A new year, but familiar challenges from COVID-19 in the USA

On Jan 2, 2021, the USA registered 297 491 new cases of COVID-19. Three days earlier, the country saw 3750 deaths from the disease. Both figures represented record highs, though with cases trending upwards, and the effect of the holiday season yet to be fully quantified, further spikes are expected. “The pandemic is at its worst moment in the USA”, said Ashish Jha, dean of Brown University School of Public Health (Providence, RI, USA). “We are unlikely to see any improvement at least until the end of January, and even then it is going to take a while before the virus is brought under control.”

As The Lancet Respiratory Medicine went to press, the USA had confirmed almost 21 million cases of COVID-19, more than twice as many as India, the country with the next highest caseload. Hospitals and intensive care units (ICUs) are struggling to cope. By mid-December, all but three of Utah's 537 ICU beds were occupied. Several hospitals in the western state were operating beyond capacity. An analysis by the New York Times published on Dec 9, 2020, found that one in ten Americans lived in a region where ICU capacity was less than 5%.

“There is pretty good evidence that the problem is stretching beyond COVID-19”, adds Jha. “We have seen a substantial decline in ICU and hospital care for non-COVID patients; when things get full, they get full for everyone.” California Health and Human Services Secretary Mark Ghaly has revealed that at least 90% of hospitals in the well-populated Los Angeles County were forced to send emergency patients elsewhere during the last weekend of 2020. Ghaly warned that the situation might well deteriorate further in January.

Nonetheless, there is cause for optimism. The US Food and Drug Administration (FDA) has now approved the Pfizer-BioNtech and the Moderna vaccines, both of which have shown efficacy rates in excess of 90%. The vaccines require two doses. As of Jan 4, 2021, 15 418 500 doses have been distributed and first shots have been administered to 4 563 260 people. Benjamin Singer, a critical care medicine specialist at Northwestern Memorial Hospital (Chicago, IL, USA). “The hospital has been vaccinating its frontline workers and it is going pretty well; it is certainly improving morale”, Singer told The Lancet Respiratory Medicine.

The USA has ordered 200 million doses of each of the approved vaccines, which implies 200 million vaccinations. The country's entire population numbers around 330 million. The FDA has yet to make a decision on the AstraZeneca vaccine, which was approved in the UK on Dec 30, 2020, and has an efficacy rate of 70%. Moderna aims to have completed delivery of its US order by the end of June, 2021, with the final tranche of the Pfizer-BioNtech expected the following month. Matters are somewhat complicated by the requirement to maintain the Pfizer-BioNtech product at –70°C (it can be stored for up to 5 days in a conventional refrigerator after it has been thawed). The Moderna vaccine has to be kept at a more manageable –20°C.

In any event, the vaccination drive will be an enormous logistical exercise. “The USA is a huge country, with lots of layers of bureaucracy”, points out Singer. “The federal health departments will need to work closely with state and local authorities to make sure we can get the vaccines out there in a fair, equitable, and effective way.” CVS and Walgreens, two giant pharmacy chains, have started despatching vaccinators to 75 000 or so nursing homes and long-term care facilities across the country.

Still, vaccines are no good unless people agree to take them. The most recent edition of the Kaiser Family Foundation COVID-19 Vaccine Monitor, published on Dec 15, 2020, found that 71% of Americans would probably or definitely agree to receive a vaccine, assuming it was demonstrably safe and freely available. But the same survey also found rates of vaccine hesitancy of 42% among Republicans, compared to 12% amongst Democrats.

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