Mind the Gap: A Wary Shift from Pandemic to Endemic
De-escalating while poised for rapid change
As COVID-19 cases drop dramatically and public health officials relax masking guidelines based on the local situation, there is the temptation to assume the pandemic is over and is entering a broadly defined endemic phase.
To some degree, this same optimism has accompanied the rise and fall of every variant, reminded Gregory Poland, MD, director of the Vaccine Research Group at the Mayo Clinic in Rochester, MN, in a podcast.1
“What we have seen globally, five times in a row now, is a peak in cases, a sharp reduction in those cases, a short interval of suppression, and then another surge,” he said. “We have to be ready for another surge with another variant.”
As of March 15, 2022, compared to the prior week, COVID-19 cases were down 47% nationally, hospitalizations declined 27.5%, and deaths fell 25%. Despite the declines, the average daily deaths still were running at 1,180.2,3
“People are weary of COVID, and I understand,” Poland said “But I want to caution everybody: We did this just a summer ago, right before Delta emerged and we took masks off, pretended it was over, and we had a major surge. We need to be careful, we need to be cautious.”
However, with COVID cases in steep decline, the prevailing attitude among many is that immunization no longer is necessary.
“The sad reality is, because everybody is exhausted, as the case numbers dropped dramatically so has the vaccination uptake,” says Ann Marie Pettis, RN, BSN, CIC, immediate past president of the Association for Professionals in Infection Control and Epidemiology (APIC).
The Centers for Disease Control and Prevention (CDC) reports that, as of March 9, 2022, the seven-day average number of administered vaccine doses was 302,787, an 11.9% decrease from the previous week. The rate of COVID-19 immunizations fell another 12% from that mark by March 9, representing a 59% decline in vaccinations in two weeks.3
“That’s the message that we need to keep sharing with people: ‘We understand you feel less need to get vaccinated, but there is still an increased risk of bad outcomes if you get infected,’” Pettis says. “[The vaccine] has a good safety profile. Is it perfect? No. Nothing is — there’s risk to everything. But if you look at the risk-benefit and long COVID, and all the other stuff we’re still learning about, I say hedge your bets and get vaccinated.”
Adverse outcomes of infection still are a concern because “only about 30% of America is fully vaccinated and boosted,” Poland said.
The unvaccinated clearly are at greater risk in CDC data on hospitalizations through Jan. 29, 2022. The CDC reports that unvaccinated adults 18 years of age and older have a sevenfold higher rate of hospitalization than those who are vaccinated. The CDC definition of vaccinated in this comparison includes people with both the basic two-shot regimen and also those who received a booster dose.4
A Seasonal Virus?
If indeed it is becoming endemic, SARS-CoV-2 likely will continue to decline in the near term, but reach peak circulation in the winter months, said Paul Offit, MD, director of the Vaccine Education Center and professor of pediatrics in the Division of Infectious Diseases at Children’s Hospital of Philadelphia.
Even at an endemic level, COVID-19 still could be a seasonal killer along the lines of influenza.
“Two years before this pandemic, influenza in the United States caused 700,000 hospitalizations and 60,000 deaths,” Offit said. “The year before the pandemic, it caused roughly 400,000 hospitalizations and 20,000 deaths. That’s not considered a pandemic. Basically, that’s considered an endemic winter virus. I think by next winter, we will probably feel that this virus falls into that category.”
Since the original SARS-CoV-2 emerged in China in late 2019, a succession of variants has followed — each more contagious than its predecessor.
“But in all cases, the vaccine protects against serious disease, because the immunological mediator of protection against serious disease are memory cells,” Offit said in a recent interview.5 “[These include] memory B cells, and especially memory T cells, memory T helper cells, memory cytotoxic T cells. Those cells recognize more conserved regions of the SARS-CoV-2 spike protein. Even with two doses of an mRNA-containing vaccine, you are protected probably for years against serious illness.”
A member of the Food and Drug Administration’s (FDA) vaccine advisory committee, Offit said the duration of protection against serious illness likely would make annual shots or boosters unnecessary.
“The goal for this vaccine — which is the goal for any mucosal viral vaccine, like rotavirus or flu vaccine — is to protect against moderate to severe illness,” he said. “This vaccine does that.”
CDC Masking Changes
As part of the transition to endemicity, the CDC has set up an online county tracker that recommends precautions based on COVID-19 risk at low, medium, and high levels as measured by “hospital beds being used, hospital admissions, and the total number of new COVID-19 cases in an area.”6
Only people living in communities designated as high risk are recommended to wear masks indoors. In the medium category, the CDC recommends “people at high risk for severe illness [should] talk to your healthcare provider about whether you need to wear a mask and take other precautions.” People in low-risk areas need only keep up on their COVID-19 vaccinations and get tested if they develop symptoms.
“This new framework moves beyond just looking at cases and test positivity to evaluate factors that reflect the severity of disease, including hospitalizations and hospital capacity,” Rochelle Walensky, MD, CDC director, said at a press conference.
For ease of understanding, the CDC has posted a regularly updated, online U.S. map, with the risk levels for COVID-19 color coded for every county nationally as orange (high), yellow (medium), and green (low).
“None of us know what the future may hold for us and for this virus and we need to be prepared and we need to be ready for whatever comes next,” she added. “We want to give people a break from things like mask wearing when our levels are low, and then have the ability to reach for them again should things get worse in the future.”
The CDC guidelines are getting mixed reviews, but one voice of support is Linda Dickey, RN, MPH, CIC, FAPIC, president of APIC.
“They have come up with something that they have modeled and determined to be predictive, which is helpful as long as we can readily take action,” Dickey says. “In terms of our behavior within healthcare, it is pretty much the same. This is more of an encouragement in the community, especially since we are seeing cases drop. I think people are in a place where they can see this is as logical.”
Poland is less enthusiastic about the revised CDC guidelines, citing several factors that make the transition to an endemic posture something of an “experiment.”
“They’re trying to get away from community [precautions] because there are a number of people immunized, a number of people previously infected, and, as they keep saying, fatigue over precautions,” he said. “I don’t think fatigue over precautions is a good motivating factor in the midst of a pandemic. Furthermore, how are people going to know [the risk categories]? Are they really going to go to a website?” (See editor’s note.)
Poland said he will keep masking in the community because the situation is subject to rapid change, there are children younger than 5 years of age who are not eligible for a vaccine, and there are many immunocompromised people who may not mount an immune response even if immunized. The specter of chronic, long COVID also is of concern.
“This [CDC guidance] is focused on more of the severe hospitalized cases, how many beds are being used by people who have COVID,” he said. “It ignores all of the consequences of COVID that don’t end up in the hospital, such as long COVID, as one example.”
Vaccination reduces the risk of developing long COVID by 30% to 50%, he estimated. The cause of long COVID remains open to speculation, Poland noted.
“In some cases, it may be these auto-antibodies that are generated,” he said. “In other cases, it probably reflects organ damage from the viral infection. In other cases, maybe it’s the consequence of activating another latent virus. We have a lot to learn [about its etiology] and treatment.”
If there is a silver lining, it is that more research on long COVID may open new paths to understand and treat chronic conditions associated with other viral infections, like Lyme disease and Epstein-Barr, he said.
‘Entering the Phase of Endemic Management’
Another signal of impending endemicity is the projected increase in immunity through infection, vaccination, or both.
“Scientists at Johns Hopkins Bloomberg School of Public Health estimate that about three out of four people in the United States will have been infected by Omicron by the end of the surge, which gives the population a large amount of natural immunity and hybrid immunity,” says Monica Gandhi, MD, an infectious disease physician at the University of California, San Francisco.
The authors of a recently published commentary argued this immunity level has skewed the perception that Omicron is a relatively mild infection, although they did report that it is about 25% less severe than the preceding Delta variant.7 (See Hospital Infection Control & Prevention, March 2022.)
“I think the [CDC] recommendations make sense,” Gandhi says. “The former CDC guidance recommended masking based on case counts. But in places of high vaccination or [natural] immunity, cases become ‘decoupled’ from hospitalizations, since vaccines and recovery immunity are so effective at preventing severe disease.”
Essentially, the CDC now considers new COVID-19 admissions of less than 10 per 100,000 population, and no more than 15% of staffed inpatient hospital beds occupied by SARS-CoV-2 patients, as the “range where masking is not necessary by the general population,” she says. “We are entering the phase of endemic management.”
Part of the challenge of closing the gap between pandemic and endemic is “de-escalating” infection control measures, but remaining flexible enough to change course as the situation warrants, said Ruth Carrico, PhD, FSHEA, RN, CIC, a professor of infectious disease at the University of Louisville.
“It’s worth reminding everybody, we’ve been in this pandemic now for only two years,” she said at an APIC webinar. “Look at everything that has happened.”
That includes ongoing research and updated guidance on multiple fronts, as the “virus keeps changing,” she said. “The CDC and WHO [World Health Organization] have been trying to pull in evidence and come out with guidelines, and the week they publish it [there is] something new. They’ve been struggling to keep up, and we’ve been struggling to keep up. Flexibility is the name of the game and keeping up with what’s going on is vital.”
Editor’s note: To find the CDC risk level in your county, go to www.cdc.gov or call 1-800-CDC-INFO.
REFERENCES
- YouTube. Mayo Clinic Q&A podcast: New cases of COVID-19 continue downward trend. Mayo Clinic. Published March 1, 2022. https://www.youtube.com/watch?v=6ZESUolO4rE
- The New York Times. Track coronavirus cases in places important to you. Updated March 15, 2022. https://www.nytimes.com/interactive/2021/us/covid-cases-deaths-tracker.html
- Centers for Disease Control and Prevention. COVID Data Tracker Weekly Review. Updated March 9, 2022. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html
- Centers for Disease Control and Prevention. Rates of laboratory-confirmed COVID-19 hospitalizations by vaccination status. COVID Data Tracker. Updated March 3, 2022. https://covid.cdc.gov/covid-data-tracker/#covidnet-hospitalizations-vaccination
- YouTube. Dr. Paul Offit on where we are with the COVID-19 pandemic. College of Physicians of Philadelphia. Published Jan. 28, 2022. https://www.youtube.com/watch?v=Hp5cmG_8BT4
- Centers for Disease Control and Prevention. COVID-19 by County. Updated March 11, 2022. https://www.cdc.gov/coronavirus/2019-ncov/your-health/covid-by-county.html
- Bhattacharyya RP, Hanage WP. Challenges in inferring intrinsic severity of the SARS-CoV-2 Omicron variant. N Engl J Med 2022;386:e14.
As COVID-19 cases drop dramatically and public health officials relax masking guidelines based on the local situation, there is the temptation to assume the pandemic is over and is entering a broadly defined endemic phase.
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