Covid-19 and the ‘New Normal’

By Paul E. Lemanski, MD, MS, FACP

In my first ten articles on Covid-19, lifestyle based risk mitigation strategies – including masking, social distancing, hand washing, targeted quarantine, and, when necessary, lock downs – were recommended to keep the population well until a safe and effective vaccine was developed and “in the arms” of 85% of Americans; in this way, SARS-CoV-2 vaccination would help achieve so called “herd immunity” (see Non-Medicated Life, February 2021 ) and stop the transmission of the virus to those who were not vaccinated. Unfortunately, despite our having a safe and effective vaccine and having boosters that dramatically lower risk of severe disease, many individuals for a variety of reasons have refused vaccination (see Non-Medicated Life, September 2021) and herd immunity has not yet been achieved. 

However, the new year brings hope that herd immunity will soon be achieved and SARS-CoV-2 will move from pandemic to endemic and create a new normal. I’d like to make some predictions what that ‘new normal’ may look like and the importance of reinforcing our notions of a healthy lifestyle in order to maintain it.

In the history of infectious diseases, no virus – save small pox – has ever been eradicated. Rather, viruses will emerge into a population and may at times spread rapidly in a geographically unrestrained fashion called a pandemic. Since no one in the population has immunity to a new virus, as individuals become sick, some die and some recover with varying degrees of morbidity. Those who recover develop an immune response that generally protects them – partially or fully – from subsequent exposure to the same virus. When a sufficient number of individuals in a population develop such an immune response, herd immunity is achieved and the spread of that virus through the population is essentially stopped or slowed dramatically, and the virus is said to have become endemic within that geographical area. 

With the advent of vaccination for viruses, natural infection and the accompanying risk of morbidity and mortality is avoided, and herd immunity is achieved through the vaccine’s effect on the immune system. Examples would be the polio vaccine, measles vaccine, and rubella vaccine. These viruses are considered endemic in the United States and still naturally cause disease in small numbers of individuals who are not vaccinated.

SARS-CoV-2 is a newly emerged virus that has been rapidly spreading in pandemic fashion causing morbidity and mortality because the population has no natural immunity. With the advent of vaccination for SARS-CoV-2 in those naive to the virus, morbidity and mortality have been reduced markedly, and the ability to infect others has also been reduced. Along with individuals surviving natural infection, vaccinated individuals have – at low risk to themselves – shortened the time to herd immunity. 

The emergence of a highly infectious variant, Omicron, that may not cause the same severity of morbidity and mortality, has rapidly accelerated natural infection and may possibly also aid in shortening the time to herd immunity – albeit at a markedly higher risk to the individual than vaccination. As a consequence of increased vaccinations and an increase in natural infections due to Omicron, herd immunity may be achieved in the United States in the first quarter of 2022. SARS-CoV-2 will then become an endemic virus here, occurring at a low rate in the general population, primarily in areas of low vaccination and create a new situation that – for lack of a better term – one may call a new normal.

What may the new normal of the SARS-CoV-2 endemic virus then require and what will it look like? I suggest that we still will rely on masking in certain situations of exposure to large groups of people, especially where the rate of infection is known to be elevated. Reliance on phone apps such as COVID Alert NY, that identifies the rate of infection in New York counties, may inform our decisions on mask wearing in such situations. Covid vaccinations and boosters will still be required as the mainstay of prevention and anyone not vaccinated as well as boosted will remain at elevated risk. Moreover, individuals contracting Covid naturally have been shown to get additional immune benefit from subsequent vaccination and boosting. 

Finally, improved access to government/healthcare subsidized, affordable home Covid testing will also be critically important because of a game changing development due out early this year: effective antiviral pills for Covid. Pfizer’s Paxlovid and Merck’s Molnupiravir when taken in the first few days after the onset of symptoms of SARS-CoV-2 may reduce the risk of hospitalization and death by up to 88% for Paxlovid and 30% for Molnupiravir. Current recommendations require a positive Covid nasal antigen (aka rapid or home) test or PCR test for antiviral treatment to be dispensed. The home test can be found at pharmacies and is inexpensive. The antivirals may be in short supply initially because manufacturing has just recently been given high priority. As the Federal government puts it main efforts into subsidized affordable home Covid testing and the expedited production of antivirals, a new normal becomes possible sooner.

Hopefully, with the above tools utilized effectively, the new normal will look a lot like the old pre-Covid normal. Schools will be open, businesses will remain open, hospitals will not be overloaded with Covid patients, and people will be able to socialize without undue concern. Patients’ ability to prevent non-Covid related disease will be enhanced, as they no longer will feel the need to forgo preventive services such as colonoscopies, PAP smears, and mammography for fear of contracting Covid. 

However, beyond these changes, adopting a traditionally healthy lifestyle will become even more critical to maintaining the new normal. Because comorbid conditions lead to increased risk once Covid is contracted, reversing comorbid conditions through lifestyle change becomes the bedrock strategy for healthy immune function. Weight loss in those overweight and obese will by itself reduce risk, but weight loss in its ability to improve and remit comorbid conditions such as diabetes, prediabetes, and hypertension will do more. 

In the Diabetes Prevention Study, individuals who were able to lose just 5% of their body weight were able to decrease the development of diabetes by 57%. For a person weighing 200 pounds, this is just 10 pounds – a practical and achievable goal to optimize immune function. Moreover, weight loss of just five pounds can lower blood pressure. Daily aerobic exercise will also help reduce weight, blood sugar and blood pressure and has proven effects on improving immune function. As low vitamin D levels appear to increase risk of poor outcomes, measurement and normalization of 25-hydroxy vitamin D levels between 30-100 will also help ensure optimal immune antiviral function.

In summary, 2022 holds hope for the end of the Covid pandemic. We are close to achieving herd immunity that will usher in the endemic stage of the virus. Maximizing the number of individuals receiving vaccination and boosters – including those recovering from Covid – will help in this regard. Additionally, available and affordable home Covid tests and available antivirals Paxlovid and Molnupiravir will usher in the new normal. Maintaining the new normal will require use of above-mentioned new tools and a reemphasis on adopting a traditionally healthy lifestyle to optimize immune function.

Paul E. Lemanski, MD, MS, FACP is a board-certified internist practicing internal medicine and lifestyle medicine in Albany (centerforpreventivemedicine.com). Paul has a master’s degree in human nutrition, he’s an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.