REPORTS

Cite as: J. S. Lavine et al., Science

10.1126/science.abe6522 (2021).

Immunological characteristics govern the transition of

COVID-19 to endemicity
Jennie S. Lavine1*, Ottar N. Bjornstad2, Rustom Antia1
1
Department of Biology, Emory University, Atlanta, GA 30322, USA. 2Department of Biology and Center for Infectious Disease Dynamics, The Pennsylvania State University,
University Park, PA 16802, USA.
*Corresponding author. Email: [email protected]

We are currently faced with the question of how the CoV-2 severity may change in the years ahead. Our
analysis of immunological and epidemiological data on endemic human coronaviruses (HCoVs) shows that
infection-blocking immunity wanes rapidly, but disease-reducing immunity is long-lived. Our model,
incorporating these components of immunity, recapitulates both the current severity of CoV-2 and the

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benign nature of HCoVs, suggesting that once the endemic phase is reached and primary exposure is in
childhood, CoV-2 may be no more virulent than the common cold. We predict a different outcome for an
emergent coronavirus that causes severe disease in children. These results reinforce the importance of
behavioral containment during pandemic vaccine rollout, while prompting us to evaluate scenarios for
continuing vaccination in the endemic phase.

Humans have regularly been threatened by emerging patho- population in which older age-groups with no previous expo-
gens that kill a substantial fraction of all people born. Recent sure are most vulnerable to severe disease. We use our esti-
decades have seen multiple challenges from acute virus infec- mates of immunological and epidemiological parameters for
tions including SARS, MERS, Hendra, Nipah and Ebola. For- endemic HCoVs to develop a quantitative model for endemic
tunately, all were locally contained. When containment is not transmission of a virus with SARS-CoV-2 -like characteristics,
immediately successful, as is likely for the novel betacorona- including the age-dependence of severity. Our model explic-
virus SARS CoV-2 (CoV-2) (1, 2), we need to understand and itly considers three separate measures for immune efficacy
plan for the transition to endemicity and continued circula- that wane at different rates (fig. S1).
tion, with possible changes in disease severity due to virus Building on ideas from the vaccine modeling literature,
evolution and build-up of host immunity and resistance. immunity may provide protection in three ways (7). In its
CoV-2 is an emerging virus that causes COVID. The virus most robust form, “sterilizing” immunity can prevent a path-
has a high basic reproductive number (R0) and which is trans- ogen from replicating, thereby rendering the host refractory
missible during the asymptomatic phase of infection, both of to reinfection. We term this property immune efficacy with
which make it hard to control (3). However, there are six respect to susceptibility, IES. If immunity does not prevent
other coronaviruses with known human chains of transmis- reinfection, it may still attenuate the pathology due to rein-
sion, which may provide clues to future scenarios for the cur- fection (IEP) and/or reduce transmissibility or infectiousness
rent pandemic. There are four human coronaviruses (HCoVs) (IEI). Indeed, experimental reexposure studies on endemic
that circulate endemically around the globe; they cause only HCoVs provide evidence that the three IE’s do not wane at
mild symptoms and are not a significant public health bur- the same rate (8, 9). Callow’s experimental study (8) shows
den (4). Another two HCoV strains, SARS CoV-1 and MERS, that reinfection is possible within one year (relatively short
emerged in recent decades and have higher case fatality ra- IES); however, upon reinfection symptoms are mild (high IEP)
tios (CFRs) and infection fatality ratios (IFRs) than COVID- and the virus is cleared more quickly (moderate IEI). Details
19 but were contained and never spread widely (5, 6). on the derivation of the model can be found in section 2 of
We propose a model to explore the potential changes in the supplementary materials (SM).
both transmission and disease severity of emerging HCoVs We reanalyze a detailed dataset that estimates age-spe-
through the transition to endemicity. We focus on CoV-2 and cific seroprevalence based on both IgM (acute response) and
discuss how the conclusions would differ for emerging coro- IgG (long-term memory) against all four circulating HCoVs
naviruses more akin to SARS and MERS. Our hypothesis is in children and adults (10) to estimate parameter ranges for
that all HCoVs elicit immunity with similar characteristics, transmission and waning of immunity (see Fig. 1A). The rapid
and the current acute public health problem is a consequence rise in both IgM and IgG seroprevalence indicates that pri-
of epidemic emergence into an immunologically naïve mary infection with all four endemic HCoV strains happens

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early in life, and our analysis of these data gives us an esti- dynamics for higher R0, which are more akin to those of CoV-
mate for the mean age of primary infection (MAPI) between 2 in the absence of control measures. If transmission is high,
3.4 and 5.1 years, with almost everyone infected by age 15 (see the model predicts a high case load and death rate in earlier
SM section 1 for details). The absence of detectable IgM titers years following emergence (Fig. 2 and fig. S5). In Fig. 2B we
in any individual over the age of 15 years suggests reinfec- see that, as might be expected, longer lasting sterilizing im-
tions of adults causes a recall response, indicating that while munity slows down the transition to endemicity.
CoV specific immunity may wane it is not lost. Whether im- These results are robust to a more biologically realistic
munity would wane to naïve levels in the absence of high distribution for the duration of sterilizing immunity and the
pathogen circulation remains an open question. possibility that the generation of protective immunity re-
For most people to be infected so early in life—younger quires more than one infection (see SM section 3 and figs. S5
even than measles in the pre-vaccine era—the attack rate to S9).
must exceed transmission from primary infections alone. The Slowing down the epidemic through social distancing
model shows a high attack rate can arise from a combination measures that reduce R0 to close to one flattens the curve,
of high transmissibility from primary infections (i.e., high R0), thus delaying infections and preventing most deaths from
waning of sterilizing immunity and significant transmission happening early on, affording critical time for the develop-

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from reinfections in older individuals. The rapid waning of ment of an effective vaccine (fig. S10). If vaccine-induced IES
sterilizing immunity is also reported in experimental HCoV and IEP immunity is similar to that induced by HCoV infec-
infections of humans which showed that reinfection is possi- tions, the vaccine may usher in the endemic regime more
ble 1 year after an earlier infection, albeit with milder symp- quickly. The model code (see acknowledgments) provides a
toms (IEP) and a shorter duration (IEI) (11). Figure 1B shows flexible scaffolding for studying alternative vaccination sce-
the plausible combinations of waning immunity and trans- narios. Notably, the model predicts that once the endemic
mission from reinfected individuals that are required to pro- state is reached, mass vaccination may no longer be necessary
duce the MAPI observed in Fig. 1A, based on steady-state to save lives (see SM section 4 and fig. S11).
infection levels (see SM section 2.1 for details). Table 1 shows We can extend our predictions to two other potentially
the ranges of the parameters used in our simulations. emerging coronavirus infections—SARS and MERS. Our
At the beginning of an outbreak, the age distribution of model predicts that in the endemic state the IFR of a circu-
cases mirrors that of the population (Fig. 2A). However, once lating CoV depends primarily on the severity of childhood in-
the demographics of infection reaches a steady state, our fections. In the case of CoV-1, which is more pathogenic than
model predicts primary cases occur almost entirely in babies CoV-2, we still expect a low disease burden in the endemic
and young children, who in the case of COVID-19, experience phase because CoV-1, like CoV-2, has a low IFR in the young
a low CFR and a concomitantly low infection fatality ratio (Fig. 3). However, data suggest not all emerging HCoVs follow
(IFR). Reinfections in older individuals are predicted to be this optimistic pattern; the overall IFR of an endemic MERS-
common during the endemic phase and contribute to trans- like virus would not decrease during the transition to ende-
mission, but in this steady-state population, older individu- micity as seen in Fig. 3B, and this is because disease severity
als, who would be at risk for severe disease from a primary (and IFR) is high in children, the age group expected to expe-
infection, have acquired disease-reducing immunity follow- rience the bulk of primary cases during the endemic phase.
ing infection during childhood. The top panel of Fig. 3B illus- In the endemic phase, a vaccination program against MERS
trates how the overall IFR for CoV-2 drops dramatically, would therefore be necessary to avoid excess mortality (fig.
eventually falling below that of seasonal influenza (approxi- S11).
mately 0.001) once the endemic steady-state is reached. The key result from our new model framework that ex-
The time it takes to complete the shift in IFR as endemic- plicitly recognizes that functional immunity to reinfection,
ity develops depends on both transmission (R0) and loss of disease and shedding are different is that, in contrast with
immunity (ω and ρ), as is shown in Fig. 2B and fig. S4. The infections that are severe in childhood, CoV-2 could join the
transition from epidemic to endemic dynamics is associated ranks of mild, cold-causing endemic human coronaviruses in
with a shift in the age-distribution of primary infections to the long run. A critical prediction is that the severity of emer-
lower age groups (Fig. 2A). This transition may take any- gent CoVs once they reach endemicity depends only on the
where from a few years to a few decades depending on how severity of infection in children (Fig. 3) because all available
fast the pathogen spreads. The rate of spread, measured by evidence suggests immunity to HCoVs has short IES and mod-
R0, is determined by a combination of viral properties and the erate IEI, leading to frequent reinfection throughout adult-
frequency of social contacts, and may therefore be reduced by hood (11, 12) but strong IEP such that childhood infection
social distancing. The top panel shows the effect of reducing provides protection from pathology upon reinfection in
R0 to 2, whereas the middle and bottom panels show the adulthood, as evidenced by the rarity of severe infections or

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detectable IgM titers in adults. Strain-specific virulence fac- to be maintained in younger individuals. During the transi-
tors, such as the shared cellular receptor, ACE-2, to which tion to endemicity, primary CoV-2 infections will frequently
CoV-1, CoV-2 and the endemic strain NL63 all bind (13–16), occur in older individuals, and we need to determine if im-
may affect the CFR during the emergence phase but have lit- munity induced by infection or vaccination in adulthood is
tle impact on the severity of disease in the endemic phase. similar to that produced by natural infections in childhood.
Because the four endemic HCoVs have been globally circulat- Thus far, there have been few reinfections reported with CoV-
ing for a long time and almost everyone is infected at a young 2, and disease severity has varied (24); the only population-
age, we cannot ascertain how much pathology would result level study of reinfection of which we are aware estimates a
from a primary or even secondary case of any of these in an low rate of reinfection within the first six months after pri-
elderly or otherwise vulnerable person. mary infection and mild disease upon reinfection (25), but
The key insights come from how our model explicitly in- further analysis and monitoring are vital.
corporates different components of immunological protec- The findings presented here suggest that using symptoms
tion with respect to susceptibility, pathology and infectivity as a surveillance tool to curb the virus’s spread will become
(IES, IEP and IEI) and their different rates of waning. In our more difficult, as milder reinfections increasingly contribute
analysis we hypothesized that these components of immunity

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to chains of transmission and population level attack rates.
for CoV-2 are comparable to those of endemic HCoVs, and In addition, infection or vaccination may protect against dis-
this needs to be determined. Additionally, during the transi- ease but not provide the type of transmission-blocking im-
tion to endemicity, we need to consider how the IE’s depend munity that allows for shielding (26) or the generation of
on primary and secondary infections across ages (17) and how long-term herd immunity (2).
responses differ between vaccination and natural infection. The details of the change in overall IFR through the tran-
Longitudinal analysis of CoV-1 patients provides an op- sient period will be impacted by a wide array of factors, such
portunity to measure the durability of immune memory in as age-specific human contact rates (27) and susceptibility to
the absence of reexposure. The only long-term study we know infection (28), as well as improvement in treatment protocols,
of that follows CoV-1-specific antibodies suggests they wane hospital capacity, and virus evolution. The qualitative result
faster compared with antibodies to other live viruses and vac- of mild disease in the endemic phase is robust to these com-
cines such as measles, mumps, rubella and smallpox (18) and plexities, but quantitative predictions for the transient phase
fall below the threshold of detection in six years (19). In con- will depend on a careful consideration of these realities and
trast to antibody responses, memory T cells persist for much how they interact with the dynamics of infection and compo-
longer periods (19, 20) and confer protection in animal model nents of immunity (29).
systems (21). The changes in the IFR over time predicted by the model
We further consider the effects of strain variation both for have implications for vaccination strategy against current
natural infection and vaccination. Strain variation and anti- and future emerging HCoVs. Social distancing and an effec-
body escape may occur in endemic strains (22), however the tive vaccine are critical for control during a virgin epidemic
fact that symptoms are mild suggests that immunity induced and the transition out of it, but once we enter the endemic
by previously seen strains is nonetheless strong enough to phase, mass vaccination may no longer be necessary. The ne-
prevent severe disease. Indeed among HCoVs, frequent rein- cessity for continual vaccination will depend on the age-de-
fections appear to boost immunity against related strains pendence of the IFR. If primary infections of children are
(12). However, the effect of strain variation may differ for vac- mild (CoV-1 and CoV-2), continued vaccination may not be
cine-induced immunity, especially in light of the narrower needed as primary cases recede to mild childhood sniffles. If,
epitope repertoire of many currently authorized vaccines. on the other hand, primary infection is severe in children (as
If frequent boosting of immunity by ongoing virus circu- for MERS), then vaccination of children will need to be con-
lation is required to maintain protection from pathology, tinued.
then it may be best for the vaccine to mimic natural immun- From an ecological and evolutionary perspective, our
ity insofar as preventing pathology without blocking ongoing study opens the door to questions regarding the within-host
virus circulation. Preliminary results suggest the adenovirus- and between-host dynamics of human immunity and patho-
based vaccine is better at preventing severe than mild or gen populations in the face of IE’s with different kinetics. It
asymptomatic infections (23), and it will be important to col- also opens the question of how these IE’s interplay with
lect similar data for the other vaccines. Should the vaccine strain cross-immunity, which is likely relevant within the al-
cause a major reduction in transmission, it might be im- pha- and beta-coronaviruses. Considering data and model
portant to consider strategies that target delivery to older in- predictions from emergence through endemicity of HCoVs
dividuals for whom infection can cause higher morbidity and revealed a framework for understanding immunity and vac-
mortality, while allowing natural immunity and transmission cination that may apply to a variety of infections, such as RSV

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ACKNOWLEDGMENTS
We gratefully acknowledge helpful conversations with H. Ahmed, V. Zarnitsyna and
K. Fuller. Funding: This work was funded by NIH grants U01 AI150747, U01
HL139483 and U01 AI144616. Author contributions: J.S.L.: Conceptualization,
Methodology, Software, Formal analysis, Data curation, Writing – original draft,
review and editing, Visualization; R.A.: Conceptualization, Methodology, Writing,
Visualization, Supervision, Funding acquisition; O.N.B.: Conceptualization,
Methodology, Writing – review and editing. Competing interests: The authors
declare no competing interests. Data and materials availability: The scripts and
data used to perform the analysis and generate the figures in this paper are
available on GitHub (https://github.com/JennieLavine/covid-immunity-
endemicity) and archived in Zenodo (35). This work is licensed under a Creative
Commons Attribution 4.0 International (CC BY 4.0) license, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited. To view a copy of this license, visit
https://creativecommons.org/licenses/by/4.0/. This license does not apply to
figures/photos/artwork or other content included in the article that is credited
to a third party; obtain authorization from the rights holder before using such
material.

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Table 1. Characteristics of coronavirus-immune interactions and relevant parameter ranges.
Characteristic and symbol Estimates from Value Citations
literature (range)
Primary infectious period ≥5.6 days 9 days (8)
(1/γ) ∼10 days (30)

Primary transmissibility 4 to 9 2 to 10 (31)

[R0 = β/(γ + μ)]

Secondary transmissibility 0.35 0 to 1 (8)

(relative to primary, ρ) 0.04 to 0.97 Fig. 2 and fig. S2

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Duration of sterilizing 0.91 years 0.5 to 10 years (8) and SM section 5
immunity (1/ω) 1.67 years (8) and SM section 5
0.5 to 2 years (11, 32)

Relative pathology of mild – (8)

reinfections

Age-specific IFR SARS See (33)

(primary infections) MERS Fig. 3 (5)
COVID-19 (34)

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Fig. 1. A low mean age of primary infection suggests partially transmissible reinfections are common.
(A) Mean proportion seropositive for IgG (green, top lines) and IgM (purple, bottom lines) against the four
endemic HCoV strains [dots connected by dashed lines; vertical lines represent the 95% CI; data from
Zhou et al. (10)]. The mean age of primary infection (MAPI) based on IgM data with 95% CI is shown in text
inside each panel (see SM for details). (B) MAPI as a function of waning of sterilizing immunity (ω, y axis)
and transmissibility of reinfections (ρ, x axis). The MAPI was calculated from the equilibrium dynamics of
the model shown in fig. S1 and supplementary equations 3 to 9 with a plausible basic reproductive number
(R0 = 5) and 0 < ω < 2 and 0 < ρ < 1. See SM section 2.1 for details. The white band in indicates the plausible
combinations of values of ρ and ω consistent with the MAPI for HCoVs estimated in (A). [See fig. S1 for
parallel figures calculated at extreme plausible values for R0 (i.e., R0 = 2 and R0 = 10).]

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Fig. 2. The time scale of the transition from epidemic to endemic dynamics for emerging coronaviruses
depends on R0 and the rate of immune waning. Transition from epidemic to endemic dynamics for emerging
HCoVs, simulated from an extension of the model presented in fig. S1 that includes age structure. Demographic
characteristics (age distribution, birth, and age-specific death rates) are taken from the United States, and
seasonality is incorporated via a sinusoidal forcing function (see SM section 2.2). Weak social distancing is
approximated by R0 = 2. (See figs. S9 to S11 for strong social distancing results, R0 < 1.5.) (A) Daily number of
new infections (black line, calculations in SM section 2.3). An initial peak is followed by a low-incidence endemic
state (years 5 to 10 shown in the inset). A higher R0 results in a larger and faster initial epidemic and more rapid
transition to endemic dynamics. The proportion of primary cases in different age groups changes over time
(plotted in different colors), and the transition from epidemic to endemic dynamics results in primary cases
being restricted to younger age groups. Parameters for simulations: ω = 1 and ρ = 0.7. (B) Time for the average
IFR (6-month moving average) to fall to 0.001, the IFR associated with seasonal influenza. Gray areas represent
simulations where the IFR did not reach 0.001 within 30 years. The time to IFR = 0.001 decreases as the
transmissibility (R0) increases and the duration of sterilizing immunity becomes shorter. Results are shown for
ρ = 0.7. See SM section 2.3 and figs. S4 to S7 for sensitivity analyses and model specifications.

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Fig. 3. The overall infection fatality ratio (IFR) of emerging coronaviruses once they reach endemicity is
strongly influenced by the IFR of young children in the initial epidemic. The age dependence of the IFR
determines how the overall IFR changes during the transition from epidemic to endemic dynamics for emerging
CoVs. (A) Age dependence of the IFRs for the three emerging CoVs. Primary infections with MERS and CoV-1
are consistently symptomatic and the IFR and CFR are therefore assumed to be the same. CoV-1 and CoV-2
have J shaped profiles, with a monotonic increase in IFR with age. The age-specific IFR for MERS is U shaped,
with high mortality in the young and old age groups. Details of the statistical smoothing are described in SM
section 6. (B) The overall IFR changes during the transition to endemic dynamics. These calculations assume
deaths due to reinfections are negligible. We relax this assumption to allow for a slower build-up of immunity
and possible death due to secondary infection in figs. S5 to S9 and show the qualitative results do not change.

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Immunological characteristics govern the transition of COVID-19 to endemicity
Jennie S. Lavine, Ottar N. Bjornstad and Rustom Antia

published online January 12, 2021

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