The COVID Endgame

The end of the pandemic is in sight, the World Health Organization said last week, but only if we keep doing what needs to be done.

“We can see the finish line, we’re in a winning position,” said the director general of WHO, Dr. Tedros Adhanom Ghebreyesus. “But now is the worst time to stop running. Now is the time to run harder and make sure we cross the line and reap the rewards of all our hard work.”

Which brings us to the unfinished work of vaccinating New Yorkers, as illustrated by Brian Elbel, professor in the Departments of Population Health and Medicine at NYU Grossman School of Medicine.

Elbel and his colleagues looked at the vaccination rates in New York’s 1,500 public schools and found dramatic evidence of our continuing vulnerabilities to COVID-19. Vaccination rates are wildly disparate, to put it mildly, by race, ethnicity and geography, Elbel reported.

A kid at a Manhattan school, in one example, was far more likely to be vaccinated (59.7%) than a kid at a Staten Island school (38.6%).

There are obvious equity issues revealed in this data. But there is also the universal challenge, highlighted by Tedros at WHO, that groups of people who are under-vaccinated form human petri dishes for the continuing transmission and transmogrification of this persistent virus.

Oldest and Youngest

New York City’s lowest vaccination rates are at opposite ends of the city’s demography – oldest and youngest. Among those 85 and over only two out of three are vaccinated, despite their vulnerability (and compared to nearly nine out of ten among all adults), according to the city health department’s data.

But kids have the lowest vaccination rates of all, with only about half of those under 18 receiving even a dose of vaccine, the city data show. Using data about the city’s public schools, Elbel looked below that citywide figures and identified the wide disparities.

This became particularly relevant in recent days as public health officials think anew about the purposes of COVID-19 vaccination. For most of the pandemic, health leaders stressed that the key purpose of the vaccines was to prevent serious illness and death, which is why they rationed the vaccine first to the older and most vulnerable.

But the new, “bivalent” version of the COVID-19 vaccine — the one that includes protection against the current variants of Omicron – will be better than the original, researchers believe, at preventing spread of the virus, not just serious illness and death.

Which increases the argument for vaccinating not only the aged or otherwise vulnerable, but everyone else, including all those public school kids whose risk of serious illness is low but capacity to spread the virus is high.

“It’s probably not as important as a 70 year-old getting vaccinated,” Elbel said. “It’s still a very high benefit, very, very low risk activity, overall.”

Highest Rates

At the moment, the numbers Dr. Elbel reported are nothing to cheer about. He looked below that citywide rate – of just over 50 vaccinated – to find several groups of kids with significantly lower vaccination rates.

The highest vaccination rates are at schools with majority Asian student bodies, where two out of three kids are vaccinated, mirroring the generally high vaccination rates among Asian New Yorkers.

In schools that are majority Hispanic, just over half the kids are vaccinated. But in schools that are majority white, or majority black, the vaccination rate is 44 percent.

Even these numbers conceal more than they reveal. That 44 percent vaccination rate at majority white public schools includes majority white Manhattan schools, where the vaccination rate is 61 percent, and majority white Staten Island schools where the rate is 25 percent.

The SaRs-Cov-2 virus doesn’t judge its victim’s political leanings, but it will circulate more aggressively in places where people aren’t vaccinated.

The borough-wide rates capture the disparities. Manhattan public schools of any racial or ethnic majority report the highest vaccination rate, an average across all schools of 59.7 percent, according to Elbel. Staten Island had the lowest vaccination rate at 38.6 percent. The rate was 50.6 percent in the Bronx, 52.3 percent in Brooklyn and 54.5 percent in Queens.

Understanding these disparities is a necessary precondition to closing them, said Elbel

“There’s lots of things going on here,” said Elbel, who published the data this week online in the scientific journal, JAMA Network Open. “There could be difference in access to health services. There could be difference in trust in the medical or public health system. There could be differences in political persuasions here. All of these things are potential factors that we need to look at more carefully in some of the future work.”

Retarding Infection

Elbel’s work comes at a moment of transition in how public health officials are thinking about vaccination.

According to the WHO, vaccinating kids is still the lowest priority worldwide. But at the same time the WHO is now urging researchers to accelerate efforts to improve the ability of the vaccines to retard infection as well as reduce illness.

That already seems to be happening with this latest so-called bivalent vaccine, which includes protection against current variants of COVID-19. A the moment, only the Pfizer version of this vaccine is approved for use in kids 12 to 18.

As the goal expands from protecting the most vulnerable to blocking the virus, the urgency to vaccinate everyone rises in tandem. Even as governments and companies in New York and around the country retreat from mandating vaccination, that idea of “herd immunity” returns.

“Substantially reducing SARS-CoV-2 transmission will help manage risks associated with the emergence of new variants of concern and diminish the likelihood of repeated large global waves of disease resulting from immune escape,” WHO said in a policy statement this week.

Elbel sees two messages in his data.

“One is that vaccination is still really important and something we need to be paying attention to for kids,” he said. “And two, it shows us there is a lot more work to do to really understand what’s driving some of these differences for children and families.”

Or, as Dr. Tedros at WHO said: “If we don’t take this opportunity now, we run the risk of more variants, more deaths, more disruption and more uncertainty. So let’s seize this opportunity.”