March 1, 2022 – What will the future of SARS-CoV-2 look like, and what should we as a community consider in our response to changing conditions? Yonatan Grad, Melvin J. and Geraldine Glimcher Associate Professor of Immunology and Infectious Diseases at Harvard T.H. Chan School of Public Health, offers thoughts in this Big 3 Q&A.
Q: When will the pandemic be “over”?
A: There are a few ways to think about this, recognizing that by “the end of the pandemic” we don’t mean “the end of COVID-19,” because SARS-CoV-2 will continue to circulate for the foreseeable future. We might ask instead what factors will help determine when the mitigation measures put in place in response to the COVID-19 pandemic can be set aside without concern that they will have to be quickly reintroduced.
We know we’ll see future waves of COVID-19. The virus will continue to evolve to escape immune pressure, and immunity from vaccination and infection will wane. When there are enough individuals susceptible to infection and enough opportunities for transmission between infectious and susceptible individuals to sustain spread, we’ll see surges. But how much severe disease and death will these waves cause? Our hope is that enough of the population has immunity from vaccination and/or infection and we have enough antiviral therapies that the amount of severe disease and death is low—low enough, that is, that we as a community can accept it. I don’t think we’ll know for sure about how this will play out until the next wave is here.
What burden of disease and death from COVID-19 are we, as a community, willing to tolerate? Some have suggested that we’ll be at this point when the rate of COVID-19 death is around that of seasonal influenza. But I’m not sure why we’d use flu as a comparison. Why do we accept the roughly annual 20,000-60,000 deaths from influenza in the U.S. when many of those are preventable? If COVID-19 were to behave like another influenza, the two together would place a huge strain on the capacity of our healthcare systems. So I think that determining how much COVID-19 we’re willing to tolerate is more of an expression of our values as a community than it is a predetermined threshold.
I’d also like to point out that how we define our community really matters for deciding what “over” means. Cholera is another pandemic disease that continues to flare in much of the world. We successfully ended our cholera pandemics in the developed world by building infrastructure for clean water and sewer systems, but cholera remains a threat for many. So where do we draw our boundaries? Who do we include in our “community”?
Q: States and localities are pulling back on COVID restrictions such as masking, and there are calls from various quarters for things to “return to normal.” What do you think of this turn of events, given the current state of the pandemic?
A: Now that we’re on the other side of the Omicron wave, there’s an understandable inclination to lift mitigation measures and balance the risks of COVID-19 and the costs of interventions. I think it’s helpful to use this time to take stock of the measures that we know work to reduce disease and figure out how to codify these into our everyday lives. For example, we should emphasize the importance of high-quality ventilation systems in all of our buildings. We should establish ways to support those who are sick to stay home—providing paid sick leave for employees and recorded or hybrid in-person/online classes for students—and discourage “presenteeism,” which is when people show up to work in person even when they’re not feeling well. We should continue to make masks available and normalize the choice to wear them, so that those who want to use them to protect themselves and others feel free to do so. We know we’ll see additional waves of COVID-19 and other diseases, so even as we respond to a decreased prevalence of COVID-19 we can prepare for what’s coming and help support a healthier new normal.
Q: As mitigation measures are lifted, how do we best protect those who are most vulnerable, including young children, older people, and those who have health problems or are immunocompromised?
A: The risks of COVID-19 are borne unequally across the population, and we should do what we can to help improve the situation for those at highest risk. I believe that means recognizing not only those who are individually at highest risk but also those communities hit hardest by COVID-19. In addition to continuing work to make existing interventions widely available—including those like improved ventilation, easy access to rapid tests and masks, support for staying at home when sick—that will improve conditions for everyone, one critical effort should be the continued development of antiviral therapeutics. One of our main tools to protect people, beyond non-pharmaceutical interventions, is vaccines, but there will always be a fraction of the population for whom vaccines don’t work for some reason or who remain unvaccinated. In those cases, having access to prophylactic and therapeutic antiviral agents would make an important difference, with easy-to-take oral medications being the ideal form. And we’ll need to continue development of new antiviral agents, because we should anticipate that resistance will arise.