The COVID-19 Pandemic Will Be Over When Americans Think It Is
Shoppers, some wearing masks, some not, make their way along Santee Alley in Los Angeles on December 6, 2022. Los Angeles County appears in the midst of another full-blown coronavirus surge, with cases rising by 75% over the last week. The spike which partially captures but likely does not fully reflect exposures over the Thanksgiving holiday is prompting increasingly urgent calls for residents to get up to date on their vaccines and consider taking other preventative steps to stymie viral transmission and severe illness. Credit - Genaro Molina-Los Angeles Times
When will the COVID-19 pandemic end in the U.S.? Is it over when the president says so, by scientific consensus, or when the public thinks so? Historians of pandemics think it’s mainly the latter. Although blunting the epidemic curve is a major measurement, the perception of when we can “return to normal” resides largely in the subjective individual human domain. But can we come up with a measurable definition to help track progress and serve as the basis for public policy and awareness of the pandemic’s endpoint? That seems an exercise that is vital in this moment of pandemic confusion. Here’s my proposed definition: the country will not fully emerge from the COVID-19 pandemic until most people in our diverse nation accept the risk and consequences of exposure to a ubiquitous SARS-CoV-2, the virus that causes COVID-19.
The signal of the pandemic-phase end is not the disappearance of the virus, the attenuation of acute COVID-19 disease, the interruption of transmission, the solving of long-COVID, diminishing emerging variants, or the pronouncements of political or public health leadership; it is instead when the mass of Americans move from avoiding to accepting exposure and its consequences. In practice this requires a societal paradigm-shift. In our culture this transition is often viewed through a distorting political prism. Instead a sharper understanding can be gained through an agnostic evaluation of the evidence and science. Today, this strongly supports a new paradigm of “living with the virus” through accepting exposure for most Americans.
But a recent national poll demonstrates a strikingly divided public, not ready to make peace with the virus: while nearly half say that they have returned to their pre-COVID life, one-third still believe this is more than a year away or never.
Since the Omicron strain achieved predominance in early 2022, and now with over 500 sub-strains in circulation, the risk-benefit balance has progressively tilted in favor of planning for and accepting exposure of most non-high risk Americans. In this schema, people age 65 and higher, immunocompromised or frail with chronic disease constitute “high risk” for serious disease. The remaining significant majority of the population is “non-high risk.”
There are four seismic changes in both the virus and its human host that dictate this reset:
1) Decreased virulence in non-high risk people
Omicron on average is one-tenth the severity of the prior Delta variant. Infection fatality rates for COVID are now lower than that for the seasonal flu for non-high risk people. CDC respiratory virus surveillance data indicates that in the 18-64 age group, ER visit and hospitalization rates for COVID-19 and the flu have been comparable throughout this winter.
2) Serious disease heavily concentrated in high-risk people
It’s in the high-risk population where society’s attention and resources must be focused—where the disease toll is concentrated and where protection from exposure through both public policy and personal action will have by far the greatest impact. These are the people who must not be left behind as the nation adapts to an indefinite endemic future.
People age 65 and older represent 17 percent of the population but are now responsible for 92% of national COVID-19 deaths. Those aged 75 and over are 6.8% of the population and suffer 68% of COVID-19 deaths. The 1.15 million nursing home residents face by far the highest risk. They have experienced 15% of the 1.1 million national deaths to date, and comprise only 0.35% of the population. The age-specific risk of severe disease is exponentially lower in age cohorts under 65 and decreases progressively through younger age groups. The risk of serious COVID disease for the non-high risk majority is comparable to other familiar communicable diseases such as the flu, as well as traumatic causes such as motor vehicle accidents over which they have little control.
3) Inability to control exposure and transmission
The currently circulating Omicron sub-variants are the fastest spreading viruses in human history. An estimated 98 percent of Americans have been infected at least once and many multiple times. Currently an estimated 11 million Americans are newly-infected each week. Each infected index case may expose dozens of contacts. This natural experiment has generated a high level of population immunity, that even when supplemented by public health measures, has not been sufficient to consistently reduce the effective reproductive number (Rt) to below 1 in most U.S. states. An Rt<1, where each index case infects fewer than one other person, is the level necessary to decrease transmission toward eventual control and elimination. Currently 41 states exceed this critical threshold. This demonstrates that in practice, reliance on exposure-avoidance to deliver a sustained decrease in infection burden is a futile national strategy.
4) Highly protective population immunity against serious disease
With the endemic-phase transmission characteristics of Omicron, the infection swirling the globe will continue into the indefinite future. Population immunity will wax and wane dynamically as it finds its own equilibrium of protection. Given the limited durability of protection against infection of hybrid immunity (vaccination and natural infection), we are unlikely to reach classical herd immunity thresholds that drive elimination. However, the current levels of hybrid immunity are highly protective against severe disease. This protection is currently estimated to be 89 percent. The already intrinsically lower virulence of the current Omicron sub-variants is additionally reduced through extensive population immunity.
The reality of this paradigm-shift is reflected in the study design of a recent randomized trial to evaluate the efficacy of oral antiviral treatments. None of 822 enrolled high-risk patients with symptomatic COVID progressed to severe disease or death. Absent hospitalization or death, “time to sustained clinical recovery” had to serve as the study’s end-point. Future COVID-19 vaccine or drug trials in the U.S. may face difficulty using severe disease endpoints because these events are now too rare even in high risk patients. This was unthinkable in earlier stages of the pandemic.
After three years of the imposition, followed by gradual easing, of lockdowns, quarantine, isolation, testing, vaccination and masking, how does the holdout one-third of the country move from the current obsolete but ingrained “avoid exposure” paradigm to an endemic “accept exposure” reality? This not only has significant medical, public and mental health implications; it will also accelerate a return to a fully-functioning and dynamic society.
There are three segments of society—policymakers, experts (scientists, biomedical and public health practitioners), and the media—that form an ecosystem that has played a major interactive role in shaping our current pandemic paradigm. This ecosystem is also the one that could help catalyze and speed a frame-shift.
The U.S. COVID ecosystem is largely playing catch-up with the public rather than leading this transformation. Separately and together it forms powerful networks to enable those with an understandable difficulty of letting go of three years of ingrained avoidance behaviors to cling to their practices.
This collective force still leaves some people suggestible to health alarms fearful, anxious, and confused about how to protect themselves and others in a time of rapid societal transformation.
The U.S. is now at a major pandemic crossroad. “Follow the science” has been a central policy guidepost in the pandemic. Science and public health knowledge and expertise is the conduit to both sound policy and public education through media channels. New courageous “accept exposure” policies, public education and behavior change strategies are needed to capture the benefits of the new paradigm. This could be a major step in bridging our national COVID divide.