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The Coronavirus Exposed. Part 4: More Updates

HIV (AIDS) viruses in blood with red blood cells and white blood cells. 3D illustration

I know COVID has been around a while, so now even my third part is acting very sluggish. So I will start a 4th part. The previous three sections will remain all accessible for viewing, though they will now function as an archive.

Table of Contents

-COVID rebounds aren’t definitively linked to Paxlovid—here’s what we know

-Doctors Sue Biden Admin, Big Tech Over COVID Censorship

-COVID-19 took a unique toll on undocumented immigrants

-What scientists have learnt from COVID lockdowns

-One of Long COVID’s Worst Symptoms Is Also Its Most Misunderstood

-Is the COVID-19 pandemic over?


COVID rebounds aren’t definitively linked to Paxlovid—here’s what we know

When Anthony Fauci announced in June that he had experienced a “rebound” case of COVID-19—testing positive mere days after a negative test result—many Americans were shocked this could happen. But in the intervening weeks, a growing number of people have suffered a rebound themselves or encountered others in similar straights, including another high-profile case just last week of President Joe Biden.

“It’s hard to ignore the anecdotal evidence of rebounding peppered throughout social and mass media,” says Katelyn Jetelina, an epidemiologist at the University of Texas School of Public Health who writes the popular blog Your Local Epidemiologist.

A rebound occurs when a person tests positive for COVID-19 or suffers a recurrence of symptoms between two and eight days after recovering from the initial infection and testing negative, according to a health alert for physicians issued by the Centers for Disease Control and Prevention in May. In many cases, the rebound is happening in people taking an antiviral medication, which is recommended for individuals at high risk of progressing to a severe form of COVID-19, ending up in the hospital or dying from the infection.

Those are the known facts. Everything else about rebound is currently subject to speculation.

“There’s a lot we don’t know right now,” Jetelina says. “We don’t know how often this is happening, and we don’t know what’s causing it.” And while the phenomenon is often linked to antivirals, more than one factor may be involved.

How frequently are COVID-19 patients rebounding? 

Pfizer’s official clinical trial for its antiviral Paxlovid took place when the Delta variant was predominant in the U.S. That trial reported that fewer than 2 percent of people taking the medication—which involves two pills taken twice daily for five days—experienced rebound.

But doctors who have prescribed Paxlovid in more recent months say that figure is likely now a woeful undercount.

Scott Roberts, an infectious diseases physician at Yale Medicine, says his experience puts the number closer to 5 percent. That tracks with a study posted online but not yet peer-reviewed in which researchers from Case Western Reserve University evaluated rebound cases following courses of Paxlovid and Lagevrio—the Merck antiviral generically known as molnupiravir—between January and June 2022.

Paxlovid is the more widely prescribed antiviral, with three million courses given since its emergency authorization by the U.S. Food and Drug Administration last December. By contrast fewer than half a million courses have been administered for Lagevrio.

In the Case Western Reserve research, some 3.5 percent of Paxlovid takers rebounded after seven days; for those taking Lagevrio, the number was close to 6 percent.

With the latest Omicron variant, BA.5, dominant in the U.S. since early July, some doctors think today’s rebound numbers are not only higher but will continue to rise. Aftab Khan, an internal medicine physician in Davenport, Florida, says that about a quarter of his elderly Paxlovid patients have rebounded, and he expects a further increase because this wily subvariant is likely even better at evading antibodies.

Is rebound linked to antiviral treatment? 

Though the rate of rebounds seems to be higher in those taking antiviral medicine, there isn’t enough data to definitively say that there is a link between the two.

In the Pfizer Paxlovid trial, patients taking placebos rebounded at rates similar to those getting the drug. The CDC states that a brief return of symptoms “may be part of the natural history” of COVID-19 in some people, whether or not they’ve received an antiviral. For this reason, the CDC calls the phenomenon COVID-19 rebound rather than the more widely used term Paxlovid rebound.

But Yale’s Roberts says that while symptoms did reappear in some cases before the antivirals were authorized, this was very rare.

What causes COVID-19 to rebound is another issue that’s currently unclear. According to Jetelina, it’s possible the drug doesn’t sufficiently clear the virus in some people, so once the patient stops taking it after the fifth day, the microbe can start multiplying again.

It may also be that rebound happens when treatment is started too early; current recommendations call for initiation as soon as possible, ideally within the first five days, but that may not give the immune system time to mount a full response. It’s also possible that some people had been reinfected after their illness ended, although this wouldn’t explain rebound cases in people who hadn’t had any additional exposure after recovering.

According to Pfizer spokesperson Kit Longley, rebound is not caused by the virus becoming resistant to Paxlovid, although he notes that the company continues to monitor the data. In a report posted online in June but not yet published in a medical journal, Pfizer researchers describe details from their original study, in which rebound was not linked to any mutations occurring in the virus in people taking the drug.

This is consistent with research published in June by a team at the University of California, San Diego, School of Medicine. That team performed detailed antiviral sensitivity and neutralizing antibody testing on a single rebounding patient. They concluded the relapse was not caused by drug resistance or by impaired immunity, but instead likely resulted from the virus having insufficient exposure to the drug.

Who is at greatest risk of rebounding and what should you do?

Who might rebound—and what they should do about it—are also open questions.

In the Case Western Reserve research, people with the most serious medical conditions, such as organ transplant recipients, those on immunosuppressant medicines, those with comorbidities like heart disease or diabetes, and tobacco users were most prone to COVID-19 rebound.

Of course, this is also the group most likely to reap the benefits from taking an antiviral.

Taking an antiviral also seems to be especially important for high-risk individuals over age 65, according to an Israeli study of more than 2,000 people that has not yet been reviewed by other scientists. People in that age group treated with antiviral therapy were 67 percent less likely to be hospitalized and 81 percent less likely to die than those not taking the drug, a finding not found for the younger study subjects.

If someone does experience rebound, the CDC says they should assume they’re infectious and begin another round of five-day isolation, followed by five days of masking. However, the agency admits that no one knows yet whether a person’s infectiousness during rebound differs from that during their initial bout.

Some doctors say rebound patients can leave their homes as soon as an antigen test again comes back negative. But Yale’s Roberts thinks it’s imprudent to end isolation early no matter the test results. “Testing errors are frequent, and the lower sensitivity of rapid antigen tests would make me nervous if someone leaves isolation before the allotted time,” he says.

Fortunately, most cases of rebound have been mild. Rebound led to hospitalization in fewer than one percent of cases, according to a CDC study published in June. This makes sense, Roberts says, “since the virus is starting at a lower amount, and the initial drug course allowed time for immunity to build.”

Some doctors are prescribing a second round of Paxlovid—something Fauci says was given to him—but there is no evidence yet to support this expanded regimen. Pfizer’s Longley says the company is currently working with the U.S. Food and Drug Administration to finalize a study protocol evaluating whether this is beneficial.

It’s also possible that a longer course of the initial antiviral medication, such as seven or 10 days instead of five, might be more effective at blocking replication of the BA.5 Omicron subvariant, which generates higher viral loads than its predecessors, says Jill Weatherhead, an infectious diseases expert at Baylor College of Medicine. She notes, though, that such a protocol would need to be studied before physicians might start prescribing it.

Uncertainties surrounding rebound should not prevent people who could benefit from antivirals from taking them, Roberts insists, even though some patients have told him they want to avoid the drug for this reason.

“This is a dangerous and misguided strategy,” he says. The purpose of an antiviral is to prevent hospitalization and death, not to keep someone from needing to isolate longer.

Doctors Sue Biden Admin, Big Tech Over COVID Censorship

A group of doctors has filed a lawsuit against several big tech companies, claiming that Twitter, Google, and Facebook worked with the government to censor criticism of federal and state COVID policies in violation of the First Amendment.

The case, State of Missouri v. Joseph R. Biden, involves a group of prominent physicians and epidemiologists who were critical of the government’s restrictive COVID policies, including lockdowns, mask mandates, and vaccine mandates.   The doctors made Freedom of Information Act requests related to the White House’s public statements in 2021 about working with Big Tech to suppress COVID misinformation. As a result of those FOIA requests, they claim to have found emails and documentation that can prove that the CDC and the Department of Homeland Security asked Google, Twitter, and Facebook to take down certain social media posts and to suspend certain accounts for questioning COVID policies.   The lawsuit is arguing that at that point, these companies were no longer acting just as private entities, but as arms of the government. If true, their actions would be unconstitutional.    New Civil Liberties Alliance’s press release states in part, “This insidious censorship was the direct result of the federal government’s ongoing campaign to silence those who voice perspectives that deviate from those of the Biden Administration. Government officials’ public threats to punish social media companies that did not do their bidding demonstrate this linkage.”
Tech Response
The tech companies could deny they were acting as a result of government pressure, as part of the Communications Decency Act, known as Section 230, gives Big Tech some special protection from civil liability. Kara Frederick, director of the Tech Policy Center at the Heritage Foundation, told Morning Wire that will likely be their defense.

(Update 9/2/2022)

*Note it looks like that my Covid Vaccine article has reached a critical mass, and since the Covid related updates have slowed down substantially I will be just adding all of these updates to this posting. So the vaccine posting can now be considered to be a archived file along with the three main Covid postings as well.

COVID-19 took a unique toll on undocumented immigrants

The pandemic compounded barriers to accessing medical care—and many continue to delay or forgo treatment.

(Update 9/4/2022)

Imelda fled sexual violence at the hands of drug cartels in rural Puebla, about two hours outside of Mexico City, and arrived in New York City in 2013. She had no health insurance, barely spoke English, and as an undocumented immigrant, she avoided situations that required revealing her identity.

So in March 2020, even as the city became the national epicenter of the COVID-19 pandemic, Imelda, who asked that her surname not be used due to risk of deportation, resisted going to the hospital for her escalating fever and fatigue. “When the symptoms began, I wanted to go,” Imelda says, but her fears outweighed her desire for treatment.

Since arriving in the U.S. Imelda had visited a hospital only once, for the birth of her second daughter. But in addition to worries about revealing her immigration status, she was afraid of incurring medical bills that exceeded what she earned cleaning houses. Delaying or forgoing care for COVID-19 was a decision that Imelda and many other undocumented immigrants made due to the unique healthcare challenges they face in America—challenges of inequality that are having nationwide consequences.

The U.S. is home to more immigrants than any other country in the world: Per the latest estimates, 46.7 million foreign-born individuals reside in America, making up nearly 14 percent of the national population. About 11 million of these people are undocumented, but they’ve filled critical jobs that citizens often don’t want, including working in agricultural fields, the service industry, and in healthcare facilities, while paying billions in taxes each year.

According to a December 2020 report from the bipartisan political organization, 69 percent of undocumented immigrant workers in the U.S. held jobs that were deemed essential during the pandemic—and they were 50 percent more likely to get COVID-19 than U.S.-born workers. For many, that’s meant surviving a public health emergency while working low-paying jobs (often on the frontlines) that don’t offer benefits; it can also mean being ineligible for free or subsidized public health insurance. To compound these problems, countless workers are unaware of their coverage options or fear accessing them.

A 2017 study found that about half of the undocumented immigrants living in America lacked necessary health insurance. That often leaves a large proportion of this community delaying care, which could result in health complications or an advanced illness and a greater reliance on emergency rooms. “When they’re unable to pay those costs, the money goes into uncompensated care costs, raising the debt in the healthcare system,” says Drishti Pillai, director of immigrant health policy at the Kaiser Family Foundation, a nonprofit organization focusing on national health issues.

For those like Imelda living in the shadows, the COVID-19 pandemic once again revealed the deep-seated inequities to accessing medical care in America. Even today, people in this underserved community continue to suffer, often with little help.

Too little care, too late

In addition to medical costs and insurance access, a sustained lack of trust has dissuaded the country’s growing immigrant population from engaging with the healthcare system. This mistrust arises in part from the discrimination immigrants have experience based on how they look, where they’re from, or their inability to speak English. “It’s really hard,” Imelda says.

Anti-immigrant rhetoric has also kept the undocumented community from accessing timely care. At the Elmhurst Hospital Center in New York City, which caters largely to New York City’s low-income immigrant population, “we’ve watched our volume dip at times when there are national discussions about immigration and whether it was good or bad for the country,” says Stuart Kessler, one of the hospital’s emergency medicine physicians.

In Houston, researchers noted that Latina immigrants delayed their first prenatal care visit and reduced the number of visits overall during their pregnancies after July 2015, when rhetoric around deportation intensified in the lead-up to the 2016 presidential election.

That fear of accessing healthcare in a climate of growing anti-immigrant sentiment continued through 2020 when the COVID-19 pandemic hit and further exacerbated already existing barriers between the healthcare system and this underserved population.

“We just didn’t realize our systems of care were this fractured, and that so many people could fall through the cracks because the cracks were just so huge,” says Jairo Gúzman, president of Mexican Coalition, an advocacy group for child and family rights based in New York.

That was true for Imelda in March 2020. With no one to consult and no place to isolate, she endured her COVID-19-like symptoms for a week in the three-bedroom apartment she shared with seven others—including her husband and two kids. As she found herself struggling to breathe a hospital visit became an urgent necessity.

She went to a hospital and, at an overwhelmed emergency room, nervously waited for an online interpreter so she could talk with the medical staff and find out if she had COVID-19. “Five minutes is all I got,” she says, which wasn’t enough for her to explain all her symptoms while also answering the doctor’s questions and noting his instructions about next steps.

The medical team didn’t give her a COVID-19 test because a chest x-ray showed no irregularities. Instead a nurse gave her Tylenol to reduce her fever and, within a few hours, Imelda was sent home with the assurance that she’d receive check-in phone calls and could return if her symptoms worsened.

But no calls came, and Imelda’s health continued to deteriorate. Over the next four weeks, her breathing became increasingly difficult and her body was consumed by extreme exhaustion. “I would walk a little and I’d be gasping for breath, and on some days I couldn’t stand up at all,” she says. “I thought I was done—this was it.”

A $400 bill from her initial ER visit deterred her from seeking further care. (The hospital later reduced her bill by half because she had lost her cleaning job.)

Recalling these struggles brought Imelda to tears when we met at her home in May 2022. She is aware that the consequences of delaying care could have been fatal, and she knows others who are still batting lingering symptoms without seeking medical help.

COVID-19 hits those living in the shadows

Even now the true impact of COVID-19 on undocumented immigrants, especially in the early months of the pandemic, remains murky.

One of Susan Rodriguez’s patients in New York—an 88-year-old Ecuadorian women—lost her son to COVID-19, possibly because they waited too long to seek medical care. They were both undocumented and uninsured and decided to treat his symptoms at home. Eventually, they had no choice but to call 911 and take him to a hospital. But the medical interventions came too late. He passed away two days later, leaving his mother distraught and unsure how to cope.

“She had never sought therapy in her life,” says Rodriguez, a clinical social worker and a licensed therapist. “She came with a lot of guilt,” and wished she had known she could have applied for emergency Medicaid to cover the costs.

“We heard of cases where people stayed at home or delayed care for COVID-19 almost every day,” adds Don Garcia, medical director at Clínica Romero, a community health center in Los Angeles that primarily serves Latino and immigrant populations. Some of these people narrowly escaped death.

Antonio, who asked that his full name not be used due this immigration status, was one of them. He is undocumented and had arrived in Oxnard, a city in the Greater Los Angeles Area, from Mexico in 2019. Terrified of revealing his personal details, the 40-year-old restaurant worker remained uninsured and unvaccinated. He got infected in December during the Omicron wave and his condition deteriorated rapidly.

“By the sixth day I was so desperate that I wanted to go to a hospital,” he says, but he decided against it because of his immigration status. “There were three days when I was completely lost, barely conscious, I had no clue if I was alive,” he says, overwhelmed with emotion as he shifts in his chair and grabs a tissue to wipe away tears.

Embarrassed, Antonio apologizes and looks around the conference room at the nonprofit Mixteco Indigena Community Organization Project’s office in Oxnard in April this year. After a pause, Antonio recalls how he begged his boss to take him back after missing work for almost 22 days; he was behind on rent and had a family to support. “I think it’s very different to have COVID as an immigrant in this country,” he says.

Those who did turn to the medical system sometimes experienced discriminatory behavior in the form of being treated rudely or disrespectfully for not speaking English, or they felt that they weren’t being heard.

“People in the healthcare system can come with a biased lens,” says Mireya Vilar-Compte, a public health professor at Montclair State University in New Jersey with expertise in healthcare inequities. She stresses a need for more doctors, nurses, and administrative staff from diverse ethnic and racial backgrounds as one part of the solution.

Living with long COVID

More than two years into the pandemic, undocumented immigrant populations still feel they have few places to turn as they battle the aftereffects of the disease that disproportionately impacted them. With little help, some are enduring long COVID symptoms, including fatigue, brain fog, and breathing and sleeping difficulties, as well as anxiety and depression.

In Los Angeles, Ana, who asked that her last name not be used fearing deportation, has been self-medicating to manage the fatigue and body pain that has lingered for months after her COVID-19 infection last summer. She has been avoiding a visit to a doctor because she’s uninsured and undocumented, so the 38-year-old part-time house cleaner uses painkillers that she buys from street vendors in downtown L.A.

“It has gotten to a point where I feel depressed that I’m going to have to take these pills for life,” she says. “I need to work fast, but I do get tired.”

Fortunately for Imelda, who despite being vaccinated has contracted COVID-19 twice since her March 2020 diagnosis, New York expanded its healthcare-for-all program to her borough, Queens, in September 2020. Called NYC Care, this city-funded program guarantees low-cost and no-cost services to all New Yorkers who don’t qualify or can’t afford health insurance, irrespective of immigration status.

Since then Imelda has been seeking healthcare to cope with her heart palpitations, trouble sleeping and breathing, and post-COVID depression. She’s had MRIs, cardiac screenings, and has been seeking physical and psychotherapy.

Nationwide, though, such programs are rare, Pillai says. Today, seven states and the District of Columbia offer some type of healthcare coverage for some or all age groups of the undocumented population, but she says the effort should be expanded nationwide. When individuals can use primary and preventative care, they rely less on emergency medical services, which are extremely expensive. “Economically, in the long-term, it’s not the best idea to prevent some groups from accessing benefits to which a lot of them already contribute,” Pillai says.

But such an effort would require addressing the existing bias and discrimination in the medical system. Despite now being insured, Imelda says “I don’t feel like they see me the same way as they see someone who’s American.” Especially when it comes to healthcare, “I wish everyone was treated the same.”

What scientists have learnt from COVID lockdowns

Restrictions on social contact stemmed disease spread, but weighing up the ultimate costs and benefits of lockdown measures is a challenge.

(Update 9/7/2022)

A man walks across a deserted highway in Wuhan, China, in February 2020, during the city’s first lockdown. Credit: Getty Images

In March 2021, a doctor in Brazil named Ricardo Savaris published a now-discredited research paper that went viral on social media.

It had been a year since the first wave of the COVID-19 pandemic forced governments to apply the desperate measures collectively known as lockdowns — cancelling sporting and cultural events, closing retail outlets, restaurants, schools and universities, and ordering people to stay at home. At the time, countries were once again dialling lockdown policies up or down, as the Alpha variant of the coronavirus SARS-CoV-2 surged in different places.

Lockdown measures did what they were supposed to. When they were enforced rigorously enough to reduce people’s social contacts sharply, they shrank COVID-19 outbreaks; several studies had demonstrated this.

But Savaris, an obstetrician and gynaecologist at the Federal University of Rio Grande do Sul in Porto Alegre, tried a fresh analysis together with three colleagues (who worked in statistics, computer science and informatics). They compared 87 locations around the world, in pairs, to see whether a lower rate of COVID-19 deaths correlated with greater time spent at home, assessed using anonymized cellphone data released by Google. In most cases, their paper in Scientific Reports concluded, it didn’t.

The paper was highlighted by prominent lockdown sceptics and some news sites and swiftly gained notoriety. “The findings were quite remarkable, on the face of it,” says Gideon Meyerowitz-Katz, an epidemiologist at the University of Wollongong, Australia. As he and others would show, the results were wrong, because of errors in the paper’s choice of statistical methods.

Within a week, Scientific Reports added an ‘editor’s note’ to the paper, alerting readers to criticisms. Nine months later, the journal published two letters that laid out the paper’s errors. A week after that, it retracted the work, although neither Savaris nor his co-authors agreed with the retraction. (Scientific Reports is published by Springer Nature; Nature’s reporting is editorially independent of its publisher.)

The retracted paper is not the only one to contend that lockdowns failed to save lives. But these analyses are out of step with the majority of studies. Most scientists agree that lockdowns did curb COVID-19 deaths and that governments had little option but to restrict people’s social contacts in early 2020, to stem SARS-CoV-2’s spread and avert the collapse of health-care systems. “We needed to buy ourselves some time,” says Lauren Meyers, a biological data scientist at the University of Texas at Austin.

At the same time, it’s clear that lockdowns had huge costs, and there is debate about the utility of any subsequent lockdown measures. School and university closures disrupted education. Closing businesses contributed to financial and social hardship, mental ill health and economic downturns. “There’s costs and benefits,” says Samir Bhatt, a public-health statistician at Imperial College London and the University of Copenhagen.

Scientists have been studying the effects of lockdowns during the pandemic in the hope that their findings could inform the response to future crises. They have reached some conclusions: countries that acted quickly to bring in stringent measures did best at preserving both lives and their economies, for instance. But researchers have also encountered difficulties. Analysing competing harms and benefits often comes down not to scientific calculations, but to value judgements, such as how to weigh costs that fall on some sections of society more than others. That is what makes lockdowns so hard to study — and can lead to bitter disagreement.

Tricky calculation

There’s a fundamental difficulty with analysing the effects of COVID-19 lockdowns: it is hard to know what would have happened in their absence.

Lockdowns do reduce viral transmission, as the shutdown of Wuhan, China, showed when SARS-CoV-2 first emerged. Even in countries that didn’t emulate China’s all-in approach of closing borders, ordering citizens to stay at home and isolating people with COVID in central facilities, lockdown measures still cut disease spread. In May 2020, for instance, Bhatt and others analysed lockdowns in 11 European countries and extrapolated from the fall in viral transmission that these measures alone had saved more than 3 million lives.

That paper’s methodology has also been questioned, however. One issue is that it could have overstated the size of the benefit because it assumes that without lockdown mandates, people wouldn’t have reduced their social contacts. In reality, rising deaths would probably have changed people’s behaviour.

That happened in Florida, for instance, where data show a reduction in mobility during the first wave about two weeks before lockdowns, says health-policy researcher Thomas Tsai at the Harvard T.H. Chan School of Public Health in Boston, Massachusetts. “People were watching the news in New York and Boston and seeing how severe COVID could be,” he says.

One analysis5 by political scientist Christopher Berry and his colleagues at the University of Chicago, Illinois, supports this. It suggests that US states’ shelter-in-place orders did little to further reduce COVID-19 cases and deaths, not because social distancing doesn’t work, but because people were already avoiding contact before the orders were imposed.

Other researchers have tried instead to compare whether countries with stricter lockdown policies performed better than those with more relaxed ones on measures such as disease transmission rates or deaths. This isn’t simple, either: enforcement, levels of government aid and compliance with official policies differed from one region to another — as did cultural context and a host of other factors, including population densities, levels of social contact and viral prevalence.

Take Sweden, for instance, which imposed relatively light restrictions in early 2020, keeping schools open for all but the oldest students. It experienced a lower rate of excess deaths in 2020 than did many other western European nations. But it is also a country where many people live alone (the average household size in Sweden is the lowest in the European Union), and where people have high trust in government, making it much easier for official recommendations alone — rather than mandates — to reduce social contacts and slow disease spread. Far from carrying on life as normal, Swedes reduced their mobility, as shown by mobile-phone data. Even so, its Nordic neighbours that imposed lockdowns performed better in 2020: age-standardized mortality rates show that Denmark, Finland and Norway experienced fewer deaths than normal that year, whereas Sweden experienced slightly more than usual. (As in other countries, Sweden also failed to prevent the most vulnerable people, such as those in elder-care homes, from dying of COVID-19.)

“It wasn’t really clear what is the best way of estimating the effectiveness of [lockdown] measures,” says Peter Klimek, a data scientist at the Medical University of Vienna. Still, by tracking the stringency and timing of government policies in more than 100 countries, researchers at the University of Oxford, UK, and their colleagues did find that the more stringent a nation’s containment policies, the more successful it was at averting deaths from COVID-19.

It is even harder to tease out subtler insights, such as which of the grab bag of lockdown policies — from closing schools to ordering people to stay at home — had the most effect, especially because policies were often announced in quick succession.

After the first wave of COVID-19, Klimek’s team analysed thousands of government interventions. The group noted that some measures seemed effective according to one modelling approach, but not according to others, and that their effectiveness estimates came with wide uncertainty ranges. But the researchers were able to produce an overall ranking (see ‘How effective were COVID-19 interventions?’). The most effective measures were policies banning small gatherings and closing businesses and schools, closely followed by land-border restrictions and national lockdowns. Less-intrusive measures — such as government support for vulnerable populations, and risk-communication strategies — also had an impact. Airport health checks, however, had no discernible benefit.

Other studies have tried to put more precise figures on the effects of lockdown policies, but their findings differ. An analysis of 41 countries in Europe and elsewhere found that stay-at-home orders had a relatively small impact on transmission, reducing R — the average number of people that one person with COVID-19 will go on to infect — by just 13% beyond what could be achieved by closing schools and universities (38%) or limiting gatherings to 10 people or fewer (42%). Yet Bhatt’s analysis of 11 countries suggested that stay-at-home orders cut R by 81%, with school closures, public-event bans and other measures being less important. Klimek warns against generalizing about the effectiveness of lockdown policies on the basis of figures such as these. “The effectiveness of each intervention is highly context dependent,” he says. What several analyses suggest is that no single intervention can reduce R to below 1 (signifying that infections are declining): multiple measures achieve this by working in concert.

Go hard, go fast

The pre-vaccine period of the pandemic does show that countries that acted harshly and swiftly — the ‘go hard, go fast’ approach — often fared better than those that waited to implement lockdown policies. China’s harsh lockdowns eliminated COVID-19 locally, for a time. Successful countries that learnt from this were “proactive”, according to a May 2021 report by the Independent Panel on Pandemic Preparedness & Response, established by the World Health Organization in September 2020 to review the global response. Examples include island nations such as Iceland, Australia and New Zealand, which also benefited from being able to close their borders and take action before many people with the virus arrived.

Others have echoed this. Epidemiologist Edward Knock and other members of the Imperial College COVID-19 response team concluded that nationwide lockdown was the only measure that consistently took R below 1 in England. And the earlier that strict measures were imposed, the better. Knock estimated that had England introduced a nationwide lockdown one week earlier in March 2020, it would have halved deaths during the first wave. A study of government responses in Asia also suggested that a ‘go hard, go fast’ approach was best.

But harsher lockdowns aren’t always more effective by themselves, especially in countries where it is difficult for people to stay at home. Peru is an example. It imposed early and strict lockdown measures, but experienced an excess death rate much higher than did other countries in the region that used less draconian measures. Peru is still held up as evidence that lockdowns don’t work — but in fact it struggled to enforce them. The country has a large informal workforce, combined with expensive and inadequate health infrastructure. Despite lockdowns, many Peruvians continued to venture out to shop and to work, and so transmission remained stubbornly high, says Camila Gianella Malca, a public-policy researcher at the Pontifical Catholic University of Peru in Lima.

Second wave

The impacts of lockdowns also differed from one pandemic wave to the next. By the time second waves emerged, so much had been learnt about the virus that people’s behaviour was quite different. By October 2020, population-wide masking policies had become common. Schools and other settings established physical-distancing measures to keep people apart, and people took more precautions when local transmission increased. Hospitals also learnt quickly how best to treat COVID-19: death rates after the first wave decreased by 20% owing to improved treatment alone.

Together, these changes dampened the extent to which countries benefited from lockdowns. For example, several studies found that school closures during the first wave reduced the spread of COVID-19. Yet Bhatt’s analysis suggests that second-wave school closures had a much smaller effect. “We were surprised by that, to be honest,” he says.

Only a handful of countries continued to take a ’go hard, go fast’ approach after the first wave. Countries that had aimed for elimination — China, Australia, New Zealand and Vietnam, for example — saw that it worked and then went harder and faster, according to research by Anna Petherick, a public-policy researcher at the University of Oxford’s Blavatnik School of Government and her colleagues, who tracked government policies in more than 180 countries. But in countries where belated first-wave lockdowns had merely lessened transmission, governments became less likely to take early action, tolerating higher case numbers in subsequent waves before ordering lockdowns (see ‘Thresholds for lockdown’).

Blunt tool?

Some researchers argue that countries could have avoided blunt all-of-society lockdowns, especially after the measures taken early in 2020. Among them is Mark Woolhouse, an infectious-disease epidemiologist at the University of Edinburgh, UK, who advised the Scottish government during the pandemic. He argues that it might have been possible to avoid the closing of schools and cooping-up of younger people — who were at lower risk of COVID-19 — while focusing efforts on protecting vulnerable and older people as soon as high-risk individuals and settings were identified. “This pandemic was crying out for [a] precision public-health response, because the risks associated with the public-health threat with the virus were so focused on a small minority, and the harms done by things like lockdown were not focused on the same people,” he says.

But many researchers have pushed back against the idea that a more targeted approach was ever possible. Klimek says that roughly one-third of the population in wealthy nations was vulnerable because of underlying health conditions, so targeted measures would have been difficult to implement. And the virus has caused not only deaths but also post-infection illnesses such as long COVID — which has emerged as a health burden even for people who had mild disease.

Another targeted option for governments considering how to reopen societies might have been to keep only high-risk locations closed — restaurants and bars, say, or even neighbourhoods with high population mobility, says Serina Chang at Stanford University in California, who worked with colleagues to identify such places using cellphone data. But shutting down neighbourhoods would probably disproportionately affect socially disadvantaged communities. “Fairness is such an important question here,” she says.

Benefits versus harms

Woolhouse says there was scant effort to debate the scale of potential harms caused by lockdowns, meaning that policymakers were unable to weigh up costs and benefits properly. Indeed, early on, many countries adopted a ‘save lives at any cost’ approach, he says.

And lockdown policies did bring costs. Although they delayed outbreaks, saving lives by allowing countries to hang on for vaccines and drugs, they also brought significant social isolation and associated mental-health problems, rising rates of domestic violence and violence against women, cancelled medical appointments and disruption to education for children and university students. And they were often (although not always) accompanied by economic downturns.

But the common refrain that lockdowns involved a choice — saving lives versus livelihoods, or lives versus the economy — is a false dichotomy, says Stuart McDonald, an actuary and founder of the UK-based COVID-19 Actuaries Response Group, a community of specialists who have carried out regular analyses of mortality during the pandemic. If the UK government had not imposed belated lockdowns in 2020, hospital systems would have been overrun, death rates for all kinds of illnesses would have rocketed and economies and livelihoods would have collapsed anyway, he says. One analysis15 up to November 2021 estimated that the United States lost US$65.3 billion a month during lockdowns. But another16 estimated that US lockdowns from early March until the end of July 2020 added between $632.5 billion and $765 billion to the economy, compared with the alternative of no lockdowns. Unsurprisingly, the countries that did best in terms of saving lives and protecting the economy were those that acted fast with strict lockdowns.

What is more, some governments did at least try to consider various harms, McDonald says. In July 2020, for instance, McDonald attended a meeting of the UK government’s COVID-19 advisory group to discuss efforts to model the direct and indirect health impacts of lockdowns, measured by the preservation or loss of quality-adjusted life years — QALYs. (This measure gives more weight to younger lives than the lives of older people, who are judged to have lost fewer QALYs if they die.) Fewer deaths from road accidents were tallied as a benefit of lockdown, for instance; QALYs lost owing to delayed cancer diagnoses, or poorer health owing to loss of income, were harms. In August 2020, the report discussed at the meeting was publicly released: it argued that QALYs lost would have been three times higher had there been no mitigation measures, such as lockdowns, in place. (McDonald was not involved in writing it, but contributed to subsequent versions of the report.)

Not all harms can be accounted for in this way. Loss of education because of school closures might indirectly harm children in the long run, potentially decreasing their future earnings and placing them at greater risk of poorer health outcomes. McDonald says that such harms are so far off — decades, in some cases — that they can’t readily be factored into a QALY ledger.

Value judgements

Pure economic analyses of whether lockdowns were worth it generally try to estimate the value of lives saved and compare that with the costs of economic downturns. But there is no consensus on how to make this comparison. Tweaks to the value placed on human life in these analyses can alter conclusions about whether lockdowns were worth it, found Lisa Robinson, a public-policy analyst at the Harvard T.H. Chan School of Public Health, and her colleagues. If older lives are assigned a lower monetary value than younger ones, for instance, then — because COVID-19 disproportionately affected older people — lockdowns might be judged to have provided less benefit than if all lives are valued equally.

Jonathan Aldred, an economist at the University of Cambridge, UK, says that cost–benefit calculations of this kind are ill-suited to decision-making during an emergency, given the numerous sources of uncertainty. Putting monetary values on everything — from lives lost to the economic hit caused by shop closures — can give the impression that decisions about lockdowns are objective. But, says Aldred, the upshot is that “you’re hiding the fact that there are ethical judgements that have been made”. Policymakers should instead have a transparent discussion about the ethics of weighing costs and benefits, says Aldred, rather than suggest there is a ‘scientific’ answer. Without this kind of reckoning, we could be “back to square one” in a future pandemic, he says, with the same contentious debates about whether to close schools and at what harm to other sections of society.

The next pandemic

Now that COVID-19 vaccines and treatments for severe disease are widely available, most countries that have taken full advantage of them are unlikely to return to lockdowns. So what have researchers learnt that can inform decisions when another viral pandemic arrives?

One lesson that Klimek takes from lockdown studies is that there was an early window of opportunity when the virus could have been eliminated — as it was, in effect, in countries such as China, Australia and New Zealand. Had harsher measures been adopted sooner, and more widely, the pandemic might have played out very differently. “I think this is the big learning that we need to take away,” he says.

The paradox is that a successful early clampdown, or hard and fast action against a virus that turns out to be milder than initial indications suggest, could lead to complaints of overreaction.

A future threat might, of course, also spread in a completely different way from COVID-19. Ethical choices could look very different if the next pandemic is caused by an influenza virus that predominantly affects and is spread by young children.

Lockdowns hold another clear lesson: they exacerbate inequalities that already exist in society. Those already living in poverty and insecurity are hit hardest. Guarding against these unequal impacts requires improved health access and financial safeguards when times are good.

And transparency is key, too: the public needs to know more about how pandemic-control policies are decided, says Tsai. “That makes public-health policymaking seem less capricious,” he says, “because it’s reactive to both the science and values.”

One of Long COVID’s Worst Symptoms Is Also Its Most Misunderstood

Brain fog isn’t like a hangover or depression. It’s a disorder of executive function that makes basic cognitive tasks absurdly hard.

(Update 9/22/2022)

On March 25, 2020, Hannah Davis was texting with two friends when she realized that she couldn’t understand one of their messages. In hindsight, that was the first sign that she had COVID-19. It was also her first experience with the phenomenon known as “brain fog,” and the moment when her old life contracted into her current one. She once worked in artificial intelligence and analyzed complex systems without hesitation, but now “runs into a mental wall” when faced with tasks as simple as filling out forms. Her memory, once vivid, feels frayed and fleeting. Former mundanities—buying food, making meals, cleaning up—can be agonizingly difficult. Her inner world—what she calls “the extras of thinking, like daydreaming, making plans, imagining”—is gone. The fog “is so encompassing,” she told me, “it affects every area of my life.” For more than 900 days, while other long-COVID symptoms have waxed and waned, her brain fog has never really lifted.

Of long COVID’s many possible symptoms, brain fog “is by far one of the most disabling and destructive,” Emma Ladds, a primary-care specialist from the University of Oxford, told me. It’s also among the most misunderstood. It wasn’t even included in the list of possible COVID symptoms when the coronavirus pandemic first began. But 20 to 30 percent of patients report brain fog three months after their initial infection, as do 65 to 85 percent of the long-haulers who stay sick for much longer. It can afflict people who were never ill enough to need a ventilator—or any hospital care. And it can affect young people in the prime of their mental lives.

Long-haulers with brain fog say that it’s like none of the things that people—including many medical professionals—jeeringly compare it to. It is more profound than the clouded thinking that accompanies hangovers, stress, or fatigue. For Davis, it has been distinct from and worse than her experience with ADHD. It is not psychosomatic, and involves real changes to the structure and chemistry of the brain. It is not a mood disorder: “If anyone is saying that this is due to depression and anxiety, they have no basis for that, and data suggest it might be the other direction,” Joanna Hellmuth, a neurologist at UC San Francisco, told me.

And despite its nebulous name, brain fog is not an umbrella term for every possible mental problem. At its core, Hellmuth said, it is almost always a disorder of “executive function”—the set of mental abilities that includes focusing attention, holding information in mind, and blocking out distractions. These skills are so foundational that when they crumble, much of a person’s cognitive edifice collapses. Anything involving concentration, multitasking, and planning—that is, almost everything important—becomes absurdly arduous. “It raises what are unconscious processes for healthy people to the level of conscious decision making,” Fiona Robertson, a writer based in Aberdeen, Scotland, told me.

For example, Robertson’s brain often loses focus mid-sentence, leading to what she jokingly calls “so-yeah syndrome”: “I forget what I’m saying, tail off, and go, ‘So, yeah …’” she said. Brain fog stopped Kristen Tjaden from driving, because she’d forget her destination en route. For more than a year, she couldn’t read, either, because making sense of a series of words had become too difficult. Angela Meriquez Vázquez told me it once took her two hours to schedule a meeting over email: She’d check her calendar, but the information would slip in the second it took to bring up her inbox. At her worst, she couldn’t unload a dishwasher, because identifying an object, remembering where it should go, and putting it there was too complicated.

Memory suffers, too, but in a different way from degenerative conditions like Alzheimer’s. The memories are there, but with executive function malfunctioning, the brain neither chooses the important things to store nor retrieves that information efficiently. Davis, who is part of the Patient-Led Research Collaborative, can remember facts from scientific papers, but not events. When she thinks of her loved ones, or her old life, they feel distant. “Moments that affected me don’t feel like they’re part of me anymore,” she said. “It feels like I am a void and I’m living in a void.”

Most people with brain fog are not so severely affected, and gradually improve with time. But even when people recover enough to work, they can struggle with minds that are less nimble than before. “We’re used to driving a sports car, and now we are left with a jalopy,” Vázquez said. In some professions, a jalopy won’t cut it. “I’ve had surgeons who can’t go back to surgery, because they need their executive function,” Monica Verduzco-Gutierrez, a rehabilitation specialist at UT Health San Antonio, told me.

Robertson, meanwhile, was studying theoretical physics in college when she first got sick, and her fog occluded a career path that was once brightly lit. “I used to sparkle, like I could pull these things together and start to see how the universe works,” she told me. “I’ve never been able to access that sensation again, and I miss it, every day, like an ache.” That loss of identity was as disruptive as the physical aspects of the disease, which “I always thought I could deal with … if I could just think properly,” Robertson said. “This is the thing that’s destabilized me most.”

Robertson predicted that the pandemic would trigger a wave of cognitive impairment in March 2020. Her brain fog began two decades earlier, likely with a different viral illness, but she developed the same executive-function impairments that long-haulers experience, which then worsened when she got COVID last year. That specific constellation of problems also befalls many people living with HIV, epileptics after seizures, cancer patients experiencing so-called chemo brain, and people with several complex chronic illnesses such as fibromyalgia. It’s part of the diagnostic criteria for myalgic encephalomyelitis, also known as chronic fatigue syndrome, or ME/CFS—a condition that Davis and many other long-haulers now have. Brain fog existed well before COVID, affecting many people whose conditions were stigmatized, dismissed, or neglected. “For all of those years, people just treated it like it’s not worth researching,” Robertson told me. “So many of us were told, Oh, it’s just a bit of a depression.

Several clinicians I spoke with argued that the term brain fog makes the condition sound like a temporary inconvenience and deprives patients of the legitimacy that more medicalized language like cognitive impairment would bestow. But Aparna Nair, a historian of disability at the University of Oklahoma, noted that disability communities have used the term for decades, and there are many other reasons behind brain fog’s dismissal beyond terminology. (A surfeit of syllables didn’t stop fibromyalgia and myalgic encephalomyelitis from being trivialized.)

For example, Hellmuth noted that in her field of cognitive neurology, “virtually all the infrastructure and teaching” centers on degenerative diseases like Alzheimer’s, in which rogue proteins afflict elderly brains. Few researchers know that viruses can cause cognitive disorders in younger people, so few study their effects. “As a result, no one learns about it in medical school,” Hellmuth said. And because “there’s not a lot of humility in medicine, people end up blaming patients instead of looking for answers,” she said.

People with brain fog also excel at hiding it: None of the long-haulers I’ve interviewed sounded cognitively impaired. But at times when her speech is obviously sluggish, “nobody except my husband and mother see me,” Robertson said. The stigma that long-haulers experience also motivates them to present as normal in social situations or doctor appointments, which compounds the mistaken sense that they’re less impaired than they claim—and can be debilitatingly draining. “They’ll do what is asked of them when you’re testing them, and your results will say they were normal,” David Putrino, who leads a long-COVID rehabilitation clinic at Mount Sinai, told me. “It’s only if you check in on them two days later that you’ll see you’ve wrecked them for a week.”

“We also don’t have the right tools for measuring brain fog,” Putrino said. Doctors often use the Montreal Cognitive Assessment, which was designed to uncover extreme mental problems in elderly people with dementia, and “isn’t validated for anyone under age 55,” Hellmuth told me. Even a person with severe brain fog can ace it. More sophisticated tests exist, but they still compare people with the population average rather than their previous baseline. “A high-functioning person with a decline in their abilities who falls within the normal range is told they don’t have a problem,” Hellmuth said.

This pattern exists for many long-COVID symptoms: Doctors order inappropriate or overly simplistic tests, whose negative results are used to discredit patients’ genuine symptoms. It doesn’t help that brain fog (and long COVID more generally) disproportionately affects women, who have a long history of being labeled as emotional or hysterical by the medical establishment. But every patient with brain fog “tells me the exact same story of executive-function symptoms,” Hellmuth said. “If people were making this up, the clinical narrative wouldn’t be the same.”

Earlier this year, a team of British researchers rendered the invisible nature of brain fog in the stark black-and-white imagery of MRI scans. Gwenaëlle Douaud at the University of Oxford and her colleagues analyzed data from the UK Biobank study, which had regularly scanned the brains of hundreds of volunteers for years prior to the pandemic. When some of those volunteers caught COVID, the team could compare their after scans to the before ones. They found that even mild infections can slightly shrink the brain and reduce the thickness of its neuron-rich gray matter. At their worst, these changes were comparable to a decade of aging. They were especially pronounced in areas such as the parahippocampal gyrus, which is important for encoding and retrieving memories, and the orbitofrontal cortex, which is important for executive function. They were still apparent in people who hadn’t been hospitalized. And they were accompanied by cognitive problems.

Although SARS-CoV-2, the coronavirus that causes COVID, can enter and infect the central nervous system, it doesn’t do so efficiently, persistently, or frequently, Michelle Monje, a neuro-oncologist at Stanford, told me. Instead, she thinks that in most cases the virus harms the brain without directly infecting it. She and her colleagues recently showed that when mice experience mild bouts of COVID, inflammatory chemicals can travel from the lungs to the brain, where they disrupt cells called microglia. Normally, microglia act as groundskeepers, supporting neurons by pruning unnecessary connections and cleaning unwanted debris. When inflamed, their efforts become overenthusiastic and destructive. In their presence, the hippocampus—a region crucial for memory—produces fewer fresh neurons, while many existing neurons lose their insulating coats, so electric signals now course along these cells more slowly. These are the same changes that Monje sees in cancer patients with “chemo fog.” And although she and her team did their COVID experiments in mice, they found high levels of the same inflammatory chemicals in long-haulers with brain fog.

Monje suspects that neuro-inflammation is “probably the most common way” that COVID results in brain fog, but that there are likely many such routes. COVID could possibly trigger autoimmune problems in which the immune system mistakenly attacks the nervous system, or reactivate dormant viruses such as Epstein-Barr virus, which has been linked to conditions including ME/CFS and multiple sclerosis. By damaging blood vessels and filling them with small clots, COVID also throttles the brain’s blood supply, depriving this most energetically demanding of organs of oxygen and fuel. This oxygen shortfall isn’t stark enough to kill neurons or send people to an ICU, but “the brain isn’t getting what it needs to fire on all cylinders,” Putrino told me. (The severe oxygen deprivation that forces some people with COVID into critical care causes different cognitive problems than what most long-haulers experience.)

None of these explanations is set in stone, but they can collectively make sense of brain fog’s features. A lack of oxygen would affect sophisticated and energy-dependent cognitive tasks first, which explains why executive function and language “are the first ones to go,” Putrino said. Without insulating coats, neurons work more slowly, which explains why many long-haulers feel that their processing speed is shot: “You’re losing the thing that facilitates fast neural connection between brain regions,” Monje said. These problems can be exacerbated or mitigated by factors such as sleep and rest, which explains why many people with brain fog have good days and bad days. And although other respiratory viruses can wreak inflammatory havoc on the brain, SARS-CoV-2 does so more potently than, say, influenza, which explains both why people such as Robertson developed brain fog long before the current pandemic and why the symptom is especially prominent among COVID long-haulers.

Perhaps the most important implication of this emerging science is that brain fog is “potentially reversible,” Monje said. If the symptom was the work of a persistent brain infection, or the mass death of neurons following severe oxygen starvation, it would be hard to undo. But neuroinflammation isn’t destiny. Cancer researchers, for example, have developed drugs that can calm berserk microglia in mice and restore their cognitive abilities; some are being tested in early clinical trials. “I’m hopeful that we’ll find the same to be true in COVID,” she said.

Biomedical advances might take years to arrive, but long-haulers need help with brain fog now. Absent cures, most approaches to treatment are about helping people manage their symptoms. Sounder sleep, healthy eating, and other generic lifestyle changes can make the condition more tolerable. Breathing and relaxation techniques can help people through bad flare-ups; speech therapy can help those with problems finding words. Some over-the-counter medications such as antihistamines can ease inflammatory symptoms, while stimulants can boost lagging concentration.

“Some people spontaneously recover back to baseline,” Hellmuth told me, “but two and a half years on, a lot of patients I see are no better.” And between these extremes lies perhaps the largest group of long-haulers—those whose brain fog has improved but not vanished, and who can “maintain a relatively normal life, but only after making serious accommodations,” Putrino said. Long recovery periods and a slew of lifehacks make regular living possible, but more slowly and at higher cost.

Kristen Tjaden can read again, albeit for short bursts followed by long rests, but hasn’t returned to work. Angela Meriquez Vázquez can work but can’t multitask or process meetings in real time. Julia Moore Vogel, who helps lead a large biomedical research program, can muster enough executive function for her job, but “almost everything else in my life I’ve cut out to make room for that,” she told me. “I only leave the house or socialize once a week.” And she rarely talks about these problems openly because “in my field, your brain is your currency,” she said. “I know my value in many people’s eyes will be diminished by knowing that I have these cognitive challenges.”

Patients struggle to make peace with how much they’ve changed and the stigma associated with it, regardless of where they end up. Their desperation to return to normal can be dangerous, especially when combined with cultural norms around pressing on through challenges and post-exertional malaise—severe crashes in which all symptoms worsen after even minor physical or mental exertion. Many long-haulers try to push themselves back to work and instead “push themselves into a crash,” Robertson told me. When she tried to force her way to normalcy, she became mostly housebound for a year, needing full-time care. Even now, if she tries to concentrate in the middle of a bad day, “I end up with a physical reaction of exhaustion and pain, like I’ve run a marathon,” she said.

Post-exertional malaise is so common among long-haulers that “exercise as a treatment is inappropriate for people with long COVID,” Putrino said. Even brain-training games—which have questionable value but are often mentioned as potential treatments for brain fog—must be very carefully rationed because mental exertion is physical exertion. People with ME/CFS learned this lesson the hard way, and fought hard to get exercise therapy, once commonly prescribed for the condition, to be removed from official guidance in the U.S. and U.K. They’ve also learned the value of pacing—carefully sensing and managing their energy levels to avoid crashes.

Vogel does this with a wearable that tracks her heart rate, sleep, activity, and stress as a proxy for her energy levels; if they feel low, she forces herself to rest—cognitively as well as physically. Checking social media or responding to emails do not count. In those moments, “you have to accept that you have this medical crisis and the best thing you can do is literally nothing,” she said. When stuck in a fog, sometimes the only option is to stand still.

Is the COVID-19 pandemic over?

President Joe Biden said that the pandemic has ended. Here’s what scientists say.

(Update 9/22/2022)

After more than two and a half years of COVID-19 restrictions and mandates, many people are yearning for an official nod that marks the pandemic’s end. And watching the news last week could have led many to conclude that we’ve finally reached that point.

World Health Organization Director-General Tedros Adhanom Ghebreyesus told reporters at a press conference that the end of the pandemic is in sight. A few days later, United States President Joe Biden declared during an interview on 60 Minutes, “The pandemic is over.” But he also acknowledged, “We still have a problem with COVID. We’re still doing a lot of work on it.”

A pandemic is a disease outbreak spanning several countries that affects many people. The WHO is responsible for declaring when an outbreak has grown into a pandemic and deciding when it stops being a public health emergency of international concern. Worldwide, COVID-19 is still causing nearly 1,600 deaths each day and case numbers haven’t plateaued at a low level, leading WHO’s chief scientist, Soumya Swaminathan, to conclude, “It’s still a little premature to say that we’re over it.”

A volunteer disinfects a street in Chengdu, Sichuan Province, China, on September 3, 2022. The city of Chengdu is under lockdown because of the virus.PHOTOGRAPH BY CFOTO, FUTURE PUBLISHING/GETTY IMAGES

In the U.S. the virus is killing between 400 and 500 people daily. “That’s still too many,” says epidemiologist Jennifer Nuzzo, who is the director of Brown University’s Pandemic Center. Others agree with Nuzzo, adding that declaring the end of the pandemic may compromise ongoing testing and vaccination efforts as the highly contagious Omicron BA.5 continues to circulate in the U.S. and many parts of the world, and as cases may rise as more people gather indoors in cooler weather.

Complicating matters, say some epidemiologists, is that there aren’t established criteria—an acceptable level of cases and deaths, for example—to use to determine whether the pandemic is over. While it’s true that humans are more resistant to SARS-CoV-2—through vaccination and or COVID-19 infection—says Eric Topol, founder and director of Scripps Research Translational Institute in California, “the virus is still ahead of us.” To him, the end of the pandemic isn’t imminent, and “that’s for sure.”

What factors tell us when the pandemic is over

While the number of daily deaths is one metric to gauge whether the pandemic is coming to an end, others include case numbers, seasonality of outbreaks, vaccination rates, availability of effective treatments, and the transmissibility of current and new COVID-19 variants. But drawing such conclusions will be complicated, Swaminathan says. “This is a new virus, and we haven’t had a global coronavirus pandemic before.”

Another confounding element is the lack of data from many countries, she says. Figuring out when the pandemic shifts from its acute phase to an endemic one, meaning that COVID-19 is still around but not causing large outbreaks, might only be able to be determined retrospectively. “We may be able to look back and say it was the summer of 2023, for example, that the world came out of the effects of the pandemic.”

A child from Kanishail Primany School in Sylhet, Bangladesh, receives a COVID-19 shot during vaccination program on August 28, 2022.PHOTOGRAPH BY MD RAFAYAT HAQUE KHAN, EYEPIX GROUP/FUTURE PUBLISHING/GETTY IMAGES

For Topol, that judgment has to be based on the trajectory of the pandemic. “I look at where we were in summer 2021—we were down to 12,000 [daily] cases in the U.S. and deaths were just over 200,” he says. “If we held there,” Topol says, he’d be comfortable declaring the pandemic phase over. “But we’re nowhere near that.” Topol also fears that new variants may cause another wave of cases and hospitalizations enabling the pandemic to drag on.

To Lone Simonsen, an epidemiologist at Roskilde University in Denmark, the seasonality of outbreaks, in addition to fewer deaths, could help indicate when the pandemic might end. If case numbers soar in the summer, when the virus has fewer opportunities to spread, “we’re still in the pandemic phase,” she says. That was the case in 2021, when cases were driven by the Delta variant and this past summer with Omicron. So, for Simonsen, it’s a wait and see.

But Denmark and other European countries with high levels of vaccination scrapped most pandemic mandates and restrictions months ago, as COVID-19 hasn’t been causing severe illness or overwhelming hospitals. However, long COVID remains a concern, Simonsen says.

Amesh Adalja, an infectious disease specialist at the Johns Hopkins Center for Health Security argues that the global pandemic phase is largely over given that hundreds of millions of people have already been infected by the virus, there are vaccines and treatments that can prevent severe illness, and COVID-19 is unlikely to completely disrupt the healthcare system like it once did. “It doesn’t mean all of a sudden things go back to 2019. It doesn’t mean that COVID-19 disappears, and all action stops,” he says. “It means there is going to be a baseline number of cases, hospitalizations, and deaths.”

What those acceptable levels of hospitalizations and deaths may be is a political decision, says David Heymann, an infectiousdisease epidemiologist at the London School of Hygiene and Tropical Medicine and former head of WHO’s communicable diseases cluster.

Saying it is over when it isn’t

Nuzzo and others worry that statements like the pandemic is over may be a disservice.

With the U.S. rolling out an Omicron specific booster, “I’m really worried this is going to send out a signal to millions of Americans who are at the risk of severe illness that they may not need to get boosted,” Nuzzo says. “That’s really, really unfortunate.” (See 6 big questions about the new Omicron-targeting booster answered.)

She is also concerned that such statements may lead to a greater reduction in access to free COVID-19 testing and treatments, especially for those uninsured.

Topol worries that it could also undermine the motivation and funding to ramp up development of better COVID-19 vaccines and treatments, jeopardizing the health of millions who are immunocompromised or at the risk of developing long COVID.

This isn’t the right time to make bold assertions about the end of the pandemic, he says. “But it’s time to be bold about accelerating to a point where we look to say, we nailed it, we did it.”

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