Vol. 271 February 1, 2022 Can COVID become an endemic?

February 1, 2022

Is this pandemic showing any signs
of evolving into an endemic, like the flu?

Amidst the cresting of the Omicron peak, the less virulence of Omicron, the rising vaccination rates, and the success of vaccines in preventing serious disease, is it possible to think of COVID-19 as evolving to an endemic stage?

Epidemic: a rapid increase of cases in a particular location or region. Does not have to be an infectious or contagious disease. We have an “epidemic of obesity” in the U.S.. 

Pandemic: when a disease’s growth skyrockets; the number of cases increase every day in several countries or different populations. Rapid, unpredictable, seemingly irrational spread globally across continents with widespread disruption of society.

Endemic: a disease that is consistently present in a described region with predictable rates of spread. Outbreaks can occur, but are local and can be contained. We have rare outbreaks of measles and periodic outbreaks of flu in the U.S.

The first stage after the crisis stage of a pandemic is “deceleration”of its spread and reduction of its effects. The number of new cases is slowing down in some countries, but, in fact, is NOT decelerating in all regions of the U.S. The number of hospitalizations has not decelerated markedly yet, but the rates of serious illness and death have decreased among the vaccinated. The next stage of an infectious disease is “control”, meaning the “virus is present, but is not disrupting society”, an element in the endemic definition.

Indications that we might be slowly approaching the endemic stage are suggested by the following very recent public articles and scientific newsletters:

“Its time to revamp testing and quarantine policy for asymptomatic students.”
“The test-and-stay approach for both vaccinated and unvaccinated students was shown in a large U.K. study to not lead to substantial increases in in-school transmission events.” (BosGlobe 1/20/22; 3 infectious disease professors from Boston)

“College COVID restrictions have become overkill.
“Mandatory masking in a highly vaccinated community is of questionable value… It is now clear that we will be living with an endemic respiratory virus for the foreseeable future.” ((BosGlobe 1/23/22; 4 non-medical professors from UMass)

“Test and Stay for child care centers”
“The Massachusetts experience this fall in keeping up with Delta was effective in keeping transmission rates very low.” (Bos Globe  Jan 20, 2022)

Culturable virus can be present up to 12 days after symptoms which correlates very closely with antigen test
 “If the antigen test is negative you are not contagious.” Antigen level peaks at 5-7 days after exposure and is undetectable (non-contagious) by day 12.  (NEJM 386; 3 Jan 20, 2022)

“Most PCR positive people who are being identified as still infectious (contagious) are not really so.”
PCR tests can be positive when viral loads (number of live viral units) are very low. More than 50% of PCR positive tests post-infection had thresholds lower than 30.  (NEJM 383, Nov. 26, 2020)

CDC and WHO now recommend BOTH PCR and antigen rapid diagnostic tests (RDT) as a valid test for COVID-19
International travel requirements have changed from accepting only a PCR to accepting an antigen RDT for travel clearance. WHO does not accept a home-based antigen RDT. Also, people who had a COVID illness can produce a “letter of recovery” from a physician that could allow travel if the person had a prolonged positive (and non-contagious) post-infection PCR tail. (NEJM 386;1/20/22)

“Test and stay home if sick.”
”We need to look toward paving a path to normalcy for our kids. We need to move toward treating COVID-19 like we treat every other endemic respiratory virus: Get vaccinated, stay home when you are sick, rest yourself if you have symptoms, and protect yourself with a mask if you are at high risk.” (Harvard and Tufts Prof. of Medicine, Bos Globe Jan. 20,2022) 

“College COVID restrictions have become overkill.”
“Mandatory masking in a highly vaccinated population is of questionable value. It is now clear that we will be living with an endemic respiratory virus for the foreseeable future.” (UMass BosGlobe jan. 23. 2022)

“Schools can now safely make masks optional.”
Due to the effectiveness of vaccine and the waning of the Omicron variant we can let one-way masking (self-protection) be a matter of choice. (2 Boston medical center infectious disease doctors; MashupMD newsletter)  

Vaccination reduces the incidence of transmission to household contacts in a recent Israeli study. (MashupMD)

The first oral prescription medicine for certain outpatients approved by the FDA
An antiviral agent (PAXLOVID) has received FDA emergency authorization, but true effects are still uncertain. Early evidence shows that it is as effective as IV monoclonal antibodies in high risk patients in reducing severe illness if used early in the illness. Effectiveness against all variants, real-world toxicities (kidney and liver damage), and interactions with other common prescription medicines remain to be elucidated. However, it is the first treatment that does not depend on an immune response. It blocks the replication of the virus directly. (unpublished Pfizer study in a FDA notice) This is the reverse of HIV treatment of combinations of multiple anti-viral meds, and no vaccine.

The next stages in a pandemic are “elimination” (the virus persists in the world but has been eliminated in some countries: like polio in the U.S.) and “eradication” (small pox is the only human infectious disease that has been eradicated per Dr. Fauci). Neither of these stages is probably obtainable for coronaviruses.

New Variants:
The longer a virus is present in humans the more likely it is to undergo mutations into new variants. Some observers have noted that new variants of COVID-19 seem to pop up about every 4 months or so after the previous variant’s peak. Some have also noted that new variants seem to appear first in the East and travel West. (For you flat-worlders, that would be from right to left.) Four new variants have been recently discovered in Laos. Little is known about their virulence or contagiousness.

New Vaccines:
There are about 60 coronavirus vaccines in early stages of development. One new non-mRNA vaccine (CORBEVAX) developed at Texas Children Hospital is based on the older techniques of yeast culture. It produces immune stimulating proteins, and its developers are not seeking a patent, so the vaccine , if proved effective, will be less expensive, will be able to be mass produced by numerous manufacturers, and will be more accessible to low-income countries. (MashupMD

An Urgent Need for Universal Coronavirus Vaccines  
Four coronaviruses are the causes of most of our common colds and are now endemic (here to stay).  SARS-CoV-2 is unlikely to be eliminated, let alone eradicated. It will probably continue to circulate indefinitely in periodic out-breaks and become endemic. Reinfections may be common after illness with coronaviruses as opposed to measles, german measles, chicken pox where reinfection is rare. (NIAID, Fauci, et al. NEJM Jan 27, 2022) This matches  Bill Gates’ 2018 call for ((N Engl J Med 2018) and his foundation’s massive support of efforts to develop a universal flu vaccine.

My Rose-colored Crystal Ball:
My best hope is that SARS-CoV-2 future variants will be less virulent and will be ameliorated by current vaccines, so that we do evolve into a “flu-like endemic model”: get a booster short every year, stay home with your cold symptoms if your antigen home test is positive, and call your PCP if you are at high risk. Unfortunately some commentators have estimated that the list of CDC high risk factors actually encompasses about 80% of the U.S. population. Hence, we will continue to need medical guidance as to when we should opt for early treatment which will reduce the severity of our illness.

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