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Senior British scientists have warned that a lack of long-term planning in the battle against Covid is leaving the nation vulnerable to major outbreaks of the disease for at least another year.

The rollout of vaccines currently under way would cut hospital admissions and deaths among the old and vulnerable, they said, but it would still leave many other people at risk of being infected and suffering from the long-term effects of the disease.

Even though millions of doses of vaccine are being administered, serious outbreaks of Covid-19 are likely to continue throughout the year and into next year. These issues should be the focus of careful planning now, the scientists warned.

"Having 20 million people vaccinated is likely to reduce numbers of cases but we must not forget that this is a highly transmissible virus and if we do not continue with social measures, it will soon whip round communities again and cause havoc," said Liam Smeeth, professor of clinical epidemiology at the London School of Hygiene & Tropical Medicine.

"I can understand the short-term panic that is going on at present as hospital cases rise so quickly but I am amazed at the sheer lack of long-term strategy there has been for dealing with Covid," he told the Observer. "I can see no signs of any thinking about it."

This view was backed by Mark Woolhouse, professor of infectious disease epidemiology at Edinburgh University. "This epidemic would have unfolded very differently and in a much happier way if we had accepted, back in February, that we were in this for the long term," he said. "However, the view that it was a short-term problem prevailed.

"It was thought we could completely suppress the virus, and that is why we are in the mess that we are in now."

The idea that the virus could be eradicated was a costly mistake, said Martin Hibberd of the London School of Hygiene & Tropical Medicine. "We have to understand Covid-19 is going to become endemic. The virus will not disappear. We are not going to eradicate it. Even if every human on Earth was vaccinated, we would still be at risk of it coming back."

Several other issues still have to be resolved, added Hibberd. These include concerns about how long vaccines provide protection and how new variants might evade vaccine protection. "We might be lucky and find the virus does not change very much and vaccine cover is not affected, causing the virus level to drop to low prevalence," Hibberd said.

"However, the virus might turn out to be as good as influenza at changing its coat. In that case, we will end up having to make new vaccines and distribute them every year. We should be thinking about that problem now."

The prospect of restrictions being enforced for many months was also raised by Anne Johnson, an epidemiologist at University College London. "In March, we are still going to be under restrictions which will have to be imposed for months after that. What happens in autumn will depend on our success in keeping the virus down over the summer," she said.

"We will also need to analyse how much virus there is in the community and calculate what antibody levels have been triggered by natural infections and by vaccination. These are going to be very important in determining the spread of the virus next winter."

Smeeth argued that social distancing measures could possibly have to continue until next winter and warned of the dangers of new virus mutations evading vaccine protection. "Sadly, I feel we are very far from being out of this epidemic," he said. "It is possible the virus could mutate tomorrow to become harmless. That is not a totally naive hope.

"But having said that, so far all we have discovered are mutations that actually made it more infectious and that is something we should be preparing to deal with - though I don't see much sign of that happening."

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Plan for the future now or Covid will last for years, UK scientists warn

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Senior British scientists have warned that a lack of long-term planning in the battle against Covid is leaving the nation vulnerable to major outbreaks of the disease for at least another year.

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Near the end of World War One, a nasty flu started spreading around the world. The virus responsible for the disease, which became known as Spanish flu, infected over a quarter of the world's population. With an estimated death toll of between 50 million and 100 million, it was one of the deadliest pandemics in human history.

In the midst of this pandemic, during September 1918, cities around the US were planning parades to promote liberty bonds, being sold to help pay for the war effort in Europe. In Philadelphia, Pennsylvania, where 600 soldiers were already infected with the flu virus, city chiefs decided to go ahead with their parade. Meanwhile, the city of Saint Louis, Missouri, opted to cancel their parade and introduce other measures to limit public gatherings. One month later, more than 10,000 people in Philadelphia had died of Spanish flu, while the number of fatalities in Saint Louis stayed below 700.

The parade was not the only reason for the difference in death rates, but the figures show the importance of measures now known as "social distancing" can have during pandemics. "Social distancing refers to a way of creating a barrier of physical distance between two or more people so that transmission of virus can be prevented or halted," says Arindam Basu, associate professor of epidemiology and environmental health at the University of Canterbury, in New Zealand.
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One analysis of the interventions made in several cities around the US during 1918 showed that those that banned public gatherings, closed theatres, schools and churches early had far lower peak death rates.

Just over 100 years later, the world is facing another pandemic, this time from a different virus - the Covid-19 coronavirus. Today the global population stands six billion higher than it did in 1918. While Covid-19 is different in many ways from the Spanish flu - particularly in terms of who it affects and its mortality rate so far - there is a very important lesson about the difference social distancing can make. It might still be one of the best ways of fighting this pandemic. ( Read more about the other lessons we can learn from Spanish flu.)

"At this time, we do not know of a safe and effective vaccine, nor do we know if a safe and effective drug will work to eliminate the Covid-19 infection once it has occurred," says Basu. "In the absence of these, our best bet is based on prevention."

Many countries around the world are now experiencing different measures in an attempt to enforce social distancing to slow the spread of Covid-19. They range from ending mass gatherings, closing public spaces like leisure centres, pubs and clubs to closing schools and in some places a total lockdown with people forced to stay indoors.

While self-isolation is a form of social distancing, there is an important distinction to be made. Self-isolation and quarantine are aimed at preventing people who are infected or are known to have had contact with people who are infected from passing on the virus. Social distancing is a wider measure aimed at stopping the kind of mixing of people that allows infections to spread through a population. ( Read more about what social distancing means.)

And we may need to keep our distance from others for some time to come. New computer modelling research from Harvard University, which has yet to be published in an academic journal, warns that it may be necessary for intermittent social distancing measures to be maintained into 2022 in the US unless other interventions such as vaccines, drug therapies and aggressive quarantine measures can be put into place. This is because while a one-off period of social distancing might delay the peak of the outbreak until later this year, there is likely to be a resurgence in cases towards the end of the year if the virus shows some seasonal variation. ( Read more about how Covid-19 might change with the seasons.)

But there is a good reason why social distancing has become such an important strategy in controlling the Covid-19 pandemic.

Each person infected with the Covid-19 coronavirus is thought to pass it on to an average of 2-3 other people in the early stages of an outbreak. This contagiousness is measured by epidemiologists using something known as a "reproduction number". By comparison, influenza has a reproduction number of 1.06-3.4 depending on the strain. Spanish flu was found to have a reproduction number of about 1.8 by one study. Rhinovirus, which is one of those that causes the common cold, has a reproduction number of 1.2-1.83. Most estimates for Covid-19 have put its reproduction number at between 1.4-3.9.

What exactly is social distancing?

The incubation period - the time between infection and symptoms appearing - has been found to be around five days for Covid-19, although it can take up to 14 days for symptoms to appear, according to research in China. If you are infected, and continue to socialise as normal, it is likely you will pass the virus on to between two and three friends or family members, who could each then go on to infect a further 2-3 people. Within one month one case can lead to 244 other cases in this way and in two months, this soars to 59,604. ( Read about how a virus can spread around an office.)

To further complicate this, the virus is also thought to be able to spread from people who have been infected but yet to show any symptoms. One study by Lauren Ancel Meyers at the University of Texas at Austin estimated that this silent transmission can occur in up to 10% of cases. An estimated 1-3% of people who catch the disease will remain asymptomatic. These people might not know to self-isolate, but if they observed good social-distancing practices would be prevented from spreading the virus unwittingly.

There is already some evidence that staying at home, and maintaining a safe distance from others, can slow the spread and stop this domino effect. Research looking at infections in Wuhan showed that the introduction of large-scale control measures saw the reproduction number in the city fall from 2.35 to almost one. When a reproduction number reaches one, the number of cases will stop rising as effectively each infected person is passing it on to just one other person.

Modelling work in China has shown that substantial levels of social distancing was key to reducing this reproduction number in Wuhan and the wider Hubei region. It concluded that the earlier a lockdown is put in place in the epicentre of an outbreak, the smaller it ends up being.

One of the main aims of social distancing is to "flatten the curve", which means delaying the spread of the virus so it reaches people more slowly. The idea is to lengthen the time period over which the virus travels through a population and push the peak number of cases back so it appears later. A graph showing the number of infections would peak much more quickly without social distancing. With it, the curve is much flatter, meaning at any given time the number of infected people, and therefore people needing urgent care and resources, is lower.

But how does this translate to real life situations? Different countries have taken different approaches to prevention strategies. The UK is among those that has been stepping up its efforts in response to a report using computer modelling to predict how the virus might spread by researchers at Imperial College London, published on 16 March.

The scientists looked into two potential methods of tackling the pandemic in simulations of the UK and the US populations. The first, mitigation, focused on only socially isolating those most at risk and quarantining those with symptoms. The second, suppression, involved everyone in the population taking steps to social distance themselves while those with symptoms and others in the household quarantine themselves at home.

The paper found that without any measures at all the UK could face 510,000 deaths while the US could expect 2.2 million from Covid-19. While they estimated the first mitigation strategy could potentially reduce demand for healthcare by two thirds and halve the number of deaths, it would still result in hundreds of thousands of people dying. It would also still overwhelm the health services, particularly intensive care, "several times over".

Before the report was published, the UK was aiming to achieve "herd immunity", a situation in which a substantial proportion of the members of a society become immune, either following an infection or by vaccination. By shrinking the pool of people who can catch the infection, this herd immunity effectively halts the virus from spreading much further.

"When herd immunity is used as a strategy, those who use this allow some practices, knowing well that it can potentially spread infection," says Basu. "Things such as mass gathering are still allowed with a view that people who will attend them are healthier and 'stouter' and will recover and in the process confer immunity to others."

When it comes to Covid-19, Basu says, we know very little about the short- and longer-term consequences of infections. It is also still not clear how much immunity people who have been infected develop once they recover (although some tests in monkeys suggest it is possible to develop immunity following infection).

"So knowingly exposing otherwise healthy individuals and letting an infection spread through when isolation or lockdown may work can be dangerous," says Basu. "If people who are infected pass infection to other susceptible people who live with them, then the situation can escalate very quickly."

In response to the Imperial research, the UK government changed its advice, introducing increasingly strict control measures and restrictions on businesses and the public.

The age of a population, as well as the way people live in a society, has a big impact on how Covid-19 is spreading, according to researchers at Oxford University and Nuffield College.

Jennifer Dowd and her colleagues looked at the demographics and spread of the disease in different parts of the world. In Italy, which has an older population and intergenerational families tend to live more closely together, the Covid-19 virus has claimed more lives. This is because the fatality rate in people over 80 is estimated at 14.8%, compared to 0.4% for those aged between 40 and 49, according to their study of cases and deaths up to 13 March.

But even in Italy, social distancing seems to have had an impact. Different strategies implemented in two towns - Bergamo and Lodi - have led to a striking difference in the number of infections.

In Lodi, the first case of coronavirus was detected on 21 February, and travel restrictions were implemented two days later. "On 24 February, all schools, universities, cultural, recreational and sporting events were also cancelled," says Dowd. "Cases also began to be discovered in Bergamo on 23 February within a small number of municipalities, and there was press discussion of similar restrictions, but this was not enacted until the broader shutdown on 8 March."

On 7 March, both towns had around 800 cases, but by 13 March Bergamo's number of cases had risen to around 2,300 while Lodi's had just under half that amount at around 1,100. The two provinces have similar age structures, both with roughly 21% of the population above age 65, says Dowd.

"While Bergamo overall has a larger population than Lodi, the clusters of municipalities in which cases originated were of similar size and thus comparable for looking at the early progression of the outbreak," says Dowd.

The situations look astonishingly similar to those seen in Philadelphia and Saint Louis. But it is still too early to say if history will repeat itself, the researchers say. One major difference is the numbers they are comparing in these Italian towns are cases of the virus rather than deaths.

"There could be other things that differed across these contexts such as particular super-spreading event, different social networks," says Dowd. "But given the similarity at baseline and the extreme interventions that happened in Lodi, we think it is strongly suggestive of the effectiveness of these measures."

Overall, says Dowd, it is safe to say social distancing works. "We are seeing real evidence for the effectiveness of these measures."

Another study in Washington State that looked at the spread of respiratory viruses in general - but not Covid-19 - showed that social distancing can reduce the spread of these diseases over the long term too. Unusually high snowfall in February 2019 led to widespread school and workplace closures, which saw a reduction in cases over the rest of the season of 3-9%.

The trouble is, when people start meeting together again, the virus will start spreading and cases are likely to rise. Which is why we may see a stop-start approach to social distancing, where measures might be eased a little, allowing the number of cases to rise before stricter measures are put back in place to keep infection levels within the bounds of what health services can cope with. This has been likened to turning on and off the tap of the Covid-19 pandemic to ensure hosptials and medical staff are not overwhelmed. ( Read more about how long it may take before we have a vaccine against Covid-19.)

Of course, staying away from friends and family is not easy, especially during a global pandemic. There can be some unintended consequences that come from avoiding people. In the long term, staying isolated from social groups is linked to heart disease, depression, and dementia.

But social distancing does not necessarily mean stopping all contact. Unlike in 1918, today there are plenty of ways for people to stay in touch with loved ones. Technology has brought us social media, messaging apps and online video calls.

And if it keeps the ones we love around us safe, it may ultimately be worth it.

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Why social distancing might last for some time

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Near the end of World War One, a nasty flu started spreading around the world. The virus responsible for the disease, which became known as Spanish flu, infected over a quarter of the world's population. With an estimated death toll of between 50 million and 100 million, it was one of the deadliest pandemics in human history.

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Anxiety and fear weave coarsely through the testimonies of many young people who have shared their experiences of the Covid-19 crisis.

In a special collaboration between the Irish Examiner [i]and youth information resource SpunOut.ie, we take a look at the impact of the pandemic on a generation of young people, whose short-term plans and long-term prospects alike have been overlooked in the national conversation.[/i]

Job insecurity, no 'real' college experience, the lack of a social life impacting on mental health; these are just some of the things young people are worried about because of the pandemic.

While Covid-19 is believed to mainly affect the older generation and those with underlying health conditions, it's safe to say young people have been affected in different ways.

Cut off from friends, forced to move back home after living an independent life, many struggled to cope with lockdown and its aftermath.

Some may have been returning to a family situation that college gave them an escape from.

Others who didn't go to college may now be out of work, in industries which have shuttered, like pubs or event management.

Education was severely disrupted too, with many students wondering when they will be able to return to school or college.

Primary schools students will be worried about social distancing, and being able to play with their friends.

Other students who have compromised immune systems, or live with vulnerable family members, might be worried that their return to the classroom is putting their loved ones at risk.

College students must also be anxious about paying €3,000 in fees, with timetables remaining uncertain, in-person classes limited, and with the need to book accommodation fast approaching.

With little opportunity for work placements, study abroad, clubs and societies, which keep many students going when the studies get tough, one wonders what the current cohort of students will get out of their degrees, which everyone agrees is about more than just academics nowadays.

People graduating are perhaps in the most precarious situation, with many internships and graduate programmes suspended indefinitely. What supports will be given to them? You can't get the PUP, or be on the Wage Subsidy Scheme, if you were a full-time college student with no part-time job.

In terms of mental health, it is a well-known fact that both CAMHS and adult mental health services waiting lists were long before a pandemic.

Many younger service users were unable to speak to their counsellors in person, and there may have been an increase in people seeking help for the first time because of the pandemic. How will they be supported?

Serious questions remain about how the government will best support young people as they head into an uncertain future.

There are those who will say that Covid-19 concerns young people far less than their elders. But rather than passing them by, Covid-19 has compounded the risks faced by a generation who came of age in one global economic crisis, and are now destined to endure another.

For many young people, the idea that their generation would be better off than that of their parents has taken a heavy blow. Whether it be the cost of education and housing, the growth of precarious work, the impact of climate change or the burgeoning crisis in mental health, there is much to suggest that the future, for Irish young people, simply isn't what it used to be.

In the illuminating My World Survey, published by UCD and Jigsaw in November 2019, respondents were asked to name the aspects of their lives that brought them the most stress.

Alongside exams and finance, "the future" was among the top three most salient endorsed stressors for young adults. This bears thinking about. Though it may seem a world away, the Ireland of November 2019 was one in which most indicators of economic growth were strong, where unemployment was low, and where the country was often praised as a post-recession success story.

And yet, that was a country in which large numbers of young people found themselves increasingly stressed about the future. Looking back, it's hard not to concede that at least some of that concern was well-placed: no sooner had the 2020s begun, than an unprecedented and unpredicted global health emergency brought the lives of so many young people to a shuddering halt.

For those in full-time education, the experience of 2020 has been equally unsettling. With schools and colleges shuttered, the prospects for summer exams waxed and waned with each announcement from the Department of Education.

For many students this was a significant inconvenience; for those who had spent two or more years preparing for their Leaving Certificates, it was close to unbearable. The delay and indecision no doubt took a heavy toll on the mental health of the class of 2020. Now, they face the prospect of a truncated and remote college education, after months of unnecessary stress.

The picture is even less heartening for those coming to the end of their third-level education, and for those who planned to enter the jobs market directly after leaving school. If the past is any guide, we should expect a newly-depressed economy to be a tough place for first-time job-seekers, even after the threat of the virus subsides. For the second time in little over a decade, we are perilously close to a full-blown crisis in youth unemployment.

All of these factors are having an understandable effect on a generation who were already apprehensive about what the future held. More than half (52%) of all messages to '50808', a free crisis support service launched this year, have involved anxiety or stress.

Many young people have reported negative effects on their mental health, with significant numbers concerned about their education and the uncertainty of the world in which they live.

Statements like the above must surely cut to the heart of our self-image as a modern, developed and caring country. Yet there is no reason her prophecy needs to be fulfilled. Each of the issues raised above have direct and achievable political solutions.

In the short term, we must continue to recognise that younger workers need their incomes supported while the risk of fully reopening society remains. Thinking bigger, the lack of immediate job opportunities creates space and time for younger workers to return to education or upskill - all that is lacking is the funding to make it a viable choice.

The college experience for our current undergraduates would be bolstered by an influx of investment as our third-level institutions grapple with the loss of overseas student fees.

But improving young people's long-term economic opportunities is only part of the story. As the numbers reporting anxiety and stress continue to grow, sustained investment in youth mental health services, and reliable funding for youth work services, are more necessary now than they have ever been.

By taking a holistic view of its role in a young person's welfare, the state can ensure that for many of our young people, the future need no longer be a source of worry.

A pandemic like Covid-19 was never something I had thought about. Never did I think I would be spending four months at home because going to work wouldn't be safe.

However, as I talk to my friends and family, I can't help but feel ripped off. Growing up we're told we'll have plenty of time for nights out, holidays and spontaneity once we've completed school and college.

Parents, family and neighbours were only too quick to tell you about the fun they had in their twenties. "You have your whole life ahead of you", they said.

So, I went to college for three years with grants, worked hard and graduated. I got a job, and felt like at last this was finally my time to go out, have fun, plan holidays and enjoy my twenties. Then Covid-19 came and changed everything. We got told to stay in, not see our friends and wait.

As someone who struggles with depression and anxiety, the first few months of lockdown were extremely difficult. Not only was I struggling in the present, but the constant worry of what was to come and the uncertainty that ensnared us all was paralysing.

I work as a preschool teacher in a primary school, and as talks of a second wave in the winter get louder and louder, I'm worried that the dark nights will bring back the darkness.

I'm looking forward to going back to work so much that the thoughts that the schools may close again is just too much to really think about.

Covid-19 has not just affected my short-term plans, but it has also affected my ability to plan long term too. My partner and I were beginning to talk about getting a mortgage and buying our first apartment before Covid-19.

Where would we live? How many bedrooms? What colours would we paint the walls? Now it feels futile to plan anything long term as we just have no idea what the next month will bring let alone the next year.

How are we supposed to feel secure enough to make the biggest financial decision of our lives, when so many people are losing their jobs and stability each day?

The easing of restrictions however has brought rays of hope. With each reunion with a loved one, I feel optimistic, grateful and feel the darkness lose control over me. I feel mostly free of its grips and hopeful that we will get our lives back, eventually.

One thing I know is that there needs to be more support for young people during this time, because not only has it affected what we thought our present would be, but Covid-19 continues to affect our ability to make any plans for the future.

Although Covid-19 has not led to substantial changes to my long-term plans, short-term, it has led to huge upheaval in my life. I have lost my job, my social life has possibly been destroyed, and my view of the world has been moulded in a shape that I never thought possible.

My long-term plan has been to change career in 2020 for some time, and although Covid-19 has made this more difficult I still intend to press ahead with it.

Moving from a marketing executive role to being a secondary school teacher was always going to be a huge change - even in the best of times. But with the looming threat of school closures, disruption to third level education, and unknown changes to working practices - to say the future is cloudy would be an understatement.

When you add to this losing my job having a huge effect on my personal finances, and it's easy to arrive at a position of self-doubt in making such a change.

Like most people I have been able to make almost no short-term plans. Holidays, day trips, and even going for a drink seem to be massive ordeals now. With pubs/restaurants/cafes now open nearly a month I am still yet to see a major influx of social groups back to these establishments, certainly in the 18-30 age category.

We cannot play down the effect that social isolation has on the mental health of young people - me included. The ongoing monotony of Netflix, Zoom quizzes, and online poker games is no substitute for the meeting of like-minded individuals to discuss trivial matters for hours on end.

A lack of social interaction leads to feelings of depression and anxiety. I'm lucky to have the coping mechanisms to deal with mental health issues, but for people who don't, emerging from their solitary shelter will be very difficult - even if the threat of contracting the virus becomes non-existent.

In 2020 uncertainty comes in many forms. Uncertainty in our health and wellbeing, uncertainty in our careers and education, and uncertainty in our social environments. We've battled to flatten to curve, but the battle to regain our previous lives has just begun. The only certainty is this - there will be more uncertainty to follow.

The Covid-19 pandemic and the subsequent lockdown have impacted all our lives. As a Leaving Cert student, I like the rest of my peers have been strapped into a rollercoaster of emotions that we are yet to disembark from. In my own case the lockdown had initially appeared to be a blessing.

I was diagnosed with narcolepsy late in fifth year, which has impacted my grades and ability to study. I had failed Maths and Irish in my mocks, and had poor grades throughout the Leaving Cert cycle. The lockdown gave me an opportunity at redemption and all in the comfort of my own home, which I took full advantage of.

I felt hopeful and confident that I could achieve the necessary grades to take a place at Queen's University Belfast, or the University of Limerick. Then the exams were cancelled. This was not a shock, I had suspected for some time that this would be the case.

Thinking about the year ahead, I may re-sit certain subjects in November, at which point why shouldn't I just repeat the whole Leaving Cert? Repeating the whole year is an option, but I just can't see myself resitting Leaving Cert and dealing with the stress that comes with that. Either way I'd have to forgo college for a year, and then what would I do?

I had received a conditional offer to study at Queen's University Belfast, but the odds seem to be aligned against me now. Having family in the North, I know that most students have received full offers, despite not yet having their predicted A-level results.

Leaving Cert students here in the Republic are at a major disadvantage when it comes to securing one of the limited places left in UK colleges.

The alternative and my first choice on the CAO was the University of Limerick. Securing a place in UL will hopefully be easier, but college in both UL or Queens will likely be mainly online for the first year.

For some courses this isn't too bad, but it does make me rethink whether I should go to college this year, when learning and making friends will be much harder.

Then I think, should I just go and do an apprenticeship as many of my friends are doing? With my narcolepsy is that even possible? The more time I've had to think, the more I've realised college may be a poor choice. For most of the courses, bar maybe computer science and a few specific courses in certain institutions, there could be bad career prospects once you finish the course.

I haven't even factored into my thinking a second or third wave, and more subsequent lockdowns, which could mean very little time on campus.

All in all, if there's one thing 2020 has taught me is that the days of stability are over. I think I'll just have to cross these bridges when I come to them.

September 2020 was one that was meant to change my life. I was to embark on a once-in-a-lifetime opportunity to study for a year in Texas State University.

Being the only person in my family to attend university, the fact the I was now also going to America for a year was just incredible. It seemed too good to be true - which it now seems it is. The world has completely changed and my plans within it.

As of right now, I do not really know what the next year of my life will look like. Officially I am to stay in UCC for semester one, and then attend Texas State University for semester two. But if I am being realistic, with how bad things are going in America - especially in Texas - I can practically see this opportunity slipping away from me.

At twenty years of age all I have ever really known is the education system. Next year was my chance to experience being an adult, while still in a somewhat familiar environment.

The next two years of my life, which seemed so clearly laid out in front of me are now in a complete mess. The reality that I might be graduating college in just a few months' time is starting to set in.

Graduating college so soon brings into sharp focus the fact that I have no idea what I want to do with my life. I am at a loss as to do. I know that once I graduate I need a job - preferably one in my chosen field, but any at all really.

This brings into focus the unanswered question of what the economy will be like over the next few years. Are we headed back into a recession? If we are, who will want to hire a 20-year-old, fresh out of college, with no experience?

I have now gone from a hiring pool of mainly just my peers, to one with people with twenty years of experience, having just lost their job.

One thing that the Covid-19 pandemic has most certainly brought into my life is uncertainty. My plan, which I had once so carefully cultivated has been irreversible change. This brings about one comforting thought: that the whole world is also filled with this uncertainty. I am not alone.

As one of the many thousands across Ireland who's recently finished my third level degree, Covid-19 has put a huge amount of uncertainty on my future plans. Like many of my classmates, I had plans to gain valuable work experience to help kickstart my career in the field of Medical Biotechnology.

However, due to the pandemic, my paid internship in the Netherlands was cancelled. This now means that as a fresh graduate I don't have the practical work experience in a professional environment that would have given me that edge to stand out amongst other job applicants.

These last few months have taken a major toll on everyone's mental health, which will certainly have long-term impacts over the months and years to come. Being in the final year of your degree is stressful enough as it is, without a global pandemic changing everything.

Thousands of students and teaching staff had to adapt to online teaching, adding further to the uncertainty for final year students.

I was very lucky, being a student in IT Sligo, where many of my lecturers already have experience teaching courses online. Having gotten through final year exams via online methods, I've been reminded that I can always further my education online in the future should I need to.

Not only endocrinology, but other services such as counselling and voice training therapy, which are all very crucial for the wellbeing of transgender patients.

I am very lucky to have been in a part-time job two years ago that allowed me to save up and go abroad to Belfast to start therapy privately, and it's now been one whole year since I had my top surgery (a double mastectomy) in Warsaw, Poland. However, my financial situation has changed quite a bit since then.

While I haven't had the opportunity to kickstart my career as a fresh graduate, I am lucky to be living independently as a young LGBTQ+ person. I can only imagine what the lockdown restrictions have meant for other young queer folk who have been forced into isolation with less-than-accepting family members. This will have a big impact on peoples' mental health going forward.

Despite the widespread impact that Covid-19 has had, it hasn't managed to put a damper on Pride celebrations. I was given a wonderful opportunity to help with Pride Inside in July. This gave us a chance to learn new skills for delivering online events. The future is becoming ever more digital, and hopefully this will make it more accessible for everyone.

While nothing about a global pandemic has been ideal, the impact of Covid-19 on our social behaviours does make me hopeful for the future in our ability to adapt to unexpected circumstances.

This pandemic has definitely affected my future plans. I had hoped to start college this September, after finally deciding what I want to study. The uncertainty of not knowing what's going to happen with schools and colleges has given me a lot of anxiety.

I want everyone to be safe, but I also am so eager to start a new chapter of my life. I plan on studying TV and Film Production at Dundalk IT, but it is a very hands-on course and just can't be done remotely. I, along with many other students, have been left in the dark.

I have heard many things, such as the courses being done 50% in college and 50% at home. This is not ideal for me as I live in Kilkenny. I can't afford to travel up and down the country each week. I have also applied for accommodation that I don't even know if I'll be allowed to live in.

I feel I won't get the proper college experience if I'm doing my course from home. The opportunities and social interaction won't be the same through a computer screen. Meeting people for the first time through a Zoom call is just not ideal.

This year I had the pleasure of starting a post-Leaving Certificate course. I had months of interaction with my now-friends before the pandemic happened. If the course started online, I truly don't think I would have the same bond with them as I do now.

Dundalk has numerous clubs and societies I'd love to take part in, such as dance and a comedy club. I believe joining extracurricular activities is so important to meet new people outside of your course, but this is something I may now miss out on.

I think more and more everyday that maybe I should just reapply next year. Honestly it's hard to say that anything will be different in a year's time. Things may be more organised but I can't see this situation changing for a long time.

As a person with mental health issues, the uncertainty of the future has taken a massive toll on my health. My advice to fellow students who are feeling the same is to talk to the people in your life. You are not the only person feeling this way, and we need to do what we can to support each other in these difficult times.

I honestly can't see colleges or schools ever go back to normal. It makes me feel very frustrated, because deciding to take the next leap to college is hard enough without all the uncertainty on top of it.

The Covid-19 pandemic is set to take a massive toll on the economy here in Ireland, with talk of another big recession to follow in its wake. This recession would be the second I've lived through.

In the short term, it's likely to be more difficult to find part-time employment to sustain myself, especially if restrictions are tightened again. It will also have a major impact on my education. Blended or digital learning is set to continue for the foreseeable future. I personally found it really difficult to engage with this type of learning and to stay focused last semester.

I was surprised how difficult it was to find the energy to attend the virtual classes which themselves are far less effective than face-to-face, so I think it will have a negative effect on my grades.

In the long-term I believe it will become far more difficult to find an internship and professional experience in my desired field of work. My course has internships in 3rd year, which I was due to start in September, but cancelling these is of grave concern to me, as professional experience is vital to getting a job in the field I want to work.

Ireland already has one of the highest costs of living in Europe, which along with the increased lack of job security associated with the impending economic crisis, makes for a very compelling push to emigrate.

Having to start seriously consider leaving everything behind, to start afresh in a more affordable country, is not a fantastic prospect to look towards.

Many of my peers have also started to take the idea of emigrating seriously now, especially those studying in the health sciences.

Some of them have experienced the worst of the pandemic on the frontlines, and the poor working conditions, not to mention students on placement weren't actually given any compensation for putting their lives at risk. That has taken a toll on them too.

The pandemic to date has definitely taken a toll on my health, both mental and physical. Virtual learning coupled with studying during the semester meant that I stayed fixed at my desk for large portions of the day, leaving little to no time for physical exercise.

My sleep schedule was also heavily disrupted by this lack of routine frequently leaving me tired and in a cycle of oversleeping during the weekend and undersleeping during the week. Still being in the dark about the exact nature of how the upcoming college year will play out leaves a real possibility of that trend continuing.

Of course a drop in physical health takes its toll on your mental health. Aside from the isolation that everyone experienced during the height of the restrictions, having a seemingly endless to-do list on little sleep has not helped my mental health. I fear that this will continue in the new semester.

When I think about the future, it is uncertain and unclear. I should be feeling lost and fearful for the future, yet that is not the case. Instead, I feel an overwhelming sense of hope and excitement for what lies ahead.

This is because we live in a country where we have access to healthcare if needed, where doctors, to receptionists, to cleaners, are tirelessly working to keep us all safe. For that I am so grateful.

To the essential workers holding our country together, from collecting the bins to deciding governmental policy, I am so thankful. To everyone doing their part, staying home, keeping our distance, washing our hands, and wearing masks, we are protecting our community. For that I am so proud.

Although we may not know what is waiting for us in the future, I know that we can get through and overcome whatever obstacles are thrown at us, together.

I am a Traveller and live on a halting site in Coolock in Dublin. Where I'm living is hard during Covid. We only have electricity from our own generators, so there would often be power cuts. We also had no water, and the council put some in during Covid which was helpful. Hopefully after the pandemic they'll do more.

I worked hard this year in school and was due to sit my Leaving Cert. I'm pretty okay with predictive grades for the Leaving Cert, but with no laptop at home it was hard to keep up with online classes and homework. At home I would just have my phone.

Here's hoping, as I definitely want to go on and get more qualifications in the future.

Covid ruined my plans to transition. I recently came out to close family, but I can't go to my doctor to get put on the five-year waiting lists for any sort of gender therapy. It ruined my friendships, it ruined my chances at bettering myself. It left me in an abusive home. I might be 21, but my parents treat me like a small child.

As a result of the pandemic, all of my plans are basically on hold until next year at the earliest. My partner and I were planning on going travelling in October, specifically we wanted to visit New Zealand. Visas were approved, and flights were booked and paid in full.

But the pandemic caused the borders to close, and they remain closed with no date given as to when they will open to foreigners again. Even if they were to open later this year, I wouldn't be in a position to travel, as like many, I was made unemployed during the lockdown.

I graduated UCD in 2019. I had planned to work for one year and then to go abroad to Belgium to study a Masters in International Politics. Because of the Covid-19 pandemic I don't feel safe traveling abroad and I have deferred my studies until next year.

It is a one-year course and I don't want to spend that year stuck in my house, unable to enjoy the new country I will be living in. This means another year of living at home with my family.

After starting my own business three years ago, in the arts sector, I was finally after building up a client base, and a great following and brand.

When Covid-19 hit, I had to close on March 14, and I remain closed until September. I worry about the future of my business, the hours I must put in to build it back up again, and I worry about the staff that rely on me to make it work.

My husband, who also works in the arts and events sector and is highly qualified in his field of work, has also been out of work for six months and for the foreseeable future. It has caused us a lot of stress and worry.

Covid-19 has made the last few months feel like a pile-on collision: as soon as you think it's over another car comes flying around the corner to join the fray. Sixth year is supposed to be a difficult time in our lives, but with this pandemic, it feels like I've been running a marathon for six years, only to find out that there isn't a finish line.

With no graduation in sight, and predicted grades being an unknown variable, it's been a time of great anxiety. Looking for accommodation in Dublin is hard enough on a good day, but the way things are now most of us will be lucky to find somewhere before college is supposed to begin.

Between the months of false and slow information, the stressful online classes and the isolation from the people I've spent the last six years of my life with, it's been a weird period of my life.

Last August, I decided to defer my place in college in order to save as my course is in Dublin. When the pandemic occurred, I was not worried at first, but as it worsened I became concerned about moving to Dublin next year.

I'm worried about moving out to somewhere completely new during a pandemic and being surrounded by new people.

I was supposed to graduate from my degree this year. Because of Covid, and the quarantine restrictions placed, my mental health took a nosedive, and all my usual supports were suddenly gone.

I was meant to be running music events and joinng a music events company over the summer, which has been cancelled. I'm now trying to repeat the assignments I've been unable to do, and I won't be graduating till next year.

Hopefully I'll actually get a graduation next time around, and not just an online one. The future is uncertain where I had once had plans, plans to graduate and join my dream industry. Now, I'm back in mental health services hoping for everything to ease off.

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Special Report: Ireland's young people 'fear the future more than anything' amid the ongoing Covid-19 crisis

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Anxiety and fear weave coarsely through the testimonies of many young people who have shared their experiences of the Covid-19 crisis.

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As millions are inoculated against coronavirus, and the pandemic's end finally seems to glimmer into view, scientists are envisioning what a postvaccine world might look like - and what they see is comforting.

Coronavirus is here to stay, but once most adults are immune - following natural infection or vaccination - the virus will be no more of a threat than the common cold, according to a study published in the journal Science this week. The virus is a grim menace now because it is an unfamiliar pathogen that can overwhelm the adult immune system, which has not been trained to fight it. That will no longer be the case once everyone has been exposed to either the virus or the vaccine.

Children, on the other hand, are constantly challenged by pathogens that are new to their bodies, and that is one reason they are more adept than adults at fending off coronavirus. Eventually, the study suggests, the virus will be of concern only in children younger than five, subjecting even them to mere sniffles - or no symptoms at all.

Depending on how fast the virus spreads, and on the strength and longevity of the immune response, it would take a few years to decades of natural infections for this coronavirus to become endemic

In other words, coronavirus will become "endemic", a pathogen that circulates at low levels and only rarely causes serious illness. "The timing of how long it takes to get to this sort of endemic state depends on how quickly the disease is spreading, and how quickly vaccination is rolled out," says Jennie Lavine, a postdoctoral fellow at Emory University, in Atlanta, who led the study. "So, really, the name of the game is getting everyone exposed for the first time to the vaccine as quickly as possible."

Lavine and her colleagues looked to the six other human coronaviruses - four that cause the common cold, plus the Sars and Mers viruses - for clues to the fate of the new pathogen. The four common-cold coronaviruses are endemic, and produce only mild symptoms. Severe acute respiratory syndrome and Middle East respiratory syndrome, which surfaced in 2003 and 2012, respectively, made people severely ill, but they did not spread widely.

Although all of these coronaviruses produce a similar immune response, the new virus is most similar to the endemic common-cold coronaviruses, Lavine and her colleagues hypothesise. Reanalysing data from a previous study, they found that the first infection with common-cold coronaviruses occurs on average at three to five years of age. After that age, people may become infected again and again, boosting their immunity and keeping the viruses circulating. But they don't become ill.

The researchers foresee a similar future for Covid-19 virus. Depending on how fast the virus spreads, and on the strength and longevity of the immune response, it would take a few years to decades of natural infections for this coronavirus to become endemic, Lavine says.

Without a vaccine, the fastest path to endemic status is also the worst. The price for population immunity would be widespread illness and death along the way. Vaccines completely alter that calculus. The faster people can be immunized, the better. An efficient vaccination rollout could shorten the timeline to a year, or even just six months, for the Covid-19 virus to become an endemic infection. Still, the vaccines are unlikely to eradicate it, Lavine predicts. The virus will become a permanent, albeit more benign, inhabitant in our environment.

Other experts say this scenario is not just plausible but likely. "The overall intellectual construct of the paper I fully agree with," says Shane Crotty, a virus expert at the La Jolla Institute for Immunology, in San Diego. If the vaccines prevent people from transmitting the virus, "then it becomes a lot more like the measles scenario, where you vaccinate everybody, including kids, and you really don't see the virus infecting people any more," Crotty says.

Covid-19: an infected cell, taken from a patient sample. Photograph: National Institutes of Health/EPA

It is more plausible that the vaccines will prevent illness - but not necessarily infection and transmission, he adds. And that means the Covid-19 virus will continue to circulate. "It's unlikely that the vaccines we have right now are going to provide sterilising immunity," the kind needed to prevent infection, says Jennifer Gommerman, an immunologist at the University of Toronto.

Natural infection with coronavirus produces a strong immune response in the nose and throat. But with the current vaccines, Gommerman says, "you're not getting a natural immune response in the actual upper respiratory tract, you're getting an injection in the arm." That raises the likelihood that infections will still occur, even after vaccination.

Ultimately, Lavine's model rests on the assumption that the new coronavirus is similar to the common-cold coronaviruses. But that assumption may not hold up, cautions Marc Lipsitch, a public-health researcher at the Harvard TH Chan School of Public Health, in Boston.

Another plausible scenario is that the virus may come to resemble the seasonal flu, which is mild some years and more lethal in others

"Other coronavirus infections may or may not be applicable, because we haven't seen what those coronaviruses can do to an older, naive person," Lipsitch says. (Naive refers to an adult whose immune system has not been exposed to the virus.) Another plausible scenario, he says, is that the virus may come to resemble the seasonal flu, which is mild some years and more lethal in others. New variants of the Covid-19 virus that evade the immune response may also complicate the picture.

"Their prediction of it's becoming like common-cold coronaviruses is where I'd put a lot of my money," Lipsitch says. "But I don't think it's absolutely guaranteed."

When and how the common-cold coronaviruses first appeared is a mystery, but since the emergence of the new coronavirus, some scientists have revisited a theory that a pandemic in 1890, which killed about a million people worldwide, may have been caused by OC-43, one of the four common-cold coronaviruses.

"People have suggested that the human population developed a low-grade, broad immunity to OC-43 that terminated the pandemic," says Andre Veillette, an immunologist at Montreal Clinical Research Institute, in Canada. "This coronavirus currently broadly circulates in the community in a rather peaceful way." - New York Times

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The future of coronavirus? Nothing worse than a common cold

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As millions are inoculated against coronavirus, and the pandemic's end finally seems to glimmer into view, scientists are envisioning what a postvaccine world might look like - and what they see is comforting.

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We May Never Eliminate COVID-19. But We Can Learn to Live With It

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As COVID-19 continues to spread widely throughout the U.S., the challenge may not be eliminating the virus but learning to live with it.

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For much of the past year, life in Western Australia has been coronavirus-free. Friends gathered in pubs; people kissed and hugged their relatives; children went to school without temperature checks or wearing masks. The state maintained this enviable position only by placing heavy restrictions on travel and imposing lockdowns - some regions entered a snap lockdown at the beginning of the year after a security guard at a hotel where visitors were quarantined tested positive for the virus. But the experience in Western Australia has provided a glimpse into a life free from the SARS-CoV-2 coronavirus. If other regions, aided by vaccines, aimed for a similar zero-COVID strategy, then could the world hope to rid itself of the virus?

It's a beautiful dream but most scientists think it's improbable. In January, Nature asked more than 100 immunologists, infectious-disease researchers and virologists working on the coronavirus whether it could be eradicated. Almost 90% of respondents think that the coronavirus will become endemic - meaning that it will continue to circulate in pockets of the global population for years to come (see 'Endemic future').

"Eradicating this virus right now from the world is a lot like trying to plan the construction of a stepping-stone pathway to the Moon. It's unrealistic," says Michael Osterholm, an epidemiologist at the University of Minnesota in Minneapolis.

But failure to eradicate the virus does not mean that death, illness or social isolation will continue on the scales seen so far. The future will depend heavily on the type of immunity people acquire through infection or vaccination and how the virus evolves. Influenza and the four human coronaviruses that cause common colds are also endemic: but a combination of annual vaccines and acquired immunity means that societies tolerate the seasonal deaths and illnesses they bring without requiring lockdowns, masks and social distancing.

More than one-third of the respondents to Nature 's survey thought that it would be possible to eliminate SARS-CoV-2 from some regions while it continued to circulate in others. In zero-COVID regions there would be a continual risk of disease outbreaks, but they could be quenched quickly by herd immunity if most people had been vaccinated. "I guess COVID will be eliminated from some countries, but with a continuing (and maybe seasonal) risk of reintroduction from places where vaccine coverage and public-health measures have not been good enough," says Christopher Dye, an epidemiologist at the University of Oxford, UK.

"The virus becoming endemic is likely, but the pattern that it will take is hard to predict," says Angela Rasmussen, a virologist from Georgetown University, who is based in Seattle, Washington. This will determine the societal costs of SARS-CoV-2 for 5, 10 or even 50 years in the future (see 'Coronavirus: here to stay?').

Childhood virus

Five years from now, when childcare centres call parents to tell them that their child has a runny nose and a fever, the COVID-19 pandemic might seem a distant memory. But there's a chance the virus that killed more than 1.5 million people in 2020 alone will be the culprit.

This is one scenario that scientists foresee for SARS-CoV-2. The virus sticks around, but once people develop some immunity to it - either through natural infection or vaccination - they won't come down with severe symptoms. The virus would become a foe first encountered in early childhood, when it typically causes mild infection or none at all, says Jennie Lavine, an infectious-disease researcher at Emory University in Atlanta, Georgia.

Scientists consider this possible because that's how the four endemic coronaviruses, called OC43, 229E, NL63 and HKU1, behave. At least three of these viruses have probably been circulating in human populations for hundreds of years; two of them are responsible for roughly 15% of respiratory infections. Using data from previous studies, Lavine and her colleagues developed a model that shows how most children first come down with these viruses before the age of 6 and develop immunity to them. That defence wanes pretty quickly so it is not sufficient to block reinfection entirely, but it seems to protect adults from getting sick, says Lavine. Even in children, the first infection is relatively mild.

Whether immunity to SARS-CoV-2 will behave in the same way is so far unclear. A large study of people who have had COVID-19 suggests that their levels of neutralizing antibodies - which help to block reinfection - start to decline after around six to eight months. But their bodies also make memory B cells, which can manufacture antibodies if a new infection arises, and T cells that can eliminate virus-infected cells, says Daniela Weiskopf, an immunologist at the La Jolla Institute for Immunology in California, who co-authored the study. It's yet to be established if this immune memory can block viral reinfection - although cases of reinfection have been recorded, and new viral variants might make them more likely, they are still considered rare.

Weiskopf and her colleagues are still tracking the immune memory of people infected with COVID-19 to see if it persists. If most people develop life-long immunity to the virus, either through natural infection or vaccination, then the virus is unlikely to become endemic, she says. But immunity might wane after a year or two - and already there are hints that the virus can evolve to escape it. More than half the scientists who responded to Nature 's survey think waning immunity will be one of the main drivers of the virus becoming endemic.

Because the virus has spread around the world, it might seem that it could already be classed as endemic. But because infections continue to increase worldwide, and with so many people still susceptible, scientists still technically class it as in a pandemic phase. In the endemic phase, the number of infections becomes relatively constant across years, allowing for occasional flare-ups, says Lavine.

To reach this steady state could take a few years or decades, depending on how quickly populations develop immunity, says Lavine. Allowing the virus to spread unchecked would be the fastest way to get to that point - but that would result in many millions of deaths. "That path has some huge costs," she says. The most palatable path is through vaccination.

Vaccines and herd immunity

Countries that have begun distributing COVID-19 vaccines soon expect to see a reduction in severe illness. But it will take longer to see how effectively vaccines can reduce transmission. Data from clinical trials suggest that vaccines that prevent symptomatic infection might also stop a person from passing on the virus.

If vaccines do block transmission - and if they remain effective against newer variants of the virus - it might be possible to eliminate the virus in regions where enough people are vaccinated so that they can protect those who are not, contributing to herd immunity. A vaccine that is 90% effective at blocking transmission will need to reach at least 55% of the population to achieve temporary herd immunity as long as some social distancing measures - such as face masks and many people working from home - remain in place to keep transmission in check, according to a model developed by Alexandra Hogan at Imperial College London and her colleagues. (A vaccine would need to reach almost 67% of people to provide herd immunity if all social distancing measures were lifted.) But if the rate of transmission increases because of a new variant, or if a vaccine is less effective than 90% at blocking transmission, vaccine coverage will need to be greater to blunt circulation.

Vaccinating even 55% of the population will be challenging in many countries. "The virus will stick around if parts of the world don't get vaccinated," says Jeffrey Shaman, an infectious-disease researcher at Columbia University in New York City.

Even if the virus remains endemic in many regions, global travel will probably resume when severe infections are reduced to levels that health services can cope with, and when a high proportion of people who are vulnerable to severe illness have been vaccinated, says Dye.

Similar to flu?

The 1918 influenza pandemic, which killed more than 50 million people, is the yardstick by which all other pandemics are measured. It was sparked by a type of virus known as influenza A, which originated in birds. Almost all cases of influenza A since then, and all subsequent flu pandemics, have been caused by descendants of the 1918 virus. These descendants circulate the globe, infecting millions of people each year. Flu pandemics occur when populations are naive to a virus; by the time a pandemic virus becomes seasonal, much of the population has some immunity to it. Seasonal flu still has a significant toll globally, claiming roughly 650,000 lives per year.

Jesse Bloom, an evolutionary biologist at the Fred Hutchinson Cancer Research Center in Seattle, thinks the coronavirus might follow a similar path. "I do think SARS-CoV-2 will become a less serious problem and something like flu," he says. Shaman and others say the virus could also settle into a seasonal pattern of annual winter outbreaks similar to flu.

Flu seems to evolve much faster than SARS-CoV-2, allowing it to sneak past the immune system's defences. This feature is why flu vaccines need to be reformulated each year; that might not be needed for SARS-CoV-2.

Still, the coronavirus might be able to dodge immunity acquired by infection, and possibly outsmart vaccines. Already, laboratory studies show that neutralizing antibodies in the blood of people who have had COVID-19 are less capable of recognizing a viral variant first identified in South Africa (called 501Y.V2), than variants that circulated earlier in the pandemic. That is probably because of mutations in the virus's spike protein, which vaccines target. Trial results suggest that some vaccines might be less effective against 501Y.V2 than against other variants, and some vaccine makers are exploring redesigns of their products.

Still, the immune system has lots of tricks up its sleeve, and can respond to many features of the virus, not just spike, says Lavine. "The virus is probably going to have to go through lots of mutations to make a vaccine ineffective," she says. Preliminary trial results also suggest that vaccines can protect people with 501Y.V2 against severe disease, says Rasmussen.

More than 70% of the researchers surveyed by Nature think that immune escape will be another driver of the virus's continuing circulation (see 'Driving factors'). This would not be a first for a human coronavirus. In a study yet to be peer reviewed, Bloom and his colleagues show that the endemic coronavirus 229E has evolved so that neutralizing antibodies in the blood of people infected with the viral variant circulating in the late 1980s and early 1990s are much less effective against more recent variants. People are reinfected with 229E over their lifetime, and Bloom suspects that it might be harder to stave off the variants that have evolved to escape previous immunity. But scientists don't know whether these reinfections are associated with worse symptoms. "I would expect that over many years, accumulated mutations to SARS-CoV-2 will more completely erode neutralizing antibody immunity as we saw for CoV-229E, although I can't say for sure how the rates will compare among the two coronaviruses," says Bloom.

Bloom thinks it's probable that SARS-CoV-2 vaccines will need to be updated, possibly every year. But even then, immunity from either past vaccination or infection will probably blunt serious disease, he says. And Lavine notes that even if people are reinfected, this might not be a big deal. With the endemic coronaviruses, frequent reinfections seem to boost immunity against related variants and typically people experience only mild symptoms, she says. But it is possible that vaccines won't stop some people developing severe symptoms, in which case the virus will continue to be a significant burden on society, says Shaman.

Measles-like virus

If SARS-CoV-2 vaccines block infection and transmission for life, the virus might become something akin to measles. "It's probably less likely [than other scenarios] but it's still possible," says Shaman.

With a highly effective measles vaccine - two doses and a person is protected for life - the measles virus has been eliminated in many parts of the world. Before a vaccine was developed in 1963, major epidemics killed about 2.6 million people, mostly children, a year. Unlike flu vaccines, the immunization for measles has never needed to be updated because the virus has yet to evolve in ways that evade the immune system.

Measles is still endemic in parts of the world with insufficient immunization. In 2018, a global resurgence killed more than 140,000 people. A similar situation could emerge with SARS-CoV-2 if people decline vaccines. A survey of more than 1,600 US citizens found that more than one-quarter would definitely or probably decline a COVID-19 vaccine, even if it were free and deemed safe (see go.nature.com/3a9b44s). "How successful we are at addressing those concerns will determine how many people get the vaccine and how many remain susceptible," says Rasmussen.

Animal reservoirs

The future of SARS-CoV-2 will also depend on whether it establishes itself in a wild animal population. Several diseases brought under control persist because animal reservoirs, such as insects, provide chances for pathogens to spill back into people. These include yellow fever, Ebola and chikungunya virus.

SARS-CoV-2 probably originated in bats, but it might have passed to people through an intermediate host. The virus can readily infect many animals, including cats, rabbits and hamsters. It is particularly infectious in mink, and mass outbreaks on mink farms in Denmark and the Netherlands have led to huge animal culls. The virus has also passed between minks and people. If it became established in a wild-animal population and could spill back into people, it would be very difficult to control, says Osterholm. "There is no disease in the history of humankind that has disappeared from the face of the Earth when zoonotic disease was such an important part of, or played a role in, the transmission," he says.

The path that SARS-CoV-2 might take to become an endemic virus is challenging to predict, but society does have some control over it. In the next year or two, countries can reduce transmission with control measures until enough people have been vaccinated either to achieve herd immunity or to drastically reduce the severity of infections. That would significantly reduce deaths and severe disease, says Osterholm. But if countries abandon strategies to reduce spread and let the virus reign unchecked then "the darkest days of the pandemic are still ahead of us", he says.
doi: https://doi.org/10.1038/d41586-021-00396-2

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The coronavirus is here to stay - here's what that means

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A Nature survey shows many scientists expect the virus that causes COVID-19 to become endemic, but it could pose less danger over time. A Nature survey shows many scientists expect the virus that causes COVID-19 to become endemic, but it could pose less danger over time.

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Finance & Development, June 2020, Vol. 57, Number 2PDF version

Life Post-COVID-19

Six prominent thinkers reflect on how the pandemic has changed the world

Daniel Susskind, James Manyika, Jean Saldanha, Sharan Burrow, Sergio Rebelo, and Ian Bremmer

Daniel Susskind

In March 2020, Rabbi Jonathan Sacks, an influential figure in British intellectual life, described the COVID-19 catastrophe as "the nearest we have to a revelation for atheists."

At the time I thought the comparison was apt. It captured the biblical sense of shock that many of us felt in the face of such a sudden, extreme, and swiftly accelerating crisis. We "have been coasting along for more than half a century," he remarked, and all at once "we are facing the fragility and vulnerability of the human situation."

Now, a few months on, Rabbi Sacks' comparison with revelation still seems fitting, but for a different reason, and one that matters for thinking about a world after COVID-19.

This crisis is alarming, in part, because it has several new and unfamiliar features. A global medical emergency caused by a virus we still do not fully understand. A self-inflicted economic catastrophe as a necessary policy response to contain its spread.

And yet as time has passed, it has also become clear that much of what is most distressing about this crisis is not new at all. Striking variations in COVID-19 infections and outcomes appear to reflect existing economic inequalities. Remarkable mismatches between the social value of what "key workers" do and the low wages they receive follow from the familiar failure of the market to value adequately what really matters.

The happy embrace of disinformation and misinformation about the virus was to be expected, given a decade of rising populism and declining faith in experts. And the absence of a properly coordinated international response ought to have come as no surprise, given the celebration of "my country first" global politics in recent years.

The crisis then is a revelation in a far more literal sense-it is focusing our collective attention on the many injustices and weaknesses that already exist in how we live together. If people were blind to these faults before, it is hard not to see them now.

What will the world look like after COVID-19? Many of the problems we will face in the next decade will simply be more extreme versions of those that we already confront today. The world will only look significantly different this time if, as we emerge from this crisis, we decide to take action to resolve these problems and bring about fundamental change.

James Manyika

The world after COVID-19 is unlikely to return to the world that was. Many trends already underway in the global economy are being accelerated by the impact of the pandemic.

This is especially true of the digital economy, with the rise of digital behavior such as remote working and learning, telemedicine, and delivery services. Other structural changes may also accelerate, including regionalization of supply chains and a further explosion of cross-border data flows.

The future of work has arrived faster, along with its challenges-many of them potentially multiplied-such as income polarization, worker vulnerability, more gig work, and the need for workers to adapt to occupational transitions. This acceleration is the result not only of technological advances but also of new considerations for health and safety, and economies and labor markets will take time to recover and will likely emerge changed.

With the amplification of these trends, the realities of this crisis have triggered reconsideration of several beliefs, with possible effects on long-term choices for the economy and society. These effects range from attitudes about efficiency versus resilience, the future of capitalism, densification of economic activity and living, industrial policy, our approach to problems that affect us all and call for global and collective action-such as pandemics and climate change-to the role of government and institutions.

Over the past two decades, in advanced economies, responsibility has generally shifted from institutions to individuals. Yet health systems are being tested and often found wanting, while benefits from paid sick leave to universal basic income are getting a second look. There is potential for a long-term shift in how institutions support people, through safety nets and a more inclusive social contract.

As history has shown, choices made during crises can shape the world for decades to come. What will remain critical is the need for collective action to build economies that deliver inclusive economic growth, prosperity, and safety for all.

Jean Saldanha

In The Pandemic Is a Portal, Indian author Arundhati Roy writes, "Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next."

The way multilateralism operates will have to change to reflect this very different world. The COVID-19 pandemic has been testing the limits of global cooperation. Support for developing economies in particular remains inadequate. They were hit early by the global economic downturn, including through record capital outflows and tightening financial conditions. Facing the worst humanitarian crisis since World War II, these economies are experiencing unprecedented pressure on their already limited fiscal capacity to tackle urgent public health and social needs.

Choices made now will have far-reaching consequences. Reliance on more of the same is untenable and ignores the scale of human suffering unleashed by the pandemic.

A fitting UN-led reform agenda must include the IMF in addressing the structural problems that have driven debt vulnerability across developing economies. Such an agenda must shift development finance away from market-friendly reforms and incentives for private investment. It must abandon the dogma of austerity. Furthermore, rich countries must finally meet their official development assistance commitments.

Power imbalances in global institutions must also be corrected to give fair recognition to the needs and rights of the two-thirds of the world's population who reside in the Global South.

If the international community fails to respond decisively now, the 2030 Agenda and the Paris Agreement will be fatally derailed. A new multilateralism-in which reform of the Bretton Woods institutions will play a key role-is needed now and must be based on a vision of development that puts human rights, gender equality, and climate at its center.

Sharan Burrow

The world after the first wave of COVID-19 must be more inclusive, resilient, and sustainable. Today, we live in a world in which inequality between and within countries has grown as a result of businesses' race to the bottom and working poverty among a vast portion of the global workforce. Too many countries suffered the external shocks of COVID-19 without universal social protection, robust public health systems, a plan to reach net-zero carbon emissions by 2050, or a sustainable real economy with quality jobs.

The Bretton Woods conference occurred while a war was still raging and helped formed the basis of a postwar social contract. Similarly, we need to craft an ambitious reconstruction plan while working to end the pandemic. International support is a matter of collective survival and an investment in the future of health, the global economy, and multilateralism. The choice is ours, and the actions of the IMF and the multilateral system will be a deciding factor.

Our goal for recovery should be full employment and a new social contract. Public investment in the care economy, education, and low-carbon infrastructure can form the backbone of stimulus that reduces inequality. Wage policy, collective bargaining, and labor market regulation can revive demand and income while putting an end to a business model that allows companies to take no responsibility for their workers.

Debt should be addressed through a relief process focused on the United Nations Sustainable Development Goals and enduring economic growth for every country. Shortsighted fiscal consolidation hindered debt management and reduction after the global financial crisis and would again leave us even less able to deal with future health and economic crises.

Shared prosperity can be the fruit of a COVID-19 world marked by shared ambition and global solidarity.

Sergio Rebelo

COVID-19 will leave a lasting imprint on the world economy, causing permanent changes and teaching important lessons.

Virus screening is likely to become part of our life, just like security measures became ubiquitous after 9/11. It is important to invest in the infrastructure necessary to detect future viral outbreaks. This investment protects economies in case immunity to COVID-19 turns out to be temporary.

Many economies adopted versions of Germany's Kurzarbeit (short work) subsidy during the pandemic. This policy keeps workers employed at reduced hours and pay, with the government compensating some of the shortfall in wages. By keeping matches between firms and workers intact, the economy is better prepared for a quick recovery. It is important to improve the implementation of these policies and make them a permanent part of our economic recovery tool kit.

Remote work is likely to become more common. We had some evidence that working from home is at least as productive as working at the office. However, many companies were reluctant to embrace remote work. Now that many have tried it with good results, remote work might be here to stay.

The pandemic crisis has accelerated the pace of digital transformation, with further expansion in e-commerce and increases in the pace of adoption of telemedicine, videoconferencing, online teaching, and fintech.

Companies with international supply chains are dealing with shortages and bottlenecks. We are likely to see many of these companies reshore some of their production. Unfortunately, this trend will not create many jobs because most of the production is likely to be automated.

Governments will be bigger after playing the role of insurer and investor of last resort during the crisis. Public debt will balloon, creating financial challenges around the world.

The most important lesson from the COVID-19 pandemic is the importance of working together on problems that affect the entire human race. We are much stronger united than divided.

Ian Bremmer

The global order was in flux well before the COVID-19 crisis. Coronavirus has accelerated three of the key geopolitical trends that will shape our next world order... which will await us on the other side of this pandemic.

The first trend is deglobalization; the logistic difficulties brought to light by the current crisis are already pointing to a shift away from global just-in-time supply chains. Yet as economic difficulties mount, the inevitable growth of nationalism and "my nation first" politics will push companies to localize business operations that favor national and regional supply chains.

The third trend, China's geopolitical rise, has been more than three decades in the making. But while China has successfully transformed itself into an economic and technological superpower, no one expected it to become a "soft power" superpower. This crisis can change that, if China's crisis diplomacy continues and the perception endures that Beijing has been far more effective than the rest of the world in its response to the outbreak.

Of course, just because China appears to be faring better doesn't mean it actually is. There's a reason people take Chinese numbers with a grain of salt. This general distrust was further fueled by the initial Chinese cover-up of the outbreak, which enabled its global spread. Donald Trump and his administration are leaning into this narrative as an election strategy and to deflect attention from their own handling of the pandemic. China won't take this lying down, making it increasingly likely that once the world emerges from the current pandemic, we will be plunged into a new cold war, this time between the United States and China.

New world order or not, some things just don't change.

ART: ISTOCK / DRAFTER123; PHOTOs: SUKI DHANDA; COURTESY OF MCKINSEY GLOBAL INSTITUTE; COURTESY OF EURODAD; HORSTWAGNER.EU/ITUC; MARIA REBELO ; RICHARD JOPSON
Opinions expressed in articles and other materials are those of the authors; they do not necessarily represent the views of the IMF and its Executive Board, or IMF policy.

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How Will the World Be Different After COVID-19 - IMF F&D

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Finance & Development, June 2020, Vol. 57, Number 2PDF version Six prominent thinkers reflect on how the pandemic has changed the world Daniel Susskind, James Manyika, Jean Saldanha, Sharan Burrow, Sergio Rebelo, and Ian Bremmer Daniel Susskind In March 2020, Rabbi Jonathan Sacks, an influential figure in British intellectual life, described the COVID-19 catastrophe as "the nearest we have to a revelation for atheists."

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It came from nowhere, ripped savagely through our lives and is currently overstaying its welcome. But when will the Covid-19 pandemic end? Or will it even end?

The second answer is easier to answer than the first. There will be an end to this pandemic, as there has been to others. But how soon that arrives, and in what manner, remains opaque for now.

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The future of Covid-19 in Ireland: Best-case, worst-case and even-worse-case scenarios

# data[].attributes.attachment_link.description
It came from nowhere, ripped savagely through our lives and is currently overstaying its welcome. But when will the Covid-19 pandemic end? Or will it even end? The second answer is easier to answer than the first. There will be an end to this pandemic, as there has been to others.

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Abstract

SARS-CoV-2 has recently emerged, becoming a global threat, affecting directly all human beings owing to its morbidity and mortality and indirectly, due to the enormous economic and psychological impact produced by social isolation, the most effective measure so far, but unsustainable for a long period. The scientific effort to understand and control SARS-CoV-2 transmission and clinical impact has been huge, and important achievements are highlighted in this review. Diagnosis is central and is the first step in recognizing and fighting any infectious agent. Instrumental to that is the quality of the data, relying on serological and molecular surveys in addition to trustworthy clinical records. However, the fast spread of a virus adapted for human-to-human respiratory transmission raised a demand for millions of molecular tests that are simply not available. Several candidate drugs are under evaluation in clinical trials. Those with an already recognized safety profile are more auspicious, since, if proven effective, can cut several steps of production and phase 2 and 3 trials. More than one hundred vaccine prototypes are in different stages of development, however, safety and efficacy evaluations cannot be obviated, implicating, most optimistically, in at least months for us to have an effective immunization, the definite measure to allow a safe return to the pre-pandemic lifestyle. Science has never been more necessary and present in daily life. Relying on the best of human wit is the only way out to this pandemic, saving as many lives as possible.

Keywords: SARS-CoV-2, COVID-19, RT-PCR, Diagnosis, Origin, Treatment

Introduction

It is quite a challenge to write a review on the most recently emergent coronavirus (SARS-CoV-2) and the disease caused by it, named COVID-19. In a few months, thousands of papers were produced by all scientific branches, impossible to be followed, properly rated, and summarized. We will focus here on our areas of expertise: molecular epidemiology, diagnostics, and clinical management, briefly touching other aspects.

Sadly, we have to admit that the global community, including scientists working closer to the problem, such as virologists, infectologists, epidemiologists, vaccinologists, public health authorities, and the pharmaceutical industry, collectively failed in avoiding this pandemic to occur. It was not unpredictable; in fact, it was anticipated by many ( 1, 2), and we had at least two "rehearsals", SARS-CoV in 2002/2003 and MERS-CoV in 2012, that provided enough evidence of the risk and harm of coronaviruses jumping from animals to humans ( 3). There was time enough for the development of a pancoronavirus vaccine and treatments. This mistake is now causing thousands of lives to be taken directly by viral action and indirectly by the economic deprivation that follows.

As we write this manuscript, Brazil presents the 2nd highest absolute number of cases, approximately two million, and deaths, now reaching 70,000 ( 4). Due to its large population and territory, intense flow of international passengers and immigrants from all over the world, and many densely populated urban centers, the country has a fertile environment for emerging agents. The Zika virus crisis in 2014 is an example of an arthropod-borne disease that in Brazil has shown a previously unknown feature of a flavivirus human infection: the ability to cause fetal growth anomalies ( 5). More recently, we were at a perilous limit for the resurgence of urban Yellow Fever, avoided by a massive immunization effort ( 6), while Dengue viruses keep causing thousands of infections and hundreds of deaths every year ( 7). Even with all these warnings, a public health strategy to prevent or minimize the risk of another emergent infectious agent is not in place. We lack a robust surveillance system with advanced testing technologies able to rapidly identify such agents and react to them. It is certainly very expensive but undoubtedly cost-effective. This should be one painful lesson we take as a country but that could lead the world to become more strongly connected.

SARS-CoV-2 origin and spread

Origin

The earliest report of a cluster of an atypical pneumonia, later named SARS-CoV-2, dates from late December 2019, and it was linked to people that visited the Huanan seafood and wildlife market in Wuhan city in Hubei province, China ( 8, 9). Analyses of nucleotide sequences of complete SARS-CoV-2 genomes led to the estimation that the virus might have emerged as early as October 2019, therefore a couple months before its first detection ( 10).

SARS-CoV-2 belongs to the subgenus Sarbecovirus of the genus Betacoronavirus, and phylogenetic analysis demonstrated that it is more related to two bat-SARS-like coronaviruses (88% identity at nucleotide level) than to the human SARS-CoV and MERS-CoV (79 and 50%, respectively). Further analysis has revealed 95.4% identity between the SARS-CoV-2 to a coronavirus found in pangolins (Pangolin-CoV), suggesting a possible intermediate host ( 11, 12).

Although no animal coronavirus sampled so far is sufficiently similar to SARS-CoV-2 to implicate it as direct source to the human virus, the most plausible hypothesis tells us that an animal hosted SARS-CoV-2-like jumped into humans, and during the first stages of human-to-human transmission, it acquired very particular genetic features. The 'humanized' virus then became highly infectious and able to efficiently spread among humans.

While all evidence points to a zoonotic origin of the SARS-CoV-2, there were conspiracy theories claiming that it could have been deliberately created. Some genetic particularities, like the presence of specific mutations in the receptor-binding domain (RBD) of the spike protein, provide definite evidence that the new coronavirus is not a product of human manipulation. Analysis of this region among human and animal SARS-CoV-2-related viruses revealed that the RBD of SARS-CoV-2 evolved for binding to human ACE2 receptor with an efficient interaction, distinct to those predicted through structural and functional analysis ( 13, 14).

Phylogenetic analysis

Just few months after the first genome description in January 2020, thousands of global SARS-CoV-2 partial and complete genome sequences were generated by several groups, allowing epidemiological and all sorts of genetic and phylogenetic analyses. Until the writing of this text, 49,607 SARS-CoV-2 partial and complete genomes have been sequenced worldwide and made available at repositories such as GISAID ( https://www.epicov.org). Although the sequencing efforts vary considerably among the countries and regions, initial analysis demonstrated some structured geographical distribution, which becomes weaker as the epidemic progresses. Some organizations and institutions have made efforts to sequence rapidly and on a large scale, as the COVID-19 Genomics UK (COG-UK) Consortium, from the United Kingdom, and the SPHERE, from the Centers for Disease Control and Prevention (CDC, USA). In Brazil, nearly 500 complete genomes have been sequenced and made available at a public database ( https://www.gisaid.org). Different efforts and consortia for this purpose are ongoing and include state and federal institutions and universities including Oswaldo Cruz Foundation, University of São Paulo, São Paulo State University, Campinas State University, and the Federal Universities of Minas Gerais, Tocantins, Brasilia, and Rio de Janeiro, among others.

Geographical and phylodynamic inferences are possible as more representative viral genomic data become available. Currently, it is possible to recognize up to ten SARS-CoV-2 lineages (being A1a, A2a, B, and B1 the most widespread). So far, viruses from A2a, A1a, and B lineages were described in Brazil, with more than 90% of sequences belonging to the A2a lineage (NEXTSTRAIN, <nextstrain.org>). In fact, the increase in frequency of the A2a (which carries a mutation D614G in the spike protein) has been explosive, and today it is the most widespread lineage globally. Some speculation exists that this lineage may present better fitness than the original one, or that it is more infectious and adapted to human cell receptors ( 15, 16), but not enough data is available at the moment to confirm or refute any of these theories.

The analysis of the first sequences sampled in Brazil revealed that they were imported mainly from Europe and the USA and the epidemic here is a result of multiple and distinct introductions ( 17). With few exceptions ( 18), it has been recognized that the outbreak in nearly all countries is the result of multiple introductions from different places into the region and not from a single source ( 19 - 24).

SARS-CoV-2 evolutionary rate was estimated to be of about 8×10⁻⁴ substitutions per site per year, which is similar to the related SARS-CoV-1 and MERS ( 25). Comparison analysis among worldwide isolates revealed moderate genetic diversity accumulated at this point of the pandemic. Pairwise comparisons reveal no more than 10 single nucleotide polymorphisms (SNPs) between any two genomes, thus resulting in >99.9% similarity among SARS-CoV-2 genomes. Although some of these SNPs result in non-synonymous mutations, none of them have shown significant shifts in the functional context of the respective proteins or in the transmission rates. Nevertheless, as is the case for any other pathogen, nucleotide mismatches could lead to a lower sensitivity and inclusivity of the molecular diagnostic assays, thereby resulting in false-negative diagnosis ( 26).

In sum, phylogenetic, clinical, and epidemiological data together offer insights into how the viruses are related and evolve over time. At the moment, data from the SARS-CoV-2 genomes indicate that we still have much to learn about the evolution of this virus and how it spreads.

Diagnosis

Management of infectious diseases always begin at the identification of the agent. Therapeutic and preventive strategies start by taking into account the kind of microorganism, its transmission routes, and spreading capacity. As pointed out above, SARS-CoV-2 was quickly recognized as the etiological agent by the most modern diagnostic technology available today, metagenomics ( 27), which consists of the unbiased study of the microbial diversity directly from a clinical or environmental sample by high-throughput DNA sequencing. By excluding DNA from human origin, either in vitro or in silico, researchers can focus the analysis on non-human sequences, disclosing microbial diversity and allowing the discovery of new agents ( 28).

By this approach, on January 11, 2020, the full-sequence of the first new coronavirus genome was made publicly available by Chinese scientists. The availability of the first whole genome 29,903 bases RNA sequence made possible the development of real-time PCR protocols, forming the groundwork of SARS-CoV-2 identification in symptomatic patients. From this date on, many RT-PCR protocols were created, targeting different genomic regions. The non-structural proteins seem to accumulate diversity faster than the structural ones, in particular nsp2, 3, and 4, and some insertions and deletions are also common along ORF8. Complete genome analysis suggests that the conserved Orf1b, envelope and spike encoding genes are more conserved, hence better targets for molecular assays, whereas the N gene displays more variability between current isolates ( 26, 29).

As the number of cases grew exponentially, it was realized that the global availability of reagents for RNA extraction and PCR amplification was much inferior to the actual need for the diagnosis of symptomatic subjects and to assist selective social isolation.

Currently there are dozens of PCR kits for SARS-CoV-2 diagnosis in respiratory samples, targeting one, two, or three distinct genomic fragments (see ). Including multiple targets is a strategy to cope with the uncertainty of the mutation rate of each gene, which can lead to false-negatives due to primer mismatches. For instance, the original PCR protocol described by the Charité group from Berlin ( 30) proposed to screen the samples with an E-gene pan sarbecoviruses (a subgroup of beta-coronaviruses) and to confirm reactive samples with an assay targeting specifically the SARS-CoV-2 RNA dependent RNA polymerase viral gene (RdRP). Later, the RdRP assay was found to lead to false-negatives in some isolates ( 31, 32). In general, many assays use the panSarbeco E gene amplimer in addition to a second target, either in parallel or as a sequential confirmatory approach. The US CDC had initially proposed 3 targets on the nucleocapsid gene (N1-N2-N3) but later withdrew the third one (N3) due to low efficiency ( 33). Primers and probes spanning the open reading frames 1 and 3 have also been adopted in different combinations. One single target permits higher throughput testing and makes interpretation easier in comparison to two or three targets, which demands more complex interpretation algorithms and increase the number of indeterminates.

High-throughput labs able to process thousands of samples per day were and are still being created. In parallel, innovative approaches are in development and validation, in order to expand testing capacity, speeding up and simplifying the process. One approach has been to employ high-throughput sequencing (Next-Generation Sequencing - NGS) platforms able to read millions of bases simultaneously. Since reading of less than 100 bps with a low coverage is more than sufficient to assign a sample as SARS-CoV-2 detected or undetected, this strategy could solve the testing bottleneck. However, NGS does require RNA extraction and libraries are made of PCR amplicons. Thus, if one needs to extract RNA and further amplify it, in fact NGS in this context is being used as a sophisticated PCR reader. Moreover, NGS working flow still requires manual steps and takes 2-3 days to run one flow cell, contrasting to the automated flow of some PCR systems. These caveats indicate that NGS is more appropriate for epidemiological surveillance and phylogenetic studies but at the moment does not represent a practical solution for the routine high volume testing demand. Actually, countries with a large number of NGS platforms, such as China and the USA, rely exclusively on qPCR for the purpose of SARS-CoV-2 diagnosis.

Due to the RNA extraction constraint, researchers have shown that it is feasible to use the nasopharyngeal wash, in saline, water or viral transport medium, directly into the PCR tube, obviating the need for RNA extraction ( 34). As expected, there is some loss in sensitivity when comparing to extracted material, but hopefully new PCR mixtures that can surpass the inhibitory effect of unextracted substances will allow a huge increase in testing capacity.

Another alternative to the complexity of RT-qPCR and its reagents shortage is the loop-mediated isothermal amplification (RT-LAMP), which has shown a sensitivity similar to qPCR but faster and simpler. LAMP amplicons can be detected by visual inspection ( 35) or even by the collateral ssDNAse activity of the CRISPR-Cas12a system after target recognition, which adds a second level of specificity in addition to elevated sensitivity ( 36).

In spite of the viral RNA protocol adopted, it must be emphasized that the clinical sensitivity of molecular testing for COVID-19 has never achieved >99% as seen in many other infectious diseases. Both preanalytical and analytical conditions contribute to an average clinical sensitivity of 70% ( 37, 38). So, it is not uncommon that nasopharyngeal samples from evident COVID-19 patients return as negative, while more invasive samples from the lower respiratory tract, such as broncoalveolar lavage from the same day, return positive for SARS-CoV-2 RNA ( 39).

Serology

Serological assays represent the most common way for the diagnosis of viral infections. As early as March 2020, commercial kits became available in different formats: lateral flow immunoassays, enzyme-linked immunosorbent assays (ELISAs), and chemiluminescent immunoassays (CLIA). They also may differ in the antibody class detected (IgA, IgG, IgM, IgM/IgG, or total antibodies) and their composition of viral antigens.

However, due to the time between infection and antibody production, the so-called window period, detection of antibodies is not useful in the early symptomatic phase, when most patients seek clinical support. This limitation is magnified in the specific case of SARS-CoV-2 where the development of the classical marker of acute phase, IgM, does not seem to behave as usual. It may be an imperfection of the first generation of serological tests, but current IgM assays have failed to detect a significant fraction of truly infected (qPCR positive) subjects in the first 2 weeks from symptoms onset ( 40). Moreover, about 25% of the COVID-19 patients develop IgM concomitantly or after the appearance of IgG ( 41). Noticeably, in the third week after symptoms onset, the rate of seroconversion is >95%, allowing the use of antibody presence to estimate the exposure rate of a population, which is of key importance for the epidemiological monitoring of the epidemic but also to allow a planned safe return to professional and social life ( 42). Auspiciously, second generation assays are showing improved sensitivity ( 43) while the specificity has not been a significant drawback since the first-generation serological assays were introduced.

Today, it is premature to state that antibody-positive subjects are protected from a potential re-infection, which is likely because after millions of cases globally there is no well-documented report of re-infections ( 44, 45). A related uncertainty is whether recovered patients with positive swabs are able to transmit the virus. In this sense, accumulating data are showing that the presence of neutralizing antibodies more than 8 days from symptom onset correlates inversely with the capacity of the isolated virus to infect susceptible cells in vitro ( 46).

Clinical and therapeutic aspects

Clinical manifestation of COVID-19 can vary from mild and moderate to severe and critical disease, with patients requiring mechanical ventilation. Asymptomatic cases can occur, and asymptomatic and presymptomatic patients play an important role in the spread of the virus ( 47, 48). The median incubation period is 4 days with more than 95% of symptomatic cases showing symptoms at 11 days ( 47, 49). In 80% of persons, the disease is mild to moderate, presenting as a flu-like syndrome with resolution of symptoms in 10-14 days. The most common symptoms are fever, cough, myalgia, anorexia, and fatigue. Headache, chills, sore throat, anosmia, and ageusia are frequently described in different series. Uncommon presentations with different manifestations like diarrhea, rash, or abdominal pain can occur (49-51, ). The Kawasaki syndrome has been described recently in children and adolescents ( 52). Twenty percent of patients present severe symptoms requiring hospitalization and about 5% will evolve to critical illness and intensive care unit (ICU) admission, the majority of them with acute respiratory distress syndrome (ARDS), requiring mechanical ventilation. Renal failure occurs in 30% of critically ill patients, most of them in need of hemodialysis ( 53, 54). Overall case fatality rate varies between 1-6% but in patients who need mechanical ventilation, mortality can be as high as 61% ( 49, 53). Median time for hospital admission is 7 days and for ICU admission, 9.5 days ( 8, 53, 54). Risk factors for severe disease and death are described in ( 50, 51, 55).

Table 2

Table 3

Severe COVID-19, with pneumonia and ARDS, is related to hyper-inflammation and release of pro-inflammatory cytokines. Pulmonary inflammation leads to rapid deterioration of pulmonary function and organ failure. Macrophage activation syndrome (MAS), known as cytokine storm, occurs specifically in lungs, with release of tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-1, and IL-8. Besides that, SARS-CoV-2 causes massive alveolar cell death that contributes to more inflammation. This process is reflected by elevated C-reactive protein (CRP), hyperferritinemia, increased level of IL-6 in blood, and altered liver function tests with coagulopathy. D-dimer and fibrinogen elevation can be observed in severe patients with COVID-19, due to extensive pulmonary microthrombosis. Lymphopenia occurs as result of induced immunosuppression ( 56, 57).

For patient stratification, it is important to look for inferior respiratory symptoms. Those patients with a respiratory rate >22 breaths/minute or oxygen saturation (SatO ₂) <92% are considered at risk for complication and must be hospitalized. Chest computed tomography (CT) scan and calculation of the quick sepsis-related organ failure assessment (qSOFA) score is recommended for risk stratification. Patients with qSOFA=1, SatO ₂<92% in room air and extensive ground-glass opacities in >25% of lungs must be hospitalized in the medical ward. Criteria for ICU admission is qSOFA≥2 or qSOFA=1 plus SatO ₂≤92%, mechanical ventilation, arterial hypotension, persistent respiratory rate >30, or unconsciousness. One study proposed the use of lactic dehydrogenase (LDH), lymphocyte count, and CRP with a clinical route as a predictor score for mortality ( 58, 59). Presence of lymphopenia, elevated LDH, hyperferritinemia, or altered D-dimer are predictors of severe disease and mortality.

As a new disease emerges, several drugs are proposed for treatment based on in vitro effectiveness against the etiological agent. However, their in vivo activity must be confirmed in randomized clinical trials. There are several drugs being tested. Chloroquine and hydroxychloroquine associated or not with azithromycin were first indicated as candidate drugs, although there are no randomized clinical trials supporting this indication. Only small uncontrolled trials were published, some of them show no benefit in reducing progression of the disease or mortality. Recently, studies published as preprints that showed some benefits were withdrawn by authors or after peer-review. Concerns with toxicity have arisen with studies showing increase in mortality due to cardiovascular adverse events with the use of chloroquine or hydroxychloroquine alone or in combination with a macrolide ( 60, 61). Until randomized clinical trials show benefits of these drugs in the treatment of COVID-19, they should not be recommended.

Remdesivir, an RNA polymerase inhibitor and experimental drug from the beginning of this pandemic, is now allowed in the USA and Europe for treatment of hospitalized patients with COVID-19 after a randomized clinical trial comparing the drug with placebo showed shortened recovery time in the remdesivir group (11 vs 15 days in placebo arm) at preliminary analysis ( 62). The trial continues, now comparing remdesivir with remdesivir plus baricitinib, an anti-inflammatory drug that inhibits cytokines.

Tocilizumab, an anti-human IL-6 receptor monoclonal antibody, is being studied in severe and critical COVID-19 patients. One observational study in 21 patients, 20 with ventilatory support, showed reduction in respiratory support in 75% of patients. Randomized controlled studies are needed to recommend the drug, although it may be beneficial in the treatment of patients with cytokine storm ( 63).

Corticosteroid therapy was associated to increased mortality in patients with severe or critical COVID-19, but the studies were not randomized and involved heterogeneous populations. One study in patients with ARDS showed a decrease in the risk of death with the use of methylprednisolone ( 64). More controlled studies are needed to recommend this drug as adjuvant treatment in patients with severe disease.

Conclusions and future perspectives

There are two interrelated variables that are key to project the future of the pandemic: immunity and viral evolution. As previously stated, >95% of the exposed subjects do develop a detectable IgG. What is unknown is whether this signifies sterilizing immunity and, if it does, for how long. There is some evidence that re-infection is unlikely, at least in the short term ( 65). However, we still need more time, data, and experience to prove that the presence of IgG is indeed a correlate of immunity for SARS-CoV-2. Even if antibodies wane, protection may remain through cellular memory and fast regain of antibodies production upon exposure, as observed in other viral infections. In this scenario, seroprevalence rates will indicate the actual risk for a determined population, and above a level of infection, estimated as 60-70%, the herd immunity may ensue ( 66). Viral evolution correlates with immunity in the context of viral escape. It is recognized that the generation of a large progeny composed of minor genomic variants, the quasispecies concept ( 67), is a phenomenon common to all RNA viruses. In contrast, SARS-CoV-2 has shown moderate substitution rates that may be attributed to the proofreading activity of its RNA polymerase ( 68), lacking on most RNA viruses. Thus, the optimistic scenario is one where immune response to SARS-CoV-2 is long lasting and, in populations with high seroprevalence, new cases will be rare and self-contained, while the pessimistic one is where immunity lasts for only a few months, as seen for other human coronaviruses ( 69), and thus we will continue to witness periodic outbreaks, as the majority of the population remains susceptible.

Countries and regions are currently at different stages of the epidemic. During these 6 months, it became more evident which approaches work better, when saved lives and the preservation of the health system are the parameters considered. Social isolation is extremely efficient in flattening the curve of the disease but it is unsustainable in the long run. Identifying, by massive molecular testing, asymptomatic and presypmtomatic carriers that are contacts of index symptomatic SARS-CoV-2 RNA positive cases, is clearly the strategy that reduces the rate of new infections while allowing the relaxation of containment measures ( 70).

Meanwhile, there are great expectations for a definite solution represented by an effective vaccine. There are currently many candidates including a few in phase 3 trials ( 71). Until we have a vaccine, it is likely that SARS-CoV-2 will continue to cause outbreaks requiring new rounds of social closure and protection to susceptible groups. Masks will be mandatory in public spaces and events. Hopefully, this tragedy will enhance international cooperation, empower multinational organizations, and highlight to the world the importance of science.

Acknowledgments

We thank Dr. Guido Levi for the careful review of this manuscript.

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Past, present, and future of COVID-19: a review

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SARS-CoV-2 has recently emerged, becoming a global threat, affecting directly all human beings owing to its morbidity and mortality and indirectly, due to the enormous economic and psychological impact produced by social isolation, the most effective measure so far, but unsustainable for a long period.

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Future scenarios for the COVID-19 pandemic

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The COVID-19 pandemic has been met by unequal responses in different countries1,2 and led to unequal impacts, with populations in Europe, the USA, and Latin America disproportionately impacted.3 Science has uncovered much about SARS-CoV-2 and made extraordinary and unprecedented progress on the development of COVID-19 vaccines, but there is still great uncertainty as the pandemic continues to evolve.

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Life globally will not return to normal for two or three years based on the rate of the current vaccination rollout, it has been warned - but there are early signs jabs are reducing cases in the UK.

Speaking to Sky News, Dr Clare Wenham, assistant professor of global health policy at London School of Economics, said the COVID-19 pandemic will not be over until the world's population is protected.

"At the moment, the data is showing it's going to be 2023/24 before the global vaccines are distributed to everybody," she said.

"That's a long time. And distributing some now might be able to get us back to normal life sooner."

Even once the UK population had been vaccinated, restrictions such as border controls would continue to exist because of the threat posed by resistant coronavirus variants being brought in from outside, she said.

"This pandemic isn't going to be over until it's over globally," Dr Wenham said.

"We're still going to be living in some form of restrictions - travel restrictions, border controls - even when we're vaccinated, until it's over round the world. So there's a real imperative to make sure that everybody round the world has at least minimum levels of vaccines at the same time."

It came as the World Health Organisation urged the UK to pause its vaccination programme once vulnerable groups have received their jabs to help ensure the global rollout is fair.

Britain currently has one of the highest levels of vaccine coverage but many poorer countries are yet to start any immunisations.

WHO director general Dr Tedros Adhanom Ghebreyesus has repeatedly called for equitable distribution of jabs and warned that a "me first" approach would prolong the pandemic, as well as human and economic suffering.

Ministers recently pointed out the UK had committed £548m to the WHO's Covax programme to support access to Covid-19 vaccines for up to 92 developing countries.

However, the EU has sparked controversy and a diplomatic row after imposing vaccine controls in a dispute over supply shortages.

Dr Wenham told Sky News: "If we want to return to global systems of trade and travel we need to make sure that the vulnerable globally are vaccinated."

As well as the moral argument, she said: "From an economic standpoint, to be able to relieve border controls and go back to some form of normalcy we need to make sure people around the world are vaccinated - so we don't see these new variants created, so we are not risking bringing something new into the country which we might not have vaccine protection against."

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Sir Jeremy Farrar, a member of the government's Scientific Advisory Group for Emergencies (SAGE), has also warned that vaccinating "a lot of people in a few countries, leaving the virus unchecked in large parts of the world, will lead to more variants emerging".

Meanwhile, initial research shows that Britons are definitely being protected by the rollout of vaccines across the UK, according to The Times.
Subscribe to the Daily podcast on Apple Podcasts, Google Podcasts, Spotify, Spreaker
Anthony Harnden, deputy chairman of the Joint Committee on Vaccination and Immunisation (JCVI), which advises the government, told the paper it was clear that mass vaccination was helping bring down case numbers.

He also said it was possible that those who have received a jab may "get stronger and better long-term protection" by a delayed second dose.

If this if confirmed, it would be a vindication for the government of delaying second shots in order to ensure more people received initial injections.
Over three nights, Sky News will host a series of special programmes examining the UK's response to the pandemic. Watch COVID Crisis: Learning the Lessons at 8pm on 9, 10 and 11 February.

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COVID-19: Life won't return to normal for at least two years, expert warns, saying pandemic 'isn't over until it's over globally'

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Life globally will not return to normal for two or three years based on the rate of the current vaccination rollout, it has been warned - but there are early signs jabs are reducing cases in the UK.

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1. Introduction

The coronavirus disease 2019 (COVID-19) is transmitted from the release of droplets when an infected person coughs or exhales. Then, the released droplets will fall on the nearby objects and surfaces, thus contaminating them. A nearby person can be infected by touching fomites, and then touching their mouth and nose [ 1]. Moreover, the virus itself has the potential for viral entry from the human eyes [ 2]. The common symptoms of COVID-19 are mild fever, dry cough, shortness of breath and muscle pain [ 3]. However, severe symptoms such as high fever, pneumonia and acute kidney failure can be observed in the older persons and persons with comorbidities [ 4]. Bear in mind that anyone could be in contact with COVID-19. Furthermore, this virus can cause severe complications to a high-risk group such as children, older persons, persons with comorbidities, persons with a weak immune system, pregnant women, and disabled persons [ 5]. Because of that, vulnerable people must be protected at all costs as the disease can be deadly to them. In addition, most of the COVID-19 patients show no symptoms [ 6, 7]. COVID-19 patient with no symptoms is known as silent spreader [ 8, 9] and can spread the disease unknowingly through physical contact and close conversation.

There are three ways to stop the spreading of COVID-19 [ 10]. One involves the movement restriction on social and economic sectors. Secondly, an efficient vaccine is developed, which may take at least 12-18 months for clinical trials and mass production [ 11]. The third way is to stop the COVID-19 outbreak naturally with herd immunity [ 10].

Countries such as Taiwan, South Korea and Sweden are not implementing movement restriction, as they are relying on a high level of self-regulation and self-discipline among their citizens. The citizens have been engaged and empowered to do their parts in preventing the spread of COVID-19. Meanwhile, Malaysia and Singapore implement both movement restriction and self-regulation approaches. In Malaysia, movement restriction is implemented in the first few weeks to contain the outbreak. Once the COVID-19 infection curve has been flattened, the self-regulation and self-discipline approaches are implemented to restart and recover the social and economic sectors.

Movement restriction puts a lot of pressure on the population's physical, mental, health, social and economy. Moreover, global economies are hardly hit by the COVID-19 outbreak [ 12]. Hence, there is an increasing pressure to restart and resurrect the social and economic sectors, and to allow people to get back to work. This must be well planned before the movement restriction is lifted. The developed procedures should find the right balance between economic resurrection and COVID-19 prevention [ 13]. The social and economic sectors must open in phases by emphasizing safety and health than an economic recovery.

Hence, this paper reviews and recommends new normals and procedures for daily activities and work-lives to protect people's safety and health. Medical possibilities are not considered while compiling these new normals and procedures. This soft-landing approach is crucial to restart and resurrect the social and economic sectors. No ethical approval required in this study.

2. Responsibility

The World Health Organization (WHO) has recommended six criteria for countries that consider lifting the movement restriction. The first criterion is the COVID-19 transmission in a country has been controlled. The second criterion is the health care facilities including hospitals and clinics are able to find, test, isolate, treat and trace every close contact. The third criterion is the transmission risk for a high-risk group has been minimised such as in the health care facilities and nursing homes. The fourth criterion is the preventive measures are in place in the essential places such as kindergartens, schools, shops and workplaces. The fifth criterion is the imported COVID-19 transmission risks such as from the travellers, tourists and foreign students can be managed. The final criterion is the communities have been prepared for a new normal [ 14].

The WHO recommends social distancing and personal hygiene to be adopted by the population. Social distancing or physical distancing is a safe distance between individuals to prevent respiratory droplet transmission while working and social interactions [ 15]. Meanwhile, personal hygiene is a good hand-washing practice as in Ref. [ 16]. Moreover, a facemask is recommended to be used if the mass gatherings and crowded places are unavoidable [ 17, 18]. A study reported that the cotton or cloth mask could prevent the spread of viral load up to 96% [ 19]. Furthermore, it shows a strong signal to the community that the current pandemic is still ongoing [ 20].

The government must develop the standard operating procedures (SOPs) for every industry based on the WHO recommendations. The economic sectors open in phases, by prioritising the most essential businesses. Besides, the government should consider developing contact tracing and geofencing systems. Contact tracing is a system to trace people who have physical contact and close conversation for a prolonged period with an infected person. Geofencing refers to the use of application to establish a virtual fence that limits the movement of an infected person, hence alarming the authority if the virtual fence is disregarded. This system requires active monitoring using location-based applications tied with the bearer. Moreover, the close contacts of the suspected person can be traced, thus isolation and diagnostic testing can be done on them. Close contact is being closer than 1 m apart for more than 15 min with an infected person [ 18]. Furthermore, the government should consider enforcing a strict law for those who are violating COVID-19 preventive measures [ 21].

The procedures introduced by the government must be enforced by the local authorities to ensure the safety and health of the people. The authorities can also prepare a list of dos and don'ts to help the people from contacting this coronavirus. Moreover, the local authorities should disinfect high-risk areas such as public parks and public transports. COVID-19 cleaning and disinfecting practices are referred to Ref. [ 22].

Occupational safety and health (OSH) professionals can help and advise their employers regarding the COVID-19 issues to maintain the right balance between health and business operations. The OSH professionals are not only protecting the workers but also the clients, visitors and customers. They can also plan and enforce the COVID-19 safety measures in their workplaces.

Meanwhile, the employers must ascertain the essential and non-essential works in their operations. After that, an adequate number of workers for essential operations can be organised. Employers who are unable to comply are advised to remain close and work from home. Moreover, the employers should adapt and embrace the industry 4.0 technologies such as artificial intelligence, internet of things, big data, virtual reality, halography, cloud computing, autonomous robot, 3D scanning, 3D printing and biosensor which can reduce contacts among their employees [ 23].

Other than that, people must be responsible for themselves and their families. A person should go out or travel only when it is necessary such as to get medical treatment, groceries, foods, necessities, essential works and emergency situations [ 24], and must return home promptly. It is well recommended that only one person is allowed to go out at a time. The person should disinfect his or her shoes or leave them outside before entering their houses, as the coronavirus could be present on the floor surfaces. Then, a person should go straight to the bathroom to take a bath with water and soap, before touching their family members. Clothes must be changed and washed upon returning home.

3. New normals and procedures

Rapid diagnostic, drug and vaccine are not the only COVID-19 exit strategy. Self-regulation and self-discipline are equally important to prevent the virus from reappearing in the future [ 25]. The people must regulate themselves by following procedures provided by the government and authorities. Besides, people must discipline themselves to avoid violating the procedures. Temperature checking will become a new normal or routine as an initial measure for COVID-19 detection [ 26, 27]. The persons with 37.5 °C or above temperature will be denied entry, and must seek medical attention immediately.

The other normal is the organisers, workers, visitors and participants at the meetings, events and gatherings must provide their contact details such as their name, telephone number, email and home address. These pieces of information will be shared with the health authorities if COVID-19 infection happens in the respective places.

However, if COVID-19 infection happens, the respective workplaces, premises and buildings must be shut down immediately and all operations are suspended. The health authorities must be informed and contact details will be shared for contact tracing. Then, the diagnostic test is implemented on all workers and visitors. A person must self-isolate, be treated, and not be allowed to come to work after being infected. The infected person can come to work after at least 11 days of self-isolation. This is because the infected person is no longer infectious after 11 days of getting sick [ 28]. The workplaces can be opened after being disinfected.

3.1. Working from home

Working from home has become a new option for employers to operate during the outbreak. Some employers are encouraging their workers to work from home as long as they are comfortable and necessary [ 29]. Moreover, working from home can prevent workers from contacting the COVID-19 infection outside of their homes. The workers with comorbidities are advised to work from home as much as possible. However, it is equally important to protect the workers' physical and mental healths by providing them the appropriate tools and environment to work from home.

A worker must stick to the same working time for example from 8 a.m. to 5 p.m. During working time, a worker must take intermittent breaks to stretch and do light exercises for 15 min, every 2 h. Breathing in fresh air has many advantages such as improving heart rate and blood pressure, giving sharper mind, cleaning lungs and providing energy.

A dedicated workspace must be prepared for working from home. The workspace must be comfortable, quiet, has mild temperature and good lighting. Moreover, it must be an uninterrupted space and separated from the rest of the house. This is important to avoid distractions from their family during the working hours. The workspace could be in a garage, basement, veranda or bedroom, as long as it is comfortable.

Nevertheless, full productivity is not expected and realistic since each worker needs to adapt to a new normal. Some workers might experience anxiety and stress when starting to work from home. However, productivity can be improved over time. The given tasks and assignments can be completed efficiently. Moreover, the geofencing can be used to enable and inform employers about the whereabouts of their workers. This is to ensure the workers commitment towards their tasks.

Recently, there is increasing evidence that domestic animals such as cats can spread the virus to the other cats [[30], [31], [32]] and show no symptoms [ 33]. Previously, the SARS-CoV-2 virus is originated from bats and transmitted from animals to humans [ 34]. Therefore, precautions must be taken to prevent transmission from pets to humans. Pets must be quarantined to prevent physical interactions with other animals outside.

3.2. Workforce and workplace

It is recommended for the employers to resume operations with half of their workforce. This can prevent a large presence of workers in the workplace, thus can reduce physical contact among them. Only essential works are done in the workplace, while others should work from home. Flexible working and business hours are recommended to avoid a large crowd in public transports during peak hours. Moreover, the workers can work on alternate days in the office. Furthermore, a four-day workweek has been encouraged in New Zealand and Japan to boost the struggling economy and increase productivity [ 35]. Therefore, this will allow people to travel during their off days and boost the local economy.

The employers must promote and enforce social distancing, personal hygiene and personal protective equipment (PPE) among their workers. Everybody must adhere to social distancing at least 1 m apart. This is to ensure no physical contacts and close conversations. Moreover, the hand-washing facilities can be accessed by workers, contractors and visitors. Hand sanitisers must be provided at all entrance points. On the other hand, a good cough etiquette is emphasised if a face mask is unavailable. Besides, the geofencing system can be used to ensure social distancing is observed by the workers. The workers who are violating social distancing will be warned by their employers.

The face-to-face meeting can be substituted with an online meeting. However, the face-to-face meeting should be short, if it is unavoidable. Moreover, the workers are encouraged to telework between departments, regional offices and international offices. Work travel should be limited to essential works only. On the other hand, handshaking is not encouraged to avoid close contact.

The workers must clean and disinfect their workplace to prevent the spreading of COVID-19. The virus itself can be transmitted through fomites such as handle, doorknob, tabletop, lift button, lamp switch, fan switch and rail. The virus can remain infectious on these surfaces up to 9 days [ 36]. However, these fomites can be insulated with copper as the virus is not viable on its surface [ 37]. The floor should be disinfected too as there were cases where the virus is detected on the shoes of the health care workers [ 38]. Furthermore, toilet equipment such as tap, sink, door, hand rail, toilet seat and toilet cover must be disinfected regularly. Preventive maintenance on the ventilation system must be carried out periodically. The ventilator filter must be replaced to prevent cross contamination from bacteria and viruses. In fact, the previous coronavirus outbreak (SARS) was transmitted through an airborne transmission from the toilet flush and an exhaust fan of the plumbing system [ 39]. Because of that, efficient air circulation and ventilation must be maintained to ensure people's safety. Also, it is recommended to avoid crowded places such as the canteen and cafe during the lunch hour. The workers can order their meals for takeaway and enjoy their lunch at their desks.

On the other hand, workers with COVID-19 symptoms must stay at home and notify their employers. The sick worker must avoid close contact with others and seek medical attention immediately. Furthermore, an emergency plan must be carried out when the worker shows COVID-19 symptoms during the working hours. Prompt action to be taken by isolating in a dedicated room. This dedicated room must have good ventilation and a necessity for the suspected worker. The suspected worker is not allowed to leave the room. Then, the employer must contact the health authority immediately. Specific procedures must be taken to transfer the suspected worker from the workplace to the hospital. If the worker is infected, the whole household members must self-isolate. Then, the health authority will conduct a diagnostic test for household members. The household members are not allowed to leave the house until the result is obtained.

3.3. Manufacturing, construction and machinery

In the manufacturing and construction industries, the employers through their OSH professionals can promote COVID-19 awareness such as the method of spreading, protection, and prevention from the infection. The information can be conveyed via brief meetings, posters and intranet. OSH professionals can also observe the compliance of social distancing, personal hygiene, and PPEs among the workers. Moreover, the OSH professionals must identify the high-risk workers that can get severe complications from the COVID-19 infection. High-risk workers are recommended to work from home. The common contact surfaces such as table, chair, doorknob, handrail, lift button, handle and hand tool, need to be cleaned regularly. Based on the hierarchy of controls, engineering control is more effective than the administrative control and PPE control. The engineering control includes; installing high-efficiency air filters, increasing ventilation rates in the workplace and installing physical barriers. Furthermore, high humidity and high temperature can reduce the transmission rate of COVID-19 [ 40]. Hence, the humidity level of 40%-70% must be implemented in the workplace.

In the manufacturing industry, employers and OSH professionals must ensure the safety of the workers by implementing COVID-19 control measures. Upon arrival at the workplace, the body temperature of the workers must be checked at the entrance facility. The number of access points can be increased to reduce congestion during the temperature check. Then, each worker is required to clean their hands with hand sanitiser upon leaving the entrance facility. The attendance system that requires physical contact must be removed. According to Refs. [ 38], an elevated concentration of COVID-19 is measured in the confined space. Hence, adequate ventilation must be provided in confined spaces and rooms, at least 4 times per day. Moreover, the workers must be provided with PPEs such as the face masks and hand gloves, correspond to the OSH regulation. Meanwhile, at the working site, social distancing must be observed and physical contact must be reduced. Crowded canteen during breaks and lunch hours is not allowed. Each worker should sit 1 m apart while eating. If not possible, acrylic panels can be installed on the tables to separate the workers. Furthermore, a shift start time can be delayed for the cleaning and disinfection of equipment. If not possible, equipment sharing must be reduced to a minimum. The shift swapping is not allowed to reduce COVID-19 transmission. Furthermore, the foreign workers must be screened as the infection within them can contribute to a major outbreak [ 41].

The construction industry is one of the largest and dangerous industries in the world, especially in the United States (US) [ 42]. Because of that, more control measures should be taken at the construction sites to prevent the spreading of COVID-19. The safety and health officers (SHO) and safety site supervisors (SSS) are responsible to ensure the workers adhere to OSH regulations and COVID-19 procedures. Posters and signages must be installed at appropriate places to promote social distancing and personal hygiene. Moreover, the geofencing system can be used to monitor the number of workers and visitors on the construction sites. This will allow the employer to control and manage the large crowd in the construction site. The temperature gun or scanner can be installed at each site entrance to measure the body temperature of the workers. Workers with COVID-19 symptoms will be denied entry and must seek medical attention immediately. The number of site entrances could be increased to reduce congestion during the temperature check. The start and finish times can be altered to reduce interactions among the workers. The toolbox meeting must be short, to reduce close conversation among them. At the working site, the workers must adhere to social distancing and avoid physical contact. The skin-to-skin works should not be carried out during the outbreak [ 43]. If not possible, the exposure time between each work must be minimised. Moreover, ventilation must be increased in confined spaces. All windows in the room must be opened to allow good air circulation. The common contact surfaces such as tables, chairs, doorknobs, handrails, lift buttons, hoist buttons, handles and hand tools, must be sanitised regularly. During the lunch break, each worker should sit 1 m apart while eating. Only wrapped and pre-packed foods are allowed in the canteen. The workers are recommended to bring the pre-prepared meal and refillable drinking bottle from home. A special tap mechanism for water dispensers must be designed to ensure its cleanliness [ 44]. The dining tables must be cleaned between each use. Furthermore, toilet facilities must be sanitised and cleaned regularly. The number of workers in the toilet facility at a time must be restricted. Moreover, the hand washing facilities must be installed at appropriate places with extra supplies of soap, hand sanitiser and paper towels. Sufficient rubbish bins must be provided for wastes disposal. Bathroom facility should be provided to allow workers to clean themselves before going home. Furthermore, the COVID-19 preparedness and response team (CPRT) must be formed to prepare an emergency response plan (ERP) if the worker is suspected of COVID-19 infection. If a worker shows symptoms in the construction site, prompt action must be taken by isolating them in a dedicated room. This dedicated room must have good ventilation and necessities for the suspected worker. After that, the employer must contact the local health authority to transfer the suspected worker from the construction site to the hospital. Then, the construction site will be closed for disinfection. All workers are required to be diagnosed to trace the COVID-19 infection. The construction site can resume operation after being cleared by the health authority.

Machines and equipment must be sanitised and cleaned regularly. Equipment sharing is not recommended to minimize COVID-19 transmission. The drivers of loading vehicles are recommended to remain in the vehicles, and must clean their hands when loading and unloading goods. Contactless communication such as walkie talkie and mobile phones are preferred instead of a close conversation. The electronic paperwork must replace the traditional paperwork in order to reduce physical contact between workers. Furthermore, the workers must be divided into small groups and group members are not interchangeable. The workers must be cross-trained and alternative sources must be identified to facilitate works that require specific skills.

3.4. Health care services

The health care workers must clean their hands with water and soap before putting the face mask, face shield and gown on or when taking them off. The reusable PPEs must be cleaned after each use and cannot be shared with other workers. Meanwhile, the single use PPEs must be disposed of after each use in the biomedical waste bin.

The health care service providers such as the hospitals and clinics must limit the number of health care workers engaged with the patients [ 45]. Moreover, the number of patients in health care facilities must be minimised to reduce COVID-19 transmission. Only patients with appointments are allowed in the facilities. Furthermore, the patients must be punctual to their appointment time. The patients must go home immediately after consultation with their physician.

The health care service providers should provide a dedicated place to evaluate persons with COVID-19 symptoms. This can reduce the close contacts between the non-COVID-19 patients, suspected COVID-19 patients and health care workers. Moreover, persons with COVID-19 symptoms are advised not to visit hospitals or clinics without prior notice. Furthermore, COVID-19 patients must be treated separately from other patients. The dedicated wards for COVID-19 patients must comply with the WHO guidelines. Sufficient ventilation must be provided to each COVID-19 patient (288 m ³/h) to avoid airborne transmission [ 46].

If the health care facilities are overcrowded with COVID-19 patients, then the geofencing system can be used to ensure the COVID-19 patients remain at home for self-isolation and reduce the risk of the community from getting infected. For the high-risk group, stocking up medication is recommended to avoid frequent outings. Other than that, hospitals, clinics and pharmacies can deliver medications to their home.

Temporary accommodation should be provided to the health care workers as they are not recommended to go home, to avoid transmitting COVID-19 to their family. The health authority must ensure the welfare of health care workers is not overlooked. Hence, the health authority should provide food and essentials to them.

3.5. Elderly care

The older person is included in the high-risk group recommended by the WHO. Moreover, the older person may have the pre-existing conditions which can cause the severe implications if infected with COVID-19. In Sweden, 90% of the death cases were reported from the patients over 70 years of age. Half of them came from the care homes, while another quarter came from their own homes [ 47]. Because of that, the older person must be protected from contacting the COVID-19 infection.

The temperature gun or scanner must be used to measure the body temperature of the care workers, older persons and visitors at the entrance. Upon arrival at the entrance, the entire body, clothes, shoes and belongings will be sprayed with sanitiser for disinfection. The care workers, older persons and visitors with COVID-19 symptoms will be denied entry and must seek medical attention immediately. The number of visitors will be limited in order to reduce interaction with the outside community. All activities and events must be conducted in small groups to reduce close contact and close conversation. The mealtimes must be rescheduled to avoid mixing between them. Moreover, the disposable plates, cups and cutlery are preferred to reduce object sharing between the residents. The physical contacts and activities between the older persons and care workers must be reduced. The care workers must wear an adequate PPE such as the apron, face shield and face mask in the care home. Meanwhile, the older persons must wear a face mask. The older persons are recommended to stay in the care home to reduce exposure to the outside community. If not possible, the people who live with the older persons must minimize the physical and close contacts with the outside community. Moreover, the medical services can be provided in the care home instead of at the hospital, while medication must be taken at the right time.

3.6. Bodies management

The funeral must be conducted and attended by the close relatives. Only a limited number of visitors is allowed to attend the funeral. The social distancing and personal hygiene must be observed during the funeral. Moreover, the bodies must be certified free from COVID-19. The bodies of normal death cases must be screened for COVID-19 infection by the medical practitioner and only being given to the family if free from the disease. If the deceased is tested positive of COVID-19, then the body will be managed by the authority. This is to ensure no COVID-19 related deaths are undetected and to protect those who are managing the bodies. These persons can be infected from the deceased since there is an evidence that the virus can appear on the surface of the bodies [ 48].

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COVID-19 exit strategy: Transitioning towards a new normal

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The coronavirus disease 2019 (COVID-19) is transmitted from the release of droplets when an infected person coughs or exhales. Then, the released droplets will fall on the nearby objects and surfaces, thus contaminating them. A nearby person can be infected by touching fomites, and then touching their mouth and nose [ 1].

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A novel coronavirus, now called severe acute respiratory coronavirus 2 (SARS-CoV-2), began in Wuhan, Hubei province, China, and is now a public health emergency of international concern [,]. In the United States, the COVID-19 pandemic has led to widespread social distancing, shelter-in-place, and workplace closures. Because of concerns for healthcare resources in initial US pandemic modeling and the experience within New York City and surrounding areas, the US Surgeon General and the Centers for Medicare and Medicaid Services issued guidance to stop performing elective surgeries in the United States [, , ]. This recommendation was based on concerns for the quantity of personal protective equipment present within the United States. A recent report regarding the COVID-19 pandemic from the US Department of Health and Human services showed that hospitals are experiencing increasing costs and decreasing revenues which threaten their financial viability. Hospitals have reported that ceasing elective procedures and other services has decreased revenues while their costs have increased as they prepare for a potential surge of patients. Many hospitals reported that their cash reserves are quickly depleting, which could disrupt ongoing hospital operations []. As predictive models of the impact of COVID-19 on the United States continue to be refined with more data, the delivery of healthcare services outside of COVID-19 must be addressed.

One of the more commonly cited COVID-19 projection models is produced by the Institute for Health Metrics and Evaluation at the University of Washington. Their current projections show that April 11, 2020, will be the day with maximum resource utilization (intensive care unit beds, ventilators) within the United States. This model assumes that social distancing will be in place until the death rate from COVID-19 falls below 0.3/million people, or likely through the end of May. It also forecasted zero deaths in July and August from COVID-19 if appropriate measures, including mass screening, contact tracing, and foreign national testing upon entry to the United States, and quarantine of infected patients are put in place to guard against the reintroduction of COVID-19 from another state or country. Historical examples like the "1918 Spanish flu" pandemic show that multiple waves of the viral diseases occurred over many months. In the 1918 pandemic, the highest mortality was in the second wave (fall) of 1918. The 2002 severe acute respiratory syndrome (SARS) and the 2009 H1N1 swine flu did not follow similar patterns as the earlier pandemic. Indeed, the evidence suggests that there is no predictable temporal patterns for major viral influenza pandemics [].

The 2020 COVID-19 pandemic has drastically negatively affected the US economy. While the traditional definition of a recession necessitates 2 quarters of economic downturn, many have already referred to the United States as in a recession []. A systematic review showed that economic downturn generally decreases the volume of most elective surgical procedures, although a few procedures increased in volume []. One study reported that the rate of cancellations of total joint arthroplasties was increased during the last economic recession and appeared to be related to unemployment and consumer confidence []. Conversely, another study using the US Nationwide Inpatient Sample showed that the 2007 economic recession did not substantially influence growth trends in total hip and total knee arthroplasty. Importantly, the acute economic downturn could result in the loss of employer-provided healthcare insurance for 12 to 35 million people, with an increase of 11 to 13 million people enrolled in Medicaid, and the number of uninsured could increase to 40 million with bigger impacts in Medicaid nonexpansion states []. The economic downturn and associated volatility have the potential to meaningfully impact the volume of elective total joint arthroplasty procedures.

As the medical system looks ahead to resume elective arthroplasty cases, there are certain financial issues to be considered. As with the so-called practice of "cherry-picking" and "lemon-dropping" of patients based on the case complexity and resource requirements, an analogous scenario exists with the payer mix. By the time elective surgeries are resumed, the medical system will be under considerable financial strain due to a several month hiatus of incoming revenue. As such, there will be enormous pressure to quickly ramp-up surgical volume to meet both the financial needs of the institution and the medical needs of the large cohort of patients whose surgical procedures were put on hold because of the COVID-19 pandemic. There could very well be a tendency to prioritize patients with straightforward cases who have minimal comorbidities and insurance plans with favorable reimbursement fees. Previous studies have demonstrated that patients with increased medical comorbidities can increase the risk of postoperative complications which can lead to increased costs to the medical system [, , , , , ]. It has also been shown that economically disadvantaged patients have lower function and quality of life before and after total joint arthroplasty [,] and experience higher risk of certain complications and use more resources after primary total joint arthroplasty when compared with noneconomically disadvantaged patients []. With this in mind, there is potential for a widening disparity of care for those who are most vulnerable and for the underserved to become even less served [,]. It remains to be seen how the systems will address these potential disparities while striving for economic stability.

The resurgence of elective surgeries will likely require abundant administrative resources. In order to meet these demands, optimizing hospital and practice administrative resources for scheduling surgeries, obtaining pre-authorization (when necessary), and coordinating preoperative medical clearances will be critical to avoid an overwhelming situation. Moreover, insurance companies will need to be ready on their end to process the large number of pre-authorization requests. It is unclear whether the healthcare administrative and payer infrastructure will be able to withstand the potential vast increase in surgeries in the post-COVID period.

For academic programs during this time period, financial regrowth and optimizing efficiency may be at odds with resident and fellow education. Previous reports have demonstrated longer operative times, greater healthcare resource utilization, longer hospital stays, and higher costs at teaching hospitals [, , ]. Balancing the need for efficiency and cost mindfulness with the need to educate residents and fellows in the operating room may be challenging. One solution to this may be to utilize existing midlevel staff (ie, physician assistants and nurse practitioners) to help with the increased caseload and overall throughput in the hospital and thereby facilitate attending surgeons' ability to continue with resident and fellow education. Also, to address the backlog of postponed surgeries and remain efficient, hospital systems may need to utilize multiple "flip rooms" with extended hours into the evening and weekends. Initially this may result in an increased overhead as there will a time lag between the start of elective surgery recommencing and receipt of payments. But over time, the revenue stream will be revived, and hopefully economic equilibrium will be achieved.

Aside from the financial implications, logistical planning as it relates to handling of known positive or suspected COVID-19 patients is still under discussion. At the time of this writing, the only tests available for detecting the virus are nasopharyngeal swab or bronchoalveolar lavage polymerase chain reaction rapid testing for the SARS-CoV-2 genetic material. Some institutions with capacity for testing have implemented preoperative testing for all preoperative patients. For nonemergent, urgent elective cases, a COVID-19 test is obtained 48 hours before the scheduled procedure. If test is negative, then surgery may proceed as scheduled with patient and surgeon understanding that the true false-negative rate for testing in asymptomatic patients is unknown. However, if the test is positive and the procedure can be delayed, the surgery is rescheduled for a later date.

Antibody testing may be another means to assess patients' COVID-19 status. There is still only preliminary data regarding the antibody response that occurs after exposure to the novel coronavirus. In a recent study out of China, the median duration of IgM and IgA antibody detection was 5 days, while IgG was detected 14 days after symptom onset []. It remains unknown for how long the IgG antibody response will persist, and whether it will confer long-term immunity. Nonetheless, serologic testing for antibodies to the SARS-CoV-2 virus is under development for clinical use. On April 1, 2020, the Food and Drug Administration approved the first commercial serologic test in the United States. It is anticipated that there will be several commercial tests available in the near future. Antibody testing would provide a clearer understanding of the prevalence and fatality rate of the disease, because it could identify patients who had the virus even if they had mild or no symptoms. The widespread utilization of antibody testing may also have a large impact on the clinical care pathways for arthroplasty patients as it may have implications for an enhanced ability to segregate patients into known immune and nonimmune categories (if the case for long-term immunity can be proven with IgG antibody detection). This may facilitate the establishment of separate COVID-19 and non-COVID-19 zones within a hospital or perhaps even the designation of dedicated COVID-19 and non-COVID-19 hospitals.

This also raises the question of how to maintain underutilized staff within the hospital during the ongoing pandemic surge and keep them healthy and prepared to resume elective surgical procedures once the temporary restriction is lifted. There have been some reports of health systems cutting the salaries of underutilized medical staff or even furloughing them during this crisis []. Other health systems have proposed repurposing staff to help with the overwhelming number of COVID-19 patients that are engulfing much of the financial and manpower resources within the hospital systems. With the passage of the recent Coronavirus Aid, Relief, and Economic Security Act ("CARES Act"), $100 billion has been made available to "eligible healthcare providers" for healthcare-related expenses or lost revenues attributable to the COVID-19 pandemic. This influx of emergency financial assistance may help offset lost revenue during the pandemic and permit the preservation of a healthy workforce which would be well prepared for redeployment.

Another issue which will likely require significant attention is how to decide which patients should receive priority for proceeding with surgery once elective surgeries are reinstated. It is likely that elective procedures will slowly be reinstated in a staged fashion over a period of weeks to months once the surge has passed. Because SARS-CoV-2 is a newly identified pathogen, there is no preexisting immunity to it in the human community, and there is no definitive cure to treat the disease. This is problematic for all patients. However, the elderly, those with underlying chronic conditions, and those with weakened immune systems are particularly vulnerable. From the early experience with COVID-19 in China, it was reported in a recent JAMA article that those aged 70 to 79 years had an 8.0% case fatality rate (CFR), and in those aged 80 years and older the CFR was 14.8%. The CFR was notably elevated among those with preexisting comorbid conditions-10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer []. In a recent meta-analysis from China which evaluated 46,248 infected patients, it was noted that hypertension, respiratory system disease, and cardiovascular disease were significant risk factors for patients infected with the SARS-CoV-2 virus to develop severe disease compared to patients who had nonsevere disease []. A recent study from Wuhan, China, reported on 34 patients who were in the incubation period of infection with COVID-19 and were unintentionally scheduled for elective surgery. Postoperatively all 34 patients developed pneumonia, and 44.1% of the patients needed intensive care unit care, and 20% of the patients died []. This mortality rate is much higher than the reported overall CFR of 2.3% in COVID-19 patients without surgery []. The authors also noted a shorter onset of severe symptoms in this group of postsurgical patients compared to other reports of nonsurgical COVID-19 patients. Because of this and the overall significantly higher mortality rate, the authors hypothesized that surgery may accelerate and exacerbate disease progression of COVID-19 []. As such, it may be reasonable to initially restrict elective arthroplasty to those patients without significant medical comorbidities during the early stages of resuming elective procedures when there will still be some degree of COVID-19 patients present in the hospital. This could minimize the risk of postoperative patients developing severe disease should they be exposed and infected with the coronavirus. Analysis of US Medicare data reveals substantial regional variation in patients at the highest risk, and rates of arthroplasty resumption may concomitantly differ []. As the census of COVID-19 patients begins to diminish, it may then be safe to reintroduce patients with more concerning comorbid diseases into the hospital setting to undergo elective surgical procedures in parallel pathways of care.

One of the considerations moving forward is to further increase the volume of outpatient arthroplasties in a nonhospital setting. This approach is attractive because an ambulatory surgery center located remote from a hospital might be better able to isolate and prevent the spread of the coronavirus. Over the past decade, there has been increasing interest in performing primary hip and knee arthroplasty in the outpatient setting, with these procedures having been successfully performed during the past decade by a select group of surgeons and institutions with multidisciplinary care team coordination, standardized perioperative protocols, discharge planning, and careful patient selection [, , , , , , , , , , , , , , ]. Multiple systematic reviews have reported that outpatient arthroplasty is safe and effective [,,]. In 2018, the American Association of Hip and Knee Surgeons, Hip Society, Knee Society, and American Academy of Orthopaedic Surgeons put forth a position statement supporting the notion that some primary hip and knee arthroplasties can be appropriately and safely performed in the outpatient setting with discharge on the day of surgery provided strict preoperative patient selection, standardized perioperative protocols, safe discharge plans, and sufficient practitioner and surgeon experience are maintained []. The current COVID-19 pandemic may impel an increased utilization of outpatient surgery centers for primary total hip and knee arthroplasty in appropriate patients in order to disencumber the strain currently placed on hospital systems managing patients with COVID-19 disease.

Regardless of the location of the procedure, it is likely that there will be increased demands placed on surgeons to handle the large volume of procedures that will need to be performed over the course of the next several months. Questions will arise as to how we as surgeons will meet this demand, maintain quality care and safety for our patients, and protect ourselves from COVID-19 exposure and from fatigue and surgical errors. Discussions are already occurring regarding increased operating room (OR) volumes with extended hours into the evening and weekends []. Such an increased work burden will undoubtedly place additional stress on surgeons, anesthesia staff, residents, fellows, physician assistants, nurse practitioners, nurses, and surgical technicians which may lead to physical and mental fatigue as well as strain on their mental health and overall well-being. Fatigue has been described as both physical and mental weariness and has been shown to negatively impact surgeon performance []. Recent literature has also described another component of fatigued performance known as "decision fatigue" which describes a declining ability to repeatedly make critical decisions-independent of physical or mental weariness []. A 2003 study of surgical errors by Gawande et al [] found that 16% of self-reported surgical errors at 3 teaching hospitals in Massachusetts were attributed to surgeon fatigue. A similar study among Harvard orthopedic residents found that those functioning at a fatigued, sleep-deprived level demonstrated a mean 22% increased risk of medical errors attributable to fatigue []. The number of cases being performed in a day along with the case order is also important. A recent study demonstrated that surgical case order is an independent risk factor for adverse events in arthroplasty procedures, with procedures performed later in the day having a higher risk of arthroplasty-specific adverse events (but not for systematic adverse events). Significantly increased operative time, higher cost, and longer length of stay were noted for fourth or later arthroplasty cases ( P < .01) [].

Taking this all into consideration will be critical to developing a safe and efficient strategy for moving forward once elective surgeries are reinstated. Fatigue risk mitigation and enhanced safety strategies have been outlined by Janofer et al. Key components include comprehensive preoperative planning, promoting fatigue awareness, and taking intraoperative "microbreaks" []. Some of the key applications of these strategies include establishment of clear operative team roles, responsibilities, and assigned tasks in a preoperative team brief; reduction of need for extra intraoperative decisions; optimization of surgeon sleep, nutrition, and hydration to maximize surgeon endurance; and establishment of a detailed backup contingency plan []. Preoperative safety checklists are another procedural safeguard to help ensure patient safety. It has been shown in multiple studies that performance of a preoperative safety checklist reduces wrong site surgery, improves timely administration of prophylactic antibiotics, and decreases postoperative complications and mortality [,].

How to optimally balance the needs for processing a large surgical volume with patient and staff safety will likely be varied and institutionally dependent. However, there have been several reports in the literature outlining integral strategies to successfully yield high operative efficiency and productivity. An article by Attarian et al [] reported improved OR efficiency and productivity via improved communication, elimination of silo mentalities, enhanced team work, and high-efficiency OR teams adapting parallel processing. Implementation of these types of strategies, particularly enhanced communication with anesthesia, OR staff, and central processing for short turnover times, will be crucial for high efficiency and productivity. One of the more profound tenets identified in this article for the success of the program was "sincere gratitude to the team players every day" []. During this critical time, the importance of such a creed cannot be overemphasized. In addition, clear communication with industry vendors during this time will also be essential for ensuring the necessary instruments and implants are available, especially if supply chains are disrupted or not fully replenished to keep up with the heightened demand.

Temporary regulatory changes could help the nation's surgeons meet pent-up demand, especially if surgeons have been sharing off/on rotations. In academic medical centers, allowing more liberal overlap of routine procedures with resident assistance would increase efficiency. Many programs have developed new active and remote resident rotations; guidance from the Accreditation Council for Graduate Medical Education (ACGME) and/or the Residency Review Committee (RRC) on tracking compliance with the 80-hour workweek during the pandemic would help avoid multiple disparate interpretations.

Many patients are limited in terms of expertise with the technology to be reached through telemedicine. Temporary relief of certain Health Insurance Portability and Accountability Act (HIPAA) requirements has been granted from the Department of Health and Human Services' (HHS) Office of Civil Rights through notification of enforcement discretion that allows for temporary use of more commonly used video and messaging products so long as they are "nonpublic facing" [,]. This could make communication smoother and help reduce telephone "tag." Temporary allowance to use smart phones in this fashion would allow virtual rounding through nurses or physician assistants on stable patients at hospitals separate from the one where the surgeon is busy in the OR and would diminish hospital-to-hospital contamination. It is recommended that the reader familiarize oneself with the details of this temporary change and be prepared for its ending.

Younger surgeons are facing added stress, and the American Board of Orthopaedic Surgeons could help relieve that part arising from meeting certification requirements. This has occurred in part already on April 8, 2020, with the American Board of Orthopaedic Surgeons announcing changes to the case collection period []. They had already allowed for time away limits to be averaged over time. They have yet to change the dates for written and oral boards in July of this year; given the disruption, postponing both by 4 to 8 weeks would probably be welcomed by applicants. Finally, failure on the written boards is usually accompanied by notification that the applicant is unable to self-describe as "board eligible" until passing; again, given the disruption, relaxing that rule to allow for one failed examination before receiving that status could be understood to be a one-time exception.

All normal timelines should be negotiable. A collective action by fellowships to allow for an extra month before new fellows start would allow the programs to keep their current fellows an extra month if outside practices and hospitals do not have the reserves to hire at this time. The funding for graduate medical education could be revised for 1 year to allow for current chief residents to stay as instructors with a salary increase for 1 or 2 months awaiting to start fellowship. In both cases, the more site-specific efficiencies would be maintained and the pandemic curve allowed to reach its nadir before multiple young physicians move from one medical center to another throughout the country.

There has already been noteworthy short-term regulatory relief from the Centers for Medicare and Medicaid Services [,]. It would help if the overlapping procedure rules when with residents could be relaxed such that the key or critical presence component has been physically met for routine cases without having to document an available second surgeon. The Center for Medicare and Medicaid Innovation had proposed a 3-year extension of the Comprehensive Care for Joint Replacement (CJR) alternative payment plan/bundle with new rules; the current CJR has been extended to March 31, 2021; in addition, caps on expenditures were placed 30 days before and during the declared national emergency, and the Extreme and Uncontrollable Circumstances policy applied to CJR, MIPS, and ACOs [,]. COVID-19 is a new disease affecting the population broadly with yet to be defined long-term consequence for those who become ill, especially those of Medicare-eligible age. The risk adjustments for CJR, Value-Based Purchasing, the Readmission Reduction Program, and the hospital-specific and surgeon-specific cost measures are now hampered. The disease and its aftermath could arguably warrant a new hierarchical condition category to be considered in federal performance measure risk models. Knowing its full impact may take time and clearly is going to be regionally disparate; temporarily lifting those measures and their financial impacts could avoid undue burdens on the hospitals of the regions hardest hit.

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After the COVID-19 Pandemic: Returning to Normalcy or Returning to a New Normal?

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A novel coronavirus, now called severe acute respiratory coronavirus 2 (SARS-CoV-2), began in Wuhan, Hubei province, China, and is now a public health emergency of international concern [,]. In the United States, the COVID-19 pandemic has led to widespread social distancing, shelter-in-place, and workplace closures.

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When will life go back to normal post Covid-19? It's a question people are increasingly looking for answers to; for some it's prompted by the horrors of a prolonged lockdown and an unspoken fear that we could be facing the same again next winter.

The short answer is that life will never return to a pre-pandemic normal. The novel coronavirus isn't going to disappear, and so our lives will change. The real question is: to what degree?

The most likely scenario is that Covid-19 will circulate just like influenza, with a seasonal burst of infection. Many of us will require annual vaccination against the coronavirus, in the same way we need a flu jab.

Prof Adam Finn of the University of Bristol predicts an "endemic epidemic picture" as occurs with flu, where the virus "constantly changes to evade our immunity so we're always playing catch-up with it and it moves around the world with the seasons to find populations with insufficient immunity".

Endemic viruses are those that have constant presence within a geographical area. Examples include the rhinovirus and influenza virus. There are currently four endemic coronaviruses that, for most people, just cause a common cold. Whether SARS-CoV-2 will join them will be down to two main factors that control how a virus behaves in a population: the virus's biology and the immunity of the host population.

According to Dr Grace Roberts, a research fellow in virology at Queens University Belfast, "with Covid-19, it seems that children have milder illness, while more severe disease tends to appear in people over 60. Given this, if lots of people develop immunity early in life (whether via infection or vaccination), over time this could tip the balance towards SARS-CoV-2 being a mild illness if we assume that young people retain some level of immunity throughout life".

Speaking to the UK medical magazine Pulse, Dr Peter English, chair of the British Medical Association's Public Health Committee, says there will come a point where healthcare leaders "decide to allow the virus to circulate more widely while expecting there to be fewer serious cases".

At what point can we say the damage of lockdown outweighs the health benefits?

This scenario may be acceptable to most, but in order to achieve it, vaccination uptake will need to remain high. And the more we can get the number of cases down, the fewer opportunities there will be for mutations to arise.

But what would it mean if vaccine uptake decreases and new variants reduce the effectiveness of vaccines? Poor uptake would allow the virus to evolve away from the vaccine. Dr English says this would mean an "arms race" between vaccines and the new mutations. He doesn't expect to see a vaccine for the South African strain before "mid to late autumn". However other experts have said they are confident modified versions of the jabs can be developed quickly.

There are so many variables at play: the efficacy of the vaccines against transmission; how successful future treatments may prove to be; whether vaccination acceptance remains high; and how the virus mutates.

Mental health

But alongside the science, there are important societal issues. At what point can we say the damage of lockdown outweighs the health benefits? When does ongoing harm to our mental health trump the number of infections? And at what point do we decide that the dire economic effects of lockdown must be reversed even as zero Covid eludes us?

Certainly, there will be no silver bullet moment of sudden liberation from Covid-19. Instead, society will have to continue to manage a complex array of risks as the pandemic evolves.

My personal guesstimate of our new normal looks something like this: an annual Covid -19 vaccination campaign; an acceptance of a certain level of morbidity and mortality from coronavirus as we currently do with influenza; and, regrettably, a big question mark over our freedom to travel internationally.

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When - or will - life ever go back to normal?

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When will life go back to normal post Covid-19? It's a question people are increasingly looking for answers to; for some it's prompted by the horrors of a prolonged lockdown and an unspoken fear that we could be facing the same again next winter.

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Recently there has been a gradual shift in the COVID-19 discourse based on an acknowledgement that clearer communication is needed to manage public expectations. Although not directly factored into this shift of tone, the so-called fatalism effect can teach us something. This concept essentially warns that if a problem is characterised as nearly insurmountable then many people will just give up. These people surmise that the cost of the intervention is not worth it, given they perceive that the cost yields little benefit. Conversely, it is also important to guard against overly optimistic assessments, such as those from certain governments relating to a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. Many governments have confidently asserted, without due consideration of the consequences, that a vaccine will abruptly end the pandemic.

Given the potential for misunderstanding at this point, let us be clear: an approved vaccine will be beneficial and its uptake should be strongly encouraged, but it can only be a part of the solution. The reason a vaccine cannot be the complete solution is illustrated with the three vaccine scenarios recently put forth by Zain Chagla, Isaac Bogoch, and Sumon Chakrabarti: a vaccine that prevents nearly all person-to-person spread (presumably also halting illness; scenario 1), one that prevents some spread and reduces severe illness and death (scenario 2), and one that does not prevent spread but reduces severe illness and death (scenario 3). At this stage of clinical assessment it is difficult to be certain whether the real vaccines will fit into scenario 2 or 3. They are unlikely to fit into scenario 1, although even this scenario would not be an instantaneous solution given the mind-boggling logistics of delivering a vaccine to over 7 billion people.

All the vaccine scenarios will require that the mitigation measures employed worldwide continue for a few years at least. Of course, the scenario 1 vaccine would, in time, allow us to reach a point where other measures to prevent transmission of SARS-CoV-2 become unnecessary. Ideally, in a show of global solidarity, the measures would be retained until the world had largely brought COVID-19 under control. However, it would be naive to assume that individual nations would not lift restrictions as soon as possible. The other scenarios are more tricky propositions and illustrate that political optimism can be genuinely dangerous. If we use the scenario 3 vaccine as our example, this might eliminate severe and potentially deadly disease in those able to receive the vaccine, but the virus would still be able to spread through the population unhindered. So those unable to receive the vaccine, a group which overlaps with many groups current measures are protecting, would be unprotected.

For months many governments have proclaimed that a vaccine is the complete solution, without any mention that not all potential vaccines will fill this role. Nonetheless, some quarters will push to roll out a vaccine, irrespective of its properties, and abandon other measures. It is not unreasonable for the public to expect this drive, given the failure to manage expectations to date. In this setting most people would experience little disease but those who currently are at greatest risk would find themselves completely exposed. This would be an inversion of the underlying principles guiding current interventions. Some might see this characterisation as absurd, but we have seen the world over how easily physical distancing seems to have been abandoned when people are led to believe, deliberately or otherwise, that new measures replace rather than complement earlier interventions.

Often it is difficult to offer solutions, but it is straightforward in this case: interventions that have been in use since early in the pandemic, most crucially physical distancing and hand hygiene, must continue indefinitely. The benefits of these simple measures will have far-reaching implications as shown in a news story in this issue by Paul Adepoju, which describes how work to control neglected tropical diseases has benefitted from the drive for improved hygiene in response to the pandemic. It might be that the vaccines that ultimately become available are more like those described under scenario 2: slowing transmission in addition to limiting illness and death. This scenario will be more welcome than scenario 3 but will not change the need to maintain earlier interventions in place. It is time to forcefully impress on people that basic measures to limit the transmission of SARS-CoV-2 are here to stay. This is the new normal.

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COVID-19: we will not be returning to the old normal

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Recently there has been a gradual shift in the COVID-19 discourse based on an acknowledgement that clearer communication is needed to manage public expectations. Although not directly factored into this shift of tone, the so-called fatalism effect can teach us something.

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Rebuilding after COVID-19 shouldn't mean going back to how things were

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The third stage - rebuilding - following a catastrophe requires the most imagination, but it will be needed more than ever in the aftermath of coronavirus.

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Underpinning much of the recovery work are those working in health and care themselves. We already know the toll Covid-19 is having on the health and care workforce, with rising demand and shortages of protective equipment leading to increasing stress, exhaustion and burnout .

Evidence from disasters across the world shows that, in addition to managing the initial burden, people who work in health and care are also at an increased risk of developing mental health problems following disasters, such as post-traumatic stress disorder (PTSD), depression, anxiety and compassion fatigue. In Fukushima, Japan, following the earthquake in 2011 this culminated in high levels of absenteeism among health care workers for up to 18 months after the disaster, with nurses experiencing significantly greater stress levels than the general population four years after the disaster. If the health and care workforce is to support communities through recovery, it needs to be recognised and supported as a community with its own needs.

In Christchurch, New Zealand, health leaders understood the connection between the health and care workforce and the community. The local health board continued to support and develop community-based health and care services, despite much of the physical infrastructure being destroyed by the earthquakes. Carolyn told us:
There were two reasons for doing it. One was to make sure that we didn't get workforce flight... But secondly, it sent a really strong signal to our community that everything else may be going to hell but your health system is okay. They are still there. They are still delivering services every day. You know, your GP is still there.
So, what strategies or actions could help health and care staff recover and build resilience in teams?

Leading in disaster recovery, a pocket book of wisdom from more than 100 recovery leaders, makes one thing clear: usual methods of support for staff are not enough - more is needed.
Your team not only provides support to disaster-impacted people but are also likely to be impacted themselves. Understand the load they carry, how long they will carry it for and work with them to make it manageable. Even the most capable and resilient people need support.
Staff need to be given the time, space and resources to recover, which might include adequate breaks and time off following intense periods, a supportive work environment, access to training and education programmes and access to psychological support. In New York following the 9/11 attacks, Project Liberty sought to overcome the stigma around mental health support with a media campaign and free counselling service, with the slogan 'even heroes need to talk'.

Leaders at all levels need to recognise the importance and value of supporting the workforce and to consider their role in in helping this group to recover from such a significant and prolonged event. Evidence suggests that all health and care staff are at risk, regardless of the roles they took on during the pandemic. For example, following the SARS outbreak, staff who had been in contact with SARS patients were more likely to experience PTSD, as might be expected. However, further research has shown that health care staff as a whole - irrespective of their contact with SARS patients - experienced more psychological problems than the general population. It's not hard to imagine a similar response to Covid-19, given the disruption to people's work, the perceived risk of infecting family members, and the disproportionate impact of Covid-19 on the health care workforce. Just like the wider population, it's not easy to predict exactly who will need help.

Throughout the pandemic health and care staff have often been referred to as heroes, but this image shouldn't mask the reality of their experience. Many of the challenges facing the workforce are longstanding but have been exacerbated by the pandemic. Leaders should use this time to make wellbeing a priority, especially when under great pressure to deliver services at pace and 'get back to normal'. Longer term cultural change is needed to ensure collaborative, compassionate and inclusive working environments, with leaders at all levels tackling workload issues and leading cultural change to support them to provide the care they want to provide.

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Covid-19 recovery and resilience: what can health and care learn from other disasters?

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Underpinning much of the recovery work are those working in health and care themselves. We already know the toll Covid-19 is having on the health and care workforce, with rising demand and shortages of protective equipment leading to increasing stress, exhaustion and burnout .