Charting the pandemic over the next 12 months and beyond – STAT – STAT

Think back through the pandemic. Think about the moments that stand out as beacons in the haze signposts of how it would change all of our lives.

Not all of these moments were clear at the time. Chinas decision to shut down cities of millions of people in January was staggering, but to most Americans, this new coronavirus remained an ocean away, not something that would demand our own version of a lockdown.

Other moments form pits in our stomachs when we look back. Perhaps, for you, its when the Centers for Disease Control and Prevention touted it was developing its own test for SARS-CoV-2 instead of relying on international designs. Or when leaders in New York delayed containment plans as cases built. Or when President Trump embraced the unproven and ultimately fruitless hydroxychloroquine as a miracle drug.

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Then there were moments when the new reality arrived with the subtlety of a sonic boom. Take March 11: Trump halted most travel from Europe. Tom Hanks and Rita Wilson announced they had Covid-19. The NBA suspended its season.

Now with health authorities saying it may not be until at least the end of 2021 before theres a degree of post-Covid normalcy in our lives look forward. Imagine the next 15 months and what life will be like.

In this project, STAT describes 30 key moments, possible turning points that could steer the pandemic onto a different course or barometers for how the virus is reshaping our lives, from rituals like Halloween and the Super Bowl, to what school could look like, to just how long we might be incorporating precautions into our routines.

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This road map is informed by insights from more than three dozen experts, including Anthony Fauci and Bill Gates, people on the frontlines at schools and hospitals, as well as STAT reporters. It largely focuses on the U.S.

Perhaps making forecasts during whats habitually described as unprecedented is foolish. Im kind of done predicting none of my predictions worked out for me, Kelly Wroblewski of the Association of Public Health Laboratories said, with a resigned laugh, about when she thought the testing problems that have dogged us from the earliest days might get resolved. And indeed, some of the events will unfold in different ways and at other times than weve charted out.

Yet for all thats caught us off guard about Covid-19, some factors like how a virus spilled from animals and swept around the world are straight out of pandemic playbooks. We can see the coming crossroads.

So many challenges still lie ahead. Flu season. An ongoing child care quandary. A tumultuous election and potential transition of power. Whoever wins, well need them to shepherd a vaccine rollout a logistical and public relations campaign without (heres that word again) precedent.

The virus is not through with us yet, said family physician and epidemiologist Camara Phyllis Jones of Morehouse School of Medicine. The virus has only one job. And thats to replicate itself, and to go from person to person to person and it doesnt care which person.

Throughout the pandemic, whats maddened U.S. public health experts has been the nations inability and unwillingness to take the steps that could reduce illness and death, steps that other countries have used with success. Instead, were trying to force the activities commerce, schools, and festivities that controlling the virus in the first place would enable but that, in our case, are contributing to infection counts.

Theres this attitude that public health measures are getting in the way of opening up the country, Fauci, the countrys most prominent infectious disease expert, told STAT. Its exactly the opposite. In a prudent way, the public health measures are the gateway, the vehicle, the pathway to opening the country. Thats the point that gets lost in this thats so frustrating.

As Fauci monitors the coronavirus trajectory, so do the rest of us, wondering what other hallmarks the pandemic will soon touch like Thanksgiving feasts. At Adams Turkey Farm in Westford, Vt., theyre anticipating this year selling fewer of their signature birds around 24 pounds Oh my gosh, theyre beautiful, said owner Judy Adams and more smaller birds. The holiday meal will still happen; there just might be fewer people squeezing around the table.

Weve weathered different things certainly not a pandemic but I just trust in the holiday, I trust in the turkeys, Adams said. But if this is the year that we make less money, well, that will be OK, and we will get through this.

Overstretched ambulance crews. Overflowing hospitals. Overstuffed morgues. The grimmest images from the spring and summer peaks could appear again this fall and winter if the country doesnt drive its case count down urgently.

If were not going into the fall with a huge running start in terms of having cases at very, very low levels we run the risk of having uncontrollable outbreaks, said Michael Mina, an epidemiologist at Harvards T.H. Chan School of Public Health.

People are returning to offices or schools and interacting with others more. Residents of the northern half of the country, who embraced al-fresco summers, will move indoors. States and cities are inclined to keep easing restrictions.

Then theres the virus itself.

While this is our first fall with SARS-2, experts believe that its activity could accelerate as temperatures drop, as is the case with other viruses, including the four coronaviruses that cause common colds. These viruses survive longer in cold, dry settings, tied to a measure called absolute humidity.

But the virus spread like gossip this summer in the South. Was the heat really slowing it down?

To an extent, experts think. But whatever advantage summer provided was overtaken by the fact that none of us was protected against the virus, and that restrictions like closing bars were lifted. The summer epidemic probably would have been worse if it had been winter, said disease ecologist Marta Shocket of UCLA.

Some communities will have one partial shield this fall: a level of population immunity. Most people who recover from Covid-19 will be protected from a second case for some time, its thought. In hard-hit areas, 20% of residents or more have had the illness already many without knowing it meaning fewer people can be infected and spread the virus.

Were not dealing with a situation like we were in February and March when it was a totally naive population, said epidemiologist Wafaa El-Sadr of Columbia University. These areas have not reached herd immunity when the percentage of protected people is high enough that the spread burns out but, El-Sadr said, its a plus.

Mathematical epidemiologist Gerardo Chowell of Georgia State University has what could be considered an almost optimistic autumnal outlook: a flat number of cases, as increases in the northern half of the country offset declines in the South and some safeguards are kept up.

But Chowell doesnt imagine the real glass-half-full scenario: cases going down. Having seen how U.S. society is split on face masks, Im not very hopeful, he said.

Its possible the fall wont realize our worst fears. The flu season could be mild. Outbreaks in nursing homes and prisons could be prevented. But were approaching the danger zone with lots of virus circulating, when it was presumed that the country would be in a better position.

Ahead of the fall, we were envisioning that there would be a continued downward trajectory of Covid-19, new infections and deaths, Brian Hainline, the NCAAs chief medical officer, said in August. That there would be a national surveillance system, national testing, and national contact tracing that would allow us to really navigate this pandemic and to resocialize both in sport and in the rest of society. And that hasnt happened.

For colleges, theres one over-arching dilemma: How can they safely keep students on campus?

As we look for clues, the University of Wisconsin-Madison is one to watch. Desperate to contain the virus, the school this month mandated that residents of two dormitories and 22 Greek houses quarantine for two weeks. I literally felt like I was being arrested, one student told a TV reporter.

As the students emerge in the coming days, it will become clear whether the gambit worked.

If it does, it could show that universities might be able to hem in the virus and slog through this semester. If it doesnt, it might be a sign that more schools will have to throw in the towel, following the likes of Colorado College and the University of North Carolina in canceling their in-person plans after students showed up. Some schools have gone from in-person to virtual teaching and then given in-person another chance.

College clusters are fueling a sizable portion of new Covid-19 infections around the country. But some schools are soldiering on: The University of Illinois at Urbana-Champaign and schools in New England, for example, have unveiled ambitious testing schemes. Some are holding lectures in basketball gyms or in tents.

But colleges, by design, bring packs of people close together. If cases crop up, they easily beget more. And if one things clear from the start of the semester, its that college kids like to party, Covid or not.

It would be pure luck if you didnt have clusters of cases at some point during the semester, said epidemiologist Nita Bharti of Pennsylvania State University.

The colleges that allowed students to return did so in part because its what students wanted. They pleaded they were missing out on spontaneous 3 a.m. philosophical discussions and intellectual breakthroughs that come only after a group all-nighter. But for the schools, it was also a grasp at a financial lifeline as budgets collapsed.

Universities are in such a hard place, said Meira Levinson, an educational ethicist at Harvard. They are educating people who have the transmission patterns of adults but who are developmentally not making choices the way older adults would.

The deeper impact of college closures could come if schools dont sequester students before sending them home. Absent that, they could spray the virus across the country like shrapnel.

You can practically mouth the script: On stage at Case Western Reserve University in Cleveland (and before a limited audience), former Vice President Joe Biden lambastes Trump for the nations disastrous pandemic response and for failing the American people. Trump tries to convince millions of viewers that the U.S. has turned a corner that his administration defeated the virus and is this close to a vaccine.

And with that, experts say, the election discourse poses real risks.

Since the beginning of the pandemic, scientists have struggled to address Covid-19 misinformation from the administration. While they would normally advise looking to the Food and Drug Administration or CDC, the agencies at times have become megaphones for White House messaging.

We have offices that have credibility and we have noncredible people in those offices, said Penn States Bharti. That has created a disconnect for us for how to handle misinformation.

Trumps attempts to paint a rosier picture of the situation could make it worse, experts say. If politicians prematurely declare victory, it sends the message that people no longer need to wear masks or distance from others.

Im worried that if leaders say to the public like they did back in April or May, that this will be over, if those messages come back, it will confuse people again and well see another surge in cases, said Tom Inglesby, director of the Johns Hopkins Center for Health Security. Its really important for leaders not to sugarcoat things when they are not going well.

Picture the cable news coverage of Septembers unemployment report, a crucial proxy for the economy and the last one before the election. A flashing chart showing the pandemics toll on jobs, and an immediate pivot to the political implications. Trump will likely be watching.

There had been hopes that the economy would bounce back from the depths of the spring in a V-shaped recession. Jobs returned as states allowed more business activity heading into the summer, but only to an extent, and hiring has since cooled. A bad or stagnant jobs report, then, could drive Trump to demand that states lift the remaining restrictions meant to keep a lid on Covid-19.

But the central reason for the sputtering economy, economists say, is the uncontrolled epidemic. Government restrictions certainly dampened activity, but much of the persistent drag is because people do not feel safe traveling or hitting the town or spending money in their usual ways.

People look around and say, the risks are too high, Im not going to go about my activities, said economist Kosali Simon of Indiana University.

This recession stands out for how quickly the economy cratered and for how it devastated select industries while leaving others unscathed. Its also amplified the divide between white-collar workers who could slide into working from home, and lower-wage employees, many of whom lost their jobs or risked infection at their workplaces.

The looming concern is that the pain may spread. Government spending has kept components of the economy treading water. If that support ends before a vaccine arrives, demand could collapse, unemployment could become long-term, and the recession could become entrenched.

Were setting the stage for another decade of massive unemployment and a lost generation of workers, said Harvard economist James Stock. A public health response is not only about saving lives, its holding the economy in its hands.

The solution is not another lockdown, said Stock, whos studying the effectiveness of interventions. Simple but sustained strategies, he said, can sufficiently drive infections down: donning masks, minimizing super-spreading opportunities, maintaining distancing, and restricting indoor activity. Build up testing. If cases get low enough, contact tracing becomes feasible.

Its essential that the country embraces these measures uniformly, Fauci said. If one area in the country does it really well, and another area is careless and it surges up, thats like playing whack-a-mole.

Its too early to say weve overcome all the horrors of testing, from a CDC test that didnt work to shortages of swabs and reagents to delayed (and thus meaningless) results.

But, perhaps, finally, things are looking up. A lot more ubiquitous testing is coming, Ashish Jha, the dean of Brown Universitys public health school, said at a STAT event in September. Ive been saying that for months, but maybe now it will actually be coming.

Faster and cheaper tests are becoming available, supported by a National Institutes of Health program. The Trump administration is distributing millions of antigen tests (which detect viral proteins) to nursing homes. Employers and universities have hatched ambitious testing strategies that could be models.

A potentially more potent tool could also arrive in the coming months: rapid, at-home coronavirus tests, akin to pregnancy tests. This type of antigen test, which could use a saliva sample and is still in development, is not as accurate as PCR diagnostics (which detect the virus genetic material). But the vision is that it could offer individuals a pretty good clue as to whether they have infectious Covid-19 within minutes information that would allow them to go about their lives (with precautions) or isolate themselves. Having a test that can find you when youre transmissible is the whole goal, Harvards Mina said.

Still, plenty of challenges remain. Experts say testing capacity needs to be expanded many times over. Test kits abound on movie sets and in professional sports, yet many people still have trouble locating one. Whatever national testing strategy exists is defined by deferring to states, leaving local labs more vulnerable to supply chain snags and to getting overwhelmed.

The idea of what a rational testing plan looked like you know, we were on the phone with all the key people in the federal government in those key months [February and March], and it just didnt happen, Bill Gates told STAT.

Within two weeks of schools in Cherokee County, Ga., opening in August, when local coronavirus transmission was still high, more than 1,000 students and staff found themselves in quarantine and three high schools reverted to online learning.

In the Northeast, as schools considered welcoming students for in-person instruction in September, communities generally had low Covid-19 rates the surest signal that schools can reopen safely. But even there, last-minute snafus threw some plans into disarray, showing the difficulty of trying to hold together a strategy in a changing pandemic.

New York City, which planned to open schools for a mix of classroom and remote learning Sept. 21, delayed for another week on Sept. 17. In Carle Place School District on Long Island, the superintendent made the call to switch to virtual learning two days before school started, after parties led to a spike in Covid-19 cases. As we are learning the hard way, the actions of a few can impact the many, Superintendent Christine Finn wrote in a letter to families.

By mid-October, the northeastern schools that did welcome students back will be a month in time for a report card on their strategies. Rhode Island, for example, opened schools in most districts, starting with some students as they moved toward full classes. There will also be signals whether schools that needed more time to get staff on board with in-person plans or to retrofit classrooms to meet safety standards can get kids back.

Other countries have made it clear that low community transmission levels and rigorous strategies can enable schools to reopen and stay open. In a recent editorial in Science, researchers wrote that with distancing, limited classroom size, ventilation, and masks, transmission within schools has been rare. But in the U.S., schools havent been prioritized. In some places, movie theaters and gyms and indoor dining came back, even as local viral levels were deemed too high for in-person teaching. Were making choices that dont necessarily make a lot of sense, said Zo McLaren, a health policy expert at the University of Maryland, Baltimore County.

Cases will be detected at school, experts stress. The question is what happens then. Districts need plans for how extensive quarantines should be, how many cases would trigger a shutdown, and how long that should last.

Returning to school, of course, is not just about the risk to kids, who are much less likely to get serious Covid-19 cases than adults. About 40% of teachers and 40% of adults living with children have health conditions that increase the likelihood of more severe Covid-19, according to one study. Many children live with a grandparent. Households have been key transmission points during the pandemic, and kids cant isolate from their family. If your kid gets sick, youre probably going to get sick too, said Maia Majumder, a computational epidemiologist at Boston Childrens Hospital.

The first treatments specifically crafted to fight SARS-2 could join clinicians armaments this fall.

Called monoclonal antibodies, they are designed to block the virus from slipping into cells. A number of candidates are in clinical trials, with results possible starting in October.

The real boon could be if monoclonals keep patients with mild Covid-19 from progressing to more severe illness. They are also in earlier-stage testing to see if they can stop infection, akin to a vaccine.

What we really need are therapies that can be administered early to prevent someone from actually needing to go to the hospital, Fauci said. Thats the big gap that we have.

When the pandemic erupted, the worlds medicine cabinet was bare of any coronavirus therapies. Researchers adapted, finding that an experimental antiviral called remdesivir helped hospitalized patients recover faster and that common steroids reduced deaths. Theyre exploring blood thinners to stop clots, and ways to calm overhyped immune systems that paradoxically cause many patients deaths. And then theres the still maybe-beneficial convalescent plasma an antibody-rich blood component donated by people recovered from Covid-19.

Monoclonals have been seen as providing a bridge for the pandemic a treatment for patients who get sick while vaccines are being rolled out. But there are questions about whether their development will take too long to make a real impact. There hasnt been a significant push, for example, to manufacture them en masse.

It makes sense for something like Ebola, sure, when there arent that many people who get infected at a time, said Juliet Morrison, a University of California, Riverside, virologist. But with Covid-19, can we scale up to really do that for the whole population?

Usually, these meetings are eye-glazing to anyone beyond scientists and drug companies, yet another expert gathering in a conference room at the FDAs suburban Maryland campus. But the topic will be Covid-19 vaccines, and given the timing 12 days before the election people nervous about potential White House interference in the FDAs evaluations have this date circled on their calendars.

At a routine meeting of these outside scientific advisers, the group might discuss the composition of that years flu shot or debate clinical trial data for a vaccine. At this one, its expected that results from Covid-19 vaccine candidates wont be ready. Still, the (virtual) meeting could be a chance for the experts to build up a scientific bulwark against meddling from Trump a moment when they will punctuate the importance of a rigorous review of immunizations, conducted only once adequate safety and efficacy data are available.

The medical science community must stop this dance as we get closer to rolling out a vaccine for Covid-19 because we now know that we wont get any help from the federal government, Holden Thorp, the editor-in-chief of the Science journals, wrote in an editorial. Were on our own.

FDA Commissioner Stephen Hahn has said that the meeting is part of the agencys commitment to being as open and transparent as possible and that it will help the public understand the data needed to facilitate [vaccines] authorization or licensure. Hahn has pledged that politics and pressure from the White House wont force the agencys hand.

But the president has already accused the agency of harboring the deep state and slowing treatment development. Hes also staked his reelection on a vaccine, promising at the Republican National Convention that we will produce a vaccine before the end of the year, maybe even sooner, without mentioning the uncertainty around clinical trials.

OK, so this one might not happen.

But if it does, imagine the juxtaposition. A spike-the-football Trump tweet, and scientists fretting that a hastily released vaccine desecrated the regulatory process.

To be clear, there is a small but legitimate possibility that, should one of the vaccine candidates be wildly effective, clinical trials could demonstrate that by the end of October. Executives at Pfizer have said they could have results by then. But most experts think that the requisite data wont be available until later.

Everyone involved in the vaccine review process, including the companies testing them, says they are committed to ensuring the safety and efficacy of immunizations. And yet experts still cant shake the feeling that something untoward might happen before the election. Call it an October surprise, pandemic style.

Perhaps the FDA will try to thread the needle. Hahn has suggested a possible authorization for a vaccine for certain populations, such as health workers. But the great fear is that, if some issue emerges with a vaccine after it is authorized, it will only steepen the uphill climb vaccine campaigns are facing. A not insignificant portion of Americans are dubious about Covid-19 vaccines. Unforced errors could only entrench their uneasiness.

If [the FDA] is bullied on this for vaccines, there are going to be a lot of people who stand up and say, I wouldnt get this vaccine. And then what youve done is youve scared people and you only get one chance to make a first impression, Paul Offit, director of the Vaccine Education Center at Childrens Hospital of Philadelphia, said in August.

Even if a vaccine meets the standards for an emergency use authorization, it might still raise eyebrows. The track record of the FDA for EUAs with Covid has not been good, said UMBCs McLaren, citing the flip-flop on the hydroxychloroquine EUA and the politicization around the convalescent plasma EUA.

The endgame is not vaccine No. 1, McLaren said, noting that the world will need multiple vaccines to have enough supply. If trust in the EUA pathway is further damaged with vaccine No. 1, its going to hurt vaccines No. 2, 3, 4.

Parents, it may be time to have a difficult talk with your children.

Los Angeles County has advised against trick-or-treating. Towns in Ohio have canceled public trick-or-treating events. And in Salem, Mass., a city of 43,000 that normally hosts a monthlong Haunted Happenings festival that welcomes half a million people, pretty much all the events had to be canceled, rescheduled, or go virtual, said Kate Fox of Destination Salem. Fox said people will still make the pilgrimage to Salem, but stressed that Massachusetts requires a negative Covid-19 test or a quarantine for people coming from most states.

Perhaps nothing will change, or everything will.

If Biden is elected, he has said his first post-election phone call would be to Fauci, with a request that the scientist continue his service. He has a plan to assemble a new team of health officials to guide the country out of the pandemic. If Trump is re-elected, dont expect any major shifts in strategy.

But its not Covid-19 policy differences driving voters, said Robert Blendon of Harvard, an expert on the intersection of politics and health policy. When it comes to the pandemic, voters are thinking pragmatically how a Trump or Biden presidency would affect whether they can go to work and send their kids to school, or whether their businesses will survive.

And, Blendon added, Whats important to understand is that if there was some public health miracle in October, the polls would change dramatically.

In 2018, so many people came down with the flu that Pennsylvanias Lehigh Valley Health Network threw up tents to handle the influx of patients. In April of this year, the hospital almost had to turn operating rooms into ICUs for Covid-19 patients. The question for Lehigh Valley is: What would a double whammy look like?

My hope is that with all the education of the public, maybe its not as bad, Jennifer Rovella, the systems chief of critical care, said about the approaching flu season.

Its clear why experts worry about a wave of Covid-19 coinciding with a bad flu season whats been dubbed the twindemic. But its also possible that all the precautions against SARS-2 will reduce transmission of influenza; the Southern Hemispheres flu season, for instance, was remarkably mild.

Health officials arent taking chances. Theyre warning that people could get infected by both viruses, potentially making them more likely to get seriously ill. Theyre pleading with the public to get flu shots, which, even if they dont prevent infection, reduce the chances of severe disease. Weve ordered about twice the number of flu vaccines as we normally do, said Rachel Levine, Pennsylvanias health secretary.

Beyond the threat to health systems, distinguishing between the infections will be a head-scratcher for clinicians. Flu and Covid-19 have overlapping symptoms, including cough, fever, and aches. Doctors often dont even test for flu and diagnose a case based on an exam, but they wont be able to do that this year. Some tests that detect both viruses are being rolled out, but the urgency to tell if someone has flu or Covid-19 or both with implications for isolation and contact tracing could worsen bottlenecks.

You rely on the same laboratories and very similar testing supplies and equipment, said the lab associations Wroblewski.

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Charting the pandemic over the next 12 months and beyond - STAT - STAT