The influenza pandemic of 1918 lasted approximately two years in three distinct waves, claiming an estimated 675,000 lives in the U.S. and more than 50 million worldwide. Although COVID-19 results from a different virus, its nearly two-year time period appears to share some characteristics: Across asynchronous global waves, there have been more than 775,000 COVID deaths reported in the U.S. and 5 million globally; and an estimated 17 million excess deaths worldwide from COVID burden.
As COVID recedes in the rearview mirror, it is appropriate to reflect on the current situation and what’s next. Vaccination rates are increasing nationwide and in much of the world, and COVID case counts generally are decreasing. Despite this generally positive picture, a more guarded and nuanced perspective is required to best prepare for the upcoming six months.
To understand what lies ahead, focus on Europe. Across much of the European Union, especially Western Europe, vaccination rates are greater than 70%, but case counts still are staggering in countries such as Austria, Germany and Belgium. In the United Kingdom, a place with a high vaccination rate but also one of the first European countries to relax measures such as masking, surges in COVID case counts continue to be reported.
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These ongoing surges reflect an important limit in current vaccine-reliant mitigation strategies. And as temperatures drop and activities move indoors—often in poorly ventilated spaces, and with limited masking and social distancing—we should expect a resurgent wave of COVID infections, primarily in the unvaccinated. In Romania, vaccine refusal is high and fewer than half of adults have received at least one dose. The country recently reported the world’s highest per capita COVID death rate.
Austria reported a significant spike in COVID cases in late October and early November, prompting a response from the government. In Austria and Germany, where vaccination rates are just below 70%, additional measures impose stricter rules on unvaccinated individuals, such as requiring negative COVID tests to ride public transportation. In Italy, negative COVID swabs are required for unvaccinated individuals to go to work. Herd immunity will require at least 85% community vaccination.
Similar COVID-related public health challenges are imminent in the U.S. this winter, with surges of infections and hospitalizations in the unvaccinated. At present, a vast majority of COVID hospitalizations are unvaccinated individuals.
Although health care systems are better prepared for this challenge—with improved diagnostic testing, adequate personal protective equipment and more effective, evidence-based treatments—the burden on health care workers remains substantial. Appropriate staffing models, with contingency planning for surges, are required for the coming winter COVID surge.
Face masks and social distancing should be strongly encouraged this winter, particularly in indoor crowded environments, regardless of vaccination status. Mask use also may curtail the spread of influenza and other respiratory viruses.
Roughly 59% of the U.S. population is vaccinated against COVID, and decreasing the vaccination gap requires a multimodal approach. This includes relentless, effective public health messaging, with a particular focus on increasing childhood COVID vaccination.
Employer-mandated COVID policies effectively increase adult vaccination coverage and should be accelerated as broadly as feasible. Booster shots now are available for all adults and should be strongly encouraged by health authorities, especially for the most vulnerable. For unvaccinated individuals, negative COVID tests may be required as a public health safety measure for large gatherings and events, and for commercial airline, rail or bus travel, especially as case counts rise.
It is unreasonable to expect an eradication of COVID. Levels of immunity likely greater than 85% of the population are required to minimize community transmission and make it an endemic disease—one that is consistently present at lower levels, much like influenza or other respiratory viruses. If we do not reach herd immunity, wearing masks indoors and some social distancing will be a part of our new normal.
Many unanswered questions remain, such as the duration of natural or vaccine-acquired COVID immunity, along with the frequency of necessary revaccination. New strains of COVID may appear, particularly from geographic areas with low vaccination and high community transmission. These epidemiologic issues and evolving challenges will clarify with time.
As the second year of the COVID pandemic draws to a close, there is reason for optimism. In addition to highly effective vaccines, we now have two oral medications to effectively treat early COVID infection. However, strong public health messaging on mask use, social distancing and vaccination are urgently required to minimize the winter case surge and facilitate the transition from COVID pandemic to endemic.
Gonzalo Bearman, M.D., is a professor of medicine and chief of infectious diseases at VCU Health. Michelle Doll, M.D., is an assistant professor of medicine and associate hospital epidemiologist at VCU Health. Richard P. Wenzel, M.D., is an emeritus professor of medicine at VCU Health.