Living with COVID-19

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Living with COVID-19 is a term used to describe a management strategy for the COVID-19 pandemic, under which Coronavirus disease 2019 (COVID-19) is treated as an endemic illness—in line with other illnesses such as influenza—that cannot be fully contained, and a return to a form of pre-pandemic lifestyles is emphasised over continued use of rolling public health measures (including lockdowns and restrictions on gatherings, mandatory self-isolation, PCR testing programmes, and mask mandates), due to COVID-19 vaccines and other factors having reduced the severity of the virus among the general public.

It is contrary to COVID-Zero, a strategy that aims to suppress or eliminate any community transmission of the virus.

Background[]

The widening availability of COVID-19 vaccines, and the development of drugs for treating COVID-19 infections, led to discussions over whether they would allow populations to reach herd immunity, or otherwise be able to accept the idea of "living with COVID-19"—where COVID-19 is treated as an endemic illness that can not be fully eliminated, and a focus is placed on returning to "normal" life where the disease is still present, but is no longer considered to be as severe of a threat to public health than it was prior to the availability of vaccines.[1][2][3][4]

Studies have suggested that early COVID-19 vaccines had a lower efficacy against SARS-CoV-2 variants such as Delta and Omicron (causing more breakthrough infections), especially in the case of Omicron,[5][6][7][8][9] but that booster doses of the most common two-dose vaccines were shown to have an increased response to Omicron.[10][11][12] Omicron was also described as being less fatal[13] and more "mild" in comparison to past variants,[14] but more contagious, which can lead to an exponential growth of cases.[15][16][17]

Since Omicron, there have been trends in some areas where the number of patients being admitted to intensive care units (ICUs) have decreased. There has been a greater focus on distinguishing "incidental" hospitalizations—where a patient tested positive for COVID-19 at the hospital (which could be mild or asymptomatic), but was originally admitted for an unrelated reason or condition—from patients being specifically hospitalized for COVID-19 complications. However, there is still a chance that the patient's condition may have been influenced by COVID-19 complications.[18][19] It has been argued that the general public may have become fatigued by the ongoing cycles of government-imposed restrictions, which can also have an economic impact on various industries.[20][21][22]

Characteristics[]

The aim of the strategy is for a population to be able to return to either a pre-pandemic lifestyle,[23] or a "new normal" where personal risk assessment and voluntary practice of infection control techniques (such as masks) may remain normalised or recommended on a case-by-case basis, but are no longer employed on a wider scale.[24][25][26] Characteristics of the strategy include:[27][28][29]

  • Treating COVID-19 as an "endemic" illness that can be managed via vaccination and future prescription treatments (similar to other illnesses such as influenza)
  • Deemphasis on extraordinary public health measures as the primary means of controlling spread, such as large-scale lockdowns or capacity restrictions, and reducing or eliminating mandatory self-isolation.[30]
  • Deemphasis on laboratory PCR testing outside of those at the highest risk, in favour of using rapid tests for self-screening.[31][32]
  • Focusing more on severe outcomes such as hospitalizations, ICU admissions, and deaths as metrics rather than positive cases.[33][34]

By countries[]

Australia[]

Australia had initially pursued a zero-COVID strategy of suppressing any community transmission of COVID-19, which led to strict border controls both internationally and between states and territories, extensive contact tracing, and localised "snap lockdowns" and restrictions in response to even small numbers of cases in some areas (with the city of Melbourne having faced some of the longest lockdown periods worldwide).[35][36][37][38] This strategy initially proved successful in most of the country, until the emergence of variants of SARS-CoV-2 in mid-2021, and especially Omicron, which made it increasingly difficult to contain outbreaks.[35][36]

By July 2021, most of the country had begun to shift their focus towards a strategy focusing on vaccination, with the National Cabinet agreeing on a four-phase framework based on vaccination targets. As vaccination rates increase, travel restrictions would be eased, and larger lockdowns would become "less likely"; by the final phase, COVID-19 would be treated as endemic.[39][40][41] An exception is Western Australia, which has continued to enforce strict entry restrictions and infection control measures.[35][42] The state had also enforced a ban on COVID-19 rapid antigen testing due to accuracy concerns in an environment with little community spread (with fines of up to A$20,000 for individuals and A$100,000 for companies),[43][44] which was only lifted on 9 January 2022 in anticipation of the reopening of borders.[45]

In January 2022, Prime Minister Scott Morrison stated that Omicron's severity was "far less than perhaps was anticipated" despite its quick spread, and argued that "you've got two choices here: you can push through or you can lock down. We are for pushing through."[35] The Omicron wave subsequently led to supply chain issues, labour shortages,[35][42] as well as supply issues surrounding rapid test kits.[43][44] The following month, Western Australia indefinitely delayed a planned reopening of its borders scheduled for 5 February.[46] Premier Mark McGowan stated that it would be "reckless and irresponsible" to open its borders without sufficient distribution of booster doses to protect against Omicron variant, explaining that "if you have a look at the alternative, which is what is going on in the eastern states at the moment, they basically have hundreds of people dying, they have mass dislocation in the economy, in logistics, freight, and all elements of the economy."[47]

Canada[]

Alberta[]

In late-July 2021, after it had lifted almost all of its remaining restrictions (with Premier Jason Kenney having promoted the province as being "Open for Summer"), the Canadian province of Alberta proposed that COVID-19 be treated as an endemic disease, and that wider testing, contact tracing operations, and self-isolation rules be phased out. The provincial chief medical officer Deena Hinshaw encouraged residents to "not see [COVID-19] as the primary number one risk that all other things are secondary to", arguing that most COVID-19 cases were among unvaccinated residents, vaccination had reduced the number of hospitalisations and deaths, and that the province wanted to stop prioritising COVID-19 over other illnesses and medical concerns (including the Opioid crisis).[48][49][50] Hinshaw later stated that the province also wanted to focus on localised measures rather than "province-wide extraordinary measures".[51]

The announcement faced criticism for being premature, as a new wave of COVID-19 cases was beginning to develop in the province, and it was feared that the loosened protocols (including no longer offering testing of asymptomatic individuals) could worsen it, especially in schools (as there was not yet a vaccine approved for children in Canada).[52][53]

Amid criticism of the changes, they were later delayed.[54] Due to a new surge, the province re-enacted its mask mandate on 4 September (as well as restrictions on operating hours for alcohol sales),[55] and the province ultimately enacted a new public health emergency on 15 September due to the new wave. This included new restrictions on the capacity of businesses and prohibiting indoor dining, unless eligible businesses chose to mandate proof of vaccination. Premier Kenney admitted that the decision to treat COVID-19 as endemic was premature.[56][57] Due to Omicron variant, restrictions were made tighter in December 2021, applying even to establishments requiring proof of vaccination.[58]

Alberta once again began to ease its restrictions in February 2022; during a press conference, Hinshaw cited trends regarding Omicron variant in other provinces, and stated that "COVID will not go away. There will continue to be impacts on our acute-care systems that will rise and fall with seasonality and new variants that may emerge", and that "There has never been single right way to respond. But what is always true is that the actions that each of us take every day matter to our communities." These comments were interpreted as an intent to return to an endemic strategy.[59]

Denmark[]

On 2 February 2022, Denmark announced that it would lift most restrictions implemented since the Omicron wave (including those on gatherings, masks, and vaccine passport).[60] Despite having the highest case numbers within the European Union (and increasing presence of the BA.2 sublineage), health minister Magnus Heunicke argued that COVID-19 was no longer a "socially critical" disease, citing the country's high vaccination rate, that there were fewer patients being admitted to intensive care, and an increasing number of hospitalizations were incidental.[61][60] It was noted that the Danish population had a high degree of trust in their government for imposing and lifting health measures in their best interest, and that a survey by government advisor and Aarhus University professor Michael Bang Petersen showed that they were more concerned about the state of their hospital system, and that their "feeling of societal threat" was at its lowest since the start of the pandemic.[18]

North Korea[]

On 10 January 2022, Rodong Sinmun reported that North Korea would like to switch its COVID-19 measurement from a "strict" to an "advanced and people-friendly" approach.[62] Cargo train services between Sinuiju and Dandong was restarted from 16 January.[63] Several South Korean media analysed that North Korea would like to launch a "living with COVID-19" strategy.[62][63]

Singapore[]

In June 2021, Gan Kim Yong, Ong Ye Kung and Lawrence Wong—chairs of Singapore's COVID-19 task force—stated that "COVID-19 may never go away", but that due to high vaccination rates, a roadmap was being developed for how the city state could eventually live "normally with [COVID-19] in our midst", and manage it as an endemic disease, which would include:[33][34]

  • Using rapid COVID-19 tests for screening, as opposed to slower PCR tests, contact tracing, and quarantine.
  • Deemphasis on COVID-19 case numbers in favour of "outcomes"
  • Emphasis on COVID-19 patients being able to recover at home.[64]
  • Easing restrictions on gatherings and avoiding lockdowns
  • Easing travel restrictions for those who are fully-vaccinated

They stated that "Science and human ingenuity will eventually prevail over COVID-19. Cohesion and social consciousness will get us there faster. We must all do our part."[33][34] Shortly after the plans were revealed, however, outbreaks tied to Delta variant began to emerge, leading the Singapore government to reintroduce restrictions on gatherings. In October 2021, Prime Minister Lee Hsien Loong admitted that it would take at least six months to reach a "new normal", but that Singapore's high vaccination rates and low mortality meant that COVID-19 "has become a treatable, mild disease for most of us", the impact of COVID-19 variants had made a COVID-Zero strategy less feasible, and that maintaining restrictions would impact the economy and mental health of the country.[65][66]

South Korea[]

On 22 October 2021, , the Mayor of Suncheon, announced that the city will move to a "living with COVID-19" strategy starting from 25 October.[67][68] This made Suncheon as the first South Korean city to launch the strategy.[69][70]

On the same day when Suncheon launched the strategy, the Ministry of Health and Welfare held a public hearing at Central District, Seoul, and the ministry suggested a so-called "Step-by-step Recovery" strategy starting from 1 November.[71][72] Based on the plan, the South Korean government was planning to halt all restrictions by 24 January 2022.[72]

However, on 3 December, after about a month of "Step-by-step Recovery", the government temporarily suspended the strategy by re-imposing stricter measurements from 6 December amid the spike on new cases and the appearance of Omicron variant.[73]

United Kingdom[]

See also: British government response to the COVID-19 pandemic

The initial lifting of most COVID-19 restrictions in England (besides those requiring self-isolation after a positive test) on 19 July 2021 was popularly referred to as "Freedom Day" by residents and the press.[74] However, due to Omicron variant, restrictions were partially reimposed in England from 10 December 2021, including mask mandates and a proof of vaccination requirement for large gatherings and events.[75] These restrictions ended on 27 January 2022; when announcing the change in policy on 19 January, Prime Minister Boris Johnson admitted that "we must learn to live with COVID in the same way we live with flu".[76] The British government titled its February 2022 plan to lift remaining restrictions "Living with Covid".[77][78]

United States[]

See also: COVID-19 pandemic in the United States

The concept of living with COVID was invoked by then-President Donald Trump in a 22 October 2020 debate against his Democratic opponent in the 2020 presidential election, Joe Biden. Trump, who had repeatedly downplayed the severity of COVID-19 in his administration's public communications, argued that the United States was "rounding the turn" in the pandemic, and was "learning to live" with COVID because "we can't lock ourselves up in a basement like Joe does. He has the ability to lock himself up, we can't close up our nation, or you're not going to have a nation." In response, Biden argued that the United States was "learning to die with [COVID]", telling the audience that "You folks home will have an empty chair at the kitchen table this morning. That man or wife going to bed tonight and reaching over to try to touch … out of habit, where their wife or husband was, is gone. Learning to live with it? Come on. We're dying with it."[79][80]

Citing a desire to preserve freedoms, U.S. states such as Florida and Texas—led by members of the conservative Republican Party—have attempted to enforce orders prohibiting cities, counties, and in some cases, private businesses, from imposing COVID-19 mitigations such as mask mandates, vaccine mandates, and vaccine passports.[81][82] Both states have also pursued legal action to block mask mandates implemented by school boards in violation of these orders.[83][84] South Dakota never implemented any public health measures over the course of the pandemic, with public awareness, testing, and vaccination campaigns coordinated primarily by the state's three health regions rather than the government.[85][86][87]

During his 2022 State of the Union Address on 1 March 2022, Biden stated that "because of the progress we’ve made, because of your resilience and the tools we have, tonight I can say we are moving forward safely, back to more normal routines." However, he also stated that the federal government would "never just accept living with COVID-19", explaining that it would "continue to combat the virus as we do other diseases." The White House released a new action plan the next day, which includes plans to make COVID-19 antiviral medication available for free to high-risk patients at testing locations such as pharmacies and clinics, funding in support of vigilance and preparedness in the event of new surges and variants, preventing the closure of schools and businesses, and ensuring global vaccine distribution.[88][89]

Reception[]

A 2021 article in The Lancet called restrictions being lifted in the United Kingdom "dangerous and immature" and expressed concern that mass infection could lead to vaccine resistance and would impact young people, children and health services.[90] In The BMJ in February 2022, several health policy and public health experts criticised the British government's "living with COVID" plan, suggesting the end of free COVID-19 testing could exacerbate health inequality, and suggesting the plan did not account for required resources for localised contact tracing and hospital capacity.[91]

In February 2022, epidemiologist Gregg Gonsalves, writing for The Nation, called an endemic strategy for COVID-19 "wishful thinking" and a "surrender to needless death and preventable disease."[92]

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