When it’s safe to go back to normal, according to Covid-19 experts

President Joe Biden last week suggested Americans will be able to gather more freely by July 4. Some states have started to ease Covid-19 restrictions. Covid-19 cases, hospitalizations, and deaths have continued to drop from their fall and winter peaks, and vaccination rates have continued to climb.

Is this it? Is America finally inching back to the pre-Covid-19 normal — the life many of us desperately miss?

Experts are of two minds. On the one hand, things are heading in the right direction: Negative outcomes from Covid-19 are falling and the vaccine rollout is steadily improving. On the other hand, there’s the same story we’ve heard since the beginning of the pandemic: If the country eases up too quickly, especially as variants of the virus circulate, there’s still plenty of room for yet another surge in cases and deaths.

Most realistically, we won’t mark a specific date, like July 4, on the calendar and hold a big “back to normal” parade.

The process, instead, will be much more gradual, and many of us may not even notice it’s happening. In broad strokes, more of us will get vaccinated. We’ll start gathering more, especially with those who have been vaccinated. Businesses will start to reopen, maybe at first asking for vaccine passports, as states see hospitalizations drop and lift restrictions. The spring and summer will bring warmer weather for outdoor events. Pretty soon, even indoor gatherings will feel pretty safe, with more people vaccinated and fewer ending up in hospitals. All of a sudden, we’ll find ourselves doing what we were doing two years ago.

“I reckon that point will become apparent in retrospect,” Bill Hanage, an epidemiologist at Harvard, told me. “We will suddenly realize that we are laughing, indoors, with people we don’t know and whose vaccine status is unknown, and we will think, ‘Wow, this would have been unimaginable back when …’”

Less cautious Americans have spent the pandemic already living their lives fairly close to normal. Some had to as a result of their job or other responsibilities. But they will also benefit from the return to normal, with the lower risk of infection, businesses reopening, and the economy hopefully roaring back.

That’s not to say everything will return to the pre-pandemic days. Some people could keep wearing masks in public, particularly during flu season. Some businesses and their employees may decide that remote work is a better fit for them. And perhaps schools will use the lessons of the pandemic to turn, say, snow days not into days off — but Zoom days.

There’s also a lot that could go wrong between here and there. New coronavirus variants could evade our natural or vaccine-induced immunity, making us vulnerable to Covid-19 again. The fall could bring yet another surge, especially if restrictions are eased too quickly and not enough people are vaccinated.

“A lot depends on our actions still,” Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security, told me.

Thankfully, there are ways to secure a victory. Most obviously, the vaccine rollout needs to continue apace. The country should also ensure cases and, in particular, hospitalizations and deaths continue to drop. The same old metrics we’ve come to rely on throughout the pandemic remain vital, even as more people get vaccinated, because we still don’t know the proper threshold of vaccinations for population protection, or “herd immunity.” Those numbers — cases, hospitalization rates, and deaths — can gauge just how safe it is to go back to a pre-Covid-19 normal.

If it all goes right, that could mean the kind of big Independence Day barbeque that Biden hinted at in his first primetime national address. But it all has to go right.

When should you go back to normal? Look to the vaccine.

The truth is that getting back to a pre-pandemic normal will vary from person to person and place to place.

For the individual, the most important consideration may be their own risk tolerance. Some people have been living their lives with few changes over the past year, deciding that the coronavirus is not a threat to them. That’s not necessarily true — Covid-19 has killed even young and healthy people — and such carelessness helped spread the disease, but it shows that caution toward the virus is ultimately a personal choice.

For those who have decided to and are able to be cautious, though, the biggest question is whether they’re vaccinated. And, at current rates, all US adults should be able to get their shots by mid-summer.

Based on the clinical trials and real-world evidence, all the vaccines currently approved by the Food and Drug Administration greatly reduce the risk of illness due to the coronavirus and drive the risk of hospitalization and death to nearly zero. There’s also growing evidence the vaccines drive down the rate of transmission, making it much less likely that someone who’s vaccinated could actually spread the disease.

Already, the Centers for Disease Control and Prevention put out guidance suggesting vaccinated people can safely take part in smaller private gatherings without masks. If evidence for the vaccines’ protective value grows, and as more people get vaccinated, the guidance on all of this will likely get more lax — letting people who are vaccinated feel more comfortable living life closer to normal.

“My expectation is that if I want to hang out with someone else who’s been vaccinated and have a cup of coffee and not wear a mask, I think it’s probably pretty safe,” Ashish Jha, dean of the Brown University School of Public Health, told me. “There’s a lot of upsides to getting vaccinated.”

Some public health experts are already pushing further, arguing that people can engage in other activities, from larger gatherings to travel, once they get vaccinated. Jha, for one, has said he plans to host a July Fourth barbecue at his home.

The disagreement between experts comes down to the risk of transmission. The vaccines nearly eliminate the vaccinated person’s own risk of getting seriously ill from Covid-19, but it’s not clear yet how much the vaccines prevent that person from spreading the virus — it seems there’s some effect, but it’s not yet clear how much. Some public health experts remain cautious, arguing people should wait for more evidence and higher vaccination rates before going back to normal. Others are more convinced the vaccine will drive down transmission and believe telling people they’ll regain their freedoms is important to fight vaccine hesitancy, so they’re encouraging people to see their vaccines as a passport to a more normal life.

At the very least, though, the consensus is that getting vaccinated allows at least some return to normalcy for individuals who are inoculated, even if the coronavirus is still out in that person’s broader community. And eventually, the vaccinated can expect to go back to their pre-pandemic lives.

“If you don’t have variants circulating in any meaningful way that somehow evades the protection of the vaccine, and we have evidence that the immunity you get from a vaccine is durable, meaning it’s not short-lived, then whether there’s still ongoing transmission in the community shouldn’t mean that you have to alter your life substantially,” Michael Osterholm, director of the Center for Infectious Disease Research and Policy, told me. “We don’t tell kids who have measles vaccinations that just because there’s measles in the community, you can’t go out and play.”

When should states reopen? That will depend on cases and hospitalizations.

For states, the considerations for returning to more normal times should be more expansive — covering cases, hospitalizations, deaths, and vaccination rates at the population level.

In a perfect world, the country would at some point reach herd immunity. That’s when so much of the population is immunized, whether by natural or vaccine-induced means, that the coronavirus can no longer hop from person to person because each person with preexisting immunity would act as a barrier to the virus making the next jump.

But the reality is a little messier, in large part because we still don’t really know what the right threshold for herd immunity is for Covid-19. The numbers that we often hear — 70 to 90 percent — are rough estimates and could be totally wrong. There’s still too much we don’t know about Covid-19, its variants, and how immunity to the coronavirus works to say with any certainty what the number is.

Given that, experts have advised the country to not chase herd immunity as the final goal. As Anthony Fauci, the top federal infectious disease expert, said at a press conference this week, “We should not get so fixated on this elusive number of herd immunity. We should just be concerned about getting as many people vaccinated as quickly as we possibly can, because herd immunity is still somewhat of an elusive number.”

The better path forward, experts say, is to take a more comprehensive look at the spread of the virus. That includes the same metrics that we’ve come to rely on over the past year: cases, hospitalizations, and deaths. It also means, now, looking at vaccination rates.

The goal is to get Covid-19 cases, hospitalizations, and deaths to drop below levels the US hasn’t seen since at least before the fall-winter surge, and then continue declining. Meanwhile, vaccination rates should continue going up. As long as a place is hitting those marks, it can feel comfortable easing restrictions around Covid-19 over time.

These metrics can also work together, flagging problems beyond exactly what they’re measuring. “For example, if I look at a hospital, and I see there’s still a lot of people over 65 landing in the hospital, I know in that community there’s not enough access to the vaccine,” Pia MacDonald, an epidemiologist at RTI International, told me.

Crucially, this has to be managed locally. If the country or a state hits a vaccination rate of 90 percent, that’s not going to matter much to the town that’s still stuck at 20 percent. The city-by-city, county-by-county, and state-by-state stories will matter as much as the national picture.

There are also demographic considerations. Covid-19 doesn’t hit all groups equally, with older people and those with certain medical conditions at greater risk. If these people are vaccinated, then a state or local government could have a lot more confidence in a move to ease restrictions.

And the reopening process should be done slowly. One of the biggest mistakes that’s been repeated during the pandemic is places reopen too much too quickly, creating hotbeds for the coronavirus to suddenly and quickly spread. As was true for the past year, states should move toward reopening bit by bit, not all at once.

The US, as a whole, is not yet safe. Although many of the coronavirus numbers have improved since the fall and winter surge, they’re still very bad. The number of Covid-19 cases, hospitalizations, and deaths remains higher than it was for much of last summer, when America experienced a continued wave that drove its Covid-19 death toll above most of its developed peers. And the vaccination rate still isn’t very high: Only 12 percent of the US is fully vaccinated so far.

The same is true at the state level — yet many states are pushing forward with reopening anyway. Texas, for one, recently moved to reopen everything and end its mask mandate. But while Texas’s Covid-19 cases, hospitalizations, and deaths have dropped from very high peaks in January, they’re still largely elevated compared to what they were before the fall-winter surge. The state’s fully vaccinated rate is only 10 percent.

That could lead to another surge before the vaccine campaign finishes up. The end is near, but it’s not quite here yet — with most of us still at risk of Covid-19.

Coronavirus variants, and the coming fall, could ruin things

There are other factors that could screw things up further — three of which in particular may demand continued vigilance, even if the vaccines bring the summer calm many of us want.

One is the variants — specifically, the possibility that Covid-19 will mutate to evade vaccine-induced immunity. That doesn’t appear to be the case so far with the variants that we know of, with the vaccines triggering enough of an immune response to still protect from these mutations.

But the coronavirus could still change further. The virus spreads in its hosts by replicating, with each potential replication carrying the chance that the virus will transform into a new variant. If one of these mutations proves advantageous to the virus and it sticks, it could make the coronavirus even worse — maybe more infectious, more likely to evade immunity, deadlier, or all of the above. This is all more likely the more the virus replicates.

One risk lies outside the US. So far, the major variants that have popped up have come from other countries. But with globalization and international travel, these variants have still ended up in the US to varying degrees. That speaks to the importance of controlling Covid-19 not just in the US but abroad; otherwise, a new variant from elsewhere could invalidate our efforts at home.

Given the many remaining problems with vaccine campaigns in other countries, especially low-income nations, Osterholm said, “I’m convinced the variants we’re seeing today are not going to be the last of the variants.”

A second potential concern is the coming fall. As we learned over the past few months, the coronavirus appears to be seasonal — perhaps because of how the weather affects the virus, people’s behavior, or both. That led to the US’s biggest surge in Covid-19 cases, hospitalizations, and deaths from October to January. And it could happen again if enough people aren’t vaccinated by the fall, if the virus mutates to evade immunity, or both.

Finally, if immunity to Covid-19 is only temporary, not lifelong, then it’s possible the virus will come back in the next few years and beyond. That could require some mitigation efforts — temporary closures, a return to masking, or booster shots — on a regular basis. But we just don’t know to what extent that’s true. “We still have a lot to learn about the virus for the long term,” Watson said.

Combined, these problems could upend all our current gains, not only causing a surge of cases, hospitalizations, and deaths but, in the case of a new, evasive virus variant, possibly require a new vaccine or booster that would take time to develop. That would kick the finish line further down the road.

The best way to avoid all of these problems is to get the coronavirus under control quickly and globally — to prevent it from mutating, and to put out embers of the virus so they can never turn into wildfires.

If we do this right, we could find ourselves in a restaurant or movie theater in the coming months, gathered with strangers in spaces that were considered dangerous one long year ago. At that point, maybe the news will rarely mention the virus. Reported cases and especially hospitalizations could fall close to zero.

“We should see a cliff in terms of hospitalizations of Covid-19,” MacDonald said, adding that this could happen in the next few months. “When that’s true, that means the vaccines have gotten to the right people.”

It’s a moment that probably won’t be advertised beforehand, and there will be no parade to mark its official arrival. But once it happens, we’ll know, in retrospect, that we’re finally back to normal.

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