The Pandemic’s End
We asked three University of Vermont Health Network infectious disease and pulmonology experts to weigh in on the future of COVID-19.
- Jessie Leyse, MD, MPH, infectious disease physician at UVM Health Network – Central Vermont Medical Center
- David Kaminsky, MD, pulmonary and critical care physician at UVM Medical Center
- Tim Lahey, MD, MMSc, infectious disease physician at UVM Medical Center
What does endemic virus mean?
Dr. Leyse: For infectious diseases like COVID-19, endemic means that an illness is routinely found within a population or geographic region and that the number of cases remains relatively constant. For example, malaria is endemic in many parts of the world – it is known to cause disease in those areas, and it happens at a fairly constant rate.
Epidemic on the other hand, means that cases increase over that normal baseline. So, each year during the winter months, we in the United States experience epidemics of influenza, RSV and other respiratory viruses.
Pandemic means that the epidemic is happening on a broader scale – worldwide in the case of COVID-19.
How does a pandemic virus downgrade and become endemic?
Dr. Leyse: A sufficient number of people need to have been exposed to the virus, either by vaccination or infection, or both. Also, the illness caused by the virus gradually becomes less severe (although that is not necessarily a requirement for it to become endemic). We’ve seen this with the omicron variant of COVID-19; it is more transmissible, but less severe. In these scenarios, the virus is more successful because it can infect more people but because it is less severe more people are likely to survive and infect others. When the virus is more deadly, like the delta variant of COVID-19, the host person may die before the virus can spread to other people. So, if you think about it, humans and the virus have to come to near-balanced existence.
When will COVID-19 transition from pandemic to endemic?
Dr. Leyse: That’s difficult to say for sure, but I would guess that over the next 1 to 2 years we will start seeing more seasonal variation like with influenza. We’ve already seen COVID-19 behave this way with cases increasing during the winter months when more activities are indoors. I think this seasonality will likely become more pronounced as time goes on.
Dr. Kaminsky: I agree. If we can make it through the 2022-2023 winter season without detecting new, dramatic surges in the virus, then I think we will be out of the pandemic phase.
Are you feeling optimistic that we’re moving closer to an endemic stage?
Dr. Lahey: I think it is appropriate to feel optimistic, but to be reasonable about it.
The development of safe and effective vaccines, plus a quiver full of COVID treatments, has been nothing short of miraculous. It makes sense to feel grateful for those scientific discoveries.
Yet, endemic does not mean gone – I am not optimistic that COVID-19 is just going to suddenly disappear and become a non-issue. That would be incredibly surprising. COVID-19 is so transmissible and so capable of evolving that it’s extremely unlikely that we’re going to be permanently, perfectly immune to it. I expect that we will always have some version of COVID-19 and that at times we’ll still need to use mitigation measures (masking, vaccination, distancing) like we’ve used throughout the pandemic.
Overall, I do think that COVID-19 will become like many other illnesses that are now just part of the backdrop to our otherwise happy lives. It makes sense for people to feel a sense of relief that the omicron surge is starting to get behind us. But I do think we need to pay attention to people who are still struggling – from loss, long COVID or other trauma – and how to get that right.
What is long COVID and how is it affecting people?
Dr. Kaminsky has been researching the disease’s short- and long-term impact on people’s lung function; he treats many people suffering from long COVID.
Dr. Kaminsky: We tend to define long COVID as the persistence of symptoms 12 weeks after infection. The most common symptoms include fatigue, shortness of breath and “brain fog,” but more than 50 other symptoms have been formally associated with long COVID.
Long COVID is more likely in those with more severe disease, but it can happen in anyone, even people who were asymptomatic. Vaccines reduce the risk of developing long COVID, so this is another reason to encourage everyone to be vaccinated. Other risk factors are unclear, but there is some evidence that suggests higher viral loads, having certain autoantibodies and reactivation of Epstein Barr virus are associated with developing long COVID. There is a lot we still do not know.
But we do know that long COVID is much more prevalent than we originally thought. It is now estimated that 10% to 30% of people with COVID-19 infection will develop long COVID. That’s a lot of people!
Will cases of long COVID happen even after the virus has become endemic and less of a day-to-day threat to public health?
Dr. Kaminsky: I started a long COVID support group in the fall of 2020 here at UVM Medical Center – together with Katie Menson, MD, and our colleagues from rehab services. Some of the people in our group are still symptomatic, nearly two years later. However, the recovery time is highly variable – many people are improving over time and some people have fully recovered. I anticipate that we will still see a very large number of people suffering from long COVID even after it becomes endemic – perhaps as much as the 10 to 30% we’ve seen already.
Do you think long COVID is being adequately researched?
Dr. Kaminsky: Research into long COVID is very active now around the world. The National Institutes of Health is funding a huge study of long COVID, and many other groups are studying it as well. I think with time, more and more people will recognize the importance of long COVID, and hopefully we will learn more about what causes it and how to treat it.
Will we still need prevention measures – like social distancing, masking, vaccination – when COVID-19 becomes endemic?
Dr. Leyse: It’s been amazing to see the falloff of other respiratory viruses during our use of these prevention measures for COVID-19. For example, last winter, there was hardly any influenza or RSV circulating. These measures work, and I’m hopeful that we will eventually be able to use these only when the virus is actively circulating at high levels in our communities.
How do you see vaccines evolving – will we need booster shots every year?
Dr. Leyse: I imagine that COVID-19 will continue to evolve quickly, and we will need to get updated booster shots at some interval. Whether this is yearly, like influenza, or some other interval, remains to be seen. Given the spread of COVID-19, I think it will likely be similar to influenza with yearly shots that are directed at the most common circulating strains at the time. Thankfully, with the mRNA vaccine technology now available, we will hopefully be able to better match the vaccines to the active circulating strains because it’s possible to manufacture these vaccines more quickly than it has been with the currently-used influenza vaccine technology.
What can we do to remain prepared for future epidemics of COVID-19?
Dr. Lahey: Well, I still think it’s too early to be looking that far into the future. Despite declining case numbers, we still have a lot of people in the hospital with COVID-19, including many in the ICU.
But overall, what you’re touching on is a huge communications challenge. Whenever somebody says “Hey, the building is on fire,” it's pretty easy to get people to call the fire department and get the hoses out. But that’s a lot different than saying: “Hey, that fire that started five years ago is still hot.”
We’re going to need nuanced messaging that emphasizes taking precautions, without being overbearing, while helping people to live with the inherent risks of COVID-19. You know, we all know the risks associated with driving a car, so we do things to protect ourselves, like wearing a safety belt or driving the speed limit. We view those things as just part of being adults and I think we're going to get to the same place with COVID-19.
Above all, I think we need to do everything we can to increase trust within our society. There are some interesting studies that look at trust within societies and how that seems to predict how badly the pandemic impacts them. Societies tend to fare better when people trust their leaders and have faith in their neighbors to act in their collective best interest.
So whatever the future brings, we need to work together and build trust through dialogue. We will never have crystal balls. There will always be uncertainty. But if we know we have good neighbors who care about our well-being, we will get through it better than if we felt alone.