It’s becoming the mantra of 2022, the most optimistic formulation of the end of the pandemic, less ambitious than “stop COVID” but more than “flatten the curve.” The world, we are told, must learn to “live with the virus.”
But what “live with the virus” means may depend on where you live.
In Britain, Prime Minister Boris Johnson has been talking about a “long-term strategy for living with COVID-19” that would “protect our liberty and avoid restrictions in future by relying instead on medical advances — especially the vaccines, which have already saved so many lives.”
In Spain, Prime Minister Pedro Sánchez is encouraging people to start thinking about “the evolution of COVID from pandemic to an endemic illness … It’s not going to be from one day to the next. And it won’t be immediately. But it will come.”
Health experts have warned against declaring that moment too soon. But many countries in Europe, where vaccination rates are high and hospitalizations through the omicron wave have been manageable, think they will get there before the United States. Already this week, Denmark became the first European Union country to lift almost all its remaining restrictions, concluding that COVID-19 no longer poses a “critical threat” to society. Prime Minister Mette Frederiksen said she looked forward to “an open Denmark with hugs, parties and festivals.”
Yet while people the world over are eager for a return to normal, there’s intense debate about what that should look like. Should people have to stay home if they’re infected? How should we track cases? How long do mass public health campaigns make sense?
The end of mandatory isolation
Most countries have ratcheted down their isolation requirements for people who test positive for the virus. Some followed the United States in recommending five days at home. Denmark advises four days for anyone with mild or no symptoms.
But as part of living with the virus, some countries and regions want to scrap isolation requirements entirely.
In England, the law pertaining to isolation — with associated fines of up to 10,000 pounds, or about $13,500 — is set to expire on March 24. Johnson said he doesn’t expect to renew it, and may ask Parliament to move the date forward.
“As COVID becomes endemic,” Johnson said, “we will need to replace legal requirements with advice and guidance, urging people with the virus to be careful and considerate of others.”
In Spain, the Catalonia region has pondered abandoning isolation requirements for infected but asymptomatic people as soon as this spring. The thinking is that the vast majority of asymptomatic people will never know they had it anyway, and punishing those who took tests voluntarily would be unfair.
Antonio Zapatero, the deputy health secretary of the Madrid region, told The Washington Post he anticipated the rise of a “culture of self-care.”
“If you have symptoms, do a test. If you have symptoms, don’t go to work. If you have symptoms, don’t meet with other people,” he said.
But scientists are divided over how quickly governments should cede decisions about acceptable risk to individuals. “There is a huge amount of disagreement between different scientists on this issue,” said Paul Hunter, a professor of medicine at Britain’s University of East Anglia.
Hunter said his position has evolved over the past year and he now assesses the “costs and benefits of isolation have tipped away from being beneficial overall, probably to being harmful” in Britain, even if not everyone with symptoms would follow common sense and public health guidance going forward. He cited the negative impact of isolation on labor shortages and mental health, and the growing number of infections that already go undetected despite current isolation rules.
Troels Lillebaek, chairperson of Denmark’s national coronavirus variant assessment committee, cautioned that exposing a large share of the population to the virus within a short time span could still overwhelm emergency rooms. Lillebaek suggested that restrictions may need to be re-envisioned in a seasonal context — with tighter rules in colder months that are most conducive to viral spread. “You could have a situation during spring and summer where there are other restrictions than during the winter,” he said.
Changing how to count cases
Since the earliest weeks of the pandemic, the world has been tracking the spread of the virus case by case by case. Those case counts have helped governments make decisions about when to impose restrictions and when to lift them, and because hospitalizations lag behind infections, case numbers have provided a critical early warning system for health systems.
But by definition, if and when it becomes endemic, the virus would persist in a more predictable way, at low or moderate levels in societies. Counting individual cases would lose some of its significance. And so some governments and epidemiologists have begun to explore new ways to track the virus.
Spain is working on a “sentinel surveillance system” that would estimate cases based on a statistically significant sample rather than counting each infection. That sort of system is regularly used for the flu. And several Spanish regions have been experimenting with it for the coronavirus.
Scientists in Madrid, for instance, selected eight community health centers and three hospitals where anyone who gets treated and has symptoms of a respiratory infection will get tested for the flu and the coronavirus.
“It is a very significant and representative sample of the Madrid region,” Zapatero said. Going forward, he said, “I don’t think we’ll count each case.”
At a national level, the plan could still face hurdles, including whether other countries would accept estimated cases as a legitimate way to assess risk levels in Spain. Spanish health officials say their model may in fact boost their understanding of the virus’s spread, as self-tests and strained official testing capacity currently skew the official figures.
In a report last fall, the European CDC cautioned that “a sentinel approach would need a higher coverage of the population under surveillance compared with influenza surveillance, and both higher testing and sequencing intensity.”
Hunter agreed that sequencing will remain crucial. Similar to how the influenza shots’ composition is decided based on large-scale sequencing efforts, monitoring could be key to developing future vaccine generations against the coronavirus, he said.
“I could well imagine that we would be still sequencing many of the strains from the most severely ill people, and looking for the appearance of variants that are potentially threatening,” Hunter said.
From mass campaigns to targeted approaches
Responding to the pandemic has involved the largest-scale public health campaign the world has ever seen, with nationwide lockdowns, more than 4 billion people vaccinated and billions upon billions of tests. To be sure, the rollout of protection has reflected and reinforced global inequalities. Vaccination is still just getting underway in some countries, leaving populations vulnerable to infection and the world vulnerable to new variants. But as the global omicron wave begins to subside, some countries are beginning to talk about moving away from mass public health efforts. Instead, they want to focus on protecting the most vulnerable and on intercepting disease progression in those most susceptible to severe illness.
“As we evolve to move to living with COVID,” the U.K. Health Security Agency wrote in a draft policy paper viewed by Reuters, “response will move from a whole nation approach to a targeted response, focused on protecting the vulnerable.”
In Britain, that may mean the end of free antigen tests offered to all by the National Health Service. There was an uproar last month after a report in the Times that free tests would be limited to symptomatic people and people in high-risk communal settings. Johnson tried to calm fears — but would only commit to free tests being available “for as long as they’re very important.”
While Denmark dropped most coronavirus restrictions on Tuesday, including health passports and general mask mandates, it will maintain certain measures to protect vulnerable groups. Face masks will remain recommended in nursing homes, for example, and a new round of booster shots for vulnerable people could be rolled out later in the year.
Danish authorities have considered their massive testing and sequencing capacity a major advantage through the pandemic. But going forward, Lillebaek said he anticipates “more guidance for specific situations, rather than the general society.” Instead of mass testing, for example, authorities may advise people to get tested before meeting an immunocompromised or elderly person.
Yves Hansmann, the head of an infectious diseases hospital unit in the French city of Strasbourg, said there may also need to be frequent testing of vulnerable individuals, to be able to provide care at early stages of illness. European countries have ordered millions of doses of anti-viral pills that the most vulnerable could take soon after the first sign of symptoms.
The focus of future booster campaigns may similarly lie on vulnerable groups, as is already the case with the fourth vaccine shot that’s become available in Denmark and Israel.
“We can’t vaccinate the planet every four to six months. It’s not sustainable or affordable,” Andrew Pollard, chair of the U.K.’s Committee on Vaccination and Immunization and chief investigator for the Oxford-AstraZeneca coronavirus vaccine, said in an interview with the Telegraph newspaper.
Clive Dix, the former chair of Britain’s vaccine task force, has called for more efforts to develop vaccines that are fine-tuned to protect vulnerable groups.
After two years of living with restrictions, learning to live with the virus may be daunting. People are understandably more excited about the return of indoor dining and consistent schooling than they are about the possibility, for instance, of working alongside someone newly infected with the virus. But there may not be a viable alternative.
“Neither the health system nor society as a whole can afford to continue testing asymptomatic people or people with mild symptoms and isolating all the positive ones, with the consequences that this entails at a social and economic level due to the massive sick leave of healthy people,” writers linked to one of the biggest medical associations in Spain opined in a recent oped. “We must put an end to the exceptionality: COVID-19 must be treated like other diseases.”
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Noack reported from Paris, Rolfe from Madrid and Booth from London.