March 17, 2023 -- It's been 3 years since the World Health Organization officially declared the COVID-19 emergency a pandemic. Now, with health systems no longer overwhelmed and more than a year of no surprise variants, many infectious disease experts are declaring a shift in the crisis from pandemic to endemic.
Endemic, broadly, means the virus and its patterns are predictable and steady in designated regions. But not all experts agree that we’re there yet.
Eric Topol, MD, founder and director of the Scripps Research Translational Institute in La Jolla, CA, and editor in chief of Medscape, WebMD’s sister site for health professionals, said it’s time to call COVID endemic.
He wrote in his Substack, Ground Truth, that all indications -- from genomic surveillance of the virus to wastewater to clinical outcomes that are still being tracked -- point to a new reality: “[W]e’ve (finally) entered an endemic phase. “
No new SARS-CoV-2 variants have yet emerged with a growth advantage over XBB.1.5, which is dominant throughout much of the world, or XBB.1.9.1, wrote Topol.
But he has two concerns. One is the number of daily hospitalizations and deaths – hovering at near 26,000 and 350, respectively, according to The New York Times COVID tracker. That’s far more than the daily number of deaths in a severe flu season.
“This is far beyond (double) where we were in June 2021,” he wrote.
Topol’s second concern is the chance that a new family of virus might evolve that is even more infectious or lethal – or both – than the recent Omicron variants.
Three Reasons to Call It Endemic
William Schaffner, MD, infectious disease expert at Vanderbilt University Medical Center in Nashville, is in the endemic camp as well for three reasons.
First, he said, “We have very high population immunity. We’re no longer seeing huge surges, but we’re seeing ongoing smoldering transmission.”
Also, though noting the concerning numbers of daily deaths and hospitalizations, Schaffner said, “it’s no longer causing crises in health care or, beyond that, into the community economically and socially anymore.”
“Number three, the variants causing illness are Omicron and its progeny, the Omicron subvariants. And whether because of population immunity or because they are inherently less virulent, they are causing milder disease,” Schaffner said.
Changing societal norms are also a sign the U.S. is moving on, he said. “Look around. People are behaving endemically.”
They're shedding masks, gathering in crowded spaces, and shrugging off additional vaccines, “which implies a certain tolerance of this infection. We tolerate the flu,” he noted.
Schaffner said he would limit his scope of where COVID is endemic or close to endemic to the developed world.
“I’m more cautious about the developing world because our surveillance system there isn’t as good,” he said.
He added a caveat to his endemic enthusiasm, conceding that a highly virulent new variant that can resist current vaccines could torpedo endemic status.
No Huge Peaks
“I’m going to go with we’re endemic,” said Dennis Cunningham, MD, system medical director of infection prevention of the Henry Ford Health System in Detroit.
“I’m using the definition that we know there’s disease in the population. It occurs regularly at a consistent rate. In Michigan, we’re no longer having those huge peaks of cases,” he said.
Cunningham said though the deaths from COVID are disturbing, “I would call cardiovascular disease endemic in this country and we have far more than a few hundred deaths a day from that.”
He also noted that vaccines have resulted in high levels of control of the disease in terms of reducing hospitalizations and deaths.
The discussion really becomes an academic argument, Cunningham said.
“Even if we call it endemic, it’s still a serious virus that’s really putting a lot of a strain on our health care system.”
Not So Fast
But not everyone is ready to go all-in with “endemic.”
Stuart Ray, MD, professor of medicine in the Division of Infectious Diseases at Johns Hopkins School of Medicine in Baltimore, said any endemic designation would be specific to a certain area.
“We don’t have much information about what’s happening in China, so I don’t know that we can say what state they’re in, for example,” he said.
Information in the U.S. is incomplete as well, Ray said, noting that while home testing in the U.S. has been a great tool, it has made true case counts difficult.
“Our visibility on the number of infections in the United States has, understandably, been degraded by home testing. We have to use other means to glean what’s happening with COVID,” he said.
“There are people with infections we don’t know about and something from that dynamic could surprise us,” he said.
There are also a growing number of young people who have not yet had COVID, and with low vaccination rates among young people, “we might see spikes in infections again,” Ray said.
Why No Official Endemic Declaration?
Some question why endemic hasn’t been declared by the WHO or CDC.
Ray said health authorities tend to declare emergencies, but are slower to make pronouncements that an emergency has ended if they make one at all.
President Joe Biden set May 11 as the end of the COVID emergency declaration in the U.S. after extending the deadline several times. The emergency status allowed millions to receive free tests, vaccines, and treatments.
Ray said we will only truly know when the endemic started retrospectively.
“Just like I think we’ll look back at March 9 and say that Baltimore is out of winter. But there may be a storm that will surprise me,” he aid.
Not Enough Time to Know
Epidemiologist Katelyn Jetelina, PhD, MPH, director of population health analytics at the Meadows Mental Health Policy Institute in Dallas, and a senior scientific consultant to the CDC, said we haven’t had enough time with COVID to call it endemic.
For influenza, she said, which is endemic, “It’s predictable and we know when we’ll have waves.”
But COVID has too many unknowns, she said.
What we do know is that moving to endemic does not mean an end to the suffering, said Jetelina, who also publishes a Substack called Your Local Epidemiologist.
“We see that with malaria and [tuberculosis] and flu. There’s going to be suffering,” she said.
Public expectations for tolerating illness and death with COVID are still widely debated.
“We don’t have a metric for what is an acceptable level of mortality for an endemic. It’s defined more by our culture and our values and what we do end up accepting," she said. "That’s why we’re seeing this tug of war between urgency and normalcy. We’re deciding where we place SARS-CoV-2 in our repertoire of threats.”
She said in the U.S., people don’t know what these waves are going to look like -- whether they will be seasonal or whether people can expect a summer wave in the South again or whether another variant of concern will come out of nowhere.
“I can see a future where (COVID) is not a big deal in certain countries that have such high immunity through vaccinations and other places where it remains a crisis.
“We all hope we’re inching toward the endemic phase, but who knows? SARS-CoV-2 has taught me to approach it with humility," Jetelina said. "We don’t ultimately know what’s going to happen.”