After the pandemic: perspectives on the future trajectory of COVID-19

This Perspective discusses possible future patterns of SARS-CoV-2 infection, the development of variants, potential changes in the patterns of spread and the implications for vaccine deployment and the potential consequences of these issues for the development of policy. There is a realistic expectation that the global effort in vaccination will bring the pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) under control. Nonetheless, uncertainties remain about the type of long-term association that the virus will establish with the human population and, in particular, whether coronavirus disease 2019 (COVID-19) will become an endemic disease. Although the trajectory is difficult to predict, the conditions, concepts and variables that influence this transition can be anticipated. Persistence of SARS-CoV-2 as an endemic virus, perhaps with seasonal epidemic peaks, may be fuelled by pockets of susceptible individuals and waning immunity after infection or vaccination, changes in the virus through antigenic drift that diminish protection and re-entries from zoonotic reservoirs. Here we review relevant observations from previous epidemics and discuss the potential evolution of SARS-CoV-2 as it adapts during persistent transmission in the presence of a level of population immunity. Lack of effective surveillance or adequate response could enable the emergence of new epidemic or pandemic patterns from an endemic infection of SARS-CoV-2. There are key pieces of data that are urgently needed in order to make good decisions; we outline these and propose a way forward.

Automated summary

This article discusses the future patterns of SARS-CoV-2 infection, the development of variants, and the implications for vaccine deployment. It suggests that the virus may become endemic fueled by pockets of susceptible individuals and waning immunity. Effective surveillance and response are crucial to prevent new epidemic or pandemic patterns.