Why COVID-19 Is Still the Pandemic of the Unvaccinated

Over the summer of 2021, as the Delta variant swept the nation, Americans’ experience with COVID-19 bifurcated. Among vaccinated people, cases were low and deaths were rare; at the same time, people with no immunity were getting sick and dying at alarming rates. COVID-19 became the pandemic of the unvaccinated.

Then in December, Omicron showed up. Cases have surged in recent weeks, blowing past records set during the Delta wave. Driving this trend is Omicron’s extremely high transmissibility, compounded by waning immunity among vaccinated people who are experiencing symptomatic breakthrough infections. With cases rising among both the vaccinated and unvaccinated, it may seem like the gap between the two groups is narrowing—and that the “pandemic of the unvaccinated” is now a misnomer.

But that’s not the case. Studies from Pfizer, Moderna, and Johnson& Johnson show that vaccines continue to offer protection against severe disease. And booster shots stand up to Omicron much like the initial vaccine regimens stood up to Delta. Anecdotal evidence and recent hospitalization data is proving this out.

“We’re seeing breakthrough infections at a much higher rate,” says Chris Ruder, chief operating officer for the Kansas City division of the University of Kansas Health System. “Yet those individuals that are vaccinated are not the individuals that are being hospitalized, by and large.”

On a national level, the hospitalization picture is incomplete, as not all states publicly track patient vaccination status, and those that do aren’t always consistent with each other and therefore can’t be compared side by side. For example, states account for partial vaccinations in different ways, and may exclude children from their analysis or only track hospitalizations in a select number of counties.

Among states that publish recent stats on a regular basis, which offers visibility into Omicron-wave hospitalizations, a few report per-capita admissions, like in the below chart:

Other states report the ratio of vaccinated vs. unvaccinated status among currently hospitalized patients, as shown in the next chart:

Methodology differences aside, the broad trends indicate that the situation in Ruder’s own hospital system is playing out across the country. Unvaccinated Americans in every region are still driving this pandemic.

To be sure, there’s been an uptick in the number of vaccinated patients in the hospital since Omicron arrived. Recent studies show that immunity from the vaccines wanes over time, which means those who were first in line to get vaccinated last year may be less protected now than those who got their shots more recently. Booster shots re-fortify the immune system, but many people hadn’t gotten a booster when Omicron first arrived. In mid-November, just before the variant had established a toehold in many areas of the country, less than half of eligible seniors—of whom 87% had been fully vaccinated at the time—had received a booster.

Further, most patients hospitalized as a result of breakthrough infections in recent weeks have had underlying health conditions. Take, for example, the 128 COVID-19 patients at Michigan Medicine, the hospital system affiliated with the University of Michigan, on January 10. Of the 49 vaccinated patients, only nine were younger than 65, not immunocompromised and didn’t have a significant underlying lung disease. Of the 79 unvaccinated patients, 34 were similarly young and healthy.

In New York, one of the first states to get slammed by the Omicron wave, both vaccinated and unvaccinated have seen an uptick in serious COVID-19 cases—but the gap in hospitalization rates between the two groups is effectively widening. Before mid-November, unvaccinated New Yorkers were hospitalized for COVID-19 at about 10 times the rate as their vaccinated neighbors. But since then, they’ve been about 14 times more likely to wind up in the hospital.

Even as hospitalizations continue to tick up, some are resisting getting a booster shot, with about 20% of vaccinated adults reporting that they will “probably not” or “definitely not” get boosted in a November KFF survey. And still many Americans continue to shun COVID-19 vaccines entirely.

Studies—supported by real-world data from South Africa—showing that Omicron symptoms are less severe may lead people to believe that the shots aren’t as necessary to combat this wave. (In the U.S., the picture remains fuzzy—particularly because some parts of the country are still experiencing both Delta and Omicron.) The problem with this reasoning is that even if the hospitalization rate among infected people is lower with Omicron than with past variants, the enormous surge in cases is resulting in more hospitalizations than ever before. Earlier this month, the U.S. recorded more COVID-19 hospitalizations than last year’s peak, before vaccines were widely available.

This great influx of patients is overwhelming hospitals, which are stretched so thin that they cannot accommodate non-COVID patients that may need emergency care due to a heart attack or stroke or car accident. “The number of beds and the number of resources that it’s taking to care for patients with COVID is reducing our capacity to care for other things that just normally occur every day,” says Ruder.

Compounding the problem is that health care employees have been in short supply. In early September, the American Nurses Association called on the Biden Administration to declare the nursing shortage a national crisis. The White House didn’t follow suit, and since then, it’s only worsened as some systems lost employees who were unwilling to comply with vaccine mandates that went into place in recent months. And since the Omicron surge, large numbers of vaccinated health care workers—70% of hospital personnel were vaccinated as of mid-September—have tested positive at some point, further reducing the workforce along the way.

Nineteen states are grappling with critical staff shortages at a quarter of their hospitals as of Jan. 10, according to a TIME analysis of data from the U.S. Department of Health & Human Services. That’s up from 13 states in early December. The situation is particularly dire in New Mexico, Vermont and Rhode Island, where at least half of the hospitals have hit critical staff levels.

Ruder doesn’t mince words when describing the situation in the Kansas City region. “In smaller hospitals and in small rural communities, we absolutely know—and have validation—that patients are not able to transfer to higher levels of care [at larger hospitals] because there are no beds. There is not enough staffing. There are not enough resources. And patients are dying.”

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