Believe it or not, the world is about to enter its fourth year of living with covid.

2022 began with an unprecedented surge in cases, driven by the wildly transmissible omicron variant, which overwhelmed many hospital systems. Offshoots of omicron continued circulating, killing more than 250,000 people in the United States alone. Amid that ongoing toll, many Americans decided the pandemic was over, as vaccine and treatment availability took some of the bite out of the coronavirus’ threat. Masks were no longer required on planes, states largely abandoned what social distancing measures they had left, and the Centers for Disease Control and Prevention relaxed their guidance.

And yet covid is still with us.

Cases are creeping up across the country with the holidays in full swing, and some worry hospitalizations and deaths may increase, too. The coronavirus has defied prediction so far, and experts differ in their outlook on the imminent surge, and what might lie ahead in this fourth year of the pandemic. Grid spoke with sh, virologists and public health experts about what covid might bring in 2023.

Here’s what they had to say — edited for length and clarity.

How are you thinking about the next several weeks and months? Could we see another omicron-like surge, or are we in a different place nows

Amesh Adalja, epidemiologist at the Johns Hopkins University Bloomberg School of Public Health: We’re in a different era with this virus, one where it’s becoming more manageable but still has the ability to cause severe disease, hospitalization and death in high-risk people. I think [this winter] can only be different because we have a lot more tools that we didn’t have, or had in limited capacity, during the omicron wave. And that’s on top of the level of immunity in the population, in terms of how many have been infected and vaccinated. That’s not going to stop a surge in cases, but it stops the surge in hospitalizations and deaths we saw in the past.

Georges Benjamin, executive director of the American Public Health Association: The surge we have now is not going to be as big as the one that we had last winter. That’s a guess of course, but we’re just in a very different place with more immunity. But I think there’s one really big outlier out there, China. If China gets hit with a big spike, then it is quite possible that it will bleed into the U.S. And if we get a variant that dramatically changes from what we’ve seen so far, we could be off to the races with a big outbreak. That’s my one caveat, and I’m worried to death about that.

Jennifer Nuzzo, epidemiologist at Brown University: It’s hard to imagine that it’s going to be like omicron in terms of the sheer number of infections. At omicron’s peak you had more than a million infected people per day [and] those infections left a lot of immunity in their wake. But our challenge now is not only a rise in covid infections, but also a flu season that’s overlapping, and very low booster uptake among senior citizens. I’m most worried about the lack of up-to-date immunity in the high-risk group.

Paul Offit, infectious-disease physician and the director of the Vaccine Education Center at Children’s Hospital of Philadelphia: We’re heading into the winter months with what is basically a winter virus; we’re going to see an increase in cases. The critical question is, are you going to have a concomitant increase in hospitalizations and deaths? At this point, roughly 95 percent of the population has been naturally infected, vaccinated or both. I think we’re going to see an increase in cases, but already you’re not seeing a concomitant increase in hospitalizations and deaths, and I think that’s the future of this virus.

Could 2023 be the year that we settle into a more seasonal pattern of spikes in winter, but relative calm in warmer months?

Adalja: It’s hard to know — and has a lot to do with the evolution of the virus. I don’t think that this virus has particularly settled down yet in terms of its evolutionary pace. It is still very high compared to other seasonal viruses. I don’t know what’s going to cause that to settle down. But once it settles down, maybe it will become a virus whose behavior is driven more by seasonality and behavior, rather than being driven by new mutations in the virus.

Michael Osterholm, public health researcher at the University of Minnesota: We still have so many unknowns with this virus. I’ve seen nothing yet to suggest that it’s a seasonal virus. It surely makes sense that It could be. But at this point, I don’t think that we can at all say that. There’s not an epidemiological pattern yet that would allow us to better predict.

Since omicron burst onto the scene last year, we haven’t seen another major variant emerge. How likely is it that the coronavirus will throw us another variant curveball?

Thomas Friedrich, virologist at the University of Wisconsin-Madison: It is possible that a “game-changing variant” could emerge, but it is very difficult to predict where or when. Each new infection provides the virus more chances to generate new combinations of mutations. The continuing circulation of SARS-CoV-2 therefore means that we should expect the virus to continue to evolve. In the U.S., as in most other countries, the vast majority of people have some immunity to SARS-CoV-2 through infection, vaccination, or both. For many or most of these people, this immunity would likely “cross-react,” at least a little bit, with new SARS-CoV-2 variants. So this population-level preexisting immunity could mitigate the impact of new variants. [The surge of cases in China] is concerning. We should of course first be concerned for people in China who are suddenly facing a wave of infections. But there is indeed also concern that a wave of infections will provide new opportunities for the virus to evolve.

Adalja: It’s a stochastic process, I don’t know that anybody can say. It seems that this virus has kind of latched onto the omicron lineage and is moving down that pathway, but we thought that with delta and then omicron came about. There’s also ongoing evolution in many different animal species, which could get spit back out to us, and long-lived infections in immunocompromised people where there’s lots of evolution going on. It’s difficult to predict.

Salim Abdool Karim, epidemiologist at the Centre for the AIDS Programme of Research in South Africa: The worst-case scenario is that the virus finds a new set of mutations to create “pi,” a radically different variant, and we will see new waves of infection occurring. And these new waves of infection will put us back to where we were in 2020, 2021. I think on a positive note, even if it does create a new variant in pi, it’s unlikely that pi will be able to escape all of the T cell immunity. It will escape the antibodies but may not escape all the T cells. So we may not see as bad clinical illness as we have in the past. However, I think the likelihood of this scenario is quite small.

Do you think vaccines will need to be tweaked again? What are the prospects for intranasal vaccines that could better prevent transmission, or variant-proof vaccines?

Nuzzo: These [existing] vaccines are pretty darn good, and we’re not giving them enough credit. We really need to make sure that our 65-plus people are up to date. I just saw the data recently about nursing homes showing less than half of residents have gotten boosted, and about less than a quarter of the staff has gotten boosted. How do we engage with people such that they can discover for themselves the value of vaccines?

[On nasal vaccines] I would love for intranasal vaccines to prevent infections. I’m not fully convinced that that will happen since the intranasal flu vaccine doesn’t necessarily prevent infection. But I think there are benefits of intranasal vaccines because a lot of people don’t like needles. That’s actually one reason why people don’t get vaccinated. But you talk to researchers studying this and they say they need a lot more support, there hasn’t been much progress.

Adalja: I think there probably will be some incremental improvements in the vaccines and hopefully more flexibility. There’s some data for example that using the Novavax vaccine as a booster may augment the protection from other vaccines. But right now the regulatory environment is so constrained and Novavax boosters can only be used for Novavax people. So you might see some more innovative mixing and matching.

Offit: I think we have the vaccine we need. There may be a time when the virus has mutated away from T cell recognition. And if that’s true, then we’re starting all over again. But that hasn’t happened yet. I’d like to see the public health people and the administration focus on those who most benefit from these vaccines — elderly people, the immunocompromised and people with high-risk medical conditions. I think by saying that everyone over six months of age now should get a bivalent vaccine booster, [the CDC and FDA] weaken the recommendation. Everybody should be vaccinated, but those who should be boosted really should be limited to those who are most likely to benefit. The goal of this vaccine is to keep people out of the hospital, keep them out of the intensive care unit and keep them out of the morgue. The goal of this vaccine is not to prevent cases, because that’s not possible.

Osterholm: A tweak to the booster is possible. At this point it’s fair to say that we’re living with the vaccines we have and are a ways away from new vaccines. Early on, these vaccines were sold like the measles vaccine, where you get two doses and are good for life. Within months it became clear that no, this is more like a flu vaccine, where you’re going to need a boost every year, maybe even every six months. That’s a largely failing proposition from a public health standpoint. If we just keep recommending boosters, we’re just going to continue to eat away at how many people are protected; you see how few people are already getting this booster.

What about treatments? The tool kit available to practitioners is shrinking as the virus evolves. What updates would you like to see in 2023?

Adalja: For sure we’re going to see new antivirals. Shionogi already has an easier [to take] version of Paxlovid approved in Japan, and other companies are [looking for new drugs] too. I think there will be a push for more monoclonal antibodies to better fit the variants, and maybe there will be an updated version of Evusheld, which is slowly losing potency as well.

Karim: Worldwide, we are witnessing treatment inequity. If you get covid-19, in the U.S. or Europe, or Australia or anywhere like that, you have ready access to Paxlovid. But it’s just not available in many other countries. It’s not even registered in any country in Africa, as far as I’m aware.

2022 was a year of many pandemic policy changes. What do you think went well this year?

Nuzzo: I think we’ve made some important progress in democratizing access to in-home tests and I’d like to see us really build more on that. Rapid testing is much more available now than in 2021.

Osterholm: Paxlovid was a good news issue. We have clear and compelling data that Paxlovid, when taken early, can be an important tool in reducing serious illness, hospitalization and death, and in addition up to a 30 percent reduction in long covid. But its utilization is so disjointed in this country. What’s wrong — why can’t we get that out?

What didn’t we do well this year?

Benjamin: I think the biggest thing we didn’t do is we didn’t explain the transition [away from more restrictive measures]. It was “the pandemic is here” or “the pandemic is gone.” That was the wrong perspective. We should’ve given people several scenarios, and what we want you to do in certain situations, so the public has clear expectations. Right now, it seems like we’re stumbling along.

Nuzzo: The narrative of vaccines has just gotten out of control. There’s recent data showing an increasing percentage of parents who don’t think we should mandate vaccines for school entry, not even covid vaccines, just childhood immunizations. This spillover to previously noncontroversial immunizations is a deeply worrisome development that has the potential to erode major public health gains.

Offit: I think the biggest communications error we have right now is when you hear people in the administration say, “There’s going to be an increase in cases [this winter].” Of course, there’s going to be an increase in cases. That’s not the point. The point is, with this increase in cases, will you be protected against severe disease if you’ve been naturally infected or previously were vaccinated? Yes, you will be, unless you’re in a high-risk group, in which case you should get a booster dose. I think we’ve inadvertently scared people and we’ve habituated them to those scare tactics, which is why you have 14 percent uptake on this [bivalent booster].

What’s one big covid policy change you would like to see in 2023?

Adalja: I’d like to see the CDC become more empowered and more independent. Through two successive administrations the CDC has been held captive by the White House. Everything is coming from the White House and not from the CDC director. I think the CDC director shouldn’t be confirmed by the Senate, to help it become more independent. It should be a regular civil service job, like Dr. Fauci at NIAID [National Institute of Allergy and Infectious Diseases], because if you let politicians near it, it will ruin it with senators who don’t know anything about anything grandstanding over it.

Karim: For me, the highest priority outside of vaccinating everybody is to get this pandemic treaty sorted out. Without a pandemic treaty, if we have another coronavirus or any virus spreading, we are back to square one, which is a disjointed, uncoordinated response. There’s no scenario in the world that sees us controlling a pandemic by some countries doing well and other countries just letting the virus spread. in order to really control a pandemic, you have to treat it like a pandemic, you’ve got to have the whole world working together.

State and local public health offices have had a hard time dealing with the pandemic, harassment, and staff departures. How do you feel about their ability to keep doing the day-to-day work of protecting the health of their communities?

Nuzzo: I’m really worried because of the political attacks and the polarization — attacking public health seems to be a way to achieve cheap political points. That worries me the most. But I’m also worried about the lack of support for public health as a critical infrastructure and the untenable situation in our healthcare environment. We have provider-to-patient staffing ratios that are meant to minimize cost but are really not helpful when we have a public health emergency and suddenly there’s a surge of patients.

We need public health to be seen as critical infrastructure such that it can not only respond to a single public health emergency, but multiple ones at the same time. I mean right now we’re talking RSV, flu, covid, measles, polio. It’s a staggering and increasingly long list, and we need to make sure the infrastructure can handle it. We have failed to do that not just with covid, but all the things that are going to come after it. And that’s what worries me, that we’re not thinking of it as these as the hazards of our time.

Benjamin: Right now, they’re really stressed and worn down, and they’re stumbling through. That’s not just because of covid — they’ve got a raging STD outbreak, they’ve still got an opioid epidemic. The chronic-disease people are still trying to deal with heart disease, strokes, and obesity and diabetes. So there, they’ve got a lot on their plate. There’s a light at the end of the tunnel — it’s the $3.2 billion that CDC has just awarded to begin rebuilding the public health system. But the system is so fragile, it’s at the breaking point.

What else should people should know as we enter our fourth year of this pandemic?

Adalja: I think that there are some elements of the population that are really still wishing for 2019 to come back. They’ve not acclimatized to the fact that this is a new infectious disease that’s always going to be with us and they have to incorporate that into their risk calculations. A lot of them are not doing that and they’re perpetually putting their life on hold. I’d like to see a more frank conversation about this as an endemic infectious disease. This Christmas, next Christmas, and at the Christmas after that there’s going to be covid transmission. And people have to start to learn to use the tools that we have to make this a more manageable infection.

Karim: Over the next several years, after the waves of infection, there will be a tsunami of chronic diseases. The first we’re going to see is an increase in cardiovascular disease, something we’re seeing already — the main private insurance here in South Africa has already reported a 50 percent increase in claims for cardiovascular disease this year. The second is we’re going to see more diabetes. And the third is neurological problems, depression, fatigue. We’re going to see a lot more of these manifestations of chronic diseases. Next year, it’s going to get worse.

Osterholm: We surely are in a better place today with 450 deaths a day in the country versus 2,000. But to me, that’s almost a shifting baseline analogy. It’s better than 2,000 deaths a day when things were at their worst. But when you stop and think about it, the number one cause of cancer deaths in the United States is lung cancer, and that’s 350 deaths a day. That gives you a relative idea of where we are. Surely we’re not out of the woods yet.

Thanks to Dave Tepps for copy editing this article.


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