Living with endemic COVID-19.

After 2 long years, the COVID-19 pandemic has now led to more than 304 million confirmed infections and more than 5.4 million deaths, as well as causing significant societal disruption worldwide. Unfortunately, the pandemic has not run its course, with many countries still in the grip of the latest wave of infections caused by the Omicron variant. That said, the world is in a different, and better, place now than a year ago, with multiple effective vaccines and new therapeutic options currently available, stronger testing and surveillance infrastructure and better knowledge of public health measures that work. Indeed, Dr Tedros Adhanom Ghebreyesus, Director General of the World Health Organization, has sounded an optimistic note that this may be the year we end the pandemic.

For some countries, there is an increasing belief that the pandemic will tail off in the coming year based on their achievement of high levels of vaccine coverage. Thoughts naturally now turn toward contemplating life beyond COVID-19. It is highly unlikely at the present time that SARS-CoV-2 will be eliminated from human populations but instead will become one of the endemic human coronaviruses. The two key questions many people are wondering are as follows: when will the pandemic end? and how do we live with COVID-19?

Defining when exactly the pandemic will end is not easy. An epidemiologic definition is when the pathogen becomes well established with sustained transmission in human populations. Some add the caveat that the infections become more predictable, and usually (but not always) less severe. Infections will settle to an “equilibrium” where the incidence of infections reaches a stable baseline, possibly with seasonal variations.

An endemic disease can still have serious consequences. Take the examples of malaria, HIV, tuberculosis and other infectious diseases that are endemic worldwide. In 2020, there were an estimated 241 million cases of malaria worldwide and around 627,000 deaths. Outbreaks and sporadic infections will continue to occur, particularly in population groups with little or no immunity from either past infection or immunisation. We know some population groups will be more vulnerable (such as the elderly, the very young and those with certain pre-existing health conditions), as exemplified by malaria, where most of the infections occur in children aged <5 years. Public health measures postpandemic must continue to focus on protecting the vulnerable.

We also know certain groups will suffer significant health inequality with infectious disease. These include those who have limited access to health resources or experience greater disadvantage due to a variety of socio-economic and other risk factors. These health inequalities were evident in the last 2 years, particularly amongst marginalised ethnic or faith communities, the homeless, substance misusers, migrants and refugees and others, and most certainly will continue. There will be an ongoing need for public health efforts to try and address these entrenched health inequalities.

We need to be careful in how we communicate ‘endemicity’ to the general public. Could the public perceive this to mean that the infection is now somehow mild and inconsequential like the common cold? If so, this could lead to relaxation of protective behaviours that help to keep infections in check. It is well recognised that risk perceptions have a powerful influence on health-related behaviours. For many, ‘living with COVID’ may mean going back to the prepandemic normal ways of living. This desire to return to familiar old ways of living is understandable but also risks recreating the same conditions of vulnerability. Effective risk communication, particularly in the social media age, is therefore both a challenge and necessity.

Instead of returning to the old ways, it may be desirable to establish new norms for living with COVID. For example, could a greater appreciation of the airborne and fomite routes of transmission and the necessary precautions needed help societies minimise future burdens of winter respiratory viral illness? Could behavioural changes such as more ubiquitous use of face coverings, social distancing, better hand hygiene, and people more readily self-isolating when ill, also help curb the spread of these diseases? Similarly, the lessons learned around the need for better ventilation in high-risk indoor settings may help not just reduce respiratory infections but also air pollution–related illnesses. That said, the possibility of widespread public ‘pandemic fatigue’ may present a significant barrier and lead to lower adherence to such protective behaviours.

Undoubtedly, some of the public health interventions introduced in the pandemic era will probably need to cease, such as the mass test and trace programmes that were implemented at great cost in the United Kingdom totalling £27 billion over 2 years simply because of their unsustainability and questionable cost-effectiveness in the longer term.

There is therefore value now in considering now what (if any) new norms are needed, as well as what are the societal costs entailed and benefits that may accrue from them. Without deliberate intent, it is likely that we will revert to the old norms.

On a final note, whilst we may speak of a time beyond the pandemic, we are still very much in the midst of one. We are not out of it yet. At the present time, the world continues to grapple with the Omicron variant. Fortunately, infections with the current Omicron variant appears to be less severe in populations with high levels of immunity, but it remains a dangerous disease for unvaccinated populations and for vulnerable high-risk population groups.

There also remains the risk of new variants emerging, including ones that will evade population immunity. Whilst viruses usually tend to evolve into less virulent forms, and we may hope the severity of future infections will attenuate; there is no guarantee that a more virulent form will not emerge. Public health systems will need to be vigilant and ready to respond in a timely way should that happen. In the meantime, vaccines remain our best bet out of the pandemic, and global efforts are still needed to achieve global vaccine coverage.