Additionally, we are uncertain about whether the COVID-19 vaccines in use will provide long-lasting immunity, as the smallpox and polio vaccines do. If not, that could leave individuals unprotected as their vaccine immunity wanes. Furthermore, to attempt eradication, the vaccine must be available to all, which is not feasible right now, though manufacturing is expected to ramp up in the rest of 2021 and 2022. Asymptomatic cases of infection would also stymie an eradication campaign, as they have for polio, allowing for undetected spread. Having very distinct symptoms, as with the smallpox rash, made it easier to identify cases and control smallpox transmission during the eradication campaign.
So eradication is out, and elimination would be very difficult, at least at this point in time. That leaves us with the third possibility: an endemic virus. This means it will be present at a low level in the population for the foreseeable future. Dr. Najera suggests that SARS-CoV-2 will become more similar to the four endemic human coronaviruses that generally cause colds: “another nuisance virus for some and severe enough to kill for others.” However, with a considerable portion of the population vaccinated, we’ll see far fewer infections and deaths than we’ve experienced over the past 16 months, and even when outbreaks occur, they will be less likely to overwhelm hospitals.
This endemic conclusion is consistent with the outcome of the 2009 H1N1 “swine flu” pandemic. On August 10, 2010, approximately 16 months after it first began, the World Health Organization (WHO) declared the pandemic “over” but cautioned: “As we enter the post-pandemic period, this does not mean that the H1N1 virus has gone away. Based on experience with past pandemics, we expect the H1N1 virus to take on the behavior of a seasonal influenza virus and continue to circulate for some years to come.” This has come true. More than a decade later, descendants of the 2009 pandemic virus are still circulating, as pandemic influenza viruses did after the 1918, 1957, and 1968 influenza pandemics. At some point, the WHO will issue a similar declaration for COVID-19, when levels of new cases are sufficiently low in most countries around the world. But this will not be the end of the virus.
The next phase of pandemic life
Monica Green, Ph.D., historian of medicine and global health and independent scholar, points out that a pandemic “ending” is really in the eye of the beholder; pandemics last longer than just the acute and most deadly outbreaks. “Most history of medicine focuses on epidemics: the visible part of outbreaks in human communities,” she says. “And most human communities have always only been able to see things at small scales. So ‘epidemics’ end when a disease is no longer visible to us,” however “us” is defined, from city to nation-state. Dr. Green’s own work studying the spread of Yersinia pestis, the bacterium that causes bubonic plague, the agent of the Black Death, shows that past pandemics technically lasted hundreds of years or more. But that doesn’t mean those outbreaks were at their most severe the entire time—different phases were involved.
So, although we don’t seem to be out of the woods yet, we are likely heading for the start of the post-pandemic phase of the outbreak in the U.S. New variants may still pop up, and transmission is expected to flare occasionally, especially in areas that have low vaccination rates.
It’s important to note that the reduction in cases in the U.S. will not automatically mean the end of the pandemic, which is by definition global. Depending on the speed of worldwide vaccine distribution, the pandemic could linger for another year or more in low-income countries. Dr. Kenny hopes that vaccines will “crush any future waves” in the U.S., but there is a very real fear for many low- and middle-income countries “that the waves will keep coming unless we do a far better and far faster job of scaling up global production and distribution of those vaccines.” Currently, there are proposed partnerships to increase vaccine distribution and production in these countries, and additional vaccines are still being tested that could be used in countries that are still experiencing high levels of COVID-19 infections.
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