Why COVID-19 Isn’t the Endemic Phase in the U.S. Yet

They were the words everyone has been waiting to hear—that the COVID-19 pandemic is dialing down from the five-alarm fire that flared up in 2020 to a somewhat lesser conflagration. On April 27, the U.S.’s chief medical advisor, Dr. Anthony Fauci, described the country as in a “transitional phase, from a deceleration of the numbers into hopefully a more controlled phase and endemicity” in an interview with the Washington Post.

Two years ago, pharmaceutical companies shipped their first COVID-19 vaccines to early testing. Fauci pointed out that vaccines and drug therapies that are effective in controlling the virus in people infected have largely contributed to the end of panic over the pandemic. But COVID-19 itself isn’t quite finished with us. The virus continues to mutate, and the latest variations being reported out of South Africa—new subvariants of Omicron including BA.4 and BA.5—are sobering reminders that the virus isn’t standing still.

“Pandemic” vs. “Endemic”

Although we may be out of the urgent pandemic phase, we’re not quite ready to call COVID-19 endemic, which would mean the virus is still among us but relatively under control, similar to influenza.

And it’s not clear when that will happen. It is possible that health professionals may differ on the timing of this transition. There are no hard and fast definitions for “pandemic” and “endemic,” and no thresholds for case numbers or deaths that mark a shift from one to the other. The World Health organization considers a pandemic to be an “epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people.” Experts have noted that these parameters say nothing about how quickly the outbreak is spreading, how much disease it’s causing, or what role immunity in the population plays.

These are crucial factors for political leaders and public health professionals as they deal with a pandemic. It is not possible to determine when it is best to reduce the initial urgency or to rescind drastic measures like lockdowns and mandates for masks.

That’s what the world is grappling with now—figuring out whether the risk of SARS-CoV-2 is now at a point where we can treat it more like influenza, by protecting ourselves as much as we can with immunization and basic hygiene such as washing our hands and covering our coughs, or whether we still need to manage SARS-CoV-2 as a serious enough threat for most people that we should maintain public health measures such as mask-wearing and social distancing.

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What a “controlled pandemic” looks like

Fauci argues that we are somewhere in between those two situations, describing our current status as a “controlled pandemic”—not quite the urgent threat of a pandemic, but again not quite ready for the ease of mind that comes with being in an endemic phase of an outbreak. The numbers back that up: In the United States, the number of cases has dropped from 700,000 to 800,000. per week, to an average of 30,000 to 50.000 per week since the start of this year. About 66% have been fully vaccinated for COVID-19 and the number of deaths has decreased steadily from January. It is clear that we are not as vulnerable now than in 2020. The vaccines are able to provide some protection against the virus. That is a big plus. But that immunity still isn’t enough to declare COVID-19 over.

Nevertheless, those numbers encouraged a push to loosen public health restrictions that have been in place since 2021—federal mandates that people wear masks in indoor settings, and on public transportation including subways, buses, trains and planes, as well as requiring proof of vaccination for certain gatherings at sports and entertainment complexes. The federal mask law was struck down by an American District Judge in Florida in April. He declared it illegal and said that the Centers for Disease Control exceeded its authority to impose it. While the Biden administration appeals this ruling, the airlines and major public transportation systems have stopped requiring passengers to wear masks.

That coincided with an uptick in cases of COVID-19—there’s no direct way to prove one caused the other, but the coincidence is hard to ignore. Cases rose from 24,000 to 25,000. Infected persons per week during April to nearly 50,000 in April. While hospitalizations have been increasing, their trends are behind those of case rates.

How to get rid of the COVID-19 virus completely

These trends indicate that we may not be able to let down our vigilantes about COVID-19. It remains a serious threat due to a variety of factors. COVID-19 shots, while effective, aren’t 100% immune to disease and infection. The shots can be effective at preventing the most severe COVID-19 symptoms, such as those caused by the Chinese virus strain. However, they are not effective against the newer SARS-CoV-2 variants. And the virus continues to mutate, with each version appearing to improve on the last strain’s ability to infect quickly and efficiently. Fortunately these changes haven’t led to a more virulent strain so far, but they could veer in that direction, and cause more serious disease on top of being more transmissible. To prevent this, current drugs and vaccines may be inadequate.

That leads to the second reason that COVID-19 isn’t fading into the background any time soon. Despite the effectiveness of the vaccines, scientists still don’t know exactly what it takes to fully protect someone from COVID-19. The question is actually broken down into two queries. What are the requirements to avoid infection? How can you protect yourself against serious illnesses? Even into the third year of the COVID-19 pandemic, scientists still don’t have solid answers for either.

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Although the mRNA shot is effective in preventing COVID-19, it has not prevented people from becoming infected. That’s not unusual for a vaccine, since the best way to block infection is with a pre-existing store of antibodies that can stick to the virus and interrupt them from infecting cells—and before getting immunized, most people in the world didn’t have any antibodies against SARS-CoV-2. Even after vaccination, antibody levels decrease after several months. Health officials recommend that booster doses be given. While these boosters seem to have been slightly more effective at decreasing the chance of infection, vaccines cannot be used as an effective way to end infection.

These immune systems are much more effective at stopping serious COVID-19 diseases. But even there, it’s still not clear exactly how much of an immune response, or what type, is enough to stop severe COVID-19 symptoms that can lead to hospitalization and even death. Studies of people who have been vaccinated, as well those involving people who have been naturally infected with SARS-CoV-2, are trying to shed some light on this, but scientists still can’t point to exactly what kind of immune reaction will be essential to finally push SARS-CoV-2 back.

This knowledge, which scientists refer to as the “correspondences of immunity”, could help shape U.S. policies on the use of booster shots this fall. Food and Drug Administration and other experts in public health are currently using antibody data to assess the effectiveness of vaccines and determine what kind of immunity is necessary. But in a recent meeting of the FDA’s vaccine advisory committee, the experts raised concerns about how reliable the current metrics of antibody levels are in serving as surrogates for these correlates of immunity. Until further research reveals how much immune protection is enough, it’s not likely that the world will move past seeing COVID-19 as a continuing pandemic threat, albeit, as Fauci proposed, one that is under better control now than when it first emerged in 2020.

That’s why the White House, with the support of the CDC, is pushing back on lifting the federal mandate for mask-wearing on public transit, and stressing that while the hospitalization and death numbers are trending in the right direction, the virus is far from gone and is still a threat to public health.

It’s not likely that there will be consensus any time soon on when the pandemic shifts from even Fauci’s so-called “controlled” phase into becoming endemic. Some experts in health advise people not to wait for broad statements on the end of the pandemic to decide if they are safe or not. If they have underlying chronic conditions that can put them at higher risk of severe COVID-19, such as diabetes or asthma, for example, or if they have compromised immune systems, it makes sense for them to continue wearing masks even on planes and trains where they aren’t required. Or if people live in households with elderly people or with children under six years old who aren’t eligible to get vaccinated yet, then continuing to wear masks in certain indoor settings and avoiding crowded situations might be wise.

Government and global health organization statements about the pandemic are critical for helping nations to navigate responses and allocate resources for addressing public health, but once those tools are in place, it’s up to us as individuals to use them in the combination and frequency that provides us with the most protection in our specific circumstances. SARS-CoV-2 may become a pandemic, but it’s still a risk for certain populations, much like flu. It is important that these people continue to practice all of the protection measures they can take to prevent infection. It might be more beneficial to reduce some protection measures for people who are less likely. The mandates provided guidance for how best to combat the pandemic. However, as we learn to live with COVID-19 in all its forms, individuals will no longer be able to depend on them.

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