Part 2: We need 35 million Americans to get vaccinated (or get sick) to end this pandemic – Which will it be?

In Part 1, we examined how the unvaccinated went unmasked and were confirmed with infections at a rate of 1 in 40 (and likely 1 in 13, if considering the ratio of confirmed cases to infections). In contrast, those fully vaccinated had so few infections (1 in 709) that the virus would have burned itself out but for the unvaccinated and unmasked.

Part 1 showed how it is the unvaccinated that are dying of COVID at a rate twice that of Heart Disease or Cancer, making COVID by far the #1 killer among the unvaccinated. Over 75 deaths per million occurred in the first week of September, among the unvaccinated.

The Fully Vaccinated, on the other hand, are experiencing some breakthrough cases, but these rarely result in deaths. For the Vaccinated, COVID is killing at a rate less than that of a bad year of the Flu. Put another way, even though the fully vaccinated are now a larger share of the total US population, their death rate is less than one-tenth that of the unvaccinated. The deaths that do occur among fully vaccinated are concentrated in an older population, with a median age in the 70s. For this reason, we expect booster shot adoption to be strong for the 65 and older cohort, and to provide further protection for the Fully Vaccinated. 

There is an easy way out of this pandemic — and there is a hard way out. The hard way is unvaccinated people spreading the virus, racking up hospital bills most can’t afford, and burying another 150,000 Americans (mostly unvaccinated) by the end of the year as 35 million more people become infected as a way to get to herd immunity without more vaccinations.

The hard way out is not only deadly to the unvaccinated, it is risky for everyone, as each incremental infection is a chance for a more dangerous mutation.

The easier way out of the pandemic is vaccinating 35 million more of the unvaccinated and masking up so we reduce transmission, hospitalizations and deaths significantly. My model shows that if 11% (35 million) of Americans vaccinate in the next month, we can significantly reduce deaths and effectively end the pandemic.

Part 2 examines the major segments of the unvaccinated population. While this analysis is specific to the US, many European countries have similar segments. Many European countries have a similar segment of children that are not yet vaccinated. Many European countries have a similar less educated populist conservative segment that are undervaccinated. Many European countries have historically marginalized minorities, often associated with colonialism, that have a historical basis to lack trust in government institutions — and for this segment, this lack of trust has held many back from being among the first to be vaccinated.

Looking more closely at each segment in the US, from the fewest to most populated segment, we start with unvaccinated Black Americans.

Black Americans

Black Americans are about 20% less likely to be vaccinated, compared to the national average. Unvaccinated Black Americans represent about 5% of the total US population. It is understandable why Black Americans would be hesitant to be first in line for a new vaccine, given the history of Tuskegee. The Ad Council has worked to address the historical concerns of Tuskegee with this video. Now that more than 170 million people in the US have been fully vaccinated with an impressive safety record, it seems that a concerted effort to support vaccinations efforts in Black American communities could save lives. The share of vaccinations going to Black people in August increased from 26% to 43% in DC and from 25% to 38% in Mississippi, according to an analysis by KFF. Overall, rates of vaccinations among Black Americans have been increasing recently. While a lack of trust in government is the leading barrier, for some Black Americans, access remains a challenge.

Black Americans are a little more likely to mask, based on my analysis of data from Carnegie Mellon University / Delphi Group. Among counties with 40% or less of the population fully vaccinated as of August 15, with a population that indexes above the national average in terms of black population, 67% report masking regularly. This is above the national average of 65%. This population has experienced more COVID infections, hospitalizations and deaths than the overall US population. Increasing masking and increasing vaccinations will help avoid more COVID-19 suffering.

Children under 12

Those under 12, which are not currently eligible for vaccination, represent 15% of the total US population (about 48 million in total). More than 500,000 children tested positive for Covid-19 in the US from August 5 to August 26, according to state data analyzed by the American Academy of Pediatrics, representing 16% of total cases reported. This equates to about 1 in 100 children with a confirmed case, and likely about 1 in 30 infected — in less than one month, before back to school has started in many areas. What is clear in the data is children can become infected with COVID and they can (and do) infect others.

Cases today among children are now about as high as they were in the peak of January 2021, and they are growing quickly. Children rarely die of COVID, but the rate of death is about one to two children per day in the US. Hospitalization is rare for children, compared to other age cohorts, but it is increasing at a rapid pace. Long-covid and other health effects are concerning for this population. In addition, because children can become infected and can spread it to others, the household dynamics of an unvaccinated child are important to consider. Are the parents and grandparents and other caregivers fully vaccinated? If not, the risk to the household is meaningful. To date, applying the coefficient published in JAMA Pediatrics, approximately 50,000 children under 18 have lost one or more parents to COVID-19. While there are a variety of chains of transmissions, to have a child become infected and lose a parent as a result is devastating, and we should seek to minimize this outcome.

Mandating vaccinations among parents and guardians in the household of school age children could be considered as a condition of attending in-person classes. Such an approach may be workable in many European Democracies, but may prove challenging in many US states. Several mostly conservative states, as pointed out in Part 1, have placed prohibitions on mandating vaccinations or masking.

While masking is practiced for this age group in many Asian countries without negative effects, it is a new element of American education and has been hotly debated. In Marin, California, where masks are required, the health department documented how an unvaccinated teacher removed a mask to read aloud, and infected half the students in his classroom.

Taking extra care to protect children that can not yet be vaccinated, and the people around these children, should be a priority.

The FDA may approve vaccinations for 5 and older, and perhaps 2 and older before the end of the year, but that is uncertain. I had expected the FDA to prioritize Emergency Use Authorization approval consideration before the start of the school year. Instead, the FDA asked for more data.

My modeling currently assumes the FDA will approve vaccination of those 5 and older before the end of October, and about one-third of parents will get their children vaccinated before the end of the year. This will contribute to the US achieving vaccination rates of approximately 70% by the end of the year. However, if The FDA does not approve vaccinations for children, it will be very difficult to achieve the 35 million incremental vaccinations I calculate as necessary to effectively end the pandemic without losing another 150,000 lives.

White conservatives

The largest population segment among the unvaccinated are White Conservatives. This unvaccinated population is about 16%^[1] of the total US population. Most live in counties where Trump won by an average of 47 points in the 2020 election. These counties are also much less likely to mask, making this group particularly susceptible to infection, and spreading the infection to others.

The reasoning of White Conservatives may seem inconsistent. Statements like, “Requiring vaccinations is un-American” despite the fact George Washington required vaccinations of his soldiers at Valley Forge and Ben Franklin wrote of his own regret in not vaccinating his son early enough. History suggests there may not be an America without vaccinations. Or, un-ironically using slogans like “My Body, My Choice,” a slogan popularized by the pro-choice movement, which most White Conservatives oppose. The key to understanding this segment is to consider this group’s distrust of government – especially when they didn’t vote for the leader. This largely rural population has lower overall educational attainment, which may make a studied analysis of vaccine clinical trials or masking randomized controlled experiments challenging.

White conservatives were actually MORE likely to be vaccinated early on, prior to the change of administration. Even though the vaccine didn’t change in formulation, when the leader in the White House changed, vaccination rates within conservative leaning counties decreased significantly. It appears to be the case that if the opposing party is in favor, then they are against. 

Without vaccinations and without masks, SARS-CoV-2 will keep spreading in these predominantly white, conservative and rural communities. Perhaps lower population density will reduce spread, but with schools, churches and other social interactions which too often will not include masks, hospitals and funeral homes should expect a busy end to the year. As the US learned the hard way with the measles outbreak, even if the overall vaccination rate is high, unvaccinated pockets of people can become infected and can cause meaningful outbreaks.

Forecast

As described in previous forecasts, those vaccinated will experience much fewer deaths. While the total number of vaccine breakthroughs will increase over time, there will be fewer hospitalizations and deaths among the vaccinated. Booster shots, particularly for those over 60, should lower both hospitalizations and deaths. Of those fully vaccinated that are hospitalized or die, the typical age is likely to remain in the 70s and 80s. The death rate for the vaccinated should be less than a bad year of the Flu.

For those unvaccinated, it is a different story. The current model projects 794,880 COVID deaths by the end of the year, almost all of them among unvaccinated. This number may be conservative, as we are expecting weekly cases to stop increasing, and begin to decline due to masking, increased testing, and downward pressure from vaccinations and infection recoveries. It is possible that the unvaccinated do not mask up, do not get vaccinated, and mutations lead to more breakthroughs with more severe outcomes. While it is logistically possible to end the pandemic in a month, with 35 million of the unvaccinated taking the jab, that outcome is unlikely. It is more likely another 150,000 people will die of COVID, hundreds of thousands will be hospitalized, and over a trillion dollars in economic impact will be experienced. The US is likely to take the hard way out of the pandemic.

Many countries in Europe may take an easier exit. While most countries in Europe have had less infections than the US and therefore have less natural immunity, vaccination rates are now surpassing the US. With vaccine passes, easy testing, and vaccination mandates encouraging more to get vaccinated now, Europe is in a race to avert a rough fall and winter.

^[1] Calculation: 3,095 Counties are first sorted by 2020 Election vote Margin. 2003 counties with a total population of 105,843,469 have are 89% White. The unvaccinated rate of 63.5% (Vaccinated is 36.5%). The calculated size of White Unvaccinated Conservatives is 50,844,821, which removes children under 12 within these white conservative families from the calculation. Total county population sum to 318,321,030, and is used as the denominator. The figure is an approximation. White conservative live in other counties (and are not counted here), and not all whites in these counties are conservative.