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COVID-19 case rates continue to decline, yet most of U.S. remains at high risk for the unvaccinated

Health and Benefits|Wellbeing
COVID 19 Coronavirus

By Jeff Levin-Scherz, MD | October 26, 2021

CDC seems likely to approve vaccines for children ages five to 11 as a further measure to reduce community spread.

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About our “The COVID-19 Crisis” series

“The COVID-19 Crisis” series is a weekly update by Dr. Jeff Levin-Scherz covering the latest developments related to the COVID-19 pandemic in the U.S. Explore the entire blog series.

COVID-19 case rates continue to decline in the U.S. — we are now at under 75,000 new cases a day — an impressive decline. We still continue to see high rates of new infection especially in under-vaccinated areas. Most of the country remains at extremely or very high risk for those who are unvaccinated, and the overwhelming majority of counties in the U.S. continue to have high rates of transmission (82%, >100 new cases per 100,000 population per week) or substantial rates of transmission (11%, >50 new cases per 100,000 population per week).

The seven-day moving average of cases is 70,153; death rate per 100,000 is 2.69.
Daily trends in number of cases and incidence of death in the U.S. as reported to CDC.

Source: CDC

CDC rolls out new tool showing relative protection from vaccines

The CDC has been criticized for not tracking infections of those who have been vaccinated nationally. It has been tracking so-called “breakthrough” infections in 16 states or large cities that represent almost a third of the country. The CDC rolled out a tool last week to visualize the data.

This shows that across the entire database, the risk of getting a COVID-19 infection is six times higher for the unvaccinated. The unvaccinated group includes those who have some degree of immunity from recovering from a COVID-19 infection.

Unvaccinated deaths per 100,000 stand at around 650; fully vaccinated around 100.
Rates of COVID-19 cases by vaccination status

Source: CDC, April 4, 2021, to September 4, 2021.

The tool also shows the relative effectiveness of the different approved vaccines. While Moderna provides almost twice the protection of J&J in August, those who got the J&J shot had more than four times fewer infections than the unvaccinated.

Deaths per 100,000 for unvaccinated are 665, compared to 113 for fully vaccinated.
Rates of COVID-19 cases by vaccination status and vaccine product

Source: CDC, April 4, 2021, to September 4, 2021.

The tool also shows that full vaccination provides good protection against infection in all age groups, and that in late August there was a higher risk of infection among unvaccinated young people (especially those ages 12 to 17). This a powerful argument that parents should prioritize getting their adolescents vaccinated.

In August, unvaccinated person had 6 times greater risk of testing positive and 11 times greater risk of dying from COVID-19.
Rates of COVID-19 cases by vaccination status and age group

Source: CDC, April 4, 202,1 to September 4, 2021.

Implications for employers: Data continue to show high effectiveness of vaccinations, and employers should continue to strongly encourage their employees and family members to get vaccinated.

CDC approves additional booster shots

The CDC followed the FDA and approved booster shots of both the J&J (Janssen) and Moderna vaccines.

Everyone who got a J&J shot is recommended to get a booster at least two months after the first injection. While the CDC recommendation is to get another J&J vaccine, there are multiple studies showing that following an adenovirus vaccine (Astra Zeneca or J&J) with an mRNA vaccine (Pfizer or Moderna) leads to higher antibody levels. The supply of mRNA vaccines is now excellent, so those who would like a booster with Pfizer or Moderna should have no trouble getting this. Going forward, the J&J vaccine will be a two-shot regimen with injections two months apart.

The Moderna booster is half the dose of the primary vaccine series. Those over age 65 and over age 50 with immunosuppression should get boosters. All adults with compromised immune systems and those with occupational risks (like healthcare workers) or residential risks (like prison inmates) are eligible to get a booster. These recommendations are the same as for those who got Pfizer vaccines. The CDC recommends that people continue getting the brand vaccine they started with but are clear that “mix and match” is also perfectly acceptable. Side effects from boosters are similar or less severe than those from the initial vaccine series.

The FDA also announced that it will be examining data next week to determine whether to recommend booster shots for all those over age 40. All three vaccines continue to be highly effective, but with adequate supply of vaccines in the U.S. now, boosters are likely to decrease the number of infections and further help break the chain of transmission.

Implications for employers:

  • Onsite vaccination clinics should allow both primary vaccination and boosters for those who are eligible.
  • Employers with mandates should not require boosters at this point since the value of the primary vaccination in preventing disease is much higher than the value of boosters.
  • Employers developing a tracking system should incorporate data fields for boosters too.
  • Any vaccine mandate should accept any combination of vaccines.

Vaccines for ages five to 11 likely to be approved soon

The FDA and the CDC are expected to approve a low dose of the Pfizer vaccine for children between ages five and 11 over the next week or so. Data released last week shows that it is 90% effective at preventing symptomatic infection in that age group, and antibody levels were similar to those in young adults given the higher dose vaccine. The federal government has announced that vaccine doses will be shipped immediately and will be available at schools and physician offices.

Children under age 12 will need a lower dose of vaccine, which makes the rollout somewhat more complex. Children are far less likely to get seriously ill with COVID-19 than adults, but kids make up a disproportionate share of cases now (since they are unvaccinated). Vaccinating children provides them individually with protection, helps decrease the rate of community transmission, and may prevent long COVID-19 in these children. Vaccination can also help prevent disruption of schools as we stay indoors more in the cold weather.

As with adults, children will be able to get the COVID-19 vaccine at the same time as the flu shot if they haven’t already received the flu vaccine.

Implications for employers:

  • Employers can make it easy for parents to get their children vaccinated by allowing for flexible scheduling.
  • Employers should expect to see more charges for vaccination, which will help us have fewer costs for COVID-19 hospitalizations in the months to come.

Protecting those with compromised immune systems

About 3% of adults in the U.S. have compromised immune systems. Some have cancer; some are on chemotherapy; many are on biologic drugs to treat diseases like rheumatoid arthritis, inflammatory bowel disease and multiple sclerosis. The COVID-19 vaccines often don’t work nearly as well in those with compromised immune systems. They are at higher risk of dying of COVID-19 and thus should certainly get boosters.

This has been in the news with the death of Colin Powell, who was fully vaccinated and being treated for cancer. CNN’s John King discussed his own increased risk if exposed to COVID-19 because of his ongoing treatment for multiple sclerosis.

Boosters can help — but they aren’t necessarily enough. The best protection for people whose immune systems are compromised is to have a high vaccination rate among the people who they spend time with, including both families and coworkers.

Implications for employers:

  • High employee vaccination rates make the workplace safer for everyone — but the extra protection is especially important for employees whose immune systems are compromised.
  • Decreased immune function is a medical disability covered by the Americans with Disabilities Act. Employers should be familiar with the Equal Employment Opportunity Commission guidelines around accommodations for those with disabilities and talk to their counsel if they have questions about their policies.

Ivermectin poisonings up

The Oregon Poison Control Center reported that calls for Ivermectin poisoning went up from about one every four months (2020) to 21 in August 2021 alone. Six of these cases required hospitalization and four required intensive care; none died of this poisoning. While most of those who called Poison Control had used veterinary formulas, half of those hospitalized had been prescribed Ivermectin. Those who took overdoses had symptoms including confusion, ataxia (trouble with coordination), dizziness, low blood pressure and seizures.

Ivermectin is an antiparasitic drug effective for various intestinal parasites; in the U.S. it is also used for treatment of lice. Some early studies showed that in a test tube at high levels it could be effective against SARS CoV2, the virus that causes COVID-19. A large clinical study from Egypt that purported to show a very high success rate at preventing death was determined to be fraudulent.

Oral medicines to treat COVID-19 will be important going forward, as we expect the virus will remain in circulation even after the pandemic is over. There are promising antivirals now in clinical trials and one, Merck’s molnupiravir, is awaiting FDA approval. Vaccination remains the best way to prevent COVID-19, and the only medicines recommended right now to treat early COVID-19 or exposure in high risk individuals is monoclonal antibodies, which are expensive and require injections.

Implications for employers: Pharmacy benefit management companies have put in place edits to try to diminish the chances that providers will inappropriately prescribe Ivermectin.


Population Health Leader, Health and Benefits, North America

Jeff is a practicing physician and has led Willis Towers Watson’s clinical response to COVID-19. He has served in leadership roles in provider organizations and a health plan, and is an Assistant Professor at Harvard Chan School of Public Health.

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