Glossary

• Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses (genes and protein coat), and on it goes.
• Variant- also known as a mutation, a variant strain of a virus is the same species of virus but with a change in the genetic code.  The change is minor if it has no impact on contagious the new variant is, or how deadly it is, or if it allows the virus to neutralize our vaccines. Variants that substantially increase harm are now listed by Greek letters, the most troublesome one now is Omicron.

• Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
• SARS-CoV-2– the specific name of the new coronavirus
• COVID-19-the name of the illness that the new coronavirus is causing
• Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
• Epidemic– a sudden burst of an illness that comes and goes over a limited time
• Pandemic– an epidemic that bursts across the world not just one region
• Spreadability– how contagious is the disease, how many people will end up infected
• Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
• Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
• Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
• Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
• Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
• Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
• PCR Test–  swabs the nose to detect the genes of the COVID virus.  The genes if detected are almost certainly there, but they can persist long after contagion ends.  Very few false positives, positives can be trusted.
• Antigen Test (the home kit)- swabs the nose to detect the proteins on the coating of the COVID virus, the spike proteins.  If it does not detect those proteins, you are almost certainly not infected, negatives can be trusted.  These proteins are also on the coating of many common cold viruses, so one positive test may indicate you have a cold rather than COVID.  Two positive home tests though reliably indicate you have COVID.
• Vaccine Terms
• Vaccine or Immunization– a dose of a substance that activates your immune system, as if you have the actual infection you are hoping to prevent, leaving you in fact protected from having that infection.
• Efficacy– the percentage of people immunized with a particular vaccine who will not get infected if exposed to the target infection.  For example, a COVID-19 vaccine will be said to be 95% effective if 95% of people immunized with that particular COVID-19 vaccine will not get COVID-19 if exposed to COVID-19
• mRNA– DNA works by dictating exactly which proteins your cell will make.  The message on how to construct each protein is delivered to the cell machinery that makes proteins by a piece of genetic material called messenger RNA, or mRNA
• mRNA vaccine– an mRNA vaccine places a small bit of mRNA code that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected
• Viral vector vaccine– a viral vector vaccine takes a harmless virus that is known to infect people reliably and places that weakened virus in a person where that virus will in fact infect the person.  The virus is not only weakened, but also attached to a set of genes  that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected.

You see it everywhere, and so of course also in this blog, Real Answers with Dr. Lavin.  The clarity of the initial attack of COVID-19 was given way to a gnawing sense of unease.  When once we could take solid lines, knowing the right thing to do, seeing millions of life hanging on our decisions, including our own, now the infection seems to have grown more complicated.  More contagious but less deadly, worries fading despite deaths continuing, immunization protects but does not end threat, the danger of the virus retreats but waves of infection accelerate.

Is the confusion our fault, are we simply too tired to follow every curve of this catastrophe, are we too tired to protect when we could?  Or is the confusion not our fault, but the nature of a complex, new infection, how it usually goes?

In this post of Real Answers, we will take a close look at the best review of the current situation I have read since the early, clearer days, just published in the NY Times and written by David Wallace-Wells, here it is.  This is a very meaty review, packed with details, and to my mind, just what we need to understand what turns out to be a pretty complex reality.  I left reading this account of the now with far more clarity, I hope to offer the same to those who read this post.

Where to Start?  How about with Pandemic v. Endemic

Every infection has a pattern to it.  Some are very, very familiar, some are very unfamiliar.  Four patterns that germs take come to mind: sporadic, epidemic, pandemic, and endemic.

Perhaps the most familiar is the epidemic.   Technically an epidemic is a sudden outburst of a germ on a limited scene, for a limited time.  A great example of an epidemic is the outburst of measles amongst those choosing not to be protected from that germ by use of a vaccine.  The most famous measles epidemic in our nation in this century was the 2019 measles epidemic in Disneyland.  It had all the features of an epidemic.  It was in one geographic location, Disneyland, then 7 US states, Mexico, Canada.  It happened in one contained time period, December 2014 to April 2015, then over.  It was a sudden burst of infection.  Those areas had no measles for a long time prior to December 2014, and rates have nearly vanished since, except for other limited outbursts.  The bad thing about epidemics is that they can kill lot of people who prior to the epidemic were in no danger from that germ.  The good thing is that they do not put everyone at risk, and they end.

The other familiar pattern is sporadic.  This is the pattern of the germ causing one infection here, one there, in no great outburst, in unpredictable places, perhaps often now, absent then, very unpredictable.  A good example of such infection patterns are abscesses.  Most people don’t get them, they don’t spread really, their appearance is unpredictable, and they never sustain a pattern of becoming common.

The Constant Dance of Infection: The Germ Changes, Humanity Changes, On and On

So now we come to pandemic and endemic, the two states of our current concern, COVID.   A pandemic is essentially an epidemic that happens across the entire human community, in every location.  Like epidemics, every pandemic has a beginning, middle, and end.  No pandemic across all of human history has ever become permanent.  We can’t say exactly why, but there are strong indications this is because germs and their victims tend to adapt to each other over time.  That adaptation is crucial in understanding all patterns of how germs spread.

So let’s think about that for a moment.  COVID is a great example.  The COVID germ bursts onto the scene, and not ever having experienced it, has its way with humanity, ripping across our bodies and continents with little to stop it.  But within just a few weeks humanity takes steps to stop the spread, and limit the death.  We develop tests to detect it, and places to go to have infected people not spread it.  We spread masks around the world.  And we develop vaccines.  At every turn, humanity tries to stop the killing.  But at the very same time, whenever anything blocks the virus from spreading, it changes too, and finds a way to spread again.

When the virus overpowers our ability to manage it, spreads across the globe to all humanity, it is a pandemic.

When the virus reaches an equilibrium with humanity, when cases stop exploding, when the viral urge to spread develops a steady state with humanity’s ability to stop its spread, but keeps spreading, that is an endemic state.   Some pandemics never enter into the endemic state, they cease.  Nearly all the great epidemics and pandemics that cease to be only ended through the human invention of immunizations- people choosing to be protected by immunizations no longer suffer smallpox or polio, for example.

But some viruses have found ways to outfox even the power of immunizations, at least the power of them to stop their existence.  The SARS-CoV-2 virus is sadly one of these viruses.  There is essentially no hope that an immunization program will make this virus extinct, like smallpox.  But the good news is that the COVID vaccines continue to keep the virus from killing far more people than it would otherwise, it saves lives, and will save millions of them.  Just in the US it has already saved over 1 million of our lives and the lives of those we love.

COVID will certainly not go away, it will certainly cease being a pandemic, when will it become endemic?

It turns out there is no surprise about the tragedy that this damn virus will never go away, because viruses that spread in the air and infect our tissues that touch air (eyes, mouth, throat, vocal cords, airways and lungs) almost never do.  Our immune systems simply are not built to stop these viruses from landing on us, such viruses mutate (or change) like crazy, and so the dance of the virus finding a way to infect us and we finding a way to stop them, never ends.   About a quarter of all our common colds are caused by 4 ancient coronaviruses that likely appeared in humanity about 8,000 years ago, and they still are causing millions of infections every year.  Over 8,000 years these 4 coronaviruses, and all the viruses that cause the common cold, have danced with humanity and we have danced with them, long enough we are not very much harmed by them.  The common cold does not kill many people, even though everyone on the planet gets colds, usually several every year.  The common cold is endemic- a constant presence- but, thankfully, a pretty harmless endemic.  There is wide consensus that over the vast reaches of time that this COVID virus will be the fifth coronavirus that causes common colds, and become truly harmless.

But not yet.

On the other extreme from common colds sits the COVID pandemic.  This germ, this disease was brand new, not thousands of years old.  And it ravaged humanity and our world.  It clearly earned its place in the domain of pandemics, no one argues this.  But as this Times essay demonstrates, it is shifting right now from its wild pandemic stage, to a more nuanced, sustained equilibrium, the very definition of endemic.

One quality of the COVID experience that will mark its transition from pandemic to endemic is how much it disrupts our lives.  Clearly COVID was at its most disruptive here in the US in the Spring of 2020, when all schools closed, everyone who could had to work at home.  The disruption defined patterns of business activity, it eventually actually shut down colds and flus for a year.  Across the world, during the heyday of the COVID pandemic, an urgent sense was demonstrated in nations around the world that steps could be taken to save millions of lives and if they were not, millions would die by our choices.   This was the experience of pandemic, a new virus roaring across humanity and humanity scrambling to contain the devastation.

Had all of humanity acted together to identify all cases, isolate the infected, wear masks, and in time, vaccinate, the hope was this pandemic would go the way of smallpox, and truly end.  But that was never possible.  We could have saved millions of lives lost to our foolish choices, but we never had the power to rid the planet of the SARS-CoV-2 virus, we never have been able to get rid of any respiratory virus, as noted.

This essay in the Times notes that respiratory viruses tend to mutate into significant new types about twice a month.  The SARS-CoV-2 virus has done exactly that, creating about 70 new significant mutations, so that means it is very much like all other viruses that infect our airways, and like all of them, will continue to change over time.  This means it will almost certainly enter into the endemic state.

The essay goes on to make a very strong case that we are likely leaving the pandemic state of COVID and already in the endemic state.  Remember, the endemic state is not necessarily good or safe, its key property is that it’s steady.  It’s the state, as noted, where the germ and humanity have reached a balance.   The virus no longer roars with humanity powerless, but humanity’s protections cannot rid itself of it either.  So numbers of infections, hospitalizations, and most importantly, deaths, become rather steady.

And now we come to a tragic but unavoidable aspect of the endemic state.  It is that situation where the equilibrium, most importantly, the number of deaths per month or year, becomes acceptable.  Acceptable to the point we accept our control measures as reasonable and enough.  When a sense that the devastation is no longer that, but simply part of the background to life.  Endemic states do not call for vast emergency measures, but instead for powerful sustained efforts to minimize the harm.

There is lots to suggest that COVID has hit endemic equilibrium in the US and most of the world, with China being the major exception.

During the pandemic, the sense of urgency, that every death was potentially avoidable, propelled our nation, and nearly all nations, into passionate debates about how much to do to save life.  Now that passion has given way to acceptance of a certain level of COVID, including deaths from COVID.

We see this whenever any respiratory pandemic becomes endemic.  For us in the US, the influenza pandemic transitioned into an endemic state when it stopped killing about 340,000 Americans a year and moved to killing about 40,000.  Today the influenza virus, including the H1N1 subtype that caused the 1918 pandemic, circulates every winter (except the winter of ’20-’21), and in the US kills about 30,000-50,000 a year.  We do not quarantine for influenza, we do not mask for it, we have a lackluster vaccine campaign, that could save many more lives if more people got it, particularly children who are a major source of the virus that kills most of its victims (the elderly).  But no one really cares much about influenza.  It is clearly in the background. Nearly all of those who the virus kills are elderly or otherwise at risk.  Like all endemic states, it just is, it hovers unchanging year to year, it disrupts no one’s lives, except those it takes.

If the number of deaths that remains a constant and acceptable for the influenza virus is say 40,000, what will it be for COVID?

The evidence is that we are indeed, right now, transitioning from the COVID Pandemic, to the endemic state of COVID.  An equilibrium is clearly emerging where the powers of the virus and of humanity are in balance and not changing much.

The Look of the COVID Endemic State

More than in any other way, this essay in the Times does a masterful job of painting the picture of life in the COVID endemic state.

Here are the key realities of the COVID endemic state in America:

1. Essentially every American has had COVID by now.  The actual number currently stands somewhere between 95% and 98%.
2. The COVID virus continues to mutate at the rates long expected and is expected to mutate essentially forever.  No one has any idea what the new forms or variants of COVID will be like.  Will they be more deadly is the big question, so far not.
3. More than any other action, getting fully COVID vaccinated is the STRONGEST step available to not be killed, or pass along the virus to kill others.
4. But despite all our precautions, including vaccination, COVID continues to kill.
5. Our current dominant form of COVID, Omicron, is crazy contagious.  By the end of 2022, about 80% of all COVID cases will have occurred in 2022!
6. Thankfully, Omicron can pile up cases without causing the piling up of hospitalizations and deaths we saw during the Pandemic stage of COVID.
7. It took six months for Delta to emerge and take over the original.  Omicron subvariants are emerging every 6 weeks.  This makes getting a handle on this infection nearly impossible and adds dramatically to a sense of equilibrium- that rapidly mutating COVID, constant infection, without surges in death- will be the way of the world for a long time.
8. Hospitalization rates tell us that it is case numbers, not severity, that is surging with Omicron.  There are more cases of COVID infection in San Francisco today than when Omicron really hit so hard in January of this year.  And yet, the number of people with COVID in the ICU remains small, and not increasing remarkably.
9. Top infection mathematicians and epidemiologists calculate that these patterns listed above will be the way of COVID for many years to come.  We are very likely in an actual equilibrium, the definition of being endemic.
10. This endemic is not good.  About 5% of America now gets COVID in each month, and that rate looks like it will persist for some years.  And the balance of spread v. vaccination and precaution has yielded what will look like an annual loss of life in the US of 100,000 deaths a year, for many years.  During the Pandemic phase, the US lost about 400-500,000 lives a year.
11. The drop in death numbers from say 500,000 deaths a year to 100,000 is almost entirely the result of humans developing active immunity to this virus, our bodies have raised up defenses.  And this has been by two realities- getting infection after infection, and getting vaccine after vaccine.  Both have played big roles.  Together, it leaves us with 100,000 deaths a year going forward.  We are nearing that number, 2022 will see 250,000 Americans die, but the trend is towards 100,000 per year.
12. If the 100,000 deaths per year becomes an accepted part of our background, COVID will end up being the 7th leading cause of death in the US, exceeding diabetes, kidney disease for years to come, and the #1 cause of death by germ.
13. The Pandemic gave everyone two eras of control.  The first was, as noted, the option to isolate, which did wonders in nations that managed that well.  The second was, as noted, the option to vaccinate, which again did wonders in nations that managed that well.
14. But now in the Endemic State, the wildly changing nature of Omicron, and threats of entirely new variants, leaves the tried and true strategies of isolation and vaccination appearing unable anymore to achieve total control.  The wily virus has found its path to a deadly equilibrium that leaves us all having to find ways to live with this reality.   This was not the case in the Pandemic phase, but it appears to be so now.
15. During this Endemic State, every American will experience 10-15 COVID infections over the next five years, and perhaps beyond.  More than the common cold, which happens about 3 times a year to adult Americans, and 8 times a year for young children.
16. While COVID continues to spread, over and over, the elderly remain the most at risk, along with all the rest of us who like the elderly have weaker immune systems.  We now know that the chance of dying of COVID goes up 200% every 8 years of age.  By the time you hit 80 years old, that risk of a COVID infection killing you is hundreds of times even that of young A repeated infections and increased vaccination develop, that gap between young and adult will actually widen.
17. However, in time, the harm done by COVID to the elderly will diminish as young folks with intense and powerful immunity to COVID will become the elderly, coming to old age with the powerful fences built in youth remaining intact.  The problem all those older than 50 face is that we can’t build such powerful fences as well anymore.
18. Since the COVID virus will always continue to mutate, it’s current forms that yield our current equilibrium of 100,000 deaths (US) a year could change, as could seasonal changes in our gathering together indoors.  Some see the new equilibrium at 250,000 deaths a year rather than 100,000.  But no one knows, truly.

The essay ends by observing that the wild card of mutation means so much of what we know as listed above current equilibrium could be upended anytime.  A very, very deep, and cold fact about this COVID virus and we humans is that although we have concluded the first major clash, and are entering a new equilibrium, the virus and we humans are not done trying to outdo each other.  The author cites an expert who observes that just like one human goes from being born with an immature and weaker immune system that gains strength and power every year, so all of humanity is doing the same with COVID.  If a newborn is most vulnerable, and say a 6 year old child has hit terrific immune strength, we are right now at about the level of the 3 year old with COVID.  Not openly able to be killed like in 2020, but not yet fully settled in our ability to withstand the assault, in an uneasy, unsteady equilibrium.

Why Posts on Real Answers are Less Frequent on COVID

Readers of Real Answers may have been wondering, posts used to fly about once a week or so, why fewer now?  The above tells all.

In the first two years of COVID, the emerging facts were stark, the choices to stay and preserve being alive were clear.  The updates had to fly often, those facts needed to be shared.

But as I hope the above illustrates, and as I think we all can intuitively feel strongly, we are not in that situation anymore.  Everyone has been infected with COVID, nearly everyone in the US.  The COVID infection will sweep through us many times a year for many years to come.  Vaccines and pills to treat are widely available.  New Omicron vaccines are on the way.

But COVID is proving to be like other respiratory viruses, it mutates like they do.

Together we are entering the world of the Endemic.  It is less clear.  There are far fewer certainties to share.  We struggle with accepting 100,000 or more deaths a year, but struggle just as much to find a way to reduce that number.  We live in a muddy equilibrium with an uncertain future.

That is where COVID and we sit right now, and likely where we will continue to sit for much of the rest of our lives, at least for many, many years.

Even so, Real Answers will continue to share news, there will continue to be news on COVID- how the germ adapts and how we humans adapt; and, we will continue to offer our analysis.  And I remain most grateful that so many have found these thoughts of some help.

Bottom Lines:

1. We are entering the Endemic State of COVID.
2. The bold, devastating period when the virus had its way with us, bursting on the scene, collapsing health systems, is gone, for the moment.  It might still return, but we are now in a different state, a state of equilibrium, a state where the virus is doing all it can to spread, and we are doing all we can to keep it from killing us.
3. That equilibrium leaves us with about 100,000 COVID deaths a year as a steady state reality.  I find that number horrifying, but hard to reduce given the stunning ability of Omicron to spread and mutate.
4. We all, those who have and those how have not, need to get down on our knees and thank our lucky stars that a vaccine exists to keep so many of us alive.  The Omicron variants have cracked the door to spread to the immunized, but being COVID vaccinated remains a potent, the MOST potent way, to stay alive as COVID continues to spread.
5. Nearly every American (95-98%) has had COVID, and current trends suggest each of us, on average will get 10-15 COVID infections a year for at least the next 5 years.  Unless the new Omicron vaccine changes this level of spread, this will be our new equilibrium, our Endemic State.
6. Getting COVID and getting immunized are helping, they have brought death counts down from about 500,000 to 100,000 a year, but both forms of protection help the elderly the least, and so for now, those over 65 years old are where most deaths from COVID happen.  Someone 80 years old is hundreds of times more likely to die from getting COVID than even a young adult.
7. Both the virus and humanity are doing all in their power to have their way.
8. COVID will always mutate to forms that spread better, let’s just hope its new forms do not become more deadly.
9. Humanity will always search for ways to stop its spread.  Let us hope that new vaccines will bring that annual death equilibrium down as close to zero as possible.

My One Takeaway Sentence

The Endemic State is murky, confusing, with changes by virus and humanity always happening, but one fact remains true throughout:  GET VACCINATED, IT IS THE ONE BEST STEP YOU CAN TAKE TO TRULY SAVE THE LIVES OF YOUR FAMILY AND ALL THOSE YOU CARE ABOUT!

To your health,
Dr. Arthur Lavin