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Is this the Covid-19 endgame?

Why experts believe life could be “normal-ish” by fall — and why they fear it won’t be.

A masked violinist onstage.
Covid-19 cases are down from their winter peak but still high. Experts wonder: Will the pandemic keep improving, or does the US risk another surge if reopening goes too fast?
Eva Marie Uzcategui/Bloomberg via Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Are we in the endgame now?

The Covid-19 pandemic in the United States has decelerated from its winter peak. On January 8, the country saw more than 300,000 new cases — a single-day record. Also on January 8, the US peaked at nearly 250,000 cases a day based on a weekly rolling average, according to Our World in Data.

As of February 24, the US is averaging a little more than 68,000 new Covid-19 cases every day. Hospitalizations have also decreased (to about 54,000 patients currently hospitalized, down from a peak of 130,000 in mid-January), as have deaths.

The improvement in the pandemic is significant. It’s likely attributable to a combination of people staying home after the winter holidays and more Americans gaining protection against future infection (whether through infection or vaccination).

The big question now is whether we’re seeing the beginning of the end. As more people are vaccinated, will this downward trajectory continue, or even accelerate? Or will case numbers start to level off and stay high (relative to most of 2020) for months?

The progress should be celebrated. Hospitalizations and deaths, arguably the more important metrics, are also way down. As more people get vaccinated, those numbers should continue to fall, as the approved vaccines have proven exceptionally effective at preventing the most serious illness. The US is now averaging about 1.3 million shots every day; with some improvement, the country may be able to deliver enough shots to reach herd immunity by the fall, according to some rough estimates.

But there are already signs that some states, particularly in the Northeast, are beginning to see cases plateau. A plateau would mean a more drawn-out final stage of the pandemic until widespread protection is reached — and more sickness and death than we’d see if cases keep falling. And it was a very real fear for the half-dozen public health experts I spoke with for this story.

“I think that you could call it an endgame, but it might take a long time,” Bill Hanage, a Harvard epidemiologist, told me. “I think we have passed the worst of the pandemic, but there is the potential for local bushfires to spring up.”

Experts worry people will relax their social distancing or mask-wearing too quickly, giving the virus more opportunities to spread. The more infectious new variants will continue to become more dominant and could exacerbate community transmission if people stop taking precautions.

Still, the general attitude I detected from epidemiologists is one of guarded optimism that the pandemic is entering its last stage — paired with anxiety that these final months could be more painful than need be if people get complacent.

“We need to take the pandemic seriously and not let up on our prevention efforts,” Josh Michaud, associate director of global health policy at the Kaiser Family Foundation, told me. “At least until our case numbers are much lower than they are now.”

Cases are going down nationally. But the decline may be tapering off.

The national numbers speak for themselves: The US is now seeing about one-fourth as many daily new cases as it was six weeks ago.

But that progress is more a representation of just how bad things got in December and January than it is an acceptable level of infection on its own terms. Right now, the national caseload is at roughly the same level as in the weeks before Election Day, which nobody would have called acceptable at the time. As Vox’s German Lopez has reported, every state in the country except for one — Hawaii — still has too many daily new Covid-19 infections, according to benchmarks set by experts.

“We’re still far from being out of the woods,” Tara Smith, a professor at the Kent State University College of Public Health, told me. “It’s better than where we were for late fall and early winter, but not nearly back to our lowest level of spread.”

National data can also obscure some of the important trends happening at the regional and state levels, where experts see indications that cases are not falling with the same speed.

Look at the Northeast: The average number of daily new cases dropped from 28,000 on February 1 to 19,400 on February 14. But the improvement seems to be slowing down in the back half of the month, with new cases in the region hovering right around 16,000 as of February 23. Cases have actually risen in Connecticut and Rhode Island over the past week. And while case numbers are going down a bit in several states in the region, including New York, Massachusetts, and Maine, the declines have been smaller than in other parts of the country.

Covid Tracking Project

“The Northeast in general appears to be settling down into a plateau,” Hanage said. Yet those states are pushing ahead with reopening: Massachusetts is moving into a new phase, allowing indoor performance spaces to hold events at 50 percent capacity. New York is now permitting more indoor dining.

Several experts told me they are also watching Florida, where the new B.1.1.7 variant is spreading rapidly and Gov. Ron DeSantis has been generally lax about social distancing and mask measures throughout the pandemic. New cases are down just 12 percent in the last week, and the state has one of the higher rates of new cases per capita outside of the Northeast.

So, there are already some potential trouble spots worth watching. But fortunately, the country has some important things working in its favor that could prevent these outbreaks from spiraling out of control again.

The reasons for optimism about the pandemic winding down

The way the Covid-19 pandemic ultimately ends is the virus runs out of people to infect. Every day, more Americans are gaining protection from the coronavirus, making it more difficult for it to spread.

There are the 28.4 million people who have had a confirmed case of Covid-19, for starters — likely an undercount, however, given the inadequate testing in the United States. A study published in JAMA last month estimated that, as of mid-November, the real number of infections had reached 46.9 million, a number that would have only grown since then.

In addition, roughly 45 million Americans have received at least one dose of the Pfizer/BioNTech or Moderna vaccines, which gives them some level of protection against the virus. We are nowhere near herd immunity yet (generally thought to mean at least 60 percent of the population has protection against the virus, and we may need closer to 70 or 80 percent for a virus as infectious as SARS-CoV-2), but the number of people who are vulnerable to the coronavirus is shrinking.

People may also be socially distancing more than they did around Thanksgiving and Christmas, when indoor gatherings seemed to drive the winter surge. As the Atlantic’s Derek Thompson observed, public health officials have cited Google mobility data showing less movement as one likely explanation for the downturn in cases. People may be nervous about the surge or the variants, but other factors might be in play, too, such as a normal post-holiday lull, or the bad weather across much of the country. The result is the same: The reduction in activity means fewer opportunities for people to spread the virus to one another.

Polling also continues to show most Americans say they are wearing masks every time they leave their house. These behaviors are hopefully having the desired effect and helping to lower transmission.

“We’re reaping some benefit from changes to individual behaviors and policies that occurred during and after the December and January surge in cases,” Michaud told me, “which eventually helped drive down transmission through things like greater adherence to masking and social distancing in many places.”

The warming weather should also work in our favor. While scientists still don’t perfectly understand how seasonality affects Covid-19’s spread, hotter temperatures will make it easier for people to gather outside, where the virus has a harder time moving from person to person.

The reasons for concern that the US will enter a long plateau

Experts still worry the end of the Covid-19 pandemic will be more protracted than necessary if local officials and individuals are too cavalier about resuming public activities and relaxing social distancing.

The problem starts with how many people are still susceptible to the virus. If we combine the numbers above on real infections and vaccinations, somewhere in the neighborhood of 100 million to 120 million Americans probably have some immunity to the coronavirus. But that still leaves 200 million people who don’t.

Yet people and politicians may look at the dropping case numbers and, after a year of quarantine and economic turmoil, be eager to get life back to normal as soon as possible. It’s a pattern we saw last year, when states started reopening businesses even while public health experts warned the virus wasn’t contained. The dips didn’t last and cases rose again.

Recent policy changes, such as New York City’s plan to permit movie theaters to hold screenings at limited capacity and Iowa lifting its mask mandate, suggest that the country might repeat the same cycle over the next few months.

“The risks come from reopening too soon and removing mask and distancing requirements,” Smith said. “I’m worried about complacency as cases decrease. It seems we haven’t yet learned the lessons of the pandemic, that if you start trying to return to ‘normal’ too soon, cases creep back up again.”

Any slowdown in the vaccination campaign would also lengthen the pandemic. For now, there is plenty of demand for the vaccines and more supply on the way. People seem to be growing more comfortable with the idea of getting the vaccine.

But the US may reach a point, before too long, when it has more shots than people willing to take them. David Celentano, who leads the epidemiology department at Johns Hopkins, said that if 20 percent to 30 percent of Americans remain hesitant about getting the vaccines, “we are in for trouble.”

So to keep up momentum, we need to remain vigilant about wearing masks and maintaining distance when we’re with people outside our household. We need to stick to outdoor activities as the weather makes them more palatable. And we need to keep getting our vaccines in order to keep building toward the herd immunity that will eventually bring the pandemic under control and allow life to return to normal.

Several of the experts I spoke with said they saw autumn as the critical moment in the pandemic. If over the summer we can keep cases suppressed while continuing to vaccinate people at a high rate, by the time the weather turns, the situation could be very different from 2020. Smith told me she had hope for a “normal-ish” late summer and fall.

“One of the best-case scenarios is that next fall, this will be like the flu,” Hanage said. “I think that will have been a good place to have reached.”

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