As early as April, leading infectious disease expert Anthony Fauci was already warning of a “likely” fall coronavirus surge in the U.S.
Roughly a month after that, the Biden administration put a number on the prediction: 100 million Americans – equivalent to nearly a third of the country’s population – could get COVID-19 infections in the coming fall and winter. They warned that the number was the median estimate, meaning significantly more cases are possible if a new variant enters the scene.
Now, in September, coronavirus cases are actually decreasing after plateauing during the summer months at over 100,000 new cases each day, which was likely a massive underestimate as many relied on at-home tests that aren’t reported to health departments.
But the decline might not last long.
The combination of waning COVID-19 immunity and colder weather on the horizon that will see more people heading indoors could send infections right back up, with the trend reversing as soon as next month.
“We are expecting a rise,” says Ali Mokdad, an epidemiologist with the Institute for Health Metrics and Evaluation at the University of Washington. “The rise will be in reported cases. There’ll be a rise in hospitalization and mortality but not as high proportionally to the rise in cases simply because many of us – the majority of Americans right now – have been either infected or vaccinated or both, so we have some immunity.”
It’s the country’s third fall with COVID-19, and while infections and deaths remain elevated, much of society has returned to a semi-normal state of affairs. Children are heading to school while many offices are bustling with workers. Federal agencies have significantly rolled back COVID-19 recommendations, citing a desire to “limit social and economic impacts.”
While the number of Americans who believe the pandemic is getting better has starkly dropped since spring, the country is also reporting a record-low rate of mask-wearing, highlighting a growing divide between the pandemic’s status on the ground and what actions Americans are willing to take to combat it.
With many mitigation measures gone out the window, the question remains as to how significant fall and winter surges will be. Could the U.S. really see 100 million more infections like the Biden administration predicted?
Such a number is “very possible” according to Mokdad. The projection remains feasible, he says, even if another variant doesn’t come in to replace the current dominant subvariant, BA.5, because the omicron subvariant is just that contagious.
Others agree. David Dowdy, an epidemiologist at Johns Hopkins Bloomberg School of Public Health, says that it’s possible the U.S. saw a similar number over the past three months, considering the latest surge in the U.S. was drastically undercounted.
“I don’t think it’s unreasonable to think that we’ve had about 100 million infections the past three months, so why couldn’t that happen again in winter?” Dowdy says.
Unclear if Updated Boosters Will Be a ‘Game Changer’
What’s different about the next surge is that new COVID-19 shots specifically targeting circulating variants will be available.
It’s the first time the U.S. has updated its coronavirus shots, and the Biden administration hopes it will be an effective tool at reducing transmission.
“We are looking at a possible fall wave with a peak around Dec. 1, and by giving the booster now we will hopefully both control the current plateau that we’re in – even though we’re dropping off very slowly – as well as address this future potential wave that looms out there,” FDA’s top vaccine official Peter Marks said on Wednesday.
He added that the shots “hopefully bring us the protection we need through October, November, December to prevent yet another wave that shuts down things like holiday plans, et cetera.”
But data on how effective the updated shots are in humans is not yet available, so it remains unclear what effect the shots could have on the course of the pandemic.
“I think the new vaccine will be better at preventing infection from the currently circulating variants, so I do think they have an important role to play,” Dowdy says. “I don’t think it’s going to be a major game changer.”
It’s also unknown how many people will be willing to roll up their sleeves for another shot. The odds aren’t in the new shot’s favor, considering the majority of Americans are undervaccinated and only a third of people ages 50 and older who are eligible for a second coronavirus booster shot have gotten one.
While Mokdad acknowledges that getting people to take the new shots could be difficult without the right communication strategy, he has slightly higher hopes for the vaccines.
“If the data is solid and shows high protectiveness against infection, that will be a game changer because automatically it means less infection, less Paxlovid, less hospitalization and less death,” Mokdad says, referring to Pfizer’s antiviral treatment.
New Variant Threat Lingers
The Biden administration warned that the 100 million number could grow if a new variant takes over. For the moment, experts are optimistic that another Greek letter isn’t yet on the horizon.
“The virus doesn’t need or feel the urge for mutation in a way that will escape our defense mechanism because quite honestly our defense mechanism against infection is very low,” Mokdad says.
In particular, experts say it would be unlikely that a new variant would be both more transmissible than BA.5 – allowing it to rise to dominance – and cause more severe disease.
“The virus doesn’t care if it makes someone really sick or not,” Dowdy says. “All it cares is that it gets to transmit from one person to the next. So what’s driving the virus is transmission, not severity.”
That’s not to say that BA.5 is harmless beyond infections. The coronavirus is still killing on average close to 400 Americans each day. Continuing at such a rate would mean about 145,000 deaths in a year. The figure would be well below the 2021 COVID-19 death toll of 415,000 but much greater than the number of Americans who die of the flu each year, which ranged from 12,000 to 52,000 deaths annually between 2010 and 2020.
And of course, it’s still possible a new variant arises that is more transmissible and more severe, but “the variants that we have right now are already so transmissible that it is tough for new variants to out-compete,” Dowdy adds.
Without a variant showing up out of left field, the fall and winter surge appears likely to be fueled by BA.5. But experts are also keeping an eye on BA.4.6 and BA.2.75.
The most recent variant update from the Centers for Disease Control and Prevention showed that as BA.5 has started to level off at about 88% of new infections, BA.4.6 has shown a slight increase, going from about 4% of cases at the end of July to 7% of infections as of last week. It remains unclear if this moderate increase will continue or if the subvaraint can compete with BA.5.
BA.2.75 has yet to show up on CDC’s variant tracker, but it has nine more mutations on the spike protein than BA.2, or “stealth omicron.” BA.2.75 “still shows a relatively low prevalence globally, but a number of countries have observed recent increasing trends,” according to the World Health Organization.
Is the U.S. Prepared for a Surge?
In the face of a Congress that appeared uninterested in authorizing more COVID-19 funding, the Biden administration in June signaled that it would be going all in on coronavirus vaccines and treatments with its remaining funds.
The decision meant that testing and stockpiling protective equipment would fall by the wayside – the repercussions of which could be seen this week when the White House suspended its free, at-home testing program.
“Ordering through this program will be suspended on Friday, September 2 because Congress hasn’t provided additional funding to replenish the nation’s stockpile of tests,” the ordering website states.
A senior Biden administration official said that if “Congress provides funding, we will expeditiously resume distribution of free tests through covidtests.gov.”
But until then, the administration believes that “reserving the remaining tests for distribution later this year is the best course.”
Mokdad says the decision is “quite honestly, a disaster.”
The move increases worries over a testing shortage once the next surge hits – an issue that the U.S. has run into before.
“I am concerned about testing capacity,” Dowdy says. “I feel like we should have learned this lesson last year, when we had this omicron surge and within a matter of one to two weeks, everyone was looking for a test and you couldn’t find one anywhere across the country.”
Testing issues are not a new problem for the U.S., as many experts decried shortages during the surge of the delta variant, as well.
“I think that we’re disempowering our population by making it harder for them to access tests,” Dowdy says.
Regardless of what projection numbers are floating around, the nation’s preparedness for pandemics needs work, Dowdy says.
“The bigger picture issue here is that we should be strengthening our pandemic preparedness infrastructure because we don’t know what to expect from this and other pandemics, not because we have projections of the future,” Dowdy says.