The Cost of Herd Immunity in the U.S.

— Likely involves more than a million deaths; "That cannot be our price"

MedpageToday
An infographic depicting the concept of herd immunity

The latest physician added to President Donald Trump's advisory team is pushing a herd immunity strategy, according to the Washington Post.

Scott Atlas, MD, has advocated using the Swedish approach, allowing people to become infected naturally in order to build immunity to COVID-19 while focusing on protecting the vulnerable, like nursing home residents. The Post's report is based on interviews with five people who were familiar with the discussions.

Atlas denied advising that the administration pursue a herd immunity strategy. During a press briefing with Florida Gov. Ron DeSantis (R) on Monday, Atlas called the Post's report a "lie."

"There's news, there's opinion, and then there's overt lie," he said. "And that was never a strategy advocated by me in the administration. The President does not have a strategy like that. I have never advocated that strategy."

Public health experts roundly criticized that approach, noting that it hasn't worked in Sweden, which has the highest COVID-19 mortality rates among the Nordic countries. Its 574 deaths per million people far outnumber Denmark's 108 deaths per million, Finland's 61 deaths per million, and Norway's 49 deaths per million. The Swedish figure is closer to Italy's 587 deaths per million.

"Sweden tried this 'herd immunity' approach and had many more deaths than their European peers per capita and hasn't escaped the economic carnage they had hoped by this strategy," tweeted Gregg Gonsalves, PhD, an epidemiologist at Yale School of Medicine.

"Herd immunity? Sweden model? Sweden had a higher death rate than Denmark, Norway, and Finland, AND its economy did worse. The only alternative to controlling the virus is more deaths and more economic devastation. Choose health," tweeted Tom Frieden, MD, MPH, a former CDC director.

"Dr. Atlas, a radiologist, has no training or expertise in infectious diseases, but what he does have are the words the President wants to hear: you can let the virus spread widely throughout the US if you just try to keep the elderly safe, open up everything and let 'er rip," he tweeted.

According to the California Medical Board, Atlas is board certified in diagnostic radiology and neuroradiology.

The Post reported that Atlas was hired because Trump was looking for a doctor whose opinions on the pandemic were more in line with his own vision. Other physicians on the White House coronavirus task force, notably Anthony Fauci, MD, and Deborah Birx, MD, have fallen out of favor with the president.

Atlas, a fellow at the conservative Hoover Institution, has made numerous appearances on Fox News, pushing reopening of the economy and highlighting the adverse effects of shutting it down, such as an increase in depression and suicidal thinking.

The Post reported that he meets with Trump every day, more than any other health official.

Moreover, according to the Post, other administration actions are in line with a herd immunity strategy, even if officials don't admit it. For instance, the Department of Health and Human Services has ramped up shipments of tests to nursing homes, but hasn't increased spending on testing in other areas.

As well, controversial revised CDC guidance effectively calls for less testing in asymptomatic people, despite estimates that 25% to 40% of all infections are asymptomatic.

Atlas has also advocated for opening schools despite outbreaks that have occurred once in-person learning resumed.

The newspaper noted that countries that have best controlled the virus implemented strict lockdowns that were heeded by citizens, imposed mask mandates, and deployed widespread testing and contact tracing.

It's not certain what percentage of the U.S. population of about 328 million would need to be infected to achieve herd immunity. Given its transmissibility, the World Health Organization (WHO) estimates that 65% to 70% of a population would need to be immune to the virus before it would burn itself out -- though in some recent reports, experts have argued that the number may be closer to 40% or 50%.

Currently, the U.S. has a case fatality rate of about 3%, based on 187,000 deaths and 6.2 million infections; however, the infection fatality rate is likely lower since most asymptomatic infections probably aren't detected. The CDC uses 0.65% in its pandemic planning scenarios.

Using the WHO (65%) and CDC (0.65%) figures, 213 million people in the U.S. would need to be infected to achieve herd immunity, leaving 1,385,800 Americans dead.

Stress on the nation's hospitals could also be tremendous. Thus far, about 370,000 Americans have been hospitalized with COVID-19. If we assume that, for each case diagnosed so far, five cases occurred without symptoms or diagnoses, that leads to a hospitalization rate of about 1%. With 213 million infections, then, about 2.3 million could be expected to end up hospitalized.

Those hospitalizations come with a cost, of course. Studies have yielded a wide range of median or average costs, from just over $10,000 to more than $70,000. If for simplicity we assume it averages $30,000, the total hospital bill to achieve herd immunity is about $80 billion.

And herd immunity works only if people can't get re-infected with the virus, which isn't a certainty, according to Leana Wen, MD, of George Washington University.

"We don't even know if we can achieve lasting immunity -- most likely, we can't," Wen tweeted. "And even if we could, it would take hundreds of millions more #covid19 infections & millions of preventable deaths. That cannot be our price."

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    Kristina Fiore leads MedPage’s enterprise & investigative reporting team. She’s been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Send story tips to k.fiore@medpagetoday.com. Follow