Viewpoint: Public health mandates should be tied to hospitalization numbers, not cases

Instead of only using virus case counts, policymakers should tie pandemic guidance to COVID-19 hospitalization metrics, especially in highly vaccinated areas, Monica Gandhi, MD, and Dr. Leslie Bienen wrote in an op-ed published Dec. 11 by The New York Times.

Dr. Gandhi is an infectious disease physician, professor of medicine at the University of California, San Francisco, and the director of the UCSF Center for AIDS Research. Dr. Bienen is a faculty member at the Oregon Health & Science University-Portland State University School of Public Health.  

Rising cases don't reliably predict hospitalization surges, meaning COVID-19 policies tied to cases alone are no longer effective, the authors wrote. Here are six reasons why:

1. There's much unknown about the new omicron variant, including how quickly it will spread in highly vaccinated areas and whether it causes more mild disease than delta. However, the variant is arriving in a different pandemic landscape than delta did, with vaccines, tests and, soon, oral treatments available. The U.S. needs to adjust to the new landscape by introducing a new public health policy framework.

2. As the virus becomes endemic, living with it will require both mindset and policy changes. Using hospitalizations as the most important metric will provide the most reliable picture of how an area is faring and allow health professionals to better focus on reducing them.

3. For vaccinated individuals, a case of COVID-19 doesn't mean what it used to. Most breakthrough cases remain mild, though mild infections may still be linked to long-COVID-19. While antibodies can wane and effectiveness may be affected by variants, vaccines should continue to protect against severe illness. Currently, in areas of high vaccination, an uptick in cases doesn't necessarily signal a comparable increase in hospitalizations or deaths.

4. Some places have shifted to hospitalization-based guidance. Marin County, Calif., dropped mask mandates in November when virus hospitalizations remained low. Though the county's cases have oscillated over the past two weeks, the decision to bring back masks will no longer rely on case counts, said Matt Willis, MD, the county's health officer. After omicron was identified in the area, he reiterated that the county ― with 89 percent of eligible people vaccinated ― would consider a new mask mandate if its COVID-19 hospitalization rate reaches 5 per 100,000 residents.

5. With at-home testing on the rise and more people testing outside the public health infrastructure, case numbers are becoming less accurate.  

6. If the U.S. focused more on hospitalizations, health authorities could expend more resources on reaching people who are unvaccinated and at high risk for hospitalization.  

The authors note that case counts are still important to track, providing data on breakthrough infections, identifying hot spots, allocating resources and tracking emerging variants.  

 

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