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With the end of pandemic COVID-19 in sight, endemic COVID-19 awaits

The hope for a permanent, low-level rate of the virus is one that envisions intense need for local case surveillance, isolated periods of regional masking, ongoing protection of the vulnerable, and seasonal vaccination against new variants.

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ROCHESTER, Minn. — A post-pandemic conversation has finally begun within the state's high-profile health systems, but it starts with a disclaimer: Endemic COVID-19 means never getting to say goodbye to the virus.

"Eradication is not going to be possible with COVID-19," said Mayo Clinic infectious disease specialist Dr. Jack O'Horo during a press call on Tuesday, March 8. "We can eradicate disease that are only in humans, but if it can jump into deer or bats, then jump back in to humans, that makes eradication not possible."

O'Horo met twice with local press last week, a window marking the second anniversary of the arrival of the virus in state. He mostly delivered good news. After acknowledging the U.S. recently passed "a grim milestone" of 1 million deaths, O'Horo noted the post-omicron plummet in cases.

"The actual rates of infection continue to drop precipitously in the U.S. and most places throughout the globe," O'Horo said.

It's enough, he said, to raise the question: "If we are heading toward COVID-19 being an endemic disease that's always present in the background," he said. "In all likelihood, that's where we are heading."

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Dr. John O'Horo
Contributed / Mayo Clinic

A formal transition to endemic status has to follow a stabilization of case numbers at very low levels, he said, something he expects could become apparent "in coming weeks."

"It will take some time to see where rates level off in order to determine a normal background rate of cases," he said. "We don't have any relevant experience with COVID-19 to define that."

In the meantime, O'Horo sees the state entering six months of post-COVID-19 respite. Enough non-vaccinated people were infected in his view that they will carry some form of immunity, albeit for how long is unknown.

"I am hopeful we will continue to see the cases drop, and that will be sustained for at least a good part of the spring and summer," O'Horo said. "The fall remains the big unknown."

"This isn't a one-way door," as he put it during a rural health care conference on Thursday, March 10. "As we enter this, the potential remains for the virus to surge back."

What is a normal level of COVID-19?

Endemic COVID-19 means the virus has become just another part of life going forward for the small number of people who become infected. How small that number is, remains to be seen.

What endemic COVID-19 won't mean is an end to vaccination.

Far from it, O'Horo said, the odds look strong that with continuous rise of variants, new vaccinations for seasonal COVID-19 will become an ordinary and lasting healthcare routine traced back to its swift development and slow uptake in the present.

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"There's going to be need for some sort periodic vaccination," O'Horo said. "We're likely to see new variants like we've seen all along, and likely to need new vaccines for those variants."

"I wouldn't be surprised to see something very similar to what we see with needing a seasonal shot for the flu," he said. "That's what keeps the disease in manageable enough that we don't overwhelm our hospitals and clinics."

O'Horo said we should not expect future variants will necessarily be milder than previous variants, or even that the ongoing need for masks for some people, in some places, during some windows is ever going away for good.

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This is especially true he said for places where the vulnerable gather, like hospitals.

"Those who are at higher risk, or those who have higher risk individuals in their household, may very reasonably choose to wear masks and observe cautions as masks are lifted for the general population," he said. "It's really shifting to more of a mask-optional mindset."

He says there likely will be need for local public health to reinstate mask orders to contain isolated outbreaks. In this way, if anything defines endemic COVID-19, O'Horo suggested, it will be the ascending importance of regional public health orders as needed to offset the stark differences in case counts from one area to the next.

"Just because it's safe to take off masks three counties over," he said, "doesn't mean it's safe in this county for those in a more vulnerable setting."

On the bright side, when COVID-19 become endemic, an outbreak in one county doesn't necessarily mean the rest of the state must go on alert.

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"As we go down to rates that are lower," O'Horo said, "the size of these flare ups will get smaller. That gives them a better chance of being contained locally."

Paul John Scott is the health reporter for NewsMD and the Rochester Post Bulletin. He is a novelist and was an award-winning magazine journalist for 15 years prior to joining the FNS in 2019.
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