Five key milestones in the Covid-19 pandemic that we’re anticipating in 2021

On the first day of fall, STAT published its best guesses of 30 moments to come in the pandemic that could mark a change in its course or serve as a time to reflect on how Covid-19 had reshaped our lives.

In reality, some of the turning points have turned out better than they could have. Schools, particularly for younger children, seem to be safer than initially feared, although many students continue to be stuck with virtual classes. Separately, the vaccine regulatory reviews rebuffed potential political interference, with the candidates going through the process of obtaining emergency authorization with the regular rigor.

At the same time, the U.S. epidemic has grown even more dire. We knew the fall would be bad, but with new records of infections, hospitalizations, and deaths regularly being set, and many states not implementing intensive strategies in response (to say nothing about any sort of federal initiative to rein in transmission), the outlook continues to worsen. As an example, we had speculated the country would hit 250,000 deaths from Covid-19 in late November. Instead, the country crossed that mark in mid-November, a sign of how transmission accelerated.

Now, we’re taking another look ahead, to milestones in the next year that we’ll be watching to see if and how they redirect the pandemic and what they signal about the progress in the fight against the coronavirus.

If 2020 was defined by the explosion of the SARS-CoV-2 virus, 2021 could be about its dwindling. But how many people will fall ill, and die, as that happens is dependent on our leaders, individuals, vaccine makers, and public campaigns to encourage people to get the Covid-19 shots developed with unprecedented speed.

As always when making forecasts, some of these moments could take place in different ways or at different times than charted out below.

Jan. 20 — Inauguration of Joe Biden

With the president-elect’s team already telling people to stay home for the inauguration, the formal start of the Biden administration won’t look like past transition-of-power ceremonies. The absence of throngs of people on the National Mall will be a stark reminder that the top job for President Biden will be Covid-19.

His administration will take over the vaccine rollout, ensuring that the logistical web of distributing hundreds of millions of doses continues apace and that Americans get the shots as they become available. But Biden will also likely be inheriting an out-of-control viral outbreak in some places. He won’t be able to snap his fingers and put the country on a new path immediately, but there could be a more forceful federal campaign to rally the country to slow transmission.

Biden has been modeling the precautionary behavior experts say can put a drag on spread, and has urged Americans to wear masks. His advisers have previewed that a Biden administration will get more involved in efforts like procuring testing supplies and PPE. And he’ll need to chart the country’s recovery from the ongoing economic fallout.

Biden has stressed that he’ll let science lead the U.S. Covid-19 strategy. Expect to see more briefings from career government employees. Biden’s health officials will become leaders of agencies that to varying levels have been subject to intervention from the Trump White House and suffered reputational blows. Restoring credibility and independence will take time, but the task for the Biden administration starts on this day.

Late January — 400,000 deaths

The country hit 300,000 deaths from Covid-19 in the middle of December, so it seems unbelievable that another 100,000 could be dead by the end of January. But with more than 2,000 or even 3,000 people dying some days, that’s how quickly the toll goes up. Given the number of people currently infected, transmission at the levels it is, and the resistance to the most extreme interventions in many places, the ball is already rolling.

A cognitive dissonance will pervade early 2021. Based on the number of hospitalizations and deaths, the U.S. epidemic could be at its worst point yet. At the same time, more and more people will be getting vaccinated. The disconnect shows how deep of a hole the country is in, and how it will take months for enough people to get immunized to noticeably reduce the number of new symptomatic cases.

Care for Covid-19 has improved over the months, and people are now more likely to survive an infection than in March (that is, as long as hospitals aren’t overwhelmed). But that progress has come in the absence of groundbreaking treatments cooked up for Covid-19. U.S. regulators approved the antiviral remdesivir to treat hospitalized patients, but it’s just been shown to speed recovery, not to save lives. Monoclonal antibodies can help people with mild illness from progressing to more serious disease, but they have run into issues reaching patients. It’s still not clear whether convalescent plasma is effective for Covid-19. In fact, the most important therapy for the pandemic has been an old, cheap steroid called dexamethasone, which has been shown to reduce deaths in people with the most severe cases.

Scientists far outpaced expectations as they developed vaccines in record time, but they have not had the same success with therapies. That could change in 2021, however, with oral antivirals from Atea Pharmaceuticals and Merck/Ridgeback Biotherapeutics, for example, among a number of possible treatments moving through clinical trials.

End of June — Status update on vaccinations

There are various estimates for when vaccines will be widely available to Americans. But during the first half of the year, supplies from Moderna and Pfizer/BioNTech will grow, and the U.S. could also see the arrival of shots from such companies as Johnson & Johnson, AstraZeneca, and Novavax, depending on clinical trial data and regulatory authorization.

Let’s say (hope?) that, broadly, Americans will have the opportunity to get immunized in the first half of the year (at least adults — vaccines for children might not be available until later). The question then becomes, how many will do so? Polling data has indicated a warming toward the shots among people who had been hesitant about the vaccines, and experts think that seeing millions of people get what trials have shown to be highly effective vaccines will reassure some who might have otherwise been nervous.

But as scientists are quick to say, even the best vaccines won’t do much unless lots of people get them. The purpose of the vaccine campaign is to get as much uptake as possible — the way to get to herd immunity, and an end to the pandemic. By the start of the summer, we should have a good idea of whether the campaign is finding success in connecting with target communities — including people of color and those who don’t have access to regular medical care — and what portion of people are willing to roll up their sleeves.

July 23 — The Olympics begin in Japan

The games, originally scheduled for 2020, will begin in Japan after more than a year when big gatherings were verboten in many places and international travel evaporated. What will this Olympiad look like? Will fans be streamed in virtually like in the NBA bubble? What kind of testing and quarantine steps will athletes, coaches, and trainers have to pass through? It might be jarring for competitors from places that have successfully contained the virus to endure such a rigmarole that’s required because other countries haven’t put a lid on their epidemics.

But we’re not just interested in the Olympics to see how organizers pull off such a massive event. By the time the starter’s pistol fires for this ultimate expression of international goodwill, there could be a massive global divide in vaccine coverage. Wealthy countries have been trying to scoop up as many millions of doses as possible for themselves, while experts have warned that immunizations won’t be more widely available in some low- and middle-income countries until 2022. Depending on the success of campaigns to broaden vaccine access, it’s possible that by the summer, countries will still be competing for vials, not just for medals.

November and December — The holidays

The holidays in 2020 were a lonely stretch for some, and the source of infection for others who didn’t heed warnings not to travel nor to celebrate with people outside their households. A year later, the festivities should be much safer, and jollier to boot.

But what an end to a pandemic looks like remains abstract. It won’t just happen one day, like waking up on Christmas morning. Experts describe a gradual easing of restrictions and strategies, as more activities we’ve spurned become safe again as the virus recedes. SARS-2 likely won’t be eradicated, and cases could crop up if not enough people get vaccinated. But if all goes to plan, the holidays — at least in the U.S. — should be a time to celebrate making it through, and perhaps to consider all that was lost.

Still, we won’t be free of the ghost of Covid past. The effects of the pandemic will be felt for years to come. At a minimum, scientists will still be studying the long-term protection and effects from vaccines, which will affect how frequently people will need booster shots. They’ll also be on the lookout for significant mutations to the virus, like those that emerged recently in the U.K., that could potentially allow it to evade the protection afforded by the vaccines — and for other pathogens that could ignite the next pandemic.