Why We are Headed for a Brutal Fall with Delta Covid-19

The tsunami of suffering people are not yet seeing

I wish I didn’t have to write this.

I’ve been optimistic that we had effectively beaten the coronavirus pandemic (at least in the United States) and that we could safely move on.

But I’ve spent a lot of time in the last week analyzing available information on the Delta variant and the scenario in front of us, coming to shocking conclusions.

I’m going to lay out the fact pattern and the math that points towards a brutal fall season for the United States (and much of the rest of the world).

The math points to exceeding our past peak in daily new cases by mid-September and a mass overwhelm of the medical system due to Delta’s higher hospitalization rate.

This would be especially pronounced in right-leaning counties and states with low vaccination rates but the medical system overwhelm will be extensive as hospitals balance the load.

It’s important to see this coming so we can prepare for it and do our best to avert as much suffering as we can.

Effectively, what is happening is that we are about to face a different pandemic because the Delta variant is both much more transmissible and, even worse, has close to two times the hospitalization rate according to a Scientific American article based on a Lancet study from Scotland that pegged the increase at 85%.

If you’re not tracking the general story line, the Delta variant has developed a few mutations that make it able to spread more quickly. The R0 (the average number of additional people infects from one person in the absence of preventative measures) has gone up to somewhere into the range of 5-8 versus the original Wuhan variant of the Covid-19 virus (in the range of 2-2.4), which was itself supplanted by the faster-spreading Alpha.

Delta is shockingly fast in out-competing previous variants. In England, it took about 50 days to nearly completely supplant other variants. In this BBC article, scroll down to look specifically at the orange graph of Delta cases, which climbs from zero cases in early to mid-April to over 6,000/day by mid-June.

Total daily new cases in the UK have gone from 2400 on April 15 to 35,000 on July 9, a multiple of 14 in 57 days. More troubling is the fact that such rapid growth is masking the faster growth in Delta alone.

And this is in a country with a higher vaccination rate than the United States and with vaccination itself not as politically polarized.

Places like Moscow, where Delta has become dominant, are experiencing explosive outbreaks. Even more troubling is the reporting that many of the antiviral treatments are appearing to be less effective. Tunisia’s medical system has effectively collapsed with Delta-driven overload. South Africa is in a world of pain with its largest caseload spike yet. Indonesia is in its worst phase now as well.

Basically, the entire pandemic globally is going to turn into a Delta pandemic because it has spread to 100 countries and it rapidly out-competes other variants once it gets established. The countries where it got established early are now surging fast.

We need to think of Delta almost like a new pandemic because it requires new thinking and measures to address it. Our assumptions about what is safe will need to change.

Based on the pattern in the UK, soon almost all United States transmission will be happening as a result of the Delta variant. We are currently where the UK was around early June, which means we are lagging by around 38 days.

In the last 38 days in the UK, daily new Covid-19 cases have gone from 3100 to 35,000 or more than 10x. If the United States follows the same curve, we’ll go 10x in cases in the next 38 days, from 20K/day now to 200k+/day by around August 15.

The growth could be slower than that but it’s not clear to me what would make it go slower except a re-imposition of masking, closures, and social distancing or a big uptick in vaccination, which has been slowing way down.

Vaccination is the only lasting solution and we’re simply way behind where we would need to be to beat Delta. Over the last week, we averaged 339K new fully vaccinated people per day, which adds to our current 159M total. That means unless the pace of vaccination speeds up (vs. the current slowing down), the best we’re looking at it is adding 10M people a month to our total, or about 3% of the United States population each month. By the start of October, unless something dramatically changes, we’re looking at 185M fully vaccinated people, not enough to stop Delta with its higher transmission rate.

Here’s why this is important. With a much higher R0 of at least 5, the average Delta patient is likely to infect at least 5 others. Even if 70% of their connections are vaccinated, that means that they will, on average, infection 5 x .3 = 1.5 new people. Given that infection cycles are around a week, that means that 1 infected person becomes 1.5 infected people becomes 2.25 in two weeks. In other words, Delta will double around every two weeks without protections. If R0 is actually 6 , it means more like 1.8 people per reproductive cycle.

Even if Delta acts as if it’s completely blind to all vaccinated people (which actually is not true since there is infection and spreading in the vaccinated), it still nearly has the explosive growth rate potential of the original Wuhan variant even if it ONLY grows through unvaccinated populations.

Here are some numbers we have to consider regarding Delta’s path before us:

  • New R0 estimates = 5-8

  • With R0 of 6, Herd Immunity reached at: 83% (80% if it is 5, 90% if it is 8)

  • % of US citizens who currently say they will definitely or probably not get vaccinated: 30%

  • Actual # of fully vaccinated citizens in the United States: 159M

  • Even if we get to our current 70% full voluntary vaccination ceiling (and we’ve got a lot of work to do ), then somewhere in the range of 13% of the remaining population would either have to get Delta for it to stop transmitting OR enough of them would have to retain natural immunity from a previous infection, which apparently is limited.

  • Nonetheless, let’s be over-generous and say 50% of that population already got a previous variant and is still protected.

  • That rosy scenario would STILL leave us with an absolute minimum of 6.5% of the United States population that will end up getting Delta before transmission slows down naturally as we approach herd immunity. It’s far more likely in the range of 10-20% because of people who just got 1 dose or haven’t gotten around to vaccinating.

  • 6.5% is 21.5M out of 330M people

To think about it differently, we have something like a 100 million person Unvaccinated Nation that will effectively be facing a new pandemic with a transmission rate that is 60% higher than the last and a hospitalization rate that is close to double. They will be facing this pandemic without a vaccine and with beliefs that are often at odds with taking even cheap and easy precautions like masking.

Plus a sizable percentage of that group believe that the government and media are lying to them, so trust in warnings will be low.

Now here’s the additional challenge: vaccine-refusal is correlated with social network so this 100 million Unvaccinated Nation are, on average, more associated with each other than members of the Vaccinated Nation. This population could effectively act like it’s own separate unvaccinated culture into which the newly-supercharged and more dangerous Delta pandemic is now heading. The current vaccination gap between Biden-voting counties and Trump-voting counties is 11%.

So it’s theoretically possible that it could strike up to 83% of Unvaccinated Nation before it stops via herd immunity. That would be 83M people.

If the Unvaccinated Nation were intermingled perfectly with Vaccine Nation, it might only require infection of 21M to stop things naturally because of the buffering of herd immunity but it could run as high as 83M if Unvaccinated Nation acts more like one giant social network.

We could guess 30M new infections to be fairly conservative but my guess is that with the slower vaccination rates and the amount of time remaining to get to even 70% fully vaccinated, plus the fact that there is at least some transmission in the vaccinated, we are likely looking at closer to 50M.

In other words, statistically we’re trending towards another 30-50M infections in the United States mostly among those who have opted out of current vaccines and are not planning to be vaccinated.

And it’s likely this will happen very fast because of the current doubling trajectory.

We can envision this like a separate island of 100M Americans that is about to be hit by a pandemic tsunami in which their beliefs will be a barrier to them taking adequate protective measures. Instead of moving away to high ground, they will be standing on the shore as the surge hits.

They will assume that their risks will be the same as in previous waves when, in fact, the Delta variant puts close to 2x more people in the hospital and transmits far more easily.

Behaviors that were safe last year will not be this fall, which will take some real psychological adjustment.

And they won’t have as much peer pressure and social cues from folks who are now vaccinated to help them be rigorous since the fully vaccinated will likely be laxer due to lowered risk.

So here’s my best case scenario, unless there’s a mass shifting of belief systems or unified mask mandates during July or August, which seems unlikely.

Delta will be getting close to full dominance of our caseload by July 15, when it will represent close to 90% of new cases. Over the last two months, it has been doubling its numbers every two weeks in the United States. In the absence of more rigorous protective measures, there is nothing to prevent it from continuing that doubling pace.

If we assume cycles of two-week doubling from July 15 and start with 20K new daily cases (optimistic given we’ve passed that mark the last 4 days), we will see 40K (aug. 1), 80K (Aug. 15), 160K (Aug. 29), 320K (Sept. 12), 640K (Sept. 26), and 1.28M (Oct. 10).

Now we have to assume that at a certain point major interventions are going to kick in but remember that the unvaccinated have chosen not to vaccinate AFTER the last major peak and the wave of death it created.

The above growth rate is actually SLOWER than the growth in the UK over the last 38 days. Which makes me suspect we may hit those numbers earlier, especially when we read about hotspots such as Branson, Missouri that are taking zero precautions and acting as super-spreaders.

So what looks likely is that early alarm bells will get louder each day now and increase in crescendo through late August. There will be calls for renewed mass action and reimposition of masking, social distancing and shutdowns.

Internationally, that will be happening all over the planet.

But in the Unvaccinated Nation part of the United States, resistance has hardened and become seen as a badge of honor. And the states that have the lowest vaccination levels have had the greatest resistance to enacting stronger protections in previous waves.

That’s why I believe the growth pattern is unlikely to change that much until people in Unvaccinated Nation personally see more friends and community get seriously ill, be hospitalized, or die.

If that is true, then the likely scenario for a breaking point in Unvaccinated Nation would be around mid-September when we hit around 480K daily cases, which would be 60% above our previous highest daily caseload. This caseload will be concentrated in areas of the country in which vaccination is low. In those locations, there will be overwhelmed hospitals and massive sickness.

I think it’s going to be very hard to keep our Fourth Peak below 500K/day cases in America. We’re now in summer and people are loving the freedom. In the coming weeks, Delta will be sneaking up on us fast but won’t seem too menacing for a bit, especially for those who are vaccinated. By mid to late August, though, we’ll be entering a national emergency again.

Here’s where this analysis gets sobering and even heartbreaking.

I think it is likely that somewhere between 33 and 83% of Unvaccinated Nation are likely to get Delta before it peters out via herd immunity. They simply aren’t going to be able or willing to vaccinate fast enough or adapt their behaviors to the new reality.

They’re mostly going to get it.

That could mean from 33-83M more cases, in the United States alone. Let’s be over-generous again and assume 50% of them have retained immunity from a previous infection. That would still leave us a high likelihood of at least 17-41M more cases.

And that doesn’t even count the folks who are partially vaccinated and therefore vulnerable, plus some level of vaccinated transmission as well (even if mostly of the more mild kind).

Given the growth rate I projected above, if we top out at 480K infections/day, we could be infecting more than 10M people in the range of Sept. 15-October 15 - a single month.

Even if the curve is slowed somewhat by increased protections (masks, social distancing, capacity limits, etc.) it will be tough to flatten it altogether given the suspicions of those measures and the difficulties of re-imposing top-down lockdowns, and the increased transmission rate.

So here’s where the math gets brutal.

In January our highest daily hospitalization was 131,000. The peak number of known infections in January, with no Delta, was 300K in a day.

So if in September or early October 2021 we hit only 480K infections per day (which I think is an optimistic next peak), that means we would expect to see not just 60% more hospitalizations than January’s peak but another 85% higher because of the increased rate of hospitalization.

That math would point towards a 321,000 peak in hospitalizations as an optimistic scenario.

We were almost at the system breaking point in January with 131,000.

2.5 times the hospital case load as we faced in January.

Oh my God.

That’s the logic of the coming Delta-driven wave that is charging hard into the 100 million population of Unvaccinated Nation. And make no mistake, this would also endanger Vaccinated Nation because there will not be space for all the people who need hospitals for normal illnesses, plus we are seeing more breakthrough sickness and deaths within the vaccinated population than with previous variants, not to mention a certain percentage of the debilitating Long Covid.

The above projection of 321,000 peak hospitalizations would lead to mass hospital overwhelm, particularly in the rural areas of our country but probably in most of the big cities as well who take in transfers. Which would lead the death rate to increase as care is compromised.

Part of me wants to believe that the scenario is not going to happen but all I am doing is projecting out the trend lines onto our current ideological landscape using the best available scientific estimates and making the assumption that the unvaccinated will need to see things get worse on a personal, local level before taking strong enough actions in their self-defense.

Now it’s important to also address the case fatality rate, which has been focused upon by some right-leaning Delta skeptics. The initial reported early case fatality rate out of England was very low (.1%), and the death rate has not yet surged there. However, those cases represented a small sample, skewed heavily to the young and also had only a fairly short 28-day window of assessment. Basically, they had vaccinated the vast majority of their at-risk population, so they ended up with a low case fatality rate.

If we look at the trend lines for deaths in Russia, as a counter-example, they more closely follow the spike in caseloads as the Delta-driven infection spike is ramping up. Russia is now at their peak daily deaths of the whole pandemic, which doesn’t support the idea of greatly diminished mortality. South Africa’s deaths are now at peak as well. England’s early data may be an anomaly based on the high rate of vaccination of those 50+. Africa’s overall death rate from Covid-19 surged 43% in the last week, attributed to Delta.

This research article from Ontario, Canada actually pegs the fatality rate at 121% HIGHER compared to the last variants, which makes more sense considering the increased hospitalization rate.

Most experts think the jury is still out on whether the case fatality rate is any lower for Delta. Logically, it doesn’t seem likely that hospitalizations could increase so dramatically without the fatality rate following.

If the case fatality rate ends up closer to previous variants, we would be facing many more daily deaths than our January peak of 4400. Those would lag the infections and hospitalizations but could overwhelm morgues and funeral homes nationwide, particularly in small town communities without adequate infrastructure.

So my above analysis points to a Fourth Peak promising to crest between September and mid-October and be perhaps 2.5 worse in terms of hospitalizations as our Third Peak in January and it’s not yet clear what that will mean in terms of fatalities.

I do pray that this conclusion is wrong and that we can collectively change the trajectory. Please do correct anything above if I am off. Challenge my assumptions. Offer a good rebuttal. Because I frankly feel horrified.

We simply can’t let this happen to our country without at least doing our best to avoid the worst.

So what happens next to be part of the solution?

  • If you find flaws in this article, please do let me know in the comments and I’ll keep updating it.

  • If you are a credible authority on this matter and want to endorse the analysis in this article, add a comment and I’ll keep a running list at the bottom.

  • If you find my logic compelling, share this article with friends and allies to start to shift their perspective on what is coming

  • Start raising alarm bells with any decision-maker (politics, business, non-profit) you can that we need to be seriously prepared for a big Delta surge and to put protections back again as early as possible

  • Reactivate your own masking in public indoor spaces (double is better), even if you are fully vaccinated and be aware that Delta also has been shown to have more outdoor transmission as well, such as in this fully vaccinated outdoor wedding.

  • Strongly encourage those you know who have gotten one shot of Pfizer or Moderna to get their second.

  • Alert open-minded members of Unvaccinated Nation to what is likely coming so they can optimize their protection of themselves and their family. Have a heart-to-heart with them about the risks of staying unvaccinated as the next tsunami hits and do your best to get them to take precautions.

  • Open your heart to all those who may suffer in this, even if they hold belief systems that you don’t agree with. They are human beings. They are our fellow citizens. Let’s not judge them for their choices but do our best to help change the trajectory of this next wave and protect those we can.

If this Delta scenario indeed plays out, it will be devastating for so many communities that are on the margins economically. It will create long-term damage in so many lives. And it will actually increase the risk of a still-more deadly variant arising.

Making matters worse in all this is the likelihood that this will be our biggest fire season yet with the scorching of the West via successive heatwaves on top of an historic drought. Throughout the coming weeks, there’s a high likelihood of massive fires taking headlines while Delta surges. By the time Delta dominates our national discourse and we update ourselves mentality about the major differences of this wave from past waves, we’re going to be heading into huge daily caseloads.

With pandemic fatigue everywhere, it’s going to be hard to get people to pay full attention until it gets worse. That doesn’t mean we don’t try.

Many scientists express “concern” that the United States could follow in Britain’s footsteps but don’t actually paint the scenario of where we are headed. They express worry that we are facing potential localized outbreaks but it’s clear that it can and probably will get far worse.

One former CDC employee, virologist and front-line Covid doctor to whom a draft of this article was sent said that he agreed with both the analysis and the timeline.

For whatever reason, though, our public officials are not painting the full picture.

Lest you think I’m being overly pessimistic, there are also things that could make the fourth peak worse, ranging from higher rates of transmission via kids to an R0 at the upper end of the estimated range, to longer delays in taking action due to politicization to increased transmission through the vaccinated. I think we have a non-zero risk of hitting 1M daily cases if those scenarios play out in the worst case direction.

Perhaps the only good news in this is that the wave is unlikely to endure for very long. It will be more like a raging fire that burns quickly until it starts to exhaust itself with herd immunity and run out of people to infect. However, it will leave behind a terrible trail of damaged lives.

On the global stage, the logic of Delta gets far more brutal. Hospitals world-wide are going to be overwhelmed sooner than we imagine.

To get a foretaste of what is starting to happen globally, here are accounts from Moscow, Lisbon, and Tunisia.

In many articles, people express surprise at the suddenness and intensity of the Delta wave. If they did the math and let go of their previous assumptions of what they know about the pandemic, they would see that there is nothing surprising about the Delta surge that is coming fast.

It is simple math.

So let’s shift our perception and get engaged to help mitigate what is heading our way. I know we are all desperately tired of the pandemic, but the Delta surge is promising to be the worst yet.