What’s next with COVID?
November 9, 2020
By Tom Vasich
Andrew Noymer is an associate professor of public health at UCI, and he’s an expert on public health responses to pandemics like COVID-19 and their long-term consequences. In this special UCI Podcast, he discusses what we’ve learned over the last eight months of the pandemic and what we can expect next with the novel coronavirus. For instance, we need to get prepared for a harsh winter with a surge of infections. Also, he talks about the impact a vaccine can make for having the general population reach herd immunity levels, and our realistic future living with a virus that won’t be going away anytime soon. And don’t forget, wearing a face covering works.
It’s been eight months since COVID-19 began its assault on American society. Many of us were sent home from work, and all but essential businesses closed down. This fall restrictions were eased, but now the virus is coming back with a vengeance with illness rates matching those of this spring. It seems a long dark winter of COVID awaits us.
I’m Tom Vasich, and this is the UCI Podcast. Andrew Noymer is an epidemiologist in the UCI Program in Public Health with a particular expertise on viral pandemics. He even wrote his Ph.D. thesis about the great 1918 influenza, and he has quickly risen to the top as an expert during this COVID-19 outbreak. And he continues to be interviewed by leading news outlets across the nation, including the, the Atlantic, CNN, the LA Times, the Washington Post and The New York Times. If anyone knows about the future we face with COVID-19, it’s Andrew, and he joins us on the podcast to offer his insights into how the next few months will shape up what we can expect beyond that. And when COVID-19 will end.
UCI Podcast: At the time we’re recording this, 230,000 Americans have died from COVID. There are 9 million cases and probably more for reasons well discuss later. And the United States has 331 million residents. How can we interpret these numbers when we really have nothing to compare it to?
Andrew Noymer: Well, thank you for having me on this podcast, and I’ll do my best to give you a frame of reference, to understand what these numbers mean. So here we have 230,000 deaths and counting from COVID so far this year. It’s going to take a long time before we fully understand all the dimensions of COVID mortality. Those are deaths that have been reported as COVID deaths. We’re going to have to compare when we have all the final mortality statistics for the year, you know, how many deaths we see this year, but, and, and, and that takes time. It takes, there’s an enormous lag in mortality statistics. And here, I’m not just referring to the fact that the deaths lag cases of COVID, I’m referring to the fact that it takes time for the national center for health statistics to compile all the death certificates.
And let me give your listeners an example of what I’m talking about here. The latest numbers that I’ve crunched have been through week 30 of 2020, and that is a week that is the end of July. And according to the 21st of October dump from the national center for health statistics, there was an excess mortality of about 150,000 deaths in the U.S. compared to what we would expect from previous trends. And then using the same data dump from one week later, 28th of October, and using the same timeframe through the 30th week of the year, which is through the end of July, we see 400 more deaths. It, so even in late October, going back to the end of July week on week, we’re seeing more deaths being reported because it just takes time. So we don’t have a full perspective on the mortality impact of this pandemic. Yet. The other thing that your listeners are going to want to know is that there are approximately 3 million deaths a year in the United States. The population is over 328 million. And death rate is about nine tenths of 1percent. So there’s a large number of deaths every year in the U.S. and these COVID deaths are going to be about a 10 percent increase over what’s normal. So that’s a significant increase, but it’s not a doubling or tripling.
UCI Podcast: So far there have been 9 million reported cases of COVID in the United States. And that’s a little below 3 percent of the population getting COVID. Looking at it historically in is this really a very serious problem?
Andrew Noymer: Well, there’ve been 9 million recorded cases that 9 million unique individuals have tested positive, according to COVID tests. So the true number is higher than that. It’s anywhere from five to 10 times higher than that, because there were a lot of asymptomatic cases, and because particularly in the early days of the epidemic, we weren’t testing enough. So there are missed cases and, well, I mean, there’s probably closer to 90 million, and perhaps not quite that many, but there’s been very many more infections than that. But it’s still a minority of the population that has been touched by COVID yet asymptomatically or symptomatically. And so, you know, your listeners have heard a lot about herd immunity and, you know, it’s important to understand we’re not not there yet. And herd immunity is the point where the epidemic sort of just slows down to the point of almost vanishing because so many people are already immune and that the disease has nowhere to go. So to say, but we’re not there yet. And, so we still have some tough sledding ahead of us.
UCI Podcast: Well, most of us have been at home since March because of COVID. Rates are increasing in the United States and also around the world, which leads to this question, what are the next few months going to look like? How is this winter looking? Will this be the winter of our discontent once again?
Andew Noymer: It’s a great question. And there’s lots of dimensions here. I mean, for restaurants, that might be the winter of our dinner in a tent because, because that’s what a lot of them are doing in terms of outdoor seating. But what we have to understand is that respiratory viral diseases are seasonal phenomenon with winter dominance. So our respiratory cylical viruses – influenza, common colds – even these are viruses that are spread via the respiratory route. And, and these are all seasonal phenomenon with winter dominance, and coronavirus will be the same thing. It’s going to be a highly seasonal phenomenon. And your listeners may be wondering, well in California or wherever I am, there was a huge wave in the summer. So how can you say it’s seasonal with winter dominance? The thing is this virus is newly emerging, and when viruses are newly emerging, they seek a population that’s immuno-naïve. And so they, they kind of expand, and they can break the rules. And you have an outbreak in the summertime or whatever, because of that immuno-naïve activity of the whole population. But as we go forward, COVID will be kind of in the background; it’s gonna become more like its normal self. That is to say a seasonal phenomenon with winter dominance.
In Europe, we are seeing second waves. And the United States is seeing a patchwork of really different epidemiology, but the U.S. is seeing a second wave in Massachusetts, for example, as we’re taping this at the end of October. And so, you know, it, the atmospheric conditions and the our behavior in the wintertime – kids in school, people indoors, everything just combines to make these diseases more transmissible in the, in the winter time.
And, you know, we kind of dodged a bullet by having this emerge in early spring this year, because we were in heading into spring from the last days of winter. And then we were heading into deep spring and then summer, and things were getting better. I mean, looking back, it may not seem that way because California had a shelter-in-place order, and there was a big summer wave, but, believe me, it was getting better from the seasonal perspective. And now we’re in mid-fall heading into winter, and it’s going to be a winter that begins with COVID among us. And in fact, COVID is seated in every major metropolitan area of the United States already, as opposed to coming here for the first time. So it’s going to be a long, difficult winter. You know, yesterday, we hit a record number of COVID test positives in the U.S. in the upper Great Plains states. They’re seeing huge surges in COVID cases. So we definitely need to steel ourselves for a very tough period.
UCI Podcast: President Trump has repeatedly said that we’ve turned the corner on COVID and that it will eventually go away. And that raises this really important question. How do pandemics go away?
Andrew Noymer: That’s a great question. And I think the President is right, that it will go away, depending on what one means by that. But I would take issue with the idea that we’ve turned a corner. I think that’s at best premature. And, as I said, yesterday we had a record number of positive diagnoses. So, I wouldn’t say that I would call that turning a corner.
How pandemics go away is a complicated question. Where I see this going is we’ll have two SARS coronaviruses in circulation in the human population at equilibrium level after the pandemic phases over. So, it’s not going to be eradicated. We’re going to be hearing something about COVID for decades to come. It won’t be at the level of emergency that all of your listeners are hearing now, but COVID is not going to be completely vanquished.
Another point is that there are different pandemics, and not every disease outbreak is a pandemic. So, I mean, plenty of epidemics go away. Your listeners will remember that the so-called Disneyland outbreak of measles in 2014, which began at Disneyland, but which has now gone away. But the HIV/AIDS pandemic, for example, hasn’t gone away at all; it’s still with us. So, pandemics don’t necessarily go away, per se, but they do evolve. And another really instructive thing to think about is the 1918 so-called Spanish influenza epidemic, which we’ve all heard a lot about by now, because there are certain parallels with COVID and that one did go away, but it went away on its own way and in its own fashion.
The H1N1 flu virus that emerged in 1918 was different than the flu viruses that had been circulating before then, and which caused so many problems, it just sort of evolved. And the H1N1 flu virus that was in circulation as the regular flu from 1919, up until 1956 was, descendants of that flu virus. So, it just sort of faded away. It didn’t burn out, so to speak. And then in 1957, there was another flu pandemic in which a different type of flu virus – in this case, H2N2 – came. And that became the dominant flu virus. So dominant that the H1N1 virus vanished. So, the 1918 flu pandemic, in a sense, lasted until 1956, but you don’t hear about that because it it evolved towards lower variance. And so I do expect something similar to happen with this outbreak. We’ll have COVID for decades, but it won’t be, killing people in the hundreds of thousands every year.
UCI Podcast: You mentioned earlier that the number of reported cases of COVID is far fewer than what the actual reality is. And just this week, your colleagues in public health released a study in which they tested a representative sample of 3,000 Orange County residents and discovered that nearly 12 percent of them carried the novel coronavirus antibodies. That’s about seven times higher than what has been believed to be the infection rate. It suggests, like you said, that a majority of people who have COVID are asymptomatic, experience weak symptoms, or just don’t report it or don’t get tested. How does this change your interpretation of the novel coronavirus, and how we should address it?
Andrew Noymer: That’s a great question. And first of all, full disclosure, I am involved in that study. And although I’m not the principal investigator, there’s other people here at UC Irvine who have been more principally involved in that work. I mentioned that it varies from place to place in that between five and 10 times as many people are in the total infection rate compared to overt cases. And we see that here in Orange County, based on the antibody study UC Irvine conducted over the summer, that the multipliers is seven times. And it’s so important to collect these data, to have some sense of where we’re at. Is Orange County much higher in total infections than we believe based on overt cases, or is it closer to the number of revert cases?
I mean, this number will vary from place to place, and it it’s really important for the science of the pandemic to understand where very many communities are at, including Orange County. Another important reason to do this study over the summer, and then to repeat it, hopefully this fall or winter, and then again in the spring is to find out how the antibodies fade. However, fading antibodies does not mean doomsday. It just means that the immune system will rely on cellular immunity to fight off re-infection. And I do believe that the science still shows that reinfection is very rare. The fact is that antibodies fade, so it’s not doomsday from the point of view of we’re all going to get reinfected and reinfected and reinfected, but it, but it is creating a hurdle for those of us who want to study the properties of the epidemiology of the virus.
Because when antibodies fade, and we do another serologic survey, some of those people will test negative, and then we’ll have to wonder, well, were they infected; or were they infected, then they lost antibodies; or were they never infected? And having early data will really help us interpret the later data, because if we have again 11 percent in a survey over the winter, we now know because of antibody fade, it doesn’t mean that it’s reached a plateau. It means that people are churning in and out of antibody status. So I realize it’s a little bit esoteric for most people who don’t spend all their time thinking about these weird dynamics of epidemics, but it’s really important for that. We collected early data that we, that we collected data over the summer so that we can repeat it and map our way out of this pandemic
UCI Podcast: Right now, pretty much everybody in is pointing to the panacea of a vaccine that this is going to solve the problem of the pandemic. But once a vaccine is approved – and we don’t know when that’s going to happen – it’ll take many, many months before the vaccine is widely available to everyone, and at least a third of Americans will refuse to take it. Will that limit the vaccine’s effectiveness for controlling the spread of the virus?
Andrew Noymer: Not at first, but in the long run, yes. Let me what I mean by that. At first there won’t be an effective number of doses for everyone in any case with priority lists [receiving the first batches], including first responders, military and people who work in hospitals. And, other people who are exposed to a lot of other people. Like, for example, teachers. It’s just a fact that the way vaccine logistics are particular, with some of these vaccines that require storage at cold temperatures, that we just won’t have enough doses for everyone who wants one at first. So the fact that there are anti-vaxxers who will refuse the vaccine, I mean, fine, let them refuse it. We can just give it to people who want it. There won’t be enough anyway. And so I know a lot of people have been really concerned about the role that anti-vaxxers will play in hamstringing our ability to respond to this epidemic. And I’m not trying to be a gadfly here, but for the first few months, the anti-vaxxer just won’t actually make a difference because there won’t be enough doses of vaccine. Anyway, as the vaccine supply becomes better over months and months, it will make more and more of a difference because then we’re going to be getting into a situation in which there is an effect seen for everyone. And some people will be refusing it. And that the role that a vaccine can play in curtailing an outbreak is to push us over the herd immunity threshold that your listeners have heard so much about.
And if people are refusing, and we’ve remained below the herd immunity threshold, then it can sort of not only ruin it for them, but it can sort of ruin it for everybody, so to speak, because the, the epidemic will continue. I’m optimistic, and there’s a few things to bear in mind. First of all, the people who are have survived infection – it may be hard to identify these people because of the antibody issues that I mentioned earlier – don’t need to be vaccinated. If some of the vaccine refusers are people who’ve survived infection, they’re probably a dead end for the virus anyway; they’re probably immune anyway. So to that extent, we can just sort of skate by, and the fact that we will unfortunately have a lot of people in that situation. A lot of people who have survived natural infection that combined with the people who are willing to take the vaccine, I’m hopeful will be enough to put us over the herd immunity threshold. And so the people who, who refuse well, sort of ruin it for everybody.
UCI Podcast: A question about herd immunity. What is the point in which herd immunity becomes effective? What is percentage of the population that determines the effect of herd immunity – is it 70 percent, 80 percent? 60, 50?
Andrew Noymer: That’s a wonderful question. Let me just say also that I heard on a debate this morning about the virus this wonderful phrase: herd immunity is an outcome, not a strategy. So your listeners need to understand that herd immunity has been talked about and many times mis-characterized. Herd immunity is this property in which once a certain threshold of the population has been already immune that the epidemic dies out because the virus sort of has nowhere to go. And it doesn’t need to be a hundred percent of the population. The virus just sort of thrives off of bouncing from case to case to case. But when it bounces into an immune person, it’s a dead end. And so you get this herd immunity, and it’s less than a hundred percent. And so the herd immunity concept is a valid concept, but it’s been, it’s been sort of dragged into the mud by this idea that we’re just the best thing to do is nothing and just let everyone get infected. Sweden tried a flavor of it, and it’s been a topic of vociferous debate.
I just want the listeners to the pod to understand that when we’re talking about herd immunity, we’re talking about a threshold value. That’s going to be an outcome of this epidemic, and we’re not talking about let’s just do nothing. But to answer the kernel of your question, we actually don’t know what the herd immunity threshold is. It’s something we’re going to have to discover, and we have some guesses, but it depends on what kind of model one asses for how the population mixes with itself. And also, the herd immunity threshold varies from pathogen to pathogen. So my guess is the herd of immunity threshold will be 70 percent for this virus. It could be anywhere from 50 to 80 percent. In my opinion, I don’t think it will be greater than 80 percent. There’s been some work suggesting it will be much lower around 40 percent. And that’s based on purely on mathematical models
UCI Podcast: We’re seeing that superspreader events can cause spikes in infection rates. Probably the one that people think most about now is the Sturgis motorcycle rally in the Dakotas, and what you are seeing in some that region of the country are the highest infection rates now. And there’s been some correlation between that and superspreader events. And were coming up on New Year’s Eve, which is the ultimate superspreader event. What are the best approaches to take? First of all, what are you going to do on New Year’s Eve. I’m sure you’ll be at home. But what should we do? I mean, it’s easy enough to say, stay at home, but that’s not how people really function.
Andrew Noymer: Yes. So that’s a great question. And, and before New Year’s Eve, there’s Thanksgiving and the winter religious holidays, as well. I intend to stay home and enjoy the new year, either by myself or with a select few people. I mean, a pandemic, and it’s going to mean that we’re all going to have to change our behavior and make sacrifices. I mean, the sacrifices that we’re going to have to make voluntarily in the form of cases and deaths are going to be a lot greater than missing out on a New Year’s Eve party. We’re going to have to do the holidays different this year. The best practice would be to have Thanksgiving as a nuclear family event this year, as opposed to a large gathering, if certain precautions are taken. I don’t think I would go so far to say that thou shalt not go to Thanksgiving dinner, but, but I would definitely say best practice is to have Thanksgiving with our households in our regular house.
UCI Podcast: I’ve got one last question for you, and I’m sure you’re asked this question a lot. What can we do to limit our exposure to the virus?
Andrew Noymer: Well, masking, as your listeners have all heard about by now is, is really something that can work. And I mask whenever I leave the house. So it’s not something that I can tell your listeners to do in good faith, because it’s something I do myself. You know, a mask provides a barrier. They’re not a hundred percent, and you know we’re not going outside in some sort of you know, diving bell. You know, we’re not completely hermetically sealed from the rest of the world, but they provide a barrier. So the particles being exhaled have to go through the mask and particles being inhaled have to go through the mask. So there’s less spreading when people mask. So if someone is sick, and they go out to the grocery store, and they sneeze, they sneeze into the mask. And other people at the grocery store have to have those particles cross the mask barrier before they inhaled them. It just provides a level of protection. It reduces the R-naught of the virus, and it reduces the herd, therefore the herd immunity threshold. And it’s just the most basic thing that we can all do.
I think a reasonable amount of hand hygiene is a good move, but there’s no need to obsess about surfaces. In March, there was a lot of actions that were taken out of an abundance of caution, because we know the virus can, in theory, persist on surfaces. So people were doing things like washing their groceries up as soon as they got home. And, as you say, it takes these superspreader events, like the Sturgis motorcycle rally to really get these large-scale transmission events. If every Kroger’s was a superspreader event, we would know by now. And so there’s no need to pick up a can of corn that you got at the grocery store and steam sterilize it, as soon as you get home. I mean, so just as far as surfaces go, a reasonable amount of hand hygiene is fine, but the real big deal is, is the masks.
UCI Podcast: Well, thank you, Andrew. This was really informative, and I’m glad you joined us to talk about I guess the next phase of COVID in the United States when the rest of the world.
Andrew Noymer: Thank you. It’d be my pleasure to talk to your listeners and to I’ll look forward to joining you in the future.
UCI Podcast: Thank you, Andrew. The UCI podcast is a production of UCI strategic communications and public affairs. Thank you for listening.