Ideas
January 5, 2022 7:00 AM EST
Phillips M.D.,M.P.H., Vice President Science and Strategy, COVID Collaborative and Fellow of the American College of Epidemiology

Hopes of eliminating COVID-19 in the U.S. through vaccine-generated herd immunity are now dashed. Instead, with the rapid spread of the highly infectious Omicron variant, we need to focus on 2022 as the year that in the U.S. will usher in a new era of “living with the virus.”

In epidemiology terms this means transitioning from pandemicity to endemicity, as the virus moves from its phase of widespread devastation to episodic local flare-ups and settles into long-term cohabitation with its human host. SARS-CoV-2 will still pose a threat to vulnerable and unvaccinated Americans, but experts believe it will no longer represent a major public health danger to those who are immune through either vaccination or natural infection. Widespread U.S. natural immunity has occurred at a tragic cost with over 800,000 deaths and a significant trail of Long COVID disability and extensive economic, mental health and educational damage. With Omicron this toll will increase further, but with the projected near universal infection of the unvaccinated, its health impact will be increasingly blunted.

Whether closer to the common cold, the flu, or the toll of motor vehicle accidents, in 2022 COVID-19 will become a familiar individual and societal risk but no longer be a disruptor of daily routine family and community life. Although this will occur as an uneven and bumpy ride, there is an expectation of an eventual return to a post-pandemic normal.

Why and how will we adapt to this new endemic reality in the ways we live, work, travel, attend school, gather and enjoy life in 2022? Especially as Omicron is currently triggering a reversion to the early days of the pandemic where avoiding infection at almost any cost is gripping a large segment of society.

Forecasting COVID-19 is a fraught endeavor. Complex multidisciplinary science must be merged with a multitude of social, psychological, political and cultural forces. Evolving information, uncertainty and debate require ongoing testing and reassessment of forecasts.

Here are four predictions of why and how we will go a long way towards living with the virus in 2022:

1) The COVID-19 disease burden will decrease

Disease burden—medically called “virulence”—is defined as serious illness requiring hospitalization and causing deaths. It does not mean cases or infections, which are only a snapshot of how much virus is circulating in a community. Omicron is a variant that is much more infectious but less virulent than its Delta predecessor. As it quickly spreads through the remaining susceptible U.S. population it may cause sporadic surges in local hospitalization levels. But it should not cause systematic widespread overwhelming of hospital capacity in most U.S. geographies that have high levels of vaccine and natural immunity and where vulnerable populations are protected.

As with any virus that causes a preponderance of asymptomatic infection or mild illness, going forward it will be increasingly recognized that cases—as defined by positive tests—will generally not serve as a useful metric upon which to base public health decisions.

The level of individual and population immunity that protects against serious disease is dynamic and waxes and wanes continually over time and across geographies. Currently 205 million Americans are fully vaccinated. The CDC has recorded 53 million positive COVID tests to date and estimates that 150 million Americans have been infected. Many in these two groups overlap to an unknown degree, but it’s likely that well over 80% of the 330 million Americans have at least some immunity to SARS-CoV-2. With widespread availability of boosters and a highly communicable variant we can expect effective population immunity to increase from an already high base in 2022.

Whether by intention (vaccination) or default (infection), the pool of susceptible people available to the virus is steadily decreasing. More variants of concern could emerge, but evolutionary biology and pandemic history foreshadow that these will likely be more infectious and less virulent. Vaccine technology has evolved to handle this eventuality and can produce new vaccines of greater specificity much more quickly than ever before.

2) Protecting the elderly and the immunocompromised should gain more attention and resources

Of the more than 800,000 U.S. COVID-19 deaths recorded to date about 75% have been in those over the age of 65. CDC data has revealed that compared to 18-29 year olds (of whom 4,781 have died), those in age groups of 65 to 85+ have 5-10 fold greater hospitalization rates and 65-370 times greater death rates. About twenty percent of the U.S. population is over age 65 or immunocompromised for whom avoiding infection is essential. Employing known preventive measures especially in congregate settings and multigenerational households remains critically important. The impact of boosters, new oral antiviral medicines, and rapid testing of contacts to avoid infection will be especially beneficial in saving lives in this group.

3) Expect continued political polarization, but paradoxically actual societal risk behavior will converge and normalize

Attitudes around masking, vaccination, mandates and most forms of exposure-prevention are based on deeply-held personal values and beliefs. It is unlikely that there will be significant shifts in these attitudes no matter what the course of the pandemic or of public policy. Political polarization is as vivid over COVID as it is in other aspects of contemporary American life. However we all rub shoulders daily in workplaces, planes, stadiums and restaurants. Through these multitude of interactions we will indirectly influence each other as public life continues to normalize in fits and starts. Over time public behavior and acceptance of exposure risk is likely to converge.

4) Recognition that “living with the virus” means living with cases and infection

Most importantly the meaning of the goal “staying safe” from COVID has never been clearly defined either at the federal policy or personal level. Empirically, for many it means avoiding infection at all cost, with the markers of safety being boosters, masks, rapid tests, virtual work and school, avoiding public transport and virtually any potential exposure. For others, it’s close to business-as-usual; for them exposure to infection is an acceptable risk. This broad swath of definition of safety will begin to narrow and accelerate toward convergence in 2022 and be the critical driver of a return to a robust dynamic society.

It will do so because with Omicron and its successors we can expect an inexorable high infection case rate in the non-vulnerable 80% of population, whether vaccinated or not. Yet this group of 260 million people can return to near-normal lives and still have very low objective risk of serious illness. The urgency to get on with life, and inescapable pandemic fatigue will slowly but decisively alter the national psyche. The steady drumbeat of cases will force us to gradually move the goalpost (as the NFL and NCAA will demonstrate) from stringent avoidance to living with the risk of infection, to tolerating what will become the very low risk of serious disease. As a comparison, influenza and pneumonia are estimated to cause about 50,000 deaths and several hundred thousand hospitalizations per year. This is in the same ballpark as the likely toll from COVID’s endemic phase. Can we shift our risk behavior to a comparable response?

In practice by year-end 2022 these forces will converge in increased societal risk tolerance and associated behavior. Workplaces, schools, retail establishments, airports, stadiums and borders will be open for business. We will come to recognize that our path out of the pandemic is not through managing the virus, but by challenging ourselves to live by its rules.

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