Throughout the COVID-19 pandemic the most important metric to me was never cases, but hospitalizations. When dealing with an inevitable endemic respiratory virus that cannot be eradicated, the goal should be shifting disease to mild disease.
In the U.S. this has not been an easy task as much of the population have not had to individually risk calculate as extolling these techniques were not a major component of official response (which was heavily “abstinence-only” focused), vulnerable populations such as nursing home residents were not protected, and too many high-risk individuals have shunned the life-saving vaccines.
These factors were compounded by more contagious variants such as delta and omicron. The variants, because of their characteristics, prolonged the process of taming the virus and decoupling cases from hospitalization to the degree needed to remove hospital capacity concerns. Additionally, uncertainty about the variants made public health officials reticent to aggressively scale back mitigation measures that were in place.
As the omicron wave recedes and hospitalization numbers fall, I am optimistic that omicron will, hopefully, be the last time we experience major sustained hits to hospital capacity (although there will always be a baseline of COVID-19 hospitalizations and hot spots that flare). I am optimistic because of the hospitalization data and the success of vaccines, antivirals, monoclonal antibodies and home tests — tools that are finally being used to their full potential to defang the virus and relegate its status to equivalent to many other respiratory viruses we deal with year in and year out.
Currently, the Centers for Disease Control and Prevention’s (CDC) mask guidance is based on case counts in each geographic area and when those case counts cross a threshold that exceeds “significant transmission” masks are recommended to be worn in indoor settings by all irrespective of vaccination status. With omicron’s prolific spread the entire country was soon awash in a sea of red on maps but with very different conditions in hospitals — some where under stress others were not. If a metric being used for masking guidance cannot meaningfully distinguish areas in which hospitals were not threatened from those in which they were, it is not a useful metric to gauge public health measures. These measures, which originated from an earlier time in the pandemic when there were not oral antivirals, prophylactic monoclonal antibodies for the immunocompromised and lower levels of vaccination, do not make sense any longer.
Masking will soon become a personal decision, they will not be, as leading infection disease expert Dr. Anthony Fauci recently stated, “centrally mandated.” Everyone’s risk tolerance will govern whether and when they mask. For those with high-risk conditions that cause poor responses to the vaccine, it will be important for them to continue to be vigilant in high-risk settings (similar to what they are counseled to do during every respiratory virus season), make sure they are up-to-date on vaccinations, and have access to oral antivirals and monoclonal antibodies. One-way masking, especially with the higher quality masks that are available and recommended, does have benefit.
For some it may be difficult at first to navigate risk with a new endemic respiratory virus that will continue to infect, hospitalize and kill. But the tools and knowledge that medicine and science that we now have make this a much more manageable risk, along with second generation vaccines and more treatments, we will continue to destroy the ability of the virus to ever threaten the human species the way it once could.
Amesh Adalja, M.D., is an infectious disease physician and a senior scholar at the Johns Hopkins Center for Health Security.
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