states have opted for essentially a “vaccine-only” strategy, the interim goals we previously recommended take on heightened importance. A recent article found that countries that strongly aimed for COVID elimination using intensive, short bursts of effort fared better than countries that only aimed for mitigation, in terms of health and economic benefits and personal freedoms enjoyed. 

We have excellent COVID prevention tools available to us when many persons around the world, tragically, do not. We must use these measures synergistically, effectively, and equitably — a COVID death roughly every two minutes in the U.S. is not acceptable. We do not need to use every tool in the COVID prevention toolbox forever. Just a bit longer if important July 4 benefits are to be realized. 

David Holtgrave, Ph.D., is the dean of the University at Albany School of Public Health and SUNY distinguished professor. His three-decade career in public health has included senior positions at CDC, Emory University and Johns Hopkins University, and he served on the Presidential Advisory Council on HIV/AIDS during President Obama’s administration. Follow him on Twitter: @HoltgraveHealth (The opinions noted here are not to be interpreted as a position of Holtgrave’s current or former employers.)  

Ronald O. Valdiserri M.D., MPH is a professor in the Department of Epidemiology, Rollins School of Public Health, Emory University. Valdiserri held senior leadership positions at the Centers for Disease Control and Prevention; the Department of Veterans Affairs; and the Office of the assistant secretary for Health, DHHS. As deputy assistant secretary for Health for Infectious Diseases at DHHS, he oversaw the implementation of the National HIV/AIDS Strategy and the National Viral Hepatitis Action Plan.