As vaccination numbers rise and both Vermont and New Hampshire move to lift restrictions and reopen, their case numbers are rising dramatically, matching and in some cases exceeding last fall's spike. Anne Sosin, a Policy Fellow at the Nelson A. Rockefeller Center at Dartmouth College, has been a watchful observer of both states since the beginning of the pandemic. So it seemed fitting to ask her what's going on, and where this may all be leading.

Thanks for being willing to do this, Anne. Let's start with this: Are you seeing things in the numbers that disturb you?

Yes, I’ve been worried about the trends in both New Hampshire and Vermont. Vermont has registered its highest case counts since the start of the pandemic over the past couple of weeks. New Hampshire has also seen rapid growth in its epidemic and currently has one of the highest infection rates in the country. I am optimistic as I look to the summer; however, I am very concerned about the next few weeks. We’re not yet at a point where we can expect vaccinations to have a significant impact on the trends we’re seeing.

Are there particular aspects to the states' vaccination strategies that are worth noticing?

I’ve focused more of my attention on Vermont over the past few months, and I have been concerned that the state's approach has been too narrowly focused in its public health aims. Vermont shifted away the CDC's suggested approach and used an age-based strategy, starting with its oldest residents. That may appear to be the most effective and equitable, given that we know age and underlying illness are risk factors for severe illness and death, but what it doesn’t account for is the differential risk that some groups have of being exposed to Covid-19 in the first place.

The two primary factors that determine your risk of being exposed to Covid-19 are where you live and where you work. So even though older populations have the highest risk of death, outside of congregate living facilities they typically have much lower rates of infection.

We see the highest rates of infection in 20-29 year olds. Many people believe that this is because young people are more likely to break the rules, but the reality is that they are more likely to be in the essential workforce or in public-facing jobs, like food service or retail. I believe we should give priority to populations with a much higher risk of infection, including the essential workforce, prison inmates, and college students. This would not only protect vulnerable groups but would also benefit the larger population, given the role that these groups play in shaping transmission and the impacts that outbreaks among these populations have on communities.

So as younger people start to get vaccinated now, what can we expect?

Well, we are only now beginning to vaccinate the younger age groups with the highest rates of infection. We need to achieve substantial coverage of that age group before we see a decrease in infection rates in younger people.

Does this mean we just have to wait for vaccinations to take hold before we see numbers come down meaningfully?

Many states are now trying to outrun the virus using only vaccines. Vaccines aren’t the only tools we have, and we can employ other public health and policy measures to reverse the trends that we are seeing. For most of the pandemic, we have relied on non-pharmaceutical interventions, including mask mandates, as well as restrictions on restaurants, bars, travel, and gatherings. Both states are now rolling these restrictions back to varying degrees even as transmission increases. I'm concerned that the epidemiology does not yet support these decisions and that we are removing these measures prematurely.

On Thursday, Gov. Chris Sununu said that he's letting NH's mask mandate expire as of today (Friday, April 16). What's your reaction to that?

Many of my public health students work in grocery stores and retail where enforcement is really weak already, and they haven’t been able to get vaccinated. This puts them in harm’s way unnecessarily. New Hampshire is averaging more cases and hospitalizations per day than when the mask mandate first went into effect. The state needs to achieve greater vaccination coverage and stabilize its epidemic before it lifts the mandate or removes further restrictions. Governor Sununu has been less willing than Governor Scott to institute restrictions in response to the state's changing epidemiology and has faced significant pressure from within his own political party to lift the public health measures in place. The Scott administration has not gone so far as to suggest that it will lift its mask mandate; however, it has also started to roll back some of the public health measures that have been so critical to the state's performance in responding to the pandemic.

I am concerned about the pace of reopening for two reasons. First, these decisions are not well-aligned with some of the states' policy goals, including the push to increase in-person education. We have good evidence that the mitigation strategies in place in schools can limit in-school transmission and we now have most of our educators vaccinated, but our lived experience in the bi-state region highlights the impact of frequent cases on schools and the families and communities that rely on them. Many schools across Vermont and New Hampshire have experienced significant disruption as cases have increased over the last few weeks.

Second, I am concerned that relaxing restrictions on high-risk settings, most notably restaurants and bars, concentrates risk on a young workforce that has not yet had access to vaccines. We have evidence that capacity constraints aren’t sufficient to stop transmission in indoor restaurants and bars and that these settings contribute disproportionately to spread at the community level. Most importantly, food service workers in Vermont and other settings have consistently had among the highest rates of infection, even with substantial restrictions in place. And while we know that young people are at much lower risk of severe illness and death, we have growing evidence that a significant percentage of young people infected with the virus will go on to develop long Covid, or chronic forms of the disease. For this reason, my hope is that we will maintain public health measures until young people living and working in high-risk settings can benefit from vaccination.

I know it's hard and unwise to make predictions, but what do you see happening over the next few weeks?

Vermont has done incredibly well at achieving coverage within each of its age bands, and I would anticipate this will continue among younger populations, given the vaccine enthusiasm we're seeing across the state. The state may continue to see high case counts in the immediate future, but my expectation is that we will see a drop in the numbers once we're a few weeks out. New Hampshire currently has one of the highest percentages of its population vaccinated, but it has not yet done as well in ensuring coverage within age groups. It is more difficult to predict the trajectory of NH's epidemic. However, I'm concerned that we may see an overlay of population that is less inclined to adhere to public health measures, more vaccine hesitant, and at greater risk of exposure. This could leave localized pockets of the population with low vaccination coverage, where we might see outbreaks develop over time.

As you look ahead, are there any particular metrics you think are most important to watch?

I will be following the situation in our schools over the next several weeks. We will soon have a large part of the adult population vaccinated in both states; however, most students will not be old enough to be vaccinated before the end of the school year. We are already seeing more cases in school-age children in part due to the presence of more transmissible variants, and I am worried about the operational impacts that this will have on schools that are trying to return more children to classrooms.