Lookahead: What will year three of the pandemic bring?

Jordan I remember a time when I thought that this pandemic would last a couple of months. And then I thought it would end in the summer. And then I thought it would end the following spring, and then the following summer, and then when we all got vaccinated. And I’m sick of it. I never thought we’d be here today heading into year three. I know you all feel the same way. But the virus doesn’t care. Sometimes I wish it did. I wish it really was an evil super villain, just so we’d have an actual enemy with emotions to fight instead of this stupid microbe.

Anyway, year three, let’s take a look ahead to COVID in 2022, is this the year the pandemic ends or at least becomes endemic? Or at least dwindles, please, to manageable levels and stays there? Or is this an example of the same vain hope I’ve had 27 times, I don’t know, over the last 24 months? What do we know about this virus now that we didn’t know way back then? What do we know about the next 12 months that we didn’t know at this time last year? What will we know one year from now that we don’t even suspect? That, to me, is the most hopeful and scariest question of all.

I’m Jordan Heath-Rawlings, this is The Big Story. Dr. Raywat Deonandan is a global health epidemiologist and associate professor with the interdisciplinary school of health sciences at the University of Ottawa. Hello, Dr. Deonandan.

Dr. Deonandan Hello, how are you?

Jordan I’m doing well. I want you to start by trying to think back to your daily life as an epidemiologist before the pandemic, do you even remember what it was like?

Dr. Deonandan I do sort of, I remember every conversation I had was trying to explain to someone what an epidemiologist is. In fact, I wrote a book called It Has Nothing To Do With Skin because everyone thought we were dermatologists. But now everyone knows what we do, at least a portion of what we do, and so life is definitely different. And I thought my career was winding down. It looks like it just got reinvigorated for all the wrong reasons.

Jordan Back before the general public knew what an R-naught value was.

Dr. Deonandan Exactly and I wish they still didn’t.

Jordan Did you imagine at the outset of that, when things first started getting scary and lockdowns happened and we’re talking March of 2020 here, that we would eventually end up in a pandemic, still, in early 2022? Do pandemics usually last this long?

Dr. Deonandan Actually, I thought it would last four years, if not longer. And when the vaccines became available, I was stunned that we could be seeing the end of this within the next year or so. So the fact that we have a few setbacks now, is taking me back to where I was in March of 2020.

But the question is when do pandemics typically end? Well there is no set rule. It depends on the kind of pandemic, frankly. If you look back at the Spanish flu, which everyone talks about all the time now, of 1918, that had about three big waves, maybe a couple of smaller waves after that. Lasted two or three years, depending upon when you want to draw the end point. Some say it’s still with us today because the descendants of the Spanish flu are still the influenza A virus that occasionally makes for particularly bad seasonal flu years.

The answer is, respiratory viruses like this in the pandemic milieu, last a few years. But they do eventually go away, in the sense that eventually it will be a non-emergency.

Jordan As we speak, I should note in case people listen to this later, it’s mid December. We’ll be entering 2022 in Canada, it looks like, in the middle of a wave driven by a new variant. What do we know so far about this wave, or Omicron in general—and I realize this is changing by the day—that can make it different from the last one, both good and bad?

Dr. Deonandan Right. So we know it is highly mutated, has about 32 changes to the spike protein. And the spike protein is the license plate by which your body identifies the virus. And by that identification, it deploys the antibodies that prevents that vehicle from entering the cell. So the fact that the license plate is being blurred, caused people to suspect that maybe our bodies and therefore the vaccines won’t be able to identify the license plate, and therefore the virus would get in. And we are seeing that.

So in South Africa where this was first detected, the rate of increase in cases was substantial, also amongst those who had previous been infected and also vaccinated. So that caused some suspicion that this was the dreaded vaccine escape variant. The one that would get by all of our defences. So as of now, it looks like it is a hyper, hyper, transmissible virus. The Delta variant I used to say was probably the most contagious respiratory virus we’ve seen in modern times. Omicron leaves Delta in the dust. That’s how contagious it is.

Now, there’s some suspicion, some whisperings that it might be less serious, more mild. But I don’t think that’s a safe thing to say at this juncture. And it might be a dangerous thing to say as well. A lot of unknowns, a lot of moving parts, and some epidemiological suspicion that those observations might be skewed.

Jordan As we talk, are you optimistic or pessimistic, I’m going to guess the answers pessimistic, but about the general impact Omicron could have on Canada, but also on the pandemic in general, because I know mutations can also be a sign of approaching endemicity. Is that true?

Dr. Deonandan Yes. The question though, am I pessimistic? I’m an optimist by nature.

Jordan Good. We can use it right now.

Dr. Deonandan Yeah. There’s some good news here. And the good news is the vaccines do seem to work to a large extent. Some initial data suggests that two doses of Pfizer confer about 70% protection against hospitalization, which is great. It means that those who are vaccinated are not likely to be filling up the hospitals, which is what we ultimately care about the most. And it looks like three doses probably confer sufficient protection to prevent infection to begin with. So we have the tools to roll out three doses for most people, if we get sufficient supplies. So we know what to do.

The other good news is that we have finally accepted that COVID is airborne. That’s a critical thing to say, because with aerosol transmission we have new tools, engineering tools, that work against every variant. Ventilation, air purification, N95 masks. All these things work really well. So we can deploy those things. Artificially reduce the reproduction number, and prevent this thing from taking over our lives.

The pessimism of course, is in the hyper transmissibility, and this is important for people to understand. So it’s so infectious that the entire country can be infected in a matter of weeks if we do everything wrong. And let’s say it is less serious, And I say that with a huge caveat, maybe it’s not less serious, but I’ve seen the most conservative estimates of COVID classic’s infection, hospitalization rate. The proportion of cases that end up being hospitalized at about 2%. Which is a very, very low number, if that’s correct. If Omicron is a quarter of that, if it hospitalizes 0.5% of cases, if all of Canada gets infected, that’s still what? 200,000 people being hospitalized in a very short period of time. it will overwhelm a hospital system.

So I want to disavow people of the sense that a less serious or a more mild disease rather is something we should applaud. Not when it is this infectious or contagious. So we have to do everything we can to curtail transmission. But again, the good news is we can do those things. We have the tools, we have the knowledge.

Jordan There’s a lot of talk around the fact that vaccines still mostly prevent hospitalizations and death among vaccinated people. So why would so many restrictions become necessary if it’s mostly unvaccinated people, people who have refused this vaccine we’re talking about. And look, I don’t know if I agree with that, but there’s a lot of anger out there towards people who won’t protect themselves and others causing the rest of us to shut down.

Dr. Deonandan Yeah. It’s a dangerous and difficult conversation to have. Ultimately we are a liberal democracy. We have to respect people’s individual choices, but we can massage the environment to encourage people to make choices that are more amenable to the public good. So that’s why we have things like vaccine passports. That’s why we make life a little bit more difficult for the un-vaccinated, to show them, look, if you’re going to make these choices, they come at a price. So what’s the appropriate path forward here. I think we have to continue to cajole, encourage, incentivize vaccination, now up to three doses, and educate. In a liberal democracy our only path forward is public education. We cannot compel by force. And that’s a difficult thing to say. But this disease has a way of challenging our core values and we must rise above that challenge.

Jordan Let’s look at the big picture now. And just given what you’ve kind of said about how transmissible this thing is, as well as maybe possibly don’t know yet, could be more mild. Is that the path towards, what you kind of mentioned at the beginning? Is the end game where it becomes a virus like the flu or whatever, that circulates and is there any chance that this could be like the last big wave?

Dr. Deonandan Yeah. Again, it’s a dangerous thing to say, but it’s possible. If you look at South Africa, they have a very low vaccination rate, maybe 25% vaccination, maybe 25 or 30% have had vaccination plus previous infection because they experienced the disease more voluminously than we did. Only 7% had no immunity at all. In Canada, we’ve got 20% of people with no immunity at all. Meaning not recovered from disease and not having been vaccinated. So maybe the supposed mildness that some people are reporting in South Africa has more to do with the amount of immunity that’s in the population due to repeated infections that they have suffered.

Now, if that becomes our future, it’s possible that we will have sufficient population resilience that we never suffer another large wave again. It will come at a high price though. We don’t want to let Omicron rip through our population. Let’s be clear about that. There’s no good part of that. But it may, as one of my colleagues put it, it may leave behind the gift of immunity, if that is the case. So it’s possible.

Like I said, the Spanish flu, eventually it ended probably because there was no one left to infect, because everyone who is alive, probably had some immunity leftover from the residual infection. And that could be our future.

Jordan Let’s look at the big picture then of next year from your point of view, and not talking now about tomorrow, or next week as we fight Omicron. But from your point of view, what could we do during the next 12 months that would help get us to that place we’ve been talking about, where it’s an annoyance and not a deadly threat?

Dr. Deonandan Number one, we have to slow transmission, to buy us time. We slow transmission by doing those things I mentioned. Getting high quality N95 masks, using ventilation and air purification to high effectiveness. And looking at our individual exposures, using that tool that has been underused criminally almost, that is the rapid antigen test. Using those as part of our social lives. Slow transmission that way.

Number two is we use that bought time to really ramp up vaccination, especially third doses. And number three, we have a global concerted effort to push N95 quality masks and vaccines to those parts of the world where the variants are emerging the most. This is a global endeavor and we solve it with a global effort. So if we have that kind of focus and political will and resource application, I think we can be done with this next year.

One way or another, we’re probably done with this to a large extent next year. And I hope it is the comfortable way and not the painful way.

Jordan With that in mind then, what makes you hopeful for that outcome and what are you still worried about that could stop us from getting there?

Dr. Deonandan I’m hopeful because it doesn’t require any new knowledge. We have the tools and we know what we need to do. And we have additional tools coming down the pipeline, like new therapeutics that can treat COVID once you’ve been hospitalized. Now I wouldn’t hang my hat on that. That’s not a strategy for individual choice making. Your best choice is to get vaccinated, but that could probably render some space into our healthcare system.

What I’m worried about is our inability to make those proper choices. And the fact that we have some resources that are not renewable. Most prominently, our healthcare workers. We’re getting a nursing shortage in Canada. We’re getting to the point where that’s going to be at crisis levels. We can’t restock them in a matter of weeks. It’ll take years. So we don’t have the capacity we had back in March, to suffer an assault on our healthcare system. So this is an emergency, this has to be fixed and addressed before we get to the point where our healthcare system is on the verge of collapse.

But I’m optimistic, because again, we know what to do. There’s no mystery here. And we just got to deploy the tools with some urgency and focus, and expedience. And I think we can, I have… faith, isn’t the right word. But my experience with my fellow Canadians is that ultimately we always do the right thing and I think we will do so this time around.

Jordan I want to ask what could be a dumb question, but it’s certainly something I’ve seen and heard. There’s been a lot of fatalism, I think, around Omicron, with the kind of attitude of, well, this is the new one, there’ll be another one after that, there’s always going to be another worse variant that’s more transmissible and can escape immunity, et cetera, et cetera. How, how real is that fear? Is that how viruses progress?

Dr. Deonandan Well, evolution in the short run is somewhat random when it comes to viruses. We can’t tell what direction the variants will emerge, in a direction towards more virulence or less virulence. But the Spanish flu ended, as I said, when enough people had immunity, but also when something called antigenic drift happened. That’s when a mutation occurs, and it happened in such a way that the disease became milder. Now it’s a cause for a more serious seasonal flu, but not a cause for shutting down society.

So the nightmare scenario is of course that a variant will emerge that is a thorough escape variant, meaning it’ll evade all of our vaccine protections. That might still happen. It becomes less likely as we push immunity into the population. So the more vaccines we deliver around the world, the better we control transmission, and frankly, the more infection that happens and leaves behind the ugly gift of earned immunity, it becomes less likely.

So I think if we do those things that I mentioned, especially pushing vaccination around the world, we can lower the probability of an escape variant emerging substantially. Not down to zero, but substantially. And this is a game of probabilities unfortunately. The best we can do is lower the chances of the thing happening. As we are investing in better and better therapeutics, even that escape variant, when it comes out, might not be the challenge to our healthcare system, as it would have been a year ago.

Jordan If there’s one thing I’ve learned in the last two years, aside from what an R-naught value is, it’s to not demand epidemiologists try to predict something with certainty. So instead I’ve started asking them what they’ll be watching for. So I’ll ask you kind of just a quick two-part question: What will you be watching for just in the next couple of weeks here with Omicron, that’ll give us a sense of what’s going to happen? And then beyond that, to determine what 2022 will really be like?

Dr. Deonandan I’m looking at how it behaves in terms of hospitalization rates in a variety of age brackets, especially the very young who cannot be vaccinated yet. And I’m looking to see exactly how it behaves in breakthrough infections. Does it create comparable or lesser or more rates of hospitalization with breakthrough infections? So in other words, how good are our vaccines? And also, how good are three doses really? We don’t have a lot of data on that yet when it comes to Omicron, and that’ll be really useful to see. And if that data comes out positive, well then we definitely have a path forward of how to quash this emergency soon enough.

When it comes to the next few months, I’m looking to see, do we have the public thirst, the political will to get it done?Like, what is the public demand going to look like? What is our tolerance for inaction going to look like? And frankly, what is the state of science literacy? We had to battle science literacy at incredible levels these past few months, but frankly, I think we’re coming around on the positive side of that. I think most people are on board with learning more and on following science, not involving conspiracy theories. So will that battle turn again or will it be clear that we’re winning that particular work?

So I’m looking for those social changes, those social triggers. And when I see that the leadership is present and when I see that the public demand for action is palpable, then I’ll be filled with confidence that we can get this done this coming year.

Jordan I’m going to follow up on one thing quickly, cause I know we have some parents listening, heck including me, who won’t forgive me if I don’t. You mentioned you’ll be watching how this impacts very young, who can’t be vaccinated. Do we have any indication of if this is different? I know a lot of parents have been relying on the fact throughout this, that that children seem to handle COVID relatively well.

Dr. Deonandan I’ve not seen any compelling data to convince me one way or the other how this is going. In South Africa, they are seeing more kids in the hospitals. Now that might be simply a matter of the fact that more people are being infected, but the proportion of hospitalizations might be the same.

They’re not seeing an increased use of oxygen. That suggests that maybe these cases aren’t as serious. I don’t know, these are hand-waving arguments and we can’t be really confident with that. But I have a small child who’s too young to be vaccinated and this concerns me deeply. So I’m watching it carefully.

I think the best thing we can do is wrap those kids around with community immunity. Everybody who can be vaccinated, make sure they are vaccinated. And prioritize things accordingly. Keep schools safer than bars. Prioritize school safety ahead of restaurant safety. Even though those things are important for the economy, absolutely. I think we have to make sure that our kids are the number one priority, and I don’t think we’ve been doing that to the extent that we can.

And I’m buoyed, by recent conversations by policymakers around things like improving ventilation quality in schools and daycares, I’m encouraged by the rapidly accelerating use of rapid tests, which is fantastic. We should have been doing that a long time ago. And with that must come an overlaid education campaign, so we know exactly how to use these rapid tests.

And I think back in March of 2020, we had a nationwide N95 shortage. We don’t have that problem anymore. We have manufacturers making high quality face fitting respirators. I think we can get those out in large numbers and normalize they’re wearing so much so that the reproduction number artificially drops below one, while we solve the bigger problem.

So, while I’ll be watching for the hospitalization rates to give me a sense of how serious this actually is, I’m actually watching more how society responds. Because ultimately, it almost doesn’t matter how bad the virus is if we are well-organized and focused in our response.

Jordan Last question. And it’s a big one for 2022. And I feel like we’ve kind of danced around it a lot during this conversation. Does this end with all of us getting COVID to some degree or another and hoping that immunity, vaccinations, milder strains through virus evolution keeps it from being too bad, and that’s when we get back to normal?

Dr. Deonandan I think it ends when everyone has some immunity. Now, what does that look like? It doesn’t mean that everyone is going to get the disease. I think everyone is going to get exposed to it at this point, but exposure does not mean infection. Those of us who have chosen the most vaccination you can get, three doses, probably can get away with not being infected. And for those who are not well vaccinated, they’re going to be infected, I think, eventually. And that combination of high rates of vaccination and adequate rates of infection and recovery, mean we will have sufficient amounts of community immunity that something resembling herd immunity will be achieved. So that, those cases that are residual, that are bubbling in the background, won’t be newsworthy.

I think that’s the way it’s going to go, but again, don’t hold me to that. I can’t tell the future, I’ve been wrong many times.

Jordan Listen, just because this is my job, I really look forward to it not being news worthy. Thank you so much, Dr. Deonandan.

Dr. Deonandan It’s my pleasure, thank you.

Jordan Dr. Raywat Deonandan from the University of Ottawa.

That was The Big Story. For more from us, head to thebigstorypodcast.ca. Find us on Twitter at @TheBigStoryFPN. Talk to us via email at thebigstorypodcast@rci.rogers.com [click here!].

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Thanks for listening, I’m Jordan Heath-Rawlings, we’ll talk tomorrow.

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