An interesting discussion that I came across and shamelessly stole. Worth taking a few mins to read it. Added some extra posts in parentheses for context:
I don't think leaders here have wrapped their heads around the impact of Delta in the US. This is a new era: A) A bad phase of the pandemic for unvaccinated adults and B) The beginning of the endemic reality for vaccinated people. Policy responses require a new paradigm.
On A: A bad phase of the pandemic for unvaccinated adults. US vaccinations have flattened at an embarrassing level vs. peer countries. Lots of blame to go around here - I point fingers both at people yelling for NPIs forever and the nuts on Fox News - but the numbers are bad.
I was hopeful that the fact that the fast expansion into vaccinating younger people in the US would help suppress the Delta wave in unvaccinated people (herd immunity), but math for ~85% HITs given Delta probably makes that a pipe dream.
Scott Gottlieb hints at the CDC sitting on modeling showing a significant wave in the US.
In light of that, takes like this (So basically your choices are to get vaccinated or to get COVID) are probably fair.
Cases are just creeping up in the US on aggregate but I think we need to be prepared for a bad outbreak (in case numbers) like the UK, concentrated on unvaccinated people.
So far, the reaction has been mask mandates being reinstated in parts of CA, but other areas moving forward without NPIs. That is in a ~40k/day case environment. I'm not sure how the national mood will shift in a ~100k+/day case environment, concentrated on the unvaccinated.
But more on my policy thoughts later in the thread.
On B: The beginning of the endemic reality for vaccinated people. With Delta, it's unlikely that Covid will ever go away, or be held at low levels. I'm not convinced there's any realistic level of vaccination that could make that happen (it probably is now at a level that is unachievable even w/ very high vaccine coverage except maybe in some areas).
The dream would be treating this like the measles, of course. We know that global Zero Covid isn't possible, but in theory if you could keep sterilizing immunity high enough, you could keep infections low enough to not ever think about.
(Elimination is a red herring. Measles has extremely high R, has a low but notable rate of serious complications, and is not eliminated. But you never worry about it because over 90% of people were vaccinated as kids and it doesn't spread anymore. That should be our goal).
But transmissibility like Delta makes that unlikely. And we should remember that antigenic drift is real, and will likely break SARS-CoV-2 out of sterilizing immunity over time anyway. This isn't measles.
(CoV antigenic drift is capable of giving us a virus capable of evading sterilizing immunity & giving us a nasty cold for a few days. this is not the same as an immunologically novel virus).
Delta and low vaccination rates have ushered in the world where endemic SARS-CoV-2 is swirling around vaccinated people, but I suspect this was an inevitable reality. I was seduced by the VeryLowCovid reality of early Summer, hoping it would stay, but it's fleeting.
My takeaway here is that all vaccinated people will be at least exposed to SARS-CoV-2, and, with antigenic drift and waning nABs, will contract the virus at some point. Clearly, there are plenty of vaccinated people worried about this reality. How worried should we be?
The odds-on answer seems to be that once everyone is exposed (and we should expect 100% seroprevalence) it will be a common cold-level threat due to immunological memory, even with new variants over time.
If that's not the case, and this thing does burst through all immunity over time including protection against severe disease, I have no good answer. Boosters will be necessary but it will be a constant race to update them as variants spread. Let's hope not.
But I also suspect there is an outsized threat right now to some vaccinated people that is worse than the long-term threat of the endemic virus. My going hypothesis here is that some people who did not have a strong immune reaction to the vaccine are at risk right now.
There have been 791 deaths in the US of fully-vaccinated people, so we unfortunately cannot fully claim 100% protection against death from Covid-19 with the vaccines. Still, this of course pales in comparison to unvaccinated deaths.
There are signs that severe Covid cases are concentrated in sicker people who are less likely to have mounted a strong immune response to the vaccine, vs. breakthrough cases in the rest of the population.
(Almost all of them (96%) had comorbidities: heart disease, lung disease, renal disease, dementia, cancer, or other common ailments. People who get breakthrough infections and are admitted are sicker than a usual person).
In this world, the meaning of endemic Covid is that most of the vaccinated will be infected by SARS-CoV-2 at some point. For most of us that will be a cold. For those who don't seroconvert from the vaccine it could be a worse threat.
But, in this world, everyone will seroconvert eventually, one way or another. It will be a cold to everyone at that point. But on the road to that, vaccines won't perfectly protect everyone who is vaccinated from death.
That is both a tragedy and something I'm not sure we can solve.
Where does that leave us in terms of policy?
If my hypotheses are right, this leaves leaders in a dark place in the short-term but an okay place in the long-term. In the short term, there is nothing that leaders can really do to prevent 100% seroconversion, with all its consequences.
Obviously encouraging vaccination will reduce domestic deaths in the heretofore-unvaccinated, but even that comes at the cost of fewer vaccines available for abroad. And I don't think it protects those who don't mount strong immune responses long-term.
NPIs? Those come at a cost, and just delay the inevitable. We will not defeat Covid using NPIs - potentially just delay some infections into the future. That made sense when vaccines were on the horizon. Not as much now, unless there is imminent threat of HC system failure.
I make fun of places adding back light-weight NPIs with a history of failing. The reality is that masks won't stop the train to 100% seroconversion, but they do have real costs (bars / clubs / music can't functionally operate with masks; return to office just won't happen).
The sad reality here is that, even if the endemic steady state is okay, there are dark days ahead for the world. The sadder reality is that NPIs aren't very helpful tools, and come at a real cost. The sort-of exception is if you can buy time to higher vaccination with them.
I think the reality of endemic Covid needs to be communicated to the world at this point. As I said at the top of the thread, I don't think many US leaders have fully wrapped their heads around it. Maybe the CDC has, but probably not state leaders.
In a sense, I admire Boris Johnson and Chris Whitty for being pretty honest with their people about this reality.
The summer has been a fun summer of reopening in the US for many (myself included), but my crystal ball is foggy about both how leaders will react to the immediate surge in cases and to the reality of long-term endemicity.
