In one week, Pennsylvania will lift its mask mandate. Indoors or outdoors, vaccinated or unvaccinated, old or young, no one in the state will be required to wear a mask in the vast majority of situations.
The move is largely symbolic at this point: Regardless of vaccination status, many people have already tossed their masks, and others will continue to wear them. Still, the lifting of the mask mandate is one of the most visceral markers of our transition back toward the pre-pandemic world we once knew.
Throughout the pandemic, it often has been difficult to know what to believe and who to trust. Information has changed rapidly, and data has been incomplete. The whole experience has been disorienting and confusing.
So, as COVID cases slow and the region returns to something approaching normal, we’re taking the opportunity to look back at what has transpired during the past 15 months, what we have learned and where we are headed next.
Flattening The Curve
Back in March 2020, public health officials and medical systems talked about “flattening the curve:” containing spread of the coronavirus enough so that hospitals would not become overwhelmed. For about three weeks after shutdown orders were announced, cases in Allegheny County continued to climb. The seven-day average of daily new cases peaked on April 7 at 52 cases; the number of people hospitalized for COVID-19 peaked about two weeks later, at 93. Nearly two-thirds of them were on ventilators.
In mid-April, a statewide mask mandate went into effect, and when case numbers began to fall again, many thought the worst was over. On May 15, Allegheny County entered the “yellow phase” of Pennsylvania’s reopening plan. Daycares resumed operations, and non-essential businesses such as garden centers and clothing stores welcomed customers back. They would not be required to close their doors again.
Peak seven-day average of new cases: 52
Peak hospitalizations: 93
Average daily deaths: 2.3
Reopening
On June 5, Allegheny County entered the “green phase” of Pennsylvania’s reopening plan. Bars, restaurants, gyms, spas, casinos and theaters opened their doors at half capacity. For a couple of weeks, case counts continued to fall. On June 17, for the first time since the pandemic began, Allegheny County reported no new cases of COVID-19.
Days later, the trend reversed, and a series of record-setting days followed. Believing bars to be major sites of transmission, Allegheny County officials banned the on-site consumption of alcohol at bars and restaurants. On July 2, the county reported 233 cases — more than double the day before — and ordered bars, restaurants and casinos to close for one week.
At the height of what had become known as the “second wave” of coronavirus infections, Gov. Tom Wolf imposed further restrictions on restaurants, bars and gatherings. That wave crested in mid-July, when the seven-day average of daily case counts exceeded 200 for the first time. On July 23, COVID-19 hospitalizations peaked at 184. The next day, bars and restaurants in Allegheny County re-opened to dine-in customers.
While numbers of cases and hospitalizations were both higher during the reopening period than in the spring, the number of deaths did not follow suit. This is likely because the age of those infected skewed younger than it had previously; many of the county’s spring outbreaks were concentrated in nursing homes. A comparison of the numbers of patients on ventilators suggests illnesses were less severe in the summer as well. Nearly twice as many people were hospitalized during the peak of the reopening wave of infections, but the number of patients on ventilators was about the same.
By mid-August, daily case counts had fallen to where they were during the height of the initial surge in the spring. County officials begged businesses to follow state and local restrictions but declined to impose any new rules.
Peak seven-day average of new cases: 206
Peak hospitalizations: 184
Average daily deaths: 1.7
The Winter Surge
Late summer and early fall were marked by dropping case counts and the easing of restrictions on large gatherings as well as bars, restaurants, casinos, gyms and other businesses. But by mid-October, Pennsylvania Secretary of Health Dr. Rachel Levine confirmed the fall resurgence of the virus was underway, and experts began to issue dire warnings about the long, dark winter ahead (an alarm also sounded by an ousted federal government scientist in May).
On Nov. 18, the number of cases reported in Allegheny County reached 600 for the first time; statewide the figure topped 6,000. That day, county health officials issued a stay-at-home advisory: a recommendation and request that people stay home as much as possible. Unlike the order issued earlier in the pandemic, however, this was not a mandate. Days later, the state followed suit and urged people to stay home for Thanksgiving.
As the weeks wore on and cases soared, some Pittsburghers began to question why officials were not ordering the kind of shutdown seen in the spring, when local case counts numbered in the dozens, not the hundreds. The Wolf administration argued that a total shutdown was a “blunt instrument” and instead favored an approach largely targeted toward businesses such as bars, restaurants, gyms, casinos, theaters and other places where the public congregates. County health department director Dr. Debra Bogen cited economic concerns, but she did urge people to shun businesses not complying with coronavirus mitigation orders such as masking and physical distancing.
The case numbers during the winter surge were staggering compared to earlier waves of infection. Allegheny County’s seven-day average of daily new infections peaked at more than 1,000 cases per day in mid-December, about five times the summer surge and 20 times the initial spring surge. Around the same time, nearly 900 people were hospitalized with COVID-19 in the county, and facilities around the state complained of staffing and bed shortages.
“We're stretched so thin,” said Jodi Faltin, a Pittsburgh ICU nurse. “We want to provide the best, most compassionate care that we can, and it's hard when … there aren't enough hours in the day and there aren't enough of us.”
The severity of illness was far less than it was during the initial spring surge and later in the summer. Still, between Oct. 1, 2020 and Jan. 31, 2021, an average of 10 Allegheny County residents died of COVID-19 every day.
In mid-December, health care workers received the first vaccinations administered in Allegheny County, and in late December, nursing home residents began to get their shots. But the early weeks of the rollout were plagued with problems. Some non-hospital health care workers said they couldn’t figure out how to get vaccinated, as large health systems controlled thousands of doses of vaccine. UPMC appeared to buck the state’s vaccine guidance, inoculating its own remote, non-clinical staff before other non-affiliated health care providers in the area. Demand for the vaccine far outstripped supply, and as the state opened up eligibility to more groups, concerns about disparities in vaccine access began to grow.
Peak seven-day average of new cases: 1,055
Peak hospitalizations: 881
Average daily deaths: 10
The Fourth Wave
Public health experts voiced cautious optimism in mid-February due to the ongoing decline in cases that began over the holiday season. This drop in case numbers was a surprise, as many had anticipated that infections would spike after the holiday season. And with the increasing availability of both the Moderna and Pfizer COVID-19 vaccines, as well as the approval of a third vaccine from Johnson & Johnson on the horizon, the light at the end of the tunnel appeared brighter. But with the proliferation of the more infectious B.1.1.7, or so-called “UK variant,” what had first appeared to be a spring plateau turned into another surge of coronavirus cases.
In addition to the new variant, a restless public who had been cooped up for a year to avoid the virus appears to have contributed to the surge of cases, which officials called the “fourth wave.” During a March 17 press conference, Dr. Debra Bogen, director of the county’s health department,said case investigation data showed that people were participating in more activities and gatherings, including visits to restaurants, parties and travel.
Despite this case surge, deaths were still declining. That’s because residents and staff of long-term care facilities were among the first people to receive the vaccine, followed by people age 65 and older. Age is a major risk factor for death from COVID, buta Feb. 24 report by the Kaiser Family Foundation found that with the advent of the vaccine, COVID deaths among nursing home residents declined by 66 percent.
Like deaths, COVID hospitalizations also declined through the first half of March. But when cases began to climb again in mid-March, so did hospitalizations. This was especially true for those involving Black residents. Deaths largely remained flat, in part because elderly residents, particularly those in long-term care facilities had earlier access to the vaccine. Additionally, therapies and treatments developed during the course of the pandemic made surviving COVID more likely.
The inequitable rollout of the vaccination campaign likely contributed to racial disparities in hospitalizations. The distribution of vaccinations was marked by poor communication and haphazard planning on the local, state and federal levels, by both medical providers and government agencies. Many public health experts say much of this could have been avoided if the Trump Administration more effectively funded and distributed the vaccine.
The first months of the vaccine rollout were chaotic. Appointments were hard to find, resulting in a situation where people with the most resources were among the first to be vaccinated. As a result white people in Allegheny County were more likely to be vaccinated than Black residents. That’s even though Black and brown communities have been disproportionately affected by the pandemic, and public health experts had warned that racial inequities would affect vaccine access.
Black residents continue to be underrepresented among the county’s vaccinated population, even though recent survey data show that vaccine hesitancy is slightly higher among whites than Blacks. Part of the solution to increase Black vaccination is making the vaccine more accessible.
“When community [-based] events started to happen, we saw vaccination rates in Black populations increase,” University of Pittsburgh epidemiologist Tiffany Gary-Webb pointed out during a June 15 panel discussion with the Black Equity Coalition.
Some of these disparities were likely exacerbated by the fact that providers were focused on quickly vaccinating a large number of people and therefore prioritized speed over equity. (The Wolf Administration admitted as much during an April 23 visit to a neighborhood pharmacy in Harrisburg.) This decision was prompted in part by surging case numbers; the more people inoculated against the virus, the fewer human hosts it had to infect.
Mass clinics, such as those held at Heinz Field and Pittsburgh Mills, were an efficient way to vaccinate large numbers of people. However, these sites weren’t accessible to many people — including those who lacked reliable transportation and technology, along with hourly workers and people with mobility concerns. Appointment slots in mid-to-late March increasingly went unused.
While there are still unvaccinated people wanting to get their jabs, accessibility continues to be an issue. Emphasis has shifted to the establishment of smaller clinics designed to serve specific populations or communities who have had less access. For example, on May 4, a clinic at the Whitehall Presbyterian Church was staffed with more than a dozen Nepali-language medical translators and equipped with written materials in Nepali. Walk-in appointments at neighborhood locations, such as pharmacies or community centers, are now more readily available.
Additionally, the county and area medical systems are working to address vaccine hesitancy. On June 6, Bogen noted that her department used a portion of its CARES Act funding to contract Pittsburgh-based production company Ya Momz House to create a series of videos and messages sharing “stories of safety, reliance and hope in our communities of color.” Bogen said she hopes these documentary-style essays will encourage people to get vaccinated.
Peak seven-day average of new cases: 545
Peak hospitalizations: 313
Average daily deaths: 3.7
Taking Stock and Looking Forward
While vaccine hesitancy and access remain huge issues, the rate of new coronavirus cases has been dropping since mid-April. The county now reports an average of fewer than 25 new cases a day; hospitalizations are at a level last seen during the second week of October 2020. This largely can be attributed to vaccination efforts. More than half of Allegheny County residents are fully vaccinated, and an additional 15 percent are partially vaccinated.
The COVID vaccines were developed, produced and distributed more quickly than initially predicted. That’s due in part to vaccine manufacturers exceeding expectations on when doses would be available. Because of the vaccination effort, life is starting to feel more like a pre-pandemic normal. Nearly all pandemic-related restrictions on businesses and individuals expired on Memorial Day, and Gov. Tom Wolf will lift the statewide mask mandate on June 28. Many Pennsylvanians already have dispensed with the coverings, as fully vaccinated people are no longer required to wear them in most settings.
Matt Ferrari, director of Penn State’s Center for Infectious Disease Dynamics, said he suspects the U.S. is entering a new phase of the pandemic in which there will still be sporadic outbreaks of the virus.
“It remains to be seen how disruptive those will be — e.g. leading to limited school and business closures, possibly leading to targeted efforts to increase vaccination,” he said.
While some worry that the COVID vaccines were developed too quickly, the speed at which they came out can be attributed to at least two decades of scientific research on mRNA and various coronaviruses.
“I hope we can celebrate the windfall from that investment and build upon the momentum from their success to improve the world we live in,” said Kevin McCarthy of the University of Pittsburgh’s Center for Vaccine research.
Health department director Bogen said in addition to the vaccine, the low transmission rate in Allegheny County is buoyed by natural immunity. There have been nearly 102,000 documented cases of the virus among county residents, though the actual figure is certainly higher.
“Especially early on, we didn’t test everybody for COVID-19. So we know that there were people who had cases, but we didn’t test. And there were a lot of asymptomatic people who didn’t have any symptoms, who would have never gotten tested,” said Bogen during an April 28 press conference.
Additionally, warmer weather is leading more people to socialize outdoors, where the virus is less likely to spread.
On rare occasions, people do become infected post-vaccination. Among them are 420 cases out of 603,121 fully vaccinated people in Allegheny County, as of June 16. Experts say that vaccinated COVID patients are more likely to have mild symptoms, showing that the vaccine — while not 100 percent effective — provides a profound benefit.
Conversely, the greatest tragedies of the pandemic could have been avoided, or at least mitigated, through increased investments in the public health system. Black and brown communities, elder-care facilities, and people living in poverty all bore disproportionate burdens in terms of severe COVID illness and death. Notably, many of the same factors that caused Black Americans to be more likely to contract HIV also put the community at higher risk for COVID, despite the two being very different infectious diseases in terms of how they spread and affect the body.
“We would be, I think, remiss if we didn’t take the lessons from the pandemic and make sure that going forward we address them,” said Dr. Denise Johnson, Pennsylvania’s Acting Surgeon General.
During the Black Equity Coalition panel on June 15, Johnson detailed several changes she’d like to see post-COVID: Medical systems ensuring that people can access health care not just through the internet but also the telephone; considerations around transportation when selecting the locations of health care centers; and medical care that’s culturally appropriate and culturally sensitive.
“If we don’t transform the way that we’re delivering health care and the way we’re ensuring equity, then we’re going to be at the same position with another pandemic,” she said.
Public health historian Aishah Scott of Carnegie Mellon University agrees, and said she fears, “A ‘return to normal’ that allows people to continue ignoring gaping health disparities along lines of race and socioeconomic status in the United States that were highlighted by COVID-19.”
It may seem like the pandemic is on its way out, but variants still threaten the security that’s been hard-won by the vaccination campaign, as there is always a chance that the virus may mutate in a way that renders the vaccines less effective or ineffective. For this reason, addressing vaccine hesitancy is "paramount," said Elaine Jenkins of Pittsburgh Black Nurses in Action.
“I continue to be alarmed at the reasons given for vaccine hesitancy,” she said. “Especially in the marginalized community which has the highest mortality and morbidity conditions.”
Additionally, most of the global population remains unvaccinated. It may be at least a couple of years before the entire international community can access the vaccine. The Biden administration has pledged to send 80 million doses to other countries by the end of June, but this meets just a fraction of the need.
“Polio and measles still persist despite ... not being common here. And every year we have measles outbreaks in the U.S. that have their origins elsewhere,” said Ferrari. “Unfortunately, what we’ve tended to see is that as a disease becomes rarer, interest in vaccination tends to wane and doesn’t get renewed support until outbreaks start popping up again.”
To date, the only infectious disease to be completely eradicated due to a vaccine is smallpox.
Even when the pandemic does truly end, the long-term effects are unknown. Many so-called COVID long-haulers suffer brain fog and fatigue months after infection. Researchers are still learning how the virus has created permanent damage to the body.
“I’m concerned that we will have a relatively large group of people who will be chronically ill … without known ways to treat them,” said Dr. Amy Crawford-Faucher, head of primary care at Allegheny Health Network.
Many people who haven’t gotten sick with COVID will still suffer long-term effects of the pandemic: millions of people are out of work or facing eviction. Some 600,000 Americans have died from COVID-19, and even those who haven’t lost loved ones still must contend with the trauma of witnessing a more than year-long mass casualty event.
“We’re going to have a huge impact in terms of the need for mental health services and supports,” said Johnson.
As the immediate crises created by the pandemic recede in Allegheny County, the ways COVID has forever changed the world we live in are still taking shape. It remains to be seen whether society heeds the lessons of the pandemic and meets the challenges still to come.
