Responding to the Rise of the Delta Variant

Earlier this Spring, President Biden set a goal to try to get 70% of all American adults at least one vaccine dose against COVID-19 by July 4. Within the overall U.S. population of adults age 27 years and above, it appears this goal was met (55.8% of the U.S. population aged 12 and up is now fully vaccinated). However, there is still quite a lot of work to be done to ensure broad community protection against COVID-19 and its variants. The percentage of 18-26-year-olds willing to get vaccinated continues to lag. We continue to see troubling differences in vaccination uptake rates across racial/ethnic, as well as political affiliation, lines. This has led to sizeable clusters of continued vulnerability to the COVID-19 virus and its far more virulent Delta strain in many communities, and we’re starting to see case positivity rates rise again.

Some may look at these trends and ask: “So what? Numbers are rising, but we’re not at risk for overwhelming our hospitals, and our most vulnerable are largely protected from being hospitalized or dying. Why should we care if those who choose not to get vaccinated continue to put themselves at risk?”

We should be concerned in part because some populations — in particular (but not exclusively) younger children — have very few natural defenses against Covid-19. And younger children do not yet themselves have access to the vaccine. The longer the virus continues spread through our communities, the greater the chance they may end up getting sick, potentially being hospitalized, suffering from long-term symptoms, and/or dying from the virus, and the greater the chance they have of keeping the virus spreading through our communities.

Second, thanks to the Covid-19 vaccines, these rises in Covid-19 Delta-variant hospitalizations, disability, & death in our communities are highly (if not entirely “easily”) preventable. We want all members of our community (in fact: all communities) to have an opportunity to flourish, and using low-cost, highly effective prevention measures to stop the spread of a dangerous infectious disease advances such opportunities. And while care for these individuals won’t overwhelm our health system the way hospitals and families were slammed in 2020, the Covid-related costs to our local health and public health systems will continue to accrue and to drain both funding and human resources away from other health efforts.

Masks in Mississippi 

Mississippi has the lowest Covid-19 vaccination rate in the country, and has seen a surge of the Delta variant cases and hospitalizations, especially among the unvaccinated. In particular, state health officials are worried about indoor mass gatherings, as they have traced recent outbreaks to such settings as “summer camps, churches, funerals, nursing homes and work places.” As a result, the state health official has recommended that all Mississippians age 65+ (irrespective of vaccination status), and all unvaccinated state residents with chronic health conditions avoid all indoor mass gatherings through July 26, and that all unvaccinated state residents wear masks when indoors in public settings.

Schools & Childhood Covid Vaccination

Earlier this week, the CDC issued its new Covid-19 guidelines for K-12 schools as they look to facilitate safe, in-person learning environments in the fall. The CDC recommends:

• Masks should be worn indoors by all individuals (age 2 and older) who are not fully vaccinated. Consistent and correct mask use by people who are not fully vaccinated is especially important indoors and in crowded settings, when physical distancing cannot be maintained.
• CDC recommends schools maintain at least 3 feet of physical distance between students within classrooms, combined with indoor mask wearing by people who are not fully vaccinated, to reduce transmission risk. When it is not possible to maintain a physical distance of at least 3 feet, such as when schools cannot fully re-open while maintaining these distances, it is especially important to layer multiple other prevention strategies, such as indoor masking.
• Screening testing, ventilation, handwashing and respiratory etiquette, staying home when sick and getting tested, contact tracing in combination with quarantine and isolation, and cleaning and disinfection are also important layers of prevention to keep schools safe.
• Students, teachers, and staff should stay home when they have signs of any infectious illness and be referred to their healthcare provider for testing and care.
• Many schools serve children under the age of 12 who are not eligible for vaccination at this time. Therefore, this guidance emphasizes implementing layered prevention strategies (e.g., using multiple prevention strategies together consistently) to protect people who are not fully vaccinated, including students, teachers, staff, and other members of their households.

The state of California indicated that, because many schools in that state would not be able to meet the CDC’s social distancing guidelines in their classrooms, they would provide free testing access at all schools, and would require that students continue to wear masks this fall.

The CDC’s Morbidity & Mortality Weekly newsletter also published the results of a national survey of parents of adolescents aged 12-17, as well as adolescents aged 13-17, concerning their attitudes related to COVID-19 vaccination. The survey was conducted in April 2021. According to the survey, “Among parents with unvaccinated adolescents aged 12–17 years, 55.5% reported that they ‘definitely will’ or ‘probably will’ have their adolescent child receive a COVID-19 vaccination. Parent-reported intent for their adolescent to receive a COVID-19 vaccination was significantly lower among female (49.3%) than among male (63.0%) parents and among those having less than a bachelor’s degree or living in the Midwest or South Census regions.”

The factors most likely to increase vaccination intent of both the parents of unvaccinated adolescents and of the adolescents who did not indicate they definitely would get their kids the shot included “having more information about safety and efficacy” of the vaccines for teens, as well as “having vaccination be a school requirement.” Interestingly, while the largest share of parents and adolescents said they would feel most comfortable with the vaccination taking place at the adolescent’s usual doctor’s office or clinic, “Very few parents (9.9%) or adolescents (8.9%) selected a COVID-19 vaccine recommendation by a health care professional as a factor that would increase vaccination intentions.”

COVID-19, Equity, and Inclusiveness – I coauthored an editorial on these topics published last week in the BMJ. As we state in our piece:

It is not too late to start helping struggling individuals, communities, and countries through this pandemic. Given the real possibility of further covid-19 waves, even in countries where vaccines are lowering transmission, we need to ensure case counts stay low by giving people the resources they need to maintain social distance and eliminating contexts that increase transmission. As US states set up vaccine lotteries and scholarships instead of investing in equitable access and pandemic resilience, we must continue to push for these structural supports.

Yet supportive measures are only part of the solution. Pandemic resilience requires repairing or restoring individuals and communities who have experienced severe loss or deprivation from mismanaged or ill applied control measures; have lost access to their basic needs through government negligence; or who contracted covid-19 because a lack of equitable control measures forced them into high risk situations. This also should include the substantial population with long term symptoms from covid.

This piece is a follow up to a perspective piece on the impact of Covid-19 on equity we wrote early in the pandemic, as we have found that many of the structural concerns have not been addressed that we worried would result in disparities that would disproportionately harm already vulnerable individuals and communities.

Long Covid: “Our Next National Health Disaster”

As we note in our BMJ editorial linked above, we have significant concerns about the new population of so-called “long haul” Covid sufferers whose disabilities have arisen as a result of the pandemic. In their New England Journal of Medicine perspective piece from earlier this week, Drs. Steven Phillips and Michelle Williams describe long Covid as our next “national health disaster” that is “likely to cast a long shadow on our health care system and economic recovery.” Furthermore, because long Covid has disproportionately affected women, they worry, based on their examination of the emergence of past post-infection syndromes, that those suffering will be marginalized and system responses might be fragmented, absent deliberate planning. The piece offers five recommendations for fostering an effective, coordinated response to address the needs of this new population of tens of millions of chronically ill Americans.

A Few More Law, Ethics, and Policy Pieces of Note:

• COVID-19 Vaccination of Health Care Personnel as a Condition of Employment: A Logical Addition to Institutional Safety Programs (JAMA Internal Medicine)
• Mandatory SARS-CoV-2 Vaccinations in K-12 Schools, Colleges/Universities, and Businesses (JAMA) – While the authors do believe that colleges/universities and some businesses may be ethically, legally, and epidemiologically justified in adopting Covid-19 vaccine mandates, the authors do not believe vaccination should be mandated in K-12 schools, due to the need for additional postmarketing surveillance within that population and a lack of health care expert and public support for such initiatives.
• NY Governor signs legislation prohibiting public employers from penalizing employees for Covid-19-related absences
• The real toll from prison Covid cases may be higher than reported, as some hospitalized inmates were officially released from custody before they died
• According to data recently released from the U.S. Treasury, only $1.5 billion of emergency relief dollars allotted for rental aid had been spent by the end of May, raising further concerns about the scope and impact of the eviction crisis

NOTE: You may have noticed that this post is titled a Monthly review, as opposed to the weekly reviews you’ve been receiving on Monday mornings for the past year or so. As the flow of literature emerging related to Covid-19 has slowed, our Expert Review team also has decided to spread out our updates. You’ll continue to receive updates on Mondays; they’ll just be on select topics each week, rather than covering all our expert-curated areas.