Delta Dysfunction

The United States Update

When I warned about the more transmissible Delta variant last May, I was most worried about the many countries around the world without access to vaccines. That situation remains catastrophic. Estimates are now putting India’s death toll at potentially over 3.5 million — most of it in just a month-and-a-half, as Delta swept over the country. Similar waves are now sweeping over many other countries like Indonesia, South Africa and Malaysia.

Then there’s the United States, as I write in my latest piece, where it’s our dysfunction and impaired politics that’s holding us back.

We have more than enough vaccines. The country is not poor, but our health-care system is broken. Our science is advanced, but our public health infrastructure is neglected and even attacked. Our media and social media are structured to pull things even further apart—highlighting the extreme, the deliberate, the caricature. And our vaccination coverage is insufficient in many places to hold back something as transmissible as Delta, a problem compounded by its immune evasion — likely resulting in more breakthroughs, including symptomatic ones that can potentially transmit onwards — and perhaps even more severity.

I wrote a piece about it all, specifically focusing on the United States. I think there’s a lot to be done, and we should not just throw up our hands and give up.

To start with, not everyone who’s vulnerable is unvaccinated by choice.

To start with, not everyone is unvaccinated by choice. Children under 12 are not eligible to get the shots — that’s about 50 million young people. Plus, the immunocompromised may not respond as well to vaccines, which is at least about five million more people.

Then there’s the risk that, especially over time, the elderly, whose immune systems are not as robust, may lose some of their vaccine protection — as occurs with other illnesses, and as we’ve seen with Covid, to some extent, in Britain and Israel.

For example, we haven’t talked enough about vaccine mandates. They are a perfectly-acceptable answer that we have precedent for, and they can and should be deployed much more widely. About 40% of nursing home and long-term care staff are unvaccinated, for example—this should not be acceptable. But for that to happen, the FDA has to fully approve the vaccines as soon as possible. The safety data is there, and has been there, for two months now.

Some large employers already mandate flu vaccines. Kentucky legally requires everyone working at a long-term care facility to be vaccinated against the flu and pneumococcal disease, unless they have a medical or religious exemption. Mandates for Covid vaccines, too, should be issued, especially for people who work with high risk or vulnerable populations — children, the elderly, the incarcerated and those in medical settings — and possibly for employees in workplaces where large numbers of people congregate indoors. Exemptions, too, should be re-examined so that they aren’t overly broad.

A staggering 40 percent of workers at nursing homes and other long-term care facilities remain unvaccinated. This is terrible, considering that the elderly, even if vaccinated, would be expected to have more breakthrough infections.

People may have a right to take their chances with an infection but not to risk transmitting the virus to vulnerable others.

I know the urge to blame this all on the willfully unvaccinated because they’re dialed into Tucker Carlson every night, but the situation in the United States is complicated and the unvaccinated are not a monolith—they range from the willful antivaxxers to people just afraid of side effects and unable to take a day off from work.

We should make every effort to reach more communities and get them vaccinated. It’s possible that Delta’s renewed threat can be the tipping point for many.

We should also reconsider indoor mask mandates in places facing a surge, and tie relaxing them to concrete benchmarks.

Even if we can’t expect people to keep masking indoors forever while others refuse vaccination, too many remain vulnerable now to throw up our hands. One lesson in this pandemic has been that waiting too long to respond or relaxing rules too early can create serious problems.

Then there’s the vaccinated. I continue to believe that our vaccines have brought back the risk essentially to baseline for healthy, immunocompetent individuals. But the CDC stopped tracking vaccine breakthroughs unless very severe, and that was a mistake. We also need to understand transmission risks to craft better policy.

There is also a question about how likely the vaccinated are to transmit to others if they are infected with Delta. In May the C.D.C. stopped tracking breakthrough cases unless people became hospitalized. That was a mistake. Its explanation was that such cases were rare, and they may well have been when the decision was made. Delta is a reminder that the reason for surveillance is to be able to quickly notice changes in an outbreak.

Since Delta came onto the scene, I’ve acquired a pile of anecdotes from social media and a few examples from countries, like Singapore, that are doing a better job of tracing such cases that indicate vaccinated people are sometimes transmitting the virus. In comparison, I had hardly heard of any such examples from the Alpha variant, and studies did not indicate it could evade immunity in a substantive way. We also know that Delta has a higher viral load and infected people start shedding viral particles much earlier, so it makes sense why all this is happening.

Shouldn’t we have better evidence, though, so we can have better guidance, especially for those who live with unvaccinated children or have immunocompromised family members?

We need OSHA to step up with better workplace rules.

Given the ongoing nature of the threat and many remaining unknowns, the Occupational Safety and Health Administration should provide rules for rapid testing in workplaces, paid sick leave and, as appropriate, high-filtration masks and even ventilation standards.

I know we heard the phrase that it’s all become a “pandemic of the unvaccinated.” This has truth to it: the highest risk is for the unvaccinated, but just the children under 12 who are ineligible for any vaccine in this country is about 50 million.

Meanwhile, schools will open in the coming weeks, and yet so much remains unclear and confusing about protecting younger children until they can get vaccinated. Even if they seem to be largely spared from severe outcomes of Covid-19, they are not invulnerable. Plus, they can bring the infection home.

The CDC and the American Academy of Pediatrics now have contradictory recommendations about masking in schools, and some states are banning mask mandates. Ventilation, essential to limiting spread, is in the recommendations but implementation remains haphazard and hard to parse.

How is a parent supposed to navigate this situation?

The piece itself has a bunch of recommendations on schools, masks, vaccine mandates. But in some sense, what we need most is strong and unified leadership that helps people navigate this phase. The exact implementation could vary, but we need a better road map than what we have.

As I wrote, the acute phase of this pandemic is far from over. It’s a shame to let our dyfunction hobble us so badly when millions around the world dying for lack of access to vaccines that we have so much of that they are expiring on the shelf.