he Biden administration is facing a delicate balancing act between relaxing US Covid-19 precautions during the current lull in case numbers in the US and conveying the urgency of the possible next surge, experts say.

Cases and hospitalizations have fallen sharply in recent weeks. The US is nearing the lowest Covid hospitalization rate of the entire pandemic, and case numbers are now at the lowest they have been in eight months, since July 2021.

Precautions such as mask mandates and proof of vaccination requirements have dropped in many of the states and cities that instituted them.

But thousands of Americans are still dying every week, and the recent spike in Europe has officials watching for a possible surge, either from the new Omicron sublineage BA.2 or another variant. The US has typically followed UK surges by a few weeks.

It’s difficult to understand how much of Europe’s wave can be attributed to relaxed precautions, waning immunity or intrinsic properties of BA.2, like its increased transmissibility.

But many of these countries have higher vaccination rates, especially higher booster rates in older adults, than the US.

“We’re playing with infectious disease fire right now,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

The US has not reached the endemic phase yet, but even endemic viruses need careful management and steady funding, said Gregg Gonsalves, an epidemiologist at Yale School of Public Health. “We spend billions of dollars to keep things modestly in check. We’re not even doing that” with Covid.

Officials have discussed what actions to take if cases in the US begin to tick back up – including recommending masks, distributing tests, strengthening hospital capacity, and improving vaccination rates.

The administration’s plan for moving forward, unveiled in early March, included protecting against and treating Covid cases, preparing for new variants, keeping the economy and schools open, and vaccinating the world.

But actions like these could be hampered by lack of funding, which risks undoing the progress the US has made.

“We will see, within the next month, really severe challenges with regards to funding for vaccines, drugs, and testing, and that’s going to be a real challenge if we don’t get this funding,” Osterholm said.

Congress unexpectedly cut $15bn in pandemic funds from an omnibus spending bill earlier this month.

The funds for testing and treating uninsured patients already expired on Tuesday, which could be a significant roadblock in suppressing a surge from BA.2 or another variant.

Widespread domestic testing could end by June, the White House said in a memo on the sweeping effects of funding shortfalls. Money for booster shots and treatments is expected to run out by the end of the month.

The US has been unable to complete the purchases of more monoclonal antibody treatments planned for 25 March and preventive treatments for the immune-compromised planned for 30 March.

Purchases of the antiviral treatment Paxlovid may also be halted. Pfizer plans to deliver 10m courses of Paxlovid, its highly effective antiviral treatment, by the end of June, with another 10m before the end of the year. So far, however, only 1m doses of the treatment have been allocated to states.

Treatments represent an important turning point of managing the pandemic, and they are a core element of the administration’s “test to treat” strategy, where those at high risk of severe illness or death are prescribed medications immediately for free.

Because treatments like these take months to manufacture, falling behind on purchasing deadlines means there could be shortages through the end of the year.

Even the $22.5bn the White House requested may have been too low to address the fallout of the pandemic. US Speaker of the House Nancy Pelosi recommended that the White House double its request to $54bn.

The efforts to prepare for the next wave could also be undermined by recent actions from the administration, including changes to the CDC’s community risk guidelines that seem more driven by politics than public health.

“That did not come from public health recommendations; that came from governors reading the tea leaves saying the public is tired of this,” Osterholm said.

Democrats were advised to “take credit” for ending the crisis phase of the pandemic because Americans are tired of restrictions, according to a memo from the polling firm Joe Biden used in 2020.

Politicians and officials feel a “political imperative,” Gonsalves said, to “take the win” in order to sway voters in the midterm elections.

This relaxed approach to the pandemic is “not laissez-faire, it’s basically surrender – and I think we’re in trouble,” Gonsalves said. “The pandemic is not over, the virus is not over, and I think we’re doing policy based on wishful thinking and policy paralysis born of fear and cowardice.”

As a result, the American public’s assessment of risk has been distorted, Gonsalves said. “If we see another surge that increases hospitalizations and deaths in the next few weeks, we’re not going to be prepared.”

Incoming coronavirus response coordinator Ashish Jha wrote recently that “relying entirely on cases to dictate risk no longer makes sense,” urging instead a shift to hospitalizations. But other public health experts worry that by the time hospitalizations have increased, rising infections will be much harder to control.

Physicians are warning that health systems are not strong enough to contend with surges every few months. “It’s not a sustainable future,” Gonsalves said.

If cases, hospitalizations, and deaths start to increase again, “we need to be ready, if necessary, to pivot back” to taking precautions like wearing masks, Anthony Fauci, the president’s chief medical adviser, said recently, adding that “if we want to continue this, as I call it, tiptoeing back to normality, we want to make sure that we do everything within our power to prevent the kinds of things that will set us back.”

The pandemic is not like a sporting event with a beginning, middle, and end, Osterholm said. “What we haven’t done is help the public understand that this is a continuum – there isn’t a start and a stop with this right now.”

It’s more like the weather, he said. “It never ends, it’s just some days are better than others.”

Above all, officials need to stay flexible and understand that the virus will continue to evolve and surge, experts said.

“Be careful how you describe the end of the pandemic, because we may be a ways from it from actually occurring,” Osterholm said. “What we’re learning about this virus every day is very humbling.”

Melody Schreiber

---