How to handle a winter surge in COVID-19

The Bay Area’s recent wave of COVID infections, driven by the delta variant, is well into its decline. Cases are down by over 75% since their peak in early August, hospitalizations have waned, and we’re entering the “moderate” transmission category, where the CDC no longer recommends universal indoor masking.

All of this is great news. Yet, having gone through a summer in which many of us thought COVID wouldn’t surge again, followed by another surge in cases anyway, people are wondering what comes next. Now is a good time to look back at what we learned from delta and to study best practices from around the world in

both preventing future hospitalizations and deaths, and getting our society back to normal.

Let’s start with the data: delta mortality in the Bay Area so far has been similar to a typical flu. Over a winter flu season, influenza leads to on average 10.95 deaths per 100,000 population, or about 860 deaths in the Bay Area. According to the California state COVID database, last winter’s surge accounted for nearly 4½ times that many deaths in spite of extensive control measures, including stay-at-home orders and closures of bars, restaurants, schools and houses of worship.

Thanks to widespread vaccination, however, the delta-driven surge that began in mid-June has resulted in 711 deaths, a much milder result (83% of typical annual flu deaths) despite taking fewer precautions against a more transmissible virus. In San Mateo and Marin counties, where vaccination rates are highest, the delta death toll has been only around one-third of a typical influenza season. If we control for season by comparing the mid-June to mid-Oct time frame in 2020 and 2021, our analysis found that cases were 40% higher this year but deaths were 40% lower.

With the majority of the population protected by vaccines, COVID is becoming less deadly regardless of season. Vaccination prevents hospitalization and death with 90% to 95% efficacy, while vaccinated people who do end up in the hospital often have clear risk factors: they are older than 65 and have two chronic underlying medical conditions. Booster shots can now further protect those groups. Both Centers for Disease Control and Prevention, and Federal Drug Administration expert advisory panels have concluded the rest of us are already well-protected.

The Bay Area population’s immunity levels are clearly game-changing. And so, as a possible winter COVID surge approaches, we should be looking to other places with high immunity to learn how to move forward, rather than looking with fear at the impact on places with low immunity.

The Bay Area’s full vaccination rate (including non-eligible children) is similar to the 75% rate in Denmark, 74% in Norway and 68% in the Netherlands. Just as these highly vaccinated European countries don’t set policy based on what’s happening in Romania or Croatia, we here in the Bay Area don’t need to be afraid based on what happens in

Alabama or even in less-well vaccinated parts of California. Denmark lifted all COVID-19 restrictions on Sept. 10, Norway did the same on Sept. 25, and the Netherlands removed most restrictions the same day. (Of note, none of these countries recommended masking of children 12 and under at any point in the pandemic.)

These highly vaccinated countries are recognizing the profound value of prioritizing normalcy, for children most of all.

Data in the U.S. and globally has thankfully confirmed that although delta spreads more easily than earlier variants, it does not cause more serious disease in the children it infects. Unvaccinated children are still on average at even lower risk of hospitalization due to COVID-19 than fully vaccinated middle-aged adults, while the risk of serious disease in vaccinated children is essentially nonexistent.

While the media was filled with nerve-wracking stories of full pediatric wards in other places, the highly vaccinated Bay Area experienced almost no pediatric hospitalization surge. It should also be noted that post-viral infection symptoms from COVID (often referred to as long COVID) in kids were found in controlled studies to be overwhelmingly mild, similar to those seen with other common infections and self-resolving with time.

Promptly prioritizing a return to normal school (and normal life) reduces the harms of job losses, interrupted education and the physical, psychiatric and economic costs of ongoing restrictions. Armed with immunity, highly vaccinated countries are successfully dropping both masks and school contact quarantines without notable surges in child hospitalizations. This makes sense: Whatever quarantines and masks achieve in slowing COVID, it is certainly dwarfed by what well-prepared immune systems do.

With vaccination rates exceeding 90% in many Bay Area high schools, risk is now very small, almost certainly lower than that of seasonal influenza. However, our updated COVID rules place fewer restrictions on adults in bars, restaurants, gyms, and offices than they do on our overwhelmingly vaccinated, very safe high school students. After 18 months of massive disruption to their education, and with the American Academy of Pediatrics declaring a national children’s mental health emergency, we should let our kids experience the normal life they’ve needed so badly.

Vaccines will soon be available for our younger kids, too. While we wait, we can also follow the examples set in other countries to make life as normal as possible for them. Current California guidelines require quarantines for those who come into contact with COVID, a highly disruptive practice that keeps healthy children out of school, in many cases repeatedly. Fortunately, rapid antigen tests can be used to prevent quarantines for children by testing exposed children every morning for a week. This has been demonstrated effective in the United Kingdom, and many school districts across the U.S. are avoiding excessive quarantines of students with “Test to Stay” programs. Treating every sniffle as a cause for quarantine is highly disruptive for families. Thankfully, other states and

countries are showing us an alternatives that are much less disruptive than our current protocols.

Lastly, it’s time to switch our focus away from COVID cases when making public health decisions and instead focus on severe disease. The Bay Area’s delta wave didn’t bring an unusual

level of hospitalization or death. Other highly vaccinated places are adapting to this reality. After dropping restrictions, Denmark and the Netherlands have seen some increase in cases, but hospitalizations are similar to when restrictions were in place in early September and death rates have remained low and unchanged. In Norway, new cases and hospitalizations have continued to decline. In Germany, officials are switching from cases to hospitalizations as the metric for considering any future restrictions, and with 79% vaccinated the U.K. has remained open, despite sustained delta transmission

and the emergence of a new variant, because severe disease levels remain manageable.

Bay Area public health plans still hold the possibility of keeping restrictions in place based on cases alone. This should be updated to ensure we don’t disrupt life based on disease levels that are flu-like or less.

COVID isn’t going away. Delta has the ability to replicate in the noses of people with immunity gained though vaccination or infection, so it and other COVID variants will spread in perpetuity. But that doesn’t mean we don’t have an endgame with the virus. Population

immunity is already preventing unusual levels of serious disease. Just as we embraced the science of vaccination to get to where we are today, embracing other best practices from around the world can give us the freedom to move forward and reclaim our whole, unfettered lives.