Are we ready for the endemic phase of COVID-19?

Dear Patients:

Following are our personal thoughts on the future with COVID-19. Remember, we are not virologists, epidemiologists or public health experts so don’t regard what we say as gospel. However, also remember that our experts have been wrong about this pandemic more often than they have been right.

After nearly two years of this pandemic, it is clear that exposure to and infection by COVID-19 is not preventable. This virus is everywhere and will continue to move around the world in surges. Most experts believe that we have long since entered an endemic phase where the virus will circulate in a way similar to influenza and many cold viruses. In fact, prior to Sars-CoV-2, other coronaviruses have been responsible for circulating respiratory illnesses such as the common cold.

Vaccines are key, but not the entire solution.

Let’s ponder a moment on two statements we hear often about the pandemic.

  1. If those unvaccinated people would just get vaccinated, we would beat this virus.
  2. There is no good reason to get vaccinated if the vaccine doesn’t protect against infection.

Both of these statements are false, but a great number of people are fully invested in one or the other narrative and I believe it will be difficult for many to accept a new paradigm for COVID-19 which emphasizes management and not eradication of the virus. We need this new paradigm.

We certainly had high hopes that the vaccine would squash the spread of the virus, but the Delta variant and breakthrough cases have dispelled that notion. It is important to note that most of the Omicron variant cases found outside of Africa were transported by vaccinated individuals. Fortunately, the vaccine does substantially protect against serious illness from the Delta variant circulating now. For seniors and those with significant medical problems, this is very good news and reason for optimism. Healthy people, vaccinated people and those who have natural immunity should be ok, and we believe this to be true even with the new Omicron variant.

It is past time for us to decide how to handle the endemic phase of COVID-19.

Many experts have been writing about this over the last year and it is time for this administration and the Centers for Disease Control (CDC) to develop a new strategy and more importantly, new public health messaging. For me and many experts, putting all our eggs in the vaccination basket is not enough. Thankfully, we are about to enter a new phase of effective treatment of COVID disease which should keep more and more people out of the hospital and prevent deaths.

Here is what we believe is needed:

It is critically important for us to understand everything possible about breakthrough cases. We initiated booster doses here based, not on our data, but on breakthrough infection research in Israel. This is because the CDC is only tracking breakthrough cases that require hospitalization, leaving many uncounted. How will we know the impact of the new Omicron variant and future variants on the vaccinated if we do not have data from our own population? We need to know how much protection the vaccine affords and whether vaccination can limit spread. Above all, we need to be honest and transparent so people can regain their trust in health authorities. We believe there will be good news about protection soon and the public health messaging should focus on reassuring us that current vaccines dramatically reduce the risk of Omicron hospitalizations and deaths. We need to focus on this full-time and encourage those who are unvaccinated, at least the high-risk ones, to take the jab.

We need to acknowledge that most of the new and possibly more deadly variants will come from unvaccinated countries, and make it a high priority to get vaccines to those countries. The WHO has made many requests to first-world countries to forego boosters and vaccination of low-risk children and to help supply vaccine to the third world. The Delta variant came from India and Omicron from Africa. More are on the way if we don’t supply vaccine and work to overcome vaccine hesitancy in the third world. In the US we are very fortunate to have an abundance of vaccine but after this round of boosters, perhaps we should focus beyond our borders.

We need to determine whether natural immunity is good immunity. Several well-designed studies in Europe have shown this to be true but our own CDC and National Institutes of Health (NIH) have not conducted a study.  We must settle the question of natural immunity as soon as possible. Post infection natural immunity may be the way we finally reduce COVID-19 to the same status as flu and other endemic viral infections, and any vaccine mandate must take the viability of natural immunity into account.

PLAN B: our strategy for living with endemic COVID-19.

Vaccinate all high-risk individuals and provide boosters periodically until we have a more durable vaccine. High-risk people need to get vaccinated, period. High-risk vaccinated people must get a booster. To date, only 42% of those over 65 have gotten their booster. This is far too low and we need to make a push. New vaccines are coming. A protein sub-unit vaccine by Novavax is nearing submission to the FDA as well as a whole virus vaccine from India called Covaxin. These are not mRNA vaccines and hopefully will be an acceptable alternative to those reluctant to accept the new mRNA technology. While it is possible to use mRNA technology to quickly update vaccines for each new variant, we don’t think this is a viable long-term strategy nor do we think there will be wide acceptance of 4th, 5th or 6th booster shots. Perhaps these new vaccines will provide more durable immunity than the mRNA vaccines.

Develop and deploy effective early treatment options. We have monoclonal antibody infusion centers in our area and any high-risk individual who gets COVID should consider acute treatment. We have used it and it works. The treatment is simple and takes 20 minutes but needs to be administered as soon as possible after the onset of illness. Also, new drugs are nearing approval. Products by Merck and Pfizer are poised for review by the FDA and may come to market soon.  Both are protease inhibitors, a class of drug that prevents viruses from multiplying and have been successfully used to suppress HIV. Interestingly, Ivermectin, which has been in the news frequently, acts in a similar manner and is now being evaluated by NIH in a study scheduled to enroll 15,000 patients. It is not currently approved for use with COVID-19 but if found to be effective, it would be a much cheaper alternative ($2) to the projected $700 per treatment cost of the Pfizer drug. A cheap, repurposed treatment for COVID is essential for less developed countries. We hope that these treatments will finally help us transition into an effective treatment phase after the robust vaccination phase of the pandemic.

Recognize that it is important to safely resume normal personal and economic activities. While policies that included lockdowns (school and business closures) were critical in the period when we knew very little about the virus and before vaccines, they had an enormous negative impact on societies globally and the actions of wealthy countries had a dramatic economic effect on poor countries. Many experts believe that the sum total of deaths related to our response to COVID may exceed the deaths from COVID itself once we complete a review of the data. Global poverty and starvation have skyrocketed (more than 30 million entered severe poverty) and have reversed decades of progress in food security and childhood vaccination. We have previously mentioned our concerns about delayed cancer diagnosis, delayed childhood vaccination, overdoses, depression and suicide, and violent crime. These issues have become a worldwide crisis and the full impact will take years to assess.

Recognize and accept that the virus is with us until we have substantial population immunity worldwide (vaccine or natural) or the virus mutates into a minor rather than a major problem. We remain hopeful that both are possible. Until then, we must keep the most vulnerable among us safe with reasonable protection strategies, vaccination, testing, and treatment as we do with other dangerous viruses like influenza. It is important to accept that we cannot vaccinate this virus into extinction. We can be disappointed that this is true, but we need to accept it and move on. Everyone needs to decide how they will live their lives with COVID – how they will safely socialize with family and friends, what activities they will deem safe and what level of risk they are willing to take. (It will be different for everyone, but we can tell you that many patients considered high-risk are participating in more activities than we would like to see.)  Soon, when infections happen to high-risk individuals, we will be able to treat them and keep almost all out of the hospital.

Stop politicizing the COVID-19 pandemic. It’s not just that we’re tired of the political battle over COVID policy, but we are frustrated knowing how harmful this battle is for the good people of this country. We need a reasonable and practical Plan B in order to live with this virus.  Pandemic politics will prevent us from getting to where we need to be. It stifles science and innovation and delays progress towards learning how to live with COVID.

We hope we’ve provided a reasonable perspective on a topic that can be difficult to consider objectively. Thank you for reading this, and most importantly, for allowing us to take care of you throughout these challenging times.


Cathy Tong, CFNP

Eugene Shmorhun, M.D.