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Are We There Yet? This Pandemic May Not Be Over Even When We Think It’s Over.

By Robert C. Chandler, Ph.D:

We are at a very important junction in the unfolding of this pandemic and preparing to make some critical decisions about “what might happen next” and whether it is time to return to life as normal. Thinking about this current COVID-19 pandemic situation from the vantage point of my study and teaching in the areas of health communication, crisis management, organizational preparation and contingency planning leads me to have both a sense of optimism and caution which suggests to me that now is the time for a bit of anticipatory foresight.

This pandemic has been globally disastrous and right here in the USA. As of the date of writing this essay, COVID-19 cases world-wide total more than 2.5 million people and there have been almost 200,000 fatalities. In this country, nearly, 800,000 Americans have been infected by the coronavirus and more than 40,000 have died from the disease, COVID-19. Families have lost loved ones; workers have lost colleagues and students have lost teachers. Acts of heroism make us proud and those seeking to take unfair advantage of the situation disappoint us. This disease outbreak has resulted in fearfulness, anxiety and angst by everyone, including those who have not yet gotten infected.

The economy has been derailed and the resulting recession has destroyed businesses, values, and revealed vulnerabilities in supply chains, consumer behavior, and resiliency. We have stress tested front line workers and redefined the fundamental assumptions of “essential” workers in our society (perhaps changing the hierarchy of importance of various professions forever). New questions about products and food safety and due diligence for hygiene have been raised. Most of us (non-essential) workers have been restricted to our homes and a sizable number of citizens have lost their jobs and/or sources of income in the rapidly evolving economic recession. Weddings have been postponed, funerals delayed, major events canceled, and the tensions of social isolation put an undue burden on almost everyone. This pandemic has impacted all of us in multiple ways, including economically, psychologically, and behaviorally. There is a collective desire for getting past this whole experience and wanting it to be over. Some are so frustrated that they are taking their demands for the end of the restrictions and full resumption of “normal life” practices to the streets in the form of protest.

Why is This Pandemic Different?
The COVID-19 epidemic is different from the recent SARS and MERS outbreaks. We were able to contain the 2003 SARS epidemic largely through case isolation and quarantine of known contacts because most individuals with SARS were symptomatic and only spread the disease to other individuals after they had been sick for a while. Similarly, most MERS infections were also observably symptomatic, and the MERS virus did not transmit very efficiently from person to person. However With SARS-CoV-2 (COVID-19), it is now estimated that 50-60% of people who are infected don’t exhibit symptoms, but can still spread it to others, and even those who do develop symptoms may be highly infectious before such symptoms appear.

When Will it Be Over?
With only the current (or even more modest) control measures (such as isolation of cases and quarantine of their household contacts or partial adherence to social distancing guidelines), most models predict the current outbreak peak should occur in June and the current outbreak would persist at some levels until early fall, and perhaps reoccurring in subsequent peaks until finally enough of the population had built up immunity to the virus or an effective vaccine is widely utilized. We don’t know if those who have been exposed will have immunity to the virus and of course viruses evolve and like the seasonal influenza viruses there may be multiple strains circulating at the same time. Therefore, it is likely that the COVID-19 pandemic will only “be over” if and when enough people have become immune to the virus, either through having been infected with it and if that offers immunity or through the development of a vaccine (probably multiple vaccines that will need to be updated regularly) but in all scenarios the SARS-CoV-2 virus is likely to survive (perhaps evolve) and be a persistent issue for humans in the long term (it might eventually become a source for seasonal epidemics, much like influenza viruses and other human coronaviruses already are) requiring on-going mitigation efforts.

But the question of when this disruptive and destructive pandemic will be over is one that a lot of us are asking (and wishfully hoping that it would be over soon). The problem is that it is inherently difficult to predict precisely when an epidemic wave is “over.” Most criteria focus on the question of whether the number of new cases and hospitalizations has decreased for more than four consecutive weeks, (for example), this may be a sign that an epidemic wave has ended. However, it is important to know whether the number of cases is decreasing because most people are immune (naturally limiting the transmission of the virus) or because the control measures that have been imposed have been effective. If it is the latter, then it is likely that people will still need to take precautions at that point, and another round of interventions may be needed if and when the number of cases go back up. An effective test to detect antibodies to SARS-CoV-2 could help to determine if it is the former; such tests are currently in development. Nevertheless, we would need to remain vigilant, as it is unclear if immunity occurs and if it occurs how long that immunity to the current form of the virus may last or if it offers any protection from possible mutations of the virus.

Are We There Yet?
Although the pain of the current disruptions and impacts on people (and families) cannot (should not ever) be minimized, there are some reasons to be somewhat optimistic about the status of the COVID-19 pandemic and our management of the threats, perhaps at the top of such a threat list, is the successful avoidance of a health care system overwhelming demand surge leading to a systemic collapse here in the USA. (On the other hand, I fear that the impact of the COVID-19 pandemic in other parts of the globe, particularly areas with less developed medical and infrastructure support may yet be tragic.) Nonetheless, there is a reason to believe that there is a light at the end of the tunnel for us here in this country. My concern is the possibility that the light at the end of the tunnel just might be a freight train rushing towards us. In fact, I think that given the current economic and political pressures as well as the epidemiological evidence, suggests that that we’re going to return to a semi-normal work and personal life (with new normative physical distancing requirements, limits on very large groups, spectator sports to resume without spectators, etc.) in most of the USA by the end of May or very early June. This will probably unfold region by region and state by state in a reverse series of steps much like the sequence in which the restrictions were enacted last month.

However, these most welcome and eagerly desired steps back towards “normalcy” need to be undertaken with the acknowledgement (acceptance and anticipation) that we all must prepare ourselves to go through a similar shelter at home type exercise at some point again – most likely in the late fall and lasting for a period onwards next winter. I think that we are in a ‘race’ of the potential (probable) resurgence of the COVID-19 virus this coming October and/or November and either the development of an effective/safe vaccine and/or the emergence of sufficient post-exposure to the threshold level for herd immunity by a significant percentage of the population.

The occurrence of pandemics in multiple waves is largely predicted based on our experience with influenza pandemics. Spatial-temporal variation in the epidemiological patterns of successive waves of pandemic virus in humans has been documented but never fully illuminated as to the causation or key variables. The epidemiology of the major influenza pandemics of the 20th century (1918 [H1N1], 1957 [H2N2], and 1968 [H3N2]) have been studied intensively, particularly the variation in mortality and transmissibility among countries and cities and manifestation of successive waves of contagion.

You can also get multiple waves of pandemic if control measures are insufficient, relaxed too soon or not enforced. The sequence of multiple waves of a pandemic can also in part be attributed to the peaks occurring at different times in different locations. For example, cities that had more cases of influenza in the spring of 2009 tended to experience a smaller peak in the fall and cities that had fewer cases in the spring tended to experience a larger number of cases in the following fall resurgence. It is important to note that it is unclear whether the experiences with influenza pandemics are indicative of what might happen with SARS-CoV-2 (COVID-19). Nevertheless, it is unlikely that we will be able to eliminate SARS-CoV-2 (COVID-19) completely this spring, (and given that other human coronaviruses are known to peak in the fall), we may very well see a resurgence of COVID-19 this fall or in 2021. More importantly, if government imposed control measures are lifted too soon, we may be likely to see another peak in the disease (at least until enough immunity has built up in the population, or until we are able to develop an effective vaccine against SARS-CoV-2) in the coming summer months.

Previous pandemics such as the 2009 and 1918-1919 influenza virus pandemics began with a comparably smaller “epidemic peak” in the spring season, subsequently followed by a larger epidemic peak in the fall. In the 1918-1919 influenza pandemic, these surges were followed by subsequent peaks. The reasons behind the multiple epidemic “waves” are not entirely understood. In part, the distinct spring and fall waves of influenza pandemics may be due to a decrease in the transmission of the virus associated with the school vacations or less favorable environmental conditions (notably higher absolute humidity or inherent social distancing factors) in the summer. There is also some speculation that the virus may evolve between the spring and fall waves, allowing it to escape any immunity that had built up in the population, or that the spring waves could be due to a completely different virus, (but conclusive data to prove any of these hypotheses is lacking).

If you look at the fluctuation contagion patterns of other viral epidemics it is readily apparent that outbreaks come in waves – with clear ebb demarcations (peaks and troughs) rather than a linear pattern. Looking back a century ago, the 1918-1919 influenza pandemic might provide us with a navigational chart to anticipate how this may play out in the coming months. Among the lessons learned (and applications for our planning priorities) is the realization that we should prepare assuming that we are going to go through this again in the coming months regardless of what steps for “normalization” occur in the next few weeks.

One “take away” from the 1918 – 1919 pandemic was the seasonal progression of the waves of contagion (e.g. spring-fall-winter-spring). For example, the 1918-1919 influenza pandemic occurred in three distinctive “waves.” There were three different global waves of illness during the pandemic, starting in March 1918 and subsiding by summer of 1919. (The pandemic peaked in the U.S. during the second wave, in the fall of 1918.) This highly fatal second wave was responsible for most of the U.S. deaths attributed to that pandemic, as the vast majority of deaths were packed into three especially cruel months in the fall of 1918 “second peak contagion period.” Most scholars argue that the rapid spread of the virus in the fall of 1918 was at least partially to blame on public health official’s unwillingness to impose quarantines and strict social limitations. Numerous writers have also argued that the public health response to the crisis in the United States was further hampered by other factors including; a severe nursing shortage (as thousands of nurses had been deployed to military camps and the front lines during the Great War) and dysfunctional social norms (including bitter racial prejudice that limited the utilization of African-American nurses to care for the infected) and perhaps most significantly the lack of a vaccine for the virus. Nonetheless, by December 1918, the second outbreak wave was subsiding, but the global pandemic was far from over.

A third wave began in January 1919 and eventually worked its way back to Europe and the United States that year. The mortality rate of the third wave was just as high as the second wave. The third wave of contagion peaked during the winter and spring of 1919, adding to the total global pandemic death toll. The third wave of the pandemic eventually subsided during the summer of 1919.

It’s Probably Not Over Even When We Think It’s Over
There are substantial reasons for us to consider the probability of subsequent waves of COVID-19 sweeping across society in the coming autumn and winters seasons even if the case numbers stabilize or decline in the next few weeks. We need to be prepared to mitigate and manage such outbreaks. Although it is fair to concede that every pandemic is unique and non-linear dynamic multi-variable prediction models offer only general notions of case level rate probability with a rather low degree of specificity accuracy. Furthermore, our experience with past (influenza) pandemics cannot be assumed to be predictive of what might happen next with SARS-CoV-2 (COVID-19) which is not an influenza strain. However, to assume that a short respite in the contagion rates means that this is “over” is an error in reasoning and may result in in some terrible decision-making. In fact, based on experience we ought to be prepared to go through subsequent peaks in contagion before “it’s all over.” It is unlikely that we will be able to eliminate SARS-CoV-2 completely, and other human coronaviruses are known to typically peak in the fall season, so we should be prepared for a resurgence of COVID-19 disease this coming autumn. Perhaps even more importantly, if control measures are lifted too soon, we might likely to see another peak in the disease, at least until enough immunity has built up in the population, or until we are able to develop an effective vaccine against SARS-CoV-2 (COVID-19). Other variables, such as the prospect of the virus mutating into more virulent or easier to transmit forms also play a role in when, where and how new surges in the number of infections may occur.

Like all living things that evolve, a virus is likely to mutate and adapt. Many such mutations are harmful to the virus itself, but occasionally a mutation occurs that enables the virus to transmit more efficiently. Mutations in the influenza virus strains, for example, can allow the virus to escape the immune response among people who had been infected with or vaccinated against a different flu virus in the past. However, the big changes that allow the flu virus to escape immunity often take place over multiple years, and not all viruses are able to evolve in a way that allows them to escape immunity.

Summary
The expectation of pandemics occurring in multiple waves [not necessarily three] pertains specifically to our experience with past influenza pandemics. The 1918 and 2009 pandemics, for example, both began with a generally smaller epidemic peak in the spring, followed by a larger epidemic peak in the subsequent fall. In 1918, this was followed by a third peak in the winter of 1918-19. The reasons behind the multiple epidemic waves are not entirely understood but experience provides sufficient evidence to justify our planning and preparing for subsequent peaks of outbreaks. In addition to a possible resurgence of COVID-19, there will be other communicable disease viruses emerging which could be the source of a totally new pandemic risk. Such communicable disease disasters are not a matter of “if’ the next one will occur but “when.” There is also the very real danger that the next global pandemic will be from a source even more dangerous, highly infectious, and easy to transmit communicable disease. (Imagine for a moment that we were all currently trying to cope with an Ebola Virus Disease (EVD) like virus rather than COVID-19.) There are more than sufficient reasons to accept that this pandemic (or the next pandemic) is not over even when we think it is over and we ought to take steps now anticipating doing this again in the future.

Here is the crux of the matter, just some simple questions to ask ourselves and ask those responsible for our communities, businesses, schools and other key players in our lives: Are we prepared for the next wave? Are we watching, testing, tracking and monitoring? What’s your continuity plan for if/when we go through the next peak contagion period? If this past month was disruptive to your business, life, or daily operations, then learn from your experiences and be better prepared for going through it all again. We are all eager to get back to ‘normal’ and put all of this disruption behind us – but in reality now is the time to prepare the manage the possible next dramatic disruption that may occur this coming 2020 fall and/or 2021 winter-spring seasons. This past month may have just been a sample of what could be coming next for us this fall, next winter and/or next spring – so what are we going to do about it? What are you going to do to be better prepared for the next wave and/or the next pandemic?


About the Author: Robert C. Chandler, Ph.D. is a professor at Lipscomb University (Nashville, Tennessee). He directs the graduate and professional programs in communication. His teaching and research areas include public communication, crisis and emergency communication, crisis and consequence management, intercultural communication, and health communication. Graduate studies in communication offer advanced training in both on-line and hybrid learning formats in professional communication fields, including study in key areas such as health communication and crisis and emergency communication. Read more of his coverage here on LinkedIn.

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