I love how you close each section with "what this means to you". Thank you for making all this complicated information useful for those of us without a medical background.
A beautiful, clear and thoughtful piece as always. But just as the five emergencies didn't really exist for most Americans for the last several months (at least), the ending of the self-same five will be recognized in a totally opposite fashion. Specifically, most Americans will wake up only when free healthcare (Medicare expansion), free tests disappear, free vaccines disappear, and free drugs disappear. And by the time that happens, I predict that the ship has sailed, and it will be impossible to bring it back into port.
Wow, excellent job untangling a lot of complicated pieces and explaining things in simple terms that are easy to understand. Thank you!
Where I live (Marin County, CA) wastewater is at an all time high (higher than January 2022), reported cases and test positivity are low, and nearly everyone is back to normal. Our county has excellent public health, and vaccination/booster rates are among the highest on the planet.
I am having trouble reconciling the high wastewater level with low cases and test positivity. Does this mean there’s a lot of asymptomatic transmission going on that’s not being picked up through testing? How does this translate in to personal risk of catching covid when I’m out and about?
My *guess* is that it's not that it isn't picked up by testing; it's that people are testing at home and it's not reported anywhere.
My child had covid last week. She had cold symptoms and tested positive on an at-home rapid test. Her positive case isn't recorded anywhere -- there's no place to report it. The absence form for her school asks for the child's symptoms (sore throat, runny nose, etc.) but does not ask for a diagnosis. So, her virus would (maybe) be reflected in our town's wastewater but it would not show up in any kind of test positivity numbers.
I suspect that the only tests that are recorded positives are people in the hospital or who are tested in a doctor's office (or who seek out a PCR test from a pharmacy or testing center). Thankfully, it seems like most people who are positive (after vaccination) have mild enough cases that they don't require a doctor visit, but people are testing at home (if at all) and there is no figure that accurately reflects the true number of positive cases.
Adding to this: My child had cold symptoms for four days before she tested positive. I tested her each day because I wanted to be responsible about her going to school. But my guess is that most people would test on day one or two and then chalk it up to being a cold (I almost did) and assume it's garden-variety cold, but they are actually walking around with covid.
Thanks. I should have mentioned that in our county, it’s pretty easy to self report Covid on the health department website. I do think many people don’t test long enough once symptoms develop, as you point out. Also, if you’re asymptomatic, you have no reason to test yourself, which means you unknowingly spread it to others because you don’t know you’re infectious. Given that so many people in Marin are vaxed and boosted, it’s possible this contributes to people being more likely to be asymptomatic when infected versus symptomatic, but that’s just a guess. Things aren’t adding up.
Yes, I agree that those are all possibilities. My county website has a reporting form that I believe is now defunct; it says on the county website that only PCR tests are counted. There was self reporting a year ago but no real mechanism for that anymore.
My community is also highly vaccinated and boosted; I am sure it's possible that people are asymptomatic and therefore don't think they have any reason to test.
I just think that most people are taking it less seriously, therefore testing less diligently and frequently, and there's not much reporting anymore -- all of which would absolutely explain why wastewater is high but reported positivity rates are low.
Ah! So, that's interesting to me. My county doesn't track variants but my state (NY) does. XBB.1.5 is about 75% prevalent here, with XBB just on its heels. So, really the XBB variants are about 80% of cases right now where I am. I assume that when my daughter caught covid last week, it was XBB. Mixed news from me... my daughter had her bivalent booster in early November and still managed to get covid last week. :(
BUT, the rest of our household had our bivalent boosters in September and (as of right now) none of us caught it from her as far as we know.
have been saying for a long time, Dr. Daniel Griffin gives the weekly clinical updates yes for COVID but also the unfortinate measles outbreak in Ohio, and he covered the Ebola outbreak in Uganda (if I remember correctly?) and on the twiv channel which has been around since ca 2005 has different shows. One on Wednesdays that has aired throughout the COVID pandemic with the virologists Vincent Racaniello prof of virology at Columbia U Med school and a polio researcher for 40 years there and his one time associate Dr. Amy Rosenfeld, a somewhat cranky but brilliant researcher now at the FDA, has recently changed to Office Hours w/ VC where he will have guests and answer questions on a livestream.
Interesting. Did the rest of your house also test to see if anyone was asymptomatic or are you concluding nobody else caught covid because nobody else had symptoms?
I’m glad your daughter is better and everyone is healthy!
I'd expect that less testing would result in higher test positivity rates but lower case counts. A while ago there was a lovely paper suggesting using the geometric mean of the two as an indicator of the "true" prevalence and the model lined up with serology surveys (this was pre-vaccine).
I would have agreed on this a year ago... because I think the positivity rates were mainly worthwhile when a lot of people were getting routine, scheduled tests (for work or school) and they would catch people who had the virus but were asymptomatic (or people who were required to test if they had symptoms). Now that the only people being tested are people who have symptoms, AND fewer symptomatic people are testing anyway, AND there is no reporting of most positives, I don't think that's a good indicator anymore, either.
I expect our Covid future (and future pandemics) to be as unnecessarily shambolic and sociopathically omni-destructive as our behavior in the face of the far worse, elemental problems of carbon and plutonium.
As usual this is a good, levelheaded analysis, but it leaves out oh, so many, important considerations, such as
(1) The end of emergency restraints on rent payments and evictions.
(2) The specification of an actual concrete and transparent plan with explicit criteria to monitor for surges, new variants, and other infectious epidemics (Measles is sure to explode soon.)
(3) Draft legislation to strengthen central CDC data collection authority.
(4) Specific public health guidance on protecting the 10+ million medically high risk and the 40-50 elderly high risk Americans from COVID.
(5) The development of an all variant vaccine
(6) The federal creation of a memorial (day?) for those who died and their families.
(7) Expedited federal disability for people with long covid.
BTW It is impossible to consider exiting the emergency without attending to the continued infection and suffering of our fellow citizens, mostly the elderly, the unvaccinated and the Republicans.
Hi, Dr. Jetelina: thank you so much, once again, for coming to the rescue with clear public facing communications. I do have one question. You note, “After May, insurers will be able to choose whether to reimburse for those tests or not. We don’t have word yet, either way.” From what I have read, from calling my congresspeople, and in listening to Jha speak about this, it does not appear that “insurers” includes Medicare. In the case of Medicare (or at least those of us on traditional Medicare), my understanding is that Medicare will not cover antigen tests at all after 5/11. If you have information that indicates this is not the case, it would be great if you would pass it on.
Thank you for this information! Beautifully and clearly written as always. The skeleton monitoring of Covid that will occur is beyond disappointing. And the lack of access to testing will seem to mean we will be flying blind. Do you have any concrete recommendations for a better approach going forward? Covid is still a leading cause of death, but with no data, who will know?
High risk person --like Ron above, decreased antibody production/primary immune deficiency--with health insurance who already feels so constrained/abandoned. And the front page of the Boston Globe highlighted that there are no primary care physicians available in this area.
No primary care physicians? Ugh. This is another emergency that is so much less dramatic than something like a pandemic. I would love to see a plan to a) get more instructors in medical schools and b) encourage medical students to go into primary care.
If it's any consolation, there was the same communication mess in France (I'm French) until a few weeks ago, when the government decided to form a new "scientific council" supervised by Brigitte Autran, a well-respected immunologist with a talent to communicate (almost) as good as yours! This will be the only voice (we hope!) for anything Covid and beyond. So you know what to do: reduce 5 to 1 (easier said than done). As always, highly useful information. Many thanks!
Again thank you Dr. Jetelina. You are outstanding. First of all the CDC should hire you so you could communicate to everyone. Actually I don't want that to happen because all they will do is muzzle you. As someone who is elderly and immune compromised and suppressed (I don't produce natural antibodies) the end of the emergency declaration sound so bad. Our health policy is helping to destroying the lives of so many. The only good thing is that we don't live in the UK where the National Health Service is so underfunded and understaffed that many are dying because of these situations. But no one cares. That could likely happen here when the emergency declarations are removed. My understanding is that a reformulation of Evershield is in clinical trial with availability??? in second half of 2023. Can you confirm this? Thank you again. Assuming this is the case I am already standing in line for it.
Yes, "AstraZeneca is accelerating the development of AZD5156 and is aiming to make it available in the second half of 2023, subject to trial readouts and regulatory reviews."
Excellent review of the meaning/impact of ending the national Pandemic emergency in May. Thank you for breaking it down in five buckets.
In my opinion, looking backward, there was a critically important sixth bucket that has already been dismantled. This sixth bucket is the “emergency preparedness” bucket. This $22 billion bucket was dismantled by Congress last March and was not restored in the final spending bill for this year that was passed in December.
Sadly, we still have not learned the lessons about the importance of Covid response and pandemic preparedness primarily for:
• developing, manufacturing and distributing new vaccines and therapies,
But also, as partially addressed in YLE assessment:
• surveillance/testing capacity to track existing/emerging infectious diseases;
• targeting public awareness efforts about treatments and vaccines (with special emphasis addressing vaccine hesitancy); and,
• supporting international efforts to track, prevent and treat infectious diseases.
While we are in a better place with Covid today than we were last year, there are still more than 500 Covid deaths every day (as of February 6) and mutations continuing to lead to new variants.
To stay ahead of the threat of this virus, NIH and drug companies need to develop new vaccines to more effectively prevent severe illness, and improved antiviral treatments. Public-private partnerships with robust government funding and direction are essential to make sure this happens.
Unfortunately, without a public announcement, this sixth Covid emergency bucket was dismantled last year, and our country is at risk. We have learned so much from the Covid pandemic and now is not the time to drop the preparedness ball. And yet it has been more than 18 months since new funding was approved for Covid-fighting programs. Congressional funding support is needed to make this a winnable battle.
Consider the wisdom of Yogi Berra when he said - “it ain’t over ‘til it’s over.”
Excellent newsletter. You mentioned that we may have more clarity regarding a second bivalent booster after a meeting of experts in mid February. When exactly is that meeting? Thanks for all you do. I am a non scientist (with deep admiration for the scientific community) and I appreciate the vibe of inclusion and non judgment for those of us who are from other fields but follow to be informed citizens.
This was an excellent article--but you still agree that the public health emergency should end, as you clearly stated in your last newsletter. You clearly stated *here* what is at stake for millions of uninsured/underinsured/low-income/disadvantaged people when this is allowed to expire. How do you square these two wildly opposite points-of-view? Clinically vulnerable people are waiting to know.
Re: vaccines -- the current EUAs prohibit parties other than the federal government from purchasing or distributing the vaccines. Either the EUAs will need to be revised to allow for private purchase and distribution (as was previously done with bevtelovimab), or BLAs will have to be issued.
I'm sure one or both of those things will happen, but if they hypothetically did not, then there would be no legal way for people to obtain COVID-19 vaccines after current supplies run out.
Thank you so much for this. I'm sure it took a lot of time to figure out and even more time to explain in a clear way. I wish this explanation was given out everywhere. The Medicaid check thing was a big problem before COVID, and I am sorry to see that situation return.
I love how you close each section with "what this means to you". Thank you for making all this complicated information useful for those of us without a medical background.
I’ll second that! I always appreciate the time and care you take to break very important information into layperson terms.
A beautiful, clear and thoughtful piece as always. But just as the five emergencies didn't really exist for most Americans for the last several months (at least), the ending of the self-same five will be recognized in a totally opposite fashion. Specifically, most Americans will wake up only when free healthcare (Medicare expansion), free tests disappear, free vaccines disappear, and free drugs disappear. And by the time that happens, I predict that the ship has sailed, and it will be impossible to bring it back into port.
Yes and that makes me angry and sad!
Wow, excellent job untangling a lot of complicated pieces and explaining things in simple terms that are easy to understand. Thank you!
Where I live (Marin County, CA) wastewater is at an all time high (higher than January 2022), reported cases and test positivity are low, and nearly everyone is back to normal. Our county has excellent public health, and vaccination/booster rates are among the highest on the planet.
I am having trouble reconciling the high wastewater level with low cases and test positivity. Does this mean there’s a lot of asymptomatic transmission going on that’s not being picked up through testing? How does this translate in to personal risk of catching covid when I’m out and about?
My *guess* is that it's not that it isn't picked up by testing; it's that people are testing at home and it's not reported anywhere.
My child had covid last week. She had cold symptoms and tested positive on an at-home rapid test. Her positive case isn't recorded anywhere -- there's no place to report it. The absence form for her school asks for the child's symptoms (sore throat, runny nose, etc.) but does not ask for a diagnosis. So, her virus would (maybe) be reflected in our town's wastewater but it would not show up in any kind of test positivity numbers.
I suspect that the only tests that are recorded positives are people in the hospital or who are tested in a doctor's office (or who seek out a PCR test from a pharmacy or testing center). Thankfully, it seems like most people who are positive (after vaccination) have mild enough cases that they don't require a doctor visit, but people are testing at home (if at all) and there is no figure that accurately reflects the true number of positive cases.
Adding to this: My child had cold symptoms for four days before she tested positive. I tested her each day because I wanted to be responsible about her going to school. But my guess is that most people would test on day one or two and then chalk it up to being a cold (I almost did) and assume it's garden-variety cold, but they are actually walking around with covid.
Thanks. I should have mentioned that in our county, it’s pretty easy to self report Covid on the health department website. I do think many people don’t test long enough once symptoms develop, as you point out. Also, if you’re asymptomatic, you have no reason to test yourself, which means you unknowingly spread it to others because you don’t know you’re infectious. Given that so many people in Marin are vaxed and boosted, it’s possible this contributes to people being more likely to be asymptomatic when infected versus symptomatic, but that’s just a guess. Things aren’t adding up.
Yes, I agree that those are all possibilities. My county website has a reporting form that I believe is now defunct; it says on the county website that only PCR tests are counted. There was self reporting a year ago but no real mechanism for that anymore.
My community is also highly vaccinated and boosted; I am sure it's possible that people are asymptomatic and therefore don't think they have any reason to test.
I just think that most people are taking it less seriously, therefore testing less diligently and frequently, and there's not much reporting anymore -- all of which would absolutely explain why wastewater is high but reported positivity rates are low.
My county also tracks variants, and XBB.1.5 hasn’t really taken off yet. It will be interesting to see what happens to wastewater levels once it does.
Ah! So, that's interesting to me. My county doesn't track variants but my state (NY) does. XBB.1.5 is about 75% prevalent here, with XBB just on its heels. So, really the XBB variants are about 80% of cases right now where I am. I assume that when my daughter caught covid last week, it was XBB. Mixed news from me... my daughter had her bivalent booster in early November and still managed to get covid last week. :(
BUT, the rest of our household had our bivalent boosters in September and (as of right now) none of us caught it from her as far as we know.
The experts I have been watching, esp on https://www.microbe.tv/twiv/archive/
have been saying for a long time, Dr. Daniel Griffin gives the weekly clinical updates yes for COVID but also the unfortinate measles outbreak in Ohio, and he covered the Ebola outbreak in Uganda (if I remember correctly?) and on the twiv channel which has been around since ca 2005 has different shows. One on Wednesdays that has aired throughout the COVID pandemic with the virologists Vincent Racaniello prof of virology at Columbia U Med school and a polio researcher for 40 years there and his one time associate Dr. Amy Rosenfeld, a somewhat cranky but brilliant researcher now at the FDA, has recently changed to Office Hours w/ VC where he will have guests and answer questions on a livestream.
Interesting. Did the rest of your house also test to see if anyone was asymptomatic or are you concluding nobody else caught covid because nobody else had symptoms?
I’m glad your daughter is better and everyone is healthy!
I'd expect that less testing would result in higher test positivity rates but lower case counts. A while ago there was a lovely paper suggesting using the geometric mean of the two as an indicator of the "true" prevalence and the model lined up with serology surveys (this was pre-vaccine).
I would have agreed on this a year ago... because I think the positivity rates were mainly worthwhile when a lot of people were getting routine, scheduled tests (for work or school) and they would catch people who had the virus but were asymptomatic (or people who were required to test if they had symptoms). Now that the only people being tested are people who have symptoms, AND fewer symptomatic people are testing anyway, AND there is no reporting of most positives, I don't think that's a good indicator anymore, either.
Nicely done—keep digging!
I expect our Covid future (and future pandemics) to be as unnecessarily shambolic and sociopathically omni-destructive as our behavior in the face of the far worse, elemental problems of carbon and plutonium.
As usual this is a good, levelheaded analysis, but it leaves out oh, so many, important considerations, such as
(1) The end of emergency restraints on rent payments and evictions.
(2) The specification of an actual concrete and transparent plan with explicit criteria to monitor for surges, new variants, and other infectious epidemics (Measles is sure to explode soon.)
(3) Draft legislation to strengthen central CDC data collection authority.
(4) Specific public health guidance on protecting the 10+ million medically high risk and the 40-50 elderly high risk Americans from COVID.
(5) The development of an all variant vaccine
(6) The federal creation of a memorial (day?) for those who died and their families.
(7) Expedited federal disability for people with long covid.
BTW It is impossible to consider exiting the emergency without attending to the continued infection and suffering of our fellow citizens, mostly the elderly, the unvaccinated and the Republicans.
Maybe if you successfully ran for public office, all of these points could be dealt with to satisfaction....
Thanks for the endorsement. Would love to, but I am 81 years old. I need to turn to guerrilla war far!
Ha ! I beat you, at 82.
Having difficulty adjusting to the egg-crate handling by my son and the grandkids.
I totally agree. So many people are just being written off. Thank you for this list!
Hi, Dr. Jetelina: thank you so much, once again, for coming to the rescue with clear public facing communications. I do have one question. You note, “After May, insurers will be able to choose whether to reimburse for those tests or not. We don’t have word yet, either way.” From what I have read, from calling my congresspeople, and in listening to Jha speak about this, it does not appear that “insurers” includes Medicare. In the case of Medicare (or at least those of us on traditional Medicare), my understanding is that Medicare will not cover antigen tests at all after 5/11. If you have information that indicates this is not the case, it would be great if you would pass it on.
Oh, I do hope that is not true since Medicare tends to cover those most vulnerable to COVID.
Thank you for this information! Beautifully and clearly written as always. The skeleton monitoring of Covid that will occur is beyond disappointing. And the lack of access to testing will seem to mean we will be flying blind. Do you have any concrete recommendations for a better approach going forward? Covid is still a leading cause of death, but with no data, who will know?
High risk person --like Ron above, decreased antibody production/primary immune deficiency--with health insurance who already feels so constrained/abandoned. And the front page of the Boston Globe highlighted that there are no primary care physicians available in this area.
No primary care physicians? Ugh. This is another emergency that is so much less dramatic than something like a pandemic. I would love to see a plan to a) get more instructors in medical schools and b) encourage medical students to go into primary care.
wastewater seems to be the only reliable surveillance method left, if it exist in your area:
https://biobot.io/data/
If it's any consolation, there was the same communication mess in France (I'm French) until a few weeks ago, when the government decided to form a new "scientific council" supervised by Brigitte Autran, a well-respected immunologist with a talent to communicate (almost) as good as yours! This will be the only voice (we hope!) for anything Covid and beyond. So you know what to do: reduce 5 to 1 (easier said than done). As always, highly useful information. Many thanks!
Again thank you Dr. Jetelina. You are outstanding. First of all the CDC should hire you so you could communicate to everyone. Actually I don't want that to happen because all they will do is muzzle you. As someone who is elderly and immune compromised and suppressed (I don't produce natural antibodies) the end of the emergency declaration sound so bad. Our health policy is helping to destroying the lives of so many. The only good thing is that we don't live in the UK where the National Health Service is so underfunded and understaffed that many are dying because of these situations. But no one cares. That could likely happen here when the emergency declarations are removed. My understanding is that a reformulation of Evershield is in clinical trial with availability??? in second half of 2023. Can you confirm this? Thank you again. Assuming this is the case I am already standing in line for it.
See https://www.astrazeneca-us.com/media/statements/2022/first-participant-dosed-in-supernova-phase-I-III-trial-evaluating-azd5156-a-next-generation-long-acting-antibody-combination-for-prevention-of-covid-19.html
Yes, "AstraZeneca is accelerating the development of AZD5156 and is aiming to make it available in the second half of 2023, subject to trial readouts and regulatory reviews."
Excellent review of the meaning/impact of ending the national Pandemic emergency in May. Thank you for breaking it down in five buckets.
In my opinion, looking backward, there was a critically important sixth bucket that has already been dismantled. This sixth bucket is the “emergency preparedness” bucket. This $22 billion bucket was dismantled by Congress last March and was not restored in the final spending bill for this year that was passed in December.
Sadly, we still have not learned the lessons about the importance of Covid response and pandemic preparedness primarily for:
• developing, manufacturing and distributing new vaccines and therapies,
But also, as partially addressed in YLE assessment:
• surveillance/testing capacity to track existing/emerging infectious diseases;
• targeting public awareness efforts about treatments and vaccines (with special emphasis addressing vaccine hesitancy); and,
• supporting international efforts to track, prevent and treat infectious diseases.
While we are in a better place with Covid today than we were last year, there are still more than 500 Covid deaths every day (as of February 6) and mutations continuing to lead to new variants.
To stay ahead of the threat of this virus, NIH and drug companies need to develop new vaccines to more effectively prevent severe illness, and improved antiviral treatments. Public-private partnerships with robust government funding and direction are essential to make sure this happens.
Unfortunately, without a public announcement, this sixth Covid emergency bucket was dismantled last year, and our country is at risk. We have learned so much from the Covid pandemic and now is not the time to drop the preparedness ball. And yet it has been more than 18 months since new funding was approved for Covid-fighting programs. Congressional funding support is needed to make this a winnable battle.
Consider the wisdom of Yogi Berra when he said - “it ain’t over ‘til it’s over.”
Excellent newsletter. You mentioned that we may have more clarity regarding a second bivalent booster after a meeting of experts in mid February. When exactly is that meeting? Thanks for all you do. I am a non scientist (with deep admiration for the scientific community) and I appreciate the vibe of inclusion and non judgment for those of us who are from other fields but follow to be informed citizens.
This was an excellent article--but you still agree that the public health emergency should end, as you clearly stated in your last newsletter. You clearly stated *here* what is at stake for millions of uninsured/underinsured/low-income/disadvantaged people when this is allowed to expire. How do you square these two wildly opposite points-of-view? Clinically vulnerable people are waiting to know.
Wow. Huge thank you for this very clear article.
Re: vaccines -- the current EUAs prohibit parties other than the federal government from purchasing or distributing the vaccines. Either the EUAs will need to be revised to allow for private purchase and distribution (as was previously done with bevtelovimab), or BLAs will have to be issued.
I'm sure one or both of those things will happen, but if they hypothetically did not, then there would be no legal way for people to obtain COVID-19 vaccines after current supplies run out.
Thank you so much for this. I'm sure it took a lot of time to figure out and even more time to explain in a clear way. I wish this explanation was given out everywhere. The Medicaid check thing was a big problem before COVID, and I am sorry to see that situation return.
We are wondering, as a couple in our seventies, if we will still be able to get vaccines every six months, even if we have to pay for them.