With COVID-19 hospitalizations and cases setting records in Maine as winter approaches, the pandemic that began 20 months ago seems like it will never end.
And scientists are now saying the coronavirus may always be with us.
“There is never going to be a pandemic ‘mission accomplished’ day,” Dr. David Dowdy, an epidemiologist at Johns Hopkins University, said during a conference call with reporters last week. “Zero COVID is not going to happen.”
But public health experts say society may learn to live with COVID-19. The tools scientists have developed to combat the pandemic are expanding, from greater access to vaccines to antiviral drugs to monoclonal antibody infusions. Protective policies such as vaccination cards to attend indoor events and employee vaccine mandates also are becoming more common.
Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, said there’s been a “gradual acceptance” among scientists, who initially believed eradication was possible, that the delta variant – among other factors – has deep-sixed elimination of the virus as a goal. But that doesn’t mean the virus can’t be controlled, he said.
“I’m hoping that in 2022 we can contend with COVID on the prevention front and on the treatment front,” Shah said in an interview.
Just in the past three weeks, children 5 to 11 became eligible for vaccinations, and Maine approved boosters for everyone 18 and older. Children under age 5 will likely be eligible for the vaccines in early 2022.
Two extremely promising antiviral drugs, one developed by Merck and the other by Pfizer, could soon be used to treat people who fall ill with COVID-19 and potentially could reduce hospitalizations by 50 percent to 90 percent. The medications could be approved as soon as late this year or early next year, although supplies could be limited.
“All these strategies we are putting forward are not going to eradicate the coronavirus, but are ways to keep people most safe and at lower risk of severe illness or dying,” said Dr. Navneet Marwaha, vice president and chief quality officer for Northern Light Health, the parent entity of Eastern Maine Medical Center in Bangor and Mercy Hospital in Portland.
LEARNING TO LIVE WITH COVID-19
While COVID-19 is far more deadly and transmissible than influenza – especially for people not fully vaccinated against the coronavirus – we may have to learn to live with COVID-19 the way society copes with flu season. People get flu shots annually, and for those who fall ill from influenza, antiviral medications help reduce symptoms and keep people out of the hospital.
“This doesn’t mean we send the white flags up, as we continue to fight this virus,” said Dr. Dora Anne Mills, chief health improvement officer for MaineHealth, the parent entity of Maine Medical Center in Portland and several other hospitals in Maine. “But we are in the process of learning to live with it.”
COVID-19 case rates and hospitalizations in Maine remain stubbornly high nearly a year after vaccinations first became available. And the state is setting daily records for new infections and hospitalizations on the brink of winter, the same point in time that a similar surge was just beginning one year ago.
The Maine CDC on Saturday reported a record 673 cases on a seven-day daily average, and hospitalizations reached a pandemic peak of 280 on Wednesday. State officials say to expect high numbers for at least the next few weeks.
Despite the grim metrics, a return to lockdowns or new mask mandates or other restrictions seems unlikely. Scientists have provided powerful tools to fight COVID-19, and those continue to improve. Vaccines are widely available, and about 70 percent of the state’s residents have the protection of at least two doses.
In schools, while mask mandates largely remain, the availability of vaccines for all schoolchildren is a huge improvement, Shah said. All vaccinated children, as well as any children who participate in pooled testing, no longer need to quarantine with an exposure to COVID-19. That will lead to fewer disruptions in schools.
Shah said there is even some preliminary talk internally within the Maine CDC and federal counterparts at the U.S. CDC about whether and when to recommend that masks do not need to be worn indoors by schoolchildren. He said he’s not sure where the recommendations will land, or if there will be guidelines, but case counts would need to decline first. There have been 4,433 infections and 167 outbreaks in Maine schools in the past 30 days, according to state data.
Pressed last week about the possibility of re-imposing restrictions, such as an indoor mask mandate, on the general population, Maine’s top health officials emphasized personal responsibility to get the vaccine.
“We’ve moved away from needing to do large-scale public policy interventions to keep people safe to trying to do everything we can to promote vaccination, because it has shifted from a public policy responsibility to an individual responsibility,” said Jeanne Lambrew, Maine’s health and human services commissioner.
Shah said during the same briefing that “things are bad.”
“We’ve broken a ton of records, but what differs now and compared to last year is that we’ve got vaccines that are resoundingly effective,” Shah said. “The situation we are in and the risk people face is, on some level, an elective risk. You need not put yourself and your family at risk of COVID-19.”
With 68 percent of the state’s 1.3 million population immunized, that leaves about 425,000 unvaccinated Mainers, most by choice. When the rollout of vaccination for children 5 to 11 years old is complete, it’s expected to increase Maine’s overall vaccination rate by 3 percent to 7 percent.
Choosing to forgo vaccination has resulted in deadly consequences in rural Maine, where case counts and hospitalizations have soared. Meanwhile, Cumberland County, the most-vaccinated county in Maine, has undergone an increase in cases this fall but has experienced a far shallower surge than rural counties.
Mills said from what she’s seen even within Cumberland County, hospitalized patients are much more likely to come from rural parts of Cumberland County rather than Portland and its suburbs, where vaccine rates are high and few people have needed to be hospitalized in recent weeks. About two of every three hospitalized patients are unvaccinated, and if a vaccinated patient gets a breakthrough case and needs to be hospitalized, they are much less likely to need critical care.
With large portions of rural Maine unwilling to get immunized, the antiviral drugs will likely be a game changer, Marwaha said. While monoclonal antibody infusions are an effective treatment, they are more difficult to administer than a pill.
“The ability to get these antiviral pills to patients, it may just help us turn the corner,” Marwaha said.
Vaccination rates vary widely by county, with Cumberland County leading at 78 percent of its total population vaccinated, compared with Oxford, Piscataquis, Somerset and Franklin counties recording less than 60 percent of the population getting their shots. Knox, Lincoln and Sagadahoc counties reported 70 percent or higher vaccination rates.
With the emergence of the delta variant this summer, projections for when Maine and the United States could reach herd immunity shifted. Herd immunity occurs when enough of a population has immunity – either from vaccination or previous infection – that the virus is contained and everyone benefits. Delta is far more transmissible than earlier strains of the virus, eliminating any hopes that the virus could be crushed at vaccination rates of 70 percent.
“I think herd immunity as people are conceptualizing it is unachievable,” said Dowdy, the Johns Hopkins professor, while also saying increasing vaccination rates should still be the “No. 1 goal.”
Also, scientists are detecting the virus in animals, such as deer, and a mammalian reservoir for the virus likely means it will continue to transmit to humans, Mills said.
However, Shah said over the long term, years or perhaps even decades, the virus may evolve to be less deadly.
“What can end up evolutionarily taking hold are the less deadly but more transmissible forms of the virus,” Shah said.
In the short term, public health officials continue to advocate for vaccination.
A poll of 1,080 Maine people released last week by the Maine People’s Alliance, a liberal advocacy group, shows that among those who are unvaccinated, 46 percent are open to getting the vaccine, although only 11 percent said they planned to get immunized.
There were sharp ideological differences among those willing to get the shots, with 29 percent of people who said they were “very conservative” saying they would refuse vaccination, and 17 percent who labeled themselves “conservative” also refusing vaccination. Ten percent of moderates and 3 percent to 4 percent of “liberals” or “very liberal” respondents said they would refuse vaccination.
But even while Maine and the U.S. roll out vaccinations and booster shots, officials with other parts of the health care system are learning to cope with the case surge.
Mills said that MaineHealth’s rural hospitals, such as Franklin Memorial Hospital in Farmington, Stephens Memorial Hospital in Norway and Waldo County General Hospital in Belfast, have in recent months started to care for COVID-19 patients, increasing the system’s capacity. Another factor is that even as hospitalizations have increased, the number of patients in the intensive care units has remained relatively flat during the fall surge, between about 70 and 80 patients since early September.
“We are seeing breakthrough cases of people who need to be hospitalized but are not sick enough to go to the ICU,” Mills said. About 23 percent of hospitalized patients since vaccines became widely available this spring are breakthrough cases, 389 breakthrough cases among 1,648 COVID-19 hospitalizations. Vaccinated people are many times less likely to be infected, and those who are infected usually have mild symptoms.
Marwaha said that breakthrough cases are much less likely to need to be in the ICU compared with the unvaccinated, which “speaks to the effectiveness of the vaccine.”
“The whole point of vaccination is to give our bodies a chance to fight the infection,” Marwaha said.
Another factor keeping people out of ICUs is the use of monoclonal antibody treatment, Marwaha said, which works to prevent hospitalization. People who get the antibody infusions, by avoiding hospitalization, are preventing greater use of the ICU. The treatment must be applied before symptoms are severe.
Mills said another reason hospitals have been able to cope with the surge in patients is that the vaccine mandate for health care workers has kept more people on the job. Fewer frontline medical workers are having to quarantine after falling ill with COVID-19.
Despite some reasons for optimism, the next few months could be difficult, Mills said. Those who do need critical care seem to be getting sicker from the delta variant.
“We’re very concerned about the next three to four months, with persistent vaccine resistance in rural Maine,” Mills said. “People are going to be gathering for the holidays like it’s 2019. We can’t predict how COVID is going to be this winter.”