Treating COVID-19 as an endemic illness will have far-reaching consequences for Missouri and other states that follow similar paths (photo by Sean Gallup/Getty Images).

The state of Missouri is planning an official end to the COVID-19 pandemic as a public health crisis and will transition to treating the virus as endemic, much like it does the seasonal flu.

The target date for when Missouri’s public health agencies would begin treating COVID-19 as endemic is mid-March, the two-year anniversary of when the virus first showed up in the U.S., according to internal meeting notes. 

But the Missouri Department of Health and Senior Services said in a statement that no specific date has been set. 

“There is no set timeline in place,” the department’s spokeswoman said in a statement. “When the time is right, we believe our approach is sensible and flexible should the need arise to revert to standards of reporting, contact tracing and case investigations as they exist today.”

Treating COVID-19 as an endemic illness will have far-reaching consequences for Missouri and other states that follow similar paths, according to internal meeting minutes about the transition obtained by the Documenting COVID-19 project and The Independent as part of a Sunshine Law request. (The full PowerPoint presentation can be found here.) 

Missouri state epidemiologist Dr. George Turabelidze, according to meeting minutes, said the endemic change “will snowball really quickly once a few states move in this direction.”

Among the planned changes: 

  • Case investigations and contact tracing, where local health departments’ staffers reach out to people exposed to the virus in workplace or other public settings, will cease, unless a new, more transmissive or deadly variant emerges;
  • Daily reports on COVID-19 cases and deaths by the state health department will be replaced by aggregate weekly reports. In some cases, metro health departments, including those in St. Louis and Springfield, will likely continue collecting and disseminating daily reports but the state will stop its reporting;
  • Positivity rates will be phased out, as they are already difficult to interpret, with many Americans having switched from PCR tests to at-home antigen tests. Most people don’t report their results to local health departments. Missouri officials in January said they were prepared to be a “trend setter” in eliminating positivity rate reporting.
  • Hospitalization data will become even more important, with state health officials hoping to make reporting more timely;
  • Wastewater surveillance will become a more relied-on data point for public health officials, as a way to spot COVID-19 early in its life cycle and identify potential hot spots. Missouri is a leader in wastewater surveillance, as the state has the highest number of collection sites reported on a new CDC dashboard.

The state has been internally planning for the shift since December, even as the omicron variant of the virus surged across the U.S. The Missouri Center for Public Health Excellence, a nonprofit that represents local health departments on state issues, is working with its members “to help align our questions, ideas and opportunities for how we can all address COVID as a system,” it said in a statement. 

“We are happy to partner with the state on planning for the next phase of the pandemic,” the group said.

‘Crystal ball has been broken every time with COVID’

Missouri’s shift to treating COVID-19 as endemic is not wholly unexpected. 

The Biden administration has been working internally to shift its COVID-19 strategy toward an endemic model. The Association of State and Territorial Health Officials, which represents U.S. health agencies, has been convening calls amongst its members in recent weeks to develop guidelines and recommendations. 

Other states have begun working behind the scenes on endemic transition plans, including California and Colorado, hoping to bring a sense of normalcy given that many Americans have grown increasingly tired and frustrated with shifting public health messaging

Despite the trend, some epidemiologists have criticized the political use of the term “endemic,” saying that a desire to return to a pre-COVID normal doesn’t align with the actual science around how pandemics end.

Ellie Murray, an epidemiologist at Boston University’s School of Public Health who has been particularly vocal about this issue, has defined an endemic disease as “controlled at or below an acceptable level.”

This “acceptable” level is typically determined by health experts based on how much of a risk a disease poses to humans. But an endemic status shouldn’t lead to less data collection, Murray wrote in a recent Medium post. “Endemic means someone is ALWAYS thinking about covid,” she wrote. 

For the seasonal flu — a common comparison to “endemic COVID” — thousands of scientists and health providers work to monitor and respond to this disease each year.

Internal meeting notes from the Missouri Department of Health and Senior Services show the challenges in making a pivot like the one Murray described, going from an all-hands approach to combating the virus to something more like regular monitoring of the flu — albeit a pivot that is not tied to clear metrics indicating the disease has reached an acceptable level in Missouri.

Some metro local health departments, including those in Springfield and St. Louis, are expected to continue collecting case-specific COVID-19 data in order to track the virus’s spread in hard-hit communities. The state health department’s planning document notes that at least six health departments might have “issues” with the shift from daily to weekly reporting while also noting that the change could elicit “some criticism from media” and questions from the public. 

Some health departments have already stopped posting COVID-19 data after the state attorney general and a circuit court judge in Cole County said health departments can’t issue their own local COVID-19 orders.

“We do need to be thinking about entire systems of operation that need to switch, how data is collected, housed and disseminated,” said Lynelle Phillips, who serves as vice president of the Missouri Public Health Association and president of the Missouri Immunization Coalition. “We don’t have one singular system in Missouri and setting a timeline for having these discussions is good.”

And several public health experts have cautioned against setting a specific deadline for the endemic transition, as Missouri plans to do, given the ever-shifting nature of the virus and its variants.

“Most epidemiologists would say their crystal ball has been broken every time with COVID. I’m very leery of saying that, in March, this is all a good idea,” Phillips said. 

Waiting until COVID-19 infection rates were at a low, sustained level for at least two full incubation periods, possibly as long as four weeks, would help Missouri health departments prepare for the transition, said Enbal Shacham, an epidemiologist and professor of behavioral at Saint Louis University. 

“We had hoped for a quiet season last spring and summer and it didn’t happen,” Shacham said. “Unlike the flu, it doesn’t stay dormant.” 

But from a practical perspective, deadlines help policymakers, giving employers time to make operating decisions and agencies time to institute new reporting methods, said Dr. Georges Benjamin, a former emergency room physician who serves as executive director of the American Public Health Association, a nonprofit representing public health leaders.

“You do have to decide a date in which to go forward,” said Benjamin, who previously served as Maryland’s secretary of health.

Given declining cases and hospitalizations after the wintertime Omicron surge, Benjamin called the endemic transition process in Missouri “a reasonable debate.” Still, he said that three metrics related to the virus stand out as especially important to continue — hospitalization rates, community prevalence of COVID-19 and vaccination rates. 

155 wastewater testing sites in Missouri, and a few holdouts

The rise of wastewater surveillance as a trusted tool to identify COVID-19 variants and spread is somewhat new. Missouri is one of a handful states and jurisdictions that publicly reports weekly results of wastewater analysis, at 155 sewershed sites across the state. 

In early February, the CDC added wastewater tracking to its COVID-19 data dashboard. Wastewater has been an important COVID-tracking tool throughout the pandemic but it gained more public interest in recent months as omicron’s rapid spread showed its utility as an early warning system. 

Experts say this surveillance is particularly useful in the era of at-home rapid tests, because everyone is included in a sewershed regardless of whether they can access a PCR test that would be reported to the public health system.

Missouri’s wastewater surveillance system, which includes genetic sequencing for variants, identified Delta cases last summer weeks before PCR testing did. However, at the time, the state failed to respond to this wastewater warning; it wasn’t until beds were filling up in Springfield hospitals that DHSS provided additional resources to address the highly contagious variant.

Some public health officials caution that making wastewater results public could stigmatize local communities but those involved in wastewater sampling say testing sites cover large enough areas as to avoid individually identifying those who are infected.

“I am philosophically almost always in favor of transparency,” said Marc Johnson, the University of Missouri virologist who oversees the state’s wastewater work. “In Missouri, we started out limiting the information and have gradually made the information more public. So far, there have been no negative consequences from making data public that I am aware of.”

Just a handful of Missouri counties have opted out of the program, either citing a lack of funds to pay for sampling or some other political or privacy-related concern. 

One such example: In December, Macon County, a 15,000-population agricultural region of northern Missouri, rejected federal funding to continue wastewater surveillance. That amounted to roughly $100 per sample test for up to $6,000 per year,

The reason for the rejection is unclear but Macon County made headlines last summer when the local coroner acknowledged that he let families decide whether to omit COVID-19 as a cause of death on death certificates. 

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