Transitioning to a post-pandemic mindset

On Monday, the US recorded over a million new covid-19 cases, a new record, largely driven by the Omicron variant, and we may have not yet reached the peak, which is expected to be reached around mid-January. That statistic is a bit misleading since it includes corrections for delays in reporting over the holidays. In general, I do not pay attention to the daily numbers but instead focus on the averages taken over seven days. But that too has reached a record level of around 575,000, easily surpassing the previous high of around 250,000 set back on January 11, 2021.

Given this grim news, it may be hard to find a silver lining but there is one in that the death and hospitalization rates have not kept pace with the rise in case rates, even allowing for the usual two-week lag. The seven-day average of the death rate is currently around 1,200, compared to its previous peak of 3,400 a year ago. That may be an indication that Omicron is the first phase of the virus transitioning to an endemic, flu-like virus of the kind that we are accustomed to. Some indications of this are that the earlier symptoms of Covid-19, such as loss of a sense of smell and taste and low blood oxygen levels, are no longer as common with the new variant. It also appears that Omicron affects the upper respiratory tract more and is less like to affect the lungs.

Pandemics do end, not with a bang but a whimper. There will not come a day when we can declare that we are virus free but there will come a time when the danger posed by the virus takes its place alongside other everyday risks that we have learned to live with. The Spanish flu that caused a pandemic a century ago made such a transition and is now part of the flu strains that we deal with. Thus we should start thinking about how to recognize when we are shifting to a new state and one way would be to shift the focus on the data. We may need to start thinking about what statistic is the best measure to describe the situation.

Pandemics do eventually end, even if omicron is complicating the question of when this one will. But it won’t be like flipping a light switch: The world will have to learn to coexist with a virus that’s not going away.

“Certainly COVID will be with us forever,” Ko added. “We’re never going to be able to eradicate or eliminate COVID, so we have to identify our goals.”

At some point, the World Health Organization will determine when enough countries have tamped down their COVID-19 cases sufficiently – or at least, hospitalizations and deaths – to declare the pandemic officially over. Exactly what that threshold will be isn’t clear.

Even when that happens, some parts of the world still will struggle – especially low-income countries that lack enough vaccines or treatments – while others more easily transition to what scientists call an “endemic” state.

They’re fuzzy distinctions, said infectious disease expert Stephen Kissler of the Harvard T.H. Chan School of Public Health. He defines the endemic period as reaching “some sort of acceptable steady state” to deal with COVID-19.

The omicron crisis shows we’re not there yet but “I do think we will reach a point where SARS-CoV-2 is endemic much like flu is endemic,” he said.

For comparison, COVID-19 has killed more than 800,000 Americans in two years while flu typically kills between 12,000 and 52,000 a year.

Exactly how much continuing COVID-19 illness and death the world will put up with is largely a social question, not a scientific one.

“We’re not going to get to a point where it’s 2019 again,” said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. “We’ve got to get people to think about risk tolerance.”

With the flu, although the CDC collects data on the number of cases, hospitalizations, and deaths, the figure that the media and public pays attention to is the annual number of deaths, which in the last decade ranged in the 12,000-52,000 range. The number of hospitalizations was between 140,000-710,000 while the number of symptomatic cases ranged from 9 million to 40 million. Since seasonal flu is not a reportable disease and not everyone who gets sick goes to a doctor, the number of hospitalizations and symptomatic cases are estimates based on models. It would be good to keep these numbers as benchmarks.

Health experts are already suggesting that we begin to focus on the death and hospitalization rates instead of infection rates.

Some US infectious disease experts and public health officials are questioning whether to continue using the number of coronavirus cases as a metric for determining which mitigation efforts are appropriate, as data suggests Omicron is less severe but much more contagious than previous variants.

Those experts argue that the US has reached a stage in the pandemic where reports of dramatic surges in case counts prompt unnecessary worries and that government officials and the public should instead review death and hospitalization data when considering precautions.

Case counts “are causing a lot of panic and fear, but they don’t reflect what they used to, which was that hospitalizations would track with cases”, said Dr Monica Gandhi, an infectious disease specialist and professor of medicine at University of California, San Francisco.

Anthony Fauci seems to be supportive of such a shift.

On ABC’s This Week, Fauci, director of the National Institute of Allergy and Infectious Diseases, was asked if it was time to focus less on just the case count, which has soared close to 500,000 reported new daily infections.

A number of experts have questioned if such reports cause unnecessary worry, and suggest deaths and hospitalisation data should better inform mitigation efforts.

“The answer is, overall, yes,” Fauci said. “This is particularly relevant if you’re having an infection that is much, much more asymptomatic and minimally symptomatic, particularly in people who are vaccinated and boosted.

This is not to say that covid-19 has become like the flu. Far from it. It is still much more lethal. And we should not forget that flu can be lethal too but the point is that that level of risk is something we are comfortable taking. By focusing on the death and hospitalization rates, we may be in a better position to gauge when we have transitioned from a pandemic state to an endemic state.

It will not be easy to get the public and the media to shift its focus from infectious case counts to death and hospitalization counts. Once an indicator becomes fixed in the public mind as an important marker, it is not easy to change the perception. Take the case of the stock market. News reports tend to lead with the Dow Jones Index even though most market watchers think that it is not a good indicator since the number of stocks involved is so small and prefer more broad-based indicators like the S&P. So the transition to a new benchmark for the pandemic will be slow.


  1. sonofrojblake says

    Once an indicator becomes fixed in the public mind as an important marker, it is not easy to change the perception

    Why bother?

    Your stock market example suggests you needn’t. Let the public focus on the number they’re used to hearing (infection rates, the Dow Jones). As long as the experts know what they should be looking at (hospitalisations and deaths/S&P), who gives a fuck what the ignorant public are doing?

    And yes, at some point a responsible government (not like the UK’s, for example) will make a decision based on the relevant number, and some shockjock will kick up a fuss about why they’re “ignoring the science”, and some well-meaning expert and come on and patronise them by pointing out that they’re not qualified to hold, much less express an opinion on a deeply technical subject, and why they’re right and the public are wrong, and so on.

    The only danger is that if you have a government of venal crooks led by a clown (e.g. the UK) then the likelihood is policy decisions will be based not on the science but more on how it’s going to look on the front page of the Daily Mail.

  2. says

    Is there some theoretical optimum deadliness and infectiousness for a virus? Ebola tends to burn out because it’s too lethal. I wonder if there’s a sweet spot that is typically occupied by flu.

  3. says

    Months ago, Ron Desantis mocked Nikki Fried (a democrat opposing him for goveror in the next election) for telling the media that a million COVID-19 test kits were going to expire. He told her “stay in your lane”.

    On Thursday, Desantis has had to explain to the media and public why the million test kits expired and were now useless, while tens of thousands of Floridians were unable to get the tests they wanted.

    I swear, the republiclowns actually want mass deaths on their hands, just to prove they never flinched in their ideology. As if that would make them more electable.

  4. invivoMark says

    @Marcus Ranum #2,

    The answer is, of course, it depends.

    It depends on the virus’s method of transmission. It depends on what tissues the virus can infect. It depends how quickly the virus can proliferate in a host. It depends how long the virus needs to replicate in a host before being passed along. Etc., etc.

    The common rhetoric that’s been circulating that “emerging viruses tend to evolve toward a less lethal phenotype” is mostly nonsense. If a mutation allows a virus to destroy 200% more lung tissue, and as a result it’s twice as lethal, but spreads to four times as many people, the mutant virus will become dominant.

    There are many known examples of viruses evolving to become either more or less virulent. The most famous example is when myxoma virus was intentionally released as population control of European rabbits in Australia. The initial virus was extremely deadly to rabbits, with nearly 100% lethality. A few years later, virus variants emerged that were much less lethal, and those variants became dominant. But over the following few decades, the dominant viruses were those with an intermediate lethality.

    There’s a great paper that reviews what we know about virus virulence evolution here: (paper is free) -- I like Table 1, which is a list of specific mutations that have been observed that were advantageous to the virus, and which affected virulence in one direction or another.

    I would like to note that Omicron is not the result of SARS-CoV-2 “fine-tuning” virulence to a more ideal point or “sweet spot.” Omicron is unrelated to Delta, and all the other defined variants that have evolved. That means that while Omicron is able to spread very quickly, the virus it evolved from was not. It evolved from a virus that was so much less contagious than Delta that it was effectively invisible to our surveillance. The evolutionary breakthrough that has caused Omicron to become the dominant variant is its ability to spread rapidly. Any changes to its lethality (and we still don’t have enough data to determine it) are almost certainly incidental, and not major evolutionary drivers.

  5. Deepak Shetty says

    Im already hearing rumblings that this change in messaging is being done to protect Biden/Democrats.

  6. Dauphni says

    People seem to have confused milder with mild when it comes to the omikron variant. In this case milder means you’re less likely to actually die from it compared to other variants, but you’re still getting a very high chance of long covid and other complications. And given just how much more transmissible it is, that also means that there are going to be that many more people who are directly affected.

  7. says

    @InvivoMark -- thanks that confirms and redirects what I was thinking.

    Its hard to avoid teleological thinking when evolution sometimes appears purposeful -- it is, except it’s all “well that worked”. I’ve always had a problem with virus’ apparently suicidal strategy that has worked so well for so long and is arguably the most successful strategy ever.

  8. KG says

    I don’t think we yet know how likely Omicron is to lead to long Covid -- it hasn’t been around long enough! For that matter, long Covid is far from understood, and may not be a single entity. But certainly any talk of “Transitioning to a post-pandemic mindset” is premature, both for these reasons, and because more new variants may arise -- and could be able to infect people who have already had Omicron, and be more virulent than Omicron.

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