The following is an excerpt from the Mayo Clinic Press book Endemic by Monica Gandhi, M.D.
How do we manage COVID-19 now?
As we’ve discussed, SARS-CoV-2, unlike smallpox, is not eradicable. For one thing, as noted, at least twenty-nine species of animals can harbor the virus, and any virus with such extensive animal reservoirs cannot be eradicated worldwide. Not that some authorities haven’t tried eliminating these animal reservoirs; some violent episodes with animals during the COVID-19 pandemic included the slaughter of 17 million mink in Denmark in November 2020 after the mink were found to carry coronavirus; the culling of pet hamsters in Hong Kong in November 2021; and the killing of pet dogs and cats in China as late as spring 2022. I remember hearing in April 2020 that big cats in a New York zoo were found to have COVID-19. I knew then that we will never eradicate the virus and that we needed to get to a phase of control, where population immunity, vaccines, and therapeutics controlled severe disease.
Endemic management for COVID-19 came in fits and starts in 2022
The ancestral strain of the virus was first identified in January 2020. There was a variant, D614G, that became the dominant strain in the summer of 2020 but never got its own Greek letter designation. The alpha variant became a worldwide variant in late 2020 and early 2021, but the beta (first detected in South Africa) and gamma (first identified in Brazil) variants stayed relatively confined to certain geographical areas, since they were less transmissible than previous strains. The delta variant, first identified in India in March 2021, was extremely transmissible and just as deadly as earlier variants; it led to terrible death and suffering in India, which had only a 4 percent vaccination rate at the time. But the omicron variant—which was first identified by South African scientists in mid-November 2021—was different. Omicron could not infect lung cells as effectively as previous variants, making it a more “feeble” variant.
In the United States, COVID-19 vaccination was still extremely protective against hospitalization from the omicron variant, as it had been against the delta variant. However, there are estimates that by March 2022 over 60 percent of the world’s population had been exposed to omicron and its subvariants, leading to a great deal of immunity in the population. The CDC reported on April 26, 2022 (drawing on data through February 2022), that 60 percent of the adult population of the United States and 75 percent of children up to age eighteen had been exposed to COVID-19, as measured by the nucleocapsid antibody, which is not generated by the vaccines but only by natural infection. Just a few months later, in August, the seroprevalence (rate of natural infection) among children in the United States rose to 86 percent. This population immunity, combined with worldwide dissemination of the vaccines since January 2021, led to the low number of deaths from COVID-19 seen in the spring of 2022. All this was what led up to the April 2022 statements by the WHO, the European CDC, and US public health officials that the emergency phase of the pandemic was ending. However, although Europe stayed true to its promise to enter the endemic phase of management for COVID-19 in the spring of 2022 (acknowledging that other aspects of public health had been neglected), it took several more months, until August, for the CDC to change its guidance to acknowledge the high levels of both vaccine-induced and natural immunity.
None of this meant that the controversy over COVID-19 in the United States was over. Some US public health experts came out against the CDC’s new guidance in August 2022; there was a storm when a prominent CNN and Washington Post commentator who was a physician endorsed the guidelines; and some blue states, like California, ignored the CDC guidance in favor of continuing asymptomatic testing and school masking. All this spoke to our polarization along party lines around COVID-19. The New England Journal of Medicine published a piece that month pleading with public health practitioners to consider nuance and trade-offs in their recommendations, arguing that “complex decisions” like mask mandates “should be widely and publicly debated by public health institutions . . . and it would behoove public health practitioners to stop suggesting in social media posts that nuanced questions have universally correct answers.”
I couldn’t have agreed more with the New England Journal of Medicine piece urging nuance and acknowledging trade-offs in our COVID pandemic response, especially given the evolving science. Nearly a year earlier, in November 2021, several public health practitioners and I wrote a piece about ten evidence-based policies for COVID-19 management (these form the basis of the pandemic preparedness I discuss in the final chapter). In March 2022, the director of UCSF’s emergency room response to COVID-19 and I wrote a piece about a “rational road map” to managing COVID-19 in the future.
Specifically, we suggested the following:
- Discontinuing mass asymptomatic testing and quarantines, especially in schools, but maintaining wastewater surveillance.
- Continuing the five-day isolation period for people after they test positive for COVID-19 and asking people to stay home when sick.
- Investing in a test-and-treat program, so that we can more effectively use antivirals in those who are unvaccinated and at risk of severe infection or in those who are vaccinated and at risk of a severe breakthrough.
- Acknowledging natural infection in our vaccination strategies as well as discontinuing the divisive strategies of vaccine mandates and vaccine “passports,” since—with the newer variants—transmission can occur even from vaccinated people.
- Extending the interval between vaccination doses for the primary series to at least eight weeks.
- Clarifying our vaccine booster strategy to focus on preventing severe disease, not trying to chase the impossible goal of preventing every infection.
- Expanding our vaccine arsenal in the United States to include Novavax (a more traditional protein-based vaccine) and Covaxin (an inactivated whole-virus vaccine) (discussed later in this chapter).
- Discussing how vaccines can help prevent the symptoms of PASC (long COVID) by reducing severe disease, which is most closely associated with post-COVID symptoms.
- Continuing to upgrade and improve ventilation systems for indoor spaces.
- Retiring mask mandates for good in favor of recommendations of fit and filtered masks for vulnerable individuals.
