The Delta Variant and Beyond: Learning to Live With Covid

Cases are dramatically up again, but simple protective measures can still control the disease if we deploy them flexibly

The Wall Street Journey
By Tom Frieden
Aug. 13, 2021

Dr. Frieden was the director of the Centers for Disease Control and Prevention from 2009 to 2017. He is the president and CEO of Resolve to Save Lives, an initiative of the public-health organization Vital Strategies, and a senior fellow at the Council on Foreign Relations.

Just when we thought it was safe to throw away our masks and go out again, the Delta variant looks poised to set us back to square one
Many Americans are left wondering if this pandemic is permanent. 
Can we ever go back to our lives as we once led them-in workplaces and schools, social gatherings and leisure activities-and if there is no going back, where are we headed?

There’s plenty of bad news to fuel these anxieties. 
The Delta variant is more than twice as infectious as the virus we’ve been fighting for the past 18 months. It seems slightly more able to evade even our best defenses, which are the mRNA vaccines produced by Pfizer and Moderna, and vaccinated people with breakthrough infections can further spread the virus.

Delta’s contagiousness, together with low vaccination rates and a premature end to indoor masking and distancing, has led to a dramatic resurgence of cases, hospitalizations and deaths in the U.S., just as schools and businesses were planning to reopen. 
Vaccine hesitancy is prolonging and exacerbating the pandemic, with explosive spread and overwhelmed hospitals in areas with the lowest vaccination rates. 
And Delta may well not be the worst that Covid has in store for us: Future variants could be even more infectious, more deadly or better at evading our immunity.

Within the next month, at current trends, there will be more than 200,000 cases per day in the U.S. 
More hospitals, particularly in places with low vaccination rates, may find themselves unable to handle the load. Deaths will at least double. 
Our two most potent tools to control the pandemic-vaccinations and mask-wearing-have themselves been infected with toxic partisanship. 
Unless we become less divided on these basic protective measures, we may allow the virus to conquer us.

Globally, the Covid pandemic is still in full swing, with many countries experiencing devastating burdens of illness and death. 
In most of the world, vaccination is progressing far too slowly. 
There is simply not nearly enough effective vaccine to meet global demand, and wealthy countries are monopolizing most of the supply. 
At the current rate, much of the world could remain unvaccinated-and global stability out of reach-until 2023.

But there’s plenty of good news as well. In fact, I believe the good news far outweighs the bad. 

  • Our vaccines are stunningly effective and remarkably safe. 
    The mRNA vaccines, in particular, are preventing severe illness and death, even from Delta. 
    And we now know that the simple measures of wearing masks indoors, spending more time outside, opening windows, increasing ventilation and avoiding superspreading events can stop Covid. 
  • It’s encouraging to see companies such as Tyson mandate vaccination for employees-a sure sign that businesses are coming to understand that controlling Covid can boost economic growth rather than hinder it.
  • Delta’s trajectory in the U.K. and elsewhere offers another possible reason for guarded optimism. 
    The variant first spread explosively, but then case rates declined precipitously, most likely because these countries sharply curtailed super-spreading events.
    The U.K., which has a higher rate of vaccination than the U.S., did not experience the spike we’ve seen in deaths and hospitalizations associated with Delta.

Indeed, in places with high vaccination rates, including much of the U.S., the worst is over: 
There will be many breakthrough infections, but 80% of the most vulnerable Americans are fully vaccinated, which means that the death rate will be much lower than it once was. 
Although Covid will remain a deadly threat for the unvaccinated, for the vaccinated-unless more dangerous variants emerge-Delta will have a risk of death roughly similar to that of flu.

Of course, mortality from the flu is already too high, and we will have to face new risks, including that of the post-viral syndrome known as “long Covid.” 
But the advent of new vaccine technologies, particularly mRNA, could usher in a new golden era
in combating infectious disease. 
Norovirus, which causes tens of millions of illnesses a year, can likely be prevented with vaccination. 
Respiratory syncytial virus, which causes millions of illnesses, sends tens of thousands of children to the hospital each year and kills thousands of seniors, could become a distant memory. 
Even bacterial infections, such as methicillin-resistant staphylococcus aureus, may be tamed by vaccination.

Unfortunately, despite its role in hastening such developments, Covid is likely here to stay. 
It will almost certainly become endemic, continuing to spread and to flare up at different times and places for many years. 
The latest evidence suggests that variants can evade infection-induced immunity, and that immunity from infection is not as strong as immunity from vaccination. 
To limit the risk and damage, given how infectious the new variants are, we would need to vaccinate more than 85% of people. 
But there’s too much vaccine hesitancy in the U.S. and many other countries, and too little vaccine globally, to achieve this threshold any time soon.

What’s more, breakthrough infections, particularly among older and immunocompromised people, may allow the virus to continue spreading even among the vaccinated
We don’t yet know whether vaccine-induced immunity will wane with time, requiring periodic booster shots and making high levels of population immunity even harder to maintain. 
And because the virus has many animal reservoirs, it can continue to circulate and evolve indefinitely.

Pathogens that jump from animals to humans commonly undergo rapid adaptation during their initial phase of spread. 
Coronaviruses aren’t known to have as changeable a genetic makeup as some other organisms: Influenza mutates more rapidly, and trypanosomes, parasitic microbes that can cause sleeping sickness or heart failure, may be the wiliest. 
Among other genetic tricks, trypanosomes keep a library of hundreds of genes they combine and swap out to evade the human immune system. 
Still, the virus that causes Covid is evolving to spread faster and to escape our antibody defenses more readily.

Our social arrangements will evolve, too. Pandemics before this one have generated profound political, economic and cultural changes. 

  • The plague that devastated Europe in the 14th century led to labor shortages that hastened the end of feudalism and the birth of capitalism. 
  • The HIV pandemic led to safer sexual practices and a global commitment to equitable care.

In the acute phase of this pandemic, Covid transformed much about the way most people conducted their daily lives. 

The question for the next phase is how many of those adaptations will remain and how we can calibrate them to a world in which Covid is endemic. We’ll need to maximize control of the disease while minimizing the harm that control measures can do to our economy and society. 

One way to achieve this is to dial specific protective measures up or down depending on the level of viral spread. 
Just as we may modify our behavior when there is excess smog or a high risk of wildfires, we may mask up and increase telework when we find ourselves facing a threatening Covid storm.

  • When Covid isn’t spreading widely (as in Vermont today, for example), most vaccinated people will live in a largely pre-Covid world. 
    People for whom the vaccines don’t work as well-people with organ transplants, for example-may choose to wear highly protective masks, such as N95s, when they are indoors with many other people, such as on public transportation, in theatres or while shopping.
  • Where Covid is spreading widely, however, the voluntary use of N95 masks will not be enough to protect the vulnerable. 
    Many people may not mask because they are unaware-or unwilling to admit-that they are medically vulnerable. 
    Furthermore, N95 masks need to fit tightly, don’t work well for people with beards and are unpleasant to wear for any length of time. 
    Wearing a mask can carry a stigma that would become more powerful if masking were an advertisement of one’s medical frailty.

In any case, masking is most effective at source control: When people with Covid infection wear masks, they drastically reduce the risk to others. 
And masking is likely to remain with us for some time. 
That is because a great deal of Covid transmission occurs before people feel sick. 
In East Asian countries, people have long worn masks during influenza season or when they were feeling ill but had to leave home. 
Even before Covid, I and others had suggested that we could adopt some of these practices in the U.S. We likely will. 
At a minimum, mask-wearing will be seen as less aberrant, if not well accepted everywhere.

For schools to stay open safely in this new era, they will need to layer mitigation measures atop one another-vaccination, masking, distancing, ventilation, isolation of the sick and quarantines for those who are exposed and unvaccinated. 
Those who manage buildings, including hospitals and schools, will become much more aware of ventilation, moving more activities outdoors and bringing more of the outdoors inside with open windows and increased air exchanges. 
Innovations such as z-ducts and buried refrigerant tubes can help make these improvements more energy-efficient and affordable.

The way we move and congregate will not fully return to pre-pandemic norms. 
Telework will increase, and in-person meetings will become less frequent. 
The proportion of travel that we see as truly essential will decline. 
Large events will continue, possibly with vaccination, masking or testing requirements-and they may also continue to result in outbreaks.

Until the global pandemic is over, travel and trade will continue to be disrupted. 
It will make sense to limit travel between areas with differing levels of spread, so that people don’t bring infections from regions with high case rates to areas with low ones.

In the U.S., vaccine hesitancy has seemed immutable, with a stable minority saying they will refuse the shots. 
But hesitancy will decrease as the death toll from Covid rises again. 
Vaccine mandates will eventually be widely accepted-particularly in health care settings, where the case for preventing avoidable and deadly spread to patients is clear; in schools, which will have difficulty staying open without them; and ultimately in many workplaces, as companies realize that having an outbreak tied to their businesses poses a legal, ethical and reputational risk as well as economic costs. 
Vaccine verification certificates (aka vaccine passports) will inevitably be necessary, including for international travel.

Although there are suspicions about the vaccine in some countries, lower-income countries generally have less hesitancy and are much more familiar with both vaccination campaigns and the deadly toll of diseases that vaccines prevent. 
To stop the global pandemic, much more vaccine will be needed-and quickly. 
The best way to meet that demand is to expand production of the Pfizer and Moderna mRNA vaccines.
This technology is faster to scale up than that of other available shots. 
It’s also more easily tweaked to address variants and less susceptible to production delays. 
Producing more of these two mRNA vaccines would save many months by making new clinical trials unnecessary.

As we come to terms with the implications of the Covid pandemic, we may recognize that we, as individuals, are not the sole masters of our destinies and that what we can do safely depends on what we do effectively as a society. 
If nothing else, the devastating toll and multitrillion-dollar cost of the Covid pandemic will make the cost of prevention seem reasonable by comparison to the price we have already paid and the potential for even larger costs from future pandemics.

Better health surveillance at home and abroad, for example-meaning the collection and transmittal of data related to the patterns of disease-can inform doctors, public health authorities and the public where Covid is spreading, how to contain it, who if anyone should get a third initial dose and whether booster shots might be needed. 
A global commitment to improving the safety of every laboratory in the world that works with potentially dangerous pathogens could reduce our risk going forward, regardless of the actual origins of the virus that causes Covid. 
And the pandemic has made plain the need for vaccine research and development: 
The 2003 SARS outbreak led to substantial development work on mRNA technology and coronavirus vaccines. 
We may not have this type of head start the next time unless we make it a priority.

As the Danish proverb goes, it’s difficult to make predictions, especially about the future. It’s possible-but unlikely-that a more infectious but less virulent strain of the virus will emerge, spread around the world and convert Covid into something no worse than the common cold. It’s also possible that the virus will necessitate tweaks to our mRNA vaccines and periodic boosters for years to come. But Covid is very unlikely to be the last or only significant threat: A new, far deadlier pandemic could arrive on our shores, or antimicrobial resistance could usher in a post-antibiotic era for some organisms.

In the long run, Covid may help us to recognize that many deadly and expensive health threats are optional. 
We can choose to adopt programs and policies that can relegate to history many of the infections and conditions that today drive up health care costs and drive down productivity and life expectancy.

What we must now change is the cycle of panic and neglect of public health in response to health threats. 
Doing the same thing over and over but expecting different results may or may not be a good definition of insanity, but it’s certainly a formula for failing to end the Covid crisis and leaving the world vulnerable to the next-potentially even more devastating-pandemic.

Dr. Frieden was the director of the Centers for Disease Control and Prevention from 2009 to 2017. He is the president and CEO of Resolve to Save Lives, an initiative of the public-health organization Vital Strategies, and a senior fellow at the Council on Foreign Relations.

Originally published at on August 13, 2021.

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