It’s time to rethink your COVID-19 risk tolerance

JThe United States is taking a crash course in learning to “live with the virus”. Policy makers and health experts agree that we have migrated to a less disruptive COVID-19 endemic phase. This produced detailed commentary on what life with the virus and achieving the ‘new normal’ might look like – freeing some while confusing others. Many people have spent two years avoiding and fearing the virus and are now advised that it is safe to unmask and resume normal social life. For them, it did not usher in a comfortable sense of natural transition, but rather caused a national emotional boost. Psychologists call this conflict avoidance.

The new CDC research map tool for COVID-19 community risk level attempts to balance the key goals of preventing hospital overcrowding and flattening the curve for serious illness. The agency’s previous map based on transmission level reflected most counties in bright high-intensity red. the new map is mostly a reassuring low-risk green. Critics of this new approach say the agency “seems to have moved the goal posts to justify the political imperative to allow people to return to normal life. What critics and proponents of the CDC’s new tool have missed is that – whether red or green – the tool is not it changing our previous fundamental relationship with the virus that we have had since the start of the pandemic. We are all still advised to avoid it with caution until it becomes “safe enough”. This old paradigm will not lead us to a “new normal”.

With new CDC guidelines, our old paradigm dilemmas remain endless. When should I hide? Do I send my child to school with the sniffles? Can I return to work after cancer chemotherapy? Do I need a fourth shot? When should I use rapid home tests? Should our family fly to our usual summer vacation spot?

In this age of cautious and charged optimism, few have grasped the stark reality that for the country to successfully navigate a sustained endemic phase, most of us must move from avoidance to acceptance of transmission and infections. Let’s sit with that for a second. This should be the focus of our endemic phase policies and practices. It is the seismic shift that will ultimately allow us to live in a sustainable new normal.

Here are five benchmarks that should help us get there:

1) Accept that we cannot outrun Omicron

Omicron is an extraordinarily communicable variant. It is ubiquitous and will eventually infect almost all susceptible people, whether or not they try to avoid infection. The Institute of Health Metrics and Evaluation estimates that about three quarters of the country have already “functional immunity” to Omicronand expects this to continue to “develop through the end of the Omicron Wave”.

As with many respiratory viruses like the flu, colds and pneumonia, we should expect to see a seasonal pattern with more case surges (positive tests). New outbreaks of high case numbers should not set off alarm bells to deviate from a new constant endemic phase paradigm, as long as the vulnerable population – bearing the brunt of the disease burden – is protected from the infection. We have accepted coexistence with many other transmissible pathogens with similar characteristics in the past, without undue mental trauma or physical disturbance. Now it’s the turn of COVID-19.

2) Identify “vulnerable” and “non-vulnerable” risk subgroups

The public has been conditioned by dire numbers on the whole population (all test positive cases, hospitalizations and deaths). This guides risk perceptions and actions for much of COVID-19 policy. Throughout the pandemic, this has resulted in a grossly inaccurate and a distorted view of individual risk and has led to excessive mass avoidance behaviors and poor policy. This faulty lens must now be replaced.

To enable the “new normal,” Americans can be separated into two distinct risk-based subpopulations: those who, if infected, have a similar or lower risk of hospitalization and death than the flu (called the “non-vulnerable”) and those with a much higher comparative risk of these outcomes (called the “vulnerable”.) Risk is actually a continuum from very low to very high, but this simplistic binary categorization is intended to provide a clear understanding of the audience.

The determination of vulnerability is based on three extremely dominant factors that lead to serious consequences of Omicron infection: age, immunological susceptibility and underlying conditions. Poverty and ethnic/racial factors also confer risk, but indirectly through social disparities and health equity.

Age is the strongest predictor of infection outcome. A recent CDC study found that compared to people under 30, people over 65 who are infected are 5 to 10 times more likely to be hospitalized and 65 to 340 times more likely to die. The absolute numbers are staggering. Those over 65 make up 13 percent of the population and in January produced 80 percent of Omicron’s total deaths. Those over 75 make up 6% of the population and produced about half of the daily average of 2,600 deaths during the January increase.

Individual and population susceptibility is reduced either by infection or by full vaccination. Is around 80 to 90% protective against serious illness and death, effectiveness decreasing dramatically with age and over time. The level of susceptibility is an ever-changing dynamic balance between increasing and decreasing forces. It should slowly increase in the coming months as Omicron declines. With the expected increase in transmission and further booster shots later in the year, we should again expect higher population immunity.

The CDC has listed more than twenty underlying medical conditions with conclusive evidence of a higher risk of serious consequences of COVID-19: obesity, advanced diabetes, mental disorders highest association with death. Additionally, there are approximately ten million immunocompromised Americans, who have autoimmune disease, cancer, chemotherapy regimens, or other reasons for immunosuppression.

In this new paradigm, approximately 20-25% of the US population has a current risk of serious illness from Omicron that is significantly higher than from seasonal flu. These vulnerable people are all people over the age of 65 and increase exponentially with advanced age, immunological susceptibility and significant comorbidities. Immunocompromised people of all ages are also included. This group must avoid infection, which is its main preventive measure.

The remaining 75-80% of Americans are “non-vulnerable,” meaning they have a similar or lower risk of serious outcomes from Omicron compared to seasonal flu. This group does not need to avoid infection. Their important metric is serious illness and deaths, not cases.

3) Prioritize the protection of the vulnerable population at high risk

This binary pattern now produces a much simpler, more focused, and effective disease mitigation framework: the new non-vulnerable normal can be similar to the old normal when interacting with other non-vulnerable ones. However, when the non-vulnerable interact directly with the well-being of the “vulnerable” population, specific arrangements should be necessary. In practice, this means universal masking on public transport, vaccination, reinforcement and masking for healthcare workers and in congregate settings, such as nursing homes. As a country, we have precedents for balancing ‘freedom from’ with ‘freedom from’ – for example in creating smoke-free public spaces.

For people in the vulnerable group, there is unfortunately no dramatic new normal. It is not a societal imposition but viral. COVID-19 and its variants have wreaked unimaginable and inequitable havoc on the vulnerable population. Vaccines and boosters have slowed but have unrooted this tide. Society will have to work hard through protective public housing, and every vulnerable individual and household will need a workable plan.

4) Plan for the most likely scenario

Many rightly fear the significant “known unknowns” related to COVID-19 infection. This includes the emergence of new variants, the dangers of Long Covid, the lack of an approved vaccine for infants and young children, and other possible adverse developments. These are all legitimate concerns, but the positive calculation of risks and benefits for most individuals and society is helping our normal lives resume. Wartime strategic decisions typically focus on “most likely case” assumptions while also preparing for the “worst case.” As new information develops, we need to maintain the ability to pivot quickly if things change for the worse.

5) Unite the country by minimizing restrictions

This “new normal” can perhaps shift us from the resentment of partisan politics and ideology to focusing on what works for the country to save and restore lives. The main issue becomes protecting vulnerable people, not masking and other interventions. Mandatory protections should focus only on areas where vulnerable people intersect. And I hope that many or even most Americans, regardless of their political outlook, can agree on this priority.

Coming together as a society is likely to be most effective when it comes to the collective embodiment of individual expression. This would not only yield public health dividends, but would also stimulate the economy and help restore America to full productivity and vibrancy at a particularly difficult time in our history.

Adopting these beacons will accelerate our progress towards the new normal. It will take time, tenacity and societal consensus to achieve our goal. But the pandemic exit ramp is clearly in sight.

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