‘Everybody is sick of COVID’

The US is in a stealth wave of stealth Omicron—probably.

It can’t be known for certain because the country doesn’t have the data it should have. That’s not for lack of technology or supply, but for lack of will power. Americans largely don’t want to get tested for COVID right now.

But it sure seems like another COVID wave, and Americans want to ignore it.

On Thursday the US had a seven-day average of nearly 42,000 cases, according to the Johns Hopkins University and Medicine Coronavirus Resource Center dashboard, based on US Department of Health and Human Services data—up 6,000 cases from a week ago and 14,000 cases from two weeks ago

These results don’t look like a wave. But it’s all about perspective, Fractal Therapeutics CEO and COVID researcher Dr. Arijit Chakravarty told fortune.

“We probably already are in a wave—the wave is the same size as the first wave in March 2020, which these days looks like a small wave to us.”

There’s no doubt US COVID cases are rising, said Dr. Stuart Ray, vice chair of medicine for data integrity and analytics at Johns Hopkins’ Department of Medicine—but by how much, it’s hard to say. Previous eras of the pandemic “aspired to a monolithic data collection strategy” in which tests were centrally reported to authorities. But results of at-home tests in the US, now widely available, aren’t tracked. Some with COVID don’t test because they don’t want to, or don’t have access to testing. And others with COVID don’t test because they don’t know they have it.

“It’s a complex, distorted landscape right now,” Ray said.

‘Waiting for the possibility of Pi’

Case counts and wastewater data in Massachusetts during the Delta wave look very similar to case counts and wastewater data in Massachusetts now, Chakravarty said, leading him to believe that current COVID numbers “aren’t massively deflated.”

But “the fact that we’re having this conversation at all tells us how the wheels are falling off the surveillance machine. We have to look at these things and make our own inferences.”

So far Ray sees a relatively small increase in cases, mostly BA.2, widely known as stealth Omicron. But he cautions that recorded case counts may not be reflective of actual COVID levels, adding that the official upward slope we see “might be shallower” than reality.

“I do worry that we are in the midst of a growing surge. We’re flying a little bit blind.”

The travel industry is reporting that flight volumes are beginning to normalize; mask rules are relaxing; and spring break almost certainly increased spread.

“All these things may have conspired to cause this rise. It’s unknown if numbers will continue to grow or plateau,” Ray said.

One possibility: The country is heading not for another spike, but toward an endemic state “where cases exist but are less disruptive than they have been historically.” But endemicity isn’t necessarily a good thing, he said.

“Endemic doesn’t mean mild, it just means predictable—and predictability can be bad,” he said.

Yet another: “It’s still possible the virus will evolve into something more evasive or more severe,” Ray said. “There was [the wild-type strain of 2020]then Alpha, Beta, Gamma, Delta, and now Omicron.

“We’re all waiting for the possibility of Pi. Each time a new Greek letter arises, it’s coming from an area we weren’t watching closely. Maybe the virus is evolving somewhere and we’re not going to notice until it’s picking up.”

That scenario is perhaps more possible with a rise in home testing versus testing at a medical facility, where positive samples can be genetically sequenced to determine lineage.

“You can’t do that with rapid tests that just get thrown in the trash.”

Searching for data in ‘hospitals and morgues’

Plots of officially reported positive COVID cases have never represented the full picture—but they might reveal less of it now than they ever have.

There are other helpful indicators, though, beyond positive tests that demonstrate where a society might be in terms of disease spread. Percent positivity, or the percent of individuals tested whose results come back positive, appears to be trending upward, Ray said. While there isn’t a seven-day average for this metric, positivity sat around 1% in mid-March. Over the past week it has hovered between 2% and 4%, according to Johns Hopkins. (At the beginning of the pandemic, the World Health Organization set a goal of a percent positivity of below 5% for communities wishing to reopen.)

If testing is inadequate, percent positivity can appear higher than it should because, generally, only the sickest are being tested, Ray cautioned.

Though percent positivity is rising, “it’s still not a huge number,” he said. “We were dealing with 15%, 20% at the height of Omicron. It’s not anything like that really sharp rise back in the winter.”

And there’s hospital data, also a helpful indicator of the presence of disease in a community. But hospitalizations lag a rise in disease, and reporting can lag even further, rendering this prevalence metric even less helpful than percent positivity.

“It’s hard to manage things when you’re looking in the rearview mirror to see where we are,” Ray said of hospitalization data.

Chakravarty similarly worries that the US is looking at lagging indicators in the absence of sufficient real-time data.

“If we only look at hospitals, there’s going to come a week when we’re going to say the hospitals are full, and it’s too late. The idea of ​​keeping on top of these things simply by looking at hospitals and morgues seems a little optimistic.

“Saying the vaccine is working well and only tracking hospitalizations is an invitation to finding ourselves in a situation where the vaccines aren’t working well after there’s anything you can do about it.”

Pandering to the electorate, and the path forward

Last weekend Dr. Anthony Fauci, COVID czar and chief medical adviser to US President Joe Biden, told ABC’s “This Week” that “each individual is going to have to make their calculation of the amount of risk they want to take” when it comes to COVID.

“This is not going to be eradicated, and it’s not going to be eliminated,” he said.

This week Philadelphia announced a return of its mask mandate starting Monday, citing rising cases. It’s a move that seems unlikely at this stage of the pandemic from many other governmental entities, Ray said.

“At a governmental level it’s increasingly hard to push mandates,” he said. “I get a sense folks don’t have much appetite for broad mandates.”

Another potential factor in local governments’ decision to issue, or not issue, mandates: this year’s midterm election.

In the early days of the pandemic “you could have been strongly pro-mask and only worry about having lost the Trump votes,” Dr. Nick Beauchamp, assistant professor of political science at Northeastern University, told Fortune.

Now, that’s not necessarily so. Manys are “now taking the centrist position” on pandemic precautions “in order to get swing politicians voters,” he said.

When it comes to mandates, Ray would “rather we empower people with the ability to manage risk and try to think of the most vulnerable when we make decisions about how we behave.”

Nearly two and a half years into the pandemic, “I’d like to think that folks have learned a lot,” he said, adding that individuals can choose to mask when levels rise in their area and test before attending large gatherings.

Beauchamp wishes local authorities would go back to announcing rising cases instead of burying their heads in the sand and remaining silent.

“We do this stuff for a lot of other things,” he said, citing warnings about adverse weather and road conditions from governmental entities. “When driving a car, when the roads get slippery, you drive more cautiously—you don’t see that as a threat to your freedom. You don’t drive 75 no matter how foggy and icy.

“The belief that you can’t even say that is slightly disheartening.”

And masking is such a small, simple request, he said.

“Each wave will last only like three, four months. Once it’s going down, people can dial back. Four to eight weeks, two to three times a year or something.

“People are like, ‘Oh my god, you’re saying we have to wear masks for three months out of the year?’ The answer is, ‘We do that for a few more years, and hopefully we have it under control, it goes down to low case levels.’”

Chakravarty recommends improving ventilation in homes and workplaces or the use of personal portable ventilation “as much as possible.”

“Get boosted,” he said, “because boosting does help.”

“And then focus on upgrading your masks,” he added, recommending religious use of N95 masks, especially ones with a silicone seal around the mouth.

He doesn’t see stealth Omicron, BA.2, as a huge crisis because so many caught Omicron, BA.1, and the two are sufficiently similar that there should be an overlapping immune response.

“BA.2 is less worrying than the way we’re dealing with BA.2,” he said. “If this is a test run of the ‘let ‘er rip’ approach,” he said, referencing the tendency of US health officials to allow the virus to spread freely, “that might work with BA.2.”

But such an approach might not work as well with the next variant.

“Everybody is sick of COVID,” he said. “Everyone says, ‘No one knows what will happen next,’” so there’s no way to prepare.

“That’s a bit like saying, ‘My house is on fire. I’ve heard some fires burn out and some fires don’t. I don’t really know what’s going to happen next, so I’m not going to do anything about it.’”

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