The Perfect Enemy | COVID is endemic. Here’s how we keep it that way - San Francisco Chronicle
February 17, 2024

COVID is endemic. Here’s how we keep it that way – San Francisco Chronicle

COVID is endemic. Here’s how we keep it that way  San Francisco Chronicle

On Sept. 18, President Biden famously said “the pandemic is over.” He very quickly followed that up by saying: “We are doing a lot of work on it.”

These notions may sound contradictory, but they are indeed the way to approach the concept of endemicity; combating COVID-19 will take ongoing and hard work.

Saying we are exiting the emergency phase, which the World Health Organization also signaled in September, does not mean COVID is over. Unfortunately, COVID will never be over. This virus is not eradicable.

Smallpox was successfully eradicated worldwide in 1979, not only because of the vaccine but because of some unique characteristics of the virus, including its lack of an animal reservoir, pathogenic features that made it easy to quickly recognize in those who have the disease and a short period of infectiousness. Smallpox infection also conferred natural immunity for life.

SARS-CoV-2, which causes COVID-19, has none of these features. It is found in 29 species of animals, at least, which means we will always be dealing with COVID in the medical system. 

In August, the Centers for Disease Control and Prevention released its latest guidelines for COVID-19, which dramatically streamlined the approach to protecting oneself and to understanding personal risk. These guidelines acknowledged the prevalence of natural immunity and no longer distinguished between vaccinated and unvaccinated in isolation and quarantine recommendations. Asymptomatic testing was no longer recommended. Masking in health care settings was no longer recommended as of September if community transmission levels were low. 

As is always the case with new guidelines, the response from experts was mixed. Some agreed that it was time to learn to live with the virus with minimal disruptions to life while others pointed out that the daily death toll was still unacceptably high — and that public health involves sacrifices for the greater good.

It has since become clear, however, that many hospitalizations officially counted as caused by the coronavirus were actually of patients who happen to be infected but were admitted for other reasons. That almost certainly remains true with the host of highly transmissible new variants like XBB.1.5, the so-called “Kraken” variant.

Because everyone admitted to most hospitals is still routinely tested for the coronavirus (despite the main U.S. infection control organization recommending against this practice), many patients admitted for other ailments also test positive. This inflates the official number of COVID-19 hospitalizations. Miscategorized hospitalizations lead to miscategorized deaths.

An analysis of Los Angeles County + USC Medical Center data found that less than one-third of official hospitalizations attributed to COVID were meaningfully related to the coronavirus. In Massachusetts, over 70% of “COVID” hospitalizations are similarly “with” rather than “for” COVID-19. This of course is consistent with the fact that over 95% of Americans have been infected and/or vaccinated. The resulting strong population immunity coupled with the less-virulent nature of omicron strains is resulting in much less severe clinical outcomes.

Overcounting hospitalizations and deaths from COVID in the U.S. due to antiquated screening policies can sow discord and differing recommendations across the country in terms of boosters and masks. However, when public health rules differ from county to county and state to state — and more importantly when they don’t seem to make sense — trust in public health suffers.

In May 2021, only about half of Americans trusted the CDC, according to a Robert S. Woods Foundation/Harvard T.H. Chan School of Public Health poll. By January 2022, an NBC News poll found that only 44% of Americans trusted the health agency, and by March 2022, a Gallup poll put the level of trust at 32%.

We are now seeing the untoward effects of that mistrust; it is impacting the uptake of vaccines for COVID and, more recently, other vaccine-preventable diseases, including influenza, measles and polio. A lack of public trust in health experts has other costs, including avoidance of medical care, which may have a more dangerous impact on communities of color. Without a unified and trustworthy public health voice, divisiveness continues to characterize the discourse around COVID in our country at a time when we need to unite in our efforts to repair the educational, financial and health damages incurred during the pandemic.

Local, state and federal public health officials desperately need to find and speak with such a unified voice. Officials not only need to tell the public what it should do in order to prevent morbidity and mortality from COVID-19, but what it must stop doing in order to prevent the negative consequences of the very mitigation strategies that we employed in the early days of the pandemic.

Despite the recent scary headlines about XBB.1.5 and other new variants, there has long been, and remains, a profound decoupling of cases and deaths. The pandemic has taken a terrible toll, but the public health outlook is improving drastically, owing to our miraculous and life-saving vaccines, high rates of immunity and a plentiful supply of effective therapies (including Paxlovid).

Given that the pandemic has changed, scientific knowledge has changed and the level of risk has changed, policies must change as well. I propose five ways to keep us in the endemic phase, relatively consistent with CDC guidelines:

Retire quarantines

Prior post-exposure quarantine recommendations differentiated between those who were and those not up-to-date on vaccination. This is simply not scientifically accurate today, given the degree of natural immunity in the population.

Because the CDC stopped recommending universal contact tracing long ago, the brunt of post-exposure quarantine policies fell on settings like daycare centers, where careful case monitoring was occurring, resulting in disproportionate impacts on the socialization and education of children and the earnings of women, single parents and lower-income individuals. Mindful of these issues, in May, Massachusetts ended quarantines in daycares, schools and camps. Its guidance for the new school year was clear: “No asymptomatic person should be excluded from school as a result of exposure, regardless of vaccination status or exposure setting.” All locales should adopt this rational approach and retire quarantines.

Stop asymptomatic testing

Asymptomatic testing frustrates families when positive tests, sometimes representing remote infection or a false positive, lead to missed school and important events. A major erosion of public trust occurred during the winter omicron wave of 2022 when the general public struggled to access testing — which was and remains critical for high-risk individuals to qualify for life-saving treatments like Paxlovid — while colleges maintained multiple-time-per-week testing programs for low-risk students.

Thankfully, such testing is finally being phased out in most colleges. But it is not needed in schools or daycares, where the majority of persons are low risk. Vaccines are thankfully now available for children as young as 6 months, providing additional protection for the youngest Americans.

Asymptomatic testing in educational settings was a critical tool early in the pandemic to better understand transmission patterns and to provide reassurance to families and educators. But it is time to retire these programs. Although the CDC endorses this policy in general, the new school guidance asks for the resumption of asymptomatic testing when community levels are high, a practice that will continue to be disruptive.

End all mask mandates

Masks have been the most polarizing intervention of the pandemic.

CDC guidelines recommend universal masking during times of high community transmission. But the time has come to put mask mandates behind us. Paradoxically, masks work but mask mandates do not.

Masking was an important tool early in the pandemic when vaccines were not yet available and people were trying to emerge from their bubbles and rejoin society. However, more than two years later, we must admit that evidence is lacking that broad mask use (including in schools) has a significant impact on slowing coronavirus transmission or hospitalizationswhether due to inconsistent use or variability in mask quality or both. High-risk individuals can always choose to protect themselves with well-fitting high-quality masks and do not need to rely on others to protect them.

Shorter isolation periods

For those who become sick due to COVID, a five-day isolation period recommended by the CDC still seems prudent. But as population immunity continues to build, we should look to transition to a shorter time frame followed by masking and eventually a “stay home when sick” model. This recommendation needs to be accompanied by national paid sick leave policies.

Boosters for some, but not all

Public health officials need to tout the amazing success of vaccines at preventing severe disease while simultaneously acknowledging their shortcomings in preventing infection and transmission. They should also better publicly recognize the power of immunity from prior infection. That means discouraging booster mandates in places with low-risk populations like schools, colleges and universities.

Boosters should instead be strongly encouraged for older individuals. Vaccine mandates and passports made sense earlier in the pandemic when the vaccines were highly protective against asymptomatic and symptomatic infection. That has changed. We must be responsive and willing to change recommendations based on new knowledge.

There remains too much sickness and death from COVID even today. The terrible losses the virus has inflicted on the country should not be minimized. But there have also been immense harms from the mitigation strategies designed to slow the spread of COVID. It is past time to strike the right balance between the two. To do so, we need our nation’s health experts to get on the same page, return to a position of trusted authority and bring our nation together toward one collective goal: comprehensive health and well-being.

Monica Gandhi is an infectious diseases doctor and professor of medicine at UCSF, the director of the UCSF Center for AIDS Research and the medical director of the Ward 86 HIV Clinic. She is the author of an upcoming book “Endemic: A Post-Pandemic Playbook.”