A BA.2 Surge Could Wreak Unequal Havoc

Weeks after political leaders and media elites put the U.S. on a course to “return to normalcy,” the country finds itself again contending with an uptick in cases fueled by the highly transmissible BA.2 Omicron subvariant and the ending of public health measures. Some regions and cities, like Washington, D.C. and New York, are seeing particularly sharp rises in new daily cases. Many lawmakers and Biden administration officials have tested positive in recent weeks, including from a super-spreader event at the Gridiron Club.

The U.S. is clearly in a very different place today than we were when we faced the first surge. We now have safe, highly effective vaccines that dramatically reduce the risk of hospitalization and death from COVID-19. We have rapid tests and powerful new antiviral drugs like nirmatrelvir/ritonavir (Paxlovid) that can keep vulnerable people out of the hospital. However, we have not done nearly enough to ensure these life-saving tools reach those who need them the most.

As a result, there’s a risk that if BA.2 does lead to a wave, it could wreak unequal havoc. We worry that the “new normal” will be plentiful boosters and rapid, easy access to antivirals for the well-off, while the least-off are left behind.

The last surge, driven by the Omicron variant, affected Americans unequally, a pattern likely to repeat itself. The share of Americans killed by the coronavirus during the Omicron surge was 63% higher than other large, wealthy nations and peak daily deaths exceeded the peak of the surge driven by the more virulent Delta variant. Deaths and hospitalizations were not evenly spread: Black adults were hospitalized at four times the rate of white adults at Omicron’s peak. Children too young to be vaccinated were hospitalized at record levels, and one in five COVID deaths among children occurred during the Omicron surge.

The U.S. response continues to be crippled by an unwillingness to see these outcomes not only as an indictment of our pandemic strategy but as an imperative to close the gaps that fuel them. A COVID response package has stalled in the Senate. All states have dropped their indoor mask mandates — Hawaii was the last state to do so, on March 25. The CDC’s new thresholds for recommending mask wearing dictates that right now, people in 99.4% of counties do not need to wear a mask indoors, even in the face of rising cases. Based on the new CDC guidance, Joshua Salomon, PhD, at Stanford University and Alyssa Bilinski, PhD, MS, at Brown University estimate that the CDC would not recommend more prevention measures, such as indoor masking, unless daily deaths nationwide were projected to reach at least 1,000 per day. Freezing funding for COVID-19 control and scaling back public health measures as a possible BA.2 surge looms risks accelerating COVID-19’s uneven path of destruction.

Data on disparities must drive our response — not simply our outrage. Strategies designed around the highest risk groups can both narrow the sharply uneven outcomes and help to bring the pandemic under control.

Less than 70% of vaccinated Americans 65 or older have received a booster, and less than 80% of nursing home residents have been boosted. After narrowing racial disparities in vaccination, gaps have once again opened in booster coverage. As a possible BA.2 surge looms, the U.S. should pursue a targeted campaign to bring vaccines and boosters to nursing homes, workplaces, schools, and communities with lagging vaccination and booster coverage. The model should be one of bringing vaccines to people rather than people to vaccines, and should include strategies that include door-to-door vaccination programs and continued support of trusted messengers for sustained individual outreach.

Antiviral treatments will only save lives if they reach those who need them most. Therapy was already scarce before funding ran dry. In places where supply isn’t an issue, these treatments remain underused while early data shows racial disparities in treatment. Gaps in treatment are compounded by increasingly poor access to testing. Many of the hardest-hit communities had poor access to community and at-home testing, even before testing sites began shuttering across the country. Rural communities have outpaced urban ones in COVID-19 deaths; however, limited access to testing, dwindling pharmacies, and transportation barriers mar access in rural and underserved urban areas. Reliance on mass media and on only existing clinical systems further places treatment out of reach for individuals with limited access to care and high-quality information, as well as those facing language barriers.

To overcome all of these barriers, the U.S. must intentionally design systems to deliver testing and treatment to the individuals and communities at highest risk. The U.S. should automatically mail rapid tests to low-income households, and distribute tests as well as N95 masks via public schools and other community institutions. The “test-to-treat” programs should be expanded to include a broader range of sites and tailored to local realities, particularly in areas with limited pharmacy and primary care coverage. These strategies should be paired with a public information campaign enlisting both mass media and trusted local messengers.

Our public health strategies must also be adapted to protect those at greatest risk. An estimated 7 million Americans — or in 1 in 37 adults — are immunocompromised and cannot benefit fully from the protection of vaccines, and severe COVID-19 outcomes are overwhelmingly concentrated in this group. Independent analyses have demonstrated that the CDC’s new community thresholds for action are too high to protect the most vulnerable members of communities and to operate schools safely. As mask mandates in schools and workplaces fall away, a potential BA.2 wave could exact a devastating toll on the lives and livelihoods of our highest risk community members. Schools, workplaces, and other essential services should reinstate masking at the earliest signs of a surge and provide accommodations to enable immunocompromised people to participate fully in daily life.

Significant investments have yielded a growing arsenal of tools to control the pandemic. It will be a moral stain on the country if we do not invest the political will and material resources to bring them to the Americans that need them most.

Anne Sosin, MPH, is a policy fellow and public health researcher at the Nelson A. Rockefeller Center at Dartmouth College. Lakshmi Ganapathi, MBBS, is Instructor of Pediatrics at Harvard Medical School and Associate Director of the Pediatric Infectious Diseases Fellowship Program. Gavin Yamey, MD, MPH, is a professor of global health and public policy at Duke University, where he directs the Center for Policy Impact in Global Health.