2022: Endemic COVID-19 and Preparing for COVID-2x

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The value of experience is not in seeing much, but in seeing wisely.”

-William Olser

What does our future look like with COVID-19 becoming endemic? While vaccines and “natural” infections give some temporary immune protection from infection and re-infection, our collective immune system memories may render these infections less severe as time goes on, but this protection will be less for those who are older or immune compromised. Like influenza, regular COVID vaccine (possibly annual) will be recommended to slow spread of the infection (for healthier people), and make infections less deadly (for those with medical conditions rendering them more susceptible).

This has happened before. Paleo epidemiologists suspect that the “Russian flu” pandemic of 1889 to 1891 was actually caused by a coronavirus, possibly the grandfather of one of the subtypes that currently causes seasonal cold symptoms. Because modern DNA sequencing did not exist in the 19th century, we cannot be sure.

For this current Omicron outbreak, our system is strained, so there is a risk that too many people will let down their guards prematurely, increasing hospitalizations to a degree that forces dangerous staffing patterns, and before new powerful treatments like Paxlovid can become more widely available.

COVID-19 will become endemic, which will not make it benign. Omicron is more infectious than influenza and cold viruses, and immunity to coronaviruses if proving very transient. In the H1N1 outbreak of 2009 killed over 12,000 Americans, the majority under age 65. Hospitals were very full, but not as strained as by COVID in 2021. A massive immunization campaign resulted in just 20% of the population being vaccinated, enough vaccination with natural immunity to keep H1N1 at lower levels in subsequent years. However, the R0 of H1N1 was just 1.5, compared to about 4 for Omicron in the UK where vaccination was relatively high. Seasonal vaccination rates in the United States will not be enough to prevent annual waves of seasonally mutated COVID-19 in the years to come. We may get more used to them, but they will be worse than annual influenza seasons, at least for 2022, and maybe for years to come.

In the end, our annual winter “flu” season, which is actually caused by a collection of flu-like respiratory viruses, will be a more severe each winter, as COVID-19 joins influenza, RSV, parainfluenza, rhinovirus, the other four coronaviruses that cause milder respiratory infections, and others in causing illness and hospitalization each winter. The summer waves we saw the last two years are likely to continue, to some degree, as well.

Quarantines for COVID-19 will be phased out, but some amount of voluntary isolation of those that are ill will persist, and there will be a high usage of masks to prevent spread of respiratory pathogens in the next several years.  Virtual visits will continue to be a significant part of our health care delivery.

There will be other new coronavirus infections in the future. Now is a good time to prepare for the next coronavirus that jumps species.

In the 21st century, COVID-19 is the third coronavirus to appear that causes severe respiratory symptoms (after SARS-1 and MERS). Given the huge reservoir of viruses in other species, we are quite likely to have a Coronavirus infection caused by a different strain sometime in the next decade, a COVID-2x epidemic that could lead to another pandemic. Looking at the shortages we had early in this pandemic, we can prepare for COVID-2x, as well as more severe influenza outbreaks. There are lessons for industry, government, public health authorities, and the general public. Here are some that might be most helpful for clinical leaders in primary care:

  • Ensure local community stockpiles of highly effective masks such as N-95s are ready –enough to last for a couple of months. Encourage patients to keep some on hand as well, for future winter “flu” seasons and future pandemics. Don’t let them all expire at once, set up a system for regular purchase and replenishment.
  • Gather together and organize policies, procedures and leadership lessons, and find a way to go through these systematically each year, so the knowledge is refreshed as staff change. Include not just best practices, but also any mistakes made and options for responding to the most challenging parts of a pandemic.

Transition community connections that were forged in the COVID-19 pandemic to work on other important health issues. Set up regular meetings with your local health officer to work together on shared priorities. Relationships will be key to rapidly and effectively responding to future public health needs.