Time to Prepare People to Accept COVID-19 Endemicity

SARS-CoV-2 has taken us on a rollercoaster, and not just on graphs of case counts. The natural tendency to project linearity to trends makes each hill and dip feel unnatural. The media exacerbates perceptual changes with its hyperfocal attention on each new development, even expected ones like breakthrough infections. People feel they are being jolted around.

The early efficacy results of the mRNA vaccines from Pfizer-BioNTech and Moderna were positively stunning. Demonstrating more than 90% vaccine effectiveness against symptomatic infection when the goal was a 50% reduction in severe disease caught people off guard. It was the first bit of good news in quite a while, coming at a time when school buildings were shut in much of the country and we adapted to e-school, working from home, and the awkwardness of Zoom happy hours. When vaccines started to be given in December 2020, people began to envision a world without COVID-19.

Things have not turned out that way. Despite commanding the greatest portion of vaccine supply and getting a head start, vaccinations in the US have fallen behind that of most high-income countries; at this writing, the US is at the bottom of the G7 and 60th in the world in percentage vaccinated. However, that is only part of the picture. The virus has not waited for us to vaccinate the world’s population- it keeps evolving towards more transmissible variants. In the Delta variant, SARS-CoV-2 has transformed into not just a highly transmissible variant, but one of the world’s most transmissible infectious diseases. We are fortunate that Delta came to the US after vaccines became widely available or we would be looking at a very different society right now.

The combination of Delta and vaccine hesitancy has cost many lives, but it also highlights the need to reset expectations on the COVID-19 endgame. Herd immunity may never have been a realistic goal, but it seems clear it is an impossibility. Over the next several years, everyone is likely to be infected with SARS-CoV-2. With the attenuation that vaccination provides, most vaccinated people will have asymptomatic, mild, or moderate infection. Unvaccinated people with previous COVID-19 will have less severe reinfection, and the ever-decreasing number of unvaccinated people without previous COVID-19 will be susceptible to severe disease.

The continued spread of immunity, whether acquired by vaccination or infection, will drive overall cases down. However, the incomplete nature of immunity and future mutations in SARS-CoV-2 will allow it to remain a circulating human pathogen like other endemic human coronaviruses.

One of the most apparent issues that the pandemic has revealed is ineffective communication. To increase vaccine uptake, ‘get vaccinated and you’re good’ became the narrative. People listened. When Delta became pervasive and changed things again, momentum towards a ‘post-pandemic’ dream was harder to change. Therefore, it is time to prepare people for a future with endemic COVID-19 now. We won’t be masked forever, but we aren’t wiping the virus off the earth either.