Next pandemic surge....

How the next pandemic surge will be different

The same: The brutal math of exponential growth. Different: Our pandemic fatigue is worse than ever.

By Keren Landman

Covid-19 cases are rising again in Europe. They’re outright exploding across much of Asia. The United States, however, is in a Covid lull, having just come down from the winter’s omicron outbreak.

It’s an uneasy time. On one hand, it’s likely the worst of the pandemic is over, at least in terms of severe illness and death. But on the other hand, we have to ask: Do these upticks in the rest of the world foreshadow America’s future?

It’s true that the US often sees cases rise several weeks after they tick upward in the United Kingdom. We are again watching a new(ish) variant, BA.2, trace a familiarly steep curve on graphs tracking new cases, provoking a familiar but chronically contentious question: What should we do about it, as individuals and as a society?

While this moment feels familiar in many ways, several factors set it apart from previous pandemic lulls.

Collectively, we have more immunity, and more treatments, than ever before. At the same time, we’re more fatigued about the state of the pandemic and arguably less prepared for a wave, considering there’s more confusion than ever about what our individual risk is at any place and time.

Taking a hard look at what’s new and what’s not about ourselves, the virus, and our policy landscape can help us convert some of that painful familiarity — and some of the scary unknowns — into preparedness. To do that, it’s helpful to take stock of how a next wave will likely behave like past waves, and how it might be different. So let’s start with what won’t change.

The same: The brutal math of exponential growth

Although the omicron subvariant BA.2 was first identified in November 2021, it has only become a dominant variant over the past several weeks in parts of Asia and Europe. Early laboratory work has suggested this variant is about 30 percent more contagious than the already highly transmissible BA.1 omicron variant, which was the dominant strain during the last US surge.

Regardless of the exact variant, the shape of each wave is determined by the same brutal math. Small upticks in cases quickly explode due to exponential growth, and case counts grow exponentially until they don’t. We’re already starting to see that growth start as transmission rises in the United Kingdom, Germany, and other European countries.

At home and abroad, we can generally expect to see hospitalizations rise one to two weeks after cases rise, and deaths to rise another four to six weeks after that, depending on the public health system’s capacity. Hong Kong and South Korea are in this phase, reporting increasing and record-high death rates.

The same: The tools we used to fight past waves still work

No matter how transmissible a variant is, the same precautionary measures — like vaccination, quarantine and isolation, masking, and testing — work to prevent its spread.

If those measures are in effect, transmission slows. If they are dropped, it speeds up. In this light, the current waves in Europe and Asia may have as much to do with policy decisions as they do with the transmissibility of the BA.2 variant.

In Europe, rising cases coincided with the lifting of rules requiring masking and other preventive measures in multiple countries (such as requiring isolation after a positive test, vaccination proof requirements for entering shops, and pre-travel negative test requirements). That suggests the continent’s increase in BA.2 transmission was facilitated at least in part by a drop in protective behaviors, all leading to more infected people mixing socially while contagious.

In Asia, too, the causes of rising deaths seem to go beyond the virus’s intrinsic properties. The BA.2 subvariant doesn’t appear to cause more severe disease than earlier omicron variants, nor to be any more evasive of vaccines than other variants. While it can still cause severe illness and death, especially in elderly people, vaccines seem to remain highly effective even in this high-risk population.

In Hong Kong, the sudden spike in deaths is likely due to the lack of vaccine coverage among elderly people. There, the pandemic is raging largely among unvaccinated seniors without much previous exposure to Covid-19; few vaccinated people are being hospitalized.

Notably, even though deaths are higher than ever in both countries, the death rate is actually much lower in South Korea, likely due to its much higher rate of vaccinations among elderly residents in particular.

America has the tools to fight a new wave — it’s just a question of how and whether it uses them, said Dr. Joshua Sharfstein, a professor at Johns Hopkins University’s Bloomberg School of Public Health. “The fundamental question,” Sharfstein said, is “can we be nimble and flexible to the facts of the pandemic?” Will people and policymakers be willing to bring back restrictions like mask mandates now that they’ve been dialed down?

Masks, especially respirators (these are the high-quality N95s or KN95s), still work to protect individuals if they’re exposed to people infected with Covid-19. N95 respirators offer excellent protection from viral exposure, even if you’re the only one wearing one in a group of people. And manufacturers are getting better at making them more comfortable to wear for hours on end.

Rapid home Covid-19 tests still work to provide in-the-moment actionable information. During the first omicron wave, some people got in the habit of testing before any group social activity, and after exposures. When a wave is rising, that practice should resume. It should be helpful that rapid tests are now far more widely available than they were during the previous wave.

We also know more about ventilation and air filtration than we have at earlier points in the pandemic. The Environmental Protection Agency just released new guidance on ventilation, and as the weather warms, opening windows and using fans to choreograph good air flow can do a lot to reduce risk during gatherings. When fresh air isn’t an option, air cleaners (think HEPA filters) help — and while many good ones are commercially available, DIY options also work well and are relatively easy to construct.

Whichever protective measures work best in your world, it’s a good idea to gather several weeks’ worth of supplies before cases rise.

Different: US levels of population immunity are higher now than ever before, and there are more therapies to avoid severe disease

One of the key differences between this moment and previous pandemic lulls is the level of community immunity. The US has high rates of vaccination — 65 percent of all Americans have received at least two vaccines, and 50 percent of those eligible have been boosted. There’s also more infection-acquired immunity; a high proportion of even those who are unvaccinated have some infection-related protection.

All told, nearly three-quarters of the US population has some level of immunity, according to researchers at the University of Washington’s Institute for Health Metrics and Evaluation. More immunity means people are less likely to be hospitalized with Covid-19, even if case counts surge.

For those who do get sick, a range of therapies is now more broadly available than at any other point during the pandemic. Monoclonal antibodies, which identify and attack viral particles before they can cause severe disease, now come in long-lasting formulations to protect immunocompromised people; the antibodies act like an additional, durable layer of immunity on top of vaccinations, which can help prevent infections in this vulnerable group. Several shorter-acting forms of this therapy can also be used to treat high-risk or severely ill people if infection has already happened. Additionally, antiviral medications are now available in both oral and intravenous forms.

The biggest challenge to getting these therapies right now is politics: Congress recently axed $15 billion in Covid-19 funding that would have covered the costs of antibody treatments and maintained access to Paxlovid, an antiviral medication. The abrupt vacuum of resources severely muddled the path forward on identifying and accessing Covid-19 treatment for everyone, but especially for people without insurance. Whether and how this problem will be solved is unclear, although without continued funding, people needing treatment will feel the effects of the cuts beginning in April.

“Not all of the policymakers have learned their lesson,” said Dial Hewlett, an infectious disease physician who is deputy commissioner of the Westchester County health department in White Plains, New York. Without investments in research, public health infrastructure, and regulatory agency staff, he said, “We may be doomed to repeat history.”

Different: Assessing personal risk is deeply confusing

In early April 2020, federal guidance recommended masks in public places, and masks have been required in federal buildings since January 2021. The CDC issued recommendations for schools in September 2020 recommending masking and other strategies for students and teachers.

All of those recommendations have now expired, replaced by a system for assessing county Covid-19 levels based on case counts and hospitalizations. (A federal requirement to wear masks when using most public modes of travel will stay in place until at least April 18.)

The CDC’s new website offers guidance to state and local health departments and school districts, with the specific guidance varying based on local transmission rates and hospitalizations. It’s these more local authorities who ultimately make the rules for their jurisdictions.

However, because these authorities follow the CDC’s guidance to widely varying degrees, neighboring counties may take very different approaches to public preventive measures like indoor masking requirements or capacity limits. For the near term, many US residents will continue to live amid a patchwork of precaution that might be different in the county where you live than in the one where you work or send your kids to school.

If you live in a jurisdiction that’s proactive about instituting preventive policies, congrats, your next steps may be clear. However, many are not in that position, and may feel baffled about the best way to determine when to mask up or take other safety measures.

What’s a well-intentioned person to do amid all this confusion — especially given the concern that so many other people are not going to do that much?

The CDC’s county check website, while imperfect, may be a good place to start: It allows people to view safety recommendations specific to their county’s Covid-19 levels (i.e., a metric based on cases and hospitalizations), and suggests additional layers of protection high-risk people should add. But it has a big limitation: “It doesn’t help you understand your own personal vulnerability,” said Jay Varma, a physician and epidemiologist based in New York City.

For individual users of the website, there’s no easy way to determine what “high risk” means and whether your age, medical conditions, or lifestyle places you in that category. “It’s not the best tool for individuals to use as an instrument to guide them — it’s not as good as a weather report,” said Varma.

While determining your local risk level day to day may not be straightforward, ensuring your Covid-19 vaccinations are up to date — including a fourth shot, if that’s what’s recommended for you — is the simplest way for most people to minimize their individual risk. Additionally, wearing a high-quality mask like a KN95 or N95 when you judge yourself or your situation to be high-risk protects you regardless of what other people are doing (or not doing).

Different: Pandemic fatigue is real

Two years into the pandemic, our collective level of exhaustion is manifesting in some worrisome ways. Deaths are creeping toward a million, but collective action isn’t keeping pace. Anger and denial have led to irrational decision-making and behavior by leaders and individuals.

Panagis Galiatsatos, a physician and professor at the Johns Hopkins School of Medicine who has engaged Baltimore-area faith leaders and congregations in Covid-19 education since the pandemic’s early days, said he is concerned about the level of pandemic fatigue he’s heard during recent meetings. After the holiday omicron wave forced many worship services online, “what they fear is going back to not being in person again,” he said.

If public health leaders forbid in-person gatherings due to another wave of transmission, he fears it will lead many members of the public to lose faith in public health leaders altogether. “I think we’re going to lose our audience,” he said. “So I think what’s different now is definitely the fatigue is there.”

One of the biggest risks of low social morale is that it could delay buy-in to critical Covid-19 prevention measures even if the virus is causing a great deal of community suffering. People may take longer to agree to mask up, or may be more reluctant to show vaccination cards. And when precautions are eventually implemented, will it be too late? Is there hope of doing something about denial and fatigue before they become the death of us?

With our trust in institutions at a low point, one-on-one conversations between individuals may be one of the most important ways forward. “If it’s not going to be public messaging, let’s do private messaging,” said Galiatsatos. That involves a lot of listening and compassion by scientists and public health authorities, but it also involves making recommendations that meet people where they are.

“People aren’t switches to turn off and on,” he said. “We’re not going to be ignorant of the next wave, but we’re definitely going to discuss it in a way, like, ‘How do you make it adaptable?’”

Perhaps the biggest difference we can hope for is a broader understanding of the pandemic itself, not as a thing we can turn off or on, but as a dimmer switch that our collective action moves — and keeps — up or down.