Dean's COVID-19 Commentary

Colorado’s epidemic curve continues to rise without clear indication as to future direction. We remain with more than twice as many people currently hospitalized with COVID-19 than were hospitalized at the end of June. The Delta variant has 13 sub-lineages, referred to as Delta Plus. The Colorado Department of Public Health and Environment now includes these variants in its data, which show an increasing proportion of the AY.3 sub-lineage. The clinical and public health significance of Delta Plus has yet to be learned, but the emergence of these sub-lineages is a reminder of the constant mutations of SARS-CoV-2 as it continues to circulate. 

Across the United States and globally, the pandemic is still soaring with frightening consequences in some U.S. states and other countries. In Colorado, state and local public health agencies have had the goal of not breaching critical care bed capacity through non-pharmaceutical interventions, and now vaccination. To date, that goal has been comfortably met in Colorado, but not in some other states like Alabama. Disturbing news reports from Alabama describe a statewide shortage of critical care beds and a failing healthcare system; the state’s rate of full vaccination is at only 36%. Other southern states are poised for catastrophe, including Florida which has experienced 3 million cases. Nonetheless, the irrational antics of Florida Governor DeSantis continue. And you can read more about another state doing poorly – Texas. Even after testing virus positive, Texas Governor Abbott opposes mask and vaccination mandates.  

Over the last few weeks, there was an indecisive discussion about the need for boosters, culminating in the announcement last week that CDC guidelines have changed. The core change is: “We are prepared to offer booster shots for all Americans beginning the week of September 20 and starting 8 months after an individual’s second dose. At that time, the individuals who were fully vaccinated earliest in the vaccination rollout, including many healthcare providers, nursing home residents, and other seniors, will likely be eligible for a booster.” The rationale cites inevitably waning immunity over time, the heightened transmissibility of the Delta variant, and other evidence from around the world. Waning vaccine effectiveness against infection in Israel may have been part of the rationale for the change in guidelines. 

Last week, Marc Moss commented on the toll of this latest surge of the pandemic from his perspective as a critical care provider and Chief of the Division of Pulmonary Sciences and Critical Care at the CU School of Medicine. This week, I invited Bill Burman, MD, Chief of Denver Public Health to comment on this bruising 18 months for public health. 

Reflections on local public health
Bill Burman, MD

This has been a tough month for local public health across the country. In the spring and early summer, COVID cases decreased by more than 90% and economies opened back up as vaccinations were rolled out to adults and then adolescents. There were a thousand challenges in getting vaccines out in an equitable way, but many communities, like Denver, made great progress. Then, in mid-July it became clear that COVID, and specifically the Delta variant, was on its way back. The first resurgences were in under-vaccinated communities, but then cases began to go up across the country and many other parts of the world. As of this morning (August 22), the COVID case rate has increased more than 10-fold in Denver (from 2.1 to 25 per 100,000/day), hospitalizations in Colorado have more than doubled (from 268 to 627), and the national death rate is back up to 1,000 COVID-related deaths per day. These changes are strong evidence that the Delta variant has fundamentally changed the pandemic. Back in June, we thought that community transmission could be controlled with vaccination coverage of ~70%, but case and hospitalization rates have markedly increased in many settings, like Denver, that exceed that threshold.
 
It is a tough time to respond to the COVID resurgence: everyone is tired, and many are angry. A major focus is on getting kids back in the classroom full-time. The evidence continues to mount that children and youth suffered academically and emotionally from long periods of remote teaching during the last two school years. Given the importance of full in-person learning for students, families, employers and the entire society, it is very discouraging that there has been such controversy about masking and vaccination of young people. Putting unvaccinated persons in close proximity indoors for 6-8 hours per day in the presence of rising community rates of transmission of a hyper-transmissible viral variant is a recipe for outbreaks. Unfortunately, this scenario has already played out in schools that opened without mask mandates earlier in the month in the presence of high community case rates – outbreaks, followed by a return to remote learning within two weeks of beginning the school year. Yet many of my colleagues are being severely criticized and even threatened for following the science and adopting public health orders to require universal masking in elementary schools.
 
What can be done? To the extent possible, we need to reframe this vitriolic debate. Our regional public health collaboration, the Metro Denver Partnership for Health, is working to combat the false dichotomy that a community can have either COVID control or open schools and a thriving economy. We are working with business and community groups to say that COVID control, based on vaccination and targeted masking requirements, is what will allow schools to reopen successfully (and thereby contribute to a thriving economy and community). We hope to develop a broad community standard of vaccination for those who interact with the public and for those who want to be in high-risk indoor venues (e.g., restaurants, bars, and gyms). We’re not sure whether such a sense of shared responsibility for the health of the community can be reached without public health orders, but it is time to try. 
 
During the first nine months of COVID vaccine availability, 75% of eligible persons in the metro area (those 12 years of age and older) have started vaccination – a notable accomplishment, but clearly not enough in the era of the Delta variant. There are still large disparities in vaccination, with lower coverage among racial/ethnic minorities. Furthermore, stopping the Delta variant will require higher vaccine coverage (~90%) and may require booster doses for those who have completed the initial vaccine series. We and our partners have developed effective innovations in community engagement, vaccine outreach, and no-wrong-door vaccine availability. Adding in targeted vaccine requirements, additional incentives for being vaccinated, and sufficient funding, I think we can control the Delta variant. 

Classes start today at CSU and UNC, and next week at CU Anschutz. I look forward to seeing our students in class with masks (for now).  

Jonathan Samet, MD, MS
Dean, Colorado School of Public Health

P.S. Back by popular demand, and resulting from the Delta variant spike in cases and hospitalizations, there will be a special bonus episode of the COVID-19 webinar series with the Denver Museum of Nature &  Science and its Institute for Science & Policy. Join us this week on August 26 at noon as we cover the latest on vaccines and variants, and examine what we know so far about breakthrough infections and the ongoing effort to bolster vaccines to keep pace with new mutations.