Three Years into the Pandemic, Six Questions about Our Future with COVID-19

When COVID-19 emerged in 2020, few of us thought we would be heading into a third winter season with the virus still impacting our daily lives. Whether we call it pandemic or endemic, COVID-19 persists, continuing to change and evolve.

Fortunately, we too have evolved in response to the virus, developing and adapting vaccines to protect against severe disease and death, and treatments to help us recover more quickly from COVID-19 infections.

To gain some perspective on the state of the pandemic today and what our future with COVID-19 may hold, we interviewed Todd B. Ellerin, MD, Director of Infectious Disease at South Shore Health.

Now in our third year of the pandemic, how are we doing dealing with COVID-19 and what do you think is the most important thing we’ve learned about the virus? 

We are doing much better from a severity perspective because we have a greater immune wall as communities. Through vaccination, boosting and infection, the overall severity of infection has decreased.

Still, a significant number of people are dying each day in the U.S. A good portion of those deaths are preventable with vaccination and boosting, especially with elderly and immunocompromised people.

One of the things we underestimated is the constant evolution of the virus, which keeps throwing new mutations at us. The shape-shifting power of the virus has made it so that herd immunity seems out of reach.

It’s a continuous cat and mouse game; we develop vaccines faster than ever through mRNA and other platforms, but then the virus changes again.   

We are lucky and need to really laud the scientific and clinical research and pharmaceutical communities for their ability to give us a vaccine that’s currently matched to the circulating strain – BA.5. That’s a medical miracle. Capitalize on this moment, rollup your sleeve and get the new vaccine.

The most important thing we learned about the pandemic is that we work better when we work together across the country and the globe, than when we work in silos or don’t’ communicate. We work better when we collaborate with each other, than we do when we create conflict through misinformation and disinformation.  

What we’ve learned about the virus and what we didn’t predict, was how destabilizing it could be on a global level and specifically, we underestimated its mutational power and power to evade natural and vaccine-induced immunity.  That power affords it the possibility of being here in 100 years – just like influenza.  In 2119, we may be marking the 100th anniversary of COVID-19.

Many health experts have said COVID-19 isn’t going away. Has the pandemic become an endemic?  And what does that really mean for us?

Pandemic, epidemic, endemic – you can have all three of those terms at once.  It does feel as though the pandemic has become endemic.  It’s able to survive in all seasons and tends to rise to greater peaks, or follow epidemic curves, during the colder months. 

The pandemic has changed and fortunately, overall has become less severe.  It’s still a significantly greater threat than influenza.  It is still today, one of top causes of mortality in the U.S.  

Influenza is a severe respiratory illness and can kill 20,000 to 40,000 people in an average year, but it is generally relegated to the winter months. COVID-19 is killing throughout the year.

Every fall and winter as we begin spending more time indoors, we have experienced a surge in COVID-19 case numbers -- often fueled by new variants. Do you expect the same thing over the next few months, and how concerned are you about more mutations of the virus that evade immunity, boosters or even treatments we have?

Yes, we expect increased COVID-19 cases as we get into the colder months.  The number of people that can be infected increases in winter when we’re in closer contact with one another indoors.  Whether BA.5 will be the dominant strain or we’ll see a new variant emerge remains to be seen.

Subvariant BA.5 is hanging on strong, but it’s unclear if it will carry through the fall and winter or give way to a new variant able to evade immunity. There is not a question of if there will be a new variant, it’s just when.  We’ll be watching closely other Omicron subvariants like BA.4.6 and BA.2.75  as possible variants to take over from BA.5.

Mask requirements have been lifted in most public places, including on public transportation and on flights. Should we still be wearing masks when in public places, particularly heading into a season when there are higher rates of flu and other respiratory illnesses? 

Certainly we know masks reduce respiratory illness in the winter.  It is why we’ve seen historic low case numbers of influenza in the past two years. 

It’s important to assess your personal risk. Are you at high risk or do you live with someone who’s at high risk of severe respiratory illness? For those who are immunocompromised or have comorbidities that put them at risk, masking will help protect from respiratory illness.

We know masking works, but it should be considered one of the tools of reducing the risk, along with staying home when you’re sick, getting vaccinated and staying up to date on boosters.  

The new bivalent COVID-19 vaccine booster was not tested on humans before its release. Should we have any safety concerns about the shot? And do those who have already been vaccinated and boosted, need another booster?  

We shouldn’t be concerned because that’s the way we produce the influenza vaccine each year.  We now have clinical data from Europe on the shot’s safety published in the New England Journal of Medicine. There shouldn’t be any safety concerns with the shot.

As far as additional booster doses are concerned, a recent CDC report shows they are very effective in preventing serious illness and death. The study looked at the effectiveness of three doses versus four doses of the (monovalent) COVID-19 vaccine in reducing mortality in nursing home residents – people who are among the highest risk in the country. 

While the vaccine has not been great at preventing infection (about 25% effective), in those residents who had the fourth dose, there was a 75% reduction in severe illness and hospitalization and a 90% reduction in mortality, according to the study.

I recommend we follow the CDC guidance for all age groups but most of all for those who are high risk. If you are at high risk, you should go out and get the new bivalent booster.

Three years ago, few of us would have imagined we’d still be dealing with COVID-19 today. While none of us have a crystal ball, where do you see us headed in managing and living with the virus over the next few years? 

First of all, never underestimate the power of science, clinical investigation, and drug development.

The virus has become very comfortable in the U.S and around the world. It will continue to persist.  But with new drug development, vaccine adaptation and more of the population becoming immune through infection, vaccination and boosting, it will continue to be a less severe illness and more similar to the common cold and influenza.

It’s important to remember, that while the trend has been for each successive variant to be more contagious and better able to evade immunity, but not more severe, it’s still possible that certain mutations could arise that could make the virus more severe or deadly.

We need to learn to live with COVID-19. And we need to keep our kids and teachers in school.  Could mask mandates come back? Possibly, as a temporary measure to mitigate outbreaks and keep our schools open. With nearly three years’ experience with this virus, we are now better equipped to live with it.

Todd B. Ellerin, MD is Director of Infectious Disease at South Shore Health.