Pandemics end. It's in their nature. And in recent weeks there's a large amount of data pointing to declining deaths worldwide and the logical end of the one that's plagued us for two-plus years. Finally. But how will we know when it's really "over"? What's the criteria? What comes after the pandemic phase of Covid-19, and what does the future look like? (Oh, and how worried should you be about Monkeypox?) GUEST: Dr. David Fisman, epidemiologist, Dalla Lana School of Public Health, University of Toronto
Pandemics end. It's in their nature. And in recent weeks there's a large amount of data pointing to declining deaths worldwide and the logical end of the one that's plagued us for two-plus years. Finally. But how will we know when it's really "over"? What's the criteria? What comes after the pandemic phase of Covid-19, and what does the future look like? (Oh, and how worried should you be about Monkeypox?)
GUEST: Dr. David Fisman, epidemiologist, Dalla Lana School of Public Health, University of Toronto
Jordan Over the past two and a half years, I have spoken with an awful lot of infectious disease experts, more than I previously knew existed, to be honest. And I've learned so much from all of them. Of course, most of what I've learned from them has been bad, depressing, discouraging, troubling, worrying, scary, that kind of stuff. But that's the nature of asking questions to epidemiologists during a pandemic. Makes sense. But there is one thing that one of our guests has continually told me every time we invite him onto the show, even when we're in the middle of a wave, even as hospitals are overrun, even as our governments roll back restrictions at inopportune times and put the elderly and immunocompromised at risk, even as new variants emerge. And what he said every time is this 'pandemics end'. That's what they all do. Eventually. We just need to hold on and we'll get there. So today I'm going to ask him, as case numbers and death rates fall daily, almost everywhere in the world. Is the COVID-19 pandemic really finally ending? If so, what comes next? Oh, and how worried should we be about monkeypox?
I'm Jordan Heath-Rawlings. This is The Big Story. Dr. David Fisman is an epidemiologist at the Dalla Lana School of Public Health at the University of Toronto. He has been our most trusted, most frequent guest during this entire pandemic. He and his dog, if you listen carefully, join us today. Hello, Dr. Fisman.
David Fisman Hello.
Jordan At several dark moments when we had you on the show over the past couple of years, at the beginning of waves or the emergence of new variants, you said one thing that I always clung to, which is that pandemics end eventually. So I want to ask you now, are we in the end stages of this COVID-19 pandemic?
David Fisman I think we pretty clearly are. Pandemics, and I think I may have used this metaphor previously, pandemics are like forest fires in that they are victims of their own success because they burn up all the fuel. For a pandemic, the fuel that drives it is having a lot of susceptible people who have never experienced that infection before. It's a new infectious disease. What we have now globally is a lot of the population, the majority of the Globe's population now likely has immune experience with SARS coronavirus two, either by a vaccination via infection or via both. Since the emergence of the Omicron sub variants, there's a group of them, which was really last fall, kind of November 2021 was when things really started taking off, the rate at which people have become infected has just been astonishing. I did some back of the envelope math on kids in the US, where the CDC has some serology estimates. So you can look at how serology in kids has changed over time. And infection in kids was happening about seven times faster after Omicron emerged than before. It's not just the variant. Obviously, there have been changes in policy and different places have stopped, I think, working as hard to try to contain infection. And that's also sped its spread.
But where you see this really manifest is in daily deaths globally. For about a 2 year period from, I guess, March 2020 until three or four weeks ago, the world was sort of chugging along somewhere between 7000 and up to 15,000 deaths a day. counted deaths a day. Those are under counts. We know that true Covid deaths are probably around three times higher than that on average. So that's somewhere between 20k and 50k people dying of this globally a day. Over the last few weeks, that's just fallen and fallen and fallen, and continues to fall. And so what you see now is we're down around, the moving average is around 1000 deaths a day. So much lower level of fatality. Now, what this is going to transition to is just as influenza did in 1919 and 1920. It's going to go away. I think we have probably a pretty good summer coming, for example, in Canada and much of the Northern hemisphere. But I think we probably are going to see this emerge as a new, basically flu season pathogen. And it's a bad bug. So we're going to transition from pandemic, which has been this weird, highly disruptive two years that we've lived through, to a situation where we have a new bug. We basically have a SARS in the wintertime, and that's now normal.
If you want to pop the champagne over that statement, go ahead. I don't think that's necessarily great news. Knowing what a much less virulent pathogen like influenza does to our health care system every winter. This is going to be a challenge for the foreseeable future. So that's not great news. But in terms of, as I've said before, pandemic qua pandemic, I think that is ending or maybe is over. And I don't think there's a hard and fast bright line that you cross where suddenly it's not a pandemic anymore, but we're clearly transitioning from pandemic to no longer pandemic.
Jordan I was going to ask that question. Is there, I know there's probably not a brightly painted line, but are there conditions at which I guess the WHO was the body that declared this a pandemic, will put out a Press release or hold a Press conference or issue a statement saying, okay, no longer a pandemic. And how do they determine that?
David Fisman Yeah, the WHO, I don't think they declared a pandemic. I think they declared a public health emergency of international concern, is the lingo and it still is that. And I don't know at what point they reverse that and say it's no longer an emergency. I think that's coming. I don't know what the process would look like inside that institution. I think what you probably have going on now is we're moving into Northern hemisphere summer. And what you can see is that some countries in the Southern hemisphere are having this take off now. Australia has got a lot more cases than they've had. I believe Argentina has a lot. Some African countries are sort of reporting sharp increases. So I think it would probably be problematic for them to say, well, the pandemic is over in the Northern hemisphere, so it's not a pandemic anymore, even if that's actually the Southern hemisphere telling us what future flu seasons are going to look like.
But in terms of a pandemic, what a pandemic is, it's simultaneous epidemics in many places, and you kind of don't have that anymore, certainly in the Northern hemisphere. And as I say, the Southern hemisphere, this may just be what flu season looks like now. So I think it is ending for all practical purposes.
Jordan When you talk about it becoming a more seasonal virus or seeing seasonal waves, is that what endemic means? And I want to ask this because this is a term that I've heard a lot, not just from people who really want to get out of this pandemic and get back to normal, but also from people who have followed all the rules and gotten all the shots and now kind of see the time for lockdowns and any public health restrictions as over. But endemicity, unless I'm wrong, has a specific meaning, right? And what is it, and are we there yet?
David Fisman Endemicity sort of just means it's of the place. And it's got roots in kind of colonialism where I mean, a lot of public health institutions have roots in kind of the colonial enterprise. In the 19th century, things like London School of Hygiene, Liverpool School of Hygiene were built as institutions to support Empire. Because one of the big challenges to the British or French or what have you imperialist enterprise was disease. Go to places and the colonizers die of disease and you have to send more or what have you. So there's a tremendous amount of work that went on around diseases like malaria, diseases like plague in the late 19th century because they were important to Empire. And I think the terminology endemic sort of just meant that in place there's this disease that's of that place. It's there.
Endemic doesn't talk about what's the burden of that disease. We can talk about childhood diarrheal disease globally as endemic, and we don't have a sudden epidemic of childhood diarrhea disease. It's just a steady incidence of this particular disease. It kills about one and a half million children every year. The fact that it's endemic doesn't mean it's no big woo. It just means that it's just kind of some sort of stable equilibrium. From an infectious disease modelling point of view, endemic is when the reproduction number is sitting at one. So each old case makes one more new case before it gets better so that you don't have a rising incidence of disease or falling incidence of disease, it just stays pretty much constant. Sometimes people use the term hyper endemic to describe something that's endemic. It's not really rising or falling, but there sure is a lot of it.
One of the frustrations as an epidemiologist is the degree to which our basic vocabulary has been bastardized out of all recognition, particularly in the kind of political sphere and on the fringes of media, where media sort of bleeds into the disinformation enterprise. Terms like herd immunity and endemicity have really been appropriated and kind of ruined for those of us who use them in our day jobs. The thing with endemicity also is that seasonality and endemicity kind of go hand in hand, because if you imagine diseases cause epidemics when the reproduction numbers go above one, it's endemic if it's reproduction numbers sitting around one. But what you get in the wintertime with a lot of respiratory diseases, in summertime with a lot of diarrhea diseases is you get what we call seasonal forcing, which is a combination of behaviors and environmental factors combined to nudge upwards that reproduction number above that threshold. And that's sort of how flu seasons happen.
Jordan Right. Just with people inside naturally in the winter and the reproduction number jumps.
David Fisman I think we've talked about this on your podcast, but I think for many of us we've learned so much about the behavior of aerosols that prepandemic, I thought it was an interesting question, why is flu wintertime seasonal? I don't think it's that interesting anymore, because I think it's kind of bloody obvious. It's an aerosol transmitted disease, and you have aerosol behavior indoors versus outdoors and cold weather versus warm weather. Of course it's winter time seasonal, but that's going to bump that reproduction number up. And that's why my expectation would be that we're going to have a few kind of flu seasons that aren't actually flu but are rather COVID for the next few years at least.
One of the worries is we may have because we've had a hiatus from a bunch of other diseases due to Covid mitigation, is we may have Covid combined with a resurgent flu season combined with resurgent Pneumococcal disease, which is a bacterial disease that causes pneumonia, combined with research and respiratory syncytial virus, that we've already started to see a bit in kids. So we could have some choppy waters ahead in terms of respiratory disease. I mean, most people aren't going to see that because most people don't work in hospitals, but where I used to work, they would basically take part of the waiting room in the emergency room and turn it into a care area. And that's just influenza. How this is going to play out with Covid as part of the mix as well is unclear, but probably not good.
Jordan Well, we've talked a few times now on this show about COVID variants and how they form and how vaccine inequity can contribute to making them. I guess what I want to know, looking forward, is what should we be on the lookout for in terms of these variants? Is there still the possibility of a brand new super-variant emerges, God knows where, and can set us significantly back in terms of all our progress so far, or will we continue to see you mentioned the Omicron variants, subsets of variants, BA.2, BA.4, BA.6, that will be roughly the same and perform the way the ones we've seen so far have. What's the concern there?
David Fisman Yes. So one of the interesting things about infectious disease epidemiology is you're talking about at least two populations. You're talking about the population of hosts, us, for human infectious diseases. And you're also talking about the population of microbes and for some infectious diseases you're also talking about the population of reservoir animals or insect vectors or what have you. But here let's just focus on the humans and the viruses. The viruses aren't static. They change and they evolve. SARSCoV-2 viruses are good at recombining, and you've already seen that, there's an XE variant, which is this Frankenstein variant, that's part Omicron and part Delta. It's got bits of both. That's what viruses do, and RNA viruses make mistakes also as they replicate, so they're very mutation prone. I still haven't seen a good explanation of where Omicron came from. Omicron remains pretty mysterious to me. Most of the other emergence of variants through the course of the pandemic looked very much like what you'd expect from infectious diseases. The Omicron stuff is weird. The hypotheses out there, did it go into an immune compromised person who carried it for a while, and it had all these mutations? There's another hypothesis that it went down into the sewer and rats passed it around, and then it came back into human populations. I don't think we have any idea. And the Omicron stuff was pretty weird, sort of a black Swan embedded within a black Swan. So is that going to happen again? I have no idea.
I think you will, though, see, these things continue to evolve. Omicron is interesting because Delta was already highly infectious. So the room to grow with Omicron has really been on immune evasion. And you do see some of that, that people with prior infection and also vaccination against pre-Omicron strains became less protective with Omicron. So those are basically the two things the virus has to work with. It can increase how effective it is. And these things are already so infectious, I don't think there's much room to grow there. And then it can also work on immune evasion, which seems to be the frontier. So we'll be doing probably with SARS what we do with influenza, which is the vaccine gets changed up. I'm not sure what the progress is on Omicron specific vaccines, but I think you'll start to see those emerge over the next year.
Jordan I'm really glad to hear that as much as we may be in for a rough ride, that it seems that the global case rate and the global death rate is petering out. I want to ask you now, I swear I'm not trying to scare anyone here or bring us back to two years ago, two plus years ago when we had these conversations. But just as we seem to be hitting the end of this pandemic or at least a summer lull, everyone is freaking out about monkeypox. And I just want to ask, how worried should we be? I know there's a bit of a stigma attached to this disease. Maybe you could just tell us what we need to know.
David Firman So I think I'm chastened because two years ago, we talked about this weird disease in a seafood market in Wuhan, China. And my comment was that I don't think you should be very worried because I think it'll be contained in China. And here we are two years later, and I was obviously exuberantly wrong about that. So caveat emptor. I think what you're seeing with monkeypox is a couple of things. One is to backtrack to the colonialism comments I made earlier, we do have this issue globally that a lot of diseases are not a big deal until they get into rich countries and then all of a sudden they're front page news. So monkeypox is a pox virus. It's a smallpox relative. Smallpox is eradicated. That means it's an extinct virus in nature. It exists in labs. But when smallpox was eradicated, was made extinct by vaccination, people stopped vaccinating against smallpox. So you have this related virus that no longer has competition from smallpox and is no longer being vaccinated against.
So you've had this resurgence over the last 20 years in monkeypox, and it's also caused some outbreaks, sporadic cases, and also outbreaks in North America. About ten years ago, there was an outbreak in the US Midwest associated with, I think it was pet Gambian rats. Kids were getting monkeypox infected pets because the rats were being transported across with monkeys and the rats had gotten monkeypox and transmitted it among themselves. And then kids who bought these rats as pets were getting monkeypox. It's been around.
What you seem to see here is and I want to sort of choose my words carefully here, because there's enough nonsense and stigmatization already without us adding fuel to the fire. But what you do seem to see with monkeypox is I think we're globally at around 200 recognized cases. The overwhelming majority of those seem to have very distinctive epidemiology, do seem to be associated with kind of basically the sex party scene. And people have sort of said, well, all these people weren't at simultaneous sex parties in all these different countries. Well, no, but we've seen this before with other things that have moved through networks where folks travel and travel to enjoy themselves and go have fun in one locale and then come back and have fun in another locale. So, speaking as a former sexually transmitted infections clinic director 20 years ago, this is familiar epidemiology. What's unfamiliar is we haven't really seen this with monkey pox or we haven't seen this with monkeypox. But the epidemiology of this, we've seen exactly the same epidemiology with other bugs.
Now, monkeypox, of course, does have a lung phase to it. It's a systemic infection. And so we'll get into the same stuff as we've had with Covid around it. A lot of the transmission to date has been sexual. But if people are sick with a virus that affects their lungs as well, we breathe these tiny particles, these aerosols that can be full of virus. So you do have the potential for non sexual transmission. And I would expect that you'll see some spillover outside what so far has been a fairly well understood network, and we'll see where that goes. So hopefully, we do have a vaccine, which is the smallpox vaccine. The countries that are reacting to this right now, I think, are high income countries that have abundant access to those vaccines. And it should be possible to stop this in its tracks.
I think in terms of the bigger picture. And again, I say this as somebody, I don't think monkeypox is our next pandemic. I think it's important for people to understand that the upstream drivers of COVID and of monkeypox are also upstream drivers of lots of other things. And we can't be playing whack-a-mole with dangerous viruses in a globally connected world that's being subjected to intense environmental degradation. We are creating the conditions for these things to emerge, and then we're flipping out every time they emerge. There's a list. And I think we've talked about this before. There's a list of about ten priority pathogens that the who has flagged that have pandemic potential for which we have no vaccine. We need to start thinking a little bit more strategically about this. Is this the world we want to live in, a world where we kind of have a red alert because of a new plague every four or five months? I wouldn't think so. I mean, it's annoying and stressful to say nothing of the fact that it kills people. But if we don't want this to be our reality, we really need to start thinking upstream about what the drivers are of emerging infectious diseases.
All the threats are Zoonotic. That means they're all animal viruses that jump to humans, whether its SARS-CoV-2 or monkeypox or Lassa fever or Crimean Congo hemorrhagic fever, Rift Valley fever, Marburg virus, avian influenza, which we now have in the Eastern seaboard of Canada and I guess Ontario, too. These are all happening at human animal interface, and they're all happening for the same reasons. We have climate change, environmental change, food production, habitat loss, migration of human populations, those are the drivers. So being frustrated that novel infectious diseases keep emerging when we are the species that's creating the conditions for that to happen all the time, It doesn't make sense to be upset with viruses. It's like sitting by a campfire and being annoyed that sparks are flying off the campfire and saying, gosh, I wish we could do something about these sparks. Well, the sparks are coming Because you've got a campfire, and as long as the campfire is roaring away, you're going to get more and more sparks. The unfortunate thing for us globally Is we are the campfire. It's humans. It's not the animals. It's what we do to the animals and the wilderness areas and the environment and what we're doing in labs and so forth. We're the campfire. We're making the sparks. So at some point we might have to get serious about that.
But frustratingly for me, I feel like the major lesson I've learned from this pandemic Living in an affluent country that has a lot of infrastructure and tools and which I thought had a pretty decent commitment to doing the right thing. Something I've learned during this pandemic Is don't count on goodness saving you, don't count on rational action and foresightedness saving you. Human beings just don't seem to be capable of acting collectively in the face of predictable threats to mitigate the threats before they're actually upon us. We seem to be an incredibly reactive species, and that's pretty depressing.
Jordan Yeah, that's an analysis I could literally apply to any one of the next, I don't know, six stories that we have lined up for the podcast. Dr. Fisman, thank you as always. I'm going to hold you to being right about the monkeypox prediction.
David Fisman You can have me back on your podcast and mock me if I'm wrong.
Jordan I really don't want to do that. Thanks again.
David Fisman It's a pleasure. Anytime.
Jordan Dr. David Fisman of the Dalla Lana school of public health. I love talking to Dr. Fisman. I hope that's the last time we have to do it for a good long while. I hope he gets a lovely summer.
That was The Big Story. For more from us, Head to thebigstorypodcast.ca, find us on Twitter @TheBigStoryFPN, email us at hello@thebigstorypodcast.ca [click here!], and call us if you like to leave us a voicemail: 416-935-5935. Ask us a question, suggest a story, yell and rant for a while. It's okay. We're here for you. You can listen to this podcast wherever you get your podcasts, Apple, Google, Stitcher, Spotify. Via a smart Speaker by saying, 'hey, smart speaker, play The Big Story podcast'.
Thanks for listening. I'm Jordan Heath-Rawlings. We'll talk tomorrow.