While things look terribly dark in the short term for the US COVID-19 outlook (pro tip: wear a mask, it works), it seems like there is hope soon to come. This is my forecast for what I expect to happen, and how I feel like we’re closer to the end that the beginning. I’m not a medical export or logistics expert but I’ll still give it my best shot.
Still though, wear a fucking mask. I’ve been to Target and Costco lately and there are a few assholes who wear them to get in the door and then put them away or under their chin once they’re far enough into the store and away from the front doors/cashiers.
December
In December, we should have FDA Emergency Use Approval (EUA) for the first vaccine (Pfizer), which means that the government/military, and front-line health care workers will start to receive the vaccine. By the end of January I’d expect most if not all front-line health care workers to have received the second dose shot, along with other Tier 1 people (government officials, all health care workers who work in hospitals or communal living situations). The interval between shots for this vaccine is 3 weeks, not 4, and the conferred immunity is “effective” 4 weeks from the first dose if everything is on schedule.
We may also have the second EUA from Moderna. Depends on whether the federal government stays open through all of December (there is currently a December 11 deadline to pass a budget resolution). There is significant de-mobilization and re-mobilzation effort within the federal government if a budget isn’t adopted in a timely manner (not December 12 at 1AM). This could impact EUA review at the FDA.
However, this is the darkest month for COVID in America, I expect we’ll likely hit at least 3,000 dead from COVID per day sometime in December (if not more, 5.000 is not unreasonable if people’s behaviors don’t change) and a lot of families will have a terribly sad holiday, missing the 300,000+ friends and family members who died from COVID since the beginning of 2020.
Cumulative population started vaccination: less than 5 million (<2%)
Cumulative population completed vaccination: ~50,000 (those who enrolled in phase 1/2/3 studies in the US in the vaccine arm, and those in the placebo arm who opted into getting the real vaccine at the end of the trial)
January
Second vaccine (Moderna) gets EAU after reporting out final results in late November, if they didn’t get it in December. By the end of January, most states will have their top tier of those prioritized for getting the vaccine to have their first dose (about 5% of the population, about 30M doses) with the health care workers having received their second doses.
And President Biden is inaugurated.
Cumulative population started vaccination: 30 million (10%)
Cumulative population completed vaccination: 7 million (2%)
February and March
Most states have their top tier groups fully vaccinated, and are working through their second tier (the next 15%, cumulative 20%) which includes teachers, medical staff outside of the first tier, people who work in supermarkets, meat packing plants, and other high-risk areas (Amazon warehouses, not gonna lie). This will require another 100M doses on top of the 30M doses from the end of 2020, which should be achievable by the end of March, especially if we have at least two vaccines going at this point, and probably more.
In February in March, Johnson & Johnson should receive their 1-dose vaccine emergency approval (assuming its effective) and will likely be able to start to vaccinate, and it might be a bit slower to rollout if they need to target various sub-groups if the data on the mRNA vaccines show that they are less effective on certain groups while this vaccine is more effective in those same groups (older, younger, etc.). J&J estimates they may have 100M doses ready by the end of March (worldwide) so I’d expect 30M or so doses for the US.
Also, the Oxford/AstraZeneca vaccine should receive EUA during this time as well as Novavax (again, assuming they are both effective). Each one of those could contribute tens of millions of doses by the end of March, however it will still be early in their logistical ramp.
Cumulative population started vaccination: 100 million (30%)
Cumulative population completed vaccination: 80 million (25%)
April through June
Where the rubber hits the road.
With at least three successful vaccines at this point, and possibly up to five, there is where the logistics and how we go about getting people vaccinated matters to ensure we don’t waste doses to get the bulk of the 80% of the unvaccinated portion of the country through the regimen. In the logistic curve, this is the steep middle part.
I expect once we get further down into the lower tiers, there will be some lottery system (based on birth date?) that will determine when you (or your household) gets vaccinated.
While not everyone will be able to get vaccinated (children under 12 and pregnant/breastfeeding women, for example) I would expect that most of the rest will be vaccinated during this period. By the end of June 2021, I’d expect somewhere in the neighborhood of 60% of the population of the country would be vaccinated. Combined with a weighted vaccine effectiveness somewhere around 85%, that puts us at an effective population immunity at 51%. Not great, so we’ll have to probably wear masks for the remainder of 2021 when we go out in public until the new cases per day is less than 50 per state. Ideally we’d want to have effective population immunity above 70% which reduces the “R number” of COVID-19 to less than 1 which means that each infected person, on average, infects less than 1 person, over time, reducing the infection rate down to close to zero. The higher the number (and the longer we keep wearing masks) the faster the number goes to zero.
Cumulative population started vaccination: 250 million (77%)
Cumulative population completed vaccination: 200 million (63%)
July Onward
Mass-vaccinations may drag on into July and maybe August based on logistical issues, but it won’t be much longer. From then on, it’ll be more about maintaining the current levels of population-level immunity, and trying to reach out to those refusing or just otherwise missed their opportunity be vaccinated. This means immunizing adults when they are eligible for the vaccine (done with pregnancy or breastfeeding) and kids as they turn 12. Children under 12 make up around 15% of the population, so until the vaccine can be proven safe for children, they’ll remain unvaccinated.
However, don’t expect things to be “normal” again for a while. Countries still may not allow foreign nationals to enter until a country has certified that most of its population is vaccinated and there is little to no community spread within the country.
Travel within the US will likely return to normal by late 2021. Expect crowded airports and very expensive flights for Thanksgiving and Christmas 2021 – a lot of older airplanes and older pilots are retiring during the pandemic which means that when travel tries to bounce back, it will run into capacity shortages of both planes and pilots. Travel by car will still be popular, but not by choice.
The Cold Chain
There is a lot of concern about the “cold chain”, that the first vaccines (mRNA-based) will need to be kept at very low temperatures (negative 70-80 degrees Celsius). While this does present some logistical issues, I don’t believe they’re out of hand or will pose major problems. At the cheapest level, dry ice and a very well insulated container can keep it cold (dry ice sublimates at -78.5C). Moderna said their mRNA vaccine doesn’t need to be kept as cold, standard medical freezers would work for 6 months. And Pfizer said they were are currently conducting studies at higher temperatures and will have more in December. But vaccines shouldn’t be stored for more than 6 months – shots belong in arms, not cold storage.
It really comes down to whether you have a can-do attitude or a can’t-do attitude about this whole project.
Communication and Managing Expectations
The final thing that experts and politicians need to start doing as we turn the corner and prepare for large-scale vaccinations is to set public expectations.
Encouraging Vaccination: sadly, this is first on the list. Do whatever you can to ensure individuals to get vaccinated. I worry about a lot of anti-vax pushback (a recent poll showed 12% of people were considering delaying or rejecting a COVID vaccine). Estimating that 15% of the population that can’t be vaccinated initially due to age or other issues, that is a total of 27%, which is pretty high even for a 90% effective vaccine if we want to force the virus out of circulation. The encouragement also needs to be bipartisan. We can’t make it through this if one party rejects the vaccine for political gain.
Masks: you will still need to wear your mask in public for a while after you are vaccinated, even beyond the 7-14 day window from your last dose. One of the underlying unknowns of these studies is that while we know the vaccines prevent symptomatic infections, we don’t know if they prevent asymptomatic infections, and if those individuals who have asymptomatic infections after being vaccinated shed enough virus to infect others. You will probably need to wear a mask until the number of new cases per day in you state drops below a certain threshold (~50 cases a day over a 7 day moving average, more or less depending on state population). The worst-case scenario is that vaccinated individuals have asymptomatic infections and then infect the unvaccinated population (who may or may not have a choice to be vaccinated).
Return to Normal: It will still take a while for the economy to return to normal. Specialized and targeted stimulus might help speed up the process (e.g. lets help all those families who used to run restaurants and went out of business start new ones). We shut everything down in a matter of weeks, but don’t expect things like packed stadiums and concert halls right away. By the end of 2021 and early 2022 I expect the economy to be close to where it was in fall 2019. However, areas that rely on international tourism or business meetings may continue to see economic impact since it will take much longer to open up international borders (CES 2022 will be smaller, but I expect CES 2023 will be back to close to normal).
Source for vaccine amount estimates:
NY Times – The Vaccines Will Probably Work, Making Them is the Hard Part