“Epidemics have punctuated humanity’s timeline for centuries, sowing panic and killing millions, whether the culprit was plague, smallpox, or influenza. And when infections abate, their imprints on society can remain, some short-lived and some enduring.”
- Jennifer Couzin-Frankel, staff writer, Science
“There comes a point where you no longer care if there’s a light at the end of the tunnel or not. You’re just sick of the tunnel.”
- Ranata Suzuki, Australian writer
SARS-CoV-2, the novel coronavirus that causes COVID-19, has captured our undivided attention for the past two years. Even though we are barely three months into a worldwide explosion of COVID-19 cases caused by the Omicron variant, many authorities are declaring this a turning point—the beginning of the end of the pandemic. They suggest it’s time that we shift from a public health emergency mentality to one of learning how to live with this virus. In this Germ Gems post, I provide my view of what living with SARS-CoV-2 may look like.
What is the endgame? SARS-CoV-2 will not be eradicated. Smallpox virus is the only pathogen that met this fate, and it took over two centuries of heroic vaccination campaigns to achieve this goal. Once the COVID-19 status has shifted from a pandemic to an endemic, the endgame will be reached. Then, like the other approximately 1,400 known microbial species (including viruses, bacteria, fungi, protozoa and helminths) that cause human disease, we are going to have to learn to live with SARS-CoV-2.
What do the terms pandemic and endemic signify? The World Health Organization (WHO) declares a pandemic when a disease’s growth is exponential and spreading worldwide. In the case of COVID-19, the WHO declared this benchmark reached on March 11, 2020. To date, the COVID-19 pandemic has afflicted almost 400 million people and killed close to 6 million. As yet, neither the WHO nor the Centers for Disease Control and Prevention has redefined COVID-19 as an endemic disease.
Some scientists consider influenza, another viral infection that targets the respiratory tract, to be a potential model for endemic COVID-19. Like several of the coronaviruses, influenza virus also causes pandemics. Of the four most recent flu pandemics (1918, 1957, 1968, and 2009), the 1918-1919 pandemic was by far the most devastating, infecting an estimated 500 million people and killing more than 50 million worldwide.
In a January 2022 New York Times article, “What We Can Learn From How the 1918 Pandemic Ended,” Tulane University distinguished scholar and author John Barry relates that long before the H1N1 influenza A virus mutated into ordinary “seasonal influenza” in 1921, signs of public weariness—or misguided hope—were everywhere, and the world had moved on. He warns us, however, that the end of the COVID-19 pandemic is not going to arrive anytime soon.
Even when COVID-19 becomes endemic, it does not mean it is harmless. Jacob Stern and Katherine Wu, writing for The Atlantic, underscore this point in their February 1, 2022 article, “Endemicity is Meaningless.” As they put it, “Endemic diseases can be innocuous or severe; endemic diseases can be common or vanishingly rare. Endemicity, then, just identifies a pathogen that’s fixed in our population so stubbornly that we cease to be seriously perturbed by it. We tolerate it.” This fits the status of a large majority of the 1,400 or so pathogens that can infect us. They are endemic, that is, somehow we’ve learned to live with, or tolerate, them.
Until COVID-19 came along, tuberculosis (TB) was the leading infectious disease killer claiming 1.5 million lives a year. TB is endemic to certain regions of the world, such as Africa, Russia, Eastern Europe, Asia, Latin America, and the Caribbean. HIV/AIDS infection is another endemic infection primarily centered in sub-Saharan Africa, the home of two-thirds of all people infected with HIV. Almost 1 million people die from HIV/AIDS each year; in some countries it’s the leading cause of death.
In addition to the three coronaviruses that wreaked major havoc this century (SARS-CoV-1, MERS-CoV, and SARS-CoV-2), four other coronaviruses (designated types 229E, NL63, OC43, and HKU1) cause 15 to 30% of “common” or “seasonal” colds. Most of us get infected with one or more of these viruses at some point in our lives. Intriguingly, some epidemiologists think that the OC43 strain that emerged in the late 19th century caused the “Russian flu,” a pandemic lasting from 1889 to 1891. In a similar scenario, some researchers posit that when SARS-CoV-2 becomes endemic, it will be yet another common cold virus, although one we’d just as soon not catch.
Perhaps a harbinger of COVID-19’s endemicity is the fact that after a “historically low” flu season last year, the number of flu cases for the 2021-2022 season appear to be rising to pre-pandemic levels. The remarkably low level of seasonal flu cases last year is thought to be due to protective measures against the spread of SARS-CoV-2, such as masking and social distancing. As seasonal flu kills on average about 50,000 Americans per year, abandoning these personal protective behaviors too soon could come at a cost.
The “new normal”? Most scientific and public health advisors are cautiously optimistic that the COVID-19 endgame is in sight. In his February 9 article in The Atlantic, “Open Everything,” political scientist and associate professor at Johns Hopkins University School of Advanced International Studies, Yascha Mounk, suggests that the “time to end pandemic restrictions is now.” He proposes that just as we are willing to take calculated risks in other areas of our lives, so too should we be willing to tolerate some risk of infectious diseases, like COVID-19. He argues, “Because COVID will likely remain endemic for the foreseeable future, delaying a return to normal life until the risk it poses has been completely eliminated simply is not a realistic plan. . . Let’s drop the remaining restrictions on our everyday lives. Let’s shake off the pandemic malaise. Open everything.”
I agree. But let’s proceed with some degree of caution and not abandon entirely the public health practices that work. No one knows for sure what endemic COVID-19 will look like. (Stay tuned.) We do know, however, that an arsenal of tools—including vaccines, wearing properly fitted masks, and social distancing—helped reduce the risks of getting infected and of severe disease, hospitalization, and death. As COVID-19 precautions ease, the most vulnerable (the elderly, those who are immunocompromised, and the unvaccinated) are still in jeopardy. For their sake, where and when appropriate, we shouldn’t abandon what we now know works.
In addition, many questions remain such as how long will immunity conferred by vaccines or natural infection last? Will we need another booster sometime soon? And should everyone over six months of age get jabbed annually with a COVID-19 vaccine as is recommended to prevent seasonal flu? Also, based on its past performance, SARS-CoV-2 is likely to throw us more “curveballs.” Nobody wants to see, for example, the next Variant of Concern, but if it arrives, we are now much better prepared to deal with it.
What then does living in the “new normal” mean? It means replacing panic and divisiveness over the COVID-19 pandemic with cautious optimism. It means we can more fully “open up” because public health measures (vaccination, masks, and social distancing) work in preventing COVID-19. It means we have new medicines that are effective in early treatment of the disease. It means recognizing SARS-CoV-2 is becoming an endemic pathogen—one among many microbes that isn’t going away but that we can learn to live with and tolerate.
