How State and Local Leaders Can Prepare for Future COVID-19 Surges
With national data suggesting that the omicron variant is subsiding throughout the United States—and polls showing a new level of COVID-19 fatigue—public conversation has turned to “learning to live with Covid” and reaching a “new normal.” How the nation defines these terms and selects the data used to make decisions has implications for policymakers as they dial back public health measures while maintaining readiness to prevent future surges.
The Centers for Disease Control and Prevention’s (CDC) most recent seven-day moving average as of February 27 shows new cases fell by 38 percent, deaths fell by 13 percent, and new COVID-19 hospitalizations fell by 31 percent. New CDC guidelines released at the end of February labeled 70 percent of local U.S. areas as having “low” or “medium” community risk, in contrast to the previous classification—based on new case incidence alone—that placed 95 percent of the country in the “high” category for community spread. However, more than 60,000 new infections still occurred each day, and there were almost 12,000 deaths over the course of the week. According to experts, the country needs to be prepared for continued COVID-19 cases, like with other respiratory viral illnesses, but take actions to reduce health and economic complications. COVID-19 may be moving toward an endemic stage (see text box below), but it still poses great risks and is unpredictable, warranting a gradual transition in policies.
CDC 7-day moving average as of February 27 reveals COVID-19 spread is waning
Decrease in new COVID-19 cases
Decrease in COVID-19 deaths
Decrease in COVID-19 hospitalizations
As states and local governments relax public health measures, it is imperative that they maintain readiness for future surges and closely monitor the public health system’s capacity to provide protective equipment, tests, treatment, and hospital care. Monitoring the extent of transmission, the severity of disease, and levels of protection—particularly in concert—can reveal the level of threat and degree of readiness.
Epidemic, pandemic, or endemic?
Understanding these three terms can be helpful for policymakers as they determine mitigation measures.
An outbreak is called an epidemic when there is a sudden increase in cases. When it spreads across several countries and affects many people, it is called a pandemic.
An infection is endemic when the overall rates are neither rising nor falling.
When an infection becomes endemic, it does not mean that it is less widespread, nor less serious. Malaria, for instance, an endemic disease, killed more than 600,000 people globally in 2020. Tuberculosis, another endemic disease, caused 10 million illnesses and 1.5 million deaths in 2020.
A path forward
As COVID-19 cases wane, policymakers are seeking clear guidelines and metrics for decision-making. Decisions about how and when to relax public health measures require examining scientific evidence, setting goals and benchmarks, and weighing trade-offs. For instance, given the extensive impact of COVID-19 on the economy and on the mental health of America’s youth, keeping businesses and schools open should be a priority, but doing so also requires keeping the virus in control.
Policymakers face the challenge of protecting public health amid public weariness of the pandemic. A Yahoo News/YouGov survey from January found that 46 percent of respondents thought Americans should “learn to live with” the pandemic “and get back to normal,” while 43 percent thought, “We need to do more to vaccinate, wear masks and test.” In fact, precautions may be precisely what enables the resumption of previous activities. Any “new normal” should include precautions to protect communities, avoid new surges, and enable continuation, or safe resumption, of activities. For instance, masking that prevents disease and absenteeism could allow schools to resume activities that students have missed, such as field trips and assemblies.
While there are steps that individuals can take to protect themselves regardless of local policy, public policy should prioritize the needs of high-risk populations and disabled people.
Indicators for relaxing restrictions must be sensitive to community conditions given the potential for spread and the recognition that there are particularly vulnerable populations who may not be able to protect themselves, including people who are immunocompromised, disabled people, older adults, and children who are too young to be vaccinated. While there are steps that individuals can take to protect themselves regardless of local policy, public policy should prioritize the needs of high-risk populations and disabled people without requiring them to bear the brunt of protective measures. As a public health pandemic, the worldwide spread of COVID-19 has demonstrated that, as the World Health Organization says, “No one is safe from COVID-19 until everyone is safe.”
As the United States enters a new stage of the pandemic, policymakers should clearly communicate which guideposts they are using for scaling up or reducing COVID-19 precautions. While policymakers, scientists, and public health experts may disagree about the optimal timing for rolling back COVID-19 pandemic restrictions—and as case rates and positivity rates, two factors closely tracked early in the pandemic, become complicated by unreported at-home testing—policymakers should consider a variety of factors to understand the current situation, predict the future, and make sound decisions. The CDC recently unveiled a new “community levels” classification designed to guide decisions about community prevention strategies and individual behaviors. The guidance relies on a combination of three metrics: new COVID-19 hospital admissions, share of staffed inpatient beds occupied by COVID-19 patients, and whether the new case rate is above or below 200 per 100,000 people in the past seven days. While these indicators are informative for making policy decisions and assessing risk, this column urges state and local leaders to also pay close attention to other early indicators of surges in COVID-19 spread and the local public health system’s capacity to respond to crises.
Indicators for consideration
Metrics related to COVID-19 prevalence and severity, precautions and protections, and treatment provide a guide for policymakers to prepare for new variants or surges, as well as suggest where to dedicate resources now. Some indicators are straightforward, while others may be challenging to measure. Indicators should emphasize community conditions and center the needs of disabled people and the most vulnerable to reduce harm during transitions. Policymakers should also consider these indicators in conjunction with each other: For instance, high vaccination and testing rates might justify relaxing mask requirements earlier. Decision-makers must consider a variety of indicators, as critical factors keep changing and data may be delayed.
COVID-19 prevalence and severity
The CDC has been using new case incidence as its chief metric for community transmission but recently updated its guidance for recommended prevention behaviors such as masking in indoor public settings. Transmission data, while important, provide only one piece of the puzzle and can be challenging to interpret, given that at-home test results often are not reported and thus not included in case rates. Case rates also do not provide information on disease severity, which varies depending on virus strain and vaccination status. Trends are important in addition to rates; even with positive trends, policymakers may seek continued stable trends over time before making decisions.
Wastewater surveillance provides another mechanism to measure case rates, detecting the coronavirus in people with and without symptoms. Wastewater surveillance has several benefits: It can track trends in infections over time and can be an early indicator of increasing or decreasing incidence, and it captures the entire population served by the municipal wastewater system, regardless of symptoms or testing practices. For example, the drop in the viral load in wastewater helped reveal when omicron had peaked in Boston and New York City in January and provided a warning that it was rising in other cities. The CDC’s National Wastewater Surveillance System is supporting 37 states in developing wastewater surveillance systems. Sustained federal financial investments in health departments would support state and local capacity to develop and maintain these systems, which can be used to identify other community health concerns, such as foodborne infections and influenza.
Policymakers should also track trends in hospitalizations as an indicator of COVID-19 prevalence and severity. A comparison between the delta and omicron variants illustrates the value of hospital data. The omicron variant is less likely than the delta variant to cause severe illness, but it also spreads more easily, even among the vaccinated population, which led to the January spike in hospitalizations; more people contracted the virus, increasing the chance for hospitalizations. Despite decreased severity, the omicron variant led to high patient loads and critical staffing shortages, which have ramifications for patients needing care for both COVID-19 and other conditions.
Another indicator for tracking transmission trends is absentee rates at schools and businesses. By dialing up precautions such as masking in response to growing absences, communities and school districts may be able to avert future situations such as those experienced during the omicron surge, in which businesses did not have sufficient healthy employees to stay open and schools did not have enough healthy staff to operate in person. These trends also are important to track the prevalence of COVID-19 cases that may appear mild but become the more severe, disabling condition of long COVID.
COVID-19 precautions and protections
Of all the strategies available to support pandemic recovery, vaccination is most effective. According to CDC data, in December 2021, unvaccinated people ages 5 and older were 14 times more likely to die from COVID-19 than fully vaccinated people. What’s more, on average, boosted Americans are 97 times less likely to die of COVID-19 than those who have not been vaccinated. Vaccines are safe and effective and can reduce the spread of disease, protecting both individuals and communities. School districts could consider vaccination rates of staff and students in deciding whether it is safe to ease mask requirements. Ensuring older adults are up to date on their vaccinations, including boosters, is critical, and these rates could also be used as a metric for determining when to ease mask requirements in settings such as long-term care facilities, given this group is most at risk. Compared with 18- to 29-year-olds, the rate of death is 65 times higher for 65- to 74-year-olds, and risk increases substantially for those 75 and older. Currently, 66 percent of adults age 65 or older have received a booster shot, with the highest rates in Vermont, Minnesota, and Wisconsin.
According to CDC data, in December 2021, unvaccinated people ages 5 and older were 14 times more likely to die from COVID-19 than fully vaccinated people.
Ensuring sufficient availability and accessibility of free COVID-19 supplies, including high-quality masks and rapid at-home tests, is critical for individuals and communities to avoid infection, regardless of income, location, or individual or community vaccination status. The American Rescue Plan provided states with funding for critical COVID-19 public health activities, including vaccine distribution, testing, contact tracing, and surveillance. Gov. Tim Walz (D) in Minnesota and Gov. Gretchen Whitmer (D) in Michigan, for example, have provided free KN95 masks to residents, forming partnerships with schools and child care centers, community groups including area agencies on aging, local public health departments, and health clinics to ensure distribution of high-quality masks reaches higher-risk people and higher-risk settings. Wisconsin formed a collaboration that allows state residents, with or without symptoms, to test for COVID-19 using saliva samples collected in their own homes, at no cost. California issued a plan to prepare for future surges by stockpiling masks, maintaining capacity to provide vaccine doses and coronavirus tests, tracking trends, and supporting vulnerable communities.
Finally, quality ventilation and filtration systems improve air circulation inside buildings and reduce the spread of COVID-19, which is particularly important as schools roll back mask requirements. The Elementary and Secondary Schools Emergency Relief Fund, the Governor’s Emergency Education Relief Fund, and the Higher Education Emergency Relief Fund can be used to support measures that improve school indoor air quality. Although long-standing school infrastructure improvements, including ventilation improvement, are still needed, the quality of these systems can be one of a variety of indicators of readiness to ease off COVID-19 precautions.
New drugs can help prevent COVID-19 in people with weakened immune systems, and monoclonal antibody treatment such as bebtelovimab can keep high-risk patients with COVID-19 from needing to be hospitalized. The Biden administration is purchasing 600,000 courses of bebtelovimab, given intravenously to keep high-risk patients with COVID-19 from getting so sick they need to be hospitalized. Policymakers need to make sure that these therapeutics are available and that consumers know if they are eligible and how to get them; this requires communication mechanisms that reach the most marginalized groups, who may not have access to a computer or the internet. As supply ramps up, policymakers also should prioritize the most vulnerable. New York City, for example, is providing free, same-day, at-home oral antiviral pills for those who test positive and are at higher risk for severe illness. New Yorkers can contact their doctors or call 212-COVID19 to request a delivery.
Policymakers should monitor hospital and ICU capacity as an indicator of COVID-19 spread and severity and use limited capacity as a warning sign.
Hospitals have been strained throughout the pandemic, with intensive care units (ICUs) in many cities stretched beyond capacity due to COVID-19 surges and scheduled procedures. Policymakers should monitor hospital and ICU capacity as an indicator of COVID-19 spread and severity and use limited capacity as a warning sign for when health care systems may need to take measures—such as canceling elective procedures—to prevent the system from becoming overwhelmed and for other community action. For example, one new tool created by NPR uses analyses from the University of Minnesota’s COVID-19 Hospitalization Tracking Project to provide information on local hospital strain, through a ratio of COVID-19 hospitalizations to total beds. According to experts, the ratio is concerning when it rises above 10 percent, while “high stress” and “extreme stress” ratios are indicated at 30 percent and 60 percent, respectively. Similarly, a dashboard that shows critical levels of transmission and hospital capacity could be used to trigger temporary steps to limit the spread, such as reducing indoor dining capacity, to keep hospitals from being overrun. With federal investments, states could create and manage such tools to provide assurance of sufficient surge capacity to avoid overwhelming health care providers, which is critical at this stage of the pandemic to avoid burnout, ensure care for non-COVID-19 health issues, and safeguard patient safety.
COVID-19 safety and readiness indicators
Policymakers should look to a mix of indicators as they adjust COVID-19 precautions.
COVID-19 prevalence and severity:
- Test positivity rates
- Case rates, according to case reporting and wastewater surveillance
- Local hospitalization rates, including ICU bed utilization
- Death rates among those who are up to date on vaccinations
- Absentee rates in schools or in the workforce
Availability of COVID-19 precautions and protections:
- Vaccination rates among full population and subsets
- Rates of booster doses among older adults
- Sufficient affordable supply of COVID-19 tests in the community
- Sufficient affordable supply of quality masks (KN95, N95)
- Quality of ventilation and filtration systems
Capacity for COVID-19 treatment:
- Availability of therapeutics such as monoclonal antibody treatment and antiviral medication
- Assurance of sufficient surge capacity for health care providers
As the omicron variant wanes, the United States will continue adapting and moving away from a heightened state of emergency. However, policymakers should commit to funding robust public health surveillance systems; be prepared and equipped to resume precautions if new surges materialize; and ensure availability of tools to protect communities, with particular priority given to the most vulnerable. Keeping an eye on indicators that reflect COVID-19 prevalence and severity, appropriate COVID-19 precautions and protections, and treatment is crucial to preventing future waves of illness and economic disruption.
The author would like to thank Emily Gee, Jerry Parshall, Marquisha Johns, and Mia Ives-Rublee for their input.
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Director, Public Health