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Returning to normal: A Covid-19 Q&A with Dr. David Rubin

Dr. David Rubin (Source: PolicyLab)

Dr. David Rubin (Source: PolicyLab)
Dr. David Rubin (Source: PolicyLab)

As January's omicron-fueled Covid-19 surge begins to ebb locally and nationwide, a public health expert is recommending two things: Vaccination, and a return to normal.

"We're learning to live with this virus now akin to other seasonal viruses," Dr. David Rubin told NPR in mid-January.

Rubin is the head of PolicyLab, a research entity at Children's Hospital of Philadelphia that tracks and projects Covid-19 data county by county. PolicyLab works with Philadelphia-area schools on Covid-19 testing and tracking.

In early January, the organization published updated school guidance. Noting the widespread availability of vaccines, the generally milder course of omicron, and the documented impacts of school closures on learning loss and children's mental health, it says, "The time has come to pivot towards solutions that prioritize normalization of in-school education across all communities alongside practical safety measures."

It calls for maintaining indoor masking requirements (most Lancaster County school districts are mask-optional) but it counsels against regular "surveillance" testing of asymptomatic students, teachers and staff.

The rationale? Even before omicron, PolicyLab said, it was challenging for schools, especially under-resourced ones, to implement effective asymptomatic testing programs; omicron essentially rendered those efforts futile.

The guidance says that individuals who were exposed to Covid but have no symptoms can remain in school provided they wear masks at all times and are screened daily for illness, a so-called "mask to stay" policy. If exposure took place outside school, mask-to-stay should be allowed only if the individual is vaccinated, PolicyLab said.

One United Lancaster recently spoke with Rubin about the pandemic and PolicyLab's recommendations. The following has been edited for length and clarity.

OUL: To begin, I wanted to get a sense of where we are and where we might be heading [with Covid-19].

Dr. David Rubin: Cold weather is sustaining our peaks a little bit, but overall, we're now moving in a good direction in terms of declining transmission, and we're seeing [hospital] admissions start to drop. ...

There was clearly a big seasonal surge occurring with delta, and omicron topped that off as it came through, but for most individuals, [omicron] turned out to be milder than the previous strains.

I think the rates stayed up a little bit longer in Lancaster, but in terms of the overall directionality of Pennsylvania admissions, we're in a pretty good place now.

OUL: LNP newspaper ran a piece on low childhood Covid-19 vaccination rates. They quote pediatricians saying it'd be good to increase it, because 1. most kids do fine, but some don't; and 2. Low vaccination rates among children increases the chance of community transmission. Would you concur?

Rubin: Yeah, I would. Vaccination greatly reduces the risk of severe disease. Fortunately, the omicron variant has been milder. But ... for both children and adults, if you look at the admissions, you can see a number of individuals, particularly older children, who were hospitalized and who were unvaccinated. [And] there are secondary consequences with regards to other health issues that can develop as a consequence of the infection.

OUL: Are you referring to long COVID?

Rubin: Some of it is long COVID. But there have been some reports of inflammatory syndrome and an increased risk of diabetes following COVID exposure, at least with earlier strains. ...
For me, the safest recommendation would be for families to highly consider the benefits of the vaccine in terms of the broad immunity it provides.

OUL: Back in spring and summer of 2020, we did a pretty comprehensive state lockdown in an attempt to keep that initial surge from overwhelming hospitals. Now we've seen [another] surge. In a perfect world, would we have had stronger mitigation efforts heading into November, December, January? Is this what we were trying to prevent back in March 2020?

Rubin: I think it's tough. We had a rapid shift to a virus that acted more like a seasonal virus, and we don't normally collect information on what it looks like to be in the middle of a cold season or influenza season in terms of the rates of positivity, and all the testing.

Looking back, we didn't have sufficient testing inventory that could help manage this transition over the winter. Certainly, higher vaccination rates, particularly booster rates, could have could have helped those who were vulnerable in terms of who were swept up into this current wave of hospitalizations.

That said, this is a different moment. The vaccinations and boosters have been offered, particularly [for] those who were the most vulnerable. [We have] a variant strain that for most people is producing milder illness compared to previous strains. I think this is about individuals now having the ability to navigate their own sense of risk and trying to help transition communities back to normal.

OUL: What is that path back to normal, and what does normal look like?

Rubin: We asked folks to wear masks during a period of really high transmission. When our hospitals were really having a difficult time, that was something I think we all could understand. But we also understand that those types of measures are really time-limited.

Once we start seeing declining transmission and hospitalizations like we're starting to see, I think we have to continue to take that next step towards allowing individuals to make their own choices. ...

We are working with the schools in our own region, to find that moment here in February, when they can take that next step toward recommending masks during high transmission but not requiring [them], giving people more flexibility to make those decisions. We're reducing the footprint around the necessity for testing of people with milder illness, trying to shorten the length of isolation, like the CDC has done. ...

I hope by early spring, we're in a much more favorable position, assuming we don't have another curveball with a more virulent virus, which is less likely.

OUL: What about 2023, 2024?

Rubin: It's a bit of conjecture here, but I think it [Covid-19] is starting to act more like a seasonal virus. So, we would suspect that we'd likely see some Covid next winter.

The level of virulence, I think remains uncertain, but it's likely to be of a similar if not less. That's unless we have a new variant, particularly from one of the earlier lineages like Delta. But most likely, we're going to be looking at something that has a lower virulence, that over time through each of these ways may have a lower amplitude, but certainly a lower amplitude in terms of hospitalizations.

There may be times that people individually decide during flu season or during a Covid season to wear a mask. I think it's less likely we'll see restrictions or requirements placed on individuals, and probably less likely to see them in our schools, beyond individual recommendations.

OUL: There are reports on the idea of a "super vaccine" that can target coronaviruses generally. Might those be part of the way out?

Rubin: There might be some benefit in broadening immunity through vaccinations, using boosters for some of these lineages that have developed like the delta lineage. Particularly for vulnerable individuals, I think we're moving into more of a tempo around seasonal transmission. It's allowing a little more time between winters to develop and test some of these booster solutions.

We're also waiting, for review and approval [of vaccination] for children under five, which will be important, sometime in the spring.

OUL: It sounds like what you're describing is a world in which we have a flu / Covid season. And it warrants some attention, but it's no longer a pandemic.

Rubin: Right. The most likely scenarios are, you're going to be dealing with both during a typical winter season and watching the data in terms of the impacts in terms of hospitalizations, and whether that's changing.

Hopefully, it's becoming milder with respect to Covid. There are scenarios where Covid continues to grow even milder over time than influenza or is more similar to an influenza virus in terms of its impacts, but I think we have to wait. The data will demonstrate to us as we move into fall the direction of where things are going. The upper Midwest usually gives us a clue by September, October.

OUL: What is your advice to the average person?

Rubin: I think it's time to get back to work and back to school and try to take that push to normal. The risks now of not addressing [children's learning loss or pandemic anxiety] are now much greater than the virus itself for most individuals. I think the American public has figured that out.

Assuming we don't have another virus or a variant that's more virulent — and at this point in the winter season and moving towards spring, I see that as highly unlikely — I see the American public and our states and cities making broad moves to lessen the required need for mitigation and allow individuals to make these choices about how they'd like to manage their lives.