Every winter in the U.S., the public puts up with tens of millions of flu infections and on average tens of thousands of deaths. Respiratory syncytial virus, which mostly affects children and those over 65, causes about 235,000 hospitalizations and 15,000 deaths.
While families can be devastated by these diseases, the majority of us go on, barely paying attention.
When will we reach that point with the coronavirus, people have often asked over the last two years. What is an acceptable level of sickness, hospitalizations and deaths from COVID-19?
The omicron variant opens the door to this kind of thinking, expert say, because at least so far it appears so much milder than delta or the original virus.
But first, we have to get through the current surge.
As of Jan. 5, COVID-19 cases had increased by more than 85% from a week earlier – averaging 586,391 new infections per day,
according to the Centers for Disease Control and Prevention. More than 16,000 American are being admitted to the hospital every day and 1,200 are dying.
It's time, however, for public and political leaders to start talking about what levels of disease we
would accept, argue a trio of health experts in a
new commentary in the scientific journal JAMA.
Having a formal risk threshold would trigger emergency actions when cases exceed them, and health systems could use this threshold for planning for normal and surge capacity
A variant that is widespread but causes little disease could be something everyone can put up with, like the flu and RSV, wrote Ezekiel Emanuel, an oncologist and health policy expert at the University of Pennsylvania; Michael Osterholm, an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota and Dr. Celine Gounder, an infectious disease specialist at NYU Grossman School of Medicine.
With omicron, "We're not there yet," Emanuel stressed in an interview about this next "new normal" phase. But "we need a plan to get there and a plan how to stay sustainably there and not have more big outbreaks."
What an endemic virus looks like
Smallpox is the only virus that's ever been completely eliminated from the human population, and measles and polio have the potential to be, experts say, because all three can be completely prevented with vaccination.
Respiratory viruses like the flu and now SARS-CoV-2, the virus that causes COVID-19, will be impossible to eliminate, because they mutate so much the immune system can't protect against them forever, said Dr. Paul Offit, a pediatric infectious disease expert and director of the Vaccine Education Center at the Children's Hospital of Philadelphia
An endemic virus may come every few years or a few times a year, bringing a week or two of misery and missed appointments, but little risk of severe disease or death. Four coronaviruses in the same family as SARS-CoV-2 already are among those considered the common cold.
Immunity to these infections fades fast and there's no vaccine or even a decent treatment to fight them. Most people just slog through.
But there are still some open questions with COVID-19 that prevent experts from putting those infections in the same category.
One is whether infection with omicron will protect against a subsequent infection of the virus, and for how long.
Lab data suggests than an omicron infection does protect against one with delta, Dr. Rochelle Walensky, the director of the Centers for Disease Control and Prevention said in a Friday call with reporters.
"We don't yet know whether if you've had omicron you are more susceptible or less susceptible to another infection with omicron," she said. "We are setting up studies to evaluate that."
Omicron is described as being "milder" than previous variants, but it's not entirely clear how mild it is in people who are unvaccinated and have never been infected. And many people are still ending up in the hospital, overcrowding the health care system – which isn't sustainable.
"We could have an endemic state where disease burden is still unacceptable, if it stays very severe," said Elizabeth Halloran, a biostatistician and epidemiologist at the University of Washington and the Fred Hutchinson Cancer Research Center.
it also remains unclear whether omicron carries a lower risk of
long-haul COVID, where symptoms such as fatigue, headaches, lung damage or a loss of smell last for months or even longer. People who've been vaccinated and boosted probably run a smaller risk of long COVID, but that risk hasn't been quantified yet.
Early research suggests long COVID might increase the risk for dementia and other health challenges long-term.
"Will we see a spate of neurodegenerative disorders, like we did with the 1918 influenza, like we do with measles?" wondered Dr. Gregory Poland, a vaccine expert at the Mayo Clinic. What will happen to a person when heart muscle damage from COVID-19 is compounded by typical aging and hypertension? "Now you're running the risk of cardiac failure," he said.
Why we need to worry about more variants
Anyone who thinks they understand viruses and knows what they will do next hasn't thought about viruses for very long, said Poland, who has studied them for four decades.
Although omicron seems milder, the next variant might not be. Many people think and hope that viruses naturally get less dangerous over time, but there are other options, too, Halloran said.
"It could evolve to be less severe. That's what my expectation is," she said. "But it's surprised us a couple of times already."
It may be a good idea to make variant-specific vaccines for the next round of boosters, instead of repeatedly delivering the same, original shots, Halloran said. That will expand immunity and potentially prevent the virus from evolving to avoid vaccine protection.
Variants can arise from a variety of sources.
Researchers believe omicron likely came from an immunocompromised person, who unsuccessfully battled the virus for months, while it evolved to keep the immune system at bay.
Animals are another possible source of variants, Poland noted. It's been shown that
deer can catch the coronavirus. It might mutate in them, develop some new properties and then jump back to people.
"There's a host of scenarios out here that the American public doesn't understand, will be shocked at if it happens and will blame the 'experts' for not warning them," Poland said.
Bruce Walker, an immunologist and director of the Ragon Institute of MGH, MIT, and Harvard, worries about the potential for a variant with the transmissibility of omicron and the deadliness of delta – or even worse, the lethality of the first SARS virus, which killed roughly 10% of those infected, or
MERS-CoV, which kills about one-third.
"That's a real existential threat," Walker said.
What are the tools for managing an endemic virus?
Omicron causes many infections very quickly. In South Africa, cases dropped almost as fast as they climbed.
The United States is much bigger and more diverse. Still, "omicron is eventually going to run out of people to infect and it will have to decline," Walker said. That won't happen simultaneously everywhere, though, so he expects waves of infection. "We will be dealing with crises that are moving geographically across the country."
The chances people who are immunized and boosted will suffer severe illness "are markedly diminished," he said. But parts of the country with low rates of vaccination "are going to feel the worst of this surge."
Once the vast majority of the population has been infected, boosted or both, public policy should shift to protecting those who remain vulnerable, Walker said, particularly those who are older, have multiple risk factors or weakened immune systems.
Walker, who helps advise Harvard University on how to manage the pandemic, said officials are currently discussing whether to change their response during the spring semester.
So far, he said, they've focused on preventing infection through frequent testing and mask-wearing. But after this wave of infection dies down, he said, it might be smarter to focus instead on protecting the most vulnerable through medications that prevent disease or reduce risk of serious disease.
"Everybody's trying to figure this out," Walker said. "You want to maximize safety and minimize disruption and those two compete with each other."
The federal government has ordered 700,000 doses of AstraZeneca's
long-acting combination antibody Evusheld, for about $300 per dose. The drug, which would provided for free, was
authorized in December to prevent infection with COVID-19 in immunocompromised adults and adolescents, as well as those who cannot get vaccinated for medical reasons.
Roughly 7 million Americans would fit these categories, so the drug will not be available to everyone who could benefit.
Similarly, Pfizer's antiviral
Paxlovid, also recently authorized, has been shown extremely effective at preventing high-risk people from requiring hospitalization if given within 5 days of the start of COVID-19 symptoms.
But only 20 million doses of the drug, which is hard to manufacture, will be available throughout 2022, according to contracts between the company and the government, which has pre-purchased treatment courses for about $530 each.
"You're not going to have that much available," Emanuel said of each drug, limiting their usefulness. "It is part of the solution, but only part of the solution."
Right now, he said, both testing and treatment are being distributed without much of a plan. "We know what happens when we have haphazard circumstances," he said. "The rich and well connected benefit and it's not equitably distributed."
So should I get COVID to get it over with? Experts say that's a bad idea.
Healthy people who've been vaccinated and boosted shouldn't worry too much about getting infected, Poland said.
"The reality is all of us are going to get infected with coronavirus. That's a given," he said. "The only question is how do I modify it to be a trivial disease and not run the risk of death or complications."
He'd still like to see everyone who doesn't have a valid excuse to get vaccinated and boosted and wear a mask in crowded indoor areas. "That's how you transition" to an endemic virus, he said. "When you don't do those things, you are giving a lottery ticket to the virus every time it infects somebody."
Halloran said she would strongly discourage anyone from intentionally exposing themselves to omicron. They might still get long-COVID. And even though most people are handling omicron just fine, some are not.
"I'm not afraid of getting omicron (myself)," Halloran said. But "I wouldn't want to give it to somebody."
Walker said he's worried about the cumulative effect of so many people being infected at once. "We just can't handle it from a health care standpoint and a societal standpoint for everybody to be sick at the same time," he said.
Still, the pandemic is changing.
In their JAMA paper, Emanuel and his colleagues recommended a four-pronged strategy for coping with this new reality: a better data system for keeping track of infections, more opportunities to provide medical care via telehealth, rebuilding trust in the public health system and establishing a public health workforce supplemented with school nurses that can manage seasonal surges in infections.
If omicron does turn out to be far less dangerous for most people, doesn't cause a lot of long-COVID and doesn't mutate into something worse, public policy should change, Walker agreed.
"That is the time for us to reassess what our approach is to this pandemic," he said. "It's a very different pandemic and I think we need to put some fresh eyes on it."