What Will Our Covid Future Be Like?

Here
Are Two Signs to Look Out For.

Written on March 4, 2022 By Jeffrey Shaman

(Dr. Shaman is an infectious disease modeller and epidemiologist at Columbia. His
team built one of the first Covid-19 models)

Omicron cases, hospitalizations and deaths have been substantially declining across
the United States for more than a month. In response, governors and mayors are
rolling back restrictions like mask mandates and vaccine passports. Many wonder
whether this period of low cases and decreasing demands on hospitals is a turning
point in the pandemic or is simply a lull before a new variant causes another
dangerous surge.

Even before Omicron swept across the world, scientists and public health officials
pondered how Covid-19 would continue to affect society once the pandemic phase
was behind us. It is the trillion-dollar question: Will outbreaks occur several times a
year, once a year or every few years? And how much sickness and disease will those
outbreaks produce?

Epidemiologists refer to the persistence of a pathogen in a community or population

as endemicity. How endemicity manifests varies from pathogen to pathogen. In the
United States, some respiratory viruses, such as influenza and respiratory syncytial
virus, also known as R.S.V., are much more abundant during winter. These viruses
regularly exact a toll on society in lost work, strained health care systems and deaths.
An estimated 12,000 to 52,000 people die of the flu each year in the United States.

Yet not all respiratory viruses follow this pattern; some, such as rhinovirus, circulate
year-round at lower levels and with less disruption to human health. Others, such as
parainfluenza, may produce outbreaks more erratically or during other seasons.
So what will the pattern look like for SARS-CoV-2, the virus that causes Covid-19,
once it becomes endemic? And how much disruption will it cause? The short answer
is: We don’t know yet. The endemic pattern of any disease is more easily understood
retrospectively, and the coronavirus has been with us for only about two years.
However, there are signs and factors that we can all watch for, which provide
indications of how Covid-19 will affect our lives in the seasons and years to come.
Those signs are worth discussing and bookmarking in our brains as we move toward
a more normal, functioning society.

An optimistic scenario is for SARS-CoV-2 to settle into a less disruptive flu like
pattern, producing wintertime outbreaks with hospitalisation and mortality rates
lower than we saw in 2020 and 2021. A more pessimistic scenario is for the virus to
continue to generate variants that evade immunity and are capable of infecting large
numbers of the population.

While it is difficult to know how endemic coronavirus will manifest, there are two
important characteristics worth monitoring in the coming months and years: the
frequency and severity of outbreaks. These two factors will delineate the disruption
caused by the coronavirus going forward.

The future frequency of coronavirus outbreaks is strongly linked to population

immunity and how the virus changes. A population’s resistance to circulating
variants depends on people’s history of infection, vaccination and boosting. Variants
with only minor differences from a vaccine formulation or an older variant may not
produce much disease. However, a variant with substantive changes — such as
Omicron — may infect many people by evading immunity. This winter, many people
who had good protection against Delta, the variant that Omicron displaced, were still
susceptible to infection and disease from Omicron.

A big unknown is whether SARS-CoV-2 can continue to produce variants that skirt
around the immune system like Delta and Omicron. If the virus has this capacity,
outbreaks could occur several times a year, much like during 2021. This endemic
pattern might hold for a few more years or indefinitely. On the other hand, if the
capacity to produce highly immune evasive variants is tapped out, future versions of
the virus might be less aggressive and produce fewer outbreaks, perhaps once a year
during winter, much like the flu.
The severity of outbreaks will depend on a number of factors, including the intrinsic
capacity of new variants to make people sick. To date, not all SARS-CoV-2 variants
have produced identical levels of disease. Omicron, for instance, has typically
produced milder illness.

A popular narrative is that the virus will become progressively milder over time and
that perhaps Omicron is the first evidence of this progression. Unfortunately, this is
most likely wishful thinking. Though Omicron has been milder, the next impactful
variant could easily be more deadly, as Delta was.

While the virus is not driven toward becoming milder, other factors, like protection
from prior infections, vaccinations, boosting and drugs, should help reduce disease
severity, hospitalisation rates, time spent in the hospital and the risk of death from
Covid. For instance, mRNA vaccination has already reduced the likelihood of
hospitalisation and death to roughly one-tenth of that for the unvaccinated. It is
important that vaccine effectiveness continues to be monitored and that vaccine
formulations are updated as needed so that any loss of protection can be countered
through boosting.
Given all this uncertainty, we should not become complacent. The coronavirus is wily
and much more transmissible than influenza. We need to keep a watchful eye even
though we now appear to be entering a lull in activity, because it is uncertain how
long any lull will last. We shouldn’t assume Covid will ultimately become a mild flu
like nuisance. Instead, stay prepared: Get vaccinated and boosted, listen to public
health advisories, keep some at-home Covid tests on hand and use them if you’re
exposed or feeling sick and mask up when needed. And keep an eye on the frequency
and severity of future outbreaks.