Outlook

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without overwhelming hospital capacity would require an unlikely balancing of multiple poorly defined forces (Brett 2020).

Very few experts expected safe and effective vaccines to become available Christmas 2020. Modern technologies, massive funding, and both international cooperation and competition are making it a reality. However, even if vaccines are confirmed effective and safe soon, mass vaccination for COVID19 will be a huge logistic challenge and nobody should expect vaccines to have a noticeable impact on the SARS-CoV-2 pandemic before at least the summer of next year. In the meantime, people will need to be patient and continue to practice and observe the established alternative ways of protection.

Reducing the viral SARS-CoV-2 inoculum might not only reduce the probability of infection but also favor an asymptomatic infection while still generating immunity. A few papers (Bielecki 2020, Ghandi 2020; see also the comments to the paper by Rasmussen 2020, Brosseau 2020) suggested that if facial masking may help in reducing the size of the viral inoculum, universal facial masking might ensure that a greater proportion of new infections are asymptomatic. If universal masking could be proved to be a form of ‘variolation’ (inoculation), it would be an additional argument in favor of mandatory mask wearing.

At the beginning of autumn, many feared a second COVID-19 wave comparable to the devastating influenza pandemic during the autumn and winter 1918/1919 (Soper 1919). Fortunately, physical distancing (Bedford 2020) and –when needed – partial selective lockdowns have not allowed SARS-CoV-2 to play out its full potential. Now, with the first vaccine (BioNTech/Pfizer) approved in the UK and more vaccines and more approvals in other countries within reach, we can be confident: SARS-CoV-2 will not be like H1N1 and we have the tools and capacities to get through the winter (Bedford 2020). A month ago, we asked ourselves, ‘How long will SARS-CoV-2 stay with us? How long will it be before we return to pre-COVID-19 normalcy? For how long a combination of physical distancing, enhanced testing, quarantine, and contact tracing will be needed?’ We were skeptical, saying that ‘even vaccines might not have a substantial impact on the pandemic before 2024, if ever.’ We felt – and still feel today – that before mass vaccination, classical infection

Epidemiology | 53

control measures are the only way to reduce the number of infections and avoid healthcare systems from breaking down, leaving patients with other morbidities – common emergencies and surgery, cancer treatment, management of patients with chronic diseases – stranded and abandoned in a medical no-man’s land. In December 2020, however, we see the light at the end of the SARS-CoV-2 tunnel. The prospects are bright – vaccines for 99% of people who are at risk of severe COVID-19. This new future is still a few months away, though, and how long the vaccine-induced immunity will last is still unknown. Bright prospects should not induce the fateful error of lowering the guards. No nation should repeat this winter the errors of the past summer. Summer 2020 taught us that post-lockdown epidemic dynamics may be driven by younger adults with gradual ‘spill-over’ into older age groups. The formula ‘young adults -> parents -> grandparents -> death’ is clearly a simplistic model for the European second wave. SARS-CoV-2 is introduced and spread in communities via all conceivable routes. Yet, there are simple rules and behaviors than can minimize the need for local lockdowns and economic hardship. In situations of intense SARS-CoV-2 community transmission, the prevention triad is simple: 1. Stop people from meeting each other in large gatherings. 2. If they MUST meet, have them wear face masks. 3. In any case reduce the time infected or suspected infectious people meet any other people at all: test as much as possible, isolate cases quickly and track the close contacts. In transmission hotspots, restrictive social-distancing measures will need to continue to be combined with widespread testing and contact tracing to slow down the pandemic (Giordano 2020 + less realistic, Peto 2020). People should concentrate on the essential activities of providing food and shelter as well as continuing their job, school and university activities. All ‘après-work’ and ‘après-school’ activities should be reduced to a minimum (no evening bars, no night life). In such social slowdowns, people will need to avoid prolonged meetings with people from outside their inner-core “friends-and-family-bubble”, in particular social events which bring people from many different families together (e.g., marriages, funerals, religious events). Even inside the inner-core “friends-and-family-bubble”, meetings should be restricted to a handful of people. Economically, a social slowdown implies the temporary closure of places where foreigners, strangers or simply unacquainted people meet: discos, amusement parks, bars, restaurants, brothels and many more. In a situa-