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One of the worst aspects of SARS-CoV-2 at the beginning of the coronavirus pandemic was that it was so novel: There was no available protection, medication, or vaccination. Additionally, it was difficult to obtain tests, which made diagnosis difficult—except when it wasn’t. According to Summer Chavez, an emergency physician at the University of Houston, distinguishing SARS-CoV-2 from other viruses occasionally became “sort of a slam dunk” because the symptoms of COVID grew so strange and off-book. Patients would present with both the anticipated and unexpected symptoms of respiratory illness, including fever, coughing, and the like, as well as rashes, diarrhea, shortness of breath, and a loss of taste or smell. The way a bizarre new virus was interacting with people’s bodies was so out of the ordinary that it was impossible to ignore it.
Nearly three years into the outbreak, people know more about the virus and its symptoms. “It’s significantly tougher to discern the distinction” between COVID-19, flu, and cold this winter, Chavez told me. Headache, sore throat, runny nose, congestion, sneezing, and coughing are the most common COVID symptoms today. Many of the wonkier ones that attracted attention have disappeared. As more people manage their COVID-19 infections while maintaining their taste and smell, many can’t remember the last time they worried about “COVID toes.” According to Tim Spector, an epidemiologist at King’s College London and project leader, even fever, a longstanding COVID mainstay, no longer enters the top-20 list from the ZOE Health Study, a long-running UK symptom-tracking program. SARS-symptoms CoV-2’s are growing “quite near to other viruses’,” Spector informed me. Longer, stranger, and deadlier diseases persist. A cold is coming.
Many experts have expected this since the outbreak began. Infections and immunizations may eventually make COVID as harmless as the common cold or the seasonal flu. According to this view, widespread immunity will continue to lessen COVID’s severity. Considering American immunity, such a plateau may be possible: Hundreds of millions of Americans have received bivalent vaccinations, some of whom have recently seen the virus for the second, third, or fourth time. We may be approaching the cumulative exposure threshold that irreversibly chills COVID. So? Possibly never.
COVID’s trend has been promising recently. Protracted COVID is decreasing, and the normal disease is shorter and milder. Averagely, symptoms have progressed up the airway, sparing delicate organs below. Omicron’s fall 2021 debut produced several of these changes, and others may be attributed to the virus: Omicron and its offspring prefer infecting nose and throat cells over lung cells. Scientists told me that immune reactions before and after that variety’s spread are doing most of the work. Prior infection and immunization can help keep the virus in the nose and mouth and prevent it from spreading. “Disease is actually going to differ based on the compartment that’s predominantly affected,” says St. Jude virologist Stacey Schultz-Cherry. SARS-CoV-2 has adapted to a narrower anatomical niche, making it easier to contain.
The pathogen is also quickly cleared from the airway and may be less likely to spread because the virus is largely confined to limited areas of the body. On an individual level, a condition that may have previously developed into pneumonia is now controlled into a mild cold that poses less of a threat to others; on a population level, infection, hospitalization, and death rates decrease.
With respiratory viruses, things typically proceed in this manner. Repeat RSV bouts typically develop milder with time, although post-vaccination flu is typically milder. According to Diane Griffin, a virologist and immunologist at Johns Hopkins University, those few people who contract measles after receiving vaccinations are less likely to spread the virus and typically have such a mild course of illness that their illness is known as “modified” measles.
It’s encouraging that the average COVID case got milder and lasted less time around the turn of 2022, but it’s a little depressing to think that symptoms haven’t gotten any softer since then. According to Schultz-Cherry, the complete spectrum of disease outcomes—from quiet infection through long-term impairment, major disease, and death—remains a possibility now and for the foreseeable future. Where a person falls on that range can depend on their vaccination history and any immunocompromising disorders they may have. Age, along with other elements like sex, heredity, underlying medical issues, and even the amount of an incoming virus, can all affect health globally, according to Patricia Garca, a global health expert at the University of Washington.
Even in young, healthy people, new antibody-dodging viral variations could still emerge and cause more severe illness, as the flu occasionally does. Omicron’s BA.2 subvariant, which is more immune-evasive than its BA.1 forerunner, appeared to amass in the airway more quickly, causing more symptoms to manifest, some of which were more severe. Data on more recent Omicron subvariants are still being obtained, but epidemiologist Shruti Mehta of Johns Hopkins says she’s observed some signs that some gastrointestinal symptoms, including vomiting, may be making a slight comeback.
The road ahead is muddy. Yonatan Grad, an epidemiologist at Harvard’s School of Public Health, says COVID hasn’t yet become a common cold. SARS-CoV-2 still spreads faster and causes more severe sickness than a cold. Past pandemics may help predict the future one. According to University of Michigan epidemiologist Aubree Gordon, each flu pandemic in the last century has caused a mortality surge that returned to normal after two to seven years. SARS-CoV-2 isn’t a flu virus, hence it won’t follow the same epidemiological rules or timeframe. Gordon says no number of immunizations or prior infections may prevent illness, even the flu. Gordon continued, “And I think we know even less about coronavirus immunity.”
It may be important to consider the timing of when and how those defenses appear. By the time they enter grade school, almost everyone has had the flu or has at least received a flu shot. In contrast, SARS-CoV-2 and COVID vaccines were introduced to the majority of the world’s population in adulthood, when the immune system may be less pliable. The global population may find it more difficult to attain its severity asymptote as a result of these experiences in later life. If so, we’ll be in a COVID limbo for another generation or two, until the majority of people still alive are those who were exposed to this coronavirus as children.
COVID can yet worsen to an annoyance before stabilizing. Gordon informed me, “I actually expected it would be more like common-cold coronaviruses. However, the harshness hasn’t lessened as drastically as she had planned. To her dismay, SARS-CoV-2 infections in vaccinated cohorts of patients in Nicaragua, where Gordon has been doing studies for years, had been “still more severe than influenza,” she told me. Even if that changes in the future, if the coronavirus spreads year-round with this level of vigor, it may still result in more fatalities than the flu, as it is doing right now.
The moment a severity plateau is reached, Gordon told me, “once we go back and say, ‘Oh, yeah, it’s been about the same for the last five years,'” that is when we can confirm we have arrived there. But as public interest in the virus declines and research efforts to track COVID’s fluctuating symptoms encounter difficulties, it is becoming more difficult to gather the information required to make that determination. The ZOE Health Study lost its government funding earlier this year, and its COVID-symptom app, which at its peak had 2.4 million active users, is now down to just 400,000 users. Some of these users may have signed up to take advantage of the app’s more recent features for tracking diet, sleep, exercise, and mood. Spector told me, “I think people just said, ‘I need to go on.
Similar difficulties were found by Mehta, a Johns Hopkins epidemiologist, when doing her COVID research. When Mehta and her colleagues were looking for participants for their community studies at the height of the Omicron wave, their rosters would instantly fill up past capacity. She said, “Now we’ve been out there for weeks, and still haven’t hit the mark. For their long-COVID trial, even weekly enrolment has decreased. Sign-ups do climb when cases increase, but they fall down particularly sharply as waves ebb. Perhaps some potential study participants believe that COVID has, paradoxically, turned into a common cold and is therefore no longer worth their time.
Researchers are concerned that it will become increasingly difficult to determine whether we are approaching the COVID-severity plateau. Perhaps it’s preferable if the mildness asymptote is still some distance off. As SARS-CoV-2 plays musical chairs with RSV and flu in the U.S. and elsewhere, subvariants are still circling, bivalent-shot acceptance is still slowing, and hospitalizations are once more creeping up. Access and quality disparities in vaccines, as well as China’s protracted zero-COVID policy, have left wide inequalities in global immunity. With this many daily deaths, this many off-season waves, this much extended COVID, and this rate of viral evolution, it would be bleak to enter symptom stasis. Gordon informed me, “I don’t think we’re quite there yet.” I hope we haven’t arrived yet.
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