By Mike Dougherty/VTDigger
Recent trends in Vermont’s Covid-19 case counts have officials and experts feeling optimistic about the course of the pandemic — but all warn it would be premature to brush off the Omicron threat just yet.
As of Friday, Jan. 28, the state’s seven-day average for daily new cases had fallen by more than half since its peak Jan. 9, a sign the worst of the past month’s surge may have passed.
But officials continue to warn that case counts have been skewed: The more people that use at-home rapid tests rather than state-administered PCR tests, the less accurate Vermont’s case and test positivity metrics will be.
And many of the most drastic effects of the Omicron variant are still being felt. Hospitals remain under serious strain with elevated numbers of Covid-19 patients continuing to stress a diminished workforce. Schools and families are still contending with the disruptions of widespread staff and student absences due to Covid-19 infections. And fatalities in Vermont continue to climb, with 54 Covid deaths — the third-highest monthly total of the pandemic — reported so far in January, as of Friday.
“I want to preach against overconfidence,” Vermont Health Commissioner Mark Levine said Tuesday, Jan. 25, at Gov. Phil Scott’s weekly press conference. “We’re grateful for the direction of the curve, but we’re still at a time of high levels of community transmission. So this is not the time to totally loosen up completely.”
“There is a light at the end of the tunnel,” said Tim Lahey, an infectious disease physician and director of clinical ethics at the University of Vermont Medical Center. “But I do think we need to temper that by saying that the thing we actually care about — how overworked the hospitals are and the deaths of our friends and neighbors — are still in a bad place and will be that way in a couple weeks.”
Lahey and others said it likely will be mid-February before the state turns a corner on hospitalizations and fatalities. Even then, caution should be warranted.
But many are eager to reach the transitional phase of the pandemic, and the shift toward managing Covid-19 as endemic rather than pandemic — and some are insisting we are already there.
So when the state will reach a baseline of infection that could be considered safe, scientifically?
Reading the curve
First the recent decline in reported cases is bolstered by data points other than just case rates, according to officials. Other New England states also are reporting declining cases and stabilizing hospitalizations, and national trends are moving in the same direction. Wastewater testing indicates that the prevalence of the virus in Burlington dropped off following a peak in the second week of January.
Those trends alone are not enough to justify a change in approach, Levine said. “It’s one thing to see our numbers come down and to see the national numbers curving in the same direction. It’s another thing to qualify for a level of virus transmission that’s below ‘high’ — substantially lower, in the ‘low’ to ‘moderate’ range.”
The U.S. Centers for Disease Control and Prevention defines moderate transmission as fewer than 50 cases per 100,000 people in a week. As of Thursday, Jan. 27, Vermont was reporting 1,272 cases, more than 25 times that threshold.
A test positivity rate below 5%, which state officials used as a reopening benchmark in spring 2020, is still a useful indicator of transmission being under control, said Michael Calderwood, an infectious disease physician who has led the Covid-19 response at Dartmouth-Hitchcock Medical Center. Vermont’s seven-day average positivity rate, 10.2%, has remained above 5% since Dec. 23.
“I would say we have a number of weeks ahead where we need to continue to see improvement before we can really say that community transmission is no longer substantial,” Calderwood said.
In countries like South Africa, or U.S. cities like New York and Boston, Omicron cases have dropped off nearly as quickly as they rose. But that’s not a guarantee we will see the same pattern across the Northeast, according to Anne Sosin, a public health researcher at Dartmouth College.
The steep rise of the U.S. surge was driven partly by holiday travel and gatherings — meaning the decline may not be a mirror image. Plus, cases tend to drop off more slowly in rural areas than cities.
“We don’t really know yet what the downward slope of the surge will look like,” Sosin said.
Risk assessment
Throughout the pandemic, previous peaks have triggered conversations about when to relax restrictions. This time, there are few measures left to unwind.
In the past two months, more than 30 cities and towns in Vermont enacted local mask mandates under a new state law that allowed municipal governments to do so. Those measures must be renewed every month, and they will automatically be repealed April 30 if municipalities don’t let them expire first.
School mask guidelines will remain in place at least through Feb. 28, Education Secretary Dan French said last week during the Covid press conference. Unless that date is extended, the state recommends that schools where more than 80% of the eligible population has begun vaccination can then drop their masking rules.
Mostly, individuals will need to continue to assess their own risk of contracting or spreading the virus. Experts said that even when Omicron is in the rearview mirror, that could be a complicated prospect.
“A lot of people are going to take the mask off the second you tell them it’s OK. And there’s going to be a lot of people that are going to wear masks for years,” said Josh White, chief medical officer at Gifford Health Care.
The benefits of mask-wearing will be “relatively low,” White said, once the state reaches a level of transmission similar to June 2021 — roughly 10 new cases per day.
As in past waves, policy shifts should be incremental and responsive to current levels of transmission, according to Lahey of UVM Medical Center.
“We’re going to have to just expect this sort of two steps forward, one step back … It’s going to be like that for a little bit until we know for sure, when the oscillations and Covid epidemiology are within a range that we’re just going to tolerate and not worry about,” he said.
After Omicron
Past moments of cautious optimism turned out to warrant more caution than optimism. The Delta and Omicron variants delayed the prospect of treating Covid-19 as endemic — an active but manageable virus like influenza. Will this time be different?
Experts said what happens after Omicron recedes is an open question.
In the ideal scenario, widespread recent infections, combined with Vermont’s strong vaccination rate, would leave the population with a heightened level of immunity.
“It’s not going to be too long before virtually everyone has antibodies, either because you got vaccinated or you got Covid or you got both. And once that occurs, transmission is going to go way down,” White said.
The virus will still mutate, but a new variant would have to be more contagious than Omicron — a high bar to clear — to become dominant.
If and when that occurs, health systems would be better prepared to handle another epidemic wave thanks to pharmaceutical treatments.
The Pfizer pill Paxlovid has proven to be highly effective at keeping Covid-19 patients out of the hospital when deployed early in the course of illness, White said. Supplies were scarce at the start of the Omicron wave, but the Biden administration has since ordered 20 million more courses of treatment to deploy in the coming months.
Vaccines will continue to play a key role. Experts are heartened by the fact that the current vaccines — especially with a booster dose — continued to prove effective against hospitalizations and deaths with Delta and Omicron. Vaccine manufacturers are working to become more responsive to new variants, meaning the next booster shot — or a combined flu-and-Covid-19 shot — could be more tailored to future strains.
On the other hand, none of these outcomes are guaranteed.
Omicron was a reminder of Covid’s tendency to mutate quickly and unpredictably, experts said. The variant’s ability to reinfect so many people throws into question how protective it will prove to be against future strains.
“It is possible that the end of the Omicron wave will be followed by a period of low case numbers and low risk. But we know that this virus can evolve to evade immunity conferred by currently available vaccines or by previous infection, and when that happens, we will probably experience another epidemic wave,” said Annie Hoen, an infectious disease epidemiologist at the Geisel School of Medicine at Dartmouth.
Scientists from the World Health Organization warned this week that the risk of a variant that is more contagious and deadlier than Omicron is real.
That puts more pressure on vaccines to provide population-level immunity. While Vermont’s booster rate is the highest in the nation — as of Friday, 63% of the vaccinated population had received a booster — more people need to step up for their third shots, experts said.
Health Commissioner Levine said Tuesday, Jan. 25, that he would like to see that rate reach 90%.
“The key emphasis continues to be vaccinating as much of the nation and the world as possible,” he said, “so the next new variant with its new Greek name doesn’t become an issue that is a game-changer again, in terms of our scientific approach to how we live.”
Preparing for the unknown
Regardless of which scenario comes to pass, experts agree that a post-Omicron lull would be the time to prepare for the worst.
Sosin and others have repeatedly advocated for a data-driven mask policy, which would take effect only when transmission rises above a certain threshold. Vermont lawmakers introduced a bill to establish such a system this session, but House and Senate leaders have said the measure has no path forward.
Even without a statewide mandate, Sosin said, governments can help citizens prepare by distributing masks and rapid tests well in advance of future threats, unlike the catch-up efforts seen during the Omicron wave.
“We need the administration to have those things ready to go at the onset of another surge or when we detect another variant,” she said. “We shouldn’t be mailing out tests after a lot of public pressure a month into a surge. These things need to be there.”
Careful surveillance to detect a future surge early will be key, according to Jan Carney, the associate dean for public health at UVM’s Larner College of Medicine and a former Vermont health commissioner.
Standard PCR testing should be augmented with more robust genomic testing for variants, as well as expanded wastewater surveillance. Six Vermont municipalities this month were invited to join a CDC-led wastewater testing program in addition to four cities that were already monitoring their systems.
“There’s a risk in saying, ‘Oh, it’s here forever, so we should just go on,’” Carney said. “There are reasons, in my view, not to let our guard down and not to surrender.”
More broadly, experts have called for a renewed investment in public health.
The pandemic hit when state health departments, including Vermont’s, had faced years of funding and personnel cuts. Rebuilding that infrastructure now would help the state prepare for the next health crisis — whether that’s another Covid-19 variant or an unrelated epidemic.
The Covid-19 response has been similar to hurricane relief, said Calderwood, the Dartmouth-Hitchcock official. “The hurricane comes through, and there’s a lot of promises made. There’s an injection of funds that usually lasts a couple of years, but then it goes away.”
“People really need to be thinking about public health as something we always have a need for,” he said. “How do you make sure that it is properly resourced — not over one or two years but over 10 years?”
The pre-pandemic approach to public health does not inspire confidence, said White of Gifford Health Care.
“The citizenry and the hospitals and the governmental infrastructure in Vermont stepped up to the plate pretty fast, but they weren’t ready when it happened,” he said. “There were no stockpiles of masks. There were no staff ready to start making these phone calls or contact tracing.
“Are we going to learn from this? Are we going to invest in this? I have to say I’m kind of skeptical,” White said.
