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About our “The COVID-19 Crisis” series
COVID-19 case rates in the U.S. continue to decline, and we are finally below 100,000 new cases per day. The rates of new hospitalizations and deaths have also started to decline. This is typical of previous waves of COVID-19, where a surge of cases subsides after about two-and-a-half months. The question now will be if rates drop down to those from early summer, as they have in much of the world as the Delta wave passed, or whether we stay at a high plateau, as is happening in the U.K., which has a higher vaccination rate than the U.S.
Seven-day moving average rate of cases: 92,622; deaths per 100,000: 3.09. Source: CDC, October 8, 2021
Pregnant women face a high risk of respiratory failure from COVID-19, which also has been associated with increases in miscarriage rates as well as maternal deaths. Only 31% of pregnant women in the U.S. are currently vaccinated against COVID-19, and the CDC issued an advisory a week ago strongly recommending “COVID-19 vaccination either before or during pregnancy because the benefits of vaccination outweigh known or potential risks.”
So far there have been over 127,000 cases of COVID-19 diagnosed in pregnancy. Almost one in five have been hospitalized (22,000), and an estimated 4,000 have been treated in intensive care units. There are 171 reported maternal deaths.
In addition to protection for mothers, vaccination protects babies: Maternal antibodies produced from the vaccine cross the placenta and provide protection for the newborn baby. There is no evidence that any of the COVID-19 vaccines interfere with fertility or increase miscarriage rates.
Three new studies in the New England Journal and The Lancet evaluate potential waning of protection in those who received the Pfizer vaccine. The first study, from Israel, shows that antibody levels decline substantially over the first six months. Antibodies decline faster in older subjects and in men. It’s not clear what level of antibody is fully protective.
The second study, from Qatar, shows that protection against COVID-19 infection drops from 78% (one month after the second Pfizer shot) to 17% (six months after the second Pfizer shot). Protection against severe infection remains much better preserved (89% at six months and 56% at seven months, although the number of people who were observed at seven months is small, so there is more uncertainty around that number).
The third study, from Kaiser Permanente in the U.S., showed a decline in effectiveness against any infection from 88% to 47% over five months for those who received the Pfizer vaccine. Protection against hospitalization remained around 90% at five months across all age groups (92% for those ages 16 to 44, and 86% for those 65 and over).
This is consistent with our experience of many breakthrough infections, although we’ve seen few hospitalizations and deaths among those fully vaccinated, regardless of which vaccine people have received. The Moderna mRNA vaccine is a much higher dose, and some preliminary research suggests that waning of antibody levels will be less. The decrease in antibody levels in those who received the Pfizer vaccine supports booster shots — though these remain most important in those at highest risk due to advanced age (over 65 years) or immune system compromise.
Pfizer applied for emergency use authorization for a lower dose of its vaccine for children ages five to 11, and the Food and Drug Administration (FDA) advisory committee will meet to discuss this on October 26. We expect data on children from ages six months to five years before the end of the year.
Children represent a larger portion of current cases now (> 25%), as a larger portion of adults have gotten vaccinated. Nonetheless, severe illness, hospitalization and death are rare in children under 12.
Vaccinating younger children will further decrease the number of school-associated infections and quarantines, which will mean fewer work disruptions for parents who are employees.
I’ve been saying for a year now that soon we’ll have access to inexpensive rapid antigen tests that will help us identify more cases and prevent more transmission. And I’ve been consistently wrong. Antigen test costs have come down to $7 per test, but that’s still too expensive for most families to test regularly, and many retail outlets are out of stock or limit purchases. In contrast, the U.K. gives these away free to all, Canadian schools are distributing them free to students and these tests cost less than a dollar in Germany.
Two new developments this week give me hope. The FDA approved the Acon lateral flow test, which is widely used in Europe. And the Biden administration announced that it will spend $1 billion to purchase rapid antigen tests. Unfortunately, the projections of getting to 200 million antigen tests a month won’t provide enough rapid tests for a country with 320 million people.
There was vaccine news outside of the pandemic last week. The World Health Organization just recommended a malaria vaccine for countries with endemic malaria last week. There were 229 million cases of malaria in 2019, killing over 400,000 people, mostly children in Africa. This vaccine could save many thousands of lives.
It’s easy to forget how much infectious diseases affected American life not so long ago. This chart shows how many cases of various infectious diseases we had annually during the 1900s, compared to how many we had in 2020.
| Disease | 20th-century annual morbidity* | 2020 reported cases** | Percent decrease |
|---|---|---|---|
| Smallpox | 29,005 | 0 | 100% |
| Diphtheria | 21,053 | 1 | 99% |
| Measles | 530,217 | 13 | 99% |
| Mumps | 162,344 | 621 | > 99% |
| Pertussis | 200,752 | 5,398 | 97% |
| Polio (paralytic) | 16,316 | 0 | 100% |
| Rubella | 47,745 | 6 | > 99% |
| Congenital rubella syndrome | 152 | 0 | 100% |
| Tetanus | 580 | 15 | 97% |
| Haemophilus influenzae (Hib) | 20,000 | 11*** | > 99% |
This is personal for me! I was a Boy Scout, and my scoutmaster was in a wheelchair due to childhood polio. He was a great role model for my fellow scouts; he even went camping with the troop. But it’s easy to forget that parents were scared to let their kids out to play in the 1950s before they could be protected by the polio vaccine.
I served as a nurse's aide at a residential facility for teenagers who had congenital rubella syndrome, which means they caught “German Measles” from their mothers when they were in the womb. These kids were blind and deaf and had severe cognitive disabilities. Few spoke more than a few words, and none would ever be able to live in the community. There are no cases of congenital rubella syndrome now, because of vaccines.
At this point, when it doesn’t look like we’ll eradicate the virus that causes COVID-19, vaccination remains our most effective weapon. Our treatments, both monoclonal antibodies and upcoming antivirals, will improve and prevent substantial disease and death. But vaccines, which remain in the body for just a few days and prompt the natural immune system to create antibodies to naturally ward off disease, remain the best way to save lives.
Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.
