Manhattan's COVID risk levels move from low to medium: Here's what health experts recommend

In late February, the Centers for Disease Control and Prevention released a new way for counties to judge the status of the pandemic in their area. Those “COVID-19 Community Levels” are meant to dictate when to return public health recommendations such as indoor mask wearing.

What some New Yorkers may not realize is that the CDC only updates this risk assessment once a week — every Thursday evening. It looks at specific cutoffs for cases per 100,000 residents, new hospitalizations and hospital bed capacity recorded over the past seven days. The CDC then labels a county or borough as low risk (green), medium risk (yellow) or high risk (orange).

Manhattan has been green for weeks since the new rubric launched. Yet there is a hack for any keen person who can’t wait for a once-a-week update and wants to track these seven-day rates in real-time. Type in your county into the Community Levels webpage and scroll down.

Residents of Manhattan — or New York County — would have noticed on Wednesday that their borough was now reporting more than 200 cases per 100,000 residents. This case rate means that Manhattan has technically moved from being low risk to medium risk.

The shift threatens to scupper the rollback of city and state health precautions, but also comes at an inconvenient time for the pandemic response. Mayor Eric Adams, for example, had promised to remove mask mandates in childcare settings for the city’s youngest by April 4th — but only if risk levels remained low. Earlier this month, Congress opted to pull $15.6 billion in funding for immediate pandemic health care, meaning that the Biden administration can no longer buy or reimburse tests and medicine such as the COVID pills or vaccines. In the aftermath, some leaders in Congress continue to seek a standalone bill for these medical funds but are hitting resistance.

New York City health officials told Gothamist that they’d be able to maintain testing at publicly run sites.

“There's going to be no change to our city run sites in terms of our mobile sites, our fixed sites,” said Dr. Ted Long, the executive director of the NYC Test and Trace Corps. “We're going to be continuing full force ahead and even expanding as we need to, to meet the demands of testing across New York City.”

But the city and state’s vaccine supply so far has come from deals crafted by the federal government with drugmakers. This stock of vaccines will now dwindle at a time when booster shots will become more crucial, especially first booster shots for fully vaccinated people. An analysis this week by the health policy nonprofit KFF predicts that once the current federal supply of vaccines runs out, private health care providers will need to negotiate new contracts with vaccine makers, which “could translate to higher costs and premiums for employers and individuals.”

“It's not just the impact on uninsured New Yorkers that we are concerned about. It's the impact on our overall COVID response going forward,” Dr. Ashwin Vasan, the New York City health commissioner said, citing the rollout of first boosters, the push to get kids vaccinated and the expected authorization of shots for kids under 5. “These are all under threat if Congress doesn't decide to authorize this spending.”

Read More: What to know now about NYC school COVID protocols

Health data from overseas shows protection against severe disease is waning in the face of omicron for people with only two shots, emphasizing the need of initial booster shots for those eligible.

Similar concerns apply to unvaccinated people relying on immunity from a prior infection, said Dr. Bruce Farber, the chief of public health and epidemiology at Northwell Health and the chief of infectious diseases at North Shore University Hospital and LIJ Medical Center.

“We know people are not going to have lifelong immunity,” Farber said. He added that people who had BA.1 infections over the winter should have protection from BA.2. But as Gothamist reported on Sunday, this status might only apply to one in five New York City residents. Farber and other health experts recommend booster shots for unvaccinated New Yorkers who were infected prior to omicron’s arrival in December.

This guidance is being lost amid a debate over fourth shots — or second boosters — for people older than 50. Health experts said that’s a whole separate conversation. So for the confused, here’s a guide of recommendations based on age, vaccination status and prior infection.

What to do if you already caught omicron this winter

Booster: You’re probably OK, but a booster could seal the deal.

Masks: If boosted, you can mostly skip the masks indoors.

Testing: Only test within 90 days of coronavirus infection if you experience symptoms.

Farber said vaccinated people who caught BA.1 over the winter are in the best shape. One study has found BA.2 reinfections are rare among people who’ve had BA.1.

“The best immunity is hybrid immunity. Those who have been infected with some type of COVID and have gotten at least one booster,” Farber said. The same goes if you were vaccinated first and experienced a breakthrough infection. BA.1 accounted for approximately 90% of New York State’s cases by New Year’s Day, so if you caught the coronavirus in the weeks before and since this date, it was most likely omicron.

Unvaccinated people who were infected with omicron could be protected, too, but only if their immunity was actually established. The pitfall of so-called natural immunity is that it is less likely to develop solid protection relative to vaccination. While past infection can build antibodies to stop initial infections, studies show the strength of the shields can vary by as much as 200-fold. Similar differences are witnessed with T-cells, which are generally viewed as the wardens against severe disease. After natural infection, T-cells start to decline after about 100 days, whereas they stay stable for vaccinated people during this period — out to 6 to 8 months.

What to do if you’re fully vaxxed, didn’t get BA.1 and are older than 50

Booster: Get the first one immediately and consider the second.

Masks: Wear a mask indoors if totally unboosted.

Testing: If you test positive, seek early treatments

As Gothamist reported in early March, data from the U.K. Health Security Agency shows that fully vaccinated older adults — two doses in people over 50 — are gradually losing their ability to avoid death from COVID-19. The effectiveness here drops to 59% after about 5 months, but this protection returns to 90% immediately after boosting.

The initial waning is due to the fact that humans are more likely to develop underlying conditions — such as high blood pressure, obesity and immunocompromising disorders — as we age, according to Dr. Wafaa El Sadr, a professor of epidemiology and medicine at Columbia University.

“As soon as we know, there's this decay over time of protection against severe illness, it becomes really critically important, particularly for people who are most vulnerable, to actually get another dose of the vaccine as soon as possible,” El Sadr said, adding that a second booster could also make sense for people over 50 for similar reasons. Health commissioner Vasan and Farber from Northwell Health agreed.

“If you're eligible for your second booster per the FDA guidance, we recommend that you go do that,” said Vasan. This week, the Food and Drug Administration and the CDC cleared fourth shots for people older than 50, which can be taken four months after a third dose.

Farber and El Sadr also recommended indoor mask wearing for vulnerable adults if they’re unboosted and want to be cautious.

“That's a reasonable thing to do,” Farber said. “That's appropriate, particularly for high-risk individuals and elderly individuals.”

City officials are imploring older adults and other high-risk individuals to take advantage of its “Test-to-Treat” services. A number of COVID treatments — such as antiviral pills and monoclonal antibodies — are going unused nationwide, and these remedies are only effective within the first week of symptoms.

If an at-risk New Yorker tests positive, even with an at-home test, the city can send many of these treatments to their homes the same day.

“We are the largest city in the country to have that same day delivery system,” said Vasan. “If you test positive at home, the first call you need to make is 212-COVID-19 [212-268-4319].”

The city’s public health team can set a person up with an ExpressCare telehealth visit, where a clinician can walk the person through their symptoms to see if the patient fits the description of being at-risk. The health providers will then schedule a delivery of COVID-19 pills or a home infusion of monoclonal antibodies.

What to do if you’re fully vaxxed, didn’t get BA.1 and younger than 50

Booster: Get one when you can if you don’t have underlying conditions

Masks: Indoor masking is less necessary unless you have a pre-existing condition.

Testing: If you test positive, stay home. Consult a doctor if you are in a high-risk population.

Last week, the U.K. Health Security Agency released a surveillance report and a preprint study on the outcomes of 400,000 COVID-19 patients, where it tried to tease apart true cases of severe COVID-19 from incidental cases — people who just happen to catch the virus while they’re in the hospital for other conditions.

Part of the analysis looked at adults ages 18 to 64 who ended up staying at the hospital for at least two days due to a respiratory emergency with COVID-19. Two doses of the vaccine gradually lost their power to prevent this outcome over time, with effectiveness slipping to 56% after about five months. Booster shots restore this protection — elevating the vaccine effectiveness back to 80-90% for another four months.

These younger adults were less likely to need serious treatment, such as mechanical ventilation or intensive care, whether they had two doses or an extra booster shot. The vaccines, in other words, still prevent the absolute worst outcomes for them.

But raise your hand if you’re in this group and are ok with staying in a hospital for at least two days with a serious chest infection — as long as you don’t die? It’s probably not ideal. Long COVID is also worse overall if an initial bout is severe.

Akin to people over 50, the chances of bad outcomes rise for younger adults and children if they have pre-existing conditions, so El Sadr said these people might want to consider masking indoors if they don’t have all their shots.

Despite the rising risks, the booster rollout has largely stalled. In New York City, only 44% of fully vaccinated adults have taken an initial booster. For teenagers, the booster rate drops to 22%. Kids under 12 aren’t eligible yet for booster shots.

Health commissioner Vasan said now is the time for all ages to get boosters given that BA.2 cases are rising.

“Go now to get your booster if you're eligible,” he said.

Farber added that second boosters might also eventually be recommended more broadly for younger adults — most likely just before next autumn when respiratory infections tend to increase naturally. Both he and international regulators want those shots to be better adapted to universally protect people against future variants.

The latest guidance from the FDA and CDC did not include additional shots for people under 50. More details behind the authorization may be revealed at a scientific advisory meeting on April 6th.

In light of Manhattan's medium risk, Gothamist asked Mayor Adams' office if it still plans to remove mask mandates for kids under 5 on April 4th but received no reply.

Why boosters are valuable against BA.2

New York’s current case uptick is due to the BA.2 omicron variant, which has steadily grown in proportion across New York State since early February. As of last Saturday, BA.2 now makes up the majority — 60% — of COVID-19 cases analyzed statewide, taking the perch from its sister BA.1, which raged earlier this winter.

“The State Department of Health urges New Yorkers to continue to be vigilant, by getting a COVID-19 vaccine and booster dose when eligible, tested following an exposure or when symptomatic, seek treatment when positive, and to stay home and isolate when sick,” agency spokesperson Erin Silk said in an emailed statement.

Even though the CDC’s COVID Community Levels account for cases, most observers would not have noticed how far infections have risen in recent weeks — because the levels place a large emphasis on hospitalizations. Here’s what the Community Levels look like for the tri-state region. Rural areas have been lighting up recently because their hospital capacity is lower.

Ok, let’s look at a map of local transmission, which is based on how the CDC used to measure COVID risk. It’s based on only case rates and test positivity — the percentage of tests with a confirmed infection.

Thursday evening, the CDC’s newest weekly edition of the COVID Community Levels put Manhattan’s seven-day average at 199.85 cases per 100,000 residents. But the health agency still classified the borough as low risk, reaffirming the arbitrary nature of this readout and how it downplays the bigger picture around infections.

De-emphasizing case rates makes sense at this stage of the pandemic, according to every health expert interviewed for this story. That’s because eliminating the coronavirus is likely no longer possible.

We just have to focus more on the prevention of illness, said El Sadr from Columbia University. “Another aspect that's really important is protecting the most vulnerable,” she said.

Read More: Why NYC isn’t recording most at-home COVID tests

But vulnerability comes in many different forms. For older adults, the immunocompromised and people with pre-existing conditions, the threat is a lengthy hospitalization or death. But for anyone who catches the virus, there’s the specter of long COVID.

“We certainly hear a lot about people with the brain fog, the fatigue and they can't get back to work — higher incidence of diabetes in people that got COVID,” Dr. Daniel Griffin, an infectious disease clinician and researcher at Columbia University told Brian Lehrer on Wednesday when asked about long COVID. “We're seeing high incidents of cardiovascular disease, heart attacks, strokes. COVID can really do a job on the body.”

But he added those trends appear to be less likely in people who keep up to date with their vaccines.

“We are very hopeful that the vaccine not only will prevent you from getting COVID, not only prevent you from getting severe disease, but will hopefully decrease your risk of all these many issues that fall under that umbrella,” Griffin said.

Where to get a test and a vaccine in New York City

For New Yorkers who need a test, you can go to nyc.gov/COVIDtest to find one. For a shot, visit nyc.gov/vaccinefinder. Or if you prefer the phone, call 212-COVID-19 [212-268-4319] for both services.