COVID at 2 Years: Preparing for a Different 'Normal'

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Two years into the COVID-19 pandemic, the United States is still breaking records for hospital overcrowding and new cases.

The US is logging nearly 800,000 cases a day, hospitals are starting to fray, and deaths in the US have topped 850,000. Schools oscillate from remote to in-person learning, polarizing communities.

A Medscape Special Report: COVID at 2

The vaccines are lifesaving for many, yet frustration mounts as the number of unvaccinated people in this country stays relatively stagnant (63% in the US are fully vaccinated) and other parts of the world have seen hardly a single dose. Africa has the slowest vaccination rate among continents, with only 14% of the population receiving one shot, according to The New York Times tracker.

Yet there is good reason for optimism among leading US experts because of how far science and medicine have come since the World Health Organization first acknowledged person-to-person transmission of the virus in January 2020.

Effective vaccines and treatments that can keep people out of the hospital were developed at an astounding pace, and advances in tracking and testing — in both access and effectiveness — are starting to pay off.

Some experts see the possibility that the raging Omicron surge will slow, possibly by late spring, providing some relief and possibly shifting the pandemic to a slower-burning endemic.

But other experts caution to keep our guard up, saying it's time to settle into a "new normal" and upend the strategy for fighting COVID-19.

Time to Change COVID Thinking

Three former members of the Biden-Harris Transition COVID-19 Advisory Board wrote recently in the Journal of the American Medical Association that COVID-19 has now become one of the many viral respiratory diseases providers and patients will manage each year.

The group of experts from the University of Pennsylvania, University of Minnesota, and New York University write that "many of the measures to reduce transmission of SARS-CoV-2 (eg, ventilation) will also reduce transmission of other respiratory viruses. Thus, policy makers should retire previous public health categorizations, including deaths from pneumonia and influenza or pneumonia, influenza, and COVID-19, and focus on a new category: the aggregate risk of all respiratory virus infections."

Dr Amesh Adalja

Other experts, including Amesh Adalja, MD, senior scholar at the Johns Hopkins Center for Health Security in Baltimore, Maryland, have said that it's been clear since the early days of SARS-CoV-2 that we must learn to live with the virus because it "will be ever present for the remaining history of our species."

But that doesn't mean the virus will always have the upper hand. Although the US has been reaching record numbers of hospitalizations in January, these hospitalizations differ from those of last year — marked by fewer extreme life-saving measures, fewer deaths, and shorter hospital stays — due in part to medical and therapeutic advances and in part to the nature of the Omicron variant itself.

One sign of progress, Adalja said, will be the widespread decoupling of cases from hospitalizations, something that has already happened in countries such as the United Kingdom.

"That's a reflection of how well they have vaccinated their high-risk population and how poorly we have vaccinated our high-risk population," he said.

Omicron Will Bump Up Natural Immunity

Adalja said though the numbers of unvaccinated in the US appear stuck, Omicron's sweep will make the difference, leaving behind more natural immunity in the population.

Currently, hospitals are struggling with staffing concerns as a "direct result" of too many unvaccinated people, he said.

Dr Andrew Badley

Andrew Badley, MD, an infectious diseases specialist at Mayo Clinic in Rochester, Minnesota, and director of the clinic's COVID-19 Task Force, said the good news with Omicron is that nearly all people it infects will recover. Over time when the body sees foreign antigens repeatedly, the quantity and quality of the antibodies the immune system produces increase and the body becomes more efficient at fighting disease.

Therefore, "a large amount of the population will have recovered and have a degree of immunity," Badley said.

His optimism is tempered by his belief that "it's going to get worse before it gets better."

But Badley still predicts a turnaround. "We'll see a downturn in COVID in late spring or early summer where well into the second quarter of 2022 "we'll see a reemergence of control."

Right now, with Omicron, one infected person is infecting three to five others, he said. The hope is that it will eventually reach one to one endemic levels.

As for the threat of new variants, Badley said, "It's not predictable whether they will be stronger or weaker."

Masks May Be Around for Years

Many experts predict that masks will continue to be part of the national wardrobe for the foreseeable future.

"We will continue to see new cases for years and years to come. Some will respond to that with masks in public places for a very long time. I personally will do so."

Two Mindsets: Inside/Outside the Hospital

Emily Landon, MD, an infectious disease physician and the executive medical director of Infection Prevention and Control at University of Chicago Medicine, told Medscape Medical News she views the pandemic from two different vantage points.

As a healthcare provider, she sees her hospital, like others worldwide, overwhelmed. Supplies of a major weapon to help prevent hospitalization, the monoclonal antibody sotrovimab, are running out. Landon said she has been calling other hospitals to see if they have supplies and, if so, whether Omicron patients can transfer there.

Bottom line: the things they relied on a month ago to keep people out of the hospital are no longer there, she said.

Meanwhile, "We have more COVID patients than we have ever had," Landon said.

Last year, UChicago hit a high of 170 people hospitalized with COVID. This year, so far, the peak was 270.

People are exhausted from having to do a risk-benefit analysis for every single activity they, their friends, their kids want to participate in. Dr Emily Landon, University of Chicago Medicine

Dr Emily Landon

Landon said she is frustrated when she leaves that overburdened world inside the hospital for the outside world with people wearing no masks or ineffective face coverings and gathering unsafely. Although some of that behavior reflects an intention to flout the advice of medical experts, some is due in part, she said, to the lack of a clear national health strategy and garbled communication from those in charge of public safety.

Americans are deciding for themselves on an a la carte basis whether to wear a mask or get tested or travel, and school districts decide individually when it's time to go virtual.

"People are exhausted from having to do a risk–benefit analysis for every single activity they, their friends, their kids want to participate in," she said.

US Behind in Several Areas

Despite our self-image as the global leader in science and medicine, the United States stumbled badly in its response to the pandemic, with grave consequences both at home and abroad, experts say.

In a recent commentary in JAMA, Lawrence Gostin, JD, from Georgetown University in Washington, DC, and Jennifer Nuzzo, DrPH, at Johns Hopkins Bloomberg School of Public Health, point to several critical shortfalls in the nation's efforts to control the disease.

One such shortfall is public trust.

WebMD reported last summer that a poll of its readers found that 44% said their trust in the Centers for Disease Control and Prevention (CDC) had waned during the pandemic, and 33% said their trust in the Food and Drug Administration (FDA) had eroded as well.

It's one of the greatest moral failures of my lifetime. Lawrence Gostin, O'Neill Institute for National and Global Health Law, Georgetown University

Healthcare providers who responded to the WebMD poll lost trust as well. About half of the doctors and nurses who responded said they disagreed with the FDA's decision-making during the pandemic. Nearly 60% of doctors and 65% of nurses said they disagreed with the CDC's overall pandemic guidance.

Lack of trust contributes to aversion to vaccines and mitigation efforts, the authors write.

Lawrence Gostin

"This will become really relevant when we have ample supply of Pfizer's antiviral medication," Gostin, who directs the O'Neill Institute for National and Global Health Law at Georgetown, told Medscape Medical News. "The next phase of the pandemic is not to link testing to contact tracing, because we're way past that, but to link testing to treatment."

Lack of regional manufacturing of products is also thwarting global progress.

"It is extraordinarily important that our pharmaceutical industry transfer technology in a pandemic," Gostin said. "The most glaring failure to do that is the mRNA vaccines. We've got this enormously effective vaccine and the two manufacturers — Pfizer and Moderna — are refusing to share the technology with producers in other countries. That keeps coming back to haunt us."

Another problem: When the vaccines are shared with other countries they are being delivered close to their expiry date or arriving at a shipyards without warning so even some of the doses that get delivered are going to waste, Gostin said.

"It's one of the greatest moral failures of my lifetime," he said.

Also a failure is the "jaw-dropping" state of testing 2 years into the pandemic, he said, as people continue to pay high prices for tests or endure long lines.

The US government last week updated its calculations and ordered 1 billion tests for the general public. The website to order the free tests is now live.

It's a step in the right direction. Gostin and Nuzzo write that there is every reason to expect future epidemics that are as serious or more serious than COVID.

"Failure to address clearly observed weaknesses in the COVID-19 response will have preventable adverse health, social, and economic consequences when the next novel outbreak occurs," they write.

Adalja, Badley, Landon, and Gostin have disclosed no relevant financial relationships.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick

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