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Tag: COVID deaths

  • Why Are We Still Flu-ifying COVID?

    Why Are We Still Flu-ifying COVID?

    Four years after what was once the “novel coronavirus” was declared a pandemic, COVID remains the most dangerous infectious respiratory illness regularly circulating in the U.S. But a glance at the United States’ most prominent COVID policies can give the impression that the disease is just another seasonal flu. COVID vaccines are now reformulated annually, and recommended in the autumn for everyone over the age of six months, just like flu shots; tests and treatments for the disease are steadily being commercialized, like our armamentarium against flu. And the CDC is reportedly considering more flu-esque isolation guidance for COVID: Stay home ’til you’re feeling better and are, for at least a day, fever-free without meds.

    These changes are a stark departure from the earliest days of the crisis, when public-health experts excoriated public figures—among them, former President Donald Trump—for evoking flu to minimize COVID deaths and dismiss mitigation strategies. COVID might still carry a bigger burden than flu, but COVID policies are getting more flu-ified.

    Read: The flu-ification of COVID policy is almost complete

    In some ways, as the population’s immunity has increased, COVID has become more flu-like, says Roby Bhattacharyya, a microbiologist and an infectious-disease physician at Massachusetts General Hospital. Every winter seems to bring a COVID peak, but the virus is now much less likely to hospitalize or kill us, and somewhat less likely to cause long-term illness. People develop symptoms sooner after infection, and, especially if they’re vaccinated, are less likely to be as sick for as long. COVID patients are no longer overwhelming hospitals; those who do develop severe COVID tend to be those made more vulnerable by age or other health issues.

    Even so, COVID and the flu are nowhere near the same. SARS-CoV-2 still spikes in non-winter seasons and simmers throughout the rest of the year. In 2023, COVID hospitalized more than 900,000 Americans and killed 75,000; the worst flu season of the past decade hospitalized 200,000 fewer people and resulted in 23,000 fewer deaths. A recent CDC survey reported that more than 5 percent of American adults are currently experiencing long COVID, which cannot be fully prevented by vaccination or treatment, and for which there is no cure. Plus, scientists simply understand much less about the coronavirus than flu viruses. Its patterns of spread, its evolution, and the durability of our immunity against it all may continue to change.

    And yet, the CDC and White House continue to fold COVID in with other long-standing seasonal respiratory infections. When the nation’s authorities start to match the precautions taken against COVID with those for flu, RSV, or common colds, it implies “that the risks are the same,” Saskia Popescu, an epidemiologist at the University of Maryland, told me. Some of those decisions are “not completely unreasonable,” says Costi Sifri, the director of hospital epidemiology at UVA Health, especially on a case-by-case basis. But taken together, they show how bent America has been on treating COVID as a run-of-the-mill disease—making it impossible to manage the illness whose devastation has defined the 2020s.

    Each “not completely unreasonable” decision has trade-offs. Piggybacking COVID vaccines onto flu shots, for instance, is convenient: Although COVID-vaccination rates still lag those of flu, they might be even lower if no one could predict when shots might show up. But such convenience may come at the cost of protecting Americans against COVID’s year-round threat. Michael Osterholm, an epidemiologist at the University of Minnesota School of Public Health, told me that a once-a-year vaccine policy is “dead wrong … There is no damn evidence this is a seasonal virus yet.” Safeguards against infection and milder illness start to fade within months, leaving people who dose up in autumn potentially more susceptible to exposures by spring. That said, experts are still torn on the benefits of administering the same vaccine more than once a year—especially to a public that’s largely unwilling to get it. Throughout the pandemic, immunocompromised people have been able to get extra shots. And today, an advisory committee to the CDC voted to recommend that older adults once again get an additional dose of the most recently updated COVID vaccine in the coming months. Neither is a pattern that flu vaccines follow.

    Read: Fall’s vaccine routine didn’t have to be this hard

    Dropping the current COVID-isolation guideline—which has, since the end of 2021, recommended that people cloister for five days—may likewise be dangerous. Many Americans have long abandoned this isolation timeline, but given how new COVID is to both humanity and science, symptoms alone don’t yet seem enough to determine when mingling is safe, Popescu said. (The dangers are even tougher to gauge for infected people who never develop fevers or other symptoms at all.) Researchers don’t currently have a clear picture of how long people can transmit the virus once they get sick, Sifri told me. For most respiratory illnesses, fevers show up relatively early in infection, which is generally when people pose the most transmission risk, says Aubree Gordon, an epidemiologist at the University of Michigan. But although SARS-CoV-2 adheres to this same rough timeline, infected people can shed the virus after their symptoms begin to resolve and are “definitely shedding longer than what you would usually see for flu,” Gordon told me. (Asked about the specifics and precise timing of the update, a CDC spokesperson told me that there were “no updates to COVID guidelines to announce at this time,” and did not respond to questions about how flu precedents had influenced new recommendations.)

    At the very least, Emily Landon, an infectious-disease physician at the University of Chicago, told me, recommendations for all respiratory illnesses should tell freshly de-isolated people to mask for several days when they’re around others indoors; she would support some change to isolation recommendations with this caveat. But if the CDC aligns the policy fully with its flu policy, it might not mention masking at all.

    Read: No one really knows how much COVID is silently spreading … again

    Several experts told me symptom-based isolation might also remove remaining incentives to test for the coronavirus: There’s little point if the guidelines for all respiratory illnesses are essentially the same. To be fair, Americans have already been testing less frequently—in some cases, to avoid COVID-specific requirements to stay away from work or school. And Osterholm and Gordon told me that, at this point in the pandemic, they agree that keeping people at home for five days isn’t sustainable—especially without paid sick leave, and particularly not for health-care workers, who are in short supply during the height of respiratory-virus season.

    But the less people test, the less they’ll be diagnosed—and the less they’ll benefit from antivirals such as Paxlovid, which work best when administered early. Sifri worries that this pattern could yield another parallel to flu, for which many providers hesitate to prescribe Tamiflu, debating its effectiveness. Paxlovid use is already shaky; both antivirals may end up chronically underutilized.

    Flu-ification also threatens to further stigmatize long COVID. Other respiratory infections, including flu, have been documented triggering long-term illness, but potentially at lower rates, and to different degrees than SARS-CoV-2 currently does. Folding this new virus in with the rest could make long COVID seem all the more negligible. What’s more, fewer tests and fewer COVID diagnoses could make it much harder to connect any chronic symptoms to this coronavirus, keeping patients out of long-COVID clinics—or reinforcing a false portrait of the condition’s rarity.

    The U.S. does continue to treat COVID differently from flu in a few ways. Certain COVID products remain more available; some precautions in health-care settings remain stricter. But these differences, too, will likely continue to fade, even as COVID’s burden persists. Tests, vaccines, and treatments are slowly commercializing; as demand for them drops, supply may too. And several experts told me that they wouldn’t be surprised if hospitals, too, soon flu-ify their COVID policies even more, for instance by allowing recently infected employees to return to work once they’re fever-free.

    Early in the pandemic, public-health experts hoped that COVID’s tragedies would prompt a rethinking of all respiratory illnesses. The pandemic showed what mitigations could do: During the first year of the crisis, isolation, masking, distancing, and shutdowns brought flu transmission to a near halt, and may have driven an entire lineage of the virus to extinction—something “that never, in my wildest dreams, did I ever think would be possible,” Landon told me.

    Most of those measures weren’t sustainable. But America’s leaders blew right past a middle ground. The U.S. could have built and maintained systems in which everyone had free access to treatments, tests, and vaccines for a longer list of pathogens; it might have invested in widespread ventilation improvements, or enacted universal sick leave. American homes might have been stocked with tests for a multitude of infectious microbes, and masks to wear when people started to cough. Vaccine requirements in health-care settings and schools might have expanded. Instead, “we seem to be in a more 2019-like place than a future where we’re preventing giving each other colds as much as we could,” Bhattacharyya told me.

    Read: Next winter, what if we test for even more viruses?

    That means a return to a world in which tens of thousands of Americans die each year of flu and RSV, as they did in the 2010s. With COVID here to stay, every winter for the foreseeable future will layer on yet another respiratory virus—and a particularly deadly, disabling, and transmissible one at that. The math is simple: “The risk has overall increased for everyone,” Landon said. That straightforward addition could have inspired us to expand our capacity for preserving health and life. Instead, our tolerance for suffering seems to be the only thing that’s grown.

    Katherine J. Wu

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  • U.S. Avoids Predicted Winter COVID Surge

    U.S. Avoids Predicted Winter COVID Surge

    March 13, 2023 – Last year, federal officials warned of a likely COVID-19 surge this winter. It never happened, making this the first pandemic winter without a significant spike.

    Deaths from COVID-19 and official case counts declined dramatically, compared to the surges seen during the winter of 2021-2022.

    Many experts have said that wave never appeared because so many Americans have either been vaccinated, infected, or both. That created a wall of immunity. 

    While the infection rate didn’t skyrocket this winter, COVID-19 still played a deadly role across America. Weekly deaths peaked at 4,439 the week of Jan. 11, compared to a peak of 17,378 in early February 2022. From peak to peak, that’s a decline of 75%. 

    Compared to last winter, cases reported to the CDC this winter were down about 90%. The week of Jan. 19, 2022, infections peaked at 5.6 million cases. This winter, the peak was 494,946 weekly cases at the end of December 2022. After that end-of-year high, cases declined for a couple of weeks, tipped back up to 479,604 in early January, and have steadily headed down since, with 170,576 cases reported last week. 

    Comparing data can be a problem, because home testing use and reporting vary, John Brownstein, PhD, a biomedical informatics expert at Harvard Medical School, told ABC News. Declines in COVID-19 hospitalization and death rates still point to a less severe season, he said.

    COVID-19 isn’t going away, though. The latest projection models from the University of Washington, which has been analyzing COVID-19 statistics since the pandemic started, show a steady infection rate and slightly declining death and hospitalization rates through the spring.

    Globally, the virus has been less deadly but is forecast to remain a problem. From November 2021 to December 2022, worldwide infection counts doubled, compared to the prior year, but there were just one-fifth of the deaths, according to a report released last week by the Institute for Health Metrics and Evaluation, a global health research center at the University of Washington. 

    “The massive Omicron waves and high vaccination rates in many high-income countries have together contributed to high levels of immunity against SARS-CoV-2 infection,” the authors wrote.

    They predicted there will be significant COVID-19 activity outside the U.S. in the coming year, particularly in China, where many people don’t have immunity provided by prior infection and models project an uncontrolled outbreak. 

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  • China’s COVID Wave Is Coming

    China’s COVID Wave Is Coming

    In China, a dam seems on the verge of breaking. Following a wave of protests, the government has begun to relax some of its most stringent zero-COVID protocols, and regional authorities have trimmed back a slew of requirements for mass testing, quarantine, and isolation. The rollbacks are coming as a relief for the many Chinese residents who have been clamoring for change. But they’re also swiftly tilting the nation toward a future that’s felt inevitable for nearly three years: a flood of infections—accompanied, perhaps, by an uncharted morass of disease and death. A rise in new cases has already begun to manifest in urban centers such as Chongqing, Beijing, and Guangzhou. Now experts are waiting to see just how serious China’s outbreak will be, and whether the country can cleanly extricate itself from the epidemic ahead.

    For now, the forecast “is full of ifs and buts and maybes,” says Salim Abdool Karim, an epidemiologist at the Centre for the AIDS Programme of Research in South Africa. Perhaps the worst can be averted if the government does more to vaccinate the vulnerable and prep hospitals for a protracted influx of COVID patients; and if the community at large reinvests in a subset of mitigation measures as cases rise. “There is still the possibility that they may muddle through it without a mass die-off,” says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. “But even the most smooth and orderly transition,” he told me, “will not prevent a surge of cases.”

    China represents, in many ways, SARS-CoV-2’s final frontier. With its under-vaccinated residents and sparse infection history, the nation harbors “a more susceptible population than really any other large population I can think of,” says Sarah Cobey, an computational epidemiologist at the University of Chicago. Soon, SARS-CoV-2 will infiltrate that group of hosts so thoroughly that it will be nearly impossible to purge again. “Eventually, just like everyone else on Earth, everyone in China should expect to be infected,” says Michael Worobey, an evolutionary virologist at the University of Arizona.

    Read: How many COVID deaths will Chinese protesters accept?

    Whatever happens, though, China’s coming wave won’t recapitulate the one that swept most of the world in early 2020. Though it’s hard to say which versions of the virus are circulating in the country, a smattering of reports confirm the likeliest scenario: BF.7 and other Omicron subvariants predominate. Several of these versions of the virus seem to be a bit less likely than their predecessors to trigger severe disease. That, combined with the relatively high proportion of residents—roughly 95 percent—who have received at least one dose of a COVID vaccine, might keep many people from falling dangerously ill. The latest figures out of China’s CDC marked some 90 percent of the country’s cases as asymptomatic. “That’s an enormous fraction” compared with what’s been documented elsewhere, says Ben Cowling, an epidemiologist at the University of Hong Kong.

    That percentage, however, is undoubtedly increased by the country’s ultra-rigorous testing practices, which have been catching silent cases that other places might miss. All of Omicron’s iterations also remain capable of triggering severe disease and long COVID. And there are still plenty of worrying omens that climbing cases could reach a horrific peak, sit on a prolonged plateau, or both.

    One of China’s biggest weak spots is its immunity, or lack thereof. Although more than 90 percent of all people in the country have received at least two COVID shots, those over the age of 80 were not prioritized in the country’s initial rollout, and their rate of dual-dose coverage hovers around just 66 percent. An even paltrier fraction of older people have received a third dose, which the World Health Organization recommends for better protection. Chinese officials have vowed to buoy those numbers in the weeks ahead. But vaccination sites have been tougher to access than testing sites, and with few freedoms offered to the immunized, “the incentive structure is not built,” says Xi Chen, a global-health expert at Yale. Some residents are also distrustful of COVID vaccines. Even some health-care workers are wary of delivering the shots, Chen told me, because they’re fearful of liability for side effects.

    Regardless of the progress China makes in plugging the holes in its immunity shield, COVID vaccines won’t prevent all infections. China’s shots, most of which are based on chemically inactivated particles of the 2020 version of SARS-CoV-2, seem to be less effective and less durable than mRNA recipes, especially against Omicron variants. And many of China’s residents received their third doses many months ago. That means even people who are currently counted as “boosted” aren’t as protected as they could be.

    All of this and more could position China to be worse off than other places—among them, Australia, New Zealand, and Singapore—that have navigated out of a zero-COVID state, says Caitlin Rivers, a senior scholar at the Johns Hopkins Center for Health Security. Australia, for instance, didn’t soften its mitigations until it had achieved high levels of vaccine coverage among older adults, Rivers told me. China has also clung to its zero-COVID philosophy far longer than any other nation, leaving itself to contend with variants that are better at spreading than those that came before. Other countries charted their own path out of their restrictions; China is being forced into an unplanned exit.

    What Hong Kong endured earlier this year may hint at what’s ahead. “They had a really, really bad wave,” Kayoko Shioda, an epidemiologist at Emory University, told me—far dwarfing the four that the city had battled previously. Researchers have estimated that nearly half the city’s population—more than 3 million people—ended up catching the virus. More than 9,000 residents died. And Hong Kong was, in some respects, in a better place to ease its restrictions than the mainland is. This past winter and spring, the city’s main adversary was BA.2, a less vaccine-evasive Omicron subvariant than the ones circulating now; officials had Pfizer’s mRNA-based shot on hand, and quickly began offering fourth doses. Hong Kong also has more ICU beds per capita. Map a new Omicron outbreak onto mainland China, and the prognosis is poor: A recent modeling paper estimated that the country could experience up to 1.55 million deaths in the span of just a few months. (Other analyses offer less pessimistic estimates.)

    Lackluster vaccination isn’t China’s only issue. The country has accumulated almost no infection-induced immunity that might otherwise have updated people’s bodies on recent coronavirus strains. The country’s health-care system is also ill-equipped to handle a surge in demand: For every 100,000 Chinese residents, just 3.6 ICU beds exist, concentrated in wealthier cities; in an out-of-control-infection scenario, even a variant with a relatively low severe-disease risk would prove disastrous, Chen told me. Nor does the system have the slack to accommodate a rush of patients. China’s culture of care seeking is such that “even when you have minor illness, you seek help in urban health centers,” Huang told me, and not enough efforts have been made to bolster triage protocols. More health-care workers may become infected; patients may be more likely to slip through the cracks. Next month’s Lunar New Year celebration, too, could spark further spread. And as the weather cools and restrictions relax, other respiratory viruses, such as RSV and flu, could drive epidemics of their own.

    That said, spikes of illness are unlikely to peak across China at the same time, which could offer some relief. The country’s coming surge “could be explosive,” Cobey told me, “or it could be more of a slow burn.” Already, the country is displaying a patchwork of waxing and waning regulations across jurisdictions, as some cities tighten their restrictions to combat the virus while others loosen up. Experts told me that more measures may return as cases ratchet up—and unlike people in many other countries, the Chinese may be more eager to readopt them to quash a ballooning outbreak.

    Read: China’s zero tolerance for Xi’s COVID restrictions

    A major COVID outbreak in China would also have unpredictable effects on the virus. The world’s most populous country includes a large number of immunocompromised people, who can harbor the virus for months—chronic infections that are thought to have produced variants of concern before. The world may be about to witness “a billion or more opportunities for the virus to evolve,” Cowling told me. In the coming months, the coronavirus could also exploit the Chinese’s close interactions with farmed animals, such as raccoon dogs and mink (both of which can be infected by SARS-CoV-2), and become enmeshed in local fauna. “We’ve certainly seen animal reservoirs becoming established in other parts of the world,” Worobey told me. “We should expect the same thing there.”

    Then again, the risk of new variants spinning out of a Chinese outbreak may be a bit less than it seems, Abdool Karim and other experts told me. China has stuck with zero COVID so long that its population has, by and large, never encountered Omicron subvariants; people’s immune systems remain trained almost exclusively on the original version of the coronavirus, raising only defenses that currently circulating strains can easily get around. It’s possible that “there will be less pressure for the virus to evolve to evade immunity further,” says Emma Hodcroft, a molecular epidemiologist at the University of Bern; and any new versions of the virus that do emerge might not fare particularly well outside of China. In other words, the virus could end up trapped in the very country that tried to keep it out the longest. Still, with so many people susceptible, Cobey told me, there are zero guarantees.

    Either way, viral evolution will plod on—and as it does, the rest of the world may struggle to track it in real time, especially as the cadence of Chinese testing ebbs. Cowling worries that China will have trouble monitoring the number of cases in the country, much less which subvariants are causing them. “There’s going to be a challenge in having situational awareness,” he told me. Shioda, too, worries that China will remain tight-lipped about the scale of the outbreak, a pattern that could have serious implications for residents as well.

    Even without a spike in severe disease, a wide-ranging outbreak is likely to put immense strain on China—which may weigh heavily on its economy and residents for years to come. After the SARS outbreak that began in 2002, rates of burnout and post-traumatic stress among health-care workers in affected countries swelled. Chinese citizens have not experienced an epidemic of this scale in recent memory, Chen told me. “A lot of people think it is over, that they can go back to their normal lives.” But once SARS-CoV-2 embeds itself in the country, it won’t be apt to leave. There will not be any going back to normal, not after this.

    Katherine J. Wu

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  • COVID Attacks DNA in Heart, Unlike Flu, Study Says

    COVID Attacks DNA in Heart, Unlike Flu, Study Says

    Sept. 30, 2022 — COVID-19 causes DNA damage to the heart, affecting the body in a completely different way than the flu does, according to a recent study published in Immunology 

    The study looked at the hearts of patients who died from COVID-19, the flu, and other causes. The findings could provide clues about why coronavirus has led to complications such as ongoing heart issues.

    “We found a lot of DNA damage that was unique to the COVID-19 patients, which wasn’t present in the flu patients,” Arutha Kulasinghe, one of the lead study authors and a research fellow at the University of Queensland in Australia, told the Brisbane Times.

    “So in this study, COVID-19 and flu look very different in the way they affect the heart,” he said.

    Kulasinghe and colleagues analyzed the hearts of seven COVID-19 patients, two flu patients, and six patients who died from other causes. They used transcriptomic profiling, which looks at the DNA landscape of an organ, to investigate heart tissue from the patients.

    Due to previous studies about heart problems associated with COVID-19, he and colleagues expected to find extreme inflammation in the heart. Instead, they found that inflammation signals had been suppressed in the heart, and markers for DNA damage and repair were much higher. They’re still unsure of the underlying cause.

    “The indications here are that there’s DNA damage here, it’s not inflammation,” Kulasinghe said. “There’s something else going on that we need to figure out.”

    The damage was similar to the way chronic diseases such as diabetes and cancer appear in the heart, he said, with heart tissue showing DNA damage signals. 

    Kulasinghe said he hopes other studies can build on the findings to develop risk models to understand which patients may face a higher risk of serious COVID-19 complications. In turn, this could help doctors provide early treatment. For instance, all seven COVID-19 patients had other chronic diseases, such as diabetes, hypertension, and heart disease. 

    “Ideally in the future, if you have cardiovascular disease, if you’re obese or have other complications, and you’ve got a signature in your blood that indicates you are at risk of severe disease, then we can risk-stratify patients when they are diagnosed,” he said. 

    The research is a preliminary step, Kulasinghe said, due to the small sample size. This type of study is often difficult to conduct because researchers have to wait for the availability of organs, as well as request permission from families for post-mortem autopsies and biopsies, to be able to look at the effects on dead tissues.

    “Our challenge now is to draw a clinical finding from this, which we can’t at this stage,” he added. “But it’s a really fundamental biological difference we’re observing [between COVID-19 and flu], which we need to validate with larger studies.”

     

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  • The ‘End’ of COVID Is Still Far Worse Than We Imagined

    The ‘End’ of COVID Is Still Far Worse Than We Imagined

    When is the pandemic “over”? In the early days of 2020, we envisioned it ending with the novel coronavirus going away entirely. When this became impossible, we hoped instead for elimination: If enough people got vaccinated, herd immunity might largely stop the virus from spreading. When this too became impossible, we accepted that the virus would still circulate but imagined that it could become, optimistically, like one of the four coronaviruses that cause common colds or, pessimistically, like something more severe, akin to the flu.

    Instead, COVID has settled into something far worse than the flu. When President Joe Biden declared this week, “The pandemic is over. If you notice, no one’s wearing masks,” the country was still recording more than 400 COVID deaths a day—more than triple the average number from flu.

    This shifting of goal posts is, in part, a reckoning with the biological reality of COVID. The virus that came out of Wuhan, China, in 2019 was already so good at spreading—including from people without symptoms—that eradication probably never stood a chance once COVID took off internationally. “I don’t think that was ever really practically possible,” says Stephen Morse, an epidemiologist at Columbia. In time, it also became clear that immunity to COVID is simply not durable enough for elimination through herd immunity. The virus evolves too rapidly, and our own immunity to COVID infection fades too quickly—as it does with other respiratory viruses—even as immunity against severe disease tends to persist. (The elderly who mount weaker immune responses remain the most vulnerable: 88 percent of COVID deaths so far in September have been in people over 65.) With a public weary of pandemic measures and a government reluctant to push them, the situation seems unlikely to improve anytime soon. Trevor Bedford, a virologist at the Fred Hutchinson Cancer Center, estimates that COVID will continue to exact a death toll of 100,000 Americans a year in the near future. This too is approximately three times that of a typical flu year.

    I keep returning to the flu because, back in early 2021, with vaccine excitement still fresh in the air, several experts told my colleague Alexis Madrigal that a reasonable threshold for lifting COVID restrictions was 100 deaths a day, roughly on par with flu. We largely tolerate, the thinking went, the risk of flu without major disruptions to our lives. Since then, widespread immunity, better treatments, and the less virulent Omicron variant have together pushed the risk of COVID to individuals down to a flu-like level. But across the whole population, COVID is still killing many times more people than influenza is, because it is still sickening so many more people.

    Bedford told me he estimates that Omicron has infected 80 percent of Americans. Going forward, COVID might continue to infect 50 percent of the population every year, even without another Omicron-like leap in evolution. In contrast, flu sickens an estimated 10 to 20 percent of Americans a year. These are estimates, because lack of testing hampers accurate case counts for both diseases, but COVID’s higher death toll is a function of higher transmission. The tens of thousands of recorded cases—likely hundreds of thousands of actual cases every day—also add to the burden of long COVID.

    The challenge of driving down COVID transmission has also become clearer with time. In early 2021, the initially spectacular vaccine-efficacy data bolstered optimism that vaccination could significantly dampen transmission. Breakthrough cases were downplayed as very rare. And they were—at first. But immunity to infection is not durable against common respiratory viruses. Flu, the four common-cold coronaviruses, respiratory syncytial virus (RSV), and others all reinfect us over and over again. The same proved true with COVID. “Right at the beginning, we should have made that very clear. When you saw 95 percent against mild disease, with the trials done in December 2020, we should have said right then this is not going to last,” says Paul Offit, the director of the Vaccine Education Center at Children’s Hospital of Philadelphia. Even vaccinating the whole world would not eliminate COVID transmission.

    This coronavirus has also proved a wilier opponent than expected. Despite a relatively slow rate of mutation at the beginning of the pandemic, it soon evolved into variants that are more inherently contagious and better at evading immunity. With each major wave, “the virus has only gotten more transmissible,” says Ruth Karron, a vaccine researcher at Johns Hopkins. The coronavirus cannot keep becoming more transmissible forever, but it can keep changing to evade our immunity essentially forever. Its rate of evolution is much higher than that of other common-cold coronaviruses. It’s higher than that of even H3N2 flu—the most troublesome and fastest-evolving of the influenza viruses. Omicron, according to Bedford, is the equivalent of five years of H3N2 evolution, and its subvariants are still outpacing H3N2’s usual rate. We don’t know how often Omicron-like events will happen. COVID’s rate of change may eventually slow down when the virus is no longer novel in humans, or it may surprise us again.

    In the past, flu pandemics “ended” after the virus swept through so much of the population that it could no longer cause huge waves. But the pandemic virus did not disappear; it became the new seasonal-flu virus. The 1968 H3N2 pandemic, for example, seeded the H3N2 flu that still sickens people today. “I suspect it’s probably caused even more morbidity and mortality in all those years since 1968,” Morse says. The pandemic ended, but the virus continued killing people.

    Ironically, H3N2 did go away during the coronavirus pandemic. Measures such as social distancing and masking managed to almost entirely eliminate the flu. (It has not disappeared entirely, though, and may be back in full force this winter.) Cases of other respiratory viruses, such as RSV, also plummeted. Experts hoped that this would show Americans a new normal, where we don’t simply tolerate the flu and other respiratory illnesses every winter. Instead, the country is moving toward a new normal where COVID is also something we tolerate every year.

    In the same breath that President Biden said, “The pandemic is over,” he went on to say, “We still have a problem with COVID. We’re still doing a lot of work on it.” You might see this as a contradiction, or you might see it as how we deal with every other disease—an attempt at normalizing COVID, if you will. The government doesn’t treat flu, cancer, heart disease, tuberculosis, hepatitis C, etc., as national emergencies that disrupt everyday life, even as the work continues on preventing and treating them. The U.S.’s COVID strategy certainly seems to be going in that direction. Broad restrictions such as mask mandates are out of the question. Interventions targeted at those most vulnerable to severe disease exist, but they aren’t getting much fanfare. This fall’s COVID-booster campaign has been muted. Treatments such as bebtelovimab and Evusheld remain on shelves, underpublicized and underused.

    At the same time, hundreds of Americans are still dying of COVID every day and will likely continue to die of COVID every day. A cumulative annual toll of 100,000 deaths a year would still make COVID a top-10 cause of death, ahead of any other infectious disease. When the first 100,000 Americans died of COVID, in spring 2020, newspapers memorialized the grim milestone. The New York Times devoted its entire front page to chronicling the lives lost to COVID. It might have been hard to imagine, back in 2020, that the U.S. would come to accept 100,000 people dying of COVID every year. Whether or not that means the pandemic is over, the second part of the president’s statement is harder to argue with: COVID is and will remain a problem.

    Sarah Zhang

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