What will it mean if COVID-19 becomes endemic?
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* Kim Krisberg

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/52/7/1.1/F1.medium.gif)

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A man stands outside Los Angeles City Hall in July. California adopted a “readiness” approach to COVID-19 in February.

Photo by Hans Gutknecht, courtesy MediaNews Group/Los Angeles Daily News/Getty Images

> “To me, it’s less about giving labels of epidemic versus endemic and more about appropriately communicating risk. People need a frame of reference for how big of a problem it is.”
> 
> — David Dowdy

As new, more transmissible COVID-19 variants drive surges of infection worldwide, it is clear the pandemic is far from over. Safety measures and behaviors have relaxed in many places, but with case counts rising and more mutations expected, is the disease truly moving toward an endemic phase? The answer may be as murky as consensus on the meaning of the word “endemic.”

Endemic typically refers to the constant presence or baseline prevalence of a disease in a population within a geographic area, according to the Centers for Disease Control and Prevention. Endemic does not necessarily mean a disease is circulating at low levels or is harmless, but that its spread and rates are more predictable. For instance, most flu strains are endemic, with health officials able to predict upswings of illness. This is opposed to “epidemic,” which refers to an unexpected, often sudden increase in disease cases in a certain area.

For COVID-19, there is no universal scientific agreement on the threshold for declaring endemicity, according to David Dowdy, MD, PhD, an associate professor at the Johns Hopkins Bloomberg School of Public Health. But the popular understanding seems to be when COVID-19 “isn’t much of a problem anymore.” But whether that is correct is complicated. If the definition is a lack of spikes in disease cases, then endemicity seems far off; if it means causing illness and death on a scale similar to other public health threats, the world may, in fact, be somewhat close to entering an endemic COVID-19 phase, Dowdy said.

“To me, it’s less about giving labels of epidemic versus endemic and more about appropriately communicating risk,” he told *The Nation’s Health*. “People need a frame of reference for how big of a problem it is.”

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Alia Dawra, 7, colors while waiting for her mom, Namrata Nayyar, and brother, Ari Dawra, 18 months, after he received a COVID-19 vaccination in San Jose, California, in June.

Photo by Jane Tyska, courtesy Digital First Media/The Mercury News/Getty Images

Some researchers are trying to answer that question more precisely. For example, a study published in July in *PNAS Nexus* suggests COVID-19 may enter its endemic phase within the next two years.

Researchers used rats to gather data on COVID-19 reinfection rates and then modeled the virus’ potential trajectory. They found that as vaccination and infection combine to facilitate widespread immunity, the virus could become endemic in the U.S. about four years after the pandemic began in March 2020. After entering the endemic phase, according to the study’s modeling, about 15% of the population would be susceptible to COVID-19 infection.

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A man visits a COVID-19 testing site in New York City in June. As many people in the U.S. moved away from safety measures such as masking and physical distancing, the BA.5 subvariant of COVID-19 was fueling new cases. Parts of Manhattan were back at 20% COVID-19 positivity.

Photo by John Smith, courtesy VIEWpress/Getty Images

## Some states shifting their approach

Regardless of official declarations or definitions, a number of states have shifted away from treating COVID-19 as an emergency and returned to a more standard public health approach to dealing with the virus. California was the first, with Gov. Gavin Newsom unveiling the state’s Smarter Plan in February. The plan emphasizes continued readiness, awareness and flexibility, with a focus on tools that can control the disease, such as vaccines, testing, therapeutics and masking.

Other states that have shifted to treating COVID-19 as less of an emergency include Arizona, Kansas, Missouri and New Jersey. In Utah, Gov. Spencer Cox also announced in February that the state would shift away from emergency mode to what officials were calling a “steady state” by the end of March. Among the changes that came with the shift are fewer updates to the state’s COVID-19 dashboard, the shuttering of many state-sponsored testing sites and the end of free travel testing.

“Our goal is to move to a more typical approach throughout the whole public health system,” Leisha Nolen, MD, PhD, state epidemiologist at the Utah Department of Health and Human Services, told *The Nation’s Health*.

Nolen said a number of metrics undergirded the decision to shift to a more endemic-like approach, including at-home COVID-19 testing, normalized hospital capacity, the availability of antiviral medications and waning public willingness to adhere to strict COVID-19 precautions. However, she said the agency is still at the ready to respond to outbreaks and support vulnerable residents.

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Free COVID-19 tests at a library in Washington, D.C., in June. Testing remains an important part of preventing COVID-19 transmission.

Photo by Michele Late

For example, while the agency shut down its mass testing sites, it is still offering free COVID-19 testing in underserved communities, Nolen said. It also has mobile COVID-19 testing teams that can quickly respond to outbreaks, such as those that occur in nursing homes.

“So many people are vaccinated and we have so much more protection in the community, it allows us to pursue things differently,” she said. “We still aim to get people as much information as we can so they can consider what their own actions should be based on their risk.”

Arizona also shifted to a more traditional approach, ending its COVID-19 emergency declaration in March.

“We now have the experience and tools in place to address what may be to come while public health continues doing what we do best: infectious disease surveillance, prevention and control,” said APHA member Richard Carmona, MD, MPH, a former U.S. surgeon general and special advisor to Arizona Gov. Doug Ducey, in a news release.

Practically, it is too early to say if COVID-19 has entered an endemic phase in Arizona, especially with the unpredictability of virus variants, said Carla Berg, MHS, deputy director for public health services at the Arizona Department of Health Services. Operationally, the agency is maintaining its ability to scale up emergency responses if needed, while also integrating COVID-19 work into its everyday duties, Berg said.

Equity remains at the forefront during the shift, Berg told *The Nation’s Health*, with workers relying on social vulnerability index data to help ensure COVID-19 resources remain available to those at disparate risk.

“We’re monitoring a number of indicators to help tell the story of where we are,” Berg said. “And keeping a close eye on vaccination, which is key.”

Since the start of the pandemic, Ann Falsey, MD, a professor of medicine and infectious disease expert at University of Rochester Medical Center, said she has long believed COVID-19 would eventually become endemic. However, she also sees such labels as “slightly artificial terms,” meaning the shift from pandemic to endemic is much more nuanced than crossing over a particular line.

Eventually, she said she sees COVID-19 morphing into a health threat similar to the flu, with certain groups more protected against severe disease than others, who may need to take extra precautions. Falsey said she also hopes health officials can take the equity-based lessons learned during the pandemic response and use them to help address other disparate health outcomes.

“I’d encourage people to have personal responsibility,” she told *The Nation’s Health*. “As mandates and shutdowns are a thing of the past, remember: If you are sick, stay home. Be kind, think about other people. It’s common sense, but this particular virus can still be very nasty.”

For information on community-level COVID-19 transmission, visit CDC’s COVID-19 Data Tracker at [https://covid.cdc.gov](https://covid.cdc.gov).

*   Copyright The Nation’s Health, American Public Health Association