COVID-19: Where to Go from Here

When I started this newsletter my vision was to write about pregnancy and parenting.

The COVID pandemic dramatically changed the focus of this work, and for most of the first two years, the majority of the posts here were about COVID-19. Over the past year, this has become less and less true. Looking through the archives, it has been months since I wrote about COVID.

One reason for this is that there haven’t been a lot of updates. But more importantly, people stopped asking. This newsletter aims to be responsive, and, frankly, I get more questions these days about lead in chocolate than COVID-19. But the other day someone emailed asking, more or less, “What is the general deal with COVID now? How do we think about it going forward?”

It seemed like an appropriate time to address this. The COVID situation has evolved, for now, to what seems like a steady state. COVID is not gone, and (more on this below) it is still a significant health concern. But with high vaccination rates, and a large share of the population having had the virus, it has receded as a threat. Barring unexpected changes, we have arrived at a place where we are likely to stay for a while.

This means that when I address questions — which I’ll do below — these are really long-term answers. There was a time when the COVID situation seemed to change minute by minute; that time is not now.

Questions below! (Here’s a list if you want to jump…)

How to keep up with current COVID rates
Why are we still seeing so many COVID deaths
Scary headlines on COVID and child deaths
Long term booster planning
Vaccines for kids: timing, and boosters
I’m pregnant: What should I do differently?
Updates on long COVID
New study on masking
Ending the state of emergency – what does that mean?
The Bottom Line

How do I keep up with current COVID rates?

We do not know precisely. The U.S. has never been good at tracking COVID rates during the pandemic, and this has gotten essentially impossible over the past year. If people test at all, it’s with rapid tests at home, and these are generally not reported.

Some hospitals still do asymptomatic testing, but it is not common and not necessarily reported.

Your best bet for ongoing surveillance is wastewater, and the CDC has a nice wastewater tracking site. This doesn’t translate in a direct way to case rates, but it gives you a sense of how things are evolving over time. Most of these data showed a seasonal peak in December 2022 and now a decline.

I know there are still a lot of COVID deaths every day. Why is this?

There are still many COVID deaths every day, which is tragic. An extremely large share of these deaths are in older individuals. This has been true throughout the pandemic, and it has continued to be true.

Based on CDC COVID tracker data, the death rate from COVID in the 75+ group (in the most recent week with complete reporting) was five times higher than for those 65-75, 17 times higher than for those 50-64, 73 times higher than for those 40-49, 166 times higher than for those 30-39, and 664 times higher than for those 20-29. There were no deaths in people under 20 during this period, so we cannot do a calculation there.

What this means is that understanding why we are still seeing COVID deaths means understanding why we are still seeing them in older people. One reason is that this is, sadly, an age group with high mortality from many things. In the case of COVID, though, there are interventions that are likely to reduce death rates in this group. This includes booster vaccination and treatments like Paxlovid. Higher vaccine uptake and better treatment access isn’t going to completely eliminate these deaths, but it would reduce them.

I read a scary headline about COVID and child deaths — can you unpack this?

A study was recently published looking at causes of deaths in children ages 0-19 in the U.S. and arguing that COVID-19 was the eighth leading cause of death in this age group. The time period for the study was August 2021 through July 2022.

The methods in the study are straightforward and do not need much explanation. They look at pediatric deaths, and their causes, and rank them. What I think is probably useful to unpack is some context.

Every death of a child is an unspeakable tragedy. Full stop. Thankfully, child deaths in this age range are very rare. By far the most common cause, amounting to 25%, is preterm birth or other perinatal conditions. Accidents are the second (18% of deaths), followed by congenital conditions and chromosomal abnormalities, assault, suicide, cancer, and heart disease. COVID follows heart disease.

It is not clear why cause-of-death rankings are of inherent interest. Depending on how you group the causes, these rankings would change. What we should focus on is actual numbers. During this period, COVID accounted for 821 deaths of children in the U.S., the vast majority in children under 1 or 15-19. This makes it a very rare cause of death, but, again, that is not to dismiss it.

The perhaps more important context is where we have come to since this moment. At this point, post-Omicron, the vast, vast majority of children have had COVID-19. A good share, especially those over 5, are also vaccinated. Since September 2022, there have been a very small number of deaths in any child age group. The risks are therefore much lower even than they were before.

What is the long-term plan for COVID boosters?

The current plan for COVID-19 boosters is to recommend them once a year, similar to the flu, with a shot that is targeted to the expected strain. There is some debate about exactly when the CDC will choose the strain (this matters to vaccine manufacturers). As consumers, we should expect a recommendation to get a COVID-19 booster at around the same time we get a flu shot.

The value of the booster is an increase in protection for several months after vaccination. This includes good protection against serious illness and death, and likely some protection against symptomatic infection. The expectation is that COVID will have a seasonal pattern similar to other respiratory viruses, so the vaccination in the fall will provide protection during that key season.

Boosters are likely to be recommended for everyone, but they are most important for people who are at risk for serious illness and death — older people and the immunocompromised (more specifically on pregnancy below).

From the ParentData Archive: Should You Get the Bivalent Booster?

Vaccines for kids: Should they get boosters? Should I vaccinate at six months?

For healthy children who are already fully vaccinated or have had COVID, or both, the added value of a booster is fairly minimal. They are already extremely well-protected from severe illness, and the protection from symptomatic illness is relatively short-term and incomplete. If you would like to get your child a booster, the safety profile looks great, so there is no reason not to. But the protection value is small.

If your child has not been vaccinated and has not had COVID, an initial vaccine is the best way to give them some protection against serious illness. This category includes babies who reach six months without having had COVID. An initial vaccine series will provide good protection.

I’m pregnant. How much more careful should I be? Should I get a booster? What if I get COVID?

Pregnancy is a mild form of immunocompromise, so it is always a good idea to be a little more cautious about any disease exposure. And during the Delta wave of COVID (in fall 2021), there was evidence that unvaccinated women in particular faced higher risks of stillbirth and maternal morbidity as a result of COVID. A large review, based on global data from the early pandemic period, recently underscored this.

With vaccinations and with the Omicron variant, though, these excess risks appear much lowered. At this point, for healthy and vaccinated pregnant people, it makes sense to think of COVID like other respiratory illnesses — perhaps with a slightly higher threshold to avoid, but not a cause of panic. You will probably not be prescribed Paxlovid, given the lower risk and the digestive side effects. However, there are some circumstances in which it might be prescribed, and the limited data on safety are reassuring.

There is some value to getting a booster during pregnancy, if you do not get COVID while pregnant, for the same reason you get a Tdap booster: to provide immunity to the baby. Ramping up maternal antibodies at the right time (toward the end of the second trimester of pregnancy) increases the amount of active antibodies for your baby. This has been shown to protect infants against hospitalization in the first six months of life, before they can get their own vaccines.

From the ParentData Archive: Pregnancy COVID Updates

Are there any updates on long COVID?

Long COVID, the persistence of symptoms past acute infection, has remained somewhat elusive. We still have no clear agreement on what symptoms should appear in this definition and no comprehensive sense of how common it is. The most common long COVID symptom is persistent loss of taste and smell, but depending on the paper, you’ll see lots of other symptoms there.

We see figures like “20% of people develop long COVID,” but this seems extremely unlikely given what we observe in the world. What we do know is that persistent COVID symptoms are less likely with the Omicron variant, and even before Omicron, kids appeared to be unlikely to develop long COVID. New research out of Israel has shown that most long COVID symptoms resolve within a year.

Bottom line: This remains an evolving space, but the data we do have so far is becoming more reassuring.

From the ParentData Archive: Long-Term COVID Risks in Kids and Pandemic Baby Developmental Delays

I heard there was a study saying masking doesn’t work — true?

There is a recent Cochrane Review that discusses masking and also hand-washing. A Cochrane Review is intended to be a comprehensive review and meta-analysis of randomized controlled trials. In this case, when the researchers look at masking, they look at trials that covered both flu and the COVID-19 pandemic.

Based on trials of masks in community settings (i.e. where some people are encouraged to mask and some are not), they conclude that there is little overall evidence to suggest that encouraging masking works to reduce incidence. Basically, these community-based studies generally do not show lower flu or COVID-19 infection rates when masks are used.

Some people were very upset with this conclusion, although there is general agreement that Cochrane Reviews represent a high standard of quality. What I would say is that the findings are true but deserve context.

Mandating or encouraging masks in a community setting does not seem to have measurable impacts on COVID-19. A big part of this is likely about adherence. That’s not to dismiss this — the real world is the real world, so this is definitely the answer to the question What would happen if we mandated masks? (Answer: nothing.)

It’s not necessarily the answer to the question of whether you could lower your own illness risk by constantly wearing a well-fitting N95 mask at all times when around other people. Based on our understanding of the physical impact of masks, probably you could. This may have some downsides (for you personally), and it’s worth weighing those against your personal risk of illness.

I heard the COVID state of emergency is ending. What does that mean?

This has implications for the powers of the executive branch. Most of this isn’t likely to be super-visible to people on the ground, at least not in the short term. One change that does matter broadly is the link between the Medicaid continuous enrollment program and the end of the COVID emergency. More detail on this is here.

Bottom line: should I still be taking COVID precautions, and which ones?

One concrete answer: boosters for older people, vaccinations (or boosters) for pregnant people, and vaccination for babies at six months if they haven’t had COVID yet.

I also want to acknowledge:

For some people, their school or child care center still has COVID-specific policies that make getting COVID very disruptive. Despite CDC guidelines generally updating away from these, it is a challenge for working parents when it is still part of the protocol.
For people whose children are immunocompromised or under six months (and can’t be vaccinated yet), the need for precautions may remain. This is as much about other illnesses at this point as it is about COVID, but it is a reality that remains more front-of-mind than it has been in the past.

Going forward, different people are going to make different choices about risks. In case it is useful, I have two thoughts to frame your thinking.

First: for the vast majority of people, COVID-19 illness at this point will present like a standard respiratory virus. That doesn’t mean you want to court it! No one likes to be sick. But treating it very differently than you treat colds or the flu isn’t well backed-up by the evidence.

Second: whatever precautions you plan to take now should be ones you are comfortable with indefinitely, since you should not expect the situation to change.

One legacy of the past three years is continued fear of COVID, especially for people who have been extremely cautious. It may be difficult to break out of this and to put COVID in a broader context, but it may be time to do so.