How will the COVID-19 pandemic end?
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The WHO reported the largest single-day increase in cases of COVID-19 this week, with WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, emphasizing that countries have “a long way to go in this pandemic” at a press briefing. As states throughout the country and cities around the world begin to reopen, in spite of the ongoing increases in COVID-19 cases and deaths, many have begun wondering what the end of the pandemic could potentially look like.
Infectious Disease News asked infectious diseases experts for their opinions on this question, including how far away the “end” may be, what trends people can expect to indicate the end and what, if any, guidelines are in place to indicate when it is appropriate to end infection control methods. – by Eamon Dreisbach, Julia Ernst, MS, and Caitlyn Stulpin
Cornelius (Neil) J. Clancy, MD:
I anticipate the pandemic lasting another 2 years or until such a time that herd immunity is attained by natural infection or mass vaccination. That timeline is contingent upon exposure conferring protective immunity, which, based on limited data to this point, seems plausible. The end of the pandemic in the United States will be late among nations of comparable economic standing, unless we develop and mass produce a protective vaccine first and do not share it broadly with the rest of the world. It is possible the timeline could change if the 2020 election shakes up the political status quo, but that will not impact disease trajectory for the next year.
At present, our de facto national policy is to accept a threshold level of newly diagnosed cases and COVID-19-related deaths daily. Events of the past few weeks lead me to believe that 1,000 to 2,000 deaths a day might be politically acceptable. Distributed over the country and concentrated in the economically or socially marginalized, this level is probably such that most people would not feel distressed enough for outrage. As a result, we will probably see something of a plateau nationally for the next few months, with periodic booms due to localized outbreaks or clusters. Restrictions on activity will loosen, but physical distancing will still be in place, which some people will adhere to more than others. Measures will need to be intensified in response to local increases. Large gatherings will not take place. Spectator sports, at least those within stadiums or other close confines, will not resume. Travel will remain curtailed. Then, in late fall-winter, we’ll see an increase in COVID-19 cases, at which point a key question becomes: How bad will the 2020-2021 influenza season be?
Trends to follow will be temporal-spatial serologic data to get a sense of nationwide exposure, and — assuming we ever get to the scale of diagnostic testing we really need — new infection rates among symptomatic and asymptomatic, nonimmune hosts. I would be looking to see 60% or more of the population exposed and sustained reductions in new diagnoses with widespread testing as signals we may be approaching an end.
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Clancy is associate professor of medicine and director of the extensively drug-resistant pathogen lab and mycology program at the University of Pittsburgh and chief of the infectious diseases section in the VA Pittsburgh Healthcare System.
Disclosures: Clancy reports receiving investigator-initiated research grants from Astellas, Cidara, Melinta and Merck for studies unrelated to this project, serving on advisory boards or consulting for Astellas, Cidara, Merck, Needham & Company, Qpex, Scynexis, Shionogi and The Medicines Company and speaking at symposia sponsored by Merck and T2Biosystems.
Aaron Glatt, MD, FACP, FIDSA, FSHEA:
Unfortunately, it is impossible to predict with any accuracy when we will see the end of the horrific COVID-19 pandemic. I will go out on a limb and provide predictions for the U.S. and even globally. We currently are fighting a lethal enemy with our hands tied behind our backs, without a vaccine or a safe, effective and definitive treatment. With insufficient, noninvasive rapid testing still unavailable, the only tool we have to control COVID-19 is social distancing.
Although social distancing is an effective tool, it comes with a very high price tag — essentially uprooting society as we knew it. Social distancing is causing spiritual and economic upheaval (that has not peaked yet), massive unemployment and delayed nonemergency medical care and disease screening, and is disrupting our educational system. In short, it has very negatively impacted people’s lives.
At this point in time, we are struggling to even control spread of disease with these draconian distancing measures. I do not think society as we know it can continue in this fashion for a long period of time. Ultimately, I believe technology will be the only solution besides prayer. My best guess is that a vaccine that is efficacious and safe will be developed for use in early 2021, which will be our best chance for bringing COVID-19 to its knees. Short of that, we will be constantly counterpunching with only moderate success.
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Glatt is chairman of medicine, chief of infectious diseases and hospital epidemiologist at Mount Sinai South Nassau and professor of medicine at the Icahn School of Medicine at Mount Sinai.
Disclosure: Glatt reports no relevant financial disclosures.
Jeanne Marrazzo, MD, MPH, FACP, FIDSA:
I wish I had a crystal ball to predict an answer to how this pandemic will end. My instinct is that it is going to be like a self-filling pot of water left on the stove. The burner is totally regulated by how much opportunity for transmission the community provides — which, in turn, depends on the community’s “infectious prevalence” and density of gatherings relative to spatial dynamics (buildings vs. outdoors, for example). With a lot of infected people in densely populated settings with high potential for significant transmissions, you’ll boil and outbreaks of varying sizes will occur. Otherwise, we are facing a long-term simmer before the burner eventually is extinguished, either by a vaccine, exhaustion of exposure of susceptibles to infections (that is, severe physical distancing — which is not sustainable) or herd immunity (which is not looking good).
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Marrazzo is an Infectious Disease News Editorial Board Member, director of the division of infectious diseases and C. Glenn Cobbs, MD, Endowed Professor in Infectious Diseases at the University of Alabama at Birmingham School of Medicine.
Disclosure: Marrazzo reports no relevant financial disclosures.
Gitanjali Pai, MD, AAHIVS:
With the COVID-19 pandemic, we are paying the price for our lack of interest in public health and underinvestment in health care infrastructure globally. As of today, we don’t know whether we are at the end of the beginning of this pandemic or the beginning of the end. In any case, as this pandemic reaches 4 months in the U.S. since our first case, there has been a discernible shift toward social distancing in all walks of life. Telehealth services have expanded with a broader range of communication tools. The sweep of the disease across continents has provided, and will continue to provide, material for data analysts, which will help us gain a better understanding of COVID-19. It has spurred research in viral pathogenesis and vaccine development. ID specialists have their hands full with the ongoing challenges of COVID-19.
Regarding how the whole situation will pan out, it is hazardous to prognosticate for two reasons. There are many differences between this COVID-19 pandemic and previous coronavirus outbreaks. In particular, asymptomatic and presymptomatic transmission is making any prediction difficult. Secondly, the effects that the lack of universally available diagnostic tests and effective medications, as well as the socioeconomic conditions, are having on the transmission, treatment and prevention of the disease are far greater than in earlier epidemics. Social distancing measures to “flatten the curve” have led to more mental health problems affecting all age groups.
The after-effects of this pandemic will linger for a long time. What started as a health care challenge is now evolving into a socioeconomic problem over and above the health care repercussions. Historically, nearly every disease has continued to recur until an effective vaccine has been developed or the virus has mutated enough to lose its virulence. Even though we are better armed today, development of an effective vaccine in a timely manner is a monumental challenge. Scientists across nations are racing against time to have the vaccine ready.
The course of the pandemic will vary widely across different geographic areas and economic strata. In this age of globalization, an infection anywhere is an infection everywhere. Hence, we need global coordination to control this virus. Lastly, this pandemic has underscored the importance of a robust health care system and public health. We will have to guard against complacency, lest the control slips from our hands.
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Pai is an Infectious Disease News Editorial Board Member and an infectious disease physician at Memorial Hospital and Physicians’ Clinic in Stilwell, Oklahoma.
Disclosure: Pai reports no relevant financial disclosures.
Raghavendra Tirupathi, MD:
It is difficult to predict how far we are from the end of the pandemic, but I think we are still in the early stages. The current stay-at-home and social distancing measures have bought us time without drastically overwhelming health care capacity except in some regions. The mitigation of the curve will truly happen only when we have widespread availability of accurate diagnostic testing, robust public health infrastructure for contact tracing and isolation of every positive case, better therapeutics, increased ICU and hospital capacity and — it is hoped — efficient, effective vaccines that can result in durable immunity. Social distancing is the only effective nonpharmaceutical intervention we currently have. We need to learn from history that, when social distancing measures were relaxed during the 1918 pandemic after the first wave, the Spanish flu came back with a vengeance.
Durable herd immunity, where two-thirds of the population is immune because of infection or immunization, may be an indicator. One way to achieve herd immunity is to allow the pandemic to run its course without any interventions, but this approach will come at an enormous cost of human lives. The other way would be to have staggered social distancing in several areas of the country to allow cases to occur by letting go of restrictions intermittently and hence allowing herd immunity to evolve over a few months. This will also come at the risk of overwhelming the ICUs if not done meticulously. The third option is intense social distancing until an effective vaccine is discovered, which is already getting a lot of opposition. This proposition is an uncertain one, given we don't know if and when we will have an effective vaccine.
I think that there has to be a persistent downward trend of cases over several days to weeks, as well as a transitionary period with no new cases in a given country and all over the world, before we can say we are even near the end of the pandemic.
I don't think we have, at this time, a definite point for when we can end the infection prevention guidelines in health care settings or an understanding of how to go about it. It all depends on how the pandemic evolves over the coming months. I am concerned that we will be in a worse situation in the fall of 2020, given relaxing of social distancing measures across the country and the world.
For more information:
Tirupathi is an Infectious Disease News Editorial Board Member, medical director at Keystone Infectious Diseases/HIV, chair of infection prevention at Summit Health and clinical assistant professor of medicine at Penn State University School of Medicine.
Disclosure: Tirupathi reports no relevant financial disclosures.
Paul Volberding, MD:
Although I sincerely hope we will soon see this pandemic end, I fear it will take many months to several years. I expect we will see improvements in care — better ways of treating the extremely ill in the ICU to improve survival and at least modestly effective antivirals to reduce the inpatient burden of COVID-19. However, because the virus is so clearly here and widely distributed, only a very effective vaccine can really change the pandemic trajectory toward full control. Even with a vaccine, challenges will persist. We will need massive scale production and global distribution and administration. We will continue to be hampered by anti-vaccine activists and those whose fear stems from cultural or religious beliefs. We will know that our efforts to end the pandemic are succeeding when our testing and contact tracing programs can show a sustained and substantial reduction in incidence and our death rates approach historic control levels. I fear, though, that these positive trends will be maldistributed. Disparities in the U.S. will be magnified in lower income countries struggling with other disasters like war, poverty and limited science literacy. But it is hoped that infection control measures will have shown their power and convince our leaders that, for this and the next pandemic, they must be funded permanently and not torn down as soon as COVID-19 becomes history and not a present reality.
For more information:
Volberding is Chief Medical Editor of Infectious Disease News, professor of medicine and director of the AIDS Research Institute at the University of California, San Francisco.
Disclosure: Volberding reports no relevant financial disclosures.
Perspective
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Miguel Regueiro, MD
This article is very interesting. Everyone is looking for a crystal ball to predict the future. COVID-19 is a moving target. I like some of the high-level concepts discussed such as looking at herd immunity, what a second surge of the virus look like, social distancing and mask wearing. And hopefully, a vaccine later this year.
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