Expert Q&A: COVID-19 - Where do we go from here?

When the Centers for Disease Control and Prevention changed their guidelines for mask wearing a few weeks ago, loosening their recommendations for areas with low to medium rates of cases and hospitalization, many people rejoiced. Others didn’t know what to think. And some people fear the move may backfire, leading to more illness and death.

The seeming about-face came as a result of rapidly falling case counts, as the highly transmissible Omicron variant ripped through the country, leaving fewer people to infect. Now that more than 70% of the United States can take off their masks indoors under the new guidelines, some are deciding to leave them on, while others abandoned masks long ago. However, the change does signal some good news, as cases and hospitalizations are in fact declining.

But how do we, as a population and as individuals, adjust to our new reality?

Are we at herd immunity with COVID-19?

“I don’t think we are at herd immunity,” said Adam Lauring, M.D., Ph.D., a physician in the University of Michigan Health Division of Infectious Disease and associate professor in the U-M Medical School. Herd immunity would mean that there is enough immunity, either through vaccination or prior infection, that the virus can’t cause an epidemic or surge, he explains.

SARS-CoV-2’s latest known variant, Omicron, is different enough from previous variants, which led it to cause infections in people who were vaccinated and reinfections in others. But Lauring adds that he doesn’t envision massive surges and hospitals getting stretched the way they have been.  

“Even though it could happen, it seems less likely moving forward [due to acquired or vaccine immunity and available therapies]. So, the way society copes is going to look different moving forward.”

Is COVID-19 an endemic disease?

Many viruses are endemic, including HIV and influenza, meaning that they are always present, either at low or high levels. “The virus and COVID-19 aren’t going away and no matter what policy changes we announce, that won’t change, says Lauring.

Epidemiologists will continue to monitor for the virus, as they do for the flu. Local health departments and the CDC will monitor hospitalizations and case counts, looking for increased activity. Labs such as Lauring’s and others, will continue to work with state and local health departments and the CDC, while sequencing samples of the virus from patients and looking for new variants.

However, as we emerge from the pandemic emergency, notes Lauring, epidemiologists will have to adapt how their monitoring is accomplished. “We’ll have to consider, for example, if people are rapid testing at home and not getting PCR tests, how are we going to know what’s out there?”

The answer in part will be an expansion of surveillance programs that were ramped up during the past two years, such as monitoring of wastewater and sampling of the coronavirus in wildlife.

What about people who are immunocompromised?

“There was a sense of safety when people were masking and a feeling like we’re all in this together,” said Amy Van Zee, a senior clinical social worker with the U-M Lung Transplant Program. She notes that walking back mask recommendations will likely spark anxiety in people who are immunocompromised. But part of that will be balancing the need to feel safe with the need for connection with others.

“There’s been a huge increase, not just in immunocompromised patients, but also in the mental health needs of people as a whole,” she said.

She recommends that people look for ways to reach out to a community of people on similar health journeys, either online or in person as “there can be a lot of validation and connectedness in that.” And many of the recommendations regarding gatherings during the height of the pandemic can be continued.

“We need to learn how to be happy, have a life and maintain relationships – it’s just finding a safe way to do it,” Van Zee said. “Some people love Zoom gathering and its working for them, but there are some that don’t want to do them. In those situations, it’s OK to get together, either outdoors or masked and/or spread out indoors. It’s being safe about it and having clear expectations laid out.”

If despite all best efforts and low case counts, someone who is immunocompromised and at high risk manages to become infected, there are effective therapies, such as the antiviral drugs paxlovid, molnupiravir and remdesivir, that can reduce the risk of serious illness by 80 to 90% compared to placebo, reports Jason Pogue, Pharm.D., a clinical pharmacist specialist in Infectious Diseases.

What about long COVID?

Many people, including those who are vaccinated, have been alarmed by the prospect that long COVID can result from even mild cases. Long COVID is a real burden, affecting according to one U-M study, 53% of people who were infected a month after the acute illness. Defined as persistent COVID-related symptoms lasting four weeks or more following SARS-CoV-2 infection, known effects of long COVID can look like everything from a continued loss of taste or smell to debilitating fatigue, joint and muscle pain, brain fog and even new heart issues.

“Long COVID is now considered a disability under the American with Disabilities Act; specifically a person with long COVID has a disability if the person’s condition or any of its symptoms is a physical or mental impairment that substantially limits one or more major life activities,” said Tammy Eaton, Ph.D., R.N.,  a VA postdoctoral research fellow and member of the U-M Institute for Healthcare Policy and Innovation who specializes in critical illness survivorship.

“But with long COVID being a new medical condition, we just don’t have enough information. We don’t know the long-term effects.”

As the pandemic raged on, health systems around the country scrambled to develop multidisciplinary post-COVID clinics to help these new patients, but accessing care is heavily dependent on local support, said Eaton.

Adding to that, “there are also socioeconomic consequences, like extensive financial care needs and loss of employment, which can effect health care coverage and cause the financial toxicity that comes along with having an illness,” said Eaton.

For these people, moving on from the pandemic is not as simple as taking off a mask and will include striving to get the care they need to recover fully. Eaton is heartened by the fact that policymakers recently introduced legislation to increase funding for research into long COVID and support for health systems.

As for reducing the risk of long COVID, she notes, keeping up to date with vaccination and avoiding infection in the first place are still the best methods. Recent data points to reduced rates of long COVID in people who are vaccinated.

Moving forward post-pandemic

For too many, moving forward involves grieving the loss of a loved one. For others, it’s adjusting to frequent policy changes that have varying impacts on our everyday lives, from wearing masks to getting tested for travel to grappling with caring for sick family members and protecting the people who are at greatest risk around us.

“The real challenge here is there are big policies that affect millions of people, but on the individual level the considerations can be different for different people,” said Lauring. The color-coded risk levels outlined by the CDC, as well as guidance from health departments both consider the changing conditions on the ground and masks may once again be called for if a new variant emerges and cases and hospitalizations rise. But individuals can continue to wear a mask if they want to (and may still be required to in certain settings, like health care facilities.)

The fact of the matter is that COVID is here to stay. Yet, “for most people, it’s not going to be this horrible thing like we all feared in 2020,” said Lauring. “Over the next year, we will be going through this shift in the way we’re living with COVID.”