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Projecting COVID-19 Mortality as States Relax Nonpharmacologic Interventions

JAMA Health Forum. 2022;3(4):e220760. doi:10.1001/jamahealthforum.2022.0760

Benjamin P. Linas, MD, MPH1,2; Jade Xiao, BE3; Ozden O. Dalgic, PhD4; et al

Key Points

Question What is the expected trend in COVID-19 mortality if US states were to lift nonpharmacologic interventions (NPIs) at different times over the remainder of 2022?

Findings In this simulation modeling study, lifting NPIs was likely to result in rebounding epidemics regardless of the delay in lifting. The degree of population-level immunity was associated with the size of the rebounding peak in incident deaths.

Meaning This simulation study found no path to the end of the COVID-19 pandemic that avoided difficult trade-offs between prolonged NPIs and increased COVID-19 mortality following their removal.


Importance A key question for policy makers and the public is what to expect from the COVID-19 pandemic going forward as states lift nonpharmacologic interventions (NPIs), such as indoor mask mandates, to prevent COVID-19 transmission.

Objective To project COVID-19 deaths between March 1, 2022, and December 31, 2022, in each of the 50 US states, District of Columbia, and Puerto Rico assuming different dates of lifting of mask mandates and NPIs.

Design, Setting, and Participants This simulation modeling study used the COVID-19 Policy Simulator compartmental model to project COVID-19 deaths from March 1, 2022, to December 31, 2022, using simulated populations in the 50 US states, District of Columbia, and Puerto Rico. Projected current epidemiologic trends for each state until December 31, 2022, assuming the current pace of vaccination is maintained into the future and modeling different dates of lifting NPIs.

Exposures Date of lifting statewide NPI mandates as March 1, April 1, May 1, June 1, or July 1, 2022.

Main Outcomes and Measures Projected COVID-19 incident deaths from March to December 2022.

Results With the high transmissibility of current circulating SARS-CoV-2 variants, the simulated lifting of NPIs in March 2022 was associated with resurgences of COVID-19 deaths in nearly every state. In comparison, delaying by even 1 month to lift NPIs in April 2022 was estimated to mitigate the amplitude of the surge. For most states, however, no amount of delay was estimated to be sufficient to prevent a surge in deaths completely. The primary factor associated with recurrent epidemics in the simulation was the assumed high effective reproduction number of unmitigated viral transmission. With a lower level of transmissibility similar to those of the ancestral strains, the model estimated that most states could remove NPIs in March 2022 and likely not see recurrent surges.

Conclusions and Relevance This simulation study estimated that the SARS-CoV-2 virus would likely continue to take a major toll in the US, even as cases continued to decrease. Because of the high transmissibility of the recent Delta and Omicron variants, premature lifting of NPIs could pose a substantial threat of rebounding surges in morbidity and mortality. At the same time, continued delay in lifting NPIs may not prevent future surges.

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