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What It Means for a Pandemic Like Covid to Become 'Endemic' – The New York Times

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Eleanor Lutz and April 7, 2022
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For months, some American and European leaders have foretold that the coronavirus pandemic would soon become endemic. Covid-19 would resolve into a disease that we learn to live with. According to several governors, it nearly has.
But we are still in the acute phase of the pandemic, and what endemic Covid might look like remains a mystery. Endemic diseases can take many forms, and we do not know yet where this two-year-old disease will fall among them.
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At its most basic, an endemic disease is one with a constant, predictable or expected presence. It’s a disease that persists. Beyond that, there is no fixed definition.
Endemic diseases infect millions of people around the world each year, and some endemic diseases kill hundreds of thousands. Some we can treat and vaccinate against. Yet they can also cause unexpected outbreaks and significant suffering.
Interviews with two dozen scientists, public health experts and medical historians suggest the rush to recast Covid as endemic may be missing the point.
“There’s been a political reframing of the idea of endemic as something that is harmless or normal,” said Lukas Engelmann, a historian of medicine and epidemiology at the University of Edinburgh. But epidemiologists use endemic to mean something we should watch carefully, he said, because an endemic disease can become epidemic again.
Endemic diseases can be mild or deadly
When people think of endemic disease, they often think of the common cold. Upper respiratory infections, including colds, are estimated to infect billions of people worldwide every year but kill several thousand. Other endemic diseases can be much more lethal. Malaria killed more than 600,000 people globally in 2019, and flu killed more than 200,000, though estimates suggest these tolls could be much higher.
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Many scientists predict that endemic Covid may have a similar burden to other respiratory viruses.
“It will be no more deadly than seasonal flu, or may be mild like one of the cold-causing coronaviruses,” said Lone Simonsen, the director of the PandemiX Center at Roskilde University in Denmark.
“The reason for this is that we have a lot of immunity and we keep getting boosted from the infections that we run into,” she said.
Some scientists warn that immune protection from vaccination and infection may wane over time, and future variants might sidestep those defenses. And mutations are random, so there is always a chance a variant that causes more severe disease could arise in the future.
Endemic diseases can have epidemic periods
The common cold and the flu are widespread endemic diseases that persist year round, but their levels are not constant. Instead they cause seasonal epidemics, where infections rise beyond baseline endemic levels, often in the winter when people gather indoors.
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These patterns are predictable, but people can change them: The control measures used to blunt the Covid pandemic dampened flu and cold waves in recent years, too.
Scientists say that endemic Covid could be seasonal, but it could also have irregular and significant epidemic waves.
“Covid is much, much more transmissible than the flu,” said Jeffrey Shaman, an infectious-disease modeler at Columbia University. “Only a small portion of the population needs to be susceptible for an outbreak to foment, and that can happen at any time of year.”
The burden of endemic disease is unequal
One community’s experience with endemic disease can be vastly different from another’s, often depending on who is getting sick and whether they have access to tests, treatments and health care.
H.I.V., which has persisted across the globe for more than 40 years, is one example, though scientists and public health workers use both “epidemic” and “endemic” to describe the virus.
“One definition of endemic is defined by geographic location,” said Dr. Diane Havlir, an infectious disease specialist and professor of medicine at the University of California, San Francisco. “Through that lens, H.I.V. is endemic in the United States, where approximately 1.2 million persons are living with H.I.V.”
“But H.I.V. is epidemic in subpopulations in the U.S.,” she added.
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Infectious diseases often remain in communities where poverty or discriminatory systems prevent access to health care, Dr. Havlir said.
“Disease disparities increase over time unless they are addressed at the outset,” she said. “And that raises the question: Are we addressing those disparities with Covid or are we on that same trajectory?”
With one-third of the global population unvaccinated against Covid and life-saving treatments not available to all, the virus’s burden will likely continue to be unequal, experts say, even as parts of the world decide their levels are endemic.
Endemic disease is all about control
Among the many forms endemic disease can take, one thing is clear: Endemic does not mean the end of the disease.
Instead, it means living with, and often managing, a disease that has not been, or cannot be, stamped out. Health experts say that countries must use control measures, like testing, treatments and vaccinations, to keep endemic diseases in check.
Countries with endemic malaria aspire to eradicate the mosquito-borne disease and rely on interventions like insecticides and preventative treatments to reduce its incidence. These control measures can drastically alter the course of endemic malaria, as they have in South Africa.
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In addition to environmental controls, vaccination programs can reduce cases and deaths. But when communities do not adhere to vaccination recommendations, outbreaks can happen.
Measles, for example, remained endemic in the United States for 40 years after the introduction of vaccines. During that period, unvaccinated people remained vulnerable, fueling occasional outbreaks. In 2019, two decades after the disease was declared eliminated in the United States, several outbreaks, many associated with unvaccinated travelers, infected more than a thousand people.
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Unlike malaria or measles, public health experts say that Covid cannot be eradicated, so control measures will help determine the size and course of future waves. (We have eradicated just one human disease: smallpox, which behaved quite differently from Covid.)
Keeping up with Covid means staying focused on vaccinating, treating and updating vaccines, said Dr. Monica Gandhi, an infectious disease specialist and professor of medicine at the University of California, San Francisco. “It’s going to take constant vigilance to keep it — not to eradicate it, which would be what humans want — but to keep it under control.”
When will we know what Covid’s endemic phase looks like?
Probably not for a while. Scientists usually determine a disease’s endemic pattern after observing it for many years.
Pandemics can take years to settle, and the consequences of widespread illness can last long after new infections fade.
Much of what we know about the transition out of pandemics comes from flu — humans have witnessed four influenza pandemics in the last 100 years. The 1918-19 pandemic, which killed more than 50 million people globally, dwarfs them all.
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It took the 1918 flu pandemic three years to settle into a more regular pattern, and the United States had a significant 1920 wave that killed more people in some cities than previous waves had. In the years that followed, some seasonal outbreaks were larger than others.
The assumption about Covid’s endemic period is that it will look meaningfully different from the pandemic of the last two years. But endemic Covid, in the worst-case scenario, could look something like where we’ve been.
“You can imagine a situation where Omicron-like events happen every year,” said Trevor Bedford, a virologist at the Fred Hutchinson Cancer Research Center in Seattle.
“That can be the endemic state,” Dr. Bedford said. “And it doesn’t mean that it’s mild, and it doesn’t mean that it’s easy to deal with.”
Sources for top graphic: U.S. National Notifiable Diseases Surveillance System via Project Tycho (measles); Centers for Disease Control and Prevention (influenza); South Africa National Department of Health, Barnes et al (malaria); New York Times database of reports from state and local health agencies (Covid-19)
Marco Hernandez contributed reporting.
New Research
A large new study from Israel found that a second booster shot of the Pfizer-BioNTech Covid vaccine provided additional, though only short-term, protection against Omicron infections.
Scientists are exploring an intriguing theory that may explain why the flu and Covid-19 never gripped the United States simultaneously.
In the United States
The highly transmissible BA.2 subvariant of Omicron has become the dominant form of Covid in the United States. Here are four possible reasons cases haven’t begun to rise.
In New York City, cases have been ticking up steadily in some areas, threatening the city with a fifth wave just weeks after many mask and vaccine requirements were lifted.
Around the World
Saudi Arabia will allow one million foreign and domestic Muslims to travel to the holy city of Mecca this year for the annual hajj pilgrimage in July, the country’s Ministry of Hajj and Umrah announced.
German lawmakers rejected a Covid vaccine mandate for those 60 and older, the first defeat for Chancellor Olaf Scholz’s three-party coalition.
Health Guidance
If You Get Sick: Like previous coronavirus variants, BA.2 can be wildly unpredictable in its timeline and range of symptoms. Here’s what you need to know at every stage of an infection.
Home Tests: A negative test is not a guarantee you don’t have Covid. If you have symptoms, make sure to take precautions and test again.
Heart Health: Covid survivors have substantially higher chances of developing cardiovascular disease. But there are ways to minimize the risk.
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